Central Retinal Artery Occlusion with Concomitant Intracranial Hemorrhage Secondary to Streptococcus Gordonii Endocarditis.

Purpose: To report a case of central retinal artery occlusion (CRAO) associated with subacute Streptococcus gordonii endocarditis secondary to a dental infection. Observations. A 27-year-old male presented with acute monocular vision loss in the setting of a stroke and seizure. A fundus exam revealed macular whitening and a cherry-red spot. Edema of the inner retinal layers was confirmed on macular optical coherence tomography, consistent with CRAO. Initial imaging (carotid Doppler, EKG, and transthoracic echocardiography) and a comprehensive laboratory workup did not reveal an etiology for the stroke or vision loss. Brain magnetic resonance imaging showed T1 hyperintensity with surrounding edema, which prompted a workup for possible septic emboli versus occult malignancy. Subsequent blood cultures led to the detection and diagnosis of Streptococcus gordonii endocarditis. It was subsequently revealed that the patient had self-extracted his molar two months prior to the onset of symptoms. Conclusions: Endocarditis has been associated with Roth spots and inflammatory findings in the posterior segment. However, CRAO caused by vegetal septic embolism is rare. To our knowledge, this represents the first reported case of endocarditic CRAO with Streptococcus gordonii confirmed as the causative microbe. Retinal vascular occlusion in a young patient with no distinct risk factors should prompt a comprehensive dental history and infectious workup, with consideration given to early transesophageal echocardiography.

Imaging ex vivo and in vitro brain morphology in animal models with ultrahigh resolution optical coherence tomography.

The feasibility of ultrahigh resolution optical coherence tomography (UHR OCT) to image ex vivo and in vitro brain tissue morphology on a scale from single neuron cells to a whole animal brain was investigated using a number of animal models. Sub-2-microm axial resolution OCT in biological tissue was achieved at different central wavelengths by separately interfacing two state-of-the-art broad bandwidth light sources (titanium:sapphire, Ti:Al2O3 laser, lambdac=800 nm, Deltalambda=260 nm, Pout=50 mW and a fiber laser light source, lambdac=1350 nm, Deltalambda=470 nm, Pout=4 mW) to free-space or fiber-based OCT systems, designed for optimal performance in the appropriate wavelength regions. The ability of sub-2-microm axial resolution OCT to visualize intracellular morphology was demonstrated by imaging living ganglion cells in cultures. The feasibility of UHR OCT to image the globular structure of an entire animal brain as well as to resolve fine morphological features at various depths in it was tested by imaging a fixed honeybee brain. Possible degradation of OCT axial resolution with depth in optically dense brain tissue was examined by depositing microspheres through the blood stream to various depths in the brain of a living rabbit. It was determined that in the 1100 to 1600-nm wavelength range, OCT axial resolution was well preserved, even at depths greater than 500 microm, and permitted distinct visualization of microspheres 15 microm in diameter. In addition, the OCT image penetration depth and the scattering properties of gray and white brain matter were evaluated in tissue samples from the visual cortex of a fixed monkey brain.

The distribution of cadmium, copper, lead, zinc and calcium in the tissues of the earthworm Lumbricus rubellus sampled from one uncontaminated and four polluted soils.

The tissue distribution of Cu, Cd, Pb, Zn, and Ca in the earthworm Lumbricus rubellus living in non-polluted and heavy-metal polluted soils was investigated. Cd, Pb and Zn were primarily accumulated within the posterior alimentary canal. As the whole-worm Pb burden increased, the proportion of the metal accumulated within this tissue fraction increased. A similar pattern was found for Zn. By contrast, 70%-76% of the Cd burden was found in the posterior alimentary canal, irrespective of the whole-worm Cd content. The accumulation of Cd, Pb and Zn primarily in the posterior alimentary canal prevents dissemination of large concentrations of these metals into other earthworm tissues, and may thus represent a dextoxification strategy based on accumulative immobilisation. Cu was distributed fairly evenly in the tissue fractions investigated. There was no evidence of sequestration of this metal. The apparent lack of a detoxification strategy may contribute to the well-known susceptibility of earthworms to low environmental Cu concentrations. Indeed, earthworms from the site of highest soil Cu (Ecton) were markedly smaller than those from the other sites sampled. The highest Ca concentrations were found in the anterior alimentary canal, and were related to calciferous gland activity. A large proportion of Ca was also stored as a physiologically available pool in the posterior alimentary canal. Despite huge variations in soil Ca concentrations, the body wall Ca levels were fairly similar in L. rubellus from all the study sites. Thus, L. rubellus may become physiologically adapted to soils of exceptionally low Ca concentration. The observations are discussed in the context of the merits of analysing specific tissues, rather than whole organisms, for the purpose of monitoring metal bioaccumulation.

Morphological plasticity in metal-sequestering earthworm chloragocytes: morphometric electron microscopy provides a biomarker. of exposure in field populations.

Morphometric measurements of the volume fractions (Vv) of two prominent metal-sequestering compartments, chloragosome granules and debris vesicles, were made on transmission electron micrographs of chloragocytes in Dendrodrilus rubidus (Annelida: Oligochaeta: Lumbricidae) from one uncontaminated site and three qualitatively and quantitatively different metalliferous soils associated with disused Pb/Zn mines. We also examined the relative volume fractions of the alimentary wall and attached chloragogenous tissue by light microscopy. Several conclusions relevant to environmental diagnostics were reached: Metal identity and degree of soil pollution exert strong effects on chloragocyte ultrastructure; morphometry by light microscopy indicated that the metal-induced structural effects are characterized by intracellular alterations not accompanied by a significant expansion of the tissue volume; elevated metal burdens can reduce chloragosome Vv and, concomitantly, increase the Vv of their autophagic derivatives, the debris vesicles; the measured cellular alterations were more closely correlated with integrated tissue metal burdens than they were with integrated soil metal burdens; and estimates of tissue metal distribution, derived by combining morphometric data and published whole-worm and chloragosome metal concentrations, suggested that the alimentary wall of earthworms may sequester Pb, Zn, and Cd. Our study shows that cellular changes, directly or indirectly, may yield quantifiable expressions of metal loads bioaccumulated by earthworms. However, the practical use of cellular changes as biomarkers of soil quality probably will require automated light-microscopic morphometry in combination with organelle-specific molecular probes to be cost effective.

A 100% departmental mortality review improves observed-to-expected mortality ratios and University HealthSystem Consortium rankings.

BACKGROUND: Public reporting of mortality, Patient Safety Indicators (PSI) and hospital-acquired conditions (HACs) is the reality of quality measurement. A review of our department's data identified opportunities for improvement. We began a surgeon-led 100% review of mortality, PSIs, and HACs to improve patient care and surgeon awareness of these metrics. STUDY DESIGN: From December 2012 through August 2013, there were 11,899 patients cared for on 12 surgical services. A surgeon from each service led monthly reviews of all mortality, PSIs, or HACs with central reporting of preventability and coding accuracy. We compared the University HealthSystem Consortium observed-to-expected (OE) mortality ratios (mean <1 fewer observed than expected deaths) and University HealthSystem Consortium relative rankings (lower number is better) before and after implementation. Statistical significance was p < 0.05 by Poisson regression. RESULTS: Of the 11,899 patients in the study period, there were 235 deaths, 290 PSIs, and 26 HACs identified and reviewed. The most common PSIs were postoperative deep vein thrombosis/pulmonary thromboembolism (n = 75), respiratory failure (n = 61), hemorrhage/hematoma (n = 33), and accidental puncture/laceration (n = 33). Before December 20, 2012, the OE ratio for mortality was consistently >1, then fell and remained <1 during the study period (p < 0.05). The OE mortality ratio in the fourth quarter of 2012 was 1.14 and fell to 0.88, 0.91, and 0.75 in the first, second, and third quarters of calendar year 2013 (p < 0.05). The overall Inpatient Quality Indicators #90 (composite postoperative mortality rank) rankings increased from 109 of 118 in the third quarter of 2012 to 47 of 119 in the third quarter of 2013. CONCLUSIONS: A surgeon-led systematic review of mortality, PSIs, and HACs improved our OE ratio and University HealthSystem Consortium postsurgical relative rankings. Surgeon engagement and ownership is critical for success.

Laparoscopic two-team slings for women with stress urinary incontinence.

STUDY OBJECTIVE: To review long-term success and complication rates of laparoscopic two-team sling procedures in women with stress urinary incontinence or mixed incontinence confirmed by urodynamic testing and cystoscopy. DESIGN: Prospective study (Canadian Task Force classification II-2). SETTING: Tertiary urogynecology unit at a university-affiliated teaching hospital. PATIENTS: One hundred seventy-five women. INTERVENTIONS: Laparoscopic two-team sling procedure. MEASUREMENTS AND MAIN RESULTS: The extraperitoneal approach to the space of Retzius was accomplished using a balloon device, and the intraperitoneal approach involved a transverse incision through the anterior parietal peritoneum 6 cm above the symphysis. A 1.5- to 2.0-cm wide strip of polypropylene mesh was inserted through a vertical incision along the anterior vaginal wall, perforating the urogenital diaphragm under laparoscopic guidance. The mesh was sutured to Cooper's ligaments bilaterally with 0 polypropylene sutures. Mean operating time was 80.1 +/- 30.0 minutes, mean estimated blood loss was 160 +/- 146 ml, and mean hospital stay was 2.4 +/- 1.2 days. Patients were followed at 6 weeks, 6 months, 1 year, and yearly (mean 17.8 mo, range 1-5 yrs). CONCLUSION: Laparoscopic two-team sling procedures can be performed safely in women with recurrent stress incontinence and those with risk factors for failure of retropubic urethropexy. Long-term success rates are excellent (91.1%) with few complications.