Sreenivas Vishnubhatla

Publications

• 6.34

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  Pediatric nonlymphoblastic non-Hodgkin lymphoma: baseline, interim, and posttreatment PET/CT versus contrast-enhanced CT for evaluation--a prospective study.

  Sameer Bakhshi, Venkatraman Radhakrishnan, Punit Sharma, Rakesh Kumar, Sanjay Thulkar, Sreenivas Vishnubhatla, Deepa Dhawan, Arun Malhotra

  Radiology. 03/2012; 262(3):956-68.

  To prospectively examine the roles of positron emission tomography (PET)/computed tomography (CT) and conventional contrast material-enhanced CT at baseline, after two cycles of chemotherapy, and after completion of chemotherapy in pediatric patients with nonlymphoblastic non-Hodgkin lymphoma (NHL) ... [more] To prospectively examine the roles of positron emission tomography (PET)/computed tomography (CT) and conventional contrast material-enhanced CT at baseline, after two cycles of chemotherapy, and after completion of chemotherapy in pediatric patients with nonlymphoblastic non-Hodgkin lymphoma (NHL) who were treated with similar standard treatment protocols. The institutional ethics committee approved the study protocol, and all patients were enrolled after written informed consent was obtained. Patients with nonlymphoblastic NHL were prospectively enrolled between January 2008 and March 2010. Patients underwent contrast-enhanced CT and PET/CT for staging and for response assessment after two cycles of chemotherapy (interim) and treatment completion. Complete metabolic response versus no metabolic response at PET/CT and complete response versus no complete response at contrast-enhanced CT was analyzed by using Kaplan-Meier survival analysis. The final study included 34 patients with nonlymphoblastic NHL (median age, 10.5 years). Baseline PET/CT and contrast-enhanced CT showed concordance in depiction of 112 disease sites; PET/CT depicted 18 more disease sites and two fewer disease sites than contrast-enhanced CT (P = .0003). Disease in five of 34 patients was upstaged, and disease in no patient was downstaged at PET/CT. There was 100% (four of four) concordance between bone marrow involvement at biopsy and stage at PET/CT. The median length of follow-up was 20.3 months. Response at interim PET/CT and contrast-enhanced CT could not predict progression-free survival (PFS) (P = .083 and .18, respectively) or overall survival (OS) (P = .159 and.08, respectively). Posttreatment PET/CT and contrast-enhanced CT findings could predict PFS (P = .036 and .002, respectively) and posttreatment contrast-enhanced CT findings could predict OS (P = .035); however, posttreatment PET/CT findings could not predict OS (P = .067). PET/CT depicts additional sites compared with contrast-enhanced CT and results in upstaging of disease. Either PET/CT or contrast-enhanced CT may be used for response assessment and prognostication in stage III or IV nonlymphoblastic pediatric NHL.

• Treatment of Chronic Hepatits due to Hepatitis Virus C (CH-C) in India: A Randomized Controlled Trial Comparing Daily Interferon-alfa-2b and Ribavirin with Daily Interferon-alfa-2b and Glycyrrhizin—A Multicenter Study

  Acharya SK, Sreenivas V, Datta Gupta S, Shakti Kumar, Chawla YK, Tandon A, AejaZ Habeeb, Kar P, Chowdhury A, Choudhury G, Sarin SK, Amarapurkar DN, Arankalle V, Gupte MD, Sushma Gupta, Deepali Mukherjee, Divya Seth, Rohit Goel, Tandon BN

  Journal of Clinical and Experimental Hepatology. 03/2012; 2(1-2):10-18.

  Background and Aim: Pegylated-interferon-alfa (PEG-IFN-a) with ribavirin is an established treatment in chronic hepatitis due to hepatitis C virus (HCV) (CH-C). Such treatment is expensive and in resource-poor countries such as India, alternative less expensive therapy is needed. Methods: Multicente... [more] Background and Aim: Pegylated-interferon-alfa (PEG-IFN-a) with ribavirin is an established treatment in chronic hepatitis due to hepatitis C virus (HCV) (CH-C). Such treatment is expensive and in resource-poor countries such as India, alternative less expensive therapy is needed. Methods: Multicenter randomized controlled trial comparing two treatment regimens (interferon-alfa-2b [IFN-a-2b] 3 million unit/day [MU/day] and ribavirin 1000 mg/day [I + R] vs IFN-a-2b 3 MU/day and glycyrrhizin 250 mg [I + G]) in CH-C. Viral, host characteristics and therapeutic responses were assessed (ICMR—6 months trial for chronic hepatitis—CTRI/2008/091/000105). Results: One hundred and thirty-one patients meeting the inclusion criteria were randomized to I + G (n = 64) or I + R (n = 67) during the period February 2002 to May 2005. About 85% (I + G = 53, I + R = 58) completed 6 months of treatment and 89% of them (I + G = 46, I + R = 53) completed 6 months of follow-up after completion of treatment. Hepatitis C virus genotype 3 was the major type detected (71% patients). The mean log10 viral load (copies/mL), histological activity index, and fibrosis stage for all patients were 5.1 ± 0.98, 5 ± 2, and 2 ± 1.5, respectively. Sustained viral response (SVR) was significantly higher in I + R group than in I + G group (65.7% vs 46.9%, OR = 2.2, P = 0.03). Treatment with I + G was associated with significantly lower frequencies of leukopenia (2% vs 17%, P < 0.01) and anemia (8% vs 40%, P < 0.001) as compared to treatment with I + R. Conclusion: Genotype 3 HCV infection with low viral load is prevalent in India. Daily IFN with ribavirin showed significantly better responses. Leukopenia and anemia were significantly more in ribavirin group. Responses observed with IFN + ribavirin were similar to the reported response rates with PEG-IFN suggesting that this modality may be considered as a cheaper alternative of treatment for chronic hepatitis C. ( J CLIN EXP HEPATOL 2012;2:10–18)

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• 2.67

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  Prevalence of psychiatric morbidity at Mobile Health Clinic in an urban community in North India.

  Harshal Salve, Kiran Goswami, Baridalyne Nongkynrih, Rajesh Sagar, V Sreenivas

  General hospital psychiatry. 03/2012; 34(2):121-6.

  The objective was to estimate the prevalence of psychiatric morbidity amongst patients attending Mobile Health Clinic (MHC) in an urban community in South Delhi. Adult subjects were recruited by systematic random sampling at outpatient MHC. Primary Care Evaluation of Mental Disorder Patient Health Q... [more] The objective was to estimate the prevalence of psychiatric morbidity amongst patients attending Mobile Health Clinic (MHC) in an urban community in South Delhi. Adult subjects were recruited by systematic random sampling at outpatient MHC. Primary Care Evaluation of Mental Disorder Patient Health Questionnaire (PHQ) was used for screening, and Mini International Neuropsychiatric Interview (M.I.N.I.) was used for the confirmation of diagnosis of psychiatric disorder of all PHQ-positive and 20% of PHQ-negative patients. Association of selected sociodemographic factors with psychiatric morbidity was also assessed. In total, 350 subjects were recruited, out of which 92 (26.3%) [95% confidence interval (CI) 21.7-31.0] were found to be PHQ positive. M.I.N.I. was administered to 141 subjects (92 PHQ positives and 52 PHQ negatives). Total estimated magnitude of psychiatric morbidity by M.I.N.I. was 25.4% (95% CI 20.9-29.9). Depression (15.7%) was observed to be the most common psychiatric disorder followed by generalized anxiety disorder (11.1%) and phobic disorders (10.1%). Suicidal ideation was reported by 37 (10.6%) patients. Literate status [odds ratio (OR)=0.43] and duration of migration >20 years to study area (OR=1.27) were found to be significantly associated with psychiatric morbidity. In resource-poor country like India, high psychiatric morbidity at MHC justifies the use of MHC for providing outreach mental health services in difficult areas.

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• Palliative stenting with or without radiotherapy for inoperable esophageal carcinoma: a randomized trial.

  Amit Javed, Sujoy Pal, Nihar Ranjan Dash, Vineet Ahuja, Bidhu Kalyan Mohanti, Sreenivas Vishnubhatla, Peush Sahni, Tushar Kanti Chattopadhyay

  Journal of gastrointestinal cancer. 03/2012; 43(1):63-9.

  A majority of patients with esophageal cancer present with inoperable disease and require rapid and long-lasting palliation of dysphagia. To compare the duration of relief of dysphagia in patients with inoperable esophageal cancer treated with esophageal stenting alone or a combination of esophageal... [more] A majority of patients with esophageal cancer present with inoperable disease and require rapid and long-lasting palliation of dysphagia. To compare the duration of relief of dysphagia in patients with inoperable esophageal cancer treated with esophageal stenting alone or a combination of esophageal stenting and external beam radiotherapy (EBRT), and to assess overall survival, treatment-related complications, and quality of life (QOL) in the two groups. Patients with inoperable esophageal cancer and with high grade dysphagia were randomized to receive esophageal stenting with self-expandable metal stent (Ultraflex) alone (Group I), versus a combination of stenting followed by EBRT (30 gray in ten divided fractions over 2 weeks) (Group II). Dysphagia relief, overall survival, QOL (using European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30, version 3), and treatment-related complications were assessed in the two groups. From April 2007 to March 2009, 84 patients were randomized to receive esophageal stent alone (42 patients) or a combination of stent and EBRT (42 patients). The two groups were comparable in demographics, tumor characteristics, indications for palliative treatment, and pretreatment dysphagia score. Dysphagia scores improved significantly in both groups following stent insertion. However, dysphagia relief was more sustained in Group II than in Group I (7 vs. 3 months, p = 0.002). Overall median survival was significantly higher in Group II than in Group I (180 vs. 120 days, p = 0.009). Addition of radiotherapy following stenting prolonged the mean dysphagia-free survival (118.6 ± 55.8 vs. 96.8 ± 43.0 days, p = 0.054). There was significant improvement in all QOL parameters at 1 week after stenting. The QOL, however, significantly declined immediately after radiotherapy. There was no treatment-related mortality, and the incidence of complications was similar in the two groups. Post-stenting EBRT effectively prolongs duration of dysphagia relief and improves overall survival in inoperable esophageal cancer.
• 3.20

  Impact points

  Prevalence and progression of basal ganglia calcification and its pathogenic mechanism in patients with idiopathic hypoparathyroidism.

  Ravinder Goswami, Raju Sharma, Vishnubhatla Sreenivas, Nandita Gupta, Arthi Ganapathy, Sathi Das

  Clinical endocrinology. 01/2012;

  BACKGROUND: The pathogenesis of basal ganglia calcification (BGC) in hypoparathyroidism is not clear. Its occurrence in hypocalcaemic milieu of hypoparathyroidism is believed to be due to high serum calcium-phosphorus product and poor calcium control. OBJECTIVE: To report details of BGC in patients ... [more] BACKGROUND: The pathogenesis of basal ganglia calcification (BGC) in hypoparathyroidism is not clear. Its occurrence in hypocalcaemic milieu of hypoparathyroidism is believed to be due to high serum calcium-phosphorus product and poor calcium control. OBJECTIVE: To report details of BGC in patients with idiopathic hypoparathyroidism (IH) and factors determining its progression during follow up. METHOD: Clinical, biochemical characteristics and a meningioma-expressed-antigen-6 (MGEA6) gene polymorphism were analyzed in 145 patients with IH, recruited since 1998, to determine the factors associated with BGC. Progression of BGC and its relationship with metabolic control of serum calcium, phosphorus, serum 25(OH)D and 1,25(OH)(2) D were assessed after a mean of 6.9 ± 3.5 yrs in 49 of them. RESULTS: BGC was present in 73.8% (95% CI: 66.6%-81.0%) of subjects affecting the globus pallidus (68.8%) putamen (55.9%) and caudate nucleus (54.8%). The other sites calcified were grey-white-junction (39.8%), cerebellar parenchyma (31.2%), thalamus (29.0%) and dentate nuclei (24.7%). Parkinsonism and dystonic symptoms were present in three cases. Presence of BGC at presentation was associated with calcification of the choroid plexus, cataract and an increased risk of seizures but not tetany. Progression of BGC during follow-up was related to calcium-phosphorus ratio. For every 1% increase in this ratio the odds of progression decreased by 5% (OR: 0.95, 95% CI: 0.93-0.99, P<0.001). A MGEA6 polymorphism, serum 25(OH)D and 1,25(OH)(2) D did not affect progression of BGC. CONCLUSION: BGC occurs in 73.8% of patients with IH and correlates with the duration of hypocalcaemia, choroid plexus calcification, seizures and cataract. Progression of BGC is related to the calcium-phosphorus ratio during follow up. This brings forth the importance of adequate phosphorus control in the management of hypoparathyroidism. © 2012 Blackwell Publishing Ltd.

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• 1.83

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  An aetiological & clinicopathological study on cutaneous vasculitis

  Pooja Khetan, Sethuraman Gomathy, Khiatan BK, Sharma VK, Rajeeva Gupta, Dinda AK, Sreenivas V, Singh MK

  The Indian journal of medical research. 01/2012;
• 1.83

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  Bone mineral density in patients of Graves disease pre- & post-treatment in a predominantly vitamin D deficient population.

  Viveka P Jyotsna, Abhay Sahoo, Singh Achouba Ksh, V Sreenivas, Nandita Gupta

  The Indian journal of medical research. 01/2012; 135:36-41.

  Hyperthyroidism causes bone loss, and its treatment may restore bone mass, however, concomitant vitamin D deficiency may prevent this. We undertook this study to measure the bone mineral density (BMD) 25 (OH) vitamin D levels in patients with Graves disease in our population which is predominently v... [more] Hyperthyroidism causes bone loss, and its treatment may restore bone mass, however, concomitant vitamin D deficiency may prevent this. We undertook this study to measure the bone mineral density (BMD) 25 (OH) vitamin D levels in patients with Graves disease in our population which is predominently vitamin D deficient and how we change with when patients become euthyroid. The biochemical, thyroid functions, serum vitamin D levels and BMD were estimated in 80 consecutive patients with Graves and 80 euthyroid controls. Patients were treated and rendered euthyroid. Fifty four completed one year, and 27 completed two years of follow up. Patients had significant reduced BMD during hyperthyroid state compared to normal healthy controls. The mean vitamin D levels at baseline were in the insufficient range both patients (12.67 ± 6.24 ng/ml) and controls (10.99 ± 7.05 ng/ml). The BMD improved at all sites with antithyroid treatment. But, the BMD adjusted for body mass index (BMI) and age at all sites showed significant decrease with time. Age and body mass index positively correlated with BMD. There was improvement in absolute BMD of patients at one and two years of follow up. When the BMD was adjusted for age and BMI, there was a decrease in BMD at one year which was less in the second year including that the damage in BMD caused by thyroid hormone excess is not made up even after two years of patient being euthyroid. Whether vitamin D replacement would change this needs to be studied.

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• 47.05

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  CPAP for the metabolic syndrome in patients with obstructive sleep apnea.

  Surendra K Sharma, Swastik Agrawal, Deepak Damodaran, Vishnubhatla Sreenivas, Tamilarasu Kadhiravan, Ramakrishnan Lakshmy, Priya Jagia, Atin Kumar

  The New England journal of medicine. 12/2011; 365(24):2277-86.

  Obstructive sleep apnea is associated with an increased prevalence of the metabolic syndrome and its components. It is unclear whether treatment of obstructive sleep apnea syndrome with continuous positive airway pressure (CPAP) would modify these outcomes. In our double-blind, placebo-controlled tr... [more] Obstructive sleep apnea is associated with an increased prevalence of the metabolic syndrome and its components. It is unclear whether treatment of obstructive sleep apnea syndrome with continuous positive airway pressure (CPAP) would modify these outcomes. In our double-blind, placebo-controlled trial, we randomly assigned patients with obstructive sleep apnea syndrome to undergo 3 months of therapeutic CPAP followed by 3 months of sham CPAP, or vice versa, with a washout period of 1 month in between. Before and after each intervention, we obtained measurements of anthropometric variables, blood pressure, fasting blood glucose levels, insulin resistance (with the use of homeostasis model assessment), fasting blood lipid profile, glycated hemoglobin levels, carotid intima-media thickness, and visceral fat. The metabolic syndrome was defined according to National Cholesterol Education Program Adult Treatment Panel III criteria, with Asian cutoff values for abdominal obesity. A total of 86 patients completed the study, 75 (87%) of whom had the metabolic syndrome. CPAP treatment (vs. sham CPAP) was associated with significant mean decreases in systolic blood pressure (3.9 mm Hg; 95% confidence interval [CI], 1.4 to 6.4; P=0.001), diastolic blood pressure (2.5 mm Hg; 95% CI, 0.9 to 4.1; P<0.001), serum total cholesterol (13.3 mg per deciliter; 95% CI, 5.3 to 21.3; P=0.005), non-high-density lipoprotein cholesterol (13.3 mg per deciliter; 95% CI, 4.8 to 21.8; P=0.009), low-density lipoprotein cholesterol (9.6 mg per deciliter; 95% CI, 2.5 to 16.7; P=0.008), triglycerides (18.7 mg per deciliter; 95% CI, 4.3 to 41.6; P=0.02), and glycated hemoglobin (0.2%; 95% CI, 0.1 to 0.4; P=0.003). The frequency of the metabolic syndrome was reduced after CPAP therapy (reversal found in 11 of 86 patients [13%] undergoing CPAP therapy vs. 1 of 86 [1%] undergoing sham CPAP). Accelerated hypertension developed 1 patient receiving CPAP therapy first, intolerance to CPAP developed in 2 others, and another patient declined to continue sham CPAP. In patients with moderate-to-severe obstructive sleep apnea syndrome, 3 months of CPAP therapy lowers blood pressure and partially reverses metabolic abnormalities. (Funded by Pfizer; ClinicalTrials.gov number, NCT00694616.).

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• 1.83

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  Genital mycoplasma & Chlamydia trachomatis infections in treatment naïve HIV-1 infected adults.

  Arnab Ghosh, Benu Dhawan, Rama Chaudhry, Madhu Vajpayee, Vishnubhatla Sreenivas

  The Indian journal of medical research. 12/2011; 134(6):960-6.

  Sexually transmitted infections (STIs) enhance the transmission of human immunodeficiency virus (HIV). Thus, screening for STIs is a routine component of primary HIV care. There are limited data for selective screening guidelines for genital mycoplasmas and Chlamydia trachomatis in HIV-infected adul... [more] Sexually transmitted infections (STIs) enhance the transmission of human immunodeficiency virus (HIV). Thus, screening for STIs is a routine component of primary HIV care. There are limited data for selective screening guidelines for genital mycoplasmas and Chlamydia trachomatis in HIV-infected adults. The aim of the present study was to determine the frequency of genital infections with Ureaplasma spp., Mycoplasma hominis, M. genitalium and C. trachomatis in treatment naïve asymptomatic HIV-1 - infected adults and study their association with CD4+ T-cell count. First-void urine samples were collected from 100 treatment-naïve HIV-1-infected adults and 50 healthy volunteers. C. trachomatis and M. genitalium were detected by polymerase chain reaction (PCR). Ureaplasma spp. and M. hominis were detected by both culture and PCR. Circulating CD4+ cell counts of HIV-1-infected patients were determined from peripheral blood by flow-cytometry. C. trachomatis was detected in 7 per cent of HIV-1-infected adults compared to none in control population. Ureaplasma spp. and M. hominis showed infection rates of 6 and 1 per cent in the HIV group and 2 and 0 per cent in the control group, respectively. None of the individuals from the patient and control groups was tested positive for M. genitalium. A significant association was found between CD4 cell count and detection of C. trachomatis in HIV-infected adults (P = 0.01). Screening of HIV-infected individuals for C. trachomatis infection could be recommended as a routine component of HIV care. The role of mycoplasmas as co-pathogens of the genitourinary tract in HIV-1 infected patients seems to be unlikely. Further longitudinal studies need to be done to confirm these findings.

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• 1.02

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  Oral voriconazole versus intravenous low dose amphotericin B for primary antifungal prophylaxis in pediatric acute leukemia induction: a prospective, randomized, clinical study.

  Sushil Mandhaniya, Chetanya Swaroop, Sanjay Thulkar, Sreenivas Vishnubhatla, Sushil K Kabra, Immaculata Xess, Sameer Bakhshi

  Journal of pediatric hematology/oncology. 12/2011; 33(8):e333-41.

  Invasive fungal infections (IFI) are a major cause of infection-related mortality during induction chemotherapy of acute leukemia (AL) patients. Data on antifungal prophylaxis (AFP) in children are limited by retrospective design, small sample size, and variability of chemotherapy phases having diff... [more] Invasive fungal infections (IFI) are a major cause of infection-related mortality during induction chemotherapy of acute leukemia (AL) patients. Data on antifungal prophylaxis (AFP) in children are limited by retrospective design, small sample size, and variability of chemotherapy phases having different risk of IFI. There are no data comparing voriconazole versus amphotericin B (AmB) as AFP in either adult/pediatric AL. The objectives of this study were to compare efficacy and toxicity of AmB and voriconazole as AFP in pediatric AL patients. As a pilot study, total 100 children (≤15 y) with denovo acute myeloid leukemia and acute lymphoblastic leukemia were randomized to either oral voriconazole or low dose intravenous AmB as AFP during induction chemotherapy. Failure of prophylaxis occurred in 14/50 patients in voriconazole arm (1 proven mucormycosis, 1 possible IFI, 11 empirical antifungal therapy, and 1 withdrawal owing to hepatotoxicity) and 17/50 patients in AmB arm (3 possible IFI, 13 empirical antifungal therapy, and 1 withdrawal owing to difficult venous access) (P=0.66). Of the 29 patients who had failure of prophylaxis unrelated to drug toxicity, computed tomography of the chest showed infiltrates in 10 patients with 3/12 in voriconazole arm and 7/16 in AmB arm (P=0.43). Drug-related serious adverse events were 6% versus 30% in voriconazole and AmB arms, respectively (P<0.01). Further, total number of toxicities per patient in AmB arm were significantly higher as compared with voriconazole arm (P<0.0001). This is the first randomized study comparing voriconazole with AmB in pediatric AL patients as AFP during induction chemotherapy; our results showed that oral voriconazole seems to be comparable with AmB with less toxicity and more convenience. (ClinicalTrials.gov identifier: NCT00624143).
• 1.83

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  Prevalence of metabolic syndrome in a north Indian hospital-based population with obstructive sleep apnoea.

  Swastik Agrawal, Surendra K Sharma, Vishnubhatla Sreenivas, Ramakrishnan Lakshmy

  The Indian journal of medical research. 11/2011; 134(5):639-44.

  Obstructive sleep apnoea (OSA) is known to be associated with cardiovascular risk factors and metabolic syndrome (MS). The burden of MS in patients with OSA in India is unknown. We investigated the prevalence of MS and its components in a cross-sectional study in patients with and without OSA in a h... [more] Obstructive sleep apnoea (OSA) is known to be associated with cardiovascular risk factors and metabolic syndrome (MS). The burden of MS in patients with OSA in India is unknown. We investigated the prevalence of MS and its components in a cross-sectional study in patients with and without OSA in a hospital-based population of a tertiary health care centre in New Delhi, India. Consecutive patients undergoing overnight polysomnography in the Sleep Laboratory of the Department of Internal Medicine of All India Institute of Medical Sciences (AIIMS) hospital, New Delhi, were studied. Anthropometry and body composition analysis, blood pressure (BP), fasting blood glucose, insulin resistance by homeostasis model assessment (HOMA-IR) and fasting blood lipid profile were measured. MS was defined using the National Cholesterol Education Program Adult treatment panel III criteria, with Asian cut-off values for abdominal obesity. Of the 272 subjects recruited, 187 (82%) had OSA [apnoea-hypopnoea index (AHI)>5 events/h] while 40 (18%) had a normal sleep study. Prevalence of MS in OSA patients was 79 per cent compared to 48 per cent in non-OSA individuals [OR 4.15, (2.05-8.56), P<0.001]. Prevalence of OSA in mild, moderate and severe OSA was 66, 72 and 86 per cent, respectively (P<0.001). Patients with OSA were more likely to have higher BP [OR: 1.06 (1.02-1.11)], fasting insulin [OR: 1.18 (1.05-1.32)], HOMA-IR [OR: 1.61 (1.11-2.33)] and waist circumference [OR: 1.20 (1.13-1.27)]. Our findings suggest that OSA is associated with a 4-fold higher occurrence of MS than patients without OSA. The prevalence of MS increases with increasing severity of OSA, therefore, early detection will be beneficial.

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• 4.26

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  Vitamin D deficiency and rickets in children and adolescents with ichthyosiform erythroderma in type IV and V skin.

  K Chouhan, G Sethuraman, N Gupta, V K Sharma, M Kabra, B K Khaitan, V Sreenivas, M Ramam, S Kusumakar, S Thulkar, A S Paller

  The British journal of dermatology. 10/2011; 166(3):608-15.

  Background  Ichthyosiform erythroderma due to keratinizing disorders may suppress cutaneous vitamin D synthesis, leading to vitamin D deficiency and rickets. Objectives  To determine the prevalence of vitamin D deficiency and rickets in children and adolescents with congenital ichthyosis and other k... [more] Background  Ichthyosiform erythroderma due to keratinizing disorders may suppress cutaneous vitamin D synthesis, leading to vitamin D deficiency and rickets. Objectives  To determine the prevalence of vitamin D deficiency and rickets in children and adolescents with congenital ichthyosis and other keratinizing disorders with erythroderma and scaling. Patients and methods  In this cross-sectional study, 45 children and adolescents with ichthyosiform erythroderma due to keratinizing disorders, and 66 controls (group 1: age and sex matched, with skin diseases other than keratinizing disorders; group 2: age and sex matched, healthy volunteers) were included. Evidence of rickets was determined clinically (physical examination and radiographs) and biochemically {serum calcium, phosphorus, alkaline phosphatase, 25-hydroxy vitamin D [25(OH)D] and parathyroid hormone (PTH)}. Results  All patients in the disease group had clinical, radiological or biochemical evidence of rickets [25(OH)D < 20 ng mL(-1) ], and analysis was done for all subjects with the available biochemical reports. The mean serum 25(OH)D levels of the disease group was 8·38 ± 5·23 ng mL(-1) and was significantly lower than in control group 1 (11·1 ± 5·8 ng mL(-1) ) (P < 0·01) and control group 2 (13·5 ± 6·9 ng mL(-1) ) (P < 0·001). The prevalence of vitamin D deficiency [25(OH)D < 20 ng mL(-1) ] was significantly higher in the disease group (n = 38 of 39, 97·4%) than in control group 2 (n = 12, 70·6%) (P < 0·01), and total controls (n = 56, 84·8%) (P = 0·04). The frequency of hyperparathyroidism (PTH > 65 pg mL(-1) ) was also significantly higher in the disease group than in controls (P < 0·01). Conclusions  Children and adolescents with various forms of ichthyosiform erythroderma, especially those with pigmented skin (types IV-VI), are at increased risk of developing vitamin D deficiency and clinical rickets.

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• 1.02

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  Prediction of chemotherapy response by PET-CT in osteosarcoma: correlation with histologic necrosis.

  Jyoti Bajpai, Rakesh Kumar, Vishnubhatla Sreenivas, Mehar Chand Sharma, Shah Alam Khan, Shishir Rastogi, Arun Malhotra, Shivanand Gamnagatti, Rajender Kumar, Rajni Safaya, Sameer Bakhshi

  Journal of pediatric hematology/oncology. 10/2011; 33(7):e271-8.

  The current standard for neoadjuvant chemotherapy (NACT) response evaluation in osteosarcoma is histopathologic necrosis (HN). However, it is accessible only after NACT completion and may get affected by confounding factors. Thus, noninvasive surrogate such as (18)Fluorine-Fluorodeoxyglucose-positro... [more] The current standard for neoadjuvant chemotherapy (NACT) response evaluation in osteosarcoma is histopathologic necrosis (HN). However, it is accessible only after NACT completion and may get affected by confounding factors. Thus, noninvasive surrogate such as (18)Fluorine-Fluorodeoxyglucose-positron emission tomography-computerized tomography (PET-CT) scan would be useful to individualize therapy. Thirty-one treatment naive osteosarcoma patients evaluated prospectively by PET-CT scan preceding and after 3 cycles of NACT and surgery during 2006 to 2008. Various anatomic and metabolic parameters of PET-CT scan were compared with HN (good response ≥90% HN) as reference standard. Receiver operating characteristic curves were generated to assess the best threshold and predictability. Median age was 17 years; 25 were male patients and 23 were nonmetastatic. Ten cases were good, whereas 21 cases were poor histologic responders. PET-CT parameters including post-NACT (2) and pre-NACT (1) standard uptake value (SUV)max ratio (SUV2:SUV1), SUV2, pre-NACT and post-NACT volumes (V1and V2), change in V after NACT, pre-NACT and post-NACT metabolic burden (MB) and change in MB after NACT correlated with HN. Two independent predictors were identified in stepwise multivariable analysis; if V1 ≤300 mL and SUV2:SUV1 ≤0.48, observed good histologic response proportions was 83%, whereas if V1 >300 mL and SUV2:SUV1 >0.48, it was 0%. NACT response can be predicted reliably by PET-CT scan early in disease course (even at baseline) and PET-CT parameters correlate well with HN. MB seems to be sensitive substitute for response evaluation. Independent predictors may have wider clinical applications if further validation can be done.
• 2.13

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  Clinical predictors of high risk histopathology in retinoblastoma.

  Seema Kashyap, Rachna Meel, Neelam Pushker, Seema Sen, Sameer Bakhshi, Vishnubhatla Sreenivas, Sumita Sethi, Bhavna Chawla, Supriyo Ghose

  Pediatric blood & cancer. 06/2011; 58(3):356-61.

  Previous studies show that clinical features at presentation, in retinoblastoma patients, like glaucoma and neovascularization of iris are associated with a higher incidence of high risk histopathology findings (HRF) in enucleated eyes. Herein, we analyze association between clinical features at tim... [more] Previous studies show that clinical features at presentation, in retinoblastoma patients, like glaucoma and neovascularization of iris are associated with a higher incidence of high risk histopathology findings (HRF) in enucleated eyes. Herein, we analyze association between clinical features at time of enucleation and occurrence of HRF including invasion of anterior chamber, iris, ciliary body, choroid (massive), sclera, extrascleral tissue, optic nerve beyond lamina cribrosa, and optic nerve cut end, in a large series of eyes enucleated for retinoblastoma. We retrospectively studied demographic, clinical, and histopathology findings in all retinoblastoma patients who underwent primary enucleation at our center, over a 5 years duration. Statistical analysis was done to find any association between clinical features at presentation and the presence of HRF. Three hundred twenty-six eyes were studied. Median age of presentation was 2 years. Glaucoma was the most common clinical finding at presentation apart from leucocoria. Out of 326 enucleated eyes, 28 (8.6%) had extrascleral and/or optic nerve transection invasion. Among remaining 298 eyes, with completely resected tumor, 115 (38.6%) had massive choroidal invasion, 54 (17%) had retrolaminar optic nerve invasion, and 24 (7%), 29 (9%), and 23(7%) had anterior chamber, iris, and ciliary body invasion, respectively. Age more than 2 years, lag period more than 3 months, hyphema, pseudohypopyon, staphyloma, and orbital cellulitis were associated with occurrence of three or more HRF on univariate analysis. Clinical variables including older age, longer lag period, hyphema, pseudohypopyon, staphyloma, and orbital cellulitis were strongly associated with occurrence of HRF in this study.

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• 2.36

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  Stepped approach for prediction of syndrome Z in patients attending sleep clinic: a north Indian hospital-based study.

  Swastik Agrawal, Surendra Kumar Sharma, Vishnubhatla Sreenivas, Ramakrishnan Lakshmy, Hemant K Mishra

  Sleep & breathing = Schlaf & Atmung. 06/2011;

  PURPOSE: Syndrome Z is the occurrence of metabolic syndrome (MS) with obstructive sleep apnea. Knowledge of its risk factors is useful to screen patients requiring further evaluation for syndrome Z. METHODS: Consecutive patients referred from sleep clinic undergoing polysomnography in the Sleep Labo... [more] PURPOSE: Syndrome Z is the occurrence of metabolic syndrome (MS) with obstructive sleep apnea. Knowledge of its risk factors is useful to screen patients requiring further evaluation for syndrome Z. METHODS: Consecutive patients referred from sleep clinic undergoing polysomnography in the Sleep Laboratory of AIIMS Hospital, New Delhi were screened between June 2008 and May 2010, and 227 patients were recruited. Anthropometry, body composition analysis, blood pressure, fasting blood sugar, and lipid profile were measured. MS was defined using the National Cholesterol Education Program (adult treatment panel III) criteria, with Asian cutoff values for abdominal obesity. RESULTS: Prevalence of MS and syndrome Z was 74% and 65%, respectively. Age, percent body fat, excessive daytime sleepiness (EDS), and ΔSaO(2) (defined as difference between baseline and minimum SaO(2) during polysomnography) were independently associated with syndrome Z. Using a cutoff of 15% for level of desaturation, the stepped predictive score using these risk factors had sensitivity, specificity, positive predictive value, and negative predictive value of 75%, 73%, 84%, and 61%, respectively for the diagnosis of syndrome Z. It correctly characterized presence of syndrome Z 75% of the time and obviated need for detailed evaluation in 42% of the screened subjects. CONCLUSIONS: A large proportion of patients presenting to sleep clinics have MS and syndrome Z. Age, percent body fat, EDS, and ΔSaO(2) are independent risk factors for syndrome Z. A stepped predictive score using these parameters is cost-effective and useful in diagnosing syndrome Z in resource-limited settings.
• 3.01

  Impact points

  Burden of healthcare-associated infections in a paediatric intensive care unit of a developing country: a single centre experience using active surveillance.

  A Gupta, A Kapil, R Lodha, S K Kabra, S Sood, B Dhawan, B K Das, V Sreenivas

  The Journal of hospital infection. 06/2011; 78(4):323-6.

  Healthcare-associated infections (HAIs) are an important cause of morbidity and mortality among critically ill patients of all age groups. This prospective surveillance study was performed to estimate the burden of HAIs in a paediatric intensive care unit (PICU) of a developing country. During the 1... [more] Healthcare-associated infections (HAIs) are an important cause of morbidity and mortality among critically ill patients of all age groups. This prospective surveillance study was performed to estimate the burden of HAIs in a paediatric intensive care unit (PICU) of a developing country. During the 12-month study, 187 patients were treated in the PICU for ≥48h, of whom 36 patients had 44 episodes of HAIs. The crude infection rate and incidence density (ID) of HAI were 19.3/100 patients and 21/1,000 patient-days, respectively. Of the 44 episodes of HAI, 27 (61%) were healthcare-associated pneumonia (HAP), 12 (27%) were bloodstream infections (HA-BSI) and four (9%) were urinary tract infections. Mean length of stay and mortality were significantly higher in patients who developed an HAI [25 vs 7 days (P<0.0001) and 50% vs 27.8% (P<0.005), respectively]. Acinetobacter spp. were the commonest infecting bacteria in both HAP and HA-BSI. For developing countries, active surveillance is essential to reduce the burden of HAIs in high risk groups.
• 2.92

  Impact points

  Hodgkin's lymphoma--long-term outcome: an experience from a tertiary care cancer center in North India.

  Prasanth Ganesan, Lalit Kumar, Vinod Raina, Atul Sharma, Sameer Bakhshi, Vishnubhatla Sreenivas, Malini Vijayaraghavan, Sanjay Thulkar

  Annals of hematology. 05/2011; 90(10):1153-60.

  Limited information is available from developing countries on long-term outcome of patients with Hodgkin's lymphoma (HL). Between January 1998 and December 2005, 262 patients (age ≥15 years) underwent treatment. Patients' median age was 30 years, ranging from 15 to 72 years. Male to female r... [more] Limited information is available from developing countries on long-term outcome of patients with Hodgkin's lymphoma (HL). Between January 1998 and December 2005, 262 patients (age ≥15 years) underwent treatment. Patients' median age was 30 years, ranging from 15 to 72 years. Male to female ratio was 2.8:1. B symptoms were present in 64% of patients. Seventy percent of patients had stage III and IV disease. Mixed cellularity (52.3%) was the most common histology followed by nodular sclerosis (38%). ABVD chemotherapy was used in 85% of the patients, and 50% received radiotherapy as consolidation. Following treatment 92% of patients achieved complete response. Five-year freedom from treatment failure (FFTF) and overall survival rate are 78.3% and 86.6% ± 0.02% (95% CI 80.0-93.2%), respectively. Stage at presentation, number of lymph node regions involved (≥3 vs ≤2), presence of B symptoms, and serum albumin (≥40 vs <40 g/L) were important determinants of FFTF. In a subset analysis of stage I and II HL patients, presence of bulky disease and pure infradiaphragmatic disease was associated with inferior outcome. On multivariate analysis involvement of three or more number of lymph node regions was a significant predictor of inferior freedom from treatment failure survival (hazard ratio 2.2, p < 0.01). Our analysis confirms excellent outcome for patients of Hodgkin's lymphoma with results comparable to developed countries.
• 0.75

  Impact points

  Comparison of alert verbal painful unresponsiveness scale and the Glasgow Coma Score.

  Shomi Raman, V Sreenivas, J M Puliyel, Nirmal Kumar

  Indian pediatrics. 04/2011; 48(4):331-2.

  To determine how the AVPU (alert, verbal, painful, unresponsiveness) scale corresponds to Glasgow Coma Score (GCS), we compared the two scales. Two months to 12 years old patients were included in the study. The median GCS score (inter quartile range) for A/V/P/U were 14 (12-15), 11 (10-12), 6 (5.5-... [more] To determine how the AVPU (alert, verbal, painful, unresponsiveness) scale corresponds to Glasgow Coma Score (GCS), we compared the two scales. Two months to 12 years old patients were included in the study. The median GCS score (inter quartile range) for A/V/P/U were 14 (12-15), 11 (10-12), 6 (5.5-8) and 3 (3-4), respectively.

• Trans-arterial chemoembolization (TACE) in patients with unresectable Hepatocellular carcinoma: Experience from a tertiary care centre in India.

  Shashi Bala Paul, Shivanand Gamanagatti, Vishnubhatla Sreenivas, Sheragaru Hanumanhtappa Chandrashekhara, Amar Mukund, Manpreet Singh Gulati, Arun Kumar Gupta, Subrat Kumar Acharya

  The Indian journal of radiology & imaging. 04/2011; 21(2):113-20.

  To evaluate the outcome following transarterial chemoembolization (TACE) and to identify the predictors of survival in patients with unresectable hepatocellular carcinoma (HCC). HCC patients reporting to our hospital (2001-2007) were subjected to clinical, biochemical, and radiological examination. ... [more] To evaluate the outcome following transarterial chemoembolization (TACE) and to identify the predictors of survival in patients with unresectable hepatocellular carcinoma (HCC). HCC patients reporting to our hospital (2001-2007) were subjected to clinical, biochemical, and radiological examination. TACE was performed in those who fulfilled the inclusion criteria. Follow-up assessment was done with multiphase CT scan of the liver at 1, 3, and 6 months. Tumor response and survival rate were estimated. Univariate and multivariate analyses were done for determinants of survival. A total of 73 patients (69 males, 4 females; mean age 49±13.4 years) were subjected to 123 sessions of TACE. The Child's classification was: A - 56 patients and B - 17 patients. Barcelona Clinic staging was: A - 20 patients, B - 38 patients, and C - 15 patients. Tumor size was ≤5cm in 28 (38%) patients, >5-10 cm in 28 (38%) patients, and >10 cm in 17 (23%) patients. Median follow-up was for 12 months (range: 1-77 months). No significant postprocedure complications were encountered. Overall survival rate was 66%, 47%, and 36.4% at 1, 2, and 3 years, respectively. Tumor size emerged as an important predictor of survival. TACE offers a reasonable palliative therapy for HCC. Initial tumor size is an independent predictor of survival.

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• 2.80

  Impact points

  Genotypic variation of Pneumocystis jirovecii isolates in India based on sequence diversity at mitochondrial large subunit rRNA.

  Rashmi Gupta, Bijay Ranjan Mirdha, Randeep Guleria, Sanjay Kumar Agarwal, Jyotish Chandra Samantaray, Lalit Kumar, Sushil Kumar Kabra, Kalpana Luthra, Vishnubhatla Sreenivas, Venkateswaran K Iyer

  International journal of medical microbiology : IJMM. 03/2011; 301(3):267-72.

  Pneumocystis pneumonia (PCP), a common and serious opportunistic infection in immunocompromised patients, is caused by Pneumocystis jirovecii (formerly known as Pneumocystis carinii f. sp. hominis). The aim of the present study was to describe the prevalence and distribution of genotypes of P. jirov... [more] Pneumocystis pneumonia (PCP), a common and serious opportunistic infection in immunocompromised patients, is caused by Pneumocystis jirovecii (formerly known as Pneumocystis carinii f. sp. hominis). The aim of the present study was to describe the prevalence and distribution of genotypes of P. jirovecii based on sequence polymorphisms at mitochondrial large subunit ribosomal RNA (mt LSU rRNA) region in both HIV and non-HIV immunocompromised individuals with a positive PCR result for PCP in a tertiary health care centre in northern India. From January 2005 to October 2008, 50 patients [22 HIV-seropositive individuals, 10 post-renal transplant (PRT) recipients, 3 cancer patients, and 15 patients with various other kinds of immunosuppression] were found to be positive for P. jirovecii using PCR at the mt LSU rRNA gene. Genotyping of the positive samples was performed at the mt LSU rRNA locus. Genotype 2 was the most common accounting for 42% of total types. This was followed by the genotypes 3 (24%), 1 (20%), and 4 (8%). Mixed infection was observed in 3 cases (6%). The rates of genotype distribution were similar in HIV-seropositive individuals, cancer patients, and in patients with other kinds of immunosuppression. In the PRT recipients, genotype 1 was the most prevalent type (80%). This is the first study describing the prevalence of genotypes in HIV-infected and HIV-uninfected, immunocompromised patients based on the mt LSU rRNA gene from the Indian subcontinent. The most prevalent genotype observed was type 2 in contrast to many studies from other parts of the world where genotype 1 was the most prevalent type, suggesting geographical variation.