Referral Center In South India Research Articles

Clinical, microbiologic, and treatment outcomes of dematiaceous fungal keratitis - A retrospective study.

Dematiaceous fungi, the third most common causative organism of fungal keratitis, constitute 3.5% to 43.5% of fungal keratitis worldwide. Several studies on filamentous fungi (Aspergillus and Fusarium) are available as opposed to that on dematiaceous fungal keratitis. This study aims to describe the profile of dematiaceous fungal keratitis in South India. This institutional cohort study on culture-proven dematiaceous fungal keratitis was performed in a single ophthalmology referral center in South India for a 6-year period. Records were analyzed for demographic, clinical, microbiological, and treatment outcomes for 3 months from the date of presentation. This study comprised 312 cases involving dematiaceous fungal keratitis (DFK). During the study period, DFK accounted for 10% of microbial keratitis and 24.6% of fungal keratitis cases. The mean (standard deviation) age was 54 (14) years. Males were commonly affected (73.4%). Keratitis was ≤1/3rd depth in 47.8% of cases. Fifty-four cases (17.3%) demonstrated surface pigmentation, and 69 cases (22.1%) had endothelial plaque. Curvularia spp. (99 eyes, 31.7%) was the most common fungal isolate among the speciated fungi. Topical medications resulted in the healing of 63.5% of cases. A total of 193 cases (79%) healed, and 49 cases had to undergo therapeutic penetrating keratoplasty (TPK). Early TPK was performed for 20 cases (40.8%). Seventeen eyes (34.6%) maintained clear grafts at the end of 3 months. In this extensive study on DFK, we report a high incidence of this group of fungal keratitis. We found an excellent healing rate in our cohort of patients.

Histopathological Study and Expression of Beta-Catenin in Congenital Choledochal Cyst in a Tertiary Care Pediatric Referral Center in South India.

Choledochal cysts are congenital anomalies that occur as localized cystic or fusiform dilatations of the biliary tree. Reflux and stasis of pancreatic enzymes in the biliary duct may relate to the development of intestinal metaplasia which might be an important factor related to the carcinogenesis of choledochal cyst, thus the expression of beta-catenin in the metaplastic epithelium might be associated with malignant transformation of choledochal cyst epithelium. This study was conducted at a tertiary care pediatric center between October 2014 and March 2017. Forty patients were evaluated for epithelial lining, mural ulceration, fibrosis, inflammation, and metaplasia. Out of 40, 12 cases (30.0%) were the infantile age group and 28 cases (70.0%) were in the classic pediatric group. Ulceration was classified as grade 0 (14 cases, 35.0%), grade 1 (17 cases, 42.5%), or grade 2 (nine cases, 22.5%). Inflammation was classified as grade 0 (2 cases, 5.0%), grade 1 (26 cases, 65.0%), or grade 2 (12 cases, 30.0%). Fibrosis was classified as grade 0 (five cases, 12.5%), grade 1 (11 cases, 27.5%), grade 2 (17 cases, 42.5%), or grade 3 (seven cases, 17.5%). Metaplasia was noted in five (12.5%) out of 40 cases. All choledochal cysts with metaplasia showed beta-catenin nuclear positivity on immunohistochemistry and were followed up. This study emphasizes the importance of detailed histopathological examination and documentation of metaplastic changes. Metaplasia was associated with beta-catenin nuclear positivity. These findings suggest a potential role for beta-catenin as a marker of metaplastic changes in choledochal cysts.

Pancreatic bleeding Pseudo-aneurysms-A critical analysis of challenges in its multi-modal management protocol at a tertiary care referral center in South India

Pancreatic bleeding Pseudo-aneurysms-A critical analysis of challenges in its multi-modal management protocol at a tertiary care referral center in South India

The Outcome of Pediatric Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia: Experience from a Referral Center in South India.

The online version contains supplementary material available at 10.1007/s12288-023-01684-9.

Molecular profile & clinical outcome in 121 cases - experience from a tertiary referral centre in South India

Ewing sarcoma is the second most common sarcoma involving the bones in children and adolescents. Published data on the clinical features, morphology, translocation and follow-up of patients with Ewing sarcoma from India, is sparse. Objectives of this study were to analyse the clinico-pathologic features of Ewing sarcoma and compare with translocation status, BCoR immunohistochemistry, treatment and survival. 406 cases of Ewing sarcoma were diagnosed in the Department of Pathology, Christian Medical College, Vellore during the period 2008-2015. 135 patients underwent molecular testing for common translocations by RT-PCR and were included in this study.Mean age of patients at diagnosis was 22 years. Most common location of tumour was appendicular skeleton (31.4%) and 19% had solid organ involvement. Distant metastasis was present in 21.5% patients. Translocation was seen in 63 (46.7%) cases, EWS-FLI1 type I (87%), EWS-FLI1 type II(11%) and one patient had EWS-ERG translocation. Seven out of 30 patients were classified as “Sarcoma with BCOR genetic alteration”. Patients who underwent 6 cycles of chemotherapy had a better mean survival. Mean follow-up was 13.72 months and 3 year event free survival of patients was 93.8%.Percentage of viable tumour <10% was the only significant histologic parameter predicting survival. Age at diagnosis ≤15yrs, female sex, size ≤12cm, extra-osseous site, chemotherapy and translocation positivity predicted an improved survival. This study has analysed the type of mutations/translocations seen in a subset of Indian patients with Ewing sarcoma and correlated the clinical and pathological factors affecting survival.

Predictors of optimum continous positive airway pressure level in obstructive sleep apnoea patients

Background: Obstructive sleep apnoea (OSA) is a breathing disorder during sleep which leads to life-threatening events. The recommended treatment for moderate to severe OSA is continuous positive pressure therapy (CPAP). Aim: To predict the optimal CPAP level in OSA. Methodology: This was a cross sectional observational study, carried out in pulmonary medicine department at a tertiary referral centre in South India. Twenty patients were recruited in the study over a period of 6 months. All patients in study group underwent CPAP titration with optimal or good titration over a full night polysomnography. Results: We correlated the optimal CPAP level with demographic, anthropometric and polysomnographic variables, which showed a trend of association between body mass index (BMI), neck circumference, apnoea hypopnoea index (AHI), oxygen desaturation index (ODI) and severity of OSA with optimal CPAP level Conclusion: No statistically significant association was observed between demographic, clinical, anthropometric and polysomnographic variables with optimal CPAP level.

Study protocol: ‘a large cohort study of postnatal events in a not-for-profit referral centre in Vellore, South India’

IntroductionIn a large developing country, with diverse population characteristics and differential access to healthcare, it is important to identify factors that influence postnatal health. This knowledge will help frame recommendations...

The Nutritional Trajectory of Children with Acute Lymphoblastic Leukemia: A 10-Year Follow up Study from a Referral Center in South India

ObjectiveSurvivors of childhood acute lymphoblastic leukemia (ALL) are vulnerable to late adverse events such as obesity and an associated metabolic syndrome.MethodsChildren treated for ALL from 2002 to 2012 were included. BMI was calculated at diagnosis, end of treatment, and 5, 8, and 10-years from diagnosis. BMI-centiles were used to categorize the patients: underweight (<5th-percentile), normal (5th–85th percentile), overweight (85th–95th percentile), and obese (≥95th centile).ResultsThe study included 179 children with ALL (median age: 59-months). The proportions of patients who were underweight, normal, overweight/obese, were 37%, 56% and 7%, respectively, at diagnosis; and 15%, 51% and 34%, respectively, at 5-years from diagnosis. The median (IQR) BMI Z-score at diagnosis was −1.12(−2.40, −0.26). The median (IQR) BMI z-score of the cohort was higher after 5 [0.22(−0.83,1.24), P < 0.001] and 10-years of diagnosis [0.30(−0.69,0.99), P < 0.001], respectively. The proportion of overweight/obese individuals was higher after 5 (34%, P < 0.001) and 10 (26%, P = 0.001) years. There was a significant correlation between the baseline BMI Z-score and that observed after 5-years (ρ = 0.49, P < 0.001), and 10-years (ρ = 0.55, P < 0.001).ConclusionAt 10-years of follow-up, >25% of children with ALL were overweight/obese. The BMI Z-score at the time of diagnosis continued to correlate with the Z-score after 10-years.

EP31.05: Fetal megacystis in the first trimester: does the LBD matter? A follow‐up study of 84 fetuses in a tertiary referral centre in South India

EP31.05: Fetal megacystis in the first trimester: does the LBD matter? A follow‐up study of 84 fetuses in a tertiary referral centre in South India

Glaucoma management in congenital ectropion uveae: Surgical outcomes from a large tertiary referral center in South India.

To evaluate the long-term outcomes of glaucoma management in patients with congenital ectropion uveae (CEU) over a period of three decades at a single large referral tertiary eye care center. Retrospective chart review of all patients with CEU treated surgically from 1990 to 2019 was performed. Primary combined trabeculotomy-trabeculectomy (CTT), trabeculectomy with and without mitomycin-C (MMC) (0.2 mg/mL for 1 min) and transscleral cyclophotocoagulation (TSCPC) were performed. Intraocular pressure (IOP) ≥6 and ≤16 mmHg without medications was considered as complete success and IOP≤ 16 mmHg with the use of upto 2 medications as qualified success. A total of 26 eyes of 21 patients were identified with a median age of 7 years (range, 6 days to 19 years) at the time of glaucoma surgery. Median follow-up was 51.1 months (range, 7-244.6 months). Primary CTT was performed in 17 eyes (65%), trabeculectomy in 5 eyes (19%) with application of MMC in 2 eyes, and 3 eyes (12%) underwent TSCPC. One painful blind eye (4%) underwent evisceration. Mean IOP reduced from 30.8 ± 7.6 mmHg on a mean of 1.3 ± 0.8 glaucoma medications preoperatively to a mean IOP of 15.2 ± 5.9 mmHg (P < 0.0001) on a mean of 0.2 ± 0.5 medications postoperatively at final follow-up (P = 0.0009). Complete success was achieved in 20 eyes, and qualified success in 2 eyes. CTT is a safe and efficacious primary procedure for management of early-onset glaucoma in CEU. Trabeculectomy with or without adjuvant MMC is a viable second line of treatment in late-onset glaucoma with CEU for IOP control.

Role of Ultrasonography in Upper Airway Assessment for Decannulating Tracheostomy in Acquired Brain Injury—A Pilot Study

ObjectiveTo compare the findings of ultrasonography of the upper airway with flexible fiberoptic laryngoscopy and determine the efficacy of transcutaneous laryngeal ultrasonography for decannulation. DesignProspective cross-sectional study. SettingTertiary care referral center in South India. ParticipantsTwenty-four patients with acquired brain injury (N=24). Main Outcome MeasuresParticipants underwent an airway assessment by ultrasonography followed by assessment of airway by flexible laryngoscopy done within the next 72 hours. ResultsVocal cord assessment by ultrasonography revealed a sensitivity of 81.2% and specificity of 87.5%. A statistically significant association between vocal cord mobility as assessed by ultrasonography and decannulation was observed (sensitivity of 81.25%, specificity of 87.5%, P=.002). Although aspiration was not assessed by ultrasonography, a statistically significant association was observed between vocal cord mobility on ultrasonography and aspiration as assessed by laryngoscopy (sensitivity of 81.25%, specificity of 87.5%, P=.011). ConclusionLaryngeal ultrasonography is an emerging diagnostic modality with a potential role for assessing vocal cord mobility and airway prior to decannulation in centers that lack the expertise and the infrastructure to perform a flexible laryngoscopy.

Protocol and immunohistochemistry-based diagnosis and treatment of Non-Hodgkin lymphoma in children: Experience over two decades from a tertiary referral centre in South India

Protocol and immunohistochemistry-based diagnosis and treatment of Non-Hodgkin lymphoma in children: Experience over two decades from a tertiary referral centre in South India

Disorders of Sexual Differentiation: A Clinicopathological and Histological Study

Introduction: The term ‘Disorders of Sexual Differentiation’ (DSD) is defined as a congenital discrepancy between external genitalia, gonadal and chromosomal sex. The Chicago consensus based on the primary genetic defect is used for current nomenclature and classification. A child with DSD, if identified and treated early, may grow to become a well-adjusted, functional member of the society. Patients with DSD carry a low but definite risk of developing germ cell tumours which necessitates a histological analysis in all cases. Aim: To describe the clinicopathological features of individuals with DSD and to classify the available cases according to the Chicago consensus which is based on karyotype and histopathology. Materials and Methods: The study was a retrospective descriptive study done at a tertiary referral centre in South India, for a period of four months from May to August 2016. Case charts and histopathology slides of cases received in the department of Pathology from January 2011 to May 2016 were included and reviewed. Cases where the histopathology slides/blocks were not retrievable/difficult to assess due to technical issues were excluded. Case charts and slides were reviewed retrospectively with a view to classify as per karyotypic or histological classification. The slides were reviewed by two pathologists to help in the classification wherever possible. Statistical measures like mean and percentages were used to describe the results. Results: A total of 22 cases of DSD were studied for which karyotype was available in 13 cases. Common clinical presentations were primary amenorrhoea, cryptorchidism and ambiguous genitalia. Age at presentation varied from nine months to 30 years. The initial diagnosis based on karyotype, clinical findings, hormonal assays and imaging were concordant with the final diagnosis in 11 cases. In two cases, histopathology was essential in arriving at a definitive diagnosis. Of the 13 cases with karyotype reports available, five were sex chromosome DSD, five were 46XY DSD and three were 46XX DSD. Gonadoblastoma was seen in three cases. Conclusion: Histopathological examination together with karyotype plays a crucial role in proper categorisation of disorders of sexual differentiation. A multidisciplinary team approach for early diagnosis and management of DSD is essential for the psychosexual development of these individuals.

Clinical Efficacy of Inhaled Nitric Oxide in Preventing the Progression of Moderate to Severe COVID-19 and Its Correlation to Viral Clearance: Results of a Pilot Study

Abstract Hypoxic patients with coronavirus disease 2019 (COVID-19) are at high risk of adverse outcomes. Inhaled nitric oxide (iNO) has shown anti-viral and immunomodulatory effects in vitro. However, in vivo evidence of efficacy in hypoxic COVID-19 is sparse. This open label feasibility study was conducted at a single referral center in South India and evaluated the effectiveness of repurposed iNO in improving clinical outcomes in COVID-19 and its correlation with viral clearance. We recruited hypoxemic COVID-19 patients and allocated them into treatment (iNO) and control groups (1:1). Viral clearance on day 5 favored the treatment group (100% vs 72%, P &lt; 0.01). The speed of viral clearance as adjudged by normalized longitudinal cycle threshold (Ct) values was positively impacted in the treatment group. The proportion of patients who attained clinical improvement, defined as a ≥2-point change on the World Health Organization ordinal scale, was higher in the iNO cohort (n = 11, 79%) as compared to the control group (n = 4, 36%) (odds ratio 6.42, 95% confidence interval 1.09-37.73, P = 0.032). The proportion of patients progressing to mechanical ventilation in the control group (4/11) was significantly higher than in the treatment group (0/14). The all-cause 28-day mortality was significantly different among the study arms, with 36% (4/11) of the patients dying in the control group while none died in the treatment group. The numbers needed to treat to prevent an additional poor outcome of death was estimated to be 2.8. Our study demonstrates the putative role of repurposed iNO in hypoxemic COVID-19 patients and calls for extended validation.

O19: FROZEN GEL-PACKS REDUCE POST-OPERATIVE PAIN AND NARCOTIC USAGE IN PATIENTS UNDERGOING SURGERY FOR BREAST CANCER

Abstract Introduction Adequate post-operative analgesia is important for recovery, early rehabilitation and patient satisfaction. We aimed to prove that patients undergoing surgery for breast cancer who receive cryotherapy via frozen gel-packs in the immediate postoperative period would report lower pain, require lesser narcotics and pain medication. Method This prospective randomized study was conducted at our tertiary care referral centre in South India. The pre-operative characteristics, intra-operative variables and post-operative outcomes were compared between two sets of matched cases and controls. Cryotherapy was delivered via frozen gel-packs for 12 hours immediately following surgery. Pain relief was assessed with the visual analog pain scale(VAS). Comparisons between groups were measured by the chi-square test, Fischer's-exact test, Independent samples t-test or Mann-Whitney U test as appropriate. Result 81 patients were included in the study( Study-group=41 and control-group=40). For the primary outcome, mean postoperative pain score on postoperative days(PODs) 1(5.13±0.648 vs. 4.44±.502; t (79) = 5.3; p&amp;lt;0.001) and POD 5(4.1±0.9 vs. 3.29±.642; t (79)=3.26; p&amp;lt;0.001) were significantly lower in the cryotherapy group. The overall post-operative narcotic requirement(morphine equivalence) was reduced in the cryotherapy group(61.32±9.4 vs 55.8±11; t(79) = 2.421; p=0.018). The overall paracetamol requirement(grams) was also reduced in the cryotherapy group(2.1±.38 vs 1.9±.36; t(79) = 2.66; p=0.009). No significant difference was seen in the NSAID use between the groups. The cryotherapy group also demonstrated earlier functional recovery and lesser shoulder and arm stiffness(p=0.015). Conclusion Cryotherapy is a simple, cost-effective adjuvant to standard postoperative pain management which reduces pain, narcotics and promotes early rehabilitation. Take-home message Ice packs are a simple, cost-effective adjuvant to standard postoperative pain management which reduces pain, narcotic use and promotes early rehabilitation.

A study on Acanthamoeba keratitis in a tertiary eye care centre South Kerala, India

Introduction: Acanthamoeba keratitis (AK), a potentially devastating disease is caused by free-living amoebae of the genus Acanthamoeba . The number of reported cases worldwide is increasing year after year, mostly in contact lens wearers as also in non-contact lens wearers. Interestingly, AK has remained significant due to an incomplete understanding of the pathogenesis and pathophysiology of the disease, diagnostic delays and problems associated with chemotherapeutic interventions. Corneal blindness is a major public health problem worldwide and infectious keratitis is one of the predominant causes. Aim: To find out the Parasitic Etiological Agents in Suppurative Keratitis at a tertiary eye care referral centre in South India. Materials and Methods: A hospital based study was done on total of 350 cases of keratitis, during the period from January 2013 to December 2013 .The samples were examined as wet mount as well as cultured onto Non nutrient agar with E.coli overlay. Result: Acanthamoeba species were isolated from 314 cases. Most of the corneal ulcers responded well to treatment which was started early in their course due to early detection of the parasite by direct microscopy and confirmation by culture. Keywords: Acanthamoeba spp, Etiological Agents, Suppurative keratitis.

Predictive Factors of Early Recurrence in Patients with Phyllodes Tumor of the Breast.

Phyllodes tumor (PT) is a rare entity accounting for 1% of breast neoplasms with a high propensity of recurrence. This study aimed to identify factors that are predictive of early recurrence in patients with PT. This study reviewed clinical data of patients with PT (n=57) treated at our tertiary care referral center in South India between February 2010 and December 2019. The Pearson χ2 test was used to investigate the relationship between patient's clinical features and tumor histotypes. Survival curves were obtained using the Kaplan-Meier method based on the log-rank test. Multivariate Cox regression analyses were performed to identify predictors of early recurrence or local recurrence-free-interval (LRFI). The mean age was 38.3 [standard deviation (SD)=13.6] years, and the mean follow-up was 18 (SD=13.5) months. The median tumor size was 5 cm (interquartile range 3 and range: 3-22 cm). Moreover, 64.9% (n=37) of the tumors were benign, 21.1% (n=12) were borderline, and 14% (n=8) were malignant. Of the 57 patients, 17 (29.8%) developed local recurrence and one developed distant metastasis. Of the 17 patients, three were unwilling to undergo completion surgery. The median LRFI was 20 (range: 7-60) months. Multivariate cox regression analyses showed that mitotic rate >10/high power field [hazard ratio (HR) 0.147; p=0.04], stromal overgrowth (HR: 4.904; p=0.05), margin status (HR: 0.037; p<0.001), and preoperative neutrophil-to-lymphocyte ratio [(NLR), HR: 4.891; p=0.04)] were significant predictors of LRFI. A high mitotic rate, positive margin, stromal overgrowth, and NLR >3.5 were associated with early recurrence. These attributes mandate stringent follow-up, especially in a resource-limited setting.

A Five-Year Review of Ovarian Torsion Cases: Lessons Learnt.

The aim of the study was to analyse risk factors, surgical findings, ovarian salvage rate and histology of ovarian mass. We reviewed 81 cases of surgically proven ovarian torsion retrospectively from June 2014 to June 2019 at a tertiary care referral centre in South India. Demographic, clinical and surgical details of all patients were noted from the medical records. Mean age of the patients was 26years. Most of the patients were nulliparous and had a pre-existing ovarian mass of size > 5cm. Ovarian salvage rate was 43.2%. Concomitant cystectomy with detorsion was done in 30 patients without increase in blood loss or complications. Extensive necrosis was present in 78.2% of oophorectomy specimens. Most common histology of ovarian mass in cystectomy specimens was simple ovarian cyst.

Transcranial Doppler for Monitoring and Evaluation of Idiopathic Intracranial Hypertension.

Background Idiopathic intracranial hypertension (IIH) is a disorder of unknown origin, characterized by features of raised intracranial pressure (ICP). Existing literature is inconclusive about the role of transcranial Doppler (TCD) in the management of IIH. Objective To study the TCD changes in IIH patients, pre- and post-cerebrospinal fluid (CSF) drainage. Materials and Methods This was a prospective study, conducted between July 2017 and December 2019, in a tertiary care referral center in South India. Sixteen consecutive patients, suspected to have IIH, underwent magnetic resonance imaging ofthe brain, a baseline TCD, and lumbar puncture with CSF drainage and pressure monitoring. Post-CSF drainage, TCD was repeated and mean flow velocities, peak systolic velocities, end-diastolic velocities, and pulsatility index (PI), in the middle cerebral artery (MCA), vertebral artery, and basilar artery (BA) were noted. Thirteen patients had elevated CSF pressure, and fulfilled the diagnostic criteria for IIH. These patients were included in the final analysis and pre- and post-CSF drainage TCD blood flow velocities and PI were compared. Results The mean age of study participants was 29.92 ± 6.92 years. There was a significant reduction in the cerebral flow velocities in bilateral MCA, after CSF drainage and normalization of ICP. Flow velocities in posterior circulation and PI in MCA, PCA, and BA showed an insignificant reduction. Two patients, who did not show any reduction in flow velocities after CSF drainage, developed optic atrophy on follow-up. Conclusion TCD-derived systolic blood flow velocities can be used in the management and follow-up of patients with IIH.

Matched Family versus Alternative Donor Hematopoietic Stem Cell Transplantation for Patients with Thalassemia Major: Experience from a Tertiary Referral Center in South India.

Hematopoietic stem cell transplantation (HSCT) is the only curative option available for patients with thalassemia major in India with increasing access to alternate donor transplantation for patients with no matched family donor. We aimed to analyze the impact of family and alternate donor HSCT on morbidity and mortality post-HSCT. We conducted a retrospective study in the department between July 2007 and December 2018 where all children who underwent HSCT for thalassemia major were included. A total of 264 children were included with a median age of 6 years (male/female, 1.4:1). The graft source was matched related donor (MRD) (76%; parent 15%, sibling 85%) and matched unrelated donor (MUD) (22%). All children received a myeloablative conditioning regimen with treosulfan/thiotepa/fludarabine in 93% and busulfan/cyclophosphamide in 7%. The source of stem cells was peripheral blood in 61%, bone marrow in 38%, and umbilical cord blood in 3%. The incidence of bacteremia was 14% versus 25% in MRD versus MUD groups. There was a higher incidence of posterior reversible encephalopathy syndrome (PRES) in the MUD group (10% versus 3%). Engraftment occurred in 97% with a higher trend toward mixed chimerism in the MRD group (12% versus 2%). When indicated, whole-blood donor lymphocyte infusion was used to ensure complete chimerism in children in the MRD group. A statistically significant difference was found in the incidence of graft versus host disease (GVHD), both acute and chronic between the MUD versus MRD groups, 60% versus 20% and 41% versus 17%, respectively (P=.001). Similarly, immune cytopenia and cytomegalovirus reactivation were also significantly higher in the MUD group, 27% versus 1.4% and 25% versus 2%, respectively (P=.001). Thalassemia-free survival in our cohort was 96%, 94%, and 84% with a median follow-up of 65 months in the matched sibling donor, matched family donor, and MUD groups, respectively. Overall survival of 95% and 90% with a median follow-up of 65 months was noted in those who underwent transplantation less than and greater than 7 years of age, respectively. MUD transplantation for patients with thalassemia major involves specific challenges such as PRES and unusual manifestations of GVHD such as immune cytopenia. Early interventions to optimize supportive care and measures to reduce GVHD are required to ensure survival rates of over 90%.