Conversion of gestational diabetes mellitus to future Type 2 diabetes mellitus and the predictive value of HbA1c in an Indian cohort

AIM

To investigate the distribution of and risk factors for dysglycaemia (Type 2 diabetes and prediabetes) in women with previous gestational diabetes mellitus in India.

METHODS

All women (n = 989) from two obstetric units in New Delhi and Hyderabad with a history of gestational diabetes were invited to participate, of whom 366 (37%) agreed. Sociodemographic, medical and anthropometric data were collected and 75-g oral glucose tolerance test were carried out.

RESULTS

Within 5 years (median 14 months) of the pregnancy in which they were diagnosed with gestational diabetes, 263 (72%) women were dysglycaemic, including 119 (32%) and 144 (40%) with Type 2 diabetes and prediabetes, respectively. A higher BMI [odds ratio 1.16 per 1-kg/m² greater BMI (95% CI 1.10, 1.28)], presence of acanthosis nigricans [odds ratio 3.10, 95% CI (1.64, 5.87)], postpartum screening interval [odds ratio 1.02 per 1 month greater screening interval 95% CI (1.01, 1.04)] and age [odds ratio 1.10 per 1-year older age 95% CI (1.04, 1.16)] had a higher likelihood of having dysglycaemia. The American Diabetes Association-recommended threshold HbA_1c value of ≥ 48 mmol/mol (6.5%) had a sensitivity and specificity of 81.4 and 90.7%, respectively, for determining the presence of Type 2 diabetes postpartum.

CONCLUSION

The high post-pregnancy conversion rates of gestational diabetes to diabetes reported in the present study reinforce the need for mandatory postpartum screening and identification of strategies for preventing progression to Type 2 diabetes. Use of the American Diabetes Association-recommended HbA_1c threshold for diabetes may lead to significant under-diagnosis.

Osteochondral fractures of the knee in skeletally immature patients: short term results of operative fixation using Omnitech screws

PURPOSE

Osteochondral fractures in skeletally immature patients are rare. A retrospective case series is reported looking at the use of Omnitech compression screws for these injuries.

METHOD

Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months.

RESULTS

The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively.

CONCLUSION

The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

Outcome of operable oral cavity cancer and impact of maintenance metronomic chemotherapy: A retrospective study from rural India

BACKGROUND

Oral cavity cancer is the most common cancer among rural India. There is a paucity of data for outcomes of operable oral cavity cancer from rural India. Use of maintenance metronomic may delay or avoid relapse.

AIM

To evaluate outcomes of operable oral cavity carcinoma and evaluate impact of maintenance metronomic chemotherapy.

OBJECTIVES

To evaluate disease-free survival (DFS), overall survival (OS), and factors affecting the outcome in operable oral cavity cancer.

MATERIALS AND METHODS

Data of patients diagnosed with oral cavity cancer registered between May 2008 and May 2014 were retrieved. Only those patients with operable oral cavity cancer and upfront definitive surgery were included in the study. Demographic profile, stage, tobacco consumption, adjuvant therapy, and pattern of failure were collected. Kaplan-Meir survival analysis was used to determine DFS and OS. Log-rank test was used to evaluate factors affecting outcome.

RESULTS

Median follow-up is 24 months. Out of 335 patients, 225 (67%) had advanced operable cancer with 42/225 (18%) and 183/225 (82%) as Stages III and IVA, respectively. Buccal mucosa was the most common subsite (178/335, 53%) followed by tongue (63/335, 19%). Ninety-two percent patients were addicted to smokeless tobacco, whereas 27% were smokers. Median DFS is 13 months with 2 years relative DFS 32%. Median OS is 30 months, with 2 years OS of 54%. Metronomic adjuvant oral chemotherapy was given in 130/225 (58%); Stage III and IVA patients with median of 14 months (3-18 months). Use of metronomic chemotherapy improved DFS (8 vs. 14 months, P = 0.22) and OS (14 vs. 26 months, P = 0.04).

CONCLUSION

Oral cavity cancer is a major health care problem in rural India. Presentation at advanced stage leads to suboptimal outcomes. Benefit of metronomic maintenance chemotherapy in locally advanced oral cavity needs to be further evaluated prospectively.

Regional uptake an variations in orthopaedic enhanced recovery pathways in knee and hip total arthroplasty

The use of enhanced recovery (ER) pathways for hip and knee arthroplasty has increased over the last decade, and the adoption within orthopaedics is becoming more common. We have demonstrated a regional variation and institutional inconsistency of uptake and delivery of ER pathways in our region. Units that have a unified pathway were more likely to have consistency in treatment and early analgesia for patients. We would advocate that units use an agreed enhanced recovery pathway to optimise patient recovery from hip and knee arthroplasties.

Regional and seasonal variations in ultraviolet B irradiation and vitamin D synthesis in India

Evaluation of ultraviolet B index (UVBI) and its impact on vitamin D synthesis is important. We observed the maximum UVBI between 11 am and 1 pm. There was no increase in serum 25(OH)D levels following sun exposure during winter as the UVBI was significantly low, emphasizing the need for vitamin D supplementation during these months.

INTRODUCTION

The amount of vitamin D3 synthesizing UVB irradiation (290-320 nm) reaching the earth's surface at different altitudes and seasons in different parts of India and it's impact on vitamin D synthesis has not been well studied.

METHODS

The hourly UVB index (UVBI) from 10 am to 3 pm everyday for 12 months was measured by a solar meter in 4 different zones (North, Northeast, West and South) of the country. To study the impact of sun light exposure on vitamin D synthesis during winter, healthy school children aged 10-15 years were exposed to sunlight for a period of 30 min per day, between 11 am to 12 noon with 10 % body surface area, for 4 weeks. The main outcome measures were serum 25(OH)D, PTH, calcium, phosphate, and alkaline phosphatase levels before and after sun exposure.

RESULTS

The mean UVBI was highest between 11 am and 1 pm throughout the year in all locations. The highest UVBI was recorded from the North zone (4.5 ± 2.7 μW/Cm(2)), while the least was recorded in the Northeast zone (2.1 ± 1.2 μW/Cm(2)). UVBI readings in the Northeast zone were consistently low throughout the year, while all the other three zones showed significant seasonal fluctuations. Surprisingly, we observed a significant decrease in serum 25(OH)D levels from baseline (6.3 ± 4.6 to 5.1 ± 2.7 ng/mL; p < 0.001) despite sun exposure.

CONCLUSION

The mean UVBI was highest between 11 am and 1 pm throughout the year in all locations. No increase in the serum 25(OH)D levels was observed following sun exposure in winter, emphasizing the need for vitamin D supplementation during these months.

Abstract PD2-02: NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early breast cancer

COX2 has been implicated in breast tumorigenesis, tumour proliferation & invasion. The role of COX2 in carcinogenesis is thought to be related to its abilities to increase production of prostaglandins, convert pro-carcinogens to carcinogens, inhibit apoptosis, promote angiogenesis, modulate inflammation & immune function & increase tumour cell invasiveness. COX2 inhibition may synergise with aromatase inhibition in controlling endocrine responsive breast cancer. The COX2 product prostaglandin E2 (PGE2) & cytokines such as interleukin-6 (IL6) can up regulate aromatase expression suggesting that aromatase inhibition may be more effective in combination with a COX2 inhibitor. There may be additional COX2 mediated anticancer activity. The hypothesis addressed is that activity of aromatase inhibitors(AI) as neoadjuvant endocrine therapy for early breast cancer may be enhanced by the addition of a COX2 inhibitor.

TRIAL OBJECTIVES

To determine whether the activity of AIs as neo-adjuvant endocrine therapy for ER positive breast cancer in postmenopausal women may be enhanced by the addition of the selective COX2 inhibitor celecoxib.

TRIAL DESIGN

Prospective phase III multicentre randomised trial. Patients were randomised to receive 16 weeks of exemestane 25 mg daily or letrozole 2.5 mg daily (open label) and celecoxib 400 mg twice daily or matched placebo (double blinded). Translational research tumour samples were collected before, during & after therapy.

KEY ELIGIBILITY CRITERIA

Post menopausal, ER positive, invasive cancer, 2cms or greater with calipers & visible on USS.

PRIMARY OUTCOME MEASURE

Objective clinical response to neoadjuvant treatment by RECIST criteria.

RESULTS

Primary Outcome; Response to treatment has been calculated for 266 patients (Table 1). Response rate was 73% in the celecoxib arm & 55% in the placebo arm (p=0.0022). The response rates 4 arm comparison are shown in Table 2. After adjustment for AI effect the significant difference in response rates remained (p=0.0023); the difference in response rates was greater in the exemestane treated group (29%) compared to the letrozole group (7%) although heterogeneity between AI arms was statistically non-significant (p=0.06).

Table 1 Primary Outcome Results: response ratesOUTCOMEPLACEBO N (%)CELECOXIB N (%)TOTAL N (%)X2statisticP-valueRESPONSE73(55)97(73%)170 (64%)9.38820.0022NO RESPONSE60 (45%)36 (27%)96 (36%)  TOTAL133133266  

Table 2: Response Rates 4 Arm Comparison EXEMESTANELETROZOLERESPONSEPLACEBO n(%)CELECOXIB n(%)TOTAL n(%)PLACEBO n(%)CELECOXIB n(%)TOTAL n(%)RESPONSE33 (49)52(78)85(63)40(61)45(68)85(64)NO RESPONSE34(51)15(22)49(37)26(39)21(32)47(36)TOTAL67671346666132

Secondary outcome; There was an USS response rate of 42% v 37% for celecoxib & placebo arms respectively (p=0.2513)

CONCLUSION

The addition of the COX2 inhibitor celecoxib to an AI significantly & substantially increased the clinical response from 55% to 73%. Effect on tumour size assessed with USS is less marked with a non-significant increase in responses from 37% to 42%.

This work was supported by CRUK: CRUK/06/005 and Pfizer.

Citation Format: Rea D, Francis A, Poole C, Brookes C, Stein R, Bartlett J, Dunn J, Canney P, Sutton R, Daoud R, Hallissey M, Achuthan R, Grant M, Babrah J, Smith S, Fraser J, Desai A, Al Dubaisi M, Patel A, Bristol J, Chandrasekharan S, Prest C, Jewkes A. NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD2-02.

Resectable extra-pleural and extra-meningeal solitary fibrous tumours: A multi-centre prognostic study

BACKGROUND

Extra-pleural and extra-meningeal solitary fibrous tumour (SFT) is a rare sarcoma histotype curable with surgery in the majority of patients. The behaviour of these tumours ranges from indolent/very low grade to malignant/high grade but it is still not possible to accurately predict prognosis after surgery. We have investigated a multi-centre series to stratify the risk of recurrence to patients with SFTs.

METHODS

We retrospectively analysed the data from 243 patients who underwent surgery (2002-2011) at four sarcoma referral centres.

RESULTS

Upon univariate analysis, hypercellularity, atypia, necrosis, high mitotic rate (ie >4 mitoses/10 HPF) were associated with both disease-free and overall survival. Surgical margins were a significant prognostic factor for disease-free (P = 0.007) but not for overall survival. Unexpectedly, larger tumour size was associated with a better prognosis (P = 0.038) and fewer recurrences (P = 0.024). Upon multivariable analysis, high mitotic rate (hazard ratio, HR = 2.85, P = 0.002), cellular atypia (HR = 1.62, P = 0.015) and hypercellularity (HR = 1.82, P = 0.031) were significantly associated with recurrences. A SFT recurrence score has been provided to stratify risk of recurrence.

CONCLUSION

This study provides a prognostic model to stratify risk of recurrence in patients with resectable SFTs. This allows clinician to decide on an optimal follow-up strategy and to select patients that may benefit from adjuvant treatments.

Evaluation of the hard and soft tissue changes after maxillary advancement with rigid external distractor in unilateral cleft lip and palate induced maxillary hypoplasia

BACKGROUND

Midfacial growth retardation in cleft lip and palate (CLP) cases, is seen in all the three dimensions. Conventionally these cases are managed by orthographic surgery which has a high rate of relapse. The application of the distraction osteogenesis (DO) has revolutionized the management protocol. The aim of the study was to evaluate the efficacy of rigid external distractor (RED) in management of cleft induced maxillary hypoplasia.

METHODS

Ten cases of unilateral CLP between 11 and 20 years of age having gross midfacial deficiency and those who have undergone presurgical orthodontic treatment were included in the study. The cases were operated for Le Fort 1 osteotomy and application of RED. DO was carried out through transnasal traction wires. Clinico-radiological evaluation of presurgical and 1, 6 and 12 months post distraction parameters were statistically analysed by application of paired 't'-test.

RESULT

There were 4 males and 6 females with a mean age of 15.1 years. The mean distraction carried out was 14.95 mm. There was a significant improvement in all the hard and soft tissue parameters except SNB. Facial profile improvement and stable occlusion was achieved in all the cases.

CONCLUSION

Midfacial DO using RED is a versatile procedure where the maxilla can be moved in multiple planes to achieve a functional, aesthetic and occlusal balance. Keeping in view of the significant relapse rate the clinicians are required to plan 15-20% excess amount of distraction.

Osteochondral Fractures of the Knee in Skeletally Immature Patients: Short-Term Results of Operative Fixation using Omnitech Screws

PURPOSE OF THE STUDY

Retrospective case series looking at the use of Omnitech compression screws for the management of osteochondral fractures in skeletally immature patients.

MATERIAL AND METHODS

Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months.

RESULTS

The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively.

CONCLUSION

The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

Molecular Mechanism Linking BRCA1 Dysfunction to High Grade Serous Epithelial Ovarian Cancers with Peritoneal Permeability and Ascites

Ovarian cancer constitutes the second most common gynecological cancer with a five-year survival rate of 40%. Among the various histotypes associated with hereditary ovarian cancer, high-grade serous epithelial ovarian carcinoma (HGSEOC) is the most predominant and women with inherited mutations in BRCA1 have a lifetime risk of 40-60%. HGSEOC is a challenge for clinical oncologists, due to late presentation of patient, diagnosis and high rate of relapse. Ovarian tumors have a wide range of clinical presentations including development of ascites as a result of deregulated endothelial function thereby causing increased vascular permeability of peritoneal vessels. The molecular mechanisms remain elusive. Studies have shown that fallopian tube cancers develop in women with BRCA1 gene mutations more often than previously suspected. Recent studies suggest that many primary peritoneal cancers and some high-grade serous epithelial ovarian carcinomas actually start in the fallopian tubes. In this article we have addressed the molecular pathway of a recently identified potential biomarker Ubc9 whose deregulated expression due to BRCA1 dysfunction can result in HGSEOC with peritoneal permeability and formation of ascites. We also discuss the role of downstream targets Caveolin-1 and Vascular Endothelial Growth Factor (VEGF) in the pathogenesis of ascites in ovarian carcinomas. Finally we hypothesize a signaling axis between Ubc9 over expression, loss of Caveolin-1 and induction of VEGF in BRCA1 mutant HGSEOC cells. We suggest that Ubc9-mediated stimulation of VEGF as a novel mechanism underlying ovarian cancer aggressiveness and ascites formation. Agents that target Ubc9 and VEGF signaling may represent a novel therapeutic strategy to impede peritoneal growth and spread of HGSEOC.

Differentiating Tumor Progression from Pseudoprogression in Patients with Glioblastomas Using Diffusion Tensor Imaging and Dynamic Susceptibility Contrast MRI

BACKGROUND AND PURPOSE

Early assessment of treatment response is critical in patients with glioblastomas. A combination of DTI and DSC perfusion imaging parameters was evaluated to distinguish glioblastomas with true progression from mixed response and pseudoprogression.

MATERIALS AND METHODS

Forty-one patients with glioblastomas exhibiting enhancing lesions within 6 months after completion of chemoradiation therapy were retrospectively studied. All patients underwent surgery after MR imaging and were histologically classified as having true progression (>75% tumor), mixed response (25%-75% tumor), or pseudoprogression (<25% tumor). Mean diffusivity, fractional anisotropy, linear anisotropy coefficient, planar anisotropy coefficient, spheric anisotropy coefficient, and maximum relative cerebral blood volume values were measured from the enhancing tissue. A multivariate logistic regression analysis was used to determine the best model for classification of true progression from mixed response or pseudoprogression.

RESULTS

Significantly elevated maximum relative cerebral blood volume, fractional anisotropy, linear anisotropy coefficient, and planar anisotropy coefficient and decreased spheric anisotropy coefficient were observed in true progression compared with pseudoprogression (P < .05). There were also significant differences in maximum relative cerebral blood volume, fractional anisotropy, planar anisotropy coefficient, and spheric anisotropy coefficient measurements between mixed response and true progression groups. The best model to distinguish true progression from non-true progression (pseudoprogression and mixed) consisted of fractional anisotropy, linear anisotropy coefficient, and maximum relative cerebral blood volume, resulting in an area under the curve of 0.905. This model also differentiated true progression from mixed response with an area under the curve of 0.901. A combination of fractional anisotropy and maximum relative cerebral blood volume differentiated pseudoprogression from nonpseudoprogression (true progression and mixed) with an area under the curve of 0.807.

CONCLUSIONS

DTI and DSC perfusion imaging can improve accuracy in assessing treatment response and may aid in individualized treatment of patients with glioblastomas.

Significance of Epstein-Barr virus (HHV-4) and CMV (HHV-5) infection among subtype-C human immunodeficiency virus-infected individuals

PURPOSE

Opportunistic viral infections are one of the major causes of morbidity and mortality in HIV infection and their molecular detection in the whole blood could be a useful diagnostic tool.

OBJECTIVE

The frequency of opportunistic DNA virus infections among HIV-1-infected individuals using multiplex real-time PCR assays was studied.

MATERIALS AND METHODS

The subjects were in two groups; group 1: Having CD4 counts<100 cells/µl (n=118) and the group 2: counts>350 cells/µl (n=173). Individuals were classified by WHO clinical staging system. Samples from 70 healthy individuals were tested as controls. In-house qualitative multiplex real-time PCR was standardised and whole blood samples from 291 were tested, followed by quantitative real-time PCR for positives. In a proportion of samples genotypes of Epstein-Barr virus (EBV) and CMV were determined.

RESULTS

The two major viral infections observed were EBV and CMV. The univariate analysis of CMV load showed significant association with cryptococcal meningitis, oral hairy leukoplakia (OHL), CMV retinitis, CD4 counts and WHO staging (P<0.05) while the multivariate analysis showed an association with OHL (P=0.02) and WHO staging (P=0.05). Univariate analysis showed an association of EBV load with CD4 counts and WHO staging (P<0.05) and multivariate analysis had association only with CD4 counts. The CMV load was significantly associated with elevated SGPT and SGOT level (P<0.05) while the EBV had only with SGOT.

CONCLUSION

This study showed an association of EBV and CMV load with CD4+ T cell counts, WHO staging and elevated liver enzymes. These viral infections can accelerate HIV disease and multiplex real-time PCR can be used for the early detection. Genotype 1 and 2 of EBV and genotype gB1 and gB2 of CMV were the prevalent in the HIV-1 subtype C-infected south Indians.

First-trimester fetal cardiac examination using spatiotemporal image correlation, tomographic ultrasound and color Doppler imaging for the diagnosis of complex congenital heart disease in high-risk patients

OBJECTIVE

A four-dimensional (4D) fetal echocardiographic technique utilizing spatiotemporal image correlation, tomographic ultrasound imaging display (STIC-TUI echo) and color Doppler has previously been shown to be effective in displaying the examination planes constituting the extended cardiac examination. The aim of this study was to evaluate the performance of this first-trimester STIC-TUI echo technique in identifying complex congenital heart disease (CHD) in high-risk pregnancies.

METHODS

This was a prospective study of patients presenting at first-trimester screening who were at high risk for CHD owing to pregestational diabetes, in-vitro fertilization (IVF), increased nuchal translucency (NT) thickness, first-trimester tricuspid regurgitation or reversed ductus venosus (DV) a-wave, a previous child with CHD or who were on anticonvulsant medication. First-trimester STIC-TUI echo was performed, and the findings were correlated with second-trimester echocardiography and post-delivery echo findings in survivors.

RESULTS

One hundred and sixty-four fetuses from 152 patients were enrolled (77 diabetics, 38 IVF, 14 with increased NT, 23 cases of tricuspid regurgitation or reversed a-wave in the DV, 22 with prior CHD and two on anticonvulsants). STIC-TUI echo was abnormal in 20 (12%), showing atrioventricular canal defect (n = 9), hypoplastic left heart (n = 2), pulmonary stenosis (n = 2), right aortic arch (n = 1), interrupted aortic arch (n = 1), tricuspid atresia (n = 1), heterotaxy (n = 1), persistent truncus arteriosus (n = 1), double outlet right ventricle and ventricular septal defect (n = 1) and double inlet ventricle with transposition of the great arteries (n = 1). 85% of these anomalies were evident in the four-chamber view plane of the TUI display, and the remainder were diagnosed in the outflow tract planes with color Doppler imaging. In 13, CHD was isolated while seven had extracardiac anomalies. Thirteen fetuses had aneuploidy and all 13 underwent first-trimester termination of pregnancy. In the remaining seven, second-trimester echocardiography and neonatal echo/postmortem examination confirmed anomalies (two stillborn neonates, one neonatal death, four live births). Two cases of CHD missed by first-trimester STIC-TUI echo were diagnosed on second-trimester echo. Accordingly, first-trimester STIC-TUI echo had 91% sensitivity and 100% specificity for the detection of CHD.

CONCLUSIONS

First-trimester 4D echocardiography using a standardized application of STIC, TUI and color Doppler imaging is effective in displaying the imaging planes that are necessary for achieving the diagnosis of complex cardiac anomalies in high-risk patients. Optimal imaging of the four-chamber view with two-dimensional ultrasound is the major determinant of successful volume acquisition.

Glucocorticoids interact with noradrenergic activation at encoding to enhance long-term memory for emotional material in women

Evidence from the animal literature suggests that post-training glucocorticoids (GCs) interact with noradrenergic activation at acquisition to enhance memory consolidation for emotional stimuli. While there is evidence that GCs enhance memory for emotional material in humans, the extent to which this depends on noradrenergic activation at encoding has not been explored. In this study, 20-mg hydrocortisone was administered to healthy young women (18-35 yrs old) in a double-blind fashion 10 min prior to viewing a series of emotional and neutral images. Saliva samples were taken at baseline, 10 min after drug or placebo administration, immediately after viewing the images, 10, 20, and 30 min after viewing the images. Participants returned 1 week later for a surprise recall test. Results suggest that, hydrocortisone administration resulted in emotional memory enhancement only in participants who displayed an increase in endogenous noradrenergic activation, measured via salivary alpha-amylase at encoding. These results support findings in the animal literature, and suggest that GC-induced memory enhancement relies on noradrenergic activation at encoding in women.