Current state of non-hematologic cancer-associated thrombosis at a tertiary care hospital in India

Abstract Introduction Cancer-associated thrombosis is a leading cause of morbidity and mortality in malignancy patients. Prophylactic anticoagulation is under-utilized and the cost of low-molecular-weight heparin (LMWH) and direct oral anticoagulants is a major barrier in developing countries. Material and methods A retrospective analysis was performed of all cancer-associated thrombosis patients attending the thrombosis clinic at a tertiary-level referral hospital based in North India between 2011 and 2015. Patient demographics and disease-related parameters were collected and analyzed. Results A total of 771 patients attended the thrombosis clinic during study period, of which 64 cases were malignancy-associated. Of these, 56% of the patients were female and 20% were bedridden. The median age was 48.5 years, adenocarcinoma (48%) being the most common histological subtype. Gynecological malignancies (30%) were the most common malignancies, followed by genitourinary (11%) malignancies. Most of the cases occurred during first year of diagnosis (51%), and only 14% occurred after 3 years. Most of the patients were on combined treatment. Almost 40% of the patients developed thrombosis within 30 days of surgical treatment. Lower limb thrombosis was the most commonly seen type (56%), while abdominal and pulmonary thrombosis were both seen in 5%. Patients were managed with LMWH and vitamin K antagonists (84.3%) and only 6.25% with LMWH alone. Direct oral anticoagulants were not commonly used during the study period. Discussion At the hospital studied, most of the cases occurred early in the disease course. Postoperative prophylaxis could have contributed towards reducing thrombosis in the peri-operative period. Early suspicion and prompt treatment can improve quality of life in such patients.

Study of Inflammatory Markers in Chronic Obstructive Pulmonary Disease

Introduction: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is the sudden worsening of symptoms of COPD like shortness of breath, increased quantity and color of sputum, and systemic inflammation, and has a significant impact on survival. Biomarkers such as high-sensitivity C-reactive protein (hsCRP) and procalcitonin have been studied in AECOPD patients as prognostic markers. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are two new inflammatory markers and play a significant role in prognosis in patients with AECOPD. NLR and PLR are easily available and cost-effective markers and have the potential for helping in the risk stratification of hospitalized AECOPD patients. Aim: Study of inflammatory markers in COPD and their correlation with clinical outcome. Methods: A prospective observational comparative study was conducted on 100 patients of COPD at the Department of General Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, and all necessary investigations were done. Results: A total of 100 patients of COPD were taken, 50 patients were in a stable state (controls) and the same number of patients were in an acute exacerbation state (cases). Mean levels of NLR, hsCRP, and procalcitonin in cases were significantly higher as compared to controls whereas levels of PLR in cases and controls were comparable with no significant difference between them. Levels of both of these inflammatory markers (NLR and PLR) were positively correlated with levels of hsCRP and levels of procalcitonin. Of the total 50 patients, 23 (56.00%) patients needed mechanical ventilation and 11 (22%) needed inotropic support. Only 6 out of 50 patients (12.00%) died. Levels of NLR and PLR were positively correlated with the duration of hospitalization. Levels of NLR and PLR were not significantly associated with the need of inotropic support and mortality, levels of NLR were also not significantly associated with the need of mechanical ventilation whereas levels of PLR were significantly higher in patients who required mechanical ventilation. Conclusion: Levels of NLR were raised in patients with AECOPD (cases) than stable state COPD patients (controls). So levels of NLR can be used as a marker to predict acute exacerbation and there was a positive correlation of NLR and PLR with levels of hsCRP and procalcitonin.

Severity and Cardiac Involvement in Multisystem Inflammatory Syndrome in Children

Multisystem infammatory syndrome in children (MIS-C) occurs secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A retrospective study, involving 6 tertiary-care centers in Haryana, was conducted to evaluate the clinical features, severity, laboratory fndings, and outcomes of patients with MIS-C. Disease severity was graded (mild/ moderate/severe) and presence of cardiac abnormalities noted. Patients with and without cardiac abnormalities and with and without severe disease were compared. Forty-eight children with MIS-C were included (median age - 9.5 y). Fever (100%), gastrointestinal (83.3%) and mucocutaneous (50%) symptoms were common. Only 16.7% patients had previous history of documented SARS-CoV-2 infection/contact. Severe disease and cardiac abnormalities were seen in 47.9% and 54.2% patients, respectively. NT-proBNP>1286.5 pg/mL and thrombocytopenia (?119500/µL) were signifcant risk factors for severe MIS-C. Forty-fve patients (93.8%) recovered and 3 died. Median hospitalization duration was 7 d (5–9.5). MIS-C must be considered as a possibility in any febrile child, even if a positive epidemiological history is absent. High NT-proBNP and thrombocytopenia are signifcant risk factors for severe MIS-C.

Epidemiological scenario of leprosy in marginalized communities of India: Focus on scheduled tribes

The Scheduled Tribes (STs) are designated among the most disadvantaged social groups in India. Until the year 2005 (pre-elimination era of leprosy in India), several leprosy-specific control field programmes were implemented, which have been discontinued subsequently. Since then, leprosy diagnosis and treatment have been integrated with General Health Services. Thereafter, specialized expertise for the early diagnosis of leprosy has been gradually diminishing, especially at the peripheral clinics in remote areas. Hence, leprosy cases usually remain undetected for a long time and persist as endemic reservoirs. The tribal population of India accounts for just 8.6 per cent of the overall population. However, 18.5 per cent of the new leprosy cases were detected within the tribal community in the year 2020, indicating a disproportionately high burden of leprosy among the tribal population. Recent data suggest that these health disparities can be mainly related to the increased marginalization of STs as compared to other communities. This shows the need to further explore the current situation of leprosy in STs so that suitable interventions can address the contributing factors, leading to health inequalities in disadvantaged socio-economic groups. Therefore, this review aims to present the current distribution of leprosy in marginalized communities with a special emphasis on STs. Further, this review discusses how resources might be mobilized for such communities to find and treat undetected leprosy patients in STs to enable effective control of leprosy through early detection and timely treatment.

STUDY TO CORRELATE HISTOPATHOLOGICAL FINDINGS WITH ENDOMETRIAL THICKNESS EVALUATED BY TRANSVAGINAL SONOGRAPHY IN POST MENOPAUSAL BLEEDING

almost ninety percent of post-menopausal females with endometrial cancer report a vaginal bleeding experience. Objectives: To ?nd correlation of radiological and histopathological ?ndings so that early evaluation of malignancy can be done. The Present Study included 50 Patients with abnormal uterine Materials And Methods: bleeding in postmenopausal women, aged between 45-70 years. All patients were subjected to transvaginal ultrasonographic evaluation of the endometrium and the results were correlated to the histopathological picture of the endometrium after curettage in an attempt to discriminate normal endometrium from abnormal pathological patterns. Results And Analysis: Thirteen patients (26%) had pathological ?ndings. There was signi?cant difference in the mean endometrial thickness of non- pathological and abnormal endometrium in postmenopausal patients with P value <0.001**. Among the thirteen patients with pathological ?ndings eight had endometrial hyperplasia, two had polyp and three had malignancies. It may be Conclusions: concluded that vaginal sonographic measurement of endometrial thickness is an acceptable less invasive alternative to hysteroscopy and D & C and needs to be popularized as ?rst line investigation in the management of Postmenopausal bleeding in rural population

A COMPARATIVE RANDOMISED STUDY OF EFFECT OF INTRATHECAL CLONIDINE AS AN ADJUVANT TO INTRATHECAL LEVOBUPIVACANE AT DIFFERENT DOSES TO DETERMINE THE OPTIMUM DOSE IN LOWER ABDOMINAL SURGERIES

Background and Aims: Clonidine is widely used as an adjuvant to spinal anaesthesia to improve quality of anaesthesia but with haemodynamic side effects with increasing dose. We have conducted a study to observe the effects of Clonidine as an adjuvant to intrathecal isobaric levobupivacaine at different doses in terms of time to onset, duration and quality of block along with hemodyanamic changes to determine the optimal dose. Seventy-?ve Methods: patients were divided randomly in three groups of 25 patients each who got admitted for lower abdominal surgeries. Group LC15: 0.5% 15mg 3 ml levobupivacaine with Clonidine 15?g (0.1ml) and 0.4cc of normal saline. Group LC30: 0.5% 15mg 3 ml levobupivacaine with Clonidine 30?g (0.2ml) and 0.3ml of normal saline. 0.5% 15mg 3 ml levobupivacaine with Group LC45 : Clonidine 45?g (0.3ml) and 0.2ml of normal saline. volume of drug was equal in all three groups. The time to onset of Results: sensory as well as motor block was decreased in dose dependant manner, was least in group LC45 and most in group LC15 (Pvalue=0.0001). The two segment regression, duration of analgesia was most in group LC45 (Pvalue=0.0001). There was signi?cant fall (>80%) in blood pressure in group LC45 seen in 9 cases out of 25 (36%) than in group LC30 seen in 3 cases out of 25 (12%) and LC 15 seen in 0 cases. the optimum dose of Clonidine as an adjuvant to spinal anaesthesia given Conclusion: with intrathecal isobaric levobupivacaine 0.5% was 30?g with dose dependant decrease in duration to onset of sensory and motor blockade and prolonged postoperative analgesia with haemodynamic stability most with 30?g dose.

COVID-19 infection in patients with haematological disease - A tertiary centre experience from north India

This retrospective study was aimed to understand the clinical, laboratory, radiological parameters and the outcome of COVID-19 patients with underlying haematological disease. All patients with known haematological disease admitted with COVID-19-positive status from April to August 2020 in the COVID-19 facility of a tertiary care centre in north India, were included. Their medical records were analyzed for outcome and mortality risk factors. Fifty four patients, 37 males, were included in the study. Of these, 36 patients had haematological malignancy and 18 had benign disorder. Fever (95.5%), cough (59.2%) and dyspnoea (31.4%) were the most common symptoms. Nine patients had severe disease at diagnosis, mostly malignant disorders. Overall mortality rate was 37.0 per cent, with high mortality seen in patients with aplastic anaemia (50.0%), acute myeloid (46.7%) and lymphoblastic leukaemia (40.0%). On univariate analysis, Eastern Cooperative Oncology Group performance status >2 [odd ratio (OR) 11.6], COVID-19 severity (OR 8.2), dyspnoea (OR 5.7) and blood product transfusion (OR 6.4) were the predictors of mortality. However, the presence of moderate or severe COVID-19 (OR 16.6, confidence interval 3.8-72.8) was found significant on multivariate analysis. The results showed that patients with haematological malignancies and aplastic anaemia might be at increased risk of getting severe COVID-19 infection and mortality as compared to the general population

Hematological and biochemical reference intervals of wild‑caught and inhouse adult Indian rhesus macaques (Macaca mulatta) / 한국실험동물학회지

Background@#Nonhuman primates are used for research purposes such as studying diseases and drug discovery and development programs. Various clinical pathology parameters are used as biomarkers of disease conditions in biomedical research. Detailed reports of these parameters are not available for Indian-origin rhesus macaques. To meet the increasing need for information, we conducted this study on 121 adult Indian rhesus macaques (57 wild-sourced and 64 inhouse animals, aged 3–7 years). A total of 18 hematology and 18 biochemistry parameters were evaluated and reported in this study. Data from these parameters were statistically evaluated for significance amongst inhouse and wild-born animals and for differences amongst sexes. The reference range was calculated according to C28-A3 guidelines for reporting reference intervals of clinical laboratory parameters. @*Results@#Source of the animals and sex appeared to have statistically significant effects on reference values and range. Wild-born animals reported higher WBC, platelets, neutrophils, RBC, hemoglobin, HCT, MCV, and total protein values in comparison to inhouse monkeys. Sex-based differences were observed for parameters such as RBCs, hemoglobin, HCT, creatinine, calcium, phosphorus, albumin, and total protein amongst others. @*Conclusions@#Through this study, we have established a comprehensive data set of reference values and intervals for certain hematological and biochemical parameters which will help researchers in planning, conducting, and interpreting various aspects of biomedical research employing Indian-origin rhesus monkeys.

Sustainable health financing system for India: The economic perspective

Health policy discussions in India have primarily centred around the low level of public health financing, ignoring that total health expenditure in India is at par with many other countries with similar economic development. India spends 3.7% of its gross domestic product (GDP) on healthcare, but the health outcomes are not commensurate with spending. We argue that simply increasing public health spending will not improve health outcomes unless inefficiencies in the existing health financing arrangements, public as well as private, are addressed. Using economic reasoning, we identify several allocative and technical inefficiencies in existing health financing arrangements. We argue that increasing resource allocation in the present pattern of financing may even worsen the situation. We give recommendations to correct inefficiencies in current health financing arrangements before more allocations are made to improve the performance of the health financing system.

Intracranial Inflammatory Myofibroblastic Tumor: A Review of 49 cases

Inflammatory Myofibroblastic Tumor (IMT) is a rare pathologic entity that was first described in 1973. This lesion is most commonly found in the lungs, but other organs' involvement has also been reported. Intracranial location of Inflammatory Myofibroblastic Tumor is rare, and the first case was reported in 1980. An intriguing fact about the intracranial IMT is its resemblance with meningioma on clinical presentation and neuroimaging. We came across a case of intracranial Inflammatory Myofibroblastic Tumor (IIMT) in a 27-year-old male who presented with recurrent episodes of seizures and was diagnosed as meningioma on neuroimaging. The lesion did not subside with medical management and kept on progressing in size. The patient had to undergo surgery, and diagnosis of Inflammatory Myofibroblastic Tumor was ascertained on histopathology. This 'surprise' diagnosis prompted us to review the literature on all cases of IIMTs reported to date to better understand the entity and its implications. In this review article, we present our observations regarding various studied parameters, including patient profile, clinical presentation, site of involvement, focality of the lesion, special associations, and lines of management of the 49 published cases of IIMTs.

Effect of Advanced Strengthening Program on Physical Fitness Test Performance in Injury Prone Pre-Military Trainee Cadets.

The pre military trainee cadets are mostly unaware about proper training techniques and because of their lack of knowledge they are prone to have musculoskeletal problems especially their shoulder, spine, and knee joint are more prone to any injury. So, in order to avoid injuries, effort was made to make them aware about the risk of getting injured and proper fitness techniques which will prevent their injuries as well as help them to improve fitness level and field performance also. We wanted to evaluate the effect of advance strengthening program on physical fitness test performance in pre-military trainee cadets.METHODSIn this comparative study, injury prone trainee cadets were randomly allocated in to two groups of 25 each with advanced training program. Group one did conventional type of routine exercise; group two followed advanced training protocol. Physical fitness test performance was assessed and compared between the two groups. Outcome measures were Burpees test, shoulder press, chin-ups, planks, leg press, 1600 meters running.RESULTSIn Burpees test, 37% improvement was seen by conventional exercise program; whereas, it was 63% for advanced strengthening exercise program. In shoulder press, 38% improvement was seen for conventional exercise program; whereas, it was 62% for advanced strengthening exercise program. In chin ups, 34% improvement was seen for conventional exercise program; whereas, it was 66% for advanced strengthening exercise program. In planks, 45% improvement was seen with conventional exercise program; whereas, it was 55% for advanced strengthening exercise program. In leg press, 39% improvement was seen with conventional exercise program; whereas, it was 61% with advanced strengthening exercise program. In 1600 meters running, 37% improvement was seen with conventional exercise program; whereas, it was 63% by advanced strengthening exercise program. P value was <0.0001 which is significant.CONCLUSIONSA significant improvement was found in muscle performance, and occurrence of injury was seen to be reduced with advanced training program in injury prone trainee cadets.

Unilateral absence of pulmonary artery: a radiographically occult cause of life-threatening hemoptysis

Unilateral absence or agenesis of pulmonary artery (UAPA) is a rare congenital abnormality with an estimated prevelance of 1 in 2,00,000 adults. The entity occurs commonly in association with other congenital heart diseases like septal defects or patent ductus arteriosus. The condition usually runs a benign clinical course with patients usually presenting clinically in adulthood with history of recurrent respiratory tract infections. Two such patients presented with recurrent respiratory tract infections, breathlessness and hemoptysis. The chest radiograph of first patient was reported as normal in the referring hospital, while that of second patient showed volume loss in left lung. CT Pulmonary Angiography (CTPA) was then performed which demonstrated the absence of right and left pulmonary arteries respectively in the first and second patients. Pulmonary artery branches were reformed distally by multiple collaterals arising from systemic arteries. The entire spectrum, including embryology, imaging features and management of UAPA are discussed. UAPA remains a potential cause for life-threatening hemoptysis, due to extensive collateralization associated with the condition. It is important for radiologists to be aware of this uncommon entity in order to suspect it on a routine chest radiograph, diagnose it and map associated collaterals on CTPA and also embolize the bleeding collaterals.

Chronic Nonhealing Ulcers ‒ Garhwal Region (Etiopathology, Microbiology with Susceptibility, Managements & Outcomes)

Introduction:Chronic nonhealing ulcers, with varied etio-pathologies, are difficult to manage and warrant meticulous, early and prolonged directed treatment to prevent their development and complications.Methods:Patients of chronic ulcers (>3 months’ duration), having undergone surgical management at our Institute, VCSGGMS&RI-UT, between January 2018 –August 2019, numbering one hundred twenty five (N= 125), were included in this concurrent observational study, aimed at identifying implicated microrganism(s) and their antibiotic susceptibility, for promoting wound healing, along with surgical measures Results:Male patients (M:F :: 87:38; 69.6% males) in the “20-50 year” age-group (74; 59.2%), with diabetic ulcers (35;28.0%), burns etc. (21;16.8%) and traumatic ulcers (18;14.4%) etc. predominated in the chronic non-healing state. Gram positive (68; 54.4%) organisms (including Staphylococcus) were the major isolates from the ulcers; organisms showing higher sensitivity to the newer generations/groups of antibiotics. Uncontrolled Diabetes, other prolonged illnesses &/or under-nutrition were important causative factors, requiring their remediations and also debridements ± skin/flap coverage (45; 36.0%) with prolonged course of antibiotics and occasional amputations (18; 14.4%) for adequate treatment.Conclusion:Skilled intensive multidisciplinary effort is essential to achieve satisfactory healing and prevent disfigurement and to limit disability and death (11; 8.8%) among the patients.

Role of PfGCN5 in nutrient sensing and transcriptional regulation in Plasmodium falciparum

Malaria is a deadly, infectious disease caused by the parasite Plasmodium, leading to millions of deathsworldwide. Plasmodium requires a coordinated pattern of sequential gene expression for surviving in bothinvertebrate and vertebrate host environments. As parasites largely depend on host resources, they also developefficient mechanisms to sense and adapt to variable nutrient conditions in the environment and modulate theirvirulence. Earlier we have shown that PfGCN5, a histone acetyltransferase, binds to the stress-responsive andvirulence-related genes in a poised state and regulates their expression under temperature and artemisinintreatment conditions in P. falciparum. In this study, we show upregulation of PfGCN5 upon nutrient stresscondition. With the help of chromatin immunoprecipitation coupled high-throughput sequencing (ChIP-seq)and transcriptomic (RNA-sequencing) analyses, we show that PfGCN5 is associated with the genes that areimportant for the maintenance of parasite cellular homeostasis upon nutrient stress condition. Furthermore, weidentified various metabolic enzymes as interacting partners of PfGCN5 by immunoprecipitation coupled withmass spectroscopy, possibly acting as a sensor of nutrient conditions in the environment. We also demonstratedthat PfGCN5 interacts and acetylates PfGAPDH in vitro. Collectively, our data provides important insights intotranscriptional deregulation upon nutrient stress condition and elucidate the role of PfGCN5 during nutrientstress condition.

Post-mortem findings in Staphylococcus aureus acute infective endocarditis

Infective endocarditis (IE) is a microbial infection of the heart valves or the mural endocardium that leads to the formation of vegetations composed of thrombotic debris and microorganisms often associated with the destruction of the cardiac tissues. Most of the infections are bacterial (bacterial endocarditis), although fungi and other microorganisms can be etiological agents. Causative organisms differ among the major high-risk groups. Virulent microorganisms like Staphylococcus aureus, commonly found on the skin, can infect normal or deformed valves and are responsible for 20-30% of all IE cases. Staphylococcus aureus is the major offender in IE among intravenous drug abusers. Acute infective endocarditis is typically caused by infection of a previously normal heart valve by a highly virulent organism (e.g., Staphylococcus aureus) that rapidly produces necrotizing and destructive lesions. These infections may be difficult to cure with antibiotics, and despite appropriate treatment, death can ensue within days to weeks. Here we present autopsy findings of a 31-year-old male patient who died of acute infective endocarditis caused by Staphylococcus aureus as the causative organism.

Electronic Nicotine Delivery Systems (ENDS): Smoking Cessation Tools or Escalating Nicotine Addiction

Introduction: Electronic nicotine delivery systems (ENDS)are used to smoke or ‘vape’, a flavoured solution containingnicotine, an addictive chemical found in cigarettes and tobaccoproducts. Contrary to popular belief that they are useful assmoking cessation tools, current data does not support thistheory. In fact, they cause various deleterious effects in bodyincluding death. Their use has seen exponential rise amongstyouth. We conducted a study in northern India to assess itsprevalent use and awareness amongst youth.Material and methods: A questionnaire with variousquestions related to ENDS was circulated amongst highersecondary schools and university students to ascertain theiruse and awareness amongst students regarding its usagepattern and health effects. After receiving first 200 confirmedresponses of use, the data was analysed.Results: First 200 confirmed users were obtained after 764responses. 82% were exposed to ENDS at an age of 15-20 years. 38% said vaping was ‘COOL’ and 32% started itbecause of nice flavours. 28% believed that ENDS are safeand 47% were either not sure or not aware. 41% were nowmore open to the idea of regular smoking.Conclusion: Nicotine is one of the most addictive drug andexposure of youth to ENDS predisposes them to nicotine atan early age. Understanding of the potential harmful effects ofENDS is not fully comprehended by them predisposing themto addiction. Therefore, the ban on ENDS by the governmentis justified.

Evaluation of thyroid nodule in pediatric population in a tertiary care hospital

Background: Thyroid nodules are commonly present in adult population but are rare in pediatric age group. Inspite of being rare, thyroid nodule have a higher chance of malignancy in children. Thus, pediatric patients presenting with thyroid nodule found clinically or incidentally should be worked up to rule out any possibility of malignancy. The besthesda system for reporting thyroid cytopathology (TBSRTC) is widely used for reporting in adults. The present study aims to use TBSRTC for pediatric thyroid lesions reporting.Methods: All pediatric patients with age ? 18 years presenting with thyroid nodule during January 2018 to April 2019 were included in the study, fine needle aspiration (FNA) was done and findings were compared with histology. Statistical analysis was done using SPSS version 18.Results: 42 pediatric patient were included in the study, out of which 2.38% were malignant and suspicious for nmalignant each and 83% were benign.Conclusion: TBSRTC is quite sensitive and specific reporting guideline in pediatric population as in adult population with 100% accuracy in diagnosing benign and malignant cases. This is useful for avoiding unnecessary surgeries.