A study on awareness and perception about perinatal death auditing among health care workers in two districts of Karnataka State, India.

Background: To start perinatal death auditing, doctors should have good knowledge about it. Objectives: To know the awareness and perceptions of doctors about different aspects of perinatal death auditing like 1) different types of contributors; 2) high-risk approach; 3) consequences; 4) documentary requirements; and 5) existing system of mortality meeting/child death reviews. Methodology: The perinatal death auditing project was implemented in two districts of Karnataka state. As a part of the pre-intervention survey, awareness and perceptions of doctors and a few health care administrators were explored. They were requested to participate in the study. Those who consented were approached in their hospitals and interviewed. Trained medical social workers conducted the interviews. Awareness was scored from 0 to 3 with 0 being no knowledge and 3 being good knowledge. Perceptions were scored from 0 to 3 with 0 being no negative perceptions and 3 being fear of legal consequences. The responses were documented, scored, and described. Results: Though 22 doctors were eligible, only 16 consented to participate in the study. Knowledge of doctors about different contributors was inadequate. They were apprehensive about legal consequences. They knew that documentation could protect them and be useful in a court of law. They were not clear about the conduct of mortality meeting/existing system of child death reviews. Conclusion: Knowledge was inadequate. They were apprehensive about legal consequences. Training of doctors and allaying apprehensions are required for starting perinatal death auditing.

Evaluation of factors influencing lymph node metastasis in endometrial cancers: A retrospective study.

OBJECTIVES: The role of lymphadenectomy in the management of early endometrial cancer remains controversial. The aim of our study was to evaluate risk factors associated with nodal metastases in endometrial cancer and to devise a predictive risk model based on the significant risk factors in predicting node metastasis. MATERIALS AND METHODS: A retrospective study was conducted on women diagnosed with uterus-confined endometrial cancer, and who underwent surgical staging with pelvic and/or paraaortic lymphadenectomy from our center during July 1, 2017 to June 30, 2019. Clinical details, Magnetic Resonance imaging (MRI)-detected myometrial invasion, and pre and post-operative histological details of tumor were correlated with pelvic and/or para-aortic lymph node metastasis. Risk factors were assessed using logistic regression model and risk models devised. RESULTS: 128 patients were included in the study. Paraaortic lymphadenectomy was done in 72.7% patients. Nodal metastasis was seen in 14.8% of patients. Logistic regression analyses revealed lymphovascular invasion (P = 0.002), parametrial involvement (P = 0.017) and nonendometrioid histology (P = 0.004) to be significant risk factors. Tumor size >2 cm, grade 3 and deep myometrial invasion had higher risk for nodal metastasis, although non-significant. Risk models were derived with sensitivity of 79-89.5%, specificity of 58.7-69.7%, Negative predictive value (NPV) of 95-97% and accuracy of 63-71%. CONCLUSION: Lymphovascular invasion, nonendometrioid histology and parametrial involvement are independent predictors of lymph node metastasis in endometrial cancer. Risk models using these risk factors can better predict the risk of nodal metastasis and thus avoid lymph node dissection in low risk patients. Our risk models had reasonably good sensitivity in nodal metastasis prediction and require further validation.

MPNST of Uterine Round Ligament: A Report of a Surgically Challenging Aggressive Rare Case and Literature Review.

MPNSTs (malignant peripheral nerve sheath tumours) arise rarely from the female genital tract, even more rarely from the uterus. A literature review showed 18 cases affecting the uterine cervix, but only four affecting the uterus per se, making our present case the fifth to be involving the uterus, specifically round ligament. It was the first time a uterine lesion (not uterine cervix) was defined in a neurofibromatosis patient. This was a young patient who initially underwent a uterus-sparing surgery for a round ligament tumour which was finally diagnosed to be MPNST. She received adjuvant chemotherapy but recurred with pelvic vascular involvement. A challenging surgery was performed, and the tumour was resected without morbidity. She was followed up with radiotherapy; however, she quickly developed extensive peritoneal disease and succumbed to the disease. High-grade nature of MPNST along with the background of NF could have made the tumour more aggressive, highlighting the importance of suspecting MPNST in spindle cell tumours of pelvis and performing total resection in the first setting.

Molecular diagnosis of bacterial and viral diarrhoea using multiplex-PCR assays: An observational prospective study among paediatric patients from India.

PURPOSE: In developing countries, the aetiology of diarrhoea goes undiagnosed as only microscopy, stool culture or enzyme immunoassay are done to find the causative agent. The present study aims to detect common paediatric viral and bacterial diarrhoea pathogens by microscopy, stool culture for bacteria, and multiplex polymerase chain reaction (mPCR) for bacteria and virus detections. MATERIALS AND METHODS: Diarrheal stool samples (n â€‹= â€‹109) received at the laboratory from paediatric patients aged one month to 18 years were included in the study. They were cultured for common bacterial pathogens and simultaneously subjected to two multiplex PCRs one for the detection of Salmonella spp., Shigella spp., Enteroinvasive E.coli and Enteropathogenic E.coli, another for the detection of adenovirus, astrovirus, rotavirus and norovirus. RESULTS: Of the 109 samples cultured for bacterial aetiology, 0.9% (1/109) grew Salmonella enterica ser.Typhi and 2% (2/109) Shigella flexneri. By mPCR, 16% of samples (17/109) were positive for Shigella spp., 0.9% (1/109) for Salmonella spp., and 21% (23/109) for rotavirus. One sample (0.9%) had rotavirus and Shigella spp., which indicates mixed aetiology. CONCLUSIONS: Shigella spp. and rotavirus are the prime causative agents of childhood diarrhoea in our region. The rate of detection of bacterial aetiology by culture was poor. Isolation of pathogens by conventional culture helps to know the species, serotypes and antibiotic susceptibility of the pathogens. Virus isolation is cumbersome, time-consuming, and not available for routine diagnostic use. Therefore, real-time mPCR would be a better choice for early detection of pathogens, thereby ensuring timely diagnosis, treatment, and a reduction in mortality.

Breastfeeding Self-efficacy in COVID-19 Positive Postpartum Mothers in a Community Maternal Facility in South India: A Case Control Study.

Background: Breastfeeding experiences have altered during the COVID-19 pandemic. Breastfeeding self-efficacy is a strong determinant of the breastfeeding behaviour of women. We aimed to study breastfeeding self-efficacy and assess the perceived factors for breastfeeding hindrance in COVID-19 positive mothers in the postpartum period. Method: A facility based case-control study was conducted with 63 COVID-19 positive (cases) and 63 COVID-19 negative postnatal mothers (controls). A breastfeeding self-efficacy short form (BFSE SF) instrument measured Breastfeeding self-efficacy 24 to 48 hours post-delivery. Mothers who tested positive for COVID-19 were interviewed about perceived factors for breastfeeding hindrance. Data was analyzed by SPSS version 25. Descriptive statistics were used for maternal parameters. BFSE SF scores were compared by a t test. Results: The mean BFSE SF score of COVID-19 positive mothers was 53.14 which was significantly lower than the mean BFSE SF score of 56.52 of COVID-19 negative mothers (p=0.013). Mothers who had received postpartum breastfeeding advice had significantly higher BFSE SF mean scores (p= 0.031). Sixty-seven percentage of COVID-19 positive mothers reported fear of transmission of illness to the neonate as a hindering factor. Conclusions: Breastfeeding self-efficacy scores were significantly lower in COVID- 19 positive mothers. Higher breastfeeding self-efficacy scores were observed in mothers who had received postpartum breastfeeding advice. The fear of transmission of the COVID-19 illness to the neonate was perceived as a breastfeeding hindering factor in most of the mothers. These observations imply the need for professional lactation support programs.

Feasibility of Sentinel Lymph Node Sampling in Early-Stage Carcinoma Endometrium: Single-Institution Experience.

Introduction: Accurate surgical staging is an essential component in the management of carcinoma endometrium to assess the stage of disease and to tailor adjuvant treatment. Sentinel node technique was introduced as an alternative for extensive lymphadenectomy in early stages to avoid complications associated with lymphadenectomy. Aims and Objectives: To assess the detection rate and diagnostic accuracy of SLN mapping in patients with early-stage carcinoma endometrium. Materials and Methods: Prospective validation study involving 30 patients diagnosed to have early-stage carcinoma endometrium. Sentinel nodes were detected by combined methods of radio colloid dye and isosulphan blue dye injection. Results: Sentinel lymph node was detected in 19 patients (63.4%). 11 patients had no sentinel nodes. Total number of sentinel nodes isolated was 68 with a mean of 2.26 per patient (range 0-4). Ten (33.33%) patients had single sentinel node location, while 9 (30%) had more than 1 sentinel lymph nodes. Twelve patients had bilateral sentinel nodes, and the most frequent location of sentinel node was obturator, 19 (63.3%) especially on right hemi-pelvis. One patient had a hot para-aortic node, while none had blue para-aortic sentinel node. Average number of lymph nodes obtained by lymphadenectomy was 13 per patient (range 7-22). All patients with sentinel node had negative frozen report as well as in histopathology. Two patients in whom no sentinel nodes were detected by either techniques had metastatic nodes in histopathology report. Conclusion: Detection rate was maximum with radiocolloid dye, and it is better to utilize the technique for less graded tumours and endometrioid variants.

Uterine Sarcoma: Retrospective Study From A Single institute.

Abstract: Uterine sarcomas are heterogeneous group of tumours comprising 1% of gynaecological malignancies. There is lack of concences on optimal treatment of uterine sarcomas. This is because of lack of randomised controlled trials due to rarity of these tumours. Surgical management without spill remains the standard primary treatment. Most of the times uterine sarcomas are diagnosed postoperatively from histopathology report of either myomectomy or hysterectomy. This retrospective study analysed the clinico pathological characteristics, prognostic factors, treatment details and survival outcome of different types of uterine sarcomas. Materials and methods: This is a retrospective analysis of 59 patients of uterine sarcomas. All patients underwent surgery. Adjuvant chemotherapy or radiation treatment were given according to histopathological report and FIGO stage. Patients were followed up every three months for first two years and then every six months. Disease free survival (DFS) and Overall survival (OS) were calculated. Statistical analysis: The data were summarized using descriptive statistics as mean, percent and range. Survival probabilities were estimated using Kaplan-Meier method and the significance of difference between the survival curves were calculate using log-rank test. Results: Uterine sarcomas are rare and aggressive tumours of uterus. Majority of these tumours present in early stage. Surgery remains the main treatment modality. Role of adjuvant radiation treatment remains controversial. Tumour stage is the most important prognostic factor.

Can Flip-Chart Assisted Maternal Education Improve Essential New Born Care Knowledge and Skills? A Randomized Controlled Trial.

BACKGROUND: Despite the implementation of essential newborn care (ENC) by the World Health Organization, knowledge gaps among postpartum women persist. Inappropriate breastfeeding practices and lack of knowledge regarding ENC among mothers has resulted in higher neonatal mortality. PURPOSE: Our study focused on evaluating the effectiveness of flip-chart assisted postpartum maternal education in improving ENC knowledge and skills. MATERIAL AND METHODS: A single blind parallel randomized controlled trial was carried out with 120 primigravidae. Participants were allocated to the intervention group (IG) or the control group (CG) by block randomization. A pretested validated questionnaire was administered to participants in both groups within 24 h post-delivery. Women in the IG were provided flip-chart assisted education regarding ENC approximately 24 h post-delivery. Women in both groups received verbal advice on ENC from the postnatal ward nurses, as per the existing hospital policy. ENC skills were observed in all participants in postnatal wards by independent observers. 6 months later, knowledge retention was assessed and analyzed in both groups. RESULTS: Antenatal education remained at 32% among all postnatal women. Postnatal flip-chart-assisted maternal education had a significant impact on ENC skills in the IG (p < 0.01) and precipitated higher knowledge scores at the end of 6 months (p < 0.01) in the IG. CONCLUSION FOR PRACTICE: Flip-chart assisted education soon after delivery had a sustained effect on ENC knowledge and practices that persisted for 6 months post-delivery.

Improving Underweight Mothers' Essential Newborn Care During Early Infancy: A Single-Blinded, Parallel-Randomized, Controlled Trial.

OBJECTIVE: To evaluate the effectiveness of using a standardized Essential Newborn Care (ENC) module taught by pediatric residents on ENC skills and growth of offspring born to underweight primigravida mothers. STUDY DESIGN: This facility-based, single-blinded, parallel, randomized controlled trial was conducted between May 2018 and March 2019. Eighty-eight underweight primigravida mothers and their vaginally delivered offspring were blindly allocated into the intervention group (IG) or control group (CG). The IG mothers received education on ENC through pictorial aids, demonstrations, and practice sessions. All mothers received information from ongoing public health programs. A trained hospital nurse, blinded to the study, assessed the mothers' neonatal care skills on the second postnatal day. The infants were followed until 6 months. Weight, length, and head circumference were measured at birth and age 6 weeks, 10 weeks, 14 weeks, and 6 months (±1 week). RESULTS: Mothers in the IG had significantly better ENC skills in all domains (P < .001). Their infants had a statistically significant increase in weight (at 10 and 14 weeks and 6 months), length (at 14 weeks and 6 months), and head circumference (at 6 months). Infants' z-scores indicated significant improvements in anthropometry in the IG compared with the CG. At age 6 months, the number of infants with weight <3rd percentile decreased in the IG (from 20 of 44 to 5 of 41) and increased in the CG (from 17 of 44 to 22 of 42) compared with birth percentiles. CONCLUSIONS: An educational intervention to strengthen maternal ENC knowledge and skills soon after delivery improved physical growth in infants born to underweight primigravida mothers. TRIAL REGISTRATION: Clinical Trials Registry-India: CTRI/2018/04/013096.

Impact of Surgery on Extramammary Paget's Disease Vulva: a Case Series.

Extramammary Paget's disease is a rare neoplasm that may affect the vulva. It usually presents as a pruritic red eczematous lesion with islands of hyperkeratosis that is often mistaken for other benign conditions. There are no specific guidelines for the management of this disease. Surgical excision is the standard treatment but recurrences are common in spite of extensive surgery with negative margins. We report here a series of 7 cases of Paget's disease vulva treated by primary surgery. The series highlights some of the challenges in the diagnosis and management of Paget's disease vulva.

Evaluation of Factors Affecting Margin Positivity and Persistent Disease After Leep for Cervical Intraepithelial Neoplasia.

BACKGROUND: Cervical intraepithelial neoplasia (CIN) is the precursor lesion of cervical cancer. Untreated high-grade CIN significantly increases the risk of developing invasive cancer. Conization is the main treatment. Loop electrosurgical excision procedure (LEEP) is the most common conization method used. The study aims to assess the risk factors associated with positive margin and persistent disease after LEEP for CIN. MATERIALS AND METHODS: A total of 156 patients who underwent LEEP during 2011-2018 included in the study. We analyzed the socio-demographic characteristics, colposcopy details, dimensions of LEEP specimen (thickness, length, volume) and histopathology (margin positivity, grade). Persistent disease was histologically confirmed by repeat LEEP and hysterectomy. RESULTS: Margin positivity was noted in 33.3% (52) patients. Residual disease was noted in 26.2% (41) of the patients who had undergone a repeat LEEP or hysterectomy. There was a significant association between margin positivity and Swede score of 5 or more, a high-grade lesion on IFCPC score, inner margin involvement, LEEP done in a single pass. The cutoff for margin positivity was length of 0.513 cm and thickness of 0.35 cm. A significant association between residual disease and margin positivity, postmenopausal status, Swede score of 5 or more, high-grade lesion on IFCPC score, inner margin involvement was observed. The chance of residual disease was less if the cone specimen had minimum length of 0.775 cm and minimum thickness of 0.65 cm. CONCLUSION: When in doubt regarding the margins, it is always better to perform multiple passes for lesions with a high Swede score with an initial smear of HSIL. Postmenopausal women with inner margin positivity have a high chance of residual disease and should be either kept on close follow-up or consider a repeat procedure.

Comparison of urine albumin creatinine ratio with the pediatric index of mortality 2 score for prediction of pediatric intensive care unit outcomes.

BACKGROUND: Predicting morbidity and mortality in a pediatric intensive care unit (PICU) is of extreme importance to make precise decisions for better outcomes. AIM: We compared the urine albumin creatinine ratio (ACR) with the established PICU score, pediatric index of mortality 2 (PIM 2) for predicting PICU outcomes. METHODS: This cross-sectional study enrolled 67 patients admitted to PICU with systemic inflammatory response syndrome. Urine ACR was estimated on admission, and PIM 2 score was calculated. ACR was compared with PIM 2 for PICU outcome measures: the need for inotropes, development of multiple organ dysfunction syndrome (MODS), duration of PICU stay, and survival. RESULTS: Microalbuminuria was found in 77.6% of patients with a median ACR of 80 mg/g. ACR showed a significant association with the need for inotropes (p < 0.001), MODS (p = 0.001), and significant correlation to PICU stay (p 0.001, rho = 0.361). The area under the receiver operating characteristic curve for ACR (0.798) was comparable to that of PIM 2 (0.896). The cutoff value of ACR derived to predict mortality was 110 mg/g. The study subjects were divided into 2 groups: below cutoff and above the cutoff. Outcome variables, inotrope use, MODS, mortality, and PICU stay compared between these subgroups, were statistically significant. CONCLUSION: ACR is a good predictor of PICU outcomes and is comparable to PIM 2 for mortality prediction.

Pattern of Lymph Node Metastasis in Endometrial Cancer: a Single Institution Experience.

Surgical staging remains the standard primary treatment of endometrial cancer. Lymph node metastasis is the most important prognostic factor which helps in deciding adjuvant treatment. Extensive lymphadenectomy is associated with increased incidence of morbidity. The role of lymphadenectomy in surgical staging is still controversial especially in early stage disease. The surgico-pathological pattern of 155 patients with apparently stage 1 cancer endometrium who had undergone pelvic alone or pelvic and para-aortic lymph node dissection and its correlation to the grade of the tumour, myometrial infiltration and presence of peritoneal disease and incidence of peri-operative morbidity are analysed and described.

Hypothyroidism Presenting as Ovarian Cysts-a Case Series.

Ovarian cysts can be caused by endocrine disorders. Hypothyroidism causing ovarian cysts is an uncommon entity, but rarely does it cause an ovarian cyst which can mimic malignancy. We report three cases of ovarian masses which were referred to our institute suspecting malignancy. These patients on further evaluation were found to have severe hypothyroidism and started on thyroxine supplementation. There was dramatic symptomatic relief as well as resolution of the ovarian masses on subsequent imaging. Hypothyroidism should be considered in the differential diagnosis of bilateral multicystic adnexal masses to avoid inadvertent surgery.

A case report of acute disseminated encephalomyelitis following severe dengue in a child.

INTRODUCTION: Acute disseminated encephalomyelitis (ADEM) is a rare neurological complication seen in association with severe dengue infection. Here we report a case of a six-year-old male child with ADEM following dengue fever. CASE REPORT: A six-year-old boy was admitted with fever, hematuria, and melena of five days duration. On evaluation, the child had shock and features of coagulopathy. Dengue NS 1 antigen and IgM ELISA were positive. The child received treatment as per the 2009 WHO dengue protocol. On day seven of illness, he developed neurological symptoms. Magnetic resonance imaging (MRI) done on day eight of illness showed T2/FLAIR hyperintensities in bilateral frontoparietal subcortical deep white matter, occipital periventricular white matter, pons and cerebellar hemispheres, diagnostic of ADEM. He responded to intravenous methylprednisolone. He was discharged 2 weeks after hospitalization. His neurological examination was normal at follow up after a month. CONCLUSIONS: Early recognition and prompt treatment of ADEM in dengue can lead to a successful outcome without neurological deficits.

Comparative validity of microalbuminuria versus clinical mortality scores to predict pediatric intensive care unit outcomes.

BACKGROUND: Predicting the prognosis of patients admitted to the pediatric intensive care unit (PICU) is very important in determining further management and resource allocation. The prognostication of critically ill children can be challenging; hence, accurate methods for predicting outcomes are needed. PURPOSE: To evaluate the role of microalbuminuria at admission as a prognostic marker in comparison to standard Pediatric Risk of Mortality (PRISM) and Pediatric Logistic Organ Dysfunction (PELOD) mortality scores in children admitted to the PICU. METHODS: This cross-sectional study was conducted from January 2015 to October 2016. Eighty-four patients aged 1 month to 18 years admitted to the PICU of teaching hospitals for more than 24 hours were enrolled by convenience sampling method. Microalbuminuria was estimated by spot urinary albumin-creatinine ratio. PRISM and PELOD scores were calculated using an online calculator. Outcome measures were PICU length of stay, inotrope usage, multiorgan dysfunction, and survival. ACR was compared with mortality scores for predicting survival. RESULTS: Microalbuminuria was present in 79.8% with a median value of 85 mg/g (interquartile range, 41.5-254 mg/g). A positive correlation was found between albumin-creatinine ratio and PICU length of stay (P=0.013, r=0.271). Albumin-creatinine ratio was significantly associated with organ dysfunction (P=0.004) and need for inotropes (P=0.006). Eight deaths were observed in the PICU. The area under the curve for mortality for albumin-creatinine ratio (0.822) was comparable to that for PRISM (0.928) and PELOD (0.877). Albumin-creatinine ratio >109 mg/g predicted mortality with a sensitivity of 87.5% and specificity of 63.2%. CONCLUSION: Microalbuminuria is a good predictor of PICU outcomes comparable with mortality scores.