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Purpose To investigate patient-level factors associated with first-line glaucoma therapy with laser trabeculoplasty (LT) versus topical medication. Design Population-based study. Participants All patients 66 years of age and older in Ontario, Canada, receiving first-ever therapy for glaucoma with either LT or topical medication between April 1, 2007, and March 31, 2019. Methods Linked health care databases were used to identify patients receiving first-line glaucoma therapy and to ascertain patient-level factors potentially associated with receipt of LT versus medication. Multivariate logistic regression analyses were undertaken. Main Outcome Measures Factors associated with receiving LT versus medications were evaluated using adjusted odds ratios (ORs) for age, gender, previous cataract surgery, previous corneal transplantation, previous retina surgery, level of systemic comorbidity, socioeconomic status (SES), and rural versus urban residence. Results In total, 194 759 patients were included. Older patients were less likely to be treated with LT versus medication (≥81 years of age vs. 66–70 years of age: OR, 0.49; 95% confidence interval [CI], 0.48–0.50), whereas women were more likely than men to receive LT (OR, 1.42; 95% CI, 1.39–1.45). Previous ocular surgeries were associated with decreased probability of treatment with LT, including cataract surgery (OR, 0.31; 95% CI, 0.30–0.32), corneal transplantation (OR, 0.39; 95% CI, 0.31–0.49), and retina surgery (OR, 0.46; 95% CI, 0.41–0.51). Patients with high comorbidity were less likely to receive LT (highest vs. lowest level of comorbidity: OR, 0.94; 95% CI, 0.91–0.97). Laser trabeculoplasty use was less likely among patients at higher levels of SES (highest vs. lowest level: OR, 0.86; 95% CI, 0.84–0.89) and from a rural residence (versus urban: OR, 0.92; 95% CI, 0.90–0.95). Increasing utilization of LT over time was noted (for each additional calendar year: OR, 1.05 per year; 95% CI, 1.05–1.05 per year). Conclusions Our results identified patient characteristics associated with use of LT as primary therapy for glaucoma, including factors related to patient demographics, ocular history, and comorbidity. Many of these associations are unexpected based on efficacy data or evidence-based guidelines. These results are topical considering growing evidence supporting use of first-line LT.

Ciliopathies are a class of genetic diseases resulting in cilia dysfunction in multiple organ systems, including the olfactory system. Currently, there are no available curative treatments for olfactory dysfunction and other symptoms in ciliopathies. The loss or shortening of olfactory cilia, as seen in multiple mouse models of the ciliopathy Bardet-Biedl syndrome (BBS), results in olfactory dysfunction. However, the underlying mechanism of the olfactory cilia reduction is unknown, thus limiting the development of therapeutic approaches for BBS and other ciliopathies. Here, we demonstrated that phosphatidylinositol 4,5-bisphosphate [PI(4,5)P2], a phosphoinositide typically excluded from olfactory cilia, aberrantly redistributed into the residual cilia of BBS mouse models, which caused F-actin ciliary infiltration. Importantly, PI(4,5)P2 and F-actin were necessary for olfactory cilia shortening. Using a gene therapeutic approach, the hydrolyzation of PI(4,5)P2 by overexpression of inositol polyphosphate-5-phosphatase E (INPP5E) restored cilia length and rescued odor detection and odor perception in BBS. Together, our data indicate that PI(4,5)P2/F-actin-dependent cilia disassembly is a common mechanism contributing to the loss of olfactory cilia in BBS and provide valuable pan-therapeutic intervention targets for the treatment of ciliopathies.

To explore the utility of the Catquest 9SF visual function (VF) questionnaire along with visual acuity (VA) for determining appropriateness and priority for cataract surgery. To evaluate the feasibility of administering the Catquest-9SF in a clinical setting using web-based electronic data capture and interpretation.Prospective multicentred interventional observational study.Subjects undergoing sequential cataract surgery in both eyes at 4 sites in Ontario.We recorded best-corrected VA (BCVA) and VA with current correction (CCVA) in each eye and both eyes (OU) and Catquest-9SF responses on a tablet before and after cataract surgery. Linear regression models were employed to test for associations between VA and visual function (VF).Preoperative BCVA and CCVA in the worse eye were significant predictors of change in VF (p = 0.006 and p = 0.008, respectively); subjects with worse VA had a greater improvement in VF after surgery. There was a significant association between improvement in VF and improvement in CCVA OU (p = 0.001). Fourteen of 151 subjects (9%) had no improvement or worse VF scores after surgery. Within this group, 10 of 14 subjects had a preoperative score ≤-3, which is suggestive of minimal visual disability. Within this subset, 4 of 14 subjects (2.6%) had a preoperative BCVA of 20/30 or better in their worse eye.For patient groups with equal VA, the Catquest-9SF score can help determine priority for surgery. Web-based data capture and interpretation allow for efficient virtual assessments of VF. A BCVA in the worse eye of 20/30 or better combined with a Catquest-9SF score-3 can be used as a guideline for lowest priority.

An important potential unintended consequence of the growth of surgical subspecialization is the narrowing of surgical practice among comprehensive ophthalmologists. We investigated trends in the narrowing of surgical practice and the exclusive provision of cataract surgery.Population-based, retrospective study.All ophthalmologists and all ophthalmologic surgical patients in Ontario from 1994 to 2016.We linked several health care databases to evaluate the proportion of ophthalmologists who exclusively provided cataract surgery (and no other ophthalmologic surgery) and the proportion who provided other types of ophthalmologic surgical care. To further investigate surgical focus, we evaluated the proportion of surgical cases within each surgical area for each ophthalmologist.Between 1994 and 2016, the proportion of ophthalmologists who exclusively provided cataract surgery rose from 10.0% to 34.9% (p0.0001). In contrast, the proportions of ophthalmologists providing other types of subspecialized surgical care were stable over the study period. Cataract surgeons showed high degrees of focus with a median percentage of surgical cases approaching 100% in all years. Among exclusive cataract surgeons, the median annual cataract case volume increased from 138 (interquartile range: 87-214) to 529 (interquartile range: 346-643) between 1994 and 2009 (p0.0001) and then plateaued.Between 1994 and 2016, exclusive cataract surgical focus among ophthalmologists in Ontario rose dramatically from 1 in 10 to 1 in 3 surgeons. This evolution was similar among recent graduates and established ophthalmologists. Our data may have important implications for policies regarding surgeon human resources as well as residency and fellowship training programs.

To evaluate the long-term evolution of first-line glaucoma therapy (FLGT) initiated by ophthalmologists and optometrists.Retrospective population-based study using validated provincial health care databases.194,759 Ontario residents, 66 years of age or older, who received FLGT between 2007 and 2018.A total of 194,759 individuals from 12 annual cohorts were enrolled, and rates of first-line medical treatment (prostaglandin analogue [PGA], beta-blocker, alpha-2-agonist, and carbonic anhydrase inhibitor) and laser trabeculoplasty (LT) were calculated. Provider (ophthalmologist or optometrist) rates also were assessed.Across the entire study period, of the 194,759 enrolled individuals who received FLGT, 60.2% initially received medical treatment and 39.8% underwent LT. Approximately 94.6% were treated by ophthalmologists. PGA therapy was the most common therapy prior to 2010, whereupon LT became the most common FLGT. By 2015, LT exceeded the total of all medications as FLGT. The annual rate of initial medication prescriptions by optometrists rose to 101.4 per 100,000 population between 2011 and 2018. In 2018, PGA and non-PGA prescription rates by ophthalmologists were 2.6 and 5.0 times higher, respectively, than prescription rates by optometrists.LT therapy has become the most common FLGT for Ontario residents 66 years of age or older. PGAs remain the most frequently prescribed glaucoma medication. While ophthalmologists continue to provide the majority of FLGT, optometrists now provide a small but growing fraction of FLGT following the introduction of glaucoma medication prescribing privileges.

Background Jurisdictions worldwide ramped down ophthalmic surgeries to mitigate the effects of COVID-19, creating a global surgical backlog. We sought to predict the long-term impact of COVID-19 on the timely delivery of non-emergent ophthalmology sub-specialty surgical care in Ontario. Methods This is a microsimulation modelling study. We used provincial population-based administrative data from the Wait Time Information System database in Ontario for January 2019 to May 2021 and facility-level data for March 2018 to May 2021 to estimate the backlog size and wait times associated with the COVID-19 pandemic. For the postpandemic recovery phase, we estimated the resources required to clear the backlog of patients accumulated on the wait-list during the pandemic. Outcomes were accrued over a time horizon of 3 years. Results A total of 56 923 patients were on the wait-list in the province of Ontario awaiting non-emergency ophthalmic surgery as of Mar. 15, 2020. The number of non-emergency surgeries performed in the province decreased by 97% in May 2020 and by 80% in May 2021 compared with the same months in 2019. By 2 years and 3 years since the start of the pandemic, the overall estimated number of patients awaiting surgery grew by 129% and 150%, respectively. The estimated mean wait time for patients for all subspecialty surgeries increased to 282 (standard deviation [SD] 91) days in March 2023 compared with 94 (SD 97) days in 2019. The provincial monthly additional resources required to clear the backlog by March 2023 was estimated to be a 34% escalation from the prepandemic volumes (4626 additional surgeries). Interpretation The estimates from this microsimulation modelling study suggest that the magnitude of the ophthalmic surgical backlog from the COVID-19 pandemic has important implications for the recovery phase. This model can be adapted to other jurisdictions to assist with recovery planning for vision-saving surgeries.

To determine the feasibility and acceptability of connecting optometrists to ophthalmologists on an eConsult service.Descriptive analysis of utilization data and an anonymous survey.All eConsult cases sent by optometrists between March 2019 and February 2020 (utilization data); optometrists and ophthalmologists participating in the eConsult Vision Pilot Project (survey).Utilization data for the study period were collected automatically and underwent descriptive analysis. Participating optometrists and ophthalmologists received an email invitation to a survey assessing the project.Thirteen optometrists from 5 clinics in the southeast region and 7 ophthalmologists were recruited to participate in the pilot project. Optometrists sent 109 eConsults in a 13-month period, representing 33% of all cases submitted to ophthalmology through the eConsult service provincially (March 2019-March 2020). Sixty-eight percent of respondents to an anonymous online survey valued the recruitment and engagement of eye care professionals from the same health region. The influence of the eConsult service was reported to have a "somewhat positive" (27%) to "very positive" (50%) influence on the relationship between the two professional groups.The eConsult Vision Pilot Project fills a gap in service and provides an opportunity for patients to get access to specialty advice. We demonstrated that allowing optometrists to solicit specialist advice from ophthalmologists was acceptable and feasible.

Background In Canada, First Nations populations experience a higher incidence of diabetes and diabetes-related complications than other people. Given the paucity of information on use of preventive eye examinations and the need for interventional care for severe retinopathy among First Nations people, we carried out a population-based study to compare rates of eye examinations and interventional therapies to treat vision-threatening stages of diabetic retinopathy among First Nations people and other people with diabetes in Ontario. Methods In collaboration with the Chiefs of Ontario, we carried out a population-based study to identify cohorts of First Nations people and other people with diabetes in Ontario from 1995/96 to 2014/15. We used linked health administrative databases to evaluate rates of eye examination (2005/06-2014/15) and severe diabetic retinopathy treatment and compared them between the 2 populations, and between First Nations people living in and outside of First Nations communities. Results We identified 23 013 First Nations people and 1 364 222 other people diagnosed with diabetes from 1995/96 to 2014/15, of whom 49.8% (95% confidence interval [CI] 48.9%-50.7%) and 53.8% (95% CI 53.7%-54.0%), respectively, received an eye examination in 2014/15. Eye examination rates were similar for First Nations people regardless of whether they lived in or outside a First Nations community. First Nations people developed severe diabetic retinopathy at a faster rate than other people (hazard ratio 1.19, 95% CI 1.02-1.38). The gap between First Nations people and other people in the proportion requiring therapy for severe diabetic retinopathy was especially prominent among younger people. There were no significant differences in rates of diabetic retinopathy treatment in First Nations people stratified by place of residence. Interpretation Eye examination rates remain suboptimal among people with diabetes in Ontario and were lower among First Nations people. This is particularly concerning in light of our other findings showing an increased risk of requiring treatment for advanced diabetic retinopathy and the accelerated rate of diabetic retinopathy progression among First Nations people with diabetes.

BACKGROUND: Across Canada, graduates from several medical and surgical specialties have recently had difficulty securing practice opportunities, especially in specialties dependent on limited resources such as ophthalmology. We aimed to investigate whether resource constraints in the health care system have a greater impact on the volume of cataract surgery performed by recent graduates than on established physicians. METHODS: We used population-based administrative data from Ontario for the period Jan. 1, 1994, to June 30, 2013, to compare health services provided by recent graduates and established ophthalmologists. The primary outcome was volume of cataract surgery, a resource-intensive service for which volume is controlled by the province. RESULTS: When cataract surgery volume in Ontario entered a period of government-mandated zero growth in 2007, the mean number of cataract operations performed by recent graduates dropped significantly (−46.37 operations/quarter, 95% confidence interval [CI] −62.73 to −30.00 operations/quarter), whereas the mean rate for established ophthalmologists remained stable (+5.89 operations/quarter, 95% CI 95% CI −1.47 to +13.24 operations/quarter). Decreases in service provision among recent graduates did not occur for services without volume control. The proportion of recent graduates providing exclusively cataract surgery increased over the study period, and recent graduates in this group were 5.24 times (95% CI 2.15 to 12.76 times) more likely to fall within the lowest quartile for cataract surgical volume during the period of zero growth in provincial cataract volume (2007–2013) than in the preceding period (1996–2006). INTERPRETATION: Recent ophthalmology graduates performed many fewer cataract surgery procedures after volume controls were implemented in Ontario. Integrated initiatives involving multiple stakeholders are needed to address the issues facing recently graduated physicians in Canada.

Objective To report on patterns of optometry prescribing and adherence to prescribing regulations at a tertiary care ophthalmology centre. Design Prospective cohort study. Participants All new referrals from optometrists and other health care professionals to the emergency eye care service (n = 1965) between July 2011 and June 2012, as well as optometry referrals to 2 subspecialty services (glaucoma [n = 71] and cornea [n = 212]). Methods In our primary analysis, the frequency of prescribing and classes of medications prescribed were reported and compared amongst various referral sources to the emergency eye care service. As a secondary analysis, we reported frequency of prescribing in optometry referrals to 2 subspecialty clinics. Adherence to prescribing guidelines was reported for all optometry referrals. Results Of 296 referrals from optometrists to the emergency eye care service, 20 (6.8%) had received a prescription medication; this was significantly less compared to emergency and family physicians ( p Conclusions After the introduction of prescribing privileges, optometrists prescribe a variety of medications in their practices. Current prescribing guidelines are not always followed in practice, suggesting that continued study and collaboration is necessary to create an optimal model of interdisciplinary care that provides access to the highest quality of care.

PURPOSE OF REVIEW The development of vascular endothelial growth factor (VEGF) inhibitors has revolutionized the treatment of retinal diseases. However, VEGF functions in many physiological and pathological processes. Consequently, inhibition of this signalling molecule carries the potential to cause serious adverse events. RECENT FINDINGS Numerous clinical trials, meta-analyses and population-based studies have provided data regarding the safety of intravitreal VEGF inhibitor injections. Although individual trials and some meta-analyses have not found significant risks, other meta-analyses have suggested possible risks, especially in patients with multiple baseline risk factors. Population-based studies have not found increased risks of vascular adverse events. SUMMARY Overall, results across studies with differing methodologies provide some reassurance that the widespread use of intravitreal injections of VEGF inhibitors has not resulted in significant increases in the risks of adverse events. However, ongoing vigilance and further study remain priorities, with a particular need for greater evaluation of high-risk subgroups. Rapidly evolving treatment options for ocular diseases including new drugs and new delivery technologies will require ongoing evaluations of safety.

To compare retinal nerve fibre layer (RNFL) thickness measurements acquired using spectral domain (SD) and time domain (TD) optical coherence tomography (OCT) systems.Prospective clinical study.Twenty eyes of 20 healthy volunteers.All patients underwent 3 sets of circular OCT scans around the optic disc using both a TD OCT system, and a new SD OCT system. RNFL thickness measures within each of 4 quadrants, as well as overall mean RNFL thickness, were compared. Bland-Altman plots were also used to assess agreement.Using the RTVue-100, RNFL measurements in the superior quadrant were, on average, 20 microm greater than those obtained from the Stratus (151.8 microm vs 131.7 microm, p0.0001). RNFL measures within other quadrants and overall mean RNFL thickness were not significantly different between systems. Bland-Altman plots indicated large differences between Stratus and RTVue-100 for all variables, with 95% limits of agreement spanning clinically important ranges of50 microm for all RNFL variables.Significant differences exist between RNFL measurements obtained from the TD and SD OCT systems used in this study. These related, but distinct, technologies are not interchangeable. Further studies will be required to allow for appropriate clinical use of new SD OCT systems.

RESUME Background: New laser and surgical techniques have had a significant effect on glaucoma therapy. A precise understanding of how these developments are affecting overall glaucoma management is fundamental to health services planning. The objective of this study was to synthesize Canadian national and provincial data regarding glaucoma laser and surgical procedure rates from 1992 to 2004. Methods: Canadian provincial health insurance databases, which cover virtually all surgical procedures provided domestically to Canadians, were accessed to ascertain yearly total glaucoma procedure numbers. To estimate the number of individuals with glaucoma, an age-stratified glaucoma prevalence model was applied to population census data. Results: Laser trabeculoplasty rates dramatically increased between 2001 and 2004 with the national Canadian rate more than doubling. However, this increase varied widely across regions, ranging from 0% to 530%. Trabeculectomy surgery rates slowly increased from 1992 to 1995, then declined by 29% nationally between 1995 and 2004. Implantation rates of glaucoma drainage devices increased 12-fold nationally between 1992 and 2004; by 2004 this procedure accounted for 10% of incisional glaucoma surgical procedures in Canada. Interpretation: In Canada, laser trabeculoplasty rates have risen significantly over recent years. Trabeculectomy rates have recently declined, and implantation of glaucoma drainage devices is playing an increasingly important role in glaucoma management in this country. Contexte : Les nouvelles techniques au laser et chirurgicales ont eu d'importants effets sur la therapie du glaucome. Pour la planification des services de sante, il est essentiel de comprendre precisement comment ces developpements affectent dans l'ensemble la gestion de la maladie. Cette etude a pour objet de faire la synthese des donnees canadiennes, nationales et provinciales, sur les taux des procedures au laser et chirurgicales de 1992 a 2004. Methodes : Les bases de donnees provinciales d'assurance-maladie, qui couvrent virtuellement toutes les procedures chirurgicales pratiquees au Canada, ont ete evaluees pour confirmer la somme annuelle des interventions pour le glaucome. Pour estimer le nombre de personnes atteintes du glaucome, on a applique aux donnees du recensement un modele de prevalence du glaucome stratifie par groupes d'âges. Resultats : Les taux de trabeculoplastie au laser ont augmente de facon spectaculaire entre 2001 et 2004, le taux a l'echelle nationale ayant plus que double. Toutefois, la hausse a varie considerablement entre les regions, s'etalant de 0 % a 530 %. Les taux de trabeculectomie ont augmente lentement de 1992 a 1995, puis, ils ont baisse de 29 % a l'echelle du pays entre 1995 et 2004. Les taux d'implantation des appareils de drainage pour le glaucome se sont multiplies par 12 au pays entre 1992 et 2004; en 2004, cette procedure comptait 10 % des chirurgies incisionnelles pour le glaucome au Canada. Interpretation : Au Canada, les taux de trabeculoplastie au laser ont augmente de facon signi- ficative ces dernieres annees. Les taux de trabeculectomie ont diminue et l'implantation d'ap- pareils de drainage du glaucome joue un role de plus en plus important dans la gestion du glaucome au pays.

To investigate the immediate and longer-term effect of ocular massage on intraocular pressure (IOP) after Ahmed valve insertion.A retrospective chart review was undertaken of the effects of ocular massage in patients with inadequately controlled IOP after Ahmed valve surgery. During a 20-month period between January 2004 and August 2005, 20 of 52 patients underwent a course of ocular massage. They were compared on IOP and the number of ocular hypotensive medications required with the 32 patients whose IOP was satisfactory after surgery.The mean time to initiation of massage was 29 days (range 8-141 days), and the mean total duration of massage was 127 days (range 18-273 days). At the initiation of massage, the mean IOP was 19.2 mm Hg, significantly higher than at any other postoperative visit (p = 0.001-0.02). Immediately following massage, the IOP was reduced by 40% to 11.6 mm Hg (p0.001). When compared with those patients not requiring massage, there were no differences in IOP at any subsequent visit (p = 0.1-0.9). There were also no differences in final absolute IOP reduction (11.1 [SD 5.9] for the massage group vs. 10.64 [SD 8.0] mm Hg for those not requiring massage, p = 0.8), percentage IOP reduction (46% vs. 40%, p = 0.5), or number of glaucoma medications required at 1 year (2.9 vs. 2.6, p = 0.4), respectively. The massage group was receiving more medications than the group not requiring massage at 3 months (3.1 vs. 1.9) and 6 months (3.5 vs. 2.2). No complications arose due to ocular massage.This is the first report to document that ocular massage is a safe and effective manoeuvre for the management of elevated IOP after Ahmed valve insertion. Massage resulted in an immediate reduction of IOP, and, despite initial higher postoperative IOP in the massage group, there were no differences between groups at 1 year with regard to IOP reduction or requirements for medications.

In this article, we review the laparoscopic experience of general surgery and colorectal residency training programs in the United States during the past 5 and 12 years, respectively. The purpose of this study was to determine whether an adequate experience was being provided, and at what level of training, to safely and effectively perform advanced laparoscopy.General Surgery Operative Reports from the training years 2000 to 2004 were obtained from the Accreditation Council for Graduate Medical Education. Similarly, colorectal operative performance logs from the training years 1994 to 2005 were obtained from the American Board of Colon and Rectal Surgery.From 2000 to 2004, basic and advanced laparoscopic cases (as designated by the Accreditation Council for Graduate Medical Education) have increased from 10.1 to 12.2 percent and 2.1 to 3.7 percent, respectively. Within this period, the number of laparoscopic colon cases/resident/career has increased from 1.8 to 4.6. The percentage of cases performed laparoscopically increased from 3.9 to 22.5 percent from 1993-1994 to 2004-2005 training years. From 1993 to 2001, the average number of laparoscopic cases/resident increased from 6.3 to 16.1. In 2004, the average number of cases/resident increased to 45.3. Of this number, 30 were colon, 9.4 were rectal, and the remaining 5.9 were miscellaneous colorectal procedures.Learning curves for laparoscopic colectomy are reported in the range of 20 to 60 cases. Based on the most recent data reviewed, colon and rectal resident experience is tending toward this threshold. Recent general surgery graduates may be lacking the appropriate volume to reach proficiency in laparoscopic colorectal surgery.

Objective To compare the peripapillary retinal nerve fibre layer (RNFL) thickness in nonexudative versus exudative age-related macular degeneration (wet AMD) eyes treated chronically with intravitreal injections of anti–vascular endothelial growth factor (anti-VEGF). Design Cross-sectional study. Participants Twenty-nine patients with unilateral wet AMD with at least 12 prior intravitreal anti-VEGF injections and 2 years of therapy were analyzed. The fellow eye with nonexudative (dry) AMD with no prior treatment served as the control group. Methods All patients were prospectively enrolled from a single academic subspecialist practice. Bilateral spectral-domain optical coherence tomography (Cirrus SD-OCT; Carl Zeiss Meditec, Dublin, Calif.) of the peripapillary RNFL was performed on all pairs of eyes. Optic nerve head (ONH) parameters were also computed. The primary outcome was mean difference in peripapillary RNFL thickness compared between the treated and the nontreated eyes. Results Mean RNFL in the chronically treated eyes (95.0 [95% CI 89.8–100.2] μm) was significantly greater than the nontreated fellow eyes (89.9 [95% CI 85.5–94.3] μm) ( p = 0.01). Quadrantic optic nerve analysis revealed the temporal RNFL to be greater in the treated group ( p = 0.02), whereas all other locations were similar. No significant differences were found between the 2 groups in any ONH parameters. Conclusions This study demonstrated no deleterious optic nerve RNFL thinning in a series of wet AMD eyes with long-term repetitive exposure to intravitreal anti-VEGF injections. Furthermore, we observed that those with wet AMD have a relatively thickened temporal peripapillary RNFL layer, which is an important association for all observers of optic nerve disease.

BACKGROUND: Because proximal colorectal cancers have a tendency to present at a more advanced stage and thus have a poorer prognosis, it is important to understand the factors associated with the development of proximal colorectal cancer. We hypothesized that older age, female gender, and the presence of comorbid illness would be associated with proximal cancers. METHODS: Incident cases of colorectal cancer (n=9,550) occurring in 1994 were identified from Florida's population-based statewide cancer registry. We categorized colorectal cancers as either proximal (cecum, ascending colon, and transverse colon) or distal (descending colon, sigmoid colon, rectosigmoid, and rectum). Multiple logistic regression analysis was used to determine the multivariable relationship between clinical characteristics and the odds of a proximal-occurring lesion. RESULTS: Four characteristics emerged as independent predictors of a proximal lesion. Each year of increasing age was associated with a 2.2 percent increase in the odds of a proximal lesion, whereas female gender was associated with a 38 percent increase in the odds of a proximal lesion. The presence of a comorbid condition was associated with a 28 percent greater odds of a proximal lesion, and, finally, black, non-Hispanic race was associated with a 24 percent greater odds of a proximal lesion. CONCLUSIONS: We found that increasing age, female gender, black, non-Hispanic race, and the presence of comorbid illnesses were factors associated with a greater likelihood of developing colorectal cancer in a proximal location. Further studies will be required to confirm these findings and to establish the mechanism by which comorbidity influences the site of colorectal cancer development.

Background: Routine eye examinations for healthy adults aged 20–64 years were delisted from the Ontario Health Insurance Plan in 2004, but they continue to be insured for people with diabetes regardless of age. We sought to assess whether the delisting of routine eye examinations for healthy adults had the unintended consequence of decreasing retinopathy screening for adults with diabetes. Methods: We used administrative data to calculate eye examinations for people with diabetes ages 40–64 years and 65 years and older in each 2-year period from 1998 to 2010. We examined differences by sex, income, rurality and type of health care provider. We used segmented linear regression to assess the change in trend before and after 2004. Results: For people with diabetes aged 65 years and older, eye examinations rose gradually from 1998 to 2010, with no substantial change between 2004 and 2006. For people with diabetes aged 40–65 years, there was an 8.7% (95% confidence interval [CI] 6.3%–11.1%) decrease in eye examinations between 2004 and 2006. Results were similar for all population subgroups. Ophthalmologic examinations decreased steadily for both age groups during the study period, and there was a decline in optometry examinations for people ages 40–65 years after 2004. Interpretation: The delisting of routine eye examinations for healthy adults in Ontario had the unintended consequence of reducing publicly funded retinopathy screening for people with diabetes. More research is needed to understand whether patients are being charged for an insured service or to what degree misunderstanding has prevented patients from seeking care.

The debate surrounding the use of new drugs for age related macular degeneration has sparked worldwide controversy. Robert Campbell and colleagues highlight how differing funding systems have affected use of these drugs in different countries and suggest how to deal with similar challenges in future

The vertical expandable prosthetic titanium rib (VEPTR) was originally designed to treat chest and spine deformities in young children. However, older children with complex spinal deformities may also benefit from placement of a VEPTR when vertebral column resections are deemed too risky neurologically. We report: (1) the changes in Cobb angle, T1 angle, and head tilt; and (2) the occurrence of complications in children older than 10 years of age treated with VEPTR. From a database of 214 patients treated in a Food and Drug Administration Investigational Device Exemption study of VEPTR, we identified 10 patients with assorted diagnoses who underwent surgery after age 10 and had a minimum of 24-month followup (mean, 39.6 months; range, 24–75 months). No patient sustained neurologic injury. Patients underwent an average of five lengthenings. The mean preoperative Cobb angle was 64.7° and improved to 48.4°. Head shift improved an average of 3.8 cm. Two device-related complications occurred (both in the same patient). Four patients have since undergone definitive spinal fusion. For a select group of patients 10 years of age or older, the VEPTR offers a reasonable alternative to potentially risky vertebral column resections for correcting deformities in selected patients. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background The success with which primary care physicians are able to meet American Diabetes Association (ADA) clinical goals is unknown. Methods Charts of 218 randomly sampled type 2 diabetic patients were abstracted to assess the attainment of six ADA treatment goals and receipt of four ADA-recommended health services. Results The mean number of ADA goals attained was 4.9 (SD, 1.6). Only one patient had attained all 10 goals. Most patients had attained ADA goals for triglycerides, diastolic blood pressure, hemoglobin A1c, low-density lipoprotein cholesterol, and diabetic education. Most patients had not received an annual eye examination or urine microalbuminuria screening, most were not taking daily aspirin, and most had not attained treatment goals for high-density lipoprotein or systolic blood pressure. Conclusion ADA treatment goals may be quite difficult to attain in the primary care setting. Further studies are needed to understand the barriers to diabetes control.

Background: Increasing supplies of dermatologists and family physicians have been associated with earlier detection of malignant melanoma. We investigated whether physician supply was similarly related to incidence and mortality rates of malignant melanoma. Methods: Using the state tumor registry, we determined melanoma incidence and mortality rates for the years 1993 to 1995 for each Florida county. We measured physician supply for each Florida county using data from the 1994 American Medical Association Physician Masterfile. Multiple linear regression analysis was used to determine relationships between physician supply and melanoma incidence and mortality rates, controlling for other county-level characteristics. Results: Among male patients, an increasing supply of family physicians was associated with higher melanoma incidence and lower melanoma mortality. Increasing supplies of dermatologists were associated with lower overall melanoma mortality rates, and increasing supplies of general internists were associated with higher overall melanoma mortality. Conclusion: We found that melanoma incidence and mortality rates varied substantially among Florida's 67 counties, and that differences in physician supply explained some of this variability. Further study is needed to confirm these findings and to elucidate possible mechanisms that would account for these associations.

Stylar canal cells of Lilium longiflorum were labeled before pollination with 5-(3)H-uridine or 5-(3)H-orotic acid dissolved in water, or the stylar canal was filled 6 hr after pollination with stigmatic exudate supplemented with 5-(3)H-uridine, 2-(14)C-uridine or H3 (32)PO4. Nucleic acids extracted from compatible and incompatible pollen tubes grown in these styles were separated by methylated albumin kieselguhr column chromatography. Label occurred in all portions of the RNA profile, but no label appeared in the DNA peak. Using 5-(3)H-uridine, pollen tubes of different genotype had different labeling patterns.

In Reply.— Soller and Stander, on the basis of an unpublished analysis of our data, raise the issue of two potential biases: protopathic and product confusion bias. The existence of protopathic bias, or bias caused by the disease preceding the risk factor, depends on how the onset of RS is defined. We defined the onset of RS as the first day of severe vomiting. In the second year of our study, aspirin was classified as a positive exposure for cases only if ingested before the first day of severe vomiting. Thus, this bias regarding the temporal association of aspirin and RS should not be a problem if the onset of vomiting properly identifies the onset of RS. Even if clinical RS can precede severe vomiting, a retrospective determination of the exact onset on the basis of a complex of nonspecific symptoms, eg, headache, fever, or sore throat, symptoms all compatible

Ninety-seven Reye's syndrome (RS) cases in Ohio children with onsets from December 1978 through March 1980 were studied for medication use during their pre-RS illness. They were matched with 156 control subjects for age, race, sex, geographic location, time, and type of illness. Only the use of aspirin was reported by significantly more cases (97%, 94/97) than controls (71%, 110/156) during the pre-RS matched illness. Using a multiple logistic model to control for the presence of fever, headache, and sore throat statistically, the difference in aspirin use remained significant. Conversely, fewer cases (16%) took medications containing acetaminophen than controls (33%). In 87% of the cases receiving aspirin, their maximum daily dosage did not exceed recommended levels, but their doses were higher than those of controls receiving aspirin. No relationship was found between dosage and stage of RS encephalopathy. ( JAMA 1982;248:687-691)

In Reply.— The Ohio Department of Health received only two reports of Reye's syndrome cases from the Cleveland Clinic during the study period (December 1978 through March 1980). The first of the two cases reported to us was not included in the study because our nurse coordinator could not get timely access to the child's record to verify fulfillment of the case definition. This child was reported by Dr Orlowski to have received aspirin. The other patient who was included in our study did not have a history of aspirin ingestion. Thirty-three hospitals reported cases to the Ohio Department of Health. With the exception of Dr Orlowski, there is no evidence of similar reporting problems at the other 32 hospitals. The vast majority of cases (85% ) of the 227 cases were reported from the state's six major pediatric referral centers. In Cleveland, this was Rainbow Babies and Children's Hospital (affiliated