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Lens colobomas extending more than 4 clock hours and causing visual impairment require lens extraction along with capsular support devices with scleral fixation for adequate centration of the capsular bag and for prevention of capsular fornix aspiration with inadvertent extension of zonular dialysis intraoperatively. In this case series, we describe a technique for the management of isolated lens colobomas involving 4-5 clock hours by clear lens extraction and intraocular lens implantation using a combination of a capsular tension ring with a capsular tension segment (CTS) for the centration and stability of the capsular bag. Hoffman's corneoscleral pocket and half-bow sliding knot technique were used for scleral fixation of the CTS., Competing Interests: There are no conflicts of interest.

Introduction: We investigated the awareness of palliative care (PC) services in advanced cancer patients and their family caregivers and whether negative perceptions was a possible barrier to PC utilisation in Singapore., Materials and Methods: Patients with stage 4 solid cancer and their caregivers were interviewed between July 2016 and March 2018 at outpatient clinics located in the medical oncology departments of 2 major public hospitals in Singapore. Patients and caregivers were asked whether they were aware of PC services, how they first learned about them, who first recommended PC to the patient, whether the patient had received PC, and reasons for not receiving PC., Results: Awareness of PC was lower in patients compared to caregivers (43% vs 53%; P <0.01). The odds of being aware in patients was higher if they had higher education (odds ratio [OR] = 2.927; P <0.001) and higher income (OR = 1.798; P = 0.005). Compared to patients, more caregivers reported that a healthcare provider recommended PC to the patient (10% vs 20%; P <0.012). Furthermore, 7% of patients and 15% of caregivers reported that the patient received PC ( P = 0.031). The most common reasons for not receiving PC reported by patients and caregivers (respectively) were that the patient was still receiving treatment (68% and 78%), it is not time for PC (76% and 59%) and PC would not be of help (18% and 19%)., Conclusion: Less than half of patients indicated an awareness of PC. Our findings suggest that efforts should be made to increase awareness of PC and promote its acceptance in cancer patients and their family caregivers in Singapore.

Competing Interests: There is no conflict of intrest.

Competing Interests: None

The juxtaposition of a young city-state showing relative maturity as a rapidly aging society suffuses the population aging narrative in Singapore and places the "little red dot" on the spotlight of international aging. We first describe population aging in Singapore, including the characteristic events that shaped this demographic transition. We then detail the health care and socioeconomic ramifications of the rapid and significant shift to an aging society, followed by an overview of the main aging research areas in Singapore, including selected population-based data sets and the main thrust of leading aging research centers/institutes. After presenting established aging policies and programs, we also discuss current and emerging policy issues surrounding population aging in Singapore. We aim to contribute to the international aging literature by describing Singapore's position and extensive experience in managing the challenges and maximizing the potential of an aging population. We hope that similar graying populations in the region will find the material as a rich source of information and learning opportunities. Ultimately, we aspire to encourage transformative collaborations-locally, regionally, and internationally-and provide valuable insights for policy and practice., (© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To evaluate the patient demographics and morphological characteristics of corneal endothelium by in vivo confocal microscopy (IVCM), in patients with Iridocorneal Endothelial (ICE) Syndrome., Methods: In this retrospective observational series, IVCM acquired endothelial images of patients with ICE syndrome were evaluated. 'ICE cells' morphology was classified as "-" or "+" if they were larger or smaller than contralateral normal endothelium. It was correlated with patient demographics and clinical manifestations., Results: IVCM was performed on 41 eyes of 21 patients, with 13 males (62%) and 8 females (38%). The disease was unilateral in 19 (90.5%) and bilateral but asymmetric in two (9.5%) patients. Total ICE was seen in 91% eyes. Eighty percent patients (12 out of 15) with ICE-cells were males while 83.3% (5 out of 6) patients with ICE + cells were females. Mean age of patients with ICE- cell type and ICE + cell type was 45.8 ± 17.8 years and 40.3 ± 9.2 years respectively (P = 0.02). Both ICE - and ICE + eyes had similar incidence (33.3%) of corneal edema. ICE + eyes had more severe (grades 2/3) glaucoma (n = 5/6 eyes, 83.3%) compared to ICE - eyes (n = 8/15 eyes, 53.3%)., Conclusion: A male preponderance, predilection of ICE - and + cell variants for male and female gender respectively, lack of association of the endothelial cell morphology with corneal edema, and apparent association of ICE + phenotype with more severe glaucoma occurring at a relatively younger age, are some novel findings of the present study. In the clinical setting correlation of patient demographics with these IVCM findings may help in better long-term prognostication of eyes with ICE syndrome., Competing Interests: None

Competing Interests: None

Objectives: To make informed choices about use of future invasive life-sustaining interventions (ILSI), patients with congestive heart failure (CHF) need to correctly understand the intent of their current treatments. However, healthcare providers may be wary of having these discussions due to fear of distressing patients. In this study, we assessed whether patients who understand their treatment intent are less willing to undergo ILSI and are indeed more psychologically distressed., Design, Participants and Outcomes: As part of a cross-sectional survey conducted prior to randomising patients for a trial, we asked 282 patients with advanced CHF (New York Heart Association Class III and IV) whether they believe their existing treatments would cure their heart condition, their willingness to undergo ILSI and assessed their anxiety and depression using the Hospital Anxiety and Depression Scale., Results: Approximately half of patients reported a willingness to undergo ILSI if needed. Only 22% knew that their current treatments were not curative. These patients were far less willing to undergo ILSI (OR 0.28, 95% CI 0.15 to 0.56) and were not at a greater risk of having clinically significant anxiety (OR 0.72, 0.34 to 1.54) and depression (OR 0.70, 0.33 to 1.47) compared with those who did not understand their current treatment intent., Conclusions: Improving patients' understanding of the intent of their current treatments can help patients make informed choices about ILSI., Trial Registration Number: NCT02299180; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introductio: Understanding the symptom and health expenditure burden among patients with advanced congestive heart failure (CHF) and their family caregivers is essential to reform policy and practice needed to provide quality care to these patients at affordable prices. The proposed cohort study titled Singapore Cohort of Patients with Advanced Heart Failure aims to describe trajectories of quality of life among patients and their primary informal caregivers, quantify healthcare utilisation and expenditures, assess changes in patient and caregiver awareness of and preferences for knowing diagnostic and prognostic information, awareness and utilisation of palliative care services, preferences for treatments and decision making, perceived quality of care, self-care, caregiver psychological distress and caregiver burden., Methods: This cohort study will recruit 250 patients with New York Heart Association Classification class III and IV CHF from inpatient wards at two public tertiary healthcare institutions in Singapore. Patients and their primary informal caregiver are being surveyed every 4 months until patients' death; caregivers are followed until 8 weeks postpatient death. Medical and billing records of patients are obtained and merged with patients' survey data., Ethics and Dissemination: The study has been approved by an ethics board. Results from the study will be disseminated through publications and presentations targeting researchers, policy makers and clinicians interested in understanding and improving care for patients with advanced CHF., Trial Registration Number: NCT03089034., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In this communication, we describe a technique for creation of a single stage, adequately sized capsulorrhexis in intumescent cataracts by depressurizing the anterior and posterior intralenticular compartments in a nonleaky anterior chamber (AC) to prevent capsulorrhexis extension and Argentina flag sign. Initially, an incomplete main-port incision is made by the partial entry of a 2.2-mm keratome. A cohesive dispersive ophthalmic viscosurgical device (OVD) is injected into AC. Standard side-port incisions are made, followed by anterior capsular staining. The fluid cortex in anterior intralenticular compartment is aspirated by puncturing anterior capsule in the center using a 30-gauge needle entered through a separate limbal stab incision. The nucleus edge is gently tipped posteriorly with the needle tip to release the fluid from posterior intralenticular compartment also and as much fluid aspirated as possible. OVD is again injected and capsulorrhexis is performed in a single stage using micro-capsulorrhexis forceps., Competing Interests: There are no conflicts of interest

Context: Advance care planning (ACP) has been shown to improve end-of-life care, but it was developed in the U.S., and most research has been conducted in western communities., Objectives: We aimed to study the attitudes and perceptions of patients with life-limiting illnesses, informal caregivers, doctors, nurses, and medical social workers regarding ACP in a multicultural family centric community., Methods: We conducted an explorative qualitative study, using focus groups and individual in-depth interviews. We used purposive sampling techniques to recruit 61 adults (15 doctors, 13 nurses, 5 medical social workers, 15 patients, and 13 caregivers) from multiple health care settings across the country., Results: The participants are genuinely anxious about the implementation of ACP. They had positive and negative expectations of ACP. Many were confused about the legal framework for health care decision-making and expected ACP to be of limited value because family members, rather than the patient, were usually the key decision makers., Conclusion: A nuanced approach to ACP that considers the family network is required in multicultural family centric communities. Policies should be reconciled to create a more consistent message that respects patients, the family, and is legally coherent. Further research could focus on adaptations of ACP to promote its acceptance in such communities., (Copyright © 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Despite literature suggesting conservative management (CM) is a viable option for elderly comorbid ESRD patients, the vast majority in Singapore receive dialysis. We hypothesized that the high demand for dialysis is driven by 1) lack of knowledge of CM and relative benefits of dialysis to CM, 2) adherence to physician recommendations which favour dialysis, and 3) high subsidies for haemodialysis (HD)., Methods: We tested these hypotheses via a survey, including a discrete choice experiment (DCE), administered to 151 elderly pre-dialysis kidney patients and their family caregivers., Results: Results are consistent with the hypotheses: 40% (95% Confidence Interval (CI) 32-48) of patients and 46% (CI 38-55) of caregivers reported not being aware of CM, and 43% (CI 35-51) of patients and 24% (CI 17-31) of caregivers could not provide information on expected survival for dialysis or CM. Yet, once aware of CM as an option, 54% of patients and 42% of caregivers chose CM. However, if their physician recommended dialysis, 49% (CI 40-58) of patients and 68% (CI 59-77) of caregivers switched their choice. Subsidies on HD further reduced demand for CM by 6 percentage points., Conclusions: These results reveal that the high demand for dialysis is driven mostly by lack of awareness of CM as an option and by physician recommendations for dialysis over CM., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Competing Interests: There are no conflicts of interest

Introduction: Diabetes and hypertension are two leading non-communicable conditions, which are suboptimally managed in India. Thus, innovative comprehensive approaches that can concomitantly improve their detection, prevention and control are warranted., Methods and Analysis: UDAY, a 5-year initiative, aims to reduce the risk of diabetes and hypertension and improve management by implementing a comprehensive intervention programme in the two selected study sites, Sonipat and Visakhapatnam (Vizag). It has a pre-post evaluation design with representative cross-sectional surveys before and after intervention. Within these two sites, urban and rural subsites each with a total population of approximately 100 000 people each were selected and a baseline and postintervention assessment was conducted deploying five surveys [among general population (including body measurements or biosamples), patients, healthcare providers including physicians and pharmacists, health facilities], which will determine the knowledge levels about diabetes and hypertension, the proportion treated and controlled; the patient knowledge and self-management skills; healthcare providers' management practices; the level of access and barriers to obtaining care.The interventions will include: tailored health promotion for improving public knowledge; screening of adults aged ≥ 30 years for identifying those at high risk of diabetes and/or hypertension for linkage to the healthcare system; patient education using technology enabled community health workers, geographic information system (GIS) based mapping of the communities, healthcare provider training on management guidelines, community based diabetes registry and; advocacy to improve access to healthcare. The baseline surveys have been completed, the study areas mapped using GIS and the interventions are being implemented. UDAY is expected to increase over baseline the levels of: public knowledge about diabetes and hypertension; those treated and controlled; patient self-management skills; the use of guideline based management by providers and; access to healthcare, leading to improved health outcomes and inform development of a India relevant chronic care model., Ethics and Dissemination: Ethical clearance for conduct of the study was obtained from the Institutional Ethics Committee (IEC) of the Public Health Foundation of India. The findings will be targeted primarily at public health policymakers and advocates, but will be disseminated widely through other mechanisms including conference presentations and peer-reviewed publications, as well as to the participating communities., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Advanced cancer significantly impacts quality of life of patients and families as they cope with symptom burden, treatment decision-making, uncertainty and costs of treatment. In Singapore, information about the experiences of advanced cancer patients and families and the financial cost they incur for end-of-life care is lacking. Understanding of this information is needed to inform practice and policy to ensure continuity and affordability of care at the end of life. The primary objectives of the Cost of Medical Care of Patients with Advanced Serious Illness in Singapore (COMPASS) cohort study are to describe changes in quality of life and to quantify healthcare utilization and costs of patients with advanced cancer at the end of life. Secondary objectives are to investigate patient and caregiver preferences for diagnostic and prognostic information, preferences for end-of-life care, caregiver burden and perceived quality of care and to explore how these change as illness progresses and finally to measure bereavement adjustment. The purpose of this paper is to present the COMPASS protocol in order to promote scientific transparency., Methods: This cohort study recruits advanced cancer patients (n = 600) from outpatient medical oncology clinics at two public tertiary healthcare institutions in Singapore. Patients and their primary informal caregiver are surveyed every 3 months until patients' death; caregivers are followed until 6 months post patient death. Patient medical and billing records are obtained and merged with patient survey data. The treating medical oncologists of participating patients are surveyed to obtain their beliefs regarding care delivery for the patient., Discussion: The study will allow combination of self-report, medical, and cost data from various sources to present a comprehensive picture of the end-of-life experience of advanced cancer patients in a unique Asian setting. This study is responsive to Singapore's National Strategy for Palliative Care which aims to identify opportunities to meet the growing need for high quality care for Singapore's aging population. Results will also be of interest to policy makers and researchers beyond Singapore who are interested to understand and improve the end-of-life experience of cancer patients., Trial Registration: NCT02850640 (Prospectively registered on June 9, 2016).

Purpose: Patients with advanced cancer and their caregivers experience many negative emotions. Empathic responses from oncologists can help alleviate their distress. We aimed to assess expressions of negative emotions among patients with advanced cancer and their caregivers and oncologists' empathic responses during consultations in an Asian setting. We also assessed the association between oncologists' expression of empathy and patients' and caregivers' perception of communication quality., Methods: We surveyed 100 patients with advanced cancer and their caregivers and audio recorded consultations with their oncologists. We coded expressions of negative emotions by patients and caregivers and oncologists' empathic responses. We also surveyed participating oncologists (n = 30) about their confidence in expressing empathy and perceived communication behavior outcomes., Results: About 52% of patients and 49% of caregivers expressed at least one negative emotion during the consultation, though 59% of patients and 48% of caregivers reported not wanting to discuss negative emotions. Oncologists responded empathically to 12% of patients' negative emotions and 9% of caregivers' negative emotions, despite 92% of them reporting confidence in expressing empathy. Oncologists' expression of empathy did not vary significantly by patient, caregiver, or their own demographic characteristics. It also did not differ based on their confidence in expressing empathy and positive outcome expectations. When oncologists responded empathically just one time, patients perceived communication more favorably., Conclusions: In this Asian setting, patients and caregivers commonly expressed negative emotions. Oncologists' expressed empathy infrequently, although when they were empathic, it was related to improved patient perception of communication quality.

Purpose: To compare the demarcation line depth after contact lens-assisted corneal crosslinking (CXL) for progressive keratoconus using dextran-based and hydroxypropyl methylcellulose (HPMC)-based riboflavin solutions., Setting: Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India., Design: Retrospective case series., Methods: Patients with preoperative epithelium-on (epi-on) minimum corneal thickness between 350 μm and 450 μm having contact lens-assisted CXL for progressive keratoconus were crosslinked with isoosmolar 0.1% riboflavin in 20% dextran 500 or HPMC 1.1%. The primary outcome measure was the mean demarcation line depth measured 1 month postoperatively on anterior-segment optical coherence tomography. The secondary outcome measure was change in endothelial cell density (ECD) 6 months from baseline., Results: The study comprised 21 patients (21 eyes, 9 in the HPMC group and 12 in the dextran group). The mean demarcation line depth was deeper in the HPMC group (308.22 μm ± 84.19 [SD]) than in the dextran group (235.33 ± 64.87 μm) (P < .04). This difference remained significant (P = .02) even after controlling for the preoperative lesser epi-on minimum corneal thickness in the HPMC group (385.56 ±13.81 μm) versus the dextran group (413.08 ± 29.58 μm) (P < .02). The ECD 6 months after contact lens-assisted CXL was comparable to the baseline levels in both groups (P = .19 and P = .09, respectively)., Conclusion: During contact lens-assisted CXL, HPMC-based riboflavin seemed to be associated with a deeper demarcation line than dextran-based riboflavin, although both solutions were safe for the endothelium at 6 months., (Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Objective: Applying prospect theory to end-of-life decision making, we hypothesize that community-dwelling older adults (CDOAs) will be relatively less inclined towards extending length over improving quality of life compared with patients. We also hypothesize that differences in relative inclination for length over quality of life between the 2 groups will decrease with advancing age., Methods: We tested these hypotheses by administering the quality-quantity questionnaire to 1067 CDOAs and 320 stage IV cancer patients and applying a linear regression model to assess whether relative inclination for length over quality of life, as estimated by the questionnaire, differed between CDOAs and patients after controlling for differences in sociodemographic characteristics. We also assessed the effect of interaction between age and participant status (CDOA compared to patient) on relative inclination for length over quality of life., Results: Consistent with prospect theory, a lower proportion of CDOAs (26%) than patients (42%) were relatively more inclined towards length over quality of life. Results were significant even after adjusting for differences in sociodemographics (P < .01). With increasing age, the difference in relative inclination between CDOAs and patients increased (P = .01)., Conclusions: Findings indicate that attitudes towards length and quality of life differ by life stage. This has implications for end-of-life care decisions made by CDOAs, such as purchasing health or disability insurance and signing advance directives or care plans., (Copyright © 2016 John Wiley & Sons, Ltd.)

Background/aims: To describe in vivo confocal microscopy (IVCM) features of microsporidial keratoconjunctivitis in immunocompetent adult patients., Methods: Patients suspected clinically to be suffering from microsporidial keratoconjunctivitis (ie, presence of unilateral follicular and/or papillary conjunctivitis in conjunction with multifocal, coarse corneal epitheliopathy) were subjected to IVCM with the Rostock Cornea Module of the Heidelberg Retinal Tomograph 3, and combined potassium hydroxide and calcofluor white (KOH+CFW) staining of the corneal scrapings, to detect the microsporidial spores. Detection of spores in corneal scrapings was considered as being confirmatory for microsporidial infection., Results: Of a total of 10 patients screened, 8 patients (7 male, 1 female) demonstrated the presence of oval, non-budding microsporidial spores which fluoresced bluish white on combined KOH+CFW staining. IVCM in seven of these eight patients demonstrated multiple rosette-like clusters/plaque of epithelial cells, within which hyper-reflective, pinpoint oval intracellular bodies (similar to the spores seen on microbiological staining) were present. One patient who had been on prolonged treatment with topical steroids showed the presence of the oval bright bodies scattered diffusely within the epithelial cells, without rosette formation., Conclusions: In microsporidial keratoconjunctivitis, IVCM is able to detect presence of bright, ovoid spore-like structures in the epithelial layers. Epithelial rosette formation is another characteristic feature seen in a majority of these patients. These features may be used as a reliable screening tool for starting therapy, precluding the need for corneal scrapings in a majority of patients., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Cellular responses to nerve injury play a central role in the pathogenesis of neuropathic pain. However, the analysis of site specific cellular responses to nerve injury and neuropathic pain is limited to immunohistochemistry staining with numerous limitations., New Methods: We proposed to apply flow cytometry to overcome some of the limitations and developed two protocols for isolation of cells from small specimens of the sciatic nerve and dorsal root ganglion (DRG) in mice. RESULTS AND COMPARASION WITH EXISTING: methods We found that both the non-enzymatic and enzymatic approaches were highly effective in harvesting a sufficient number of cells for flow cytometry analysis in normal and pathological conditions. The total number of cells in the injury site of the sciatic and its DRGs increased significantly 14days after chronic constriction injury (CCI) of the sciatic nerve, compared to sham surgery control or the contralateral control. The enzymatic approach yielded a significantly higher total number of cells and CD45 negative cells, suggesting that this approach allows for harvest of more resident cells, compared to the non-enzymatic method. The percentage of CD45 + /CD11b + cells was significantly increased in the sciatic nerve but not in the DRG. These results were consistent with both protocols., Conclusions: We thus offer two simple and effective protocols that allow for application of flow cytometry to the investigation of cellular and molecular mechanisms of neuropathic pain., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Improvement in overall responsiveness to people's expectations is an important goal for any health system; socioeconomic equity in responsiveness is equally important. However, it is not known if socioeconomic disparities in responsiveness can be reduced through greater public health expenditures. This article assesses the relationship of the proportion of public health expenditure over total health expenditure (PPHE) with responsiveness for poorest individuals and the difference in responsiveness between the richest and poorest individuals. We used data from six responsiveness dimensions (prompt attention, dignity, choice, clarity of information, confidentiality and quality of basic amenities) of outpatient services from World Health Survey data from 63 countries. Hierarchical Ordered Probit (HOPIT) models assessed the probability of 'very good' responsiveness in each domain among the poorest and richest individuals for each country, correcting for reporting heterogeneity through vignettes. Linear regression models were then used to assess the association between predicted probabilities from HOPIT models and PPHE, adjusting for (log) Gross Domestic Product per capita. The study findings showed that higher PPHE was associated with a higher probability of 'very good' responsiveness for each domain among the poorest individuals, and with smaller pro-rich disparities in responsiveness between the richest and poorest individuals. In conclusion, increasing PPHE may improve the responsiveness of health services for the poorest individuals and reduce disparities in responsiveness between the richest and poorest individuals., (© The Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To determine the effect of oral omega-3 fatty acid (ω3FA) supplementation in laser in situ keratomileusis (LASIK)-associated dry eye., Methods: In this prospective, open-label study, patients undergoing LASIK were randomized to receive either 1.2 g/d of a triglyceride formulation of oral ω3FA (treatment group) or 400 mg/d vitamin E (control group) for 1 week before and continued for 12 weeks after surgery. Ocular surface disease index, tear breakup time, ocular surface staining, and Schirmer scores were evaluated and compared preoperatively and at 3 months after LASIK., Results: The study included 30 patients in each group. All parameters were comparable at baseline. Ocular surface disease index scores increased comparably in both groups (1.9 ± 0.6 increase in the treatment group; 2.8 ± 0.5 in the control group) (P = 0.267). Compared with baseline levels, tear breakup time decreased significantly (P < 0.01) but comparably in both treatment (-2.3 ± 0.4 seconds decrease) and control (-3.5 ± 0.7 seconds decrease) groups (P = 0.105). More eyes in the control group (43.4%) had conjunctival staining with Lissamine green at 3 months compared with the treatment group (14%) (P = 0.009). The Schirmer score at 3 months was higher (P = 0.003) in the treatment group (30.5 ± 0.90 mm) than in the control group (25.7 ± 1.3 mm) with a increase of 5.9 ± 1.3 mm from baseline in the treatment group and a decrease of 1.5 ± 1.2 mm in the control group., Conclusions: Supplementation with ω3FA in patients undergoing LASIK had a positive influence on tear secretion, whereas tear film stability remained unaffected when compared with the control group.

Introduction: For elderly end-stage renal disease (ESRD) patients with multiple comorbidities, dialysis may offer little survival benefit compared to conservative management (CM). Yet, many elderly ESRD patients undergo dialysis, partly due to physicians' recommendations regarding treatment choice. This study aims to elucidate the factors that influence these recommendations., Methods: We surveyed a convenience sample of physicians who attended the 9th Asian Forum of Chronic Kidney Disease Initiative conference. We used vignettes that vary by age and comorbidity status, and asked physicians to recommend dialysis or CM for a hypothetical patient with that profile and to predict survival with both treatment options. We also compared the physician's recommendations to patients for what they would recommend for themselves if they were diagnosed with ESRD., Results: On average, physicians believed that dialysis extends life relative to CM. Yet, a large subset believed that CM confers greater survival. Estimates range from 17.3% (for a 65-year-old with diabetes and CHF) to 50% for patients with advanced cancer. Results further reveal high discordance regarding treatment recommendations. For a 65-year-old patient with diabetes, 62% recommended dialysis and 38% did not. For advanced cancer, the split was 25% and 75%. Physicians were far more likely to recommend dialysis for themselves than for their patients., Discussion: This study suggests that physicians would benefit from a greater understanding of survival benefits of dialysis and CM for elderly patients with different comorbidity profiles. This would allow patients to make more informed decisions.

A detailed ocular examination and in vivo confocal microscopy (IVCM) using the Heidelberg retinal tomograph 3 with Rostock cornea module were performed in a patient with multiple endocrine neoplasia (MEN) 2b syndrome. Ocular findings included ptosis secondary to thickening of the lid margins, subconjunctival and perilimbal neuromas, and prominent corneal nerves extending up to the pupillary area. IVCM demonstrated structural alterations of both the main nerve trunks and the smaller branches. The main nerve trunks were grossly thickened while the smaller fibers were present in an intertwining manner in the anterior stroma. Some fibers showed prominent looping and nodular dilatations at irregular intervals along the length of the nerves. These nodular dilatations were in all probability ganglioneuromas of corneal nerves demonstrated by histopathology in earlier reports of MEN 2b. IVCM may be potentially useful in detecting the nerve alterations in MEN 2b even before other ocular or systemic features become apparent clinically., Competing Interests: There are no conflicts of interest.

Purpose: To compare the outcomes of topography-guided and wavefront-optimized treatment in patients having laser in situ keratomileusis (LASIK) for myopia., Setting: Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India., Design: Prospective contralateral-eye case study., Methods: Patients had topography-guided LASIK in 1 eye and wavefront-optimized LASIK in the contralateral eye using the Customized Refractive Surgery Master software and Mel 80 excimer laser. Refractive (residual manifest refraction spherical equivalent [MRSE], higher-order aberrations [HOAs]), and visual (uncorrected distance visual acuity [UDVA] and photopic and mesopic contrast sensitivity) outcomes were prospectively analyzed 6 months postoperatively., Results: The study comprised 35 patients. The UDVA was 0.0 logMAR or better and the postoperative residual MRSE was ±0.50 diopter in 94.29% of eyes in the topography-guided group and 85.71% of eyes in the wavefront-optimized group (P = .09). More eyes in the topography-guided group than in the wavefront-optimized group had a UDVA of -0.1 logMAR or better (P = .04). Topography-guided LASIK was associated with less deterioration of mesopic contrast sensitivity at higher spatial frequencies (12 cycles per degree [cpd] and 18 cpd) and lower amounts of induced coma (P = .04) and spherical aberration (P = .04). Less stromal tissue was ablated in the topography-guided group (mean 61.57 μm ± 16.23 [SD]) than in the wavefront-optimized group (mean 79.71 ± 14.81 μm) (P < .001)., Conclusion: Although topography-guided LASIK and wavefront-optimized LASIK gave excellent results, topography-guided LASIK was associated with better contrast sensitivity, lower induction of HOAs, and a smaller amount of tissue ablation., Financial Disclosure: None of the authors has a financial or proprietary interest in any material or method mentioned., (Copyright © 2016 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine the extent to which financial assistance, in the form of subsidies for life-extending treatments (LETs) or cash payouts, distorts the demand for end-of-life treatments., Methods: A discrete choice experiment was administered to 290 patients with cancer in Singapore to elicit preferences for LETs and only palliative care (PC). Responses were fitted to a latent class conditional logistic regression model. We also quantified patients' willingness to pay to avoid and willingness to accept a less effective LET or PC-only. We then simulated the effects of various LET subsidy and cash payout policies on treatment choices., Results: We identified three classes of patients according to their preferences. The first class (26.1% of the sample) had a strong preference for PC and were willing to give up life expectancy gains and even pay for receiving only PC. The second class (29.8% of the sample) had a strong preference for LETs and preferred to extend life regardless of cost or quality of life. The final class (44.1% of the sample) preferred LETs to PC, but actively traded off costs and length and quality of life when making end-of-life treatment choices. Policy simulations showed that LET subsidies increase demand for LETs at the expense of demand for PC, but an equivalent cash payout was not shown to distort demand., Conclusions: Patients with cancer have heterogeneous end-of-life preferences. LET subsidies and cash payouts have differing effects on the use of LETs. Policymakers should be mindful of these differences when designing health care financing schemes for patients with life-limiting illnesses., (Copyright © 2016. Published by Elsevier Inc.)

Background: Despite the promise and popularity of advance care planning, there is insufficient evidence that advance care planning helps patients to meet their end-of-life care preferences, especially in Asian settings. Thus, the proposed study aims to assess whether patients with advanced heart failure who are receiving advance care planning have a greater likelihood of receiving end-of-life care consistent with their preferences compared to patients receiving usual care. Secondary objectives are to compare differences in health care expenditures, quality of life, anxiety and depression, understanding of own illness, participation in decision-making and concordance with their caregiver's preferences for end-of-life care, between patients with advanced heart failure receiving advance care planning and usual care., Methods/design: This is a two-arm randomized controlled trial of advance care planning versus usual care (control) conducted at two institutions in Singapore. Two hundred and eighty-two patients with advanced heart failure (n = 94 in the advance care planning arm; n = 188 in the control arm receiving usual care) will be recruited from these centers and followed for 1 year or until they die, whichever is earlier. Additionally, the study will include up to one caregiver per patient enrolled., Discussion: If advance care planning is proven to be effective, the results will help to promote its uptake among health care providers and patients both within Singapore and in other countries., Trial Registration: NCT02299180 . Registered on 18 November 2014.

Background: Although efficient designs have sample size advantages for discrete choice experiments (DCEs), it has been hypothesised that they may result in biased estimates owing to some respondents using simplistic heuristics., Objectives: The main objective was to provide a case study documenting that many respondents choose on the basis of a single attribute when exposed to highly efficient DCE designs but switch to a conventional multi-attribute decision rule when the design efficiency was lowered (resulting in less need to trade across all attributes). Additional objectives included comparisons of the sizes of the estimated coefficients and characterisation of heterogeneity, thus providing evidence of the magnitude of bias likely present in highly efficient designs., Methods: Five hundred and twenty-five respondents participating in a wider end-of-life survey each answered two DCEs that varied in their design efficiency. The first was a Street and Burgess 100% efficient Orthogonal Main Effects Plan design (2(7) in 8), using the top and bottom levels of all attributes. The second DCE comprised one eighth of the full Orthogonal Main Effects Plan in 32 pairs, (a 2 × 4(6)). Linear probability models estimated every respondent's complete utility function in DCE1. The number of respondents answering on the basis of one attribute level was noted, as was the proportion of these who then violated this rule in DCE2, the less efficient DCE. Latent class analyses were used to identify heterogeneity., Results: Sixty per cent of respondents answered all eight tasks comprising DCE1 using a single attribute; most used the rule "choose cheapest end-of-life care plan". However, when answering the four less efficient tasks in DCE2, one third of these (20% overall) then traded across attributes at least once. Among those whose decision rule could not be described qualitatively, latent class models identified two classes; compared to class one, class two was more concerned with quality rather than cost of care and wished to die in an institution rather than at home. Higher efficiency was also associated with smaller regression coefficients, suggesting either weaker preferences or lower choice consistency (larger errors)., Conclusion: This is the first within-subject study to investigate the association between DCE design efficiency and utility estimates. It found that a majority of people did not trade across attributes in the more efficient design but that one third of these then did trade in the less efficient design. More within-subject studies are required to establish how common this is. It may be that future DCEs should attempt to maximise some joint function of statistical and cognitive efficiency to maximise overall efficiency and minimise bias.

Background: In order to increase breast and cervical cancer screening uptake in Singapore, women's perceived barriers to screening need to be identified and overcome. Using data from both focus groups and surveys, we aimed to assess perceived barriers and motivations for breast and cervical cancer screening., Materials and Methods: We conducted 8 focus groups with 64 women, using thematic analysis to identify overarching themes related to women's attitudes towards screening. Based on recurring themes from focus groups, several hypotheses regarding potential barriers and motivations to screen were generated and tested through a national survey of 801 women aged 25-64., Results: Focus group participants had misconceptions related to screening, believing that the procedures were painful. Cost was an issue, as well as efficacy and fatalism., Conclusions: By identifying barriers to and motivators for screening through a mixed-method design that has both nuance and external validity, this study offers valuable suggestions to policymakers to improve breast and cervical cancer screening uptake in Singapore.

Singapore is in the midst of several healthcare reforms in efforts to finance and deliver health services for a rapidly aging population. The primary focus of these reforms is to make healthcare services, including those at the end of life (EOL), affordable. Given the increasingly high health care costs at the EOL, policy makers need to consider how best to allocate resources. One strategy is to allocate resources based on the preferences of sub-populations most likely to be affected. This paper thus aims to quantify preferences for EOL care both among community dwelling older adults (CDOAs) and among patients with a life-limiting illness. A discrete choice experiment was administered to CDOAs and advanced cancer patients in Singapore and willingness to pay (WTP) for specific EOL improvements was estimated. We find that patients have a higher WTP for nearly all EOL attributes compared with CDOAs. We also show that, for both groups, moderate life extension is not the most important consideration; WTP for one additional life year is lower than common thresholds for cost-effectiveness. Irrespective of whose preference are considered, the results highlight the importance of pain management and supporting home deaths at the EOL, perhaps at the expense of public funding for costly but only marginally effective treatments., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: There is high variability in end-of-life (EOL) treatments. Some of this could be due to differences in physician treatment recommendations, their knowledge/attitude regarding palliative care, and their perceived roles in treating patients with advanced serious illness (ASI). Thus, the objective of this paper was to identify potential variation in physician recommendations, their knowledge/attitude regarding palliative care and perceived roles in treating ASI patients., Methods: A cross-sectional survey consisting of vignettes describing patient characteristics that varied by age, expected survival, cognitive status and treatment costs and asked physicians whether they would recommend life-extending treatments for each scenario, was administered to 285 physicians who treat ASI patients in Singapore. Physicians were also assessed on their knowledge/attitude in palliative care. They were administered a best-worst scaling exercise requiring them to select their most and least important role as a physician caring for an ASI patient., Results: There was a wide variation in physician recommendations for life-extending treatments for patients with similar profiles, which can partly be attributed to physician characteristics (years of experience and place of training). Only about one-fourth of the physicians answered all knowledge/attitude questions correctly. Statements assessing knowledge/attitude regarding pain management had the fewest correct responses. The most important perceived role regarding provision of EOL care concerned symptom management., Conclusions: Results suggest that variation in physician treatment recommendations may be partly related to their own characteristics, raising concerns regarding the EOL care being provided to patients. Efforts should be made to better understand this variation and to provide the physicians with additional training in key aspects of palliative care management.

Background: Patients with advanced cancer often have to make difficult decisions, such as how much to spend on moderately life-extending treatments. This and other end-of-life decisions are also influenced by their informal caregivers. Understanding the relative value that patients and their caregivers place on various aspects of end-of-life care can help clinicians tailor treatments to best meet the preferences of their patients., Aim: To quantify willingness to pay of patients with advanced cancer and their caregivers to extend the patients' life by 1 year and to compare this result to their willingness to pay for other end-of-life improvements., Design: Cross-sectional survey using a discrete choice experiment., Participants: A total of 211 patients with stage IV cancer and their informal caregivers., Results: The willingness to pay of patients to extend their life by 1 year (S$18,570; 95% confidence interval: S$6687-S$30,542) was not statistically different from their willingness to pay to avoid severe pain (S$22,199; S$11,648-S$32,450), to die at home (S$31,256; S$21,249-S$41,391), not be a burden on family and friends (S$4051; -S$3543 to S$11,568), or to receive a high-quality health-care experience (S$16,191; S$9266-S$23,037). Consistent with our hypothesis, caregivers had a greater willingness to pay than patients to extend life (S$61,368; S$37,030-S$86,210) and for most other end-of-life improvements., Conclusion: Results highlight the importance of pain management, supporting home deaths, and addressing other end-of-life concerns, in addition to efforts to extend life. Differences in willingness to pay of patients and caregivers suggest the need for eliciting patient preferences during treatment decision making as opposed to relying on caregiver input., (© The Author(s) 2015.)

Purpose: To evaluate the characteristics of pre-Descemet membrane corneal dystrophy by 3 different imaging modalities: in vivo confocal microscopy (IVCM), anterior segment optical coherence tomography (ASOCT), and Scheimpflug corneal densitometry analysis., Methods: A 32-year-old male patient with pre-Descemet membrane corneal dystrophy was subjected to imaging by IVCM, ASOCT, and Scheimpflug tomography., Results: Slit-lamp biomicroscopy showed the presence of tiny pleomorphic opacities in the posterior stroma, immediately anterior to Descemet membrane bilaterally. On IVCM, pleomorphic, hyperreflective punctate particles were seen both intracellularly and extracellularly in the anterior and mid stroma with increased reflectivity of some keratocytes that, however, were of normal size. These changes increased in severity from the anterior to mid stroma. The posterior stroma had grossly enlarged hyperreflective keratocytes with prominent processes. The hyperreflective particles were also seen scattered on the endothelium. ASOCT revealed a well-delineated homogenous band of increased reflectivity of approximately 70 μm width in the posterior stroma of both eyes with a normal-appearing anterior and mid stroma. Corneal densitometry measured by Scheimpflug optical analysis revealed a higher amount of backscattered light from the posterior stroma with a posterior to anterior ratio of 0.8., Conclusions: In pre-Descemet membrane corneal dystrophy, although the structural changes seem to be limited to the posterior stroma as seen clinically and on ASOCT, IVCM demonstrates that the pathology is more extensive involving the entire corneal stroma and endothelium.

Purpose: The aim of this study was to compare the outcomes of wavefront-optimized sub-Bowman keratomileusis (SBK) performed using the 150 KHz IntraLase femtosecond (IFS) laser (Abbot Medical Optics) with those using the Moria Evo 3 One Use-Plus SBK mechanical microkeratome (Moria SA)., Design: A prospective comparative clinical trial., Methods: Fifty patients had bilateral wavefront-optimized SBK performed for myopia or myopic astigmatism. In 25 patients, the flap was created with the 150 KHz IFS laser (group 1) and in the other 25 with the Moria One Use-Plus SBK mechanical microkeratome (group 2). All other treatment parameters were the same. Results were reported for 1 eye per patient in each group (ie, 25 eyes in each group)., Results: Efficacy, refractive stability, predictability, and safety profiles were comparable between the 2 groups. Although higher order aberrations (HOAs) increased significantly in both groups after laser in situ keratomileusis, intergroup comparison revealed that group 1 was associated with a significantly higher induction of both total HOAs [mean root mean square (RMS), 0.63 ± 0.20 in group 1 vs 0.52 ± 0.14 in group 2; P = 0.031] and spherical aberrations (RMS, 0.37 ± 0.17 in group 1 vs 0.22 ± 0.09 in group 2; P < 0.001) as compared with group 2., Conclusions: Flaps created using the Moria Evo 3 One Use-Plus SBK mechanical microkeratome were associated with significantly lower induction of total HOAs and spherical aberrations as compared with 150 KHz IFS flaps at the end of 3 months follow-up.

Purpose: To evaluate the effect of oral supplementation with omega-3 (ω-3) fatty acids (FAs) in improving contrast sensitivity (CS) of patients with moderate meibomian gland dysfunction (MGD)., Methods: In this prospective study, 60 patients with moderate MGD were allocated alternately to treatment and control groups. Both groups received warm compresses, lid massage, and artificial tear substitutes. The treatment group also received oral supplements of 1.2 g ω-3 FAs per day. All parameters were recorded at baseline and at 12 weeks and included Ocular Surface Disease Index scores, CS testing at 3, 6, 12, and 18 cycles per degree (cpd), tear break-up time, Schirmer test I without anesthesia, corneal and conjunctival staining scores, and meibum quality and expressibility., Results: At the end of 12 weeks, significant improvement in CS was seen in the treatment group in 7 of the 8 testing conditions (3, 6, 12, and 18 cpd photopic and 6, 12, and 18 cpd mesopic), whereas in the placebo group, significant improvement was seen only in 3 of the 8 testing conditions (3 cpd photopic, 6 and 18 cpd mesopic). Ocular Surface Disease Index, tear break-up time, ocular surface staining, and meibum quality and expressibility improved significantly in both groups, but more so in the treatment group. Schirmer scores showed no significant improvement in either group., Conclusions: Oral supplementation with ω-3 FAs significantly improved CS under both photopic and mesopic testing conditions in patients with moderate MGD. Tear film stability also improved significantly, whereas no effect was seen on aqueous tear production.

Aim: To determine the extent of interviewer error on the Short Portable Mental Status Questionnaire (SPMSQ), the association between interviewer-level variables and SPMSQ score, compare the prevalence of SPMSQ cognitive status categories before and after correction for interviewer error, and identify SPMSQ items prone to interviewer error., Methods: Data of 4542 older adults from a national survey in Singapore were utilized. Multilevel models, which adjusted for respondent-level variables known to be associated with cognitive status, were utilized to determine the intraclass correlation on the SPMSQ, association of interviewer-level variables (age, ethnicity, education and number of interviews carried out) with SPMSQ and identify SPMSQ items prone to interviewer error., Results: The intraclass correlation, after adjusting for respondent-level variables, was 0.265. Interviewer educational status was associated with SPMSQ score. Correction for interviewer error resulted in an "improvement" in cognitive status of a substantial proportion of those initially classified as moderately or severely impaired. Two of the SPMSQ items, "Please count backward from 20 by 3" and "When were you born?" were particularly prone to interviewer error., Conclusions: Investigators using the SPMSQ, and potentially, other instruments, for assessing cognitive function in surveys of older adults and using face-to-face interviews for data collection should be cognizant of the sensitivity of such instruments to interviewer error. Intensive training of interviewers to standardize instrument administration as well as assessment for interviewer error and its correction, using appropriate statistical models, such as multilevel models, is warranted., (© 2014 Japan Geriatrics Society.)

Purpose: The aim of this study was to compare the recurrence rates for primary pterygia after fibrin glue-assisted conjunctival autograft (CAG) versus conjunctivolimbal autograft (CLAG) transplantation, using a technique of limited conjunctival resection and Tenon extended removal., Method: In this comparative case series, 49 eyes of 47 patients with primary nasal pterygium were included. Patients were randomized into 2 groups to undergo fibrin glue-assisted CAG (group 1, 24 eyes) or fibrin glue-assisted CLAG (group 2, 25 eyes) following excision of pterygium. The surgical technique used in all patients involved limited conjunctival resection combined with extensive removal of the Tenon capsule up to the caruncle medially and also 5 mm beyond the inferior and superior free edges of the conjunctiva. The main outcome measure studied was the absence or presence of recurrence., Results: There was 0% recurrence rate in both groups after a mean follow-up of 63 weeks (range, 54-81 weeks) with all eyes completing at least 1-year of follow-up., Conclusions: Fibrin glue-assisted CAG and CLAG using the technique of conjunctival resection and Tenon extended removal were equally efficacious in terms of preventing recurrences in patients with primary pterygia in our series.

The objective of this study was to examine the association of maternal autonomy with preventive and curative child health care utilization in India. Data from the National Family Health Survey 2005-2006 were used to ascertain association of maternal autonomy (in 3 dimensions: decision making, access to financial resources, freedom of movement) with child's primary immunization status (indicative of preventive health care use) and treatment seeking for child's acute respiratory infection (indicative of curative health care use). Low maternal freedom of movement was associated with higher odds of incomplete primary immunization of the child and for not seeking treatment for the child's acute respiratory infection. Low maternal financial access was associated with increased odds for incomplete primary immunization of the child. The findings show that improvement in autonomy of Indian mothers, especially their freedom of movement, may help improve utilization of health care for their children., (© 2012 APJPH.)

The amniotic membrane (AM) is the inner layer of the fetal membranes and consist of 3 different layers: the epithelium, basement membrane and stroma which further consists of three contiguous but distinct layers: the inner compact layer, middle fibroblast layer and the outermost spongy layer. The AM has been shown to have anti-inflammatory, anti-fibrotic, anti-angiogenic as well as anti-microbial properties. Also because of its transparent structure, lack of immunogenicity and the ability to provide an excellent substrate for growth, migration and adhesion of epithelial corneal and conjunctival cells, it is being used increasingly for ocular surface reconstruction in a variety of ocular pathologies including corneal disorders associated with limbal stem cell deficiency, surgeries for conjunctival reconstruction, as a carrier for ex vivo expansion of limbal epithelial cells, glaucoma surgeries and sceral melts and perforations. However indiscriminate use of human AM needs to be discouraged as complications though infrequent can occur. These include risk of transmission of bacterial, viral or fungal infections to the recipient if the donors are not adequately screened for communicable diseases, if the membrane is not processed under sterile conditions or if storage is improper. Optimal outcomes can be achieved only with meticulous case selection. This review explores the ever expanding ophthalmological indications for the use of human AM.

Purpose: To present a case of iridocorneal endothelial (ICE) syndrome showing phenotypic heterogeneity of endothelial morphology between the 2 eyes of a patient as visualized by in vivo confocal microscopy (IVCM)., Methods: Confocal microscopy using the Heidelberg Retina Tomograph (HRT)-3 with Rostock Cornea Module was performed bilaterally during routine follow-up on a 60-year-old lady being managed as a case of ICE syndrome with secondary glaucoma in the right eye., Results: IVCM revealed endothelial changes in both eyes, which however varied in morphology. Endothelium of the right eye showed a "total ICE" pattern with "ICE-type of cells," that is, diffuse involvement with enlarged, pleomorphic "epithelioid" cells having hyper-reflective nuclei and no intervening areas of the normal endothelium. The left endothelium had broad areas of normal hexagonal endothelial mosaic interspersed with different types of ICE cells showing nipple-shaped evaginations, light dark reversal and central craters with hyper-reflective rims., Conclusions: This report with the help of IVCM demonstrates that though ICE syndrome is a clinical entity which classically has been considered predominantly unilateral, the endothelial changes can be bilateral and heterogeneous. The apparent heterogeneity in the present case may represent 2 different stages of the disease process at the level of the corneal endothelium-advanced disease OD and presymptomatic disease OS.

Objective: To estimate the health impact, in terms of depression, self-rated health, and health services utilization, of providing care to older adults (75+) requiring human assistance in at least one activity of daily living (ADL) limitation., Method: Data from 1,077 caregivers and 318 noncaregivers, interviewed in the Singapore Survey on Informal Caregiving, was used to examine differences in depressive symptoms, self-rated health, and number of outpatient visits in the last 1 month between caregivers and noncaregivers. Multivariate models for the outcomes, adjusting for characteristics of the caregiver/noncaregiver and care-recipient/potential care recipient, were run., Results: Caregivers were more depressed, had poorer self-rated health, and had a higher rate of outpatient visits in the past month compared to noncaregivers., Discussion: The study indicates the need for support services to family caregivers of older adults with ADL limitations.

Objective: To assess the magnitude of socio-economic disparities in health system responsiveness in India after correcting for potential reporting heterogeneity by socio-economic characteristics (education and wealth)., Methods: Data from Wave 1 of the Study on Global Ageing and Adult Health (2007-2008) involving six Indian states were used. Seven health system responsiveness domains were considered for a respondent's last visit to an outpatient service in 12 months: prompt attention, dignity, clarity of information, autonomy, confidentiality, choice and quality of basic amenities. Hierarchical ordered probit models (correcting for reporting heterogeneity through anchoring vignettes) were used to assess the association of socio-economic characteristics with the seven responsiveness domains, controlling for age, gender and area of residence. Stratified analysis was also conducted among users of public and private health facilities., Results: Our statistical models accounting for reporting heterogeneity revealed socio-economic disparities in all health system responsiveness domains. Estimates suggested that individuals from the lowest wealth group, for example, were less likely than individuals from the highest wealth group to report 'very good' on the dignity domain by 8% points (10% vs 18%). Stratified analysis showed that such disparities existed among users of both public and private health facilities., Conclusion: Socio-economic disparities exist in health system responsiveness in India, irrespective of the type of health facility used. Policy efforts to monitor and improve these disparities are required at the health system level.