Acute postoperative pain is an independent predictor of chronic postsurgical pain following total knee arthroplasty at 6 months: a prospective cohort study.

BACKGROUND: Approximately 15% of patients report persistent knee pain despite surgical success following total knee arthroplasty (TKA). The purpose of this study was to determine the association of acute-postsurgical pain (APSP) with chronic postsurgical pain (CPSP) 6 months after TKA controlling for patient, surgical and psychological confounding factors. METHODS: Adult patients with osteoarthritis undergoing primary elective tricompartmental TKA, with the operated knee the primary source of preoperative pain, were studied between March 2011 and February 2017. Patients received standard operative management and a perioperative multimodal analgesia regimen. The primary outcome was CPSP at 6 months. The primary variable of interest was the APSP (weighted mean pain score) for 72 hours postoperatively. Patient, surgical and psychological confounders were assessed using binary logistic regression. RESULTS: 245 cases were analyzed. The incidence of CPSP was 14% (95% CI 10% to 19%). Median APSP values were 4.2 (2.2-5.0) in the CPSP group and 2.8 (1.8-3.7) without CPSP, difference 1.4 (95% CI 0.1 to 1.8, p=0.005). The unadjusted odds for CPSP with an increase of 1 in APSP was 1.46 (95% CI 1.14 to 1.87, p=0.002)). After multivariable risk adjustment, the OR for CPSP for an increase of 1 in the APSP was 1.53 (95% CI 1.12 to 2.09, p=0.008). CONCLUSIONS: APSP is a risk factor for CPSP following TKA even after adjusting for confounding variables such as pain catastrophizing, anxiety, depression and functional status. Studies are needed to determine if APSP is a modifiable risk factor for the development of CPSP.

Clinical outcomes and antibiotic susceptibilities of Staphylococcus aureus endophthalmitis.

PURPOSE: To compare the antibiotic susceptibilities and visual acuity (VA) outcomes in endophthalmitis caused by methicillin-resistant (MRSA) versus methicillin-sensitive S. aureus (MSSA). METHODS: The records of 34 cases of S. aureus endophthalmitis at The New York Eye and Ear Infirmary from Jan 1997 to June 2011 were reviewed. Antibiotic susceptibility profiles over time and VA at presentation and at 3, 6, and ≥12 months were recorded. S. aureus isolates were grouped based on oxacillin resistance. RESULTS: Of the 34 cases, 15 (44 %) were MRSA and 19 (56 %) MSSA. Median presenting VA was hand motions (logMAR 4.0) in both the MRSA and MSSA groups. There was no statistically significant difference in VA between the MRSA and MSSA groups at 3, 6, or ≥12 months. No MRSA isolates were resistant to vancomycin or gentamicin. While over 85 % of MRSA isolates tested for fourth-generation fluoroquinolones were resistant, just 10 % MSSA isolates tested were resistant. There was a trend suggesting an increase in the proportion of MRSA isolates compared to MSSA isolates over the course of the study period. CONCLUSIONS: There was no statistical difference in short- or long-term VA outcomes between the MRSA and MSSA groups at any time point. Resistance to fourth-generation fluoroquinolones was present in over 85 % of MRSA isolates, but just 10 % of MSSA isolates. An increasing proportion of MRSA amongst S. aureus isolates was noted over the course of the study period.

Microbiological spectrum and antibiotic sensitivity in endophthalmitis: a 25-year review.

PURPOSE: To identify the spectrum and susceptibility pattern of pathogens responsible for culture-positive endophthalmitis referred to a single institution and investigate possible trends in both pathogens and antibiotic sensitivities over the past 25 years. DESIGN: A retrospective, laboratory-based study of consecutive microbiological isolates. PARTICIPANTS: A total of 988 consecutive culture-positive endophthalmitis isolates from 911 eyes. METHODS: All culture-positive endophthalmitis isolates collected from 1987 to 2011 were identified. Susceptibility rates to a variety of antibiotics were calculated. Chi-square test for trend was used to detect changes in spectrum or susceptibility over time. MAIN OUTCOME MEASURES: Microbial spectrum and susceptibility pattern over time. RESULTS: A total of 988 isolates were identified from 911 eyes. The average patient age was 67 ± 18 years, and 55% of the patients were female. The most prevalent pathogens were coagulase-negative staphylococcus (39.4%), followed by Streptococcus viridans species (12.1%) and Staphylococcus aureus (11.1%). Gram-negative organisms and fungi accounted for 10.3% and 4.6% of all isolates, respectively. With the exception of 2 isolates, Enterococcus faecium and Nocardia exalbida, all the other 725 (99.7%) gram-positive bacteria tested were susceptible to vancomycin. Of the 94 gram-negative organisms tested against ceftazidime, 2 were of intermediate sensitivity and 6 were resistant. For 8 antibiotics, increasing microbial resistance over time was observed: cefazolin (P = 0.02), cefotetan (P = 0.006), cephalothin (P<0.0001), clindamycin (P = 0.04), erythromycin (P<0.0001), methicillin/oxacillin (P<0.0001), ampicillin (P = 0.01), and ceftriaxone (P = 0.006). For 3 antibiotics, increasing microbial susceptibility was observed: gentamicin (P<0.0001), tobramycin (P = 0.005), and imipenem (P<0.0001). CONCLUSIONS: Coagulase-negative staphylococcus remains the most frequently identified cause of endophthalmitis. Vancomycin and ceftazidime seem to be excellent empiric antibiotics for treating endophthalmitis. Although a statistically significant trend toward increasing microbial resistance against a variety of antibiotics, including cephalosporins and methicillin, was observed, a significant trend toward decreasing microbial resistance against aminoglycosides and imipenem also was detected.

Health improvement for disadvantaged people in Nepal - an evaluation.

BACKGROUND: An evaluation of progress with participatory approaches for improvement of health knowledge and health experiences of disadvantaged people in eight Districts of Eastern Nepal has been undertaken. METHODS: A random selection of Village Development Committees and households, within the eight Districts where participation and a Rights-based Approach had been promoted specifically by local NGOs were compared with similar villages and households in eight Districts where this approach had not been promoted. Information was sought by structured interview and observation by experienced enumerators from both groups of householders. Health knowledge and experiences were compared between the two sets of households. Adjustments were made for demographic confounders. RESULTS: Complete data sets were available for 628 of the 640 households. Health knowledge and experiences were low for both sets of households. However, health knowledge and experiences were greater in the participatory households compared with the non-participatory households. These differences remained after adjustment for confounders. CONCLUSIONS: The study was designed to evaluate progress with participatory processes delivered by non-governmental organisations over a five year period. Improvements in health knowledge and experiences of disadvantaged people were demonstrated in a consistent and robust manner where interventions had taken place.

Isolated Nocardia exalbida endogenous endophthalmitis.

PURPOSE: To report an immunocompetent patient with Nocardia exalbida endogenous endophthalmitis. DESIGN: Case report. METHODS: Clinical-pathologic correlation and microbiologic evaluation were performed on an enucleated eye. RESULTS: A 56-year-old man presented with rapidly progressive vision loss associated with a posterior choroidal mass and serous retinal detachment. Pathologic evaluation of the enucleated eye demonstrated endogenous endophthalmitis. Nocardia exalbida was identified microbiologically. Systemic workup failed to demonstrate definite foci of systemic infection or evidence of immunocompromise. Review of literature failed to identify previously reported cases of Nocardia exalbida endophthalmitis. CONCLUSIONS: Nocardia can rarely cause isolated endogenous endophthalmitis in immunocompetent patients, which can contribute to a delay in diagnosis and vision loss. Endogenous Nocardia endophthalmitis typically occurs in immunocompromised patients with disseminated nocardiosis. Isolated endogenous Nocardia endophthalmitis in immunocompetent patients is rare. We describe isolated endogenous intraocular infection caused by Nocardia exalbida, a novel species, not previously associated with endophthalmitis.

Shifting trends in in vitro antibiotic susceptibilities for common bacterial conjunctival isolates in the last decade at the New York Eye and Ear Infirmary.

BACKGROUND: Bacterial conjunctivitis is one of the most common forms of ocular diseases worldwide. The purpose of this study is to determine the most common pathogens causing bacterial conjunctivitis, their in vitro susceptibility to existing antibiotics, and the changing trends in bacterial resistance to antibiotics over the last decade. METHODS: Records of all conjunctival bacterial cultures performed at the NYEEI Microbiology Laboratory from 1 January 1997 through 30 June 2008 were reviewed. Data on species of bacterial isolates and their in vitro susceptibility to the antibiotics tetracycline, trimethaprim/sulfamethoxazole (TMP/SMZ), imipenem, fluoroquinolones (ciprofloxacin, moxifloxacin, gatifloxacin), aminoglycosides (gentamicin, tobramycin), erythromycin, cefazolin, oxacillin, and vancomycin were collected. RESULTS: Review of records yielded 20,180 conjunctival bacterial cultures, 60.1% of which were culture-positive. Of the culture-positive isolates, 76.6% were gram-positive and 23.4% were gram-negative pathogens. Staphylococcus aureus was the most common gram-positive pathogen isolated, and also the most commonly isolated pathogen overall. Haemophilus influenzae was the most common gram-negative pathogen. A significant increase in the percentage of methicillin-resistant Staphylococcus aureus (MRSA) was observed in the course of 11.5 years. The highest levels of antibiotic resistance were observed to tetracycline, erythromycin, and TMP/SMZ. Gram-positive isolates were least resistant to vancomycin, and gram-negative isolates were least resistant to imipenem. The lowest broad-spectrum antibiotic resistance was observed in the case of moxifloxacin, gatifloxacin, and aminoglycosides. CONCLUSION: Staphylococcus aureus is the most common pathogen in bacterial conjunctivitis. Conjunctival bacterial isolates demonstrated high levels of resistance to tetracycline, erythromycin and TMP/SMZ. Moxifloxacin and gatifloxacin appear to be currently the best choice for empirical broad-spectrum coverage. Vancomycin is the best antibiotic for MRSA coverage.

Primary large cell neuroendocrine carcinoma of the vagina: cytomorphology of previously unreported case.

Squamous carcinoma is the most common malignancy of the vagina. Other malignancies include adenocarcinoma, melanoma, lymphoma, and very rarely, neuroendocrine carcinoma/small-cell carcinoma. Large cell neuroendocrine carcinoma (LCNEC) has not been reported in this location. In this report, we describe a case of LCNEC of the vagina, which is believed to be the first case to date in the English literature. The patient is a 53-year old gravida 3, para 2, African-American woman who had a 4 month history of severe pelvic pain and difficulty voiding and was found to have a firm plate-like mass on the anterior vaginal wall. Thin prep of vaginal swap was interpreted as atypical glandular cells; however, the biopsies showed a large cell neuroendocrine carcinoma which was confirmed by diffuse strong immunoreactivity to AE1/3, CAM5.2, CK7, and CD56 in the tumor cells. Subsequent clinical workup showed that the patient also had numerous metastatic nodules in the bilateral lungs and a vaginal-urethral fistula caused by the tumor. The patient underwent palliative radiation of pelvis for local pain control and then chemotherapy. Although the vaginal tumor increased in size even after radiation, her symptoms were under control and she was doing well for a short period of time. The patient is still alive but developed brain metastasis a year later after initial diagnosis. Despite its rarity, large cell neuroendocrine cell carcinoma should be included in the differential diagnosis when cytomorphology shows features suggestive of neuroendocrine differentiation.

Aspiration biopsy cytology of ectopic thyroid tissue in the lateral chest wall: a case report.

BACKGROUND: Ectopic thyroid tissue is a rare abnormality that mainly occurs in the midline of the neck but also in other unusual locations. Because fine needle aspiration biopsy (FNAB) is a widely used procedure for evaluating head and neck and other palpable masses, sampling of these lesions may be encountered. CASE: A 66-year-old woman presented with left lateral chest wall mass during follow-up for chronic obstructive pulmonary disease, hypertension and diabetes mellitus. Initial evaluation by FNAB suggested ectopic thyroid tissue, which was confirmed later by tissue biopsy and immunostains. This is the first reported case of ectopic thyroid tissue in the lateral chest wall area. CONCLUSION: Awareness of this abnormality and the possibility of ectopic thyroid tissue in erratic locations will help cytopathologists make the correct interpretation on FNAB sampling.

Chondroblastic osteosarcoma of the cuboid: a literature review and report of a rare case.

UNLABELLED: Chondroblastic osteosarcoma accounts for about 25% of all cases of osteosarcoma, which is the most common primary malignancy of the skeleton. Currently, only a few cases of chondroblastic osteosarcoma have been reported to involve the bones of the foot. In this report, we describe the previously unreported occurrence of chondroblastic osteosarcoma involving the left tarsal cuboid in a 15-year-old male. Histologically, the tumor showed an unusually extensive osteoclastic giant cell reaction that initially led to an erroneous diagnosis of giant cell tumor of bone. Because treatment and prognosis are very different for chondroblastic osteosarcoma as compared to giant cell tumor of bone, it is important to make the distinction between these 2 different bone tumors. In this report, we wish to draw attention to occurrence of chondroblastic osteosarcoma in the small bones of the foot, and to the possibility of an extensive giant cell reaction making accurate diagnosis difficult. We also provide a comprehensive review of the literature related to chondroblastic osteosarcoma. LEVEL OF CLINICAL EVIDENCE: 4.

Aspiration biopsy cytomorphology of primary pulmonary germ cell tumor metastatic to the brain.

Extragonadal germ cell tumors are uncommon and such tumors originating from the lung parenchyma are extremely rare. This is a case of 68-year-old female who was admitted with complaints of right-sided weakness, inability to maintain her balance, right-sided headache, and bloody sputum. Her workup revealed two enhancing brain lesions and large lung mass involving the left lower lobe. Fine-needle aspiration (FNA) of the lung followed by craniotomy was performed and the patient was initially diagnosed with lung adenocarcinoma metastatic to the brain based on the cytomorphology of the lung FNA and histology of the brain mass. However, retrospective investigation revealed markedly elevated alpha fetoprotein (AFP) of which the cytopathologist was unaware at the time of diagnosis. A review of the cytology and surgical specimen slides, as well as immunohistochemistry (IHC) on the brain tumor and FNA cell block were preformed. On the basis of the slides review, clinical findings, and immunostaining results, a diagnosis of primary pulmonary mixed germ cell tumor, containing choriocarcinoma and yolk sac elements, with brain metastases, was retrospectively made.

The prevalence and pathogenicity of Propionibacterium acnes keratitis.

PURPOSE: To study the prevalence, pathogenicity, and virulence of Propionibacterium acnes keratitis. METHODS: All cases of infectious keratitis submitted to the microbiologic laboratory of the New York Eye and Ear Infirmary between January 1, 2003, and April 6, 2006, were reviewed. Those cases in which P. acnes was recovered from culture were collected, and the medical records studied in depth. RESULTS: Of 1555 cultures submitted to the microbiology laboratory, 1329 (85.5%) were positive for growth. One hundred twenty four (9.3%) of the 1329 cases yielded P. acnes in at least 1 culture medium. Seventy eight (62.9%) of 124 cases had not been pretreated with antibiotics before culture, and 66.7% of the nonpretreated ulcers were monomicrobial (P. acnes only). Fifty one (65.4%) of 78 cases of the nonpretreated corneal ulcers presented with a cellular reaction in anterior chamber, 12 (15.4%) with a hypopyon (6 were monomicrobial), 21 (26.9%) had stromal thinning (12 of which were monomicrobial), and 2 (2.6%) progressed to perforation (both polymicrobial). Corneal ulcers associated with P. acnes tended to be small (66.7%) and were widely distributed: central (n = 17, 21.8%), paracentral (n = 44, 56.4%), and peripheral (n = 17, 21.8%). The most common risk factors were contact lens wear and previous history of ocular surgery. Three of the 78 nonpretreated patients were unresponsive to medical treatment and required surgery for keratitis. CONCLUSION: This study provides evidence that P. acnes is a frequent cause of bacterial keratitis and may cause significant morbidity.

Incidence and clinical characteristics of enterococcus keratitis.

PURPOSE: To study the incidence, clinically relevant factors, and antibiotic sensitivity profile of cases of enterococcal keratitis presenting at the New York Eye and Ear Infirmary between January 1, 1996, and December 31, 2005. METHODS: The records of all corneal cultures submitted to the Microbiology Laboratory of the New York Eye and Ear Infirmary between January 1, 1996, and December 31, 2005, were reviewed. All cases that were positive for Enterococcus species were identified, and the corresponding patients' medical records were obtained and studied. RESULTS: There were 15 cases of enterococcal keratitis identified during the study period, and all were E. faecalis species. The age of the patients ranged from 17 to 98 years (mean age, 57.5 years). Twelve of the patients were women. Two patients developed keratitis in existing corneal grafts. Two patients were on topical steroid medications, with 1 having an existing corneal graft. Fourteen of the 15 had abnormalities of the ocular surface or wore contact lenses. Eight (53%) of the patients were soft contact lens wearers. Only 1 case was directly attributable to trauma. Fourteen (93%) of the bacterial isolates were sensitive to vancomycin. One case had intermediate sensitivity. Eleven cases resolved with topical antibiotics, 3 cases required penetrating keratoplasty, and in 1 case, the outcome is unknown. CONCLUSIONS: Enterococcus faecalis keratitis is associated with abnormalities of the corneal surface and contact lens wear. Most of the isolates were sensitive to vancomycin, although 1 was of intermediate sensitivity, the importance of which is not known.

Efficacy and safety of voriconazole as an additive in Optisol GS: a preservation medium for corneal donor tissue.

PURPOSE: To assess the endothelial toxicity and the microbiological efficacy of voriconazole (100 microg/mL) as an antimicrobial additive to Optisol GS. METHODS: A total of 533 donor rims were studied. One half of each donor rim was placed in standard Optisol GS and the other half rim in Optisol GS fortified with voriconazole (100 microg/mL). All rims were refrigerated for 24 hours at 3 degrees C and placed in thioglycolate broth and incubated at 37 degrees C for 7 days. A pair of donor buttons not used in transplantation was stored for 2 days in each solution and examined for endothelial changes with electron microscopy (EM). A second pair of cornea buttons was examined for toxicity by endothelial staining with 0.3% trypan blue and 0.2% alizarin red. RESULTS: Seven of 533 corneal rim cultures were positive for fungal organisms in the Optisol GS group. No rims were positive for fungal growth in the voriconazole-fortified Optisol GS medium. The difference was statistically significant (P = 0.015; Fisher exact test). There was no difference in the cellular morphology of the button stored in voriconazole fortified Optisol GS compared with Optisol GS using EM. In the bioassay, the percentage of nonviable cells in the voriconazole-fortified medium compared with the control medium was nonsignificant (P < 0.05, Student t test). CONCLUSIONS: Voriconazole seems to be safe as a fortifying agent for cornea storage medium. It significantly reduces the rate of positive fungal rim cultures and shows no signs of endothelial cytotoxicity as viewed by EM and by a bioassay of trypan blue and alizarin red.

Isolation, purification and cultivation of conjunctival melanocytes.

The purpose of the present study was to develop methods for isolation, purification and cultivation of human conjunctival melanocytes. Conjunctiva excised from donor eyes or corneal rims was subjected with various enzyme digestion methods or by the enzyme-microdissection method. Cells were cultured with F12 medium supplemented by fetal bovine serum, basic fibroblast growth factor, isobutylmethylxanthine and cholera toxin. Contaminant cells were eliminated by a selective cytotoxic agent, geneticin. Both trypsin digestion and dispase-microdissection methods provided pure conjunctival melanocyte cultures with high cell yields, good viability and rapid growth rate. Melanocytes isolated with dispase-microdissection method showed better viability and growth capacity. Cells grew well, could be passaged for 5-10 generations and divided 20 times in vitro. They maintained a constant melanin content per cell and produced measurable amounts of melanin in vitro. Melanogenesis correlated with the degree of pigmentation of the eyes (iris color). This method provides a valuable source of large numbers of human conjunctival melanocytes, which can be used to study their biological behavior, to compare with the epidermal and uveal melanocytes; and to compare them to their malignant counterparts in the exploration of the pathogenesis of conjunctival melanoma.

Molecular characterization, biofilm analysis and experimental biofouling study of Fusarium isolates from recent cases of fungal keratitis in New York State.

BACKGROUND: To characterize Fusarium isolates from recent cases of fungal keratitis in contact lens wearers, and to investigate fungal association with MoistureLoc solution. METHODS: We studied six fungal isolates from recent cases of keratitis in New York State. The isolates were characterized by nucleotide sequencing and phylogenetic analyses of multiple genes, and then typed using minisatellite and microsatellite probes. Experimental fungal biofilm formation was tested by standard methods. MoistureLoc solutions were tested in biofouling studies for their efficacy in elimination of Fusarium contamination. RESULTS: Fusarium solani--corneal ulcers (2 isolates), lens case (1 isolate), and F. oxysporum--corneal ulcer (1 isolate), eye (1 isolate), were recovered from five patients. An opened bottle of MoistureLoc solution provided by a patient also yielded F. solani. Two distinct genotypes of F. solani as well as of F. oxysporum were present in the isolated strains. Remarkably, F. solani strains from the lens case and lens solution in one instance were similar, based on phylogenetic analyses and molecular typing. The solution isolate of F. solani formed biofilm on contact lenses in control conditions, but not when co-incubated with MoistureLoc solution. Both freshly opened and 3-month old MoistureLoc solutions effectively killed F. solani and F. oxysporum, when fungal contamination was simulated under recommended lens treatment regimen (4-hr). However, simulation of inappropriate use (15-60 min) led to the recovery of less than 1% of original inoculum of F. solani or F. oxysporum. CONCLUSION: Temporary survival of F. solani and F. oxysporum in MoistureLoc suggested that improper lens cleaning regimen could be a possible contributing factor in recent infections.

Efficacy and safety of moxifloxacin as an additive in Optisol-GS a preservation medium for corneal donor tissue.

PURPOSE: To assess the endothelial toxicity and the microbiological efficacy of moxifloxacin (250 microg/mL) as an additive to Optisol-GS. METHODS: Five hundred nine donor rims were studied. One half of each donor rim was placed in standard Optisol-GS and the other half of the rim in Optisol-GS fortified with moxifloxacin (250 microg/mL). All rims were refrigerated for 24 hours at 3 degrees C and placed in thioglycolate broth and incubated at 37 degrees C for 7 days. One pair of donor buttons not used in transplantation stored in each solution was examined for endothelial changes by using electron microscopy (EM). A second pair of cornea buttons was examined for toxicity by endothelial staining with 0.3% trypan blue and 0.2% alizarin red. All endothelial cells that stained (nonviable cells) and nonstained cells (viable cells) were counted, and the ratio of nonviable cells was calculated. RESULTS: The rate of culture-positive donor rims in the Optisol-GS group was 11.9% (61/509) and in the moxifloxacin-fortified Optisol-GS media was 2.5% (13/509). The difference was statistically significant (P < 0.01; chi test). There was no difference in the cellular morphology of the button stored in moxifloxacin-fortified Optisol-GS compared with Optisol-GS using EM. In the bioassay, the rate of nonviable cells in the moxifloxacin-fortified media compared with the control media was nonsignificant (P > 0.05). CONCLUSION: Moxifloxacin (250 microg/mL) seems to be safe as an additive agent for cornea storage media. It significantly reduces the rate of positive rim cultures and shows no signs of endothelial cytotoxicity as viewed by EM and by a bioassay of trypan blue and alizarin red.

Fungal keratitis at the new york eye and ear infirmary.

INTRODUCTION: This study was designed to review the clinical experience at our institution with fungal keratitis during a 16-year period. MATERIALS AND METHODS: A review of the clinical and microbiology records of the New York Eye and Infirmary identified 61cases of fungal keratitis in 57 patients between January 1, 1987 and June 1, 2003. The medical records of all patients were retrospectively reviewed to better delineate patient demographics, risk factors, etiologic organisms, treatment, and outcomes. RESULTS: A total of 5083 positive corneal cultures were recorded'from January 1, 1987 to June 1, 2003. Sixty-one eyes in 57 patients (37 women) were positive for fungus (1.2%). Three'patients had bilateral simultaneous infections. Candida albicans accounted for 29 of 61 cases (48%). Human immunodeficiency virus (HIV) seropositivity (15 eyes), chronic ocular surface disease (14 eyes), and trauma (7 eyes) were the most commonly associated risk factors. CONCLUSIONS: Our experience with fungal keratitis in the northeastern United States appears to be different than those reported from other areas of the United States. Serologic positivity for HIV and chronic ocular surface disease were the most common associated risk factors followed by trauma, herpes simplex keratitis, and contact lens use. Candida species predominated, whereas filamentous fungi were uncommon.