Clinical profile and treatment outcomes among patients with sporadic and multiple endocrine neoplasia syndrome-related primary hyperparathyroidism

OBJECTIVE

Accurate demarcation between multiple endocrine neoplasia, type 1 (MEN1)- related primary hyperparathyroidism (MPHPT) and sporadic PHPT (SPHPT) is important to plan the management of primary parathyroid disease and surveillance for other endocrine and nonendocrine tumours. The objective of this study is to compare the clinical, biochemical and radiological features and surgical outcomes in patients with MPHPT versus SPHPT and to identify the predictors of MEN1 syndrome in PHPT.

DESIGN, PATIENTS AND MEASUREMENTS

This was an ambispective observationalstudy involving 251 patients with SPHPT and 23 patients with MPHPT evaluated at the endocrine clinic of All India Institute of Medical Sciences, New Delhi, India between January 2015 and December 2021.

RESULTS

The prevalence of MEN1 syndrome among patients with PHPT was 8.2% and a genetic mutation was identified by Sanger sequencing in 26.1% of patients with MPHPT. Patients with MPHPT were younger (p < .001), had lower mean serum calcium (p = .01) and alkaline phosphatase (ALP; p = .03) levels and lower bone mineral density (BMD) Z score at lumbar spine (p < .001) and femoral neck (p = .007). The prevalence of renal stones (p = .03) and their complications (p = .006) was significantly higher in MPHPT group. On multivariable analysis, factors predictive of MPHPT were hyperplasia on histopathology [OR 40.1, p < .001], ALP levels within reference range [OR 5.6, p = .02] and lumbar spine BMD [OR 0.39 per unit increase in Z score, p < .001].

CONCLUSIONS

Patients with MPHPT have more severe, frequent and early onset of bone and renal involvement despite milder biochemical features. A normal serum ALP, low BMD for age and gender at lumbar spine and histopathology evidence of hyperplasia are predictive factors for MEN1 syndrome in PHPT.

Characteristics & outcomes of cancer patients with COVID-19: A multicentre retrospective study from India

Background & objectives

High mortality has been observed in the cancer population affected with COVID-19 during this pandemic. We undertook this study to determine the characteristics and outcomes of cancer patients with COVID-19 and assessed the factors predicting outcome.

Methods

Patients of all age groups with a proven history of malignancy and a recent diagnosis of SARS-CoV-2 infection based on nasal/nasopharyngeal reverse transcriptase (RT)-PCR tests were included. Demographic, clinical and laboratory variables were compared between survivors and non-survivors groups, with respect to observed mortality.

Results

Between May 11 and August 10, 2020, 134 patients were included from the three centres and observed mortality was 17.1 per cent. The median age was 53 yr (interquartile range 39-61 yr) and thirty four patients (25%) were asymptomatic. Solid tumours accounted for 69.1 per cent and breast cancer was the most common tumour type (20%). One hundred and five patients (70.5%) had received chemotherapy within the past four weeks and 25 patients (19.3%) had neutropenia at presentation. On multivariate analysis, age [odds ratio (OR) 7.99 (95% confidence interval [CI] 1.18-54.00); P=0.033], haemoglobin [OR 6.28 (95% CI 1.07-37.04); P=0.042] neutrophil-lymphocyte ratio [OR 12.02 (95% CI 2.08-69.51); P=0.005] and baseline serum albumin [OR 18.52 (95% CI 2.80-122.27); P=0.002], were associated with higher mortality. Recent chemotherapy, haematological tumours type and baseline neutropenia did not affect the outcome.

Interpretation & conclusions

Higher mortality in moderate and severe infections was associated with baseline organ dysfunction and elderly age. Significant proportion of patients were asymptomatic and might remain undetected.

Abstract PD8-06: Fluorescence guided breast conserving surgery

Background. Palpation guided breast conserving surgery for breast cancer is associated with tumor involved margins in up to 41% of cases. Ultrasound guided breast conserving surgery and frozen section biopsy result in a significant reduction in margin positivity. However, intra-operative USG and Frozen section biopsy are not widely available. We aimed to find a simple and effective technique for intra-operative margin assessment during breast conserving surgery.

Hypothesis. Intravenously injected Fluorescein reaches tumor tissue in high concentration due to increased tumor blood flow and increased capillary permeability which can be detected by blue light (494 nm).

Objective. To find diagnostic accuracy of fluorescence guided identification of tumor margins during breast conserving surgery.

Methods. A total of 60 patients with T1–T2 invasive breast cancer who underwent breast conserving surgery at AIIMS, New Delhi between March, 2016 to Feb, 2018 were included. Each patient received 2 ml of intra-venous 20% Fluorescein sodium just before skin incision. Breast conserving surgery was performed under USG guidance. Specimen was bisected and examined under blue light. Fluorescent tumor margins were identified and six biopsies taken from non-fluorescent area 5mm outside from fluorescent tumor margins at 2,4,6,8,10 and 12 o'clock position. The involvement of USG guided margin was compared with Fluorescence guided margins on histopathology.

Results. Mean age of the patient was 51.2 (SD=6.4) years. Fourteen patients (20.3 %) had T1 tumors while 46 patients(69.7%) had T2 tumors. Axillary nodes were involved in 19 patients (20.1%) and all underwent axillary node dissection. Eight patients (13.3%) received NACT. Fluorescent margins in two (3.3%) out of 60 patients were involved by tumor while USG guided margins in all the 60 patients were free. The specificity of fluorescence in identifying uninvolved tumor margins during breast conserving surgery is 96.7%.

No patient developed adverse drug reactions.

Conclusion. The fluorescence identifies tumor free margins with 96.7% accuracy. It is simple, effective and affordable method of identifying margin positivity in breast conservation surgery.

Citation Format: Sharma CK, Ranjan P, Qaiser D, Dhar A, Srivastava A, Kataria K. Fluorescence guided breast conserving surgery [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-06.

Malaria control in a forest fringe area of Assam, India: a pilot study

A study was conducted to evaluate the preventive efficacy of insecticide-treated mosquito nets (ITMNs) and mosquito repellent (MR) in a malaria-endemic foothill area of Assam, India, with forest ecosystem. During the first year, a survey was conducted in four demarcated sectors (A-D) to observe the malaria endemicity and vector prevalence patterns before implementing intervention measures. All four sectors were endemic for malaria. The prevalence of established malaria vectors such as Anopheles dirus, A. minimus and A. philippinensis was observed. During the second year, intervention measures were implemented in the four sectors as follows: A, ITMN + MR; B, ITMN; C, MR; D, no intervention. The most effective intervention was in sector A, followed by sectors B and C. Sectors A and B exhibited significantly higher (P < 0.001) malaria protective efficacy during both the first and second years of intervention compared with sector D. The total vector population in the three intervention sectors decreased significantly compared with that of the non-intervention one. Information-education-communication activities motivated the residents to participate actively in the intervention programme. The finding could be an effective model for containment of high malaria morbidity in inaccessible forest fringe areas of the northeastern region of India.

Mosquito biodiversity of Dibru-Saikhowa biosphere reserve in Assam, India

Entomological surveys were conducted for three consecutive years in core and buffer zone of the Dibru-Saikhowa biosphere reserve in pre monsoon, monsoon and post-monsoon seasons. A total of 52 species of mosquitoes under eleven genera have been detected. The genus Anopheles (18 species) was the predominant followed by Culex, Aedes, Mansonia, Armigeres, Mimomyia, Ochlerostatus, Malaya, Toxorhynchites, Ficalbia and Aedeomyia. The buffer zone of the forest reserve where human habitations are there exhibited the presence of maximum number of species (49 species under 10 genera) in comparison to core zone (42 species under 10 genera). In buffer zone, maximum numbers of species (38) were recorded in monsoon season followed by post- monsoon (35 species) and Pre-monsoon season (34 species). Whereas in core zone, maximum number of species were collected in post monsoon season followed by pre monsoon season and monsoon season. In Core and buffer zone, the maximum species were recorded from the ground pool habitat and slow flowing stream respectively. Among the disease vectors, the potential Japanese encephalitis vectors incriminated in India were very much prevalent. This study provides the list of available mosquito species recorded for the first time in the Dibru-Saikhowa biosphere reserve.

An updated checklist of species of Aedes and Verrallina of northeastern India

A mosquito faunistic survey conducted during 1999-2005 in 7 different states of the northeastern (NE) region of India revealed that the region is very rich in mosquito fauna, particularly of the genus Aedes. From the present survey and earlier published reports, a total of 48 species of Aedes and a related genus Verrallina were recorded. The state of Assam contributed the highest number of species compared to the other 6 states, namely Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, and Tripura. Larvae of 46 species were collected from 16 different habitats and for some species the habitats were species specific. The known dengue vectors, Aedes aegypti and Ae. albopictus, were recorded from all 7 states, although Ae. aegypti was not known earlier from Mizoram, Nagaland, and Tripura states. Aedes albotaeniatus was a new addition to the Aedes fauna of the region.

Biodiversity of mosquitoes in Manipur State and their medical significance

Entomological studies conducted during monsoon and post-monsoon season in Manipur State revealed the presence of fifty-five species of mosquitoes under ten genera. Out of the seventeen Anopheles species recorded, Anopheles aconitus, An. dirus and An. nivipes were recorded for the first time from the state. The present study has confirmed the existence of An. dirus, the major malaria vector in the Northeast from a selected area of the state. Among Culicines, four species viz., Aedes nigrostriatus, Malaya genurostris, Aediomyia catasticta and Toxorhynchites splendens which were not reported earlier from this state have been recorded in the present study. With the addition of these seven species of mosquitoes to the earlier record of mosquitoes so far reported from Manipur, the mosquito fauna swells up to one hundred and eleven including the major vectors of malaria of the Northeast and the potential vectors of Japanese encephalitis and dengue virus transmission in India.

Entomological observations on dengue vector mosquitoes following a suspected outbreak of dengue in certain parts of Nagaland with a note on their susceptibility to insecticides

Three species of Aedes viz., Aedes albopictus, Aedes aegypti and Aedes annandalei were detected from different breeding sources in and around human habitats during entomological study conducted following an outbreak suspected to be of dengue (which occurred during, 1994) in parts of Medziphema PHC area of Nagaland in two different points of time ie., in the year, 1994 and, 2000. The potential dengue vector, Aedes albopictus showed high preponderance by breeding in all types of containers searched with high Breteau Index (BI) value of 85.0 and 72.72 recorded in, 1994 and, 2000 respectively whereas the BI value for other potential vector, Aedes aegypti was recorded low (4.9) in the year, 1994 with a substantial increase (31.81) in, 2000. The change in ecosystem along with the process of urbanization has facilitated the growth of these dengue vector mosquitoes in the area of investigation. Adults of both Aedes aegypti and Aedes albopictus were found to be susceptible to DDT, dieldrin and malathion in insecticide bioassay carried out using WHO test kit.

Epidemiology of malaria outbreak (April/May, 1999) in Titabor Primary Health Centre, district Jorhat (Assam)

An investigation was undertaken of a malaria outbreak in the Primary Health Centre Titabor, district Jorhat, Assam during May/June 1999. The fever rate in the community since March 1999, was 44.4 per cent with an average case load of 2.5 per family. The fever cases peaked in the third week of May. Slide positive and slide falciparum rates in mass blood survey, in the study village were 16.1 and 14.5 per cent respectively with 90 per cent infection of Plasmodium falciparum. Males (SPR 17.5%) suffered relatively more than females (SPR 14.7%). Malaria prevalence was significantly less in individuals above 15 yr of age (SPR 11.0%) as compared to those below 15 yr (SPR 22.9%). Prevalence of malaria as well as mosquito densities in different clusters of the village were inversely related to the distance from the forested Naga hills. Anopheles minimus and A. dirus were collected in good numbers with comparatively higher densities of the former. Several factors like unusual climatic conditions, inadequate surveillance, unsatisfactory laboratory services and inadequate indoor residual insecticide spray were instrumental for the outbreak.

Lymphatic filariasis in two distinct communities of upper Assam

Current status of bancroftian filariasis among two distinct communities of Upper Assam was evaluated. High prevalence (10.3% mf rate) in tea workers descendents of tribals migrated from endemic states such as Orissa, Bengal, Uttar Pradesh and southern states of India, were recorded. Among non tea workers (indigenous population) significantly low mf rate was found in spite of the fact that both the communities are living in close vicinity and in similar ecological and mosquitogenic conditions. Culex quinquefasciatus was incriminated as vector in the areas of both the communities. A group of recent migrants of Bihar and Bengal living in the locality of non tea worker population were also found microfilaraemic. Significantly lower infection rate in non tea worker population appears to be associated with host susceptibility to the infection. Familial clustering in microfilaraemic subjects noticed in tea workers group also suggests involvement of racial susceptibility to infection.

Distribution of potential dengue vectors in major townships along the national highways and trunk roads of northeast India

Surveys were conducted in some townships along the national highways and trunk roads of northeast India to detect breeding of Aedes mosquitos in used/waste tire dumps piled outdoors by the tire repairing shops during summer season of 1996-1997. The breeding of both the potential vectors of dengue, viz. Aedes aegypti and Ae. albopictus were detected, prevalence rate being in the range of 30.0-88.0 (CI = container index value). The preponderance of Ae. aegypti was considerably much higher than that of Ae. albopictus and all the urban and semiurban areas coming up along the side of the roads were observed to be infested with Ae. aegypti. With respect to transmission of dengue, this study clearly indicates that waste tire dumps in every urban agglomeration should receive primary attention in view of their relative contribution to the abundance and dispersal of these vector mosquitos.

Feeding patterns of Anopheles dirus, the major vector of forest malaria in north east India

The feeding behavior of Anopheles dirus, the forest breeding, major malaria vector in northeast India was studied. The analysis of blood meals collected from this mosquito revealed that the species was highly anthropophilic in nature, the anthropophilic index being 90.5. The results of bait collection on human and cattle bait also confirmed its biting preference for human hosts. The species was observed to land on human bait throughout the night, showing prominent biting time at 20.00-21.00, 23.00-24.00 and 02.00-03.00 hours during the study period.

Host feeding patterns of Culex vishnui sub group of mosquitoes in Dibrugarh district of Assam

The host feeding patterns of three species of mosquitoes belonging to vishnui sub group, Culex tritaeniorhynchus, Culex vishnui and Culex pseudovishnui, the most prevalent species in Dibrugarh district were determined by analysing their blood meals. All 3 species were found be essentially zoophilic. High percentage of pig feeding was observed in Culex tritaeniorhynchus (40 per cent) and Culex vishnui (35.3 per cent) in comparison to other prevalent species in this area. In contrast Culex pseudovishnui another member of this group was not attracted to pigs (0.4 per cent). Few human feeds were recorded for Culex tritaeniorhynchus (0.4 per cent), Culex vishnui (0.4 per cent) and Culex pseudovishnui (0.8 per cent), indicating their occasional contact with human hosts. Considering the importance of this group as proven vectors of Japanese encephalitis the relevance of these results to JE transmission in this area are discussed.

Anopheline fauna of parts of Tirap district, Arunachal Pradesh with reference to malaria transmission

In a survey on the anopheline fauna in highly malaria endemic areas of the Tirap district of Arunachal Pradesh, 7476 anophelines belonging to 17 species were collected, including seven species of anophelines which are recognized malaria vectors in India. Anopheles tessellatus and A. jamesii were recorded for the first time in this area. The parasitological survey revealed that the area was endemic for malaria particularly P. falciparum, the slide positivity rate and slide falciparum rate being 25.63 and 19.21 per cent respectively. On dissection of 10 anopheles species, malarial infection was detected in two viz., A. minimus and A. dirus.

The importance of Anopheles dirus (A. balabacensis) as a vector of malaria in northeast India

Anopheles dirus (A. balabacensis) is the most prevalent among twelve anopheline species collected during the course of entomological studies carried out in Changlang district of Arunachal Pradesh during July and August, 1988. It is observed to be a forest species and is found to breed in small stagnant water pools completely or partially shaded by plants in the open jungle. Sporozoites have been detected in several specimens of A. dirus (A. balabacensis) supporting its role in transmission of malaria in forest areas.

Prevalence and pattern of mental health problems

Three hundred and forty eight children of age group 5-15 years were studied. A reporting questionnaire was administered to the parents and then affected children were examined in detail by history, physical examination and mental status examination. Fifty out of 348 children were having mental health problems. Male and first born children were affected more. Common problems observed were poor scholastic performance, enuresis, hyperkinetic syndrome, speech disorders and sleep disorders. In males, poor scholastic performance, hyperkinetic syndrome and temper tantrums were common while in females enuresis, speech disorders and hysterical symptoms were more frequent. Among the adverse perinatal factors of etiological importance low birth weight, difficult deliveries, birth injuries, delayed cry, neonatal jaundice and convulsions were common. Predominant psychosocial stress factors were quarrels between parents, separated parents, deaths of parents, siblings or relatives and chronic illness in the family.