Simplified updates on the pathophysiology and recent developments in the treatment of amblyopia: A review

Amblyopia is the most common cause of monocular visual impairment affecting 2-5% of the general population. Amblyopia is a developmental cortical disorder of the visual pathway essentially due to abnormal visual stimulus, reaching the binocular cortical cells, which may be multivariate. Ganglion cells are of two types: parvocellular (P cells) and magnocellular (M cells); they are the first step where the light energy is converted in to neural impulse. P cells are involved in fine visual acuity, fine stereopsis, and color vision and M cells are involved in gross stereopsis and movement recognition. Strabismus, refractive error, cataract, and ptosis, occurring during critical period are highly amblyogenic. The critical period extends from birth to 7--8 years. The earlier the clinically significant refractive error and strabismus are detected and treated, the greater the likelihood of preventing amblyopia. Treatment for amblyopia in children includes: optical correction of significant refractive errors, patching, pharmacological treatment, and alternative therapies which include: vision therapy, binocular therapy, and liquid crystal display eyeglasses are newer treatment modalities for amblyopia. Age of starting the treatment is not predictive of outcome, instituting treatment on detection and early detection plays a role in achieving better outcomes. This review aims to give a simplified update on amblyopia, which will be of use to a clinician, in understanding the pathophysiology of the complex condition. We also share the cortical aspects of amblyopia and give recent developments in the treatment of amblyopia.

Study of audio vestibular dysfunction in type2 diabetes mellitus

Background: Improved quality of life is prime concern of management of diabetes, which is affecting vast population in later years. Audio vestibular function monitoring and care in the diabetics is part of such concern. Materials and methods: A cross sectional investigation was carried out, of type 2 diabetes patients at different stages of disease and therapy to evaluate audio vestibular dysfunction profiles. Results: Hearing loss (HL) was fairly common even in mild early disease while, tinnitus and vertigo too, occurred in all age, gender, disease duration and therapy categories of diabetics. Some 39% of patients bearing tinnitus or vertigo had normal audiograms. Aged males were found to have more exaggerated prevalence of audio vestibular problems than females. Insulin therapy in presumably, patients of long standing disease had lower prevalence of vertigo. Conclusion: Findings imply, more complex relation of audio vestibular complications to diabetes than, to glycemic status or duration of disease. Monitoring of such complications from the earliest, may alone, bring understanding of their pathogenesis and proper prevention and management.

Efficacy of stem cell in improvement of left ventricular function in acute myocardial infarction - MI3 Trial.

Background & objectives: Acute myocardial infarction (AMI) is characterized by irreparable and irreversible loss of cardiac myocytes. Despite major advances in the management of AMI, a large number of patients are left with reduced left ventricular ejection fraction (LVEF), which is a major determinant of short and long term morbidity and mortality. A review of 33 randomized control trials has shown varying improvement in left ventricular (LV) function in patients receiving stem cells compared to standard medical therapy. Most trials had small sample size and were underpowered. This phase III prospective, open labelled, randomized multicenteric trial was undertaken to evaluate the efficacy in improving the LVEF over a period of six months, after injecting a predefined dose of 5-10 × 108 autologous mononuclear cells (MNC) by intra-coronary route, in patients, one to three weeks post ST elevation AMI, in addition to the standard medical therapy. Methods: In this phase III prospective, multicentric trial 250 patients with AMI were included and randomized into stem cell therapy (SCT) and non SCT groups. All patients were followed up for six months. Patients with AMI having left ventricular ejection fraction (LVEF) of 20-50 per cent were included and were randomized to receive intracoronary stem cell infusion after successfully completing percutaneous coronary intervention (PCI). Results: On intention-to-treat analysis the infusion of MNCs had no positive impact on LVEF improvement of ≥ 5 per cent. The improvement in LVEF after six months was 5.17 ± 8.90 per cent in non SCT group and 4.82 ± 10.32 per cent in SCT group. The adverse effects were comparable in both the groups. On post hoc analysis it was noted that the cell dose had a positive impact when infused in the dose of ≥ 5 X 108 (n=71). This benefit was noted upto three weeks post AMI. There were 38 trial deviates in the SCT group which was a limitation of the study. Interpretation & conclusions: Infusion of stem cells was found to have no benefit in ST elevation AMI. However, the procedure was safe. A possible benefit was seen when the predefined cell dose was administered which was noted upto three weeks post AMI, but this was not significant and needs confirmation by larger trials.

Cardiac amyloidosis.

We present a 54 year old male who presented with congestive cardiac failure and was diagnosed as restrictive cardiomyopathy with mild mitral regurgitation on 2D echocardiography. Cardiac amyloidosis was diagnosed in view of renal biopsy revealing amyloid deposition. Patient did not have any obvious etiology for secondary amyloidosis.

Regional brain metabolism in schizophrenia: The influence of antipsychotics.

BACKGROUND: Schizophrenia has been associated with a plethora of metabolic changes in the brain that vary with duration and type of psychoses. Additionally, it has been observed that antipsychotics can further alter cerebral glucose metabolism. These changes resulting from antipsychotics have been postulated to be reflective of the duration and mechanism of action of the medication. AIMS: We aimed to examine the influence of antipsychotics on brain metabolism in individuals with schizophrenia in a naturalistic setting. SETTINGS AND DESIGN: A cross-sectional study was carried out by the psychiatry department of a tertiary care hospital in collaboration with the Radiation Medicine Centre. MATERIALS AND METHODS: Eighteen male patients with schizophrenia in different phases of treatment underwent an 18F-deoxyglucose positron emission tomography scan in a resting state 12 hours after the last dose of antipsychotic. Statistical Analysis: The types and duration of treatment were then compared with the regional glucose uptake in 14 predetermined regions of interest. The relative Uptake Values were further compared using SPSS 11.0. RESULTS: An immediate increase followed by a decrease in cortical uptake was noted while the basal ganglia uptake remained high, albeit with a decreasing trend. Typical antipsychotics were associated with lower frontal cortical and higher basal ganglia and cerebellar uptake as compared to atypical antipsychotics. CONCLUSION: The differential influence of the type and duration of antipsychotic on glucose uptake suggests a possible trend towards long-term side effects with typical medications that were not noted on clinical examination. This however needs to be confirmed with larger, controlled studies.

Safety and reactogenicity of a low dose diphtheria tetanus acellular pertussis vaccine (Boostrix) in pre-school Indian children.

OBJECTIVE: To evaluate the safety and reactogenicity of a reduced-antigen-content combined Diphtheria Tetanus Acellular Pertussis (dTpa) vaccine in Indian preschool children. METHODS: GlaxoSmithKline Biologicals combination dTpa vaccine was administered as a single booster dose to 347 children aged 46 years in seven centers across India. All children were subsequently followed up for two weeks for safety and reactogenicity assessment. RESULTS: A total of 345 subjects completed the study and two subjects were lost to follow-up. One serious adverse event (head injury) unrelated to vaccination was reported. Otherwise, all subjects were in good health throughout the study period. Three subjects (0.9%) reported transient general symptoms (such as irritability and drowsiness), which prevented normal activity. Pain at injection site, swelling and redness was reported in 31.1%, 18.2% and 8.9% subjects respectively. Five subjects (1.4%) reported severe pain preventing normal movement. This resolved within 48 hours in all cases. There were no other severe local reactions including large injection site reactions. CONCLUSION: The reduced antigen content combined dTpa vaccine is safe and well tolerated in Indian pre-school children.

Systemic humicolus cryptococcosis.

We report a 71/2-year-boy with disseminated systemic cryptococcosis. Although other species have been incriminated, this appears to be the first report of Cryptococcus humicolus. The child was HIV negative. He was treated with amphotericin B and fluconazole with intensive supportive care. The child responded after 6 weeks and is now on maintenance fluconazole therapy.

Ecthyma gangrenosum in a new born child.

Ecthyma gangrenosum is one of the most serious and specific cutaneous infection caused by Pseudomonas aeruginosa. We report a case of ecthyma gangrenosum in a new born child who responded poorly to the antipseudomonas treatment to highlight the poor prognosis in new born.

Correlation of fine needle aspiration cytology, smear and culture in tuberculous lymphadenitis: a prospective study.

BACKGROUND AND AIM: Bacteriological studies are necessary to confirm the diagnosis of tuberculous lymphadenitis, as cytological appearances mimic other granulomatous lesions. The objective was to assess the diagnostic role of culture of fine needle aspiration done on clinically suspected cases of tuberculous lymphadenitis and to determine the prevalence of drug resistance in M. tuberculosis isolates. SETTING AND DESIGN: A prospective, double-blind study over a period of one year in a tertiary care hospital. MATERIAL AND METHODS: Fine needle aspiration cytology and culture were done on 250 patients with clinical suspicion of tuberculous lymphadenitis. STATISTICAL ANALYSIS: Data was statistically analysed using chi square test. Sensitivity, specificity, positive predictive and negative predictive values and likelihood ratio were also calculated. RESULT: Of the 161 cytologically or microbiologically proven cases of tuberculous lymphadenitis, cytological changes consistent with tuberculosis were observed in 133 patients, out of which mycobacteria were isolated in 102 aspirates. Mycobacteria were also isolated from 28 aspirates cytologically missed as tuberculous lymphadenitis. Of the 130-mycobacterial isolates, 5 were non-tuberculous mycobacteria. Culture positivity was significantly higher (P<0.001) than smear positivity. Drug susceptibility studies showed resistance to one or more drugs in 61% of isolated strains with maximum resistance to isoniazid (16% primary and 48% secondary) and minimum to ethambutol (4% primary and 12% secondary). CONCLUSION: Culture for mycobacteria should be carried out on all aspirates from patients suspected with tuberculous lymphadenitis.

Mullerian adenosarcoma of the uterine cervix.

Sarcomas in the uterine cervix are rare, the incidence being 0.5% to 1% of all cervical malignancies. This is a report of cervical mullerian adenosarcoma, which was encountered in a hysterectomy performed for prolapse. The tumor was composed of benign glandular elements and malignant stromal component, thus justifying its nomenclature. We wish to emphasize the distinctive morphological features of this rare cervical tumor.

Induction of oxidative stress in antitubercular drug-induced hepatotoxicity.

BACKGROUND AND AIM: Oxidative stress could play a role in the pathogenesis of antitubercular drug (ATD)-induced hepatotoxicity. We therefore studied the plasma level of reduced glutathione (GSH) and malondialdehyde (MDA) in patients with ATD-induced hepatotoxicity (cases), ATD-treated controls (disease controls) and in healthy volunteers. METHODS: This study was carried out in a case-control design. Twenty-one cases, 21 age- and sex-matched disease controls, and 10 healthy volunteers were enrolled. Plasma levels of GSH and MDA were measured. RESULTS: Plasma levels of GSH (median [range] 11.5 [6.2-21.2] mmol/dL) and MDA (1390 [560-2310] nmol/dL) of cases were significantly different (p<0.01) from GSH (18.4 [10.5-24.4]) and MDA (290 [240-550]) of disease controls. Further, plasma GSH and MDA levels of both the ATD-treated groups were different from those in healthy controls. CONCLUSION: Lower levels of plasma GSH and higher levels of MDA may be due to oxidative stress resulting from ATD therapy.

Mortality and morbidity in high risk infants during a six year follow-up.

OBJECTIVE: To study the mortality and morbidity in high risk infants after discharge from the hospital. DESIGN: Prospective, 6 year follow up. SETTING: High Risk Clinic (HRC). METHODS: Infants discharged from a Neonatal Special Care Unit were identified for follow up using predetermined risk criteria. Home visits were made by the social worker, if appointments to HRC were missed. Verbal autopsy was performed in case of home deaths. Intercurrent illnesses and rehospitalizations were recorded. At six years, the children who had come for the final assessment at 30 months on the Bayley Scales, were recalled for assessment of the intelligence quotient, by Stanford-Binet Scale. RESULTS:Four hundred and four high risk infants and eighty six controls were enrolled. There were 40 deaths in the study period, out of which 38 occurred in the first year of life, sixty per cent of these occurring in the first three months. The mortality was significantly higher in the VLBW group. Out of the 22 hospital deaths, 72.7% were due to infection. There was a significant difference (p < 0.001) in the mortality rate between the group which attended the HRC regularly (6.4%) as compared to that of the defaulters (27.6%). Ninety five children had rehospitalization in the High Risk group as compared to two in the control group (p < 0.001). In the 286 children who were assessed at 6 years, the incidence of borderline intelligence was 14.6% as compared to 5.6% in the controls (p < 0.05). CONCLUSION: Mortality and rehospitalization rate is high in high risk infants, after discharge from the hospital. Children who appear to have normal development in the third year, may show a high incidence (14.6%) of borderline intelligence at six years.

Fulminant hepatic failure: etiology, viral markers and outcome.

OBJECTIVE: To investigate the etiology and outcome of fulminant hepatic failure (FHF) in children. SETTING: Hospital based descriptive. METHODS: 36 children (22 males and 14 females) presenting with FHF over a period of one year were investigated. The ages ranged from 1.5 to 9 years. FHF was defined as occurrence of encephalopathy within eight weeks of onset of jaundice with no evidence of pre-existing liver disease. Detailed history, clinical examination, routine biochemical parameters and relevant diagnostic tests were carried out. Viral markers studied were anti HAV-IgM, HBsAg, anti HBc-IgM, anti-HCV and anti HEV-IgM. RESULTS: A viral etiology could be established in 22 children (61.1%). Hepatitis A (n = 12), Hepatitis B (n = 3), Hepatitis A and B (n = 2), and Hepatitis A and E (n = 4). Two children had enteric fever (1 with associated HEV), 2 children had Wilson's disease, 1 child had Indian Childhood Cirrhosis (ICC) and 2 children had drug induced hepatitis. Etiological diagnosis was not possible in 8 children (22%). Fourteen children (39%) died. Poor outcome was associated with spontaneous bleeding, raised prothrombin time, lower transaminases and higher bilirubin on admission. CONCLUSION: Viral hepatitis is the commonest cause of FHF in children. HAV alone or in combination is responsible for upto 50% of all FHF in children. Chronic liver disease can also present as FHF. Etiological diagnosis is not possible to upto one-fourth of all cases.

Pune low birth weight study--a six year follow up.

OBJECTIVE: To evaluate the intelligence, visuo-motor perception, emotional problems and preschool skills in low birth weight (LBW) infants and the impact of social and environmental factors on their development. DESIGN: A prospective cohort study. SETTING: Infants discharged from a Neonatal Special Care Unit of a referral hospital with birth weight less than 2000 g followed up in the High Risk Clinic. METHODS: Low birth weight infants were assessed by Stanford Binet Scales of intelligence, Bender Gestalt Test for visuo-motor perception, Human Figure Drawing for emotional indicators and occupational therapy assessment. A detailed evaluation of their environment and socio-economic status was done. Hearing and ophthalmic assessment was also done and the school progress report was scrutinized. RESULTS: Two hundred and one LBW and seventy one control children were assessed. The mean IQ of LBW children was within normal limits (94.3), though significantly lower than controls (101.3). Preterm SGA children had the lowest mean IQ. Visuo-motor perception and preschool skills and language development was poorer in LBW children. There was no difference in the emotional indicators. Thirteen per cent of LBW children had borderline IQ, as compared to 5.6% in controls (p<0.05). Mother's education and spaciousness of the house had a positive impact and chronic medical problems had a negative impact on the IQ. CONCLUSIONS: The mean IQ of LBW children was within normal limits. The incidence of children with borderline intelligence (IQ 70-85) was significantly higher than controls. Mother's education had a positive impact on the intelligence of the children. A longer follow up is necessary to identify "slow learners".

Pancreatic lymphoma masquerading as adenocarcinoma.

Primary pancreatic lymphoma is rare. We report a young man with primary lymphoma in the pancreatic head who presented with obstructive jaundice.

Growth and development of twins compared with singletons at ages one and four years.

OBJECTIVE: To compare the growth and development of twins with normal control singletons and also with matched 'high risk' singletons, at one and four years of age. DESIGN: A four year prospective follow up study. SETTING: High risk clinic (HRC) of a referral hospital. SUBJECTS: Twin pairs enrolled in the HRC; normal full term singleton controls; and high risk "matched" singletons enrolled in the HRC. METHODS: The height, weight and head circumference was measured at one and four years. Development was assessed at 1 year using the Bayley Scales of Infant Development. At 4 years, the intelligence quotient was determined by the Stanford Binet Intelligence Scale. RESULTS: Forty two twins and an equal number of controls were assessed at one year. All the twins weighed less than 2 kg at birth. They lagged behind in all three parameters of growth, namely, height, weight and head circumference. AT 4 years, 24 twins came for follow up. Although, they had caught up for head circumference, they lagged behind in height and weight, particularly the group of fourteen SGA twins. The growth parameters of LBW twins and LBW matched singletons did not show any significant difference. At one year, the development of twins was within normal limits although the motor quotients were significantly lower than that of controls. At 4 years, the intelligence quotients of twins were well within normal limits. CONCLUSIONS: Twins were lighter and shorter than controls at four years, particularly the SGA twins. The growth parameters of LBW twins and LBW matched singletons showed no significant difference. The intelligence of twins was normal at four years.