Clinical profile and mortality predictors in hospitalised patients of tuberculous meningitis

Background& Objective: Tuberculous meningitis (TBM) is a serious public health problem in developing countries like India as it leads to significant mortality and neurological sequelae. Aim of study was to describe clinico-radiological profile of TBM and determine predictors of mortality. Methods: This was a prospective study and data collected including demographic details, clinical, laboratory parameters and neuroimaging finding. Diagnosis of TBM was based according to a standard case definition proposed by Marais et al.(2010). Results: One hundred and forty two TBM patients were recruited with 54.93% males and 45.07% females. Fever was most common symptom followed by headache, vomiting, altered sensorium and seizure. Most common cranial nerve palsy was of 6th cranial nerve followed by 2nd cranial nerve. Cerebrospinal fluid (CSF)study in 77.46% of patients showed protein >100 mg/dL, 61.27% patients had CSF sugar <40 mg/dL while 87.32% of patients had total cell count >10 cells/cumm. Most common Neuroimaging finding was meningeal enhancement followed by hydrocephalus, infarcts, basal exudates and tuberculoma. In-hospital mortality was 17.61%. Higher age, low Glasgow Coma Scale (GCS) score, absence of headache, seizure, altered sensorium, anemia, low CSF glucose, infarct, hydrocephalus, and British medical research council (BMRC) Stage III at presentation were predictors of in-hospital mortality. Conclusions:. Age, GCS score, absence of headache, seizure, altered sensorium, anemia, low CSF glucose, infarct, hydrocephalus, and BMRC Stage III at presentation were predictors of in-hospital mortality based on this study from Bihar, India.

Clinico- radiological profile of genetically proven Complicated Hereditary Spastic Paraparesis: A case series

Complicated Hereditary Spastic Paraparesis (HSP) is a group of heterogenous neurodegenerative disease characterized by progressive spastic paraparesis with additional features like cognitive impairment, seizures, movement disorders, visual loss, deafness, peripheral neuropathy, and pes cavus. There have been few case series reported in literature from India. We herein report four cases of complicated HSP. Four (three females and 1 male) patients of genetically confirmed HSP with a mean age of onset 10.5 years were recruited. There was mean delay of 8 years in reaching diagnosis. MRI brain showed thinning of corpus callosum in three patients and Ear of lynx sign in two patients. Next Generation Clinical Exome Sequencing confirmed mutations in SPG11 gene in three patients and SLC2A1 in one patient. SPG11 gene mutations were the most frequent genetic abnormality with SLC2A1 gene mutation in single patient. Genetically confirmed diagnosis helps in prognostication and genetic counselling.

Area postrema syndrome: An initial presentation of double Seropositive AQP4 and MOG Antibody: A case report

Objectives:

Area postrema syndrome (APS) is one of the core clinical feature of neuromyelitis optic spectrum disorder (NMOSD). APS is mostly associated with neuromyelitis optica (NMO) and rarely reported in myelin oligodendrocyte glycoprotein antibody disease (MOGAD). We herein report a case of area postrema syndrome as the initial presentation of double seropositive aquaporin-4 (AQP-4) and myelin oligodendrocyte glycoprotein (MOG)antibody.

Methods:

The patient fulfilled the NMOSD diagnostic criteria. MRI brain, CSF studies, electrophysiological test and serum NMO and MOG antibody testing were done.

Results:

An elderly female initially presented in Gastroenterology outpatient department with a history of nausea, vomiting and hiccups for 3 weeks. Detailed medical evaluation including upper gastrointestinal endoscopy was normal with no improvement with symptomatic therapy. Neurological examination showed bilateral nystagmus, postural imbalance and gait ataxia. MRI brain showed T2/FLAIR hyperintensity in dorsal medulla involving area postrema. Both anti NMO and MOG antibodies were found to be positive in serum. She was treated with intravenous methyl prednisolone with complete symptomatic resolution.

Discussion:

Double seropositive APS-onset NMOSD has not been previously reported in literature. Early diagnosis and treatment results in resolution of APS- related symptoms and prevents further progression of disease.

Stroke in Tuberculous Meningitis and Its correlation with Magnetic Resonance Angiography Manifestations

Objective  The primary objective of the study was to assess the location of cerebral infarction and look for corresponding magnetic resonance angiography (MRA) changes in patients with tuberculous meningitis (TBM). We also evaluated the predictors of ischemic stroke in TBM and the impact of these infarctions on patient's outcome.

Methods  This was a single-center prospective study between September 2018 and September 2020. Demographic and laboratory parameters were noted. Cranial magnetic resonance imaging and MRA were performed at the time of admission to the hospital.

Results  Among 120 patients with TBM, 46 had stroke. Nineteen (15.8%) patients died, of which 12 (10%) suffered from stroke. The most common site of infarction was the basal ganglia (54.3%). The commonest site of MRA abnormalities was the middle cerebral artery (39.1%). British Medical Research Council (BMRC) stage 3, cerebrospinal fluid (CSF) sugar, CSF adenosine deaminase (ADA) level, basal exudates, hydrocephalus, and hyponatremia were found to be predictors of stroke in TBM, while BMRC stage 3, CSF cell count, CSF ADA level, and anemia were found to be significantly associated with mortality in TBM patients with stroke.

Conclusion  The basal ganglia were the most common site of ischemic stroke in TBM, and middle cerebral artery was the most often involved intracranial blood vessel. BMRC stage 3 was significantly associated with both stroke and mortality in TBM patients with stroke.

Magnetic Resonance Imaging of Perianal Fistulas in Clinically Symptomatic Patients and the Correlation Among Plain, Contrast, and Post Jelly MRI Fistulography

Objectives To evaluate different types of perianal fistulas and their complications on magnetic resonance imaging (MRI) and to compare plain, contrast, and jelly magnetic resonance fistulography findings.

Materials and Methods This prospective study was performed in 30 patients who presented with perianal pus discharge or external fistulous opening. Magnetic resonance imaging of the perianal region before and after giving intravenous contrast and after injecting jelly through a percutaneous opening was performed on a 3T scanner and the results were correlated.

Results The mean age of the patients was 40.13 ± 13.88 years (range 19–75 years). The male to female ratio was 14:1. The most common type of fistula was St. James classification type I, which was seen in 13 patients (43%), followed by type IV in 30%, type III in 16%, type II in 6.66%, and type V in 3.33% of the patients. Using agreement analysis, we compared the number of primary and secondary tracts, internal openings, and horseshoe tracts and found a significant agreement between plain and post Jelly MRI fistulography (kappa statistic close to 1). When comparing plain and contrast MRI, there was significant agreement in the primary and secondary tracts, while statistically insignificant results were obtained (p > 0.05) for the horseshoe tract and internal openings. Contrast injection was helpful in 7 subjects (23.3%) as peripheral enhancement of abscesses were better delineated.

Conclusion Magnetic resonance imaging is the one stop diagnostic modality for perianal fistulas. Acquisition of axial (Ax) T2, axial T2 FS, coronal T2 and coronal T2 FS sequences without administering intravenous contrast or jelly is usually sufficient for the diagnosis of fistulas and their complications.

Sphenoid sinus aspergilloma clinically mimicking as malignancy—a case report

Background

Fungal sphenoid sinusitis mimicking as malignant tumor and invading the pituitary fossa is an uncommon entity. This report aims to highlight radiological salient features to help differentiate fungal lesion from malignant tumor in sphenoidal sinus mass lesions.

Case presentation

We intend to report a case of middle-aged female who presented with gradual progressive diminution of vision since 3 years complicated with acute attack of unilateral headache and numbness. Computed tomography (CT) showed hyperdense lesion involving the sphenoid sinus extending into pituitary fossa and bilateral cavernous sinuses with smooth bony remodeling. Lesion appeared hypointense on T2-weighted and hyperintense on T1-weighted images on magnetic resonance imaging (MRI). Surgical excision of the lesion was done and pathological examination showed fungal hyphae and aspergillus fumigatus species on culture after 2 weeks of incubation. Post-operative CT revealed empty sinuses with surrounding bone remodeling.

Conclusion

Combination of T1 hyperintensity, T2 hypointensity, and hyperdense sinus is a strong predictor of fungal mass lesion involving sphenoid sinus.

Consensus and development of document for management of stabilized acute decompensated heart failure with reduced ejection fraction in India

Aim

Ensuring adherence to guideline-directed medical therapy (GDMT) is an effective strategy to reduce mortality and readmission rates for heart failure (HF). Use of a checklist is one of the best tools to ensure GDMT. The aim was to develop a consensus document with a robust checklist for stabilized acute decompensated HF patients with reduced ejection fraction. While there are multiple checklists available, an India-specific checklist that is easy to fill and validated by regional and national subject matter experts (SMEs) is required.

Methodology

A total of 25 Cardiology SMEs who consented to participate from India discussed data from literature, current evidence, international guidelines and practical experiences in two national and four regional meetings.

Results

Recommendations included HF management, treatment optimization, and patient education. The checklist should be filled at four time points- (a) transition from intensive care unit to ward, (b) at discharge, (c) 1st follow-up and (d) subsequent follow-up. The checklist is the responsibility of the consultant or the treating physician which can be delegated to a junior resident or a trained HF nurse.

Conclusion

This checklist will ensure GDMT, simplify transition of care and can be used by all doctors across India. Institutions, associations, and societies should recommend this checklist for adaptability in public and private hospital. Hospital administrations should roll out policy for adoption of checklist by ensuring patient files have the checklist at the time of discharge and encourage practice of filling it diligently during follow-up visits.

Clear cell variant of Oral Squamous cell carcinoma

Among the various histopathological variants of oral squamous cell carcinoma, clear cell variant is a rarity. (1) This report is a compilation of two cases which showed the presence of clear cells. The clear cells were of koilocytic type. Although clear cell variant of squamous cell carcinoma is more common in skin, few cases have been found in oral region also. (2) This variant is considered more aggressive than the others, and hence requires more aggressive treatment protocol. Being rare, the percentage of clear cells determines whether it should be considered as a clear cell variant. The literature has been evaluated for similar cases, and discussed about the clear cells and their origin. An effort has also been made to compile the reported cases of clear cell variant of OSCC.

Intermittent CT fluoroscopic guided lung biopsy - Retrospective analysis of success rate, radiation exposure, complications and duration of procedure

OBJECTIVE

Intermittent CT fluoroscopic biopsy is a new technology, but has not been studied widely. This study aims to investigate correlation between the radiation dose and fluoroscopic CT exposure factors to establish the low dose parameters for performing percutaneous lung biopsies, as well as the relationship of the mean diameter and depth of lesions with radiation dose, procedure time, success and complication rates.

MATERIALS AND METHODS

This is a retrospective study to analyse lung biopsies performed using intermittent CT fluoroscopic technique with 18 G semi-automated coaxial gun on 256 slice scanner. A total of 50 patients were included in the study. Biopsy was done in three mAs and KVp settings (30 and 70, 10 and 120, 30 and 120, respectively). The statistical data analysis was performed using SPSS Statistics software.

RESULTS

Pneumothorax occurred in 22 % of cases. Sampling rate was 98% but histopathological diagnosis was made in 94% cases. Mean procedure time was 30.5±11.1 minutes. Low dose protocol (30 mAs and 70 KVp) had least radiation exposure during biopsy procedure (p < 0.001) with similar success rate, complications and procedure time (p > 0.05) in comparison with high dose protocol (10 and 120, 30 and 120 mAs and KVp, respectively). Mean diameter of lesions didn't correlate with radiation dose, success rate, complications and duration of procedure (p > 0.05) while significant association was found when depth was correlated with radiation exposure during fluoroscopic biopsy, duration of procedure and complication rates (p < 0.05) while no association was found with success rates.

CONCLUSION

On third generation dual energy source CT scanner, reducing mAs and KVp to 30 and 70 during fluoroscopy biopsy can produce images whose complications and success rates are comparable to high dose CT. In general, intermittent CT fluoroscopy guided lung biopsy has good success rates with acceptable complications, while utilising less radiation dose and procedure time.

Computational fluid dynamics analysis of the hydraulic (filtration) efficiency of a residential swimming pool

Hydraulic or filtration efficiency of residential swimming pools, quantified in terms of residence time characteristics, is critical to disinfection and thus important to public health. In this study, a three-dimensional computational fluid dynamics model together with Eulerian and Lagrangian-based techniques are used for investigating the residence time characteristics of a passive tracer and particles in the water, representative of chemicals and pathogens, respectively. The flow pattern in the pool is found to be characterized by dead zone regions where water constituents may be retained for extended periods of times, thereby potentially decreasing the pool hydraulic efficiency. Two return-jet configurations are studied in order to understand the effect of return-jet location and intensity on the hydraulic efficiency of the pool. A two-jet configuration is found to perform on par with a three-jet configuration in removing dissolved constituents but the former is more efficient than the latter in removing or flushing particles. The latter result suggests that return-jet location and associated flow circulation pattern have an important impact on hydraulic efficiency. Thus return-jet configuration should be incorporated as a key parameter in the design of swimming pools complementing current design standards.

Giant fibroepithelial polyp of the thigh and retroperitoneal fibromatosis in a young woman: a rare case

We present a case of 20-year-old woman who presented with a large pedunculated skin covered mass lesion arising from the left thigh, measuring 40 × 25 cm, with no history of pain or skin ulceration and a feeling of a lump with dragging pain in the left side of the abdomen for about 7 years. Subsequently, ultrasound, contrast-enhanced computed tomography, and magnetic resonance imaging of abdomen and left thigh region were carried out. The lesion was broad-based toward the left upper thigh with a central core of interspersed fat supplied by branches of the superficial and deep femoral arteries. Another lesion was seen in the left retroperitoneum anterior to the psoas muscle in a left paravertebral location encasing the left common iliac vessels extending into the left pelvic cavity and inguinal region inferiorly. The lesion showed dense post-acoustic shadowing on ultrasound, mild enhancement on contrast-enhanced computed tomography, and appeared hypointense on T1- and T2-weighted images. A left thigh lesion was excised, whereas incisional biopsy was done for the left retroperitoneal lesion. The diagnosis of a giant fibroepithelial polyp arising from the left thigh and left retroperitoneal fibromatosis was made. This is the first report of such a giant fibroepithelial polyp arising from the thigh with associated retroperitoneal fibromatosis.

Isotopic study of intraseasonal variations of plant transpiration: an alternative means to characterise the dry phases of monsoon

The isotopic characteristics of plant transpired water are strongly controlled by soil evaporation process, primarily by relative humidity. The monsoon system is characterised by large variability of several atmospheric parameters; the primary one being the rainfall, which in turn, modulates the relative humidity. Due to the strong dependency of transpiration on relative humidity, it is expected that this process would vary in accordance with the active and break periods of the monsoon season, which are known to produce cycles of humid and relatively dry phases during a monsoon season. To study the transpiration process, an experiment was conducted wherein rainwater and transpired water were collected from a few plants and analyzed for their isotopic ratios during the summer monsoon seasons of 2016 and 2017. The difference between the isotopic characteristics of the transpired water and rain water is expected to be nominally positive, however, a large variability was observed. This difference is found to be high (low) during the reduced (enhanced) humidity conditions and varies in tandem with the break and active phases of the monsoon season. This characteristic feature may thus be used to delineate the dry and wet phases of monsoon on local to regional scale.

Transport of Liposome Encapsulated Drugs in Voxelized Computational Model of Human Brain Tumors

There are many obstacles in the transport of chemotherapeutic drugs to tumor cells that lead to irregular and non-uniform uptake of drugs inside tumors. The study of these transport problems will help with accurate prediction of drug transport and optimizing treatment strategy. To this end, liposome mediated drug delivery has emerged as an excellent anticancer therapy due to its ability to deliver drugs at site of action and reducing the chances of side effects to the healthy tissues. In this paper, a computational fluid dynamics (CFD) model based on realistic vasculature of human brain tumor is presented. This model utilizes dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) data to account for heterogeneity in tumor vasculature. Porosity of the interstitial space inside the tumor and normal tissue is determined voxel-wise by processing the DCE-MRI images by general tracer kinetic model (GTKM). The CFD model is applied to predict transport of two different types of liposomes (stealth and conventional) in tumors. The amount of accumulated liposomes is compared with accumulated free drug (doxorubicin) in the interstitial space. Simulation results indicate that stealth liposomes accumulate more and remain for longer periods of time in tumors as compared with conventional liposomes and free drug. The present model provides us a qualitative and quantitative examination on the transport and deposition of liposomes as well as free drugs in actual human brain tumors.

Perfusion kinetics in human brain tumor with DCE-MRI derived model and CFD analysis

Cancer is one of the leading causes of death all over the world. Among the strategies that are used for cancer treatment, the effectiveness of chemotherapy is often hindered by factors such as irregular and non-uniform uptake of drugs inside tumor. Thus, accurate prediction of drug transport and deposition inside tumor is crucial for increasing the effectiveness of chemotherapeutic treatment. In this study, a computational model of human brain tumor is developed that incorporates dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) data into a voxelized porous media model. The model takes into account realistic transport and perfusion kinetics parameters together with realistic heterogeneous tumor vasculature and accurate arterial input function (AIF), which makes it patient specific. The computational results for interstitial fluid pressure (IFP), interstitial fluid velocity (IFV) and tracer concentration show good agreement with the experimental results. The computational model can be extended further for predicting the deposition of chemotherapeutic drugs in tumor environment as well as selection of the best chemotherapeutic drug for a specific patient.

Targeted radiotherapy enhancement during electronic brachytherapy of accelerated partial breast irradiation (APBI) using controlled release of gold nanoparticles

Several studies have demonstrated low rates of local recurrence with brachytherapy-based accelerated partial breast irradiation (APBI). However, long-term outcomes on toxicity (e.g. telangiectasia) and cosmesis remain a major concern. The purpose of this study is to investigate the dosimetric feasibility of using targeted non-toxic radiosensitizing gold nanoparticles (GNPs) for localized dose enhancement to the planning target volume (PTV) during electronic brachytherapy APBI while reducing normal tissue toxicity. We propose to incorporate GNPs into a micrometer-thick polymer film on the surface of routinely used lumpectomy balloon applicators and provide subsequent treatment using a 50 kVp Xoft device. An experimentally determined diffusion coefficient was used to determine space-time customizable distribution of GNPs for feasible in-vivo concentrations of 7 mg/g and 43 mg/g. An analytical approach from previously published work was employed to estimate the dose enhancement due to GNPs as a function of distance up to 1 cm from the lumpectomy cavity surface. Clinically significant dose enhancement values of at least 1.2, due to 2 nm GNPs, were found at 1 cm away from the lumpectomy cavity wall when using electronic brachytherapy APBI. Higher customizable dose enhancement was also achieved at other distances as a function of nanoparticle size. Our preliminary results suggest that significant dose enhancement can be achieved to residual tumor cells targeted with GNPs during APBI with electronic brachytherapy.

Analysis of carbapenem-resistant Acinetobacter from a tertiary care setting in North India

Multidrug-resistant (MDR) Acinetobacter baumannii is a worldwide concern as cause of serious nosocomial infections. We analysed 140 non-duplicate Acinetobacter sp. isolates from hospitalised patients in a tertiary care centre; 87% were MDR and 20% (28/140) meropenem resistant. Metallo-β-lactamase was produced by 16 of these, detected by ethylene-diamine-tetra-acetic acid disc synergy test. AmpC β-lactamase and efflux pump were present in 17 and 4 of the meropenem-resistant Acinetobacter, respectively. 9/16 MBL-positive isolates carried genes for carbapenem resistance as shown by polymerase chain reaction.

Caregiver characteristics and economic cost of home-based care: a case study of Maun and Gumare villages in North West District, Botswana

The home-based care programme in Botswana was initiated partly to augment hospital or clinical care by reducing the healthcare costs associated with chronic illnesses such as HIV/AIDS. A number of studies have pointed to the psyco-social impacts of home based care, however there has been few attempts to quantify the direct and indirect costs associated with home based care. This study was carried out in the North West District of Botswana, which is noted for a relatively larger proportion of households with critically ill persons. The objectives of the study were to identify the characteristics of the caregivers and their patients; to estimate the direct and indirect costs of home-based care; and to estimate caregivers' willingness to pay for care services. Data was collected using a structured questionnaire addressed to 120 primary caregivers and analyzed using SPSS. The economic cost of caregiving was estimated using the replacement cost method. The annual value per caregiver was estimated at P31 320 (US$4818.46). The study also revealed that more often than not, women are involved in caregiving activities.