Spectrum of ocular digoxin toxicity in the elderly: A case report

Introduction: We report a case of digoxin intoxication with severe visual symptoms. Patients (or Materials) and Methods: Digoxin 0.25 mg QD for atrial fibrillation was prescribed to a 91-year-old woman with an estimated creatinine clearance of 18 mL/min. Within 2 to 3 weeks, she developed nausea, vomiting, and dysphagia, and began complaining of snowy and blurry vision, photopsia, dyschromatopsia, aggravated bedtime visual and proprioceptive illusions (she felt as being on a boat), and colored hallucinations. She consulted her family doctor twice and visited the eye clinic once until, 1 month after starting digoxin, impaired autonomy led her to be admitted to the emergency department. Results: Digoxin intoxication was confirmed by a high plasma level measured on admission (5.7 μg/L; reference range, 0.8-2 μg/L). After stopping digoxin, general symptoms resolved in a few days, but visual symptoms persisted. Ophtalmologic care and follow-up diagnosed digoxin intoxication superimposed on pre-existing left eye (LE) cataract, dry age-related macular degeneration (DMLA), and Charles Bonnet syndrome. Visual acuity was 0.4 (right eye, RE) and 0.5 (LE). Ocular fundus was physiologic except for bilateral dry DMLA. Dyschromatopsia was confirmed by poor results on Ishihara test (1/13 OU). Computerized visual field results revealed nonspecific diffuse alterations. Full-field electroretinogram (ERG) showed moderate diffuse rod and cone dysfunction. Visual symptoms progressively improved over the next 2 months, but ERG did not. Complete resolution was not expected due to the pre-existing eye disease. The patient was finally discharged home after a 5-week hospital stay. Conclusion: Digoxin intoxication can go unrecognized by clinicians, even in a typical presentation. The range of potential visual symptoms is far greater than isolated xanthopsia (yellow vision) classically described in textbooks. Newly introduced drugs and all symptoms must be actively sought after, because they significantly affect quality of life and global functioning, especially in the elderly population, most liable not to mention them.

Prevalence of cerebral amyloid pathology in persons without dementia: a meta-analysis.

IMPORTANCE: Cerebral amyloid-β aggregation is an early pathological event in Alzheimer disease (AD), starting decades before dementia onset. Estimates of the prevalence of amyloid pathology in persons without dementia are needed to understand the development of AD and to design prevention studies. OBJECTIVE: To use individual participant data meta-analysis to estimate the prevalence of amyloid pathology as measured with biomarkers in participants with normal cognition, subjective cognitive impairment (SCI), or mild cognitive impairment (MCI). DATA SOURCES: Relevant biomarker studies identified by searching studies published before April 2015 using the MEDLINE and Web of Science databases and through personal communication with investigators. STUDY SELECTION: Studies were included if they provided individual participant data for participants without dementia and used an a priori defined cutoff for amyloid positivity. DATA EXTRACTION AND SYNTHESIS: Individual records were provided for 2914 participants with normal cognition, 697 with SCI, and 3972 with MCI aged 18 to 100 years from 55 studies. MAIN OUTCOMES AND MEASURES: Prevalence of amyloid pathology on positron emission tomography or in cerebrospinal fluid according to AD risk factors (age, apolipoprotein E [APOE] genotype, sex, and education) estimated by generalized estimating equations. RESULTS: The prevalence of amyloid pathology increased from age 50 to 90 years from 10% (95% CI, 8%-13%) to 44% (95% CI, 37%-51%) among participants with normal cognition; from 12% (95% CI, 8%-18%) to 43% (95% CI, 32%-55%) among patients with SCI; and from 27% (95% CI, 23%-32%) to 71% (95% CI, 66%-76%) among patients with MCI. APOE-ε4 carriers had 2 to 3 times higher prevalence estimates than noncarriers. The age at which 15% of the participants with normal cognition were amyloid positive was approximately 40 years for APOE ε4ε4 carriers, 50 years for ε2ε4 carriers, 55 years for ε3ε4 carriers, 65 years for ε3ε3 carriers, and 95 years for ε2ε3 carriers. Amyloid positivity was more common in highly educated participants but not associated with sex or biomarker modality. CONCLUSIONS AND RELEVANCE: Among persons without dementia, the prevalence of cerebral amyloid pathology as determined by positron emission tomography or cerebrospinal fluid findings was associated with age, APOE genotype, and presence of cognitive impairment. These findings suggest a 20- to 30-year interval between first development of amyloid positivity and onset of dementia.

Visual signs and symptoms in patients with the visual variant of Alzheimer disease.

BACKGROUND: Prominent visual symptoms can present in the visual variant of Alzheimer's disease (VVAD). Ophthalmologists have a significant role to play in the early diagnosis of VVAD. METHODS: We retrospectively reviewed the files of ten consecutive patients diagnosed with VVAD. All patients had a full neuro-ophthalmologic examination, a formal neurological and neuro-psychological testing, and cerebral MRI to confirm diagnosis. In addition, functional neuroimaging was obtained in seven patients. RESULTS: The common primary symptom at presentation with all patients was difficulty with near vision (reading difficulty n = 8, "visual blur" in near vision n = 2), and difficulty writing (n = 3). Following assessment, impaired reading and writing skills were evident in 9/10 and 8/10 patients respectively. Median distance visual acuity was 20/25 and at near the median visual acuity was J6. Partial homonymous visual field defect was detected in 80 % (8/10) of the patients. Color vision was impaired in all patients when tested with Ishihara pseudoisochromatic plates, but simple color naming was normal in 8/9 tested patients. Simultanagnosia was present in 8/10 patients. Vision dysfunction corresponded with cerebral MRI findings where parieto-occipital cortical atrophy was observed in all patients. PET scan (5 patients) or SPECT (2 patients) revealed parieto-occipital dysfunction (hypometabolism or hypoperfusion) in all 7 tested patients CONCLUSIONS: Visual difficulties are prominent in VVAD. Dyslexia, incomplete homonymous hemianopia, preserved color identification with abnormal color vision on Ishihara, and simultanagnosia were all symptoms observed frequently in this patient series. Ophthalmologists should be aware of the possibility of neurodegenerative disorders such as VVAD in patients with unexplained visual complaints, in particular reading difficulties.

Spectrum of digoxin-induced ocular toxicity: a case report and literature review.

BACKGROUND: Digoxin intoxication results in predominantly digestive, cardiac and neurological symptoms. This case is outstanding in that the intoxication occurred in a nonagenarian and induced severe, extensively documented visual symptoms as well as dysphagia and proprioceptive illusions. Moreover, it went undiagnosed for a whole month despite close medical follow-up, illustrating the difficulty in recognizing drug-induced effects in a polymorbid patient. CASE PRESENTATION: Digoxin 0.25 mg qd for atrial fibrillation was prescribed to a 91-year-old woman with an estimated creatinine clearance of 18 ml/min. Over the following 2-3 weeks she developed nausea, vomiting and dysphagia, snowy and blurry vision, photopsia, dyschromatopsia, aggravated pre-existing formed visual hallucinations and proprioceptive illusions. She saw her family doctor twice and visited the eye clinic once until, 1 month after starting digoxin, she was admitted to the emergency room. Intoxication was confirmed by a serum digoxin level of 5.7 ng/ml (reference range 0.8-2 ng/ml). After stopping digoxin, general symptoms resolved in a few days, but visual complaints persisted. Examination by the ophthalmologist revealed decreased visual acuity in both eyes, 4/10 in the right eye (OD) and 5/10 in the left eye (OS), decreased color vision as demonstrated by a score of 1/13 in both eyes (OU) on Ishihara pseudoisochromatic plates, OS cataract, and dry age-related macular degeneration (ARMD). Computerized static perimetry showed non-specific diffuse alterations suggestive of either bilateral retinopathy or optic neuropathy. Full-field electroretinography (ERG) disclosed moderate diffuse rod and cone dysfunction and multifocal ERG revealed central loss of function OU. Visual symptoms progressively improved over the next 2 months, but multifocal ERG did not. The patient was finally discharged home after a 5 week hospital stay. CONCLUSION: This case is a reminder of a complication of digoxin treatment to be considered by any treating physician. If digoxin is prescribed in a vulnerable patient, close monitoring is mandatory. In general, when facing a new health problem in a polymorbid patient, it is crucial to elicit a complete history, with all recent drug changes and detailed complaints, and to include a drug adverse reaction in the differential diagnosis.

Synaptic dysfunction, memory deficits and hippocampal atrophy due to ablation of mitochondrial fission in adult forebrain neurons.

Well-balanced mitochondrial fission and fusion processes are essential for nervous system development. Loss of function of the main mitochondrial fission mediator, dynamin-related protein 1 (Drp1), is lethal early during embryonic development or around birth, but the role of mitochondrial fission in adult neurons remains unclear. Here we show that inducible Drp1 ablation in neurons of the adult mouse forebrain results in progressive, neuronal subtype-specific alterations of mitochondrial morphology in the hippocampus that are marginally responsive to antioxidant treatment. Furthermore, DRP1 loss affects synaptic transmission and memory function. Although these changes culminate in hippocampal atrophy, they are not sufficient to cause neuronal cell death within 10 weeks of genetic Drp1 ablation. Collectively, our in vivo observations clarify the role of mitochondrial fission in neurons, demonstrating that Drp1 ablation in adult forebrain neurons compromises critical neuronal functions without causing overt neurodegeneration.

Enhancing teaching and learning speech acts: action research of Japanese as a foreign language /

This action research observes a second year Japanese class at a university where foreign language courses are elective for undergraduate students. In this study, using the six strategies to teach Japanese speech acts that Ishihara and Cohen (2006) suggested, I conducted three classes and analyzed my teaching practice with a critical friend. These strategies assist learners toward the development of their understanding of the following Japanese speech acts and also keep the learners to use them in a manner appropriate to the context: (I) invitation and refusal; (2) compliments; and (3) asking for a permission. The aim of this research is not only to improve my instruction in relation to second language (L2) pragmatic development, but also to raise further questions and to develop future research. The findings are analyzed and the data derived from my journals, artifacts, students' work, observation sheets, interviews with my critical friend, and pretests and posttests are coded and presented. The analysis shows that (I) after my critical friend encouraged my study and my students gave me some positive comments after each lesson, I gained confidence in teaching the suggested speech acts; (2) teaching involved explaining concepts and strategies, creating the visual material (a video) showing the strategies, and explaining the relationship between the strategy and grammatical forms and samples of misusing the forms; (3) students' background and learning styles influenced lessons; and (4) pretest and posttests showed that the students' Icvel of their L2 appropriate pragmatics dramatically improved after each instruction. However, after careful observation, it was noted that some factors prevented students from producing the correct output even though they understood the speech act differences.

Sensibilidad al contraste y percepción de color en pacientes con lentes intraoculares amarillos : estudio de corte transversal

El presente estudio descriptivo de corte transversal, comparó la percepción de color (Test de Farnsworth-100 y de Ishihara) y la sensibilidad al contraste en un grupo de 35 ojos con implantes de lentes intraoculares claros esféricos y otro grupo de 35 ojos con LIOs amarillos esféricos, para evaluar las diferencias entre tener o no el filtro de luz azul. Adicionalmente, después de un examen oftalmológico completo en el ojo a estudiar, se realizaron preguntas de satisfacción POP para evaluar el resultado subjetivo del procedimiento. Todos los pacientes tenían más de 3 meses POP. No se encontraron diferencias estadísticamente significativas en las pruebas de percepción de color que sugirieran que las alteraciones correspondían al filtro de luz azul, y aunque los pacientes con los LIOs amarillos lograron un mejor desempeño en la prueba de sensibilidad al contraste al analizarlos estadísticamente, clínicamente esto no parece tener importancia. La satisfacción general en ambos grupos tuvo una gran puntuación, y dentro de las molestias referidas más frecuentemente y que estaban presentes desde el procedimiento, se encontraban ardor ocular, lagrimeo y dificultad para ver de cerca sin corrección. Según estudios en modelos animales, hay evidencia que sugiere que los LIOs amarillos, al compararlos con LIOs claros, protegen de mejor manera la retina una vez el cristalino se ha retirado. Según este y otros estudios publicados a la fecha, la agudeza visual, sensibilidad al contraste y percepción de color no varían de manera importante entre ambos tipos de lentes en la población general.

Eficacia del diagnóstico prenatal no invasivo por células fetales libres en sangre materna 1990-2014. Revisión sistemática

ANTECEDENTES: El aislamiento de células fetales libres o ADN fetal en sangre materna abre una ventana de posibilidades diagnósticas no invasivas para patologías monogénicas y cromosómicas, además de permitir la identificación del sexo y del RH fetal. Actualmente existen múltiples estudios que evalúan la eficacia de estos métodos, mostrando resultados costo-efectivos y de menor riesgo que el estándar de oro. Este trabajo describe la evidencia encontrada acerca del diagnóstico prenatal no invasivo luego de realizar una revisión sistemática de la literatura. OBJETIVOS: El objetivo de este estudio fue reunir la evidencia que cumpla con los criterios de búsqueda, en el tema del diagnóstico fetal no invasivo por células fetales libres en sangre materna para determinar su utilidad diagnóstica.  MÉTODOS: Se realizó una revisión sistemática de la literatura con el fin de determinar si el diagnóstico prenatal no invasivo por células fetales libres en sangre materna es efectivo como método de diagnóstico.  RESULTADOS: Se encontraron 5,893 artículos que cumplían con los criterios de búsqueda; 67 cumplieron los criterios de inclusión: 49.3% (33/67) correspondieron a estudios de corte transversal, 38,8% (26/67) a estudios de cohortes y el 11.9% (8/67) a estudios casos y controles. Se obtuvieron resultados de sensibilidad, especificidad y tipo de prueba. CONCLUSIÓN: En la presente revisión sistemática, se evidencia como el diagnóstico prenatal no invasivo es una técnica feasible, reproducible y sensible para el diagnóstico fetal, evitando el riesgo de un diagnóstico invasivo.

Alteraciones en la percepción del color e integración escolar.

Evaluar el nivel de incidencia de los daltonismos entre la población infantil de la Comunidad Autónoma de Madrid. Determinar el modo en que se utilizan las categorías cromáticas por parte de los niños daltónicos y aplicarles un programa de compensación perceptiva. Niños/as con edades comprendidas entre 5 y 8 años, pertenecientes a preescolar, primero y segundo de primaria de 6 CPs de la ciudad de Madrid y 4 de Majadahonda. Las distintas muestras elaboradas se detallan en el estudio. Se aplican 3 tests de láminas pseudoisocromáticas y se le pide al niño que indique cuál de los tests prefiere. En los casos en que se produce una respuesta patológica, se confirma el diagnóstico mediante una nueva aplicación de la batería de tests transcurridas 3 ó 4 semanas. A continuación, se presentan 34 muestras de color, pidiéndole al niño la categorización verbal de cada una de ellas. Se realiza un análisis cuantitativo (para identificar las láminas en las que se diferencian las respuestas de los distintos grupos de observadores) y un análisis cualitativo (para concretar la naturaleza de las respuestas). Por último, se aplica el entrenamiento en discriminación perceptiva, y se envían cuestionarios a padres y profesores, informándoles de la evolución desde el inicio de la intervención. Tests CUT (City University Test), Ishihara y TIDA (Test de Identificación de Daltonismos); entrevistas. Tablas, porcentajes. El TIDA se muestra como la prueba más atractiva, especialmente para los niños más pequeños. Los niveles de incidencia entre los varones son similares a los de otros países de nuestro entorno. Los niños daltónicos han evolucionado con la pérdida de la funcionalidad del mecanismo rojo-verde y carecen, por tanto, del referente perceptivo que permite distinguir entre ciertas categorías cromáticas. Estos niños pueden utilizar estrategias para reducir las consecuencias negativas de su limitación perceptiva, siendo capaces de aprender a utilizar la información complementaria que acompaña a la basada en el color y los cambios en la luminancia producidos por los filtros cromáticos. El programa de compensación perceptiva produjo efectos positivos, aunque puede ser mejorado. También fue apreciado de forma positiva por parte de padres y profesores.

Effects of planting density and nitrogen application on seed yield and other morphological traits of the leafy vegetable kale (Brassica oleracea).

The relationship between food security and sustainable land use is considered to be of the uttermost importance to increase yields without having to increase the agricultural land area over which crops are grown. In the present study nitrogen concentration (25 and 85 kg ha-1) and planting density (6.7, 10 and 25 plants m-2) were investigated for their effect on whole plant physiology and pod seed yield in kale (Brassica oleracea), to determine if the fruit (pod) yield could be manipulated agronomically. Nitrogen concentration did not significantly affect seed yield and it is therefore recommended that the lower concentration be used commercially. Conversely planting density did have a significant effect with increases in seed yield observed at the highest planting density of 25 plants m-2, therefore this high planting density would be recommended commercially to maximise area efficiency, highlighting that simple agronomic changes are capable of increasing crop yields over a set area.

Photoproduction of J/psi and of high mass e(+)e(-) in ultra-peripheral Au plus Au collisions at root s(NN)=200 GeV

We present the first measurement of photoproduction of J/psi and of two-photon production of high-mass e(+)e(-) pairs in electromagnetic (or ultra-peripheral) nucleus-nucleus interactions, using Au + Au data at root s(NN) = 200 GeV. The events are tagged with forward neutrons emitted following Coulomb excitation of one or both Au* nuclei. The event sample consists of 28 events with m(e+e-) > 2 GeV/c(2) with zero like-sign background. The measured cross sections at midrapidity of d sigma/dy (J/psi + Xn, y = 0) = 76 +/- 33 (stat) +/- 11 (syst) pb and d(2)sigma /dm dy (e(+) e(-) + Xn, y = 0) = 86 +/- 23(stat) +/- 16(syst) mu b/ (GeV/c(2)) for m(e+e-) epsilon vertical bar 2.0, 2.8 vertical bar GeV/c(2) have been compared and found to be consistent with models for photoproduction of J/psi and QED based calculations of two-photon production of e(+)e(-) pairs. (C) 2009 Elsevier B.V. All rights reserved.

Dilepton mass spectra in p plus p collisions at root s=200 GeV

PHENIX has measured the electron-positron pair mass spectrum from 0 to 8 GeV/c(2) in p + p collisions at root s = 200 GeV. The contributions from light meson decays to e(+)e(-) pairs have been determined based on measurements of hadron production cross sections by PHENIX. Within the systematic uncertainty of similar to 20% they account for all e(+)e(-) pairs in the mass region below similar to 1 GeV/c(2). The e(+)e(-) pair yield remaining after subtracting these contributions is dominated by semileptonic decays of charmed hadrons correlated through flavor conservation. Using the spectral shape predicted by PYTHIA, we estimate the charm production cross section to be 544 +/- 39(stat) +/- 142(syst) +/- 200(model) pb. which is consistent with QCD calculations and measurements of single leptons by PHENIX. (C) 2008 Elsevier BV. All rights reserved.

Condição ocular entre trabalhadores de uma indústria metalúrgica brasileira

OBJETIVO: Avaliar a condição ocular em população de trabalhadores de uma indústria metalúrgica paulista. MÉTODOS: Amostra de 2516 funcionários de uma fábrica na cidade de São Paulo foi submetida a uma avaliação oftalmológica como exame ocupacional periódico. Foi aplicado um questionário e realizado o exame de acuidade visual (Snellen) e teste de Ishihara. Os funcionários com acuidade visual menor que 0,7 ou com diferenças maior que duas linhas ou que apresentassem alguma queixa ocular, passaram por avaliação complementar (biomicroscopia, refração, tonometria e fundo de olho). Prescreveu-se óculos conforme indicação. RESULTADOS: Houve predomínio do sexo masculino (62,5%) e faixa etária de 20 a 29 anos (41%). A maioria não apresentava antecedentes oculares (97,6%) ou sistêmicos (96,6%).A acuidade visual estava acima de 0,7 em 95,5% dos olhos e 84% não utilizavam correção. O diagnóstico final foi exame normal em 55% dos casos, presbiopia em 13.6%, astigmatismo miópico em 10% e hipermetrópico em 7,7% dos indivíduos. Baixa visão foi encontrada em 2,4%, cegueira unilateral em 0,4%, não havendo casos de cegueira ou de deficiência visual entre os trabalhadores. As principais causas de baixa visão foram erros refrativos e ambliopia. CONCLUSÃO: A maioria dos funcionários da indústria pesquisada apresentava exame oftalmológico normal e nenhum deles apresentava cegueira bilateral.

Stochastic exponential stability of singular linear systems with Markov jump parameters

This paper deals with exponential stability of discrete-time singular systems with Markov jump parameters. We propose a set of coupled generalized Lyapunov equations (CGLE) that provides sufficient conditions to check this property for this class of systems. A method for solving the obtained CGLE is also presented, based on iterations of standard singular Lyapunov equations. We present also a numerical example to illustrate the effectiveness of the approach we are proposing.