A comparative bacteriological profile and antibiogram of dacryocystitis.

INTRODUCTION: Dacryocystitis is an infection and an inflammation of the lacrimal sac and is an important cause of ocular morbidity in India. OBJECTIVE: To isolate and identify the bacterial patterns associated with dacryocystitis and to determine their antibacterial sensitivity pattern. MATERIALS AND METHODS: A total of 100 lacrimal swab materials were subjected to bacterial analysis. Children less than 8 years were not included in the study. RESULTS: The chances of chronic dacryocystitis were more than acute dacryocystitis and were commonly found in the age group of 41 - 50 years. Females were more vulnerable to the infection than males. From a 100 samples a total of 122 bacterial isolates were obtained. Both Gram positive and Gram negative bacteria were equally distributed in the study. The most common organism associated with the infection was S. aureus. The antibacterial sensitivity showed more effectiveness towards Gram positive isolates than Gram negative isolates. CONCLUSION: Both Gram positive and Gram negative organism are associated with with chronic dacryocystitis. Knowledge of the bacteriology of dacryocystitis and the susceptibility of the bacteria towards antibiotics will better guide a clinician in the choice of the medication for the most appropriate drug for the treatment.

Dilution induced thickening in hydrotrope-rich rod-like micelles.

Dilution induced changes in the microstructure and rheological behavior of micelles formed by a cationic surfactant-anionic hydrotrope mixture has been investigated in the hydrotrope-rich region. The surfactant used is cetyltrimethylammonium bromide (CTAB) and the hydrotropic salt is sodium 3-hydroxy naphthalene 2-carboxylate (SHNC). The concentration of the mixture is varied from 0.5% to 10.0% w/w (φ=0.005-0.100) at a fixed weight ratio of hydrotrope to surfactant (85:15). Rheological studies indicate Newtonian flow behavior at low and high volume fractions (0.005 and 0.100) while a shear thinning behavior is observed at intermediate volume fractions. The zero-shear viscosity η(0) also passes through a maximum upon changes in the concentration. The most striking feature in our study is that a low viscosity Newtonian fluid transforms to a viscoelastic fluid, upon dilution, and then again to a Newtonain fluid. Small angle neutron scattering studies of 10.0% micellar solution show the presence of rod-like aggregates. Upon dilution, the scattering intensity per unit concentration shows an increase in the low q-region. The nature of pair distance distribution function and subsequent model fitting indicates a transition from rod-like micelles to unilamellar vesicles upon dilution. This behavior is explained in terms of the volume fraction dependant solubilization of hydrotropes in the rod-like micelles and consequent changes in the composition of the mixed micelles.

Ocular candidiasis: a review.

AIMS: To review the epidemiology, diagnosis and changing treatment paradigm of ocular candidiasis, and report current prevalence rates and risk factors at one inpatient hospital. DESIGN: Retrospective review; systematic literature review. METHODS: All Wills Eye Institute inpatient ophthalmology consultations from Thomas Jefferson University Hospital were retrospectively reviewed between June 2006 and November 2006. All consultations for candidaemia were included. The outcome variables included chorioretinitis, endophthalmitis, visual symptoms and Candida speciation. The ophthalmic literature was reviewed using PubMed. Keywords included Candida, candidaemia, chorioretinitis, vitritis and endophthalmitis. Bibliographies were manually searched. RESULTS: Three of the 38 consultations for candidaemia (7.9%) had chorioretinitis. There were no cases of vitritis or endophthalmitis. The presence of symptoms, or the inability to articulate symptoms, was significantly associated with risk of ocular candidiasis (p = 0.003). All three cases of chorioretinitis had positive blood cultures for Candida albicans (p = 0.089) and were treated with oral fluconazole. CONCLUSIONS: Various factors have led to the increasing prevalence of inpatient candidaemia. Risk factors for ocular involvement include albicans species and the presence of, or inability to articulate, visual symptoms. For those without abnormal findings on initial examination, a subsequent retinal examination should be performed in 2 weeks, particularly if new symptoms develop or if the patient is unable to relay symptoms. Patients with chorioretinitis should be treated with systemic antifungal agents. For those with vitritis or endophthalmitis, particularly if worsening on systemic therapy alone, intravitreal antifungal medications or early vitrectomy should be considered.

Sciatic neuropathy secondary to infiltrating intermuscular lipoma of the thigh.

Sciatic neuropathy is a rare mononeuropathy of the lower limbs that is commonly misdiagnosed as spinal stenosis or herniated nucleus pulposus. We describe an unusual case in which a patient underwent surgical excision of a large soft-tissue mass on his right side that involved the posterior and medial compartment of the thigh with displacement of the sciatic nerve posteriorly. The patient had full resolution of his pain and restoration of his neurologic function.

Adenosine-induced ventricular fibrillation.

The use of adenosine has been suggested as a diagnostic tool in the evaluation of wide ORS complex tachycardia. However, adenosine shortens the antegrade refractoriness of accessory atrioventricular connections and may cause acceleration of the ventricular rate during atrial fibrillation. We observed ventricular fibrillation in 2 patients who presented to the emergency department with pre-excited atrial fibrillation and were given 12 mg of adenosine.

Role of weight-bearing flexion and extension myelography in evaluating the intervertebral disc.

Magnetic resonance imaging has many advantages compared with myelography and/or computed tomography in evaluating the lumbar spine for herniated nucleus pulposus. The authors have included a series of three patients whose histories and physical examinations were clinically suggestive of herniated nucleus pulposus but whose magnetic resonance imaging scans were interpreted by a radiologist as a disc bulge without nerve root compression. Because all patients had not responded to a conservative care treatment program and surgical intervention was to be considered, subsequent testing with lumbar myelography with weight-bearing flexion and extension views demonstrated more clearly the presence of herniated nucleus pulposus along with compression of the nerve root; it also revealed that a positional change in the disc occurred with flexion and extension.

Dual chamber pacing for neurally mediated syncope with a prominent cardioinhibitory component.

The role of cardiac pacing for treatment of recurrent neurally mediated syncope (NMS) remains controversial. We hypothesized that dual chamber pacing in NMS patients with a prominent cardioinhibitory component may be beneficial. Twelve patients (mean age = 37.8+/-17 years, range 15-78 years, 7 men and 5 women) with a mean of 4+/-2.2 episodes of syncope underwent tilt table evaluation. Patients were passively tilted to 70 degrees head-up position for 20 minutes and then returned to the supine position. Isoproterenol was then infused at 1-2 microg/min to increase heart rate by > or = 25% and tilt was repeated. Patients lost consciousness after 16+/-6 minutes of tilt; nine patients had syncope in the baseline state and three during isoproterenol infusion. All patients had at least 5 seconds of asystole with a mean of 9.5+/-4 seconds (range 5-20 s). A dual chamber permanent pacemaker with a special feature allowing heart rate acceleration in response to bradycardia was implanted in all patients. During a mean follow-up of 18.6+/-4.2 months, 11 (92%) of these patients were free of syncope and had negative tilt table test. One (8%) patient had two episodes of syncope. We conclude that dual chamber pacing may be beneficial in patients with NMS with a prominent cardioinhibitory component.

QT dispersion may be a useful adjunct for detection of myocardial infarction in the chest pain center.

BACKGROUND: QT dispersion has been proposed as a noninvasive measurement of the degree of inhomogeneity in myocardial repolarization. Increased QT dispersion has been reported after myocardial infarction. We hypothesized that increased QT dispersion may be a useful adjunct for risk stratification in patients being evaluated in a chest pain center. METHODS AND RESULTS: Patients were admitted to the chest pain center for evaluation of chest pain. Exclusion criteria included (1) systolic blood pressure <90 mm Hg, (2) ischemia or infarction on the initial electrocardiograph (ECG), (3) elevated creatine kinase or MB fraction, and (4) chest pain associated with cocaine use. Serial creatine kinase and MB levels and ECGs were obtained at 0, 6, and 9 hours. Patients were monitored for (1) creatine kinase and MB rise, (2) ECG changes for infarction, (3) ST-segment changes, and (4) rest angina. A negative evaluation at the chest pain center led to an exercise stress test. Patients with a positive exercise stress test were admitted for further evaluation and patients with a negative exercise stress test result were discharged home. Patients were divided into 3 groups. Group 1 consisted of patients who were found to have an acute myocardial infarction (AMI), group 2 consisted of patients with prior history of coronary artery disease but no evidence of AMI, and group 3 consisted of patients without prior coronary artery disease or AMI. QT dispersion was measured on the initial ECG in all patients. A total of 586 patients were evaluated. Group 1 consisted of 13 patients with mean QT dispersion of 44.6+/-18.5 ms, group 2 consisted of 267 patients with a mean QT dispersion of 10.0+/-13.8 ms, and group 3 consisted of 303 patients with a mean QT dispersion of 10.5+/-10.0 ms. Analysis of variance showed a significantly higher QT dispersion in patients who had AMI compared with other patients with chest pain (P< .001). CONCLUSIONS: QT dispersion can be a useful diagnostic adjunct for detection of AMI in patients with chest pain with a normal ECG and normal cardiac enzymes.

Spongy left ventricular myocardium in an adult.

"Spongy left ventricular myocardium," or noncompaction of left ventricular myocardium, is a rare disorder of endomyocardial morphogenesis. It is usually seen in the pediatric population and is often associated with other congenital cardiac malformations. We describe an adult with noncompaction of left ventricular myocardium without associated congenital cardiac anomalies.

Clinical differentiation of narrow QRS complex tachycardias.

Supraventricular tachycardias generally present with narrow QRS complexes and are quite commonly seen in the emergency department. Regular narrow QRS complex tachycardias occur in all age groups and may be associated with minimal symptoms, such as palpitations, or, present with hemodynamic compromise resulting in syncope. While history and physical examination are indispensable, they usually do not lead to a definitive diagnosis. The diagnosis is made by careful analysis of the 12-lead ECG. Therapy is based on hemodynamic assessment and understanding of the tachycardia mechanism.

Clinical approach to wide QRS complex tachycardias.

Wide QRS complex tachycardia is a frequently encountered arrhythmia in the emergency department and presents a diagnostic challenge to the emergency physician. The history, physical examination, chest radiograph, and electrocardiogram analysis are important in making the correct diagnosis. The diagnosis of ventricular tachycardia is supported by, 1) a history of prior myocardial infarction or congestive heart failure; 2) a physical examination showing cannon A-waves in the jugular venous pulsation or variable heart sounds; 3) a chest radiograph showing cardiomegaly or evidence of prior cardiac surgery; and 4) characteristic ECG features that include AV dissociation, fusion-capture beats, QRS concordance, or, typical morphologic features in leads V1 and V6. This article presents the diagnostic and therapeutic approaches to wide QRS tachycardias.

Permanent cardiac pacing.

Implantation of a permanent pacemaker is the most commonly performed surgical operation involving the heart. The modern cardiac pacemaker is a complex device that can sense and pace in both the atrium and ventricle. It also modulates the pacing rate based on sensed physiologic parameters. This article reviews the fundamental principles of pacemaker technology and provides the emergency physician with approaches to common pacemaker problems.

Implantable cardioverter defibrillators.

Implantable cardioverter defibrillators have proven to be an effective therapy for life-threatening ventricular arrhythmias. Given the ever-increasing number of patients who have these devices, increasing numbers of patients are likely to present to emergency departments with defibrillator-related problems. This article discusses normal device function, indications for implantation, and technique of implantation. It also focuses on the evaluation and management of patients with these devices presenting to the emergency department.

Management of mobile right atrial thrombi: a therapeutic dilemma.

BACKGROUND: Mobile right atrial thrombus is an uncommon finding on two-dimensional (2D) echocardiography. Therapeutic alternatives include systemic heparinization, systemic or local thrombolysis, and surgical removal. We report our clinical experience in six patients over a 3-year period (6000 echocardiograms) at a tertiary care referral center. METHODS: There were four men and two women with a mean age of 63 years (range: 47 to 73 years). Indications for echocardiography consisted of progressive dyspnea and chest pain in five patients and syncope with chest pain in one patient. RESULTS: All were observed to have a mobile thrombus in the right atrium. Ventilation perfusion (V/Q) scanning confirmed V/Q mismatch in all patients. Subsequent echocardiography (minutes to 1 day later) in three patients demonstrated absence of the thrombus suggesting pulmonary embolization. One patient died during transesophageal echocardiography (TEE) and autopsy confirmed a large pulmonary embolization in the main pulmonary artery. Treatment consisted of heparinization in 3 patients, systemic thrombolysis in 1 patient, and surgical removal of the thrombus in 1 patient. At surgery, a long serpiginous thrombus was seen in the right atrium, tethered to a fenestrated eustachian valve. There were 3 deaths: 1 patient treated with heparin; 1 patient treated with thrombolysis; and 1 during TEE. Two of the three patients treated with heparin and one patient undergoing surgical removal survived hospitalization. CONCLUSIONS: Mobile thrombus in the right atrium is an unusual echocardiographic finding. It portends a poor prognosis with death due to pulmonary embolism.

The visiting lectureship on aboriginal health: an educational initiative at the University of Toronto.

Many recent reports on Aboriginal issues have identified three major deficits in Canadian universities: a lack of Aboriginal curriculum content, a lack of faculty role models, and low student enrollment. Many health professional schools have responded by recruiting more Aboriginal students and by introducing Native content into their curricula. This paper describes the six-year experience of the annual program of the Visiting Lectureship on Native Health at the University of Toronto as one of the ways to increase the Aboriginal curricular content. The three-week program covers the selected Aboriginal health issue by sequentially exploring its historical background, the extent of the current problem and its future solutions. Over six years, 37 Native speakers delivered 83 lectures, 19 public fora and 98 seminars and workshops to 3 universities and 12 professional and community agencies. Over 7,900 individuals have participated in the program and the response has been very positive.

The impact of unemployment on health: a review of the evidence.

OBJECTIVE: To review the scientific evidence supporting an association between unemployment and adverse health outcomes and to assess the evidence on the basis of the epidemiologic criteria for causation. DATA SOURCES: MEDLINE was searched for all relevant articles with the use of the MeSH terms "unemployment," "employment," "job loss," "economy" and a range of mortality and morbidity outcomes. A secondary search was conducted for references from the primary search articles, review articles or published commentaries. Data and definitions of unemployment were drawn from Statistics Canada publications. STUDY SELECTION: Selection focused on articles published in the 1980s and 1990s. English-language reports of aggregate-level research (involving an entire population), such as time-series analyses, and studies of individual subjects, such as cross-sectional, case-control or cohort studies, were reviewed. In total, the authors reviewed 46 articles that described original studies. DATA EXTRACTION: Information was sought on the association (if any) between unemployment and health outcomes such as mortality rates, specific causes of death, incidence of physical and mental disorders and the use of health care services. Information was extracted on the nature of the association (positive or negative), measures of association (relative risk, odds ratio or standardized mortality ratio), and the direction of causation (whether unemployment caused ill health or vice versa). DATA SYNTHESIS: Most aggregate-level studies reported a positive association between national unemployment rates and rates of overall mortality and mortality due to cardiovascular disease and suicide. However, the relation between unemployment rates and motor-vehicle fatality rates may be inverse. Large, census-based cohort studies showed higher rates of overall mortality, death due to cardiovascular disease and suicide among unemployed men and women than among either employed people or the general population. Workers laid off because of factory closure have reported more symptoms and illnesses than employed people; some of these reports have been validated objectively. Unemployed people may be more likely than employed people to visit physicians, take medications or be admitted to general hospitals. A possible association between unemployment and rates of admission to psychiatric hospitals is complicated by other institutional and environmental factors. CONCLUSIONS: Evaluated on an epidemiologic basis, the evidence suggests a strong, positive association between unemployment and many adverse health outcomes. Whether unemployment causes these adverse outcomes is less straightforward, however, because there are likely many mediating and confounding factors, which may be social, economic or clinical. Many authors have suggested mechanisms of causation, but further research is needed to test these hypotheses.

Acquired tracheo-oesophageal fistula.

Acquired tracheo-oesophageal fistula is rare. The most common causes are tuberculosis and malignancy. Here we report a patient who had come with dysphagia and aspiration pneumonia with paratracheal lymphnodes on X-ray chest and was diagnosed to have a tracheo-bronchial fistula on barium studies. Transtumoral intubation by pull-through method was carried out.