Regular Reassessment Research Articles

The 2024 ESC guidelines for management of atrial fibrillation : AF-CARE as new credo

The new 2024 ESC guidelines on the management of patients with atrial fibrillation (AF) introduces the AF-CARE pathway as the central acronym for AF management. As aresult, the management of Comorbidities and risk factors is moving to the forefront of AF management. However, the new guideline also includes important changes in Avoidance stroke and thromboembolism, such as amodified risk score (CHA2DS2-VA) and astatement on anticoagulation in subclinical atrial fibrillation. There are also changes in the concepts of Rhythm and rate control with an upgrading of rhythm control and catheter ablation. Finally, the guideline recommends regular Evaluation and reassessment of the patient's course for optimal AF management. Here, we summarize key points of the new guidelines and discusses some recommendations on aspects that can also be assessed differently.

Implementation of trans-cystic biliary stenting during acute cholecystectomy to facilitate elective ERCP: a quality improvement initiative.

A predominantly endoscopic approach for acute admissions with choledocholithiasis with a gallbladder in situ (CGIS) resulted in prolonged hospital length of stay due to delays at investigation and treatment junctures. We initiated a quality improvement program of trans-cystic biliary stenting to facilitate efficient patient progress to acute cholecystectomy and outpatient ERCP if required. We utilized implementation frameworks with regular re-assessment for this quality improvement project. Patients who required both ERCP and cholecystectomy for management of CGIS were identified for comparison of total length of stay before and after implementation. The outcomes for stent insertion and ERCP were also collected for analysis. Twenty-three trans-cystic stents were attempted with 22 inserted successfully. The median total length of stay for all patients requiring both ERCP and cholecystectomy for management of CGIS was shorter compared to 6 months prior to implementation (5 days (range 3-18) vs. 6 days (range 5-17); P = 0.009). The median stenting time was 14 min (range 9-48). After stent insertion, more ERCPs were performed as day-only outpatient cases (20/23 (87.0%) vs. 6/44 (13.6%) P < 0.001). The rate of pancreatic duct wire cannulation at ERCP was also lower (1/23 (4.3%) vs. 18/44 (40.9%); P = 0.002). No complications of stent insertion or ERCP were recorded in the study cohort. Implementation of trans-cystic stents can lead to reductions in total hospital length of stay and improve ERCP processes. Our experience suggests that surgical initiatives can be successfully added to routine practice by establishing a project team and applying quality improvement principles.

Extrapulmonary Mycobacterium abscessus Infections, France, 2012-20201.

Mycobacterium abscessus infection is challenging to treat. Extrapulmonary M. abscessus infections (EP-MAB) are less common than pulmonary M. abscessus infections. To evaluate treatment regimens, we retrospectively analyzed consecutive microbiologically confirmed EP-MAB cases diagnosed in France during 2012-2020. We studied 45 patients with EP-MAB, including 14 bone and joint infections, 10 skin and soft tissue infections, and 8 lymph node infections. Most (62%) patients had no reported immunodeficiency. In 27 patients, EP-MAB followed healthcare-associated (44%) or environmental (16%) injuries. Of the 45 isolates, 25 were subspecies abscessus, 10 bolletii, and 9 massiliense; 1 was unidentified. Cure was achieved for 36 (80%) patients who received a median antimicrobial regimen of 6 months; 22 (55%) also underwent surgery. Four patients died, and 5 were unavailable for follow-up. EP-MAB predominantly affects immunocompetent patients after an injury; outcomes are favorable. We propose a >6-month regimen of antimicrobial therapy with consideration for surgery and regular patient reassessment.

Mapping coastal resilience: a Gis-based Bayesian network approach to coastal hazard identification for Queensland’s dynamic shorelines

Coastal regions worldwide face increasing threats from climate change-induced hazards, necessitating more accurate and comprehensive vulnerability assessment tools. This study introduces an innovative approach to coastal vulnerability assessment by integrating Bayesian Networks (BN) with the modern coastal vulnerability (CV) framework. The resulting BN-CV model was applied to Queensland's coastal regions, with a particular focus on tide-modified and tide-dominated beaches, which constitute over 85% of the studied area. The research methodology involved beach classification based on morphodynamic characteristics, spatial subdivision of Queensland's coast into 78 sections, and the application of the BN-CV model to analyze interactions between geomorphological features and oceanic dynamics. This approach achieved over 90% accuracy in correlating beach types with vulnerability factors, significantly outperforming traditional CVI applications. Key findings include the identification of vulnerability hotspots and the creation of detailed exposure and sensitivity maps for Gold Coast City, Redland City, Brisbane City, and the Sunshine Coast Regional area. The study revealed spatial variability in coastal vulnerability, providing crucial insights for targeted management strategies. The BN-CV model demonstrates superior precision and customization capabilities, offering a more nuanced understanding of coastal vulnerability in regions with diverse beach typologies. This research advocates for the adoption of the BN-CV approach to inform tailored coastal planning and management strategies, emphasizing the need for regular reassessments and sustained stakeholder engagement to build resilience against climate change impacts.Recommendations include prioritizing adaptive infrastructure in high-exposure areas like the Gold Coast, enhancing flood management in Brisbane, improving socio-economic adaptive capacity in Redland, and maintaining natural defences in Moreton Bay. This study contributes significantly to the field of coastal risk management, providing a robust tool for policymakers and coastal managers to develop more effective strategies for building coastal resilience in the face of climate change.

An approach to risk categorization of Products of Animal Origin imported into the United Kingdom

There are thousands of potential hazards associated with imported foods and to achieve an excellent food safety record, resources need to be focused on higher-risk foods and preventive mechanisms.We were tasked to develop an automated tool to assess public health risks from imported foods across multiple countries of origin, hazards and product types to replace manually conducted single product-hazard qualitative import assessments.In this paper we describe the generic import assessment of risk to consumers from importing foodborne microbiological hazards into the UK, to identify those higher-risk foods. A risk categorization approach was developed as recommended by international standards laid out in the CODEX principles and guidance by FAO and WHO on food control. The approach combines an assessment of the inherent risk of the commodity (product characteristics), and any hazard mitigation or control measures undertaken in the producing country (control characteristics) and incorporates real-world global data relating to food safety incidents over a three-year time window (compliance) for that product.With the broad diversity of foods imported, food stuffs are grouped into commodity groups using the codes in the international Harmonised System of classification. The mapping of trade into commodity groups and the scoring system developed to estimate risk are presented.Results by exporting country were generated for 16 selected public health hazards identified from global food safety incident data using expert elicitation.To ensure the approach is dynamic, can keep pace with global trends, and uses resources efficiently, the assessment has been automated and predominantly uses data that is global, publicly available and routinely updated.The results support risk managers in their regular reassessment of the controls that should be placed on foodstuffs imported into the UK.

Ocular melanosis in the adult Cairn Terrier population within the United Kingdom.

Prospective investigation to determine the prevalence of ocular melanosis in adult Cairn Terriers within the United Kingdom using a previously established staging scheme. Ophthalmic assessment was performed on adult Cairn Terriers, recruited from various geographic locations within the United Kingdom. Examination included gonioscopy, rebound tonometry, slit lamp biomicroscopy, and indirect ophthalmoscopy, performed by one examiner (AM). A total of 93 dogs were examined, including 52 females and 41 males, aged between 15 months and 16 years 4 months. Sixty of 93 dogs (64.5%) were >7 years of age. Nine of 93 dogs (9.6%) demonstrated changes consistent with ocular melanosis. Four of 9 (44.4%) had Stage 1 disease and 5 of 9 (55.6%), Stage 2. Stages 3 or 4 were not identified in any dogs. Mean intraocular pressures in affected and unaffected dogs were 14.7 mmHg (range 12-17 mmHg) and 12.8 mmHg (range 5-21 mmHg), respectively. Incomplete pupil dilation was noted in affected dogs following pharmacologic mydriasis. Ocular melanosis was identified in approximately 10% of examined dogs, over half were dogs of breeding age (<7 years of age). It is possible that Grade 1 disease could go undetected, prior to obvious scleral pigment accumulation (Grade 2 disease). It is therefore recommended that dogs undergoing pre-breeding screens have pre-dilation assessment of the anterior segment using slit lamp biomicroscopy with subsequent gonioscopy to clearly assess for circumferential thickening of the iris base that might otherwise go undetected. Additionally, regular reassessment of breeding dogs is advised as disease progression could be rapid.

Redefining disability certification for mental illness in India: Towards global standards and functional assessments.

This viewpoint advocates for significant reforms in the disability certification guidelines for mental illnesses in India. Currently, two years duration of illness is required before certification, which delays essential support. The proposed model emphasizes assessing the functional impact of conditions, aligns with global standards, and suggests regular reassessments to improve accessibility and inclusivity in mental health services.

Update on Effects of the Prophylactic HPV Vaccines on HPV Type Prevalence and Cervical Pathology.

Most national prophylactic HPV vaccination programs started in approximately 2008, with either the bivalent Cervarix HPV16/18 or quadrivalent Gardasil (HPV6/11/16/18) vaccines, which were then followed by introduction of the nonavalent Gardasil 9 (HPV6/11/16/18/ 31/33/45/52/58) vaccine from 2015. Since that time, these products have demonstrated their ability to prevent infection with vaccine-covered HPV types and subsequent development of HPV-related cervical and genital pathologies. The data indicate that vaccination of young girls prior to sexual debut is more effective than vaccination of older HPV+ve women. Although some studies have shown a decline in the prevalence of vaccine-covered HPV types, there are national and regional differences in overall vaccine efficacy. Furthermore, several recently published studies show an increase in the prevalence of non-vaccine-covered HPV types in vaccinated populations, which is indicative of HPV type-replacement. It is also notable that vaccine-related changes in HPV type prevalence spread between vaccinated and unvaccinated women at the same geographical location-presumably via sexual transmission. In conclusion, it is not yet clear what effect dissemination of vaccine-associated changes in HPV type prevalence will have on vaccine efficacy and cervical pathology, particularly in mixed populations of vaccinated and unvaccinated women. However, it is very clear these observations do underscore the need for long-term continuation of cervical screening combined with regular reassessment of testing practices.

"Re-evaluation of variants of uncertain significance in patients with hereditary arrhythmogenic disorders"

BackgroundGenetic diagnostics support the diagnosis of hereditary arrhythmogenic diseases, but variants of uncertain significance (VUS) complicate matters, emphasising the need for regular reassessment. Our study aims to reanalyse rare variants in different genes in order to decrease VUS diagnoses and thus improve risk stratification and personalized treatment for patients with arrhythmogenic disorders.MethodsGenomic DNA was analysed using Sanger sequencing and next-generation sequencing (NGS). The Data was evaluated using various databases and in silico prediction tools and classified according to current ACMG standards by two independent experts.ResultsWe identified 53 VUS in 30 genes, of which 17 variants (32%) were reclassified. 13% each were downgraded to likely benign (LB) and benign (B) and 6% were upgraded to likely pathogenic (LP). Reclassifications mainly occurred among variants initially classified in 2017–2019, with rates ranging from 50 to 60%.ConclusionThe results support the assumption that regular reclassification of VUS is important, as it provides new insights for genetic diagnostics, that benefit patients and guide therapeutic approach.

Optimizing diuretic management in acute decompensated heart failure: the impact of diuretic algorithm in real-world setting

Abstract Background/Introduction Achieving euvolaemia is an important prognostic factor in acutely decompensated heart failure (ADHF). The European Society of Cardiology (ESC) guidelines suggest that a stepwise diuretic treatment algorithm based on regular reassessment of urinary output and natriuresis may be superior compared to current standard of care. We studied the implementation and effectiveness of such a pre-specified algorithm in a real-word cohort for realizing euvolaemia. Methods In 2020 we implemented the stepped diuretic strategy from the Heart Failure Association position statement, now stated in the 2021 ESC guidelines, in a peripheral hospital. Afterwards we conducted a retrospective cohort study, including patients with ADHF (with hospitalization duration &amp;gt; 3 days for decongestive treatment). Patients admitted between 10-Jan-2021 and 04-Dec-2021, who were treated according to the diuretic algorithm (protocol cohort), were compared to patients who were treated between 04-Jan-2018 and 19-jan-2019 (before implementation of this algorithm). Our primary outcomes were length of hospital stay (days), complications during hospitalization, such as electrolyte disturbance, kidney function, arrhythmias, infections and mortality during hospitalization. Results The study comprised 221 patients, with 107 in the pre-protocol cohort and 114 in the protocol cohort. Baseline characteristics were similar between the cohorts, expect for the kidney function and NT-proBNP levels at admission. Mean eGFR was slightly better in the protocol cohort (53 [36-71] vs 43 [29-63] ml/min/1.73m2, p .016), were as NT-proBNP was higher in the pre-protocol cohort (990 vs 480 pmol/l) (Table 1). The mean length of stay was shorter in the protocol cohort (7.0 [5.1-10.3] vs 7.5 [5.9-10.9] days). The incidence of complications, such as electrolyte disturbances and arrhythmias, were comparable. Notably, the mean eGFR on third day of hospitalization was higher in the protocol cohort (50 ± 21 vs. 42 ± 19 ml/min/1.73m2). There was a difference in the median weight lost during the admission between the two cohorts (Figure 1). Conclusion Our data suggest that a pre-specified stepwise diuretic treatment algorithm, based on urinary output is feasible and effective in achieving euvolaemia in a real-world cohort. Furthermore, it reduces length of hospital stay without increasing the risk of complications.

Obesity and Asthma: Implementing a Treatable Trait Care Model.

Recognition of obesity as a treatable trait of asthma, impacting its development, clinical presentation and management, is gaining widespread acceptance. Obesity is a significant risk factor and disease modifier for asthma, complicating treatment. Epidemiological evidence highlights that obese asthma correlates with poorer disease control, increased severity and persistence, compromised lung function and reduced quality of life. Various mechanisms contribute to the physiological and clinical complexities observed in individuals with obesity and asthma. These encompass different immune responses, including Type IVb, where T helper 2 cells are pivotal and driven by cytokines like interleukins 4, 5, 9 and 13, and Type IVc, characterised by T helper 17 cells and Type 3 innate lymphoid cells producing interleukin 17, which recruits neutrophils. Additionally, Type V involves immune response dysregulation with significant activation of T helper 1, 2 and 17 responses. Finally, Type VI is recognised as metabolic-induced immune dysregulation associated with obesity. Body mass index (BMI) stands out as a biomarker of a treatable trait in asthma, readily identifiable and targetable, with significant implications for disease management. There exists a notable gap in treatment options for individuals with obese asthma, where asthma management guidelines lack specificity. For example, there is currently no evidence supporting the use of incretin mimetics to improve asthma outcomes in asthmatic individuals without Type 2 diabetes mellitus (T2DM). In this review, we advocate for integrating BMI into asthma care models by establishing clear target BMI goals, promoting sustainable weight loss via healthy dietary choices and physical activity and implementing regular reassessment and referral as necessary.

Predictive value of the World falls guidelines algorithm within the AGELESS-MELoR cohort

AimThe World Falls Guidelines (WFG) Task Force published a falls risk stratification algorithm in 2022. However, its adaptability is uncertain in low- and middle-income settings such as Malaysia due to different risk factors and limited resources. We evaluated the effectiveness of the WFG risk stratification algorithm in predicting falls among community-dwelling older adults in Malaysia. MethodsData from the Malaysian Elders Longitudinal Research subset of the Transforming Cognitive Frailty into Later-Life Self-Sufficiency cohort study was utilized. From 2013–2015, participants aged ≥55 years were selected from the electoral rolls of three parliamentary constituencies in Klang Valley. Risk categorisation was performed using baseline data. Falls prediction values were determined using follow-up data from wave 2 (2015–2016), wave 3 (2019) and wave 4 (2020–2022). ResultsOf 1,548 individuals recruited, 737 were interviewed at wave 2, 858 at wave 3, and 742 at wave 4. Falls were reported by 13.4 %, 29.8 % and 42.9 % of the low-, intermediate- and high-risk groups at wave 2, 19.4 %, 25.5 % and 32.8 % at wave 3, and 25.8 %, 27.7 % and 27.0 % at wave 4, respectively. At wave 2, the algorithm generated a sensitivity of 51.3 % (95 %CI, 43.1–59.2) and specificity of 80.1 % (95 %CI, 76.6–83.2). At wave 3, sensitivity was 29.4 % (95 %CI, 23.1–36.6) and specificity was 81.6 % (95 %CI, 78.5–84.5). At wave 4, sensitivity was 26.0 % (95 %CI, 20.2–32.8) and specificity was 78.4 % (95 %CI, 74.7–81.8). ConclusionThe algorithm has high specificity and low sensitivity in predicting falls, with decreasing sensitivity over time. Therefore, regular reassessments should be made to identify individuals at risk of falling.

Aetiology of vaginal discharge, urethral discharge, and genital ulcer in sub-Saharan Africa: A systematic review and meta-regression.

Syndromic management is widely used to treat symptomatic sexually transmitted infections in settings without aetiologic diagnostics. However, underlying aetiologies and consequent treatment suitability are uncertain without regular assessment. This systematic review estimated the distribution, trends, and determinants of aetiologies for vaginal discharge, urethral discharge, and genital ulcer in sub-Saharan Africa (SSA). We searched Embase, MEDLINE, Global Health, Web of Science, and grey literature from inception until December 20, 2023, for observational studies reporting aetiologic diagnoses among symptomatic populations in SSA. We adjusted observations for diagnostic test performance, used generalised linear mixed-effects meta-regressions to generate estimates, and critically appraised studies using an adapted Joanna Briggs Institute checklist. Of 4,418 identified records, 206 reports were included from 190 studies in 32 countries conducted between 1969 and 2022. In 2015, estimated primary aetiologies for vaginal discharge were candidiasis (69.4% [95% confidence interval (CI): 44.3% to 86.6%], n = 50), bacterial vaginosis (50.0% [95% CI: 32.3% to 67.8%], n = 39), chlamydia (16.2% [95% CI: 8.6% to 28.5%], n = 50), and trichomoniasis (12.9% [95% CI: 7.7% to 20.7%], n = 80); for urethral discharge were gonorrhoea (77.1% [95% CI: 68.1% to 84.1%], n = 68) and chlamydia (21.9% [95% CI: 15.4% to 30.3%], n = 48); and for genital ulcer were herpes simplex virus type 2 (HSV-2) (48.3% [95% CI: 32.9% to 64.1%], n = 47) and syphilis (9.3% [95% CI: 6.4% to 13.4%], n = 117). Temporal variation was substantial, particularly for genital ulcer where HSV-2 replaced chancroid as the primary cause. Aetiologic distributions for each symptom were largely the same across regions and population strata, despite HIV status and age being significantly associated with several infection diagnoses. Limitations of the review include the absence of studies in 16 of 48 SSA countries, substantial heterogeneity in study observations, and impeded assessment of this variability due to incomplete or inconsistent reporting across studies. In our study, syndrome aetiologies in SSA aligned with World Health Organization guidelines without strong evidence of geographic or demographic variation, supporting broad guideline applicability. Temporal changes underscore the importance of regular aetiologic re-assessment for effective syndromic management. CRD42022348045.

Management of cognitive impairment associated with post-COVID-19 syndrome: recommendations for primary care.

Introduction: Although post-COVID-19 syndrome (PCS) with cognitive impairment is increasingly encountered in primary care, evidence-based recommendations for its appropriate management are lacking. Methods: A systematic literature search evaluating the diagnosis and treatment of cognitive impairment associated with PCS was conducted. Practical recommendations for the management of PCS-associated cognitive impairment in primary care are summarized, based on an evaluation of pharmacological plausibility and clinical applications. Results: Currently, the pathology of cognitive impairment associated with PCS remains unclear with no high-quality data to support targeted interventions. Existing treatment approaches are directed towards symptom relief where counseling on the chronicity of the disease and regular reassessments at 4- to 8-week intervals is considered reasonable. Patients should be informed and encouraged to adopt a healthy lifestyle that centers around balanced nutrition and appropriate physical activities. They may also benefit from the intake of vitamins, micronutrients, and probiotics. The administration of Ginkgo biloba extract could offer a safe and potentially beneficial treatment option. Other non-pharmacological measures include physiotherapy, digitally supported cognitive training, and, if indicated, ergotherapy or speech therapy. In most patients, symptoms improve within 8 weeks. If serious, ambiguous, or when new symptoms occur, specialized diagnostic measures such as comprehensive neurocognitive testing or neuroimaging should be initiated. Very few patients would require inpatient rehabilitation. Conclusion: PCS with cognitive impairment is a debilitating condition that could affect daily functioning and reduce work productivity. Management in primary care should adopt a multidisciplinary approach, centering around physical, cognitive, and pharmacological therapies.

Review of recommendations for bisphosphonate treatment interruption-discontinuation

Bisphosphonates are the main medications in the treatment of osteoporosis, which are effective in reducing the risk of fractures in patients with osteoporosis. It is known that after treatment with bisphosphonates, bone mineral density remains quite stable for a certain time, as well as markers of bone metabolism remain reduced, which, along with the side effects of long-term bisphosphonate therapy, determines the possibility of “Drug holidays”. At the same time, during a break in bisphosphonate treatment, the risk of fractures begins to increase, which is a reason to resume therapy.Currently, there is no uniform worldwide data of starting a “drug holidays” on bisphosphonates. The duration of the “drug holidays” also differs in clinical recommendations from different countries. When to conduct a risk assessment of fractures during a “drug holidays”? To answer these questions, we assessed existing clinical recommendations for treatment interruption/discontinuation of bisphosphonates. A literature search was conducted using the following resources: PubMed®, the Cochrane Library, websites of major international osteoporosis associations, and other targeted Internet searches. The main search terms were “Clinical Guideline of Osteoporosis”, “Bisphosphonates”, “Drug holidays in osteoporosis”, “Discontinuation of bisphosphonates”. Тhe search was carried out using articles in Russian and English published between January 1, 2016 and September 15, 2023. 17 clinical guidelines from different countries (Russian, American, European, Asian and Australian) were found and analyzed in which was information about the break in the treatment and withdrawal of bisphosphonates.The majority of clinical recommendations have the same opinion on the issue of starting “drug holidays”: with a moderate risk of fractures, you can take a break from treatment with tableted bisphosphonates after 5 years, after zoledronic acid — after 3 years of therapy. At high and very high risk of fractures, the duration of treatment is 10 and 6 years, respectively. The duration of “drug holidays” vary in the recommendations, but in most cases the decision-making is based not on the duration, but on the assessment of the risk of fractures with their regular reassessment, which includes previous and new low-energy fractures, the emergence of new risk factors, a decrease in BMD, the dynamics of bone markers, re-evalua­tion of FRAX®.

Comparing the Performance of Popular Large Language Models on the National Board of Medical Examiners Sample Questions.

Large language models (LLMs) have transformed various domains in medicine, aiding in complex tasks and clinical decision-making, with OpenAI's GPT-4, GPT-3.5, Google's Bard, and Anthropic's Claude among the most widely used. While GPT-4 has demonstrated superior performance in some studies, comprehensive comparisons among these models remain limited. Recognizing the significance of the National Board of Medical Examiners (NBME) exams in assessing the clinical knowledge of medical students, this study aims to compare the accuracy of popular LLMs on NBME clinical subject exam sample questions. The questions used in this study were multiple-choice questions obtained from the official NBME website and are publicly available. Questions from the NBME subject exams in medicine, pediatrics, obstetrics and gynecology, clinical neurology, ambulatory care, family medicine, psychiatry, and surgery were used to query each LLM. The responses from GPT-4, GPT-3.5, Claude, and Bard were collected in October 2023. The response by each LLM was compared to the answer provided by the NBME and checked for accuracy. Statistical analysis was performed using one-way analysis of variance (ANOVA). A total of 163 questions were queried by each LLM. GPT-4 scored 163/163(100%), GPT-3.5 scored 134/163 (82.2%), Bard scored 123/163 (75.5%), and Claude scored 138/163 (84.7%). The total performance of GPT-4 was statistically superior to that of GPT-3.5, Claude, and Bard by 17.8%, 15.3%, and 24.5%, respectively. The total performance of GPT-3.5, Claude, and Bard was not significantly different. GPT-4 significantly outperformed Bard in specific subjects, including medicine, pediatrics, family medicine, and ambulatory care, and GPT-3.5 in ambulatory care and family medicine. Across all LLMs, the surgery exam had the highest average score (18.25/20), while the family medicine exam had the lowest average score (3.75/5). Conclusion: GPT-4's superior performance on NBME clinical subject exam sample questions underscores its potential in medical education and practice. While LLMs exhibit promise, discernment in their application is crucial, considering occasional inaccuracies. As technological advancements continue, regular reassessments and refinements are imperative to maintain their reliability and relevance in medicine.

Enhancing Occupant Comfort and Building Sustainability: Lessons from an Internet of Things-Based Study on Centrally Controlled Indoor Shared Spaces in Hot Climatic Conditions.

It is well known that buildings have a sizeable energy and environmental footprint. In particular, in environments like university campuses, the occupants as well as occupancy in shared spaces varies over time. Systems for cooling in such environments that are centrally controlled are typically threshold driven and do not account for occupant feedback and thus are often relying on a reactive approach (fix after identifying problems). Therefore, having a fixed thermal operating set point may not be optimal in such cases-both from an occupant comfort and well-being as well as an energy efficiency perspective. To address this issue, a study was conducted which involved development and deployment of an experimental Internet of Things (IoT) prototype system and an Android application that facilitated people engagement on a university campus located in the UAE which typically exhibits hot climatic conditions. This paper showcases data driven insights obtained from this study, and in particular, how to achieve a balance between the conflicting goals of improving occupant comfort and energy efficiency. Findings from this study underscore the need for regular reassessments and adaptation. The proposed solution is low cost and easy to deploy and has the potential to reap significant savings through a reduction in energy consumption with estimates indicating around 50-100 kWh/day of savings per building and the resulting environmental impact. These findings would appeal to stakeholders who are keen to improve energy efficiency and reduce their operating expenses and environmental footprint in such climatic conditions. Furthermore, collective action from a large number of entities could result in significant impact through this cumulative effect.

Identifying opportunities for high resolution pesticide usage data to improve the efficiency of endangered species pesticide risk assessment

The US pesticide registration and review process requires regular re-assessment of the risk of pesticide use to species listed under the Endangered Species Act (ESA), yet current assessment methods are inefficient when applied to hundreds of pesticides potentially impacting multiple species across a continent. Thus, many pesticides remain on the market without complete review. We assessed the value of using high resolution pesticide usage data in the risk assessment process to rapidly improve process efficiency. By using data available only in California, we found that high resolution data increased the number of species deemed not likely to be adversely affected by pesticides from <5 % to nearly 50 %. Across the contiguous US, we predicted that 48 % of species would be deemed not likely to be adversely affected using high resolution data, compared to 20 % without. However, if such data were available in just 11 states, 68 % of the available gains in efficiency could be obtained. Overall, using existing high-resolution data in California and a focused collection of such information from 11 other states could reduce risk assessment burden across the contiguous U.S. by one-quarter.

Seasonal prediction of the distribution of three major malaria vectors in China: Based on an ecological niche model.

Against the backdrop of a global malaria epidemic that remains severe, China has eradicated indigenous malaria but still has to be alert to the risk of external importation. Understanding the distribution of vectors can provide an adequate and reliable basis for the development and implementation of vector control strategies. However, with the decline of malaria prevalence in recent years, the capacity of vector monitoring and identification has been greatly weakened. Here we have used new sampling records, climatic data, and topographic data to establish ecological niche models of the three main malaria vectors in China. The model results accurately identified the current habitat suitability areas for the three species of Anopheles and revealed that in addition to precipitation and temperature as important variables affecting the distribution of Anopheles mosquitoes, topographic variables also influenced the distribution of Anopheles mosquitoes. Anopheles sinensis is the most widespread malaria vector in China, with a wide region from the northeast (Heilongjiang Province) to the southwest (Yunnan Province) suitable for its survival. Suitable habitat areas for Anopheles lesteri are concentrated in the central, eastern, and southern regions of China. The suitable habitat areas of Anopheles minimus are the smallest and are only distributed in the border provinces of southern China. On this basis, we further assessed the seasonal variation in habitat suitability areas for these three major malaria vectors in China. The results of this study provide new and more detailed evidence for vector monitoring. In this new era of imported malaria prevention in China, regular reassessment of the risk of vector transmission is recommended.

Misdiagnosis of Cutaneous Epithelioid Angiosarcoma as Diabetic Foot Ulcer: A Case Study

Background. AS is a malignant tumor that originates from vascular endothelial cells and is known for a high rate of local recurrence and metastasis. Case Report. A 48-year-old male presented with cutaneous epithelioid AS. Cutaneous AS of the foot is quite rare, especially in the absence of predisposing factors, and in this patient it was previously misdiagnosed as a DFU. Conclusion. Physicians should be aware of this rare presentation of cutaneous AS. The authors of the current report advise regular clinical reassessment of chronic ulcers and biopsies of nonhealing wounds, even when adequate wound treatment has been administered, with the goal of identifying ulcerated skin malignancies and preventing delay in providing appropriate treatment.