Epidemiology of lung cancer in India: focus on the differences between non-smokers and smokers: a single-centre experience

CONTEXT

Lung cancer has varied epidemiology depending on the geographic region. Globally, there have been important changes in incidence trends amongst men and women, histology, and incidence in non-smokers. Indian epidemiological data on lung cancer is scarce.

AIMS

We set out to study the epidemiological patterns and clinical profile of lung cancer in India.

MATERIALS AND METHODS

We interviewed patients discussed in the thoracic oncology multidisciplinary meetings between 2008 and 2009. Demographic data, smoking history, place of residence, histology, stage at presentation, and treatment details were collected. Data was entered and analyzed in SPSS.

RESULTS

There were 489 patients, with a median age of 56 years, of which 255 (52%) were non-smokers and 234 (48%) were smokers. One hundred and thirty-three patients had consumed smokeless tobacco. The male-to-female ratio was 3.5:1. Sixty-nine patients (14.1%) were incorrectly diagnosed and treated with anti-tuberculosis treatment, which delayed the diagnosis of lung cancer by four months. Eight percent of patients had small-cell carcinoma; of the 92% patients with non-small-cell carcinoma (NSCLC), the most common histology was adenocarcinoma (43.8%), followed by squamous cell (26.2%), large cell (2.1%) and other (8.3%). Eighteen percent of patients were diagnosed by cytology, therefore were diagnosed as NSCLC, without further histologic subtyping. Most patients (43%) were in Stage III at presentation. Lung followed by bone were the common sites of metastases. The majority of the patients (49%) received palliative chemotherapy. Among definitive therapy, concurrent chemo-radiation (13%) was offered more frequently than surgery (6%).

CONCLUSION

Considerably higher numbers of Indian patients with lung cancer are non-smokers, compared to the West. The global trend of rise in adenocarcinoma is paralleled in India. Non-tobacco-related risk factors need further investigation.

Abstract PD01-01: Overcoming endocrine therapy resistance related to PTEN loss by strategic combinations with mTOR, AKT, or MEK inhibitors

Background: Hyperactive PI3K signaling is associated with a more aggressive subtype of estrogen receptor (ER) positive breast cancer (BC) and with endocrine resistance. Loss or downregulation of PI3K's inhibitor PTEN is more common in basal and luminal B vs. luminal A BC. However, the role of PTEN in modulating response to various endocrine therapies is unclear. Here we investigated the effects of PTEN knockdown (KD) on endocrine sensitivity and the potential of multiple kinase inhibitors to restore and improve responses.

Methods: Nude mice bearing ER+ BC xenograft tumors of MCF7 cells stably expressing a doxycycline (Dox)-inducible PTEN-shRNA were randomized to four endocrine treatment groups [continued estrogen (E2) supplementation, or E2-deprivation (ED) alone or in combination with tamoxifen (Tam) or fulvestrant (Ful)]; all -/+ Dox. The effects of single or combined kinase inhibitors on these endocrine treatments -/+ Dox were studied in vitro using inhibitors (i) to mTOR (AZD2014, 0.2 μM), AKT (AZD5363, 1 μM), or MEK (Selumetinib/ARRY-142886, 1 μM). Cell growth, apoptosis, and ER and progesterone receptor (PR) signaling were analyzed using cell cytometry, qRT/PCR, and Western blotting. Synergism tests were used to examine the growth effects of the most promising combinatorial therapy with multiple kinase inhibitors in different endocrine settings.

Results: In wild-type (WT) PTEN xenograft tumors, endocrine therapies were very effective, inducing frequent tumor regression. In PTEN KD tumors endocrine therapies were less effective — PTEN KD delayed tumor regression in all endocrine regimens and accelerated tumor progression in the Tam treated group. Furthermore, at day 250, only 1/8 and 0/7 tumors had developed resistance in the ED and the Ful (−Dox) groups, respectively, while with PTEN KD (+Dox), 7/15 and 5/15 tumors developed resistance to ED and to Ful. In vitro PTEN KD also induced resistance to all endocrine therapies. mRNA and/or protein levels of ER and PR were suppressed by PTEN KD and restored by mTORi and AKTi. In cells with WT PTEN, mTORi was highly effective with or without endocrine therapy. However, AKTi and MEKi were more effective in combination with endocrine therapy. All three inhibitors were less effective upon PTEN KD. The mTORi plus AKTi combination resulted in a potent synergistic inhibition in PTEN KD cells in the presence of E2 or with ED. In contrast, in the presence of Tam, AKTi plus MEKi, independent of PTEN status, was the most effective combination at the doses chosen. Finally, these inhibitors and combinations were more effective in the presence of Ful than ED or Tam in WT PTEN cells. AKTi combined with Ful was still highly effective even in PTEN KD cells, but mTORi and MEKi were less effective.

Conclusions: Our results suggest that PTEN loss renders endocrine therapy less effective in in vitro and in vivo experimental models. Single AKT/MEK kinase inhibitors are more potent in the presence of endocrine therapy. In PTEN KD cells, the activity of all three kinase inhibitors is largely diminished, except for AKTi in the presence of fulvestrant. Kinase inhibitor combinations are generally more effective, but the optimal combinations vary by PTEN status and type of endocrine therapy.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD01-01.

Massive ascites in severe pre-eclampsia: a rare complication

We report a rare case of massive maternal ascites complicating severe pre- eclampsia toxaemia (PET) seen in April 2013. This complication developed in association with the rise of blood pressure of 160/110 mmHg or more, worsening of proteinuria and hyperuricaemia. The onset of massive ascites caused respiratory compromise to the patient, thus necessitating immediate termination of pregnancy.

Endoscopic excision of Angiofibroma

We present a case of Juvenile Nasopharyngeal Angiofibroma (JNA) managed by endoscopic excision alone. The selection of the case, technical difficulties and the advantages offered by this technique are detailed.

"What's in a name?" Delirium by any other name would be as deadly. A review of the nature of delirium consultations

INTRODUCTION

Delirium is often underdiagnosed, resulting in adverse clinical outcomes. The goal of this study was to identify how patients correctly diagnosed with delirium differ from those who are misdiagnosed.

METHODS

A retrospective chart review was conducted using a database of 1,000 consecutive psychiatric consultation requests. Patients were identified based on a diagnosis of delirium made by the consultation team. Charts were then reviewed for data on race, gender, age, time and month of the consultation, documented diagnosis of mental illness, and information that would help establish a delirium diagnosis based on DSM-IV-TR criteria. Univariate and multivariate analyses were performed.

RESULTS

Cases were judged to be diagnostically concordant (consultation requested for delirium or encephalopathy, n = 30) or discordant (n = 81). The two groups did not differ significantly in age, sex, race, time and month of the consultation, or documentation of mental illness. The concordant group had a significantly greater number of identifiable diagnostic criteria compared to the discordant group (mean 3.0 ± 0.8 criteria vs. 1.9 ± 1.3 criteria, P < 0.001). Identification of individual diagnostic criteria was greater in the concordant group, with significant differences for two of four categories, namely acute onset (100.0% vs. 50.6%, P < 0.001) and fluctuating course (93.3% vs. 66.7%, P = 0.004). Multivariate analysis suggested increased odds of identifying delirium if more diagnostic criteria were identifiable (OR: 2.355, P < 0.001, confidence interval [CI] 1.502-3.690), and increased likelihood of the delirium diagnosis being missed if there was documentation of psychiatric illness (OR: 0.387, P = 0.049, CI: 0.151-0.995).

CONCLUSION

This study highlights the need for educational programs and easy to implement screening tools to ensure delirium is not overlooked.

Calcaneal Myxoid Chondrosarcoma: A Rare Case

Skeletal myxoid chondrosarcoma is an extraordinarily rare neoplasm with a distinct histological morphology. Although it grows slowly, the clinical course was found to be worse than usual chondrosarcoma. We report a case of a Skeletal myxoid chondrosarcoma in the calcaneus of a 21-year-old female who presented to us with a feature of gradually increasing benign swelling left foot for last two years. Initial investigations were indicating towards a benign lesion for which excision of the lesion was performed. But intra operative findings were suggestive of an aggressive lesion, and to our utter surprise histopathologically it turned out to be Myxoid Chondrosarcoma. Because of its high malignant nature below knee amputation was performed as second definitive surgery. Since her clinical course and radiological pictures were suggestive of benign lesion we got carried away with a diagnosis of chondrmyxoid fibroma and excision of the lesion was attempted without attempting histopathological diagnosis by less invasive methods. Keywords: caldaneal; chondrosarcoma; myxoid.

Increased nitric oxide activity compensates for increased oxidative stress to maintain endothelial function in rat aorta in early type 1 diabetes

Hyperglycaemia and oxidative stress are known to acutely cause endothelial dysfunction in vitro, but in the initial stages of diabetes, endothelium-dependent relaxation is preserved. The aim of this study was to investigate how endothelium-dependent relaxation is maintained in the early stages of type 1 diabetes. Diabetes was induced in Sprague-Dawley rats with a single injection of streptozotocin (48 mg/kg, i.v.), and after 6 weeks, endothelium-dependent and endothelium-independent relaxations were examined in the thoracic aorta in vitro. Lucigenin-enhanced chemiluminescence was used to measure superoxide generation from the aorta. Diabetes increased superoxide generation by the aorta (2,180 ± 363 vs 986 ± 163 AU/mg dry tissue weight). Acetylcholine (ACh)-induced relaxation was similar in aortae from control (pEC(50) 7.36 ± 0.09, R (max) 95 ± 3 %) and diabetic rats (pEC(50) 7.33 ± 0.10, R (max) 88 ± 5 %). The ACh-induced relaxation was abolished by the combined presence of the nitric oxide synthase inhibitor N-nitro-L-arginine (L-NNA, 100 μM) and an inhibitor of soluble guanylate cyclase, 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ, 10 μM) in control rats, but under the same conditions, the diabetic aortic rings showed significant relaxation to ACh (pEC(50) 6.75 ± 0.15, R (max) 25 ± 4 %, p < 0.05). In diabetic aortae, the addition of haemoglobin, which inactivates nitric oxide, to L-NNA + ODQ abolished the response to ACh. The addition of the potassium channel blockers, apamin and TRAM-34, to L-NNA + ODQ also abolished the relaxation response to ACh. Diabetes significantly elevated plasma total nitrite/nitrate and increased expression of endothelial nitric oxide synthase (eNOS) and calmodulin in aortae. These data indicate that after 6 weeks of diabetes, despite increased oxidant stress, endothelium-dependent relaxation is maintained due to the increased eNOS expression resulting in increased NO synthesis. In diabetic arteries, NO acts both through and independently of cGMP pathways to cause relaxation.

Endothelium-dependent nitroxyl-mediated relaxation is resistant to superoxide anion scavenging and preserved in diabetic rat aorta

The aim of the study was to investigate whether diabetes-induced oxidant stress affects the contribution of nitroxyl (HNO) to endothelium-dependent relaxation in the rat aorta. Organ bath techniques were employed to determine vascular function of rat aorta. Pharmacological tools (3mM l-cysteine, 5mM 4-aminopyridine (4-AP), 200μM carboxy-PTIO and 100μM hydroxocobalamin, HXC) were used to distinguish between NO and HNO-mediated relaxation. Superoxide anion levels were determined by lucigenin-enhanced chemiluminescence. In the diabetic aorta, where there is increased superoxide anion production, responses to the endothelium-dependent relaxant ACh were not affected when the contribution of NO to relaxation was abolished by either HXC or carboxy-PTIO, indicating a preserved HNO-mediated relaxation. Conversely, when the contribution of HNO was inhibited with l-cysteine or 4-AP, the sensitivity and maximum relaxation to ACh was significantly decreased, suggesting that the contribution of NO was impaired by diabetes. Furthermore, whereas HNO appears to be derived from eNOS in normal aorta, in the diabetic aorta it may also arise from an eNOS-independent source, perhaps derived from nitrosothiol stores. Similarly, exposure to the superoxide anion generator, pyrogallol (100μM) significantly reduced the sensitivity to the NO donor, DEANONOate and ACh-induced NO-mediated relaxation but had no effect on responses to the HNO donor, Angeli's salt and ACh-induced HNO-mediated relaxation in the rat aorta. These findings demonstrate that NO-mediated relaxation is impaired during oxidative stress but the HNO component of relaxation is preserved under those conditions.

Seasonal population dynamics of the potato psyllid (Hemiptera: Triozidae) and its associated pathogen "Candidatus Liberibacter solanacearum" in potatoes in the southern great plains of North America

The potato psyllid, Bactericera cockerelli (Sulc) (Hemiptera: Triozidae), and its associated pathogen "Candidatus Liberibacter solanacearum" (Ca. L. solanacearum), the putative causal agent of zebra chip (ZC) disease in potatoes (Solanum tuberosum L.), were sampled in commercial potato fields and untreated control plots for 3 yr in multiple locations in Texas, Kansas, Nebraska, and Colorado. Populations of the potato psyllid varied across years and across potato growing regions. However, the percentage of potato psyllids infected with Ca. L. solanacearum although variable across years, was consistently highest in the Lower Rio Grande Valley of Texas (LRGV), the reported overwintering location for this pest. The numbers of Ca. L. solanacearum-infected psyllids collected on field traps and large nymphs counted on leaf samples were both positively correlated with the final percentage of ZC in tubers. In the LRGV, where vector and disease pressure is the highest, population levels of immature life stages of the psyllid and percentage of ZC differed greatly between commercial and untreated fields. These results show that the pest management program that was used can be effective at controlling development of the psyllid and ultimately reducing the incidence of ZC.

Reduction of Acute Anterior Shoulder Dislocation Using Intraarticular Lidocaine(IAL) and Stimson’s Technique

Introduction: Shoulder dislocation is common injury requiring urgent reduction. For the reason that patient is not nill orally and anesthetists are not available, reduction under intra venous anaesthesia is not possible. This study was aimed to evaluate the effectiveness of intraarticular lidocaine and stimson’s technique of shoulder dislocation, which could be performed without anesthetist and irrespective of nill orally status. Methods: A prospective observational study was performed from December 2009 to December 2010. Under all antiseptic precautions 20 ml of Lidocaine was injected intraarticularly and reduction was performed by Stimson’s technique. Visual Analogue Score, time for reduction and failure to reduction by this technique was recorded. Results: Out of 27 dislocations 22 were successfully reduced and remaining required added scapular manipulation. The mean VAS scor was 2.3±1.26 and the mean time of reduction was 17.96±1.9 minutes. Conclusion: Stimson’s method with Intraarticular Lidocaine is effective, safe, less costly and can be performed in periphery where anesthetist and monitoring facilities are not available. DOI: http://dx.doi.org/10.3126/mjsbh.v10i1.6406 Medical Journal of Shree Birendra Hospital Jan-June 2011 10(1) 6-8

Combined Spinal Epidural Anesthesia for Total Hip Replacement Surgery in Birendra Army Hospital

Introduction: Total Hip Replacement surgery is one of the most commonly performed surgeries worldwide. Epidural anaesthesia have shown decrease incidence of DVT in these patient. Hence, combined spinal epidural spinal anesthesia is now a preferred technique over spinal anesthesia alone. We have been practicing combined spinal epidural anesthesia routienely in total joint replacement, but have not analyzed the result. The aim of this study was to analyse various aspect of combined spinal epidura anesthesia. Methods: thirteen cases of ASA I and II who underwent Total Hip Arthroplasty under combined spinal epidural anesthesia were analysed. First epidural was given in space L2-3/L3-4 and patency was confirmed with test dose with InjXylocaine 2% with Adrenaline 3 ml, followed by Spinal anesthesia one space below with Bupivacaine 0.5% 3 ml. Results: Intra operative Mean Blood Pressure had dropped up to 55 mm of Hg.To maintain Blood pressure, Intravenous Fluid was given in average is 2423.077 ml and Vasopressure drug (Mephenteramine Maleate) was given in average of14.769 mg. Dura was accidentally puncture in one patient during epidural insertion and two epidural failed to provide post operative analgesia. Post operative rehabilitation was easy, one one patient developed DVT after 4 weeks of surgery. Conclusion: Combined epidural analgesia effectively manages postoperative pain, allows early ambulation and reduces the risk of deep vein thrombosis and thromboembolism, Although significant drop of Blood pressure was noted in all cases. DOI: http://dx.doi.org/10.3126/mjsbh.v10i1.6447 Medical Journal of Shree Birendra Hospital Jan-June 2011 10(1) 32-36

Calcaneal myxoid chondrosarcoma: a rare case

Skeletal myxoid chondrosarcoma is an extraordinarily rare neoplasm with a distinct histological morphology. Although it grows slowly, the clinical course was found to be worse than usual chondrosarcoma. We report a case of a skeletal myxoid chondrosarcoma in the calcaneus of a 21-year-old female who presented to us with a feature of gradually increasing benign swelling left foot for last two years. Initial investigations were indicating towards a benign lesion for which excision of the lesion was performed. But intra operative findings were suggestive of an aggressive lesion, and to our utter surprise histopathologically it turned out to be myxoid chondrosarcoma. Because of its high malignant nature below knee amputation was performed as second definitive surgery. Since her clinical course and radiological pictures were suggestive of benign lesion we got carried away with a diagnosis of chondromyxoid fibroma and excision of the lesion was attempted without attempting histopathological diagnosis by less invasive methods.

Genetic polymorphisms in the P2X7 gene and its association with susceptibility to tuberculosis

BACKGROUND

Several studies have reported the influence of genetic variations on susceptibility to tuberculosis (TB). Polymorphism in P2X7 gene coding for P2X7 receptor present on macrophages has been linked to TB in different populations.

OBJECTIVE

To assess the role of P2X7 gene -762T/C and -1513A/C polymorphisms in TB susceptibility.

DESIGN

In a case-control study, polymerase chain reaction (PCR) amplification of genomic DNA extracted from peripheral blood samples of cases and controls was followed by restriction fragment length polymorphism or allele-specific PCR.

RESULTS

The 1513C allele was found to be associated with TB susceptibility (P = 0.02, OR for variant C allele 1.33, 95%CI 1.03-1.73). A significant protective association against TB was found for -762T/C polymorphism (P < 0.01, OR for variant C allele 0.72, 95%CI 0.57-0.91). On classifying samples on the basis of sex, only males showed a significant association between P2X7 -1513A/C and P2X7 -762T/C and TB in the present study.

CONCLUSION

A significant association of 762T/C and 1513A/C polymorphisms with TB in the P2X7 gene was found in our study population. A sex bias, with only males showing a significant association with the disease, is the first report of this kind. Genetic studies for the characterisation of the susceptibility genes can help to gain a better understanding of TB pathogenesis.

Plasma factor VII-activating protease antigen levels and activity are increased in ischemic stroke

BACKGROUND

Factor VII-activating protease (FSAP) is a recently discovered plasma protease with a role in the regulation of hemostasis and vascular remodeling processes. Higher levels and activity of FSAP have been reported in patients with deep vein thrombosis, but there are no data on plasma FSAP in ischemic stroke (IS).

OBJECTIVE

To investigate whether FSAP antigen levels and activity are associated with IS and/or etiologic subtypes of IS.

PATIENTS AND METHODS

To assess the potential association between FSAP and IS, plasma FSAP antigen levels and activity were measured in 600 consecutive IS patients and 600 population-based controls from the case-control study the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS). Blood sampling was performed in the acute phase and 3 months after the index stroke. FSAP was also investigated at the genetic level by genotyping of 33 single-nucleotide polymorphisms.

RESULTS

Increased FSAP antigen level and activity, at both time-points, were independently associated with IS. Subtype analysis revealed similar associations for both FSAP measures, at both time-points, in all main IS subtypes. FSAP genotypes showed association with both FSAP plasma measurements, but not with IS.

CONCLUSIONS

Increased plasma FSAP antigen levels and activity were associated with IS and all main etiologic subtypes, suggesting a possible role for FSAP in the pathophysiology of IS, irrespective of the underlying etiology.

Impurity concentration and temperature dependence of the refractive indices of Er3+ doped ceramic Y2O3

The refractive indices and thermo-optic coefficients for varying concentrations of Er3+ doped polycrystalline yttria were measured at a variety of wavelengths and temperatures. A Lorenz oscillator model was employed to model the room temperature indices and thermo-optic coefficients were calculated based on temperature dependent index measurements from 0.45 to 1.064 microns. Some consequences relating to thermal lensing are discussed.

Renal transplantation and pregnancy

INTRODUCTION

Although pregnancy after kidney transplantation is feasible, complications are relatively common and this needs to be considered in patient counseling and clinical decision making.

REVIEW

Fertility generally returns after renal transplantation. Approximately 74% of pregnancies in kidney transplant recipients end successfully in life births. Published reports suggest that pregnancy has no adverse affects on graft survival although patients with higher pre-pregnancy serum creatinine have a trend toward increased post-pregnancy serum creatinine. There is, however, a significantly increased risk of preeclampsia, gestational diabetes, cesarean section and preterm delivery compared to the general population. Almost half life births are preterm, and low birth weight is very common. Immunosuppressive medications are required to be continued during pregnancy in transplant recipients to prevent graft rejection, except for sirolimus and mycophenolate mofetil (MMF) which are contraindicated during pregnancy. The incidence of birth defects in the live born is similar to the general population, except for pregnancies exposed to MMF which have a high incidence of birth defects. Every female in the reproductive age group should be counseled regarding pregnancy including the potential risks to the graft, to the mother and to the child. Timing pregnancy should be based upon whether graft function is optimal, but the general recommendation is to wait one year post transplantation before conception.

CONCLUSION

Pregnancy in renal transplant patients should be planned with combined care from surgeons, nephrologists, obstetricians, pediatricians and dietitians which offers the best chance of a favorable outcome in the mother and the fetus.

Applications of soluble, encapsulated and cross-linked peroxidases from Sapindus mukorossi for the removal of phenolic compounds

Peroxidases have been known to polymerize phenolic compounds and precipitate them from solution. Sapindus peroxidases (SPases) were extracted from the leaves of Sapindus mukorossi and precipitated with four volumes of chilled methanol. Soluble, encapsulated and cross-linked forms of enzymes were used for the removal of phenolic compounds (initial concentration 1.0 mM) in a stirred batch reactor. Calcium alginate beads were prepared using sodium alginate and calcium chloride at 1.5% and 5.0% (w/v), respectively. Sodium alginate and glutaraldehyde at 1.0% (w/v) and 0.8% (v/v), respectively, were optimized for cross-linking of SPases. The maximal removal of 2-chlorophenol was found in the buffers ofpH range 4-7 and at 30-60 degrees C in the presence of 1.2 mM H2O2 by soluble enzymes, but encapsulated and cross-linked enzymes worked well at pH 5 and at 50 degrees C in the presence of 0.8 mM H2O2. The optimized doses of soluble, encapsulated and cross-linked SPases were 1.2, 4.2 and 1.2 mg/mL, respectively, for the removal of phenolic compounds. Encapsulated and cross-linked enzymes showed a lower efficiency than soluble enzyme but can be reused in multiple cycles for the removal of phenolic compounds.

Which psychotropic medications induce hepatotoxicity?

OBJECTIVE

Safe prescribing practices to minimize pharmaceutically induced liver damage or worsening of preexisting conditions require knowledge about medicines with hepatotoxic potential. This paper reviews psychotropic medications and their effects on the liver.

METHODS

A MEDLINE search was performed utilizing the phrase "drug-induced liver injury" with various categories of psychiatric drugs. Only articles written in English were utilized.

RESULTS

Hepatotoxicity can be acute or chronic in nature. Medication discontinuation is necessary in acute forms, while close monitoring is required in milder forms of medication-induced chronic liver damage. Nefazodone, pemoline and/or tacrine are the highest offenders. Carbamazepine and valproate products (e.g., divalproex) can lead to this adverse event and should be avoided in patients with liver disease, persons with alcohol misuse or those consuming high doses of acetaminophen.

CONCLUSION

Knowing the risk levels associated with various medicines is important; prescribing multiple drugs with hepatotoxic effects should be avoided. One should educate patients about early warning signs of liver injury. Always provide clinical and laboratory monitoring before and during the use of hepatotoxic drugs. Clinical features and laboratory results govern medication prescribing with ongoing risk-to-benefit ratio assessment during pharmacotherapy.