Increasing incidence of adenocarcinoma lung in India: Following the global trend?

BACKGROUND

Lung cancer is one of the most common malignant neoplasms worldwide and accounts for more deaths than any other cancer. The clinicopathological profile of lung cancer has shown marked regional and geographical variation.

AIMS

We aimed to compare the demographic and pathological profile of lung cancer patients from North India with other Indian and International series.

SETTING AND DESIGN

A retrospective study over a period of 5 years from January 2008 to May 2013 was conducted in the Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi.

PATIENTS AND METHODS

A total of 397 newly diagnosed patients with lung cancer from January 2008 to May 2013 were included in the study. The clinical, demographic, and pathological features were reviewed and compared with other major National and International reports. Data were entered and analyzed using SPSS software (SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc.

RESULTS

A total of 397 patients (86% men, mean age 57.8 years) were studied. The ratio of men to women was 7.4. Majority of patients (78.3%) were current/previous smokers. Small cell carcinoma was diagnosed in 14.6% (58) of patients while 85.4% (339) had nonsmall cell lung carcinoma (NSCLC). Within NSCLC, the most common histology types were squamous cell carcinoma (30%), followed closely by adenocarcinoma (ADC) (28.3%) and large cell carcinoma (1.7%). Majority (87%) of the patient were staged III and IV. About 30.1% patients received anti-tubercular treatment during the current episode before a diagnosis of lung cancer was made.

CONCLUSION

The clinicopathological profile of lung cancer has undergone noticeable changes over the last four decades, especially in the increase in ADC incidence and their frequent presence in smokers. Lung cancer is often mistreated as tuberculosis in the Indian subcontinent and hence continues to be diagnosed late.

Study of the structure and functioning of referral mechanism of patients receiving treatment and records linkage under Revised National Tuberculosis Control Programme (RNTCP) of Government of India

BACKGROUND

The reliable and successful performance of the Revised National Tuberculosis Control Programme (RNTCP) "referral mechanism" is profoundly important in the medical college scenario, and it is an important requirement of the programme to have feedback status report of the referred patients.

METHODS

An observational study on tuberculosis (TB) patients referred from Directly Observed Treatment (DOT) Centre, Sri Venkateswara Institute of Medical Sciences (SVIMS) was conducted during the years 2010 to 2012 (n=622). Subjects referred to other TUs within the District but failed to report there within 45 days constituted "cases" and subjects, who obtained treatment from the TUs they were referred to "controls". The initial information or confirmation of registration for treatment status feedback were obtained from patient/Senior Treatment Supervisor (STS)/District Tuberculosis Centre (DTC) levels respectively both before using intervention (Phase I, year 2010) and after using intervention (Phase II, years 2011 and 2012) by sending day-to-day text messaging of referral details of patients to the STS and District Tuberculosis Officer (DTO).

RESULTS

During Phase I, the distribution of subjects (n=242) in the ages ≤25, 26-50, and ≥51 years was similar in both the cases and control subjects (p=0.054). Further, there was no statistically significant difference in the median age of the cases and controls [34.5 (interquartile range, IQR 31-51) vs 39 (30-54); p=0.319]. There was no statistically significant difference in other parameters, such as gender distribution (p=0.9748); availability of phone numbers (p=0.9614); type of disease (p=0.8395); and type of case (p=0.0793). In Phase II, the effect of intervention on feedback related parameters showed statistically significant improvement in all the parameters such as initial feedback levels obtained within 15 days (p=0.0077); within 45 days (p<0.0001); above 45 days (p<0.0001); registration status confirmation within 45 days (p=0.0343); mismatch of feedback received by observer (p<0.0001); and telephone number of patients recorded (p<0.0001).

CONCLUSION

Our findings suggest that text messaging reminders may be an important tool to achieve optimal feedback response in resource-limited settings.

Circulating genotypes of Pneumocystis jirovecii and its clinical correlation in patients from a single tertiary center in India

The present study was carried out with the objectives of genotyping Pneumocystis jirovecii at three distinct loci, to identify the single nucleotide polymorphisms (SNPs), and to study its clinical implications in patients with Pneumocystis pneumonia (PCP). Analysis of genetic diversity in P. jirovecii from immunocompromised patients was carried out by genotyping at three distinct loci encoding mitochondrial large subunit rRNA (mtLSU rRNA), cytochrome b (CYB), and superoxide dismutase (SOD) using polymerase chain reaction (PCR) assays followed by direct DNA sequencing. Of the 300 patients enrolled in the present study, 31 (10.33%) were positive for PCP by a specific mtLSU rRNA nested PCR assay, whereas only 15 P. jirovecii could be amplified at the other two loci (SOD and CYB). These positives were further subjected to sequence typing. Important genotypic combinations between four SNPs (mt85, SOD110, SOD215, and CYB838) and clinical outcomes could be observed in the present study, and mt85A, mt85T, and SOD110C/SOD215T were frequently associated with "negative follow-up". These SNPs were also noted to be relatively more prevalent amongst circulating genotypes in our study population. The present study is the first of its kind from the Indian subcontinent and demonstrated that potential SNPs of P. jirovecii may possibly be attributed to the clinical outcome of PCP episodes in terms of severity or fatality in different susceptible populations likely to develop PCP during their course of illness.

Programmed death-1+ T cells inhibit effector T cells at the pathological site of miliary tuberculosis

Optimal T cell activation is vital for the successful resolution of microbial infections. Programmed death-1 (PD-1) is a key immune check-point receptor expressed by activated T cells. Aberrant/excessive inhibition mediated by PD-1 may impair host immunity to Mycobacterium tuberculosis infection, leading to disseminated disease such as miliary tuberculosis (MTB). PD-1 mediated inhibition of T cells in pulmonary tuberculosis and TB pleurisy is reported. However, their role in MTB, particularly at the pathological site, remains to be addressed. The objective of this study was to investigate the role of PD-1-PD-ligand 1 (PD-L1) in T cell responses at the pathological site from patients of TB pleurisy and MTB as clinical models of contained and disseminated forms of tuberculosis, respectively. We examined the expression and function of PD-1 and its ligands (PD-L1-PD-L2) on host immune cells among tuberculosis patients. Bronchoalveolar lavage-derived CD3 T cells in MTB expressed PD-1 (54·2 ± 27·4%, P ≥ 0·0009) with significantly higher PD-1 ligand-positive T cells (PD-L1: 19·8 ± 11·8%; P ≥ 0·019, PD-L2: 12·6 ± 6·2%; P ≥ 0·023), CD19⁺ B cells (PD-L1: 14·4 ± 10·4%; P ≥ 0·042, PD-L2: 2·6 ± 1·43%; not significant) and CD14⁺ monocytes (PD-L1: 40·2 ± 20·1%; P ≥ 0·047, PD-L2: 22·4 ± 15·6%; P ≥ 0·032) compared with peripheral blood (PB) of MTB and healthy controls. The expression of PD-1 was associated with a diminished number of cells producing effector cytokines interferon (IFN)-γ, tumour necrosis factor (TNF)-α, interleukin (IL)-2 and elevated apoptosis. Locally accumulated T cells were predominantly PD-1⁺ -PD-L1⁺ , and blocking this pathway restores the protective T cell response. We conclude that M. tuberculosis exploits the PD-1 pathway to evade the host immune response by altering the T helper type 1 (Th1) and Th2 balance at the pathological site of MTB, thereby favouring disease dissemination.

Differential KrasV12 protein levels control a switch regulating lung cancer cell morphology and motility

INTRODUCTION

Oncogenic Kras mutations are important drivers of lung cancer development and metastasis. They are known to activate numerous cellular signaling pathways implicated in enhanced proliferation, survival, tumorigenicity and motility during malignant progression.

OBJECTIVES

Most previous studies of Kras in cancer have focused on the comparison of cell states in the absence or presence of oncogenic Kras mutations. Here we show that differential expression of the constitutively active mutation Kras^V12 has profound effects on cell morphology and motility that drive metastatic processes.

METHODS

The study relies on lung cancer cell transformation models, patient-derived lung cancer cell lines, and human lung tumor sections combined with molecular biology techniques, live-cell imaging and staining methods.

RESULTS

Our analysis shows two cell functional states driven by Kras^V12 protein levels: a non-motile state associated with high Kras^V12 levels and tumorigenicity, and a motile state associated with low Kras^V12 levels and cell dissemination. Conversion between the states is conferred by differential activation of a mechano-sensitive double-negative feedback between Kras^V12/ERK/Myosin II and matrix-adhesion signaling. Kras^V12 expression levels change upon cues such as hypoxia and integrin-mediated cell-matrix adhesion, rendering Kras^V12 levels an integrator of micro-environmental signals that translate into cellular function. By live cell imaging of tumor models we observe shedding of mixed high and low Kras^V12 expressers forming multi-functional collectives with potentially optimal metastatic properties composed of a highly mobile and a highly tumorigenic unit.

DISCUSSION

Together these data highlight previously unappreciated roles for the quantitative effects of expression level variation of oncogenic signaling molecules in conferring fundamental alterations in cell function regulation required for cancer progression.

High prevalence of malnutrition and deranged relationship between energy demands and food intake in advanced non-small cell lung cancer

The relation between dietary intake and metabolic profile in non-small cell lung cancer (NSCLC) was evaluated. Patients with NSCLC were recruited and their caloric requirement and resting energy expenditure (REE) were calculated using the Harris-Benedict equation and Katch-McArdle formula respectively. Hypermetabolic state was defined as REE more than 10% above the basal metabolic rate (BMR). Body composition parameters were calculated by bioelectric impedance method. The 24-h dietary intake method and Malnutrition Universal Screening Tool assessed nutritional intake. One hundred and forty-eight subjects were included (87% males). Of these, 46.6% subjects were hypermetabolic and 31% cachexic, with lower calorie and protein intakes than recommended, although per cent of total energy derived from protein, fat and carbohydrates were similar. Hypermetabolic patients had lower BMI, though the per cent deficit in energy and protein consumption was similar. Cachexia was associated with lower BMR but not with deficit in energy or protein consumption. No correlation was seen between dietary intake and body composition parameters. The calorie and protein intake of NSCLC patients is lower than recommended. The discordance between elevated REE and dietary intake implies that the relationship between increased energy demands and food intake may be altered.

The use of electrodessication in the treatment of cutaneous neurofibromatosis: A retrospective patient satisfaction outcome assessment

INTRODUCTION

Neurofibromatosis I (NF-1) is an autosomal dominant disease giving rise to hundreds of cutaneous neurofibromas. In addition to localised symptoms such as pain and pruritus, these lesions can have a devastating psychosocial impact. To date, there is no consensus on the optimal management of these lesions. We present the clinical and patient-reported outcomes of a series of NF-1 patients treated with electrodessication by one surgeon.

METHODS

All patients treated by electrodessication for cutaneous neurofibromas between 2012 and 2015 by one clinician were retrospectively reviewed. Clinical and patient-reported outcomes were measured using a patient satisfaction questionnaire and review of the notes.

RESULTS

Six patients were operated on during the study period (five women and one man). Prior to this new technique, patients had on average eight episodes (range 4-20) of excisional procedures under local anaesthesia removing one to five lesions. With electrodessication, patients had on average three (range 1-5) electrodessication episodes under general anaesthesia, treating hundreds of lesions per session. All patients were treated as a day case. One patient experienced a minor wound infection and another minor bleeding. Five of six patients preferred electrodessication to surgical excision.

CONCLUSION

Electrodessication enables the treatment of hundreds of neurofibromas in a single operation. The procedure has low complication rates with high levels of clinical and patient-reported outcomes.

Fetal hydantoin syndrome: A case report

Fetal hydantoin syndrome (FHS) is a spectrum of defects caused to the developing fetus by exposure to the teratogenic effects of antiepileptic drug (AED) phenytoin during pregnancy. Its clinical manifestations include limb abnormalities, ocular defects, central nervous system anomalies, intrauterine growth restriction, and hand and phalangeal anomalies. This case report presents an 8-year-old child born to an epileptic mother with a history of AED therapy, with features suggestive of FHS.

Hesperetin exerts apoptotic effect on A431 skin carcinoma cells by regulating mitogen activated protein kinases and cyclins

Dietary agents and phytochemicals have been utilised for the management of cancer for many years. Hesperetin, a dietary flavonoid found abundantly in citrus fruits, was evaluated for its cytotoxic and pro-apoptotic activities in A431 human skin carcinoma cells. Effect of hesperetin in regulating MAPK (Mitogen-Activated Protein Kinase) signalling pathway and levels of various cyclins and other downstream apoptotic proteins were investigated. Its critical role in regulating other apoptotic proteins especially p21, Bcl-2 and Bax were also assessed. Hesperetin stimulated alterations in MAPK (Mitogen-Activated Protein Kinase) signalling pathway by modulating the expression levels of ERK (Extracellular signal Regulated Kinase), JNK (c-Jun NH2-terminal Kinase) and p38; thereby induced apoptosis in A431 cells. Hesperetin regulated the levels of cyclin A2, B1, D1, D3 and E1. It also modulated the levels of various proteins involved in apoptotic pathway especially p21, Bcl-2 and Bax. The study revealed the efficiency of hesperetin against human skin carcinoma cells and proposed its mechanism of action; there by opens up new avenues for the use of this dietary flavonoid against skin malignancies.

Study on relationship between the nutritional status and dental caries in 8-12 year old children of Udaipur City, India

BACKGROUND

The future health of individuals depends on the well being of the children of today. Proper nutrition for children is very important. The most commonly used index of obesity and over weight is Body Mass Index. The growth of children should be monitored using the Body Mass Index (BMI) and risk factors assessed through a dietary and physical activity history. The increase in obesity is attributed to increased carbohydrate consumption among children. Obesity and caries are both diet-based conditions that share a cause that is, excessive ingestion of fermentable carbohydrates.

OBJECTIVE

This study was undertaken to determine the association of nutritional status with dental caries in 8 to 12 year old children of Udaipur city.

METHOD

The present study was conducted on a random sample of 1000 boys and girls, aged 8-12 years. The children were selected from schools located in the Udaipur City, Rajasthan. The schools examined were of government and private sector schools in Udaipur city. The children from schools of Udaipur city was taken in the study with male, female and age group ratio as per distribution in population. A proforma was used to record children's age, gender, school, year, height, weight, parental income and dental caries status. Statistical analysis was done using Statistical Package of Social Science (SPSS Version 15; Chicago Inc., USA).

RESULT

It was found that caries free individuals were more from normal nutritional status group with 134 (13.4 %) subjects where as only 11 (1.1 %) of subjects obese children were found caries free.

CONCLUSION

Study shows that the children with normal BMI for age had more caries in their primary teeth, as well as in their permanent teeth, than the overweight children.

Evaluation of Metered Dose Inhaler Use Technique and Response to Educational Training

BACKGROUND

Prescribing inhalers without imparting adequate education regarding proper technique of their usage may result in suboptimal clinical improvement and wastage of medication. Training interventions using a standard check-list may help improve faulty techniques and enhance drug efficacy.

METHODS

Patients using metered dose inhaler (MDI) were included in the study. Inhaler technique was first evaluated at baseline using a standard check-list of recommended steps (National Institute of Health guidelines; see Table) and scores were given for each step correctly performed. Those who could not perform all steps correctly were given training intervention. The patients were assigned to two methods of educational intervention; one group was trained by providing written material giving step-wise instructions while the other group was given an actual physical demonstration using a placebo device. The technique was re-evaluated and scored following each educational session, and continued till the patient achieved a full score, or for a maximum of 3 sessions, whichever occurred earlier. Median score was calculated after each session and was compared between the two groups. Each patient was followed up after two months and the re-evaluated the same way.

RESULTS

One hundred and seventeen subjects were enrolled in the study (59 in the written group and 57 in the practical demonstration group). At baseline, only 1 of the 117 subjects could perform all the steps of inhaler usage correctly. This patient was, therefore, not provided the inhaler technique education. The overall median (range) score of the whole group was 3 (range 1-8). This score rose to 6, 7 and 8 after each of the three subsequent educational intervention sessions. At one-month follow-up, the median score dropped to 7 and improved with a repeat educational session as previously done. A significant difference was observed in the median score improvement achieved in the practical demonstration group compared with the written instruction group (3.0 versus 2.0 respectively, p < 0.001).

CONCLUSIONS

Inhalation technique of patients improves after imparting systematic educational intervention. A practical demonstration of all the steps proved more effective than simple verbal/written advice. In view of increasing errors being committed over a period of time, repeated demonstration of the proper technique using a standard check-list significantly improves the errors committed during inhaler use.

Using a TightRope® to treat a complex fracture of the trapezium

We present the case of a 23-year-old man with a combined scaphoid fracture and comminuted trapezium fracture, treated surgically with percutaneous fixation of the scaphoid fracture and concomitant Arthrex Mini TightRope(®) stabilisation of base of thumb metacarpal to base of index finger metacarpal. The patient made a good functional recovery, returning to usual activities within six weeks. We suggest that this technique could be used to treat complex trapezium fractures that cannot be reconstructed with surgery.

CC genotype of anti-apoptotic gene BCL-2 (-938 C/A) is an independent prognostic marker of unfavorable clinical outcome in patients with non-small-cell lung cancer

BACKGROUND

B cell lymphoma 2 (BCL-2) gene is a well-known regulator of apoptosis and a key element in cancer development and progression. A regulatory (-938C>A, rs2279115) single-nucleotide polymorphism in the inhibitory P2 BCL-2 gene promoter generates significantly different BCL-2 promoter activities and has been associated with different clinical outcomes in various malignancies. The aim of the present study was to analyze the possible influence of the (-938C>A) SNP on the risk and survival of Indian patients suffering from NSCLC.

MATERIALS AND METHODS

A hospital-based case-control study of 155 age- and sex-matched patients diagnosed with NSCLC and 155 cancer-free controls was conducted and genotyped by performing PIRA-PCR to elucidate the putative association between clinical outcome and genotypes of BCL-2 (-938C>A, rs2279115). The association of the polymorphism with the survival of NSCLC patients was analyzed by Kaplan-Meier curves.

RESULTS

In Indian NSCLC, patients increased risk of developing NSCLC was found to be associated with BCL-2 (-938) CC genotype, [OR 3.68 (1.92-6.79), RR 1.87 (1.35-2.57) and RD 31.03 (16.79-45.27) p 0.00006 for CC and OR 2.08 (1.18-3.66), RR 1.36 (1.08-1.71) and RD 17.74 (4.68-30.81) p 0.01 for AC genotype]. Patients homozygous for C allele exhibited a significant poor overall survival compared with patients displaying AC + CC or AC or AA genotype [median survival (months) 8 vs. 11 vs. 14 vs. 35.5 (p < 0.0001)]. In addition, significant associations were observed between TNM stage, histological type, distant metastases status, family history of any cancer, gender and age group of NSCLC patients with BCL-2 (-938C>A) polymorphism.

CONCLUSION

Genetic polymorphism in the inhibitory P2 promoter region of anti-apoptotic BCL-2 genes contributes to the risk of developing non-small-cell lung cancer in Indian population. BCL-2 (-938CC) genotype was an independent adverse prognostic factor for patients with NSCLC.

Legionella pneumophila infection associated with renal failure causing fatality in a known case of sarcoidosis

Legionella pneumophila infection may become fatal in immunocompromised state. We report here the first known fatal case from India due to Legionella pneumophila infection complicated by renal failure in a patient undergoing treatment for Sarcoidosis. Sarcoidosis is an idiopathic systemic inflammatory disease involving multiple organs. Urine antigen detection and polymerase chain reaction targeting 16S rRNA gene could help in rapid diagnosis of the infection and thereby start specific therapy. Clinical awareness along with availability of rapid diagnostic tests and institution of specific therapy may reduce morbidity and mortality associated with this infection especially in immunocompromised state.