Cataract surgical outcome at the Vancouver Eye Care Centre: can it be predicted using current data?

BACKGROUND: Patients selected for cataract surgery have an increasingly wider range of coexisting ocular and systemic diseases. The aim of this study was to determine whether preoperative patient characteristics can assist surgeons in identifying patients who are at increased risk of having little or no improvement in visual outcome after cataract surgery. METHODS: We prospectively studied a randomly selected subset (20%) of patients with cataract undergoing cataract extraction at a tertiary centre in Vancouver. There were no patient exclusion criteria. Pre-, intra- and postoperative clinical data were collected from medical records. RESULTS: We studied 1329 cataract surgical procedures from March 1999 to December 2000. Of the 1329, 851 had complete pre- and postoperative visual acuity data. The mean age of the 851 patients was 73.2 (standard deviation 10.6) years, 575 (67.6%) were women, and 472 procedures (55.5%) were first-eye procedures. Preoperatively, the best-corrected visual acuity was 20/40 or better in 146 eyes (17.2%), 20/50 in 173 (20.3%), 20/60 to 20/70 in 248 (29.1%), and 20/80 or worse in 284 (33.4%). Almost half of the patients (419 [49.2%]) had at least one coexisting eye disease in the operated eye. At about 3 months postoperatively, the best-corrected visual acuity had improved in 786 eyes (92.4%), remained the same in 42 (4.9%) and had worsened in 23 (2.7%). Of the 23 eyes with worse visual acuity, half had preoperative visual acuity of 20/40 or better; most of the remaining eyes had preoperative vision of 20/50 to 20/70. Of the 42 eyes with unchanged vision, 22 (52%) had preoperative visual acuity worse than 20/100; the remaining eyes were distributed across the visual acuity range. An increase of 1 year of age increased the odds of having a poor visual acuity outcome by 2% to 4%. Worse preoperative visual acuity predicted an increased likelihood of a poor outcome; this effect increased sharply for eyes with preoperative visual acuity of 20/80 or worse. After adjustment for age and preoperative visual acuity, patients with three or more coexisting eye diseases in the operated eye were 10 to 24 times more likely to have the worst postoperative visual acuity. INTERPRETATION: The presence and number of coexisting ocular diseases, increased age and poor preoperative visual acuity predicted an unchanged or worse visual acuity after cataract surgery.     

Improving population health or the population itself? Health technology assessment and our genetic future

The province of British Columbia (BC), Canada is developing its first population-wide prenatal genetic screening program, known as triple-marker screening (TMS). TMS, initiated with a simple blood test, is most commonly used to screen for fetuses with the chromosomal abnormality known as Down syndrome or neural tube disorders. Women testing TMS-positive are offered diagnostic amniocentesis and, if the diagnosis is confirmed, selective second-trimester abortion. The project described in this study was initiated to address the broad range of issues arising from this testing technology and provides an example of the new type of health technology assessment (HTA) contribution emerging (and likely to become increasing necessary) in health policy development. With the advent of prenatal genetic screening programs, would-be parents gain the promise of identifying target conditions and, hence, the option of selective abortion of affected fetuses. There is considerable awareness that these developments pose challenges in every dimension (ethical, political, economic, and clinical) of the health-care environment. In the effort to construct an appropriate prenatal screening policy, therefore, administrators have understandably sought guidance from within the field of HTA. The report authors concluded that, within the restricted path open to it, the role of government is relatively clear. It has the responsibility to maintain equal access to prenatal testing, as to any other health service. It should also require maintenance of medical standards and evaluation of program performance. At the same time, policy-makers need actively to support those individuals born with disabilities and their families.     

Continuity of care is associated with well-coordinated care.

CONTEXT: The importance of continuity of care as a means to promote care coordination remains controversial. OBJECTIVE: To determine if there is an association between having an objective measure of continuity of care and parental perception that care is well coordinated. DESIGN: Cross-sectional study. SETTING AND POPULATION: Seven hundred fifty-nine patients presenting to a primary care clinic completed surveys that included 5 items from the Components of Primary Care Index (CPCI) that relate to care coordination. MAIN PREDICTOR VARIABLE: A continuity of care index (COC) that quantifies the degree of dispersion of care among providers. MAIN OUTCOME MEASURES: Likelihood of parents reporting high scores on the care coordination domain as well as each of the 5 individual CPCI items related to care coordination. RESULTS: Greater continuity of care was associated with higher scores on the CPCI care-coordination domain (P <.001). Continuity of care was also specifically associated with increased odds of agreeing with all 5 individual CPCI items, including reporting that their child's provider "always knows about care my child received in other places" (OR 3.97 [2.11-7.49]), "communicates with the other health care providers my child sees" (OR 2.98 [1.63-5.44]), "knows the results of my child's visits to other doctors" (OR 2.02 [1.08-3.80]), and "always follows up on a problem my child has had, either at the next visit or by phone" (OR 6.20 [2.88-13.35]) and wanting one provider to coordinate all of the health care that the child receives (OR 3.28 [1.48-7.27]). CONCLUSIONS: Greater continuity of primary care is associated with better care coordination as perceived by parents. Efforts to improve and maintain continuity may be justified.     

Nurses' perceptions of care and caring

Care and caring have been identified as inherently difficult concepts to define, but many authors believe that care is the central and unifying core of nursing. It is vital that nurses understand what care is, with the current issues about measuring and justifying exactly what they do for patients in order to be clear about what good care is. If nurses are to constantly improve the care they give, they need to be clearer about how to care for patients. Nurses need to make sure that they are giving the patients what they want and not what the nurses want. This review of the literature explores nurses' perceptions of care and compares it with what patients want in terms of care. It also highlights some important and interesting differences between what patients and nurses perceive as good care.     

Comparison of individual and combination DNA vaccines for B. anthracis,Ebola virus,Marburg virus and Venezuelan equine encephalitis virus

Multiagent DNA vaccines for highly pathogenic organisms offer an attractive approach for preventing naturally occurring or deliberately introduced diseases. Few animal studies have compared the feasibility of combining unrelated gene vaccines. Here, we demonstrate that DNA vaccines to four dissimilar pathogens that are known biowarfare agents, Bacillus anthracis, Ebola (EBOV), Marburg (MARV), and Venezuelan equine encephalitis virus (VEEV), can elicit protective immunity in relevant animal models. In addition, a combination of all four vaccines is shown to be equally as effective as the individual vaccines for eliciting immune responses in a single animal species. These results demonstrate for the first time the potential of combined DNA vaccines for these agents and point to a possible method of rapid development of multiagent vaccines for disparate pathogens such as those that might be encountered in a biological attack.     

Use of propofol sedation in a pediatric emergency department: a prospective study.

The purpose of this study was to determine the efficacy and safety of propofol sedation for pediatric procedures in the emergency department. For patients needing painful procedures, propofol was administered intravenously. Vital signs, complications, and time to recovery were recorded. Patient amnesia and parent, patient, and operator satisfaction with sedation were assessed. The mean age was 7.4 years; 65% were male. Most underwent fracture reduction. Mean total dose was 3.3 mg/kg. Thirty percent experienced desaturation. One required assisted ventilation. Most had decreases in blood pressure. Mean recovery time was 18 minutes. Satisfaction with sedation was rated "excellent." Propofol was an effective sedation with minimal complications in the emergency department setting.     

Prospective comparison of flexibility radiographs in adolescent idiopathic scoliosis

STUDY DESIGN: A prospective evaluation of radiographs in patients undergoing anterior spinal fusion or posterior spinal fusion for adolescent idiopathic scoliosis. OBJECTIVE: To determine the most effective preoperative radiographic method for evaluating coronal plane flexibility by comparing preoperative and postoperative correction. SUMMARY OF BACKGROUND DATA: Curve flexibility is traditionally evaluated with side-bending radiographs. Recently, the fulcrum-bending radiograph was shown to provide better correction of thoracic curves undergoing posterior spinal fusion but was not evaluated in thoracolumbar/lumbar curves or in patients undergoing anterior spinal fusion. METHODS: Preoperative coronal radiographs of 46 consecutive patients undergoing spinal fusion for adolescent idiopathic scoliosis obtained while standing, lying supine, side-bending (maximally bending while supine), push-prone (padded bolsters applied to chest wall while prone), and fulcrum-bending (curve apex suspended over a radiolucent fulcrum while lateral) were compared with standing postoperative radiographs. Cobb angles were determined and evaluated for statistical significance. RESULTS: The fulcrum-bending radiograph demonstrated statistically better correction than other preoperative methods for main thoracic curves (P < 0.01) but fell short of demonstrating the correction obtained surgically. There was no statistical difference between side-bending, fulcrum-bending, or postoperative correction for thoracolumbar/lumbar curves (all P values > 0.07). The left side-bending was the most effective method for reducing upper thoracic curves (P < 0.001). There was no difference in the results obtained for curves corrected by anterior spinal fusion or anterior spinal fusion. CONCLUSION: To achieve maximal preoperative correction, thoracic fulcrum-bending radiographs should be obtained for evaluating main thoracic curves, whereas side-bending radiographs should continue to be used for evaluating both upper thoracic and thoracolumbar/lumbar curves.