A Comparison of Refill Procedures and Patient Outcomes Following Ultrasound-Guided and Template-Guided Intrathecal Drug Delivery Systems With Recessed Ports.

OBJECTIVE: Intrathecal drug delivery systems (IDDS) are refilled using templates and palpation. The 2017 Polyanalgesic Consensus Conference recommends ultrasound only when reservoir ports are difficult to identify. The purpose of this study was to compare procedural outcomes and patient's preference for refill method of IDDS. MATERIALS AND METHODS: The study was approved by the Rush University IRB. Participants were randomized to have their IDDS with ultrasound or template using a 2:1 allocation. The time to reservoir port access, number of needle maneuvers/punctures, pain (NRS 0-10), complications, patient satisfaction, and patient refill modality preference, were recorded. RESULTS: A total of 107 patients underwent 192 refills. There were 67 template-guided refills and 125 ultrasound-guided refills. No procedural pain (NRS = 0) was reported in 84% of the ultrasound-guided refills compared with 67% of the template-guided procedures, difference - 17% (95% difference - 3% to -31%, p = 0.01). When adjusted for age, gender, procedure duration, needle sticks, needle maneuvers and refills in the same patient, the odds ratio for a pain-free procedure with ultrasound-guidance was 3.1 (95% CI 1.3 to 7.2, p = 0.01). There was no difference between the groups in needle punctures (p = 0.87) or redirections (p = 0.34). Following 35/67 (52%) template-guided procedures, patients stated they preferred the ultrasound-guided but following only 12/125 (10%) of ultrasound-guided procedures, patients stated they preferred template-guidance (p < 0.001). CONCLUSIONS: Patients preferred ultrasound even though it lengthened the duration of refills compared to template-guided procedures. Fewer patients experienced procedural pain with ultrasound compared with template-guided refills. No safety issues were observed in either group.

Relative incidence of blepharoptosis subtypes in an oculoplastics practice at a tertiary care center.

PURPOSE: In patients referred with blepharoptosis, the possibility of an underlying systemic cause for their ptosis can warrant a more detailed evaluation. The purpose of this study is to determine both the incidence and demographic characteristics associated with different types of ptosis in patients referred to the oculoplastics division at a tertiary care center. METHODS: A retrospective chart review was performed on all patients referred to the oculoplastics division between 2007 and 2010. Final etiology for each patient's ptosis was determined based on history, standard eyelid measurements, and ancillary testing. Based on etiology, ptosis was categorized as aponeurotic, neurogenic, myogenic, traumatic, congenital, or mechanical. Demographics, including median age and sex were analyzed for patients in each category of ptosis. RESULTS: Of the 251 patients, aponeurotic ptosis was the most common type of ptosis (60.2%), followed by traumatic (11.2%), congenital (10.4%), mechanical (8.8%), neurogenic (5.6%), and myogenic (4.0%). Of the neurogenic group, 35.7% of patients had cranial nerve 3 (CN 3) palsy, 28.6% had myasthenia gravis, 14.3% had aberrant regeneration, and 7.1% had Horner's syndrome. Thirty percent of the myogenic group had chronic progressive external ophthalmoplegia (CPEO). The congenital group had the youngest median age (10.5 years), yet the aponeurotic group had the oldest (62 years). CONCLUSIONS: A significant proportion of patients referred with ptosis had more serious conditions such as neurogenic or myogenic ptosis. Thus, clinicians should maintain a high degree of suspicion and thoroughly evaluate all patients with ptosis in order to properly assess for underlying systemic associations.

Lower-eyelid tarsal ectropion repair with the Putterman ptosis clamp for lower-eyelid conjunctival Mueller's muscle resection and lateral tendon tuck.

PURPOSE: To describe a technique for treatment of lower-eyelid tarsal ectropion using the Putterman ptosis clamp for excision of conjunctiva and Mueller's muscle as an adjunct to the lateral canthal tendon tuck. METHODS: Retrospective case series. Patients with moderate-to-severe lower-eyelid ectropion underwent lateral canthal tendon tucking followed by eversion of the lower eyelid over a desmarres retractor, separation of the lower-eyelid conjunctiva and Mueller's muscle from the underlying capsulopalpebral fascia, placement of the Putterman ptosis clamp, and resection of the incarcerated tissue followed by closure of the conjunctiva and the lateral canthus. RESULTS: Six patients and 8 eyes were studied. Of the 8 eyes, 6 (75%) had complete resolution of tarsal ectropion and 2 (25%) had mild residual ectropion at last follow up. All 8 eyes (100%) had symptomatic improvement and 0 patients required re-operation. There were no noted severe adverse events. CONCLUSION: Lower-eyelid conjunctival Mueller's muscle resection using the Putterman ptosis clamp as an adjunct to lateral canthal tendon reinforcement is a safe and effective procedure in the treatment of lower-eyelid tarsal ectropion.

Ultra-wide-field imaging for cytomegalovirus retinitis.

BACKGROUND AND OBJECTIVE: To compare the Optomap imaging system (Optos PLC, Dunfermline, Scotland) with conventional fundus photography in patients with cytomegalovirus (CMV) retinitis. PATIENTS AND METHODS: Patients treated at Rush University for acquired immune deficiency syndrome and CMV retinitis were studied prospectively. Conventional nine-field photography and Optomap ultra-wide-field photography were performed on the same day. A patient satisfaction questionnaire was completed. The main outcome measures were total retinal area imaged, area of CMV retinitis imaged, and patient satisfaction. RESULTS: Twelve eyes met the inclusion criteria. Ultra-wide-field imaging captured 48.3% greater retinal area and 40.0% greater CMV retinitis area compared with standard photography. Standard photography missed peripheral CMV lesions in two eyes. The patient satisfaction survey indicated a preference for ultra-wide-field imaging based on increased comfort and decreased imaging time. CONCLUSION: The ultra-wide-field Optomap imaging system tended to capture greater areas of total retina and peripheral CMV retinitis lesions. Patients tended to prefer ultra-wide-field imaging because of the perceived time requirements and comfort of use.

Impact of administration angle on the cost of artificial tear solutions: does bottle positioning minimize wastage?

PURPOSE: The aim of this study was to describe the cost considerations of multidose artificial tear products according to drop volume and the number of usable drops per bottle, based on a 45- versus 90-degree administration angle. METHODS: Densitometric assessment of the drop volume of five multidose artificial tear products of a 15-mL labeled bottle size in conjunction with predictive cost analysis. RESULTS: The correlation between drop volume and density was not significant (Spearman correlation, P = 0.4500; alpha < 0.05). Overall, drop size ranged from 65.9 microL to a nadir of 30.8 microL, with a statistically significant difference (Student t test, P < 0.05) between 45- and 90-degree volumes for all but one product. Cost analysis demonstrated up to a $1.93 per bottle cost savings by the administration of drops at a 45- rather than a 90-degree bottle angle. CONCLUSIONS: Products that provide a higher number of drops per dollar of product offer economic advantages that may not be otherwise discernible by the examination of the product retail price alone. Furthermore, it is shown that altering the angle of administration may, in general, result in significant economic ramifications in the use of multidose artificial tear products longitudinally.

Complexity of program and clinical outcomes of heart failure disease management incorporating specialist nurse-led heart failure clinics. A meta-regression analysis.

OBJECTIVES: To determine whether a hierarchy of effectiveness exists with respect to complexity of published protocols of heart failure (HF) disease management (DM) incorporating specialist nurse-led HF clinics. DATA SOURCES AND STUDY SELECTION: We searched MEDLINE (1966-November 2004), the Cochrane Library, article bibliographies, and contacted experts. Inclusion criteria were random allocation of at least 100 patients, specialist HF nurses, HF clinics, and readmission as an outcome measure. DATA EXTRACTION: Paired reviewers conducted quality assessment, deconstructed and categorized protocols by complexity, and extracted results for readmission, mortality, the combined endpoint of mortality and hospitalization, HF readmission, and hospital days utilized. DATA SYNTHESIS: Six trials were selected (N=949, mean age 73 years [range 62-79], men 58%, LVEF 34% [27-41], and average follow-up of 8.5 months [3-12]). Compared with usual care, the overall relative risk [95% confidence interval] for readmission with this strategy was 0.91 [0.72, 1.16], mortality was 0.80 [0.57, 1.06], and the combined endpoint of mortality and hospitalization was 0.88 [0.74, 1.04]. We observed better outcomes for programs with versus programs without hospital discharge planning and immediate post-discharge follow-up; readmission 0.30 [0.04, 2.60] vs. 1.00 [0.86, 1.17], mortality 0.96 [0.63, 1.47] vs. 0.75 [0.55, 1.03], the combined endpoint of mortality and hospitalization 0.61 [0.18, 2.02] vs. 0.91 [0.80, 1.03], HF readmission 0.09 [0.10, 0.65] vs. 0.65 [0.43, 1.00], and hospitalized days utilized per patient -0.26 [-0.49,-0.02] vs. 0.09 [-1.17, 1.34]. CONCLUSIONS: HF DM with specialist nurse-led HF clinics is a promising strategy or effective alternative whose benefit may be optimized by programs with a homogeneous structure and components that are delivered with consistency.

Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis.

CONTEXT: Comprehensive discharge planning plus postdischarge support may reduce readmission rates for older patients with congestive heart failure (CHF). OBJECTIVE: To evaluate the effect of comprehensive discharge planning plus postdischarge support on the rate of readmission in patients with CHF, all-cause mortality, length of stay (LOS), quality of life (QOL), and medical costs. DATA SOURCES: We searched MEDLINE (1966 to October 2003), the Cochrane Clinical Trials Register (all years), Social Science Citation Index (1992 to October 2003), and other databases for studies that described such an intervention and evaluated its effect in patients with CHF. Where possible we also contacted lead investigators and experts in the field. STUDY SELECTION: We selected English-language publications of randomized clinical trials that described interventions to modify hospital discharge for older patients with CHF (mean age > or =55 years), delineated clearly defined inpatient and outpatient components, compared efficacy with usual care, and reported readmission as the primary outcome. DATA EXTRACTION: Two authors independently reviewed each report, assigned quality scores, and extracted data for primary and secondary outcomes in an unblinded standardized manner. DATA SYNTHESIS: Eighteen studies representing data from 8 countries randomized 3304 older inpatients with CHF to comprehensive discharge planning plus postdischarge support or usual care. During a pooled mean observation period of 8 months (range, 3-12 months), fewer intervention patients were readmitted compared with controls (555/1590 vs 741/1714, number needed to treat = 12; relative risk [RR], 0.75; 95% confidence interval [CI], 0.64-0.88). Analysis of studies reporting secondary outcomes found a trend toward lower all-cause mortality for patients assigned to an intervention compared with usual care (RR, 0.87; 95% CI, 0.73-1.03; n = 14 studies), similar initial LOS (mean [SE]: 8.4 [2.5] vs 8.5 [2.2] days, P =.60; n = 10), greater percentage improvement in QOL scores compared with baseline scores (25.7% [95% CI, 11.0%-40.4%] vs 13.5% [95% CI, 5.1%-22.0%]; n = 6, P =.01), and similar or lower charges for medical care per patient per month for the initial hospital stay, administering the intervention, outpatient care, and readmission (-359 dollars [95% CI, -763 dollars to 45 dollars]; n = 4, P =.10 for non-US trials and -536 dollars [95% CI, -956 dollars to -115 dollars]; n = 4, P =.03, for US trials). CONCLUSION: Comprehensive discharge planning plus postdischarge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.

Evisceration and enucleation: a national survey of practice patterns in the United States.

BACKGROUND AND OBJECTIVE: The management of evisceration and enucleation has changed over time. The authors assessed the practice patterns regarding eye removal among oculoplastic surgeons. PATIENTS AND METHODS: Internet-based surveys were sent to American Society of Ophthalmic Plastic and Reconstructive Surgeons members regarding preferences in evisceration and/or enucleation, including indications, surgical techniques, preoperative evaluation modalities, implant types used, and postoperative complications experienced. RESULTS: Surgeons who recently completed fellowship training are more likely to perform eviscerations than their senior counterparts. The variety of viable implant types and the use of enucleation or evisceration for certain indications were not always in concordance with historical guiding principles. However, changing trends are in line with the current literature. CONCLUSION: Current practice patterns reflect recent literature and historical trends.

Dosage variability of topical ocular hypotensive products: a densitometric assessment.

PURPOSE: To ascertain consequence of variability in drop volume obtained from multiuse topical ocular hypotensive products in terms of uniformity of product dosage. METHODS: Densitometric assessment of drop volume dispensed from 2 alternative bottle positions. RESULTS: All except one product demonstrated a statistically significant difference in drop volume when administered at either a 45-degree or 90-degree bottle angle (Student t test, P<0.001). Product-specific drop volume ranged from a nadir of 22.36 microL to a high of 53.54 microL depending on bottle angle of administration. Deviation in drop dose was directly proportional to variability in drop volume. Variability in per drop dosage was conspicuous among products with a coefficient of variation from 1.49% to 15.91%. In accordance with drop volume, all products demonstrated a statistically significant difference in drop dose at 45-degree versus 90-degree administration angles. Drop volume was found unrelated to drop uniformity (Spearman r=0.01987 and P=0.9463). CONCLUSIONS: Variability and lack of uniformity in drop dosage is clearly evident among select ocular hypotensive products and is related to angle of drop administration. Erratic dosage of topical ocular hypotensive therapy may contribute in part to therapeutic failure and/or toxicity.

Individual-based computational modeling of smallpox epidemic control strategies.

In response to concerns about possible bioterrorism, the authors developed an individual-based (or "agent-based") computational model of smallpox epidemic transmission and control. The model explicitly represents an "artificial society" of individual human beings, each implemented as a distinct object, or data structure in a computer program. These agents interact locally with one another in code-represented social units such as homes, workplaces, schools, and hospitals. Over many iterations, these microinteractions generate large-scale macroscopic phenomena of fundamental interest such as the course of an epidemic in space and time. Model variables (incubation periods, clinical disease expression, contagiousness, and physical mobility) were assigned following realistic values agreed on by an advisory group of experts on smallpox. Eight response scenarios were evaluated at two epidemic scales, one being an introduction of ten smallpox cases into a 6,000-person town and the other an introduction of 500 smallpox cases into a 50,000-person town. The modeling exercise showed that contact tracing and vaccination of household, workplace, and school contacts, along with prompt reactive vaccination of hospital workers and isolation of diagnosed cases, could contain smallpox at both epidemic scales examined.