Tertiary Care Center Research Articles

Clinical Profile Of Severe Acute Respiratory Infection In Children Aged 1-12 Years In A Tertiary Care Centre, Tamil Nadu

Clinical Profile Of Severe Acute Respiratory Infection In Children Aged 1-12 Years In A Tertiary Care Centre, Tamil Nadu

Myeloid sarcoma: A 7-year retrospective study from a tertiary cancer care center, illustrating the clinical, morphological, and immunohistochemical features

Myeloid sarcoma: A 7-year retrospective study from a tertiary cancer care center, illustrating the clinical, morphological, and immunohistochemical features

Epidemiological Profile And Practices Of Animal Bite Victims Attending The OPD Of Rural Health And Training Centre Affiliated To A Tertiary Care Centre In Rewa

Epidemiological Profile And Practices Of Animal Bite Victims Attending The OPD Of Rural Health And Training Centre Affiliated To A Tertiary Care Centre In Rewa

The Epidemiology of Syphilis and Co-infection with HIV in a Tertiary Care Center in Lebanon: A Retrospective Review

Introduction: Syphilis is an ancient STI causing a new worldwide outbreak in general and in Lebanon specifically. Methods: We conducted a retrospective chart review to assess the rate of syphilis increase in an infectious diseases clinic in Lebanon from 2006 to 2023. We studied the epidemiology of these cases, stage and treatment response and their association to HIV infection and its control. Results: There was an 862% increase in syphilis cases from 2006 to 2019.Most of our cases were middle aged men living with HIV. Most of them had well-controlled HIV infection with good CD4 counts. Most of the diagnosed cases of syphilis were primary and secondary, responding to penicillin G. Discussion: Our data mostly parallels international data, except for gender distribution. Despite successful treatment of most cases in our clinic, the alarming rise of new cases highlights the urgent need for public health measures to mitigate this epidemic. Conclusion: Inclusive awareness is needed to stop syphilis spread in Lebanon, and more screening is key in identifying new cases early for a successful eradication.

Clinico-genetic profile of seven patients with PARK-PINK1: A case series from a tertiary care centre from India and review of literature.

Recessive variants in the PINK1 gene is a known cause of early-onset Parkinson's disease (EOPD). To describe the clinical features and genetic profile of patients of PARK-PINK1. Retrospective chart review of demographic, clinical and genetic details of patients carrying biallelic PINK1 variants from our database. Seven cases were recruited with median age at onset 33 years (Range: 20-49). All had asymmetrical onset, tremor in four, abnormal posturing in two and slowness in one patient. Parkinsonism phenotype was noted in six patients (with dystonia in four) and isolated dystonia in one. Among 6 patients with parkinsonism, five had rest tremor, all had good levodopa-response, and four had motor-fluctuation with choreiform-dyskinesia. Exome-sequencing revealed bi-allelic pathogenic/likely pathogenic variants in all of which five were novel. PARK-PINK1 presents as an EOPD with tremor-predominant phenotype, good levodopa-responsiveness, early motor fluctuation and dyskinesia. We describe five novel variants in PINK1 gene.

Functional outcome and quality of life index after endonasal versus external dacryocystorhinostomy

Abstract Purpose: To compare the functional outcome and quality of life (QOL) index following non-endoscopic endonasal dacryocystorhinostomy (NEN-DCR) and external dacryocystorhinostomy (EXT-DCR). Methods: Patients were prospectively allocated to two groups. All adult patients presenting with primary nasolacrimal duct obstruction (PANDO) undergoing EXT-DCR and NEN-DCR at a tertiary eye care center were included. Patients in one group underwent EXT-DCR and others NEN-DCR. Functional outcomes were measured by Munk Score and fluorescein dye disappearance test (FDDT). A validated quality of life questionnaire (EQ-5D-3L) in the local language (Odiya) was used to measure health status (social impact score) before and 1 day, 2 weeks, 6 weeks, and 3 months after surgery. The primary outcome measure was the functional outcome–Munk Score and secondary outcome measures included the QOL index and the FDDT. Results: A total of 110 patients were recruited and equally distributed (n = 55) in both groups. The mean age of the population was 47.6 years (SD = 14.02; range 20–79 years). The majority (71%, 79/110) were female. When longitudinally followed over time, functional outcome and QOL index showed reasonably rapid and marked improvement in both groups after surgery compared to baseline scores. The Munk score (P = 0.037) and QOL index (P = 0.007) were marginally better on the first postoperative day for the NEN-DCR group compared to EXT-DCR but comparable at all subsequent visits. At a median follow-up of 9 weeks (range: 0.5–24 weeks), the anatomical outcome was comparable between both groups. Conclusion: Our results demonstrate that functional outcome and QOL index show rapid and marked improvement in both NEN-DCR and EXT-DCR after surgery. NEN-DCR outcomes were marginally better on the first postoperative day but comparable to EXT-DCR thereafter.

Placental lesions in patients with antiphospholipid antibody syndrome: experience of a single tertiary-care Italian reference center

Placental lesions in patients with antiphospholipid antibody syndrome: experience of a single tertiary-care Italian reference center

The effectiveness of vedolizumab in advanced therapy-experienced ulcerative colitis patients: Real world data from the Inflammatory Bowel Disease of the Middle East (IBD-ME) Registry group.

Vedolizumab is an approved ulcerative colitis (UC) treatment. Multiple large randomized clinical trials have demonstrated the drug's efficacy and safety. However, real-world data from Middle Eastern countries are spare. The study aims to evaluate the clinical efficacy of vedolizumab (VDZ) therapy in advanced therapy experienced UC patients. A retrospective electronic chart review of a cohort study of 153 moderately to severely active UC patients who failed or were intolerant to TNF antagonists and received vedolizumab from two large tertiary care centers was performed. Rates of clinical response and remission were retrospectively evaluated at 3,6, and 12 months post VDZ therapy using Patient Simple Clinical Colitis Activity Index (P-SCCAI); clinical response was defined as a decrease in P-SCCAI ≥3, and clinical remission was defined as a P-SCCAI score of ≤3 points. Logistic regression analysis was used to identify predictors of response to vedolizumab. A total of 153 UC patients had sufficient data for analysis. Clinical remission rates were 61.9% for patients on vedolizumab every 8 weeks and 89.3% for those receiving every 4 (Q4) weeks dosing. A significant reduction in CRP and improvement of albumin post vedolizumab treatment were observed, and corticosteroids were stopped in most patients. In a multiple logistic regression analysis, several factors were found to influence the clinical effectiveness of VDZ in inducing remission. Female gender was associated with a higher likelihood of remission [OR =3.09, 95% CI = (1.05-9.13), P = 0.04]. Conversely, a greater number of biologics used prior to VDZ treatment was associated with a lower likelihood of remission [OR =0.418, 95% CI = (0.203-0.859), P = 0.017]. Patients with extensive disease (E3) had an increased likelihood of remission [OR =3.81, 95% CI = (1.32-10.97), P = 0.0129]. Additionally, a VDZ dosing frequency of Q4 weeks was associated with a significantly higher likelihood of remission [OR =6.08, 95% CI = (1.73-21.39), P = 0.0049]. No significant safety signals were reported. In this current real-world study, vedolizumab effectively achieved clinical response and remission in most advanced therapy experienced UC patients treated for up to 12 months. Future studies with larger sample sizes and more robust study designs should be conducted to further validate the results of this study.

De-implementation of Routine Maternal Oxygen Supplementation for Intrauterine Fetal Resuscitation: A Retrospective Cohort Study.

Current practice guidelines for laboring patients with category II intrapartum tracings recommend maternal oxygen supplementation despite emerging randomized data challenging its benefit and utility. We aim to validate that de-implementing maternal oxygen supplementation for fetal resuscitation did not increase the risk of neonatal acidemia in a real-world setting. This is a retrospective observational study conducted at a single tertiary care center from January 2019 to June 2021. All laboring deliveries during the study period was reviewed and eligible participants included singleton or twin pregnancies between 23-42 weeks gestational age with persistent category II tracings. Known major fetal anomalies, contraindications to labor, and maternal indication for O2 supplementation, including active COVID-19, were excluded. Cohorts were allocated based on time of delivery. Those occurring prior to our hospital policy change identified as historical controls and deliveries after April 1, 2020, as the post-de-implementation cohort. Primary outcome was fetal acidemia, defined as umbilical cord pH < 7.2. Secondary outcomes included severe acidemia (pH < 7.0), 5-minute Apgar score < 4 and neonatal intensive care admission. Regression analyses controlling for known variables associated with neonatal acidemia generated adjusted odds ratios with 95% confidence intervals. Among 9088 deliveries during the study period, 1162 tracings were flagged as persistent category II, including 681 (59%) in the post-intervention group. The two cohorts had comparable baseline and obstetric characteristics. No difference in neonatal acidemia was observed between the post-de-implementation group and historical controls (13.8% vs 15.4%, aOR 0.87, 95% CI 0.62-1.22). Severe acidemia, 5-minute Apgar < 4 and neonatal intensive care admission were not increased in the post-de-implementation group. De-implementation of routine maternal oxygen supplementation for fetal resuscitation did not increase likelihood for neonatal acidemia in a real-world setting, validating guidelines recommending against the intervention.

Patients with influenza admitted to a tertiary-care hospital in Riyadh between 2018 and 2022: characteristics, outcomes and factors associated with ICU admission and mortality

BackgroundInfluenza is a common cause of hospital admissions globally with regional variations in epidemiology and clinical profile. We evaluated the characteristics and outcomes of patients with influenza admitted to a tertiary-care center in Riyadh, Saudi Arabia.MethodsThis was a retrospective cohort of adult patients admitted with polymerase chain reaction-confirmed influenza to King Abdulaziz Medical City-Riyadh between January 1, 2018, and May 31, 2022. We compared patients who required intensive care unit (ICU) admission to those who did not and performed multivariable logistic regression to assess the predictors of ICU admission and hospital mortality.ResultsDuring the study period, 675 adult patients were hospitalized with influenza (median age 68.0 years, females 53.8%, hypertension 59.9%, diabetes 55.1%, and chronic respiratory disease 31.1%). Most admissions (83.0%) were in the colder months (October to March) in Riyadh with inter-seasonal cases even in the summertime (June to August). Influenza A was responsible for 79.0% of cases, with H3N2 and H1N1 subtypes commonly circulating in the study period. Respiratory viral coinfection occurred in 12 patients (1.8%) and bacterial coinfection in 42 patients (17.4%). 151 patients (22.4%) required ICU admission, of which 62.3% received vasopressors and 48.0% mechanical ventilation. Risk factors for ICU admission were younger age, hypertension, bilateral lung infiltrates on chest X-ray, and Pneumonia Severity Index. The overall hospital mortality was 7.4% (22.5% for ICU patients, p < 0.0001). Mortality was 45.0% in patients with bacterial coinfection, 30.9% in those requiring vasopressors, and 29.2% in those who received mechanical ventilation. Female sex (odds ratio [OR], 2.096; 95% confidence interval [CI] 1.070, 4.104), ischemic heart disease (OR, 3.053; 95% CI 1.457, 6.394), immunosuppressed state (OR, 7.102; 95% CI 1.803, 27.975), Pneumonia Severity Index (OR, 1.029; 95% CI, 1.017, 1.041), leukocyte count and serum lactate level (OR, 1.394; 95% CI, 1.163, 1.671) were independently associated with hospital mortality.ConclusionsInfluenza followed a seasonal pattern in Saudi Arabia, with H3N2 and H1N1 being the predominant circulating strains during the study period. ICU admission was required for > 20%. Female sex, high Pneumonia Severity Index, ischemic heart disease, and immunosuppressed state were associated with increased mortality.

The Factors Associated With Mutant Epidermal Growth Factor Receptor Positivity in Patients With Lung Cancer: A Study From a Tertiary Care Center in Pakistan

The Factors Associated With Mutant Epidermal Growth Factor Receptor Positivity in Patients With Lung Cancer: A Study From a Tertiary Care Center in Pakistan

Laparoscopic cholecystectomy in a patient with Fontan circulation.

Fontan circulation is created when a baby is born with only one functioning cardiac ventricle. A series of surgeries are performed to allow the ventricle to provide oxygenated blood to the systemic circulation and to create passive flow of venous blood to the pulmonary circulation via a conduit. Laparoscopic surgery poses several hemodynamic challenges to a patient with Fontan physiology attributable to carbon dioxide insufflation, positive pressure ventilation, and reverse Trendelenburg positioning. A 39-yr-old male with a Fontan physiology was referred to our tertiary care centre because of repeated bouts of cholecystitis requiring a percutaneous drain and now elective laparoscopic cholecystectomy. Because of repeated cardiac surgeries, the patient also had complete heart block and was pacemaker dependent. We placed an arterial catheter prior to induction of general anesthesia with tracheal intubation. Transesophageal echocardiography allowed for real-time intraoperative assessment of venous blood flow through the patient's extracardiac diversion system throughout the surgery. This information was used to guide management and determine circulation tolerance during the various stages of laparoscopy. Inhaled milrinone resulted in the shunt fraction returning to the patient's baseline. Intraperitoneal pressure was kept below 10mm Hg, and systemic blood pressure was supported with a low-dose norepinephrine infusion. Intraoperative transesophageal echocardiography is a useful monitoring device during laparoscopic surgery when a patient has Fontan circulation. Knowing how to administer inhaled milrinone is a useful skill to decrease the shunt fraction through a patient's conduit, increasing pulmonary blood flow while avoiding hypotension.

Endoscopic dacryocystorhinostomy in acute dacryocystitis: a multicenter study in China.

To report the clinical profile, endoscopic dacryocystorhinostomy (En-DCR) management, and acute dacryocystitis (AD) outcomes in China. Clinical data of 554 adult AD patients (554 eyes) who presented in 7 tertiary eye care centers for 10y from Jan 2010 to Mar 2020 were retrospectively analyzed. Clinical profile, En-DCR management, and outcomes of all cases were recorded. The anatomical and functional success were evaluated for 12mo post-operation. The analysis included 149 males and 368 females with a median age of 55.2y (range: 18-84y). There were 459 eyes with a history of epiphora or purulent secretion. The time between a symptom of lacrimal duct obstruction and acute onset was 1 to 540 (66.1±58.2)mo. Fifty-nine eyes had a history of the previous acute attack. Seventy-four eyes developed a cutaneous fistula, while 11 eyes had post septal cellulitis pre-operation. En-DCR with an anatomical success of 91.7% and functional success of 90.1%. The success rate of the patients with a history of acute episodes and the preoperative fistula was lower than the overall success rates. En-DCR can be performed during an acute episode in AD with a success rate of over 90%.

Ultrasound-guided percutaneous thrombin injection for the management of upper extremity pseudoaneurysms: 20 years of tertiary care center experience.

To evaluate the safety and efficacy of ultrasound-guided percutaneous thrombin injection for the treatment of upper extremity pseudoaneurysms. An institutional database containing 8,316,467 radiology reports was searched for suitable cases over a 241-month period. Fourteen female and 10 male patients, average age of 69.7 years (range 29-93) underwent a total of 26 procedures for the management of upper extremity pseudoaneurysms, involving the radial (n = 9), brachial (n = 9) or other upper extremity arteries (n = 6). Baseline demographic and pseudoaneurysm characteristics were documented, together with primary and secondary success, failures, and complications. All procedures were performed with real-time ultrasound guidance. The mean pseudoaneurysm volume was 9.93 cm3 (range 0.06-111.62 cm3). Twelve cases were related to central line placement or arterial access. Primary success was obtained in 50% (n = 12) after a single ultrasound-guided thrombin injection, and secondary success was achieved in an additional six (for a total success of 75%). Success was highest for the treatment of brachial artery pseudoaneurysms (87.5%), and in those who were diagnosed within 7 days of the inciting event, findings that were statistically significant (p-value 0.046 and 0.002, respectively). Ultrasound-guided percutaneous thrombin injection is safe and effective for managing upper extremity pseudoaneurysms.

Adult-Onset IgA Vasculitis Complicated by Kidney Failure at Disease Onset in a Nepalese Patient: A Case Report

Introduction: Immunoglobulin A (IgA) vasculitis, previously known as Henoch-Schönlein purpura, is an immune complex-mediated small vessel vasculitis primarily affecting children. While rare in adults, it can present with more severe manifestations, particularly involving the kidneys. This case report details the presentation and management of adult-onset IgA vasculitis with significant renal involvement.  Case Report: A 43-year-old male with a history of bipolar disorder presented with facial swelling, shortness of breath, and decreased urine output following an upper respiratory infection. Initial investigations revealed elevated blood pressure and renal impairment. Despite supportive treatment, his condition worsened, leading to a referral to a tertiary care center. He exhibited symptoms consistent with IgA vasculitis, including joint pain, rash, and nephrotic-range proteinuria. The diagnosis was confirmed through a skin biopsy and 24-hour urine collection. The patient was treated with intravenous methylprednisolone, oral prednisone, and an ACE inhibitor. His renal function improved with this regimen.  Discussion: Adult-onset IgA vasculitis can present with severe kidney involvement, including nephrotic-range proteinuria and elevated serum creatinine, which are associated with poorer outcomes compared to pediatric cases. The patient's management, involving glucocorticoids and an ACE inhibitor, aligns with current treatment recommendations for significant renal involvement. Long-term prognosis in adults remains challenging, with a higher risk of end-stage kidney disease compared to children. Vigilant monitoring and tailored treatment strategies are crucial for improving outcomes.  Conclusion: This case underscores the potential severity of adult- onset IgA vasculitis and highlights the importance of early diagnosis and aggressive management to mitigate long- term renal complications. Ongoing research is necessary to refine treatment approaches and enhance outcomes for adults with this condition.

Evolving Trends in Safe Surgery in Otolaryngology: Experience from a Tertiary Care Centre

Evolving Trends in Safe Surgery in Otolaryngology: Experience from a Tertiary Care Centre

Marginal Mandibulectomy in Oral Cavity SCC: Experience in a Tertiary Care Centre

Marginal Mandibulectomy in Oral Cavity SCC: Experience in a Tertiary Care Centre

Manifestations Reported by Inflammatory Bowel Disease Patients in University Hospital.

Inflammatory bowel disease (IBD) may affect organs outside the intestines, it is called extraintestinal manifestations of IBD. Data on the prevalence of mu-cocutaneous manifestations in IBD patients are very limited, therefore, the aim of this study was to assess the prevalence of skin and mucosal lesions and to determine the relationship with demographic factors, clinical features, and systemic treatment. Prospective study included 162 out-patients with IBD who were managed in the tertiary care center. Ulcerative colitis (UC) was diagnosed in 117 patients, Crohn's disease (CD) in 45. Patients completed the questionnaire containing demographic and IBD data, questions about mucocutaneous lesions (in past or present state). Overall mucocutaneous lesions were reported by 48.1% of IBD patients. Skin lesions were reported by 40.7% of patients, oral mucosal lesions were reported by 16.7%, without significant differences between sexes or IBD types. In 47 (29%) of patients, skin lesions appeared together with IBD or during the course of the disease. The most common skin lesions were psoriasis (8.0%), erythema nodosum (5.6%), pyoderma gangrenosum and acne (3.7% each). UC patients mostly reported about psoriasis (9.4%), while CD patients about erythema nodosum (11.1%). There were more frequent skin lesions in patients with more extensive UC type (p = 0.01), while no difference was noticed between different types of CD. The average duration of IBD in patients with skin lesions was similar to those without lesions (9.3±6.7 vs. 9.4±6.7 years). Mucocutaneous lesions were reported by 48.1% of inflammatory bowel disease patients. The frequency of mucocutaneous lesions does not differ significantly between UC and CD, and a longer duration of illness is not a predictive factor for the appearance of lesions. More extensive UC is related to higher frequency of skin lesions.

The association between nutritional status measured by body mass index and outcomes in the pediatric intensive care unit

Aim/IntroductionThe relationship between nutritional status upon admission to a pediatric intensive care unit (PICU) and clinical outcomes remains unclear. We examined the relationship between nutrition status, as indicated by body mass index-for-age (BMI-for-age), and clinical outcomes in the PICU.MethodIn this retrospective study at a tertiary care center, records of 1,015 critically ill children and adolescents aged one month to 18 years old with available anthropometric parameters were included. The nutritional status upon admission was determined by calculating the BMI-for-age z-score using the WHO growth charts as the reference. The participants were categorized as underweight (BMI-for-age z-score &amp;lt; −2), normal weight (−2 ≤ BMI-for-age z-score ≤ +1), and overweight/obese (BMI-for-age z-score &amp;gt; +1). Multi-variate odds ratios (OR) with 95% confidence intervals (CI) were used to investigate the association between malnutrition (being underweight and overweight/obese) and odds of Prolonged PICU stay (≥7 days) and PICU mortality after controlling for descriptive characteristics, Glasgow Coma Scale score status, fluctuations in serum sodium, and acute kidney injury confounders.ResultsThe proportions of patients in underweight, normal weight, and overweight/obese categories were 34.2%, 45.8%, and 20%, respectively. During the study period, 21.5% of patients had prolonged PICU stay, and 5.6% of patients in PICU died. Compared to normal-weight patients, underweight patients had higher odds of prolonged PICU stay (OR: 1.52; 95% CI: 1.05–2.22) and PICU mortality (OR: 2.12; 95% CI: 1.22–4.01). Age- and gender-stratified full-adjusted analysis showed that the increased odds of prolonged PICU stay remained significant among underweight boys and underweight individuals aged 5–19 years old. Furthermore, the increased odds of PICU mortality remained significant among underweight individuals aged 2–5 years old. However, being overweight or obese during PICU admission did not demonstrate a significant association with our outcomes in the total sample or subgroup analysis.ConclusionOur findings showed that PICU patients who were underweight had higher odds of prolonged PICU stay and PICU mortality than their normal-weight counterparts. This underscores the importance of closely monitoring underweight patients in the PICU upon admission in order to improve clinical outcomes.

"Code Headache": Development of a protocol for optimizing headache management in the emergency room.

Patients presenting at the emergency room (ER) with headache often encounter a hostile atmosphere and experience delays in diagnosis and treatment. The aim of this study was to design a protocol for the ER with the goal of optimizing the care of patients with urgent headache to facilitate diagnosis and expedite treatment. A narrative literature review was conducted via a MEDLINE search in October 2021. The "Code Headache" protocol was then developed considering the available characteristics and resources of the ER at a tertiary care center within the Spanish National Public Health system. The Code Headache protocol comprises three assessments: two scales and one checklist. The assessments identify known red flags and stratify patients based on suspected primary/secondary headaches and the need for pain treatment. Initial assessments, performed by the triage nurse, aim to first exclude potentially high morbidity and mortality etiologies (HEAD1 scale) and then expedite appropriate pain management (HEAD2 scale) based on scoring criteria. HEAD1 evaluates vital signs and symptoms of secondary serious headache disorders that can most benefit from earlier identification and treatment, while HEAD2 assesses symptoms indicative of status migrainosus, pain intensity, and vital signs. Subsequently, ER physicians employ a third assessment that reviews red flags for secondary headaches (grouped under the acronym 'PEACE') to guide the selection of complementary tests and aid diagnosis. The Code Headache protocol is a much needed tool to facilitate quick clinical assessment and improve patient care in the ER. Further validation through comparison with standard clinical practice is warranted.