Victoria C. Leung

Cost Effectiveness of Hepatitis C-Related Interventions Targeting Substance Users and Other High-Risk Groups

AbstractBackground and Objective: In developed countries, injection drug users have the highest prevalence and incidence of hepatitis C virus (HCV) infection. Clinicians and policy makers have several options for reducing morbidity and mortality related to HCV infection, including preventing new infections, screening high-risk populations, and optimizing uptake and delivery of antiviral therapy. Cost-effectiveness analyses provide an estimate of the value for money associated with adopting healthcare interventions. Our objective was to determine the cost effectiveness of hepatitis C interventions (prevention, screening, treatment) targeting substance users and other groups with a high proportion of substance users. Methods: We conducted a systematic search of MEDLINE, EMBASE, CINAHL, HealthSTAR and EconLit, and the grey literature. Studies were critically appraised using the Drummond and Jefferson, Neumann et al. and Philips et al. checklists. We developed and applied a quality appraisal instrument specific to cost-effectiveness analyses of HCV interventions. In addition, we summarized cost-effectiveness estimates using a single currency and year (

Inter-Eye Differences in Patients with Pseudoexfoliation Syndrome Presenting with Intraocular Lens Dislocation

US, year 2009 values). Results: Twenty-one economic evaluations were included, which addressed prevention (three), screening (ten) and treatment (eight). The quality of the analyses varied greatly. A significant proportion did not incorporate important aspects of HCV natural history, disease costs and antiviral therapy. Incremental cost-effectiveness ratios (ICERs) ranged from dominant (less costly and more effective) to

The relationship between sociodemographic factors and persistence with topical glaucoma medications.

US603 352 per QALY. However, many ICERs were less than

Clinical efficiency and resident education: a fine balance

US100 000 per QALY. Screening and treatment interventions involving pegylated interferon and ribavirin were generally cost effective at the

Severe Intraoperative Orbital Venous Congestion during Resection of a Frontal Meningioma Presenting with Post-operative Vision Loss and Ophthalmoplegia: A Case Report

US100000 per QALY threshold, with the exception of some subgroups, such as immune compromised patients with genotype 1 infections. Conclusions: No clear consensus emerged from the studies demonstrating that prevention, screening or treatment provides better value for money as each approach can be economically attractive in certain subgroups. More high-quality economic evaluations of preventing, identifying and treating HCV infection in substance users are needed.

Endovascular Management of a Traumatic Infraorbital Pseudoaneurysm Causing Orbital Compartment Syndrome.

PURPOSE To analyze differences in glaucoma diagnosis and glaucoma severity between fellow eyes in patients with pseudoexfoliation syndrome (PXF) who present with intraocular lens (IOL) dislocation. DESIGN Retrospective matched case-control study. Eyes presenting with IOL dislocation (case group) were compared with fellow eyes (control group). PARTICIPANTS Patients from a tertiary referral practice in Mississauga, Ontario, Canada. METHODS Consecutive patients with PXF and prior bilateral uneventful cataract surgeries with in-the-bag IOLs who presented with IOL dislocation between 2008 and 2013 were identified (n=71). Indicators of glaucoma severity were compared between fellow eyes using McNemars test and Wilcoxon signed-rank tests. Indicators of glaucoma severity were also compared pre- and post-IOL exchange/repositioning in the eye with IOL dislocation. MAIN OUTCOME MEASURES Glaucoma diagnosis, corrected distance visual acuity (CDVA), intraocular pressure (IOP), optic nerve cup-to-disc (C/D) ratio, mean deviation (MD) on visual field, retinal nerve fiber layer (RNFL) thickness, and glaucoma medication requirements (GMRs). RESULTS Seventy-one participants were included. The affected eye was more likely to have glaucoma (P<0.0001) and have more severe glaucoma (P=0.0001). In addition, the affected eye had worse mean CDVA (1.14±0.79 logarithm of the minimum angle of resolution [logMAR] vs. 0.35±0.46 logMAR, P<0.0005), higher mean IOP (19.2±7.2 vs. 14.7±3.6, P<0.0005), higher C/D ratio (0.54±0.22 vs. 0.51±0.20, P=0.006), greater mean number of glaucoma medication classes (1.4±1.4 vs. 0.5±1.1, P<0.0005), worse MD (-13.83±6.89 decibels [dB] vs. -6.59±6.63 dB, P<0.0005), and worse mean RNFL thickness (69.2±26.3 vs. 82.4±13.7, P=0.001). In the affected eye, there were early postoperative improvements in mean CDVA, IOP, and GMRs. CONCLUSIONS In patients with PXF, the eye presenting with IOL dislocation was more likely than its fellow eye to have a diagnosis of glaucoma and to have glaucoma of greater severity.

TegadermTMdressing and Lacri-lube ointment moisture chamber to manage exposure keratopathy

Purpose:To investigate the relationship between sociodemographic factors and nonpersistence with topical glaucoma medication. Design:This was a retrospective, observational cohort study. Patients and Methods:We invited glaucoma patients on medical therapy from a general ophthalmology practice to complete a standardized questionnaire between November 2011 and April 2012. Nonpersistence was defined as having ≥1 gaps (≥14 d without medication) in therapy over the last year. Patients’ pharmacy records, dating back 1 year from study enrollment, were used to determine the total number of gaps and the cumulative number of days off therapy in the last year. Prevalence ratios (PR) and 95% confidence intervals (CI) were used to assess the relationship between sociodemographic factors and nonpersistence. The relationships between sociodemographic factors and the median number of gaps, as well as the median number of days off, were also assessed. Results:Sixty-one patients were included for analysis. The mean age was 72 years; 61% were male patients and 71% were on one medication for glaucoma. Fifty-four percent of patients (n=33) were nonpersistent with glaucoma medications over the 1 year study period. Median numbers of gaps and days off therapy were 1 and 11, respectively. Patients reporting below average income were twice as likely to be nonpersistent (prevalence ratio, 2.02; 95% confidence interval, 1.37-2.96; P<0.01). Below average income also trended toward a greater median number of days off therapy (P=0.07). Conclusions:Below average socioeconomic status may negatively impact persistence with topical glaucoma medications, potentially threatening long-term visual outcomes.

Role of patient choice in influencing wait time for cataract surgery

Demand for healthcare is growing at an unprecedented rate owing to an ageing population and the rising prevalence of chronic disease.1 In order to meet increasing demand with limited resources, clinical efficiency has become of utmost importance. Clinical efficiency balances quality of care against healthcare costs and has become a central tenet of high-functioning health systems.2 Increasing attention has been directed towards developing metrics that capture quality and costs of care and funding models to match. Although efforts to improve efficiency are important in todays fiscally limited, high-demand environment, top-level policies may have important unintended repercussions for frontline healthcare workers. Resident physicians, for instance, are a unique group of healthcare professionals, whose educational opportunity may be adversely affected by heightened attention to highly efficient care. In the past decade, funding has changed from fee-for-service to non-traditional models that link reimbursement to the achievement of prespecified targets for health processes or outcomes. Examples include health-based allocation models, accountable care models and pay-for-performance.3 ,4 Governments have implemented wait time strategies to increase clinical volumes. In Ontario, Canada, the Wait Time Strategy dedicates resources to measuring and achieving improvements in wait times.5 Hospitals use this information to highlight inefficiencies, increase patient …

Corneal Collagen Cross-Linking in the Management of Keratoconus in Canada: A Cost-Effectiveness Analysis

ABSTRACT We describe a unique case of a middle-aged man who noticed complete vision loss in the right eye after awaking from resection of a large right-sided frontal meningioma. Visual acuity was hand motions, and there were multiple signs of right orbital venous congestion. Magnetic resonance imaging and venography (MRI/V) of the brain and orbits demonstrated expected post-operative findings with no evidence of cavernous sinus thrombosis or fistula. Empiric treatment with intravenous antibiotics and intravenous methylprednisolone were ineffective. Immediate post-operative computerised tomography (CT) images were re-reviewed and revealed right restricted diffusion of the entire intraorbital right optic nerve. Discussion with the neurosurgical team revealed that during craniotomy, a prominent diploic venous plexus in the frontal bone adjacent to the meningioma was identified and coagulated with bone wax. Review of pre-operative imaging revealed large diploid flow voids in the right frontal bone, corresponding to the intraoperative findings. This prominent venous plexus appeared to drain from the meningioma posteriorly into the vein of Labbe. A second pathway drained anteriorly through the right angular vein into the orbit. We hypothesise that the posterior outflow pathway was coagulated intraoperatively, causing redirection of all venous outflow from the meningioma into the right orbit through the anterior pathway. This resulted in significant orbital hypertension with manifest signs and symptoms. Furthermore, sudden rise in intraorbital pressure led to infarction of the optic nerve, leaving the patient with hand motions vision. We suggest that pre-operative vascular imaging should be performed in patients with large meningiomas, as pre-operative embolisation of venous outflow channels may prevent severe post-operative complications.

Phacomorphic Angle Closure Following Silicone Oil Tamponade in a Pediatric Patient

An 89-year-old woman presented after blunt injury to the left orbit from a fall. Examination findings were suggestive of left-sided orbital compartment syndrome, unresponsive to emergent lateral canthotomy and cantholysis. CT revealed a left-sided orbital floor blowout fracture involving the infraorbital canal, with a large maxillary and infraorbital hematoma. Angiography revealed a pseudoaneurysm supplied by the infraorbital artery. Interventional neuroradiology successfully achieved hemorrhage control by endovascular obliteration of the parent artery close to the pseudoaneurysm. To our knowledge, this is the first reported case of successfully managing active intraorbital hemorrhage causing orbital compartment syndrome by endovascular vessel sacrifice of an infraorbital artery pseudoaneurysm.