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Abstract
Objective: Community addiction treatment agencies have utilized Network for the Improvement of Addiction Treatment (NIATx), a proven implementation strategy, to reduce appointment wait-times. However, its effectiveness at reducing medication access wait-times has not been explored. Thus, we conducted an exploratory analysis to evaluate the impact of the NIATx implementation strategies on reduced wait-times to addiction, psychotropic or both medications for individuals with co-occurring disorders (COD). Methods: In a cluster-randomized waitlist control group design, community addiction treatment agencies (n = 49) were randomized to receive the NIATx strategy (Cohort 1, n = 25) or to a Waitlist control (Cohort 2, n = 24). All agencies had a 12-month active intervention period. The primary outcome was the medication encounter wait-time. A univariate general linear model analysis utilizing a logarithmic (log10) transformation examined medication wait-times improvements. Results: The intent-to-treat analysis for psychotropic medications and both medications (reflecting integrated treatment) showed significant main effects for intervention and time, especially comparing Baseline and Year 1 to Year 2. Conversely, only the main effect for time was significant for addiction medications. Wait-time reductions in Cohort 1 agencies was delayed and occurred in the sustainment phase. Wait-times to a psychotropic, addiction, or both medications encounter declined by 3 days, 4.9 days, and 6.8 days, respectively. For Cohort 2 agencies, reduced wait-times were seen for psychotropic (3.4 days), addiction (6 days), and both medications (4.9 days) during their active implementation period. Same- or next-day medication access also improved. Conclusions: NIATx implementation strategies reduced medication encounter wait-times but timing of agency improvements varied. Despite a significant improvement, a three-week wait-time to receive integrated pharmacological interventions is clinically suboptimal for individuals with a COD in need of immediate intervention. Community addiction treatment agencies should identify barriers and implement changes to improve medication access so that their patients "wait no longer" to receive integrated treatment and medications for their COD.
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Affiliation(s)
- James H. Ford
- University of Wisconsin – Madison, School of Pharmacy – Social and Administrative Sciences Division, Madison, WI 53705
| | - Deepika Rao
- University of Wisconsin – Madison, School of Pharmacy – Social and Administrative Sciences Division, Madison, WI 53705
| | - Aaron Gilson
- University of Wisconsin – Madison, School of Pharmacy – Social and Administrative Sciences Division, Madison, WI 53705
| | - Arveen Kaur
- University of Wisconsin – Madison, School of Pharmacy – Social and Administrative Sciences Division, Madison, WI 53705
| | - Helene Chokron Garneau
- Center for Behavioral Health Services and Implementation Research, Division of Public Health & Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA 94304
| | | | - Mark P. McGovern
- Center for Behavioral Health Services and Implementation Research, Division of Public Health & Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA 94304
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304
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Chokron Garneau H, Assefa MT, Jo B, Ford JH, Saldana L, McGovern MP. Sustainment of Integrated Care in Addiction Treatment Settings: Primary Outcomes From a Cluster-Randomized Controlled Trial. Psychiatr Serv 2022; 73:280-286. [PMID: 34346729 PMCID: PMC8814048 DOI: 10.1176/appi.ps.202000293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Integrated treatment services are the gold standard for addressing co-occurring mental and substance use disorders, yet they are not readily available. The Network for the Improvement of Addiction Treatment (NIATx) was hypothesized to be an effective strategy to implement and sustain integrated mental health and substance use care in addiction treatment programs. This study examined sustainment of integrated services for up to 2 years after the active implementation phase. METHODS The effectiveness of NIATx strategies to implement and sustain integrated services was evaluated by using a cluster-randomized, waitlist control group design. Forty-nine addiction treatment organizations were randomly assigned to either NIATx1 (active implementation strategy) or NIATx2 (waitlist control). The Dual Diagnosis Capability in Addiction Treatment Index was used to evaluate organizations' capability to provide integrated care. The NIATx Stages of Implementation Completion scale was used to assess participation in and adherence to the NIATx implementation process. Linear mixed-effects modeling was used to evaluate changes from baseline to end of the sustainment period. RESULTS Both cohorts sustained their capability to provide integrated treatment services. Both groups achieved successful implementation and sustained integrated services to a similar degree, regardless of sustainment year. Sustainment did not vary as a function of NIATx adherence. CONCLUSIONS The delivery of integrated treatment services was sustained for 2 years after receipt of active implementation support. Future research should consider how contextual factors may predict, mediate, and moderate sustainment outcomes.
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Affiliation(s)
- Helene Chokron Garneau
- Center for Behavioral Health Services and Implementation Research, Division of Public Health and Population Sciences (Chokron Garneau, Assefa, McGovern) and Center for Interdisciplinary Brain Sciences Research (Jo), Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California; School of Pharmacy, Social and Administrative Sciences Division, University of Wisconsin-Madison, Madison (Ford); Oregon Social Learning Center, Eugene (Saldana)
| | - Mehret T Assefa
- Center for Behavioral Health Services and Implementation Research, Division of Public Health and Population Sciences (Chokron Garneau, Assefa, McGovern) and Center for Interdisciplinary Brain Sciences Research (Jo), Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California; School of Pharmacy, Social and Administrative Sciences Division, University of Wisconsin-Madison, Madison (Ford); Oregon Social Learning Center, Eugene (Saldana)
| | - Booil Jo
- Center for Behavioral Health Services and Implementation Research, Division of Public Health and Population Sciences (Chokron Garneau, Assefa, McGovern) and Center for Interdisciplinary Brain Sciences Research (Jo), Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California; School of Pharmacy, Social and Administrative Sciences Division, University of Wisconsin-Madison, Madison (Ford); Oregon Social Learning Center, Eugene (Saldana)
| | - James H Ford
- Center for Behavioral Health Services and Implementation Research, Division of Public Health and Population Sciences (Chokron Garneau, Assefa, McGovern) and Center for Interdisciplinary Brain Sciences Research (Jo), Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California; School of Pharmacy, Social and Administrative Sciences Division, University of Wisconsin-Madison, Madison (Ford); Oregon Social Learning Center, Eugene (Saldana)
| | - Lisa Saldana
- Center for Behavioral Health Services and Implementation Research, Division of Public Health and Population Sciences (Chokron Garneau, Assefa, McGovern) and Center for Interdisciplinary Brain Sciences Research (Jo), Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California; School of Pharmacy, Social and Administrative Sciences Division, University of Wisconsin-Madison, Madison (Ford); Oregon Social Learning Center, Eugene (Saldana)
| | - Mark P McGovern
- Center for Behavioral Health Services and Implementation Research, Division of Public Health and Population Sciences (Chokron Garneau, Assefa, McGovern) and Center for Interdisciplinary Brain Sciences Research (Jo), Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California; School of Pharmacy, Social and Administrative Sciences Division, University of Wisconsin-Madison, Madison (Ford); Oregon Social Learning Center, Eugene (Saldana)
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Chokron Garneau H, Hurley B, Fisher T, Newman S, Copeland M, Caton L, Cheng H, McGovern MP. The Integrating Medications for Addiction Treatment (IMAT) Index: A measure of capability at the organizational level. J Subst Abuse Treat 2021; 126:108395. [PMID: 34116810 DOI: 10.1016/j.jsat.2021.108395] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/05/2021] [Accepted: 04/04/2021] [Indexed: 10/21/2022]
Abstract
Primary care provides a treatment opportunity for many persons with opioid use disorder (OUD). The push to integrate and expand reach and adoption of medications for opioid use disorder (MOUD) within primary care has been a major focus of national, state and health systems endeavors. To guide high capability MOUD practice, we introduce the Integrating Medications for Addiction Treatment (IMAT) Index. The research team has developed IMAT along similar lines to other organizational measures of integrated services capability. We present the development and validation of the measure, and suggest its applicability for systems and organizations, as well as for process improvement and implementation research. Forty-one primary care clinics completed the IMAT at two time points: baseline and 9-month follow-up. Findings support the IMAT Index as psychometrically acceptable and pragmatically useful. It has good internal consistency, as well as concurrent and predictive validity. Changes in IMAT scores between baseline and follow-up significantly predicted increases in proportion of patients on MOUD. The IMAT has the potential to support both scientific and public health care activities.
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Affiliation(s)
- Helene Chokron Garneau
- Center for Behavioral Health Services and Implementation Research, Division of Public Mental Health and Population Sciences, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Brian Hurley
- Los Angeles County Department of Health Services, Los Angeles, CA, USA; Department of Family Medicine, University of California, Los Angeles, CA, USA
| | | | | | | | - Lauren Caton
- Center for Behavioral Health Services and Implementation Research, Division of Public Mental Health and Population Sciences, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Hannah Cheng
- Center for Behavioral Health Services and Implementation Research, Division of Public Mental Health and Population Sciences, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mark P McGovern
- Center for Behavioral Health Services and Implementation Research, Division of Public Mental Health and Population Sciences, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA; Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Ford JH, Kaur A, Rao D, Gilson A, Bolt DM, Garneau HC, Saldana L, McGovern MP. Improving Medication Access within Integrated Treatment for Individuals with Co-Occurring Disorders in Substance Use Treatment Agencies. Implement Res Pract 2021; 2:26334895211033659. [PMID: 34988462 PMCID: PMC8726008 DOI: 10.1177/26334895211033659] [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] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The best approach to provide comprehensive care for individuals with co-occurring disorders (CODs) related to substance use and mental health is to address both disorders through an integrated treatment approach. However, only 25% of behavioral health agencies offer integrated care and less than 7% of individuals who need integrated treatment receive it. A project used a cluster-randomized waitlist control group design to evaluate the effectiveness of Network for the Improvement of Addiction Treatment (NIATx) implementation strategies to improve access to addiction and psychotropic medications. METHODS This study represents a secondary analysis of data from the NIATx project. Forty-nine agencies were randomized to Cohort1 (active implementation group, receiving the NIATx strategy [n=25]) or Cohort2 (waitlist control group [n=24]). Data were collected at three time points (Baseline, Year1 and Year2). A two-level (patient within agency) multinomial logistic regression model investigated the effects of implementation strategy condition on one of four medication outcomes: both medication types, only psychotropic medication, only addiction medication, or neither medication type. A per-protocol analysis included time, NIATx fidelity, and agency focus as predictors. RESULTS The intent-to-treat analysis found a statistically significant change in access to addiction versus neither medication, but Cohort1 compared to Cohort2 at Year1 showed no differences. Changes were associated with the experimental intervention and occurred in the transition from Year 1 to Year 2, where greater increases were seen for agencies in Cohort2 versus Cohort1. The per-protocol analysis showed increased access to both medications and addiction medications from pre- to post-intervention for agencies in both cohorts; however, differences in change between high- and low-implementation agencies were not significant. CONCLUSIONS Access to integrated services for people with CODs is a long-standing problem. NIATx implementation strategies had limited effectiveness in improving medication access for individuals with CODs. Implementation strategy adherence is associated with increased medication access.
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Affiliation(s)
- James H Ford
- School of Pharmacy, Social and Administrative Sciences Division, University of
Wisconsin–Madison, USA
| | - Arveen Kaur
- School of Pharmacy, Social and Administrative Sciences Division, University of
Wisconsin–Madison, USA
| | - Deepika Rao
- School of Pharmacy, Social and Administrative Sciences Division, University of
Wisconsin–Madison, USA
| | - Aaron Gilson
- School of Pharmacy, Social and Administrative Sciences Division, University of
Wisconsin–Madison, USA
| | - Daniel M Bolt
- School of Education, Educational Psychology Division, University of
Wisconsin–Madison, USA
| | - Helene Chokron Garneau
- Center for Behavioral Health Services and Implementation Research,
Division of Public Health & Population Sciences, Department of Psychiatry and
Behavioral Sciences, Stanford University School of
Medicine, USA
| | | | - Mark P McGovern
- Center for Behavioral Health Services and Implementation Research,
Division of Public Health & Population Sciences, Department of Psychiatry and
Behavioral Sciences, Stanford University School of
Medicine, USA
- Division of Primary Care and Population Health, Department of
Medicine, Stanford University School of
Medicine, USA
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Chen IQ, Chokron Garneau H, Seay-Morrison T, Mahoney MR, Filipowicz H, McGovern MP. What constitutes "behavioral health"? Perceptions of substance-related problems and their treatment in primary care. Addict Sci Clin Pract 2020; 15:29. [PMID: 32727589 PMCID: PMC7388518 DOI: 10.1186/s13722-020-00202-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 07/18/2020] [Indexed: 11/15/2022] Open
Abstract
Background Integrating behavioral health in primary care is a widespread endeavor. Yet rampant variation exists in models and approaches. One significant question is whether frontline providers perceive that behavioral health includes substance use. The current study examined front line providers’: 1. definition of behavioral health, and 2. levels of comfort treating patients who use alcohol and other drugs. Frontline providers at two primary care clinics were surveyed using a 28-item instrument designed to assess their comfort and knowledge of behavioral health, including substance use. Two questions from the Integrated Behavioral Health Staff Perceptions Survey pertaining to confidence in clinics’ ability to care for patients’ behavioral health needs and comfort dealing with patients with behavioral health needs were used for the purposes of this report. Participants also self-reported their clinic role. Responses to these two items were assessed and then compared across roles. Chi square estimates and analysis of variance tests were used to examine relationships between clinic roles and comfort of substance use care delivery. Results Physicians, nurses/nurse practitioners, medical assistants, and other staff (N = 59) participated. Forty-nine participants included substance use in their definition of behavioral health. Participants reported the least comfort caring for patients who use substances (M = 3.5, SD = 1.0) compared to those with mental health concerns (M = 4.1, SD = 0.7), chronic medical conditions (M = 4.2, SD = 0.7), and general health concerns (M = 4.2, SD = 0.7) (p < 0.001). Physicians (M = 3.0, SD = 0.7) reported significantly lower levels of comfort than medical assistants (M = 4.2, SD = 0.9) (p < 0.001) caring for patients who use substances. Conclusions In a small sample of key stakeholders from two primary care clinics who participated in this survey, most considered substance use part of the broad umbrella of behavioral health. Compared to other conditions, primary care providers reported being less comfortable addressing patients’ substance use. Level of comfort varied by role, where physicians were least comfortable, and medical assistants most comfortable.
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Affiliation(s)
- Ida Q Chen
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1520 Page Mill Road, Palo Alto, CA, 94304, USA
| | - Helene Chokron Garneau
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1520 Page Mill Road, Palo Alto, CA, 94304, USA
| | - Timothy Seay-Morrison
- Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA
| | - Megan R Mahoney
- Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA
| | - Heather Filipowicz
- Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA
| | - Mark P McGovern
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1520 Page Mill Road, Palo Alto, CA, 94304, USA. .,Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Stanford, CA, 94305, USA.
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Glasner S, Chokron Garneau H, Ang A, Ray L, Venegas A, Rawson R, Kalichman S. Preliminary Efficacy of a Cognitive Behavioral Therapy Text Messaging Intervention Targeting Alcohol Use and Antiretroviral Therapy Adherence: A Randomized Clinical Trial. PLoS One 2020; 15:e0229557. [PMID: 32163431 PMCID: PMC7067560 DOI: 10.1371/journal.pone.0229557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 02/05/2020] [Indexed: 12/21/2022] Open
Abstract
TRIAL REGISTRATION This trial was registered with ClinicalTrials.gov, NCT02603471.
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Affiliation(s)
- Suzette Glasner
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States of America
- School of Nursing, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Helene Chokron Garneau
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Alfonso Ang
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Lara Ray
- Department of Psychology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Alexandra Venegas
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States of America
- Department of Psychology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Richard Rawson
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States of America
- Department of Psychiatry, Center for Behavior and Health, University of Vermont, Burlington, Vermont, United States of America
| | - Seth Kalichman
- Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Mansfield, Connecticut, United States of America
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Glasner-Edwards S, Patrick K, Ybarra ML, Reback CJ, Rawson RA, Chokron Garneau H, Chavez K, Venegas A. A Cognitive Behavioral Therapy-Based Text Messaging Intervention Versus Medical Management for HIV-Infected Substance Users: Study Protocol for a Pilot Randomized Trial. JMIR Res Protoc 2016; 5:e131. [PMID: 27341852 PMCID: PMC4938885 DOI: 10.2196/resprot.5407] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 12/03/2015] [Revised: 02/15/2016] [Accepted: 02/20/2016] [Indexed: 02/02/2023] Open
Abstract
Background Evidence-based psychosocial interventions for addictions and related conditions such as cognitive behavioral therapy (CBT) are underutilized. Obstacles to implementation of CBT in clinical settings include limited availability of quality training, supervision, and certification in CBT for clinicians; high rates of clinician turnover and high caseloads; and limited qualifications of the workforce to facilitate CBT expertise. Objective Mobile phone–based delivery of CBT, if demonstrated to be feasible and effective, could be transformative in broadening its application and improving the quality of addiction treatment. No experimental interventions that deliver CBT targeting both drug use and medication adherence using text messaging have been previously reported; as such, the objective of this study is to develop and test an SMS-based treatment program for HIV-positive adults with comorbid substance use disorders. Methods With user input, we developed a 12-week CBT-based text messaging intervention (TXT-CBT) targeting antiretroviral (ART) adherence, risk behaviors, and drug use in a population of HIV-infected substance users. Results The intervention has been developed and is presently being tested in a pilot randomized clinical trial. Results will be reported later this year. Conclusions This investigation will yield valuable knowledge about the utility of a cost-effective, readily deployable text messaging behavioral intervention for HIV-infected drug users.
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Affiliation(s)
- Suzette Glasner-Edwards
- Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA, United States.
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Zhang-Nunes SX, Dang S, Garneau HC, Hwang C, Isaacs D, Chang SH, Goldberg R. Characterization and outcomes of repeat orbital decompression for thyroid-associated orbitopathy. Orbit 2015; 34:57-65. [PMID: 25244551 DOI: 10.3109/01676830.2014.949784] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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] [Indexed: 06/03/2023]
Abstract
Orbital decompression for thyroid-associated orbitopathy (TAO) is commonly performed for disfiguring proptosis, congestion, and optic neuropathy. Although one decompression typically achieves goals, a small percentage requires repeat decompression. We performed a 10-year retrospective chart review of all orbital decompressions for TAO at a single tertiary referral institution. Four-hundred and ninety-five orbits (330 patients) were decompressed for TAO, with 45 orbits (37 patients) requiring repeat decompression. We reviewed the repeat cases for indications, clinical activity scores, approach, walls decompressed, and outcomes. Nine percent of orbits required repeat decompression for proptosis (70%), optic neuropathy (25%) or congestion (45%). Sixty-four percent were for recurrence of disease, 36% were for suboptimal decompression. Three incisional approaches were used: lateral upper eyelid crease, inferior transconjunctival, and transcaruncular, with inferior transconjunctival being most common. Of the three walls removed, deep lateral, inferior, and medial, the deep lateral wall was most common (51%). A repeat lateral decompression was the most frequent pattern. Of 37 patients requiring repeat decompression, 40% had diplopia prior to repeat, and an additional 24% developed diplopia after the repeat. Whereas previous studies published by our group cited only 2.6% of deep lateral wall orbital decompressions leading to new-onset primary gaze diplopia, repeat orbital decompressions have a much higher rate of post-operative diplopia. The new onset primary gaze diplopia after repeat decompression group had a higher average preoperative CAS (3.3 vs. 2.4, p < 0.01), higher mean blood loss (56 vs. 19 mL, p = 0.04), more frequent medial wall decompressions (47% vs. 29%, p = 0.33), and greater proptosis reduction (2.4 vs. 1.7 mm, p = 0.24).
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Affiliation(s)
- Sandy X Zhang-Nunes
- USC Eye Institute, Department of Ophthalmology, Keck School of Medicine, University of Southern California , USA
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Papageorgiou KI, Mancini R, Garneau HC, Chang SH, Jarullazada I, King A, Forster-Perlini E, Hwang C, Douglas R, Goldberg RA. A three-dimensional construct of the aging eyebrow: the illusion of volume loss. Aesthet Surg J 2012; 32:46-57. [PMID: 22231412 DOI: 10.1177/1090820x11430829] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The eyebrows and eyebrow fat pads, key structures in upper facial aesthetics, are particularly vulnerable to age-related changes. OBJECTIVES In this study, the authors compare the impact of aging on the eyebrows and eyebrow fat pad volume in men and women through three-dimensional (3D) volumetric analysis. METHODS Electronic medical records of patients seen at the Jules Stein Eye Institute in the Division of Orbital and Ophthalmic Plastic Surgery between 2005 and 2010 were reviewed. Patients were included if they had undergone investigative imaging of the orbit for unilateral pathology. Computed tomography (CT) scans of patients with Graves disease diagnosis, extensive orbital trauma, and/or previous eyebrow surgery were excluded. A total of 52 CT scans (24 men and 28 women) were retained for analysis. A 3D reconstruction software was used to analyze the scans and calculate volumes of the retroorbicularis oculi fat (ROOF), galeal fat (ROOF and subcutaneous fat), and soft tissue muscles. RESULTS Galeal and brow fat volumes showed a significant positive trend toward enlargement in women (P values of .01 and .05, respectively). Although men showed a tendency toward fat enlargement with age, this was not statistically significant. Soft tissue-muscle volume decreased significantly in aging women (9.32 mm(3)/y) (P = .02). Data indicated that soft tissue volume in men tended to increase with age (3.92 mm(3)/y) but not significantly (P = .36). Neither total volume nor brow thickness appeared to change significantly in women (P = .56, P = .73). In men, total volume and brow thickness showed weak evidence of increasing with age (P = .12, P = .22). Linear regressions of Hertel measurements with and without sex interaction showed no statistically significant trend between the amount of proptosis and the galeal or brow fat. CONCLUSIONS Although overall eyebrow volume does not change with age, the relative contribution of fat and soft tissue to the total volume does seem to change. This pattern also differs between males and females. As women age, the fat volume increases and the soft tissue volume decreases. In men, the shift from soft tissue volume to fat volume is less pronounced. Although many clinicians have been drawn to the concept of fat volume deflation as a key element of facial aging, this study does not support this perspective in the eyebrow fat pad. An increasingly refined understanding of the dynamics of facial aging is mandatory for clinical diagnosis and will likely provide the framework from which to develop more innovative treatment options.
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Affiliation(s)
- Konstantinos I Papageorgiou
- Division of Orbital and Ophthalmic Plastic Surgery, Jules Stein Eye Institute, University of California-Los Angeles, 100 Stein Plaza 2-267, Los Angeles, CA 90049 USA.
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Khanna D, Chong KKL, Afifiyan NF, Hwang CJ, Lee DK, Garneau HC, Goldberg RA, Darwin CH, Smith TJ, Douglas RS. Rituximab treatment of patients with severe, corticosteroid-resistant thyroid-associated ophthalmopathy. Ophthalmology 2009; 117:133-139.e2. [PMID: 19818507 DOI: 10.1016/j.ophtha.2009.05.029] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 05/17/2009] [Accepted: 05/21/2009] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To study the effectiveness of anti-CD20 (rituximab [RTX]; Rituxan; Genentech, Inc., South San Francisco, CA) therapy in patients with severe, corticosteroid (CS)-resistant thyroid-associated ophthalmopathy (TAO). DESIGN Retrospective, interventional case series. PARTICIPANTS Six consecutive subjects with severe, progressive TAO unresponsive to CS. METHODS Electronic medical record review of consecutive patients receiving RTX during the previous 18 months. Responses to therapy were graded using standard clinical assessment and flow cytometric analysis of peripheral lymphocytes. MAIN OUTCOME MEASURES Clinical activity score (CAS), proptosis, strabismus, treatment side effects, and quantification of regulatory T cells. RESULTS Six patients were studied. Systemic CS failed to alter clinical activity in all patients (mean CAS+/-standard deviation, 5.3+/-1.0 before vs. 5.5+/-0.8 during therapy for 7.5+/-6.4 months; P = 1.0). However, after RTX treatment, CAS improved from 5.5+/-0.8 to 1.3+/-0.5 at 2 months after treatment (P<0.03) and remained quiescent in all patients (CAS, 0.7+/-0.8; P<0.0001) at a mean follow-up of 6.2+/-4.5 months. Vision improved bilaterally in all 4 patients with dysthyroid optic neuropathy (DON). None of the 6 patients experienced disease relapse after RTX infusion, and proptosis remained stable (Hertel measurement, 24+/-3.7 mm before therapy and 23.6+/-3.7 mm after therapy; P = 0.17). The abundance of T regulatory cells, assessed in 1 patient, increased within 1 week of RTX and remained elevated at 18 months of follow-up. CONCLUSIONS In progressive, CS-resistant TAO, rapid and sustained resolution of orbital inflammation and DON followed treatment with RTX. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Dinesh Khanna
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA 90095, USA
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Douglas RS, Tsirbas A, Gordon M, Lee D, Khadavi N, Garneau HC, Goldberg RA, Cahill K, Dolman PJ, Elner V, Feldon S, Lucarelli M, Uddin J, Kazim M, Smith TJ, Khanna D. Development of criteria for evaluating clinical response in thyroid eye disease using a modified Delphi technique. ACTA ACUST UNITED AC 2009; 127:1155-60. [PMID: 19752424 DOI: 10.1001/archophthalmol.2009.232] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To identify components of a provisional clinical response index for thyroid eye disease using a modified Delphi technique. METHODS The International Thyroid Eye Disease Society conducted a structured, 3-round Delphi exercise establishing consensus for a core set of measures for clinical trials in thyroid eye disease. The steering committee discussed the results in a face-to-face meeting (nominal group technique) and evaluated each criterion with respect to its feasibility, reliability, redundancy, and validity. Redundant measures were consolidated or excluded. RESULTS Criteria were parsed into 11 domains for the Delphi surveys. Eighty-four respondents participated in the Delphi 1 survey, providing 220 unique items. Ninety-two members (100% of the respondents from Delphi 1 plus 8 new participants) responded in Delphi 2 and rated the same 220 items. Sixty-four members (76% of participants) rated 153 criteria in Delphi 3 (67 criteria were excluded because of redundancy). Criteria with a mean greater than 6 (1 = least appropriate to 9 = most appropriate) were further evaluated by the nominal group technique and provisional core measures were chosen. CONCLUSIONS Using a Delphi exercise, we developed provisional core measures for assessing disease activity and severity in clinical trials of therapies for thyroid eye disease. These measures will be iteratively refined for use in multicenter clinical trials.
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Affiliation(s)
- Raymond S Douglas
- Department of Ophthalmology, Jules Stein Eye Institute and David Geffen School of Medicine at University of California, Los Angeles, CA 90095, USA
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