Presence Of Advanced Disease Research Articles

Gender difference in advanced HIV disease and late presentation according to European consensus definitions.

Effectiveness of highly active antiretroviral therapy is limited for a large proportion of individuals living with HIV presenting for medical care at an advanced stage. Controversial results of gender differences in risk of late HIV diagnosis were reported among existing literatures. Therefore, we conducted this meta-analysis to synthesize a summary of gender differences in risk of advanced HIV disease (AHD) and late presentation (LP) according to European consensus definitions. Totally, 32 studies were included based on predetermined selection criteria. The pooled adjusted odds ratios of males presenting with AHD and LP compared with females were 1.73 (95% confidence interval [CI], 1.59–1.89) and 1.38 (95% CI, 1.18–1.62) with significant heterogeneity observed (I2 = 78.50%, and I2 = 85.60%, respectively). Subgroup analysis revealed that time lag, study location, number of patients, proportion of females, study design, number of adjusted variables might be potential source of heterogeneity. Sensitivity analysis showed robustness of the results. No publication bias was observed in studies on AHD or LP. The current meta-analysis indicated that males are at higher risk of AHD or LP compared with females. More attention should be paid to males to make sure early testing, diagnosis, and treatment, and ultimately improve individual and population health.

Management of Chemotherapy-Induced Thromboembolism in Breast Cancer

Thromboembolic events are common in cancer patients and, apart from contributing to significant morbidity, are regarded as the second leading cause of death in this population. Breast cancer patients are considered low risk for venous thromboembolism; however, the presence of advanced disease and use of chemotherapy and/or other adjunct treatments significantly raises this risk by altering the balance of pro- and anti-coagulant proteins. Low molecular weight heparin is central to the management of venous thromboembolism in this context, whether for prophylaxis, acute management or prevention of recurrences. Risk stratification models need to be incorporated to guide decision making where available.

The contemporary management of urethral strictures in men resulting from lichen sclerosus.

Lichen sclerosus (LS) is a chronic, inflammatory disease primarily involving the genital skin and urethra in males. Historically, the treatment of this common condition was a challenge due to its uncertain etiology, variable response to therapy, and predilection to recur. The etiology of LS is still debated and has been linked to autoimmune disease, infection, trauma, and genetics. Today, topical steroids are a mainstay of therapy for patients, even in the presence of advanced disease, and can induce regression of the disease. In advanced cases, surgery may be required and range from circumcision, meatoplasty, or, in the case of advanced stricture disease, urethroplasty or perineal urethrostomy. When urethroplasty is required, the use of genital skin as a graft or flap is to be avoided due to the predilection for recurrence. Surgical management should be approached only after failure of more conservative measures due to the high risk of recurrence of LS in the repaired site despite the use of buccal grafting. LS may be associated with the development of squamous cell carcinoma and for this reason, patients should undergo biopsy when LS is suspected and long-term surveillance is recommended.

Unusual small bowel metastatic localization in a castration-resistant prostate cancer patient

The introduction of docetaxel into clinical practice and the more recent availability of other active therapeutic options, such as cabazitaxel, abiraterone acetate, enzalutamide and radium-223, have significantly improved the clinical outcomes of patients affected by castration-resistant prostate cancer (CRPC). Bone and nodes metastases are usually the first presentation of advanced disease, but the improvement in overall survival and the greater use of imaging techniques for restaging of metastatic CRPC patients have led to a previously unexpected clinical scenario characterized by an increased incidence of visceral metastases not only in the liver and lungs, but also in atypical sites such as the brain or gastrointestinal tract. We describe a rare case of CRPC metastasizing to the small bowel with particular endoscopic and radiographic findings.

Choroidal Changes Associated With Bruch Membrane Pathology in Pseudoxanthoma Elasticum

To investigate the impact of Bruch membrane pathology on the choroid in pseudoxanthoma elasticum (PXE). Monocenter cross-sectional prospective case series. The study included 61 eyes of 51 patients with PXE and 54 eyes of 54 normal subjects. The diagnosis of PXE was based on skin biopsy, genetic analysis or both. Eyes with PXE were subdivided into 3 groups: eyes without choroidal neovascularization (CNV) or chorioretinal atrophy (Group 1); eyes with active or fibrotic CNV (Group 2); and eyes with chorioretinal atrophy only (Group 3). Choroidal thickness was measured using enhanced-depth imaging optical coherence tomography (EDI-OCT). Compared to controls (331 μm ± 24; mean ± 95% CI), mean subfoveal choroidal thickness in eyes of patients with PXE was significantly reduced within all 3 groups (Group 1: 243 μm ± 29; Group 2: 184 μm ± 28; Group 3: 104 μm ± 28; P < 0.001). Associated structural changes included apparent loss of small choroidal vessels. The difference of PXE compared to control eyes was largest close to the optic disc and approximated the level of controls toward the periphery. Within the PXE subgroups, eyes without CNV or chorioretinal atrophy (Group 1) showed the least reduction of choroidal thickness, while it was most pronounced in Group 3. The results indicate that changes of Bruch membrane can be associated with choroidal alterations, which are most pronounced in the presence of advanced disease. A role of Bruch membrane in choroidal homeostasis may reflect a possible contribution of Bruch membrane alterations to CNV and geographic atrophy development in age-related macular degeneration.

BSR and BHPR guideline for the management of adults with ANCA-associated vasculitis.

The ANCA associated vasculitides (AAV) comprise are a group of conditions characterized by inflammation and necrosis of small and medium-sized blood vessels. They comprise Wegener's granulomatosis, Churg–Strauss syndrome and microscopic polyangiitis. Early diagnosis and treatment is important as the presence of advanced disease at diagnosis limits the potential benefit of therapy. The aim of this document is to provide guidelines for the management of adults with systemic vasculitis. The guidelines concentrate on the indications for using cyclophosphamide and the different therapeutic regimens available. The guideline does not cover the treatment of children or other types of systemic vasculitis. The target audience is rheumatologists, nephrologists and general physicians, together with trainees and nurse practitioners.

Pelvic Ultrasound Simulation Training Models and Case Scenarios

ABSTRACT Pelvic ultrasound simulation training using high-fidelity mannequins can provide a safe and controlled learning environment to foster the ultrasound education of medical students, residents and faculty. The instruction can be tailored to the specific needs of the learners. Topics for instruction range from teaching basic anatomy and ultrasound scanning techniques to common and advanced obstetrics and gynecology disease presentations and pathological processes. Simulation can closely approximate patient encounters using case based scenarios which will aid in developing knowledge and skills that can be transferred to the clinical environment. The goal of simulation is to help the learners to become more confident and competent to care for their patients. How to cite this article Sarmiento J, Stewart K, Aguila J, Bagherpour A, Kupesic Plavsic S. Pelvic Ultrasound Simulation Training Models and Case Scenarios. Donald School J Ultrasound Obstet Gynecol 2014;8(1):22-30.

Predictors of advanced disease and late presentation in new HIV diagnoses reported to the surveillance system in Spain

ObjectiveTo present surveillance data on advanced disease (AD) and late presentation (LP) of HIV in Spain and their determinants. MethodsWe included all new HIV diagnoses notified by the autonomous regions that consistently reported such cases throughout the period 2007–2011. Coverage was 54% of the total Spanish population. Data sources consisted of clinicians, laboratories and medical records. AD was defined as the presence of a CD4 cell count <200cells/μL in the first test after HIV diagnosis, while LP was defined as the presence of a CD4 cell count <350cells/μL after HIV diagnosis. Odds ratios and their 95% confidence intervals (OR, 95% CI) were used as the measure of association. Logistic regressions were fit to identify predictors of AD and LP. ResultsA total of 13,021 new HIV diagnoses were included. Among these, data on the outcome variable were available in 87.7%. The median CD4 count at presentation was 363 (interquartile range, 161–565). Overall, 3356 (29.4%) patients met the definition of AD and 5494 (48.1%) were classified as LP. Both AD and LP increased with age and were associated with male sex and infection through drug use or heterosexual contact. All immigrants except western Europeans were more prone to AD and LP. Multivariate models disaggregated by sex showed that the effect of age and region of origin was weaker in women than in men. ConclusionsDespite universal health care coverage in Spain, men, immigrants and people infected through drug use or heterosexual contact seem to be experiencing difficulties in gaining timely access to HIV care.

Prevalence of parasitic infections in HIV-positive patients in southern Ethiopia: A cross-sectional study

Intestinal parasitic infections are a major public health burden in tropical countries. Although all HIV/AIDS patients are susceptible to parasitic infections, those having lower immune status are at greater risk. The aim of this study was to determine the prevalence of intestinal parasitic infections in patients living with HIV/AIDS. This was a facility-based cross-sectional study. A total of 343 consecutively sampled HIV/AIDS patients from the HIV care clinic of Hawassa University Referral Hospital were included. Subjects were interviewed for demographic variables and diarrheal symptoms using structured questionnaires. Stool examinations and CD4 cells counts were also performed. The prevalence of intestinal parasitic infection was 47.8% among HIV/AIDS patients; single helminthic infection prevalence (22.7%) was higher than that the prevalence of protozoal infections (14.6%). About 54% of study participants had chronic diarrhea while 3.4% had acute diarrhea. The prevalence of intestinal parasites in patients with chronic diarrhea was significantly higher than in acute diarrhea (p <0.05). Non-opportunistic intestinal parasite infections such as Ascaris lumbricoides, Taenia spp., and hookworm were commonly found, regardless of immune status or diarrheal symptoms. Opportunistic and non-opportunistic intestinal parasitic infection were more frequent in patients with a CD4 count of <200/mm(3) (OR=9.5; 95% CI: 4.64-19.47) when compared with patients with CD4 counts of ≥500 cells/mm(3). Intestinal parasitic infections should be suspected in HIV/AIDS-infected patients with advanced disease presenting with chronic diarrhea. Patients with low CD4 counts should be examined critically for intestinal parasites, regardless of diarrheal status.

Using non-invasive biomarkers to identify hepatic fibrosis in people with type 2 diabetes mellitus: The Edinburgh type 2 diabetes study

It is difficult to determine the different stages of non-alcoholic fatty liver disease without the use of invasive liver biopsy. In this study we investigated five non-invasive biomarkers used previously to detect hepatic fibrosis and determined the level of agreement between them in order to inform future research. In the Edinburgh Type 2 Diabetes Study, a population-based cohort aged 60-74 years with type 2 diabetes, 831 participants underwent ultrasound assessment for fatty liver and had serum aspartate aminotransferase to alanine aminotransferase ratio (AST/ALT), aspartate to platelet ratio index (APRI), European Liver Fibrosis panel (ELF), Fibrosis-4 Score (FIB4) and liver stiffness measurement (LSM) measured. Literature based cut-offs yielded marked differences in the proportions of the cohort with probable liver fibrosis in the full cohort. Agreement between the top 5% of the distribution for each biomarker pair was poor. APRI and FIB4 had the best positive agreement at 76.4%, but agreement for all of the other serum biomarker pairs was between 18% and 34%. Agreement with LSM was poor (9-16%). We found poor correlation between the five biomarkers of liver fibrosis studied. Using the top 5% of each biomarker resulted in good agreement on the absence of advanced liver disease but poor agreement on the presence of advanced disease. Further work is required to validate these markers against liver biopsy and to determine their predictive value for clinical liver-related endpoints, in a range of different low and high risk population groups.

Central pontine myelinolysis in advanced HIV infection with tuberculosis and multicentric Castleman's disease

We present a case of central pontine myelinolysis (CPM) in a patient with advanced HIV infection and miliary tuberculosis. While hospitalized the patient developed an unusual ataxic variant of CPM with full clinical recovery. Follow-up imaging revealed resolution of pontine lesions. To our knowledge, this is the first report of a clinical and radiological recovery from CPM in advanced HIV disease. Our report extends our knowledge of neurological presentations in patients with advanced HIV infection. It highlights the importance of considering CPM in patients with advanced HIV disease presenting with an ataxic syndrome, even in the absence of an electrolyte derangement.

Economic burden of late presentation in HIV disease in Austria: a comparison of the initial costs imposed by advanced HIV disease vs. non-late presentation

In addition to increasing the health risk to the individual patient, late diagnosis of HIV infection affects the costs of the medical care. Comprehensive data on the precise financial burden posed by late presentation are lacking. This retrospective analysis in Austria aimed to compare the marginal costs of initial care after diagnosis in patients presenting with advanced HIV disease vs. non-late presenters. Treatment-naïve late and non-late presenters were matched by age and risk group and were followed up for an average of 15 months. Using a marginal cost approach, the costs of medications, outpatient consultations, diagnostic interventions, and inpatient stays were compared. Cases had significantly higher viral load and lower CD4 cell counts. At first diagnosis, 45.8 % of cases had CDC stage A vs 85.2 % of controls. Late presenters had 70 % more outpatient consultations (p < 0.01) and three-fold higher total marginal costs (<euro> 722,761 vs. 244,976). Cost per patient and month ranged from <euro> 600 to 17,108 for cases and from <euro> 102 to 26,958 for controls. Largest cost difference was noted for antiretroviral (ART) medication (monthly average <euro> 1,089 per case vs. 77 per control), accounting for 42 % of overall costs for cases compared to 10 % of total costs for the controls. Higher costs were also seen for hospitalizations, diagnostics, and non-ART-medication in cases. Late presentation places a significant economic burden on the Austrian healthcare system. Patients and society would benefit from effective screening programs to enable earlier diagnosis with more efficient linkage to care at least in the period immediately following diagnosis.

A phase II trial of androgen deprivation therapy (ADT) plus chemotherapy as initial treatment for local failures or advanced prostate cancer

Long-term hormonal ablation in prostate cancer is associated with decreased overall health and quality of life. Few reports emphasized the role of chemotherapy in the management of early stage prostate cancer. This study analyzed the safety and efficacy of androgen deprivation therapy (ADT) plus chemotherapy as initial treatment for patients identified as local failures or not eligible for prostatectomy or radiation therapy due to advanced disease presentation. Enrolled patients received ADT in the form of leuprolide every 12 weeks for 24 months with bicalutamide initiating after the completion of chemotherapy. Chemotherapy consisted of ketoconazole and doxorubicin for weeks 1, 3, and 5 and estramustine and docetaxel and for weeks 2, 4 and 6. During weeks 7 and 8, no treatment was received. Forty-six patients were enrolled, and forty-five patients were evaluable. Median progression-free survival (PFS) was 23.4 months. Median overall survival (OS) was 53.7 months. Out of 45 patients with measurable disease, 22 patients had an objective response: 9 patients achieved a complete response; 2 patients achieved a partial response; 10 patients achieved stable disease. Frequent grade 3 adverse events included elevated ALT (17 %), hypokalemia (13 %), and hypophosphatemia (13 %). Grade 4 adverse events were rare and included low bicarbonate (2 %), hypokalemia (2 %), leukocytopenia (2 %), and neutropenia (2 %). The treatment demonstrated clinical benefit in all patient subsets with minimal reversible treatment-related adverse events. Subgroup analysis suggests that having prior local therapy resulted in greater PFS and OS.

Chemoembolization and Radioembolization for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) continues to represent a major worldwide problem. Although treatments such as resection, transplantation, and ablation may provide a chance for a cure, these options are often precluded because of advanced disease presentation. Palliative treatments include transarterial embolization and systemic therapies. This review will summarize the state of the science for embolic therapies in HCC (conventional and drug-eluting chemoembolization, radioembolization) as well as discuss related topics including HCC staging, assessment of response, and ongoing clinical trials.

Burnt-out Metastatic Prostate Cancer

A burnt-out prostate cancer tumor is a very rare clinical entity. The term ‘burnt-out’ refers to a primary tumor that has spontaneously and nearly completely regressed without treatment. Since metastasis of prostate cancer is usually encountered in the presence of advanced disease, distant metastasis with an undetectable primary tumor is very rare. We report herein a case of a burnt-out prostate cancer tumor that metastasized to the thoracic (T) spine and caused cord compression. A 66-year-old man visited the Emergency Department due to weakness of both legs for the past two days. His blood and urine tests were normal at the time. His spine magnetic resonance imaging (MRI) scans looked like bone metastasis that involved the T-7 vertebral body and a posterior element, and caused spinal cord compression. Other images, including from the brain MRI, neck/chest/abdomino-pelvic computed tomography (CT) scan and 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) and endoscopy, revealed no lesions that suggested malignancy. After total corpectomy T-7 and screw fixation/fusion at T5 to T10, the pathology report revealed a metastatic carcinoma that was strongly positive for prostate-specific antigen (PSA). The serum PSA value was 1.5 ng/mL. The transrectal 12-core prostate biopsy and ultrasonography showed no definitive hypoechoic lesion, but one specimen had slight (only 1%) adenocarcinoma with a Gleason score of 6 (3+3). The final diagnosis was burned-out prostate cancer with an initial normal PSA value. Although metastatic disease with an unknown primary origin was confirmed, a more aggressive approach in seeking the primary origin could provide a more specific treatment strategy and greater clinical benefit to patients.

Avascular necrosis of femoral head in patients with human immunodeficiency virus type 1 (HIV‐1) infection: a single‐centre experience

Purpose of the studyIntroduction of highly active antiretroviral therapy (HAART) has led to an improvement of life expectancy and quality of life in patients living with HIV. Concomitantly, concerns are arising about long‐term side effects of chronic use of antiretroviral therapy. Avascular necrosis of the femoral head (ANFH) and other epiphyses is increasingly reported as one of these debilitating complications. The objective of this study is to analyse clinical characteristics and outcome of patients with avascular necrosis (AN) followed in our centre.Patients and methodsWe analysed retrospectively the charts of 1020 HIV‐1 infected patients followed in our centre and focused on symptomatic patients with radiologicaly proven AN. We analysed risk factors, demographic and clinical characteristics, treatment and outcome in these patients.Summary of resultsTen patients with AN were identified (prevalence of 0.98%). The average interval between HIV diagnosis and diagnosis of AN was 89.1 months (1–254). Four patients had no evidence of risk factors (40%) whereas 6 (60%) had at least one risk factor. One patient had three cumulated risk factors and for him the onset time for AN was shorter (36 months). All patients had been treated by antiretroviral therapy when AN was diagnosed, but one of the patients developed symptoms prior to start of antiretroviral treatment. All classes of antiretroviral drugs have been used: protease inhibitors (mean use duration of 34.7 months before the ONFH onset), non‐nucleoside reverse transcriptase inhibitors (12 months), and nucleoside reverse transcriptase inhibitors (40.5 months). ANFH was unilateral in 4 patients and bilateral in 6 patients. In one of these 6 cases, multiple AN locations were present (table). In eight patients, total hip arthroplasty (THA) (88.8%) was the definitive treatment. Diagnosis of ANFH in the two patients who were not operated is very recent (5 and 13 months) but surgery is already indicated. The average interval between ANFH diagnosis and the first THA was 10.5 months. Median age Years (min–max) Age 46.2 (24–84) Age at AN diagnosis 40.8 (22–69) Men 6 (60%) Caucasian 7 (70%) Median CD4 count (/µl) CD4/µl (range) Nadir 65 (4–242) At diagnosis of AN 405 (13–957) Viral load at AN diagnosis N (%) Undetectable 5 (50%) Detectable 5 (50%) Lipid Profile mg/dl (range) TC 234 (145–335) LDL 134 (65–230) TG 214 (78–512) Haemoglobin electrophoresis: N (%) Normal 8 (80%) Abnormal (heterozygote) 1 (10%) Risk factors: N (%) Cortisone 1 (10%) Alcohol 4 (40%) Chemotherapy 2 (20%) Smoking 1 (10%) Radiotherapy 1 (10%) Average duration of HAART use Month (range) PI 34.2 NNRTI 12 NRTI 40.5 Average time between HIV diagnosis and AN (months) 89.1 (1–254) Average time between onset of symptoms and first arthroplasty (months) 10.5 (2–20) ConclusionAN, and particularly ANFH, is a rare but debilitating complication in HIV‐1 infected patients. The role of ARV in the pathogenesis of AN remains unclear. However, classical risk factors play an essential role and accumulation of several risk factors could shorten the time before onset of AN. In the presence of advanced disease (stage III–IV) the final treatment remains arthroplasty.

NK/T-Cell Lymphomas: Pathobiology, Prognosis and Treatment Paradigm

The current World Health Organization (WHO) classification includes two types of natural killer (NK)-cell lymphomas: extranodal NK/T-cell lymphoma, nasal type (ENKL), and aggressive NK-cell leukemia (ANKL). These diseases are mostly endemic to East Asia and Latin America. The Epstein-Barr virus (EBV) is usually detected in tumor cells, suggesting that EBV plays an important role in lymphomagenesis. At the site of origin, ENKL can be divided into two major subtypes: nasal and extranasal diseases. The advanced disease presentation, highly aggressive clinical course, and poor prognosis of the latter are analogous to ANKL. It is well known that P-glycoprotein, which is a product of the multi-drug resistance (MDR1) gene, is expressed on neoplastic cells of ENKL or ANKL. This is a major cause of the refractoriness of malignant lymphoma to conventional chemotherapeutic regimens containing anthracycline. Recent studies, however, have identified that L-asparaginase-containing regimens, such as SMILE (steroid, methotrexate, ifosfamide, L-asparaginase and etoposide), are effective for ENKL. Considering the myelotoxicity of SMILE, its use in the treatment of ANKL needs some modifications, but this treatment scheme is promising in improving the prognosis of NK-cell lymphomas.

The Development of a Peritoneal Surface Malignancy Program: a Tale of Three Hospitals

An increasing amount of evidence supports the use of cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC) for the treatment of select patients with carcinomatosis. The care of such patients is optimal at centers where physicians with expertise in the recognition, treatment, and follow-up of carcinomatosis collaborate to manage issues particular to patients undergoing HIPEC. New Peritoneal Surface Malignancy Programs should be introduced to meet the growing interest in this field; however, there are few guidelines available on how to propose, develop, and safely implement them across different hospital models. A new Peritoneal Surface Malignancy Program was initiated at a large academic medical center affiliated with three hospital systems serving distinct patient populations: a private hospital, a public hospital, and a Veterans Affairs hospital. Ten groups were identified as playing key roles in program implementation. Program approval was successfully obtained at all three hospitals. The initial two-year experience included a total of 20 cases across the three sites. Six of these cases were aborted due to high tumor volume, most of which (4/6) were at the public hospital. No 30-day mortalities occurred. Hospitals vary significantly in their approval process and timeline for new Peritoneal Surface Malignancy Program development. Patient populations differ in their awareness of HIPEC as a therapeutic modality. Public hospitals may serve patient populations with more advanced disease presentations. Careful coordination by the surgical oncologist with ten key groups allows for the safe introduction of a complex procedure within varied hospital models.

DNA repair gene excision repair cross complementing‐group 1 (ERCC1) in head and neck squamous cell carcinoma: analysis of methylation and polymorphism (G19007A), protein expression and association with epidemiological and clinicopathological factors

To evaluate the associations of excision repair cross complementing-group 1 (ERCC1) (DNA repair protein) (G19007A) polymorphism, methylation and immunohistochemical expression with epidemiological and clinicopathological factors and with overall survival in head and neck squamous cell carcinoma (HNSCC) patients. The study group comprised 84 patients with HNSCC who underwent surgery and adjuvant radiotherapy without chemotherapy. Bivariate and multivariate analyses were used. The allele A genotype variant was observed in 79.8% of the samples, GG in 20.2%, GA in 28.6% and AA in 51.2%. Individuals aged more than 45 years had a higher prevalence of the allelic A variant and a high (83.3%) immunohistochemical expression of ERCC1 protein [odds ratio (OR) = 4.86, 95% confidence interval (CI): 1.2-19.7, P = 0.027], which was also high in patients with advanced stage (OR=5.04, 95% CI: 1.07-23.7, P = 0.041). Methylated status was found in 51.2% of the samples, and was higher in patients who did not present distant metastasis (OR = 6.67, 95% CI: 1.40-33.33, P = 0.019) and in patients with advanced stage (OR = 5.04, 95% CI: 1.07-23.7, P = 0.041). At 2 and 5 years, overall survival was 55% and 36%, respectively (median = 30 months). Our findings may reflect a high rate of DNA repair due to frequent tissue injury during the lifetime of these individuals, and also more advanced disease presentation in this population with worse prognosis.

Outcomes of Goniotomy for Primary Congenital Glaucoma in East Africa

To evaluate the effectiveness of goniotomy to treat primary congenital glaucoma in an east African population. A retrospective series using case records. For patients who underwent goniotomies in both eyes, only the first was analyzed. Forty-seven children undergoing goniotomy (47/80 operated eyes analyzed). Thirty-six children (77%) were male. Mean age was 19 months (range 1-204 months, standard deviation [SD] = 35). First goniotomy was performed from the temporal side. Repeat surgery, if necessary, was performed via nasal side approach and 100% ethanol-soaked cotton-tipped swabs were used to clear the corneal epithelium when necessary for angle visualization. Postoperative intraocular pressure (IOP) <21 mmHg was considered success. Potential risk factors for failure were analyzed. Quantitative visual acuities were measured with Cardiff acuity cards and Lea tests in older children. A total of 36 of 47 children (77%) returned for follow-up. Mean follow-up interval was 12 months (range, 1-62 months; SD = 15). A total of 28 of 47 children (60%) had >3 months of follow-up, and 11 children had >1 year of follow-up. A total of 12 of 47 eyes (26%) required repeat goniotomy. Three of these required further trabeculectomy with mitomycin C, 1 of which required eventual enucleation after failure to control IOP, enlargement, and pain. A total of 11 of 28 children (39%) with >3 months follow-up required repeat surgery. A total of 24 of 28 children (86%) with follow-up intervals of at least 3 months achieved postoperative IOPs of <21 mmHg. Mean IOPs decreased (t = 6.1, P < 0.0005) from 23.4 mmHg (SD = 5.3 mmHg) to 14.4 mmHg (SD = 7.6 mmHg). Only 1 predictor of failure to achieve successful control of IOP was identified: female gender (relative risk = 5.3, 95% confidence interval, 1.1-26.3). Corneas were clear in 4 of 47 eyes (8.5%) preoperatively and 32 of 41 eyes (78%) postoperatively. Of 25 children with preoperative and postoperative acuities measured, 22 (88%) recorded improvement. Preliminary results of goniotomy in an African population with advanced disease and late presentation are reasonably encouraging. Overall results are comparable with historical drainage procedures, with the advantage of preserving conjunctiva. Further studies are justified.