A case of aspartate aminotransferase macroenzyme

Aspartate aminotransferase (AST) macroenzyme can result in elevated AST activity in patients with no disease. This case report describes a six-year-old boy who presented to his family doctor with a history of chronic constipation and lower back pain. Routine blood tests showed normal creatine kinase activity (CK), normal alanine aminotransferase activity (ALT) but raised AST. The patient was referred to a hospital paediatrician for further investigation of the abnormal AST and back pain. The raised AST was confirmed as the only biochemical abnormality. Further investigation with polyethylene glycol, followed by measurement of AST in the supernatant, showed undetectable enzyme activity. The sample was sent to a specialist laboratory where it was analysed by Sephacryl S300 gel filtration. This procedure confirmed the presence of a high molecular mass form of AST. AST macroenzyme should be considered as a cause of isolated AST increase, which may avoid further costly investigations.

Quantitative estimation of permeability surface-area product in astroglial brain tumors using perfusion CT and correlation with histopathologic grade

BACKGROUND AND PURPOSE

Glioma angiogenesis and its different hemodynamic features, which can be evaluated by using perfusion CT (PCT) imaging of the brain, have been correlated with the grade and the aggressiveness of gliomas. Our hypothesis was that quantitative estimation of permeability surface area product (PS), cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transit time (MTT) in astroglial brain tumors by using PCT will correlate with glioma grade. High-grade gliomas will show higher PS and CBV as compared with low-grade gliomas.

MATERIALS AND METHODS

PCT was performed in 32 patients with previously untreated astroglial tumors (24 high-grade gliomas and 8 low-grade gliomas) by using a total acquisition time of 170 seconds. World Health Organization (WHO) glioma grades were compared with PCT parameter absolute values by using Student or nonparametric Wilcoxon 2-sample tests. Receiver operating characteristic (ROC) analyses were also done for each of the parameters.

RESULTS

The differences in PS, CBV, and CBF between the low- and high-grade tumor groups were statistically significant, with the low-grade group showing lower mean values than the high-grade group. ROC analyses showed that both CBV (C-statistic 0.930) and PS (C-statistic 0.927) were very similar to each other in differentiating low- and high-grade gliomas and had higher predictability compared with CBF and MTT. Within the high-grade group, differentiation of WHO grade III and IV gliomas was also possible by using PCT parameters, and PS showed the highest C-statistic value (0.926) for the ROC analyses in this regard.

CONCLUSIONS

Both PS and CBV showed strong association with glioma grading, high-grade gliomas showing higher PS and CBV as compared with low-grade gliomas. Perfusion parameters, especially PS, can also be used to differentiate WHO grade III from grade IV in the high-grade tumor group.

Protocol for the combined immunosuppression & radiotherapy in thyroid eye disease (CIRTED) trial: a multi-centre, double-masked, factorial randomised controlled trial

BACKGROUND

Medical management of thyroid eye disease remains controversial due to a paucity of high quality evidence on long-term treatment outcomes. Glucocorticoids are known to be effective initially but have significant side-effects with long-term use and recrudescence can occur on cessation. Current evidence is conflicting on the efficacy of radiotherapy and non-steroid systemic immunosuppression, and the majority of previous studies have been retrospective, uncontrolled, small or poorly designed.The Combined Immunosuppression and Radiotherapy in Thyroid Eye Disease (CIRTED) trial was designed to investigate the efficacy of radiotherapy and azathioprine in combination with a standard course of oral prednisolone in patients with active thyroid eye disease.

METHODS/DESIGN

Patients with active thyroid eye disease will be randomised to receive (i) azathioprine or oral placebo and (ii) radiotherapy or sham-radiotherapy in this multi-centre, factorial randomised control trial. The primary outcome is improvement in disease severity (assessed using a composite binary measure) at 12 months and secondary end-points include quality of life scores and health economic measures.

DISCUSSION

The CIRTED trial is the first study to evaluate the role of radiotherapy and azathioprine as part of a long-term, combination immunosuppressive treatment regime for Thyroid Eye Disease. It will provide evidence for the role of radiotherapy and prolonged immunosuppression in the management of this condition, as well as pilot data on their use in combination. We have paid particular attention in the trial design to establishing (a) robust placebo controls and masking protocols which are effective and safe for both radiotherapy and the systemic administration of an antiproliferative drug; (b) constructing effective inclusion and exclusion criteria to select for active disease; and (c) selecting pragmatic outcome measures.

TRIAL REGISTRATION

Current controlled trials ISRCTN22471573.

Inferior oblique schwannoma: diagnosis and management

INTRODUCTION

Orbital schwannoma accounts for less than 5% of orbital tumours and few cases arising in the superior orbit are reported in the literature.

PURPOSE

To present, to our knowledge, the first report of inferior oblique-associated orbital schwannoma.

METHODS

Interventional case report with clinical photographs, MRI imaging, intra-operative photographs and histology.

RESULTS

A 68 year-old man presented with decreased right vision and double vision in downgaze. Examination revealed a right 3 mm ptosis, hypertropia and limitation of depression. Exploration and excision, via anterior orbitotomy, and histological examination confirmed a schwannoma located within the right inferior oblique muscle. Vision normalised post-operatively and there has been no clinical or radiological recurrence of the lesion at 2 years.

CONCLUSIONS

This rare case highlights that schwannoma may occur in association with the inferior oblique complex and we suggest that schwannomas should now be considered in the differential diagnosis when patients present with a clinically-suspected or radiologically-proven orbital mass.

Outcome of sixty four cases of ethylene dibromide ingestion treated in tertiary care hospital

BACKGROUND AND AIMS

In view of high incidence and mortality due to ethylene dibromide poisoning, a prospective study was planned to assess demographic, toxicological, clinical profile and outcome.

MATERIAL AND METHODS

Prospectively collected data of sixty four patients with ethylene dibromide poisoning were reviewed. All the patients were from Gwalior and neighbouring districts.

RESULTS

Majority were males in the age group 21-30 years. Out of sixty-four cases 26 patients (40.6%) survived and 38 patients (59.4%) expired. Nausea vomiting and pain abdomen were most common symptoms at presentation. Diarrhoea, drowsiness, palpitations and oliguria were other features. Pulse rate was normal (< 100) in 22 (84.6%) survived patients whereas it was > 100 in 24 (63.1%) of expired patients at the time of admission (p value = 0.0004199). Half ampoule (1.5ml.) of ethylene dibromide was sufficient as fatal dose. Mortality was 20% and 46.15% with half and one ampoule respectively. Best outcome was when the patient presented to the hospital within six hours. Death occurred anywhere between twelve hours and five days. Gastrointestinal toxicity was predominant at presentation. Nausea, vomiting and abdominal pain was present in all the patients. Nephrotoxicity 32 (50%), hepatotoxicity 28 (43.8%), cardiotoxicity 28 (43.8%), central nervous system 8 (12.5%) toxicity and hypoglycemia 24 (37.5%) were also observed.

CONCLUSION

Ethylene dibromide is highly toxic. Patients who consumed half to one ampoule usually survived with supportive care provided they presented to the hospital within six hours. Pulse rate more than 100 at presentation was a poor prognostic factor. Patients with normal pulse and blood pressure at admission had better prognosis.

Role of perfusion CT in glioma grading and comparison with conventional MR imaging features

BACKGROUND AND PURPOSE

Perfusion imaging using CT can provide additional information about tumor vascularity and angiogenesis for characterizing gliomas. The purpose of our study was to demonstrate the usefulness of various perfusion CT (PCT) parameters in assessing the grade of treatment-naïve gliomas and also to compare it with conventional MR imaging features.

MATERIALS AND METHODS

PCT was performed in 19 patients with glioma (14 high-grade gliomas and 5 low-grade gliomas). Normalized ratios of the PCT parameters (normalized cerebral blood volume [nCBV], normalized cerebral blood flow [nCBF], normalized mean transit time [nMTT]) were used for final analysis. Conventional MR imaging features of these tumors were assessed separately and compared with PCT parameters. Low- and high-grade gliomas were compared by using the nonparametric Wilcoxon 2-sample tests.

RESULTS

Mean nCBV in the high- and low-grade gliomas was 3.06 +/- 1.35 and 1.44 +/- 0.42, respectively, with a statistically significant difference between the 2 groups (P = .005). Mean nCBF for the high- and low-grade gliomas was 3.03 +/- 2.16 and 1.16 +/- 0.36, respectively, with a statistically significant difference between the 2 groups (P = .045). Cut points of >1.92 for nCBV (85.7% sensitivity and 100% specificity), >1.48 for nCBF (71.4% sensitivity and 100% specificity), and <1.94 for nMTT (92.9% sensitivity and 40% specificity) were found to identify the high-grade gliomas. nCBV was the single best parameter; however, using either nCBV of >1.92 or nCBF of >1.48 improved the sensitivity and specificity to 92.9% and 100%, respectively. The sensitivity and specificity for diagnosing a high-grade glioma with conventional MR imaging were 85.7% and 60%, respectively.

CONCLUSIONS

PCT can be used for preoperative grading of gliomas and can provide valuable complementary information about tumor hemodynamics, not available with conventional imaging techniques. nCBV was the single best parameter correlating with glioma grades, though using nCBF when nCBV was <1.92 improved the sensitivity. An nCBV threshold of >1.92 was found to identify the high-grade gliomas.

Acute bone crises in sickle cell disease: the T1 fat-saturated sequence in differentiation of acute bone infarcts from acute osteomyelitis

AIM

To prove the hypothesis that acute bone infarcts in sickle cell disease are caused by sequestration of red blood cells (RBCs) in bone marrow, and to evaluate the unenhanced T1 fat-saturated (fs) sequence in the differentiation of acute bone infarction from acute osteomyelitis in patients with sickle-cell disease.

MATERIALS AND METHODS

Two studies were undertaken: an experimental study using in-vitro packed red blood cells and normal volunteers, and a retrospective clinical study of 86 magnetic resonance imaging (MRI) studies. For the experimental study containers of packed RBCs were placed between the knees of four healthy volunteers with a saline bag under the containers as an additional control, and were scanned with the pre-contrast T1-fs sequence. Signal intensity (SI) ratios were obtained for packed RBCs:skeletal muscle and packed RBCs:saline. For the clinical study, the SIs of normal bone marrow, packed RBCs, bone and/or soft-tissue lesions, and normal skeletal muscle of 74 patients (86 MRI studies) were measured using unenhanced, T1 fat-saturated MRI. The ratios of the above SIs to normal skeletal muscle were calculated and subjected to statistical analysis.

RESULTS

Fifty-one of 86 MRI studies were included in the final analysis. The ratios of SIs for normal bone marrow, packed red cells, bone infarction, acute osteomyelitis, and soft-tissue lesions associated with bone infarct, compared with normal skeletal muscle were (mean+/-SD) 0.9+/-0.2, 2.1+/-0.7, 1.7+/-0.5, 1.0+/-0.3, and 2.2+/-0.7, respectively. The difference in the ratio of SIs of bone infarcts and osteomyelitis was significant (p=0.003). The final diagnoses were bone infarction (n=50), acute osteomyelitis (n=1), and co-existent bone infarction and osteomyelitis (n=2). Seven patients who had suspected osteomyelitis underwent image-guided aspiration.

CONCLUSION

Acute bone infarcts in sickle cell disease are caused by sequestration of red blood cells in the bone marrow. The unenhanced, T1-fat-saturated sequence alone is diagnostic for acute bone infarcts. Contrast enhancement aids in the diagnosis of acute osteomyelitis. MRI can thus help in early diagnosis, specific treatment, and preventing empirical antibiotic therapy.

Phase I/II study of neoadjuvant bevacizumab with radiation therapy and 5-fluorouracil in patients with rectal cancer: initial results

4041

Background: A phase I/II study of neoadjuvant bevacizumab with 5-fluorouracil and radiation therapy in patients with locally advanced rectal cancer was undertaken to determine whether inhibition of VEGF is safe and has clinical benefits by enhancing chemo- radiation therapy. Methods: 22 patients with endoscopic ultrasound or surface coil MRI staged T3/T4 non-metastatic rectal cancer were enrolled from 2001–2006. All patients completed 4 cycles of neoadjuvant therapy including: 1) bevacizumab infusion (5 or 10 mg/kg) on day 1 of each cycle; 2) peripheral venous infusion 5-FU (225 mg/m2/24 hours) administration each treatment week of cycles 2 - 4; 3) external beam irradiation delivery (50.4 Gy in 28 fractions over 5.5 weeks); and 4) surgery 7 to 9 weeks after completion of all neoadjuvant therapy. Correlative studies were undertaken before and during the trial. We collected serial tumor biopsies, PET-FDG scans, and analyzed blood and urine for potential biomarkers. Results: Mean pre-therapy tumor size was 4.7 cm (2–9 cm). Post-treatment surgical specimens usually had well-demarcated shallow ulcerations with a mean diameter of 2.4 cm (0.7–6 cm). In response to the neoadjuvant regimen, all patients had significantly (p<0.01) decreased FDG-uptake by PET. Histologic examination showed no residual primary cancer in 5 patients (ypT0). Of 17 patients with residual disease, microscopic disease usually occurred as malignant glands embedded in fibrosis (ypT1 in 3 patients, ypT2 in 4 patients, ypT3 in 10 patients). Downstaging was seen in 12/22 tumors. 8 patients had microscopic nodal metastases. Bevacizumab alone and combined treatment were both associated with increased plasma VEGF and PlGF levels in 18/18 patients (P<0.01 at all 4 timepoints compared to baseline). Viable CECs were decreased by VEGF blockade at day 3 (P<0.01 compared to baseline), and peak CEC levels during treatment was correlated with histologic tumor response (2.77 [1.18–3.18] for T3 patients, n=9 versus 1.14 [0.82–1.53] for T0-T2 patients, n=12; p=0.05). Conclusions: Addition of bevacizumab at a dose of 5 mg/kg to standard chemo-radiation is safe in patients with locally advanced rectal cancer. Bevacizumab is active and the combined regimen yields promising results.

[Table: see text]

Single fraction radiosurgery of epidural spinal cord compression: Tumor control and neurologic outcome

2041

Purpose: Spine radiosurgery improves the pain and quality of life in spine metastasis. Phase II study was performed to determine the clinical efficacy of radiosurgery for malignant epidural spinal cord compression. Method: Total 67 patients with 93 lesions of epidural spinal cord compression at the solitary spine level were accrued. All patients had pathology-proven malignancy and had epidural tumor seen on MRI or CT scan. For radiosurgery, grossly visible tumor including the involved spine was treated with single fraction radiosurgery dose of 14–20 Gy. Spinal cord dose constraint was 10 Gy to 10% partial volume of the cord. Followup included neurological exam and imaging studies every 2 months. Endpoints were radiographic tumor control and neurological outcome. Median followup time was 8 months (2–30 months). Results: Objective radiographic tumor response was seen in 82% of patients. At 2 months, complete response was in seen 27%, partial response in 30%, and minimal response in 23%, Epidural tumor progressed in 6% at or the adjacent spine level. Thecal sac patency (= decompression effect) seen on T2-weighted MR image was improved in 82% of the lesions. There was average 68% volumetric reduction of tumor at the level of most severe cord compression. This tumor reduction opened the thecal sac patency to average 75% following radiosurgery, compared to 45% before radisourgery (p<0.05). Majority of patients with neurological deficit prior to radiosurgery were ambulatory with an improved neurological function or remained clinically stable. There was one case of likely long-term radiation-induced myelopathy 13 months after radiosurgery. Conclusion: Single fraction radiosurgery achieves significant tumor response and decompressive effect of spinal cord compression. Even minimal tumor response relieves the spinal cord compression and potential neurologic improvement. Spine radiosurgery can be a viable treatment option for spinal cord compression.

No significant financial relationships to disclose.

A phase II trial of AZD2171 (cediranib), an oral pan-VEGF receptor tyrosine kinase inhibitor, in patients with recurrent glioblastoma

2001

Background: AZD2171 (cediranib) is a potent, oral pan-VEGF receptor tyrosine kinase inhibitor with a half-life of 20 hours compatible with once-daily dosing. A primary target of AZD2171, VEGFR2, is expressed on glioblastoma endothelium. We have demonstrated normalization of tumor vessels in recurrent glioblastoma patients treated with daily doses of AZD2171. Normalization has rapid onset, is reversible and is associated with alleviation of brain edema [Cancer Cell 2007; 11: 83]. Methods: In this phase II study of 30 recurrent glioblastoma subjects the primary endpoint was the proportion of patients alive and progression-free at 6 months (APF6). Secondary endpoints include radiographic response proportion; progression-free survival; overall survival and toxicity. At this time we are presenting radiographic response data and toxicity on the first 16 consecutive patients and APF6, PFS and OS on all 30 patients. Complete information will be available on all 30 patients at the time of presentation. Results: Twenty-eight patients have experienced disease progression and two patients remain in follow-up without progression. The primary and secondary endpoints are tabulated below: Only one of the first 16 patients was removed from the study due to toxicity (fatigue). Dose limiting toxicities of hypertension, fatigue and diarrhea were observed in 9/16 patients. There were no intracerebral hemorrhages. AZD2171 alleviated brain edema, a major cause of morbidity in glioblastoma patients, and had a steroid-sparing effect in the first 16 patients enrolled. Blood biomarkers were serially assessed and elevated levels of bFGF, SDF1a and viable circulating endothelial cells correlated with disease progression. Conclusions: AZD2171 has activity in patients with recurrent glioblastoma. Combination studies of AZD2171 with radiation and chemotherapy are planned.

[Table: see text]

[Table: see text]

Chlamydia sp. in hospitalised children with community acquired pneumonia

Our aim was to document the prevalence of chlamydial infection in children less than five years of age with Community Acquired Pneumonia (CAP). Seventy three children, 1 month to 5 years of age, hospitalized with CAP were enrolled over a period of one year. Microimmunofluorescence (MIF) was done to detect IgM antibodies against Chlamydia sp. in sera of all patients; PCR was performed to detect C. pneumoniae DNA in nasopharyngeal aspirates. The prevalence of Chlamydia species infection in CAP in children < 5 years of age was 5.5% (4/73). Two cases were positive for C. trachomatis antibodies; one case was positive for C. pneumoniae antibodies and one case was positive for C. pneumoniae DNA. Chlamydia sp. have an important role in CAP in children < 5 years and for early diagnosis of infection, use of more than one method i.e. PCR and serology both is advisable.

Patient consultation survey in an ophthalmic outpatient department

INTRODUCTION

Consultation methods differ between medical practitioners depending on the individual setting. However, the central tenet to the doctor-patient relationship is the issue of confidentiality. This prospective survey highlights patient attitudes towards consultation methods in the setting of an ophthalmic outpatient department.

METHOD

Questionnaires were completed by 100 consecutive patients, who had been seen by an ophthalmologist in a single room, which had a joint doctor-patient consultation occurring simultaneously.

RESULTS

Each question of all 100 questionnaires was completed. 58% of patients were not concerned about sharing a consultation room with another patient or doctor. However, this did not equate to the 49% of patients who were indifferent to discussing issues in the joint consultation room. The most common factor was the general issue of confidentiality.

DISCUSSION

Ensuring total patient confidentiality may be deemed more necessary for certain medical specialties than for others, as seen in the practice of separate medical records in genitourinary medicine, for instance. However, with regard to patient consultations, the same level of confidentiality should be afforded across all specialties, and such factors should be borne in mind when planning outpatient clinics.

Application of neural networks in the interpretation of impedance cardiovasograms for the diagnoses of peripheral vascular diseases

An Impedance Cardio-vasograph (ICVG) system has been developed at the Electronics Division, Bhabha Atomic Research Centre (B.A.R.C) for the assessment of Peripheral Blood Flow and has been installed at the Department of Medicine, J.J. Hospital, Mumbai, India. Impedance cardio-vasography (ICVG) gives an indirect assessment of blood volume changes by measurement of normalized rate of change of electrical impedance (N dZ/dt) of the body segment. Parameters like Blood Flow Index (BFI) and Differential Pulse Arrival Time (DPAT) at different locations in both lower extremities (upper thigh, knee, calf and ankle) can be computed from these measurements. This work deals with the analysis of these parameters by a neural network system for obtaining proper diagnosis of subjects with peripheral vascular diseases. The designed network identified the presence of anatomical block or narrowing for most of cases presented to it during testing and also the status of collateral circulation in the lower limbs. The neural network was trained again, with the few cases, which were not predicted correctly. The collaterals after the site of occlusion were classified as good, moderate or poor as an aid to the physician. The network identified cases with athero-sclerotic narrowing satisfactorily and was also able to categorize cases where changes are observed only in one extremity, other remaining normal as in the cases of hemi-Leriche's syndrome. An additional parameter CVS (Coefficient of venous Statis) was calculated which is useful for the diagnosis of primary and secondary varicosity of the veins.

Subjective effects of additional doses of buprenorphine in patients on buprenorphine maintenance

OBJECTIVES

Buprenorphine has considerable abuse potential. Patients who are maintained on buprenorphine (for opioid dependence) further use additional doses besides its maintenance dose. Subjective effects of the additional doses of buprenorphine in patients on buprenorphine maintenance patients is focused in this study.

METHODS

Nineteen subjects who were maintained on buprenorphine 4mg, s/l per day for at least 1month were admitted and given three additional doses of buprenorphine 2mg, s/l at the interval of 2h each and subjective effects were assessed with the help of standard tools after 2h of each dose and the next day also. Drug was given in a cumulative dose design in the inpatient unit of a de-addiction centre.

RESULTS

Dysphoria and sleepiness increased while euphoria and drug liking decreased with additional doses of buprenorphine. These changes were statistically significant and were highest at maximum cumulative dose of 10mg.

CONCLUSION

Results suggest that abuse liability of buprenorphine in these subjects is low in higher doses. However, these findings need to be replicated in this group of patients to make a comment on clinical implication.