Correction: Management of nystagmus in children: a review of the literature and current practice in UK specialist services.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Management of nystagmus in children: a review of the literature and current practice in UK specialist services.

Nystagmus is an eye movement disorder characterised by abnormal, involuntary rhythmic oscillations of one or both eyes, initiated by a slow phase. It is not uncommon in the UK and regularly seen in paediatric ophthalmology and adult general/strabismus clinics. In some cases, it occurs in isolation, and in others, it occurs as part of a multisystem disorder, severe visual impairment or neurological disorder. Similarly, in some cases, visual acuity can be normal and in others can be severely degraded. Furthermore, the impact on vision goes well beyond static acuity alone, is rarely measured and may vary on a minute-to-minute, day-to-day or month-to-month basis. For these reasons, management of children with nystagmus in the UK is varied, and patients report hugely different experiences and investigations. In this review, we hope to shine a light on the current management of children with nystagmus across five specialist centres in the UK in order to present, for the first time, a consensus on investigation and clinical management.

Preoperative systemic inflammation and perioperative myocardial injury: prospective observational multicentre cohort study of patients undergoing non-cardiac surgery.

BACKGROUND: Systemic inflammation is pivotal in the pathogenesis of cardiovascular disease. As inflammation can directly cause cardiomyocyte injury, we hypothesised that established systemic inflammation, as reflected by elevated preoperative neutrophil-lymphocyte ratio (NLR) >4, predisposes patients to perioperative myocardial injury. METHODS: We prospectively recruited 1652 patients aged ≥45 yr who underwent non-cardiac surgery in two UK centres. Serum high sensitivity troponin T (hsTnT) concentrations were measured on the first three postoperative days. Clinicians and investigators were blinded to the troponin results. The primary outcome was perioperative myocardial injury, defined as hsTnT≥14 ng L-1 within 3 days after surgery. We assessed whether myocardial injury was associated with preoperative NLR>4, activated reactive oxygen species (ROS) generation in circulating monocytes, or both. Multivariable logistic regression analysis explored associations between age, sex, NLR, Revised Cardiac Risk Index, individual leukocyte subsets, and myocardial injury. Flow cytometric quantification of ROS was done in 21 patients. Data are presented as n (%) or odds ratio (OR) with 95% confidence intervals. RESULTS: Preoperative NLR>4 was present in 239/1652 (14.5%) patients. Myocardial injury occurred in 405/1652 (24.5%) patients and was more common in patients with preoperative NLR>4 [OR: 2.56 (1.92-3.41); P<0.0001]. Myocardial injury was independently associated with lower absolute preoperative lymphocyte count [OR 1.80 (1.50-2.17); P<0.0001] and higher absolute preoperative monocyte count [OR 1.93 (1.12-3.30); P=0.017]. Monocyte ROS generation correlated with NLR (r=0.47; P=0.03). CONCLUSIONS: Preoperative NLR>4 is associated with perioperative myocardial injury, independent of conventional risk factors. Systemic inflammation may contribute to the development of perioperative myocardial injury. CLINICAL TRIAL REGISTRATION: NCT01842568.

Arterial pulse pressure and postoperative morbidity in high-risk surgical patients.

BACKGROUND: Systemic arterial pulse pressure (systolic minus diastolic pressure) ≤53 mm Hg in patients with cardiac failure is correlated with reduced stroke volume and is independently associated with accelerated morbidity and mortality. Given that deconditioned surgical and heart failure patients share similar cardiopulmonary physiology, we examined whether lower pulse pressure is associated with excess morbidity after major surgery. METHODS: This was a prospective observational cohort study of patients deemed by their preoperative assessors to be at higher risk of postoperative morbidity. Preoperative pulse pressure was calculated before cardiopulmonary exercise testing. The primary outcome was any morbidity (PostOperative Morbidity Survey) occurring within 5 days of surgery, stratified by pulse pressure threshold ≤53 mm Hg. The relationship between pulse pressure, postoperative morbidity, and oxygen pulse (a robust surrogate for left ventricular stroke volume) was examined using logistic regression analysis (accounting for age, sex, BMI, cardiometabolic co-morbidity, and operation type). RESULTS: The primary outcome occurred in 578/660 (87.6%) patients, but postoperative morbidity was more common in 243/ 660 patients with preoperative pulse pressure ≤53 mm Hg{odds ratio (OR): 2.24 [95% confidence interval (CI): 1.29-3.38]; P<0.001). Pulse pressure ≤53 mm Hg [OR:1.23 (95% CI: 1.03-1.46); P=0.02] and type of surgery were independently associated with all-cause postoperative morbidity (multivariate analysis). Oxygen pulse <90% of population-predicted normal values was associated with pulse pressure ≤ 53 mm Hg [OR: 1.93 (95% CI: 1.32-2.84); P=0.007]. CONCLUSIONS: In deconditioned surgical patients, lower preoperative systemic arterial pulse pressure is associated with excess morbidity. These data are strikingly similar to meta-analyses identifying low pulse pressure as an independent risk factor for adverse outcomes in cardiac failure. Low preoperative pulse pressure is a readily available measure, indicating that detailed physiological assessment may be warranted. CLINICAL TRIAL REGISTRATION: ISRCT registry, ISRCTN88456378.

Comparing methods to identify hip fracture in a nursing home population using Medicare claims.

UNLABELLED: The inpatient principal diagnosis in Medicare claims identified 96% of hip fractures in hospitalized nursing home residents with high rates of confirmation by other claims files. INTRODUCTION: Hip fracture is typically identified in Medicare claims by examining only the principal diagnosis in the inpatient file, but this simple approach might be inadequate for nursing home residents. Our objective was to examine the impact of varied operational definitions for identifying hip fracture hospitalizations in administrative claims data. METHODS: We conducted a retrospective examination of Medicare inpatient and outpatient claims data for dually Medicaid- and Medicare-eligible nursing home residents in 1999 in California, Florida, Missouri, New Jersey, and Pennsylvania (n = 197,514). We determined the number of hip fractures identified in inpatient (Medicare A) diagnoses codes using differing definitions that varied according to whether or not hip fracture was required to be the principal diagnosis and whether or not confirmatory imaging and procedure codes were required to be found in other (Medicare B) claims files. RESULTS: Hip fractures were found in any inpatient diagnosis position in 4,680 subjects, with 4,479 of these found in the principal diagnosis position. With either approach to diagnosis position, confirmatory imaging and procedure codes were identified for 95% of persons hospitalized with hip fracture. CONCLUSION: The principal diagnosis alone will identify 96% of hip fracture diagnoses in hospitalized nursing home residents. Such diagnoses are confirmed at very high rates by other sources of claims data. Researchers may be confident using a simple approach to identifying hip fracture hospitalizations in this population, using inpatient claims alone and interrogating only the principal diagnosis position.

Development and usage of eXtension's HorseQuest: an online resource.

eXtension (pronounced e-extension) is an online resource transforming how faculty can collaborate and deliver equine education. As the first Community of Practice launched from eXtension, HorseQuest (HQ) offers free, interactive, peer-reviewed, online resources on a variety of equine-related topics at http://www.extension.org. This group has adapted traditional educational content to the online environment to maximize search engine optimization, to be more discoverable and relevant in the online world. This means that HQ resources are consistently being found on the first page of search results. Also, by researching key words searched by Internet users, HQ has guided new content direction and determined potential webcast topics based on relevance and frequency of those searches. In addition to establishing good search engine optimization, HQ has been utilizing the viral networking aspect of YouTube by uploading clips of existing equine educational videos to YouTube. HorseQuest content appears in mainstream media, is passed on by the user, and helps HQ effectively reach their community of interest (horse enthusiasts). HorseQuest partners with My Horse University to produce webcasts that combine concise knowledge exchange via a scripted presentation with viewer chat and incoming questions. HorseQuest has produced and published content including 12 learning modules, 8 webchats, 21 webcasts, and 572 videos segments. After the official public launch, there was a steady increase in average number of visits/mo and average page views/mo over the 26-mo period. These regressions show a statistically significant increase in visits (P < 0.001) of approximately 450 visits per month and a significant increase in page views (P = 0.004) of about 373 page views per month. HorseQuest is a resource for several state 4-H advancement and competition programs and will continue to be incorporated into traditional extension programs, while reaching and affecting global audiences.

A randomised control trial of oral health education provided by a health visitor to parents of pre-school children.

OBJECTIVES: To determine the effect of oral health education carried out by a specially trained health visitor on the dental health of young children. DESIGN AND SETTING: Children, who were recruited during their 8-month distraction-hearing test, were randomly allocated to intervention and control groups. A home visit by the health visitor was arranged to parents in the intervention group who were given dental health advice. A second home visit, when the child was about 20 months old, focused on a completed diet record sheet and discussions about what and when the child was eating and drinking. Children in the intervention group received a toothbrush and toothpaste containing 440 ppm fluoride at both visits while those in the control group received the level of care usually provided by health visitors in the area. The children's teeth were examined when they were three years old and two years later as part of a census survey of 5-year-old children in the area. MAIN OUTCOME MEASURES: The numbers of decayed, missing and filled tooth surfaces. RESULTS: 251 children were recruited to the control group and 250 to the intervention group. At age three, they were examined; the mean dmfs scores were 2.19 (95% Confidence Interval: 1.41-2.97) in the control group (n = 171) and 2.03 (CI: 1.39-2.67) in the intervention group (n = 181). During the census survey 276 of the children in the study were examined at school. At this age the mean dmfs scores were 4.84 (CI: 3.39-6.29) in the control group (n = 129) and 3.99 (CI: 2.54-5.04) in the intervention group (n = 147). However, the mean dmfs of the remaining 2,253 children who were examined was 5.94 (CI: 5.55-6.33). CONCLUSIONS: No statistically significant differences in mean dmfs scores were found between the control and intervention groups of children, although, as the children grew older, the gap between them widened. However, the mean dmfs score of other 5-year-olds in the area was significantly worse than that of children in the intervention group. Asking the control parents to take part in the study and examining their children at three years may have had an effect on their dental health status and have made it more difficult to detect any differences achieved by the programme.

Dental health of prisoners in the north west of England in 2000: literature review and dental health survey results.

BACKGROUND: A caries prevalence study of prisoners in the North West of England was conducted to allow comparisons with results of the 1998 United Kingdom Adult Dental Health Survey. METHOD: A random sample of prisoners in the North West of England was interviewed and examined using the same criteria as the 1998 United Kingdom Adult Dental Health Survey. RESULTS: From a random sample of 316 prisoners, 279 (88%) were interviewed and 272 (86%) received a dental examination. Prisoners enter prison with twice as many decayed teeth (mean 4.2) than found in the general population in the North West of England (mean 1.9). Prisoners also have fewer restored teeth. There was little difference between the mean DMFT of adult male prisoners and young offender male prisoners. There was little difference in the mean DMFT of those in prison for more or less than two years. CONCLUSIONS: Prisoners in the North West of England had more decayed or unsound teeth, and fewer restored teeth than both non-institutionalised adults in the North West of England and social classes IV and V in England. Attempts to improve the effectiveness and efficiency of the Prison Dental Service in the North West of England may render the prison population dentally fit more speedily.

Lip and tongue piercing: experiences and views of general dental practitioners in South lancashire.

PURPOSE OF THE STUDY: To ascertain the numbers of patients with pierced lips or tongues seen by dentists during routine consultations. The study also examined the provision of advice by dentists, and the nature of piercing-related complications. BASIC PROCEDURE: A postal questionnaire was sent to dentists in two Primary Care Trust areas in South Lancashire. MAIN FINDINGS: Sixty-four of the 106 questionnaires were returned, giving a response rate of 60%. Sixty-two dentists (96.9%) reported that they had seen patients with lip or tongue piercings during the previous 12 months and that they had seen a mean number of 2.8 patients with lip piercing and a mean of 9.0 patients with tongue piercing. A total of 56.5% of the dentists gave advice on oral hygiene and 79.0% on possible damage to the oral structures. Twenty-seven dentists (43.5%) said that their patients had oral health problems as a result of lip or tongue piercing. PRINCIPAL CONCLUSIONS: The dentists who responded to the questionnaire commonly saw lip and tongue piercings. All dentists should therefore be prepared to offer appropriate advice. A public health information leaflet available in all medical and dental practices would help to ensure that patients were better informed about body piercing and its complications.

Preoperative anthropometric analysis of the cleft child's face: a comparison between groups.

This study examines the facial surfaces of different groups of cleft babies aged up to eleven months, prior to any corrective surgery, with the aim of identifying and assessing differences in their facial morphology. Measurements of standard anthropometric landmarks were made on plaster casts taken pre-operatively of the faces of babies presenting for surgical correction of lip and palate deformities. Periorbital and mid face measurements show no difference between control and cleft groups. The nasal base is shown to be wider in infants with cleft lip on both cleft and non-cleft sides. Upper lip measurements indicate shortening, lateral deviation and superolateral rotation. A diagrammatic model is proposed to illustrate facial anatomy in control and cleft individuals. Modifications to the technique are proposed. Further study in this field is suggested, in order to produce a comprehensive database of facial morphological changes in the cleft and non-cleft populations both pre-operatively and over time, with a view to producing a potential redefinition of the cleft syndrome based on anthropometric principles.

An audit of the hepatitis B vaccination status of staff in general dental practices in Lancashire.

PURPOSE OF THE STUDY: To audit compliance, by general dental practitioners working in two health authorities in Lancashire, with the British Dental Association recommendations on vaccination against hepatitis B. BASIC PROCEDURE: A postal questionnaire to dental practices. MAIN FINDINGS: Replies were received from 85% of practices. The respondents consisted of 187 dentists, 270 dental nurses and 132 non-clinical staff. Totals of 98.9% of dentists, 96.7% of nurses and 72.7% of the non-clinicians reported that they had been vaccinated but fewer had undergone a blood test in the past five years. The poorest compliance was in having written evidence of immune status, with only 46.5% of dentists, 51.0% of nurses and 62.5% of non-clinical staff having this. PRINCIPAL CONCLUSIONS: Greater publicity about the BDA recommendations is needed to improve compliance. An extension of the occupational health services currently being set up for general medical practitioners and their staff to dental practices would also help.

Discovery of genes with highly restricted expression patterns in the Drosophila wing disc using DNA oligonucleotide microarrays.

The Drosophila wing disc is divided along the proximal-distal axis into regions giving rise to the body wall (proximal), wing hinge (central) and wing blade (distal). We applied DNA microarray analysis to discover genes with potential roles in the development of these regions. We identified a set of 94 transcripts enriched (two fold or greater) in the body wall and 56 transcripts enriched in the wing/hinge region. Transcripts that are known to have highly restricted expression patterns, such as pannier, twist and Bar-H1 (body wall) and knot, nubbin and Distal-less (wing/hinge), showed strong differential expression on the arrays. In situ hybridization for 50 previously uncharacterized genes similarly revealed that transcript enrichment identified by the array analysis was consistent with the observed spatial expression. There was a broad spectrum of patterns, in some cases suggesting that the genes could be targets of known signaling pathways. We show that three of these genes respond to wingless signaling. We also discovered genes likely to play specific roles in tracheal and myoblast cell types, as these cells are part of the body wall fragment. In summary, the identification of genes with restricted expression patterns using whole genome profiling suggests that many genes with potential roles in wing disc development remain to be characterized.

Intermuscle differences in activation.

The objective of this study was to investigate differences within individual subjects in the ability to activate the quadriceps, plantar flexors (PF), dorsiflexors (DF), and elbow flexors (EF) during isometric contractions. Twelve male subjects performed submaximal and maximal voluntary isometric contractions, and maximal tetanic contractions were also induced by electrical stimulation. The interpolated twitch technique was used to gauge the extent of muscle inactivation or inability to produce maximum force. Measurements included torque output, absolute and relative rate of force development (RFD), and percentage of muscle inactivation. The quadriceps exceeded all other muscle groups in voluntary and tetanic torque output, voluntary absolute RFD, and absolute and relative tetanic RFD. The quadriceps also exceeded the PF and DF in voluntary relative RFD and had greater muscle inactivation (15.5%) than the EF (5.0%), PF (5.0%), and DF (1.3%). Although the higher RFD may suggest a higher percentage of type II fibers in the quadriceps, their higher threshold of recruitment leads to greater difficulty in fully activating the quadriceps.

The relationship between socio-demographic characteristics and dental health knowledge and attitudes of parents with young children.

OBJECTIVE: To determine if parental socio-demographic characteristics are associated with dental knowledge and attitude. DESIGN: A questionnaire survey of 500 consecutive parents with children aged approximately 8-months, attending clinics in 1999/2000, in Burnley, Pendle and Rossendale, for health visitor distraction-hearing tests. OUTCOME MEASURES: Scores were obtained for dental knowledge and attitudes. The socio-demographic variables of parental ethnicity, age, education and area of residence were used to determine any associations. RESULTS: Parental age ranged between 16-46 years. Child age ranged between 7-11 months. Significant differences were detected for parental dental knowledge according to ethnicity (P = 0.003), educational status (P = 0.000), and area of residence (P = 0.016). Significant differences were also found in dental attitudes; ethnicity (P = 0.000), educational status (P = 0.004) and area of residence (P = 0.005). Parental age was not significant for either knowledge or attitude. CONCLUSIONS: Lack of further education, being Asian and living in a deprived area means parents have less chances of high dental knowledge and positive dental attitudes.

Natural history of claudication: long-term serial follow-up study of 1244 claudicants.

OBJECTIVE: The purpose of this study was to delineate the natural history of claudication and determine risk factors for ischemic rest pain (IRP) and ischemic ulceration (IU) among patients with claudication. METHODS: We prospectively collected data on 1244 men with claudication during a 15-year period, including demographics, clinical risk factors, and ankle-brachial index (ABI). We followed these patients serially with ABIs, self-reported walking distance (WalkDist), and monitoring for IRP and IU. We used Kaplan-Meier and proportional hazards modeling to find independent predictors of IRP and IU. RESULTS: Mean follow-up was 45 months; statistically valid follow-up could be carried out for as long as 12 years. ABI declined an average of 0.014 per year. WalkDist declined at an average rate of 9.2 yards per year. The cumulative 10-year risks of development of IU and IRP were 23% and 30%, respectively. In multivariate analysis using several clinical risk factors, we found that only DM (relative risk [RR], 1.8) and ABI (RR, 2.2 for 0.1 decrease in ABI) predicted the development of IRP. Similarly, only DM (RR, 3.0) and ABI (RR, 1.9 for 0.1 decrease in ABI) were significant predictors of IU. CONCLUSION: This large serial study of claudication is, to our knowledge, the longest of its kind. We documented an average rate of ABI decline of 0.014 per year and a decline in WalkDist of 9.2 yards per year. Two clinical factors, ABI and DM, were found to be associated with the development of IRP and IU. Our findings may be useful in predicting the clinical course of claudication.

Is warfarin really underused in patients with atrial fibrillation?

CONTEXT: There is agreement that warfarin decreases stroke risk in patients with atrial fibrillation (AF), but prior studies suggest that warfarin is markedly underused, for unclear reasons. OBJECTIVE: To determine if warfarin is underused in the treatment of patients with atrial fibrillation. DESIGN: Cross-sectional. SETTING: Tertiary care VA hospital. PATIENTS: All patients with a hospital or outpatient diagnosis of AF between 10/1/95 and 5/31/98. DATA COLLECTION: One or more physician investigators reviewed pertinent records for each patient. When any of the 3 investigators thought warfarin might be indicated, the patient's primary care provider completed a survey regarding why warfarin was not used. RESULTS: Of 1,289 AF patients, 844 (65%) had filled at least 1 warfarin prescription. Of the 445 remaining, 19 had died, 5 had inadequate medical records, and 54 received warfarin elsewhere, leaving 367 patients. Of these, 160 had no documented AF, 53 had only a history of AF, and 49 had only transient AF. Of the remaining 105 patients, 17 refused warfarin therapy and 72 had documented contraindications to warfarin use including bleeding risk or history, fall risk, alcohol abuse, or other compliance problems. The reasons for not using warfarin among the 16 patients remaining included provider oversight (n = 4) and various reasons suggesting provider knowledge deficits. CONCLUSION: In contrast to prior studies that suggested that warfarin is markedly underused, we found that few patients with AF and no contraindication to anticoagulation were not receiving warfarin. We believe that differing study methodologies, including the use of physician review and provider survey, may explain our markedly different rate of warfarin underutilization, although local institutional factors cannot be excluded. The findings suggest that primary providers may be far more compliant with the standard of care for patients with atrial fibrillation than previously believed.

Management information failings and future requirements for dental commissioning groups.

OBJECTIVE: To examine existing secondary care management information systems for dental specialities, and to determine their completeness and suitability for supporting effective primary care led purchasing decisions. DESIGN: An observational cross-sectional study of current information systems in selected secondary care provider units and the applicability of their data for contracting dental services. A comparative study of two information systems in two settings (primary and secondary care) and the utility of the data gathered for contracting for dental services. SUBJECTS: Secondary care activity data was sought from the key secondary dental care providers (hospitals) in two dental total purchasing localities. Referral data were also collected directly from general dental practitioners. MAIN OUTCOME MEASURES: The integrity, quality and accuracy of current secondary care activity data in dental specialities, in comparison to data supplied from primary dental care. RESULTS: The secondary care activity data was found to be incomplete, inadequate and inaccurate. It was found that due to data retrieval insufficiency, indicative budgets for secondary providers may be reduced to less than half of their actual entitlement. The data inflated individual dental outpatient attendance by 3.3 times between 1995/6 and by 2.5 times between 1996/7. CONCLUSION: Existing management information systems within secondary care providers are not structured in a way which will adequately inform future commissioning by the dental profession. Communication between primary and secondary care must be increased and data inputting methods in secondary care provider units must be substantially improved.

Outcome events in patients with claudication: a 15-year study in 2777 patients.

OBJECTIVE: The purpose of this study was to delineate the natural history of claudication and determine risk factors for death. METHODS: We reviewed the key outcomes (death, revascularization, amputation) in 2777 male patients with claudication identified over 15 years at a Veterans Administration hospital with both clinical and noninvasive criteria. Patients with rest pain or ulcers were excluded. Data were analyzed with life-table and Cox hazard models. RESULTS: The mean follow-up was 47 months. The cohort exhibited a mortality rate of 12% per year, which was significantly (P <.05) more than the age-adjusted US male population. Among the deaths in which the cause was known, 66% were due to heart disease. We examined several baseline risk factors in a multivariate Cox model. Four were significant (P <.01) independent predictors of death: older age (relative risk [RR] = 1.3 per decade), lower ankle-brachial index (RR = 1.2 for 0.2 change), diabetes requiring medication (RR = 1.4), and stroke (RR = 1.4). The model can be used to estimate the mortality rate for specific patients. Surprisingly, a history of angina and myocardial infarction was not a significant predictor. Major and minor amputations had a 10-year cumulative rate less than 10%. Revascularization procedures occurred with a 10-year cumulative rate of 18%. CONCLUSIONS: We found a high mortality rate in this large cohort and four independent risk factors that have a large impact on survival. Risk stratification with our model may be useful in determining an overall therapeutic plan for claudicants. A history of angina and myocardial infarction was not a useful predictor of death, suggesting that many patients in our cohort presented with claudication before having coronary artery symptoms. Our data also indicate that claudicants have a low risk of major amputation at 10-year follow-up.