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After atrial fibrillation ablation, left atrial appendage closure was associated with a lower risk of bleeding than oral anticoagulation and was noninferior to oral anticoagulation with respect to clinical outcomes at 36 months.

Primary angle-closure glaucoma affects 20 million people worldwide. People classified as primary angle closure suspects have a higher but poorly quantified risk of developing glaucoma. We aimed to assess efficacy and safety of laser peripheral iridotomy prophylaxis against primary angle-closure glaucoma in Chinese people classified as primary angle closure suspects. In this randomised controlled trial, bilateral primary angle closure suspects aged 50–70 years were enrolled at the Zhongshan Ophthalmic Center, a tertiary specialised hospital in Guangzhou, China. Eligible patients received laser peripheral iridotomy in one randomly selected eye, with the other remaining untreated. The primary outcome was incident primary angle closure disease as a composite endpoint of elevation of intraocular pressure, peripheral anterior synechiae, or acute angle-closure during 72 months of follow-up in an intention-to-treat analysis between treated eyes and contralateral controls. This trial is registered with the ISRCTN registry, number ISRCTN45213099. Of 11 991 screened individuals, 889 individuals were randomly assigned from June 19, 2008 (889 treated and 889 untreated eyes). Incidence of the primary outcome was 4·19 per 1000 eye-years in treated eyes compared with 7·97 per 1000 eye-years in untreated eyes (hazard ratio 0·53; 95% CI 0·30–0·92; p=0·024). A primary outcome event occurred in 19 treated eyes and 36 untreated eyes with a statistically significant difference using pair-wise analysis (p=0·0041). No serious adverse events were observed during follow-up. Incidence of angle-closure disease was very low among individuals classified as primary angle closure suspects identified through community-based screening. Laser peripheral iridotomy had a modest, albeit significant, prophylactic effect. In view of the low incidence rate of outcomes that have no immediate threat to vision, the benefit of prophylactic laser peripheral iridotomy is limited; therefore, widespread prophylactic laser peripheral iridotomy for primary angle-closure suspects is not recommended. Fight for Sight, the Sun Yat-Sen University 5010 Project Fund, Moorfields Eye Charity, and the National Natural Science Foundation of China.

Small clinics are important in providing health care in local communities. Accurately predicting their closure would help manage health care resource allocation. There have been few studies on the prediction of clinic closure using machine learning techniques. This study aims to test the feasibility of predicting the closure of medical and dental clinics (MCs and DCs, respectively) and investigate important factors associated with their closure using machine running techniques. The units of analysis were MCs and DCs. This study used health insurance administrative data. The participants of this study ran and closed clinics between January 1, 2020, and December 31, 2021. Using all closed clinics, closed and run clinics were selected at a ratio of 1:2 based on the locality of study participants using the propensity matching score of logistic regression. This study used 23 and 19 variables to predict the closure of MCs and DCs, respectively. Key variables were extracted using permutation importance and the sequential feature selection technique. Finally, this study used 5 and 6 variables of MCs and DCs, respectively, for model learning. Furthermore, four machine learning techniques were used: (1) logistic regression, (2) support vector machine, (3) random forest (RF), and (4) Extreme Gradient Boost. This study evaluated the modeling accuracy using the area under curve (AUC) method and presented important factors critically affecting closures. This study used SAS (version 9.4; SAS Institute Inc) and Python (version 3.7.9; Python Software Foundation). The best-fit model for the closure of MCs with cross-validation was the support vector machine (AUC 0.762, 95% CI 0.746-0.777; P<.001) followed by RF (AUC 0.736, 95% CI 0.720-0.752; P<.001). The best-fit model for DCs was Extreme Gradient Boost (AUC 0.700, 95% CI 0.675-0.725; P<.001) followed by RF (AUC 0.687, 95% CI 0.661-0.712; P<.001). The most significant factor associated with the closure of MCs was years of operation, followed by population growth, population, and percentage of medical specialties. In contrast, the main factor affecting the closure of DCs was the number of patients, followed by annual variation in the number of patients, year of operation, and percentage of dental specialists. This study showed that machine running methods are useful tools for predicting the closure of small medical facilities with a moderate level of accuracy. Essential factors affecting medical facility closure also differed between MCs and DCs. Developing good models would prevent unnecessary medical facility closures at the national level.

This study investigated the distinctive features and management outcomes of combined exfoliation syndrome and angle-closure glaucoma (XFS-PACG) through a prospective, multicenter observational cohort study including 350 patients (118 XFS, 127 PACG, 105 combined XFS-PACG). Combined pathology demonstrated unique characteristics including bimodal diurnal IOP fluctuations, asymmetric angle closure correlating with exfoliation material distribution, and accelerated zonular weakness with progressive anterior lens displacement. Disease progression was significantly more aggressive in combined cases (visual field deterioration − 2.9 ± 0.8 dB/year versus − 1.7 ± 0.6 and − 1.4 ± 0.5 dB/year in XFS and PACG respectively). Therapeutic response evaluation revealed that prostaglandin-alpha2agonist combinations were most effective pharmacologically in combined cases, while traditional laser peripheral iridotomy achieved limited sustained control (38.1%). Early phacoemulsification with minimally invasive glaucoma surgery demonstrated superior surgical outcomes (72.4% complete success) compared to filtering procedures (53.3%). These findings support an individualized treatment approach for combined XFS-PACG, with early intervention and condition-specific protocols to optimize outcomes in this challenging clinical entity.

Background/aimsTo assess baseline ocular parameters in the prediction of long-term intraocular pressure (IOP) control after clear lens extraction (CLE) or laser peripheral iridotomy (LPI) in patients with primary angle closure (PAC) disease using data from the Effectiveness of Early Lens Extraction for the treatment of primary angle-closure glaucoma (EAGLE) tria.MethodsThis study is a secondary analysis of EAGLE data where we define the primary outcome of ‘good responders’ as those with IOP<21 mm Hg without requiring additional surgery and ‘optimal responders’ as those who in addition were medication free, at 36-month follow-up. Primary analysis was conducted using a multivariate logistic regression model to assess how randomised interventions and ocular parameters predict treatment response.ResultsA total of 369 patients (182 in CLE arm and 187 in LPI arm) completed the 36-month follow-up examination. After CLE, 90% met our predefined ‘good response’ criterion compared with 67% in the LPI arm, and 66% met ‘optimal response’ criterion compared with 18% in the LPI arm, with significantly longer drops/surgery-free survival time (p<0.05 for all). Patients randomised to CLE (OR=10.1 (6.1 to 16.8)), Chinese (OR=2.3 (1.3 to 3.9)), and those who had not previously used glaucoma drops (OR=2.8 (1.6 to 4.8)) were more likely to maintain long-term optimal IOP response over 36 months.ConclusionPatients with primary angle closure glaucoma/PAC are 10 times more likely to maintain drop-free good IOP control with initial CLE surgery than LPI. Non-Chinese ethnicity, higher baseline IOP and using glaucoma drops prior to randomisation are predictors of worse long-term IOP response.

Primary angle-closure glaucoma is a leading cause of irreversible blindness worldwide. In early-stage disease, intraocular pressure is raised without visual loss. Because the crystalline lens has a major mechanistic role, lens extraction might be a useful initial treatment. From Jan 8, 2009, to Dec 28, 2011, we enrolled patients from 30 hospital eye services in five countries. Randomisation was done by a web-based application. Patients were assigned to undergo clear-lens extraction or receive standard care with laser peripheral iridotomy and topical medical treatment. Eligible patients were aged 50 years or older, did not have cataracts, and had newly diagnosed primary angle closure with intraocular pressure 30 mm Hg or greater or primary angle-closure glaucoma. The co-primary endpoints were patient-reported health status, intraocular pressure, and incremental cost-effectiveness ratio per quality-adjusted life-year gained 36 months after treatment. Analysis was by intention to treat. This study is registered, number ISRCTN44464607. Of 419 participants enrolled, 155 had primary angle closure and 263 primary angle-closure glaucoma. 208 were assigned to clear-lens extraction and 211 to standard care, of whom 351 (84%) had complete data on health status and 366 (87%) on intraocular pressure. The mean health status score (0·87 [SD 0·12]), assessed with the European Quality of Life-5 Dimensions questionnaire, was 0·052 higher (95% CI 0·015–0·088, p=0·005) and mean intraocular pressure (16·6 [SD 3·5] mm Hg) 1·18 mm Hg lower (95% CI –1·99 to –0·38, p=0·004) after clear-lens extraction than after standard care. The incremental cost-effectiveness ratio was £14 284 for initial lens extraction versus standard care. Irreversible loss of vision occurred in one participant who underwent clear-lens extraction and three who received standard care. No patients had serious adverse events. Clear-lens extraction showed greater efficacy and was more cost-effective than laser peripheral iridotomy, and should be considered as an option for first-line treatment. Medical Research Council.

State and local governments imposed social distancing measures in March and April 2020 to contain the spread of the novel coronavirus disease (COVID-19). These measures included bans on large social gatherings; school closures; closures of entertainment venues, gyms, bars, and restaurant dining areas; and shelter-in-place orders. We evaluated the impact of these measures on the growth rate of confirmed COVID-19 cases across US counties between March 1, 2020, and April 27, 2020. An event study design allowed each policy's impact on COVID-19 case growth to evolve over time. Adoption of government-imposed social distancing measures reduced the daily growth rate of confirmed COVID-19 cases by 5.4 percentage points after one to five days, 6.8 percentage points after six to ten days, 8.2 percentage points after eleven to fifteen days, and 9.1 percentage points after sixteen to twenty days. Holding the amount of voluntary social distancing constant, these results imply that there would have been ten times greater spread of COVID-19 by April 27 without shelter-in-place orders (ten million cases) and more than thirty-five times greater spread without any of the four measures (thirty-five million cases). Our article illustrates the potential danger of exponential spread in the absence of interventions, providing information relevant to strategies for restarting economic activity.

AimsTo compare the change in iris–trabecular contact (ITC) area using swept-source optical coherence tomography (SS-OCT) in eyes with primary angle closure glaucoma (PACG) and cataract that underwent phacoemulsification (PE) with intraocular lens implantation alone compared with PE with goniosynechialysis (GSL).MethodsOne eye of 22 patients with PACG with peripheral anterior synechiae (PAS) detected by indentation gonioscopy was randomised into two groups (PE alone (n=11) and PE+GSL (n=11)). The anterior chamber angles were evaluated by SS-OCT under dark conditions before and 12 months after surgery using the three-dimensional angle analysis scan protocol that simultaneously obtains 128 cross-sectional radial scans across the anterior chamber at equal intervals (every 1.4°). The ITC area, defined as the area of extent of the circumferential contact of peripheral iris to the angle wall, was computed automatically by SS-OCT after an observer marked the scleral spurs of all 128 scans of each eye.ResultsThe majority of the 22 subjects were women (77.3%) and the mean±SD age was 67.3±5.8 years. The ITC area was significantly reduced in the PE+GSL group compared with the PE alone group (10.2 mm2 vs 4.6 mm2, β=0.54, p=0.03) after adjusting for age, gender, intraocular pressure, extent of PAS and pupil diameter before surgery. Smaller iris volume at baseline was associated with greater ITC area reduction by PE+GSL (β=−0.728, p=0.03).ConclusionsEyes that undergo PE+GSL surgery have a greater reduction in circumferential ITC area than eyes that undergo PE alone.

We examine the effects of Covid-19 and related restrictions on individuals with dependent children in Germany. We specifically focus on the role of day care center and school closures, which may be regarded as a “disruptive exogenous shock” to family life. We make use of a novel representative survey of parental well-being collected in May and June 2020 in Germany, when schools and day care centers were closed but while other measures had been relaxed and new infections were low. In our descriptive analysis, we compare well-being during this period with a pre-crisis period for different groups. In a difference-in-differences design, we compare the change for individuals with children to the change for individuals without children, accounting for unrelated trends as well as potential survey mode and context effects. We find that the crisis lowered the relative well-being of individuals with children, especially for individuals with young children, for women, and for persons with lower secondary schooling qualifications. Our results suggest that public policy measures taken to contain Covid-19 can have large effects on family well-being, with implications for child development and parental labor market outcomes.

Purpose Abdominal wall complications can be reduced by adhering to guidelines for midline laparotomy closure. However, implementation of guidelines can be challenging. To address this issue, a laparotomy closure device for swift and standardized abdominal closure was developed. The study evaluated the quality of the suture, safety, and speed of the device in a clinical setting. Methods A prospective, one-armed investigation was carried out. Five surgeons participated in the study. The introduction to the device involved reading the user instructions and unsupervised dry lab training. Thirty-eight patients with colorectal disease, selected for laparotomy, were recruited. The primary endpoint was the proportion of patients that received a fascial closure with a suture-length to wound-length (SL/WL) ratio ≥ 4. Secondary endpoints included suturing time, glove puncture rate, wound infection (SSI), burst abdomen, and other adverse events. Follow-up included physical examination during hospital stay and postoperative visit and chart review six weeks postoperatively. Results All patients achieved the primary endpoint SL/WL ratio ≥ 4. The mean suturing time was 10.5 min, while the mean net closure time (NCT) was 7.4 min. The shortest NCT recorded was 2.2 min. Net mean closure speed was 27 s/cm. There were no glove punctures. One case of SSI was reported, and no burst abdomen was detected. The learning curve stabilized after the third fascial closure. Conclusion The SutureTOOL is a promising device for clinical application. It is perceived as safe, user-friendly, and fast, yielding a standardized laparotomy closure with a brief learning curve. The next steps involve a multi-center randomized trial to evaluate the potential impact of SutureTOOL on short- and long-term complications related to abdominal wall closure.