The Royal Melbourne Hospital

In this systematic review and meta-analysis, we aimed to investigate the effectiveness and safety of corneal cross-linking (CXL) in patients with keratoconus and thin corneas (corneal thickness <400μm).

Guidelines for the conventional (Dresden) CXL protocol to treat keratoconus recommend patients have a minimum stromal thickness of ≥400μm to avoid endothelial damage. Newer CXL methods have been developed for thinner corneas. Evaluation of clinical outcomes is required to inform surgical decisions and maximize the number of people who can safely benefit from CXL.

MEDLINE Ovid, Embase Ovid, and Scopus were searched in July 2024 for studies published in peer-reviewed journals in English. Prospective and retrospective case series, cohort studies, and randomized clinical trials of people with corneal thickness of <400μm (with or without epithelium) who underwent CXL for keratoconus were eligible, regardless of CXL approach. Key outcomes included maximum and mean corneal curvature (K_max and K_mean) corrected and uncorrected distance visual acuity, refractive error, corneal thickness, and endothelial cell density at 3, 6, 12, and 24 months. Random effects meta-analysis was used to pool average change from preoperative values across CXL protocols. Study quality was assessed using the JBI Critical Appraisal Checklist for Case Series. PROSPERO registration: CRD42023403190.

Twenty-nine records published between 2011 and 2024 were included with a total of 470 eyes. Most studies were retrospective case series with substantial potential for bias. Substantial heterogeneity was observed between studies in terms of patients, CXL approach and observed outcomes. At 12 months, flattening of the maximum corneal curvature (mean change in K_max: -1.4D, 95% CI [-2.0, -0.9], n=17/402 studies/eyes, I² =93%) and improvement in corrected distance visual acuity (mean change -0.09 log MAR units, 95% CI [-0.13, -0.06], n = 19/443 studies/eyes, I² = 68%) were observed relative to baseline. No study reported major complications and there were minimal reductions in corneal thickness and endothelial cell density.

Visual and keratometric parameters improved following CXL without major complications, suggesting CXL may be suitable for patients with stromal thicknesses of <400μm, providing adequate modifications have been applied. Prospective comparative studies are required to guide the choice of approach.

In patients receiving continuous renal replacement therapy (CRRT) for acute kidney injury (AKI), excessive net ultrafiltration (NUF) rates >1.75 mL/kg/h have been associated with increased mortality, delayed AKI recovery and complications of hemodynamic instability. There is limited information on fluid removal practices and NUF rates in AKI patients treated with intermittent hemodialysis (IHD).We conducted a retrospective study of AKI patients who underwent IHD at our center between 2020 and 2023. The primary outcome was NUF rate, assessed as body weight-scaled, body surfaces area-scaled and unadjusted values. Secondary outcomes included mortality and measures of renal recovery at 90 days (estimated glomerular filtration rate [eGFR], major adverse kidney events [MAKE], IHD dependence and days to liberation from IHD).We studied 74 patients (median age 62 years [IQR 46-71], median baseline eGFR 81 mL/min/1.73 m² [IQR 71-96]). The median NUF rate was 5.61 mL/kg/h (weight scaled), 228 mL/h/m² (BSA-scaled), and 462 mL/h (unadjusted). Higher fluid removal rates were observed in patients with better baseline kidney function, while older age, diabetes and hypertension were associated with lower rates. No significant differences in AKI recovery, dialysis dependence, or change in renal function at 90 days were observed between high and low NUF groups. By 90 days, 45 patients (60.8%) had developed a MAKE.Among AKI patients, median NUF rates during IHD was higher than reported for CRRT and influenced by comorbidity and pre-morbid eGFR. At 90 days, MAKE was common, two thirds of patients had a > 25% eGFR reduction, and one in 12 had died.

Stroke incidence and outcomes are disproportionately unfavorable among Indigenous populations in Western colonized countries. These inequities are often attributed to poor health literacy. This paper summarizes recent evidence on the topic of Indigenous health literacy, describes current gaps, and proposes priorities for future work/research.

Traditionally, much focus has been placed on improving health literacy for Indigenous Peoples as a key intervention to address Indigenous stroke and other health disparities. Recent literature, however, challenges this approach as it risks stigmatization and marginalization and portrays the deficiencies as sitting with Indigenous people. Increasingly, an emphasis is placed on the need for health literacy approaches to be culturally responsive for the populations of interest, for institutions to provide high quality culturally relevant stroke care, and for providers to upskill in cultural safety to better meet the needs of Indigenous patient populations. Very little evidence exists to indicate that stroke care providers are meeting these needs. To close the health gap and improve stroke care for Indigenous Peoples, the focus needs to shift from promoting health literacy among Indigenous Peoples to providing high quality culturally relevant health care. More research into this topic and monitoring of progress over time is needed.