Critical Appraisal of Paediatric Embryonal Cancers Treated with Image-guided Intensity-modulated Proton Therapy.

AIM: To carry out a comprehensive critical appraisal of image-guided intensity-modulated proton therapy practice for craniospinal irradiation (CSI). MATERIALS AND METHODS: An image-guided intensity-modulated proton therapy database of 45 consecutive paediatric patients with central nervous system embryonal malignancies treated between January 2019 and April 2022 were critically appraised for demography, diagnosis, treatment planning strategy and treatment delivery accuracy. RESULTS: Most patients (median age: 7.5 years; male:female ratio: 34:11) had medulloblastoma (56%), followed by recurrent ependymoma (19%), pinealoblastoma (5%), germ cell (5%) and others (15%). The dose to the planning target volume-craniospinal (PTV-CS; length 39.06-79.59 cm) varied from 21 to 35 GyRBE, whereas the combined median dose to craniospinal and boost was 54 GyRBE. In all patients, the 95% isodose line covered the cribriform plate completely and optic nerves mostly, with a median V95% of 100% and 82.96%, keeping Dmax to the lens <3.9 GyRBE. In skeletally immature patients (88.38%), the anterior vertebral body was completely covered in 18.18% and underdosed in 70.15% of the cases, resulting in a median Dmean of 10.11 GyRBE to the oesophagus. Lateral spine coverage was maintained on the edges of the vertebral body in 52.2%, whereas it extended beyond in 48.8%. The median V98% for clinical target volumes and V95% for PTVs of the brain, spine and craniospinal were >97%, with excellent conformity (0.89) and homogeneity (0.07) indices for PTV-CS. All neurological organs at risk received a median Dmax ranging from 36 to 44 GyRBE from the combined CSI and boost regimens. Analysis of patient-specific quality assurance results revealed that 545 (97.67%) planar dosage verification had gamma (3% at 3 mm) values >95%. The online patient set-up verification showed translational and rotational deviation within 2 mm and 0.5° in 88-94% and 97% of the cases. Systematic and random error were within 0.90 mm and 1.71 mm in translation and 0.1° and 0.2° in rotation. CONCLUSION: A change in practice pattern was observed. The findings from our comprehensive critical appraisal add to the growing library of CSI practice and may serve as a reference for inter-institutional comparison.

Prognostic Predictors of Visual Outcome in Open Globe Injury: Emphasis on Facial CT Findings.

BACKGROUND AND PURPOSE: The present prognostic models for open globe injuries have a limited ability to predict visual outcome before a comprehensive ophthalmologic examination or operation because they depend on the data derived from the ophthalmologic examination and intraoperative findings. The purpose of our study was to determine the specific CT and preoperative clinical data that can predict the prognosis of open globe injury. MATERIALS AND METHODS: We analyzed the relationship of 29 variables derived from clinical and CT data from 97 globe injuries with visual acuity at 1 month. A prediction model was derived from 49 globe injuries by regression analysis, followed by receiver operating characteristic curve analysis of the best CT predictor. RESULTS: Four variables with significance on a regression model were the following: posterior segment hemorrhage (ß = -0.93, P < .0001), presenting visual acuity (ß = 0.28, P = .042), orbital emphysema (ß = 0.46, P = .0018), and complex facial fracture (ß = -0.43, P = .009). Receiver operating characteristic analysis of the posterior segment hemorrhage predicted profound vision loss (light perception or no light perception) with an area under the curve of 0.97. The receiver operating characteristic table indicated that grade III posterior segment hemorrhage has a strong positive predictive value of 100% for profound vision loss. On the other hand, the absence of posterior segment hemorrhage has a strong positive predictive value of 93% for mild-to-severe vision loss (visual acuity better than light perception). CONCLUSIONS: Radiologists, with the help of CT and preoperative clinical data, can predict visual acuity after open globe injury.

Aortic arch tortuosity with PHACE syndrome - a rare case scenario.

PHACE syndrome is a rare neurocutaneous disorder characterised by an association of infantile haemangiomas with structural anomalies of brain, cerebral vasculature, eye, aorta and chest wall.1 Coarctation of aorta (COA) is most the common cardiac anomaly reported in PHACE syndrome. COA or interrupted aortic arch in PHACE is unique and complex both in location and character compared to the typical coarctation anatomy. Arterial tortuosity of the cerebral vasculature has been well described in literature in PHACE syndrome. We present a rare case of tortuous aortic arch continuing as descending aorta in an infant with PHACE syndrome.

Evaluation of different culture methods for the diagnosis of peritonitis in patients on continuous ambulatory peritoneal dialysis.

A total of 170 continuous ambulatory peritoneal dialysis (CAPD) fluids were processed by various culture methods, including direct inoculation of the centrifuged sediment, inoculation into automated blood culture bottles, water lysis, Tween-80 incorporated blood agar, and Triton-X treatment of the specimen. Of 170 CAPD fluids, 127 showed the growth of bacteria/fungi. Sixty-three fluids showed growth by all methods, the water lysis alone detected 24 additional positive cultures, while Tween-80 blood agar and Triton-X yielded 30 additional positive cultures. A combination of water lysis, Tween-80 blood agar and Triton-X treatment of the CAPD fluid is recommended for diagnosis of CAPD peritonitis in resource-limited settings.

Is microsporidial keratitis a seasonal infection in India?

Microsporidia are emerging ocular pathogens. In this study, we describe the seasonal trends of microsporidial keratitis. The incidence of microsporidial keratitis is increasing in India, with a seasonal trend towards disease onset during the monsoon.

PCR for the diagnosis and species identification of microsporidia in patients with keratitis.

Corneal scrapings from 30 patients with microbial keratitis were subjected to microsporidial PCR. PCR was positive for microsporidia in ten of 30 patients. The species was identified as Vittaforma corneae by sequencing in all ten patients. The remaining 20 patients were negative for microsporidia and showed the growth of other organisms (Acanthamoeba, fungi or bacteria).

Loop-mediated isothermal amplification assay for the diagnosis of retinitis caused by herpes simplex virus-1.

A loop-mediated isothermal amplification (LAMP) assay was developed for the detection of herpes simplex virus 1 (HSV-1). The specificity of the assay was tested using DNA extracted from HSV-1-infected rabbit corneal epithelium cultures, HSV-2 grown on Vero cell line, cytomegalovirus (CMV) (AD-169), varicella zoster virus (VZV) (Oka-vaccine), adenovirus, Aspergillus flavus and Staphylococcus aureus. The specificity of LAMP was confirmed by bidirectional sequencing of the amplicons. The sensitivity of the LAMP assay was tested using different concentrations of HSV-1 DNA. To evaluate the application of the LAMP assay in clinical diagnosis, we tested vitreous samples from 20 patients with suspected viral retinitis using LAMP and real-time PCR for HSV-1. The LAMP primers amplified only HSV-1 DNA; no LAMP products were detected with the DNAs of HSV-2, CMV, VZV, adenovirus A. flavus and S. aureus. The sequences of the positive HSV-1 LAMP products perfectly (99-100%) matched the HSV-1 sequences deposited in the GenBank database. LAMP is as sensitive as real-time PCR, with the lowest detection limit being 10 copies/µL of HSV-1 DNA. Of the 20 patients with suspected viral retinitis, four tested positive for HSV-1 using real- time PCR and LAMP. A 100% concordance was observed across the two methods. The LAMP assay is a rapid, highly specific and sensitive method for the diagnosis of retinitis caused by HSV-1.

Oestrus ovis ophthalmomyiasis with keratitis.

A 35-year-old male patient presented with complaints of redness, swelling around the eyelids, watering, and irritation in the right eye. At presentation his best-corrected visual acuity was 20/20 partial in the right eye. The tarsal conjunctiva of the upper eyelid showed injection with pseudomembrane. Underneath the pseudomembrane we noticed four motile larvae. The cornea showed an irregular cobweb-like mucous plaque adherent to the epithelium, with a clear stroma. The pseudomembrane was easily peeled-off under topical anaesthesia. The organisms were removed and identified as Oestrus ovis. Three days later the patient was comfortable and his visual acuity was 20/20 in the right eye.

Spectrum and clinicomicrobiological profile of Nocardia keratitis caused by rare species of Nocardia identified by 16S rRNA gene sequencing.

PURPOSE: To report the predisposing factors, clinical profile, and treatment outcome of patients with keratitis that was caused by a rare species of Nocardia. METHODS: Between April 2006 and October 2008, medical and microbiology records of patients with keratitis that was caused by Nocardiawere reviewed. Isolates were identified to species level by 16S rRNAgene sequencing, and antibiotic susceptibility testing was performed by E-test to amikacin, azithromycin, clarithromycin, ciprofloxacin, gatifloxacin, and tobramycin. RESULTS: Of 19 cases with Nocardiakeratitis, 8 were caused by unusual isolates. Species distribution among the eight isolates was as follows: the Nocardia levis (2 of 8), Nocardia amamiensis (2 of 8), Nocardia abscessus (1 of 8), Nocardia puris (1 of 8), Nocardia beijingensis (1 of 8), and Nocardia thailandica (1 of 8). All eight (100%) isolates were sensitive to amikacin and tobramycin. Trauma to the cornea was the major predisposing factor in seven of the eight patients. Five patients presented with the characteristic wreath-pattern infiltrate. The infection resolved to topical therapy with amikacin sulphate (2.5%) in six patients, whereas two patients treated with the same antibiotic were lost to follow-up at a point when the lesion was showing signs of resolution. CONCLUSION: The healing response in Nocardiakeratitis cases was the same, irrespective of species.

Speciation and susceptibility of Nocardia isolated from ocular infections.

Twenty Nocardia spp. isolated from ocular infections were identified by 16S rRNA gene sequencing and susceptibility was determined using the E-test (AB Biodisk, Sweden). Species distribution among the 20 isolates was as follows: Nocardia levis (n = 7), Nocardia farcinica (n = 3), Nocardia abscessus (n = 2), Nocardia brasiliensis (n = 2), Nocardia amamiensis (n = 2), Nocardia puris (n = 1), Nocardia beijingensis (n = 1), Nocardia otitidiscaviarum (n = 1) and Nocardia thailandica (n = 1). All isolates were sensitive to amikacin. Eighteen (90%) isolates were sensitive to tobramycin, 11 (55%) to ciprofloxacin and gatifloxacin, and seven (35%) to azithromycin and clarithromycin. Molecular methods are useful for the identification and for the detection of Nocardia species that have not so far been reported in human infections.

Protection of Penaeus monodon from Infection of White spot syndrome virus by DNA Construct Expressing Long Hairpin-RNA Against ICP11 Gene.

A plasmid construct (pICP11-LH) was designed to constitutively express long-hairpin RNA (lhRNA) against icp11 gene, which is reportedly the most highly expressed gene of White spot syndrome virus (WSSV) and likely to have an important role in viral pathogenesis. The construct was used singly and in combination with other similar constructs designed against vp28 and vp19. A total of 6 treatments, T1 (pICP11-LH; 35 µg), T2 (pVP28-LH; 35 µg), T3 (pVP28-LH and pVP19-LH; 17.5 µg each), T4 (pVP28-LH and pVP19-LH; 25 µg:10 µg), T5 (pICP11-LH, pVP28-LH and pVP19-LH; 11.5 µg each) and T6 (pGFP-LH; 35 µg) were injected intramuscularly into 20 g Penaeus monodon specimens. The shrimp were challenged with WSSV 24 hpi and protection efficacy was measured in terms of survival and viral load 15 days after challenge. Appropriate negative and positive controls were used. T2 and T3 offered highest protection (75%) followed by T1 (67%) and T4 and T5 groups (58%), while T6 showed 25% protection. In all the target specific treatments, the viral load as estimated by single tube WSSV kit was kept in check (10-100 copies), whereas in the unimmunized challenged controls it progressed to severe infection (>10(5) copies). In spite of over 3 times higher expression of ICP11 compared to VP28, its knockdown by pICP11-LH did not offer any protective advantage over pVP28-LH, either singly or in combination. Moreover, none of the combinations bettered the protection efficacy of pVP28-LH administered alone. To investigate concerns about deleterious effect of plasmid persistence and constitutive expression on shrimp growth, a lab-scale 1 month growth study was conducted with 4 treatments T2, T3, T4 and T6, where no difference in specific growth rate was observed compared to controls.

Comparison of in vitro susceptibilities of Gram-positive cocci isolated from ocular infections against the second and fourth generation quinolones at a tertiary eye care centre in South India.

PURPOSE: To compare the in vitro antimicrobial susceptibilities of Gram-positive cocci isolated from the ocular infections to the second and fourth generation fluoroquinolones at a tertiary eye care centre in south India. METHODS: A retrospective review of microbiology records at LV Prasad eye institute, Hyderabad, India, identified 787 Gram-positive cocci isolated from different ocular infections between January 2005 to May 2008.The isolates were identified using culture characteristics and biochemical tests. In vitro antibiotic susceptibility of the isolates was determined by using Kirby-Bauer disc diffusion method. We analysed the susceptibility data of ciprofloxacin, ofloxacin, gatifloxacin, and moxifloxacin. RESULTS: Out of 787 isolates, 147 (18.7%) were Staphylococcus aureus, 279 (35.2%) were coagulase-negative Staphylococci, 357 (45.4%) were Streptococcus pneumoniae,and 4 (0.4%) were other Streptococcus species. Of the four quinolones, susceptibility to gatifloxacin was highest (85.6%) followed by ofloxacin (65.6%), moxifloxacin (63.9%), and ciprofloxacin (60.5%). In all, 33 (4.2%) of 787 isolates were resistant to all the four fluoroquinoles. S. aureus and coagulase-negative Staphylococcus isolates that were resistant to ciprofloxacin and ofloxacin were most susceptible to gatifloxacin. S. pneumoniae were more susceptible to gatifloxacin, ofloxacin, and ciprofloxacin than moxifloxacin. CONCLUSIONS: In our institute, we observed that gatifloxacin is more potent than moxifloxacin against Gram-positive cocci isolated from ocular infections.

Epidemiology of animal bites and rabies cases in India. A multicentric study.

Rabies, a disease of antiquity continues to be a major public health problem in India. Multiple factors contribute to high mortality and morbidity due to animal bites. An effective strategy for control of rabies takes into account the epidemiology of animal bites, rabies and factors influencing post exposure treatment. The study was carried out as a part of Agreement for Performance of Work (APW) from World Health Organization (WHO) during the period April 2001 to September 2002. Two sets of proformae were developed and used after field testing to interview cases of animal bites and get retrospective information about rabies cases. The study was carried out at six selected centres across the country viz. Delhi, Hyderabad, Raipur, Jamnagar, Coonoor and Rajahmundry and was co-ordinated by National Institute of Communicable Diseases (NICD), Delhi. The officials engaged in the study work were thoroughly trained in the study methodology before the start of the study itself. To maintain quality and uniformity supervisory checks were done during the survey. A total of 1357 fresh animal bite victims were interviewed (exit interview) from the anti-rabies centres (ARCs). Dog bites caused maximum morbidity (92%). Second most common biting animal was monkey (3.2%), followed by cat (1.8%), fox (0.4%) etc. Most bites (64.3%) were unprovoked bites by stray (64.7%) animals. In this study 72.4% animal bite victims were males and 47.5% were children in age group of 2-18 years. 63% had Category III exposure as per the WHO classification. Before coming to ARCs 58.5% people had washed the wound with water/soap or water alone. Some of the bite victims (10.8%) had also applied chillies, salt, turmeric powder, lime, snuff powder, paste of leaves, acid, ash given by Peer Baba (magician) etc. These practices varied from one region to another. The practice of wound washing at the ARC which is an important component of animal bite management was being practiced at only one of the six centres. Of the six centres, Rabies Immunoglobulin (RIG) was available and was being used at only two centres. The study was conducted in public sector ARCs where Nervous Tissue Vaccine (NTV) was available free of cost. All the centres were using NTV except Coonoor, which is using indigenously produced Tissue Culture Vaccine along with NTV. Analysis of 192 case records of rabies cases, from two centres, revealed that dog bites caused maximum mortality (96.9%). Nearly 40% were children below 15 years of age and 78.6% were males indicating that it is an exposure related disease. In all cases, failure to seek timely and appropriate treatment led to development of disease. This paper provides an overview of epidemiology of animal bites and retrospective information about rabies patients. There is a need to strengthen Information, Education and Communication (IEC) programme regarding merits of local wound management including "do's and don'ts". ARCs should be strengthened in terms of facilities and availability of safe and effective anti rabies immunobiologicals. There is a need to create awareness regarding epidemiology and at-home and hospital management of animal bites among the service providers and general community.

Evaluation of commercially available third-generation anti-hepatitis C virus enzyme-linked immunosorbent assay in patients on haemodialysis.

Restricted antibody reactivity to hepatitis C virus (HCV) synthetic peptides has been observed in HCV-infected patients on haemodialysis (HD). The aim of this study was to evaluate third-generation anti-HCV enzyme-linked immunosorbent assay (ELISA) test systems containing either synthetic peptide HCV antigens or recombinant HCV antigens or a combination of synthetic and recombinant antigens in screening of 69 chronic renal failure patients on HD for HCV infection. Seven patients were detected to have antibodies to HCV by the 'recombinant HCV antigens'-containing kits, of which the recombinant immunoblot assay for HCV confirmed four cases. The recombinant kits had a sensitivity of 100% and a specificity of 66%. However, the ELISA kits with only synthetic HCV antigens failed to detect antibodies in any of the cases (zero sensitivity). Hence a recombinant protein containing ELISA test system is ideal for screening of HCV infection in patients on hemodialysis.

Utility of HCV core antigen ELISA in the screening for hepatitis C virus infection in patients on hemodialysis.

An enzyme immuno assay for hepatitis C core antigen was recently developed and its performance was compared with that of the hepatitis C virus (HCV) RNA in the screening of HCV infection in patients on hemodialysis. One hundred and eleven chronic renal failure patients undergoing haemodialysis between May 2003 and October 2004 were included in the study. All the patients were tested for anti HCV antibody, core antigen and RNA. Fifteen patients were anti HCV antibody positive, three patients were positive for HCV core antigen and RNA, three patients were positive for HCV RNA, while two patients were positive only for core antigen but negative for RNA. In anti HCV antibody positive patients, the core antigen was negative while the viral RNA continued to be present. Hence, relying solely on a single HCV core antigen assay may not be useful for a definite diagnosis of early HCV infection. The sensitivity and specificity of the assay were 60% and 83% respectively, while the positive predictive value was 14.3%, negative predictive value was 97.7% and the efficiency was 81.9%.

Prevalence of HCV infection in patients on haemodialysis: survey by antibody and core antigen detection.

PURPOSE: The present study was undertaken to determine the prevalence of HCV infection by antibody testing and HCV core antigen (HCVcAg) determination by ELISA in haemodialysis patients and to evaluate the HCV c Ag assay in the detection of HCV infected patients on haemodialysis. MATERIALS AND METHODS: A total of 151 chronic renal failure patients on haemodialysis from May 2003 to October 2004 were studied. One hundred patients out of 151 were followed for 2-5 months. All the patients were tested for anti HCV and HCV core antigen once a month. Anti HCV ELISA positive specimens were confirmed by RIBA. RESULTS: The overall prevalence of HCV infection was 13.23%. Antibody positivity was observed in 9.93% and HCVcAg alone was detected in 2.64%. One patient (0.66%) was initially positive for core antigen and later seroconverted. CONCLUSIONS: Screening for HCV antibodies alone does not exclude infection with HCV in patients on haemodialysis and HCVcAg may be a useful test for identifying HCV infected patients on haemodialysis in the early phase of infection before seroconversion.

Management of vasospasm in a neurosurgical center / Management of vasospasm in a neurosurgical center

Background: Cerebral vasospasm after subarachnoid hemorrhage remains a major source of morbidity and mortality. Various agents have come into vogue to deal with this complication but none has shown any absolute results. We conducted this study to asses the effectiveness of intracisternal lavage of papavarine both prophylactically and therapeutically in a simple cost effective way. Methods: This is a retrospective analysis of patients who were admitted at our institution between January 2002 and July 2003. Eighty five patients with anterior circulation aneurysmal bleed who underwent microsurgical clipping were divided into two groups. Group A: patients who received papavarine through a reservoir and Group B patients who did not receive papavarine. The location of aneurysm, timing of surgery , incidence and outcome of vasospasm were assessed in the patients in two comparable groups. Results: 13 por ciento of patients in Group A developed vasospasm whereas 38 por ciento of patients in Group B developed vasospasm. Symptoms of vasospasm reversed in all patients in Group A. There were 3 deaths in Group A but none where attributed to vasospasm. Four of seven deaths in Group B were attributed to consequence of vasospasm. Eleven patients who survived in Group B in spite of vasospasm had significant morbidity at the time of discharge. Conclusion: Intracisternal lavage with papavarine both prophylactically and theraputically can prevent and reverse vasospasm and this can be achieved by installing a simple reservoir. It is a cost effective and rapid bedside procedure for dealing with vasospasm

Management of vasospasm in a neurosurgical center / Management of vasospasm in a neurosurgical center

Background: Cerebral vasospasm after subarachnoid hemorrhage remains a major source of morbidity and mortality. Various agents have come into vogue to deal with this complication but none has shown any absolute results. We conducted this study to asses the effectiveness of intracisternal lavage of papavarine both prophylactically and therapeutically in a simple cost effective way. Methods: This is a retrospective analysis of patients who were admitted at our institution between January 2002 and July 2003. Eighty five patients with anterior circulation aneurysmal bleed who underwent microsurgical clipping were divided into two groups. Group A: patients who received papavarine through a reservoir and Group B patients who did not receive papavarine. The location of aneurysm, timing of surgery , incidence and outcome of vasospasm were assessed in the patients in two comparable groups. Results: 13 por ciento of patients in Group A developed vasospasm whereas 38 por ciento of patients in Group B developed vasospasm. Symptoms of vasospasm reversed in all patients in Group A. There were 3 deaths in Group A but none where attributed to vasospasm. Four of seven deaths in Group B were attributed to consequence of vasospasm. Eleven patients who survived in Group B in spite of vasospasm had significant morbidity at the time of discharge. Conclusion: Intracisternal lavage with papavarine both prophylactically and theraputically can prevent and reverse vasospasm and this can be achieved by installing a simple reservoir. It is a cost effective and rapid bedside procedure for dealing with vasospasm (AU)

CSF flow study in Chiari I malformation.

OBJECTIVE: The aim of this prospective study was to define the role of cardiac gated phase-contrast ciné magnetic resonance imaging in deciding the therapeutic strategy in patients with Chiari I malformation. MATERIALS AND METHODS: Twenty-one patients operated on between February 2000 and July 2002 were enrolled in the study. All patients underwent a detailed preoperative neurological examination. MRI of the craniovertebral junction and the whole spine was done, followed by cardiac gated phase contrast ciné magnetic resonance imaging. RESULTS: Signs and symptoms of syringomyelia were noted in 15 patients and cerebellar signs in 11 patients. Three of them had trigeminal nerve involvement, and 4 had ninth and tenth cranial nerve involvement. The sixth and accessory nerves were involved in 1 patient each. Preoperative CSF flow studies revealed obstructive flow both anteriorly and posteriorly in 6 patients and only posterior block in 15 patients. One patient investigated for failed foramen magnum decompression revealed obstruction to CSF flow ventrally. Foramen magnum decompression with duroplasty was done in all these cases. The patient who had a persistent ventral flow block underwent odontoidectomy. Patients were followed up for a maximum of 36 months, with a mean of 18 months. MRI CSF flow studies revealed established flow dorsally in all cases. Seventeen patients showed clinical improvement and 2 of them did not show any neurological changes. Two patients deteriorated following an initial period with a shunt. CONCLUSION: MRI CSF flow study is an effective tool for deciding the type of surgery to be performed and also for monitoring patients postoperatively.