Severe endogenous endophthalmitis with panophthalmitis-lessons to learn

Endogenous endophthalmitis is a devastating intraocular infection. Finding the primary infection and directed treatment is life-saving. We describe a 47-year-old man, with uncontrolled diabetes mellitus, who presented with two weeks history of progressive reduced vision and redness of the left eye (LE). He was generally unwell since a month, previously. Examination showed relative afferent pupillary defect (RAPD) in the affected eye and visual acuity was hand movement. There was moderate anterior chamber and vitreous reaction. Fundus examination showed a huge dome-shaped choroidal mass covering the entire macula. Diagnosis of severe endogenous endophthalmitis was made, with isolation of Enterobacter sp. from his blood culture. Meanwhile, he also had elevated inflammatory markers with presence of leucocytosis, neutrophilia and elevated erythrocyte sedimentation rate (ESR) as well as C-reactive protein (CRP). Vitreous tap and aqueous tap had no growth, He improved with combination of intravitreal and systemic antibiotic, as shown by the resolved fever and reduced inflammatory markers but progressive inflammation occluded the fundus details and the LE vision eventually became no projection of light despite treatment. Subsequently, he developed rubeotic glaucoma and was treated conservatively because the LE was painless with poor vision. The repeated blood culture and urine was normal. In conclusion, endogenous endophthalmitis with eventual panophthalmitis is difficult to treat and has very poor visual prognosis. Our case highlights the challenges faced in the management of vision-threatening endophthalmitis and panophthalmitis in this patient

Clinical implications of Plasmodium resistance to atovaquone/proguanil: a systematic review and meta-analysis.

Background: Atovaquone/proguanil, registered as Malarone®, is a fixed-dose combination recommended for first-line treatment of uncomplicated Plasmodium falciparum malaria in non-endemic countries and its prevention in travellers. Mutations in the cytochrome bc1 complex are causally associated with atovaquone resistance. Methods: This systematic review assesses the clinical efficacy of atovaquone/proguanil treatment of uncomplicated malaria and examines the extent to which codon 268 mutation in cytochrome b influences treatment failure and recrudescence based on published information. Results: Data suggest that atovaquone/proguanil treatment efficacy is 89%-98% for P. falciparum malaria (from 27 studies including between 18 and 253 patients in each case) and 20%-26% for Plasmodium vivax malaria (from 1 study including 25 patients). The in vitro P. falciparum phenotype of atovaquone resistance is an IC50 value >28 nM. Case report analyses predict that recrudescence in a patient presenting with parasites carrying cytochrome b codon 268 mutation will occur on average at day 29 (95% CI: 22, 35), 19 (95% CI: 7, 30) days longer than if the mutation is absent. Conclusions: Evidence suggests atovaquone/proguanil treatment for P. falciparum malaria is effective. Late treatment failure is likely to be associated with a codon 268 mutation in cytochrome b, though recent evidence from animal models suggests these mutations may not spread within the population. However, early treatment failure is likely to arise through alternative mechanisms, requiring further investigation

‘Boating’ out migrated dexamethasone implant; surgical management of removal of anterior chamber migrated dexamethasone intravitreal implant : a case report

It is rare for anterior chamber migration of an Ozurdex® implant from vitreous cavity, but it is seen more frequently in aphakic eyes or in pseudophakic cases with zonular dehiscense. We describe a case of a middle-aged gentleman who had persistent diabetic macular oedema not responding to anti-VEGF (vascular endothelium growth factor), who was treated with intravitreal Ozurdex® in his post vitrectomized eye and developed anterior migration of the implant to the anterior chamber. Anterior dislocation of an intravitreal implant of dexamethasone can be managed by repositioning it to the vitreous cavity or removing it through a corneal limbal incision. Ozurdex® is a friable implant, especially after a few weeks of implantation. Therefore, removal of the implant by grasping or aspiration may lead to its fracture or dispersion of the implant material. This is a report of a simple,fast and effective technique to remove a migrated Ozurdex® from the anterior chamber using a modified silicone tip

The REstart or STop Antithrombotics Randomised Trial (RESTART) after stroke due to intracerebral haemorrhage: study protocol for a randomised controlled trial

Background For adults surviving stroke due to spontaneous (non-traumatic) intracerebral haemorrhage (ICH) who had taken an antithrombotic (i.e. anticoagulant or antiplatelet) drug for the prevention of vaso-occlusive disease before the ICH, it is unclear whether starting antiplatelet drugs results in an increase in the risk of recurrent ICH or a beneficial net reduction of all serious vascular events compared to avoiding antiplatelet drugs. Methods/design The REstart or STop Antithrombotics Randomised Trial (RESTART) is an investigator-led, randomised, open, assessor-blind, parallel-group, randomised trial comparing starting versus avoiding antiplatelet drugs for adults surviving antithrombotic-associated ICH at 122 hospital sites in the United Kingdom. RESTART uses a central, web-based randomisation system using a minimisation algorithm, with 1:1 treatment allocation to which central research staff are masked. Central follow-up includes annual postal or telephone questionnaires to participants and their general (family) practitioners, with local provision of information about adverse events and outcome events. The primary outcome is recurrent symptomatic ICH. The secondary outcomes are: symptomatic haemorrhagic events; symptomatic vaso-occlusive events; symptomatic stroke of uncertain type; other fatal events; modified Rankin Scale score; adherence to antiplatelet drug(s). The magnetic resonance imaging (MRI) sub-study involves the conduct of brain MRI according to a standardised imaging protocol before randomisation to investigate heterogeneity of treatment effect according to the presence of brain microbleeds. Recruitment began on 22 May 2013. The target sample size is at least 720 participants in the main trial (at least 550 in the MRI sub-study). Discussion Final results of RESTART will be analysed and disseminated in 2019. Trial registration ISRCTN71907627 (www.isrctn.com/ISRCTN71907627). Prospectively registered on 25 April 2013

The Communicability of Graphical Alternatives to Tabular Displays of Statistical Simulation Studies

Simulation studies are often used to assess the frequency properties and optimality of statistical methods. They are typically reported in tables, which may contain hundreds of figures to be contrasted over multiple dimensions. To assess the degree to which these tables are fit for purpose, we performed a randomised cross-over experiment in which statisticians were asked to extract information from (i) such a table sourced from the literature and (ii) a graphical adaptation designed by the authors, and were timed and assessed for accuracy. We developed hierarchical models accounting for differences between individuals of different experience levels (under- and post-graduate), within experience levels, and between different table-graph pairs. In our experiment, information could be extracted quicker and, for less experienced participants, more accurately from graphical presentations than tabular displays. We also performed a literature review to assess the prevalence of hard-to-interpret design features in tables of simulation studies in three popular statistics journals, finding that many are presented innumerately. We recommend simulation studies be presented in graphical form

Illiteracy, low educational status, and cardiovascular mortality in India

Background: Influence of education, a marker of SES, on cardiovascular disease (CVD) mortality has not been evaluated in low-income countries. To determine influence of education on CVD mortality a cohort study was performed in India. Methods: 148,173 individuals aged ≥ 35 years were recruited in Mumbai during 1991-1997 and followed to ascertain vital status during 1997-2003. Subjects were divided according to educational status into one of the five groups: illiterate, primary school ( ≦ 5 years of formal education), middle school (6-8 years), secondary school (9-10 years) and college (> 10 years). Multivariate analyses using Cox proportional hazard model was performed an

Cloud Computing As a Tool for Enhancing Ecological Goals?

Cloud computing has been introduced as a promising information technology (IT) that embodies not only economic advantages in terms of increased efficiency but also ecological gains through saving energy. The latter has become particularly important in view of the rising energy costs of IT. The present study analyzes whether necessary preconditions for accepting cloud computing as a new infrastructure, such as awareness and perceived net value, exist on the part of the users. The analysis is based on a combined research framework of the theory of reasoned action (TRA) and the technology acceptance model (TAM) in a cloud computing setting. Two consumer surveys, the one to elicit beliefs and the second to gain insight into the ranking of the variables, are employed. This study uses structural equation modeling (SEM) to evaluate the hypotheses. The results indicate support for the proposed research framework. Surprisingly however, the ecological factor does not play a role in forming cloud computing intentions, regardless of prior knowledge or experience. Empirical evidence of this study suggests increasing efforts for informing actual and potential users, particularly in respect to possible ecological advantages through applying the new IT infrastructure

Search for neutral MSSM Higgs bosons decaying to a pair of tau leptons in pp collisions

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