Impact of inverted internal limiting membrane-flap technique on functional outcome and structural restoration of small and medium size macular holes

Purpose: To evaluate the impact of the inverted internal limiting membrane (ILM)?flap technique on the visual outcome and anatomical recovery for small (<250 ?), medium (<400 ?), and large (>400 ?) macular holes (MHs). Methods: Retrospective study included consecutive idiopathic MH cases operated on using the inverted ILM?flap technique. Clinical data were retrieved from electronic medical records (EMRs), surgical videos, and optical coherence tomography (OCT) machines. Eyes with axial length >25 mm, coexisting macular diseases, and follow?up <6 weeks were excluded. Data included the presence or absence of ILM flap and restoration of External Limiting Membrane (ELM), Ellipsoid Zone (EZ) lines. Mean visual improvement and structural recovery were compared between eyes showing ILM flap and those showing no flap in three MH size groups. Results: Forty eyes of 38 patients with a mean age of 62.7 ± 10.1 years and a mean MH diameter of 348 ± 152 ?m were included. The mean follow?up was 527 ± 478 days with anatomical closure observed in all eyes. Mean best?corrected visual acuity (BCVA) improved significantly from 0.87 ± 0.38 to 0.35 ± 0.26. ILM flap was visible in 29 (72.5%) all MHs, 7 (53.8%) small MHs (n = 13), 8 (61.5%) medium MHs (n = 13), and 14 (100%) large MHs (n = 14). The mean BCVA change was 0.47 ± 0.34, 0.53 ± 0.48, and 0.56 ± 0.20 in large, medium, and small MHs, respectively, and the difference between eyes showing ILM flap versus no flap in each MH size group was not statistically significant (P > 0.05). However, for medium MHs, it was higher in the ILM flap (0.66 ± 0.52) group compared to the no flap (0.32 ± 0.37) group. One eye with small MH developed significant gliosis resulting in reduced BCVA. ELM was restored in all eyes with small and medium MHs. Conclusion: We observed that the ILM flap did not adversely affect anatomical and visual outcomes for MHs <400 ?m. Restoration of ELM suggests minimal interference in structural recovery by an ILM flap.

Thrombocytopenia in Children: A Large Prospective Study on Clinical Manifestations, Seasonal Variation, Etiology, and Outcome

Aim: To study the clinico-etiological profile of children with thrombocytopenia. Methods: This prospective hospital-based study included all children (<18 years) with thrombocytopenia at the time of hospitalization and/or thrombocytopenia during the course of their hospital stay. A detailed history was recorded and appropriate laboratory investigations were carried out. Results: The study group comprised 246 children (mean age, 9.29 years; median age, 10 years) with male to female ratio of 1.5:1. Nearly 45% of children were above 10 years of age. Trends of admissions showed that the majority of children with thrombocytopenia (n = 115) got hospitalized during the rainy season, followed by summer (n = 84). Fever (72.8%), pallor (52.8%), bleeding manifestations (22%), lymphadenopathy (20.3%), and splenomegaly (20.3%) were common clinical features. Petechiae was the most common bleeding manifestation (63%). Septicemia (24%) was the most common etiology, followed by megaloblastic anemia (14.6%), undiagnosed fever (10.2%), local infection (9.3%), hepatitis (6.5%), and scrub typhus (6.1%). About nine children died. All those who died had septicemia and multi-organ dysfunction (MOD). On logistic regression analysis, age >10 years, presence of bleeding, arthralgia, rash, pallor, gastrointestinal (GI) symptoms, hematological disorders, and malignancy were associated with severe thrombocytopenia. Conclusion: Thrombocytopenia is a common hematological observation. This study revealed seasonal variation in the occurrence of thrombocytopenia in children, with the maximum number of cases in the rainy season. Septicemia is the commonest etiology. The majority of children with thrombocytopenia have no bleeding manifestations. Age >10 years, presence of bleeding, arthralgia, rash, pallor, GI symptoms, hematological disorders, and malignancy are associated with severe thrombocytopenia.

COVID-19-related bilateral acute de-pigmentation of iris with ocular hypertension

A 43-year-old male patient presented with acute blurring of vision in both eyes associated with photophobia, redness, and mild pain following coronavirus disease 2019 (Covid-19) infection. Clinical examination revealed extensive pigment dusting in the corneal endothelium and the trabecular meshwork with de-pigmentation bands in the iris periphery. The patient was managed empirically with topical anti-glaucoma medications for high intra-ocular pressure. The patient was prescribed systemic antibiotics including cephalosporins and amoxicillin for respiratory symptoms. A rare condition called bilateral acute de-pigmentation of iris (BADI) was suspected after ruling out common entities, for example, viral kerato-uveitis, pigment dispersion syndrome, and Fuchs iridocyclitis. Covid-19 infection and systemic antibiotics including cephalosporins have shown to cause BADI in the literature. The patient responded well with good outcome.

CONCORDANCE: A real?world evidence study to evaluate the concordance of detecting epidermal growth factor receptor (EGFR) mutation by circulating tumor DNA* versus tissue biopsy in patients with metastatic non?small cell lung cancer

Background: Molecular tissue testing in non?small cell lung cancer (NSCLC) is done for the assessment of epidermal growth factor receptor (EGFR) mutation. EGFR mutation status is the basis for deciding the targeted treatment option for patients with metastatic NSCLC. The nonavailability of tissue samples and contraindications for biopsy pose a significant challenge. Hence circulating tumor DNA (ctDNA) by liquid biopsy can be a viable alternative for NSCLC patients. Methods: This study was conducted at 15 sites across India. EGFR mutation testing from plasma was done as part of the study at the central laboratory by the next?generation sequencing (NGS) method and EGFR mutation test results from tissue samples (done as part of routine practice) were recorded for all the patients. Results: Out of the total patients enrolled (N = 245) the majority (64.5% n = 158) were men. The median age of patients was 58.0 (range: 26�) years. The concordance between plasma and tissue testing was found to be 82.9% (95% confidence interval [CI]: 77.55 87.45). The sensitivity and specificity of NGS were 68.4% (95% CI: 56.92 78.37) and 90.1% [95% CI: 84.36 94.21) respectively. Plasma testing detected 1.2% (n = 3) and tissue sample testing detected 2.4% (n = 6) positive status of exon 20 T790M EGFR mutation. Out of the total number of patients enrolled 25 were tissue positive and plasma negative while 16 were plasma positive and tissue negative. Conclusions: This real?world study in Indian patients suggests that plasma testing for EGFR mutation analysis is a viable diagnostic option in newly diagnosed advanced/metastatic NSCLC patients. The noninvasive plasma procedure in patients without available/evaluable tumor sample may enable more patients to receive appropriate targeted therapies by providing clinicians with valuable insights into the patient抯 tumor mutation status. ClinicalTrials.gov Identifier: NCT03562819

Comparing IOLM700 TK, Berdahl and Hardten astigmatism fix calculator and Barrett Rx formula in managing residual astigmatism due to toric intraocular lens misalignment

Purpose: To compare the accuracy in astigmatism reduction by using IOLM 700 steep total keratometry (TK) axis, Berdahl and Hardten astigmatism fix, and Barrett Rx formula following misaligned toric intraocular lens (IOL). Methods: Ten patients with residual refractive astigmatism due to misalignment following toric IOL implantation were included in this retrospective study. They were analyzed at days 4, 7/8, and 10/11 following primary cataract surgery on the platform of Berdahl and Hardten astigmatism fix, Barrett Rx formula, and IOLM 700 to determine the optimum axis of repositioning, and underwent IOL realignment on the steep TK axis of IOLM 700 assisted by the Callisto eye. The final outcome parameters were subjective refraction and orientation of toric IOL assessed 22 ± 1 days following repositioning surgery. These parameters were fed in the Barrett Rx formula and its vector analysis graph was utilized to determine the predicted ideal axis with the least residual astigmatism and the estimated residual astigmatism if the toric IOL was realigned according to the axis suggested by Berdahl and Hardten astigmatism fix and Barrett Rx formula. Results: Realigning the toric IOL on IOLM 700 steep TK axis along with the Callisto eye reduces the residual refractive astigmatism significantly (P = 0.003) from 2.00 ± 0.78 D to 0.18 ± 0.12 D (90.5 ± 7.6%) in comparison to the estimated 0.57 ± 0.31 D (68.4 ± 21.9%) by Berdahl and Hardten astigmatism fix and 0.61 ± 0.33 D (66.4 ± 23.5%) by Barrett Rx formula. Conclusion: Realigning the misaligned toric IOL on the IOLM 700 steep TK axis gives a better reduction in the residual refractive astigmatism in comparison to Berdahl and Hardten astigmatism fix and Barrett Rx formula

Acute critical care course for interns to develop competence

BACKGROUND All medical graduates must know how to stabilize and manage critically ill patients. A 2-day intensive course, called the acute critical care course (ACCC), was conducted to train interns in technical and non-technical skills for managing a patient whose condition is deteriorating. This analysis aims to assess the feasibility and effectiveness of ACCC for interns. METHODS We developed and conducted the ACCC to train interns. It included lectures and skill stations. Twenty-four interns participated in the course. Immediate, post-course, quantitative and qualitative feedback was taken online. Qualitative information was also collected verbally and later by email. These data were analysed both quantitatively and qualitatively. Thematic analysis was used to identify, analyse and report the patterns of responses and behaviour. RESULTS The average score for the utility of the course was 4.7 and for the skill stations it was 4.6 on a scale of 5. The qualitative analysis of the feedback emphasized the need for the course before the clinical posting and more skill-based modules rather than lectures. The interactive style of teaching and training in communication using role-play was appreciated. Few suggestions to improve the course were provided. CONCLUSIONS Implementing the ACCC needed simulation, interactive discussions, role-play, modified Pendleton’s feedback, and reflective exercise that form the basis of a range of educational principles. The blended learning set of objectives of ACCC were the pillars for this successful internship training programme.

Communication skills training through ‘role play’ in an acute critical care course

Background. Effective patient–doctor communication is a key component of patient-centred care, which is one of the six pillars of quality healthcare delivery. Structured and effective communication skills training for healthcare providers is the need of hour in medical education. We assessed the efficacy of role play and simulation in developing communication skills. Methods. As a key component of an acute critical care course (ACCC), communication skills are taught using role play models and simulation. Live feedback is critical in learning during this course as per the principles of adult learning (andragogy). Quantitative and qualitative data were collected to assess the efficacy of ACCC. Results. The 19th ACCC was introduced to interns at the All India Institute of Medical Sciences, New Delhi in December 2018. The teaching methodology and objective-oriented structured training in ACCC were much appreciated for training in human factors with emphasis on communication. A positive response was obtained from the candidates 3 weeks after they completed the course to assess whether interns are able to make use of this training in their day-to-day clinical practice amounting to a reliable evidence level of Kirkpatrick's ‘return of investment’. Conclusion. The use of ‘role play’ to teach communication skills is effective and superior to lecture-based teaching. Further structured and interactive programmes in communication skills training will improve patient care, relatives’ satisfaction and the image of medical profession.

Cardiac magnetic resonance in tropical endomyocardial fibrosis

Background: Endomyocardial fibrosis has varied presentatation and difficult to diagnose. Aim to elucidate the role of Cardiac Magnetic Resonance (CMR) imaging in the evaluation of Endomyocardial Fibrosis (EMF) and to devise diagnostic criteria for the disease.Methods: Retrospective analysis of cases of restrictive cardiomyopathy referred for Magnetic resonance imaging over a period of 5 years. All patients underwent 1.5 T CMR imaging (Magnetom Avanto, Siemens, Germany) with standard cardiomyopathy protocol. Criteria for diagnosis of RCM included normal sized ventricles, normal/reduced systolic function, uni-/bi-atrial enlargement, normal pericardium and absent septal bounce. Cases diagnosed as EMF on CMR were included in this study. Statistical analysis performed using SPSS software.Results: EMF was diagnosed in 20 patients (31%) [12 males; age 39±18 years]. Ten patients had Right Centricular (RV) EMF, 3 had Left Ventricular (LV) EMF, while 7 had bi-ventricular EMF. Oedema indicating ongoing inflammation was seen in 4 (20%) cases. Apical thrombus was seen in 8(40%) cases and was present in 35% cases of RV and 20% cases of LV involvement. Subendocardial delayed enhancement was always present in the involved ventricle. The RV apex was obliterated in 100% of patients with RV EMF, while LV apex was similarly obliterated in 66% cases with LV disease. Mild-moderate pericardial effusion was observed in 8 patients. On the basis of CMR findings, the disease was classified as early necrotic phase in 1, thrombotic necrotic in 4 and late fibrotic phase in 13 and of different stages in ventricles in 2 cases.Conclusions: EMF was the commonest cause of RCM in this series. Major diagnostic criteria of EMF on CMR include subendocardial delayed enhancement and apical obliteration. Oedema and thrombus are variable findings, depending on disease severity.

Accuracy and reliability of ultrasound estimation of fetal weight in women with a singleton term pregnancy

Background: Prenatal estimation of birth-weight is of utmost importance to predict the mode of delivery. This is also an important parameter of antenatal care. This study was conducted to evaluate the accuracy of estimated fetal weight by ultrasound, compared with actual birth weight.Methods: This was a prospective and comparative study comprising 110 pregnant women at term. Patients who had their sonography done within 7 days from date of delivery were included. Fetal weight was estimated by Hadlock 2 formula, the software of which was preinstalled in ultrasound-machine. The estimated fetal weight was compared to the post-delivery birth-weight. The Pearson's correlation coefficient was used and the accuracy of sonographic fetal weight estimation was evaluated using mean error, mean absolute error, mean percentage error, mean absolute percentage error and proportion of estimates within 10% of actual birth weight.Results: Mean estimated and actual birth weights were 3120.8±349.4 gm and 3088.2±404.5 g respectively. There was strong positive correlation between estimated fetal weight and actual birth weight (r = 0.58, p<0.001). The mean percentage error and mean absolute percentage error of ultrasound fetal weight estimations were 1.96±11.8% and 8.7±8.2% respectively. The percentage of estimates within ±10% of the actual birth weight was found to be 67.3%. In 23% of the cases, ultrasound overestimated the birth weight. In 13% of the cases, ultrasound underestimated the birth weight.Conclusions: There was strong positive correlation between actual and sonographically estimated fetal weight. So, ultrasonography can be considered as useful tool for estimating the fetal weight for improving the perinatal outcome.

Risk Prediction of Cardiovascular Events Using Thickness of Carotid Intima Media: An Institutional Based Study

Background: The load of coronary artery disease is on therise worldwide, developing countries, Like India, are acceptinglifestyle alterations that predispose to cardiovascular disorders.The present study was conducted with the aim to determinethe role of carotid intima media thickness in predictingcardiovascular events.Materials and Methods: The present prospective study wasperformed in the Department of Cardiology, Dr. Ram ManoharLohia Hospital & PGIMER, New Delhi, India. A detailed historyof all the subjects including medical history, biochemicalevaluation and ECG was performed amongst all the patients.The thickness of internal carotid artery and common carotidartery were measured bilaterally. A total of 3 readings wereobtained and mean was calculated. All the data thus obtainedwas arranged in a tabulated form and analyzed using SPSSsoftware.Results: A total of 200 subjects were enrolled in the study, themean age of the subjects was 44.87+/-3.89 years. There were120 males and 80 females in the study. The mean thickness ofright common carotid amongst cases was 0.12 ± .0085 andamongst control was 0.05 ± 0.0095. There was a significantdifference between the two as the p value was less than 0.05.Conclusion: Association between intimal thickness andcoronary artery disease is significant. Atherosclerosis is evenlydistributed amongst vasculature and primarily responsible forheart diseases.

Synergistic Occurrence of EGFR, ALK, and KRAS Gene Mutations in a Patient with Non-small Cell Lung Cancer (Adenocarcinoma)

Lung cancer is a commonly diagnosed malignancy. Adenocarcinoma, a subgroup of non-small cell lung cancer, is the commonest form and presents in an advanced stage of the disease, leaving a limited treatment option. Response to the standard chemotherapy regimens is overall poor. We present a case of synergistic occurrence of triple gene mutations in a patient with well-diff erentiated adenocarcinoma lung treated at a tertiary cancer care center in North India.

Case Report of Non-small Cell Lung Cancer Patient with EGFR T790M Mutation Treated with Th ird Generation Inhibitor

Lung cancer treatment based on the molecular classifi cation of the tumor has paved the way for multiple lines of targeted treatment, even though the development of resistance remains a major cause of concern. Epidermal growth factor receptor (EGFR) remains the poster boy for the use of targeted therapy, and the presence/absence of mutations in this gene has led to the development of inhibitors targeting specifi c mutations. We present the case of an advanced non-small cell lung cancer patient with EGFR T790M mutation treated with Osimertinib, a third-generation inhibitor.

A Prospective Study to Compare the Outcome of Early Surgical and Conservative Line of Management in Patients of Traumatic Intracerebral Hematomas

Introduction and Objective: Traumatic brain injuries (TBIs) are a leading cause of morbidity, mortality, disability, and socioeconomic losses in India and other developing countries. It is a global health epidemicthat has deleterious consequences for the individuals with the brain injury, their families, and the society. The development and validation of effective treatments are imperative. The present study aims to compare the outcomes of early surgical intervention and conservative line of management in traumatic ICH patients. Materials and Methods: The present study was carried out on patients admitted in surgical wards as a case of head injury due to road traffic accidents, assaults, and falls who attended Casualty Department or Surgery/Neurosurgery Outpatient Department, Sanjay Gandhi Memorial Hospital during June 1st, 2016 to May 31st, 2017. Patients who presented within 24 h of TBI and had evidence of a traumatic ICH on CT with a confluent volume of 20 mL or more were included in the study. Only traumatic ICH patients for whom the treating neurosurgeon was in equipoise about the benefits of early surgical evacuation, compared with initial conservative treatment, were eligible for the study. Result: 63.15% of severe head injury patients who underwent early surgical evacuation of hematoma died and 36.85% had a poor outcome as compared to 80% of severe head injury patients under conservative management group died and 20% had a poor outcome. 62.5% of moderate head injury patients who underwent early surgical evacuation of hematoma had a good outcome where as only 45.45% of moderate head injury patients who were managed conservatively had good outcome. Also mortality of moderate head injury patients was higher in conservatively treated group where 36.37% patients died where as only 18.75% of patients died in early surgical evacuation group. 100% of patients of mild head injury under early surgical evacuation of hematoma group had a good outcome as compared to 96.00% of mild head injury patients of conservative management group had a good outcome and 4.00% had a poor outcome. Conclusion: There is a strong evidence in favor of early surgical evacuation of hematoma in patients with traumatic intracerebral hemorrhage who have a GCS of 9–12. Those who have mild head injury (GCS 13–15) can probably be watched carefully for any deterioration because there is a safety margin, which diminishes as the GCS of the patient descends. Once the GCS has descended below 9, surgical intervention appears to be less effective. A larg

Mesenteric Leiomyosarcoma Mistaken as Subserosal Fibroid: A Rare Case Report.

Mesenteric leiomyosarcoma is a rare entity. It is usually seen in middle-aged individuals. The tumor usually remains asymptomatic for longer duration until it acquires a big size. Surgical removal is the main modality of treatment. Common symptoms of the patients are usually pain or distension abdomen. Pre-operative diagnosis is usually difficult. Ultrasonography and computed tomography scan can help in the diagnosis. In this case, the tumor was mistaken for subserosal fibroid but intraoperatively turned out a mesenteric mass with retroperitoneal extension. On histopathological examination, it was a leiomyosarcoma. Reoccurrence can occur. Early diagnosis and wide surgical resection can improve the prognosis of the patient.

A case of nevirapine-induced exfoliative dermatitis in an immunocompromised patient: a case report.

Nevirapine is a non-nucleoside reverse transcriptase inhibitor used as one of the first-line drugs for the highly active antiretroviral therapy (HAART) in human immunodeficiency virus positive patients. The side effects range from skin rashes to fulminant hepatotoxicity. The most of the side effects are manifested in the first 6-10 weeks indicating a need for close monitoring and follow-up of the patient in first few weeks. We hereby are presenting a case of a 41-year-old female who developed exfoliative dermatitis after 4 weeks of therapy. Keywords: Highly active antiretroviral therapy, Human immunodeficiency virus, Exfoliative dermatitis, Non-nucleoside reverse transcriptase inhibitors, Nucleoside reverse transcriptase inhibitor.

Carbamazepine-induced Stevens Johnson syndrome: a case series of three case reports.

Carbamazepine is an iminostilbene derivative that was initially used as an antiepileptic but has been used with increased frequency for different indications including chronic pain, trigeminal neuralgia, and herpetic neuralgias. This has resulted in increased incidence of carbamazepine related adverse effects such as nausea, vomiting, and serious hematological toxicities such as aplastic anemia, agranulocytosis, eosinophilia, lymphadenopathy, and splenomegaly. Life-threatening hypersensitivity reactions such as Steven Johnson syndrome (SJS) and toxic epidermal necrolysis can also occur. We hereby present a series of three cases that were prescribed carbamazepine for different indications and presented with SJS.

Survival After Immunosuppressive Therapy in Children with Aplastic Anemia.

Objective: To determine the survival of children ≤18y, treated with immunosuppresive therapy (IST) using equine antithymocyte globulin (e-ATG) and cyclosporine (CsA). Design: Prospective data entry as per a specified format. Setting: Tertiary care hospital. Patients: From January 1998 to December 2009, 40 children were diagnosed with acquired aplastic anemia; 33 patients, who received IST, were analyzed. 31 children (94%) received one course of e-ATG and CsA. 2 patients (6%) received two courses of ATG. Intervention: Immunosuppressive therapy using equine ATG and cyclosporine. Main Outcome Measures: Overall response and overall survival. Results: The overall response (complete response + partial response) to IST at 6 months was 87.9%. 8 (24.2%) patients achieved CR, 21 (63.6%) patients had PR and 4 (12.1%) patients did not respond to IST. Median follow-up was 24 (6-102) months. Overall survival at 24 months was 90%, with an acturial survival of 85.4% at 5 years. Seventeen patients (51.5%) received G-CSF for a median duration of 32 (23-64) days. The patients who received G-CSF had fewer infectious complications (P=0.002), but G-CSF administration did not influence survival/ outcome. No patient developed myelodysplastic syndrome or acute leukemia. Conclusions: The survival of patients who respond to IST is excellent. Also, G-CSF reduces the infectious complications without conferring any survival advantage.

Recombination in human leukocyte antigen region in two Asian Indian families.

BACKGROUND: Recombination (crossing over) may generate novel haplotypes that can be beneficial to a population against recently introduced pathogens. It may lead to the generation of new alleles. SETTINGS AND DESIGN: A prospective study at a tertiary care centre. AIM: To report two rare cases of crossing over in HLA region. MATERIALS AND METHODS: Tissue-typing was done by sequence specific primers (SSP) for DR locus and by both SSP and serology for Class I which was reconfirmed on fresh samples. RESULTS: In one patient crossing over had taken place in the region of A locus resulting in inheritance of A*01 instead of expected A*11. In second family crossing over had taken place in region of DRB1 locus and the sibling inherited DRB1*08 instead of DRB1*10. CONCLUSIONS: Possibility of recombination must be considered when interpreting implausible tissue-typing results of families worked up for BMT.

Effect of induction of meconium evacuation using per rectal laxatives on neonatal hyperbilirubinemia in term infants: A systematic review of randomized controlled trials.

Objective: To study the efficacy of early meconium evacuation using per rectal laxatives on the level of serum bilirubin and the need for phototherapy in healthy term infants. Materials and Methods: Systematic review of randomized controlled trials comparing per rectal laxatives versus no intervention was conducted using English language articles identified from the Cochrane Central Register of Controlled Trials, Medline, Ovid, and CINAHL databases and bibliographies of selected articles. Eligible studies were assessed for the risk of bias in conduct and reporting. Results: A total of three trials (n = 469) mostly with "unclear risk" were eligible for inclusion. Two trials used glycerin suppository whereas one used glycerin enema for meconium evacuation. Meta-analysis was not possible due to clinical heterogeneity in the choice of laxatives and frequency of intervention. In all the three studies, serum bilirubin levels at 48 h and the need for phototherapy was not significantly different between the two groups. Passage of first meconium and the transitional stools occurred significantly early in the intervention group compared to controls. Conclusion: Early evacuation of meconium using per rectal laxatives does not offer any significant clinical advantage for neonatal jaundice.