Revisiones bibliográficas. Documentación científica en Ortopedia y Traumatología, medicina deportiva, artroscopia, artroplastia y de todas las patologías del sistema Músculo-Esquelético
El Viernes, 3 de enero, 2014 22:48:26, Enrique Mendoza <enrique@pediatramendoza.com> escribió:
Estimado Ciberpediatra te invito al Seminario de Pediatría, Cirugía Pediátrica y Lactancia Materna. El día 8 de Enero 2014 las 21hrs (Centro, México DF, Guadalajara y Lima Perú) a la Conferencia: “Beneficios de la leche materna en padecimientos gastrointestinales” por “Dr. Federico Bribiesca Godoy” Gastroenterologo Pediatra de la Cd. de Zamora Mich. La sesión inicia puntualmente las 21 hrs. Para entrar a la Sala de Conferencia: 1.- hacer click en la siguiente liga, o cópiala y escríbela en tu buscador http://connectpro60196372.adobeconnect.com/lactancia_gi/ 2.- “Entra como Invitado” Escribes tu nombre y apellido en el espacio en blanco 3.- Hacer click en el espacio que dice “Entrar en la Sala” 5.- A disfrutar la conferencia
6.- Recomendamos que dejes tu Nombre Completo, Correo electrónico y que participes. Henrys
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Dr. Enrique Mendoza López Webmaster: CONAPEME Coordinador Nacional: Seminario Ciberpeds-Conapeme Av La Clinica 2520-310 col Sertoma Monterrey N.L. CP 64718 Tel (81) 83482940, (81) 83485701 Cel 0448183094806 www.pediatramendoza.com www.conapeme.org www.ciberpeds.org
Pregabalina en dolor agudo y crónico Pregabalin in acute and chronic pain.
Baidya DK, Agarwal A, Khanna P, Arora MK. Department of Anaesthesia and Intensive Care, All India Institute of Medical Sciences, New Delhi, India. J Anaesthesiol Clin Pharmacol. 2011 Jul;27(3):307-14. doi: 10.4103/0970-9185.83672. Abstract Pregabalin is a gamma-amino-butyric acid analog shown to be effective in several models of neuropathic pain, incisional injury, and inflammatory injury. In this review, the role of pregabalin in acute postoperative pain and in chronic pain syndromes has been discussed. Multimodal perioperativeanalgesia with the use of gabapentinoids has become common. Based on available evidence from randomized controlled trials and meta-analysis, the perioperative administration of pregabalin reduces opioid consumption and opioid-related adverse effects in the first 24 h following surgery. Postoperative pain intensity is however not consistently reduced by pregabalin. Adverse effects like visual disturbance, sedation, dizziness, and headache are associated with higher doses. The advantage of the perioperative use of pregabalin is so far limited to laparoscopic, gynecological, and daycare surgeries which are not very painful. The role of the perioperative administration of pregabalin in preventing chronic pain following surgery, its efficacy in more painful surgeries and surgeries done under regional anesthesia, and the optimal dosage and duration of perioperative pregabalin need to be studied. The efficacy of pregabalin in chronic pain conditions like painful diabetic neuropathy, postherpetic neuralgia, central neuropathic pain, and fibromyalgia has been demonstrated.
Eficacia de pregabalina en dolor agudo postoperatorio. Meta-análisis
Efficacy of pregabalin in acute postoperative pain: a meta-analysis. Zhang J, Ho KY, Wang Y. Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, No. 1 East-Jianshe Road, Zhengzhou 450052, China. Br J Anaesth. 2011 Apr;106(4):454-62. doi: 10.1093/bja/aer027. Epub 2011 Feb 26. Abstract Multimodal treatment of postoperative pain using adjuncts such as gabapentin is becoming more common. Pregabalin has anti-hyperalgesic properties similar to gabapentin. In this systematic review, we evaluated randomized, controlled trials (RCTs) for the analgesic efficacy and opioid-sparing effect of pregabalin in acute postoperative pain. A systematic search of Medline (1966-2010), the Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar was performed. We identified 11 valid RCTs that used pregabalin for acute postoperative pain. Postoperative pain intensity was not reduced by pregabalin. Cumulative opioid consumption at 24 h was significantly decreased with pregabalin. At pregabalin doses of <300 mg, there was a reduction of 8.8 mg [weighted mean difference (WMD)]. At pregabalin doses ≥300 mg, cumulative opioid consumption was even lower (WMD, -13.4 mg). Pregabalin reduced opioid-related adverse effects such as vomiting [risk ratio (RR) 0.73; 95% confidence interval (CI) 0.56-0.95]. However, the risk of visual disturbance was greater (RR 3.29; 95% CI 1.95-5.57). Perioperative pregabalin administration reduced opioid consumption and opioid-related adverse effects after surgery.
Prevención de dolor crónico postoperatorio utilizando gabapentina y pregabalina: combinación de revisión sistemática y meta-análisis
The prevention of chronic postsurgical pain using gabapentin and pregabalin: a combined systematic review and meta-analysis.
Clarke H, Bonin RP, Orser BA, Englesakis M, Wijeysundera DN, Katz J.
Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, Eaton North 3 EB 317, Pain Research Unit, Toronto, ON M5G 2C4, Canada. hance.clarke@utoronto.ca
BACKGROUND:Many clinical trials have demonstrated the effectiveness of gabapentin and pregabalin administration in the perioperative period as an adjunct to reduce acute postoperative pain. However, very few clinical trials have examined the use of gabapentin and pregabalin for the prevention of chronic postsurgical pain (CPSP). We (1) systematically reviewed the published literature pertaining to the prevention of CPSP (≥ 2 months after surgery) after perioperative administration of gabapentin and pregabalin and (2) performed a meta-analysis using studies that report sufficient data. A search of electronic databases (Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, IPA, and CINAHL) for relevant English-language trials to June 2011 was conducted.
METHODS:The following inclusion criteria for identified clinical trials were used for entry into the present systematic review: randomization; double-blind assessments of pain and analgesic use; report of pain using a reliable and valid measure; report of analgesic consumption; and an absence of design flaws, methodological problems or confounders that render interpretation of the results ambiguous. Trials that did not fit the definition of preventive analgesia and did not assess chronic pain at 2 or more months after surgery were excluded. RESULTS:The database search yielded 474 citations. Eleven studies met the inclusion criteria. Of the 11 trials, 8 studied gabapentin, 4 of which (i.e., 50%) found that perioperative administration of gabapentin decreased the incidence of chronic pain more than 2 months after surgery. The 3 trials that used pregabalin demonstrated a significant reduction in the incidence of CPSP, and 2 of the 3 trials also found an improvement in postsurgical patient function. Eight studies were included in a meta-analysis, 6 of the gabapentin trials demonstrated a moderate-to-large reduction in the development of CPSP (pooled odds ratio [OR] 0.52; 95% confidence interval [CI], 0.27 to 0.98; P = 0.04), and the 2 pregabalin trials found a very large reduction in the development of CPSP (pooled OR 0.09; 95% CI, 0.02 to 0.79; P = 0.007). CONCLUSIONS: The present review supports the view that perioperative administration of gabapentin and pregabalin are effective in reducing the incidence of CPSP. Better-designed and appropriately powered clinical trials are needed to confirm these early findings.
Anestesiología y Medicina del Dolor se complace en desearle que este año 2014 que da inicio hoy sean 12 meses plenos de Salud, de Alegría, de Felicidad, de Progreso y de Éxitos que vengan a complementar sus más elevadas metas personales. Sabemos que nuestra profesión es ardua, que requiere de dedicación y estudio continuo para poder contribuir en el cuidado de cada uno de nuestros pacientes. Por eso es que nuestro grupo se complace en ser partícipe de esta meta de actualización. Este es nuestro envío 1461 y lo celebramos con júbilo ya que hoy cumplimos 4 años de enviar un correo electrónico diario con información científica disponible en Internet con temas relacionados o de interés en su especialidad. Nuestro Programa Educativo Alfa es recibido por casi 4000 colegas alrededor del mundo. La meta es llegar a los 5000 colegas en este 2014, para lo cual pedimos su apoyo difundiendo este programa educativo entre sus colegas y amigos locales o a distancia, los cuales se pueden inscribir en www.anestesia-dolor.org !Feliz Año 2014! Anestesiología y Medicina del Dolor is pleased to wish you that this year 2014, that starts today, will be 12 months full of Health, Joy, Happiness, Progress and Successes which will complement your highest personal goals.
We know that our profession is arduous, requiring dedication and daily study to contribute to the care of each of our patients. That's why our group is pleased to be part of this goal. This is our 1461 e-mail. We celebrate with joy because today fulfill four years to send a daily e-mail with free available scientific information on the Internet related to your specialty subjects. Our Programa Educativo Alfa is received by nearly 4,000 colleagues around the world. The goal is to reach 5,000 colleagues in this 2014, for which we ask your support spreading this education program among your colleagues and friends local or remote. They can register on www.anestesia-dolor.org ! Happy New Year 2014! Anestesiología y Medicina del Dolor tem o prazer de desejar que este ano de 2014 , que começa hoje será de 12 meses completos de Saúde , Alegria, Felicidade, Progresso e sucessos que complementarão seus mais altos objetivos pessoais.
Sabemos que a nossa profissão é árdua , exigindo dedicação e estudo continuado a contribuir para o atendimento de cada um dos nossos pacientes. É por isso que o nosso grupo é o prazer de fazer parte dessa meta refresh . Este é o nosso transporte 1461 e celebrar com alegria porque hoje cumprir quatro anos para enviar um e-mail diário com a informação científica disponível na Internet relacionada ou interesse em seus temas de especialidade. Nosso Programa de Educação Alpha é recebido por cerca de 4.000 colegas em todo o mundo. A meta é chegar a 5.000 colegas neste 2014, para o qual pedimos seu apoio espalhando este programa de educação entre os seus colegas e amigos locais ou remotos , que podem registar-se www.anestesia-dolor.org ! Feliz Ano Novo 2014 !
¿Cómo alcanzar el profesionalismo en la práctica de la anestesiología?
Vásquez-Márquez PI, Castellanos-Olivares A Rev Mex Anest 2013; 36 (4) RESUMEN Independientemente del nivel cultural que tenga la gente, una gran cantidad piensa que el anestesiólogo es un técnico, un enfermero o un médico general adiestrado para ejercer la anestesiología. Desafortunadamente nosotros como anestesiólogos somos responsables de estas opiniones, debido a las actitudes que proyectamos en nuestro entorno. Es necesario reflexionar sobre ¿qué es el profesionalismo?, ¿cómo se puede alcanzar?, y ¿cómo se puede medir? El profesionalismo es algo específico para la profesión de que se trate y constituye un manto de conductas. Es un estado que toma años alcanzar y debe mantenerse durante toda la carrera profesional. Para Hilton y Slotnik, el profesionalismo está constituido por atributos personales y atributos de cooperación; pero ¿cómo se puede lograr el profesionalismo? Se alcanza a través del protoprofesionalismo, período de tiempo antes del profesionalismo adquirido, comienza cuando un individuo inicia su carrera como estudiante de medicina y termina cuando el individuo es un profesional maduro que posee Phronesis o sabiduría práctica. ¿Cómo se puede medir? Uno de los principales problemas de la enseñanza y la evaluación del profesional es la falta de una adecuada enseñanza con profesionalidad dirigida a los médicos residentes de anestesiología. El profesionalismo tiene muchos factores de difícil medición y la mayor parte son subjetivos, es decir, muchos de los rubros que nos pueden servir para medirlo dependen de la percepción de los evaluadores; existen estudios con buen nivel de evidencia científica para evaluar las habilidades de comunicación y la profesionalidad de los médicos en ejercicio y residentes de anestesiología en una variedad de entorno mediante una técnica de multiescalas con retroalimentación. La medición o evaluación del aprendizaje del residente de anestesiología, así como los profesores se debe realizar con estudios bien estructurados que nos permita alcanzar evaluaciones cada día más objetivas. http://new.medigraphic.com/cgi-bin/resumen.cgi?IDREVISTA=37&IDARTICULO=46896&IDPUBLICACION=4827
Profesionalismo: la visión desde fuera de la medicina
Professionalism: The view from outside medicine Roger Collier Additional article information CMAJ. 2012 Sep 4;184(12):1347-8. doi: 10.1503/cmaj.109-4257. Epub 2012 Aug 7.
There have been journal articles, commentaries and editorials galore. There have been codes, charters and changes to medical curricula. There have been crisis warnings, rallying cries and rhetoric thicker than refrigerated gravy. Oodles of hours, tonnes of text and wads of worry - all in the name of improving professionalism in medicine. The point of this effort, according to many physicians, is to rescue medicine from the clutches of commercialism. Even cynics would have trouble slamming that.
Profesionalismo médico: valores de conflicto para los médicos de mañana Medical professionalism: conflicting values for tomorrow's doctors. Borgstrom E, Cohn S, Barclay S. Author information J Gen Intern Med. 2010 Dec;25(12):1330-6. doi: 10.1007/s11606-010-1485-8. Epub 2010 Aug 26. Abstract BACKGROUND: New values and practices associated with medical professionalism have created an increased interest in the concept. In the United Kingdom, it is a current concern in medical education and in the development of doctor appraisal and revalidation. OBJECTIVE:To investigate how final year medical students experience and interpret new values of professionalism as they emerge in relation to confronting dying patients and as they potentially conflict with older values that emerge through hidden dimensions of the curriculum. METHODS: Qualitative study using interpretative discourse analysis of anonymized student reflective portfolios. One hundred twenty-three final year undergraduate medical students (64 male and 59 female) from the University of Cambridge School of Clinical Medicine supplied 116 portfolios from general practice and 118 from hospital settings about patients receiving palliative or end of life care. RESULTS: Professional values were prevalent in all the portfolios. Students emphasised patient-centered, holistic care, synonymous with a more contemporary idea of professionalism, in conjunction with values associated with the 'old' model of professionalism that had not be directly taught to them. Integrating 'new' professional values was at times problematic. Three main areas of potential conflict were identified: ethical considerations, doctor-patient interaction and subjective boundaries. Students explicitly and implicitly discussed several tensions and described strategies to resolve them. CONCLUSIONS: The conflicts outlined arise from the mix of values associated with different models of professionalism. Analysis indicates that 'new' models are not simply replacing existing elements. Whilst this analysis is of accounts from students within one UK medical school, the experience of conflict between different notions of professionalism and the three broad domains in which this conflict arises are relevant in other areas of medicine and in different national contexts.
El volumen de sangre parche epidural en obstetricia. Estudio randomizado y ciego
The volume of blood for epidural blood patch in obstetrics: a randomized, blinded clinical trial. Paech MJ, Doherty DA, Christmas T, Wong CA; Epidural Blood Patch Trial Group. School of Medicine and Pharmacology, University of Western Australia, Crawley, Australia. michael.paech@health.wa.gov.a Anesth Analg. 2011 Jul;113(1):126-33.
doi: 10.1213/ANE.0b013e318218204d. Epub 2011 May 19. Abstract BACKGROUND: Our aim in this multinational, multicenter, randomized, blinded trial was to determine the optimum of 3 volumes of autologous bloodfor an epidural blood patch. METHODS: Obstetric patients requiring epidural blood patch after unintentional dural puncture during epidural catheter insertion were allocated to receive 15, 20, or 30 mL of blood, stratified for the timing of epidural blood patch and center. Participants were followed for 5 days. The primary study end point was a composite of permanent or partial relief of headache, and secondary end points included permanent relief, partial relief, persisting headache severity, and low back pain during or after the procedure. RESULTS:One hundred twenty-one women completed the study. The median (interquartile range) volume administered was 15 (15-15), 20 (20-20), and 30 (22-30) mL, with 98%, 81%, and 54% of groups 15, 20, and 30 receiving the allocated volume. Among groups 15, 20, and 30, respectively, the incidence of permanent or partial relief of headache was 61%, 73%, and 67% and that of complete relief of headache was 10%, 32%, and 26%. The 0- to 48-hour area under the curve of headache score versus time was highest in group 15. The incidence of low back pain during or after the epidural blood patch was similar among groups and was of low intensity, although group 15 had the highest postprocedural back pain scores. Serious morbidity was not reported. CONCLUSIONS:Although the optimum volume of blood remains to be determined, we believe these findings support an attempt to administer 20 mL of autologous blood when treating postdural puncture headache in obstetric patients after unintentional dural puncture. http://www.csen.com/patch.pdf#!
Dolor radicular tardio después de dos parches epidurales con gran volumen para CPPL. Informe de caso
Delayed radicular pain following two large volume epidural blood patches for post-lumbar puncture headache: a case report. Desai MJ, Dave AP, Martin MB. George Washington University Hospital, Washington, DC, USA. mdesai@mfa.gwu.edu Pain Physician. 2010 May-Jun;13(3):257-62. Abstract INTRODUCTION: Postdural puncture headache (PDPH) is a known complication of diagnostic lumbar puncture. Multiple factors including needle size, type, and needle bevel orientation, have been postulated to contribute to the development of PDPH. The presentation of PDPH tends to have classic symptoms that include a postural headache, nausea, vomiting, tinnitus, and ocular disturbances. Conservative treatment measures include bed rest, intravenous hydration or caffeine, and analgesics. Resistant cases might require an epidural blood patch (EBP). Though complications are rare, cases of immediate post-procedural pain and subdural epidural hematoma have been reported. Here we present a case of PDPH treated with sequential EBPs that resulted in delayed radicular pain. CASE REPORT:A 29-year-old female presented to the emergency room with a severe frontal headache of several days duration. She underwent a diagnostic lumbar puncture as a part of her work-up. Then, 24-48 hours later she developed a severe postural headache unresponsive to conservative care. Two days later she underwent an epidural blood patch with 20 mL of autologous blood. Her symptoms did not abate, prompting a repeat EBP within 24 hours with an additional 20 mL of autologous blood. Five days later the patient began experiencing muscle spasms and radicular pain in the buttocks and left posterior leg that radiated to her posterior calf. The patient was initially started on pregabalin 25mg 3 times daily, and underwent a gadonlinum-enhanced MRI of the lumbar spine. She followed up 5 days later with unchanged symptoms and a negative MRI. She was then started on a methylprednisolone taper and continued the pregabalin. At the 10-day follow-up, there was 90% resolution of symptoms and a pain intensity of 1/10 on NRS. At this time she is continuing the pregabalin with plans to discontinue medication. DISCUSSION:Although EBP is typically a safe procedure, complications might occur. An inflammatory response, secondary to the injection ofblood, or mechanical compression, due to the total volume of blood injection, are highlighted as possible causative agents in the development of this complication. The role of fluoroscopic imaging, particularly in patients who have failed an initial EBP, must also be examined. Given the rates of false loss of resistance (17-30%) reported in the literature, the use of real-time imaging to ensure proper needle placement and subsequent injectate spread should be considered.
Paro cardiaco durante anestesia en un hospital universitario en Nigeria
Cardiac arrest during anesthesia at a university Hospital in Nigeria Rukewe A, Fatiregun A, Osunlaja T O. Niger J Clin Pract [serial online] 2014 [cited 2013 Dec 10];17:28-31. Abstract Background: We assessed the incidence and outcomes of cardiac arrest during anesthesia in the operating room at our university hospital. A previous study on intraoperative cardiac arrests covered a period from 1994-1998 and since then; anesthetic personnel, equipment, and workload have increased remarkably. Materials and Methods: After obtaining institutional ethics approval, we retrospectively reviewed patients' hospital records such as anesthetic charts and register and ICU admission charts between 1 st July 2005 and 30 th June 2010. The cardiac arrests encountered during anesthesia was identified from anesthetic charts and followed-up in the intensive care unit (ICU) for the first 24 h postoperatively. We consider that cardiac arrest occurred in any patient under anesthesia with asystole or ventricular fibrillation requiring cardiac compression or electrical defibrillation. We define recovery as an alive and non-comatose patient 24-h after the cardiac arrest. Results: During the study period, a total of 12,143 surgeries were done; the median age of all the patients was 30 years (range: 1 day-119 years). A total of 31 cardiac arrests identified (frequency 25.5:10,000; 95% confidence interval (CI) 17.7-35.8) out of which 17 were nonfatal. Mortality related to anesthesia was 11.5:10,000 (95% CI 6.5-18.9). The median age of patients with cardiac arrests was 39 years (range: 2 months-78 years). Overall, 80.7% cardiac arrests occurred in the American Society of Anesthesiologists' (ASA) physical status 3-5. Cardiothoracic and neurosurgical operations accounted for 54.8% of the total cardiac arrests. The known risk factors identified among those who had cardiac arrest were, ASA physical status 3-5 (80.7%), procedures performed out-of-work hours (60%), and manually ventilating patients during general anesthesia (39%). Conclusion: Cardiac arrest during anesthesia is higher in poor risk patients (ASA 3-5) who are manually ventilated under general anesthesia and operated during out-of-work hours. Keywords: Anesthesia, cardiac arrest, fatal, nonfatal, outcome http://www.njcponline.com/downloadpdf.asp?issn=1119-3077;year=2014;volume=17;issue=1;spage=28;epage=31;aulast=Rukewe;type=2
Risk of sudden cardiac death. Sadeghi R, Adnani N, Sohrabi MR, Alipour Parsa S. ARYA Atheroscler. 2013 Sep;9(5):274-9. Abstract BACKGROUND:The aim of this study was to determine characteristics of patients with sudden cardiac arrest (SCA) and/or sudden cardiac death (SCD). We need an effective risk stratification method for SCD in patients without low left ventricular ejection fraction (LVEF). METHODS:The study population of this cross-sectional study consisted of 241 patients with SCA or SCD who were admitted to an academic hospital, in Tehran, Iran, from 2011 through 2012. SCD was defined as unexpected death from cardiac causes, heralded by abrupt loss of consciousness within one hour of the onset of acute changes in cardiovascular status, or an unobserved death in which the patient was seen and known to be doing well within the previous 24 hours. Survivors of aborted SCD were also included in the study. Clinical and paraclinical characteristics as well as emergency department complications of patients were recorded. RESULTS:The mean age of population was 66.0 ± 16.5 (17 to 90 years). Among the patients, 166 (68.9 %) were male, 50 (20.7%) were smoker, 77 (32.0%) had hypertension, 47 (19.5%) had diabetes mellitus, 21 (8.7%) had hyperlipidemia, and 32 (13.3%) had renal insufficiency. According to New York Health Association (NYHA) functional class, 31 (12.9%) patients were asymptomatic, 42 (17.4) and 99 (41.1%) subjects were in NYHA I and II, respectively and only 69 (28.6%) patients were in NYHA III or IV. In this study, presenting arrhythmia was pulseless electrical activity or asystole which was observed in 130 (53.9%) subjects. Ventricular tachycardia (VT) or ventricular fibrillation (VF) was seen in 53 (22%) patients. Cardiopulmonary resuscitation in emergency room was successful only in 46 (19.1%) subjects. CONCLUSION:Low ejection fraction (EF) may be an independent predictor of sudden cardiac death in patients, but it is not enough. While implantable cardioverter defibrillators can save lives, we are lacking effective risk stratification and prevention methods for the majority of patients without low EF who will experience SCD. KEYWORDS:Death, Sudden Cardiac Arrest, Sudden Cardiac Death
Error humano y Paro Cardiaco Intraoperatorio. ¿Un Problema Actual? Dra. Marina Beatriz Vallongo Menéndez Anest Mex 2009:21: 107-111
Resumen Errar es parte de nuestra naturaleza humana. Ha sido demostrado que en medicina, y en especial en anestesiología, los errores son más frecuente de lo debido y son causa importante de evolución perianestesiológica inadecuada, que en ocasiones pueden producir paro cardiaco y muerte. Las principales causas de paro cardiaco secundario a la anestesia son los reflejos vagales que se presentan en la anestesia neuroaxial y que no son corregidos a tiempo, el error en la medicación anestésica o coadyuvante administrados, la falta de reposición de volumen, estimación inapropiada del riesgo anestésico, errores o dificultad en el manejo de la vía aérea, la desatención por monitoreo inadecuado o falta de comunicación, equipo disfuncional, fatiga, prisa. La mayor parte de estos errores se pueden prevenir con oportunidad. Por otra parte, el manejo oportuno del paro cardiaco puede revertir la mayoría de casos. Palabras clave: Paro cardiaco, anestesia, error humano.
Paro cardiaco asociado a la combinación de ranitidina y ondansetron en cirugía ambulatoria ginecológica
Cardiac arrest associated with ranitidine and ondansetron combination in day care gynecologic surgery. Srivastava VK, Jaisawal P, Agrawal S, Kumar D. J Anaesthesiol Clin Pharmacol. 2013 Oct;29(4):563-4. doi: 10.4103/0970-9185.119136.