Clinicoradiological profile and outcome of cavernous sinus syndrome with coronavirus disease-2019-associated rhino-orbito-cerebral mucormycosis

Objective

With coronavirus disease 2019 (COVID-19) pandemic across the world, there had been an exponential increase in rhino-orbito-cerebral mucormycosis (ROCM). Extension of infection to cavernous sinus leads to cavernous sinus syndrome (CSS). This study aims to describe incidence, clinicoradiological profile, and outcome of CSS positive along with comparative analysis of CSS negative COVID-19-associated ROCM.

Material and Method

This was a prospective and observational study conducted from May 1, 2021, to July 31, 2021. Subjects included ROCM with active or recovered COVID-19 (past 6 weeks) and were categorized and staged. CSS was defined as involvement of two or more of third, fourth, fifth, or sixth cranial nerve with one each direct and indirect qualitative neuroradiological features. Clinicoradiological features of CSS-positive and negative COVID-19-associated ROCM groups were compared.

Results

Incidence of CSS with COVID-19-associated ROCM was 28%. Mean age of subjects was 44 ± 15 years with 60% being males and 73% were proven ROCM. Significant differences seen across the CSS-positive and negative groups were ocular, nasal, and cerebral findings including eyelid and periocular discoloration, ptosis, proptosis, ophthalmoplegia, nasal discharge, mucosal inflammation, and fever. Oculomotor, trochlear, and abducens nerves were significantly involved more in CSS-positive group. Significant radiological findings across two groups included indirect features in orbit, nose, and paranasal sinuses along with direct features in cavernous sinus. Surgical intervention was more common in CSS-positive group. Mortality in CSS-positive group at 8-24 weeks was 13 and 27%, respectively.

Conclusion

Extension of ROCM to CSS was more common in young males in advanced stages of proven ROCM with concurrent COVID-19. CSS-positive group had significant difference in clinicoradiological features involving orbit, nose, paranasal sinuses, and central nervous system as compared to CSS-negative group. This study highlights the need to develop an objective scoring system considering clinical and radiological features for diagnosis of CSS with COVID-19-associated ROCM.

Comparative pathology, molecular pathogenicity, immunological features, and genetic characterization of three highly pathogenic human coronaviruses (MERS-CoV, SARS-CoV, and SARS-CoV-2)

The last two decades have witnessed the emergence of three deadly coronaviruses (CoVs) in humans: severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV), and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). There are still no reliable and efficient therapeutics to manage the devastating consequences of these CoVs. Of these, SARS-CoV-2, the cause of the currently ongoing coronavirus disease 2019 (COVID-19) pandemic, has posed great global health concerns. The COVID-19 pandemic has resulted in an unprecedented crisis with devastating socio-economic and health impacts worldwide. This highlights the fact that CoVs continue to evolve and have the genetic flexibility to become highly pathogenic in humans and other mammals. SARS-CoV-2 carries a high genetic homology to the previously identified CoV (SARS-CoV), and the immunological and pathogenic characteristics of SARS-CoV-2, SARS-CoV, and MERS contain key similarities and differences that can guide therapy and management. This review presents salient and updated information on comparative pathology, molecular pathogenicity, immunological features, and genetic characterization of SARS-CoV, MERS-CoV, and SARS-CoV-2; this can help in the design of more effective vaccines and therapeutics for countering these pathogenic CoVs.

Modulation of host epigenome by coronavirus infections and developing treatment modalities for COVID-19 beyond genetics

The recent Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) outbreak has resulted in coronavirus disease 2019 (COVID-19) pandemic worldwide, affecting millions of lives. Although vaccines are presently made available, and vaccination drive is in progress to immunize a larger population; still the risk of SARS-CoV-2 infection and related mortality is persistent amid threats of the third wave of the ongoing pandemic. In the scenario of unavailability of robust and efficient treatment modalities, it becomes essential to understand the mechanism of action of the virus and deeply study the molecular mechanisms (both at the virus level and the host level) underlying the infection processes. Recent studies have shown that coronaviruses (CoVs) cause-specific epigenetic changes in the host cells to create a conducive microenvironment for replicating, assembling, and spreading. Epigenetic mechanisms can contribute to various aspects of the SARS-CoV-2 multiplication cycle, like expressing cytokine genes, viral receptor ACE2, and implicating different histone modifications. For SARS-CoV-2 infection, viral proteins are physically associated with various host proteins resulting in numerous interactions between epigenetic enzymes (i.e., histone deacetylases, bromodomain-containing proteins). The involvement of epigenetic mechanisms in the virus life cycle and the host immune responses to control infection result in epigenetic factors recognized as emerging prognostic COVID-19 biomarkers and epigenetic modulators as robust therapeutic targets to curb COVID-19. Therefore, this narrative review aimed to summarize and discuss the various epigenetic mechanisms that control gene expression and how these mechanisms are altered in the host cells during coronavirus infection. We also discuss the opportunities to exploit these epigenetic changes as therapeutic targets for SARS-CoV-2 infection. Epigenetic alterations and regulation play a pivotal role at various levels of coronavirus infection: entry, replication/transcription, and the process of maturation of viral proteins. Coronaviruses modulate the host epigenome to escape the host immune mechanisms. Therefore, host epigenetic alterations induced by CoVs can be considered to develop targeted therapies for COVID-19.

Intraocular pressure response to airway management: Comparison between LMA Supreme® and C-MAC® videolaryngoscope in day care surgery

Background: Airway maintenance procedures during anesthesia are usually associated with a rise in intraocular pressure (IOP). This is an important issue especially in vulnerable patients. In the present study we compared the rise in IOP with two different group of airway devices i.e. Laryngeal mask airway Supreme (LMA-S) and endotracheal intubation (ETT) using C-MAC® videolaryngoscope (VLS). Methodology: The present study was conducted on 100 adult patients of ages >18 yrs, of either sex, belonging to American Society of Anesthesiologist (ASA) I and II, scheduled to undergo non-ophthalmic elective surgery under general anesthesia. Patients were divided into two equal groups of 50 each, Group A and Group B. In group A (n = 50), lubricated appropriate sized LMA-S was inserted and in Group B (n=50), lubricated appropriate sized ETT was inserted by an anesthesiologist using VLS. IOP was measured in right eye just before insertion of device and subsequently at 1 min, 3 min, 5 min and 10 min after insertion of device. Hemodynamic parameters were recorded along with IOP measurement. Results: Both the groups were comparable regarding demographic data (p > 0.05), ASA grade (p = 0.069), and Mallampati grade (MPG) (p = 0.646). Airway establishment time (p = 0.011) was significantly less with C-MAC VLS. IOP were comparable at all measurement times, e.g., 1 min (p = 0.216), 3 min (p = 0.093), 5 min (p = 0.859) and 10 min (p = 0.060) after insertion of each device. Hemodynamic parameters measured were also comparable between two groups (p > 0.05). Conclusion: Both LMA Supreme and intubation using C-MAC® videolaryngoscope are safe regarding rise in intraocular pressure. Both methods can be safely used for airway management in suitable patients. Key words: Airway; Anesthesia; Intraocular pressure; LMA; Endotracheal intubation Citation: Kaur H, Singh G, Singh J, Kaur, Dhawan M, Singh A. Intraocular pressure response to airway management: Comparison between LMA Supreme and C-MAC® videolaryngoscope in day care surgery. Anaesth. pain intensive care 2020;24(6):__ Received: 27 January 2020, Revised: 12 May 2020, Reviewed: 25 October 2020, Accepted: 27 October 2020

The Islet De-stress Hypothesis: A potential explanation for the gluco metabolic effects of ketogenic diet

Ketogenic diet (KD) is an established therapy with indications which span multiple disciplines. Initial skepticism about the role of KD in diabetes and obesity has been replaced by interest in its mechanism of action. We propose that KD works by de-stressing the islet of Langerhans, and reducing its workload. This de-stress occurs at both beta and alpha cell, and suggests that the islet should be considered a single anatomic-functional unit. The Islet De-stress Hypothesis, as we term it, is based upon the Law of Endocrine Parsimony. Simply put, this states that minimal burden should be placed on any gland, including the islet of Langerhans, while managing endocrine disease.

Creating happiness in the diabetes care clinic

Happiness is an essential part of human health. The purpose of health care, including diabetes care, is to achieve happiness, or euthymia. Happiness, can also be viewed as a means to achieving good health, as well as a technique to overcome challenges, encourage team work and ensure better adherence to therapy. This opinion piece shares simple ways of achieving happiness in the diabetes care clinic. It lists best practices related to environment communication style, communication content, and inter-consultation contact. If integrated into daily practice, these will help create a happy health care ecosystem, which in turn will enhance patient satisfaction.

Evaluation of Vision-related Quality of Life in Patients with Glaucoma: A Hospital-based Study

Introduction

Quality of life (QoL) is a broad concept that is affected in a complex way by many factors. Healthcare interventions are targeted now days to improve quality of life of affected individuals. Glaucoma is a major cause of irreversible blindness throughout the world and affects patient's quality of life in several ways. In present study, we aim to evaluate and quantify vision related quality of life in glaucoma patients in a tertiary care hospital setting.

Materials and methods

Vision related quality of life was evaluated in glaucoma patients using GQL-15 questionnaire, which compares the subjective performance of various vision related tasks in these patients. Fifty diagnosed cases of glaucoma and fifty healthy volunteers were included in the study. In both these groups, standard tests for visual function were done and both were assigned to complete the questionnaire. GQL-15 questionnaire includes 15 items divided between 4 factors pertaining to visual disability: central and near vision, peripheral vision, dark adaptation and glare, and outdoor mobility. Higher scores indicate greater difficulty in performing vision-related activities and poorer QoL.

Results

A total of 100 cases were enrolled out of which 50 were diagnosed glaucoma cases and 50 were controls. Almost three fourth of glaucoma patients, i.e., 72% were diagnosed as chronic open angle glaucoma where 24% were angle closure patients and rest 4% were normal tension glaucoma patients. The mean GQL score of glaucoma cases was 26.00 ± 10.84 and for controls it was 15.02 ± 0.14 (p value < 0.05). All subscale scores also showed a uniform rise in their value as we move from mild to severe cases thereby concluding that all visual parameters worsen with increase in severity pattern of disease.

Conclusions

As glaucoma patients have reduced vision related quality of life, so every effort should be made to preserve visual functions in these patients. Many activities that define independence and productivity in society require good vision and hence one of most devastating consequences of advancing visual impairment in glaucoma is progressive loss of independence thereby affecting patients quality of life.

How to cite this article

Dhawan M, Hans T, et al. Evaluation of Vision-related Quality of Life in Patients with Glaucoma: A Hospital-based Study. J Curr Glaucoma Pract 2019;13(1):9–15.

The diabetes clinic: Creating an illusion of time

Diabetes care is challenging task, both for both the person with diabetes, and for the diabetes care provider. One of the challenges is the pressure to see a huge case load in limited time. This leads to poor patient satisfaction, and result in suboptimal outcome. Creating an illusion of time is an art which helps the astute physician enhance patient satisfaction. This opinion piece shares means of creating a feeling of time well -spent with the diabetes care professional. It explains how to "expand" the time frame, the interviewing team, the reference, the definition of health, and create remembrance points in order to improve the quality of interaction. The authors enjoin the physician to feel relaxed from within, "stimulate" all five senses of the patient, and structure the conversation in a systematic manner. Best practices for time enhancement are shared, along with relevant examples.

Ketogenic diet: situational analysis of current nutrition guidelines

Ketogenic diet is gaining popularity as a nonpharmacological intervention for weight loss and glycaemic control. There is abundant literature on this topic, which serves to confuse the reader. No scientific recommendations have been formulated to guide evidence-based or rational use of ketogenic diet in obesity and diabetes management. This article is a situational analysis of leading professional guidelines on diabetes care, with regards to their coverage of ketogenic diet. It underscores the need for leading experts to pay attention to this upcoming field of metabolic medicine..

The Ketogenic Diet

The ketogenic diet (KD), a well-established treatment for childhood epilepsy, is gradually gaining acceptance as a therapeutic modality for obesity and type 2 diabetes. The perception of ketone bodies as an unhealthy or “sinful” entity has led to concerns and doubts regarding the efficacy and safety of KD in physicians. This article describes the mechanism of action of KD and shares a pragmatic approach to its usage. It highlights the importance of predietary counseling, screening for indications/contraindications, and clinico-nutritional monitoring during therapy. Robust indications for KD are mentioned, to help place KD’s utility in the management of obesity and type 2 diabetes.

Safety and efficacy of intraoperative intravitreal injection of triamcinolone acetonide injection after phacoemulsification in cases of uveitic cataract

PURPOSE

To evaluate the safety and efficacy of a single intraoperative intravitreal injection of triamcinolone acetonide after phacoemulsification in patients with chronic idiopathic anterior uveitis or intermediate uveitis.

SETTING

Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

METHODS

This prospective randomized controlled study included 40 eyes (40 patients) with chronic idiopathic anterior uveitis or intermediate uveitis that had phacoemulsification with intraocular lens implantation. Twenty eyes received an intravitreal injection of triamcinolone acetonide (4 mg/0.1 mL) intraoperatively (triamcinolone acetonide group), and 20 received oral steroids (steroid group) postoperatively. Outcome measures were Early Treatment Diabetic Retinopathy Study best corrected visual acuity (BCVA), anterior chamber reaction, intraocular pressure (IOP) by applanation tonometry, and central macular thickness by optical coherence tomography.

RESULTS

The mean BCVA (decimal) improved from a baseline of 0.13 +/- 0.14 to 0.64 +/- 0.32 in the triamcinolone acetonide group and from 0.05 +/- 0.06 to 0.61 +/- 0.36 in the steroid group (P = .74). There were no statistically significant differences between the 2 groups in postoperative anterior chamber reaction, IOP, or central macular thickness. Four patients in the triamcinolone acetonide group and 5 in the steroid group had recurrence of uveitis; 5 patients in the triamcinolone acetonide group had ocular hypertension. One patient in the triamcinolone acetonide group and 3 in the steroid group had cystoid macular edema postoperatively.

CONCLUSION

A single intraoperative intravitreal injection of triamcinolone acetonide seemed to be a safe and efficacious route of steroid delivery during phacoemulsification in patients with chronic idiopathic anterior uveitis or intermediate uveitis and is recommended as a substitute for postoperative oral steroid administration.

Pattern of intraocular pressure in epidemic dropsy in India

This study was conducted to report on the intraocular pressure (IOP) pattern in patients with epidemic dropsy. Two hundred and thirty proven cases of epidemic dropsy were sent for ocular examination. We measured IOP by applanation tonometry at different intervals. Patients were followed up until 24 weeks. Intraocular pressure of more than 22 mm of Hg was detected in 10.86% patients at the start of the study. However, at 12 weeks only 0.43% patients needed medication for control of IOP. None required medication for IOP control after 20 weeks. The rise of IOP in this case series of epidemic dropsy appeared to be a transient phenomenon and drugs needed to be titrated on a weekly basis.

In heme catabolism C2 and C4 vinyl groups reduction of cobalt protoporphyrin forms cobalt mesoporphyrin and alters the nature of action of the metalloporphyrin in vivo

Heme is a tetrapyrrolic ring with iron as the central metal atom and acts as a prosthetic group for a number of enzymes, e.g. cytochromes and globins. It also plays an important role in the regulation of transcription, translation, protein translocation and erythroid differentiation. Thus, heme regulation is under strict control in the body. Our studies on the regulatory enzymes of heme anabolism, aminolevulinic acid synthetase (ALA-S), and of catabolism, heme oxygenase (HMOX), in the spleen has revealed that cobalt protoporphyrin acts as an inducer of HMOX. It is revealed that by alteration of side groups at C2 and C4 changes the nature of action of Co-protoporphyrin from an inducer to a strong inhibitor of HMOX activity. All the three analogues Co-protoporphyrin, Co-mesoporphyrin and Co-hematoporphyrin have been shown to induce the ALA-S activity to the similar extent. NADPH-cytochrome c reductase, a microsomal membrane bound enzyme, is required by HMOX for the enzymatic conversion of heme into biliverdin IXc and is also required for NADPH-dependent lipid peroxidation in the microsomes. It has been observed that Co-mesoporphyrin causes an inhibition of HMOX activity and consequently leads to an induced level of microsomal NADPH-dependent lipid peroxidation.

Influence of selenium supplementation during chelation of lead in rats

The influence of selenium supplementation during chelation therapy to reduce body burden and toxicity of lead was investigated in rats. Selenium had marginal effects on liver, kidney and blood lead decorporation by calcium disodium ethylenediamine tetra acetic acid (CaNa2EDTA) and activation of inhibited delta- aminolevulinic acid dehydratase (ALAD) activity by calcium trisodium diethylenetriamine penta acetic acid (CaNa3DTPA). Selenium supplementation however, had no influence on lead induced inhibition of renal and hepatic transaminases and alkaline phosphatase. The results suggest that selenium supplementation slightly augments lead mobilization by chelating drugs.

Biochemical changes and essential metals concentration in lead-intoxicated rats pre-exposed to ethanol

The effects of chronic lead exposure on some hematopoietic and hepatic biochemical indices and urine, feces, and tissue essential metal concentration were investigated in rats pre-exposed to different doses of ethanol. Exposure to ethanol (0.5, 1.0, and 2.0 g/kg intraperitoneally, once daily) for 4 weeks produced an inhibition of blood delta-aminolevulinic acid dehydratase (ALAD) activity and a decrease in hepatic glutathione (GSH) concentration. Ethanol ingestion also produced a dose-dependent elevation of hepatic lipid peroxidation. Blood and hepatic calcium and hepatic magnesium contents decreased and urinary Ca and fecal Ca and Mg contents increased significantly following 4-week exposure to ethanol (2 g/kg). Lead administration (10 mg/kg, orally) for 4 weeks in ethanol pre-exposed (2 g/kg) animals produced a more pronounced inhibition of blood ALAD and elevation of urinary delta-aminolevulinic acid (ALA) excretion and hepatic GSH contents. Hepatic GSH contents decreased and hepatic lipid peroxidation increased significantly in rats given lead and pre-exposed to ethanol (2 g/kg). A more pronounced depletion of blood Ca and Mg and hepatic Mg was observed along with significant elevation of urinary Mg and fecal Ca excretion in animals administered lead and pre-exposed to ethanol (2 g/kg). The results suggest that nutritional deficiencies, particularly depletion of body Ca and Mg levels, play an important role in increasing susceptibility to lead intoxication in the rat.

Effects of combined exposure to aluminium and ethanol on aluminium body burden and some neuronal, hepatic and haematopoietic biochemical variables in the rat

The effects of the daily administration of aluminium (25 mg kg-1, orally), ethanol (10% v/v, in drinking water) or both to adult rats, for 6 weeks, on the amount of aluminium present in the tissues and the functioning of brain biogenic amines, hepatic and serum transaminases and some haematopoietic variables were investigated. Ethanol alone was seen to inhibit the activity of delta-aminolevulinic acid dehydratase (ALAD), while aluminium alone elevated the activity of blood ALAD. However, aluminium and ethanol combined produced a more pronounced inhibition of blood ALAD and hepatic glutamic pyruvic transaminase (GPT) than either aluminium or ethanol alone. Simultaneous exposure to aluminium and ethanol also produced a significant elevation in urinary delta-aminolevulinic acid (ALA) blood zinc protoporphyrin (ZPP), serum glutamic oxaloacetic transaminase (GOT) and brain homovanillic acid (HVA), and a depletion in brain dopamine (DA) and 5-hydroxytryptamine (5-HT) levels, when compared to rats given aluminium alone. The concentration of aluminium in the blood and liver was significantly higher in rats exposed to both aluminium and ethanol than in those exposed to aluminium alone. Thus the consumption of alcohol may increase the rat's susceptibility to certain effects of aluminium.

Chelation of lead during co-exposure to ethanol

Efficacy of calcium disodium EDTA, D-penicillamine (DPA), 2,3 dimercaptosuccinic acid (DMSA), and alpha-mercapto-beta-(2-furyl) acrylic acid (MFA) to reduce the body burden of lead and restore the altered biochemical variables in lead or lead + ethanol administered rats was investigated. The investigation was aimed to suggest suitable prophylaxis of lead intoxication prevalent among workers co-exposed to lead and alcohol ingestion. Administration of lead (10 mg/kg, oral, once daily for 8 weeks) produced a significant inhibition in the activity of blood delta-aminolevulinic acid dehydratase (ALAD), elevation in the blood zinc protoporphyrin (ZPP) and urinary elimination of lead and delta-aminolevulinic acid (ALA). Lead contents of blood, liver, kidney and brain were also significantly higher than the normal control. The above changes were more marked in animals co-exposed to lead + ethanol (20% in drinking water) compared to lead alone. All the chelators were effective in increasing the urinary lead elimination, reducing the above biochemical alterations and lead contents of tissues. The order of effectiveness being DMSA greater than Calcium disodium EDTA greater than DPA greater than MFA. However, the protection was more noticeable in animals treated with lead alone than with lead and ethanol.

Influence of thiamine and ascorbic acid supplementation on the antidotal efficacy of thiol chelators in experimental lead intoxication

The influence of the administration of thiamine (vitamin B1), ascorbic acid (vitamin C) or their combination on the efficacy of two thiol metal chelators, viz. alpha-mercapto-beta-(2-furyl) acrylic acid (MFA) and 2,3-dimercaptosuccinic acid (DMS), in counteracting lead (Pb) toxicity was investigated in rats. Ascorbic acid or its combination with thiamine enhanced the urinary elimination of Pb, reduced the hepatic and renal burden of Pb, and reversed the Pb-induced inhibition of the activity of blood delta-aminolevulinic acid dehydratase (delta-ALA-D). All these effects were more evident in DMS- than in MFA-treated rats. The combination of MFA and DMS treatments further improved the performance of the animals in enhancing urinary Pb excretion and in reducing Pb hepatic levels.

Asymmetries in hemispheric control of attention in schizophrenia

Investigators have long suggested that schizophrenia might be related to an impairment in the regulation of attention. In this report, the performance of schizophrenic patients was compared with nonschizophrenic control subjects in their ability to direct visual attention. In the first experiment, patients were distinguished from controls by a slower response to a target in the right visual field than to a target in the left visual field when attention was not first directed to the target location. In the second experiment, patients were distinguished from controls by a stronger bias in favor of symbolic information over language information about spatial direction. In both experiments, the patients demonstrated deficits in attention similar to patients from previous studies who had unilateral lesions of the left hemisphere. The identification of performance abnormalities using tasks that are simple, have dissectable cognitive components, have been related to discrete neural systems, and control for nonspecific variables provide the basis for constructing reasonable hypotheses about the cognitive psychology and functional neuroanatomy of schizophrenia.

Differential distraction effects in short-term and long-term retention of pictures and words

Picture and word triads were followed by single visual and acoustic distraction tasks and by both tasks in sequence. Short-term retention between and within modalities differed as a function of type of distraction. Individual subject-recall probabilities for each single distraction condition failed to predict performance in the sequential dual-distraction conditions, underestimating performance for words and overestimating performance for pictures. A final delayed recall showed a reversal among distraction conditions within each modality, such that the best short-term retention condition (visual distraction) was poorest in long-term retention. However, long-term retentions of pictures was superior to that of words across all distraction conditions and irrespective of level of short-term retention. The results were interpreted in terms of separate acoustic and visual processing systems and the level of individual item processing within each system as a function of the type of interference originally expected.

Short-term retention of pictures and words: evidence for dual coding systems

The recall of picture and word triads was examined in three experiments that manipulated the type of distraction in a Brown-Peterson short-term retention task. In all three experiments recall of pictures was superior to words under auditory distraction conditions. Visual distraction produced high performance levels with both types of stimuli, whereas combined auditory and visual distraction significantly reduced picture recall without further affecting word recall. The results were interpreted in terms of the dual coding hypothesis and indicated that pictures are encoded into separate visual and acoustic processing systems while words are primarily acoustically encoded.