Cutaneous side-effects of epidermal growth factor receptor-tyrosine kinase inhibitor (TKI) in the treatment of lung cancer: description and its management

Epidermal growth factor receptor (EGFR)--tyrosine kinase inhibitors (TKI) like erlotinib and gefitinib have been approved as monotherapy for the treatment of patients with locally advanced or metastatic non small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen. The use of EGFR-TKI is associated with unique and dramatic dermatologic side effects. We report 2 patients with NSCLC developing a typical acneiform (papulo-pustular) eruption shortly after initiation of EGFR-TKI.

Can age and sex explain the variation in COPD rates across large urban cities? A population study in Canada

OBJECTIVE

To measure the prevalence of chronic obstructive pulmonary disease (COPD) and determine the effect of age and sex on the variation in prevalence across major cities within the same country and health care system.

METHOD

We used the Burden of Obstructive Lung Disease (BOLD) methodology to estimate the prevalence of COPD in adults aged ≥ 40 years in different Canadian cities. The study used interviewer-administered questionnaires on respiratory, smoking and occupational history, medication use and comorbidities. Post-bronchodilator spirometry was used to classify subjects. We determined the prevalence and severity of COPD with and without adjustments for age and sex distribution across different cities.

RESULTS

The study population was 3042. Overall, 16.7% (95%CI 14.8-18.7) of study subjects met the criteria for Global Initiative for Chronic Obstructive Lung Disease (GOLD) severity Stage 1 or higher. The prevalence according to the criteria for the lower limits of normal of the ratio forced expiratory volume in 1 second/forced vital capacity was 11.6% (95%CI 9.9-13.3). COPD prevalence varied by severity across site (P = 0.0025). After age-sex adjustment, the variation disappeared (P> 0.16).

CONCLUSION

Age and sex differences account for most of the heterogeneity in COPD estimates across large cities within the same country. Adjustments for age and sex are essential in comparing COPD rates across the country.

Kaposi's sarcoma: case report and treatment options

Kaposi's sarcoma (KS) is strongly associated with Human Herpes Virus 8 (HHV8) and Human Immunodeficiency Virus infection (HIV). It was the first malignancy to be linked with Acquired Immunodeficiency Syndrome (AIDS). We report a case of Kaposi's sarcoma in a newly diagnosed retroviral homosexual patient with CD4 count of 21. He had multiple firm discrete violaceous plaques and nodules scattered over the face, scalp, hard palate, trunk and genitalia. Biopsy of a skin nodule over the trunk and a biopsy of a lesion from the gastric mucosa confirmed Kaposi's sarcoma. He was started on Highly Active Antiretroviral Therapy (HAART) and cryotherapy (liquid nitrogen) was given for the lesions over the skin. He responded well to treatment. Liquid nitrogen is a useful adjuvant treatment for Kaposi's sarcoma.

Adult ischemic necrotizing enterocolitis

A 66-year-old male presented with posterior myocardial infarction and painless rectal bleeding. He was treated for acute coronary event but despite extensive investigations the cause of his lower gastrointestinal bleeding remained elusive. Patient died 5 days after admission. Postmortem examination showed evidence of severe atherosclerosis and thrombosis in branches of abdominal aorta leading to bowel ischemia with multiple perforations and necrosis. The findings are consistent with the diagnosis of necrotizing enterocolitis (NEC). Main factors responsible for pathogenesis of NEC are bowel ischemia and bacterial infection. It can be classified into 3 stages according to the level of severity. Treatment ranges from mainly supportive in the initial phase to surgery in severe cases.

Balloon kyphoplasty versus vertebroplasty for treatment of osteoporotic vertebral compression fracture: a prospective, comparative, and randomized clinical study

Bone pain and spinal axial deformity are major concerns in aged patients suffering from osteoporotic vertebral compression fracture (VCF). Pain can be relieved by vertebroplasty or kyphoplasty procedures, in which the compressed vertebral body is filled with substitutes. We randomly assigned 100 patients with osteoporotic compression fracture at the thoraco-lumbar (T-L) junction into two groups: vertebroplasty and kyphoplasty; we used polymethylmethacrylate (PMMA) as the bone filler. Pain before and after treatment was assessed with visual analog scale (VAS) scores and vertebral body height and kyphotic wedge angle were measured from reconstructed computed tomography images. More PMMA was used in the kyphoplasty group than in the vertebroplasty group (5.56 +/- 0.62 vs. 4.91 +/- 0.65 mL, p < 0.001). Vertebral body height and kyphotic wedge angle of the T-L spine were also improved (p < 0.001). VAS pain scores did not differ significantly between the treatment groups. The duration of follow-up was 6 months. Two patients in the kyphoplasty group had an adjacent segment fracture. In terms of clinical outcome there was little difference between the treatment groups. Thus, owing to the higher cost of the kyphotic balloon procedure, we recommend vertebroplasty over kyphoplasty for the treatment of osteoporotic VCFs.

INTRODUCTION

Spinal axial deformities are major concerns in aged patients suffering from osteoporotic vertebral compression fracture. Pain may be relieved by vertebroplasty or kyphoplasty. We investigated the radiological and clinical outcomes of these procedures.

METHODS

One hundred cases of VCF at the thoraco-lumbar junction were randomly assigned into two groups: vertebroplasty or kyphoplasty (50 cases each). We used polymethylmethacrylate as the bone filler. Pain before and after treatment was assessed with visual analog scale scores and vertebral body height and kyphotic wedge angle were measured from reconstructed computed tomography images.

RESULTS

More PMMA was used in the kyphoplasty group than in the vertebroplasty group (5.56 +/- 0.62 vs. 4.91 +/- 0.65 mL, p < 0.001). Vertebral body height and kyphotic wedge angle of the T-L spine were also improved (p < 0.001). VAS pain scores did not differ significantly between the treatment groups. The duration of follow-up was 6 months. Two patients in the kyphoplasty group had an adjacent segment fracture.

CONCLUSIONS

In terms of clinical outcome there was little difference between the treatment groups. Thus, with the higher cost of the kyphotic balloon procedure, we recommend vertebroplasty over kyphoplasty for the treatment of osteoporotic VCFs.

Endocrine complications in transfusion dependent thalassaemia in Penang Hospital

Frequent blood transfusions can lead to iron overload which may result in several endocrine complications especially in the absence of adequate chelation therapy. The objectives of this study are to determine the prevalence of endocrine complications in transfusion dependent thalassaemia patients and the correlation of endocrine complications with the degree of iron chelation. This retrospective study looked at cases of adult patients with transfusion dependent thalassaemia treated in the Haematology Unit, Penang Hospital. Of the 25 transfusion dependent thalassaemia patients, there were 10 male and 15 female patients respectively with almost equal number of Malay and Chinese patients (13 and 12 patients respectively). Short stature was seen in 36.0% of our patients. In our cohort, 12 patients had delayed puberty (male 70.0% and female 33.3%). Prevalence of osteoporosis was 36.0%. Hypogonadism was noted in 40.0% of males and 46.7% of females. 53.4% of the female population had menstrual abnormalities with prevalence of primary and secondary amenorrhoea at 26.7% each. The prevalence of other endocrinopathies was much lower: 8.0% had diabetes mellitus and only one patient had hypocortisolism. Iron chelation appeared insufficient in our study population. The high frequency of endocrine complications noted in our study supports the rationale for regular follow-up of transfusion dependent thalassaemic patients to ensure early detection and timely treatment of associated complications.

Pyoderma gangrenosum

Pyoderma Gangrenosum (PG) is a non-infective, necrotising neutrophilic dermatosis. Many diseases may mimic PG. It may be idiopathic or may be associated with a systemic disorder. We report a case of PG in association with ulcerative colitis.

Two years review of cutaneous adverse drug reaction from first line anti-tuberculous drugs

First line Anti-TB therapy with rifampicin, isoniazid, pyrazinamide, and ethambutol/streptomycin is very effective. However, major adverse reactions to antituberculous drugs can cause significant morbidity and mortality. Cutaneous adverse drug reaction (CADR) is one of the commonly observed major adverse events. This retrospective study looked at the cases of TB treated in Respiratory Unit, Penang Hospital from January 2004 to December 2005. Of 820 patients treated for active TB, 47 patients (25 females; 22 males) developed CADR (5.7%). CADRs observed include morbiliform rash (72.3%), erythema multiforme syndrome (8.5%), urticaria (8.5%) and others (which include exfoliative dermatitis and lichenoid eruption). Ninety-seven percent of events occurred within two months after the initial dose. Incidence rate of CADR among the first line anti-TB drugs, pyrazinamide was the commonest offending drug (2.38%), followed by streptomycin (1.45%), ethambutol (1.44%), rifampicin (1.23%) and isoniazid (0.98%). Various clinical characteristics of patients with CADR identified include Human Immunodeficiency Virus (HIV) infection (27.7%), polypharmacy (21.3%), elderly (19.1%), autoimmune disorders (6.4%), pre-existing renal impairment (4.3%), pre-existing liver disorders (4.3%). In conclusion, CADR is common and majority of cases occurred within two months after initiation of anti-TB treatment, particularly in HIV infected patients. Pyrazinamide is the commonest offending drug.

Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is the infection of ascitic fluid in the absence of any intra-abdominal, surgically treatable source of infection. Despite timely diagnosis and treatment its reported incidence in ascitic patients varies between 7-30%. Ascitic paracentesis remains the chief diagnostic procedure. Automated cell counters have the same diagnostic accuracy as the manual measurement of white cells. Lately, the use of leucocyte reagent strips (dipsticks) has emerged as a useful alternative. Examination of the fluid is not complete unless the sample is inoculated in blood culture bottles. Treatment is currently with third-generation cephalosporins or oral quinolones. Following a single episode of SBP patients should have long term antibiotic prophylaxis.

Lymphocytic interstitial pneumonitis (LIP)-the liver and the lung

Chronic liver disease may involve the lung through abnormal communications between the portal and pulmonary veins or by changes in the lungs caused by similar biochemical abnormalities to those in liver parenchyma. Lymphocytic interstitial pneumonitis(LIP) is more common in women and is associated with autoimmune diseases. Chest x-ray findings include reticular or reticulonodular opacities while computed tomography (CT) usually shows subpleural fibrosis (predominately in basal areas), ground-glass attenuation, traction bronchiectases and pulmonary parenchymal cysts.

Identification of human metapneumovirus and Chlamydophila pneumoniae in children with asthma and wheeze in Singapore

INTRODUCTION

The aim of our study was to determine if human metapneumovirus (hMPV) and Chlamydophila pneumoniae (CP) could be detected in Singaporean asthmatic children and wheezing infants during an acute asthma attack.

METHODS

The study was performed on 30 older children (mean age 9.8 years) and 30 young children (mean age 1.3 years), who were admitted with an acute exacerbation of wheezing. Nasopharyngeal aspirates were collected and tested by polymerase chain reaction for CP, and for a panel of viruses (hMPV, respiratory syncytial virus, adenovirus, influenza virus types A and B, parainfluenza virus types 1 and 3, and rhinovirus).

RESULTS

hMPV was isolated in eight out of 60 children (13.3 percent), while CP was isolated in two cases. Overall, 48/60 (80 percent) samples were positive for the presence of viruses.

CONCLUSION

In most of the children admitted because of acute wheezing, a virus could be detected. hMPV was isolated for the first time in Singapore in children who were admitted with an acute asthma attack.

Dissemination and implementation of guidelines for the treatment of asthma

Asthma remains a serious global health problem that affects people of all ages. Many asthma management guidelines, both national and international, are available, but they are seldom implemented. The implementation of guidelines remains a challenge worldwide, as barriers exist at several levels. These barriers are generic, such as poverty, inadequate resources and poor infrastructure, or specific, such as organisational, health care provider and patient factors. The barriers are, however, potentially correctable, and the goal of guideline implementation is to translate evidence-based asthma management recommendations into real-life practice to improve patient health. This state of the art article reviews the challenges and current status of and strategies for asthma dissemination and implementation globally, and highlights the specific strategies for such improvement in developing countries.

Attitudes towards cancer survivors: a small survey

INTRODUCTION

The National Cancer Survivors Day Foundation defines a cancer "survivor" as anyone living with a history of cancer--from the moment of diagnosis through the remainder of life. Little is known about the size and make-up of this population or about the medical care experience of and social implications for patients who have had a diagnosis of cancer in Singapore. An opportunistic survey was undertaken to understand how members of the public believe about this population.

METHODS

A sample of the general public was undertaken during the "CancerVive" event in 2004. Questionnaires regarding employment as well as attitudes towards cancer and cancer survivorship were distributed.

RESULTS

Members of the public held certain misconceptions about cancer survivors. They also have certain negative attitudes toward cancer survivors. Beliefs and attitudes about cancer are similar for cancer survivors and the general public. Although members of the public had positive attitudes towards working with cancer survivors, the majority felt that cancer survivors should not be given equal opportunities at work, by not employing cancer survivors if they were in the position to hire.

CONCLUSION

Further research with larger and more representative samples needs to be undertaken to extend the understanding into cancer survivorship issues.

The Clinical Predictors of Hypertension and Sleepiness in an Asian Population with Sleep-disordered Breathing

Introduction: The objective of this study was to identify the clinical predictors for hypertension and sleepiness in an Asian population with sleep-disordered breathing (SDB). Materials and Methods: This is a retrospective, consecutive case series of 228 patients with symptoms of SDB referred to a tertiary level sleep disorders unit. A full sleep history, body mass index (BMI), Epworth Sleepiness Score (ESS), apnoea-hypopnoea index (AHI) and lowest oxygen saturation were recorded. All patients had an in-hospital polysomnogram. AHI ≥5 defined SDB. ESS >8 defined sleepiness. Results: A BMI of 25 had a positive and negative predictive value of 75% and 56%, respectively, for predicting AHI ≥5, area ROC (receiver operating curve) = 0.668. Patients with AHI >5 had 3 times the risk of developing hypertension compared to the population with AHI <5. Using stepwise multivariate analyses with constant, age, BMI and lowest oxygen desaturation were predictors for hypertension. Patients with AHI ≥5 were 1.88 times more likely to have ESS >8. After stepwise multivariate analyses, the subjective complaint of sleepiness and lowest oxygen saturation during sleep were predictors of ESS >8. Conclusion: The lowest oxygen saturation attained during sleep was the common factor for hypertension and sleepiness in our Asian SDB population. Mild obesity predisposes to AHI ≥5 in our population, the threshold at which the risk of hypertension is 3-fold compared with AHI <5. The subjective complaint of sleepiness predicted an ESS of >8.

The clinical predictors of hypertension and sleepiness in an Asian population with sleep-disordered breathing

INTRODUCTION

The objective of this study was to identify the clinical predictors for hypertension and sleepiness in an Asian population with sleep-disordered breathing (SDB).

MATERIALS AND METHODS

This is a retrospective, consecutive case series of 228 patients with symptoms of SDB referred to a tertiary level sleep disorders unit. A full sleep history, body mass index (BMI), Epworth Sleepiness Score (ESS), apnoea-hypopnoea index (AHI) and lowest oxygen saturation were recorded. All patients had an in-hospital polysomnogram. AHI > or =5 defined SDB. ESS >8 defined sleepiness.

RESULTS

A BMI of 25 had a positive and negative predictive value of 75% and 56%, respectively, for predicting AHI > or =5, area ROC (receiver operating curve) = 0.668. Patients with AHI >5 had 3 times the risk of developing hypertension compared to the population with AHI <5. Using stepwise multivariate analyses with constant, age, BMI and lowest oxygen desaturation were predictors for hypertension. Patients with AHI > or =5 were 1.88 times more likely to have ESS >8. After stepwise multivariate analyses, the subjective complaint of sleepiness and lowest oxygen saturation during sleep were predictors of ESS >8.

CONCLUSION

The lowest oxygen saturation attained during sleep was the common factor for hypertension and sleepiness in our Asian SDB population. Mild obesity predisposes to AHI > or =5 in our population, the threshold at which the risk of hypertension is 3-fold compared with AHI <5. The subjective complaint of sleepiness predicted an ESS of >8.

Management of chronic obstructive pulmonary disease in Asia and Africa

This review examines whether the comprehensive programme recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), developed mostly by physicians in industrialised countries, can be applied in developing countries. In developing countries, there are several major limitations to the implementation of the programme. First, management of chronic obstructive pulmonary disease (COPD) patients is not a priority in competing for health care resources. Second, only major medical centres in developing countries have spirometers; the reliance on spirometric testing for diagnosis, staging and treatment options, as recommended by the GOLD guidelines, makes it almost impossible for the programme to be implemented. Third, in many Asian and African countries, regular monitoring is often restricted to patients with severe COPD who have frequent hospitalisations or clinic visits for exacerbations and complications. Fourth, the choice of therapy usually depends on the availability and cost of drugs. Finally, given the aetiological role of sequelae of lung infections, including tuberculosis, the appropriateness and safety of using intermittent courses of oral steroids during acute exacerbations and of long-term, high-dose inhaled corticosteroids for moderate to severe COPD in developing countries has not been evaluated. Developing countries in Asia and Africa may need to adapt the GOLD guidelines according to varying aetiology, local health care resources, socio-economic and cultural factors and development of health services. Prevention programmes, especially for tobacco control, are of paramount importance. National and international efforts must be directed towards controlling the tobacco epidemic in developing countries to reduce the burden of COPD and other tobacco-induced diseases.

The burden and impact of COPD in Asia and Africa

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. The World Health Organization (WHO) estimated that COPD is currently the seventh leading cause of death and disability worldwide, but will rise to the fifth position by 2020. The estimated prevalence of COPD worldwide in 2001 was 1013/100,000 population; it was highest in the Western Pacific Region and lowest in Africa. The mortality from COPD followed the same pattern. The prevalence of smoking is slowly decreasing in the industrialised world and rising in developing countries, especially in Asia and Africa. Cigarette consumption per adult has also decreased in the Americas, remained the same in Europe but increased in all other regions, especially the Western Pacific. Indoor air pollution from combustion of biomass/traditional fuels and coal, previous tuberculous infection, outdoor air pollution and childhood respiratory infections are other important risk factors for COPD in developing countries. The rise in morbidity and mortality from COPD will be most dramatic in Asian and African countries over the next two decades, mostly due to progressive increase in the prevalence of smoking. As developing countries can ill afford the added economic burden of COPD and other smoking-related diseases, there is an urgent need for multi-dimensional actions in reducing the main risk factor of cigarette smoking.

Overview on SARS in Asia and the world

Severe Acute Respiratory Syndrome (SARS) is the first major novel infectious disease to hit the international community in the 21st century. It originated in southern China in November 2002, reached Hong Kong in February 2003 and spread rapidly thereafter to 29 countries/regions on five continents. At the end of the epidemic, the global cumulative total was 8098 with 774 deaths. Seven Asian countries/regions were among the top ten on the list. Mainland China and Hong Kong, SAR, accounted for 87% of all cases and 84% of all deaths. Severe acute respiratory syndrome is caused by a novel coronavirus. It has alarmed the world with its infectivity and significant morbidity and mortality, its lack of a rapid, reliable diagnostic test and lack of effective specific treatment and vaccination. The adverse impact on travel and business around the world, particularly in Asia, has been enormous. Some lessons learnt from this epidemic included: (1) any outbreak of infectious disease can rapidly spread around the world by air travel; (2) early reporting of the outbreak to neighbouring countries/regions and the World Health Organization is essential to prevent international spread; and (3) infection control, tracing and quarantine of contacts are essential to control the epidemic. Many questions remain unanswered, including the origin and pathogenesis of the novel coronavirus, the natural history and the best specific treatment of the disease. The SARS-CoV has probably jumped from an animal host to humans. There is an urgent need to evaluate the human-animal habitat in southern China and to remove animal reservoirs if found.

Audit of 'crash' emergency caesarean sections due to cord prolapse in terms of response time and perinatal outcome

OBJECTIVE

The objective was to audit 'crash' emergency caesarean sections (CS) with respect to response time (the diagnosis to delivery interval [DDI]) and perinatal outcome.

MATERIALS AND METHODS

The computerised database at the Singapore General Hospital (SGH) delivery suite was used to identify all cases of 'crash' emergency CS activated for the diagnosis of cord prolapse from 1992 to 2002. Patients' case notes and neonatal charts were reviewed and the following variables were evaluated: parity, gestational age at the time of delivery and the DDI. Neonatal outcome was measured by Apgar scores at 1 and 5 minutes, cord pH and admission to the neonatal intensive care unit (NICU).

RESULTS

A total of 34 cases of umbilical cord prolapse were identified from 29,867 deliveries, giving an incidence of 0.11% (1 in 900). The median gestational age was 38.5 weeks (range, 25 to 41 weeks). The median time from diagnosis to delivery was 20 minutes (range, 10 to 40 minutes). Seventy-six percent (19/30) were delivered within 30 minutes. The time of diagnosis was not recorded for 5 cases. Sixty-three percent of neonates had an Apgar score < or = 7 at 1 minute of life, increasing to 97% at 5 minutes. There were 3 NICU admissions for reasons of prematurity. There was no perinatal mortality. Cord pH was not performed for 47% of (14/30) neonates. Among the remaining 16 neonates, an umbilical cord pH of < or = 7.20 was found in 62% (10/16). There was poor correlation between the DDI and umbilical cord pH.

CONCLUSION

Three-quarters of our 'crash' emergency CS for cord prolapse were performed within 30 minutes with a good perinatal outcome. However, we have identified areas for improvement to optimise further the operational efficiency of 'crash' emergency CS.

Survival among Chinese women with lung cancer in Singapore: a comparison by stage, histology and smoking status

Lung cancer generally carries a poor prognosis and the determinants of survival have been of interest. However, survival estimates in Asian populations are scarce. This study describes survival rates and their determinants in Singapore Chinese women, a primarily non-smoking population. Three hundred and twenty-six Chinese women, diagnosed with primary lung carcinoma in three major hospitals in Singapore between April 1996 and December 1998, were followed up till 31 December 2000. The Kaplan-Meier method was used for survival analysis. Two hundred and eighty (85.7%) died from the disease during follow-up. The median survival time was 0.7 years and the three-year survival was 15.8%. These survival rates are similar to those of Western populations, and they provide a basis for examining trends over time. Age at diagnosis was an independent prognostic factor [adjusted hazard ratio (relative risk) 1.4, 95% confidence intervals (CI) 1.1-1.9 for women above 65 years relative to younger women]. Most (70.5%) tumours were stage III/IV at diagnosis. Three-year survival ranged from 72% among patients with stage I tumours to 7% for stage IV tumours. Overall, there was no survival difference among different histological types in all stages combined. When limited to stages I and II cancers, adenocarcinomas were associated with a better outcome relative to other histological subtypes combined (adjusted relative risk 0.4, 95% CI 0.1-1.0). Smoking was an independent risk factor (adjusted relative risk 1.3, 95% CI 1.0-1.8). Nevertheless, non-smokers comprised 57.4% of this series, highlighting the importance of increased awareness among health professionals and the public that lung cancer is not only a disease of smokers. The high proportion of late-stage tumours in this study and the impact of disease stage on outcome underline the importance of early detection in improving survival of lung cancer.

Changing trends in indications for caesarean sections in a tertiary hospital

OBJECTIVES

To study the caesarean section rate and the trends in indications for caesarean delivery at the Singapore General Hospital (SGH) during two study periods of 6 months each.

MATERIALS AND METHODS

The percentages of caesarean sections attributable to specific indications were computed for the first 6 months of 1998 and the last 6 months of 2001. Subgroup analysis of "less common indications" was performed.

RESULTS

In the first half of 1998, 170 caesarean sections were performed giving a rate of 16.77%. 54.12% of women were multiparous. The main indication for caesarean section was dystocia (4.24% of deliveries). Two hundred and sixty caesarean sections were performed in the later half of 2001 giving a caesarean section rate of 25.10%. 53.46% of women were multiparous. The main indication for caesarean section was dystocia (5.41% of deliveries). Increase in caesarean section rate in 2001 was attributed to statistically significant increase in caesarean section for previous caesarean section and placenta previa major. Other changes in practice included shorter operating time which may be related to decision not to perform peritoneal closure.

CONCLUSION

Studying indications for caesarean section are useful for hospitals, clinicians and researchers in determining strategies to lower primary and repeat caesarean section rate.

Role of antibiotic prophylaxis for wound infection in percutaneous endoscopic gastrostomy (PEG): result of a prospective double-blind randomized trial

A randomized, double-blind, controlled trial was carried out to determine the value of antibiotic prophylaxis in the prevention of wound infection in percutaneous endoscopic gastrostomy (PEG) procedures. The wound was evaluated using ASEPSIS method and categorized as disturbance of healing, minor or major wound infection on the 7th day and the 28th day. The rate of infection including major wound infection was lower in the prophylaxis group of patients at both seven and 28 days.

Dietary isothiocyanates, glutathione S-transferase -M1, -T1 polymorphisms and lung cancer risk among Chinese women in Singapore

Chinese populations consume a diet relatively high in isothiocyanates (ITCs), a derivative of cruciferous vegetables known to have cancer-protective effects. This class of compounds is metabolized by the glutathione S-transferase family of enzymes, which are also involved in the detoxification of tobacco-related carcinogens such as polycyclic aromatic hydrocarbons and alkyl halides. We evaluated the association between dietary isothiocyanate intake, GSTM1 and GSTT1 polymorphisms, and lung cancer risk in 420 Chinese women: 233 histologically confirmed lung cancer patients and 187 hospital controls. Among these, 58.8% of cases and 90.3% of controls were lifetime nonsmokers. An allele-specific PCR method was used to detect the presence or absence of the GSTM1 and GSTT1 genes in DNA isolated from peripheral blood. Higher weekly intake of ITCs (above the control median value of 53.0 micromol) reduced the risk of lung cancer to a greater extent in smokers [adjusted odds ratio (OR), 0.31; 95% confidence interval (CI), 0.10-0.98] than nonsmokers (OR, 0.70; 95% CI, 0.45-1.11). The inverse association was stronger among subjects with homozygous deletion of GSTM1 and/or GSTT1. Among nonsmokers with GSTM1-null genotype, higher intake of ITCs significantly reduced the risk of lung cancer (OR, 0.54; 95% CI, 0.30-0.95), an effect not seen among those with detectable GSTM1 (OR, 1.07; 95% CI, 0.50-2.29). Our results, in a Chinese female population, are consistent with the hypothesis that ITC is inversely related to the risk of lung cancer, and we show that among nonsmokers this effect may be primarily confined to GST-null individuals. Conjugation and elimination of ITCs is enhanced in GST-non-null relative to -null individuals, such that the GST metabolic genotype modifies the protective effect of ITCs on lung cancer development.

Cytokines involved in the systemic inflammatory response induced by exposure to particulate matter air pollutants (PM(10))

Elevated levels of ambient particulate matter (PM(10)) have been associated with increased cardiopulmonary morbidity and mortality. We previously showed that the deposition of particles in the lung induces a systemic inflammatory response that includes stimulation of the bone marrow. This marrow response is related to mediators released by alveolar macrophages (AM) and in this study we measured cytokines produced by human AM exposed to ambient particles of different composition and size. Identified cytokines were also measured in the circulation of healthy young subjects exposed to air pollutants during the 1997 Southeast Asian forest fires. Human AM were incubated with particle suspensions of residual oil fly ash (ROFA), ambient urban particles (EHC 93), inert carbon particles, and latex particles of different sizes (0.1, 1, and 10 microm) and concentrations for 24 h. Tumor necrosis factor-alpha (TNF-alpha) increases in a dose-dependent manner when AM were exposed to EHC 93 particles (p < 0.02). The TNF response of AM exposed to different sizes of latex particles was similar. The latex (158 +/- 31%), inert carbon (179 +/- 32%), and ROFA (216 +/- 34%) particles all show a similar maximum TNF response (percent change from baseline) whereas EHC 93 (1,020 +/- 212%, p < 0.05) showed a greater maximum response that was similar to lipopolysaccharide (LPS) 1 microg/ml (812 +/- 320%). Macrophages incubated with an optimal dose of EHC 93 particles (0.1 mg/ml) also produce a broad spectrum of other proinflammatory cytokines, particularly interleukin (IL)-6 (p < 0.01), IL-1 beta (p < 0.05), macrophage inflammatory protein-1 alpha (MIP-1 alpha) (p < 0.05), and granulocyte macrophage colony-stimulating factor (GM-CSF) (p < 0.01) with no difference in concentrations of the anti-inflammatory cytokine IL-10 (p = NS). Circulating levels of IL-1 beta, IL-6, and GM-CSF were elevated in subjects exposed to high levels of PM(10) during an episode of acute air pollution. These results show that a range of different particles stimulate AM to produce proinflammatory cytokines and these cytokines are also present in the blood of subjects during an episode of acute atmospheric air pollution. We postulate that these cytokines induced a systemic response that has an important role in the pathogenesis of the cardiopulmonary adverse health effects associated with atmospheric pollution.