23 Using visual data and teleophthalmology in paediatric ophthalmology with an app-free, browser-based, visual data platform: ISLACARE

Visual data is underutilised in ophthalmology particularly within paediatrics. Following the pandemic, virtual and remote clinics in the form of telephone and video consultations have increased but there are limitations within paediatric ophthalmology as synchronous telephone or video calls are time-consuming.Using a platform known as ISLACARE, we are able to run remote photo and video clinics that has the capability to support asynchronous or synchronous consultations. With this software, parents and clinicians do not need to create logins or download apps thus increasing compliance with the technology.In an audit of 101 consecutive cases, the following was found. Mean age: 6.67 years (0-17years). The top 4 categories used in were anterior segment (36%), Strabismus (24%), Orbit/Trauma (17%), and Oculoplastics (12%).On the use of photographs to support consultations , it was felt that 91% reduced time to treatment/supported clinical decision making and 75% improved clinician to clinician communication. We have found a 30% increase in capacity in our remote teleophthalmology clinics by utilising a pre-consultation proforma. A particular improvement has been in post-operative strabismus cases where 90% of all our first appointment checks are now done remotely.We would like to demonstrate the clinical flow of how we use ISLACARE for asynchronous consultations, remote monitoring, and visual data archiving.

Initial Experiences in Adolescents and Young Adults with T-Cell Acute Lymphoblastic Leukemia/Lymphoma Treated with the Modified BFM 2002 Protocol in a Resource-Constrained Setting

Prutha Jinwala T-cell acute lymphoblastic leukemia/lymphoblastic lymphoma (T-ALL/LBL) in adolescents and young adults (AYAs) is a clinically aggressive malignancy and life-threatening at diagnosis. Intensive chemotherapy protocols, inspired by the Berlin-Frankfurt-Münster (BFM) regimen, along with central nervous system (CNS) prophylaxis, have achieved a 75 to 85% 5-year disease-free survival rate. However, in cases of marrow and CNS relapses, second-line chemotherapy is usually ineffective. This study aimed to assess the safety and efficacy of the BFM 2002 protocol and to correlate clinical profiles and prognostic factors with survival outcomes in AYA T-ALL/LBL patients. We retrospectively analyzed data from T-ALL/LBL patients treated at the Department of Medical Oncology, Sri Aurobindo Institute of Medical Sciences (SAIMS), Indore, between 2018 and 2021. Twenty-one patients aged 15 to 29 years were studied for their clinical course and laboratory parameters over 36 months. Diagnosis and risk stratification were performed following the guidelines of the BFM 2002 protocol. All patients received treatment and monitoring according to this pediatric-inspired protocol. The median age of the patients was 17 years (range: 15-28 years). Eleven patients presented with mediastinal lymph node enlargement, 10% exhibited CNS involvement, and none had testicular involvement. Eleven patients had marrow blasts greater than 25%, indicative of acute lymphoblastic leukemia. All 21 patients were treated according to the intensive modified BFM 2002 protocol and achieved morphological remission after a median follow-up of 24 months (range: 18-36 months). Seventeen patients achieved minimal residual disease (MRD) negativity post-induction. MRD at day 33 showed a significant association with the probability of disease relapse ( p  = 0.0015). There were five deaths (24%), one due to toxicity and four due to relapse. The study recorded an 18-month overall survival of 76%. These results were achieved despite financial constraints. Data were entered into a spreadsheet, and statistical analysis was performed using IBM SPSS version 23. Continuous data are presented as ranges and medians, while categorical variables are shown as percentages and numbers. A chi-squared test for association, with a significance level set at p  < 0.05, was conducted as indicated. AYA T-ALL/LBL requires intensive treatment regimens. With biological characterization of LBL/ALL and close therapy monitoring, encouraging outcomes can be achieved even in resource-limited settings.

Granulocyte Transfusion Therapy: Institutional Experience of Benefit in Cancer Patients with Prolonged Neutropenic Sepsis—A Retrospective Study

Introduction Patients undergoing intensive chemotherapy for hematological malignancy and stem cell transplantation are at increased risk of neutropenia.

Neutropenia is among the frequent side effects of intensive treatments, and when absolute neutrophil count (ANC) falls < 500/µL, the risk of microbial and fungal infection increases significantly.

As neutropenia is the main cause of these infections, transfusion of granulocyte immediately as a replacement is a life-saving therapeutic option to support these patients by restoring neutrophil counts and aiding in the resolution of infection.

Objective The present study is a retrospective single institutional analysis of granulocyte transfusion therapy in children and young adults with cancer who received treatment with GT during prolonged and profound life threatening neutropenia.

Materials and Methods This study was a retrospective analysis of 66 granulocyte transfusions in 36 patients of hematological and solid malignancy with severe and prolonged neutropenia in the department of Medical Oncology, Sri Aurobindo Institute of Medical Sciences Indore, between September 2019 and March 2022.

Donors were either patients' relatives or voluntary donors without comorbidities.

All granulocyte concentrates were collected by centrifugation leukapheresis and irradiated with 2500 centigray and immediately transfused in full, to the patient over 60 ot 120 minutes with appropriate premedication.

Results A total of 36 patients (M:F, 19:17) with a median age of 16 years (2–43) received 66 granulocyte transfusions. The diagnosis of patients included acute myelogenous leukemia (n = 17), B cell acute lymphoblastic leukemia (n = 10), non-Hodgkin lymphoma (n = 3), Ewing's sarcoma (n = 2), neuroblastoma (n = 1), malignant melanoma (n = 1), aplastic anemia (n = 1), osteosarcoma (n = 1). All had severe neutropenia with absolute neutrophil count < 0.5 × 109/L. The median duration of severe neutropenia was 16 days. Patients received a median cell dose of granulocytes 2.9 × 1010/L. A favorable response was seen in 28 (78%) patients, whereas an unfavorable response was seen in 8 patients (23%).

Conclusion A granulocyte therapy was effective in many critically sick patients with prolonged and profound neutropenia. Granulocyte transfusions may be more beneficial in selected patients where it provides more time to overcome refractory infections with broad-spectrum antibiotics. Granulocyte transfusion are at best a “bridge” that gives time to marrow recovery. The challenges to using GT are clinical, finding patients who may get benefitted, and logistical, selection of donors and harvest technique. Randomized trials with large numbers of patients are required to prepare guidelines for granulocyte use.

Assessment of Psychological Distress Among Indian Adolescents and Young Adults with Solid Cancer Using the National Comprehensive Cancer Network Distress Thermometer

Purpose The incidence of cancer has increased in India with a visible impact on the young population (aged 15–39 years). The present study aims to evaluate psychological distress among Indian adolescents and young adults (AYAs) with solid cancer using the National Comprehensive Cancer Network (NCCN) distress thermometer.

Methods The demographic and clinical characteristics of AYAs patients (age 15–39 years) with cancer were recorded. Assessment of psychological distress of patients using the NCCN distress thermometer was performed at three time points over a period of 3 months. Distress thermometer scale and a self-administered questionnaire in English and Hindi languages was handed over to participants at three time points: at treatment commencement (T1), at 1 month, and 3 months (T2 and T3, respectively) into therapy.

Results Of the 259 patients, 63% were women and 37% men; the median age was 34 years. In total, 71 (27%) were ≤ 24 years old and 188 (73%) were>24 years old. Bone sarcoma (39%) was common cancer in AYA patients aged ≤ 24 years and breast cancer (21%) in >24 years of age. The distress scores in both the groups were the highest at diagnosis (T1) followed by that measured at 1 (T2) and 3 months (T3) after diagnosis. The distress score in the age ≤ 24 years was the highest (6.7) at T1, followed by those measured at T2 (2.6) and T3 (1.1) and among age>24 years was the highest (6.6) at T1, followed by those measured at T2 (2.6) and T3 (1.2). Among AYA patients>24 years old, worry, nervousness, sadness, transportation, and sleep were the top five identified problems and in ≤ 24 years old, the top identified problems were worry, financial support, sleep, nervousness, and sadness.

Conclusion Adolescents and young adults experience some level of distress associated with the cancer diagnosis, effects of the disease, treatment regardless of the stage and various transitions throughout the trajectory of the disease. The distress thermometer is an easy and useful tool for the assessment of psychological distress in AYA cancers. Early identification of distress burden with the distress thermometer leads to effective interventions in patients with cancer which could improve outcomes including survival in AYAs with cancer in India.

Small-cell carcinoma of the gall bladder: Report of three cases and review of the literature

Gallbladder (GB) Small Cell Carcinoma (SCC) is an uncommon entity with very poor prognosis. There is a paucity of literature regarding its natural history and management, with only 73 prior cases reported in the world literature. In this case report, we present three cases of SCC of the GB with varied presentations, clinical course, management, and outcomes along with a brief review of the available literature on this subject.

Anatomical Variations of Corona Mortis in the Anterior Intrapelvic Approach: A Cadaveric Study

Corona mortis (CMOR) is an anastomotic channel either arterial, venous or both connecting the obturator and external iliac systems excluding aberrant channels in the retropubic space. The goal of this study is to illustrate the type of CMOR via the Anterior Intrapelvic approach (AIP) which has not been studied in tandem. This descriptive observational study was performed in the Department of Anatomy, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India from January 2018 to December 2020. It is a potential culprit for significant haemorrhage in scenarios of pelvic trauma or when sectioned accidentally, augmenting difficult haemostasis behind the superior pubic ramus. Previously reported to be exclusively arterial, the venous variant has now emerged as the more frequent anastomosis. AIP was performed on 31 adult human cadavers of 62 hemipelvises to record variations and statistical analysis of retropubic anastomosis with respect to gender, weight groups and side distribution was done. Corona Mortis was observed in 50(80.6%) hemipelvises. To ramify, venous CMOR and arterial CMOR were exclusively encountered in 25(40.3%) and 10(16.10%) hemipelvises respectively. Males recorded a higher prevalence of CMOR. Despite being a frequent anastomotic variant, it is a rare entity in textbooks. CMOR can potentially alter patient outcome and have serious implications in pelvic surgeries via AIP owing to its easier accessibility. Besides, venous CMOR being more common, a venous bleed is inherently more arduous to manage in the pelvis. A larger calibre, less frequent aberrant channel could also prove to be lethal in its injury. Hence, cadaveric simulation of the technique is paramount to master the technique and to mitigate catastrophic vascular events.

A Rare Case of Life-Threatening Extensive Mucocutaneous Adverse Reaction Induced by Docetaxel in a Breast Cancer Patient: Toxic Epidermal Necrolysis, a Case Report with Review of Literature

Fever and extensive necrosis with 30% or more epidermal involvement along with mucous membrane is known as toxic epidermal necrolysis (TEN). It is a life-threatening mucocutaneous disease and is usually drug induced. We report a rare case of docetaxel-induced TEN. A patient with metastatic breast carcinoma received single agent docetaxel and developed severe skin and mucous membrane reaction involving more than 30% of the skin, and managed conservatively in intensive care unit but she succumbed to her illness. Although common toxicities reported with docetaxel include alopecia, nail damage, myelosuppression, and erythema multiforme major, TEN after docetaxel is very rare and can be a life-threatening complication as in our case.

The Impact of COVID-19 Pandemic on Cancer Care in a Tertiary Care Facility

Background  Coronavirus disease 2019 (COVID-19) pandemic had an overwhelming impact on health care worldwide. Cancer patients represent a subgroup that is vulnerable and is under high risk. It is, therefore, necessary to analyze factors that predict outcomes in these patients so that they can be triaged accordingly to mitigate the effects of COVID-19 on cancer management. To date, the impact of COVID-19 on cancer patients remain largely unknown.

Methods  Data of 291 cancer patients undergoing active treatment from March 23 to August 15, 2020 were retrospectively reviewed; the incidence, demographic and clinical characteristics, treatment, and outcomes of cancer patients infected by COVID-19 were included in the analysis.

Discussion  During the index period (March 23–August 15, 2020), 4,494 confirmed cases of COVID-19 were admitted at our institute. In the department of medical oncology out of 578 patients presented to outpatient department, 291 patients were admitted for active treatment. Considering the cancer patients, infection rate was 7.9% (23/291) and mortality 13% (3/23). Median age was 40 years and the majority of patients were male (60%). The most common cancer type was acute lymphoblastic leukemia presented at various stages of treatment. Twenty patients (86.9%) were discharged after full clinical recovery and negative real-time polymerase chain reaction on a nasopharyngeal swab. Anticancer treatment was modified according to the type of cancer under intensive surveillance.

Conclusion  Although mortality rate in COVID-19 cancer patients is elevated, our results support the feasibility and safety of continuing anticancer treatment during pandemic by endorsing consistent preventive measures, but however should be modified based on the type and prognosis of cancer.

A Comparative Study of Two Chemo-Radiation Regimens for the Cancer of Larynx

The region of head and neck is critical for respiration, nutrition, and speech. The management of laryngeal tumours can stimulate mutilations and cosmetic deformities and worsen the life. A “non-operative approach” is preferred for patients to whom radiation following surgery, possibly, will direct severe functional destruction predominantly in advanced stage patients having a bulk of carcinoma larynx. The case material for the study was selected from the cross-section of patients registered at the J. K. Cancer Institute, Kanpur. Histologically squamous cell carcinoma 64 patients were registered and equally and randomly placed into Arm I and Arm II. “Arm I” patients and “Arm II” was comprised of randomly selected 64 patients, having histopathologically proven squamous cell carcinoma of the larynx. All patients (32 patients) belonging to “Arm I” received concurrent chemoradiotherapy of Inj. Cisplatin 100 mg/m² for three-weekly underwent EBRT with 60 Co/LINAC and photon radiation of 70 Gy in 35 fractions for 7 weeks (2 parallel opposed fields). All the patients (32 patients) belongs to “Arm II” received chemo boost as Inj. Cisplatin 6 mg/m2 on last 15 fractions of treatment underwent EBRT with 60 Co/ LINAC photon radiation of 70 Gy in 35 fractions for 7 weeks. Radiotherapy was delivered in supine position by parallel opposing fields including the primary tumour, disease extension, and neck nodes. The study concluded that the loco-regional responses are analogous in Arm I and Arm 2, however Arm II had additional treatment allied toxicities and resulting from numerous of treatment breaks.

Percutaneous ureterolitholapaxy: the best bet to clear large bulk impacted upper ureteral calculi

OBJECTIVES

The outcome of treating impacted upper ureteral calculi by extra corporeal shock wave lithotripsy was less satisfactory than antegrade litholapaxy in our earlier experience. During a four year period (October 1988 to September 1992) 86 reno-ureteral units with impacted upper ureteral calculi were treated by percutaneous litholapaxy. We review our methods and results of this accumulated experience.

METHODS

Moderate to severe proximal hydronephrosis on excretory urography or ultrasound was taken as evidence of impaction. Antegrade extraction was performed in a single stage, except in patients who presented with anuria, severe azotemia and urosepsis where the system was decompressed by initial nephrostomy drainage.

RESULTS

86 impacted upper ureteral calculi in 80 patients were treated by the percutaneous antegrade approach. Eleven were in a solitary functioning unit; 33% presented with moderate to severe renal failure. The average stone size was 256 sq mm. Associated renal calculous disease was present in 22 ipsilateral and 28 contralateral units. Total clearance was achieved in 74 units (86%) by antegrade litholapaxy alone. Adjunct ESWL (5) and ureteroscopy (4) rendered 96% of the units free; 3 units with recurrent calculi were salvaged by ESWL (2) and ureterolithotomy (1). Complications encountered in 17 (20%) patients were fewer in 13 (16%), ureteric perforation in 7 (9%), hematuria in 6 (7%) and ureteric stricture 1 (1%). Hospital stay was 5 days in uncomplicated cases; prolongation of stay (average 8.8 days) was necessitated in staged procedures (sepsis, renal failure), treatment of the contralateral unit or due to postoperative morbidity. The majority of the stones (80%) were of the calcium oxalate monohydrate variety.

CONCLUSION

It is concluded that failing a retrograde manipulation, percutaneous ureterolitholapaxy offers the best bet to clear large bulk impacted upper ureteral calculi.

Upper urinary tract stone analysis using X-ray diffraction: results from a tertiary referral centre in northern India

BACKGROUND

The spectrum of urinary stone disease has changed considerably in India from the common childhood bladder stone to the more frequent upper tract calculi. We analysed the gravel retrieved from the upper urinary tract using X-ray diffraction analysis in an attempt to evaluate the composition of the stones.

METHODS

We analysed 434 upper urinary tract calculi from May 1993 to June 1994 obtained endourologically, as well as by extracorporeal shock wave lithotripsy and open surgery. The stones were analysed using a Phillips compact X-ray diffractometer (PW1840). The PC-APD software was used for data collection and peak search. The phase matching was done by the software using the JCPDS reference database.

RESULTS

Oxalate stones comprised 97% of the total stones with calcium oxalate monohydrate forming 90% and calcium oxalate dihydrate and mixed stones forming the remainder. Struvite stones were found in 1.4%, while uric acid and apatite stones were less than 1%. There were no cystine calculi. Seventy per cent of calcium oxalate monohydrate and 40% of calcium oxalate dihydrate stones were pure. All the struvite and apatite calculi were almost pure. Only 15% of staghorns did not consist of oxalate. Nine of the ten stones in children were of the calcium oxalate monohydrate variety. The stone composition in females was similar to that in males.

CONCLUSIONS

X-ray diffraction data indicate that urinary stone disease in north India is different from that in the western world. Calcium oxalate monohydrate stones predominate. These stones are hard to break and have a different metabolic origin from those consisting of calcium oxalate dihydrate. These findings might help in selecting the most appropriate method of treatment in north India and they indicate directions in which further metabolic studies might be planned.