Sameer Bakhshi

Anti‐emetic effect of ginger powder versus placebo as an add‐on therapy in children and young adults receiving high emetogenic chemotherapy

Chemotherapy‐induced nausea and vomiting (CINV) are major adverse effects of chemotherapy. Ginger has been used in postoperative and pregnancy‐induced nausea and vomiting. Data on its utility in reducing CINV in children and young adults are lacking.

Whole-body MR imaging with the use of parallel imaging for detection of skeletal metastases in pediatric patients with small-cell neoplasms: comparison with skeletal scintigraphy and FDG PET/CT

BackgroundIn pediatric patients with small-cell tumors, there is an increasing demand for accurate and early detection of skeletal, especially bone marrow, metastases as new treatment protocols are introduced. Whole-body MR imaging (WB-MR) and 18F-fluorodeoxyglucose PET/CT (FDG PET/CT) are new promising imaging methods that can detect metastases before osteoblastic host response occurs, which is the basis for detection of metastases by skeletal scintigraphy (SSC).ObjectiveTo assess the ability of WB-MR to detect marrow metastases in children with small-cell neoplasms and compare its performance with that of FDG PET/CT and SSC.Materials and methodsDuring a 16-month period, 26 children and adolescents with histopathologically proven small-cell neoplasms underwent WB-MR, FDG PET/CT and Tc-phosphonate-based SSC in a random order within a 25-day period. Metastases were localized in relation to eight regions of the body.ResultsWB-MR revealed metastases in 39 out of a total of 208 regions in 26 patients (sensitivity 97.5%, specificity 99.4%, positive predictive value 97.5%, negative predictive value 99.4%), SSC in 12 regions (sensitivity 30%, specificity 99.4%, PPV 92.3%, NPV 85.6%) and FDG PET/CT in 36 regions (sensitivity 90.0%, specificity 100%, PPV 100%, NPV 97.7%). Both WB-MR and FDG PET/CT showed excellent agreement (kappa) with the final diagnosis (96.9% and 93.6% respectively), whereas SSC showed only moderate agreement (39.6%).ConclusionOur results suggest that WB-MR and FDG PET/CT studies are robust imaging modalities for screening for skeletal metastases, and are far more accurate than SSC. The lack of radiation is an additional advantage of WB-MR, especially in the pediatric population.

INFECTIONS IN CHILDHOOD ACUTE LYMPHOBLASTIC LEUKEMIA: An Analysis of 222 Febrile Neutropenic Episodes

A retrospective analysis was performed on febrile neutropenic episodes in patients with acute lymphoblastic leukemia (ALL) from 1992 to 2002. There were 222 febrile neutropenic episodes in 266 ALL patients with documented ANC < 500/mm3. Of the 222 episodes, 98 (44%) had documented focus of infection; the rest were fever without focus. There were 274 different sites of infection in the 98 episodes of documented focus of infection; pulmonary infections were the commonest site of infection (27.3%) followed by HEENT (22.9%). Of 69 bacterial isolates, gram-negative bacteria (n = 46, 67%) were twice as common as gram-positive bacteria (n = 23, 33%). Most common site of isolation for gram-negative bacteria was blood (50%) followed by urine (32.6%). Blood (78.3%) was predominant site of isolation of gram-positive bacteria followed by HEENT (8.7%). Escherichia coli (45.7%) was the commonest gram-negative isolate, while Staphylococcus aureus (39%) was the commonest gram-positive bacterial isolate. There were a total of 22 fungal isolates, the majority from urine (n = 12) and HEENT (n = 9). Of the 22 fungal isolates, 19 were detected in induction phase of chemotherapy. A total of 95/222 (42.8%) febrile neutropenic episodes improved with first-line antibiotic therapy, while modification was required in 127 episodes (57.2%). Antifungal therapy was used in 86 episodes (38.7%). There were a total of 13 deaths, 6 each during induction and intensification/consolidation phases, while 1 died during maintenance phase. Of the 13 deaths, 10 had pneumonia, 8 had bacteremia, and 7 had fungal infection. The current study stresses the importance of frequent reviewing of type, frequency, severity, and outcome of infection complications over the years to detect changing epidemiological patterns. The majority of fungal infections were detected during induction chemotherapy, which highlights the need to consider this type of infection in the evaluation of patients.

Role of MRI in osteosarcoma for evaluation and prediction of chemotherapy response: correlation with histological necrosis

BackgroundHistological necrosis, the current standard for response evaluation in osteosarcoma, is attainable after neoadjuvant chemotherapy.ObjectiveTo establish the role of surrogate markers of response prediction and evaluation using MRI in the early phases of the disease.Materials and methodsThirty-one treatment-naïve osteosarcoma patients received three cycles of neoadjuvant chemotherapy followed by surgery during 2006–2008. All patients underwent baseline and post-chemotherapy conventional, diffusion-weighted and dynamic contrast-enhanced MRI. Taking histological response (good response ≥90% necrosis) as the reference standard, various parameters of MRI were compared to it. A tumor was considered ellipsoidal; volume, average tumor plane and its relative value (average tumor plane relative/body surface area) was calculated using the standard formula for ellipse. Receiver operating characteristic curves were generated to assess best threshold and predictability. After deriving thresholds for each parameter in univariable analysis, multivariable analysis was carried out.ResultsBoth pre-and post-chemotherapy absolute and relative-size parameters correlated well with necrosis. Apparent diffusion coefficient did not correlate with necrosis; however, on adjusting for volume, significant correlation was found. Thus, we could derive a new parameter: diffusion per unit volume.ConclusionIn osteosarcoma, chemotherapy response can be predicted and evaluated by conventional and diffusion-weighted MRI early in the disease course and it correlates well with necrosis. Further, newly derived parameter diffusion per unit volume appears to be a sensitive substitute for response evaluation in osteosarcoma.

Hodgkin's disease in Indian children: Outcome with chemotherapy alone

To assess the efficacy of chemotherapy alone, using four cycles of COPP alternating with four cycles of ABVD in all stages of childhood Hodgkins disease (HD).

VEGF expression as a prognostic marker in osteosarcoma.

The vascular endothelial growth factor (VEGF) pathway is the key regulator of angiogenesis. In osteosarcoma baseline VEGF is of proven prognostic value but prognostic potential of post‐NACT VEGF expression is largely unexplored.

Prognostic markers in osteosarcoma

Osteosarcoma is the most common bone tumor seen in the pediatric and adolescent age group. Survival rates in osteosarcoma have improved considerably from 20 to 65% since the 1980s with the advent of multiagent chemotherapy. Further improvement in survival has not been achieved owing to lack of well-validated prognostic markers and better therapeutic agents. Markers involved with angiogenesis, cell adhesion, apoptosis and cell cycle have been shown recently to play an important role in osteosarcoma growth, differentiation and metastasis. Over the coming years, the new molecular markers may be able not only to prognosticate osteosarcoma patients at baseline but also to serve as therapeutic targets and thereby improve survival rates further. Noninvasive imaging methods in osteosarcoma such as PET-CT and dynamic contrast enhanced and diffusion-weighted MRI hold a lot of promise as surrogate methods for prognostication and response assessment.

Vincristine-induced Neuropathy in Childhood ALL (Acute Lymphoblastic Leukemia) Survivors Prevalence and Electrophysiological Characteristics

The prevalence and the burden of vincristine-induced neuropathy have been poorly documented in childhood acute lymphoblastic leukemia survivors. This cross-sectional study was carried out at a tertiary care center in northern India from October 2011 to June 2012. Eighty consecutive acute lymphoblastic leukemia survivors aged 5 to 18 years, within 3 years of completion of their chemotherapy, were enrolled. After clinical evaluation, detailed nerve conduction studies were performed and the reduced version of the Total Neuropathy Score was calculated. The mean age at the time of evaluation was 11.2 ± 3.2 years. 33.75% had neuropathy electrophysiologically. Symmetric motor axonal polyneuropathy was the most common pattern of involvement seen in 19 (23.8%) children. There was significant improvement with time, as revealed by lower prevalence of neuropathy with increasing interval following vincristine injection. 33.75% of the children had Reduced version of Total Neuropathy Score ≥ 1.

Clinical predictors of high risk histopathology in retinoblastoma.

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.

Randomized control trial comparing oral amoxicillin-clavulanate and ofloxacin with intravenous ceftriaxone and amikacin as outpatient therapy in pediatric low-risk febrile neutropenia.

Background Outpatient oral therapy is infrequently used in pediatric low-risk febrile neutropenia (LRFN) as there is insufficient data regarding its equivalence as compared with parenteral therapy. Methods This is a single institutional, randomized control trial in pediatric LRFN aged 2 to 15 years, in which 123 episodes in 88 patients were randomized to outpatient oral ofloxacin 7.5 mg/kg 12 hourly and amoxycillin-clavulanate 12.5 mg/kg 8 hourly or outpatient intravenous (IV) ceftriaxone 75 mg/kg and amikacin 15 mg/kg once daily after blood cultures. Results Out of 119 evaluable episodes, one-third were leukemia patients in maintenance and rest were solid tumors. Success was achieved in 55/61 (90.16%) and 54/58 (93.1%) in oral and IV arms, respectively, (P=0.56). There were 3 hospitalizations but no mortality. Median days to resolution of fever, absolute neutrophil count >500/mm3 and antibiotic use were 3, 5, and 6 days in both arms. There were 5 blood culture isolates (3 gram-positive and 2 gram-negative bacteria). Failure of outpatient therapy was associated with perianal infections, bacteremia, febrile neutropenia onset before day 9 of chemotherapy in solid tumors and Vincristine, actinomycin-D, and cyclophosphamide chemotherapy for rhabdomyosarcoma. All gram-positive isolates were successes, whereas both gram-negative isolates were failures. Diarrhea in IV arm and Vincristine, actinomycin-D, and cyclophosphamide chemotherapy in the oral arm predicted failure in subgroup analysis. Conclusions Outpatient therapy is efficacious and safe in pediatric LRFN. There was no difference in outcome in oral versus IV outpatient therapy. Amoxycillin-clavulanate and ofloxacin may be the oral regimen of choice.