The accuracy of the Edinburgh Red Eye Diagnostic Algorithm

Purpose

To assess the diagnostic accuracy of the Edinburgh Red Eye Algorithm.

Methods

This was a prospective study. A questionnaire was designed and made available to clinicians referring patients to the acute ophthalmology service within Edinburgh. The questionnaire involved them using the algorithm to reach a diagnosis in patients presenting with red eye(s). Patients were then referred to the emergency eye clinic and the questionnaire faxed to the clinic or sent with the patients. Patients were then examined by an experienced ophthalmologist (not blinded) to reach a ‘gold standard'' diagnosis. The concordance between the ‘algorithm assisted'' diagnosis and the ‘gold standard'' was then assessed.

Results

All patients presenting with red eye(s) were eligible for inclusion. Forty-one questionnaires were completed, two were excluded. The algorithm assisted diagnosis was correct 72% (28/39) of the time. It correctly diagnosed: acute angle closure glaucoma in 100% of cases (4/4); iritis in 82% (9/11); stromal keratitis in 63% (5/8); epithelial keratitis in 70% (7/10); and infective conjunctivitis in 50% (3/6).

Discussion

The diagnostic accuracy of The Edinburgh Red Eye Diagnostic Algorithm is 72, rising to 76% when only the most serious red eye(s) causes are included. The diagnostic accuracy of nonophthalmologists when assessing patients presenting with red eye(s) is greater when the algorithm is used. We hope that the use of this algorithm will prevent delayed presentations of certain serious eye conditions and reduce the morbidity from delayed treatment.     

Temporal pattern of de novo lipogenesis in the postprandial state in healthy men

BACKGROUND: Recent data suggest that hepatic de novo lipogenesis (DNL) is elevated in the fed state compared with the fasting state, but the rate at which lipogenesis can increase with meal consumption is currently unknown. OBJECTIVE: The objective was to quantify the diurnal pattern of lipogenesis after 2 consecutive mixed meals were fed to healthy men (n = 8). DESIGN: A liquid diet was administered after a 12-h fast. During the fasting and postprandial periods, serum insulin, glucose, triacylglycerol, and nonesterified fatty acid concentrations were measured, and rates of DNL were quantified via intravenous infusion of [1-(13)C] sodium acetate and mass isotopomer distribution analysis. RESULTS: The temporal pattern of postprandial lipogenesis was similar in all subjects. Lipogenesis rose significantly from 4.7 +/- 3.3% at fasting, peaked at 18.2 +/- 7.1% after meal 1 (P = 0.003 compared with fasting), rose further to 23.1 +/- 8.9% after meal 2 (P = 0.01 for difference between meals), and then decreased toward baseline (P < 0.001). Lipogenesis peaked 4.2 h after the meals; lipoprotein-triacylglycerol concentrations peaked sooner, 2.0 h after the meals (P < 0.02). Maximum postprandial DNL ranged from 10.3% to 37.5%. Peak insulin concentrations after meal 1 correlated with peak DNL (R = 0.838, P = 0.037), although the leanest subjects had some of the highest rates of postprandial DNL. CONCLUSION: These data confirm the acute stimulation of DNL after meals in healthy subjects and validate the contribution of this pathway to elevations in triacylglycerol concentration.     

Randomized, controlled study of long-acting local anesthetic (levobupivacaine) in femoral artery sheath management during and after percutaneous coronary intervention

OBJECTIVE: To assess the effect of long-acting local anesthetic (levobupivacaine) in addition to lidocaine for the management of femoral artery sheaths during and after percutaneous coronary intervention (PCI). BACKGROUND: Femoral artery sheaths are commonly used during PCI. Sheath removal is often delayed after the procedure by which time short-acting local anesthetic agents may no longer be effective. METHODS: Sixty patients were randomized to either usual care or the administration of local levobupivacaine after PCI. Patients were asked to report their pain experienced on a visual analogue score. RESULTS: Thirty patients received additional levobupivacaine (0.5%) and 30 received standard care. There were no procedural differences between the groups, except that more patients in the control group received intravenous (IV) morphine at the time of sheath removal. There was no difference between the control group and levobupivacaine group in pain scores at the time of sheath insertion. (2.0 +/- 0.4 versus 1.8 +/- 0.3; p = 0.80). Both groups recorded low pain scores while waiting for sheath removal, and the score was slightly (but not significantly) lower in the levobupivacaine group (1.3 +/- 0.2 versus 0.8 +/- 0.2; p = 0.09). Pain scores were lower in the levobupivacaine group during sheath removal 2.2 +/- 0.4 versus 1.1 +/- 0.2; p = 0.02). There were no differences in terms of blood pressure between the groups at any time point. CONCLUSIONS: Levobupivacaine reduced the need for IV opiate and provided better analgesia than lidocaine alone in patients undergoing PCI.     

Surgical management of traumatic protrusio acetabuli in the elderly

We report a case of traumatic protrusio acetabuli in an elderly patient managed by primary total hip replacement with reconstruction of the right acetabulum using the Kerboul shell plate and autologous bone grafting.     

Thymosin-inducible lymphocytes in the peripheral blood of patients with malignant melanoma.

E rosette-forming (T) lymphocytes and surface immunoglobulin-bearing lymphocytes were estimated in 85 patients with malignant melanoma. The melanoma patient group had lower mean levels of T lymphocytes and higher mean levels of immunoglobulin-bearing (? B) lymphocytes than did normal subjects. The absolute and percentage depressions of T-cell levels in the melanoma patients were stage-related, as was the depression of total lymphocyte and B-lymphocyte levels. The T lymphopenia in the melanoma patients could, in vitro, be partially abolished by fetal calf serum (as used in many E rosetting methods), and could be totally abolished by thymosin fraction 5 (Hoffmann-La Roche) at optimum concentration. In view of the ability of thymosin to restore T cells to normal levels in all of the T-lymphopenic patients, a clinical trial of this hormone in selected melanoma patients of all stages appears to be warranted.     

Urgent in-patient coronary angiography: a comparison of centres with and without cardiac catheter facilities

OBJECTIVES: To review the referral of patients to a tertiary centre for urgent angiography and to determine if there are differences in invasive treatment strategies for patients with acute coronary syndrome (ACS). METHODS: There were 2 parts to the study, a retrospective part over 3.5 years from a computerised cardiac laboratory booking data base and a prospective part over 3 months. RESULTS: There were 1190 urgent in-patient angiograms performed with 499 (42%) admitted initially to the tertiary centre while the remaining 691 (58%) were admitted to district general hospitals (DGH), with no on-site access to a cardiac laboratory, and subsequently transferred to the tertiary centre. Once referred, DGH patients waited longer for their angiogram (2.7 +/- 3.2 vs 2.0 +/- 2.8 days, p < 0.0001). Interestingly, DGH patients appear to spend an average of 4 days in hospital prior to referral for angiography. DGH patients were more likely to have a higher Thrombosis in Myocardial Infarction (TIMI) risk score at presentation and following angiography were more likely to have coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) and less likely to have angiographically normal arteries. CONCLUSIONS: Our findings are consistent with previous studies demonstrating that access to coronary angiography varies considerably between hospitals. However, we have demonstrated that patients in DGHs wait on average 4 days before referral for coronary angiography suggesting that there may be triage based on initial responses to medical therapy. Further research is needed to determine whether this has a direct effect on outcomes.     

Spinal injuries in Irish rugby: a ten-year review

This study assessed the frequency of acute injury to the spinal cord in Irish Rugby over a period of ten years, between 1995 and 2004. There were 12 such injuries; 11 were cervical and one was thoracic. Ten occurred in adults and two in schoolboys. All were males playing Rugby Union and the mean age at injury was 21.6 years (16 to 36). The most common mechanism of injury was hyperflexion of the cervical spine and the players injured most frequently were playing at full back, hooker or on the wing. Most injuries were sustained during the tackle phase of play. Six players felt their injury was preventable. Eight are permanently disabled as a result of their injury.     

Minimally invasive 360° instrumented lumbar fusion

A retrospective preliminary study was undertaken of combined minimally invasive instrumented lumbar fusion utilizing the BERG (balloon-assisted endoscopic retroperitoneal gasless) approach ¶anteriorly, and a posterior small-incision approach with translaminar screw fixation and posterolateral ¶fusion. The study aimed to quantify the clinical and radiological results using this combined technique. The traditional minimally invasive approach to the anterior lumbar spine involves gas insufflation and provides reliable access only to L5-S1 and in some cases L4-5. A gas-mediated approach yields many technical drawbacks to performing spinal surgery. A minimally invasive posterior approach involving suprafascial pedicle screw instrumentation has been developed, but without widespread use. Translaminar facet fixation may be a viable alternative to transpedicular fixation in a 360° instrumented fusion model. Past studies have shown open 360° instrumented lumbar fusion yields high arthrodesis rates. The study examined the cases of 46 patients who underwent successful 360° instrumented lumbar fusion using a combined minimally invasive approach. Anterior lumbar interbody fusion (ALIF) at one or two levels was performed through the BERG approach; a gasless retroperitoneal approach to the lumbar spine allowing the use ¶of standard anterior instrumentation. Posteriorly, all patients underwent successful decompression, translaminar fixation, and posterolateral fusion at one or two levels through ¶one small (2.5–5.0 cm) incision. Results showed mean hospital stay of 2.02 days; mean combined blood loss was 255 cc; and mean pain relief was 56%, with 75.5% of patients reporting good, excellent, or total pain relief. Forty-two of 46 patients (93.2%) achieved a solid fusion ¶24 months after surgery. A total of 47% of all patients working prior to surgery returned to work following surgery. The study showed that minimally invasive 360° instrumented lumbar fusion, when performed utilizing these approaches, yields a high rate of solid arthrodesis (93.3%), good pain relief, short hospital stays, low blood losses, accelerated rehabilitation, and a quick return to the workforce. The BERG approach offers technical advantages over the traditional gas-mediated laparoscopic approach to the anterior lumbar spine.