The effect of personality on measures of quality of life related to vision in glaucoma patients.

AIM: To determine the effect of personality on vision-specific health-related quality of life (HRQoL). METHODS: Based on power calculations, 148 individuals diagnosed as having glaucoma or ocular hypertension, without ocular comorbidity, were selected using criteria that included age over 30, no recent or upcoming surgery, the absence of a diagnosis of clinical depression or any other psychiatric illness. Qualifying participants completed the 25-Item National Eye Institute's Visual Function Questionnaire (VFQ), the Neuroticism, Extraversion and Openness Personality Inventory Revised (NEO PI-R) and the 15-Item Geriatric Depression Scale (GDS-15), and provided information regarding their demographic characteristics and past medical history. Each patient also underwent an ocular examination. Data analysis was conducted to determine the relationship between NEO PI-R personality profiles and VFQ scoring, while controlling for the effects of a range of demographic, psychiatric, past medical and clinical ophthalmic variables. RESULTS: Multivariate analysis indicated that after controlling for a range of covariates, three out of five NEO PI-R personality domains shared statistically significant associations with a variety of VFQ total and subscale score measurements. CONCLUSION: Normal variations in personality characteristics influence how patients report their vision-specific HRQoL.

Comparison of the 20-MHz ultrasound probe with ultrasound biomicroscopy in glaucoma.

The 20-MHz ultrasound probe was compared with ultrasound biomicroscopy to determine its usefulness in imaging various glaucomatous conditions. Ten patients with glaucoma underwent anterior segment imaging with both the 20-MHz probe, which attaches to the I3 B-scan (Innovative Imaging Inc., Sacramento, CA), and the Ultrasonic BioMicroscope (UBM; Paradigm Medical Industries, Salt Lake City, UT). All pathology was easily demonstrable using the 20-MHz probe, in one case showing a retinal detachment not seen with the UBM. However, anterior findings such as fluid in the suprachoroidal space and sclerostomy sites in postoperative trabeculectomy cases were more difficult to view with the 20-MHz probe. The use of coupling enhanced the quality of the latter images. The 20-MHz ultrasound probe may be a viable aid in diagnosis and follow-up of certain glaucomatous conditions, and the use of a coupling device enhances its images.

A randomized trial of the long-term effects of digital ocular compression in the late postoperative period.

PURPOSE: To determine whether digital ocular compression is a viable technique to lower intraocular pressure in patients at least 3 months after trabeculectomy. PATIENTS AND METHODS: A 6-month prospective, randomized, controlled, single-masked trial of 29 patients who underwent a trabeculectomy at the Glaucoma Service of Wills Eye Hospital. Patients were assigned to two groups: ocular compression or cheekbone compression (control group). The ocular compression group performed compression to the operated eye three times a day in the pattern of 10 seconds of pressure, 5 seconds of rest, and 10 seconds of pressure. Pressure was applied with the index finger through the closed lid to the center of the cornea. Pressure was steady and firm, but not painful. No massaging was performed. The cheekbone compression group applied pressure to the zygomatic arch with an identical style and frequency. RESULTS: At 6 months, the change in mean intraocular pressure for the ocular compression group was 0.25 mm Hg compared with -0.44 mm Hg for the control group (P = 0.7). A few patients in both groups experienced large swings in intraocular pressure and mild to moderate discomfort. CONCLUSION: Ocular compression had little to no success in the long-term management of increased intraocular pressure in the late postoperative period in this study.

Risk of type 2 diabetes mellitus in young adults from a biracial community: the Bogalusa Heart Study.

BACKGROUND: Since type 2 diabetes has a strong familial component, characteristics of young adult offspring of type 2 diabetics were examined in a community sample to determine early abnormalities in black and white persons at risk. METHODS: The sample consisted of 1,338 fasting young adults (72% white, 28% black) aged 19 to 37 years from a biracial community, including those with positive parental history of type 2 diabetes (one offspring per family, n = 230) or conditions of impaired fasting glucose and type 2 diabetes (n = 22). RESULTS: Positive family history of diabetes or impaired fasting glucose and type 2 diabetes in young adults of both races were significantly associated with adverse profiles of measures of obesity and abdominal fat (body mass index, triceps and subscapular skinfolds, waist circumference, and abdominal height), systolic and diastolic blood pressures, serum total cholesterol, triglycerides, VLDL cholesterol, and HDL cholesterol, and indicators of glucose homeostasis (plasma glucose and insulin and insulin resistance index). The magnitude of the differences in obesity and abdominal fat measures and plasma glucose between individuals with and without parental diabetes was greater among blacks versus whites (P = 0. 047-0.004). Further, black offspring of both diabetics and non-diabetics had unfavorable profiles of obesity and abdominal fat measures, blood pressure, insulin, and insulin resistance index (P = 0.0001). In a multivariate analysis, adiposity measured as body mass index (P = 0.03) and plasma glucose (P = 0.003) emerged as the two independent characteristics that distinguished those with parental diabetes from those without parental disease. Insulin (P = 0.0001) and the insulin resistance index (P = 0.0001) were independently associated with conditions of impaired fasting glucose or type 2 diabetes. CONCLUSIONS: The risk factors of young adults with parental type 2 diabetes or conditions of impaired fasting glucose and type 2 diabetes can be detected early. These observations have implications for early prevention and intervention, especially for blacks.

Home healthcare orders: an assessment of service satisfaction by internists, surgeons, and medical subspecialists.

We conducted a pilot study to evaluate the satisfaction of general internists, medical subspecialists, and surgeons with the quality of home health orders generated by home health agencies. Using a mail survey, we polled 69 physician specialists at Tulane University Medical Center. The percentage of physicians satisfied with the appropriateness of services for the level and type of care, consistency of medication with that prescribed, sufficiency of data on the certification form to assess service continuation, timeliness of orders, and overall health service delivery was 94%, 92%, 69%, 52%, and 88%, respectively. Compared with medical subspecialists and surgeons, general internists were more likely to report that the data on the form were sufficient. Physicians who were satisfied with at least one of the four measures of quality for home health orders were more likely to be satisfied with the overall delivery of services by home health agencies. Our results demonstrate, for the first time, that physicians overall are satisfied with home healthcare orders. However, level of satisfaction with orders is related to the physician's specialty. Areas that physicians were less satisfied with included timeliness of orders and sufficiency of data on the form to assess service continuation. Further studies using a larger population and more specific indicators of healthcare orders quality are recommended.

St. Thomas Immunization Initiative. A student-run community action project.

The objectives of the St Thomas Immunization Initiative are to provide a clinical community medicine experience for first- and second-year medical students, expose students to a community immunization program, teach students the principles of a community immunization program, and demonstrate a working relationship between the residents of an underserved community and medical students. From 1993 to 1995, first- and second-year students at Tulane University Medical School participated in class projects known as Shots for Tots and the St Thomas Immunization Initiative. Students received instruction about immunizations and administered vaccinations to children and adults in low-income neighborhoods. A total of 754 immunizations were administered to 331 children from 1993 to 1995. Participating students were surveyed and 82% of those who responded to a questionnaire felt that the project benefited the community it served while 79% felt that they personally benefitted from participating in the project. Given their experience, 96% of the students would be more likely to participate in a community development project in the future.

Comparison of fourth and fifth Korotkoff diastolic blood pressures in 5 to 30 year old individuals. The Bogalusa Heart Study.

The use of fourth phase Korotkoff sound (K4) versus fifth phase Korotkoff sound (K5) for the determination of diastolic blood pressure (DBP) has been a subject of controversy since the indirect method of determining arterial blood pressure was described. Using data from the Bogalusa Heart Study, we evaluated the differences between K4 and K5 (K4-K5) from 4633 subjects 5 to 30 years of age examined between 1987 and 1991. The overall mean difference between K4 and K5 was 9.9 +/- 5.6 mm Hg (mean +/- SD). The average difference was highest in 5 to 8 year olds, where it measured 12.3 +/- 5.5 mm Hg. The average K4-K5 difference fell with increasing age and reached a value of 6.3 +/- 2.6 mm Hg by 25 years of age. For all race/sex groups, the youngest two age groups differed statistically from the oldest age groups in K4-K5 difference (P < .006). There were significant differences between blacks and whites (P < .015) and between men and women (P < .001) for subjects between 13 and 17 years of age. Additional analyses were performed with individuals having K5 = 0 added to yield an expanded population of 5117 persons. Overall, 9.5% had at least one of six measurements of K5 = 0 and most were young subjects: 27% of children 5 to 8 years and 13% of children 9 to 12 years. We conclude that by age 15 there may be no relevant clinical difference in K4-K5. However, in children, K4 and K5 should be recorded and K4 is a more reproducible measure of diastolic blood pressure.

[Digoxin is effective in th treatment of patients with heart failure and sinus rhythm]. / La digoxina es efectiva en el tratamiento de pacientes con insuficiencia cardiaca y ritmo sinusal.

Due to differences in treatment effect in studies on the effectiveness of digoxin in patients with congestive heart failure in sinus rhythm, a cross-over placebo-controlled, randomized double blind clinical trial was performed. Thirty one patients, without previous treatment with digoxin, in New York Heart Association (NYHA) functional class II to IV, with a dilated left ventricle and/or ventricular systolic dysfunction were included. Patients received digoxin, adjusted for blood levels, or placebo, during an 8 week period, prior to crossing over to the other treatment for another 8 weeks. The order of treatments was randomly allocated. Outcome measurement were performed at the end of each 8 week period. Digoxin, compared with placebo, improved NYHA class, 6.9% vs 41.4% (p = 0.013) and increased the treadmill exercise time, 406 +/- 204 s vs 484 +/- 185 s (p = 0.003). During the digoxin treatment the left ventricular and systolic diameter was reduced from 52.9 +/- 8.9 to 50.1 +/- 9.7 mm (p = 0.016) and the shortening fraction increased from 21.4 +/- 8.3 to 24.8 +/- 8.1% (p = 0.009). No significant difference was observed in the left ventricular end diastolic diameter (LVED) of the left ventricle and in a estimation of quality of life. In conclusion, digoxin treatment produced a significant improvement in functional capacity, exercise time, and left ventricular performance.

Aqueous shunts. Molteno versus Schocket.

The authors conducted a multicenter, randomized, controlled trial to test whether the Schocket shunt with a larger shunt reservoir surface area would provide a lower final intraocular pressure than the double-plate Molteno implant. However, the Molteno implant produced a statistically lower intraocular pressure at 6 months compared with the Schocket shunt. Postoperative visual acuity, glaucoma medications, and complications were not statistically different.

Surgical and medical management of patients with narrow anterior chamber angles: comparative results.

We retrospectively reviewed case records of 70 patients (114 eyes) to assess long-term outcome of surgical and medical treatment of narrow anterior chamber angles. Fifty eyes had undergone a peripheral iridectomy, incisional or laser; 64 had been treated medically, without surgery. The two groups were not strictly comparable. (It is assumed but not proven that, since iridectomy was considered necessary in one group and not in the other, the surgically-treated patients were more seriously diseased.) Comparing clinical data obtained at the first visit with data obtained at the last visit, the eyes receiving iridectomies, as compared with those receiving medical treatment alone, showed a greater number of improved anterior chamber configurations (74% vs 28%), had a lower incidence of peripheral anterior synechiae (2% vs 10%), and required fewer glaucoma medications (30% fewer vs 10% fewer). The percentage of eyes with increased intraocular pressure was similar in both groups (36% vs 28%), as was the percentage of those with decreased visual field (17% vs 21%) and decreased visual acuity (66% vs 60%). No significant complications occurred in the eyes receiving laser iridectomies; however, one of the incisionally-treated eyes lost nine Snellen lines of vision.

Expert agreement in evaluating the optic disc for glaucoma.

The authors studied intraobserver and interobserver agreement, under monoscopic and stereoscopic conditions, in estimating vertical cup-to-disc ratios and in assessing whether a disc had glaucomatous damage. Six glaucoma experts evaluated 75 optic disc photographs under both viewing conditions. The experts also re-evaluated 25 photographs. Intraobserver agreement in estimating vertical cup-to disc ratios was high (median weighted kappa, 0.79). Interobserver agreement in estimating vertical cup-to-disc ratios was moderate (stereoscopic median weighted kappa, 0.67); individual experts differed by as much as 0.2 disc diameters (DD) monoscopically and 0.16 DD stereoscopically. The observers estimated larger vertical cup-to-disc ratios when evaluating the same discs under stereoscopic conditions than under monoscopic conditions. Intraobserver agreement in assessing glaucomatous disc damage was substantial (median kappa, 0.76). Interobserver agreement in assessing glaucomatous damage was moderate (stereoscopic median kappa, 0.50). This study confirms the ability of experts to reliably evaluate the optic disc within themselves and emphasizes the need for developing standardized methods for interobserver evaluation of the optic disc in glaucoma.

The effects of postoperative corticosteroids on trabeculectomy and the clinical course of glaucoma: five-year follow-up study.

A randomized, prospective study on 68 eyes of 54 patients with progressive, uncontrolled, noninflammatory open-angle glaucoma showed that eyes that received topical prednisolone 1% had a lower intraocular pressure (IOP) 18 months following trabeculectomy than the eyes that received no prednisolone. The addition of systemic prednisone had no definite further effect. In the present study, we reevealuated 58 eyes of 45 of these patients 5 years after the time of initial surgery. The number of cases lost to follow up was similar in the steroid and the nonsteroid-treated groups. Mean IOP of the steroid-treated patients was 14.5 +/- 1.8 mm Hg, and of the nonsteroid-treated patients, 19.3 +/- 2.1 mm Hg. Visual field, optic disc, and IOP were stabilized in 94% of the steroid-treated cases and in 43% of the nonsteroid-treated cases. Thus, postoperative steroids significantly increased the success rate of trabeculectomy in these eyes, and the eyes with lower IOPs had a significantly better prognosis than those with higher IOPs.

Risk factors for hip fractures in men: a preliminary study.

Although hip fracture rates are higher in women than in men, for older men the lifetime risk of fractures of the femur is substantial. Very little is known about risk factors for hip fracture in men. A preliminary case control study was conducted comparing the medical charts of men with first hip fractures with two sets of age-matched controls. The major risk factors for hip fracture that emerged were preadmission ambulatory problems, confusion, heavy alcohol use, and low body mass. Although this study is limited to a medical chart review in a veteran population, these results confirm some of the known associations for hip fracture in women. Further studies in men are recommended.

Use of trabeculectomy with postoperative 5-fluorouracil in patients requiring extremely low intraocular pressure levels to limit further glaucoma progression.

The authors conducted a randomized, controlled clinical trial to quantify the effect of 5-fluorouracil (5-FU) on filtration surgery. Both eyes of 17 patients with either bilateral low-tension glaucoma or advanced chronic open-angle glaucoma that would be expected to progress at intraocular pressures in the normal range were included. One eye received a full-thickness filtering procedure with a modified shell tamponade technique, and the other received a trabeculectomy with postoperative 5-FU. Follow-up was equal for both eyes and averaged 9.2 months. In eyes in the shell group, the average postoperative pressure was 10.94 mmHg, and in the 5-FU group it was 6.94 mmHg, (P = 0.0001). However, the postoperative visual acuity decrease was significantly greater in the 5-FU group (P less than 0.05). Choroidal detachments also were more frequent in the 5-FU group, but this was not statistically significant.

The effect of chronic miotic therapy on the results of posterior chamber intraocular lens implantation and trabeculectomy in patients with glaucoma.

We reviewed the charts of 18 patients (20 glaucomatous eyes) who had not used pilocarpine prior to undergoing trabeculectomy combined with or performed later with posterior chamber lens implantation. We then compared postoperative results and complications in these patients with those in 35 other patients (40 glaucomatous eyes) in two age- and stage-matched groups who had used pilocarpine prior to undergoing the same procedures. All patients had a minimum follow-up of 6 months. There was no significant difference between these groups in terms of postoperative intraocular pressure and required glaucoma medications. However, in the pilocarpine-treated groups, there was a significantly higher incidence of complications, especially intraocular lens capture (P less than 0.05), and of worse visual outcomes (P less than 0.01).

A comparative evaluation of three methods of analyzing optic disc topography.

Topographical evaluations of the optic discs of 17 eyes obtained using a clinical planimeter, the Rodenstock video-ophthalmograph, and the IS 2000 image analyzer were compared. The parameters studied were vertical and horizontal cup-to-disc ratios, cup volumes, rim areas, disc areas, and rim area-to-disc area ratios. There was good correlation between the measurements obtained by the three methods (correlation coefficients ranged from 0.46 to 0.88). For various parameters, the correlations between clinical planimetry and image analysis were higher than either those between image analysis and video-ophthalmography, or those between clinical planimetry and video-ophthalmography. The mean horizontal cup-to-disc ratios and rim areas as measured by clinical planimetry were significantly higher than those measured by image analysis. Image analysis measured significantly higher disc area and rim areas and lower cup volumes than video-ophthalmography.