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Guillain-Barré syndrome (GBS) is an acute polyradiculoneuropathy. This is the first systematic clinical guideline, developed by an international task force using formal GRADE methodology. The diagnostic criteria remain primarily clinical, based on history and examination findings of acute progressive limb weakness and areflexia. Variants of GBS may include motor GBS, Miller Fisher Syndrome, and regional variants with weakness predominantly in lower limbs, face, or pharynx/neck/ arms. The differential diagnosis is wide. When uncertain, diagnosis may be assisted by nerve conduction tests, raised cerebrospinal fluid protein, and less often by MRI spine with contrast, or serum antibodies to gangliosides (especially for variants) or nodalparanodal antibodies (especially if not improving). Axonal versus demyelinating subtyping does not affect clinical management. A history of recent gastrointestinal or respiratory infection or of surgery may support the diagnosis. The risk of GBS is only very slightly increased after Covid-19 infection and after the adenovirus-vector vaccines to SARS-CoV2 (AstraZeneca or Johnson & Johnson) but not mRNA vaccines. Immune treatment is recommended with intravenous immunoglobulin or plasma exchange, for most patients except those mildly affected or after four weeks from onset. A repeat course is reasonable after a treatment-related fluctuation. Corticosteroids are not recommended. There is no evidence of benefi t from any other disease-modifying treatment. Respiratory function should be monitored by forced vital capacity and single breath count to assess the risk of needing mechanical ventilation, guided by the mEGRIS scale. Pain is very common. It may be musculoskeletal or neuropathic, and treated with gabapentin, tricyclic antidepressants or carbamazepine. Patients who fail to improve should be reassessed for the correct diagnosis and for axonal degeneration. Around 5% of patients with GBS may later develop CIDP but no test can reliably indicate this within the first eight weeks. Nodal-paranodal antibodies should be tested if CIDP is suspected or if the patient is not recovering well. The long-term outcome is less good in patients of older age, with preceding diarrhoea, or more severe weakness, as quantified by the mEGOS scale, and also in patients with smaller motor potential amplitudes or raised serum neurofilament light chain level.
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Introduction: Rhino-orbito-cerebral Mucormycosis (ROCM) is an uncommon but devastating fungal infection caused by Mucoraceae family fungi, which are angiotropic and filamentous, with significantly high morbidity and mortality despite treatment. Post Coronavirus Disease-2019 (COVID-19), there was a sudden surge in ROCM cases nationwide due to immunologically and metabolically compromised status. Aim: To describe retinal manifestations in ROCM in a tertiary eye care centre of Northern India. Materials and Methods: An analytic, cross-sectional and hospital-based study was conducted in Regional Institute of Ophthalmology, PGIMS Rohtak, Haryana, India, from May 2021 to September 2021. This study was conducted on 200 admitted patients of RCOM in the institute, which was only designated Nodal centre in Haryana, India. Detailed history was recorded in every patient regarding presenting symptoms, history of COVID-19, hospital stay, oxygen inhalation, steroid intake and immunisation. Thorough ocular examination was done in every patient including visual acuity, ocular movements and pupillary reactions. Dilated fundus examination was done by Indirect Ophthalmoscopy (IDO) for posterior segment evaluation. Contrast Enhanced Magnetic Resonance Imaging (CE-MRI) brain with orbit and Paranasal Sinus (PNS) was done in every patient to see the extent of spread and planning further management. Results: Out of 200 patients of ROCM, majority of patients (64/200) were of 51-60 year age group (32%) followed by 41-50 year age group (28%). Out of 200 cases of ROCM, 146 patients (73%) had history of COVID-19 infection in past and 134 (67%) patients had history of hospital stay during COVID-19 infection. Oxygen (O2) supplementation was given to 98 patients either at home or during hospital stay. History of steroid intake was present in 34 patients and 46 patients received injection Remedsivir. Only 12 patients had vaccine against COVID-19 and none of them were fully vaccinated. Most common presenting symptom was unilateral nasal stiffness (22%) followed by loss of vision (17%). Most common predisposing factor was Diabetes Mellitus (DM) in 78 patients (39%) followed by steroid intake in 34 patients (17%). Out of 200 patients, only 60 patients had retinal manifestations and most common was Central Retinal Artery Occlusion (CRAO) (35/60) and the main mechanism is the direct infiltration of central retinal artery due to angioinvasion of fungi from the orbit. Conclusion: CE-MRI brain with orbit is an important tool in diagnosing and monitoring progression of RCOM but it cannot provide information regarding retinal findings like CRAO, central retinal venous occlusion (CRVO), disc pallor and optic atrophy. Thus, the fundus examination of every ROCM patient should be emphasised, as it not only helps in categorising ROCM but also tells about the visual potential of affected eye. Patients with CRAO and combined vascular occlusion should be considered for exenteration on urgent basis, so that intracranial spread can be prevented and patient's life can be saved.
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INTRODUCTION: It is believed that greater time from diagnosis to surgery increases the likelihood of sentinel lymph node positivity for patients with melanoma who present with clinical N0M0 disease. There is a paucity of data, however, on a safe window for surgery, which has become particularly relevant during the COVID-19 pandemic. We sought to determine how the risk of N+ disease changed with increasing time to surgery, and to evaluate what may be a safe window for surgery. METHODS: We performed an IRB approved retrospective review of patients diagnosed with clinical N0M0 malignant melanoma who underwent wide local excision and sentinel lymph node biopsy at two institutions from 1/2018-6/2021. Student's t-test, Wilcoxon-Mann-Whitney, bivariate and multivariable logistic regression analyses were performed where appropriate. RESULTS: There were 437 patients identified, 140 (32%) surgically treated within 30 days, 238 (55%) 31-60 days, and 59 (13%) 60+ days post-diagnosis, 128 (29%) with positive sentinel lymph node(s) (Table with demographics). Time to surgery was not a significant predictor of N+ disease for 0-30 vs 31-60 days (OR 0.72;95% CI 0.46-1.13) or 0-30 vs 60+ days (OR 0.65;95% CI 0.33-1.29). This remained true adjusting for T-stage, mitosis, ulceration, and institution (OR 0.75 95% CI 0.45-1.20, and OR 0.62;95% CI 0.29-1.30, respectively), and when only examining T3-T4 lesions (OR 0.91;95% CI 0.46-1.83 and OR 0.88;95% CI 0.32-2.45, respectively). T-stage expectedly was the greatest predictor of N+ disease (T1 vs T2 OR 3.08;95% CI 1.44-6.59, vs T3 OR 5.89;95% CI 2.64-13.10, vs T4 OR 10.63;95% CI 4.08-27.68). CONCLUSIONS: Increased time from melanoma diagnosis to wide local excision and sentinel lymph node biopsy did not appear to significantly influence final nodal positivity rate in patients who presented with clinical N0M0 disease. These findings warrant further evaluation to determine if it is safe to wait up to 60 days or longer prior to undergoing surgical treatment for malignant melanoma.
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Background: Tuberculosis (TB) is a communicable disease that is a major cause of illness and one of the leading causes of death. Until the COVID-19 pandemic, TB was the leading cause of death from a single infectious agent, ranking above HIV. Multi drug-resistant TB remains a public health crisis. In this situation, an attempt of using the shorter course Regimen to face the MDR-TB crisis as an alternate method proves to be promising. Therapy of MDR-TB using shorter course regimen is crucial and essential to explore, as it has the potential to increase the success of MDR-TB treatment. Methods: The proposed study was a hospital based, nonrandomized and without control group observational and prospective study, in cohort of 180 DRTB patients conducted at Nodal DRTB Centre, SNMC AGRA. Results: Among 180 patients 54% were male and 46% female. Maximum number of patients 39% in 21-30 years of age group.48% patients were known to their contacts.54% patients developed resistance due to failure of previous regimen.126 patients were reported with adverse effects. Cough was the most common clinical feature.46 completed the treatment.39% patients were declared cured. Conclusion: 70% of the patients faced adverse events during the course. 1.6% patients required change in regimen.61% completed the treatment and 39% were declared cured.
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Background: Adjuvant endocrine therapy remains the standard of care for patients (pts) with early stage, HR+ BC who can safely omit chemotherapy based on RS results;however, the role of NET remains unclear. There are limited data regarding the optimal duration of treatment with NET and the ideal patient (pt) population for NET in terms of age and RS result. This question rose to critical importance amidst the COVID-19 pandemic, during which NET was utilized more broadly in attempts to delay surgery or chemotherapy while preserving optimal pt outcomes. This study re-examines the use of NET among a cohort of pts with HR+ BC randomized to NET or neoadjuvant chemotherapy (NCT) based on RS (performed on initial core biopsy specimens). Methods:Data were pooled from two independent studies performed at Emory's Winship Cancer Institute and Massey Cancer Center at Virginia Commonwealth University (VCU) from 2010-2012. These studies evaluated rates of clinical and pathologic complete response (pCR) among pts with early stage, HR+ BC assigned to treatment groups based on RS results. Pts with RS 0-10 received NET (Group (Grp) A), RS 11-24/25 (Emory 11-24 vs VCU 11-25) were randomized to NET (Grp B) or NCT (Grp SC), and those with RS 25/26-100 received NCT (Grp D). Associations between RS result, neoadjuvant therapy and pCR in the breast, lymph nodes (LN) and breast plus LN were evaluated using Fisher's exact test. Results:109 pts were included in this analysis. The Emory cohort was younger (median age 56 years (yrs) vs 63 yrs in VCU cohort) and more diverse (37.5% African American (AA) vs 18.6% AA in VCU cohort). The pts were predominantly post-menopausal (69.6% Emory vs 83.1% VCU). Nodal status among the Emory cohort was evenly divided with 50% N0 and 50% N+, while the majority of VCU pts were N0 (76.3% N0 vs 22.0% N+). Pts were grouped based on RS result: RS <11 (18% Emory vs 20.3% VCU), RS 11-24/25 (36% Emory vs 55.9% VCU) and RS 24/25 or higher (46% Emory vs 23.7% VCU). Pts with low RS result were older (median 64 yrs vs 59 yrs among RS > 24/25) with higher percentage of low-grade tumors (47.6% grade 1 vs 5.4% grade 1 among RS >24/25). With regard to pCR, there were no significant differences among pts with low or intermediate RS results, as no pts in these groups achieved pCR in the breast or breast + LN (Table). Pts with RS result 25/26-100 (Grp D) were the only pts shown to achieve pCR in breast + LN (18.9%, p= 0.0043 across groups). Notably, while pts on the Emory study received longer courses of NET (median 10 months vs 5.5 months), there were no significant differences in pCR across RS result subgroups noted between the two institutions. Conclusion:Our results demonstrate that the use of Oncotype DX Breast Recurrence Score® or other genomic assays in the neoadjuvant setting may help guide treatment decisions when considering the use of NET versus NCT. Pt age and length of endocrine therapy as well as pt preferences should be considered when determining neoadjuvant treatment plans. There are currently ongoing studies evaluating the use of NET with CDK4/6 inhibitors that will offer further insight into optimal neoadjuvant treatment strategies in HR+ BC. Subsequent phase III evaluation of the role of genomic assays in the neoadjuvant setting is feasible and may help determine whether NET + CDK 4/6 inhibitors could replace NCT for pts with higher RS values.
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Background: The COVID-19 pandemic has had many obvious consequences seen in the number of cases and deaths reported. It is suspected there are multiple unseen or unmeasured consequences as a result of increased pressures on the health service and redistribution of resources. We conducted a single-trust review of 2 week-wait colorectal cancer (CRC) referrals across an 11-month period from before the 1st lockdown to the 2nd lockdown to establish whether there was any change in the patients presenting and their cancers. Methods: Referrals were provided by cancer services and information collected from EPR. Referrals from January (Jan), April, May and November (Nov) 2020 were reviewed, these were considered as pre-COVID, 1st lockdown (April/May) and 2nd lockdown. Information was collected on initial assessments and investigations, pre-op staging, fitness for surgery, treatment and post-op staging. Data was analysed in Excel. Results: Total number of referrals was 1060. Of these 58 had CRC. The volume of referrals dropped in April (from 204 Jan to 158 April) then steeply increased to 438 in Nov. The proportion diagnosed with CRC increased across the year (Jan, April, May, Nov -3.7, 3.1, 8.1, 5.7% respectively). There was an increased time to colonoscopy from average 21 days in Jan to 54 in Nov. The percentage of patient unfit for surgery increased through the year (Jan 12.5%, April 25%, May 25% and Nov 34%). On pre-op staging Tumour (T) staging was significantly worse in Nov compared to Jan (p = 0.05). This significance did not remain for post-op staging, however there was a suggestion of it. There was no difference in Nodal or Metastatic staging across the year. Nodal staging was downgraded from pre-op to post-op staging. Discussion: As well as the direct consequence of the pandemic, this review demonstrates other indirect impacts with clear disruptions to CRC referrals and diagnosis pathway. There are now higher numbers being referred and longer times to diagnosis and treatment. The ongoing backlog of patients is causing significant delays in diagnosis. As a possible consequence of COVID-19 patients are becoming more unfit for surgery on initial diagnosis. Ultimately, you would assume this result in overall poorer mortality. With patient potentially presenting at a later T staging, are we going to see more long-term consequences like increased recurrence rates.
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Background: COVID-19 outbreak has correlated with the disruption of screening activities, regular follow up visits, and diagnostic assessments. The risk of misdiagnosis and delayed diagnosis has consequently increased during the pandemic. Endometrial cancer is one of the most common gynecological malignancies and it is often detected at an early stage, because it frequently produces symptoms (e.g. abnormal vaginal bleeding). Here, we aim to investigate the impact of COVID-19 outbreak on patterns of presentation and treatment of endometrial cancer patients. Material and methods: This is a retrospective study involving 53 centers in Italy. We evaluated patterns of presentation and treatment of endometrial cancer patients before (i.e. period 1: from 03/01/2019 to 02/29/2020) and during (i.e. period 2: from 01/04/2020 to 3/31/2021) the COVID-19 outbreak. Results: Medical records of 5,117 endometrial cancer patients have been retrieved: 2,688 and 2,429 women treated in period 1 and period 2, respectively. The prevalence of endometrioid International Federation of Obstetrics and Gynecologists (FIGO) grade 1, 2, and 3 was consistent over the study period (p=0.769). However, the prevalence of non-endometrioid endometrial cancer was lower in period 1 than in period 2 (15.7% vs. 17.9%;p=0.015). The characteristics and pattern of different surgical approaches were consistent in the two study periods (p=0.664). Before COVID-19 pandemic, 1,838 (73.2%), 647 (25.7%), and 25 (0.9%) patients had minimally invasive, open and vaginal surgery, respectively. During the COVID-19 pandemic, 1,661 (73.2%), 567 (24.9%), and 41 (1.8%) patients had minimally invasive, open, and vaginal surgery, respectively. Nodal assessment was omitted in 684 (27.3%) and 478 (21%) patients treated in period 1 and 2, respectively (p<0.001). While, the prevalence of patients undergoing sentinel node mapping (with or without backup lymphadenectomy) has increased during the COVID-19 pandemic (46.8% in period 1 vs. 53.1% in period 2;p<0.001). Adjuvant therapy was omitted in 1,269 (50.5%) and 1,019 (44.9%) patients receiving treatment in period 1 and 2, respectively (p<0.001). Adjuvant therapy use has increased during the COVID-19 pandemic (p<0.001). Conclusions: Our data suggest that the COVID-19 pandemic had a significant impact on the characteristics and patterns of care of endometrial cancer patients. These findings highlight the need to implement healthcare services during the pandemic.