Reduced narcotic and sedative utilization in a NICU after implementation of pain management guidelines.

OBJECTIVE: To assess the opioid and benzodiazepine usage in a level IV NICU after implementation of pain guidelines. STUDY DESIGN: Guidelines were developed for infants undergoing surgical procedures and infants on mechanical ventilation. Data collected for period 1 (July to December 2013) and period 2 (March to August 2014). RESULTS: Gestational age, birth weight and infants with hypoxic respiratory failure or requiring major procedures were comparable in two periods. Number of patients exposed to opioids decreased from 62.9% (129/205) in period 1 to 32.8% (82/250) in period 2, P=<0.001. Cumulative dose exposure decreased, opioids in morphine equivalent dose, mg kg-1 (1.64 (0.38 to 6.94) vs 0.51 (0.04 to 2.33), P=0.002), sedatives in midazolam equivalent, mg kg-1 (0.16 (0.03 to 7.39) vs 0.10 (0.00 to 4.00), P=0.03). Ten patients required treatment for iatrogenic opioid withdrawal versus only three in post guideline, P=0.02. CONCLUSIONS: Evidence-based guidelines led to significant reduction in opioids and sedatives exposure, and in the number of infants requiring methadone for iatrogenic narcotic dependence.

Safety and acceptability of an organic light-emitting diode sleep mask as a potential therapy for retinal disease.

PurposeThe purpose of the study was to study the effect of an organic light-emitting diode sleep mask on daytime alertness, wellbeing, and retinal structure/function in healthy volunteers and in diabetic macular oedema (DMO).Patients and methodsHealthy volunteers in two groups, 18-30 yrs (A), 50-70 yrs (B) and people with DMO (C) wore masks (504 nm wavelength; 80 cd/m2 luminance; ≤8 h) nightly for 3 months followed by a 1-month recovery period. Changes from baseline were measured for (means): psychomotor vigilance task (PVT) (number of lapses (NL), response time (RT)), sleep, depression, psychological wellbeing (PW), visual acuity, contrast sensitivity, colour, electrophysiology, microperimetry, and retinal thickness on OCT.ResultsOf 60 participants, 16 (27%) withdrew, 8 (13%) before month 1, due to sleep disturbances and mask intolerance. About 36/55 (65%) who continued beyond month 1 reported ≥1 adverse event. At month 3 mean PVT worsened in Group A (RT (7.65%, P<0.001), NL (43.3%, P=0.005)) and mean PW worsened in all groups (A 28.0%, P=0.01, B 21.2%, P=0.03, C 12.8%, P<0.05). No other clinically significant safety signal was detected. Cysts reduced/resolved in the OCT subfield of maximal pathology in 67% Group C eyes. Thinning was greater at 3 and 4 months for greater baseline thickness (central subfield P<0.001, maximal P<0.05).ConclusionSleep masks showed no major safety signal apart from a small impairment of daytime alertness and a moderate effect on wellbeing. Masks were acceptable apart from in some healthy participants. Preliminary data suggest a beneficial effect on retinal thickness in DMO. This novel therapeutic approach is ready for large clinical trials.

Near-infrared reflectance and autofluorescence imaging characteristics of choroidal nevi.

PurposeTo report near-infrared reflectance (NIR-R), near-infrared autofluorescence (NIR-AF) and blue wave autofluorescence (BW-AF) appearance of choroidal nevi using a confocal scanning laser ophthalmoscope (cSLO).Patients and methodsNIR-R, NIR-AF and BW-AF images of choroidal nevi were compared with color fundus photos (CF). Images were graded as hyperreflective if reflectance was much greater than background, hyporeflective if less than background, and isoreflective if the same as the background.ResultsForty-two nevi of 39 patients were imaged. When compared with CF, nevi could be identified on 95% (40/42) NIR-R images (95% CI: 83.5-99.3). On NIR-R 71% (30/42) demonstrated hyperreflectance and 24% (10/42) were hyporeflective. Hyperreflectivity was demonstrated in 96% (23/24) of NIR-AF images (95% CI: 79.1-99.9) and 34% (14/41) of BW-AF images (95% CI: 20.0-50.5). On NIR-R, 29/40 (73%) were apparently smaller in comparison with CF and 11/40 (28%) had the same area. A correlation was found between NIR-R and NIR-AF (P=0.02) but not with BW-AF (P=0.15).ConclusionsNevi can be visualized well using NIR-R and NIR-AF imaging modalities, but are less frequently visible using BW-AF. These changes may be related to melanin within the choroid or chronic changes of the overlying retinal pigment epithelium.

Hearing Sensitivity in 40-60 Years Old Hypertensive Male Adults.

Declining hearing sensitivity is appreciated as a normal age related change. However, studies reveal that health variables other than age play significant role in hearing impairment over time. Hypertension is one such variable. The objective of this study was to assess whether the hypertension has an accelerating effect on age related reduction in hearing function in males in the age group of 40-60 years. Systolic and Diastolic blood. pressure and Pure Tone thresholds in frequency range 250-8000 Hz were measured in 30 known hypertensive (HT) male subjects in the age group of 40-60 years and 30 age and sex-matched normotensive (NT) controls. There was no significant difference in hearing thresholds at various frequencies between HT and NT group and between uncontrolled HT (n = 15) and controlled HT subgroups (n = 15). However, a significantly positive correlation between the systolic blood pressure and Air conduction thresholds at 4000 Hz and 8000 Hz and Bone conduction thresholds at 4000 Hz were noted in uncontrolled HT subgroup. Results of the current study demonstrated towards the potentially negative impact of uncontrolled hypertension on the auditory function in the age group of 40-60 years.

Aural hygiene practices among underprivileged children of Delhi.

BACKGROUND: Though ear hygiene is important for proper hearing, it is usually neglected. Improper ear care practices may have serious consequences such as loss of hearing. In childhood, loss of hearing may affect learning and development. There is scarcity of information on ear care practices in the community in India. We aimed to ascertain the magnitude of problems related to aural hygiene and assess ear care practices among children of schoolgoing age in a resettlement colony of Delhi. METHODS: A cross-sectional community-based survey was done among 1398 children 5-14 years of age. The houses were selected by systematic random sampling and all eligible children in the selected house were interviewed and examined. The data were analysed using SPSS version 12 and chi-square test was used to ascertain significance between two variables. RESULTS: Almost two-thirds (60%; 834) of the children gave a history of themselves or an elder cleaning the ear using unhealthy methods. Earbuds were used by 21.7% (304) of children. Match and broomsticks were used for cleaning by 18.3% (256) and 3% (43) of children, respectively. One hundred and fifty-nine children (11.3%) were applying oil to clean the ear canal. Ear cleaning with unhealthy means was significantly higher (56% v. 44%, p<0.03) among children belonging to low socioeconomic strata. There was a significant association between unhealthy ear cleaning practices and middle ear infection (p<0.001). CONCLUSION: A majority of children practised unhealthy/ not recommended methods for cleaning their ear. There is a need to raise awareness about healthy ear cleaning practices in the community.

Design, characterization, and evaluation of intranasal delivery of ropinirole-loaded mucoadhesive nanoparticles for brain targeting.

CONTEXT: Parkinson disease (PD) is a common, progressive neurodegenerative disorder, characterized by marked depletion of striatal dopamine and degeneration of dopaminergic neurons in the substantia nigra. OBJECTIVE: The purpose of the present study was to investigate the possibility of targeting an anti-Parkinson's drug ropinirole (RH) to the brain using polymeric nanoparticles. MATERIALS AND METHODS: Ropinirole hydrochloride (RH)-loaded chitosan nanoparticles (CSNPs) were prepared by an ionic gelation method. The RH-CSNPs were characterized for particle size, polydispersity index (PDI), zeta potential, loading capacity, entrapment efficiency in vitro release study, and in vivo distribution after intranasal administration. RESULTS AND DISCUSSION: The RH-CSNPs showed sustained release profiles for up to 18 h. The RH concentrations (% Radioactivity/g) in the brain following intranasal administration (i.n.) of RH-CSNPs were found to be significantly higher at all the time points compared with RH solution. The concentration of RH was highest in the liver (7.210 ± 0.52), followed by kidneys (6.862 ± 0.62), intestine (4.862 ± 0.45), and lungs (4.640 ± 0.92) in rats following i.n. administration of RH-CSNPs. Gamma scintigraphy imaging in rats was performed to ascertain the localization of drug in the brain following intranasal administration of formulations. The brain/blood ratios obtained (0.251 ± 0.09 and 0.386 ± 0.57 of RH (i.n.) and RH-CSNPs (i.n.), respectively) at 0.5 h are indicative of direct nose to brain transport, bypassing the blood-brain barrier (BBB). CONCLUSION: The novel formulation showed the superiority of nose to brain delivery of RH using mucoadhesive nanoparticles compared with other delivery routes reported earlier.

Transient receptor potential melastatin 7 is involved in oestrogen receptor-negative metastatic breast cancer cells migration through its kinase domain.

Oestrogen receptor negative (ER(-)) invasive ductal carcinoma (IDC) represents a significant clinical challenge and therefore prompts the discovery of novel biomarkers. Transient receptor potential melastatin 7 (TRPM7), a channel protein that also contains a regulatory kinase domain, is overexpressed in IDC and regulates migration. However, the molecular mechanism remains poorly defined. Here, we examined whether TRPM7 regulates migration by its channel function or by its kinase domain. A Magnesium Inhibited Cation current was recorded in two ER(-) highly metastatic breast cancer cell lines. Down-regulation of TRPM7 neither affected Ca(2+)-, nor Mg(2+)-homoeostasis but significantly reduced cell migration via a Ca(2+)-independent pathway. Notably, the overexpression of the truncated kinase domain form of TRPM7 decreased cell migration, while the overexpression of the wild-type form strongly increased it. Concomitantly, TRPM7 silencing reduced the myosin IIA heavy chain phosphorylation. Furthermore, we found higher TRPM7 expression in ER(-) IDC tissues and lymph nodes than in the non-invasive tumoural samples. In conclusion, TRPM7 plays a critical role in breast cancer cell migration through its kinase domain, and our data support the consideration of using TRPM7 as a novel biomarker and a potential therapeutic target in the treatment of human ER(-) IDC.

Bilateral Choanal Atresia: Is it Really a Surgical Emergency?

To review the need of emergency recanalization surgical procedure in cases of bilateral choanal atresia. A retrospective analysis was undertaken for the cases of bilateral choanal atresia which were recanalized between January 2000 and February 2010 in a teaching hospital. Out of 135,954 live births (0.004%), six cases of bilateral choanal atresia were diagnosed and operated during this period. Five cases were hospital deliveries from our hospital whereas one case was referred from another hospital. Three cases were recanalized with dilatation procedure whereas the other three were endoscopically recanalized with micro-drill. All the cases were operated in routine operation theatre. All were managed with orogastric tube or oropharyngeal airway during the waiting period for surgery. No neonate required emergency intubation or tracheostomy. The average age at the time of surgery was 10 days (range 5-21 days). As per our observations recanalization surgery for bilateral choanal atresia is not a surgical emergency. Neonates can be managed temporarily with orogastric tube/oropharyngeal airway during waiting period. Subsequently surgery can be done in routine and unhurried operation theater by experienced surgical hands thus minimizing the morbidity.

Adverse ophthalmic reaction in poppers users: case series of 'poppers maculopathy'.

BACKGROUND: Poppers are a recreational substance of abuse belonging to the alkyl nitrite family of compounds. In the United Kingdom, where they are legal to purchase but illegal to sell for human consumption, 10% of the general population have tried them. They are considered low risk to physical and mental health. Two recent case series from France demonstrated foveal pathology in individuals associated with poppers use. METHOD: A case series of seven patients presenting to four hospitals in the United Kingdom with visual impairment and maculopathy associated with inhalation of poppers. RESULTS: All patients experienced visual symptoms associated with poppers use. The majority had impaired visual acuity, central scotomata, distortion, or phosphenes. Clinical signs on fundoscopy ranged from normal foveal appearance to yellow, dome-shaped lesions at the foveola. Spectral domain optical coherence tomography (SD-OCT) showed varying degrees of disruption of the presumed inner segment/outer segment (IS/OS) junction. DISCUSSION: Although poppers have been in use for several decades, in 2007, following legislative changes, there was a change in the most commonly used compound from isobutyl nitrite to isopropyl nitrite. There were no reports of 'poppers maculopathy' before this. Poppers maculopathy may be missed if patients are not directly questioned about their use. The disruption or loss of the presumed IS/OS junction on SD-OCT are a characteristic feature. Further study of maculopathy in poppers users is now needed. Raising public awareness of the ocular risks associated with their use may be necessary.

Radiofrequency ablation of laryngeal saccular cyst in infants: a series of six cases.

Saccular cysts of larynx are uncommon entity. These are infrequent causes of respiratory obstruction in neonates and infants. The saccular cysts are thought to arise in the saccule of the ventricle as a result of atresia of the ventricular orifice. The treatment options used in the management of saccular cysts are endoscopic needle aspiration, marsupialization and endoscopic extended ventriculotomy. We have found that removal of the saccular cyst can be achieved relatively safely and effectively by endoscopic radiofrequency ablation with improved surgical precision and better healing. We share our experience with a series of six cases, diagnosed under the sedation, thereafter radiofrequency ablation of laryngeal saccular cysts was done.

Effectiveness of ranibizumab for neovascular age-related macular degeneration using clinician-determined retreatment strategy.

AIMS: To report the effectiveness of intravitreal ranibizumab treatment for neovascular age-related macular degeneration in a tertiary centre. METHODS: 1 year prospective cohort study of patients with a diagnosis of neovascular age-related macular degeneration on fundus fluorescein angiography treated with ranibizumab. Patients received three consecutive monthly treatments, followed by a clinician-determined re-treatment strategy. Data collected included demographic details, baseline and subsequent follow-up visit measurements, refraction protocol best corrected visual acuity (BCVA), contrast sensitivity (CS) and central foveal thickness (CFT) on optical coherence tomography. RESULTS: 81 patients were included in the study. The mean age was 79.5 years with a male:female ratio 32:49. The mean number of treatments was 5.6 ± 2.3. Visual outcomes at 12 months showed 17.1% gained ≥ 15 letters BCVA, 97.4% lost <15 letters and 2.5% lost ≥ 15 letters. Mean changes at 12 months were: BCVA +3.7 ± 11.1 (p<0.01); CS +2.3 ± 5.1 letters (p<0.001); CFT -100.1 ± 111.9 µm (p<0.001). CONCLUSIONS: Clinician-determined re-treatment after a three-dose initiation phase appears to be less effective in improving BCVA than in randomised controlled trials.

Head and neck teratomas in children: a case series.

Teratomas of the head and neck due to their obscure origin, bizarre microscopic appearance, unpredictable behaviour and often dramatic clinical presentation are a clinical surprise. This article focuses on pediatric head and neck teratomas and on their diversity and rarity and also reviews the recent terminology of this group of tumours.

Primary tuberculosis of tonsil and posterior oropharyngeal wall.

Pharyngeal tuberculosis is rare and usually occurs in association with primary pulmonary disease. Primary tuberculosis involving the palatine tonsils and the posterior oropharyngeal wall is still a rare clinical entity. We report one such case of primary tuberculosis involving both the palatine tonsils and the posterior oropharyngeal wall in a 22 year-old male. The patient responded to anti-tubercular treatment with complete disappearance of lesion and no sign of recurrence on one year follow-up. The final diagnosis was based upon histopathological report.

Design and in vitro characterization of buccoadhesive drug delivery system of insulin.

A buccoadhesive drug delivery system of Insulin was prepared by solvent casting technique and characterized in vitro by surface pH, bioadhesive strength, drug release and skin permeation studies. Sodium carboxymethylcellulose-DVP was chosen as the controlled release matrix polymer. The optimized formulation J(4) contained Sodium carboxy methyl cellulose-DVP 2% (w/v), insulin (50 IU/film), propylene glycol (0.25 ml) and Isopropyl alcohol: water (1:4) as solvent system. Bioadhesive strength of the prepared patches was measured on a modified physical balance using bovine cheek pouch as the model membrane. In vitro release studies were carried out at 37 +/- 2 degrees using phosphate buffer pH 6.6, in a modified dissolution apparatus fabricated for the purpose. Cumulative amount of drug released from the optimized formulation J(4) was 91.64% in 6 hours. In vitro permeation studies were carried out on J(4) at 37 +/- 2 degrees using Franz diffusion cell. Cumulative amount of drug permeated from J(4) was 6.63% in 6 hours. In order to enhance the permeation of protein drug, different permeation enhancers were evaluated. The results suggested that sodium deoxycholate 5% (w/v) was the best permeation enhancer among those evaluated. It enhanced the permeation of insulin from 6.63% to 10.38% over a period of 6 hours. The optimized patches were also satisfactory in terms of surface pH and bioadhesive strength. It can also be easily concluded that the system is a success as compared to the conventional formulations with respect to invasiveness, requirement of trained persons for administration and most importantly, the first pass metabolism.

Lipoma of the deep lobe of parotid gland - a case report and review of literature.

Lipoma of deep lobe of parotid gland is a rare clinical entity. Less than 10 cases have been reported in the literature in our knowledge. Because of their rarity, they are not often considered in the differential diagnosis of parotid tumors. A case of 45-year-old man with an unusually large deep lobe lipoma of parotid gland is presented in this article which was surgically managed by total conservative parotidectmy. The clinical picture, radiological and histopathological features of this entity is being discussed here. Review of literature of this clinical situation has been presented in the present article.

Proteus syndrome with huge tonsillar mass causing dysphagia: a rare case.

Proteus syndrome is a rare and highly variable hamartomatous syndrome that can affect multiple organ systems. It is characterized by hyperplasia of connective tissue, vascular malformations, epidermal naevi and hyperostosis. Most of the cases present to plastic and orthopaedic surgeons. Otolaryngologic presentations are minimal. We report such a rare case, which presented with a huge unilateral tonsillar mass causing dysphagia.

Optical coherence tomography in photodynamic therapy for subfoveal choroidal neovascularisation secondary to age related macular degeneration: a cross sectional study.

AIMS: To introduce new terminology and validate its reliability for the analysis of optical coherence tomography (OCT) scans, compare clinical detection of cystoid macular oedema (CMO) and subretinal fluid (SRF) with OCT findings, and to study the effect of photodynamic therapy (PDT) on the foveal morphology. METHODS: Patients with subfoveal, predominantly classic choroidal neovascularisation (CNV) secondary to age related macular degeneration (AMD) undergoing PDT were evaluated with refraction protocol best corrected logMAR visual acuity (VA), slit lamp biomicroscopy, stereoscopic fluorescein angiography (FFA), and OCT. New terminologies introduced to interpret the OCT scans were: neuroretinal foveal thickness (NFT), bilaminar foveal thickness (BFT), outer high reflectivity band thickness (OHRBT), intraretinal fluid (IRF), subretinal fluid (oSRF), and vitreomacular hyaloid attachment (VMHA). RESULTS: Fifty six eyes of 53 patients were studied. VA was better in eyes with a thinner outer high reflectivity band (OHRBT) (p = 0.02) and BFT (p = 0.05). BFT was less in eyes that had undergone a greater number of PDT treatments (p = 0.04). There was poor agreement between OCT and clinical examination in the detection of CMO and subretinal fluid (kappa = 0.289 and kappa = 0.165 respectively). To validate the interpretation and measurements on OCT, two groups of 20 scans were analysed by two independent observers. There was good agreement between the observers in the detection of IRF, oSRF, and VMHA (p<0.001). Measurements of NFT and BFT had a high reproducibility, and of OHRBT reproducibility was low. CONCLUSIONS: New terminology has been introduced and tested. OCT appears to be superior to clinical examination and FFA in the detection of CMO. In this study, better vision was associated with a thinner OHRBT and/or the absence of SRF giving insight into the biological effect of PDT.

Treated threshold stage 3 versus spontaneously regressed subthreshold stage 3 retinopathy of prematurity: a study of motility, refractive, and anatomical outcomes at 6 months and 36 months.

AIM: To compare the visual acuity (VA), spherical equivalent refractive error, motility, and anatomical outcomes in children with treated regressed threshold stage 3 retinopathy of prematurity (ROP) and those with spontaneously regressed subthreshold stage 3 ROP. METHOD: 6 month and 3 year data collected from infants examined between 1989 and 1999 with regressed stage 3 ROP, with or without treatment were retrospectively reviewed. RESULTS: 85 infants were included in this study. 40 eyes received cryotherapy, 81 eyes laser photocoagulation, and 34 eyes had spontaneously regressed subthreshold stage 3 ROP. Grating acuity score > or =2 cycles/degree (c/d) at 6 months was predictive of optotype acuity > or =6/9 in 69% of eyes and a score <2 c/d at 6 months was predictive of acuity < 6/9 in 88% of eyes. Eyes with subthreshold stage 3 ROP were twice as likely to have VA of 6/9 or better at 36 months than the treated eyes. The mean spherical equivalent refractive error at 36 months was -6.5 dioptres (D) (-21.5D to +1.38D) in cryotherapy treated eyes, -2.4D (-13D to +4D) in the laser group, and -0.22D (-9D to +2.25D) in the subthreshold group. Eyes within the treated groups were more myopic than the eyes within the spontaneously regressed group (p = 0.005). At 36 months, 42 out of the 85 infants (that is, 49%) had strabismus (44% in the cryotherapy group, 26% in the laser group, and 25% in the subthreshold group). There was a statistically significant association between the presence of strabismus and anisometropia (p = 0.016) and strabismus and intraventricular haemorrhage (IVH) (p = 0.005). There was a statistically significant difference in the incidence of strabismus between mild and moderate and severe grade IVH (p = 0.01). Eight out of 40 eyes in the cryotherapy group and six out of the 81 eyes in the laser group developed macular ectopia. None of the eyes in the spontaneously regressed group had macular dragging. CONCLUSIONS: In this study, the grating acuity at 6 months was a good predictor of the 3 year optotype acuity in all groups. Eyes with spontaneously regressed subthreshold stage 3 ROP were associated with better vision at 3 years of age and a lesser degree of myopia compared to the treated groups. Strabismus developed predominantly in the treated groups and was frequently associated with neurological damage and/or anisometropia. The spontaneously regressed subthreshold stage 3 group had a better anatomical outcome compared to the groups in which the retinopathy regressed following treatment.