The incidence, clinical features, and management of essential infantile esotropia in the United Kingdom. A British Ophthalmology Surveillance Unit (BOSU) study

BACKGROUND/OBJECTIVES

A national study was undertaken through the British ophthalmology surveillance unit (BOSU) to determine the incidence, presenting features and management of essential infantile esotropia (EIE) in the UK.

METHODS

Data from a prospective national observational study of newly diagnosed EIE presenting to clinicians in the United Kingdom over a 12-month period were collected. Cases with a confirmed diagnosis by a clinician of a constant, non-accommodative esotropia ≥20 prism dioptres (PD), presenting at ≤12 months, with no neurological or ocular abnormalities were identified through BOSU. Follow-up data were collected at 12 months.

RESULTS

A total of 57 cases were reported giving an incidence of EIE of 1 in 12,828 live births. The mean age of diagnosis and intervention were 7.05 ± 2.6 months (range 2-12) and 14.7 ± 4.9 months (range 6.5-28.1), respectively. Management was surgical in 59.6%, botulinum toxin alone in 22.8%, and 17.5% were observed. The preoperative angle of esotropia was smaller in the observation group (P = 0.04). The postoperative angle of esotropia was not statistically significant between botulinum toxin or surgery (P = 0.3), although the age of intervention was earlier in the botulinum group (P = 0.007). Early intervention (before 12 months of age) did not influence the post-intervention motor outcomes between 0 and 10 prism dioptres of esotropia (P = 0.78).

CONCLUSIONS

The incidence of EIE in the UK is considerably lower than reported in other population-based studies. The preferred method of treatment was surgical with earlier intervention in those treated with botulinum toxin. An early age of intervention (<12 months) did not influence motor outcomes.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

2 Pathways to detection of non-infectious childhood uveitis in the UK: findings from the UNICORN cohort study

INTRODUCTION

Prompt detection of childhood uveitis is key to minimising negative impact. From an internationally unique inception cohort, we report pathways to disease detection.UNICORNS is a national childhood non-infectious uveitis study with longitudinal collection of a standardised clinical dataset and patient reported outcomes. Descriptive analysis of baseline characteristics are reported.Amongst 150 recruited children (51% female, 31% non-white ethnicity) age at detection ranged from 2-18yrs (median 10). In 69%, uveitis was diagnosed following onset of symptoms: time from first symptoms to uveitis detection ranged from 0-739days (median 7days), with longer time to detection for those presenting initially to their general practitioner. Non symptomatic children were detected through JIA/other disease surveillance (16%), routine optometry review (5%) or child visual health screening (1%). Commonest underlying diagnoses at uveitis detection were JIA (17%), TINU (9%, higher than pre-pandemic reported UK disease frequency) and sarcoid (1%). 60% had no known systemic disease at uveitis detection. At disease detection, in at least one eye: 34% had structural complications (associated with greater time to detection - 17 days versus 4 days for uncomplicated presentation).The larger relative proportions of children with non-JIA uveitis reported here increase the importance of improving awareness of childhood uveitis amongst the wider clinical communities. There is scope for improvement of pathways to detection. Forthcoming analysis on the full cohort (251 recruited to date across 33 hospitals and 4 nations) will provide nationally representative data on management and the determinants of visual and broader developmental/well-being outcomes.

4 Peripapillary hyperreflective ovoid mass-like structures (PHOMS) in children: optical coherence tomography measurements and refractive status

Peripapillary hyperreflective ovoid mass-like structures (PHOMS) are a recently described entity. They are a common and non-specific cause of pseudopapilloedema. We aim to determine if there is a relationship between optical coherence tomography (OCT) measurements and refractive status on the presence of PHOMS.Retrospective analysis of optic nerve head OCT scans from children seen in the suspected papilledema virtual clinic between August 2016 and March 2021 at University Hospital of Wales, Cardiff. Three assessors graded each scan for the presence of PHOMS. Numerical data on the disc morphology (disc area (DA (mm2)) and scleral canal diameter (SCD (µm)) was obtained from the OCT scans. Refractive data was obtained from the initial optometric referral where available. Logistic regression analysis was performed to assess the effect of age, sex, spherical equivalent, DA and SCD on the likelihood of the presence of PHOMS.The SCD was significantly larger in eyes with PHOMS (mean diameter 1771 µm) vs no PHOMS (mean diameter 1621 µm). Odds ratio 1.0042 (1.0016 to 1.0069). The other variables were not significantly associated, but there was a tendency towards a younger age, larger disc area and the presence of a refractive error if PHOMS were present.Anatomical and developmental differences in the size of the scleral canal and optic nerve may explain the presence of PHOMS in children. In contrast to other recently published studies, we show that a wider scleral canal diameter was significantly associated with the presence of PHOMS.

12 The incidence, clinical features, and management of essential infantile esotropia in the United Kingdom. A British Ophthalmology Surveillance Unit (BOSU) study - Final Report

Studies from the UK have reported declining rates of surgery for childhood esotropia. It is not known if this equates to a reduced incidence of essential infantile esotropia (EIE). A national study was undertaken through the British ophthalmology surveillance unit (BOSU) to determine the incidence presenting features and management of EIE in the UKData from a prospective national observational cohort of newly diagnosed EIE presenting to clinicians in the United Kingdom over a 12-month period was collected. Cases with a confirmed diagnosis by a clinician of a constant, non-accommodative esotropia ≥ 20 prism dioptres (PD), presenting at ≤ 12months, with no neurological or ocular abnormalities were identified through BOSU. Follow up data was collected at 12 months. Data was collected on the age, gender, ethnicity, birth history, age at diagnosis, age at intervention, angle of esotropia, refraction, associated features of amblyopia, overelevation in adduction (OEIA), latent nystagmus and dissociated vertical deviation (DVD), method of management and outcomes.During the period of observation between October 2017 to October 2018 a total of 57 cases were reported giving an incidence of EIE of 1 in 12,828 live births with a corrected incidence of 1 in 9027 live births allowing for estimated under reporting. The mean age of diagnosis and intervention were 7.05± 2.6 months (range 2 to 12 months) and 14.7± 4.9 (range 6.5-28.1 months) respectively. The majority were Caucasians 86.5% and 52.7% were female. Management was surgical in 59.6%, and botulinum toxin alone in 22.8%, 17.5% were observed. There was no significant difference in the age of presentation (P=0.6), gender (P=0.8), prematurity (P=0.5), deprivation indices (P=0.68), refraction (P=0.7), OEIA (P=0.6), DVD (P=0.7) or follow up (P=0.3) between the three groups. The preoperative angle of esotropia was smaller in the observation group (P=0.04). The post-operative angle of esotropia was not statistically significant between botulinum toxin or surgery (P=0.3) though the age of intervention was earlier in the botulinum group (P=0.007). Early intervention did not influence the motor post intervention outcomes between 0-10 prism dioptres of esotropia (P=0.78). Amblyopia (P=0.02) and latent nystagmus (P=0.009) was more common in the observation group.The incidence of EIE in the UK is considerably lower than reported in other population-based studies. The preferred method of treatment was surgical with earlier intervention in those treated with botulinum toxin. An early age of intervention did not influence motor outcomes. Parental choice and amblyopia treatment were reasons cited for conservative management in the observational group.

Prevalence of peripapillary hyperreflective ovoid mass-like structures (PHOMS) in suspected papilloedema in children

PURPOSE

Suspected papilloedema is a frequent cause of referral to paediatric ophthalmology clinics. Recent publications have described a new finding called peripapillary hyperreflective ovoid mass-like structures (PHOMS) that may cause pseudopapilloedema. We evaluated the optical coherence tomography (OCT) scans of the optic nerve in all children referred with suspected papilloedema for the presence of PHOMS and report their frequency.

METHODS

The optic nerve OCT scans from children seen in our suspected papilloedema virtual clinic between August 2016 and March 2021 were evaluated for the presence of PHOMS by three assessors. A Fleiss' kappa statistic was calculated to test the agreement between the assessors for the presence of PHOMS.

RESULTS

A total of 220 scans from 110 patients were evaluated during the study period. The mean patient age was 11.2 SD ± 3.4, (range 4.1-16.8). PHOMS were identified in at least one eye in 74 (67.3%) patients. Of these, 42 (56.8%) patients had bilateral and 32 (43.2%) had unilateral PHOMS. Excellent agreement between assessors for the presence of PHOMS (Fleiss' kappa 0.9865) was observed. PHOMS were common in association with other identified causes of pseudopapilloedema (81.25%) but were also common in papilloedema (66.67%) and otherwise normal discs (55.36%).

CONCLUSIONS

Misdiagnosis of papilloedema can lead to unnecessary and invasive tests. PHOMS are found frequently within the paediatric population referred for suspected disc swelling. They appear to be an independent cause of pseudopapilloedema but are often seen in conjunction with true papilloedema and other causes of pseudopapilloedema.

Stress and cataract surgery: A nationwide study evaluating surgeon burnout

BACKGROUND

We aimed to evaluate the nationwide prevalence of stress induced burnout among cataract surgeons. We believe that knowledge of these factors can help formulate a solution to this underreported problem.

METHODS

A three-part nationwide cross-sectional survey was disseminated with via the Royal College of Ophthalmologists (RCOphth) in the United Kingdom(UK). All consultants, trainees and specialty doctors and associate specialists(SAS) were invited to participate. We evaluated burnout using the Maslach Burnout Inventory (MBI). Logistic regression modelling was completed to look at factors linked to high level burnout in certain domains.

RESULTS

A total of 406 respondents completed our survey. Prevalence of cataract surgery-related high burnout was estimated at 3.45% (Section A and/or B) and 40% within Personal Accomplishment (PA)(Section C of the MBI). Multiple factors were associated with increased burnout within PA: Increasing age: 61+ OR: 2.99 (1.02-8.78, p = 0.05), Number of cataract operations completed: >3000 OR 2.98 (1.03-8.64, p = 0.04), Lists per week: 2: OR 2.99 (1.38-6.47, p < 0.01), 2.5: OR 8.95 (2.58-31.02, p < 0.01), 3 or more: OR 2.64 (1.07-6.54, p = 0.04). Sleeping 8 h or more was found to be protective OR 0.52 (0.28-0.96, p = 0.04). 17% of respondents indicated they would be willing to give up cataract surgery if given the opportunity.

CONCLUSION

The prevalence of stress induced burnout by cataract surgery appears to be present in a minority of surgeons. There appears to be a significant reduction in the feeling of personal achievement within the profession. A large proportion of this cohort appears to be willing to give up surgical responsibilities.

The use of occlusive contact lenses after failure of conventional for treatment of amblyopia

PURPOSE

The purpose of this study was to evaluate the usefulness and assess the risks associated with occlusive contact lenses (OCLs) use to treat refractory amblyopia in children who failed the conventional amblyopia treatment with patching and atropine penalization.

METHODS

This was a retrospective case series of all children treated with an OCL in the sound eye over an 8-year period. Data were collected on the age, gender, and type of amblyopia, previous treatment received, and its duration. The compliance, tolerance, and adverse effects of OCL were recorded.

RESULTS

There were 12 patients of which 10 were male. The mean age at the time of OCL use was 47.3 months (range 26-86 months). Anisometropic amblyopia was present in 1, combined anisometropia and strabismus in 3, strabismic amblyopia in 5, and stimulus deprivation amblyopia in 3. All patients had conventional patching for a mean period of 14 months, followed by atropine penalization in nine patients for a mean period of 4 months. The mean duration of OCL use ranged from 2 weeks to 6 months. There were nine patients with visual improvement (75%). The mean improvement seen was 0.4 log of the minimum angle of resolution. There was no occlusion amblyopia. Four patients had conjunctivitis; one had a peripheral corneal abrasion.

CONCLUSION

The OCL is a useful adjunct in the treatment of amblyopia that is refractory to conventional treatment. The side effect profile is acceptable, but patients require close monitoring.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Measuring therapeutic engagement in acute mental health inpatient environments: the perspectives of service users and mental health nurses

BACKGROUND

A key component of caring for service users (SUs) in acute mental health inpatient environments is Therapeutic Engagement (TE). To that end, the Therapeutic Engagement Questionnaire (TEQ) was developed and validated. The TEQ measures TE between SUs and registered mental health nurses (RMHNs) from the perspective of both parties and can quantify and recognise how nurses engage with SUs and monitor this activity as well as its enhancement of SU care and recovery. The aim of this study was to explore the views of SUs and RMHNs in relation to the TEQ and how it could be adopted into clinical practice within an acute inpatient environment.

METHODS

As part of the validation stage of the development of the TEQ, the views of 628 SUs and 543 RMHNs were collected using a qualitative approach by way of free text at the end of the questionnaire. Two questions required free text response: - 'what do you think of the TEQ?', and 'how can it be utilised?'

RESULTS

Following thematic analysis, it was found that both sets of participants stated that such a tool could be utilised to improve the service, could help nurses with reflective practice, be utilised as part of clinical supervision and to aid nurses' professional development. The nurse participants also stated that such a tool would help track SU participation and enablement in their care. Furthermore, the nurses noted that the tool would help to reinforce the core 'caring' value of nursing and the overall goal of recovery. The SUs added that the TEQ would recognise the work of mental health nurses and provide them with a clear opportunity to express their views in relation to nursing staff.

CONCLUSIONS

Therapeutic engagement (TE) has been identified as part of the repertoire of mental health nursing and both groups of participants identified how a tool to assess this construct may be utilised in day-to-day clinical practice to the benefit of each group.

Risk factors for having diabetic retinopathy at first screening in persons with type 1 diabetes diagnosed under 18 years of age

OBJECTIVE

To determine the risk factors for having diabetic retinopathy (DR) in children and young people (CYP) with type 1 diabetes (T1DM) at first screening.

METHODS

Records from the Diabetes Eye Screening Wales (DESW) service for people in Wales, UK, with T1DM diagnosed under age 18 years were combined with other electronic health record (EHR) data in the Secure Anonymised Information Linkage (SAIL) Databank. Data close to the screening date were collected, and risk factors derived from multivariate, multinomial logistic regression modelling.

RESULTS

Data from 4172 persons, with median (lower quartile, upper quartile) age 16.3 (13.0, 22.3) years and duration of diabetes 6.6 (2.3, 12.3) years were analysed. 62.6% (n = 2613) had no DR, 26.7% (n = 1112) background DR, and 10.7% (n = 447) had referable DR (RDR). No RDR was observed under 19 years of age. Factors associated with an increased risk of DR were diabetes duration, elevated HbA1c, and diastolic blood pressure. People diagnosed with T1DM at 12 years or older had an additional risk for each year they had diabetes compared to those diagnosed before age 12 controlling for the diabetes duration (odds ratios 1.23 and 1.34, respectively).

CONCLUSIONS

This study found that 37.4% of the study cohort had DR at first screening, the risk being greater the longer the duration of diabetes or higher the HbA1c and diastolic blood pressure. In addition, people diagnosed at 12 years of age or over were more likely to have DR with each additional year with diabetes.

Vertical Tropia Following Horizontal Transposition Surgery

Aim

The aim of this study was to determine the prevalence of vertical tropia following horizontal transposition of both vertical rectus muscles (HToVR) in patients with Duane syndrome or sixth nerve palsy.

Methods

This retrospective study included patients with Duane syndrome or sixth nerve palsy who had undergone HToVR muscles. Data collected included: age, gender, diagnosis, laterality, pre-operative angle of deviation, type of surgery and post-operative angle of deviation at one week, three months and six months. Information on the use of botulinum toxin (BT) ipsilateral medial rectus (MR), additional surgery was performed, and the presence of preoperative and postoperative binocular function and any vertical deviation was collected.

Results

There were 11 patients, eight patients with a diagnosis of Duane syndrome and three patients with a diagnosis of sixth nerve palsy. The mean age of the patients was 13 ± 14.79 years (range 5-55 years), four were female. The prevalence of post-operative vertical tropia was 54%. The mean vertical deviation for distance, was 7.6^ ± 2.94 (SD) (range 3^-9^). Stereoacuity was present preoperatively in 5 patients and 8 postoperatively. No patient developed diplopia or received further surgery for the vertical tropia. Of the six patients who had intraoperative BT at the time of the HToVR, four developed a vertical deviation.

Conclusion

The prevalence of vertical deviation following HToVR muscles was 54% in our series. None of the patients with an induced postoperative vertical deviation reported diplopia or required further surgery for it.

Cloud Computing Mobile Application for Remote Monitoring of Bell's Palsy

Mobile applications provide the healthcare industry with a means of connecting with patients in their own home utilizing their own personal mobile devices such as tablets and phones. This allows therapists to monitor the progress of people under their care from a remote location and all with the added benefit that patients are familiar with their own mobile devices; thereby reducing the time required to train patients with the new technology. There is also the added benefit to the health service that there is no additional cost required to purchase devices for use. The Facial Remote Activity Monitoring Eyewear (FRAME) mobile application and web service framework has been designed to work on the IOS and android platforms, the two most commonly used today. Results: The system utilizes secure cloud based data storage to collect, analyse and store data, this allows for near real time, secure access remotely by therapists to monitor their patients and intervene when required. The underlying framework has been designed to be secure, anonymous and flexible to ensure compliance with the data protection act and the latest General Data Protection Regulation (GDPR); this new standard came into effect in April 2018 and replaces the Data Protection Act in the UK and Europe.

Genotype-phenotype correlation at codon 1740 of SETD2

The SET domain containing 2, histone lysine methyltransferase encoded by SETD2 is a dual-function methyltransferase for histones and microtubules and plays an important role for transcriptional regulation, genomic stability, and cytoskeletal functions. Specifically, SETD2 is associated with trimethylation of histone H3 at lysine 36 (H3K36me3) and methylation of α-tubulin at lysine 40. Heterozygous loss of function and missense variants have previously been described with Luscan-Lumish syndrome (LLS), which is characterized by overgrowth, neurodevelopmental features, and absence of overt congenital anomalies. We have identified 15 individuals with de novo variants in codon 1740 of SETD2 whose features differ from those with LLS. Group 1 consists of 12 individuals with heterozygous variant c.5218C>T p.(Arg1740Trp) and Group 2 consists of 3 individuals with heterozygous variant c.5219G>A p.(Arg1740Gln). The phenotype of Group 1 includes microcephaly, profound intellectual disability, congenital anomalies affecting several organ systems, and similar facial features. Individuals in Group 2 had moderate to severe intellectual disability, low normal head circumference, and absence of additional major congenital anomalies. While LLS is likely due to loss of function of SETD2, the clinical features seen in individuals with variants affecting codon 1740 are more severe suggesting an alternative mechanism, such as gain of function, effects on epigenetic regulation, or posttranslational modification of the cytoskeleton. Our report is a prime example of different mutations in the same gene causing diverging phenotypes and the features observed in Group 1 suggest a new clinically recognizable syndrome uniquely associated with the heterozygous variant c.5218C>T p.(Arg1740Trp) in SETD2.

A multi-wavelength streaked optical pyrometer for dynamic shock compression measurements above 2500 K

This article presents a concept and implementation of a calibrated streaked spectral pyrometer (SSP) temperature diagnostic used in dynamically driven shock experiments on a two-stage gas gun. This system relies upon measuring the total system response using a tunable monochromator, a NIST-traceable calibrated power meter, and a SSP. The diagnostic performance is validated against previously measured temperatures of shock driven z-cut quartz at 99 GPa and 93 GPa. The results are found to agree with the literature to within 5% and are discussed in this manuscript. The experimental setup utilizes measurements from multiple SSP systems per sample, providing several independent measurements and substantially increasing confidence in the extrapolated shock driven sample temperature.

Heterochromia irides and mistaken identity of retinoblastoma

Retinoblastoma is the most common intraocular malignancy of infancy which frequently manifests with a white pupillary reflex. We report a case of delayed presentation of a child with retinoblastoma in his left eye because parents thought the change in iris colour in this eye was due to the innocent heterochromia irides that was previously diagnosed in his elder sibling. This late presentation necessitated enucleation of the affected eye followed by chemotherapy.

Fresh frozen plasma (Octaplas) and topical heparin in the management of ligneous conjunctivitis

Ligneous conjunctivitis is a rare form of chronic recurrent membranous conjunctivitis with reduced plasminogen activity. It is characterized by the formation of characteristic firm ("woody") membranes on the tarsal conjunctiva. Similar lesions may occur on other mucous membranes. When treated with local excision, ligneous conjunctivitis is invariably associated with recurrences. Various therapeutic modalities, including topical heparin, cyclosporine, fresh frozen plasma (FFP), plasminogen, and amniotic membrane transplantation have been reported to reduce postoperative recurrences. We present 2 cases of recurrent ligneous conjunctivitis in children successfully managed with surgical excision under cover of FFP transfusion, amniotic membrane grafting, and combined with concomitant postoperative administration of topical heparin, steroids.

Abusive head trauma and the triad: a critique on behalf of RCPCH of 'Traumatic shaking: the role of the triad in medical investigations of suspected traumatic shaking'

The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) has recently published what they purported to be a systematic review of the literature on 'isolated traumatic shaking' in infants, concluding that 'there is limited evidence that the so-called triad (encephalopathy, subdural haemorrhage, retinal haemorrhage) and therefore its components can be associated with traumatic shaking'. This flawed report, from a national body, demands a robust response. The conclusions of the original report have the potential to undermine medico-legal practice. We have conducted a critique of the methodology used in the SBU review and have found it to be flawed, to the extent that children's lives may be put at risk. Thus, we call on this review to be withdrawn or to be subjected to international scrutiny.

The presentation, clinical features, complications, and treatment of congenital dacryocystocele

PurposeTo determine the incidence and presenting features of congenital dacryocystocele in the United Kingdom. To report on those cases complicated by dacryocystitis, respiratory compromise, and the treatment undertaken.MethodsA prospective observational study of cases of congenital dacryocystocele presenting in the United Kingdom between September 2014 and October 2015. Infants <3 months of age presenting with a cystic swelling in the medial canthal area were included. Cases were identified via the British Ophthalmology Surveillance Unit (BOSU) reporting system.ResultsA total of 49 cases were reported during the study period. This gives an incidence of 1 in 18 597 live births. There was a 71% response rate to the questionnaire. The average age at presentation was 16.94 days. Dacryocystoceles were unilateral in 91% of cases. Dacryocystitis was a complicating factor in 49% of patients and 17% had respiratory distress. Uncomplicated dacryocystocele responded well to conservative measures in 86%. Surgical intervention was required in 23% of patients. Those cases complicated by dacryocystitis (29%) and nasal obstruction (17%) were more likely to require surgical intervention compared to those with dacryocystocele alone (14%). Digital massage appears to reduce the likelihood of requiring surgical intervention. The mean time to resolution was 19 days.ConclusionsCongenital dacryocystocele is a rare presentation in the United Kingdom. Dacryocystitis and respiratory compromise commonly complicate a dacryocystocele. The use of digital massage as an early intervention is advocated and conservative measures may be sufficient in cases of uncomplicated dacryocystocele.

The impact on relationships following disclosure of transgenderism: a wife's tale

WHAT IS KNOWN ON THE SUBJECT?: The experiences of transgender people are becoming increasingly more visible in popular culture, biographical literature and the media. The topic has received little attention within the psychiatric and mental health nursing literature. There is a paucity of literature exploring the impact on relationships following a disclosure of transgenderism. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: A narrative account of the consequences for the wife of one transwoman and their relationships with friends and family following the disclosure of transgenderism. The article identifies a range of issues that require further attention in relation to healthcare provision. These include the mental health needs of partners and spouses; attitudes of healthcare professionals towards transgender issues; and the adequacy of the formal support offered to partners and spouses of transgender people. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is a need for healthcare practitioners to explore their understanding of transgender issues and how these may impact on the mental health of partners and spouses. It is important that healthcare professionals provide a hopeful and supportive environment to enable couples to explore their relationships following disclosure of transgenderism.

Altered ratios of pro- and anti-angiogenic VEGF-A variants and pericyte expression of DLL4 disrupt vascular maturation in infantile haemangioma

Infantile haemangioma (IH), the most common neoplasm in infants, is a slowly resolving vascular tumour. Vascular endothelial growth factor A (VEGF‐A), which consists of both the pro‐ and anti‐angiogenic variants, contributes to the pathogenesis of IH. However, the roles of different VEGF‐A variants in IH progression and its spontaneous involution is unknown. Using patient‐derived cells and surgical specimens, we showed that the relative level of VEGF‐A₁₆₅b was increased in the involuting phase of IH and the relative change in VEGF‐A isoforms may be dependent on endothelial differentiation of IH stem cells. VEGFR signalling regulated IH cell functions and VEGF‐A₁₆₅b inhibited cell proliferation and the angiogenic potential of IH endothelial cells in vitro and in vivo. The inhibition of angiogenesis by VEGF‐A₁₆₅b was associated with the extent of VEGF receptor 2 (VEGFR2) activation and degradation and Delta‐like ligand 4 (DLL4) expression. These results indicate that VEGF‐A variants can be regulated by cell differentiation and are involved in IH progression. We also demonstrated that DLL4 expression was not exclusive to the endothelium in IH but was also present in pericytes, where the expression of VEGFR2 is absent, suggesting that pericyte‐derived DLL4 may prevent sprouting during involution, independently of VEGFR2. Angiogenesis in IH therefore appears to be controlled by DLL4 within the endothelium in a VEGF‐A isoform‐dependent manner, and in perivascular cells in a VEGF‐independent manner. The contribution of VEGF‐A isoforms to disease progression also indicates that IH may be associated with altered splicing. © 2016 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.

Characteristics of non-vitreoretinal ocular injury in child maltreatment: a systematic review

PurposeTo identify the spectrum of non-vitreoretinal ocular injury due to child maltreatment.MethodsAll language search of MEDLINE, PsychINFO, EMBASE, AMED, Web of Science, and CINAHL databases, 1950-2015, was conducted.

INCLUSION CRITERIA

explicit confirmation of injury aetiology, age <18 years, examination conducted by an ophthalmologist. Exclusion: post-mortem data, organic diseases, review articles. Standardised critical appraisal and narrative synthesis was conducted of included publications by two independent reviewers.ResultsOf 1492 studies identified, 153 full texts were assessed, 49 underwent full review, resulting in five included studies: three case series and two case reports. The 26 included cases describe a wide variety of ocular, facial and skeletal injuries occurring as a consequence of child maltreatment. Ocular signs included periorbital oedema, chemosis, injection, abrasion, hyphaema, and cataract. Of interest all children that had suffered physical abuse with ocular injury had subconjunctival haemorrhages. Children presenting with abusive ocular injuries had a mean age of 13.9 months (range 1-68), while those who suffered violent corporal punishment were considerably older (mean 96 months). All cases, apart from severe corporal punishment, underwent screening for occult fractures, but neuroimaging only apparent in 2/5 eligible cases.ConclusionAlthough, the face is the most common site of abusive injury, there is a paucity of high-quality data on non-vitreoretinal ocular abusive injury. Thus, while subconjunctival haemorrhages are a potential sentinel injury of maltreatment, and may warrant further evaluation, the lack of large-scale published data limits our ability to highlight further specific characteristics of non-vitreoretinal ocular injury indicative of child abuse.

Doping of inorganic materials in microreactors - preparation of Zn doped Fe3O4 nanoparticles

Microreactor systems are now used more and more for the continuous production of metal nanoparticles and metal oxide nanoparticles owing to the controllability of the particle size, an important property in many applications. Here, for the first time, we used microreactors to prepare metal oxide nanoparticles with controlled and varying metal stoichiometry. We prepared and characterised Zn-substituted Fe3O4 nanoparticles with linear increase of Zn content (ZnxFe3-xO4 with 0 ≤ x ≤ 0.48), which causes linear increases in properties such as the saturation magnetization, relative to pure Fe3O4. The methodology is simple and low cost and has great potential to be adapted to the targeted doping of a vast array of other inorganic materials, allowing greater control on the chemical stoichiometry for nanoparticles prepared in microreactors.

Clustering of lifestyle risk behaviours among residents of forty deprived neighbourhoods in London: lessons for targeting public health interventions

BACKGROUND

Clustering of lifestyle risk behaviours is very important in predicting premature mortality. Understanding the extent to which risk behaviours are clustered in deprived communities is vital to most effectively target public health interventions.

METHODS

We examined co-occurrence and associations between risk behaviours (smoking, alcohol consumption, poor diet, low physical activity and high sedentary time) reported by adults living in deprived London neighbourhoods. Associations between sociodemographic characteristics and clustered risk behaviours were examined. Latent class analysis was used to identify underlying clustering of behaviours.

RESULTS

Over 90% of respondents reported at least one risk behaviour. Reporting specific risk behaviours predicted reporting of further risk behaviours. Latent class analyses revealed four underlying classes. Membership of a maximal risk behaviour class was more likely for young, white males who were unable to work.

CONCLUSIONS

Compared with recent national level analysis, there was a weaker relationship between education and clustering of behaviours and a very high prevalence of clustering of risk behaviours in those unable to work. Young, white men who report difficulty managing on income were at high risk of reporting multiple risk behaviours. These groups may be an important target for interventions to reduce premature mortality caused by multiple risk behaviours.

Newborn retinal hemorrhages: a systematic review

PURPOSE

To systematically review the characteristics, prevalence, evolution, and obstetric associations of retinal hemorrhages (RH) in newborns.

METHODS

A systematic review, searching 10 databases (1970-2011), identified 45 studies, which underwent two independent reviews via the use of standardized critical appraisal. Studies meeting the following criteria were included: examination by an ophthalmologist, use indirect ophthalmoscopy, and first examination conducted within 96 hours of birth and before hospital discharge.

RESULTS

Thirteen studies were included, representing 1,777 infants. The studies revealed that 25.6% of newborns born via spontaneous vaginal deliveries had RH. In contrast, infants delivered by vacuum extraction had a 42.6% rate of RH (OR, 2.75; 95% CI, 1.32-5.70), and infants delivered by double-instrument deliveries (forceps and vacuum) had a 52% rate of RH (OR, 3.27; 95% CI, 1.68-6.36). The hemorrhages are commonly bilateral (59%), of varying severity, from "mild" (22%-56%) to "severe" (18%-37%), and predominantly intraretinal and in the posterior pole. The majority of RH (83%) resolved within 10 days; isolated cases persisted to 58 days.

CONCLUSIONS

Birth-related RH in infants occurs in one-quarter of normal deliveries and are far more common after instrumental deliveries. Commonly bilateral, they were predominantly intraretinal, posterior, resolved rapidly, and very rarely persisted beyond 6 weeks.

Mach-Zehnder recording systems for pulsed power diagnostics

Fiber-optic transmission and recording systems, based on Mach-Zehnder modulators, have been developed and installed at the National Ignition Facility (NIF), and are being developed for other pulsed-power facilities such as the Z accelerator at Sandia, with different requirements. We present the design and performance characteristics for the mature analog links, based on the system developed for the Gamma Reaction History diagnostic at the OMEGA laser and at NIF. For a single detector channel, two Mach-Zehnders are used to provide high dynamic range at the full recording bandwidth with no gaps in the coverage. We present laboratory and shot data to estimate upper limits on the radiation effects as they impact recorded data quality. Finally, we will assess the technology readiness level for mature and developing implementations of Mach-Zehnder links for these environments.

Development and validation of a standardized tool for reporting retinal findings in abusive head trauma

PURPOSE

To develop and validate a robust standardized reporting tool for describing retinal findings in children examined for suspected abusive head trauma.

DESIGN

A prospective interobserver and intraobserver agreement study.

METHOD

An evidence-based assessment pro forma was developed, recording hemorrhages (location, layer, severity) and additional features. Eight consultant pediatric ophthalmologists and 7 ophthalmology residents assessed a series of 105 high-quality RetCam images of 21 eyes from abusive head trauma cases with varying degrees of retinal hemorrhage and associated findings. The pediatric ophthalmologists performed a repeat assessment of the randomized images. The images were observed simultaneously with standardized display settings. Interobserver and intraobserver agreement was assessed using free-marginal multirater kappa, intraclass correlation coefficients, and concordance coefficients.

RESULTS

Almost-perfect interobserver agreement was observed for residents and pediatric ophthalmologists recording the presence and number of fundus hemorrhages (intraclass correlation coefficients 0.91 and 0.87, respectively) and the location of hemorrhages (concordance coefficients 0.86 and 0.85, respectively). Substantial agreement was observed by both groups regarding size of hemorrhage (concordance coefficients 0.73 and 0.76), moderate agreement for hemorrhage morphology (concordance coefficients 0.53 and 0.52), and other findings (concordance coefficients 0.48 and 0.59). Intraobserver agreement for pediatric ophthalmologists varied by question, ranging from substantial to perfect for the presence, number, location, size, and morphology of fundus hemorrhage.

CONCLUSION

We have developed and validated a standardized clinical reporting tool for ophthalmic findings in suspected abusive head trauma, which has excellent interobserver and intraobserver agreement among consultant specialists and residents. We suggest that its use will improve standardized clinical reporting of such cases.

Validity and ease of use of a computerized Hess chart

PURPOSE

To investigate agreement between computerized and conventional methods for obtaining Hess charts and to compare relative ease of use of both methods.

METHODS

Hess charts of 65 patients were obtained by the use of the computerized Assaf Ocular Motility Analyzer (OMA) and the conventional Lees screen method. The Hess charts produced by each method were compared with a previously described scoring system. Patients compared the ease of testing by using a 5-point Likert scale.

RESULTS

For horizontal deviations of the right eye, the OMA provided a significantly larger (P = 0.0001) deviation (301° ± 267°) than the Lees screen (204° ± 306°). The Lees screen gave a significantly larger score for vertical deviations of the left eye (117° ± 158° vs 96° ± 129°; P = 0.003). Vertical deviations of the right eye and horizontal deviations of the left eye did not differ significantly between tests. Patients required the same amount of time to complete both tests, but the OMA was slightly easier to perform than the Lees screen (Likert score, 1.2 ± 0.5 vs 1.3 ± 0.4; P = 0.046).

CONCLUSIONS

The scores measured were larger with OMA in the horizontal and smaller in the vertical direction than with the Lees screen in some directions. Although the OMA did not save time, patients found it easier to perform than the Lees screen. The OMA may be considered a useful alternative to the Lees screen.

Adrenal suppression following intralesional corticosteroids for periocular haemangiomas

BACKGROUND/AIMS

Treatment with intralesional triamcinolone/betamethasone is recommended for infantile sight-threatening periocular haemangiomas. This study investigates the endocrine and weight changes in 15 infants undergoing therapy over 12 years.

METHODS

15 infants, median age 19 weeks (range 10-56) receiving intra/perilesional triamcinolone/betamethasone underwent serial measurement of weight, early morning serum cortisol and adrenocorticotropic hormone (ACTH) before and after injection.

RESULTS

Cortisol fell from a median (range) of 383 (112-594) to 28 (<10-506) nmol/l (p=0.005) and ACTH from 26 (14-134) to 9 (5-20) ng/l (p=0.05) from before injection to 4 weeks after treatment. Prolonged adrenal suppression occurred in 13 out of 15 cases with time to recovery being 19.5 (4-65) weeks. Failure to gain weight appropriately was observed in 14 infants but recovered once normal adrenal function was re-established.

CONCLUSION

Prolonged adrenal suppression following triamcinolone/betamethasone injection for periocular haemangiomas is common and associated with faltering weight gain.

Use of proton transfer reaction time-of-flight mass spectrometry for the analytical detection of illicit and controlled prescription drugs at room temperature via direct headspace sampling

The first reported use of proton transfer reaction time-of-flight mass spectrometry (PTR-TOF-MS) for the detection of a range of illicit and prescribed drugs is presented here. We describe the capabilities of PTR-TOF-MS to detect the following commonly used narcotics-ecstasy (N-methyl-3,4-methylenedioxyamphetamine), morphine, codeine, cocaine and heroin-by the direct sampling of the headspace above small solid quantities (approximately 50 mg) of the drugs placed in glass vials at room temperature, i.e. with no heating of the sample and no pre-concentration. We demonstrate in this paper the ability to identify the drugs, both illicit and prescribed, using PTR-TOF-MS through the accurate m/z assignment of the protonated parent molecule to the second decimal place. We have also included in this study measurements with an impure sample of heroin, containing typical substances found in "street" heroin, to illustrate the use of the technology for more "real-world" samples. Therefore, in a real-world complex chemical environment, a high level of confidence can be placed on the detection of drugs. Although the protonated parent is observed for all drugs, the reactant channel leading to this species is not the only one observed and neither is it necessarily the most dominant. Details on the observed fragmentation behaviour are discussed and compared to electrospray ionisation MS(n) studies available in the literature.

In Situ Simulation Training for Paediatric Cardiorespiratory Arrest: Initial Observations and Identification of Latent Errors

In response to a successful, although difficult resuscitation in one of our paediatric wards, we developed and implemented an educational program to improve the resuscitation skills, teamwork and safety climate in our multidisciplinary acute-care paediatric service. The program is ongoing and consists of didactic presentations, high-fidelity in situ simulation and facilitated debriefing to encourage reflective learning. The underlying goal, to provide this training to all staff over a two-year period, should be achieved by late 2011. In this preliminary report we describe teamwork difficulties that are commonly found during such training. These included inconsistent leadership behaviours, inadequate delegation of areas of responsibility, failure to communicate problems during the execution of technical tasks (such as difficulty opening the resuscitation trolley) and failure to challenge inadequate or inappropriate therapy (such as poor chest expansion during bag-mask ventilation). In addition, we unexpectedly discovered seven latent errors in our clinical environment during the first nine months of course delivery. The most disturbing of these was that participants repeatedly struggled to identify and overcome the locking-mechanism and tamper-proof device on a newly introduced resuscitation trolley.

Ocular findings in pediatric patients with partial agenesis of corpus callosum

PURPOSE

To evaluate the ocular associations with corpus callosum agenesis.

METHODS

All children who had corpus callosum agenesis diagnosed by computed tomography or magnetic resonance imaging scans during a 10-year period were included in the study. A complete ophthalmological assessment was undertaken. Data were collected for age, sex, neurological findings, visual acuity, refractive errors, ocular motility defects, and ocular abnormalities. There were no children with Aicardi syndrome in the study.

RESULTS

Nineteen children with corpus callosum agenesis were identified, of whom 13 were examined. All had partial agenesis of the corpus callosum. Visual acuity was better than 20/60 in 5 children (38%), between 20/60 and 20/200 in 3 children (23%), and less than 20/200 in 5 children (38%). Refractive errors were present in 8 children (62%), strabismus in 6 children (46%), nystagmus in 2 children (15%), hypoplastic discs in 3 children (23%), and microphthalmos in 1 child (8%).

CONCLUSION

Non-syndromic corpus callosum agenesis may be associated with several ocular defects. Poor visual acuity, refractive errors, and strabismus predominate and need to be appropriately addressed to optimize visual function in these children. Global developmental delay (62%) and epilepsy (46%) were the most common neurological associations in this series.

Opaque intraocular lens for intractable diplopia-UK survey

AIMS

To assess the practice of the use of an opaque intraocular lens (IOL) for intractable diplopia in the UK.

METHODS

A questionnaire was sent to 892 consultant ophthalmologists in practice requesting information on the treatment of intractable diplopia with an opaque IOL. Respondents were asked whether they would consider using an opaque IOL for intractable diplopia. Information was gathered on the numbers of lenses implanted, the type of lens used, and whether the lens was implanted inside or outside the capsular bag. In addition, we asked for the causes of intractable diplopia, the success in eliminating diplopia, the use of postoperative pilocarpine, and whether postoperative surveillance was part of the follow-up protocol.

RESULTS

Of the 481 completed questionnaires received, 72% would consider implanting an opaque IOL. A total of 48 surgeons had implanted 1 or more lenses. There were 97 patients who were implanted with an opaque IOL over the past 15 years. Strabismus, nerve palsies, and previous retinal detachment surgery with diplopia were the main indications. Pseudophakic lenses were used by 38 surgeons in the capsular bag, 6 used iris-supported phakic lenses, and 2 used phakic lenses in the anterior chamber angle. The use of postoperative pilocarpine was reported by 9 surgeons, and 6 surgeons used regular ultrasound fundal surveillance. Patients were reported to be completely asymptomatic at discharge by 31 surgeons, with 15 surgeons reporting patients who were still symptomatic postoperatively. Only 1 intraoperative complication was reported.

CONCLUSIONS

An opaque IOL is a safe method for treating intractable diplopia. This survey confirms that its practice is widely accepted in the UK.

The development and evaluation of a conducting matrix for the electrochemical regeneration of the immobilised co-factor NAD(H) under continuous flow

Through the preparation of a novel controlled pore glass-poly(pyrrole) material we have developed a conducting support that is not only suitable for the co-immobilisation of enzymes and co-factors, but also enables the facile electrochemical regeneration of the co-factor during a reaction. Employing the selective reduction of (rac)-2-phenylpropionaldehyde to (S)-phenyl-1-propanol as a model, we have demonstrated the successful co-immobilisation of the HLADH enzyme and co-factor NAD(H); with incorporation of the material into a continuous flow reactor facilitating the in situ electrochemical regeneration of NAD(H) for in excess of 100 h. Using this approach we have developed a reagent-less, atom efficient system applicable to the cost-effective, continuous biosynthesis of chiral compounds.