Chemoradiation in locally advanced cervical cancer : A randomized trial

Background: Radiation with concurrent chemotherapy (weekly cisplatin) is currently standard of care for locally advanced cervical cancer. Gemcitabine, a pyrimidine analogue is a potentially radio-sensitizing drug. We compared cisplatin and gemcitabine in the treatment of locally advanced cervical cancer. Methods: 90 patients with locally advanced squamous cell cancer of the cervix (stage IIB-IVA) were randomized to receive either cisplatin 40mg/m2 weekly or gemcitabine 150 mg/m2 weekly (45 patients in each arm) along with external beam radiation (50Gy in 25# over 5 weeks). This was followed by three insertions of high dose radiation (HDR) intracavitary brachytherapy one week apart. Results: At a median follow up of 13months, 25 (55.56%) patients were in complete response (CR) in the cisplatin arm compared to 22 patients (48.89%) [p=0.67] in gemcitabine arm. 10 patients (22.22%) in cisplatin arm had either died or lost to follow up compared to 11 patients in gemcitabine (24.44%) arm. Nausea/vomiting was higher in cisplatin arm. Diarrhea, skin reaction and hematological toxicity were more in gemcitabine arm. Conclusion: Cisplatin seems to be a better option than gemcitabine when used concurrently with radiation for locally advanced cervical cancer both in terms of response and toxicity.

PET imaging in the management of tumors of testis and ovary: current thinking and future directions

The role of fluoro-D-deoxyglucose positron-emission tomography (FDG-PET) in testicular malignancies has been examined in various studies primarily in three specific settings: 1) differentiation of active disease from fibrosis/mature teratoma in patients with residual mass following chemotherapy and evaluation of the response to treatment; 2) initial staging and disease assessment after orchidectomy identification of suspected recurrences in the context of elevated circulating serum markers; and 3) predicting response to treatment. Of these, the area where FDG-PET imaging has been examined the most in testicular tumors is the evaluation of postchemotherapy residual mass in both seminoma and nonseminomatous germ cell tumors (NSGCT) of the testis, a critical step in determining the subsequent management approach of these tumors that vary amongst various centers. From the available data, this should be the test of choice for the assessment of a computed tomography (CT)-visualized residual mass following chemotherapy. In patients with residual masses or raised marker levels following therapy, positron-emission tomography (PET) appears sensitive and specific for detecting recurrent disease, at suspected and unsuspected sites. Fewer studies are available investigating its usefulness for staging at diagnosis and this requires further investigation to determine its eventual place as an imaging modality in this setting. Its precise role in disease prognostification is yet to be clearly defined in this malignancy but the initial results are promising. With regard to its role in ovarian carcinoma, it appears to be particularly useful for the diagnosis of recurrence when CA125 levels are rising and conventional imaging is inconclusive or negative. The role of fluoro-D-deoxyglucose (FDG)-PET/CT for the detection of recurrent ovarian cancer appears very promising and has the potential to replace the current surveillance techniques in detecting recurrent disease.

Outcome of Newborn Hearing Screening Programme delivered by health visitors

BACKGROUND

The Newborn Hearing Screening Programme (NHSP) was introduced in England in 2001 to detect congenital hearing loss in the newborn. The screen is either hospital- or community-based.

OBJECTIVES

This is the first large-scale study of community-based NHSP published in the United Kingdom which aims to evaluate the performance of the community-based screen and compare it against national targets for NHSP and the outcome of national pilot projects.

METHOD

Hearing screening data recorded for 10,074 well babies between March 2004 and December 2005 were analysed. Babies who were admitted to the Special Care Baby Unit were excluded. The case notes of all children who failed the initial hearing screen, either unilateral or bilateral, were reviewed retrospectively. Specific performance measures include coverage rate, referral rate and yield. Reasons for failure to complete the screen were identified.

RESULTS

The community programme met all the standards set by the NHSP and the results are comparable with the average of the pilot sites reported in 2004.

CONCLUSION

The data demonstrate that a community-based hearing screening programme conducted by Health Visitors meets all the current national standards and could be implemented across wider areas in this country. Its advantages include a low false positive rate and convenience for parents living in rural areas. The babies identified can be diagnosed and rehabilitated in a time which meets national standards.

PET imaging in neuroendocrine tumors: current status and future prospects

Neuroendocrine tumors (NET) are relatively rare diverse group of tumors that possess several unique characteristics and occur most commonly in the gastrointestinal tract. An important feature of these tumors is that they express somatostatin (SST) receptors, and thus can be successfully targeted with specific radiolabeled SST receptor related compounds. This has led to the introduction of multitude of single photon emission computed tomography (SPECT) and positron emission tomography (PET) tracers, which have significantly improved the ability for imaging these neoplastic lesions with high spatial resolution in the abdomen and elsewhere in the body. The introduction of Gallium-68 labeled radiopharmaceuticals as viable PET agents have added a new dimension to the management of patients with NET by providing high quality images compared with planar or SPECT with single photon emitting preparations. (18)F-labeled DOPA has demonstrated impressive results in differentiating between focal and diffuse disease in hyperinsulinism of the newborn which appears to be of crucial clinical benefit and has altered the management of these patients significantly. With regard to other types of NET, the current experience with such agents is relatively limited and therefore prospective studies are required to further define the role of PET in this complicated group of patients.

Fetal ascites owing to congenital cytomegalovirus: response to ganciclovir

A term newborn with severe congenital cytomegalovirus (CMV) infection is described. Fetal ascites was detected at 28 weeks gestation, and at birth there was tense ascites. There was intra-uterine growth retardation, microcephaly, chorioretinitis, jaundice, purpura and pneumonitis. Computed tomographic scan of the brain showed ventriculomegaly with periventricular calcifications. Serology was positive for cytomegalovirus-specific immunoglobulin M, and cytomegalovirus DNA was detected in the ascitic fluid and urine by nested polymerase chain reaction. He received 6 weeks of treatment with ganciclovir. Ascites resolved spontaneously and liver function tests became normal. Although there was a good clinical response to ganciclovir therapy without any side-effects, on follow-up the infant had global developmental delay and bilateral sensorineural deafness.

Gamma c-signaling cytokines induce a regulatory T cell phenotype in malignant CD4+ T lymphocytes

In this study, we demonstrate that malignant mature CD4(+) T lymphocytes derived from cutaneous T cell lymphomas (CTCL) variably display some aspects of the T regulatory phenotype. Whereas seven cell lines representing a spectrum of primary cutaneous T cell lymphoproliferative disorders expressed CD25 and TGF-beta, the expression of FOXP3 and, to a lesser degree, IL-10 was restricted to two CTCL cell lines that are dependent on exogenous IL-2. IL-2, IL-15, and IL-21, all of which signals through receptors containing the common gamma chain, induced expression of IL-10 in the IL-2-dependent cell lines as well as primary leukemic CTCL cells. However, only IL-2 and IL-15, but not IL-21, induced expression of FOXP3. The IL-2-triggered induction of IL-10 and FOXP3 expression occurred by signaling through STAT3 and STAT5, respectively. Immunohistochemical analysis of the CTCL tissues revealed that FOXP3-expressing cells were common among the CD7-negative enlarged atypical and small lymphocytes at the early skin patch and plaque stages. Their frequency was profoundly diminished at the tumor stage and in the CTCL lymph node lesions with or without large cell transformation. These results indicate that the T regulatory cell features are induced in CTCL T cells by common gamma chain signaling cytokines such as IL-2 and do not represent a fully predetermined, constitutive phenotype independent of the local environmental stimuli to which these malignant mature CD4(+) T cells become exposed.

International Monetary Fund programs and tuberculosis outcomes in post-communist countries

BACKGROUND

Previous studies have indicated that International Monetary Fund (IMF) economic programs have influenced health-care infrastructure in recipient countries. The post-communist Eastern European and former Soviet Union countries experienced relatively similar political and economic changes over the past two decades, and participated in IMF programs of varying size and duration. We empirically examine how IMF programs related to changes in tuberculosis incidence, prevalence, and mortality rates among these countries.

METHODS AND FINDINGS

We performed multivariate regression of two decades of tuberculosis incidence, prevalence, and mortality data against variables potentially influencing tuberculosis program outcomes in 21 post-communist countries for which comparative data are available. After correcting for confounding variables, as well as potential detection, selection, and ecological biases, we observed that participating in an IMF program was associated with increased tuberculosis incidence, prevalence, and mortality rates by 13.9%, 13.2%, and 16.6%, respectively. Each additional year of participation in an IMF program was associated with increased tuberculosis mortality rates by 4.1%, and each 1% increase in IMF lending was associated with increased tuberculosis mortality rates by 0.9%. On the other hand, we estimated a decrease in tuberculosis mortality rates of 30.7% (95% confidence interval, 18.3% to 49.5%) associated with exiting the IMF programs. IMF lending did not appear to be a response to worsened health outcomes; rather, it appeared to be a precipitant of such outcomes (Granger- and Sims-causality tests), even after controlling for potential political, socioeconomic, demographic, and health-related confounders. In contrast, non-IMF lending programs were connected with decreased tuberculosis mortality rates (-7.6%, 95% confidence interval, -1.0% to -14.1%). The associations observed between tuberculosis mortality and IMF programs were similar to those observed when evaluating the impact of IMF programs on tuberculosis incidence and prevalence. While IMF programs were connected with large reductions in generalized government expenditures, tuberculosis program coverage, and the number of physicians per capita, non-IMF lending programs were not significantly associated with these variables.

CONCLUSIONS

IMF economic reform programs are associated with significantly worsened tuberculosis incidence, prevalence, and mortality rates in post-communist Eastern European and former Soviet countries, independent of other political, socioeconomic, demographic, and health changes in these countries. Future research should attempt to examine how IMF programs may have related to other non-tuberculosis-related health outcomes.

Yes-associated protein (YAP) functions as a tumor suppressor in breast

Yes-associated protein (YAP) has been shown to positively regulate p53 family members and to be negatively regulated by the AKT proto-oncogene product in promoting apoptosis. On the basis of this function and its location at 11q22.2, a site of frequent loss of heterozygosity (LOH) in breast cancer, we investigated whether YAP is a tumor suppressor in breast. Examination of tumors by immunohistochemistry demonstrated significant loss of YAP protein. LOH analysis revealed that protein loss correlates with specific deletion of the YAP gene locus. Functionally, short hairpin RNA knockdown of YAP in breast cell lines suppressed anoikis, increased migration and invasiveness, inhibited the response to taxol and enhanced tumor growth in nude mice. This is the first report indicating YAP as a tumor suppressor, revealing its decreased expression in breast cancer as well as demonstrating the functional implications of YAP loss in several aspects of cancer signaling.

Predictors of mortality in very low birth weight neonates in India

INTRODUCTION

Very low birth weight (VLBW) neonates constitute approximately 4-7 percent of all live births and their mortality is very high. The objective of the present study was to determine the predictors of mortality in VLBW neonates.

METHODS

A retrospective cohort of VLBW neonates admitted over three years was studied. Exclusion criteria were: (1) neonates weighing less than 500 g and with gestational age less than 26 weeks; (2) presence of lethal congenital malformations; and (3) death in the delivery room or within 12 hours of life. The outcome measure was in-hospital death. Medical records were reviewed and data was analysed. Univariate analysis and logistic regression analysis were done to determine the predictors of mortality.

RESULTS

A total of 260 cases were enrolled, of which a total of 96 (36.9 percent) babies died. The survival rate was found to increase with the increase in birth weight and gestational age. Univariate analysis showed maternal per vaginal bleeding, failure to administer steroid antenatally, Apgar score less than or equal to 5 at one minute, apnoea, gestational age, neonatal septicaemia and shock are the factors directly responsible for neonatal mortality. Logistic regression equation showed maternal bleed (1.326), apnoea (3.159), birth weight (0.037), gestational age (0.063), hypothermia (1.132) and shock (3.49) predicted 65 percent of mortality in VLBW babies.

CONCLUSION

Common antenatal and perinatal predictors of mortality in VLBW infants in India include maternal bleed, failure to administer antenatal steroids, low Apgar score, apnoea, extreme prematurity, neonatal septicaemia and shock.

High molecular mass multimer complexes and vascular expression contribute to high adiponectin in the fetus

CONTEXT

High plasma adiponectin concentrations in human fetuses and neonates are unique features of early developmental stages. Yet, the origins of the high adiponectin concentrations in the perinatal period remain elusive.

OBJECTIVE

This study was undertaken to identify the sources and functional properties of adiponectin in utero.

DESIGN AND METHODS

Tissue specimens were obtained at autopsy from 21- to 39-wk-old stillborn human fetuses. Adipose tissue and placenta were obtained at term elective cesarean section. Adiponectin complexes and expression were measured by immunodetection and real-time PCR.

RESULTS

Adiponectin mRNA transcripts were detected in fetal sc and omental adipose depots at lower concentrations than in maternal adipose tissue. Immunoreactive adiponectin was also observed in vascular endothelial cells of fetal organs, including skeletal muscle, kidney, and brain. The absence of adiponectin in all placental cell types and lack of correlation between maternal and umbilical adiponectin indicate that umbilical adiponectin reflects its exclusive production by fetal tissues. The most prominent forms of adiponectin in fetal plasma were high and low molecular mass (HMW and LMW) multimers of 340 and 160 kDa, respectively. The proportion of the HMW complexes was 5-fold (P < 0.001) higher in umbilical plasma than in adult. The high HMW and total adiponectin levels were associated with lower insulin concentration and lower homeostasis model of assessment of insulin resistance indices in umbilical plasma, reflecting higher insulin sensitivity of the fetus compared with adult.

CONCLUSIONS

The abundance of HMW adiponectin and its vascular expression are characteristics of human fetal adiponectin. Combined with high insulin sensitivity, fetal adiponectin may be a critical determinant of in utero growth.

Exact trait-model-free tests for linkage detection in pedigrees

A number of trait-model-free tests have been proposed for linkage detection between a genomic region and a trait. These tests involve testing the dependence in segregation between a trait and marker alleles by assigning a score to every possible identity-by-descent configuration of the pedigree members without modeling the trait, and then averaging the scores over all such configurations compatible with the observed marker genotypes and genealogical relationship of the pedigree members. In this paper we propose a permutation test as an alternative to the existing exact trait-model-free tests for linkage detection. The proposed test is computationally efficient and is applicable on complex multigeneration pedigree structures. In this paper, we have compared the performance of the permutation test with two other exact trait-model-free tests for linkage detection on simulated datasets. We have demonstrated that the proposed permutation test is fully robust against mispecification of marker allele frequencies and has very good power for linkage detection. The permutation test is implemented in the program lm_ibdtests within the framework of MORGAN 2.8 (http://www.stat.washington.edu/thompson/Genepi/MORGAN/Morgan.shtml).

Oncologic PET tracers beyond [(18)F]FDG and the novel quantitative approaches in PET imaging

In this review, we focus on the oncological applications of positron emission tomography (PET) tracers other than [(18)F]fluoro-2-deoxy-D-glucose (FDG) and the novel quantitative approaches in PET imaging. Oncological non-FDG PET tracers can be broadly categorized into 3 groups: those labeled with (18)F, (11)C and other non-FDG tracers. Fluorine-18 and (11)C are labeled with different amino acids, substrates involved in fatty acid synthesis, protein synthesis, amino acid transport substrate and tracers linked to nucleic acid synthesis. These tracers are also labeled with specific ligands for receptor imaging (i.e. estrogens, dihydrotestosterone or somatostatin). The other non-FDG radiotracers can be labeled with (68)Ga, (60)Cu, (64)Cu, etc. and are aimed to detect cell hypoxia, bone metabolism and receptor. Many of these have shown promising results in the management of various cancers where FDG has limited role. These radiotracers have more specific mechanism of uptake and is likely be investigated in the near future. In the era of fusion imaging, novel approaches for accurate quantitative analysis include partial volume correction for measured values in small lesions, dual-time point and delayed PET imaging, and global metabolic activity for assessment of various stages of disease. Major changes are likely to occur in the future that may overcome deficiencies that are associated with the current quantitative (standardized uptake value) techniques.

Antibiotic misuse in children by the primary care physicians--an Indian experience

OBJECTIVE

To determine the misuse of antibiotics in the Pediatric outpatients department' (OPD) of a busy teaching hospital and to ascertain the probable reasons behind it.

METHODS

Over a 6 months period, new cases primarily treated with antibiotics by Medical Officers (first contact physicians in Peadiatric Medicine and Surgery OPD) were recruited in the study after obtaining written consent from the parents. Various errors of antibiotic usage were noted. All Medical Officers were asked to fill up a preformed questionnaire and the parents/guardians were interviewed on their ideas about antibiotics. Data were analyzed by the statistical software SPSS 10.

RESULTS

Antibiotics were prescribed in 2427 (84.9%) new patients. Misuse of antibiotics was documented in 36.8% patients (no indication in 35.3%, improper selection in 17.9% and incorrect dosage in 7.7%). All medical officers were aware that they overuse antibiotics. The various reasons sited were demand of the parents, reluctance to counsel due to patient overload, free supply of medicines from OPD and sympathetic grounds as follow up visits were uncertain. Majority of the parents/attendants belonged to poor socioeconomic status and did not have any idea regarding antibiotics. All parents wanted quick relief without hospitalization and only 2.3% were willing to revisit the OPD for the same illness. Both medical officers and parents felt that base line investigations were unnecessary.

CONCLUSION

Antibiotic misuse is quite common in this part of the world. Irrational use was mostly seen in over-prescribing and improper selection of antibiotic. Poor socio-economic status and overcrowding of patients in OPD were the main responsible factors.

Obesity in pregnancy stimulates macrophage accumulation and inflammation in the placenta

Obesity and pregnancy are associated with a combination of insulin resistance and inflammatory changes which exacerbate in combination. Based on the similarity between the inflammatory transcriptomes of adipose tissue and placenta, we hypothesized that the placenta develops exaggerated inflammation in response to obesity. The aim of this study was to characterize placental inflammatory mediators and macrophage accumulation in relation to peripheral inflammation in obesity. Placental macrophages and maternal peripheral blood mononuclear cells (PBMC) from 20 obese and 15 lean women were functionally and phenotypically characterized using immunohistochemistry, flow cytometry and expression for macrophage markers and inflammatory cytokines. The number of resident CD68+ and CD14+ cells was increased 2-3 fold in the placenta of obese as compared to lean women. The macrophage population was characterized by a marked phenotypic heterogeneity with complex subsets of CD14+, CD68+ and CD11b+ (mac-1) cells and by an increased expression of the pro-inflammatory cytokines IL-1, TNF-alpha, IL-6. Placental inflammation was associated with an activation of PBMC gene expression with an increase in the monocyte differentiation and maturation markers CD14 and CD68 in maternal but not fetal PBMC. The inflammatory changes were associated with higher plasma concentrations of C-reactive protein and IL-6 in obese compared to lean women. In conclusion, the chronic inflammation state of pre-gravid obesity is extending to in utero life with accumulation of a heterogeneous macrophage population and pro-inflammatory mediators in the placenta. The resulting inflammatory milieu in which the fetus develops may have critical consequences for short and long term programming of obesity.