Effectiveness of a Recertification Vision Screening Training Module for Preschool Teachers

Background

Certified training must be provided for lay vision screeners prior to their conduct of a vision screening programme. However, the effectiveness of trained lay screeners does deteriorate over time. This study aims to evaluate the effectiveness of a recertification vision screening training module using the KieVision™ Preschool Vision Screening Kit for preschool teachers in Malaysia.

Methods

This was a randomised control trial. Fifty-nine preschool teachers previously enrolled in a Knowledge Transfer Programme were divided into a Study Group (n = 31) to receive recertification training and a Control Group (n = 28) to attend briefing sessions. Subjects was then asked to perform vision screening on 15 preschool children aged 4 years old-6 years old at their respective premises, then verified by optometrists after 2 weeks from the initial screening on the same children.

Results

A total of 894 children were screened, with the Study Group and Control Group screened 49.7% and 50.3%, respectively. There was higher validity in vision screening findings from the Study Group (sensitivity = 66.7%, positive predictive value (PPV) = 61.5%) compared to the Control Group (sensitivity = 36.0 %, PPV = 40.9%).

Conclusion

Teachers who received recertification training were more competent in detecting children's vision impairment using KieVision™ Preschool Vision Screening Kit. Thus, timely recertification training should be emphasised to ensure sustainable consistency and reliability of vision screening programmes conducted by lay vision screeners.

Sustainability of the effect of optical intervention on the reading performance of children with dyslexia

Background

Dyslexia is a learning disability associated with reading difficulties in children. Due to the potential of poor school outcomes interventions have been employed to help students with dyslexia read. This study was aimed at identifying the sustainability of the effect of combined Visual Tracking Magnifier (VTM) and Ministry of Education (MOE) interventions and MOE intervention alone on the reading performance of school children with dyslexia after discontinuation of intervention.

Methods

This prospective, interventional study was conducted on primary school children with dyslexia aged 8 - 11 years. The participants underwent comprehensive ophthalmic and optometric examinations and were categorized into groups A, B, and C, comprising primary school children at level 1 or 2. Groups A and B received combined VTM and MOE interventions for 12 and 24 weeks, respectively, and group C received MOE intervention alone. The reading performance was assessed at baseline and 12, 24, and 36 weeks post-intervention.

Results

Both components of the reading performance improved significantly for school children at both levels in all study groups (all P < 0.05). However, the reading performance improvement was only approximately 28% in group C and 38% - 50% in groups A and B. In group A, students at level 1 showed significantly improved reading speed from baseline to 12 weeks post-VTM intervention and reading rate from baseline to 24 weeks post-VTM intervention (both P < 0.05). Students at level 2 showed significantly improved reading speed and rate from baseline to 12 and 24 weeks post-VTM intervention (all P < 0.05). In group B, students at both levels showed significantly improved reading speed and rate from baseline to 24 and 36 weeks post-VTM intervention (all P < 0.05). Students at level 2 showed significantly improved reading speed 12 weeks after cessation of intervention (at 36 weeks post-VTM intervention) compared to 24 weeks post-VTM intervention (P < 0.05). The improvement remaining stable 12 weeks after discontinuation of intervention indicated a sustained effect.

Conclusions

Combined or individual intervention improved the reading performance of school children with dyslexia at levels 1 and 2. However, combined intervention showed a better reading improvement effect. Improvement in the reading performance was maintained after discontinuation of the VTM intervention. Further interventional studies with a longer study period after discontinuation of this optical intervention are required to confirm the long-term sustainability of its positive effects on the reading performance of school children with dyslexia.

O106 Maximising the benefits of bariatric surgery through targeting ghrelin: a randomised, double-blind, placebo-controlled crossover study in people with suboptimal weight loss after bariatric surgery

Introduction

One in 5 people have a suboptimal weight-loss (WL) response to bariatric surgery. The causes are unclear, but patients report resumed hunger and increased food intake, eating behaviours driven by the orexigenic hormone, ghrelin. This proof-of-concept study aimed to evaluate the impact of reducing circulating acyl-ghrelin, the biologically active isoform, on appetite and energy intake in people with suboptimal WL and aberrant ghrelin profile after bariatric surgery.

Methods

Thirty-five patients with &lt;20%WL from 12 months after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) and aberrant circulating ghrelin profile underwent 10 days of treatment with a novel, highly-selective ghrelin o-acyltransferase inhibitor, GLWL-01, and placebo. The primary endpoint was within-person change in ad libitum energy intake during a test meal on day 10. Secondary endpoints assessed subjective appetite, food cravings, macronutrient intake, gut hormones, cardiometabolic profile and body composition. Ethical approval was obtained.

Results

Thirty-one participants (26 RYGB, 9 SG) completed both cycles. GLWL-01 produced a 58.9±27.2% decrease in fasting plasma acyl-ghrelin and 29.3±27.1% increase in desacyl-ghrelin after 10 days. Marked reduction in subjective hunger, food cravings and hedonic influence on appetite was observed with GLWL-01, however objective appetite measures – ad libitum and free-living energy intake – did not change. Circulating levels of cardiovascular risk-conferring lipoproteins significantly improved and no adverse impact on glycaemic control was observed.

Conclusion

Pharmacological modulation of the ghrelin system may be used as part of a personalised therapeutic approach to optimise clinical outcomes in patients with suboptimal WL after bariatric surgery.

Take-home message

This first-in-human mechanistic study shows that pharmacological modulation of the ghrelin system is a promising therapeutic strategy for maximising weight loss response to bariatric surgery.

Validity of vision screening program conducted by preschool teachers: An interventional study

Background

Clear vision is crucial for effective learning among preschool children. Hence, early detection of vision impairment and prompt treatment are required to improve prognosis. Currently, limited information is available, and no program exists to screen for vision impairment among preschoolers in Bangladesh. This study aimed to validate the KieVision™ Preschool Vision Screening Kit, translated into the Bengali language, to improve vision impairment detection among preschool children.

Methods

In this prospective case-control study, 60 preschool teachers from Chittagong were randomly selected. The study group was trained to conduct vision screening among preschool children using the translated kit, whereas the control group was trained using the Chittagong Eye Infirmary and Training Complex (CEITC) School Teachers' Training Module. Fifteen preschool children aged 4-6 years were screened by each preschool teacher and again by the optometrist.

Results

Sixty preschool teachers screened 900 children. The results showed a higher validity of vision screening findings by the preschool teachers in the study group (sensitivity, 68.00%; specificity, 92.75%) than in the control group (sensitivity 47.37%, specificity 70.39%). The level of agreement between the preschool teachers and optometrists was high for all tests (first-order agreement coefficient [AC1] ≥ 0.80 in the study group). The sensitivity and specificity of the visual acuity test for the study group were 59.65% and 94.15%, respectively, while in the control group it was 13.33% and 62.54%, respectively. A similar trend was noted in the general observation component and Hirschberg's test.

Conclusions

The Bengali Language KieVision™ Preschool Vision Screening Kit can be used effectively by preschool teachers in vision screening programs to improve the identification of vision impairment among preschool children in Bangladesh.

Distribution of refractive error among chinese primary school children in a rural area in Pahang, Malaysia

PURPOSE

This study aimed to determine the prevalence and status of refractive error among Chinese primary school children in a rural area in Pahang.

METHODS

This investigation entailed a cross-sectional retrospective study design involving case file analyses. The study site was a Chinese medium primary school in a rural locality within Bentong district. A total of 82 school children met the B40 classification and selection criteria; therefore, universal sampling was done. Analyses were done according to age group: Level 1 included ages 7 to 9 years, while Level 2 comprised 10- to 12-year-olds.

RESULTS

The mean age of the 82 Chinese school children was 9.72±1.5 years; the percentage of refractive errors found was 80.48%. A total of 53 (64.63%) children had myopia. Two-way ANOVA showed a significant difference (P=0.038) in the refractive error between age groups Level 1 and 2, but no significant difference (P=0.947) was observed in refractive error between genders. The chi-square test and Fishers exact test showed no significant association between the type of refractive error with gender (P>0.05) and age group (P=0.319).

CONCLUSION

Myopia was the most common type of refractive error among Chinese school children in a rural area in Pahang. Refractive error severity was influenced by age group but not by gender. Types of refractive error were not associated with age group and gender. Hence, it is recommended that Chinese school children in rural areas seek an annual vision screening or eye test.

A situational analysis of clinical refraction services in the capital city of the Maldives

Background

Uncorrected refractive error is a leading cause of visual impairment globally. This study aimed to determine the current state of clinical refraction services and barriers to service provision in the capital city of the Maldives.

Methods

This cross-sectional, descriptive-analytical study used a purposive sampling technique. The list of facilities providing refraction services in the city of Malé was compiled through a desk review and finalized after verification by personnel from the Ministry of Health. The availability of human resources and infrastructure was measured using a pre-coded questionnaire that also listed barriers to service provision, followed by on-site observations and subsequent data analysis.

Results

Three clinical ophthalmology departments within hospitals, two ophthalmology hospitals, and nine primary eye care centers were selected for this study. The private sector (n = 12, 85.7%) was the primary provider of refractive error services. All facilities possessed the essential equipment required for refraction. Only optometrists and ophthalmologists conducted refraction. Contact lens assessment and low vision services were not available at any facility. The number of refractions conducted in Malé annually was 145,392. Human resources and management-related factors were the major barriers to the provision of clinical refraction services (n = 21, 44.7%).

Conclusions

Accessibility to refractive error management and low vision services is needed in Malé to meet current population needs. Existing resources, including humans and equipment, require augmentation regarding service provision and enhancement. Knowledge of these barriers could lead to the upscaling of refraction services in Malé, Maldives by health policy makers.

The Relationship Between Choroidal and Photoreceptor Layer Thickness With Visual Acuity in Highly Myopic Eyes

Purpose

The aim of this study was to evaluate the choroidal and photoreceptor thickness in highly myopic eyes and its correlation with visual acuity.

Methods

This is a cross-sectional, observational study involving 57 eyes of 57 highly myopic subjects [spherical equivalent ≥ –6 diopters (D) or axial length ≥ 26 mm] seen in a tertiary institutional center. Eyes with any clinical evidence of maculopathy or amblyopia were excluded. All subjects underwent a refraction assessment, visual acuity, axial length measurement using the IOL Master, and full ocular assessment. Eyes were imaged using Spectralis Optical Coherence Tomography by one experienced operator. Two independent investigators manually measured subfoveal choroidal thickness (SFCT) and foveal photoreceptor thickness (FPT).

Results

The mean SFCT was 195.88 ± 87.63 μm (range: 32–373) and mean FPT was 96.68 ± 11.23 μm (range: 67–100), after correction for ocular magnification. The best corrected visual acuity (BCVA) in LogMAR was negatively correlated with SFCT (r = –0.510, p = 0.001) and FPT (r = –0.397, p = 0.002) and positively correlated with age (r = 0.418, p = 0.001) and axial length (r = 0.551, p = 0.001). Multiple linear regression analysis showed that age, axial length, and corrected FPT were significant risk factors for poorer BCVA (p = 0.021, &lt; 0.001, and 0.02, respectively).

Conclusion

FPT, age, and axial length are significant moderate predictive factors for poorer visual acuity in highly myopic eyes without myopic maculopathy. Thinner SFCT does not translate into poorer vision.

Characteristics of eye injuries, medical cost and return-to-work status among industrial workers: a retrospective study

OBJECTIVE

The aim of this study is to determine the characteristics of eye injuries, medical costs and return-to-work status among industrial workers to provide better vision rehabilitative services.

SETTING

Nationwide data from the Social Security Organisation (SOCSO) of Malaysia.

PARTICIPANTS

A stratified random sample of workers registered with the SOCSO of Malaysia with documentation of eye injury.

PRIMARY AND SECONDARY OUTCOME MEASURES

Characteristics of eye injuries and medical costs related to eye injury (primary) and return-to-work status (secondary).

RESULTS

A total of 884 from 8861 case files workplace accidents involving eye injury registered with Social Security Services (SOCSO) were identified. The mean age was 35±10 years and the highest incidence of work-related eye injury occurred in the age group 30-39 years and among Malay ethnics. Males are affected more than females' workers. The highest cause of eye injury was the impact from a moving object excluding falling objects (89.2%) and anterior segment injuries occurred more than posterior segment injuries. The total direct and Indirect medical cost was RM1 108 098.00 (US$316 599.40) and RM4 150 140.00 (US$1 185 754.20) for 884 cases.

CONCLUSION

The majority of workers suffered from the low level of eye injury. A significant relationship was found between the severity of eye injury and employee work status. The indirect cost of medical and vision rehabilitation was higher than the direct cost. Awareness and vision rehabilitation programmes at the workplace need to be addressed for better prevention and rehabilitative service.

Refractive amblyopia among children aged 4-12 years in a hospital-based setting in Gaza Strip, Palestine

Background

Refractive amblyopia is the most common cause of amblyopia in the Gaza Strip. However, the pattern of this condition has not yet been studied in this region. This study aimed to determine the pattern of refractive amblyopia in Gazan children aged 4‒12 years.

Methods

This was a hospital-based cross-sectional study using a purposive sampling method. Children aged 4‒12 years who attended the Children's Unit at Gaza Ophthalmic Hospital, Gaza Strip, Palestine from September 2019 to July 2020, were examined. A comprehensive eye test was conducted for all participants. Those who failed the eye examinations and were diagnosed with refractive amblyopia were included in the study. Demographic data and amblyopic refractive error patterns were analyzed accordingly.

Results

Of the 107 children, 72.9% were newly diagnosed with refractive amblyopia. The mean (standard deviation [SD]) of age of the children who participated was 7.85 (1.55) years. Approimately two-thirds of the patients were female (57.9%). Unilateral amblyopia was predominant in 60.7% of the cases. Moderate amblyopia was common (81.9%). A total of 149 amblyopic eyes were examined in total, with a mean (SD) (range) of best-corrected distance visual acuity and spherical equivalent of 0.45 (0.19) (0.2 to 1.3) logarithm of the minimum angle of resolution and + 0.76 (4.51) diopters (- 10.25 to + 11.50). Astigmatism was the most common amblyogenic factor (53.7%) among children with amblyopia.

Conclusions

The frequency of refractive amblyopia was 72.9%, and meridional amblyopia accounted for the highest percentage. Girls were more commonly affected than boys. The majority were in the 7-year-old age group. Most cases were unilateral with moderate refractive amblyopia. Our study yields insights into the patterns of refractive amblyopia among children in the Gaza Strip.

A pilot randomised controlled trial of befriending by volunteers in people with intellectual disability and depressive symptoms

BACKGROUND

People with intellectual disability (ID) are more likely to experience chronic depression compared with the general population, which may be compounded by loneliness and lower levels of social support. Befriending aims to provide social support and promote engagement in community activities. No randomised controlled trials have examined whether befriending improves symptoms of depression and social outcomes in people with ID. The aim of this pilot trial was to assess the feasibility and acceptability of a future larger trial of one-to-one befriending by volunteers in people with ID and depressive symptoms.

METHODS

Participants were adults with mild or moderate ID with a score of 5 or more on the Glasgow Depression Scale for People with Learning Disabilities (GDS-LD). They were randomised to the intervention arm (matched to a volunteer befriender for 6 months) or the control arm (usual care). Volunteers received training and supervision provided by two community befriending schemes. The main outcomes were feasibility of recruitment (minimum target n = 35), retention rate of participants, adherence (minimum 10 meetings), acceptability of the intervention, changes in depressive symptoms (assessed at baseline and 6 months) and feasibility of collecting data for a health economic analysis.

RESULTS

Recruitment was challenging, and only 16 participants with ID and 10 volunteers were recruited. Six participants were matched with a volunteer and no participants dropped out (except for two volunteers). Four participants completed 10 meetings (mean 11.8). Befriending was thought to be acceptable, but modifications were suggested. An exploratory analysis suggested that GDS-LD score was lower in the intervention group compared with the control group after adjusting for baseline scores, but not significant (adjusted mean difference: -4.0; 95% confidence interval: -11.2 to 3.2).

CONCLUSIONS

A large trial would not be feasible based on the recruitment strategies employed in this study. A further feasibility study addressing these challenges or the use of other study designs should be considered.

External validation of the HCM Risk-Kids model for predicting sudden cardiac death in childhood hypertrophic cardiomyopathy

Background

Sudden cardiac death (SCD) is the most common mode of death in childhood hypertrophic cardiomyopathy (HCM). The newly developed HCM Risk-Kids model provides clinicians with individualised estimates of risk. The aim of this study was to externally validate the model in a large independent, multi-centre patient cohort.

Methods

A retrospective, longitudinal cohort of patients diagnosed with HCM aged 1–16 years independent of the HCM-Risk-Kids development and internal validation cohort was studied. Data on HCM Risk-Kids predictor variables (unexplained syncope, non-sustained ventricular tachycardia, maximal left ventricular wall-thickness, left atrial diameter and left ventricular outflow tract gradient) were collected from the time of baseline clinical evaluation. The performance of the HCM Risk-Kids model in predicting risk at 5 years was assessed.

Results

The cohort consisted of 421 patients with a median age at baseline evaluation of 12.3 years (IQR 7.3, 14.4). Over a median total follow up 3.48 years (IQR 1.83, 6.62, range 1 month – 20.7 years). Fourteen patients (3.3%) died and 10 (2.4%) underwent cardiac transplantation. Twenty-three patients (5.4%) met the SCD end-point within 5-years, with an overall incidence rate of 2.03 per 100 patient years (95% CI 1.48–2.78). Model validation showed a Harrell's C-index of 0.745 (95% CI 0.52–0.97) and Uno's C-index 0.714 (95% 0.58–0.85) with a calibration slope of 1.15 (95% 0.51–1.80). Figure 1a describes the agreement between predicted and observed 5-year cumulative proportion of SCD or equivalent events for each tertile of predicted risk in one imputed data set. One hundred and twenty-five (29.7%) patients had a predicted 5-year risk of ≥6%. SCD events occurred in 6 patients (2.0%) with a predicted risk &lt;6% and 17 (13.6%) with a predicted risk ≥6. A 5-year predicted risk threshold of ≥6% identified 17 (73.9%) SCD-events with a corresponding C-statistic of 0.702 (95% CI 0.60–0.81) (Figure 1b).

Conclusions

This study reports the first external validation of the HCM Risk-Kids model in a large and geographically diverse patient population. A 5-year predicted risk of ≥6% identified over 70% of events, confirming that HCM Risk-Kids provides a method for individualised risk predictions and shared decision making in children with HCM. Incorporation of the model into routine clinical care will enable independent prospective model validation and assessment of the effect of its use in clinical practice.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): British Heart FoundationMedical Research Council Observed vs predicted risk by tertilesObserved vs predicted by threshold

Improving management of visually impaired patients from occupational therapy perspective: A case report

The ability to detect and recognise visual deficits among visually impaired patients can improve the management of daily living skills and activities of these patients. In this report, the importance of using objective and subjective visual performance measures by occupational therapists in managing visually impaired patients is discussed. We describe a case of a 17-year-old Malay female who had vision impairment due to a cataract, a secondary complication from diabetes mellitus (DM). The Brain Injury Visual Assessment Battery for Adult (biVABA) can provide occupational therapists with additional visual performance information and a better understanding of managing visually impaired patients. The biVABA was used in conjunction with other activities of daily living skills tools such as Modified Barthel Index (MBI), Lawton Instrumental Activities of Daily Living Scale (IADL) and EVS Orientation and Mobility Screening (EVS-O&M) for a more holistic assessment. This approach provides more relevant and essential information in managing visually impaired patient rehabilitation from the occupational therapy perspective.

Quantification of dark adaptation dynamics in retinitis pigmentosa using non‐linear regression analysis

PURPOSE

Non-linear regression analysis was used to determine dark adaptation indices in people with retinitis pigmentosa and in control subjects.

METHODS

Dark adaptation data were collected for 13 people with retinitis pigmentosa and 21 controls using the Goldmann-Weekers Dark Adaptometer. Data were analysed using an exponential non-linear regression model and dark adaptation indices derived. The results were compared to age-related values.

RESULTS

The mean cone threshold of the group with RP (4.73 +/- 0.19 log units) was significantly greater than that found in the control group (3.69 +/- 0.12 log units). The rate of cone dark adaptation in the RP group was not significantly different from that of the control group. The a break in the RP group (6.46 +/- 0.70 minutes) was delayed when compared to the control group (4.29 +/- 0.21 minutes) and the rate of rod dark adaptation in the RP group was slower (10 +/- 2 per cent per minute) than that of the control group (15 +/- 1 per cent per minute).

CONCLUSIONS

This study has shown that a relatively simple data analysis can provide a more quantitative and intuitive description of dark adaptation rates in people with retinal disease. This technique will enable more effective use of dark adaptometry as a supplement to objective electrophysiology, when monitoring people with retinitis pigmentosa.

The relationship between left ventricular outflow tract gradient and sudden cardiac death in childhood hypertrophic cardiomyopathy

Background

The most common mode of death in childhood hypertrophic cardiomyopathy (HCM) is sudden cardiac death (SCD). Left ventricular outflow tract obstruction (LVOTO) is an established risk factor for SCD in adults with the disease. In contrast, the prognostic implications of LVOTO in childhood disease is unclear, with recent studies suggesting that it may have an inverse relationship with the risk of SCD.

Purpose

The aim of this study was to explore the role of LVOTO and the risk of SCD in childhood HCM.

Methods

A multi-centre, retrospective, longitudinal cohort of 871 children (diagnosed with HCM &lt;16 years of age) was used to explore the relationship between SCD and LVOTO (LVOT gradient ≥30mmHg).

Results

189 patients (23%) had LVOTO, which was mild (30–50mmHg), moderate (50–100mmHg) or severe (&gt;100mmHg) in 58 (6.7%), 98 (11.3%) and 33 (3.8%), respectively. The risk of SCD showed an inverse relation to LVOT gradient severity compared to those with no obstruction: mild HR 1.75 (95% CI 0.89–3.44), moderate HR 1.04 (95% 0.55–1.98), and severe HR 0.7 (0.36–1.35) [figure].On univariable analysis [table] LVOTO was associated with heart failure symptoms (NYHA&gt;1) [p &lt;0.001], maximal wall thickness (MWT) [p &lt;0.001], left atrial (LA) diameter [p &lt;0.001], and future myectomy occurring during follow up [p &lt;0.001]. The inverse relationship observed was not altered by the presence or absence of other traditional risk factors.

Conclusions

LVOTO appears to have a complex relationship with the risk of SCD in childhood HCM, with multiple contributing factors. The pathophysiological mechanisms behind this observation need further exploration, which may be limited by low patient numbers

Cummulative incidence of SCD by LVOTO

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): British Heart Foundation

Status of visual impairment among indigenous (Orang Asli) school children in Malaysia

Background

School children are considered a high-risk group for visual impairment because uncorrected refractive errors and problems such as amblyopia can seriously affect their learning abilities and their physical and mental development. There are many studies reporting the prevalence of refractive errors among school children of different ethnic groups in Malaysia, however, studies concerning the prevalence of refractive errors among indigenous or Orang Asli children are very limited. Therefore, the objective of this study was to determine the prevalence and causes of visual impairment among Orang Asli children.

Methods

One hundred ten Orang Asli children aged 7 to 12 years old in Negeri Sembilan, Malaysia were selected. 51% of these children were boys while the remainders were girls. They underwent visual acuity test, cover test, Hirschberg’s test, ocular external assessment and ophthalmoscopy. Children who failed the vision screening were then referred for further eye examination.

Results

Of these 110 Orang Asli children, 46 failed the vision screening and subsequently 45 of them were confirmed to have visual problems (40.9% of the total subjects). The main cause of visual impairment in this study was refractive error (34.5% of the total subjects) where the main refractive error found was hyperopia (28.2%) followed by amblyopia (2.7%), strabismus (1.8%) and ocular abnormalities (1.8%).

Conclusion

Hence, vision screening and a comprehensive eye examination is very important and needs to be done on all Orang Asli children so that any visual problems can be detect at an early stage to avoid the development of learning difficulties among these already disadvantaged children.

From high to low malaria transmission in Zanzibar-challenges and opportunities to achieve elimination

BACKGROUND

Substantial global progress in the control of malaria in recent years has led to increased commitment to its potential elimination. Whether this is possible in high transmission areas of sub-Saharan Africa remains unclear. Zanzibar represents a unique case study of such attempt, where modern tools and strategies for malaria treatment and vector control have been deployed since 2003.

METHODS

We have studied temporal trends of comprehensive malariometric indices in two districts with over 100,000 inhabitants each. The analyses included triangulation of data from annual community-based cross-sectional surveys, health management information systems, vital registry and entomological sentinel surveys.

RESULTS

The interventions, with sustained high-community uptake, were temporally associated with a major malaria decline, most pronounced between 2004 and 2007 and followed by a sustained state of low transmission. In 2015, the Plasmodium falciparum community prevalence of 0.43% (95% CI 0.23-0.73) by microscopy or rapid diagnostic test represented 96% reduction compared with that in 2003. The P. falciparum and P. malariae prevalence by PCR was 1.8% (95% CI 1.3-2.3), and the annual P. falciparum incidence was estimated to 8 infections including 2.8 clinical episodes per 1000 inhabitants. The total parasite load decreased over 1000-fold (99.9%) between 2003 and 2015. The incidence of symptomatic malaria at health facilities decreased by 94% with a trend towards relatively higher incidence in age groups > 5 years, a more pronounced seasonality and with reported travel history to/from Tanzania mainland as a higher risk factor. All-cause mortality among children < 5 years decreased by 72% between 2002 and 2007 mainly following the introduction of artemisinin-based combination therapies whereas the main reduction in malaria incidence followed upon the vector control interventions from 2006. Human biting rates decreased by 98% with a major shift towards outdoor biting by Anopheles arabiensis.

CONCLUSIONS

Zanzibar provides new evidence of the feasibility of reaching uniquely significant and sustainable malaria reduction (pre-elimination) in a previously high endemic region in sub-Saharan Africa. The data highlight constraints of optimistic prognostic modelling studies. New challenges, mainly with outdoor transmission, a large asymptomatic parasite reservoir and imported infections, require novel tools and reoriented strategies to prevent a rebound effect and achieve elimination.

Visual efficiency among teenaged athletes and non-athletes

AIM

To compare visual efficiency, specifically accom-modation, vergence, and oculomotor functions among athletes and non-athletes.

METHODS

A cross-sectional study on sports vision screening was used to evaluate the visual skills of 214 elementary students (107 athletes, 107 non-athletes), aged between 13 and 16y. The visual screening assessed visual parameters such as ocular motor alignment, accommodation, and vergence functions.

RESULTS

Mean visual parameters were compared between age-group matched athletes (mean age 14.82±0.98y) and non-athletes (mean age 15.00±1.04y). The refractive errors of all participants were corrected to maximal attainable best corrected visual acuity of logMAR 0.0. Accommodation function assessment evaluated amplitude of accommodation and accommodation facility. Vergence functions measured the near point of convergence, vergence facility, and distance fusional vergence at break and recovery point. Ocular motor alignment was not statistically significant between both groups. Athletes had a statistically significant amplitude of accommodation for both the right eye (t=2.30, P=0.02) and the left eye (t=1.99, P=0.05). Conversely, non-athletes had better accommodation facility (t=-2.54, P=0.01) and near point of convergence (t=4.39, P<0.001) when compared to athletes. Vergence facility was found to be better among athletes (t=2.47, P=0.01). Nevertheless, non-athletes were significantly better for both distance negative and positive fusional vergence.

CONCLUSION

Although the findings are still inconclusive as to whether athletes had superior visual skills as compared to non-athletes, it remains important to identify and elucidate the key visual skills needed by athletes in order for them to achieve higher performance in their sports.

Determination of the 99th percentile upper reference limit for high-sensitivity cardiac troponin I in Malaysian population

Introduction of high-sensitivity cardiac troponin I (hscTn I) assays for routine clinical use in Malaysia requires determination of the 99^th percentile upper reference limit (URL) for each assay to suit local context. Hence, this study aimed to determine the 99^th percentile URL for hscTn I in the Malaysian population. A total of 250 (120 males and 130 females) healthy Malaysian blood donors aged 18 to 60 years old were recruited. Blood samples for hscTn I were measured using Abbott Diagnostics hscTn I assay on Architect i2000sr analyser. The 99^th percentile was calculated using a non-parametric method and gender specific results were compared. The 99^th percentile URL for hscTn I for the overall population was 23.7 ng/L, with gender specific values being 29.9 ng/L and 18.6 ng/L for male and female, respectively. Females had significantly lower hscTn I compared to males. This study confirms the use of gender specific 99^th percentile URL for hscTn I for clinical use in a multi-ethnic Malaysian population.

Effectiveness and cost-effectiveness of a cardiovascular risk prediction algorithm for people with severe mental illness

Introduction

Cardiovascular risk prediction tools are important for cardiovascular disease (CVD) prevention, however, which algorithms are appropriate for people with severe mental illness (SMI) is unclear.

Objectives/aims

To determine the cost-effectiveness using the net monetary benefit (NMB) approach of two bespoke SMI-specific risk algorithms compared to standard risk algorithms for primary CVD prevention in those with SMI, from an NHS perspective.

Methods

A microsimulation model was populated with 1000 individuals with SMI from The Health Improvement Network Database, aged 30–74 years without CVD. Four cardiovascular risk algorithms were assessed; (1) general population lipid, (2) general population BMI, (3) SMI-specific lipid and (4) SMI-specific BMI, compared against no algorithm. At baseline, each cardiovascular risk algorithm was applied and those high-risk (> 10%) were assumed to be prescribed statin therapy, others received usual care. Individuals entered the model in a ‘healthy’ free of CVD health state and with each year could retain their current health state, have cardiovascular events (non-fatal/fatal) or die from other causes according to transition probabilities.

Results

The SMI-specific BMI and general population lipid algorithms had the highest NMB of the four algorithms resulting in 12 additional QALYs and a cost saving of approximately £37,000 (US$ 58,000) per 1000 patients with SMI over 10 years.

Conclusions

The general population lipid and SMI-specific BMI algorithms performed equally well. The ease and acceptability of use of a SMI-specific BMI algorithm (blood tests not required) makes it an attractive algorithm to implement in clinical settings.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Low vision rehabilitation and ocular problems among industrial workers in a developing country

AIM

Work-related ocular injuries and illnesses were among the major causes of job absenteeism. This study was conducted to determine if low vision rehabilitation was provided following work-related ocular problems among industrial workers in a developing country. This was a retrospective analysis of case records.

METHOD

Randomly selected records of all employees from the Social Security Organization (SOCSO) Medical Board for 2004 who suffered from ocular injuries and illnesses were selected. Rates of ocular injuries and illnesses according to age, gender, races, types of injuries, types of industries, visual rehabilitation and types of medical interventions were tabulated and analysed.

RESULTS

A total of 26 cases of ocular injuries and illnesses were identified where 46.2% suffered from ocular injuries. The remaining 53.8% had ocular and/or systemic diseases. The 40-49-yearold age group suffered the greatest number of injuries (26.92%). Ocular perforating injuries (66.67%) and ocular contusions (33.33%) were the most common types of ocular injury among industrial workers in Kuala Lumpur. Most injuries occurred among workers in the service industry (50%). Almost 60% of these injured workers did not receive any low vision rehabilitation after medical intervention while 25% were given contact lenses or spectacles as rehabilitation and remaining had surgery.

CONCLUSION

The low vision rehabilitation is still unexplored in the management of ocular injuries and illnesses among industrial workers. Introducing low vision rehabilitation can benefit both workers and employers as it provides care beyond spectacles or contact lens prescriptions.

Mental health state and quality of life questionnaire in low vision assessment: a case report

Background

Vision impairment associated with diabetic retinopathy, is well known and low vision rehabilitation is always recommended. In this report, the importance of objective measure of mental health and quality of life screening in diabetic retinopathy low-vision assessment is discussed.

Case presentation

We describe the case of a 43-year-old Asian female who has mild vision impairment due to tractional retinal detachment secondary to diabetic retinopathy and how mental health screening and quality of life screening during low vision rehabilitation can improve in the management of this patient.

Conclusion

Although vision impairment was mild, the psychological impact was enormous and affected her quality of life substantially. This case report illustrates that recognition of the mental health and quality of life impact on visual impairment is critical to the rehabilitation management of low vision patients with diabetic retinopathy.

Restorative Treatment Decisions for Deep Proximal Carious Lesions in Primary Molars

AIM

To assess clinicians' individual variables that might influence decision-making for the restoration of deep proximal carious lesions in primary molars.

METHODS

A pre-coded questionnaire that sought participants' treatment choices for a deeply carious second mandibular primary molar, as depicted in a simulated periapical radiograph, along with a specific clinical scenario, was distributed among a random sample of 157 dentists and 15 paediatric dentists. Participants were asked to answer questions. After combining the pulpotomy and pulpectomy treatment choices under a 'pulp therapy' category, a binary dependent variable was constructed. Logistic regression of the ratio of the participants who would restore the questioned tooth by a method in question, was run.

RESULTS

A total of 155 dentists (116 males and 39 females) completed the survey, giving a response rate of 90%. Of these 53% of dentists recommended pulpotomy followed by definitive restoration and 39% recommended removal of caries and restoration without pulp therapy. In the logistic regression model, males and graduates of English language undergraduate dental programs had higher probabilities of restoring without prior pulp therapy (p<0.03 and p<0.02, respectively). Compared with graduates of Asian programs, dentists who graduated from Eastern Europe and the Middle East, showed lower likelihoods of restoring the tooth without prior pulp therapy (p<0.01 and p<0.004, respectively). Dentists who treated an average of 6-16 child patients during a week had a lower probability of restoring the tooth without prior pulp therapy than those who were not currently involved in treating children (p<0.01). No other measured variables were associated with participant's treatment choices.

CONCLUSIONS

The lack of agreement among dentists regarding their optimal treatment recommendations for deep proximal carious lesions appears to be due mainly to inter-individual, educational, training and practice characteristic factors.

Management of visual disturbances in albinism: a case report

INTRODUCTION

A number of vision defects have been reported in association with albinism, such as photophobia, nystagmus and astigmatism. In many cases only prescription sunglasses are prescribed. In this report, the effectiveness of low-vision rehabilitation in albinism, which included prescription of multiple visual aids, is discussed.

CASE PRESENTATION

We present the case of a 21-year-old Asian woman with albinism and associated vision defects. Her problems were blurring of distant vision, glare and her dissatisfaction with her current auto-focus spectacle-mounted telescope device, which she reported as being heavy as well as cosmetically unacceptable. We describe how low-vision rehabilitation using multiple visual aids, namely spectacles, special iris-tinted contact lenses with clear pupils, and bi-level telemicroscopic apparatus devices improved her quality of life. Subsequent to rehabilitation our patient is happier and continues to use the visual aids.

CONCLUSIONS

Contact lenses with a special iris tint and clear pupil area are useful aids to reduce the glare experienced by albinos. Bi-level telemicroscopic apparatus telemicroscopes fitted onto our patient's prescription spectacles were cosmetically acceptable and able to improve her distance vision. As a result these low-vision rehabilitation approaches improved the quality of life of our albino patient.

Comparison of Lea Symbols chart and Sheridan Gardiner chart in assessing vision screening among pre-school children: a Malaysia perspective

OBJECTIVE

Compare the performance of Lea Symbols and Sheridan Gardiner charts against the standard test chart used to determine reduced VA during vision screening among pre-schoolers.

MATERIAL AND METHOD

Seven hundred seventy five pre-school participated where 389 subjects were boys and 386 subjects were girls were tested using the Lea Symbols chart and the Sheridan Gardiner chart. The mean age of the pre-school children was 5.3 +/- 0.7 years old.

RESULTS

The Lea Symbols chart showed a higher sensitivity (97.5%) compared to the Sheridan Gardiner chart (57.1%). While the Sheridan Gardiner chart showed higher specificity (92.0%) compared to the Lea Symbols chart (45.0%).

CONCLUSION

The Lea Symbols chart offers a better pick-up rate of visual impairment during a vision-screening program especially cases of amblyopia among pre-school children compared to the Sheridan Gardiner chart in Malaysia.

Awareness, knowledge and practice of evidence-based dentistry amongst dentists in Kuwait

This study assessed the awareness, knowledge and practice of evidence-based dentistry (EBD) amongst dentists working in the public sector in Kuwait. Of the 150 randomly selected dentists from all five health districts in Kuwait who had originally been approached, 120 participated by completing a pre-tested, self-administered questionnaire (80% response rate). Whereas 60.9% of the group stated that they practice EBD most of the time, fewer (40.8%) had a reasonable understanding of EBD based upon tested knowledge scores of EBD-related topics. Clinical decisions appeared to be mostly based on the clinician's own judgment (73.3%) rather than on evidence-based sources such as PubMed (28.3%) or the Cochrane Library (6.7%). A number of within-group differences were noted, with women (P<0.05), those working in a particular district (P<0.05), those with <10years' experience (P=0.05), those whose first dental qualification had been obtained in Kuwait (P<0.05), and those who had had any EBD training (P<0.05) showing greater knowledge of EBD. Training in EBD was felt necessary by a majority of the group, and this may be facilitated if dental centres have access to evidence-based sources to remove some of the possible barriers to implementation of EBD.

Comparison of reading performance between visually impaired and normally sighted students in Malaysia

The aim of this study is to compare reading performance between visually impaired and normally sighted school children. Participants ( n = 299) were divided into three groups: normal vision (NV, n = 193), visually impaired print reader (PR, n = 52), and Braille reader (BR, n = 54). Reading performance was determined by measuring reading rate and comprehension. ANOVA was used to compare the results. A statistically significant difference was found in reading rate between the three groups ( p < 0.0001). The BR had the lowest reading rate compared to other groups. Only a small percentage of the visually impaired children were able to achieve a reading rate within the normal values of normally sighted children. Results of the comprehension test showed no significant difference in the scores of the three groups ( p = 0.232). The findings of this study suggests that visually impaired students required a longer time to read and understand a text and this has implications on the time given to them, especially during examinations.

Prosthodontic decision-making: what unprompted information do dentists seek before prescribing treatment?

This study explored the nature of the unprompted information that clinicians seek before making a treatment decision and whether this decision corresponded with the clinical parameters of the case. Interns, general practitioners (GP) and prosthodontists (n = 70, mean age 33 years, range 23-68) were presented with a written vignette of partial edentulism that included two spaces and were invited to ask any questions for the purpose of making a treatment recommendation. A list of 48 potential question/answer items was available to the interviewer, of which 38 were asked. These were then allotted to four thematic categories. Mean number of questions asked did not differ significantly amongst groups, although prosthodontists asked significantly more questions in the 'clinical and radiographic information' category than GPs (P = 0.0001) and interns (P = 0.003). The relationship between a prescribed treatment and questions asked was tested by dichotomizing all recommendations into 'possible' or 'not possible' based on the authors' knowledge of the actual case history. There were no significant differences amongst the groups in the frequency of prescribing 'possible' treatment (Pearson chi-square 0.083 and 0.108 for upper and lower spaces, respectively), but those who prescribed 'possible' treatment asked significantly more questions in the 'clinical and radiographic information' category, specifically about bone adequacy in the edentulous areas: upper jaw (P = 0.0001) and lower jaw (P = 0.003). It may be concluded that prosthodontists generally opted for more 'possible' treatments, as well as seeking items of information that seemed to improve the chance of making recommendations that conformed to the actual case characteristics.

Measuring disease progression in frontotemporal lobar degeneration: a clinical and MRI study

OBJECTIVES

There is currently much interest in biomarkers of disease activity in frontotemporal lobar degeneration (FTLD). We assessed MRI and behavioral measures of progression in a longitudinal FTLD cohort.

METHODS

Thirty-two patients with FTLD (11 behavioral variant frontotemporal dementia [bvFTD], 11 semantic dementia [SemD], 10 progressive nonfluent aphasia [PNFA]) and 24 age-matched healthy controls were assessed using volumetric brain MRI and standard behavioral measures (Mini-Mental State Examination, Frontal Assessment Battery, Clinical Dementia Rating Scale, Neuropsychiatric Inventory with Caregiver Distress scale) at baseline and 1 year later. A semi-automated image registration protocol was used to calculate annualized rates of brain atrophy (brain boundary shift integral [BBSI]) and ventricular expansion (ventricular boundary shift integral [VBSI]). Associations between these rates and changes in behavioral indices were investigated.

RESULTS

Rates of whole brain atrophy were greater in the entire FTLD cohort and in each subgroup compared with controls (all p < or = 0.004). Rates of ventricular expansion were greater in the entire cohort (p < 0.001) and the SemD (p = 0.002) and PNFA (p = 0.05) subgroups compared with controls. Changes in Mini-Mental State Examination, Frontal Assessment Battery, and Clinical Dementia Rating Scale scores were associated with MRI measures of progression, though not uniformly across FTLD subgroups. Both BBSI and VBSI yielded feasible sample size estimates for detecting meaningful treatment effects in SemD and PNFA language subgroups. Sample sizes were substantially larger using MRI biomarkers for the bvFTD subgroup, and using behavioral biomarkers in general.

CONCLUSIONS

Semi-automated MRI atrophy measures are potentially useful objective biomarkers of progression in frontotemporal lobar degeneration (FTLD); however, careful stratification of FTLD subtypes will be important in future clinical trials of disease-modifying therapies.

The future of complete dentures in oral rehabilitation. A critical review

Based on available investigations and current trends in oral rehabilitation published in the dental literature, an attempt is made to describe the possible future role of complete dentures. For edentulous patients, complete dentures have for long been the only prosthodontic treatment option. Whereas a large number of edentulous patients report satisfaction with denture usage, a smaller number are unable to adapt; for such patients, sophistication of clinical and technical processes or quality of denture-supporting tissues, appear to have little influence on patient-perceived outcomes. Since the 1980s, osseointegrated dental implants have dramatically improved the therapeutic possibilities, especially so for maladaptive patients. Those able to access such treatment can expect significant improvements in oral functional status and quality of life. While there is a downward trend in edentulism in several countries, it is region-specific, confirming the overriding influence of socio-economic factors on health status. In most societies, despite ageing populations, the need for complete dentures is not likely to reduce in the near future. Whereas a two- or even a one-implant overdenture for the edentulous mandible is increasingly regarded as a minimum standard of care in many developed countries, its routine prescription for the majority in the world who are disadvantaged is unrealistic; for them, even 'low-tech' therapies like conventional dentures are beyond their reach. Improving the conventional management of edentulous patients is a necessity and requires a keener focus by researchers, educators and clinicians in the developed world on the needs of populations with fewer resources.

Profile of low vision children in the special education schools in Malaysia

This study looked at the causes of vision loss, levels of distance, near vision and the use of low vision devices (LVDs) in children studying at special schools in Malaysia. A total of 139 children from two special education schools took part. Visual acuity was measured with and without LVDs. Those who required further assessment were referred to Low Vision Clinic. Near visual acuity in 71 children ranged from N4 to N64. Sixty eight children could not read the N64 chart or they were totally blind. Only eight students were using LVDs before intervention. Seventy one children were referred for low vision assessment and 48 were found to benefit from the LVDs prescribed. The major cause of visual impairment was cataract (17%). Hand held magnifier was the most preferred LVD. Majority of the children attending the blind schools had residual vision but did not have LVDs. LVDs are able to significantly improve near visual acuity and hence there is a need to prescribe and train the children to use the LVDs.

Rehabilitation of the worn dentition

The purpose of this review was to evaluate the literature on the rehabilitation of tooth wear, with some pertinent historical, epidemiological and aetiological aspects of tooth wear provided as background information. In historical skull material, extensive tooth wear, assumed to be the result of coarser diets, was found even in relatively young individuals. Such wear is seldom seen in current populations. Although many of the factors associated with extensive tooth wear in historical material are no longer present or prevalent, new risk factors have emerged. In the young individual, the literature points to a global rise in soft drink consumption as the most significant factor in the development of tooth wear through dental erosion. Among older individuals, lifestyle changes and chronic diseases that are controlled with medications that may, in turn, result in regurgitation and/or dry mouth, are possible reasons amongst others for the widespread clinical impression of an increasing prevalence of tooth wear. The aetiology of tooth wear is multifactorial and the role of bruxism is not known. Clinical controlled trials of restorative and prosthodontic approaches for the range of clinical conditions that wear can give rise to, are limited in number and quality. Equally, the striking lack of evidence regarding the long-term outcomes of treatment methods and materials calls for caution in clinical decision-making. Notwithstanding these observations, clinicians have provided and continue to provide rehabilitative strategies for managing their patients' worn dentitions that range traditionally from extensive prosthodontics to an increasing reliance on adhesive techniques.

Tracking progression in frontotemporal lobar degeneration: serial MRI in semantic dementia

BACKGROUND

Semantic dementia is a sporadic neurodegenerative disorder characterized by the progressive erosion of semantic processing and is one of the canonical subtypes of frontotemporal lobar degeneration. This study aimed to characterize the pattern of global and regional longitudinal brain atrophy in semantic dementia and to identify imaging biomarkers that could underpin therapeutic trials.

METHODS

Twenty-one patients with semantic dementia (including eight pathologically confirmed cases) underwent whole-brain and region-of-interest analyses on volumetric brain MRI scans at two time points. Sample size estimates for trials were subsequently calculated using these data.

RESULTS

Mean (SD) whole-brain atrophy rate was 39.6 (31.9) mL/y [3.2 (12.0) mL/y in controls], with ventricular enlargement of 8.9 (4.4) mL/y [1.0 (1.0) mL/y in controls]. All patients had a smaller left temporal lobe at baseline [left mean 31.9 (6.9) mL, right mean 49.2 (9.5) mL; p < 0.0001]; however, the mean rate of atrophy was significantly greater in the right temporal lobe [right 3.9 (1.7) mL/y, left 2.8 (1.2) mL/y; p = 0.02]. Similarly, whereas the left hippocampus was smaller at baseline, the mean atrophy rate was significantly greater in the right hippocampus. Using the atrophy rates generated, sample size requirements for clinical trials were found to be smallest for temporal lobe measurement.

CONCLUSIONS

These findings show that the rate of tissue loss in the right temporal lobe overtakes the left temporal lobe as semantic dementia evolves, consistent with the later development of symptoms attributable to right temporal lobe dysfunction. Furthermore, our findings demonstrate that MRI measures of temporal lobe volume loss could provide a feasible and sensitive index of disease progression in semantic dementia.