The effect of a primary tumour resection on the progression of synchronous colorectal liver metastases: an exploratory study

AIM

The objective of this study was to determine the effect of an upfront primary tumour resection on the progression of synchronous colorectal liver metastases.

MATERIALS AND METHODS

Patients with synchronous colorectal liver metastases referred between 2005 and 2010 were identified. Patients were analysed according to the following two groups: 1) an upfront primary tumour resection and 2) neo-adjuvant chemotherapy. A univariate and multivariate analysis was performed to identify factors significantly contributing to progressive disease. Cox regression analysis was undertaken to determine the effect of management on overall survival (OS) and time to tumour progression (TTP).

RESULTS

A total of 116 patients with synchronous colorectal liver metastases were identified of which 49 patients received an upfront primary tumour resection and 67 received neo-adjuvant chemotherapy. Liver resections were performed in 18 (36.7%) and 14 (20.9%) of the patients in the upfront and neo-adjuvant groups respectively (P 0.06). On multivariate analysis, an upfront primary tumour resection significantly affected progressive disease (p < 0.001, OR 5.67; 95% CI 2.71-11.79). An upfront tumour resection was not a significant predictor of overall survival (P = 0.83; HR 1.10; 95% CI 0.48-2.52).

CONCLUSION

Our findings suggest that an upfront primary tumour resection in patients with synchronous colorectal liver metastases results in progressive disease. These preliminary findings need to be validated in a future multi-centre independent study.

Comparison of fracture toughness of all-ceramic and metal-ceramic cement retained implant crowns: an in vitro study

To evaluate the fracture toughness of cement-retained implant-supported metal-ceramic molar crown with that of all-ceramic crowns, fabricated using IPS Empress 2 and yttria-stabilized zirconia copings. An dental implant and abutment was embedded in a clear polymethyl methacrylate model. A wax pattern reproducing the anatomy and dimension of a mandibular molar was made using inlay wax. Copings were made from the manufacturers guidelines for zirconia, metal ceramic and empress crown, in total of 21 copings, which were built for the crowns with metal layering ceramics specified by the manufacturers. The polymethylmethacrylate block-implant abutment complex was mounted on universal testing machine, and a static continuos vertical compressive load with a crosshead speed of 0.5 mm/min was applied. The breaking load and the peak load (in kilo Newtons) were recorded. The fractures for group I (zirconia-ceramic) and group II (metal-ceramic) occurred on the mesio-buccal aspect of the crowns involving the veneered ceramic layer while the catastrophic/bulk fracture was not observed. The mean value of breaking load for zirconia-ceramic, metal-ceramic and IPS-empress 2 was 3.4335, 3.071 and 1.0673 kN respectively. The mean value of peak load for zirconia-ceramic, metal-ceramic and IPS-empress 2 was 4.7365, 3.2757 and 1.566 kN respectively. It can be concluded that the zirconia-ceramic crown with the fracture toughness of 4.7365 ± 2.2676 kN has sufficient strength to allow clinical testing of these crowns as an alternative for metal-ceramic crowns (3.2757 ± 0.4681 kN).

Use of the Trauma Embolic Scoring System (TESS) to Predict Symptomatic Deep Vein Thrombosis and Fatal and Non-Fatal Pulmonary Embolism in Severely Injured Patients

Fatal pulmonary embolism is the third most common cause of death after major trauma. We hypothesised that the Trauma Embolic Scoring System (TESS) would have adequate calibration and discrimination in a group of severely injured trauma patients in predicting venous thromboembolism (VTE), and could be used to predict fatal and non-fatal symptomatic pulmonary embolism. Calibration and discrimination of the TESS were assessed by the slope and intercept of the calibration curve and the area under the receiver operating characteristic curve, respectively. Of the 357 patients included in the study, 74 patients (21%) developed symptomatic VTE after a median period of 14 days following injury. The TESS predicted risks of VTE were higher among patients who developed VTE than those who did not (14 versus 9%, P=0.001) and had a moderate ability to discriminate between patients who developed VTE and those who did not (area under the receiver operating characteristic curve 0.71, 95% confidence interval 0.65 to 0.77). The slope and intercept of the calibration curve were 2.76 and 0.34, respectively, suggesting that the predicted risks of VTE were not sufficiently extreme and overall, underestimated the observed risks of VTE. Using 5% predicted risk of VTE as an arbitrary cut-point, TESS had a high sensitivity and negative predictive value (both ≥0.97) in excluding fatal and non-fatal pulmonary embolism. In summary, the TESS had a reasonable ability to discriminate between patients who developed VTE and those who did not and may be useful to select different preventive strategies to prevent VTE in severely injured patients.

Impact of right-handedness on anaesthetic sensitivity, intra-operative awareness and postoperative mortality

Anatomical, neurological and behavioural research has suggested differences between the brains of right- and non-right-handed individuals, including differences in brain structure, electroencephalogram patterns, explicit memory and sleep architecture. Some studies have also found decreased longevity in left-handed individuals. We therefore aimed to determine whether handedness independently affects the relationship between volatile anaesthetic concentration and the bispectral index, the incidence of definite or possible intra-operative awareness with explicit recall, or postoperative mortality. We studied 5585 patients in this secondary analysis of data collected in a multicentre clinical trial. There were 4992 (89.4%) right-handed and 593 (10.6%) non-right-handed patients. Handedness was not associated with (a) an alteration in anaesthetic sensitivity in terms of the relationship between the bispectral index and volatile anaesthetic concentration (estimated effect on the regression relationship -0.52 parallel shift; 95% CI -1.27 to 0.23, p = 0.17); (b) the incidence of intra-operative awareness with 26/4992 (0.52%) right-handed vs 1/593 (0.17%) non-right-handed (difference = 0.35%; 95% CI -0.45 to 0.63%; p = 0.35); or (c) postoperative mortality rates (90-day relative risk for non-right-handedness 1.19, 95% CI 0.76-1.86; p = 0.45). Thus, no change in anaesthetic management is indicated for non-right-handed patients.

DJ stent - boon or curse?

DJ stent is considered as a boon by the urologist but without proper knowledge it turns to be curse for the patient. We report a case of a 34 year old man who developed vesical calculus secondary to DJ stent in a short span of 6-8 months. He underwent cystolithotomy for removal of the vesical calculus along with the DJ stent. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-3, 55-59 DOI: http://dx.doi.org/10.3126/jcmsn.v9i3.10224  

Topical application of a sandal wood oil and turmeric based cream prevents radiodermatitis in head and neck cancer patients undergoing external beam radiotherapy: a pilot study

OBJECTIVE

The study objective was to assess the effectiveness of a turmeric- and sandal wood oil-containing cream [Vicco(®) turmeric cream (VTC); Vicco Laboratories, Parel, India] on radiodermatitis in patients with head and neck cancer undergoing radiotherapy.

METHODS

A total of 50 patients with head and neck cancer requiring >60 Gy of curative radiotherapy/chemoradiotherapy were enrolled in the study. The volunteers were randomly divided into two groups of 25 patients. Group 1 was assigned to a topical application of Johnson's(®) baby oil (Johnson & Johnson Ltd, Baddi, India) and Group 2 for VTC. Prophylactic application of the cream was initiated on Day 1 and continued every day until 2 weeks after the end of treatment. Both agents were symmetrically applied within the irradiated field five times a day, and the acute skin reactions were assessed twice weekly in accordance with the Radiation Therapy Oncology Group scores by an investigator who was unaware of the details.

RESULTS

The incidence of radiodermatitis increased with the exposure to radiation and was the highest in both groups at Week 7. However, a significant reduction in grades of dermatitis were seen in cohorts applying VTC at all time points, including 2 weeks post radiotherapy (p < 0.015 to p < 0.001). The occurrence of Grade 3 dermatitis was lower in the cohorts using VTC and was statistically significant (p < 0.01). Additionally, follow-up observations 2 weeks after the completion of radiotherapy also showed a reduced degree of radiodermatitis in cohorts applying VTC, which was significant (p = 0.015).

CONCLUSION

VTC is shown to be effective in preventing radiodermatitis and needs to be validated in larger double-blind trials.

ADVANCES IN KNOWLEDGE

For the first time, this study shows that the turmeric- and sandal oil-based cream was effective in preventing radiation-induced dermatitis.

Clinical, electrophysiological, imaging, and ultrastructural description in 68 patients with neuronal ceroid lipofuscinoses and its subtypes

PURPOSE

We evaluated the clinical, electrophysiological, imaging, and ultrastructural features of neuronal ceroid lipofuscinoses and its subtypes.

METHODS

The clinical, electrophysiological, imaging, histopathological, and ultrastructural features of 68 (age at onset: 4.3 ± 5.4 years) neuronal ceroid lipofuscinoses and its subtypes (infantile neuronal ceroid lipofuscinoses [9], late infantile neuronal ceroid lipofuscinoses [34], juvenile neuronal ceroid lipofuscinoses [23], and adult neuronal ceroid lipofuscinoses [2] were evaluated. Skin (n = 56), brain (n = 12), muscle (n = 4) and nerve (n = 1) biopsies confirmed the diagnosis.

RESULTS

Clinical manifestations were milestone regression (93%), involuntary movements (92%), seizures (89%), myoclonus (79%), and visual impairment (68%). Response to anticonvulsants was unsatisfactory. Electroencephalography (n = 59) was abnormal in 90%: background slowing (90%); epileptiform discharges (71%), and photoparoxysmal response (4/21). Visual-evoked (n = 33) and somatosensory evoked (n = 40) potentials were abnormal in 62% and 63% of patients. Cranial computed tomography (n = 33) showed diffuse cerebral (61%) and cerebellar (27%) atrophy. Magnetic resonance imaging was abnormal in all 43 patients who were scanned: diffuse atrophy (100%), cerebellar atrophy (40%), leukoencephalopathy (65%), and thalamic T2 W hypointensity (33%). Dermal inclusions such as curvilinear inclusions were the most common abnormality: late infantile neuronal ceroid lipofuscinoses (97%), juvenile neuronal ceroid lipofuscinoses (100%), and infantile neuronal ceroid lipofuscinoses (88%). Additional fingerprint inclusions were noted: juvenile neuronal ceroid lipofuscinoses (43%), late infantile neuronal ceroid lipofuscinoses (15%), and infantile neuronal ceroid lipofuscinoses (13%). Granular osmiophilic deposits were noted in 50% of infantile neuronal ceroid lipofuscinoses. In 75% of patients, there was good correlation between the clinical subtype and ultrastructural inclusion pattern. In 27% of neuronal ceroid lipofuscinoses, multiple inclusions were noted.

CONCLUSIONS

The diagnosis of neuronal ceroid lipofuscinoses should be considered in individuals with characteristic clinical presentations and characteristic ultrastructural dermal inclusions. Three fourths showed morphological correlation of the inclusions with neuronal ceroid lipofuscinoses subtype.

Probiotics for preterm neonates: what will it take to change clinical practice?

Necrotizing enterocolitis (NEC) is a major cause of mortality (25%) and morbidity including recurrent sepsis, dependence on parenteral nutrition, need for surgery, and survival with short bowel syndrome in preterm very low birth weight infants. Mortality (45-100%) and morbidity including the risk of long-term neurodevelopmental impairment are higher in extremely preterm infants needing surgery for NEC. Systematic reviews of randomized controlled trials (RCT) indicate that probiotics significantly reduce the risk of NEC (RR 0.39; 95% CI 0.29-0.52; p < 0.00001) and all-cause mortality (RR 0.52; 95% CI 0.40-0.69; p < 0.00001) while facilitating enteral feeds in preterm infants. At present, data from 25 RCT (∼5,000 neonates) and reports on routine use (∼3,000 neonates) indicates that significant adverse effects of probiotics are rare. Despite the robust evidence, there is still reluctance in incorporating routine probiotic prophylaxis in clinical practice. If the goal is to have zero tolerance for NEC, then probiotic prophylaxis must be adopted as soon as possible. Current gaps in knowledge can be addressed by continued research while providing routine probiotic supplementation. We believe that the concept of evidence-based practice of medicine has been stretched too far in this case. Trial sequential analysis has already shown that the evidence for probiotic supplementation was conclusive after 10 trials. Results of the ongoing trials are unlikely to change the conclusions of the systematic reviews significantly. Currently we are at trial number 25; how many more trials do we need? What will it take to change clinical practice?

Snowmelt contributions to discharge of the Ganges

Himalayan headwaters supply large quantities of runoff derived from snowmelt and monsoon rainfall to the Ganges River. Actual snowmelt contribution to discharge in the Ganges remains conjectural under both present and future climatic conditions. As snowmelt is likely to be perturbed through climatic warming, four hydrological models, VIC, JULES, LPJmL and SWAT, appropriate for coupling with regional climate models, were used to provide a baseline estimate of snowmelt contribution to flow at seasonal and annual timescales. The models constrain estimates of snowmelt contributions to between 1% and 5% of overall basin runoff. Snowmelt is, however, significant in spring months, a period in which other sources of runoff are scarce.

Diffusion tensor imaging (DTI) and its clinical correlates in drug naïve Wilson's disease

The purpose is to evaluate white matter (WM) abnormalities in Wilson's disease (WD) using the technique of diffusion tensor imaging (DTI). The prospective case-control study comprised of 15 drug-naïve patients with WD and 15 controls. The phenotype of subjects was evaluated. The DTI/conventional MRI was acquired (3T MRI): Fractional anisotropy (FA) and mean diffusivity (MD) values were extracted from regions of interest placed in pons, midbrain, bilateral frontal and occipital cerebral white matter, bilateral internal capsules (IC), middle cerebellar peduncles (MCP) and corpus callosum (CC). Six patients showed lobar WM signal changes on T(2)-Weighted (T2W)/Fluid attenuation inversion recovery (FLAIR) images while remaining had normal appearing WM. MD was significantly increased in the lobar WM, bilateral IC and midbrain of WD patients. FA was decreased in the frontal and occipital WM, bilateral IC, midbrain and pons. Normal-appearing white matter on FLAIR images showed significantly increased MD and decreased FA values in both frontal and occipital lobar WM and IC compared with those in controls. Correlation of clinical scores and DTI metrics revealed positive correlation between neurological symptom score (NSS) and MD of anterior limb of right internal capsule, Chu stage and MD of frontal and occipital WM. Negative correlation was observed between the Modified Schwab and England Activities of Daily Living (MSEADL) score and MD of bilateral frontal and occipital WM and IC. This is the probably the first study to reveal widespread alterations in WM by DTI metrics in drug naïve WD. DTI analysis revealed lobar WM abnormalities which is less frequently noted on conventional MRI and suggests widespread WM abnormalities in WD. It may be valuable in assessing the true extent of involvement and therefore the severity of the illness.

Dural ectasia in Marfan's syndrome: magnetic resonance imaging appearances and anaesthetic experience of three deliveries

Neuraxial anaesthetic techniques are considered useful to minimise haemodynamic stress during labour. In Marfan's syndrome, connective tissue abnormalities not only affect the thoracic aorta but also predispose to dural ectasia. A dural ectatic sac may cause difficulties with neuraxial analgesia and anaesthesia. We discuss magnetic resonance imaging appearances and anaesthetic experience of three deliveries in a parturient with stable echocardiographic findings. We consider that epidural analgesia and anaesthesia are a safe and pragmatic solution for labour and delivery. Lumbo-sacral magnetic resonance imaging at presentation will define dural ectasia and assist in management.

Reconstruction with fibular autograft and silicone implant arthroplasty after resection of giant-cell tumour of the proximal phalanx: a case report with 18-month follow-up

Primary giant-cell tumour of phalanx is a rare entity. Only few cases are described in the literature. Giant-cell tumour of hand is reported to have high local recurrence rate. Curettage and bone grafting have been performed by few authors with limited success. Most of the cases have been treated with ray amputation. We report this case as the first reported case in the literature that has been treated with fibular autograft and silicone implant arthroplasty for giant-cell tumour of the proximal phalanx.

Prevalence and profile of sleep disturbances in Guillain-Barre Syndrome: a prospective questionnaire-based study during 10 days of hospitalization

INTRODUCTION

Sleep disturbances in Guillain-Barre Syndrome (GBS), though common, have not received focused attention.

OBJECTIVES

To study frequency and nature of sleep disturbances in patients with GBS, using validated questionnaires, and analyze the contributing factors.

MATERIALS AND METHODS

This prospective study included 60 patients fulfilling National Institute of Neurological and Communicative Diseases and Stroke (NINCDS) criteria for GBS (mean age: 32.7 ± 12.9 years; median: 30 years; M:F = 46:14), evaluated from 2008 to 2010. Data regarding sleep were collected on 10 consecutive days following admission using Richard Campbell Sleep score, St Mary's Hospital Sleep Questionnaire, and Pittsburgh Sleep Quality Index (PSQI) and correlated with various possible contributing factors like pain, paresthesia, anxiety, depression, autonomic dysfunctions, severity of disease, and therapeutic interventions among others.

OBSERVATIONS

Qualitative and quantitative sleep disturbances were rather frequent and involved over 50% patients: abnormal PSQI - 13.3%, abnormal score on Richard scale - 51.6%, abnormal sleep onset latency - 35%, sleep fragmentation - 40%, and reduced sleep duration - 46.6%. The symptoms were severe during the first week of hospitalization and reduced thereafter. Sleep disturbances as scored on Richard scale significantly correlated with anxiety, pain, paresthesia, and severity of immobility (P < 0.05) but not with depression and use of analgesics or antineuritic drugs.

CONCLUSIONS

This study first of its kind suggests that sleep disturbance in GBS is frequent, multi-factorial, often disturbing, and varies during the course of illness. Routine enquiry into the sleep disturbances and timely intervention may reduce morbidity and improve their quality of life.