Comparison of the clinical profile of patients with glaucoma between private and government clinics in the Philippines

@#<p style="text-align: justify;"><strong>OBJECTIVE</strong>: To describe the demographic and clinical characteristics of patients with glaucoma managed at private and government institutions in the Philippines between 2009 and 2014.</p><p style="text-align: justify;"><strong>METHODS</strong>: A research team from two private and two government institutions in the Philippines reviewed the case records of 1246 patients seen who met the following criteria: intraocular pressure of >21 mmHg, optic nerve and nerve fiber layer abnormalities, and visual field defects. For bilateral cases, we selected the eye with worse glaucoma parameters.</p><p style="text-align: justify;"><strong>RESULTS</strong>: There were 600 and 646 patients in the private and government groups (mean age at presentation, 60.51 and 55.88 years), respectively, with the majority being Filipino (91%). Patients with visual acuity (VA) of 20/20 to 20/40 were more frequently observed in private centers (58.7% vs. 41.3%), while a VA worse than counting fingers was more frequently observed in government centers (66.1% vs. 33.9%). Within-group analysis showed that primary angle-closure glaucoma was the most frequent glaucoma subtype in both private (27.3%) and government institutions (37.8%). In between-group analysis showed the following to be more common in private than government centers: primary open-angle glaucoma (61.3% vs. 38.7%), normal-tension glaucoma (63.9% vs. 36.1%), ocular hypertension (92.3% vs. 7.7%), and glaucoma suspects (80.4% vs. 19.6%) while government institutions registered a larger number of primary angle-closure glaucoma (59.8% vs. 40.2%) and secondary glaucoma (70.3% vs. 29.7%) cases. Medical treatment using a single drug and multiple drugs was employed for 245 (23%) and 825 (77%) patients, respectively. Within-group analysis showed that laser iridotomy and trabeculectomy were the most commonly performed laser and surgical procedures in both institution types.</p><p style="text-align: justify;"><strong>CONCLUSION</strong>: There is a contrasting profile of glaucoma between clinical institutions in the Philippines with openangle glaucoma being more predominant in private centers while closed-angle glaucoma and secondary glaucoma being more frequent in government centers. Our findings may provide important preliminary information that can aid future health studies or training programs.</p>

Short wavelength automated perimetry and peripapillary retinal nerve fiber layer in early diabetes

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To investigate the significance of short wavelength automated perimetry (SWAP) in detecting retinal functional impairment in early diabetic patients without retinopathy and with mild non-proliferative diabetic retinopathy (NPDR). <br /><br /> <strong>METHODS:</strong> This is a prospective, cross-sectional study of 37 eyes of early diabetics which were divided into 2 groups: no DR with 18 subjects and mild NPDR with 19. All subjects underwent HBA1C, SWAP, peripapillary RNFL thickness measurement and fundus photo. Visual field indices: MD and PSD as well as average RNFL thickness were compared among the 2 groups. Correlation of MD with RNFL thickness and HBA1C were also analyzed. <br /><br /> <strong>RESULTS:</strong> There was no statistically significant difference in the MD (-4.46 ± 3.03 vs -2.94 ± 2.21; p=0.09), PSD (3.08 ± 1.28 vs 2.69 ± 0.47; p=0.23) and average peripapillary RNFL thickness (98.47 ± 6.89 vs 98.72 ± 11.01; p=0.93) among early diabetics with mild NPDR and no signs of DR. There is no correlation between MD and RNFL thickness in the no DR group (R2=0.017) and the mild DR group (R2=0.000). There was a weak correlation between MD and HBA1C in the no DR group (R2=0.137), while no correlation was seen in the mild NPDR group (R2=0.000). <br /><br /> <strong>CONCLUSION:</strong> SWAP does not appear to be a sensitive measure of worsening retinopathy in older individuals with early diabetes. The usefulness of SWAP and peripapillary RNFL thickness in the early stages of retinopathy are inconclusive.</p>

Excellent ultrafiltration and clearance after more than 12 years of peritoneal dialysis: two case reports.

Because of a higher (but improving) incidence of technique failure, peritoneal dialysis (PD) is not thought to equal hemodialysis (HD) for long-term use. Other than death and transplantation, the reasons that patients leave PD include peritonitis, catheter problems, patient burnout, and (in long-duration patients) the development of encapsulating peritoneal sclerosis or ultrafiltration failure. Here, we report 2 patients who have been on continuous ambulatory PD continuously for more than 12 years, maintaining good ultrafiltration and clearances. In the case reports, we suggest potential reasons for the long duration of therapy in these women. We conclude that, in some patients on continuous ambulatory PD who sparingly use very hyperosmolar dextrose solutions and who are able to avoid frequent episodes of peritonitis, long-term PD is possible and may not require transition to HD.

Utility of percutaneous renal biopsy in chronic kidney disease.

BACKGROUND: We tested the hypothesis that patterns of serum creatinine concentrations (S-cr) prior to percutaneous renal biopsy (PRB) predict the utility of PRB in safely making renal diagnoses, revealing treatable disease, and altering therapy in chronic kidney disease patients. METHODS: PRB specimens (170 patients) were assigned to 1 of 5 groups: S-cr never greater than 0.11 mM for at least 6 months prior to PRB (Group 1); S-cr greater than 0.11 mM but less than 0.18 mM during the 6 months prior to PRB (Groups 2); S-cr less than 0.18 mM during the 6 months prior to PRB but greater than 0.18 mM prior to these 6 months (Group 3); S-cr greater than 0.18 mM for less than 6 months prior to PRB (Group 4); S-cr greater than 0.18 mM for more than 6 months prior to PRB (Group 5). RESULTS: Histopathology chronicity score (0-9) increased with increasing group number: 2.1 (Group 1); 4.4 (Group 2); 4.5 (Group 3); 5.4 (Group 4); 7.0 (Group 5). Post-PRB bleeding was more common with increasing group number. New therapy was instituted after PRB most frequently in Group 4 (62%) and least frequently in Group 5 (24%). CONCLUSION: After more prolonged elevations of S-cr, PRB may be less safe and less likely to reveal treatable disease and opportunities for therapy.

Diabetic nephropathy in the elderly.

Although diabetes is clearly linked to macro- and microvasculopathy in multiple organs resulting in cardiovascular and cerebrovascular catastrophic diseases, blindness, and limb amputations, it is the relentless progression of diabetic nephropathy toward becoming the major cause of end-stage renal disease (ESRD) that now challenges budgets and treatment facilities providing hemodialysis, peritoneal dialysis, and kidney transplantation. Nephrology, as a specialty, is now dominated by the necessity to address geriatrics and endocrinology to cope with the tidal wave of elderly ESRD patients suffering from uremia caused by diabetes. On the brighter side, emergence of effective renoprotective regimens now slow the incidence rate of ESRD in those with diagnosed diabetes. There is bona fide reason to hope that within a decade, kidney failure attributable to diabetes will be transformed into a preventable complication of a disease that has dominated and directed our heritage.

The effect of laser in situ keratomileusis on low contrast vision.

PURPOSE: To determine the effects of laser in situ keratomileusis (LASIK) on low contrast visual acuity. METHODS: Thirty eyes of 15 LASIK patients with myopia and astigmatism were evaluated preoperatively, and 1 and 3 months postoperatively. High contrast visual acuity (HCVA), low contrast visual acuity (LCVA), and contrast threshold were determined. RESULTS: Mean spherical correction (SE) was -3.24 +/- 1.90 D; 16 eyes had a mean SE between -1.00 and -3.00 D, and 14 eyes were between -3.25 and -6.50 D. There was no significant change in HCVA observed at 1 and 3 months in any eye. There was a decrease in LCVA in eyes with a correction >3 D SE at 1 month (P=.04), which returned to normal at 3 months (P=.13). There was an increase in the contrast threshold at 1 month (P=.016). When eyes were divided into groups, those with >3D SE correction had an increase in contrast threshold at 1 month (P=.002); no change was seen in eyes with <3D SE correction (P=.15). At 3 months, contrast threshold was similar to baseline values in all eyes (P=.226). CONCLUSION: LASIK transiently decreased low contrast visual function in patients with greater than 3.00 D of myopic correction.

Impact of contemporary guideline compliance on risk stratification models for acute coronary syndromes in The Registry of Acute Coronary Syndromes.

We compared the predictive value of the Rush score with the Thrombolysis In Myocardial Infarction (TIMI) risk score in unselected patients with an acute coronary syndrome and evaluated the effect of compliance with established guidelines on the accuracy of these models. The Registry of Acute Coronary Syndromes is a retrospective registry of 3,754 consecutive patients (38% women; mean age 67 years) who presented with acute coronary syndrome to the emergency department between April 1, 1999, and December 31, 2000, at 9 hospitals. The primary end point was death, myocardial infarction, or urgent revascularization during hospitalization. Rush classification was based on quartiles of predicted risk of cardiac complication (<2% for class I vs >15% for class IV). The TIMI score was implemented as published. Compliance with guidelines for acute coronary syndrome was assessed with a 4-point scale based on the aggregate use of aspirin, beta blockers, heparin, and glycoprotein IIb/IIIa inhibitors. Fifteen percent of patients met the primary end point. The primary end point rates for TIMI scores 0/1, 2, 3, 4, 5, and 6/7 were 11%, 14%, 13%, 11%, 14%, and 12%, respectively (p = NS). The primary end point rates for Rush classes I, II, III, and IV were 6%, 8%, 9%, and 17%, respectively (p <0.001). After controlling for compliance with established guidelines, the odds ratio of an event increased by 46% for each unit increase in Rush score (p <0.001). After adjusting for the Rush score, the odds ratio decreased by 54% for each unit increase in compliance (p <0.001). Thus, compliance with current American College of Cardiology/American Heart Association guidelines significantly improves prognosis, regardless of the risk score. The use of established risk scores may overestimate event rates in unselected populations.

The chest pain center as an operational model.

The purposes of this paper are to establish the acute coronary syndrome as a pathophysiologic model, to establish the Chest Pain Center model as a complementary operational model that can be employed by a wide range of hospitals that seek to improve the process of care related to acute coronary syndromes, to differentiate process improvement versus performance improvement, and to establish the individual facility as the nidus for the improvement process.

A formal, standardized and evidence-based approach to Chest Pain Center development and process improvement: the Society of Chest Pain Centers and Providers accreditation process.

The notion of a Chest Pain Center has continued to develop over the past twenty years. The designation of "Chest Pain Center" now applies to the entire facility, much the same as that of "Trauma Center." The Chest Pain Center model incorporates both operational and clinical considerations required to develop proper Acute Coronary Syndrome (ACS) care in the context of a complex health-care system. The Society of Chest Pain Centers and Providers has launched a Chest Pain Center Accreditation initiative that provides an organizational road map for success in approaching the care for patients with ACS.

Perioperative care of the patient with renal failure.

Preventing postoperative ARF, especially in subjects with pre-existing chronic kidney disease, and caring for ESRD patients undergoing surgery are challenging and best accomplished by a team comprised of primary care physician, nephrologist, cardiologist, surgeon, anesthesiologist, endocrinologist, and nutritionist. Elimination of risk factors for ARF whenever possible, as well as early diagnosis, may improve the outcome of this devastating illness. Drugs capable of preventing or changing the course of postoperative ARF may be available soon. For uremic patients, a comprehensive approach is necessary to minimize morbidity and mortality imposed by numerous comorbid conditions.

Late traumatic displacement of laser in situ keratomileusis flaps.

PURPOSE: To report the occurrence, management, and outcome of late-onset traumatic dehiscence and dislocation of laser in situ keratomileusis (LASIK) flaps. METHODS: Two interventional case reports of patients with late-onset LASIK corneal flap dislocation after ocular trauma occurring at 7 and 26 months after surgery, respectively. RESULTS: The flaps were lifted, stretched, and repositioned after irrigation and scraping of the stromal bed and the underside of the flap. A bandage contact lens was placed, and topical antibiotic and corticosteroids were given postoperatively. The dislocated corneal flaps were successfully repositioned in both cases. The patient whose dislocated flap was repositioned 4 hours after the trauma recovered his uncorrected visual acuity (UCVA) of 20/20 1 week after the procedure and had a well-positioned flap with a clear interface. The patient who was managed 48 hours after the injury required repeat flap repositioning at 10 and 24 days after the initial procedure for treatment of persistent folds and striae in the visual axis. His uncorrected visual acuity 2 weeks after the third flap repositioning was 20/40 + 2. Diffuse lamellar keratitis developed in both patients that resolved with the use of topical corticosteroids. CONCLUSION: Laser in situ keratomileusis corneal flaps are vulnerable to traumatic dehiscence and dislocation, which can occur more than 2 years after the procedure.

Selective laser trabeculoplasty: a new treatment option for open angle glaucoma.

Selective laser trabeculoplasty (SLT) is a safe and effective treatment modality for lowering the intraocular pressure in patients with open angle glaucoma. The preservation of the trabecular meshwork architecture and the demonstrated efficacy in lowering intraocular pressure makes the SLT a reasonable and safe alternative to argon laser trabeculoplasty. In addition, SLT is a potentially repeatable procedure because of the lack of coagulation damage to the trabecular meshwork and the demonstrated efficacy in patients with previously failed argon laser trabeculoplasty treatment. Furthermore, SLT can be considered as a primary treatment option in patients who cannot tolerate or are noncompliant with their glaucoma medications, while not interfering with the success of future surgery. Due to its nondestructive properties and low complication rate, SLT has the potential to evolve as an ideal first-line treatment in open angle glaucoma.