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Biomedical subjects

Gary C Brown

Publications and source records attributed to Gary C Brown.

At least 19 recordsLinked to original sources
PubMed2006

Endophthalmitis after open globe injury: microbiologic spectrum and susceptibilities of isolates.

PURPOSE: To present the microbiologic spectrum and susceptibilities of isolates in posttraumatic endophthalmitis, and to provide a review of the literature. DESIGN: Retrospective consecutive case series. METHODS: A review of 1182 consecutive open globe injuries was performed, identifying 10 patients with culture-proven endophthalmitis. RESULTS: Thirteen organisms were isolated from 10 eyes with posttraumatic endophthalmitis. Isolated organisms included Streptococcus species (46.2%), coagulase-negative Staphylococcus (23.1%), and Bacillus cereus (15.4%). All organisms tested were susceptible to vancomycin and tobramycin. The most commonly isolated organisms from an aggregate posttraumatic endophthalmitis pool of 372 cases obtained by literature-based meta-analysis were coagulase-negative Staphylococcus (21.5%) and Bacillus cereus (18.5%). CONCLUSION: We report a high prevalence of gram-positive pathogens and a notable prevalence of Bacillus cereus in posttraumatic endophthalmitis. Susceptibility results suggest that posttraumatic endophthalmitis isolates are generally susceptible to vancomycin and tobramycin.

Anti-Bacterial Agents↗
PubMed2006

The cost utility of strabismus surgery in adults.

PURPOSE: Cost-utility analysis evaluates the cost of medical care in relation to the gain in quality-adjusted life years (QALYs). Our purpose was to develop a cost model for surgical care for adult strabismus, to estimate the mean cost per case, to determine the associated gain in QALYs, and to perform cost-utility analysis. METHODS: A cost model incorporated surgery, pre- and postoperative care, and a mean of 1.5 procedures per patient. The gain in QALYs was based on the improvement of utility on a scale from 0 (death) to 1 (perfect health). Utility was measured through physician-conducted interviews employing a time tradeoff question (seeking to estimate the portion of life expectancy a patient would be willing to trade for being rid of disease and associated effects). The interviews were conducted before and 5 to 8 weeks after surgery in 35 strabismic patients (age 19-75 years). RESULTS: The cost model resulted in an estimated total cost of 4,254 dollars per case. A significant improvement of utility was found: 0.96 +/- 0.11 postoperatively versus 0.85 +/- 0.20 preoperatively (p = 0.00008). Based on the mean life expectancy (36.0 years) of these patients, and discounting outcomes and costs by 3% annually, this resulted in a mean value gain of 2.61 QALYs after surgery and a cost-utility for strabismus surgery of 1,632 dollas/QALY. CONCLUSIONS: In the United States, treatments <50,000 dollars/QALY are generally considered "very cost-effective." Strabismus surgery in adults falls well within this range.

Adult↗
PubMed2006

Pars plana vitrectomy versus combined pars plana vitrectomy-scleral buckle for primary repair of pseudophakic retinal detachment.

PURPOSE: To evaluate pars plana vitrectomy (PPV) versus a combined PPV and scleral buckle (PPV/SB) for repair of noncomplex, pseudophakic retinal detachment. DESIGN: Retrospective, nonrandomized, comparative interventional study. PARTICIPANTS: One hundred fifty-two eyes of 152 patients followed up for a mean of 10 months. The case series included 68 consecutive patients who underwent PPV and 84 consecutive patients who underwent a PPV/SB for primary repair of primary pseudophakic retinal detachment at Wills Eye Hospital between 2002 and 2004. METHODS: All primary PPV cases were performed by 2 surgeons who perform primary vitrectomy without regard to location of detachment, number and location of break(s), refractive error, or macula status. All primary PPV/SB were performed by a group of surgeons who solely perform PPV/SB on pseudophakic retinal detachments. All eyes underwent a standard 3-port 20-gauge PPV under wide-field viewing and scleral depression. Endolaser photocoagulation was applied either around the retinal tears or 360 degrees to the vitreous base region followed by gas tamponade. Patients with proliferative vitreoretinopathy grade C or worse were excluded from the study. MAIN OUTCOME MEASURES: (1) Single surgery anatomic success rates, (2) preoperative and postoperative visual acuity, and (3) complications. RESULTS: The single surgery anatomic success rate in the primary PPV group was 63 of 68 eyes (92.6%; 95% confidence interval [CI], 84%-98%) and in the primary PPV/SB group was 79 of 84 eyes (94.0%; 95% CI, 87%-98%). Both groups obtained 100% final reattachment rate. There was no statistically significant difference between the success rates (P = 0.75, Fisher exact test). The PPV group's best-corrected postoperative visual acuity demonstrated a +0.10 logarithm of the minimum angle of resolution improvement over the PPV/SB group (P = 0.07). The PPV group had a smaller incidence of postoperative complications (13/68 patients [19.1%] vs. 27/84 patients [32.1%]; P = 0.10, Fisher exact test). CONCLUSIONS: Primary PPV and PPV/SB seem to have similar efficacy in the repair of a matched group of patients with primary noncomplex pseudophakic retinal detachment. There was no statistically significant difference in complication rate between the 2 groups.

Adult↗
PubMed2006

Laser treatment for retinopathy of prematurity: evolution in treatment technique over 15 years.

PURPOSE: To assess the number of laser burns applied to the peripheral retina to treat retinopathy of prematurity (ROP) in a recent population of patients and to compare that number with historical data. METHODS: The authors performed a retrospective chart review of all patients treated for ROP within a single practice from 2002-2004. There were 183 eyes from 93 patients. Sufficient data for analysis were available on 112 eyes from 57 patients. Data from these patients were compared to those of patients reported upon in 1991. RESULTS: The average number of laser burns applied to the 112 eyes was 2163. Eyes with zone 1 disease had an average of 3077 spots and those with zone 2 disease had an average of 2072 spots. Greater than three months follow-up was available on 42 eyes from 21 patients. Of those eyes, 90% had complete regression of ROP. In an initial report of laser treatment for ROP by several of the same authors in 1991, the average number of laser burns applied for treatment of ROP was 816. There was a 265% increase in the average number of laser applications from the early study to the present. CONCLUSION: The data indicate that there has been a trend towards more confluent laser treatment to the avascular zone in ROP.

Follow-Up Studies↗
PubMed2006

Retinal nerve fiber layer analysis in the diagnosis of glaucoma.

PURPOSE OF REVIEW: The detection of optic disc and retinal nerve fiber layer damage and change is the cornerstone of glaucoma management. Assessment of the retinal nerve fiber layer for localized and diffuse damage has been traditionally based on clinical examination, with documentation of change primarily qualitative. With the latest improvements in optical imaging instruments, objective and quantitative measurements of the retinal nerve fiber layer are now possible. This review summarizes the results from recent cross-sectional studies evaluating the discriminating ability of automated retinal nerve fiber layer measurements to detect glaucoma, and from longitudinal studies assessing the ability to predict and monitor glaucomatous changes. RECENT FINDINGS: Numerous cross-sectional studies have documented good diagnostic accuracy of a scanning laser polarimeter (GDx VCC), the optical coherence tomograph (Stratus), and the Heidelberg Retina Tomograph retinal nerve fiber layer measurements for differentiating between healthy and glaucoma eyes. There are only limited data available on the ability of these retinal nerve fiber layer measurements to document change over time. SUMMARY: It is essential that the clinician understand the specific strengths and weaknesses of each technique so that only good quality retinal nerve fiber layer information will be used in conjunction with careful clinical examination and visual function testing for glaucoma management decisions. Longitudinal studies are needed to evaluate the ability of these instruments to document retinal nerve fiber layer change over time.

Diagnostic Imaging↗
PubMed2006

Pain and suffering disability index.

PURPOSE OF REVIEW: This report summarizes the increasing financial resources required to deal with personal injury tort cases and medical malpractice. The largest single component in personal injury torts is noneconomic damages, which encompasses 'pain and suffering' and punitive damage, the latter of which comprises only a small percentage. Overall, noneconomic damages account for 24% of the greater than US$250 billion spent annually on personal injury torts. RECENT FINDINGS: A pain and suffering disability index has been developed that quantifies the loss of life's value attributable to personal injury. Based upon time-tradeoff utility analysis, the value loss is predicated upon the values of people who have experienced the same degree of disability or injury as the plaintiff, only outside the courtroom environs. It is believed that the pain and suffering disability index will readily identify frivolous, personal injury torts, decrease the number of frivolous, personal injury torts, markedly decrease the variance of noneconomic tort settlements, facilitate the earlier settlement of personal injury tort cases, and decrease the proportion of personal injury tort cases progressing to jury trial. SUMMARY: The pain and suffering disability index is a novel instrument that quantifies the 'pain and suffering' associated with a personal injury tort according to the values of patients who have experienced a similar injury outside the courtroom environs.

Disability Evaluation↗
PubMed2006

56,000 Ways? No way!

Explore the source record for details and available documents.

Antihypertensive Agents↗
PubMed2005

Incidence of intraocular pressure spike and other adverse events after vitreoretinal surgery.

PURPOSE: To determine the incidence of significant postoperative intraocular pressure (IOP) elevation and other adverse medical events during the first postoperative day in patients undergoing inpatient vitreoretinal surgery. DESIGN: Noncomparative interventional case series. PARTICIPANTS: Two hundred two consecutive patients were admitted prospectively as inpatients after vitreoretinal surgery (vitrectomy and/or scleral buckling). METHODS: Intraocular pressure was measured preoperatively, 5 to 12 hours postoperatively, and on postoperative day 1. Additionally, pain, nausea, and serious systemic adverse events were monitored. RESULTS: Seventeen patients (8.4%) had a 5- to 12-hour IOP measurement above 29 mmHg. Thirty patients (14.8%) had a postoperative day 1 IOP measurement above 29 mmHg. Three patients (1.5%) required a parenteral narcotic to achieve adequate analgesia. Nine patients (4.5%) utilized a parenteral antiemetic for nausea control. Six patients (3.0%) had a hyperglycemic event. No serious systemic adverse events occurred in the early postoperative period. CONCLUSIONS: The incidence of a significant IOP spike or systemic adverse events in the early postoperative period in patients undergoing vitreoretinal surgery is low.

Adult↗
PubMed2005

The cost-utility of photodynamic therapy in eyes with neovascular macular degeneration--a value-based reappraisal with 5-year data.

PURPOSE: To assess the value conferred by photodynamic therapy (PDT) and the cost-utility of PDT for the treatment of classic, subfoveal choroidal neovascularization associated with age-related macular degeneration (ARMD). DESIGN: Average cost-utility analysis utilizing clinical trial data, patient-based time tradeoff utility preferences, and a third party insurer cost perspective. METHODS: Five-year visual acuity data from the TAP (Treatment of Age-related Macular Degeneration With Photodynamic Therapy) Investigation were modeled into a 12-year, value-based, reference case, cost-utility model utilizing year 2004 Medicare costs and an outcome of dollar/QALY (dollars/quality-adjusted life-year). Discounting of outcomes and costs using net present value analysis with a 3% annual rate was performed as recommended by the Panel for Cost-Effectiveness in Health and Medicine. RESULTS: PDT with verteporfin (Visudyne) dye for classic subfoveal choroidal neovascularization confers an 8.1% quality of life (value) improvement over the 12-year life expectancy of the reference case, while during the last 8 years the value improvement is 9.5%. The average cost-utility of the intervention is dollar 31,103/QALY (quality-adjusted life-year). Extensive one-way sensitivity analysis values range from dollar 20,736/QALY if treatment efficacy is increased by 50% to dollar 62,207 if treatment efficacy is decreased by 50%, indicating robustness of the model. CONCLUSIONS: PDT using verteporfin dye to treat classic subfoveal choroidal neovascularization is a very cost-effective treatment by conventional standards. The marked improvement in cost-effectiveness compared with a previous report results from the facts that the treatment benefit increasingly accrues during 5 years of follow-up while the number of yearly treatments diminishes markedly during that time.

Choroidal Neovascularization↗
PubMed2005

Coats' disease diagnosed in adulthood.

PURPOSE: To investigate the manifestations and clinical course of Coats' disease diagnosed in adulthood and to describe the characteristics of patients who develop it. DESIGN: Retrospective observational case series. PARTICIPANTS: Thirteen eyes of 13 patients with Coats' disease diagnosed after age 35 years. METHODS: All patients examined in the authors' referral practices for Coats' disease diagnosed after the age of 35 years were identified. Patients with a history of radiation exposure, intraocular inflammation, retinal vascular occlusion, or Coats' response were excluded. A review of their historical, clinical, and fluorescein angiographic features and demographics was performed. RESULTS: There were 13 patients with a mean age at diagnosis of 50 years (range, 36-79) and a mean follow-up of 5.8 years (range, 0-17). These patients manifested many findings typical of Coats' disease, including the unilateral nature of the disease (13/13 patients), male predominance (12/13), vascular telangiectasis, lipid exudation, macular edema, and areas of capillary nonperfusion with adjacent webs of filigreelike capillaries. Disease was limited to < or =6 clock hours in 10 of 13 patients (76.9%), did not generally involve the retinal vasculature anterior to the equator, and showed limited potential to expand during the follow-up period. A localized hemorrhage was noted in 10 of 13 patients (76.9%), almost always near larger aneurysmal dilatations. Limited exudative detachment of the retina was seen in 4 eyes, 3 of which responded to localized laser photocoagulation. One patient had subretinal fluid seen on ocular coherence tomography that did not require treatment. On average, patients lost 2.1 lines of visual acuity during the follow-up period; 6 patients had a decline in vision, 2 patients had improved vision, and 3 patients had stable vision. No patient had end-stage findings of Coats' disease, such as iris neovascularization or total exudative detachment. CONCLUSIONS: Coats' disease can first be diagnosed in adulthood with retinal vascular abnormalities similar to those seen in younger patients. There are a number of important differences in disease manifestation in adults, including limited area of involvement, slower apparent progression of disease, and hemorrhage near larger vascular dilatations.

Adult↗
PubMed2005

Age-related macular degeneration: economic burden and value-based medicine analysis.

It can be estimated that 17,100 new cases of neovascular (wet) AMD and 180,000 new cases of geographic-atrophy (dry) AMD occur in Canada annually. In addition to having a devastating effect on patients' lives, the condition causes significant adverse consequences for the economy. The deleterious effect of AMD on quality of life is markedly underestimated by ophthalmologists who treat patients with AMD, by non-ophthalmic physicians and by the public. In fact, patients with different degrees of severity of AMD have a perceived impairment of their quality of life that is 96% to 750% greater than the impairment estimated by treating ophthalmologists. Mild AMD causes a 17% decrease in the quality of life of the average patient, a decrease similar to that encountered with symptomatic human immunodeficiency virus infection or moderate cardiac angina. Moderate AMD produces a 40% decrease in quality of life, a decrease similar to that associated with permanent renal dialysis or severe cardiac angina. Very severe AMD causes a 63% decrement in quality of life, a decrease similar to that encountered with advanced prostatic cancer with uncontrollable pain or a severe stroke that leaves a person bedridden, incontinent and requiring constant nursing care. The adverse economic consequences of AMD include an annual $2.6 billion negative impact on Canada's gross domestic product. The return on investment is high for both current AMD therapies and research into new treatment modalities.

Canada↗
PubMed2005

The macroeconomics of vitreoretinal diseases.

PURPOSE OF REVIEW: The purpose of this review is to examine the macroeconomics of vitreoretinal diseases. RECENT FINDINGS: Approximately 6% of the Medicare Part B expenditure was spent on ocular diseases and 0.3% on vitreoretinal interventions. Among the 17,674 practicing ophthalmologists, 1849 (10.5%) designated themselves as specializing in the treatment of vitreoretinal diseases. Ophthalmologists receive 38% of their payments from Medicare; 13% of their total income were capitated. Age-related macular degeneration and diabetic retinopathy, two conditions commonly treated by vitreoretinal specialists, are projected to affect more than 10 million people in 2020. SUMMARY: Vitreoretinal interventions account for only a small portion of the total health care expenditure. The rising demand from the aging population and health care costs will continue to put pressure on all physicians and society. The changes in the sources of payment and managed care will directly affect the economics of a physician's practice.

Eye Diseases↗
PubMed2005

How to interpret a healthcare economic analysis.

PURPOSE: The purpose of the review is to present guidelines to help the clinician to interpret healthcare economic analyses and review pertinent recent analysis in the ophthalmic literature. RECENT FINDINGS: There are four variants of healthcare economic analyses: (1) cost-minimization analysis; (2) cost-benefit analysis; (3) cost-effectiveness analysis and (4) cost-utility analysis. Cost-utility utility analysis has assumed an increasingly important role in healthcare, with increasing number of analyses occurring in the peer-reviewed ophthalmic literature. These include cost-utility analyses of cataract surgery in the first and second eyes, amblyopia treatment, and cost-utility analyses encompassing the vitreoretinal interventions of the following: (1) laser photocoagulation for exudative macular degeneration; (2) laser treatment for diabetic retinopathy; (3) laser photocoagulation for branch retinal vein obstruction; (4) diabetic vitrectomy; (5) treatment of proliferative retinopathy of prematurity and (6) treatment of retinal detachment associated with proliferative vitreoretinopathy. As an increasing number of cost-utility analyses become available they will provide the information system for the practice of value-based medicine, or medicine based upon the patient-perceived value conferred by interventions. SUMMARY: Increasing numbers of cost-utility analysis in the ophthalmic literature suggest that ophthalmic interventions, including vitreoretinal interventions, are cost effective. Cost-utility analysis is a major tool in value-based medicine, the practice of medicine based upon the patient-perceived value conferred by healthcare interventions.

Cost-Benefit Analysis↗
PubMed2005

The burden of age-related macular degeneration: a value-based medicine analysis.

PURPOSE: To assess the quality-of-life loss and the macroeconomic financial consequences associated with age-related macular degeneration (ARMD). METHODS: Time tradeoff utility analysis was performed to assess the quality-of-life diminution caused by ARMD (both dry and neovascular) in cohorts consisting of (1) patients with ARMD, (2) ophthalmologists asked to assume they had various degrees of severity of ARMD, (3) healthcare providers asked to assume they had various degrees of severity of ARMD, and (4) participants from the general community asked to assume they had various degrees of severity of ARMD. ARMD was classified according to vision in the better-seeing eye as (1) mild: 20/20 to 20/40, (2) moderate: 20/50 to 20/100, (3) severe: < or = 20/200, or (4) very severe: < or = 20/800. RESULTS: Mild ARMD caused a 17% decrement in the quality of life of the average patient, similar to that encountered with moderate cardiac angina or symptomatic human immunodeficiency virus syndrome. Moderate ARMD caused a 32% decrease in the average patient's quality of life, similar to that associated with severe cardiac angina or a fractured hip. Severe ARMD caused a 53% decrease in quality, more than that of dialysis, and very severe ARMD caused a 60% decrease in the average ARMD patient's quality of life, similar to that encountered with end-stage prostate cancer or a catastrophic stroke that leaves a person bedridden, incontinent, and requiring constant nursing care. Patients with varying degrees of severity of ARMD were found to have quality-of-life impairment ranging from 96% to 750% greater than that estimated by treating ophthalmologists for the same condition. An economic analysis based upon losses to the gross domestic product suggests that ARMD has approximately a $30 billion annual negative impact. The return on investment is therefore potentially high for both treatment with current ARMD therapies and the research costs invested in the development of new ARMD treatment modalities. CONCLUSIONS: ARMD is a major public health problem that has a devastating effect upon patients and marked adverse financial consequences for the economy.

Adult↗