The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis.

TOPIC: Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial. CLINICAL RELEVANCE: This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat. METHODS: Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR). RESULTS: Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data. DISCUSSION: Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

To disclose or not to disclose: an ethnographic exploration of factors contributing to the (non) disclosure of Ghanaian women's breast cancer diagnosis to social networks.

BACKGROUND: Although there may be theoretical support linking positive health outcomes with cancer disclosure to social networks, women from contexts such as Ghana where cancer is not openly talked about may have concerns around breast cancer disclosure. Women may not be able to share their experiences about their diagnosis, which may prevent them from receiving support. This study aimed to obtain the views of Ghanaian women diagnosed with breast cancer about factors contributing to (non) disclosure. METHODS: This study is based on secondary findings from an ethnographic study that employed participant observation and semi-structured face to face interviews. The study was conducted at a breast clinic in a Teaching Hospital in southern Ghana. 16 women diagnosed with breast cancer (up to stage 3); five relatives nominated by these women and ten healthcare professionals (HCPs) participated in the study. Factors contributing to breast cancer (non) disclosure were explored. Data were analysed using a thematic approach. RESULTS: The analysis indicated that most of the women and family members were very reticent about breast cancer disclosure and were secretive with distant relatives and wider social networks. Whilst remaining silent about their cancer diagnosis helped women protect their identities, prevented spiritual attack, and bad advice, the need for emotional and financial support for cancer treatment triggered disclosure to close family, friends, and pastors. Some women were discouraged from persevering with conventional treatment following disclosure to their close relatives. CONCLUSIONS: Breast cancer stigma and fears around disclosure hindered women from disclosing to individuals in their social networks. Women disclosed to their close relatives for support, but this was not always safe. Health care professionals are well placed to explore women's concerns and facilitate disclosure within safe spaces to enhance engagement with breast cancer care services.

The cultural and structural influences that 'hide' information from women diagnosed with breast cancer in Ghana: an ethnography.

BACKGROUND: Socio-cultural factors may influence the uptake of breast cancer treatments. This study aimed to explore these socio-cultural influences on treatment decision-making for women in Ghana. METHOD: An ethnographic approach was adopted. Observation was conducted of women newly diagnosed with breast cancer, nominated relatives, nurses and doctors at a breast clinic in Ghana. Semi-structured interviews followed participant observation. Thematic analysis was employed. FINDINGS: Over 16 weeks (July 2017-November 2017), 31 participants were observed and 29 took part in semi-structured interviews. Three overarching themes were identified: (1) unequal power relationships; (2) Language barriers and (3) structural constraints. Following a breast cancer diagnosis, essential information necessary for treatment decision making is 'hidden' from women due to an unequal patient-provider relationship. Patients acknowledged cultural behaviours of deference to experts. Doctors deliberately misrepresented treatment information to women to encourage them to undergo surgical treatment. Structural issues such as the lack of privacy during consultations hindered quality patient engagement with decision-making. High treatment costs and the lack of resources to assist women with fertility after treatment impeded open discussions around these issues. Language barriers included a lack of terms in the local Twi language to explain cancer and its treatment. There was also an absence of appropriate information materials. CONCLUSION: Findings highlight the need for health professionals to be aware of the socio-cultural factors that limit access to quality information which is needed for informed treatment decision making. Policies that aim to provide adequate logistics; increase staffing levels; improve staff cultural awareness training and remove financial barriers are recommended.

Inter-rater reliability of the QuIS as an assessment of the quality of staff-inpatient interactions.

BACKGROUND: Recent studies of the quality of in-hospital care have used the Quality of Interaction Schedule (QuIS) to rate interactions observed between staff and inpatients in a variety of ward conditions. The QuIS was developed and evaluated in nursing and residential care. We set out to develop methodology for summarising information from inter-rater reliability studies of the QuIS in the acute hospital setting. METHODS: Staff-inpatient interactions were rated by trained staff observing care delivered during two-hour observation periods. Anticipating the possibility of the quality of care varying depending on ward conditions, we selected wards and times of day to reflect the variety of daytime care delivered to patients. We estimated inter-rater reliability using weighted kappa, κ w , combined over observation periods to produce an overall, summary estimate, [Formula: see text]. Weighting schemes putting different emphasis on the severity of misclassification between QuIS categories were compared, as were different methods of combining observation period specific estimates. RESULTS: Estimated [Formula: see text] did not vary greatly depending on the weighting scheme employed, but we found simple averaging of estimates across observation periods to produce a higher value of inter-rater reliability due to over-weighting observation periods with fewest interactions. CONCLUSIONS: We recommend that researchers evaluating the inter-rater reliability of the QuIS by observing staff-inpatient interactions during observation periods representing the variety of ward conditions in which care takes place, should summarise inter-rater reliability by κ w , weighted according to our scheme A4. Observation period specific estimates should be combined into an overall, single summary statistic [Formula: see text], using a random effects approach, with [Formula: see text], to be interpreted as the mean of the distribution of κ w across the variety of ward conditions. We draw attention to issues in the analysis and interpretation of inter-rater reliability studies incorporating distinct phases of data collection that may generalise more widely.

The cluster-randomized BRIGHT trial: Proactive case finding for community-dwelling older adults.

PURPOSE: People are now living longer, but disability may affect the quality of those additional years of life. We undertook a trial to assess whether case finding reduces disability among older primary care patients. METHODS: We conducted a cluster-randomized trial of the Brief Risk Identification Geriatric Health Tool (BRIGHT) among 60 primary care practices in New Zealand, assigning them to an intervention or control group. Intervention practices sent a BRIGHT screening tool to older adults every birthday; those with a score of 3 or higher were referred to regional geriatric services for assessment and, if needed, service provision. Control practices provided usual care. Main outcomes, assessed in blinded fashion, were residential care placement and hospitalization, and secondary outcomes were disability, assessed with Nottingham Extended Activities of Daily Living Scale (NEADL), and quality of life, assessed with the World Health Organization Quality of Life scale, abbreviated version (WHOQOL-BREF). RESULTS: All 8,308 community-dwelling patients aged 75 years and older were approached; 3,893 (47%) participated, of whom 3,010 (77%) completed the trial. Their mean age was 80.3 (SD 4.5) years, and 55% were women. Overall, 88% of the intervention group returned a BRIGHT tool; 549 patients were referred. After 36 months, patients in the intervention group were more likely than those in the control group to have been placed in residential care: 8.4% vs 6.2% (hazard ratio = 1.32; 95% CI, 1.04-1.68; P = .02). Intervention patients had smaller declines in mean scores for physical health-related quality of life (1.6 vs 2.9 points, P = .007) and psychological health-related quality of life (1.1 vs 2.4 points, P = .005). Hospitalization, disability, and use of services did not differ between groups, however. CONCLUSIONS: Our case-finding strategy was effective in increasing identification of older adults with disability, but there was little evidence of improved outcomes. Further research could trial stronger primary care integration strategies.

The Use of Preoperative Prophylactic Systemic Antibiotics for the Prevention of Endopthalmitis in Open Globe Injuries: A Meta-Analysis.

TOPIC: This study reports the effect of systemic prophylactic antibiotics (and their route) on the risk of endophthalmitis after open globe injury (OGI). CLINICAL RELEVANCE: Endophthalmitis is a major complication of OGI; it can lead to rapid sight loss in the affected eye. The administration of systemic antibiotic prophylaxis is common practice in some health care systems, although there is no consensus on their use. METHODS: PubMed, CENTRAL, Web of Science, CINAHL, and Embase were searched. This was completed July 6, 2021 and updated December 10, 2022. We included randomized and nonrandomized prospective studies which reported the rate of post-OGI endophthalmitis when systemic preoperative antibiotic prophylaxis (via the oral or IV route) was given. The Cochrane Risk of Bias tool and ROBINS-I tool were used for assessing the risk of bias. Where meta-analysis was performed, results were reported as an odds ratio. PROSPERO registration: CRD42021271271. RESULTS: Three studies were included. One prospective observational study compared outcomes of patients who had received systemic or no systemic preoperative antibiotics. The endophthalmitis rates reported were 3.75% and 4.91% in the systemic and no systemic preoperative antibiotics groups, a nonsignificant difference (P = 0.68). Two randomized controlled trials were included (1555 patients). The rates of endophthalmitis were 17 events in 751 patients (2.26%) and 17 events in 804 patients (2.11%) in the oral antibiotics and IV (± oral) antibiotics groups, respectively. Meta-analysis demonstrated no significant differences between groups (odds ratio, 1.07; 95% confidence interval, 0.54-2.12). CONCLUSIONS: The incidences of endophthalmitis after OGI were low with and without systemic antibiotic prophylaxis, although high-risk cases were excluded in the included studies. When antibiotic prophylaxis is considered, there is moderate evidence that oral antibiotic administration is noninferior to IV. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Monocanalicular versus bicanalicular intubation in external dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction.

PURPOSE: Monocanalicular intubation offers potential advantages over bicanalicular intubation including ease of removal and use of only one canaliculus. Recent reports suggest equal outcomes with both types of tubes for nasolacrimal intubation. This study aimed to evaluate the outcome of monocanalicular intubation during external dacryocystorhinostomy. METHODS: Fifty-seven lacrimal systems of 54 adults with primary acquired nasolacrimal duct obstruction were prospectively randomized into two cohorts for either bicanalicular intubation (n = 29) or monocanalicular intubation (n = 28) during external dacryocystorhinostomy. All subjects had their symptoms evaluated subjectively according to a modified Munk scale and objectively by the dye disappearance test along with probing and irrigation, pre- and post-operatively. Complete success was defined as a total disappearance of symptoms, partial success as an improvement with some residual symptoms, and failure as an absence of improvement or worsening of symptoms at the last follow-up. Patients with concurrent lid or ocular pathology were excluded. RESULTS: Bicanalicular subjects had a significantly higher complete success rate (21/29, 72.4%) compared to the monocanalicular group (12/28, 42.9%) (p = 0.03). Complications included 3 slit punctuae and 2 early tube removals with bicanalicular intubation; 6 temporary superficial punctate keratopathies, 1 punctal stenosis and 4 premature tube losses occurred with monocanalicular intubation. CONCLUSIONS: Patients with monocanalicular intubation during external dacryocystorhinostomy had a significantly lower success rate than patients with bicanalicular intubation in the treatment of nasolacrimal duct obstruction.

Human Reliability Analysis of Cataract Surgery.

OBJECTIVE: To evaluate the use of the Human Reliability Analysis of Cataract Surgery tool to identify the frequency and pattern of technical errors observed during phacoemulsification cataract extraction by surgeons with varying levels of experience. DESIGN: Observational cohort study. Thirty-three consecutive phacoemulsification cataract operations were performed by 33 different ophthalmic surgeons with varying levels of operative experience: group 1, fewer than 50 procedures; group 2, between 50 and 250 procedures; and group 3, more than 250 procedures. Face and content validity were surveyed by a panel of senior cataract surgeons. The tool was applied to the 33 randomized and anonymous videos by 2 independent assessors trained in error identification and correct tool use. Task analysis using 10 well-defined end points and error identification using 10 external error modes were performed for each case. The main outcome measures were number of errors performed per task, nature of performed errors (executional or procedural), and surgical experience of operating surgeon. RESULTS: Analysis of 330 constituent steps of 33 operations identified 228 errors, of which 151 (66.2%) were executional and 77 (33.8%) were procedural. The overall highest error probability was associated with sculpting, followed by fragmentation of the nucleus; this was most evident in group 1. Surgeons in group 3 proportionally performed more errors during removal of soft lens matter than those in group 1 or 2. Surgical experience had a significant effect on the number of errors, with a statistically significant difference among the 3 groups (P < .001). CONCLUSIONS: The Human Reliability Analysis of Cataract Surgery tool is useful for identifying where technical errors occur during phacoemulsification cataract surgery. The study findings, including the high executional error rate, could be used to enhance and structure resident surgical training and future assessment tools. Face, content, and construct validity of the tool were demonstrated.

Emergency department case-finding for high-risk older adults: the Brief Risk Identification for Geriatric Health Tool (BRIGHT).

OBJECTIVE: The objective was to test the ability of the Brief Risk Identification for Geriatric Health Tool (BRIGHT) to identify older emergency department (ED) patients with functional and physical impairment. METHODS: This was a cross-sectional study in which 139 persons > or = 75 years, who presented to an urban New Zealand ED over a 12-week period, completed the 11-item BRIGHT case-finding tool. Then, within 10 days of their index ED visit, 114 persons completed a comprehensive geriatric assessment. A "yes" response to at least 3 of the 11 BRIGHT items was considered "positive." Primary outcome measures were instrumental activities of daily living (IADL), cognitive performance scale (CPS), and activities of daily living (ADL). RESULTS: The BRIGHT-identified IADL deficit (64% prevalence) with a sensitivity of 0.76, specificity of 0.79, and receiver operating characteristic (ROC) of 0.83 (95% confidence interval [CI] = 0.74 to 0.91, p < 0.01); cognitive deficit (35% prevalence) sensitivity of 0.78, specificity of 0.54, and ROC of 0.66 (95% CI = 0.55 to 0.76, p = 0.006); and ADL deficit (29% prevalence) sensitivity of 0.83, specificity of 0.53, and ROC of 0.64 (95% CI = 0.53 to 0.75, p = 0.020). Positive likelihood ratios (LR+) for the three outcomes of interest were 3.6, 1.7, and 1.8, respectively. Negative likelihood ratios (LR-) were 0.3, 0.4, and 0.3. CONCLUSIONS: The 11-item BRIGHT successfully identifies older adults in the ED with decreased function and may be useful in differentiating elder patients in need of comprehensive assessment.

The BRIGHT tool.

OBJECTIVE: the size of the burden of unmet needs of older people living in the community is unknown. We aim to validate a brief postal questionnaire, the Brief Risk Identification of Geriatric Health Tool (BRIGHT) questionnaire, to find cases of older people with disabilities (case-finding) living in the community. METHODS: community-dwelling patients over the age of 75 years were invited from two general practitioners in Auckland, New Zealand. Participants completed the 11-item BRIGHT questionnaire twice and were assessed at home using the Minimum Dataset for Home Care (MDS-HC) comprehensive geriatric assessment tool by a trained gerontology nurse. Retest reliability of the BRIGHT was assessed with a correlation coefficient, and receiver operator characteristic (ROC) curves were used to assess the utility of the tool against standard outputs from the MDS-HC reflecting level of disability; the instrumental activities of daily living clinical assessment protocol (IADL CAP), and the MAPle score for dependency. RESULTS: 101 participants completed both the BRIGHT questionnaires and the comprehensive MDS-HC assessment. Test-retest reliability was modest with a correlation of 0.77. A sensitivity of 0.86 and specificity of 0.86 were observed for a score of 3 or more on the questionnaire in relationship to the IADL CAP. A sensitivity of 0.65 and specificity of 0.84 were observed when BRIGHT questionnaire score of 3+ was related to the MAPLe score from the MDS-HC assessment. CONCLUSIONS: the BRIGHT questionnaire has acceptable utility in identifying community-dwelling older people with disability, and excellent utility in ruling them out of needing further assessment. This tool may be useful as part of an intervention process to detect unmet needs and to improve systematic surveillance of primary care populations.

The professional and personal debriefing needs of ward based nurses after involvement in a cardiac arrest: An explorative qualitative pilot study.

BACKGROUND: Current research demonstrates that debriefing staff post cardiac arrest in clinical practice is rare, with little evidence of effectiveness. OBJECTIVES: The aim of this pilot study was to identify the needs of ward based nurses for debriefing after involvement in a cardiac arrest and to identify any barriers to participating in debriefing. METHODOLOGY: An explorative qualitative study was undertaken with a purposive sample of seven nurses working on acute adult wards in a United Kingdom hospital. Data were collected by audio-recorded interviews and analysed using framework analysis. FINDINGS: Two key themes emerged relating to the nurses debriefing needs post a cardiac arrest. Nurses expressed 'professional needs' to use the experience as an opportunity to learn and improve practice, and 'personal needs' for reassurance and validation. Nurses identified barriers to engaging in debriefing including lack of awareness and uncertainty about the role of a debrief, identifying time for debriefing and the lack of clear guidance from organisational protocols. CONCLUSION: Nurses make a distinction between 'professional' and 'personal needs' which may be met through debriefing. Debriefing is an untapped opportunity, which has the potential to be capitalised on after every cardiac arrest in order to improve care of patients and nurses.

Hydrogen Peroxide-Based Fluorometric Assay for Real-Time Monitoring of SAM-Dependent Methyltransferases.

Methylated chemicals are widely used as key intermediates for the syntheses of pharmaceuticals, fragrances, flavors, biofuels and plastics. In nature, the process of methylation is commonly undertaken by a super-family of S-adenosyl methionine-dependent enzymes known as methyltransferases. Herein, we describe a novel high throughput enzyme-coupled assay for determining methyltransferase activites. Adenosylhomocysteine nucleosidase, xanthine oxidase, and horseradish peroxidase enzymes were shown to function in tandem to generate a fluorescence signal in the presence of S-adenosyl-L-homocysteine and Amplex Red (10-acetyl-3,7-dihydroxyphenoxazine). Since S-adenosyl-L-homocysteine is a key by-product of reactions catalyzed by S-adenosyl methionine-dependent methyltransferases, the coupling enzymes were used to assess the activities of EcoRI methyltransferase and a salicylic acid methyltransferase from Clarkia breweri in the presence of S-adenosyl methionine. For the EcoRI methyltransferase, the assay was sensitive enough to allow the monitoring of DNA methylation in the nanomolar range. In the case of the salicylic acid methyltransferase, detectable activity was observed for several substrates including salicylic acid, benzoic acid, 3-hydroxybenzoic acid, and vanillic acid. Additionally, the de novo synthesis of the relatively expensive and unstable cosubstrate, S-adenosyl methionine, catalyzed by methionine adenosyltransferase could be incorporated within the assay. Overall, the assay offers an excellent level of sensitivity that permits continuous and reliable monitoring of methyltransferase activities. We anticipate this assay will serve as a useful bioanalytical tool for the rapid screening of S-adenosyl methionine-dependent methyltransferase activities.

Camera adapter for anterior segment slitlamp photography.

We describe an original, affordable and readily accessible slit lamp camera adapter. This is easily assembled from parts already available in most eye units, allowing ready access to anterior segment photography, using both digital and analog cameras.

Talking about persons--thinking about patients: An ethnographic study in critical care.

BACKGROUND: Nursing involves caring for the 'whole person' and it is considered inappropriate for nurses to think or talk about patients in objectifying or dehumanising ways. Objectifying discourses can dominate within the arena of critical care, and critical care nurses can experience moral distress as they struggle to think about patients as persons. No previous study has examined the role played by 'impersonal' talk in the delivery of nursing care. This paper reports a study which examined the relationship between nursing practice and the way(s) in which critical care nurses think and talk about patients. OBJECTIVES: The study objectives were to (1) identify and characterise the ways in which critical care nurses think and talk about patients; and (2) describe patterns of nursing practice associated with these different ways of thinking. STUDY DESIGN: An ethnographic study was undertaken within one critical care unit in the United Kingdom. Data were collected over 8 months through 92h of participant observation and 13 interviews. Seven critical care nurses participated in the study. Data analysis adopted the perspective of linguistic ethnography. FINDINGS: Analysis of these data led to the identification of seven Discourses, each of which was characterised by a particular way of talking about patients, a particular way of thinking about patients, and a particular pattern of practice. Four of these seven Discourses were of particular significance because participants characterised it as 'impersonal' to think and talk about patients as 'routine work', as a 'body', as '(un)stable' or as a 'medical case'. Although participants frequently offered apologies or excuses for doing so, these 'impersonal' ways of thinking and talking were associated with practice that was essential to delivering safe effective care. CONCLUSIONS: Critical care practice requires nurses to think and talk about patients in many different ways, yet nurses are socialised to an ideal that they should always think and talk about patients as whole persons. This means that nurses can struggle to articulate and reflect upon aspects of their practice which require them to think and talk about patients in impersonal ways. This may be an important source of distress to critical care nurses and emotional exhaustion and burnout can arise from such dissonance between ideals and the reality of practice. Nursing leaders, scholars and policy makers need to recognise and legitimise the fact that nurses must think about patients in many ways, some of which may be considered impersonal.

Self-reported hearing, vision and quality of life: Older people in New Zealand.

AIM: To establish associations between sensory-related disability and quality of life (QOL). METHODS: A total of 3817 people aged 75 years and older, including 173 Maori aged 61 years and older, were surveyed. Measures included: sociodemographic and health factors; World Health Organization quality of life (WHOQOL)-BREF for QOL; and self-rated hearing- and vision-related disability. RESULTS: Hearing disability was reported by 866 (51%) men and 736 (36%) women. A total of 974 (26% of all, 61% of hearing disabled) used hearing aids. A total of 513 (30%) men and 618 (30%) women reported vision disability. Vision and hearing disability were both independently associated with lower QOL, with hearing difficulty affecting physical and social domains more, and the environmental domain least. Vision difficulty impacted the environmental domain most and the social domain least. QOL impact was higher for those with both hearing and visual disability (631, 17%). CONCLUSIONS: Hearing and vision disability are associated with poorer QOL.

Met and unmet need for personal assistance among community-dwelling New Zealanders 75 years and over.

Ageing in place initiatives that aim to keep older people out of hospitals and rest homes and in their own homes for longer have been at the forefront of aged care policy since the early 1990s. The success of these policies depends largely on the availability of a suitable home environment, a supportive social network and regular assessment to detect changes in the older person's health status and needs for support. The BRIGHT Trial was a randomised control trial investigating the effectiveness of introducing case finding in primary care settings to detect unmet need and risk of disability among older people. We used baseline questionnaire data collected in 2008-2009 from 3753 community-dwelling older people to estimate and describe use and need for additional personal assistance. Logistic regression was used to identify the most important predictors of reporting some need for support and unmet need. Eighty-one per cent of participants required support with at least one instrumental activity of daily living. Sixty-six per cent were meeting their needs with the support they were currently receiving. Unmet need was most frequently reported for heavy housework (65%) and light housework (53%). While spouses, family members and friends were the main providers of support for light housework, meal preparation, shopping, finances and transportation, paid staff most frequently provided personal care and heavy housework assistance. Reporting mobility difficulty (OR = 3.5), identifying as a care provider (OR = 1.7) and being female (OR = 1.9) were all significant predictors of some need for assistance as well as unmet need for assistance (OR = 2.5, 1.7 and 1.7 respectively). The findings highlight the importance of regular needs assessment for older people living in the community particularly, given the reliance on spousal support for the majority of activities.

Medication use in community-dwelling older people: pharmacoepidemiology of psychotropic utilisation.

INTRODUCTION: Psychotropic medications have a significant adverse drug event profile, particularly in older adults, and appropriate use is paramount. Patterns of prescribing in community-dwelling older adults in New Zealand remain unknown. AIM: This study aimed to determine the prevalence and the pattern of psychotropic use amongst community-dwelling older people in New Zealand and to identify any association between depressive symptomatology and psychotropic medication use. METHODS: Data were collected on the demographics, medication use and mood status of community-dwelling older adults from two New Zealand studies: the BRIGHT trial, which recruited potentially disabled participants (N=141) and the DeLLITE trial, which recruited potentially depressed participants (N=193). The prevalence and the pattern of psychotropic use were established and the gender, age and level of depression assessed using regression analysis. RESULTS: The use of any psychotropic medication was 28.9% in the BRIGHT trial and 43.5% in the DeLLITE trial. Antidepressants were the most commonly used psychotropic medication in the two studies, followed by hypnotics and sedatives. Psychotropic use was highly correlated with the presence of depressive symptoms in the BRIGHT trial and with female gender in the DeLLITE trial. Age was not associated with psychotropic medication use. In both studies, there is possible underdiagnosed, undertreated and inappropriately treated depression. DISCUSSION: The prevalence of psychotropic medication use is high in community-dwelling older people with disability and very high in community-dwelling older people with depressive symptoms, but varies by gender and level of depression.

Merkel cell carcinoma of the eyelid: management and prognosis.

IMPORTANCE: The literature on Merkel cell carcinoma (MCC) of the eyelid remains scarce, and there has yet to be a study using the most up-to-date TNM staging system for this rare but aggressive tumor. OBJECTIVE: To analyze the TNM stage, management, and outcomes of patients with MCC of the eyelid. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case series of 21 patients from 5 tertiary referral centers in the United Kingdom and Australia with primary MCC of the eyelid presenting at a median age of 77 years, with median follow-up of 54 months. Tumors were staged according to the American Joint Committee on Cancer, 7th edition, TNM criteria for eyelid carcinoma and MCC. MAIN OUTCOMES AND MEASURES: TNM stage, treatment modalities, and clinical outcome. RESULTS: The eyelid carcinoma TNM stages were T2aN0M0 for 5 patients, T2bN0M0 for 7 patients, T3aN0M0 for 4 patients, T3bN0M0 for 3 patients, T2bN1M0 for 1 patient, and T3aN1M0 for 1 patient. The MCC TNM stages were T1N0M0 for 12 patients, T2N0M0 for 7 patients, T1N1M0 for 1 patient, and T2N1M0 for 1 patient. One patient had a sentinel lymph node biopsy, and 8 patients underwent head/neck imaging. Eighteen patients underwent a wide local excision, 12 with a paraffin section and 6 with a frozen section. Two patients underwent Mohs surgery, 1 of whom required an orbital exenteration. Twelve patients (57%) received adjuvant radiotherapy, and 2 patients received chemotherapy. The local recurrence rate was 10%, the regional nodal recurrence rate was 10%, and the distant metastatic recurrence rate was 19%. The lowest T category tumor metastasizing to both regional nodes and distant locations was a T2a (eyelid TNM)/T1 (Merkel TNM) tumor measuring 8 mm. Two patients with T3a (eyelid TNM)/T2 (Merkel TNM) tumors died of metastatic MCC. CONCLUSIONS AND RELEVANCE: The majority of patients with MCC of the eyelid present with localized eyelid disease of T category T2 (eyelid TNM)/T1 (Merkel TNM). A wide local excision with margin control remains the mainstay of treatment, whereas the use of radiotherapy is institution specific. Tumors with a low T category are associated with regional nodal and distant metastatic disease. It may therefore be reasonable to consider a sentinel lymph node biopsy or strict regional lymph node surveillance for all MCCs of the eyelid, regardless of T category or size.

The long and winding road: contact lens-induced ptosis.

Intrapalpebral migration is a rare complication of hard contact lens use. We report a case of a 52-year-old man who presented with right upper eyelid ptosis and requested cosmetic correction. He had no ocular history apart from myopia, which was corrected with the use of hard contact lenses. Prior to the ptosis he recalled losing his right contact lens during a bout of sneezing. He replaced the missing lens and continued to wear contact lenses as usual. After careful clinical examination, an ipsilateral small, mobile eyelid mass was detected, and orbital MRI verified the suspected presence of a hard contact lens. Following surgical removal and ptosis correction, the patient made a full recovery. The phenomenon of hard contact lens migration in the periocular tissues has been reported in the literature before, but most patients experienced symptoms of variable severity. In this patient, however, there were no symptoms to indicate the presence of a contact lens. This case highlights the importance of including intrapalpebral contact lens migration in the differential diagnosis of an eyelid mass or ptosis in patients.

A novel approach to lacrimal sac dissection in dacryocystorhinostomy.

The use of membrane-peeling vitreoretinal forceps to facilitate lacrimal sac dissection in external dacryocystorhinostomy is demonstrated. The closed vitreoretinal forceps are advanced via the upper punctum and canaliculus, through to the lacrimal sac. They are then opened maximally providing two points of elevation. This maneuver allows for easier identification of the plane of dissection during lacrimal flap creation. It is especially useful with complex anatomy and for junior trainees in helping to orient the dissection. No tissue or instrument damage has been noted, and because many ophthalmic units have a vitreoretinal service, the forceps may be readily available at no extra cost.