Initial Report of Boswellia Serrata for Management of Cerebral Radiation Necrosis after Stereotactic Radiosurgery for Brain Metastases

PURPOSE/OBJECTIVE(S)

Radiation necrosis (RN) is a concerning late toxicity after radiation therapy (RT) for brain metastases. Oral corticosteroids are the mainstay of management; however, they are not optimal for long-term use given multiple side effects and drug interactions, particularly with the emergence of immunotherapy for several cancers. Boswellia serrata (BS) is an over-the-counter supplement used for its anti-inflammatory properties and has been recently shown to reduce cerebral edema after brain RT. We evaluated the response rates with BS in a series of patients with brain metastases treated with stereotactic radiosurgery (SRS) who developed RN.

MATERIALS/METHODS

We included patients who developed RN after SRS for brain metastases at our institution from 2020-2022 and were treated with BS. Patients were prescribed over the counter BS 4.2-4.5g daily in divided doses. Follow-up MRI imaging was obtained every 2-3 months after starting BS. Response was assessed using Response Assessment in Neuro-Oncology (RANO) criteria. Primary endpoint was ≥25% decrease in edema volume on T2-FLAIR MRI from baseline. Patients were censored if they had tumor progression or repeat RT to necrotic area, or death. Kaplan-Meier curves were used for survival estimates.

RESULTS

A total of 50 patients received BS for Grade 1-3 CTCAE v5.0 RN (G1 = 11, G2 = 36, and G3 = 3). Median age was 62.8 years (range 36.9 - 50) and median RT dose was 24 Gy in 3 fractions. Median time to RN after SRS was 10 months(m). Median follow-up after starting BS was 6m and 40 patients had at least 1 follow up MRI available to evaluate response. The best response was complete response (CR) in 15% patients and partial response (PR) in 40% while 35% had stable disease (SD) and 10% had progressive disease. Median time to CR was 9m (6-12m) and PR was 6m (3-12m). Percentage of patients who had any response (CR or PR) at 3, 6, 9 and 12 months was 25%, 60%, 43% and 50%, respectively. 56% patients had symptomatic RN, of which 35.7% had improvement in symptoms with BS alone, while 64% required steroid use. Overall, median duration of response in patients with CR, PR or SD was 7.5m(range 2-31m). Salvage treatment for RN was steroids (33), surgery (4), Bevacizumab (5) or hyperbaric oxygen therapy (1). No patients had any CTCAE grade 3 or higher toxicities. 3 patients (6%) had any side-effects all of whom had Grade 1-2 gastrointestinal intolerance or diarrhea. 2 patients stopped treatment due to enrolment on an immunotherapy clinical trial. Overall, 39 patients remained on BS at last follow-up or death.

CONCLUSION

We observed >50% response rates with use of BS in our cohort of patients with Grade 1-3 RN after SRS. More than 1/3rd patients with symptomatic RN were able to avoid long-term steroid use. BS is an easily available over-the-counter drug that appears to be a safe and promising treatment option for RN, and can potentially decrease steroid dependence in these patients, reducing the risk of several side-effects. Further prospective studies to compare Boswellia with placebo is warranted.

Comparative Analysis of Tumor Microbiome, Molecular Profile and Immune Cell Abundance by HPV Status in Head and Neck Cancers and Their Impact on Survival

PURPOSE/OBJECTIVE(S)

Traditional clinical and molecular prognostic factors offer valuable insight into the heterogeneous natural history and treatment response of head and neck squamous cell carcinoma (HNSCC) yet fail to explain the full spectrum of observed variability. The tumor microenvironment (TME), comprising microbiome and immune cells can impact treatment response and prognosis. We analyzed The Cancer Genome Atlas (TCGA) to evaluate the association of specific microbes and genes in TME with survival and their differential expression in HPV positive (+) and HPV negative (-) HNSCC.

MATERIALS/METHODS

HNSCC RNA sequencing (RNAseq) samples from TCGA were processed through the Exogenous sequencing in Tumors and Immune Cells (ExoTIC) pipeline to identify gene expression and microbial presence. HPV status was assessed by detection of papillomaviridae family of microbes. Clinical data from TCGA was extracted to compare overall survival (OS) and control for competing variables using Cox proportional hazards regression. Difference in immune cell abundance was evaluated by Kruskal-Wallis test. All statistical analysis was performed using R.

RESULTS

A total of 498 RNAseq samples from TCGA were analyzed. Oral cavity, oropharynx, hypopharynx, and larynx tumors comprised 21.6%, 15%, 1.8%, and 22.2% of specimens, respectively. HPV was detected in 111 patients (22%), most commonly Alpha papillomavirus 9 (90.1%). Of the 5838 enriched microbes, 330 were significantly associated with OS after controlling for tumor stage, smoking, and age. Specifically, the presence of Alpha papillomavirus 9 was associated with significantly improved OS [adjusted HR = 0.60 (95% CI 0.40 - 0.89, p = 0.01)]. Microbial species found in more abundance in HPV- tumors included Citrobacter farmeri, Thermoanaerobacter kivui and Yersinia pestis which are gram negative anaerobes. Genes related to cellular transport and DNA repair were enriched while genes related to proliferation (e.g., SAGE1) were depleted in HPV+ samples. HPV- tumors had a significantly higher number of M0 (p < 0.001) and M2 macrophages (p = 0.035) while HPV+ tumors had more T regulatory cells (p < 0.001) and CD8+ T-cells (p < 0.001).

CONCLUSION

Tumor microenvironment was significantly associated with survival for HNSCC patients, with particular microbes such as Alpha papillomavirus 9 correlating with improved OS. Greater abundance of certain anaerobic microbes was seen in HPV- tumors. These findings suggest TME can be used to predict patient outcomes and potentially guide personalized treatment approaches. We found an abundance of M0 and M2 macrophages in HPV- tumors, which are considered pro-tumorigenic, while anti-tumor M1 macrophages were similar in the two groups. This may help identify mechanism of resistance to immunotherapies and tailor novel immunotherapy combinations in specific patient subgroups. With further prospective research and external validation these findings have the potential to significantly impact the way we treat HNSCC in the future.

Upfront Osimertinib Alone vs. Osimertinib and Radiotherapy for the Treatment of EGFR-Positive NSCLC Brain Metastases: A Multi-Institutional Series

PURPOSE/OBJECTIVE(S)

Given the increased brain penetrance of osimertinib, the role of upfront radiotherapy (RT) has been questioned for the management of patients with EGFR+ NSCLC brain metastases (BM). We conducted a multi-institutional review of patients with EGFR+ NSCLC treated with upfront osimertinib or osimertinib in combination with RT for new or progressing BM.

MATERIALS/METHODS

Our multi-institutional analysis included 128 patients with 714 BM treated between 2013 and 2022. Two BM treatment groups were evaluated: (1) upfront osimertinib alone (n = 66) and (2) osimertinib + RT [whole brain radiation therapy or stereotactic/fractionated radiosurgery (SRS/FSRT)] prior or concurrently with osimertinib (n = 62)]; both groups began treatment within 2 months of BM diagnosis. Time-to-event analysis was conducted with the Kaplan-Meier (KM) method, and outcomes included intracranial control (IC) [both local and distant], intracranial progression free survival (IPFS), and overall survival (OS). A Cox proportional hazards model was utilized for multivariate analysis (MVA).

RESULTS

Median follow-up from BM diagnosis was 33.9 months (0.13-76.2 months). No differences in age (p = 0.46), sex (p = 0.72), DS-GPA (p = 0.08), KPS (p = 0.57), number of BM (p = 0.19) or volume of BM (p = 0.45), RT dose (p = 0.45), number of systemic metastases (p = 0.88), and patients symptomatic at presentation (p = 1.0) were noted. Prior treatment of BM was more common in the osimertinib + RT group (50% osimertinib + RT and 27% osimertinib; p = 0.01). The 12-month KM rates for osimertinib vs osimertinib + RT groups for IC were 72% vs 73% (p = 0.33); IPFS 53% vs 66% (p = 0.007); and OS 65% vs 80% (p = 0.025). On MVA, higher KPS (p = 0.002) was associated with increased OS and no extracranial metastasis with increased OS (p = 0.01) and IPFS (p = 0.001). MVA showed no association between osimertinib vs osimertinib + RT for IC, IPFS, or OS. Of the 66 patients treated with upfront osimertinib, 18 patients (27%) with 31 lesions eventually required RT for intracranial progression with the majority 72% being treated with SRS/FSRT at median of 13.5 months (1-22 months) following the start of osimertinib.

CONCLUSION

This study suggests that upfront osimertinib alone may provide sufficient intracranial control to allow RT to be deferred until further intracranial progression in select patients. Prospective trials are warranted to further guide treatment.

WBRT is Associated with Higher Rates of Hematologic Toxicity than Stereotactic Radiosurgery in Brain Metastasis Patients

PURPOSE/OBJECTIVE(S)

Whole brain radiotherapy (WBRT) has historically been a standard of care in patients with multiple brain metastases. Studies show that WBRT may be associated with a transient detriment in hematological parameters because of exposure to a larger proportion of circulating lymphocytes, platelets and hematopoietic cells within the bone marrow of the cranium. In this study, we tested the hypothesis that stereotactic radiotherapy (SRS) may cause reduced hematologic toxicity in patients compared to WBRT.

MATERIALS/METHODS

We retrospectively identified 100 patients treated for brain metastasis, with either SRS or WBRT from 2016 to 2019, and queried their pre- and post-treatment hematological parameters including hemoglobin, total white blood cell (WBC), absolute neutrophil count (ANC), absolute lymphocyte count, and platelet count. CTCAE v5.0 was used for grading hematologic toxicities. Serial values were compared by treatment type and controlled for age, gender, and systemic therapy. Student t-test was used for intergroup comparison and p-value <0.05 was considered significant.

RESULTS

Of 100 patients, median brain metastases was 3 (range 1-22), 51 received SRS and 49 received WBRT. We observed that patients treated with WBRT had a significantly higher post-treatment reduction in platelet count (-51.2 vs 9.8; p = 0.001) and higher incidence of any grade thrombocytopenia (31.2% vs 10%; p = 0.019) compared to patients treated with SRS. We also noted that compared with SRS, WBRT was associated with a higher post-treatment reduction in circulating lymphocytes (-0.80 vs 0.14; p = 0.071) and higher incidence of G3+ lymphopenia (43.2% vs 22.2%; p = 0.07). Numerical incidence of any G3+ hematological toxicity was also higher in the WBRT group but the difference was not statistically significant (40% vs 28%, p = 0.162). Hemoglobin count, WBC, and ANC were not meaningfully different pre- and post-treatment for either group.

CONCLUSION

WBRT results in an increased amount and duration of radiation exposure to circulating intracranial blood volume. In our study, patients treated with WBRT experienced higher rates of clinically significant lymphopenia & thrombocytopenia compared to patients treated with SRS. In addition to the cognitive benefits of SRS compared to WBRT, there may be significant hematologic benefits as well. Further studies are warranted to clarify and validate these findings.

Patient-Reported Cognitive Outcomes and Survival after Stereotactic Radiosurgery for 15 or More Brain Metastases

PURPOSE/OBJECTIVE(S)

Overall survival (OS) in metastatic cancer patients has been improving with continued advancements, necessitating greater attention to treatment related toxicities. Patients with ≥ 15 brain metastases (BM) continue to be treated with whole brain radiation therapy (WBRT), despite poor neurocognitive outcomes. We analyzed our institutional experience of treating these patients with stereotactic radiosurgery (SRS), with the aim of evaluating safety, cognitive outcomes, and survival metrics.

MATERIALS/METHODS

Patients who received SRS for ≥ 15 BMs in 1-5 fractions from 2014-2022 using the previously described single isocenter multi-target technique were included. Cognitive outcomes were objectively evaluated using serial Patient-Reported Outcome Measurement Information System (PROMIS) scores. Kaplan-Meier method was used for survival analysis and log-rank test was used for intergroup comparisons.

RESULTS

A total of 118 patients underwent 124 courses of LINAC-based SRS. The mean and median number of lesions treated per patient was 24.8 and 20, respectively (range 15 - 94). Most common primary histologies were lung (47.6%), melanoma (21.0%), and breast (14.5%). The median SRS dose was 24 Gy (range 18 - 30 Gy) with 87.9% receiving 3 fraction SRS. At the time of SRS, 19.4% patients had received prior WBRT and 24.2% had received at least one prior SRS course. The rate of any grade radiation necrosis (RN) and ≥ grade 3 RN were 15.3% and 3.2% respectively. New onset seizures were seen in 2.4%, alopecia in 2.4%, and subjective cognitive decline in 4% of patients. Median follow-up by reverse Kaplan-Meier method was 17.8 months (m). Cognitive data was available for 38 patients. Mean PROMIS scores at baseline, 3m, 6m and 9m after SRS were 32.0, 31.6, 30.4 and 28.7 out of 40, respectively. When longitudinal trends were available, 25 of 31 patients had a stable or improved PROMIS score. The 12m local control was 97.6%. Cumulative incidence of distant intracranial failure was 79.2%. One year freedom from neurological death, leptomeningeal disease, and salvage WBRT were 85.6%, 87.6% and 71.7% respectively. Median OS from brain metastases diagnosis was 11.3m (95% CI 7.2m - 15.3m) overall, while it was 9.2m (6.5 - 11.8m) after excluding patients who had prior WBRT or SRS (n = 79). One-year survival was 40% from diagnosis and 38.7% from SRS. On Cox regression analysis, prior WBRT (p = 0.002), higher KPS (p = 0.050), systemic therapy after SRS (p<0.001), and controlled extracranial disease (p = 0.007) predicted for improved OS.

CONCLUSION

We present here the largest study evaluating SRS for patients with ≥ 15 BMs. We found that SRS was safe, had favorable cognitive outcomes, and comparable survival outcomes to contemporary studies evaluating WBRT in this patient population. Treatment-naïve patients had a median survival of > 6 months, long enough to benefit from cognitive sparing with SRS. Our study supports further randomized studies comparing SRS and memory avoidance WBRT approaches for patients with ≥ 15 BMs.

Enhancement Patterns of Metastatic Intrahepatic Cholangiocarcinoma and Outcomes after Chemotherapy and Radiation

PURPOSE/OBJECTIVE(S)

Patients with metastatic intrahepatic cholangiocarcinoma (M1-iCCA) have a poor prognosis with a 5-year survival rate of less than 20%. Definitive doses of radiation therapy (RT) after upfront chemotherapy (chemo/RT) in this patient population have shown to prolong survival by reducing the risk of tumor-related liver failure compared to chemotherapy alone. Our group has also identified a baseline radiographic feature, the arterial enhancement pattern, which has pathological and prognostic associations for iCCA. We tested the hypothesis that baseline arterial enhancement is independently associated with survival outcomes for patients who receive chemo/RT or chemo alone.

MATERIALS/METHODS

Patients with M1-iCCA from 2010 to 2021 were included in this retrospective study. Patients were grouped into those who underwent chemo alone and those who underwent chemo/RT. The inclusion criteria included confirmed diagnosis of M1-iCCA, availability of baseline multi-phasic computed tomography (CT), and follow-up for at least six months or until death. Tumor arterial enhancement patterns were categorized as previously described into hypovascular or hypervascular, where the tumors that were hypervascular had either peripheral enhancement or central enhancement. Mean tumor density in Hounsfield units was recorded for each patient. Survival was estimated using the Kaplan Meier method, and Cox proportional models were used to adjust for prognostic variables.

RESULTS

A total of 281 patients with iCCA were identified and 229 had evaluable CT scans. Demographic and baseline characteristics of patient groups are shown in the Table. On univariate analysis, patient age, ECOG performance status (PS) at diagnosis, treatment type, and arterial enhancement patterns associated with overall survival (OS). On multivariable analysis, the arterial enhancement pattern independently associated with OS after accounting for covariates. Patients with hypervascular tumors had prolonged OS compared to those with hypovascular tumors (HR = 0.72, [0.54 - 0.96], p = 0.02). Prolonged OS was also observed in the chemo/RT group compared to the chemo alone group (HR = 0.37, [0.25-0.54], p< 0.0001).

CONCLUSION

Baseline enhancement patterns of M1-iCCA were prognostic in the contexts of chemo alone and chemo/RT. This imaging-based biomarker may improve the ability to stratify patients for therapeutic management.

Indian consensus statements on irritable bowel syndrome in adults: A guideline by the Indian Neurogastroenterology and Motility Association and jointly supported by the Indian Society of Gastroenterology

The Indian Neurogastroenterology and Motility Association (INMA), earlier named the Indian Motility and Functional Diseases Association developed this evidence-based practice guidelines for the management of irritable bowel syndrome (IBS). A modified Delphi process was used to develop this consensus containing 28 statements, which were concerning diagnostic criteria, epidemiology, etiopathogenesis and comorbidities, investigations, lifestyle modifications and treatments. Owing to the Coronavirus disease-19 (COVID-19) pandemic, lockdowns and mobility restrictions, web-based meetings and electronic voting were the major tools used to develop this consensus. A statement was regarded as accepted when the sum of "completely accepted" and "accepted with minor reservation" voted responses were 80% or higher. Finally, the consensus was achieved on all 28 statements. The consensus team members are of the view that this work may find use in teaching, patient care, and research on IBS in India and other nations.

Acute Pancreatitis in Severe COVID Pneumonia

Covid-19 has emerged as a global pandemic with significant morbidity and mortality. Although it is predominantly a respiratory disorder, the gastrointestinal involvement in Covid 19 infection has been extensively documented. We report two cases of acute pancreatitis in severe Covid pneumonia. Detailed history taking, physical examination, laboratory and radiological investigations were used to rule out common causes of acute pancreatitis in these cases. This case report aims to highlight SARS CoV-2 virus as an important etiological factor of acute pancreatitis, in line with few reports from around the world. There is a scarcity of data regarding acute pancreatitis in Covid infection from India.

Role of whole-body vibration exposure and posture of dumper operators in musculoskeletal disorders: a case study in metalliferous mines

Objectives. The combined role of whole-body vibration (WBV) exposure and awkward posture on musculoskeletal disorders (MSDs) experienced by dumper operators in two metalliferous mines in India was evaluated through a cross-sectional study. Methods. Frequency-weighted root mean square (rms) acceleration was used for WBV exposure assessment. Anthropometry and rapid upper limb assessment (RULA) were used for static and dynamic posture assessment, respectively. Prevalence of MSDs was assessed using the Nordic musculoskeletal questionnaire (NMQ). Logistic regression was used to assess the factors contributing to MSD problems. Results. The rms values revealed that the operators exceeded the lower limit of Standard No. ISO 2631-1:1997. The dynamic posture study revealed that the majority of dumper operators were taking awkward postures and 58-74% of them were subjected to high and medium levels of MSD risk. The adjusted odds ratio (7.96, 95% confidence interval [1.24, 41.35]) for the most awkward postures revealed WBV exposure as the significant risk factor for MSD problems among the operators. Conclusion. WBV exposure and posture of operators should be regularly monitored and corrective actions implemented to reduce their MSD problems. Ergonomic seat design based on the anthropometry of the operators should be assessed at the time of procuring new equipment.

PPIs and Safety Concerns - A Pending Verdict?

Proton pump inhibitors (PPIs) with a high therapeutic index have strong evidence to support their efficacy in the management of common gastrointestinal (GI) conditions such as gastroesophageal reflux (GERD), peptic ulcer diseases, H. pyloriinfection etc. Despite this, the list of adverse effects being cited across literature with chronic use of these drugs is on an upward trend. Studies and published literature have associated PPI use with risk of bone fractures, various micronutrient deficiencies, gastro-intestinal infection, pneumonia, cardiac complications, dementia, kidney disease, intestinal bacterial overgrowth and drug interactions. It is however of clinical interest to note that in most of the studies published, the risk association reported with PPIs is weak. Unfortunately, widespread media publicity around these studies has prompted discontinuation of the drug in patients in whom it is indicated and created generalized anxiety among its users 20 years later since their introduction. The primary objective is to review the literature for an unbiased translation of the knowledge to appropriately guide decision in clinical practice.

API-ISG Consensus Guidelines for Management of Gastrooesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common problem in the community. The Indian Society of Gastroenterology and Association of Physicians of India have developed this evidence-based practice guideline for management of GERD in adults. A modified Delphi process was used to develop this consensus containing 43 statements, which were generated by electronic voting iteration as well as face-to-face meeting, and review of the supporting literature primarily from India. These statements include 4 on epidemiology, 9 on clinical presentation, 11 on investigations, 18 on treatment (including medical, endoscopic, and surgical modalities), and one on complications of GERD. The statement was regarded as accepted when the proportion of those who voted either to accept completely or with minor reservation was 80% or higher. The prevalence of GERD in large population-based studies in India is approximately 10% and is probably increasing due to lifestyle changes and increase in obesity. The diagnosis of GERD in the community should be mainly based on presence of classical symptoms like heartburn and sour regurgitation, and empiric treatment with a proton pump inhibitor (PPI) or H2 receptor antagonist should be given. All PPIs in equipotent doses are similar in their efficacy in the management of symptoms. Patients in whom symptoms do not respond adequately to PPI are regarded as having PPIrefractory GERD. Invasive investigations should be limited to patients with alarm symptoms and those with refractory GERD.

Effect of knowledge management on software product experience with mediating effect of perceived software process improvement: An empirical study for Indian software industry

The software development industry is characterised by swift innovation and competition. To survive, software engineering (SE) organisations need to develop high-quality software products in a timely fashion and at low cost. Knowledge-based approaches to software development are extremely supportive to acquiring new knowledge and leveraging existing knowledge from software projects; this enables constant improvement of software development practices. In this empirical study of Indian SE organisations, we study the impact of managing knowledge for perceived software process improvement (PSPI) and its effect on software product quality. Information technology (IT) in knowledge management (KM) is an important facilitator for any SE organisation desiring to exploit evolving technologies for management of their knowledge assets and for carrying out various KM processes of knowledge capture, storage, retrieval and sharing. Surveys collected from Indian SE organisations were analysed to propose a model using a structured equation modelling (SEM) technique. Our findings reveal that the relation between KM and quality of software product is positively mediated by PSPI. These findings reinforce an arena that is of growing importance to researchers and practitioners and which has seen only a limited number of empirical studies to date in the context of Indian SE organisations.

Indian consensus on chronic constipation in adults: A joint position statement of the Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology

The Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology developed this evidence-based practice guideline for management of chronic constipation. A modified Delphi process was used to develop this consensus containing 29 statements, which were generated by electronic voting iteration as well as face to face meeting and review of the supporting literature primarily from India. These statements include 9 on epidemiology, clinical presentation, and diagnostic criteria; 8 on pathophysiology; and the remaining 12 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The members of the consensus team believe that this would be useful for teaching, clinical practice, and research on chronic constipation in India and in other countries with similar spectrum of the disorders.

Non-alcoholic Fatty Liver Disease and Metabolic Syndrome-Position Paper of the Indian National Association for the Study of the Liver, Endocrine Society of India, Indian College of Cardiology and Indian Society of Gastroenterology

Non-alcoholic fatty liver disease (NAFLD) is closely associated with metabolic syndrome. Prevalence of metabolic risk factors including diabetes mellitus, obesity, etc. is rapidly increasing in India putting this population at risk for NAFLD. Patients with NAFLD are at increased risk for liver-related morbidity and mortality and also cardiovascular disease risk and increased incidence of diabetes mellitus on long-term follow-up. Management of patients with NAFLD may require a multi-disciplinary approach involving not only the hepatologists but also the internists, cardiologists, and endocrinologists. This position paper which is a combined effort of the Indian National Association for Study of the Liver (INASL), Endocrine Society of India (ESI), Indian College of Cardiology (ICC) and the Indian Society of Gastroenterology (ISG) defines the spectrum of NAFLD and the association of NAFLD with insulin resistance and metabolic syndrome besides suggesting preferred approaches for the diagnosis and management of patients with NAFLD in the Indian context.

Correction of penile torsion and chordee by mobilization of urethra with spongiosum in chordee without hypospadias

OBJECTIVE

To investigate the feasibility of correcting coexistent penile torsion and chordee without hypospadias by mobilization of the urethra and spongiosum.

MATERIALS AND METHODS

A retrospective study of nine patients with simultaneous penile torsion and chordee without hypospadias was undertaken between January 2006 and December 2012. During this period, a total of 364 cases of hypospadias and 38 of chordee without hypospadias were operated on, making a total of 402 patients with hypospadias-related complexes. The same steps were used for correction of both torque and chordee. After a circumcoronal incision, the penis was fully degloved and the spongiosum with urethra was lifted up off the cavernosa. Next, mobilization of the hypoplastic urethra with spongiosum was extended into the glans. If chordee or torque persisted, urethral mobilization was performed proximally up to the bulbar urethra, as required. Spongioplasty and glansplasty were done and a per-urethral stent was kept in for three to five days.

RESULTS

The age of the patients ranged from 5 to 16 years (median 6 years). Penile torsion ranged from 30° to 120°, with a median of 75°. Ventral chordee ranged from 45° to 100°, with a median of 50°. A ratio of 1:9.6 was found for chordee without hypospadias compared to the total hypospadias cases, with an incidence of 9.5%. The ratio of chordee without hypospadias with torsion compared to the total hypospadias cases was 1:29. There was an incidence of chordee without hypospadias with penile torsion of 3.5% in all patients with hypospadias. The ratio of chordee without hypospadias with torsion to only chordee without hypospadias was 1:1.71, with an incidence of 37.0%. Every step contributed to the correction of curvature and torsion. Chordee was corrected in two patients by penile degloving and lifting of the spongiosa off the urethral plate; three patients required additional mobilization of the urethra into the glans. Another two patients needed proximal urethral mobilization and one required a dorsal plication. In five patients, torque was corrected by penile degloving, lifting of the spongiosa and mobilization of the urethra into the glans; four patients required further proximal urethral mobilization. All patients had excellent functional and cosmetic results. No residual chordee or torque was observed in any patient on follow-up at 12-24 months.

CONCLUSION

The technique of distally mobilizing a hypoplastic urethra with spongiosum from the corpora into the glans, and proximally up to the bulbar region corrects moderate to severe chordee and torsion with excellent cosmetic results. The incidence of torsion with chordee without hypospadias was 3.5% of all cases of hypospadias.

COX-2 gene polymorphisms and risk of chronic periodontitis: a case-control study and meta-analysis

OBJECTIVE

Cyclooxygenase-2 (COX-2) enzyme is a major mediator of inflammation in periodontitis, leading to loss of gingival tissues and alveolar bone supporting the teeth. Previous studies have explored the role of COX-2 polymorphisms with the risk of periodontitis in different ethnic groups; however, findings are inconsistent. So, we aimed to investigate the association of COX-2 polymorphisms (rs20417, rs689466, and rs5275) in susceptibility to chronic periodontitis (CP) in northern Indian population. Meta-analysis was also carried out to precisely estimate the effect of COX-2 polymorphisms in CP.

MATERIALS AND METHODS

Genotyping of COX-2 polymorphisms was carried out through PCR-RFLP in 200 CP cases and 200 controls. For risk estimation, binary logistic regression was applied using SPSS, version 15.0, while meta-analysis was carried using MIX 2.0 software.

RESULTS

None of the COX-2 polymorphisms independently were associated with the risk of CP. Meta-analysis suggested a significant reduced risk of CP with rs5275+8473 C allele and rs20417 in Chinese population.

CONCLUSIONS

No association was observed in any of the studied COX-2 polymorphisms with CP in North India. But, the study should be replicated in larger sample size to arrive at a definitive conclusion. Meta-analysis suggested a role of rs5275 COX-2 polymorphisms in susceptibility to overall CP, and on ethnic basis, rs20417 showed reduced risk of CP in Chinese population.

Epidemiological and clinical profile of irritable bowel syndrome in India: report of the Indian Society of Gastroenterology Task Force

AIMS

To study the profile of irritable bowel syndrome (IBS), and the frequency of such symptoms among the general population, in India.

METHODS

In this prospective, multi-center study, data were obtained from 2785 patients with chronic lower gastrointestinal symptoms (complainants) with no alarm feature and negative investigations for organic causes visiting physicians at 30 centers, and from 4500 community subjects (non-complainants), using separate questionnaires.

RESULTS

Most complainants were middle-aged (mean age 39.4 years) and male (1891; 68%). The common symptoms were: abdominal pain or discomfort (1958; 70%), abdominal fullness (1951; 70%); subjective feeling of constipation (1404 of 2656; 53%), or diarrhea (1252 of 2656, 47%), incomplete evacuation (2134; 77%), mucus with stools (1506; 54%), straining at stools (1271; 46%), epigastric pain (1364; 49%) and milk intolerance (906; 32%). Median stool frequency was similar in patients who felt they had constipation or those who felt they had diarrhea. Information to subtype symptoms using standard criteria was available in 1301 patients; of these, 507 (39%) had constipation-predominant IBS ( 3 <or= stools/week), 50 (4%) had diarrhea-predominant IBS (>3 stools/day) and 744 (57%) had indeterminate symptoms. Among non-complainants, most subjects reported daily defecation frequency of one (2520 [56%]) or two (1535 [34%]). Among non-complainants, 567 (12.6%) reported abdominal pain, 503 (11%) irregular bowel, 1030 (23%) incomplete evacuation, 167 (4%) mucus and 846 (18%) straining at stools; a combination of abdominal pain or discomfort relieved by defecation, and incomplete evacuation was present in 189/4500 (4.2%) community subjects.

CONCLUSIONS

Most patients with IBS in India are middle-aged men, and have a sense of incomplete evacuation and mucus with stools. Abdominal pain or discomfort is frequent but not universal. Importantly, stool frequency was similar irrespective of whether the patients felt having constipation or diarrhea. Most (90%) non-complainant subjects had 1 or 2 stools per day; symptoms complex suggestive of IBS was present in 4.2% of community subjects.

Complete blood count may provide risk stratification for survival and AML transformation in CMML

17502

We performed a retrospective analysis of 120 patients with CMML (98 de novo CMML and 22 evolving from MDS) to examine clinical features that may influence survival and AML transformation. Univariate analysis showed low hemoglobin level; WBC > 13,000, platelet count < 50,000 and abnormal cytogenetics as poor prognostic features. Univariate analysis also determined that BM blasts >5% and Int2/High IPSS were associated with higher rates of AML but IPSS could not be used for survival assessment. Multivariate analysis showed hemoglobin < 12 g/dL, older age, abnormal cytogenetics as risk factors for shorter survival; older age, male sex, low platelet count, BM blasts > 5%, lymphocyte and monocyte counts were independent risk factors for AML transformation. Previous attempts to devise prognostic scoring systems for CMML have incorporated both peripheral blood and bone marrow features. We have used hemoglobin, lymphocyte count and platelet count to generate 3 prognostic scoring systems, which differed by severity of thrombocytopenia. Score 1 (>100, 50–100, <50) identified 3 different risk groups (low, intermediate, and high) with median OS: not reached (n/a), 18, and 9 months for all CMML patients (p<0.0001) as well as for the de novo CMML patients (p<0.0001). Score 2 (>50, <50) divided patients into 3 risk groups (low, intermediate, and high) with median OS: n/a, 19 and 10 months for all CMML (p=0.0002) versus n/a, 28 and 11 months for de novo CMML patients (p=0.0011). Score 3 (<100, >100) separated all CMML (p=0.0073) and de novo CMML patients (p=0.0054) into 2 risk groups (high, low) with median time to AML 53 months and n/a. In conclusion we suggest three new scoring systems for CMML patients that can be easily calculated after an initial CBC. Scores 1 and 2 help to assess survival while score 3 indicates risk for AML transformation. *Acknowledgements: This work has been partially supported by the AMA Foundation Seed Grant Research Program 2006.

No significant financial relationships to disclose.

Assessment of peroxidase isozyme marker-based model for cross identifications in hybrids (F(1)) of urdbean [ Vigna mungo (L.) Hepper]

Four hybrids (4 F(1)s) were chosen out of crosses in the urdbean [ Vigna mungo (L.) Hepper, 2n = 22] having contrasting morphological characters. Zymograms for isozyme peroxidase were drawn from the patterns obtained from parents and their respective F(1) hybrids on the basis of relative similarities to parental bands. The selfed or crossed nature of hybrid pods was determined from the zymograms and their analysis. The number of bands and their intensities gave an idea about the extent of crossing in F(1) populations. Genetic identity (I) values were indicative of their selfed nature. Dendrograms were constructed on the basis of genetic identity values to display the relative similarities between the populations. Analysis was based on individual pods to confirm their hybrid or selfed nature. Possible use of this technique for identification of F(1) pods and elimination of selfed pods might be implemented to shorten the breeding operations during crossing.

Trans-acting factors that interact with the proximal promoter sequences of ovalbumin gene are tissue-specific and age-related

Aging or deterioration of functions of various organs occurs after adulthood due to alterations in the expression of genes that maintain adulthood functions. Molecular changes that occur in regulation of genes in higher organisms after adulthood can be understood by using genes whose timing and rate of expression run parallel with specific functions during the life span. One such function is egg formation in birds which is dependent on the expression of egg protein genes, ovalbumin, lysozyme, vitellogenin, etc. Trans-acting factors are known to play a pivotal role in the regulation of transcription of genes. We show here a decrease in the level/binding of nuclear trans-acting factors with specific cis-acting elements of the promoter of the ovalbumin gene of oviduct of old Japanese quail. This parallels the decrease in the expression of the ovalbumin gene in the oviduct after adulthood. These factors are tissue-specific and bind in a cooperative and sequential manner to the ovalbumin gene promoter.

Activation of vitellogenin II gene expression by steroid hormones in the old Japanese quail

Alterations in the basal transcription rates of eukaryotic genes are believed to involve the binding of trans-acting factor(s) with specific DNA sequences in the promoter. We show here two interrelated events for the VTGII gene of the old, non-egg laying Japanese quail: alterations in the structure of the chromatin encompassing the gene, and binding of trans-acting factors to the promoter of the gene. Estradiol/progesterone alone or together cause alterations in the conformation of the chromatin of the promoter region of the gene. This may allow free access of nuclear protein(s) to the cis-acting elements, ERE, PRE and NF1, in the promoter of the gene and cause activation of transcription.

Molecular biology of ageing

The process of deterioration or ageing of functions that occurs in all organisms after the attainment of reproductive ability is the sum total of the decline in activity of various organs. The functions of different organs begin to deteriorate at different times of the life span and at different rates. It is believed that different genes are involved in the ageing of different organs. Studies on isoenzyme patterns of enzymes show that the genes responsible for coding of different subunits of the enzymes are sequentially expressed during the life span. Also, the decrease in the levels of enzymes seen after adulthood is reversible and can be raised to adult level by inducing their genes by steroid hormones. Another factor that contributes to the decrease in the levels of enzymes is increasing compaction of the chromatin that houses the genes as seen from digestion of chromatin by DNase I and MNase. This decreases the rate of transcription of genes. The expression of many genes declines after adulthood which is due to the decrease in trans-acting nuclear proteins that bind to specific cis-acting sequences in the promoter regions of genes. These proteins are inducible by steroid hormones. Hence the deterioration of functions that occurs after adulthood can be delayed, and the adulthood period can by prolonged by manipulation of the expression of genes.

Age-related changes in the ovalbumin gene of the Japanese quail

Northern hybridization studies showed that the level of ovalbumin mRNA decreases in the oviduct of the Japanese quail after adulthood. In order to find out if this is due to changes in the conformation of the chromatin containing the promoter region of the gene, nuclei of the oviduct of young, adult and old birds were digested by DNaseI and micrococcal nuclease (MNase). Southern hybridization with the labelled promoter showed that this region is less sensitive to the two enzymes in the old birds. Both the endonucleases recognized the same hypersensitive sites. The results indicate that the chromatin containing the promoter is present in an open conformation in adult birds. Gel mobility shift assay using a 20-mer dsDNA containing the CAAT-box and nuclear extract of oviduct shows the presence of trans-acting factors that bind to this region. The levels of these factors are lower in old birds. This may be the reason for the lower expression of the gene in old birds.

Protection from gastrointestinal side-effects by azapropazone by its incorporation into a glucose-sodium acid citrate formulation

Addition of glucose and sodium citrate to azapropazone, in proportions of 1:1:1 by weight reduced gastric mucosal damage in rats and there was a trend towards reduction in radiolabelled faecal red cell loss in human volunteers compared with that with azapropazone alone. The glucose and citrate did not affect the pharmacokinetics of azapropazone, or its therapeutic efficacy. While no difference was observed in endoscopic injury and in symptomatic gastrointestinal complaints in a multicentre comparison in rheumatic patients, a striking reduction in symptoms was observed in those patients with a history of severe gastrointestinal intolerance to non-steroidal anti-inflammatory drugs.

Gastric antral vascular ectasia (watermelon stomach)--therapeutic options

We have encountered five cases of chronic iron deficiency anaemia due to bleeding from gastric antral vascular ectasia (watermelon stomach). Two cases were associated with a lymphoma and in three cases there was evidence of portal hypertension. Two patients were treated conservatively by blood transfusions. The other patients required either surgery or tranexamic acid or endoscopic laser therapy to control the chronic haemorrhage.

Helicobacter pylori: bridging the credibility gap

In summary, therefore, there are interesting associations between H pylori, duodenal ulcer, and non-ulcer dyspepsia. In type B gastritis there may be enough evidence to suggest a causal role. The relation between gastritis and upper gastrointestinal symptomatology, however, remains contentious. The relation between H pylori and acid secretion may be more intimate than was previously thought. 'Pylorites' must temper their enthusiasm and provide hard data; 'Schwartzians' must broaden their horizons.

Iron deficiency anaemia in patients with rheumatic disease receiving non-steroidal anti-inflammatory drugs: the role of upper gastrointestinal lesions

Upper gastrointestinal lesions associated with non-steroidal anti-inflammatory drug (NSAID) treatment are commonly implicated as the cause for iron deficiency anaemia in patients with rheumatic diseases. Such patients, however, may also have other causes for iron deficiency, including blood loss from the intestine. One hundred and four patients (mean age 58 years; male 21, female 83; smokers 14) with rheumatic disease (rheumatoid 91, others 13) and absent bone marrow iron stores (mean haemoglobin 83 g/l) were examined. At endoscopy 47 of 104 (45%) had upper gastrointestinal lesions (oesophageal ulcer 4, gastric ulcer 25, gastric erosion 13, duodenal ulcer 4, gastric ulcer and duodenal ulcer 1). Endoscopic healing was assessed in 23 patients with upper gastrointestinal lesions. Eighteen of 23 (78%) lesions healed with treatment. An improvement of anaemia occurred in 10 of 18 (56%) patients with healed lesions. Twenty three of 104 (22%) patients had dyspeptic symptoms. Ten of 23 (43%) patients with dyspepsia had an upper gastrointestinal lesion as compared with 30 of 81 (37%) patients without dyspepsia. A faecal occult blood test result was available in 53 patients. Of these, 13 were positive while 40 were negative. An upper gastrointestinal lesion was present in seven of 13 (54%) patients positive for the faecal occult blood test as compared with 14 of 40 (35%) negative for the test. Thus upper gastrointestinal lesions have previously been overestimated as the cause of iron deficiency anaemia in patients receiving NSAIDs. A positive faecal occult blood test or the presence of dyspepsia is not associated with upper gastrointestinal lesions in such patients.

Gastric mucosal prostaglandin synthesis in the presence of Campylobacter pylori in patients with gastric ulcers and non-ulcer dyspepsia

It is unclear how Campylobacter pylori (CP) interacts with gastric mucosal prostaglandins (PG). In a double-blind study we measured gastric PG synthesis in 22 patients with benign gastric antral ulcers (GU) and 26 with non-ulcer dyspepsis (NUD). CP status was determined by histology and bacteriology: 26 (16 GU plus 10 NUD) were CP positive, and 22 (6 GU plus 16 NUD) were CP negative. Patients with severe gastritis regardless of CP status) had significantly higher PGE2 and PGI2 values than those with mild gastritis. Severe gastritis was found in 36% of CP-negative subjects and 77% of the CP-positive patients (chi 2 = 8.64, p less than 0.01), but no significant differences in PG values were found between CP-positive or -negative patients.

Campylobacter pylori and gastroduodenal disease. Is there a relationship?

Much has been discovered about Campylobacter pylori in the past 6 years. Yet, many questions remain: Is the organism commensal or is it a pathogen? What is its environmental source? How is it transmitted? What is its role in gastroduodenal disease? The authors of this article discuss these and other issues relating to this common organism.

Campylobacter pylori associated gastritis in patients with rheumatoid arthritis taking nonsteroidal anti-inflammatory drugs

Fifty-two patients with rheumatoid arthritis taking nonsteroidal anti-inflammatory drugs were studied in order to assess the carriage rate of Campylobacter pylori (C. pylori) with reference to dyspeptic symptoms, endoscopic appearance and antral histology. All patients were interviewed using a standard gastrointestinal symptom scoring questionnaire and underwent endoscopy at which two antral biopsies were obtained. Sections were examined for the presence and severity of gastritis and of C. pylori. Forty-four of 52 patients (85%) had histological evidence of gastritis. Twenty-six of 44 (59%) patients with gastritis were positive for C. pylori. Twenty-six of 28 patients with 'active' (polymorph infiltration) chronic gastritis were positive for C. pylori (p less than 0.002). Sixteen of 26 bacteria-positive patients had gastrointestinal symptoms compared with eight of 26 bacteria-negative patients (p less than 0.05) and this may have therapeutic implications. There was no correlation between the presence of organisms and the appearances at endoscopy.

Acute mesenteric ischaemia: a presenting feature of coeliac disease?

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Results of simple aspiration of pneumothoraces

The results of simple aspiration in 30 cases of pneumothorax are presented. The procedure was successful in 33% of cases with known pre-existing lung disease, and in 83% of those without. Aspiration was also more successful in those patients under 50 years of age and if the estimated degree of lung collapse was less than 50%.