Interaction of cannabis cultural use and health: A case of acute myocardial infarction following consumption of cannabis beverage (Bhang).

Cannabis is a psychoactive substance consumed worldwide in the form of smoking, vapors, food additives, or beverages. Delta 9 tetrahydrocannabinol (THC) is a primary component responsible for short and long-term effects on various cognitive and motor functions in a dose-dependent manner. The legal status of cannabis has shifted significantly in recent decades. Some regions maintain strict penalties, but others have legalized them for medicinal use. In India, the use of cannabis in any form is illegal; however, the use of bhang, a cannabis beverage made from leaves, is acceptable due to cultural reasons and thus permitted in some places. We report the case of a 28-year-old male who developed massive anterior wall myocardial infarction after consuming bhang during the Holi festival. He presented with sudden retrosternal chest pain, which was initially ignored till it intensified enough, prompting him to seek emergency medical help approximately 24 hours after symptom onset. Cannabis intoxication impaired attention and information processing, leading to delayed presentation. The patient was managed successfully by timely cardiac intervention. The evolving landscape of cannabis regulations necessitates heightened awareness among health authorities about potential cardiovascular risks associated with its consumption, particularly in forms like Bhang, where concentrations are unregulated and variable.

Understanding parental hurdles in accessing strabismus treatment.

Purpose: To explore the parental factors that impede early intervention for strabismus and thus identify strategies for improving access to specialized care. Methods: This hospital-based cross-sectional study included 110 parents of children under 19 years with strabismus receiving treatment at the squint clinic of a tertiary health care center in north India. A pre-validated survey questionnaire was administered to the participants, that had a section about the socio-demographics of the participants, another section addressed the parental knowledge about strabismus about diagnosis, and the need for an eye examination. It also sought information about referral source, the felt need for squint examination, and reasons for not seeking treatment. Results: A total of 110 parents/guardians of strabismus patients (59 exotropes and 51 esotropes) were interviewed using a survey questionnaire. Parents themselves identified 80% of cases, and a substantial link (P â€‹< â€‹0.0001) was found between the education status of parents and the age of identification of strabismus. Fear of surgical outcomes (41.79%) was a significant barrier to timely surgery with a higher percentage of parents expressing fear of surgical outcomes (P â€‹= â€‹0.025). The cost of surgery (34.33%) and the non-availability of facilities (23.88%) also delayed the intervention. Conclusions: It is essential to educate parents about the importance of strabismus therapy at an appropriate time, stressing its reconstructive rather than merely cosmetic nature, as there are notable gaps in their knowledge. Also, we need to do away with the fear of surgical outcomes of surgical interventions for strabismus.

Evaluation of C-Reactive Proteins Levels in Peri-Implantitis Patients.

Background: To evaluate C-reactive protein (CRP) levels in peri-implantitis patients. Material and Methods: This study comprised a total of 100 participants. Fifty participants with a confirmed clinical and radiological diagnosis of peri-implantitis formed one group. Another group of 50 volunteers who came in for a normal health checkup served as healthy controls. All the patients were recalled in the morning. Fasting venous blood samples were collected. CRP concentrations in the laboratory were determined using an auto-analyzer. Results: In this study, there were 40 females and 60 males. Mean CRP levels among subjects of the peri-implantitis group and the control group were 0.615 and 0.201 mg/dL, respectively. Conclusion: It was observed that mean CRP levels were higher among subjects having peri-implantitis as compared to the controls.

A rare association of monocular elevation deficiency and goldenhar syndrome secondary to vascular insufficiency: A case report.

INTRODUCTION AND CLINICAL IMPORTANCE: Goldenhar syndrome (GS) manifests as a triad of ocular, auricular, and vertebral anomalies. We present a rare case report presenting with monocular elevation deficiency (MED) in association with GS secondary to radiologically proven vascular insufficiency. CASE PRESENTATION: A 9-year-old male presented with drooping of the upper eyelid in the right eye (OD), absence of right ear, and swelling near the ear remanent. On detailed Ophthalmic evaluation revealed right MED, moderate anisometropia amblyopia with right-side lower motor neuron facial nerve palsy with right infected first branchial cyst with radiological evidence of stenosed common carotid artery. Thus, a diagnosis of GS secondary to vascular insult was made. He was advised to use prescribed spectacle correction and part-time occlusion for amblyopia and was referred to plastic surgery, pediatric, and ear nose throat (ENT) team for further evaluation. CLINICAL DISCUSSION: Goldenhar syndrome is a complex disorder encompassing a spectrum of abnormalities affecting the heart, lungs, neurological system, gastrointestinal, and musculoskeletal. Several theories have been offered to explain the etiology, but none have been validated until now. The most common malformations are facial asymmetry (65 %), epibulbar dermoids (35 %), and external ear anomalies with pre-auricular tags. MED in GS secondary to vascular insult is a rare presentation, which is not been reported in the literature to date. CONCLUSION: GS can have variable presentation depending upon the underlying etiology and severity of the insult. In such cases we must adopt a multidisciplinary approach to ensure the optimal treatment plan for the patient's well-being.

Association of smartphones use, ocular symptoms and binocular dysfunctions in adolescents: a hospital-based cross-sectional study.

PURPOSE: Given the current scenario of increased smartphone use in youth, this study aims to evaluate the proportion of ocular symptoms and binocular dysfunction and their association with smartphone use in adolescents through a hospital-based cross-sectional study. METHODS: The participants were asked to fill out questionnaires related to smartphone use and symptoms of eyestrain experienced (Balik et al. and Kucer). They were asked about the following seven symptoms: blurring of vision, redness, visual disturbance, secretion, inflammation, lacrimation, and dryness. Each symptom out of the 7, was scored on a scale of 0-1 and was used to calculate an Ocular Symptom Score (OSS) by summing the scores of each symptom.Depending upon the duration of smartphone usage, the participants were classified into four groups: <2 hours/day, 2-4 hours/day, 4-6 hours/day, and >6 hours/day. Binocular functions were assessed using near point of convergence (NPC), near point of accommodation (NPA), Accommodative convergence/Accommodation (AC/A) ratio, dissociated heterophoria, and binocular accommodative facility (BAF). RESULTS: A total of 123 smartphone user adolescents, aged 10-19 years were included in this study. The mean age of the study population was 16.58 + 2.8 years, out of which 52.03% were males. Prevalence of ocular symptoms was higher in groups with greater duration of smartphone use (2 to 4, 4 to 6, and >6 hours/day as compared to <2 hours/day: 90.48%, 94.74%, 100% vs. 75% respectively). The mean of NPC was 8.51, it was highest in subjects using smartphones for >6 hours. (p-value = .001). The mean AC/A ratio was 2.83 + 1.03: 1. A low AC/A ratio was associated with a longer duration of smartphone usage (p-value = .0001). The mean of BAF was 7.4 + 3.18 cycles/min, only 30 (24.4%) participants had BAF beyond the normal range (<5 cycles/min). The mean of BAF was lowest in the group with >6 hours/day of smartphone use (p-value < .0001). No significant change was found in NPA and dissociated heterophoria with the duration of smartphone usage. CONCLUSION: Higher duration of smartphone use (>2 hours/day) is associated with various ocular symptoms and binocular dysfunction. However, additional research is necessary to authenticate the results of the study.

Assessment of Carotid Plaque Enhancement on Contrast-Enhanced Ultrasound as a Predictor for Severe Coronary Artery Disease.

Background and Aim Contrast-enhanced ultrasound (CEUS) can reliably identify vulnerable plaques. As atherosclerosis is a systemic disease, we evaluated whether contrast enhancement of carotid plaque (CECP) can predict severe coronary artery disease (CAD) by comparing CECP in patients who have had acute coronary syndromes (ACS) recently with asymptomatic individuals. Settings and Design This case-control study was done at a tertiary care center during 2022. Materials and Methods Fourteen participants were recruited in each group, after screening in-patients for carotid plaques and inclusion and exclusion criteria. Those who had history of ACS were enrolled as cases, while those who did not were enrolled as controls. All these patients underwent grayscale, Doppler, and CEUS examination for characterization of the carotid plaque. For cases, findings on CEUS were also compared with the severity of CAD on catheter coronary angiography. Statistical Analysis Diagnostic parameters including sensitivity, specificity, and diagnostic accuracy were calculated and proportions were compared by using Fisher's exact test. Results Eight out of 28 patients showed CECP. CECP and CAD were positively associated with p -Value of 0.033. Eighty-three percent patients with triple vessel disease and 50% patients with double vessel disease on coronary angiography showed CECP. Sensitivity and specificity of CECP for prediction of CAD were 50 and 92.9%, respectively. Conclusion CECP on CEUS can predict CAD and is a more reliable indicator of severe CAD than plaque characteristics on grayscale and Doppler imaging; making it useful for screening of patients at risk of having CAD.

Young hearts at risk: Unveiling novel factors in myocardial infarction susceptibility and prevention.

The increasing incidence of acute myocardial infarction (AMI) among the young population represents a significant and emerging health concern, contributing substantially to both mortality and morbidity. Unlike myocardial infarctions occurring in older individuals, traditional risk factors such as diabetes and hypertension exhibit a weaker association in the younger demographic. Consequently, there is a pressing need for a deeper understanding of novel risk factors that contribute to AMI in young patients. In this review, we explore distinct risk factor profiles associated with young-onset AMI in comparison to older patients. Special attention is given to novel risk factors, examining their susceptibility factors and exploring preventive measures. The comprehensive risk profile of extremely young South Asians who develop early coronary arterial disease is not yet fully understood. There are many novel evolving risk factors associated with young AMI which need intervention to reduce morbidity and mortality. It has been seen that established inflammatory markers like lipoprotein (a), dyslipidaemia, long COVID, and new emerging risk factors like air pollution (micro- and nanoplastics), periodontitis, acute stress, energy drinks, misuse of recreational drugs may increase risk and influence treatment, and outcomes of AMI in this young population. Screening of emerging novel risk markers and their optimization is important in preventing young patients with AMI. The role of conventional risk factors should not be overlooked and should be treated aggressively. Sex and geographic-specific base approaches are required to reduce risk factors and prevent AMI in young. More prospective studies are needed to evaluate the increasing incidence of young AMI and its associated novel risk factors.

A simple, ingenious approach for intra-operative detection of coronary cameral fistula.

A 56-year-old female presented to us with rheumatic mitral stenosis with a left atrial clot. We found one coronary cameral fistula on the coronary angiography from the posterior left ventricular branch to the left ventricle. She was taken up for surgical mitral valve replacement and clot removal. A residual coronary fistula may increase the risk of infective endocarditis, especially in the presence of mechanical prosthesis. Henceforth, intra-operatively, we used the methylene blue dye injection as an easy technique to detect and safely close the coronary fistula from inside the left ventricular chamber. She recovered smoothly with a successful outcome.

Systematic Review of Sleep Duration and Development of Myopia.

There is a knowledge gap in the relationship between sleep duration and myopia. Since sleep duration is a modifiable risk factor, its association with the development and progression of myopia has implications for public health. This review was conducted in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The bibliographic databases of PubMed and Scopus were searched for published studies on the association between sleep duration and myopia. These databases were searched in December 2023 with no date or study design limits. The relevant literature was extracted and met the priori determined population (children, adolescents, and adults suffering from myopia with or without corrective glasses), intervention/exposure (sleep), and the outcome (various indicators of sleep especially sleep duration/bedtime/wake time and sleep quality). Data were gathered by gender, age, and refraction technique and standardized to the definition of myopia as refractive error ≥0.50 diopter. The relevant literature was extracted from these electronic databases using the keywords "sleep," "sleep duration," "bedtime," and "myopia." English language articles related to the topic were included. Articles that have discussed the role of risk factors for myopia but did not mention any relation to sleep were excluded. Sixteen studies were included after reviewing the relevant literature, and only six studies have shown a significant relationship between shorter duration of sleep and the development of myopia. This review suggests that apart from other environmental factors, sleep duration may have a role in developing myopia. Thus, increasing awareness about optimum sleep duration has a potential utility to reduce the development and progression of myopia.

An atypical case of bilateral optic neuritis after strabismus surgery under general anesthesia.

INTRODUCTION: Strabismus surgery under general anesthesia is a common procedure with rare complications in the form of hemorrhage, infection, slipped muscle, lost muscle, scleral perforation, and anterior segment ischemia. We report a unique case of bilateral optic neuritis following squint surgery under general anesthesia in a 15-year-old girl. METHODS: A 15-year-old girl presented with accommodative esotropia with V pattern. She underwent uneventful bilateral inferior oblique recession surgery under general anesthesia with Propofol 60 mg, Atracurium 30 mg, and Fentanyl 70 mcg. On the first post-operative day, the patient had an acute onset of temporal headache which was non-radiating. She responded to supportive treatment and was discharged. However, on the 7th postoperative day, she presented with a constant severe headache in the bitemporal region (left > right) for 3 days. She also experienced a painless diminution of vision for 2 days. There was no vomiting, fever, loose stools, diplopia, difficulty in breathing, peripheral sensation loss, generalized weakness, or bowel/bladder incontinence. RESULTS: The best corrected visual acuity was 6/9 in right eye, and 6/9p in left eye with a relative afferent pupillary defect (RAPD) in the left eye. Both optic discs appeared hyperemic with blurred margins. Magnetic resonance imaging (MRI) of the brain and orbit showed hyperintensity along the intraorbital and intracanalicular parts of bilateral optic nerves on T2 weighted image suggesting bilateral optic neuritis. She received intravenous methylprednisolone pulse therapy followed by oral steroids and responded to the medical treatment with improvement in vision but developed steroid-induced glaucoma requiring medical management over several weeks. DISCUSSION: Neuro-ophthalmic complication in the form of non-arteritic ischemic optic neuropathy has been reported after various ophthalmic surgeries, but bilateral optic neuritis has not been reported to date. This possibility should be kept in mind if any patient presents with similar symptoms. This report also highlights IOP monitoring in pediatric patients receiving systemic steroids to prevent loss of vision due to steroid-induced glaucoma.

Subclinical right ventricular dysfunction in patients with asymptomatic type 2 diabetes mellitus: A cross-sectional study.

BACKGROUND: Diabetic cardiomyopathy, which involves both the right and left ventricles, progresses from a preclinical stage to overt heart failure. Detection of this entity at a preclinical stage could be crucial in intervening to halt its progression to overt heart failure. There is a paucity of literature on subclinical RV dysfunction in diabetic patients, and it is even rarer in the Indian literature. Our study intended to study this clinical entity through an echocardiographic assessment of asymptomatic patients. OBJECTIVES: This was a cross-sectional observational analytic study, comparing subclinical RV dysfunction in diabetic and non-diabetic subjects by using echocardiography as a primary objective, while the secondary objective of the study was to find out the correlation between RV dysfunction and the duration of diabetes mellitus and HbA1C levels. METHODS: Conventional echocardiography with tissue Doppler imaging (TDI) was used to measure nine different echocardiographic parameters in the diabetic and non-diabetic groups. All probable causes of RV dysfunction were excluded before enrolling the patients in the study. Unpaired t-test was used to compare the parameters between the two groups, and multivariate regression analysis was done taking into consideration age, duration of diabetes, and HbA1C levels as the independent variables, and echocardiographic parameters as the dependent variables. RESULTS: Out of the nine different echocardiographic parameters, Tricuspid annular plane systolic excursion (TAPSE), RV end diastolic diameter (RVEDD), Tricuspid peak late diastolic velocity (A), E/A ratio, RV basal segment peak myocardial systolic velocity (Sm), RV basal segment peak early diastolic velocity (Em), RV basal segment peak late diastolic velocity (Am), and E/Em ratio showed statistically significant differences between the two groups. These results show the presence of subclinical RV dysfunction in diabetic patients. TAPSE and E/A ratio showed a significant correlation with the duration of diabetes, while Em showed a significant correlation with HbA1C. CONCLUSION: Diabetes mellitus is associated with subclinical systolic as well as diastolic RV dysfunction. In addition to helping identify people at high risk, the early recognition of RV dysfunction gives us a window of opportunity to take action and slow down the disease's course. This study emphasizes that the early identification of RV diastolic as well as systolic dysfunction in asymptomatic Type 2 diabetic patients can be a helpful tool in halting the progression of disease from subclinical to frank clinical cases, thereby preventing the morbidity and mortality associated with heart failure. Hence, it adds value to the pre-existing literature.

Prognostic Significance of Diastolic Dysfunction in Type 2 Diabetes Mellitus Patients With Sepsis and Septic Shock: Insights From a Longitudinal Tertiary Care Study.

BACKGROUND: Sepsis is one of the leading contributors to global mortality and morbidity, causing multi-organ failure, mainly involving cardiovascular failure, both systolic and diastolic dysfunction, leading to adverse clinical outcomes. There is little clinical data on the correlation with the mortality of patients with type 2 diabetes mellitus (T2DM) with sepsis and septic shock and left ventricular diastolic dysfunction. Our study sought to assess whether the severity of diastolic dysfunction could predict 28-day mortality. METHODOLOGY: The study included T2DM patients admitted to the intensive care unit (ICU) with sepsis and septic shock defined according to the Third International Consensus Definitions for Sepsis and Septic Shock at a tertiary care center in northern India. A total of 132 patients (age = 61.01 ± 13.12 years; 62% male; mean APACHE II (Acute Physiology and Chronic Health Evaluation II) score = 25.74 ± 4.79; Sequential Organ Failure Assessment (SOFA) score = 12.34 ± 3.36) underwent transthoracic echocardiography within two hours of ICU admission till 28 days of admission or till mortality occurred. Clinical variables (APACHE II and SOFA score) and cardiac biomarkers, such as N-terminal pro-B-type natriuretic peptide (NT-pro-BNP), troponin I, and creatine phosphokinase-MB, were measured at the time of admission and after 72 hours to compare with mortality. Diastolic dysfunction was defined according to the American Society of Echocardiography (ASE) 2009 guidelines, classifying subjects into grade 0 (normal), if early diastolic velocity (e') ≥ 8 cm/s; grade 1 (impaired relaxation), if e' < 8 cm/s and early (E) to late (A) ventricular filling velocities (E/A) ratio < 0.8; grade 2 (pseudo normal), if e' < 8 cm/s, E/A = 0.8-1.5, and peak E-wave velocity by the peak e' velocity (E/e') ratio = 9-12; and grade 3 (restrictive), if e' < 8 cm/s, E/A > 2, deceleration time (DT) < 160 ms, and E/e' ≥ 13. RESULTS: Thirty-seven (40.65%) out of 132 patients had diastolic dysfunction on initial echocardiography, while 54 (59.34%) had diastolic dysfunction on at least subsequent echocardiography. Total mortality was 68.93% with the highest mortality (100%) observed among those with grade 3 diastolic dysfunction. The 28-day mortality with diastolic dysfunction in sepsis and septic shock patients showed significant results (p < 0.001), indicating that with a higher E/A ratio or higher grade of diastolic dysfunction with the increase in SOFA score, the early ICU mortality is the highest and have the shortest duration of ICU stay with mean ± SD = 6.2 ± 2.48, as compared to other grades with 100% mortality. Also, the cardiac biomarker NT-pro-BNP was markedly elevated with a mean ± SD value of 503 ± 269.3 pg/ml, indicating early predicted mortality. No correlation was detected between mortality and the mean levels of fasting blood sugar, postprandial blood sugar, and glycosylated hemoglobin. CONCLUSION: Our study concluded that diastolic dysfunction is an important and strongest independent mortality predictor in patients with T2DM with severe sepsis and septic shock, and the higher the grade of diastolic dysfunction, the higher the mortality with the lowest mean ICU stay.

Clinico-Epidemiological Profile of Patients Presenting With Acute Chest Discomfort in Emergency Medicine Department of a Tertiary Care Hospital in Uttarakhand, India: A Prospective Observational Study.

Background Acute chest discomfort is a common presenting complaint in the emergency department. There is a paucity of studies related to clinico-epidemiological profile of patients with acute chest discomfort in the emergency department (ED). Hence, we intended to conduct the study to address the dearth of research in this field. Aims and objectives The primary objective of this study was to study the clinico-epidemiological profile of patients with acute chest discomfort presenting to the ED. The secondary objectives were to assess the prevalence of premature acute coronary syndrome (ACS), to study the ED disposition and final hospital discharge diagnosis, and to assess the predictors of 24-hour mortality in such patients. Methods A prospective observational study of patients presenting with acute chest discomfort was conducted in the emergency medicine department of a tertiary care hospital. We included adults above the age of 18 years from December 2021 to December 2022 and excluded trauma patients. A standardized form was used to document patient demographic patterns, comorbidities, chest discomfort description, physical findings, investigations, consultations, ED management, and disposition. Variables having p-value ≤ 0.05 were considered to be significant. Results A total of 200 patients were included. The most common cause of chest discomfort in the ED was cardiac, accounting for 48.5% (n = 97) of patients. The most common cardiac cause of acute chest discomfort was ST-elevation myocardial infarction (STEMI) ~ 21% (n = 42). Cardiac diagnosis was associated with the maximum number of admissions (≈80%; n = 78). The prevalence of premature ACS was 13.9% (n = 10). A 24-hour mortality was significantly associated with male gender, ambulance transport, history of coronary artery disease, and hypoxia and hypotension at the initial presentation. Conclusions ACS followed by respiratory causes are the predominant etiologies of acute chest discomfort in the ED. Knowledge of the differential diagnosis of acute chest discomfort in the ED can aid in prompt diagnosis and delivery of lifesaving treatment to these patients.

Surgical Outcomes of Levator Resection in Moderate and Severe Ptosis With a Good Levator Function: A Retrospective Study.

INTRODUCTION: An abnormally drooping upper eyelid in comparison with the normal position in primary gaze refers to ptosis. Levator resection should be the procedure of choice in patients with moderate to severe ptosis and a good levator function. METHODS: In this retrospective study, we analysed the surgical outcomes after large and maximal levator resection in patients with moderate and severe ptosis with a good levator function and Bell's phenomenon. All patients had a good levator function; therefore, levator resection was the procedure of choice. We performed levator resection of 20 mm and above and the desired post-operative correction was achieved. RESULTS: One patient had microcornea, and hence, he was undercorrected and his post-operative marginal reflex distance 1 (MRD 1) was 3 mm. Two patients who had severe ptosis pre-operatively had a post-operative MRD 1 of 3 mm. Rest of the patients had a post-operative MRD 1 of 4 mm. CONCLUSION: Levator resection of 20 mm or more should be performed in patients with congenital simple ptosis with a good levator function and Bell's phenomenon to achieve a favourable post-operative outcome.

Ocular involvement-An unusual initial presentation of chronic myeloid leukemia: A case report.

Chronic myeloid leukemia (CML) patients frequently exhibit systemic symptoms such as fatigue, abdominal discomfort, weight loss, and fever but rarely can have atypical initial presentation in the form of ophthalmic manifestations, which can precede the diagnosis of the primary malignancy. We describe a case of a 29-year-old male who presented in our ophthalmology out-patient department (OPD) with complaints of painless, diminution of vision, which was sudden in onset in right eye (RE) and loss of vision in left eye (LE) for four and seven days, respectively. There had been a history of loss of weight and appetite for the past 2 months. The visual acuity (VA) recorded was finger counting two meters in RE and perception of light in LE with an inaccurate projection of rays in both eyes (BE). The anterior segment evaluation of both eyes (BE) was normal. Fundus revealed multiple elevated yellow subretinal lesions with exudative detachment in the RE and no view in the LE. Ultrasound-Brightness (USG B) scan in the LE revealed multiple hyperreflective echoes likely vitreous hemorrhage. Optical coherence tomography (OCT) showed subretinal hyperreflectivity with surrounding edema in RE suggestive of leukemic infiltrates. On further systemic investigations, chronic myeloid leukemia-chronic phase (CML-CP) was detected; hence, the diagnosis of RE exudative retinal detachment (RD) and LE vitreous hemorrhage with CML-CP was made. Ophthalmic involvement is more often seen in acute than chronic leukemia, which makes the diagnosis challenging. We describe a unique case of a young patient with CML-CP who initially presented with ocular involvement preceding systemic diagnosis. This case report illustrates the importance of a primary care physician or an ophthalmologist in the early diagnosis and prompt management of hematological malignancy, as ophthalmic manifestations may be a rare initial presenting feature in CML-CP. These conditions require urgent referral to a hematologist by a primary care physician in the view of early commencement of therapy.

Total external ophthalmoplegia and orbital apex syndrome as first presenting feature of Rhabdomyosarcoma involving petrous part of the temporal bone: A case report.

INTRODUCTION AND IMPORTANCE: Rhabdomyosarcoma (RMS) can have various unusual presentations. We report an unusual presentation of RMS as orbital apex syndrome in a six-year-old boy involving the petrous part of the temporal bone. CASE PRESENTATION: A six-year-old boy presented with drooping of the left eyelid for seven days associated with headache, left-sided hearing loss, and nasal blockage. Contrast-enhanced magnetic resonance imaging (CE-MRI) brain and orbit revealed an ill-defined expansile vascular lesion centered at the petrous part of the left temporal bone with extension to the cavernous sinus, which was confirmed as RMS on histopathology and immunohistochemistry. The patient was managed by chemotherapy and radiotherapy. CLINICAL DISCUSSION: RMS is the most common aggressive malignant soft tissue tumor in the pediatric population. It accounts for 4-8 % of all malignancies in children below 15 years of age, with strong male preponderance. The most common site for RMS is head and neck (45 %), having maximum incidence during the first decade of life. CONCLUSION: Total external ophthalmoplegia in a child is an acute emergency; it should be properly worked up, and neuroimaging should always be advised. Prompt diagnosis and management by a multidisciplinary team can be both life and sight-saving.

Noninvasive assessment of pulmonary congestion in heart failure: Need of the hour.

Early pulmonary congestion detection and surveillance in acute heart failure patients can prevent decompensation, minimize hospitalizations, and improve prognosis. In India, the warm and wet types of HF are still the most common types and residual congestion at discharge is still a significant concern. Thus, there is an urgent need for a reliable and sensitive means of identifying residual and subclinical congestion. Two such monitoring systems are available and approved by US FDA. These include CardioMEMS HF System (Abbott, Sylmar, California) and ReDS System (Sensible Medical Innovations, Ltd., Nanya, Israel). CardioMEMS is a wireless pressure-sensitive implantable device, while ReDS is a wearable noninvasive device for measurement of the lung fluid and hence direct detection of PC. This review discusses the role of noninvasive assessment in PC monitoring in patients with heart failure and its implications from an Indian perspective.

Long-Term Surgical Outcomes of Bilateral Symmetrical Superior Oblique Nasal Tenotomy in Patients of Large A-Pattern Exotropia.

Purpose: To report the long-term outcomes of bilateral symmetrical superior oblique (SO) nasal tenotomy in patients with large A-pattern exotropia (≥25 prism diopter [PD]). Methods: This retrospective study was conducted on 15 patients (aged: 4-28 years) of large A-pattern exotropia. An A-pattern was defined as >10 PD difference between up and down gaze at 6 m by use of the alternate prism cover test. Objective ocular torsion was assessed by fundus photography and subjective torsion by double Maddox rod test. All patients underwent horizontal muscle surgery according to the primary position horizontal deviation and bilateral symmetrical SO nasal tenotomy for A-pattern. Surgical success was defined as postoperative A-pattern of ≤10 PD, the absence of vertical and torsional diplopia, and the absence of V-pattern. The minimum follow-up period was 24 months. Results: A total of 15 patients of large A-pattern exotropia (7 males and 8 females) with a mean age of 17.09 ± 7.9 years were included in the study. All patients had bilateral SO overaction of grade +3 or +4 with a mean preoperative A-pattern of 30.3 ± 3.9 PD. At 24 months of follow-up, esotropia in down gaze (V-pattern) was present in four patients with a mean of 11.25 ± 2.5 PD, (range, 10-15 PD). The rest of the 11 patients maintained successful alignment with a mean A-pattern of 3.18 ± 1.17 PD, (range, 2-5 PD). There was significant A-pattern collapse with a mean of 31 ± 9.1 PD after 2 years of follow-up, which was significantly associated with preoperative A-pattern (Pearson correlation, r = 0.7; t[15] = 4.0; P = 0.002). The mean of pre- and postoperative objective ocular torsion was found to be -0.5 ± 4° and -4.8 ± 3.8° with a mean extorsion effect of 4.67 ± 3.85°. There was a statistically significant difference between pre- and postoperative ocular torsion (°) (t [30] = 5.42; P < 0.001), the change in ocular torsion was significantly associated with preoperative torsion (Pearson correlation, r = 0.5; t [30] = 7.2; P < 0.001). None of the patients had subjective torsion on the double Maddox rod test pre- and postoperatively. Conclusions: Bilateral symmetrical SO nasal tenotomy is effective in cases with large A-pattern (>25 PD). The reduction of A-pattern and postoperative change in fundus torsion have a positive correlation with preoperative A-pattern and preoperative torsion, respectively.

Effect of non-pharmacological interventions on adults with cardiovascular risk in a rural community.

Background: Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality worldwide, with three-fourth of deaths occurring in low- and middle-income countries (LMICs) like India. Currently, three out of the top five causes of morbidity and mortality in the country are NCDs. Objective: This study evaluated the impact of non-pharmacological interventions as a comprehensive approach toward adults with cardiovascular risk in Indian rural communities. Material and Methods: It was a quasi-experimental study conducted in Rishikesh, a holy city of Uttarakhand known as the world's yoga capital at the foothills of Himalaya. Out of 87 villages, four villages were randomly selected. Eighty-eight participants were enrolled (22 from each village and household). It was a multi-stage random sampling. All the participants with cardiovascular risk and age >30 years were recruited. Pregnant, severely ill, and unwilling to consent were excluded. Non-pharmacological intervention as a comprehensive approach, including yoga, meditation, mental health counseling, dietary counseling, tobacco, and alcohol cessation counseling has been provided to cardiovascular risk participants. Results: Data of 76 participants were analyzed as the per-protocol analysis method. The drop-out rate was 13.63%. Male and female participants were 52 (68.4%) and 24 (31.6%) in number. Mean age of the participants was 55.28 ± 13.64 years. Diastolic blood pressure or DBP (P = 0.017*), systolic blood pressure or SBP (P = 0.008**), waist circumference (WC) (P = 0.000**), waist-to-hip ratio (P = 0.000**) and waist-to-height ratio (P = 0.000**) significantly improved in the post intervention group. Conclusion: Non-pharmacological interventions as a comprehensive approach can significantly reduce modifiable risk factors for cardio-metabolic disease.

Impact of Universal Health Insurance on Total Ischemia Time and Door-to-Balloon Time in STEMI: A Single-Center Study from a Geographical Adverse Region.

Introduction: We studied the impact of a Universal Health Insurance (UHI) Scheme introduced in India on total ischemia time (an important determinant of ST-elevation myocardial infarction [STEMI] outcome). Materials and Methods: This is a retrospective hospital-based comparative study which evaluated the total ischemia time (min) of all the patients presenting with STEMI and undergoing primary angioplasty before (Group A) and after (Group B) implementation of this scheme. Results: A total of 221 patients (mean age: 54.18 ± 13.02 years in Group A and 57.59 ± 11.42 years in Group B) were included in the study. Median pain to first medical contact time was 300 and 360 min (P = 0.49), whereas the median first medical contact to percutaneous coronary intervention PCI center time was 330 and 210 min (P = 0.32), for Groups A and B, respectively. A statistically significant difference was noted in the mean door-to-device time between two groups (67.46 ± 33.10 min in Group A vs. 58.48 ± 12.99 min in Group B; P = 0.02). Conclusions: A significant difference in door-to-balloon time was found after implementation of UHI, but total ischemia time was no different. It emphasizes the importance of establishing a system of STEMI care that can decentralize the benefits of early reperfusion like hub-and-spoke model.