A Study of Adverse Effects Following Administration of Anti-Rabies Vaccination - A Hospital Based Study

Rabies is an acute viral zoonotic disease that affects all warm-blooded animals including mammals and occurs in more than 150 countries and territories. Although rabies is a 100% fatal disease, it can be pre-vented by the use of potent anti-rabies vaccines (ARV). The present study was a hospital based descrip-tive longitudinal study conducted during February 2019 to July 2020 amongst the animal bite patients attending the Anti -Rabies clinic (ARC) of Vardhman Mahavir Medical College and Safdarjung Hospital (VMMC & SJH), New Delhi, to study the adverse events (vaccine reactions) if any following administra-tion of the ARV. The age of the study participants ranged from 2 to 65 years and the mean age was (29.315.2) years. No severe or serious adverse events were reported. Of the minor reactions, the most commonly reported symptom was pain at the injection site (34; 9.4%) followed by occurrence of tingling sensation (29; 8.1%), headache (22; 6.1%) and itching at the injection site (19; 5.3%). These findings corroborate with those found in previous studies in the literature. It was concluded that although there are possible local or mild or systemic adverse reactions to rabies vaccination, but once initiated, rabies prophylaxis should not be interrupted or discontinued.

Raising cut-off value of prostate specific antigen (PSA) for biopsy in symptomatic men in India to reduce unnecessary biopsy.

Background & objectives: The characteristics of prostate specific antigen (PSA) for trans-rectal ultrasonography guided prostate biopsy in men with lower urinary tract symptoms (LUTS) are not well defined. This study was carried out to analyse the threshold of PSA for biopsy in symptomatic men in India. Methods: From January 2000 to June 2011, consecutive patients who had digital rectal examination (DRE) and PSA testing done for LUTS were included in this study. PSA was done with ELISA technique. Patients with acute or chronic prostatitis, prostatic abscess, history of surgery on prostate within the previous three months and patients on 5α-reductase inhibitors or on urethral catheter were excluded. Results: Of the 4702 patients evaluated, 70.9 per cent had PSA of less than 4 ng/ml and 29.1 per cent had PSA of more than 4 ng/ml. Of these, 875 men with a mean age of 65.72±7.4 (range 50-75 yr) had trans rectal ultrasonography (TRUS) guided biopsy. Twenty five men had biopsy at PSA level of <4 ng/ml due to positive DRE, 263 at 4.1-10ng/ml, 156 at 10.1-20 ng/ml and 431 at >20 ng/ml. Positive predictive value of PSA in ranges of 4.1-10, 10.1-20, >20 ng/ml was 15.2, 24 and 62.6 per cent, respectively with negative DRE. PSA cut-off to do biopsy was derived by ROC curve as 5.82 ng/ml for all the men. When the subjects were further stratified on the basis of DRE findings, a cut-off of 5.4 ng/ml was derived in men with normal DRE. Interpretation & conclusions: A cut-off for biopsy in symptomatic men with negative DRE could safely be raised to 5.4 ng/ml, which could avoid subjecting 10 per cent of men to undergo unnecessary biopsy.

Role of neoadjuvant concurrent chemoradiation in locally advanced unresectable pancreatic cancer: A feasibility study at tertiary care centre.

BACKGROUND: Pancreatic cancer has an extremely poor prognosis and prolonged survival is achieved only by resection with macroscopic tumor clearance. There is a strong rationale for a neoadjuvant approach, since a relevant percentage of pancreatic cancer patients present with non‑metastatic but locally advanced disease. The objective of the present study was to assess the effect of neoadjuvant chemoradiation therapy (NACRT) on tumor response, down staging and resection, toxicity and any survival advantage. MATERIALS AND METHODS: A prospective pilot study was carried out from January 2009 to June 2011 in which 15 patients of locally advanced unresectable pancreatic cancer were included. All patients were treated with NACRT protocol with oral Capecitabine and 3D conformal radiotherapy (3DCRT) of 30 Gy in 10 fractions. The patients were restaged 3 to 4 weeks after the completion of NACRT and explored for resection. RESULTS: Out of 15 patients, fourteen were evaluable. Four patients underwent surgery, 5 had partial response but remained unresectable, 2 patients had stable disease and 3 had progressive disease. Most of the toxicities were slight and were in grade 1 to 2. None of the patients developed grade 3 or 4 gastrointestinal or hematological toxicity. The median survival was 15 months for resected patients and 8.6 months for unresected patients, respectively. The 2 year actuarial overall survival was 34.6%. CONCLUSION: All patients with locally unresectable pancreatic cancer should be offered chemoradiation therapy, in hopes of down staging the tumor for possible resection and achieving higher survival.

Spectrum of malignancies in Jaipur region (2004‑2008).

CONTEXT: Cancer data from Rajasthan is limited. Only three studies, one from Western Rajasthan, and the other two from Eastern Rajasthan have been published previously. AIMS: To find out the spectrum of malignant neoplasms in Jaipur region by studying the proportion and site wise distribution of malignancy cases reported at five major hospitals and pathology centers in Jaipur region. SETTINGS AND DESIGN: A retrospective analysis of histopathology records of 5 years (2004-2008) was done. Approximately 200,000 histopathology and cytology reports were analyzed and 34,486 new cancer cases were identified. STATISTICAL ANALYSIS USED: Percentages and proportions. RESULTS: A total of 34,486 new cases of cancers were recorded in five years. There were 58.58% (20202) males and 41.42% (14284) females, with the male to female ratio being 1.41:1. Organ wise, Lung (13.25%), Larynx (5.35%), Oropharynx (5.09%), Brain (4.84%), Tongue (4.62%) and Prostate (4%) were the most common sites involved in males, whereas Breast (25.6%), Cervix (10.26%), Ovary (5.4%), Brain (3.68%), Esophagus (3.4%), Lung (3.01%) and Gall Bladder (2.35%) were common sites for malignancies in females. CONCLUSIONS: Significant findings were, a higher frequency of tobacco related cancers i.e., Lung cancer and Head and neck cancer in males, and screening detectable cancers (Breast and Cervix) in females. A higher frequency of Lung cancer in females was also noted as compared to previous studies. An unusually high frequency of Gall Bladder Cancers especially among the female population in this region is also a cause of concern. Our data was compared with the national data.

Port site metastasis after laparoscopic radical nephrectomy: A single-center experience.

Objective: To assess the incidence and review the probable etiologies of port site recurrence in patients undergoing laparoscopic radical nephrectomy. Materials and Methods: One hundred thirty-six patients undergoing laparoscopic surgeries for renal malignancy, including 133 radical nephrectomies and 3 partial nephrectomies, from December 1999 to December 2008 at our institution were followed up for a median period of 59 months (12-120 months). Of the procedures, 121 were performed by transperitoneal, 5 by retroperitoneal and 10 by combined approach (retroperitoneal renal artery clipping followed by transperitoneal nephrectomy). Formal lymphadenectomy was not performed. Postoperative surveillance after radical nephrectomy included history and physical examination with blood tests 3-6 monthly, chest X-ray yearly and abdominal contrast-enhanced computed tomography (CECT) 1-2 yearly. The development of port site recurrence was diagnosed by physical examination, CECT and pathological findings. Results: Conversion to open surgery was done in 33 patients. Two (1.47% overall) port site recurrences were observed, both after radical nephrectomies done for renal masses with clinical stages T2N0M0 and TIN0M0. The pathological staging in the two were T2N1M0 Fuhrman's Grade III and T3aN1M0 Grade III, respectively. Conclusion: Our results report that laparoscopic approach does not necessarily increase the risk of port site recurrence, provided the cases are carefully chosen, principles of oncologic surgery are followed, and conditions that increase the risk of port site metastasis are avoided.

Does extended lymph node dissection affect the lymph node density and survival after radical cystectomy.

Background : Diagnostic and therapeutic importance of pelvic lymph node (LN) dissection (PLND) in radical cystectomy (RC) has gained recent attention. A method of pathological analysis of LN affects total number of LN removed, number of LN involved, and LN density. Objective : To compare extended lymphadenectomy to standard lymphadenectomy in terms of LN yield, density, and effect on survival. Materials and Methods : From Jan 2004 - July 2009, 78 patients underwent RC whose complete histopathological report was available for analysis. All were transitional cell carcinoma. From July 2007 onward extended LN dissection was started and LNs were sent in six packets. Twenty-eight patients of standard PLND kept in group I. Group II had 23 patients of standard PLND (LN sent in four packets), and group III had 23 patients of extended PLND (LN sent in six packets). SPSS 15 software used for statistical calculation. Results : Distribution of T-stage among three groups is not statistically significant. Median number of LN harvested were 5 (range, 1-25) in group I, 9 (range, 3-28) in group II, and 16 (range, 1-25) in group III. Although this is significant, we did not find significant difference in number of positive LN harvested. We did not find any patient with skip metastasis to common iliac LN in group 3. Conclusions : Separate package LN evaluation significantly increased the total number of LN harvested without increasing the number of positive LN and survival.

KCNJ11 activating mutation in an indian family with remitting and relapsing diabetes.

Objective. To identify the genetic cause of transient neonatal diabetes mellitus in three siblings from an Indian family. Methods. Case reports with clinical and molecular evaluation of an activating mutation in the KCNJ11 gene are presented. We describe an Indian family with two asymptomatic parents with 3 children presenting with hyperglycemia at 6, 1.5 and 1 month of age respectively. Blood glucose levels at presentation were 22.2, 18.3 and 20 mmol/L and the diabetes remitted in all three children by 5 years of age. None of the affected siblings had dysmorphism or neurological abnormalities. Diabetes relapsed in the oldest sibling at 9.4 years of age and she is now euglycemic on 1mg/Kg of Glibenclamide twice a day. Results. A novel heterozygous missense mutation (G53V) in the KCNJ11 gene was identified in all 3 affected children and the father. Conclusions. The report suggests that screening for KCNJ11 mutations is appropriate in patients diagnosed with neonatal diabetes as it provides valuable information concerning possible course of the disease and choice of treatment.

Impact of delay in inguinal lymph node dissection in patients with carcinoma of penis.

Aim: To study the impact of delay in inguinal lymph node dissection (LND) in patients with squamous cell carcinoma of the penis, who have indications for LND at the time of presentation. Materials and Methods: In total, 28 patients (mean age 52.1 ± 12.8 years) with squamous cell carcinoma of the penis, treated from January 2000 to June 2008, were retrospectively studied with regard to clinical presentation, time of LND, and the outcome. The patients were divided into two groups based on the time for LND. Group 1 patients had LND at mean of 1.7 months (range 0-6 months) of treatment of the primary lesion, and group 2 had LND at a mean of 14 months (range 7-24 months) after treatment of the primary lesion. Statistical Analysis: The statistical analysis of survival was done using the Kaplan-Meier method and the Log Rank test, with p < 0.05 considered to be statistically significant. The Mann-Whitney test and Fisher's exact test were used for univariate comparison. Results: Twenty-three of the 28 patients had inguinal LND. In group 1, of 13 patients, 12 were alive, with no recurrence of disease at a mean follow-up of 37 months (8-84) months. In group 2, only two patients were alive and disease-free, at a mean follow-up of 58 months (33-84 months). The five-year cancer-specific survival rates for early and delayed LND were 91 and 13%, respectively, (p = 0.007). Conclusions: When compliance with follow-up is suspect, patients with high grade or T stage (greater than T1) tumor are better treated by inguinal LND during the same hospital admission or within two months of primary treatment.

Radiation Schedules for Palliation in Carcinoma Esophagus.

This study was undertaken to compare the three different radiation schedules for their efficacy in symptom relief, dysphagia free survival and radiation morbidity (if any), in carcinoma oesophagus. A total of 116 inoperable patients were prospectively randomized to three different arms of radiation. Arm-A received external beam radiation (EBRT) to a dose of 30Gy/10 #/2 weeks along with two sessions of intraluminal brachytherapy (ILBT), 600cGy each, one week apart, after a gap of two weeks from EBRT. Arm-B received only EBRT to a dose of 30Gy/10 #/2 weeks. Arm-C received EBRT to a dose of 20Gy/5#/1week without brachytherapy. The age of the patients ranged from 30 - 70 years. Improvement in dysphagia was seen in 76% of patients in Arm-A, 56% in Arm-B & 54% in Arm-C at 1 month. The dysphagia progression free survival was 10.6+0.6 months in Arm-A, 9.8+0.8 months in Arm-B and 9.9+0.6 months in Arm-C respectively. Grade 1 & 2 acute radiation toxicity was seen in 50% of patients in Arm-A, 55% patients in Arm-B & 30% patients in Arm-C. It is concluded that all the three radiation schedules achieved good palliation with similar dysphagia free survival.

Evidence for non-HFE linked hemochromatosis in Asian Indians.

BACKGROUND: Hereditary hemochromatosis is commonly due to two HFE1 (Histone Family E1) gene mutations - H63D and C282Y. Mutations in the Asian Indians are less well studied. AIMS: The aim of this preliminary study was to find out the prevalence of HFE gene mutations in nonviral liver cirrhosis patients. SETTINGS AND DESIGN: Unexplained liver cirrhosis cases with transferrin saturation> 45%, attending the gastroenterology clinic in the years 2004 and 2005 were subjects of the prospective study. Asymptomatic individuals with negative family history of hemolytic anemia or liver disease served as controls. MATERIALS AND METHODS: The clinical presentation was recorded in the patients. Transferrin saturation was estimated by standard colorimetric technique. The two common mutations in HFE1 gene and Y250X mutation of TFR (transferrin receptor) gene were studied by polymerase chain reaction based methods. RESULTS: A majority of the cases were sporadic, but family history was positive in four patients. In one family with multiple affected members, there was clear evidence of autosomal dominant inheritance. Seven out of 31 (22.6%) of unexplained cirrhosis cases were positive for mutations. One was homozygous for H63D. In healthy controls, prevalence was 8.1% (6/74). None of the patients or controls was positive for C282Y mutation of HFE1 or Y250X of TFR gene. CONCLUSIONS: Thus, in a number of cases of hemochromatosis in Indians, a gene with dominant inheritance may be involved in causation of the phenotype. The prevalence of HFE mutations in Indians is comparable to that reported from neighboring countries. It is worth studying other mutations in HFE gene and other iron overload genes in cryptogenic cirrhosis cases.

Clinical Spectrum and Prognosis of Multiple Myeloma in Patients Younger than 30 Years : Is it Different from the Elderly

Multiple Myeloma (MM) is a disease of the elderly. The occurrence of MM in patients younger than thirty years is rare. Over the last ten years five patients with MM of less than thirty years of age were evaluated at our centre and which constituted 3.3% of all the MM cases. Three patients had initial extramedullary involvement. All patients responded to the initial planned therapy and were clinically disease free at the time of last follow-up. In the background of clinical and laboratory features, a brief review of literature was carried out and the prognosis of this subgroup has been discussed.

Paraneoplastic leukocytoclastic vasculitis in chronic lymphoid leukemia.

A 50-year-old female who was a known case of chronic lymphoid leukemia (CLL) developed ecchymoses, purpuric spots with papules, some nodules (1-3 mm) and crusts all over the body associated with severe burning and itching along with exaggeration of CLL. The lesions were more prominent on lower limbs and face. Skin biopsy was reported as leukocytoclastic vasculitis. These lesions regressed after treatment with leukeran and glucocorticoids.

Management and Outcome of Thymoma: A Retrospective Analysis

Thymoma is a rare disease. The treatment of invasive thymoma remains controversial. To evaluate the outcome of thymoma we reviewed aseven years [1996-2002] experience with 26 patients at PGIMER Chandigarh. It constituated about 16% of all mediastinal tumours in our institutions. All the patients had surgical intervention and diagnosis was made on pathologicalstudy. Post-operative staging was made on mordified Masoaka staging system. Out of 26 patients, six were with stage-1, 5 with stage- 2, 7 with stage-3 and 8 with stage 4. The pathological classification included 6 lymphocytic predominant,12 epitheloid and 8 mixed lymphoepitheloid histology. Myasthenia gravis was associated with 12 patients. Ten patients had complete surgical resection, 7 had incomplete surgery and 9 had only biopsy. All thepatients received external beam radiation with doses ranging from 3000 Cgy to 5000 Cgy in 3 to 5 weeks with a fraction size of 180-200 Cgy. Three patients received systemic chemotherapy with multidrug platinum based regimens. The median follow up was 26.2 months. Patients who received adjuvant external radition after complete surgery did better than who had incomplete surgery or only biopsy. Overall five years survival was 56.85. Post operative radiotherapy improved locoregional controls, however clinical stage and type of surgery were the two most important prognostic factors. Role of chemotherapy needs to be further assessed.

Prognosticfactors in patients with renal cell carcinoma: is TNM (1997) staging relevant in Indian subpopulation?

BACKGROUND: RCC (Renal Cell Carcinoma) is a common genitourinary malignancy, but its behavior has not been studied in the Indian Subpopulation. AIMS: The aim of this study was to assess the validity of 1997 AJCC TNM staging in Indian subpopulation and also to identify independent predictors for survival in patients having RCC. SETTING AND DESIGN: Retrospective uncontrolled analysis of patients with RCC was performed at our centre. MATERIAL AND METHODS: Medical records of patients of undergoing radical nephrectomy at our center between 1994 to August 2003 were identified retrospectively. Medical records of 178 patients were available for analysis. Patient characteristics, preoperative imaging and surgical details were reviewed. Each tumor was staged according to the 1997 AJCC TNM classification. Nuclear grade was assigned according to the Fuhrman's grading system. STATISTICAL METHODS: Statistical analysis was performed using statistical software and descriptive statistics and survival functions were obtained. Univariate and multivariate analysis of factors affecting outcome of the patient were performed. RESULTS: Mean follow up period was 42.3 months (range 3 to 108 months). Stage wise 5-year Cancer specific survival was 87.2% in stage 1 disease, 74.3% in stage 2, 36.4% in stage 3 and 3.1% in stage 4. Univariate analysis revealed that stage, grade and lymph node status were statistically significant (P=0.009, 0.007 and 0.003 respectively). Sub-classifying stage 1 tumors between tumor of less than 4 cm. and more than 4 cm. did not reveal any statistically significant difference in survival (P=0.32). Multivariate analysis model revealed that Fuhrman's grade and lymph node status were statistically significant (P=0.007 and 0.002 respectively). CONCLUSION: This study validates the TNM (1997) staging for RCC as having significant survival impact in the Indian subpopulation. Sub-classifying stage 1 tumors between tumor of less than 4 cm. and more than 4 cm is not of much importance. Nuclear grade and lymph node involvement are important independent predictors of survival. Organ confined tumors with high nuclear grades need to be followed up more rigorously.

Eptifibatide-induced profound thrombocytopenia.

We report a case of profound thrombocytopenia, 2 hours following eptifibatide therapy which got reversed within 12 hours of discontinuation of eptifibatide.

Correlation of radiological and clinical features of metanephric neoplasms in adults.

The main objective was to determine the clinical and radiological features of metanephric neoplasms. The tumors were diagnosed on histopathological examination. The clinical data and imaging features were retrospectively analyzed. Between 1998 and 2003, 3 patients underwent radical nephrectomy for renal masses turning out as metanephric neoplasms on histopathology. Two of these tumors were metanephric adenoma (MA) and one was metanephric adenofibroma (MAF). Clinical and radiological features were reviewed. All patients were adult females who presented with flank pain. Tumor was detected on screening ultrasound as a hyperechoic lesion. In all cases CT showed a hyper-attenuating exophytic lesion with cystic areas that enhanced with IV contrast. Based on combination of clinical and imaging features it may be possible to prospectively identify metanephric neoplasms and thus avoid unnecessary radical nephrectomy in favor of conservative surgery.

Local control of high-grade gliomas with limited volume irradiation versus whole brain irradiation.

INTRODUCTION: To evaluate the role of limited field radiation therapy in the management of high-grade gliomas and glioblastoma multiforme (GBM). MATERIAL AND METHODS: From July '96 to January '98, 50 newly diagnosed patients of high-grade gliomas (Grade III and IV) and glioblastoma multiforme who underwent surgery in the form of partial, sub-total or near-total excision as the primary treatment were enrolled in this study. The patients were randomized to receive two different postoperative external radiation protocols, Study Group A: Localized field external radiotherapy 50 Gy/25#/5 wks followed by Boost 10 Gy/5#/1 wk, Control Group B: Whole brain external radiotherapy 40 Gy/20#/4 wks followed by Boost 20 Gy/10#/2 wks by localized field. RESULTS: 20/25 (80%) patients in the study group and 14/25 (56%) patients in the control group showed improvement in their Karnofsky Performance Status (KPS). Thus a significant difference in the performance status was noted in favor of limited field irradiation. No significant difference in the local response was seen between the two groups after radiotherapy. Six months progression-free survival of the study group was 44% as compared to 26% in the control group. Six months overall survival was 66.67% in the study group and 50.72% in the control group (P<0.01). Maximum recurrences were noticed within 2 cm of the original tumor margin in both the groups. CONCLUSIONS: Although local control and survival of the patient in both the groups were same, performance status definitely improved in patients treated with localized field irradiation only.