Brown’y points for guessing!- A case report of an unusual pigmented corneal plaque.

A 54-year-old female presented with complaints of blurring in the right eye since 2 years. A grade 3nuclear sclerosis and a peculiar band-shaped subepithelial brown corneal patch, within the inter-palpebral area was noted. The overlying epithelium was scraped for smears and cultures which cameback negative. The patient underwent uneventful cataract surgery, but returned 2 weeks later withcomplaints of watering and grittiness. Surprisingly a dendritic ulcer was noted within the pigmentedpatch, which responded to topical antivirals and tear substitutes. History of a similar episode, 3years back was elicited upon questioning the patient.

Who by Fire

The Pururava-caritai (‘The Adventures of Pururavas’) is an unstudied sixteenth-century Tamil adaptation of the famous Vedic legend of Pururavas, which introduces an extensive addition to the original story. One episode within this supplement narrates a trial by fire gone through by the protagonist’s wife, which draws heavily on a similar episode from the Ramayana epic, both in Valmiki’s classical Sanskrit version and in Kampan’s twelfth-century Tamil retelling. This article sheds new light on the ways in which classical literary gender roles and gender models were reimagined in premodern south India. I argue that the re-articulation of the epic fire-ordeal in the Pururava-caritai is a critical reflection on the feminine model that the Ramayana heroine, Sita, represents. I show that, through a synthesis of classical and folk motifs, the author has created an implicit intertextual dialogue that concludes with a complex matrix of values of ‘proper’ femininity and ‘true’ divinity.

Abstract 14767: Thrombolysis of Stroke Mimics via Telestroke

Introduction: Telestroke allows stroke expertise for thrombolysis decision making remotely using high-quality bidirectional audiovisual technology. Hypothesis: Intravenous tissue plasminogen activator (IVtPA) is administered via telestroke network to a proportion of patients without a stroke diagnosis (i.e. stroke mimic) Methods: Our academic comprehensive stroke program telestroke program includes 26 spoke Emergency rooms (ERs) through which IVtPA is administered throughout central Ohio. From July 1, 2016 to Sept 30, 2017, nearly all patients who received IVtPA at the outside hospital telestroke ERs were transferred to our institution for post-IVtPA care. Data was collected on final diagnosis, demographics, National Institutes of Health Stroke Scale (NIHSS), door to needle (DTN) time, and outcomes. Results: Among 270 acute ischemic stroke patients who received IVtPA via telestroke, we identified 64 (23.7%) with a stroke mimic diagnosis. Stroke mimics were younger (mean age 56.4 vs 68.2, p <0.0001), more likely female (60.9% vs 45.6%, p 0.03), and had higher DTN times (85.3 vs 69.9 minutes, p 0.0008). The increase in DTN was due to longer time to recommend by the telestroke neurologist for stroke mimic (65.0 vs 53.2 minutes, p 0.0034). The stroke mimic diagnosis included Migraine 26 (40.6%), Factitious disorder 12 (18.8%), Encephalopathy 7 (10.9%), and Unmasking 6 (9.4%). The stroke mimics did not differ from each other based upon initial NIHSS, DTN, or sex. Compared to the other stroke mimics, Migraine and Factitious disorder patients were younger (51.2 vs 63.9 years, p <0.0006), more likely to have a personal history of migraines (42.1% vs 0%, p < 0.0001), and more likely to have functional exam findings (42.1% vs 3.8%, p 0.0007). There were no hemorrhagic complications in the stroke mimic patients. Among all stroke mimics, 26 (40.6%) had a history of similar prior episodes and 10 (15.6%) would have future recurrence of another similar episode, with 2 patients receiving IVtPA again in the future (1 Migraine and 1 Factitious disorder). Conclusions: In a tertiary academic telestroke network, nearly one-quarter of patients receive IVtPA for a non-stroke diagnosis, with migraine and factitious disorder being the most commonly seen.

ARRHYTHMIAS, PACING, ABLATIONC1 A DEPENDENT SYNCOPE

A 33-year-old man, ex drug addict on methadone therapy. He arrives to emergency department for syncope, reported by his wife reversion of the eyeballs and fine tremors with subsequent recovery of consciousness. A similar episode had happened a year ago. It was performed ECG: sinus bradycardia , 45 bpm, QT 600 msec, QTc 554 msec . Neurological examination performed: no motor deficits, negative Romberg. At brain CT no parenchymal tomodensitometric changes. Median line structures in axis. At the EEG: slight diffuse slow intercritical changes. Prescribed therapy with levetiracetam 500 mg. Cardiological examination and echocardiogram performed within the limits. Laboratory tests showed Trop HS 80 pg / ml. On the basis of the ECG and the slight increase of the troponin he was hospitalized in Cardiology and monitored. The following day, cardiac arrest due to torsade de pointes degenerated into ventricular fibrillation, DC shock was performed with the restoration of electrical and mechanical activity. Urgent coronary angiography was performed with evidence of coronary artery free from angiographically significant stenosis. SERT has been contacted: the patient had not been treated by them for some time and was using excessive doses of self-procuring methadone. In consideration of cardiac arrest from methadone long QT ventricular arrhythmia, ICD implantation was proposed, refused by the patient because he wanted to start detoxification therapy. During the hospitalization, progressive reduction of QT up to normalization in discharge. After a month new access to emergency department for presynopal episode, ECG showed sinus bradycardia with QTC 552 msec; the patient reports continuing to take excessive methadone doses and refuses treatment at a recovery center; considering that the ICD can be life-saving in this typ77e of patient (intractable addiction), we have re-proposed the ICD implant, rejected by the patient.

A Case Report of Recurrent unilateral Bell’s Palsy in young female

Most facial palsies comprise of lower motor neuron type or Bell’s palsy. The mean incidence of recurrence of Bell’s palsy is 6.5% and can recur at any age. Although it was first reported in the year 1871, most of its etiology, pathology, management and progression are still neither fully described nor reported. We reported a case of Bell’s palsy in a young Saudi female who was presented with a unilateral recurrent episode of Bell’s palsy. Patient came to the emergency department with facial asymmetry, severe neck pain, loss of sensation on the left side of face and headache, while she was also not responding to oral medications. She was admitted to the hospital for an intravenous treatment and for further evaluation. Her serologic investigation was unremarkable. Similar episode had occurred five years ago as well, which was completely resolved after treatment. Her brain MRI localized T2 and T2 weighted sequence showed hyperintense lesion at the superior anterior aspect of left orbit and could represent lipoma versus hemangioma. Her presenting complaint responded well on IV treatment and patient was discharged on 11th day. She was also referred for plastic and neurosurgery services for the treatment of underlying cause. Recurrent Bell’s palsy is infrequent with etiology not fully elucidated. However, our case emphasizes that the timely medical treatment with regular follow-up is necessary for better prognosis and identification and treatment of underlying cause.

Amoxicillin-induced Aseptic Meningitis

Amoxicillin is a semi synthetic beta-lactam antibiotic that belongs to the penicillin family. It is the most prescribed antibiotic in the world. It has few side effects, even though hypersensitivity reactions may occur, with potential life-threatening effects. The authors present the case of a 63 years-old male admitted in the emergency department with a two-week history of fever and occipital headache. The symptoms began after he started antibiotic prophylaxis with amoxicillin for a dental procedure. Cerebrospinal fluid analysis was suggestive of aseptic meningitis and the patient improved quickly after discontinuation of the drug. The patient’s previous medical history highlighted a similar episode after he had started taking amoxicillin as part of a scheme for the treatment of a Helicobacter pylori infection. Aseptic meningitis is an extremely rare adverse reaction of amoxicillin, with only 16 cases reported in literature.

Laparoscopic reduction and repair of a left paraduodenal hernia

Left paraduodenal hernias are the most common type of congenital internal hernia, but they are difficult to diagnose without appropriate imaging. A 79-year-old man with a history of recurrent abdominal pain had another similar episode of abdominal pain, which prompted him to seek evaluation. The pain resolved spontaneously on arrival to the hospital. Enhanced CT scan showed the characteristic findings of a left paraduodenal hernia and laparoscopic repair was undertaken. The small intestine was reduced successfully, and the hernia orifice was approximated with a continuous closure. He was discharged uneventfully 4 days after admission. The characteristic clinical and imaging findings of paraduodenal hernias are reviewed. Laparoscopic repair is reasonable in patients who have a paraduodenal hernia without intestinal ischemia.

Simple predictors to differentiate acute respiratory infections from acute asthma in children 6 months to 5 years

Background: Acute respiratory infections constitute one of the principal causes of morbidity and mortality in children less than five years of age in developing countries. For logistic reasons, WHO recommended case management is structured towards treatment as pneumonia in preference to acute asthma. It is warned that wheezing can occur during pneumonia and therefore, care must be taken when treating wheezing not to miss treating pneumonia with an antibiotic. Current WHO ARI CASE MANAGEMENT guidelines, in a child presenting with cough and rapid breathing, there is a predilection for over -treatment of pneumonia and under treatment of asthma.Methods: Totally 245 children were included in the study. They were classified into asthmatic and LRI prone with the help of simple predictors.Results: The combination of fever, chest indrawing and persistent tachypnoea after bronchodilator has an excellent specificity of 96.12% in predicting the presence of pulmonary infiltrate. The presence of more than two episodes of similar respiratory distress, previous H/O of nebulization and family H/O asthma, either alone or in combination may point more towards asthma as a cause of cough and respiratory distress.Conclusions: In a child presenting with cough and fast breathing with a previous similar episode, trial nebulization can be given before investigating further for pneumonia.

Norfloxacin Induced Recurrent Fixed Drug Eruption in a self Treated Adult Female Patient - A Case Report

Background: Fixed drug eruption is a clinical entity occurring at the same site each time the drug is administered. They are usually found on lips, genitalia, abdomen, and legs but can occur at any location. The eruptions usually occur within hours of administration of the drug and resolves spontaneously. Most common drugs causing them include antimicrobials. Fluroquinolones especially norfloxacin is commonly used in the treatment of gastrointestinal infections. Cutaneous adverse drug reactions are very rare with norfloxacin. Case Report: In this case report, a young female, soon after taking Nofloxacin tablet, developed a blister with erythema and itching after self treatment for urinary tract infection. It got cured after stopping the drug and taking treatment from a dermatologist. It resolved as a hyper-pigmented scar. She experienced a similar episode of drug eruption on the same site when she again self medicated herself with Norfloxacin for diarrhoea. This time the reaction occurred within few hours and resolved with hyperpigmentation after medication. She was advised not to indulge in self-treatment in future. Suspecting association between the drug and the rash was confirmed and a diagnosis of Norfloxacin induced fixed drug eruption was made. Conclusion: Causality assessment by Naranjo’s algorithm revealed a definite relationship between the cutaneous adverse drug reaction and the offending drug.

Afterword

This afterword develops a brief critique of the way analysts and activists on the left continue to use the concept of capitalism. My main argument is that the term “capitalism” was effectively stolen by the right wing in the 1970s and 1980s and infused with a meaning that emphasizes capitalism’s durability and its unchanging nature. So when those on the left use the term, they inadvertently reinforce the problematic claims of their political opponents. A similar episode of linguistic larceny happened earlier. Between 1890 and 1910, political thinkers in England and the United States effectively stole the term “liberalism” and redefined it from “economic liberalism” to “political liberalism.”...