Search

Purpose The effective mechanical advantage (EMA) of the plantarflexor muscles is important for gait function and is likely different from typical in equinus gait. However, this has never been quantified for children who idiopathically toe-walk (ITW), despite being routinely altered through clinical intervention. Methods This study quantified the Achilles tendon and ground reaction force (GRF) moment arms, and the plantarflexor EMA of 5 children who ITW and 14 typically developing (TD) children, whilst walking on an instrumented treadmill. Results There was no difference in the Achilles tendon moment arm length throughout stance between groups (p > 0.05). Children who ITW had a significantly greater GRF moment arm length in early stance (20–24% p = 0.001), but a significantly shorter GRF moment arm length during propulsion (68–74% of stance; p = 0.013) than TD children. Therefore, children who ITW had a greater plantarflexor EMA than TD children when active plantarflexion moments were being generated (60–70% of stance; p = 0.007). Consequently, it was estimated that children who ITW required 30% less plantarflexor muscle force for propulsion. Conclusion Clinical decision making should fully consider that interventions which aim to restore a typical heel-toe gait pattern risk compromising this advantageous leverage and thus, may increase the strength requirements for gait.

Purpose\ud To assess differences in rod-mediated dark adaptation (RMDA) between different grades of age-related macular degeneration (AMD) severity using an Optical Coherence Tomography (OCT)-based criterion compared to the Beckman Colour Fundus Photography-based (CFP) classification. To assess association between subretinal drusenoid deposit (SDD) presence and RMDA at different AMD severity grades, using an OCT-based classification.\ud \ud Design\ud Cross-sectional study\ud \ud Participants\ud Participants from the Northern Ireland Sensory Aging study (NISA; Queen's University Belfast).\ud \ud Methods\ud Complete RMDA (rod-intercept time [RIT; AdaptDx; Maculogix, USA]) data, CFP (Canon CX-1 Digital Fundus Camera; Canon, USA) and spectral domain OCT (Heidelberg Spectralis SD-OCT; Heidelberg Engineering, Germany) images were extracted. Participants were stratified into four Beckman groups (omitting late-stage AMD) and three OCT-based groups. OCT grading included: participants with no drusen/retinal pigment epithelium (RPE) abnormalities (OCT0), participants with drusen present but no RPE abnormalities (OCT1) and participants with drusen and RPE abnormalities present (OCT2). SDD presence and stage was identified via OCT.\ud \ud Main Outcome Measure\ud RIT data (age-corrected) assessed across AMD severity groups\ud \ud Results\ud Data from the eye with the worse visual acuity in 459 participants (median [interquartile range[IQR]) age 65[59,71] years) were stratified by both classifications. SDDs were detected in 109 eyes. Median (IQR) RMDA for Beckman classification (Beckman0-3, with 3 being intermediate AMD[iAMD]) groups were 6.0(4.5,8.7), 6.6(4.7,10.5), 5.7(4.4,7.4) and 13.2(6,21.1)minutes, respectively. OCT classifications OCT0-OCT2 yielded - different median (IQR)values: 5.8(4.5,8.5), 8.4(5.2,13.3) and 11.1(5.3,20.1) minutes, respectively. After correcting for age, eyes in Beckman 3 (iAMD) had statistically significantly worse RMDA compared to other Beckman groups (p=

Background/aimsTo model the suitability of conventional ready-made spectacles (RMS) and interchangeable-lens ready-made spectacles (IRMS) with reference to prescribing guidelines among children and adults using a large, global database and to introduce a web-based application for exploring the database with user-defined eligibility criteria.MethodsUsing refractive power and interpupillary distance data for near and distance spectacles prescribed to children and adults during OneSight clinics in 27 countries, from 2 January 2016 to 19 November 2019, we modelled the expected suitability of RMS and IRMS spectacle designs, compared with custom-made spectacles, according to published prescribing guidelines.ResultsRecords of 18 782 presbyopic adult prescriptions, 70 619 distance adult prescriptions and 40 862 paediatric prescriptions were included. Globally, 58.7%–63.9% of adults could be corrected at distance with RMS, depending on the prescribing cut-off. For presbyopic adult prescriptions, coverage was 44.1%–60.9%. Among children, 51.8% were eligible for conventional RMS. Coverage for all groups was similar to the above for IRMS. The most common reason for ineligibility for RMS in all service groups was astigmatism, responsible for 27.2% of all ineligible adult distance prescriptions using the strictest cut-off, 31.4% of children’s prescriptions and 28.0% of all adults near prescriptions globally.ConclusionDespite their advantages in cost and convenience, coverage delivered by RMS is limited under current prescribing guidelines, particularly for children and presbyopic adults. Interchangeable designs do little to remediate this, despite extending coverage for anisometropia. Our free application allows users to estimate RMS coverage in specific target populations.

New Findings\ud • What is the central question of this study?\ud • What are the in vivo operating lengths of the gastrocnemius muscle in children who idiopathically toe-walk?\ud • What is the main finding and its importance?\ud • We show, for the first time, that children who idiopathically toe-walk operate at more plantarflexed positions but at longer fascicle lengths than typically developing children during gait. However, these ranges utilised during gait correspond to where children who idiopathically toe-walk are optimally strong. This should be considered when prescribing clinical treatments to restore typical gait.\ud Abstract\ud Children who idiopathically toe-walk (ITW) habitually operate at greater plantarflexion angles than typically developing (TD) children, which might result in shorter, sub-optimal, gastrocnemius fascicle lengths. However, currently no experimental evidence exists to substantiate this notion. Five children who ITW and 14 TD children completed a gait analysis, whilst gastrocnemius fascicle behaviour was simultaneously quantified using ultrasound. The moment-angle (hip, knee and ankle) and -length (gastrocnemius) relationships were determined from isometric maximum voluntary contractions (MVC) on an isokinetic dynamometer combined with ultrasound. During gait, children who ITW operated at more plantarflexed angles (Δ = 20°; p = 0.013) and longer muscle fascicle lengths (Δ = 12mm; p = 0.008) than TD children. During MVC, no differences in the peak moment of any joint were found. However, peak plantarflexor moment occurred at significantly more plantarflexed angles (-16 vs. 1°; p = 0.010) and at longer muscle fascicle lengths (44 vs. 37mm; p = 0.001) in children who ITW than TD children. Observed alterations in the moment-angle and -length relationships of children who ITW coincided with the ranges used during gait. Therefore, the gastrocnemius muscle in children who ITW operates close to the peak of the force-length relationship, similarly to TD children. Thus, this study indicates that children who ITW present with substantial alterations in the gastrocnemius muscle functional properties, which appear well adapted to the characteristic demands of equinus gait. The absence of proximal joint weakness also supports the notion that idiopathic toe-walking is truly an ankle joint pathology. These findings should be considered when prescribing clinical treatments to restore typical gait.

Lake-effect convective snowstorms frequently produce high-impact, hazardous winter weather conditions downwind of the North American Great Lakes. During lake-effect snow events, the lake surfaces can cool rapidly, and in some cases, notable development of ice cover occurs. Such rapid changes in the lake-surface conditions are not accounted for in existing operational weather forecast models, such as the National Oceanic and Atmospheric Administration’s (NOAA) High-Resolution Rapid Refresh (HRRR) model, resulting in reduced performance of lake-effect snow forecasts. As a milestone to future implementations in the Great Lakes Operational Forecast System (GLOFS) and HRRR, this study examines the one-way linkage between the hydrodynamic-ice model [the Finite-Volume Community Ocean Model coupled with the unstructured grid version of the Los Alamos Sea Ice Model (FVCOM-CICE), the physical core model of GLOFS] and the atmospheric model [the Weather Research and Forecasting (WRF) Model, the physical core model of HRRR]. The realistic representation of lake-surface cooling and ice development or its fractional coverage during three lake-effect snow events was achieved by feeding the FVCOM-CICE simulated lake-surface conditions to WRF (using a regional configuration of HRRR), resulting in the improved simulation of the turbulent heat fluxes over the lakes and resulting snow water equivalent in the downwind areas. This study shows that the one-way coupling is a practical approach that is well suited to the operational environment, as it requires little to no increase in computational resources yet can result in improved forecasts of regional weather and lake conditions.

The original version of this article unfortunately contained a mistake. The original abstract was published on 16th March 2022. https://doi.org/10.1007/s00421-022-04913-7

Aim: To examine the cross‐sectional associations between single nutrient intakes and posteriori nutrient‐based dietary patterns and periodontal disease risk in a subset of the UK Biobank cohort. Materials and Methods: Dietary data were collected by 24‐h dietary recall on up to five separate occasions over 16 months. A touchscreen questionnaire was used to collect oral health information. Participants were considered at high risk of periodontal disease if they reported having painful gums and/or bleeding gums and/or loose teeth. Principal component analysis identified four nutrient‐based dietary patterns from 20 nutrients. Logistic regression was used to estimate the odds ratio of periodontal disease risk for single nutrients and nutrient‐based dietary patterns. Results: A total of 9476 participants (mean age 56.2 years [SD 8.0]) were included in the analysis. Higher intakes of vitamin B6, B12, C, and E, folate, iron, potassium, magnesium, polyunsaturated fatty acids, and total sugar were associated with a lower risk of periodontal disease. Higher intake of saturated fat was associated with an increased risk. A dietary pattern characterized by high micronutrients and fibre intake was associated with low risk of periodontal disease. Conclusion: Within this sample of middle‐aged and older adults, a “high micronutrient and fibre” dietary pattern was associated with reduced risk of periodontal disease.

Background We aimed to evaluate the nationwide prevalence of stress induced burnout among cataract surgeons. We believe that knowledge of these factors can help formulate a solution to this underreported problem. Methods A three-part nationwide cross-sectional survey was disseminated with via the Royal College of Ophthalmologists (RCOphth) in the United Kingdom(UK). All consultants, trainees and specialty doctors and associate specialists(SAS) were invited to participate. We evaluated burnout using the Maslach Burnout Inventory (MBI). Logistic regression modelling was completed to look at factors linked to high level burnout in certain domains. Results A total of 406 respondents completed our survey. Prevalence of cataract surgery-related high burnout was estimated at 3.45% (Section A and/or B) and 40% within Personal Accomplishment (PA)(Section C of the MBI). Multiple factors were associated with increased burnout within PA: Increasing age: 61+ OR: 2.99 (1.02–8.78, p = 0.05), Number of cataract operations completed: >3000 OR 2.98 (1.03–8.64, p = 0.04), Lists per week: 2: OR 2.99 (1.38–6.47, p < 0.01), 2.5: OR 8.95 (2.58–31.02, p < 0.01), 3 or more: OR 2.64 (1.07–6.54, p = 0.04). Sleeping 8 h or more was found to be protective OR 0.52 (0.28–0.96, p = 0.04). 17% of respondents indicated they would be willing to give up cataract surgery if given the opportunity. Conclusion The prevalence of stress induced burnout by cataract surgery appears to be present in a minority of surgeons. There appears to be a significant reduction in the feeling of personal achievement within the profession. A large proportion of this cohort appears to be willing to give up surgical responsibilities.

Across all industries, material specifications are tightening beyond previously understood process capabilities. Slight shifts in material grade, microstructure, heat treatment, or alloy composition can significantly impact long term material integrity. This study examines the feasibility of noncontact, 100% inline magneto-inductive testing on materials and components to ensure material quality standards. To investigate the hypothesis that material grade, carbon content, density, and alloy composition can be accurately tested in real time during production, an experiment was conducted using magneto-inductive test instrumentation and an encircling coil. The results of the investigation confirmed that 100% of the material in a component could be thus tested, accurately, efficiently, and autonomously verifying that the specified material grade with the proper composition and properties had been used.

PurposeTo report prevalence and risk factor associations for age-related macular degeneration (AMD) and AMD features from multimodal retinal grading in a multidisciplinary longitudinal population-based study of aging in Northern Ireland.Study designPopulation-based longitudinal cohort study.MethodsRetinal imaging at the Norther Ireland Cohort for the Longitudinal Aging Study health assessment included stereo Colour Fundus Photography (CFP) (Canon CX-1, Tokyo, Japan) and Spectral-Domain Optical Coherence Tomography (SD-OCT) ((Heidelberg Retinal Angopgraph (HRA)+OCT; Heidelberg Engineering, Heidelberg, Germany). Medical history and demographic information was obtained during a home interview. Descriptive statistics were used to describe the prevalence of AMD and individual AMD features. Multiple imputation followed by multiple regression modelling was used to explore risk factor associations including relationships with AMD genetic risk score.ResultsRetinal images from 3386 participants were available for analysis. Mean age of the sample was 63.4 (SD 9.01, range: 36–99). Population weighted prevalence of AMD using colour grading in those over 55 years was: no drusen: 6 0.4%; drusen 125 µm or pigmentary changes: 8.3%; late AMD: 1.6%. Prevalence of AMD features in those over 55 years was: OCT drusen 27.5%, complete outer retinal pigment epithelium and outer retinal atrophy (cRORA) on OCT was 4.3%, reticular drusen 3.2% and subretinal drusenoid deposits 25.7%. The genetic risk score was significantly associated with drusen and cRORA but less so for SDD alone and non-significant for hyperpigmentation or vitelliform lesions.ConclusionsMultimodal imaging-based classification has provided evidence of some divergence of genetic risk associations between classical drusen and SDD. Our findings support an urgent review of current AMD severity classification systems.

Children who idiopathically toe‐walk (ITW) habitually operate at greater plantarflexion angles and thus, at shorter muscle‐tendon unit (MTU) lengths than typically developing (TD) children. Therefore, it is often assumed that habitual use of the gastrocnemius muscle in this way will cause remodelling of the muscle‐tendon architecture compared to TD children. However, the gastrocnemius muscle architecture of children who ITW has never been measured. It is essential that we gain a better understanding of these muscle‐tendon properties, to ensure that appropriate clinical interventions can be provided for these children. Five children who ITW (age 8 ± 2 years) and 14 TD children (age 10 ± 2 years) participated in this study. Ultrasound was combined with isokinetic dynamometry and surface electromyography, to measure muscle architecture at common positions and passive lengthening properties of the gastrocnemius muscle and tendon across full range of motion. Regardless of which common condition groups were compared under, both the absolute and normalised to MTU muscle belly and fascicle lengths were always longer, and the Achilles tendon length was always shorter in children who ITW than TD children (p 0.05); however, passive joint stiffness was greater in children who ITW at maximum dorsiflexion (p = 0.001) and at a joint moment common to all participants (p = 0.029). Consequently, the findings of this pilot study indicate a remodelling of the relative MTU that does not support the concept that children who ITW commonly experience muscle shortening. Therefore, greater consideration of the muscle and tendon properties are required when prescribing clinical interventions that aim to lengthen the MTU, and treatments may be better targeted at the Achilles tendon in children who ITW., We used ultrasound to measure the gastrocnemius medialis muscle architecture in children who idiopathically toe‐walk (ITW). Despite habitually operating at shorter muscle‐tendon unit lengths, children who ITW presented with longer muscle and shorter tendon lengths than typically developing children. Therefore, these findings indicate a remodelling of the relative muscle‐tendon unit that does not support the concept that children who ITW commonly experience muscle shortening.

Background High-grade spondylolisthesis (HGS) (Myerding grade III-V) in adolescents can lead to a marked alteration of gait pattern and maybe the presenting symptom in these patients. This characteristic gait pattern in patients with HGS has been referred to as the "pelvic waddle." Modern 3-dimensional (3D) gait analysis serves an important tool to objectively analyze the different components of this characteristic gait preoperatively and postoperatively and is an objective measure of postoperative improvement.This study demonstrates the use of 3D gait analysis preoperatively and postoperatively in a cohort of 4 consecutive patients with HGS treated surgically at a single tertiary referral center and utilize this to objectively evaluate outcome of surgical treatment in these patients. This has not been reported previously in a cohort of patients. Methods This is a prospective analysis of patients with HGS who underwent surgical intervention for spondylolisthesis at a single institution. Patient demographics, clinical, and radiologic assessment were recorded, and all patients underwent 3D gait analysis before and after surgical intervention. Kinetic, kinematic, and spatial parameters were recorded preoperatively and postoperatively for all patients. This allowed the outcome of change in gait deviation index, before and after surgical treatment, to be evaluated. Results We were able to review complete records of 4 adolescent patients who underwent surgical treatment for HGS. Mean age at surgery was 13.5 years with a minimum follow-up of 2.5 years postoperatively (average 40 mo). Preoperative gait analysis revealed marked posterior pelvic tilt in 2 patients, reduced hip and knee extension in all 4 patients and external foot progression in 3 of the 4 patients. Along with an observed improvement in gait, there was an objective improvement in gait parameters postoperatively in all 4 patients. Gait deviation index score improved significantly from 78.9 to 101.3 (mean). Conclusions Preoperative gait abnormalities exist in HGS and can be objectively analyzed with gait analysis. Surgical intervention may successfully resolve these gait abnormalities and gait analysis is a useful tool to assess the outcome of surgery and quantify an otherwise intangible benefit of surgical intervention. Level of evidence Level IV-case series.

Data Availability Statement: The datasets generated for this study are available on request to the corresponding author. Copyright © 2020 Harkness-Armstrong, Debelle, Maganaris, Walton, Wright, Bass, Baltzopoulos and O’Brien. Aim: To study the causes of locomotor dysfunction, estimate muscle forces, or understand the influence of altered sarcomere and muscle properties and behaviours on whole body function, it is necessary to examine the leverage with which contractile forces operate. At the ankle joint, current methods to quantify this leverage for the plantarflexors do not account for curvature of the Achilles tendon, and so may not be appropriate when studying equinus gait. Thus, novel methodologies need to be developed and implemented to quantify the Achilles tendon moment arm length during locomotion. Methods: Plantarflexor internal moment arm length and effective mechanical advantage of 11 typically developed young adults were calculated throughout stance, while heel-toe walking and voluntarily toe-walking on an instrumented treadmill. Achilles tendon moment arm was defined in two-ways: (1) assuming a straight tendon, defined between the gastrocnemius medialis myotendinous junction and Achilles tendon insertion point, and (2) accounting for tendon curvature, by tracking the initial path of the Achilles tendon from the calcaneal insertion. Results: When accounting for tendon curvature, Achilles tendon moment arm length and plantarflexor effective mechanical advantage did not differ between walking conditions (p > 0.05). In contrast, when assuming a straight tendon, Achilles tendon moment arm length (p = 0.043) and plantarflexor effective mechanical advantage (p = 0.007) were significantly greater when voluntary toe-walking than heel-toe walking in late stance. Discussion: Assuming a straight Achilles tendon led to a greater Achilles tendon moment arm length and plantarflexor effective mechanical advantage during late stance, compared to accounting for tendon curvature. Consequently, plantarflexor muscle force would appear smaller when assuming a straight tendon. This could lead to erroneous interpretations of muscular function and fascicle force-length-velocity behaviour in vivo, and potentially inappropriate and ineffective clinical interventions for equinus gait. Liverpool John Moores University Ph.D. scholarship.

Proper modeling of the turbulent heat fluxes over lakes is critical for accurate predictions of lake-effect snowfall (LES). However, model evaluation of such a process has not been possible because of the lack of direct flux measurements over lakes. The authors conducted the first-ever comparison of the turbulent latent and sensible heat fluxes between state-of-the-art numerical models and direct flux measurements over Lake Erie, focusing on a record LES event in southwest New York in November 2014. The model suite consisted of numerical models that were operationally and experimentally used to provide nowcasts and forecasts of weather and lake conditions. The models captured the rise of the observed turbulent heat fluxes, while the peak values varied significantly. This variation resulted in an increased spread of simulated lake temperature and cumulative evaporation as the representation of the model uncertainty. The water budget analysis of the atmospheric model results showed that the majority of the moisture during this event came from lake evaporation rather than a larger synoptic system. The unstructured-grid Finite-Volume Community Ocean Model (FVCOM) simulations, especially those using the Coupled Ocean–Atmosphere Response Experiment (COARE)-Met Flux algorithm, presented better agreement with the observed fluxes likely due to the model’s capability in representing the detailed spatial patterns of the turbulent heat fluxes and the COARE algorithm’s more realistic treatment of the surface boundary layer than those in the other models.

The aim of this study was to evaluate the rate of open reduction and complications of elastic stable intramedullary nailing (ESIN) in treating unstable diaphyseal forearm fractures in children. We performed a retrospective review of a consecutive series of 102 paediatric patients with a mean age of 9 years (range: 7-14 years) who underwent ESIN of unstable closed forearm fractures at three different centres. Closed reduction of one or both bones was achieved in 68 (67%) patients and open reduction was required in 34 (33%) patients. The rate of open reduction in single-bone fractures (52.2%) was significantly higher than that in both-bone fractures (27.8%) (P=0.04, Fisher's exact test). All the fractures united within 3 months. There were six refractures following nail removal. Five patients had superficial wound infections. Seven patients developed neuropraxia of the sensory branch of the radial nerve. All resolved spontaneously within 3 months of the surgery. ESIN is an effective technique in treating unstable diaphyseal forearm fractures. The need for open reduction should be decided promptly following failed attempts of closed reduction. Single-bone fractures are more likely to require open reduction than both-bone fractures. The radius should be reduced and stabilized first. If open reduction is required, this should be performed through a volar approach rather than a dorsal one.

U.S. health systems, policy makers, and patients increasingly demand high-value care that improves health outcomes at lower cost. This study describes the initial design and analysis of the Mental Health Management System (MHMS), a performance data and quality improvement tool used by the Veterans Health Administration (VHA) to increase the value of its mental health care. The MHMS evaluates access to and quality of mental health care, organizational structure and efficiency, implementation of innovative treatment options, and, in collaboration with management, resource needs for delivering care. Performance on 31 measures was calculated for all U.S. VHA facilities (N = 139). Pearson correlations revealed that better access to care was significantly associated with fewer mental health provider staffing vacancies (r = -.24) and higher staff-to-patient ratios for psychiatrists (r = .19) and other outpatient mental health providers (r = .27). Higher staff-to-patient ratios were significantly associated with higher performance on a number of patient and provider satisfaction measures (range of r = .18-.51) and continuity of care measures (range of r = .26-.43). Relationships observed between organizational and clinical performance measures suggest that the MHMS is a robust informatics and quality improvement tool that can serve as a model for health systems planning to adopt a value perspective. Future research should expand the MHMS framework to measure patient and health systems costs and psychosocial outcomes, as well as evaluate whether quality improvement solutions implemented as a result of using organizational information leads to higher-value mental health care. (PsycINFO Database Record

Background Flexion deformity of the knee is a common presentation in children with cerebral palsy with hamstring surgery as an option for addressing this. However, concerns with regard to increased pelvic tilt have been raised. The purpose of this study was to compare preoperative and postoperative pelvic tilt after isolated hamstring lengthening versus combined hamstring lengthening and the influence of Gross Motor Function Classification System (GMFCS) levels on pelvic tilt. Methods This retrospective study included 46 ambulatory children with cerebral palsy who had had open medial hamstring lengthening (mean age at surgery, 11 y 11 mo; SD, 2 y 11 mo; GMFCS I, 16; GMFCS II 20; GMFCS III 10). Twelve children underwent isolated surgery and 34 children underwent combined surgery. The isolated hamstring procedures could be combined with foot and/or ankle-level surgery, as only the hamstring procedure would affect the pelvic tilt. Combined surgery was defined as hamstring lengthening with other procedures performed at the knee or more proximally. The preoperative and postoperative 3-dimensional gait analysis data were evaluated in this study. Results Both the isolated and combined hamstring lengthening groups showed no significant change in pelvic tilt ([INCREMENT]1.28, P=0.203; [INCREMENT]1.47, P=0.113, respectively). A significant change in pelvic tilt was seen in children functioning at GMFCS III ([INCREMENT]4.66, P=0.009) but not GMFCS I and II ([INCREMENT]0.37, P=0.718; [INCREMENT]0.48, P=0.697). Significant postoperative decreases in the knee flexion angle at initial contact were seen for both isolated ([INCREMENT]5.72, P=0.010) and combined hamstring lengthening ([INCREMENT]10.95, P Conclusions Hamstring lengthening, for the majority of patients, did not lead to a clinically significant change in mean pelvic tilt and improved knee flexion angle at initial contact. Children who functioned at GMFCS level III had an increase in anterior pelvic tilt and caution should be exercised in this group. Study design Level IV evidence-case series.

There is little consensus on whether Kirschner wire (K-wire) burial is preferable in the management of paediatric lateral humeral condyle fractures. We identified 124 patients from May 2008 to August 2014. Sixty received buried K-wires and 64 received unburied wires. We found no significant difference in the infection rates between groups, but a high rate of skin erosion (23%) in the buried group, with a subsequent high rate of infection in this subgroup (40%). We found a strong association of wire erosion following early surgery. There is a considerable cost saving associated with using unburied wires. We therefore recommend the routine use of unburied wires.

Aim To examine associations between uptake of free primary eye care, service availability (density of optometric practices) and service accessibility (household car access and drive time to nearest provider) after accounting for socioeconomic status and other individual, household and area factors. Methods We constructed a cohort of 294 870 community-dwelling adults aged 60 years, drawing contextual information from the 2011 Northern Ireland Census. Minimum drive times to the nearest optometry practice (1–19 min) and number of practices were derived for 890 geographical areas. The primary outcome was attendance at one or more publicly funded eye examinations to which all cohort members were entitled between 2009 and 2014. We used multiple log-binomial regression to estimate associations between eye care uptake, car ownership and drive time. Results Eye examination uptake was 60.0%. 23.7% of the cohort had no car access, and these individuals had lower uptake than car owners (unadjusted risk ratio (RR) of uptake=0.86 (0.86, 0.87)). Among non-car owners, uptake decreased with drive time (longest vs shortest: RR=0.92 (0.88, 0.97)) with the largest decrease at 4 min drive time (approximately 1.5 miles). This pattern was weaker among car owners. These associations were independent of service availability, which was not associated with uptake. Conclusion Both drive time and household car access were associated with eye care use, adjusting for individual, household and area factors. Policies to improve uptake should target those with no car access, especially those beyond walking distance from the nearest eye care provider.

© 2017 Elsevier Ltd Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63–1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06–3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [