Assessment of Babesia spp. prevalence in various domestic animals across Southern Punjab, Pakistan.

Parasitic diseases, notably babesiosis, exert a substantial impact on the global cattle industry, posing challenges to commerce, economies, and human health. This study, conducted in Southern Punjab, Pakistan, aimed to assess the prevalence of Babesia spp. across various livestock species using microscopic and PCR methods. A total of 180 blood samples (60 from each district) were systematically collected from apparently healthy animals, with 36 samples obtained from each domestic animal species, including camel, cattle, buffalo, goat, and sheep, noting that 12 samples were collected from each district for each animal species. Overall prevalence was determined to be 32.8% (59/180), with varying rates among species: 25.0% in cattle, 41.66% in buffalo, 30.55% in goats, 33.3% in sheep, and 33.3% in camels. Microscopic examination revealed slightly varied infection rates among large and small domestic animals (22.2%), while PCR results indicated a 32.8% overall infection rate in both large and small domestic animals, with no statistical significance. District-wise analysis showed regional variations, with Muzaffargarh recording a prevalence rate of 23.33% through microscopic examination, while Lodhran and Bahawalpur recorded 21.67%. PCR results revealed higher rates (38.33%, 26.67%, and 33.33%, respectively), underlining the importance of employing PCR for accurate detection. Examining ruminant types, large ruminants exhibited a 32.4% infection rate, while small domestic animals showed 33.3%, with no significant difference (p=0.897). District-wise prevalence showcased significant variation, with Muzaffargarh demonstrating a 25% prevalence, Lodhran 22%, and Bahawalpur 22%, through microscopic examination. PCR results displayed 38.33%, 27%, and 33.3%, respectively, with no statistical significance. Detailed analysis of individual districts highlighted variations in infection rates among camels, cattle, buffalo, goats, and sheep. The binomial test indicated significant differences through microscopic analysis (P=0.011) but non-significant variations through PCR (P=0.065), emphasizing the precision of PCR. Regional variations in prevalence, notably with Punjab exhibiting the highest frequency (33.87%) and KPK the lowest (13.24%), suggest potential influences from varying veterinary practices and environmental factors. This study underscores the pivotal role of PCR alongside microscopy for accurate babesiosis diagnosis. These findings contribute to the broader understanding of babesiosis prevalence, emphasizing the necessity of advanced molecular techniques for informed control measures.

Epidemiology, Causes, and Management of Gastro-esophageal Reflux Disease: A Systematic Review.

Our comprehensive systematic review aimed to examine gastroesophageal reflux disease (GERD), a disorder that occurs when stomach contents flow back into the esophagus. It may manifest as either non-erosive reflux disease or erosive esophagitis. The activity depicts the assessment and medical management of GERD and emphasizes the interprofessional team's involvement to enhance care for people with this ailment. Data sources were PubMed/Medline and Embase. Our review investigated English-language articles (from 2014 to 2023) according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Overall, there were seven articles. Surveys and analyses of national databases were the most widely used methods (n=7). The search identified 3,730 studies, and seven were eligible for inclusion in the analysis. Further understanding of GERD and treatment protocols may help improve evaluation and management in the future. Millions of individuals worldwide suffer from GERD, a common clinical condition. Patients can be identified by symptoms that are both common and uncommon. For many GERD patients, acid suppression treatment reduces symptoms and avoids clinical complications. Our capacity to recognize and treat disease consequences has improved with the advancement of diagnostic and treatment methods. Here, we go into the etiology and consequences of GERD and offer details on the treatment strategy for this prevalent illness.

Correlation of Relative Value Units With Surgical Complexity and Physician Workload: A Contemporary Nationwide Analysis of Orthopaedic Procedures.

INTRODUCTION: Although previous studies have demonstrated inconsistencies between surgeon work and reimbursement, no previous study has calculated expected relative value units (RVUs) based on procedure-specific variables. Our study aimed to evaluate how measures of physician workload and surgical complexity correlate with the work RVUs (wRVUs) assigned to orthopaedic procedures and compare our predicted wRVUs with actual wRVUs. METHODS: The National Surgical Quality Improvement Program was used to identify orthopaedic surgeries with the highest procedural volume in 2019. For each Current Procedural Terminology (CPT) code, variables related to surgical complexity and postoperative management were retrieved. A multivariable linear regression was conducted, and R 2 values were calculated. RESULTS: A total of 229,792 cases from the top 20 CPT codes by frequency in 2019 were identified. Base RVU values ranged from 7.03 mRVUs for arthroscopic meniscectomy to 30.28 mRVUs for revision total hip arthroplasty. A total of 15 (75%) of the projected mRVUs were lower than the actual mRVU of the procedure. For the 5 (25%) procedures with mRVU projections higher than actual values, the largest differences were seen for CPT codes 29,888 (arthroscopic anterior cruciate ligament [ACL] repair; difference: 7.81), 22,630 (posterior arthrodesis of the lumbar interbody; difference: 7.75), and 27,487 (revision total knee arthroplasty; difference: 4.04). CONCLUSION: Our analysis demonstrates that current orthopaedic wRVUs do not appropriately compensate for objective measures of overall complexity as it relates to each procedure. Significant undercompensation in projected RVUs was noted for several high-volume orthopaedic procedures including arthroscopic ACL repair and revision total knee arthroplasty.

Leveraging image complexity in macro-level neural network design for medical image segmentation.

Recent progress in encoder-decoder neural network architecture design has led to significant performance improvements in a wide range of medical image segmentation tasks. However, state-of-the-art networks for a given task may be too computationally demanding to run on affordable hardware, and thus users often resort to practical workarounds by modifying various macro-level design aspects. Two common examples are downsampling of the input images and reducing the network depth or size to meet computer memory constraints. In this paper, we investigate the effects of these changes on segmentation performance and show that image complexity can be used as a guideline in choosing what is best for a given dataset. We consider four statistical measures to quantify image complexity and evaluate their suitability on ten different public datasets. For the purpose of our illustrative experiments, we use DeepLabV3+ (deep large-size), M2U-Net (deep lightweight), U-Net (shallow large-size), and U-Net Lite (shallow lightweight). Our results suggest that median frequency is the best complexity measure when deciding on an acceptable input downsampling factor and using a deep versus shallow, large-size versus lightweight network. For high-complexity datasets, a lightweight network running on the original images may yield better segmentation results than a large-size network running on downsampled images, whereas the opposite may be the case for low-complexity images.

Standard threshold laser versus subthreshold micropulse laser for adults with diabetic macular oedema: the DIAMONDS non-inferiority RCT.

BACKGROUND: The National Institute for Health and Care Excellence recommends macular laser to treat diabetic macular oedema with a central retinal subfield thickness of < 400 µm on optical coherence tomography. The DIAMONDS (DIAbetic Macular Oedema aNd Diode Subthreshold micropulse laser) trial compared standard threshold macular laser with subthreshold micropulse laser to treat diabetic macular oedema suitable for macular laser. OBJECTIVES: Determining the clinical effectiveness, safety and cost-effectiveness of subthreshold micropulse laser compared with standard threshold macular laser to treat diabetic macular oedema with a central retinal subfield thickness of < 400 µm. DESIGN: A pragmatic, multicentre, allocation-concealed, double-masked, randomised, non-inferiority, clinical trial. SETTING: Hospital eye services in the UK. PARTICIPANTS: Adults with diabetes and centre-involving diabetic macular oedema with a central retinal subfield thickness of < 400 µm, and a visual acuity of > 24 Early Treatment Diabetic Retinopathy Study letters (Snellen equivalent > 20/320) in one/both eyes. INTERVENTIONS: Participants were randomised 1 : 1 to receive 577 nm subthreshold micropulse laser or standard threshold macular laser (e.g. argon laser, frequency-doubled neodymium-doped yttrium aluminium garnet 532 nm laser); laser treatments could be repeated as needed. Rescue therapy with intravitreal anti-vascular endothelial growth factor therapies or steroids was allowed if a loss of ≥ 10 Early Treatment Diabetic Retinopathy Study letters between visits occurred and/or central retinal subfield thickness increased to > 400 µm. MAIN OUTCOME MEASURES: The primary outcome was the mean change in best-corrected visual acuity in the study eye at 24 months (non-inferiority margin 5 Early Treatment Diabetic Retinopathy Study letters). Secondary outcomes included the mean change from baseline to 24 months in the following: binocular best-corrected visual acuity; central retinal subfield thickness; the mean deviation of the Humphrey 10-2 visual field in the study eye; the percentage of people meeting driving standards; and the EuroQol-5 Dimensions, five-level version, National Eye Institute Visual Function Questionnaire - 25 and Vision and Quality of Life Index scores. Other secondary outcomes were the cost per quality-adjusted life-years gained, adverse effects, number of laser treatments and additional rescue treatments. RESULTS: The DIAMONDS trial recruited fully (n = 266); 87% of participants in the subthreshold micropulse laser group and 86% of participants in the standard threshold macular laser group had primary outcome data. Groups were balanced regarding baseline characteristics. Mean best-corrected visual acuity change in the study eye from baseline to month 24 was -2.43 letters (standard deviation 8.20 letters) in the subthreshold micropulse laser group and -0.45 letters (standard deviation 6.72 letters) in the standard threshold macular laser group. Subthreshold micropulse laser was deemed to be not only non-inferior but also equivalent to standard threshold macular laser as the 95% confidence interval (-3.9 to -0.04 letters) lay wholly within both the upper and lower margins of the permitted maximum difference (5 Early Treatment Diabetic Retinopathy Study letters). There was no statistically significant difference between groups in any of the secondary outcomes investigated with the exception of the number of laser treatments performed, which was slightly higher in the subthreshold micropulse laser group (mean difference 0.48, 95% confidence interval 0.18 to 0.79; p = 0.002). Base-case analysis indicated no significant difference in the cost per quality-adjusted life-years between groups. FUTURE WORK: A trial in people with ≥ 400 µm diabetic macular oedema comparing anti-vascular endothelial growth factor therapy alone with anti-vascular endothelial growth factor therapy and macular laser applied at the time when central retinal subfield thickness has decreased to < 400 µm following anti-vascular endothelial growth factor injections would be of value because it could reduce the number of injections and, subsequently, costs and risks and inconvenience to patients. LIMITATIONS: The majority of participants enrolled had poorly controlled diabetes. CONCLUSIONS: Subthreshold micropulse laser was equivalent to standard threshold macular laser but required a slightly higher number of laser treatments. TRIAL REGISTRATION: This trial is registered as EudraCT 2015-001940-12, ISRCTN17742985 and NCT03690050. FUNDING: This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 50. See the NIHR Journals Library website for further project information.

The retina is a layer at the back of the eye. Its centre is called the macula and is responsible for central vision. Some people with diabetes develop diabetic macular oedema. In diabetic macular oedema fluid leaks from retinal blood vessels and builds up at the macula, resulting in sight loss. Diabetic macular oedema can be mild or severe; this can be determined measuring the thickness of the macula, which is measured in micrometres (µm). One micrometre is one thousandth of a millimetre. In mild diabetic macular oedema, the thickness of the macula increases, but is less than 400 µm. Patients with mild diabetic macular oedema can be treated with a laser and there are two laser types. The standard threshold macular laser has been available for many years. It clears the diabetic macular oedema but produces a 'burn' in the retina. The subthreshold micropulse laser is newer. It does not produce a burn but also clears the diabetic macular oedema. The lack of a burn, however, has led to doubts about whether or not this laser works as well as the standard threshold macular laser because 'no burn' was taken to mean 'less benefit'. These doubts led to our establishing the DIAMONDS (DIAbetic Macular Oedema aNd Diode Subthreshold micropulse laser) trial, which compared these two lasers for people with mild diabetic macular oedema. A total of 266 people suitable for either laser joined the study at 16 NHS hospitals across the UK; 133 received standard threshold macular laser and 133 received subthreshold micropulse laser. The choice of laser was determined by chance. The DIAMONDS trial found that the subthreshold micropulse laser was as good as the standard threshold macular laser (i.e. 'clinically equivalent') in terms of improving people's vision, reducing macula thickness, allowing people to meet driving standards and maintaining their quality of life, both in general terms and for vision in particular. There was a small increase (less than one session on average per person) in the number of laser treatment sessions needed with subthreshold micropulse laser. The costs of both laser treatments were about the same.

CD200 expression on Sezary cells: A valuable tool for flow cytometric assessment of peripheral blood T-cell neoplasms.

BACKGROUND: CD200 (OX-2) is a valuable marker in the diagnosis of B-cell neoplasms and is commonly used in the screening panels for assessment of peripheral blood B-cell lymphoproliferative disorders. However, there is limited understanding about CD200 expression in T-cell neoplasms. A previous study has shown that CD200 is expressed on the neoplastic cells of angioimmunoblastic T-cell lymphoma (AITL) by immunohistochemistry, but no study has evaluated CD200 expression in T-cell neoplasms by flow cytometry. METHODS: We assessed CD200 expression in peripheral blood T-cell lymphoproliferative disorders by retrospective analysis of our institutional flow cytometry screening database over a 6-year period. RESULTS: In addition to AITL, we identified CD200 expression in a significant number of mycosis fungoides/Sezary syndrome cases (58%, 19 of 33 samples), while most other T-cell neoplasms were negative for CD200. These findings were confirmed by CD200 immunohistochemical staining of tissue specimens from our patient cohort. CONCLUSIONS: CD200 is commonly expressed on circulating Sezary cells, a feature that can potentially improve the diagnostic value of flow cytometry for assessment of T-cell neoplasms.

Humanistic and economic burden of depression and anxiety among adults with migraine: A systematic review.

BACKGROUND: Depression and anxiety are well-recognized comorbid health conditions among adults with migraine due to their humanistic and economic burden. This review was conducted to systematically assess the humanistic and economic burden of comorbid depression and/or anxiety disorder among adults with migraine. METHODS: A systematic literature search was conducted using MEDLINE and CINAHL via EBSCO, EMBASE, and Cochrane Database of Systematic Reviews via OVID. Studies evaluating the humanistic burden and the economic burden of comorbid depression and anxiety among adults with migraine that were published in peer-reviewed English language journals from inception until January 2020 were included. RESULTS: Out of the 640 identified articles, 23 studies were found eligible and included in this review. Regarding the humanistic burden, health-related quality of life (HRQoL) was examined by 11 studies, 7 studies examined disability, while 2 studies evaluated both HRQoL and disability measures. These studies reported an association between depression and/or anxiety and lower HRQoL and higher disability among adults with migraine. Regarding the economic burden, only three studies were identified and all concluded that depression and/or anxiety are significantly associated with higher healthcare expenditures and utilization among adults with migraine. CONCLUSIONS: Results of this review highlight the substantial burden of depression and/or anxiety for adults with migraine. Healthcare providers need to identify and treat anxiety and depression for patients living with migraine.

Diabetic macular oedema and diode subthreshold micropulse laser (DIAMONDS): study protocol for a randomised controlled trial.

BACKGROUND: In the UK, macular laser is the treatment of choice for people with diabetic macular oedema with central retinal subfield thickness (CST) < 400 µm, as per National Institute for Health and Care Excellence guidelines. It remains unclear whether subthreshold micropulse laser is superior and should replace standard threshold laser for the treatment of eligible patients. METHODS: DIAMONDS is a pragmatic, multicentre, allocation-concealed, randomised, equivalence, double-masked clinical trial that aims to determine the clinical effectiveness and cost-effectiveness of subthreshold micropulse laser compared with standard threshold laser, for the treatment of diabetic macular oedema with CST < 400 µm. The primary outcome is the mean change in best-corrected visual acuity in the study eye from baseline to month 24 post treatment. Secondary outcomes (at 24 months) include change in binocular best corrected visual acuity; CST; mean deviation of the Humphrey 10-2 visual field; change in percentage of people meeting driving standards; European Quality of Life-5 Dimensions, National Eye Institute Visual Functioning Questionnaire-25 and VisQoL scores; incremental cost per quality-adjusted life year gained; side effects; number of laser treatments and use of additional therapies. The primary statistical analysis will be per protocol rather than intention-to-treat analysis because the latter increases type I error in non-inferiority or equivalence trials. The difference between lasers for change in best-corrected visual acuity (using 95% CI) will be compared to the permitted maximum difference of five Early Treatment Diabetic Retinopathy Study (ETDRS) letters. Linear and logistic regression models will be used to compare outcomes between treatment groups. A Markov-model-based cost-utility analysis will extend beyond the trial period to estimate longer-term cost-effectiveness. DISCUSSION: This trial will determine the clinical effectiveness and cost-effectiveness of subthreshold micropulse laser, when compared with standard threshold laser, for the treatment of diabetic macular oedema, the main cause of sight loss in people with diabetes mellitus. TRIAL REGISTRATION: International Standard Randomised Controlled Trials, ISRCTN17742985 . Registered on 19 May 2017 (retrospectively registered).

Analysis of basal and reflex human tear osmolarity in normal subjects: assessment of tear osmolarity.

PURPOSE: The aim of this study is to evaluate the difference between reflex and basal tear osmolarity among healthy normal subjects. METHOD: The right eyes of 20 healthy normal male subjects aged 20 to 40 years were recruited for this study. The inclusion criteria for the subjects were the Ocular Surface Disease Index questionnaire score of less than 12 and wetting length of the phenol red thread of more than 10 mm. Tear film osmolarity was assessed using TearLab osmometer. Basic tear osmolarity was measured normally without inducing any irritation to the eye. In order to stimulate reflex tear, subjects were asked to open their eye as long as they can till they feel ocular surface irritation (minimum 20 s). RESULTS: The mean score on the Ocular Surface Disease Index questionnaire was 5.5 ± 3. The mean value obtained from the phenol red thread was 21 ± 4.5 mm. There were no statistically significant differences between the osmolarity readings of basal and reflex tear osmolarity (p > 0.05). The mean value was 308 ± 12 and 306 ± 9 mOsm/l for basic and reflex tear osmolarity, respectively. CONCLUSION: This study found that the osmolarity of the basal and reflex tears fell within the same range. The values found in this study are in agreement with published results for normal subjects.

Assessment of anti-factor Xa activity of enoxaparin for venous thromboembolism prophylaxis in morbidly obese surgical patients.

BACKGROUND: Venous thromboembolism (VTE) can be encountered by 60% of hospitalized patients. Anticoagulants have been recommended to reduce the risk of VTE in patients with risk factors. However, no specific dosing recommendations for obese patients are provided in the current practice guidelines. The purpose of this study was to determine the efficacy and safety of weight-based dosing of enoxaparin for VTE prophylaxis among morbidly obese patients undergoing surgery. METHODS: Adult patients were enrolled if they have a body mass index (BMI) of ≥35 kg/m2 and were scheduled for surgery. These patients were prescribed enoxaparin (0.5 mg/kg subcutaneously [SC] once daily). Peak anti-factor Xa levels were measured 4 h after the third dose of enoxaparin. The primary outcome measure was to determine whether a weight-based dosing of enoxaparin of 0.5 mg/kg produce the anticipated peak anti-Xa levels (0.2-0.6 IU/m) among obese patients undergoing surgery. Secondary outcomes include the incidence of VTE, the incidence of minor or major bleeding, and the incidence of heparin-induced thrombocytopenia (HIT). RESULTS: Fifty patients were enrolled in the study. The mean age was 53 ± 16 years, 74% of the patients were female. The mean BMI was 40.5 ± 5, and the average enoxaparin dose was 50 ± 9.8 SC daily. Nearly 88% of the patients reached the target anti-factor Xa (0.427 ± 0.17). None of the patients developed HIT or VTE. There was no incidence of major or minor bleeding. CONCLUSIONS: Weight-based enoxaparin dose led to the anticipated peak anti-Xa levels (0.2-0.6 IU/mL) in most of the morbidly obese study patients undergoing surgery without any evidence of major side effects. The weight-based dosing of enoxaparin was also effective in preventing VTE in all patients. Although these results are promising, further comparative trials are needed in the setting of morbidly obese surgical patients.

Assessment and comparison of CHADS2, CHA2DS2-VASc, and HAS-BLED scores in patients with atrial fibrillation in Saudi Arabia.

AIMS: No previous reports on the utilization of CHADS2, CHA2DS2-VASc, and HAS-BLED scores in atrial fibrillation (AF) patients in Saudi Arabia have been identified in the literature. The main objectives of this study were to assess and compare the distribution of CHADS2, CHA2DS2-VASc, and HAS-BLED scores and to identify the most common risk factors for stroke and bleeding among AF patients attending clinical pharmacists managed anticoagulation clinic. SETTINGS AND DESIGN: This cross-sectional study was conducted over 2 months period at clinical pharmacists managed anticoagulation clinic. METHODS: CHADS2, CHA2DS2-VASc, and HAS-BLED scores were calculated and compared for all eligible patients. RESULTS: Two hundred and sixty-four patients with AF were included in the analysis. The number of patients at low risk for stroke was found to be 14 (5.3%) using CHADS2 and only 4 (1.5%) using CHA2DS2-VASc. On the other hand, 64 patients (24.2%) were found at moderate risk for stroke using CHADS2 compared with 17 patients (6.4%) using CHA2DS2-VASc. Most of the patients were found to be at high risk for stroke using either the CHADS2 (70.5%) and CHA2DS2-VASc (92%). The study also revealed that most of the patients were at moderate (63.3%) to high (27.7%) risk of bleeding. CONCLUSIONS: The results of this study show that the percentage of patients at high risk for stroke and bleeding is very high. The study revealed that this could be attributed to the high prevalence of modifiable risk factors for stroke and for bleeding in Saudi patients with AF.

Prevalence, prescribing and barriers to effective management of hypertension in older populations: a narrative review.

OBJECTIVES: Hypertension is the leading modifiable cause of mortality worldwide. Unlike many conditions where limited evidence exists for management of older individuals, multiple large, robust trials have provided a solid evidence-base regarding the management of hypertension in older adults. Understanding the impact of age on how the prevalence of hypertension and the role of pharmacotherapy in managing hypertension among older persons is a critical element is the provision of optimal health care for older populations. The aim of this study was to explore how the prevalence of hypertension changes with age, the evidence regarding pharmacological management in older adults and to identify known barriers to the optimal management of hypertension in older patients. METHODS: A review of English language studies published prior to 2013 in Medline, Embase and Google scholar was conducted. Key search terms included hypertension, pharmacotherapy, and aged. RESULTS: The prevalence of hypertension was shown to increase with age, however there is good evidence for the use of a number of pharmacological agents to control blood pressure in older populations. System, physician and patient related barriers to optimal blood pressure control were identified. CONCLUSIONS: Despite good evidence for pharmacological management of hypertension among olderpopulations, under treatment of hypertension is an issue. Concerns regarding adverse effects appearcentral to under treatment of hypertension among older populations.

Routine versus As-Needed Bevacizumab with 12-Weekly Assessment Intervals for Neovascular Age-Related Macular Degeneration: 92-Week Results of the GMAN Trial.

PURPOSE: To evaluate the efficacy and safety of intravitreal bevacizumab (Avastin; Genentech, South San Francisco, CA) in patients with neovascular age-related macular degeneration (nAMD) using 2 different treatment regimens in which patients were assessed clinically at up to 12-week intervals. DESIGN: Randomized, controlled, noninferiority trial. PARTICIPANTS: A total of 331 patients with nAMD. METHODS: Patients were treated with 1.25 mg intravitreal bevacizumab and followed up to 92 weeks. They were randomized into 2 arms. All patients received 3 loading doses 4 weeks apart and thereafter were assessed every 12 weeks until the end of the study. One arm received a routine treatment at each 12-week assessment, and the other arm was treated at these assessments on an as-needed basis. After the loading doses, patients in either arm who showed signs of disease activity had an additional assessment after 6 weeks and at that visit had top-up treatments on an as-needed basis. MAIN OUTCOME MEASURES: Mean best-corrected visual acuity (BCVA) at 92 weeks. RESULTS: At 92 weeks, patients who had treatments every 12 weeks had superior BCVA to those treated on an as-needed basis every 12 weeks (P = 0.008), with the regular treatment arm gaining a mean BCVA of 5.5 letters and the as-needed treatment arm gaining 0.6 letters. The regular treatment arm of the study showed significantly improved outcomes with respect to 5-, 10-, and 15-letter changes in BCVA from baseline compared with the as-needed treatment arm, as well as superior reading speed. In patients who completed the study, up to but not including week 92, the mean number of treatments was 10.8 for the regular treatment arm and 9.1 for the as-needed treatment arm. CONCLUSIONS: A treatment regimen with regular bevacizumab injections every 12 weeks after loading doses supplemented with as-needed top-up treatments produced a stable improvement in BCVA from baseline. The improvement in BCVA was broadly similar to that obtained in other studies using anti-vascular endothelial growth factor drugs with more frequent assessments and treatments.

Optimisation and assessment of three modern touch screen tablet computers for clinical vision testing.

Technological advances have led to the development of powerful yet portable tablet computers whose touch-screen resolutions now permit the presentation of targets small enough to test the limits of normal visual acuity. Such devices have become ubiquitous in daily life and are moving into the clinical space. However, in order to produce clinically valid tests, it is important to identify the limits imposed by the screen characteristics, such as resolution, brightness uniformity, contrast linearity and the effect of viewing angle. Previously we have conducted such tests on the iPad 3. Here we extend our investigations to 2 other devices and outline a protocol for calibrating such screens, using standardised methods to measure the gamma function, warm up time, screen uniformity and the effects of viewing angle and screen reflections. We demonstrate that all three devices manifest typical gamma functions for voltage and luminance with warm up times of approximately 15 minutes. However, there were differences in homogeneity and reflectance among the displays. We suggest practical means to optimise quality of display for vision testing including screen calibration.

Insulin vials vs. insulin cartridges: Further cost considerations.

SCOPE: Many studies have provided evidence that favor the use of insulin pens over traditional insulin vials due to lower overall costs. The cost of insulin in the Royal Medical Services in Jordan is subject to other considerations due to the favorable tender prices and the process of dispensing of insulin within the Royal Medical Services. OBJECTIVE: To highlight further cost considerations associated with the wastage in the use of insulin vials and cartridges in the Jordanian Royal Medical Services. METHODS: Two random samples were selected from prescriptions dispensed for diabetic patients using insulin in January 2012 from the outpatient pharmacy in Al-Hussein Hospital, King Hussein Medical Center, Amman, Jordan. First sample was selected from prescriptions of patients using vials; second sample was selected from prescriptions of patients using pens and cartridges. Average costs for insulin and wastage were calculated per patient from the Royal Medical Services perspective. RESULTS: The average direct cost per patient using vials was JD 5.197 and for those using cartridges was JD 22.135. The average wasted quantity per patient in the first sample was more than ten times that of the second sample. The cost of the average wasted quantity per patient in the first sample (1.022 JD) was more than the double that in the second sample (0.441 JD). CONCLUSION: Although, the direct cost of insulin per patient by using vials was lower than cartridges, there was a substantial reduction in the cost of wastage by using the cartridges in the Jordanian Royal Medical Services outpatients.

An assessment of a modern touch-screen tablet computer with reference to core physical characteristics necessary for clinical vision testing.

There are a multitude of applications using modern tablet computers for vision testing that are accessible to ophthalmology patients. While these may be of potential future benefit, they are often unsupported by scientific assessment. This report investigates the pertinent physical characteristics behind one of the most common highest specification tablet computers with regard to its capacity for vision testing. We demonstrate through plotting of a gamma curve that it is feasible to produce a precise programmable range of central luminance levels on the device, even with varying background luminance levels. It may not be possible to display very low levels of contrast, but carefully using the gamma curve information allows a reasonable range of contrast sensitivity to be tested. When the screen is first powered on, it may require up to 15 min for the luminance values to stabilize. Finally, luminance of objects varies towards the edge of the screen and when viewed at an angle. However, the resulting effective contrast of objects is less variable. Details of our assessments are important to developers, users and prescribers of tablet clinical vision tests. Without awareness of such findings, these tests may never reach satisfactory levels of clinical validity and reliability.

Detecting undiagnosed diabetes using glycated haemoglobin: an automated screening test in hospitalised patients.

OBJECTIVE: To assess the utility of glycated haemoglobin (HbA(1c)) level as an automated screening test for undiagnosed diabetes among hospitalised patients and to estimate the prevalence of undiagnosed diabetes among hospitalised patients. DESIGN, PARTICIPANTS AND SETTING: A 3-month prospective study of all adult patients admitted to a tertiary hospital. An HbA(1c) test was automatically undertaken on admission for all patients with a random plasma glucose (RPG) level ≥ 5.5 mmol/L. Demographic, admission and biochemical data were obtained from hospital databases. A subset of patients was recruited for an oral glucose tolerance test (OGTT) after discharge. MAIN OUTCOME MEASURES: Prevalence of undiagnosed diabetes (defined as HbA(1c) ≥ 6.5% in accordance with International Expert Committee and American Diabetes Association recommendations) and utility of automated HbA(1c) testing. RESULTS: The prevalence of undiagnosed diabetes was 11% (95% CI, 9.8%-12.4%) (262/2360) during the study period. A further 312 patients with known diabetes were admitted. The prevalence of undiagnosed diabetes was highest in the 65-74-years age group. The HbA(1c) test cost was $152 per new diagnosis of diabetes. Conservatively assuming an annual incidence of undiagnosed diabetes of 0.8%, the ongoing cost of testing hospitalised patients would be $2100 per new diagnosis of diabetes. RPG testing was not sensitive or specific in diagnosing diabetes. Patients were poorly compliant with the post-discharge OGTT (27% completion rate). CONCLUSIONS: HbA(1c) is a simple, inexpensive screening test that can be automated using existing clinical blood samples. Hospital screening for diabetes needs to be coupled with resources for management in the community.

A successful chronic care program in Al Ain-United Arab Emirates.

BACKGROUND: The cost effective provision of quality care for chronic diseases is a major challenge for health care systems. We describe a project to improve the care of patients with the highly prevalent disorders of diabetes and hypertension, conducted in one of the major cities of the United Arab Emirates. SETTINGS AND METHODS: The project, using the principles of quality assurance cycles, was conducted in 4 stages.The assessment stage consisted of a community survey and an audit of the health care system, with particular emphasis on chronic disease care. The information gleaned from this stage provided feedback to the staff of participating health centers. In the second stage, deficiencies in health care were identified and interventions were developed for improvements, including topics for continuing professional development.In the third stage, these strategies were piloted in a single health centre for one year and the outcomes evaluated. In the still ongoing fourth stage, the project was rolled out to all the health centers in the area, with continuing evaluation. The intervention consisted of changes to establish a structured care model based on the predicted needs of this group of patients utilizing dedicated chronic disease clinics inside the existing primary health care system. These clinics incorporated decision-making tools, including evidence-based guidelines, patient education and ongoing professional education. RESULTS: The intervention was successfully implemented in all the health centers. The health care quality indicators that showed the greatest improvement were the documentation of patient history (e.g. smoking status and physical activity); improvement in recording physical signs (e.g. body mass index (BMI)); and an improvement in the requesting of appropriate investigations, such as HbA1c and microalbuminurea. There was also improvement in those parameters reflecting outcomes of care, which included HbA1c, blood pressure and lipid profiles. Indicators related to lifestyle changes, such as smoking cessation and BMI, failed to improve. CONCLUSION: Chronic disease care is a joint commitment by health care providers and patients. This combined approach proved successful in most areas of the project, but the area of patient self management requires further improvement.

Secular trend in height in Al Ain-United Arab Emirates.

Correlation between cycles in human stature and those in economic variables is well established. A recent review of international trends in this area provided information from most parts of the world but none on Arabs in the Middle East or more specifically the gulf region. The United Arab Emirates experienced a transformation in economic and social life followed the discovery of oil in the late 1960s and the wealth that it generated. No data is available on human growth at this period of time because its population never had health services prior to the 1970s. A study on conventional cardiovascular risk factors in 2004-2005 included 817 randomly selected national adults (> or =18 years) from both genders. The relationship between height and age in this study showed both men and women have increased in height with time demonstrating the secular change in height most likely a result of changing socioeconomic factors.