MIGS have been developed as a surgical alternative for glaucomatous patients.
To analyze the change in intraocular pressure (IOP) and glaucoma medications using different MIGS devices (Trabectome, ...iStent, Excimer Laser Trabeculotomy (ELT), iStent Supra, CyPass, XEN, Hydrus, Fugo Blade, Ab interno canaloplasty, Goniscopy-assisted transluminal trabeculotomy) as a solo procedure or in association with phacoemulsification.
Randomized control trials (RCT) and non-RCT (non randomized comparative studies, NRS, and before-after studies) were included. Studies with at least one year of follow-up in patients affected by primary open angle glaucoma, pseudoexfoliative glaucoma or pigmentary glaucoma were considered. Risk of Bias assessment was performed using the Cochrane Risk of Bias and the ROBINS-I tools. The main outcome was the effect of MIGS devices compared to medical therapy, cataract surgery, other glaucoma surgeries and other MIGS on both IOP and use of glaucoma medications 12 months after surgery. Outcomes measures were the mean difference in the change of IOP and glaucoma medication compared to baseline at one and two years and all ocular adverse events. The current meta-analysis is registered on PROSPERO (reference n° CRD42016037280).
Over a total of 3,069 studies, nine RCT and 21 case series with a total of 2.928 eyes were included. Main concerns about risk of bias in RCTs were lack of blinding, allocation concealment and attrition bias while in non-RCTs they were represented by patients' selection, masking of participants and co-intervention management. Limited evidence was found based on both RCTs and non RCTs that compared MIGS surgery with medical therapy or other MIGS. In before-after series, MIGS surgery seemed effective in lowering both IOP and glaucoma drug use. MIGS showed a good safety profile: IOP spikes were the most frequent complications and no cases of infection or BCVA loss due to glaucoma were reported.
Although MIGS seem efficient in the reduction of the IOP and glaucoma medication and show good safety profile, this evidence is mainly derived from non-comparative studies and further, good quality RCTs are warranted.
Although cancer is typically a disease of the older age groups, some types start emerging early in adulthood. This implies that exposures and stressors occurring before adulthood might play a role in ...the risk of cancer in adults. Little research has been conducted in this area.
We used European data from the Cancer in Five Continents Vol. XI to calculate cumulative risks by the end of subsequent adulthood decades of age (20–29, 30–39, 40–49) for 34 cancer sites and classified them as early-age emerging cancers if they reached 0.005% by 29 years old, intermediate-age emerging cancers by 39 years old, and late-age emerging cancers after 40 years old. We used data from Cancer in Five Continents Plus to analyse time trends in incidence rates by age groups over the period 1998–2012.
We identified 14 early-age emerging cancers. Nine of them showed significant increasing trends over calendar time in the early decades of adulthood, often more pronouncedly so in 20–29-year-olds than in 30–39 or 40–49-year-olds. The increase of colon cancer rates in the 20–29-year-olds was particularly high with an average annual percent change of 7.9% (95% confidence interval: 5.9%–10%). Decreases in incidence rates were only observed for cancer types classified as intermediate- or late-age emerging cancers.
Cancer prevention efforts seem to have favourably impacted intermediate- and late-age emerging cancer incidence rates. For early-age emerging cancers, aetiological research is needed to identify exposures and stressors occurring early in life, especially for those cancers that have been increasing in young adults. This knowledge will be essential to develop preventive strategies.
•Several cancer types start emerging early in adulthood at the population level.•Many of these have shown increasing incidence trends, especially in young adults.•The increase of colon cancer rates in the 20–29-year-olds was particularly striking.•Identifying early-life causes is needed to develop prevention strategies.
To provide values of retinal vessel density (VD) in the three retinal capillary plexuses, foveal avascular zone (FAZ) area, and retinal layer thickness in a cohort of healthy subjects.
The optical ...coherence tomography angiography maps of 148 eyes of 84 healthy subjects, aged 22 to 76 years, were analyzed for measuring VD of the retinal capillary plexuses, using the Optovue device comprising a projection artifact removal algorithm. Foveal avascular zone metrics were measured, and the relationship between optical coherence tomography angiography findings and age, sex, and image quality was studied.
The deep capillary plexus showed the lowest VD (31.6% ± 4.4%) in all macular areas and age groups compared with the superficial vascular plexus (47.8% ± 2.8%) and intermediate capillary plexus (45.4% ± 4.2%). The mean VD decreased by 0.06%, 0.06%, and 0.08% per year, respectively, in the superficial vascular plexus, intermediate capillary plexus, and deep capillary plexus. Mean FAZ area, FAZ acircularity index, and capillary density in a 300-µm area around the FAZ were 0.25 ± 0.1 mm, 1.1 ± 0.05, and 50.8 ± 3.4%, respectively. The yearly increase in FAZ area was 0.003 mm (P < 0.001).
The deep capillary plexus, a single monoplanar capillary plexus located in the outer plexiform layer, has the lowest VD, a significant finding that might be used to evaluate retinal vascular diseases. Vascular density decreased with age in the three capillary plexuses.
Summary Background Data from EUROCARE have consistently shown lower survival for adolescents and young adults (AYAs; aged 15–24 years) than for children (0–14 years) for most cancers that affect both ...groups, and modest survival improvements up to 2000–02. AYAs have longer survival than that of adults for most cancers. We used the latest definition of AYAs (aged 15–39 years) and provided estimates of 5-year relative survival for European AYAs with cancer diagnosed in 2000–07, compared with children and adults (40–69 years) with cancer, and assessed survival improvements over time. Methods We analysed data from population-based cancer registries of 27 European countries participating in EUROCARE-5. We used the so-called complete method to estimate 5-year, population-weighted relative survival for 19 cancers affecting AYAs and children, and for 27 cancers affecting AYAs and adults. We assessed relative-survival differences between children versus AYAs, and between AYAs versus adults, using the Z test. We used the period approach to estimate 5-year relative survival over time for children and AYAs, and used a generalised linear model to model survival time trends (1999–2007) and to assess the significance of changes over time. Findings We analysed 56 505 cancer diagnoses in children, 312 483 in AYAs, and 3 567 383 in adults. For all cancers combined, survival improved over time for AYAs (from 79% 95% CI 78·1–80·5 in 1999–2002 to 82% 81·1–83·3 in 2005–07; p<0·0001) and children (from 76% 74·7–77·1 to 79% 77·2–79·4; p<0·0001). Survival improved significantly in children and AYAs for acute lymphoid leukaemia (p<0·0001) and non-Hodgkin lymphoma (p<0·0001 in AYAs and p=0·023 in children). Survival improved significantly in AYAs only for CNS tumours (p=0·0046), astrocytomas (p=0·040), and malignant melanomas (p<0·0001). Survival remained significantly worse in AYAs than in children for eight important cancers: acute lymphoid leukaemias, acute myeloid leukaemias, Hodgkin's lymphomas, non-Hodgkin lymphomas, astrocytomas, Ewing's sarcomas, and rhabdomyosarcomas (p<0·0001 in all cases), and osteosarcomas (p=0·011). Interpretation Notwithstanding the encouraging results for some cancers, and overall, we showed poorer survival in AYAs than in children for the eight important cancers. Recent European initiatives to improve outcomes in AYAs might reduce the survival gap between children and AYAs, but this reduction can only be verified by future population-based studies. Funding Italian Ministry of Health, European Commission.
Lung ultrasonography (LUS) has emerged as a noninvasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure (ADHF) still ...raises some concerns. We tested the hypothesis that an integrated approach implementing LUS with clinical assessment would have higher diagnostic accuracy than a standard workup in differentiating ADHF from noncardiogenic dyspnea in the ED.
We conducted a multicenter, prospective cohort study in seven Italian EDs. For patients presenting with acute dyspnea, the emergency physician was asked to categorize the diagnosis as ADHF or noncardiogenic dyspnea after (1) the initial clinical assessment and (2) after performing LUS ("LUS-implemented" diagnosis). All patients also underwent chest radiography. After discharge, the cause of each patient's dyspnea was determined by independent review of the entire medical record. The diagnostic accuracy of the different approaches was then compared.
The study enrolled 1,005 patients. The LUS-implemented approach had a significantly higher accuracy (sensitivity, 97% 95% CI, 95%-98.3%; specificity, 97.4% 95% CI, 95.7%-98.6%) in differentiating ADHF from noncardiac causes of acute dyspnea than the initial clinical workup (sensitivity, 85.3% 95% CI, 81.8%-88.4%; specificity, 90% 95% CI, 87.2%-92.4%), chest radiography alone (sensitivity, 69.5% 95% CI, 65.1%-73.7%; specificity, 82.1% 95% CI, 78.6%-85.2%), and natriuretic peptides (sensitivity, 85% 95% CI, 80.3%-89%; specificity, 61.7% 95% CI, 54.6%-68.3%; n = 486). Net reclassification index of the LUS-implemented approach compared with standard workup was 19.1%.
The implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the ED.
Clinicaltrials.gov; No.: NCT01287429; URL: www.clinicaltrials.gov.
Aims
Although acute decompensated heart failure (ADHF) is a common cause of dyspnoea, its diagnosis still represents a challenge. Lung ultrasound (LUS) is an emerging point‐of‐care diagnostic tool, ...but its diagnostic performance for ADHF has not been evaluated in randomized studies. We evaluated, in patients with acute dyspnoea, accuracy and clinical usefulness of combining LUS with clinical assessment compared to the use of chest radiography (CXR) and N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) in conjunction with clinical evaluation.
Methods and results
This was a randomized trial conducted in two emergency departments. After initial clinical evaluation, patients with acute dyspnoea were classified by the treating physician according to presumptive aetiology (ADHF or non‐ADHF). Patients were subsequently randomized to continue with either LUS or CXR/NT‐proBNP. A new diagnosis, integrating the results of both initial assessment and the newly obtained findings, was then recorded. Diagnostic accuracy and clinical usefulness of LUS and CXR/NT‐proBNP approaches were calculated. A total of 518 patients were randomized. Addition of LUS had higher accuracy area under the receiver operating characteristic curve (AUC) 0.95 than clinical evaluation alone (AUC 0.88) in identifying ADHF (P < 0.01). In contrast, use of CXR/NT‐proBNP did not significantly increase the accuracy of clinical evaluation alone (AUC 0.87 and 0.85, respectively; P > 0.05). The diagnostic accuracy of the LUS‐integrated approach was higher then that of the CXR/Nt‐proBNP‐integrated approach (AUC 0.95 vs. 0.87, p < 0.01). Combining LUS with the clinical evaluation reduced diagnostic errors by 7.98 cases/100 patients, as compared to 2.42 cases/100 patients in the CXR/Nt‐proBNP group.
Conclusion
Integration of LUS with clinical assessment for the diagnosis of ADHF in the emergency department seems to be more accurate than the current diagnostic approach based on CXR and NT‐proBNP.
Lung ultrasound (LUS) is a largely employed diagnostic tool but an operational protocol for implementation has never been proposed. The lack of standardization clearly introduces variability in LUS ...results. We enrolled adult patients presenting for acute dyspnea with a clinical suspect of etiology related to heart failure. We calculated agreement among four providers in assessing B-lines. We varied probes, depth, evaluation time and scanning areas and we estimated the importance of each factors on B-lines assessment. Overall agreement among raters varied from a kappa of 0.70 to 0.81. The mean number of B-lines was 5.44 (95% confidence interval, CI, 4.1-6.8). This estimate did not suffer variation by the depth used (0.03, 95% CI -0.2-0.2, more B-lines, using 19 cm versus 10 cm). The use of a convex probe and expertise in LUS reduced the number of artifacts by 1.7 (95% CI 1.5-1.9) and 1.1 in comparison with a phased array probe and naive operators. Evaluation time increased estimates by 1.2 (95% CI 1-1.5) and 2.9 (95% CI 2.7-3.9) B-lines for 4" and 7" clips (reference was 2" clips). This study suggests that the probe, the evaluation time and the level of expertise might affect the results of quantitative assessment of B-lines.
Childhood cancer survivors are at the risk of developing subsequent colorectal cancers (CRCs), but the absolute risks by treatment modality are uncertain. We quantified the absolute risks by ...radiotherapy treatment characteristics using clinically accessible data from a Pan-European wide case-control study nested within a large cohort of childhood cancer survivors: the PanCareSurFup Study.
Odds ratios (ORs) from a case-control study comprising 143 CRC cases and 143 controls nested within a cohort of 69,460 survivors were calculated. These, together with standardized incidence ratios for CRC for this cohort and European general population CRC incidence rates and survivors' mortality rates, were used to estimate cumulative absolute risks (CARs) by attained age for different categories of radiation to the abdominopelvic area.
Overall, survivors treated with abdominopelvic radiotherapy treatment (ART) were three times more likely to develop a subsequent CRC than those who did not receive ART (OR, 3.1 95% CI, 1.4 to 6.6). For male survivors treated with ART, the CAR was 0.27% (95% CI, 0.17 to 0.59) by age 40 years, 1.08% (95% CI, 0.69 to 2.34) by age 50 years (0.27% expected in the general population), and 3.7% (95% CI, 2.36 to 7.80) by age 60 years (0.95% expected). For female survivors treated with ART, the CAR was 0.29% (95% CI, 0.18 to 0.62) by age 40 years, 1.03% (95% CI, 0.65 to 2.22) by age 50 years (0.27% expected), and 3.0% (95% CI, 1.91 to 6.37) by age 60 years (0.82% expected).
We demonstrated that by age 40 years survivors of childhood cancer treated with ART already have a similar risk of CRC as those age 50 years in the general population for whom population-based CRC screening begins in many countries. This information should be used in the development of survivorship guidelines for the risk stratification of survivors concerning CRC risk.
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•In an Italian birth cohort three indirect methods to assess pesticide exposure during pregnancy were used.•The association of each of the maternal exposure variables with infant ...wheezing occurrence was evaluated.•Self-reported pesticide use during pregnancy was weakly associated with infant wheezing.•Involvement in agricultural activities during pregnancy was not associated with infant wheezing.•In rural areas, living in proximity of crops, especially fruit trees, during pregnancy was associated with infant wheezing.
Pesticide exposure in pregnancy may have health effects in the offspring. We studied whether maternal pesticides exposure during pregnancy is associated with infant wheezing.
The study involved 5997 children from the Italian NINFEA birth cohort, whose mothers were recruited during pregnancy between 2005 and 2016. We used questionnaires completed during pregnancy and 6 months after delivery to derive the following indirect measures of exposure: i) Self-reported pesticide use during the first and the third trimester of pregnancy; (ii) Agricultural activities during the same trimesters. We also evaluated the exposure to agricultural pesticides applied near home using the Corine Land Cover inventory to derive the proportion of a 200-metre buffer area around maternal home address covered by agricultural crops and specific crop types (arable land, fruit trees, heterogeneous cultivations). Questionnaires completed when the child turned 18 months reported information on wheezing between 6 and 18 months of age. We estimated the odds ratios of wheezing adjusting for the following maternal characteristics: age, education, parity, asthma, atopy, smoking in pregnancy, region and area of residence, pet ownership during pregnancy. Crops proximity analyses were restricted to residents in rural areas (N = 1674).
Agricultural activities during pregnancy were not associated with infant wheezing. Compared to no pesticide use, there was a weak positive association for self-reported use in the third trimester (POR: 1.30; 95 %CI 0.95–1.78) and a stronger association for use in both trimesters (POR: 1.72; 95 %CI 1.11–2.65). The relationship between the proportion of crops around the home address and the risk of infant wheezing, was J-shaped, in particular for fruit trees with the lowest risk for mid values and elevated risk for higher values.
We found some evidence of association for maternal pesticide use in pregnancy and residential proximity to fruit trees cultivations with infant wheezing.
Heart failure (HF) is a potentially life-threatening complication of treatment for childhood cancer. We evaluated the risk and risk factors for HF in a large European study of long-term survivors. ...Little is known of the effects of low doses of treatment, which is needed to improve current treatment protocols and surveillance guidelines.
This study includes the PanCareSurFup and ProCardio cohort of ≥ 5-year childhood cancer survivors diagnosed between 1940 and 2009 in seven European countries (N = 42,361). We calculated the cumulative incidence of HF and conducted a nested case-control study to evaluate detailed treatment-related risk factors.
The cumulative incidence of HF was 2% (95% CI, 1.7 to 2.2) by age 50 years. The case-control study (n = 1,000) showed that survivors who received a mean heart radiation therapy (RT) dose of 5 to < 15 Gy have an increased risk of HF (odds ratio, 5.5; 95% CI, 2.5 to 12.3), when compared with no heart RT. The risk associated with doses 5 to < 15 Gy increased with exposure of a larger heart volume. In addition, the HF risk increased in a linear fashion with higher mean heart RT doses. Regarding total cumulative anthracycline dose, survivors who received ≥ 100 mg/m
had a substantially increased risk of HF and survivors treated with a lower dose showed no significantly increased risk of HF. The dose-response relationship appeared quadratic with higher anthracycline doses.
Survivors who received a mean heart RT dose of ≥ 5 Gy have an increased risk of HF. The risk associated with RT increases with larger volumes exposed. Survivors treated with < 100 mg/m
total cumulative anthracycline dose have no significantly increased risk of HF. These new findings might have consequences for new treatment protocols for children with cancer and for cardiomyopathy surveillance guidelines.
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