A Perception-Based Survey on Practice Patterns Pertaining to the Diagnosis and Management of Allergic Rhinitis in India.

INTRODUCTION: Allergic rhinitis (AR) is increasingly prevalent in India, affecting a significant portion of the population and adversely impacting their quality of life. This nationwide survey aimed to explore the perceptions and clinical preferences of Indian physicians regarding the perceived prevalence, common symptoms, and various available treatments for AR. METHODS: This cross-sectional, observational, digital questionnaire-based survey was conducted from September 2022 to March 2023, involving physicians sharing insights on prevalence rates, diagnostic approaches, medication preferences, and immunotherapy practices in AR management. RESULTS: A total of 1608 physicians participated in this survey. The majority of physicians (n=684, 42.5%) reported that the prevalence of AR in routine clinical practice is between 21 and 40%. Physicians also noted a substantial burden of AR with asthma (n=626, around 40%). Total IgE count was reported as a mandatory test for the diagnosis of AR by 47.5% of physicians (n=764). For the management of mild cases of seasonal or perennial AR, 980 (60.9%) physicians preferred fexofenadine as an oral antihistamine of choice. Fluticasone furoate was the preferred intranasal corticosteroid (INCS) option (67.1% of physicians (n=1079)), for the management of patients with moderate to severe AR, the most recommended duration of INCS therapy was two to four months (40.9% of physicians). Doctors recommended a montelukast and antihistamine combination in mild AR (n=152, 9.5%), mild AR not responding to antihistamine alone (n=291, 18.1%), moderate to severe AR along with INCS (n=252, 15.7%), and AR with mild asthma (n=74, 4.6%). The majority of physicians (n=1512, 75.6%) preferred using fexofenadine in combination with montelukast for the management of AR. The majority of physicians (n=839, 52.2%) opined that the efficacy rate of oral montelukast-fexofenadine was 60-90% in the management of mild-moderate AR. Around 55.3% of physicians (n=889) had not used immunotherapy in their clinical practice. CONCLUSION: These observations offer a holistic view of how Indian physicians perceive the management of AR, a condition highly prevalent in India and often associated with asthma. It also highlights the treatment strategies employed in their day-to-day clinical practice.

The prevalence of frailty and its relationship with sociodemographic factors, regional healthcare disparities, and healthcare utilization in the aging population across India.

Objective: To estimate frailty prevalence and its relationship with the socio-economic and regional factors and health care outcomes. Methods: In this study, participants from the harmonized Diagnostic Assessment of Dementia for the Longitudinal Aging Study in India (LASI-DAD) were included. The frailty index (FI) was calculated using a 32-variable deficit model, with a value of ≥ 25% considered as frail. Data on demographic (including caste and religion) and socioeconomic profiles and health care utilization were obtained. The state-wise health index maintained by the government based on various health-related parameters was used to group the participants' residential states into high-, intermediate-, and low-performing states. Multivariable and zero-inflated negative binomial regression was used to assess the relationship of frailty index with sociodemographic characteristics, health index, and health care expenditure or hospitalization. Results: Among the 3953 eligible participants, the prevalence of frailty was 42.34% (men = 34.99% and women = 49.35%). Compared to high-performing states, intermediate- and low-performing states had a higher proportion of frail individuals (49.7% vs. 46.8% vs. 34.5%, P < 0.001). In the adjusted analysis, frailty was positively associated with age, female sex, rural locality, lower education level, and caste (scheduled caste and other backward classes). After adjusting for the socio-economic profile, FI was inversely associated with the composite health index of a state (P < 0.001). FI was also significantly correlated with total 1-year health care expenditure and hospitalization (P < 0.001 and 0.020, respectively). Conclusion: There is a high prevalence of frailty among older Indian adults that is associated with sociodemographic factors and regional health care performance. Furthermore, frailty is associated with increased health care utilization and expenditure.

Cone-Beam Computed Tomographic Assessment of Maxillary Sinus Characteristics in Patients With Cleft Lip and Palate: A Systematic Review and Meta-Analysis.

The aim of this systematic review and meta-analysis was to evaluate the maxillary sinus characteristics of patients with cleft lip and palate (CLP).The study included manuscripts which met the following criteria: (1) study of individuals with CLP in any age group or gender and (2) study of individuals in whom assessment of maxillary sinus characteristics had been done by cone-beam computed tomography. Studies with (1) individuals having special health-care needs and (2) individuals with any syndrome affecting the development of the head and neck were excluded.In total, 11 articles were included in the review, based on the inclusion and exclusion criteria. Pooled maxillary sinus volume (MSV) on the cleft sides of patients with unilateral cleft lip and palate (UCLP) was found to be 9433.14 mm3 (95% CI, 7453.99-11 412.30), which was significantly smaller than that of controls. The meta-analyses also revealed significantly reduced MSV on the cleft sides of patients with UCLP. The differences between cleft and noncleft sides of the patients with UCLP were not found to be statistically significant. Strength-of-evidence was found to be moderate in 4 characteristics, along with 10 out of 11 articles showing low risk-of-bias.It was concluded that MSV was reduced and mucosal thickening was increased/present in patients with CLP as compared with controls. The differences between MSV of cleft and noncleft sides of the patients with UCLP could not be established. However, heterogeneity was found in terms of sample size, stratification of samples by age, and evaluation of some confounding factors.

How Informative Is YouTube Regarding Feeding in Infants with Cleft Lip and Palate?

OBJECTIVE: To assess the characteristics of popular videos on YouTube about the feeding of infants with cleft lip and palate (CLP) and analyze the adequacy of information provided by them. DESIGN: A cross-sectional design was used. METHODS: YouTube was systematically searched for consecutive relevant videos about the feeding of infants with CLP, using predefined keyword combinations, without any limitations on language or duration. Scrutiny of the top 50 videos for each keyword combination was performed and a self-designed data-extraction sheet was used. A content adequacy index was developed by an expert group, and used to assess content adequacy, classifying it into categories from excellent to poor. RESULTS: From an initial retrieval of 200 videos, 42 were included in the final assessment. The videos originated from nine different countries, with more than half coming from the USA and in English. Five of the videos came from the channel of the American Cleft Palate-Craniofacial Association. Content adequacy analysis showed that no video could be classified as excellent, while 33.3% were classified as optimal, 21.4% as suboptimal and 45.2% as poor. CONCLUSIONS: The content adequacy of the majority of videos on YouTube, relating to the feeding of infants with CLP was inadequate, with only one third of them achieving optimal content adequacy. Efforts must be made to develop informative and standardized videos for social media and video-sharing platforms, perhaps through professional associations to ensure that families with an infant with CLP receive appropriate information.

Is application of salt for 3 days locally is sufficient to treat umbilical granuloma?

BACKGROUND: The falling of Umbilical stump occurs by 7-15 days of age. The healing of umbilical stump may be complicated by Umbilical Granuloma. It is often treated by chemical cauterisation which require repeated applications and may lead to local or systemic complications. Common salt by way of its dessicative property may help in treatment of Umbilical Granuloma. OBJECTIVE: The objective of the study is to assess the role of common salt application in umbilical granuloma. MATERIALS AND METHODS: This is retrospective study over 3 years from a pediatric surgery unit in Northern India. The study subjects were infants less than 10 weeks of age who presented with umbilical granuloma. The method of salt application was 1 pinch of common salt for 1 hour twice a day for 3 consecutive days. The babies were assessed at day 5th for resolution. The success was defined as thrice resolution after 3 cycles. The baseline demographic details were taken and the association of success of treatment was analyzed. RESULTS: A total of 36 infants were given treatment in form of common salt application for treatment of umbilical granuloma. The success of around 96% and the cases which presented early responded well. Most of the cases resolved after 3 cycles of treatment. CONCLUSION: The common salt application is effective in treatment of granuloma without any side effects.

Predictors of infection in viral-hepatitis related acute liver failure.

OBJECTIVE: Infections are common and associated with complications and mortality in acute liver failure (ALF). The temporal relationship between ammonia and infection in ALF patients is unclear. We aimed to evaluate the predictors of infection and its relationship with arterial ammonia levels. MATERIALS AND METHODS: Consecutive ALF patients hospitalized between January 2004 and December 2015, without signs of infection at/within 48 h of admission, were included. Occurrence of infection after 48 h was documented and ammonia levels were estimated for five consecutive days. Multivariate logistic regression analysis was used to assess factors associated with development of infection. Generalized estimating equations (GEE) were used to evaluate five-day time trend of ammonia in patients with and without infection. RESULTS: Of 540 consecutive patients, 120 were infected at admission/within 48 h and were excluded. Of the rest 420 patients, 144 (34.3%) developed infection after 48 h and 276 (65.7%) remained non-infected. Infected patients had higher mortality than non-infected patients (61.8% vs 40.0%, p < .001). On multivariate analysis, presence of cerebral edema(HR 2.049; 95%CI, 1.30-3.23), ammonia level on day 3 of admission (HR 1.006; 95%CI, 1.003-1.008), and model for end stage liver disease (MELD) score (HR 1.051; 95%CI, 1.026-1.078) were associated with development of infection. GEE showed group difference in serial ammonia values between infected and non-infected patients indicating lack of ammonia decline in infected patients. CONCLUSIONS: Cerebral edema, elevated ammonia on day 3, and higher MELD score predict the development of infection in ALF. Ammonia persists at high levels in infected patients, and elevated ammonia on day 3 is associated with complications and death.

Multimodal Therapy for Stage III Retinoblastoma (International Retinoblastoma Staging System): A Prospective Comparative Study.

PURPOSE: To compare the efficacy of 2 chemotherapeutic drug combinations as part of multimodal therapy for orbital retinoblastoma. DESIGN: Prospective, comparative, study. PARTICIPANTS: Patients with stage III retinoblastoma (International Retinoblastoma Staging System). METHODS: Demographic and clinical features were recorded at presentation. Treatment consisted of a multimodal protocol with neoadjuvant chemotherapy, enucleation, orbital external-beam radiotherapy, and adjuvant chemotherapy. For chemotherapy, patients were randomized into 2 groups: group A patients were treated with vincristine, etoposide, and carboplatin (VEC) and group B patients were treated with carboplatin and etoposide, alternating with cyclophosphamide, idarubicin, and vincristine. Treatment outcomes and adverse effects were recorded. Efficacy parameters were compared between the groups. MAIN OUTCOME MEASURES: Survival probability, cause of death, and chemotherapy-related toxicity. RESULTS: A total of 54 children were recruited (27 in each group). The mean ± SD follow-up was 21.3±11.34 months. The overall Kaplan-Meier survival probability was 80% (95% confidence interval [CI], 0.67-0.89) and 42% (95% CI, 0.24-0.59) at 1 year and 4 years, respectively. There were 9 deaths in group A and 15 deaths in group B. The Kaplan-Meier survival probability at 1 year was similar between the groups: 81% (95% CI, 0.60-0.91) and 79% (95% CI, 0.58-0.9) for groups A and B, respectively. At 4 years, the survival probability for group A was higher (63% [95% CI, 0.41-0.79] vs. 25% [95% CI, 0.08-0.46] for groups A and B, respectively), with a strong trend of better survival in group A over time (P = 0.05). The major cause of death was central nervous system relapse (8 patients in group A and 7 patients in group B). Two patients in group B died of sepsis after febrile neutropenia. Grade 3 and grade 4 hematologic toxicities were more common in group B, with a significant difference in grade 4 neutropenia (P = 0.002). CONCLUSIONS: This study compared the outcomes of VEC chemotherapy with a 5-drug combination of etoposide and carboplatin, alternating with cyclophosphamide, idarubicin, and vincristine, for stage III retinoblastoma. The VEC combination was found to be more effective and may be recommended as neoadjuvant and adjuvant chemotherapy.

Evaluation of moxifloxacin 0.5% in treatment of nonperforated bacterial corneal ulcers: a randomized controlled trial.

PURPOSE: To compare the equivalence of moxifloxacin 0.5% with a combination of fortified cefazolin sodium 5% and tobramycin sulfate 1.3% eye drops in the treatment of moderate bacterial corneal ulcers. DESIGN: Randomized, controlled, equivalence clinical trial. PARTICIPANTS AND CONTROLS: Microbiologically proven cases of bacterial corneal ulcers were enrolled in the study and were allocated randomly to 1 of the 2 treatment groups. INTERVENTION: Group A was given combination therapy (fortified cefazolin sodium 5% and tobramycin sulfate) and group B was given monotherapy (moxifloxacin 0.5%). MAIN OUTCOME MEASURES: The primary outcome variable for the study was percentage of the ulcers healed at 3 months. The secondary outcome variables were best-corrected visual acuity and resolution of infiltrates. RESULTS: Of a total of 224 patients with bacterial keratitis, 114 patients were randomized to group A, whereas 110 patients were randomized to group B. The mean ± standard deviation ulcer size in groups A and B were 4.2 ± 2 and 4.41 ± 1.5 mm, respectively. The prevalence of coagulase-negative Staphylococcus (40.9% in group A and 48.2% in group B) was similar in both the study groups. A complete resolution of keratitis and healing of ulcers occurred in 90 patients (81.8%) in group A and 88 patients (81.4%) in group B at 3 months. The observed percentage of healing at 3 months was less than the equivalence margin of 20%. Worsening of ulcer was seen in 18.2% cases in group A and in 18.5% cases in group B. Mean time to epithelialization was similar, and there was no significant difference in the 2 groups (P = 0.065). No serious events attributable to therapy were reported. CONCLUSIONS: Corneal healing using 0.5% moxifloxacin monotherapy is equivalent to that of combination therapy using fortified cefazolin and tobramycin in the treatment of moderate bacterial corneal ulcers. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Use of fibrin glue in preventing urethrocutaneous fistula after hypospadias repair.

UNLABELLED: Urethrocutaneous fistula is one of the most common complications after hypospadias surgery. The incidence of fistula development has varied from 4% to 20% in larger series. We sought to investigate the role of fibrin glue (Tisseel manufactured by Baxter India Pvt Ltd, Chennai, India) to reduce the chances of fistula formation in cases in proximal penile hypospadias. METHOD: A total of 120 patients with proximal penile hypospadias (patients having urethral meatus at posterior third of penile shaft and at penoscrotal junction) were included in the present study. Patients were randomly allocated into 2 groups of 60 each by using Strata 9 software random number table. In group A, fibrin glue was used as a sealant after hypospadias surgery, whereas in group B, no sealant was used. All the operations were performed by single surgeon using transverse preputial tubularized island flap urethroplasty. RESULT: Fistula formation occurred in 6 cases in group A (10%) and 19 cases in group B (32%) (P = .027). The fistulae observed in fibrin glue group A were single and small in size (<1 mm). Multiple (>or=2 fistulae) and larger fistulae (>2 mm) were observed in group B. Overall complication was significantly higher in group B (P = .006). CONCLUSION: Fibrin glue in hypospadias repair does not eliminate fistula formation. However, it seems that it minimizes the incidence of fistula formation.

Is pneumoperitoneum an absolute indication for surgery in necrotizing enterocolitis?

BACKGROUND: Necrotizing enterocolitis (NEC) is the most common gastrointestinal medical/surgical emergency in neonates. Non-operative support is needed in 70% of NEC cases, and surgical intervention in the rest 30%. Historically, pneumoperitoneum has been considered as an absolute indication for laparotomy. In the present study we emphasize that pneumoperitoneum is not an absolute indication for exploratory laparotomy in NEC cases. METHODS: We prospectively studied 58 patients with severe NEC having pneumoperitoneum on abdominal X-ray in the last 5 years. At the time of admission, the patients were given intravenous fluid, total parental nutrition, blood transfusion and broad spectrum antibiotics followed by abdominal tapping (paracentesis). All the patients with pneumoperitoneum were closely monitored for 48 hours if abdominal tapping was repeated. When the disease seemed to worsen clinically, radiologically and laboratorially, the patient was subjected to exploratory laparotomy. RESULTS: Of the 58 patients, 40 were treated conservatively whereas 18 underwent surgical intervention. The overall mortality in the present study was 12.1%, including 5% of the patients managed conservatively and 27% of the patients undergoing surgery. CONCLUSIONS: Pneumoperitoneum is not an absolute indication for surgery in cases of neonatal NEC. Most of the patients can be treated conservatively.

Single-stage repair for rectovestibular fistula without opening the fourchette.

BACKGROUND: Anorectal malformations are one of the most common congenital defects. This study is conducted to demonstrate new technique for treatment of rectovaginal fistula without disturbing the fourchette through posterior sagittal approach. METHOD: All the patients of rectovestibular fistula admitted after the neonatal age were treated with posterior sagittal anorectoplasty without opening the fourchette. The results were evaluated for cosmetic appearance and anal continence. RESULT: A total of 40 patients were included in our study. All patients were more than 1 month old. Operative time ranges from 70 to 150 minutes. The cosmetic appearance was good. Anal continence was good in 72% cases and fair in 20% cases. Fifteen percent of patients had minimal constipation and 7.5% patients had mucosal prolapse. CONCLUSION: Single-stage repair for vestibular anus through posterior sagittal anorectoplasty without opening fourchette has a good cosmetic appearance and good anal continence.

Prognosis of congenital tracheoesophageal fistula with esophageal atresia on the basis of gap length.

Congenital tracheoesophageal fistula (TEF) with esophageal atresia (EA) is not an uncommon disease of newborns. Several classifications have been advocated for predicting the outcomes of these patients but all are physiological and concentrated on associated medical condition that influences survival. We emphasize a new classification on the basis of gap between two esophageal pouches to define the magnitude of surgical problems in the primary repair and correlate them with the outcomes in terms of anastomotic leak, esophageal stricture and mortality, keeping other prognostic factors constant. A total of 50 cases of congenital TEF with EA were included and all underwent primary esophageal anastomosis after the ligation of TEF. The gap between the two pouches was meticulously measured intraoperatively using a vernier caliper before the ligation of TEF, and patients were divided into four groups on the basis of gap length. Group A, where gap length was >3.5 cm (ultralong), group B where gap length was 2.1-3.5 cm (long gap), group C where gap length was >1 cm but not more than 2 cm (intermediate group) and group D, where the gap between two esophageal pouches was 1 cm or less (short gap). The incidence of anastomotic leak was 80, 50, 28, 10.5% and the incidence of esophageal stricture was 100, 75, 22.5, 19% after successful primary repair, respectively, in groups A, B, C and D. The mortality was highest in group A (80%) followed by group B (50%) and 22% in group C and least 15.6% in group D. The incidences of esophageal leak and mortality were found to be statistically significant. This classification which is based on easily measurable criteria provides a useful method to predict morbidity, long-term outcome and mortality of EA with TEF surgery.