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Background It is imperative that non-compliance with statins be identified and addressed to maximize their clinical benefits. Patient self-reporting methods are convenient to apply in clinical practice but need to be validated. Objective We studied the concordance of a patient self-report method, Morisky eight-item medication adherence scale (MMAS)), with the pill count method in measuring adherence with statins and their correlation with extended lipid profile parameters and serum hydroxyl-methylglutaryl coenzyme A reductase (HMGCoA-R) enzyme levels. Methods MMAS and the pill count method were used to measure the adherence with statins in patients on statins for any duration. Patients were subjected to an estimation of extended lipid profile and serum HMGCoA-R levels at the end of three months follow-up. Results Out of a total of 200 patients included in the study, 117 patients had a low adherence (score less than 6 on MMAS) whereas 65 and 18 patients had medium (score 6 or 7) and high adherence (score of 8), respectively. The majority of patients who had low adherence to statins by MMAS were nonadherent by the pill count method yielding a concordance of 96.5%. Medium or high adherence to statins by the MMAS method had a concordance of 89.1% with the pill count method. The levels of total cholesterol, low-density lipoprotein-cholesterol, apolipoprotein B, and HMGCoA-R were negatively correlated with compliance measured by pill count and MMAS in a statistically significant way and with similar correlation coefficients. HMGCoA-R levels demonstrated a plateau phenomenon, with levels being 9-10 ng/ml when compliance with statin therapy was greater than 60% by pill count and greater than 6 on the Morisky scale. Conclusion In conclusion, MMAS and the pill count method showed concordance in measuring adherence to statins. These methods need to be explored further for their interchangeability as surrogates for biomarker levels.

Primary surgical management is successful as the sole therapeutic modality in the majority of women with early-stage cervical, vaginal and vulvar cancer, but the presence of certain risk factors in the surgico-pathological specimen indicates a poorer prognosis. Adjuvant treatment can improve overall survival in such cases. Important risk factors in cervical cancer include intermediate-risk factors (large tumor size, deep cervical stromal invasion, lymph-vascular space invasion) and high-risk factors (positive or close margins, lymph nodes, or parametrial involvement). In vulvar cancer, positive margins and lymph nodes are the two most important factors for adjuvant therapy. Radiation therapy has been the mainstay of adjuvant therapy in these cancers, supplemented by chemotherapy. Recent advances have witnessed the inclusion of newer therapeutic modalities such as immunotherapy. This review addresses the current status of various adjuvant therapeutic modalities for these gynecological cancers.

Introduction: Delirium is underdiagnosed especially in ICU. In a study done in the Netherlands investigators found not only ICU nurses but also intensivists had difficulty in diagnosing delirium. With the impact that delirium has on patients’ health, its monitoring and detection should be considered an integral part of patient care in critical care medicine, Knowledge and attitude are one of the primary unmet needs regarding early detection and treatment of delirium. Since nurses are the first line assessors in any ward we would like to carry out this cross-sectional survey on a group of nurses. Objective: To assess the nurses’ knowledge about delirium & to compare the knowledge between those that have worked in ICU or critical care to those who haven’t. Methodology: This was a cross-sectional survey carried out at Birat medical college and teaching hospital. Here all nurses were requested to fill a questionnaire that consisted of 15 questions. A time-frame of 1 week was taken to gather the data. Results: We collected data from 124 nurses, who had varying educational degrees, Eighty-four were currently working in an ICU and 32.5% of those not working had previously worked in an ICU. Over all knowledge level for nurses was poor where 94 of 124 nurses had less than 50% scores. About 27% of those who had worked in an ICU setting had good knowledge compared to 17.5% of those who had not. Conclusion: Training regarding delirium is required to increase identification and adequate management to decrease morbidity due to delirium.

It is evident, in the face of the COVID-19 pandemic that has physicians confronting death and dying at unprecedented levels along with growing data suggesting that physicians who care for dying patients face complex emotional, psychological and behavioural effects, that there is a need for their better understanding and the implementation of supportive measures. Taking into account data positing that effects of caring for dying patients may impact a physician’s concept of personhood, or “what makes you, ‘you’”, we adopt Radha Krishna’s Ring Theory of Personhood (RToP) to scrutinise the experiences of physicians working in intensive care units (ICU) using a fictional scenario that was inspired by real events. The impact of death and dying, its catalysts, internal constituents, external factors, dyssynchrony, and buffers, specific to ICU physicians, were identified and explored. Such a framework allows for ramifications to be considered holistically and facilitates the curation of strategies for conflict resolution. This evaluation of the RToP acknowledges the experience and wide-ranging effects it has on ICU physicians. As such, our findings provide insight into their specific needs and highlight the importance of support on a personal and organisational level. Although further research needs to be conducted, the RToP could serve as the basis for a longitudinal assessment tool supported by the use of portfolios or mentorship due to their provision of personalised, appropriate, specific, timely, accessible and long-term support.

BACKGROUND Mediastinal lesions are one of the most common lesions of the chest in children and adults. Multidetector computed tomography (MDCT) is the most common investigation done in patients with suspected abnormalities on X-ray. Crosssectional imaging visualises complex anatomy, helps in predicting the tissue of origin, characterises lesions and depicts the extent of involvement of adjacent structures. Complications of mediastinal lesions and emergent conditions, for example, sealed pneumo-mediastinum, tracheoesophageal / pulmonary fistula, a peri-lesional abscess can be well assessed on CECT. The possibility of the lesion as benign or malignant and can be well predicted. Vascular lesions like aneurysms, dissections, and embolism can be evaluated and stable lesions requiring to follow up and unstable lesions requiring emergent treatment are differentiated using MDCT. The objectives of the study were to characterize and identify features pathognomic of specific mediastinal masses on computed tomography and find out diagnostic accuracy of MDCT in mediastinal masses and compare them with pathological results wherever possible. METHODS A prospective study was done in the Department of Radiodiagnosis, Rohilkhand Medical College and hospital, Bareilly for a span of 1 year from November 2018 to October 2019. Our study included 51 patients. Mediastinal lesions were assessed based on size, compartmental localisation, and attenuation and enhancement patterns. RESULTS In our study with 51 patients, 16 lesions were non-neoplastic and 35 were neoplastic lesions. Anterior mediastinal lesions constituted maximum lesions followed by middle and posterior mediastinal lesions. Lymph nodal masses were the commonest lesions out of which 4 cases were tubercular in origin, 4 were lymphomatous and 4 were metastatic. Neurogenic tumours were most common in the posterior mediastinum consisting of 6 cases. 2 vascular lesions were seen, 1 of aortic aneurysm and 1 aortic dissection. The diagnostic accuracy of MDCT was 93 % compared to histopathological results. Computed tomography (CT) plays a major role in evaluating mediastinal masses by virtue of its excellent multiplanar reconstruction capabilities and demonstration of exact anatomic relationships. However, in many situations, histopathological examination is needed to know the exact tissue of origin and for further management. CONCLUSIONS We conclude that CT has a major role in evaluating mediastinal masses regarding location, extent and tissue characterization. It can display certain features pathognomic for particular masses thus obviates the need for invasive procedures. KEY WORDS Mediastinal Lesions, MDCT, Imaging Modality, Histopathology

Background Treatment of patients with platinum resistant/refractory epithelial ovarian cancer (EOC) is an unmet need. We evaluated the role of oral metronomic therapy in this setting. Patients and methods Between October 2017 and September 2019 seventy five patients with platinum resistant/refractory EOC were enrolled. Patients received oral etoposide (50 mg, day 1 to 14, cyclophosphamide 50 mg, day 1 to 28, every 4 weeks (Arm A, n = 38). Patients in Arm- B (n = 37) received Pazopanib (400 mg once daily) in addition to etoposide and cyclophosphamide. Quality of life (QoL) was evaluated using the EORTC questionnaire. Serum VEGF and PDGF were estimated at baseline, after 3rd and 6th cycle. The primary endpoint was progression free survival (PFS). Secondary endpoints were overall survival (OS), toxicity and QoL. Results Patients characteristics were well matched. Median PFS was higher in arm B, 5.1 months (95% CI 3.13 to10.33) compared to 3.4 months (95% CI 3.0 to 6.53) in arm A, p = 0.045. Median OS has ‘not reached’ in Arm B compared to 11.2 months (95% CI, 5.66 - not reached) in arm A, p = 0.032. Therapy was tolerated well; oral mucositis (p = 0.36) and fatigue (p = 0.08) being more in arm B. QoL assessment revealed modest improvement in ‘symptom scales’ in Arm B. Serum VEGF and PDGF levels decreased with therapy in both arms (Arm A-p Conclusion Addition of pazopanib to etoposide and cyclophosphamide could be a novel oral combination for metronomic therapy for platinum resistant/refractory EOC. Trial registration CTRI/2017/10/010219.

Regardless of progress in therapy management which are developed for colon cancer (CC), it remains the third most common cause of mortality due to cancers around the world. Conventional medicines pose side effects due to untoward action on non-target cells. Their inability to deliver drugs to the affected regions of the colon locally, in a reproducible manner raises a concern towards the efficacy of therapy. In this regard, nanoparticles emerged as a promising drug delivery system due to their flexibility in designing, drug release modulation and cancer cell targeting. Not only are nanoparticles making their way into colon cancer research in the revolution of conventional onco-therapeutics, but they also offer promising scope in the development of colon cancer vaccines and theranostic tools. However, there are challenges with respect to drug delivery using nanoparticles, which may hamper the delivery of these novel carriers to the colon. The present review addresses recent advents in nanotechnology for colon-specific drug delivery (CDDS) which may help to overcome the existing challenges and intends to recognize futuristic potentials in the treatment of CC with CDDS.

Introduction: Medullary thyroid carcinoma is an uncommon primary thyroid tumour (5-10% of all thyroid malignancies) arising from parafollicular cells or C-cells. Most tumours are sporadic (75-80%) and familial syndrome multiple endocrine neoplasia; MEN-2A, MEN-2B and familial MTC in 20 to 25% cases. Case Report: We report a case of primary medullary thyroid carcinoma in a 30 years old male patient presented with complaint of midline neck swelling. On fine needle aspiration cytology diagnosis of medullary carcinoma was suggested with a differential of SETTLE (spindle epithelial tumor with thymus like differentiation). The swelling was excised and send for histopathological examination which revealed polygonal to plump spindle shaped tumor cells, arranged in lobules separated by fibrous septa, having abundant eosinophilic granular cytoplasm with round to oval nuclei, finely stippled nuclear chromatin and indistinct nucleoli and diagnosed as primary medullary thyroid carcinoma, confirmed on immunohistochemistry. Conclusion: MTC is the first human malignancy known to be associated with tumour marker and hormone calcitonin. Immunohistochemistry has definite role in confirmation of diagnosis. Keywords: Amyloid, Medullary carcinoma, Procalcitonin, Synaptophysin.

Intra-abdominal hypertension (IAH) is a known but neglected complication in acute pancreatitis. The present study was conducted to establish the role of intra-abdominal pressure (IAP) as a prognostic marker in patients with acute pancreatitis and also to correlate IAP with APACHE II and SOFA scores. A prospective observational single-center cohort study was conducted on adult patients diagnosed with acute pancreatitis. Intra-abdominal pressure was measured through a transurethral Foley’s bladder catheter. APACHE II and SOFA scores were calculated at the time of admission (day 1). APACHE II score was reevaluated on day 3 and 5. SOFA score was reevaluated everyday till day 5. APACHE II score, SOFA score, and IAP at admission were significantly higher among non survivors when compared to survivors. There was significant correlation of IAP with APACHE II and SOFA scores. APACHE II and SOFA scores at cut-off values of 12 and 6 predicted IAP of > 12 (mm of Hg) with reasonable sensitivity and specificity. IAP could be used as a reliable negative prognostic marker in acute pancreatitis. APACHE II and SOFA scores could be used to predict intra-abdominal hypertension in patients of acute pancreatitis.

Human metapneumovirus (hMPV) is an enveloped virus that causes serious respiratory tract infection among immunocompromised populations especially haematopoietic stem cell transplant (HSCT) recipients. Here, we describe 3 cases of hMPV infection which led to mortality among post HSCT adults. 66 post HSCT adults enrolled between January 2017 and March 2019 at Dr. B. R. Ambedkar Institute Rotary Cancer Hospital, AIIMS, New Delhi, were followed up for a period varying from 16 days to 18 months for any episode of respiratory illness until March 2019. Real time reverse transcriptase polymerase chain reaction (rRT-PCR) was used to detect the virus from appropriate specimens when symptoms of acute respiratory infection appeared. Samples from 88 out of a total of 172 episodes of suspected acute respiratory infection could be tested by rRT-PCR. Of these, 9 episodes were positive for hMPV. Three patients with hMPV associated lower respiratory tract infection (LRTI) expired within 30 days of HSCT. The possible risk factors associated with mortality included LRTI, infection during early post-transplant period (first week following HSCT), absolute lymphocyte count less than 200/µl, absolute neutrophil count less than 500/µl, use of steroid within 30 days prior to infection and need for mechanical ventilation.

Purpose: Trauma is the leading cause of mortality in people below the age of 45 years. Abdominal trauma constitutes one-fourth of the trauma burden. Scoring systems in trauma are necessary for grading the severity of the injury and prior mobilization of resources in anticipation. The aim of this study was to evaluate RTS, ISS, CASS and TRISS scoring systems in blunt trauma abdomen. Materials and methods: A prospective single-center study was conducted on 43 patients of blunt trauma abdomen. Revised trauma score (RTS), Injury Severity Score (ISS), Clinical Abdominal Scoring System (CASS) and Trauma and Injury Severity Score (TRISS) were calculated and compared with the outcomes such as need for surgical intervention, post-operative complications and mortality. Results: The majority of the study subjects were males (83.7%). The most common etiology for blunt trauma abdomen as per this study was road traffic accident (72.1%). Spleen was the most commonly injured organ as per the study. CASS and TRISS were significant in predicting the need for operative intervention. Only ISS significantly predicted post-operative complications. All scores except CASS significantly predicted mortality. Conclusions: Among the scoring systems studied CASS and TRISS predicted the need for operative intervention with good accuracy. For the prediction of post-operative complications, only the ISS score showed statistical significance. ISS, RTS and TRISS predicted mortality with good accuracy but the superiority of one score over the other couldn’t be proved.

Background: An association between lichen planus and systemic disorders such as diabetes mellitus, dyslipidemia and metabolic syndrome has been reported. Aim: To assess the clinico-epidemiological profile of lichen planus, evaluate prevalence of underlying metabolic complications and compare the clinical profile of patients with and without metabolic syndrome. Material and methods: All the patients with lichen planus attending dermatology out patient department of a tertiary care centre in South Rajasthan over a period of one year were studied. Patients with lichenoid drug eruptions and those receiving systemic treatment for lichen planus were excluded from the study. Statistical analysis was done using the chi – square test. A p value < 0.05 was considered significant. Results: A total of 270 patients of lichen planus were enrolled. Male to female ratio was found to be 0.76: 1. Maximum (64; 23.7%) patients belonged to the age group of 31 – 40 years. Classical morphology was the most common (128; 47.4%) cutaneous pattern. Mucosal and nail involvement was seen in 80 (29.6%) and 87 (32.2%) patients respectively. Koebner phenomenon was present in 57 (21.1%) patients. The investigations were completed by 175 (64.8%) patients. Diabetes mellitus and hypertension were found in 12.6% (22/175) and 14.3% (25/175) patients respectively. The diagnostic criteria for dyslipidemia and metabolic syndrome were fulfilled by 39.4% (69/175) and 27.4% (48/175) patients respectively. Majority (81.2%) of the patients with metabolic syndrome belonged to age group 40 years and above, and oral and nail involvement was found to be more common in them. It is recommended that these patients should be screened for complications like diabetes, hypertension, dyslipidemia and metabolic syndrome. Conclusion: Significant numbers of lichen planus patients were found to have dyslipidemia and metabolic syndrome. Patients aged 40 years and above, with oral and nail involvement have higher propensity to be associated with metabolic syndrome and therefore such patients should be screened for metabolic complications. Timely screening and early intervention may reduce the risk of related morbidity and mortality. Limitations: Lack of control group is the drawback of our study. Age and sex matched comparative studies are required for confirmation of the results.

As surface of tibia is subcutaneous along most of its length and its vascular supply of tibia is perilous compared to any other bone surrounded by heavy muscles? These type of fracture are often associated with compartment syndrome or neuro-vascular injuries. As there is existence of hinge joint at the knee and the ankle that permits no adjustment for rotational deformity after fracture, distinctive care is being required during reduction of these type of fractures to correct such deformity. The problems associated with fixation of distal tibia fractures include local and deep infections, local implant irritation, knee pain, stiffness of ankle, transient peroneal nerve palsy, malalignment and subsequent malunion and non-unionThis study deals with the ability to maintain a mechanically stable reduction in extraarticular distal one third tibia fractures managed with intramedullary nailing.Materials and Methods: This was a hospital based prospective study on the outcome in 20 patients of extra articular distal one-third tibia fractures, who will be admitted in the Department of Orthopaedics of Muzaffarnagar Medical College, Muzaffarnagar over a period of 18 months.Results: Mean age of patients was 39.05 years (18-80). Fracture union was seen radiologically within 3 to 6 months depending upon the pattern of fracture.Conclusion: We conclude that fractures of extraarticular distal one-third tibia with or without associated fractures of fibula managed with closed intramedullary nailing had least number of complications, allows early partial weight bearing and 95% of the patients achieved union by the end of 6 months. Thorough planning and placement of the nail at the center of a wide metaphysis in anteroposterior and lateral view is essential to overcome varus, valgus and posterior tilt.

BACKGROUND AND AIM: Chronic Hepatitis B (CHB) is a global health problem affecting around 400 million of people worldwide. Two available first-line antiviral drugs are tenofovir disoproxil fumarate (TDF) and Entecavir (ETV). Till date,there are few published reports from India comparing efficacy of TDF and ETV in CHB cases. Therefore, this present study was carried out with an aim to compare the efficacy of ETV and TDF in patients with nucleos(t)ide naïve CHB. MATERIALS AND METHODS: This retrospective cohort study was carried out in 192 treatment naïve CHB cases, who completed 24 months of treatment with either TDF or ETV between March 2015 and August 2017. The primary end point of the study was undetectable hepatitis B virus DNA after 24 months of therapy. RESULTS: Of total 192 patients with CHB, 38 hepatitis B e-antigen (HBeAg)–positive and 53 HBeAg-negative patients were treated with tenofovir, whereas 40 HBeAg-positive and 61 HBeAg-negative patients were treated with ETV. Pretreatment characteristics at baseline were not statistically different between the TDF and ETV groups. Patients treated with TDF achieved significantly higher complete viral suppression as compared with ETV-treated patients (Log rank: 7.04, P = 0.008) in HBeAg-positive CHB during the 24 months follow-up time; whereas no significant difference in viral suppression rate could be noticed in HBeAg-negative patients (Log rank: 0.98, P = 0.38). Both univariate and multivariate analysis by cox proportional hazard model confirmed that tenofovir had significant rate of complete viral suppression in comparison with ETV in HBeAg-positive patients (P < 0.05); whereas complete viral suppression rates were similar in HBeAg-negative patients. CONCLUSION: In our study, tenofovir had more effective antiviral suppressive effect compared with ETV in HBeAg-positive, nucleos(t)ide-naïve CHB cases.

Background: Before the approval of first-line immune checkpoint inhibitors, platinum doublets were the standard of care in patients with treatment-naïve advanced non-small cell lung cancer (NSCLC) without targetable driver mutations. Pemetrexed-platinum combinations are preferred in non-squamous NSCLC. However, there has been no direct comparison to paclitaxel-carboplatin. Methods: This open-label randomized trial was designed to compare pemetrexed-carboplatin with (weekly) paclitaxel-carboplatin in treatment-naïve advanced/metastatic non-squamous NSCLC without driver mutations. Patients received either pemetrexed 500 mg/m2 and carboplatin AUC 5 every 3 weeks, or paclitaxel 80 mg/m2 on day 1, day 8, and day 15 with carboplatin AUC 5 every 4 weeks for 4 cycles. Patients in both arms were allowed to receive pemetrexed maintenance. Results: A total of 180 patients were enrolled. The study was terminated early; however, at the time of analysis 75.8% of the required events had occurred. Finally, 164 patients were evaluable, 83 in the pemetrexed arm and 81 in the paclitaxel arm. After a median follow-up of 17 months, progression-free survival (PFS) rates at 6 months were not different in the two treatment arms (47.45 vs. 48.64%, p = 0.88). The median PFS values were 5.67 months (95% CI 3.73–7.3) and 5.03 months (95% CI 2.63–7.43) in each arm, respectively (HR 1.13, 95% CI 0.81–1.59, p = 0.44). The median overall survival was also not different: 14.83 months (95% CI 9.5–18.73) and 11.3 (95% CI 8.3–19.7; HR 1.19, 95% CI 0.8–1.78, p = 0.37). All grade toxicities were similar except for alopecia and peripheral neuropathy, which were higher in the paclitaxel arm. Conclusion: Pemetrexed-carboplatin is not superior to (weekly) paclitaxel-carboplatin as the first-line regimen in advanced non-squamous NSCLC in terms of PFS.

Introduction: Tracheoesophageal fistula (TEF) is one of the common congenital anomalies presented at birth. Management of TEF is a challenging task as outcome of these cases not only depends on surgeon and anaesthesiologist’s skills but also depends on various factors associated with new born. This prospective study evaluates the association of various factors on survival of TEF patients. Materials and Methods: 16 newborn patients in a calendar year were enrolled in this prospective study and impact of various factors like age, weight, parity of mother, associated congenital anomalies and family history, mode of delivery, place of delivery, associated hydramnios and type of TEF were evaluated on the survival of neonates born with TEF. Results: Male, female ratio was equal. Patient with birth weight >2.5 kg had higher survival rate (100%) compared to patient Conclusion: Birth weight remains the single most important predictor of mortality among TEF patients, as suggested with Waterston risk classification. Keywords: Tracheoesophageal fistula, Birth weight, Neonates, Waterston classification.

Female urethral defects are rare, congenital defects being more uncommon than acquired, and difficult to manage. Most female urethral defects are associated with incontinence or acute urinary retention. There is a lack of standard protocol-based management of female urethral defects because of limited experience. In this study, we describe our results of using anterior or posterior bladder wall flaps in the management of a variety of female urethral defects. We reviewed the case records of 22 patients who had undergone either anterior or posterior bladder wall-based flap procedures for complex urethral defects at our institute. Patients were assessed by taking a comprehensive history including aetiological factors and details of prior surgical intervention, thorough physical and pelvic examination, cysto-urethroscopy and relevant imaging. These factors, along with availability and status of tissue available for reconstruction affected the selection of procedure for reconstruction. Out of 22 patients, anterior and posterior bladder flaps were used in 16 and 6 patients respectively. A total of 18 patients became socially dry and 15 achieved complete continence after removal of the catheter and were voiding satisfactorily, whereas the remaining 4 patients had incontinence postoperatively. An additional 3 out of 18 patients had minimal stress incontinence requiring conservative treatment and 2 patients developed voiding difficulty requiring self-calibration. Female urethral defects with bladder neck involvement are complex and challenging to manage. Bladder wall-based flaps offer a good chance of successful repair of these complex urethral defects.

Introduction: Stroke is life threatening & debilitating neurological disease, defined as focal neurological deficit of sudden onset lasting >24 hours & vascular in origin. Significant association between ischemic type of stroke with carotid artery disease seen, more prevalent with carotid artery stenosis. Objectives: This study was done to show association between extracranial carotid artery disease & cerebrovascular accidents (CVAs) with the help of Color Doppler Sonography (CDS). The association between carotid artery disease with associated risk factors were also assessed. Methodology: In this ethically approved prospective study, carotid CDS was done in 79 consecutive patients with diagnosis of acute ischemic stroke (AIS). The various parameters studied included peak systolic velocity (PSV) of internal carotid artery (ICA) & common carotid artery (CCA), ICA/CCA PSV ratio & plaque characteristics. The data collected was analyzed with appropriate statistical test of significance was calculated. Results: Total 79 patients with AIS included out of which 53 were males & 26 were females. The most common presenting complains were hemiparesis (30.4%) & most commonly associated risk factors included hypertension (62.02%). Right sided strokes were most common (44.3%) & middle cerebral artery was most commonly involved vascular territory. Significant stenosis (≥50%) of carotid artery was seen in 27 patients with ICA most common site (45.8%) for plaque formation. Bilateral carotid artery involvement (52.1%) with hypoechoic echotexture of atheromatous plaques (46.6%) was most responsible for significant stenosis & increased intima media thickness. Increased value of PSV & EDV was seen in the stenotic area in the proportion of stenosis with increased PSV ICA/CCA ratio of more than three indicates >60% stenosis. Conclusion: The present study showed well documented role of carotid doppler in detection of site & extent of carotid artery stenosis due to atheromatous plaques of various characteristics playing critical role in thromboembolic phenomenon responsible for development of stroke.

CD123 is overexpressed in many hematologic malignancies and found to be useful in characterizing leukemic blasts of both acute myeloid leukemia (AML) and B-acute lymphoblastic leukemia (B-ALL). CD123 has been recently found to be a marker of leukemic stem cells, and its utility to measure residual disease and potential role in disease relapse is under evaluation.Herein, we have evaluated the expression of CD123 in 757 samples of acute leukemia including 479 treatment-naive and 278 follow-up samples and compared with post-induction morphologic complete remission and measurable residual disease (MRD) status. Multiparametric flow cytometry was used for assessment of CD123 expression and immunophenotypic characterization of leukemic blasts at diagnostic and MRD assessment time points.Using variable cutoffs of 5%, 10%, and 20% to define a case as CD123-positive, expression of CD123 was observed in 75.6%, 66.2%, and 50% of AML and 88.6%, 81.8%, and 75% of B-ALL, respectively. Of 11 patients, 7 (63.63%) had mixed phenotype acute leukemia, but none of the 12 patients with T-acute lymphoblastic leukemia showed positivity for CD123. CD123 expression at diagnosis was associated with post-induction MRD-positive status in both B-ALL (P .001) and AML (P = .001). We also evaluated the utility of CD123 as a leukemia-associated aberrant immunophenotype and found it to be useful in both patients with AML (baseline, 50.6%; follow-up, 53%) and B-ALL (baseline, 75%; follow-up, 73.07%).In conclusion, CD123 may be considered as a cardinal marker for residual disease assessment and response evaluation in AML and B-ALL.

Introduction: Cutaneous leishmaniasis (CL) is a vector-borne protozoal infection of the skin with variable clinical manifestations. In Rajasthan, western Thar desert is endemic for this disease. Aim: The present study was aimed to describe clinico-epidemiological features of cutaneous leishmaniasis cases from a non-endemic area of South Rajasthan. Materials and Methods: A hospital-based prospective study was carried out during a period of 3 years (2017-2019). Data regarding clinical profile and treatment outcome were recorded in a predesigned proforma for analysis. Diagnosis of CL was made clinically and confirmed by demonstration of amastigotes in microscopic examination of Giemsa stained tissue smear of lesions. Results: Out of 24 patients, 16 (67%) were females and 8 (33%) were males. The age ranged from 3 months to 68 years (median-25). Face (67%) and extremities (29%) were the common sites affected. The most common morphological form was crusted plaques (54%) followed by nodular lesions (38%). Slit skin smear for Leishmania donovani bodies was positive in all patients (100%). Conclusion: This study highlights a focus of CL in non-endemic areas of South Rajasthan. Of late leishmaniasis is breaking out of its classical boundaries and is increasingly being reported from new geographic locations with a possibility of a novel parasite variant. Therefore, a high clinical suspicion of CL should be kept in non-endemic area.

Novel energy devices such as ultrasonic shears (US) are widely used in laparoscopic surgery due to convenience and outcomes. However, these are expensive and add to the procedure cost. Electrocautery (EC) can often provide similar surgical outcomes and existing literature in unclear on the benefits of one over the other. We conducted a randomized trial between US and EC use in laparoscopic nephrectomy. Twenty patients undergoing laparoscopic nephrectomy between January 2019 and January 2020 at our tertiary referral center were included. Patients were randomly allocated in 2 groups according to energy used, i.e., EC and US. We assessed operative time, blood loss, intra- and postoperative complications, drain output and duration, hospital stay, readmission rates within 30 days of discharge, and surgeon satisfaction with the instruments used. The mean operative time and estimated blood loss were 113 min and 170 ml in EC group while 106 min and 180 ml in US group (p > 0.05). The mean change in hematocrit values after surgery were 6.12% and 5.27% in EC and US group, respectively (p = 0.812). There were no significant differences in mean hospital stay (2.7 in EC group, 2 days in US group), drain output (35.6 ml in EC and 26.3 ml in US group), and drain duration (1.7 days in EC and 1.9 days in US group). One patient in EC group had retroperitoneal hematoma due to Veress needle injury. Similarly only 1 patient in US group had severe intraoperative bleeding requiring conversion to open procedure. Two patients in the EC group had postoperative complications, i.e., fever and purulent collection under surgical site. Electrocautery and ultrasonic shears appear to be comparable in efficacy and safety in laparoscopic nephrectomy. However larger prospective studies are required to confirm our findings.

Introduction: Knowledge and awareness of sepsis among various health care professionals is essential for prompt diagnosis and appropriate initial resuscitation and management of patient with sepsis. Objective: To assess and compare the knowledge and awareness of sepsis among health care professionals working at Birat Medical College and Teaching Hospital. Methodology This was a questionnaire-based survey with comparative study in 200 health care professionals conducted at Birat Medical College and Teaching Hospital from July– September, 2019. Questions were designed to assess the knowledge on diagnosis, initial resuscitation and management of sepsis. The knowledge level of the participants was assessed with scoring system as good, average and poor which was finally compared between the various health care professionals. Result Out of 200, only 180 health care professionals were included for statistical analysis. While assessing the knowledge on diagnosis of sepsis, 55.6% consultant doctors, 42.8% medical officers and 21.5% nursing/paramedics answered correctly on an average. Similarly, 51.7 % consultant doctors, 33.7% medical officers and 26.6% nursing/ paramedics gave correct answers while assessing knowledge on initial resuscitation and management. The nursing/paramedics had comparatively lower knowledge level on sepsis than the doctors. Around 31.7%, 51.2% and 17% of health care professionals working in Emergency, ICU and Anesthesiology departments had good, average and poor knowledge on sepsis respectively as compared to 14.2%, 28.5% and 57.1% of participants working in other departments. Conclusion: The nursing/paramedics had lower knowledge level on sepsis as compared to the doctors while health care professionals working in Emergency,ICU and Anesthesiology departments had better knowledge on sepsis as compared to staffs working in other departments.

Eyes are among the first features of the face to be noticed. Loss of an eye due to congenital, traumatic, or pathologic etiologies causes disfigurement and loss of sensory feedback. It leaves a psychological impact on the patient; thus, prosthesis should be provided at the earliest to raise the spirits of the afflicted. Iris positioning is one of the important steps in fabricating customized ocular prosthesis. In facial asymmetry cases, comparison of both irises together can be a major disadvantage. This case report illustrates the use of a regular eyeglass in one technique and the use of a bioart facebow in the second technique for centering of iris in a customized ocular prosthesis to overcome the disadvantages of earlier used standard techniques (McArthur’s ocular locator and fixed calliper, pupillometer, visual judgement, and graph grid) of iris centering.

Congenital diaphragmatic hernia (CDH) is a condition characterized by defect in the diaphragm which leads to protrusion of abdominal contents or viscera into the thoracic cavity interfering with normal development of the lungs. CDH is a developmental defect of diaphragm associated with significant neonatal mortality and morbidity. Incomplete development of diaphragm allows the abdominal content to invade the thoracic cavity resulting in compression of the developing lungs. Most of the CDH diagnosed in the new born or early childhood. Around 1% with CDH have no symptoms and may be detected incidentally. Diaphragmatic hernias can be divided into two broad categories: congenital and acquired. A congenital diaphragmatic hernia (CDH) occurs through embryologic defects in the diaphragm, and most patients present early in life rather than later. However, a subset of adults may present with a smaller CDH that was undetected during childhood. Infants with CDH often present in the neonatal period with severe respiratory distress. Early surgery is mainstay of treatment in newborn as mortality is very high in this condition. Here, we are describing very late presentation of a case of congenital diaphragmatic hernia treated by surgery with good post operative outcome. This case report summarizes how to diagnose and manage a late-presenting congenital diaphragmatic hernia to prevent further complications.

Background: Meckel's diverticulum is the commonest gastrointestinal congenital anomaly. Though most of the cases do not present clinically, they are challenging to diagnose if become symptomatic. Spectrum of clinical presentation may be different from umbilical fistula, omphalomesenteric cyst to fibrous band from diverticulum to umbilicus. Bleeding, obstruction and infection are the most common complications. Vast majority of them are detected only intra-operatively. Methods: We analyzed our patients who were intra-operatively diagnosed as symptomatic Meckel's Diverticulum. Socio-demographic profile and immediate outcome of operated patients was analyzed from patient's records. Results: Total 9 patients were operated for symptomatic Diverticulitis. All patients were diagnosed intraoperatively. Intestinal obstruction was the commonest presentation. Diverticulectomy was the most common procedure performed followed by wedge resection and segmental bowel resection. Conclusions: Symptomatic Meckel’s Diverticulum is difficult to diagnose pre-operatively. Vast majority of them are found only intra-operatively. Most of the patients do well after resection of Meckel's Diverticulum. Keywords: Meckel’s diverticulum; surgery; symptoms.

Background: Fibroepithelial polyps in the upper ureter are a rare cause of pelviureteral junction obstruction (PUJO). Its diagnosis usually remains challenging by clinical and radiologic means. Case Presentation: We discuss a case of 19-year-old boy who present with intermittent left flank pain. Radiologic imaging suggested diagnosis of PUJO. We planned for robotic pyeloplasty. Intraoperatively pelviureteral junction (PUJ) was dependent, nonstenotic with upper hydroureteronephrosis creating suspicion of polyp. Keeping suspicion of polyp in upper ureter, we did robotic upper ureterotomy. This procedure revealed a 1 × 1 cm benign polyp at PUJ, which was excised completely. Conclusion: Polyps in the upper ureter constitute uncommon clinical cause of PUJO and usually diagnosed intraoperatively. Robotic approach is a feasible, acceptable, and safe option in such clinical scenario. It provides all the benefits of minimal invasive surgical procedures.

Introduction: Urinary tract infections (UTI) are infections affecting any part of the urinary tract and are most commonly caused by a multitude of bacteria. Most tests used these days to detect UTI are based on chemical test strips and cultures, both of which are labor and time-intensive. The aim of our study is to establish parameters that could detect UTI with high certainty. Material & Methods: The study was conducted in the Department of Pathology of Rajiv Gandhi Super Speciality Hospital, Delhi. The samples received between January to March 2017 were included in the study. All the samples were run in the Sysmex UX 2000, a fully automated urine analyzer. Results: A total of 236 patients were registered in this study. The study participants range from 4 years to 88 years with 56% males and 44% females. Out of these 21% were positive for UTI whereas 9% were inconclusive and 70% were negative. Cutoff values for white blood cells (WBC) and bacterial counts taken were 20.2 cells/µl and 143.2 cells/µl, respectively. Flowcytometric analysis of both WBC and bacterial cells showed high sensitivity (81%) as well as high negative predictive value (NPV) of 93%. Analysis of nitrites showed 97% specificity and 81% NPV, while leucocyte esterase showed 87% specificity and 92% NPV. Conclusion: Flow cytometry-based bacterial counts, total leucocyte counts, as well as nitrites and leucocyte esterase, could be used as screening tests for early as well as subclinical urinary tract infections and will reduce the need for urine culture.

Introduction Interprofessional communication (IPC) enhances patient experiences and outcomes and improves well-being and satisfaction among health care professionals. This scoping review seeks to guide design of IPC training in internal medicine. Methods The framework of Arksey and O'Malley (2005) guided this systematic scoping review in internal medicine across PubMed, Embase, CINAHL, Scopus, PsycINFO, ERIC, JSTOR, and Google Scholar databases for publications from the years 2000 to 2018. Results Twenty-two thousand eight hundred seventy-four abstracts were retrieved, 326 full-text articles were reviewed, and 32 articles were included. The themes identified using directed content analysis were indications for an IPC program, training stages, and obstacles. The rationale for IPC programs was to improve interprofessional teamwork and enhance patient care. IPC training occurs in five stages beginning with instilling the role, value, and skills behind IPC and gradually practicing these skills within the clinical setting. The challenges to IPC highlight the need to confront workplace hierarchies and the lack of resources. Discussion The findings of this systematic scoping review also serve to underscore the importance of understanding, evaluating, and influencing the clinical environment and the work environment and the need for new assessment tools that will guide the individualized, longitudinal, competency-based learning process that underpins IPC training.

Background: Hematopoietic stem cell transplantation (HSCT) is an established treatment for a number of malignancies. Quality of life (QOL) is an important marker for assessing arduous treatment modalities. Diagnosis of cancer, HSCT, and the physical and psychosocial sequelae of the intensive treatment lead to a deficit in the QOL of the recipient. This study aimed to assess the impact of HSCT on psychiatric morbidity and QOL in patients with hematological malignancies. Methods: A longitudinal pre-post study was conducted at a cancer research center. Thirty patients with hematological malignancies were assessed at three different time points for psychiatric symptoms and QOL. Sociodemographic and clinical variables were collected using a semi-structured questionnaire. Comprehensive psychopathological rating scale was used to assess the psychiatric symptoms. WHO QOL Bref and cancer-specific European Organisation for Research and Treatment of Cancer Quality of life Questionnaire (EORTC-QLQ) were used to measure the quality of life. Results: The mean (SD) age of the sample was 42.3 (12.8) years, with 24 males and 6 females. Most patients reported anxiety and depressive symptoms, reaching a peak at 3 week post-HSCT. The maximum deficit in QOL scores was seen at 3 weeks, with further improvement at 3-month post-transplant. Conclusions: HSCT leads to an increase in symptoms and a decrease in QOL during the acute phase. In the long run, it leads to improvement in physical and psychological wellbeing, with improvement in QOL. The recent surge in the long-term survivors of the procedure calls for further research in this direction so as to aid in their full recovery.

Context : There are few international studies about the continuous use of sedatives (CUS) in the last days of life. Objectives : We aim to describe the experiences and opinions regarding CUS of physicians caring for terminally ill patients in seven countries. Methods : Questionnaire study about practices and experiences with CUS in the last days of life among physicians caring for terminally ill patients in Belgium (N=175), Germany (N=546), Italy (N=214), Japan (N=513), the Netherlands (N=829), United Kingdom (N=114) and Singapore (N=21). Results : The overall response rate was 22%. Of the respondents, 88-99% reported that they had clinical experience of CUS in the last 12 months. More than 90% of respondents indicated that they mostly used midazolam for sedation. The use of sedatives to relieve suffering in the last days of life was considered acceptable in cases of physical suffering (87-99%). This percentage was lower but still substantial in cases of psycho-existential suffering in the absence of physical symptoms (45-88%). These percentages were lower when the prognosis was at least several weeks (22- 66% for physical suffering and 5-42% for psycho-existential suffering). Of the respondents, 10% or less agreed with the statement that CUS is unnecessary because suffering can be alleviated with other measures. A substantial proportion (41-95%) agreed with the statement that a competent patient with severe suffering has the right to demand the use of sedatives in the last days of life. Conclusion : Many respondents in our study considered CUS acceptable for the relief of physical and psycho-existential suffering in the last days of life. The acceptability was lower regarding CUS for psycho-existential suffering and regarding CUS for patients with a longer life expectancy. Funding : Ministry of Education, Culture, Sports, Science and Technology, Japan Key message : This questionnaire study among physicians caring for terminally ill patients showed that many considered the continuous use of sedatives acceptable to relieve physical and psycho-existential suffering in the last days of life. Respondents’ regarded the practice as less acceptable in patients with a longer life expectancy.

POEMS syndrome, a rare plasma cell disorder, is challenging both in the diagnostic and therapeutic management. We present real word retrospective analysis of 108 cases analyzing clinical features and therapeutic modes. We compare our results with the available literature. This is the first description with such wide use of proteasome inhibitors in first line treatment. POEMS (Polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes) syndrome is a rare and challenging plasma cell disorder, both in the diagnostic and therapeutic management of the disease. Currently, the literature on POEMS is sparse with most evidence being case reports and small case studies. We present a retrospective real world experience of 108 patients with POEMS. We analyzed the clinical features and therapeutic interventions. Regarding clinical features, our findings demonstrated that skin lesions, thrombocythemia and polycythemia were present less frequently than reported previously. Regarding clinical interventions, this is one of the largest analyses of front line treatment in POEMS and the first one to include frequent utilization of proteasome inhibitors (37%). Bortezomib monotherapy was the most effective therapy achieving complete remission/very good partial remissions (CR/VGPR) in 69% of patients. Thirty percent of patients proceeded to planned autologous stem cell transplant (ASCT) as part of the front-line treatment resulting in statistically superior progression-free (PFS) and overall survival (OS) compared to non-ASCT treated patients (P= .003). In multivariate analysis, anemia, thrombocytopenia, and as age over 60 were associated with a negative impact on patient outcomes.

IntroductionThere is a scarcity of data from India on the impact of cell of origin (COO) on outcomes of diffuse large B-cell lymphoma (DLBCL). This study was conducted to evaluate the impact of COO on outcomes of DLBCL patients treated with uniform rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (RCHOP) protocol.Materials and MethodsThis retrospective analysis included patients who received uniform RCHOP chemoimmunotherapy during the study period (2014–2020) at the Department of Medical Oncology at All India Institute of Medical Sciences (AIIMS), New Delhi, India. The patients were classified as germinal center B-cell like (GCB) or activated B-cell (ABC) type using the Hans classification.ResultsFour hundred seventeen patients with median age of 48 years (range, 18–76) and a male-female ratio of 2:1 were included in the analysis. B symptoms and bulky disease were seen in 42.9% and 35.5%. Extranodal involvement was seen in 50.8% of cases. ECOG performance status (0-2) was present in 65%, and 51% presented with advanced disease. GCB subtype was seen in 43%, and 47% were ABC type. Low- and intermediate-risk international prognostic index (IPI) score was seen in 76% of cases. The overall response rate to RCHOP was 85.8%, including a complete response rate of 74.8%. After a median follow-up of 30 months, the 3-year event-free survival (EFS) and overall survival (OS) were 80% and 88%, respectively. The presence of B symptoms and poor ECOG performance status (3-4) was associated with inferior CR rate. Low albumin (p < 0.001), age >60 years (p = 0.001), bulky disease (p < 0.001), and extranodal involvement (p = 0.001) were associated with inferior EFS, whereas a high IPI risk score was associated with an inferior OS (p < 0.001). EFS and OS were not significantly different between the GCB and ABC subtypes. Grade III/IV anemia, neutropenia, and thrombocytopenia were seen in 7.6%, 13.6%, and 2.7% of patients, respectively. Febrile neutropenia was seen in 8.9% of patients, and there were four treatment-related deaths.ConclusionsCell of origin for DLBCL has no impact on CR, EFS, and OS if patients are appropriately treated with standard doses and frequency of RCHOP. RCHOP is well tolerated in our patients, and results are comparable with the Western data.

Objective: The aim of this study was to compare the post-operative effects of closed incision negative pressure wound therapy with conventional dressing in emergency laparotomy. Methods: This study was conducted from 1st November 2018 to 31st March 2020 in ABVIMS & Dr. R.M.L. Hospital, New Delhi. The potential candidates for the study were patients of 18 years and above who were admitted in surgical emergency and underwent emergency laparotomy by a midline incision. Fifty random patients were alternatively allotted to group A (25 patients) and group B (25 patients). In the patients of group A, closed incision negative pressure wound therapy (ciNPWT) was applied on midline closed wound after an exploratory laparotomy procedure. The patients in group B, standard dry gauze dressing was done. Results: The mean age of patients in group A and group B were 46.76±12.20 and 41.96±8.33 years, respectively (p-value-0.11). The wound infection was present in 12% of cases in group A and 32% in group B, but when we calculate the p-value, it was found to be statistically non-significant (p-value-0.08). Similarly, seroma formation and wound dehiscence were found less in group A as compared to group B but not reached up to a statistically significant limit (p-value 0.55 and 0.38 respectively). The frequency of dressing change was 1-2 per week in 92% of cases in group A while it was 3-4 per week in 68% of cases in group B. The mean time of the frequency of dressing change was 1.24±0.72 per week and 4.28±1.90 per week in both the groups respectively (p-value 0.05) difference in the duration of hospital stay between group A (mean hospital stay 8.20±2.34 days) and group B (mean hospital stay 8.21±3.37 days). Conclusion: Closed incision negative pressure wound therapy has no advantages over conventional dressing in terms of post-operative complications and hospital stay. However, it reduces the frequency of dressing change significantly, which reduces the mental stress of the patient and the burden of changing daily dressing.

Highlights • Ilio-psoas abscess due to gallstone entero-retroperitoneal fistulation post-cholecystectomy has not been reported previously. • De-novo stone formation in the CBD can occur post-cholecystectomy and can lead to complications. • Surgeons should consider gallstones as a differential in small bowel fistulation., Introduction and importance This is a novel case of a 50-year-old female presenting with several months of left iliac fossa pain, on a background of a cholecystectomy 5 years prior. The aetiology of her pain was an ilio-psoas abscess secondary to an entero-retroperitoneal gallstone fistula, a condition not previously reported in the literature. Case presentation CT imaging revealed an abscess superior to the left psoas muscle, with a clear fistula to the small bowel and two calcified stones at the site of the fistula. The patient was managed operatively, with the fistula disconnected and a 5 cm section of small bowel disconnected. Clinical discussion This is a novel case whereby a left sided iliopsoas abscess occurred due to entero-retroperitoneal fistulation of gallstones several years after the patient underwent laparoscopic cholecystectomy. Gallstone fistulation from within the small bowel does not appear to have previously been documented and the exact pathogenesis is unknown. Conclusion Gallstones should remain an important, albeit rare, differential diagnosis of small bowel fistulation and abscess formation following cholecystectomy.

Objective: Penetrating abdominal trauma secondary to bamboo stick injury is a rare entity in the developed world. Most of such kind of trans abdominal penetrating bamboo stick injury is associated with multiple solid and hollow viscus injuries. In developing countries like India, where nearly 70% of the population reside in rural areas, it is not that uncommon. Aim of this report is to recognition of risk factors and explain optimum surgical management in trans-abdominal bamboo stick injury. Case Presentation: Here we describe a case of penetrating trans abdominal bamboo stick injury resulting due to fall over a branch of bamboo stick with multiorgan damage, which was successfully managed by early surgical exploration in our institute. Conclusion: There are many factors which can prognosticate the penetrating trauma cases. The most important factors include a long interval between injury and surgical exploration, presence or absence of shock, and other associated organ injuries at the time of admission. Early recognition of the severity of injury with surgical management is utmost necessary. These patients have high morbidity and mortality rates due to multiorgan damage and post-operative infection.

In cases of ovarian carcinoma, primary cytoreductive surgery (CRS) is the standard treatment up to stage IIIB, but patient selection for neoadjuvant chemotherapy (NACT) in selected cases is controversial. A total of 200 patients with advanced ovarian cancer were analyzed retrospectively, according to specific selection criteria. Primary CRS was performed in 95 patients (47.5%) and interval CRS after 3–6 cycles of NACT was performed in 105 patients (52.5%). After median follow-up of 35 months, 5-year overall survival was 53.7% in the upfront CRS group and 42.2% in the NACT group. Primary CRS is the standard in advanced stages of ovarian carcinoma, but in certain subset of patients, NACT is preferred. Identifying that group is challenging but feasible. Proper selection of patients is key to successful outcomes.

IntroductionThe rising economic burden of cancer on healthcare system and patients in India has led to the increased demand for evidence in order to inform policy decisions such as drug price regulation, setting reimbursement package rates under publicly financed health insurance schemes and prioritising available resources to maximise value of investments in health. Economic evaluations are an integral component of this important evidence. Lack of existing evidence on healthcare costs and health-related quality of life (HRQOL) makes conducting economic evaluations a very challenging task. Therefore, it is imperative to develop a national database for health expenditure and HRQOL for cancer.Methods and analysisThe present study proposes to develop a National Cancer Database for Cost and Quality of Life (CaDCQoL) in India. The healthcare costs will be estimated using a patient perspective. A cross-sectional study will be conducted to assess the direct out-of-pocket expenditure (OOPE), indirect cost and HRQOL among cancer patients who will be recruited at seven leading cancer centres from six states in India. Mean OOPE and HRQOL scores will be estimated by cancer site, stage of disease and type of treatment. Economic impact of cancer care on household financial risk protection will be assessed by estimating prevalence of catastrophic health expenditures and impoverishment. The national database would serve as a unique open access data repository to derive estimates of cancer-related OOPE and HRQOL. These estimates would be useful in conducting future cost-effectiveness analyses of management strategies for value-based cancer care.Ethics and disseminationApproval was granted by Institutional Ethics Committee vide letter no. PGI/IEC-03/2020-1565 of Post Graduate Institute of Medical Education and Research, Chandigarh, India. The study results will be published in peer-reviewed journals and presented to the policymakers at national level.

We used plerixafor in 'a risk adapted approach' for stem cell mobilization for multiple myeloma (MM) patients prior to autologous stem cell transplantation (ASCT).Between January, 2017 and December, 2019 105 consecutive patients of MM were recruited (Study Cohort). Patients received inj G-CSF 10 µg/kg in 2 divided doses for 5 days. Day 4 peripheral blood (PB) CD34+ count was used as a guide; if count was20 cells/µl, patients received plerixafor. For those with ≥ 20 cells/µl apheresis was commenced on day 5. We compared their outcome with 156 MM patients transplanted between 2012 and 2016 with G-CSF mobilized PB stem cells (Control Cohort). Primary end point was to collect ≥2.0 × 1096.2% of patients achieved ≥ 2.0 × 10Plerixafor in this risk adapted strategy resulted in successful mobilization, decreased time to engraftment and was cost effective.

Extrarenal rhabdoid tumour (ERT) of vulva is a rare gynaecological neoplasm with an aggressive course and no clear management guidelines. We present the case of a 25-year-old woman with a rapidly increasing mass in right vulva suggestive of sarcoma. Wide local excision was done. Histopathology examination revealed ERT of vulva. Six weeks later she manifested lung metastases. Despite adjuvant chemotherapy, the disease progressed and she died 8 months later. We review the literature and briefly discuss the epidemiology, treatment approaches, prognostic factors and expected outcomes of this rare disease.

BackgroundThe extension of palliative care services to meet the needs of patients with chronic non-malignant life-limiting conditions faces misconceptions amongst healthcare professionals. A study of prevailing perceptions of healthcare professionals on this wider palliative care service was thus conducted to identify current obstacles, guide the education of local healthcare professionals and improve service accessibility.MethodsA cross-sectional study was carried out at the Singapore General Hospital. An anonymised and close-ended online questionnaire was disseminated to 120 physicians and 500 nurses in the Department of Internal Medicine. The online survey tool focused on participant demographics; perceptions of palliative care and its perceived benefits; roles and indications; and attitudes and behaviours towards palliative care referrals.ResultsForty four physicians and 156 nurses suggested that care of terminally ill patients with chronic non-malignant life-limiting conditions are compromised by concerns over the role of palliative care in non-cancer care and lapses in their prognostication and communication skills. Respondents also raised concerns about their ability to confront sociocultural issues and introduce palliative care services to patients and their families.ConclusionsGaps in understanding and the ability of nurses and physicians to communicate end of life issues, introduce palliative care services to patients and their families and confront sociocultural issues suggest the need for a longitudinal training program. With similar concerns likely prevalent in other clinical settings within this island nation, a concerted national education program targeting obstacles surrounding effective palliative care should be considered.

Background Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has recently emerged as a viable management option for peritoneal surface malignancy (PSM). CRS and HIPEC is a complex, multidisciplinary and resource-intensive surgical procedure. It has a steep learning curve and is associated with significant morbidity and mortality. The expertise is mostly limited to few dedicated high-volume centers located in developed countries. We present a single institutional experience of 232 cases of CRS and HIPEC performed at a tertiary care cancer center in a low- and middle-income country (LMIC). Methods A multidisciplinary PSM program was initiated in 2015 at a high-volume public-sector tertiary care cancer center in North India catering largely to patients belonging to low- and middle-income groups. Perioperative protocols were developed, and a prospective structured database was created to capture data. All patients undergoing CRS and HIPEC between January 2015 and December 2020 were identified, and the data was retrospectively analyzed for clinical spectrum, surgical details, and perioperative morbidity and mortality. Results Two hundred and thirty-two patients underwent CRS and HIPEC during the study period. Epithelial ovarian carcinoma (56.5%) was the most common malignancy treated, followed by pseudomyxoma peritonei (18.5%), colorectal carcinoma (13.4%), and malignant mesothelioma (5.6%). Optimal CRS could be achieved in 94.4% of patients. Cisplatin and mitomycin were the most common drugs used for HIPEC. A total of 28.0% of patients had morbidity including deep vein thrombosis, subacute intestinal obstruction, sepsis, burst abdomen, lymphocele, urinoma, acute renal failure, and enterocutaneous fistula. The overall treatment-related mortality was 3.5%. Conclusions Results of the current study indicate that it is feasible to establish a successful CRS and HIPEC program for PSM in government-funded hospitals in LMIC facing resource constraints. The most common indication for CRS and HIPEC were carcinoma of the ovary followed by pseudomyxoma peritonei and colorectal carcinoma. Overall morbidity and mortality in the current series are comparable to global standards, reported from high-income countries. A protocol-based multidisciplinary team approach, optimal patient selection, and surgical expertise can help achieve optimal outcomes in government-funded hospitals in LMIC.

Introduction: Gastrointestinal tract is uncommon location for lipomas. If present, 90% are seen submucosally and 10% in subserosal location. Mostly located in the colon, but they can be found in the esophagus, small intestine, and rarely in the stomach. The vast majority of cases with intestinal lipomatosis are usually asymptomatic and some of the cases present with intermittent obstruction, colonic perforation and rarely intussusception. Case Report: A 20 year male presented in emergency department with history pain in abdomen 15 days back, progressively increasing in intensity and no passage of stool from 4 days. On the basis of history, examination and computed tomography scan of abdomen, possible diagnosis of ileoileal intussusception was made. Patient was admitted in emergency department of surgery and planned for surgery and exploratory laparotomy with resection of ileum 5 cm on both sides was done. A growth was seen in ileal intussusceptum area within 5cm margin and sent for histopathological examination to the department of pathology. On histopathologic examination, a diagnosis of lipoma was made. Conclusion: Lipomas are benign tumours with no risk of recurrence. They should always be kept in the differential diagnosis of sessile polypoid lesions. Surgery is usually curative. Keywords: Ileoileal intussusception, Ileal lipoma.

Rectal prolapse defined as mucosal or full-thickness layer of rectal tissue protrudes through the anal orifice (Gourgiotis and Baratsis Int J Colorectal Dis. 22 (3):231-43, 2007). It can present with various symptoms including pain, incomplete evacuation, bloody or mucous rectal discharge, and fecal incontinence or constipation. Complete external rectal prolapse is characterized by a circumferential, full-thickness protrusion of the rectum through the anus, which may be intermittent and have risk of strangulation. Mucosal prolapse, in contrast, is defined as protrusion of only the rectal mucosa from the anus. Here we are describing a case of complete rectal prolapse with extensive maggot infestation treated by perineal proctosigmoidectomy and proximal transverse colostomy. The patient doing well after 1-month follow-up planned for colostomy closure now.

Introduction POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes) syndrome is a rare multisystem paraneoplastic syndrome characterized by peripheral neuropathy and monoclonal plasmacytosis. Retrospective institutional experiences from the Mayo Clinic as well as Chinese, European, and Japanese series have provided important insights into the characteristics and treatment of this disease, but Indian data are extremely limited. We retrospectively analyzed 49 cases from our institute including 10 patients who underwent autologous stem-cell transplantation (ASCT). Patients and Methods We analyzed clinical and laboratory characteristics, treatment details and outcome of all patients diagnosed with POEMS syndrome between 1993 and 2017. Results Complete medical records were available for 49 patients with a median age of 44 years. Male/female ratio was 38:11. Twenty patients (40.8%) had Eastern Cooperative Oncology Group performance status of 4. Before 2012, melphalan/prednisolone was the most common regimen provided, while bortezomib/dexamethasone and lenalidomide/dexamethasone were used later. Hematologic response was available for 40 patients, 15 (37.5%) of whom experienced complete response, 13 (32.5%) partial response, and 11 (27.5%) stable disease. The median modified Rankin score at baseline was 4 (range, 1-5), which improved to 3 (range, 1-5). Ten patients underwent consolidation ASCT after a median of 4 cycles of induction. Median melphalan dose was 140 mg/m2. Engraftment syndrome was observed in 4. After ASCT, all 10 patients experienced hematologic complete response and clinical improvement. Conclusion This retrospective analysis provides important information on the clinical characteristics of POEMS syndrome in Indian patients, which will help the clinician’s decision-making process.

We investigated the impact of renal impairment (RI) on the outcome in multiple myeloma (MM) patients following induction and autologous stem cell transplantation (ASCT). Among 349 patients who received a first ASCT for MM, 86 (24.6%) had RI at diagnosis, defined as estimation of glomerular filtration rate (eGFR)

Background: Pulmonary infection is the major risk during neutropenia induced by chemotherapy as well as stem cell transplantation. In spite of potent new-generation antifungal and broad-spectrum antibiotics, one-third of patients usually die from infectious complications. Early diagnosis and prompt administration of appropriate therapy improve the survival. Materials and Methods: We prospectively carried out the study to identify the infectious etiology of pulmonary infiltrates in febrile neutropenia patients by imaging and bronchoscopy. Bacterial culture, fungal culture, galactomannan and molecular diagnosis for pneumocystis, and other infectious agent were carried out in the bronchoalveolar lavage (BAL) fluid and blood. Results: A total of 27 patients were evaluated. Half of the patients belonged to acute leukemia (46%). We had a diagnostic yield of 65% with the most common isolates being Gram-negative bacteria and Aspergillus species. Conclusion: Gram-negative organisms were the predominant infectious agents of pulmonary infection. Our finding emphasizes the importance of BAL in evaluating pulmonary infiltrates in neutropenic patients with hematological malignancies.