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Priyanka Sharma,1 Haifa A Madi,1 Richard Bonshek,2 Stephen J Morgan11Sunderland Eye Infirmary, Sunderland, UK; 2National Specialist Ophthalmic Pathology Service, Department of Histopathology, Manchester Royal Infirmary, Manchester, UKSummary: We report a case of previously unsuspected myeloma, presenting with cornea verticillata due to intracorneal paraprotein deposition.History: An 85-year-old female presented via her optician with a 4-month history of cloudy vision. She had undergone an uneventful bilateral phacoemulsification surgery 7 years earlier. Extensive spiraling corneal epithelial opacification was noted on slit-lamp examination. On further investigation, she was found to have a previously unsuspected low-grade multiple myeloma. We established the nature of the corneal deposits with corneal epithelial biopsy histopathology and electron microscopy. It is very rare for multiple myeloma to present in this fashion. Ophthalmologists should be aware that such a presentation may rarely be due to systemic multiple myeloma.Keywords: corneal crystals, multiple myeloma, crystalline keratopathy, vortex keratopathy

Saurabh Ghosh,1 Richard Bonshek,2 Stephen J Morgan1 1Sunderland Eye Infirmary, Sunderland, UK; 2National Specialist Ophthalmic Pathology Service (NSOPS) Laboratory, Department of Histopathology, Manchester Royal Infirmary, Manchester, UK Purpose: To report a case of corneal graft failure due to epithelial ingrowth after an uneventful combined Descemet stripping automated endothelial keratoplasty (DSAEK) and phacoemulsification cataract surgery with intraocular lens implant treated successfully with a repeat DSAEK. Methods: A 77-year-old male patient underwent combined DSAEK and phacoemulsification with intraocular lens implant implantation for Fuchs’ endothelial dystrophy plus cataract in the right eye. The donor cornea was cut on the Moria ALTK system and introduced using a suture pull-through technique. After an episode of endothelial rejection, the graft failed, with signs suggesting epithelial ingrowth. It was stripped from the host cornea using a Descemet’s membrane stripper, and a Simcoe irrigation-aspiration cannula was used to remove all traces of interface material. The excised lenticule was examined histologically using a hematoxylin and eosin stain. Result: The patient regained and maintained excellent visual acuity with no sign of recurrence of epithelial ingrowth. Histopathological evaluation of the donor tissue of the first graft showed epithelial ingrowth on the stromal surface of the graft and very few endothelial cells, in keeping with the diagnosis of graft failure. Conclusion: Epithelial ingrowth is a possible cause of endothelial graft failure, but histologically proven cases are rare. Surgical intervention can achieve successful clearance, with the potential for cure and an excellent outcome. Keywords: epithelial ingrowth, Descemet stripping automated endothelial keratoplasty, graft failure

Despite the ever-increasing literature on hip fractures, current treatment guidelines are conflicting and provide no authorative, evidence-based recommendations on the ideal timing and modality of surgical management. [ABSTRACT FROM AUTHOR]

The PF-LCP represents a feasible alternative for the treatment of unstable inter- and subtrochanteric fractures. [ABSTRACT FROM AUTHOR]

During a group A streptococcus (GAS) outbreak 21 abattoir workers developed skin infections. The unusual outbreak strain (emm 108.1) was cultured from five workers and four persons in the community with links to the abattoir. The attack rate was 26% in the lamb line. Communal nailbrushes were neither routinely disinfected nor changed, and had high bacterial counts. A cohort study found a higher risk from working in the gutting area and getting cuts on hands more than weekly. Despite high bacterial counts daily nailbrush use had a lower risk, as did always wearing disposable gloves. Working in the gutting area (OR 11.44) and nailbrush use at least once a day (OR 0.04) were significant in the multivariate model. Transmission of infection is likely to have occurred on carcasses. GAS infection among abattoir workers was once common. Simple hygiene measures, such as nailbrush use, may reduce the impact of future outbreaks. [ABSTRACT FROM AUTHOR]

Background: Autologous bone graft is the so-called gold standard for reconstruction of bone defects and nonunions. The most frequent complication is donor site pain. The iliac crest is a common source for autologous bone graft. The purpose of this study was to determine whether a continuous infusion of 0.5% bupivacaine into the iliac crest harvest site provides pain relief that is superior to the relief provided by systemic narcotic pain medication alone in patients undergoing reconstructive orthopaedic trauma procedures.Methods: A prospective, double-blind randomized study of patients over eighteen years of age who were undergoing harvesting of iliac crest bone graft was conducted. The patients were randomized to the treatment arm (bupivacaine infusion pump) or the placebo arm. Postoperatively, all study patients received morphine sulfate with use of a patient-controlled analgesia pump. The patients recorded the pain at the donor and recipient sites with use of a scale ranging from 0 to 10. The use of systemic narcotic medication was recorded. Independent-samples t tests were used to assess differences in perceived pain relief between the treatment and control groups at zero, eight, sixteen, twenty-four, thirty-two, forty, and forty-eight hours after surgery. Pain was also assessed at two and six weeks postoperatively.Results: Sixty patients were enrolled. Across all data points, except pain at the recipient site at twenty-four hours, no significant differences in the perception of pain were found between the bupivacaine group and the placebo group. On the average, patients in the treatment group reported more pain than those in the control group. No significant difference was found between the two groups with regard to the amount of narcotic medication used.Conclusions: No difference in perceived pain was found between the groups. The results of this small, unstratified study indicate that continuous infusion of bupivacaine at iliac crest bone-graft sites during the postoperative period is not an effective pain-control measure in hospitalized patients receiving systemic narcotic medication. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine the prevalence of posttraumatic stress disorder among patients seen following an orthopaedic traumatic injury and to identify whether injury-related or demographic variables are associated with the disorder.Methods: Five hundred and eighty patients who had sustained orthopaedic trauma completed a Revised Civilian Mississippi Scale for Posttraumatic Stress Disorder questionnaire. Demographic and injury data were collected to analyze potential variables associated with posttraumatic stress disorder.Results: Two hundred and ninety-five respondents (51%) met the criteria for the diagnosis of posttraumatic stress disorder. Patients with posttraumatic stress disorder had significantly higher Injury Severity Scores (p = 0.04), a higher sum of Extremity Abbreviated Injury Scores (p = 0.05), and a longer duration since the injury than those without posttraumatic stress disorder (p < 0.01). However, none of these three variables demonstrated a good or excellent ability to discriminate between patients who had posttraumatic stress disorder and those who did not. The response to the item, "The emotional problems caused by the injury have been more difficult than the physical problems," was significantly associated with the presence of posttraumatic stress disorder (p < 0.0001) and showed a fair ability to identify patients with the disorder.Conclusions: Posttraumatic stress disorder is common after orthopaedic trauma. Patients who respond positively to the item, "The emotional problems caused by the injury have been more difficult than the physical problems," may meet diagnostic criteria for this disorder and should be evaluated further. [ABSTRACT FROM AUTHOR]

Purpose: To describe the incidence of reoperation and factors contributing to surgical revision within a minimum of 10 years after spinal fusion for scoliosis in patients with nonambulatory cerebral palsy (CP)., Methods: We conducted a retrospective review of consecutive nonambulatory patients with CP who underwent primary spinal fusion at a single specialty care center with a minimum of 10 years from their index surgery (surgery dates 2001-2011). Causes of reoperation were classified as implant failure/pseudoarthrosis, surgical site infection (SSI), proximal junctional kyphosis, prominent/symptomatic implants, and implant removal. Reoperation rates with 95% confidence intervals were calculated for each time interval, and an actuarial survival curve was generated., Results: 144 patients met inclusion criteria (mean age = 14.3 ± 2.6 years, 62.5% male); 85.4% had 5 years follow-up data; and 66.0% had 10 years follow-up data. Estimates from the actuarial analysis suggest that 14.9% (95% CI: 10.0-22.0) underwent reoperation by 5 years postsurgery, and 21.7% (95% CI: 15.4-30.1) underwent reoperation by 10 years postsurgery. The most common causes for reoperation were implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants., Conclusions: To our knowledge, this study is the largest long-term follow-up of nonambulatory patients with CP and neuromuscular scoliosis who underwent spinal fusion. Approximately 22% of these patients required reoperation 10 years after their index surgery, primarily due to implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. Complications and reoperations continued throughout the 10 years period after index surgery, reinforcing the need for long-term follow-up as these patients transition into adulthood., Level of Evidence: III., (© 2024. The Author(s).)

Background: Rainbow young people (RYP; people of diverse genders, sexualities, and variations in sex characteristics) face barriers accessing primary care, often report negative experiences and the need to educate clinicians on rainbow-specific issues. This study explores general practice staff views and experiences of providing care to RYP., Methods: Three focus groups were held with staff from 5 general practices in an urban area of Aotearoa New Zealand (25 participants in total). Practices were purposively selected to include some known to be more "rainbow-friendly" seeing larger numbers of RYP and some with no particular focus on RYP. All members of each practice were invited to participate, including administration and reception staff. Focus groups were audio-recorded, transcribed, and analysed in NVivo using inductive thematic analysis., Results: Four main themes were identified: (i) Practice experience, (ii) Feeling awkward, (iii) Knowledge and training, and (iv) Structural barriers. Differences were apparent in health provider knowledge, comfort, and experience in providing care to RYP. Participants identified a lack of knowledge and training and wanted more resources and education. Systems limitations were common (e.g. with IT systems for recording gender) and often contributed to awkward clinical encounters., Conclusions: Participants recognized shortcomings in their training, knowledge, and level of confidence providing care to RYP and expressed a desire to improve their competency. Further work is needed to identify and trial practical strategies that help improve communication skills, knowledge, and the delivery of more equitable healthcare to RYP., (© The Author(s) 2023. Published by Oxford University Press.)