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.

Memory mixed with desire : a preliminary study of philosophy and literature in the works of Friedrich Nietzsche and Milan Kundera

Memory Mixed with Desire: A preliminary study of Philosophy and Literature in the works of Friedrich Nietzsche and Milan Kundera Robert Spinelli Brock University, Department of Philosophy This thesis studies intertextuality in the works of Friedrich Nietzsche and Milan Kundera through the primary themes of memory and forgetting. The thesis starts with two introductory chapters that delineate memory according to Nietzsche and Kundera respectively. From here, I move into a discussion of Nietzsche's Ubermensch as an example of the type of forgetting that Nietzsche sees as a cure for the overabundance of memory that has led to Christian morality. Next, I explore the Kunderan concept of kitsch as the polar opposite of what Nietzsche has sought in his philosophy, finishing the chapter by tying the two thinkers together in a Kunderan critique of Nietzsche. The thesis ends with a chapter devoted to the Eternal Return beginning with an exegesis of Nietzsche's idea and ending with a similar exegesis of Kundera's treatment of this thought. What I suggest in this chapter is that the Eternal Return might itself be a form of kitsch even in its attempt to revalue existence.

Face to face with the mexicans : the domestic life, educational, social, and bussines ways statesmanship and literature, legendary and general history of the mexicana people.

UANL

LMS software study and a practical application in language and literature didactics. 'Aplicación práctica en Didáctica de la lengua y la literatura del software LMS'.

Resumen en español

Towards an interface of language and literature. 'Hacia una interfaz de la Lengua y la Literatura'.

Se analiza la conveniencia de usar textos simplificados o en su formato original para propositos pedagógicos dentro de la enseñanza de la segunda lengua. El autor considera que ambas clases de textos (simplificados u originales) pueden formar el nivel intermedio de aprendizaje de lenguas extranjeras.

Landscape and the environment.

Muestra las diferentes maneras que tienen los pintores de relacionarse con el paisaje y cómo lo expresan en sus obras a lo largo de distintas épocas y culturas. Ayuda a interpretar los estilos artísticos y entender el momento histórico en que fueron creados.

AQA GCSE English language and literature. Foundation.

Recurso aprobado por AQA, ha sido escrito para apoyar a los estudiantes en la preparación del General Certificate of Secondary Education (GCSE) inglés lengua y literatura inglesas. Todas las unidades son totalmente compatibles con recursos digitales. Estructurado en diecisiete unidades: las siete primeras ayudarán con los exámenes, las unidades restantes con evaluaciones controladas. Incluye secciones de gramática, ortografía y puntuación.

AQA GCSE English language and literature. Higuer.

Recurso aprobado por AQA, ha sido escrito para apoyar a los estudiantes en la preparación del General Certificate of Secondary Education (GCSE) inglés lengua y literatura inglesas. Todas las unidades son totalmente compatibles con recursos digitales. Estructurado en diecisiete unidades: las siete primeras ayudarán con los exámenes, las unidades restantes con evaluaciones controladas. Incluye secciones de gramática, ortografía y puntuación.

AQA GCSE English language and literature. Teacher's resource book. Higher and foundation.

Recurso para el profesor con directrices detalladas y consejos prácticos para los estudiantes que preparan el General Certificate of Secondary Education (GCSE) AQA de lengua y literatura inglesas. Estructurado en diecisiete unidades, las siete primeras preparan los exámenes y las restantes incluyen unidades con evaluaciones controladas.

Investigation and literature review of unilateral hearing loss

Literature and research were gathered and analyzed to determine the impact UHL has on a child’s education, speech and language development. The effects of early intervention and amplification were also analyzed.

Libraries and literature in Rome

A chapter of 6,000 words on books, literary culture, and public and private libraries in the ancient city of Rome