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Mishra AV, Tong CM, Faes L, Cheema MK, Plemel D, Rubin U, Bao B, Nazarali S, Lapere SRJ, Somani R, Hinz BJ, Tennant MTS. Comparison of Endophthalmitis Rates after Alcohol-Based Chlorhexidine and Povidone-Iodine Antisepsis for Intravitreal Injections. Ophthalmol Retina 2024; 8:18-24. [PMID: 37611695 DOI: 10.1016/j.oret.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 08/08/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE Intravitreal injections (IVIs) are the most frequently performed intraocular procedure in Canada. Povidone-iodine (PI) is the current gold standard for antisepsis for IVI and is widely used; chlorhexidine (CH) is a possible alternative antiseptic agent. This study aims to compare rates of endophthalmitis after IVI with 0.05% chlorhexidine with a 4% alcohol base antisepsis to rates of endophthalmitis after IVI with 10% PI antisepsis. DESIGN Retrospective cohort study. SUBJECTS Eyes that received IVI between May 2019 and October 2022 at a group retina practice in Edmonton, Canada. METHODS Eyes at a single center received focal conjunctival application of either 10% PI antisepsis or 0.05% CH in 4% alcohol antisepsis for 30 seconds before each IVI. MAIN OUTCOME MEASURE Rates of endophthalmitis between the PI and CH groups. RESULTS A total of 170 952 IVIs were performed during the study period. A total of 31 135 were performed using CH prophylaxis compared with 139 817 with PI prophylaxis. Among all IVIs there were 49 total cases of endophthalmitis, 29 in the PI group (0.021%) and 20 in the CH group (0.064%). There was a statistically significant difference in the rates of endophthalmitis between the 2 groups (P < 0.001). The odds ratio for developing endophthalmitis with CH antisepsis was 3.1 (95% confidence interval, 1.9-5.2) compared with PI antisepsis. There were increased odds of developing endophthalmitis with aflibercept injection compared with bevacizumab (odds ratio, 3.48; 95% confidence interval, 2.09-7.24). CONCLUSIONS There is a statistically significant difference in rates of endophthalmitis between alcohol-based CH and PI antisepsis for IVI in our patient population utilizing the methods discussed. In our center, alcohol-based CH is now considered a second-line antiseptic agent. Further studies are warranted to further assess the endophthalmitis rate utilizing these 2 antiseptic agents. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Amit V Mishra
- University of Alberta, Edmonton, Canada; Alberta Retina Consultants, Edmonton, Canada
| | | | - Livia Faes
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust & UCL, Institute of Ophthalmology, London, United Kingdom
| | | | | | - Uriel Rubin
- University of Alberta, Edmonton, Canada; Alberta Retina Consultants, Edmonton, Canada
| | - Bo Bao
- University of Alberta, Edmonton, Canada
| | | | - Steven R J Lapere
- University of Alberta, Edmonton, Canada; Alberta Retina Consultants, Edmonton, Canada
| | - Rizwan Somani
- University of Alberta, Edmonton, Canada; Alberta Retina Consultants, Edmonton, Canada
| | - Brad J Hinz
- University of Alberta, Edmonton, Canada; Alberta Retina Consultants, Edmonton, Canada
| | - Matthew T S Tennant
- University of Alberta, Edmonton, Canada; Alberta Retina Consultants, Edmonton, Canada.
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Konnyu KJ, Yogasingam S, Lépine J, Sullivan K, Alabousi M, Edwards A, Hillmer M, Karunananthan S, Lavis JN, Linklater S, Manns BJ, Moher D, Mortazhejri S, Nazarali S, Paprica PA, Ramsay T, Ryan PM, Sargious P, Shojania KG, Straus SE, Tonelli M, Tricco A, Vachon B, Yu CH, Zahradnik M, Trikalinos TA, Grimshaw JM, Ivers N. Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes. Cochrane Database Syst Rev 2023; 5:CD014513. [PMID: 37254718 PMCID: PMC10233616 DOI: 10.1002/14651858.cd014513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations. OBJECTIVES To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care. SEARCH METHODS We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section. SELECTION CRITERIA We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy. DATA COLLECTION AND ANALYSIS We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors. Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available. MAIN RESULTS We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted. Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three. Combinations of the three most effective QI strategies were estimated to lead to the below effects: - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%; - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg; - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other). AUTHORS' CONCLUSIONS There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.
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Affiliation(s)
- Kristin J Konnyu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sharlini Yogasingam
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Johanie Lépine
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Katrina Sullivan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Alun Edwards
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Michael Hillmer
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Sathya Karunananthan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Canada
| | - John N Lavis
- McMaster Health Forum, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Stefanie Linklater
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Braden J Manns
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sameh Mortazhejri
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Samir Nazarali
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - P Alison Paprica
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Timothy Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Peter Sargious
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Kaveh G Shojania
- University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
| | - Marcello Tonelli
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - Andrea Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
- Epidemiology Division and Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Queen's Collaboration for Health Care Quality: A JBI Centre of Excellence, Queen's University, Kingston, Canada
| | - Brigitte Vachon
- School of Rehabilitation, Occupational Therapy Program, University of Montreal, Montreal, Canada
| | - Catherine Hy Yu
- Department of Medicine, St. Michael's Hospital, Toronto, Canada
| | - Michael Zahradnik
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Thomas A Trikalinos
- Departments of Health Services, Policy, and Practice and Biostatistics, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Noah Ivers
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Canada
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Tong CM, Ellis D, Nazarali S, Machuk RWA, Kissick B, Kurji K, Climenhaga DB, Mah DY. Survivability of locally prepared versus imported Descemet membrane endothelial keratoplasty grafts in Edmonton. Canadian Journal of Ophthalmology 2023:S0008-4182(23)00069-8. [DOI: 10.1016/j.jcjo.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/25/2023] [Accepted: 02/26/2023] [Indexed: 03/30/2023]
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Abtahi M, Rudnisky CJ, Nazarali S, Damji KF. Incidence of steroid response in microinvasive glaucoma surgery with trabecular microbypass stent and ab interno trabeculectomy. Can J Ophthalmol 2021; 57:167-174. [PMID: 33992593 DOI: 10.1016/j.jcjo.2021.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 03/26/2021] [Accepted: 04/12/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To determine the incidence and risk factors for steroid response in patients undergoing combined phacoemulsification cataract extraction (PCE) and microinvasive glaucoma surgery with either trabecular microbypass stent implantation (iStent) or ab interno trabeculectomy (Trabectome). DESIGN Retrospective, noncomparative, single-institutional observational chart review. PARTICIPANTS Consecutive patients with open-angle glaucoma who underwent PCE with iStent or Trabectome with 3 months of follow-up. METHODS Data were collected from patient charts, including pre- and postoperative intraocular pressure (IOP) following application of topical corticosteroid on postoperative visits for at least 3 months. A steroid response was defined as an IOP rise of greater than 5 mm Hg beginning at least 3 days after surgery with no other obvious explanation and with IOP < 20 mm Hg following rapid tapering or withdrawal of the steroid. RESULTS A total of 118 eyes from 89 patients, average age of 71.4 ±12.1 years, were included. Overall, a steroid response was seen in 12.7% of eyes (n = 15), and no difference was noted between Trabectome (11.8%) and iStent (13.6%, p = 0.782) eyes. Axial length (AL; p = 0.01), younger age (p = 0.009), traumatic glaucoma (p = 0.004), and normal-tension glaucoma (NTG; p = 0.0048) were significant predictors of steroid response in a multivariate analysis. In eyes with AL ≥ 25 mm, the steroid response rate was 40%, in contrast to eyes with AL < 25 mm, where it was 10.2%. CONCLUSION A steroid response develops in approximately 1 in 8 patients undergoing PCE with Trabectome or iStent. Young age, AL > 25 mm, traumatic glaucoma, and NTG were found to be significant predictors of steroid response.
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Affiliation(s)
- Maryam Abtahi
- Department of Ophthalmology, University of Ottawa, Ottawa, Ont..
| | - Chris J Rudnisky
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alb
| | - Samir Nazarali
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alb
| | - Karim F Damji
- Department of Ophthalmology and Visual Sciences, University of Alberta and the Walter C. Mackenzie Health Sciences Centre, Edmonton, Alb
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Nazarali S, Liu H, Syed M, Wood T, Asanad S, Sadun AA, Karanjia R. Aircraft Cabin Pressurization and Concern for Non-Arteritic Anterior Ischemic Optic Neuropathy. Aerosp Med Hum Perform 2020; 91:715-719. [PMID: 32867902 DOI: 10.3357/amhp.5498.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND: Cabin pressurization is the process by which aircraft maintain a comfortable and safe environment for passengers flying at high altitudes. At high altitudes, most patients can tolerate changes in pressurization; however, passengers at high risk of hypoxia may experience ischemic events. The purpose of this study was to evaluate variations in pressurization of commercial aircraft at cruising altitude and describe its relevance in relation to patients with non-arteritic anterior ischemic optic neuropathy (NAION).METHODS: Altimeters were used to measure altitude and cabin altitude at cruising altitude aboard 113 commercial flights, including 53 narrow-body and 60 wide-body aircraft.RESULTS: Cabin altitude ranged from 4232 ft to 7956 ft at cruising altitudes ranging from 30,000 ft to 41,000 ft. The mean cabin altitude for all flights was 6309 876 ft. Narrow-body aircraft had a significantly higher mean cabin altitude (6739 829 ft) compared to wide-body aircraft (5929 733 ft). For all flights, the mean cruising altitude was 35,369 2881 ft with narrow-body aircraft cruising at a lower altitude of 34,238 2389 ft compared to wide-body aircraft at 36,369 2925 ft. Newer generation aircraft had a mean cabin altitude of 6066 837 ft, which was lower than the mean cabin altitude of older aircraft (6616 835 ft).DISCUSSION: Innovation in flight design has offered the ability for aircraft to fly at greater altitudes while maintaining lower cabin altitude. Those at high risk of hypoxia-induced complications may consider aircraft type when air travel is required.Nazarali S, Liu H, Syed M, Wood T, Asanad S, Sadun AA, Karanjia R. Aircraft cabin pressurization and concern for non-arteritic anterior ischemic optic neuropathy. Aerosp Med Hum Perform. 2020; 91(9):715719.
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Cheema M, Aghazadeh H, Nazarali S, Ting A, Hodges J, McFarlane A, Kanji JN, Zelyas N, Damji KF, Solarte C. Keratoconjunctivitis as the initial medical presentation of the novel coronavirus disease 2019 (COVID-19). Can J Ophthalmol 2020; 55:e125-e129. [PMID: 32284146 PMCID: PMC7124283 DOI: 10.1016/j.jcjo.2020.03.003] [Citation(s) in RCA: 240] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 01/26/2023]
Affiliation(s)
- Marvi Cheema
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta
| | - Helya Aghazadeh
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta
| | - Samir Nazarali
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta
| | - Andrew Ting
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta
| | - Jennifer Hodges
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta
| | - Alexandra McFarlane
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alta; Infection Prevention and Control, Alberta Health Services, Edmonton, Alta
| | - Jamil N Kanji
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alta; Provincial Laboratory for Public Health (Microbiology), Alberta Health Services, Edmonton, Alta
| | - Nathan Zelyas
- Provincial Laboratory for Public Health (Microbiology), Alberta Health Services, Edmonton, Alta; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alta
| | - Karim F Damji
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta
| | - Carlos Solarte
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta.
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Nathoo NA, Nazarali S, Gardiner J, Maberley D. Evaluation of ophthalmology clerkships across teaching sites at the University of British Columbia. Can J Ophthalmol 2019; 54:150-154. [DOI: 10.1016/j.jcjo.2018.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 03/16/2018] [Accepted: 04/03/2018] [Indexed: 11/30/2022]
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Nazarali S, Arora A, Ford B, Schlenker M, Ahmed IK, Poulis B, Gooi P. Cadaver corneoscleral model for angle surgery training. J Cataract Refract Surg 2019; 45:76-79. [DOI: 10.1016/j.jcrs.2018.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/07/2018] [Accepted: 08/07/2018] [Indexed: 11/30/2022]
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Nazarali S, Damji F, Damji KF. What have we learned about exfoliation syndrome since its discovery by John Lindberg 100 years ago? Br J Ophthalmol 2018; 102:1342-1350. [PMID: 29567789 DOI: 10.1136/bjophthalmol-2017-311321] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 02/06/2018] [Accepted: 03/07/2018] [Indexed: 12/14/2022]
Abstract
Exfoliation syndrome (XFS) is a systemic disease with significant ocular manifestations, including glaucoma and cataract. The disease impacts close to 70 million people globally and is now recognised as the most common identifiable cause of open-angle glaucoma. Since the discovery of XFS 100 years ago by Dr John G. Lindberg, there has been considerable advancement in understanding its pathogenesis and resulting clinical implications. The purpose of this paper is to summarise information regarding the epidemiology, pathophysiology, ocular manifestations and systemic associations of XFS with the objective of sharing clinical pearls to assist in early detection and enhanced management of patients.
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Affiliation(s)
- Samir Nazarali
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Faraz Damji
- School of Kinesiology, Faculty of Education, University of British Columbia, Vancouver, British Columbia, Canada
| | - Karim F Damji
- Department of Ophthalmology and Visual Sciences, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Marco S, Damji KF, Nazarali S, Rudnisky CJ. Cataract and Glaucoma Surgery: Endoscopic Cyclophotocoagulation versus Trabeculectomy. Middle East Afr J Ophthalmol 2018; 24:177-182. [PMID: 29422751 PMCID: PMC5793448 DOI: 10.4103/meajo.meajo_232_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
PURPOSE: To compare the efficacy and safety of endoscopic cyclophotocoagulation (ECP) versus trabeculectomy with mitomycin C (trab) in combination with cataract surgery. MATERIALS AND METHODS: We evaluated the 6-month results of patients undergoing phacoemulsification (phaco) with either ECP or trab. The primary outcome was mean intraocular pressure (IOP) at 6 months; secondary outcomes were change in glaucoma medications, visual acuity, intraocular inflammation, and postoperative complications. Complete success was a target IOP of <21 mmHg and >6 mmHg without glaucoma medications. Qualified success was target IOP achieved through glaucoma medications. RESULTS: We evaluated 53 eyes of 53 patients; 24 (45.3%) eyes were treated with ECP-phaco and 29 (54.7%) with trab-phaco. At 6 months, there was no significant difference in mean IOP of the two groups (ECP-phaco 14.2 ± 3.6 mmHg; trab-phaco 13.0 ± 2.5 mmHg; P = 0.240). Six (25.0%) ECP-phaco eyes and 20 (69.0%) trab-phaco eyes achieved complete success (P = 0.002). Qualified success was achieved in 18 (75.0%) ECP-phaco eyes and 9 (31.0%) trab-phaco eyes (P = 0.002). The mean reduction of medication from baseline was significant (ECP-phaco 1.2 ± 1.1; trab-phaco 2.1 ± 1.5; P = 0.020). ECP-phaco resulted in more IOP spikes on the 1st postoperative day (P = 0.040) and more anterior cellular reaction at 1 week and 1 month compared to trab-phaco (P < 0.05). The rate of postoperative complications was not significantly different between groups. CONCLUSION: At 6 months, ECP-phaco demonstrated similar improvements in IOP and visual acuity compared to trab-phaco. However, ECP-phaco patients had higher incidences of immediate postoperative IOP spikes and anterior chamber inflammation as well as requiring additional medications postoperatively.
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Affiliation(s)
- Sheila Marco
- Department of Ophthalmology, University of Nairobi, Nairobi, Kenya
| | - Karim F Damji
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - Samir Nazarali
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Chris J Rudnisky
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
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Nazarali SA, Nazarali S, Friedman J, Damji KF. Ophthalmology at the University of Alberta: Over 8 Decades of People-driven Contributions. Can J Ophthalmol 2017; 52:620-624. [PMID: 29217033 DOI: 10.1016/j.jcjo.2017.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 06/01/2017] [Accepted: 06/13/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Safia A Nazarali
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta
| | - Samir Nazarali
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta
| | - Judith Friedman
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta
| | - Karim F Damji
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta.
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Nazarali S, Mathura P, Harris K, Damji KF. Improving patient identification in an ophthalmology clinic using name alerts. Can J Ophthalmol 2017; 52:564-569. [PMID: 29217024 DOI: 10.1016/j.jcjo.2017.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/01/2017] [Accepted: 05/10/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To develop a standardized process for reviewing daily patient lists and identifying potential risks of misidentification. Our goal was to develop a proactive approach to identify and eliminate risks of patient misidentification. METHODS Assessment of current patient identification practices took place over a period of 4 weeks. Using a process map, a patient survey was developed to determine the encounter points when patient identification was confirmed. This information was used to develop a standardized protocol for review of daily appointment lists. RESULTS Review of daily appointment lists was completed to identify potential similar/same name risks. A standardized manual process of chart review, flagging, and tracking was developed. CONCLUSIONS The name alert process resulted in a simple manual process for identifying which patients have a higher name risk and allowed care providers to take preventative action to decrease potential risk of incorrect diagnostic testing, procedure, or medication administration.
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Affiliation(s)
- Samir Nazarali
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | | | - Karim F Damji
- Department of Ophthalmology and Visual Sciences, University of Alberta, Alberta, Canada.
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14
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Karanjia R, Berezovsky A, Sacai PY, Cavascan NN, Liu HY, Nazarali S, Moraes-Filho MN, Anderson K, Tran JS, Watanabe SE, Moraes MN, Sadun F, DeNegri AM, Barboni P, do Val Ferreira Ramos C, La Morgia C, Carelli V, Belfort R, Coupland SG, Salomao SR, Sadun AA. The Photopic Negative Response: An Objective Measure of Retinal Ganglion Cell Function in Patients With Leber's Hereditary Optic Neuropathy. Invest Ophthalmol Vis Sci 2017; 58:BIO300-BIO306. [PMID: 29049835 DOI: 10.1167/iovs.17-21773] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose The photopic negative response (PhNR) is a slow negative component of a flash photopic full-field ERG that has been shown to be specific for retinal ganglion cell (RGC) activity. Direct evaluation of RGC function is desirable in patients with Leber's hereditary optic neuropathy (LHON) in which the loss of central acuity can make it difficult to monitor patients with standard metrics. The purpose of this study was to evaluate the use of PhNR as an objective noninvasive clinical metric in LHON. Methods Full-field photopic ERG recordings were collected in subjects with the mt.11778G>A/ND4 LHON mutation using a red on blue stimulus. The PhNR was identified using a computer-based automated detection system, and data were manually examined to remove movement artifacts. Results The PhNR amplitude was compared between controls (n = 13), carriers (n = 17), and affected (n = 6). Mean PhNR amplitude decreased significantly across groups (P < 0.0001). Post hoc Tukey's test revealed a significant decrease in PhNR amplitude between carriers and controls (P < 0.05) and between carriers and affected (P < 0.01). Conclusions We are able to demonstrate that the PhNR amplitude is significantly decreased in patients affected by LHON compared to carriers in a well-described pedigree. Surprisingly, there was also a decrease in PhNR in carriers, suggesting potential subclinical RGC dysfunction in some carriers. This is important in patients affected with LHON who typically have a dense central scotoma. The PhNR may be a useful objective outcome measure for future clinical trials.
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Affiliation(s)
- Rustum Karanjia
- Doheny Eye Institute, Los Angeles, California, United States.,Doheny Eye Centers of UCLA, Department of Ophthalmology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, United States.,Ottawa Eye Institute, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Adriana Berezovsky
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Paula Yuri Sacai
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Nivea Nunes Cavascan
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Henry Yuheng Liu
- Ottawa Eye Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Samir Nazarali
- Ottawa Eye Institute, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Kirsten Anderson
- Doheny Eye Institute, Los Angeles, California, United States.,Doheny Eye Centers of UCLA, Department of Ophthalmology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, United States
| | | | - Sung EunSong Watanabe
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | - Federico Sadun
- Department of Ophthalmology, Ospedale Parodi Delfino, Colleferro, Rome
| | | | | | | | - Chiara La Morgia
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Institute of Neurological Sciences of Bologna, Bellaria Hospital, Bologna, Italy.,Unit of Neurology, Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Valerio Carelli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Institute of Neurological Sciences of Bologna, Bellaria Hospital, Bologna, Italy.,Unit of Neurology, Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Rubens Belfort
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Stuart Glenn Coupland
- Ottawa Eye Institute, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Solange Rios Salomao
- Departamento de Oftalmologia e Ciências Visuais, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Alfredo A Sadun
- Doheny Eye Institute, Los Angeles, California, United States.,Doheny Eye Centers of UCLA, Department of Ophthalmology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, United States
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15
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Nazarali S, Liu H, Syed M, Ter-Zakarian A, Karanjia R, Sadun A. Cabin pressure aboard commercial aircraft and non-arteritic ischemic optic neuropathy. Acta Ophthalmol 2017. [DOI: 10.1111/j.1755-3768.2017.0t038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S. Nazarali
- Faculty of Medicine; University of Ottawa; Ottawa ON Canada
| | - H. Liu
- Faculty of Medicine; University of Ottawa; Ottawa ON Canada
| | - M. Syed
- Faculty of Medicine; University of Ottawa; Ottawa ON Canada
| | | | - R. Karanjia
- Faculty of Medicine; University of Ottawa; Ottawa ON Canada
- Ottawa Eye Institute; University of Ottawa; Ottawa ON Canada
- Ophthalmology; Doheny Eye Institute; Los Angeles CA USA
- The Ottawa Hospital Research Institute; The Ottawa Hospital; Ottawa ON Canada
- UCLA; Doheny Eye Center UCLA; Los Angeles CA USA
| | - A.A. Sadun
- Ophthalmology; Doheny Eye Institute; Los Angeles CA USA
- UCLA; Doheny Eye Center UCLA; Los Angeles CA USA
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16
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Liu H, La Morgia C, Di Vito L, Nazarali S, Gauthier I, Syed M, Chahal J, Ammar M, Carbonelli M, De Negri A, Sadun A, Carelli V, Karanjia R. Differences in onset between eyes in patients with Leber's hereditary optic neuropathy (LHON). Acta Ophthalmol 2017. [DOI: 10.1111/j.1755-3768.2017.0t039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- H. Liu
- Medicine; University of Ottawa; Ottawa Canada
| | - C. La Morgia
- Ophthalmology; IRCCS-Institute of Neurological Sciences of Bologna; Bologna Italy
- Department of Biomedical and NeuroMotor Sciences, Ophthalmology; Bologna Italy
| | - L. Di Vito
- Ophthalmology; IRCCS-Institute of Neurological Sciences of Bologna; Bologna Italy
| | - S. Nazarali
- Medicine; University of Ottawa; Ottawa Canada
| | - I. Gauthier
- Medicine; University of Ottawa; Ottawa Canada
| | - M. Syed
- Medicine; University of Ottawa; Ottawa Canada
| | - J. Chahal
- Ophthalmology; Doheny Eye Institute; Los Angeles United States
| | - M. Ammar
- Ophthalmology; Doheny Eye Institute; Los Angeles United States
| | - M. Carbonelli
- Ophthalmology; IRCCS-Institute of Neurological Sciences of Bologna; Bologna Italy
- Ophthalmology; Studio Oculistico D'Azeglio; Bologna Italy
| | - A.M. De Negri
- Ophthalmology; S.Camillo-Forlanini Hospital; Rome Italy
| | - A. Sadun
- Ophthalmology; Doheny Eye Institute; Los Angeles United States
- Ophthalmology; David Geffen School of Medicine at UCLA; Los Angeles United States
| | - V. Carelli
- Ophthalmology; IRCCS-Institute of Neurological Sciences of Bologna; Bologna Italy
| | - R. Karanjia
- Medicine; University of Ottawa; Ottawa Canada
- Ophthalmology; IRCCS-Institute of Neurological Sciences of Bologna; Bologna Italy
- Ophthalmology; David Geffen School of Medicine at UCLA; Los Angeles United States
- Ophthalmology; Ottawa Hospital Research Institute; Ottawa Canada
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17
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Nazarali S, Kuzel P. Vitamin B Derivative (Nicotinamide)Appears to Reduce Skin Cancer Risk. Skin Therapy Lett 2017; 22:1-4. [PMID: 28888216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Nicotinamide, an amide form of vitamin B3, has shown the potential to treat a variety of dermatological conditions, including acne, rosacea, and atopic dermatitis. Recent studies have demonstrated the role of nicotinamide, in both topical and oral forms, as a chemopreventive agent against skin cancer. Its anti-carcinogenic role may be due to its ability to enhance DNA repair and prevent ultraviolet (UV)-induced immunosuppression, which is known to contribute to the progression of pre-malignant lesions. Furthermore, nicotinamide is a precursor of essential coenzymes for many important reactions in the body, including the production of nicotinamide adenine dinucleotide (NAD). NAD is a key coenzyme in the synthesis of adenosine triphosphate (ATP), which transports chemical energy within cells. Therefore, nicotinamide plays a significant role in supporting energy-dependent cellular processes, including DNA repair.
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Affiliation(s)
- S Nazarali
- University of Alberta, Faculty of Medicine and Dentistry, Edmonton, AB, Canada
| | - P Kuzel
- University of Alberta, Faculty of Medicine and Dentistry, Edmonton, AB, Canada
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18
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Nazarali S, Lapere S, Somani R, Badilla J. A rare case of perfluoro-n-octane in the orbit following vitreoretinal surgery. Can J Ophthalmol 2017; 52:e113-e115. [PMID: 28576221 DOI: 10.1016/j.jcjo.2017.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/18/2016] [Accepted: 01/04/2017] [Indexed: 11/19/2022]
Affiliation(s)
| | - Steven Lapere
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta.
| | - Rizwan Somani
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta
| | - Jaime Badilla
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Alta
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19
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Damji KF, Nazarali S, Giorgis A, Kiage D, Marco S, Philippin H, Daniel N, Amin S. STOP Glaucoma in Sub Saharan Africa: enhancing awareness, detection, management, and capacity for glaucoma care. Expert Review of Ophthalmology 2017. [DOI: 10.1080/17469899.2017.1295848] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Nazarali N, Altalibi M, Nazarali S, Major MP, Flores-Mir C, Major PW. Mandibular advancement appliances for the treatment of paediatric obstructive sleep apnea: a systematic review. Eur J Orthod 2015; 37:618-26. [PMID: 25681125 DOI: 10.1093/ejo/cju101] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 12/22/2014] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of mandibular advancement appliances (MAAs) for treatment of pediatric obstructive sleep apnea (OSA). METHODS Several electronic databases (The Cochrane Database, EMBASE, Healthstar, MEDLINE, PubMed) were systematically searched, as well as a limited grey literature (Google Scholar) and manual searches. A health sciences librarian helped with the selection of Medical Subject Headings (MeSH), key words, and combinations of key words with truncations to account for any differences in controlled terminology in the different databases. Only studies that evaluated the effects of MAAs in children with OSA were pursued. RESULTS Only 4 articles satisfied all inclusion criteria. Selected studies were retrospective except one study that was a quasi-randomized clinical trial. High risk of bias (Cochrane Risk of Bias assessment) was judged in all included studies. Based on the limited available evidence use of MAAs in a POSA population may result in improvements in Apnea Hypopnea Index (AHI) scores. However complete normalization of AHI scores was not demonstrated. Heterogeneity in study designs and collected information precluded meta-analysis. LIMITATIONS There are significant weaknesses in the existing evidence due primarily to absence of control groups, small sample sizes, lack of randomization and short-term results. Determination of AHI scores with MAAs still in the mouth should be avoided. CONCLUSIONS The current limited evidence may be suggestive that MAAs result in short-term improvements in AHI scores, but it is not possible to conclude that MMAs are effective to treat pediatric OSA. Medium- and long-term assessments are still required.
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Affiliation(s)
- Natasha Nazarali
- *Division of Orthodontics, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. and
| | - Mostafa Altalibi
- *Division of Orthodontics, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. and
| | - Samir Nazarali
- Health Sciences (Hons) Programme, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Michael P Major
- *Division of Orthodontics, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. and
| | - Carlos Flores-Mir
- *Division of Orthodontics, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. and
| | - Paul W Major
- *Division of Orthodontics, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. and
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21
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Lander J, Brady-Fryer B, Metcalfe J, Nazarali S, Muttitt S. Comparison of Ring Block, Dorsal Penile Nerve Block, and Topical Anesthesia for Neonatal Circumcision. A Randomized Controlled Trial. J Urol 1998. [DOI: 10.1016/s0022-5347(01)63145-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- J. Lander
- Faculties of Medicine and Nursing, University of Alberta and Divisions of Research Administration and Pharmacy, University of Alberta Hospitals, Edmonton, Alberta, Canada
| | - B. Brady-Fryer
- Faculties of Medicine and Nursing, University of Alberta and Divisions of Research Administration and Pharmacy, University of Alberta Hospitals, Edmonton, Alberta, Canada
| | - J.B. Metcalfe
- Faculties of Medicine and Nursing, University of Alberta and Divisions of Research Administration and Pharmacy, University of Alberta Hospitals, Edmonton, Alberta, Canada
| | - S. Nazarali
- Faculties of Medicine and Nursing, University of Alberta and Divisions of Research Administration and Pharmacy, University of Alberta Hospitals, Edmonton, Alberta, Canada
| | - S. Muttitt
- Faculties of Medicine and Nursing, University of Alberta and Divisions of Research Administration and Pharmacy, University of Alberta Hospitals, Edmonton, Alberta, Canada
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22
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Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial. JAMA 1997; 278:2157-62. [PMID: 9417009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CONTEXT Beliefs about the safety and effectiveness of current anesthetics have resulted in many newborns being circumcised without the benefit of anesthesia. OBJECTIVE To compare ring block, dorsal penile nerve block, a topical eutectic mixture of local anesthetics (EMLA), and topical placebo when used for neonatal circumcision. The placebo represented current practice, with no anesthetic for neonatal circumcision. DESIGN A randomized controlled trial. SETTING Antenatal units in 2 tertiary care hospitals in Edmonton, Alberta. PARTICIPANTS A consecutive sample of 52 healthy, full-term, male newborns, aged 1 to 3 days. INTERVENTIONS Physiological and behavioral monitoring occurred in a series of trials: baseline, drug application, preparation, circumcision, and postcircumcision. Surgical procedures defined the following 4 stages of the circumcision: cleansing, separation, clamp on, and clamp off. Methemoglobin level was assessed 6 hours after surgery. MAIN OUTCOME MEASURES Heart rate, cry, and methemoglobin level. RESULTS Newborns in the untreated placebo group exhibited homogeneous responses that consisted of sustained elevation of heart rate and high-pitched cry throughout the circumcision and following. Two newborns in the placebo group became ill following circumcision (choking and apnea). The 3 treatment groups all had significantly less crying and lower heart rates during and following circumcision compared with the untreated group. The ring block was equally effective through all stages of the circumcision, whereas the dorsal penile nerve block and EMLA were not effective during foreskin separation and incision. Methemoglobin levels were highest in the EMLA group, although no newborn required treatment. CONCLUSIONS The most effective anesthetic is the ring block; EMLA is the least effective. It is our recommendation that an anesthetic should be administered to newborns prior to undergoing circumcision.
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Affiliation(s)
- J Lander
- Faculty of Medicine, University of Alberta, Edmonton, Canada.
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23
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Abstract
Although EMLA is known to be an effective topical anesthetic, its rate of success is unknown. Indeed, researchers have suggested that EMLA may fail with young and apprehensive children. Therefore, the objectives of this study were to assess EMLA's rate of success as well as factors which predict success. A double-blind, placebo-controlled design was utilized. The sample included 258 children and adolescents aged 5-18 years who were having venipuncture or intravenous (i.v.) cannulation. After having their anxiety assessed, subjects were randomly assigned to have EMLA or placebo applied over the procedure site for 90 min. The visual analogue scale was used to assess pain caused by removal of the semi-permeable dressing and by the procedure. Other information that was collected included: duration of drug application, interval between drug removal and procedure, skin changes at bandage and drug sites and rated difficulty of the procedure. EMLA was successful 84% of the time for venipuncture and 51% of the time for i.v. cannulation. Factors which predicted success of EMLA included type of procedure, duration of drug application and anxiety. EMLA was less successful for i.v. cannulation compared to venipuncture even with duration of drug application controlled. Those who had a poor outcome were more anxious than those with a good outcome. Age of child was not a factor. Strategies for improving efficient use of EMLA were recommended.
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Affiliation(s)
- J Lander
- Clinical Sciences, University of Alberta, Edmonton, Alberta T6G 2G3 Canada
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24
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Affiliation(s)
- J Lander
- University of Alberta, Edmonton, Canada
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25
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Abstract
A child with respiratory distress was found to have been given an antibiotic which was reconstituted with methadone. A delay in standard emergency room management led to a delay in diagnosis and treatment.
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Affiliation(s)
- M O Gayle
- Pediatric Intensive Care Unit, University of Alberta Hospitals, Edmonton, Alberta
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