Dihydropyrimidine dehydrogenase deficiency in patients treated with 5FU or capecitabine based regimens: A single center experience from South India

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Background: DPYD deficiency is present in 3-5% of patients. The risk of treatment-related death in DPYD mutation carriers who receive fluoropyrimidine chemotherapy has been estimated at 3-10%. There is growing data in support of widespread screening for DPYD deficiency prior to fluoropyrimidine chemotherapy. The purpose of our study was to identify the prevalence of DPYD deficiency among patients receiving 5-fluorouracil (5FU) or capecitabine based combination chemotherapy, and to analyse the toxicity profile among the DPYD deficient group. Methods: The study involved patients who have received 5FU and capecitabine based chemotherapy for the treatment for gastrointestinal, breast and head and neck cancers between 2019-2020. Four DPYD variants were checked using real-time PCR based Genotyping assay. Three common DPYD variants recommended by the CPIC guidelines (IVS14+1 G>A (*2A), c.1679T>G (*13), c.2846A>T) and a common variant in Asian population (c.496A>G), based on previous studies, was included in our analysis. These variants were assessed prior to the initiation of the chemotherapy and dose was modified based on the activity score and the toxicity profile was assessed. Descriptive statistics was performed using SPSS version 20. Results: 375 patients were included in this analysis. The median age of the cohort was 61years (21-84 years). 51.3% were males and 49.7% females. Among the 375 patients, 47 patients had DPYD mutation (12.5%). The median age of the DPYD mutated patients were 68 years; 29 (61.7%) males and 18 (38.2%) females. 32 (68.8%) had deleterious mutation in DPYD variant c.496A>G (rs2297595) and 15 (31.9%) showed mutation IVS14+1 G>A (rs3918290). 35 out 47 patients had grade II-III toxicity even after dose reduction during the first cycle of chemotherapy. The commonly seen adverse events were hand and foot syndrome in 18 (38.3%), mucositis in 7 (14.9%), diarrrhoea in 15 (31.9%) and neutropenia in 25 (31.9%) patients. Four patients had febrile neutropenia. One patient experience myocardial infarction. There was no mortality. Chi square analysis showed DPYD mutation had significant association with presence of severe adverse reaction (74.5%, p-value. 0.002). Conclusions: Prevalence of DPYD mutation in our patients was 12.5%. They experienced more toxicities while receiving 5-FU/Capecitabine even after dose modification. c.496A>G (rs2297595) was the most common variant seen in our patients. Screening of patients for DPYD mutations prior to administration of 5-FU/capecitabine using pharmacogenetic methods may help identify those patients who are at risk for adverse effects, allowing a more individualized approach to their chemotherapy management. c.496A>G (rs2297595) variant should also be in included routinely in DPYD screening among South Asian population.

Incidence and risk factors for falls among community-dwelling elderly subjects on a 1-year follow-up: a prospective cohort study from Ernakulam, Kerala, India

OBJECTIVES

There is limited knowledge regarding epidemiology and risk of falls among the elderly living in low-income and middle-income countries. In this situation, the current study aims to report the incidence of falls and associated risk factors among free living elderly population from Kerala, India.

DESIGN

Prospective cohort study with stratified random cluster sampling.

SETTING

The study location was Ernakulam, Kerala, India, and we collected information via house visits using a questionnaire. During the research, the subjects were followed up prospectively for 1 year by phone at intervals of 3 months and missing subjects were contacted by house visits.

PARTICIPANTS

Community-dwelling elderly above 65 years of age.

RESULTS

We recruited a total of 1000 participants out of which a total of 201 (20.1%) subjects reported a fall during the follow-up. The incidence rate of falls was 31 (95% CI 27.7 to 34.6) per 100 person-years. Female sex (OR 1.48, 95% CI 1.05 to 2.10, p=0.027), movement disorders including Parkinsonism (OR 2.26, 95% CI 1.00 to 5.05, p=0.048), arthritis (OR 1.48, 95% CI 1.05 to 2.09, p=0.026), dependence in basic activities of daily living (OR, 3.49, 95% CI 2.00 to 6.09, p<0.001), not using antihypertensive medications (OR, 1.53, 95% CI 1.10 to 2.13, p=0.012), living alone during daytime (OR 3.27, 95% CI 1.59 to 6.71, p=0.001) and a history of falls in the previous year (OR, 2.25, 95% CI 1.60 to 3.15, p<0.001) predicted a fall in the following year.

CONCLUSIONS

One in five community-dwelling senior citizen fall annually and one in four who fall are prone to fall again in the following year. Interventions targeting falls among the elderly need to focus on modifiable risk factors such as living alone during daytime, movement disorders, arthritis and dependence on basic activities of daily living.

Prevalence of Voice Disorders in School Teachers in a District in South India

BACKGROUND

Many professions tend to carry inherent risks for the practitioners. In such cases, it becomes mandatory for them to be aware of the risks and counselled about the preventive measures. The inevitable first step, however, is to ascertain the burden of risk. In the case of school teachers, it is known that they are prone to voice disorders of varying hues, at some point of their career. There should be an attempt to find the prevalence in the community. Presently, there is no such data documented from Kerala, a highly literate State in southern India.

AIM AND OBJECTIVES

The primary objective of this study was to document the prevalence of subjective dysphonia among the school teacher community. The secondary objective was to compare the prevalence and severity of dysphonia between primary and secondary school teachers.

MATERIALS AND METHODS

A cross-sectional study was conducted in 28 schools, using a screening questionnaire, based on similar ones used in other studies. All the schools were in the city of Kochi, the largest and most populous metropolitan area in Kerala. Teachers reporting a current voice complaint at the time of study were administered the validated vernacular version of the voice handicap index questionnaire (VHI 30). The completed questionnaires were collected and statistically analyzed.

RESULTS

The screening questionnaire was administered to 702 teachers; 165 were Primary school teachers (Class I-V), 242 Secondary (Class VI-XII), while 279 teachers had to take classes in both sections. The reported prevalence was 45.4% for present difficulty related to their voice, 52.8% for some voice problem in the last 1 year, and 70.1% for problems experienced during the duration of their teaching career. Possible risk factors like age, total years of teaching, hours of daily teaching and number of students taught did not show any significant association with voice problem.

CONCLUSIONS

Nearly, half of all the screened school teachers reported a current voice problem, increasing to nearly three-fourths for symptoms during entire career. This is clearly a significant burden which must be addressed at various levels. The secondary school teachers seem to bear a bigger burden in this study.

Brain Injury Lesion Imaging Using Preconditioned Quantitative Susceptibility Mapping without Skull Stripping

BACKGROUND AND PURPOSE

Identifying cerebral microhemorrhage burden can aid in the diagnosis and management of traumatic brain injury, stroke, hypertension, and cerebral amyloid angiopathy. MR imaging susceptibility-based methods are more sensitive than CT for detecting cerebral microhemorrhage, but methods other than quantitative susceptibility mapping provide results that vary with field strength and TE, require additional phase maps to distinguish blood from calcification, and depict cerebral microhemorrhages as bloom artifacts. Quantitative susceptibility mapping provides universal quantification of tissue magnetic property without these constraints but traditionally requires a mask generated by skull-stripping, which can pose challenges at tissue interphases. We evaluated the preconditioned quantitative susceptibility mapping MR imaging method, which does not require skull-stripping, for improved depiction of brain parenchyma and pathology.

MATERIALS AND METHODS

Fifty-six subjects underwent brain MR imaging with a 3D multiecho gradient recalled echo acquisition. Mask-based quantitative susceptibility mapping images were created using a commonly used mask-based quantitative susceptibility mapping method, and preconditioned quantitative susceptibility images were made using precondition-based total field inversion. All images were reviewed by a neuroradiologist and a radiology resident.

RESULTS

Ten subjects (18%), all with traumatic brain injury, demonstrated blood products on 3D gradient recalled echo imaging. All lesions were visible on preconditioned quantitative susceptibility mapping, while 6 were not visible on mask-based quantitative susceptibility mapping. Thirty-one subjects (55%) demonstrated brain parenchyma and/or lesions that were visible on preconditioned quantitative susceptibility mapping but not on mask-based quantitative susceptibility mapping. Six subjects (11%) demonstrated pons artifacts on preconditioned quantitative susceptibility mapping and mask-based quantitative susceptibility mapping; they were worse on preconditioned quantitative susceptibility mapping.

CONCLUSIONS

Preconditioned quantitative susceptibility mapping MR imaging can bring the benefits of quantitative susceptibility mapping imaging to clinical practice without the limitations of mask-based quantitative susceptibility mapping, especially for evaluating cerebral microhemorrhage-associated pathologies, such as traumatic brain injury.

Health-related quality of life in infants and toddlers with congenital heart disease: a cross-sectional survey from South India

OBJECTIVE

There are limited data on health-related quality of life (HRQOL) for infants and toddlers with congenital heart disease (CHD). We sought to compare generic HRQOL of infants and toddlers between CHD subjects and controls.

DESIGN

Dual-setting, cross-sectional analytical survey.

SETTING

We collected HRQOL data on infants and toddlers through a community survey for controls and through a hospital-based survey for those with CHD.

PATIENTS

A total of 499 subjects with confirmed CHD in the age group of 1-24 months admitted for elective surgery in the study institution were selected by consecutive sampling. In addition, we selected 628 control children in the same age group from an area within the 10 km radius of the study institution.

MAIN OUTCOME MEASURES

The data contain parent proxy report of HRQOL. The Pediatric Quality of Life Inventory (PedsQL 4.0) was used to collect HRQOL data. Questionnaires were self-administered for parents.

RESULTS

The mean total proxy HRQOL scores were significantly higher in control infants compared with infants with CHD (adjusted mean difference 5.0, 99% CI 2.5 to 7.5, p<0.001). Corresponding figure for toddlers was 7.6 (95% CI 5.0 to 10.2, p<0.001). There was no significant difference in total HRQOL scores across CHD functional classes among infants and toddlers (p=0.212 and p=0.502, respectively).

CONCLUSIONS

Infants and toddlers with uncorrected CHD have significant deficiency in proxy HRQOL compared with their controls. The functional class of CHD appears to have no differential impact on overall HRQOL deficiency in this age group.

Films and fiction leading to onset of psycho-phenomenology: Case reports from a tertiary mental health center, India

Mind is influenced by socio-cultural religious belief systems, experiences and attributions in the development of psychophenomenology. Film viewing is a common entertainment among young adults.

Objectives

Influence of repetitive watching of films of fiction and horror genres on onset phenomenology in young adults.

Method

Two case reports on onset of psychotic features and mixed anxiety depressive phenomenology were seen in two patients aged 16 and 20 years respectively and based on the fantastic imagination created by films. The 28-year-old female patient diagnosed with schizoaffective disorder had onset at 16 years of age and the course of phenomenology was influenced by the fiction movie ‘Jumanji’ with partial response to medications over 10 years. The depressive and anxiety symptoms of less than 6 months duration of a 20-year-old male patient was influenced by film ‘Hannibal’ and responded to antidepressant and cognitive behavior therapy.

Conclusions

Horror and fiction films can influence the thinking patterns and attribution styles of a young adult by stimulating fantasy thinking which if unrestrained can lead to phenomenology. Viewing films compulsively, obsessive ruminations on horror and fictional themes can lead to onset of psychopathology of both psychosis and neurotic spectrum. Further research on neurobiological, psychological correlates is needed. Parental guidance and restricted viewing of horror genre films with avoidance of repeated stimulatory viewing of same genre movies in children, adolescents, young adults and vulnerable individuals is required.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Gender Differences in Perceived Social Support and Stressful Life Events in Depressed Patients

OBJECTIVE

To study the gender differences in perceived social support and life events in patients with depression.

METHODS

A total of 118 patients aged 18 to 60 years, with depressive disorder according to the DSM-IV-TR, were evaluated using the Multidimensional Scale of Perceived Social Support and Presumptive Stressful Life Events Scale.

RESULTS

The perceived social support score was significantly higher in males than females (p < 0.001). Males perceived significantly higher social support from friends than females (p < 0.001), whereas support from significant others was higher in females. There was a higher mean number of total life events as well as specific type of life events in males that became apparent after controlling for education (p < 0.05). Financial loss or problems was the most commonly reported life event in both males and females. Work-related problems were more commonly reported by males, whereas family and marital conflict were more frequently reported by females.

CONCLUSION

Perceived social support and stressful life events were higher in males with depression than females.

Improved T2* imaging without increase in scan time: SWI processing of 2D gradient echo

BACKGROUND AND PURPOSE

2D gradient-echo imaging is sensitive to T2* lesions (hemorrhages, mineralization, and vascular lesions), and susceptibility-weighted imaging is even more sensitive, but at the cost of additional scan time (SWI: 5-10 minutes; 2D gradient-echo: 2 minutes). The long acquisition time of SWI may pose challenges in motion-prone patients. We hypothesized that 2D SWI/phase unwrapped images processed from 2D gradient-echo imaging could improve T2* lesion detection.

MATERIALS AND METHODS

2D gradient-echo brain images of 50 consecutive pediatric patients (mean age, 8 years) acquired at 3T were retrospectively processed to generate 2D SWI/phase unwrapped images. The 2D gradient-echo and 2D SWI/phase unwrapped images were compared for various imaging parameters and were scored in a blinded fashion.

RESULTS

Of 50 patients, 2D gradient-echo imaging detected T2* lesions in 29 patients and had normal findings in 21 patients. 2D SWI was more sensitive than standard 2D gradient-echo imaging in detecting T2* lesions (P < .0001). 2D SWI/phase unwrapped imaging also improved delineation of normal venous structures and nonpathologic calcifications and helped distinguish calcifications from hemorrhage. A few pitfalls of 2D SWI/phase unwrapped imaging were noted, including worsened motion and dental artifacts and challenges in detecting T2* lesions adjacent to calvaria or robust deoxygenated veins.

CONCLUSIONS

2D SWI and associated phase unwrapped images processed from standard 2D gradient-echo images were more sensitive in detecting T2* lesions and delineating normal venous structures and nonpathologic mineralization, and they also helped distinguish calcification at no additional scan time. SWI processing of 2D gradient-echo images may be a useful adjunct in cases in which longer scan times of 3D SWI are difficult to implement.

Drug resistance in Mycobacterium tuberculosis isolates from tuberculosis patients in Kerala, India

OBJECTIVE

To analyse the extent of drug resistance in clinical isolates of Mycobacterium tuberculosis from patients attending various tuberculosis (TB) clinics in Kerala, India.

DESIGN

Mycobacteria were isolated from sputum samples of TB patients. Isolates from 92 new and 104 retreatment cases were tested for resistance to four first-line drugs (isoniazid, rifampicin, ethambutol and streptomycin).

RESULTS

Twenty-three per cent of the isolates from new cases and 14% from retreatment cases were pan-susceptible, and the rest were resistant to at least one of the drugs. Multidrug-resistant isolates accounted for 5.4% among new cases and 16.4% among retreatment cases. It should be noted that 18.5% of the isolates were mycobacteria other than tuberculosis.

CONCLUSION

There is an urgent need for statewide surveys to assess the level of drug resistance using quality-assured culture and drug susceptibility services. Considering that the Revised National TB Control Programme in India has been made operational nationwide, this kind of screening should be made mandatory under the programme to effectively control the spread of TB.

The Dynamic Aviation Data System (DADS)

This paper proposes The Dynamic Aviation Data System (DADS), which integrates a variety of existing information sources regarding flight to serve as a tool to pilots in dealing with the challenges of flight. The system is composed of three main parts: a pilot's history on disk; a system that can read proposed flight plans and make suggestions based upon Geographical Information Systems, weather, aircraft, and case report databases that exist throughout North America; and a small hand-held computer that interfaces with the aircraft's instruments and that can be brought into the cockpit to aid the pilot before and during flight. The system is based upon technology that currently exists and information that is already regularly collected. While many issues regarding implementation and cost efficiency of the system need to be addressed, the system shows promise in its ability to make useful flight safety information available to all pilots in order to save lives.

Monocyte contamination in Ficoll-Hypaque mononuclear cell concentrates

Monocyte contamination in mononuclear concentrates prepared by Ficoll-Hypaque (F-H) centrifugation was assessed by the following criteria: (a) morphology (Wright-Giemsa stain), (b) function (phagocytosis), and (c) cytochemical staining (non-specific esterase both manually and by flow cytophotometry). Studies on F-H preparations from blood samples obtained from 50 randomly selected patients irmined by functional and cytochemical staining. Monocyte counts determined by flow cytophotometric studies of cells stained in suspension for esterase were very similar to those based on phagocytosis and manual cytochemical staining technics. It is concluded that: (1) manual Wright-Giemsa staining alone is not adequate to accurately quantitate monocyte populations in F-H concentrates, and (2) cytochemical staining and flow cytophotometry can be used for rapid and accurate quantitation of monocyte contamination in F-H mononuclear concentrates.