Pranay Gaikwad’s research while affiliated with Christian Medical College & Hospital and other places

Aims Characteristics of diabetes-related foot ulcers(DFU), association with recurrence and amputation are poorly described in the Asian Indian population. Methods A prospectively maintained database was reviewed to characterize DFU and its association with amputation and recurrence. Results Of 200 patients, 63.5% were male, the median age was 62 years(Min-Max:40-86),and median BMI was 27.90kg/m2(Min-Max:18.5-42.7).Median duration of Diabetes mellitus was 15 years(Min-Max:2-43).Complete healing occurred at a median of three months(Min-Max:0.23-37.62).Amputation for the current ulcer was required in 43.4% of individuals. Ulcer recurrence was documented in 42.4% instances, 66.1% evolving on the ipsilateral side. Previous amputation was associated with the risk of subsequent amputation(Adjusted OR-3.08,p-0.047). Median time to ulcer recurrence was 4.23 years among those with amputation, in contrast to 9.61 years in those with healing. Cardiovascular death was the commonest cause of mortality, followed by sepsis. At a median follow up of 6.08 years, mortality at 1,3,5 and 10 years was 2.5%,2.5%,8.2% and 30.9% respectively among those who underwent amputation versus 0%,0%,10.1% and 24.5% respectively for those who achieved healing. Conclusions Patients with DFU in India incur amputations at rates higher than conventionally described. With previous amputation, subsequent amputation risk triples. Ten-year mortality is 25%-30%. Underestimates of the burden of recurrence and mortality are consequential of limited follow-up.

Epidermodysplasia verruciformis (EV) is a rare autosomal recessive genodermatosis due to mutations in EVER1 and EVER2 genes. The genetic profile of Indian patients with EV has not been previously studied. This report describes the clinical presentation and molecular analysis of a family with EV. Using genomic DNA from two affected probands and healthy controls (two other siblings), conventional polymerase chain reaction (PCR) was conducted with novel primer sets designed to amplify the coding and splice-site regions in the genes EVER1 and EVER 2. This revealed no amplification with a primer set for exons 16 to 18 in the EVER1 gene of both the probands. Subsequently, long-range PCR spanning the length of exon 15-20 and next-generation sequencing demonstrated a homozygous deletion of 2078 bp in the EVER1 gene (EVER1:c.2072_2278del). Screening the family revealed the same homozygous deletion (similar to index cases) in two other affected siblings. The parents and two asymptomatic siblings were heterozygous carriers for the deletion while one healthy sibling was negative. These results were validated with Sanger sequencing. This deletion in exons 17 and 18 of the EVER1 gene results in a frameshift, followed by a premature termination resulting in a severe phenotype. The identification and validation of this large deletion was detected using stepwise amplicon-based target enrichment and long-range PCR, respectively. In this family, this simple strategy greatly enhanced genetic counseling as well as early genetic diagnosis and screening. However, functional assays and larger studies are required to characterize and validate the genetic diversity among Indians with EV.

Oral cancer decreases quality of life despite timely medical management. The carcinogens in tobacco products and their role in tumorigenesis are well documented. Langerhans cells (LCs) are a subset of antigen-presenting cells (APCs) that monitor the tumor microenvironment and engulf carcinogens and foreign bodies. We investigated the distribution and size of LCs and their relation to the mode of tobacco consumption and clinical outcome in patients with buccal carcinoma. We recruited patients with oral cancer who were scheduled for tumor excision and men with urethral stricture undergoing substitution urethroplasty using buccal mucosa. Normal and tumor-adjacent tissues were stained with CD1a antibody. The distribution and mean diameter of 100 LCs/patient were determined. We found significantly smaller LCs in patients who chewed only tobacco compared to those who consumed tobacco by other means. The size of LCs decreased significantly with progressive stages of malignant disease. We found that patients with larger LCs survived longer than those with smaller LCs during an average follow-up of 24 months. We suggest a relation between the size of LCs and clinical outcomes in patients with buccal carcinoma.

To compare inter-rater, intra-rater and inter-system reliability of modified House-Brackmann and Sunnybrook grading systems. The study was conducted in a tertiary care hospital with a single cohort of 20 patients and 3 raters. The patients, eligible to be included for the study, were those over 18 years of age planned for nerve sparing parotidectomy. In the postoperative period, patients were video recorded performing specific movements according to the requirements of modified House-Brackmann and Sunnybrook systems. These recordings were used for the grading once recruitment was completed. The inter-rater, intra-rater and inter-system reliability of modified House-Brackmann and Sunnybrook systems were assessed using the intraclass coefficient. The intra-rater reliability was good-to-excellent for both groups with Intra-Class coefficient (ICC) ranging from 0.902 to 0.958 in modified House-Brackmann and in 0.802 to 0.957 Sunnybrook system. The inter-rater reliability was good-to-excellent with ICC ranging from 0.806 to 0.906 in modified House-Brackmann and 0.766 to 0.860 in Sunnybrook system. The inter-system reliability was good-to-excellent with ICC ranging from 0.892 to 0.937. There was no significant difference in the reliability of modified House-Brackmann and Sunnybrook systems. Thus, an interval scale accomplishes the task of grading facial nerve palsy in a reliable way, and the choice of the specific instrument will be based on other factors like expertise involved, ease of administration and generalisability to the incumbent clinical scenario.

Phyllodes tumour is a rapidly growing neoplasm with a propensity to involve the entire breast tissue. In large tumours, the treatment comprises a wide local excision or a mastectomy. A woman in her 20s from rural India presented with complaints of a recurrent left breast lump. The lump progressed to a large size, limiting her social activities and causing depression. On examination, she had a mass occupying almost the entire left breast, with stretched skin, dilated veins and pressure necrosis. There were no palpable axillary nodes. She was offered a wide local excision and reconstruction with a latissimus dorsi pedicled flap. After much discussion and clarification of some misconceptions around breast reconstruction, she underwent the planned surgery. This was followed by adjuvant radiation therapy as the histopathology was consistent with a complex phyllodes tumour with close margins. She was well at 1-year follow-up and led a good family and social life. Breast conservation and reconstruction are seldom offered as part of cancer treatment in India. All women should be offered surgical options that are oncologically safe while preserving body image, and hence healthcare providers must work towards breaking the barriers that prevent breast reconstruction.

Purpose: Determination of oxygen concentration in tissues affected by chronic venous insufficiency (CVI) has shown inconsistent results over the years and has confounded the pathophysiology of venous diseases. This study measured transcutaneous partial oxygen pressure (TcPO2) levels in patients with CVI to assess oxygenation and variation in oxygenation according to CVI stage. Materials and. Methods: A prospective study was performed on consecutive patients with unilateral CVI. TcPO2 of diseased and unaffected limbs was measured in the supine and dependent positions. A single TcPO2 value was measured at the site of greatest skin change or at the edge of the ulcer. The TcPO2 values were analyzed and compared according to stage. Results: A total of 96 patients were included in the study with C4 (24.0%), C5 (19.8%), and C6 (56.3%) disease. The mean age was 44.7 years, and 85 (88.5%) were male. There was a statistically significant (P<0.01) difference in mean TcPO2 levels between the unaffected limb (supine, 32.1 mmHg; dependent, 50.7 mmHg), C5 diseased limb (supine, 16.6 mmHg; dependent, 35.5 mmHg), and C6 diseased limb (supine, 24.2 mmHg; dependent, 40.4 mmHg). In the supine and dependent positions, the mean TcPO2 in the affected limb was significantly lower (P<0.01) than that in the unaffected limb. Conclusion: TcPO2 in advanced CVI can be used as a marker of oxygenation status. This is the first study in an Indian population looking at the relevance of TcPO2 in the prognostication of advanced CVI.

Myoepithelial neoplasms are rare tumors of the salivary glands with predominant myoepithelial differentiation and a broad histologic spectrum. Their histological features, immunohistochemical profile and biological behavior are not well characterized and pose a diagnostic challenge. A total of 15 myoepithelial tumors, diagnosed during 2012 and 2019 were subcategorized and correlated with MIB-1 labeling index (LI) and various histological parameters. Immunohistochemical stains for MIB-1 and other antibodies were performed. Statistical analysis was done by chi-square test, Fisher's exact test and Kaplan Meier curve. Nine patients were male and six were female with the median age of 44 years (range 21-83 years). Of the 15 patients, 6 cases were classified as myoepithelioma (ME) and 9 cases as myoepithelial carcinoma (MECA). Parotid gland was the most common site (46.7%) followed by the palate. MEs showed well circumscribed tumor borders whereas MECAs exhibited focal capsular to extensive invasion into adjacent tissues. Epithelioid cell morphology was most common followed by mixed cell morphology. MIB-1 LI was significantly associated with invasive tumor borders, necrosis and high mitosis. Increased frequency of recurrence was noted with high MIB-1 LI, though it was not statistically significant. MIB-1 LI was high in nearly all MECAs with focal capsular to extensive invasion while low in MEs. Myoepithelial tumor with multinodular growth pattern and focal capsular invasion may have an indolent behavior if mitotic activity and MIB-1 LI is low. Early diagnosis and treatment of MECAs significantly improves the patient's survival and prognosis.

BACKGROUND Salivary gland diseases are rare but an important group of disorders. Following surgeries involving the parotid gland, facial nerve paresis is a common postoperative complication. The reported worldwide incidence of facial nerve paresis following parotidectomy is approximately 20 - 60 %. We need to determine the incidence of facial nerve paresis in the post-operative period following superficial, adequate, or extra-capsular parotidectomy of benign parotid tumours with the use of intraoperative facial nerve monitoring. METHODS A non-randomised interventional trial was initiated once cleared by the institutional review board. With the calculated sample size of 44, the patients underwent nervemonitoring for the identification of the branches of the facial nerve. Clinical grading of the nerve function was done using the House-Brackmann score on the postoperative days 2, 7, and 60. The findings were compared with the historical controls (HC) of 53 patients who underwent similar procedures but with no intraoperative facial nerve monitoring. All patients were recruited in continuity for over two years. RESULTS The incidence of facial nerve paresis was 30 - 40 % and 10 - 20 % in the historical control and nerve monitoring group, respectively (P = 0.07). The duration of surgery in the nerve monitoring group was 83 ± 30 minutes and 95 ± 15 minutes in the HC group. The incidence of nerve paresis was similar among the trainees and consultants suggestive of adequate training. CONCLUSIONS Intraoperative facial nerve monitoring is a useful adjunct to reduce the incidence of early postoperative facial nerve paresis. The technique would not prolong the duration of the procedure. The technique may be utilized safely on a routine basis even during surgical training.