Streamlined mail-based methods for large randomised trials: lessons learnt from the ASCEND study.

Reliable assessment of the effects of an intervention usually requires large randomised trials but such studies are becoming increasingly complex and costly to run. 'Streamlined' trials are needed in which every aspect of the trial design and conduct is simplified, retaining only those elements needed to answer the research question and ensure the safety of the individual participants. In this review we discuss how the trial 'A Study of Cardiovascular Events iN Diabetes' (ASCEND) was streamlined. The study included a two-by-two factorial design: it assessed the effects of low-dose aspirin and, separately, supplementation with n-3 fatty acids on serious vascular events in 15,480 people with diabetes but no overt cardiovascular disease. Other key streamlined design features, such as mail-based recruitment and follow-up, mainly by post, with no in-person visits and use of a run-in period, are also described. We go on to discuss the success of the study and other studies that have employed a similar mail-based approach, and the type of clinical trials that are suitable for mail-based design. Finally, we consider the limitations of the study, and how these could be circumvented in future studies. ASCEND randomised large numbers of eligible participants, achieved good adherence rates and almost complete follow-up at a fraction of the cost of traditional clinic-based trials. Such studies are necessary if researchers are to address the important clinical questions most relevant to improving health.

LDL-cholesterol reduction in chronic kidney disease: options beyond statins.

PURPOSE OF REVIEW: Individuals with chronic kidney disease (CKD) are at increased risk of atherosclerotic cardiovascular disease (ASCVD) events. LDL cholesterol (LDL-C) is a key modifiable cause of ASCVD and lowering LDL-C with statins reduces the risk of ASCVD events in a wide range of populations, including those with CKD. This review considers the utility of recently developed nonstatin LDL-C-lowering therapies in CKD. RECENT FINDINGS: The cholesterol absorption inhibitor, ezetimibe, reduces LDL-C by 15-20% and is well tolerated in CKD. Monoclonal antibodies (mAbs) targeting proprotein convertase subtilisin kexin type 9 (PCSK9) reduce LDL-C by 50-60% and reduce the risk of ASCVD events. However, these agents require self-administration by subcutaneous injection every 2-4 weeks. The PCSK9 synthesis inhibitor, inclisiran, is administered approximately 6 monthly and may be more suitable for widespread use, although outcome trials are awaited. These PCSK9 targeting therapies require no dose adjustment in CKD and have no drug interactions. SUMMARY: Statins and ezetimibe are safe and reduce ASCVD risk in CKD populations. PCSK9 targeting agents may be useful in high-risk CKD patients, including those with prior ASCVD.

Growth of Rhodes grass and leaching of ions from seawater neutralized bauxite residues after amendment with gypsum and organic wastes.

A 32-week leaching column study was carried out in the greenhouse to investigate the effects of incorporation of gypsum, cattle manure, biosolids, gypsum plus cattle manure and gypsum plus biosolids into the topsoil layer (0-10 cm) on growth of Rhodes grass, and on root distribution and chemical and microbial properties in the topsoil and subsoil (10-30 cm) layers of seawater neutralized bauxite residues. The columns were leached for a period of 8 weeks prior to sowing Rhodes grass and during that time the bulk of the salts accumulated during seawater neutralization were leached out. The main cation leached was Na+ and the main balancing anions were Cl- and SO42-. During this period the pH of leachates rose from 7 to 8 up to 9-10. At the end of the study, exchangeable Na and pH were lowered in the surface horizon by all treatments with a combination of gypsum plus organic amendments having the greatest effect. The latter treatments also caused a significant decrease in pH, extractable Al and exchangeable Na in the subsoil. Rhodes grass dry matter production followed the order Control < gypsum < cattle manure = gypsum plus cattle manure < biosolids = gypsum plus biosolids. Growth of roots into the subsoil layer was inhibited in the Control and gypsum treatments but when organic amendments were applied, 50% or more of root dry matter was recovered in the subsoil layer. It was concluded that incorporating a combination of gypsum and organic matter into the surface soil is an effective strategy for revegetation of bauxite residue.

Properties of seawater neutralized bauxite residues and changes in chemical, physical and microbial properties induced by additions of gypsum and organic matter.

Seawater neutralization is a technique that can be used to treat bauxite residue prior to its storage but, as yet, no attempts have been made to revegetate it. Seawater neutralized bauxite residue was found to have a pH1:5 of 9.3 and to be highly saline (EC1.5 16.5 dS m-1). After leaching pH1:5 rose to 9.7 and the residue was still highly sodic (ESP = 64-69%). Addition of 1% gypsum, prior to leaching, arrested this increase in pH while with 5% gypsum addition the pH1:5 was lowered to 8.9. Addition of 5% gypsum also reduced ESP to 38% and increased watercress germination in the residue from 58% in control treatments to 88%. The major ions in leachates were Na+ and Cl- and gypsum application increased the quantities of Na+, Ca2+ and SO42- leached. Addition of 6% biosolids or 6% poultry manure added exchangeable cations to the mud and lowered ESP by 5-11%.The EC was 2.8-3.7 (mean 3.1) times higher and pH 0.2-0.7 (mean 0.43) units lower in saturation paste compared with 1:5 soil:water extracts. Addition of amendments had only small effects on physical properties. While organic C content was increased more by biosolids than poultry manure addition the reverse was the case for soluble organic C, microbial biomass C and basal respiration. It was concluded that although seawater neutralization initially lowers the pH of bauxite residues it is unlikely to increase the ease with which they can be revegetated.

Rhegmatogenous retinal detachment following intravitreal ocriplasmin.

PURPOSE: To describe the characteristics and outcomes of patients presenting with rhegmatogenous retinal detachment (RRD) after ocriplasmin (OCP) injection. METHODS: Retrospective, multi-centre, observational case series with case note review. RESULTS: Eight patients with symptomatic vitreomacular traction (six with concomitant macular hole) were diagnosed with RRD after a median of 16 days (range 3-131 days) post-OCP injection. Presentation was within 3 weeks of the OCP injection in six of the cases. Five patients presented with symptoms post-OCP, and three were diagnosed asymptomatically on planned visits. Seven cases were phakic, one had high myopia (>8 dioptres), and two cases had lattice degeneration. Following RRD surgery, hole closure was achieved in 5/6 MH cases. The final median BCVA at 7 months was 20/80 (range 20/40-20/1200) similar to the baseline BCVA 20/80, with four patients gaining ≥1 line of vision compared to baseline but three losing ≥3 lines. CONCLUSIONS: RRD is a non-negligible risk associated with intravitreal OCP, and it should be used with caution in eyes with high myopia and peripheral retinal pathology predisposing to RRD. Detailed peripheral retinal examination is recommended pre- and postoperatively at all visits. Patients should be advised to seek attention if symptoms recur after initial presentation.

Sequential Hypothesis Testing to Characterise the Learning Curve and Monitor Surgical Performance in Retinal Detachment Surgery.

PURPOSE: To characterise the learning curve of primary retinal detachment (RD) repair for trainee surgeons and monitor the outcomes of surgery for established surgeons. PROCEDURES: Primary RD operations were analysed sequentially using the cumulative sum (CUSUM) and the sequential probability ratio test (SPRT). RESULTS: 359 analysed cases of primary RD were audited with a recurrent RD (ReRD) rate of 14.7%. The individual rate of ReRD ranged from 9.4 to 17.4% (p = 0.74). SPRT and CUSUM analyses showed that ReRD occurred at random when operated by senior surgeons but a learning curve was discernible for junior surgeons. There was a trend for a higher proportion of ReRD caused by untreated breaks in cases operated by junior surgeons (p = 0.75). CONCLUSION: SPRT and CUSUM are useful methods to monitor surgical outcomes and should be included in audits of sequential operations such as RD. Trainee surgeons experience a quantifiable learning curve.

Accuracy of heart failure ascertainment using routinely collected healthcare data: a systematic review and meta-analysis.

BACKGROUND: Ascertainment of heart failure (HF) hospitalizations in cardiovascular trials is costly and complex, involving processes that could be streamlined by using routinely collected healthcare data (RCD). The utility of coded RCD for HF outcome ascertainment in randomized trials requires assessment. We systematically reviewed studies assessing RCD-based HF outcome ascertainment against "gold standard" (GS) methods to study the feasibility of using such methods in clinical trials. METHODS: Studies assessing International Classification of Disease (ICD) coded RCD-based HF outcome ascertainment against GS methods and reporting at least one agreement statistic were identified by searching MEDLINE and Embase from inception to May 2021. Data on study characteristics, details of RCD and GS data sources and definitions, and test statistics were reviewed. Summary sensitivities and specificities for studies ascertaining acute and prevalent HF were estimated using a bivariate random effects meta-analysis. Heterogeneity was evaluated using I2 statistics and hierarchical summary receiver operating characteristic (HSROC) curves. RESULTS: A total of 58 studies of 48,643 GS-adjudicated HF events were included in this review. Strategies used to improve case identification included the use of broader coding definitions, combining multiple data sources, and using machine learning algorithms to search free text data, but these methods were not always successful and at times reduced specificity in individual studies. Meta-analysis of 17 acute HF studies showed that RCD algorithms have high specificity (96.2%, 95% confidence interval [CI] 91.5-98.3), but lacked sensitivity (63.5%, 95% CI 51.3-74.1) with similar results for 21 prevalent HF studies. There was considerable heterogeneity between studies. CONCLUSIONS: RCD can correctly identify HF outcomes but may miss approximately one-third of events. Methods used to improve case identification should also focus on minimizing false positives.

Simultaneous necrotizing glomerulonephritis and Hodgkin's lymphoma: a case report and review of the literature.

Glomerulonephritis occurs in 1% of Hodgkin's lymphoma patients. In the even rarer setting of rapidly progressive glomerulonephritis, lymphoma may go unrecognized. We describe a case of necrotizing glomerulonephritis in which treatment with cyclophosphamide and steroids led to resolution of lymphadenopathy. Two years later, recrudescent lymphadenopathy was shown to be Hodgkin's lymphoma, but renal disease did not recur.

Presentation and survival of patients with severe acute kidney injury and multiple myeloma: a 20-year experience from a single centre.

BACKGROUND: Myeloma is the second most common haematological malignancy and is a cause of severe acute kidney injury (serum creatinine >or=500 micromol/L) that has long been associated with a poor prognosis, although previous series have been small. METHODS: We have therefore documented the natural history of all 107 patients referred to a large regional renal unit over a 20-year period and investigated factors associated with survival over a long period of time using Cox regression methods. RESULTS: Three factors were found to be significantly and independently associated with survival: use of chemotherapy [hazard ratio (HR) 0.21, 95% CI: 0.08-0.46, P < 0.001], serum albumin (HR 0.49, 95% CI: 0.29-0.82, P = 0.02 for >or=35 g/L versus <35 g/L) and dialysis independence (HR 0.43, 95% CI: 0.24-0.76, P = 0.005). However, survival was not found to be better for patients presenting in the second decade compared to the first (HR 0.88, 95% CI: 0.52-1.50, P = 0.65). CONCLUSIONS: This analysis highlights the need for clinical trials of novel chemotherapy regimens in this complicated group of patients. Furthermore, whether strategies to restore or preserve dialysis-independent renal function provide additional benefit to effective chemotherapy also requires further investigation. The advent of efficacious low toxicity chemotherapy (such as thalidomide and bortezomib) and new dialysis techniques to remove free light chains may radically alter the outcome of this group of patients.

Removal of Al, Ga, As, V and Mo from alkaline wastewater using pilot-scale constructed wetlands.

The study was initiated to evaluate constructed wetland technology as a method for treating alkaline (pH 8.0-8.6) drainage high in Al, Mo, V, As and Ga originating from bauxite residue storage areas. Pilot-scale horizontal flow constructed wetlands were operated over a 40-week period using three filter materials (granitic gravel, bauxite and alum water treatment sludge), and half of the wetlands were planted with Phragmites australis and the other half left unplanted. Gravel was the least effective medium for removing the target elements, while of the two active media, water treatment sludge was more effective than bauxite. Plants removed only small amounts of elements into their above- and below-ground dry matter (0.4-4.9% of that added). Nonetheless, the presence of plants greatly increased the effectiveness of all three media since their presence decreased effluent pH values by 0.5-1.3 pH units and that of the filter media by 0.4 pH units. Removal of elements followed the order Al > Ga > V > As > Mo. For planted wetlands, total elemental removal ranged from 18 to 98% for gravel, 80 to 99% for bauxite, and 93 to 99% for water treatment sludge. The lowest removal was for Mo (ranging from 18% for gravel to 93% for water treatment sludge) and the highest for Al (ranging from 98% in gravel to 99% in water treatment sludge). A sequential fractionation scheme for As, V and Mo on filter material at the end of the experiment showed that for bauxite and water treatment sludge, V and As were concentrated in the NaOH extractable fraction while Mo was concentrated in the less strongly adsorbed NaHCO3 extractable fraction. It was concluded that a constructed wetland with water treatment sludge as an active filter material is an effective technology for removal of the target elements from the alkali drainage.

Outcomes after Epiretinal Membrane Surgery with or Without Internal Limiting Membrane Peeling.

INTRODUCTION: The aim of this study was to assess the incidence of persistent postoperative cystoid macular edema (pCME) in patients undergoing pars plana vitrectomy with epiretinal membrane peel (ERM) only versus those with ERM peel combined with internal limiting membrane peel (ILM). Secondary endpoints of the study were to review both the central macular thickness (CMT) and visual acuity. METHODS: The patients were divided in two groups, one group in which only the ERM was peeled (n = 36 patients) and another group in which both the ERM and the ILM were removed (n = 62 patients). The results were analyzed retrospectively. Each patient received a complete ophthalmological examination, including best-corrected visual acuity (BCVA) using an ETDRS chart and spectral domain optical coherence tomography, at three time points: prior to surgery and 3 weeks and 3 months after surgery. RESULTS: A total 98 eyes of 98 patients were included in this study. The mean follow-up time was 7.7 months. CMT decreased significantly after surgery in all patients, and none of these changes differed significantly between the two groups. The BCVA increased significantly after surgery across all patients, and there were no significant changes between the two treatment groups. Postoperative pCME occurred in eight patients in each group, representing 22.2% of the 36 patients in the ERM only group and 12.9% of the 62 patients in the ERM/ILM peel group. However, this difference was not statistically significant. CONCLUSIONS: No difference was found between the two groups in terms of incidence of pCME. Both groups experienced had similar decrease in the CMT and improvement in the BCVA postoperatively.

Effect of pH and added slag on the extractability of Si in two Si-deficient sugarcane soils.

The effects of increasing pH on the adsorption and extractability of Si in two Si-deficient Australian sugarcane soils was investigated and the effects of increasing rates of fertilizer Si (as blast furnace slag) on pH and extractable Si were also examined. Equilibrium studies showed that maximum adsorption of Si by the two soils occurred in the pH range 9-10. When soil pH was increased from 5.0 to 6.5, subsequent adsorption of Si by the two soils, as measured by adsorption isotherms, increased. After incubation with progressive lime additions there was a decline in CaCl2- extractable Si due to its increased adsorption and an increase in acid (H2SO4- and acetic acid)-extractable (mainly adsorbed) Si. The increase in acid extractable Si was greater than the decrease in CaCl2- extractable Si suggesting a supply from an additional source. Alkali (Na2CO3 and Tiron)-extractable Si decreased greatly with increasing pH suggesting dissolution of the amorphous (mainly biogenic) pool of silica was occurring with increasing pH. When increasing rates of slag were incubated with the soils, pH, CaCl2- and acid- extractable Si were all increased because upon dissolution slags release both silicic acid and OH- ions. There was, therefore, a positive relationship between extractable Si and soil pH. However, Na2CO3-and Tiron-extractable Si decreased with increasing slag rates (and increasing soil pH) suggesting dissolution of the biogenic pool of soil Si. It was concluded that future research needs to examine the desorption potential of adsorbed Si and the effects of liming on dissolution of the biogenic pool of soil silica under field conditions.

Competitive adsorption and desorption of arsenate, vanadate, and molybdate onto the low-cost adsorbent materials alum water treatment sludge and bauxite.

When low-cost adsorbents are being used to remove contaminant ions (e.g. arsenate, vanadate, and molybdate) from wastewater, competitive adsorption/desorption are central processes determining their removal efficiency. Competitive adsorption of As, V, and Mo was investigated using equimolar oxyanion concentrations in single, binary, and tertiary combinations in adsorption isotherm and pH envelope studies while desorption of previously adsorbed oxyanions was examined in solutions containing single and binary oxyanion combinations. The low-cost adsorbent materials used were alum water treatment sludge (amorphous hydroxy-Al) and bauxite ore (crystalline Al oxides). Adsorption isotherm and pH envelope studies showed that Mo had only a small effect in decreasing adsorption of As and V but V and As had substantial and similar effects in reducing adsorption of the other. As had a greater effect than V in reducing adsorption of Mo and it was concluded that the affinity of oxyanions for the surfaces of water treatment sludge and bauxite followed the order As > V >> Mo. In 0.3 M NaCl electrolyte, desorption of previously adsorbed oxyanions amounted to 0.3-3.4% for V and As, and 11-20% for Mo. As had approximately four times greater effect than Mo in increasing desorption of V while V had about three times the effect of Mo in increasing desorption of As. Thus, the order of oxyanions in inducing desorption of the other oxyanions (i.e. As on V and As) was the same as that for adsorption selectivity: As > V >> Mo. Water treatment sludge was a more effective adsorbent than bauxite because it had a greater adsorption capacity for all three anions and, in addition, they were held more strongly so desorption in the background electrolyte was proportionately less. It was concluded that at similar molar concentrations, arsenate would tend to reduce adsorption of vanadate as well as displace vanadate already held on adsorbent surfaces while both anions will compete effectively with molybdate. The limiting factor for simultaneous removal of As, V, and Mo from multielement solutions by adsorption will therefore be the removal of Mo.

Increased leaching and addition of amendments improve the properties of seawater-neutralized bauxite residue as a growth medium.

Laboratory and greenhouse experiments were carried out to investigate the chemical, physical, and microbial properties of seawater-neutralized bauxite residues and the effects of additional leaching (1 pore volume of deionized water versus an additional 6 pore volumes) and amendment with gypsum (5%) and/or cattle manure (6%) on its properties and on the growth of Rhodes grass (Chloris gayana). Additional leaching resulted in a decrease in EC, exchangeable Na, SAR, and ESP. For unamended control treatments, additional leaching induced a rise in pHSE from 8.5 to 9.6 and pH1:5 from 9.1 to 10.1 due to dissolution of residual alkalinity. Addition of gypsum arrested this pH increase resulting in a final pHSE of 7.5 and pH1:5 of 8.8. In control treatments, additional leaching resulted in a pronounced decrease in Rhodes grass yields. However, in gypsum and cattle manure-amended treatments, it led to substantial yield increases and decreases in tissue Al and Na concentrations and increased K/Na ratios. Upon drying for the first time, bauxite residue was shown to contract and form a solid massive structure. The aggregates formed from crushing this material were water stable (as measured by wet sieving). Additions of cattle manure or gypsum to residue aggregates did not affect pore size distribution. Addition of cattle manure increased organic C and microbial biomass C content and basal respiration rate while additional leaching increased basal respiration and metabolic quotient. It was concluded that a combination of drying and crushing the residue, amending it with gypsum and organic manure followed by extensive leaching results in the formation of a medium that supports plant growth.

The management of macular hole retinal detachment and macular retinoschisis in pathological myopia; a UK collaborative study.

PURPOSE: To study UK practice patterns for the management of retinal detachment secondary to macular hole (MHRD) and macular retinoschisis (MRS) in pathological myopia (PM). To review the anatomical and visual outcomes of the surgically managed cases. METHODS: A prospective observational case series for the management of MHRD was undertaken in association with the British Ophthalmological Surveillance Unit (BOSU). The results were combined with retrospective data, collected by the COllaboration of British RetinAl Surgeons (COBRA), on the management of both MHRD and MRS in PM in the UK. A total of 20 cases of MHRD and 53 cases of MRS (27 surgical cases and 26 cases managed conservatively) are reported in this combined study. RESULTS: MHRD: Mean baseline best corrected visual acuity (BCVA) was 1.60 logMAR. All cases underwent pars plana vitrectomy (PPV). Mean post-operative BCVA was 1.49 logMAR (p = 0.674). The macular hole was closed in 5/20 (25%) cases, open/flat in 10/20 (50%) cases and open/elevated in 4/20 cases (20%). MRS: Mean baseline BCVA was 0.87 logMAR in the surgical group and 0.45 logMAR in the conservatively managed group (p = 0.002). All eyes that had surgical intervention underwent PPV. Mean post-operative BCVA was 0.68 logMAR (p = 0.183). Anatomical outcomes demonstrated a persistent MRS in 2/27 (7.4%) cases, partial resolution in 7/27 (25.9%) cases and complete resolution in 16/27 (59.2%) cases. CONCLUSIONS: PPV is the only surgical procedure performed for the management of MHRD and MRS amongst the study participants. Success rates and visual outcomes are limited for MHRD and consistent with the current literature for MRS.

Recovery from macular phototoxicity after corneal triple procedure.

PURPOSE: Visual recovery from macular phototoxicity in 2 cases after prolonged exposure to operating microscope light from uncomplicated corneal triple-procedure surgery. Recovery is discussed in the context of repair and regeneration. METHODS: Retrospective case reports. RESULTS: Immediately postoperatively, both patients reported positive scotomata and were found to have macular retinal pigment epithelial depigmentation. In 1 case, the fovea was involved. By 6 to 12 months, the scotomata had disappeared despite large areas of retinal pigment epithelial hyperpigmentation remaining. CONCLUSION: Recovery from macular phototoxicity occurs, although the mechanism remains unclear. Positive scotomata in these cases resolved over several months. The time scale of recovery was consistent with the time required for cellular replacement and possible differentiation from neural progenitor cells.

The Core Competencies for General Orthopaedic Surgeons.

BACKGROUND: With the changing delivery of orthopaedic surgical care, there is a need to define the knowledge and competencies that are expected of an orthopaedist providing general and/or acute orthopaedic care. This article provides a proposal for the knowledge and competencies needed for an orthopaedist to practice general and/or acute care orthopaedic surgery. METHODS: Using the modified Delphi method, the General Orthopaedic Competency Task Force consisting of stakeholders associated with general orthopaedic practice has proposed the core knowledge and competencies that should be maintained by orthopaedists who practice emergency and general orthopaedic surgery. RESULTS: For relevancy to clinical practice, 2 basic sets of competencies were established. The assessment competencies pertain to the general knowledge needed to evaluate, investigate, and determine an overall management plan. The management competencies are generally procedural in nature and are divided into 2 groups. For the Management 1 group, the orthopaedist should be competent to provide definitive care including assessment, investigation, initial or emergency care, operative or nonoperative care, and follow-up. For the Management 2 group, the orthopaedist should be competent to assess, investigate, and commence timely non-emergency or emergency care and then either transfer the patient to the appropriate subspecialist's care or provide definitive care based on the urgency of care, exceptional practice circumstance, or individual's higher training. This may include some higher-level procedures usually performed by a subspecialist, but are consistent with one's practice based on experience, practice environment, and/or specialty interest. CONCLUSIONS: These competencies are the first step in defining the practice of general orthopaedic surgery including acute orthopaedic care. Further validation and discussion among educators, general orthopaedic surgeons, and subspecialists will ensure that these are relevant to clinical practice. CLINICAL RELEVANCE: These competencies provide many stakeholders, including orthopaedic educators and orthopaedists, with what may be the minimum knowledge and competencies necessary to deliver acute and general orthopaedic care. This document is the first step in defining a practice-based standard for training programs and certification groups.

Functional significance of bone density measurements in children with osteogenesis imperfecta.

BACKGROUND: The treatment of osteogenesis imperfecta has been directed at improvement of bone mineral density, yet the importance of bone mineral density in predicting functional and clinical outcome in this patient population has not been demonstrated. We used a validated functional outcome measure to identify the relationship between bone mineral density and physical function in children with osteogenesis imperfecta, and we also evaluated the relationship of bone mineral density to the rate of surgery and fracture in patients with osteogenesis imperfecta. METHODS: Twenty patients (age range, four to seventeen years) with osteogenesis imperfecta who had undergone bone mineral densitometry as measured by dual x-ray absorptiometry of the lumbar spine, wrist, and proximal aspect of the femur between November 1999 and April 2001 were retrospectively analyzed. Functional outcome was measured with use of the Pediatric Outcomes Data Collection Instrument. These questionnaires were completed by the parents of all twenty patients and, in addition, by fifteen patients in the study who were between the ages of eleven and eighteen years. Fracture and surgery rates were calculated on the basis of the number of documented fractures and surgical procedures that the patient had had from the time of the initial presentation until the time of the latest follow-up visit. RESULTS: There were significant relationships between the bone mineral density of the lumbar spine and the scores obtained on the parent-completed questionnaires with regard to upper-extremity functioning (r = 0.57, p < 0.01), transfers and basic mobility (r = 0.55, p = 0.01), sports and physical functioning (r = 0.55, p = 0.01), and global functioning (r = 0.60, p < 0.004). There were also significant relationships between the bone mineral density of the wrist and the scores obtained on the child-completed questionnaires with regard to upper-extremity functioning (r = 0.82, p < 0.01), sports and physical functioning (r = 0.76, p < 0.01), and global functioning (r = 0.83, p = 0.001). There were significant negative relationships between the bone mineral density of the lumbar spine and the rate of fractures (r = -0.69, p < 0.001) and the bone mineral density of the lumbar spine and the rate of surgery (r = -0.60, p < 0.01). CONCLUSIONS: There is a relationship between bone mineral density and the functional outcome, rate of fracture, and rate of surgery in patients with osteogenesis imperfecta. Bone mineral density appears to be an indicator of disease severity and may be predictive of long-term functional outcome. To establish specific guidelines for treatment, more data on normative bone-mineral density in children with osteogenesis imperfecta will be needed.

Risk factors for retinal detachment following cataract surgery: the impact of posterior capsular rupture.

AIM: To investigate risk factors for retinal detachment (RD) after cataract surgery, particularly posterior capsular rupture (PCR) with or without vitreous loss. METHODS: Single centre electronic medical record database study of 18 065 consecutive first eye cataract operations performed between 2005 and 2014. Survival analysis was performed with Kaplan-Meier curves and a Cox proportional hazard regression analysis to calculate HRs with respect to RD. RESULTS: The RD rate at 3 months and 7 years was 0.067% and 0.30%, respectively, with a median time to RD of 15 months (mean: 18 months, range: 0-84 months). Men had a higher RD risk (HR 2.00; 95% CI 1.03 to 3.88; p=0.03) in the univariate model. Patients <60 years and those >80 years had an HR of 5.12 (95% CI 2.60 to 10.07; p<0.001) and 0.16 (95% CI 0.38 to 0.69; p=0.01), respectively, compared with patients 60-80 years of age. Eyes longer than 25 mm had an HR of 3.98 (95% CI 1.93 to 8.20; p<0.001) compared with eyes 23-25 mm. PCR occurred in 400 (2.2%) eyes. The HR for RD was 12.83 (95% CI 5.62 to 29.30; p<0.001) for PCR with vitreous loss. There were no RD events in eyes with PCR without vitreous loss. CONCLUSIONS: The risk for RD after cataract surgery is higher in younger patients and eyes with longer axial length or PCR with vitreous loss during surgery.