ABSTRACT
Purpose: To compare retrobulbar anesthesia injection (RAI) with hyaluronidase and without hyaluronidase in vitreoretinal surgery using clinical efficacy measures and orbital manometry (OM). Methods: This prospective randomized double-masked study enrolled patients who had surgery using an 8 mL RAI with or without hyaluronidase. Outcome measures were clinical block effectiveness (akinesia, pain scores, need for supplemental anesthetic or sedative medications) and orbital dynamics assessed by OM before and up to 5 minutes after RAI. Results: Twenty-two patients received RAI with hyaluronidase (Group H+), and 25 received RAI without hyaluronidase (Group H-). Baseline characteristics were well matched. No differences in clinical efficacy were found. OM showed no difference in preinjection orbital tension (4 ± 2 mm Hg in both groups) or calculated orbital compliance (0.6 ± 0.3 mL/mm Hg, Group H+; 0.5 ± 0.2 mL/mm Hg, Group H-) (P = .13). After RAI, the peak orbital tension was 23 ± 15 mm Hg in Group H+ and 24 ± 9 mm Hg in Group H- (P = .67); it declined more rapidly in Group H+. Orbital tension at 5 minutes was 6 ± 3 mm Hg in Group H+ and 11 ± 5 mm Hg in Group H- (P = .0008). Conclusions: OM showed faster resolution of post-RAI orbital tension elevation with hyaluronidase; however, there were no clinically evident differences between groups. Thus, 8 mL RAI with or without hyaluronidase is safe and can achieve excellent clinical results. Our data do not support the routine use of hyaluronidase with RAI.
ABSTRACT
BACKGROUND: In 1992, the American Academy of Pediatrics and the American Public Health Association jointly published guidelines for temporary exclusion of sick children from child care. However, little is known about key stakeholders' compliance with these guidelines. OBJECTIVES: The purpose of this work was to compare pediatricians', parents', and child care providers' compliance with American Academy of Pediatrics guidelines and determine predictors for higher rates of compliance. METHODS: We conducted a cross-sectional survey of 215 randomly selected Maryland pediatricians, 223 parents, and 192 child care providers from 22 Baltimore, Maryland, child care centers from January to July 2004. Questionnaires contained the following 6 case vignettes depicting common child care illnesses: upper respiratory infection, conjunctivitis, gastroenteritis, mild febrile illness, tinea capitis, and atopic dermatitis. The instrument measured the correctness of exclusion and inclusion decisions (using American Academy of Pediatrics/American Public Health Association guidelines as gold standard) according to varying levels of fever, disease severity (eg, clear versus yellow eye discharge), familiarity with the child, and parent work schedule flexibility. RESULTS: Response rates were 71% for pediatricians, 56% for parents, and 85% for child care providers. Guideline compliance was higher for pediatricians (74%) than for child care providers (60%) and parents (61%). Only 23% of pediatricians and parents and 29% of child care providers reported familiarity with American Academy of Pediatrics/American Public Health Association guidelines by name. In general, child care providers and parents had lower false-negative rates (allowed fewer children to attend who met criteria for exclusion) than pediatricians, suggesting that pediatricians may underexclude. Child care providers and parents correctly excluded in 65%-98% of cases requiring exclusion, whereas pediatricians correctly excluded 31%-86% of cases requiring exclusion, depending on the vignette. Yet pediatricians were much more specific about which children met criteria (pediatricians correctly included 61%-93% of cases requiring inclusion versus child care providers and parents who correctly included 20%-75% of such cases), suggesting that child care providers and parents may overexclude. Compliance rates varied significantly by stakeholder, vignette (disease), level of fever, and disease severity but did not vary with the stakeholder's familiarity with the child or the flexibility of the parent's work schedule. CONCLUSIONS: Pediatricians, parents, and child care providers were unfamiliar with American Academy of Pediatrics/American Public Health Association illness exclusion guidelines by name but moderately compliant with them. When noncompliant, child care providers and parents generally overexcluded, and pediatricians underexcluded. Stakeholder- and disease-specific predictors for noncompliance gleaned from this study suggest how educational interventions aiming to increase guideline compliance could be individually tailored to child care providers, parents, and pediatricians.
