Ranibizumab (Lucentis) in neovascular age-related macular degeneration: evidence from clinical trials

BACKGROUND: Neovascular age-related macular degeneration (AMD) has a poor prognosis if left untreated, frequently resulting in legal blindness. Ranibizumab is approved for treating neovascular AMD. However, further guidance is needed to assist ophthalmologists in clinical practice to optimise treatment outcomes. METHODS: An international retina expert panel assessed evidence available from prospective, multicentre studies evaluating different ranibizumab treatment schedules (ANCHOR, MARINA, PIER, SAILOR, SUSTAIN and EXCITE) and a literature search to generate evidence-based and consensus recommendations for treatment indication and assessment, retreatment and monitoring. RESULTS: Ranibizumab is indicated for choroidal neovascular lesions with active disease, the clinical parameters of which are outlined. Treatment initiation with three consecutive monthly injections, followed by continued monthly injections, has provided the best visual-acuity outcomes in pivotal clinical trials. If continued monthly injections are not feasible after initiation, a flexible strategy appears viable, with monthly monitoring of lesion activity recommended. Initiation regimens of fewer than three injections have not been assessed. Continuous careful monitoring with flexible retreatment may help avoid vision loss recurring. Standardised biomarkers need to be determined. CONCLUSION: Evidence-based guidelines will help to optimise treatment outcomes with ranibizumab in neovascular AMD.

Population based screening - the difficulty of how to do more good than harm and how to achieve it

Screening people without symptoms of disease is an attractive idea. Screening allows early detection of disease or elevated risk of disease, and has the potential for improved treatment and reduction of mortality. The list of future screening opportunities is set to grow because of the refinement of screening techniques, the increasing frequency of degenerative and chronic diseases, and the steadily growing body of evidence on genetic predispositions for various diseases. But how should we decide on the diseases for which screening should be done and on recommendations for how it should be implemented? We use the examples of prostate cancer and genetic screening to show the importance of considering screening as an ongoing population-based intervention with beneficial and harmful effects, and not simply the use of a test. Assessing whether screening should be recommended and implemented for any named disease is therefore a multi-dimensional task in health technology assessment. There are several countries that already use established processes and criteria to assess the appropriateness of screening. We argue that the Swiss healthcare system needs a nationwide screening commission mandated to conduct appropriate evidence-based evaluation of the impact of proposed screening interventions, to issue evidence-based recommendations, and to monitor the performance of screening programmes introduced. Without explicit processes there is a danger that beneficial screening programmes could be neglected and that ineffective, and potentially harmful, screening procedures could be introduced.

Geographic information system-based decision support for soil conservation planning in Tajikistan

Soil erosion on sloping agricultural land poses a serious problem for the environment, as well as for production. In areas with highly erodible soils, such as those in loess zones, application of soil and water conservation measures is crucial to sustain agricultural yields and to prevent or reduce land degradation. The present study, carried out in Faizabad, Tajikistan, was designed to evaluate the potential of local conservation measures on cropland using a spatial modelling approach to provide decision-making support for the planning of spatially explicit sustainable land use. A sampling design to support comparative analysis between well-conserved units and other field units was established in order to estimate factors that determine water erosion, according to the Revised Universal Soil Loss Equation (RUSLE). Such factor-based approaches allow ready application using a geographic information system (GIS) and facilitate straightforward scenario modelling in areas with limited data resources. The study showed first that assessment of erosion and conservation in an area with inhomogeneous vegetation cover requires the integration of plot-based cover. Plot-based vegetation cover can be effectively derived from high-resolution satellite imagery, providing a useful basis for plot-wise conservation planning. Furthermore, thorough field assessments showed that 25.7% of current total cropland is covered by conservation measures (terracing, agroforestry and perennial herbaceous fodder). Assessment of the effectiveness of these local measures, combined with the RUSLE calculations, revealed that current average soil loss could be reduced through low-cost measures such as contouring (by 11%), fodder plants (by 16%), and drainage ditches (by 53%). More expensive measures such as terracing and agroforestry can reduce erosion by as much as 63% (for agroforestry) and 93% (for agroforestry combined with terracing). Indeed, scenario runs for different levels of tolerable erosion rates showed that more cost-intensive and technologically advanced measures would lead to greater reduction of soil loss. However, given economic conditions in Tajikistan, it seems advisable to support the spread of low-cost and labourextensive measures.

Experiences in Monitoring and Assessment of Sustainable Land Management

Although sustainable land management (SLM) is widely promoted to prevent and mitigate land degradation and desertification, its monitoring and assessment (M&A) has received much less attention. This paper compiles methodological approaches which to date have been little reported in the literature. It draws lessons from these experiences and identifies common elements and future pathways as a basis for a global approach. The paper starts with local level methods where the World Overview of Conservation Approaches and Technologies (WOCAT) framework catalogues SLM case studies. This tool has been included in the local level assessment of Land Degradation Assessment in Drylands (LADA) and in the EU-DESIRE project. Complementary site-based approaches can enhance an ecological process-based understanding of SLM variation. At national and sub-national levels, a joint WOCAT/LADA/DESIRE spatial assessment based on land use systems identifies the status and trends of degradation and SLM, including causes, drivers and impacts on ecosystem services. Expert consultation is combined with scientific evidence and enhanced where necessary with secondary data and indicator databases. At the global level, the Global Environment Facility (GEF) knowledge from the land (KM:Land) initiative uses indicators to demonstrate impacts of SLM investments. Key lessons learnt include the need for a multi-scale approach, making use of common indicators and a variety of information sources, including scientific data and local knowledge through participatory methods. Methodological consistencies allow cross-scale analyses, and findings are analysed and documented for use by decision-makers at various levels. Effective M&A of SLM [e.g. for United Nations Convention to Combat Desertification (UNCCD)] requires a comprehensive methodological framework agreed by the major players.

Homeopathic Preparations of Quartz, Sulfur and Copper Sulfate Assessed by UV-Spectroscopy

Homeopathic preparations are used in homeopathy and anthroposophic medicine. Although there is evidence of effectiveness in several clinical studies, including double-blinded randomized controlled trials, their nature and mode of action could not be explained with current scientific approaches yet. Several physical methods have already been applied to investigate homeopathic preparations but it is yet unclear which methods are best suited to identify characteristic physicochemical properties of homeopathic preparations. The aim of this study was to investigate homeopathic preparations with UV-spectroscopy. In a blinded, randomized, controlled experiment homeopathic preparations of copper sulfate (CuSO(4); 11c-30c), quartz (SiO(2); 10c-30c, i.e., centesimal dilution steps) and sulfur (S; 11×-30×, i.e., decimal dilution steps) and controls (one-time succussed diluent) were investigated using UV-spectroscopy and tested for contamination by inductively coupled plasma mass spectrometry (ICP-MS). The UV transmission for homeopathic preparations of CuSO(4) preparations was significantly lower than in controls. The transmission seemed to be also lower for both SiO(2) and S, but not significant. The mean effect size (95% confidence interval) was similar for the homeopathic preparations: CuSO(4) (pooled data) 0.0544% (0.0260-0.0827%), SiO(2) 0.0323% (-0.0064% to 0.0710%) and S 0.0281% (-0.0520% to 0.1082%). UV transmission values of homeopathic preparations had a significantly higher variability compared to controls. In none of the samples the concentration of any element analyzed by ICP-MS exceeded 100 ppb. Lower transmission of UV light may indicate that homeopathic preparations are less structured or more dynamic than their succussed pure solvent.

Effectiveness of integrated psychological therapy (IPT) for schizophrenia patients: a research update

Standardized recovery criteria go beyond symptom remission and put special emphasis on personal and social functioning in residence, work, and leisure. Against this background, evidence-based integrated approaches combining cognitive remediation with social skills therapy show promise for improving functional recovery of schizophrenia patients. Over the past 30 years, research groups in 12 countries have evaluated integrated psychological therapy (IPT) in 36 independent studies. IPT is a group therapy program for schizophrenia patients. It combines neurocognitive and social cognitive interventions with social skills and problem-solving approaches. The aim of the present study was to update and integrate the growing amount of research data on the effectiveness of IPT. We quantitatively reviewed the results of these 36 studies, including 1601 schizophrenia patients, by means of a meta-analytic procedure. Patients undergoing IPT showed significantly greater improvement in all outcome variables (neurocognition, social cognition, psychosocial functioning, and negative symptoms) than those in the control groups (placebo-attention conditions and standard care). IPT patients maintained their mean positive effects during an average follow-up period of 8.1 months. They showed better effects on distal outcome measures when all 5 subprograms were integrated. This analysis summarizes the broad empirical evidence indicating that IPT is an effective rehabilitation approach for schizophrenia patients and is robust across a wide range of sample characteristics as well as treatment conditions. Moreover, the cognitive and social subprograms of IPT may work in a synergistic manner, thereby enhancing the transfer of therapy effects over time and improving functional recovery.

Ordering CT pulmonary angiography to exclude pulmonary embolism: defense versus evidence in the emergency room

To identify reasons for ordering computed tomography pulmonary angiography (CTPA), to identify the frequency of reasons for CTPA reflecting defensive behavior and evidence-based behavior, and to identify the impact of defensive medicine and of training about diagnosing pulmonary embolism (PE) on positive results of CTPA.

[Integrating psychotherapeutic treatment of severe mental illness: between desirability and clinical practice]

Psychiatric care for severe and persistent mentally ill individuals has considerably changed over the last three decades. Striving for improvement in services provision for these patients has led to the emergence of various specialized community services, suited housing and supported work offers. Moreover, community-based treatment is also offered during acute episodes of mental illness. At the same time a range of evidence-based psychotherapeutic approaches targeting treatment needs of people with severe mental illness were developed in a process independent of the rise of community psychiatry. At present, however, a sufficient level of coordination of psychiatric services and integration of evidence-based psychological treatment into psychiatric care has not been achieved. Thus, these issues represent important steps in the further development.This paper discusses recent developments in psychiatric care of people with severe mental illness and reviews the evidence-based psychotherapy approaches suited to fit the needs of patient-centered integrated care.

The precipitous decline of the ortolan bunting Emberiza hortulana: time to build on scientific evidence to inform conservation management

In recent decades there has been a marked decline in most ortolan bunting Emberiza hortulana populations in temperate Europe, with many regional populations now extinct or on the brink of extinction. In contrast, Mediterranean and, as far as we know, eastern European popula-tions seem to have remained relatively stable. The causes of decline remain unclear but include: habitat loss and degradation, and related reduction in prey availability; climate change on the breeding grounds; altered population dynamics; illegal captures during migration; and environmental change in wintering areas. We review the current knowledge of the biology of the ortolan bunting and discuss the proposed causes of decline in relation to the different population trends in temperate and Mediterranean Europe. We suggest new avenues of research to identify the factors limiting ortolan bunting populations. The main evidence-based conservation measure that is likely to enhance habitat quality is the creation of patches of bare ground to produce sparsely vegetated foraging grounds in invertebrate-rich grassy habitats close to breeding areas.

Integrated psychological therapy (IPT) for schizophrenia: is it effective?

Against the background of evidence-based treatments for schizophrenia, nowadays the implementation of specific cognitive and behavioral interventions becomes more important in the standard care of these patients. Over the past 25 years, research groups in 9 countries have carried out 30 independent evaluations of Integrated Psychological Therapy (IPT), a group program that combines neurocognitive and social cognitive interventions with social skills approaches for schizophrenic patients. The aim of the present study was to evaluate the effectiveness of IPT under varying treatment and research conditions in academic and nonacademic sites. In a first step, all 30 published IPT studies with the participation of 1393 schizophrenic patients were included in the meta-analysis. In a second step, only high-quality studies (HQS) (7 studies including 362 patients) were selected and analyzed to check whether they confirmed the results of the first step. Positive mean effect sizes favoring IPT over control groups (placebo-attention conditions, standard care) were found for all dependent variables, including symptoms, psychosocial functioning, and neurocognition. Moreover, the superiority of IPT continued to increase during an average follow-up period of 8.1 months. IPT obtained similarly favorable effects across the different outcome domains, assessment formats (expert ratings, self-reports, and psychological tests), settings (inpatient vs outpatient and academic vs nonacademic), and phases of treatment (acute vs chronic). The HQS confirmed the results of the complete sample. The analysis indicates that IPT is an effective rehabilitation approach for schizophrenia that is robust across a wide range of patients and treatment conditions.

Opportunistic and systematic screening for chlamydia: a study of consultations by young adults in general practice

BACKGROUND: Opportunistic screening for genital chlamydia infection is being introduced in England, but evidence for the effectiveness of this approach is lacking. There are insufficient data about young peoples' use of primary care services to determine the potential coverage of opportunistic screening in comparison with a systematic population-based approach. AIM: To estimate use of primary care services by young men and women; to compare potential coverage of opportunistic chlamydia screening with a systematic postal approach. DESIGN OF STUDY: Population based cross-sectional study. SETTING: Twenty-seven general practices around Bristol and Birmingham. METHOD: A random sample of patients aged 16-24 years were posted a chlamydia screening pack. We collected details of face-to-face consultations from general practice records. Survival and person-time methods were used to estimate the cumulative probability of attending general practice in 1 year and the coverage achieved by opportunistic and systematic postal chlamydia screening. RESULTS: Of 12 973 eligible patients, an estimated 60.4% (95% confidence interval [CI] = 58.3 to 62.5%) of men and 75.3% (73.7 to 76.9%) of women aged 16-24 years attended their practice at least once in a 1-year period. During this period, an estimated 21.3% of patients would not attend their general practice but would be reached by postal screening, 9.2% would not receive a postal invitation but would attend their practice, and 11.8% would be missed by both methods. CONCLUSIONS: Opportunistic and population-based approaches to chlamydia screening would both fail to contact a substantial minority of the target group, if used alone. A pragmatic approach combining both strategies might achieve higher coverage.

Potential of information technology in dental education

The use of information technology (IT) in dentistry is far ranging. In order to produce a working document for the dental educator, this paper focuses on those methods where IT can assist in the education and competence development of dental students and dentists (e.g. e-learning, distance learning, simulations and computer-based assessment). Web pages and other information-gathering devices have become an essential part of our daily life, as they provide extensive information on all aspects of our society. This is mirrored in dental education where there are many different tools available, as listed in this report. IT offers added value to traditional teaching methods and examples are provided. In spite of the continuing debate on the learning effectiveness of e-learning applications, students request such approaches as an adjunct to the traditional delivery of learning materials. Faculty require support to enable them to effectively use the technology to the benefit of their students. This support should be provided by the institution and it is suggested that, where possible, institutions should appoint an e-learning champion with good interpersonal skills to support and encourage faculty change. From a global prospective, all students and faculty should have access to e-learning tools. This report encourages open access to e-learning material, platforms and programs. The quality of such learning materials must have well defined learning objectives and involve peer review to ensure content validity, accuracy, currency, the use of evidence-based data and the use of best practices. To ensure that the developers' intellectual rights are protected, the original content needs to be secure from unauthorized changes. Strategies and recommendations on how to improve the quality of e-learning are outlined. In the area of assessment, traditional examination schemes can be enriched by IT, whilst the Internet can provide many innovative approaches. Future trends in IT will evolve around improved uptake and access facilitated by the technology (hardware and software). The use of Web 2.0 shows considerable promise and this may have implications on a global level. For example, the one-laptop-per-child project is the best example of what Web 2.0 can do: minimal use of hardware to maximize use of the Internet structure. In essence, simple technology can overcome many of the barriers to learning. IT will always remain exciting, as it is always changing and the users, whether dental students, educators or patients are like chameleons adapting to the ever-changing landscape.

A comparison of pixel and object-based land cover classification. A case study of the Asmara region, Eritrea

In this paper we compare the performance of two image classification paradigms (object- and pixel-based) for creating a land cover map of Asmara, the capital of Eritrea and its surrounding areas using a Landsat ETM+ imagery acquired in January 2000. The image classification methods used were maximum likelihood for the pixel-based approach and Bhattacharyya distance for the object-oriented approach available in, respectively, ArcGIS and SPRING software packages. Advantages and limitations of both approaches are presented and discussed. Classifications outputs were assessed using overall accuracy and Kappa indices. Pixel- and object-based classification methods result in an overall accuracy of 78% and 85%, respectively. The Kappa coefficient for pixel- and object-based approaches was 0.74 and 0.82, respectively. Although pixel-based approach is the most commonly used method, assessment and visual interpretation of the results clearly reveal that the object-oriented approach has advantages for this specific case-study.

Sustainable Land Management (SLM) Practices in Drylands: How Do They Address Desertification Threats?

Managing land sustainably is a huge challenge, especially under harsh climatic conditions such as those found in drylands. The socio-economic situation can also pose challenges, as dryland regions are often characterized by remoteness, marginality, low-productive farming, weak institutions, and even conflict. With threats from climate change, disputes over water, competing claims on land, and migration increasing worldwide, the demands for sustainable land management (SLM) measures will only increase in the future. Within the EU-funded DESIRE project, researchers and stakeholders jointly identified existing SLM technologies and approaches in 17 dryland study sites located in the Mediterranean and around the world. In order to evaluate and share this valuable SLM experience, local researchers documented the SLM technologies and approaches in collaboration with land users, utilizing the internationally recognized WOCAT questionnaires. This article provides an analysis of 30 technologies and 8 approaches, enabling an initial evaluation of how SLM addresses prevalent dryland threats, such as water scarcity, soil degradation, vegetation degradation and low production, climate change, resource use conflicts, and migration. Among the impacts attributed to the documented technologies, those mentioned most were diversified and enhanced production and better management of water and soil degradation, whether through water harvesting, improving soil moisture, or reducing runoff. Favorable local-scale cost–benefit relationships were mainly found when considered over the long term. Nevertheless, SLM was found to improve people’s livelihoods and prevent further outmigration. More field research is needed to reinforce expert assessments of SLM impacts and provide the necessary evidence-based rationale for investing in SLM.

Infection Prevention in the Emergency Department.

Infection prevention remains a major challenge in emergency care. Acutely ill and injured patients seeking evaluation and treatment in the emergency department (ED) not only have the potential to spread communicable infectious diseases to health care personnel and other patients, but are vulnerable to acquiring new infections associated with the care they receive. This article will evaluate these risks and review the existing literature for infection prevention practices in the ED, ranging from hand hygiene, standard and transmission-based precautions, health care personnel vaccination, and environmental controls to strategies for preventing health care-associated infections. We will conclude by examining what can be done to optimize infection prevention in the ED and identify gaps in knowledge where further research is needed. Successful implementation of evidence-based practices coupled with innovation of novel approaches and technologies tailored specifically to the complex and dynamic environment of the ED are the keys to raising the standard for infection prevention and patient safety in emergency care.