Validation of the Canadian c-spine rule in the UK emergency department setting.

AIM: To determine the potential of the Canadian Cervical Spine Rule (CCR) to safely reduce the number of cervical spine (c-spine) radiographs performed in the UK emergency department setting. METHODS: The study was conducted in two UK emergency departments with a combined annual attendance of >150,000 adult patients. Over the 24 month trial period, 148 doctors were provided training in the use of the CCR and instructed to assess eligible patients presenting with potential c-spine injury. Doctors were instructed to manage patients according to existing practice and not according to the decision obtained from the rule. A subsample of patients was reassessed by a second doctor to test interobserver reliability. RESULTS: A total of 1420 patients were enrolled in the study (50.4% male). 987 (69.5%) had c-spine radiography performed, with 8 (0.6%) having a c-spine injury. If the decision for radiography had been made according to the outcome of the CCR, only 815 (57.4%) would have had c-spine radiography and all 8 abnormal cases would have undergone imaging. Doctors were comfortable using the rule in 91% of cases. Interobserver reliability was good (κ=0.75 95% CI 0.44 to 1.06). CONCLUSION: The CCR can be applied successfully in the UK. Had the CCR been in use during the study period, a 17.4% reduction in radiography could have been achieved without compromising patient care.

A comparison of 2 methods for estimating residual stromal bed thickness before repeat LASIK.

PURPOSE: To compare 2 methods of calculating residual stromal bed (RSB) thickness after repeat LASIK, to determine which method generates more conservative RSB thickness estimates, and to determine any factors related to the discrepancy between these 2 calculation methods. DESIGN: Retrospective nonrandomized comparative trial. PARTICIPANTS: Seventy-nine patients (one eye per patient) undergoing primary LASIK and 2 repeat procedures (second and third LASIK) from 1998 to 2002. METHODS: We compared calculated RSB thickness after second and third LASIK using either original corneal thickness (CT) minus flap thickness and all ablations (original CT method) or pre-enhancement CT minus flap thickness and enhancement ablation (repeat CT method). MAIN OUTCOMES MEASURES: Differences in calculated RSB thickness after second and third LASIK by each method. RESULTS: Calculated RSB thickness averaged 329 microm by the repeat CT method compared with 305 microm by the original CT method after second LASIK (mean difference, 24 microm; P<0.0001) and 320 microm by the repeat CT method compared with 289 microm by the original CT method after third LASIK (mean difference, 31 microm; P<0.0001). After second LASIK, for 54% of eyes the repeat CT method was greater by >or=20 microm, and for 19% of eyes it was greater by >or=40 microm. After third LASIK, for 67% of eyes the repeat CT method was greater by >or=20 microm, and for 26% of eyes it was greater by >or=40 microm. The repeat CT method gave greater RSB thickness values than the original CT method in 73 of 79 eyes (92%) after second LASIK and in 72 of 79 eyes (91%) after third LASIK. The difference between the 2 methods was not associated with age, gender, initial preoperative refractive error, or refractive error before repeat LASIK. CONCLUSION: Using original preoperative CT measurements provides a more conservative and thus safer approach than using CT measurements obtained before repeat LASIK to calculate RSB thickness after repeat LASIK.

Delayed reactivation of presumed adenoviral subepithelial infiltrates after laser in situ keratomileusis.

OBJECTIVE: To report the reactivation of presumed adenoviral keratitis after laser in situ keratomileusis (LASIK). METHODS: Case report and literature review. RESULTS: The patient underwent uneventful LASIK more than 5 years after an episode of adenoviral keratitis that left subepithelial corneal scarring. Three months after LASIK, new subepithelial infiltrates appeared in the right eye. These lesions resolved without sequelae during treatment with topical steroids. The patient's uncorrected and best-corrected visual acuity returned to her postoperative baseline. CONCLUSION: LASIK may cause delayed exacerbation of subepithelial infiltrates caused by adenoviral keratitis. However, good visual outcomes can be achieved with recognition of this reactivation and treatment with topical corticosteroids.

Corneal and conjunctival changes after posterior segment surgery.

Significant corneal compromise can occur subsequent to vitreoretinal surgery, especially in diabetic corneas. Associated factors include the operating lens systems used, irrigating solutions, preoperative lens and anterior capsule status, and the use of adjunctive agents such as intraocular gasses or silicone oil. Corneal, conjunctival, and ocular surface complications can also occur after scleral buckling procedures, often related to buckle extrusion or infection.

Refractive changes after posterior segment surgery.

Retinal surgery can induce significant refractive errors. These errors include spherical changes caused by alterations in axial length after scleral buckle placement, astigmatic changes induced by a scleral buckle or pars plana vitrectomy, and focal alterations in corneal curvature that can significantly limit postoperative visual acuity. The adjunctive use of silicone oil can impose alterations directly, by the oil's interaction with the other refractive elements of the eye, and indirectly, through its effects on intraocular lens power calculations for subsequent cataract surgery.

Summertime and the patient is itchy.

A 21-year-old man presented to the emergency department with a 36 h history of a painful, itchy maculopapular rash and associated vesicles to his arms and neck. He had no history of exposure to new chemicals or hygiene products and no significant medical history. His physiological observations were normal and systemic examination was unremarkable. On close inspection the rash was noted to be present only on areas of skin exposed while wearing a polo shirt. On further questioning it transpired that he had been gardening 12 h prior to the development of the rash. A diagnosis of phytophotodermatitis was made. The patient was discharged with chlorphenamine, simple analgesia and the advice to wear a long-sleeved t-shirt and sunscreen when gardening in future. Phytophotodermatitis is a cutaneous reaction caused by contact with light-sensitising compounds found in plants and exposure to ultraviolet A radiation. It is self-limiting and can be managed symptomatically.