The safety and efficacy of combined phacoemulsification and trabeculectomy with releasable sutures.

AIM: To evaluate the combined phacoemulsification with acrylic intraocular lens implantation and trabeculectomy with releasable sutures, without the use of antimetabolites, performed by one surgeon. METHODS: A retrospective analysis was performed on 251 eyes of 198 patients after a combined phaco/trabeculectomy procedure, followed up for an average of 16 months for vision, intraocular pressure (IOP), and number of glaucoma medications. Cox proportional hazard regression analysis provided measures of relative risk (RR) or hazards ratios and 95% confidence intervals (CIs) associated with the occurrence of several conditions or complications of surgery. RESULTS: Mean preoperative variables were best corrected vision, 0.6 (SD 0.4) logMAR (20/80 Snellen); IOP, 18.7 (4.9) mm Hg; and number of glaucoma medications, 1.7 (0.8). Mean postoperative results were best corrected vision, 0.2 (0.4) logMAR (20/32 Snellen); IOP, 15.1 (3.2) mm Hg; and number of glaucoma medications, 0.3 (0.6). Postoperatively, the mean decreases from baseline were 19.2% for IOP and 84.1% for number of glaucoma medications; 85% of eyes required fewer glaucoma medications and 78% of eyes were medication free, with IOP control. There were no significant operative or postoperative complications. CONCLUSION: Combined phacoemulsification and trabeculectomy with releasable sutures, in the absence of antimetabolites, is a safe, effective, and stable alternative for patients with cataracts and glaucoma.

Clinical spectrum of posterior ischemic optic neuropathy.

PURPOSE: To describe the systemic and visual characteristics and prognosis in patients with posterior ischemic optic neuropathy (PION). DESIGN: Observational case series. METHODS: Retrospective chart review in a multicenter setting. Seventy-two patients (98 eyes) with a clinical diagnosis of PION. Co-morbid systemic diseases and visual function were recorded at both initial presentation and after mean visual follow-up of 4.1 years and systemic follow-up of 5.4 years. RESULTS: PION occurred in three main settings: in the perioperative period following a variety of surgical procedures (28 patients), associated with giant cell (temporal) arteritis (6 patients), and associated with nonarteritic systemic vascular disease (38 patients). Patients with perioperative and arteritic PION were more likely to have severe, bilateral visual loss that did not improve. Among eyes with nonarteritic PION, 34% experienced improvement in vision, 28% remained stable, and 38% worsened. Among patients with nonarteritic PION, carotid artery disease and a history of stroke (with or without carotid artery disease) were both associated with a statistically significant increased risk of poor final visual outcome. CONCLUSIONS: There are three distinct subtypes of PION: perioperative, arteritic, and nonarteritic. Patients with PION that is unassociated with surgery should undergo an evaluation for systemic vascular diseases, including giant cell arteritis, that may or may not be apparent at the time of vision loss. The visual prognosis for patients with perioperative or arteritic PION is poor, whereas that for nonarteritic PION is similar to that for patients with nonarteritic AION.

Prevalence of the different types of age-related cataract in an African population.

PURPOSE: To describe the prevalence of different types of cataract and their association with visual acuity in a Tanzanian population aged 40 years and older. METHODS: A prevalence survey for lens opacity, glaucoma, and visual impairment was carried out on all residents age 40 and older of six villages in Kongwa, Tanzania. One examiner graded the lens for presence of nuclear (NSC), posterior subcapsular (PSC), and cortical cataract (CC), using the new WHO Simplified Cataract Grading System. Visual acuity was measured in each eye, both presenting and best corrected, using an illiterate E chart. RESULTS: The proportion of eligible subjects participating was 90% (3268/3641). The prevalence of cataract was as follows: NSC, 15.6%; CC, 8.8%; and PSC, 1.9%. All types of cataract increased with age, from NSC, 1.7%; CC, 2.4%; and PSC, 0.4% for those aged 40 to 49 years to NSC, 59.2%; CC, 23.5%; and PSC, 5.9% for those aged 70 years and older (P < 0.0001 for all cataract types, chi(2) test for trend). Cataract prevalence was higher among women than men for NSC (P = 0.0001), but not for CC (P = 0.15) or PSC (P = 0.25), after adjusting for age. Prevalence rates of visual impairment (BCVA < 6/12), US blindness (< or = 6/60) and WHO blindness (< 6/120) for this population were 13.3%, 2.1%, and 1.3%, respectively. Older age and each of the major types of pure and mixed cataract were independently associated with worse vision in regression modeling. CONCLUSIONS: Unlike African-derived populations in Salisbury and Barbados, NSC rather than CC was most prevalent in this African population. The seeming lower prevalence of CC may to some extent be explained by different grading schemes, differential availability of cataract surgery, the younger mean age of the Tanzanian subjects, and a higher prevalence of NSC in this population.

Treatment of childhood myopia with atropine eyedrops and bifocal spectacles.

BACKGROUND: Animal and human studies have suggested that muscarinic antagonists and bifocal spectacles may decrease the progression of myopia in children. The purpose of this study is to report the largest known series of patients treated simultaneously with bifocals and topical atropine. DESIGN: Retrospective, interventional, non-comparative case series. METHODS: 706 myopic children (296 boys and 410 girls, ages 6 to 16 years) were prescribed full cycloplegic spectacle corrections, with photochromic lenses and +2.25 diopter (D) reading adds in each eye. Both eyes were treated with atropine 1% drops once daily. OUTCOME MEASURES: Annual change in cycloplegic refractions of right eyes. Compliance with therapy was monitored by patient and parental report. RESULTS: 496 (70%) of the 706 patients reported full compliance with the treatment regimen, whereas the remaining 210 (30%) patients were partially compliant. The median interval of treatment was 3.62 years (range, 21 days-10.1 years). The mean rate of myopic progression was significantly less (P<0.001) in patients who were fully compliant with atropine therapy and bifocals (0.08 D/year) than in patients who were partially compliant with the treatment regimen (0.23 D/per year). No serious adverse effects were associated with atropine therapy. CONCLUSIONS: Full compliance with topical atropine therapy and bifocal spectacles was associated with decreased progression of myopia compared to partial compliance with treatment. For each of the treated groups, the mean rate of myopic progression was significantly less (P<0.05) than the mean annual rates of myopic progression published for the pediatric population.

Psychopathology and the initiation of disability payments.

OBJECTIVE: Longitudinal prospective data from the multisite Epidemiologic Catchment Area (ECA) survey were examined to determine relationships between mental disorders, alcohol abuse or dependence, and transfer payments for disability. METHODS: ECA respondents who were not receiving disability benefits at baseline but who were receiving them at the one-year follow-up were identified. The effects of six psychiatric disorders on the risk of starting payments were examined. They were major depressive disorder, panic disorder, alcohol abuse or dependence, phobic disorder, obsessive-compulsive disorder, and schizophrenia. The odds of starting to receive payments were calculated for persons with these disorders, any mental or addictive disorder, or any two or more disorders, while the analysis controlled for sociodemographic characteristics. RESULTS: A total of 15,567 people were interviewed at baseline; 7 percent received disability payments. Among the 11, 981 people interviewed at one year, 261 had begun to receive payments that year, for a starting rate of 2.2 percent. Significant predictors of the initiation of payments were little education (odds ratio=3.7) and low household income (OR=2.6). Respondents with panic disorder were 5.2 times more likely to begin receiving benefits than those without this disorder; respondents with schizophrenia were 4.5 times more likely and those with two or more disorders were 2.8 times more likely to start benefits than those without these disorders. CONCLUSIONS: Differences in social class influenced the initiation of disability payments. However, having a mental or addictive disorder was a more significant predictor, strongly increasing the risk of receiving payments. Given the economic burden to society and potential loss of earnings and opportunity costs for persons with disability and their families, intervening to prevent or alleviate mental disorders should be considered as one alternative to reducing disability payments.

Influence of comorbid alcohol and psychiatric disorders on utilization of mental health services in the National Comorbidity Survey.

OBJECTIVE: This study sought to determine how comorbidity of psychiatric and substance abuse disorders affects the likelihood of using mental health services. METHOD: The analysis was based on data on adults aged 18-54 years in the National Comorbidity Survey (N = 5,393). Users and nonusers of mental health and substance abuse services were compared in terms of their demographic characteristics, recent stressful life events, social support, parental history of psychopathology, self-medication, and symptoms of alcohol abuse/dependence. RESULTS: The prevalence of service utilization varied by diagnostic configurations. Comorbid psychiatric or alcohol disorders were stronger predictors of service utilization than a pure psychiatric or alcohol disorder. Factors predicting utilization of services differed for each disorder. CONCLUSIONS: Since comorbidity increases the use of mental health and substance abuse services, research on the relationship of psychiatric and alcohol-related disorders to service utilization needs to consider the coexistence of mental disorders. Attempts to reduce barriers to help seeking for those in need of treatment should be increased.

Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey.

OBJECTIVE: The authors present nationally representative descriptive data on 12-month use of outpatient services for psychiatric problems. They focused on the relationship between DSM-III-R disorders and service use in four broadly defined service sectors as well as the distribution of service use in multiple service sectors. METHOD: Data from the National Comorbidity Survey were examined. RESULTS: Summary measures of the seriousness and complexity of illness were significantly related to probability of use, number of sectors used, mean number of visits, and specialty treatment. One-fourth of the people in outpatient treatment were seen in multiple service sectors, but no evidence was found of multisector offset in number of visits. CONCLUSIONS: Use of outpatient services for psychiatric problems appears to have increased over the decade between the early 1980s and early 1990s, especially in the self-help sector. Aggregate allocation of treatment resources was related to need, highlighting the importance of making provisions for specialty care in the triage systems currently evolving as part of managed care.

Absence of social networks, social support and health services utilization.

BACKGROUND: This study examines the effects of distress and three types of social relationships (family, friends, and confidantes) on the use of out-patient health services in an adult sample from a community survey of 3481 persons in Baltimore, Maryland. METHODS: Independent effects of predisposing (age, education, marital status, race and sex), enabling (employment, income and insurance) and need (physical health) factors are adjusted for in estimating the odds of using health care services. RESULTS: Illness, being female, and having insurance were positively related to use of services, while being aged was inversely related. After adjustment for the above factors, social support interacted with psychological distress to effect the use of medical care: the combination of high distress and low social support by a confidante results in a fourfold increase of medical utilization. CONCLUSIONS: Our findings support the inclusion of psychological distress and social network variables in addition to physical health status in models attempting to explain the use of health services. Despite an inability to analyse change over time, our data suggest an understanding of the interrelationship between psychosocial factors, distress and health care use would benefit health providers and their patients.

Psychopathology and the development of disability.

The objective was to determine the effect of preexisting psychopathology on days missed from work or usual activities ("disability days") in a large community sample (N = 3481). Logistic regression analyses were performed with the presence or absence of disability days (wave 2) as the dependent variable. The effects of sociodemographic variables, six psychiatric disorders, a high distress score, and chronic physical conditions (wave 1) were studied. Separate analyses were conducted for the total sample and four subgroups (labor force participants, homemakers, men, and women). The adjusted odds ratios and 95% confidence intervals (95% CI) for subjects with onset of panic disorder were 7.3 (95% CI = 1.8, 28.7); for those with chronic major depressive disorder, 7.2 (95% CI = 0.3, 160.6); and for those with chronic high distress, 5.0 (95% CI = 2.6, 9.9). The relative odds for developing a disability were greater for those with either type of psychiatric disorder or high distress than for those with any prior physical illness or those with a prior disability day. Disability days experienced by persons with psychopathology result in diminished quality of life, economic losses, and increased need for health services. Improved health services and educational and work adjustments for emotionally disabled persons are recommended.

School-based health centers and adolescent use of primary care and hospital care.

PURPOSE: Little is known about the impact of school-based primary care on adolescents' use of hospital and emergency room care. METHODS: Students (grades 6-12) in nine Baltimore schools with school-based health centers and four schools without health centers were surveyed in May 1991 using an anonymous classroom questionnaire. Self-reported use of primary care services and emergency rooms and hospitalization were examined over the academic year. Logistic regression was used to assess factors influencing use of health care including the presence of a school health center. RESULTS: Students (n = 3,258) in health center schools and comparison schools reported similar rates of chronic health conditions. Students from schools with health centers were more likely to report seeing a social worker or counselor and more likely to report the use of certain health services in the past 4 years. Self-reported emergency room use (38%) and hospitalization (19%) were common. Students in schools with health centers were less likely to report hospitalization (OR = 0.80, 95% CI = 0.66-0.98). Emergency room use was also lower but only for students attending the school with a health center for more than 1 year (OR = 0.78, 95% CI = 0.62-0.99). Significant predictors of hospital care included reporting one or more chronic health condition, having health insurance, being of African-American race, or older age, and lower grade. CONCLUSIONS: Access to school-based, primary health care for adolescents was associated with increased use of primary care, reduced use of emergency rooms, and fewer hospitalizations. These findings have implications for both access to primary care and funding of school-based primary care.

Stage of behavior change for condom use: the influence of partner type, relationship and pregnancy factors.

A theoretical model was used to examine the influence of relationship factors, pregnancy intentions, contraceptive behavior and other psychosocial characteristics on stages of behavior change in condom use among heterosexual black women of reproductive age. Data from an inner-city street survey compared women who were not contemplating condom use, women who were attempting to use condoms or had used them consistently for short periods of time, and those who had achieved long-term consistent use. Women's relationship with their main partner appears to be an important factor in understanding their use of condoms both with main partners and with other partners. For condom use with the main partner, factors such as emotional closeness and partner support were significant predictors of the likelihood that women would be attempting to use condoms rather than not contemplating use. Cohabitation and the belief that condom use builds trust were significant predictors of long-term consistent condom use. Having a regular or main partner was strongly associated with intentions to use condoms with other partners. Women who wanted to become pregnant were much less likely to intend to use condoms with their main partner, and women using oral contraceptives were less likely to be long-term consistent condom users.

PIP: This study examines the influence of five groups of factors on the stages of change in condom use among Black women in Baltimore, Maryland, in 1993. The stages of change included: precontemplation, contemplation, ready for action, action, and maintenance. Interviews were obtained from women aged 17-35 years in designated neighborhoods. The sample included 625 women equally divided among age groups 17-20 years, 20-24 years, and 25-35 years. 63% of the 625 women had a main sexual partner and 42% had other partners, of which 33% had a main partner and other partners. Most women with main partners were in the precontemplation stage (50%) and most women with other partners were in the maintenance stage (41%). Women with main and other partners were primarily in the maintenance stage (37%). Few were classified as being in the contemplation or action stages. Changes between the precontemplation stage and the middle stage are viewed as "developing intentions." Changes between the middle stage and maintenance stage are viewed as "using consistently." Condom use with a main partner was associated with all five groups of factors: demographic, social, pregnancy intentions, outcome expectations or HIV risk, and efficacy. Having a regular partner who supported condom use significantly increased the odds of developing intentions to use condoms and of using condoms consistently. Friends support of condom use and condom use among friends raised the odds of becoming a consistent condom user. Having two or more partners and having one or more HIV risk factors was positively associated with the likelihood of consistent condom use. The strongest effects on developing intentions to use condoms with a main partner were emotional closeness, partner support for condom use, and women's potential happiness if pregnancy was an outcome. Consistent condom use with a main partner was predicted best by cohabitation with the main partner, use of the pill at the last intercourse, and the belief in condoms as a means of building trust. Prediction among other partners was more difficult.

Student attitudes toward school-based health centers.

PURPOSE: Little is known about student attitudes toward school-based health centers (SBHCs) or about factors that influence SBHC enrollment. METHODS: Students in 9 Baltimore schools with SBHCs and 4 schools without health centers were surveyed in May 1991, using an anonymous classroom questionnaire. SBHC enrollees, nonenrollees from health center schools, and students in schools without health centers were compared using bi-variate analyses. Logistic regression analyses identified predictors of enrollment. RESULTS: A total of 91% of enrollees supported having a SBHC compared with 89% of nonenrollees and 77% of students from non-health center schools (p < .001). Support for a variety of services (including contraceptive services) was significantly higher among enrollees and nonenrollees compared with students in non-SBHC schools. A total of 86% of enrollees rated the quality of care "satisfactory" to "excellent" and 79% rated privacy in the school health center as "satisfactory" to "excellent." The most common reason given for not enrolling was satisfaction with current provider. Independent predictors of student confidence in the privacy of SBHCs included prior SBHC use and enrollment of close peers. Predictors of enrollment included: one or more self-reported health problems; having medical assistance; attending one or more special education classes; enrollment of close peers; membership in a school club, sports team, or church organization; and being African-American. CONCLUSIONS: Students overwhelmingly supported school-based health centers. Personal experience and peer influences were important in shaping student attitudes. We found evidence of a "learning curve" gradient in student attitudes such that students with the greatest exposure to SBHCs (as measured by attending a SBHC school, enrolling in the SBHC, and using the health center) had the most favorable attitudes.

Cost recovery and improved drug availability in Niger--implications for total patient treatment costs.

Using quasi-experimental design methods, this study investigated, for a cost recovery intervention in Niger, how the total costs of an episode of treatment for an acute illness for a typical patient changed when user fees were imposed but accompanied by an improved drug supply. Episode costs included both cash and opportunity costs. With few exceptions, the comparisons of both the unadjusted and adjusted patient episode costs showed that patient total episode costs in the intervention sites increased relative to the control site. The infusion of resources in Say and Boboye meant that now patients had essential medicines to buy, in comparison to Illela where stocks of essential medicines continued to deteriorate. Trends in episode costs within each intervention district demonstrated that to some extent cost recovery accompanied by an improved drug supply did not significantly change the total cost of an episode of treatment. In Say, this was true for malaria cases, females and the poor. However, in Boboye, reductions in copayments were offset by a mandatory tax payment paid by both users and non-users.

Psychopathology and mortality in the general population.

Community studies of the relationship between mortality and mental disorders remain equivocal with mixed and unclear results. Longitudinal prospective data from the Epidemiologic Catchment Area Program are examined for the relationship between psychopathology and mortality. Analyses were performed with mortality at 1-year follow-up as the dependent variable using logistic regression. Specifically, the odds of dying from psychiatric disorders were considered while statistically adjusting for sociodemographic characteristics and treatment in primary or specialty medical care sectors. Significant predictors of dying were being male, older, and from low income households. Subjects with drug abuse or dependence were 12.4 times (CI = 2.9, 53.0) as likely to die as those without drug abuse/dependence. The odds of dying for those with major depressive disorder were over 2.6 times (CI = 1.1, 6.0) those without major depression. Separate analyses for all five communities and for only those over the age of 55 years showed similar results.

Emotional disability days: prevalence and predictors.

This study considered days missed from work or usual activities for emotional reasons associated with a range of specific psychopathologic disorders, psychosocial distress, and persons found to be asymptomatic. Analyses were performed with the presence or absence of emotional disability days as the dependent variable using logistic regression. The effects of specific mental disorders were compared with the effects of chronic physical conditions for labor force participants and for the total population. The odds ratio (and 95% confidence interval) for subjects with major depressive disorder was 27.8 (6.93, 108.96); for panic disorder, 21.1 (2.25, 198.44); and for schizophrenia, 17.8 (1.73, 182.99). Work-place adjustments for persons with psychopathology are encouraged.