The rationale and evidence base for a protective role of macular pigment in age-related maculopathy.

Age-related maculopathy (ARM) remains the most common cause of blind registration in people aged 50 years or over in the developed world, and its prevalence continues to rise. Although effective new treatments have become available in the recent past, these are expensive and cumbersome to the healthcare provider and to the patient, and many cases remain resistant to such therapy. There is a biologically plausible rationale whereby macular pigment, which is entirely of dietary origin, may prevent or delay the onset, or ameliorate the clinical course, of ARM. In this article, we review this rationale, and critically appraise the current evidence base germane to the use of supplements containing the macular carotenoids in patients with, or at risk of developing, ARM.

Intravitreal bevacizumab in the treatment of neovascular age-related macular degeneration, 6- and 9-month results.

PURPOSE: To evaluate 6- and 9-month follow-up data including the effect on vision and anatomic outcome in patients treated with intravitreal bevacizumab for neovascular age-related macular degeneration (AMD). STUDY DESIGN: Interventional consecutive retrospective case series. Patients received intravitreal bevacizumab for the treatment of neovascular AMD including choroidal neovascular membranes, pigment epithelial detachment, and macular haemorrhage. Ophthalmic evaluation included log MAR or Snellen acuity, ophthalmic examination, optical coherence tomography, and fluorescein angiography. Repeat injections were given in the presence of persistent leakage or retinal oedema. Change in vision and foveal thickness from baseline was evaluated using the paired Student's t-test. RESULTS: A total of 112 eyes of 111 patients received injections. Median follow-up was 5 months (range: 1-12 months). Mean log MAR vision pre-injection was 0.84+/-0.03 (n=112); at 3 months was 0.69+/-0.05 (P<0.0001, n=84); at 6 months was 0.74+/-0.06 (P<0.05, n=51); and at 9 months was 0.69+/-0.08 (n=29, P=0.09). Thirteen of 17 patients who received only one injection maintained improved or stable vision at 6 months. Mean baseline foveal thickness was 291+/- 9.72 microm (n=56); at 3 months was 282.7+/-28 (P<0.05, n=31); and at 6 months was 249.7+/-10.3 (P<0.05, n=12). One case of endophthalmitis, three submacular haemorrhages, and three retinal pigment epithelial (RPE) tears occurred. CONCLUSION: Intravitreal bevacizumab is an effective treatment for neovascular AMD, resulting in improved vision and foveal anatomy at 6 months and even up to 9 months. This treatment is well tolerated in the majority of patients but adverse events may include endophthalmitis, RPE tears, and submacular haemorrhage.

Trends in blind registration in the adult population of the Republic of Ireland 1996-2003.

BACKGROUND/AIM: The Republic of Ireland has a centralised database of all registered, blind people in the country. The last study of the national blind register was undertaken in 1996. The current study sought, firstly, to investigate and identify any recent changes in the register composition. Secondly, there is concern that many eligible people are not appropriately registered. To examine this further, registration levels among patients attending an Irish outpatient ophthalmology clinic were determined. METHODS: Criteria for blind registration in Ireland are (1) a best corrected visual acuity of 6/60 or less in the better eye, or (2) a visual field subtending an angle of 20 degrees or less. The National Council for the Blind in Ireland (NCBI) is the sole custodian of a national registration database recording all eligible, registered people. This computerised database was analysed to provide information on the demographics and blind registration condition of those on the register in 2003. This information was compared with the results of the 1996 study. To assess the accuracy of the current register, the registration status of eligible patients attending the outpatient clinic of a busy, tertiary referral ophthalmology department, over a 9 week period, was studied. RESULTS: 6862 adults were registered as blind on the NCBI register in Ireland in 2003, representing an increase of 37% since 1996. The leading causes of registration were age related macular degeneration (ARMD) (25%), glaucoma (12%), and retinitis pigmentosa (7%). Comparing the 1996 and 2003 data, dramatic increases in the numbers registered caused by ARMD (from 812 to 1729 people, a 113% increase) and diabetic retinopathy (DR) (from 147 people to 323 people, a 120% increase) were found. The numbers registered as a result of glaucoma were relatively stable (795 in 1996 and 811 in 2003). A substantial drop, of 53%, was noted in the number of people registered as a result of cataracts, from 561 people to 261. Of the 672 new cases registered in 2003, ARMD accounted for 44%, glaucoma 13%, and DR 7%. Over the 9 week study period 75 patients, out of a total 2320 patients who attended the outpatient department, fulfilled the blind registration criteria. It was found that 21% (16 of 75) of the eligible clinic outpatients had not been appropriately registered. CONCLUSION: An overall increase in adult blind registration of 37% in the Republic of Ireland was found between 1996 and 2003. There were large increases in registered blindness as a result of ARMD (113%) and DR (120%). A notable decrease in registration as a result of cataracts was discovered. Vigilance by clinicians is necessary to ensure that eligible patients are registered.

Tibial shaft fractures treated with the AO unreamed tibial nail.

BACKGROUND: The AO unreamed tibial nail (UTN) has been used for both open and closed tibial fractures. The reported results have been mixed. We evaluated its outcome in our unit. AIM: To assess the outcome of tibial shaft fractures treated with the AO UTN. METHODS: Forty-eight patients underwent intramedullary nailing between 1995 and 2000 using the AO UTN. Follow-up details were available for 45 patients. RESULTS: Forty-four fractures united (97%). Complications included one non-union (2.2%), 15 delayed unions (33%), nine had either broken or bent interlocking screws (20%), six malunions (13%) and three patients underwent fasciotomy for compartment syndrome (7%). Twenty-one patients underwent at least one additional operation to obtain union (47%). Of these, five underwent exchange nailing (11%). CONCLUSIONS: The AO UTN does have a high complication rate and, should it be used, we feel that early dynamisation or exchange nailing be considered to hasten union and prevent screw breakage.

Competitive tendering in NHS catering: a suitable policy?

Seeks to evaluate the policy of competitive tendering for ancillary services in the National Health Service, by reference to a number of case studies of catering services. Argues that the success of the policy was dependent on certain assumptions being met about the extent of competitive pressure and the potential for savings, largely labour cost savings, to be made. Shows by case studies that these conditions frequently did not occur and hence the policy was flawed. Furthermore, even where these conditions did occur, the evidence shows that a range of other factors influenced the extent to which labour cost savings could be made.

Enhancing substance abuse treatment with case management. Its impact on employment.

This article examines the effectiveness of strengths-based case management in assisting persons with substance abuse problems improve employment-related functioning. In a study of 632 veterans seeking treatment for substance abuse problems, Wright State University's Enhanced Treatment Project found that veterans in substance abuse treatment had improved in several areas of employment functioning, including number of days employed. Among clients who expressed interest in receiving assistance with employment-related issues, those who received strengths-based case management demonstrated additional improvement in employment functioning including more days employed, fewer employment problems and being less troubled about their employment situation. Correlations between improved employment functioning and improved functioning in other life areas further support the value of case management. The implications of these findings for the inclusion of case management services in substance abuse treatment programs will be discussed.

The strengths perspective of case management: a promising inpatient substance abuse treatment enhancement.

The medical model or disease concept approach to substance abuse treatment is practiced in most residential substance abuse treatment programs. Despite wide acceptance, many of the factors inherent in this approach may actually increase patient noncompliance with treatment regimens. These factors are related to the pathology-based nature of substance abuse treatment, an overemphasis on patient denial, and the paternalistic role that treatment staff often take in the treatment of substance abusers. The Strengths Perspective of Case Management/Advocacy has demonstrated usefulness as an adjunct to treatment that remedies these detrimental factors and improves compliance with, and retention in, treatment. The specific activities that lead to this improvement are discussed.

Strengths-based case management. A role in addressing denial in substance abuse treatment.

A strengths-based approach to case management is being used as an intervention to assist persons with substance abuse problems to access needed resources. The same strengths-based practice activities that support resource acquisition are also effective in addressing the denial that can interfere with substance abuse treatment. Both benefits, resource acquisition and a constructive approach to denial, have shown promise for enhancing client participation in treatment and subsequent outcome from that treatment.