Sentinel Surveillance for Congenital Rubella Syndrome - India, 2016-2017.

Rubella infection during pregnancy can result in miscarriage, fetal death, stillbirth, or a constellation of congenital malformations known as congenital rubella syndrome (CRS). The 11 countries in the World Health Organization (WHO) South-East Asia Region are committed to the elimination of measles and control of rubella and CRS by 2020. Until 2016, when the Government of India's Ministry of Health and Family Welfare and the Indian Council of Medical Research initiated surveillance for CRS in five sentinel sites, India did not conduct systematic surveillance for CRS. During the first 8 months of surveillance, 207 patients with suspected CRS were identified. Based on clinical details and serologic investigations, 72 (34.8%) cases were classified as laboratory-confirmed CRS, four (1.9%) as congenital rubella infection, 11 (5.3%) as clinically compatible cases, and 120 (58.0%) were excluded as noncases. The experience gained during the first phase of surveillance will be useful in expanding the surveillance network, and data from the surveillance network will be used to help monitor progress toward control of rubella and CRS in India.

Comparison of Keyes Punch Biopsy Instrument with Cervical Punch Biopsy Forceps for Diagnosing Cervical Lesions.

OBJECTIVE: To assess the feasibility and efficacy of Keyes punch biopsy instrument (KP) in diagnosing cervical lesions and compare it with cervical punch biopsy forceps (CP). METHODS: 75 women having satisfactory colposcopy with abnormal transformation zone were included and paired colposcopic directed biopsies were taken using KP followed by CP from the same target area. RESULTS: It was feasible in all cases to take cervical biopsy with KP after increasing its effective length. The volume of gross specimen obtained by KP was less than CP (0.076 ± 0.097 vs. 0.101 ± 0.156 cm3, p = 0.061), however on microscopic examination, mean length and mean depth of tissue in KP was greater than CP by 0.06 mm (p = 0.810) and 0.14 mm (p = 0.634) respectively. Exact agreement was found with the final surgical specimen in 42% of cases in both the biopsy forceps. CONCLUSION: KP is almost at par with CP for diagnosing preinvasive cervical lesions and is a useful adjunct to the existing armamentarium of biopsy forceps.

Adolescent ovarian masses: A retrospective analysis.

A retrospective study was conducted to review incidence, clinical practice, surgical management and histology of adolescent ovarian masses in order to audit and improve future practices. Complete hospital records of all adolescents between 10 and 20 years who had undergone surgery for ovarian masses were analysed between November 2006 to 2014. Parameters analysed were age, clinical features, diagnosis, operative procedure and histopathology. Ninety-four patients were included in the study and among them, 37 had non-neoplastic masses, 30 had benign neoplasms while 27 had malignant tumors. The main clinical presentations were abdominal pain (54%) and abdominal mass (41%). Dermoid was the most common benign neoplasm while germ cell tumor was the most common malignant mass; dysgerminoma being the commonest (68%). Malignancy was more common in early adolescence (12 ± 4.8 years) while non-neoplastic masses were seen more frequently in late adolescence (17.7 ± 2.2 years). There was a fair correlation between ultrasound and histopathological diagnosis.

Predictors and outcome of obstetric admissions to intensive care unit: A comparative study.

This descriptive observational study was carried out in Guru Teg Bahadur Hospital to identify predictors and outcome of obstetric admission to Intensive Care Unit (ICU). Ninety consecutive pregnant patients or those up to 42 days of termination of pregnancy admitted to ICU from October 2010 to December 2011 were enrolled as study subjects with selection of a suitable comparison group. Qualitative statistics of both groups were compared using Pearson's Chi-square test and Fisher's exact test. Odds ratio was calculated for significant factors. Low socioeconomic status, duration of complaints more than 12 h, delay at intermediary facility, and peripartum hysterectomy increased probability of admission to ICU. High incidence of obstetric admissions to ICU as compared to other countries stresses on need for separate obstetric ICU. Availability of high dependency unit can decrease preload to ICU by 5%. Patients with hemorrhagic disorders and those undergoing peripartum hysterectomy need more intensive care.

Is nuchal cord justified as a cause of obstetrician anxiety?

PURPOSE: Birth asphyxia leading to acidosis comprises 20-60 % of perinatal mortality. Nuchal cord (NC) is one of the possible causes of birth asphyxia. Majority of fetuses who are antenatally detected to have nuchal cord are able to achieve successful vaginal birth. The purpose of this study was to analyze the effect of nuchal cord on fetal acid base status and perinatal outcome in vaginal deliveries. STUDY DESIGN: 150 parturients were equally divided into three groups after vaginal delivery based on no NC, single and multiple loops. Umbilical cord arterial blood was analyzed for biochemical markers i.e. pH, PO2, SPO2, PCO2, HCO3 (-), standard base excess and lactate for acidosis. Labor complications like abnormal FHR, meconium-stained liquor, prolonged second stage, instrumental vaginal delivery, third stage complications were compared. In neonates, birth weight, Apgar score ≤7 at 5 min, NICU admission and other morbidity and mortality during hospital stay were compared among groups using suitable statistical tests. Above parameters were also compared between tight and loose loops. RESULT: Nuchal cord groups had significantly higher frequency of labor complications than no NC group, especially tight loops. Neonates with NC had significantly higher frequency of meconium-stained liquor, Apgar score ≤7 at 5 min, deranged biochemical markers, NICU transfer. However, none of the neonate had pH in acidosis range and majority were discharged in healthy condition. CONCLUSION: Patients with NC are likely to have uneventful labor and delivery as cord compression is transient and most fetuses are able to compensate for reduce umbilical blood flow. Routine antenatal ultrasound scan is not advisable, as mode of delivery and labor management does not change with detection of NC antenatally. Therefore, vaginal delivery with routine labor protocol can be allowed in cases of nuchal cord.

Frequency-Specific Audit of Audiological Outcomes Following Stapedotomy for Otosclerosis.

Stapedotomy is an effective surgical intervention used for the treatment of conductive hearing loss associated with otosclerosis. The present study aims to quantitatively evaluate the hearing outcomes following primary stapedotomy performed in patients with otosclerosis. It also aims to investigate frequency-specific hearing results of stapedotomy in these patients. This retrospective study enrolled 49 patients with clinical otosclerosis, who underwent primary stapedotomy at a tertiary-care hospital, between January 2014 and December 2019. Pure-tone audiometry (PTA) was performed pre and post-operatively (> 1 year after surgery). Post-operative air conduction (AC) and bone conduction (BC) thresholds were recorded. The primary outcome measure was post-operative air-bone gap (ABG). Low frequency (LF) ABG was calculated as the mean ABG of thresholds at 0.5 and 1 kHz. High frequency (HF) ABG was calculated as the mean ABG of thresholds recorded at 2 and 4 kHz. In all the study patients, the mean post-operative AC and the mean postoperative BC thresholds, showed significant improvement across the tested frequencies of 0.5, 1, 2 and 4 kHz (P < 0.05). The mean post-operative ABG closure was superior at HF, as compared to that at LF (9.54 ± 6.30 dB vs. 12.0 ± 6.63 dB, P = 0.014). A successful surgical outcome (post-operative ABG closure to ≤ 10 dB) was achieved in 61.22% of the study patients. Further, a greater number of patients (71.45%) recorded successful surgical outcome at HF, when compared with those at LF (46.95%, P < 0.05). Favourable hearing outcomes of this study underscore the effectiveness of primary stapedotomy in the treatment of patients with clinical otosclerosis. Better postoperative ABG closure to ≤ 10 dB was recorded at higher frequencies. Further studies assessing post-stapedotomy hearing results at HF are warranted for ensuring better hearing outcomes in the HF range as well. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04126-0.

Abnormally invasive placenta: changing trends in diagnosis and management.

Trends in patient profile, clinical presentation, diagnosis, management options and outcome of abnormally invasive placenta (AIP) were retrospectively evaluated at a tertiary care centre from 2001 to 2010. AIP was diagnosed when confirmed by ultrasound or MRI, when complete manual removal of placenta was not possible or when histological confirmation was achieved in a hysterectomy specimen. The first and second halves of the time period were compared. The total number of cases was 56 and the incidence increased significantly in the second half. Main risk factors were placenta previa and previous cesarean section. Antenatal diagnosis by ultrasound was made in 72% in the second half, compared with 35% in the first half (p = 0.009). Maternal mortality was 29% in the first half and 21% in the second half. Hysterectomy was the mainstay in management; elective procedures being significantly higher in the second half.

Comparative Study of Subjective and Objective Analysis in Diagnosis of Obstructive Sleep Apnea.

The gold standard for diagnosis of Obstructive sleep apnea (OSA) is an overnight polysomnography (PSG). However, PSG is time consuming, labour intensive and expensive. In our country PSG is not available everywhere. Therefore, a simple and reliable method of identifying patients of OSA is important for its prompt diagnosis and treatment. This study looks at the efficacy of three questionnaires to serve as a screening test for the diagnosis of OSA in the Indian population. For the first time in India, a prospective study was conducted wherein patients with history of OSA underwent PSG and were asked to fill three questionnaires-Epworth Sleepiness Score (ESS), Berlin Questionnaire (BQ) and Stop Bang Questionnaire (SBQ). The scoring of these questionnaires were compared with the PSG results. SBQ had a high negative predictive value (NPV) and the probability of moderate and severe OSA steadily increases with higher SBQ scores. In comparison, ESS and BQ had low NPV. SBQ is a useful clinical tool to identify patients at high risk of OSA and can facilitate in the diagnosis of unrecognised OSA.

Sinonasal Anatomy.

It is imperative for all imaging specialists to be familiar with detailed multiplanar computed tomography imaging anatomy of the paranasal sinuses and adjacent structures. This article reviews, in brief, the radiologically relevant embryology of the sinonasal region and discusses the imaging anatomy of the nasal cavity and paranasal sinuses. Radiologists should understand the importance and clinical implications of identifying the numerous anatomic variations encountered in this region and prepare a structured report that provides a surgical road map to the referring clinician.

UNHS: A Decade Long Feasibility and Sustenance Study from a Tertiary Care Hospital in India.

Objective The aim of this study is to estimate the incidence of hearing loss in neonates at a tertiary referral center, to assess the associated risk factors in those identified with hearing loss and to explore the challenges of starting and continuing a universal neonatal hearing screening programme in a tertiary care hospital over a decade. Materials and Methods It is a cohort prospective observational study conducted from January 2008 to January 2018. Five thousand five hundred and forty neonates underwent screening for hearing loss, of which 2688 were well babies and 2854 babies had one or more risk factors causing hearing loss. Otoacoustic emissions (OAE) is employed as the first level of screening within one month of birth. Brainstem evoked response audiometry (BERA) is done at 3 months of gestational age for all the well babies who were referred on OAE testing and all the high risk babies irrespective of the result of the OAE screening. The High risk criteria are based on the set criteria by the Joint Committee on Infant Hearing (2007) and American Academy of Pediatrics (1994). Results In our study the incidence of hearing impairment is 5.41 per 1000 neonates screened. In well babies and at risk babies it is 1.49 and 9.11 per 1000 respectively.The common neonatal risk factors associated with hearing loss in our study are babies admitted to neonatal intensive care units (NICU), intrauterine growth retardation (IUGR), birth weight less than 1500 g, respiratory distress syndrome (RDS) and hyperbilirubinemia. Conclusion The incidence of hearing loss in our study is comparable to that reported in literature (Bachmann KR, ArvedsonJC (1998) Early identification and intervention for children who are hearing impaired. Pediatr Rev. 1998 May; Vol. 19. No.5. pp. 155-165. http://www.ncbi.nlm.nih.gov/pubmed/9584525 Accessed from May 1998, Nagapoornima P, Ramesh A, Srilakshmi, Rao S, Patricia PL, Gore M, et al. Universal hearing screening. Indian J Pediatr. 2007 Jun 18; 74(6):545-9., Augustine AM, Jana AK, Kuruvilla KA, Danda S, Lepcha A, Ebenezer J, et al. (2014) Neonatal hearing screening-experience from a tertiary care hospital in southern India. Indian Pediatr. Vol. 51. No.3. pp 179-183. http://www.ncbi.nlm.nih.gov/pubmed/24277966 Accessed from Mar 2014). Hearing loss is more common in those babies with risk factors as reported in literature (Nagapoornima P, Ramesh A, Srilakshmi, Rao S, Patricia PL, Gore M, et al. Universal hearing screening. Indian J Pediatr. 2007 Jun 18; 74(6):545-9. http://www.ncbi.nlm.nih.gov/pubmed/21654001 Paul AK (2011) Early identification of hearing loss and centralized newborn hearing screening facility-the Cochin experience. Indian Pediatr. Vol. 48. No. 5. pp 355-359. Accessed from May 2011). Implementation of neonatal hearing screening program at a tertiary care hospital using a two tier system with OAE and BERA is a feasible but challenging service.

Cochlear Implant Surgery During the Covid Pandemic Lockdown-The KEM Hospital, Pune Experience.

In response to the Covid 19 pandemic many governments and professional bodies recommended cancellation of elective surgeries including cochlear implantation. Resumption of elective surgeries was recommended after appropriate permissions were given by the authorities and the hospital had adequate infrastructure in terms of equipment and manpower to start elective surgeries without compromising on patient safety and care. We began cochlear implant surgeries in April 2020. We have done 5 cochlear implants surgeries till date. This manuscript discusses the changes that we did in our preoperative, intraoperative and postoperative protocol.

A Proposed Grading System and Experience of COVID-19 Associated Rhino Orbito Cerebral Mucormycosis from an Indian Tertiary Care Center.

Mucormycosis is an opportunistic fungal infection. India faced an unprecedented increase in patients with post coronavirus disease 2019 (COVID-19) associated rhino-orbito-cerebral mucormycosis (ROCM). This study proposes a grading system which correlates the extent of the disease with the management plan. An observational study was conducted January 2021-June 2021. We identified 65 patients. Eleven patients had mild disease, 27 patients had moderate, 16 patients were severe and 11 patients were graded as very severe. The management was planned based on this grading system. Early diagnosis, aggressive surgical debridement and antifungal drug therapy is the key to improve survival in ROCM. Procedures such as endoscopic orbital clearance, sublabial maxillectomy, and modified endoscopic Denkers (MED) approach facilitate access and surgical debridement. The new grading system proposed assists in planning the approach and extent of surgical debridement.

Dysuria: don't take it lightly.

Dysuria is a very common symptom, which is taken lightly. It can lead to a diagnosis of disseminated Koch's, which if identified early can prevent permanent sequelae.

Endocervicoscopy with Office Hysteroscope for Complete Visualization of Transformation Zone in Cases of Invisible Squamocolumnar Junction on Colposcopy.

Aim: To evaluate the role of endocervicoscopy for the visualization of the T3 transformation zone (TZ) on colposcopy. Materials and Methods: Forty patients with either abnormal Pap smear or positive VIA-VILI and T3 TZ on colposcopy were recruited from the colposcopy clinic and subjected to endocervicoscopy with a 4-mm office hysteroscope. The view of the endocervical canal was recorded before and after the application of 5% acetic acid and the squamocolumnar junction was identified in its entirety. An endocervical curettage was taken in all the cases and compared with the final histopathology report. Results: Squamocolumnar junction was visible in all the 40 cases; however, in two patients (5%), cervical dilatation had to be done. The positive predictive value (PPV) of endocervicoscopy in our study was 33.3% and negative predictive value (NPV) was 100%. Dense acetowhitening/irregular polypoidal endocervical mucosa with dilated blood vessels was significant in predicting the premalignant and malignant lesions with PPV of 67% and NPV of 100%. Conclusion: Endocervicoscopy allows a panoramic view of the endocervical canal. It is a safe, effective, and feasible technique for visualization of squamocolumnar junction with 5% acetic acid in cases of T3 TZ on colposcopy.

Deossification of the Otic Bone in High Pressure CSF Otorhinorrhea: A New Radiological Finding.

To highlight a new radiological feature in a patient with labyrinthine malformation presenting with bilateral spontaneous high pressure cerebrospinal fluid (CSF) otorhinorrhea. Study design-retrospective case review. Setting-academic, tertiary cochlear implant center. A cochlear implantee with Incomplete Partition Defect (Type 1) presented with meningitis and CSF otorhinorrhea for which she initially underwent medical treatment. High resolution computed tomography (HRCT) of the temporal bone with CT cisternography was performed for identifying the site of the CSF leak. HRCT and CT cisternography revealed a defect in the region of the stapes foot plate and marked thinning/deossification of the cochlear promontory. These two findings were absent in the pre-implant imaging of the patient done 3 years ago. Surgery by endaural approach was undertaken to close the site of CSF leak. Intraoperatively, marked thinning of the cochlear promontory was observed, corresponding to 'blue lining' of the labyrinth in otologic surgery. This intraoperative finding indicating high intralabyrinthine CSF pressure correlated well with the imaging findings. Primary surgical repair resulted in successful CSF leak closure followed by theco-peritoneal shunting to prevent recurrence of the leak. The patient is using her cochlear implant and doing well with auditory verbal therapy. She is asymptomatic till date. Thinning and deossification of the otic capsule on HRCT is an important indicator of high CSF pressure in patients with labyrinthine malformations. Our case study highlights the need for heightened radiological and clinical vigilance in this subgroup of patients to predict complications and ensure prompt intervention.

Epidemiology of Congenital Rubella Syndrome (CRS) in India, 2016-18, based on data from sentinel surveillance.

BACKGROUND: Government of India is committed to eliminate measles and control rubella/congenital rubella syndrome (CRS) by 2020. In 2016, CRS surveillance was established in five sentinel sites. We analyzed surveillance data to describe the epidemiology of CRS in India. METHODOLOGY/PRINCIPAL FINDINGS: We used case definitions adapted from the WHO-recommended standards for CRS surveillance. Suspected patients underwent complete clinical examination including cardiovascular system, ophthalmic examination and assessment for hearing impairment. Sera were tested for presence of IgM and IgG antibodies against rubella. Of the 645 suspected CRS patients enrolled during two years, 137 (21.2%) were classified as laboratory confirmed CRS and 8 (1.2%) as congenital rubella infection. The median age of laboratory confirmed CRS infants was 3 months. Common clinical features among laboratory confirmed CRS patients included structural heart defects in 108 (78.8%), one or more eye signs (cataract, glaucoma, pigmentary retinopathy) in 82 (59.9%) and hearing impairment in 51. (38.6%) Thirty-three (24.1%) laboratory confirmed CRS patients died over a period of 2 years. Surveillance met the quality indicators in terms of adequacy of investigation, adequacy of sample collection for serological diagnosis as well as virological confirmation. CONCLUSIONS/SIGNIFICANCE: About one fifth suspected CRS patients were laboratory confirmed, indicating significance of rubella as a persistent public health problem in India. Continued surveillance will generate data to monitor the progress made by the rubella control program in the country.

Low-dose mifepristone in treatment of uterine leiomyoma: a randomised double-blind placebo-controlled clinical trial.

AIMS: To evaluate the effect of low-dose mifepristone on leiomyoma-related symptoms, uterine and leiomyoma in women with symptomatic leiomyomata. METHODS: In a double-blind placebo-controlled trial, 40 patients with symptomatic leiomyoma and normal endometrial histology were randomised to receive 10 mg mifepristone (group 1) or placebo (group 2) daily for three months. Leiomyoma-related symptoms, uterine, leiomyoma and largest leiomyoma volumes were assessed at baseline and every month for three months. Endometrial biopsy was repeated at the end of therapy. RESULTS: Significant change was noticed between the two groups for mean menstrual blood loss (MBL) by first month. Menstrual blood loss declined by 94.8% in group 1 at three months and 84.2% patients attained amenorrhoea in this group. In group 1 complete relief of dysmenorrhoea occurred in significant number of women (80%) but only 33% patients got rid of pelvic pain. There was no change in these symptoms in group 1 Backache, urinary complaints and dyspareunia were not relieved in either group. Uterine, leiomyoma and largest leiomyoma volume declined by 26-32% in group 1 as compared to none in group 2, and this difference was statistically significant only by the end of the third month of therapy. Mean haemoglobin increased from 9.5 to 11.2 g/dL in group 1. In group 1, at the end of therapy, 63.1% of patients had endometrial hyperplasia without atypia. CONCLUSIONS: Ten milligrams mifepristone for three months is effective in reducing MBL, increasing haemoglobin and reducing uterine and leiomyoma volume with side-effect of endometrial hyperplasia.

Pattern of severe maternal morbidity in a tertiary hospital of Delhi, India: a pilot study.

Severe maternal morbidity also known as 'near miss' may be a good indicator of the quality and effectiveness of obstetric care, as it may identify priorities in maternal care more rapidly than mortality alone. The objective of the study was to observe the pattern of severe maternal morbidity and its associated factors in a tertiary care hospital in Delhi. All patients admitted to the obstetrics and gynaecology department who fulfilled the definition of severe maternal morbidity conditions were included. A proforma was used to record sociodemographic, obstetric, antenatal care treatment and outcome details. A total of 63 women were included for analysis. The incidence of severe maternal morbidity was 3.3/100 deliveries. The mean age of the patients was 26.3 +/- 5 years. More than half (55.5%) were uneducated: almost one-third (32%) were from outside Delhi - the median distance travelled was 10 km. The majority were antenatal admissions (68.3%). The proportion of postdelivery or abortion cases were greater among women who came from outside Delhi. Only 38.1% were registered during the antenatal period. The diagnoses were: eclampsia/pre-eclampsia (35%); haemorrhage (35%); sepsis (13%); obstructed labour (9.5%) and other medical conditions (11%). Severe anaemia was observed in 22% of cases. Only 43.5% were normal vaginal deliveries and 54.5% were delivered by caesarean section or with the use of instruments; 61.3% were live births. Hysterectomy was performed in 14.8%: the proportion of hysterectomy was higher in obstructed labour. Severe maternal morbidity cases constitute a significant burden on health resources.