Distant metastasis at the time of presentation of head and neck squamous cell carcinoma: a retrospective chart review from a tertiary cancer care centre.

OBJECTIVE: To evaluate the rates and patterns of distant metastasis in head and neck SCC at the time of presentation and to study the association between distant metastasis with pre-treatment, clinical, and pathological predictors of outcomes. METHOD: This is a retrospective study conducted in a tertiary care hospital. All patients with primary head and neck squamous cell carcinoma that had been evaluated at our institute between October 2018 and December 2020 were included in the study. Various clinical data were analysed and pattern of metastasis was studied. RESULT: Ten per cent (50 cases) of 501 studied patients had distant metastasis. The most common site of distant metastasis was lung. The rate of distant metastasis was high in patients with poorly differentiated cancers. By Kaplan-Meier analysis, the median survival duration after diagnosis of metastasis was four months. CONCLUSION: The rate of distant metastasis was 10 per cent in the study. Patients with poorly differentiated tumours, locally advanced primary lesions, higher nodal stage, particularly with extra nodal extension, and hypopharyngeal primary, tend to exhibit increased risk for distant metastasis at the time of presentation.

A Study to Assess the Effect of Non-asthmatic Allergic Rhinitis on Pulmonary Functions-A Prospective Case-control Study.

Allergic rhinitis, beginning from childhood, is a global health problem. According to the literature, allergic rhinitis has been found association with asthma and other allergic manifestations. In this study we like to find out the significance and prognostic importance of spirometry in allergic rhinitis. The study was carried out over a period of 2 years, with 63 cases and controls each. Subjects in the age of 20-55 years with allergic rhinitis and SFAR score of > / = 7 were included as a case. Participants were interviewed and sent for spirometry. Controls were recruited from the retrospective data of healthy individuals with spirometry parameters done for health checkup. These controls had an SFAR score of < 7. All the data obtained were analyzed and compared between cases and controls. The mean age of the cases and controls were 33.17 ± 10.817 and 44.41 ± 7.4, respectively. Majority of cases and controls were males (60.3% and 57.1%). A statistically significant difference in FEF25-75% among cases and controls was noted (p = 0.00), thus proving probability of developing small airway obstruction in subjects with allergic rhinitis. Subjects with allergic rhinitis have a probability of developing small airway obstruction with subclinical changes, hence necessitating the need of regular follow-up.

A Comparative Study of Symptoms, Nasal Eosinophilia and Pulmonary Function Tests Before and After Short Term Treatment with Corticosteroid Nasal Spray in Patients with Allergic Rhinitis.

Allergic rhinitis has been on the rise because of urbanization and major population shift in addition to changes in the particulate matter in the atmosphere. Intranasal corticosteroid sprays are recommended as first-line prescription treatment in all cases of allergic rhinitis. The propensity of co-existing non-apparent lower airway hyper-responsiveness is also on the rise and must be evaluated. The aim of this study is to compare the symptomatic improvement, changes in nasal eosinophilia and asymptomatic airway hyper responsiveness before and after short term treatment with steroid nasal spray. Fifty patients meeting the inclusion criteria for allergic rhinitis with no symptoms of asthma underwent pulmonary function tests and assessment of symptoms before and after one-month treatment with inhalational steroid nasal spray (Fluticasone Furoate), in the standard adult dosage. Based on TNSS (Total nasal symptom score) and TOSS (Total ocular symptom score), all 50 patients showed significant improvement after treatment. Among 20 patients with > 50 eosinophils per high power field, 80% had 0-10 eosinophils per high power field on nasal smear after treatment. Among 40 patients with mild large airway obstruction, 37 showed significant improvement in FEV1 data. Also FEV1/FVC data showed significant improvement. Significant improvement (FEF25-75 > 50%) was also noticed in small airway disease after treatment among the 5 patients. The study showed that lower airway hyper responsiveness coexists with allergic rhinitis and treating allergic rhinitis with just steroid nasal spray assists in reducing the former, supporting the concept of Unified Airway Disease (UAD).

Role of Otoacoustic Emission in Early Detection of Cisplatin Induced Ototoxicity.

Cisplatin is a chemotherapeutic agent effective against head and neck carcinoma but unfortunately it is cochleotoxic. This study has been designed to investigate the efficacy of OAE in identifying early effects of cisplatin on the cochlea and the importance of protocol for audiological monitoring of cisplatin induced ototoxicity. This is a prospective observational study conducted from October 2012 to September 2014 on 70 patients, receiving Cisplatin for various malignant conditions. Audiological criteria for ototoxicity was considered as a difference of 10 d B or more in pure tone thresholds of two or more adjacent frequencies in conventional audiometry and in DPOAE-Signal noise ratio less than 6 dB or DPOAE amplitude less than 20 dBSPL (irrespective of SNR > 6 dB). According to PTA, 60.7% patients showed ototoxicity after completion of chemotherapy. In DPOAE, according to SNR and amplitude criteria more than 60% patients showed ototoxicity after first cycle of cisplatin at high frequencies (4-8 kHz). DPOAEs is a sensitive tool for early detection of ototoxicity and protocol is necessary for monitoring ototoxicity in patients receiving cisplatin to improve the quality of life.

Molecular characterisation of Candida auris isolates from immunocompromised patients in a tertiary-care hospital in Kuwait reveals a novel mutation in FKS1 conferring reduced susceptibility to echinocandins.

BACKGROUND: Candida auris is an emerging, potentially multidrug-resistant pathogen that exhibits clade-specific resistance to fluconazole and also develops resistance to echinocandins and amphotericin B easily. This study analysed 49 C auris isolates for alterations in hotspot-1 and hotspot-2 of FKS1 for the detection of mutations conferring reduced susceptibility to echinocandins. METHODS: C auris isolates (n = 49) obtained from 18 immunocompromised patients during June 2016-December 2018 were analysed. Antifungal susceptibility testing was performed by Etest and broth microdilution-based MICRONAUT-AM assay. Mutations in hotspot-1 and hotspot-2 regions of FKS1 were detected by PCR sequencing and fingerprinting of the isolates was done by short tandem repeat typing. RESULTS: The patients had multiple comorbidities/risk factors for Candida spp. infection including cancer/leukaemia/lymphoma/myeloma (n = 16), arterial/central line (n = 17), urinary catheter (n = 17), mechanical ventilation (n = 14) and major surgery (n = 9) and received antifungal drugs as prophylaxis and/or empiric treatment. Seven patients developed C auris candidemia/breakthrough candidemia, nine patients had candiduria with/without candidemia and four patients developed surgical site/respiratory infection. Resistance to fluconazole and amphotericin B was detected in 44 and four isolates, respectively. Twelve C auris isolates from eight patients showed reduced susceptibility to echinocandins. Seven isolates contained hostspot-1 mutations and three isolates from a candidemia patient contained R1354H mutation in hotspot-2 of FKS1. Ten patients died, five were cured, two were lost to follow-up and treatment details for one patient were not available. CONCLUSIONS: Our findings describe development of a novel mutation in FKS1 conferring reduced susceptibility to echinocandins in one patient during treatment and unfavourable clinical outcome for many C auris-infected patients.

Oncocytic Salivary Gland Tumours: Cytological Features and Diagnostic Pitfalls.

Oncocytes are epithelial cells having abundant eosinophilic cytoplasm. The presence of oncocytes in salivary glands pose a diagnostic challenge since they can be present in lesions ranging from non-neoplastic, benign to malignant. FNAC is a simple procedure which can aid in the pre-operative diagnosis of these lesions. This study is an eight year retrospective study in which salivary gland aspiration cytology cases having oncocytic cells and with available corresponding histopathology were included. These slides were reviewed for features like cellularity, presence of oncocytic cells, glandular elements, squamoid cells, nuclear atypia, mitosis, lymphoid tissue, necrosis. Twenty cases were included in the study. The mean age of presentation was 60 years showing male preponderance with parotid gland being the most common site of involvement. Concordant diagnosis on cytology and histopathology was seen in 16 cases and discordance was seen in 4 cases. All the discordant cases were reported as benign on cytology but on histopathology they were labelled as acinic cell carcinoma, squamous cell carcinoma, mucoepidermoid carcinoma and an intraparotid lymph node respectively. Review of discordant cases showed subtle findings like ill-formed acini, cytoplasmic vacuolation, goblet cells and dysplastic foci raising suspicion of a different diagnosis. The potential areas of pitfall and cause of discrepancy have been discussed in this study. It is crucial to be aware of the spectrum of lesions in which oncocytes are seen, to enable an accurate diagnosis on cytology. Careful evaluation of smears for subtle clues can minimize errors.

Health Care-Associated Infections in a Neurocritical Care Unit of a Developing Country.

BACKGROUND: Health care-associated infections (HAIs) in intensive care units (ICUs) specialized for neurocritical care (neurocritical care units [NCCUs]) are serious yet preventable complications that contribute significantly to morbidity and mortality worldwide. However, reliable data are scarcely available from the developing world. We aimed to analyze the incidence, epidemiology, microbial etiology, and outcomes of HAIs in an NCCU of a tertiary care teaching hospital in a high-income, developing country. METHODS: In this 3-year retrospective cohort study, all patients admitted to the NCCU at the Ibn Sina Hospital in Kuwait for ≥ 2 calendar days were included. Patient demographics, hospitalization, and details of ICU-acquired infections were evaluated. Patient-related outcomes included hospital and ICU length of stay (LOS) and in-hospital mortality. RESULTS: Among 913 patients with a total of 4921 ICU days, 79 patients had 109 episodes of HAIs. The overall incidence rate and incidence density of HAIs were 11.9/100 patients and 22.1/1000 ICU days, respectively. Multiple episodes of infection were documented in 29% of patients. The most prevalent infections were urinary tract infections (UTIs; 40/109 [37%]), bloodstream infections (30/109 [28%]), and pneumonia (16/109 [15%]). Seventy-six percent of infections were device-associated infections. A total of 158 pathogens were isolated, of which 109 were Gram-negative bacteria. Of the 40 Gram-positive bacteria, 22 were staphylococci. Seven infections were due to Clostridium difficile. There were 15 Staphylococcus aureus isolates, 47% of which were methicillin resistant. Two episodes of UTIs were due to Candida species. There were 84 Enterobacteriaceae isolates, 24% of which were extended-spectrum ß-lactamase producers. All Pseudomonas aeruginosa isolates were susceptible to aminoglycosides and carbapenems. Klebsiella species were the most common pathogen (45/158 [28%]), causing pneumonia (11/33 isolates [33%]), bloodstream infections (12/37 isolates [32%]), and UTIs (16/52 isolates [31%]). One episode of bloodstream infection was due to multidrug resistant Acinetobacter baumanii which was susceptible only to colistin. Only pneumonia was independently associated with mortality, while all HAIs that occurred were significantly associated with a prolonged ICU LOS. CONCLUSIONS: This is the first HAI surveillance study in an NCCU in Kuwait, and our results demonstrate the burden of HAIs on the neurologically injured patient, regardless of the site of infection. The high prevalence and resistant profile of HAIs in an NCCU in a developing country relative to a developed country has important implications for patient safety and emphasizes the need to strengthen collaboration between NCCU teams and infection control teams to prevent serious complications in this setting.

Pleomorphic adenoma of nasal septum: a rare case.

The most common benign tumour of the major salivary glands is the pleomorphic adenoma. They are seen rarely in the minor salivary glands, usually in hard palate, soft palate and nasopharynx. Pleomorphic adenomas in nasal cavity are unusual and may be misdiagnosed because they have predominant myoepithelial cellularity and fewer myxoid stromata compared with those elsewhere. We present a case of 38-year-old male with a 2-year history of left nasal obstruction and epistaxis since 6 months. Diagnostic nasal endoscopic examination showed a soft lobulated mass in left nasal cavity attached to anterior part of the septum. Radiological examination demonstrated soft tissue mass filling left nasal cavity with an eroded septum. The biopsy from the mass was suggestive of pleomorphic adenoma and was resected endoscopically. Histopathological examination was consistent with pleomorphic adenoma. These are rare tumours of the nasal cavity and can be managed effectively with the endoscopic approach.

Benign Lymphoepithelial Cyst of the Parotid in HIV Negative Patient.

Benign lymphoepithelial cysts are slow growing tumours commonly seen in HIV positive adults. It is rare to find them in non HIV individuals. In this article we discuss an uncommon presentation of a parotid swelling occurring in a 49-year-old non HIV male, which was diagnosed as benign lymphoepithelial cyst. The various investigative modalities and treatment options are outlined in this article.

Primary Hydatid Cyst of the Diaphragm Mimicking Diaphragmatic Tumour: A Case Report.

Echinococcus commonly affects the liver and the lung, but several organs can be affected by this disease. The isolated primary diaphragmatic hydatid cyst, not associated with liver or lung, is very rare. We report a case of hydatid cyst in a 55-year-old male, located in the abdominal side of the left hemidiaphragm which mimicked a hypovascular diaphragmatic tumour and exophytic splenic cyst. In our case the diagnosis was confirmed only with histopathological examination done after surgical excision of the cyst. The aim of this work lies in the fact that knowledge of this clinical entity especially in endemic areas as in India will enable radiologists to guide the clinicians in proper diagnosis and adequate pre-operative planning.

A 4-year prospective study of septicemia in pediatric surgical patients at a tertiary care teaching hospital in Kuwait.

BACKGROUND: Critically ill children are at high risk for developing nosocomial infections that contributes to death in 4% of all pediatric intensive care unit admissions. This prospective study was undertaken to determine the prevalence of septicemia in the pediatric surgery department of a large tertiary care teaching hospital in Kuwait and to evaluate the risk factors, the microbial etiology, and the antimicrobial susceptibility pattern of the isolated microorganisms. METHODS: All patients admitted to the pediatric surgery department from January 2001 until December 2004 with the diagnosis of septicemia were included in the study, and the microbiologically proven cases were then analyzed. The patients' demographics and risk factors for sepsis were recorded. All positive blood cultures were subjected to identification and antimicrobial susceptibility testing by VITEK 2(bioMerieux, Marcy l'Etoile, France). RESULTS: Of 3408 patients suspected to have septicemia, 78 (2.3%) patients developed microbiologically documented septicemias, 26% of those were low-birth weight patients, and 82% were patients with congenital anomalies; 87% of those needed surgical intervention. More than 50% were admitted to the intensive care unit, and 80.5% needed ventilatory support. Fifty-seven percent had early onset septicemia. Gram-positive and gram-negative bacteria accounted for 54% and 39% of the septicemia cases, respectively, whereas Candida spp was responsible for 7%. More than 50% of the staphylococci were resistant to cloxacillin, and all gram-positives were uniformly susceptible to glycopeptides and linezolid. Gram-negative bacteria showed variable resistance to cephalosporins (65%), piperacillin/tazobactam (29%), and carbapenems (11%). The attributable mortality rate for these septic episodes was 19% mainly because of gram-negative bacteria and Candida. CONCLUSION: The main etiologic agents of neonatal septicemia were coagulase-negative Staphylococcus, Pseudomonas aeruginosa, and members of the family Enterobacteriaceae. Empirical therapy with piperacillin/tazobactam or carbapenems for gram-negative septicemia and glycopeptides for gram-positive septicemia was effective.