Impact of Cochlear Dose on Hearing Preservation Following Stereotactic Radiosurgery in Treatment of Vestibular Schwannomas: A Multi-Center Study.

OBJECTIVE: Stereotactic radiosurgery (SRS) is a well-established treatment for vestibular schwannomas (VS). Hearing loss remains a main morbidity of VS and its treatments, including SRS. The effects of radiation parameters of SRS on hearing remain unknown. The goal of this study is to determine the effect of tumor volume, patient demographics, pretreatment hearing status, cochlear radiation dose, total tumor radiation dose, fractionation, and other radiotherapy parameters on hearing deterioration. METHODS: Multicenter retrospective analysis of 611 patients who underwent SRS for VS from 1990-2020 and had pre- and post-treatment audiograms. RESULTS: Pure tone averages (PTAs) increased and word recognition scores (WRSs) decreased in treated ears at 12-60 months while remaining stable in untreated ears. Higher baseline PTA, higher tumor radiation dose, higher maximum cochlear dose, and usage of single fraction resulted in higher post radiation PTA; WRS was only predicted by baseline WRS and age. Higher baseline PTA, single fraction treatment, higher tumor radiation dose, and higher maximum cochlear dose resulted in a faster deterioration in PTA. Below a maximum cochlear dose of 3 Gy, there were no statistically significant changes in PTA or WRS. CONCLUSIONS: Decline of hearing at one year in VS patients after SRS is directly related to maximum cochlear dose, single versus 3-fraction treatment, total tumor radiation dose, and baseline hearing level. The maximum safe cochlear dose for hearingtbrowd preservation at one year is 3 Gy, and the use of 3 fractions instead of one fraction was better at preserving hearing.

Predictors of Short-Term Outcomes in Living Donor Renal Allograft Recipients: A Prospective Study From a Tertiary Care Center in North India.

Background Renal transplantation is the optimal treatment for patients of all ages with end-stage kidney disease. The long-term outcomes of renal transplantation are assessed by graft and patient survival rates. These outcomes are, in turn, influenced by post-transplant events such as delayed graft function, rejections, post-transplant infections, and post-transplant diabetes mellitus (PTDM). Each of these short-term outcomes is, in turn, determined by the interplay of various factors in the pre-, peri-, and post-transplant period. This prospective study was designed to understand the factors affecting short-term outcomes in living donor transplantation and their effect on graft and patient survival. Methodology A total of 86 patients underwent live donor renal transplantation between January 1, 2015, and March 31, 2016, at a tertiary care hospital in north India. Of these, five were lost to follow-up, and the remaining 81 patients were prospectively followed up to December 31, 2017. Results The majority of the recipients were males (91%) and the donors were females (74%). Spousal and related donors comprised 49% and 51% of donations, respectively. The mean estimated glomerular filtration rate (eGFR) of donors was 98 ± 9.2 mL/minute/1.73m². Induction therapy with basiliximab was given to 21/81 (26%) recipients. The majority of recipients (68/81, 84%) received triple-drug immunosuppression with prednisolone, tacrolimus, and mycophenolate mofetil. Delayed graft function (DGF) occurred in 4/81 (4.9%) cases. Biopsy-proven acute rejections (BPARs) occurred in 15/81 (18.5%) cases, two-thirds of which were acute antibody-mediated rejections (ABMRs). During the follow-up period, 50 episodes of infections occurred in 35/81 (43.2%) recipients, with the most common being urinary tract infection (23/81, 28.5%). PTDM was diagnosed in 22/81 (27.2%) patients beyond six weeks of transplant. On multivariate logistic regression analysis, the most significant predictor of DGF was acute rejections and vice versa. Acute rejections also predicted the occurrence of post-transplant infections. Pre-transplant hepatitis C virus (HCV) infection and cyclosporine-based therapy were significant predictors of PTDM. At the six-month follow-up, 10/81 (12.3%) patients developed graft dysfunction. The predictors of graft dysfunction at six months were recipients of related donors and rural patients. One-year graft survival, death-censored graft survival, and patient survival rates were 85.2%, 92.6%, and 91.3%, respectively. The most common cause of death was post-transplant infections (5/7, 71.4%) of which the majority (4/5, 80%) were fungal infections. On multivariate logistic regression analysis, the most significant predictor of graft loss and patient loss was low pre-transplant donor eGFR and PTDM, respectively. Conclusions Graft and patient survival in living donor kidney transplantation are influenced by a multitude of interdependent factors during the pre-transplant (donor eGFR, type of donor, socioeconomic status, HCV infection in recipient, type of immunosuppression) and the post-transplant (DGF, rejections, infections, and PTDM) period.

Submacular Hemorrhage Following Aflibercept Intravitreal Injection: A Report of Two Cases.

Anti-vascular endothelial growth factor (anti-VEGF) injections are the most effective treatment for exudative age-related macular degeneration (AMD). However, both bevacizumab and ranibizumab have been reported to cause submacular hemorrhage (SMH) in the treatment of exudative AMD. Aflibercept has also been reported to cause SMH but only in the treatment of polypoidal choroidal vasculopathy and not exudative AMD. This case series presents two patients with exudative AMD who developed SMH after treatment with aflibercept injections. The first patient is an 84-year-old female with exudative AMD in both eyes who presented with SMH four days after an aflibercept injection in her right eye. The second patient is a 77-year-old female who presented with exudative AMD in her left eye and SMH one month following an aflibercept injection. This case series shows that SMH in patients treated for exudative AMD is a rare yet possible complication of aflibercept injection that requires further research to establish its incidence and risk factors.

Top 100 Most Cited Papers in Laser-Assisted in situ Keratomileusis Surgery: A Bibliometric Analysis.

PURPOSE: To conduct a bibliometric analysis of the 100 most cited publications on LASIK using the Scientific Information (ISI) Web of Knowledge database. METHODS: This analysis used keyword-specific searches within the Web of Science database to isolate the 100 most frequently cited LASIK articles published between 1996 and 2019 (T100). Number of citations per article and per year were quantified from 1996 to 2019. Title, authors (as well as affiliated institutions and countries of origin), journal, year of publication, and citation frequency were variables analyzed. RESULTS: Of the T100 articles, each article was cited between 103 to 411 times with a mean of 167 citations. Between 0-11 articles in the T100 were published every year on average with a median of 5 publications per year. The highest concentration of T100 publications occurred between 2003 and 2008 at 51%. A decrease in the annual publication rate of influential articles was observed after 2010 at 23%; 39.1% of these articles compared LASIK to newer refractive surgical approaches. The highest number of T100 articles were from the Journal of Refractive Surgery. The University of California System produced the highest number of T100 articles. The author with the most articles in the T100 is Dan Z. Reinstein. Most T100 articles originated from the United States. CONCLUSION: The peak of influential LASIK research occurred between 2000-2010, likely due to topics such as postprocedural corneal ectasia and the femtosecond laser approach. While newer surgical techniques such as SMILE may have contributed to the decline in the annual rate of LASIK-related publication, the underlying cause for this decline is unclear.

Malnutrition-Inflammation Score: A Valid Tool to Assess Nutritional Status in Patient with End-stage Renal Disease.

Nutritional assessment is a basic and necessary process in the nutritional management of dialysis patients. Malnutrition is a prevalent complication in patients on maintenance hemodialysis (HD). The study aimed to evaluate its relationship with the duration of dialysis, demographic and socioeconomic profile of HD patients, and to assess malnutrition inflammation score (MIS) in HD patients. In this descriptive-analytical study, 153 HD patients were selected with random sampling. All the patients were interviewed and the MIS of the patients was recorded. Evaluate the relationship of malnutrition with the duration of dialysis, demographic and socioeconomic profile of HD patients, and to assess MIS in HD patients. Patients were followed up for 3 months. Data were analyzed with Chi-square and t-tests and Pearson correlation coefficient. A total of 153 patients were studied, 53 (34.64%) patients had good nutritional status and 100 (65.35%) patients had malnutrition. The mean of patients MIS score was 10.71 ± 5.14. Malnutrition rates in males and females were not significantly different. There was a positive and significant relationship between age and MIS score (P = 0.035). There was also a significant correlation between the level of education and MIS score (P = 0.042). The mean dialysis duration was 25.52 ± 2 6.27 months. There was a significant difference in the duration of dialysis in mild to severely malnourished patients (P = 0.002). A significant correlation between MIS score and the serum calcium and serum iron results (r = 0.402). The rise in serum prealbumin level was significantly greater at 3 months. MIS score is the best tool to assess nutritional status in patients with ESRD undergoing HD, because it can recognize various degrees of malnutrition that may remain undetected by a single laboratory assessment. The correlation between MIS score and age and dialysis period was significant.

Clinicohistological Profile and Outcomes of Rapidly Progressive Glomerulonephritis: A Prospective Study from North India.

The prevalence of this rare and fatal entity varies in different regions and ethnicities. The objective of this study was to determine clinicopathological characteristics and predictors of outcome in rapidly progressive glomerulonephritis (RPGN). We aimed to prospectively study the clinicopathological profile and determine the predictors of renal outcome in patients with RPGN. This study included 40 patients of biopsy-proven RPGN. The diagnosis of RPGN was based on renal histology showing crescents in >50% of glomeruli. All patients were given induction with intravenous (IV) methylprednisolone (0.5 g) for three days followed by maintenance with oral prednisolone (1 mg/kg/day) and six IV pulses of cyclophosphamide (0.5 g) given fortnightly followed by maintenance therapy with azathioprine (2 mg/kg/day). The outcomes were recorded. Three-fourth of the patients (77.4%) required renal replacement therapy (RRT) at diagnosis. More than half of patients (57.5%) were antineutrophil cytoplasmic antibodies mediated. Immune complex and anti-glomerular basement membrane (GBM) disease constituted 25% and 17.5%, respectively. Clinical features, biochemical parameters, histological features, and type of RPGN were analyzed for association with primary outcomes. Entry serum creatinine, entry estimated glomerular filtration rate (eGFR), RRT on admission, interstitial fibrosis, tubular atrophy, and interstitial infiltrates were the parameters which showed association with primary outcomes of the study (P <0.05). In secondary outcomes, infections were the most common (55%), followed by neutropenia (40%). One-fourth of the patients (25%) died during the course of the study. Cause of mortality was infections (50%), cardiovascular system (30%), stroke (10%), and unknown (10%). Our prospective study from north India shows that RPGN is not an uncommon cause of renal failure and there is preponderance in the elderly patients (>60 years). Pauci-immune RPGN is the most common cause of RPGN followed by immune-complex and anti-GBM disease. Entry serum creatinine, eGFR, and RRT on admission predicted the outcome.

Changing Spectrum of Mineral Bone Disorder in Chronic kidney disease stage 3 to 5 D and Its Associated Factors, A Prospective Cross-Sectional Study from Tertiary Care Hospital in Northern India.

INTRODUCTION: Mineral bone disease is an important complication of chronic kidney disease ends up in increased cardiovascular morbidity and mortality in these patients. The aim of present study was to determine the pattern, prevalence and the clinical, biochemical and radiological profile of mineral bone disease in predialysis and dialysis (stage 5D) patients of chronic kidney disease. METHODS: Patients of stage 3, 4, 5 and 5D of chronic kidney disease admitted to the department of nephrology were enrolled in this study. RESULTS: 200 patients of chronic kidney disease (19, 29, 43 and 109 cases of stage 3, 4, 5 and 5D respectively) with mean age of 52.4 ± 16.7 years and male to female ratio of 2.4:1 were enrolled. Diabetic nephropathy (45%), hypertensive nephropathy (33%), and chronic glomerulonephritis (14.5%) were the most common etiologies of chronic kidney disease. Proximal muscle weakness (91.5%) bone pain (59.5%) and pruritus (25.5%) were the common symptoms. Biochemical parameters showed hypercalcemia (19%), hypocalcaemia (55%), hyperphosphatemia (75.5%) and vitamin D deficiency in 84.5% of cases. High turnover bone disease was present in all predialysis and only 7% of dialysis patients. Adynamic bone disease was observed in 92.7% of dialysis patients. On univariate analysis i-PTH was significantly associated with sex, eGFR, serum calcium, and 25(OH) vit-D level and no association was found with age and FGF-23 levels. CONCLUSION: Adynamic bone disease has emerged as the most common form of CKD-MBD in dialysis patients and secondary hyperparathyroidism being common in the predialysis patients of chronic kidney disease. Hyperphosphatemia and vitamin D deficiency were the most common reported biochemical abnormalities.

Changes in Cardiac Structure and Function Before and After Renal Transplantation: A Longitudinal Study.

BACKGROUND: End-stage renal disease is a major risk factor for cardiovascular disease. Kidney transplantation (KT) may lead to reversal of these cardiac changes. METHODS: Echocardiographic changes in cardiac structure and function were recorded in 30 patients with end-stage renal disease before KT, and 3 months and 6 months after KT. Patients with ischemic heart disease and valvular heart disease were not included. RESULTS: Thirty patients with a mean age of 34±12 years were studied, and 28 (93%) were male. Mean duration of hemodialysis (none on peritoneal dialysis) was 9.18±8.39 months. There was significant improvement in echocardiographic parameter of cardiac morphology and the cardiac systolic and diastolic functions after KT. CONCLUSIONS: This longitudinal prospective study found significant regression of left ventricular hypertrophy within 6 months after renal transplant. There was also an improvement in ventricular functions on echocardiography. The improvement in hemoglobin shows linear correlation with reduction in left ventricular dimension and improvement in left ventricular functions.

Effect of eyedrops and applanation tonometry on optical biometry.

PURPOSE: To determine whether eyedrops (phenylephrine, tropicamide, and fluorescein-proparacaine) and Goldmann applanation tonometry (GAT) have an effect on optical biometry measurements for preoperative cataract surgery workup. SETTING: George Washington University, Washington, DC. DESIGN: Nonrandomized controlled trial. METHODS: Participants older than 18 years with no contraindications to eyedrops or tonometry were recruited. Optical biometry measurements were obtained on a single eye using the Lenstar LS900. One drop each of phenylephrine, tropicamide, and fluorescein-proparacaine was applied to the same eye, and measurements were repeated. GAT was performed, and measurements were repeated. For controls, the contralateral eye was also measured at each interval. RESULTS: There was no statistically significant difference in mean predicted postoperative refraction (PPOR) keratometry (K) 1, K2, or axis postdrops and post-GAT 62 eyes (n = 62). After drops were applied, mean central corneal thickness increased from 540 to 542 µm (P = .0002), mean anterior chamber depth (ACD) increased from 3.68 to 3.70 mm (P < .0001), and lens thickness (LT) decreased from 3.66 to 3.65 (P = .001). After GAT, ACD increased to 3.76 mm (P < .0001), and LT increased to 3.60 mm (P < .0001). There was no statistically significant difference in PPOR or other parameters for the control eyes (n = 5). CONCLUSIONS: GAT and phenylephrine, tropicamide, and fluorescein-proparacaine drops did not affect the primary outcome of PPOR. This suggests that cataract surgery candidates do not need to return for a separate preoperative visit for optical biometry.

A rare case of pediatric Tolosa-Hunt syndrome.

Tolosa-Hunt syndrome is a rare disorder characterized by granulomatous inflammation involving the cavernous sinus, superior orbital fissure, and/or orbit with no additional underlying cause. Tolosa-Hunt syndrome most often presents with painful ophthalmoplegia involving one or multiple cranial nerves. Here we report the case of an 8-year-old girl who presented, atypically, without the hallmark finding of pain. This case of pediatric Tolosa-Hunt syndrome is the only reported example to date lacking what is considered its pathognomonic feature and thus brings to light the clinical variability of this already inconspicuous disorder.

Efficacy and outcome of intermittent peritoneal dialysis in patients with acute kidney injury: A single-center experience.

There are only a few reports on the role of peritoneal dialysis (PD) in critically ill patients requiring continuous renal replacement therapies (RRT). This study aimed to determine the efficacy and outcome of intermittent PD in acute kidney injury (AKI) patients in intensive care unit setting and to assess the procedure-related complications. This was a prospective, observational study conducted from March 1, 2015, to February 29, 2016, which included patients of either sex, aged ≥18 years, diagnosed with AKI, and undergoing RRT with intermittent PD sessions with more than 48 h of hospital stay. Patients were later shifted to sustained low- efficiency dialysis or hemodialysis, when they became hemodynamically stable. Hence, the patients who received at least 48 h of PD were included in the study. A total of 75 patients were enrolled. Overall, the mean age was 55.75 years, and around 64% were men. The most common indication to start PD was metabolic acidosis, and the most common cause of AKI was sepsis. A total of 21 patients survived, and the mortality rate was 72%. The average peritoneal urea clearance and creatinine clearance were 14.81 mL/min and 12.59 mL/min, respectively. Of the 66 patients on inotropes, 28 patients were tapered from inotropic support. Thirty-nine patients had hyperkalemia, and 27 patients had correction within 1 day of the start of PD. Forty-seven patients had correction of acidosis, and 33 of these achieved pH ≥7.25 within one day of PD. The most common complication that occurred was peri-catheter leaks followed by peritonitis. Acute PD can be an effective, simple, and safe bridge RRT in hemodynamically unstable patients until the achievement of hemodynamic stability to shift them to other modalities of RRT.

The prevalence of tuberculin sensitivity and anergy in chronic renal failure in an endemic area: tuberculin test and the risk of post-transplant tuberculosis.

BACKGROUND: Cutaneous sensitivity to the tuberculin antigen is thought to indicate latent tuberculosis infection (LTBI). Some guidelines suggest treating end-stage renal disease (ESRD) patients for LTBI on the basis of tuberculin positivity. The prevalence of tuberculin sensitivity and cutaneous anergy in Indian patients with ESRD and the utility of the tuberculin test for predicting post-transplant tuberculosis are not known. METHODS: We prospectively studied cutaneous tuberculin reactivity and anergy in 108 ESRD patients and 100 age- and sex-matched healthy controls. Mumps antigen and tetanus toxoid were used as control antigens. Patients who failed to react to all antigens were classified as anergic. Seventy-nine patients underwent living donor kidney transplants and were followed-up for approximately 2 years. RESULTS: About 44% of ESRD patients and 66% of controls showed tuberculin reactivity (P = 0.0018). The prevalence of anergy was significantly higher in the ESRD population (44% vs 16%, P<0.001). The haemoglobin, serum albumin and creatinine values were significantly higher amongst the tuberculin-reactor ESRD patients. Tuberculin positivity and anergy rates in a subgroup of well-nourished ESRD patients were similar to the control population. Four patients developed tuberculosis after transplantation. Tuberculin test had a sensitivity of 50% and a specificity of 52% for post-transplant tuberculosis. CONCLUSIONS: In comparison to healthy controls, tuberculin reactivity rates are lower and anergy rates higher in Indian ESRD patients. There is a significant relationship between markers of nutritional status (haemoglobin, albumin and creatinine) and cutaneous reactivity. Pre-transplant Mantoux positivity has low sensitivity and specificity for predicting post-transplant tuberculosis.

Acute renal failure due to cast nephropathy in nonsecretory myeloma: a case report and review of the literature.

Multiple myeloma is characterized by marrow plamacytsois, M spike in serum or urine electrophoresis and skeletal lytic lesions. The M spike may be absent in rare instances. We describe a case of myeloma cast nephropathy with acute renal failure who did not exhibit an M spike. lambda-chain staining was documented on immunoperoxidase, suggesting paraprotein-related tubular damage.