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Aims: To report trends in antibiotic resistance in cases of bacterial keratitis from a large eye hospital in South India., Methods: In this retrospective cross-sectional study, the microbiology laboratory records of patients with infectious keratitis diagnosed at an eye hospital in South India from 2002 to 2013 were reviewed to determine the proportion with antibiotic non-susceptibility., Results: 3685 bacterial isolates had susceptibility testing performed over the 12-year period. The two most common organisms with resistance were Streptococcus pneumoniae (n=1204) and Pseudomonas aeruginosa (n=894). Antibiotic non-susceptibility was generally uncommon for these two organisms and no significant trends were detected over the course of the study. In contrast, Staphylococcus aureus (N=211) isolates demonstrated a significant increase in fluoroquinolone non-susceptibility over the 12-year study period. This coincided with a significant increase in methicillin-resistant S. aureus (MRSA) during the study period, though the increase in fluoroquinolone resistance was likewise seen in methicillin-sensitive S. aureus (MSSA). For example, ofloxacin resistance in MSSA increased from 11.1% in 2002 to 66.7% in 2013 (p=0.002). No trends were apparent for the aminoglycosides, cefazolin or vancomycin, for which in vitro non-susceptibility generally appeared to be low., Conclusion: Resistance to antibiotics was generally stable for infectious keratitis isolates from a large eye hospital in South India, except for S. aureus, which experienced a significant increase in fluoroquinolone resistance from 2002 to 2013. Fluoroquinolone antibiotics currently have poor in vitro activity against both MRSA and MSSA in South India and are therefore not the ideal therapy for Staphylococcal corneal ulcers., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: To assess the trends in microbiological organisms identified from corneal scrapings from patients with infectious keratitis at a tertiary care medical centre in South India., Methods: We reviewed the records of the microbiology laboratory at Aravind Eye Hospital in Madurai, India, from 2002 until 2012. We identified the microbiological causes of all corneal ulcers from the culture and smear results, and assessed for trends in bacterial and fungal keratitis over time., Results: Of 23 897 corneal patients with ulcer with a corneal smear from 2002 to 2012 a fungal organism was identified in 34.3%, a bacterial organism in 24.7% and no organism in 38.3%. During this period, the annual number of keratitis cases due to bacteria decreased from 677 to 412, and the annual number due to fungus increased from 609 to 863. In analyses accounting for the total number of outpatients seen each year, the decline in number of smears positive for bacteria was statistically significant (p<0.001) but the increase in the number positive for fungus was not (p=0.73). The relative frequency of individual bacterial or fungal organisms remained relatively stable over this time., Conclusions: At a tertiary eye care centre in South India, there has been a reduction in the numbers of smear-positive bacterial keratitis over the past 11 years. This decline likely reflects economic development in India and increased access to antibiotics., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

The anatomy of the shoulder joint comprises a relatively large humeral head with a shallow glenoid cavity allowing a remarkable range of motion at the expense of inherent instability. Despite anterior shoulder dislocations being the most common type encountered, bilateral dislocations are rare and almost always posterior. The aetiology is usually direct or indirect trauma related to sports, seizures, electric shock or electroconvulsive therapy. We present the first reported case of atraumatic bilateral acute anterior shoulder dislocations with associated Hill-Sachs lesions in a young, fit and well patient with no comorbidities. MRI illustrated the Hill-Sachs lesions with superior labral tear from anterior to posterior, and confirmed the acute nature of the injury by demonstrating the bone marrow oedema. The patient was treated surgically with arthroscopic anterior stabilisation. At 6 months following surgery, the patient has a pain free full range of movement of both shoulders with no further dislocations and has returned to work., (2014 BMJ Publishing Group Ltd.)

Achilles tendon ruptures tend to occur more commonly in healthy men between the ages of 30 and 50 years who have had no previous injury or problem reported in the affected leg. The injury is usually due to sudden forced plantar flexion of the foot, unexpected dorsiflexion of the foot and violent dorsiflexion of a plantar flexed foot, all of which occur during high impact activities. We present the first reported case of interactive activity with Nintendo Wii games that have resulted in Achilles tendon rupture in a 46-year-old man. There have been no previous reports of Achilles tendon rupture with Nintendo Wii usage; it is a relatively uncommon mode of injury and is rare in terms of epidemiology of motion sensing video game injuries., (2014 BMJ Publishing Group Ltd.)

Aims: To compare the efficacy and safety of an escalating energy protocol with a non-escalating energy protocol using an impedance compensated biphasic defibrillator for direct current cardioversion of atrial fibrillation (AF)., Methods and Results: This prospective multicentre randomised trial enrolled 380 patients (248 male, mean (SD) age 67 (10) years) with AF. Patients were randomised to either an escalating energy protocol (protocol A: 100 J, 150 J, 200 J, 200 J), or a non-escalating energy protocol (protocol B: 200 J, 200 J, 200 J). Cardioversion was performed using an impedance compensated biphasic waveform. First-shock success was significantly higher for those randomised to 200 J than 100 J (71% vs 48%; p<0.01) and for patients with a body mass index (BMI) >25 kg/m(2) (75% vs 44%; p = 0.01). In patients with a normal BMI there was no significant difference in first-shock success. There was also no significant difference between subsequent shocks or overall success. The use of a non-escalating protocol (protocol B) resulted in fewer shocks but with a higher cumulative energy. There was no difference in duration of procedure, amount of sedation administered or post-shock erythema between the groups., Conclusion: First-shock success was significantly higher, particularly in patients with a BMI >25 kg/m(2), when a non-escalating initial 200 J energy was selected. The overall success, duration of procedure and amount of sedation administered, however, did not differ significantly between the two protocols.

Objective: To test prospectively depolarisation and repolarisation body surface maps (BSMs) for mirror image reversal, which is less susceptible to artefact, in patients with acute ischaemic-type chest pain, and to compare these BSM criteria with previously published 12 lead ECG criteria., Methods: An 80 lead portable BSM system was used to map patients presenting with acute ischaemic-type chest pain and a 12 lead ECG with left bundle branch block (LBBB). Acute myocardial infarction (AMI) was defined by serial cardiac enzymes. Each 12 lead ECG was assessed by the criteria of Sgarbossa et al and Hands et al for diagnosis of AMI. Depolarisation and repolarisation BSMs were assessed for loss of mirror image reversal of QRS with ST-T isointegral map patterns and a change in vector angle from QRS to ST-T outside 180+/-15 degrees -findings typically seen in LBBB with AMI., Results: Of 56 patients with chest pain and LBBB, 18 had enzymatically confirmed AMI. Patients with loss of BSM image reversal were significantly more likely to have AMI (odds ratio 4.9, 95% confidence interval 1.5 to 16.4, p = 0.007). Loss of BSM image reversal was significantly more sensitive (67%) for AMI than either 12 lead ECG method (17%, 33%) albeit with some loss in specificity (BSM 71%, 12 lead ECG 87%, 97%). Patients with AMI compared with those without AMI had a greater mean change in vector angle outside the normal range (180+/-15 degrees ), particularly between QRS isointegral and ST60 isopotential (the potential 60 ms after the J point at each electrode site) BSMs (19 degrees v 9 degrees, p = 0.038). Loss of image reversal and QRS-ST60 vector change outside 180+/-15 degrees had 61% sensitivity and 82% specificity for AMI (odds ratio 7.0, 95% confidence interval 2.0 to 24.4, p = 0.001)., Conclusions: BSM compared with the 12 lead ECG improved the early diagnosis of AMI in the presence of LBBB.