Recent Submissions

  • Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

    Watson, Nicholas; Gercek, Yuksel; Guy, Kramer; Holden, Douglas; Whysall, Karen (BJS, 2019-01)
    Background: The Clavien-Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien-Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods: This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien-Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results: A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien-Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion: Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.
  • Low trauma posterior native hip dislocation with acute longitudinal transverse myelitis due to SARS-CoV-2 - A case-report

    Pandya, Chiraag; Sangoi, Dhrumin; Badhe, Sachin (2021-08)
    Background: Native hip dislocations are most commonly seen after high energy trauma. While there are documented cases of hip dislocation with associated stroke, we present a case of posterior hip dislocation in the context of acute longitudinal transverse myelitis due to a rare presentation of SARS-CoV-2. Case report: A 60-year-old male presented with bilateral lower limb weakness with a shortened internally rotated left leg. Plain radiographs revealed a posteriorly dislocated native left hip and MRI of the spine showed acute longitudinal transverse myelitis of the cervical and thoracic regions. His nasopharyngeal swab was positive for SARS-CoV-2. His hip was reduced, and he was treated with intravenous steroids. His neurological symptoms improved with follow-up MRI showing resolution of the transverse myelitis. Conclusion: This case illustrates a classic orthopaedic emergency in the context of a rare presentation of SARS-CoV-2, and the vigilance that orthopaedic doctors must have when examining patients with lower limb neurological deficit.
  • Does Patellar Resurfacing Matter? Midterm Follow-Up of MRK Total Knee Replacement

    Sangoi, Dhrumin; Gokhale, Nikhil; Kothari, Paresh; Kulkarni, Sushrut (2020-09)
    Background: Many designs of TKR have been developed to optimize the kinematics and improve satisfaction, including the 'medial rotating' philosophy. The purpose of this study is to report the mid-term clinical outcome of MRK knees and evaluate whether resurfacing the patella makes any difference in outcome. Methods: A retrospective analysis was done of 104 MRK total knee replacement done between 2008 and 2017. Patients were called for a review for evaluation of OKS, Baldini and Feller scores. Demographics of the patients, clinical outcome, complications were assessed. Results: 62 had patellar resurfacing. Mean follow-up was 74.45 months in non- resurfaced and 54.93 months in resurfaced group. Mean flexion range in both groups at final follow-up was 101.45. Median OKS at follow-up was 36 (12-47) in non-resurfaced and 37 (9-48) in resurfaced group. Patella scores were better in resurfaced group-Baldini score median (range) was 90 (25-100) in non-resurfaced v/s 100 (30-100) in resurfaced, Feller score median (range) was 25 (12-30) in non-resurfaced v/s 28 (10-30) (p 0.042) in resurfaced. The patellofemoral component of the OKS (Q5 + Q7 + Q12) median showed an improvement from 3 (1-11) to 6.5 (3-11) in non-resurfaced and from 3 (0-12) to 8 (2-12) (p 0.039) in resurfaced group. There were five complications overall (4.8%). Conclusion: These results show a satisfactory outcome at mid-term follow-up. We found a statistically significant difference in Feller score and in the patellofemoral component of OKS between the groups of MRK knee suggesting specific benefits of patellar resurfacing with this implant.
  • Fire safety and emergency evacuation guidelines for intensive care units and operating theatres: for use in the event of fire, flood, power cut, oxygen supply failure, noxious gas, structural collapse or other critical incidents: Guidelines from the Association of Anaesthetists and the Intensive Care Society

    Sarkar, S (2021-10)
    The need to evacuate an ICU or operating theatre complex during a fire or other emergency is a rare event but one potentially fraught with difficulty: Not only is there a risk that patients may come to harm but also that staff may be injured and unable to work. Designing newly-built or refurbished ICUs and operating theatre suites is an opportunity to incorporate mandatory fire safety features and improve the management and outcomes of such emergencies: These include well-marked manual fire call points and oxygen shut off valves (area valve service units); the ability to isolate individual zones; multiple clear exit routes; small bays or side rooms; preference for ground floor ICU location and interconnecting routes with operating theatres; separate clinical and non-clinical areas. ICUs and operating theatre suites should have a bespoke emergency evacuation plan and route map that is readily available. Staff should receive practical fire and evacuation training in their clinical area of work on induction and annually as part of mandatory training, including 'walk-through practice' or simulation training and location of manual fire call points and fire extinguishers, evacuation routes and location and operation of area valve service units. The staff member in charge of each shift should be able to select and operate fire extinguishers and lead an evacuation. Following an emergency evacuation, a network-wide response should be activated, including retrieval and transport of patients to other ICUs if needed. A full investigation should take place and ongoing support and follow-up of staff provided.
  • Preseptal cellulitis and infraorbital abscess as a complication of a routine COVID-19 swab

    Fazekas, Balazs; Fazekas, Bence; Jayakumar, Delicia (2021-05)
    This case report describes a significant complication of a routine COVID-19 swab in a previously fit and well young patient who developed preseptal cellulitis and an infraorbital abscess as a consequence of the mentioned nasal swabbing. Other authors have previously reported various complications in connection with the use of nasal swabs, including retained swab fragments, epistaxis and cerebrospinal fluid leakage. To our knowledge, to date, this is the first reported case of an abscess as a consequence of COVID-19 swabbing. There has been a clear growth in the use of nasal swabbing worldwide over the last 9 months and many healthcare workers involved in COVID-19 prevention may not be aware of the potential risks of nasopharyngeal swabbing. The presented case highlights the need for better awareness of the complications of these routine tests and we hope that it will also lead to their safer implementation.
  • Bilateral traumatic distal femoral transphyseal fracture in a 9-year-old male

    Davis, Timothy P (Journal of Surgical Case Reports, 2021-01)
    A case of bilateral traumatic distal femoral Salter-Harris Type I fracture presented to our emergency department. History was of a 9-year-old male playing at a building site when a concrete block fell from height on to his knees, which were extended in a sitting position. Management was with analgesia and transfer to theatre followed by closed reduction and internal fixation-position was assessed under mobile X-ray. The patient made a full clinical recovery within 18 weeks and was followed-up over 5 years. There was no clinical effect on final adult length of femur and no deficit in range of movement. The foot-drop observed at presentation resolved over a period of 12 weeks. This case highlights the importance of performing a thorough neurovascular examination of the patient at presentation, followed by a careful closed reduction and internal fixation under anaesthesia, being careful not to damage the distal femoral growth plates.
  • Turning 'waiting lists' for elective surgery into 'preparation lists'

    Selwyn, David (2021-01)
    Waiting lists for surgery are an integral part of the UK National Health Service (NHS); they are used as a construct to ration surgery and to reduce costs, whilst simultaneously attempting to distribute limited health resources in an equitable manner. 1 They are a feature of health services that have central funding, financed mainly through general taxation, and are present in several other European countries including Italy, Greece, and Spain, where there is a need to manage the dynamics of capacity and demand. Waiting lists are rarer in countries that rely on private healthcare provision (including insurance) or rely on funding through social security (e.g. USA, Austria, Germany, and France). 2 Nevertheless, independent of the healthcare system, there is an inevitable period of time between diagnosis of an illness that may be amenable to surgery and admission for elective surgery. It is now acknowledged that this time can be better spent in preparing patients for surgery in order to improve the patients' experience of healthcare (including quality outcomes and satisfaction), improve population/public health, and reduce the per capita costs of healthcare.
  • The Use of Lasers in Stapes Surgery.

    Fergie, Neil (2021)
    Abstract Objectives: Otosclerosis is a disease process that usually starts around the oval window, causing fixation of the stapes, resulting in conductive hearing loss. Treatment of the conductive hearing loss caused by otosclerosis consists of either rehabilitation with hearing aids or performing surgery. Given the risks of hearing impairment and vertigo associated with the surgery, there has been a desire to advance the practice to minimize the complications. The so-called "non-contact" or "no touch" techniques with the use of various lasers are in current practice. This review article will cover the surgical aspects, the theory behind laser and the various types used in stapes surgery. It will also review the evidence of laser versus conventional stapes surgery and the comparison of different laser types. Methods: A literature search up to December 2019 was performed using Pubmed and a nonsystematic review of appropriate articles was undertaken. Keywords used were stapes, surgery, laser, stapedectomy, and stapedotomy. Results: Overall, there is no evidence to say laser fenestration is better than conventional fenestration techniques; however, with the micro drill, there is an increased risk of footplate fracture and sensorineural hearing loss. There is an increased risk of tinnitus with the laser compared to conventional techniques. Studies have favored the CO2 laser over potassium titanyl phosphate (KTP) and erbium-doped yttrium aluminium garnet (Erbium-YAG) lasers for postoperative closure of the air-bone gap; and KTP laser has less thermal, mechanical, and sound effects compared with the thulium and carbon dioxide (CO2) lasers. There is an increased risk if inner ear complications with the thulium laser. Conclusions: It can be deduced that theoretically and practically, the thulium laser is less safe compared to the KTP and CO2 lasers. The choice of laser used depends on the surgeon's preference, as well as availability, cost, side effects profile, as well as ease of use.
  • Ophthalmological Aspects of von-Hippel-Lindau Syndrome

    Ali, Wajahat (2021)
    Background: von Hippel-Lindau (VHL) syndrome is a multisystem neoplastic disorder involving eyes, central nervous system, kidneys, spine, and other tissues. A retinal capillary hemangioma (RCH) is the earliest manifestation of the VHL disease in most cases.Areas covered:This paper aims to provide an up-to-date review of the current literature about von Hippel-Lindau syndrome. Molecular background, systemic and ocular features of the diseases as well as the utility of newer imaging modalities in diagnosis and monitoring of ocular VHL disease have been described. Besides, we have discussed newer treatment modalities and therapeutic targets.Conclusion: Modern imaging technologies like optical coherence tomography and optical coherence tomography angiography are tools of the trade, in making an appropriate diagnosis and monitoring disease activity and response to treatment. Peripheral RCH may be treated using laser photocoagulation in tumors up to 3000 µm. Vascular endothelial growth factor suppression can help in reducing tumor activity and stabilize the tumor size; however, it does not regress the RCH.
  • Rehabilitation following proximal humeral fracture in the UK National Health Service: A survey of publicly facing information

    Rohun, Jason (2021)
    Introduction Proximal humeral fractures (PHF) are a common injury in the older population but there is limited research evaluating rehabilitation following PHF. The aim of this study was to understand current National Health Service (NHS) practice for rehabilitation following PHF as a platform for conducting future research. Methods Two reviewers independently undertook electronic searches for publicly available information sheets (PIS) from websites of NHS Trusts that included detail about rehabilitation following PHF, for example, duration of immobilisation. One reviewer extracted data and a second reviewer verified this. Results Seventeen PIS from 17 different NHS trusts were identified. All provided some information on the method of immobilisation but only six provided guidance on duration of immobilisation with the median time being 2 weeks (range 0–6). The median time to commencement of passive exercise was 2 weeks (range 0–4) and 9 weeks (range 6–12) for active exercise. Only one PIS reported on the time for commencement of resisted exercises and this was reported as 6 weeks. The median time recommended return to work was 7.5 weeks (range 6–12). Conclusion This study found limited publicly available information for rehabilitation following PHF in the NHS but offers some insight into current approaches. Our results will facilitate development of relevant information for patients and evaluation of rehabilitation strategies in future research.
  • A core outcome set for research on the management of otitis media with effusion in otherwise-healthy children.

    Fergie, Neil (2020-07)
    Introduction A Core Outcome Set (COS) is an agreed list of outcome domains to be reported by all studies investigating a condition. A COS for Otitis Media with Effusion (OME) in children with cleft palate exists (called MOMENT), but there isn't one for otherwise-healthy children. This study investigates whether the MOMENT COS could also be applicable to otherwise-healthy children. Results A total of 134 people took part: 53 parents/guardians (recruited through UK NHS hospitals) and 81 professionals/researchers (recruited internationally). Overall, 128 (95.5%) agreed that the MOMENT outcomes can also apply to otherwise healthy children (100% parents/guardians, 92.6% professionals/researchers). Conclusions The outcome domains identified in the COS for OME management in children with cleft palate can also be used in otherwise-healthy children.
  • A safe method to evacuate pneumoperitoneum during laparoscopic surgery in suspected COVID-19 patients.

    Hanbali, N.; Herrod, Philip; Patterson, Jane (, 2020-05)
    The COVID-19 pandemic has introduced new challenges to surgery and protection of staff in the operating theatre. Aerosol and surface viability of the virus has been shown to last at least hours, with viability lasting days on certain surfaces.[ 1] Uncontrolled evacuation of pneumoperitoneum during laparoscopy may pose an increased risk to staff and other patients. This has led to recent intercollegiate guidance advising against the use of laparoscopy unless there is a clear mortality benefit from laparoscopy over open surgery.[ 2] Several solutions have been proposed including gas filters, traps, or careful deflation.[ 2],[ 3] Here, we offer a more efficient method.
  • Adding evidence of the effects of treatments into relevant Wikipedia pages: a randomised trial.

    Chatterjee-Woolman, Suravi (, 2020-02)
    Objectives: To investigate the effects of adding high-grade quantitative evidence of outcomes of treatments into relevant Wikipedia pages on further information-seeking behaviour by the use of routinely collected data. Setting: Wikipedia, Cochrane summary pages and the Cochrane Library. Design: Randomised trial. Participants: Wikipedia pages which were highly relevant to up-to-date Cochrane Schizophrenia systematic reviews that contained a Summary of Findings table. Interventions: Eligible Wikipedia pages in the intervention group were seeded with tables of best evidence of the effects of care and hyperlinks to the source Cochrane review. Eligible Wikipedia pages in the control group were left unchanged. Main Outcome Measures: Routinely collected data on access to the full text and summary web page (after 12 months). Results: We randomised 70 Wikipedia pages (100% follow-up). Six of the 35 Wikipedia pages in the intervention group had the tabular format deleted during the study but all pages continued to report the same data within the text. There was no evidence of effect on either of the coprimary outcomes: full-text access adjusted ratio of geometric means 1.30, 95% CI: 0.71 to 2.38; page views 1.14, 95% CI: 0.6 to 2.13. Results were similar for all other outcomes, with exception of Altmetric score for which there was some evidence of clear effect (1.36, 95% CI: 1.05 to 1.78). Conclusions: The pursuit of fair balance within Wikipedia healthcare pages is impressive and its reach unsurpassed. For every person who sought and clicked the reference on the 'intervention' Wikipedia page to seek more information (the primary outcome), many more are likely to have been informed by the page alone. Enriching Wikipedia content is, potentially, a powerful way to improve health literacy and it is possible to test the effects of seeding pages with evidence. This trial should be replicated, expanded and developed.
  • What is CPOC and why now?

    Selwyn, David (2019-12)
    Clearly almost all organisations and healthcare systems are under pressure and something needs to change. For this reason, in May this year, the Centre for Perioperative Care (CPOC) was created and hosted by the Royal College of Anaesthetists (RCoA). This is a joint venture with the Royal College of Physicians (RCP), the Royal College of Surgeons of England, the Royal College of Nursing, the Royal College of General Practitioners and the Association of Anaesthetists, with a mandate to deliver transformation change across our surgical pathways. I am incredibly proud to have been appointed as CPOC’s inaugural director and believe working together, across our different specialties, we can make real improvements for our patients on their surgical journey and for ourselves in our organisation of traditional surgical pathways.
  • An infective cause for the limping child.

    Uzoho, Chukwudi; Desai, Vikram (2019-09)
    A 7-year-old girl presented with left hip pain and a limp, in the absence of any other systemic features, having recently been treated for a urinary tract infection. Examination revealed limited active hip movements on the left, with a tendency to weight bear on the contralateral side. Biochemical investigations were significant for raised inflammatory markers, and subsequent MRI imaging revealed osteomyelitis of the left pubis and ischium with an associated large soft tissue collection. Treatment was bimodal with surgical drainage and long-term antibiotics. The patient consequently recovered, without significant effect on either growth or mobility. (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)
  • The clinical and cost-effectiveness of total versus partial knee replacement in patients with medial compartment osteoarthritis (TOPKAT): 5-year outcomes of a randomised controlled trial.

    Desai, Vikram (2019-07-17)
    BACKGROUND: Late-stage isolated medial knee osteoarthritis can be treated with total knee replacement (TKR) or partial knee replacement (PKR). There is high variation in treatment choice and little robust evidence to guide selection. The Total or Partial Knee Arthroplasty Trial (TOPKAT) therefore aims to assess the clinical effectiveness and cost-effectiveness of TKR versus PKR in patients with medial compartment osteoarthritis of the knee, and this represents an analysis of the main endpoints at 5 years. METHODS: Our multicentre, pragmatic randomised controlled trial was done at 27 UK sites. We used a combined expertise-based and equipoise-based approach, in which patients with isolated osteoarthritis of the medial compartment of the knee and who satisfied general requirements for a medial PKR were randomly assigned (1:1) to receive PKR or TKR by surgeons who were either expert in and willing to perform both surgeries or by a surgeon with particular expertise in the allocated procedure. The primary endpoint was the Oxford Knee Score (OKS) 5 years after randomisation in all patients assigned to groups. Health-care costs (in UK 2017 prices) and cost-effectiveness were also assessed. This trial is registered with ISRCTN (ISRCTN03013488) and (NCT01352247). FINDINGS: Between Jan 18, 2010, and Sept 30, 2013, we assessed 962 patients for their eligibility, of whom 431 (45%) patients were excluded (121 [13%] patients did not meet the inclusion criteria and 310 [32%] patients declined to participate) and 528 (55%) patients were randomly assigned to groups. 94% of participants responded to the follow-up survey 5 years after their operation. At the 5-year follow-up, we found no difference in OKS between groups (mean difference 1.04, 95% CI -0.42 to 2.50; p=0.159). In our within-trial cost-effectiveness analysis, we found that PKR was more effective (0.240 additional quality-adjusted life-years, 95% CI 0.046 to 0.434) and less expensive (- pound910, 95% CI -1503 to -317) than TKR during the 5 years of follow-up. This finding was a result of slightly better outcomes, lower costs of surgery, and lower follow-up health-care costs with PKR than TKR. INTERPRETATION: Both TKR and PKR are effective, offer similar clinical outcomes, and result in a similar incidence of re-operations and complications. Based on our clinical findings, and results regarding the lower costs and better cost-effectiveness with PKR during the 5-year study period, we suggest that PKR should be considered the first choice for patients with late-stage isolated medial compartment osteoarthritis.
  • Understanding primary parotid squamous cell carcinoma - A systematic review.

    Tsirevelou, Paraskevi (2019-04)
    INTRODUCTION: The true incidence of primary parotid squamous cell carcinoma (SCC) is unknown and likely overestimated in the literature. The aim of this systematic review is to examine the diagnosis, aetiology and incidence of parotid SCC by analysing studies evaluating primary parotid SCC. METHODS: A systematic search of Medline, EMBASE and Cochrane library was performed. A narrative synthesis was done. RESULTS: A total of 14 observational retrospective studies on primary parotid SCC were included. There are currently no standard criteria for ascertainment of primary parotid SCC. Primary parotid SCC is thought to be due to squamous metaplasia within the ductal epithelium and subsequent invasive squamous carcinoma. Histological features that favour primary disease includes SCC confined to parotid parenchyma with no direct communication to the skin and the absence of mucin. Incidence of primary parotid SCC varied from 1.54 to 2.8 cases per million person-years. Around 30%-86% of patients recorded to have primary parotid SCC on clinical records, when scrutinised, were in fact secondary to parotid lymph node involvement following regional advancement from skin or upper aerodigestive tract SCC. CONCLUSION: Primary parotid SCC is rare and it is currently a diagnosis of exclusion. Thorough clinical assessment including endoscopy, preoperative imaging and the scrutiny of histopathological findings allow for differentiation between primary and secondary SCC within the parotid. This thus affects both initial treatment and subsequent follow-up.
  • Comparing different dosing regimens of bevacizumab in the treatment of neovascular macular degeneration: study protocol for a randomised controlled trial.

    Dhar-Munshi, Sushma (2015-03)
    Background: Bevacizumab (Avastin®) is as effective as ranibizumab (Lucentis®) in the treatment of neovascular age-related macular degeneration (nAMD). However it has two important structural differences. First, it has two active sites instead of one; second, it retains the Fc portion of the antibody which would be expected to confer a significantly longer half-life. These agents have been associated with systemic complications including strokes, so it is desirable to use the smallest effective dose. Furthermore, the standard dosing regimen requires monthly hospital visits, which present a significant challenge both to the hospital services and to the patients (who are elderly). Methods/design: Patients ≥50 years who are eligible for anti-vascular endothelial growth factor (VEGF) treatment of nAMD in the NHS, who are either newly referred for treatment or have reactivation of nAMD and who have not received treatment to either eye for the previous six months. We have designed a factorial multi-centre masked randomised controlled trial using bevacizumab as the intervention, with patients randomised to one of four arms: to standard or low dose and to monthly or two-monthly patient review. The aim is to recruit sufficient patients (around 1,000) to obtain 304 patients meeting the endpoint over a four-year period. The primary endpoint is time to treatment failure to be analysed using Cox regression. Discussion: This randomised control trial will show if half dose and two monthly as required is as effective as full dose and monthly regimes. A two monthly as required regimen of Bevacizumab would significantly reduce both the cost and the service delivery burden for the treatment of nAMD while a reduced dose would be expected to enhance the safety profile of this treatment regime.
  • The diagnostic accuracy of spectral-domain optical coherence tomography for neovascular age-related macular degeneration: A comparison with fundus fluorescein angiography.

    Lakshmanan, A.; Dhar-Munshi, Sushma; Amankwah, Ruby (2015-05)
    Purpose: To evaluate the diagnostic accuracy of spectral-domain optical coherence tomography (SD-OCT) for neovascular age-related macular degeneration (nAMD): a comparison against fundus fluorescein angiography (FFA). Methods: A retrospective review of SD-OCT, colour fundus photographs (FP), and FFA of 411 consecutive patients referred to a rapid access Macular Clinic over a 4-year period was performed. FFA images were reviewed non-stereoscopically. SD-OCT images were acquired using the Topcon 3D OCT-1000 instrument. All FFA and OCT images were graded by at least two ophthalmologists independently. Side-by-side grading took place with immediate open discussion and adjudication. If there was disagreement between the two grading ophthalmologists or they were not 90% confident of their assigned grade, then adjudication by a third ophthalmologist was performed. Results: A total of 278 eyes were graded as having choroidal neovascularisation (CNV) with SD-OCT and 231 diagnosed with FFA. The main diagnostic CNV classifications on FFA were: classic no occult in 27 eyes, predominantly classic in 16, minimally classic in 50, occult in 129, and 9 peripapillary membranes. There were a total of 47 false positives with SD-OCT: a rate of 16.9%. The sensitivity and specificity of SD-OCT alone for detecting CNV was 100 and 80.8%, respectively. Conclusion: Our study confirms SD-OCT in comparison to the reference standard of non-stereoscopic FFA is highly sensitive at detecting newly presenting nAMD in the setting of a specialist AMD clinic where the investigations are interpreted by trained specialists. However, it does not seem accurate enough to replace FFA in the diagnosis on nAMD in current practice.

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