Pain and Physiological Stress During Minimally Invasive Surfactant Therapy (MIST) in Very Preterm Infants

Objectives: To evaluate the pain or physiological stress caused during minimally invasive surfactant therapy (MIST) to very preterm neonates. Methods: In this prospective observational study conducted in a tertiary NICU, very preterm neonates were assessed for pain using Premature Infant Pain Profile-Revised (PIPP-R) score before, during and after MIST. Changes in the heart rate and oxygen saturation were also recorded during the procedure. Results: 23 neonates who received MIST were assessed for pain using PIPP-R. Mean (SD) PIPP-R score during MIST was 3.87(1.3), before; 12.83 (1.9), during; and 6.26 (1.0), after the procedure, respectively (all P<0.001). Heart rate and oxygen saturation were also significantly reduced during MIST (P<0.001). Conclusion: The high PIPP-R scores during surfactant administration suggest that MIST can cause moderate to severe pain/discomfort and significant physiological stress in very preterm infants.

Assessment of QT Interval Abnormalities on Electrocardiogram in Children With Breath-Holding Spells

Objective: To assess QT interval abnormalities among children with breath-holding spells. Methods: This case control study included 204 children (104 cases of breath-holding spells and 100 healthy children) younger than 3 years. Breath-holding spells were evaluated for age of onset, type (pallid/cyanotic), triggering factors, frequency and presence of family history. Twelve- lead surface electrocardiogram (ECG) was analyzed for QT interval (QT), corrected QT interval (QTc), QT dispersion (QTD) and QTc dispersion (QTcD) in milliseconds. Results: The mean (SD) QT, QTc, QTD and QTcD interval in milliseconds were 320 (0.05), 420 (0.07), 61.15 (16.20), 102.3 (17.24), respectively for breath-holding spells as compared to control group [300 (0.02), 370 (0.03), 38.6(14.28), 78.6 (14.28), respectively] (P<0.001). Similarly, pallid breathholding spells had prolonged mean (SD) QT, QTc, QTD and QTcD interval in milliseconds [380 (0.04), 520 (0.08), 78.88 (10.78), 123.33 (10.28), respectively] as compared to cyanotic spells [310 (0.04), 400 (0.04), 57.44 (14.64), 97.90 (15.03), respectively] (P<0.001). The mean QTc interval was 590 (0.03) and 400 (0.04) milliseconds in prolonged and non-prolonged QTc group, respectively (P<0.001). Conclusion: Abnormal QT, QTc, QTD and QTcD were observed among children with breath-holding spells. ECG should be strongly considered, especially in pallid, frequent spells occurring at younger age and having positive family history, to identify long QT syndrome.

Prevention and management of childhood progressive myopia: National consensus guidelines

Myopia is a major public health problem worldwide, including India, with the global prevalence of myopia increasing rapidly over decades. The clinical and socioeconomic impact of myopia is also expected to rise with rising prevalence. Therefore, the focus has now been shifted to prevent the incidence and progression of myopia. However, there is lack of any standardized guidelines for myopia management. This document aims to generate a national-level expert consensus statement on the management of childhood myopia in the Indian scenario. The expert panel of pediatric ophthalmologists consisted of 63 members who met in a hybrid meeting. A list of topics deliberating discussion in the meeting was provided to the experts in advance and they were instructed to provide their opinions on the matter during the meet. The panel of experts then gave their views on each of the items presented, deliberated on different aspects of childhood myopia, and reached a consensus regarding the practice patterns in the Indian scenario. In case of opposing views or lack of a clear consensus, we undertook further discussion and evaluated literature to help arrive at a consensus. A written document is prepared based on recommendations explaining definition of myopia, refraction techniques, components and methods of workup, initiation of anti-myopia treatment, type and timing of interventions, follow-up schedule, and indications for revised or combination treatment. This article formulates evidence-based guidelines for progressing myopes and pre-myopes and also establishes uniformity in the management of childhood myopia in the country.

Acute abducens nerve palsy with acute disseminated encephalomyelitis-like presentation following COVID-19 vaccination

We report two adult cases of abducens nerve palsy presenting immediately (within weeks) after they received the first dose of Covishield vaccination. Magnetic resonance imaging (MRI) of the brain obtained after the onset of diplopia demonstrated demyelinating changes. The patients had associated systemic symptoms. Post-vaccination demyelination typically known as acute disseminated encephalomyelitis (ADEM) associated with several vaccines is more common in children. Although the mechanism of the nerve palsy remains unclear, it is suspected to be related to the post-vaccine neuroinflammatory syndrome. Cranial nerve palsies and ADEM-like presentations may represent part of the neurologic spectrum following COVID-vaccination in adults, and ophthalmologists should be aware of these sequelae. Although cases of sixth nerve palsy following COVID vaccination are already reported, associated MRI changes have not been reported from India.

Evaluation of optical coherence tomography angiography changes in nonarteritic anterior ischemic optic neuropathy

Purpose: To study the long?term microvasculature changes at the macula and the optic disk in eyes with nonarteritic anterior ischemic optic neuropathy (NAION). Methods: Patients with acute NAION of less than 6 weeks duration were included. Optical coherence tomography angiography (OCTA) of the macula and the optic disk was performed at baseline, 3 and 6 months and compared with the controls. Results: The mean age of 15 patients was 52.25 (±9.06) years. The whole image superficial peripapillary density (42.49 ± 5.28) was significantly low when compared to that of control eyes (46.36 ± 2.09); similarly, radial peripapillary capillary density (49.35 ± 5.64) was also significantly reduced when compared to controls (53.45 ± 1.96, P < 0.05). These parameters showed significant progressive decrease at 3 and 6 months (P < 0.05). At the macula, both superficial (41.83 ± 3.64) and deep macular vasculature densities (47.30 ± 2.04) were significantly reduced when compared to control eyes (52.15 ± 4.84 and 55.13 ± 1.81, respectively). The vascular density at the macula remained stable at 3? and 6?months period. Conclusion: The study shows that the microvasculature in case of NAION is significantly reduced both in peripapillary area and in macular area.

Management of airway obstruction following lidocaine nebulization in a case of tracheal stenosis: case report

Abstract Stenting for lower tracheal stenosis is a tricky situation and for the safe conduct of anesthesia, it is imperative to maintain spontaneous respiration. Airway topicalization is routinely recommended for anticipated difficult airway. We report a case of upper airway obstruction following lidocaine nebulization in a patient to be taken for tracheal stenting for lower tracheal stenosis. We would like to highlight that close monitoring of the patient is advisable during airway topicalization to detect any airway obstruction at the earliest and how fiberoptic intubation can play a pivotal role to secure the airway in an emergency scenario.

5-Fluorouracil as a targeted lacrimal gland therapy for chronic Stevens-Johnson syndrome: A pilot study

Purpose: The surgical technique of periglandular 5?fluorouracil (5?FU) injection and its effects on the morphology and function of the main lacrimal gland of patients with severe dry eye disease due to Stevens–Johnson syndrome (SJS) are reported. Methods: 5?FU, as a potential antifibrotic agent, is given in the dose of 0.1 ml (50 mg/ml), subconjunctivally into the periglandular fibrosed area of the palpebral lobe of the main lacrimal gland. The injection is given using 30G needle into the subconjunctival plane and not into the substance of palpebral lobe. Results: Eight eyes (eight lobes) of seven chronic SJS patients (mean age, 32.5 years, <5 mm Schirmer) received the injection. All eight lobes demonstrated a visible reduction in the conjunctival congestion and scarring over the lobar area. The mean OSDI scoring improved from 65.3 to 51.1. Three patients with mean pre?injection Schirmer I values of 4 mm showed a mean change of 1 mm at four weeks following a single injection. The tear flow rate per lobe for the above three patients improved from 0.22, 0.12, and 0.16 ?l/min to 0.31, 0.12, and 0.21 ?l/min, respectively. Another patient with pre?injection Schirmer of 4 mm showed no change in tear flow. Three eyes with zero baseline Schirmer values (no visible secretory opening) had no improvement in tearing or ocular surface staining. Conclusion: Local 5?FU injection alters morphology of the conjunctiva overlying the palpebral lobe in SJS patients, but fails to show any significant effect on tear secretion.

Aqueous-deficient dry eye disease: Preferred practice pattern guidelines on clinical approach, diagnosis, and management

Dry eye disease (DED) is a broad term that includes a diverse group of clinical disorders. Aqueous-deficient dry eye (ADDE), a subtype of DED, is characterized by decreased tear production by the lacrimal gland. It can be seen in up to one-third of individuals with DED and can be comorbid with a systemic autoimmune process or occur secondary to an environmental insult. Since ADDE can be a source of long-term suffering and severe visual impairment, early identification and adequate treatment are imperative. Multiple etiologies can underlie ADDE, and it is critical to identify the underlying cause to not only improve the ocular health but also to improve the overall quality of life and well-being of affected individuals. This review discusses the various etiologies of ADDE, highlights a pathophysiology-based approach for evaluating underlying contributors, outlines various diagnostic tests, and reviews treatment options. We present the current standards and discuss ongoing research in this field. Through this review, we propose a treatment algorithm that would be useful for an ophthalmologist in diagnosing and managing individuals with ADDE.

Dry eye disease and risk factors for corneal complications in chronic ocular graft-versus-host disease

Purpose: The current study was carried out to evaluate the clinical features and management outcomes of dry eye disease (DED) in chronic ocular GvHD following allogenic hematopoietic stem cell transplantation (HSCT). Methods: A retrospective review of consecutive patients diagnosed with chronic ocular GvHD between 2011 and 2020 was performed at a tertiary eye care network. Multi?variate regression analysis was carried out for identifying risk factors associated with progressive disease. Results: A total of 34 patients (68 eyes) with a median age of 33 years [inter?quartile range (IQR) 23–40.5] were studied. The most common indication for HSCT was acute lymphocytic leukemia (26%). Ocular GvHD developed at a median of 2 years (IQR 1–5.5 years) after HSCT. Aqueous tear deficiency was present in 71% of the eyes, of which 84% had a Schirmer value of <5 mm. The median visual acuity at presentation and that after a median follow? up of 6.9 months were comparable at 0.1 log minimum angle of resolution (logMAR) (P = 0.97). Topical immunosuppression was required in 88% of cases, and with this, improvement in corneal (53%, P = 0.003) and conjunctival staining scores (45%, P = 0.43) was noted. A progressive disease was present in 32% with persistent epithelial defects being the most common complication. Grade 2 conjunctival hyperemia [odds ratio (OR): 2.6; P = 0.01] and Schirmer’s value <5 mm (OR: 2.7; P = 0.03) were found to be associated with progressive disease. Conclusion: Aqueous deficient DED is the most common ocular manifestation of chronic ocular GvHD, and the risk of the disease progression is greater in eyes with conjunctival hyperemia and severe aqueous deficiency. Awareness among ophthalmologists of this entity is essential for its timely detection and optimal management.

Single-nucleotide polymorphism and haplotype analysis of macrophage migration inhibitory factor gene and its correlation with serum macrophage migration inhibitory factor levels in North Indian psoriatic patients with moderate disease severity: A cross-sectional study

Background: Psoriasis is associated with significant morbidity and impaired quality of life. Identification of the host genes that influence disease susceptibility and can potentially guide future, targeted therapy is the need of the hour. Aims: The aim of the study was to investigate the associations of macrophage migration inhibitory factor (MIF) gene polymorphisms, that is, a 5–8-CATT tetra nucleotide repeats at -794 (-794*CATT5–8) and a single-nucleotide polymorphism at -173 (-173*G/C) with the risk of chronic plaque psoriasis and to observe the correlation, if any, of disease determinants with genetic functional variants and circulating MIF levels. Methods: Five hundred and seventeen individuals (265 psoriasis patients and 252 controls) were genotyped for MIF gene polymorphisms. Data were analyzed with respect to disease susceptibility, serum MIF levels, disease severity, age at onset, disease duration and presence of comorbidities. Results: The presence of co-morbidities was more frequently noted in patients with late onset disease (P = 0.01). No statistically significant differences were observed either in genotype (P = 0.680) or allele frequency (P = 0.69) with respect to distribution of MIF-173*G/C polymorphism between patients and controls. The frequencies of genotypes -794*CATT 5/7 and 7/7 were significantly lower in patients (P = 0.027* and 0.038*, respectively). CATT*5/MIF-173*C haplotype occurred at a higher frequency in patients (odds ratio 3.03, 95% confidence intervals 1.09–8.47, P = 0.02). The mean serum MIF levels were significantly higher in patients as compared to controls (P < 0.001). The presence of either extended MIF -794*CATT repeats or C allele did not reveal any significant association with serum MIF levels or age at onset. Analysis of effect of various disease determinants revealed no significant association with genetic variants and serum MIF levels. Limitations: The lesional expression of MIF could not be studied. Conclusion: Our results showed that CATT*5/MIF-173*C haplotype is associated with increased susceptibility to psoriasis vulgaris.

A Conceptual Recapture of Stanya Kshaya and Role of Stanya-Janan Mahakashaya in its Management

Breast milk is the prime source of nourishment and immunity of the baby. Stanya Kshaya, which appears to be a fairly simple ailment but is really problematic for children's health, is one of the problems of present era. Lactation insufficiency is 30–40% prevalent in Asian and tropical nations like India. In Ayurveda certain herbs are specifically indicated for increasing breast milk and Acharya Charaka has described Stanya-janana Mahakashaya for it. Few explorations have been conducted regarding above, but no one has covered all aspects comprehensively thus this paper aim to collect and comprehensive review information available regarding concept of Stanya, its Kshaya and role of Stanya-janana Mahakashaya in its management. Methodology: This review is in a narrative format and done from literature and publications relevant to Stanya Kshaya and role of Stanya-janana Mahakashaya. Results: Stanya has been described in detail along with opinion of various Acharyas, Stanya sampata and the reasons for Stanyakshya mentioned then finally role of Stanya-janana Mahakashaya of Acharya Charaka which includes 10 herbs as- Veerana, Shali, Shasthik, Ekshuvalika, Darbha, Kusha, Kaasha, Gundra, Ithkata, Katruna. Drugs in this Kashaya help in increasing quantity of milk. Discussion: Stanya-janana Mahakashaya has active principles which increase quantity of milk, so can be used in Stanya Kshaya and leads to healthy Stanya.

Early response to chemotherapy in children with Langerhans cell histiocytosis predicts long-term disease-free survival

Background: Langerhans cell histiocytosis (LCH) is a rare clonal malignancy of the monocyte-macrophage system. Patients with lesions in 搑isk organs� have significantly higher risk of mortality than patients with lesions limited to 搉on-risk� sites. The influence of early response to therapy on long-term survival in this heterogeneous multi-system disease was analyzed. Methods: During a 7-year period, we retrospectively analyzed the findings in 24 consecutive patients who required systemic chemotherapy for LCH [single system with multifocal bone involvement and multisystem involvement with or without risk organ (RO) involvement]. All patients were started on vinblastine and prednisolone. Progressive disease was treated with salvage protocols or targeted therapy. Positron emission tomography-computed tomography (PET-CT)/conventional CT based response assessment was performed at week 6 of chemotherapy, and if needed after week 12 of chemotherapy. Results: MFO bone, MS ROneg, and MS ROpos LCH was observed in 3, 4, and 17 patients, respectively. Age range of patients varied from 1 month�years (median = 18 months). The EFS and OS were 100% and 100% for MFO bone, 50% and 100%, respectively, for MS ROneg and 35% and 52%, respectively, for MS ROpos. OS was 93% and 100% for CR attained at 6 and 12 weeks respectively regardless of the risk status (P < 0.01). Conclusion: Rapid early response, that is, complete remission at 6 and 12 weeks was associated with significantly improved overall survival. In slow responders, early salvage with alternative regimens or targeted therapy may result in better outcomes

Evaluation of retinal function and morphology in isoametropic amblyopia

Purpose: To observe the photoreceptor anomalies in cases of ametropic amblyopia. Methods: A prospective study with 25 isoametropic amblyopic children in the age group of 5–14 years and 25 age?matched controls was done. Examination included refraction, best?corrected visual acuity (BCVA), and color vision. Adaptive optics (AO) and multifocal electroretinogram (mf?ERG) were done to assess the anatomy and function of photoreceptors. The subgroup analysis of the improved and non?improved groups was done. Results: The mean cone density in cases and control in the superior, temporal, and nasal quadrants was respectively as follows (21640 ± 5713, 24040 ± 3386, P = 0.01) (19755 ± 6282, 21832 ± 2911, P = 0.03) (19897 ± 5418, 22171 ± 3660, P = 0.01) (20768 ± 4799, 22819 ± 3241, P = 0.01). The amplitude of N1 wave and P1 wave in cases was significantly low compared to the controls. Cases with subnormal color vision had reduced BCVA (0.55 ± 0.018) in comparison to the children with normal response (0.350 ± 0.014). Cone density was also significantly reduced in children with subnormal color vision. Sixteen out of 25 cases showed BCVA improvement with spectacles. Baseline cone density was found to be significantly higher in the improved group. There was no correlation between BCVA and AO parameters. Conclusion: Patients with ametropic amblyopia show subnormal photoreceptor properties than controls. Low cone density may be associated with defective color vision and poor prognosis in these cases

Quality assurance of malaria rapid diagnostic tests: An aid in malaria elimination

Background & objectives: India targets malaria elimination by 2030 in a phased manner, so malaria’s assured diagnosis is crucial. Introduction of rapid diagnostic kits in India in 2010 has revolutionized malaria surveillance. The storage temperature of rapid diagnostic tests (RDTs), kit components and handling in transportations impact the results of RDTs. Therefore, quality assurance (QA) is required before it reaches end-users. The Indian Council of Medical Research-National Institute of Malaria Research (ICMR-NIMR) has a World Health Organization (WHO) recognized lot-testing laboratory facility to assure the quality of RDTs. Methods: The ICMR-NIMR receives RDTs from different manufacturing companies as well as various agencies such as National and State Programmes and Central Medical Services Society. The WHO standard protocol is followed to conduct all the tests, including long-term and post-dispatch testing. Results: A total of 323 lots tested during January 2014-March 2021 were received from different agencies. Amongst them, 299 lots passed the quality of test and 24 failed. In long-term testing, 179 lots were tested and only nine failed. A total of 7741 RDTs were received from end-users for post-dispatch testing of which 7540 qualified the QA test with a score of 97.4 per cent. Interpretation & conclusions: RDTs received for quality testing showed compliance with QA evaluation of malaria RDTs based on the protocol recommended by the WHO. However, continuous monitoring of the quality of RDTs is required under QA programme. Quality-assured RDTs have a major role, especially in areas where low parasitaemia of parasites persists.

Health Literacy and Clinic-Epidemiological Profile of Patients with COVID-19-Associated Mucormycosis: A Questionnaire-Based Study

Background: The patient partnership is desirable for the optimal management of comorbidities. This became significant more so during the coronavirus disease 2019 (COVID-19) crisis wherein health infrastructure was overburdened. Objectives?The aim of this study was to estimate the clinicoepidemiological profile, health literacy regarding predisposing risk factors, and disease management in patients with COVID-19-associated mucormycosis (CAMCR). Materials and Methods?A structured questionnaire-based study on randomly chosen 100 microbiologically proven patients of CAMCR, consisting of 38 multiple choice questions, was designed with each answer having a patient and assessor response to it. Results?A male predilection was seen (68%) with rhino-orbital (73%) being the commonest anatomic site. Forty-nine percent of the study participants had pre-existing diabetes of which 62% did not carry out regular blood sugar monitoring and in 18%, blood sugars were controlled prior to COVID-19. Thirty-five percent of patients with mild COVID-19 illness were treated with unwarranted steroids and 56% of patients had fluctuating blood sugar levels, during COVID-19 illness. Seventy-nine percent of patients were not vaccinated against COVID-19, 16% only partially vaccinated. Seventy-one percent of patients were not aware of red flag signs and of mucormycosis with 8% presenting early, on noticing nasal symptoms. Conclusion?This study observed diabetes as the most common comorbidity in patients with CAMCR. A lacuna in the health literacy of diabetics presenting with CAMCR was found. Additionally, knowledge regarding glycemic control during COVID-19 illness with or without the use of steroids and awareness of the “red flag” signs of CAMCR were mostly lacking. Interventions to improve awareness amongst patients with diabetes should help in optimal glycemic control, and avoid potential complications like severe COVID-19 illness, and mucormycosis

A cadaveric study of arteriovenous trigone of heart: the triangle of Brocq and Mouchet / 대한해부학회지

Left coronary artery divides into anterior interventricular branch and circumflex branch. As both the arteries run in their corresponding grooves, an arteriovenous trigone is formed between conus arteriosus and left auricle called triangle of Brocq and Mouchet. The triangle base is formed by great cardiac vein. This study aims to describe the frequency of triangle and its type and relationship between various boundaries and content of triangle and to supplement the existing knowledge of clinicians. This observational and descriptive study was conducted on 40 formalin fixed cadaveric hearts in department of anatomy, Kalpana chawla government medical college. The triangle was found in 92.5% of specimen with most common type being closed (51.3%) which is followed by inferiorly open in 35.1%, superiorly open in 8.1% and completely open in 5.4% hearts. Most frequent content of triangle was median artery followed by diagonal branches of anterior interventricular and circumflex branches. The mean area of the triangle was 246.3 mm2 . Relationship of vein with two arterial branches was either superficial or deep. The knowledge of different patterns of existence will be required for angiographic procedures. Further the triangle is a potential epicardial access route to left fibrous ring. Thus detailed knowledge of variations will help cardiologist to achieve better outcome in interventional procedures with minimal complications.

Assessment of Knowledge Regarding Furcation Defects among Dental Practitioners: A Multinational Survey

@#This study was undertaken to assess knowledge regarding furcation defects among dental fraternity. This is an open-ended, randomized, web-based cross-sectional multinational online survey. A total of 904 responses were gathered by sending 13 questions through a google form. Data were expressed in frequency and percentages. Chi-square test was performed to determine significant difference between gender, education level and variation between dentists of India and other countries. P value <0.05 was considered to be statistically significant. Present study had 650 dentists from India and 254 dentists from other countries. For overall knowledge regarding furcation, 90.7% (average of first and second question) of dentists had knowledge regarding furcation. There was no significant difference between males (range 54%-93%) and females (range 46%- 95%) (p>0.05) in terms of knowledge. Majority (88.7%) of post-graduates knew about the use of Nabers probe for furcation measurements and values were significant (p<0.05). Present study also revealed 65%-67% of undergraduates and post-graduates knew that Degree II furcation defects showed predictable periodontal regeneration, however values were non-significant (p>0.05). There was no statistical significance (p>0.05) between dentists of India and other countries. Dental fraternity in general had adequate knowledge regarding the furcation defects, their treatment modalities and expected complications.

Krill's disease: a newer management option

Purpose: To report a case of a young female who presented with scotoma in the right eye for few days. Case Report: Krill's disease or acute retinal pigment epithelitis (ARPE) is a self-limiting retinal disease with no specific treatment. Typical clinical and imaging features helped us to diagnose her with ARPE. Intravenous methylprednisolone (IVMP), which gives a rapid anti-inflammatory response, was advised. An SD-OCT scan post-injection showed a reduction in hyperreflectivity and height of lesion at day 3 and near total resolution by day 5. Conclusion: This case suggests rapid resolution of ARPE with the use of IVMP.