Predictors of survival end points in patients with cancer of the cervix on long-term follow-up: inferences and implications from an audit of patients treated with a specific radiotherapy protocol

AIMS

An audit of patients with cancer of the cervix treated with a specified protocol of external beam radiotherapy (EXRT) followed by intracavitary brachytherapy (ICBT) was carried out to determine the prognosticators for major survival end points.

MATERIALS AND METHODS

Patients treated between 1991 and 2003 with a uniform protocol of EXRT (50 Gy/25 fractions/5 weeks) followed by high-dose-rate ICBT (18 Gy/3 fractions/3 weeks) were selected from the database. Various clinical and treatment parameters were evaluated for extent of locoregional response at completion of EXRT, namely absence or presence of gross residual tumour (AGRT and PGRT, respectively) and survival end points. These included locoregional disease-free survival (LDFS), disease-free survival (DFS) and overall survival (OS).

RESULTS

Of the 157 evaluable patients, 145 (92%) belonged to FIGO stages II and III. Eighty-three (53%) at completion of EXRT had AGRT, which was influenced by age and gross tumour features. The estimated 10-year LDFS, DFS and OS were 38.6%, 33.1% and 38.5%, respectively. Factors significant on univariate analysis for these survival end points were EXRT duration, ICBT time, overall treatment time (OTT) and EXRT response. On multivariate analysis, AGRT to EXRT, an OTT of < or = 67 days, and patients older than 50 years were the significant favourable determinants for all the above survival end points.

CONCLUSION

The audit highlights that younger people, especially those with bulky tumours that determine response to EXRT, are poor prognosticators for survival end points. They could perhaps benefit from treatment intensification regimens using chemoradiotherapy, provided that OTT is not unduly prolonged.

Problems and uncertainties with multiple point A's during multiple high-dose-rate intracavitary brachytherapy in carcinoma of the cervix

AIMS

This study evaluates the consequences of point A as a dose prescription point during multiple high-dose-rate (HDR) intracavitary brachytherapy (ICBT) in cancer cervix.

MATERIALS AND METHODS

Fifty patients who had received teletherapy were randomised into two groups of 25 to receive three HDR ICBT fractions of 6 Gy each at point A with either a flexible Ralstron (Shimadzu Corporation, Japan) or rigid Rotterdam (Nucletron, Netherlands) applicator. The orthogonal radiographs of the 150 applications were evaluated for applicator geometry and point A co-ordinates.

RESULTS

Irrespective of the nature and rigidity of the applicators, its various components exhibited a highly significant variation during multiple fractionated HDR ICBT. The Cartesian co-ordinates of point A (left and right) for the applicator geometry also showed significant variation during multiple HDR ICBT procedures. This resulted in an average shift of 9.5 mm (SD= +/-4.4) and 11.1 mm (SD= +/-6.4) in right point A, 10.2 mm (SD= +/-4.5) and 10.8 mm (SD= +/-6.6) in left point A for Ralstron and Rotterdam applicator, respectively, during the three HDR ICBT. Consequently, doses to both right and left point A's showed significant variation during multiple ICBT application and were independent of the applicator type.

CONCLUSION

Applicator variation in the components and spatial position in the pelvis during multiple HDR ICBT results in multiple point A's irrespective of the nature of applicator, leading to uncertainty in the dose prescription. These uncertainties, which have a bearing on clinical end points, could be minimised by shifting from point-based dose prescription to image-based target localisation and treatment planning in ICBT.

Efficacy of extracorporeal shock wave lithotripsy for solitary lower calyceal stone: a statistical model

OBJECTIVE

To evaluate the effect of inferior calyceal radiographic anatomy, number of extracorporeal shock wave lithotripsy (ESWL) sessions and stone size on the successful clearance of solitary inferior calyceal calculi after ESWL.

PATIENTS AND METHODS

In a prospective study between January 2001 and November 2002, 66 renal units with a solitary inferior calyceal calculus of < or = 2 cm were treated with electrohydraulic ESWL. The infundibulopelvic angle (two definitions), infundibulovertebral angle, inferior calyceal infundibular diameter, infundibular length, cortical thickness over the lower pole, number of minor calyces and stone size were determined from intravenous urography before treatment. The number of ESWL sessions was also included in the analysis. Treatments which produced residual fragments not clearing within 3 months of satisfactory fragmentation were considered as failures. All patients in whom the treatment failed were treated successfully by percutaneous nephrolithotomy. The data were then analysed using two different statistical methods; first by intravariable differences using the test of proportion (Fisher's test) and then all the variables together using logistic regression.

RESULTS

At 3 months 78.8% of the renal units were clear of stone. All intravariable differences were statistically significant except stone size (<1 cm, 1-2 cm). In a multivariate analysis of all variables, only stone size was the most important predictor for successful stone clearance (P = 0.03).

CONCLUSIONS

ESWL is the initial treatment of choice in selected patients with inferior calyceal stones. The stone size appears to be the most important predictor for stone clearance.

A case of dextrocardia, radial ray malformation and renal anomaly

A 12-year-old boy is described with bilateral radial club hands, scoliosis, hypospadias, isolated dextrocardia, hypoplastic ribs, an ectopic kidney and spina bifida occulta. Although some of the clinical features of this patient are seen in VATER association and sacrococcygeal dysgenesis, the presence of dextrocardia, facial dysmorphism, radial, renal and vertebral anomalies preclude these diagnoses.

Balance and gait in total hip replacement: a pilot study

OBJECTIVE

Evaluation of balance, gait changes, sexual functions, and activities of daily living in patients with total hip replacement in comparison with healthy subjects.

DESIGN

A total of 30 patients were included in the study after total hip replacement. Balance was examined using dynamic posturography, and gait evaluation was done clinically. Sexual functions and activities of daily living were also assessed. A total of 30 healthy subjects of comparable age and sex served as a control group.

RESULTS

Dynamic balance and gait differed significantly in both the groups. Despite capsulectomy, no significant difference was observed on testing proprioception. In the sensory organization tests with difficult tasks, patients needed more sensory input from vision and vestibular sense, despite normal proprioceptive sense. Significant difference was observed for limits of stability, rhythmic weight shifts, and for gait variables other than walking base. Some of the patients had major difficulties with sexual functions and activities of daily living.

CONCLUSIONS

Compared with the healthy age- and sex-matched controls, patients with total hip replacement did not have any proprioceptive deficit. Patients required extrasensory input, and there was a delayed motor response. Gait and dynamic balance results also indicated the motor deficit and required a compensatory strategy. Restoration of the postural control in these patients is thus essential. Necessary training is required for balance, gait, and activities of daily living, and proper sexual counseling is necessary in postoperative care.

Effect of 7beta-hydroxycholesterol on cellular redox status and heat shock protein 70 expression in macrophages

The proatherogenic effects of oxidized low-density lipoproteins are attributed to oxysterols, particularly 7beta-hydroxycholesterol. In the present study, we have examined the effect of 7beta-hydroxycholesterol on cellular redox status and heat shock protein 70 (hsp70) expression. Murine peritoneal macrophages were incubated for 24 hours with increasing concentrations of 7beta-hydroxycholesterol (0-25 microg/ml). Intracellular reduced glutathione levels decreased and oxidized glutathione levels increased, thus increasing the redox ratio. Hsp70 expression in macrophages decreased in a dose-dependent fashion. It is suggested that 7beta-hydroxycholesterol exerts oxidative stress on macrophages and makes them more susceptible to its proatherogenic effects by impairing the cellular defense system consisting of antioxidants and stress proteins.

Synchronizing N release from organic residues: opportunities for integrated management of N

In intensive cropping systems, mineral nitrogen (N) fertilizers represent the largest component of the N cycle because the indigenous N supply is not adequate. The requirement for mineral fertilizer may be reduced with the use of organic nutrient sources. A more realistic use of organic matter, particularly in sub-Saharan Africa due to limited amounts and availability, is the combined use of organic nutrient sources and mineral fertilizers. The beneficial effects of integrated use of inorganic fertilizers and organic manures on improved nutrient recoveries, soil moisture retention, cation exchange capacity, and erosion control have been reported. However, there are as many reports indicating negligible benefits or even disadvantages of combining nutrient sources on crop production. This is not surprising given the combination of organic residue sources, soils, climatic, crops, and management factors that influence nutrient dynamics. The most widely accepted function of organic materials is improving the nutrient availability to crops by supplying N. The key to both improving efficiency of N use and reducing N losses is synchronization of N supply from soil, biological N2 fixation, organic residues, and inorganic fertilizers with the crop N demand. Organic materials are not magic; N losses also result from their use. Controlling N release from organic sources depends on their nutrient content and quality, soil properties, and the environmental and management factors. This paper will synthesize the information generated from integrated nutrient management trials in sub-Saharan Africa and the Philippines. Management strategies based on an organic resources database and a dynamic soil-crop simulation model are used to identify organic sources as N fertilizers or soil amendments. The decision support tools are also used to attain optimum synchrony between release from organic sources and soils with crop N demand.

Comparative biochemical and immunocytochemical studies reveal differences in the effects of Clostridium perfringens enterotoxin on polarized CaCo-2 cells versus Vero cells

Since most in vitro studies exploring the action of Clostridium perfringens enterotoxin (CPE) utilize either Vero or CaCo-2 cells, the current study directly compared the CPE responsiveness of those two cell lines. When CPE-treated in suspension, both CaCo-2 and Vero cells formed SDS-resistant, CPE-containing complexes of approximately 135, approximately 155, and approximately 200 kDa. However, confluent Transwell cultures of either cell line CPE-treated for 20 min formed only the approximately 155-kDa complex. Since those Transwell cultures also exhibited significant (86)Rb release, approximately 155-kDa complex formation is sufficient for CPE-induced cytotoxicity. Several differences in CPE responsiveness between the two cell lines were also detected. (i) CaCo-2 cells were more sensitive when CPE-treated on their basal surface, whereas Vero cells were more sensitive when CPE-treated on their apical surface; those sensitivity differences correlated with CPE binding the apical versus basolateral surfaces of these two cell lines. (ii) CPE-treated Vero cells released (86)Rb into both Transwell chambers, whereas CaCo-2 cells released (86)Rb only into the CPE-containing Transwell chamber. (iii) Vero cells express the tight junction (TJ) protein occludin but (unlike CaCo-2 cells) cannot form TJs. The ability of TJs to affect CPE responsiveness is supported by the similar effects of CPE on Transwell cultures of CaCo-2 cells and Madin-Darby canine kidney cells, another polarized cell forming TJs. Confluent CaCo-2 Transwell cultures CPE-treated for >1 h formed the approximately 200-kDa CPE complex (which also contains occludin), exhibited morphologic damage, and had occludin removed from their TJs. Collectively, these results identify CPE as a bifunctional toxin that, in confluent polarized cells, first exerts a cytotoxic effect mediated by the approximately 155-kDa complex. Resultant damage then provides CPE access to TJs, leading to approximately 200-kDa complex formation, internalization of some TJ proteins, and TJ damage that may increase paracellular permeability and thereby contribute to the diarrhea of CPE-induced gastrointestinal disease.

Pretransitional optical activity of short-pitched chiral nematic liquid crystals

We have developed, using the de Gennes theory of short-range orientational order in the isotropic phase, a closed-form expression for the temperature dependence of the pretransitional optical activity of chiral nematics. Detailed calculations are included and the results are expressed in a form that can be easily tested experimentally. The theoretical predictions are supported by experimental data.

Influence of 7beta-hydroxycholesterol on glutathione status and nitric oxide production in macrophages: in vitro studies

Incubation of murine peritoneal macrophages with 7beta-hydroxycholesterol (7beta-OH) for 24 hr led to dose-dependent reduction in cellular glutathione content as well as nitrite levels in the medium. Treatment with an inorganic form of selenium, sodium selenite which is a potent antioxidant, elevated the cellular glutathione levels and decreased nitrite levels. Our results suggest that 7beta-OH may exert its pro-atherogenic effect by inhibiting glutathione synthesis and nitric oxide production by macrophages present in the arterial wall and thus, impair the cellular antioxidant defense system.

Cyclin-dependent kinase (cdk) inhibitors/cdk4/cdk2 complexes in early stages of mouse mammary preneoplasia

The level of circulating ovarian hormones (estrogen and progesterone) alone or in combination with pituitary hormones have a potent mitogenic impact in the normal mammary gland, and they also play a pivotal role in the development and progression of mammary carcinoma. The differential effects of hormones on the molecular components of cyclin-dependent kinase (cdk) complexes in mammary epithelium of the hormone-dependent ductal outgrowth line, EL11, and the hormone-independent alveolar outgrowth line, TM2L, were the focus of this study. The two outgrowth lines, which represent early stages in mammary hyperplasia, were compared with normal mammary gland at different hormonal conditions: control, hormone stimulated by pituitary isograft, and hormone depleted by ovariectomy. Hormonal stimulation by a pituitary isograft resulted in DNA synthesis and lobuloalveolar development of normal mammary ducts, DNA synthesis but no lobuloalveolar development in the EL11 ductal outgrowth, and no changes either in DNA synthesis or in lobuloalveolar morphology in the TM2L outgrowth. The levels of cdk4- and cyclin D1-associated kinase activities were correlated with cell proliferation in only the alveolar phenotypes (i.e., in only hormonally stimulated normal virgin gland and in alveolar mammary outgrowth), whereas cyclin D2-dependent kinase activity was correlated with cell proliferation in only the alveolar preneoplasia. p16(INK4a) and p21(Cip1) protein levels were decreased at the earliest stages of preneoplasia, i.e., at immortalization, and were independent from changes in cyclin D1, which occurred later in preneoplasia. Although all cdk inhibitors changed in concordance with hormonal status reflected by proliferation levels, p27(Kip1) was the only cdk inhibitor that was up-regulated at the earliest stages of preneoplasia and may have a unique role in blocking alveolar differentiation in response to the loss of one or more of the cell cycle-negative regulators. We hypothesize that up-regulation of p27(Kip1) prevents immortalized ductal outgrowths (EL11) from progressing to the neoplastic state, even under hormonal stimulation.

Postoperative complications and visual results in uniocular pediatric traumatic cataract

BACKGROUND AND OBJECTIVES

This study was prospectively carried out to evaluate the postoperative complications and visual results following posterior chamber intraocular lens (PCIOL) implantation in children with unilateral traumatic cataract.

PATIENTS AND METHODS

We prospectively evaluated 40 children, 12 years or younger, with traumatic cataract (blunt trauma, n = 22 eyes, repaired penetrating eye injury, n = 18 eyes) undergoing PCIOL implantation with a minimum follow-up period of one year. Children with posterior segment ocular injury were excluded.

RESULTS

The postoperative complications were significantly higher in the penetrating eye injury group as compared to blunt trauma group (ie, pupillary capture 44.44% vs 9.09%, posterior capsulotomy rate 83.33% vs 40.90% and IOL decentration 27.77% vs 4.54%). The final visual acuity was 6/12 or better in 38.8% and 86.36% of eyes with penetrating eye injury and blunt trauma, respectively.

CONCLUSION

Extracapsular cataract extraction (ECCE) with PCIOL implantation in traumatic cataract following blunt trauma results in better visual outcome and fewer complications compared to penetrating eye injury if the posterior segment is not involved.

Multiple vasculogenic disabilities : a challenge in rehabilitation

A 37 year old male presented with left hemiplegia, left below knee amputation, right partial foot amputation and claudication pain. The limitations in the rehabilitation management in such a high-risk patient are multiplied. The appreciable benefits from supervised rehabilitation and judicious goal setting can help in improving the functional status and retard the disease progression in such patients. This study highlights that coexisting cerebrovascular, coronary and peripheral vascular diseases can pose a real challenge and can result in multiple disabilities.

Se-methylselenocysteine activates caspase-3 in mouse mammary epithelial tumor cells in vitro

Se-methylselenocysteine (MSC) inhibits mouse mammary epithelial tumor cell (TM6) growth. When synchronized TM6 cells were exposed to 50 microM MSC, either for 30 minutes or continuous, the 116 kDa poly(ADP-ribose)polymerase (PARP) was cleaved to an 85 kDa fragment indicative of cells undergoing apoptosis. The earliest cleaved PARP appears at 24 hr time point followed by elevated levels of 85 kDa fragment at 34 hr and 48 hr time points when the cells were exposed to continuous treatment with MSC. Results also showed that MSC increased caspase-3 activity at 24 hr time point. In addition, continuous treatment with MSC induced DNA fragmentation at 34 hr and 48 hr time points with caspase-3 gene expression moderately increased at 16 hr and 24 hr time points. Caspase-6 and -8 were also involved in the MSC-induced apoptosis but to a lesser extent. These results suggest that MSC mediates cleavage of PARP and apoptosis by activating one or more caspases in synchronized TM6 cells and the events are dependent on the duration of treatment.

Issues related to disability in India: a focus group study

BACKGROUND

Systematic research into disability has been scarce, especially from India, even though an estimated 5% of the population may have significant disability due to physical disorders. Depression as a common psychiatric disorder affects about 3%-5% of the population. Thus, the impact of disability related to physical, mental and substance use disorders is enormous and it influences resource allocation and policy planning.

METHODS

The issues relating to disability were addressed through a qualitative multicentered study. Focus groups were conducted at three sites in Chennai, Bangalore and Delhi on three themes: (i) parity, stigmatization and social participation; (ii) current practices and needs; and (iii) the General Disability Model as proposed by the World Health Organization. The focus groups were homogeneous and included members from six categories of participants: individuals with physical disability, individuals with mental disability, individuals with alcohol/drug-related disability, family members of mentally disabled persons, family members of physically disabled persons and health professionals. In all, 118 groups were conducted with a mean (SD) group size of 8.6 (1.6).

RESULTS

Patients with mental and alcohol/drug-related disability were more discriminated against than those with physical disability. Awareness regarding the existing laws and social programmes was uniformly poor across the three centres. Stigmatization was a major reason for under-utilization of the meagre resources available. There was poor awareness of the Disability Act, 1996. The consumers felt more comfortable with the earlier terms of 'handicap' and 'impairment'.

CONCLUSIONS

The study has implications for policy planning, clinical decision-making and social behaviour. Awareness of the laws, facilities and programmes needs to be increased, especially regarding the Disability Act, 1996 among consumers as well as health professionals. More disability-friendly facilities are required.

Multiple eccrine spiradenomas in zosteriform distribution in a child

A 9-year-old boy presented with asymptomatic papulonodular lesions on the left half of the chin of 3-years duration. On examination he had small papular lesions on the left chin varying in size from 1 to 5 mm. An additional lesion on the margin of the lip was 14 mm in diameter. The overlying skin was normal. Lesions were firm, nontender, and fixed to the skin. Histopathologic examination of the biopsy specimen revealed characteristic features of eccrine spiradenoma. A literature search produced reports of 10 cases of linear/zosteriform spiradenoma. Of these, five were in children or adolescents. We report this patient because of the rare occurrence of this presentation.

CaCo-2 cells treated with Clostridium perfringens enterotoxin form multiple large complex species, one of which contains the tight junction protein occludin

The previous model for the action of Clostridium perfringens enterotoxin (CPE) proposed that (i) CPE binds to host cell receptor(s), forming a small ( approximately 90 kDa) complex, (ii) the small complex interacts with other eucaryotic protein(s), forming a large ( approximately 160 kDa) complex, and (iii) the large complex triggers massive permeability changes, thereby inducing enterocyte death. In the current study, Western immunoblot analysis demonstrated that CPE bound to CaCo-2 human intestinal cells at 37 degrees C forms multiple large complex species, with apparent sizes of approximately 200, approximately 155, and approximately 135 kDa. These immunoblot experiments also revealed that occludin, an approximately 65-kDa tight junction protein, is present in the approximately 200-kDa large complex but absent from the other large complex species. Immunoprecipitation studies confirmed that occludin physically associates with CPE in large complex material and also indicated that occludin is absent from small complex. These results strongly suggest that occludin becomes associated with CPE during formation of the approximately 200-kDa large complex. A postbinding association between CPE and occludin is consistent with the failure of rat fibroblast transfectants expressing occludin to bind CPE in the current study. Those occludin transfectants were also insensitive to CPE, strongly suggesting that occludin expression is not sufficient to confer CPE sensitivity. However, the occludin-containing, approximately 200-kDa large complex may contribute to CPE-induced cytotoxicity, because nontoxic CPE point mutants did not form any large complex species. By showing that large complex material is comprised of several species (one containing occludin), the current studies indicate that CPE action is more complicated than previously appreciated and also provide additional evidence for CPE interactions with tight junction proteins, which could be important for CPE-induced pathophysiology.

Visual outcome following cataract surgery in rural punjab

In a cluster sample survey in rural areas of Punjab visual outcome after cataract surgery was assessed. Three hundred patients (428 cataract operated eyes) were included in the study from 24 sampled villages. The mean age at cataract extraction was 61.70 +/- 9.82 years. The average interval since the cataract surgery was 7.05 +/- 5.86 years (range 0.11-32 years). Of the 428 operated eyes, 72 (16.82%) were blind (VA < 3/60), 162 (37.85%) had low visual acuity (VA 3/60-< 6/18) and 194 (45.33%) eyes gained good visual acuity (VA > or = 6/18). Cataract surgery related complications were the principal causes leading to blindness in 50 of 72 eyes; these included corneal oedema, (17/72;23.3%), retinal detachment (14/72;19.4%), and aphakic glaucoma (13/72;18.05%). This study emphasizes the need to improve the qualitative aspect of cataract surgery including long-term follow up in rural India.