Clinical perspectives on the management of common psychiatric disorders in India

Psychiatric disorders are common health problems in patients of all age groups, under-diagnosis and under-treatment of these disorders can result in disability and serious complications. With an objective of creating a comprehensive evidence-based consensus on common mental health disorders and their management in the Indian setting, 10 expert groups meetings involving 98 psychiatrists across India were conducted in the month of May 2020. Clinical insights related to burden, signs and symptoms, diagnosis and management were summarized based on the discussions during these meetings. Experts agreed that depressive disorders and anxiety disorders represent two important psychiatric disorders in India. Selective serotonin reuptake inhibitors (SSRIs) are commonlyused for the treatment of depression. Benzodiazepines are effective for the treatment of comorbid anxiety in patients with depression, but their long-term use causes adverse events such as dependence and withdrawal reaction. Obsessive compulsive disorder (OCD), bipolar disorder, substance use especially alcohol withdrawal syndrome, and sleep disorders are other common psychiatric disorders found among Indian patients. Lithium and valproate represent the commonly used and effective pharmacological treatments for bipolar disorder. SSRIs are preferred drugs in the treatment of OCD,whereas benzodiazepines such as chlordiazepoxide and diazepam represent important pharmacological treatment optionsfor alcohol withdrawal. Early identification and timely and effective treatment of psychiatric disorders is important for prevention of complications. Treatment should be individualized based on efficacy, tolerability profile of the medicine, risk of drug interactions, and cost. This consensus may be useful to psychiatrists and general practitioners treating common psychiatric conditions in Indian patients.

A study on safe injection practices among healthcare professionals in a tertiary care hospital in Delhi

Background: As per available estimates, around three billion injections are administered annually in India and out of these, 1.89 billion are being unsafe. The present study was undertaken to observe and assess injection practices among Healthcare Professionals (HCP) in a tertiary care hospital.Methods: This was a cross-sectional, descriptive study conducted among doctors and nurses of purposively selected five departments in a government tertiary care hospital in Delhi. Primary data was collected using Self-administered questionnaire (SAQ) technique for which WHO Tool C Questionnaire was suitably modified, pre-tested and administered to HCP. Number of participants were 250 (131 doctors and 119 nurses). Injection practices were also observed in HCP and a total of 126 observations (60 in doctors & 66 in nurses) were made. Collected data was analyzed using Microsoft Excel & SPSS.Results: Though overall injection practices of the HCP were satisfactory but unsafe practices with respect to use of unclean surface for injection preparation (35%), not maintaining proper hand hygiene (33%) and not segregating bio medical waste at source by (22.3%) HCP were observed.Conclusions: Though compliance to best international injection practices in many areas were observed still unsafe practices were observed. Guidelines on Injection safety, Post Exposure Prophylaxis (PEP), judicious use of injections and reporting of adverse events/ sentinel events/near miss events to be prepared by the hospital at the earliest. It must be ensured that these guidelines are complied with by the HCP.

Comparative analysis of use of porous orbital implant with mucus membrane graft and dermis fat graft as a primary procedure in reconstruction of severely contracted socket.

Purpose: The purpose of our study is to present a surgical technique of primary porous orbital ball implantation with overlying mucus membrane graft (MMG) for reconstruction of severely contracted socket and to evaluate prosthesis retention and motility in comparison to dermis fat graft (DFG). Study Design: Prospective comparative study. Materials and Methods: A total of 24 patients of severe socket contracture (Grade 2‑4 Krishna’s classification) were subdivided into two groups, 12 patients in each group. In Group I, DFG have been used for reconstruction. In Group II, porous polyethylene implant with MMG has been used as a primary procedure for socket reconstruction. In Group I DFG was carried out in usual procedure. In case of Group II, vascularized scar tissues were separated 360° and were fashioned into four strips. A scleral capped porous polyethylene implant was placed in the intraconal space and four strips of scar tissue were secured to the scleral cap and extended part overlapped the implant to make a twofold barrier between the implant and MMG. Patients were followed‑up as per prefixed proforma. Prosthesis motility and retention between the two groups were measured. Results: In Group I, four patients had recurrence of contracture with fall out of prosthesis. In Group II stable reconstruction was achieved in all the patients. In terms of prosthesis motility, maximum in Group I was 39.2% and Group II, was 59.3%. The difference in prosthesis retention (P = 0.001) and motility (P = 0.004) between the two groups was significant. Conclusion: Primary socket reconstruction with porous orbital implant and MMG for severe socket contracture is an effective method in terms of prosthesis motility and prosthesis retention.

Comparison on testability of visual acuity, stereo acuity and colour vision tests between children with learning disabilities and children without learning disabilities in government primary schools.

Context: Children with learning disabilities might have difficulties to communicate effectively and give reliable responses as required in various visual function testing procedures. Aims: The purpose of this study was to compare the testability of visual acuity using the modified Early Treatment Diabetic Retinopathy Study (ETDRS) and Cambridge Crowding Cards, stereo acuity using Lang Stereo test II and Butterfly stereo tests and colour perception using Colour Vision Test Made Easy (CVTME) and Ishihara’s Test for Colour Deficiency (Ishihara Test) between children in mainstream classes and children with learning disabilities in special education classes in government primary schools. Materials and Methods: A total of 100 primary school children (50 children from mainstream classes and 50 children from special education classes) matched in age were recruited in this cross‑sectional comparative study. The testability was determined by the percentage of children who were able to give reliable respond as required by the respective tests. ‘Unable to test’ was defined as inappropriate response or uncooperative despite best efforts of the screener. Results: The testability of the modified ETDRS, Butterfly stereo test and Ishihara test for respective visual function tests were found lower among children in special education classes (P < 0.001) but not in Cambridge Crowding Cards, Lang Stereo test II and CVTME. Conclusion: Non verbal or “matching” approaches were found to be more superior in testing visual functions in children with learning disabilities. Modifications of vision testing procedures are essential for children with learning disabilities.

Diphenylmethyl selenocyanate attenuates malachite green induced oxidative injury through antioxidation & inhibition of DNA damage in mice.

Background & objectives: Malachite green (MG), an environmentally hazardous material, is used as a non permitted food colouring agent, especially in India. Selenium (Se) is an essential nutritional trace element required for animals and humans to guard against oxidative stress induced by xenobiotic compounds of diverse nature. In the present study, the role of the selenium compound diphenylmethyl selenocyanate (DMSE) was assessed on the oxidative stress (OS) induced by a food colouring agent, malachite green (MG) in vivo in mice. Methods: Swiss albino mice (Mus musculus) were intraperitoneally injected with MG at a standardized dose of 100 μg/ mouse for 30 days. DMSE was given orally at an optimum dose of 3 mg/kg b.w. in pre (15 days) and concomitant treatment schedule throughout the experimental period. The parameters viz. ALT, AST, LPO, GSH, GST, SOD, CAT, GPx, TrxR, CA, MN, MI and DNA damage have been evaluated. Results: The DMSE showed its potential to protect against MG induced hepatotoxicity by controlling the serum alanine aminotransferase and aspartate amino transferase (ALT and AST) levels and also ameliorated oxidative stress by modulating hepatic lipid peroxidation and different detoxifying and antioxidative enzymes such as glutathione-S-transferase (GST), superoxide dismutase (SOD), catalase (CAT), and also the selenoenzymes such as glutathione peroxidase (GPx) and thioredoxin reductase (TrxR) and reduced glutathione level which in turn reduced DNA damage. Interpretation & conclusions: The organo-selenium compound DMSE showed significant protection against MG induced heptotoxicity and DNA damage in murine model. Better protection was observed in pretreatment group than in the concomitant group. Further studies need to be done to understand the mechanism of action.

Langerhans cell histiocytosis in cervical node in an adult female - a case report.

A case of Langerhans Cell Histiocytosis (LCH) in a 58 year old woman who presented with bilateral cervical adenopathy without any other complaints is reported. Clinical examination did not reveal any other positive finding except the adenopathy. Histopathological examination confirmed the node to be Langerhans cell histiocytosis. In conclusion, LCH is a rare disease with varied clinical presentation, including cervical adenopathy. Diagnosis should be confirmed by histopathological examination of biopsy specimen. Observation may be an effective management strategy in cases of adult LCH with cervical adenopathy as the only symptom, due to its possible spontaneous regression.

Mucous membrane grafting for the post-Steven–Johnson syndrome symblepharon: A case report.

An 18-year-old woman was referred with late sequelae of chloroquine-induced Steven–Johnson syndrome. At the time of presentation, the symblepharon was involving the upper lids to almost the whole of the cornea, and part of the lower bulbar conjunctiva with the lower lid bilaterally. Other ocular examinations were not possible due to the symblepharon. B-scan ultrasonography revealed acoustically clear vitreous, normal chorioretinal thickness, and normal optic nerve head, with an attached retina. Conjunctivo-corneal adhesion released by superficial lamellar dissection of the cornea. Ocular surface reconstruction was carried out with a buccal mucous membrane. A bandage contact lens was placed over the cornea followed by the symblepharon ring to prevent further adhesion. The mucosal graft was well taken up along with corneal re-epithelization. Best corrected visual acuity of 20/120 in both sides after 1 month and 20/80 after 3 months was achieved and maintained till the 2.5-year follow-up.

Solitary fibrous tumor of the orbit presenting in pregnancy.

A 32-year-old woman, three months pregnant, reported with the complaint of protrusion of the right eye for six months. She gave history of rapid protrusion of eyeball for the last two months along with the history of double vision for the last one month. Computer tomography (CT) scan revealed a well-defined mass lesion in the intraconal space of the right orbit which was excised through a lateral orbitotomy approach. Histological examination and immunohistochemistry revealed a solitary fibrous tumor, which showed a rapid progression in pregnancy.

Ocular adnexal lymphoma in the Northeast Indian population.

We present the clinical profile of biopsy and immunohistochemistry-proven ocular adnexal lymphomas in the Northeast Indian population. Nineteen patients between October 2004 and June 2006 with ocular adnexal lymphoma were analyzed retrospectively. Histopathological classification was done according to international working formulation. Twelve patients were male and seven were female. All were diagnosed as non-Hodgkin's lymphoma and the majority were B cell type (89%). Most of the cases (42%)were treated with radiotherapy followed by chemotherapy.

Porokeratosis confined to the genital area: a report of three cases.

Genital involvement in porokeratosis (PK) is a rare occurrence even in disseminated forms. We encountered three patients who had porokeratosis affecting only the genital area. Two of them were male with involvement of the penis and scrotum and only the scrotum respectively. The lady with vulvar involvement is a hitherto unreported instance of porokeratosis confined to female genitalia. None of the cases were very easy to diagnose clinically but biopsies proved confirmatory. The male patients were advised light electrocautery under local anesthesia while the female patient underwent surgical excision.No malignant change has been reported in them till date.

Clinical spectrum of spontaneous carotid-cavernous fistula.

A carotid-cavernous fistula (CCF) is an abnormal communication between the cavernous sinus and the carotid arterial system. A CCF is divided into two categories, direct and indirect. Direct fistulas usually account for 70 to 90% of all CCF. Spontaneous, low-flow fistulas are usually associated with atherosclerosis, hypertension and collagen vascular disease or may develop in females during peripartum period. The elderly age group, especially women are at increased risk. We report three cases of spontaneous CCF presenting with ocular manifestations and hypertension, without any collagen vascular disease. One case was a direct variety and the other two were of indirect variety.

GC-rich heterochromatin in silver stained nucleolar organizer regions (NORs) fluoresces with Chromomycin A3 (CMA3) staining in three species of teleostean fishes (Pisces).

In a bid to ascertain the molecular architecture of the silver positive regions (NORs) in chromosomes of three species of fish, namely, Hemibagrus menoda (Hamilton), Sperata seenghala (Sykes) (Fam: Bagridae) and Mastacembelus armatus (Lacep6de) (Fam: Mastacembelidae), an additional staining methodology using a fluorochrome dye (Chromomycin A3) was deployed along with the AgNO3 technique. The nucleolar organizing regions (NORs) were located terminally at the shorter arms (Tp) of one pair of submetacentric chromosomes (No.3) in H. menoda (2n=58), at the longer arms (Tq) of one pair of submetacentric chromosomes (No.5) in S. seenghala (2n=50) and at the shorter arm (Tp) of one pair of homologous submetacentric chromosomes (No.6) in M. armatus (2n=48). Staining with Chromomycin A3 produced bright fluorescing zones in GC-rich heterochromatin of Ag-positive NORs. The results indicate a more general trend of existence of an overlapping region between NOR and GC-rich fluorescing zones, the active sites of rRNA genes (rDNA) in this primitive group of vertebrates although exceptions to this situation has been reported in a couple of extant fish species earlier. More data utilizing such combined methodologies are warranted to understand the structural organization of fish chromosomes more precisely.

Multicentric squamous cell carcinoma over lesions of porokeratosis palmaris et plantaris disseminata and giant porokeratosis.

Porokeratosis is a specific disorder of keratinization that has five clinical types and shows a characteristic 'cornoid lamella' on histopathology. Malignant degeneration has been described in all forms of porokeratosis. To the best of our knowledge, this is the first Indian report of multicentric squamous cell carcinoma complicating porokeratosis.