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A 54-year-old man was referred to the Princess of Wales Hospital, Bridgend, United Kingdom, for evaluation of corneal opacities found on routine eye examination. He was asymptomatic and had no history of contact lens wear. Past ophthalmic, medical, and drug history were unremarkable. Of note, the patient reported having taken various brands of multivitamins over the preceding 3 years. He did not smoke tobacco, but he had a history of smoking cannabis in the past. He denied alcohol excess. The patient reported that his siblings and mother all had recent eye examinations and no signs of corneal opacities. His mother denied drug use during pregnancy. The patient was observed over a period of 2 months, with no change in appearance of the stromal opacities.

Aims The significance of the ‘clicky hip’ in neonatal and infant examination remains controversial with recent conflicting papers reigniting the debate. We aimed to quantify rates of developmental dysplasia of the hip (DDH) in babies referred with ‘clicky hips’ to our dedicated DDH clinic. Patients and Methods A three-year prospective cohort study was undertaken between 2014 and 2016 assessing the diagnosis and treatment outcomes of all children referred specifically with ‘clicky hips’ as the primary reason for referral to our dedicated DDH clinic. Depending on their age, they were all imaged with either ultrasound scan or radiographs. Results There were 69 ‘clicky hip’ referrals over the three-year period. This represented 26.9% of the total 257 referrals received in that time. The mean age at presentation was 13.6 weeks (1 to 84). A total of 19 children (28%) referred as ‘clicky hips’ were noted to have hip abnormalities on ultrasound scan, including 15 with Graf Type II hips (7 bilateral), one Graf Type III hip, and three Graf Type IV hips. Of these, ten children were treated with a Pavlik harness, with two requiring subsequent closed reduction in theatre; one child was treated primarily with a closed reduction and adductor tenotomy. In total, 11 (15.9%) of the 69 ‘clicky hip’ referrals required intervention with either harness or surgery. Conclusion Our study provides further evidence that the ‘clicky hip’ referral can represent an underlying diagnosis of DDH and should, in our opinion, always lead to further clinical and radiological assessment. In the absence of universal ultrasound screening, we would encourage individual units to carefully assess their own outcomes and protocols for ‘clicky hip’ referrals and tailor ongoing service provision to local populations and local referral practices. Cite this article: Bone Joint J 2018;100-B:1249–52.

To report on the complications associated with the use of intravitreal triamcinolone acetonide (IVTA) in a tertiary referral hospital setting. A retrospective case series review of all IVTA injections carried out over a period of 30 months. One hundred and thirty IVTA injections were performed; nine with limited local follow-up were excluded. Thus, 121 injections (108 patients, 114 eyes) were included in the study. Triamcinolone (4 mg) was used in all cases. Indications were diabetic macular oedema (n=41 eyes), retinal vein occlusions (n=27), postoperative cystoid macular oedema (n=24), exudative age-related macular degeneration (n=16), and others (n=6). No intraoperative complications were recorded. Postoperative intraocular pressure (IOP) readings of 22, 28, 35, and 40 mmHg or higher were recorded in 46.5, 29.8, 12.3, and 7.9% of eyes, respectively. IOP elevation was treated with antiglaucoma medication in all but one eye (0.9%) that required trabeculectomy and one (0.9%) that required vitrectomy with cataract extraction for suspected phacoanaphylactic glaucoma. Two eyes (1.8%) developed retinal detachment; both had previously been treated for retinal breaks. One eye (0.9%) developed culture-positive endophthalmitis. Significant morbidity is associated with IVTA injection; clinicians should be aware when considering treatment options.

Purpose: To determine whether topical ketorolac (Acular) is more effective than artificial tears in treating the signs and symptoms of idiopathic episcleritis. Methods: In this prospective, randomised, double-blind study, 38 eyes of 37 patients presenting with idiopathic episcleritis were allocated to receive either topical ketorolac (0.5%) or artificial tears three times a day for 3 weeks. The severity of patients' signs (episcleral injection and the number of clock hours affected) were recorded at weekly intervals. Patients' symptoms (perceived redness and pain scores) were recorded using a daily diary. Results: There was no significant difference in the ophthalmic signs between the two groups at each assessment, including intensity of episcleral injection and the number of clock hours affected. No significant difference was found in the time to halve the baseline redness intensity scores (4.4 vs 6.1 days, P=0.2) or pain scores (3.6 vs 4.3 days, P=0.55). Significantly more patients on ketorolac reported stinging at the first follow-up visit (P Conclusion: Topical ketorolac is not significantly better than artificial tears in treating the signs or symptoms of idiopathic episcleritis.

The use of intravitreal vascular endothelial growth factor (VEGF) inhibitor medications has widened considerably to include indications affecting females of reproductive age. We present our experiences following intravitreal injection of bevacizumab during the first trimester of unrecognised pregnancies in four women. All our patients were inadvertently exposed to bevacizumab within the first trimester when placental growth and fetal organogenesis take place. There were three cases of pregnancy without complication and one case of complicated pregnancy in which there was a significant past obstetric history. This case series provides further insights into intravitreal injection of bevacizumab in early pregnancy. There is insufficient information to suggest that such use is safe, nor is there definitive evidence to suggest that it causes harm. We advise that ophthalmologists discuss pregnancy with women of childbearing age undergoing intraocular anti-VEGF injections. Should a woman become pregnant, counselling is needed to explain the potential risks and benefits, and the limited available data relating to the use of these agents in early pregnancy.

We report studies of the coagulation of samples of whole human blood by oscillatory shear techniques, including Fourier Transform Mechanical Spectroscopy (FTMS). These techniques are used herein to identify the Gel Point of coagulating blood in terms of the Chambon-Winter Gel Point criterion which provides a rheometrical basis for detecting the establishment of an incipient clot. A comparison of the results of FTMS with those obtained from measurements involving a Thromboelastograph (TEG) and a Free Oscillation Rheometer (FOR) indicate that the latter techniques are not capable of detecting the incipient clot, whose establishment occurs several minutes prior to TEG or FOR-based assessments of clot formation time. The results of the present study suggest that FTMS is a useful tool in blood clotting research, being capable of providing a global coagulation profile in addition to detecting the instant of incipient clot formation.

To report the presentation of apparent acute and transient vitreomacular traction causing reduction in visual acuity following routine cataract surgery. A case series describing three patients that developed acute and transient vitreomacular traction following routine cataract surgery by experienced surgeons. No patients had any significant past medical or ophthalmic history. The patients presented shortly after surgery with reduction in visual acuity and dramatic optical coherence tomography (OCT) images suggesting vitreomacular traction. All three patients experienced spontaneous resolution of symptoms and clinical signs within the first few weeks after surgery. Two patients experienced continued mild metamorphopsia. To our knowledge, this is the first documented report of such cases with associated confirmation by OCT imaging.

Top of pageAbstract Aims To assess the efficacy and safety of intravitreal triamcinolone in the treatment of postoperative cystoid macular oedema (CMO). Methods A retrospective case series review of 21 eyes (20 patients) that had an intravitreal injection of triamcinolone 4 mg for postoperative CMO. Diagnosis was confirmed by fundus fluorescein angiography and/or optical coherence tomography in all eyes. Results Mean age of patients was 71.1 years. CMO had developed following routine phacoemulsification cataract extraction (13 eyes), phacoemulsification cataract extraction complicated by posterior capsule tear and vitreous loss (two eyes), vitrectomy (three eyes), or planned combined phacoemulsification and vitrectomy (three eyes). Mean duration of CMO before triamcinolone injection was 4.9 months. Mean duration of follow-up was 7.4 months. Two eyes required a repeat injection. Mean logarithm of minimum angle of resolution (LogMAR) visual acuity (VA) before treatment was 0.53; at 1 month post injection, this increased significantly to 0.33 (P

The rheological behaviour of coagulating human blood has been measured using multiple strain wave frequencies. The results indicate that coagulating blood, prior to the point of incipient clot formation, can be modelled by a modified form of the Gross-Marvin 'ladder' model, and the benefits of such modeling for blood coagulation are discussed.

As the financial performances of US academic health centers have faltered under managed care and the Balanced Budget Act of 1997, increasing attention has been paid to the costs and benefits of operating primary care networks. This study examines the indirect revenues to a university hospital and faculty group practice that result from such a primary care network using a method of abstracting billing data.A primary care patient cohort was identified by selecting all patients who generated at least one charge in any of the 10 primary care clinics in the network over a 15-month period. All charges from the hospital and the faculty practice group for this cohort were then examined during a 6-month period, and the total charges generated in the primary care setting were compared with charges generated elsewhere in the health system.The primary care patient cohort included 56,459 patients and generated a total of $7,243,312 in charges for primary care services, $43,559,741 of charges in the hospital billing system for non-primary care services, and $8,825,611 of charges for services from specialty faculty. This cohort accounted for 18.5% of the gross charges for hospital care and 17.6% of charges generated by the specialty physicians.Using a simple and replicable methodology, this study estimates a substantial financial benefit to the hospital and specialty practices from a primary care network.

In symptomatic patients with recurrent anterior sternoclavicular dislocation, surgery may be required to stabilise the joint. Posterior sternoclavicular dislocations may also require open reduction and stabilisation due to the complications that may arise. We present a new, 'safe' technique of surgical stabilisation of the sternoclavicular joint that is not technically demanding and does not require exposure of the first rib, as is often the case in other methods described. The repair was tested in cadavers before being employed in three patients and was found to be effective under both static and dynamic loading. The early clinical results prove encouraging.

Between January 1987 and December 1988 there were 7575 births in the Swansea maternity unit. Of these 823 (10.9%) were considered to be at 'high risk' for developmental dysplasia of the hip (DDH). Static ultrasound examination was performed in each case and the results classified on the basis of the method of Graf. A total of 117 type III-IV hips in 83 infants was splinted using the Aberdeen splint. Radiographs of these hips were taken at six and 12 months. Hilgenreiner's measurements of the acetabular angle were made in all cases and the development of the femoral capital epiphysis was assessed by measuring the epiphyseal area. The effect of splintage on the acetabular angle and the epiphyseal area between the normal and abnormal splinted hips was compared. Radiographs of 16 normal infants (32 normal unsplinted hips) were used as a control group. This cohort has now been followed up for a minimum of nine years. There have been no complications as a result of splintage. The failure rate was 1.7% or 0.25 per 1000 live births. No statistical difference was found when comparing the effect of splintage on the acetabular angle and epiphyseal area between normal and abnormal splinted hips and normal unsplinted hips. Our study has shown that while the Aberdeen splint had a definite but small failure rate, it was safe in that it did not produce avascular necrosis. The current conventional view that a low rate of splintage is always best is therefore brought into question if the Aberdeen splint is chosen for the management of neonatal DDH.

Several vascular endothelial growth factor inhibitors have recently been studied as treatments for neovascular AMD.1 2 Pegaptanib sodium improved visual acuity in 6% of patients at one year;1 Ranibizumab 0.5 mg improved vision by three lines in 33% of patients at one year.2 Michels et al. 3 initially reported the use of intravenous bevacizumab for the treatment of choroidal neovascularization (CNV), and others have found visual improvement and reduction in macular thickness with intravitreal bevacizumab.4–8 We present the results from 118 cases treated with intravitreal bevacizumab based at a single centre. A retrospective review of 115 consecutive patients (118 eyes) based at Southampton Eye Unit, treated with intravitreal bevacizumab for CNV was performed. Lesions of all types irrespective of size or location that were either ineligible for photodynamic therapy (PDT) under the National Health Service (including minimally classic and occult CNV) or those not responding to PDT (classic or predominantly classic CNV with recurrent or persistent CNV activity) were included in the study (table 1). All patients underwent visual acuity testing (best corrected Snellen), slitlamp examination and fundus fluorescein angiography. Central macular thickness (CMT) was assessed using Stratus optical coherence tomography (Carl Zeiss Meditec, USA). View this table: Table 1 Baseline characteristics After discussion about the off-label nature of treatment and the potential risks, informed …

Purpose: To compare outcomes and complications of patients undergoing phacoemulsification with and without the administration of intracameral phenylephrine. Materials and Methods: In this retrospective study, a chart review was performed. Two groups with an equal number of patients who did or did not receive intracameral phenylephrine during phacoemulsification were compared for differences in outcomes, risk factors and complications. The Chi-square test was used for comparison between groups. P0.05, all comparisons). Conclusion: This retrospective study suggests that intracameral phenylephrine normalizes the intraoperative risk of small pupil cataract surgery and is not associated with an increased risk of systemic or postoperative ophthalmic complications.

A burst-superimposition technique was used to assess the strength of the quadriceps femoris muscle in three groups of patients. Group 1 comprised twenty patients who had had a torn anterior cruciate ligament of the knee and had a reconstruction of the ligament one to six months after the injury. Group 2 comprised twelve patients who had had a torn anterior cruciate ligament for an average of three months (a subacute tear). Group 3 comprised eight patients who had had a torn anterior cruciate ligament for an average of two years (a chronic tear). The patients in Groups 2 and 3 had not had an operation for the torn ligament. The patients in Groups 1 and 3 had no evidence of failure of activation of the involved quadriceps, but nine of the twelve patients in Group 2 had reflex inhibition of contraction of the muscle.

Summary Some insight into the use of the primary care team was provided by a study of encounters with families with infants. The demand for primary care was large, and varied greatly depending on the circumstances of the family. Using statistical models, five possible influences on contact were examined - the presence of other children in the family, distance from the surgery, the family's socioeconomic grouping, maternal age, and maternal depression. Having more than one child and living close to the surgery increased the likelihood of a home visit by the doctor. There were proportionately more visits by the health visitors to first-time mothers who were depressed, and this was unaffected by distance. The baby clinic was a popular meeting place, particularly for first-time mothers, and attendance showed no obvious social class bias. The degree of help sought by mothers, in terms of the number of contacts, appeared disproportionate to the child's physical problems. This indicates that more research is needed into the appropriateness of many contacts, and the extent to which the practice team is the most effective source of help.

We report 16 cases in which the upper cervical spine was approached through the mouth for operative decompression and stabilisation, with or without removal of diseased tissues. The indications are discussed and the technique is described. Results are compared with those of other reported series. We believe that this operation has a place in the treatment of certain conditions affecting the upper part of the cervical spine and the foramen magnum, with or without involvement of the medulla and spinal cord.

The diagnosis and management of benign fibrous ureteric polyps are discussed. A pre-operative diagnosis is suggested by a long history of loin pain or haematuria, both, in a younger patient with the radiological findings of ureteric obstruction or a radiolucent ureteric filling defect. The diagnosis is confirmed at operation by opening the ureter and exposing characteristic fronds of polyps arising from a common base. It is suggested that management should be conservative local excision and not nephroureterectomy, as previously practised.

This study reports the effect of increased hematocrit (packed cell volume) on the rate of decrease in plasma glucose during 6 h in blood specimens from seven newborns (cord blood) and heparin-treated blood specimens from eight adults. Mean hematocrits ranged frm 0.43 to 0.75 for the adults and from 0.51 to 0.81 for the infants. The decrease in glucose was related to time and to hematocrit. For example, in adults with a mean hematocrit of 0.43, glucose decreased from 890 +/- 40 mg/L to 570 +/- 30 mg/L (mean +/- SEM) at 6 h, whereas in adults with a mean hematocrit of 0.75, glucose decreased from 890 +/- 40 to 200 +/- 30 mg/L. In infants with a mean hematocrit of 0.51, glucose decreased from 1010 +/- 20 to 480 +/- 70 mg/L at 6 h; infants with a mean hematocrit of 0.81 had blood glucose decrease from 1010 +/- 20 to 50 +/- 30 mg/L. These results indicate that the incidence of hypoglycemia in infants with polycythemia may be overestimated, and emphasize the need for prompt handling of blood samples collected from newborns for glucose determinations.

General study design and environmental considerations. Scand j work environ health 9 (1983): suppl 1, 1-7. Recent concern regarding health hazards of methylene chloride stem primarily from the discovery of its metabolism to carboxyhemoglobin. In this report, a research program is described, the purpose of which was to assess potential health effects of methylene chloride exposure in an occupational setting. Particular attention was given to evaluating possible direct and carboxyhemoglobin-mediated effects on the hematopoietic and circulatory systems. The study involved one fiber production plant which used a methylene chloride/methanol mixture and acetone as solvents and a second fiber production plant that used acetone only. The research design included a retrospective cohort mortality study and several health evaluation studies, as well as an environmental assessment of the two plants. Industrial hygiene monitoring indicated that typical methylene chloride exposures ranged from an 8-h time-weighted average of 140 ppm in areas of low methylene chloride use to a corresponding average of 475 ppm in areas of high methylene chloride use and that methanol was present in about a one to ten ratio to methylene chloride. Acetone exposures in both plants ranged from 100 to over 1,000 ppm (time-weighted average).

Plasma glucose, glucagon, and insulin responses to oral feedings of L-alanine were assessed in 44 healthy term infants during the first three days of life. Alanine administration produced significant increases in glucagon and glucose concentrations on day 1, but not on days 2 and 3. These increases occurred within 30 minutes (mean and SEM for glucagon, 127 plus or minus 7 to 219 plus or minus 16 pg/ml, P smaller than 0.001; glucose, 45 plus or minus 3 to 60 plus or minus 7 mg/100 ml, P smaller than 0.01) and persisted at the P smaller than 0.05 level at four hours. Responsiveness to alanine seemed to be related to the baseline blood glucose levels since constant infusions of glucose inhibited the response; These results indicate that the pancreatic islet alpha cell secretion mechanism(s) is functioning in the newborn.

Twenty two operations have been performed on 20 patients for the relief of symptoms due to bullous lung disease. Open intubation drainage of the bullae was used in all patients, the technique initially devised by Monaldi for the treatment of intrapulmonary tuberculous abscesses having been modified. Three patients died after surgery. Mortality was associated with low preoperative FEV1 (median 350 ml) and higher preoperative arterial carbon dioxide tension (PaCO2) (median 7.8 kPa). Symptomatic improvement was reported by 16 of the remaining 17 patients and was maintained over a median follow up period of 1.6 years. This was accompanied by objective improvement in lung function with a 22% median improvement in FEV1, an 11% median reduction in total lung capacity, and a 26% median reduction in residual volume. In one patient symptoms were unchanged after surgery. The technique described provides a simple method for decompressing bullae by means of a minimally invasive surgical procedure. It also allows for the treatment of further bullae at a later date by closed intubation under local anaesthetic. It has proved a suitable approach for all but those with the poorest lung function and is now our treatment of choice.

Neonatal hypoglycemia and hyperinsulinemia have been reported following maternal ritodrine administration, but no prospective controlled study of the neonatal metabolic and cardiovascular effects of maternal ritodrine is available. We conducted a double-blind prospective study in 35 patients with preterm labor and/or ruptured membranes. Patients in premature labor received ritodrine (max dose, 350 mcg/min) or a placebo intravenously for 12 hours, and then orally (20 mg every 4 hours) until labor ensued. Patients with ruptured membranes received only oral therapy. Only patients who were maintained on oral therapy for a minimum of 12 hours and who were within 6 hours of their last dose of oral therapy were included in the analysis. Glucose and insulin values in cord blood at 6 and 12 hours of age were not significantly different between the ritodrine and placebo groups. There were no hypoglycemic infants in the ritodrine group. Mean systolic and diastolic blood pressure, heart rate and blood volume were similar for ritodrine and control infants. Although premature infants are at high risk for hypoglycemia it appears from this study that chronic oral ritodrine therapy does not significantly affect neonatal glucose homeostasis.