Therapeutic plasma exchange in paediatric SLE: a case series from India

Therapeutic plasma exchange (TPE) has been reported to be a useful adjunct in severe systemic lupus erythematosus (SLE) but paediatric literature continues to be scanty. We hereby present three cases of refractory paediatric SLE (pSLE) with thrombotic thrombocytopenic purpura (TTP), diffuse alveolar haemorrhage (DAH) and crescentic glomerulonephritis which were treated with TPE as an adjunctive therapy. TPE was carried out in haemodialysis units using the membrane filtration technique. Demonstrable benefit of TPE was seen in all three cases. In refractory pSLE, TPE may be a useful tool and should be considered. The report additionally highlights the feasibility of undertaking TPE in haemodialysis units, which is important as haemodialysis units are more readily available than dedicated apheresis units in developing countries.

Impacts of climate change and socio-economic scenarios on flow and water quality of the Ganges, Brahmaputra and Meghna (GBM) river systems: low flow and flood statistics

The potential impacts of climate change and socio-economic change on flow and water quality in rivers worldwide is a key area of interest. The Ganges-Brahmaputra-Meghna (GBM) is one of the largest river basins in the world serving a population of over 650 million, and is of vital concern to India and Bangladesh as it provides fresh water for people, agriculture, industry, conservation and for the delta system downstream. This paper seeks to assess future changes in flow and water quality utilising a modelling approach as a means of assessment in a very complex system. The INCA-N model has been applied to the Ganges, Brahmaputra and Meghna river systems to simulate flow and water quality along the rivers under a range of future climate conditions. Three model realisations of the Met Office Hadley Centre global and regional climate models were selected from 17 perturbed model runs to evaluate a range of potential futures in climate. In addition, the models have also been evaluated using socio-economic scenarios, comprising (1) a business as usual future, (2) a more sustainable future, and (3) a less sustainable future. Model results for the 2050s and the 2090s indicate a significant increase in monsoon flows under the future climates, with enhanced flood potential. Low flows are predicted to fall with extended drought periods, which could have impacts on water and sediment supply, irrigated agriculture and saline intrusion. In contrast, the socio-economic changes had relatively little impact on flows, except under the low flow regimes where increased irrigation could further reduce water availability. However, should large scale water transfers upstream of Bangladesh be constructed, these have the potential to reduce flows and divert water away from the delta region depending on the volume and timing of the transfers. This could have significant implications for the delta in terms of saline intrusion, water supply, agriculture and maintaining crucial ecosystems such as the mangrove forests, with serious implications for people's livelihoods in the area. The socio-economic scenarios have a significant impact on water quality, altering nutrient fluxes being transported into the delta region.

Dynamic modeling of the Ganga river system: impacts of future climate and socio-economic change on flows and nitrogen fluxes in India and Bangladesh

This study investigates the potential impacts of future climate and socio-economic change on the flow and nitrogen fluxes of the Ganga river system. This is the first basin scale water quality study for the Ganga considering climate change at 25 km resolution together with socio-economic scenarios. The revised dynamic, process-based INCA model was used to simulate hydrology and water quality within the complex multi-branched river basins. All climate realizations utilized in the study predict increases in temperature and rainfall by the 2050s with significant increase by the 2090s. These changes generate associated increases in monsoon flows and increased availability of water for groundwater recharge and irrigation, but also more frequent flooding. Decreased concentrations of nitrate and ammonia are expected due to increased dilution. Different future socio-economic scenarios were found to have a significant impact on water quality at the downstream end of the Ganga. A less sustainable future resulted in a deterioration of water quality due to the pressures from higher population growth, land use change, increased sewage treatment discharges, enhanced atmospheric nitrogen deposition, and water abstraction. However, water quality was found to improve under a more sustainable strategy as envisaged in the Ganga clean-up plan.

Assessing the impacts of climate change and socio-economic changes on flow and phosphorus flux in the Ganga river system

Anthropogenic climate change has impacted and will continue to impact the natural environment and people around the world. Increasing temperatures and altered rainfall patterns combined with socio-economic factors such as population changes, land use changes and water transfers will affect flows and nutrient fluxes in river systems. The Ganga river, one of the largest river systems in the world, supports approximately 10% global population and more than 700 cities. Changes in the Ganga river system are likely to have a significant impact on water availability, water quality, aquatic habitats and people. In order to investigate these potential changes on the flow and water quality of the Ganga river, a multi-branch version of INCA Phosphorus (INCA-P) model has been applied to the entire river system. The model is used to quantify the impacts from a changing climate, population growth, additional agricultural land, pollution control and water transfers for 2041-2060 and 2080-2099. The results provide valuable information about potential effects of different management strategies on catchment water quality.

Search for the dark photon and the dark Higgs boson at belle

The dark photon A^{'} and the dark Higgs boson h^{'} are hypothetical constituents featured in a number of recently proposed dark sector models. Assuming prompt decays of both dark particles, we search for their production in the so-called Higgstrahlung channel e^{+}e^{-}→A^{'}h^{'}, with h^{'}→A^{'}A^{'}. We investigate ten exclusive final states with A^{'}→e^{+}e^{-}, μ^{+}μ^{-}, or π^{+}π^{-} in the mass ranges 0.1  GeV/c^{2} <m_{A^{'}}<3.5  GeV/c^{2} and 0.2  GeV/c^{2} <m_{h^{'}}<10.5  GeV/c^{2}. We also investigate three inclusive final states 2(e^{+}e^{-})X, 2(μ^{+}μ^{-})X, and (e^{+}e^{-})(μ^{+}μ^{-})X, where X denotes a dark photon candidate detected via missing mass, in the mass ranges 1.1  GeV/c^{2} <m_{A^{'}}<3.5  GeV/c^{2} and 2.2  GeV/c^{2} <m_{h^{'}}<10.5  GeV/c^{2}. Using the entire 977  fb^{-1} data set collected by Belle, we observe no significant signal. We obtain individual and combined 90% credibility level upper limits on the branching fraction times the Born cross section, B×σ_{Born}, on the Born cross section σ_{Born}, and on the dark photon coupling to the dark Higgs boson times the kinetic mixing between the standard model photon and the dark photon, α_{D}×ε^{2}. These limits improve upon and cover wider mass ranges than previous experiments. The limits from the final states 3(π^{+}π^{-}) and 2(e^{+}e^{-})X are the first placed by any experiment. For α_{D} equal to 1/137, m_{h^{'}}< 8  GeV/c^{2}, and m_{A^{'}}<1  GeV/c^{2}, we exclude values of the mixing parameter ε above ∼8×10^{-4}.

Post-trial access to treatment for patients participating in clinical trials

Clinical trials are the mainstay for bringing out newer and better drugs to serve the mankind. By virtue of participating in a clinical trial, a patient receives access to the newer drugs/therapies, but nothing is generally being offered to them once their participation in the study comes to an end. Though the issue of post-trial access to treatment by patients participating in a clinical trial is debatable, there is no compelling justification either for or against it. We examined a case study in order to evaluate the applicability of post-trial access to treatment for patients participating in clinical trials. The provision of post-trial access to treatment should also keep into consideration the compassionate use of drugs on humanitarian grounds, especially in cases of trial drugs that have offered significant benefit to the trial patients and whose termination would lead to deterioration in patient's overall condition. In the present era of personalized medicine, the incorporation of genetic testing into clinical practice further authenticates the rationale of compassionate use of drugs and post-trial access to treatment.

Simeprevir with peginterferon/ribavirin for treatment of chronic hepatitis C virus genotype 1 infection: pooled safety analysis from Phase IIb and III studies

This pooled analysis of five Phase IIb and III studies evaluated the safety and tolerability of simeprevir, a once daily, oral hepatitis C virus (HCV) NS3/4A protease inhibitor. Data were summarised for patients who received simeprevir 150 mg once daily (n = 924) or placebo (n = 540) plus pegylated interferon-α/ribavirin for 12 weeks. During the first 12 weeks of treatment, few patients discontinued simeprevir or placebo due to adverse events (AEs) (both 2.2%). Pruritus (23.8% vs 17.4%), rash (any; 22.9% vs 16.7%) and photosensitivity (3.2% vs 0.6%) [Correction added on 16 January 2015, after first online publication: In the above sentence, the values in 'Photosensitivity' were previously incorrect and have now been changed to 3.2% vs 0.6%.] were more prevalent in the simeprevir vs the placebo groups. Most AEs were grade 1/2 (72.4% for simeprevir vs 71.3% for placebo). All grade 3/4 AEs occurred in <5.0% of patients, except neutropenia (9.8% vs 7.6%). Overall incidence of neutropenia was similar (17.3% vs 15.7%). Incidence of anaemia was 13.2% for simeprevir vs 10.9% for placebo, and incidence of increased bilirubin was 8.4% vs 2.8%. Bilirubin increases were mild-to-moderate and transient without concurrent transaminase increases or association with hepatic injury. Safety and tolerability did not vary with METAVIR score, although increased bilirubin and anaemia were more frequent in simeprevir-treated patients with METAVIR F4 (increased bilirubin, 13.0% vs 3.3%; anaemia, 19.0% vs 14.8%). Serious AEs were infrequent (2.1% for simeprevir vs 3.0% for placebo). No deaths were reported during the first 12 weeks of treatment. Patient-reported fatigue and other outcomes were comparable for both groups, but were of shorter duration for simeprevir due to the use of response-guided therapy. Simeprevir is well tolerated in HCV genotype 1-infected patients.

Ropivacaine: a new local anaesthetic agent in maxillofacial surgery

We have compared the anaesthetic efficacy, duration of action, pain, pulpal anaesthesia, and cardiovascular effects of 0.5% ropivacaine or 2% lignocaine hydrochloride in bilateral symmetrical impacted third molars. In a randomised single-blind trial we studied 78 healthy patients who required bilateral extraction of identical impacted lower third molars. A test dose was given to all patients with subdermal infiltration of 0.5% ropivacaine 0.5 ml. A classic inferior alveolar and long buccal nerve block was created using 0.5% ropivacaine 2 ml on one side and 2% lignocaine hydrochloride 2 ml with adrenaline on the other. The time to onset and duration of action were noted. Pain, numbness of the lip and tip of the tongue, and haemodynamic changes were monitored throughout the procedure. The teeth were extracted two weeks apart. The onset of anaesthesia ranged between 2 and 3 min after the injection and lasted for more than 5h. Ropivacaine alone did not cause appreciable changes in the cardiovascular variables, but lignocaine with adrenaline caused a transient increase in arterial pressure and heart rate 2 min after injection. We conclude the 0.5% ropivacaine alone does not affect the cardiovascular system and has more beneficial effects than 2% lignocaine hydrochloride with adrenaline. These findings may be useful for oral and maxillofacial surgeons who are looking for a local anaesthetic with minimal cardiovascular risk and without a vasoconstrictor to provide regional anaesthesia for long procedures.

Linear trichilemmoma following a blaschkoid pattern: a clinical dilemma

BACKGROUND

Trichilemmoma are benign adnexal neoplasm with follicular outer sheath differentiation. It usually appears as single or multiple papules that resembles colour of the surrounding skin. They are most commonly seen on the face particularly on the nose and cheek.

OBJECTIVES

We report a case of linear trichilemmoma following blaschkoid pattern.

METHODS

A 13 year old boy presenting with asymptomatic plaque on the right side of the nose was fully evaluated for possible cause.

RESULTS

On histopathology, a diagnosis of trichilemmoma was made.

CONCLUSION

This is the first case report where linear trichilemmoma following a blaschkoid pattern is seen.

A medium throughput device to study the effects of combinations of surface strains and fluid-flow shear stresses on cells

We report a medium throughput device to study the effects of combinations of two mechanical stimuli - surface strains and fluid flow shear stresses, on cells. The first generation prototype can screen combinations of five strain and five shear stress levels. Computational modeling and empirical measurements were used to determine the generated strains and flows. Uniform equibiaxial strains up to 20% and shear stresses up to 0.3 Pa can be generated. Compatibility of the device with cell culture and end point fixation, staining and imaging is shown using C2C12 mouse myoblast cells.

Immunoscoring of epidermal growth factor receptor expression in recurrent cases of oral squamous cell carcinoma

BACKGROUND

Oral squamous cell carcinoma (OSCC) is a genetic disease with high prevalence and poor survival. Evaluation of recurrent tumor for a valid biomarker may serve as a predictive system for analyzing prognostic course of this disease. This study was designed to evaluate and compare the immunoscoring of epidermal growth factor receptor (EGFR) expression in recurrent cases with their matched regional/locoregional recurrence and non-recurrent cases of OSCC.

METHODOLOGY

A total of 64 cases of OSCC were studied and immunostained with polyclonal EGFR antibody. Of these, 33 cases recurred at the end of 5 years of follow-up. For positive evaluation of EGFR staining, immunscoring was performed by adding the extent score and intensity score.

RESULTS

We observed significant increase in EGFR immunoscore in recurrent cases of OSCC (P-value 0.001). Immunoscoring of EGFR expression is an independent prognostic and/or predictive parameter for recurrence in OSCC (Odds Ratio: 6.52).

CONCLUSION

Immunoscore using EGFR can be incorporated into traditional classification, thus providing an essential prognostic and potentially predictive tool.

Magnetic resonance enterography in Crohn's disease: a comparison with the findings at surgery

AIM

Magnetic resonance (MR) enterography is a radiation-free small bowel investigation which identifies luminal and extra-luminal pathology in patients with Crohn's disease. Most studies have validated MR against conventional radiology. We evaluated the results of MR enterography by comparison with findings at elective surgery for patients with Crohn's disease, including complex pathology.

METHOD

Between January 2007 and March 2012 the results of preoperative MR enterography for Crohn's disease in consecutive patients in one unit were compared with the detailed findings at surgery.

RESULTS

Fifty-one patients underwent 55 laparotomies during the study period. MR enterography identified the presence of Crohn's disease in the distal ileum in 33/34 patients, in the proximal ileum in 7/12 patients, in the jejunum in 7/8 patients, in the large bowel in 10/11 patients and in the duodenum in one of two patients. MR enterography identified ileo-enteric fistula in 10/12 patients, ileosigmoid fistula in all of seven patients and other fistulae in 10/11 patients. An abscess was identified on MR enterography in eight of nine patients. Within abnormal distal ileal segments, the mean contrast enhancement ratio of acute inflammation was 2.39 ± 0.59 compared with 1.82 ± 0.63 (P < 0.05) in segments with fibrosis only.

CONCLUSION

Magnetic resonance enterography identifies small bowel Crohn's disease with an accuracy similar to or better than those of previously published series. Fistulation, abscess formation and large bowel disease can be reliably identified and disease activity assessed. Normal, uninvolved small bowel length can also be measured. Discrete proximal small bowel lesions may not always be detected. In our practice, MR enterography has replaced conventional radiology in the assessment of symptomatic patients with Crohn's disease.

Effects of endogenous and exogenous progesterone on emotional intelligence in cocaine-dependent men and women who also abuse alcohol

OBJECTIVE

As sex differences in substance dependence may impinge upon the perception and regulation of emotion, we assess emotional intelligence (EI) as a function of gender, menstrual cycle (MC) phase and hormonal changes in early abstinent cocaine-dependent individuals who abuse alcohol (CDA).

METHODS

Study 1: The Mayer, Salovey, and Caruso Emotional Intelligence Test (MSCEIT) was administered to 98 CDA (55 M/43 F) and 56 healthy (28 M/28 F) individuals. Performance in women was also assessed by MC phase. Study 2: The MSCEIT was administered to 28 CDA (19 M/9 F) who received exogenous progesterone (400 mg/day) versus placebo for 7 days (study 2).

RESULTS

Study 1: Healthy females were better than healthy males at facilitating thought and managing emotions. This gender discrepancy was not observed in the CDA group. Additionally, all women in the high compared with the low progesterone phase of their MC were better at managing their emotions. Study 2: Exogenous progesterone improved ability to facilitate thought in both males and females.

CONCLUSIONS

CDA women may be vulnerable to difficulties managing and regulating emotions. Gonadal hormones may contribute to this gender effect, as increases in both endogenous and exogenous progesterone improved selective aspects of EI.

Surgical treatment of patients with unruptured intracranial aneurysms

We present our experience with elective microsurgical clipping of unruptured intracranial aneurysms (UIA) and analyze this management. A total of 150 patients with UIA were reviewed and data were collected with regard to age, sex, presence of symptoms, location and size of the aneurysms, surgical complications and postoperative 1 year outcomes. Aneurysm size was assessed either by three-dimensional CT angiography or digital subtraction angiogram. Glasgow Outcome Scale was used to assess clinical outcomes. One hundred and fifty patients with 165 aneurysms were treated in this series. The mean size of the UIA was 5.6mm. Eighty aneurysms (48.5%) were less than 5mm in size, and 73 (44.2%) were from 5 to 10mm. Ten (6.1%) of the aneurysms were large and two (1.2%) were giant. One hundred and forty-three were asymptomatic and seven were symptomatic before surgery. The outcome was good in 147 patients (98%), and only three patients (2%) had a treatment-related unfavorable outcome. Five patients experienced transient neurological deficits and one patient experienced permanent neurological deficits. Overall 98.7% of the treated aneurysms were satisfactorily obliterated. Wound complications were seen only in three patients. In conclusion, UIA pose a significant challenge for neurosurgeons, where a delicate balance between benefits and possible risks must be weighed. If the requisite expertise is available, they can be treated surgically with low morbidity and a good outcome at specialized neurovascular centers.

Understanding the healthcare experiences of teenaged cancer patients and survivors

BACKGROUND

Despite literature supporting a client and family-centred approach to healthcare delivery in paediatric facilities, there is little information about healthcare delivery from the perspective of teenagers in the oncology setting. The objective of this study is to describe the healthcare experiences of teenagers with cancer.

METHODS

As part of a larger study on teen-centred care delivery in paediatric oncology, a survey included several open-ended questions to learn about the following: (1) what teenagers liked about the cancer care they received; (2) what they disliked about the cancer care received; and (3) what they would include if they could design the perfect cancer centre for teenagers. The survey was completed by 200 teenagers (aged 12-20 years) from three paediatric hospitals in Canada. Answers to these questions were coded and developed into themes and subthemes using a thematic analysis approach.

RESULTS

The number of patients providing answers was 89% for question 1, 63% for question 2 and 68.5% for question 3. Likes and dislikes were conceptualized in terms of four key themes as follows: (1) staff at the treatment centre; (2) the cancer care they received; (3) the treatment centre itself; and (4) social activities. The most common suggestions for the perfect cancer centre included having access to better entertainment, more social opportunities to interact with peers, and a more comfortable environment for themselves and their families.

CONCLUSION

Understanding teenagers' experiences in the paediatric oncology setting provides information that could be used to shape the delivery of healthcare in a way that is tailored to their needs. Further research in this area is required in order to improve existing oncology care.

Expression of epidermal growth factor receptor, p53, Bcl2, vascular endothelial growth factor, cyclooxygenase-2, cyclin D1, human epidermal receptor-2 and Ki-67: Association with clinicopathological profiles and outcomes in gallbladder carcinoma

BACKGROUND

The present study observed the expression levels of epidermal growth factor receptor (EGFR), p53, Bcl2, vascular endothelial growth factor (VEGF), cyclooxygenase-2 (cox-2), cyclin D1, human epidermal receptor-2 (HER-2) and Ki-67 in gallbladder carcinoma (GBC) and their association with clinicopathological profiles and disease outcomes.

MATERIALS AND METHODS

Fifty consecutive samples of cholecystectomy/biopsies from GB bed (archived formalin fixed paraffin embedded tissue blocks of different stages of GBC) were included, and patient details related to their demographic profile, investigations, tumor profile, treatment, and follow-up were recorded. Immunohistochemistry was performed to study the expression levels.

RESULTS

Overexpression of EGFR, p53, Bcl2, VEGF, cox-2, cyclin D1 and HER-2 was observed as 74%, 44%, 8%, 34%, 66%, 64%, and 4%, respectively. Association of Bcl2 overexpression in mucinous morphology (40%, P = 0.045), cox-2 overexpression in early stage (I/II) tumors (87.5%, P = 0.028) and VEGF overexpression in alive patients (47.1%, P = 0.044) was observed. Co-expression of EGFR and p53 were statistically significant (P = 0.033). Ki-67 labeling index was significantly higher in patients in age group <40 years (P = 0.027), and poorly differentiated tumors (P = 0.023). Advanced disease and poorly differentiated tumors showed a significantly poor median survival (P < 0.05).

CONCLUSION

EGFR, cox-2 and cyclin D1 were largely overexpressed. Advanced tumor stages and poorly differentiated tumors are predictors of poor survival.

Squamous cell carcinoma of the superior gingivobuccal sulcus: an 11-year institutional experience of 203 cases

OBJECTIVE

The report presents an 11-year Institutional experience of 203 cases with superior gingivobuccal sulcus tumours receiving surgical intervention at a comprehensive tertiary cancer care centre.

METHODS

A retrospective chart review of patients with a confirmed diagnosis of squamous cell carcinoma of superior gingivobuccal sulcus was done and data related to patient demographic profile; details of surgical procedure, follow-up and survival were collected.

RESULTS

Infratemporal fossa clearance was performed in 56 patients. The 10-year overall survival and disease-free survival was observed to be 39 and 52%, respectively, with a median follow-up of 15 months. The overall survival was 40 and 36%, respectively, in cases with and without infratemporal fossa clearance. Similarly, the disease-free survival was found to be 58 and 49%, respectively, in cases with and without infratemporal fossa clearance.

CONCLUSION

Patients with higher stage tumours who underwent infratemporal fossa clearance showed better overall and disease-free survival than those who did not undergo infratemporal fossa clearance.

Elucidating the clinical characteristics of patients captured using different definitions of massive transfusion

BACKGROUND AND OBJECTIVES

The type and clinical characteristics of patients identified with commonly used definitions of massive transfusion (MT) are largely unknown. The objective of this study was to define the clinical characteristics of patients meeting different definitions of MT for the purpose of patient recruitment in observational studies.

MATERIALS AND METHODS

Data were extracted on all patients who received red blood cell (RBC) transfusions in 2010 at three tertiary Australian hospitals. MT patients were identified according to three definitions: ≥10 units RBC in 24 h (10/24 h), ≥6 units RBC in 6 h (6/6 h) and ≥5 units RBC in 4 h (5/4 h). Clinical coding data were used to assign bleeding context. Data on in-hospital mortality were also extracted.

RESULTS

Five hundred and forty-two patients met at least one MT definition, with 236 (44%) included by all definitions. The most inclusive definition was 5/4 h (508 patients, 94%) followed by 6/6 h (455 patients, 84%) and 10/24 h (251 patients, 46%). Importantly, 40-55% of most types of critical bleeding events and 82% of all obstetric haemorrhage cases were excluded by the 10/24 h definition. Patients who met both the 5/4 h and 10/24 h definitions were transfused more RBCs (19 vs. 8 median total RBC units; P < 0·001), had longer ventilation time (120 vs. 55 h; P < 0·001), median ICU (149 vs. 99 h; P < 0·001) and hospital length of stay (23 vs. 18 h; P = 0·006) and had a higher in-hospital mortality rate (23·3% vs. 16·4%; P = 0·050).

CONCLUSION

The 5/4 h MT definition was the most inclusive, but combination with the 10/24 h definition appeared to identify a clinically important patient cohort.