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BACKGROUND There was a dramatic rise in the incidence of rhino-orbito-cerebral mucormycosis associated with the 2021 Covid-19 wave in India. We aim to document the demographic characteristics and risk factors of a consecutive cohort of inpatients with Covid-19-associated rhino-orbito-cerebral mucormycosis (CAROM) during the surge of April–June 2021. METHODS We included all patients of CAROM treated at our tertiary referral facility from 1 April to 14 June 2021. We prospectively gathered details with regard to Covid-19 illness and treatment, CAROM presentation, comorbid conditions and risk factors. RESULTS Our prospective cohort consisted of 200 consecutive patients, of which 146 (73%) patients tested positive on the Covid-19 RT-PCR test at presentation. CAROM occurred concurrent with the Covid-19 infection in 86%, and delayed CAROM after seeming recovery from Covid-19 was seen in 14%. Covid-19 was classified as mild, moderate and severe in 54%, 33% and 13%. The surge of CAROM followed the population peak of Covid-19 infections by about 3 weeks. Advanced disease at presentation was frequent with ocular involvement in 56.6% (111/196) and central nervous system involvement in 20% (40/199). One or more comorbid conditions were identified in 191/200 (95.5%) patients. The dominant associations were with diabetes (189/200; 94.5%) and uncontrolled hyper-glycaemia (122/133; 91.7%), recent steroid use (114/ 200; 57%), which was often considered as inappropriate in dosage or duration, lymphopenia (142/176; 80.7%), and increased ferritin levels (140/160; 87.5%). No evidence supported the role of previous oxygen therapy or previous nasal swab testing as risk factors for CAROM. CONCLUSION The inpatient volumes of CAROM were noted to parallel the Covid-19 incidence curve by about 3 weeks. Covid-19 infection may directly predispose to CAROM by way of lymphopenia and increased ferritin levels. Uncontrolled hyperglycaemia is identified as a near-invariable association. Recent steroid use is noted as very frequent and was often received in excess of treatment advisories.
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OBJECTIVE: To investigate the prognostic value of lymph node ratio (LNR) after neoadjuvant chemotherapy (NAC) according to breast cancer molecular subtypes. METHODS: From 2004 to 2014, patients with definitive surgery after NAC were identified. LNR was calculated for node positive patients who underwent axillary dissection and at least 10 nodes (LNT) were removed. Disease free and overall survivals were analysed using Kaplan-Meier test and compared using log rank test for ypN0-3, LNR categories (LNRC) ≤0.2 (low), 0.21-0.65 (intermediate), >0.65 (high), and single LNR cut-off value. RESULTS: Of 224 analysed patients: ypN0 72 (32.1%), ypN+ 152 (67.9%). Of 118 LNT ≥10 ypN+ patients LNRC: Low risk 48 (40.7%), intermediate risk 36 (30.5%), high risk 34 (28.8%). Factors significantly different in LNR categories were ypN (P < 0.001); extranodal extension (P < 0.001); present status of patients (P < 0.001); and disease status (P = 0.029). LNRC was inversely associated with 5-year DFS: Low 52.3%, intermediate 40%, and high 12.2% (log rank P < 0.001); and OS: Low 64.4%, intermediate 58.3%, and high 13.6% (log rank P < 0.001). Significant association of LNRC and DFS and OS were demonstrated in TNBC (P < 0.001) and HER2 subtypes (P = 0.045 and 0.005 respectively). A single value of LNR = 0.25 in node positive was found significant for DFS and OS in TNBC (P < 0.001) and Her2+ (P = 0.013 and P = 0.001 respectively) but not for HR+ (DFS: P = 0.132; OS: P = 0.144). CONCLUSION: Residual nodal disease after NAC analysed by LNRC or LNR = 0.25 cut-off value, is prognostic and can discriminate between favourable and unfavourable outcomes for TNBC and Her2+ breast cancers.
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CONTEXT: Infection is a major determinant in the outcome of patients with cancer. AIMS: The aim was to know the epidemiology and outcome of patients with cancer in a cancer care center in Eastern India. SETTINGS AND DESIGN: Retrospective study of pediatric patients in Tata Medical Center, Kolkata, India. Methods: Patients (n = 262) between the age group of 0 and 18 years were reviewed for infections and infection‑related outcome (January to December 2013). STATISTICAL ANALYSIS: Modified Wald method was used to determine confidence interval of proportions. RESULTS: Gram‑negative bacteria were found to be the most common cause of bloodstream infections (BSIs) (56.4%), followed by Gram‑positive cocci (34.5%), and Candida species (9.1%). Carbapenem‑resistance was noted among 24% of Gram‑negative bacilli (GNB), and extended‑spectrum beta‑lactamase among 64% of GNBs. A single case of Vibrio cholerae septicemia was also noted. No case of vancomycin‑resistant Enterococcus was observed, whereas only two cases of methicillin‑resistant Staphylococcus aureus bacteremia (1/3 of all Staphylococcus aureus bacteremia) were detected. Escherichia coli, followed by Klebsiella, Pseudomonas, and Acinetobacter were the predominant organisms detected in BSIs. Among Candida spp. BSIs no resistance to caspofungin, amphotericin B, Voriconazole was noted. Candida tropicalis was the most common isolate, and 1 isolate of Candida glabrata showed dose‑dependent sensitivity to fluconazole. Three out of 25 patients died of multi‑drug resistant Gram‑negative bacteria (12%) in 2013. Seventeen patients had radiological evidence of invasive fungal infections (no mortality was noted). CONCLUSIONS: Periodic review of infection‑related data, as well as infection control practices, is essential to optimize clinical outcome in patients with pediatric malignancies.
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BACKGROUND: Prevalence of subclinical involvement of motor pathways in clinically diagnosed Brachial Monomelic Amyotrophy (BMMA) is unknown. AIMS: To determine the prevalence of subclinical involvement of central motor pathways in BMMA using transcranial magnetic stimulation. SETTING AND DESIGN: Prospective case-control study. MATERIALS AND METHODS: Central motor conduction time (CMCT) was determined by 'F' wave method using figure-of-eight coil attached to Magstim 200 stimulator, in 17 patients with BMMA. Motor evoked potentials were recorded from first dorsal interosseous of the affected (AFF) and unaffected upper limbs (UNAFF) at rest and during partial contraction. Comparison was made with data from 10 healthy controls (CTRL). STATISTICAL ANALYSIS: Descriptive analysis and Analysis of Variance (ANOVA). RESULTS: Compared to controls, the mean CMCT of AFF was significantly prolonged, both at rest and contraction: (a) Rest: AFF-6.68+/-1.78 ms, UNAFF-6.36+/-1.16 ms, CTRL-5.71+/-1.02 ms; Fisher's PLSD for AFF vs. CTRL: P =0.037, (b) Contraction: AFF-5.78+/-1.62 ms, UAFF - 4.86+/-1.38 ms, CTRL-4.06+/-0.80 ms; Fisher's PLSD for AFF vs. CTRL; P =0.0002, AFF vs. UNAFF- P =0.044). Prolonged CMCT (>mean+2SD of controls) was observed in 29.4% of AFF and 6.25% of UNAFF at rest, and in 47.1% and 23.5% respectively during contraction. CONCLUSIONS: Dysfunction of central motor pathways was observed in both affected and unaffected upper limbs of some patients with BMMA of upper limbs. The dysfunction was more pronounced during voluntary contraction. A larger study is needed to validate the significance of these findings.