Management of severe tetanus in Afghanistan: lessons from the field.

INTRODUCTION: Tetanus is a rather rare disease in the Western countries thanks to widespread vaccination programs and the availability of prophylactics for patients with tetanus-prone injuries. The few cases that do occur are promptly managed in intensive care units (ICUs). However, tetanus is not so rare in developing countries, where access to a suitable level of care is limited. An unstable political situation can be a significant factor influencing patient outcomes. CASE REPORT: A ten-year-old boy presented at the EMERGENCY hospital in Lashkar-Gah (southern Afghanistan) with generalized tetanus after falling off his bicycle. In response to his rapidly deteriorating general conditions - respiratory failure and hemodynamic instability - the patient was urgently transferred by ambulance to the ICU at the EMERGENCY hospital in Kabul (northern Afghanistan). The patient was placed on mechanical ventilation while receiving intravenous sedation and pharmacologic paralysis for almost four weeks. A prolonged infusion of a high dose of magnesium sulphate and labetalol was also given to counteract autonomic dysfunction. Multiple complications related to the long stay in the ICU were observed and promptly addressed. During this period, several mass casualties took place in Kabul, which stretched the hospital's surge capacity. The patient was discharged and accompanied back to Lashkar-Gah three months after his admission to the hospital. CONCLUSION: This case report shows some of the many difficulties that arise when managing a patient with severe tetanus in a war zone where resources are limited.

Effect of Music Selection on Anxiety Level during Intravitreal Injections for Individuals of Varying Cultures.

PURPOSE: To investigate music selection as a treatment for anxiety during Intravitreal injections (IVI) for individuals of varying cultures. METHODS: 106 individuals were enrolled in this randomized controlled study. Individuals were randomized into one to three categories: (1) a control group in which the IVI procedure was performed without music (n = 35), (2) an experimental group in which the music was selected by the physician (n = 36), (3) an experimental group in which the music was selected by the patient (n = 35). After the procedure, all patients responded to a questionnaire regarding their level of experienced anxiety, pain and discomfort (grade 0-10). The primary outcome was anxiety level during the procedure. RESULTS: The experimental group in which patients selected music had higher number of patients with low anxiety score compared to the other groups (anxiety score <4 in 19,18 and 27 patients, respectively, p = .04). Interestingly, patients who answered the questionnaire in Arabic were less likely to desire music on subsequent injections compared to Hebrew and English speakers (52% Vs 78% Vs 100%, p = .02). Music was deemed by both experimental groups as an effective method to induce relaxation (average score of 6.6 and 7.2 in group 2 and 3, respectively). Preference for music on subsequent injections was increased in both experimental groups compared to the control group (P < .01). Patients in the third group preferred music selection on future injections more than the other groups (P < .01). CONCLUSION: Music selection may be an effective way to reduce anxiety levels during IVI. Preference for music during future injections is higher in patients who were exposed to music during IVI and may be influenced by culture.

Pediatric Ocular Injury Due to Hand Sanitizer Exposure: An Emerging Hazard.

OBJECTIVES: The objective of this study was to describe the incidence and severity of ocular exposure to alcohol-based hand rub (ABHR) in children presenting to a tertiary medical center during the severe acute respiratory syndrome coronavirus 2 pandemic. METHODS: A retrospective single-center observational study conducted from February 21, 2020, to October 11, 2020. Subjects 10 years or younger who presented with ABHR-induced ocular injury were included. The same period from 2019 was studied and a comparison was performed between the 2 years. Outcome measures included the number of subjects with ocular injury due to ABHR, extent of ocular epithelial defects, length of hospitalization and time to resolution. RESULTS: A total of 9 patients presented to the Pediatric Emergency Department after sustaining ocular chemical injuries from ABHR during this period. Treatment included immediate irrigation followed by topical antibiotics, steroids, and lubrication. Six children were discharged and followed as outpatients with no reported adverse ocular sequelae. Three patients exhibited epithelial defects involving 85% to 100% of the cornea, 30% to 75% of the conjunctiva and required inpatient treatment ranging from 4 to 11 days. All patients experienced a complete resolution of the ocular epithelial defects after 12 to 19 days. No long-term irreversible damage was observed and visual acuity returned to normal in all patients. CONCLUSIONS: The utilization of ABHR during the severe acute respiratory syndrome coronavirus 2 pandemic resulted in childhood ocular injury. Prompt treatment led to good visual outcomes. These products should be regarded as potentially toxic and stored out of the reach of young children.