Precision Endpoints for Contemporary Precision Oncology Trials

SUMMARY

Traditional endpoints such as progression-free survival and overall survival do not fully capture the pharmacologic and pharmacodynamic effects of a therapeutic intervention. Incorporating mechanism-driven biomarkers and validated surrogate proximal endpoints can provide orthogonal readouts of anti-tumor activity and delineate the relative contribution of treatment components on an individual level, highlighting the limitation of solely relying on aggregated readouts from clinical trials to facilitate go/no-go decisions for precision therapies.

Proton therapy in Asia Pacific: current resources, international disparities and steps forward

The burden of cancer in Asia Pacific, a region home to over four billion people, is growing. Because of sheer demographics alone, the Asia Pacific region arguably has the highest number of patients who can benefit from protons over conventional x-rays. However, only 39 out of 113 proton facilities globally are in Asia Pacific, and 11 of them are in low- and middle-income countries where 95% of the regional population reside. We draw attention to present resource distribution of proton therapy in Asia Pacific, highlight disparities in access, and suggest steps forward.

Discordance in Recommendation Between Next-Generation Sequencing Test Reports and Molecular Tumor Boards in India

PURPOSE

Accurate understanding of the genomic and transcriptomic data provided by next-generation sequencing (NGS) is essential for the effective utilization of precision oncology. Molecular tumor boards (MTBs) aim to translate the complex data in NGS reports into effective clinical interventions. Often, MTB treatment recommendations differ from those in the NGS reports. In this study, we analyze the discordance between these recommendations and the rationales behind the discordances, in a non-high-income setting, with international input to evaluate the necessity of MTB in clinical practice.

METHODS

We collated data from MTB that were virtually hosted in Chennai, India. We included patients with malignancies who had NGS reports on solid tissue or liquid biopsies, and excluded those with incomplete data. MTB forms and NGS reports of each clinical case were analyzed and evaluated for recommendation concordance. Concordance was defined as an agreement between the first recommendation in the MTB forms and the therapeutic recommendations suggested in the NGS report. Discordance was the absence of the said agreement. The rationales for discordance were identified and documented.

RESULTS

Seventy MTB reports were analyzed with 49 cases meeting the inclusion criteria. The recommendation discordance was 49% (24 of 49). Discordant recommendations were mainly due to low level of evidence for the drug (75% of cases).

CONCLUSION

The discordance between MTB and NGS vendor recommendations highlights the clinical utility of MTB. The educational experiences provided by this initiative are an example of how virtual academic collaborations can enhance patient care and provider education across geographic borders.

Effects of Active Compounds of Nigella sativa in COVID-19: A Narrative Review

BACKGROUND

SARS-CoV-2 infection that led to the COVID-19 pandemic has changed human health and the economy globally. SARS CoV-2 is a type of Coronaviruses that has caused pneumonia and its complications with many deaths over the past two years. The use of hydroxychloroquine and chloroquine, accepted as generally safe for patients with autoimmune diseases or malaria, was attempted in many trials for COVID-19 treatment. Nigella sativa (NS) (black caraway, also known as black cumin, nigella or Kalonji) is an annual flowering plant of the Ranunculaceae family, chemically composed of the main constituent natural Thymoquinone (TQ) (30%- 48%) in forms of thymohydroquinone, dithymoquinone (Nigellone) is a native to wider regions, including parts of eastern Europe, west Asia, North of Africa and east of Myanmar. In this review, we explored the Randomized Controlled Trial, Controlled Trial, and Systematic review studies that support Nigella sativa Thymoquinone-targeted SARS-CoV-2 targeting. Therefore, A literature search was performed for publications published on the electronic databases (PubMed, Embase, Scopus, CNKI, and Google Scholar) for Nigella sativa, black seeds, Kalonji, coronavirus, SARS-CoV -2 and COVID-19. This review aimed to find relevant evidence of Nigella sativa preferences as a natural feasible remedy with no side effects in COVID-19. Studies reported the benefits of NS as beneficial, another appropriate remedy for patients with COVID-19. However, all studies have shown limitations, such as limiting clinical symptom outcomes due to regulations imposed by isolation policies and lack of adequate funding. Therefore, the evidence suggests that the chemical contents of NS are a safe and possible treatment for COVID-19 patients that helps to improve COVID-19 infection in patients with no side effects.

CONCLUSION

Nigella sativa seeds were one of the well-documented herbal products. Three reviewed randomized controlled trials reported that NS reduced covid-19 risk and could improve immune function. It was also helpful in upper respiratory infections such as asthma and bronchitis, with one RCT showing that honey and NS significantly improved symptoms, viral clearance, and mortality of COVID-19 patients. This review concludes that NS has a positive barrier effect on people at risk of acquiring a COVID-19 infection.

Fabrication and characterization of super-hydrophilic poly (ε-caprolactone)/hydroxypropyl methylcellulose (HPMC) based composite electrospun membranes for tissue engineering applications

Tissue engineering (TE) employs scaffolds as a structural support for initially seeding of cells followed by development of new tissues. Electrospun scaffolds generally function as a template of native extracellular matrix (ECM). The chemical composition of the scaffold and its surface morphology strongly influence the interaction between various cell types and materials. In this work, PCL and PCL/HPMC-based composite membranes with varying concentrations of HPMC (20-30% by weight) were fabricated using electrospinning technique. The membranes were evaluated for their surface, physio-chemical and biological properties. It was observed probably for the first time that blending of HPMC with PCL produced super-hydrophilic scaffolds. DSC studies confirmed the semi- crystalline nature of HPMC. PCL/HPMC composite scaffolds are found biocompatible from cytotoxicity assay. From the cell culture studies (apoptosis), PCL/HPMC composite scaffolds did not inhibit the adhesion of L929 cells due to their super-hydrophilic nature. The cell adhesion and spreading varied with HPMC concentration. PCL/HPMC (70/30) membranes showed highest cell adhesion among others due to its porous structure.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Comparison of Estimated Late Toxicities between IMPT and IMRT Based on Multivariable NTCP Models for High-Risk Prostate Cancers Treated with Pelvic Nodal Radiation

Purpose

To compare the late gastrointestinal (GI) and genitourinary toxicities (GU) estimated using multivariable normal tissue complication probability (NTCP) models, between pencil-beam scanning proton beam therapy (PBT) and helical tomotherapy (HT) in patients of high-risk prostate cancers requiring pelvic nodal irradiation (PNI) using moderately hypofractionated regimen.

Materials and Methods

Twelve consecutive patients treated with PBT at our center were replanned with HT using the same planning goals. Six late GI and GU toxicity domains (stool frequency, rectal bleeding, fecal incontinence, dysuria, urinary incontinence, and hematuria) were estimated based on the published multivariable NTCP models. The ΔNTCP (difference in absolute NTCP between HT and PBT plans) for each of the toxicity domains was calculated. A one-sample Kolmogorov-Smirnov test was used to analyze distribution of data, and either a paired t test or a Wilcoxon matched-pair signed rank test was used to test statistical significance.

Results

Proton beam therapy and HT plans achieved adequate target coverage. Proton beam therapy plans led to significantly better sparing of bladder, rectum, and bowel bag especially in the intermediate range of 15 to 40 Gy, whereas doses to penile bulb and femoral heads were higher with PBT plans. The average ΔNTCP for grade (G)2 rectal bleeding, fecal incontinence, stool frequency, dysuria, urinary incontinence, and G1 hematuria was 12.17%, 1.67%, 2%, 5.83%, 2.42%, and 3.91%, respectively, favoring PBT plans. The average cumulative ΔNTCP for GI and GU toxicities (ΣΔNTCP) was 16.58% and 11.41%, respectively, favoring PBT. Using a model-based selection threshold of any G2 ΔNTCP >10%, 67% (8 patients) would be eligible for PBT.

Conclusion

Proton beam therapy plans led to superior sparing of organs at risk compared with HT, which translated to lower NTCP for late moderate GI and GU toxicities in patients of prostate cancer treated with PNI. For two-thirds of our patients, the difference in estimated absolute NTCP values between PBT and HT crossed the accepted threshold for minimal clinically important difference.

Encouraging early outcomes with image guided pencil beam proton therapy for cranio-spinal irradiation: first report from India

Background

To report our experience with image guided pencil beam proton beam therapy (PBT) for craniospinal irradiation (CSI).

Materials and Methods

Between January 2019 and December 2021, we carried out a detailed audit of the first forty patients treated with PBT. We had recorded acute toxicities, reporting early outcomes and discuss limitations of current contouring guidelines during CSI PBT planning.

Results

Median age of the patient cohort was 8 years, and histologies include 20 medulloblastoma, 7 recurrent ependymoma, 3 pineoblastoma, 3 were germ cell tumors and remaining 7 constituted other diagnoses. Forty percent patients received concurrent chemotherapy. Median CSI dose was 23.4 Gy (Gray; range 21.6–35 Gy). Thirty-five patients (87.5%) completed their CSI without interruption, 5 required hospital admission. No patient had grade 2/ > weight loss during the treatment. Forty-five percent (18) developed grade 1 haematological toxicities and 20% (8) developed grade 2 or 3 toxicities; none had grade 4 toxicities. At median follow up of 12 months, 90% patients are alive of whom 88.9% are having local control. Special consideration with modification in standard contouring used at our institute helped in limiting acute toxicities in paediatric CSI patients.

Conclusion

Our preliminary experience with modern contemporary PBT using pencil beam technology and daily image guidance in a range of tumours suitable for CSI is encouraging. Patients tolerated the treatment well with acceptable acute toxicity and expected short-term survival outcome. In paediatric CSI patients, modification in standard contouring guidelines required to achieve better results with PBT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-022-02085-4.

Drug Development in Low- and Middle-Income Countries: Opportunity or Exploitation?

Low- and middle-income countries (LMICs) represent a diverse group of regions with varied cancer presentation. Drug development and accessibility across these regions have primarily been dependent on the trials initiated and conducted across high-income countries. Representation of LMIC regions in these trials in terms of study population has been minimal, leading to inequitable distribution of optimal and affordable cancer care. In spite of many challenges, LMICs have now increasingly been able to contribute to anticancer drug development. The opportunities present in LMICs must be explored and used in conjunction with due collaborative efforts from high-income countries, health care planners, and regulatory agencies. Global drug development trials should not only factor in suitable representation of LMICs but also design studies with pragmatic objectives and endpoints so that the trial results lead to equitable and affordable cancer care. Strengthening collaboration between cancer researchers from LMICs and high-income countries and empowering the local investigator with adequate resources will help remove current disparities.

EPEN-22. Molecularly aggressive ependymomas treated with Image guided pencil beam proton therapy: consecutive patient Indian experience

AIM: To assess the toxicities and early clinical outcomes in patients of primary and recurrent ependymomas treated with image guided pencil beam scanning proton beam therapy (PBS-PBT). MATERIALS AND METHODS: Between January 2019- December 2021, we analyzed consecutive patients of ependymomas treated with image guided PBS-PBT. They were also analyzed molecularly, and all recurrent/re-irradiated patients were considered for craniospinal irradiation (CSI). Acute toxicities were assessed based on NCI CTC v5.0, local control and radiological response by 3-monthly MRI post therapy. RESULTS: Seventeen consecutive patients with ependymoma (13 Grade III and 4 Grade II) (median age-9 years) were analyzed. 9 patients were primary, 7 were treated at first recurrence and 1 at second recurrence. Majority had posterior fossa (PF) tumors (12) followed by supratentorial (ST) (3) and spine (2). Among PF ependymomas, 10 had global loss of H3K27me3, whereas amongst ST, 1 had YAP1 fusion, 1 had L1CAM positivity and other, negative L1CAM and p65/RELA on immunohistochemistry. Gross/near-total resection was achieved in 87% patients. Primary ependymomas were treated with focal radiotherapy; and among recurrent cases, 7 received CSI followed by primary site boost to a total median dose of 55CGE (50.2-55.8CGE). Grade 2 dermatitis, grade 2 and 3 hematological toxicities (CSI) were noted in 3,2 and 2 patients respectively. Grade 2 fatigue noted in 53% of all and 71% receiving CSI. With a median follow-up of 10 months (2-24 months), local control (LC) and disease-free survival (DFS) was 87.5% (primary-100%, recurrent-75%) and overall survival (OS) was 94% (primary-100%, recurrent-88%). CONCLUSION: Our experience of treating patients of ependymoma with complete resection followed by PBS-PBT including CSI is encouraging with low acute toxicities. Recurrent/molecularly aggressive cases may be considered for CSI.

Keywords: PT, proton beam therapy, ependymomas, primary and recurrent

LINC-12. Encouraging early outcomes with image guided pencil beam proton therapy for cranio-spinal irradiation and unique considerations for paediatric population – First report from India

BACKGROUND: To report our experience with image guided pencil beam proton beam therapy (PBT) for craniospinal irradiation (CSI). MATERIALS AND METHODS: Between January 2019 to Dec 2021, we carried out a detailed audit of the first forty patients treated with PBT. All patients were carefully selected after approval from our institutional multidisciplinary tumour and proton board meetings. Median age of the patient cohort was 8 years, and histologies include 20 medulloblastoma, 7 recurrent ependymoma, 3 pineoblastoma, 3 were germ cell tumors and remaining 7 constituted other diagnoses. Forty percent patients received concurrent chemotherapy. We had recorded acute toxicities on a prospectively maintained database. We also report early outcomes in this cohort and discuss limitations of current contouring guidelines during CSI PBT planning. RESULTS: Median CSI dose was 23.4 GyE (Gray Equivalent; range 21.6 - 35). Thirty-five patients (87.5%) completed their CSI without interruption as an outpatient procedure. Five patients required hospital admission during treatment, while one developed grade 3 mucosal toxicity, requiring plan adaptation and treatment break. No patient had grade 2 or more weight loss during the treatment. Forty-five percent (18) developed grade 1 hematological toxicities and 20% (8) developed grade 2 or 3 toxicities; none had grade 4 toxicities. At median follow up of 12 months, 90 % patients are alive of whom 88.9 % are having local control. Special consideration with modification in standard contouring used at our institute helped in limiting acute toxicities in paediatric CSI patients. CONCLUSION: Our preliminary experience with modern contemporary PBT using pencil beam technology and daily image guidance in a range of tumours suitable for CSI is encouraging. Patients tolerated the treatment well with acceptable acute toxicity and expected short-term survival outcome. In paediatric CSI patients, modification in standard contouring guidelines required to achieve better results with PBT

Altered electrochemical properties of iron oxide nanoparticles by carbon enhance molecular biocompatibility through discrepant atomic interaction

Recent advancement in nanotechnology seeks exploration of new techniques for improvement in the molecular, chemical, and biological properties of nanoparticles. In this study, carbon modification of octahedral-shaped magnetic nanoparticles (MNPs) was done using two-step chemical processes with sucrose as a carbon source for improvement in their electrochemical application and higher molecular biocompatibility. X-ray diffraction analysis and electron microscopy confirmed the alteration in single-phase octahedral morphology and carbon attachment in Fe3O4 structure. The magnetization saturation and BET surface area for Fe3O4, Fe3O4/C, and α-Fe2O3/C were measured as 90, 86, and 27 emu/g and 16, 56, and 89 m2/g with an average pore size less than 7 nm. Cyclic voltammogram and galvanostatic charge/discharge studies showed the highest specific capacitance of carbon-modified Fe3O4 and α-Fe2O3 as 213 F/g and 192 F/g. The in vivo biological effect of altered physicochemical properties of Fe3O4 and α-Fe2O3 was assessed at the cellular and molecular level with embryonic zebrafish. Mechanistic in vivo toxicity analysis showed a reduction in oxidative stress in carbon-modified α-Fe2O3 exposed zebrafish embryos compared to Fe3O4 due to despaired influential atomic interaction with sod1 protein along with significant less morphological abnormalities and apoptosis. The study provided insight into improving the characteristic of MNPs for electrochemical application and higher biological biocompatibility.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Poly (ε-caprolactone)-based electrospun nano-featured substrate for tissue engineering applications: a review

The restoration of normal functioning of damaged body tissues is one of the major objectives of tissue engineering. Scaffolds are generally used as artificial supports and as substrates for regenerating new tissues and should closely mimic natural extracellular matrix (ECM). The materials used for fabricating scaffolds must be biocompatible, non-cytotoxic and bioabsorbable/biodegradable. For this application, specifically biopolymers such as PLA, PGA, PTMC, PCL etc. satisfying the above criteria are promising materials. Poly(ε-caprolactone) (PCL) is one such potential candidate which can be blended with other materials forming blends, copolymers and composites with the essential physiochemical and mechanical properties as per the requirement. Nanofibrous scaffolds are fabricated by various techniques such as template synthesis, fiber drawing, phase separation, self-assembly, electrospinning etc. Among which electrospinning is the most popular and versatile technique. It is a clean, simple, tunable and viable technique for fabrication of polymer-based nanofibrous scaffolds. The design and fabrication of electrospun nanofibrous scaffolds are of intense research interest over the recent years. These scaffolds offer a unique architecture at nano-scale with desired porosity for selective movement of small molecules and form a suitable three-dimensional matrix similar to ECM. This review focuses on PCL synthesis, modifications, properties and scaffold fabrication techniques aiming at the targeted tissue engineering applications.

Adapting Management of Sarcomas in COVID-19: An Evidence-Based Review

With the novel coronavirus disease (COVID-19) being declared a global pandemic by the World Health Organization, the Indian healthcare sector is at the forefront to deliver optimal care. Patients with cancer especially are at serious risk for increased chances of morbidity and mortality due to their immunocompromised state. Currently there is a paucity of definitive guidelines for the management of sarcomas during the pandemic in a resource-constrained and diverse population setting like India. Health care professionals from various specialties involved in the management of sarcomas have collaborated to discuss various aspects of evidence-based sarcoma management during the COVID-19 pandemic. This article provides structured recommendations for HCP to adapt to the situation, optimize treatment protocols with judicious use of all resources while providing evidence-based treatment for sarcoma patients.

QOLP-25. BASELINE QUALITY OF LIFE BURDEN IN PATIENTS WITH CENTRAL NERVOUS SYSTEM (CNS) TUMOURS TREATED WITH PENCIL BEAM PROTON THERAPY AT INDIA’S FIRST PROTON THERAPY CENTRE

The aim of this study is to evaluate and assess the impact of baseline quality of life (QOL) in adult patients with central nervous system (CNS) tumours treated with pencil beam proton therapy (PT) seen consecutively at India’s first proton therapy centre. Data sets of 50 consecutive adult patients with histologically proven brain neoplasms (both primary and recurrent) who were planned for proton therapy at our centre were during one full calendar year were considered for this study. The study included detailed neurological assessment, evaluation of QOL using EORTC questionnaire (QLQ-C30) and specific Brain Cancer module (BN20). In the present analysis, QOL scores before starting adjuvant treatment were measured and impact of patient and tumour related factors were analysed. Baseline global QOL data of all patients (available in 50) was 58.3 which is relatively low including in all histological tumour types. Physical function, role function, emotion function, cognitive and social function scores were 77.9, 80, 78.5, 80.3, 69.3 (higher values better), respectively. Domains of visual disorder, motor deficit, communication deficit, headache, seizures and drowsiness scores were 21.5, 20.3, 32.3, 31, 20.4, 32.6 and 14.5 (lower values better), respectively. Elderly patients (&gt; 50 years) had poorer global score (p &lt; 0.05). Patients with lower performance status (KPS &lt; 70) had a lower global QOL (KPS &gt; or = 80 vs. &lt; or= 70; 42 vs. 75; p &lt; 0.05) including in all histological types of high-grade gliomas (HGG) (HGG vs. LGG; 67 vs. 59; p &lt; 0.05). Patients undergoing re-irradiation had poorer global score as compared to ones who had not received any radiation previously (p &lt; 0.05). Patients with malignant, recurrent tumours, poor performance status and patients who had previously been irradiated had significantly lower QOL scores even before starting adjuvant treatment.

Preliminary Experience of Treating Children and Young Adults With Image-Guided Proton Beam Therapy in India

PURPOSE

Proton beam therapy (PBT) has been a preferred modality in pediatric malignancies requiring radiotherapy. We report our preliminary experience of treating consecutive patients younger than 25 years with image-guided pencil beam scanning PBT from the first and only center on the Indian subcontinent.

METHODS

Patients were selected for PBT on the basis of a multidisciplinary tumor board decision. Patient demographic data, as well as tumor and treatment-related characteristics of the cohort, were captured. Patient and treatment-related factors and their association with acute toxicities were analyzed using univariable and multivariable analyses.

RESULTS

Forty-seven patients (27 with CNS and 20 with non-CNS tumors) with a median age of 9 years (range, 2-25 years) were evaluated. Most common diagnoses were ependymoma, rhabdomyosarcoma, and glioma. Seventy-seven percent of patients traveled more than 500 km, and 70% of them lived in metropolitan cities. Forty-nine percent of patients had recurrent disease at presentation, and 15% had received a previous course of radiation. The median dose delivered was 54.8 cobalt gray equivalents (range, 40.0-70.4 cobalt gray equivalents) to a median clinical target volume of 175 mL (range, 18.7-3,083.0 mL), with 34% of patients requiring concurrent chemotherapy (CCT). Acute grade 2 and grade 3 dermatitis, mucositis, and hematologic toxicity was noted in 45% and 2%, 34% and 0%, and 38% and 30% of patients, respectively. Grade 2 fatigue was noted in 26% of patients. On multivariable analysis, for CNS tumors, both CCT and craniospinal irradiation were independently associated with ≥ 2 grade hematologic toxicity, whereas among non-CNS tumors, a clinical target volume > 150 mL was associated with ≥ 2 grade fatigue, head and neck irradiation was associated with ≥ 2 grade mucositis, and CCT was associated with grade ≥ 2 hematologic toxicity.

CONCLUSION

This study demonstrates safe implementation of a PBT program for children and young adults on the Indian subcontinent. Image-guided pencil beam scanning PBT in judiciously selected patients is feasible and can be delivered with acceptable acute toxicities.

Total marrow and lymphoid irradiation with helical tomotherapy: a practical implementation report

Purpose

To standardize the technique; evaluate resources requirements and analyze our early experience of total marrow and lymphoid irradiation (TMLI) as part of the conditioning regimen before allogenic bone marrow transplantation using helical tomotherapy.

Materials and Methods

Computed tomography (CT) scanning and treatment were performed in head first supine (HFS) and feet first supine (FFS) orientations with an overlap at mid-thigh. Patients along with the immobilization device were manually rotated by 180° to change the orientation after the delivery of HFS plan. The dose at the junction was contributed by a complementary dose gradient from each of the plans. Plan was to deliver 95% of 12 Gy to 98% of clinical target volume with dose heterogeneity <10% and pre-specified organs-at-risk dose constraints. Megavoltage-CT was used for position verification before each fraction. Patient specific quality assurance and in vivo film dosimetry to verify junction dose were performed in all patients.

Results

Treatment was delivered in two daily fractions of 2 Gy each for 3 days with at least 8-hour gap between each fraction. The target coverage goals were met in all the patients. The average person-hours per patient were 16.5, 21.5, and 25.75 for radiation oncologist, radiation therapist, and medical physicist, respectively. Average in-room time per patient was 9.25 hours with an average beam-on time of 3.32 hours for all the 6 fractions.

Conclusion

This report comprehensively describes technique and resource requirements for TMLI and would serve as a practical guide for departments keen to start this service. Despite being time and labor intensive, it can be implemented safely and robustly.

GW190521: A Binary Black Hole Merger with a Total Mass of 150 M_{⊙}

On May 21, 2019 at 03:02:29 UTC Advanced LIGO and Advanced Virgo observed a short duration gravitational-wave signal, GW190521, with a three-detector network signal-to-noise ratio of 14.7, and an estimated false-alarm rate of 1 in 4900 yr using a search sensitive to generic transients. If GW190521 is from a quasicircular binary inspiral, then the detected signal is consistent with the merger of two black holes with masses of 85_{-14}^{+21}  M_{⊙} and 66_{-18}^{+17}  M_{⊙} (90% credible intervals). We infer that the primary black hole mass lies within the gap produced by (pulsational) pair-instability supernova processes, with only a 0.32% probability of being below 65  M_{⊙}. We calculate the mass of the remnant to be 142_{-16}^{+28}  M_{⊙}, which can be considered an intermediate mass black hole (IMBH). The luminosity distance of the source is 5.3_{-2.6}^{+2.4}  Gpc, corresponding to a redshift of 0.82_{-0.34}^{+0.28}. The inferred rate of mergers similar to GW190521 is 0.13_{-0.11}^{+0.30}  Gpc^{-3} yr^{-1}.

Clinical research during coronavirus disease pandemic: Challenges and way forward

With the novel coronavirus disease (COVID-19) being declared a global pandemic by the World Health Organization, the Indian health-care sector is at the forefront to deliver optimal care but with constrained resources and several challenges. The pandemic has also brought about a state of urgency to develop suitable management principles for COVID-19 with the help of suitably designed clinical trials. However, the pandemic along with the lockdown and other restrictions has affected the conduct of clinical trials in terms of restrictions on travelling, trial site staff availability, investigational product availability, and medical oversight among others. This article provides structured recommendations for sponsors, investigators, clinical trial personnel to adapt to the situation by identifying potential risks and challenges and mitigating them to conduct clinical trials well within the ambit of local regulatory guidelines and requirements during the COVID-19 pandemic.

PITChing (professional organisations, innovative trial designs and collaborative approach) for evidence generation for proton therapy

Developments in the field of proton beam therapy (PBT) have recently crossed the tipping point wherein the modality is now more versatile than ever before, with possibilities and likely indications expanding rapidly.

However the pace of evidence generation lags behind the developments in the field.

Generating quality evidence has its own set of challenges owing to complexities of conducting randomized controlled trials, which are the hallmark of level 1 evidence generation.

Here we discuss various challenges to clinical evidence generation in PBT and have suggested certain solutions including collaborative approaches and alternative study designs to mitigate these challenges.

Search for Subsolar Mass Ultracompact Binaries in Advanced LIGO's Second Observing Run

We present a search for subsolar mass ultracompact objects in data obtained during Advanced LIGO's second observing run. In contrast to a previous search of Advanced LIGO data from the first observing run, this search includes the effects of component spin on the gravitational waveform. We identify no viable gravitational-wave candidates consistent with subsolar mass ultracompact binaries with at least one component between 0.2  M_{⊙}-1.0  M_{⊙}. We use the null result to constrain the binary merger rate of (0.2  M_{⊙}, 0.2  M_{⊙}) binaries to be less than 3.7×10^{5}  Gpc^{-3} yr^{-1} and the binary merger rate of (1.0  M_{⊙}, 1.0  M_{⊙}) binaries to be less than 5.2×10^{3}  Gpc^{-3} yr^{-1}. Subsolar mass ultracompact objects are not expected to form via known stellar evolution channels, though it has been suggested that primordial density fluctuations or particle dark matter with cooling mechanisms and/or nuclear interactions could form black holes with subsolar masses. Assuming a particular primordial black hole (PBH) formation model, we constrain a population of merging 0.2  M_{⊙} black holes to account for less than 16% of the dark matter density and a population of merging 1.0  M_{⊙} black holes to account for less than 2% of the dark matter density. We discuss how constraints on the merger rate and dark matter fraction may be extended to arbitrary black hole population models that predict subsolar mass binaries.

Translation and validation of European Organization for Research and Treatment for Cancer quality of life questionnaire-OV-28 module into Indian languages (Hindi and Marathi) to study quality of life of ovarian cancer patients from a tertiary care cancer center

Aim:

The aim is to translate and validate the European Organization for Research and Treatment for Cancer (EORTC) ovarian cancer (OC) module (OV-28) into Hindi and Marathi to use for patients and scientific community.

Methods and Results:

The EORTC OV-28 was translated into Hindi and Marathi languages using prescribed guidelines by the EORTC. The process included forward translation by four translators (2 each for Hindi and Marathi). The questionnaires obtained were then given to independent backward-translators who then translated them back into English. These 2 questionnaires were then compared with the original EORTC questionnaire and the second intermediate questionnaires were formed. The second intermediate questionnaire was subsequently administered in twenty patients (10 each for Hindi and Marathi) diagnosed with OC who had never seen the questionnaire before, for pilot testing. Each of these ten patients after filling up the questionnaire themselves was then interviewed for any difficulty encountered during the filling up of the questionnaires. These were in the form of specific modules including difficulty in answering, confusion while answering, and difficulty to understand, whether the questions were upsetting and if patients would have asked the question in any different way. The suggestions were incorporated into the second intermediate questionnaires to form the final Hindi and Marathi ON-28 questionnaires. These questionnaires were then sent to the EORTC for the final approval to be used in clinical studies.

Conclusion:

We have successfully translated EORTC OV-28 module into Hindi and Marathi languages, and EORTC approved them to be used in clinical practice and studies for OC patients.

Aggressive Surgery in Palliative Setting of Lung Cancer: Is it Helpful?

With increase in survival and progression-free survival in the advanced metastatic cancers, the expectation of quality of life (QOL) has increased dramatically. Palliative care plays a vital role in the management of these advanced cancer patients. At present scenario, palliative care in advanced cancer has seen a completely different approach. Aggressive surgical procedures have been performed to improve the QOL in the advanced cancer patients. We report a case of advanced lung cancer with pathological femur fracture, treated with extensive total femur replacement surgery to provide better QOL.

Palliative Care in Musculoskeletal Oncology

Patients in advanced stages of illness trajectories with local and widespread musculoskeletal incurable malignancies, either treatment naive or having recurrence are referred to the palliative care clinic to relieve various disease-related symptoms and to improve the quality of life. Palliative care is a specialized medicine that offers treatment to the disease-specific symptoms, places emphasis on the psychosocial and spiritual aspects of life and help the patients and their family to cope with advance stage cancer in a stronger and reasonable way. The overall outcome of musculoskeletal malignancies has improved with the advent of multidisciplinary management. Even then these tumors do relapse and leads to organ failures and disease-specific deaths in children and young adults in productive age group thus requiring an integrated approach to improve the supportive/palliative care needs in end-stage disease. In this article, we would like to discuss the spectrum of presentation of advanced musculoskeletal malignancies, skeletal metastasis, and their management.

Management of Midline Facial Clefts

Median or midline facial clefts are rare anomalies of developmental origin, etiology of whose occurrence is still unknown precisely. The most basic presentation of midline facial clefts is in the form of a Median cleft lip which is defined as any congenital vertical cleft through the centre of the upper lip. First described by Bechard in 1823, it is the most common amongst all atypical clefts reported. The incidence is about 1:10,00,000 births. This may occur as a sporadic event or as a part of an inherited sequence of anomalies. It arises embryologically from incomplete fusion of the medial nasal prominences. The authors present a series of eight cases with varying degrees of midline facial clefts. This review article aims to give a broad idea on the various classifications used for further understanding of midline facial clefts and a brief idea about the various surgical management techniques used in the repair of these facial clefts.

Prevalence of Rubber Dam Usage during Endodontic Procedure: A Questionnaire Survey

AIM

To determine the prevalence and frequency of rubber dam usage for endodontic procedures among general practitioners, specialized practitioners, undergraduate final year students and Endodontists in the state of Odisha, India.

METHODOLOGY

A pre-piloted questionnaire was distributed among 737 subjects. Dentists and final year students were surveyed in relation to their prevalence of rubber dam usage.

STATISTICAL ANALYSIS USED

Chi-square/ Fisher Exact tests have been used to find the significance of study parameters on categorical scale between two or more groups.

RESULTS

Overall response rate was 71%. While about 94% of the subjects knew the use of rubber dam, 30% have used it for root canal cases and 23% use them for all cases of root canal treatment. Use of rubber dam was 15.4% in paediatric patients and 34.4% in adult patients. 68% of subjects received knowledge about rubber dam usage in undergraduate school. 75% felt that rubber dam should be compulsory before endodontic treatment & 90% were willing to gain knowledge through training and continuing dental education programs.

CONCLUSION

Whilst rubber dam is used frequently for root canal treatment than operative treatment, in the present survey there is a low prevalence of its usage during endodontic therapy. This presents quality issues, as well as medico-legal and safety concerns for the professional and patients alike. Greater emphasis should be placed on the advantages of using rubber dam in clinical dentistry at dental school and through continuing dental education for practitioners to update their knowledge.

Biosynthesis of silver nanoparticle from leaf extract of Desmodium gangeticum (L.) DC. and its biomedical potential

An aqueous leaf extract of Desmodium gangeticum was employed to synthesize silver nano particles. Rapid formation of stable silver nanoparticles were observed on exposure of the aqueous leaf extract with solution of silver nitrate. The silver nanoparticles were characterized by UV-visible spectroscopy, scanning electron microscopy, energy dispersive X-ray analysis and transmission electron microscopy (TEM), and Fourier Transform Infra-Red spectroscopy (FTIR) UV-visible spectroscopy, scanning electron microscopy (SEM), energy dispersive X-ray analysis (EDAX), transmission electron microscopy (TEM), and Fourier Transform Infra-Red spectroscopy (FTIR). UV-visible spectrum of the aqueous medium peaked at 450 nm corresponding to the plasmon absorbance of silver nanoparticles. SEM analysis revealed the spherical shape of the particles with sizes ranging from 18 to 39 nm and the EDAX spectrum confirmed the presence of silver along with other elements in the plant metabolite. Further, these biologically synthesized nanoparticles were found to be highly toxic against pathogenic bacteria Escherichia coli, thus implying significance of the present study in production of biomedical products.

Clinical efficacy of Shatapushpa (Anethum sowa Kurz.) powder in the management of Artava kshaya (oligomenorrhoea)

A clinical trial was carried out on 30 oligomenorrhoea [Artava Kshaya] patients aged between 15 and 35 years having complaints of irregular, scanty and painful menstruations. The patients were registered from OPD and IPD of Gopabandhu Ayurveda Mahavidyalaya Puri. They were administrated Satapuspa churna for three months in a dose of 5 g twice daily with cow grita. The specific investigations were done in order to exclude TB endometritis, endocrine disorders, diabetes and heart disease. The clinical assessment was carried out in thirty days intervals. It is inferred that the study discloses the effect of satapuspa churna on irregularity of interval of menstruation [90.47%], duration of menstruation [79.37%], amount of blood flow [90.00%] and pain during menstruation [100.00%] which were highly significant in clinical study. No untoward side effect was noticed during clinical trial.

Antibacterial Activity of Barringtonia acutangula against Selected Urinary Tract Pathogens

Barringtonia acutangula (L.) Gaertn belonging to family Barringtoniaceae was investigated to evaluate In vitro antibacterial activity of aqueous, ethanolic, petroleum ether and chloroform extracts against Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterococcus faecalis and Escherichia coli the major urinary tract infection causing pathogens were tested by disc diffusion assay method and the minimum inhibitory concentration was evaluated. Ethanol (95%) extract exhibited broader spectrum of inhibition followed by chloroform, petroleum ether and aqueous extracts against the urinary tract pathogens under test. An attempt has been made to compare the activity of extracts with standard antibiotics against selected urinary tract infection causing pathogens.

A comparative clinical trial of Chincha kshara and Kadali kshara on Amlapitta

A clinical trial was carried out on 30 patients of Amlapitta aged between 20 to 35 years with complaints of Avipaka, hrit-kanthadaha, tikta-amlodgara, utklesa, udarasula, adhmana and aruchi, who were registered from OPD and IPD of Gopabandhu Ayurveda Mahavidyalaya, Puri. They were equally divided into three groups Chincha kshara, Kadali kshara and placebo (who were administered with fresh wheat powder) for 30 days in a dose of 500 mg thrice daily with water. Investigations was done in order to exclude upper gastrointestinal tract ulcer, carcinoma in stomach, cholecystitis, carcinoma gall bladder, and heart diseases. The clinical assessments were carried out on the 30^th day by subjective and objective parameters and it was inferred that both Chincha kshara and Kadali kshara were effective and reduced the symptoms of amlapitta. Chincha kshara was found to be more effective than Kadali kshara. The study shows the effect of Chincha and Kadali kshara which led to cure in 4(40%) and 3(30%) patients respectively, and maximum improvement in 4(40%) and 5(50%) patients affected with amlapitta disease, respectively. No untoward effect was noticed due to administration of ksharas during the clinical trial period.

Optimization of physical and nutritional parameters for hyaluronidase production by <i> Streptococcus mitis</i>

The effect of some physical and nutritional parameters were studied for the optimum production of extracellular enzyme hyaluronidase employing Streptococcus mitis MTCC*2695 by submerged fermentation. The effects of initial pH, incubation temperature and time, inoculum level and age of inoculum were studied. The maximum enzymatic activity was obtained with an initial pH 5.8, incubation temperature 37°, incubation time for 48 h and inoculum level 6% with inoculum age 24 h. The effect of different carbon and nitrogen sources and antibiotics were studied. The results indicated that sucrose and ammonium chloride showed the highest enzymatic activity among various carbon and nitrogen sources. Antibiotic clarithromycin showed strong inhibitory effect on hyaluronidase production.

A PATHOLOGICAL STUDY OF BENIGN AND MALIGNANT TUMOURS OF SALIVARY GLANDS

Interest in the knowledge of salivary gland tumours is highlighted. A sample of 315 cases, collected over a period of 25 years in a busy pathology centre, is analysed both on total and individual aspects of tumours. The findings are compared to earlier works on the subject and also with contemporary literature.

Amyloidosis in leprosy

Fourteen hundred and forty five biopsied tissues of various organs including liver, skeletal muscle, kidney, lymphnode, larynx and skin from 1222 patients of leprosy obtained during the last 10 years have been examined histopathologically to study various types of pathological lesions. These patients ranged in age from 7 years to 72 years and the duration of illness varied from less than one year to twenty years. Although the presence of lepromatous granuloma, AFB in varying proportions, and some nonspecific lesions have been observed in them, but amyloidosis was not detected in any of them. This finding is discussed in view of the observations of other authors of different parts of the world in this connection. Consumption of mainly vegetarian diet in our population and that of meat in Western population has been suggested to be the probable cause of the difference of amyloidosis observed in the two groups of people.