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Abstract Background This study compares the visual and anatomical outcomes for the eyes of patients who developed sequential neovascular age-related macular degeneration (nAMD), both at the time of diagnosis and at one year after treatment. Methods The study comprised a retrospective case series of 52 patients whose eyes were diagnosed sequentially with nAMD. All eyes were treated with three monthly loading doses of anti-vascular endothelial growth factor agents, followed by further intravitreal injections, as required. Baseline characteristics and outcomes at one year after diagnosis and initial treatment were compared between first and second eyes and included visual acuity (VA), central macular thickness (CMT), and pigment epithelial detachment (PED) height on optical coherence tomography (OCT) imaging. Results VA at diagnosis was better for second eyes compared with first eyes to develop nAMD (logMAR 0.68 ± 0.51 versus logMAR 0.41 ± 0.34, P = 0.002) and remained so at one year (logMAR 0.61 ± 0.60 versus logMAR 0.42 ± 0.37, P = 0.041). Similarly, PED height at diagnosis was higher in first eyes (225 ± 176 μm versus 155 ± 144 μm, P = 0.003) and also at one year (188 ± 137 μm versus 140 ± 112 μm, P = 0.019). Whereas most patients reported symptoms at first eye diagnosis (71.2%), half as many second eyes were symptomatic (28.8%, P

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This study investigated whether the interval of monitoring at-risk, fellow eyes of patients with unilateral neovascular age-related macular degeneration (nAMD) has any bearing on the severity of the disease at the time of diagnosis. The study comprised a retrospective, cross-sectional comparative case series of treatment-naïve eyes in patients who were diagnosed sequentially with nAMD. We compared the visual acuity (VA) and central macular thickness (CMT) of patients who were actively receiving intravitreal injections (IVIs) of anti-vascular endothelial growth factor (anti-VEGF) agents at the time of second eye diagnosis with the VA and CMT of patients who had ceased treatment in their first eye because of reaching end-stages of disease. Intervals of visits and frequency of monitoring the macula of fellow eyes by means of optical coherence tomography (OCT) were abstracted from the medical record. We found that the at-risk fellow eyes of patients who had stopped treatment for nAMD in their first eye prior to fellow eye conversion were monitored significantly less frequently than the fellow eyes of patients who continued to receive treatment at the time of second eye diagnosis. Despite less frequent monitoring, VA and CMT were similar at the time of fellow eye diagnosis for both groups.

Background: Standalone thoracoscopic surgical ablation may be more effective than catheter ablation in patients with long-standing persistent atrial fibrillation. Objectives: To determine whether or not surgical ablation is clinically superior to catheter ablation as the first-line treatment strategy in long-standing persistent atrial fibrillation. Design: This was a prospective, multicentre, randomised control trial. Setting: Four NHS tertiary centres in England. Participants: Adults with long-standing persistent atrial fibrillation, who had European Heart Rhythm Association symptom scores > 2 and who were naive to previous catheter ablation or thoracic/cardiac surgery. Interventions: Minimally invasive thoracoscopic surgical ablation and conventional catheter ablation (control intervention). Main outcome measures: The primary outcome was freedom from atrial fibrillation/tachycardia ≥ 30 seconds after a single procedure without antiarrhythmic drugs (class 1C/3) at 1 year, excluding a 3-month blanking period. The secondary outcomes include the intervention-related major complication rate; clinical success (≥ 75% reduction in arrhythmia burden); and changes in symptoms, quality of life and cost-effectiveness. Methods: Patients (n = 120) were randomised to surgical ablation (n = 60) or catheter ablation (n = 60). An implanted loop recorder provided continuous cardiac monitoring following ablation. Follow-up visits were at 3, 6, 9 and 12 months. Loop recorder data were reviewed monthly by a physiologist who was blinded to the randomisation outcome. Results: The study treatment was received by 55 patients in the surgical ablation arm and 60 patients in the catheter ablation arm; five patients withdrew from surgical ablation before treatment. Data from randomised and treated patients were analysed as per intention to treat. Patients had a mean age of 62.3 (standard deviation 9.6) years, were predominantly male (74%), had a mean left atrial diameter of 44.6 mm (standard deviation 6 mm) and were in continuous atrial fibrillation for 22 months (range 16–31 months). At 12 months, 26% of patients in the surgical ablation arm (14/54) and 28% of patients in the catheter ablation arm (17/60) were free from atrial arrhythmias after a single procedure without antiarrhythmic drugs (odds ratio 1.13, 95% confidence interval 0.46 to 2.83; p = 0.84). An arrhythmia burden reduction of ≥ 75% was seen in 36 out of 54 (67%) patients in the surgical ablation arm, compared with 46 out of 60 (77%) patients in the catheter ablation arm (odds ratio 1.64, 95% confidence interval 0.67 to 4.08; p = 0.3). Procedure-related serious complications within 30 days of the intervention occurred in 15% (8/55) of patients in the surgical ablation arm (including one death) compared with 10% (6/60) of patients in the catheter ablation arm (p = 0.46). Surgical ablation was associated with significantly higher costs (£23,221 vs. £18,186; p = 0.02) and fewer quality-adjusted life-years than catheter ablation (0.76 vs. 0.83; p = 0.02). Limitations: This study was conducted in four highly specialised cardiology centres that have substantial experience in both treatment modalities; therefore, the results may not be widely generalisable. The study was not powered to detect small differences in efficacy. Conclusions: We found no evidence to suggest that standalone thoracoscopic surgical ablation outcomes were superior to catheter ablation outcomes in achieving freedom from atrial arrhythmia after a single procedure without antiarrhythmic drugs. Moreover, surgical ablation is associated with a longer hospital stay, smaller improvements in quality of life and higher health-care costs than catheter ablation (standard care therapy). Future work: Evaluation of the impact of ablation treatments on sinus rhythm maintenance and quality of life with extended follow-up to 3 years. Model-based economic analysis to estimate long-term benefits, harms and costs of surgical and catheter ablation compared with antiarrhythmic drug therapy in long-standing persistent atrial fibrillation patients. Trial registration: Current Controlled Trials ISRCTN18250790 and ClinicalTrials.gov NCT02755688. Funding: This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council (MRC) and National Institute for Health Research (NIHR) partnership. This study was supported by the UK Clinical Research Collaboration-registered King’s Clinical Trials Unit at King’s Health Partners, which is part funded by the NIHR Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King’s College London and the NIHR Evaluation, Trials and Studies Coordinating Centre. This will be published in full in Efficacy and Mechanism Evaluation; Vol. 8, No. 18. See the NIHR Journals Library website for further project information.

Empirical evidence is inadequate in Nigeria to understand the link between the coping strategies and academic engagement of part-time student teachers who face challenges that might impede their academic success. This study adopted the quantitative research paradigm to ascertain part-time undergraduate student teachers’ coping strategy and their academic engagement. One hundred and fifty-five (155) undergraduate part-time student teachers of Nnamdi Azikiwe University formed the sample size. Major findings showed that respondents adopted more of problem- focused coping than emotion-focused coping strategies and were academically engaged. Significant mean differences did not occur based on gender and marital status in the dimensions of coping strategies and academic engagement except in extra- curricular engagement but occurred in coping efficacy, emotional support coping and disengagement coping dimensions affective liking for school, extra-curricular engagement and cognitive engagement based on students’ specialty. Significant positive relationships occurred in almost all the dimensions of coping and academic engagement and the predictive powers of the independent variables on the dependent variables were ascertained. Demographic variables did not significantly moderate the relationship between problem-focused coping dimensions and the academic engagement while they did on emotion-focused coping and academic engagement. Conclusions were drawn and recommendations made based on the findings.

Background: Despite a recent decline in the annual incidence of tuberculosis (TB) in the UK, rates remain higher than in most Western European countries. The detection and treatment of latent TB infection (LTBI) is an essential component of the UK TB control programme. Objectives: To assess the prognostic value and cost-effectiveness of the current two interferon gamma release assays (IGRAs) compared with the standard tuberculin skin test (TST) for predicting active TB among untreated individuals at increased risk of TB: (1) contacts of active TB cases and (2) new entrants to the UK from high-TB-burden countries. Design: A prospective cohort study and economic analysis. Participants and setting: Participants were recruited in TB clinics, general practices and community settings. Contacts of active TB cases and migrants who were born in high-TB-burden countries arriving in the UK were eligible to take part if they were aged ≥ 16 years. Main outcome measures: Outcomes include incidence rate ratios comparing the incidence of active TB in those participants with a positive test result and those with a negative test result for each assay, and combination of tests and the cost per quality-adjusted life-year (QALY) for each screening strategy. Results: A total of 10,045 participants were recruited between May 2010 and July 2015. Among 9610 evaluable participants, 97 (1.0%) developed active TB. For the primary analysis, all test data were available for 6380 participants, with 77 participants developing active TB. A positive result for TSTa (positive if induration is ≥ 5 mm) was a significantly poorer predictor of progression to active TB than a positive result for any of the other tests. Compared with TSTb [positive if induration is ≥ 6 mm without prior bacillus Calmette–Guérin (BCG) alone, T-SPOT®.TB (Oxford Immunotec Ltd, Oxford, UK), TSTa + T-SPOT.TB, TSTa + IGRA and the three combination strategies including TSTb were significantly superior predictors of progression. Compared with the T-SPOT.TB test alone, TSTa + T-SPOT.TB, TSTb + QuantiFERON® TB Gold In-Tube (QFT-GIT; QIAGEN GmbH, Hilden, Germany) and TSTb + IGRA were significantly superior predictors of progression and, compared with QFT-GIT alone, T-SPOT.TB, TSTa + T-SPOT.TB, TSTa + QFT-GIT, TSTa + IGRA, TSTb + T-SPOT.TB, TSTb + QFT-GIT and TSTb + IGRA were significantly superior predictors of progression. When evaluating the negative predictive performance of tests and strategies, negative results for TSTa + QFT-GIT were significantly poorer predictors of non-progression than negative results for TSTa, T-SPOT.TB and TSTa + IGRA. The most cost-effective LTBI testing strategies are the dual-testing strategies. The cost and QALY differences between the LTBI testing strategies were small; in particular, QFT-GIT, TSTb + T-SPOT.TB and TSTb + QFT-GIT had very similar incremental net benefit estimates. Conclusion: This study found modest differences between tests, or combinations of tests, in identifying individuals who would go on to develop active TB. However, a two-step approach that combined TSTb with an IGRA was the most cost-effective testing option. Implications for practice and future research: The two-step TSTb strategy, which stratified the TST by prior BCG vaccination followed by an IGRA, was the most cost-effective approach. The limited ability of current tests to predict who will progress limits the clinical utility of tests. The implications of these results for the NHS England/Public Health England national TB screening programme for migrants should be investigated. Study registration: This study is registered as NCT01162265. Funding: The National Institute for Health Research Health Technology Assessment programme.

Introduction. The Chiari network is an uncommon vestigial structure of the heart that is often clinically insignificant. We present an unusual case of infective endocarditis affecting only the Chiari network in a patient who presented with septic emboli to the lungs and brain. Case summary. A 61-year-old man was admitted with a 2-month history of hemoptysis, pleuritic chest pain, and right upper extremity numbness and weakness. He was found to have multifocal bilateral pulmonary opacities and an abscess collection in the brain. Blood cultures grew Streptococcus intermedius and transthoracic echocardiogram (TTE) was normal. Subsequent transesophageal echocardiogram (TEE) revealed an 8.3 × 4.6 mm vegetation arising from the Chiari network, close to the right atrial appendage, without involvement of the tricuspid valve or any of the other valves. There were no atrial or ventricular septal defects. He was treated with appropriate antibiotics with improvement of symptoms. Repeat imaging showed improvement of the lung opacities, but not the brain abscess, warranting transfer to another hospital for neurosurgical intervention. Conclusion. The diagnosis and management of isolated Chiari network endocarditis require a high index of clinical suspicion. A multidisciplinary approach incorporating both medical and surgical approaches where necessary is essential for optimal outcome.

Background: Massive weight loss can often lead to skin redundancy and affect a patient's quality of life. Abdominoplasty has grown in popularity due to its cosmetic and functional effects. There is currently a paucity in the patient-reported outcome measures literature in low-resource areas. As such, this study aimed to apply the BODY-Q measure to evaluate factors impacting abdominoplasty outcomes in Kenya., Methods: Patients undergoing abdominoplasty were asked to complete BODY-Q scales before and after surgery. Patient demographics, medical history, and postoperative care were retrospectively collected from patient records. Inference statistics were used to assess predictors of improvement in postsurgical BODY-Q scores and seroma formation. Student t tests were used to compare means; chi-square tests were used to assess differences between proportions, and R 2 was used to determine the proportion of variance., Results: Thirty-nine patients underwent abdominoplasty, of whom 38 answered both surveys. Mean age and body mass index (BMI) were 38.30 (±6.35) years and 30.80 (±6.35) kg/m 2 , respectively. The difference in pre- and postoperative BODY-Q scores was -73.5, with an effect size of -6.67 and a minimal clinically important difference of -2.00. Positive predictors of BODY-Q score improvement were concurrent liposuction ( P = 0.004), preoperative BMI ( P = 0.001), and patient-rated scar quality ( P = 0.003). Other factors were not significantly predictive., Conclusions: Kenyan patients seem to be highly satisfied with abdominoplasty procedures, which result in significant improvements in quality of life. Factors significantly associated with higher satisfaction include concurrent liposuction, higher preoperative BMI, and postoperative scar quality., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2025 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Sexual issues post-stroke are common and can include difficulties related to arousal, orgasm, and decreased sexual desire, and satisfaction., Aim: To determine the attitudes, practices, and barriers experienced by physiotherapists in addressing sexual issues among stroke survivors., Methods: This cross-sectional survey involved 72 practicing physiotherapists purposively recruited from selected tertiary hospitals in southeast Nigeria. Modified Physiotherapists' Attitudes on sexual issues, Physiotherapists' Performance Questionnaire in dealing with sexual issues, and Barriers to Discussing Sexual Issues Questionnaires were used to collect data that were analyzed using Statistical Package for Social Science (SPSS)., Results: The results showed a significant association ( p  < 0.05) between the attitude and practice of physiotherapists in dealing with sexual issues of stroke survivors. Although most of the physiotherapists expressed confidence in their understanding of the need to address sexual issues of stroke survivors, only a quarter of them often or always assessed the patients' sexual function as well as included therapy for erectile dysfunction in their plan of care for stroke survivors. Patients' discomfort (88.9%) and insufficient knowledge and training (70.8%) were the most reported barriers. The majority (95.8%) indicated the need for a training program on the sexual issues, despite their area of specialization., Conclusion: Although the studied physiotherapists understand the need to address these issues, the practical application remains limited due to varying barriers. There is a need for structured training programs focused on sexual health to bridge the gap between knowledge and practice, thereby enhancing the overall care and quality of life for stroke survivors.

Objectives: Analysis of the clinical utility of rapid whole-genome sequencing (rWGS) outside of the neonatal period is lacking. We describe the use of rWGS in PICU and cardiovascular ICU (CICU) patients across four institutions., Design: Ambidirectional multisite cohort study., Setting: Four tertiary children's hospitals., Patients: Children 0-18 years old in the PICU or CICU who underwent rWGS analysis, from May 2016 to June 2023., Interventions: None., Measurements and Main Results: A total of 133 patients underwent clinical, phenotype-driven rWGS analysis, 36 prospectively. A molecular diagnosis was identified in 79 patients (59%). Median (interquartile range [IQR]) age was 6 months (IQR 1.2 mo-4.6 yr). Median time for return of preliminary results was 3 days (IQR 2-4). In 79 patients with a molecular diagnosis, there was a change in ICU management in 19 patients (24%); and some change in clinical management in 63 patients (80%). Nondiagnosis changed management in 5 of 54 patients (9%). The clinical specialty ordering rWGS did not affect diagnostic rate. Factors associated with greater odds ratio (OR [95% CI]; OR [95% CI]) of diagnosis included dysmorphic features (OR 10.9 [95% CI, 1.8-105]) and congenital heart disease (OR 4.2 [95% CI, 1.3-16.8]). Variables associated with greater odds of changes in management included obtaining a genetic diagnosis (OR 16.6 [95% CI, 5.5-62]) and a shorter time to genetic result (OR 0.8 [95% CI, 0.76-0.9]). Surveys of pediatric intensivists indicated that rWGS-enhanced clinical prognostication ( p < 0.0001) and contributed to a decision to consult palliative care ( p < 0.02)., Conclusions: In this 2016-2023 multiple-PICU/CICU cohort, we have shown that timely genetic diagnosis is feasible across institutions. Application of rWGS had a 59% (95% CI, 51-67%) rate of diagnostic yield and was associated with changes in critical care management and long-term patient management., Competing Interests: Drs. Rodriguez and Coufal’s institution received funding from the National Institutes of Health (NIH). Drs. Rodriguez, Kingsmore (grants U19HD077693, UL1TR002550, and 1UM1TR004407), and Coufal received support for article research from the NIH. Dr. Kingsmore received funding from Ultragenyx, Amgen, Horizon, Sanofi, Takeda, Alexion, Sarepta, Ionis, Inozyme, Travere, and Orchard. Dr. Coufal received funding from Rady Children’s Hospital. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background/objective: Immunization information systems (IIS) consolidate provider-submitted immunization information. We reassessed independently owned community pharmacies' IIS enrollment, verification of immunizations needs via IIS records retrieval, and immunization records reporting to IISs following post-pandemic shifts in community pharmacy operations., Methods: A cross-sectional online survey of National Community Pharmacists Association pharmacist, pharmacy owner, and pharmacy technician members was conducted in Fall 2022., Results: 202 complete responses were analyzed. Margin of error was an estimated 7 %. Respondents were: 53.2 % female, ∼87 % White, 69.8 % managers, and 86.1 % practicing in standalone community pharmacies. Almost all (91.6 %) were enrolled in IIS. About two-thirds frequently or always utilized IIS to retrieve immunization records prior to immunization. On average, 81.2 % of influenza and 83.5 % of non-COVID/non-influenza vaccination records were submitted., Conclusions: Enrollment rates are high among studied pharmacies, as are records reporting rates. However, records retrieval rates are suboptimal. Future work should focus on addressing suboptimal retrieval rates within immunization-providing pharmacies., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Background: Gender variation is a feature of many physiological parameters including inflammatory cytokines. Inflammation is an obvious feature of Tuberculosis (TB) infection with changes in pro and anti-inflammatory cytokines., Objective: To compare the levels of inflammatory cytokines between male and female TB patients before treatment, after 2-months and after 6-months anti-tuberculosis treatment., Materials and Methods: A total of 35 males and 25 females TB subjects were enlisted before initiation of therapy and followed up after 2-months and 6 months treatment and samples collected and analysed. Tumour necrosis factor-alpha (TNF-α), Interleukin 10 (IL-10, Interleukin -6 (IL-6), Interleukin-2 (IL-2), transforming growth factor-beta (TGF-β) were assayed by ELISA method., Results: Before treatment, the median level of IL-6 (pg/ml) was significantly higher in males compared to female TB patients (P=0.046). While after 2-months treatment, TNF-α (pg/ml) and IL-10 (pg/ml) was significantly higher in males compared with females (P=0.008 and 0.045 respectively). Conversely, the median IL-6 (pg/ml) was significantly higher in female TB patients compared to the males (P=0.042). No significant differences were observed after 6-months treatment., Conclusion: Gender differences exist in IL-6 before treatment and in IL-6, TNF-α and IL-10 at two months treatment. Thus, TB treatment contributes differentially to levels of inflammatory cytokines in male and female TB patients., (© 2023 Okeke C et al.)

Introduction: coping strategies are specific efforts that individuals use to tolerate or minimize stressful events. Most caregivers´ of children with disabilities must adjust to their social life to cope with the responsibility of caring for a child with disabilities. This study was carried out to assess caregivers´ coping strategies in raising a child with a disability in a resource-poor country., Methods: a researcher-administered questionnaire adapted from the standard COPE (Committee on Publication Ethics) inventory was used on consenting respondents recruited from a designated special education school. Coping responses were graded on a five-point Likert scale and data were analyzed using computer software SPSS version 22., Results: the mean age of the respondents was 42.75 years. Males constituted 30% (12/40) whereas females constituted 70% (28/40). The diagnosed disorders amongst their children/wards were speech and hearing impairment (32.5%), cerebral palsy (12.5%), learning disability (10%), autism (10%), Down's syndrome (15%), epilepsy (20%). Most caregivers exhibited active coping (MNR 3-4) especially in areas of planning and seeking professional help. Turning to religion and acceptance of the situation (MNR 4-5) were common emotional coping strategies noted but most of these had no significant relationship with gender or income. Caregivers with lower earnings tend to pay more attention to the child´s disability than concentrating on other activities., Conclusion: the findings support that religious belief provides endurance and resistance to people dealing with stress while low socioeconomic status negatively affects the ability to focus on other activities during stress., Competing Interests: The authors declare no competing interests., (Copyright: Chinonyelum Thecla Ezeonu et al.)

Precision medicine is essential for the modern care of a patient with cancer. Comprehensive molecular profiling of the tumor itself is necessary to determine the presence or absence of certain targetable abnormalities or biomarkers. In particular, lung cancer is a disease for which targetable genomic alterations will soon guide therapy in the majority of cases. In this comprehensive review of solid tumor-based biomarkers, we describe the genomic alterations for which targeted agents have been approved by the United States Food and Drug Administration (FDA). While focusing on alterations leading to approvals in a tumor-agnostic fashion (MSI-h, TMB-h, NTRK ) and on those alterations with approvals in multiple malignancies ( BRAF , ERBB2 , RET , BRCA , PD-L1), we also describe several biomarkers or indications that are likely to lead to an approved drug in the near future (e.g., KRAS G12C, PD-L1 amplification, HER2 overexpression in colon cancer, HER2 mutations in lung cancer). Finally, we detail the current landscape of additional actionable alterations ( EGFR , ALK , ROS1 , MET ) in lung cancer, a biomarker-rich malignancy that has greatly benefitted from the precision oncology revolution.

Background: Acute gastroenteritis is a common infectious disease with a high rate of morbidity and mortality in children below five years of age. Appropriate empirical treatment is therefore vital for reducing the incidence of the disease., Objective: This study aimed at determining the trends in the empirical treatment of hospitalized children with acute gastroenteritis., Methods: The study involved the data analysis of 88 medical folders of children who were diagnosed with gastroenteritis from January to February 2020 (a period of gastroenteritis yearly outbreak) in Mile 4 Hospital Abakaliki, Ebonyi State, Nigeria. Socio-demographic data and administered antibiotics data were collected., Results: Out of the 88 children, a total of 54 (61%) children were males, while 34 (39%) were females. The ages of the children ranged between 1-51 months, while the mean age was seen at 14 months. About 58 (66%) were diagnosed with acute gastroenteritis alone, with children aged 7-12 months recording higher numbers [25 (28%)]. Severe dehydration was seen as the most common morbidity of children with acute gastroenteritis. The guardians/parents of these children stayed at home for an average of 3 days (1-6 days) before visiting the hospital. The children were treated for an average of 5 days (2-9 days) in the hospital. The most singly used antibiotics was ciprofloxacin [31 (35%)] followed by a combination of ciprofloxacin and ceftriaxone [21 (24%)]. About 12 (14%) of the children were treated using a single dose of the antimalarial drug while 10 (11%) were treated in double combination therapy. The lowest duration in hospitalization (4 days) was seen in the use of a single dose regimen, while the highest hospitalization time (6 days) was seen in the use of a triple dose regimen., Conclusion: The best empirical treatment of acute gastroenteritis may involve the use of ciprofloxacin alone and its combination with ceftriaxone. The severity of gastroenteritis may also be exacerbated with malaria., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Aims: Long-standing persistent atrial fibrillation (LSPAF) is challenging to treat with suboptimal catheter ablation (CA) outcomes. Thoracoscopic surgical ablation (SA) has shown promising efficacy in atrial fibrillation (AF). This multicentre randomized controlled trial tested whether SA was superior to CA as the first interventional strategy in de novo LSPAF., Methods and Results: We randomized 120 LSPAF patients to SA or CA. All patients underwent predetermined lesion sets and implantable loop recorder insertion. Primary outcome was single procedure freedom from AF/atrial tachycardia (AT) ≥30 s without anti-arrhythmic drugs at 12 months. Secondary outcomes included clinical success (≥75% reduction in AF/AT burden); procedure-related serious adverse events; changes in patients' symptoms and quality-of-life scores; and cost-effectiveness. At 12 months, freedom from AF/AT was recorded in 26% (14/54) of patients in SA vs. 28% (17/60) in the CA group [OR 1.128, 95% CI (0.46-2.83), P = 0.83]. Reduction in AF/AT burden ≥75% was recorded in 67% (36/54) vs. 77% (46/60) [OR 1.13, 95% CI (0.67-4.08), P = 0.3] in SA and CA groups, respectively. Procedure-related serious adverse events within 30 days of intervention were reported in 15% (8/55) of patients in SA vs. 10% (6/60) in CA, P = 0.46. One death was reported after SA. Improvements in AF symptoms were greater following CA. Over 12 months, SA was more expensive and provided fewer quality-adjusted life-years (QALYs) compared with CA (0.78 vs. 0.85, P = 0.02)., Conclusion: Single procedure thoracoscopic SA is not superior to CA in treating LSPAF. Catheter ablation provided greater improvements in symptoms and accrued significantly more QALYs during follow-up than SA., Clinical Trial Registration: ISRCTN18250790 and ClinicalTrials.gov: NCT02755688., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Clinical and cost-effectiveness evidence on fulvestrant for untreated hormone-receptor positive locally advanced or metastatic breast cancer was submitted to the single technology appraisal process of the National Institute for Health and Care Excellence by the manufacturer of fulvestrant. The Southampton Health Technology Assessments Centre was commissioned by the National Institute for Health and Care Excellence as an independent Evidence Review Group to critique the company's submitted evidence. Fulvestrant was compared directly with anastrozole in two randomised controlled trials and was compared indirectly by means of a network meta-analysis with anastrozole, letrozole and tamoxifen. This article summarises the Evidence Review Group's review of the company's submission and summarises the guidance the National Institute for Health and Care Excellence Appraisal Committee issued in January 2018. The Evidence Review Group had several concerns, the most important of which related to the degree to which fulvestrant might confer a benefit in overall survival. This was because mature data were not available from the key phase III trial FALCON. The economic model was sensitive to changes in overall survival and the Evidence Review Group considered the incremental cost-effectiveness ratio was uncertain and likely to increase once mature results from FALCON become available. The National Institute for Health and Care Excellence Appraisal Committee concluded that fulvestrant could not be recommended for treating locally advanced or metastatic estrogen-receptor-positive breast cancer in postmenopausal women who have not received previous endocrine therapy.

Background: We report a case of heparin-induced thrombocytopenia (HIT) that was complicated by acute intracerebral hemorrhage (ICH) and bilateral adrenal hemorrhage. In the setting of worsening thrombocytopenia, the risk of expansion of ICH and additional thrombotic events is concerning; hence, we employed plasmapheresis to reduce thrombotic risk., Methods: We followed serial daily heparin antibody enzyme-linked immunosorbent assay (ELISA) optical density measurements as well as heparin-induced platelet aggregation (HIPA) assays on both pre- and post-pheresis samples in order to objectively determine when thrombotic risk was sufficiently decreased., Results: After four cycles of plasmapheresis, both heparin antibody ELISA and HIPA assays became negative., Conclusion: This case helps illustrate the utility of plasmapheresis in management of HIT when anticoagulation is contraindicated.