Posterior reversible encephalopathy syndrome in cancer patients: experience from a tertiary cancer center, South India

Posterior Reversible Encephalopathy Syndrome (PRES) is characterized by seizures, headaches, altered mental status, cortical blindness and typical transient lesions on MRI. PRES may be associated with chemotherapy, molecular targeted drugs and immunosuppressive agents used in patients with cancer. PRES is a very rare condition in cancer patients. PRES is usually reversible with appropriate supportive care and most patients can be restarted with treatment

Double malignancies: a clinicopathological and outcomes retrospective analysis from a tertiary cancer referral centre in South India

Background: The presence of second synchronous or metachronous primary malignancies in a cancer patient is not a rare phenomenon. Our study is an endeavour to present data on the frequency, types, and outcomes of double primary malignancies in Indian cancer patients.Methods: This was a retrospective study conducted in 28 cancer patients diagnosed with histologically confirmed double malignancy. Retrospective data of the cancer site, patient’s age at the presentation, gender, type of cancer (synchronous/metachronous), treatment, and outcome were recorded from patients presented with double malignancies from January 2012 to January 2019.Results: Among 28 patients (18 females; 10 males) with multiple primary malignancies, 10 (35.7%) and 18 patients (64.3%), respectively, had synchronous and metachronous primary malignancies. Overall, breast, gynecological, head, and neck cancer were the most common primary malignancies. Gastrointestinal tract, breast, and lung cancer emerged to be the most common second primary malignancy sites. Squamous cell carcinoma (SCC) and invasive ductal carcinoma (IDC) were the most common histopathological types of double malignancies. The majority of the patients received appropriate treatment for both the malignancies.Conclusions: Data from the present study clearly suggest that the occurrence of second primary malignancy is not rare in Indian cancer patients. The double malignancies can occur at any stage and for any type of cancer. Hence, we wish to highlight that the clinician should always be aware of the possibility of developing second malignancy either during evaluation or in follow up of a patient with malignancy

Retrospective analysis of clinical manifestations and treatment outcomes of patients diagnosed with langerhans cell histiocytosis from a tertiary cancer hospital in South India

Background: Langerhans cell histiocytosis (LCH) comprises a diverse group of disorders where pathologic Langerhans cells accumulate in a variety of organs. Aims and objectives of the study is to analyse the clinical manifestations and treatment outcomes of patients diagnosed with LCH in a tertiary cancer hospital in South India.Methods: Retrospective analysis of the case records of patients presenting with histological proven case of LCH over a period of 7 years from 2011 to 2018, being treated at Vydehi Institute of Medical Sciences and Research Centre.Results: 10 patients with biopsy proven LCH were included. The median age of diagnosis was 8 years (range 1 to 73 years) and 3 patients aged 18 years or older at the time of diagnosis. The male: female ratio was 3:2. Multisystem involvement was found in 4 patients (40%) and Single system Involvement in remaining 6 patients. Isolated bone lesions were found in 4 patients (40%), 1 patient had isolated Lymph node involvement; 1 patient had oral cavity lesion. None of the 4 patients with multisystem diseases had skin/mucosal involvement; 3 had bony involvement, 2 patients had lung involvement. One patients with multisystem disease expired while 5 patients were lost to follow-up. 4 out of the 10 patients are on regular follow-up and are in remission.Conclusions: Despite limitation by the retrospective nature, this descriptive study was done to provide further disease information regarding Indian population. Data from this study clearly confirms the known fact that most of the patients with Single System LCH have a very good response rate. Patients with multisystem disease have the highest risk of disease related mortality and morbidity as one among the 4 patients with multisystem disease died just after initiating treatment

Comparison of standard short infusion versus prolonged infusion of Doxorubicin in relation to its cardiotoxicity in South Indian population

Background: Anthracycline is one of the commonly used chemotherapeutic agents in the treatment of malignancies and their efficacy is undermined by potential life-threatening cardiotoxicity.  The aim of this study is to compare the cardiotoxicity in patients receiving standard short infusion (15-30 minutes) versus prolonged infusion (6 hours) of doxorubicin in the study group.Methods: In this study 80 patients who were planned for treatment with Doxorubicin >200 mg/m2 were included in this study and they were randomly allotted to either of the treatment group. Each patient was assessed clinically (History, Pulse rate, Blood pressure) along with ECG ,ECHO prior to initiation of chemotherapy, after completion of 200 mg/m2 of Doxorubicin, 3 months and 6 months after chemotherapy.Results: There were 40 patients in each group, and they received a total of 384 cycles of Doxorubicin containing regimens according to respective protocols. The median number of cycles was four (range four to six cycles). The mean cumulative dose of doxorubicin was 271.5 mg/m2 in the group which received standard short infusion and 264 mg/m2 in the group which received the drug by prolonged infusion. However, none of the patients developed any cardiac symptoms during or after the planned chemotherapy nor was there a drop in ejection fraction on serial ECHO.Conclusions: There was no benefit of prolonged infusion of doxorubicin as compared to the standard rapid infusion in terms of doxorubicin induced cardiotoxicity. At present, standard rapid infusion is the best option

Packed red cell blood transfusion practices review in medical oncology unit in a tertiary cancer center, South India

Background: Anaemia is a very common complication in cancer patients. Up to 60% of solid tumor patients and 70-90% of patients receiving myelosuppressive chemotherapy have anaemia. Pathophysiology of anaemia in cancer patients is multifactorial. The treatments for cancer related anaemia include Erythropoietin Stimulating Agents (ESAs), iron supplementing therapies (intravenous iron, oral iron) and blood transfusion. There are various safety concerns regarding usage of ESAs; also, their usage is less in India due to cost factor. There is scant literature regarding blood transfusion practices in patients undergoing chemotherapy.Methods: Patients diagnosed with cancer and patients receiving chemotherapy were included in the study. Retrospective case record review of cancer patients who received chemotherapy between January to March 2019 was done. Type of malignancy, presence of symptoms related to anemia and trigger for packed red cell transfusion were recorded.Results: Among 342 patients received total of 1365 cycles of chemotherapy in this time period. Mean age of patients was 46 years. 46 of the 342 patients received blood transfusion. Only 13% of the patients had symptoms of anemia like weakness and fatigue the average hemoglobin level at which transfusion was given was 6 gm/dL.Conclusions: Packed Red blood cell transfusion was usually administered at Hb <7 gm/dL. Very few patients reported anaemia related symptoms prior to transfusion. No patient received erythropoietin. Further data is needed from other tertiary cancer centres to understand the blood transfusion practices in Indian cancer patients undergoing chemotherapy

Imatinib induced bone marrow hypoplasia in a case of chronic myelogenous leukemia

Imatinib mesylate a tyrosine kinase inhibitor first introduced for the treatment of chronic myelogenous leukaemia (CML) since May 2001, has revolutionised the management of CML. Imatinib is the first choice of treatment for patient with CML chronic phase (CML-CP) and generally the drug is well tolerated. A number of haematological and non-haematological side effects are associated with it. Bone marrow hypoplasia is one of the rare side effects noted with imatinib. We report a case of 46-year-old male a case of CML-CP who developed bone marrow hypoplasia following treatment with imatinib for a period of six months with bone marrow biopsy showing decreased cellularity

Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

Background Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage. Methods In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283. Findings Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group. Interpretation Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset. Funding London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation

Cross-validation of an artificial intelligence tool for fracture classification and localization on conventional radiography in Dutch population

Objectives: The aim of this study is to validate the effectiveness of an AI tool trained on Indian data in a Dutch medical center and to assess its ability to classify and localize fractures. Methods: Conventional radiographs acquired between January 2019 and November 2022 were analyzed using a multitask deep neural network. The tool, trained on Indian data, identified and localized fractures in 17 body parts. The reference standard was based on radiology reports resulting from routine clinical workflow and confirmed by an experienced musculoskeletal radiologist. The analysis included both patient-wise and fracture-wise evaluations, employing binary and Intersection over Union (IoU) metrics to assess fracture detection and localization accuracy. Results: In total, 14,311 radiographs (median age, 48 years (range 18–98), 7265 male) were analyzed and categorized by body parts; clavicle, shoulder, humerus, elbow, forearm, wrist, hand and finger, pelvis, hip, femur, knee, lower leg, ankle, foot and toe. 4156/14,311 (29%) had fractures. The AI tool demonstrated overall patient-wise sensitivity, specificity, and AUC of 87.1% (95% CI: 86.1–88.1%), 87.1% (95% CI: 86.4–87.7%), and 0.92 (95% CI: 0.91–0.93), respectively. Fracture detection rate was 60% overall, ranging from 7% for rib fractures to 90% for clavicle fractures. Conclusions: This study validates a fracture detection AI tool on a Western-European dataset, originally trained on Indian data. While classification performance is robust on real clinical data, fracture-wise analysis reveals variability in localization accuracy, underscoring the need for refinement in fracture localization. Critical relevance statement: AI may provide help by enabling optimal use of limited resources or personnel. This study evaluates an AI tool designed to aid in detecting fractures, possibly reducing reading time or optimization of radiology workflow by prioritizing fracture-positive cases. Key Points: Cross-validation on a consecutive Dutch cohort confirms this AI tool’s clinical robustness. The tool detected fractures with 87% sensitivity, 87% specificity, and 0.92 AUC. AI localizes 60% of fractures, the highest for clavicle (90%) and lowest for ribs (7%).</p

Development and Initial Evaluation of a Cost-Effective Force Sensor for Ureteroscopic Application

Purpose: Retrograde intrarenal surgery is the gold-standard treatment for most kidney stones. During ureteroscopy, ureteral access sheath insertion at forces greater than 8.0 Newtons (N) risks high-grade ureteral injury. To monitor force, our institution utilizes a unique, Bluetooth-equipped device (i.e., the University of California-Irvine Force Sensor). Given the unique nature of the force sensor, we sought to develop an inexpensive and accessible force sensor based on Boyle's law and the specific amount of force required to compress an occluded 1.0 mL syringe. Materials and Methods: We evaluated three brands of 1.0 mL syringes. After setting the plunger at 1.0 mL, the syringe was occluded, and the syringe plunger was compressed. The syringe volume was recorded when the applied force on the plunger reached 4.0 N, 6.0 N, and 8.0 N. Multiple trials were performed to assess reliability and reproducibility. A method for applying this clinically was also developed. Results: The precise force thresholds identified for a 1.0 mL Luer-Lok™ Syringe (Becton Dickinson, Franklin Lakes, NJ) were 0.30 mL for 4.00 N, 0.20 mL for 6.00 N, and 0.15 mL for 8.00 N. The 1.0 mL Tuberculin Syringe and 1.0 mL Luer Slip Syringe were less precise, but compression from 1.0 to 0.40 mL, 0.25 mL, and 0.20 mL corresponded to force sensor readings that did not exceed 4.00 N, 6.00 N, and 8.00 N, respectively. Conclusions: Based on volume changes, 4.00 N, 6.00 N, and 8.00 N of force can be reliably and reproducibly achieved using an occluded 1.0 mL syringe