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1.
Int J Rheum Dis ; 2022 May 10.
Artigo em Inglês | MEDLINE | ID: mdl-35535671

RESUMO

Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating central nervous system illness encountered in the setting of immunosuppressive conditions like human immunodeficiency virus / acquired immunodeficiency syndrome, autoimmune diseases and hematologic malignancies. We had a 54-year-old woman with systemic lupus erythematosus and coexisting autoimmune hepatitis who presented with progressive cognitive decline, right hemiparesis and ataxia who was found to have PML. She had severe CD4 lymphopenia. She was managed with low-dose prednisolone and plasma exchange after which she showed significant clinical improvement. This case highlights the diagnostic and therapeutic challenges encountered in managing a case of PML in the setting of autoimmune conditions with profound lymphopenia.

2.
Breast ; 64: 7-18, 2022 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-35462344

RESUMO

IMPORTANCE: Carboplatin increases the pathological complete remission (pCR) rate in triple negative breast cancer (TNBC) when added to neoadjuvant chemotherapy, however, evidence on its effect on survival outcomes is controversial. METHODS: The study was prospectively registered at PROSPERO (CRD42021228386). We systematically searched PubMed, Embase, Cochrane Central Register of Clinical Trials, and conference proceedings from January 1, 2004 to January 30, 2022 for relevant randomized clinical trials (RCTs) of (neo)adjuvant chemotherapy in TNBC patients, with carboplatin in the intervention arm and standard anthracycline taxane (AT) in the control arm. PRISMA guidelines were used for this review. Data were pooled using fixed and random effects models as appropriate on extracted hazard ratios (HR). Individual patient data (IPD)for disease free survival (DFS) and overall survival (OS) were extracted from published survival curves of included RCTs; DFS and OS curves for each trial and the combined population were reconstructed, and HR estimated. The primary outcome was DFS; OS, pCR, and toxicity were secondary outcomes. RESULTS: Eight trials with 2425 patients were included. Carboplatin improved DFS (HR 0.60; 95% CI 0.47 to 0.78; I2 45%, p < 0.001) compared with AT at trial level and IPD level (HR 0.66; 95%CI, 0.55 to 0.80, p < 0.001) analysis. The OS also improved with carboplatin at both trial level (HR 0.69, 95%CI 0.50 to 0.95, I2 41%, p = 0.02) and IPD level (HR 0.68; 95%CI, 0.54 to 0.87, p = 0.002) analysis. The pCR as expected, was better in the carboplatin arm (OR 2.11; 95% CI = 1.44-3.08; I2 67%, p = 0.009). Anaemia and thrombocytopaenia were higher in the carboplatin arm. CONCLUSION: and relevance: Carboplatin added to (neo)adjuvant chemotherapy in TNBC improves survival, as shown in both trial level and IPD analysis.

3.
Lung India ; 39(3): 247-253, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35488682

RESUMO

Background: Hypoxia in patients with COVID-19 is one of the strongest predictors of mortality. Silent hypoxia is characterised by the presence of hypoxia without dyspnoea. Silent hypoxia has been shown to affect the outcome in previous studies. Methods: This was a retrospective study of a cohort of patients with SARS-CoV-2 infection who were hypoxic at presentation. Clinical, laboratory and treatment parameters in patients with silent hypoxia and dyspnoeic hypoxia were compared. Multivariate logistic regression models were fitted to identify the factors predicting mortality. Results: Among 2080 patients with COVID-19 admitted to our hospital, 811 patients were hypoxic with SpO2 <94% at the time of presentation. Among them, 174 (21.45%) did not have dyspnoea since the onset of COVID-19 symptoms. Further, 5.2% of patients were completely asymptomatic for COVID-19 and were found to be hypoxic only on pulse oximetry. The case fatality rate in patients with silent hypoxia was 45.4% as compared to 40.03% in dyspnoeic hypoxic patients (P = 0.202). The odds ratio of death was 1.1 (95% CI: 0.41-2.97) in the patients with silent hypoxia after adjusting for baseline characteristics, laboratory parameters, treatment and in-hospital complications, which did not reach statistical significance (P = 0.851). Conclusion: Silent hypoxia may be the only presenting feature of COVID-19. As the case fatality rate is comparable between silent and dyspnoeic hypoxia, it should be recognised early and treated as aggressively. Because home isolation is recommended in patients with COVID-19, it is essential to use pulse oximetry in the home setting to identify these patients.

6.
Lung India ; 39(1): 16-26, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-34975048

RESUMO

BACKGROUND: The "second wave" of the COVID-19 pandemic hit India from early April 2021 to June 2021. We describe the clinical features, treatment trends, and baseline laboratory parameters of a cohort of patients with SARS-CoV-2 infection and their association with the outcome. METHODS: This was a retrospective cohort study. Multivariate logistic regression models were fitted to identify clinical and biochemical predictors of developing hypoxia, deterioration during the hospital stay, and death. RESULTS: A total of 2080 patients were included. The case fatality rate was 19.5%. Among the survivors, the median duration of hospital stay was 8 (5-11) days. Out of 853 (42.3%%) of patients who had COVID-19 acute respiratory distress syndrome at presentation, 340 (39.9%) died. Patients aged >45 years had higher odds of death as compared to the 18-44 years age group. Vaccination reduced the odds of death by 40% (odds ratio [OR] [95% confidence interval [CI]]: 0.6 [0.4-0.9], P = 0.032). Patients with hyper inflammation at baseline as suggested by leukocytosis (OR [95% CI]: 2.1 [1.5-3.1], P < 0.001), raised d-dimer >500 mg/dL (OR [95% CI]: 3.2 [2.2-4.7], P < 0.001), and raised C-reactive peptide >0.5 mg/L (OR [95% CI]: 3.7 [2.2-13], P = 0.037) had higher odds of death. Patients who were admitted in the 2nd week had lower odds and those admitted in the 3rd week had higher odds of death. CONCLUSION: This study shows that vaccination status and early admission during the inflammatory phase can change the course of illness of these patients. Improving vaccination rates and early admission of patients with moderate and severe COVID-19 can improve the outcomes.

7.
Cureus ; 13(9): e17770, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34659981

RESUMO

COVID-19 produces pulmonary symptoms in the majority of symptomatic patients. However, demyelinating illnesses of the central and peripheral nervous system are reported in few patients. We report a case of multifocal demyelination involving the peripheral nerves as well as the optic nerve who developed these symptoms while on corticosteroid therapy, which was being given for treating the COVID-19-related inflammatory state. He improved with a short course of steroids. This is the first reported case of multifocal demyelinating neuropathy in relation to COVID-19 to the best of our knowledge. Though there have been reports of COVID-19-associated central nervous system and peripheral nervous system demyelinating illness, whether COVID-19 is causative or just an association is yet to be discerned.

8.
BMJ Case Rep ; 14(9)2021 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-34580133

RESUMO

Progressive multifocal leukoencephalopathy can complicate the course of a patient with sarcoidosis. Here we present a rare case of a 35-year-old patient with pulmonary sarcoidosis whose course was complicated by progressive multifocal leukoencephalopathy involving the cerebellum. Neuroimaging and cerebrospinal fluid PCR played a crucial role in the diagnosis.


Assuntos
Leucoencefalopatia Multifocal Progressiva , Sarcoidose Pulmonar , Adulto , Cerebelo , Humanos , Leucoencefalopatia Multifocal Progressiva/complicações , Leucoencefalopatia Multifocal Progressiva/diagnóstico , Imageamento por Ressonância Magnética , Neuroimagem , Sarcoidose Pulmonar/diagnóstico , Sarcoidose Pulmonar/diagnóstico por imagem
9.
Lung India ; 38(5): 494-496, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34472533
10.
Ann Indian Acad Neurol ; 24(1): 11-14, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33911373

RESUMO

The ongoing COVID-19 pandemic has precipitated a global health crisis. Non-COVID diseases across specialties have been significantly compromised. The greatest challenge has been to continue providing care to non-COVID cases with minimum transmission risk to health care workers, patients, and caregivers. In this specter, better described as a medical holocaust, we present our experiences of dealing with acute neurological patients who could access our facility. We attempted to work on three key areas - initial screening using a more inclusive, dynamic checklist for COVID suspicion over and above the emergency triage, a mandatory initial holding on a separate floor of our inpatient service equipped with infection control strategies similar to a COVID-designated area, and daily screening of health care workers and caregivers for symptoms and possible exposures. It was a steep learning curve, a couple of close shaves, and many more lessons that went into the development of an algorithm that seems to be working well.

13.
Indian J Hematol Blood Transfus ; 37(3): 347-365, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33746378

RESUMO

Convalescent plasma is currently being used in the treatment of COVID-19. Recommendations regarding use convalescent plasma in COVID-19 requires systematic summaries of available evidence. We searched the databases Medline, Embase, Cochrane CENTRAL, Epistomonikos, Medrxiv and Biorxiv. Title/abstract screening, full text screening and data abstraction were carried out in duplicate by two reviewers. Pooled effect sizes and 95% confidence intervals were calculated using random effects meta-analysis. GRADE tool was used to rate the certainty of evidence. Twenty two studies were found eligible for inclusion: nine randomized controlled trials and thirteen cohort studies. Low certainty evidence from eight RCTs showed inconclusive effects of convalescent plasma on mortality at 28 days (OR 0.85, 95% CI 0.61 to 1.18). Low certainty evidence from thirteen cohort studies showed a reduction in mortality at 28 days (OR 0.66, 95% CI 0.53 to 0.82). The pooled OR for clinical improvement was 1.07 (95% CI 0.86 to 1.34) representing low certainty evidence. Evidence from three RCTs showed inconclusive effect of CP on the need for mechanical ventilation (OR 1.20, 95% CI 0.72 to 1.98). Four cohort studies reporting unadjusted estimates suggested a reduction in the need for mechanical ventilation with convalescent plasma (OR 0.80 95% CI 0.71 to 0.91, low certainty). Pooled estimates from 2 RCTs showed inconclusive effects of convalescent plasma on the proportion of patients with nondetectable levels of virus in nasopharyngeal specimens on day 3 (OR 3.62, 95% CI 0.43, 30.49, very low-quality evidence). The present review reports uncertain estimates on the efficacy of convalescent plasma in the treatment of COVID-19. There is low certainty evidence of a possible reduction in mortality and mechanical ventilation, a faster viral clearance and the absence of any serious adverse events. However, its efficacy for these outcomes requires evidence from good quality and adequately powered randomized controlled trials. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12288-021-01417-w.

18.
Ann Indian Acad Neurol ; 23(4): 536-538, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33223673

RESUMO

Normal-sized ventricles and absence of papilledema do not rule out shunt failure and raised intracranial pressure (ICP). Raised ICP can present with false localizing signs which may be cranial nerve palsies or extensive polyradiculopathy. Our patient with a history of ventriculoperitoneal (VP) shunt presented with rapidly progressive vision loss without papilledema, as well as multiple cranial nerve palsies and radiculopathy. Imaging did not reveal hydrocephalus, however, cerebrospinal fluid (CSF) manometry revealed high CSF opening pressure. After lumbar thecoperitoneal shunting, vision did not improve, but the rest of cranial nerve palsies and radiculopathy improved. In a patient in whom VP shunt is in situ, headache and vomiting should prompt evaluation for raised ICP though there is no ventriculomegaly of papilledema. Vision can be saved if raised ICP is suspected, CSF opening pressure measured at presentation and prompt surgery is performed.

19.
Seizure ; 83: 17-20, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33075672

RESUMO

PURPOSE: To compare epilepsy-related injuries in untreated or inadequately treated patients and patients on adequate treatment. METHODS: In a cross-sectional case-control study, seizure-related injuries in patients who were either on no treatment or inadequate treatment were compared with another group of patients receiving appropriate evidence-based epilepsy treatment. The inadequately treated patients or 'cases' were drawn from an outreach epilepsy clinic while the adequately treated patients or 'controls' were recruited from a tertiary care facility providing comprehensive epilepsy management. RESULTS: The odds of injury were eight times higher in inadequately treated patients or cases compared to the adequately treated patients or controls. After adjusting for gender, epilepsy duration, seizure frequency, current medication, and number of AEDs, the odds of injury were 15. 8 times higher in the cases. Major injuries such as burns, fractures, and tooth injuries were also higher in the cases. CONCLUSION: Untreated or inadequately treated epilepsy patients have a significantly higher risk of injuries. With adequate treatment, some of the risks of injury can be mitigated.


Assuntos
Epilepsia/terapia , Fraturas Ósseas/complicações , Convulsões/terapia , Traumatismos Dentários/etiologia , Adolescente , Adulto , Estudos de Casos e Controles , Criança , Pré-Escolar , Estudos Transversais , Feminino , Fraturas Ósseas/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Traumatismos Dentários/fisiopatologia , Adulto Jovem
20.
BMJ Case Rep ; 13(9)2020 Sep 21.
Artigo em Inglês | MEDLINE | ID: mdl-32958553

RESUMO

Primary leptomeningeal lymphomatosis is a rare disease with only a few hundred cases reported. We present a patient with a relatively short history of 25 days of headache followed by diplopia who was found to have primary leptomeningeal T-cell lymphoma without evidence of systemic lymphoma. The patient responded well to chemotherapy along with intrathecal medication and cranial irradiation and returned to a completely normal state of health. Not all chronic meningitis is due to infection or self-limiting inflammatory causes. It is important to consider lymphoma as a differential even in the absence of constitutional features such as loss of weight, appetite, night sweats, lymphadenopathy or hepatosplenomegaly. T-cell lymphoma with only Central Nervous system (CNS) involvement is a rare cause of chronic meningitis, which is eminently amenable to treatment and is fatal if missed.


Assuntos
Linfoma de Células T/diagnóstico , Neoplasias Meníngeas/diagnóstico , Meningite/etiologia , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Doença Crônica/terapia , Irradiação Craniana , Ciclofosfamida/uso terapêutico , Dexametasona/uso terapêutico , Diagnóstico Diferencial , Doxorrubicina/uso terapêutico , Febre/etiologia , Febre/terapia , Cefaleia/etiologia , Cefaleia/terapia , Humanos , Injeções Espinhais , Linfoma de Células T/líquido cefalorraquidiano , Linfoma de Células T/complicações , Linfoma de Células T/terapia , Imageamento por Ressonância Magnética , Masculino , Neoplasias Meníngeas/líquido cefalorraquidiano , Neoplasias Meníngeas/complicações , Neoplasias Meníngeas/terapia , Meninges/diagnóstico por imagem , Meningite/terapia , Metotrexato/administração & dosagem , Resultado do Tratamento , Vincristina/uso terapêutico
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