ABSTRACT
CASE: A previously healthy, 27-year-old Caucasian male presented with erythema and edema in his extremities. He endorsed multiple years of injecting heroin into numerous areas from his chest to his toes, including both upper extremities. The patient was seen six months ago at local urgent care for swelling of both of his dorsal feet and a small abscess with surrounding cellulitis of the right hand. He was given a dose of Ceftriaxone and a 2-week course of Augmentin, which he completed with moderate improvement. A month prior to his presentation, he reported that this swelling started asymmetrically;it started in his legs, then in his right arm, and then in his left arm. He denied any discharge from any site on his skin. He last injected heroin the morning of his admission. He denied fever, shortness of breath, pleuritic chest pain, orthopnea, dyspnea on exertion, and any urinary symptoms. On presentation, he was afebrile and saturated 98% on room air. His extremities were warm, normal capillary refill, and distal pulses were strong and symmetric. There were also pitting edema in the right hand with associated volar erythema, pitting edema in the right foot, and left-hand edema with a punctate area around the mid-arch with associated tenderness to palpation without overlying redness, crepitus, or fluctuance. Blood cell count revealed mild leukocytosis to 12.0. CMP was unremarkable. While the infectious disease team was consulted for further evaluation, he was started on cefazolin 1g for 10 days. The urine drug screen was positive for benzodiazepines, THC, cocaine, and opiates. HIV negative, Covid negative, and blood cultures showed no growth. Histoplasma/ Blastomyces urine antigens were negative. Urinalysis without evidence of proteinuria, and transaminases were within the normal limit. Ultrasound showed occlusive cephalic vein thrombosis in the right upper extremities. Cefazolin was discontinued. Based on the presentation, the history, and the evaluation, it was concluded to be Puffy Hand Syndrome. IMPACT/DISCUSSION: Puffy hand syndrome is a form of lymphedema caused via the sclerosing nature of intravenously administered drugs, which our patient extensively utilized. Described by Abeles in 1965 as seen in New York prisoners, it affects between 7 to 16% of intravenous drug users. Its pathology is suspected to be caused due to a combination of lymphatic and venous insufficiency. Differential diagnosis of this syndrome involves identification of infection alongside cardiac or renal insufficiency, and edematous scleroderma. Treatment is mostly symptomatic. Patients are advised to stop IV drug use. Long-term use of low-stretch bandages and compression may be useful in decreasing the puffiness of the extremities. CONCLUSION: With the quality of care for drug addicts being a critical area of interest, this case displays a common drug abuse complication clinicians raise awareness for. This observation presents an opportunity to identify a possible drug abuser and intervene accordingly.
ABSTRACT
Objectives: To collate and review published evidence to assess patient impact and economic burden of cataract surgery wait times in Canada. Methods: A targeted literature search was conducted using PubMed from January 1, 2007–December 10, 2021, and supplemented by grey literature search. Included studies were those reporting Canada-specific data. Results: Overall, six publications were included. All 6 reported patient impact related to waiting for cataract surgery in Canada, including decline in visual acuity(n=4);greater risk of falls(n=4), motor vehicle accidents(n=3), and depression(n=3);reduced quality life(n=3);interference with treating other eye diseases such as glaucoma, diabetic retinopathy, and AMD(n=1);permanent disability(n=1);and even increased risk of death(n=1). Eye Physicians and Surgeons of Ontario (2018) also highlighted challenges recent ophthalmology graduates face to secure operating room time. This can potentially lead to a lack of surgical competency resulting in more complications, greater incidence of unsuccessful surgeries, decline in ophthalmologists able to perform cataract surgery, and ultimately longer wait times. Canadian Council of the Blind reported an estimated 143,000 necessary eye surgeries missed or delayed in 2020 due to COVID-19, resulting in increased risk of vision loss (vision loss costing $27,251/person/year). It’s also projected from 2021 to 2023, costs of vision loss due to additional wait times of ophthalmic surgeries (most specifically cataract surgery) will be $520.2 million annually in Canada;owing 85% of these costs to loss of well-being ($442.2 million/year) and the remainder to direct healthcare system costs ($78 million/year). Further, average costs incurred by someone with vision loss until they receive surgery is $54/day. Conclusions: Increased cataract surgery wait times in Canada has negative implications, including worse patient outcomes and increased patient and healthcare system costs. There remains an urgent need to reduce wait times to ensure timely treatment access for individuals undergoing cataract surgery in Canada.
ABSTRACT
Objectives: Pan-Canadian benchmark for cataract surgery wait times is 16 weeks, with aim for 90% of patients to meet this target timeframe. A targeted literature review was conducted to assess recent trends of Canada’s cataract surgery wait times, including impact of COVID-19. Methods: PubMed was searched January 1, 2017–December 10, 2021, and supplemented by grey literature search. Search terms included cataract surgery, wait times, epidemiology, Canada, and COVID-19. Inclusion criteria comprised of literature reporting national and provincial (Ontario, Quebec, British Columbia, Alberta) data with outcomes of interest: percentage of patients treated within 16-week benchmark, 90th percentile wait time (10% waited >x weeks), and 50th percentile/median wait time (half waited >x weeks). Results: Published data from 8 unique sources were included (n=3 white papers, n=5 government data). Canadian Institute for Health Information (CIHI) reported percentage of patients treated within 16 weeks nationally (2017=71%, 2018=70%, 2019=71%, 2020=45%) and by province (Ontario: 2017=69%, 2020=40%;Quebec: 2017=85%, 2020=53%;British Columbia: 2017=63%, 2020=53%;Alberta: 2017=56%, 2020=34%). Five sources reported 90th percentile: CIHI national data showed 10% waited >30.0-31.0 weeks from 2017–2019, and >44.0 weeks in 2020;for Ontario in 2018, 10% waited >28.9 weeks, according to the Eye Physicians and Surgeons of Ontario;provincial government data showed similar results for Alberta (2017–2018=>38.6, 2020–2021=>41.0-63.0) and British Columbia (2021=>27.9). Median wait times (weeks) were reported by 5 sources, with similar national results by CIHI and OECD (2017–2019=9.3-9.6, 2020=18.9);Fraser Institute also reported 2020 national (20.6 [12.0-64.0]) and provincial (Ontario=17.0, Quebec=12.0, British Columbia=28.0, Alberta=24.0) data. Conclusions: Approximately 30% of patients experienced a wait longer than the 16-week pan-Canadian benchmark from 2017–2019, growing to 55% in 2020 amidst COVID-19. To mitigate the impact of COVID-19 and bring wait times to the recommended threshold, collaboration among provincial health authorities and clinicians may be necessary with prioritization of stable funding and reimbursement for cataract surgery.