Child care improvement on a shoestring: evaluating a low-cost approach to improving the availability of quality child care.

The Philadelphia Early Childhood Collaborative (the Collaborative) was designed to improve the quality of child care by increasing coordination among organizations that locally deliver professional resources to child care providers. The evaluation examined the implementation of the Collaborative, utilization of its services, and the impact of service use on child care quality. Child care providers reported gains in their professional knowledge and behavior from using Collaborative resources and rated the resources highly. No long-term effects on provider behavior, knowledge, or attitudes were observed. Although the original organizations were able to function collaboratively and Collaborative services were widely used, more intensive interventions may be required to change the availability of quality child care.

Air bags and ocular injuries.

PURPOSE: This investigation retrospectively examined ocular injuries associated with air bag deployment to gain a better appreciation of potential risk factors in motor vehicle accidents. National statistics regarding the efficacy of air bags were reviewed. METHODS: Review of the literature from 1991 to 1998 identified 44 articles describing 97 patients with air-bag-induced ocular injuries. Variables extracted from each case were age, sex, height, position in the car, eye wear, vehicle impact speed, visual acuity, and specific ocular injuries. RESULTS: Corneal abrasions occurred in 49% of occupants, hyphemas in 43%, vitreous or retinal hemorrhages in 25%, and retinal tears or detachments in 15%. The globe was ruptured in 10 patients. Patients involved in higher-speed accidents (over 30 mph) sustained a greater percentage of vitreous or retinal hemorrhages and traumatic cataracts, while those at slower speeds were more prone to retinal tears or detachments. In a subset of 14 patients with serious ocular injuries, the impact speed of 11 patients was recorded at 30 mph or less. Slower speed may be a risk factor for some ocular injuries. Occupant height was not a significant factor. National statistics confirm that air bags reduce fatalities in motor vehicle accidents. However, children sitting in the front seat without a seat belt and infants in passenger-side rear-facing car seats are at risk for fatal injury. CONCLUSION: Air bags combined with seat belts are an effective means of reducing injury and death in adults during motor vehicle accidents. However, this study has documented a wide variety of ocular injuries associated with air bag deployment. It is hoped that researchers can develop modifications that continue to save lives while minimizing additional harm.

Ocular injuries related to air bag inflation.

BACKGROUND AND OBJECTIVES: The effectiveness of air bags as a safety device in decreasing fatalities and reducing morbidity in frontal impact motor vehicle accidents has been well established. However, case reports have surfaced documenting ocular injuries related to air bag inflation. The purpose of this study was to identify and analyze ocular injuries sustained during air bag inflation. PATIENTS AND METHODS: Hospital emergency room records were reviewed retrospectively for a period of 4 years for patients who had sustained ocular injuries in motor vehicle accidents. Those injuries associated with air bag inflation were analyzed as to the nature of the injury, type of vehicle, speed, and visual morbidity. RESULTS: Fourteen cases of ocular injury related to air bag inflation were identified. Hyphema (nine cases) and cornea abrasion (eight cases) were the most common. Three cases, all patients who had been wearing glasses, sustained serious and permanent ocular damage. CONCLUSION: While air bags are an unequivocal safety feature, ocular injuries do occur that are related to air bag inflation. Eyeglass wear may present an additional risk factor.

Ocular injuries associated with eyeglass wear and airbag inflation.

OBJECTIVE: The purpose of this report is to detail three cases of serious ocular injury associated with eyeglass wear during airbag inflation following motor vehicle crashes. DESIGN: Although there were too few cases to provide valid statistics, an attempt was made to determine if there were characteristics common to the glasses or accidents that would provide preventive information. MATERIALS AND METHODS: The emergency room records were reviewed for a 4-year period and cases were extracted involving ocular injuries related to airbag inflation. Fourteen cases were found, and three patients were wearing glasses. These cases were studied in detail. MEASUREMENTS AND MAIN RESULTS: All three patients sustained serious, vision-compromising ocular damage. CONCLUSIONS: Eyeglass wear presents an additional risk factor for ocular injury during airbag inflation. Frame damage and lens shatter provide potential for both blunt and penetrating types of ocular injury.

Traumatically ruptured globes in children.

This retrospective study was designed to document the etiology of traumatically ruptured globes in children and to determine the prognostic value of several clinical parameters with respect to visual outcome. Forty-six children 16 years of age and under seen in the emergency room over a 2-year period were found to have full thickness penetration of the globe. Fifty-nine percent of injuries occurred during recreational activities, and 59% occurred outside of the home. Boys outnumbered girls by a 6:1 ratio. For children, initial visual acuity proved to be less valuable as a prognostic indicator with regard to final vision than has been reported in adults. Smaller corneal wounds offered better visual outcomes. Four eyes were enucleated. Ten ruptures (22%) were related to activity involving guns. Four of six BB gun injuries were the result of a ricocheted BB. Visual outcomes in gun-related injuries were particularly poor.

The epidemiology of ruptured globes.

This retrospective study documented the demographics of 227 ruptured globes in 223 patients admitted to the Wills Eye Hospital over a two-year period from 1988 to 1990. The risk for a ruptured globe was greatest among 18-to-24-year-old men, during the noon to 8PM time frame, on Saturdays, and in the months of May, June, October, and November. The home was the most common injury setting, followed by the work place and assault. Twenty-four globes (11%) were enucleated within 11 weeks of hospital admission. These cases frequently were the result of assault, blunt-type injuries. A disproportionate number occurred in blacks.

An epidemiologic and pathologic study of globes enucleated following trauma.

This retrospective study examined demographic, clinical, and histopathologic factors in 24 traumatically ruptured globes that were enucleated at Wills Eye Hospital during a 2-year period. The majority of these injuries occurred in a violent assault setting with a blunt mechanism, during the evening and early morning hours, and in the fall and winter months. Most patients were black males, and 67% were substance abusers. Clinically, the initial visual acuity in 96% of the eyes was light perception or worse. Five of the eyes were enucleated primarily. Gross examination of the globes revealed that 92% of the wounds involved the sclera, 83% of the eyes had hyphema, and 71% of the lacerations were longer than 10 mm. Histopathologic examination demonstrated that the majority of eyes had fragmented or missing lenses, disrupted ciliary bodies, and detached choroids. Ninety-six percent of the retinas were detached. There was one case of acute endophthalmitis.

Reversible visual loss in a patient receiving high-dose ciprofloxacin hydrochloride (Cipro)

Bilateral acute visual loss characterized by cecocentral scotomas and acquired dyschromatopsia developed in a patient receiving large oral doses of ciprofloxacin hydrochloride (Cipro). The visual defects improved after cessation of this antibiotic. To our knowledge, this association has not been described previously. The use of this medication in high doses must be accompanied by careful monitoring of optic nerve function.

An eye disorder caused by chronic cardiovascular disease.

Retinal vein occlusion is a serious ophthalmologic condition that requires prompt diagnosis and treatment to avoid permanent vision loss. With acute onset of central vein occlusion, vision loss is sudden, unilateral, and painless. Vision loss from branch vein occlusion is typically less severe. Many chronic medical conditions put the patient at high risk for this problem, among them hypertension, diabetes mellitus, arteriosclerosis, and other types of cardiovascular disease. Primary care practitioners, who ordinarily see many patients with such chronic illnesses, are in an excellent position to diagnose retinal vein occlusion and to participate in its management through opthalmologic referral.

Wills Eye Hospital Traumatic Hyphema Study.

Hyphema associated with nonpenetrating ocular trauma is a common cause for emergency hospitalization. The complications which result from this form of eye injury can cause permanent impairment of vision. Complications within the study population were reviewed. Analysis found a 16% rate of rebleeding, with the majority of these occurring within three to four days following the traumatic event. Unfortunately, no risk factors could be identified to help predict which patients were more at risk of complications. However, management of the complications which did develop in the study population was effective.

Posterior subcapsular cataracts in steroid-requiring asthmatic children.

Slit-lamp examinations were performed on 24 children and adolescents with severe asthma, all of whom had received steroids for at least 365 days. Posterior subcapsular cataracts (PSCC) were detected in 7 (29.1%). None of the patients had been treated with beclomethasone. All 7 of the patients with PSCC were in the subgroup of 14 patients who had been on the highest doses of corticosteroid, 10 mg or more per day, for the longest period of time. The 7 children with PSCC were all below the fifth percentile for height and had fallen away from their normal growth curve. Of the 17 children in whom PSCC were not detected, only 1 was below the fifth percentile for height. It would seem from our results that the steroid-requiring asthmatic who is growth-suppressed is at an increased risk for developing PSCC. We have documented the reversal of PSCC in 2 children. Both of these children had been placed on beclomethasone, which allowed for the discontinuation of daily prednisone in one case and a reduction to less than 10 mg per day of prednisone in the other. The reversal occurred within 6 months of starting on beclomethasone.