Background: Family caregivers of older adults frequently navigate the health system for their loved ones. As older adults experience more medical issues, the interactions between caregivers and the health system can be fraught with conflicts. Objective: To characterize the conflicts that caregivers of older adults experience with the health-care system. Methods: A cross-sectional national online survey with open-ended questions was conducted among family caregivers ascertaining experiences with the health-care system. Qualitative thematic analysis was completed using constant comparative analysis and review by a third author. Results: Over a 2-month period, 97 caregivers completed the survey. Common themes where caregivers experienced conflicts were Difficulty With Accessing/Communicating With Providers, Delivery of Emergency Care, Disjointed Transitional Care, Unaddressed Clinical Concerns, and Financial. Caregivers reported needing to act as patient advocates in the conflicts with the health-care system. Conclusion: Understanding the conflicts that family caregivers encounter with the health system provides potential targets for future interventions to combat the challenges faced by caregivers of older adults and ultimately improve delivery of geriatric care.
Among patients with glaucoma or ocular hypertension, ineffective self-instillation of eye drops was associated with an increased long-term risk of progression or advancement of treatment to incisional surgery. Purpose:The purpose of this study was to evaluate the association between the efficacy of self-instillation of eye drops and long-term glaucoma outcomes.Methods: In a previous study, video recordings of eye drop self-instillation by patients with glaucoma or ocular hypertension were graded as effective or ineffective depending on whether the patient successfully instilled at least 1 drop on the right ocular surface. Glaucomatous progression was then retrospectively defined as retinal nerve fiber layer thinning as measured by either optical coherence tomography, visual field progression, or need for incisional glaucoma surgery as determined by a glaucoma specialist unaware of patient performance in the eye drop instillation study. Subjects with at least 2 follow-up optical coherence tomography or visual field studies were included in the current study.Results: The original study enrolled 119 patients. Sufficient follow-up data were available for 101 patients. Eighty-eight patients (87.1%) were effective in eye drop instillation at baseline. Mean follow-up was 5.1 years, during which time 73 patients (72.3%) had progression or underwent incisional surgery in either eye. A significantly higher proportion of patients in the ineffective group met the criteria for progression or underwent incisional surgery (effective: 68.2%; ineffective: 100%; N = 101; P = 0.017, Fisher exact test). Kaplan-Meier survival analyses showed a significantly faster time to reaching an endpoint in the ineffective group (N = 101; P = 0.012, log-rank test). There was no difference in age, baseline intraocular pressure, or baseline retinal nerve fiber layer thickness between the groups. Conclusion:Ineffective self-installation of eye drops was associated with an increased risk of glaucoma progression or treatment advancement to incisional surgery.
Background/Purpose: There is limited research regarding the consequences of treating lactating mothers with intravitreal anti–vascular endothelial growth factor (VEGF) agents. Balancing the need for vision-saving treatment, the benefits of breastfeeding, and the concern for affecting the newborn can present a conflict for both mothers and ophthalmologists. This review summarizes the state of the literature regarding the use of intravitreal anti-VEGF agents during breastfeeding along with details about their pharmacology. Results: Bevacizumab and aflibercept have Fc domains subjecting them to FcRn recycling and extending their half-life compared with ranibizumab which is an antibody fragment and lacks the Fc domain. Case reports and small studies have shown that ranibizumab has the lowest serum concentration after intravitreal injection and the least effect on plasma-free VEGF concentrations and breastmilk VEGF levels. Conclusion: Clinical and pharmacologic data suggest that ranibizumab has less systemic circulation and effect on maternal serum and breastmilk VEGF levels when compared to bevacizumab and aflibercept. However, there is significant need for further research on the degree and duration to which intravitreal agents circulate systemically, what fraction is transferred into breastmilk and is absorbed, and whether this results in any functional adverse effects to the infant. Other factors to consider in the medical decision-making of lactating mothers necessitating intravitreal anti-VEGF treatment include the gestational and post-natal age of the child and whether it is feasible to avoid breastfeeding for the half-life duration of the intravitreal agent rather than ceasing breastfeeding altogether.
Long-distance retrograde degeneration of the retino-geniculo-cortical pathway has been described in humans and animal models following injury to the brain. In this study, we used optical coherence tomography (OCT) to measure the severity and timing of retrograde degeneration after post-chiasmal visual pathway lesions in patients with homonymous hemianopia. We performed a retrospective study of 69 patients with homonymous hemianopia and analyzed high quality OCT macular ganglion cell complex (GCC) and retinal nerve fiber layer (RNFL). Patients with lesions involving the optic tract and thalamus were included in the anterior group, while patients with lesions of the occipital lobe were included in the posterior group. Statistical significance was determined using Mann-Whitney U test and Wilcoxon test. We found that in patients with homonymous hemianopia, those with anterior lesion exhibited earlier and more severe thinning compared with the posterior group. In fact, thinning can occur within 2 months after insult in the anterior group. Within 6 months of onset, the anterior group exhibited about 5 times more hemi-macular GCC thinning than those with acquired lesions of the posterior visual pathway (P = 0.0023). Although the severity of hemi-macular GCC thinning was different, the majority of hemi-macular thinning occurred within the first 6 months in both groups. Beyond 2 years, thinning in those with acquired anterior and posterior lesions was minimal, except in a small number of patients with multiple insults to the occipital lobe. In conclusion, using OCT, we measured the severity and rate of long-distance, retrograde degeneration in patients with homonymous hemianopia. Homonymous hemi-macular thinning after optic tract and thalamic injury was more severe and occurred earlier compared with thinning after occipital lobe insult via trans-synaptic degeneration. The presence of severe hemi-macular degeneration on OCT provides objective evidence that localizes the lesion to the post-chiasmal anterior visual pathway.
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