Lasunadi Agada in Lootha Visha Chikitsa - A Review

Agadatantra had a golden time period in Kerala, and was known in the name of Visha chikitsa. There were excellent Visha vaidhyas who used to treat extreme venomous conditions and even predict the condition of patient just through the Dootha lakshana. As a part of these practices, there were numerous textbooks on Visha chikitsa with unique and exclusive Yogas. Some of the books got maintained, and many got ruined. Among those only few practices are still in use in the management if Visha and still many are untouched. Prayoga samucchaya is a well-known traditional Keraleeya Visha chikitsa textbook written by renowned King Kochunni thamburan, which explains the concepts of Visha and its detail management. Lootha visha is a most frequent and important clinical condition that which a physician encounters in their daily practice. It has got importance in all the time, as its manifestation is in such a way that improper handling of the case may worsen the presentation. There many Agada yogas mentioned in the management of Lootha visha. Lasunadi Agada is a simple yoga explained in Prayoga samucchaya, which contains only 6 drugs, explained in the context of Lootha samanya chikitsa as Pana and Nasya. Presently this yoga is practicing in the name of Lasunadi gulika. So this paper is an attempt to review on the formulation Lasunadi Agada.

Probable Mode of Action of Panktiprasoonadi Ghritham in Vishaja Vrana Based on Analysis of Rasa Panchaka of Ingredients

Traditional management of Visha Chikitsa involves many practices that are yet to be explored. Keraleeya Visha Chikitsa Granthas possess abundant knowledge of practically used formulations in treatment of Visha as well as its complications. Vishaja Vrana can be considered as Aganthuja Vrana which has to be managed at time to prevent its complications. Vrana hara Yogas with specific indication will be working more effectively in this condition. Visha Jyotsnika, a book written in Malayalam which explains about the treatment practices followed by Visha Vaidyas from time to time in a practicable approach. Mandali Visha Chikitsa is explained in sixth chapter in detail along with various Vranahara yogas. This article highlights about the probable mode of action of Panktiprasoonadi ghritham in Vishaja Vrana. Dasa Pushpa, the divya aushadhi for Visha being the main ingredient in this formulation along with the combination of other Vrana Ropana drugs like Kupilu, Haridra, Yastimadhu, Sariva etc as a Ghrita preparation will be an excellent option for managing Vishaja Vrana from its initial condition.

Study of immunogenicity, safety and efficacy of covishield vaccine among health care workers in a tertiary cardiac care centre

Purpose: The pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) might be curtailed by vaccination. We assessed the safety, and immunogenicity of Covishield vaccine among Health care workers (HCWs) in a tertiary cardiac care centre. Methods: It's a prospective analytical study, conducted at Sri Jayadeva Institute of cardiovascular science and research centre, Mysore, between January 2021 to May 2021. Pre and Post vaccination SARS CoV2 IgG antibodies were assessed among 122 HCWs. Interval between two doses in this study were 4 and 6 weeks. Adverse events following immunisation b(AEFI) and efficacy were assessed and followed up for two month post vaccination. Results: Post vaccination seropositivity was 69.67% in overall study participants. Seropositivity and P/N ratio median value in uninfected and infected group were 60.43% (n ¼ 55),3.47 (IQR: 2.56–5.22) and 96.77% (n ¼ 30),9.49 (IQR: 7.57–12.30) respectively (P < 0.001). Seropositivity and P/N ratio after 4 and 6 weeks were 48.3% (n ¼ 60), 2.95 (IQR: 1.91–4.24), and 83.8% (n ¼ 31), 4.88, (IQR: 3.39–6.43) respectively (P < 0.001). AEFI after first and second dose was 72.9% and 27.8% (p < 0.05) respectively. The most common symptoms after both doses of vaccination were local pain (73% & 88.2%), followed by fever (38.2% & 26.5%). The average duration of symptoms in both doses was 1.75 days. Of 122 participants only 10 (8.19%) had breakthrough infection after two doses of vaccination with mild severity. Conclusion: Covishield vaccine has showed seropositivity of 69.67%.It has acceptable level of safety profile. Seropositivity and P/N ratio has increased with increase in interval between two doses. Though it has not prevented breakthrough infection it has certainly reduced the severity of infection.

Once in a blue moon: A rare case of Duchenne muscular dystrophy complicated by COVID-19

Patients suffering from Duchenne Muscular Dystrophy (DMD) are at higher risk of suffering significant morbidity resulting from COVID-19, considering their pre-existing respiratory insufficiency and immunocompromised state. We present such a case who was admitted to our intensive care unit. A 21-year-old patient, who was a diagnosed case of DMD since the age of 8 and on treatment with steroids, angiotensin-converting enzyme inhibitors, and intermittent home-oxygen support, presented with fever and breathlessness and was diagnosed to have COVID-19 pneumonia. Oxygen support was provided by non-invasive ventilation (NIV), along with therapeutic and supportive treatment, namely, azithromycin, remdesivir, dexamethasone, and heparin. Dyselectrolytemia was corrected and convalescent plasma was transfused. The patient was weaned off NIV and discharged on significant improvement in his general condition. Although the treatment of COVID-19 using convalescent plasma has now fallen out of favor, we found some clinical improvement in our patient. DMD complicated by COVID-19 can seem like a daunting challenge, but providing fundamental, yet, simple treatment measures goes a long way in the patient care

A study on maternal factors affecting low birth weight in institutional deliveries

Background: Low birth weight is defined as birth weight below 2500 mg. WHO states prevalence of LBW is 26%. LBW babies are more prone for neonatal morbidity and mortality. 1) To assess various factors like maternal age, height, education, socioeconomic status on the birth weight of the baby. 2) To assess obstetric factors like parity, gestational age, antenatal care, anemia, hypertension on the birth weight of the newborn.Methods: A hospital bound cross sectional study done at the tertiary care centre. Study was done for a period of 2 months from 1st June to 30th July 2019 in Adichunchanagiri Institute of Medical Sciences and Research Hospital a rural medical college in Karnataka. Maternal data were collected and baby weight was recorded soon after birth on weighing scale.Results: There were 65 births during the study period. There were 13 babies weighing less than 2500 gm. Prevalence of LBW was 20%. 43.47% mothers were aged between 18 to 25 years and 7.14% were more than 25 years. 30.4% mother’s height was between 140 to 150 cm and 14.2% were more than 150 cm. Regarding maternal education, 15.3% degree, 24.1% PUC, 15% High school and 33.3% were primary school level. Regarding socioeconomic status 22.2% low, 25% lower middle, 18.7% middle class, 18.7% belonged to upper middle class. Regarding gestational age 50% were <37 weeks, 15.5% between 37-42 weeks, 10% were 42 weeks.73.8% women had normal BP, 21.5% were prehypertensive, 4.6% had PIH.Conclusions: Low birth weight is one of the important factors in infant morbidity and mortality. Maternal health was important factor in delivery of low birth babies. Maternal height, sex of baby, mode of delivery has no role in low birth weight babies.

Molecular Method of Detection of Primary Endodontic Infection- An Ex Vivo Study.

The removal of microorganism and debris from the root canal system is the prerequisite for success of treatment. This can be achieved by thorough cleaning, shaping and disinfection of the root canal system. The aim of the present study is to investigate the presence of microorganism in primary endodontic infection in South Canara population using PCR technique.METHODSFifty patients with primary endodontic infection were selected for the study. Access cavity preparation was done followed by working length determination and first sample was collected by placing the paper point near the root apex for 1 min and immediately the samples were placed in Tris-EDTA buffer solution, stored at -200 C, followed by PCR analysis of the sample using specific primers for detection of microorganisms.RESULTSA total of 50 cases with primary endodontic infection were analysed for the presence of microorganism within the root canal system. Percentage analysis was done, and the positive results were obtained only for Porphyromonas endodontalis in 50 % of cases.CONCLUSIONSPorphyromonas endodontalis was the prevalent organism seen in primary endodontic infection in this particular geographic distribution.

A prospective study of role of doppler in pregnancy and the perinatal outcome

Background: The development of doppler ultrasonographic technology has provided an opportunity to obtain a qualitative and quantitative assessment of maternal and foetal circulation using a non-invasive method. It has been proved by many studies that doppler has a very important role in screening of high-risk pregnancies. Objective of this study was to evaluate the role of colour doppler study in normal and high-risk pregnancy in relation to perinatal outcome.Methods: A prospective study was done including 75 women with high risk pregnancy and 75 normal pregnant women during the period October 2018 to September 2019 in hospitals attached to Bangalore Medical College and Research Institute. Doppler examination was done after recording patients’ history, clinical examination and ultrasound. Results were analysed and conclusions were made.Results: Out of the 22 patients with PIH, 20 patients had abnormal umbilical artery S/D ratio and all 22 had abnormal MCA PI. Out of 12 patients with diabetes, 10 had abnormal umbilical artery S/D ratio. All the patients with IUGR had abnormal umbilical artery S/D ratio and abnormal MCA PI.Conclusions: Colour doppler flow velocimetry done repeatedly can predict adverse foetal events with a great degree of accuracy.

First and second trimester bleeding and pregnancy outcome: a prospective study in a tertiary government hospital

Background: Bleeding in first and second trimester of pregnancy is one of the common complications of pregnancy. there is evidence from various prospective and retrospective studies that first and second trimester vaginal bleeding which continue with pregnancy is associated with adverse pregnancy outcome, including preterm delivery, low birth weight babies, perinatal death and congenital anomalies. Objective of this study was to know the outcome of pregnancies who have bleeding in first and second trimester of pregnancy.Methods: This study was prospective study done in the department of obstetrics and gynaecology, Vanivilas Hospital, Bangalore from September 2018 to August 2019.Results: This study concludes that I trimester vaginal bleeding are at increased risk of abortion than in II trimester vaginal bleeding. Risk of placenta previa was more in II trimester vaginal bleeding than in I trimester vaginal bleeding.Conclusions: This study concludes that I trimester vaginal bleeding are at increased risk of abortion than in II trimester vaginal bleeding. Risk of placenta previa was more in II trimester vaginal bleeding than in I trimester vaginal bleeding. Bleeding in I trimester and II trimester call for special attention in view of increased risk of preterm birth and perinatal death. Recognition of these association will be useful for detection and follow up of pregnancies being at high risk.

The Non-Motor Symptom Profile of Progressive Supranuclear Palsy

Objective@#Non-motor symptoms (NMSs) significantly contribute to increased morbidity and poor quality of life in patients with parkinsonian disorders. This study aims to explore the profile of NMSs in patients with progressive supranuclear palsy (PSP) using the validated Non-Motor Symptom Scale (NMSS). @*Methods@#Seventy-six patients with PSP were evaluated in this study. Motor symptoms and NMSs were evaluated using the PSP Rating Scale (PSPRS), Unified Parkinson’s Disease Rating Scale-III, Montreal Cognitive Assessment, Hamilton Depression (HAMD) and Anxiety Rating Scales, Parkinson’s Disease Sleep Scale (PDSS) and NMSS. NMS severity and prevalence were also compared between patients with PSP-Richardson syndrome (PSP-RS) and those with PSP-parkinsonism. @*Results@#All subjects in this cohort reported at least 2 NMSs. The most prevalent NMSs in patients with PSP were in the domains of sleep/fatigue, mood/cognition, and sexual function. The least prevalent NMSs were in the domains of cardiovascular including falls, and perceptual problems/hallucinations. Significant correlations were observed between the NMSS scores and HAM-D, PDSS, PSPRS scores and PSPRS sub-scores. The severity of NMSs was unrelated to the duration of illness. Patients with PSP-RS reported a higher severity of drooling, altered smell/taste, depression and altered interest in sex and a higher prevalence of sexual dysfunction. @*Conclusion@#NMSs are commonly observed in patients with PSP, and the domains of sleep, mood and sexual function are most commonly affected. These symptoms contribute significantly to disease morbidity, and clinicians should pay adequate attention to identifying and addressing these symptoms.

A study on peripartum hysterectomy in a tertiary referral government hospital

Background: Emergency peripartum hysterectomy (EPH) is a major surgical venture invariably performed in the setting of life-threatening haemorrhage during or immediately after abdominal and vaginal deliveries. Aim of the study was to study the frequency and indications for peripartum hysterectomy and to assess the maternal outcome of peripartum hysterectomy.Methods: Cross sectional study was done in the department of obstetrics and gynaecology, Vanivilas hospital, Bangalore from September 2018 to august 2019. This study consists of 24 cases of emergency peripartum hysterectomy within 24 hours of delivery, operated at Vanivilas hospital.Results: The frequency of peripartum hysterectomy was 1.102/1000 deliveries and following caesarean section and vaginal deliveries are 3.544/1000 deliveries and 0.248/1000 deliveries respectively. Among 24 cases who had peripartum hysterectomy, 16 cases were delivered by caesarean section and 4 cases delivered by vaginal route while another 4 cases delivered by laparotomy for rupture uterus. 22 cases (91.67%) survived with major number of cases having morbidities and there were 2 (8.33%) maternal death.Conclusions: The most common mode of delivery before peripartum hysterectomy was Caesarean section. The most common indication was atonic postpartum haemorrhage. Better protocols for induction and augmentation of labour will decrease the necessity of peripartum hysterectomies.

A Clinical Study To Evaluate The Combined Effect Of Virechana Karma, Ardraka Khanda And Amruta Rajanyadi Kashaya In The Management Of Sheetapitta Vis-à-vis Chronic Urticaria

Sheetapitta is a clinical condition caused due to vitiation of Tridosha mainly by the contact of Sheetalavayu. It is characterized by Varati Damstravat Shotha (wheals), Kandu (itching), Daha (burning sensation), Toda (pricking pain), Jwara (fever) and Chardi (vomiting). Sheetapitta analogous to urticaria of western medicine. Urticaria is a vascular reaction pattern characterized by transient, erythematous and edematous wheals or papules of varying sizes and shapes which are usually pruritic. Episodes lasting more than 6 weeks are regarded as chronic urticaria. Present study is a single group open clinical trial with pre and post-test design with a sample size of 33 subjects. The diagnosis was based on the signs and symptoms of Sheetapitta vis-à-vis chronic urticaria and the assessment was based on Urticaria Activity Score which includes wheals and itch as its parameter. Subjects were administered with Virechana Karma followed by Ardraka Khandawith Amruta Rajanyadi Kashaya as Anupana for 30 days after Virechana Karma. The result obtained after the completion of intervention showed statistically highly significant with the P value 0.001 and also overall clinical improvement showed significant result in reducing the signs and symptoms of Sheetapitta vis-à-vis chronic urticaria. Sheetapitta being Tridoshajanya, Virechana Karma helped in Tridosha Nirharana (expelling dosha). Ardraka Khanda being Agnideepaka (appetiser), Sheeta Pittahara (disease pacifying action) and Rasayana (rejuvinator) followed by Amruta Rajanyadi Kashaya which is Kapha-Pitta Hara, Dahahara (reducing burning sensation) and Kanduhara (anti-itch) properties pacified the signs and symptoms of Sheetapitta. In combination of both Virechana Karma and Ardraka Khanda with Amruta- Rajanyadi Kashaya, majority of the subjects attained pacification of urticarial wheals and itching.

Spectrum of neurological disorders during pregnancy and postpartum period from a tertiary hospital

Background: Pregnancy and puerperium are states of hypercoagulability. This predisposes women in these phases to increased risk of cerebrovascular diseases. These neurological complications are important causes of maternal and foetal morbidity and mortality. These must be recognized and managed to decrease their burden on maternal and child health.Methods: The aim of this study was to consider the occurrence of neurological complications in pregnancy and puerperium and to analyse the clinical and radiological spectrum of them. This was a prospective study carried out with 1200 patients from January 2014 to August 2015.Results: Of the 1200 women, 87(7.25%) were diagnosed to have neurological complications. Overall mortality was 11.4%. Eclampsia (63.2%), Cerebral Venous sinus Thrombosis (CVT) (18.3%) and Posterior Reversible Encephalopathy Syndrome (PRES) in (8%) accounted for the majority of cases (Table 1). Eclampsia carried a significant mortality rate of 12.7% whereas CVT and PRES had favourable outcomes. Imaging of CVT revealed involvement of deep venous system in 12% and haemorrhagic infarcts in 69%.Conclusions: The commonest neurological complications seen in this cohort were eclampsia, cerebral venous thrombosis and posterior reversible encephalopathy syndrome. Hence a physician needs to bear in mind the common neurological complications that can occur during pregnancy and puerperium to avert poor pregnancy outcomes for both mother and child.

A prospective study of thyroid dysfunction in dysfunctional uterine bleeding

Background: Dysfunctional uterine bleeding is abnormal uterine bleeding in the absence of any palpable pelvic pathology and demonstrable extra genital causes. Thyroid dysfunction is the systemic disease most often associated with abnormal uterine bleeding. Aim was to evaluate thyroid function test in women with DUB; to assess bleeding pattern in thyroid dysfunction.Methods: Prospective observational study was done in the department of obstetrics and gynaecology, Vanivilas hospital, Bangalore from august 2018 to July 2019. Pre structured and predesigned proforma filled. All routine blood investigations including serum T3, T4, TSH, USG were advised. These patients were categorized as euthyroid, subclinical hypothyroid, hypothyroid or hyperthyroid based on thyroid profile.Results: 0.5% belonged to the age group of 31-40 years, prevalence of subclinical hypothyroidism is 11%, there were 5.5% of cases of hypothyroidism and 1.5% case of hyperthyroidism.Conclusions: Thyroid screening must be done mandatory for all the cases of DUB and prompt response to treatment with thyroxine would avoid unnecessary surgeries, hormonal treatment, and associated comorbities.

Correlation of serum creatine phosphokinase and serum cholinesterase in organophosphate poisoning in children

Background: Organophosphate (OP) poisoning is one of the most common pesticide poisoning in India in adolescents because of its easy availability. Serum pseudocholinesterase levels are commonly used to assess the severity and to know the prognosis in OP compound poisoning. Serum creatine phosphokinase (CPK) levels is another lab parameter which gets deranged in OP poisoning and has been tried in adults to assess the severity and to know the prognosis.'Authors objective was to study the correlation of serum pseudocholinesterase and serum CPK in organophosphate poisoning at admission and to compare outcome with serum CPK levels.Methods: All the children in the age group of 1 month to 18 yrs, who were admitted with the history of suspected OP compound poisoning were enrolled for the study. Estimation of cholinesterase and CPK levels were done at admission and after 1 week. Patients were categorised in to latent, mild, moderate and severe cases based on the S. Cholinesterase levels. These values were analysed to see the correlation.Results: Among 34 OP poisoning cases,13(38%) were males and 21(62%) were females. Mean age of study population was12.6+4.25 yrs. The median CPK values in latent, mild, moderate and severe cases were 121.5 IU/L,276.5 IU/L, 308IU/L and 467IU/L respectively (p=0.015). Spearman's rho Correlation coefficient was -0.522 between S. Cholinesterase and S CPK at admission which was significant. The median serum CPK level after 1week in non survivors was 2498.0IU/L and in survivors was 201.0IU/L (p0.014).Conclusions: There was a strong negative relationship between serum cholinesterase and serum CPK at admission in OP poisoning. Follow up values at 1 week showed that significantly high serum CPK and low cholinesterase, which was also significant and was associated with mortality.

Efficacy Of Nasya Karma With Kukkutanda Pinda Sweda And Nasya Karma In The Management Of Manyasthambha W.s.r To Cervical Spondylosis – A Comparative Clinical Study

Cervical Spondylosis is a common spinal problem now days. It is a general term for age related wear and tear affecting spinal disc of the neck. Normally soft disc between vertebras provides cushioning, with Cervical Spondylosis the disc becomes compressed, when this happens the cartilage can wear away. Once this protective cartilage is gone, spur may develop on your vertebrae where they rub together and the nerves attached to spinal cord will have less room to pass between the vertebras. Cervical Spondylosis usually starts earlier in men than women. Usually it doesn’t lead to disability but sometimes these changes in the spine can cause compression which makes the finger clumsy. In Karnataka incidence and prevalence is 7.25 cases per 1000 populations and in Bangalore prevalence of Cervical Spondylosis is 23.25 per 10000 populations. Cervical Spondylosis can be compared to Manyasthambha mentioned in the classics. Divaswapna, Asamasthana, Vivrutho Urva nirikshana are the main causes leading to Manyasthambha. Ruk and Sthambha are the main Lakshanas of Manyasthambha. Considering these Lakshanas along with radiation of pain and Motor activity as the assessment parameters, Nasya Karma and Swedana were adopted in the study, which showed highly significant result in almost all parameters with p value < 0.001 taken for assessment in the group.

A prospective clinical study to evaluate the correlation of duration of kangaroo mother care and weight gain in low birth weight babies

Background: Kangaroo Mother Care (KMC)' is an alternative to conventional neonatal care for low birth weight (LBW)' babies' in low resource settings, this study is to evaluate the correlation between the duration of KMC given and average weight gain per day in low birth weight babiesMethod: It is an observational study, 106 low birth weight babies who were less than 1.8 kg, hemodynamically stable, accepting either direct breast feed or gavage feed were included in the study, duration of KMC given per day and weight was recorded daily until discharge. Babies were monitored for complications, if any' babies were withdrawn from the study , necessary intervention was done. Average weight gain per day in these babies was estimated and correlated with the average duration of KMC.Results: Out of 120 eligible children 106 were selected for study of which 57 were male and 49 were female, 42 were 'less than 1.2 kg, 37 were between 1.21 kg to 1.5 kg and 27 were between 1.51 kg to 1.8 kg, there was statistically significant moderate correlation with Pearson r=0.6281 with p value <0.00001 and mean average weight gain was 5.27 in less than '6 hr' to 8 hr, 9.08 in 8 hr to 10 hr, 11.87 in greater than 10 hrs of KMCConclusion: The weight gain was found to increase with duration of KMC practice. hence authors recommend to increase the duration of KMC per day for the good average weight gain per day.

Rare case of an angiectatic sinonasal polyp feigning malignancy

Angiectatic sinonasal polyps are uncommon. However, riveting nature of this polyp lies in its clinical presentation mimicking a neoplasm. It is radiologically very challenging to pick up this lesion in spite of its characteristic findings on imaging. Histopathology is paramount for asserting diagnosis. We report a rare case of a patient who presented to our outpatient department with chief complaints of nasal block, nasal discharge, and epiphora for 6 months. On examination, a mass was found filling the left nasal cavity. Computed tomography scan and diagnostic nasal endoscopy were suggestive of fungal sinusitis or sinonasal malignancy as a differential diagnosis. Biopsy was reported as benign sinonasal polyp. The patient underwent endoscopic resection of the mass, which on histopathology revealed the diagnosis of an angiectatic sinonasal polyp

Complications of laser and light-based devices therapy in patients with skin of color

Lasers and light-based devices are indispensable to an aesthetic dermatology practice. The growing popularity of lasers has been matched by a sharp increase in the incidence of complications. The Indian skin with its high melanin content is more prone to injury and careful setting of laser parameters, early detection of complications and immediate therapy are vital to avoiding permanent sequelae. We review the various complications that occur during laser procedures and their management.

A Clinical Study On Erandamula Ksheera Basti In The Management Of Vataja Gridhrasi W.s.r To Sciatica

Now a day抯 large number of population are suffering from low backache because of lifestyle modification, irregular sitting posture and house hold works. Low backache is a common symptom involving the muscles, nerves and vertebral column. Sciatica refers to pain that radiates along the path of Sciatic nerve. It resembles disease 揋ridhrasi� in Ayurveda. Radiating pain is the predominant symptom with stiffness, which will hamper the daily activity of an individual. The purpose of the study is to evaluate the efficacy of Erandamula Ksheera Basti in Vataja Gridhrasi. A total 10 patients of Vataja Gridhrasi were administered Erandamula Ksheera Basti in Yoga Basti pattern for 8 days. Vataja Gridhrasi lakshanas and SLR Positive were taken as assessment parameters, which showed significant results. Hence, Erandamula Ksheera Basti has better effect on patients of Vataja Gridhrasi.

RAPDx Expanded Pupil Diagnostics: A new Dimension in Pupil Evaluation.

Introduction: Relative afferent pupillary defect (RAPD) is an imperative sign to assess the retinal and optic nerve function. However, RAPD is subjective, so leads to discrepancies and hence there is the need for a precise quantification of the same. Materials and Methods: 80 subjects were enrolled in the study, pupillary reactions were measured using RAPDx Expanded Pupil Diagnostics (Konan Medical USA, Inc., Irvine, CA, USA) and were compared with neutral density filter (NDF) (Gulden Ophthalmics) and swinging flashlight test. Results: The mean pupillary reactions assessed on NDF was less than 0.3 log units and that assessed on RAPDx was 0.28 log units (P<0.001 spearman’s coefficient). Conclusion: RAPDx is comparable to NDF and may be used as a screening tool in Ophthalmology clinic, and gives an accurate and precise quantification of pupillary responses.