Development of an integrated telerehabilitation model in children with cerebral visual impairment in South India during the COVID-19 pandemic – A pilot study

Purpose: Coronavirus disease 2019 (COVID?19) pandemic affected the in?person rehabilitation/habilitation services in families with children with cerebral visual impairment (CVI) in India. This study aimed to develop a structured and family?centered telerehabilitation model alongside conventional in?person intervention in children with CVI to observe its feasibility in the Indian population. Methods: This pilot study included 22 participants with a median age of 2.5 years (range: 1–6) who underwent a detailed comprehensive eye examination followed by functional vision assessment. The visual function classification system (VFCS) was administered to the children and the structured clinical question inventory (SCQI) to the parents. Every participant underwent 3 months of telerehabilitation including planning, training, and monitoring by experts. At 1 month, the parental care and ability (PCA) rubric was administered to the parents. After 3 months, in an in?person follow?up, all the measures were reassessed for 15 children. Results: After 3 months of Tele?rehabilitation there were significant improvements noted in PCA rubric scores (P<0.05). Also, statistically significant improvements were noted in functional vision measured using SCQI and VFCS scores (P<0.05) compared to baseline. Conclusion: The outcomes of the study provide the first steps towards understanding the use of a novel tele?rehabilitation model in childhood CVI along?side conventional face?to?face intervention. The added role of parental involvement in such a model is highly essential.

Parental perception of facilitators and barriers to activity and participation in an integrated tele-rehabilitation model for children with cerebral visual impairment in South India – A virtual focus group discussion study

Purpose: This study utilized virtual focus group discussions to document the facilitators and barriers reported by the parents as part of the tele?rehabilitation service delivery model in India. Methods: This study included 17 participants who were enrolled into the Tele?rehabilitation program (16 mothers, 1 father) and the virtual focus group discussion (V?FGD) were conducted through a WhatsApp video call. Three V?FGDs were conducted involving two moderators and a note taker. The V?FGD, focused at extracting the perceptions of parents pertaining to facilitators, barriers and coping mechanisms to barriers related to the tele?rehabilitation model. Results: Thematic analysis resulted in four themes for barriers that included: family and support, time, parent and care taker, child and place of living related; facilitators reported included: continuous monitoring, accessibility to professional services, provision of resource materials and parental empowerment. Themes “family and support” and “child” were most reported by parents with children >3 years and ?3 years respectively. Finally, the barriers and facilitators were aligned with the chapters and codes of International Classification of Functioning, children and youth version (ICF?CY) environment and personal factors. Conclusion: This V?FGD highlights the importance of parental?centred and structured Tele?rehabilitation among children with CVI in India. The outcome of this study opens avenues for creating effective intervention.

Self-assembled multifunctional nanotheranostics against circulating tumor clusters in metastatic breast cancer

Circulating tumor clusters (CTC) disseminating from the primary tumor are responsible for secondary tumor formation where the conventional treatments such as chemotherapy and radiotherapy does not prevent the metastasis at locally advanced stage of breast cancer. In this study, a smart nanotheranostic system has been developed to track and eliminate the CTCs before it can colonize at a new site, which would reduce metastatic progression and increase the five-year survival rate of the breast cancer patients. Targeted multiresponsive (magnetic hyperthermia and pH) nanomicelles incorporated with NIR fluorescent superparamagnetic iron oxide nanoparticles were developed based on self-assembly for dual modal imaging and dual toxicity for spontaneous killing of CTCs in blood stream. A heterogenous tumor clusters model was developed to mimic the CTCs isolated from breast cancer patients. The nanotheranostic system was further evaluated for the targeting property, drug release kinetics, hyperthermia and cytotoxicity against developed CTC model in vitro. In vivo model in BALB/c mice equivalent to stage III and IV human metastatic breast cancer was developed to evaluate the biodistribution and therapeutic efficacy of micellar nanotheranostic system. Reduced CTCs in blood stream and low distant organ metastasis after treatment with the nanotheranostic system demonstrates its potential to capture and kill the CTCs that minimize the secondary tumor formation at distant sites.

Transforming Fragile Perfects into Dynamic Perfects to tide over the 2020 Pandemic Crises

@#Today the world is facing challenges because of the pandemic crises and the medical students are not exempted. It is time to build the paragons of grit in our students which is one of the character strengths that is vital to keep the students in the game. In addition to academic excellence we need to inculcate these other capabilities like grit to produce resilient doctors. Our future doctors need to be “dynamic perfects” as opposed to “fragile perfects”.

A study of the symptoms of gastro oesophageal reflux disease and the associated risk factors in a tertiary care centre

Background: Gastro esophageal reflux disease is the commonest pathologies encountered by gastroenterologist in day to day practice. Longstanding and untreated gastro esophageal reflux disease can lead to many complications including adenocarcinoma. This study was conducted to evaluate the various symptoms and to analyze the lifestyle and dietary factors influencing gastro esophageal reflux disease which can be modified.Methods: Hundred patients with gastro-esophageal reflux disease of age more than 18 years were enrolled in the study. Various patient details including demographic details, lifestyle information and symptomatology data were analyzed and compared with complications.Results: Mean age of gastro esophageal reflux disease patients was 56.09±15.93 years. Gastro esophageal reflux disease is more prevalent in males than females. Gastro esophageal reflux disease is more frequent in BMI <25, greater number of co morbidities and in non-vegetarians.  Mean age of gastro esophageal reflux disease with complications was 67±11.53 years and without complications was 52.64±15.57 years. No strong association of smoking, alcohol, spicy foods, fried foods, citrus fruits, heavy meals, tea/coffee, aerated drinks, sleep disturbance and effect on work was identified in gastro esophageal reflux disease.Conclusions: Classical symptoms of gastro esophageal reflux disease were not present in all the patients. Higher age of the patient infers higher risk of complications. Daily episodes of heartburn, regurgitation and retrosternal chest pain implies higher risk of complications. Presence of Helicobacter pylori in gastro esophageal reflux disease patients signify higher risk of complications.

A retrospective study of clinical profile and outcome of patients with rodenticide poisoning in a tertiary care hospital

Background: In developing countries, the substances most commonly used for self-poisoning are agricultural pesticides including rodenticides. Authors aimed to assess the clinical status and outcomes of patients with rodenticide poisoning in a tertiary care hospital.Methods: This retrospective record-based study was carried over three years. Apart from demographic details, information regarding the time of ingestion, nature and amount of the compound. Other details included clinical features, complications, treatment and outcome of the patient. Descriptive analysis was carried out by the mean and standard deviation for quantitative variables, frequency and proportion for categorical variables.Results: Of the 120 study subjects, 85 (93.40%) participants self-harmed, 2 (2.20%) were homicidal, and 4 (4.40%) had accidentally consumed the rodenticide. About 52 (32.70%) participants had vomiting, 34 (21.38%) had giddiness, 32 (20.13%) participants had abdominal pain. On the whole, 85 (73.28%) participants recovered, 23 (19.83%) participants had absconded, 6 (5.17%) participants had referred and 2 (1.72%) of them expired.Conclusions: Phosphorous compounds, particularly yellow phosphorous are the most lethal rodenticides followed by Coumadin. Symptomatic management of the patients at the earliest possible time is the mainstay, as there are no specific antidotes for any of the compounds.

Aquagenic Wrinkling of Skin: A Screening Test for Cystic Fibrosis

Objectives: To study the utility of aquagenic wrinkling asscreening test for children with cystic fibrosis.Design: Evaluation of diagnostic test.Setting: Pediatric Chest Clinic, and Pediatric Wards of a tertiarycare hospital in New Delhi.Participants: Three groups (children with cystic fibrosis,carriers of cystic fibrosis, and controls).Method: Time taken to develop aquagenic wrinkling wasmeasured. The test was performed by asking the enrolled subjectto put their one hand in water and was checked for development ofwrinkling every minute, and a photograph was also taken everyminute.Results: A total of 64 children with cystic fibrosis, 64 controls and64 carriers were enrolled in the study. Median (IQR) time todevelop aquagenic wrinkling in the three groups was 2 (1.5,3)minutes, 4 (3,5) minutes and 8 (5,11) minutes, respectively. Theoptimal cut-off was calculated as 3 minutes by Receiveroperating characteristic curve with a sensitivity and specificityfor identification of children with cystic fibrosis as 81% and 57%,respectively. The area under curve was 76.5%. The 3 minutecut-off for development of aquagenic wrinkling was applied to 54children referred for sweat test. 20 children had sweat chloridevalues of ≥60 mEq/l and diagnosed as cystic fibrosis. 15 of thesedeveloped aquagenic wrinkling at ≤3 minutes, giving a sensitivityof 75%.Conclusion: In places with no facility for sweat test, childrenwith phenotype compatible with cystic fibrosis who developaquagenic wrinkling in 3 minutes may be diagnosed as probablecystic fibrosis and referred for confirmation by sweat tes

Supplementation with Three Different Daily Doses of Vitamin D3 in Healthy Pre-pubertal School Girls: A Cluster Randomized Trial

Objective: To compare the adequacy and efficacy of differentdoses of vitamin D3 in pre-pubertal girls.Design: Cluster Randomized controlled trial.Setting: Public school in Delhi, India, between August 2015 andFebruary 2016.Participants: 216 healthy pre-pubertal girls, aged 6.1-11.8 years.Intervention: Daily supplementation with 600 IU (n=74), 1000 IU(n=67) or 2000 IU (n=75) of vitamin D3 under supervision for 6months.Outcome measures: Primary: Rise in serum 25 hydroxy VitaminD (25(OH)D); Secondary: Change in bone formation andresorption markers.Results: Following 6 months of supplementation, the mean (SD)rise in serum 25(OH)D was maximum with 2000 IU (24.09 (8.28)ng/mL), followed by with 1000 IU (17.96 (6.55) ng/mL) and 600 IU(15.48 (7.00) ng/mL). Serum 25(OH)D levels of ?20 ng/mL wereseen in 91% in 600 IU group , 97% in 1000 IU group and 100% in2000 IU group. The overall mean (SD) rise in urinary calciumcreatinine ratio (0.05 (0.28) to 0.13 (0.12) mg/mg), and serumprocollagen type I N-terminal propeptide (538.9 (199.78) to 655.5(218.24) ng/mL), and reduction in serum carboxy-terminaltelopeptide (0.745 (0.23) to 0.382 (0.23) ng/mL) was significant(P<0.01). The change in the above parameters was comparableamong the three groups after adjustment for age.Conclusion: Daily vitamin D supplementation with 600 IU to 2000IU for 6 months results in Vitamin D sufficiency in >90% of pre-pubertal girls

Achalasia Cardia In Indian Children– Experience From A Tertiary Care Institute In Chennai, India

Introduction:Achalasia cardia a rare oesophageal motility disorder is not uncommon in children. Aim and objectives:To describe the clinical profile of achalasia from a single pediatric tertiary care centre. Materials and Methods: Retrospective analysis of case records over a period of 10 years from March 2008 to March 2018 at institute of child health and hospital for children, Chennai, India. Results: 26 children had achalasia and 11 (42.3%) were males. The mean age was 42.08±36.33 months and 19 (73.07%) were less than five years at diagnosis. Vomiting was the most common symptom (88.4%) followed by failure to thrive (80.77%). Six had features of Allgrove syndrome. Heller's cardiomyotomy with or without fundoplication was done in 24 (92.3%) and pneumatic dilatation in two. Conclusion: Achalasia cardia is not uncommon and should be considered in children presenting with vomiting, dysphagia and failure to thrive. Surgery remains to be safe and effective.

A study on the effect of topical lidocaine gel versus drops on surgeon抯 comfort during manual small incision cataract surgery

Background: Cataract is a frequent surgical procedure performed worldwide. The study compared lidocaine 4% drops with 2% gel on surgeon抯 comfort, need for supplemental anaesthesia and duration of surgery in patients who underwent manual small incision cataract surgery.Methods: This was a Prospective, Comparison study conducted at a Single centre by multiple surgeons. Patients enrolled for surgeries were divided into Group A: Lidocaine 4% drops 1ml was instilled in the conjunctival sac 5 minutes before surgery and Group B: Lidocaine 2% gel 2ml was applied. Endpoints evaluated were surgeon抯 comfort, need for supplemental anesthesia and duration of surgery.Results: The mean duration of surgery for gel was 20�minutes as compared to 29�minutes with drops (p*- value<0.001). 26 (87%) patients in gel did not require any supplemental anesthesia as compared to 3 (10%) patients in drops. Peribulbar supplementation was required for 20 (67%) patients in drops as compared to 1 (3%) patient in gel (p*- value<0.001). 26 (87%) patients in gel were operated comfortably by the surgeon as compared to 2 (6%) patients in drops. Mild to Moderate discomfort was experienced by the surgeon in operating 27 (90%) patients in drops as compared to 3(10%) patients in gel (p*- value<0.001).Conclusions: The surgeons were more comfortable using gel with least requirement of supplemental anaesthesia and faster completion compared to drops.

A prospective study on the effect of topical lidocaine gel versus drops on ocular pain in manual small incision cataract surgery

Background: Cataract is globally acknowledged leading cause of blindness. This study was undertaken to compare the effects of Lidocaine 4% drops with 2% gel on intra operative and post-operative pain in patients who underwent manual small incision cataract surgery.Methods: It was a single Centre, one-surgeon, prospective, comparison study. Patients enrolled for surgeries were divided into Group A: Lidocaine 4% drops 1 ml was instilled in the conjunctival sac 5 minutes before surgery and Group B: Lidocaine 2% gel 2ml was applied. Endpoints evaluated were ocular pain of patient during and after surgery.Results: A total of 60 patients underwent MSICS, out of which 30 each received drops and gel. Mean intraoperative pain VAS score was 2.26±0.69 for gel group and 5.13±1.13 for drops group (p*<0.001) Mean post-operative pain VAS score was 0.26±0.69 in gel group and 1.13±1.13 in drops group (p*=0.002).Conclusions: Compared to drops, Lidocaine gel has reduced intraoperative and post-operative pain.

Quest for the holy grail: Assessment of echo-derived dynamic parameters as predictors of fluid responsiveness in patients with acute aneurysmal subarachnoid hemorrhage

Background: Acute aneurysmal subarachnoid hemorrhage (aSAH) is a potentially devastating event often presenting with a plethora of hemodynamic fluctuations requiring meticulous fluid management. The aim of this study was to assess the utility of newer dynamic predictors of fluid responsiveness such as Delta down (DD), superior vena cava collapsibility index (SVCCI), and aortic velocity time integral variability (VTIAoV) in patients with SAH undergoing neurosurgery. Materials and Methods: Fifteen individuals with SAH undergoing surgery for intracranial aneurysmal clipping were enrolled in this prospective study. Postinduction, vitals, anesthetic parameters, and the study variables were recorded as the baseline. Following this, patients received a fluid bolus of 10 ml/kg of colloid over 20 min, and measurements were repeated postfluid loading. Continuous variables were expressed as mean ± standard deviation and compared using Student's t-test, with a P < 0.05 considered statistically significant. The predictive ability of variables for fluid responsiveness was determined using Pearson's coefficient analysis (r). Results: There were 12 volume responders and 3 nonresponders (NR). DD >5 mm Hg was efficient in differentiating the responders from NR (P < 0.05) with a sensitivity and specificity of 90% and 85%, respectively, with a good predictive ability to identify fluid responders and NR; r = 0.716. SVCCI of >38% was 100% sensitive and 95% specific in detecting the volume status and in differentiating the responders from NR (P < 0.05) and is an excellent predictor of fluid responsive status; r = 0.906. VTIAoV >20% too proved to be a good predictor of fluid responsiveness, with a sensitivity and specificity of 100% and 90%, respectively, with a predictive power; r = 0.732. Conclusion: Our study showed that 80% of patients presenting with aSAH for intracranial aneurysm clipping were fluid responders with normal hemodynamic parameters such as heart rate and blood pressure. Among the variables, SVCCI >38% appears to be an excellent predictor followed by VTIAoV >20% and DD >5 mmHg in assessing the fluid status in this population.

Oral manifestations of dengue fever

Background: Dengue is a life­threatening viral infection which has become an epidemic in India in the postmonsoon period (August­November). It mostly associated with nonspecific fever and rashes, arthralgia, myalgia, and thrombocytopenia in severe cases. Objective: This study aimed to study the oral manifestations of dengue fever and to observe the various features of oral presentation then to validate the significance and importance of oralmanifestation in the diagnosis of dengue fever.Materials and Methods: Patients meeting the inclusion criteria were subjected to detailed history, oral examination, and relevant investigations. Results: Intraoral manifestations were present in 24 (48%) patients, anf these included petechiae (29.2%), bleeding gums (16.6%), ulcer (4.2%), dryness of mouth (4.2%), and combined features (45.8%). Extraoral manifestations were present in 4% of the cases. Conclusion: This study highlights the thrombocytopenia related oral haemosrrhagic manifestations of dengue fever

Clinical effifi cacy of rituximab in the treatment of pemphigus: A retrospective study.

Background: Pulsed corticosteroids have been used successfully for the management of pemphigus. However, prolonged use of glucocorticoids may be associated with adverse effects and some patients show a poor response to conventional therapy. Biologics have shown a promising role in such cases; however, there is limited data from the Indian subcontinent. Objective: The primary objective was to assess the effi cacy and adverse effects of rituximab in pemphigus. The secondary objective was to measure the cumulative doses of corticosteroids required for these patients. Methods: We undertook a retrospective review of records of 25 pemphigus patients (pemphigus vulgaris: 21, pemphigus foliaceus: 4) who had received rituximab infusion (rheumatoid arthritis protocol in 21 patients, modifi ed in 4). Oral prednisolone was administered in dosages up to 0.5 mg/kg of body weight and tapered over the next 3–4 months according to the disease activity. However, other immunosuppressive agents such as cyclophosphamide and azathioprine were continued for one year after clinical remission was achieved. Results: Complete remission was observed in 22 (88%) patients. The mean time to disease control and complete remission was 1.10 and 4.36 months, respectively. Four (16%) patients experienced relapse after a mean duration of 11.75 months. The mean total dose of oral steroids administered was equivalent to 3535.64 mg of prednisolone. Exacerbation of disease was noted in two patients after the fi rst dose of rituximab and infectious complications, pneumonia and cellulitis, developed in one patient each. Limitations: A small sample size, the retrospective nature of the study and unavailability of follow-up anti-desmoglein autoantibodies levels were limitations. Conclusion: Rituximab is an effective agent in the treatment of pemphigus. The use of rituximab enabled use of a lower initial dose of oral prednisolone in pemphigus and hence reduced its total cumulative dose. Severe side effects were rare.

Cutaneous tuberculosis due to multidrug-resistant tubercle bacilli and difficulties in clinical diagnosis.

This report describes 6 HIV-negative patients including 5 children with scrofuloderma and an adult with lupus vulgaris, out of a total of 303 cases of cutaneous tuberculosis seen during a 4½-year period, who showed a positive tuberculin test and granulomatous histopathology, but failed to respond to fi rst-line antitubercular therapy. They were suspected to have multidrug-resistant infection as no other cause could be ascertained. Tissue aspirate or biopsy was sent for histopathology and culture. Mycobacterium tuberculosis was isolated from the aspirate in three patients and sputum in one with associated pulmonary tuberculosis. Drug susceptibility tests showed that all isolates were resistant to rifampicin and isoniazid, and one each additionally to streptomycin and ethambutol, respectively. In two, culture was unsuccessful. All were administered second-line antitubercular drugs. Clinical improvement was appreciable within 2 months as weight gain, and regression of ulcers, swellings and plaques. Two completed the recommended 24 months of therapy. Multidrug-resistant cutaneous tuberculosis should be suspected in patients with no response to fi rst-line drugs, with clinical deterioration, and where other causes of treatment failure are not forthcoming. Owing to poor isolation rates on culture and low sensitivity of molecular tests, in such cases, a trial of second-line anti-tubercular drugs may be justifi ed for a reasonable period of 2 months. Where facilities permit, culture and drug sensitivity tests should be done before starting treatment. Culture positivity is better from aspirated material.

Weekly azathioprine pulse versus daily azathioprinein the treatment of Parthenium dermatitis: A non-inferiority randomized controlled study.

Background: Azathioprine in daily doses has been shown to be effective and safe in the treatment of Parthenium dermatitis. Weekly pulses of azathioprine (WAP) are also effective, but there are no reports comparing the effectiveness and safety of these two regimens in this condition. Aims: To study the effi cacy and safety of WAP and daily azathioprine in Parthenium dermatitis. Methods: Sixty patients with Parthenium dermatitis were randomly assigned to treatment with azathioprine 300 mg weekly pulse or azathioprine 100 mg daily for 6 months. Patients were evaluated every month to assess the response to treatment and side effects. Results: The study included 32 patients in the weekly azathioprine group and 28 in the daily azathioprine group, of whom 25 and 22 patients respectively completed the study. Twenty-three (92%) patients on WAP and 21 (96%) on daily azathioprine had a good or excellent response. The mean pretreatment clinical severity score decreased from 26.4 ± 14.5 to 4.7 ± 5.1 in the WAP group, and from 36.1 ± 18.1 to 5.7 ± 6.0 in the daily azathioprine group, which was statistically signifi cant and comparable (P = 0.366). Patients on WAP had a higher incidence of adverse effects (P = 0.02). Limitations: The study had a small sample size and the amount of clobetasol propionate used in each patient was not determined, though it may not have affected the study outcome due to its comparable use in both groups. Conclusions: Azathioprine 300 mg weekly pulse and 100 mg daily dose are equally effective and safe in the treatment of Parthenium dermatitis.

Obstetric and perinatal outcome of elderly mothers aged 35 years and above: a comparative study

Background: Across the world, there is a rising trend among women towards delaying pregnancy and child birth. The wide educational and career choices available currently encourage women to pursue their professional goals relentlessly and many opt to delay pregnancy. Easy access to the wide range of modern contraceptive methods has enabled them to achieve better control of fertility. Methods: The study conducted in Chennai Medical College and Research Centre, Trichy over a period of 18 months compared pregnancy related complications, maternal and perinatal outcomes in elderly women, with non-elderly women as controls. Forty two elderly gravidae were compared with 50 non-elderly gravidae. Results: The mean age of women in study group was 37.1 and 27.6 in the control group. 14.3% in the study group of patients had assisted conception whereas all of patients in the control group conceived spontaneously. There were 4 (9.5%) miscarriages in the study group and none in the control group. The incidence of pre-gestational diabetes, gestational diabetes and preeclampsia was found to be higher in the study group and this was statistically significant (P Value <0.0001). Conclusion: This study analyzing the effect of advanced maternal age on pregnancy has shown favourable maternal and perinatal outcomes. The study showed a significant difference in the incidence of pre-gestational diabetes, gestational diabetes, preeclampsia, miscarriage, antepartum hemorrhage, induction of labour, instrumental deliveries and caesarean section rates in elderly gravidae. But the risk of aneuploidy, malpresentations, placenta previa and prolonged labour were not found to be high. The incidence of low APGAR score was high in the study group, but it was attributable to specific causes like placental abruption. There were no perinatal deaths in both groups.