A radiologist's guide to median sternotomy

Median sternotomy is widely recognised as the primary incision technique in cardiac surgery. This surgical procedure involves dividing the sternum to gain access to the heart and lungs, making it invaluable in correcting congenital heart defects. Furthermore, it is frequently employed in adult patients, particularly during coronary artery bypass graft (CABG) procedures. In this imaging review, we present a comprehensive overview of the pre-procedural assessment and various post-sternotomy complications encountered within our clinical experience at a tertiary cardiothoracic centre. The focus of this review is to outline the imaging features associated with mediastinal adhesions and establish the minimal safe distance between the sternum and common mediastinal structures when considering re-sternotomy. By providing visual examples, we aim to facilitate a better understanding of these key concepts. Moreover, we delve into a detailed discussion of a spectrum of postoperative complications that may arise following median sternotomy including those related to metalwork (sternal wire fracture), bone (sternal dehiscence, non-union and osteomyelitis), and soft tissue (abscess, haematoma).

Cutaneous mucormycosis in the immunocompromised host: An important cause of persistent post traumatic skin lesions

We describe a case of a 31-year-old man with a history of ocular non-Hodgkin's lymphoma who presented with a large 12-cm non-resolving traumatic skin lesion on his back. Biopsy showed fungal elements, and on fungal culture, Rhizopus arrhizus (formerly R. oryzae) was isolated. Cutaneous mucormycosis is an important diagnostic consideration for a non-resolving skin lesion in an immunocompromised host. Early tissue sampling is key, and diagnostic certainty is particularly important because first line therapy, liposomal amphotericin B, has significant systemic toxicities, notable renal toxicity, and is therefore challenging to continue empirically. Surgical debridement is an integral part of therapy, highlighting the need for early multidisciplinary care in patients with cutaneous mucormycosis.

ESTIMATION OF SERUM FERROPORTIN AND LIVER ENZYMES IN BREAST CANCER PATIENTS

Breast cancer (BC) is a common malignancy and a major cause of death in women. We sought to evaluate ferroportin plasma concentration in patients with BC. A total of 90 subjects (60 BC versus 30 control healthy) enrolled in the present study. Blood sample withdrawn and serum separated for measurement of total serum bilirubin (TSB), Aspartate Transaminase (AST), alanine transaminase (ALT), ferroportin (FPN). Results: A non-significant (p<0.852) differences exists between the level TSB in BC group (0.665±0.365) compared to control group (0.654±0.191mg/dl). AST in BC group (40.1±36.0) has shown a highly significant (p>0.001) difference comparing with the control group (22.5±14.2 U/L). ALT in BC group (29.7±26.7) has shown a highly significant (p>0.004) difference comparing with the control group (18.19±9.51U/L). FPN (ng/mL) in BC group (2.47±1.59) has shown a highly significant (p>0.002) difference comparing with the control group (4.44±1.20). Conclusion: the study concluded that breast cancer was associated with elevated AST, and ALT with reduced FPN and no changes reported with TSB levels.

Length-weight relationships of farmed major carps (Cattla cattla, Labeo rohita and Cirhinus mrigala) fed with different sources of protein in an intensive polyculture

The present findings provide information regarding the length-weight relationships (LWRs) of Indian major carps viz Cattla cattla, Labeo rohita and Cirhinus mrigala in an intensive polyculture system. Much work has been done in Pakistan with respect to fish LWRs, much of such work has been ignored. Carps were fed with twelve different formulated diets containing four different sources of protein i.e. fish meal (FM), all parts chicken meal (APCM), corn gluten (CGM) and soybean meal (SBM). Each type of protein is used at inclusion level of 25, 35 and 45% into the formulated diets to evaluate the minimum requirement of that ingredient for optimal growth of in-hand species. The values of slope "b" ranged from 2.20 to 4.90 for these species of carps which showed a strong healthy relationship among variables (level of protein and months).

FREQUENCY OF PLACENTA ACCRETA SPECTRUM DISORDERS IN NINEVAH PROVINCE HOSPITALS: A HISTOLOGIC STUDY

Objectives - to provide a view on the frequency, and the risk factors of placenta accreta spectrum disorders (PAS) in Nineveh Province, and to assess the morphological alterations associated with these disorders. A prospective and retrospective cross-sectional study was carried out on paraffinized blocks of 19 females, with gestational age ≥32 weeks, presented with peripartum haemorrhage and subjected to emergency hysterectomy at Maternity Teaching Hospitals, Nineveh Province, North of Iraq. Clinical data, including the mother's age and obstetrics history, were recorded when available. All cases were examined for the presence or absence of histological invasion of placentas supported by immunohistochemistry. The mean age of cases was 34.4±1.6 years by the dominance of the fourth decade. The mean gestational age at the time of diagnosis was 35.6±0.8 weeks. The PAS frequency was increasing and reaching up to 1.18 per 1000 live birth. About 60% of the cases gave a history of previous Cesarean section with or without a concomitant placenta previa. According to light microscopic examination, placenta accreta spectrum disorders were identified in 12(63.1%) cases. The immune expression of cytokeratin was significantly correlated with placental invasion, (p=0.001). The present study reveals an increase in the frequency of abnormal placentation in Nineveh Province. These disorders have well-known predisposing factors. The histo-pathological findings, other than interface decidual loss, may explain the abnormality in placental tissue implantation.

Evaluation of the persistent organic pollutants association with type 2 diabetes: A prospective study from Karachi, Pakistan

The aim of this study is to determine the association between environmental organic pollutants with type 2 diabetes. This prospective study was conducted in Federal Urdu University of Arts, Science and Technology (FUUAST) Gulshan-e-Iqbal Campus Karachi in duration from January 2016 to June 2017. This study was ethically approved from the Institutional Review Board of FUUAST. The study included 50 male and female convenient subjects with type 2 diabetes. Subject with other type of diabetes was excluded. Consent was obtained by each individual. Self-structured questionnaire was used for data collection. The comparative results suggest that the maximum level of summation polychlorinated biphenyls (PCBs) mean value was found in age group 27-33 as 0.695 mg/kg in 73% having total individual eleven. Median (interquartile range) of pesticides levels among subjects with normal weight, over weight and obesity were 0.49 (0.26-2.13), 1.53 (0.60-2.65), and 1.60 (1.23-2.05) respectively. It was observed that Organochlorine pesticides (OCS) levels of subjects with overweight and obesity were almost similar (P-value > 0.05) but significantly higher as compared to subjects with normal weight (P-value < 0.05). No significant differences were observed between PCB levels of subjects in terms of body mass index (BMI). In present study we trace the important elements involve in the deposition of persistent organic pollutants and established an association between pollutants with etiology of diabetes and associated disorders such as obesity.

Effect of biosal®, deltamethrin and lambda-cyhalothrin on the activity of GOT, GPT and total protein contents in two fodder pests Hermolaus modestus and Hermolaus ocimumi

The assessment of the comparative effect of biosal (phytopesticide), deltamethrin, and lambda-cyhalothrin (pyrethroids) were made against two fodder pests, Hermolaus modestus and Hermolaus ocimumi by filter paper impregnation method. The activity of total protein contents, GPT (glutamic-pyruvic transaminase) and GOT (glutamic oxaloacetate transaminase) were affected in Hermolaus modestus and Hermolaus ocimumi against biosal, deltamethrin, and lambda cyhalothrin. The activity of total protein contents in H. modestus was 31.053%, 4.607%, and 24.575%, against biosal, deltamethrin, and lambda-cyhalothrin, respectively. The activity of total protein contents was observed as 24.202%, 15.25%, and 56.036% against deltamethrin, lambda-cyhalothrin, and biosal, respectively in H. ocimumi. The activity of GOT was observed as 98.675% for biosal 33.95% for deltamethrin and 83.619% for lambda-cyhalothrin in H. modestus. The GOT activity was estimated in H. ocimumi as 78.831%, 47.645%, and 71.287% against biosal, deltamethrin, and lambda-cyhalothrin, respectively. The efficacy of GPT enzyme against biosal, deltamethrin, and lambda-cyhalothrin was calculated as 89.26%, 73.07%, and 47.58%, respectively in H. modestus. The H. ocimumi showed GPT activity as 77.58% for biosal, 68.84% for deltamethrin, and 52.67% for lambda-cyhalothrin, respectively.

Persistent organic pollutants distribution in plasma lipoprotein fractions

This study determines the associations among serum lipid profiles, risk of cardiovascular disease, and persistent organic pollutants. Using Gas chromatography technique, the intensity of toxic pollutant residues in serum samples of Hypertensive patients were measured. Based on statistical analysis, the effects of different covariates namely pesticides, age, systolic blood pressure, diastolic blood pressure, and lipid profile duration was checked using the logistic regression model. Statistical computation was performed on SPSS 22.0. The P-values of F-Statistic for each lipid profile class are greater than 0.01 (1%), therefore we cannot reject the null hypothesis for all cases. The estimated coefficients, their standard errors, Wald Statistic, and odds ratio of the binary logistic regression model for different lipid profile parameters indicate if pesticides increase then the logit value of different lipid profile parameters changes from -0.46 to -0.246 except LDL which increases by 0.135. The study reports a significantly increased threat of cardiovascular disease with increased concentrations of toxic pollutants.

Corrigendum: Human West Nile Virus Disease Outbreak in Pakistan, 2015-2016

[This corrects the article DOI: 10.3389/fpubh.2018.00020.].

The methodological quality of guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia: A systematic review

WHAT IS KNOWN AND OBJECTIVES

Clinical practice guidelines serve as a framework for physicians to make decisions and to support best practice for optimizing patient care. However, if the guidelines do not address all the important components of optimal care sufficiently, the quality and validity of the guidelines can be reduced. The objectives of this study were to systematically review current guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), evaluate their methodological quality and highlight the similarities and differences in their recommendations for empirical antibiotic and antibiotic de-escalation strategies.

METHODS

This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Electronic databases including MEDLINE, CINAHL, PubMed and EMBASE were searched up to September 2017 for relevant guidelines. Other databases such as NICE, Scottish Intercollegiate Guidelines Network (SIGN) and the websites of professional societies were also searched for relevant guidelines. The quality and reporting of included guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument.

RESULTS AND DISCUSSION

Six guidelines were eligible for inclusion in our review. Among 6 domains of AGREE-II, "clarity of presentation" scored the highest (80.6%), whereas "applicability" scored the lowest (11.8%). All the guidelines supported the antibiotic de-escalation strategy, whereas the majority of the guidelines (5 of 6) recommended that empirical antibiotic therapy should be implemented in accordance with local microbiological data. All the guidelines suggested that for early-onset HAP/VAP, therapy should start with a narrow spectrum empirical antibiotic such as penicillin or cephalosporins, whereas for late-onset HAP/VAP, the guidelines recommended the use of a broader spectrum empirical antibiotic such as the penicillin extended spectrum carbapenems and glycopeptides.

WHAT IS NEW AND CONCLUSIONS

Expert guidelines promote the judicious use of antibiotics and prevent antibiotic overuse. The quality and validity of available HAP/VAP guidelines would be enhanced by improving their adherence to accepted best practice for the management of HAP and VAP.

Human West Nile Virus Disease Outbreak in Pakistan, 2015-2016

Like most of the world, Pakistan has seen an increase in mosquito-transmitted diseases in recent years. The magnitude and distribution of these diseases are poorly understood as Pakistan does not have a nation-wide system for reporting disease. A cross-sectional study to determine which flaviviruses were causing of arboviral disease in Pakistan was instituted. West Nile virus (WNV) is a cause of seasonal fever with neurotropic findings in countries that share borders with Pakistan. Here, we describe the active and persistent circulation of WNV in humans in the southern region of Pakistan. This is the first report of WNV causing neurological disease in human patients in this country. Of 997 enrolled patients presenting with clinical features suggestive of arboviral disease, 105 were positive for WNV IgM antibodies, and 71 of these patients possessed WNV-specific neutralizing antibodies. Cross-reactivity of WNV IgM antibodies with Japanese encephalitis virus (JEV) occurred in 75 of these 105 patients. WNV co-infections with Dengue viruses were not a contributing factor for the severity of disease. Nor did prior exposure to dengue virus contribute to incidence of neurological involvement in WNV-infected patients. Patients with WNV infections were more likely to present with altered mental status, seizures, and reduced Glasgow Coma scores when compared with JEV-infected patients. Human WNV cases and vector numbers exhibited a temporal correlation with climate.

Evaluation of the predictive performance of bleeding risk scores in patients with non-valvular atrial fibrillation on oral anticoagulants

WHAT IS KNOWN AND OBJECTIVE

Bleeding risk scores (BRSs) aid in the assessment of oral anticoagulant-related bleeding risk in patients with atrial fibrillation. Ideally, the applicability of a BRS needs to be assessed, prior to its routine use in a population other than the original derivation cohort. Therefore, we evaluated the performance of 6 established BRSs to predict major or clinically relevant bleeding (CRB) events associated with the use of oral anticoagulant (OAC) among Malaysian patients.

METHODS

The pharmacy supply database and the medical records of patients with non-valvular atrial fibrillation (NVAF) receiving warfarin, dabigatran or rivaroxaban at two tertiary hospitals were reviewed. Patients who experienced an OAC-associated major or CRB event within 12 months of follow-up, or who have received OAC therapy for at least 1 year, were identified. The BRSs were fitted separately into patient data. The discrimination and the calibration of these BRSs as well as the factors associated with bleeding events were then assessed.

RESULTS

A total of 1017 patients with at least 1-year follow-up period, or those who developed a bleeding event within 1 year of OAC use, were recruited. Of which, 23 patients experienced a first major bleeding event, whereas 76 patients, a first CRB event. Multivariate logistic regression results show that age of 75 or older, prior bleeding and male gender are associated with major bleeding events. On the other hand, prior gastrointestinal bleeding, a haematocrit value of less than 30% and renal impairment are independent predictors of CRB events. All the BRSs show a satisfactory calibration for major and CRB events. Among these BRSs, only HEMORR₂ HAGES (C-statistic = 0.71, 95% CI 0.60-0.82, P < .001) and ATRIA score (C-statistic = 0.70, 95% CI 0.58-0.82, P < .001) show acceptable discrimination performance for major bleeding events. All the 6 BRSs, however, lack acceptable predictive performance for CRB events.

WHAT IS NEW AND CONCLUSION

To the best of our knowledge, this is the first evaluation study of the predictive performance of these 6 BRSs on clinically relevant bleeding events applied to the same cohort consisting of mainly Asian novel oral anticoagulant users. These BRSs show poor to acceptable predictive performance on OAC-induced major or CRB events. An improvement in the existing BRSs for OAC users is warranted.

Evidence of Decoupling between Arsenic and Phosphate in Shallow Groundwater of Bangladesh and Potential Implications

Reductive dissolution of iron oxyhydroxides and reduction of arsenic are often invoked as leading causes of high dissolved As levels in shallow groundwater of Bangladesh. The second of these assumptions is questioned here by comparing the behavior As and phosphate (P), a structural analogue for As (V) which also adsorbs strongly to Fe oxyhydroxides but is not subject to reduction. The first line of evidence is provided by a detailed groundwater time-series spanning two years for three wells in the 6-9 m depth range showing removal of As(III) from shallow groundwater during the monsoon without of loss of P. The data indicate a loss of ~90% of the dissolved As from groundwater in the intermediate well relative to a level of 3 μmol/L As predicted by conservative mixing between groundwater sampled from the shallower and the deeper well. In contrast, P concentrations of ~30 μmol/L in the intermediate well closely match the prediction from conservative mixing. Reduction therefore appears to inhibit the release of As to groundwater at this site relative to P instead of enhancing it. A re-analysis of existing groundwater As and P data from across the country provides a broader context for this finding and confirms that, without reduction, elevated concentrations of As would probably be even more widespread in shallow aquifers of Bangladesh. Without providing definite proof, X-ray absorption spectroscopy of sediment from the time-series site and elsewhere suggests that the loss of As from groundwater may be coupled to precipitation of As sulfide. Further study is needed to assess the implications of these observations for shallow aquifers that have been subjected to increased withdrawals for irrigation in recent decades.

Effectiveness of hyaluronic acid and its derivatives on chronic wounds: a systematic review

OBJECTIVE

Hyaluronic acid (HA) and its derivatives are used for chronic wounds, but evidence of their effectiveness remains unclear. The aim of this study was to provide more updated evidence for the effectiveness of HA (or its derivatives) compared with placebo or other agents for promoting healing in chronic wounds.

METHOD

The Cochrane Central Register of Controlled Trials, MEDLINE via Ovid Online, CINAHL and the EMBASE via EBSCO host databases were searched. Drug companies and experts in wounds were also contacted. Randomised controlled trials of HA (or its derivatives) compared with control were eligible for inclusion.

RESULTS

We identified nine randomised controlled trials involving 865 participants with chronic wounds were included in the review. The reporting for mixed arterial and venous ulcers seems to be better quality than that for venous leg ulcers (VLUs) and diabetic foot ulcers (DFUs). Studies provided little evidence regarding the claimed effects of HA or its derivaties on healing of chronic wounds. However, there is some evidence on their effectiveness for reducing pain intensity for mixed arterial and venous ulcers, which involved 255 patients (MD=-6.78 [95% CI: -11.10 to -2.46]).

CONCLUSION

Evidence to guide decisions regarding the use of HA or its derivatives to promote wound healing is still limited. More good-quality randomised controlled trials are warranted.

Cardiovascular risk outcome and program evaluation of a cluster randomised controlled trial of a community-based, lay peer led program for people with diabetes

Background

The 2013 Global Burden of Disease Study demonstrated the increasing burden of diabetes and the challenge it poses to the health systems of all countries. The chronic and complex nature of diabetes requires active self-management by patients in addition to clinical management in order to achieve optimal glycaemic control and appropriate use of available clinical services. This study is an evaluation of a “real world” peer support program aimed at improving the control and management of type 2 diabetes (T2DM) in Australia.

Methods

The trial used a randomised cluster design with a peer support intervention and routine care control arms and 12-month follow up. Participants in both arms received a standardised session of self-management education at baseline. The intervention program comprised monthly community-based group meetings over 12 months led by trained peer supporters and active encouragement to use primary health care and other community resources and supports related to diabetes. Clinical, behavioural and other measures were collected at baseline, 6 and 12 months. The primary outcome was the predicted 5 year cardiovascular disease risk using the United Kingdom Prospective Diabetes Study (UKPDS) Risk Equation at 12 months. Secondary outcomes included clinical measures, quality of life, measures of support, psychosocial functioning and lifestyle measures.

Results

Eleven of 12 planned groups were successfully implemented in the intervention arm. Both the usual care and the intervention arms demonstrated a small reduction in 5 year UKPDS risk and the mean values for biochemical and anthropometric outcomes were close to target at 12 months. There were some small positive changes in self-management behaviours.

Conclusions

The positive changes in self-management behaviours among intervention participants were not sufficient to reduce cardiovascular risk, possibly because approximately half of the study participants already had quite well controlled T2DM at baseline. Future research needs to address how to enhance community based programs so that they reach and benefit those most in need of resources and supports to improve metabolic control and associated clinical outcomes.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12609000469213. Registered 16 June 2009.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3538-3) contains supplementary material, which is available to authorized users.

[Towel clip reduction of zygomatic arch fracture]

INTRODUCTION

Isolated fractures of the zygomatic arch (IFZA) are common in maxillofacial emergencies. They usually require a closed reduction. Several reduction techniques have been proposed. The reduction using a Ginestet-type hook is the gold standard technique.

DISCUSSION

The reduction using a towel clip under local anesthesia is an economical, simple, reliable and safe alternative technique for the reduction of IFZA. We describe this procedure.

A systematic review of the efficacy and tolerability of hydroxyethylrutosides for improvement of the signs and symptoms of chronic venous insufficiency

WHAT IS KNOWN AND OBJECTIVE

Rutoside (rutin; quercetin rutinoside) is a glycoside found in various plant products, including apples, citrus fruits and cranberries. Hydroxyethylrutosides (HR) are semisynthetic derivatives sold as standardized products for the treatment of chronic venous insufficiency (CVI). Commercially available products include Relvène(®) (France), Venoruton(®) (Switzerland) and Paroven(®) (United Kingdom). However, the evidence for their efficacy is inconclusive. The aim of this systematic review was to evaluate the evidence of efficacy and tolerability of hydroxyethylrutosides for CVI.

METHODS

We searched electronic databases such as the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and CINAHL, and publisher databases, conference proceedings and references lists for randomized controlled trials published in English and non-English languages. We also performed hand searches for additional trials. We included all trials that assessed the effectiveness of HR for CVI. Comparisons include HR (with or without compression bandaging) vs. placebo (with or without compression bandaging) or HR vs. compression bandaging alone. Two review authors independently selected studies, extracted data and assessed risks of bias in the included trials.

RESULTS AND DISCUSSION

The search identified 1474 records. Only 15 trials involving 1643 participants met our inclusion criteria. A meta-analysis based on similar studies that compared HR with placebo showed that HR significantly reduced symptoms of pain (SMD -1·07, 95% CI -1·44 to -0·70), symptoms of heavy legs (OR 0·50; 95% CI 0·28-0·91) and cramps (SMD -1·07, 95% CI -1·45 to -0·69). No serious adverse effect due to HR was reported.

WHAT IS NEW AND CONCLUSION

The findings showed that HR produced modest improvements in several symptoms of CVI. However, all the included trials were of limited quality, and therefore, better-quality trials are still required to draw firm conclusions on the usefulness of HR for CVI.

A case of isolated rectal recurrence of muscle invasive bladder cancer

We present the case of a 53-year-old man with a twenty-five pack year smoking history and a six month history of gross hematuria, who presented with a pT3a, N0, M0, muscle invasive bladder cancer (MIBC). He declined neoadjuvant chemotherapy but did receive post-cystectomy adjuvant chemotherapy. Six months post adjuvant chemotherapy he presented with abdominal pain and a large bowel obstruction, and was found to have an isolated rectal recurrence of MIBC. This case illustrates two important issues. The first being that patients with a smoking history and symptoms of hematuria need to be carefully evaluated to rule out urothelial cancer. And second, for patients with muscle invasive disease, local pelvic recurrence is common and close surveillance for recurrence needs to be implemented.

A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds

Silver preparations are commonly used for burns, but evidence of their effectiveness remains poorly defined. The aim of the study was to evaluate the effectiveness of silver-containing dressings and topical silver for preventing infection and promoting healing in burns wounds through a meta-analysis of the available evidence. The Cochrane Central Register of Controlled Trials and relevant databases were searched. Drug companies and experts in this field were also contacted. Randomised controlled trials (RCTs) of silver dressings or topical silver (used with dressings) compared with non-silver dressings were eligible for inclusion. We identified 14 RCTs involving 877 participants. One small trial of a silver-containing dressing showed significantly better healing time compared to the control [MD -3.6; 95% CI -4.94 to -2.26 for partial thickness burns and MD -3.9; 95% CI -4.54 to -3.26 for superficial burns]. Topical silver showed significantly worse healing time compared to the non-silver group [WMD 3.96; 95% CI 2.41-5.51] and showed no evidence of effectiveness in preventing wounds infection [WMD 2.48; 95% CI 0.39-15.73]. Our review suggests that silver-containing dressings and topical silver were either no better or worse than control dressings in preventing wound infection and promoting healing of burn wounds.

Comparison of arsenic concentrations in simultaneously-collected groundwater and aquifer particles from Bangladesh, India, Vietnam, and Nepal

One of the reasons the processes resulting in As release to groundwater in southern Asia remain poorly understood is the high degree of spatial variability of physical and chemical properties in shallow aquifers. In an attempt to overcome this difficulty, a simple device that collects groundwater and sediment as a slurry from precisely the same interval was developed in Bangladesh. Recently published results from Bangladesh and India relying on the needle-sampler are augmented here with new data from 37 intervals of grey aquifer material of likely Holocene age in Vietnam and Nepal. A total of 145 samples of filtered groundwater ranging in depth from 3 to 36 m that were analyzed for As (1-1000 mug/L), Fe (0.01-40 mg/L), Mn (0.2-4 mg/L) and S (0.04-14 mg/L) are compared. The P-extractable (0.01-36 mg/kg) and HCl-extractable As (0.04-36 mg/kg) content of the particulate phase was determined in the same suite of samples, in addition to Fe(II)/Fe ratios (0.2-1.0) in the acid-leachable fraction of the particulate phase. Needle-sampler data from Bangladesh indicated a relationship between dissolved As in groundwater and P-extractable As in the particulate phase that was interpreted as an indication of adsorptive equilibrium, under sufficiently reducing conditions, across 3 orders of magnitude in concentrations according to a distribution coefficient of 4 mL/g. The more recent observations from India, Vietnam and Nepal show groundwater As concentrations that are often an order of magnitude lower at a given level of P-extractable As compared to Bangladesh, even if only the subset of particularly reducing intervals characterized by leachable Fe(II)/Fe >0.5 and dissolved Fe >0.2 mg/L are considered. Without attempting to explain why As appears to be particularly mobile in reducing aquifers of Bangladesh compared to the other regions, the consequences of increasing the distribution coefficient for As between the particulate and dissolved phase to 40 mL/g for the flushing of shallow aquifers of their initial As content are explored.

Comparison of arsenic concentrations in simultaneously-collected groundwater and aquifer particles from Bangladesh, India, Vietnam, and Nepal

One of the reasons the processes resulting in As release to groundwater in southern Asia remain poorly understood is the high degree of spatial variability of physical and chemical properties in shallow aquifers. In an attempt to overcome this difficulty, a simple device that collects groundwater and sediment as a slurry from precisely the same interval was developed in Bangladesh. Recently published results from Bangladesh and India relying on the needle-sampler are augmented here with new data from 37 intervals of grey aquifer material of likely Holocene age in Vietnam and Nepal. A total of 145 samples of filtered groundwater ranging in depth from 3 to 36 m that were analyzed for As (1-1000 mug/L), Fe (0.01-40 mg/L), Mn (0.2-4 mg/L) and S (0.04-14 mg/L) are compared. The P-extractable (0.01-36 mg/kg) and HCl-extractable As (0.04-36 mg/kg) content of the particulate phase was determined in the same suite of samples, in addition to Fe(II)/Fe ratios (0.2-1.0) in the acid-leachable fraction of the particulate phase. Needle-sampler data from Bangladesh indicated a relationship between dissolved As in groundwater and P-extractable As in the particulate phase that was interpreted as an indication of adsorptive equilibrium, under sufficiently reducing conditions, across 3 orders of magnitude in concentrations according to a distribution coefficient of 4 mL/g. The more recent observations from India, Vietnam and Nepal show groundwater As concentrations that are often an order of magnitude lower at a given level of P-extractable As compared to Bangladesh, even if only the subset of particularly reducing intervals characterized by leachable Fe(II)/Fe >0.5 and dissolved Fe >0.2 mg/L are considered. Without attempting to explain why As appears to be particularly mobile in reducing aquifers of Bangladesh compared to the other regions, the consequences of increasing the distribution coefficient for As between the particulate and dissolved phase to 40 mL/g for the flushing of shallow aquifers of their initial As content are explored.

Herbal medicines: prevalence and predictors of use among Malaysian adults

OBJECTIVE

The aim of this study was to examine the prevalence and identify factors, which predict the use of herbal medicines among Malaysian adults.

METHODS

Using a cross-sectional design, data were collected via face-to-face interview using structured questionnaire from convenience sample of adults from four towns in Malaysia. Multivariate logistic regression analysis was used to identify the significant predictors of herbal medicines use.

RESULTS

From a total of 1601 respondents, 542 (33.9%) reported use of herbal medicines in the previous 12 months. Multivariate logistic regression analysis revealed the following variables to be predictive of herbal medicines use: female gender [odds ratio (OR) 1.80, confidence interval (CI) 1.40-2.31], being married [OR 1.97, CI 1.44-2.71], having health problems [OR 2.31, CI 1.74-3.07] and having high-income levels [OR 4.21, CI 1.72-10.30]. The odds of someone using herbal medicines also increases though slightly if someone has favorable opinions about herbal medicines on the aspects examined. On the other hand, being Chinese [OR 0.74, CI 0.57-0.96] and Indians [OR 0.17, CI 0.11-0.27] were associated with decreased odds of using herbal medicines compared to Malays.

CONCLUSION

The prevalence of herbal medicines use is high. Respondents' personal attributes and opinions influence their likelihood of using herbal medicines. These findings are important because knowledge of the predictors of herbal medicines use may help health care providers to identify patients at increased risk who would be candidates for receiving guidance on safe use of herbal medicines.

Flushing history as a hydrogeological control on the regional distribution of arsenic in shallow groundwater of the Bengal Basin

Whereas serious health consequences of widespread consumption of groundwater elevated in As have been documented in several South Asian countries, the mechanisms responsible for As mobilization in reducing aquifers remain poorly understood. We document here a previously unrecognized and consistent relationship between dissolved As concentrations in reducing groundwater and the phosphate-mobilizable As content of aquifer sediment for a set of precisely depth-matched samples from across Bangladesh. The relationship holds across nearly 3 orders of magnitude in As concentrations and suggests that regional as well as local patterns of dissolved As in shallow groundwater are set by the solid phase according to a remarkably constant ratio of approximately 250 microg/L dissolved As per 1 mg/kg P-mobilizable As. We use this relationship in a simple model of groundwater recharge to propose that the distribution of groundwater As in shallow aquifers of the Bengal Basin could primarily reflect the different flushing histories of sand formations deposited in the region over the past several thousand years.

Lapatinib (L) with paclitaxel compared to paclitaxel as first-line treatment for patients with metastatic breast cancer: A phase III randomized, double-blind study of 580 patients

1011

Background: L is an oral tyrosine kinase inhibitor of EGFR/HER2, active as monotherapy and in combination for HER2-overexpressing advanced/metastatic breast cancer (BC). A Phase I study of L with paclitaxel (P) indicated no unexpected adverse events (AEs). PK profile indicated no relationship between peak plasma concentration of P+L and neuropathy, neutropenia, diarrhea, rash or myalgia. We report here blinded efficacy and safety data for patients (pts) with incurable Stage IIIb/IIIc/IV BC at first diagnosis or relapse, untested or negative (0/1+ IHC or FISH neg) for HER2. Unblinded data will be presented at ASCO 2007. Methods: Between Jan 2004 and Jul 2005, 580 pts from 24 countries were stratified by metastatic site and randomized 1:1 to L 1500 mg QD + 175 mg/m2 P q3w or placebo QD + 175 mg/m2 P q3w. Primary endpoint was TTP; secondary endpoints were AEs, ORR, PFS, CBR, RFS, and OS. Tumor tissue was obtained from the most recent biopsy of 451 (78%) pts and was centrally analyzed in blinded fashion for biomarker patterns. Serum samples were collected for central EGFR and HER2 ECD analysis. Results and Conclusions: 579 pts were analyzed; 87% presented with Stage IV BC. 55% received prior adjuvant chemotherapy or anti-hormonal therapy. No pts received previous trastuzumab. At the time of analysis, 561 (97%) pts progressed or otherwise withdrew. Most common AEs were alopecia (58%), neurological (55%, gr=3:8%), diarrhea (42%, gr=3:9%), nausea (32%), and rash (32%, gr=3:2%). Neutropenia and thrombocytopenia AEs related to study treatment were 18% and <1%, respectively. LVEF decrease of 20% relative to baseline and below LLN was reported 15 times. 12% of AEs led to treatment withdrawal. Blinded data analysis revealed a median TTP of 25 wks and ORR of 30%. CNS relapse was reported in 11 pts (2%). Enrollment predominantly came from countries with limited HER2 testing capacity thus a subgroup of pts is expected to be HER2+ve. Blinded analyses of HER2, ER and PR are ongoing at this time and final biomarker evaluations will be presented with unblinded efficacy data.

[Table: see text]

Differential Regulation of CXCR4 and CCR5 Expression by Interleukin (IL)-4 and IL-13 Is Associated with Inhibition of Chemotaxis and Human Immunodeficiency Virus (HIV) Type 1 Replication But Not HIV Entry into Human Monocytes

Chemokine receptors CXCR4 and CCR5 play a key role in Human Immunodeficiency Virus (HIV) entry into CD4+ monocytic cells. Alteration in the expression levels of these receptors by immunoregulatory cytokines may influence viral entry and hence susceptibility to HIV infection, viral tropism, and disease progression. Helper T cell type 2 (Th2) cytokines interleukin (IL)-4 and IL-13, which share a subunit of their receptor components and exhibit similar biological effects, have been shown to play a key role in HIV infection and disease progression. In this study, we investigated the effects of IL-4 and IL-13 on the expression of CXCR4 and CCR5, and the biological implications of alteration of CXCR4 and CCR5 regulation on monocytic cells with respect to their migration in response to chemokines, HIV entry, and its replication. The results suggest that both IL-4 and IL-13 inhibited the expression of CXCR4, in contrast to CCR5, which was inhibited by IL-13 alone. The downregulation of CXCR4 and CCR5 was correspondingly associated with the inhibition of their respective ligand-induced chemotaxis. Although IL-13 inhibited the expression of both CXCR4 and CCR5, this downregulation of chemokine receptor expression was not sufficient to prevent virus entry. Furthermore, both IL-4 and IL-13 inhibited viral replication in monocytic cells, suggesting that inhibition of chemokine receptor expression per se by these cytokines may not be sufficient to prevent virus entry, and indicating these cytokines may be inhibiting viral replication by targeting pathways subsequent to virus entry.

Report of an International Network of Cancer Treatment and Research workshop on non-Hodgkin's lymphoma in developing countries

The International Network of Cancer Treatment and Research (INCTR) recently organized a workshop on non-Hodgkin lymphomas (NHLs) in selected developing countries with the purpose of examining existing information relating to the pathology and management of these neoplasms, and identifying potential areas for research. This report provides a summary of the information presented and is focused primarily on the pathology of NHLs in children and adults. In most countries, the WHO classification of lymphomas was used and most participating centers included immunohistochemistry using a wide array of lymphoid antibodies as part of routine diagnosis. Some of the series had been reviewed by an external panel of experts. B-cell lymphomas accounted for 82-88% of all NHLs. The proportions of chronic lymphatic leukemia (4-6%), mantle cell lymphoma (MCL, 3-5%), and plasmacytoma (2-4%) were similar in the series presented. However, there was a significant variation in the proportion of follicular lymphoma (FL), which accounted for 15% and 11% in India and Kuwait, but less than 5% in Pakistan and Egypt. All of these frequencies are significantly lower than those reported in Western series. Diffuse large B-cell lymphoma accounted for about 35% of cases in India but for more 50% in other countries, but this difference was not accounted for by an increased incidence in a single lymphoma subtype in India, but rather an apparent paucity of several subtypes (such as mantle cell and marginal zone lymphomas (MZL)) in other series. There were relatively high frequencies of Burkitt lymphoma in Egypt (7%) and precursor T-cell lymphoblastic lymphoma in India (6-7%). Peripheral T-cell lymphomas (PTCLs) (not otherwise specified and angioimmunoblastic subtypes) accounted for 3-5% of NHLs, and extranodal lymphoma of T/NK cell type was rare (<1%). These differences in the relative proportions of NHL subtypes among developing countries and between developing countries and the rest of the world presumably arise from differences in environmental and genetic factors that influence lymphomagenesis and strongly suggest that more research in developing countries would provide valuable insights into the pathogenesis of lymphoid neoplasms.

Socioeconomic status and breast cancer survival in Pakistani women

OBJECTIVES

No data is available from developing countries correlating socioeconomic status (SES) with survival in female breast cancer patients. We decided to test the hypotheses whether SES is an independent determinant for disease stage, access to minimal expected treatment (MET) and survival.

METHODS

Two hundred eighty six patients diagnosed with breast cancer were recruited between April 1996 to May 1998. Patients were divided into three groups according to their SES. Prognostic factors analyzed were age, tumor size, nodal status; stage at presentation, estrogen receptor status, time elapsed before diagnosis and access to MET. Disease free survival (DFS) and overall survival (OS) were determined according to the SES of the patients.

RESULTS

Patients were categorized into three socioeconomic groups, high (21%), middle (44%) and low (35%). Mean age of all patients was 46 years, in patients from lower SES mean age was 43 years compared to 50 years in high SES. Mean time elapsed before diagnosis for women from high-income group was 4.3 months versus 10.6 months in low-income group. Early breast cancer was more common in affluent strata, 70% versus 41% in the lower strata. Eighty-nine percent patients received MET from the affluent group compared to only 43% patients in the lower strata. Literacy rate of patients from high SES was 73.7% compared to 15% in the low SES. Five year DFS and OS are 79% and 86% for high income group, 48% and 68% for middle income group and 31%,49% for lower strata which were statistically significant (P=.0001 and P<.0001).

CONCLUSION

In our cohort of patients strong association was noted between low SES and advanced disease, delay in diagnosis, limited access to MET and inferior DFS and OS. The outcome of these patients may be improved by patient education and availability of better health care facilities.

Down-regulation of CXCR-4 and CCR-5 expression by interferon-gamma is associated with inhibition of chemotaxis and human immunodeficiency virus (HIV) replication but not HIV entry into human monocytes

Alterations in the expression of CXCR4 and CCR5, the co-receptors for HIV entry, may be associated with susceptibility of monocytic cells to HIV infection. Interferon (IFN)-gamma has been shown to inhibit HIV replication in monocytic cells, but the molecular mechanism involved is not well understood. To determine if IFN-gamma regulates HIV replication by altering CXCR-4/CCR-5 expression and hence virus entry into monocytic cells, we investigated the effects of IFN-gamma on CXCR-4 and CCR-5 expression and its biological implications with respect to HIV entry, replication and chemotaxis towards the CXCR-4 and CCR-5 ligands SDF-1 and MIP-1alpha, respectively. IFN-gamma decreased CXCR-4 and CCR-5 expression on monocytes derived from HIV-negative adults, HIV-positive adults and HIV-negative cord blood. This down-regulation of chemokine receptor expression did not result in a corresponding change in mRNA expression but was associated with elevated levels of the endogenously produced chemokines SDF-1 and RANTES. Furthermore, IFN-gamma inhibited chemotaxis in response to SDF-1 and MIP-1alpha, inhibited HIV replication, but failed to inhibit virus entry in monocytic cells. These results suggest that although IFN-gamma-induced down-regulation of CXCR-4 and CCR-5 expression is associated with an inhibition of SDF-1-/MIP-1alpha-mediated chemotaxis, IFN-gamma-induced inhibition of HIV replication may be mediated at levels subsequent to the virus entry.

Herbal medicines: predictors of recommendation by physicians

BACKGROUND

We hypothesized that as the use of herbal medicines increases in the general population, so do patients' requests to physicians for recommendations. However, why some physicians recommend herbal medicines while others do not is not well understood.

OBJECTIVE

To identify factors, which predict recommendation of herbal medicines by physicians. DESIGN, LOCATION, SUBJECTS: Face-to-face interview using a structured questionnaire of 206 physicians working at the University of Malaya Medical Centre, Malaysia.

RESULTS

About a third (206 of 626) of the physicians in the Centre participated. Only nine of the 215 approached refused to participate. Forty physicians (19%) recommended herbal medicines to patients. Logistic regression modelling identified personal use, general interest, interest in receiving training, race and higher level of medical training as significant predictors of physicians recommending herbal medicines.

CONCLUSIONS

Physicians' personal attributes and training influence their likelihood of recommending herbal medicines.

Institution based tumor registry from Punjab: five year data based analysis

INTRODUCTION

There are no population based cancer registries in Pakistan except for Karachi Cancer Registry (KCR). No data from Punjab is available in the last decade. We decided to conduct a data base analysis to see the frequencies of different cancers in Punjab.

PATIENTS AND METHODS

A retrospective analysis of 5100 patients presenting to Jinnah Hospital between January 1997 to December 2001 with histological diagnosis of cancer was performed. A tumor registry performa on all patients was filled which included demographic data as age, sex, duration of symptoms and disease stage at presentation. All cancers were coded according to international classification of Disease-oncology (ICD-10) classification.

RESULTS

Male cancers accounted for 47.7% and female cancers 52.2% of the total cases. In males the three most frequent cancers were leukemias, non-Hodgkins lymphoma and lung cancer. In females breast cancer was the most common cancer accounting for 38.5% female followed by ovarian cancer 13.6%.

CONCLUSIONS

Our institution based cancer registry indicates hematological malignancies are the most common cancers in males in Punjab followed by lung and colorectal cancer. In females breast cancer is the commonest cancer followed by ovarian cancer. Gall bladder cancer is relatively more frequent in women while cervical cancer is less commonly observed in our patient population. Despite biases until population based incidences are available, studies like ours may prove beneficial for future health planning and research.

Phase 1 trial of ifosfamide and adriamycin in metastatic breast cancer

OBJECTIVE

A Phase 1 trial was conducted in patients with estrogen negative receptors (ER) or hormone refractory metastatic breast cancer to determine the maximum tolerated dose (MTD) of ifosfamide with a fixed dose of doxorubicin. A secondary objective was to determine the efficacy of the combination in metastatic breast cancer.

METHODS

Fifteen patients were entered in the study in cohorts of three patients at each dose level of ifosfamide. The dose of doxorubicin was fixed at 45 mg/m2. Five different dose levels of ifosfamide were tested ranging from dose level 1 of 1.5 gms/m2 day 1-3 to level V at 2.5 gms/m2 day 1-3.

RESULTS

Dose escalation of ifosfamide was stopped at 2.5 gms/m2. The MTD of ifosfamide was 2.25 gms/m2 day 1-3 in combination with doxorubicin. All patients in the study were assessable for toxicity. Neutropenia and thrombocytopenia were the major dose limiting toxicities. Other toxicities included anemia, confusion and hematuria. Objective responses were documented in 11 of 15 patients (73.3%). Median time to treatment failure (TTF) was 13 months. Median overall survival (OS) was 18 months.

CONCLUSION

The combination of ifosfamide and doxorubicin was a practical well tolerated regimen. There was substantial evidence of clinical activity in this phase I trial. This combination should be further evaluated, as an attractive alternative to taxanes for patients in developing countries where cost effectiveness is important.

A prospective randomized study of Chop versus Chop plus alpha-2B interferon in patients with intermediate and high grade non-Hodgkin's lymphoma: the International Oncology Study Group NHL1 Study

The addition of a brief alpha interferon regimen to each CHOP induction cycle, plus one year of alpha interferon thrice weekly maintenance therapy, has no early effect on response rates or survival in patients with Intermediate or High grade cell NHL.

BACKGROUND

The CHOP (Cyclophosphamide, Adriamycin. Vincristine, Prednisone) regimen is the most widely used first-line therapy for patients with Intermediate or High Grade (IG/HG) non-Hodgkin's lymphoma (NHL). Alpha 2b interferon (INF) enhances response rates and improves survival in low-grade NHL. The International Oncology Study Group (IOSG) conducted a prospective randomized study comparing CHOP alone or combined with INF in patients with IG/HG-NHL. The primary study aim was to compare the objective response rates in these patient cohorts.

PATIENTS AND METHODS

Patients with a confirmed diagnosis of measurable NHL of International Working Formulation (IWF) groups D to H histology were randomized to receive CHOP alone or CHOP with 5Mu INF s.c. for 5 days on days 22 to 26 of each 28 day cycle with INF 5 million units (Mu) given three times per week subcutaneously for 52 weeks in those patients who responded to CHOP plus INF.

RESULTS

The overall response rates were equivalent in both groups: CHOP alone (214 patients) 81% (complete 55%, partial 26%); CHOP plus INF (221 patients) 80% (complete 54%, partial 26%). At 36 months, the actuarial survival rate was equivalent in both groups.

CONCLUSIONS

There is no apparent early advantage in terms of response or survival conferred by adding the study INF regimen to CHOP therapy for patients with IG/HG-NHL.

A prospective randomized study of alpha-2b interferon plus hydroxyurea or cytarabine for patients with early chronic phase chronic myelogenous leukemia: the International Oncology Study Group CML1 study

A prospective randomized international study of 143 patients showed no apparent early survival advantage conferred by combining cytarabine, rather than hydroxyurea, with INF as first-line CML therapy. Combinations of alpha-interferon (INF) and chemotherapeutic agents are currently first-line therapy for the majority of patients with chronic myeloid leukemia (CML). The International Oncology Study Group conducted a prospective randomized study comparing INF combined with hydroxyurea or cytarabine. The primary study aim was to compare the survival durations in these patient cohorts. Patients with early chronic phase CML were randomized to receive INF 5 million units (Mu) given five times per week subcutaneously plus hydroxyurea or cytarabine as required to achieve a complete hematologic response and to maintain a WBC count between 2x10(9)/L and 10x10(9)/L and a platelet count between 75x10(9)/L and 100x10(9)/L. Therapy continued as tolerated unless progressive or blast phase disease occurred. At 36 months, the actuarial survival rate was equivalent in both groups: HI group (79 patients) survival was 85% (95% CI, 68-100%), as compared to 95% (95% CI, 79-100%) in the CI group (64 patients). In conclusion if seems that there is no apparent early survival advantage conferred by combining cytarabine, rather than hydroxyurea, with INF as first-line CML therapy.

Ifosfamide and vinorelbine in metastatic breast cancer in patients with prior anthracycline therapy

OBJECTIVE

A prospective trial to evaluate the efficacy and toxicity of ifosfamide (IFX) and vinorelbine (VNB) in patients with prior anthracycline therapy for metastatic breast cancer (MBC) was conducted. At the same time, the scheduling of VNB in order to minimize toxicity of the combination was also evaluated.

PATIENTS AND METHODS

Twenty-three patients with MBC who had already received initial chemotherapy with doxorubicin-containing regimens either as adjuvant or as first-line treatment in MBC were entered into the study. IFX 3 g/m(2) and mesna 3 g/m(2) were given in divided doses over 2 days. In 4 patients, VNB was given 25 g/m(2) on days 1 and 3 in 3-h infusion. In 8 patients, VNB was given on days 1 and 8 and in 5 patients VNB was given on days 1 and 15. Thirteen patients had received doxorubicin in adjuvant setting, while 10 patients received doxorubicin as first-line treatment in metastatic disease. Dominant disease sites were soft tissues in 7 patients, visceral in 12 patients, and bone in 4 patients. The median age was 47 years.

RESULTS

Overall objective response was seen in 12/23 patients (52.2%). Four patients achieved complete remission (CR), 8 patients achieved partial remission (PR). The median duration of response was 9 months in responding patients, and the median overall survival duration was 15 months. The major dose-limiting toxicities were neutropenia grade III and IV in 8/17 patients and asthenia grade III and IV in 4 patients.

CONCLUSION

IFX and VNB is an active combination. Neutropenia and asthenia were most significant when VNB was given on days 1 and 3. In the best-tolerated regimen, VNB was given on days 1 and 8.

Non-Hodgkin's lymphoma in Pakistan: a clinicopathological profile of 175 patients

OBJECTIVE

Non-Hodgkin's Lymphomas (NHL) are common in Southeast Asia, Middle East and Africa. The study was primarily undertaken to establish the demographic and clinicopathologic features of NHL in Pakistan. A secondary aim was to determine the applicability of the International Prognostic Index (IPI) developed by the international lymphoma task force in a developing country.

METHODS

A retrospective and prospective analysis was performed on 175 patients over 14 years age who presented to the Department of Oncology between August 1994 and December 1996. All patients underwent initial staging according to Ann Arbor Staging System. Histopathologic classification was done according to the International Working Formulation. The IPI was applied to patients with aggressive lymphomas and age adjusted index to patients < 60 years, complete remission (CR), disease free survival (DFS) and overall survival (OS) were calculated.

RESULTS

All 175 patients were evaluable. Median age of our patients was 45 years. Male to female ratio was 1.9:1. Seventeen (9.7%) patients were classified as low grade lymphomas while 158 (91.3%) had intermediate and high grade NHL. Large cell lymphoma was present in 30.9% patients. CHOP (cyclophosphamide 650 mg/m2 day 1, vincristine 1.4 mg/m2 day 1, doxorubicin--45 mg/m2 day 1 and prednisone 100 mg/m2 day 1-5) was the most common chemotherapy regimen used. Advanced stage (74.9%) > B symptoms (51%) and extranodal involvement (74.3%) were present. One hundred sixty-seven patients were evaluable for response of which 42.8% achieved CR. Median DFS was 19 months and median OS was 22 months. The IPI was applicable to 153 patients and age adjusted IPI to 124 of 153 patients.

CONCLUSION

Aggressive histology, extranodal diseases, B symptoms and advanced disease are common. International index and age adjusted international index predicted outcome accurately in various risk groups.

A randomized comparison of fluconazole with amphotericin B as empiric anti-fungal agents in cancer patients with prolonged fever and neutropenia

PURPOSE

Several studies have documented the efficacy of amphotericin B as empiric antifungal therapy in cancer patients with prolonged fever and neutropenia. Amphotericin, however, is a toxic drug. Fluconazole has broad-spectrum antifungal activity with an excellent safety profile. Although prophylactic use of fluconazole is widespread, its efficacy as an empiric antifungal agent has not been extensively investigated.

PATIENTS AND METHODS

We randomly assigned 106 patients with absolute neutropenia (< or = 500 cells microL) and persistent fever of undetermined origin (> 38 degrees C) despite 1 week of broad-spectrum antibiotic therapy to receive either fluconazole 400 mg orally daily or amphotericin B 0.5 mg/kg/day. Patients with obvious invasive fungal infections were excluded, as were those with abnormal renal or hepatic function. Success was defined as defervescence with the initially assigned antifungal regimen without development of clinically evident invasive fungal infection.

RESULTS

Six patients were excluded from the analysis, mostly because they did not have severe neutropenia. Forty-eight patients received amphotericin B, and 52 received fluconazole. Baseline clinical characteristics and laboratory parameters as well as duration of neutropenia (7.7 versus 6.9 days), duration of fever (7.8 versus 8.1 days), and duration of hospitalization (10.4 versus 8.3 days) were similar between those receiving amphotericin and fluconazole. Treatment success rates and mortality rates were similar in the two groups: 22 (46%) patients in the amphotericin group and 29 (56%) patients in the fluconazole group responded successfully to therapy (P = 0.3), whereas 16 (33%) patients in the amphotericin group and 14 (27%) patients in the fluconazole group died during hospitalization (P = 0.5). Adverse events such as chills and fever (4 versus 1), bronchospasm (2 versus none), severe hypokalemia (25 versus 12) and nephrotoxicity (9 versus 3) were more frequently observed in patients receiving amphotericin. Adverse prognostic factors included prolonged duration of neutropenia and pneumonia.

CONCLUSIONS

These results suggest that fluconazole is an equally effective but less toxic alternative to amphotericin B as empiric antifungal therapy in cancer patients with prolonged fever and neutropenia.

Phase II trial of ifosfamide and cisplatinum in advanced ovarian cancer

To evaluate the efficacy of systemic ifosfamide, cisplatin (CDDP) combination as first line treatment followed by intraperitoneal (IP) chemotherapy with carboplatin (CBCDA) and etoposide as consolidation in patients with stage III and IV epithelial ovarian cancer. A total of 40 patients with stage III and IV ovarian cancer were entered into the study. Ifosfamide 1 g/m2 plus mesna 1 g/m2 was given as six hour infusion daily for six days and CDDP 75 mg/m2 was given on day seven. Patients completing six cycles of systemic therapy underwent second look laparotomy followed by four cycles of IP chemotherapy with CBCDA 300 mg/m2 and etoposide 200 mg/m2. Of the 40 patients entering the protocol 27 patients completed six cycles with a complete remission (CR) of 65% and overall response of 67.5%. Twenty-two patients underwent second look laparotomy with pathological CR in ten patients, microscopic disease in seven and macroscopic disease in five. Eleven patients completed four cycles of IP chemotherapy. At 52 months was the overall survival (OS) was 36%. The disease free survival (DFS) at 45 months was 38%. Factors affecting OS were ascites (p < 0.011), stage (p < 0.04), weight change (p < 0.017), residual disease (p < 0.001), number of chemotherapy cycles (p < 0.0001) and IP chemotherapy (p < 0.006). Presently 35% patients are alive in CR, 15% are alive with disease, one patients has been lost to follow up while 47.5% have died. Of these four patients had progressive disease, seven relapsed, four died due to treatment related complications and two died in CR due to other causes. Subset analysis of 22 patients who had second look laparotomy and completed four cycles of IP chemotherapy revealed a distinct survival advantage. IFOS + CDDP is an effective combination as first time treatment in advanced ovarian cancer. IP chemotherapy is effective as consolidation and seems to provide a significant survival advantage. Further studies with larger number of patients need to be done to confirm these results.