In vitro profiling of fenofibrate solid dispersion mediated tablet formulation to treat high blood cholesterol

OBJECTIVE

Fenofibrate (FNF), an anti-hyperlipidemic agent, suffers from poor water solubility (0.000707mg/ml) and belongs to class II drug as per BCS, shows a slow dissolution rate. The current investigation aimed to fabricate a fast-dissolving tablet of FNF (not available in the commercial market) using solid dispersion technique employing Vitamin E-D-α-Tocopheryl polyethylene glycol 1000 succinate (vitamin E TPGS) as molecular biomaterial to enhance dissolution rate and reduce the time required to reach the systemic circulation.

MATERIALS AND METHODS

Firstly, carrier material was selected based on the release study via preparing solid dispersion using the melting method, and prepared solid dispersion was characterized. Secondly, fast-dissolving tablets from solid dispersion were fabricated using the direct compression tool and characterized for X-ray diffraction (XRD) pattern, friability, hardness, content uniformity, weight variation and in vitro disintegration test.

RESULTS

The X-ray diffraction study confirmed the successful formation of solid dispersion using vitamin E TPGS by analyzing the change in physical state. The fabricated solid dispersion exhibited higher drug content than a physical mixture of FNF. An excipient interference study was also performed in methanol and 0.75% w/v sodium lauryl sulphate. It revealed no significant alterations in the absorption peak of FNF as analyzed using UV spectroscopy at 287nm. In addition, water absorption ratio phase solubility and wetting time were also assessed. In -vitro release of FNF from developed tablets was found significantly higher (93.23%±3.11; p<0.001) as compared to prepared compressed tablet of pure FNF (12.21±2.34%). The dissolution rate was also determined, and data were then kept to various kinetic models such as zero-order chemical kinetic, first-order chemical kinetic, Hixon-Crowell and Higuchi chemical kinetic.

CONCLUSION

A complete and sequential in vitro and physicochemical characterization of developed formulation was carried out to set-up improved and effective treatment for high blood cholesterol.

Role of Decompressive Craniectomy/ Hemicraniectomy in the Management of Traumatic Brain Injury: A Retrospective Study

Introduction: Head injury is one of the most common outcomes of any kind of trauma becoming the major cause of morbidity and mortality worldwide. The critical element in the treatment of patients with severe head injuries is to prevent the progression of the condition and secondary insult to brain cells. Various protocols are followed for the treatment of severe head injury starting from conservative medical management to surgical approaches like DC/hemicraniectomy (DC). The DC is a surgical method of removal of part of skull bone so that the brain parenchyma gets space to expand and the Intracranial Pressure (ICP) can get reduced. There are various factors that contribute to the outcome of DC. Aim: To determine the various factors that affect the outcome of DC/hemicraniectomy. Materials and Methods: A retrospective descriptive study was conducted in the Institute of Gandhi Medical College and associated Hamidia hospital, Madhya Pradesh, India from May 2017 to April 2021. Hundred patients with moderate to severe head injury who underwent primary DC were included in this study. The variables such as age, preoperative GCS, the timing of surgery, preoperative pupillary reaction, and MidLine Shift (MLS) were compared in terms of survival/death and favourable/ unfavourable outcomes using the chi-square test. Results: The mean age of participants was 45±14 years. Statistical analysis showed significant results for the variables like age, preoperative the Glasgow Coma Scale (GCS), timing of the surgery, pupillary reaction at presentation, and preoperative MLS in terms of survival/death and favourable/ unfavourable outcomes. Conclusion: Younger age group, better preoperative GCS, early surgery, reactive pupils at presentation, and less preoperative MLS have positive outcome benefits with the DC/ hemicraniectomy to reduce the raised ICP.

Effectiveness of Swallow Therapy on Swallowing Ability among Patients with Cerebrovascular Accident

Cerebrovascular accident occurs when the blood supply to the brain is disturbed in some way. As a result the brain cells are deprived of oxygen. It is also known as stroke. It is being observed as a rapidly growing problem and an important cause of illness and death in Saudi arabia. The major problem of cerebrovascular accident is paralysis of swallowing muscles leading to swallowing difficulty which is known as dysphagia. It involves the mouth, throat and esophagus. The goal of this study was to see how swallow treatment affected patients with cerebrovascular accidents at Saveetha Medical College and Hospital in Chennai. The study used a quasi-experimental one-group pre- and post-test design. A total of 30 samples were chosen with care. The Mann Assessment of Swallowing Skills (MASA) was used to examine swallowing ability on regular basis. The results reveal that there is a significant difference in swallowing capacity before and after therapy when using descriptive and interferential statistical approaches. The average score of swallowing ability before swallow therapy was 155.0±16.34, while the average score after swallow therapy was 170.87±11.12. At p<0.001 level, the estimated paired ‘t’ test value of t = 7.171 was judged to be statistically highly significant. This obviously implies that administering swallow therapy to individuals with cerebrovascular accident was shown to be useful in enhancing post-test swallowing skills. The swallowing therapy was found to be one of the most successful traditional therapies for improving the swallowing skills of people with swallowing difficulties, according to the findings.

Characterization of halo-tolerant plant growth promoting endophytic Bacillus licheniformis MHN 12

Background

Endophytic bacteria overlay significant role in plant growth promotion, eliminating phyto-pathogens and combating stress-conditions. In the present study, we aimed to screen high salt tolerant bacteria and study their adaptive response to elevated salt concentrations. A total of 46 endophytic bacterial isolates from Vigna radiata were screened for salt tolerance. The high salt tolerant endophytic isolate was characterized for alteration in morphology, growth rate, protein profiling, and compatible solute concentrations.

Results

The isolate MHN12, based upon biochemical characterization and partial 16S rDNA sequencing identified as B. licheniformis (accession number MG273753) was able to tolerate up to 15% NaCl (Sodium Chloride) (2.6 M) concentration. The isolate possessed 1-aminocyclopropane-1-carboxylic acid deaminase (ACCD) activity along with indole acetic acid (IAA), siderophore, ammonia, organic acid and hydrogen cyanide (HCN) production. Accumulation of proline was apparent up to 7.5% NaCl concentration and declined afterwards. Ultrastructure analysis using TEM (transmission electron microscopy) revealed the morphological alteration from rods to filaments.

Conclusion

Acclimatization to salt stress and plant growth promoting activities could contribute to utilization of this bacterium as bioinoculant to enhance the crop yield and discourage the application of chemical fertilizers.

Exploration of plant growth-promoting endophytic bacteria from Pisum sativum and Cicer arietinum from South-West Haryana

In the present study, nonrhizobial endophytes were isolated from Pisum sativum and Cicer arietinum from Haryana, India. A total of 355 bacterial endophytes were screened for plant growth promoting traits. Out of all, 96 bacterial endophytes were selected based on morphological characters and multi-PGP traits, and their diversity analyzed by amplified ribosomal DNA restriction analysis. Based on their ARDRA profile, the 25 representative isolates (12 from P. sativum and 13 from C. arietinum), were selected and identified by 16S ribosomal DNA sequencing. Genetic relatedness based on BLAST analysis revealed the similarity of these isolates with members of three prominent phyla, that is, Proteobacteria, Firmicutes, and Actinobacteria. The dominant cluster, Firmicutes, constituted 60% of the isolates, assigned to four different genera, Bacillus, Staphylococcus, Ornithinibacillus, and Lysinibacillus. Phylum α-proteobacteria included two genera, namely Paenochrobactrum and Ochrobactrum and three genera in phylum γ-proteobacteria, namely Pseudomonas, Pantoea and Proteus. The phylum Actinobacteria was constituted of two genera, Microbacterium and Arthrobacter. Bacillus zhangzhouensis, Bacillus safensis, Arthrobacter enclensis from P. sativum and Bacillus haynesii, Paenochrobactrum sp. from C. arietinum are documented as plant growth promoting endophytic bacteria for the first time in the present study. The in vitro and in vivo assessment based on bonitur score revealed that the endophytic isolates Bacillus mojavensis PRN2, Pseudomonas chlororaphis PHN9, B. safensis PRER2, Pseudomonas sp. RCP1, Pseudomonas lini PRN1 and B. haynensii RCP3 from P. sativum and C. arietinum significantly enhanced the plant growth parameters. Therefore, these potential isolates can be further harnessed for preparation of bioformulations to enhance sustainable agriculture.

Endophytism: A Multidimensional Approach to Plant-Prokaryotic Microbe Interaction

Plant growth and development are positively regulated by the endophytic microbiome via both direct and indirect perspectives. Endophytes use phytohormone production to promote plant health along with other added benefits such as nutrient acquisition, nitrogen fixation, and survival under abiotic and biotic stress conditions. The ability of endophytes to penetrate the plant tissues, reside and interact with the host in multiple ways makes them unique. The common assumption that these endophytes interact with plants in a similar manner as the rhizospheric bacteria is a deterring factor to go deeper into their study, and more focus was on symbiotic associations and plant–pathogen reactions. The current focus has shifted on the complexity of relationships between host plants and their endophytic counterparts. It would be gripping to inspect how endophytes influence host gene expression and can be utilized to climb the ladder of “Sustainable agriculture.” Advancements in various molecular techniques have provided an impetus to elucidate the complexity of endophytic microbiome. The present review is focused on canvassing different aspects concerned with the multidimensional interaction of endophytes with plants along with their application.

POS1397 HYDROXYCHLOROQUINE INDUCED RETINAL TOXICITY IN PATIENTS WITH RHEUMATIC DISEASES

Background:

Retinal toxicity from hydroxychloroquine (HCQ) is rare, but the vision loss maybe irreversible and could have medicolegal consequences.

Objectives:

To determine the prevalence and assess the predictors of retinal toxicity due to HCQ in patients with rheumatic diseases. There is paucity of literature on retinal toxicity due to HCQ in rheumatic diseases.

Methods:

A retrospective observational study was conducted in the Department of Clinical Immnuology and Rheumatology, Sri Ramachandra Institute of Higher Education and Research,Chennai, India from November 2018-May 2020, on patients taking HCQ for more than 6 months. All patients underwent ophthalmological screening at baseline and every 6 months, and thereafter by modern day screening methods-Humphrey Visual Field (HVF)10-2, Spectral Domain Optical Coherence Tomography(SD-OCT), except for patients with evidence of suspected retinal toxicity at baseline.Fundus autofluorescence (FAF) was done in feasible patients.

Results:

9 out of 743(1.2%) patients were identified to have retinal toxicity, detected via fundus examination (n=9), SD-OCT (n=8/9), HVF 10-2 (n=6/9), FAF (n=1/9). 55.5% (n=5/9) had Rheumatoid Arthritis(RA) and 44.4% (n=4/9) had Systemic Lupus Erythematosus(SLE) as their primary diagnosis. 77.7% (n=7/9) were females. The mean age was 47.5 years (20-72 years).75%(n=3/4) of SLE patients were below 30 years of age. The average daily and cumulative dose of HCQ in these 9 patients were 244 mg (200-400mg) and 311.22g(73-730g)respectively, whereas the mean recommended dose as per real body weight was 287.2mg/day. Average duration of HCQ consumption was 3.6 years (1-10 years).Only 11.1% (n=1/9) had presented with visual complaints of black floaters.

Conclusion:

The asymptomatic nature of this irreversible toxicity, warrants frequent screening.Retinal toxicity was not age-related.Toxicity was manifested at low daily and cumulative doses.Screening should be done atleast every 6 months by fundus examination.Objective tests like HVF and SD-OCT should be done annually, especially in patients with underlying rheumatic diseases.The early manifestation of retinal toxicity in young SLE patients could have a genetic association and needs further evaluation.

References:

[1]Mortada A Abozaid et al. hydoxychloroquine retinopathy in a ohort of patients from upper Egypt.Journal of Egyptioan Ophthalmological Society 2017;110:110-113

[2]Roy AN,Samala V,Kumar YA,Fatima SS.Assessing the risk of retinopathy in Indian patients using hydroxychloroquine for rheumatic and musculoskeletal Diseases:A Retrospective Observational Study.Indian J Rheumatol 2020.

Disclosure of Interests:

None declared

AB0235 RITUXIMAB (BIOSIMILAR) IN RHEUMATOID ARTHRITIS: CLINICAL & IMMUNOLOGICAL RESPONSE TO VARYING DOSES- EXPERIENCES FROM A TERTIARY CARE CENTER IN SOUTH INDIA

Background:

Rituximab (RTX) is a chimeric monoclonal antibody against CD20. There is a paucity of studies done with RTX biosimilars. This is a Retrospective and Observational study from January 2018 to December 2019 done in the Department of Clinical Immunology & Rheumatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India.

Objectives:

1.To find the effects of varying doses of RTX in attaining clinical remission in RA.

2.To find if CD19, CD20 & IgG help in identifying impending flare & if these levels help in deciding the timing of the next dose of RTX.

Methods:

Rheumatoid arthritis (RA) cases who were given Rituximab from January 2018 were selected. Clinical Response at 6 & 12 months & wherever feasible at 18 & 24 months was assessed by Simplified Disease Activity index (SDAI). RTX initial dose was given at 0 and 14 days followed by fixed dose at six months interval.CD19, CD20 B cell count, IgG levels were tested in patients in whom it was feasible at baseline & 6 months (select patients at 12,18 &24 months). Patients were divided in to 5 groups (DMARD naïve, DMARD resistant & Interstitial Lung disease (ILD) [Lung involvement>20% in Computed Tomography (CT)]) and (500mg & 1g). Patients were divided into three clinical groups, (DMARD naïve, DMARD resistant & Interstitial Lung disease (ILD) [Lung involvement>20% in Computed Tomography (CT)]) and two treatment groups (500mg & 1g) based on clinical indication for RTX and dose of RTX, respectively. In patients with ILD, CT scan & FVC were compared at baseline & 12 months.

Results:

29 patients (seropositive 28 (RF/Anti CCP/BOTH+VE), seronegative 1) were given RTX for RA over a 2-year period of which 12 had CD19, CD20 & IgG tested. Mean SDAI reduction from baseline to 6 months post treatment was 30%, 32% & 14% while complete remission (SDAI<3.3) was attained in 100%, 18% & 20% in DMARD naïve, DMARD resistant & ILD groups, respectively. CD19, CD20 & IgG reduced from 18.6%, 18.4% & 18.53g/L to 3.7%,3.7% & 9.7g/L respectively FVC improved from 62.4% to 67% at 12. The percentage of patients with lung involvement >20% reduced from 53.3% to 46.7%. Flare was observed in one patient who received 500mg RTX. CD19, CD20 & IgG levels increased from 7.9%, 8% & 9.8g/L to 27%, 25% & 13g/L respectively. 3 patients in the 1g group were followed up at 12,18 & 24 months. In these patients there were no flares or worsening symptoms. 1 patient was double negative for RF & Anti CCP and this patient did not attain clinical remission even after 2 doses of 1g RTX.

Conclusion:

[1]Patients with early arthritis (diagnosis made within 1 year) and who were DMARD naïve had an excellent response to Rituximab.

[2]Complete remission was observed in more patients the 1g compared to 500mg group.

[3]Reduction in CD19 & CD20 was associated with significant reduction in the SDAI score.

[4]There was no significant reduction of CD19 & CD20 with 500mg dose of Rituximab where either a partial remission or mild flare was observed.

[5]There was reduction in the lung involvement to less than 20%(CT) in few patients with 1g dose.

[6]Double negative Rheumatoid arthritis poorly responded to Rituximab.

[7]The positive effects of 1g Rituximab could be noted up to 24 months.

[8]Flare of RA was associated with significant increase in CD19 & CD20.

Disclosure of Interests:

None declared

AB0773 PATTERN OF MACROPHAGE ACTIVATION SYNDROME IN RHEUMATIC DISEASES

Background:

Macrophage activation syndrome (MAS) is a rare, potentially fatal condition complicating autoimmune diseases, as their initial manifestation or during its course.

Objectives:

To describe the pattern of MAS and its salient features in patients with rheumatic diseases.

Methods:

A retrospective observational study was conducted in 16 patients diagnosed with MAS, due to rheumatic diseases in Department of Rheumatology, SRIHER, Chennai from January 2018-December 2020.

Results:

The primary diseases were Systemic Lupus Erythematosus(SLE) in 75%(n=12),Adult Onset Still Disease(AOSD) in18.7%(n=3) and Kikuchi Disease in 6.25%(n=1). 50%(n=8) presented with MAS as the initial manifestation.Others had a known rheumatic disease with an average duration of 6.5 years.Occult MAS was seen in 25%(n=4). The most frequent clinical features were unremitting fever(n=15) and splenomegaly(n=15).All had hyperferritinemia-mean of 2971.10 ng/mL(531-12536).Sub group analysis showed significant hypofibrinogenemia(129.8 vs 200.62 mg/dl) in patients presenting with MAS as their initial manifestation.Transaminitis(666/252.5 vs 243/217.62 U/L), hypertriglyceridemia(316 vs 275.8 mg/dl), high LDH(2490 vs 938.75) were more severe in this group, but not significant.All with SLE had increased disease activity, with 50%(n=8) having SLEDAI 2K of ≥15.Bone marrow aspiration showed haemophagocytes in 81.25%(n=13).H score of >169 was seen in 93.75%(n=15). Infection was the commonest trigger for MAS(n=9)-bacterial(n=5), viral(n=4), fungal(n=1) and mycobacterial(n=2),followed by parturition(n=1).All patients were managed with pulse steroids followed by intravenous cyclophosphamide(n=8), rituximab(n=2), mycophenolate mofetil(n=2) in SLE, tocilizumab(n=2) and etoposide(n=1) in AOSD.Mortality rate was 18.75%(n=3).

Conclusion:

Spectrum of MAS in rheumatic diseases could be occult, associated with infection,high disease activity,or lead to mortality. High index of clinical suspicion is required, due to overlap of features like fever, cytopenias and organomegaly in MAS & SLE.Hyperferritinemia, high LDH, & transaminitis could aid in differentiating & early diagnosis. New criteria for rheumatic diseases,including these parameters are needed, especially in resource-limited settings where sIL-2Rα & NK cell activity tests are not feasible.

References:

[1]Stuart J.Carter et al. Macrophage activation syndrome in adults:Recent advances in pathophysiology, diagnosis and treatment. Rheumatology 2019;58;5-17

[2]Ai-Chun Liu et al.Macrophage activation syndrome in systemic lupus erythematosus:a multicentre,case-control study in China.Clin Rheumatol 2017.

Table 1.

MAS-SALIENT FEATURES

FEATURESINITIAL MANIFESTATIONS [n=8]KNOWN RHEUMATIC DISEASES[n=8]P VALUE(<0.05)Primary rheumatic diseasesSLE5(62.5%)7(87.5%)-AOSD2(25%)1(12.5%)Kikuchi disease1(12.5%)0Fever8(100%)7(87.5%)0.30Respiratory2(25%)5(62.5%)0.13Neurological1(12.5%)4(50%)0.10Bleeding2(25%)1(12.5%)0.52Splenomegaly8(100%)7(87.5%)0.30Hepatomegaly6(75%)3(37.5%)0.13Haemoglobin(g/dl)8.58(5.4-11.7)8.2(5.2-11.5)0.70WBC count(/μL)5550(1000-11800)3477.5(1200-6200)0.19Platelet count(x 109/l)1.41(0.30-2.4)1.35(0.32-1.8)0.90ESR(mm/hr)76.75(42-137)68(20-127)0.65AST(U/L)666(36-3481)257.75(45-642)0.36ALT(U/L)252.5(18-790)217.62(28-1044)0.82LDH(U/L)2490.12(164-16,000)938.75(357-1569)0.44Ferritin(ng/ml)2187.46(532-7500)3754.75(531-12536)0.37Triglycerides(mg/dl)316(53-551)275.8(160-317)0.52Fibrinogen(mg/dl)129.8(76-178)200.62(140-292)0.009Complement 3(mg/dl)39.14(13-60)[n=5]57.72(32-95)[n=7]0.16Complement 4(mg/dl)4.24(1.2-6)[n=5]14.22(2.8-34)[n=7]0.07Anti dsDNA antibodies[ELISA] IU/ml596.2(90-1151)[n=5]316.82(10-800)[n=7]0.26

MAS-Macrophage activation syndrome,WBC-white blood cell,ESR-erythrocyte sedimentation rate,AST-aspartate aminotransferase, ALT-alanine aminotransferase, LDH-lactate dehydrogenase, dsDNA-double standed deoxyribonucleic acid

Disclosure of Interests:

None declared

Prospective Nonrandomized Comparison Between Open and Robot-Assisted Kidney Transplantation: Analysis of Midterm Functional Outcomes

Introduction: To compare short- and midterm outcomes of the first 55 patients undergoing robot-assisted kidney transplant (RAKT) with patients undergoing open kidney transplant (OKT) during the same period in a tertiary care hospital. Materials and Methods: Data of all end-stage renal disease patients undergoing renal transplant were prospectively maintained. All graft kidneys were harvested laparoscopically. Both RAKT and OKT were performed using standardized techniques, and all RAKTs were performed by a single experienced robotic surgeon. Chi-square test/Fisher exact test was done for categorical data, and Mann-Whitney U test was done for continuous data. Discrete variables were expressed in absolute numbers and percentages. For all tests, p < 0.05 was considered significant. All results were expressed as mean ± standard deviation or median with range. Results: Between April 2016 and September 2018, 55 patients underwent RAKT. The same was compared with 152 patients who underwent OKT. The two groups were comparable in terms of age, gender, and body mass index. Duration on hemodialysis was significantly higher in the RAKT group, and hemoglobin and donor kidney glomerular filtration rate was significantly better in the RAKT group. Requirement of perioperative analgesia was significantly less in the RAKT group. Rewarm ischemia time was significantly longer in the RAKT group. The fall in serum creatinine was slower in RAKT group till 3 months. The serum creatinine levels were statistically similar in the two cohorts at 3 months (p = 0.082), which was maintained at median 29 months of follow-up (p = 0.067). Tacrolimus levels on postoperative day 2 were found to be significantly higher in RAKT cohort (17.98 ± 14.41) vs OKT cohort (11.38 ± 6.93). Surgical-site infections were rare in the RAKT group. Conclusions: RAKT confers advantage of decreased wound morbidity with similar functional outcomes compared with OKT in midterm. It looks promising; however, long-term follow-up of larger numbers of patients is needed.

Loss of end-differentiated β-cell phenotype following pancreatic islet transplantation

Replacement of pancreatic β-cells through deceased donor islet transplantation is a proven therapy for preventing recurrent life-threatening hypoglycemia in type 1 diabetes. Although near-normal glucose levels and insulin independence can be maintained for many years following successful islet transplantation, restoration of normal functional β-cell mass has remained elusive. It has recently been proposed that dedifferentiation/plasticity towards other endocrine phenotypes may play an important role in stress-induced β-cell dysfunction in type 2 diabetes. Here we report loss of end-differentiated β-cell phenotype in 2 intraportal islet allotransplant recipients. Despite excellent graft function and sustained insulin independence, all examined insulin-positive cells had lost expression of the end-differentiation marker, urocortin-3, or appeared to co-express the α-cell marker, glucagon. In contrast, no insulin⁺ /urocortin-3^- cells were seen in nondiabetic deceased donor control pancreatic islets. Loss of end-differentiated phenotype may facilitate β-cell survival during the stresses associated with islet isolation and culture, in addition to sustained hypoxia following engraftment. As further refinements in islet isolation and culture are made in parallel with exploration of alternative β-cell sources, graft sites, and ultimately fully vascularized bioengineered insulin-secreting microtissues, differentiation status immunostaining provides a novel tool to assess whether fully mature β-cell phenotype has been maintained.

Treatment of HCV infection in liver transplant recipients with ledipasvir and sofosbuvir without ribavirin

BACKGROUND

Ledipasvir and sofosbuvir is a well-tolerated regimen with high sustained virological response (SVR) rates in pre-liver transplant patients infected with chronic hepatitis C virus (HCV), but data in liver transplant recipients outside of clinical trials is limited.

AIM

To address this knowledge gap and assess SVR rates without the use of ribavirin in liver transplant recipients METHODS: This is a retrospective study examining the treatment of 75 post-liver transplant recipients with ledipasvir and sofosbuvir without ribavirin. Differences between SVR cohorts and predictors of SVR were analysed in an intention-to-treat (ITT) fashion.

RESULTS

A total of 408 genotype 1, HCV patients were treated with ledipasvir/sofosbuvir from October 2014 to August 2015 at our centre. Seventy-three patients were post-liver transplant and were treated with a median of 2.9 years from transplant. Ledipasvir/sofosbuvir achieved an SVR12 of 95.9%. African Americans made up 28.8% of the cohort. Sixty-three per cent of patients were treated previously, including 13.7% of patients previously treated with direct-acting antivirals. Only 2.7% had recurrent allograft cirrhosis, and the majority (90.4%) was on calcineurin inhibitor based immunosuppressive therapy. Approximately 82% of patients had chronic kidney disease (CKD) stage 2 or 3. In univariate logistic regression, only detectable week 8 viral load was predictive of failure to achieve SVR.

CONCLUSION

Our data confirm excellent SVR outcomes and favourable safety and tolerability profiles with ledipasvir/sofosbuvir without ribavirin in post-liver transplant recipients infected with HCV, despite treatment guidelines to use ribavirin.

Arthroscopic treatment of femoroacetabular impingement following slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) may lead to symptomatic femoroacetabular impingement (FAI). We report our experience of arthroscopic treatment, including osteochondroplasty, for the sequelae of SCFE. Data were prospectively collected on patients undergoing arthroscopy of the hip for the sequelae of SCFE between March 2007 and February 2013, including demographic data, radiological assessment of the deformity and other factors that may influence outcome, such as the presence of established avascular necrosis. Patients completed the modified Harris hip score (mHHS) and the non-arthritic hip score (NAHS) before and after surgery. In total, 18 patients with a mean age of 19 years (13 to 42), were included in the study. All patients presented with pain in the hip and mechanical symptoms, and had evidence of FAI (cam or mixed impingement) on plain radiographs. The patients underwent arthroscopic osteoplasty of the femoral neck. The mean follow-up was 29 months (23 to 56). The mean mHHS and NAHS scores improved from 56.2 (27.5 to 100.1) and 52.1 (12.5 to 97.5) pre-operatively to 75.1 (33.8 to 96.8, p = 0.01) and 73.6 (18.8 to 100, p = 0.02) at final follow-up, respectively. Linear regression analysis demonstrated a significant association between poorer outcome scores and increased time to surgery following SCFE (p < 0.05 for all parameters except baseline MHHS). Symptomatic FAI following (SCFE) may be addressed using arthroscopic techniques, and should be treated promptly to minimise progressive functional impairment and chondrolabral degeneration.

TAKE HOME MESSAGE

Arthroscopy of the hip can be used to treat femoroacetabular impingement successfully following SCFE. However, this should be performed promptly after presentation in order to prevent irreversible progression and poorer clinical outcomes.

Combined endothelial keratoplasty and clear lens extraction for corneal decompensation in irido-corneal endothelial syndrome

A 38-year-old woman presented with corneal decompensation in left eye secondary to irido-corneal endothelial (ICE) syndrome. She underwent simultaneous Descemet's stripping endothelial keratoplasty (DSEK) and clear lens extraction with posterior chamber intraocular lens implantation. The surgery was accomplished comfortably without rupture of peripheral anterior synechiae (PAS). 5 weeks postoperatively, the graft was attached, the cornea was clear and best-corrected visual acuity improved from 20/400 to 20/30. DSEK combined with clear lens extraction appears to be an effective measure to treat corneal decompensation in patients with ICE syndrome. Associated lens extraction in such cases increases the working space in anterior chamber for DSEK, which minimizes the intra-operative graft manipulation. This also avoids a future difficult cataract surgery in the presence of PAS and an endothelial graft, which may increase the chances of graft survival.

Tonometry and Care of Tonometers

Intraocular pressure (IOP) remains the only modifiable risk factor in the management of glaucoma. Hence, IOP and its appropriate measurement deserve our ongoing interest. Over the years, not only has our understanding of glaucoma changed but also has changed our approach to the measurement of the IOP. This review is an attempt to elucidate the commonly techniques of tonometry, and critically evaluate each of them, in current glaucoma practice.

How to cite this article: Maheshwari R, Choudhari NS, Singh MD. Tonometry and Care of Tonometers. J Current Glau Prac 2012;6(3):124-130.

Thyroid associated orbitopathy

Thyroid associated orbitopathy, also known as Graves’ orbitopathy, is typically a self-limiting autoimmune process associated with dysthyroid states. The clinical presentation may vary from very mild disease to severe irreversible sight-threatening complications. Despite ongoing basic science and clinical research, the pathogenesis and highly effective therapeutic strategies remain elusive. The present article reviews the pathophysiology, clinical presentation, and management of this common, yet poorly understood disease, which remains a challenge to the ophthalmologist.

Total elbow replacement with the Coonrad-Morrey prosthesis: our medium to long-term results

INTRODUCTION

Semiconstrained total elbow replacement is now a well recognised and reliable surgical option for advanced elbow disease, mainly rheumatoid arthritis.

METHODS

We report a retrospective analysis of 31 primary total elbow replacements in 28 patients with a mean follow-up duration of 55 months. The mean age of the patients was 65 years. The indications included 27 cases of rheumatoid arthritis, 3 fractures and 1 case of osteoarthritis. Twenty-one elbows in nineteen patients were assessed using the Mayo elbow performance score (MEPS) in a special follow-up clinic. In the other nine patients (ten elbows), the assessment was carried out with case notes and x-rays.

RESULTS

The mean pre-operative MEPS in the 21 elbows recalled was 40. This improved to 89 post-operatively (range: 55-100). Sixteen of the twenty-one elbows were considered excellent, two good, two fair and one poor. The range of movement was recorded in eight of the other ten elbows and the mean was 98°. At the last follow-up visit, x-rays were normal in 23 elbows although the ulnar component was loose in 3, the humeral component loose in 2. There were also two cases of non-union of the medial epicondyle and one patient had mild heterotopic ossification. Complications included one infection, which needed irrigation and debridement with a satisfactory final result, and two cases of ulnar nerve palsy/neurapraxia. Two elbows were considered failures due to severe pain caused by prosthetic loosening. These were referred for revision surgery.

CONCLUSIONS

Excellent pain relief and good function can be achieved in the medium and long term with the Coonrad-Morrey-semiconstrained total elbow replacement prosthesis in patients with severe destructive elbow arthropathy.

Muller's muscle resection for ptosis and relationship with levator and Muller's muscle function

PURPOSE

Results of Muller's muscle resection in patients with ptosis and its relationship with levator and Muller's muscle function.

METHODS

Prospective review of medical records of all pateints who underwent open sky Mullerectomy for correction of upper eyelid ptosis. The study period was from January 2008 to July 2009. Levator function, MRD1, Phenylepherine test result and extent of ptosis correction were recorded. Excised muscle tissue in few cases were subjected to histopathology.

RESULTS

In 11 patients who underwent 13 mullerectomy procedures for correction of upper eyelid ptosis, MRD1 increased an average by 2.54 mm. The amount of ptosis correction was 4.28 mm in pateints with either good levator function and/or Muller's action and 1mm in patients where both responses to phenylepherine and levator functions were poor. Histopathology revealed both straited and smooth muscle tissue in the excised specimens in all cases.

CONCLUSION

Mullerectomy porbably involves plication of the posterior layer of the levator aponeurosis. Results of Muller's muscle resection is good in patients with good levator function and/or good Mullers action and poor if both Muller and levator function are poor.

Accommodation: its relation to refractive errors, amblyopia and biometric parameters

AIM

To study accommodation in relation to different refractive errors, amblyopia and to measure the anatomical changes in the accommodating eye

MATERIALS AND METHODS

We studied the amplitude of accommodation (AA) in 150 patients in the age group 11 ± 30 years which included emmetropes, myopes, hypermetropes and hypermetropic amblyopes using the Royal Air Force (RAF) rule. The anterior chamber depth (ACD), axial length (AxL) and lens thickness (LT) changes during accommodation were measured using an A-scan. Myopes and hypermetropes were further divided based on the amount of refractive error : less than 2D, 2 -4D and greater than 4D.

RESULTS

Corrected low myopes had the highest accommodation amplitude (p less than 0.05) followed by emmetropes. Corrected hypermetropes were found to have the lowest amplitude of accommodation (p less than 0.05). The amblyopic eye had a significantly low AA compared to the non-amblyopic eye (p less than 0.05). ACD decreased (p less than 0.05) and LT increased (p less than 0.05) during accommodation. The AxL increase was maximum in myopes (p less than 0.05) followed by hypermetropes but the change was not significant in hypermetropes (p greater than 0.05).

CONCLUSION

The amblyopic eye has low amplitudes of accommodation proving the benefit of near adds in amblyopic patients. Prolonged near work might induce myopia in susceptible eyes by increasing the axial length.

Xerosis meter-an electro-physiological device for quick screening of dry eyes

AIM

to study the role of'Xerosis Meter' in screening of dry eye cases in a large population and compare its results with Schirmer's test and tear break-up time.

MATERIALS AND METHOD

in a cross sectional study with a control group dry eye was evaluated with Xerosis Meter, Schirmer test and tear film break-up time (TBUT). Cases included in the study were divided into two groups. Group I (Control Group) comprised of asymptomatic patients while Group II (Test Group) had patients showing symptoms and signs of dry eye. The Group II was further divided into two subgroups. Group IIa had cases showing positive result with either of the two tests Schirmer test or TBUT. Group IIb had cases which showed positive results with Xerosis Meter but normal results with the other two tests.

STATISTICS

all the observations were statistically analyzed using SPSS version 11.5 software. The results obtained were compared statistically using unpaired t-test and chi-square test. The p value of < 0.05 was considered as significant.

RESULTS

There was a statistically significant difference between the means of Xerosis Meter, Schirmer test and TBUT of the two groups: Group I and Group IIa (p value < 0.001). On comparing Group I and Group IIb the difference was found to be statistically significant with Xerosis Meter (p value <0.001). The sensitivity and specificity ofXerosis Meter were 85.7% and 80.2% respectively. This was higher than that of the Schirmer's test (81.3% and 74.9%) and TBUT (73.2% and 68.7%).

CONCLUSION

the "Xerosis Meter" is an effective alternate in screening of dry eye cases. It is more effective than the TBUT and as effective as the Schirmer's test in detecting both the normal and dry eye patients.

Mask leak in one-person mask ventilation compared to two-person in newborn infant manikin study

AIM

To compare a new two-person method (four hands) of delivering mask ventilation with a standard one-person method using the Laerdal self-inflating bag (SIB) and the Neopuff (NP) infant resuscitator in a manikin model.

BACKGROUND

Recent studies of simulated neonatal resuscitation using bag and mask ventilation techniques have shown facemask leak levels of 55-57% in expert hands.

METHODS

48 participants were randomly paired and instructed to give mask ventilation for a 2-min period as single-person resuscitators, then as two-person paired resuscitators at set pressures for NP and set parameters for SIB. Airway pressure, flow, inspiratory tidal volume, expiratory tidal volume and mask leak were recorded.

RESULTS

A total of 21 578 inflations were recorded and analysed. For SIB, mask leak was greater (11.5%) with single-person compared to two-person (5.4%; mean difference 6.1%, 95% CI 1.5 to 10.7, p<0.01). For NP, mask leak was greater for single-person (22.2%) compared to two-person (9.1%; mean difference 13.1% 95% CI 3.6 to 22.6, p<0.01). For single-person mask ventilation, mask leak was greater with NP (22.2%) compared to SIB (11.5%; mean difference 10.7%, 95% CI 1.4 to 19.7, p<0.01). For two-person mask ventilation, mask leak was greater for NP (9.1%) compared to SIB (5.4%; mean difference 3.7%, 95% CI 0.1 to 6.4, p<0.05).

CONCLUSIONS

Two-person mask ventilation technique reduces mask leak by approximately 50% compared to the standard one-person mask ventilation method. NP mask ventilation has higher mask leak than Laerdal SIB for both single- and two-person technique mask ventilation.

Ventilator-delivered mask ventilation compared with three standard methods of mask ventilation in a manikin model

BACKGROUND

Little is known regarding the variations in effective ventilation during bag and mask resuscitation with standard methods compared with that delivered by ventilator-delivered mask ventilation (VDMV).

AIM

To measure the variations in delivered airway pressure, tidal volume (TV), minute ventilation (MV) and inspiratory time during a 3-min period of mask ventilation comparing VDMV with three commonly used hand-delivered methods of bag and mask ventilation: Laerdal self-inflating bag (SIB); anaesthetic bag and T-piece Neopuff.

METHODS

A modified resuscitation manikin was used to measure variation in mechanical ventilation during 3-min periods of mask ventilation. Thirty-six experienced practitioners gave positive pressure mask ventilation targeting acceptable chest wall movement with a rate of 60 inflations/min and when pressures could be targeted or set, a peak inspiratory pressure (PIP) of 18 cm water, positive end-expiratory pressure (PEEP) of 5 cm water, for 3 min with each of the four mask ventilation methods. Each mode was randomly sequenced.

RESULTS

A total of 21 136 inflations were recorded and analysed. VDMV achieved PIP and PEEP closest to that targeted and significantly lower variation in all measured parameters (p<0.001) other than with PIP. SIB delivered TV and MV over twice that delivered by VDMV and Neopuff.

CONCLUSION

During 3-min periods of mask ventilation on a manikin, VDMV produced the least variation in delivered ventilation. SIB produced wide variation and unacceptably high TV and MV in experienced hands.

Neopuff T-piece mask resuscitator: is mask leak related to watching the pressure dial?

AIM

The aim of the study is to compare mask leak and delivered ventilation during Neopuff (NP) mask ventilation in two modes: (i) with NP pressure dial hidden and resuscitator watching chest wall (CW) rise with, (ii) CW movement hidden and resuscitator watching NP pressure dial.

METHODS

Thirty-six participants gave mask ventilation to a modified manikin designed to measure mask leak and delivered ventilation for two minutes in each mode randomly assigned. Paired t-tests were used to analyse differences in mean values. Linear regression was used to determine the association of mask leak with delivered ventilation.

RESULTS

Of 7277 inflations analysed, 3621 were observing chest wall mode (CWM) and 3656 observing NP mode (NPM). Mask leak was similar between the groups; 31.6% for CWM and 31.5% (p = 0.56) for NPM. There were no significant differences in airways pressures and expired tidal volumes (TVe) between modes. Mask leak was strongly associated with TVe (R = -0.86 p < 0.0001) and with peak inspiratory pressure (PIP) (R = -0.51 p < 0.0001). TVe was associated with PIP (R = 0.51 p < 0.0001).

CONCLUSION

This study provides reassurance that NP mask leak is not greater when resuscitators watch the NP pressure dial. Mask leak is related to TVe. Mask ventilation training with manikins should include tidal volume measurements.

Bilateral simultaneous acute angle closure caused by sulphonamide derivatives: a case series

The sulphonamide group of drugs is implicated in bilateral acute angle closure (AAC) due to an idiosyncratic response. We report a series of three cases with bilateral AAC caused by different sulphonamide derivatives, their presentation and management.

Review of orbital exenteration from an eye care centre in Western India

PURPOSE

Indications for orbital exenteration performed over a 10-year period from a tertiary eye care center in Western India.

METHOD

Retrospective review of medical records of all patients who underwent exenteration of orbit over a period from January 1999 to April 2009, at a tertiary eye care center in western India.

RESULT

Out of total 236 major orbital surgeries performed, 15 (6%) underwent orbital exenteration. Age ranged from 19 years to 75 years. Of these 9 were male and 6 female. Except for one case all exenteration were for malignant neoplasm. Lesions originated from eyelid in 8 (54%) cases, orbit in 5 (33%) cases and bulbar conjunctiva in 2 (13%) cases. Histopathological classification of the neoplasm were sebaceous carcinoma (4 cases), basal cell carcinoma (3 cases), squamous cell carcinoma (3 cases), adenoid cystic carcinoma (1 case), transitional cell carcinoma (1 case), malignant fibrous histiocytoma (1 case), lymphoma (1 case) and mucormycosis (1 case).

CONCLUSION

Majority of exenterations performed were for neglected ocular or adnexal malignant lesions that could have been avoided provided patients reported earlier for treatment. Exenterations can be reduced by aggressive patient education about eye malignancy.

Balloon catheter dilation for complex congenital nasolacrimal duct obstruction in older children

PURPOSE

To evaluate the effectiveness of lacrimal balloon catheter dilation in the treatment of complex congenital nasolacrimal duct obstruction in older children.

METHODS

In a retrospective study, the case records of 65 eyes of 59 children 2 to 6 years (mean: 37 months) who underwent probing for congenital nasolacrimal duct obstruction were evaluated. Complex obstruction was noted in 21 (32.3%) of the 65 children older than 2 years who underwent probing. Secondary balloon dacryoplasty was performed in 8 (38.09%) of these 21 lacrimal systems. Patient age ranged from 3 to 6 years (mean: 47 months). Balloon catheter dilation was performed according to a standard protocol. Clinical patency of the nasolacrimal system was the main outcome measure and was defined as complete resolution of signs and symptoms (crusting, discharge, and watering) on follow-up. The procedures were performed under general anesthesia. All dilations were performed by the same lacrimal surgeon.

RESULTS

Secondary balloon dacryoplasty was successful in seven of the eight lacrimal systems (87.5%). Complex obstruction at the distal end of the nasolacrimal duct was noted in all children. All children were older than 3 years (mean: 37 months), and all underwent secondary procedures because previous probing was unsuccessful.

CONCLUSION

Balloon catheter dilation is an effective procedure for complex nasolacrimal duct obstruction in older children. It can be an alternative to silicone intubation and dacryocystorhinostomy in children after unsuccessful probing.

Extranodal Rosai-Dorfman disease presenting as an isolated epibulbar mass

Rosai-Dorfman disease is a rare idiopathic disorder characterized by painless lymphadenopathy with cervical involvement in more than 80% cases. We report a case of Rosai-Dorfman disease presenting as an isolated epibulbar mass in a healthy young adult male. Epibulbar involvement in Rosai-Dorfman disease is a rare presentation as can be seen from a review of all literature. The presentation, differential diagnosis and treatment are discussed.

Extramedullary pasmacytoma masquerading as chalazion

Extramedullary plasmacytoma (EMP) is a rare entity that belongs to the category of non-Hodgkin lymphoma. EMP make up 4% of all plasma cell tumors and occur mainly in the upper aerodigestive tract. Primary plasmacytoma involving the orbit is rare. There is a relation between solitary plasmacytoma and subsequent development of multiple myeloma. As no predictors of progression have been identified patients need indefinite follow-up. The authors report a case of EMP involving the eyelid in an otherwise healthy adult female.

Acute dacryocystitis causing orbital cellulitis and abscess

PURPOSE

Acute dacryocystitis commonly presents as preseptal cellulitis as lacrimal sac lies anterior to the orbital septum and hence infection localizes in the preseptal space. The purpose of this study is to describe presentation and management of cases of acute dacryocystitis presenting as orbital cellilitis and abscess secondary to acute dacryocystitis.

METHOD

This retrospective, non-comparative, interventional case series included 6 patients presenting with orbital cellulitis and abscess secondary to acute dacryocystitis. All patients underwent drainage of abscess under general anesthesia. External dcaryocystorhinostomy was advised as the definitive treatment for all pateints.

RESULT

Abscess was localized in the extraconal space in 4 patients and in the intraconal space in 2 patients. Patients with intraconal abscess had visual loss on presentation while vision could be preserved in patients with abscess in extraconal space. Both patients with intraconal abscess had history of acute dacryocystitis.

CONCLUSION

Acute dacryocystitis is an ophthalmic emergency that can cause orbital cellulitis with abscess formation, and even vision loss, if left untreated.

Single-prick infiltration anesthesia for external dacryocystorhinostomy

PURPOSE

To determine the effectiveness, complications and patient acceptance of single-prick local anesthesia for external dacryocystorhinostomy (DCR).

METHODS

Data were prospectively collected from January 2004 to March 2006 on 463 patients undergoing external DCR operated by a single surgeon. All surgeries were performed under single-prick local infiltration anesthesia. Replies to the Verbal Rating Scale (VRS) were recorded to measure pain intraoperatively at various steps of the surgery. Patients were specifically asked about discomfort during the surgery and whether they would undergo surgery under the same anesthesia if needed for the other eye.

RESULTS

The mean operative duration was 15.50 minutes (range 14-18 minutes). There were 298 females and 165 males. The mean age was 46.5 years (range 17-81 years). The patients reported being comfortable during and immediately after surgery. The VRS was 3-4 (mild pain) for the degree of pain during bone removal and flaps formation. The VRS was 0-2 (no pain) during skin incision and wound closure. None of the patients required additional anesthesia during surgery. None of the patients complained of nausea or vomiting intraoperatively or in the immediate postoperative period. The majority of the patients preferred the same anesthetic technique for surgery in the other eye if required.

CONCLUSIONS

Single-prick local infiltration anesthesia for external DCR is safe, effective and has good patient acceptance.

Success rate and cause of failure for late probing for congenital nasolacrimal duct obstruction

PURPOSE

To evaluate the outcome of late probing for congenital nasolacrimal duct obstruction in children 2 to 6 years old and to identify the cause of failure in these children.

METHODS

Records of 65 nasolacrimal duct obstructions in 62 children (39 boys and 23 girls) aged 2 to 6 years who underwent primary probing for congenital nasolacrimal duct obstructions were evaluated. The main observations were the type of obstruction encountered during probing (complex/simple), age at the time of probing, and success rate depending on the type of obstruction. Success was the main outcome measure and was defined as complete resolution of all signs and symptoms at 1 week of follow-up. The Mann-Whitney test for statistical significance was used to compare the results between simple and complex nasolacrimal duct obstructions.

RESULTS

Six children had bilateral obstruction. The average age at the time of probing was 37.71 months in children with complex obstruction and 37.27 months in children with simple obstruction. Twenty-one eyes (32.20%) had complex obstruction and 44 eyes (67.69%) had simple obstruction. The success rate was 33% in children with complex obstruction and 97.72% in children with simple obstruction, which was statically significant. The overall success rate of the whole cohort was 76.92%.

CONCLUSION

Older children with simple obstruction undergoing late probing had an excellent success rate in this study (97.72%). Complex obstruction is the main risk factor for failure of probing in older children. Probing is a successful and viable option in older children.

Combating antibiotic resistance in bacteria

Combinations of certain antibiotics select against resistant strains of bacteria. This finding may provide a strategy of combating antibiotic resistant bacteria.

Metacarpophalangeal joint dislocation of the thumb in children

There are few reports describing dislocation of the metacarpophalangeal joint of the thumb in children. This study describes the clinical features and outcome of 37 such dislocations and correlates the radiological pattern with the type of dislocation. The mean age at injury was 7.3 years (3 to 13). A total of 33 children underwent closed reduction (11 under general anaesthesia). Four needed open reduction in two of which there was soft-tissue interposition. All cases obtained a good result. There was no infection, recurrent dislocation or significant stiffness. So-called 'simple complete' dislocations that present with the classic radiological finding of the joint at 90 degrees dorsal angulation may be 'complex complete' injuries and require open reduction.

Late probing for congenital nasolacrimal duct obstruction

OBJECTIVE

To determine the outcome of late Nasolacrimal Duct (NLD) probing in children 2 years and above and to identify the cause of failure in these children.

STUDY DESIGN

Quasi- experimental.

PLACE AND DURATION OF STUDY

Shri Ganapati Netralaya, Jalna, India, from January 1999 to June 2003.

PATIENTS AND METHODS

Clinical diagnosis of Congenital Nasolacrimal Duct Obstruction (CNLDO) was defined in a child who presented with history of tearing and/or eye discharge. Probing was performed under general anesthesia. Intraoperative patency of probing was determined when fluorescein stained saline was recovered from throat after syringing. The type of obstruction was noted in each case as simple obstruction where the probe could bypass the obstruction and post-probing syringing was patent in these cases, and complex where the probe was snugly fit and/or could not pass the obstruction and syringing was not patent in these patients. Success was the main outcome measure and was defined as complete resolution of tearing and discharges in the affected eye.

RESULTS

Forty-nine eyes of 42 children were included in the study. The age range was from 2-7 years (average age 3.7 years). Probing was successful in 39 eyes (79.60%). Success rate was 85% in children less than 5 years and 55.55% in those older than 5 years. Out of the failed 10 cases, 5 (50%) were above 5 years of age. All cases with failed probing had complex type obstruction.

CONCLUSION

Probing is a viable option in older children. The success rate for probing depends upon the type of obstruction and children with complex obstruction are at high risk for failure of probing.

Role of fine needle aspiration cytology in diagnosis of eyelid sebaceous carcinoma

Sebaceous carcinoma of the ocular adnexa is a malignant neoplasm which can exhibit aggressive local behavior and can metastasize to regional lymph nodes and distant organs. The neoplasm is known to masquerade as other benign and less malignant lesions, resulting in delay in diagnosis and relative high morbidity and mortality. Fine needle aspiration cytology (FNAC) of recurrent upper eyelid nodules treated elsewhere as chalazion was done. Cytological smears were suggestive of malignancy. Subsequently histopathology confirmed the diagnosis of sebaceous gland carcinoma. Eyelid reconstruction was done after histopathologically confirmed tumor-free margins. The article highlights the role of FNAC in early diagnosis and subsequent appropriate surgical management of eyelid sebaceous gland carcinoma to prevent recurrence and metastasis.