A Cross-sectional Cohort Analyses Assessing Response to Levosalbutamol Bronchodilatory Cough Formulations in Outpatient Community Settings of India: 'BUS' analyses

INTRODUCTION

Cough is significant health problem with greater implication for impaired quality of life. Acute and chronic cough due to infective (viral/bacterial), allergic conditions or bronchial asthma including cough variant asthma are often treated with combination of mucolytics, expectorants and bronchodilators. Bronchodilators reduces cough sensitivity, promotes clearance of cough secretions while reducing protrusive inflammatory mediator release.

AIMS AND OBJECTIVES

To further understand the clinical utility and safety of Bronchodilatory cough formulations (BCF) containing Levosalbutamol in real world settings.

MATERIAL AND METHODS

A prospective, cross sectional, cohort analyses (Bronchodilatory coUgh formulary Survey, BUS) assessing Levosalbutamol cough formulations utilization at 40 centers involving general and consultant physicians across India.

RESULTS

Consecutive prescription records (n=1367) involving Levosalbutamol were collated for analyses. Baseline demographics included adults (21%) and children (79%) with mean age 11.1 yrs, male (60%) and female(40%). Levosalbutamol BCF was commonly prescribed for LRTI (69.7%), AECB (14.8%), Bronchial asthma (8.5%), Allergic rhinitis (5%). The predominant risk factors in both adults and children included smoking and allergic rhinitis respectively. In most cases cough severity was assessed utilizing Fisman scale score (0-4). Mean cough score improved from baseline score of 3 to 0.8 with parallel improvement in associated symptoms of wheeze and sputum. Antibiotics were prescribed in most of LRTI or acute exacerbation cases with purulent sputum. Side effects noted included tremor (1%), palpitation (0.9%), vomiting (0.7%) that were mild and transient in most cases with none requiring treatment withdrawal. In two cases (0.1%), further treatment with nebulization and antibiotics were provided.

CONCLUSIONS

Levosalbutamol containing Bronchodilatory Cough formulation remains as safe and effective option for adults and children while managing acute or chronic cough primarily due to allergic rhinitis, bronchial asthma or COPD.

Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry

Aim

A national atrial fibrillation (AF) registry was conducted under the aegis of the Indian Heart Rhythm Society (IHRS), to capture epidemiological data-type of AF, clinical presentation and comorbidities, current treatment practices, and 1-year follow-up outcomes.

Methods

A total of 1537 patients were enrolled from 24 sites in India in the IHRS-AF registry from July 2011 to August 2012. Their baseline characteristics and follow-up data were recorded in case report forms and subsequently analyzed.

Results

The average age of Indian AF patients was 54.7 years. There was a marginal female preponderance – 51.5% females and 48.5% males. At baseline, 20.4% had paroxysmal AF; 33% had persistent AF; 35.1% had permanent AF and 11% had first AF episode. At one-year follow-up, 45.6% patients had permanent AF.

Rheumatic valvular heart disease (RHD) was present in 47.6% of patients. Hypertension, heart failure, coronary artery disease, and diabetes were seen in 31.4%, 18.7%, 16.2%, and 16.1%, respectively.

Rate control was the strategy used in 75.2% patients, digoxin and beta-blockers being the most frequently prescribed rate-control drugs. Oral anticoagulation (OAC) drugs were used in 70% of patients. The annual mortality was 6.5%, hospitalization 8%, and incidence of stroke 1%.

Conclusions

In India, AF patients are younger and RHD is still the most frequent etiology. Almost two-third of the patients have persistent/permanent AF. At one-year follow-up, there is a significant mortality and morbidity in AF patients in India.

Impact of PTEN abnormalities on outcome in pediatric patients with T-cell acute lymphoblastic leukemia treated on the MRC UKALL2003 trial

PTEN gene inactivation by mutation or deletion is common in pediatric T-cell acute lymphoblastic leukemia (T-ALL), but the impact on outcome is unclear, particularly in patients with NOTCH1/FBXW7 mutations. We screened samples from 145 patients treated on the MRC UKALL2003 trial for PTEN mutations using heteroduplex analysis and gene deletions using single nucleotide polymorphism arrays, and related genotype to response to therapy and long-term outcome. PTEN loss-of-function mutations/gene deletions were detected in 22% (PTEN(ABN)). Quantification of mutant level indicated that 67% of mutated cases harbored more than one mutant, with up to four mutants detected, consistent with the presence of multiple leukemic sub-clones. Overall, 41% of PTEN(ABN) cases were considered to have biallelic abnormalities (mutation and/or deletion) with complete loss of PTEN in a proportion of cells. In addition, 9% of cases had N- or K-RAS mutations. Neither PTEN nor RAS genotype significantly impacted on response to therapy or long-term outcome, irrespective of mutant level, and there was no evidence that they changed the highly favorable outcome of patients with double NOTCH1/FBXW7 mutations. These results indicate that, for pediatric patients treated according to current protocols, routine screening for PTEN or RAS abnormalities at diagnosis is not warranted to further refine risk stratification.

Anatomical reconstruction of the spring ligament complex: "internal brace" augmentation

The calcaneonavicular (spring) ligament complex is a critical static support of the medial arch of the foot. Compromise of this structure has been implicated as a primary causative factor of talar derotation leading to the clinical deformity of peritalar subluxation. Few procedures have been described to address this deficiency. The technique we describe here is a simple yet effective method to reconstruct the spring ligament complex that can easily be used in conjunction with other more commonly used procedures for extra-articular reconstructions of this deformity. We believe this procedure allows for a more powerful deformity correction and may decrease dependency on other nonanatomic reconstructive procedures.

Early weightbearing using Achilles suture bridge technique for insertional Achilles tendinosis: a review of 43 patients

Posterior heel pain caused by insertional Achilles tendinosis can necessitate surgical intervention when recalcitrant to conservative care. Surgical treatment can necessitate near complete detachment of the Achilles tendon to fully eradicate the offending pathologic features and, consequently, result in long periods of non-weightbearing. A suture bridge technique using bone anchors is available for reattachment of the Achilles tendon. This provides restoration of the Achilles footprint on the calcaneus, including not only contact, but also actual pressure between the tendon and bone. We performed a review of 43 patients who underwent surgical treatment of insertional Achilles tendinosis with reattachment of the Achilles tendon using the suture bridge technique. The mean age was 53 (range 29 to 87) years. The mean follow-up period was 24 (range 13 to 52) months. The mean postoperative American Orthopaedic Foot and Ankle Society score was 90 (range 65 to 100). The mean preoperative visual analog scale pain score was 6.8 (range 2 to 10) and the mean postoperative visual analog scale pain score was 1.3 (range 0 to 6). The mean interval to weightbearing was 10 (range 0 to 28) days. No postoperative ruptures occurred. Of the 43 patients, 42 (97.6%) successfully performed the single heel rise test at the final postoperative visit. Concomitant procedures were performed in 35 patients, including 33 (77%) requiring open gastrocnemius recession and 2 (5%) requiring flexor hallucis longus tendon transfer. A total of 42 patients (97.6%) returned to regular shoe gear, and 42 (97.6%) returned to their activities of daily living, including running for 20 athletic patients (100%). Complications included postoperative wound dehiscense requiring surgical debridement in 2 patients (5%) and soft tissue infection requiring antibiotics and surgical debridement in 1 (2%) patient. Our findings support using the Achilles tendon suture bridge for reattachment of the Achilles tendon in the surgical treatment of insertional Achilles tendinosis.

Impact of NOTCH1/FBXW7 mutations on outcome in pediatric T-cell acute lymphoblastic leukemia patients treated on the MRC UKALL 2003 trial

Activating mutations in the NOTCH1 pathway are frequent in pediatric T-cell acute lymphoblastic leukemia (T-ALL) but their role in refining risk stratification is unclear. We screened 162 pediatric T-ALL patients treated on the MRC UKALL2003 trial for NOTCH1/FBXW7 gene mutations and related genotype to response to therapy and long-term outcome. Overall, 35% were wild-type (WT) for both genes (NOTCH1(WT)FBXW7(WT)), 38% single NOTCH1 mutant (NOTCH1(Single)FBXW7(WT)), 3% just FBXW7 mutant (NOTCH1(WT)FBXW7(MUT)) and 24% either double NOTCH1 mutant (NOTCH1(Double)FBXW7(WT)) or mutant in both genes (NOTCH1(MUT)FBXW7(MUT)), hereafter called as NOTCH1±FBXW7(Double). There was no difference between groups in early response to therapy, but NOTCH1±FBXW7(Double) patients were more likely to be associated with negative minimal residual disease (MRD) post-induction than NOTCH1(WT)FBXW7(WT) patients (71% versus 40%, P=0.004). Outcome improved according to the number of mutations, overall survival at 5 years 82%, 88% and 100% for NOTCH1(WT)FBXW7(WT), NOTCH1(Single)FBXW7(WT) and NOTCH1±FBXW7(Double) patients, respectively (log-rank P for trend=0.005). Although 14 NOTCH1±FBXW7(Double) patients were classified as high risk (slow response and/or MRD positive), only two had disease progression and all remain alive. Patients with double NOTCH1 and/or FBXW7 mutations have a very good outcome and should not be considered for more intensive therapy in first remission, even if slow early responders or MRD positive after induction therapy.

Clinical outcomes and health-related quality of life (HRQOL) following haemopoietic stem cell transplantation (HSCT) for paediatric leukaemia

BACKGROUND

Haemopoietic stem cell transplantation (HSCT) is a life-saving but intensive procedure associated with potentially severe adverse late effects. We aimed to determine morbidity and health-related quality of life (HRQOL) in a sample of survivors aged 8-18 years at least 1 year post HSCT for paediatric acute leukaemia, compared with a non-transplanted group of survivors matched for age, gender, initial disease and time since treatment.

METHODS

Families (N = 54; HSCT n= 29) recruited from four UK centres completed measures of child behaviour and school attendance, HRQOL and finances. Mothers completed measures of their own well-being. Clinical outcome data were extracted from medical records.

RESULTS

Children in the HSCT group had significantly more late effects and had received more tests for vision, bone, dental and skin health, and thyroid, lung, and gonadal function than the non-transplanted group. HRQOL scores for the HSCT group were significantly lower in all domains compared with the non-transplanted group and population norms, but were not significantly related to clinical indices. Mothers in the HSCT group had significantly poorer mental well-being than population norms.

CONCLUSION

Significant morbidity and compromised HRQOL was found in survivors of HSCT. The burden of caring for a child after HSCT has a continuing toll on mothers' well-being.The importance of counselling families about possible long-term consequences is emphasized.

Analysis of risk factors influencing outcome in children with myelodysplastic syndrome after unrelated cord blood transplantation

We describe 70 children with myelodysplastic syndrome (MDS) (refractory cytopenia (n=31) and refractory anemia with excess blasts (n=30) or blasts in transformation (n=9)) who received umbilical cord blood (UCB) transplantation with a single UCB unit and a myeloablative conditioning regimen. Approximately 20% of children had secondary MDS. Median age at transplantation was 7 years and the median follow-up was 3 years. The day-60 probability of neutrophil recovery was 76%; recovery was faster after transplantation of matched or 1-locus mismatched UCB, irradiation-containing conditioning regimen, cell dose >6 × 10(7)/kg and monosomy 7. Risks of treatment failure (recurrent disease or death) were lower in patients with monosomy 7 and transplantations after 2001. The 3-year disease-free survival (DFS) was 50% for transplantations after 2001 compared with 27% for the earlier period (P=0.018). Transplantations after 2001 occurred within 6 months after diagnosis and used UCB units with higher cell dose. DFS was highest in patients with monosomy 7 (61%) compared with other karyotypes (30%), P=0.017. These data suggest that transplantation of mismatched UCB graft is an acceptable alternative for children without a matched sibling or suitably matched unrelated adult donor.

Suture-button versus screw fixation of the syndesmosis: a biomechanical analysis

BACKGROUND

The treatment of ankle fractures with syndesmotic injuries associated with disruption of the deltoid ligament complex is controversial. The purpose of this study was to compare both the biomechanical and physiologic properties of suture-button fixation to the intact syndesmosis and screw fixation.

MATERIALS AND METHODS

Eight fresh frozen human cadaveric ankles were used in three different groups. One group had an intact syndesmosis and deltoid ligamentous complex and two groups had fixation of the syndesmosis after its disruption along with disruption of the deltoid ligaments. One fixation group used a suture-button and the other used a 3.5-mm tricortical syndesmotic screw. The syndesmotic gap after cycling at submaximal loads, laxity due to cycling, and fibular movement allowed in the sagittal plane were all measured and analyzed for statistical significance.

RESULTS

The syndesmotic gap after cycling was not significantly different between the intact group (9.1 mm) and the suture-button group (8.8 mm) (p = 0.1509). The screw fixation group had a significantly smaller gap (7.9 mm) as compared to the other two groups (screw versus intact, p = 0.00004; screw versus suture-button, p = 0.0004). The intact group did not demonstrate a significant difference in laxity before (9.0 mm) and after (9.1 mm) cycling (p = 0.0670), whereas the suture-button group did have a significant difference (before, 8.01 mm; after, 8.28 mm) (p = 0.000251). The movement of the fibula in the sagittal plane was significantly greater in the suture-button group (3.17 mm) as compared to the intact group (2.77 mm) (p = 0.00554). Screw fixation allowed significantly less fibular movement in the sagittal plane (1.16 mm) as compared to the intact (p = 0.00014) and suture-button (p = 0.0000012) groups.

CONCLUSION

Suture-button fixation maintained reduction after cycling with submaximal loads that compared favorably to the intact syndesmosis. It also allowed more physiologic movement of the fibula in the sagittal plane when compared to tricortical screw fixation.

CLINICAL RELEVANCE

Syndesmotic injury fixation has traditionally used screws to provide a rigid construct in which healing can take place. We believe a less rigid fixation method, such as suture-button fixation, provides a more physiologic type of healing of the syndesmosis.

Remyelination can be extensive in multiple sclerosis despite a long disease course

Experimental studies using models of multiple sclerosis (MS) indicate that rapid and extensive remyelination of inflammatory demyelinated lesions is not only possible, but is the normal situation. The presence of completely remyelinated MS lesions has been noted in numerous studies and routine limited sampling of post mortem MS material suggests that remyelination may be extensive in the early stages but eventually fails. However, visual macroscopic guided sampling tends to be biased towards chronic demyelinated lesions. Here we have extensively sampled cerebral tissue from two MS cases to investigate the true extent of remyelination. Sections were cut from 185 cerebral tissue blocks and stained with haematoxylin and eosin (H&E), luxol fast blue and cresyl fast violet (LFB/CFV) and anti-myelin oligodendrocyte glycoprotein, human leucocyte antigen-DR (HLA-DR) and 200 kDa neurofilament protein antibodies. Demyelinated areas were identified in 141 blocks, comprising both white matter (WMLs) and/or grey matter lesions. In total, 168 WMLs were identified, 22% of which were shadow plaques, 73% were partially remyelinated and only 5% were completely demyelinated. The average extent of lesion remyelination for all WMLs investigated was 47%. Increased density of HLA-DR(+) macrophages and microglia at the lesion border correlated significantly with more extensive remyelination. Results from this study of two patients with long standing disease suggest that remyelination in MS may be more extensive than previously thought.

Status of geriatric oncology in India: A national multicentric survey of oncology professionals

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Background: Elderly cancer patients are underrepresented in cancer services utilization and clinical research in India. National data on providers’ knowledge, attitude and practices with regard to elderly cancer patients is sparse and is urgently required to address needs of this vulnerable and growing population. Methods: A self administered questionnaire was mailed to nationally representative sample of practicing oncologists all over India. 112 Oncologists (Medical Oncologists-51%; Radiation Oncologists-25%; Surgical Oncologists-20%; allied fields-4%) responded out of 250 mailed Questionnaires. Results: A designated Geriatric Oncology unit is in existence in very few (<5%) centers. Majority (51%) considered patients with chronological age of >60 years as elderly for India. Although 75% of elderly patients receive some therapy, only 50% of potentially curable patients and a similar percentage of potentially incurable patients receive standard of care. Also, 50% patients require modification in their treatment and only two-third of treated patients complete therapy. The existent barriers to treatment included poor performance status (53%), advanced stage (16%), and co-morbidities (15%). Only 51% Oncologists always discussed and 28% always enrolled elderly patients in clinical trials. Standard of care and evidence based recommendations for elderly patients were felt to be lacking by 49% and 92% of respondents respectively. The need of separate trials for elderly and a separate discipline of Geriatric Oncology was voiced by 93% and 89% of respondents respectively. Major differences in treatment practice between medical oncologists and non medical oncologists are shown in table . Conclusions: Treatment practices and accrual of elderly cancer patients in clinical trials in India is far from optimal. Formation of a National Geriatric Oncology society and creation of designated Geriatric oncology services at key centers may enhance the understanding and clinical care of this population.

[Table: see text]

No significant financial relationships to disclose.