Variation in hepatic segmental portal venous pulsed wave Doppler flow distribution in patients with NAFLD: A pilot study

Purpose

To evaluate the segmental variations in portal venous pulsed wave colour Doppler flow velocity in patients with moderate to severe non-alcoholic fatty liver disease in comparison with healthy controls.

Materials and Methods

In this prospective, observational, case-control study, the maximum velocity of all the segmental branches of portal vein were evaluated on colour Doppler in patients with moderate to severe non-alcoholic fatty liver disease, and the values were compared between three groups (1) Healthy controls (n = 30), (2) non-alcoholic fatty liver disease group, that is moderate to severe fatty liver without features of portal hypertension (n = 32) and (3) non-alcoholic steatohepatitis-portal hypertension group, that is those non-alcoholic fatty liver disease patients with features of portal hypertension (n = 13).

Results

Compared to controls, non-alcoholic fatty liver disease group showed a lower velocity in all the eight segments of liver. The ratio of segment 2 to segment 7 peak portal vein maximum velocity was significantly higher in non-alcoholic fatty liver disease (1.03 ± 0.21) compared to controls (0.90 ± 0.17) and even higher in non-alcoholic steatohepatitis-Portal hypertension group (1.83 ± 0.40) with p value of 0.003.

Conclusion

Our study demonstrates the occurrence of flow redistribution occurring in cases of non-alcoholic fatty liver disease patients with the left lobe receiving higher portal venous flow. This flow redistribution was even more pronounced in a subset of non-alcoholic fatty liver disease patients who developed features of portal hypertension.

Age-Specific Nomograms for Antral Follicle Count in Fertile and Infertile Indian Women: A Comparative Study

Objectives  The aim of this study was to develop age-specific nomograms for antral follicle count (AFC) in fertile and infertile Indian women and (2) to compare the influence of age on AFC in both groups. Setting and Design  It is a prospective cross-sectional study in a tertiary-care hospital in north-central India. Methods and Material  One-thousand four-hundred seventy-eight fertile and 1,447 infertile women (primary infertility) of reproductive age (18-49 years) were recruited. One-thousand one-hundred eighty-one fertile and 1,083 infertile women fulfilled the selection criteria for the study. Transvaginal ultrasonography was done on the second or third day of the menstrual cycle. Statistical Analysis  Age-specific nomograms for AFC were built for the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles in both groups. Correlation and regression analysis was done to estimate the relationship between the study variables. Statistical analysis was done by using IBM SPSS Statistics for Windows, version 20. Results  At every age, each percentile value of AFC was lower in infertile than in fertile women. The decline of AFC with increasing age was linear in both fertile ( r  = - 0.431, p  < 0.001) and infertile ( r  = - 0.520, p  < 0.001) women; however, the rate was higher in the latter (0.50 follicle/year) than in former (0.44 follicle/year) group. The variation in AFC explained by age was 16.3% in fertile and 22.7% in infertile women. Conclusion  AFC decreased linearly with advancing age in both fertile and infertile women, but more rapidly in the latter. The age only modestly explained the decline of AFC. The age-specific percentile thresholds for AFC should be used instead of age-independent constant thresholds in infertility counselling.

Magnetic resonance imaging spectrum of COVID-associated rhino-orbital-cerebral mucormycosis and assessment of anatomical severity

OBJECTIVES

To describe the extent and imaging findings of COVID-associated rhino-orbital-cerebral mucormycosis on magnetic resonance imaging and to evaluate the value of MRI severity score in grading the extent of involvement.

METHODS

Proven cases of ROCM with a history of concurrent or recently (<6 weeks) treated COVID-19 underwent MRI at the initial presentation. Findings were charted for each anatomical structure and the extent of involvement was scored for sinonasal, extra-sinus soft tissues, orbits, and brain. MR severity score was defined by summing up the individual scores of each compartment (sinonasal 20, orbital 20, soft tissue 10, and brain 10) and a total score out of 60 was assigned.

RESULTS

A total of 47 patients were included in our study with variable involvement of sinonasal compartment (n = 43), extra-sinus soft tissue (n = 25), orbits (n = 23), and brain (n = 17). In the sinonasal compartment, T2, DWI, and post-contrast T1 were the most useful sequences. A significantly higher mean sinonasal score was associated with mortality (p = 0.007). In the orbits, a combination of STIR (orbital fat and extraconal muscles), DWI (optic nerves), and post-contrast images (superior ophthalmic vein) were the most accurate sequences. A higher mean orbital score was associated with vision loss (p = 0.001). Patients with uncontrolled diabetes had greater extent of cranial involvement.

CONCLUSION

A combination of magnetic resonance sequences is required to correctly evaluate the involvement of individual structures and thus to assign the correct MR scoring. The proposed MR severity score can effectively and objectively evaluate the severity of COVID-associated ROCM.

Prediction of response to radiotherapy in locally advanced carcinoma cervix using multiparametric MRI: A prospective, single-center, longitudinal study

PURPOSE

To evaluate the possible role of a multiparametric magnetic resonance imaging (MRI) and semiquantitative fusion map for the prediction of response to radiotherapy in carcinoma cervix.

METHODS

This was a prospective, single-center, longitudinal observational study performed on patients with locally advanced carcinoma cervix. Relative blood flow (rBF), relative blood volume (rBV), and apparent diffusion coefficient (ADC) values were obtained before and after the onset of radiotherapy. rBV, rBF, and ADC values were used to generate a semiquantitative pharmacokinetic model map to identify any hypoxic component of the tumor. The subjects were retrospectively classified as responders and nonresponders based on response to treatment. Prospective prediction of response status was done using pretreatment multiparametric MRI parameters (rBF, rBV, and ADC) and semiquantitative parametric map.

RESULTS

In 32 patients (29 with parametrial involvement and 15 with lymphadenopathy), pretreatment ADC of the primary tumor was the most accurate measure for predicting response to treatment as well as for treatment-induced fractional volume reduction. Although rBV and rBF were insignificant metrics in isolation for predicting response status, a combination with ADC in the form of parametric map had a sensitivity of 86.4% and 77.2%, specificity of 70% and 70%, positive predictive value of 86.4% and 85%, and negative predictive value 70% and 59% respectively by two independent observers.

CONCLUSION

ADC is the most accurate measure for predicting the response to treatment. A manual parametric map generated by an off-line fusion of the above map with those generated by pharmacokinetic modeling of perfusion-weighted MRI may be a useful tool for the prediction of response to radiotherapy.

Diagnostic Role of Transvaginal Sonography and Magnetic Resonance Imaging in Adenomyosis of the Uterus and its Correlation with Histopathology

Background and Objective

The prevalence of adenomyosis of the uterus varies from 5% to 70%, and there is no clear consensus on its imaging diagnostic criteria. The objective of this study was to evaluate the role of transvaginal sonography (TVS), combined TVS and color Doppler (TVS-CD), and magnetic resonance imaging (MRI) in the diagnosis of adenomyosis.

Materials and Methods

This was a tertiary care hospital-based prospective study, in which 365 clinically suspected cases of adenomyosis were enrolled. All three types of imaging (TVS, TVS-CD, and MRI) were done in 233/365 patients, followed by hysterectomy in 50. Imaging features were correlated with the histopathological examination (HPE), which was taken as the gold standard for the diagnosis. The diagnostic performance of each imaging modality was assessed.

Results

Among patients who underwent hysterectomy, 36/50 (72%) had adenomyosis on HPE, with or without associated benign gynecological abnormalities. Sensitivity, specificity, positive predictive value (PPV), negative PV (NPV), and diagnostic accuracy (DA) of MRI were higher than that of TVS-CD (91.67% vs. 77.78%, 85.71% vs. 78.57%, 94.29% vs. 90.32%, 80% vs. 57.89%, and 90% vs. 78%, respectively). TVS alone had lower diagnostic performance (specificity: 64.29%, PPV 84.85%, NPV 52.94%, and DA74%) than TVS-CD, but equal sensitivity (77.78%). Heterogeneous myometrium was the most sensitive (80.56%), while myometrial cyst was the most specific (92.86%) TVS feature. The maximum junctional zone thickness ≥12 mm was the most sensitive (97.22%), while the hyperintense myometrial focus was the most specific (100%) MRI feature.

Conclusion

TVS-CD should be used as an initial diagnostic imaging modality in clinically suspected cases of adenomyosis; however, MRI due to better diagnostic efficacy should be the imaging modality of choice before subjecting such patients to hysterectomy.

Effectiveness of 13-valent pneumococcal conjugate vaccine on radiological primary end-point pneumonia among cases of severe community acquired pneumonia in children: A prospective multi-site hospital-based test-negative study in Northern India

INTRODUCTION

Community acquired pneumonia (CAP) is a leading cause of under-five mortality in India and Streptococcus pneumoniae is the main bacterial pathogen for it. Pneumococcal Conjugate Vaccine 13 (PCV13) has been introduced in a phased manner, in the national immunization program of India since 2017/2018. The primary objective of this study was to evaluate the effectiveness of PCV13 on chest radiograph (CXR)-confirmed pneumonia, in children hospitalized with WHO-defined severe CAP.

METHODS

This prospective, multi-site test-negative study was conducted in a hospital-network situated in three districts of Northern India where PCV13 had been introduced. Children aged 2-23 months, hospitalized with severe CAP and with interpretable CXR were included after parental consent. Clinical data was extracted from hospital records. CXRs were interpreted by a panel of three independent blinded trained radiologists. Exposure to PCV13 was defined as ≥2 doses of PCV13 in children aged ≤ 12 months and ≥ 1 dose(s) in children > 12 months of age. Our outcome measures were CXR finding of primary endpoint pneumonia with or without other infiltrates (PEP±OI); vaccine effectiveness (VE) and hospital mortality.

RESULTS

From 1st June 2017-30th April 2021, among 2711 children included, 678 (25.0%) were exposed to PCV1. CXR positive for PEP±OI on CXR was found in 579 (21.4%), of which 103 (17.8%) were exposed to PCV. Adjusted odds ratio (AOR) for PEP±OI among the exposed group was 0.69 (95% CI, 0.54-0.89, p = 0.004). Adjusted VE was 31.0% (95% CI: 11.0-44.0) for PEP±OI. AOR for hospital mortality with PEP±OI was 2.65 (95% CI: 1.27-5.53, p = 0.01).

CONCLUSION

In severe CAP, children exposed to PCV13 had significantly reduced odds of having PEP±OI. Since PEP±OI had increased odds of hospital mortality due to CAP, countrywide coverage with PCV13 is an essential priority.

Approach to Acute Respiratory Illness in Children with Hematological Malignancy: A Prospective Study Evaluating Utility of CT Scan

Introduction Various pulmonary complications can occur in children with hematological malignancies including both infection and malignant disease infiltration of pulmonary parenchyma.

Objectives To assess the role of CT scan in determining the etiology of acute pulmonary complications in children with hematological malignancies.

Materials and Methods All children < 17 years with newly diagnosed hematological malignancy with respiratory symptoms (Group A) along with children who developed fever with persistent respiratory symptoms as well as worsening chest radiographs during treatment (Group B) and underwent CECT thorax, from February 2019 to July 2020 were enrolled. The final diagnosis was made on the basis of clinical history, laboratory as well as radiological investigations and treatment response.

Results Thirty-seven children with mean age of 7.5 ± 3.5 years and male to female ratio of 1.3:1 who underwent CECT thorax were included in our study. For newly diagnosed cases, i.e., Group A (n = 8), the most common cause of respiratory symptoms as identified on CECT thorax was pulmonary tumoral infiltration (n = 5) followed by tuberculosis (n = 3). However, in Group B (n = 29) the cause of persistent respiratory symptoms was identified as infection (n = 17) followed by leukemic infiltration (n = 12). Thus, chest CT could accurately identify pulmonary tuberculosis, fungal pneumonia, bacterial infection, and pulmonary tumoral infiltrates.

Conclusion CT scan can be used as an adjunctive tool for prompt diagnosis and management of pulmonary complications in children with persistent respiratory symptoms as they are often non-specific.

Role of Diffusion-Weighted Magnetic Resonance Imaging in Prediction of Pathological Complete Response to Neoadjuvant Chemotherapy in Locally Advanced Breast Cancer and Its Molecular Subtypes

Purpose  The aim of this study was to evaluate the role of apparent diffusion coefficient (ADC) and hence diffusion-weighted imaging in prediction of pathological complete response (pCR) to neoadjuvant chemotherapy (NACT) in locally advanced breast cancer (LABC) and its molecular subtypes.

Methods  In this tertiary hospital-based prospective study, 30 patients aged 30 to 65 years, having clinically/cytologically diagnosed LABC, were included. Magnetic resonance imaging (MRI) was done to obtain prechemotherapy ADC (ADC _pre ), postchemotherapy ADC (ADC _post ), change in ADC (ΔADC), and ΔADC% for each tumor and its subtype. Postsurgical pCR was used as the reference standard for determining tumor response. All four ADC parameters were compared between pCR and non-pCR groups.

Results  Of the 30 patients, 19 (63.3%) patients showed pCR, while 11 (36.7%) patients did not. The pCR group showed significantly lower mean ADC _pre ( p <   0.001) and higher mean ADC _post ( p <   0.05), ΔADC, and ΔADC% ( p  = 0.000) than non-pCR group. The best cutoff values to differentiate responders from nonresponders with receiver operating characteristic curve analysis of ADC _pre , ADC _post , and ΔADC% were 0.98 × 10 ⁻³ mm ² /s (68.4% sensitivity, 63.6% specificity), 1.31×10 ⁻³ mm ² /s (68.4% sensitivity, 63.6% specificity), and 25% (84.2% sensitivity, 90.9% specificity), respectively. Human epidermal growth factor receptor 2 (HER2)-enriched subtype showed significant difference in mean ADC _pre ( p  = 0.045), while triple-negative subtype showed significant differences in mean ADC _post ( p  = 0.032) and mean ΔADC ( p  = 0.019) between the two groups.

Conclusion  ADC _pre , ADC _post , and ΔADC can predict pCR to NACT in LABC. Among molecular subtypes, ADC _pre was predictive only in HER2-enriched subtype, while ADC _post and ΔADC were predictive only in triple-negative subtype.

Initial comparative analysis of pulmonary involvement on HRCT between vaccinated and non-vaccinated subjects of COVID-19

OBJECTIVES

To compare the high-resolution computed tomography (HRCT)-derived severity score in COVID-19 patients between those who had earlier received the vaccine against the SARS-CoV-2 and those who did not.

METHODS

A retrospective cross-sectional analysis of HRCT of the chest was done in correlation with the vaccination status of clinically diagnosed COVID-19 patients. The variable under evaluation was the CT severity score, whereby differential analysis of the variability on this parameter between incompletely (single dose) vaccinated, completely (both doses) vaccinated, and non-vaccinated individuals was the outcome.

RESULTS

The analysis included 826 patients of which 581 did not receive any vaccination whereas 196 patients received incomplete (single dose) vaccination and 49 received complete vaccination. Mean CT severity score was lower in completely vaccinated patients (3.5 ± 6.3) vis-à-vis incompletely vaccinated (10.1 ± 10.5) and non-vaccinated (10.1 ± 11.4) individuals. The mean CT score was significantly lower in completely vaccinated patients of lower ages (≤ 60 years) compared to patients above that age. The incidence of severe disease (CT score ≥ 20) was significantly higher in the incompletely vaccinated and non-vaccinated patients compared to that in the completely vaccinated group.

CONCLUSIONS

CT severity scores in individuals receiving both doses of SARS-CoV-2 vaccination were less severe in comparison to those receiving a single dose of vaccine or no vaccine at all.

KEY POINTS

• Patients who received complete two doses of vaccination had significantly low mean CT scores compared to the partially vaccinated patients and non-vaccinated patients. • The mean CT scores were significantly lower in completely vaccinated patients of lower ages (< 60 years) while patients > 60 years did not show significantly different CT scores between the vaccinated and non-vaccinated groups. • Consolidations and ground-glass opacities were significantly lower in the group receiving complete vaccination as compared to the unvaccinated and incompletely vaccinated patients.

Sternocleidomastoid flap for pedicled reconstruction in head & neck surgery- revisiting the anatomy and technique

Background

Previous studies on sternocleidomastoid flaps, have defined the importance of preserving sternocleidomastoid (SCM) branch of superior thyroid artery (STA). This theory drew criticism, as this muscle is known to be a type II muscle, i.e., the muscle has one dominant pedicle (branches from the occipital artery at the superior pole) and smaller vascular pedicles entering the belly of muscle (branches from STA and thyrocervical trunk) at the middle and lower pole respectively. It was unlikely for the SCM branch of STA to supply the upper and lower thirds of the muscle. We undertook a cadaveric angiographic study to investigate distribution of STA supply to SCM muscle.

Methods

It is a cross-sectional descriptive study on 10 cadaveric SCM muscles along with ipsilateral STA which were evaluated with angiography using diatrizoate (urograffin) dye. Radiographic films were interpreted looking at the opacification of the muscle. Results were analyzed using frequency distribution and percentage.

Results

Out of ten specimens, near complete opacification was observed in eight SCM muscle specimens. While one showed poor uptake in the lower third of the muscle, the other showed poor uptake in the upper third segment of muscle.

Conclusion

Based on the above findings we suggest to further investigate sternocleidomastoid muscle as a type III flap, as the STA branch also supplies the whole muscle along with previously described pedicle from occipital artery. However, this needs to be further corroborated intra-operatively using scanning laser doppler. This also explains better survival rates of superior thyroid artery based sternomastoid flaps.

Power Doppler sonography - A supplement to hysteroscopy in abnormal uterine bleeding: Redefining diagnostic strategies

Background

Abnormal Uterine Bleeding (AUB) is a very frequent cause of gynecological visits in women of all age groups. Ultrasound pelvis with or without endometrial sampling have been conventionally used to make diagnosis. Power Doppler is a comparatively recent modality which can be used to screen patients who will need endometrial biopsy/ curretage. We hereby conducted a study to compare the diagnostic accuracy of power Doppler sonography and hysteroscopy with histopathology associated with abnormal uterine bleeding. We also calculated the incidence of uterine pathology in AUB by power Doppler ultrasound and hysteroscopy and compared it with histopathology.

Methods

This prospective cohort study was conducted at the Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University. After excluding 42 women, a total of 100 women fulfilling the inclusion criteria contributed to our study. Selected women underwent power Doppler ultrasound and hysteroscopy with guided biopsy. Results were compared with histopathology as per the gold standard. Evaluation of sensitivity, specificity, positive and negative predictive values were performed for each modality. All statistical analyses were performed using the SPSS 11.0 statistical package. P value ≤0.05 was considered statistically significant for all tests used.

Results

Sensitivity and specificity of power Doppler are 75% and 100% for carcinoma endometrium, 72.72% and 98.9% for endometrial hyperplasia, and 81.81% and 100% for endometrial polyp, respectively.

Conclusion

Power Doppler sonography can be used to screen outpatients who do not need an endometrial biopsy for abnormal uterine bleeding. This will avoid unnecessary hysteroscopy in definitive benign cases, and watchful hysteroscopy in suspected premalignant and malignant cases. Irregular branching vessels and color splashes were found to be the best parameters for diagnosing endometrial carcinoma. Power Doppler should be done along with transvaginal sonography in all cases of abnormal uterine bleeding.

Epidemiology of Hypoxic Community-Acquired Pneumonia in Children Under 5 Years of Age: An Observational Study in Northern India

BACKGROUND

Community-acquired pneumonia (CAP) is the leading cause of under-five mortality in India. An increased risk of mortality has been reported in cases of hypoxic pneumonia.

METHODS

The primary objective of this study was to assess the proportion of children aged 2-59 months, hospitalized with hypoxic CAP, as well as socio-demographic, clinical, and radiological features associated with it. The secondary objective was to determine the risk of mortality among hospitalized cases of hypoxic CAP. This prospective, observational study was conducted in four districts of Northern India, between January 2015 and April 2021. A hospital-based surveillance network was established. Inclusion criteria were as follows: (a) child between 2 and 59 months, (b) hospitalization with symptoms of WHO-defined CAP, (c) resident of project district, (d) illness of <14 days, and (e) child had neither been hospitalized for this illness nor recruited previously. Children whose chest x-rays (CXRs) were either unavailable/un-interpretable and those that received any dose of pneumococcal conjugate vaccine-13 were excluded. Hypoxic pneumonia was defined as oxygen saturation <90% on pulse oximetry or requiring oxygen supplementation during hospital stay.

RESULTS

During the study period, 71.9% (7,196/10,006) children of severe pneumonia were eligible for inclusion, of whom 35.9% (2,580/7,196) were having hypoxic pneumonia. Female gender and use of biomass fuel for cooking increased the odds of hypoxic CAP. Clinical factors like wheezing, pallor, tachypnea, low pulse volume, presence of comorbidity, general danger signs, severe malnutrition, and radiological finding of primary end-point pneumonia ± other infiltrates (PEP±OI) also increased the odds of hypoxic CAP in a conditional logistic regression model. Adjusted odds ratio for mortality with hypoxia was 2.36 (95% CI: 1.42-3.92).

CONCLUSION

Almost one-third of cases hospitalized with severe CAP had hypoxia, which increased chances of mortality. Besides known danger signs, certain newer clinical signs such as pallor and wheezing as well as PEP+OI were associated with hypoxic CAP. Therefore, objective assessment of oxygen saturation must be done by pulse oximetry in all cases of CAP at the time of diagnosis.

Colour Doppler evaluation of uterine and ovarian blood flow in patients of polycystic ovarian disease and post-treatment changes

AIM

To assess the morphology and colour Doppler parameters in patients with polycystic ovarian syndrome (PCOS) and also to assess the changes in Doppler parameters in follow-up patients, who underwent treatment.

MATERIALS AND METHODS

The study was conducted on 50 women of reproductive age who had clinical and biochemical findings suggestive of PCOS. Clinico-hormonal parameters were recorded. Ultrasound and colour Doppler flow measurements of bilateral ovaries were performed in the early proliferative phase of the menstrual cycle. After assessment of the bilateral ovaries, colour Doppler ultrasound was used to evaluate the main uterine artery at the cervico-uterine junction. Follow-up imaging after 3 months was undertaken in patients who underwent treatment (metformin) and changes in the imaging and hormonal parameters were correlated.

RESULTS

The mean value of luteinising hormone (LH) and the ratio of LH: follicle-stimulating hormone (FSH) was significantly higher in PCOS patients. Ultrasound parameters were significantly higher in PCOS patients. Ovarian stromal vessels in PCOS patients had a significantly higher peak systolic velocity (PSV), low resistance index (RI), and pulsatility index (PI). The PSV of uterine arteries were significantly decreased and the RI and PI were significantly increased. On follow-up patients revealed changes in hormonal parameters.

CONCLUSION

PCOS is a heterogeneous disorder and is a convergence of multisystem endocrine derangements. Ultrasound is good diagnostic tool for PCOS and the use of Doppler aids in the evaluation of haemodynamic changes in small vessels of utero-ovarian circulation and in response assessment.

Chest radiograph findings in children aged 2-59 months hospitalised with community-acquired pneumonia, prior to the introduction of pneumococcal conjugate vaccine in India: a prospective multisite observational study

OBJECTIVES

The current study was a hospital-based surveillance of cases hospitalised with WHO-defined community-acquired pneumonia in children aged 2-59 months, to assess the radiological abnormalities in chest X-rays and to identify the demographic and clinical correlates of specific radiological abnormalities, in residents of prespecified districts of Uttar Pradesh and Bihar, India.

DESIGN

Prospective, active, hospital-based surveillance.

SETTING

Multisite study conducted in a network of 117 secondary/tertiary care hospitals in four districts of Uttar Pradesh and Bihar, India.

PARTICIPANTS

Included were children aged 2-59 months, hospitalised with community-acquired pneumonia, residing in the project district, with duration of illness <14 days and who had not been hospitalised elsewhere for this episode nor had been recruited previously.

MAIN OUTCOME MEASURE

Concordant radiological abnormalities in the chest X-rays.

RESULTS

From January 2015 to April 2017, 3214 cases were recruited and in 99.40% (3195/3214) chest X-rays were available, among which 88.54% (2829/3195) were interpretable. Relevant radiological abnormalities were found in 34.53% (977/2829, 95% CI 32.78 to 36.28). These were primary end point pneumonia alone or with other infiltrates in 22.44% (635/2829, 95% CI 20.90% to 23.98%) and other infiltrates in 12.09% (342/2829; 95% CI 10.88% to 13.29%). There was a statistically significant interdistrict variation in radiological abnormalities. Statistically significantly higher proportion of abnormal chest X-rays were found in girls, those with weight-for-age z-score ≤-3SD, longer duration of fever, pallor and with exposure to biomass fuel.

CONCLUSIONS

Among hospitalised cases of community-acquired pneumonia, almost one-third children had abnormal chest radiographs, which were higher in females, malnourished children and those with longer illnesses; and an intra-district variation was observed.

The longest tumor diameter in one dimension as a predictor for skeletal metastasis in renal cell carcinoma

INTRODUCTION

Renal cell carcinoma (RCC) comprises a diverse group of malignant neoplasms that have multifarious histopathological features and biological behavior. One-third of RCC patients develops skeletal metastasis with a poor 5-year survival rate. Data explaining how some of these tumors show sooner bony metastasis than expected is sparse. The objective of this study was to identify whether tumor size can act as a predictor of bony metastases among patients of RCC.

MATERIALS AND METHODS

We retrospectively reviewed contrast enhanced computed tomography (CECT) scan and clinical records of 66 patients with RCC, who fulfilled specified inclusion criteria. Patients who had bony metastasis at the time of presentation were selected as case and those without skeletal metastasis were referred to as controls. Receiver operating characteristic (ROC) curve analysis was used to determine the appropriate cut-off value for tumor size, which was measured as the longest tumor diameter (LTD) in one-dimensional (1D).

RESULTS

Of the 66 patients selected, 30% developed bone metastasis. The tumor size of RCCs significantly correlated with the presence of skeletal metastasis in our study. None of the patients with 1D LTD <4.8 cm on CECT were found to have skeletal metastasis. ROC analysis revealed that the accuracy of the LTD in predicting bone metastasis was high with an area under ROC curve of 0.823. A cut-off value of 7.5 cm had a sensitivity of 78.9% and specificity of 80.9%.

CONCLUSION

The 1D LTD with a cut-off value of 7.5 cm, at the time of presentation is an important predictor of skeletal metastasis. The result of this study may have role in triage of patients into a subgroup which mandates more aggressive treatment and monitoring.

Chemical Shift Artifact on Steady-State MRI Sequences for Detection of Vesical Wall Invasion in Placenta Percreta

BACKGROUND

Antenatal diagnosis of the invasiveness of a placenta percreta helps in planning the surgical approach, reducing blood loss and morbidity. Doppler sonography is the mainstay diagnostic modality with a sensitivity of 80-95 %. With the advent of high magnetic field MRI techniques, there has been recent interest in evaluation of placenta by MRI. On an extensive PUBMED search, we could not find any citations describing imaging, ultrasound, or MRI features to evaluate vesical wall invasion by placenta percreta.

PURPOSE

We attempt to evaluate transmyometrial vesical wall invasion by placenta percreta using chemical shift artifact as a marker of intact bladder-myometrial interface on steady-state MRI sequences.

MATERIALS AND METHODS

This is a prospective observational study, conducted at a university hospital. We have compiled clinico-radiological criteria for diagnosis of invasive placentae based on the existing body of evidences, in four patients. We further go on to analyze a specific proposed sign on a newly introduced MR imaging sequence i.e., loss of chemical shift artifact (India ink line) on steady-state GRE sequence (TrueFISP), to diagnose transmyometrial vesical invasion in placenta percreta.

RESULTS

Though the sample size is small, the sensitivity, specificity, positive, and negative predictive value of the proposed sign for the purpose was 100 %.

CONCLUSIONSS

Loss of chemical shift artifact (India ink line) on steady-state GRE sequences at the vesico-myometrial junction in case of invasive placentae confirms vesical wall invasion, a prospective diagnoses of which can help in planning the surgical protocol and preventing potentially fatal blood loss.

Antral follicle count in normal (fertility-proven) and infertile Indian women

Background:

Antral follicle count (AFC) has been labeled as the most accurate biomarker to assess female fecundity. Unfortunately, no baseline Indian data exists, and we continue using surrogate values from the Western literature (inferred from studies on women, grossly different than Indian women in morphology and genetic makeup).

Aims:

(1) To establish the role of AFC as a function of ovarian reserve in fertility-proven and in subfertile Indian women. (2) To establish baseline cut-off AFC values for Indian women.

Settings and Design:

Prospective observational case-control study.

Materials and Methods:

Thirty patients undergoing workup for infertility were included and compared to equal number of controls (women with proven fertility). The basal ovarian volume and AFC were measured by endovaginal. USG the relevant clinical data and hormonal assays were charted for every patient.

Statistical Analysis Used:

SPSS platform was used to perform the Student's t-test and Mann-Whitney U-test for intergroup comparisons. Correlations were determined by Pearson's ranked correlation coefficient.

Results:

Regression analysis revealed the highest correlation of AFC and age in fertile and infertile patients with difference in mean AFC of both the groups. Comparison of the data recorded for cases and controls showed no significant difference in the mean ovarian volume.

Conclusions:

AFC has the closest association with chronological age in normal and infertile Indian women. The same is lower in infertile women than in matched controls. Baseline and cut-off values in Indian women are lower than that mentioned in the Western literature.

Postnatal changes in cerebral blood flow velocity in term intra-uterine growth-restricted neonates

BACKGROUND

Intra-uterine growth-restricted (IUGR) fetuses are prone to hypoxic changes in the brain and neurodevelopmental sequelae in later life. Chronic hypoxaemia may also lead to polycythaemia in the fetal and neonatal period.

AIM

To evaluate venous haematocrit and cerebral blood flow velocity (CBFV) in term IUGR neonates in the immediate postnatal period.

METHODS

This was a prospective observational study of 54 clinically healthy term IUGR neonates as cases and 50 term, appropriate-for-gestational-age (AGA), healthy neonates as controls. IUGR was defined as birthweight <10th per centile for gestational age. Neonates with perinatal asphyxia, sepsis and other systemic diseases were excluded. Resistance index (RI), pulsatility index (PI), peak systolic velocity (PSV) and vascular diameter were measured in the internal carotid, vertebral and middle cerebral arteries by transcranial colour Doppler ultrasound between 48 and 72 hours of life, along with the estimation of venous haematocrit. Neonates were observed for development of any complications until discharge and followed up clinically and radiologically for a minimum 6 months.

RESULTS

Significantly higher resistance (RI and PI) and lower PSV was recorded in all the cerebral arteries of the IUGR than the AGA group whereas no difference was observed in vascular diameters. Mean haematocrit was significantly higher in the IUGR than in the AGA group [55·7 (4·22) vs 45·1 (2·79) g/dl]. Haematocrit was positively correlated with RI and PI, and negatively correlated with PSV. After discharge, three infants in the IUGR group showed hypertonia and delayed developmental milestones along with hypoxic changes in MRI of the brain.

CONCLUSIONS

Compared with their AGA counterparts, higher venous haematocrit and lower CBFV were observed in clinically healthy, term IUGR neonates during the early neonatal period. Delayed developmental milestones and hypoxic changes were detected by MRI in three infants. Since the study was limited by its sample size, larger studies are required to document the clinical significance of decreased CBFV and its usefulness as a marker of poor prognosis for future neurodevelopment.

Thymic size correlates with cord blood zinc levels in low-birth-weight newborns

Thymus is essential for immunity as it provides environment for T cell differentiation and maturation. There is limited information on various factors which determine thymic size at birth. We studied the influence of cord blood zinc and copper levels and maternal and neonatal nutritional status on thymic size in term low-birth-weight (LBW) newborns. A prospective observational study on 44 term LBW (<2,500 g) newborns (cases) and 71 gestational age-matched newborns weighing ≥2,500 g (controls). Sonographically determined thymic index was correlated to cord blood zinc and copper levels and maternal and neonatal nutritional status. Thymic index measured 3.74 ± 1.57 cm(3) in LBW newborns compared to 4.90 ± 2.33 cm(3) in normal-birth-weight newborns. Thymic index was significantly correlated to cord blood zinc levels but not to cord blood copper levels and had linear relationship to the maternal body mass index and midarm circumference and neonatal anthropometric parameters.

CONCLUSION

Thymic index is linearly related to cord blood zinc levels and maternal and neonatal nutritional status. Compared to thymic size in the Western newborns, the thymus is less than half in size in Indian newborns of normal birth weight. Reduced thymic size in Indian newborns in general and LBW infants in particular may have consequences for their immune competence and the risk of infections. Improving nutrition of pregnant women, particularly zinc nutriture might favorably influence thymic size in their offspring.

Biological behavior and disease pattern of carcinoma gallbladder shown on 64-slice CT scanner: a hospital-based retrospective observational study and our experience

PURPOSE

The aim of this diagnostic observational study was to assess the spread and biological behavior of gallbladder cancer using 64-slice computerized tomography (CT) scanner in this particular geographic belt (eastern Uttar Pradesh, western Bihar, and northern Madhya Pradesh provinces of North India). Indians are ethnically and culturally different from their Western counterparts among whom the incidence of this disease is comparatively low.

SUBJECTS AND METHODS

After systemic examination, all patients (87) were subjected to ultrasonographic examination. All cases were histopathologically proven. Confirmed cases were subjected to volumetric CT examination of abdomen and pelvis, plain, post contrast and delayed phase.

RESULTS

Majority of the cases were adenocarcinoma. There was female preponderance with majority belonging to fifth and sixth decades. Commonest presentation was diffuse, irregular, enhancing wall thickening in 49.4%. Majority had invasion of liver parenchyma (74.7%). Cholelithiasis was seen in 48.3% cases. Invasion of biliary radicals was high (13.8-18.4%). Eleven cases had invasion of portal vein and tumor thrombus, with hepatic artery invasion in one case. In two cases, both hepatic artery and portal vein invasion was seen. Portal and peripancreatic nodal metastasis was seen in 58.5%. Distant metastasis was reported.

CONCLUSION

Few studies involving the Indian population have attempted to use multi-row detector CT to define the biological behavior of carcinoma gallbladder. The opinion whether the pathology is operable or non-operable can reasonably be given. This large-scale, single-center study gives insight about the epidemiology and biological behavior of carcinoma gallbladder.

Clinico-immunological response to intratumoral versus intravenous neoadjuvant chemotherapy in advanced pediatric solid malignancies

Background:

There is minimal literature on the use of intralesional chemotherapy in the pediatric age group. We undertook this present study to evaluate the two modalities (intratumoral and intravenous) of giving chemotherapy in terms of toxicity of chemotherapy, hematological parameters, efficacy of chemotherapy in reduction in volume of the tumor as well as resectability of tumor with special emphasis on immunological parameters.

Materials and Methods:

Advanced cases of Wilms’ tumor and Neuroblastoma were included in the study. Intratumoral chemotherapy was given through 25 G spinal needle under aseptic precautions and ultrasound guidance in the same dose as in systemic chemotherapy. Intravenous group was given chemotherapy in the usual way. Reassessment was carried out after every course of chemotherapy.

Results:

Group A included 16 cases of Wilms’ tumor and 6 cases of neuroblastoma. In group B, there were 14 cases of Wilms’ tumor and 8 of neuroblastoma. Vomiting, diarrhea, mucositis, and thrombophlebitis were more common in the intravenous group (P<0.05). The fall in Immunoglobulin A, Immunogloblulin G, Immunoglobulin M, and T-cell rosetting was more common in the intravenous group (P<0.05). Seventy percent of patients had completely resectable tumor at the end of 6 doses of intratumoral chemotherapy as compared to 50% resectability in the intravenous group (P<0.05).

Conclusion:

Intratumoral chemotherapy, besides causing less of the adverse effects and increasing the resecability rate, also causes less suppression of the immune system. This may be offered as an alternative safe and effective modality of treatment for advanced solid tumors.

Intralesional bleomycin in lymphangioma: an effective and safe non-operative modality of treatment

Introduction:

Lymphangiomas are benign hamartomatous lymphatic tumors. The mainstay of the therapy is surgical excision, but due to its infiltration along the nerves and muscles, total excision is not always possible. In the present study, we have evaluated the clinical profile of all the cases of lymphagiomas coming to our department and evaluated the efficacy of intralesional Bleomycin as a sclerosing agent in its management.

Materials and Methods:

In this prospective study, all patients were evaluated clinically and color Doppler ultrasonography (USG). The required dose was calculated as 0.5 mg/kg body weight, not exceeding 10 units at a time. The response was assessed clinically and on the basis of color Doppler USG.

Results:

Thirty-five patients of lymphangioma were included in the study. The neck region was the most common site of involvement. The response was excellent in 7 (20%), good in 26 (74.29%), and poor in 2 (5.71%) patients. The complications included fever, transient increase in size of swelling, local infection, intraluminal bleed, and skin discoloration in 10 patients.

Conclusion:

This therapy may be used as primary modality instead of surgery in selected group of patients.

Thymic involution as a predictor of early-onset neonatal sepsis

BACKGROUND

Diagnosis of early-onset neonatal sepsis (EONS) is often difficult because of vague clinical signs and non-specific laboratory parameters.

OBJECTIVE

To assess the statistical validity of thymic size estimation as a diagnostic marker of EONS compared with cord blood interleukin-6 (IL-6) concentrations.

SUBJECTS AND METHODS

Thirty-two neonates delivered in hospital and admitted to the neonatal unit with EONS comprised the study group. EONS was diagnosed on the basis of development of clinical signs and symptoms of sepsis within 72 hours of birth in the presence of antenatal risk factors for chorio-amnionitis and a positive blood culture. Thirty-two gestational age- and gender-matched healthy neonates served as controls. Cord blood IL-6 concentrations were estimated by ELISA. Thymic size was assessed by sonological measurement of thymic dimensions (longitudinal and transverse diameters, thymic volume and thymic index) within 24 hours of birth in the study infants and the controls. Data were analyzed by SPSS 16.0.

RESULTS

Thymic size was significantly smaller whereas cord blood IL-6 concentrations were significantly higher (P<0.001) in the sepsis group than in the controls. Sensitivity and specificity of thymic dimensions were comparable to IL-6 concentrations for diagnosing EONS. Significant correlation was noted between reduction in thymic size and a rise in IL-6 concentrations.

CONCLUSION

Thymic involution can be used as a reliable diagnostic marker for EONS.

Magnetic resonance fistulogram demonstration of urethrovesicovaginal fistula in a case of müllerian agenesis due to traumatic urethral coitus

Vesicovaginal fistula is not uncommon in women of childbearing age, and can occur due to a multitude of causes, the chief ones being infection and neoplasia. An extensive PUBMED search yielded only a few reports describing causation of such a lesion due to traumatic urethral coitus. The classic method to demonstrate such fistulas is by direct contrast-enhanced fistulography. Herein we report a case of urethrovesicovaginal fistula with müllerian agenesis caused by traumatic urethral coitus, as demonstrated using indirect magnetic resonance fistulography.

Color Doppler ultrasonography for treatment response prediction and evaluation in breast cancer

Primary systemic therapy is a well-established modality of treatment in locally advanced breast cancer. Assessment of tumor response to chemotherapy not only helps in assessing the efficacy of the regimen used but also predicts the overall outcome of the patient. The tumor vascularity is a surrogate marker of tumor burden and this can be readily assessed by color Doppler ultrasound using various indices (resistivity index, pulsatility index and maximum flow velocity). The pre- and post-chemotherapy indices can be compared with in order assess the response to chemotherapy. Among various imaging modalities, MRI and PET have the highest sensitivity in detecting the tumor response, but they are not cost effective. Color Doppler ultrasound is a promising alternative for tumor response assessment owing to its availability, reproducibility and cost–effectiveness.

Esthesioneuroblastoma: a case report

Esthesioneuroblastoma (olfactory neuroblastoma) is an uncommon neuroectodermal tumor. Its biological activity ranges from indolent growth to local recurrence and rapid widespread metastasis. Treatment options consist of surgical resection followed by radiation therapy for primary lesions and the addition of chemotherapy for advanced, recurrent, or metastatic lesions. Patients often present with nasal obstruction, rhinorrhea, recurrent epistaxis, hyposmia, or anosmia. We report a case of esthesioneuroblastoma involving bilateral nasal cavity leading to bilateral nasal obstruction, epistaxis and proptosis of the right eye associated with decreased visual acquity on that eye and loss of smell. A diffuse nontender, 6x6 cms swelling with illdefined margins was seen over the nasal bridge, extending superiorly to glabella and laterally to right maxillary region. X-ray PNS showed soft tissue mass in the nasal cavity with destruction of nasal septum, intense periosteal reaction with destruction of right maxillary wall and extension to right orbit. CT scan of paranasal sinuses showed 8.5 x 4.9 x 7.8 cms irregularly marginated heterogeneous iso- to hyper dense soft tissue mass lesion with extensive adjacent bony destruction and spiculated periosteal reaction involving bilateral nasal cavity and anterior cranial fossa. Biopsy from right nasal mass showed neuroblastoma. The patient received radiotherapy and chemotherapy. The modified Kadish staging system, lymph node status, treatment modality, and age are useful predictors of survival in patients who present with esthesioneuroblastoma. Excellent outcomes for esthesioneuroblastoma are achievable. Long-term follow-up is necessary because of the extended interval for recurrent disease; unlike most sinonasal malignancies, surgical salvage is possible.

Pancreatic metastases of renal cell carcinoma--case report

Metastasis to the pancreas from renal cell carcinoma is distinctly uncommon. A solitary renal cell carcinoma (RCC) metastasis to the head of pancreas is rarely encountered. We present a 55 years old male who was admitted in our hospital with the complaint of abdominal pain on and off but more continuous since 15 days. He did not have any urinary symptoms. The laboratory tests were within the normal limits. Ultrasound of abdomen revealed an encapsulate mass in the kidney plus a mass in the head of pancreas, but no other distant metastases. On histopathological examination, sections of the renal mass showed features of a highly vascularized, clear cell neoplasm, with solid, nested, and alveolar architecture, consistent with RCC, clear cell type. Fine needle aspiration from the mass in the head of the pancreas confirmed the diagnosis of metastatic renal cell carcinoma, clear cell type. In the absence of widespread disease, pancreatic resection can provide long term survival in metastatic RCC, although few cases have been reported with lengthy follow up. The prognosis is better than for pancreatic adenocarcinoma.

Superior mesenteric artery syndrome: case report

Superior mesenteric artery (SMA) syndrome is a rare acquired disorder in which acute angulation of SMA causes compression of the third part of the duodenum between the SMA and the aorta, leading to obstruction. Loss of fatty tissue as a result of a variety of debilitating conditions is believed to be the etiologic factor causing the acute angulation. We report a case of 30 years old lady who presented with postprandial abdominal pain at the epigastric region, colic type without radiation accompanied by nausea, postprandial vomiting and weight loss. Esophageal gastric series revealed an abrupt interruption in the contrast medium flow at the level of the junction of third portion (midpart) of the duodenum in barium studies. Adiverticula is noted just proximal to the site of obstruction. High resolution ultrasound and color Doppler sonography showed narrowing of the aortomesenteric angle to 220. Duodenojejunostomy was performed in the patient. Unfortunately the patient later was admitted in the hospital for refractory gastroparesis associated with superior mesenteric artery syndrome. Although open and laparoscopic duodenojejunostomy have been described as the best surgical treatment options for Wilkie's syndrome, but further attention is needed to the management of patients with refractory symptoms of gastroparesis after corrective surgery.

Isolated islets in diabetes research

This review highlights some recent developments and diversified applications of islets in diabetes research as they are rapidly emerging as a model system in biomedical and biotechnological research. Isolated islets have formed an effective in vitro model in antidiabetic drug development programme, screening of potential hypoglycaemic agents and for investigating their mechanisms of action. Yet another application of isolated islets could be to understand the mechanisms of beta cell death in vitro and to identify the sites of intervention for possible cytoprotection. Advances in immunoisolation and immunomodulation protocols have made xeno-transplantation feasible without immunosuppression thus increasing the availability of islets. Research in the areas of pancreatic and non pancreatic stem cells has given new hope to diabetic subjects to renew their islet cell mass for the possible cure of diabetes. Investigations of the factors leading to differentiation of pancreatic stem/progenitor cells would be of interest as they are likely to induce pancreatic regeneration in diabetics. Similarly search for the beta cell protective agents has a great future in preservation of residual beta cell mass left after diabetogenic insults. We have detailed various applications of islets in diabetes research in context of their current status, progress and future challenges and long term prospects for a cure.

Color doppler ultrasound as an objective assessment tool for chemotherapeutic response in advanced breast cancer

BACKGROUND

In our part of the world, the majority of the patients with breast cancer present with locally advanced disease and require neo-adjuvant chemotherapy as the primary treatment modality. It is essential to monitor the response to chemotherapy in these patients. Clinical examination as the sole criterion of response assessment is entirely subjective and fallacious. Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) are expensive. The role of Doppler ultrasonography as an imaging modality for this purpose is therefore being evaluated.

METHODS

A prospective study was undertaken of 25 cases of locally advanced breast carcinoma (LABC) and Color Doppler sonography was used for the sequential assessment of chemotherapeutic response. The response assessed on the basis of clinical examination and Color Doppler was compared with the histological response. The parameters assessed on color Doppler were a change in the number of flow signals, maximum flow velocity (Vmax), pulsatility index (PI) and resistivity index (RI). Responses were analysed statistically using the Pearson correlation coefficient and Kappa statistics (kappa). The sensitivity, specificity, positive predictive & negative predictive values for predicting complete histological response were calculated.

RESULTS

Color Doppler showed a sensitivity of 88.88 % for predicting complete histological response. The negative predictive value of color Doppler was 92.3 %. A significant correlation was obtained between color Doppler and histopathological response.

CONCLUSIONS

Color Doppler was found to be an objective and effective tool or modality compared with clinical evaluation in sequential response assessment, especially for predicting complete histological response.

Prolonged epidural infusions of ropivacaine (2 mg/mL) after colonic surgery: the impact of adding fentanyl

We evaluated the safety and efficacy of a 72-h epidural infusion of ropivacaine and measured the impact of adding fentanyl 2 microg/mL to the required infusion rate, on the quality of postoperative pain relief and the incidence of side effects, after colonic surgery. One hundred fifty-five patients scheduled for elective colonic surgery were randomized in this trial. Epidural infusions of ropivacaine 2 mg/mL with fentanyl 2 microg/mL (R + F) and without fentanyl (R) were commenced during surgery and continued for 72 h postoperatively. This was a prospective, randomized, double-blinded, multi-center trial. The median infusion rate required was less in the R + F group (9.3 vs 11.5 mL/h, P < 0.001). Median pain scores at rest and on coughing were lower in the R + F group (P < 0.0001). The incidence of hypotension was more in the R + F group (P = 0.01). Time to readiness for discharge was delayed in the R + F group (median 6.6 vs 5.5 days, P = 0.012). The addition of fentanyl to ropivacaine resulted in decreased infusion rates and enhanced pain control; however, adverse effects were increased and readiness to discharge was delayed.

IMPLICATIONS

Epidural infusions of ropivacaine with and without fentanyl were administered to patients to control pain after colonic surgery. Patients who received ropivacaine with fentanyl had better pain control, increased side effects, and delayed readiness to discharge. This study questions the value of adding opioids to epidural infusions of local anesthetics.

Carcinoma of the gallbladder: role of sonography in diagnosis and staging

PURPOSE

In an attempt to define the sonographic characteristics of gallbladder cancer, we retrospectively analyzed the sonographic findings in 203 cases of gallbladder cancer confirmed by cytology or histopathology. Patients and Methods Patients with proven gallbladder cancer presenting to a single surgical unit between 1991 and 1995 were identified through a records search. All patients underwent sonographic examination followed by fine-needle aspiration (FNA), biopsy, or laparotomy for establishing the diagnosis.

RESULTS

A mass in the gallbladder and gallbladder wall thickening (> 12 mm) were cardinal sonographic findings of carcinoma. Liver infiltration was correctly identified in all patients who had it. Sonography was highly accurate for detecting mass lesions, gallstones, liver infiltration, metastasis, and ascites. However, visualization of lymph nodes, common bile duct infiltration, and peritoneal dissemination was poor.

CONCLUSIONS

Sonography was found to be a good diagnostic tool for carcinoma of the gallbladder; however, its sensitivity was poor for staging nodal spread of the disease.