Strategic planning and designing of a hospital disaster manual in a tertiary care, teaching, research and referral institute in India

BACKGROUND: As per the "Disaster Management Act, 2005" of India, it is mandatory for government hospitals in India to prepare a disaster plan. This study aimed to prepare a disaster manual of a 1 900 bed tertiary care hospital, in consultation and involvement of all concerned stakeholders.METHODS: A committee of members from hospital administration, clinical, diagnostic and supportive departments worked on an initial document prepared according to the Act and gave their inputs to frame a final disaster manual.RESULTS: The prepared departmental standard operating procedures involved 116 people(doctors and paramedical staff), and were then synchronized, in 12 committee meetings, to produce the final hospital disaster manual.CONCLUSIONS: The present disaster manual is one of the few comprehensive plans prepared by the stakeholders of a government hospital in India, who themselves form a part of the disaster response team. It also helped in co-ordinated conduction of mock drills.

Harnessing the power of Calculus bovis:Anti-cancer properties and Wnt pathway modulation in hepatocellular carcinoma

In this manuscript,we comment on the article,which explores the anti-cancer effects of Calculus bovis(CB)in tumor biology.We highlight its potential,particularly in hepatocellular carcinoma(HCC),where it inhibits the phosphatidylinositol 3-kinase/protein kinase B/mammalian target of rapamycin pathways and induces apoptosis.CB contains compounds such as oleanolic acid and ursolic acid that target interleukin-6,mitogen-activated protein kinase 8,vascular endothelial growth factor,and caspase-3,offering anti-inflammatory and hepatoprotective benefits.The manuscript also discusses CB sativus(CBS),an artificial substitute,which has shown efficacy in reducing hepatic inflammation and oxidative stress in animal models.We emphasize the need for further research on the effects of CBS on the gut-liver axis and gut microbiota,and on targeting Wnt signaling and M2 tumor-associated macrophage as potential therapeutic strategies against HCC.

Angioinvasive mucormycosis in burn intensive care units:A case report and review of literature

BACKGROUND Mucormycosis is a rare,rapidly progressive and often fatal fungal infection.The rarity of the condition lends itself to unfamiliarity,delayed treatment,and poor outcomes.Diagnosis of fungal infections early enough to enable appropriate treatment occurs in less than half of affected patients.CASE SUMMARY An 11-year-old girl with a history of 15%total body surface area scald burns involving both lower limbs progressed to develop angioinvasive mucormycosis.This further led to a thrombosis of the right external iliac artery and vein and rapidly progressive necrosis of surrounding soft tissues.She also had dextrocardia and patent foramen ovale.A right hip disarticulation and serial aggressive debridements were performed but she went on to develop systemic sepsis with multisystem involvement and succumbed to the infection.Pathology revealed mucor species with extensive vascular invasion.CONCLUSION This case highlights the importance of maintaining vigilance for mycotic infections and acting appropriately when there are signs of fulminant wound infection.

Virtual reality based apps are the future of patient:Counseling

The use of virtual reality to educate preoperative patients has a positive impact on nurses as well as patients undergoing treatment.It can help improve patient satisfaction and improve favorable outcomes by reducing patient anxiety and proving adequate knowledge about the procedure and possible outcomes to the patient.It also reduces burden on nursing staff and counsellors.Larger and more diverse cohort studies will help us understand the wider application of this tool on the patient population.It may be difficult to apply this tool on elderly patients with failing eyesight,multiple physical comorbidities.Also,there may be reduced acceptance of this modality by older nursing staff and practitioners who may prefer the traditional verbal version for counselling.We will benefit from a combined approach of using virtual reality apps with tradition one-on-one counselling to help alleviate patient concerns and improve patient and healthcare professional satisfaction.

Endothelial dysfunction in the kidney transplant population:Current evidence and management strategies

The endothelium modulates vascular homeostasis owing to a variety of vasoconstrictors and vasodilators.Endothelial dysfunction(ED),characterized by impaired vasodilation,inflammation,and thrombosis,triggers future cardiovascular(CV)diseases.Chronic kidney disease,a state of chronic inflammation caused by oxidative stress,metabolic abnormalities,infection,and uremic toxins damages the endothelium.ED is also associated with a decline in estimated glomerular filtration rate.After kidney transplantation,endothelial functions undergo immediate but partial restoration,promising graft longevity and enhanced CV health.However,the anticipated CV outcomes do not happen due to various transplant-related and unrelated risk factors for ED,culminating in poor CV health and graft survival.ED in kidney transplant recipients is an underrecognized and poorly studied entity.CV diseases are the leading cause of death among kidney transplant candidates with functioning grafts.ED contributes to the pathogenesis of many of the CV diseases.Various biomarkers and vasoreactivity tests are available to study endothelial functions.With an increasing number of transplants happening every year,and improved graft rejection rates due to the availability of effective immunosuppressants,the focus has now shifted to endothelial protection for the prevention,early recognition,and treatment of CV diseases.

Congenital anomalies of coronary artery misdiagnosed as coronary dilatations in Kawasaki disease:A clinical predicament

BACKGROUND 2D-echocardiography(2DE)has been the primary imaging modality in children with Kawasaki disease(KD)to assess coronary arteries.AIM To report the presence and implications of incidental congenital coronary artery anomalies that had been misinterpreted as coronary artery abnormalities(CAAs)on 2DE.METHODS Records of children diagnosed with KD,who underwent computed tomography coronary angiography(CTCA)at our center between 2013-2023 were reviewed.We identified 3 children with congenital coronary artery anomalies in this cohort on CTCA.Findings of CTCA and 2DE were compared in these 3 children.RESULTS Of the 241 patients with KD who underwent CTCA,3(1.24%)had congenital coronary artery anomalies on CTCA detected incidentally.In all 3 patients,baseline 2DE had identified CAAs.CTCA was then performed for detailed evaluation as per our unit protocol.One(11-year-boy)amongst the 3 patients had complete KD,while the other two(3.3-year-boy;4-month-girl)had incomplete KD.CTCA revealed separate origins of left anterior descending artery and left circumflex from left sinus[misinterpreted as dilated left main coronary artery(LCA)on 2DE],single coronary artery(interpreted as dilated LCA on 2DE)and dilated right coronary artery on 2DE in case of anomalous origin of LCA from the main pulmonary artery.The latter one was subsequently operated upon.CONCLUSION CTCA is essential for detailed assessment of coronary arteries in children with KD especially in cases where there is suspicion of congenital coronary artery anomalies.Relying solely on 2DE may not be sufficient in such cases,and findings from CTCA can significantly impact therapeutic decision-making.

More than Half of Patients with Schizophrenia Are Receiving Polypharmacy and Co-Prescription of Anxiolytics in Pakistan —Findings from Research on Asian Prescription Pattern in 2016

Objective: Little is known about the prescription pattern of psychotropic drugs for patients with schizophrenia in Pakistan. The purpose of this study was to evaluate the characteristic features of psychotropic drug prescriptions for patients with schizophrenia in Pakistan. Methods: Three centers in Pakistan participated in a large scale collaborative study known as Research on Asian Prescription Pattern (REAP). The 2016 REAP survey included centers from 15 countries in Asia and used a unified research protocol. The design of the study was quantitative and of descriptive epidemiology. Analysis was made on the data collected from three centers i.e., Lahore, Karachi and Islamabad. The data collected in Pakistan were compared with those from other Asian countries. The details of REAP were presented on the homepage of REAP (http://www.REAP.Asia). Results: From Pakistan, 298 patients were included. Patients with schizophrenia in Pakistan received higher rate of antipsychotic polypharmacy and a higher rate of co-prescription of mood stabilizers and anxiolytics when compared with participants from other South Asian countries (India and Bangladesh). Conclusion: The main findings of the study were that a majority of the patients were prescribed antipsychotic polypharmacy drugs in Pakistan. Insufficient training on the use of psychotropic drugs and a lack of treatment guideline are considered to be the major contributing factors. Further education and training on the proper use of psychotropic drugs are recommended to psychiatrists in Pakistan. The guidelines on pharmacotherapy for patients with schizophrenia should also be developed and promoted in Pakistan.

Controversies in diagnosis and management of Kawasaki disease

Kawasaki disease(KD) is a common medium vessel systemic vasculitis that usually occurs in small children. It has a predilection for the coronary arteries, but other medium sized arteries can also be involved. The etiology of this disorder remains a mystery. Though typical presentation of KD is quite characteristic, it may also present as incomplete or atypical disease in which case the diagnosis can be very challenging. As both incomplete and atypical forms of KD can be associated with serious coronary artery complications, the pediatrician can ill afford to miss these diagnoses. The American Heart Association has enunciated consensus guidelines to facilitate the clinical diagnosis and treatment of this condition. However, there are still several issues that remain controversial. Intravenous immunoglobulin remains the cornerstone of management but several other treatment modalities, especially glucocorticoids, are increasingly finding favour. We review here some of the contemporary issues, and the controversies thereon, pertaining to management of KD.

Prevalence of excessive internet use and its correlation with associated psychopathology in 11th and 12th grade students

Background Globally, the number of internet users has crossed the three-billion mark, while in India users grew over 17% in the first 6 months of 2015 to 354 million. This study presented a background on internet use and the existence of excessive internet use. Aim To study the extent of internet use in 11th and 12th grade students and the psychopathology, if any, associated with excessive internet use. Methods 426 students who met the inclusion criteria were recruited from 11 th and 12th grade classes from Kendriya Vidyalaya, New Delhi, India, and were assessed by Young's Internet Addiction Test and the Strength and Difficulties Questionnaire. Results Among the 426 students, the mean internet addiction total score was 36.63 (20.78), which indicated mild level of internet addiction. 1.41%(six students) was diagnosed as excessive internet users, while 30.28% and 23.94% were classified as moderate and mild internet users, respectively. The prevalence of internet addiction between gender was 58.22% in males and 41.78% in females. While both positive (prosocial) and negative (hyperactivity, emotional, conduct and peer problem) impacts of internet use were reported by students, in the current study excessive use of internet had a negative impact on students' lives as compared with positive impact, which was statistically significant (p<0.0001). Conclusion Excessive internet use led to abnormal behaviours which cause negative consequences to users. Early diagnosis of risk factors related to excessive internet use, provides education about responsible use and supervision of students by family members.

Olanzapine-induced leucopaenia and thrombocytopaenia in an elderly patient:a case report and review of the evidence

Haematological adverse effects of antipsychotics are rare but life threatening. Existing literature is limited to case reports, which are mostly reported on second generation antipsychotics(clozapine, olanzapine, risperidone, quetiapine). Elderly individuals are at risk of developing side effects with any psychotropics. Olanzapine is commonly used for the management of psychotic symptoms as well as for the management of behavioural and psychological problems with dementia in the elderly. In this case report, the authors report thrombocytopaenia and leucopaenia in an elderly individual with schizophrenia which developed after initiation of olanzapine and reverted back after stoppage of the drug. This case report highlights that the elderly are susceptible to develop haematological side effects with olanzapine and hence monitoring may be essential.

Comparison of echocardiography and device based algorithm for atrio-ventricular delay optimization in heart block patients

AIM: To compare the atrio-ventricular(AV/PV) delay optimization by echocardiography and intra-cardiac electrocardiogram(IEGM) based Quick Opt algorithm in complete heart block(CHB) patients, implanted with a dual chamber pacemaker. METHODS: We prospectively enrolled 20 patients(age 59.45 ± 18.1 years; male: 65%) with CHB, who were implanted with a dual chamber pacemaker. The left ventricular outflow tract velocity time-integral was measured after AV/PV delay optimization by both echocardiography and Quick Opt algorithm method. Bland-Altman analysis was used for agreement between the two techniques. RESULTS: The optimal AV and PV delay determined by echocardiography was 155.5 ± 14.68 ms and 122.5 ± 17.73 ms(P < 0.0001), respectively and by Quick Opt method was 167.5 ± 16.73 and 117.5 ms ± 9.10 ms(P < 0.0001), respectively. A good agreement was observed between optimal AV and PV delay as measured by two methods. However, the correlation of the optimal AV(r = 0.0689, P = 0.77) and PV(r = 0.2689, P = 0.25) intervals measured by the two techniques was poor. The time required for AV/PV optimization was 45.26 ± 1.73 min by echocardiography and 0.44 ± 0.08 min by Quick Opt method(P < 0.0001).CONCLUSION: The programmer based IEGM method is an automated, quick, easier and reliable alternative to echocardiography for the optimization of AV/PV delay in CHB patients, implanted with a dual chamber pacemaker.

Prevalence of internet addiction among college students in the Indian setting:a systematic review and meta-analysis

Background The internet is an integral part of everyone’s life.College going adolescents are highly vulnerable to the misuse of the internet.Aims To estimate the pooled prevalence of internet addiction(IA)among college students in India.Methods Literature databases(PubMed,Web of Science,Scopus,EMBASE,PsycINFO and Google Scholar)were searched for studies assessing IA using the Young Internet Addiction Test(Y-IAT)among adolescents from India,published in the English language up to December 2020.We included studies from 2010 to 2020 as this is the marked era of momentum in wireless internet connectivity in India.The methodological quality of each study was scored,and data were extracted from the published reports.Pooled prevalence was estimated using the fixed-effects model.Publication bias was evaluated using Egger’s test and visual inspection of the symmetry in funnel plots.Results Fifty studies conducted in 19 states of India estimated the prevalence of IA and the overall prevalence of IA as 19.9%(95%CI:19.3%to 20.5%)and 40.7%(95%CI:38.7%to 42.8%)based on the Y-IAT cut-off scores of 50 and 40,respectively.The estimated prevalence of severe IA was significantly higher in the Y-IAT cut-off points of 70 than 80(12.7%(95%CI:11.2%to 14.3%)vs 4.6%(95%CI:4.1%to 5.2%)).The sampling method and quality of included studies had a significant effect on the estimation of prevalence in which studies using non-probability sampling and low risk of bias(total quality score≥7)reported lower prevalence.The overall quality of evidence was rated as‘moderate’based on the Grading of Recommendations Assessment,Development and Evaluation criteria.Conclusions Our nationally representative data suggest that about 20%to 40%of college students in India are at risk for IA.There is a need for further research in the reconsideration of Y-IAT cut-off points among Indian college students.

Role of endoscopic ultrasound in the field of hepatology: Recent advances and future trends

The role of endoscopic ultrasound(EUS)as a diagnostic and therapeutic modality for the management of various gastrointestinal diseases has been expanding.The imaging or intervention for various liver diseases has primarily been the domain of radiologists.With the advances in EUS,the domain of endosonologists is rapidly expanding in the field of hepatology.The ability to combine endoscopy and sonography in one hybrid device is a unique property of EUS,together with the ability to bring its probe/transducer near the liver,the area of interest.Its excellent spatial resolution and ability to provide real-time images coupled with several enhancement techniques,such as contrast-enhanced(CE)EUS,have facilitated the growth of EUS.The concept of“Endo-hepatology”encompasses the wide range of diagnostic and therapeutic procedures that are now gradually becoming feasible for managing various liver diseases.Diagnostic advancements can enable a wide array of techniques from elastography and liver biopsy for liver parenchymal diseases,to CE-EUS for focal liver lesions to portal pressure measurements for managing various liver conditions.Similarly,therapeutic advancements range from EUS-guided eradication of varices,drainage of bilomas and abscesses to various EUS-guided modalities of liver tumor management.We provide a comprehensive review of all the different diagnostic and therapeutic EUS modalities available for the management of various liver diseases.A synopsis of all the technical details involving each procedure and the available data has been tabulated,and the future trends in this area have been highlighted.

Role of peroxisome proliferator-activated receptors alpha and gamma in gastric ulcer: An overview of experimental evidences

Peroxisome proliferator-activated receptors(PPARs) are ligand-activated transcription factors belonging to the nuclear hormone receptor superfamily. Three subtypes, PPARα, PPARβ/δ, and PPARγ, have been identifiedso far. PPARα is expressed in the liver, kidney, small intestine, heart, and muscle, where it activates the fatty acid catabolism and control lipoprotein assembly in response to long-chain unsaturated fatty acids, eicosanoids, and hypolipidemic drugs(e.g., fenofibrate). PPARβ/δ is more broadly expressed and is implicated in fatty acid oxidation, keratinocyte differentiation, wound healing, and macrophage response to very low density lipoprotein metabolism. This isoform has been implicated in transcriptional-repression functions and has been shown to repress the activity of PPARα or PPARγ target genes. PPARγ1 and γ2 are generated from a single-gene peroxisome proliferator-activated receptors gamma by differential promoter usage and alternative splicing. PPARγ1 is expressed in colon, immune system(e.g., monocytes and macrophages), and other tissues where it participates in the modulation of inflammation, cell proliferation, and differentiation. PPARs regulate gene expression through distinct mechanisms: Liganddependent transactivation, ligand-independent repression, and ligand-dependent transrepression. Studies in animals have demonstrated the gastric antisecretory activity of PPARα agonists like ciprofibrate, bezafibrate and clofibrate. Study by Pathak et al also demonstrated the effect of PPARα agonist, bezafibrate, on gastric secretion and gastric cytoprotection in various gastric ulcer models in rats. The majority of the experimental studies is on pioglitazone and rosiglitazone, which are PPARγ activators. In all the studies, both the PPARγ activators showed protection against the gastric ulcer and also accelerate the ulcer healing in gastric ulcer model in rats. Therefore, PPARα and PPARγ may be a target for gastric ulcer therapy. Finally, more studies are also needed to confirm the involvement of PPARs α and γ in gastric ulcer.

Epidemiology of electrical burns and its impact on quality of life-the developing world scenario

BACKGROUND Electrical burns are devastating injuries and can cause deep burns with significant morbidity and delayed sequelae.Epidemiological data regarding the etiology,socioeconomic differences and geographic variation are necessary to assess the disease burden and plan an effective preventive strategy.These severe injuries often lead to amputations and thus hamper quality of life in the long term AIM To identify the population at maximum risk of sustaining electrical burns.We also studied the impact of electrical burns on these patients in terms of quality of life as well as return to work.METHODS The study was conducted at a tertiary referral teaching hospital over a period of eighteen months.All patients with a history of sustaining electrical burns and satisfying the inclusion criteria were included in the study.All relevant epidemiological parameters and treatment details were recorded.The patients were subsequently followed up at 3 mo,6 mo and 9 mo.The standardized Brief Version of the Burn Speci
c Health Scale(BSHS-B)was adopted to assess quality of life.Statistical analysis was conducted using IBM SPSS statistics(version 22.0).A P value of<0.05 was considered statistically significant.RESULTS A total of 103 patients were included in the study.The mean age of the patients was 31.83 years(range 18-75 years).A significant majority(91.3%)of patients were male.The mean total body surface area(TBSA)in these patients was 21.1%.In most of the patients(67%),the injury was occupation-related.High voltage injuries were implicated in 72.8%of patients.Among the 75 high voltage burn patients,31(41%)required amputation.The mean number of surgeries the patients underwent in hospital was 2.03(range 1 to 4).The quality of life parameters amongst the patients sustaining high voltage electrical burns were poorer when compared to low voltage injuries at all follow-up intervals across nine domains.In eight of these domains,the difference was statistically significant.Similarly,the scores among the amputees were poorer when compared to non-amputees.The difference was statistically significant in six domains.CONCLUSION Electrical burns remain a problem in the developing world.Most injuries are occupation-related.The quality of life in patients with high voltage burns and amputees remains poor.Work resumption was almost impossible for amputees.These patients could not regain pre-injury status.Steps should be taken to create awareness and to implement an effective preventive strategy to safeguard against electrical injuries.

Utility of trans-vaginal ultrasound in diagnosis and follow-up of non-pregnant sexually active females with lower ureteric calculi

objective:To assess the utility of trans-vaginal ultrasonography in evaluation of non-pregnant sexually active female patients with lower ureteric calculi.Methods:A prospective study was done from January 2015 to December 2017 including non-pregnant sexually active females with suspected ureteric calculus.Trans-abdominal ultrasound was initially done in all patients.In those patients in whom trans-abdominal ultrasound was inconclusive or there was indirect evidence of lower ureteric calculus in form of ureteral dila-tion but no calculus was evident,trans-vaginal ultrasound was done.The patients with ureteric calculi detected on trans-vaginal ultrasound and kept on conservative management were also followed up with trans-vaginal ultrasound.Non-contrast computed tomography was done in patients with inconclusive trans-vaginal ultrasound.Results:As per the study protocol,156 out of the total 468 patients evaluated by trans-abdominal ultrasound were eligible for trans-vaginal ultrasound.Trans-vaginal ultrasound was done in 149 patients,as seven patients did not give consent.Seventy-nine patients were detected with a lower ureteric calculus on trans-vaginal ultrasound and 27 patients had gyne-cologic or other cause for their symptoms.Forty-three patients had an inconclusive trans-vaginal ultrasound of which 36 underwent non-contrast computed tomography,among them only one patient had a lower ureteric calculus.Stone free status could be easily demonstrated on follow-up trans-vaginal ultrasound.

Laying open(deroofing) and curettage under local anesthesia for pilonidal disease: An outpatient procedure

AIM: To test the efficacy of lay open(deroofing, not excision) with curettage under local anesthesia(LOCULA) for pilonidal sinus as an outpatient procedure. METHODS: LOCULA procedure was done for all types of pilonidal disease. The primary outcome measure was cure rate. The secondary outcome measures were hospital stay, operating time, return to work, healing time and complication rate.RESULTS: Thirty-three(M/F-30/3, mean age-23.4 ± 5.8 years) consecutive patients were operated and followed for 24 mo(6-46 mo). Eleven were pilonidal abscess and 22 were chronic pilonidal disease. Six had recurrent disease. Operating time and the hospital stay was 22.3 ± 5.6 min and 63.8 ± 22.3 min respectively. The patients could resume normal work in 4.3 ± 3.2 d and the healing time was 42.9 ± 8.1 d. Thirty(93.8%)patients had complete resolution of the disease and two(6.2%) had a recurrence. Both the recurrences happened in patients who had complete healing but ignored the prescribed recommendations. One out of these got cured after getting operated again with the same procedure. Thus the overall success rate of this procedure was 96.9%.CONCLUSION: Lay open(deroofing) with curettage procedure under local anesthesia is an effective procedure to treat both simple and complicated pilonidal sinus and abscess. It is a simple procedure, has a high cure rate(up to 97%), doesn't require admission and is associated with minimal morbidity and scarring. Considering the distinct advantages, this procedure has the potential to become the first line procedure for treating pilonidal disease.

Role of fibrinogen,albumin and fibrinogen to albumin ratio in determining angiographic severity and outcomes in acute coronary syndrome

BACKGROUND Coronavirus disease 2019(COVID-19)pandemic unmasked the huge deficit in healthcare resources worldwide.It highlighted the need for efficient risk stratification in management of cardiovascular emergencies.AIM To study the applicability of the old,available and affordable nonconventional biomarkers:albumin and fibrinogen in their ability to predict angiographic severity and clinical outcomes in patients with acute coronary syndrome(ACS).METHODS In this prospective,observational study,166 consecutive patients with ACS were enrolled.Fibrinogen,albumin and their ratio were determined from serum.Patients with underlying chronic liver disease,active malignancy,autoimmune disease,active COVID-19 infection and undergoing thrombolysis were excluded.RESULTS Mean age of the population was 60.5±1.5 years,74.1%being males.ST elevation myocardial infarction(STEMI)was most common presentation of ACS seen in 57%patients.Fibrinogen albumin ratio(FAR)≥19.2,had a sensitivity of 76.9%and specificity of 78.9%[area under the receiver operating characteristic curves(AUROC)=0.8,P=0.001]to predict≤thrombolysis in myocardial infarction(TIMI)1 flow in culprit artery in STEMI patients.Even in non-STEMI patients,FAR≥18.85 predicted the same with 80%sensitivity and 63%specificity(AUROC=0.715,P=0.006).CONCLUSION Novel biomarkers,with their high cost,lack of availability and long turn over time are impractical for real-world use.Identifying≤TIMI 1 flow in the culprit artery has significant impact of management and outcome.Our study has shown that readily available biomarkers like fibrinogen and albumin can help identify these high-risk patients with good accuracy.This allows risk-stratification and individualization of treatment in ACS.

Evaluation of antioxidants and argpyrimidine in normal and cataractous lenses in north Indian population

AIM： To assess the level of glutathione, thioltransferase, and argpyrimidine in nuclear and cortical cataractous lenses as well as in the clear lenses in the north Indian population.METHODS： Human cataractous lenses were collected from the patients who underwent extracapsular cataract extraction surgery; clear lenses were collected from the freshly donated eye bank eyes. Antioxidant molecules such as glutathione and thioltransferase enzyme activity were measured; simultaneously in these lenses a blue fluorophore argpyrimidine, an advanced glycation end（AGE） product level was assessed using high performance liquid chromatography（HPLC）.RESULTS： The protein concentration was found to be present at higher levels in the control lenses compared to cataract lenses. A significant decrease in the glutathione level was observed in the nuclear cataractous lenses compared to cortical cataractous（P=0.004） and clear lenses（P≤0.005）, but no significant change in the level of antioxidant enzyme thioltransferase was observed. Further, argpyrimidine a blue fluorophore（AGE） was found to be significantly higher in the nuclear cataract（P=0.013） compared to cortical cataract lenses.CONCLUSION： Antioxidants such as glutathione significantly decrease in age-related nuclear and cortical cataract and an AGE, argpyrimidine are present at significantly higher levels in nuclear cataract.

A conundrum of West syndrome,behavioural problems and parental expressed emotions:a case report

West syndrome(WS)is the most common epileptic syndrome in infancy characterised by epileptic spasms,hypsarrhythmia and neurodevelopmental problems.Epileptic spasms remain in many ways a conundrum,and the ideal intervention,as well as how to screen patients to provide optimal care and certainly its genetic cause,remains puzzling.It is important to screen infants for early recognition and intervention to achieve the optimal outcome.We hereby discuss the approach to management of a boy aged 4½years old with WS and behavioural problems and of parental expressed emotions.