Sudden vision loss caused by rhino-orbital zygomycosis in diabetic patients: case series

Rhino-orbital zygomycosis is a life-threatening fungal infection generally occurring in patients with an underlying disorder, such as diabetes mellitus with ketoacidosis or with immunocompromising factors, although it may rarely appear in healthy individuals. The study has been undertaken to discuss the clinical presentation, pathogenesis, diagnostic work up and management of this rapidly progressive disease. Four male patients having uncontrolled diabetes and presenting with signs and symptoms of rhino-orbital zygomycosis were studied to illustrate the serious nature of the disease. All the four patients had rapidly deteriorating vision loss either unilateral or bilateral along with other nasal and orbital signs and symptoms. All the patients were put on liposomal amphotericin B and underwent orbital exenteration and pansinusectomy. One patient died, while the other three were successfully treated. Early diagnosis is critical in the prevention of morbidity and mortality associated with the disease. There is need for a high index of clinical suspicion in immunocompromised patients. Timely medical-surgical treatment proves extremely important for prognosis.

Development of Room Temperature Stable Formulation of Formoterol Fumarate/Beclomethasone HFA pMDI

The primary aim of present investigation was to develop and formulate room temperature stable formulation of formoterol fumarate and beclomethasone dipropionate with extra fine part size of hydrofluoroalkane pressurized metered dose inhalers. Particle size distribution of hydrofluoroalkane pressurized metered dose inhalers was evaluated using Twin Stage Glass Impinger and Anderson Cascade Impactor. A tetrafluoroethane and/or heptafluoropropane were evaluated for preparation of hydrofluoroalkane pressurized metered dose inhalers. The fine particle fractions delivered from hydrofluoroalkane propellant suspension pressurized metered dose inhalers can be predicted on the basis of formulation parameters and is dependent of metering chamber of valve and orifice size of actuators. The results presented in investigation showed the importance of formulation excipients with formulation of pressurized metered dose inhalers viz, canister, valve and actuators used in formulations.

Adult chiari malformation presenting as bilateral vocal cord paralysis

In the Chiari malformations, herniation of the cerebellar tonsils through the foramen magnum into the cervical spinal canal can often result in headaches and spinal cord deficits. Bilateral vocal cord paralysis has been reported as a result of Chiari malformation but is rare and the vast majority of reports have been in the paediatric population. We report a case in a 68-year-old man with adult Chiari malformation where aspiration pneumonia from bilateral vocal cord palsy was the only manifestation of this malformation.

MRI findings in methanol intoxication: a report of two cases

Methanol is a highly toxic substance and acute methanol poisoning produces severe metabolic acidosis and serious neurological symptoms, including severe visual impairment, extrapyramidal signs and coma. Its similarity to ethanol in appearance and odour leads to accidental use. We present two cases of accidental methanol intoxication and discuss the MRI findings.

Investigation on physicochemical and biological differences of cefpodoxime proxetil enantiomers

Cefpodoxime proxetil (CP) is a prodrug of cefpodoxime acid (CA), and is supplied as racemic mixture of R- and S-enantiomers. CP has only 50% absolute bioavailability, and the reasons responsible for low bioavailability remain poorly understood. The present work ascertains physicochemical and biological properties of individual isomers of CP and explores their capacity to optimize delivery of CP. Both isomers showed similar pH stability behavior, but R-isomer was more susceptible to enzymatic metabolism compared to S-isomer, when incubated with enzymes collected from various segments of GIT. Based on the in vitro and in vivo results, use of S-isomer for development of a dosage form such as gastro-retentive dosage form can improve oral bioavailability of CP.

Investigation of factors responsible for low oral bioavailability of cefpodoxime proxetil

Learning about the behavior of a drug in biological environment enables application of better formulation strategies to improve bioavailability of the same. Cefpodoxime proxetil (CP) is a prodrug, which is orally administered cephalosporin with only 50% absolute bioavailability. Despite previous studies, reasons responsible for low bioavailability of CP remain poorly understood. The present study tries to ascertain reasons for the low oral bioavailability of CP. The in vitro, in situ and ex vivo studies showed interesting results, where metabolism of CP into cefpodoxime acid (CA) inside the intestinal epithelial cell and preferential efflux of CA into lumen was identified as primary reason for low oral bioavailability of CP. Presence of specific carriers or transportation mechanism on the apical side membrane of enterocyte, than basal side of the same was observed.

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

BACKGROUND

The transfer of care for hospitalized patients between inpatient physicians is routinely mediated through written and verbal communication or "sign-out". This study aims to describe how communication failures during this process can lead to patient harm.

METHODS

In interviews employing critical incident technique, first year resident physicians (interns) described (1) any adverse events or near misses due to suboptimal preceding patient sign-out; (2) the worst event due to suboptimal sign-out in which they were involved; and (3) suggestions to improve sign-out. All data were analyzed and categorized using the constant comparative method with independent review by three researchers.

RESULTS

Twenty six interns caring for 82 patients were interviewed after receiving sign-out from another intern. Twenty five discrete incidents, all the result of communication failures during the preceding patient sign-out, and 21 worst events were described. Inter-rater agreement for categorization was high (kappa 0.78-1.00). Omitted content (such as medications, active problems, pending tests) or failure-prone communication processes (such as lack of face-to-face discussion) emerged as major categories of failed communication. In nearly all cases these failures led to uncertainty during decisions on patient care. Uncertainty may result in inefficient or suboptimal care such as repeat or unnecessary tests. Interns desired thorough but relevant face-to-face verbal sign-outs that reviewed anticipated issues. They preferred legible, accurate, updated, written sign-out sheets that included standard patient content such as code status or active and anticipated medical problems.

CONCLUSION

Communication failures during sign-out often lead to uncertainty in decisions on patient care. These may result in inefficient or suboptimal care leading to patient harm.

An investigation of the relationship between raw coal characteristics and effluent quality of Kedla and Rajrappa Washeries, Jharkhand, India

An attempt was made to investigate the relationship between raw coal characteristics and effluent quality in two coking coal washeries of Central Coalfields Limited, Kedla and Rajrappa in Jharkhand State, India. Coal samples-raw coal feed, washed fine clean coal, washed coarse clean coal, middlings and rejects were collected. Similarly, raw water (intake to washery) and effluent samples generated in the washeries, namely, fine coal jig under water, coarse coal jig under water and slurry pond water were also collected over a period of 6 months. Parameters outlined in Ministry of Environment and Forest (MoEF) Schedule VI Indian standards were determined, both in coal samples and water/washery effluent samples. Apart from the parameters listed in the standard, sodium, potassium, calcium, magnesium, sulphate and chloride found to be present in coal were also determined in coal and water samples. The processing results essentially in production of huge quantities of suspended material, which is beyond the stipulated limit of 100mg/l as specified in the Standard. Lowering of pH was observed in both the washeries. The trace/heavy elements were found to be concentrated in the heavier fractions in rejects produced from the washery. The concentrations of major elements in coal-Na, K, Ca, Mg, and minor elements in coal-Mn; F, SO4 and Cl were found to be higher in process water than in raw water indicating that these elements are transferred from coal to the water in washeries. However, only in the case of Mn, the stipulated limit of the effluent standard was exceeded. Trace elements like As, Se, Hg, Cd, though found to be present in coal, were absent in the process water indicating that these elements are not released by coal during washing.

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

BACKGROUND

The transfer of care for hospitalized patients between inpatient physicians is routinely mediated through written and verbal communication or "sign-out". This study aims to describe how communication failures during this process can lead to patient harm.

METHODS

In interviews employing critical incident technique, first year resident physicians (interns) described (1) any adverse events or near misses due to suboptimal preceding patient sign-out; (2) the worst event due to suboptimal sign-out in which they were involved; and (3) suggestions to improve sign-out. All data were analyzed and categorized using the constant comparative method with independent review by three researchers.

RESULTS

Twenty six interns caring for 82 patients were interviewed after receiving sign-out from another intern. Twenty five discrete incidents, all the result of communication failures during the preceding patient sign-out, and 21 worst events were described. Inter-rater agreement for categorization was high (kappa 0.78-1.00). Omitted content (such as medications, active problems, pending tests) or failure-prone communication processes (such as lack of face-to-face discussion) emerged as major categories of failed communication. In nearly all cases these failures led to uncertainty during decisions on patient care. Uncertainty may result in inefficient or suboptimal care such as repeat or unnecessary tests. Interns desired thorough but relevant face-to-face verbal sign-outs that reviewed anticipated issues. They preferred legible, accurate, updated, written sign-out sheets that included standard patient content such as code status or active and anticipated medical problems.

CONCLUSION

Communication failures during sign-out often lead to uncertainty in decisions on patient care. These may result in inefficient or suboptimal care leading to patient harm.

Unbiased membrane permeability parameters for gabapentin using boundary layer approach

The present study was performed to determine the relative contribution of both passive and nonpassive transport processes in jejunal absorption of gabapentin. The oral absorption of gabapentin was studied using in situ single pass intestinal perfusion technique in fasted rats. Unbiased intrinsic membrane absorption parameters such as maximal flux, Michaelis constant, carrier permeability, and membrane permeability were calculated using a modified boundary layer model. Gabapentin intestinal perfusion results indicate that its jejunal absorption in rats occurs via a nonpassive process, with no significant passive absorption component, as demonstrated by saturable absorption kinetics and its concentration-dependent permeability. A good correlation (r2 = 0.88) between observed human absorption fraction and calculated (from in situ rat intestine) human absorption fraction was obtained.

Tuberculous gastric perforation: report of a case

A 21-year-old woman presented with a 2-day history of acute abdominal pain. Contrast-enhanced computed tomography (CT) showed a perforation in the lesser curve of the stomach. The patient suffered a bout of hematemesis, following which an endoscopy showed a bleeding blood vessel at the edge of the perforation. We performed an emergency distal gastrectomy, including the ulcer site. Histopathological examination revealed tuberculous granulation tissue and acid-fast bacilli in the ulcer. The patient was given antituberculosis therapy (ATT) postoperatively, and was well when last seen 1 year 5 months after surgery. We analyzed the clinical data of five cases of tuberculous gastric perforation (TGP), reported between 1948 and 2003, including our patient. The patients ranged in age from 21 to 45 years, with a mean age of 36.8 years (SD +/- 10.21), and a male to female ratio of 3 : 2. The diagnosis was confirmed by surgery or autopsy. Abdominal lymphadenopathy was present in all patients. Gastrectomy was performed in four patients, and two were given ATT. All four patients in the previous reports died of their disease.