Real-World Outcomes of Faricimab Treatment for Neovascular Age-Related Macular Degeneration and Diabetic Macular Edema.

Purpose: The purpose of this study was to assess preliminary real-world outcomes in neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME) treated with intravitreal faricimab. Patients and Methods: This was a retrospective, observational consecutive-case real-world study of patients with nAMD or DME initiated on intravitreal faricimab between November 2022 and April 2023. Treatment-naïve patients and patients previously treated with alternate anti-vascular endothelial growth factor (anti-VEGF) agents were initiated on an intended treatment plan of four monthly faricimab injections as a loading regime. Efficacy was assessed across four treatment groups. Primary outcomes assessed for both cohorts were changes in best corrected visual acuity (BCVA) and central subfield thickness (CST) on optical coherence tomography (OCT). Secondary outcomes were alterations in OCT-defined structural features. Results: From 127 patients, 146 eyes received at least one dose of faricimab. Mean BCVA, measured in Early Treatment of Diabetic Retinopathy Study (ETDRS) letters, from baseline to fifth visit increased from: 59.0±12.8 to 62.2±14.3 in treatment-naïve nAMD; 61.1±17.6 to 63.5±14.8 in previously-treated nAMD; 61.1±13.0 to 72.8±11.5 in treatment-naïve DME; and 60.8±14.6 to 63.3±15.6 in previously-treated DME. Mean CST reduced in all four treatment groups between initiation to final loading dose, from: 442.8±172.0µm to 305.2±117.0µm (p<0.0001) in treatment-naïve nAMD; 355.2±115.1µm to 297.9±92.54µm (p<0.0001) in previously-treated nAMD; 465.8±109.1µm to 343.1±100.3µm (p<0.0001) in treatment-naïve DME; and 492.5±133.1µm to 388.5±131.4µm (p<0.0001) in previously-treated DME. Conclusion: Real-world outcomes showed some improvement in BCVA and CST for nAMD and DME following faricimab administration, including in patients previously treated with other anti-VEGF agents. Further work involving larger cohorts over longer periods is required to determine whether improvement is maintained, and if intervals can be extended to match those observed in clinical trials.

Estimating access to surgical care: A community centered national household survey from Pakistan.

Pakistan is a lower middle-income country in South Asia with a population of 225 million. No estimate for surgical care access exists for the country. We postulate the estimated access to surgical care is less than the minimum 80% to be achieved by 2030. We conducted a randomized, stratified two-stage cluster household survey. A sample of 770 households was selected using 2017 census frames from the Pakistan Bureau of Statistics. Data was collected on choice of hospital and travel time to the chosen hospital for C-section, laparotomy, open fracture repair (OFR), and specialized surgery. Analysis was conducted using Stata 14. Access to all Bellwether surgeries (C-section, laparotomy, and open fracture repair) in Pakistan is estimated to be 74.8%. However, estimated access in rural areas and the provinces of Balochistan, Khyber Pakhtunkhwa (KP) and Sindh is far less than in urban areas and in Punjab and Islamabad. Estimated access to C-sections is more compared to OFR, laparotomy, and specialized surgery. Health system strengthening efforts should focus on improving surgical care access in rural areas and in Balochistan, KP, and Sindh. More focus is required on standardizing the availability and quality of surgical services in secondary-level hospitals.

Pneumatic Retinopexy: An Experience of 12 Years at a Tertiary Care Hospital.

Purpose The purpose of this study is to retrospectively analyze single-operation success (SOS) rates of pneumatic retinopexy (PR) for the treatment of rhegmatogenous retinal detachment (RRD) and to identify the predictors of treatment outcomes. Methods Sixty-one eyes of 61 patients who underwent PR for RRD during a period of 12 years were included in this study. Patient demographics along with pre-treatment clinical characteristics were recorded. Treatment outcomes in terms of best-corrected visual acuity (BCVA) and anatomical characteristics were reported including any post-operative complications. Visual outcomes were compared according to pre-treatment characteristics and between groups of the eyes achieving SOS and those requiring additional surgery. Results SOS was achieved in 37 (61%) eyes. Twenty-four (39%) eyes required one (36%) or two (3%) additional procedures. There was no significant association between pre-treatment characteristics and treatment failure. SOS eyes had significantly better visual outcomes (P=0.002), and so did those with macula-on status (P=0.003). New/missed breaks (9.8%) and proliferative vitreoretinopathy (PVR) (4.9%) were the most common causes of failure. Conclusions We found PR to be a beneficial technique for the treatment of RRD in this cohort. PR remains the least invasive treatment modality, and as a cost-effective technique, it is especially useful in low/middle-income countries such as Pakistan.

Assessment of outcomes after intralesional bleomycin sclerotherapy of lymphatic malformations in children.

OBJECTIVE: To evaluate the efficacy of bleomycin in the treatment of lymphatic malformations, and the concordance between photographic and radiological assessments of the outcome. METHODS: The retrospective study was conducted at the Vascular Anomalies Centre of Indus Hospital, Karachi, and comprised data of patients enrolled with diagnosis of macrocystic or mixed lymphatic malformations from January 2017 to November 2019. All patients had been treated with injection bleomycin 0.6-1mg/kg/session. Size and location of lesions, ultrasonographic findings, photographic documentation and post-procedure complications were reviewed. Photographic and radiographical assessment outcomes were categorised as excellent, good or poor, and compared for concordance. Data was analysed using Stata 14. Results: Of the 31 children, 22(68.8%) were boys. Mean age at presentation was 54.2±44 months (range: 2 months to 15.7 years). There were 32 lymphatic malformations; 29(90.6) macrocystic and 3(9.4%) mixed. Head and neck region was mostly involved 19(59.4%). Most lesions 23(71.9%) presented during the first year of life, and 29(90.6%) lesions were purely macrocystic. Excellent, good and poor response was seen in 16(50%), 15(46.9%) and 1(3.1%) lesions on photographic assessment, and 21(65.6%), 11(34.4%) and 0(0.0%) lesions on radiological assessment, respectively. Concordance in photographic and radiological outcomes was 22(69%). No complications were seen and no statistically significant difference was observed for photographic and radiographic assessment with respect to gender, malformation type, region involved, and number of sessions (p>0.05). CONCLUSIONS: Intralesional bleomycin sclerotherapy was found to be effective in the treatment of lymphatic malformations. Clinical observation was reliable in assessing progress on routine follow-up, with additional radiology done when management decisions needed to be reviewed.

Eight-year Review of a Clubfoot Treatment Program in Pakistan With Assessment of Outcomes Using the Ponseti Technique: A Retrospective Study of 988 Patients (1,458 Clubfeet) Aged 0 to 5 Years at Enrollment.

OBJECTIVE: To conduct an 8-year retrospective review of a clubfoot treatment program using the Ponseti technique with close monitoring of outcomes. METHODS: Between October 2011 and August 2019, 988 children with 1,458 idiopathic clubfeet were enrolled, ages ranging from new born up to 5 years. Ponseti treatment was used, and progress was monitored by comparing mean Pirani scores at enrollment (P1), initiation of bracing (P2), and end of treatment (P3) or most recent visit (P4) for children under treatment. RESULTS: A statistically significant reduction in Pirani scores was noted (P < 0.001) for all feet. For 320 feet completing treatment (213 children), the mean Pirani scores reduced from P1: 3.8 (±1.1) to P2: 1.1 (±0.6) and finally to P3: 0.6 (±0.3). Four hundred sixteen children are currently undergoing bracing. Higher education of the head of household and male sex of the child were markedly associated with improved outcomes in foot correction status. Correction was obtained with a mean of 5.8 casts per foot, the tenotomy rate was 68.2%, and the mean duration of bracing in children completing treatment was 3.6 years (±0.9). No surgical correction, other than tenotomy, was required. Relapse was noted in 12.1% of the total enrolled feet, and 32.0% children were lost to follow-up from the entire cohort of 988 children. CONCLUSION: Clubfoot treatment requires long-term follow-up. A dedicated clubfoot program is effective in maintaining continuity of care by encouraging adherence to treatment.

A study on the severity and prevention measures of COVID-19 among dental professionals in clinical practice management.

BACKGROUND: Medical professionals, especially dental professionals, have been adversely affected by the pandemic of COVID-19 due to an increased chance of exposure to patients because of close contact during treatments. OBJECTIVES: This study aimed to evaluate knowledge about the disease and assess ways of precautions to be taken during the pandemic. METHODS: A questionnaire was developed and registered at Google Forms. The study population included dental practitioners, working in hospitals and clinics. A total of 495 dental practitioners from 14 different countries across the world responded. Most dentists were aware of the required modifications in the management of patients. The points allotted for each correct/best answer by participants for a group of questions regarding each component (Knowledge, Perceptions, and Practices) were added/summed to generate an overall score for each of the three components. RESULTS: Both univariate and multivariate analysis employed for the evaluation of results. Moreover, the total practice score was significantly associated with gender and sector of practice. Multivariable analysis model using multiple linear regressions was formulated by including those variables which were significant at the univariate stage. Hence, the practice sector was the only variable found to be significantly associated with the total knowledge score (p-value < 0.05). CONCLUSION: This study, based on our experience and relevant guidelines and research, introduces essential knowledge about COVID-19 and infection in dental settings.

Implementation of an infant male circumcision programme, Pakistan.

OBJECTIVE: To retrospectively review outcomes of a health provider-led infant circumcision programme in Pakistan. METHODS: Based on World Health Organization guidelines, we trained surgical technicians and midwives to perform circumcisions using the Plastibell device at two Indus Health Network facilities. Programme tools include a training manual for health providers, information brochures for families, an enrolment form and standardized forms for documenting details of the procedure and outcomes. Infants aged 1-92 days were eligible for the study. Health workers contacted families on days 1 and 7 after the procedure to record any adverse events. We compared the characteristics of infants experiencing adverse events with infants facing no complications using multivariate logistic regression. FINDINGS: Between August 2016 and August 2018, 2822 circumcised male infants with mean age 22.8 days were eligible for the study. Of these, 2617 infants (92.7%) were followed up by telephone interviews of caretakers. Older infants were more likely to experience adverse events than infants circumcised between 1-30 days of age: 31-60 days: adjusted odds ratio, aOR: 2.03; 95% confidence interval, CI: 1.31-3.15; 61-92 days: aOR: 2.14; 95% CI: 1.13-4.05. Minor adverse events (100 infants; 3.8%) included failure of the bell to shed (90 infants) and minimal bleeding (10 infants). Major adverse events (eight infants; 0.3%) included bleeding that required intervention (four infants), infection (three infants) and skin tear (one infant). CONCLUSION: Standardized training protocols and close monitoring enabled nonphysician health providers to perform safe circumcisions on infants aged three months or younger.

Factors associated with patient visits to the emergency department for asthma therapy in Pakistan.

BACKGROUND: Acute asthma is a chronic condition affecting people of all ages around the world and hence, is one of the leading causes of emergency department (ED) visits and hospital admissions globally. Most of them are related to poor patient practices and a weak healthcare system. The aim of our study was to assess the reasons for the increased usage of the ED by asthmatic patients in Pakistan. METHODS: A cross-sectional study was conducted on 600 asthmatic patients reporting to the ED of Civil Hospital Karachi over a 6-month period. The consenting patients were given a questionnaire to fill and the following data was collected: demographic information, duration of the disease, medications prescribed the, frequency of and reasons for outpatient clinic and ED visits for issues related to asthma. RESULT: According to our results most of the participants visited the ED to obtain a nebulized bronchodilator (90 %) or oxygen (79.5 %). Moreover, 44.8 % of the people visited the ED to get treatment without any delay and 24.0 % considered that the severity of asthma does not allow the patient to wait for clinic visits. Strikingly, 92.8 % claimed that inhaled corticosteroid therapy treatment should be stopped when patients feel better. Irregular follow ups with clinics, low education about asthma and an education level higher than a Bachelors degree were the most important factors associated with three or more ED visits per year, p values = 0.0289, 0.0110 and 0.0150 respectively. CONCLUSION: This study identifies several preventable risk factors responsible for recurrent visits to the ED by asthmatic patients in Pakistan.