Woodlands Hospital

Renin-angiotensin-aldosterone system inhibitor (RAASi) therapies are a cornerstone of guideline-directed medical therapy in the management of cardiorenal disease, including chronic kidney disease and heart failure. Management guidelines state that these therapies should be prescribed at the maximum licensed or tolerated dose in order to prevent disease progression and adverse events. However, both cardiorenal disease and RAASi therapies increase the risk of hyperkalaemia. When hyperkalaemia occurs, clinicians often down-titrate or discontinue these important RAASi therapies, leaving patients at risk of adverse cardiorenal outcomes. Eleven cardiorenal experts considered how hyperkalaemia can act as a barrier to optimised RAASi therapy in patients with cardiorenal disease and how these issues could be mitigated. Four key areas of suboptimal and variable clinical practice were identified: optimisation of RAASi therapy; definition and management of acute hyperkalaemia; secondary to primary care communications; and patient education. In this podcast article, two of the experts discuss the clinical challenges and principles of optimal care for each of the four areas identified. The experts agreed that hyperkalaemia should be considered a predictable and manageable condition, requiring a pre-emptive and long-term approach. When hyperkalaemia occurs, down-titrating or discontinuing RAASi therapy should be a last resort, after all other management approaches have been employed. Healthcare professionals in secondary and primary care must communicate and collaborate to ensure effective, consistent management of patients with cardiorenal disease. Finally, patients should be educated to understand their cardiorenal disease and its management and the importance of optimal RAASi therapy. Supplementary file1 (MP4 173853 KB).

BackgroundBlood eosinophils have become an invaluable tool in the assessment, management, and prognostication of patients with asthma and chronic obstructive pulmonary disease (COPD). Historically, the understanding and application of blood eosinophil counts (BEC) have been primarily based on data from high-income countries, with limited information available from developing regions, including the Indian subcontinent.Research QuestionThis study aims to assess the distribution and clinical relevance of BEC among patients with asthma and COPD as well as healthy volunteers across India, to determine if patterns observed in Western studies hold true in an Indian setting.Study Design and MethodsA multi-centre cross-sectional study was conducted at 16 clinics across India. Participants included patients diagnosed with asthma or COPD and healthy volunteers who were identified from referrals to these clinics. Comprehensive data collection involved demographics, medication use, smoking status, and pre- and post-bronchodilator spirometry. All participants underwent a laboratory full blood count.ResultsThe study comprised 4782 adults, including 1,332 patients with asthma (571 males, 761 females), 1,001 patients with COPD (691 males, 310 females), and 2,449 healthy volunteers (1,399 males, 1,050 females). Among patients with asthma, the mean BEC was higher at geometric mean 173.9 [156.2, 193.6]; patients with COPD had a mean BEC of 198.4 [178.6, 220.4] which was significantly higher than that of healthy volunteers (144.7 [134.5, 155.5]).InterpretationThe range of eosinophils in the contemporary Indian population aligns with data from Europe, affirming the validity of using BEC as a biomarker in obstructive lung disease within the Indian demographic. This insight challenges the prevailing assumption of distinct eosinophil count profiles in different geographical regions and underscores the global applicability of eosinophil-based management strategies for asthma and COPD.

There is current apprehension among some clinicians and conflicting evidence regarding ocular complications in relation to Glucagon-like peptide-1 receptor agonists (GLP-1RAs). We aimed to generate multi-disciplinary, expert-led consensus recommendations relating to ocular complications to facilitate optimum prescribing of GLP-1RAs. A modified Delphi was conducted following the ACcurate COnsensus Reporting Document (ACCORD) for Delphi research. A structured literature review informed an anonymous online Delphi questionnaire, followed by a virtual consensus meeting. Eligible participants included ophthalmologists, diabetologists, and obesity specialists practising in Europe. Responses from 58 participants across 17 countries were analysed. Respondents agreed that diabetic retinopathy (DR) worsening events are primarily linked to rapid blood glucose-lowering, rather than a direct drug effect. The benefits of GLP-1RAs were deemed to outweigh potential ocular risks and should not limit access to these medicines. Prescribers should ensure that people with diabetes are screened for diabetic retinopathy before commencing GLP-1RAs, particularly in high-risk populations (>10 years duration and/or poor glucose control, (haemoglobin A1c [HbA1c] >10% or 86 mmol/mol)). When prescribing GLP-1RA to those with sight loss in one eye and/or prior history of non-arteritic anterior ischaemic optic neuropathy (NAION), the risk of ocular complications should be discussed. The Delphi study highlighted current uncertainty in the evidence, with some topics on the relationship between GLP-1RAs and ocular complications reaching limited consensus. Further research is needed into the direct effects of GLP-1RAs on the retina and ocular complications. New evidence should be disseminated rapidly to optimise outcomes and safety.

IntroductionPainful diabetic peripheral neuropathy (pDPN) affects approximately 25% of individuals with diabetes in the UK and remains underdiagnosed and suboptimally managed in primary care. The condition causes chronic pain, limits daily functioning, impairs quality of life, and increases the risk of complications like foot ulcers and amputations due to underlying neuropathy. Current care pathways are fragmented, leading to delays in diagnosis and limited access to evidence-based therapies. This article aims to address the challenges of screening, diagnosis, and management of pDPN in UK primary care by proposing a consensus-driven, five-step pragmatic strategy.MethodsAn expert panel of general practitioners and a diabetes nurse practitioner from across the UK convened to review and discuss strategies for improving pDPN care. Consensus was reached through an evaluation of barriers in clinical practice, supported by real-world experience and examples of innovative care delivery models, resulting in the development of practical recommendations and workflow.ResultsKey barriers identified include insufficient training of healthcare professionals in pDPN, underutilisation of validated screening tools such as the DN4 questionnaire, and inconsistent and outdated treatment guidelines. To address these challenges, a five-step approach was proposed to include screening high-risk patients using validated questionnaires, following up on these patients to enable early diagnoses, initiating early treatments with first-line therapies while monitoring responses, referring complex cases to secondary care on the basis of structured criteria, and ensuring coordinated follow-up to streamline and optimise care delivery. Case studies demonstrate the practical application of these strategies in improving early detection, treatment adherence, and long-term care for individuals with pDPN.ConclusionCurrent practices have fallen short in providing adequate care for one in four individuals with diabetes. Implementing a straightforward five-step approach can significantly improve diagnostic accuracy and treatment outcomes, reducing the burden of pDPN on both patients and society.

Abstract Mosquitoes are the deadliest animal on Earth, responsible for over 725,000 deaths annually due to the diseases they spread. Malaria deaths alone increased by 82% from 1980 to 2004, highlighting a growing global health crisis. To combat this problem, I developed two custom Convolutional Neural Networks (CNNs) based on the Ultralytics You Only Look Once (YOLO) v8 standard to detect Mosquito Breeding Grounds (MBGs) in both aerial and ground-based imagery. Proactively identifying and removing the MBGs promptly can save lives. I trained my aerial model, which has three million parameters, 225 layers, and a mean Average Precision at 50 Percent Intersection over Union score (mAP@50IoU) of over 90%, on a dataset comprising over 5,100 aerial images of MBGs. My UpClose model has the same structure, a dataset of over 1,200 photographs, and took 225 Epochs to train. My Aerial model can enhance the precision and efficiency of public health efforts by enabling administrative bodies worldwide to detect MBGs via drones and other aerial methods, allowing for their prompt removal. My UpClose model empowers everyday citizens to make a positive impact in their communities by detecting MBGs using a smartphone. This project demonstrates the transformative potential of Machine Learning in identifying MBGs with high accuracy, preventing outbreaks, and saving thousands of lives, making a global health impact.

The studied succession, located on Mainland Orkney and the island of Westray, lies in cyclic flagstones of Middle Devonian lake laminites. The lake bed of each cycle is constrained above and below by marginal lake facies that reflect a transition from open playa to permanent lake and vice versa, referred to as transition sequences. Abundant sedimentary structures in these sequences, previously described as subaqueous shrinkage cracks or subaqueous cracks, are reinterpreted as gypsum pseudomorphs. The study shows the small structures to have prismatic, lensoid and clustered forms of gypsum in graded stages of growth and supports a new perception of the palaeoclimate and its close interdependence with periodic gypsum growth. A lake model reconstruction of lake floor morphology and its link to seasonal palaeoclimate illustrates the case for the presence of limited size pseudomorphs. It is suggested that the occurrence of consistently small pseudomorphs is a consequence of a strongly regular, wet–dry tropical monsoon palaeoclimate, coupled with an extremely low-gradient lake floor, allowing short-term gypsum growth in strongly evaporating conditions across widely oscillating lake shorelines, the remarkable preservation of pseudomorphs being a consequence of dolomitization.

Mycorrhizal facilitation and root competition interact to determine forest adaptability to global change, specifically the myriad stressors affecting trees in temperate hardwoods. As managers seek to apply forest adaptation strategies to climate change—including maintaining current canopy conditions, expanding representation of trees at their northern range limit, or moving future climate-adapted species to forests outside their current range—it is essential to understand how belowground interactions affect seedling success under different management scenarios. We planted three species of arbuscular mycorrhizal (AM) seedlings representing different adaptation strategies: Acer saccharum (sugar maple), Prunus serotina (black cherry), and Nyssa sylvatica (black gum) under selective pre-salvage harvests of Fraxinus americana and 0.1 ha harvest gaps at three levels of root access, assessing changes in growth, survival, and foliar nitrogen (seedling success). We found that while sugar maple in the selective harvests initially demonstrated higher AM fungal colonization, survival, and foliar N, root exclusion facilitated success of all three species after a second season, especially in the harvest gaps. These findings show that despite the potential loss of root access and AM fungal inoculum with increased harvest intensity, climate-adaptive management could improve AM seedling success through competition release.