Publications by authors named "Sunesh Kumar"

164 Publications

A Cross-Sectional Analysis to Evaluate Knowledge, Attitude And Practices Among Pregnant Women During COVID-19 Pandemic.

J Obstet Gynaecol India 2021 Sep 4:1-10. Epub 2021 Sep 4.

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.

Objective: To assess knowledge, attitude and practices (KAP) towards COVID-19 among pregnant women at a tertiary care hospital.

Methods: This was a questionnaire-based cross-sectional analysis pertaining to COVID-19 which was conducted at a tertiary care obstetric facility in India among 200 consecutive consenting pregnant women. They were assessed for demographic details and KAP score (knowledge-17 questions, attitude-9 questions and practice-8 questions). Analysis of data was done using Statistical Package for the Social Sciences (SPSS) version 25.0.

Results: The participants had adequate mean knowledge score (± SD) of 22.5 (± 3.5) were following good practices [mean score (± SD) = 15.5 (± 2.6)] and showed positive attitude for preventive measures against COVID-19 [ (%) = 194(96%)]. Low knowledge score (-value 0.030) was seen in non-health care workers.

Conclusion: This study demonstrated that majority of the pregnant women had satisfactory knowledge, positive attitude and were following practices in right manner regarding COVID-19 but continued efforts for generating awareness were warranted. As India is battling the second COVID-19 wave and in the absence of definitive cure, strengthening of health policies directed at pregnant women should be prioritized with special focus on significant gaps in KAP.
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http://dx.doi.org/10.1007/s13224-021-01558-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8416569PMC
September 2021

Youssef's syndrome: diagnosis on MRI.

Int Urogynecol J 2021 Sep 9. Epub 2021 Sep 9.

Department of Radiodiagnosis, AIIMS, New Delhi, 110029, India.

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http://dx.doi.org/10.1007/s00192-021-04971-zDOI Listing
September 2021

Establishing the practice of birth companion in labour ward of a tertiary care centre in India-a quality improvement initiative.

BMJ Open Qual 2021 07;10(Suppl 1)

Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, Delhi, India

Background: Birth companion is a key component for providing respectful maternity care and has been recommended by WHO and Government of India. It is a low-cost beneficial intervention that is vital in improving quality of care during labour and delivery.

Local Problem: Despite the available evidence on benefits of birth companion, there was no policy on allowing birth companion at our hospital in the past.

Methods And Interventions: We aimed to establish the practice of allowing birth companions in all eligible women in labour ward from existing 0% to 50% in 6 weeks' duration. This study was conducted in the Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi. A quality improvement (QI) team was formed, and after obtaining the baseline data, problems were analysed using fish bone chart. A new policy of allowing birth companion was made and efforts made to sensitise and train the doctors and nurses posted in labour ward. Changed ideas were executed in multiple plan-do-study-act (PDSA) cycles. Simple interventions such as dress code for birth companions, curtains for ensuring privacy, display of posters and frequent reminders on WhatsApp groups were planned .

Results: The median value of women accompanied by birth companion marginally increased to 25% after the first PDSA cycle. Implementation of further changed ideas led to increase in median, which reached 66.6%. Thereafter, there was a decline, but by the end of 6 months, it was possible to attain the goal and sustain it.

Conclusions: Simple steps of QI methodology can be used to address the prevalent problems in our healthcare. Implementation of any new practice comes with major challenges, but we could achieve our goal because of a motivated team working together on multiple changed ideas applied sequentially in PDSA cycles.
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http://dx.doi.org/10.1136/bmjoq-2021-001409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8336223PMC
July 2021

Facility preparedness for an obstetric unit during the Covid-19 pandemic.

Natl Med J India 2020 Nov-Dec;33(6):349-357

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.

Covid-19 infection has placed health systems under unprecedented strain and foresight for preparedness is the key factor to avert disaster. Every facility that provides obstetric service needs a certain level of preparedness to be able to handle at least Covid-suspect pregnant women awaiting test reports, who need to be managed as Covid-positive patients till reports are available. Thus, these facilities need to have triage areas and Covid-suspect labour rooms. Healthcare facilities can have designated areas for Covid-positive patients or have referral linkages with designated Covid-positive hospitals. Preparation includes structural reorganization with setting up a Covid-suspect and Covid-positive facility in adequate space, as well as extensive training of staff about infection control practices and rational use of personal protective equipment (PPE). A systematic approach involving five essential steps of making standard operating procedures, infrastructural reorganization for a triage area and a Covid-suspect labour ward, procurement of PPE, managing the personnel and instituting appropriate infection control practices can ensure uninterrupted services to patients without compromising the safety of healthcare providers.
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http://dx.doi.org/10.4103/0970-258X.321135DOI Listing
August 2021

Maternal and Perinatal Outcomes of Pregnancy in Women With Autoimmune Disorder.

Cureus 2021 Jun 29;13(6):e16024. Epub 2021 Jun 29.

Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, IND.

Objective Pregnancy with an autoimmune disorder is faced with several risks for mother and fetus. The aim of the present study is to analyze the course and outcome of pregnancy in women with autoimmune disorders (AIDs). Methods A retrospective cohort study was conducted at a tertiary care teaching hospital. The hospital records of 153 pregnancies with autoimmune disorders and 1095 low-risk pregnant women who served as controls were reviewed. An adverse perinatal outcome was defined as the presence of any obstetric complications, including preeclampsia, eclampsia, abruption, antepartum hemorrhage (APH), prematurity, fetal growth restriction (FGR), intrauterine death (IUD), intrapartum event, mode of delivery, birth weight, neonatal intensive care unit (NICU) stay, or disease-specific neonatal complications. For all statistical tests with two-tailed probability, p<0.05 was considered statistically significant. Results A high incidence of adverse perinatal outcomes was observed in all women with AIDs when compared with age-matched controls. The highest incidence of adverse perinatal outcomes was observed in women with Takayasu's arteritis. The incidence of abortions was more in women with antiphospholipid antibody syndrome (APS) and Grave's disease (22.2% and 33.3%, respectively). The incidence of prematurity, fetal growth restriction (FGR), and low birth weight were highest in women with systemic lupus erythematosus (SLE). Pregnancy with myasthenia gravis and rheumatoid arthritis did not have any significant adverse impact on pregnancy outcomes. Conclusion We found a strong association between autoimmune disorders and obstetric complications. The multidisciplinary team approach and pre-pregnancy optimization of the disease improve maternal and fetal outcomes.
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http://dx.doi.org/10.7759/cureus.16024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8320712PMC
June 2021

Predictors of chemotherapy resistance & relapse in gestational trophoblastic neoplasia.

Indian J Med Res 2020 Dec;152(6):595-606

Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India.

Background & Objectives: Gestational trophoblastic neoplasia (GTN) is a chemosensitive malignancy with an excellent cure rate. The primary objective of the present study was to determine the predictors of chemoresistance and disease relapse, and the secondary objective was to appraise the WHO/FIGO risk scoring and course of disease in women with GTN.

Methods: In this retrospective study, case records of women treated for GTN from January 2011 to June 2019 were reviewed. For the purpose of comparison, sub-stratification of FIGO/WHO low risk group (≤6) into low (0-4) and intermediate (5-6) risk was done. Similarly, WHO high risk (≥7) group was sub-stratified into high (7-12) and ultra-high risk (≥13) groups.

Results: Case records of 116 patients were included: 51.7 per cent (60/116) were of low risk disease and 48.2 per cent (56/116) were of high risk disease. Chemoresistance developed in 28.4 per cent (33/116) and relapse in 10.3 per cent (12/116) cases. Risk of chemoresistance was higher in low risk (0-6) while risk of relapse was more in high risk (≥7) group. On sub-stratification, chemoresistance was more with intermediate [0-4: 28.5% (10/35), 5-6: 44% (11/25), 7-12: 22.5% (9/40), ≥13: 18.7% (3/16)] and relapse with ultra-high risk score [0-4: 5.7% (2/35), 5-6: 4% (1/25), 7-12:10% (4/40), ≥13: 31.2% (5/16)]. Age, myometrial invasion, serum beta-human chorionic gonadotropin and tumour size were not related to chemoresistance or relapse.

Interpretation & Conclusions: WHO risk score and presence of metastatic disease predict the probability of developing chemotherapy resistance and disease relapse. Risk of chemotherapy resistance was higher in women with intermediate-risk score (5-6), and risk of relapse was more in those with ultra-high risk score (≥13).
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http://dx.doi.org/10.4103/ijmr.IJMR_2585_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8224147PMC
December 2020

Pazopanib based oral metronomic therapy for platinum resistant/refractory epithelial ovarian cancer: A phase II, open label, randomized, controlled trial.

Gynecol Oncol 2021 Aug 2;162(2):382-388. Epub 2021 Jun 2.

Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi 110029, India. Electronic address:

Background: Treatment of patients with platinum resistant/refractory epithelial ovarian cancer (EOC) is an unmet need. We evaluated the role of oral metronomic therapy in this setting.

Patients And Methods: Between October 2017 and September 2019 seventy five patients with platinum resistant/refractory EOC were enrolled. Patients received oral etoposide (50 mg, day 1 to 14, cyclophosphamide 50 mg, day 1 to 28, every 4 weeks (Arm A, n = 38). Patients in Arm- B (n = 37) received Pazopanib (400 mg once daily) in addition to etoposide and cyclophosphamide. Quality of life (QoL) was evaluated using the EORTC questionnaire. Serum VEGF and PDGF were estimated at baseline, after 3rd and 6th cycle. The primary endpoint was progression free survival (PFS). Secondary endpoints were overall survival (OS), toxicity and QoL.

Results: Patients characteristics were well matched. Median PFS was higher in arm B, 5.1 months (95% CI 3.13 to10.33) compared to 3.4 months (95% CI 3.0 to 6.53) in arm A, p = 0.045. Median OS has 'not reached' in Arm B compared to 11.2 months (95% CI, 5.66 - not reached) in arm A, p = 0.032. Therapy was tolerated well; oral mucositis (p = 0.36) and fatigue (p = 0.08) being more in arm B. QoL assessment revealed modest improvement in 'symptom scales' in Arm B. Serum VEGF and PDGF levels decreased with therapy in both arms (Arm A-p < 0.0001, Arm B-p < 0.016).

Conclusion: Addition of pazopanib to etoposide and cyclophosphamide could be a novel oral combination for metronomic therapy for platinum resistant/refractory EOC.

Trial Registration: CTRI/2017/10/010219.
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http://dx.doi.org/10.1016/j.ygyno.2021.05.025DOI Listing
August 2021

Endovascular management of episiotomy site hematoma: Two cases and a brief review

Turk J Obstet Gynecol 2021 06;18(2):163-166

All India India Institute of Medical Sciences, Department of Radiology, New Delhi, India

Episiotomy site hematoma, though uncommon, can be associated with serious maternal morbidity. It arises mostly due to tissue trauma or injury to blood vessels, leading to the formation of a pseudoaneurysm. Sometimes, when surgical management fails, embolization of the bleeding vessel is a lifesaving option. Here, we report two cases of episiotomy site hematoma that required selective arterial embolization for management, following the failure of surgical management. A 28-year-old G6A5 woman underwent forceps delivery following which she developed a 6*6-cm right-sided vulvovaginal hematoma at the episiotomy site. After failed surgical management, arterial embolization was performed and hemostasis was achieved. A 26-year-old P2L2 woman with a history of surgical exploration for episiotomy site hematoma, presented postdelivery on postpartum day seven with profuse vaginal bleeding. Her computed tomography angiogram revealed a pseudoaneurysm of around 2.1*1 cm in length with a vaginal hematoma of 4*5 cm. Selective artery embolization performed and complete hemostasis was achieved with no complications. Selective arterial embolization is a safe therapeutic option for episiotomy site hematoma, especially if surgical management fails.
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http://dx.doi.org/10.4274/tjod.galenos.2021.43958DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191329PMC
June 2021

Oncologic and reproductive outcomes of borderline ovarian tumors in Indian population.

Gynecol Oncol Rep 2021 May 23;36:100756. Epub 2021 Mar 23.

Department of Medical Oncology, Dr. B.R. Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India.

Borderline ovarian tumor (BOT) is characterized by atypical epithelial proliferation without stromal invasion and majority are diagnosed at early stages and in women of reproductive age group. A retrospective review of medical records of patients diagnosed with BOT and on regular follow up at All India Institute of Medical Sciences New Delhi, during a five-year study period from March 2014 to March 2019 was performed. Surgical treatment was classified as radical, fertility sparing surgery (FSS) or cystectomy. Surgical staging was defined as complete, partial or unstaged. Median age of seventy-five women was 32 years. Follow up period ranged from 22 to 61 months (median 36 m). Radical surgery was done in 34 (45.3%), FSS in 32 (42.6%) and cystectomy in 9 (12.0%) women. Complete surgical staging was performed in 22 (29.3%), partial staging in 23 (30.6%) and 30 (40%) were unstaged. During the follow up period, 98.7% patients were alive and 90.7% were free of recurrence. Median time to recurrence was 35 months. Recurrence rate was 33.3% in cystectomy vs 6.2% in oophorectomy (p = 0.03). All seven recurrences were in unstaged (six) or partially staged patient (one). Six recurrences in ovary were salvaged by surgery and recurrent disease was of borderline histology. Spontaneous conception and live birth rate was 42.1%. FSS is a safe procedure and should be considered in a young patient with early stage disease and desirous of future fertility. Spontaneous conception and live birth rates after fertility sparing surgery in patients with BOT are modest.
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http://dx.doi.org/10.1016/j.gore.2021.100756DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050374PMC
May 2021

A descriptive audit of healthcare workers exposed to COVID-19 at a tertiary care center in India.

Int J Gynaecol Obstet 2021 Jun 18;153(3):393-397. Epub 2021 Apr 18.

Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India.

Objective: To provide a descriptive audit of healthcare workers (HCWs) exposed to COVID-19, and their contacts, to understand the dynamics of transmission among HCWs.

Methods: Retrospective analysis of contact tracing data of infected HCWs was done from March 1, 2020 to July 31, 2020 at a tertiary care center in New Delhi, India. Contacts were categorized according to the nature of contact and followed for 14 days.

Results: Qualitative RT-PCR testing was performed on 106 HCWs (from a total of 257) owing to exposure or development of symptoms. Positive results were found in 16 HCWs (6.2%) who were exposed to 120 other HCWs, generating 197 exposure incidents. Of these, 30 (15.2%) exposure incidents were high risk with multiple exposures in 48 (40.0%) HCWs. Exposure to infected HCWs was noted in 3 (18.8%) of 16 positive cases. Of the 197 exposure incidents, 54 (27.4%) were deemed avoidable exposures. Infection prevention and control policies were periodically reviewed, and the department implemented mitigating steps to minimize the risk to healthcare providers.

Conclusion: Instituting appropriate infection prevention and control policies and use of adequate precautions by HCWs is vital to minimize high-risk exposure to COVID-19.
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http://dx.doi.org/10.1002/ijgo.13691DOI Listing
June 2021

Retrospective analysis of surgically treated cases of squamous cell carcinoma vulva.

J Cancer Res Ther 2021 Jan-Mar;17(1):186-190

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.

Context: Vulvar carcinoma accounts for 3%-5% of gynecologic malignancies. The past three decades has observed changes in the trends of clinical characteristics and treatment modalities used in managing this disease.

Aims: The aim of the present study is to analyze the clinic-pathological characteristics and survival of women with squamous cell carcinoma vulva who underwent primary surgical management.

Settings And Design: This was a retrospective observational study.

Subjects And Methods: Case records of 30 consecutive patients with squamous cell carcinoma of vulva during the period of 2010-2016 were retrospectively reviewed and their clinical profile, treatment details, complications, and survival were analyzed.

Statistical Analysis Used: Kaplan-Meier survival analysis, followed by logrank test, was used for survival outcome, and Cox proportional hazard model was used to assess significant risk factors.

Results: The mean age of patients was 58 ± 12.9 years. The most common symptom was growth over vulva (73.3%), itching (63.3%), and nonhealing vulval ulcer (26.6%). The most common site for disease was labia majora. The surgical treatments ranged from wide local excision to radical vulvectomy. Postoperative adjuvant therapy was required for 16 patients. The median (95% confidence interval [CI]) overall survival was 27 (21.7-32.2) months. Five-year survival probability for early-stage disease (I + II) was 49% (95% CI: 12.9, 78.4) and for advanced disease (III + IV) was 24.8% (95% CI: 4.8, 42.6). Lymph node-positive status was found to have a significant impact on survival (hazard ratio of 4.9 [95% CI: 1.15-21.02, P = 0.02]).

Conclusions: Despite advances in detection and management modalities, the survival for vulval malignancies has not improved.
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http://dx.doi.org/10.4103/jcrt.JCRT_9_19DOI Listing
March 2021

Transvaginal Shear Wave Elastography for Assessment of Endometrial and Subendometrial Pathologies: A Prospective Pilot Study.

J Ultrasound Med 2021 Mar 1. Epub 2021 Mar 1.

Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.

Objective: To assess the role of shear wave elastography (SWE) in characterizing different endometrial and subendometrial pathologies.

Methods: Seventy-three women with pathologically proven endometrial and subendometrial pathologies were enrolled in this prospective study and assessed with transvaginal SWE. The elasticity values (in kiloPascals), and the ratio of mean elasticity of the endometrial lesion to myometrial elasticity (E/M ratio) were compared in different pathologies.

Results: There was a statistically significant difference (P <.001) in the mean, minimum, and maximum elasticity of the pathologies as well as the E/M ratio (P <.00001). In the analysis of the subgroups, the mean elasticity of endometrial polyp was statistically significantly lower than other subgroups (P <.01), while submucosal leiomyoma and focal adenomyoma had significantly higher values than other subgroups (P <.01). No statistically significant difference was noted in the mean elasticity of carcinoma and hyperplasia (P-.19).

Conclusion: SWE is a potential adjunct to ultrasound that provides an additional paradigm to characterize endometrial and subendometrial masses.
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http://dx.doi.org/10.1002/jum.15679DOI Listing
March 2021

Desmoplastic small round cell tumor of the ovary: A rare but poor prognostic disease in a young woman!

Indian J Pathol Microbiol 2021 Jan-Mar;64(1):206-209

Department of Pathology, All India Institute of Medical Sciences (AIIMS), New Delhi, India.

Desmoplastic small round cell tumor (DSRCT) is a rare, aggressive neoplasm of uncertain histogenesis that preferentially involves the abdominal and pelvic cavities. DSRCT mainly develops in adolescent and young adults with a strong male predominance; the male to female ratio is 4:1. Ovarian location is exceptional. DSRCT generally develops in the abdomen and have a tendency towards peritoneal spread, with subsequent metastasis to distant lymph nodes, liver and lungs. It is a poorly understood malignancy with a very characteristic morphology, immunophenotype, cytogenetic features, and poor prognosis. This tumor can co-express epithelial, neuronal, and mesenchymal markers. Despite intensive therapy, including surgery, radiotherapy and chemotherapy, and immunotherapy; the 5-year survival is less than 15%.
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http://dx.doi.org/10.4103/IJPM.IJPM_725_19DOI Listing
July 2021

Analysis of Multimerin 1 (MMRN1) expression in ovarian cancer.

Mol Biol Rep 2020 Dec 1;47(12):9459-9468. Epub 2020 Dec 1.

Department of Biophysics, All India Institute of Medical Sciences, New Delhi, 110029, India.

Ovarian cancer, the most lethal gynecological cancer, is the fifth most common cause of cancer-related deaths in women. A cost-effective and non-invasive early screening method for ovarian cancer is required to reduce the high mortality rate. Saliva is a clinically informative unique fluid, which is useful for novel approaches to prognosis, clinical diagnosis, and monitoring for non-invasive detection of disease. Multimerin1 (MMRN1) is a di-sulfide linked homo-polymeric glycoprotein from EMILIN family. Altered expression of MMRN1 has been reported in hepatocellular carcinoma, cervical cancer, and ovarian cancer. But, its role in epithelial ovarian cancer (EOC) is not clear and well documented. In this study, expression of Multimerin 1 was validated in saliva and tissues of EOC patients and age-matched controls by western blotting, ELISA, RT-PCR, and immunohistochemistry. Significant over expression of MMRN1 was observed by western blot and ELISA in saliva samples of EOC patients. The average concentration of MMRN1 in the saliva of healthy controls was 28.7 pg/ml (SE ± 1.76), 42.53 pg/ml (SE ± 4.06) in low grade and 52.91 pg/ml (SE ± 4.24) with p < 0.01 in high-grade EOC. Upregulated cytoplasmic expression of MMRN1 was observed in EOC tissue by immunohistochemistry. Our results suggest that MMRN1 expression is associated with EOC progression and MMRN1 may be potential biomarker candidates for early-stage EOC detection however further experiments are required in a large cohort to establish this proposition. Also, saliva can be explored as a novel medium for ovarian cancer diagnosis.
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http://dx.doi.org/10.1007/s11033-020-06027-9DOI Listing
December 2020

Normalized apparent diffusion coefficient: a novel paradigm for characterization of endometrial and subendometrial lesions.

Br J Radiol 2021 Jan 6;94(1117):20201069. Epub 2020 Nov 6.

Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.

Objectives: To assess the role of normalized apparent diffusion coefficient (ADC) in characterization of endometrial and subendometrial masses, measured as a ratio of the mean ADC of the pathology to mean ADC of two different internal controls, normal myometrium and gluteus maximus muscle, referred to as nADC and nADC respectively.

Methods: 55 females with pathologically proven endometrial and subendometrial lesions, including 27 cases of endometrial carcinoma, and 28 cases of benign masses were enrolled in this prospective study and assessed with single-shot echoplanar diffusion-weighted imaging. The normalized and absolute ADC of the lesions, measured by two radiologists, were compared in different pathologies and receiver operating characteristics (ROC) performed to distinguish benign and malignant endometrial masses. In the endometrial carcinoma group, the ADC values were further compared with tumor grade and subtype.

Results: There was good interobserver agreement (>0.800) for both internal controls, however it was higher for myometrium [intraclass correlation coefficient-0.92; confidence interval (0.86-0.95)] than gluteus maximus muscle [ICC-0.84; CI (0.72-0.90)]. There were statistically significant differences in absolute ADC (), nADC () and nADC () of benign and malignant endometrial masses.

Conclusion: Normalized ADC is useful to distinguish benign and malignant masses with comparable accuracy as absolute ADC.

Advances In Knowledge: Normalized ADC represents an easily measurable quantitative parameter which limits the influence of endogenous and exogenous factors that affect its reproducibility.
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http://dx.doi.org/10.1259/bjr.20201069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774697PMC
January 2021

Autologous Bone Marrow-Derived Stem Cell Therapy for Asherman's Syndrome and Endometrial Atrophy: A 5-Year Follow-up Study.

J Hum Reprod Sci 2020 Jan-Mar;13(1):31-37. Epub 2020 Apr 7.

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Delhi, India.

Background: Based on the role of bone marrow (BM) stem cells in regeneration of endometrium, refractory cases of Asherman's syndrome (AS) and endometrial atrophy (EA) may benefit with BM-derived intrauterine stem cell instillation. Aims and Objectives: To evaluate the role of BM-derived autologous stem cell therapy in endometrial regeneration and restoration of menstruation and fertility in refractory cases of AS and EA.

Setting: This study was conducted at a tertiary care center.

Design: This was a prospective, single-arm longitudinal study.

Materials And Methods: Twenty-five cases with refractory AS or EA were included. BM-derived mononuclear stem cells were instilled into the subendometrial zone followed by oral estrogen therapy for 3 months. Menstrual flow and endometrial thickness (ET) were assessed at 3, 6, and 9 months and 5 years.

Results: Statistical analysis was carried out using statistical software STATA version 12.0. Mean prestem cell transfer ET (mm) was 3.3 ± 1.0. At the end of 3 months, there was a significant increase in ET (mm) to 5.1 ± 1.9 ( = 0.001), but there was no significant change at 6 months (5.6 ± 1.5; = 0.164), at 9 months (6.1 ± 1.7; = 0.135), or at the end of 5 years. Six of the seven amenorrheic patients resumed menses. Three patients had a successful pregnancy outcome.

Conclusion: Intrauterine stem cell treatment is a promising novel approach for refractory cases of AS and EA.
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http://dx.doi.org/10.4103/jhrs.JHRS_64_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295252PMC
April 2020

Management of the first patient with confirmed COVID-19 in pregnancy in India: From guidelines to frontlines.

Int J Gynaecol Obstet 2020 07 17;150(1):116-118. Epub 2020 May 17.

Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1002/ijgo.13179DOI Listing
July 2020

Uterine tumor resembling ovarian sex cord tumor: A series of six cases displaying varied histopathological patterns and clinical profiles.

Indian J Pathol Microbiol 2020 Feb;63(Supplement):S81-S86

Department of Pathology, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Uterine tumors resembling ovarian sex cord tumor (UTROSCT) are a unique group of neoplasms with diverse morphology and immunophenotypic characteristics, coexpressing sex cord, epithelial, and smooth-muscle markers. To date, less than 100 cases have been reported and there is paucity of data concerning their clinical behavior.

Materials And Methods: All cases of uterine body tumors diagnosed over a period of two and a half years (2016-2018) were retrieved. Histopathological features were reviewed and extended panel of immunohistochemistry was performed to identify cases of UTROSCTs.

Results: Six cases of UTROSCTs were identified with a median age of 46.5 years. Four of them presented with menorrhagia, while two with postmenopausal bleeding including one with a history of carcinoma breast. Three of these cases were initially misdiagnosed as endometrial stromal sarcoma and adenocarcinomas. They all underwent hysterectomy with bilateral salpingo-oophorectomy.

Conclusion: It is considered a tumor with low malignant potential; however, one out of six cases (16.7%) in our study showed metastasis, within 1 year of diagnosis. It is important to recognize this entity as it mimics a wide range of both benign and malignant tumors. Molecular pathogenesis and exact management protocols remain elusive due to rarity,hence, multi-institutional studies are warranted.
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http://dx.doi.org/10.4103/IJPM.IJPM_340_19DOI Listing
February 2020

Oral metronomic chemotherapy for recurrent & refractory epithelial ovarian cancer: A retrospective analysis.

Indian J Med Res 2019 12;150(6):575-583

Department of Medical Oncology, Dr. B.R. Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India.

Background & Objectives: Advanced epithelial ovarian cancer (EOC) is associated with dismal outcome and progression-free survival (PFS) shortens with each subsequent relapse. For patients with recurrent and platinum refractory disease, therapeutic options are limited. Oral metronomic therapy (OMT) is associated with symptomatic relief and stable response in a significant proportion of patients. We retrospectively evaluated the outcome of patients with EOC treated with OMT at a tertiary care hospital in north India.

Methods: Between January 2011 to December 2017, 36 EOC patients received OMT. Patients' median age was 50 yr (range, 38-81 yr) and they had received a median of two lines of prior chemotherapy. OMT regimen included a combination of cyclophosphamide, etoposide (VP-16) and celecoxib with or without pazopanib along with supportive care. Response rates and outcomes were ascertained using the Gynecological Cancer Intergroup Guidelines. The toxicity was graded according to the Common Terminology Criteria for Adverse Events v.4.03.

Results: The median CA-125 before initiating OMT was 160 U/ml (range, 42.23-5330 U/ml). The median interval between last chemotherapy and starting OMT regimen was 159 days (range, 1-1211 days). The overall response rate was 50 per cent. The median progression-free survival (PFS) was 8.2 months [95% confidence interval (CI): 5.03-10.33], and the median overall survival was 38 months (95% CI: 25.6-NR). Patients who received two lines of chemotherapy before OMT (P=0.052) and those who received pazopanib-based OMT (P=0.0513) had better PFS.

Interpretation & Conclusions: For patients with relapse and refractory EOC, OMT could be a reasonable option. A combination of oral etoposide (VP-16) and pazopanib needs further evaluation in a large number of patients in a randomized trial.
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http://dx.doi.org/10.4103/ijmr.IJMR_2030_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7038810PMC
December 2019

Cross-sectional Study on Vitamin D Levels in Stress Urinary Incontinence in Women in a Tertiary Referral Center in India.

Indian J Endocrinol Metab 2019 Nov-Dec;23(6):623-627

Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India.

Objective: To assess the levels of vitamin D in patients with Stress Urinary Incontinence (SUI) in gynecology clinic of All India Institute of Medical Sciences, New Delhi.

Materials And Methods: This is a cross sectional study on a total of 40 women presenting to gynecology outpatient department with stress urinary incontinence diagnosed by history and examination. The women were divided with moderate, severe and very severe SUI confirmed by incontinence severity index (ISI) and pad test. Vitamin D (serum 25 OH D) levels were measured in all cases by electrochemiluminenscene Immunoassay (ECLIA) using Roche Elecsys 2010 and levels of =30 ng/ml were taken as sufficient while levels between 20-30 ng/ml as insufficient and <20 ng/ml as deficient. Statistical analysis was performed using ANOVA test with value of <0.05 taken as significant.

Results: Mean age of patients was 41.6 years. Mean parity was 2.73 and mean duration of symptoms was 4.14 years. Vitamin D levels ranged between 6-38 ng/ml with mean being 17.15±8.1 ng/ml. Levels were deficient (<20 ng/ml) in 30 (75%) women, insufficient (20-30ng/ml) in 7 (17.5%) women and sufficient (>30ng/ml) in 3 (7.57%) women. There was no significant correlation between severely of SUI and levels of vitamin D with Vit D being 19.18±5.76 ng/ml in moderate SUI, 16.96±9.03 ng/ml in severe SUI and 13.60 ± 2.09 ng/ml in very severe SUI.

Conclusion: There was very high prevalence of vitamin D deficiency in SUI patients with 75% patients showing deficient levels and 17.5% showing insufficient levels in SUI patients. There is need to provide vitamin D supplementation in such women.
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http://dx.doi.org/10.4103/ijem.IJEM_531_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6987784PMC
February 2020

A clinicopathological study of granulosa cell tumors of the ovary: Can morphology predict prognosis?

Indian J Pathol Microbiol 2020 Jan-Mar;63(1):53-59

Department of Pathology, All India Institute of Medical Sciences, New Delhi, India.

Objective: Granulosa cell tumors (GCT) are low-grade malignant sex cord-stromal tumors (SCST) with late metastasis/recurrences and long disease-free periods. We performed a clinicopathological evaluation of GCT to ascertain features having prognostic impact.

Materials And Methods: All cases of GCT of ovary from January 2006 to December 2018 were assessed for architectural patterns, nuclear grooves, and Call-Exner bodies. Each feature was graded on frequency of occurrence: not present (0)-very frequent (3). Anisonucleosis, necrosis, and inflammation were noted. Cases were grouped on mitotic count; <10 mitosis/10 High power field (HPF) or >=11 mitoses/10 HPF and Ki-67 index; <10% Ki-67 and >=11% Ki-67.

Results: GCT formed 60.1% of SCST. Sixty cases' ages were in the range of 15-78 years (median 45). Clinical details were available in 37. Commonest presentation was abnormal uterine bleeding. Serum CA125 was raised in 16.1% and Inhibin in 58.8%. Seventy percent were in stage I. Disease recurrence was associated with higher stage (P = 0.007). The most frequent pattern was diffuse sheets (47%). Call-Exner bodies were absent in 22.2%. Grooves with score 1, 2, and 3 were seen in 35.8%, 23.5%, and 13.6%, respectively. Anisonucleosis was present in 26.7%, necrosis in 11.1%, and lympho-plasmacytic infiltrate in 43%. Out of total, 93.3% had <10 mitosis/10 HPF and 43.2% had recurrence, most with high Ki-67 (P = 0.064).

Conclusion: Our study outlines histomorphological spectrum of GCT and emphasizes its frequent occurrence in lower stages with late recurrences. The presence of grooves may indicate granulosa-cell origin. Call-Exner bodies are not a necessity. Histomorphological features are not prognostically important. However, prognostic value of Ki-67 cannot be excluded. Limitation of the study was a small number of cases with follow-up.
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http://dx.doi.org/10.4103/IJPM.IJPM_403_19DOI Listing
October 2020

Peritoneal metastasis in Stage IB1 adenocarcinoma cervix: A rare entity.

J Cancer Res Ther 2019 Oct-Dec;15(6):1415-1417

Department of Pathology, All India Institute of Medical Sciences, New Delhi, India.

The presence of ovarian or peritoneal metastasis in early-stage cervical malignancy is a rare entity. It often poses a diagnostic challenge whether it is a synchronous primary tumor or a metastatic lesion. A 63-year-old postmenopausal woman presented with Stage 1B1 carcinoma cervix with ascites, and a 5.8 cm × 4.2 cm × 3.5 cm left solid adnexal mass. She underwent Type III radical hysterectomy, excision of peritoneal mass, with bilateral pelvic and paraaortic lymphadenectomy and infracolic omentectomy. On histopathology, cervix showed features of adenocarcinoma, and the peritoneal mass revealed similar histomorphology as cervical growth with metastatic tumor deposits in omentum. Immunohistochemistry (IHC) was utilized to determine the origin of mass. The early stage disease and histology may not always predict the distant metastasis. Therefore, a thorough pretreatment evaluation, meticulous intraoperative assessment, and IHC are mandatory for optimum management and prognostication.
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http://dx.doi.org/10.4103/jcrt.JCRT_830_18DOI Listing
May 2020

Correction: PARP-1 inhibitor modulate β-catenin signaling to enhance cisplatin sensitivity in cancer cervix.

Oncotarget 2019 Jul 30;10(46):4802. Epub 2019 Jul 30.

Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India.

[This corrects the article DOI: 10.18632/oncotarget.27008.].
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http://dx.doi.org/10.18632/oncotarget.27101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6677665PMC
July 2019

Pilimiction: A Rare Presentation of Ovarian Dermoid.

J Obstet Gynaecol India 2019 Aug 7;69(4):377-379. Epub 2019 Jun 7.

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, Delhi India.

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http://dx.doi.org/10.1007/s13224-019-01245-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6661053PMC
August 2019

Successful Pregnancy Outcome after Coiling of Ruptured Intracranial Aneurysm.

J Assoc Physicians India 2019 Mar;67(3):89-90

Junior Resident, All India Institute of Medical Sciences, New Delhi.

Rupture of intracranial aneurysm is a serious condition, prompt diagnosis and treatment may prevent potentially lethal complications in pregnancy and otherwise. Clipping and endovascular coiling are treatment modalities available. We accessed outcome of a pregnancy with ruptured intracranial aneurysm managed with endovascular coiling. We report a pregnant woman who suffered from SAH due to rupture of posterior cerebral artery aneurysm in third trimester. Endovascular coiling with Guglielmi detachable coil (GDC) followed by caesarean section done. She required coiling twice in pregnancy.
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March 2019

PARP-1 inhibitor modulate β-catenin signaling to enhance cisplatin sensitivity in cancer cervix.

Oncotarget 2019 Jul 2;10(42):4262-4275. Epub 2019 Jul 2.

Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India.

Cisplatin is a keystone for treatment of both recurring and locally advanced cervical cancer. However toxic side effects and acquired resistance limits its efficacy. Enhanced DNA repair is one of the mechanisms through which cancer cells acquire cisplatin resistance. Inhibitors of PARP, which is a DNA damage repair enzyme, have been approved for use in BRCA mutated cancers like breast and ovary cancer. However little is known about the therapeutic efficacy of PARP inhibitors in cervical cancer, either as a single agent or in combination with cisplatin. We hypothesized that PARP-1 inhibition might improve the sensitivity of cervical cancer cells to cisplatin by diminishing DNA repair. To ascertain this, we determined effect of PARP-1 inhibition on cisplatin cytotoxicity in HeLa and SiHa cell lines. Combination of cisplatin with PJ34, a phenanthridinone-derived PARP-1 inhibitor, augmented cisplatin toxicity by decreasing cell proliferation, enhancing cell cycle block and cell death, and decreasing invasion and metastasis, when compared with either of the single agent alone. We further show that PARP-1 inhibition inhibited β-catenin signaling and its downstream components such as c-Myc, cyclin D1 and MMPs indicating a possible link between single strand base damage repair and WNT signaling. In conclusion, PARP-1 inhibition might augment cisplatin cytotoxicity in cervical cancer cells by modulating β-catenin signaling pathway. Combining PARP-1 inhibitors with cisplatin might be a promising approach to overcome cisplatin resistance and to achieve a better therapeutic effect.
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http://dx.doi.org/10.18632/oncotarget.27008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6611509PMC
July 2019

Clinical Outcome Analysis and Correlation of Reproductive Outcome with Endometriosis Fertility Index in Laparoscopically Managed Endometriosis Patients: A Retrospective Cohort Study.

J Hum Reprod Sci 2019 Apr-Jun;12(2):98-103

Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India.

Background: Laparoscopy is important for management of endometriosis patients with estimation of endometriosis fertility index (EFI) which can predict reproductive outcome.

Aims: This study aims to evaluate clinical outcome in laparoscopically managed pelvic endometriosis and correlation of reproductive outcome with EFI.

Setting And Design: Retrospective cohort study carried out in the Department of Obstetrics and Gynecology.

Materials And Methods: Our study included 123 patients who had undergone laparoscopic management of endometriosis from January 2017 to March 2018. Case files were retrieved and meticulously analyzed. All patients were contacted and interviewed. Symptomatic relief and pregnancy in infertility patients were recorded. EFI was calculated.

Statistical Analysis: Data analyses were carried out using statistical software STATA version 12.0. < 0.05 was considered statistically significant.

Results And Conclusions: A total of 123 cases were enrolled; the most common complaint was infertility 107 (86.99%); the mean age was 32.4 years. EFI was found to be (6 to 10) in 28(26.2%) patients, EFI of (4 to 5) in 49 (45.8%) and EFI of (0 to 3) in 30 (28.0%). Post surgery, dysmenorrhoea was relieved in 56 (65.88%) patients, menstrual irregularities were relieved in 45 (76.27 %) patients, dyspareunia in 32 (54.24%) and chronic pelvic pain in 24 (40.5%) patients. 8 (40%) patients with low EFI conceived, 20 (58.82%) with moderate, and 26 (96.29%) with high EFI conceived. EFI score showed statistically significant positive correlation with pregnancy outcome = 0.001, higher the EFI score, better the reproductive outcome. Laparoscopic surgeries are important for managing patients of endometriosis. It provides significant symptomatic relief, and EFI estimation can be done, which is a good tool to predict reproductive outcome of infertility patients with endometriosis.
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http://dx.doi.org/10.4103/jhrs.JHRS_157_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594121PMC
July 2019

The effect of administration of intravenous intralipid on pregnancy outcomes in women with implantation failure after IVF/ICSI with non-donor oocytes: A randomised controlled trial.

Eur J Obstet Gynecol Reprod Biol 2019 Sep 13;240:45-51. Epub 2019 Jun 13.

All India Institute of Medical Sciences, Delhi, India.

Objective: Does the administration of intravenous intralipid in women with previous implantation failure at the time of embryo transfer improve pregnancy outcomes in terms of biochemical pregnancy rate, clinical pregnancy rate, ongoing pregnancy rate, and ongoing pregnancy rate?

Study Design: This was a single blinded randomised controlled trial of 105 subjects with previous failed IVF undergoing self donor oocyte IVF/ICSI from January 2017 to May 2018. Randomisation was by computer generated sequence after oocyte pickup. Results were analysed for 102 women, excluding three women due to poor embryo quality. Women in the study arm(n = 52) received 2 doses of 20% intravenous intralipid (Fresenius Kabi), 4 ml diluted in 250 ml normal saline by slow infusion. The first dose was given immediately after oocyte recovery, and the second dose was given on the day of embryo transfer, 1 h prior to the transfer. The control group (n = 50) received normal saline. Flexible ovarian stimulation protocols were used. All the women received routine luteal phase support with micronised vaginal progesterone.

Results: 102 women underwent analysis, 52 in the study group and 50 in control group. There was no significant difference in the baseline characteristics. There was a significant difference in the biochemical pregnancy rate in the intralipid group (40.38%) versus control (16%) [(p = 0.006), RR = 2.5 (1.23-5.16 CI)], clinical pregnancy rate [(34.62% vs 14%), p = 0.006, RR = 2.5(1.13-5.40 CI)], implantation rate [(16.6% vs 6.6%), p = 0.012, RR = 2.5(1.18 to 5.41 CI)], and take home baby rate [28.8% vs 10%, p = 0.024, RR = 2.8(1.1-7.3)]. The adjusted odds ratio for clinical pregnancy in women who received intralipid vs placebo was 3.1 (1.02-9.70 95% CI), p = 0.046. No adverse effects of intralipid were observed.

Conclusion: This study shows a statistically significant increase in implantation rate and live birth rate in women who receive intravenous intralipid with prior implantation failure after IVF/ICSI. These findings concur with other studies; however, literature is limited. The effect of intralipid on the immunological abnormalities in women who experience recurrent implantation failure needs to be investigated further.
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http://dx.doi.org/10.1016/j.ejogrb.2019.06.007DOI Listing
September 2019

Quantitative Sonoelastographic Assessment of the Normal Uterus Using Shear Wave Elastography: An Initial Experience.

J Ultrasound Med 2019 Dec 11;38(12):3183-3189. Epub 2019 May 11.

Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.

Objectives: To describe the sonoelastographic characteristics of the normal endometrium, myometrium, and cervix and to assess their variability with age and different menstrual phases.

Methods: A total of 56 women were enrolled in this prospective study, who underwent transvaginal ultrasound examinations, including B-mode imaging and shear wave elastography. The elasticity parameters (in kilopascals) of the normal endometrium, myometrium, and cervix were studied. The variability of the mean elasticity value of the endometrium in different menstrual phases and age groups was analyzed. The variability of the mean elasticity of the cervix across different age groups was also studied.

Results: The mean age of the participants was 40 years (range, 25-69 years). The normal mean elasticity values ± SDs were 25.54 ± 8.56 kPa for the endometrium, 40.24 ± 8.59 kPa for the myometrium, and 18.90 ± 4.22 kPa for the cervix. A mean endometrial-to-myometrial elasticity ratio was calculated, which was found to be 0.65 ± 0.22. There was no significant difference in the mean endometrial elasticity values for women in different menstrual phases (P = .176) or in different age groups (P = .376). There was no significant difference in the mean cervical elasticity with age (P = .192).

Conclusions: Shear wave elastography is a promising adjunct to ultrasound for the evaluation of the uterus, and the results from this study may provide normal data, which may further help in diagnosing various uterine diseases.
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http://dx.doi.org/10.1002/jum.15019DOI Listing
December 2019

Pregnancy with massive splenomegaly: A case series.

Natl Med J India 2018 May-Jun;31(3):146-148

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.

Background: Pregnancy with massive splenomegaly is a rare entity and is associated with increased risk to both mother and foetus. There is paucity of studies in the literature to guide clinicians for the management of this condition.

Methods: We reviewed the course of pregnancy, maternal and foetal outcomes of 5 pregnant women with massive splenomegaly who were managed in our unit during 2015-16.

Results: All 5 women had anaemia and thrombocytopenia, and had different causes for splenomegaly. One patient had chronic malaria, 2 had portal hypertension with cirrhosis and the remaining 2 had non-cirrhotic portal hypertension. Life-threatening complications were present in 2 patients; one of them had severe pre-eclampsia complicated by pulmonary oedema, cardiac arrest and the other patient developed spontaneous bacterial peritonitis. Intrauterine growth restriction and meconium-stained liquor were the most common perinatal complications. Two patients had vaginal delivery and 3 required emergency caesarean section. Postpartum haemorrhage was present in 2, and the hospital stay was prolonged in all the patients. All mothers and babies were discharged in a satisfactory condition.

Conclusion: Pregnancy with massive splenomegaly poses a challenge because of diverse aetiology and potentially adverse outcomes. Multidisciplinary care in a tertiary centre can help optimize the outcome.
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http://dx.doi.org/10.4103/0970-258X.255756DOI Listing
October 2019
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