Evaluation of the utility of hospital databases to provide data in assessing the quality of strabismus surgery.

AIMS AND BACKGROUND: Rates of re-operation, which may be related to an unsatisfactory surgical outcome, can provide a long-term index of the quality of strabismus surgery. This study aims to evaluate the utility of the Scottish Morbidity Records (SMR1) in determining nature and rates of re-operation for strabismus at the Royal Hospital for Sick Children (RHSC), Glasgow. METHODS: SMR1 data on strabismus surgery performed on children aged between 0 and 17 years at the RHSC, Glasgow, between January 2000 and March 2009 were analysed. RESULTS: In total, 1376 strabismus procedures were carried out on 1274 individuals. The median time between first and subsequent procedures was 19 months; the commonest reasons being under-correction or recurrence. The Kaplan-Meier rate of undergoing re-operation was 7.4% after 9 years with a 95% confidence interval of 5.4-9.9%. CONCLUSIONS: The SMR1 is a useful source of hospital-based and population data. With supplementation from parallel databases, routine administrative databases like the SMR1 can provide better quality data to inform practice.

Ophthalmic, clinical and visual electrophysiological findings in children born to mothers prescribed substitute methadone in pregnancy.

BACKGROUND AND AIMS: There are growing concerns regarding visual outcome of infants exposed to opiates (including substitute methadone) and/or benzodiazepines in utero. We describe the combined ophthalmology and visual electrophysiology findings in 20 infants and children who had been exposed to substitute methadone and other drugs of misuse in utero. METHODS: This was a descriptive case series of 20 patients, all of whom had been referred to a paediatric visual electrophysiology service because of concerns regarding visual function, and all of whom had been exposed to methadone in utero. All children underwent a full ophthalmic and orthoptic examination as well as visual electrophysiology testing deemed appropriate on an individual basis. A review was undertaken of paediatric case notes and of maternal antenatal urine toxicology. RESULTS: Ophthalmic abnormalities included reduced acuity (95%), nystagmus (70%), delayed visual maturation (50%), strabismus (30%), refractive errors (30%), and cerebral visual impairment (25%). Visual electrophysiology was abnormal in 60%. A quarter of the children had associated neurodevelopmental abnormalities. The majority of children with nystagmus (79%) had been treated for neonatal abstinence syndrome (NAS). CONCLUSION: Infants born to drug-misusing mothers prescribed methadone in pregnancy are at risk of a range of visual problems, the underlying causes of which are not clear. Those infants with NAS severe enough to receive pharmaceutical treatment may be at particular risk of developing nystagmus. The inclusion of visual electrophysiology in comprehensive visual assessment of children exposed to substance misuse in utero may help clarify the underlying causes by differentiating abnormalities of retinal and cortical origin.

The association between maternal smoking in pregnancy, other early life characteristics and childhood vision: the Twins Eye Study in Tasmania.

PURPOSE: To investigate the association between maternal smoking in pregnancy, early-life environment and childhood vision. METHODS: Twin and triplet children enrolled in the Twins Eye Study in Tasmania underwent a comprehensive ophthalmic examination and their parents/guardians retrospectively answered a questionnaire regarding crawling, walking and other measures. A subset of these twins was also in the Tasmanian Infant Health Survey, which prospectively collected data on antenatal smoking, gestation, birth weight and other factors. RESULTS: The mean age of the 346 individuals (172 multiple birth sets) at the time of examination was 9.25+/-2.4 years. Mean unaided visual acuity was 0.0 (6/6). The mean spherical equivalent was +0.87D, and decreased with increasing child age (p<0.01). A prospective analysis, accounting for birth set clustering and relevant confounders, showed increasing levels of maternal smoking in the third trimester was associated with poor stereoacuity on the Titmus test (worse (>) than 100'', p=0.05) and Lang test (p=0.001) and also with the presence of esotropia (p=0.02). These associations persisted after adjustment for infant postnatal smoke exposure at one month of age. Poor stereoacuity on Titmus stereo test circles was associated with late age of first crawling (RR=1.23 (1.06, 1.42) p=0.005 per month) and late age of first walking (RR 1.18 (1.05, 1.22) p=0.001 per month). CONCLUSIONS: Antenatal smoking was independently associated with poor stereovision and the presence of esotropia. Poor stereoacuity may be associated with delayed age at first crawling or walking.

Prevalence of CYP1B1 mutations in Australian patients with primary congenital glaucoma.

Analysis of CYP1B1 in primary congenital glaucoma (PCG) patients from various ethnic populations indicates that allelic heterogeneity is high, and some mutations are population specific. No study has previously reported the rate or spectrum of CYP1B1 mutations in Australian PCG patients. The aim of this study is to determine the frequency of CYP1B1 mutations in our predominately Caucasian, Australian cohort of PCG cases. Thirty-seven probands were recruited from South-Eastern Australia, along with 100 normal control subjects. Genomic DNA was extracted and the coding regions of CYP1B1 analysed by direct sequencing. Sequence analysis identified 10 different CYP1B1 disease-causing variants in eight probands (21.6%). Five subjects were compound heterozygotes, two subjects heterozygous and one homozygous for CYP1B1 mutations. Three missense mutations are novel (D192Y, G329D, and P400S). None of the novel mutations identified were found in normal controls. One normal control subject was heterozygous for the previously reported CYP1B1 R368H mutation. Six previously described probable polymorphisms were also identified. Mutations in CYP1B1 account for approximately one in five PCG cases from Australia. Our data also supported the high degree of allelic heterogeneity seen in similar studies from other ethnic populations, thereby underscoring the fact that other PCG-related genes remain to be identified.

Nail-patella syndrome and its association with glaucoma: a review of eight families.

BACKGROUND: Nail-patella syndrome (NPS) is a rare autosomal dominant syndrome, characterised by dysplasia of the nails, patellae, elbows and iliac horns. Mutations in the LMX1B gene were found in four North American families in whom glaucoma cosegregated with NPS. AIMS: To investigate the association of glaucoma with NPS in Australian families and to determine how common NPS is in Australia. METHODS: One family with NPS and glaucoma was identified from the Glaucoma Inheritance Study in Tasmania. A further 18 index cases of NPS were identified from the genetics database for southeastern Australia. Eight of these pedigrees were available for comprehensive glaucoma examination on available family members. DNA was sequenced for mutations in LMX1B. RESULTS: In total, 52 living cases of NPS were identified suggesting a minimum prevalence of at least 1 in 100 000. 32 subjects from eight NPS pedigrees (four familial and four sporadic cases) were examined. 14 subjects had NPS alone. 4 subjects had NPS and glaucoma or ocular hypertension. Five pedigrees with NPS had a reported family history of glaucoma, although some of these people with glaucoma did not have NPS. LMX1B mutations were identified in 5 of the 8 index cases-three sporadic and two familial. Two of the six (33%) participants over 40 years of age had developed glaucoma, showing increased risk of glaucoma in NPS. CONCLUSION: Patients with NPS should be examined regularly for glaucoma. However, because the families with NPS are ascertained primarily from young probands or probands who are isolated cases, the exact level of risk is unclear.

Altered L-selectin expression in lymphocytes and increased adhesion to endothelium in patients with diabetic retinopathy.

AIM: To investigate L-selectin expression and shedding in patients with and without retinopathy and to determine if any observed changes are reflected by a functional change in the adhesion of leucocytes to an endothelial monolayer. METHODS: Age matched diabetic patients (26 with retinopathy, 19 without retinopathy) were compared to 24 non-diabetic controls to determine L-selectin surface protein expression, L-selectin mRNA production, and serum L-selectin levels by flow cytometry, RT-PCR, and ELISA, respectively. An adhesion assay was used to determine the binding of lymphocytes from the respective test groups to a monolayer of human endothelial cells. RESULTS: Significantly reduced (p = 0.004) L-selectin expression was demonstrated on lymphocytes (CD3+) from patients with diabetes compared to controls, the lowest levels being found in those with diabetic retinopathy (p = 0.004). L-selectin mRNA levels (p = 0.007) were significantly higher in the retinopathy group than in the no retinopathy group. Serum L-selectin levels were significantly higher (p = 0.04) in those with retinopathy compared to controls. Lymphocyte adhesion relative to control (100%) was essentially unchanged (84.0% (SD 27.7%), p = 0.15) for diabetic patients with no retinopathy and was markedly increased (192% (37.6%)) for those with retinopathy (p = 0.0001). CONCLUSION: Lymphocyte activation, reduced surface L-selectin, increased circulating L-selectin, and a corresponding increase in adhesion of patients' cells using an in vitro assay, is evident in people with diabetic retinopathy. This suggests a role for lymphocyte activation in the pathogenesis of diabetic retinopathy.

Colour Doppler imaging of the ocular circulation in diabetic retinopathy.

PURPOSE: To measure blood flow velocity in the ophthalmic artery (OA) and central retinal artery (CRA) in patients with diabetic retinopathy. SUBJECTS AND METHODS: 62 age-matched subjects divided into 3 groups: nondiabetic controls (n=17); diabetics with no clinical retinopathy or background changes (n=24); diabetics with either pre-proliferative or proliferative retinopathy (n=21). Colour Doppler imaging was performed on supine patients by one masked observer using the Acuson 128 machine. RESULTS: There was a statistically significant (p<0.05) decrease in both the peak systolic velocity (PSV 0.073 m/s) and end diastolic velocity (EDV 0.014 m/s) of the central retinal artery in the pre-proliferative/proliferative group compared to the no retinopathy/background retinopathy group (PSV 0.096 m/s, EDV 0.024 m/s) and the control group (PSV 0.142 m/s, EDV 0.029 m/s). The resistance index of the ophthalmic artery was significantly increased in both the preproliferative/proliferative (0.81) and the no retinopathy/background group (0.81) compared to controls (0.72). CONCLUSION: Reduced blood flow velocity was found in the CRA of diabetic patients and appeared to become further reduced with the progression of retinopathy. This suggests that monitoring with Colour Doppler imaging may have predictive power in identifying those at greatest risk of developing sight threatening proliferative disease. The resistance index of the OA was increased in diabetics compared to controls.

Role of ultrasound biomicroscopy in managing pseudophakic pupillary block glaucoma.

We describe a case of anterior capsule adherence to the iris that occurred after phacoemulsification with in-the-bag intraocular lens (IOL) implantation. This adherence led to the development of pseudophakic pupillary block glaucoma. There were no synechias at the pupillary margin associated with the capsule-iris adherence. Ultrasound biomicroscopy, used to evaluate the anterior segment in vivo, clarified the mechanism of pseudophakic pupillary block. The pupillary block was relieved by a single laser iridotomy.

Chronic pain in the elderly: occupational adaptation as a means of coping with osteoarthritis of the hip and/or knee.

OBJECTIVE: To determine whether elderly individuals with chronic pain as a result of osteoarthritis of the hip and/or knee would report adaptations to their activities, or occupational adaptations, as a coping response to pain and, if so, to describe these adaptations and their relation to chronic pain, functional difficulty, depression, social support, and life satisfaction. DESIGN: Thirty elderly individuals completed rating scales and a structured questionnaire designed to measure occupational adaptation and the importance of activity. SETTING: Participants were community-dwelling elderly individuals and were interviewed in their homes or in a research office setting. PATIENTS: Consecutive orthopedic surgeon, family physician, or Arthritis Society patients, whose names were provided with the patient's consent, to the researcher. RESULTS: Individuals reported two approaches to occupational adaptation: they changed how they performed personal activities of daily living that they rated as most important and they stopped performing a number of avocational activities that they rated as less important. Statistically significant correlations were found among occupational adaptation, pain, depression, and difficulty with functioning. These variables were inversely related to life satisfaction. CONCLUSIONS: This sample of elderly individuals with chronic pain described occupational adaptations, or adaptations to "doing," as a means of coping with their chronic pain. There appeared to be a relation among pain, functional difficulty, depression, social support, and occupational adaptation. Additional research to increase the understanding of occupational adaptation as a means of coping with chronic pain is warranted.

Pulsatile ocular blood flow in untreated diabetic retinopathy.

PURPOSE: To measure the pulsatile component of total ocular blood flow in patients with untreated diabetic retinopathy. SUBJECTS AND METHODS: An adapted pneumotonometer attached to a slit-lamp biomicroscope. 82 age-matched subjects divided into 4 groups: non-diabetic controls (n = 22); diabetics with no clinical retinopathy (n = 20); background diabetic retinopathy (n = 20); pre-proliferative/proliferative diabetic retinopathy (n = 20). RESULTS: The mean pulsatile ocular blood flow values were found to be increased in all grades of diabetic retinopathy (no retinopathy 818 microl/min, background 1015 microl/min, pre-proliferative/proliferative 1097 microl/min) compared to the control group (644 microl/min). These pulsatile ocular blood flow values were significantly higher (p<0.05) in the background and pre-proliferative/proliferative retinopathy groups compared to controls. Pulse volume and pulse amplitude were also higher in the diabetic subjects. Mean arterial blood pressure did not differ across the groups studied. CONCLUSION: Pulsatile ocular blood flow was found to be higher in diabetics compared to controls and appears to increase as the severity of retinopathy progresses. Such a hyperdynamic circulation may contribute to the pathogenesis of diabetic eye disease.

Therapeutic horseback riding:.

This paper reviews the literature on the benefits of therapeutic horseback riding and the outcomes of eleven data-based studies purpoting to validate the claims that horseback riding offers therapeutic benefits. These studies have focused on physical and psychosocial variables. The literature on the benefits of riding reported obvious beneficial effects, while the outcome studies were able to document only some of these claims. The studies generally reported some significant effects from the therapeutic intervention. An examination of the outcome studies revealed weak scientific rigor, small sample sizes, and a lack of homogeneous populations. Furthermore, use of standardized measures was limited as authors frequently relied on nonstandardized observational techniques to evaluate change. This review indicates a need for further research into both the physical and psychosocial areas with both children and adults. In addition, there is a need for research which would improve the methodological rigor, homogeneity of populations, sample size, and use of standardized measurement instruments.

A study of therapeutic effects of horseback riding for children with cerebral palsy.

This article describes major findings from a study of the therapeutic benefits of horseback riding for children with cerebral palsy. Nineteen children (aged 4-12 years) with mild or moderate degrees of cerebral palsy were recruited from a children's treatment centre. Prior to randomization, the children were stratified according to their degree of disability. Ten children were allocated to a riding (experimental) group, and participated in one-hour weekly riding classes for six months. The remaining nine children were put on a waiting list for riding. The results of the study were inconclusive as so often in the case with children with cerebral palsy. Qualitative results gleaned from the weekly progress recordings of the riding instructor, reports of the on-site physical therapist, and reports from parents showed clear progressions in physical and psychosocial functioning. Results of standardized quantitative assessments showed few statistically significant changes in the children. The study clearly indicates a need for further research and for finding or developing instruments that are able to capture and reveal meaningful changes in physical and psychosocial status.

Pain and functional limitations in individuals with rheumatoid arthritis.

The focus of this investigation was to determine if health status variables such as pain and functional limitations are correlated with an individual's occupational profile (work, activities of daily living and leisure), and psychological adjustment (depression, anxiety and dissatisfaction with life). This study reports our findings for 143 individuals with rheumatoid arthritis (RA). It would appear from the results of this study that functional limitations have an even greater impact on individuals with RA than pain. This findings and its implications are discussed.

Cost of clinical instructors' time in clinical education--physical therapy students.

The purpose of this study was to estimate the total clinical instructor time required to conduct the clinical education program of our physical therapy school. Clinical instructors in 12 of the 29 regional health care facilities providing clinical education programs described, through questionnaires and interviews, the instructional activities in their programs and the number of hours a week required for each activity. For each activity, the instructors indicated whether it served educational purposes only (a single purpose activity) or patient care and research purposes as well (a joint purpose activity), and they estimated the time that they spent with the student (direct contact time). The sample data were used to estimate the annual requirement for clinical instructor time for the physical therapy clinical program, totaling 10,264 hours. The methodology and the findings of this study can assist governmental agencies, educational institutions, and clinical facilities to define policy and funding agreements for clinical training purposes.

An analysis and comparison of the educational costs of clinical placements for occupational therapy, physical therapy, and speech pathology and audiology students.

The purpose of this paper is to describe the methodology and summarize the results of a study of the educational costs of clinical placement for students in occupational therapy, physical therapy, and speech pathology and audiology at The University of British Columbia. The sample represented 42.9% of the facilities offering occupational therapy placements, 41.4% of those offering physical therapy placements, and 52.4% of those offering speech pathology and audiology placements. During a 12-month period, these facilities provided 77.3% of the total clinical hours for the occupational therapy students, 65.1% for the physical therapy students, and 66.1% for the speech pathology and audiology students. Estimates of the number of hours of single-purpose and joint-purpose instructional activities and percentage estimates of direct-contact time were used as a basis for calculating the costs to facilities of accepting students for clinical placement. The methodology permitted comparisons of these costs across health disciplines. Both the methodology and the findings of this study can help government, educational institutions, and clinical facilities in defining policies and funding mechanisms for clinical training programs.

Current supply and future requirements for occupational therapy manpower in British Columbia.

This paper reports the results of a survey conducted to study the current supply and future manpower requirements in occupational therapy (OT). The purpose of this study was to obtain data relating to the current supply of OTs, their geographic distribution, facilities' future requirements for OTs, solutions related to the projected manpower shortage and the reasons some potential employers do not hire OTs. Implications of the findings are discussed.