Idiopathic CD4 Lymphocytopenia: Spectrum of opportunistic infections, malignancies, and autoimmune diseases.

Idiopathic CD4 lymphocytopenia (ICL) was first defined in 1992 by the US Centers for Disease Control and Prevention (CDC) as the repeated presence of a CD4+ T lymphocyte count of fewer than 300 cells per cubic millimeter or of less than 20% of total T cells with no evidence of human immunodeficiency virus (HIV) infection and no condition that might cause depressed CD4 counts. Most of our knowledge about ICL comes from scattered case reports. The aim of this study was to collect comprehensive data from the previously published cases to understand the characteristics of this rare condition. We searched the PubMed database and Science Direct for case reports since 1989 for Idiopathic CD4 lymphocytopenia cases. We found 258 cases diagnosed with ICL in 143 published papers. We collected data about age, sex, pathogens, site of infections, CD4 count, CD8 count, CD4:CD8 ratio, presence of HIV risk factors, malignancies, autoimmune diseases and whether the patients survived or died. The mean age at diagnosis of first opportunistic infection (or ICL if no opportunistic infection reported) was 40.7 ± 19.2 years (standard deviation), with a range of 1 to 85. One-sixty (62%) patients were males, 91 (35.2%) were females, and 7 (2.7%) patients were not identified whether males or females. Risk factors for HIV were documented in 36 (13.9%) patients. The mean initial CD4 count was 142.6 ± 103.9/mm(3) (standard deviation). The mean initial CD8 count was 295 ± 273.6/mm(3) (standard deviation). The mean initial CD4:CD8 ratio was 0.6 ± 0.7 (standard deviation). The mean lowest CD4 count was 115.4 ± 87.1/mm(3) (standard deviation). The majority of patients 226 (87.6%) had at least one infection. Cryptococcal infections were the most prevalent infections in ICL patients (26.6%), followed by mycobacterial infections (17%), candidal infections (16.2%), and VZV infections (13.1%). Malignancies were reported in 47 (18.1%) patients. Autoimmune diseases were reported in 37 (14.2%) patients.

Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial.

PURPOSE: To compare outcomes of selective laser trabeculoplasty (SLT) with drug therapy for glaucoma patients in a prospective randomized clinical trial. PATIENTS AND METHODS: Sixty-nine patients (127 eyes) with open-angle glaucoma or ocular hypertension were randomized to SLT or medical therapy. Target intraocular pressure (IOP) was determined using the Collaborative Initial Glaucoma Treatment Study formula. Patients were treated with SLT (100 applications 360 degrees) or medical therapy (prostaglandin analog). Six visits over 1 year followed initial treatment. If target IOP range was not attained with SLT, additional SLT was the next step, or in the medical arm additional medications were added. PRIMARY OUTCOME: IOP; secondary: number of steps. RESULTS: Sixty-nine patients were treated. Data collection terminated with 54 patients reaching 9 to 12-months follow-up. Twenty-nine patients were in the SLT group, 25 patients in the medical group. Baseline mean IOP for all eyes was 24.5 mm Hg in the SLT group, 24.7 mm Hg in the medical group. Mean IOP (both eyes) at last follow-up was 18.2 mm Hg (6.3 mm Hg reduction) in the SLT arm, 17.7 mm Hg (7.0 mm Hg reduction) in the medical arm. By last follow-up, 11% of eyes received additional SLT, 27% required additional medication. There was not a statistically significant difference between the SLT and medication groups. CONCLUSIONS: IOP reduction was similar in both arms after 9 to 12-months follow-up. More treatment steps were necessary to maintain target IOP in the medication group, although there was not a statistically significant difference between groups. These results support the option of SLT as a safe and effective initial therapy in open-angle glaucoma or ocular hypertension.

MedlinePlus-based health information prescriptions: a comparison of email vs paper delivery.

BACKGROUND: The internet can provide evidence-based patient education to overcome time constraints of busy ambulatory practices. Health information prescriptions (HIPs) can be effectively integrated into clinic workflow, but compliance to visit health information sites such as MedlinePlus is limited. OBJECTIVE: Compare the efficacy of paper (pHIP) and email (eHIP) links to deliver HIPs; evaluate patient satisfaction with the HIP process and MedlinePlus information; assess reasons for noncompliance to HIPs. METHOD: Of 948 patients approached at two internal medicine clinics affiliated with an academic medical centre, 592 gave informed consent after meeting the inclusion criteria. In this randomised controlled trial, subjects were randomised to receive pHIP or eHIP for accessing an intermediate website that provided up to five MedlinePlus links for physician-selected HIP conditions. Patients accessing the intermediate website were surveyed by email to assess satisfaction with the health information. Survey non-responders were contacted by telephone to determine the reasons for no response. RESULTS: One hundred and eighty-one patients accessed the website, with significantly more 'filling' eHIP than pHIP (38% vs 23%; P < 0.001). Most (82%) survey respondents found the website information useful, with 77% favouring email for future HIPs delivery. Lack of time, forgot, lost instructions or changed mind were reasons given for not accessing the websites. CONCLUSIONS: Delivery of MedlinePlus-based HIPs in clinic is more effective using email prescriptions than paper. Satisfaction with the HIP information was high, but overall response was low and deserves further investigation to improve compliance and related outcomes.

Bariatric surgery: 1-year weight loss outcomes in patients with bipolar and other psychiatric disorders.

BACKGROUND: Bariatric surgery is the most effective obesity treatment in terms of weight loss and resolution of comorbidities. Roux-en-Y bypass surgery achieves weight loss of 60% to 70% excess body weight in most morbidly obese individuals. Patients with psychological disorders are reported to have less optimal results and those with bipolar, possibly worse. METHODS: A retrospective survey of Roux-en-Y bypass bariatric surgery patient clinical records to assess weight loss outcomes for morbidly obese patients, including those with bipolar disorders, other psychiatric conditions, and those without psychiatric diagnoses, was conducted. RESULTS: For all three study subgroups, the baseline mean weight exceeded 300 lbs, and mean BMI was 50. At 6 months, mean values for weight, percent weight loss, BMI, and percent change in BMI for all three groups were not significantly different. At 1 year, overall mean weight was less than 200 lbs, percent weight loss exceeded 35%, and mean BMI was 32. These outcomes were remarkably similar and not significantly different for those with bipolar disorder, other psychological conditions, and those without. The percent reaching follow-up at 12 months also did not differ between the three psychiatric status subgroups. CONCLUSION: In patients who undergo Roux-en-Y gastric bypass surgery, those with bipolar disorder have successful weight loss outcomes at 12 months that are not significantly different than those who have other psychiatric diagnoses and those with no psychiatric disorder. Despite practices that suggest the contrary, well-managed morbidly obese bipolar patients should be considered as suitable candidates for bariatric surgery using established criteria for risk assessment.

What are specialist and primary care clinicians' attitudes and practices regarding home blood pressure monitoring for hypertensive patients?

Practice guidelines recommend home blood pressure monitoring (HBPM) in the management of hypertension. We surveyed generalists and subspecialists regarding HBPM attitudes and practices in hypertensive patients. Both use HBPM for diagnostic and therapeutic purposes but question the evidence regarding HBPM efficacy. Standardized implementation and monitoring methods to improve HBPM practices are absent. Both generalists and specialists have concerns about HBPM instrument capabilities and perceive patient physical limitations and negative attitudes as additional barriers to effective blood pressure monitoring outside the office.

Survival impact of integrative cancer care in advanced metastatic breast cancer.

Integrative cancer treatment is of substantial interest to many cancer patients. Research is needed to evaluate the effects of integrative treatment on patient outcomes. We report survival data for a consecutive case series of advanced metastatic breast cancer patients who received a comprehensive clinical program combining conventional treatments with nutrition and supplementation, fitness and mind-spirit instruction at the Block Center for Integrative Cancer Treatment. Treatment outcomes using integrative care for this disease have not previously been documented; survival data will thus contribute to decisions concerning future research directions and design. Ninety consecutive patients with metastatic breast cancer diagnosed during 1984-1997 who received chemotherapy at the integrative cancer center were included. Prognostic factors, treatments and survival from onset of metastases were determined from analysis of scans, labs, pathology and medical records. The log-rank test and Cox proportional hazards analyses were used, and a Kaplan-Meier curve was calculated. All patients had metastatic disease at baseline, 96% were relapsed and 52% had received prior chemotherapy for metastatic disease. Median age at onset of metastasis was 46 years. Median survival was 38 months (95% CI 27,48). Published literature on populations with somewhat more favorable prognostic factors treated in conventional clinics showed median survivals of 20 to 23 months. Through the 1990s, median survival reported in metastatic breast cancer trials or observations generally ranged from 12 to 24 months. Five-year survival was 27% for Center versus 17% for comparison patients. Despite a higher proportion of younger and relapsed patients, survival of metastatic breast cancer patients at the Center was approximately double that of comparison populations and possibly even higher compared to trials published during this period. Explanations for the advantage relative to conventional treatment alone may include the nutritional, nutraceutical, exercise and psychosocial interventions, individually or in combination; self-selection of patients cannot be ruled out. Further research to evaluate the impact of integrative breast cancer treatment on survival is warranted.

Knowledge about glaucoma and barriers to follow-up care in a community glaucoma screening program.

OBJECTIVE: To assess perceived barriers to glaucoma follow-up care, including the lack of glaucoma knowledge and the lack of health care access, among participants in a community glaucoma screening program. DESIGN: Community survey. PARTICIPANTS: Two hundred forty-three consecutive participants in a series of free glaucoma screenings between November 2002 and August 2003. METHODS: The survey consisted of 20 questions designed to elicit knowledge of glaucoma and perception of potential barriers to follow-up care. Our aim was to find correlations between patient demographics and knowledge of glaucoma as well as perceived potential barriers to follow-up care. The data were analyzed using SPSS, v. 10.1. RESULTS: The average age of the respondents was 70 years, and females predominated (66%). About half of the respondents knew of an eye doctor in their neighborhood, and 60% had had an eye examination in the past year. Two hundred twenty-two (91%) indicated they could get to an eye doctor if the screening examination indicated they needed a follow-up examination. Two hundred twenty (90.5%) had medical insurance. One hundred seventy-eight (73%) of the participants had heard of glaucoma; 71 (29%) identified an accurate definition of glaucoma. The level of education and the language spoken at home were correlated with both glaucoma awareness (p < 0.001; p < 0.001) and knowledge of an accurate definition of glaucoma (p < 0.001; p < 0.025). CONCLUSIONS: In this population, a lack of adequate education about glaucoma may be more significantly associated with poor follow-up rates than a lack of access to care in those identified as glaucoma suspects.

Why current medical management is failing victims of Hurricane Katrina: a review of past successes and failures in postdisaster psychosocial treatment.

BACKGROUND: More than one year after Hurricane Katrina, victims exhibit symptoms of a "chronic disease," representing the disruption of psychosocial health. This systematic review assesses the effects of trauma on multiple domains of health following a disaster. METHOD: Authors searched disaster-related literature from 1971 to present, focusing on recent literature involving Hurricane Andrew and outcomes in nonphysical domains of health. Research relied mainly on PubMed, using keywords including "disaster," "hurricane," "psychosocial," "social," and "stress." RESULTS: Disaster victims are at risk for negative psychosocial health. Pre-Katrina, the majority of storm victims already exhibited several risk factors that made them candidates for low levels of health. CONCLUSIONS: Individuals affected by Hurricane Katrina, both those remaining in the Gulf Coast and evacuees, are at significant risk for low levels of psychosocial health. To prevent long-term health deficits in the region, a concerted effort of research and healthcare initiatives is needed as soon as possible.

Central corneal thickness in pediatric glaucoma.

PURPOSE: To compare the central corneal thickness (CCT) of children with and without glaucoma and to estimate the effect CCT may have on the intraocular pressure (IOP) assessment of children. PATIENTS AND METHODS: CCT and IOP measurements were performed in an unmasked fashion in 34 consecutive children with glaucoma and 28 consecutive children without glaucoma. Patients with corneal edema or extensive corneal scarring were excluded. IOPs in the pediatric glaucoma group were corrected for CCT using a linear algorithm; adjustments of 3 mm Hg or more were considered clinically significant. RESULTS: Mean CCT for eyes with glaucoma was 610.2+/-121.9 microm; for the control eyes, mean CCT was 555.6+/-38.4 microm (P < .001). Mean CCT was 543.3+/-66.9 microm for eyes with primary congenital glaucoma, 591.9+/-23.1 pm for those with Sturge-Weber syndrome, 662.7+/-68.7 microm for those with aphakic glaucoma, 754.5 +/-92.6 microm for those with aniridia, and 820.6+/-133.7 microm for those with microcornea (P < .001). Applying a correction formula for IOP with CCT adjustment, the adjusted IOP was overestimated by > or =3 mm Hg in 14 (41.2%) eyes and underestimated by > or = 3 mm Hg in 5 (14.7%) eyes. CONCLUSIONS: The mean CCT was higher for the pediatric glaucoma group than for the control group. However, the CCTs varied significantly depending on the specific diagnoses. CCT was estimated to have a clinically significant effect on IOP measurements in more than half of the patients with pediatric glaucoma. Pachymetry results should be considered in the management of these patients.

Physical activity assessment: validation of a clinical assessment tool.

BACKGROUND: Physicians report that they fail to counsel patients about physical activity due to a lack of practical tools, time, reimbursement, knowledge, and confidence. This paper reports concurrent and criterion validation of the Physical Activity Assessment Tool (PAAT), designed to rapidly assess patient physical activity in clinical settings and reduce time for assessment, and thus to facilitate counseling. METHODS: Adult volunteers (n=68) completed the PAAT and International Physical Activity Questionnaire-Long Form (IPAQ-Long) twice and wore a Manufacturing Technology, Inc. (MTI) accelerometer for 14 days in 2003. Continuous and categorical measures of physical activity by PAAT were compared to MTI accelerometer and IPAQ-Long in analyses conducted in 2003 to 2006. Consistent with national recommendations, participants were classified as active if they accumulated more than 150 minutes per week of moderate to vigorous physical activity (MVPA) or more than 60 minutes per week of vigorous physical activity. RESULTS: The PAAT was significantly correlated with the IPAQ (r=0.562, p<0.001) and MTI (r=0.392, p=0.015) for MVPA. Seven-day test-retest reliability was comparable for PAAT (r=0.618, p<0.001) and MTI (r=0.527, p<0.001). PAAT classified participants as "active" or "under-active" concordantly with MTI for 69.8% of participants and with IPAQ for 66.7%; strength of agreement was fair (kappa=0.338 and 0.212, respectively). The PAAT classified fewer participants as active than either the MTI (p=0.169) or IPAQ (p<0.001), and measured physical activity more like the direct objective measure (MTI) than did IPAQ. CONCLUSIONS: The concurrent and criterion validity of the PAAT are comparable to self-report instruments used in epidemiologic research.

Subconjunctival sodium hyaluronate 2.3% in trabeculectomy: a prospective randomized clinical trial.

PURPOSE: To investigate the efficacy of subconjunctival sodium hyaluronate 2.3% in increasing the success rate of glaucoma filtering surgery and promoting filtering blebs with characteristics presumed to predict better success. DESIGN: Randomized controlled clinical trial. PARTICIPANTS: Fifty-five patients scheduled for glaucoma surgery. INTERVENTION: Patients underwent routine trabeculectomy, with or without phacoemulsification and intraocular lens implantation. In the study group (n = 28), sodium hyaluronate 2.3% was injected between the scleral and conjunctival flaps at the conclusion of the surgery. In the control group (n = 27), balanced salt solution (BSS) was injected in the same fashion, in an unmasked design. MAIN OUTCOMES MEASURES: Surgical success was defined as (1) a complete success if the intraocular pressure (IOP) was 21 mmHg or less without any antiglaucoma medication, and (2) a qualified success if the IOP was 21 mmHg or less, with or without antiglaucoma medication. Patients requiring additional surgery, including needling, or with IOP more than 21 mmHg, even when receiving antiglaucoma medications, were considered to have failed treatment. Success rates in both groups were compared using Kaplan-Meier survival curves and the log-rank test. The morphologic characteristics of the filtering blebs were evaluated using the Indiana Bleb Appearance Grading Scale. Other outcome measures were IOP, visual acuity, need for antiglaucoma medication, and any complications. RESULTS: Fifty-two patients completed the study (27 in the study group and 25 in the control group), with a mean follow-up of 12.3 months. Complete success rates were 77.8% for the study group and 84.0% for the control group 12 months after surgery (P>0.5); qualified success rates were 88.9% for the study group and 92.0% for the control group (P>0.6). Mean IOP decreased from 26.0+/-10.0 mmHg to 11.6+/-4.1 mmHg in the study eyes (P<0.001) and from 24.9+/-9.7 mmHg to 13.0+/-4.1 mmHg in the control eyes (P<0.001). Intraocular pressure measurements in both groups were similar at all visits (P>0.05). The study eyes had more diffuse blebs than the control eyes (62.5% > or =4 clock-hours vs. 22.7%; P = 0.012). Postoperative complications were similar in the study eyes (14.8%) and the control eyes (20.0%; P>0.6). CONCLUSIONS: There was no difference in success rates in patients who received subconjunctival sodium hyaluronate 2.3% compared to BSS injections. Subconjunctival sodium hyaluronate 2.3% was associated with more diffuse blebs after filtering surgery.

Improvement in colour vision parameters following successful trabeculectomy.

PURPOSE: To determine whether colour vision improves following reduction of intraocular pressure (IOP) in glaucoma patients. METHODS: The medical records of 29 glaucoma patients (41 eyes) were reviewed. Inclusion criteria required subjects to have made more than four visits to the Glaucoma Service Laboratory and to undergo a thorough eye examination including a Farnsworth-Munsell 100-hue colour vision test and Goldmann tonometry before and after pressure lowering. Colour vision parameters of total error score (TES), yellow-blue score (YBS) and red-green score (RGS) were measured. The study group consisted of 21 eyes of glaucoma patients who underwent uncomplicated trabeculectomy with an IOP reduction of >/= 20% from baseline. The control group consisted of 21 eyes of glaucoma patients matched for age and colour vision, who received medication and/or underwent surgery with a post-intervention IOP reduction of < 20% from baseline. The primary outcome was a comparison of pre- and post-intervention colour vision parameters between the two groups. RESULTS: There was a statistically significant improvement in TES (43 +/- 44, p < 0.001), RGS (19 +/- 27, p = 0.0077) and YBS (23 +/- 29, p = 0.0007) in the study group compared with the control group. The improvement in TES (r = 0.52, p < 0.001), RGS (r = 0.55, p < 0.001) and YBS (r = 0.40, p = 0.008) was correlated with the percentage of IOP reduction. There was no statistically significant difference between improvement in Y-B and R-G scores in the study group. CONCLUSION: Intraocular pressure reduction of >/= 20% post-trabeculectomy was associated with an improvement in colour vision. Colour vision tests may be useful as an adjunctive outcome measure for therapeutic interventions.

Assessment of function related to vision (AFREV).

OBJECTIVES: To evaluate the relationship of a performance-based measure of visual functioning to clinical and subjective measures in glaucoma patients. DESIGN: Cross-sectional survey of glaucoma patients. PARTICIPANTS: Forty-three patients with primary open-angle glaucoma. METHODS: Patients were evaluated using a novel performance-based measure, the Assessment of Function Related to Vision (AFREV), standard clinical tests of visual function, and the National Eye Institute's Visual Functioning Questionnaire (NEI-VFQ-25), a self-reported quality of life measure. Correlations of the AFREV scores with visual field scores, monocular and binocular visual acuity, contrast sensitivity scores, and NEI-VFQ scores were calculated. Rasch analysis was used to estimate the visual ability required by each task of AFREV for a particular response (item measures) and to estimate the visual ability of each patient (person measures). MAIN OUTCOME MEASURES: AFREV and NEI-VFQ total scores. RESULTS: The AFREV total scores were highly correlated with contrast sensitivity (r = 0.772), binocular visual acuity (r = -0.768), better-eye visual acuity (r = -0.737), worse-eye visual acuity (r = -0.675), and Estermann visual field efficiency scores (r = 0.606) as well as with NEI-VFQ scores (r = 0.70). The resulting index, constructed from 5 items of the AFREV, is unidimensional, thereby satisfying the primary assumption of the Rasch model. The Rasch person-item map demonstrates that the "putting stick into holes" and "reading small print" tests require the most visual ability. CONCLUSIONS: The AFREV performance-based measure, a new test of a spectrum of activities, correlates well with some standard measures of visual function and certain aspects of self-report assessments. AFREV appears to be a valid measure of performance ability that may provide information not obtainable from standard measures of visual function or subjective surveys.

The effects of iridotomy size and position on symptoms following laser peripheral iridotomy.

PURPOSE: To evaluate visual disturbances following laser peripheral iridotomy (LPI). Patients sometimes note visual disturbances following laser peripheral iridotomy. The purpose of this study was to provide what we believe to be the first systematic evaluation of these visual disturbances, including a determination of whether or not they are associated with characteristics of a primary patent laser peripheral iridotomy, such as lid position and size of the iridotomy. PATIENTS AND METHODS: This was a case series of 93 consecutive (172 eyes) glaucoma patients who had had an Nd: YAG laser peripheral iridotomy. Patients returning for a follow-up visit after laser peripheral iridotomy were selected. A standardized questionnaire was prospectively administered to the study patients at least 1 month after their laser peripheral iridotomy had been performed, inquiring if they experienced any of the following either before or after the iridotomy: halo, lines, crescent, ghost image, glare, spots, shadows, blurring, or other unlisted visual disturbances. On the same visit when they answered the questionnaire, the patients were examined at the slit lamp to assess the location, lid coverage status, and size of the laser peripheral iridotomy. Selection for the performance of the LPI was not prospective. A series of 93 consecutive patients served as controls. RESULTS: Seven (4%) of the 172 study eyes had postoperative visual symptoms of shadows, ghost images, crescents, or lines. Ninety (52.3%) of the laser peripheral iridotomies were covered by the upper lid, 40 (23%) were completely exposed, and 42 (24%) were partially exposed. Visual disturbances (those listed above plus glare, blurring, haloes, spots, and miscellaneous) occurred in 8 of the 90 (8.9%) eyes with completely covered laser peripheral iridotomies, in 11 of the 42 (26%) with partially covered laser peripheral iridotomies, and in 7 of the 40 (17.5%) with fully exposed LPIs. CONCLUSION: Visual symptoms following laser peripheral iridotomy are more likely to occur in patients who have partially or fully exposed laser iridotomies than in those in whom the iridotomy is completely covered by the lid.

Timolol/dorzolamide combination therapy as initial treatment for intraocular pressure over 30 mm Hg.

PURPOSE: To determine the intraocular pressure (IOP)-lowering effect of a fixed timolol/dorzolamide combination (Cosopt) for patients with IOP over 30 mm Hg. STUDY DESIGN: Prospective interventional case series. METHODS: Eighteen patients being seen on the Wills Eye Hospital Glaucoma Service with at least one eye with an IOP > 30 mm Hg were recruited. None had used any glaucoma medications for at least 1 month. IOP was confirmed by diurnal testing. Cosopt was administered at 9 am and 9 pm. Trough IOP measurements were made at 9 am and peak IOP measurements at 11 am at baseline, 1 month, and 2 months. Pretreatment and posttreatment IOPs were compared using a paired-samples independent t test. RESULTS: Mean pretreatment IOP was 37.5 +/- 1.0 mm Hg. Baseline posttreatment IOP was 18.4 +/- 0.5 mm Hg (P < 0.01). At 2 months, the mean trough IOP was 21.1 +/- 0.9 mm Hg and the peak, 17.6 +/- 0.6 mm Hg (each, P < 0.01, as compared with pretreatment baseline IOP). One patient did not respond to Cosopt; two had a clinically insufficient response and did not complete the study. Data from these patients were included in the analysis. CONCLUSIONS: Over 80% of the eyes responded to Cosopt, with an average trough IOP reduction of 40% at 2 months.

Racial differences in cesareans: an analysis of U.S. 2001 National Inpatient Sample Data.

OBJECTIVE: To evaluate racial differences in potentially unnecessary cesareans in the United States. METHODS: The 2001 Healthcare Cost and Utilization Project Nationwide Inpatient Sample database was used to analyze various maternal demographic and clinical parameters among women having cesarean deliveries. For the purpose of our study, if there were no diagnoses related to cesarean delivery on the discharge certificate, the cesarean was classified as potentially unnecessary RESULTS: Using our methodology, 11% of 540,174 primary and 65% of 371,863 repeat cesareans for the year 2001 in the United States were classified as potentially unnecessary. After controlling for age, payment source, ZIP income, admission day, region of the country, and hospital size, location, and teaching status, black women had a higher likelihood of having potentially unnecessary primary cesareans when compared with white (P < .001) or Hispanic women (P < .001). White women had a higher likelihood of having potentially unnecessary repeat cesareans than black women (P < .001), although the magnitude of the odds ratio for race was not as striking as in primary cesarean. Potentially unnecessary primary cesareans were also more likely to occur in women aged 35 years or older, Medicare patients, weekend admissions, or those residing in the South or Northeast. Potentially unnecessary repeat cesareans were more likely to occur in women younger than 35 years, in rural hospitals, and in weekday admissions. CONCLUSION: In the United States, racial differences exist in the proportion of cesarean deliveries that are potentially unnecessary. Further exploration of these differences is warranted. LEVEL OF EVIDENCE: III.

Level of disagreement between Proview phosphene tonometer and Goldmann applanation tonometer intraocular pressure readings.

PURPOSE: To evaluate the agreement of intraocular pressure (IOP) readings obtained with the Proview phosphene tonometer and those obtained by Goldmann applanation tonometry as well as the effect of regular use of the Proview on patients' anxiety about their glaucoma. METHODS: One hundred thirty-five consecutive patients with glaucoma, 35 designated as controls, were enrolled in a 10-month randomized prospective clinical trial. The study patients but not the controls used the Proview outside the office. At office visits IOP was measured by an ophthalmologist with the Goldmann applanation tonometer (GAT) as well as by examiners and patients using the Proview. Patients in the treatment group (n = 100) were asked to measure and record their IOP at home as well. Using ANOVA, we examined the relationship between demographic variables and the level of agreement between the Proview readings and those measured by GAT at the final office visit. All participants also were asked to complete a questionnaire regarding their anxiety about their IOP at the baseline and final office visits. The primary outcome measure was the level of agreement of the Proview measurements with those obtained by GAT. Secondary outcome measures included patients' anxiety about their glaucoma. RESULTS: The absolute mean difference between GAT and Proview readings at the final visit was 3.5 +/- 2.9 mm Hg (median, 2.8 mm Hg). The treatment group reported significantly less anxiety about their glaucoma after 4 to 6 weeks of using the Proview (P = .024). CONCLUSIONS: There was considerable discrepancy between Proview and GAT readings. However, regular use of the Proview tonometer significantly reduced patients' anxiety about their glaucoma.