Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Perinatal mental health in India: protocol for a validation and cohort study

BACKGROUND

Common mental disorders (CMD) are among the largest contributors to global maternal morbidity and mortality. Although research on perinatal mental health in India has grown in recent years, important evidence gaps remain, especially regarding CMD. Our study aims to improve understanding of CMD among perinatal and non-perinatal women of reproductive age across two settings in India: Bangalore (Karnataka) and Tanda (Himachal Pradesh).

METHODS

The study is embedded within the Maternal and Perinatal Health Research Collaboration India (MaatHRI). This mixed-methods observational study comprises three consecutive phases: (i) focus group discussions and individual interviews to explore women's knowledge and seek feedback on CMD screening tools; (ii) validation of CMD screening tools; and (iii) prospective cohort study to identify CMD incidence, prevalence and risk factors among perinatal and non-perinatal women. Results of the three phases will be analyzed using inductive thematic analysis, psychometric analysis and multivariable regression analysis, respectively.

CONCLUSION

Improving understanding, detection and management of CMD among women is key to improving women's health and promoting gender equality. This study will provide evidence of CMD screening tools for perinatal and non-perinatal women in two diverse Indian settings, produce data on CMD prevalence, incidence and risk factors and enhance understanding of the specific contribution of the perinatal state to CMD.

Association of Childhood Attention Deficit Hyperactivity Disorder Symptoms with Academic and Psychopathological Outcomes in Indian College Students: a Retrospective Survey

OBJECTIVE

To survey the prevalence of retrospectively recalled clinically significant symptoms of attention deficit hyperactivity disorder (ADHD) in childhood and determine the association of ADHD symptoms in childhood with current academic achievement and psychopathological outcomes among college students in the state of Kerala, India.

METHODS

A self-administered questionnaire was distributed to 5784 students from 58 colleges selected by cluster random sampling. The Barkley Adult ADHD Rating Scale-IV was used for recollection of childhood ADHD symptoms; a total score of ≥60 (indicating the 99 percentile) was taken as the cut-off for clinically significant ADHD symptoms in childhood. The Alcohol, Smoking and Substance Involvement Screening Test was used to assess lifetime use of alcohol and tobacco. The Kessler Psychological Distress Scale was used to assess non-specific psychological distress. Lifetime suicidality and exposure to sexual abuse were assessed by asking relevant questions. Students who recalled having clinically significant ADHD symptoms in childhood were compared with those who did not.

RESULTS

Of 5784 students, 639 (11.5%) did not complete the questionnaire. Of the remaining 5145 students, 1750 (34.8%) were men and 3395 (65.2%) were women, with a mean age of 19.4 years. 143 (2.8%) students reported clinically significant ADHD symptoms in childhood. Childhood ADHD symptoms were significantly more common in men and in those living in urban areas. In the bivariate analysis, those with clinically significant ADHD symptoms in childhood had significantly higher odds of poorer academic performance, alcohol use, tobacco use, psychological distress, suicidal thoughts, suicidal attempts, and contact and non-contact sexual abuse, after adjusting for sex and residence.

CONCLUSIONS

Clinical evaluation and appropriate management may be warranted for adults who retrospectively recall clinically significant ADHD symptoms in childhood.

Systematic risk assessment in a mother-baby unit (MBU)–Importance for maternal and infant safety

Introduction

Systematic assessment of risks is an essential component of care in psychiatric mother baby units. Self-harm, infant neglect and harm or the vulnerable physical health of both mother and infant may all pose risks.

Aim

Development of a risk assessment tool and risk assessment among mother-infant dyads at a MBU in Bangalore, India.

Methods

Based on data from 200 admissions, doctors and nurses of the unit developed a 15-item tool for risk assessment. Risk was assessed by both nurses and doctors among 58 consecutive mothers admitted to the unit. Risk domains included risks to self, to infant, related to infant health and feeding and violence faced by mother. Frequencies of various risks were calculated. Nurses’ risk assessments were compared to the residents’ risk assessments.

Results

The mean age of the mothers was 25 (±4) years, age of infant 4 (±4) months and duration of episode was 4 (±14) months. Diagnoses included acute polymorphic psychosis (30%), BPAD (27%) and depression (21%). 47% had high suicidal risk and 28% had made an attempt in the current episode. 22% had expressed ideas of infant harm and 24% had physically harmed the infant. 48% of mothers had been physically violent. Multiple risks were seen in 47%. Doctors were able to identify risks more often than nurses.

Conclusion

Risks for self-harm, infant harm and related to infant health were high. Systematic risk assessment by both nurses and doctors is important in an MBU to ensure adequate care for the mother infant dyad.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Spirituality, distress, depression, anxiety, and quality of life in patients with advanced cancer

OBJECTIVE

To study the influence of spiritual well being (Sp WB) on symptoms of distress, depression, and other dimensions of quality of life in advanced cancer patients receiving palliative care.

MATERIALS AND METHODS

The study was cross-sectional in nature. Fifty patients with advanced cancer from a hospice were assessed with the following instruments: the visual analog scale for pain (VAP), M.D. Anderson symptom inventory (MDASI), Hospital Anxiety Depression Scale (HADS), Functional assessment of cancer therapy-Palliative Care (FACT-pal), and Functional assessment of chronic illness therapy-spiritual well-being (FACIT-sp). We studied the correlations between spirituality and other variables on these scales.

RESULTS

Depression and anxiety were negatively correlated with spiritual well-being (Sp WB). Sp WB was significantly correlated with fatigue (r = -0.423, P = 0.002), symptom distress (r = -0.717, P < 0.001), memory disturbance (r = -0.520, P < 0.001), loss of appetite (r = -0.399, P = 0.004), drowsiness (r = -0.400, P = 0.004), dry mouth (r = -0.381, P = 0.006), and sadness (r = -0.720, P < 0.001). Sp WB was positively correlated with all the other aspects of QOL measures. Predictors such as palliative care well-being (t = 2.840, P = 0.008), distress (t = -2.582, P = 0.015), sadness (t = -2.765, P = 0.010), mood (t = 2.440, P = 0.021), and enjoyment in life (t = -3.586, P = 0.001) were significantly correlated with Sp WB, after regression analysis.

CONCLUSIONS

This study suggests that spiritual well being is an important component of the quality of life of advanced cancer patients, and is closely related to the physical and psychological symptoms of distress. It should be addressed appropriately and adequately in palliative care settings.

Development and in vitro characterization of a bivalent DNA containing HN and F genes of velogenic Newcastle disease virus

Newcastle disease (ND) is highly contagious, economically important viral disease affecting most of avian species worldwide. Newcastle disease virus (NDV) has single stranded negative sense RNA genome which encodes for six structural and two non-structural proteins. Envelope glycoproteins i.e. hemagglutinin-neuraminidase (HN) and the fusion (F), elicit protective immune response. In this study, HN and F genes of velogenic (virulent) strain were amplified and cloned at multiple cloning sites A and B, respectively into pIRES bicistronic vector for use as bivalent DNA vaccine against ND. The recombinant plasmid was characterized for its orientation by restriction enzyme digestion and PCR. Expression of HN and F genes was assessed in transfected Vero cells at RNA level using RT-PCR in total RNA as well as protein level using IFAT, IPT and western blot using NDV specific antiserum. All these experiments confirmed that HN and F genes cloned in recombinant pIRES.nd.hn.f are functionally active. The recombinant construct is being evaluated as DNA vaccine against ND.

Differential detection of Newcastle disease virus strains by degenerate primers based RT-PCR

Degenerate primers based RT-PCR (previously described by [Avian Dis 26 (1997) 837]) has been used for the detection and differentiation of Newcastle disease (ND) viruses. Two sets of primers (A+B and A+C), with common forward primer and distinct reverse degenerate primers, designed from fusion protein gene encoding for cleavage site, could differentiate virulent and avirulent Newcastle disease viruses (NDV). Both sets of primers amplified "F" gene sequence of virulent (velogenic and mesogenic) viruses, whereas in avirulent strains, amplification was only with primer set A+C. Total 10 NDV isolates and two clinical samples including both known and unknown pathotypes, were checked. Based on amplification results 5 viruses were found to be virulent type and 6 as avirulent with one of the two clinical samples, earlier positive by RT-PCR using non-degenerate "F" gene specific primers was found negative in this study. The technique has been found to be a simple and quick for the detection and differentiation of virulent and avirulent NDV, which is important for control of the disease in the events of the outbreaks.

Characterization of an Indian bluetongue virus isolate by RT-PCR and restriction enzyme analysis of the VP-7 gene sequence

The reverse transcription-polymerase chain reaction (RT-PCR) was standardized to amplify the VP-7 gene sequences of an Indian isolate of bluetongue virus serotype 23. Using two different sets of primers, a sequence of 1156 bp comprising the complete coding sequence of the VP-7 gene and its 770 bp internal sequence were amplified. The sensitivity of RT-PCR, using these two sets of primers individually was 40 pg and 4 pg, with the external and internal primers, respectively, whereas the nested PCR was 100-fold more sensitive than the single PCR with the external primers. Further, by restriction enzyme digestion of the 1156 bp amplicon, using CfoI, PstI and TaqI enzymes, the Indian isolate was found to be genetically different from isolates from the United States and Australia. RT-PCR and restriction enzyme digestion were applied to detect virus directly in blood samples taken from sheep suspected of bluetongue virus infection.

Application of obstetric ultrasound to determine the most suitable parameters for the aging of formalin-fixed human fetuses using manual measurements

The aim of this study was to find the most suitable manual measurements to estimate the age of preserved fetuses. A new technique was used to make successful ultrasonic measurements on 86 out of 100 preserved fetuses under conditions simulating the intrauterine environment. The ultrasonographic images of the preserved specimens were very similar to those of live fetuses. Ultrasonic measurements of standard parameters, and the ages derived from them, were computed directly by the ultrasound scanning machine. Manual measurements were made of the same parameters using established techniques and standard tables for estimating fetal age. The measurements and the ages obtained for each parameter by the two techniques were statistically compared using the limits of agreement (Bland and Altman, 1986). Of the manual measurements used in the estimation of fetal age, foot length was found to be the most suitable parameter for practical use. Biparietal diameter was equally good, but the head circumference was the most precise, especially when used in conjunction with the formulae developed for ultrasonic measurements. Crown-rump length was found to be unsuitable to age fetuses beyond the first trimester due to distortion of the spine caused by compression in storage.

Pressure-jump studies of the folding/unfolding of trp repressor

The dimeric protein, trp apo-repressor of Escherichia coli has been subjected to high hydrostatic pressure under a variety of conditions, and the effects have been monitored by fluorescence spectroscopic and infra-red absorption techniques. Under conditions of micromolar protein concentration and low, non-denaturing concentrations of guanidinium hydrochloride (GuHCl), tryptophan and 8-anilino-1-naphthalene sulfonate (ANS) fluorescence detected high pressure profiles demonstrate that pressures below 3 kbar result in dissociation of the dimer to a monomeric species that presents no hydrophobic binding sites for ANS. The FTIR-detected high pressure profile obtained under significantly different solution conditions (30 mM trp repressor in absence of denaturant) exhibits a much smaller pressure dependence than the fluorescence detected profiles. The pressure-denatured form obtained under the FTIR conditions retains about 50 % alpha-helical structure. From this we conclude that the secondary structure present in the high pressure state achieved under the conditions of the fluorescence experiments is at least as disrupted as that achieved under FTIR conditions. Fluorescence-detected pressure-jump relaxation studies in the presence of non-denaturing concentrations of GuHCl reveal a positive activation volume for the association/folding reaction and a negative activation volume for dissociation/unfolding reaction, implicating dehydration as the rate-limiting step for association/folding and hydration as the rate-limiting step for unfolding. The GuHCl concentration dependence of the kinetic parameters place the transition state at least half-way along the reaction coordinate between the unfolded and folded states. The temperature dependence of the pressure-jump fluorescence-detected dissociation/unfolding reaction in the presence of non-denaturing GuHCl suggests that the curvature in the temperature dependence of the stability arises from non-Arrhenius behavior of the folding rate constant, consistent with a large decrease in heat capacity upon formation of the transition state from the unfolded state. The decrease in the equilibrium volume change for folding with increasing temperature (due to differences in thermal expansivity of the folded and unfolded states) arises from a decrease in the absolute value for the activation volume for unfolding, thus indicating that the thermal expansivity of the transition state is similar to that of the unfolded state.

Altered growth and attachment of rabbit crypt colonocytes isolated from different developmental stages

The rabbit colon was used to establish an in vitro model for examining development-related cellular changes in colonocyte function. Colonic epithelia from newborn, weanling, and adult animals were separated from the muscle and subjected to enzymatic digestion. A mixture of 0.05% Pronase, 0.015% collagenase IV, and 0.023% DTT was determined to be optimal for the isolation of newborn and weanling colonocytes. This solution yielded significantly more cells and of greater viability than a 0.1% Pronase, 0.03% collagenase IV, 0.07% DTT mixture that is optimal for adult colonocytes. The epithelial origin of the colonocytes was confirmed by immunofluorescent staining of cytokeratins. The isolation procedure resulted in a crypt-enriched population and the cell yield/g of mucosa increased with age as did the crypt depth. Colonocyte viability of adults but not of newborns and weanlings, declined from 24 to 72 h. When grown on plastic, the newborn and weanling colonocytes show a approximately 2-fold increase in number, DNA and protein content over 48 h. In contrast, for all three parameters the adult colonocytes revealed only a approximately 10% increase. The colonocytes also showed an age-related decline in attachment to extracellular matrices. Colonocytes showed maximal attachment to Matrigel and collagen IV; newborn and weanling colonocytes show > 80% attachment, whereas adult colonocytes showed only a 45% attachment. The efficacy of attachment to Matrigel compared with that on plastic also differed with age, representing 9.3-, 5.5-, and 4.4-fold increase in adult, weanling, and newborn colonocytes, respectively. Newborn and weanling colonocytes grown on Matrigel for 48 h, showed a significant, 15% increase in cell number, DNA, and protein content compared with those grown on plastic. There was no difference in these parameters when adult colonocytes grown on Matrigel were compared with those grown on plastic. In summary, we have established an in vitro model for studying colonic epithelial cells at different stages of development.

Killing of Histoplasma capsulatum by macrophage colony stimulating factor-treated human monocyte-derived macrophages: role for reactive oxygen intermediates

The interaction of human macrophages with the yeast-form of Histoplasma capsulatum was studied. The use of culture and a short-term assay period instead of microscopy gave direct evidence of the fungicidal activity of human macrophages. The present study reports the novel finding of fungicidal activity of macrophages derived from monocytes in the presence of macrophage colony-stimulating-factor (MCSF). The induction of fungicidal activity by this cytokine was dose dependent. MCSF at 10,000 U/ml was optimal with 73(SD3)% killing. Inhibition of macrophage killing by superoxide dismutase (SOD), but not catalase (CAT) or N-monomethyl-L-arginine (NMMA), established the role of the superoxide anion in the killing mechanism. The fungistatic activity of MCSF-derived human macrophages in a 24-h assay was also dose dependent and was not inhibited by SOD, CAT or NMMA. MCSF at 10,000 U/ml produced optimal macrophage fungistatic activity, 34.6(SD4)%.

Diagnosis of intestinal microsporidiosis by examination of stool and duodenal aspirate with Weber's modified trichrome and Uvitex 2B strains

Severe, chronic diarrhea is a frequent complication of human immunodeficiency virus disease, and intestinal microsporidiosis is being recognized with increasing frequency in patients with AIDS. Noninvasive, cost-effective techniques are needed to optimize its diagnosis. Weber's modified trichrome stain (MTS) and the fluorochrome Uvitex 2B stain were used to detect microsporidial spores in smears of stool and duodenal aspirate (DA) samples received from human immunodeficiency virus-infected patients for examination for ova and parasites. Of 305 samples (292 stool and 13 DA samples) from 140 patients examined by MTS, 83 samples from 26 (18.6%) of the patients were positive for microsporidia (23 patients diagnosed initially and 3 diagnosed upon review). A subset of the samples studied by MTS consisting of 108 smears of stool and DA specimens from 60 patients was examined by Uvitex 2B. All 44 samples positive by MTS were also positive by Uvitex 2B. In addition, seven specimens and three patients were initially detected as positive by Uvitex 2B only (all three patients were positive also by MTS upon review). Confirmation of the diagnosis was obtained for 24 of 26 smear-positive patients by duodenal biopsy and/or stool transmission electron microscopy. Of 114 patients with stained smears negative for microsporidia, 23 had duodenal biopsies which showed no microsporidia. For the 43 patients who underwent duodenal biopsy, the sensitivity of both the MTS and the Uvitex 2B methods compared with biopsy results was 100%. Of six patients with negative duodenal biopsies and positive stained smears, four had microsporidia demonstrated by stool transmission electron microscopy. The examination of stool and DA smears stained by Uvitex 2B and/or MTS is a sensitive, noninvasive test for diagnosis of intestinal microsporidiosis which can be successfully implemented in a clinical laboratory. Strict adherence to precise diagnostic criteria is necessary to avoid incorrect results. The simultaneous use of both staining methods enhances performance and may provide greater accuracy, especially for patients with light infections.

Clinical features of microsporidiosis in patients with AIDS

Microsporidia are protozoan parasites responsible for significant gastrointestinal disease in patients infected with human immunodeficiency virus. We report the clinical features of 20 patients with chronic diarrhea for whom microsporidian spores were identified by modified trichrome staining of stool smears and confirmed by biopsy and/or electron microscopy of stool. Of the 18 microsporidian protozoa identified to the species level, 14 (78%) were Enterocytozoon bieneusi and four (22%) were Septata intestinalis. The mean CD4 count in these patients was 35 +/- 29 cells/mm3. Parameters of absorption, specifically absorption of fat and D-xylose, and levels of zinc were strikingly abnormal in patients who were tested. Treatment with albendazole led to clinical responses in six of 10 patients, and dietary manipulation resulted in clinical improvement in eight of nine patients. We recommended that patients with chronic, intermittent diarrhea and CD4 counts of < 100 cells/mm3 be further evaluated for microsporidia by modified trichrome staining of stool and light and electron microscopy of small bowel biopsy specimens. Antiprotozoal therapies are currently experimental, but some patients who have been treated with these therapies have dramatic responses. We also recommend that special attention be paid to the measurement of parameters of absorption with appropriate modification of diet.

Residential radon exposure and lung cancer in Sweden

BACKGROUND

Residential radon is the principal source of exposure to ionizing radiation in most countries. To determine the implications for the risk of lung cancer, we performed a nationwide case-control study in Sweden.

METHODS

The study included 586 women and 774 men 35 to 74 years of age with lung cancer that was diagnosed between 1980 and 1984. For comparison, 1380 female and 1467 male controls were studied. Radon was measured in 8992 dwellings occupied by the study subjects at some time since 1947. Information on smoking habits and other risk factors for lung cancer was obtained from questionnaires.

RESULTS

Radon levels followed a log-normal distribution, with geometric and arithmetic means of 1.6 and 2.9 pCi per liter (60.5 and 106.5 Bq per cubic meter), respectively. The risk of lung cancer increased in relation to both estimated cumulative and time-weighted exposure to radon. In comparison with time-weighted average radon concentrations up to 1.4 pCi per liter (50 Bq per cubic meter), the relative risk was 1.3 (95 percent confidence interval, 1.1 to 1.6) for average radon concentrations of 3.8 to 10.8 pCi per liter (140 to 400 Bq per cubic meter), and it was 1.8 (95 percent confidence interval, 1.1 to 2.9) at concentrations exceeding 10.8 pCi per liter. The estimates of risk were in the same range as those projected from data in miners. The interaction between radon exposure and smoking with regard to lung cancer exceeded additivity and was closer to a multiplicative effect.

CONCLUSIONS

Residential exposure to radon is an important cause of lung cancer in the general population. The risks appear consistent with earlier estimates based on data in miners.

The changing pattern of surgical pathology of the thyroid gland in Zambia

Review of reports of thyroid tissue sent for histopathology to the Department of Pathology at the University Teaching Hospital, Lusaka (UTH) by one of the five general surgical units at the institution during the period January 1981-December 1990 shows a 20pc decrease in the incidence of colloid goitre and doubling of the incidence of the adenoma and carcinoma when compared to the study done at the Central Hospital, Kitwe in the late sixties. In our study for the general pathology of the thyroid gland female to male ratio is 7.4:1; 1.25:1 when only thyroid cancers are considered. The incidence of papillary carcinoma is substantially lower than in the west. Recently, there has been an increased incidence of thyroid abscesses associated with HIV infection. Knowledge of the local pattern of surgical pathology of an organ is important for planning the operative management more effectively but in many developing countries, such as ours, this information is not readily available. Goitre is common in Zambia and to our knowledge to date there is only one comprehensive report done during the period January 1966, to March 1971. This deals with the Northern and Western regions of the country. This study was undertaken to look into the surgical pathology of the thyroid gland seen at the University Teaching Hospital, Lusaka, which is in the central part of the country.

Indoor radon exposure and active and passive smoking in relation to the occurrence of lung cancer

Exposure to indoor radon and radon daughters is currently attracting great interest as a possible cause of lung cancer. This concern is supported by several studies, most of them relatively small in numbers or weak in the assessment of exposure. This study encompasses 177 persons with lung cancer and 677 noncancer referents, all deceased and with 30 years or more of residency in the same house in an area with radon-leaking alum shale deposits in the central part of southern Sweden. Exposure categories based on building material, type of house, and ground conditions were created, but measurements of the indoor radon daughter concentration were also made for 142 cases and 264 referents. Active and passive smoking was ascertained through questionnaires sent to the next-of-kin. Overall, the lung cancer risk was approximately twofold with regard to the categories of assumed radon daughter exposure for the rural sector of the population but not for the same categories of the urban sector, possibly because of less precise exposure assessment and influence from other factors. Occasional and passive smokers, as well as passive smokers alone, had a particularly increased risk of lung cancer in association with the increased exposure categories.

Criminal abortions as seen in the University Teaching Hospital, Lusaka

Every year a large number of patients who are spontaneously aborting are admitted to the Gynaecological ward of the University Teaching Hospital (Lusaka) at various clinical stages of septic, incomplete, inevitable or threatened abortion. An undetermined number of these patients are induced outside the hospital. Analysis of data revealed that 60% of admissions in the gynaecological admission ward are abortions and a number of them present with features of sepsis. In a 4 year study period there were 15 maternal deaths as a result of septic/criminal abortions. Various methods are used to procure criminal abortions; out of which a case of a patient who used a knitting needle to procure abortion is presented.