Difficulties in emotion regulation and impulse control during cocaine abstinence

RATIONALE

Prior research has shown that cocaine dependence is associated with dysfunction of brain systems involved in emotions and motivational states.

OBJECTIVES

To examine whether difficulties in emotion regulation are associated with early cocaine abstinence using the recently validated Difficulties in Emotion Regulation Scale (DERS).

METHOD

Recently abstinent treatment-seeking cocaine patients (n=60) completed the DERS during their first week of inpatient treatment and at discharge (3-4 weeks later), and scores were compared with community controls (n=50).

RESULTS

Compared with controls, cocaine-dependent individuals reported difficulties relating to understanding emotions, managing emotions and impulse control in the first week of abstinence. With continued abstinence, cocaine-dependent individuals showed continued difficulties only in impulse control.

CONCLUSION

Cocaine-dependent individuals report emotion regulation difficulties, particularly during early abstinence. Additionally, protracted distress-related impulse control problems suggest potential relapse vulnerability.

Double coins at the oesophageal inlet

Multiple foreign bodies lodged in the oesophagus are extremely rare. Here an unusual case of two coins accidentally lodged at the oesophageal inlet of a six-year-old girl is reported. The coins were successfully removed by oesophagoscopy. It is to be noted that apart from the straight x-ray (PA view) of the neck and chest, a lateral view is essential for proper characterisation and identification of the type and number of foreign bodies prior to surgical removal.

A first-in-man phase I study of R306465, a histone deacetylase (HDAC) inhibitor exploring pharmacokinetics (PK) and pharmacodynamics (PD) utilizing an electrochemiluminescent immunoassay in patients (p) with advanced tumours

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Background: R306565 is an aromatic hydroxamic acid with predominant inhibitory effects on Class 1 HDAC enzymes (with IC50 ∼10 nM). HDAC inhibitors (HDACi) affect gene expression at the transcriptional level, leading to cell cycle arrest and induction of apoptosis. Methods: P with solid tumours or lymphoma were given R306465 orally daily for 3 weeks (w) out of 4 in an escalating schedule. Objectives include safety, tolerability, PK (including food effect exploration), PD evaluation and circulating tumour cell (CTC) quantitation. Results: Four dose levels (100, 200, 300 and 400 mg) have been evaluated involving 15 p (7 male), age range 29–72 (median 59 y) and ECOG PS 0–2. A total of 37 cycles have been administered. Most common adverse events (AE) were Grade (G) 1–3 fatigue (87%), G1–2 nausea (66%), G1–2 vomiting (33%), G1–2 diarrhoea (40%), and G1–2 anorexia (40%). Dose limiting toxicity of G3 fatigue was seen in 1/6 p in the 400mg cohort. PK parameters were approximately dose proportional. Plasma concentrations increased in the fed state. PD effect of histone H3 acetylation (AcH3) in peripheral blood mononuclear cells (PBMC) was determined quantitatively with a novel validated electrochemiluminescent immunoassay developed in-house (applying Mesoscale Discovery technology). Although some interpatient variability exists, increased AcH3 was observed in 2/6 p in the 400 mg cohort, while the percentage rise in AcH3 was minimal for cohorts 1–3. Peak AcH3 achieved in 2 p dosed at 400 mg was approximately 5–10 fold increase over baseline. Using CellSearch technology for quantitation of CTCs, 8/14 p had detectable CTCs at baseline; the CTC trend will be presented. 4 p had stable disease (SD) for = 4 months. Conclusions: R306465 could be safely administered on a daily dosing schedule for 3 of 4 w up to 400 mg. Common toxicities seen were gastrointestinal and fatigue. Maximum tolerated dose has not been reached. PK suggests dose proportionality. Promising PD data showing increased acetylation in PBMC at 400 mg, further supports the utilization of the immunoassay platform in HDACi clinical trials.

No significant financial relationships to disclose.

Stab anterior preperitoneal hernioplasty in groin hernias: a new technique

With laparoscopic hernia repair still not qualifying as the ideal method, the search is still on for the optimal method of intervention combining the advantages of both open mesh repair and laparoscopic repair for groin hernias. Eighty-five patients with uncomplicated inguinal hernias classified as Nyhus type 2 or higher were operated on by the modified anterior preperitoneal (APP) repair. The peroperative parameters were studied and compared with those of totally extraperitoneal (TEP) repair to determine the efficacy of the modified approach. Eighty-eight anterior preperitoneal repairs were carried out on these 85 patients. Twenty-one patients were Nyhus type 2, 17 were type 3a (direct), 41 were type 3b (indirect), and nine were type 4 (recurrent). The results were compared with TEP parameters done by the same surgeon. The incision size was 2.8 cm (2.3-4.5 cm). The operating time was 15.7 min (11-26 min) compared with 31.2 min for the TEP repair. Discharge time was 2.3 days (range 2-4 days) compared with 2.2 days in TEP repair. Complications included seroma in eight patients, pain radiating to the scrotum even at 6 months in one patient, and superficial wound infection in one patient. Return to work in patients with stab APP was 12.6 days ( 7-15 days ), whereas it was 10.4 days in TEP repair. The overall recurrence rate was 1.66% at the end of 2 years. The results with stab APP repair were comparable with those with TEP repair. The stab APP in addition had the advantage of being easier to learn and can be done faster.

A phase I/II study of the safety and anti-cancer activity of IV-administered belinostat (PXD101) plus carboplatin (C) or paclitaxel (P), or both in patients with advanced solid tumors

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Background: Belinostat (PXD101), a HDAC inhibitor of the hydroxamate class has shown anti-tumor preclinical activity in combination with other standard chemotherapeutic agents. In Ph. I and II clinical trials the MTD for belinostat has been established at 1,000 mg/m2/d. This Ph I/II study assesses safety, and anti-cancer activity of belinostat administered in combination with C and/or P. Methods: Sequential cohorts of 3–6 patients (pts) with advanced solid tumors and PS 0–2 were recruited to determine the MTD of standard dose C and/or P with escalating doses of belinostat administered as a 30-min IV infusion daily for 5 days (d) every 21 d. C and/or P were administered 2–3 hours following infusion of belinostat on d 3. Results: 23 pts have been treated with a mean of 5 cycles (range 1 - 15) at 5 dose levels: C and belinostat (600 mg/m2) (5 pts); P and belinostat (600 mg/m2) (5 pts); C and P and belinostat (600 mg/m2) (3 pts); C and P and belinostat (800 mg/m2) (4 pts); C and P and belinostat (1,000 mg/m2) (6 pts). Possibly drug-related grade 3 or 4 toxicities were thrombocytopenia (2), vomiting (1), sensory neuropathy (1), myalgia (1), and fatigue (1).No DLT was observed. One SAE (grade 1 T-wave morphology change) was graded as possibly drug-related. No QTcf greater than 500ms were reported. There are 2 confirmed PRs: 1 with heavily treated metastatic rectal cancer and 1 with gemcitabine pre-treated metastatic pancreatic cancer. An additional 11[E1] patients had SD for 2–15 cycles, with 4 being SD for >10 cycles. One pt with mixed mullerian cancer of ovarian origin with SD had an 81% reduction in CA-125 to normal levels after 6 cycles. [E1]If you include MMMT pt as SD on radio. Conclusions: Belinostat with standard dose C and/or P is well-tolerated and shows clinical activity in heavily pre-treated patients with advanced metastatic disease. Recruitment to a phase II expansion in pts with recurrent ovarian cancer is ongoing.

No significant financial relationships to disclose.

Genetic linkage analysis of sarcoidosis phenotypes: the sarcoidosis genetic analysis (SAGA) study

The sarcoidosis genetic analysis (SAGA) study previously identified eight chromosomal regions with suggestive evidence for linkage to sarcoidosis susceptibility in African-American sib pairs. Since the clinical course of sarcoidosis is variable and likely under genetic control, we used the affected relative pair portion of the SAGA sample (n=344 pairs) to perform multipoint linkage analyses with covariates based on pulmonary and organ involvement phenotypes. Chest radiographic resolution was the pulmonary phenotype with the highest LOD (logarithm of the backward odds, or likelihood ratio) score of 5.11 at D1S3720 on chromosome 1p36 (P=4 x 10(-5)). In general, higher LOD scores were attained for covariates that modeled clustered organ system involvement rather than individual organ systems, with the cardiac/renal group having the highest LOD score of 6.65 at chromosome 18q22 (P=2 x 10(-5)). The highest LOD scores for the other three organ involvement groups of liver/spleen/bone marrow, neuro/lymph and ocular/skin/joint were 3.72 at 10p11 (P=0.0004), 5.16 at 7p22 (P=4 x 10(-5)) and 2.93 at 10q26 (P=0.001), respectively. Most of the phenotype linkages did not overlap with the regions previously found linked to susceptibility. Our results suggest that genes influencing clinical presentation of sarcoidosis in African Americans are likely to be different from those that underlie disease susceptibility.

'Layer by layer' phacoemulsification in posterior polar cataract with pre-existing posterior capsular rent

PURPOSE

To evaluate a new technique of 'Layer by Layer' phacoemulsification in eyes with posterior polar cataract with pre-existing posterior capsular rent (PCR).

METHODS

Layer by layer phacoemulsification was performed in eight eyes of eight patients of posterior polar cataract with pre-existing posterior capsular rent. All the patients had evidence of a posterior capsular defect showing presence of iridescent refractile lens particles in vitreous with onion skinning of central dense plaque.

RESULTS

The mean age of the patients was 43.75+/-2.5 years and six patients were men. All the eyes had vertical posterior capsular defect irrespective of the site of entry of phaco probe. Vitrectomy was not required in any of the eyes. Single piece foldable acrylic intraocular lens was implanted in the bag in all the eyes. The mean preoperative best corrected visual acuity was 0.14+/-0.05, which improved to 0.77+/-0.27.

CONCLUSION

Our technique of 'Layer by layer' phacoemulsification is an effective and safe technique for the management of posterior polar cataract with pre-existing PCR.

Multidetector row CT of small bowel tumours

Computed tomography is being increasingly used for the evaluation of patients with vague abdominal symptoms, and may provide the initial opportunity to detect and characterize tumours of the small bowel. The recognition of imaging features on CT allows distinction to be made between benign and malignant neoplasms. Multidetector row CT (MDCT) provides high-resolution imaging and helps in precise localization and characterization of lesions. This article illustrates the imaging appearances of small bowel tumours on MDCT and demonstrates the usefulness of multiplanar reformatting (MPR) in the diagnosis and categorization of these tumours.

Association of alpha-synuclein gene haplotypes with Parkinson's disease

In a previous study, we detected an association between a dinucleotide repeat (Rep1) in the alpha-Synuclein (SNCA) gene and sporadic Parkinson's disease (PD). To extend our previous finding in a larger sample and further determine the role of SNCA in the development of PD, we screened a sample of 194 familial PD (FPD), 327 sporadic PD (SPD), and 215 controls with the Rep1 marker and 2 single nucleotide polymorphisms (SNPs) (770 and int4) in the SNCA gene. There was significant difference in allele frequency between African American and American Indian groups for Rep1 marker (p=0.03). These two samples were excluded from further analysis because of sample size. Comparison of allele frequency differences between PD and controls for the single-locus was significant only for Rep1 and SPD (p=0.017). The global case control association was highly significant for the three loci haplotypes comparisons. Our results indicate that Rep1 locus may be in linkage disequilibrium (LD) with a mutation in the gene or itself could be a risk factor for SPD.

Reliability of salivary cortisol assessments in cocaine dependent individuals

The aim of this study was to assess the reliability of salivary cortisol as a measure of hypothalmic-pituitary-adrenal (HPA) axis function in cocaine dependent individuals. Saliva and total plasma samples were collected from 49 abusers on 3 testing days in the morning, across eight time points per day. Significant associations between saliva and plasma cortisol were observed across all time points collapsed across 3 days in both men and women. These moderately significant correlations suggest that salivary measurements represent a stable, non-invasive and broad indicator of HPA axis functioning in cocaine dependent individuals.

Rhabdomyosarcoma of nose and paranasal sinuses--a therapeutic challenge

Rhabdomyosarcoma is a highly malignant tumour of striated muscle and it is the most common soft tissue sarcoma in the paediatric age group. It is very uncommon in the nose and paranasal sinuses. Pinkish nasal mass and recurrent epistaxis are the most common presenting symptoms. Histologically embryonal rhabdomyosarcoma is the most common variant. The present series deals with seven such cases of different histopathological types including the embryonal, botryoid, and alveolar varieties in the paediatric age group. Multimodal treatment including limited surgery followed by radiotherapy and chemotherapy resulted in survival ranging from 3 days to more than 3 years, which was also influenced by the severity of the disease at presentation and its aggressiveness.

Submandibular sialogram performed through a Wharton's duct fistula: technical adaptation of conventional technique

We report a case of submandibular duct fistula in which a sialogram was performed through the fistulous opening after attempt of sialography through the Wharton's duct had failed. To our knowledge, this technical modification in obtaining a sialogram has not been described previously in scientific literature. Blunt-tipped needles and polythene catheters are commonly used for cannulation of the submandibular duct orifice for obtaining a sialogram. However, in this case, a larger gauge metallic cannula was employed to opacify the ductal system through the fistula.

Pseudomembranous colitis revisited: spectrum of imaging findings

In recent years there has been a marked increase in the incidence of pseudomembranous colitis (PMC). PMC is more common in patients over 65 years of age and can cause significant morbidity. The purpose of this article is to review the imaging features of PMC on plain radiography, sonography, computed tomography (CT), scintigraphy and magnetic resonance imaging (MRI). It is important to recognize the imaging findings of PMC using different imaging methods and encourage urgent confirmation of the diagnosis serologically, as the differential includes other fulminant colitides for which colectomy may be the required. Awareness of the spectrum of imaging findings of PMC can help radiologists make the primary or incidental diagnosis of PMC.

Prognostic significance of HER-2/neu over-expression on the incidence of brain metastasis in newly diagnosed breast cancer

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Background: As systemic therapy improves, brain metastases (BM) from breast cancer are becoming increasingly evident. An increased risk of BM in HER-2/neu over-expressing metastatic breast cancer patients has been suggested. However, the relationship between HER-2/neu over-expression and the risk of BM in newly diagnosed breast cancer patients is unknown. Methods: To determine incidence of BM in HER-2/neu over-expressing breast cancer patients, a cohort of patients between 01/1998 and 12/2003 with uniform HER-2/neu testing were identified from a cancer registry. A total of 460 patients with HER-2/neu over-expression and 500 patients with HER-2/neu negative disease were reviewed. Patients were excluded if there was breast cancer diagnosed before 01/1998 or others cancer. A total of 301 HER-2/neu over-expressing and 363 HER-2/neu negative patients were included for this analysis. The association between histological features and the occurrence of BM were evaluated with univariate and multivariate analyses. Results: BM were identified in 8% (24 patients) of HER-2/neu over-expressing breast cancer patients compared to only 1.7% (6 patients) in the HER-2/neu negative patients (hazard ratio 5.15 [2.079–12.78], p=0.0001). In patients with recurrent disease, the proportion of BM for HER-2/neu over-expressing patients was 24% compared to 10% in HER-2/neu negative patients. HER-2/neu over-expression, tumor size >2cm, ≥ 4 nodes positive and grade 2/3 were predictors of BM in univariate analysis. In multivariate analysis, HER-2/neu over-expression and tumor size>2cm were an independent prognostic factors for the development of BM, while hormone receptors expressions was protective (p=0.02). Conclusions: Our population based study show that newly diagnosed HER-2/neu over-expressing breast cancer patients are at significantly increased risk for BM. As most BM occur in HER-2/neu over-expressing patients with systemic metastatic disease, these findings could prompt consideration of brain prophylaxis strategies and/or serial radiologic screening to detect asymptomatic BM.

No significant financial relationships to disclose.

Phacoemulsification with nondominant hand

PURPOSE

Evaluation of on axis phacoemulsification surgery through temporal incision using nondominant hand with surgeon sitting at the head end, inpatients with against-the-rule astigmatism.

METHODS

Eighty eyes of 80 patients who underwent phacoemulsification through a temporal clear corneal tunnel for age-related cataract and against-the-rule astigmatism were enrolled and divided into four equal groups. In Group 1A, the surgeon was sitting at the head end for the left eye performing surgery with the left hand (nondominant hand). In group 1B, the surgeon was seated at the temporal side and surgery was performed in the left eye with dominant right hand. In group 2A, the surgeon was sitting at the head end for the right eye and performed surgery holding the phacoemulsification hand piece in his right hand. In group 2B, the surgeon sat on the temporal side of the right eye and performed phacoemulsification with his right hand. The patients were followed up on day 7, 1 month, and 3 months. Parameters evaluated included average phaco power, effective phaco time, uncorrected and best-corrected visual acuity, keratometry, intraocular pressure, surgically induced astigmatism, pachymetry, and endothelial cell counts.

RESULTS

The phaco time and phaco power among the four groups were comparable (phaco time: P=0.368; phaco power: P=0.294). The four groups were also comparable on parameters like surgically induced astigmatism (P=0.674), change in postoperative keratometric astigmatism (P=0.584), endothelial cell loss (0.921), change in ultrasonic pachymetry (P=0.476), and intraocular pressure (P=0.942). No intraoperative or postoperative complications were observed in any of the groups. The mean uncorrected visual acuity at 3 months in group 1 was 0.723+/-0.21; in group 2 it was 0.756+/-0.21; in group 3 it was 0.748+/-0.22, and in group 4 it was 0.732+/-0.23. The best-corrected visual acuity was 0.96+/-0.10, 0.97+/-0.11, 0.95+/-0.13, and 0.96+/-0.10 in the four groups at 3 months.

CONCLUSION

Phacoemulsification surgery can be successfully performed with nondominant hand with a good surgical outcome. The technique gives an alternative approach where surgeon does not have to shift the position to perform on-axis phacoemulsification.

Laparoscopic total extraperitoneal repair versus anterior preperitoneal repair for inguinal hernia

Laparoscopic inguinal hernia repair is still not the gold standard for repair although mesh implantation is unequivocally accepted as an integral part of any groin hernia repair. The aim of the study was to compare the results of anterior preperitoneal (APP) mesh repair with totally extra peritoneal (TEP) repair for inguinal hernias. The prospective study was conducted on 241 patients with 247 hernias (from January 2000 to June 2004). Anterior preperitoneal repair was done in 121 patients and 120 patients were subjected to TEP repair. Repair in both groups was done by using Prolene mesh of size 6x4 in. or 6x6 in. intraoperative and postoperative parameters and complications were recorded and the patients were followed up to 1 year post-surgery. For both unilateral and bilateral inguinal hernias, mean operative time was significantly more in patients of TEP repair as compared to APP repair (P<0.001) and significantly more patients had peritoneal tears in the TEP group (P<0.001). Patients undergoing TEP repair, however, had significantly less postoperative pain (P<0.05) and postoperative hospital stay (P<0.05) and return to work was significantly earlier is this group (P<0.01 and P<0.001). There was no difference in the recurrence rate between the two groups. Patients with inguinal hernias undergoing laparoscopic repair recover more rapidly, and have less incidence of postoperative pain. But it takes significantly more time to perform than APP repair and also the incidence of peritoneal tear is higher.