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1.
Eur J Health Econ ; 20(9): 1303-1315, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31401699

RESUMO

BACKGROUND: Although pay-for-performance (P4P) for diabetes care is increasingly common, evidence of its effectiveness in improving population health and health system sustainability is deficient. This information gap is attributable in part to the heterogeneity of healthcare financing, covered medical conditions, care settings, and provider remuneration arrangements within and across countries. We systematically reviewed the literature concentrating on whether P4P for physicians in primary and community care leads to better diabetes outcomes in single-payer national health insurance systems. METHODS: Studies were identified by searching ten databases (01/2000-04/2018) and scanning the reference lists of review articles and other global health literature. We included primary studies evaluating the effects of introducing P4P for diabetes care among primary care physicians in countries of universal health coverage. Outcomes of interest included patient morbidity, avoidable hospitalization, premature death, and healthcare costs. RESULTS: We identified 2218 reports; after exclusions, 10 articles covering 8 P4P interventions in 7 countries were eligible for analysis. Five studies, capturing records from 717,166 patients with diabetes, were graded as high-quality evaluations of P4P on health outcomes. Based on three quality studies, P4P can result in reduced risk of mortality over the longer term-when linked to performance metrics. However, studies from other jurisdictions, where P4P was not linked to specific patient-oriented objectives, yielded little or mixed evidence of positive health impacts. CONCLUSION: Evidence of the effectiveness of P4P depends on whether physicians' incentive payments are explicitly tied to performance metrics. However, the most appropriate indicators for performance monitoring remain in question. More research with rigorous evaluation in different settings is needed.

2.
Can J Ophthalmol ; 54(4): 451-457, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31358143

RESUMO

OBJECTIVE: To assess recent cataract service delivery across communities of all sizes in Ontario. DESIGN: Retrospective analysis of health records. PARTICIPANTS: All Ontario Health Insurance Plan users. METHODS: Raw physician Ontario Health Insurance Plan claims data for cataract surgery (E140A, E214A) from April 1, 2009, to March 31, 2014, were extracted from the Ontario Ministry of Health and Long-Term Care (MOHLTC) IntelliHealth database. Cataract surgery claims data were sorted by sex, by age, and by Ontario's 444 municipalities based on patient residence. Cataract surgery distribution was examined by population centre: Large Urban (≥100 000 persons), Medium (30 000-99 999 persons), Small (1000-29 999 persons), and Rural (<1000 persons) as defined by Statistics Canada. Wait times were extracted from the MOHLTC wait times database. Cataract surgery rate (CSR), defined as the number of cataract surgeries performed per million, was calculated. RESULTS: Cataract surgery volumes remained unchanged from 2010 to 2014. Mean patient age was 71.6 ± 10 years. Patients lived in large urban (63%), medium (15%), small (21%), and rural (0.6%) communities. Mean wait times increased by 28% to 68.5 days, and 90th percentile wait times increased by 44% to 154.3 days. A reduction in CSR was observed among seniors aged 65-74 years (-10%) and 75+ years (-16%). Rural communities showed the largest decline (-19%). Among seniors aged ≥75 years, CSR declined the most for those living in rural communities (-25%). CONCLUSIONS: Adjusting the current government policy of zero-growth in cataract surgery volumes will support growing demands for cataract care in our aging population.

3.
Hum Resour Health ; 17(1): 40, 2019 05 31.
Artigo em Inglês | MEDLINE | ID: mdl-31151400

RESUMO

BACKGROUND: Despite increasing popularity among health organizations of pay for performance (P4P) for the provision of comprehensive care for chronic non-communicable diseases, evidence of its effectiveness in improving health system outcomes is weak. An important void in the evidence base is whether there are gendered differences in P4P uptake and in related outcomes amenable to healthcare improvement. This study assesses the gender-specific effects of P4P among family physicians on diabetes healthcare costs in a context of universal health coverage. METHODS: We use population-based linked longitudinal administrative datasets on chronic disease cases, physician billings, hospital discharge abstracts, and physician and resident registries in the province of New Brunswick, Canada. We estimate the effects of introduction of a P4P scheme on excess public healthcare costs among cohorts of adult diabetes patients using propensity score-adjusted difference-in-differences regressions stratified by physician's gender. RESULTS: We observed greater male physician uptake of incentive payments, seemingly exacerbating gender gaps in professional remuneration. Regression results indicated P4P did not lead to improved outcomes in terms of preventing hospitalization costs among patients, only measurable increases in compensation for both the male and female physician workforce. CONCLUSIONS: While P4P was not attributed in this study to reduced hospital burden and enhanced sustainability of healthcare financing, incentive payments were found to be related to earning gaps by physician's gender. Decision-makers should consider that benefits of P4P be monitored not only for patient metrics but also for provider metrics in terms of gender equality especially given feminization of primary care medical workforces.

4.
Hum Resour Health ; 17(1): 46, 2019 06 24.
Artigo em Inglês | MEDLINE | ID: mdl-31234883

RESUMO

Women constitute 70% of the global health and social care workforce, but important knowledge gaps persist to effectively support decision making to optimize gender equity. In this Editorial introducing a new thematic series on 'Research to support evidence-informed decisions on optimizing gender equity in health workforce policy and planning,' we are calling for submissions focusing on research concerning the monitoring, evaluation and accountability of human resources for health policy options through a gender equity lens. We are particularly interested to receive manuscripts advancing the innovative use of data and methodologies in the areas of occupational segregation, decent work, gender pay gap and gendered leadership in the health workforce that could be reproducible across different country contexts.

5.
Am J Ophthalmol ; 207: 333-342, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31095952

RESUMO

PURPOSE: This study describes an incision-free minimally invasive conjunctival surgical (MICS) technique to repair late-onset leaking blebs after trabeculectomy. METHODS: A surgical technique to repair leaking blebs without incision or excision of conjunctiva is described. This is followed by retrospective review of all patients treated at the Glaucoma Unit at St. Michael's Hospital for bleb leaks repaired with MICS from 2012 to 2017. With Research Ethics Board approval, clinical data obtained from the charts included demographic information, vision, intraocular pressure (IOP) data before and after surgery, need for additional medication, and complications. Resolution of the bleb leak without the need for additional therapy or intervention for glaucoma control was considered a success. RESULTS: The MICS approach was applied to 14 eyes of 13 consecutive patients with a leaking bleb. Mean age of presentation was 70.2 ± 14.8 years, and all patients had a history of mitomycin use at the time of glaucoma surgery. The onset of bleb leak following trabeculectomy ranged from 7 months to 16.3 years. Mean pre-operative IOP was 4.5 ± 2.8 mm Hg; IOP measured 12.3 ± 3.0 mm Hg immediately after the procedure. Complete resolution of the bleb leak was observed following surgery in all cases. The follow-up period ranged from 2 weeks to 61 months (10.2 ± 18.1). Recurrent bleb leak was reported in 1 patient 2 years following initial surgery. In all cases, the initially repaired filtering blebs remained functional at last follow-up, and no additional medications were required. CONCLUSIONS: The MICS procedure is an effective option for treating late-onset leaking blebs without cutting or excising conjunctival tissue. The minimal requirements of this method make it additionally accessible to low-resource settings. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

6.
Indian Pediatr ; 56(1): 45-48, 2019 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-30806361

RESUMO

OBJECTIVE: Setting priorities in health research is a challenge at the global and national levels. Use of evidence-based approach is uncommon and needs to be promoted in low-and middle-income countries (LMIC). We describe profile of Cochrane systematic reviews focussing on participation from LMIC. METHODS: We searched six Cochrane review groups producing reviews relevant to child health in low- and middle-income countries for published Cochrane systematic reviews from 1 March, 2009 till 18 March, 2015 in the Cochrane Library. RESULTS: A total of 669 Cochrane systematic reviews from six review groups were found. Low proportion of lead authors from low- and middle-income countries was found in 4 out of 6 review groups. About 50% of the reviews showed inconclusive evidence. 101/669 (15%) empty reviews were found needing more primary studies. CONCLUSION: The proportion of Cochrane authors from low- and middle-income countries is low. Capacity-building in systematic reviews and good quality primary research in these countries is warranted.


Assuntos
Saúde da Criança , Revisão Sistemática como Assunto , Criança , Países em Desenvolvimento , Medicina Baseada em Evidências , Humanos , Metanálise como Assunto
7.
Am J Obstet Gynecol ; 220(4): 297-307, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30682365

RESUMO

Compared with adults who are admitted to general medical-surgical wards, women who are admitted to labor and delivery services are at much lower risk of experiencing unexpected critical illness. Nonetheless, critical illness and other complications that put either the mother or fetus at risk do occur. One potential approach to prevention is to use automated early warning systems, such as those used for nonpregnant adults. Predictive models that use data extracted in real time from electronic records constitute the cornerstone of such systems. This article addresses several issues that are involved in the development of such predictive models: specification of temporal characteristics, choice of denominator, selection of outcomes for model calibration, potential uses of existing adult severity of illness scores, approaches to data processing, statistical considerations, validation, and options for instantiation. These have not been addressed explicitly in the obstetrics literature, which has focused on the use of manually assigned scores. In addition, this article provides some results from work in progress to develop 2 obstetric predictive models with the use of data from 262,071 women who were admitted to a labor and delivery service at 15 Kaiser Permanente Northern California hospitals between 2010 and 2017.

8.
Can J Diabetes ; 43(5): 354-360.e1, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30679059

RESUMO

OBJECTIVES: In New Brunswick, Canada, 13.6% of the population 35 years of age and older is living with type 1 or type 2 diabetes mellitus. To address public health and clinical challenges, pay-for-performance (P4P) for family physicians was introduced in 2010 to enable comprehensive diabetes management. This study assesses the impacts of the P4P scheme on excess health-care costs. METHODS: We used a quasiexperimental study design drawing on linked population-based administrative data sets of physician billings, hospital discharge abstracts and provider and resident registrations. Prospective cohorts of patients with diabetes were identified through a validated algorithm tracing individuals' interactions with the health-care system. We applied propensity-score difference-in-differences estimation for the effects of P4P on preventable diabetes-related hospitalization costs according to patients' exposures to physicians' uptake of the incentive. RESULTS: Coverage of incentivized care peaked at less than half (44%) of adults with diabetes, who tended to be younger and less often presenting comorbid conditions compared to those whose providers did not claim incentives. The introduction of P4P was attributed to significantly lower diabetes hospitalization costs among newly diagnosed patients (-0.083; p<0.01) and improved compensation for physicians. No cost avoidance was established among medium-term and longer-term patients or for hospitalizations for conditions concordant with diabetes. CONCLUSIONS: The effects of New Brunswick's P4P for diabetes care are mixed. Results reflect the deficient evidence base on the effects of P4P on patient-oriented and policymaker-important health outcomes. The high risk for multiple morbidities among patients with diabetes and the heterogeneity of physician responses to performance incentives may be hindering the effectiveness of P4P in improving diabetes outcomes.

9.
Can J Ophthalmol ; 53(6): 580-587, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30502981

RESUMO

OBJECTIVE: To assess trends in surgical procedures and indications for all corneal transplants performed at the University of Toronto. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: One thousand one hundred and four consecutive corneal transplants performed at the Kensington Eye Institute (KEI). METHODS: Demographic, clinical, and pathological data retrieved from the Ophthalmic Pathology Laboratory on all corneal transplants performed at the KEI from January 2014 to December 2016. RESULTS: Over 3 years, partial-thickness lamellar keratoplasties were performed in 880 cases (80%) while full-thickness penetrating keratoplasties (PKP) accounted for 224 cases (20%). Leading causes of corneal transplant were Fuchs' dystrophy (42%), graft failure (17%), bullous keratopathy (15%), and keratoconus (15%). Graft failure (40%) and keratoconus (31%) were the leading causes for PKP. Descemet's membrane endothelial keratoplasty (DMEK) accounted for 37% of cases, Descemet's stripping automated endothelial keratoplasty (DSAEK) for 30%, and deep anterior lamellar keratoplasty (DALK) for 13%. By 2016, partial-thickness procedures had increased by 10%, accounting for 85% of all procedures. In addition, DMEK increased by 26%, DSAEK decreased by 13%, and PKP decreased by 11%. Fuchs' dystrophy remained the leading indication for DMEK (67%) and DSAEK (42%) procedures. In 2016, 73% of DALK procedures were for the treatment of keratoconus. CONCLUSIONS: Partial-thickness corneal transplants now account for 85% of all current graft procedures, and DMEK has emerged as the procedure of choice. Graft failure continues to be the leading indication for full-thickness grafts. Longitudinal studies are needed to determine whether these new trends persist and their future impact on graft failures.

10.
Invest Ophthalmol Vis Sci ; 59(15): 5876-5884, 2018 12 03.
Artigo em Inglês | MEDLINE | ID: mdl-30543343

RESUMO

Purpose: To determine whether cerebrospinal fluid (CSF) entry into the optic nerve is altered in glaucoma. Methods: Fluorescent 10-kDa dextran tracer was injected into the CSF of 2-month-old (n = 9) and 10-month-old DBA/2J glaucoma mice (n = 8) and age-matched controls (C57Bl/6; n = 8 each group). Intraocular pressure (IOP) was measured in all mice before tracer injection into CSF. Tracer distribution was assessed using confocal microscopy of optic nerve cross-sections of mice killed 1 hour after injection. Paravascular tracer distribution in the optic nerve was studied in relation to isolectin-stained blood vessels. Tracer intensity and cross-sectional area in the laminar optic nerve were quantitatively assessed in all four groups and statistically compared. Aquaporin 4 (AQP4) and retinal ganglion cell axonal phosphorylated neurofilament (pNF) were evaluated using immunofluorescence and confocal microscopy. Results: IOP was elevated in 10-month-old glaucoma mice compared with age-matched controls. One hour after tracer injection, controls showed abundant CSF tracer in the optic nerve subarachnoid space and within the nerve in paravascular spaces surrounding isolectin-labeled blood vessels. CSF tracer intensity and signal distribution in the optic nerve were significantly decreased in 10-month-old glaucoma mice compared with age-matched controls (P = 0.0008 and P = 0.0033, respectively). AQP4 immunoreactivity was similar in 10-month-old DBA and age-matched control mice. Half of the 10-month-old DBA mice (n = 4/8) showed a decrease in pNF immunoreactivity compared to controls. Altered pNF staining was seen only in DBA mice lacking CSF tracer at the laminar optic nerve (n = 4/5). Conclusions: This study provides the first evidence that CSF entry into the optic nerve is impaired in glaucoma. This finding points to a novel CSF-related mechanism that may help to understand optic nerve damage in glaucoma.


Assuntos
Líquido Cefalorraquidiano/metabolismo , Glaucoma/metabolismo , Doenças do Nervo Óptico/metabolismo , Animais , Aquaporina 4/metabolismo , Axônios/metabolismo , Axônios/patologia , Carbocianinas/metabolismo , Feminino , Técnica Indireta de Fluorescência para Anticorpo , Corantes Fluorescentes/metabolismo , Glaucoma/patologia , Pressão Intraocular/fisiologia , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Endogâmicos DBA , Microscopia Confocal , Proteínas de Neurofilamentos/metabolismo , Doenças do Nervo Óptico/patologia , Fosforilação , Células Ganglionares da Retina/metabolismo , Células Ganglionares da Retina/patologia
11.
Exp Eye Res ; 179: 157-167, 2018 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-30447197

RESUMO

This study describes non-invasive photoacoustic imaging to detect and monitor the growth of conjunctival melanomas in vivo. Conjunctival melanomas were induced by injection of melanotic B16F10 cells into the subconjunctival space in syngeneic albino C57BL/6 mice. Non-invasive in vivo photoacoustic tomography was performed before, and after tumor induction up to 2 weeks. Spectral unmixing was performed to determine the location and to assess the distribution of melanin. The melanin photoacoustic signal intensity was quantified from the tumor-bearing and control eyes at all timepoints. For postmortem validation, total tumor and melanotic tumor volumes were measured using H&E stained tumor sections and were compared to in vivo photoacoustic imaging measurements. Photoacoustic imaging non-invasively detected eyes bearing conjunctival tumors of varying sizes. The melanin signal was detected as early as immediately following injection of melanotic tumor cells. Changes in tumor size over time were assessed with changes in the volume and intensity of the melanin signal. Four growing tumors and one regressing tumor were observed. Three tumors without significant change in signal intensity over time were observed, showing variable growth. Photoacoustic melanin signal on the last day of in vivo imaging correlated with postmortem total tumor volume (R2 = 0.81) and melanotic tumor volume (R2 = 0.80). The results of our study show that actively growing conjunctival melanomas can be quantified in a non-invasive manner using in vivo photoacoustic tomography. The photoacoustic melanin signal intensity correlated with total and melanotic tumor volume. This novel in vivo imaging platform may help to assess new treatment modalities to manage ocular tumors.

12.
Br J Ophthalmol ; 2018 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-30348644

RESUMO

BACKGROUND: Corneal transplant failure with neovascularisation is a leading indication for full-thickness grafts in patients. Lymphangiogenesis is implicated in the pathology of graft failure, and here we systematically evaluate failed human corneal transplants with neovascularisation for the presence of lymphatic vessels. METHODS: Nine failed grafts with neovascularisation, based on H&E staining with subsequent immunoperoxidase staining for CD31, a blood vessel marker, were selected. Lymphatics were investigated by immunohistochemical and immunofluorescence approaches using podoplanin as a lymphatic marker. In two of nine cases, fluorescence in situ hybridisation (FISH) was used for detection of lymphatic mRNAs including podoplanin, VEGFR-3 and LYVE-1. All immunofluorescence and FISH samples were compared with positive and negative controls and visualised by confocal microscopy. RESULTS: Corneal neovascularisation was established in all cases by H&E and further confirmed by CD31 immunoreactive profiles. Immunohistochemistry for the podoplanin antibody was positive in all cases and showed morphologies ranging from distinct luminal structures to elongated profiles. Simultaneous immunofluorescence using CD31 and podoplanin showed lymphatic vessels distinct from blood vessels. Podoplanin immunofluorescence was noted in seven of nine cases and revealed clear lumina of varying sizes, in addition to lumen-like and elongated profiles. The presence of lymphatic mRNA was confirmed by FISH studies using a combination of at least two of podoplanin, VEGFR-3 and LYVE-1 mRNAs. CONCLUSIONS: The consistent finding of lymphatic vessels in failed grafts with neovascularisation implicates them in the pathogenesis of corneal transplant failure, and points to the lymphatics as a potential new therapeutic target.

13.
Can J Ophthalmol ; 53(4): 391-401, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30119795

RESUMO

OBJECTIVE: To assess retinal blood vessels in a live retinitis pigmentosa (RP) model with rd1 mutation and green fluorescent protein (GFP) expressed in vascular endothelium. METHODS: Homozygous (hm) Tie2-GFP mice with rd1 mutation and known retinal degeneration were crossed with wild-type CD1 mice to generate control heterozygous (ht) Tie2-GFP mice. The retinas of 16 live hm mice were evaluated at 2 weeks and 3, 5, and 8 months of age, and compared with age-matched control ht and CD1 mice by optical coherence tomography (OCT) and confocal scanning laser ophthalmoscopy (cSLO). Fluorescence intensity was measured and compared between strains at 3, 5, and 8 months. In vivo findings were validated by immunostaining with collagen IV and isolectin histopathology. RESULTS: All hm Tie2-GFP mice showed progressive outer retinal degeneration by OCT. Loss of small branches of blood vessels and then larger main vessels was seen by cSLO. Retinal tissue and vessels were preserved in control ht mice. At all ages, measurements of fluorescence intensity were reduced in hm compared with ht mice (p < 0.001). In all strains, intensity at 8 months was reduced compared with 3 months (p < 0.001) and 5 months (p = 0.021). Histopathological studies confirmed in vivo findings and revealed a pattern of blood vessel regression in the deep plexus, followed by intermediate and superficial retinal plexuses. CONCLUSIONS: This is the first evidence of progressive loss of retinal blood vessels in a live mouse model of RP. These findings may be highly relevant to understanding retinal degeneration in RP to prevent blindness.

14.
Invest Ophthalmol Vis Sci ; 59(7): 2699-2707, 2018 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-29860456

RESUMO

Purpose: To visualize and quantify lymphatic drainage of aqueous humor from the eye to cervical lymph nodes in the dynamic state. Methods: A near-infrared tracer was injected into the right eye anterior chamber of 10 mice under general anesthesia. Mice were imaged with photoacoustic tomography before and 20 minutes, 2, 4, and 6 hours after injection. Tracer signal intensity was measured in both eyes and right and left neck lymph nodes at every time point and signal intensity slopes were calculated. Slope differences between right and left eyes and right and left nodes were compared using paired t-test. Neck nodes were examined with fluorescence optical imaging and histologically for the presence of tracer. Results: Following right eye intracameral injection of tracer, an exponential decrease in tracer signal was observed from 20 minutes to 6 hours in all mice. Slope differences of the signal intensity between right and left eyes were significant (P < 0.001). Simultaneously, increasing tracer signal was observed in the right neck node from 20 minutes to 6 hours. Slope differences of the signal intensity between right and left neck nodes were significant (P = 0.0051). Ex vivo optical fluorescence imaging and histopathologic examination of neck nodes confirmed tracer presence within submandibular nodes. Conclusions: Active lymphatic drainage of aqueous from the eye to cervical lymph nodes was measured noninvasively by photoacoustic imaging of near-infrared nanoparticles. This unique in vivo assay may help to uncover novel drugs that target alternative outflow routes to lower IOP in glaucoma and may provide new insights into lymphatic drainage in eye health and disease.

15.
Artigo em Inglês | MEDLINE | ID: mdl-29866029

RESUMO

BACKGROUND: Edible mushrooms are an abundant source of carbohydrates, proteins, and multiple antioxidants and phytonutrients. This paper presents a general overview on the edible fungus describing the inventions made in the field of its cultivation, equipment and value added products. OBJECTIVE: To understand and review the innovations and nutraceutical benefits of mushrooms as well as to develop interest regarding the edible mushrooms. METHODS: Information provided in this review is based on the available research investigations and patents. RESULT: Mushrooms are an edible source of a wide variety of antioxidants and phytonutrients with a number of nutraceutical properties including anti-tumor and anti-carcinogenic. Thus, several investigations are made for cultivation and improvement of the yield of mushrooms through improvisation of growth substrates and equipment used for mushroom processing. The mushroom has been processed into various products to increase its consumption, providing the health and nutritional benefit to mankind. CONCLUSION: This paper summarizes the cultivation practices of mushroom, its processing equipments, methods of preservation, value added based products, and its nutraceutical properties. The review also highlights the various scientific feats achieved in terms of patents and research publications promoting mushroom as a wholesome food.

16.
Ophthalmology ; 125(10): 1608-1622, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29776671

RESUMO

Diabetes mellitus (DM) is a global epidemic and affects populations in both developing and developed countries, with differing health care and resource levels. Diabetic retinopathy (DR) is a major complication of DM and a leading cause of vision loss in working middle-aged adults. Vision loss from DR can be prevented with broad-level public health strategies, but these need to be tailored to a country's and population's resource setting. Designing DR screening programs, with appropriate and timely referral to facilities with trained eye care professionals, and using cost-effective treatment for vision-threatening levels of DR can prevent vision loss. The International Council of Ophthalmology Guidelines for Diabetic Eye Care 2017 summarize and offer a comprehensive guide for DR screening, referral and follow-up schedules for DR, and appropriate management of vision-threatening DR, including diabetic macular edema (DME) and proliferative DR, for countries with high- and low- or intermediate-resource settings. The guidelines include updated evidence on screening and referral criteria, the minimum requirements for a screening vision and retinal examination, follow-up care, and management of DR and DME, including laser photocoagulation and appropriate use of intravitreal anti-vascular endothelial growth factor inhibitors and, in specific situations, intravitreal corticosteroids. Recommendations for management of DR in patients during pregnancy and with concomitant cataract also are included. The guidelines offer suggestions for monitoring outcomes and indicators of success at a population level.

19.
Can J Ophthalmol ; 52(6): 583-591, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29217027

RESUMO

OBJECTIVE: To analyze optic nerve head stereophotographs for the presence of optic disc hemorrhages, and to describe bleeding patterns and patient characteristics. DESIGN: Retrospective, cross-sectional study. PARTICIPANTS: 1113 optic nerve stereophotograph pairs of 562 consecutive patients. METHODS: Stereophotographs were systematically reviewed for the presence of a disc hemorrhage with careful documentation of optic nerve head features. All charts of patients with hemorrhage were subsequently studied for demographic information and clinical data. RESULTS: Disc hemorrhages were observed in 7.1% of patients with optic disc photography. Most patients had open-angle glaucoma (57.5%) with focal ischemic phenotype of the optic disc (66.7%). The mean vertical and horizontal cup-disc ratios were 0.82 ± 0.14 and 0.76 ± 0.14, respectively. The ß-zone peripapillary atrophy was observed in 48.9% of patients. The most common location was the inferotemporal region of the disc (60.8%), and most were flame or splinter shaped (70.6%). Disc hemorrhages were found either superficial to or within the retinal nerve fibre layer (72.5%), and in association with a notch (64.4%). The average intraocular pressure was 17.3 ± 4.9 mm Hg, and most hemorrhages were associated with early visual field defects (42.5%). CONCLUSIONS: Optic disc hemorrhages in patients with glaucoma were most frequently observed inferiorly in association with a notch. Most eyes with a disc hemorrhage had an intraocular pressure within normal range and had either early or no visual field loss. These findings highlight the importance of careful examination of the optic nerve head to look for the presence of a disc hemorrhage as an important biomarker of glaucoma damage.


Assuntos
Glaucoma de Ângulo Fechado/diagnóstico , Glaucoma de Ângulo Aberto/diagnóstico , Glaucoma de Baixa Tensão/diagnóstico , Disco Óptico/patologia , Doenças do Nervo Óptico/diagnóstico , Hemorragia Retiniana/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Pressão Intraocular , Masculino , Pessoa de Meia-Idade , Doenças do Nervo Óptico/classificação , Fotografação , Estudos Retrospectivos , Tonometria Ocular , Campos Visuais
20.
Invest Ophthalmol Vis Sci ; 58(11): 4784-4791, 2017 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-28973323

RESUMO

Purpose: The purpose of this study was to determine whether cerebrospinal fluid (CSF) enters the optic nerve via a glymphatic pathway and whether this entry is size-dependent. Methods: Fluorescent dextran tracers (fluorescein isothiocyanate [FITC]) of four different sizes (10, 40, 70, and 500 kDa) and FITC-ovalbumin (45 kDa) were injected into the CSF of 15 adult mice. Tracer distribution in the orbital optic nerve at 1 hour after injection was assessed in tissue sections with confocal microscopy. Tracer distribution within the optic nerve was studied in relation to blood vessels and astrocytes identified by isolectin histochemistry and glial fibrillary acidic protein (GFAP) immunofluorescence, respectively. Aquaporin 4 (AQP4) immunostaining was performed to assess astrocytic endfeet in relation to CSF tracer. Results: One hour following tracer injection into CSF, all tracer sizes (10-500 kDa) were noted in the subarachnoid space surrounding the orbital optic nerve. In all cases, 10 kDa (n = 4/4) and 40 kDa (n = 3/3) tracers were noted within the optic nerve, while 70-kDa tracer was occasionally noted (n = 1/4). Tracer found within the nerve was specifically localized between isolectin-labeled blood vessels and GFAP-positive astrocytes or AQP4-labeled astrocytic endfeet. The 500-kDa tracer was not detected within the optic nerve. Conclusions: To our knowledge, this is the first evidence of a glymphatic pathway in the optic nerve. CSF enters the optic nerve via spaces surrounding blood vessels, bordered by astrocytic endfeet. CSF entry into paravascular spaces of the optic nerve is size-dependent, and this pathway may be highly relevant to optic nerve diseases, including glaucoma.


Assuntos
Líquido Cefalorraquidiano/fisiologia , Nervo Óptico , Animais , Astrócitos/metabolismo , Vasos Sanguíneos/metabolismo , Dextranos/farmacocinética , Modelos Animais de Doenças , Feminino , Fluoresceína-5-Isotiocianato/análogos & derivados , Fluoresceína-5-Isotiocianato/farmacocinética , Corantes Fluorescentes/farmacocinética , Masculino , Camundongos
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