A Multicenter Study of Clinician and Patient Reported Acute and Late Toxicity after Radical (Chemo)Radiotherapy for Non-Endemic Nasopharyngeal Cancer

PURPOSE/OBJECTIVE(S)

Curative (chemo)radiotherapy ((CT)RT) for Nasopharyngeal cancers (NPC) achieves excellent disease control but is associated with significant late toxicities despite modern treatment delivery. Contemporary late toxicity data, including patient reported outcomes (PROs), is limited in the non-endemic population; we present a large contemporary series of toxicity outcomes and late PROs following treatment of non-endemic NPC.

MATERIALS/METHODS

Adult patients completing radical (CT)RT for primary NPC between February 2016 and 2020 at 7 large UK cancer centers were identified on institutional databases. Patients were excluded if they had prior head and neck cancer or prior therapeutic head and neck surgery (except neck dissection). Patients with an active other cancer were excluded from PRO assessment. Demographic, treatment, acute toxicity and outcome data were collected retrospectively from patient records. Disease-free patients were invited to complete an M.D. Anderson Dysphagia Index (MDADI) and University of Washington (UoW) Quality of Life (QoL) PROs questionnaires.

RESULTS

A total of 180 eligible patients were identified: 68% male, median age 54 years, 11% ≥70 years. EBV status was positive in 61% (unknown 12%). Patients had stage I (5%), II (22%), III (37%), IV (36%) disease; 95% were performance status ≤1 at baseline. Median follow-up was 31.2 months (range 0-68). A total of 54% received 70Gy in 33-35# and 43% received 65-66 Gy in 30-33#. 66% received induction and 65% received concurrent chemotherapy. 9.5% had residual disease at the first follow-up scan. Subsequent locoregional or distant recurrence occurred in 5% and 12% respectively. At last assessment, 84% patients were alive, 16% had died (of which 70% had active disease). Acute treatment toxicity included: 63% of patients required enteral support (median duration 98 days) with 9% a feeding tube at 1 year post treatment. 18% G3 dermatitis, 53% G3 mucositis. 82% requiring opioids and 40% admitted for symptom management. 90 patients completed the PROs (76% response rate) at a median of 37.8 months post treatment (Table 1). These demonstrate significant QoL detriment: 28% report significant pain, 24% require regular analgesia, and 59% report significant impact on daily activity. This was found to persist at different timepoints (not shown).

CONCLUSION

Excellent cancer survival outcomes are seen in a non-selected, non-endemic NPC population. However significant acute and late toxicity following radical treatment is identified which can profoundly negatively impact QoL in a relatively young cohort. This highlights the importance of ongoing efforts to reduce toxicity and supports the prospective evaluation of potential toxicity sparing technologies, such as proton beam radiotherapy.

Red and brown seaweeds extracts: A source of biologically active compounds

The biological activities of Porphyra sp., Gracilaria gracilis, Alaria esculenta and Saccharina latissima extracts prepared by enzymatic and ball milling-assisted methods and hot water were evaluated. Enzyme-assisted methods allowed the highest extraction yields. Alcalase-assisted extraction (EAA) was the most effective in the recovery of polyphenolic compounds and Porphyra sp. had the highest content. The efficiency of flavonoids extraction was highly dependent on the used method. Globally, Porphyra sp. and EAA extracts exhibited the highest antioxidant and chelating activities. The highest α-amylase inhibitory activity was determined in HW Porphyra sp. extract while EAA A. esculenta extract had the highest α-glucosidase inhibitory activity. The highest ACE inhibitory activity was obtained in EAA from S. latissima. None of the extracts showed antimicrobial activity against the tested bacteria. The results showed that Porphyra sp. and S. latissima are potentially useful as ingredient in functional foods and nutraceuticals.

Antidepressant-withdrawal mania - a case report

Introduction

An uncommon adverse event of antidepressant discontinuation is the paradoxical withdrawal hypomania or mania. It is rarely described in the literature and its true incidence is unknown, may it be a consequence of underrecognition or misattribution.

Objectives

Alert clinicians of the uncommon Antidepressant-Withdrawal Mania

Methods

Report and discuss, based on online pubmed database, a case of Antidepressant-Withdrawal Mania with Citalopram

Results

A 34 year old woman, with a previous unipolar depressive episode, presents to the emergency department in june/2020 with anxiety, recurrent thoughts of death without a plan, low energy, anhedonia, loss of appetite, sadness and insomnia developing over a period of 7 months. She was prescribed Quetiapine 50 mg XR, Lamotrigine 100 mg, and sent to a psychiatry consultation. After a month and a half there was no important clinical improvement and Citalopram 20 mg was started. The patient reported slow improvement and by august she had a complete symptomatic response. In the beginning of september the patient stopped citalopram abruptly. Three weeks later, she was presented with an irritable mood, increased energy with decreased need for sleep, sweet cravings, easy irritability, racing thoughts, pressure to keep talking and suicidal thoughts. After 2 weeks of Quetiapine 300 mg XR id, Lamotrigine 100 mg id and Olanzapine 5 mg there was a partial symptomatic response.

Conclusions

Antidepressant withdrawal manic states are an under-recognized phenomena, with ill defined patho-physiological pathways and nosology. It is important to continue close follow up of the patient and to investigate whether it can be included on the bipolar spectrum.

Management of behavioral and psychological symptoms of dementia

Introduction

Behavioral and psychological symptoms of dementia (BPSD) are a heterogeneous group of clinical manifestations related to dementia, including apathy, depression, anxiety, delusions, hallucinations, disinhibition, sleep-wake cycle disturbances, aggression and agitation. BPSD have a negative impact on cognitive decline and increase complications.

Objectives

Review treatment management of BPSD including non-pharmacological and pharmacological options, but mainly interventional approaches, such as electroconvulsive therapy (ECT).

Methods

We conducted a search in PubMed and ClinicalKey with the terms: “Behavioral and psychological symptoms of dementia”; “Electroconvulsive therapy”.

Results

The vast majority of patients with dementia will develop one or more BPSD. The etiopathogenesis of BPSD is complex and multifactorial, with multiple direct and indirect factors, namely biological, psychological and social aspects and related to changes in cholinergic, dopaminergic, noradrenergic and serotoninergic circuits. Current guidelines recommend non-pharmacological interventions as the first-line approach for BPSD. Pharmacotherapy is often applied, but it carries out the risk of serious side-effects and pharmacologic interactions. There is now growing evidence that interventional approaches, such as ECT, could be safe and efficient when previous treatment options have been exhausted or ineffective, with few contraindications and transient/limited adverse effects.

Conclusions

BPSD represent a heterogeneous group of non-cognitive symptoms and behavior that affects most of dementia patients. Combination of non-pharmacological and pharmacological interventions is the recommended therapeutic for BPSD. However, there is usually limited clinical improvement and issues related to tolerability and effectiveness. Currently, ECT is considered a safe and effective option.

Retrospective Planning Study of Patients with Superior Sulcus Tumours Comparing Pencil Beam Scanning Protons to Volumetric-Modulated Arc Therapy

AIMS

Twenty per cent of patients with non-small cell lung cancer present with stage III locally advanced disease. Precision radiotherapy with pencil beam scanning (PBS) protons may improve outcomes. However, stage III is a heterogeneous group and accounting for complex tumour motion is challenging. As yet, it remains unclear as to whom will benefit. In our retrospective planning study, we explored if patients with superior sulcus tumours (SSTs) are a select cohort who might benefit from this treatment.

MATERIALS AND METHODS

Patients with SSTs treated with radical radiotherapy using four-dimensional planning computed tomography between 2010 and 2015 were identified. Tumour motion was assessed and excluded if greater than 5 mm. Photon volumetric-modulated arc therapy (VMAT) and PBS proton single-field optimisation plans, with and without inhomogeneity corrections, were generated retrospectively. Robustness analysis was assessed for VMAT and PBS plans involving: (i) 5 mm geometric uncertainty, with an additional 3.5% range uncertainty for proton plans; (ii) verification plans at maximal inhalation and exhalation. Comparative dosimetric and robustness analyses were carried out.

RESULTS

Ten patients were suitable. The mean clinical target volume D95 was 98.1% ± 0.4 (97.5-98.8) and 98.4% ± 0.2 (98.1-98.9) for PBS and VMAT plans, respectively. All normal tissue tolerances were achieved. The same four PBS and VMAT plans failed robustness assessment. Inhomogeneity corrections minimally impacted proton plan robustness and made it worse in one case. The most important factor affecting target coverage and robustness was the clinical target volume entering the spinal canal. Proton plans significantly reduced the mean lung dose (by 21.9%), lung V5, V10, V20 (by 47.9%, 36.4%, 12.1%, respectively), mean heart dose (by 21.4%) and thoracic vertebra dose (by 29.2%) (P < 0.05).

CONCLUSIONS

In this planning study, robust PBS plans were achievable in carefully selected patients. Considerable dose reductions to the lung, heart and thoracic vertebra were possible without compromising target coverage. Sparing these lymphopenia-related organs may be particularly important in this era of immunotherapy.

Ultra-short-term heart rate variability during resistance exercise in the elderly

Despite the appeal of ultra-short-term heart rate variability (HRV) methods of analysis applied in the clinical and research settings, the number of studies that have investigated HRV by analyzing R-R interval (RRi) recordings shorter than 5 min is still limited. Moreover, ultra-short-term HRV analysis has not been extensively validated during exercise and, currently, no indications exist for its applicability during resistance exercise. The aim of the present study was to compare ultra-short-term HRV analysis with standard short-term HRV analysis during low-intensity, dynamic, lower limb resistance exercise in healthy elderly subjects. Heart rate (HR) and RRi signals were collected from 9 healthy elderly men during discontinuous incremental resistance exercise consisting of 4-min intervals at low intensities (10, 20, 30, and 35% of 1-repetition maximum). The original RRi signals were segmented into 1-, 2-, and 3-min sections. HRV was analyzed in the time domain (root mean square of the of differences between adjacent RRi, divided by the number of RRi, minus one [RMSSD]), RRi mean value and standard deviation [SDNN] (percentage of differences between adjacent NN intervals that are greater than 50 ms [pNN50]), and by non-linear analysis (short-term RRi standard deviation [SD1] and long-term RRi standard deviation [SD2]). No significant difference was found at any exercise intensity between the results of ultra-short-term HRV analysis and the results of standard short-term HRV analysis. Furthermore, we observed excellent (0.70 to 0.89) to near-perfect (0.90 to 1.00) concordance between linear and non-linear parameters calculated over 1- and 2-min signal sections and parameters calculated over 3-min signal sections. Ultra-short-term HRV analysis appears to be a reliable surrogate of standard short-term HRV analysis during resistance exercise in healthy elderly subjects.

Evaluation of cell toxicity and DNA and protein binding of green synthesized silver nanoparticles

Silver nanoparticles (AgNPs) were prepared by GREEN chemistry relying on the reduction of AgNO₃ by phytochemicals present in black tea extract. AgNPs were fully characterized by transmission electron microscopy (TEM), ultraviolet-visible spectroscopy ((UV-vis)), X-ray diffraction (XRD) and energy dispersive absorption spectroscopy (EDS). The synthesized AgNPs induced a decrease of the cell viability in a dose-dependent manner with a low IC₅₀ (0.5 ± 0.1 μM) for an ovarian carcinoma cell line (A2780) compared to primary human fibroblasts (IC₅₀ 5.0 ± 0.1 μM). The DNA binding capability of CT (calf thymus) DNA was investigated using electronic absorption and fluorescence spectroscopies, circular dichroism and viscosity titration methods. Additionally, the AgNPs strongly quench the intrinsic fluorescence of BSA, as determined by synchronous fluorescence spectra.

Influence of main forcing affecting the Tagus turbid plume under high river discharges using MODIS imagery

The role of river discharge, wind and tide on the extension and variability of the Tagus River plume was analyzed from 2003 to 2015. This study was performed combining daily images obtained from the Moderate Resolution Imaging Spectroradiometer (MODIS) sensor located onboard the Aqua and Terra satellites. Composites were generated by averaging pixels with the same forcing conditions. River discharge shows a strong relation with the extension of the Tagus plume. The plume grows with the increasing river discharge and express a two day lag caused by the long residence time of water within the estuary. The Tagus turbid plume was found to be smaller under northerly and easterly winds, than under southerly and westerly winds. It is suggested that upwelling favoring winds provoke the offshore movement of the plume material with a rapidly decrease in turbidity values whereas downwelling favoring winds retain plume material in the north coast close to the Tagus mouth. Eastern cross-shore (oceanward) winds spread the plume seaward and to the north following the coast geometry, whereas western cross-shore (landward) winds keep the plume material in both alongshore directions occupying a large part of the area enclosed by the bay. Low tides produce larger and more turbid plumes than high tides. In terms of fortnightly periodicity, the maximum plume extension corresponding to the highest turbidity is observed during and after spring tides. Minimum plume extension associated with the lowest turbidity occurs during and after neap tides.

A non-exercise based V02max prediction using FRIEND dataset with a neural network

The main goal of this work is the development of models, based on computational intelligence techniques, in particular neural networks, to predict the maximum oxygen consumption value. While the maximum oxygen consumption is a direct mark of the cardiorespiratory fitness, several studies have also confirmed it also as a powerful predictor of risk for adverse outcomes, such as hypertension, obesity, and diabetes. Therefore, the existence of simpler and accurate models, establishing an alternative to standard cardiopulmonary exercise tests, with the potential to be employed in the stratification of the general population in daily clinical practice, would be of major importance. In the current study, different models were implemented and compared: 1) the traditional Wasserman/Hansen equation; 2) linear regression and; 3) non-linear neural networks. Their performance was evaluated based on the "FRIEND - Fitness Registry and the Importance of Exercise: The National Data Base" [1] being, in the present study, a subset of 12262 individuals employed. The accuracy of the models was performed through the computation of sensitivity and specificity values. The results show the superiority of neural networks in the prediction of maximum oxygen consumption.

Fecundity and bipolar spectrum disorder

Introduction

Fertility and fecundity are usually considered signs of social and emotional well-being. Bipolar disorder (BD) is a prevalent psychiatric disease that influences the individual's life style and behaviours. Some studies have addressed the issue of fecundity among women with bipolar disorder but few have focused on determining the differences between disease subtypes, which is expected, taking into account the studied differences in demographic measures.

Objectives

To examine the fecundity of a population of women with bipolar disorder.

Aim

The aim of this study is to compare the fecundity among women diagnosed with subtypes I to IV of BD, according to Akiskal's bipolar spectrum disorder classification.

Methods

A total of 108 female outpatients were divided into four groups. We analyzed number of offspring and demographic features between patients with different subtypes of BD using multivariate analyses.

Results

Our results showed a significantly higher average number of children for BD IV patients when compared with BD I patients. Although not reaching statistical significance, BD I patients had less offspring than BD II and BD III patients. BD I patients had lower marriage rates compared to the other groups.

Conclusions

Our results suggest that the subtype of bipolar disorder influences fecundity and behaviours, as is expressed by the lower number of marriages seen in BD I patients. We found that fecundity is significantly impaired among BD I patients, which may imply that female with more severe disorders are less likely to become parents. Fecundity is higher among BD IV patients, which makes a way to speculate about the adaptive role of hyperthimic temperamental traits.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Agenesis of the Corpus Callosum in A Patient With Bipolar Disorder

Background

The corpus callosum (CC) is the largest white matter structure in the brain, which plays a crucial role in interhemispheric communication. Agenesis of the CC is a rare development anomaly, with unknown cause. It could be asymptomatic or associated with mental retardation and neurologic symptoms. Some case reports, post-mortem studies and image studies have linked thickness reduction and agenesis of CC with psychotic symptoms, mainly in schizophrenia patients. Lately, anatomical abnormalities in the CC have been reported in patients with Bipolar Disorder (BD).

Case report

A 52-year-old woman was brought to the emergency room by the authorities after being physically aggressive to her 13-year-old daughter and inappropriate behavior in public. At the emergency department her mood was elevated with emotional lability, dispersible attention, slight increase of motor activity, pressured and difficult to interrupt speech, grandious and self-referent delusional ideas.

Her past history revealed hippomaniac episodes characterized by periods of excessive shopping and hyperphagia. In 2008, she had a major depressive episode.

Head CT-SCAN revealed agenesia of CC. She received the diagnosis of Manic Episode with mixed features and was treated with valproic acid, flurazepam and olanzapine.

Conclusion

This case reinforces the fact that changes in CC, probably due to deficiency in myelination, could have a crucial importance in the pathophysiology of Bipolar Disorder.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Papel do desbridamento e sinovectomia artroscópica no tratamento da rizartrose-experiência inicial do serviço

Objetivos: Apresentar a experiência inicial do serviço com o uso do desbridamento e sinovectomia artroscópica no tratamento da rizartrose.

Realizou-se um estudo retrospetivo de 10 doentes com rizartrose submetidos a desbridamento e sinovectomia artroscópica. Avaliou-se a dor através da escala visual analógica (EVA), o nível funcional com o questionário de QuickDASH, a força de pinça em relação à mão contralateral, o grau de satisfação subjetiva e as complicações no pós-operatório.

O score médio de QuickDASH no pré-operatório foi de 51,5 e no pós-operatório de 20,5 (p=0,036). Houve melhoria a nível da dor com uma avaliação pré operatória de 7,4 pontos para 2,6 pontos no pós-operatório (p= 0,012). Comparativamente ao lado contralateral, a média da força de pinça no pré operatório foi de 61,7 % melhorando para 81% no pós-operatório (p=0,067). A complicação mais grave no pós-operatório foi o desenvolvimento de um quadro de algodistrofia em um doente.

Como em qualquer nova técnica, as indicações para o seu uso serão motivo de debate e evolução ao longo do tempo, o que se aplica ao trabalho apresentado em que algumas das indicações podem ser controversas.

Além disso, trata-se de uma amostra muito pequena e com um tempo de seguimento médio curto, pelo que as conclusões obtidas devem ser interpretadas com cautela.

Genetic and Phenotypic Diversity of Sclerotium rolfsii in Groundnut Fields in Central Vietnam

Groundnut (Arachis hypogaea) is an economically important legume crop in Vietnam and many other countries worldwide. Stem and pod rot, caused by the soilborne fungus Sclerotium rolfsii, is a major yield-limiting factor in groundnut cultivation. To develop sustainable measures to control this disease, fundamental knowledge of the epidemiology and diversity of S. rolfsii populations is essential. In this study, disease incidence was monitored in eight groundnut areas in central Vietnam with a total of 240 observational field plots. The results showed that 5 to 25% of the field-grown groundnut plants were infected by S. rolfsii. Based on internal transcribed spacer (ITS) ribosomal DNA sequence analyses, three distinct groups were identified among a total of 103 randomly selected S. rolfsii field isolates, with the majority of the isolates (n = 90) in one ITS group. S. rolfsii isolates originating from groundnut, tomato, and taro were all pathogenic on groundnut and relatively sensitive to the fungicide tebuconazole but displayed substantial diversity of various genetic and phenotypic traits, including mycelial compatibility, growth rate, and sclerotial characteristics.

The portuguese version of the personal and social performance scale (PSP): reliability, validity, and relationship with cognitive measures in hospitalized and community schizophrenia patients

Introduction

Deficits in social functioning are a core feature of schizophrenia and are influenced by both symptomatic and neurocognitive variables.

Objectives

In the present study we aimed to determine the reliability and validity of the Portuguese version of the Personal and Social Performance (PSP) scale, and possible correlations with measures of cognitive functioning.

Methods

One-hundred and four community and inpatients with schizophrenia were assessed using measures of social functioning and symptom severity alongside measures of executive function, processing speed and verbal memory.

Results

The reliability of the PSP was found to be satisfactory, with a Cronbach's alpha coefficient of 0.789. Inter-rater reliability in the four domains of the PSP varied from 0.430 to 0.954. Low-functioning patients (PSP < 70) were older, had longer duration of illness, were more symptomatic and had worse cognitive performances, as compared to high-functioning patients (PSP ≥ 70). In a regression model, deficits in social functioning were strongly predicted both by symptomatic and neurocognitive variables; these together accounted for up to 62% of the variance.

Conclusions

The present study supports the reliability and validity of the Portuguese language version of the PSP and further supports the original measure. The co-administration of brief cognitive assessments with measures of functioning may lead to more focused interventions, possibly improving outcomes in this group.