The objective was to study clinical cases and understand the link betweencesarean section scar defect with hydrometra and secondary infertility. Aretrospective case series from an assisted reproductive center and infertilitytreatment clinic in the United Arab Emirates. We had five patients withsecondary infertility diagnosed with cesarean section scar defect withpersistent hydrometra based on high resolution transvaginal ultrasoundassessment. The patients underwent surgical repair for the cesarean section scardefect followed by infertility treatment. Transvaginal ultrasound examinationshowed a normal endometrial cavity with triple lining endometrium and absence ofhydrometra; and clinical pregnancy was the main outcome measure. Surgicalcorrection of cesarean section scar defect was successfully performed in thecases presented. The patients had their fertility restored. Clinical studiesrevealed that cesarean section scar defect may lead to abnormal uterinebleeding, dysmenorrhea, pre-/post-menstrual spotting, heavy or prolonged menses,pelvic pain and secondary infertility. Theoretically, an inflammatory response,such as a wound healing process in the uterus due to hydrometra associated withscar defect may impair embryo implantation. The clinical case studies presentedhere are based on the correct diagnosis of the cesarean section scar defect withhydrometra and its successful surgical repair. The patients in our study hadtheir symptoms resolved and attained clinical pregnancy. The number of cesarean sections (C-section) performed is steadily increasing acrossthe world .C-section scar defect can be visualized using transvaginal ultrasound andhysteroscopy . ThisfiThere are only a few studies on the clinical association between secondaryinfertility and C-section scar defect .Repair of C-section scar defect is done by using a minimally invasive surgical methodsuch as hysteroscopy or/and laparoscopy and vaginal procedures ; presented to Al Ain Fertility Centerbetween January 2016 and December 2020. Exclusion criteria:Infertility cases presented with C-section scar defect without hydrometra.Clinical characteristics of patients: all the patients were agedbetween 28 to 41 years who underwent surgical management for cesarean sectionscar defect with hydrometra to treat secondary infertility.Diagnosis: Symptoms related to cesarean section scar defect were reported. Clinical diagnoses were confirmed by transvaginalultrasound imaging. Surgical Treatment: All the surgicalprocedures were performed by hysteroscopy and laparoscopy as per explainedbelow: - Hysteroscopic resection: The uterine cavity isdistended using NaCl solution. Positive pressure is ensured with an automaticpressure infuser. The inferior and superior edges of the defect are resectedusing a cutting loop and coagulation is performed on the thinnest part of thescar  approval was obtainedbefore the beginning of the study. The data presented are with completeanonymity of published information and the images used are undernon-identifiable category (ultrasound). In addition, careful case-by-caseassessment was made to ensure that content is fully anonymous and presents norisk to confidentiality of the study participants.invitro fertilization (IVF) treatment under standard antagonistprotocol with preimplantation genetic testing , fluid-filled pouch at the scar site due to impaired woundhealing and thinning of the anterior uterine wall , dysmenorrhea, pelvic pain, postmenstrual spotting, adenomyosis,endometriosis, abscess formation, cesarean scar ectopic pregnancy, and infertility demonstrated that 80% of thepatients diagnosed with a C-section scar defect that had surgical treatments(hysteroscopic and laparoscopic isthmoplasty) became pregnant within 24 months anddelivered before 36 months of treatment. In cases of infertility treatment, thereproductive performance after the scar defect correction surgery shows theeffectiveness of the accurate diagnosis and treatment of patients using efficienttechniques , and when no normalendometrial lining can be visualized. Studies postulated various mechanisms by whichscar defect hydrometra may interfere with embryo implantation (


As previous studies have shown, indications of drugs adjudicated by these RCTs often get expanded m ensues .A combination of patient-specific factors very often acting wholly significant impact on ability to both adhere to and deal with consequences of rising medication counts in patients with CKD. These often take form of sub-optimal medication adherence, worsening cognitive impairment. The latter is both a factor of declining kidney function itself as well as incident on it due to overall frailty. These factors generally makes it challenging to manage medications in CKD patients.Potentially inappropriate medications maintain a bidirectional relationship with polypharmacy, and both share similar unwanted downstream consequences. Restricting the definitional threshold of polypharmacy in chronic kidney disease patients regardless of underlying primary etiology to only Kidney specific medications is key to reliably identifying patient cohorts for directed interventions. To compliment this, and additionally optimize the management of PIMs and polypharmacy in CKD patients, utility of established structural therapeutic frameworks such as pharmacotherapy optimization and or medication therapy management (MTM) may also prove invaluable long term.


Scher,3 This additional risk is not only due to the association of perinatal inflammation with cerebral haemorrhage and white matter injury,4 but also to the neuronal toxicity of supra-physiological serum concentrations of interleukin-1 beta observed in this situation.5 Even in preterm children without severe neonatal brain injury, perinatal inflammation remains independently associated with decreased motor and social abilities at 30 months of corrected age.3Perinatal inflammation exposure represents an additional risk factor for impaired developmental trajectory in preterm infants.6 This identification is crucial to provide individualised early developmental intervention programmes for these infants. Such programmes have been shown to improve motor and cognitive outcomes in preterm children.7EEG is the primary tool for functional evaluation of brain activity in preterm infants hospitalised within the neonatal unit. Serial longitudinal EEG recordings before term age can accurately assess brain maturation in preterm infants, and identify infants with an unfavourable early developmental trajectory.8 Beyond the estimation of discontinuity and amplitude offered by aEEG evaluation, conventional multi-channel EEG provides key information about other network-based brain activity, such as synchrony, frequency, and reactivity.9 It also delivers crucial information on the dynamics of transient endogenous generators occurring through the complex process of brain maturation.9 The two studies included in our systematic review were limited to aEEG analysis and reported inconsistent findings associated with perinatal inflammation exposure.2 Nevertheless, perinatal inflammation led to a modification of EEG frequencies in most of the preclinical studies assessing its effect on foetal sheep EEG, underlying the importance of the quantitative analysis of conventional EEG in the assessment of early brain maturation.2We agree that amplitude-integrated EEG (aEEG) is currently a useful tool to supervise the brain activity of critically ill preterm infants hospitalised in neonatal units that do not have 24/7 access to conventional EEG. However, aEEG provides a limited assessment compared to conventional EEG, particularly in very preterm neonates who do not demonstrate distinguishable sleep-wake cycling before 29 weeks of gestational age.10Conventional multi-channel EEG is essential to assess brain maturation in preterm infants, especially in those exposed to additional developmental risk factors such as perinatal inflammation. The need for a specialist to apply and interpret conventional multi-channel EEG has often been seen as an impediment to its widespread use within the neonatal unit. However, rather than simplifying the process by utilising fewer channels with less information, we believe that modern engineering solutions will allow the widespread introduction of conventional multi-channel EEG in neonatal units. There have been tremendous recent advances in the development of quantitative analysis and machine learning to develop automated algorithms for conventional multi-channel EEG analysis; such automatisation will soon assist in the further introduction of conventional multi-channel EEG beyond specialist centres.


Aim/ObjectiveWithin the dynamic healthcare technology landscape, this research aims to explore patient inquiries within outpatient clinics, elucidating the interplay between technology and healthcare intricacies. Building upon the initial intelligent guidance robot implementation shortcomings, this investigation seeks to enhance informatic robots with voice recognition technology. The objective is to analyze users' vocal patterns, discern age-associated vocal attributes, and facilitate age differentiation through subtle vocal nuances to enhance the efficacy of human-robot communication within outpatient clinical settings.MethodsThis investigation employs a multi-faceted approach. It leverages voice recognition technology to analyze users' vocal patterns. A diverse dataset of voice samples from various age groups was collected. Acoustic features encompassing pitch, formant frequencies, spectral characteristics, and vocal tract length are extracted from the audio samples. The Mel Filterbank and Mel-Frequency Cepstral Coefficients (MFCCs) are employed for speech and audio processing tasks alongside machine learning algorithms to assess and match vocal patterns to age-related traits.ResultsThe research reveals compelling outcomes. The incorporation of voice recognition technology contributes to a significant improvement in human-robot communication within outpatient clinical settings. Through accurate analysis of vocal patterns and age-related traits, informatic robots can differentiate age through nuanced verbal cues. This augmentation leads to enhanced contextual understanding and tailored responses, significantly advancing the efficiency of patient interactions with the robots.ConclusionIntegrating voice recognition technology into informatic robots presents a noteworthy advancement in outpatient clinic settings. By enabling age differentiation through vocal nuances, this augmentation enhances the precision and relevance of responses. The study contributes to the ongoing discourse on the dynamic evolution of healthcare technology, underscoring the complex synergy between technological progression and the intricate realities within healthcare infrastructure. As healthcare continues to metamorphose, the seamless integration of voice recognition technology marks a pivotal stride in optimizing human-robot communication and elevating patient care within outpatient settings. In recent years, the healthcare sector has witnessed significant advancements in technology integration, exemplified by the deployment of informatic robots across various medical settings. Notably, incorporating mobile intelligent guidance robots (IGRs) within outpatient clinics has emerged as a catalyst for enhancing operational efficiency, optimizing processes, and elevating patient experiences . These aIn 2021, we published a comprehensive assessment in Cureus, critically examining the initial implementation of IGRs within an outpatient clinic setting [To address inefficiencies such as frivolous inquiries and childlike interactions, this study involves augmenting the IGR with voice recognition technology. The primary objective of this augmentation is to analyze users' vocal patterns and discern age-related vocal characteristics, thereby enabling the differentiation of age through subtle vocal nuances. This process entails utilizing advanced voice analysis techniques and machine learning algorithms . This apVoice recognition operates on algorithms that evaluate vocal cadences and establish correlations with age-associated vocal attributes. It's crucial to acknowledge that while voice recognition technology possesses inherent limitations that may affect absolute accuracy, it grants the capability to approximate users' ages. By leveraging the IGR's proficiency in comprehending and analyzing conversational context, the robot can glean generational references and contextual cues, thereby facilitating an estimative boundary of the user's age range.Subsequently, in November 2022, an enhanced IGR equipped with voice recognition technology was deployed at the central lobby of an outpatient setting for 20 days, mirroring the temporal framework of the previous 2019 study. Following data accrual, the collected dataset underwent meticulous analysis, focusing on content accuracy and the frequency of successful human-robot interactions. This investigation relied on quantitative and comparative methodologies, comprehensively assessing user inquiries and data efficiencies post-upgrade. The research attempts to pinpoint areas amenable to refinement and offers strategic insights to guide future enhancements.In this study, 101,672 outpatient visits were documented throughout the designated study duration, resulting in 30,301 human-robot interactions transpiring within 20 days. Notably, within this extensive corpus, 22,423 interactions were classified as successful interactions, a criterion defined by the robot's provision of a relevant response to the inquiry presented. Acknowledging that the IGR could not respond to languages other than Mandarin Chinese and English due to inherent programming constraints is imperative. Furthermore, notable categories such as numerically focused queries, inquiries unrelated to the hospital context, childlike interactions, and nuisance inquiries were substantially minimized or systematically omitted from the recorded dataset.Quantitative data comparing the two distinct study periods is presented in Table Characterized by the continuous enhancement of system applications, Figure Compellingly, health triage-related inquiries and appointment issues emerge as the second and third most frequent themes within the top 10 questions. This observation carries implications that resonate with the existing healthcare framework within China. It mirrors the contemporary state of the healthcare landscape wherein the primary health system remains in a formative phase, accompanied by a noteworthy lack of coordination within the broader healthcare infrastructure. Simultaneously, appointment-related concerns underscore the challenges within the appointment scheduling process, potentially reflecting disparities in resource allocation and logistical intricacies.Drawing a comparative lens to the antecedent year 2019, Figure Nevertheless, amid this trajectory of advancement, latent challenges persist. Foremost among these challenges is the constraint of language selection. In a global healthcare landscape where linguistic diversity prevails, the current scope of our informatic robots remains predominantly confined to Mandarin Chinese and English. The necessity for an expanded linguistic horizon aligns with the multifaceted nature of patient demographics and the imperative of inclusivity within healthcare automation.The incorporation of voice recognition technology marks a significant milestone in the domain of informatic robots deployed in outpatient clinics. This innovative augmentation has yielded notable successes, particularly in improving patient-robot interactions. The capacity of voice recognition technology to analyze users' vocal patterns and identify age-related voice characteristics has effectively addressed a crucial communication challenge, facilitating a more tailored and efficient exchange of information between patients and robots . MoreoveOutpatient clinics consistently serve as crucial windows for patients seeking medical care. However, the introduction of informatic robots, while enhancing efficiency, potentially erodes the essential trust inherent in healthcare interactions . PatientMitigating these apprehensions necessitates comprehensive patient education initiatives . Such inBy equipping patients with relevant knowledge, the significance of the interaction is reinforced, reducing the likelihood of frivolous or childlike interactions . Design Future advancements include the integration of machine learning algorithms, which will support continuous learning from patient interactions, thereby refining responses and adapting to evolving patient needs . CarefulInformatic robots possess the potential to catalyze a transformative shift in outpatient clinics, optimizing efficiency and elevating patient care. However, the intricacies associated with their use require careful consideration . A harmoThe successful integration of voice recognition technology into informatic robots has delivered substantial benefits for patient-robot interactions within outpatient clinics. This technology is a promising step toward optimizing healthcare automation by enabling more accurate age differentiation, fostering personalized engagements, and contributing to a growing knowledge base. As the healthcare landscape evolves, voice recognition technology emerges as a cornerstone in the ongoing quest to refine patient care and enrich the human-robot interaction paradigm.In summary, the narrative surrounding the integration of informatic robots within outpatient clinics embarks on an evolutionary trajectory characterized by dynamic refinement. This narrative underscores the intricate nexus of technology and healthcare services, resonating with repercussions transcending societal and clinical paradigms. As progress is championed, the pursuit of enhancing the precision of patient inquiries resonates with overarching themes of technological amalgamation. Simultaneously, a steadfast commitment to embracing linguistic diversity epitomizes the ethos of inclusivity intrinsically linked to healthcare. Each advancement is an echelon of progress within this narrative, propelling unwavering dedication toward shaping a more nuanced and responsive healthcare future.


Long-acting injectable antipsychotics (LAIAs) are currently the most effective alternative for patients with schizophrenia who exhibit poor adherence. LAIAs can lead the course of treatment with the potential to increase adherence in schizophrenia treatment.Present the results of a network metaanalysis on the comparative efficacy of LAIs in schizophrenia.Included trials of adults with schizophrenia compared the efficacy of LAI vs LAI or placebo through the Positive and Negative Syndrome Scale (PANSS). Efficacy was evaluated through the standarized mean differences (SMD) from baseline to endpoint in the PANSS total scores.Results from 15 studies reported usable results for PANSS score (five antipsychotics compared) are shown in Figure 1. In hierarchical order, haloperidol, aripiprazole, risperidone, and paliperidone reduced the PANSS score significantly more than other drugs.Image:Most LAIAs are equally efficient at reducing overall symptoms, and differences between individual LAIAs are non-significant.None Declared


New-generation vaccines and novel vaccinal strategies against infectious diseases of livestock, wild and companion animals” highlights advances and innovations in animal vaccines.Vaccination against infectious disease is an invaluable tool to protect humans against severe morbidity and mortality. For this reason, significant advances in human vaccines have propelled the field of vaccinology forward. Emerging and neglected diseases still pose an important challenge ; fortunaTargeted delivery of oral vaccine antigens to aminopeptidase N (APN) protects pigs against pathogenic Escherichia coli challenge infection” describes the complications of oral subunit vaccines and the significant hurdles in overcoming the barriers of the gastrointestinal tract, limiting their development and efficacy. However, by utilizing APN-specific antibody-antigen fusion constructs, researchers have demonstrated the induction of both mucosal and systemic immune responses in a piglet model of bacterial infection, providing a stepping stone toward the realization of an effective and protective oral subunit vaccine targeting APN. The manuscript by Souto et al. provides data to support the development of a bivalent vaccine candidate to protect fish from viral hemorrhagic septicemia (VHS) and viral encephalopathy and retinopathy (VER), major threats in aquaculture. By modifying the genome of viral hemorrhagic septicemia virus (VHSV) and introducing an expression cassette encoding the protective antigen domain of nervous necrosis virus (NNV) capsid protein, the authors successfully demonstrated the safety, immunogenicity, and protective efficacy of the recombinant VHSVs (rVHSV) in trout and sole. These findings hold promise for the development of a valuable bivalent live attenuated vaccine for commercially valuable fish species. Anotherstudy assessed the immune responses in calves to vaccines targeting Mycobacterium avium subspecies paratuberculosis (MAP), a cause of chronic enteritis in ruminants. Here, the authors analyzed the immune response induced by truncated MAP antigens as a fusion either on protein particles or as a soluble recombinant MAP (rMAP) fusion protein and compared this to a commercial vaccine. The rMAP fusion protein vaccine displayed the strongest immune response and showed promise in providing protective immunity against MAP infection while avoiding interference with bovine tuberculosis diagnostic tests. In another article, the authors describe a promising vaccination strategy for East Coast fever, a prevalent bovine disease in Africa caused by Theileria parva. In this study, using a recombinant lumpy skin disease virus (LSDV), the authors engineered virus-like particles (VLPs) containing a modified form of the T. parva p67 surface antigen and the bovine leukemia virus (BLV) gag gene. Studies in mice demonstrated the vaccine’s immunogenicity, showing higher antibody titers in the group vaccinated with the recombinant LSDV. This encouraging progress paves the way for further investigations and potential applications of this dual vaccine candidate in cattle. Using recombinant bovine herpesvirus (BHV)-4 expressing nonstructural protein 5 (NSP5) and M fusion protein of porcine reproductive and respiratory syndrome virus (PRRSV), a study suggested that a T cell response induced in recombinant viral vector primed pigs can help in reducing PRRSV-1–associated tissue damage without reducing the viral load. A separate study explored the potential of an adenoviral-vectored Epigraph vaccine as a promising alternative to current Swine Influenza A Virus (IAV-S) vaccines. Their findings demonstrated encouraging results, with the vaccine inducing robust and durable antibody responses in vaccinated pigs, as well as significant protection against viral challenge 6 months after initial vaccination.Within this Research Topic, both original research and review articles are presented. The original article “Recent advances in antigen targeting to antigen-presenting cells in veterinary medicine” outlines the dynamic field of veterinary medicine, where the quest for innovative strategies to combat challenging diseases has gained considerable momentum. Notably, groundbreaking advancements in antigen targeting, with a particular focus on antigen-presenting cells such as dendritic cells, through the use of DC peptides and MHC-II, have emerged as a beacon of hope. Moreover, another review describes the complications of vaccination in wildlife animals. Prion diseases, such as chronic wasting disease (CWD), pose significant challenges due to their unique biology and potential zoonotic risks. Current efforts to manage CWD have been largely ineffective, emphasizing the need for new tools such as vaccines. Despite the hurdles of overcoming immune tolerance and vaccinating wild animals, progress has been made in identifying safe antigens and effective strategies for formulation and delivery, including oral delivery to wild cervids.To complement the original research outlined above, this Research Topic also delves into important questions regarding new vaccine strategies and considerations for future approaches in detailed reviews. “Immune responses in the uterine mucosa: clues for vaccine development in pigs” explores the pursuit of effective strategies, with intrauterine immunization emerging as a promising approach, aiming to elicit localized or systemic immunity that safeguards against potential threats. Finally, Type I interferons (IFNs-α/β) are vital components of the innate immune response against viral infections. However, viruses have developed clever strategies to evade the antiviral effects of IFNs, compromising the efficiency of the immune system and vaccines. Understanding these evasion mechanisms can pave the way for the development of innovative vaccines that counteract viral IFN antagonism and induce robust immune responses for enhanced protection against a wide range of pathogens. The review article “Reprogramming viral immune evasion for a rational design of next-generation vaccines for RNA viruses” explores advances in developing IFN antagonism-deficient viruses, their immune evasion, and attenuated phenotypes in natural host animal species.The intricate immune system of the upper reproductive tract (URT) serves a remarkable purpose: shielding against sexually transmitted pathogens while simultaneously embracing immune tolerance toward sperm and the developing fetus. The review “This Research Topic brings a diverse selection of topics outlining advances in the field of veterinary vaccinology. The importance of generating protective vaccines against disease in animals is critical to ensuring their health and wellness, thus favoring production systems and reducing zoonotic disease risk .BP: Writing – original draft, Writing – review & editing. RM-R: Writing – review & editing. ST: Writing – review & editing. CC: Writing – review & editing. DA: Writing – review & editing.


Verticillium wilt (VW), Fusarium wilt (FW) and Root-knot nematode (RKN) are the main diseases affecting cotton production. However, many reported quantitative trait loci (QTLs) for cotton resistance have not been used for agricultural practices because of inconsistencies in the cotton genetic background. The integration of existing cotton genetic resources can facilitate the discovery of important genomic regions and candidate genes involved in disease resistance. Here, an improved and comprehensive meta-QTL analysis was conducted on 487 disease resistant QTLs from 31 studies in the last two decades. A consensus linkage map with genetic overall length of 3006.59 cM containing 8650 markers was constructed. A total of 28 Meta-QTLs (MQTLs) were discovered, among which nine MQTLs were identified as related to resistance to multiple diseases. Candidate genes were predicted based on public transcriptome data and enriched in pathways related to disease resistance. This study used a method based on the integration of Meta-QTL, known genes and transcriptomics to reveal major genomic regions and putative candidate genes for resistance to multiple diseases, providing a new basis for marker-assisted selection of high disease resistance in cotton breeding. Upland cotton , the most widely cultivated cotton species in the world, has excellent qualities, high yield and is widely adaptable .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.


Large proportion of patients with ADHD experience sleep problems. Well conducted, good quality clinical research could identify non-pharmacological sleep improvement interventions that would benefit patients with ADHD and would inform evidence based guidelines for sleep management in ADHD.To conduct a novel meta-research assessment of available clinical trials in the field of light therapy and non‑pharmacological sleep improvement interventions for people with ADHD.Peer-reviewed publications of clinical trials were analysed. An advanced literature search strategy was performed in major medical databases, including EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials and PsycINFO. Available data at WHO-approved clinical trial registries were searched and linked to the published literature. Detailed methodological assessment of results was conducted using the Cochrane Risk of Bias Tool version 2.0 (ROB2), conflict of interest, spin and favourability of findings. Reduction in ADHD symptom severity and improvement of sleep quality served as primary outcomes for the efficacy analysis. Any adverse events were recorded. Statistical analysis of the primary outcomes was conducted by calculating standardised mean difference and transformed as necessary. Publication bias was evaluated with contour enhanced funnel plots and the trim-and-fill procedure, and by summarising unpublished trials.Analysed clinical trials often had a high risk of bias . The primary outcome interpretation and overall trial conclusions frequently favoured the trial intervention. Clinical trials showed an association between primary outcome effect size and interpretation, and risk of bias. Clinical research in this field faces many of the same challenges identified for complex interventions in mental health, such as small sample size, lack of funding and difficulties with blinding.Clinical research regarding light therapy and non‑pharmacological sleep improvement interventions for ADHD patients indicates safety and effectiveness but studies often lack methodological rigour.None Declared


In this critical analysis, we investigate the profound impact of natural disasters and pandemics on the care and adherence to treating diabetic retinopathy, a severe complication of diabetes requiring continuous monitoring and treatment to prevent vision loss. Our study also sheds light on the social and economic context of Puerto Rico, emphasizing recent emergency events that have exacerbated existing public health challenges. Through a comprehensive review of relevant literature from PubMed, Google Scholar, and the George Washington University Himmelfarb Health Sciences Library database, we identified 31 pertinent articles out of 45 evaluated, focusing on the effects of these crises on healthcare delivery, diabetic retinopathy screening, and treatment. The evidence strongly indicates that during such emergencies, barriers to healthcare escalate, leading to significant treatment delays and a reduction in diabetic retinopathy screening and diagnosis, ultimately resulting in deteriorated visual outcomes. Thus, our review underscores the urgent need for the development of effective emergency plans tailored specifically to diabetic retinopathy, particularly in Puerto Rico, where diabetes prevalence and its complications are notably higher. Such plans should not only incorporate established emergency measures but also harness emerging technological advances in the field of ophthalmology to ensure optimal preparedness for future pandemics and natural disasters. Diabetes, characterized by elevated blood glucose levels, poses a global health challenge with both macrovascular and microvascular complications. The incidence of diabetes is rising worldwide, affecting vulnerable populations, especially in disaster-prone regions . The IntThe prevalence of DR is escalating, especially in regions like North America and the Caribbean, with Puerto Rico experiencing a notable burden ,8. This Prior research underscores the exacerbation of diabetes and its complications in disaster settings ,12. DiabDR management revolves around prevention and progression control . While bThis critical analysis aims to elucidate the influence of natural disasters and pandemics on DR care and adherence to treatment. Moreover, it sheds light on Puerto Rico's recent public health challenges, magnified by its susceptibility to disasters . ThroughMaterials & methodsA comprehensive literature review was conducted to identify relevant publications on managing DR during pandemics or natural disasters worldwide. The study also aimed to identify recent public health challenges in Puerto Rico that may have affected the care of DR on the island during and after Hurricane Irma, Hurricane Maria, the 2019-2020 earthquakes, and the COVID-19 pandemic. Additionally, the research sought to assess the presence of diabetes emergency preparation procedures on the island. Furthermore, given the ongoing COVID-19 pandemic, the literature review explored suggested methods and new technological breakthroughs for managing DR.Literature searches were conducted using PubMed, Google Scholar, and the George Washington University Himmelfarb Health Sciences Library database. The search queries focused on terms related to DR, as it is the primary disease of interest in this critical analysis. Similarly, words related to disaster preparedness were included. The search terms used had "diabetic retinopathy" ("retinopatia diabética"), "retinopathy" ("retinopatia"), "retina," "diabetes," "diabetic eye disease," "diabetes mellitus," and "diabetics" ("diabéticos"), along with "disaster preparedness," "emergency preparedness," "natural disasters" , "hurricanes" ("huracanes"), "Hurricane Maria" ("Huracán Maria"), "Hurricane Irma" ("Huracán Irma"), "earthquakes" ("terremotos"), "pandemic" ("pandemia"), "covid," "covid-19," and "coronavirus." Additional terms such as "prevalence" , "Puerto Rico," "intravitreal injections," "anti-vascular endothelial growth factor," and "anti-VEGF" were used to achieve specific aims.Appendix A provides a list of combinations of the search terms mentioned above. Studies included in the literature review were limited to those written in English or Spanish, available as free full-text, and published from 2017 onwards.ResultsThis study conducted an extensive literature review spanning the period from 2017 to 2022, with the aim of delving into the intricate dynamics between natural disasters, pandemics, and the provision of care for DR. A meticulous analysis of 24 relevant articles provided valuable insights into the challenges faced by DR patients during times of adversity, as depicted in Figure Remarkably, as highlighted in Table Intriguingly, the literature appeared to have a significant gap in the specific domain of disaster preparedness strategies tailored to DR during natural disasters , a pointThe synthesis of the literature convincingly underscores the susceptibility of DR care to the disruptions posed by natural disasters and pandemics. The aftermath of events like hurricanes and the ongoing COVID-19 pandemic has underscored challenges in timely care provision, leading to delays in vital interventions such as anti-VEGF injections and DR screenings. These delays can potentially worsen the prognosis of DR and heighten the risk of vision loss. Of significant note, the region of Puerto Rico, having endured multiple natural disasters in the past decade alongside the ongoing pandemic, is a vivid example of the disproportionate impact on individuals with chronic illnesses. These crises have laid bare shortcomings in the healthcare system and accentuated the pressing need for robust contingency plans to mitigate considerable health and visual consequences. It is imperative that such plans encompass both established emergency protocols and the integration of emerging technological advancements within the field of ophthalmology.Impact of Pandemics and Natural Disasters on Diabetic Retinopathy: Challenges and Preparedness StrategiesThe ramifications of pandemics and natural disasters on DR care have garnered significant attention within the medical community. This section synthesizes key findings from the literature, shedding light on the barriers encountered by DR patients during these emergency situations and proposing effective preparedness strategies to mitigate their impact.Barriers to care during the COVID-19 pandemic: The COVID-19 pandemic highlighted several barriers that disrupted the continuity of DR care. As depicted in Table Impact of recent emergency situations in Puerto Rico: Existing healthcare challenges and socioeconomic factors amplified Puerto Rico's vulnerability to emergencies. Table Proposed pandemic and disaster preparedness plan for DR: To address the challenges highlighted by the impact of emergencies on DR care, a multifaceted preparedness plan is proposed. Table DiscussionThe prevalence of DR, a significant microvascular complication of diabetes mellitus, presents a formidable challenge due to its potential to cause vision impairment and blindness among working-age individuals. This condition is chiefly characterized by diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR), necessitating timely intervention and vigilant monitoring . The conTo mitigate the repercussions of these care disruptions, ophthalmological institutions have outlined recommendations for managing intravitreal anti-VEGF injections during pandemics . These gTelemedicine has proven invaluable when conventional medical access is limited, as witnessed in situations like natural disasters and infectious disease outbreaks. The COVID-19 pandemic has expedited the adoption of telemedicine, enabling remote healthcare delivery through digital platforms. Ophthalmology has particularly benefited from this shift, leveraging advanced hardware, sophisticated software, and high-speed communication technologies to remotely diagnose and manage eye conditions ,28. The Teleophthalmology, mainly via portable devices, has the capacity to bridge accessibility gaps in remote and underserved communities. Research has demonstrated the feasibility of cost-effective DR screening tools utilizing smartphones and telemedicine, resulting in improved DR screening coverage in rural areas . FurtherIn addition to leveraging telemedicine, public health initiatives should prioritize infrastructure enhancements to bolster visual healthcare accessibility. Strengthening hospitals, medical facilities, and primary care clinics, ensuring consistent power supply and backup generators, improving provider communication, expanding the healthcare workforce, enhancing surveillance systems, and refining patient records are imperative. Special attention should be directed toward high-risk groups, such as elderly individuals with chronic conditions and immobile patients . ExpandiCommunity pharmacists play a pivotal role in disaster preparedness and response, offering access to medications and healthcare services, thereby mitigating barriers to care . They caNational-level protocols should be established to ensure uninterrupted critical treatment schedules for DR patients. These protocols must recognize the debilitating nature of the disease and prioritize patients at high risk of DR-related blindness, exempting them from lockdown measures and ensuring their protection . SimilarThe COVID-19 pandemic has instigated transformative shifts in care delivery and spurred innovative standards in ophthalmic care. As the global population ages, the prevalence of DR and similar conditions will escalate, further straining healthcare services. In regions like Puerto Rico, where diabetes mellitus is highly prevalent, and healthcare infrastructure and resources might be less stable, swift integration of alternative care methods, such as telemedicine, is crucial to alleviate patient burden while ensuring essential disease management . TelemedFinally, developing an emergency contingency plan for DR management is essential to provide uninterrupted care during crises. Clinicians bear a moral and ethical responsibility to devise strategies to minimize treatment interruptions. Key elements of such a plan include maintaining a comprehensive database of DR patients and their demographics for guided medication distribution and personnel deployment, implementing backup power sources for electricity outages, ensuring access to electronic medical records, and refrigeration for temperature-sensitive medications. Adequate medication and supply reserves ahead of disasters and establishing post-disaster patient communication methods are also vital.It is essential to acknowledge the limitations of this study, including the absence of specific data on the intersection of DR and natural disasters, as well as the lack of tailored recommendations for the unique circumstances in Puerto Rico. However, this critical analysis aims to provide guidance to ophthalmologists in Puerto Rico for effectively managing DR patients during responses to hurricanes, earthquakes, and potential future pandemics like COVID-19. The findings should inspire collaborative efforts among scientists and stakeholders in Puerto Rico to address barriers hindering patient access to teleophthalmology services, especially during times of crisis.In conclusion, given the heightened risks posed by pandemics and natural disasters, developing a robust emergency plan for managing DR is imperative. This urgency is underscored by the heightened vulnerability of regions like Puerto Rico, where the prevalence of diabetes and its complications is substantial. An effective plan should encompass established emergency measures and embrace emerging technological advancements within the field of ophthalmology.


Opioid use for perioperative pain management in burn patients is associated with a high risk of developing chronic opioid use. Ketamine is commonly used as an analgesic adjunct due to its opioid-sparing effects. The purpose of this study is to determine whether analgesia with adjunctive ketamine reduces the risk of developing chronic opioid use in burn patients.Burn patients who underwent burn-related surgeries were identified using relevant ICD-10 Codes. Data were collected using the TriNetX Research Network, a national research database providing de-identified patient medical records.Burn patients undergoing surgical procedures were identified based on their use of opioids alone or in combination with ketamine as adjunctive analgesia. Both groups excluded patients with a prior history of opioid-related and psychiatric disorders to control for potential pre-existing conditions affecting the study outcomes. Outcome analysis included continued opioid use and related psychiatric disorders, including nicotine dependence and anxiety, up to one year after burn injury. Risk ratios for each outcome were then generated using a measure of association analysis through TriNetX.We identified 107,270 patients across 51 health care organizations who underwent burn-related surgeries within one month after burn injury. Excluded from the study were 3,296 (3.07%) patients who had a prior history of opioid-related and psychiatric disorders. The remaining 103,974 patients were sorted into respective groups that received opioids with ketamine  and without ketamine . The two cohorts were balanced using (1:1) propensity score matching for age, sex, race, ethnicity, and burn surface area.Patients without ketamine had a higher risk of continuing opioid use , developing nicotine dependence , and developing anxiety disorders  at least one year after burn injury.Burn patients whose pain management included adjunctive ketamine ceased opioid use sooner and demonstrated a lesser risk of developing various psychiatric disorders associated with chronic opioid use.This study supports the use of adjunctive ketamine as part of a multimodal approach to pain management in burn patients in order to minimize the risk of chronic opioid use.


Ophiophagus hannah; Cantor, 1836) is distributed in diverse habitats, forming independent populations, which confer differing scale markings, including between hatchlings and adults. Furthermore, king cobra venoms possess unique cytotoxic properties that are used as a defensive trait, but their toxins may also have utility as promising anticancer-agent candidates. However, the impact of geographical distribution and age on these potential venom applications has been typically neglected. In this study, we hypothesised that ontogenetic venom variation accompanies the morphological distinction between hatchlings and adults. We used non-transformed neonatal foreskin (NFF) fibroblasts to examine and compare the variability of venom cytotoxicity between adult captive breeding pairs from Malaysian and Chinese lineages, along with that of their progeny upon hatching. In parallel, we assessed the anticancer potential of these venoms in human-melanoma-patient-derived cells (MM96L). We found that in a geographical distribution and gender-independent manner, venoms from hatchlings were significantly less cytotoxic than those from adults . This is consistent with neonates occupying a semifossorial habitat, while adults inhabit more above-ground habitats and are therefore more conspicuous to potential predators. We also observed that Malaysian venoms exhibited a slightly higher cytotoxicity than those from the Chinese cobra cohorts , which is consistent with Malaysian king cobras being more strongly aposematically marked. These variations are therefore suggestive of differential anti-predator strategies associated with the occupation of distinct niches. However, all cobra venoms were similarly cytotoxic in both melanoma cells and fibroblasts, limiting their potential medical applications in their native forms.Snake venoms constitute a complex, rapidly evolving trait, whose composition varies between and within populations depending on geographical location, age and preys (diets). These factors have determined the adaptive evolution for predatory success and link venom heterogeneity with prey specificity. Moreover, understanding the evolutionary drivers of animal venoms has streamlined the biodiscovery of venom-derived compounds as drug candidates in biomedicine and biotechnology. The king cobra ( Venom is generally defined as a functional trait: a complex secretion produced by a specialised gland tissue that is delivered into the body of another animal via a wound for use in antagonistic interactions . By thisThe scale of mining venoms for drug candidates is immense, as this mixture often contains hundreds of toxins and isoforms that undergo accelerated rates of evolution . This biStudying the natural history and evolution of venomous species provides key insights regarding the biological sources reflecting toxin diversity. Snake venoms function at the ecological and biochemical interface between predator and prey, aiming mainly to facilitate predation . This haOphiophagus hannah; Cantor, 1836) belongs to the Elapidae family and is widely distributed from India to southern China and Southeast Asia in numerous geographically isolated mainland and island populations. These populations form at least four genetically distinct lineages, which are likely separate species  prism function. Data were graphed and analysed using GraphPad Prism version 9 for iOS . For the MTT assays, venom cytotoxicity data were normalised to the vehicle-treated cells (100% cell viability) to calculate the percentage of viable cells following venom treatment. Data were then tested for normality using Shapiro–Wilk tests (significance set to


Perioperative management of estradiol therapy varies considerably among plastic surgeons performing aesthetic surgeries. This study aimed to review available literature regarding perioperative management of estradiol therapy in aesthetic surgery patients, and the risk it poses for developing VTE in the perioperative period.A literature search was performed using online databases to identify studies evaluating VTE in aesthetic surgery patients taking oral contraceptives (OCPs) or hormone replacement therapy (HRT), and transgender patients on feminizing hormone therapy undergoing non-flap feminization surgery . Reported outcomes were extracted from these studies and summarized.A systematic review of the literature yielded 225 studies. Five of these studies met inclusion criteria. One study that was excluded, referenced an article that met inclusion criteria, which was ultimately included in our review for a total of six studies, representing 3,635 patients.Data regarding perioperative management of estrogen therapy is limited in the literature, and standardized guidelines for aesthetic surgery patients have not been elucidated. This has led to inconsistencies in how estrogen is managed for elective, cosmetic procedures. Further research is needed to determine standardized practice guidelines. In the meantime, case-by-case evaluation of surgical appropriateness should continue. Surgeons should also consider risk-mitigating strategies, such as a focus on patient education, more intentional patient questioning regarding estrogen-containing product use, a preoperative coagulability workup for patients with a personal or family history indicative of possible coagulopathy, and specialty-wide efforts to create an aesthetics database and evidence-based guidelines.


BackgroundMeniscal tears are the most common injury of the knee. Surgical treatment has fallen into contention recently and includes arthroscopic meniscectomy and meniscal repair. The primary aim of this study was to quantitatively evaluate patients with isolated meniscal tears and compare their outcomes with patients who have undergone arthroscopic meniscus surgery. The secondary aim of this study was to compare the clinical outcomes of patients who have undergone arthroscopic meniscectomy with patients who have undergone arthroscopic meniscal repair.MethodsThis comparative clinical study screened 334 patients to identify subjects who underwent arthroscopic knee surgery for isolated meniscal tears and compare them to patients with symptomatic isolated meniscal tears awaiting surgery using validated patient-reported outcome measures. These included the Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective Knee Form, Lysholm score, Tegner score, EuroQol-5 Dimension, and the 12-Item Short Form Health Survey.ResultsA total of 117 patients , Meniscectomy group (n=64), and Meniscal Repair group (n=17)) were included in the final data analysis. Both the Meniscectomy group and the Meniscal Repair group (mean 55-month follow-up) showed significantly better clinical outcomes than patients in the Meniscal Tear group (p<0.05). Overall, the Meniscal Repair group demonstrated superior clinical outcomes when compared to the Meniscectomy group (p<0.05).ConclusionArthroscopic knee surgery showed significant clinical benefit at medium-term follow-up in treating patients with isolated meniscal tears. When feasible, meniscal repair should be performed preferentially over meniscectomy. The menisci are crescentic wedge-shaped structures formed from fibrocartilage located within the medial and lateral compartments of the knee between the corresponding femoral condyle and tibial plateau ,2. MenisTreatment for meniscal tears broadly falls into two categories: conservative vs. surgical, the latter of which includes arthroscopic meniscectomy and arthroscopic meniscal repair. The choice depends on many factors including age, type and severity of tear, the presence of other pathology, and general patient fitness for anesthesia and surgery ,3,4. WheIn general, the treatment for traumatic meniscus tears differs from that of degenerative tears. The latter are less likely to be amenable to repair as by their very definition their blood supply is poor ,2. FurthSurgical management includes arthroscopic meniscectomy and meniscal repair. An arthroscopic partial meniscectomy (APM), in which only the torn section of the meniscus is removed, is now the most frequently performed orthopedic operation in the United States .As compared to meniscectomy, meniscal repair is a more biologically preserving procedure as it retains the native meniscal tissue within the knee joint. Multiple repair techniques have been described in the literature, the most common of which include all-inside, inside-out, and outside-in, with no significant differences in failure rates, complication rates, or clinical outcomes . OutcomeThe decision to proceed with either meniscectomy or meniscal repair involves evaluating both meniscus tear characteristics  and patient factors . Meniscal repair has been shown to decrease the incidence of early chondral degeneration and better preserve the knee’s biomechanical properties as compared to meniscectomy . Both prMeniscal repairs are more commonly performed in younger patients and have shown superior outcomes over meniscectomy in patients under 45 years of age . IncreasThere are a limited number of studies directly comparing clinical outcomes between meniscectomy and meniscal repair, with those identified only having short-term follow-up periods, meniscal repairs performed concomitant with anterior cruciate ligament (ACL) reconstruction, and a limited variety of patient-reported outcome measures (PROMs) included in the clinical evaluation.PROMs quantify clinical symptomatology as directly projected by the patients themselves. Varying from general health to disease-specific, PROMs aid clinical decision-making, inform health policy strategies, and develop and refine patient-centered care . GenericThe primary aim of this study is to quantitatively evaluate patients with isolated meniscal tears using validated PROMs and compare their outcomes with patients who have undergone arthroscopic meniscus surgery. The secondary aim of this study is to compare the clinical outcomes of patients who have undergone arthroscopic meniscectomy with patients who have undergone arthroscopic meniscal repair. The primary hypothesis is that arthroscopic surgery improves symptoms of meniscus tears. The secondary hypothesis is that arthroscopic meniscal repair has superior clinical outcomes as compared to arthroscopic meniscectomy.This is a retrospective observational clinical study. All the patients included in this study attended a specialist knee clinic and underwent arthroscopic knee surgery following clinical assessment and radiological investigation. This study was exempt from Institutional Review Board (IRB)/Ethics Committee approval as it was a pragmatic study evaluating the existing clinical practice of the senior author (consultant orthopedic surgeon). This study was registered with the hospital’s Clinical Effectiveness Department (registration number CA9828). This therapeutic research study constituted the first author’s Masters dissertation.This study compared the clinical outcomes of three separate groups. The Pre-Operative group included patients with isolated meniscal tears of the knee joint, the Meniscectomy group included patients who had undergone an arthroscopic meniscectomy, and the Meniscal Repair group included patients who had undergone an arthroscopic meniscal repair.Exclusion criteria consisted of further surgery or further injury to the affected limb, any functionally limiting illness or disease, advanced knee osteoarthritis and concurrent ACL, posterior cruciate ligament (PCL), or lateral collateral ligament (LCL) tears. The presence of any of these factors could confound surgical outcomes reported. Exclusion of these cases ensured any symptoms expressed were attributable only to the original meniscal injury and their surgical treatment. Patients with medial collateral ligament (MCL) tears were not excluded as concurrent MCL tears are relatively common with meniscus tears and the former are predominantly treated conservatively and unlikely to confound the outcome of meniscus surgery.Subjects in the Pre-Operative group constituted a cohort of patients currently on the waiting list for knee surgery who have been clinically  and radiologically (magnetic resonance imaging (MRI)) diagnosed with an isolated meniscal tear and whose symptoms were refractory to conservative treatment . The Pre-Operative group allowed for a benchmark from which to compare both surgical treatment options.Surgically treated patients in both the Meniscectomy group and the Meniscal Repair group were identified through the consultant’s surgical logbook and theatre records. All arthroscopic knee surgeries performed from August 2013 to June 2021 were reviewed using the hospital electronic health record system; MediTech version 6 . The Novel Coronavirus (COVID-19) global pandemic had implications for this study as all routine elective surgical procedures (including knee arthroscopies) were canceled for an extended period of time (March 2020 onward), reducing the number of potential participants that could be recruited into this study .o to 90o for six weeks in order to protect the meniscal repair site at the initial healing phase, thereafter the brace was discontinued, and full ROM progressed. All meniscectomies were performed using standard a basket punch followed by a motorized oscillating shaver (Smith & Nephew plc.) whereby only the torn and damaged area of meniscal tissue was resected back to a stable rim . Post-operative physiotherapy rehabilitation included full weight and full ROM without any knee brace or functional restrictions. Patient notes were perused to ascertain the type of arthroscopic knee surgery performed, conformance with the inclusion and exclusion criteria, and documenting intra-operative findings, including meniscus tear laterality , tear configuration, and specific anatomic location .All meniscal repairs included in this study were performed by using an all-inside technique using FAST-FIX 360  for tears located at the posterior horn and middle third (body) of the meniscus. For anterior horn meniscus tears, an outside-in meniscal repair technique was performed using a 1 PDS II (polydioxanone) violet suture . Microfracture around the margin of the intercondylar notch was performed at the same time in order to perforate the subchondral bone and introduce mesenchymal stem cells into the knee joint which in turn optimizes the biological milieu for the meniscal tissue healing process . Post-opData from validated patient-reported outcome measures (PROMs) regarding meniscus-related symptomatology was collected from all three groups. This included the Knee Injury and Osteoarthritis Outcome Score (KOOS) ,17, InteStatistical analysisPlotted histograms with fitted curve lines, box plots, normal Q-Q plots, and the Shapiro-Wilk statistic were used to test the normality of data distribution. Almost all the PROM data (continuous variables) displayed a skewed distribution and therefore the relevant non-parametric statistical tests were used for the data analysis. The Kruskal-Wallis H test accompanied with Dunn’s post-hoc pairwise comparison test was used for the three-way group data analysis. The level of statistical significance was set at p<0.05. Statistical analysis was performed using SPSS for Windows version 26.0 .Figure Baseline demographics for all three groups are summarized in Table Table Figure This study has shown that patients with isolated meniscus tears clinically improved following arthroscopic knee surgery as determined by validated PROM scores. Overall, the clinical outcome of arthroscopic meniscal repair surgery was superior to that of arthroscopic meniscectomy.This study found significantly different outcomes between pre-operative patients with an isolated meniscal tear and those who had undergone either a meniscectomy or meniscal repair surgery. The highest scores across all PROMs were observed in the Meniscal Repair group, with the lowest scores mostly seen in the Pre-Operative group. This study is the first to quantitively evaluate pre-operative patients with isolated meniscal tears using a wide variety of validated PROMs , allowing a standardized benchmark from which to compare surgical interventions and other modalities aimed at treating meniscus pathology. The results from this study demonstrate significant clinical benefit from both meniscectomy and meniscal repair surgery at a mean 55-month follow-up, a finding also shown by a similar study by Engler et al. ,10,22. THistorically, APM has been used in a non-specific manner in patients with knee pain and any form of tear ,22. ThisThe secondary hypothesis of this study was affirmed, finding significantly superior scores in the Meniscal Repair group across almost all PROMs, suggesting Meniscal Repairs have superior outcomes to Meniscectomy for isolated meniscal tears at medium-term follow-up. This finding is corroborated by a meta-analysis by Xu et al. , which sThe superior outcomes observed in this study in the Meniscal Repair cohort could be attributed to preservation of the meniscal tissue and therefore retaining the three key functions they play in the knee. First, they absorb axial loading forces through the joint, by converting them into hoop stresses within the tissue. Second, the menisci stabilize the knee by improving articular congruency between the flat tibial plateaus and concave femoral condyles. Third, they modulate the gliding of the articular surfaces. The removal of the meniscal tissue by meniscectomy impacts its ability to perform such functions and could be attributed to the greater rate of secondary osteoarthritis other studies have observed in this group .The menisci are innervated by the posterior articular branch of the tibial nerve. Similar to the ACL, they too contain mechanoreceptors that contribute to the proprioceptive function of the knee . StudiesA general comparison between the two operations shows that despite meniscal repair having greater day-of-surgery costs  , greaterThe main limitation of this study was patient participation and recruitment. This clinical research study was conducted during the novel coronavirus (COVID-19) global pandemic, during which all routine elective surgery had ceased due to nationwide restrictions, resulting in a reduction of individuals eligible to take part. Additionally, due to the nature of postal questionnaires, patients were understandably apprehensive about receiving an envelope that had originated from a hospital during this time, further reducing the compliance rate. This study did not analyze longitudinal patient data of the two surgical groups as pre-operative data was not collected for these patients specifically. However, a suitable comparable group of pre-operative patients, refractory to conservative treatment, on a waiting list for meniscal surgery was identified and used as a benchmark from which to assess and compare surgical outcomes. The range of follow-up periods was relatively broad for both groups. However, with a mean follow-up period of 57 and 47 months for the meniscectomy and meniscal repair cohorts, respectively, this study provides a useful perspective on medium-term outcomes following meniscal surgery.Despite limitations forced upon clinical research studies performed during the global pandemic, this analysis is based on comprehensive selection criteria and contributes key interpretation regarding the direct comparison between meniscectomy and meniscal repair in isolated meniscal tears, something only a limited number of papers have done in the past ,35. ThesSuggestions for future research in this field include undertaking a multicenter study that can allow for a larger cohort of patients to be investigated, particularly in the Meniscal Repair group, whilst encompassing various meniscal surgical techniques, to provide more generalizable results. It is likely that specific patient subgroups benefit by varying amounts from each surgical procedure. Larger cohorts would also aid identification of these predictive factors, allowing adequate treatment selection. Implementation of a national database of meniscal operations, similar to the National Joint Registry and the National Hip Fracture Database in the United Kingdom, would also confer these benefits on a larger scale.This study has demonstrated a significant clinical benefit in patients with isolated meniscal tears undergoing arthroscopic knee surgery. The outcomes of meniscal repair were superior to that of meniscectomy at medium-term follow-up. Meniscal repair is a more biologically preserving procedure of the knee joint and should be performed preferentially over meniscectomy in isolated meniscal tears when feasible. The findings of this study will greatly benefit both clinicians and patients regarding the management of meniscal tears and better inform public health resource allocation.


Major depressive disorder (MDD) is a highly prevalent mental illness that often first occurs or persists into adulthood and is considered the leading cause of disability and disease burden worldwide. Unfortunately, individuals diagnosed with MDD who seek treatment often experience limited symptom relief and may not achieve long-term remission, which is due in part to our limited understanding of its underlying pathophysiology. Many studies that use task-based functional magnetic resonance imaging (fMRI) have found abnormal activation in brain regions in adults diagnosed with MDD, but those findings are often inconsistent; in addition, previous meta-analyses that quantitatively integrate this large body literature have found conflicting results.This meta-analysis aims to advance our understanding of the neural basis of MDD in adults, as measured by fMRI activation studies, and address inconsistencies and discrepancies in the empirical literature.We employed multilevel kernel density analysis (MKDA) with ensemble thresholding, a well-established method for voxel-wise, whole-brain meta-analyses, to conduct a quantitative comparison of all relevant primary fMRI activation studies of adult patients with MDD compared to age-matched healthy controls.We found that adults with MDD exhibited a reliable pattern of statistically significant  hyperactivation and hypoactivation in several brain regions compared to age-matched healthy controls across a variety of experimental tasks.This study supports previous findings that there is reliable neural basis of MDD that can be detected across heterogenous fMRI studies. These results can be used to inform development of promising treatments for MDD, including protocols for personalized interventions. They also provide the opportunity for additional studies to examine the specificity of these effects among various populations-of-interest, including youth vs. adults with depression as well as other related mood and anxiety disorders.None Declared


To review the pathophysiology of allergic asthma and information on the pharmacology, clinical efficacy, safety profile, and direct drug costs for omalizumab to provide a basis for a defined role of this agent in allergic asthma therapy in managed care organizations.Omalizumab is a monoclonal antibody targeting the high-affinity receptor binding site on human immunoglobulin E (IgE). When bound by omalizumab, IgE does not bind to basophils. As a result, degranulation is attenuated and allergic asthma symptoms are reduced. In asthma trials, omalizumab reduced inhaled corticosteroid and rescue medication requirements and improved asthma control and asthma quality of life in moderate-to-severe allergic asthmatics with disease poorly controlled by inhaled corticosteroids. Omalizumab has generally been well tolerated. However, injection site reactions occur in nearly 1 of every 2 patients, a problem that generally becomes less with continued dose administration. Severe injection site reactions are reported in 12% of patients. Other adverse events commonly reported in clinical trials include viral infections (23%), upper respiratory infections (20%), sinusitis (16%), headache (15%), and pharyngitis (11%). Because the acquisition cost of omalizumab is high , its use is cost-prohibitive in all but the most severe, poorly controlled allergic asthmatic patients who are utilizing large amounts of emergency health care resources to manage exacerbations. Experience with use of this drug beyond 52 weeks is lacking.Although omalizumab has demonstrated efficacy and safety in adults and adolescents with uncontrolled moderate-to-severe allergic asthma, its use should be restricted to a narrowly defined population of allergic asthmatics who utilize large amounts of health care resources. If targeted only toward this population, cost-of-care studies suggest that the high cost of this product in these patients could be offset by savings resulting from the less frequent use of high-intensity medical services for asthma exacerbations. The use of omalizumab beyond 52 weeks needs evaluation.


Mental Illness Stigma is a barrier in access to healthcare. Stigma also influences population health outcomes by worsening, undermining adequate processes. The healthcare professionals show several stigmatising behavirous and cognitions, which may impair the adequate provision of care of this population with mental illness.We aimed to measure mental health stigma in healthcare professionals at a portuguese hospital center.A cross-sectional study of health profissionals was performed using a survey that included socio-economic and job related questions, personal and familiar questions regarding mental health, and Attribution Questionnaire 27 (AQ-27), a translated and validated stigma questionnaire with nine stigma sub-scales .The sample included a total of 388 participants. The majority of the respondants were female . The age ranged from 22 to 69 . According to the job place distribution, we found statistically significant differences in various stigma subscales among several healthcare settings within our center. The inpatient unit professionals showed lesser stigmatising attitudes in anger, coercion, segregation and avoidance domains; and higher stigmatising attitudes in pity and help domains. However, professionals who work at surgery room showed higher stigmatising attitudes in danger and fear, but lesser levels of help domains. We also found differences in five stigma subscales among various health professions. The study didn’t show differences in stigma domains regarding personal or professional contact with mental illness, neither academic studies in mental health.Our findings suggest that workplace environment and profession may impact mental ilness stigma levels in healthcare professionals. We propose that future studies could be done to investigate methods to mitigate mental illness stigma, tailored to address different stigma domains in different workplace settings.None Declared


Alzheimer's disease (AD) is classified as a tauopathy and is the most common neuropathological correlate of dementia/cognitive impairment. AD is neuropathologically characterized by the presence of beta-amyloid immunoreactive senile plaques and tau positive neurofibrillary tangles. Neuropsychiatric symptoms of AD however continue to be underscored, and therefore, neuropathological correlates of these neuropsychiatric symptoms are not readily studied. Presented here is a case of 60-year-old female who initially presented with anxiety and depression, and continued to be the predominant symptoms although mild cognitive impairment was noted as per the available clinical notes. Postmortem examination of the brain revealed severe Alzheimer's type neuropathological changes, which included significant tau and beta-amyloid pathology in limbic regions, which were thought to represent correlates of the patient's depression and anxiety. This case report illustrates the possible neuropathological correlates of neuropsychiatric symptoms in patients with AD. The author hopes that such a case will promote more in-depth studies into the pathophysiology of neuropsychiatric manifestations in AD. Alzheimer's disease (AD) is regarded as a tauopathy associated with cognitive and functional decline in typically elderly (>65 years) patients although cases of early-onset (before age of 65 years) are possible . NeuropaLimited clinical information was available on the electronic medical chart. As per the information available, this female patient who was 60 years-old at first presentation reported difficulty with short-term memory along with difficulty sleeping. Psychiatric history included depression and anxiety. Neurological examination was notable for mini mental status (MMSE) of 25/30. The patient was clinically diagnosed with mild cognitive impairment based on the MMSE score. Unfortunately, no additional clinical information regarding her cognition could be found. With regards to her depression and anxiety, the patient reported feeling sad about some aspects of her life, and the episodes of sadness were exacerbated by difficulty in her first marriage and from having to switch employment. Clinically, she was diagnosed with major depressive disorder, generalized anxiety disorder, and mild cognitive decline.The patient passed away at hospice facility. After passing, a restricted autopsy limited to postmortem examination of the brain was requested to determine the etiology of her cognitive impairment.The weight of the unfixed brain was recorded at 1330 g. The cerebral hemispheres did not seem to display any significant atrophy. The coronal slices of the cerebral hemispheres did not reveal evidence of atrophy. Ventricular caliber appeared unremarkable. Hippocampus and amygdala did not appear shrunken. Pigment was visible in both the substantia nigra of the midbrain and locus ceruleus of the pons.Histologic examination with immunohistochemical work-up revealed evidence of cerebral amyloid angiopathy in the form of thickened blood vessels in the leptomeninges that were stained by beta amyloid immunohistochemistry. Sampled sections from the cerebral hemispheres showed several beta amyloid positive diffuse plaques and moderate amount of senile plaques throughout neocortex, including cingulate, calcarine, and entorhinal cortices, as well as in the thalamus. There were also scattered tau positive neurofibrillary tangles, neurites, and neuropil threads throughout the cortical gray matter including the superficial and deep layers of the calcarine cortex and entorhinal cortex. Thickened blood vessels that were not stained by beta amyloid immunohistochemistry, and hence consistent with arteriolosclerosis, were noted in the subcortical white matter. Left amygdala showed scattered tau positive neurofibrillary tangles, pretangles, neurites, neuropil threads, and argyrophilic grains. There were also numerous beta-amyloid positive diffuse and senile plaques in the amygdala. Examples of these findings are shown in Midbrain showed some beta amyloid positive diffuse and senile plaques. Although beta amyloid staining was observed in blood vessels of the cerebellar leptomeninges, no definite beta amyloid staining is seen within the cerebellar parenchyma.The final neuropathological diagnosis was reported as Alzheimer's type neuropathological changes ; Braak (neurofibrillary tangle) stage = 6 of 6; CERAD (senile plaque) score = C2 (moderate)); cerebral amyloid angiopathy; relatively mild arteriolosclerosis.n = 906) that psychotic symptoms  were more strongly related to the continuum of AD-associated cognitive dysfunction than other neuropsychiatric symptoms. The group also observed a negative correlation between psychotic symptoms and brain volume [n = 1038) that included AD and Lewy body disease pathology. The authors reported higher neurofibrillary tangle (NFT) stages to be associated with depression and agitation and hallucinations associated with higher Lewy body stages [To the author's knowledge, this case is one of the first case examples to demonstrate neuropathological correlation between Alzheimer's type neuropathological changes and clinical history of neuropsychiatric symptoms. Neuropsychiatric symptoms are described in patients with Alzheimer's disease, and animal models have suggested that behavioural and psychological symptoms increase with progressive neuropathology . Depressy stages . These rAPOE-region, respectively. Association analysis excluding the APOE-region identified numerous SNPs corresponding to 40 genes, 9 of which were known LOAD-risk loci primarily in chromosome 11 regions containing the SPI1gene and MS4A genes cluster, and others were novel pleiotropic risk-loci for LOAD conditional with MDD [Interestingly, genetic etiologies shared between AD and depression have been reported. Chiba‐Falek et al. performed pleiotropy analysis using genome-wide association studies (GWAS) from publicly accessible websites of AD GWAS and major depressive disorder (MDD) GWAS. The group found moderate enrichment of single nucleotide polymorphism (SNP) associated with late-onset AD (LOAD) across increasingly stringent levels of significance with the MDD GWAS association (LOAD|MDD), of maximum four and eight-folds, including and excluding the Herein, the author has presented neuropathologically severe Alzheimer's type neuropathological changes in a patient whose predominant presentation seems to be neuropsychiatric in the form of anxiety and depression. It is hoped that such a case will encourage further studies of the neuropathological correlates and pathophysiology of neuropsychiatric symptom in AD and other neurodegenerative disorders.


During the COVID-19 pandemic, mental health services often used remote technology to deliver care. However, the rise in remote consultation was largely unplanned. Furthermore, while many patients found remote technology a useful way to access care, others did not. Going forwards, remote technology will continue to play an important role in the delivery of mental healthcare. Research on the most effective ways for mental health services to implement remote technology is thus urgently needed.Electronic health records (EHRs) have been widely adopted in mental healthcare services. EHRs not only support individual patient care, but also open the door to largescale research through the analysis of de-identified clinical data. The South London and Maudsley (SLaM) Biomedical Research Centre (BRC) Case Register is a large EHR dataset comprising structured and unstructured clinical information on patients receiving specialist mental healthcare. In this talk, I will present findings from an analysis of the SLaM BRC Case Register using the Clinical Record Interactive Search tool (CRIS) to evaluate the uptake of remote mental healthcare during the COVID-19 pandemic and its association with medication prescribing. I will discuss the implications of these findings for psychiatrists delivering community mental healthcare and how mental health services can harness remote technology to optimise clinical outcomes.R. Patel Grant / Research support from: NIHR (NIHR301690); MRC (MR/S003118/1); Academy of Medical Sciences (SGL015/1020); Janssen, Consultant of: Induction Healthcare Ltd; Holmusk


Teaching Point: Subarachnoid hemorrhage is a rare complication of spinal dural arteriovenous fistulas (dAVF) with very characteristic imaging features, knowledge of which is crucial for positive diagnosis and rapid management. We report the case of 45-year-old male without a known history of neurological disease, presenting progressive weakness of lower limbs and tingling-like paresthesia. The evolution of the disease is marked by the onset of thunderclap headache. An endocranial computed tomography (CT) performed in the emergency department showed no particular anomaly. Then, a cerebral magnetic resonance imaging (MRI) was performed showing on axial images hyperintensity in the subarachnoid compatible with a peri mesencephalic subarachnoid hemorrhage space on T2 FLAIR with a normal time of flight (TOF) angiography .Cerebral angiography showed no specific findings.A medullar MRI was then suggested and demonstrated on T2-sagittal MRI  intramedAlso, it showed on axial T2  and postPatient was put under surveillance with symptomatic treatment and showed a recovered partial recovery of his motricity and sensitivity.Spinal dural arteriovenous fistulas (dAVF) are the most common spinal vascular malformations (75 to 80%) and more frequently affect male subjects over 50 years that exhibits arteriovenous shunting at the level of the internal leaflet dura mater, corresponding to an abnormal connection between the arterial supply from the medullary dura mater and the medullary venous system and no exact etiology has been fully elucidated .The clinical presentation of sdAVF is often progressive and non-specific mimicking demyelinating or degenerative diseases of the spine, which explains a frequent delay in diagnosis, resulting in an irreversible damage despite an endovascular or surgical intervention.Hemorrhage is very rare but occasionally encountered and may be a source of unexplained subarachnoid hemorrhage.MRI shows an association of centrally located hyperintense signal on T2-weighted images on TSE sequence, corresponding to chronic hypoxic congestive myelopathy attributable to venous hyper pressure hindering venous circulation, dilated peri medullary vessels, hypointense ‘flow void’ phenomena hypo intense in T2w images, appearing as enlarged and serpiginous veins anteriorly and/or posteriorly to the cord, enhancing after administration of gadolinium The absence of dilated peri medullary vessels do not formally eliminate the diagnosis of Davf. Dynamic MRA (angio-MRI) sequences are more sensitive assets to detect this abnormality.Principal differential diagnosis on imaging includes intramedullary neoplasm, spinal arteriovenous malformation where hemorrhage is common with acute onset, affecting males and females equally.Our case is unique as it depicts the importance of including spinal cord malformations in unexplained cerebral sub arachnoid hemorrhages.


ObjectiveCaregivers support individuals undergoing cancer treatment by assisting with activities, managing care, navigating healthcare systems, and communicating with care teams. We explored the quantity and quality of caregiver participation during recorded clinical appointments in women with metastatic breast cancer.MethodsThis was a convergent parallel mixed methods study. Caregiver participation quality was operationalized using a summative thematic content analysis to identify and sum caregiver roles performed during appointments. Caregiver participation quantity was measured by calculating the proportion of speaking time. Participation quality and quantity were compared to patient activation, assessed using the Patient Activation Measure.ResultsFifty-three clinical encounters were recorded. Identified caregiver roles included: General Support; Management of Treatment or Medication; Treatment History; Decision-Making; Insurance or Money; Pharmacy; Scheduling; Travel Concerns; General Cancer Understanding; Patient Specific Cancer Understanding; Caregiver-Initiated or Emphasis on Symptom Severity; and Caregiver Back-Up of Patient Symptom Description. Caregivers averaged 5 roles (SD 3): 48% of patients had low quality (< 5 roles) and 52% had high quality (> 6 roles). Regarding quantity, caregivers spoke on average for 4% of the encounter, with 60% of patients having low quantity (< 4%) and 40% of patients having high quantity (> 4%). Greater quality and quantity of caregiver participation was associated with greater patient activation.ConclusionsCaregivers perform a variety of roles during oncological decision-making visits aiding both patient and provider. Greater participation in terms of quantity and quality by the caregiver was associated with greater patient activism, indicating a need for better integration of the caregiver in clinical decision-making environments.


Populations face a suite of anthropogenic stressors acting simultaneously, which can combine additively or interact to have complex effects on population persistence. Yet we still know relatively little about the mechanisms underlying population-level responses to multifactorial combinations of stressors because multiple stressor impacts across organisms’ life cycles have not been systematically considered in population models. Specifically, different anthropogenic stressors can have variable effects across an organism’s life cycle, resulting in non-intuitive results for long-term population persistence. For example, synergistic or antagonistic interactions might exacerbate or alleviate the effects of stressors on population dynamics, and different life-history stages or vital rates might contribute unequally to long-term population growth rates. Demographic modelling provides a framework to incorporate individual vital rate responses to multiple stressors into estimates of population growth, which will allow us to make more informed predictions about population-level responses to novel combinations of anthropogenic change. Without integrating stressors’ interactive effects across the entire life cycle on population persistence, we may over- or underestimate threats to biodiversity and risk missing conservation management actions that could reduce species’ vulnerability to stress. As humans alter multiple facets of the environment simultaneously, addressing multiple, potentially interacting stressors will be critical for predicting species' responses. Yet the effects of multiple stressors across organisms' life cycle has not been systematically considered in demographic studies. Here, Zettlemoyer proposes a framework to explore the role of multiple stressors on population dynamics in order to make realistic predictions about population viability under different conservation scenarios. Specifically, demographic modelling provides a method to integrate stressors' potential additive and non-additive effects across the entire life cycle, provide mechanistic explanations of species loss and spread under combinations of novel conditions, and improve conservation and management plans. Reviews report that only 136 studies integrate multiple vital rate responses into plant demographic models  interactions among anthropogenic stressors and (ii) counteracting effects of stressors on different vital rates might influence population dynamics. Finally, I outline potential experimental designs that integrate multiple stressor effects across the life cycle to predict extinction risk under future environmental conditions.sensuadditive effects, wherein the combined effects of two stressors are equal to the sum of their individual effects (Alliaria petiolata (garlic mustard) interacts additively with deer herbivory to reduce population growth rates of Trillium erectum , only the combination of high levels of interspecific competition and insect herbivory results in population decline  and Viola palustris   .Eurybia furcata (forked aster), but only when site-level woody encroachment and deer herbivory are high (Cypripedium candidum (white lady’s slipper) under moderate climate change scenarios. However, as drought stress increases, protecting groundwater recharge zones in sites near this hydrologically sensitive species becomes increasingly important  (λ as a function of multiple interacting (a)biotic environmental conditions . In order to examine differences in λ between multiple stressors and determine the most relevant vital rate, log-transforming λ will help interpret the impact of vital rates on λ  can quantify the sensitivity of λ to changes in each vital rate and/or environmental variable  drive differences in λ. For example, invasion and deer herbivory affect multiple vital rates in T. erectum (red trillium), including growth and seedling recruitment, but an LTRE revealed that decreases in fertility largely drive declines in plant fitness , growth and survival show compensatory responses to warming that buffers overall population growth , compensatory responses of ramet growth and clonal reproduction buffer populations from the effects of grazing and harvest , density-dependent mortality due to post-dispersal seed consumption decreases seedling density, resulting in increased fecundity and therefore compensating for low seedling numbers (Pityopsis aspera var. aspera (pineland silkgrass), increasing density decreases λ, but this effect is alleviated by fire . Thus, IPMs, by incorporating environmental covariates in sub-regressions and allowing the use of size-based regression than discrete size classes, can overcome potential pitfalls of underpowered designs or smaller datasets , temperature and precipitation affect fecundity but not growth or survival  matrix population models, which use stage- or age-structured state variables and (ii) IPM, which use continuous (often size-dependent) state variables to predict population growth rates as well as (iii) population viability analyses that estimate population size (e.g. count data) from one monitoring event to the next.Vital rates: Rates corresponding to an organism’s individual life stages or progression through development .Additive effects: Type of interaction when the combined impact of two or more stressors on an ecological response is equal to than their algebraic sum; in this case, studies of single stressors can be added to estimate their combined effect.Non-additive interactions: Type of interaction when the combined impact of two or more stressors on an ecological response is not equal to their algebraic sum, such that the intensity of response to one stressor changes with the presence of the other; can be synergistic or antagonistic.Synergistic: Type of non-additive interaction when the combined impact of two or more stressors on an ecological response is greater than their algebraic sum; one stressor can exacerbate the effects of another.Antagonistic: Type of non-additive interaction when the combined impact of two or more stressors on an ecological response is less than their algebraic sum; one stressor can alleviate the effects of another.Perturbation analyses: Demographic analyses exploring how population growth rates respond to changes in vital rates; types of perturbation analysis include (i) prospective analyses (e.g. sensitivity and elasticity) that test how much λ depends on vital rates independent of variability and (ii) retrospective analyses (e.g. LTRE) that decompose variance in λ as a function of variance in vital rates.Demographic compensation: Opposing vital rate responses to stressors wherein the positive effects of one vital rate can negate the negative effects of another.Density-dependent processes: Population-level processes  that are sensitive to fluctuations in population density .Kernel: A probability density function that maps the change in the size distribution of individuals at time t to the size distribution after one timestep (t + 1).


Acne vulgaris is a common skin condition that affects both adolescents and adults worldwide and frequently results in acne scars . AtrophiA 2016 Cochrane study  providedData from some of the included RCTs showed that fractional laser, chemical peeling (with and without skin needling), and injectable fillers were more effective than comparator treatments. Many studies that compared other treatment modalities to each other or to placebo concluded no significant difference in either participant-reported or investigator-assessed scar improvement. This review  found moP=.0005). Another multicenter, randomized, prospective study [P=.0136). These studies further support the efficacy of injectable fillers for treating acne scars, though additional research with long-term follow-up is warranted to assess the durability of outcomes.Results of clinical trials published subsequent to this review  provide


Angioleiomyoma, a rare variant of leiomyoma, is a benign tumor of mesenchymal origin. Angioleiomyomas of the female urogenital tract are extremely rare, with only six cases of uterine cervical angioleiomyoma previously reported in the literature. In this case study, we report on a 49-year-old female patient who presented with menorrhagia whose initial magnetic resonance imaging (MRI) findings suggested cervical squamous cell carcinoma (SCC). However, following the hysterectomy, histological examination confirmed the lesion to be angioleiomyoma. To the best of our knowledge, there have been no previously reported cases of angioleiomyomas presenting with MRI findings that are suggestive of uterine SCC. Recognizing that angioleiomyomas can mimic uterine malignancies on MRI may prove beneficial for future diagnostic and treatment strategies.


Background: Measles is a highly transmissible respiratory virus that presents with nonspecific prodromal symptoms followed by a characteristic cephalocaudal rash. In the prodromal phase, children with measles can be challenging to differentiate from children with other circulating respiratory viral infections. A measles outbreak in Central Ohio starting in October 2022 coincided with a national surge in children with viral respiratory infections which presented unique challenges in preventing healthcare transmission in the pediatric ambulatory setting. Methods: Following initial identification of presumed community transmission of measles in Central Ohio in November 2022, a multidisciplinary measles response team was convened at Nationwide Children’s Hospital (NCH) to prevent secondary healthcare transmission via rapid-cycle quality improvement. Prevention efforts were focused broadly across NCH ambulatory locations in Central Ohio, including the main campus and offsite emergency departments, regional urgent cares, and primary care network. Preliminary risk factors were identified via chart review of initial cases, which included vaccine status, ZIP code of residence, and known daycare or household exposure. These risk factors were used to guide an intervention bundle comprising enhanced screening at registration and triage, creation of electronic medical record alerts to identify at-risk patients, increased clinician education, and expanded community messaging. As the outbreak evolved, risk factors were updated, and interventions were adjusted to adapt response. Outcome metrics included total patient exposures as well as the relative exposure score. The exposure score was an internal metric derived using the vaccine status of exposed patients and ventilation at the site of exposure to assess likelihood of secondary cases occurring from an exposure. Results: In total, 65 patients with measles were seen at NCH facilities between October 29 and December 8, 2022. The outbreak response was divided into 4 periods: (1) cases identified retrospectively prior to first diagnosis , (2) initial case discovery , (3) implementation of prevention bundle , and (4) updates to the response . Ambulatory healthcare exposures and incidence of secondary cases decreased over the outbreak periods in response to implementation of the prevention bundle . Conclusions: An outbreak of measles occurring simultaneously with peak respiratory viral season presented challenges in early identification of suspected cases and mitigation of healthcare exposure. Transmission was effectively prevented following rapid deployment of a prevention bundle adjusted in real-time through rapid-cycle quality improvement. Ongoing longitudinal vaccination efforts are needed to sufficiently mitigate transmission risk in communities with under-vaccinated populations.Disclosures: None


Background: A sustainable, continuous supply of alcohol-based hand rub (ABHR) is essential for healthcare workers in health facilities. The WHO provides guidance for production in individual health facilities. In Uganda, using this guidance, an innovative approach was implemented at the district local government level to produce and subsequently distribute ABHR to primary-care health facilities that have limited capacity for local facility-level production. This project was supported by the CDC in collaboration with the Infectious Diseases Institute (IDI) and targeted governmental or district engagement with local partners to ensure sustainability. Methods: District stakeholders were engaged to obtain buy-in and define roles and responsibilities. Overall, 4 staff members in each of 6 supported districts were nominated by District Health Officers for training: 2 staff members were trained to produce ABHR and conduct internal quality control and 2 were trained on external quality control. Districts provided ABHR production-unit facilities and facilitated integration within the government essential supplies delivery system, National Medical Stores in Uganda, which supports last-mile delivery to facilities. An implementing partner purchased initial raw materials necessary for production. The cost of materials for local production was compared to the price of commercial ABHR available in Uganda. Results: Between January and August 2021, 23 staff members were trained, and 380 batches of quality-assured ABHR  were produced and distributed to 278 health facilities. Consumption of ABHR in the first distribution was used to benchmark predicted ABHR consumption per targeted facility in subsequent months. Increased demand for ABHR due to the COVID-19 pandemic and the Ebola virus disease outbreak in central Uganda (September 2022) was addressed through emergency requests on a case-by-case basis. ABHR local production costs $3 per liter for materials, less than half of commercial ABHR ($8 per liter). Conclusions: Early results suggest that this approach is potentially sustainable but requires national advocacy as well. Leveraging existing distribution systems while building local capacity for ABHR production and distribution may improve longevity of such innovations in similar resource-limited settings.Disclosure: None