A Comparative Study of Acute Invasive Fungal Sinusitis During the First and Second Waves of the COVID-19 Pandemic.

We aimed to compare the demography, clinical profile, histopathology, fungal culture, radiology, surgery performed, medical therapy and outcomes of patients with acute invasive fungal sinusitis seen during the first and second waves of the COVID-19 pandemic by retrospectively reviewing their case records. Of 238 patients, 43(18.1%) presented during the first wave and 195(81.9%) during the second wave. Patients seen during the first wave were older (p = 0.04) and more likely to have visual impairment (p = 0.004), frozen eye (p = 0.012), altered sensorium (p = 0.007) and stage 3 disease (p = 0.03). Those seen during the second wave were more often COVID-19 positive and had newly diagnosed diabetes mellitus (p = 0.04)and stage 1 disease (p = 0.03). Most patients had a positive culture for Rhizopus species during both waves. Histopathology showed broad aseptate hyphae in all patients but angioinvasion was seen more often during the first wave (p = 0.04). The majority of patients were treated with endoscopic+/- open debridement followed by intravenous amphotericin B and oral posaconazole. While the overall survival rate was similar (first wave 65.1%; second wave 79%; p = 0.106), mortality after discharge was greater during the first wave (11.6% vs 1.5%; p = 0.001). Mortality was higher in patients with stage 3 disease (p = 0.003). Significant differences in clinical presentation, histopathology, radiological stage of disease and post-discharge survival were noted between the two waves of the COVID-19 pandemic, the causes for which were multi-factorial.

Myofibroblast and pro-fibrotic cytokines in fibrosis of IgG4-related disease (IgG4-RD) patients from South Asia: preliminary data.

INTRODUCTION: Fibrosis is a typical pathological characteristic in IgG4-RD patients and often irreversible. There exists a lack of suitable markers for detection of earlier onset of fibrosis in various organs in IgG4-RD patients. Hence, this study aims at analysing ambispectively the myofibroblasts and the pro-fibrotic cytokines, IFN gamma and IL-33 involved in IgG4-RD associated fibrosis in South Asian patients. METHOD: Archived biopsy samples of definite/probable/possible cases of IgG4-RD, classified according to diagnostic criteria, taken from patients who attended the OPD and IPD of our tertiary care centre during January 2015-January 2020 were chosen for this study. The paraffin sections were examined qualitatively for fibrosis and the excessive collagen deposition by Hematoxylin & Eosin and Masson's Trichrome staining. Also, the presence of alpha-Smooth muscle actin (α-SMA) expressing myofibroblasts and the involvement of pro-fibrotic cytokines (IFN-gamma, IL-33) were assessed by Immunohistochemistry and scored semi-quantitatively (+mild, ++moderate, +++ severe). Serum IL-33 levels were analysed by indirect Elisa (R & D Systems). RESULTS: Myofibroblasts were present in 10/12 biopsy samples, in moderate levels in 4 (33%) and very high levels (+++) in 3 (25%) of the patients. IFN-gamma was expressed at low levels in 6 (50%) and absent in 6 (50%). All patients showed IL-33 expression with very high levels in tissue (6, 50%), as well as in serum samples. CONCLUSION: The findings of this study reinforce the role of myofibroblasts and profibrotic cytokines like IL-33 in fibrosis of Ig4-RD patients, pointing to their potential as earlier predictive markers of onset and extent of fibrosis.

Definitive Surgery after Neoadjuvant Chemotherapy for Locally Advanced Oral Cavity Cancers: Experience from a Tertiary Care Center.

Mansi AgrawalVidya KonduruBackground Oral cavity cancers require definitive surgical resection as the primary treatment, but with advanced T stage, complete resection with pathologically negative margins might be difficult to achieve. Induction chemotherapy helps achieve the balance between resection and morbidity in locally advanced technically unresectable tumors. The aim of this study was to analyze the impact of surgery in locally advanced, technically unresectable oral cavity cancers after neoadjuvant chemotherapy (NACT). Materials and Methods A retrospective analysis of patients with borderline resectable, locally advanced oral cavity cancers who were given NACT between February 2017 and December 2021 was conducted. Data regarding clinical and pathological characteristics, NACT, surgery, adjuvant therapy, and recurrences was analyzed. Results Of the 69 patients in the study, 69.6% had tongue cancer, rest were gingivobuccal complex cancers. All tumors were resected based on the post-NACT tumor volume and clear margins were achieved in 42% of cases. About 85.4% of the tongue cancers required a lesser resection than anticipated, thereby following the concept of organ and functional preservation post-NACT as proposed by Licitra et al. About 30.4% had ypT0 and 17.4% had ypN0. Recurrence and survival rates noted in our study were comparable to those reported in literature. Lymph node density of more than or equal to 0.07 was found in all recurrent cases. Conclusions Induction chemotherapy offers a chance of achieving adequate surgical resection while reducing morbidity and improving functional outcomes for patients with technically unresectable oral cavity cancers. Nodal disease may not respond to chemotherapy as well as the primary tumor. There is a need for comprehensive evaluation of prognostic factors, which could help identify the patients who will most benefit with NACT.

Evaluation of Deoxyribonucleic Acid Damage Using Neutral Comet Assay for High Radiation Doses: A Feasibility Study.

Purpose: This study aims to investigate the use of the neutral comet assay to assess deoxyribonucleic acid (DNA) damage in lymphocytes exposed to high doses of radiation. Materials and Methods: The research was conducted by obtaining informed consent, after which blood samples were taken from seven healthy individuals and this study was approved by the institutional ethics committee. At first, for the determination of dose-effect curves, samples obtained from the first five individuals were irradiated for doses ranging from 0 to 35 Gy after which they were processed under neutral comet assay. In order to verify the determined dose-effect curves, a test dose of 15 Gy was delivered to the samples obtained from the sixth and seventh individuals. The amount of DNA damage from the obtained comet assay images was analyzed using four comet assay parameters namely % tail DNA, tail length, tail moment (TM), and Olive TM (OTM). The most suitable comet assay parameter was evaluated based on the obtained dose-effect curves. Furthermore, the distribution of individual cells for each dose point was evaluated for all the four comet assay parameters to find the optimal parameter. Results: From our results, it was found that from 0 to 25 Gy all the four comet assay parameters fit well into a linear quadratic curve and above 25 Gy saturation was observed. Based on the individual cell distribution data, it was found that % tail DNA could be an optimal choice to evaluate DNA damage while using neutral comet assay for high-dose ionizing radiation. Conclusion: The neutral comet assay could be a potential tool to assess DNA damage from high doses of ionizing radiation greater than 5 Gy.

Bacterial infection-related glomerulonephritis in patients with diabetes.

AIM: Diabetic patients are prone to infections, thus making them a unique cohort at risk of developing bacterial infection-related glomerulonephritis (IRGN). METHODS: In total, 1693 adult diabetic patients underwent kidney biopsy between 2005 and 2021 at our tertiary care hospital in South India. Of these, 121 consecutive cases which met criteria of bacterial IRGN were included in this study. RESULTS: The mean age of the cohort was 53.1 ± 10.1 years and 83/121 (68.5%) were males. Majority (98.3%) had type 2 diabetes for a median duration of 6 (IQR, 2-12) years. The most common sites of infection were skin (47/121, 38.8%) and urinary tract (15/121, 12.4%). Fifty percent (58/121) of patients had underlying advanced diabetic kidney disease (DKD). Isolated C3 deposits (without immunoglobulin) occurred in 66/121 (54.5%) patients predominantly in advanced DKD patients. IgA-dominant glomerulonephritis occurred in only 9/121 (7.4%) patients. Short-course oral steroid was given to 86/121 (71.1%) patients. Steroid related dysglycemia and immunosuppression related infections occurred in 9/61 (14.8%) and 16/61 (26.2%) patients respectively. Of the 90 patients with follow up details >3 months, 46 (51.1%) progressed to kidney failure over a median period of 0.5 (IQR, 0-7.2) months. Patients diagnosed in the latter half of our study period (2013-2021) were older, less commonly presented with fever, had more pronounced hypocomplementemia and severe renal histology predominantly with a 'starry sky' immunofluorescence pattern. CONCLUSION: Superimposed bacterial IRGN on underlying DKD is associated with poor renal outcomes. Use of short course steroid was associated with significant toxicity.

Patterns of Renal Dysfunction and Profile of Kidney Biopsies in Hematopoietic Stem Cell Transplant Recipients.

Introduction: Post hematopoietic stem cell transplant (HSCT), kidney can be subjected to injury by various causes. Of these, graft versus host disease (GvHD) affecting the kidney is an under-recognized entity with no clear guidelines on its diagnosis, clinicopathological manifestations, and outcomes. Material and Methods: Out of 2,930 patients who underwent HSCT at our center between 2005 and 2020, kidney biopsy was performed in 19 allogenic and 5 autologous recipients. Results: The mean age of the cohort at transplant was 33.2 ± 7 years, and 15 (62%) were males. Median time to kidney biopsy from HSCT was 14 (IQR, 9-30) months. Aplastic anemia was the most common underlying hematological disease (54.2%). All 19 allogenic recipients were classified based on clinicopathological manifestations into either thrombotic microangiopathy (TMA, 12/19 [63%]) or nephrotic syndrome (NS, 7/19 [37%]) pattern. Glomerular tuft "mesangiolysis" was the dominant pattern of injury noted in 9/12 cases of TMA pattern. There was a predominance of acute microangiopathic changes restricted primarily to the glomerular compartment. Of the 7 patients with NS pattern, membranous nephropathy was seen in 4 (57%) and minimal change disease in 3 (43%) patients. Thirty-nine percent (7/18) stained positive for C4d which was predominantly glomerular. Allogenic recipients who did not receive immunosuppression (IS) for renal disease had a lower eGFR at biopsy, a longer latency between withdrawal of GvHD prophylaxis and biopsy, and were significantly at a higher risk of kidney failure (IS: 2/11, 18.1% vs. no IS: 2/6, 33.3%, p = 0.04). "Associated extra-renal GvHD" occurred in 11/19 (57.9%) allogenic recipients. Patients with "associated extra-renal GvHD" had significantly more deaths (6/11, 60% vs. 0, p = 0.02) but comparable renal outcomes. Conclusion: Renal GvHD can present with or without "associated extra-renal GvHD" after a prolonged period of withdrawal of GvHD prophylaxis, requiring careful diagnostic vigilance and consideration of IS.

Adding Ketamine to Epidural Morphine Does Not Prolong Postoperative Analgesia After Lumbar Laminectomy or Discectomy.

BACKGROUND: Epidural opioids provide effective postoperative analgesia after lumbar spine surgery. Ketamine has been shown to reduce opioid-induced central sensitization and hyperalgesia. We hypothesized that adding ketamine to epidural opioids would prolong the duration of analgesia and enhance analgesic efficacy after lumbar spine surgery. METHODS: American Society of Anesthesiologists physical status class I to II patients aged between 18 and 70 years with normal renal function undergoing lumbar laminectomy were recruited into this single-center randomized trial. Patients were randomized to receive either single-dose epidural morphine (group A) or epidural morphine and ketamine (group B) for postoperative analgesia. The primary objective was to compare the duration of analgesia as measured by time to the first postoperative analgesic request. Secondary objectives were the comparison of pain scores at rest and movement, systemic hemodynamics, and the incidence of side effects during the first 24 hours after surgery. RESULTS: Fifty patients were recruited (25 in each group), of which data from 48 were available for analysis. The mean±SD duration of analgesia was 20±6 and 23±3 hours in group A and group B, respectively (P=0.07). There were 12/24 (50%) patients in group A and 17/24 (71%) patients in group B who did not receive rescue analgesia during the first 24-hour postoperative period (P=0.07). Pain scores at rest and movement, systemic hemodynamics, and postoperative complications were comparable between the groups. CONCLUSIONS: The addition of ketamine to epidural morphine did not prolong the duration of analgesia after lumbar laminectomy.

A longitudinal study of sexual health and quality of life in endometrial carcinoma survivors.

OBJECTIVES: This study aimed to assess sexual health and quality of life (QoL) in endometrial cancer survivors and the factors influencing these variables. METHODS: A mixed method design comprising quantitative (cohort design) and qualitative (face-to-face interviews) aspects was chosen. A total of 132 patients who underwent surgery alone, surgery followed by adjuvant vaginal brachytherapy, or surgery followed by chemotherapy and radiation were included. Female Sexual Function Index (FSFI) and Functional Assessment of Cancer Therapy General (FACT-G) questionnaires were used to assess the participants' sexual health and QoL at 6 months and 1 year post-treatment. Multivariate logistic regression models were used to analyze the factors associated with general and sexual well-being. RESULTS: At 1 year, 89% of the participants still had low sexual function scores. Survivors over 50 years (OR 284.7, 95% CI 13 to 364, p<0.001) and educated below graduate level (OR 26.8, 95% CI 2 to 370, p=0.014) had low sexual function scores. Patients who had surgery alone had better QoL than those who received adjuvant radiation. Women who had surgery, chemotherapy, and radiation had the lowest QoL scores (OR 6.4, 95% CI 2.1 to 19.5, p=0.001). All scores improved with time. CONCLUSIONS: This study demonstrated the high prevalence of low sexual function and poor QoL in endometrial cancer survivors. There was a communication gap between the women and their partners as well as their healthcare providers. This study highlights the need for discussion about the survivors' sexual well-being and QoL.

The outcomes of surgical treatment for lateral Hoffa fracture nonunions.

INTRODUCTION: Lateral Hoffa nonunion are rare injuries. A significant percentage of these nonunions are due to missed acute lateral Hoffa fractures. Operative management of these injuries is difficult and complicated by the presence of bone loss, infection, and soft-tissue contractures. In this study, the aim was to assess clinical and functional outcome in our group of patients with lateral Hoffa nonunion who had undergone operative management and to determine whether variables such as fracture type, infection, and previous surgery affect nonunion/complication rates. MATERIALS AND METHODS: Data were analyzed for patients with lateral Hoffa nonunion who underwent surgical fixation from January 2008 to December 2020 at a tertiary-care referral center. Patients with lateral condyle Hoffa nonunion and having a minimal follow-up of 1 year were included in this study. Patients with medial Hoffa nonunion, pathological fractures, and children aged less than 16 years were excluded from the study. The fractures were classified by the AO/OTA and Letenneur classification systems. Clinical and functional outcomes were assessed by the Knee society score (KSS) and the lower extremity functional scale (LEFS). RESULTS: All the 12 patients had united in our series. One patient had reduction failure at 3 months who united after re-fixation. The union rate in our patients was 100%, with a loss of reduction rate of 7.7%, and post-traumatic arthrosis of 7.7%. The average follow-up period was 52.16 ± 27.7 months. The mean knee flexion obtained at the final follow-up was 104.5° (80°-130°). The average KSS clinical score was 80.6 (65-88). The average KSS functional score was 92 (70-100). The average LEFS score was 71 (47-79). There is a statistically significant improvement in the knee range of motion in our patients (p = 0.001). However, no correlation could be detected between variables like type of fracture, infection, and previous surgeries and outcomes. CONCLUSIONS: Lateral Hoffa nonunion can be managed with careful planning of surgical approaches and fixation techniques.

The Utility of COMPASS-31 Questionnaire to Predict Autonomic Dysfunction in Patients With Cervical/Upper Thoracic Compressive Myelopathy.

BACKGROUND: Patients with cervical/upper thoracic compressive myelopathy may have autonomic dysfunction. The composite autonomic severity score (CASS) is the gold standard test to detect autonomic dysfunction, and the self-rated composite autonomic system scale (COMPASS-31) questionnaire is a screening tool to diagnose autonomic dysfunction. This study compared the COMPASS-31 and modified CASS scores for the detection of autonomic dysfunction in patients with compressive myelopathy. METHODS: Patients with cervical/upper thoracic compressive myelopathy scheduled for decompressive surgery completed a COMPASS-31 questionnaire and underwent autonomic function tests to calculate the modified CASS score before surgery. RESULTS: Forty-two patients were included in the study; 19 (45.2%) had mild autonomic dysfunction, 5 (11.9%) had moderate autonomic dysfunction, and 18 (42.9%) had severe autonomic dysfunction. Median (interquartile range) of modified CASS and COMPASS-31 scores were 19 (6.33) and 3 (2.5), respectively. There was a positive correlation between modified CASS and COMPASS-31 scores ( r =0.43; P =0.004). Receiver operating characteristic curve analysis confirmed that COMPASS-31 had fair accuracy for prediction of moderate to severe autonomic dysfunction (area under the curve, 0.74; 95% confidence interval, 0.64-0.82; P =0.009). A cut-off of 30 for total COMPASS-31 score had a sensitivity of 52.2% and specificity of 89.5% to detect moderate to severe autonomic dysfunction, with positive and negative predictive values of 85.7% and 60.7%, respectively. CONCLUSION: Patients with cervical/upper thoracic compressive myelopathy had varying degrees of autonomic dysfunction based on the modified CASS. There was a positive correlation between the modified CASS and COMPASS-31 questionnaire. A COMPASS-31 score of >30 30 could be utilized to predict moderate to severe autonomic dysfunction in patients with compressive myelopathy.

Effect of Long-Term Embryo Cryopreservation on Subsequent Frozen Embryo Transfer Outcomes: A Retrospective Cohort Study.

Background: The duration of cryopreservation of embryos and its effect on the subsequent pregnancy outcomes, when they have been frozen for a longer duration remains a matter of concern. There is a continuous debate among studies comparing different durations of embryo cryopreservation as the results are contradictory. Aims: This study aims to find out if long-term cryopreservation of embryos has any effect on pregnancy and perinatal outcomes. Settings and Design: :Retrospective cohort study was conducted in the department of reproductive medicine and surgery in a university-level teaching hospital. Materials and Methods: The study included women who underwent frozen embryo transfer (FET) from autologous in vitro fertilisation between January 2012 and December 2020 with the duration of cryopreservation of more than 5 years as one group and 3-5 years as another group. Pregnancy and perinatal outcomes were analysed. Statistical Analysis Used: Regression analysis was performed using logistic regression by entering clinically important variables associated with pregnancy outcome, and the results were expressed as odds ratio with a 95% confidence interval (CI). All statistical analysis was performed with SPSS (version 21.0, IBM, USA). Results: A total of 1680 FET cycles were carried out during the study period. Among these, 75 cycles with a duration of 3-5 years and 20 cycles with a duration of more than 5 years were included. Live birth rate (LBR) was 40.8% in the 3-5 years group and 35% in the more than 5 years group. After adjusting for important confounders, the LBR has no significant association in the more than 5 years group (adjusted odds ratio 1.07; 95% CI 0.34-3.32; P = 0.913) compared to the 3-5 years group. Conclusion: The duration of cryopreservation of embryos has no statistically significant effect on the pregnancy and perinatal outcomes.

Long-Term Outcomes and Prognostic Factors Affecting Survival after Pulmonary Metastasectomy in Solid Tumors of Childhood: A Single Center Experience.

Introduction: This study assessed the long-term survival and the prognostic variables affecting survival following pulmonary metastasectomy (PM) secondary to childhood solid tumors. Materials and Methods: A retrospective analysis was done on 22 children who underwent PM for solid tumors between January 2007 and February 2020. The overall survival (OS) and event-free survival (EFS) at the end of the study period were noted. Tumor histology, completeness of resection, disease-free interval, laterality, location, number, and size of lung nodules were assessed for their significance in contributing to survival. Results: High-grade osteosarcoma (54.5%), followed by Wilms' tumor (18.2%), was the most common histological types. Unilateral nodules (59.1%) situated in a peripheral, sub-pleural location (91%) were the most common presentation. Pleural extension was noted in 12 (54.5%) patients. Synchronous pulmonary metastases were noted in 12 (54.5%) patients. Two developed metastases while undergoing chemotherapy and eight after the completion of therapy. The EFS and OS were both 31.8% at a median follow-up of 15.5 months (range 3-129 months). The median time required for an event to occur was 4 months (95% confidence interval [CI]: 1.4, 6.6 months) and median post-PM survival interval was 17 months (95% CI: 6.6, 27.4 months). Significant association was noted between preoperative tumor response to chemotherapy (P = 0.002) and survival. Conclusion: PM can improve survival in a select group of children with metastatic solid tumors. Favorable tumor response to chemotherapy was found to be a significant prognostic factors influencing survival.

Customized cost-effective polymethylmethacrylate cranioplasty: a cosmetic comparison with other low-cost methods of cranioplasty.

BACKGROUND: Intraoperative hand-moulded cranioplasty and polymethylmethacrylate (PMMA) prostheses made from bone impressions are economical but the cosmetic results are less than satisfactory. Commercially available customized prostheses perform better but are prohibitively expensive. We evaluate the performance of a locally developed, low-cost customized PMMA cranioplasty prosthesis. OBJECTIVE: To compare the cosmetic outcome of 3 types of PMMA cranioplasty as well as with objective measurements on postoperative CT scans METHODS: This study includes 70 patients who underwent cranioplasty between March 2016 and June 2020. In this period, patients had their cranioplasty prostheses made by intra-operative hand moulding (HM), by using the removed bone as a template and making a bone impression (BI) or by 3D printing the prosthesis based on a CT scan. Cosmetic outcomes were assessed by the patient and the operating surgeon on an 8-point scale. The degree of measured anthropometric asymmetry was measured on a postoperative CT scan and correlated with the cosmetic outcome. RESULTS: Our locally produced 3D-printed cranioplasty prostheses showed a statistically better performance in cosmetic scores when compared to the HM and BI (p value < 0.001). CT anthropometric measurements significantly correlated with cosmetic outcome (p value 0.01) CONCLUSION: Our 3D cranioplasty prostheses had better cosmetic outcomes than HM and BI prostheses, and our technique is able to produce them at 10% of the cost of the currently available commercial customized prostheses.

Prognostic significance of MR identified EMVI, tumour deposits, mesorectal nodes and pelvic side wall disease in locally advanced rectal cancer.

AIM: To study the prognostic significance of MRI identified tumour deposits (TD), extramural vascular invasion (EMVI), lymph node metastases (LNM) and pelvic sidewall (PSW) disease in rectal cancer. METHODS: This IRB approved study was conducted on patients with stage IIA-IIIC rectal adenocarcinoma treated with neoadjuvant long course chemoradiotherapy (LCCRT) and total mesorectal excision (TME) type of surgery between 2012-2018. A radiologist blinded to outcome reviewed staging and restaging magnetic resonance imaging (MRI) for TD, EMVI, LNM and PSW. The agreement between four radiologists was studied and we obtained outcome data from a prospectively maintained database. The prognostic significance of imaging findings was assessed. RESULTS: A total of 297 (186 males) patients with a mean age of 47.3 (SD14.4) years were included in the study. The majority had T3 (n = 206) or T4 (n = 59) stage disease. The mean duration of follow-up was 49.3 ± 25 months (6.6-101 months). 5-year overall (OS) and disease-free survival (DFS) was 84% and 74%, respectively. Staging and restaging MRI had EMVI in 49.5% and 31.3%; TD in 47.5% and 31.6%; LNM in 61.1% and 38.1% and PSW in 11.4% and 6.1%. OS was adversely affected by EMVI, TD and PSW with the adjusted HR (aHR) of 3.32, 3.31, 3.27 for staging MRI and 2.99, 3.1, 2.81 for restaging MRI, respectively, p < 0.05. DFS was affected by EMVI (aHR = 1.85, 2.33) and TD (aHR = 1.83, 2.19), p < 0.05. Persistence of these findings after LCCRT led to worst outcome. Intra- and interobserver agreement for EMVI, TD and LN was 0.789, 0.734, 0.406 and 0.449, 0.354, 0.376, respectively, p < 0.001. CONCLUSIONS: MRI identified that TD, EMVI and PSW disease are independent poor prognostic indicators in rectal cancer patients. Interobserver agreement for these findings was moderate to fair.

Utility of positron emission tomography-computed tomography in the evaluation of fever of unknown origin in a resource-limited tropical nation.

Positron emission tomography-computed tomography (PET-CT) has been used as an imaging modality in workup of fever of unknown origin (FUO). The aim of our study is to evaluate the diagnostic utility of PET-CT in FUO workup in a resource-limited setting. We also looked at laboratory parameters as predictors of contributory PET-CT scans and propose an algorithm for evaluation of FUO in resource-limited tropical regions. This retrospective observational study included patients admitted for FUO workup under general medicine in a teaching hospital in South India from June 2013 to May 2016. PET-CT was done when the patient remained undiagnosed after a detailed clinical assessment and first- and second-tier investigations. Among 43 patients included in our study, a definite diagnosis was established in 74% (32). Noninfectious inflammatory diseases, infections, malignancies, and miscellaneous diseases were diagnosed in 37.2% (16/43), 23.3% (10/43), 9.3% (4/43), and 4.7% (2/43), respectively. Tuberculosis was the single most common disease seen in 20.9% (9/43). PET-CT scans were contributory toward establishment of final diagnosis in 90.7% (39/43). High C-reactive protein (CRP) and aspartate aminotransferase (AST) levels were associated with contributory PET-CT scans (P = 0.006 and 0.011, respectively). PET-CT delineating organ/tissue for diagnostic biopsy was associated with final diagnosis of infectious disease (P = 0.001). Sensitivity, specificity, and positive and negative predictive value of PET-CT scans were 76.9% (20/26), 33.3% (2/6), 83% (20/24), and 25% (2/8), respectively. High CRP and AST were predictors of contributory PET-CT scans. PET-CT scans have high sensitivity and positive predictive value when used in evaluation of FUO. Although it is a useful tool in FUO workup, especially in the diagnosis of tropical infections, PET-CT should be done after a comprehensive clinical assessment and basic investigations.

Use of an Angled Blade Plate for 31A3 Intertrochanteric Fractures.

BACKGROUND: A subgroup of pertrochanteric fractures-namely, the AO/OTA 31A3 fracture-continues to be a difficult problem to treat, even with cephalomedullary nails. We present the results for 26 patients with a 31A3 fracture treated with the angled blade plate. METHODS: The records of 26 consecutive patients with a 31A3 fracture that was treated operatively with the angled blade plate device between 2007 and 2012 at our center were reviewed, and the patients were contacted for follow-up. The functional outcome (traumatic hip rating score) and radiographic outcome (the neck-shaft angle at the time of fixation and final follow-up) were obtained for 20 of the 26 patients at a minimum follow-up of 1 year. RESULTS: All 26 patients had primary surgery. At final review, 2 patients had died and 4 had been lost to follow-up. Of the 4 patients lost to follow-up, 2 had revision of the fixation with the angled blade plate. Of the 20 patients with follow-up, 1 had malreduction and implant failure but eventually had healing after revision of the fixation with the angled blade plate. The mean traumatic hip rating score at the time of follow-up was 50.0 with 4, 14, and 2 patients having excellent, good, and failed outcomes, respectively. The mean neck-shaft angle at the time of final union was 126.16°, which was an average of 4° less than that on the unaffected side. However, this did not correlate with functional outcome. There was no significant difference between the immediate postoperative and final neck-shaft angles. CONCLUSIONS: This study demonstrated that blade plate fixation for 31A3 fractures is associated with low rates of failure (15%), revision surgery (15%), and infection (15%), which are comparable with the results of nail fixation (range, 5% to 12%) and superior to those of sliding hip screw fixation. This large series demonstrates that the angled blade plate can be utilized for these complex fractures and should be part of the armamentarium for these injuries. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Sentinel Lymph Node Biopsy in Early Breast Cancer Using Methylene Blue Dye Alone: a Safe, Simple, and Cost-Effective Procedure in Resource-Constrained Settings.

Sentinel lymph node biopsy (SLNB) is done by different techniques in clinically node-negative patients with early breast cancer. In this study, we aim to estimate the identification rates, positivity rates, cost-effectiveness, and outcomes for patients who underwent sentinel node biopsy using methylene blue dye alone. This was a retrospective review of 172 patients with early breast cancer (cT1-3, N0) who underwent SLNB using methylene blue dye alone between January 2014 and December 2018 including their follow-up details until December 2019. The mean age was 51 ± 10.3 (range: 28 to 76) years. There were 63 (36.6%) patients with cT1 tumor, 108 (62.7%) with cT2, and only 1 patient with cT3 tumor. Breast conservation surgery was performed in 62 (36%) while the remaining 110 (64%) underwent simple mastectomy. Sentinel nodes were successfully identified in 165 (95.9%) with a positivity rate of 23.6%. There was no dye-related adverse reactions intra-operatively. The mean duration of follow-up was 26.68 ± 15.9 months (range: 1-60). Chronic arm pain was present in 7 (4%) while none of the patients had lymphedema or restriction of shoulder joint motion. There were no documented axillary nodal recurrences in this cohort. Eight (4.65%) patients were detected to have systemic metastasis. One patient died of brain metastasis from bilateral breast cancer. The mean disease-free survival was 57 months (95% CI: 55-59). Sentinel lymph node biopsy using methylene dye alone is a safe, simple, and cost-effective alternative to isosulfan blue or radio isotope technique in surgical centers with resource constraints.

Complications and Outcomes of Diaphragm Surgeries in Epithelial Ovarian Malignancies.

To achieve optimal debulking, cytoreductive surgery often involves diaphragm stripping. We describe our complications and survival outcomes after diaphragm surgery in epithelial ovarian cancer. A retrospective analysis on patients with advanced stage epithelial ovarian cancer between January 2012 and September 2019. The details of the diaphragmatic resections and stripping and their complications were looked into. During the study period, 616 patients with epithelial ovarian cancers were operated of which, 81 (13.2%) had diaphragm surgery. The majority underwent diaphragm stripping (60%) while 33% had resection and 7% cases had diaphragmatic nodule excision. Optimal debulking was achieved in 89% of cases. The complexity of surgery was intermediate in 64% of patients and complex in 33% as per Aletti's scoring. Mean operating time was 300 min (SD113). Moderate to severe pleural effusion was seen in 26 (32. %) patients necessitating pleural tapping in 16% and single lumen pleurex catheter insertion in 11%. Median recurrence-free and overall survival were 22 (95% CI 16.9-27) and 32 months (95% CI 25.5-38) respectively. Diaphragm stripping and resection is an important step in achieving optimal debulking of advanced and recurrent ovarian cancer. Diaphragmatic disease clearance is a necessary skill to be acquired by the gynaecologic oncology surgeons. Choosing the patients correctly and anticipation of complications can reduce morbidity and mortality.

Composite Grip Strength as a Marker of Outcome in Patients Surgically Treated for Degenerative Cervical Myelopathy.

STUDY DESIGN: Retrospective case series. PURPOSE: This study aimed to examine the efficacy of composite grip strength as a marker of surgical outcome in patients with moderate to severe degenerative cervical myelopathy. OVERVIEW OF LITERATURE: Degenerative cervical myelopathy causes loss of dexterity, muscle strength, and sensations in the hand. The impact of surgical management on improvement in composite grip strength has received scant attention. METHODS: This retrospective study was performed on degenerative cervical myelopathy patients with a complete composite grip strength assessment between January 2013 to January 2019. The Biometrics E-link hand kit was used for the assessment. The following parameters were measured: maximum grip strength, sustained grip strength, three-jaw pinch, maximum key pinch, and sustained key pinch. The pre- and postoperative functional status was assessed using the Nurick grade and the modified Japanese Orthopaedic Association (mJOA) score. RESULTS: A total of 40 patients were included in the study. The mean patient age was 51.9 years. The mean preoperative Nurick grade was 3.5 and the mJOA score was 10.9. The anterior approach was used in 25 patients, and the posterior approach was used in 15 patients. Four patients developed complications. Degenerative cervical myelopathy resulted in decreased handgrip and pinch strength as compared to normative Indian data. There was a significant improvement in the postoperative composite grip strength for all five parameters. There was no differential improvement between the anterior and posterior surgical groups. The improvement in the composite grip strength correlated with the improvement in functional scores. CONCLUSIONS: Composite grip strength analysis is an objective method for assessing the impact of degenerative cervical myelopathy on grip strength and monitoring the postoperative improvement. Decompressive surgery resulted in global improvement in all the parameters of composite grip strength.

Comparing the efficacy of aprepitant and ondansetron for the prevention of postoperative nausea and vomiting (PONV): A double blinded, randomised control trial in patients undergoing breast and thyroid surgeries.

BACKGROUND AND AIMS: Aprepitant, a Neurokinin-1 receptor antagonist, has been evaluated in abdominal and neurosurgeries, but its effect is less clear in breast and thyroid surgeries, which are also known to be high risk for post-operative nausea and vomiting (PONV). This study was done to compare the antiemetic efficacy of ondansetron and aprepitant in women undergoing mastectomy and thyroidectomy. METHODS: One hundred and twenty-five ASA I and II, female patients, aged between 18 and 65 years were randomly assigned into Group I (ondansetron group, n = 62) or Group II (aprepitant group, n = 63), by computer-generated random sequencing. Per protocol analysis was done to assess the incidence and severity of PONV, use of rescue antiemetics, and patient satisfaction with PONV control between the two groups, till 24 h post-surgery. RESULTS: In the immediate postoperative period, 79.7% of patients in Group I and 85.2% in Group II were free of emesis (P value: 0.49). In Group I, the first episode of vomiting occurred within a median duration 90 min (IQR 2575: 45-147) postoperatively, whereas the median duration in Group II was 160 min (IQR 25-75: 26-490), with request for rescue antiemetic at 60 min in Group I (IQR 25-75: 27-360) and 147 min in Group II (IQR 25-75: 11-457). CONCLUSION: A single dose of oral aprepitant has comparable effects to injection ondansetron administered eighth hourly in preventing PONV, the severity of nausea, number of rescue antiemetics, and the time to first emetic episode in the 24-h postoperative period. CTRI REG NO: REF/2017/06/014637.