Study of placental histopathology in COVID-19 mothers at a dedicated COVID-19 hospital in India.

Introduction: Maternal infections can affect the placenta, which acts as a fetomaternal barrier. This study aimed to determine the spectrum of morphologic alterations in the placentas of pregnancies complicated by SARS-CoV-2 infection and the impact on fetal or neonatal outcomes. Materials and Methods: This is a prospective case-control study. One hundred SARS-CoV-2 positive pregnant women and an equal number of SARS CoV-2 negative pregnant women in their third trimester who delivered at our tertiary care center between December 2020 and November 2021 were enrolled in the study. This study was conducted at the end of the first wave and during the second COVID-19 wave. Histopathological examination of the placentas was done using Amsterdam consensus criteria. We observed for evidence of maternal vascular malperfusion [MVM], fetal vascular malperfusion, and inflammation in the placenta. Results: The clinical findings were compared between the cases and controls. Evidence of MVM was seen in comparable numbers between the cases and controls, but as it involved less than 30% of the placental disc, it was considered an insignificant finding. Deciduitis was seen in equal proportions in both groups. The comparison between the asymptomatic and symptomatic groups failed to show any difference in placental pathology between both groups. There was no adverse fetal outcome seen in the pregnancies complicated by SARS-CoV-2 infection. Conclusion: Placental injury at the microscopic level was observed but was neither significant nor specific to the SARS-CoV-2 infection. SARS CoV-2 infection did not influence the placental pathology. Also, no adverse neonatal outcomes were observed.

Phylogenetic placement and reassessment of Asperisporium pongamiae as Pedrocrousiella pongamiae gen. et comb. nov. (Mycosphaerellaceae).

The leaf spot disease of Pongamia pinnata caused by an asperisporium-like asexual morph, which is usually referred to as Asperisporium pongamiae, is quite common during monsoon seasons in India. Phylogenetic analyses, based on LSU and rpb2 sequence data, and blast searches using ITS sequence data, revealed that this ascomycete forms a lineage within Mycosphaerellaceae distant from all other generic lineages. Pedrocrousiella gen. nov., with P. pongamiae comb. nov., based on Fusicladium pongamiae (≡ A. pongamiae), as type species is introduced for this lineage. This species has been considered the asexual morph of Mycosphaerella pongamiae (≡ Stigmatea pongamiae). However, this connection is unproven and was just based on the occasional association of the two taxa in some collections. Several attempts to induce the formation of a sexual morph in culture failed, therefore the putative connection between these morphs could not be confirmed. Asperisporium pongamiae-pinnatae is reduced to synonymy with P. pongamiae. Asperisporium pongamiae-pinnatae was introduced because of the wrong assumption that F. pongamiae had been described on another host, Pongamia globosa. But Fusicladium pongamiae was actually described in India on Pongamia glabra, which is a synonym of P. pinnata, and hence on the same host as Asperisporium pongamiae-pinnatae. Pedrocrousiella pongamiae clusters in a clade containing Distocercospora, Clypeosphaerella, and "Pseudocercospora" nephrolepidicola, a species which is not congeneric with Pseudocercospora. Phylogenetically, Pedrocrousiella is distant from the Asperisporium s. str. clade (type species A. caricae), which is more closely related to Amycosphaerella, Pseudocercosporella, Distomycovellosiella and Nothopassalora. Citation: Rajeshkumar KC, Braun U, Groenewald JZ, Lad SS, Ashtekar N, Fatima S, Anand G (2021). Phylogenetic placement and reassessment of Asperisporium pongamiae as Pedrocrousiella pongamiae gen. et comb. nov. (Mycosphaerellaceae). Fungal Systematics and Evolution 7: 165-176. doi: 10.3114/fuse.2021.07.08.

Surgical Management of Moderate Sized Spontaneous Cerebellar Hematomas: Role of Intracranial Pressure Monitoring.

AIM: Acute onset spontaneous cerebellar hematoma (SCH) is a neurosurgical emergency with unpredictable natural history and outcome. Specific guidelines are available for management of small ( < 2.5 cm) and large sized (4.0 cm < ) SCH. But, literature is sparse for treatment of moderate sized SCH (2.5-4.0 cm). MATERIAL AND METHODS: In a retrospective analysis of 32 patients, with moderate sized acute SCH, external ventricular drainage (EVD) tube was inserted for evaluation of ICP and evacuation of cerebrospinal fluid. All patients with ICP > 25 mmHg underwent emergency SCH evacuation. Postoperatively, EVD was continued for 48-72 hours for ICP monitoring. Patients showing no improvement or persistent ventriculomegaly underwent ventriculoperitoneal shunt (VPS) insertion for the management of hydrocephalus. RESULTS: 29/32 patients needed operative intervention either in the form of hematoma evacuation or shunt placement. 10 patients improved to GOS 5 and 7 to GOS 4. Overall mortality was 25% (n=8). Despite SCH evacuation, none of the patients with ICP > 40 mmHg experienced good outcome (p < 0.0001). CONCLUSION: 47% of patients with moderate sized SCH need surgical evacuation. EVD insertion not only helps in ICP management but also includes the ability to gradually decompress ventricular system by varying the outflow pressure. Apart from radiologic findings, ICP measurement should be a guideline in management decisions.

Underestimation of malignancy in biopsy-proven cases of stromal fibrosis.

OBJECTIVE: To determine the rate of underestimation of malignancy in patients with biopsy-proven stromal fibrosis. METHODS: Following institutional review board approval, we retrospectively reviewed the charts of patients with biopsy-proven stromal fibrosis who underwent percutaneous breast biopsy in the 5-year period between 1 January 2005 and 31 December 2009. The medical records and the histopathology in patients who underwent repeat biopsy and/or surgical excision at the site of stromal fibrosis within 2 years were reviewed. Interval stability for up to 2 years was documented in patients who did not undergo additional biopsy or surgical excision. An upgrade was defined as any patient with biopsy-proven stromal fibrosis or fibroadenoma with evidence of malignancy at the site of biopsy within 2 years. RESULTS: 365 cases of stromal fibrosis were identified, of which 25 (7%) were upgraded to in situ or invasive malignancy on repeat biopsy or surgical excision. 7 were upgraded to ductal carcinoma in situ and 18 were upgraded to invasive cancer. Of the upgraded cases, 8 out of 24 (32%) were considered concordant with a benign diagnosis. The false-negative rate, that is, cases of stromal fibrosis concordant with benignity, but with subsequent upgrade, comprised 2% of all cases. CONCLUSION: In biopsy-proven cases of stromal fibrosis, there is a 7% upgrade to malignancy. We recommend that all instances of stromal fibrosis with radiology-pathology discordance undergo repeat biopsy or surgical excision. Cases that demonstrate radiology-pathology concordance can be safely categorized as a Breast Imaging Reporting and Data System 3 (BI-RADS® 3) lesion with a 6-month follow-up, owing to a false-negative rate for missed cancer of 2%. ADVANCES IN KNOWLEDGE: We now recommend that concordant cases of stromal fibrosis be categorized as BI-RADS 3 with a short-term follow-up, as this results in a missed cancer rate of 2%.

Urinary tract infections in meningioma patients: analysis of risk factors and outcomes.

BACKGROUND: Urinary tract infections (UTIs) account for about 35% of all nosocomial infections and 75% are associated with the use of urethral catheters. AIM: The goal of this study was to evaluate preoperative factors associated with the risk of UTI and to estimate the impact of UTIs on patient outcome and resource utilization. METHODS: Adult meningioma patients treated with craniotomy in US hospitals between 2002 and 2007 were queried from the Nationwide Inpatient Sample (NIS) database. Univariate and multivariate analyses that correct for sample survey design data were used to study the association of perioperative UTIs and outcomes. FINDINGS: In all, 46,344 patients were included. Women comprised the majority (70.0%), had lower mortality (1.2% vs 2.0%), shorter in-hospital stay (6.7 vs 7.5 days), lower hospital charges (US$76,682 vs 87,220) and higher UTI rates (6.3% vs 3.9%) than men. In multivariate analysis, female gender (odds ratio: 2.2; P < 0.0001), older age (1.4; P < 0.001), emergency room admissions (1.8; P < 0.0001), total length of stay (1.08; P < 0.0001), comorbidity score (1.04; P = 0.0147), postoperative fluid abnormalities (1.96; P < 0.0001) and pulmonary complications (1.3; P < 0.0011) were associated with UTI. UTI was associated with an additional 2.3 days of hospital stay and an incremental US$18,920 in hospital charges. CONCLUSIONS: Perioperative UTIs are associated with specific comorbidities and postoperative complications. They significantly increase in-hospital length of stay and costs. Our data emphasize the need to support national efforts that are underway to reduce hospital-acquired UTIs within the neurosurgical population.

Evaluating an intensive ward-based writing coach programme to improve nursing documentation: lessons learned.

AIM: This study aimed to develop a ward-based writing coach programme to improve the quality of patient information in nursing documentation. BACKGROUND: Omissions in the patient information make nursing notes an unreliable source for care planning. Strategies to improve the quality of nursing documentation have been unsuccessful. An education programme, with one-to-one coaching in the clinical environment, was tested. METHOD: A concurrent mixed methods approach including a pre-post test intervention and control design for the quantitative component combined with a qualitative approach using a focus group (eight nurses) was used. Healthcare records for 87 patients (intervention) (46 pre and 41 post) and 88 patients (control) (51 pre and 37 post) were reviewed using the Nursing and Midwifery Content Audit Tool for quality nursing documentation. Sixteen nurses from two intervention wards participated in an introductory workshop with 2 weeks of coaching. No intervention was given to the control ward. RESULTS: No significant differences were found between the wards across the 14 criteria representing quality documentation; most criteria were present in 75% or more of the records. Improvements were demonstrated in both the intervention and comparison units. Themes identified from the focus groups included the impact these changes had on nurses and patients, perceived difficulties with nursing documentation, medicolegal aspects and the attributes of an effective writing coach. CONCLUSION: Writing coaching is a supportive approach to improving nursing documentation. Also, regular auditing prompts nurses to improve nursing documentation. Further research using larger sample sizes can further confirm or refute these findings.

Unusual involvement of scalp and bilateral kidneys in an aggressive mediastinal diffuse large B cell lymphoma: documentation by FDG-PET imaging.

In the present communication, an unusual combination of scalp soft tissue and underlying brain involvement with intact skull bone coupled with bilateral renal involvement from a mediastinal diffuse large B cell lymphoma (DLBL) is presented. A 45-year-old man, a diagnosed case of mediastinal DLBL with bilateral lung involvement, was treated with conventional 6 cycles of chemotherapy and local external radiotherapy with initial good treatment response evidenced by considerable regression in mass size and regression in pulmonary lesions. Three months later, he returned with complaints of soft tissue swelling over the scalp; one of them in the high parietal bone and the other over the occipital region. A whole body FDG-PET at this time showed 2 moderate-sized foci in the scalp (with preservation of both tables of skull bone) and corresponding large foci in the brain parenchyma beneath, a superior mediastinal focus, a few foci in the apical and lower zone of left lung, extensive irregular uptake in the right pleura and the right lung parenchyma coupled with a loculated effusion in its lower zone and studded foci of hypermetabolism throughout the bilaterally enlarged kidneys. CT of the head confirmed the FDG-PET findings and histopathology of the biopsy from the scalp swelling was suggestive of DLBL. Ultrasound imaging of the abdomen showed lobulated bilaterally enlarged kidneys with multiple hypoechoic areas within them. The patient underwent palliative local external radiotherapy to the brain and systemic chemotherapy with poor clinical results with raised serum beta-2 microglobulin and serum LDH levels and deranged renal function. The patient died within a month after the FDG-PET study. The event of scalp and bilateral renal involvement from DLBL is rare in lymphoma literature and this report highlights that such unusual events can occur as part of widespread dissemination and underscores the importance of whole-body imaging with FDG-PET.

Complications and outcomes after spinal cord tumor resection in the United States from 1993 to 2002.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Data on patient outcomes after surgery for spinal cord tumors have been derived from single-institution series. The objective of this study is to report inpatient complications, mortality and outcomes on a national level. SETTING: United States, national inpatient care database. METHODS: The National Inpatient Sample (NIS) was used to identify 19,017 admissions for resection of a spinal cord tumor in the United States from 1993 to 2002. The effects of patient and hospital characteristics on inpatient outcomes were analyzed using logistic regression. RESULTS: The in-hospital mortality rate and the complication rate were 0.55 and 17.5%, respectively. Urinary and renal complications (3.7%), postoperative hemorrhages or hematomas (2.5%) and pulmonary complications (2.4%) were the most common complications reported. A single postoperative complication increased the length of stay by 4 days, increased the mortality rate by sixfold and added over $10,000 to hospital charges. Multivariate analysis showed that complications were more likely in African Americans and patients with multiple comorbidities. The odds of an adverse outcome increased significantly with age greater than 64, multiple comorbidities and postoperative complications. CONCLUSION: A national perspective on inpatient outcomes after resection of spinal cord tumors has been provided. The significant negative impact of postoperative complications on mortality and resource utilization has been demonstrated. We have identified advanced age and multiple comorbidities as risk factors that predict adverse outcome. Furthermore, this study highlights the importance of avoidance, recognition and prompt management of nonneurologic complications.

Relative potential for selection of quinolone-resistance-determining-region mutations in Streptococcus pneumoniae by gemifloxacin, gatifloxacin and moxifloxacin.

Serial passage of a clinical isolate of Streptococcus pneumoniae, in the presence of moxifloxacin, gatifloxacin or gemifloxacin, gave rise to resistant isolates. Non-susceptibility as defined by Clinical and Laboratory Standards Institute (CLSI, formerly NCCLS) breakpoints arose on Days 10, 11, and 12 with gatifloxacin, gemifloxacin, and moxifloxacin respectively. Moxifloxacin and gatifloxacin selected for a single step quinolone-resistant-determining-region (QRDR) mutation in DNA gyrase (GyrA) on Day 4 and 7 respectively, whereas gemifloxacin selected simultaneously for multi-step mutations in gyrase and topoisomerase IV (ParC) on Day 17 and activated a non-reserpine inhibited efflux mechanism by Day 4. As found in clinical isolates, mutations included Ser-81-Phe and Glu-85-Lys in GyrA and Ser-79-Phe or Asp-83-Tyr in ParC. At high MICs, moxifloxacin showed a previously unreported 4 amino-acid deletion in GyrB as well as a more unusual substitution Ser-79-Leu/Ile in ParC. Gemifloxacin showed a 2- to 16-fold greater activity than moxifloxacin or gatifloxacin against strains with two or more QRDR mutations, however, its potency did not translate to nonsusceptibility and gemifloxacin MIC values were either at or well above the CLSI nonsusceptible breakpoint concentration.

Choroid plexus papilloma of the posterior third ventricle during infancy & childhood: report of two cases with management morbidities.

We report two cases of posterior third ventricular choroid plexus papilloma, one in an 8-month-old infant and another in a two-year-old child. These cases presented with features of obstructive hydrocephalus. Both these patients underwent a ventriculo-peritoneal (VP) shunt surgery prior to the tumor excision. Following the VP shunt surgery both patients developed ascitis requiring exteriorization of the abdominal end of the shunt. There was a clear proof of CSF overproduction: 1400-1500 ml/day in the eight-month-old infant and 900-1200 ml/day in the two-year-old child. In the former it was transient and could be treated with revision of the VP shunt whereas in the second case a ventriculo-arterial shunt had to be done. In the second case a staged reduction cranioplasty was also performed for an enormously enlarged head (head circumference--74 cm). Interesting clinical and radiological findings and useful management strategies are described.

Posterior fossa extradural hematoma.

OBJECTIVE: To review the clinical profile, radiology and treatment of Pediatric posterior fossa extradural hematoma (PPFEDH) and evaluate the outcome. METHODS: Posterior fossa extradural hematoma (PFEDH) is an uncommon trauma sequel and in pediatric age group is still rare. This article discusses 18 cases of PPFEDH seen over a period of 8 years and review the pertinent medical literature. Only a few studies discuss PPFEDH and in most of them outcome has been good. Trauma has been subtle and fracture of occipital bone is seen in majority of cases. Treatment has been operative in majority of the cases. RESULTS: Most of the patients were diagnosed only on high index of suspicion with a history of trauma on the occipit, fracture of the occipital bone and persistent symptoms suggestive of increasing intracranial pressure and posterior fossa space occupying lesion. CT scanning was done liberally to confirm the suspicion and the patients with hematoma were treated aggressively by surgical evacuation with good recovery in most of them. CONCLUSION: Authors suggest an aggressive approach in the event of PPFEDH. However some patients can be managed conservatively but they should be closely observed for clinical manifestation and CT scan routinely to evaluate the progress of hematoma radiologically. A strict criterion should be followed in choosing such patients for conservative treatment as highlighted in the study.

Long term outcome in patients with severe head injury and bilateral fixed dilated pupils.

Patients with severe head injury with bilateral dilated unreactive pupils are considered to have a grave prognosis. Hence proper planning and aggressive management becomes mandatory for achieving good results. We present the outcome of consecutive 166 patients with severe head injury, admitted between January 1996 and December 2000 and analysed retrospectively. All the patients had an initial GCS of 8 or less and post resuscitation bilateral dilated unreactive pupils. Our aim was to analyze the long term outcome in these patients and identify the other significant prognostic factors. Of the 166 patients, 42 (25.30%) had a functional outcome (good recovery in 10.24%, moderate disability in 15.06%), and 124 (74.69%) had a poor outcome (death in 58.43% and severe disability in 16.26% of cases). There were 45 patients with polytrauma and 24 of these patients (53.33%) succumbed to the injuries. Obliteration of the basal cisterns and contusion were the common CT scan findings. Factors adversely affecting the survival included age of the patient, polytrauma with shock, initial GCS of 3 or 4, and compression of the basal cisterns on the initial CT scans. At follow up, most of the patients with a functional outcome showed a significant improvement in their motor function but continued to have neuro-behavioral and cognitive deficits.

Fatal rhino-orbito-cerebral mucormycosis in an apparently normal host: case report and literature review.

Fungal infections of the central nervous system (CNS) are fortunately rare but remain challenging problems occurring mostly in immunocompromised individuals, with protean manifestations, unpredictable course and unfavorable outcome in many cases despite aggressive neurosurgical intervention and recent antifungal drugs. Rhino-orbito-cerebral mucormycosis is a potentially lethal opportunistic fungal infection with rapid progression and high mortality. Its pathogenic nature becomes evident when the patient's general resistance is compromised. We present a case of an invasive rhino-orbito-cerebral mucormycosis in an apparently normal adult who initially developed mild paranasal sinusitis and later developed status epilepticus and despite an aggressive management died. Interesting clinical, neuroimaging and histological findings are described, and the possibility of fatal mucormycosis in an apparently normal host is highlighted.

Pharyngeal perforation and spontaneous extrusion of the cervical graft with its fixation device: a late complication of C2-C3 fusion via anterior approach.

Stabilisation of the fracture-dislocation of the cervical spine is achieved effectively by anterior or posterior or combined methods with attendant short and long term benefits, risks and complications associated with each procedure. Recently anterior methods have gained wider acceptance. A variety of preoperative and postoperative complications associated with anterior cervical fusion are well recognised. However, the delayed pharyngeal or oesophageal perforation is a rare, serious and life threatening complication of an anterior cervical internal fusion.The authors report a case of delayed pharyngeal perforation and spontaneous extrusion of the C2-C3 graft with its fixation device. After coughing out the entire gamet of the graft with the fixation pin, the patient was relieved of excruciating pain and dysphagia and had no significant morbidity thereafter over a 12-year follow up period. Relevant aspects are discussed with a review of the pertinent literature.

Aspergillus spinal epidural abscess.

Spinal abscess due to Aspergillus is rare. A young boy with chronic granulomatous disease and aspergillosis of the rib had been treated with antifungal treatment 3 months earlier. The patient presented with a brief history of progressive paraparesis. Imaging showed D9--11 vertebral involvement and destruction of the D10 vertebral body with angulation and a large dorsally placed, multiloculated epidural abscess extending from D6 to L2. There was also extensive granulation anterior to and on either side of the vertebrae. The patient underwent extensive laminectomy and decompression of all the loculi and partial removal of the granulation tissue. Aggressive medical treatment was started. The authors recommend an aggressive surgical and medical approach in such cases of disseminated invasive aspergillosis, even though the result may not be very satisfactory. This report discusses the full clinical profile and management of Aspergillus spinal epidural abscess and emphasizes the need to follow up these cases to detect recurrence and new lesions, even if the patients are on adequate medical treatment. In spite of all efforts, high morbidity and mortality is common in such patients.

Spinal cord and cauda equina compression in 'DISH'.

Diffuse idiopathic skeletal hyperostosis (DISH) has long been regarded as a benign asymptomatic clinical entity with an innocuous clinical course. Precise information is lacking in the world literature. Authors report the results of a retrospective analysis of 74 cases of DISH. Eleven patients presented with progressive spinal cord or cauda equina compression. In nine cases ossified posterior longitudinal ligament (OPLL) and in two cases ossified ligamentum flavum (OLF) were primarily responsible. Surgically treated patients (eight) had far better outcome as compared to the patients managed conservatively, as they had refused surgery. 'DISH' is neither a benign condition, nor it always runs a innocuous clinical course. In fact, in about 15% of the cases, serious neurological manifestations occur, which may require a major neurosurgical intervention.