Tertiary Referral Center In India Research Articles

Survival analysis after radical Whipple’s Pancreatoduodenectomy (PD) in a tertiary referral centre in India, potential benefits of complete resection of the mesouncinate and mesentery of proximal jejunum

Survival analysis after radical Whipple’s Pancreatoduodenectomy (PD) in a tertiary referral centre in India, potential benefits of complete resection of the mesouncinate and mesentery of proximal jejunum

P-152 Attrition rates in multiple myeloma and factors influencing patient dropouts at a tertiary referral center in India

P-152 Attrition rates in multiple myeloma and factors influencing patient dropouts at a tertiary referral center in India

Cytomegalovirus Reactivation as a Risk Factor for All-Cause Mortality in Children Undergoing Hematopoietic Stem Cell Transplantation: Experience Over Two Decades from a Tertiary Referral Center in India.

The aim of the study was to analyse the burden of cytomegalovirus (CMV) disease in children undergoing hematopoietic stem cell transplantation (HSCT) and its correlation with all-cause mortality. We performed a retrospective study in children up to 18years of age who underwent allogeneic HSCT between February 2002 to December 2021 in the pediatric blood and marrow transplantation unit. A total of 1035 patients were included where five hundred forty-three (52.4%) patients underwent matched family donor (MFD) HSCT, 213 (20.5%) underwent matched unrelated donor (MUD) HSCT; 279 (26.9%) underwent haploidentical HSCT (T cell replete in 213 and T cell depleted in 66 patients). CMV reactivation was documented in 258 (24.9% patients). CMV was seen in 39 (7.2%) MFD, 77 (36.1%) MUD, 106T cell replete (49.7%) and 36T cell depleted (54.5%) transplants. CMV reactivation was predominantly documented in those where donor and recipient were positive (D + /R +) for CMV serostatus (77%)) prior to HSCT. Overall mortality rate was significantly higher in the CMV positive group (103/258, 39.9%), as compared to the CMV negative group (152/777, 19.6%) (p value = 0.0001). CMV was the direct cause of death in 13/1035 children (1.2%). GvHD as a cause of death was found to be significantly higher among those with CMV (n = 32) as compared to those without CMV (n = 14) (35.6 versus 9%, p value = 0.0001). The incidence of CMV reactivation was noted in 25% of HSCT recipients, and predominantly in haploidentical HSCTs. CMV reactivation was shown to significantly impact all-cause mortality and there was a significantly increased risk of mortality due to GvHD among those with CMV reactivation.

Mortality, morbidity and sequelae of COVID-associated mucormycosis; 18 months follow up study

Background: The second wave of the COVID-19 pandemic in India was associated with an increased incidence of rhino-orbital-cerebral mucormycosis. The objective of this paper was to prospectively explore the epidemiology, management, and results of 18 months follow-up of patients presenting with COVID associated mucormycosis at a tertiary referral centre in India. Methods: Patients presenting with symptoms suggestive of COVID-associated mucormycosis over two months were included in the study. Patients were staged based on the extent of the disease. Surgery was the primary modality of treatment except in those with intracranial spread, altered sensorium, and poor prognosis. A combination of liposomal amphotericin B and posaconazole was used as adjunct medical treatment. Patients were followed up and outcomes at one year of treatment were recorded. Results: Out of a total of 26 patients who were diagnosed with COVID associated mucormycosis, 21 patients underwent bimodality treatment (medical and surgical). The extent of surgery was based on the stage of the disease. Six eyes received retrobulbar injections of Amphotericin B to salvage vision. The overall mortality was 38.46% and 23.8% in those where the intent of treatment was curative. At the end of one year, 16 of 21 operated patients survived with mild to severe sequelae. Conclusions: Mucormycosis is a deadly fungal infection with high mortality. Early diagnosis and prompt, aggressive treatment is paramount in preventing mortality. A multidisciplinary approach is useful for effective management. Continuous follow up is paramount to identifying and treating complications.

Excellent outcomes in haematopoietic stem cell transplantation for children with inborn error of immunity – Experience from tertiary referral centre in India

Excellent outcomes in haematopoietic stem cell transplantation for children with inborn error of immunity – Experience from tertiary referral centre in India

An audit of institutional ethics committee queries raised after initial project submission by a single research department at a tertiary referral center in India.

The institutional ethics committees (IECs) raise queries following protocol reviews. The quality of these queries would be a useful metric to assess how well the IEC executes its fundamental role of protecting participants. Queries received after the initial review and replies sent by a single research department were evaluated. A content analysis was done to identify the domains and categories of queries. We categorized these queries as administrative, ethics related, and scientific. The impact of each query in improving the science or safeguarding the rights and safety of research participants (ethics) was evaluated by two authors of this manuscript: one affiliated and the other nonaffiliated to the institute. Kappa statistics were used to evaluate for agreement between the two. A total of 13 studies (investigator-initiated studies [IISs]: 7 and pharmaceutical industry-sponsored studies [PSSs]: 6) formed the final sample size for analysis. The total number of queries was 364 (IIS: 106 and PSS: 258; P < 0.001). With regard to the categories, we found n = 42 (11.54%) to be irrelevant at that stage of the review process; n = 51 (14.01%) were about information already available which the IEC had missed; n = 67 (18.41%) queries where the IEC needed paraphrasing; n = 50 (13.74%) were entirely relevant with the need for further clarification; and n = 154 (42.31%) had been missed by the investigator during the initial submission. The overall agreement between the affiliated and unaffiliated investigators was just 12.9% (P < 0.001). We found that approximately 25% of the queries raised by the IEC were redundant. It is our opinion that this redundancy could have been channeled into greater focus on scientific and ethical aspects of the protocol. Ongoing dialog between investigators and ethics committees may help address this. Perspectives between the affiliated and the unaffiliated investigators with regard to the relevance of queries were grossly different.

Tacrolimus as rescue therapy for steroid-dependent/steroid-refractory ulcerative colitis: Experience from tertiary referral center in India

Tacrolimus as rescue therapy for steroid-dependent/steroid-refractory ulcerative colitis: Experience from tertiary referral center in India

Demographic and Clinical Profile of Women Attending Genetic Clinic for Prenatal Invasive Testing at a Tertiary Referral Center, India

Background The Prenatal Invasive Tests (PIT) are used during pregnancy for the detection of genetic anomalies. Studies addressing the profile of women who come to seek prenatal invasive testing are scarce.&#x0D; Objective To assess the socio-demographic characteristics and clinical profile of women who are referred for prenatal invasive testing in a tertiary referral center in India.&#x0D; Method A descriptive, cross-sectional study was undertaken in 60 women who came to the genetic clinic at a tertiary referral center, New Delhi, India following counseling regarding prenatal invasive testing. Data was collected using a self-developed and validated semi-structured questionnaire, administered after the counseling for the test by the counselor. Data were analyzed using mean, percentage, standard deviation and range.&#x0D; Result The majority of the women were from urban residences and all of them were literate. Nearly half of the women were in the age group 21-30 years. Mean gestational age was 19.24 ± 2.63 weeks and most were pregnant for the second time. The main reasons for referral were advanced maternal age and abnormal obstetric ultrasonography. The participant’s understanding of the test was still incomplete despite the counseling and there was a need for additional counseling/information. One-third of them preferred additional counseling whereas, the remaining twothirds preferred booklets and pamphlets.&#x0D; Conclusion The profiles of pregnant women referred to genetic clinic provide better insight about their background for the health personnel and this study emphasizes rechecking the understanding regarding invasive tests following counseling; which eventually helps for appropriate decision making regarding the tests.

Round window versus conventional bony cochleostomy technique in pediatric cochlear implantation; A Randomized controlled double blinded trial.

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Objective of the study was to investigate the outcomes of cochlear implantation when done via two different techniques namely, the round window or the bony cochleostomy.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A single-center, double-blinded randomized controlled trial including forty prelingual, bilateral severe to profoundly deaf children less than six years from the year 2014 to 2016 in a tertiary referral center in India were randomly allocated to round window and bony cochleostomy group. Our primary outcome measures were intraoperative neural response telemetry levels, behavioral threshold (t) and comfortable (c) loudness levels. The secondary subjective outcomes were measured via the category of auditory performance (CAP) and the meaningful auditory integration scale (MAIS) score. The cases were followed up for 9 months.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; Intra-operative, electrically evoked compound action potentials (ECAP) showed comparable mean thresholds for both the techniques except intermediate electrodes (p~0.04) showed lower values for the round window. Similarly, a lower threshold (p~0.03) and comfortable mean current levels (p~0.03) were noticed for the round window group at 6 months post-implantation. Secondary speech perception outcome scores measured via category of auditory performance (CAP) and MAIS score were comparable. &lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The round window insertion technique has physiological benefit as compared to the bony cochleostomy as evidenced by better stimulation levels in the intermediate electrodes and lower mean threshold and comfortable levels in the round window with more beneficial peri-modiolar position of electrode arrays. However, comparable speech perception outcomes revealed no clinical benefit in the cochlear implant performance depending on the technique of electrode insertion. &lt;/p&gt;

Prenatal Invasive Testing at a Tertiary Referral Center in India: A Report of 433 Cases Under a Single Operator.

Chromosomal aneuploidies are major causes of perinatal death and childhood handicap. Awareness about screening and prenatal diagnosis for these disorders among obstetricians and primary care physicians is increasing. Since invasive tests like amniocentesis or chorionic villus sampling (CVS) are associated with a risk of miscarriage these tests should be carried out judiciously in pregnancies considered to be at high risk for aneuploidies and other genetic disorders. The purpose of our study was to examine the patterns, trends and outcomes of the various screening procedures and invasive tests results. Retrospective observational study done over a period of 3years and one month including 433 pregnant women with high risk for genetic disorders undergoing invasive prenatal testing like chorionic villus sampling, amniocentesis or cordocentesis. Data were collected from our department records regarding the maternal age, indication for invasive testing, past obstetric history, family history of genetic syndromes, ultrasound findings in the current sonographic examination and the results of the tests done. Any immediate or late complications of the procedure if any were telephonically addressed. A total of 436 procedures on 433 patients (418 singleton,12 single fetus of twin, 3 both fetuses of twins) were done out of which 281 were amniocentesis(64.4%), 153 were chorionic villus sampling (35.1%) and 2 were cordocentesis(< 1%). Of the 436 procedures, 373(85.5%) were done for positive screening tests for chromosomal aneuploidies and 63(14.4%) were done for previous history of genetic syndromes. The positive predictive value of biochemical marker alone was around 2.7% and higher around 13% for a combined first trimester or a second-trimester screen along with ultrasound abnormalities. The higher the biochemical risk does not translate into higher chance of chromosomal abnormality. Nineteen percentage of fetuses with NT above 95th centile had chromosomal abnormality. Twenty-one percentage of fetuses with absent nasal bone in our study had trisomy 21. Aneuploidy screening is the most common indication for prenatal invasive testing with dual marker combined with nuchal translucency, nasal bone, tricuspid regurgitation and ductus venosus flow providing the best detection rates. The chance of an affected fetus in a patient with aneuploidy screen positive overall is only 6.7%.

Acute pancreatitis: predictors of mortality, pancreatic necrosis and intervention.

Several predictive scoring systems are used in the prognostication of acute pancreatitis (AP). However, the quantity of evidence of these prognostic systems in the Indian population remains sparse. The aim of our study was to evaluate the usefulness of such prognostic scores to predict mortality, incidence of pancreatic necrosis and intervention in AP. This was an observational study of patients diagnosed with AP between June 2012 and November 2013 in a tertiary referral center in India. Vital signs, biochemical tests and CT-findings were recorded to identify SIRS, Ranson's score and CT-severity index at diagnosis. Chi square test was used to compare incidence of mortality, pancreatic necrosis, and intervention between mild versus severe acute pancreatitis groups. A total of 100 patients with AP were treated during out study period. Ranson's score more than 7 and presence of pancreatic necrosis were significantly associated with increased mortality (p <0.05). SIRS, CTSI score more than 7, inotropic support, and complications were more frequently associated with patients with necrosis. Prophylactic antibiotics did not decrease mortality, but decreased intervention rate (p <0.05). Presence of systemic inflammatory response syndrome (SIRS), Ranson's score > 7, necrosis, inotropic support and presence of complications were associated with a greater rate of interventions including surgery and percutaneous procedures (p <0.05). We validate SIRS, Ranson's, and CTSI score as prognostic markers for AP in the Indian population. These predictors, when used in combination, can direct early monitoring and aggressive management in order to decrease mortality associated with severe AP.

IVC filters - Indications for placement and retrieval trends– experience from a tertiary referral centre in India type of submission- full paper

ObjectivesThere is wide variation in the practice of IVC filter placement and retrievals. We conducted a retrospective study to identify the trends in placement and retrievals of IVC filters in a tertiary referral centre in India. MethodsThe data of patients obtained from our hospital records, in whom IVC filter was placed between 2010 and 2018, were analysed for demographics, indications for placement of IVC filter, underlying comorbidities, characteristics of the filters as well as the retrieval rates. ResultsIVC filters were placed in 50 patients, and data was retrieved for 31 patients (mean - 51.24 years, 67.74% males). According to ACCP/AHA guidelines, 24 (77.42%) had an absolute indication for IVC filter. All 31 IVC filters were temporary, 23 (74.19%) of which were placed via femoral access. 29(93.55%) patients had infrarenal IVC filter placement. The average tilt at deployment was 3.71°, whereas it was 5.3° at retrieval. There were no periprocedural complications or filter migrations during placement or retrieval. Retrieval was attempted in 11 (35.48%) patients and was successful in 10. The mean indwelling time in this group was 158.55 days (range 55–366 days). ConclusionOur study reveals low IVC filter implantation rates which are predominantly for absolute rather than relative indications. Though in sync with the worldwide trend, the poor retrieval rates reflect the urgent need for better patient and physician awareness. Periodic follow up is imperative to improve the IVC filter retrieval rate and to prevent complication rates.

Survival analysis after whipple's pancreaticoduodenectomy for adenocarcinoma in a tertiary referral centre in India

Introduction: Prognosis for Pancreatic Cancer remains poor despite advances in multimodality treatment. This study aims to determine the survival of patients undergoing pancreaticoduodenectomy (PD) for adenocarcinoma and also to compare the survival outcomes between standard PD versus with the addition of total mesopancreatic excision(TMpE). Methods: Retrospective analysis of prospectively compiled data of patients who underwent PD for adenocarcinoma between 2003 - 2017. Results: The median disease-free survival (DFS) and overall survival (OS) was 30(20 - 39months) and 39 months(30 - 47 months) respectively(N=239). With the addition of TMpE, median DFS was 45months(26 - 49 months) (p- 0.045) and OS was 48 months(28 - 67 months) (0.109). The difference in DFS was statistically significant while there was a trend towards increased OS, however it was not statistically significant. LN yield also increased significantly after addition of TMpE (p - 0.009). On univariate analysis, margin positivity, higher stage of the disease, presence of positive LN, lymphovascular and perineural invasion decreased OS/DFS significantly. Adjuvant chemotherapy increased DFS/OS. Only 1 patient (N-277) had margin positivity since TMpE. On multivariate analysis adjuvant chemotherapy, LN positivity, perineural invasion and higher stage were significantly associated. Patients with tumours arising from pancreas had worst prognosis (p - 0.006) and with tumours from ampulla had best prognosis. Postoperative mortality was 1.08%(N-3), less than all published series from India. Conclusion: Our study shows better OS and DFS compared to published literature. Survival improved with the addition of TMpE. Radical surgery remains a cornerstone in the multimodality treatment of pancreatic cancer.

Attitude of women and their husbands regarding prenatal invasive testing attending genetic clinic at a tertiary referral center, India

Introduction: Prenatal Invasive Tests (amniocentesis and chorionic villous sampling) are used during pregnancy for detection of genetic anomalies. Due to the fear of fetal loss or various other reasons, the couples who seek to avail these tests areusually in dilemma though the chances of fetal loss following the invasive tests are very minimal.&#x0D; Objectives: To assess the attitude ofhigh-risk pregnantwomen and their husbands regarding the prenatal invasive tests who are referred to the genetic clinic of a tertiary referral center in India.&#x0D; Methodology: A descriptive, cross sectionalstudy was undertaken in 60 pregnantwomen who came to genetic clinic at a tertiary referral center in Indiafor counseling on the prenatal invasive testing. Conveniencesampling technique was used. Data was collected using a self-developed, validated semi structured questionnaire. There were total 14 items in the questionnaire where the response “Yes” was given score 3, “Uncertain/did not think about it” was given score 2 and “No” was given score 1. Maximum score was 42 and minimum was 14. The subjects were contacted by the principal investigator after the counseling for test was done by the trained counselor. The questionnaire was also administered separately to 49 accompanying husbands to assess their attitude regarding the tests. Mean, percentage, standard deviation, range and Pearson’s correlation were calculated.SPSS 16.0 version was used for data analysis.&#x0D; Results: Almost half of the women reported that they had adequate information regarding the test following counselling. Both the women and their husbands had unfavorable attitude towards the tests i.e. 21.98 ± 5.44 and 22.27 ± 5.11 respectively despite adequate information following counselling. The main reasons for declining the tests were fear of identification of birth defects, fear of termination of pregnancy and influence by other family membersother than their husbands. There was a significant positive correlation between the attitude of women and their husbands towards declining the prenatal invasive tests (r=0.973) at p&lt;0.05.&#x0D; Conclusion: The pregnant women as well as their husbands had unfavorable attitudes towards prenatal invasive tests despite adequate information following counsellingsuggesting congruency indecision makingregarding the invasive tests.

Impact of bariatric surgery on carotid intima-medial thickness and cardiovascular risk: results of a prospective study

The impact of bariatric surgery on atherosclerosis is a relatively less studied subject. Obesity has been identified as an independent risk factor for cardiovascular disease (CVD). Carotid intima-media thickness (CIMT), a surrogate marker for atherosclerosis and risk of CVD, has been found to be associated with obesity. Recent literature has shown that there is significant reduction in CIMT following bariatric surgery. The aim of this study was to evaluate the impact of bariatric surgery on CIMT and risk of CVD in an Indian population. This is a prospective study conducted in a tertiary referral centre in India. Patients undergoing bariatric surgery from December 2017 to September 2019 were included. CIMT measurements and American College of Cardiology/American Heart Association (ACC/AHA)-pooled cohort CVD risk scores were done before and at 6months and 12months after surgery. Fifty-four patients were enrolled, of which 70% were females. Mean age was 40.8 ± 10.7years. Mean pre-operative weight and mean BMI were 115.2 ± 21.9kg and 45.9 ± 6.5kg/m2, respectively. Patients who completed 12-month follow-up were considered for analysis of outcomes. There was significant reduction in BMI to 33.1 ± 5.7kg/m2 at 12months after surgery (p < 0.0001). Mean CIMT reduced significantly from 0.58 ± 0.08mm at baseline to 0.52 ± 0.10mm at 12months. Lipid profile, fasting blood sugar and HbA1C also improved, which resulted in reduction of lifetime and 10-year CVD risk from 42.3 to 26% and 4 to 1.5%, respectively, at 12months after surgery. Bariatric surgery results in significant reduction in CIMT and CVD risk in patients with morbid obesity.

S0585 Unsedated Transnasal Endoscopy at a Tertiary Referral Center in India: Experience With 440 Patients

S0585 Unsedated Transnasal Endoscopy at a Tertiary Referral Center in India: Experience With 440 Patients

Pulmonary tuberculosis masquerading as coronavirus disease 2019 in an HIV-infected individual with advanced immune suppression

Pulmonary tuberculosis masquerading as coronavirus disease 2019 in an HIV-infected individual with advanced immune suppression

Fabry disease in India: A multicenter study of the clinical and mutation spectrum in 54 patients.

Fabry disease (FD) is a treatable X linked lysosomal storage disorder with a wide phenotypic spectrum. There is a scarcity of published data on the burden of FD in India. This study evaluates the clinical and molecular spectrum of Indian patients with FD. In this multicentric study involving 10 tertiary referral centers in India, we analyzed the clinical course and genotype of 54 patients from 37 families. Family screening identified 19 new patients (35%) from 12 index cases. Then, 33 GLA gene variants were identified in 49/54 (90.7%) which included 11 novel and 22 known pathogenic variants. Of the 54 patients in our cohort, 40 patients had “classical” and 10 patients had a “nonclassical” presentation. The symptoms and signs included kidney dysfunction in 38/54 (70.3%), neuropathic pain in 34/54 (62.9%), left ventricular hypertrophy in 22/49 (44.8%) and stroke in 5/54 (9.2%). Female heterozygotes were 10/54 (18.5%) of whom 2 were index cases. There was a significant delay in reaching the diagnosis of 11.7 years. Enzyme replacement therapy was initiated in 28/54 (51.8%) patients with significant improvement of neuropathic pain and gastrointestinal symptoms. This study highlights the clinical presentation and mutational spectrum of FD in India and suggests that family screening and screening of high‐risk groups (hypertrophic cardiomyopathy, idiopathic chronic renal failure and cryptogenic stroke) could be the most cost‐effective strategies for early identification of FD.

Retroperitoneal Sarcomas: Prognostic Factors and Outcomes of a Series of Patients Treated at a Single Institution.

Retroperitoneal sarcomas (RPS) are rare heterogeneous tumors arising in the retroperitoneum with unique biological and behavioral patterns that are thought to be closely linked to histology. The aim of the study was to audit our results and analyze various clinico-pathological factors including surgical excision, histology, and their implications on the recurrences and survival outcomes in RPS. Retrospective analysis of patients treated at a tertiary referral center in India from March 2008 to July 2017 was performed. The clinico-pathological variables were analyzed for their association with tumor recurrence and survival with special emphasis on histological subtype. The primary outcome was overall survival (OS). One hundred consecutive patients operated for RPS were analyzed. Of these, 27 were operated for recurrent tumors. Liposarcomas (LPS) and leiomyosarcomas (LMS) constituted 50% (n = 50) and 30% (n = 30) of patients respectively. Complete tumor excision was achieved in 83%, with 43% patients undergoing adjacent organ resection. At a median follow-up of 25.3months, the median disease-free survival (DFS) and overall survival (OS) were 30months and 87.8months respectively. On multivariate analysis, tumor grade was the only factor to significantly affect survival (p = 0.001 for DFS and 0.005 for OS). There was no difference in survival outcomes between infiltrative and adhesive tumors with respect to adjacent organ invasion (p = 0.361 for OS). Tumor grade remains an important prognostic factor affecting disease-free and overall survival in retroperitoneal sarcomas irrespective of tumor size, site, and histology.

Clinical manifestations and outcomes of ocular syphilis in Asian Indian population: Analysis of cases presenting to a tertiary referral center.

Purpose:To describe disease manifestations and outcomes of ocular syphilis in Asian Indian population.Methods:Retrospective analysis of patients diagnosed with ocular syphilis at a tertiary referral center in India. Demographics, history, extraocular and ocular manifestations, ocular and systemic investigations, treatment and visual acuity outcomes were noted. All patients were diagnosed after necessary laboratory investigations including HIV ELISA (Human immunodeficiency virus, enzyme-linked immunosorbent assay), VDRL (venereal disease research laboratory), and TPHA (treponema pallidum hemagglutination).Results:Totally, 20 patients with mean age at presentation 38.25 ± 9.76 were analyzed. 9/20 patients had bilateral involvement. 8/20 had concurrent HIV at presentation with an average CD4 counts of 592.25 ± 411.34 cells/microliter. The mean duration of symptoms at time of presentation was 15.45 ± 35.15 weeks. VDRL test was reactive in 45% (9/20) patients whereas, all patients had a reactive TPHA test. Clinical manifestations included outer retinal placoid chorioretinitis lesions (8/20, 40%), followed by retinitis mimicking acute retinal necrosis as the second most common phenotype (4/20, 20%). Other presenting manifestations noted were panuveitis, miliary retinitis lesions, retinal vasculitis, intermediate uveitis, and anterior uveitis. The clinical phenotypes in immunocompromised included panuveitis, acute retinal necrosis and isolated anterior uveitis. Mean follow up duration was 6.32 ± 6.15 months. An improvement in mean best corrected visual acuity (BCVA) of (0.63 LogMAR, approximately 6 Snellen lines, P < 0.02) was noted at last follow-up.Conclusion:Phenotypic manifestations of ocular syphilis are varied. Non-treponemal tests like VDRL may be unreliable when compared with treponemal tests in diagnosing ocular syphilis. Syphilitic uveitis is considered equivalent to neurosyphilis and is treated similar to neurosyphilis.