Exploring the therapeutic potential of allogeneic amniotic membrane for quality wound healing in rabbit model.

BACKGROUND: The amniotic membrane (AM) has shown immense potential in repairing wounds due to its great regenerative qualities. Although the role of AM as a biological scaffold in repairing wounds has been studied well, the tissue regenerative potential of AM-derived mesenchymal stem cells (MSCs) and conditioned media (CM) derived from it remains to be discovered as of now. Here, we examined the wound healing abilities of fresh and frozen thawed rabbit AM (rAM) along with the MSCs and their lyophilised CM in rabbits challenged with skin wounds. METHODS: To elucidate the role of rAM-MSCs and its CM in repairing the wound, we isolated it from the freshly derived placenta and characterised their differentiation potential by performing an in vitro tri-lineage differentiation assay besides other standard confirmations. We compared the wound repair capacities of rAM-MSCs and lyophilised CM with the fresh and cryopreserved AM at different timelines by applying them to excision wounds created in rabbits. RESULTS: By monitoring wound contractions and tissue histology of wounded skin at different time points after the application, we observed that rAM-MSCs and rAM-MSC-derived CM significantly promoted wound closure compared to the control group. We also observed that the wound closure capacity of rAM-MSCs and rAM-MSC-derived CM is as efficient as fresh and cryopreserved rAM. CONCLUSION: Our findings suggest that rAM-MSCs and rAM-MSC derived CM can be effectively used to treat skin wounds in animals and correctly delivered to the damaged tissue using AM as a bioscaffold, either fresh or frozen.

Effect of milk and mustard oil consumption: A case study on youth in Delhi-NCR.

Background: The diet is a major factor affecting the Body Mass Index (BMI) of an individual. BMI has long been the standard for measuring health and its normal range (18.5-24.9, according to the World Health Organization) is considered to be crucial for maintenance of proper health and to prevent various lifestyle disorders which are considered to have either direct or indirect effects on physical and mental well-being of our youth. Aim: To investigate the correlation between diet patterns and BMI, overall stamina and fatigue levels in the youth population residing in Delhi-NCR region of India. Methods: An online survey was conducted using a carefully designed Google form and the respondents were asked to give details about the basic health parameters and dietary lifestyle. Results: 67% of the respondents who consumed milk were found to have an ideal BMI. 64% of the respondents who consumed mustard oil as their predominant dietary fat showed normal BMI and more than 80% showed lower fatigue levels. Conclusion: Milk and mustard oil consumption is important for maintenance of an ideal BMI. Awareness should be created in the youth to have them as part of their daily diet.

Potassium Chloroaurate-Mediated In Vitro Synthesis of Gold Nanoparticles Improved Root Growth by Crosstalk with Sucrose and Nutrient-Dependent Auxin Homeostasis in Arabidopsis thaliana.

In a hydroponic system, potassium chloroaurate (KAuCl4) triggers the in vitro sucrose (Suc)-dependent formation of gold nanoparticles (AuNPs). AuNPs stimulate the growth of the root system, but their molecular mechanism has not been deciphered. The root system of Arabidopsis (Arabidopsis thaliana) exhibits developmental plasticity in response to the availability of various nutrients, Suc, and auxin. Here, we showed the roles of Suc, phosphorus (P), and nitrogen (N) in facilitating a AuNPs-mediated increase in root growth. Furthermore, the recuperating effects of KAuCl4 on the natural (IAA) auxin-mediated perturbation of the root system were demonstrated. Arabidopsis seedlings harboring the cell division marker CycB1;1::CDB-GUS provided evidence of the restoration efficacy of KAuCl4 on the IAA-mediated inhibitory effect on meristematic cell proliferation of the primary and lateral roots. Arabidopsis harboring synthetic auxin DR5rev::GFP exhibited a reinstating effect of KAuCl4 on IAA-mediated aberration in auxin subcellular localization in the root. KAuCl4 also exerted significant and differential recuperating effects on the IAA-mediated altered expression of the genes involved in auxin signaling and biosynthetic pathways in roots. Our results highlight the crosstalk between KAuCl4-mediated improved root growth and Suc and nutrient-dependent auxin homeostasis in Arabidopsis.

A unique miR775-GALT9 module regulates leaf senescence in Arabidopsis during post-submergence recovery by modulating ethylene and the abscisic acid pathway.

The submergence-induced hypoxic condition negatively affects the plant growth and development, and causes early onset of senescence. Hypoxia alters the expression of a number of microRNAs (miRNAs). However, the molecular function of submergence stress-induced miRNAs in physiological or developmental changes and recovery remains poorly understood. Here, we show that miR775 is an Arabidopsis thaliana-specific young and unique miRNA that possibly evolved non-canonically. miR775 post-transcriptionally regulates GALACTOSYLTRANSFERASE 9 (GALT9) and their expression is inversely affected at 24 h of complete submergence stress. The overexpression of miR775 (miR775-Oe) confers enhanced recovery from submergence stress and reduced accumulation of RBOHD and ROS, in contrast to wild-type and MIM775 Arabidopsis shoot. A similar recovery phenotype in the galt9 mutant indicates the role of the miR775-GALT9 module in post-submergence recovery. We predicted that Golgi-localized GALT9 is potentially involved in protein glycosylation. The altered expression of senescence-associated genes (SAG12, SAG29 and ORE1), ethylene signalling (EIN2 and EIN3) and abscisic acid (ABA) biosynthesis (NCED3) pathway genes occurs in miR775-Oe, galt9 and MIM775 plants. Thus, our results indicate the role for the miR775-GALT9 module in post-submergence recovery through a crosstalk between the ethylene signalling and ABA biosynthesis pathways.

Outcomes of surgical interventions for the treatment of limbal stem cell deficiency.

Background & objectives: In the current scenario, with availability of different surgical procedures for limbal stem cell deficiency (LSCD), there exists no common consensus as to the standardization of the management protocol for the same. In addition, there also exists diversity in the views about the clinical diagnosis, ancillary investigations and clinical parameters. The objective of the present study was to evaluate the reported outcomes of surgical interventions for the management of LSCD. Methods: A systematic review of published literature on limbal stem cell transplantation (LSCT) was performed using Ovid Medline, Embase and PubMed for a duration of 2009 to 2019. Original studies including prospective, retrospective case series and randomized controlled trials, articles in English language, articles with access to full text and studies with more than or at least 10 patients were included in this review. Data related to clinical and visual outcomes were evaluated, and pool estimates of different surgeries were calculated using random-effects model and individually using Pearson's Chi-square test. Results: A total of 1133 abstracts were evaluated. Finally, 17 studies were included for the analysis. Among these 17 studies, direct limbal lenticule transplantation was performed in five studies, of which autologous tissue from the fellow eye [conjunctival limbal autograft (CLAU)], allograft from a cadaver/live donor [keratolimbal allograft (KLAL)/conjunctival limbal allograft (CLAL)] and combination of CLAU plus KLAL were done in one, three and one studies, respectively. The ex vivo expanded cultivated limbal epithelial transplantation (CLET) was reported in six studies and simple limbal epithelial transplantation (SLET) in four studies. Two were comparative studies comparing CLET and CLAL (living-related CLAL) with cadaveric KLAL, respectively. Outcome analysis of the included studies showed significant heterogeneity. Calculated pool rate for various types of surgeries was calculated. The pool estimate for CLAL was 67.56 per cent [95% confidence interval (CI), 41.75-93.36; I2=83.5%, P=0.002]. For KLAL, this value was 63.65 per cent (95% CI, 31.38-95.91; I2=92.4%, P=0.000). Pool estimate for CLET was 78.90 per cent (95% CI, 70.51-87.28; I2=73.6%, P=0.001). Corresponding values for SLET were 79.08 per cent (95% CI, 74.10-84.07; I2=0.0%, P=0.619). CLAU and combination of CLAU plus KLAL were done in one study each; hence, statistical analysis could not be done. The functional outcome in terms of gain in visual acuity post-operatively was better in KLAL (P<0.005) and SLET group as compared to CLET group. Interpretation & conclusions: The present analysis suggests that though the anatomical success rates were almost identical between SLET, CLET, CLAL, and KLAL procedures, the functional success rates were better following KLAL and SLET procedures as compared to CLET. Decision for LSCT for cases of ocular burns based on either clinical judgement of the surgeon or individual diagnosis remains a suitable option.

Conserved LBL1-ta-siRNA and miR165/166-RLD1/2 modules regulate root development in maize.

Root system architecture and anatomy of monocotyledonous maize is significantly different from dicotyledonous model Arabidopsis The molecular role of non-coding RNA (ncRNA) is poorly understood in maize root development. Here, we address the role of LEAFBLADELESS1 (LBL1), a component of maize trans-acting short-interfering RNA (ta-siRNA), in maize root development. We report that root growth, anatomical patterning, and the number of lateral roots (LRs), monocot-specific crown roots (CRs) and seminal roots (SRs) are significantly affected in lbl1-rgd1 mutant, which is defective in production of ta-siRNA, including tasiR-ARF that targets AUXIN RESPONSE FACTOR3 (ARF3) in maize. Altered accumulation and distribution of auxin, due to differential expression of auxin biosynthesis and transporter genes, created an imbalance in auxin signalling. Altered expression of microRNA165/166 (miR165/166) and its targets, ROLLED1 and ROLLED2 (RLD1/2), contributed to the changes in lbl1-rgd1 root growth and vascular patterning, as was evident by the altered root phenotype of Rld1-O semi-dominant mutant. Thus, LBL1/ta-siRNA module regulates root development, possibly by affecting auxin distribution and signalling, in crosstalk with miR165/166-RLD1/2 module. We further show that ZmLBL1 and its Arabidopsis homologue AtSGS3 proteins are functionally conserved.

Author Correction: Sirtinol, a Sir2 protein inhibitor, affects stem cell maintenance and root development in Arabidopsis thaliana by modulating auxin-cytokinin signaling components.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Auxin signaling modulates LATERAL ROOT PRIMORDIUM1 (LRP1) expression during lateral root development in Arabidopsis.

Auxin signaling mediated by various auxin/indole-3-acetic acid (Aux/IAAs) and AUXIN RESPONSE FACTORs (ARFs) regulate lateral root (LR) development by controlling the expression of downstream genes. LATERAL ROOT PRIMORDIUM1 (LRP1), a member of the SHORT INTERNODES/STYLISH (SHI/STY) family, was identified as an auxin-inducible gene. The precise developmental role and molecular regulation of LRP1 in root development remain to be understood. Here we show that LRP1 is expressed in all stages of LR development, besides the primary root. The expression of LRP1 is regulated by histone deacetylation in an auxin-dependent manner. Our genetic interaction studies showed that LRP1 acts downstream of auxin responsive Aux/IAAs-ARFs modules during LR development. We showed that auxin-mediated induction of LRP1 is lost in emerging LRs of slr-1 and arf7arf19 mutants roots. NPA treatment studies showed that LRP1 acts after LR founder cell specification and asymmetric division during LR development. Overexpression of LRP1 (LRP1 OE) showed an increased number of LR primordia (LRP) at stages I, IV and V, resulting in reduced emerged LR density, which suggests that it is involved in LRP development. Interestingly, LRP1-induced expression of YUC4, which is involved in auxin biosynthesis, contributes to the increased accumulation of endogenous auxin in LRP1 OE roots. LRP1 interacts with SHI, STY1, SRS3, SRS6 and SRS7 proteins of the SHI/STY family, indicating their possible redundant role during root development. Our results suggested that auxin and histone deacetylation affect LRP1 expression and it acts downstream of LR forming auxin response modules to negatively regulate LRP development by modulating auxin homeostasis in Arabidopsis thaliana.

Role of chromatin modification and remodeling in stem cell regulation and meristem maintenance in Arabidopsis.

In higher plants, pluripotent stem cells reside in the specialized microenvironment called stem cell niches (SCNs) harbored at the shoot apical meristem (SAM) and root apical meristem (RAM), which give rise to the aerial and underground parts of a plant, respectively. The model plant Arabidopsis thaliana (Arabidopsis) has been extensively studied to decipher the intricate regulatory mechanisms involving some key transcriptions factors and phytohormones that play pivotal roles in stem cell homeostasis, meristem maintenance, and organ formation. However, there is increasing evidence to show the epigenetic regulation of the chromatin architecture, gene expression exerting an influence on an innate balance between the self-renewal of stem cells, and differentiation of the progeny cells to a specific tissue type or organ. Post-translational histone modifications, ATP-dependent chromatin remodeling, and chromatin assembly/disassembly are some of the key features involved in the modulation of chromatin architecture. Here, we discuss the major epigenetic regulators and illustrate their roles in the regulation of stem cell activity, meristem maintenance, and related organ patterning in Arabidopsis.

Knowledge and attitude towards eye donation among health professionals of northern India.

Background: We aimed to assess the knowledge and attitude of health professionals towards eye donation at an apex tertiary care centre of northern India. Methods: We interviewed 600 health professionals, comprising doctors, nurses, medical as well as nursing students, social workers and allied paramedical staff. A structured questionnaire (12 questions for assessing knowledge and 5 questions for assessing attitude) was used to estimate the awareness of eye donation and willingness to pledge eyes for donation. The responses pertaining to knowledge were graded as 'excellent', 'good' and 'poor' and those pertaining to attitude were grouped into 'positive' and 'negative'. Results: Of the 600 participants, 138 participants (23%) had 'excellent' knowledge and 234 participants (39%) had 'good' knowledge about eye donation. Awareness of eye donation was positively related to the level of literacy (odds ratio [OR] 8.5 [2.30-31.2]; p<0.001). Medical social workers and health supervisors had better knowledge about eye donation (OR 2.01 [1.08-3.72]; p=0.026) than other professional groups. Knowledge of eye donation had no significant association with age, gender, religion, family type and marital status of the respondent. Willingness to pledge eyes for donation was observed in only 6% of the participating health professionals. Pledging of eyes for donation was higher among older participants (OR 7.8 [2.67-22.77]; p<0.001). Conclusion: Our study shows that there is sufficient knowledge about eye donation, but an alarmingly low willingness to pledge eyes for donation among health professionals. Concerted efforts are required to alter their attitude to strengthen the Hospital Cornea Retrieval Programme.

Sutureless Customized Lamellar Corneal Transplant in a Patient with Gelatinous Drop-Like Corneal Dystrophy.

Patients with gelatinous drop-like corneal dystrophy need to be effectively managed as the disease is severely debilitating in view of associated pho-tophobia and glare. Here, we report a rare case of gelatinous drop-like corneal dystrophy effectively managed by intraoperative anterior segment optical coherence tomography-guided manual deep anterior lamellar keratoplasty in 1 eye and sutureless fibrin glue-aided, microkeratome-assisted automated lamellar therapeutic keratoplasty in the other eye. The patient, a 22-year old man, presented with gradual diminution of vision associated with foreign body sensation, glare, photophobia, and watering due to corneal lesions, which were consistent with a diagnosis of gelatinous drop-like corneal dystrophy. Visual acuity at pre-sentation was 4/60 and 3/60 in the right and left eye, respectively. The patient received customized component lamellar keratoplasty in both eyes, and host tissue was sent for histopathologic examination. Treatment resulted in a best-corrected distance visual acuity of 6/9 and 6/12 in the right and left eye, respectively. The graft was clear and well apposed, with minimal interface haze bilaterally. The histopathologic report suggested intralamellar amyloid deposition in the form of homogenous, acellular eosinophilic deposits in the epithelium and anterior corneal stroma. This is a first report of the exclusive use of a fibrin-aprotinin tissue adhesive to stabilize a donor corneal lamellar graft as a treatment modality for a patient with gelatinous drop-like corneal dystrophy, suggesting that this treatment could supplant the need for sutures.

Evaluation of strip meniscometry, tear meniscus height and depth in the diagnosis of dry eye disease in asian Indian eyes.

PURPOSE: Evaluate role of Strip Meniscometry (SMT) and lower tear meniscus [height (LTMH) & depth (LTMD)] in diagnosis of Dry Eye Disease (DED) and its comparison with TBUT. METHODS: In a prospective observational cross-sectional study of 120 eyes [60 eyes of 30 DED (Group 1) & 60 eyes of 30 controls (Group 2)] TBUT, Schirmer's, SMT, LTMH and LTMD was done. Subjects >18 years diagnosed with DED (aqueous deficient) as per Tear film and Ocular surface society-Dry Eye Workshop (TFOS DEWS) II protocol and Ocular surface disease Index (OSDI) questionnaire, with no associated systemic risk factor and previous ocular medical/surgical treatment were included as cases and subjects with no history of ocular surface disease as controls. The data was analyzed using t-test & receiver operating characteristic curve. RESULTS: TBUT & Schirmer's values were significantly lower in group 1 (p < 0.05). SMT was 2.28 ±â€¯1.28 (Range 0-6) & 8.11 ±â€¯1.39 (Range 3-10) in group 1 & 2 respectively (p < 0.05). LTMH was 169.32 ±â€¯29.84 µm (Range 85.78-209.11) and 234.41 ±â€¯19.51 µm (Range 203.89-289.53) in Group 1 & 2 respectively (p < 0.05). LTMD was 144.32 ±â€¯33.60 µm (Range 57.49-190.12) and 206.69 ±â€¯14.17 µm (Range 187.12-251.50) in Group 1 & 2 respectively (p < 0.05). The SMT, LTMH and LTMD showed a cutoff value of < 5 mm (AUC 0.994, sensitivity 96.7%, specificity 96.7%), 204.96 µm (AUC 0.998, sensitivity 98.3%, specificity 96.7%) & 190 µm (AUC 0.995, sensitivity 96.7%, specificity 95%) respectively. CONCLUSION: SMT, ASOCT, LTMD & LTMH are useful non invasive diagnostic tests for DED comparable with TBUT.

Whole mount in situ localization of miRNAs and target mRNA transcripts in plants.

The functional characterization of miRNAs often involves understanding of their spatiotemporal expression, which mostly relies on reporter-based or in situ hybridization studies. The available in situ localization methods follow separate protocols for pre-hybridization, hybridization, post-hybridization, and detection steps for both miRNA and mRNA transcripts in plants. In this study, we present a single method which can be used for whole mount in situ localization of both miRNAs and mRNAs in different plant tissues. Our modified method provides enhanced sensitivity for the localization of miRNA and their target transcripts. Consequently, a less laborious, time-saving, economic and efficient method has been proposed by the modification of pre-hybridization, hybridization, post-hybridization and detection steps.

Improved Method of RNA Isolation from Laser Capture Microdissection (LCM)-Derived Plant Tissues.

Laser capture microdissection (LCM) is a tool to isolate desired and/or less accessible cells or tissues from a heterogeneous population. In the current method, we describe an efficient and cost-effective method to obtain both high-quality mRNA and miRNAs in sufficient quantity from LCM-derived plant tissues. The quality of the isolated RNA can be assessed using Bioanalyzer. Using modified stem-loop RT-PCR, we confirmed the presence of 21-24 nucleotide (nt) long mature miRNAs. This modified LCM-based method has been found to be suitable for the tissue-specific expression analysis of both genes and small RNAs (miRNAs).

Deep blue dot corneal degeneration: confocal characteristics.

PURPOSE: To discuss the clinical features, differential diagnosis and the novel confocal microscopic findings noted in the rare 'deep blue dot corneal degeneration'. METHODS: Observational case report. RESULTS: Slit-lamp biomicroscopic examination revealed bilateral, numerous, circular to oval discrete blue opacities at the level of deep stroma and fine grey linear opacities at the level of mid to deep stroma. Confocal microscopy demonstrated two types of corresponding hyper-reflective extracellular lesions: oval deposit-like, most concentrated at a depth of 430-480 µ and needle-like at the depth 330-370 µ. CONCLUSIONS: Deep blue dot corneal degeneration is a rare entity where blue deposits of amyloid are seen in the deep corneal stroma. It should be considered as a differential diagnosis when an old-aged person presents with good vision and the above mentioned findings.

Toxic anterior segment syndrome following phakic posterior chamber IOL: a rarity.

Implantable collamer lenses (ICL) have gained popularity for correction of myopia where kerato-refractive procedures are not indicated as in cases of high myopic refractive errors. Toxic anterior segment syndrome (TASS) is a very uncommonly reported postoperative complication following ICL implantation. A young patient developed severe corneal oedema and anterior segment inflammation on the first day after ICL implantation. Analysing retrospectively, possible idiosyncratic response to intracameral pilocarpine was considered as a cause for TASS. Prompt and intensive therapy with oral and topical potent steroids was visually rewarding. TASS, though a sterile inflammation can have catastrophic sequelae such as corneal decompensation and secondary glaucoma. Hence, timely identification and management is important.

Plant small RNAs: advancement in the understanding of biogenesis and role in plant development.

MAIN CONCLUSION: Present review addresses the advances made in the understanding of biogenesis of plant small RNAs and their role in plant development. We discuss the elaborate role of microRNAs (miRNAs) and trans-acting small interfering RNAs (ta-siRNAs) in various aspects of plant growth and development and highlight relevance of small RNA mobility. Small non-coding RNAs regulate various aspects of plant development. Small RNAs (sRNAs) of 21-24 nucleotide length are derived from double-stranded RNAs through the combined activity of several biogenesis and processing components. These sRNAs function by negatively regulating the expression of target genes. miRNAs and ta-siRNAs constitute two important classes of endogenous small RNAs in plants, which play important roles in plant growth and developmental processes like embryogenesis, organ formation and patterning, shoot and root growth, and reproductive development. Biogenesis of miRNAs is a multistep process which includes transcription, processing and modification, and their loading onto RNA-induced silencing complex (RISC). RISC-loaded miRNAs carry out post-transcriptional silencing of their target(s). Recent studies identified orthologues of different biogenesis components of novel and conserved small RNAs from different model plants. Although many small RNAs have been identified from diverse plant species, only a handful of them have been functionally characterized. In this review, we discuss the advances made in understanding the biogenesis, functional conservation/divergence in miRNA-mediated gene regulation, and the developmental role of small RNAs in different plant species.

Expression dynamics of miRNAs and their targets in seed germination conditions reveals miRNA-ta-siRNA crosstalk as regulator of seed germination.

Seed germination paves the way for the dormant embryo to establish itself as a new plant marking the first critical step in postembryonic plant growth and development. Germination starts with the uptake of water (imbibition), followed by induction of transcription, translation, energy metabolism, and cell division processes. Although small RNAs have been implicated in many developmental processes, their role during seed germination stages and conditions remained elusive. Here we show that seed germination conditions, like imbibition and temperature, dynamically regulate the expression of many developmentally important miRNAs and their targets. We have identified 58 miRNAs belonging to 30 different families at different seed germination conditions. Amongst these, 15 miRNAs and their targets were significantly differentially expressed in Arabidopsis seeds in dry and 12 h, 24 h and 48 h of imbibition. Interestingly, differential expression of miR390, which targets trans-acting siRNA locus (TAS3) derived transcripts, resulted in alteration of tasiR-ARF mediated regulation of expression of target AUXIN RESPONSE FACTORs (ARF2/3/4). Our results suggest that the dynamic expression of several miRNAs, their targets, and a crosstalk between miRNA and ta-siRNA pathways contribute to the regulation of seed germination in Arabidopsis thaliana.

Awareness Regarding Eye Donation in an Urban Slum Population: A Community-Based Survey.

OBJECTIVES: Our objective was to assess the awareness of eye donation in an urban slum population and willingness to donate eyes after death. MATERIALS AND METHODS: A cross-sectional, population-based study was undertaken in 20 urban slum clusters of the Indian capital, New Delhi. A total of 2004 individuals aged 18 years and older were recruited. After written, informed consent was obtained, knowledge regarding eye donation was assessed through a predesigned close-ended questionnaire. The questionnaire was framed so as to understand the sociodemographic factors influencing the willingness to donate and the awareness of eye donation in this distinct population. RESULTS: The mean age of the recruited individuals was 36.53 ± 13.68 years. Age did not have any significant effect on awareness regarding eye donation. We observed that 34.3% of the study population had no knowledge of eye donation and that 7.78% of the study population had excellent knowledge. Education seemed to be an important determining factor regarding knowledge of eye donation. Multivariable logistic regression demonstrated better awareness among the Hindu population (81.1%) and those belonging to a higher caste (P < .05). The younger age group (those 18-30 years old) showed significant willingness to donate their eyes versus older age groups (P < .001). In our study population, male participants (P = .006), those classified as literate (P < .001), and those classified as Hindu (P < .001) were more willing to pledge their eyes for donation. CONCLUSIONS: Although there is substantial awareness about eye donation, willingness to pledge eyes was very low in the urban slum population. Additional efforts are needed to translate this awareness into actual eye donation in the urban poor population.

Vitreous hemorrhage as a clue to late presenting Pulmonary Arterio Venous Malformation.

Retinal vasculature is frequently altered in systemic vascular disorders such as Diabetes and Hypertension. We present a rare case in which vitreous hemorrhage was the presenting sign of an underlying congenital cyanotic heart disease.