Management of Extraocular Retinoblastoma: ICMR Consensus Guidelines

Retinoblastoma (RB) is the most common intraocular malignancy of childhood. Advanced stage presentation of RB is common in low middle-income countries (LMICs) due to lack of awareness, social taboos associated with enucleation, seeking alternative conservative treatment options, and poor accessibility to health care. Over the last few decades, there have been significant advancements in the management of extraocular RB (EORB) which have improved outcomes and helped in minimizing treatment-related toxicities. The incorporation of multimodality approaches including chemotherapy, surgery, and radiotherapy (RT) has shown promising results; however, prognosis remains poor especially in LMICs. In this article, authors have discussed the ICMR consensus guidelines on the management of EORB, including metastatic RB.

Management of Intraocular Retinoblastoma: ICMR Consensus Guidelines

Retinoblastoma (RB) is the most common childhood intraocular malignancy. Delayed presentation due to a lack of awareness and advanced intraocular tumors are a common scenario in low-middle income countries (LMICs). Remarkable treatment advances have been made in the past few decades allowing globe salvage in advanced intraocular RB (IORB) including systemic chemotherapy with focal consolidation and targeted treatments like intraarterial chemotherapy and intravitreal chemotherapy. However, a lack of availability and affordability limits the use of such advances in LMICs. External beam radiotherapy, despite risk of second cancers in RB with germline mutations, still remains useful for recalcitrant RB not responding to any other treatment. When choosing conservative treatment for advanced IORB, the cost and long duration of treatment, morbidity from multiple evaluation under anesthesias (EUAs), side effects of treatment and risk of treatment failure need to be taken into account and discussed with the parents. In this article, the authors discuss the ICMR consensus guidelines on the management of IORB.

Epidemiology, Diagnosis and Genetics of Retinoblastoma: ICMR Consensus Guidelines

Retinoblastoma (RB) is the most common intraocular tumor in childhood. It is mainly caused by mutations in both alleles of the RB1 tumor suppressor gene that is found on chromosome 13 and regulates the cell cycle. Approximately 8000 children are diagnosed with RB globally each year, with an estimated 1500 cases occurring in India. The survival rate of RB has improved to more than 90% in the developed world. Leukocoria and proptosis are the most common presenting features of RB in Asian Indian populations. Most cases of RB are diagnosed by fundus examination followed by ultrasound. The International Classification of Retinoblastoma is the most used scheme for the staging and classification of intraocular RB in India. Prenatal testing and preimplantation genetic testing for RB may be beneficial in high-risk families. Histopathologic risk factors such as massive choroidal invasion and post-laminar optic nerve help in predicting the occurrence of metastasis in children with RB, while presence of microscopic residual disease requires aggressive adjuvant treatment in eyes enucleated for group E RB. The review provides a consensus document on diagnosis and genetics of RB in India.

A mentored hands-on training model for scaling up implementation and intervention research in India: "connecting the dots"

Despite the high burden of mental disorders in low- and middle-income countries (LMICs), less than 25% of those in need have access to appropriate services, in part due to a scarcity of locally relevant, evidence-based interventions and models of care. To address this gap, researchers from India and the United States and the Indian Council of Medical Research (ICMR) collaboratively developed a "Grantathon" model to provide mentored research training to 24 new principal investigators (PIs). This included a week-long didactic training, a customized web-based data entry/analysis system and a National Coordination Unit (NCU) to support PIs and track process objectives. Outcome objectives were assessed via scholarly output including publications, awards received and subsequent grants that were leveraged. Multiple mentorship strategies including collaborative problem-solving approaches were used to foster single-centre and multicentre research. Flexible, approachable and engaged support from mentors helped PIs overcome research barriers, and the NCU addressed local policy and day-to-day challenges through informal monthly review meetings. Bi-annual formal review presentations by all PIs continued through the COVID-19 pandemic, enabling interim results reporting and scientific review, also serving to reinforce accountability. To date, more than 33 publications, 47 scientific presentations, 12 awards, two measurement tools, five intervention manuals and eight research grants have been generated in an open-access environment. The Grantathon is a successful model for building research capacity and improving mental health research in India that could be adopted for use in other LMICs.

A review on electronic nose for diagnosis and monitoring treatment response in lung cancer

Lung cancer is one of the common malignancies with high mortality rate and a poor prognosis. Most lung cancer cases are diagnosed at an advanced stage either due to limited resources of infrastructure, trained human resources, or delay in clinical suspicion. Low-dose computed tomography (LDCT) has emerged as a screening tool for early lung cancer detection but may not be a feasible option for most developing countries. Electronic nose (eNOSE) is a unique non-invasive device that has been developed for lung cancer diagnosis and monitoring response by exhaled breath analysis of volatile organic compounds (VOCs). The breath-print have been shown to differ not only among lung cancer and other respiratory diseases, but also between various types of lung cancer. Hence, we postulate that the breath-print analysis by electronic nose could be a potential biomarker for the early detection of lung cancer along with monitoring treatment response in a resource-limited setting. In this review, we have consolidated the current published literature suggesting the use of an electronic nose in the diagnosis and monitoring treatment response of lung cancer.

Evaluation of Vascular Cognitive Impairment Using the ICMR-Neuro Cognitive Tool Box (ICMR-NCTB) in a Stroke Cohort from India

Background and Purpose

Vascular cognitive impairment (VCI) presents with a spectrum of cognitive impairment due to stroke and poses a huge socioeconomic burden especially in low middle-income countries. There is a critical need for early recognition and identification of VCI patients. Therefore, we developed and validated culturally appropriate neuropsychological instruments, the ICMR-Neuro Cognitive Tool-Box (ICMR-NCTB) and Montreal Cognitive Assessment (MoCA) to diagnose vascular MCI and dementia in the Indian context.

Methods

A total of 181 participants: 59 normal cognition, 25 stroke with normal cognition, 46 vascular MCI (VaMCI) and 51 vascular dementia (VaD) were recruited for the study. The ICMR-NCTB and MoCA were administered to patients with VCI and major cognitive domains were evaluated.

Results

The ICMR-NCTB was found to have good internal reliability in VaMCI and VaD. The sensitivity of the ICMR-NCTB to detect VaMCI and VaD ranged from 70.8% to 72.9% and 75.9% to 79.7%, respectively, and the specificity for VaMCI and VaD ranged from 84.8% to 86.1% and 82.5% to 85.2%, respectively. The MoCA had excellent sensitivity and specificity to detect VaMCI and VaD at ideal cut-off scores.

Conclusion

The ICMR-NCTB is a valid neuropsychological toolbox that can be used for comprehensive cognitive assessment and diagnosis of VCI in India. In addition, the Indian version of MoCA is more adept as a screening instrument to detect VCI due to its high sensitivity. The ICMR-NCTB will aid in early detection and management of many patients, thereby reducing the burden of vascular MCI and dementia in India.

Mortality Associated with Ambient PM2.5 Exposure in India: Results from the Million Death Study

BACKGROUND

Studies on the extent to which long-term exposure to ambient particulate matter (PM) with aerodynamic diameter ≤2.5μm (PM2.5) contributes to adult mortality in India are few, despite over 99% of Indians being exposed to levels that the World Health Organization (WHO) considers unsafe.

OBJECTIVE

We conducted a retrospective cohort study within the Million Death Study (MDS) to provide the first-ever quantification of national mortality from exposure to PM2.5 in India from 1999 to 2014.

METHODS

We calculated relative risks (RRs) by linking a total of ten 3-y intervals of satellite-based estimated PM2.5 exposure to deaths 3 to 5 y later in over 7,400 small villages or urban blocks covering a total population of 6.8 million. We applied using a model-based geostatistical model, adjusted for individual age, sex, and year of death; smoking prevalence, rural/urban residency, area-level female illiteracy, languages, and spatial clustering and unit-level variation.

RESULTS

PM2.5 exposure levels increased from 1999 to 2014, particularly in central and eastern India. Among 212,573 deaths at ages 15-69 y, after spatial adjustment, we found a significant RR of 1.09 [95% credible interval (CI): 1.04, 1.14] for stroke deaths per 10-μg/m3 increase in PM2.5 exposure, but no significant excess for deaths from chronic respiratory disease and ischemic heart disease (IHD), all nonaccidental causes, and total mortality (after excluding stroke). Spatial adjustment attenuated the RRs for chronic respiratory disease and IHD but raised those for stroke. The RRs were consistent in various sensitivity analyses with spatial adjustment, including stratifying by levels of solid fuel exposure, by sex, and by age group, addition of climatic variables, and in supplementary case-control analyses using injury deaths as controls.

DISCUSSION

Direct epidemiological measurements, despite inherent limitations, yielded associations between mortality and long-term PM2.5 inconsistent with those reported in earlier models used by the WHO to derive estimates of PM2.5 mortality in India. The modest RRs in our study are consistent with near or null mortality effects. They suggest suitable caution in estimating deaths from PM2.5 exposure based on MDS results and even more caution in extrapolating model-based associations of risk derived mostly from high-income countries to India. https://doi.org/10.1289/EHP9538.

MoCA in five Indian languages: A brief screening tool to diagnose dementia and MCI in a linguistically diverse setting

INTRODUCTION AND OBJECTIVES

Early dementia diagnosis in low and middle-income countries (LMIC) is challenging due to limited availability of brief, culturally appropriate, and psychometrically validated tests. Montreal Cognitive Assessment (MoCA) is one of the most widely used cognitive screening tests in primary and secondary care globally. In the current study, we adapted and validated MoCA in five Indian languages (Hindi, Bengali, Telugu, Kannada, and Malayalam) and determined the optimal cut-off points that correspond to screening for clinical diagnosis of dementia and MCI.

METHODS

A systematic process of adaptation and modifications of MoCA was fulfilled. A total of 446 participants: 214 controls, 102 dementia, and 130 MCI were recruited across six centers.

RESULTS

Across five languages, the area under the curve for diagnosis of dementia varied from 0.89 to 0.98 and MCI varied from 0.73 to 0.96. The sensitivity, specificity and optimum cut-off scores were established separately for five Indian languages.

CONCLUSIONS

The Indian adapted MoCA is standardized and validated in five Indian languages for early diagnosis of dementia and MCI in a linguistically and culturally diverse population.

Non-communicable diseases as a major contributor to deaths in 12 tribal districts in India

Background & objectives

Non-communicable diseases (NCDs) are the leading cause of death in India. Although studies have reported a high prevalence of NCD in tribal populations, there are limited data pertaining mortality due to NCDs. Therefore, in this study we estimated the proportion of deaths due to NCDs among 15 yr and older age group in tribal districts in India.

Methods

We conducted a community-based survey in 12 districts (one per State) with more than 50 per cent tribal population. Data were collected using a verbal autopsy tool from the family member of the deceased. The estimated sample size was 452 deaths per district. We obtained the list of deaths for the reference period of one year and updated it during the survey. The cause of death was assigned using the International Classification of Diseases-10 classification and analyzed the proportions of causes of death. The age-standardized death rate (ASRD) was also estimated.

Results

We surveyed 5292 deaths among those above 15 years of age. Overall, NCDs accounted for 66 per cent of the deaths, followed by infectious diseases (15%) and injuries (11%). Cardiovascular diseases were the leading cause of death in 10 of the 12 sites. In East Garo Hills (18%) and Lunglei (26%), neoplasms were the leading cause of death. ASRD due to NCD ranged from 426 in Kinnaur to 756 per 100,000 in East Garo Hills.

Interpretation & conclusions

The findings of this community-based survey suggested that NCDs were the leading cause of death among the tribal populations in India. It is hence suggested that control of NCDs should be one of the public health priorities for tribal districts in India.

Preparedness of primary & secondary care health facilities for the management of non-communicable diseases in tribal population across 12 districts in India

Background and objectives

Non-communicable diseases (NCDs) are highly prevalent in the tribal populations; however, there are limited data regarding health system preparedness to tackle NCDs among these populations. We estimated the availability of human resources, equipment, drugs, services and knowledge of doctors for NCD management in the selected tribal districts in India.

Methods

A cross-sectional survey was conducted in 12 districts (one from each State) with at least 50 per cent tribal population in Andaman and Nicobar Islands, Himachal Pradesh, Madhya Pradesh, Odisha and eight northeastern States. Primary health centres (PHCs), community health centres (CHCs) and district/sub-district hospitals (DHs) were surveyed and data on screening and treatment services, human resources, equipment, drugs and information systems indicators were collected and analysed. The data were presented as proportions.

Results

In the present study 177 facilities were surveyed, including 156 PHCs/CHCs and 21 DHs. DHs and the majority (82-96%) of the PHCs/CHCs provided outpatient treatment for diabetes and hypertension. Overall, 97 per cent of PHCs/CHCs had doctors, and 78 per cent had staff nurses. The availability of digital blood pressure monitors ranged from 35 to 43 per cent, and drugs were either not available or inadequate. Among 213 doctors, three-fourths knew the correct criteria for hypertension diagnosis, and a few correctly reported diabetes diagnosis criteria.

Interpretation & conclusions

The results of this study suggest that the health system of the studied tribal districts was not adequately prepared to manage NCDs. The key challenges included inadequately trained workforce and a lack of equipment and drugs. It is suggested that capacity building and, procurement and distribution of equipment, drugs and information systems to track NCD patients should be the key focus areas of national programmes.

Picture-naming test for a linguistically diverse population with cognitive impairment and dementia

BACKGROUND

Picture-naming tests (PNTs) evaluate linguistic impairment in dementia due to semantic memory impairment, impaired lexical retrieval or perceptual deficits. They also assess the decline in naming impairment at various stages of dementia and mild cognitive impairment (MCI) that occurs due to progressive cognitive impairment. With the increasing numbers of people with dementia globally, it is necessary to have validated naming tests and norms that are culturally and linguistically appropriate.

AIMS

In this cross-sectional study we harmonized a set of 30 images applicable to the Indian context across five languages and investigated the picture-naming performance in patients with MCI and dementia.

METHODS & PROCEDURES

A multidisciplinary expert group formed by the Indian Council of Medical Research (ICMR) collaborated towards developing and adapting a picture naming test (PNT) known as the ICMR-PNT in five Indian languages: Hindi, Bengali, Telugu, Kannada and Malayalam. Based on cross-cultural adaptation guidelines and item-wise factor analysis and correlations established separately across five languages, the final version of the ICMR-PNT test was developed. A total of 368 controls, 123 dementia and 128 MCI patients were recruited for the study. Psychometric properties of the adapted version of the ICMR-PNT were examined, and sensitivity and specificity were examined.

OUTCOMES & RESULTS

The ICMR-PNT scores in all languages combined were higher in controls compared with patients with dementia and MCI (F_{2, 615} = 139.85; p < 0.001). Furthermore, PNT scores for MCI was higher in comparison with patients with dementia in all languages combined (p < 0.001). The area under the curve across the five languages ranged from 0.81 to 1.00 for detecting dementia. There was a negative correlation between Clinical Dementia Rating (CDR) and ICMR-PNT scores and a positive correlation between Addenbrooke's Cognitive Examination-III (ACE-III) and ICMR-PNT scores in control and patient groups.

CONCLUSIONS & IMPLICATIONS

The ICMR-PNT was developed by following cross-cultural adaptation guidelines and establishing correlations using item-wise factor analysis across five languages. This adapted PNT was found to be a reliable tool when assessing naming abilities effectively in mild to moderate dementia in a linguistically diverse context.

WHAT THIS PAPER ADDS

What is already known on this subject Picture-naming evaluates language impairment linked to naming difficulties due to semantic memory, lexical retrieval or perceptual disturbances. As a result, picture naming tests (PNTs) play an important role in the diagnosis of dementia. In a heterogeneous population such as India, there is a need for a common PNT that can be used across the wide range of languages. What this study adds to existing knowledge PNTs such as the Boston Naming Test (BNT) were developed for the educated, mostly English-speaking, Western populations and are not appropriate for use in an Indian context. To overcome this challenge, a PNT was harmonized in five Indian languages (Hindi, Bengali, Telugu, Kannada and Malayalam) and we report the patterns of naming difficulty in patients with MCI and dementia. The ICMR-PNT demonstrated good diagnostic accuracy when distinguishing patients with mild to moderate dementia from cognitively normal individuals. What are the potential or actual clinical implications of this work? With the growing number of persons suffering from Alzheimer's disease and other forms of dementia around the world, its critical to have culturally and linguistically relevant naming tests and diagnosis. This validated ICMR-PNT can be used widely as a clinical tool to diagnose dementia and harmonize research efforts across diverse populations.

Variations in glycated haemoglobin with age among individuals with normal glucose tolerance: Implications for diagnosis and treatment-Results from the ICMR-INDIAB population-based study (INDIAB-12)

AIM

To report on glycated haemoglobin (HbA1c) values among individuals with normal glucose tolerance (NGT) at different age groups, using data acquired from a large national survey in India.

MATERIALS AND METHODS

Data on glycaemic parameters at different age groups were obtained from the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study, in adults aged ≥ 20 years representing all parts of India. Age-wise distribution of HbA1c was assessed among individuals with NGT (n = 14,222) confirmed by an oral glucose tolerance test using the World Health Organization (WHO) criteria. Results were validated in another large epidemiological study (n = 1077) conducted in Chennai, India.

RESULTS

Among NGT individuals, HbA1c increased gradually with age from 5.16 ± 0.71% (33 mmol/mol) in the age group of 20-29 years to 5.49 ± 0.69% (37 mmol/mol) in those aged 70 + years. In the validation study, conducted in another study population, HbA1c was 5.35 ± 0.43% (35 mmol/mol) in age group of 20-29 years and 5.74 ± 0.50% (39 mmol/mol) in those aged 70 and above. In the INDIAB study, for every decadal increase in age, there is a 0.08% increase in HbA1c and this increase was more significant in females (females: 0.10% vs. males: 0.06%) and in urban (urban: 0.10% vs. rural: 0.08%) population.

CONCLUSIONS

HbA1c levels increase steadily with age. This suggests that age-specific cutoffs be used while utilizing HbA1c to diagnose diabetes and prediabetes, so as to minimize the risk of overdiagnosis and unnecessary initiation of treatment in elderly people who could have physiological increase in HbA1c levels.

Validation of ICMR Neurocognitive Toolbox for Dementia in the Linguistically Diverse Context of India

Objectives: The growing prevalence of dementia, especially in low- and middle-income countries (LMICs), has raised the need for a unified cognitive screening tool that can aid its early detection. The linguistically and educationally diverse population in India contributes to challenges in diagnosis. The present study aimed to assess the validity and diagnostic accuracy of the Indian Council of Medical Research-Neurocognitive Toolbox (ICMR-NCTB), a comprehensive neuropsychological test battery adapted in five languages, for the diagnosis of dementia.

Methods: A multidisciplinary group of experts developed the ICMR-NCTB based on reviewing the existing tools and incorporation of culturally appropriate modifications. The finalized tests of the major cognitive domains of attention, executive functions, memory, language, and visuospatial skills were then adapted and translated into five Indian languages: Hindi, Bengali, Telugu, Kannada, and Malayalam. Three hundred fifty-four participants were recruited, including 222 controls and 132 dementia patients. The sensitivity and specificity of the adapted tests were established for the diagnosis of dementia.

Results: A significant difference in the mean (median) performance scores between healthy controls and patients with dementia was observed on all tests of ICMR-NCTB. The area under the curve for majority of the tests included in the ICMR-NCTB ranged from 0.73 to 1.00, and the sensitivity and specificity of the ICMR-NCTB tests ranged from 70 to 100% and 70.7 to 100%, respectively, to identify dementia across all five languages.

Conclusions: The ICMR-NCTB is a valid instrument to diagnose dementia across five Indian languages, with good diagnostic accuracy. The toolbox was effective in overcoming the challenge of linguistic diversity. The study has wide implications to address the problem of a high disease burden and low diagnostic rate of dementia in LMICs like India.

The burden of neurological disorders across the states of India: the Global Burden of Disease Study 1990-2019

BACKGROUND

A systematic understanding of the burden of neurological disorders at the subnational level is not readily available for India. We present a comprehensive analysis of the disease burden and trends of neurological disorders at the state level in India.

METHODS

Using all accessible data from multiple sources, we estimated the prevalence or incidence and disability-adjusted life-years (DALYs) for neurological disorders from 1990 to 2019 for all states of India as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019. We assessed the contribution of each neurological disorder to deaths and DALYs in India in 2019, their trends in prevalence or incidence and DALY rates over time, and heterogeneity between the states of India. We also assessed the Pearson correlation coefficient between Socio-demographic Index (SDI) of the states and the prevalence or incidence and DALY rates of each neurological disorder. Additionally, we estimated the contribution of known risk factors to DALYs from neurological disorders. We calculated 95% uncertainty intervals (UIs) for the mean estimates.

FINDINGS

The contribution of non-communicable neurological disorders to total DALYs in India doubled from 4·0% (95% UI 3·2-5·0) in 1990 to 8·2% (6·6-10·2) in 2019, and the contribution of injury-related neurological disorders increased from 0·2% (0·2-0·3) to 0·6% (0·5-0·7). Conversely, the contribution of communicable neurological disorders decreased from 4·1% (3·5-4·8) to 1·1% (0·9-1·5) during the same period. In 2019, the largest contributors to the total neurological disorder DALYs in India were stroke (37·9% [29·9-46·1]), headache disorders (17·5% [3·6-32·5]), epilepsy (11·3% [9·0-14·3]), cerebral palsy (5·7% [4·2-7·7]), and encephalitis (5·3% [3·7-8·9]). The crude DALY rate of several neurological disorders had considerable heterogeneity between the states in 2019, with the highest variation for tetanus (93·2 times), meningitis (8·3 times), and stroke (5·5 times). SDI of the states had a moderate significant negative correlation with communicable neurological disorder DALY rate and a moderate significant positive correlation with injury-related neurological disorder DALY rate in 2019. For most of the non-communicable neurological disorders, there was an increase in prevalence or incidence from 1990 to 2019. Substantial decreases were evident in the incidence and DALY rates of communicable neurological disorders during the same period. Migraine and multiple sclerosis were more prevalent among females than males and traumatic brain injuries were more common among males than females in 2019. Communicable diseases contributed to the majority of total neurological disorder DALYs in children younger than 5 years, and non-communicable neurological disorders were the highest contributor in all other age groups. In 2019, the leading risk factors contributing to DALYs due to non-communicable neurological disorders in India included high systolic blood pressure, air pollution, dietary risks, high fasting plasma glucose, and high body-mass index. For communicable disorders, the identified risk factors with modest contributions to DALYs were low birthweight and short gestation and air pollution.

INTERPRETATION

The increasing contribution of non-communicable and injury-related neurological disorders to the overall disease burden in India, and the substantial state-level variation in the burden of many neurological disorders highlight the need for state-specific health system responses to address the gaps in neurology services related to awareness, early identification, treatment, and rehabilitation.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

SARS-CoV-2 seroprevalence among the general population and healthcare workers in India, December 2020-January 2021

BACKGROUND

Earlier serosurveys in India revealed seroprevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) of 0.73% in May-June 2020 and 7.1% in August-September 2020. A third serosurvey was conducted between December 2020 and January 2021 to estimate the seroprevalence of SARS-CoV-2 infection among the general population and healthcare workers (HCWs) in India.

METHODS

The third serosurvey was conducted in the same 70 districts as the first and second serosurveys. For each district, at least 400 individuals aged ≥10 years from the general population and 100 HCWs from subdistrict-level health facilities were enrolled. Serum samples from the general population were tested for the presence of immunoglobulin G (IgG) antibodies against the nucleocapsid (N) and spike (S1-RBD) proteins of SARS-CoV-2, whereas serum samples from HCWs were tested for anti-S1-RBD. Weighted seroprevalence adjusted for assay characteristics was estimated.

RESULTS

Of the 28,598 serum samples from the general population, 4585 (16%) had IgG antibodies against the N protein, 6647 (23.2%) had IgG antibodies against the S1-RBD protein, and 7436 (26%) had IgG antibodies against either the N protein or the S1-RBD protein. Weighted and assay-characteristic-adjusted seroprevalence against either of the antibodies was 24.1% [95% confidence interval (CI) 23.0-25.3%]. Among 7385 HCWs, the seroprevalence of anti-S1-RBD IgG antibodies was 25.6% (95% CI 23.5-27.8%).

CONCLUSIONS

Nearly one in four individuals aged ≥10 years from the general population as well as HCWs in India had been exposed to SARS-CoV-2 by December 2020.

White paper on venomous snakebite in India

Venomous snakebite is one of the leading preventable causes of mortality and morbidity with tremendous socio-economic impact on the family and nation. Venomous snakebite has been relisted as a neglected tropical disease after having been removed off the list in 2013. This paper discusses the various reasons which could be attributed to the high mortality and morbidity due to venomous snakes and also provides recommendations on policy decisions, improvement on the quality of venom and anti-snake venom and in promoting awareness on how to avoid snakebite.

Indian Council of Medical Research consensus document on hepatocellular carcinoma

This document aims to assist oncologists in making clinical decisions encountered while managing their patients with hepatocellular carcinoma (HCC), specific to Indian practice, based on consensus among experts. Most patients are staged by Barcelona Clinic Liver Cancer (BCLC) staging system which comprises patient performance status, Child-Pugh status, number and size of nodules, portal vein invasion and metastasis. Patients should receive multidisciplinary care. Surgical resection and transplant forms the mainstay of curative treatment. Ablative techniques are used for small tumours (<3 cm) in patients who are not candidates for surgical resection (Child B and C). Patients with advanced (HCC should be assessed on an individual basis to determine whether targeted therapy, interventional radiology procedures or best supportive care should be provided. In advanced HCC, immunotherapy, newer targeted therapies and modern radiation therapy have shown promising results. Patients should be offered regular surveillance after completion of curative resection or treatment of advanced disease.

India Hypertension Control Initiative-Hypertension treatment and blood pressure control in a cohort in 24 sentinel site clinics

The India Hypertension Control Initiative (IHCI) is a multi‐partner initiative, implementing and scaling up a public health hypertension control program across India. A cohort of 21,895 adult hypertension patients in 24 IHCI sentinel site facilities in four Indian states (Punjab, Madhya Pradesh, Maharashtra, and Telangana), registered from January 2018 until June 2019 were assessed at baseline and then followed up for blood pressure (BP) control and antihypertensive medication use. Among all registrations, 11 274 (51%) of the patients returned for a follow‐up visit between July 2019 and September 2019. Among patients returning for follow‐up, 26.3% had BP controlled at registration, and 59.8% had BP controlled at follow‐up (p < .001). The absolute improvement in BP control was more than two times greater in primary care (48.1 percentage point increase) than secondary care facilities (22.9 percentage point increase). Most IHCI patients received prescriptions according to state‐specific treatment protocols. This study demonstrates that a scalable public health hypertension control program can yield substantial BP control improvements, especially in primary care settings. However, high loss to follow‐up limits population health impact; future efforts should focus on improving systems to increase the likelihood that patients will return to the clinic for routine hypertension care.

A Screening Tool to Detect Stroke Aphasia: Adaptation of Frenchay Aphasia Screening Test (FAST) to the Indian Context

Background:

Aphasia is a common consequence of stroke. To optimize recovery, it becomes critical as there are early identification and treatment of language deficits. The rising burden of stroke aphasia and lack of screening tools in the Indian context necessitates the need for a screening tool.

Objective:

We aimed to adapt and validate the Frenchay Aphasia Screening Test (FAST) to the Indian context in two widely spoken Indian languages, Telugu and Kannada, for the literate and illiterate population.

Methods:

A systematic process of adaptation and culturally appropriate modifications of the original FAST were done in 116 healthy controls and 115 patients. The validity of the adapted test was established.

Results:

The optimum cut-off values for detecting aphasia in our sample ranged from 25 to 25.5 (literate) and 13.5 to 15.5 (illiterate) with high sensitivity and specificity. There was also a significant correlation between aphasia scores for adapted FAST and the Western Aphasia Battery (WAB), establishing good convergent validity.

Discussion:

Results of the adaptation and validation of two Indian versions of FAST, suggest that it is an easy-to-use screening measure for detecting stroke-related language disabilities. The psychometric properties of the Indian version of FAST met the standardised requirements for adaptation and validation.

Conclusions:

The Indian version of FAST was found to be a reliable and valid bedside screening tool for aphasia in stroke patients. We aim that this study will facilitate the use of the test across other Indian languages and a large clinical population in the future.

National Burden Estimates of healthy life lost in India, 2017: an analysis using direct mortality data and indirect disability data

BACKGROUND

Many countries, including India, seek locally constructed disease burden estimates comprising mortality and loss of health to aid priority setting for the prevention and treatment of diseases. We created the National Burden Estimates (NBE) to provide transparent and understandable disease burdens at the national and subnational levels, and to identify gaps in knowledge.

METHODS

To calculate the NBE for India, we combined 2017 UN death totals with national and subnational mortality rates for 2010-17 and causes of death from 211 166 verbal autopsy interviews in the Indian Million Death Study for 2010-14. We calculated years of life lost (YLLs) and years lived with disability (YLDs) for 2017 using published YLD-YLL ratios from WHO Global Health Estimates. We grouped causes of death into 45 groups, including ill-defined deaths, and summed YLLs and YLDs to calculate disability-adjusted life-years (DALYs) for these causes in eight age groups covering rural and urban areas and 21 major states of India.

FINDINGS

In 2017, there were about 9·7 million deaths and 486 million DALYs in India. About three quarters of deaths and DALYs occurred in rural areas. More than a third of national DALYs arose from communicable, maternal, perinatal, and nutritional disorders. DALY rates in rural areas were at least twice those of urban areas for perinatal and nutritional conditions, chronic respiratory diseases, diarrhoea, and fever of unknown origin. DALY rates for ischaemic heart disease were greater in urban areas. Injuries caused 11·4% of DALYs nationally. The top 15 conditions that accounted for the most DALYs were mostly those causing mortality (ischaemic heart disease, perinatal conditions, chronic respiratory diseases, diarrhoea, respiratory infections, cancer, stroke, road traffic accidents, tuberculosis, and liver and alcohol-related conditions), with disability mostly due to a few conditions (nutritional deficiencies, neuropsychiatric conditions, vision and other sensory loss, musculoskeletal disorders, and genitourinary diseases). Every condition that was common in one part of India was uncommon elsewhere, suggesting state-specific priorities for disease control.

INTERPRETATION

The NBE method quantifies disease burden using transparent, intuitive, and reproducible methods. It provides a simple, locally operable tool to aid policy makers in priority setting in India and other low-income and middle-income countries. The NBE underlines the need for many more countries to collect nationally representative cause of death data, paired with focused surveys of disability.

FUNDING

Ministry of Health and Family Welfare, Government of India.

A community-based pragmatic, controlled trial for preventing and reducing oral diseases among 1-6-year-old children visiting Anganwadi centers, under the Integrated Child Development Scheme, India

BACKGROUND

Early childhood caries (ECC) has reached epidemic proportions affecting millions of children worldwide. Its prevention becomes imperative owing to the significant morbidity and financial implications involved with its treatment. The Integrated Child Development Scheme (ICDS), launched in India to provide mid-day meals, pre-school education and primary healthcare to children, can be utilised to counsel and deliver oral health education to mothers. The purpose of the study is to compare the effect of an oral health care package (OHCP) with usual care on the change in dental disease status among 1 to 3-year-old children at Anganwadi centres (AWC) in periurban areas of Chandigarh and rural areas of Cuttack, Orissa over a follow-up period of three years.

METHODS

Two geographically distant ICDS blocks would be selected at each of the two study sites and would be randomly allocated to intervention and control group. Closely located AWCs under each of the selected blocks shall constitute the study setting. OHCP would be delivered to the mothers of the 1-6-year-old children enrolled in the AWCs of the experimental group whereas mothers under control group would receive usual care advice available at the AWCs.

DISCUSSION

ECC prevention had conventionally focused upon testing effectiveness of programs targeting behaviour change among the caregivers and children, but surprisingly minimal efforts have been made to seek translation of these efforts into reduction of ECC at the community level. The present study has two components; testing effect of altering maternal and child behavioral aspects on ECC incidence through cohort follow up of 1-3-year-old children for three consecutive years and cross-sectional follow up of all available 1-6-year old children at the selected AWCs at regular intervals to look for change in prevalence of ECC at community level. In other regions of the world surveys of ECC prevalence before and after the intensive educational programs have shown a significant reduction in ECC prevalence. A similar decline can be anticipated through this program.

TRIAL REGISTRATION

This trial has been prospectively registered at Clinical Trials Registry, India (CTRI/2019/02/017556, 08 February 2019).

The Bispectral Index and Induced Hypothermia— Electrocerebral Silence at an Unusually High Temperature

The optimal temperature for deep hypothermic circulatory arrest remains undefined. We present a case in which Bispectral Index monitoring during hypothermic cardiopulmonary bypass showed electrocerebral silence at a higher temperature than previously reported. Bispectral Index monitoring may be a potentially useful tool in surgery employing deep hypothermic circulatory arrest.

The impact of air pollution on deaths, disease burden, and life expectancy across the states of India: the Global Burden of Disease Study 2017

BACKGROUND

Air pollution is a major planetary health risk, with India estimated to have some of the worst levels globally. To inform action at subnational levels in India, we estimated the exposure to air pollution and its impact on deaths, disease burden, and life expectancy in every state of India in 2017.

METHODS

We estimated exposure to air pollution, including ambient particulate matter pollution, defined as the annual average gridded concentration of PM2.5, and household air pollution, defined as percentage of households using solid cooking fuels and the corresponding exposure to PM2.5, across the states of India using accessible data from multiple sources as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. The states were categorised into three Socio-demographic Index (SDI) levels as calculated by GBD 2017 on the basis of lag-distributed per-capita income, mean education in people aged 15 years or older, and total fertility rate in people younger than 25 years. We estimated deaths and disability-adjusted life-years (DALYs) attributable to air pollution exposure, on the basis of exposure-response relationships from the published literature, as assessed in GBD 2017; the proportion of total global air pollution DALYs in India; and what the life expectancy would have been in each state of India if air pollution levels had been less than the minimum level causing health loss.

FINDINGS

The annual population-weighted mean exposure to ambient particulate matter PM2·5 in India was 89·9 μg/m3 (95% uncertainty interval [UI] 67·0-112·0) in 2017. Most states, and 76·8% of the population of India, were exposed to annual population-weighted mean PM2·5 greater than 40 μg/m3, which is the limit recommended by the National Ambient Air Quality Standards in India. Delhi had the highest annual population-weighted mean PM2·5 in 2017, followed by Uttar Pradesh, Bihar, and Haryana in north India, all with mean values greater than 125 μg/m3. The proportion of population using solid fuels in India was 55·5% (54·8-56·2) in 2017, which exceeded 75% in the low SDI states of Bihar, Jharkhand, and Odisha. 1·24 million (1·09-1·39) deaths in India in 2017, which were 12·5% of the total deaths, were attributable to air pollution, including 0·67 million (0·55-0·79) from ambient particulate matter pollution and 0·48 million (0·39-0·58) from household air pollution. Of these deaths attributable to air pollution, 51·4% were in people younger than 70 years. India contributed 18·1% of the global population but had 26·2% of the global air pollution DALYs in 2017. The ambient particulate matter pollution DALY rate was highest in the north Indian states of Uttar Pradesh, Haryana, Delhi, Punjab, and Rajasthan, spread across the three SDI state groups, and the household air pollution DALY rate was highest in the low SDI states of Chhattisgarh, Rajasthan, Madhya Pradesh, and Assam in north and northeast India. We estimated that if the air pollution level in India were less than the minimum causing health loss, the average life expectancy in 2017 would have been higher by 1·7 years (1·6-1·9), with this increase exceeding 2 years in the north Indian states of Rajasthan, Uttar Pradesh, and Haryana.

INTERPRETATION

India has disproportionately high mortality and disease burden due to air pollution. This burden is generally highest in the low SDI states of north India. Reducing the substantial avoidable deaths and disease burden from this major environmental risk is dependent on rapid deployment of effective multisectoral policies throughout India that are commensurate with the magnitude of air pollution in each state.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

The increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990-2016

BACKGROUND

The burden of diabetes is increasing rapidly in India but a systematic understanding of its distribution and time trends is not available for every state of India. We present a comprehensive analysis of the time trends and heterogeneity in the distribution of diabetes burden across all states of India between 1990 and 2016.

METHODS

We analysed the prevalence and disability-adjusted life-years (DALYs) of diabetes in the states of India from 1990 to 2016 using all available data sources that could be accessed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, and assessed heterogeneity across the states. The states were placed in four groups based on epidemiological transition level (ETL), defined on the basis of the ratio of DALYs from communicable diseases to those from non-communicable diseases and injuries combined, with a low ratio denoting high ETL and vice versa. We assessed the contribution of risk factors to diabetes DALYs and the relation of overweight (body-mass index 25 kg/m2 or more) with diabetes prevalence. We calculated 95% uncertainty intervals (UIs) for the point estimates.

FINDINGS

The number of people with diabetes in India increased from 26·0 million (95% UI 23·4-28·6) in 1990 to 65·0 million (58·7-71·1) in 2016. The prevalence of diabetes in adults aged 20 years or older in India increased from 5·5% (4·9-6·1) in 1990 to 7·7% (6·9-8·4) in 2016. The prevalence in 2016 was highest in Tamil Nadu and Kerala (high ETL) and Delhi (higher-middle ETL), followed by Punjab and Goa (high ETL) and Karnataka (higher-middle ETL). The age-standardised DALY rate for diabetes increased in India by 39·6% (32·1-46·7) from 1990 to 2016, which was the highest increase among major non-communicable diseases. The age-standardised diabetes prevalence and DALYs increased in every state, with the percentage increase among the highest in several states in the low and lower-middle ETL state groups. The most important risk factor for diabetes in India was overweight to which 36·0% (22·6-49·2) of the diabetes DALYs in 2016 could be attributed. The prevalence of overweight in adults in India increased from 9·0% (8·7-9·3) in 1990 to 20·4% (19·9-20·8) in 2016; this prevalence increased in every state of the country. For every 100 overweight adults aged 20 years or older in India, there were 38 adults (34-42) with diabetes, compared with the global average of 19 adults (17-21) in 2016.

INTERPRETATION

The increase in health loss from diabetes since 1990 in India is the highest among major non-communicable diseases. With this increase observed in every state of the country, and the relative rate of increase highest in several less developed low ETL states, policy action that takes these state-level differences into account is needed urgently to control this potentially explosive public health situation.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Adhesion molecule expression and ventricular remodeling in chronic rheumatic heart disease: a cause or effect in the disease progression--a pilot study

BACKGROUND

Rheumatic fever and chronic rheumatic heart disease (RHD) remains one of the most important causes of cardiovascular morbidity leading to a major public health problem, especially in developing countries. This was a pilot study to assess the presence of inflammation and expression of adhesion molecules by immunohistochemistry (IHC) in endomyocardial biopsy specimens of patients with chronic RHD.

METHODS

Endomyocardial biopsy was obtained from 14 patients of chronic RHD with no features of activity clinically. Biopsies were processed for histology and IHC. IHC was carried using monoclonal antibodies against CD3, CD4, CD8, intercellular adhesion molecule-1, and vascular cell adhesion molecule-1.

RESULTS

Histomorphologically, varying degree of interstitial and perivascular fibrosis was seen in all the 13 patients (100%). Mild fibrosis (1+) was seen in five patients (38.5%); moderate interstitial fibrosis (2+) was present in four patients (30.8%).There was no Aschoff nodule or evidence of active myocarditis in any of the biopsy specimens. IMMUNOHISTOCHEMISTRY: Moderate positivity of (2+) and intense positivity of (3+) for intercellular adhesion molecule-1 was seen in 11 and 2 patients, respectively. With vascular cell adhesion molecule-1, four showed mild positivity (1+), and three showed intense positivity (3+). The phenotypic analysis of the inflammatory cells in our study revealed CD8(+) cells in 77%, CD4(+) in 23.1%, and CD3(+) in 38.5% of total patients, which suggests chronicity.

CONCLUSION

The nonspecific histomorphological changes and increased adhesion molecules expression could be a part of the ventricular remodeling due to the hemodynamic stress by the stenotic or regurgitant lesions of RHD itself.

Impacts of climate change on public health in India: future research directions

BACKGROUND

Climate change and associated increases in climate variability will likely further exacerbate global health disparities. More research is needed, particularly in developing countries, to accurately predict the anticipated impacts and inform effective interventions.

OBJECTIVES

Building on the information presented at the 2009 Joint Indo-U.S. Workshop on Climate Change and Health in Goa, India, we reviewed relevant literature and data, addressed gaps in knowledge, and identified priorities and strategies for future research in India.

DISCUSSION

The scope of the problem in India is enormous, based on the potential for climate change and variability to exacerbate endemic malaria, dengue, yellow fever, cholera, and chikungunya, as well as chronic diseases, particularly among the millions of people who already experience poor sanitation, pollution, malnutrition, and a shortage of drinking water. Ongoing efforts to study these risks were discussed but remain scant. A universal theme of the recommendations developed was the importance of improving the surveillance, monitoring, and integration of meteorological, environmental, geospatial, and health data while working in parallel to implement adaptation strategies.

CONCLUSIONS

It will be critical for India to invest in improvements in information infrastructure that are innovative and that promote interdisciplinary collaborations while embarking on adaptation strategies. This will require unprecedented levels of collaboration across diverse institutions in India and abroad. The data can be used in research on the likely impacts of climate change on health that reflect India's diverse climates and populations. Local human and technical capacities for risk communication and promoting adaptive behavior must also be enhanced.

Removal of displaced and impacted ASD device after 4 years

Open heart surgery is the gold standard for the closure of atrial septal defects (ASDs). Percutaneous transcatheter closure is used to close simple ostium secundum ASDs. As this method avoids sternotomy, the post-procedural morbidity is lower. These procedures are associated with complications which can be life threatening and require urgent surgical intervention. We report a rare case which required surgical removal of the Amplatzer septal occluder and closure of the ASD four years after the initial percutaneous transcatheter closure due to displacement of the device.

Propofol requirement titrated to bispectral index: a comparison between hypothermic and normothermic cardiopulmonary bypass

Though propofol requirement is expected to decrease during cardiopulmonary bypass (CPB), a few studies have failed to demonstrate this. The factors affecting pharmacokinetics of propofol and, therefore, the requirement, are different during hypothermic and normothermic CPB. We evaluated and compared the requirement of propofol during hypothermic and normothermic CPB. Fifty adult patients scheduled for elective cardiac surgery on CPB were recruited and randomly allocated into hypothermic CPB (28–300 C) (Group H) and normothermic CPB (35–370 C) (Group N) groups. Patients were induced and maintained with propofol titrated to maintain a target bispectral index (BIS) of 50 ± 10. Propofol requirement (mean ± SD) was similar in normothermic and hypothermic groups, both before CPB (4.9 ± 1.5 mg.kg−1hr−1 in Group N, 4.6 ± 1.5 mg.kg−1hr−1 in Group H) and after cessation of bypass (p > 0.05) (4.6 ± 1.8 mg.kg−1hr−1 in Group N and 4.3 ± 1.7 mg.kg−1hr−1 in Group H). CPB significantly reduced (p < 0.001) propofol requirements in both arms of the study (Group N: 2.9 ± 1.4 mg.kg−1hr−1and Group H: 1.3 ± 0.7 mg.kg−1hr−1). This reduction was more pronounced in the hypothermic group (p < 0.001). The BIS (median ± inter quartile range) remained constant during normothermic CPB (50 ± 8.8), but declined significantly during hypothermic CPB (41 ± 5.6) despite decreased usage of propofol during hypothermia. No patient had recall of intra-operative events. CPB decreases the magnitude of propofol requirements and the effect of hypothermic CPB is significantly more than that of normothermic CPB.

The transseptal T-cut--what more can we see?

An optimal approach to the mitral valve for repair or replacement must provide adequate exposure even in a small left atrial and redo cases, without need for forceful retraction. This benefit of good exposure must not be at the cost of increased morbidity from increased postoperative bleeding, SA node, or atrioventricular node dysfunction. We describe a simple technique of transseptal T-cut for exposure of the mitral valve, which is without the attendant complications of the other techniques.

Pure red cell aplasia with malignant thymoma: a rarity

Pure red cell aplasia sometimes accompanies thymoma. Herein we report a PRCA patient with malignant thymoma. Only two Indian cases of PRCA with malignant thymoma have been reported so far and six cases in the world literature, to the best of our knowledge. This paper describes a malignant thymoma in a 40 year old male who later on developed pure red cell aplasia 7 months after thymectomy.

'Extended deep inferior epigastric artery flaps' for reconstruction after excision of chondrosarcoma sternum

We describe a case of chondrosarcoma of the sternum requiring wide full thickness chest wall excision thereby creating a difficult defect for reconstruction. A mesh was used for support and two extended deep inferior epigastric artery fasciocutaneous flaps were mobilised medially into the defect.

Closed mitral valvotomy in pregnancy and labor

OBJECTIVE

To study the feasibility and benefits of closed mitral valvotomy (CMV) during pregnancy.

DESIGN

Prospective study from 2000 through 2003 to study the effect on maternal condition and perinatal outcome of closed mitral valvotomy during pregnancy were evaluated.

METHODS

Eight pregnant women with severe mitral stenosis refractory to medical therapy had closed mitral valvotomy at different stages of pregnancy (one during labor).

RESULTS

All patients improved clinically (according to the New York Heart Association classification), and the mitral valve area increased. There was no mortality or major morbidity.

CONCLUSION

Closed mitral valvotomy offers excellent results and is cost effective during pregnancy. It is still the procedure of choice in poor countries when balloon mitral valvotomy (BMV) is not affordable.

Role of Indian Council of Medical Research (ICMR) in advancement of ophthalmic research

Blindness accounts for almost 7 million Disability Adjusted Life Years (DALYS). Considering its importance ICMR has been continually conducting research in ophthalmology starting from the first nationwide blindness survey in 1970s till date. In addition ICMR also has mechanisms of sponsoring research by interested individuals which involve adhoc research schemes and fellowships. The details of these mechanisms and some of the results of major ICMR projects are presented. The identified new thrust areas and the coordinators for these are also listed.

Inflammatory pseudotumour of the lung : report of a case and review of literature

A case of unusual benign tumour of the lung is described. The patient presented with a history of prolonged cough with expectoration, and fever with generalised weakness of shorter duration. Radiological examination of the chest revealed a large non-homogeneous opacity with calcification in the left lower zone. Fine needle aspiration cytology (FNAC) was inconclusive. Therefore, surgical exploration and a left lower lobectomy was performed. The diagnosis of inflammatory pseudotumour was made on histopathological examination.

Radiation therapy in the treatment of canine and feline thymomas: a retrospective study (1985-1999)

A retrospective study was performed of 17 dogs and seven cats with various stages of thymoma treated with radiation alone or as an adjunctive therapy. Analysis revealed an overall response rate of 75% (15/20 evaluable cases). Partial (i.e., >50% reduction in tumor size) and complete (i.e., no detectable tumor) responses were included. Complete responses were rare (4/20). Three of five animals with stable disease (i.e., <50% change in tumor size) had improvements in clinical signs, despite lack of measurable response. A median survival time of 248 days (range, 93 to 1,657+ days) was achieved in dogs, and a median survival time of 720 days (range, 485 to 1,825+ days) was achieved in cats. Radiation therapy appears to be useful in the management of invasive thymomas in dogs and cats.

Role of physiological lung exclusion in difficult lung resections for massive hemoptysis and other problems

OBJECTIVES

Pulmonary tuberculosis and bronchiectasis are the major causes of massive hemoptysis in developing countries. Lung resection remains the surgical treatment of choice. This may not always be possible and may even be hazardous in some patients due to fibrosis and dense vascular adhesions between the lung and the chest wall. This leads to marked blood loss and control of hilar vessels becomes dangerous.

METHODS

A series of 20 cases is described here. Nineteen presented with massive hemoptysis where control of bleeding was obtained by physiological lung exclusion. One patient had traumatic left main bronchus transection not suitable for repair or resection. Physiological lung exclusion was performed by surgical interruption of the bronchus and pulmonary artery of the involved lobe or lung, keeping pulmonary veins intact.

RESULTS

Hemoptysis could be controlled in all these patients without any significant morbidity. There was no mortality. There was no postoperative empyema and recurrence of hemoptysis on long-term follow-up. No patient required anatomical lung resection later on.

CONCLUSIONS

Physiological lung exclusion is a safe and effective method for control of massive hemoptysis in cases where lung resection is technically hazardous or difficult. This should be kept as an alternative or adjunct to anatomical lung resection.

Multicentric lymphosarcoma in a dog with multiple-site skeletal involvement

In this report the authors describe an unusual clinical presentation of lymphosarcoma (LSA) in a dog. A 9-year-old, neutered male, Golden Retriever was presented with a primary complaint of sudden onset of tetraparesis. Routine survey radiographs revealed multiple-site bony lesions and the histology revealed a diagnosis of LSA with diffuse skeletal and soft tissue involvement. The dog responded poorly to medical management and was euthanized on day two due to poor prognosis. Malignant LSA of the bone is a rare extranodal clinicopathologic entity and presents both a diagnostic and therapeutic hurdle. Reports of this kind are sparse and currently no optimal treatment for this entity has been determined.