Real-World Outcomes of Anti-VEGF Therapy in Diabetic Macular Oedema: Barriers to Treatment Success and Implications for Low/Lower-Middle-Income Countries

Diabetic macular oedema (DMO) is the leading cause of vision loss associated with diabetic eye disease. The exponential increase in the diabetic population and thus, of DMO is an impetus for optimizing the management of DMO. One major challenge in DMO management is the discrepancy between treatment outcomes seen in clinical trials and the real world. Contrary to the homogeneity, better patient motivation and shorter study durations seen in randomised control trials, routine clinical practice is fraught with more diverse populations, undertreatment and variable compliance with long-term therapy. Under both circumstances, this review aims to compare efficacy outcomes and adverse events of DMO therapies within the scope of anti-vascular endothelial growth factor (anti-VEGF) medications, specifically the commonly used ones-bevacizumab, ranibizumab and aflibercept. Impediments and methods to achieve better treatment outcomes in the real world will be addressed to achieve better outcomes. Low- to lower-middle-income countries are faced with even more barriers which range from paucity of data on epidemiology and treatment response to scarce human and financial resources to poorer national level attention and then basic issues like transportation. Additionally, to address the lack of a global consensus in DMO treatment, this review generates and recommends, for clinical and research purposes, an up-to-date consensus algorithm for DMO management universally. Underpinned by results from clinical trials and recent guidelines, this therapeutic flowchart can be utilised in various resource settings including low- and lower-middle-income countries where affordability is a major deterrent to treatment access.

Pancreaticoduodenectomy: Outcomes of a complex surgical procedure from a developing country

BACKGROUND

Pancreaticoduodenectomy (PD) plays an integral part in the management of pancreatic, periampullary and duodenal cancers, along with a few other pathologies of this region. Despite advances in surgery PD continues to have significant morbidity and noteworthy mortality. The aim of this study is to provide an in-depth report on the patient characteristics, indications and the outcomes of PD) in a tertiary cancer hospital in Pakistan.

MATERIALS AND METHODS

The study population included patients who underwent PD between January 1, 2014 and march 31, 2019, at Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH&RC) in Pakistan. The data was retrospectively analyzed from the Hospital Information System (HIS), which is a prospectively maintained patient electronic database of SKMCH&RC. Patient characteristics, procedural details and post-operative outcomes according to internationally accepted definitions were reported.

RESULTS

A total of 161 patients underwent PD at our hospital in the study period at a median age of 53 years, ranging from 19 to 78 years. 62% of the patients were males while 37% were females. Jaundice was the most common presenting symptom (64.6%), followed by abdominal pain (26.7%). PD with pancreaticogastrostomy was performed in 110 patients (68.3%), while pancreaticojejunostomy was performed in the rest of the cohort. Surgical site infection (SSI) was observed in 64 patients (40%). The incidence of Pancreatic Fistula grade C based on the International Study Group on Pancreatic Fistula (ISGPF) definition was 7.45% (n = 12). The 30 days mortality rate was 3.1%. Median survival of the cohort was 21 ±1.13 months and disease-free survival was 16±2.62 months.

CONCLUSION

PD can be performed with acceptable morbidity and mortality in a resource constrained country, as long as it is undertaken in a high-volume center. This is in keeping with data published from other well-reputed international centers.

Anatomic outcomes of laser indirect ophthalmoscopy for retinopathy of prematurity in a tertiary referral center in the Philippines

Objective

Laser/photocoagulation criteria for retinopathy of prematurity (ROP) are generally universal, with > 90% anatomic success reported in varied settings. Outcomes in the Philippines, a developing/lower-middle income nation, were examined.

Results

This single-center retrospective chart review covered years 2014 and 2015. Of 214 infants screened, 64 had any ROP. Thirty-four were treated, and 20 had documented outcomes. Only 15 of 25 eyes (8 infants) with laser treatment-requiring ROP were successes (60%). All infants had Type 1 ROP except one with Aggressive Posterior ROP. Seven infants with bilateral “Milder than Type 1” ROP were treated successfully. Type 1 ROP treatment failures versus successes did not differ significantly in birth weight (1009 g vs. 1112.86 g, p = .5152), birth age of gestation (27.74 vs. 28.49 weeks, p = .3290), and, delay in first screening (6.74 vs. 5 weeks, p = .4649). Poorer outcomes of laser treatment-requiring ROP were documented here compared with elsewhere in the world. Variables/risk factors examined were limited and human error was not systematically considered. Subsequent studies validating this trend should incorporate other clinical (e.g. maternal/neonatal risk factors) and environmental differences that might drive pathology and treatment response in this multifactorial disease. Adherence to protocols gains importance given the widespread delay and early loss to follow-up observed.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4303-3) contains supplementary material, which is available to authorized users.

Burnout among surgical residents in a lower-middle income country - Are we any different?

Objective

To assess the presence of burnout among surgical residents working at various public sector hospitals in Pakistan.

Design

A survey based on MBI was used to assess the presence of burnout. Residents were grouped into Group A (Burn out) or Group B (No burn out). Pearson Test was used to see any correlation between different variables and burn out. A p value of <0.05 was taken as significant.

Setting/participants

A cross sectional survey of all the surgical residents at various public sector hospitals in Lahore was done.

Results

A total of 133 residents responded to our questionnaire. 74% respondents were male and 26% were female. All residents showed a very high level of burnout. 50.4% residents had high levels of burn out on the EE category, 49.6% in the DP category and 53.4% residents had low levels on the PA scale. When assessed for overall burn out 57.9% residents had overall burnout. Males were more prone to develop burnout. Job dissatisfaction was the most prevalent reason for burn out. Owning a smartphone was significantly associated with development of burnout. Awareness regarding the burnout syndrome and having children were two factors which had a protective effect against burnout syndrome. Marriage, working hours, financial conditions, smoking and consumption of coffee/tea had no effect on development of burnout syndrome.

Conclusion

There is high prevalence of burnout among the surgical residents in our hospitals. Unsatisfactory training is the number one reason for development of this syndrome.

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A cross sectional survey of surgical residents revealed very high levels of burnout among them.

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Males were most commonly affected.

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Job dissatisfaction and owning a smart phone were high risk factors for developing burn out.

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Having children and having some knowledge of burn out syndrome were protective against it.

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Working hours, financial constraints, smoking and consumption of coffee had no effect.