Predictors of mortality and nephrectomy in emphysematous pyelonephritis: a tertiary care centre study.

INTRODUCTION: Emphysematous pyelonephritis (EPN) is a deadly disease due to its associated morbidity and mortality. Attempts have been made to identify predictors of severity, mortality and need for nephrectomy in EPN with little success. METHODS: We conducted an ambispective study of EPN patients between March 2014 and September 2019. Retrospective data were collected which included age, sex, comorbidities, symptoms, signs, laboratory investigations including imaging, need for dialysis, management and any complications. All patients were then followed prospectively for renal dynamic scan, stone surgery or nephrectomy. Univariate analysis was performed to identify factors affecting mortality and need for elective nephrectomy. RESULTS: In total, 112 patients were included. Mean patient age was 50.01 years, 55% were female and 5% had bilateral involvement. Fever and flank pain were the most common symptoms. Diabetes was seen in 75% of cases and 30% of cases required haemodialysis at initial presentation. About 60% of patients improved with pigtail drainage. Need for nephrectomy was greater in Huang-Tseng stage 3a (14.8%). Huang-Tseng stages 3b and 4 had higher mortality rates (25%) than the other stages (2.2%). Twelve of 99 patients had non functional kidney on follow-up and underwent elective nephrectomy. Low platelet counts, high body mass index, septic shock, dialysis and higher Huang-Tseng stage were found to be predictive of mortality and renal parenchymal thickness on computed tomography scan was predictive of follow-up nephrectomy. CONCLUSIONS: Thrombocytopaenia, high body mass index, septic shock, haemodialysis and higher Huang-Tseng stage are predictors of mortality and renal parenchymal thickness <5mm is a predictor of poor salvage of affected kidney on follow-up.

Large distal ureteric stone with high burden urothelial cancer of the entire ureter and renal pelvis: a dual pathology.

Upper-tract urothelial cancer comprises only 3% of all urothelial cancers. Risk factors include tobacco smoking, recurrent urinary infection, urolithiasis and analgesic abuse. Urolithiasis-induced chronic inflammation leads to urothelial proliferation and eventual malignant transformation. The most common association is reported with squamous cell cancer. A 54-year man under evaluation for right flank pain was diagnosed with a large distal ureteric stone and urothelial cancer of the entire right ureter and renal pelvis. The patient underwent right nephroureterectomy and stone retrieval, with urinary bladder cuff excision and pelvic lymph node dissection. On follow-up, the patient succumbed to disease recurrence with widespread metastasis. Urothelial cancer associated with stone disease is atypical. Long-standing inflammation causing metaplastic and dysplastic changes is a possible hypothesis. Careful assessment of the malignancy should be looked for in patients with long-standing obstruction due to stone disease.

Robot-assisted pelvic urologic surgeries: is it feasible to perform under reduced tilt?

To evaluate the feasibility and outcomes of performing robot-assisted pelvic surgery at a reduced angle of Trendelenburg position. This was a prospective case-control study of 67 patients in 2:1 ratio. Controls were operated with steep Trendelenburg position of 30°, whereas cases were operated using a graduated method to achieve minimal optimal angle of operating table. Various body habitus parameters, console time, blood loss, rise in mean arterial pressure (MAP) and end-tidal carbon-dioxide (ET-CO2), duration of ileus, postoperative stay and complications were recorded. All demographic profile and body habitus parameters were comparable among two groups except age which was lower in Reduced-Tilt group. Cases were operated at a mean angle of 20.5 ± 3.1° compared to 30° in control group. Rise in MAP, ET-CO2 and facial swelling were significantly low in Reduced-Tilt group compared to control. Notably blood loss, duration of ileus, postoperative stay and complications were also low in patients with Reduced Tilt. Various body habitus parameters were analysed with multiple regression analysis to predict minimal angle required for performing surgery with Reduced Tilt. BMI, xiphisterno-umbilical distance, umbilical-pubic-symphyseal distance and subcostal angle were found to predict the same. Robot-assisted pelvic surgeries can be performed in reduced Trendelenburg tilt which is associated with less hemodynamic and respiratory stress, complication rates and early postoperative recovery. BMI, subcostal angle, xiphisterno-umbilical distance and umbilical-pubic-symphyseal distance can predict the feasible angle of tilt.

Predictors of response to pulmonary rehabilitation in stable chronic obstructive pulmonary disease patients: A prospective cohort study.

Context: Pulmonary rehabilitation (PR) has become a standard of care in the management of chronic obstructive pulmonary disease (COPD). However, a significant proportion of the patients do not show benefit after the PR program. Aims: The study was planned to find different patient- and/or disease-related factors that may predict response to PR in stable COPD. Subjects and Methods: A total of 102 stable COPD patients were prospectively enrolled. Baseline evaluation and investigations, including spirometry, arterial blood gas analysis, and bone mineral density assessment, were done. Thereafter, all patients underwent an 8-week comprehensive outpatient PR program that consisted of exercise training, education, nutritional, and psychological counseling. The response to PR was dichotomously (yes/no) defined by the combined improvement in exercise tolerance (6-min walk distance [6MWD] +54 m) and quality of life (St. George's Respiratory Questionnaire [SGRQ] score - 4 points) measured before and after the program. Thereafter, different predefined factors were analyzed for their possible association with the PR response. Results: A total of 80 patients (78.4%) completed the PR program and were subjected for analysis. Out of them, 42 (52.5%) showed improvement in both 6MWD and SGRQ score (46 in 6MWD and 54 in SGRQ score). After application of multivariate logistic regression analysis, forced expiratory volume in 1 s <50% predicted (odds ratio [OR]: 2.9; 95% confidence interval [CI]: 1.1-8.3; P = 0.04) and osteoporosis (OR: 0.26; 95% CI: 0.13-0.53; P < 0.001) were found as independent factors predicting PR efficacy. Conclusions: Poor baseline lung function predicts a short-term improvement in exercise capacity and quality of life in COPD patients, whereas osteoporosis is a negative predictor of PR response. Active search for these factors may help in better patient selection, thus leading to improved outcome after PR.

Prevalence of allergic bronchopulmonary aspergillosis among patients with severe bronchial asthma in a tertiary care hospital in Northern India.

INTRODUCTION: The link between fungi and asthma has been known for centuries. About one-third to one-half of severe asthmatics has history of atopic sensitization to filamentous fungi, most predominantly to Aspergillus fumigatus. Allergic bronchopulmonary aspergillosis (ABPA) is the one of the most documented fungal presentations among patients with asthma. This study was done on 50 patients with severe asthma who were consecutively enrolled from January 2016 to June 2017 to look for prevalence of ABPA. MATERIALS AND METHODS: Blood samples were collected from 50 patients with severe asthma, and serum was separated to test for absolute eosinophil count, total IgE, and Aspergillus fumigates-specific IgE. RESULTS: The prevalence of ABPA was found to be 70% (35/50). Of these, ABPA-B (ABPA with bronchiectasis) was less 31.4% (11/35) when compared with 68.5% (24/35) of patients with serological ABPA. Out of these 35 patients, there were 18 females and 17 were males. The mean age of the patients was 41.3 years. CONCLUSION: ABPA prevalence is high in patients with severe asthma, and there is a need to look for and evaluate this association further.

Correlation of various histopathologic prognostic factors with Nottingham prognostic index and microvessel density in invasive breast carcinoma: A study of 100 cases.

BACKGROUND: Nottingham prognostic index (NPI) is a widely used integrated prognostic variable in patients with breast cancer. NPI has been correlated with tumor size, grade, lymph node stage and patient survival. The present study aimed at evaluating and correlating the various clinical and pathologic features of breast carcinoma with NPI. METHODS: This study included 100 consecutive cases of primary breast carcinoma over a period of 2 years. Demographic data was noted and histomorphological features like tumor size, grade, lymph node involvement, necrosis, vascular invasion etc., were assessed. NPI was calculated as reported in the literature. Immunohistochemical staining for hormone receptors and CD34 (to calculate microvessel density [MVD]) was performed. Statistical analysis was used for correlation. RESULTS: Of the 100 cases, 54% of the tumors were in T2 tumor size category (2-5 cm) and lymph node metastasis in 48% of the cases. NPI ranged from 2.3 to 7.3 with 54% of the cases in the intermediate NPI group (3.41-5.4). The mean MVD was 160.93 (±69.4/mm2). On statistical analysis, tumor size and grade, lymph node stage, mitotic rate, nuclear pleomorphism, necrosis and MVD showed a correlation with NPI (P < 0.05). CONCLUSION: NPI is an important and useful prognostic indicator for breast cancer patients, which shows the correlation with other histomorphological prognostic features as well.

Combat trauma-associated invasive fungal wound infections: epidemiology and clinical classification.

The emergence of invasive fungal wound infections (IFIs) in combat casualties led to development of a combat trauma-specific IFI case definition and classification. Prospective data were collected from 1133 US military personnel injured in Afghanistan (June 2009-August 2011). The IFI rates ranged from 0·2% to 11·7% among ward and intensive care unit admissions, respectively (6·8% overall). Seventy-seven IFI cases were classified as proven/probable (n = 54) and possible/unclassifiable (n = 23) and compared in a case-case analysis. There was no difference in clinical characteristics between the proven/probable and possible/unclassifiable cases. Possible IFI cases had shorter time to diagnosis (P = 0·02) and initiation of antifungal therapy (P = 0·05) and fewer operative visits (P = 0·002) compared to proven/probable cases, but clinical outcomes were similar between the groups. Although the trauma-related IFI classification scheme did not provide prognostic information, it is an effective tool for clinical and epidemiological surveillance and research.

Mortality profile of patients with traumatic spinal injuries at a level I trauma care centre in India.

BACKGROUND & OBJECTIVES: There is no national spinal trauma registry available in India at present and the research on epidemiology of these injuries is also very limited. The purpose of this study was to describe the mortality profile of patients with spinal injuries brought to a level I trauma centre in India, and to understand the predictive factors which identify patients at an increased risk of spinal trauma mortality. METHODS: Retrospective data were collected from computerized patients records and autopsy reports maintained in the department of Forensic Medicine. All the cases with spinal injuries whether in isolation or as a part of polytrauma were reviewed. A total of 341 such cases were identified between January 2008 to December 2011. The demographic data, type of trauma, duration of survival, body areas involved, level of spinal injury and associated injuries if any, were recorded. RESULTS: There were 288 (84.45%) males and 53 (15.55%) females. Most victims (73%) were between 25 and 64 yr of age, followed by young adults between 16 and 24 yr (19.35%). Male: female ratio was 5.4:1. Fifty five per cent cases had spinal injuries in isolation. Injury to the cervical spine occurred in 259 (75.95%) patients, thoracic spine in 56 (16.42%) and thoraco-lumbar spine in 26 (7.62%) patients. The commonest cause of injury was high energy falls (44.28%), followed by road traffic accidents (41.93%). The majority of deaths (51.6%) occurred in the phase IV (secondary to tertiary complications of trauma, i.e. >1 wk). Forty patients died in phase I (brought dead or surviving <3 h), 55 in phase II (>3 to 24 h) and 70 in phase III (> 24 h to 7 days). INTERPRETATION & CONCLUSIONS: Our data suggest that there is an urgent need to take steps to prevent major injuries, strengthen the pre-hospital care, transportation network, treatment in specialized trauma care units and to improve injury surveillance and the quality of data collected which can guide prevention efforts to avoid loss of young active lives.

Experience of 100 solid organ transplants over a five-yr period from the first successful pediatric multi-organ transplant program in India.

To analyze the clinical profile and outcome of pediatric patients who had undergone a liver and/or RT at our center over a five yr period, case records of all the patients who had undergone a liver or RT were analyzed retrospectively. One hundred solid organ transplants were performed at our center between January 2007 and January 2012. These included 50 liver, 44 renal, one sequential liver and renal, and two CLKT. BA was the most common indication for an LT (38%). At a median follow-up of two yr three months, the patient survival was 88%. The most common indication for an RT was chronic glomerulonephritis (54.5%). At a median follow-up of three yr, the survival was 91%. The CLKT were performed for hyperoxaluria. Two yr post LT, a sequential RT was performed for ESRD resulting from transplant associated microangiopathy. All patients received a living related graft. The common post-operative complications were infections, vascular complications, and graft dysfunction. Survival rates for liver and RT at our center are comparable to those in the established centers in the West.

In vitro and in vivo equivalence testing of nanoparticulate intravenous formulations.

The topic of bioequivalence evaluation of nanoparticulate intravenous formulations is one that has been intensely debated in recent times since the release of the specific recommendations by many regulatory authorities worldwide. Product specific bioequivalence guidelines for many of the nanoparticulate systems where therapeutic molecules are directly coupled (human albumin bound paclitaxel nanosuspension), functionalized (iron- carbohydrate preparations) or entrapped/coated to a carrier (doxorubicin liposomal formulations), have been approved by the drug regulatory agencies. These current regulatory procedures include complete characterization of the generic formulation in terms of its physicochemical characteristics, pharmacokinetics disposition and/or non clinical testing with respect to the reference formulation. The concept of in vitro equivalency is emerging as a valuable tool in these guidances as generic product differing in in vitro parameters can result in a different biopharmaceutical profile with respect to pharmacokinetics and biodistribution. Furthermore, in case of systems with entrapped drug, classical pharmacokinetic parameters alone may only ensure the equivalent clearance of test and reference product from systemic circulation but may fail to detect the extent to which the nanoparticles are taken up by different target organs and, consequently, the safety and efficacy effects. Hence, additional tissue distribution study in preclinical study models has reflected in recent guidances. Understanding and interpretation of these regulatory requirements thus presents most critical component of a generic product development cycle. This article reviews these current regulatory procedures with special emphasis on in vitro population bioequivalence (POP BE) and preclinical testing of generic formulations.

Tuberculosis lymphadenitis in a well managed case of sarcoidosis.

Differentiation between tuberculosis (TB) and sarcoidoisis is sometimes extremely difficult. Sequential occurrence of sarcoidosis and TB in the same patient is uncommon. We present the case of a young man, with a proven diagnosis of sarcoidosis who later developed TB after completion of treatment for sarcoidosis. A 32-year-old male patient presented with low-grade fever since two months. Physical examination revealed cervical lymphadenopathy. Initial fine needle aspiration cytology (FNAC) of the cervical lymph node was suggestive of granulomatous inflammation; the chest radiograph was normal. Repeat FNAC from the same lymph node was suggestive of reactive lymphoid hyperplasia. The patient was treated with antibiotics and followed-up. He again presented with persistence of fever and lymphadenopathy and blurring of vision. Ophthalmological examination revealed uveitis, possibly due to a granulomatous cause. His repeat Mantoux test again was non-reactive; serum angiotensin converting enzyme (ACE) levels were raised. This time an excision biopsy of the lymph node was done which revealed discrete, non-caseating, reticulin rich granulomatous inflammation suggestive of sarcoidosis. The patient was treated with oral prednisolone and imporved symptomatically. Subsequently, nearly nine months after completion of corticosteroid treatment, he presented with low-grade, intermittent fever and a lymph node enlargement in the right parotid region. FNAC from this lymph node showed caseating granulomatous inflammation and the stain for acid-fast bacilli was positive. He was treated with Category I DOTS under the Revised National Tuberculosis Control Programme and improved significantly. The present case highlights the need for further research into the aetiology of TB and sarcoidosis.

Unusual traumatic spondyloptosis causing complete transection of spinal cord.

BACKGROUND: Traumatic spondyloptosis is defined as greater than 100% of traumatic subluxation of one vertebral body in the coronal or sagittal plane which usually causes the complete transaction of spinal cord. It is a rare but severe injury of the vertebral column. We present four unusual cases of traumatic spondyloptosis causing complete spinal cord transaction, which were operated upon successfully. METHODS: We reviewed the imaging findings of four patients with traumatic thoraco-lumbar spondyloptosis from our radiology database, who presented to our trauma centre from August 2008 to September 2008. Four patients were identified with ages ranging from ten to 27 years. All patients had sustained high-energy closed spinal injuries. All patients underwent plain radiography, CT and MR imaging. RESULTS: Three patients had sagittal plane spondyloptosis and one patient had coronal plane spondyloptosis. Complete cord/cauda eqina transection was present in all patients. One patient had low lying cord with complete cord transection. All patients underwent surgery. Reduction of displacement with pedicle screw and rod fixation was carried out to realign the vertebral column. None of the patients recovered neurological function postoperatively. CONCLUSIONS: To conclude, traumatic thoraco-lumbar spondyloptosis is very rare and radiology plays an important role in the diagnosis and management of traumatic spondyloptosis. Surgical reconstruction and stabilisation allows for rehabilitation.

Role of KTP-532 laser in management of oral submucous fibrosis.

INTRODUCTION: Oral submucous fibrosis is a chronic disease characterised by progressive inability to open the mouth. Various treatment modalities are available for its management, but these have largely been ineffective. MATERIALS AND METHODS: Nine cases of oral submucous fibrosis underwent a release procedure using a KTP-532 laser, from March 2005 to January 2006, within the ENT-head and neck surgery department of a tertiary centre. RESULTS: Pre- and post-operative mouth-opening was compared using the Wilcoxon signed rank test, and a significant difference observed (Z = -2.690, p = 0.007). Follow up over an average period of 12 months showed encouraging results. CONCLUSION: This preliminary study indicated that adequate release of oral submucous fibrosis can be achieved by using a KTP-532 laser release procedure, with minimal morbidity and satisfactory results. These promising results should encourage more widespread use of this technique in the management of this condition.