Author Response: Beyond the Nasal Prongs: A Joust of Oxygen Delivery Methods in Post-op Hypoxemia.

How to cite this article: Mishra S, Kothari N, Sharma A, Goyal S, Rathod DK, Meshram T, et al. Author Response: Beyond the Nasal Prongs: A Joust of Oxygen Delivery Methods in Post-op Hypoxemia. Indian J Crit Care Med 2024;28(6):626-627.

Early virus clearance of SARS-CoV-2 among co-infection with malaria.

BACKGROUND AND OBJECTIVES: India has witnessed significant number of cases of co-infection of malaria or dengue with COVID-19, especially during the monsoon season. It has been speculated that anti-malarial immunity might have a protective role in co-infection. Retrospective analysis of co-infection of vector-borne diseases with COVID-19 was done for comparing their remission with matched controls with COVID-19 by means of epidemiological data. METHODS: Medical case records of patients with co-infection of malaria or dengue with COVID-19 admitted at TNMC and BYL Nair Charitable Hospital from 1 March 2020 to 31 October 2020 were analyzed retrospectively. Out of 91 cases of co-infection of SARS-CoV-2 infection with vector-borne diseases, virus clearance (VC) analysis was done for 61 co-infections with malaria. RESULTS: Median duration of VC for co-infection with malaria was 8 days whereas, it was 12 days for controls with COVID-19 (p=0.056). Young patients (≤50 years) with co-infection recovered faster than controls age (p=0.018). INTERPRETATION & CONCLUSION: Co-infection with malaria is associated with less severe disease and early recovery in the form of early VC. Genetic and immunological studies are necessary to confirm malaria protection against SARS-CoV-2 infection.

Risk Factors associated with COVID-19 Patients in India: A Single Center Retrospective Cohort Study.

BACKGROUND AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) outbreak has caused a worldwide pandemic, resulting in >3.8 million deaths. Our aim is to identify the risk factors associated with in-hospital mortality using survival analysis considering the characteristics and outcomes of COVID-19 patients admitted to a dedicated tertiary-care hospital in Mumbai, India. MATERIALS AND METHODS: In a retrospective cohort study, 565 patients admitted from 28th March 2020 to 30th June 2020 were enrolled, and a follow-up was conducted till August 2020. To investigate the impact of COVID-19, survival analysis was performed using the Kaplan-Meier method. Potential risk factors associated with mortality were analyzed using logistic regression models for multivariate analysis and the Cox proportional hazards model for estimating hazard ratios (HRs). RESULTS: From the 565 positive COVID-19 cases, 49 patients died (8.7%) and 516 (91.3%) were discharged. Overall, 119 patients (20%) required intensive care unit (ICU) admission, of which 70 (58%) patients survived. The Kaplan-Meier survival curve showed a significant association of COVID-19 infection with age (≥60; p = 0.008), hypertension (p = 0.03), dialysis (p = 0.0001), lung commodities (p = 0.01), breathlessness (p = 0.0001), severe disease upon high-resolution computed tomography (HRCT) analysis (p = 0.0001), ICU admission (p = 0.0001), and low lymphocyte count at admission (p = 0.0001). Additionally, patients receiving tocilizumab (p = 0.0001) and deprived of hydroxychloroquine (HCQ) + azithromycin (azee) (p = 0.0001) were estimated at a high risk of mortality. INTERPRETATION AND CONCLUSION: Coronavirus disease 2019 (COVID-19) increased the risk of mortality in patients with increased age, comorbidities, and severe symptoms upon treatment with an immunosuppressant (tocilizumab). However, patients treated with HCQ + azee showed favorable results due to their antiviral effects in vitro.

Thoracoscopic Repair of Iatrogenic Bronchial Injury in a Neonate during Bronchogenic Cyst Excision.

Thoracoscopic surgery was not previously accepted in the neonatal population due to inappropriate instrumentation and lack of experience. However, our experience in the last few decades has slowly yet steadily established its safety and efficacy. The major advantages that thoracoscopy offers are early recovery and fewer long-term complications. However, we are aware that this comes at the cost of a steep learning curve and the potential challenge of facing certain complications which may compel a conversion to open. There is a paucity of literature regarding intraoperative complications of neonatal thoracoscopy and its management. Conversion to open thoracotomy is appropriate, keeping patient safety in mind, and any decision made to continue management of a complication thoracoscopically is technically demanding. Iatrogenic bronchial injury is one such rare complication of thoracoscopy with a limited mention in literature. We describe below a 25-day-old patient with a bronchogenic cyst who sustained injury to the left bronchus during thoracoscopic cyst excision, which was successfully repaired thoracoscopically.

Perioperative anesthesia challenges and outcomes of patients with Rhino-Orbito-Cerebral Mucormycosis during the second wave of COVID-19 pandemic: An observational study.

Background and Aims: A rapid surge in rhino-orbito-cerebral mucormycosis (ROCM) cases was reported during the second wave of COVID, especially in India, needing extensive surgical debridement along with medical management. The present study was planned to observe perioperative anesthesia challenges and outcomes of patients with ROCM during the second wave of the COVID-19 pandemic. The primary objective was to observe intraoperative anesthesia challenges and the secondary objectives were to observe postoperative challenges and outcomes of patients. Material and Methods: This was a single-centered, bidirectional (retrospective and prospective) observational study, conducted at a tertiary care center. We enrolled 218 adult patients scheduled for surgical debridement of ROCM under general anesthesia. Demographics, COVID status, comorbid illness, intraoperative challenges (difficult airway, hemodynamic instability, blood loss), and postoperative outcome (postoperative mechanical ventilation, and mortality rate) were noted. Results: The majority of the patients were males (71%) and had diabetes mellitus (54%). COVID-associated mucormycosis was seen in 67% and 41% of them received steroids. Post-induction hypotension was noted in 20.6% of patients, and 14.2% had intraoperative hypotension out of which 5.5% required vasopressor support. Difficult mask ventilation and difficult intubation were reported in 7.3% and 6.4% of patients, respectively. No significant difference was found among intraoperative challenges when COVID mucormycosis was compared to non-COVID mucormycosis. Postoperative mechanical ventilation and ICU care were required in 41.3%, whereas mortality was seen in 11.5% of patients. The mortality was significantly more (P = 0.041) in patients with COVID mucormycosis (13%) compared to that with non-COVID mucormycosis (4.2%). Conclusion: Diabetic male patients who received steroids during COVID illness are at the highest risk of developing ROCM. Difficult airway and hemodynamic instability, are significant perioperative challenges encountered by anesthesiologists. Postoperative ICU management is crucial for decreasing postoperative morbidity and mortality.

Intravenous cannula for percutaneous rescue needle gastrostomy in a neonate with tracheoesophageal fistula-A case report.

Tracheoesophageal fistula offers concrete difficulties for anesthesiologists, which comprise associated congenital anomalies and more importantly the problems concerning ventilation and oxygenation. Among all the types of tracheoesophageal fistula, ventilatory problems are frequently encountered with type C fistula. Effective ventilation can be a challenge in such cases where the endotracheal tube invariably ventilates the fistula causing stomach inflation and respiratory compromise. Thorough knowledge and experience are of utmost importance when it comes to the successful airway management and better survival of neonates undergoing tracheoesophageal fistula repair. We report a case of a 3-day-old neonate, diagnosed with type C tracheoesophageal fistula and esophageal atresia posted for thoracoscopic repair. We want to highlight our experience of percutaneous needle gastrostomy done using an intravenous cannula, as a rescue measure for stomach decompression, to manage life-threatening hypoxia.

Clinical Profile of Patients with Severe Acute Respiratory Syndrome Coronavirus 2 Infection Developing Pulmonary Barotrauma on Mechanical Ventilation.

Background: There is limited information on clinical profile and outcomes of patients on mechanical ventilation (MV) who developed pulmonary barotrauma (PBT) in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Patients and methods: In a retrospective observational study, all SARS-CoV-2 pneumonia patients admitted from March 28, 2020, to August 31, 2020, at Sir HN Reliance Foundation Hospital and Research Center and Seven Hills Hospital (Reliance Facility), Mumbai, India, of 18 years and above on MV and developed PBT, were included. Results: A total of 14 SARS-CoV-2 patients of 45 on MV (31.0%) developed PBT of 1,029 hospitalized. All patients were male and divided as per admission into PaO2/FiO2 (P/F) ≤100 (median 80) and P/F >100 (median 222) group. Pneumothorax developed in seven and six cases of P/F ≤100 and P/F >100 groups, respectively. Three patients in each group developed subcutaneous emphysema, while four developed pneumomediastinum in P/F >100 group. Twelve patients (7, P/F ≤100, and 5, P/F >100) were on invasive, while two (P/F >100) were on noninvasive MV. The mean P/F on the day of PBT was reduced by 27.5 and 65.3%, while peak inspiratory pressure was elevated with a median of 36 and 28 cm H2O in P/F ≤100 and P/F >100 groups, respectively. The median highest tidal volume (420 mL), positive-end expiratory pressure (8 vs 6 cm H2O) on the day of PBT, and length of hospital stay (11 vs 25 days) did not differ between two groups. Survival was 28.6% (4/14). Conclusion: SARS-CoV-2 patients requiring MV with PBT had poor outcomes. Clinicians should be vigilant about the diagnosis of PBT. How to cite this article: Kargirwar KV, Rathod D, Kumar V, Patel M, Shah M, Choudhury H, et al. Clinical Profile of Patients with Severe Acute Respiratory Syndrome Coronavirus 2 Infection Developing Pulmonary Barotrauma on Mechanical Ventilation. Indian J Crit Care Med 2022;26(5):613-618.

Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study.

BACKGROUND: We aimed to study organizational aspects, case mix, and practices in Indian intensive care units (ICUs) from 2018 to 2019, following the Indian Intensive Care Case Mix and Practice Patterns Study (INDICAPS) of 2010-2011. METHODS: An observational, 4-day point prevalence study was performed between 2018 and 2019. ICU, patient characteristics, and interventions were recorded for 24 hours, and ICU outcomes till 30 days after the study day. Adherence to selected compliance measures was determined. Data were analyzed for 4,669 adult patients from 132 ICUs. RESULTS: On the study day, mean age, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were 56.9 ± 17.41 years, 16.7 ± 9.8, and 4.4 ± 3.6, respectively. Moreover, 24% and 22.2% of patients received mechanical ventilation (MV) and vasopressors or inotropes (VIs), respectively. On the study days, 1,195 patients (25.6%) were infected and 1,368 patients (29.3%) had sepsis during their ICU stay. ICU mortality was 1,092 out of 4,669 (23.4%), including 737 deaths and 355 terminal discharges (TDs) from ICU. Compliance for process measures related to MV ranged between 62.7 and 85.3%, 11.2 and 47.4% for monitoring delirium, sedation, and analgesia, and 7.7 and 25.3% for inappropriate transfusion of blood products. Only 34.8% of ICUs routinely used capnography. Large hospitals with ≥500 beds, closed ICUs, the APACHE II and SOFA scores, medical admissions, the presence of cancer or cirrhosis of the liver, the presence of infection on the study day, and the need for MV or VIs were independent predictors of mortality. CONCLUSIONS: Hospital size and closed ICUs are independently associated with worse outcomes. The proportion of TDs remains high. There is a scope for improvements in processes of care.Registered at clinicaltrials.gov (NCT03631927). HOW TO CITE THIS ARTICLE: Divatia JV, Mehta Y, Govil D, Zirpe K, Amin PR, Ramakrishnan N, et al. Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2021;25(10):1093-1107.

A rare case of huge frontoethmoidal encephalocele projecting through mouth, with cleft palate.

Frontoethmoidal encephalocele represents protrusion of meninges and brain in a sac through a defect in the anterior skull base, mostly as swelling over the nose. Rarely it is associated with facial dysmorphism and palatal cleft. There are various perioperative concerns like airway difficulties, leaking from the swelling causing fluid and electrolyte disturbances, risk of infection, compression of the swelling causing a rise in intracranial pressure, bleeding, hypothermia, etc., In neonates, these challenges rise exponentially because of the inherent difficulties in dealing with this group of patients. Frontoethmoidal encephaloceles are common in low socioeconomic strata and are often missed in the antenatal period. We are reporting a rare case of frontoethmoidal encephalocele, with a huge swelling protruding through the cleft palate and occupying more than 50% of the face and oral cavity, making mask ventilation impossible.

Prediction of correlation between preoperative parents' anxiety and their child's anxiety before elective surgery under anaesthesia: An observational study.

Background and Aims: Preoperative parental anxiety can have a profound impact on their children undergoing surgery. The present study was done to analyse the correlation between preoperative parental anxiety and their child's anxiety in paediatric patients undergoing elective surgery. Methods: Paediatric patients aged 2-12 years, scheduled for elective surgeries under general anaesthesia, were included in the study. The child's behaviour and anxiety were assessed in the preoperative area using the modified Yale Preoperative Anxiety Scale (m-YPAS). The parent filled out the demographic questionnaire and the Spielberger State-Trait Anxiety Inventory (STAI) form in the preoperative area on the day of surgery. Statistical analysis was conducted using Statistical Package for the Social Sciences (SPSS) statistics software version 23.0 (IBM Corp, Armonk, NY, USA). Results: A total of 150 children undergoing elective surgery were analysed. Our results showed a strong positive correlation between a child's m-YPAS and his/her parents' anxiety on the day of the surgery (STAI-state) (r = 0.545, P < 0.001). However, the correlation between a child's m-YPAS and his/her parents' anxiety levels (STAI-trait) was not found to be significant (r = 0.109, P = 0.188). A positive correlation was observed between a parent's STAI-state and STAI-trait (r = 0.366, P < 0.001). Factors like area of residence, type of surgery and previous hospitalisation had an influence on the anxiety levels of the child. The birth order of the child, previous hospitalisation and gender of the parent also influenced parental anxiety. Conclusion: Parental anxiety has a significant impact on the child's anxiety during the preoperative period.

Whole genome analysis of Human Mastadenovirus D causing Keratoconjunctivitis in India - A multicentre study.

INTRODUCTION: Human mastadenovirus (HAdV) types 8, 37, 64 have been considered the major contributors in Epidemic keratoconjunctivitis (EKC) epidemics, but recent surveillance data have shown the involvement of emerging recombinants, including HAdV-53, HAdV-54, and HAdV-56. In our initial work, positive samples for adenovirus revealed that our strains were closer to HAdV-54 than HAdV-8. Hence, the current study aimed to use whole genome technology to identify the HAdV strain correctly. METHODOLOGY: Oxford Nanopore technique was used, wherein a Targeted sequencing approach using long-range PCR amplification was performed. Primers were designed using HAdV-54 (AB448770.2) and HAdV-8 (AB897885.1) as reference sequences. Amplicons were sequenced on the GridION sequencer. Sequences were annotated using Gatu software, and similarities with standard reference sequence was calculated using Bioedit software. The phylogenetic tree was built after alignment in MEGA v7.0 using Neighbour joining method for each of the genes: Penton, Hexon, and Fiber. The effect of novel amino acid changes was evaluated using the PROVEAN tool. The Recombination Detection Program (RDP) package Beta 4.1 was used to identify recombinant sequences. RESULTS: Of the five samples sequenced, OL450401, OL540403, and OL540406 showed nucleotide similarity to HAdV-54 in the penton region. Additionally, OL450401 showed a statistically significant recombination event with HAdV-54 as minor and HAdV-8 as major parents. This was further supported by phylogenetic analysis as well. CONCLUSIONS: In the present study, we have found evidence of a shift from HAdV-8 towards HAdV-54, thus stressing the need for surveillance of HAdVs and to stay updated on the rise of new recombinants.

Takotsubo cardiomyopathy following head and neck surgery: Can the fear of disfigurement be blamed?

Takotsubo cardiomyopathy is accompanied by transitory left ventricular dysfunction without substantial coronary artery disease. A history of acute physical or mental stress typically precedes such a presentation. We want to highlight a case of Takotsubo cardiomyopathy in the early postoperative period in a young female patient who underwent extensive surgery for buccal mucosal carcinoma. The onset of this cardiomyopathy can be ascribed to a fear of disfigurement and prolonged surgical stress.

A randomized controlled trial comparing ultrasound-guided versus traditional palpatory methods of posterior tibial artery cannulation in adult patients.

BACKGROUND: The palpation method of posterior tibial artery cannulation has not yet been compared to ultrasound-guided posterior tibial artery cannulation in adults. This research examined whether using ultrasound to cannulate the posterior tibial artery enhances first-pass cannulation success and lowers total procedure time. METHODS: In this randomized controlled experiment, 76 adult patients were included who were undergoing surgery under general anesthesia and required artery cannulation. Cannulation of the posterior tibial artery was performed utilizing either an ultrasound-assisted method (group U) or a palpation method (group P). Data were analyzed for cannulation success on the first attempt, number of cannulation attempts, assessment time, cannulation time, and total procedure time. RESULTS: The P group had a considerably shorter mean assessment time than the U group [14.29 ± 2.79 s vs 20.89 ± 2.70 s; p < .001]. Moreover, cannulation time was substantially longer in the P (29.20 ± 12.60 s) than in the U group (15.90 ± 6.50 s) (p < .001). The total procedure time remained statistically more in the P group than in the U group (p = 0.007). The rate of successful posterior tibial artery cannulation on the first attempt was comparable between the two groups (63.2% in the U and 55.3% in the P group, respectively; p = .484)]. CONCLUSIONS: The posterior tibial artery may be a suitable alternative to arterial cannulation for individuals with multiple failed attempts or difficult access. The application of ultrasound during posterior tibial artery cannulation in adult patients is safe and feasible and accompanied by a reduction in cannulation and total procedure time. The rate of first-attempt successful posterior tibial artery cannulation was comparable between the two groups.

Entrapped Epidural Catheter: An Anaesthetic Challenge.

Null.

Airway challenges in an adult with hemifacial microsomia along with neglected cleft palate: what to expect?

A female patient in her early 20s, with a known diagnosis of hemifacial microsomia (unilateral microtia and mandibular hypoplasia) accompanied with an unoperated cleft palate, came for an infected mandibular distraction plate removal. The anticipated difficult airway and lack of enough literature about what to expect in such a scenario, along with the psychological impact on the patient, made this case challenging and thought-provoking. Inability to perform the awake tracheal intubation because of the uncooperative patient, along with the difficult fibreoptic owing to narrowed nostrils, offered an extra set of challenges.

Cumulative Mortality and Factors Associated With Outcomes of Mucormycosis After COVID-19 at a Multispecialty Tertiary Care Center in India.

Importance: An outbreak of COVID-19-associated rhino-orbitocerebral mucormycosis (CAM) has occurred in many parts of the world. Although the clinical profile and risk factors for CAM have been studied, cumulative mortality and its risk factors have not. Objective: To report the cumulative mortality rates at different times in cases with CAM and identify risk factors for CAM-associated mortality. Design, Setting, and Participants: This retrospective case-control study was conducted from March 1 to May 30, 2021, in a tertiary care multispecialty hospital in western India. All patients diagnosed with CAM and with a minimum follow-up of 30 days or those who died before 30 days due to CAM were included. Main Outcomes and Measure: Cumulative mortality in CAM using survival analysis. Results: A total of 73 consecutive patients with CAM with a mean (SD) age of 53.5 (12.5) years were included in the analysis, of whom 48 (66%) were men. CAM developed at a median of 28 (IQR, 15-45; range, 4-90) days after recovery from COVID-19. Of the 73 patients with CAM, 26 (36%) died; the cumulative probability of death was 26% (95% CI, 16%-41%) at day 7 and doubled to 53% (95% CI, 39%-69%) at day 21. Sinus debridement was performed in 18 of 51 patients (35%), and 5 of 52 (10%) underwent exenteration, whereas intravenous lyophilized amphotericin B was administered to 48 patients (66%). A multivariate Cox proportional hazards regression analysis showed that receiving mechanical ventilation in the past was associated with a nearly 9-fold increased risk of death (hazard ratio [HR], 8.98; 95% CI, 2.13-38.65; P = .003), and patients who had visual acuity of light perception or better had a 46% lower risk of death (HR, 0.56; 95% CI, 0.32-0.98; P = .04). Intravenous amphotericin B administration was associated with a reduced rate of exenteration (0 vs 5 of 25 [20%]; P < .001). On multivariate analysis, those who received intravenous amphotericin B had a 69% reduced risk of death (HR, 0.31; 95% CI, 0.06-1.43; P = .13). Conclusions and Relevance: These findings suggest that the mortality rate after rhino-orbitocerebral mucormycosis is high and that a subgroup of patients with severe COVID-19 or presenting with severe orbital disease are more likely to die within 10 days of admission.

Norepinephrine versus phenylephrine for postspinal hypotension in parturients undergoing cesarean section: a systematic review and meta-analysis.

INTRODUCTION: Multiple studies have compared varying prophylactic and therapeutic doses of norepinephrine and phenylephrine given as either intermittent bolus or fixed-rate infusion to combat postspinal hypotension in patients undergoing cesarean section (CS). We conducted a systematic review to figure out the best alternative to treat postspinal hypotension. EVIDENCE ACQUISITION: PubMed and Cochrane databases were extensively searched for eligible RCTs. A total of 15 studies were found eligible and analyzed for the incidence of maternal bradycardia as the primary outcome and other maternal adverse effects, fetal acidosis and Apgar scores at 1 and 5 min as the secondary outcome. Data was analyzed using Review Manager Version 5.3. software. EVIDENCE SYNTHESIS: There was no significant difference in the efficacy of norepinephrine and phenylephrine for managing postspinal hypotension (OR=1.15 [95% CI: 0.91-1.45], P=0.24, I2=0%,moderate quality) in parturients undergoing CS. Odds of incidence of maternal bradycardia decrease significantly by 61% with norepinephrine versus phenylephrine (OR=0.39 [95% CI: 0.31-0.49], P<0.00001, I2=27%, high quality evidence). Significant higher umbilical artery mean pH values were observed with NE versus PE (MD=0.0 [95% CI: 0.00 to 0.01], P=0.03), although not clinical relevant. However, no significant difference was found in the incidence of other maternal adverse effects and fetal outcomes. CONCLUSIONS: Comparable efficacy for management of postspinal hypotension, though, norepinephrine was found to cause less incidence of maternal bradycardia as compared to phenylephrine.

Bowman-stromal inlay using an intraocular lens injector for management of keratoconus.

A simple approach for transplanting Bowman layer and anterior stroma Bowman-stromal inlay (BSI) in keratoconic patients as an intervention to cease progression of ectasia and increase the overall thickness is described. A femtosecond laser was used to create BSI from human eye bank donor corneas and form an intrastromal pocket in the host cornea. The inlay was placed in the intrastromal space using an intraocular lens injector. This technique was performed successfully in 10 eyes of patients with progressive corneal ectasia. Postoperatively, the increased host pachymetry was as per BSI thickness. The tomography parameters remained stable, suggesting stabilization of keratoconus over a mean 15.9 months of follow-up. The BSI may offer a technically easy and safe technique of stromal augmentation to arrest keratoconus progression. It also opens up the possibility of surface ablation in the future for visual rehabilitation.

Foldscope: A smartphone based diagnostic tool for fungal keratitis.

PURPOSE: Smartphone-based microscopy tool like foldscope (FS) may serve the purpose of a low-cost diagnostic alternative to the compound light microscope especially in areas with limited resources. The purpose of this study was to detect fungal pathogens causing keratitis on direct smear by smartphone-mounted FS and to evaluate the efficacy of FS against routine compound light microscope (CLM). METHODS: The prospective study was conducted at a tertiary eye care center from September 2019 to March 2020. The study included 60 smear examinations (Gram stain [GM] n = 30, Lactophenol Cotton Blue [LCB] n = 30) to detect fungal pathogens from corneal scraping material of clinically suspected fungal keratitis (FK) cases. The diagnostic utility of FS was compared with CLM for both GM and LCB wet mount. Data collected were used to quantify the agreement using Cohen's kappa between CLM and FS imaging. RESULTS: Forty-six samples out of 60 were positive for fungi using CLM. GM stain and LCB showed 22/30 (73.33%) and 24/30 (80%) positive results with CLM, respectively. Moderate agreement (0.49) was observed between CLM and FS with the smartphone method. LCB mount showed high specificity of 1.00 over 0.87 of GM stain for FS with the smartphone. CONCLUSION: Direct smear can be an early and sensitive measure to diagnose FK other than clinical suspicion. The smartphone-mounted FS has limited sensitivity as an alternative to CLM, but excellent specificity in the present study for FK. The FS as a smartphone-based diagnostic tool is simple, portable, and inexpensive in resource-constrained rural or remote clinical and public health settings in the absence of CLM and other higher diagnostic modalities.