Oncology Gold Standard™ practical consensus recommendations 2016 for treatment of advanced clear cell renal cell carcinoma

The Oncology Gold Standard (OGS) Expert Group on renal cell carcinoma (RCC) developed the consensus statement to provide community oncologists practical guidelines on the management of advanced clear cell (cc) RCC using published evidence, practical experience of experts in real life management, and results of a nationwide survey involving 144 health-care professionals. Six broad question categories containing 33 unique questions cover major situations in the routine management of RCC. This document serves as a ready guide for the standard of care to optimize outcome. The table of "Take Home Messages" at the end is a convenient tool for busy practitioners.

Esophageal diverticula are associated with propagating peristalsis: a study utilizing high-resolution manometry

BACKGROUND

Esophageal diverticula have been associated with esophageal motility disorders, most commonly achalasia. We aimed to evaluate high-resolution manometry (HRM) motility diagnoses and pressurization patterns in patients with esophageal diverticula.

METHODS

Patients were retrospectively identified for distal esophageal diverticula and previously completed HRM. High-resolution manometries were analyzed according to the Chicago Classification, and the pressure slope of the compartmentalization phase (time between upper esophageal sphincter closure and the transition zone) of esophageal bolus transit was measured. Pressure slopes were also measured in 10 asymptomatic volunteers (controls) for comparison.

KEY RESULTS

Nineteen patients (ages 31-83) were included. Eight (42%) patients had normal motility, five (26%) had esophagogastric junction outflow obstruction, and two (11%) had jackhammer esophagus; four patients had other motility diagnoses including only one patient with achalasia. A total of six patients (32%) had at least one hypercontractile swallow. Greater compartmentalization phase pressure slopes were observed in patients at the mid-esophageal body in both supine (median [interquartile range]: 1.9 mmHg/s [0.9, 3.6]) and upright (1.1 [0.1, 3.1]) positions than in controls (supine: -1.3 [-2.4, -0.11], p = 0.001; upright; -0.71 [-2.1, -0.02], p = 0.005).

CONCLUSIONS & INFERENCES

Propagating peristalsis, often with hypercontractility, was commonly seen in our cohort of patients with esophageal diverticula. Abnormal compartmentalization phase pressurization may indicate a relationship of abnormal esophageal wall mechanics and/or compliance with diverticula; however whether these findings are causal or reactionary remains unclear.

A rare penetrant TIMP3 mutation confers relatively late onset choroidal neovascularisation which can mimic age-related macular degeneration

PURPOSE

To perform a genotype-phenotype correlation for three patients heterozygous for a missense mutation in the tissue inhibitor of metalloproteinase 3 (TIMP3) gene.

METHODS

Retrospective, observational case series. The medical records and photographs were reviewed for three patients diagnosed at the time with neovascular age-related macular degeneration (AMD). All were later found to carry a predicted C113G mutation in the TIMP3 gene, other known mutations in which are associated with Sorsby's fundus dystrophy.

RESULTS

All three patients developed drusen and bilateral choroidal neovascularisation with subsequent disciform scarring and atrophy. Visual acuity rapidly deteriorated to <6/60 in both eyes. The age of onset varied from 56 to 64 years and the interval to contralateral eye involvement varied from 4 to 6 years. Two of the three patients had a family history of AMD. All three patients were heterozygous for the C113G nucleotide change, resulting in a Ser38Cys change at the N terminus of the TIMP3 protein.

CONCLUSION

This case series suggests the C113G TIMP3 variant may represent a novel highly penetrant mutation causing choroidal neovascularisation of relatively late onset for Sorsby's fundus dystrophy, mimicking early onset AMD.

Cross-sectional study indicates nearly a quarter of sheep population in Karnataka state of India is infected with ovine herpesvirus 2

In a cross-sectional study, prevalence of ovine herpesvirus 2 (family: Herpesviridae, subfamily: Gammaherpesvirinae, genus Macavirus and species: Ovine herpesvirus 2) infection was estimated in sheep population of Karnataka state in India. Based on the three stage cluster sampling method, whole blood samples (356) of sheep were collected from 11 sheep-dense districts of the state. The samples were tested for presence of OvHV-2 genome by recommended hemi-nested polymerase chain reaction (PCR) test. The true prevalence of OvHV-2 infection in sheep population of Karnataka was 24.44 %. Of the 11 district surveyed, highest true prevalence of 42.42 % (CI 25.56-59.29) was found in Raichur followed by Tumkur (39.02 %, CI 24.09-53.96). Inverse distance weighted interpolation of prevalence indicated that OvHV-2 prevalence within a given district is not uniform and there are areas of varied prevalence. The nucleotide sequence of the 422 bp DNA fragment, amplified in PCR, matched 99 % with OvHV-2 reference sequence and other sequences reported from India. Grouping of OvHV-2 sequences obtained from Karnataka with those from Andhra Pradesh, Tamil Nadu and Jammu and Kashmir in the neighbour joining tree indicated a close relationship among the OvHV-2s circulating in India. This is the first study in the country where systematic screening of sheep population of a state for the presence of OvHV-2 infection has been carried out, which indicated a widespread prevalence calling for an urgent need for policy measures to prevent economic losses due to the disease in susceptible cattle and buffalo species.

Systematic review with meta-analysis: the accuracy of diagnosing irritable bowel syndrome with symptoms, biomarkers and/or psychological markers

BACKGROUND

Irritable bowel syndrome (IBS) is a complex, heterogeneous disease which can be challenging to diagnose. No study has identified and assessed the accuracy of all available methods of diagnosing IBS.

AIM

To conduct a systematic review of the literature to identify and assess accuracy of symptom-based diagnostic criteria, biomarkers, psychological markers or combinations thereof.

METHODS

MEDLINE, EMBASE and EMBASE Classic were searched (until April 2015) to identify studies reporting accuracy of available methods to diagnose IBS in adult populations. Eligible studies assessed accuracy of these diagnostic tests against an accepted reference standard. Data were extracted to calculate positive and negative likelihood ratios, with 95% confidence intervals (CIs), of the diagnostic test utilised. Where more than one study used the same test, data were pooled in a meta-analysis.

RESULTS

Twenty-two studies (7106 patients) were eligible. Positive and negative likelihood ratios of the current gold standard, the Rome III criteria, were 3.35 (95% CI: 2.97-3.79) and 0.39 (95% CI: 0.34-0.46), similar to other symptom-based criteria. Eleven biomarkers performed no better than symptom-based criteria. Psychological markers performed well in one study. Five different combinations were assessed. The best in terms of positive likelihood ratio was faecal calprotectin, intestinal permeability and Rome I criteria (26.4; 95% CI: 11.4-61.9), and in terms of negative likelihood ratio serum-based biomarkers and psychological markers (0.18; 95% CI: 0.12-0.25).

CONCLUSIONS

Symptom-based diagnostic criteria, biomarkers and psychological markers performed modestly in predicting IBS. Combining symptoms with markers appears more effective, and may represent the way forward in the diagnosis of IBS.

Triethylene glycol-based poly(1,2,3-triazolium acrylate)s with enhanced ionic conductivity

A well-defined triethylene glycol-based poly(1,2,3-triazolium acrylate) having a bis(trifluoromethane)sulfonimide anion and an anhydrous ionic conductivity of 10⁻⁵ S cm⁻¹ at 30 °C is reported.

Genetic and antigenic analysis of H5N1 viruses for selection of HA-donor virus for vaccine strains

Genetic and antigenic analysis of H5N1 viruses, isolated in India during a period from year 2006 to 2010, was carried out for selection of the potential H5-HA (haemagglutinin) gene donor virus for developing a reverse genetics based DIVA marker H5 vaccine for poultry in India. Out of the 47 H5N1 viruses (clade 2.2), 14 representative viruses were selected on the basis of amino acid sequence analysis of HA1 gene for further antigenic characterization. Using antigenic cartography, an antigenic map was constructed based on the data of cross-HI (haemagglutinin inhibition) titration of 14 sera versus 14 viruses to visualize the relatedness among the antigens and antigenic coverage of the sera. Sera against five H5N1 viruses (A/crow/Assam/142119/2008, A/chicken/West Bengal/100879/2008, A/chicken/West Bengal/155505/2009, A/chicken/West Bengal/80995/2008 and A/chicken/West Bengal/81760/2008) exhibited maximum (100 %) antigenic coverage, hence, were selected as the potential HA donor viruses. However, the virus strain A/chicken/West Bengal/80995/2008 matched completely with the consensus amino acid sequence of the 47 viruses, therefore, was considered the best HA donor candidate out of the five showing 100 % antigenic coverage. The present study demonstrates a stepwise methodology for logical selection of vaccine strain or HA gene donor strain for developing H5 vaccines using genetic and antigenic data.

Abstract P2-04-04: Breast cancer risk reduction in high risk women identified at the time of screening mammography. Integrating data from an established high risk clinic

Background: At the time of screening mammography, patient data can be collected and entered into a Modified Gail Model Risk Assessment Tool to identify patients at increased risk of invasive breast cancer. In turn, these patients can be referred to high risk centers where risk reduction strategies and chemoprophylaxis can be considered. The objective of this study is to establish how many women are at high risk of invasive breast cancer in a screening population who should be referred to a high risk center for counseling.

Methods: This is an observational prospective study evaluating 1,000 women at a single institution presenting for mammographic screening or diagnostic evaluation. At the time of mammography, these women routinely complete a standard intake questionnaire addressing breast cancer risk factors put forward by the institutional clinic. Modified Gail model risk scores were calculated from these data sheets. Women with a 5 year risk of invasive breast cancer of 1.7% or greater were identified as well as women at particularly high risk (≥3.4% or double the 5-year risk). At the time of analysis patients with a history of breast cancer or who underwent diagnostic mammography were excluded. Retrospective data from our institutional high risk clinic from January 2007 to December 2009 was analyzed in respect to patient age at referral, Gail Model Score, personal history of breast cancer, history of benign breast biopsies, and recommendation for and acceptance of chemoprophylaxis.

Results: Of 1,000 women screened in the prospective analysis, 366 had ≥1.7% 5-year risk of invasive breast cancer. 26% (96) of these women were under 60 years old while 74% (270) were ≥60 years old. Among the latter group, 19.6% (53) were found to have ≥ 3.4% of developing invasive cancer. In these women with double the 5-year risk, 96.2% had a family history of breast cancer and 69.8% had a prior biopsy. Similarly, in women under 60, greater than half were high risk secondary to a prior biopsy or family history. In the retrospective analysis of 600 patients evaluated in the high risk clinic, 38.8% were eligible for chemoprevention based on age &gt;35, Gail model risk score, and no contraindications to treatment. 45.7% accepted recommendation for chemoprophylaxis as opposed 54.3% who had declined. Age was not found to be a predictor of acceptance of treatment.

Conclusions: 1/3 of patients who receive annual screening are at high risk for breast cancer. These patients can be identified from data routinely obtained at the time of screening mammography. These women should be referred for high-risk counseling and consideration of chemoprevention at the time of screening mammography. Further prospective studies may be warranted to determine if this is an effective way to provide risk reduction strategies for high risk women.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-04-04.

Bovine immunodeficiency virus: a lentiviral infection

The bovine immunodeficiency virus (BIV) is a lentivirus which is known to infect cattle worldwide. Though serological and genomic evidence of BIV in cattle has been found throughout the world, isolation of the virus has been reported only from few places. Very little is known about its impact on animal health status, pathogenesis and mode of transmission. BIV is considered generally non-pathogenic and is not known to cause any serious disease in cattle. BIV is genetically and antigenically related to Jembrana disease virus (JDV), the cause of an acute disease in Bali cattle (Bos javanicus) and human immunodeficiency virus, the cause of acquired immunodeficiency syndrome in human. Therefore, it is important to monitor the presence of BIV in cattle to keep vigil over its possible evolution in its natural host to emerge as pathogenic lentivirus like JDV. Differentiation of BIV infection in cattle from the acutely pathogenic JDV is important for diagnosis of the latter. Currently, BIV is considered as a safe model for understanding the complex genome of lentiviruses. Further research on BIV is indeed needed to elucidate its possible role in animal health as well as for insight into the molecular mechanisms adopted by related lentiviruses.

Isolated Bell's palsy - an unusual presentation of dengue infection

Dengue fever is a very common arthropod - borne infection in tropical countries. Neurological complications in dengue fever are relatively uncommon and among these, isolated cranial neuropathies have been reported only very rarely. We present an unusual neurological complication of Bell's palsy (lower motor neuron 7 th nerve palsy) associated with dengue infection. To the best of our knowledge, there have been very few documented cases of Flavivirus causing isolated Bell's palsy.

In VitroBactericidal Activity of Oxazolidinone, RBx 8700 againstMycobacterium tuberculosisandMycobacterium avium complex

RBx 8700, an investigational oxazolidinone, has excellent activity against respiratory pathogens. We evaluated the in vitro minimum inhibitory concentration (MIC) and bactericidal activity of RBx 8700 against Mycobacterium tuberculosis and Mycobacterium avium complex (MAC) isolates. RBx 8700 had an MIC of 1 gLg/ml against M. tuberculosis isolates resistant to both isoniazid (INH) and rifampicin (RIF), whereas its MIC against M. tuberculosis isolates resistant to either INH or RIF was 0.5 microg/ml.

Status of epidermal growth factor receptors family in hormone-dependent carcinomas of the breast and prostate with reference to serum lipids and lipoproteins

There are numerous growing evidences of resemblance between carcinomas of the breast and prostate. A total of 45 cases of these two hormone-dependent cancers along with appropriate controls were subjected for status of epidermal growth factor receptors as well as serum lipid profile. Paraffin embedded tissue sections from aforesald tumours were analysed by immunohistochemical staining for epidermal growth factor receptor (EGF-R), c-erbB-2 oncoprotein, estrogen receptor (ER) and progesterone receptor (PgR). Sera from same individuals were studied for serum lipid profile analysis. The study revealed that immunoexpression of all receptor proteins (EGF-R). c-erbB-2 was significantly higher in breast carcinoma. In addition, mean levels of triglycerides, total cholesterol, LDL-cholesterol were found to be significantly elevated while the level of HDL-cholesterol was observed to be lower among patients with breast cancer as compared to matched controls. Further, ER-positive breast cancer cases have significantly higher mean level of HDL-cholesterol when compared with ER-negative breast cancer patients. Contrary to this, no alteration in different serum lipid fractions was noticed among the patients with prostate cancer. However, a positive relationship was noticed between immunoexpressions of EGF-R and c-erbB-2 in prostate cancer.

Small bowel obstruction induced by spontaneous partial deflation of an intragastric balloon

The intragastric balloon (IGB) has been used for decades as a temporary measure for weight reduction in the morbidly obese. Serious complications related to the device remain rare. We present the case of a 23-year-old Caucasian man who developed signs of bowel obstruction following spontaneous partial deflation of an air filled IGB with subsequent migration and impaction in the jejunum. We discuss the role of the IGB in the treatment of obesity, side effects and the serious complications that can occur.

Is there need for a transformational change to overcome the current problems with postgraduate medical education in India?

In spite of the existence of a dual system of postgraduation, one under the Medical Council of India (MCI) and the other on a parallel track under the National Board of Examinations, postgraduate medical education in India is beset with several problems. For example, the curriculum has not been revised comprehensively for several decades. The diploma course under the MCI has become unpopular and is largely a temporary refuge for those who do not get admission to degree courses. The level of skills of the outgoing graduate is falling and the increase in the number of seats is taking place in a haphazard manner, without reference to the needs. In spite of increase in seats, there is a shortage of specialists at the secondary and tertiary care levels, especially in medical colleges, to share teaching responsibilities. Further, the distribution of specialists is skewed, with some states having far more than others. To remedy these ills and fulfil the requirements of the country over the next two decades, a working group appointed by the erstwhile governors of the MCI was asked to suggest suitable modifications to the existing postgraduate system. After an extensive review of the lacunae in the present system, the needs at various levels and the pattern of postgraduate education in other countries, it was felt that a competency-based model of a 2-year postgraduate course across all specialties, the use of offsite facilities for training and a criterion-based evaluation system entailing continuous monitoring would go a long way to correct some of the deficiencies of the existing system. The details of the proposal and its merits are outlined for wider discussion and to serve as a feedback to the regulatory agencies engaged in the task of improving the medical education system in India. We feel that the adoption of the proposed system would go a long way in improving career options, increasing the availability of teachers and dissemination of specialists to the secondary and primary levels, and improving the quality of outgoing postgraduates.

The effect of opioids and their antagonists on the nocifensive response of Caenorhabditis elegans to noxious thermal stimuli

Opiates modulate nociception in vertebrates. This has also been demonstrated in a number of invertebrate models. Herein, the effect of the opiate morphine and opioid neuropeptides Endomorphin 1 and 2 on the thermal avoidance (Tav) behavior of Caenorhabditis elegans is explored. Adult wild-type C. elegans N2 were collected from NGM plates using M9 buffer and exposed to morphine and endomorphine 1 and 2 in concentrations between 10(-8) and 10(-4) M (2.5 pmol/mg to 25 nmol/mg) for 30 min and tested for Tav. The opioid receptor antagonists Naloxone and CTOP were tested in combination with the drugs. Forty-seven percentage of the morphine exposed worms exhibited a class I response versus 76% of the control group (P < 0.001). Endomorphin 1 and 2 also caused a statistically significant reduction in class I responses, 36 and 39%, respectively. These effects were reversed with Naloxone and CTOP. Thermonocifensive behavior in C. elegans is modulated by opioids.

From reorientation of medical education to development of medical educators

Re-orientation of medical education in India has not been fully successful because the development of medical teacher, a critical component has not been adequately addressed. Faculty development is a key factor. We have identified six shifting trends in faculty development that can contribute to the development of a medical educator in India. These include a shift from: One time training to continuing professional development; information based approach to project based approach; training to scholarship; lack of accountability to accountability and recognition; individual efforts to networking; and role of treatment providers to health promoters. We have discussed how these shifts are in tune with the global trends. We recommend that the initiatives taken in India in the recent past, viz., constitution of a Task Force by the Ministry of Health and Family Welfare, establishment of several medical education centers should be harnessed by forming a national working group. Such a group would provide policy directions for faculty development which will lead to a concrete plan for implementation and thereby addressing a critical component of the re-orientation of medical education.