Breast-to-brain metastasis is exacerbated with chemotherapy through blood-cerebrospinal fluid barrier and induces Alzheimer's-like pathology

Control of breast-to-brain metastasis remains an urgent unmet clinical need. While chemotherapies are essential in reducing systemic tumor burden, they have been shown to promote non-brain metastatic invasiveness and drug-driven neurocognitive deficits through the formation of neurofibrillary tangles (NFT), independently. Now, in this study, we investigated the effect of chemotherapy on brain metastatic progression and promoting tumor-mediated NFT. Results show chemotherapies increase brain-barrier permeability and facilitate enhanced tumor infiltration, particularly through the blood-cerebrospinal fluid barrier (BCSFB). This is attributed to increased expression of matrix metalloproteinase 9 (MMP9) which, in turn, mediates loss of Claudin-6 within the choroid plexus cells of the BCSFB. Importantly, increased MMP9 activity in the choroid epithelium following chemotherapy results in cleavage and release of Tau from breast cancer cells. This cleaved Tau forms tumor-derived NFT that further destabilize the BCSFB. Our results underline for the first time the importance of the BCSFB as a vulnerable point of entry for brain-seeking tumor cells post-chemotherapy and indicate that tumor cells themselves contribute to Alzheimer's-like tauopathy.

What makes the pregnant women revisit public hospitals for research? Participant engagement and retention trial in a public hospital (PERTH): an RCT protocol

BACKGROUND

Cohort studies have public health importance as they effectively provide evidence on determinants of health from a life course perspective. Researchers often confront the poor follow-up rates as a major challenge in the successful conduct of cohort studies. We are currently recruiting in a birth cohort study, titled as "Maternal Antecedents of Adiposity and Studying the Transgenerational role of Hyperglycemia and Insulin" (MAASTHI) in a public hospital; with the aim of assessing maternal glycemic levels on the risk of adverse fetal outcomes. Nested within the ongoing cohort, the proposed trial aims to evaluate the effectiveness of two interventions in improving the follow-up in the cohort study in a public hospital.

METHODS

A randomized trial of 795 pregnant women, with 265 women each in three arms observed through pregnancy, until their baby is 14 weeks old. The comparator group receives a standard leaflet, with details on the importance of glucose testing and regular follow up in pregnancy. Intervention arm-1 will receive the standard leaflet plus individualized messages, through an Interactive Voice Response (IVR) system; a type of computer-linked telephone intervention system to remind the participants about the lab test and follow-up dates. Intervention arm- 2 will have the opportunity to attend Mother and Baby Affairs (MBA) workshops, which will provide information on Gestational Diabetes Mellitus (GDM) screening and management to pregnant women and personalized counselling services. The outcome of interest is the difference in the proportion of participants completing follow-up at different points in time, among three arms.

DISCUSSION

Between the two interventions (IVR and MBA), the study results would uncover the contextually specific, timely intervention, which can increase the proportion of pregnant women followed up in public hospitals. If effective, this study will provide information on an effective intervention, useful in ensuring the success of longitudinal follow-up in the public hospitals.

TRIAL REGISTRATION

NCT03088501 , Date Registered: 16/03/2017.

Maternal antecedents of adiposity and studying the transgenerational role of hyperglycemia and insulin (MAASTHI): a prospective cohort study : Protocol of birth cohort at Bangalore, India

BACKGROUND

India is experiencing an epidemic of obesity-hyperglycaemia, which coincides with child bearing age for women. The epidemic can be sustained and augmented through transgenerational transmission of adiposity and glucose intolerance in women. This presents an opportunity for exploring a clear strategy for the control of this epidemic in India. We conducted a study between November 2013 and May 2015 to inform the design of a large pregnancy cohort study. Based on the findings of this pilot, we developed the protocol for the proposed birth cohort of 5000 women, the recruitment for which will start in April 2016. The protocol of the study documents the processes which aim at advancing the available knowledge, linking several steps in the evolution of obesity led hyperglycemia.

METHODS

Maternal Antecedents of Adiposity and Studying the Transgenerational role of Hyperglycemia and Insulin (MAASTHI) is a cohort study in the public health facilities in Bangalore, India. The objective of MAASTHI is to prospectively assess the effects of glucose levels in pregnancy on the risk of adverse infant outcomes, especially in predicting the possible risk markers of later chronic diseases. The primary objective of the proposed study is to investigate the effect of glucose levels in pregnancy on skinfold thickness (adiposity) in infancy as a marker of future obesity and diabetes in offspring. The secondary objective is to assess the association between psychosocial environment of mothers and adverse neonatal outcomes including adiposity. The study aims to recruit 5000 pregnant women and follow them and their offspring for a period of 4 years. The institutional review board at The Indian Institute of Public Health (IIPH)-H, Bangalore, Public Health Foundation of India has approved the protocol. All participants are required to provide written informed consent.

DISCUSSION

The findings from this study may help to address important questions on screening and management of high blood sugar in pregnancy. It may provide critical information on the specific determinants driving the underweight-obesity-T2DM epidemic in India. The study can inform the policy regarding the potential impact of screening and management protocols in public healthcare facilities. The public health implications include prioritising issues of maternal glycemic control and weight management and better understanding of the lifecourse determinants in the development of T2DM.

First light from a kilometer-baseline Scintillation Auroral GPS Array

We introduce and analyze the first data from an array of closely spaced Global Positioning System (GPS) scintillation receivers established in the auroral zone in late 2013 to measure spatial and temporal variations in L band signals at 100-1000 m and subsecond scales. The seven receivers of the Scintillation Auroral GPS Array (SAGA) are sited at Poker Flat Research Range, Alaska. The receivers produce 100 s scintillation indices and 100 Hz carrier phase and raw in-phase and quadrature-phase samples. SAGA is the largest existing array with baseline lengths of the ionospheric diffractive Fresnel scale at L band. With an initial array of five receivers, we identify a period of simultaneous amplitude and phase scintillation. We compare SAGA power and phase data with collocated 630.0 nm all-sky images of an auroral arc and incoherent scatter radar electron precipitation measurements, to illustrate how SAGA can be used in multi-instrument observations for subkilometer-scale studies.

KEY POINTS

A seven-receiver Scintillation Auroral GPS Array (SAGA) is now at Poker Flat, Alaska SAGA is the largest subkilometer array to enable phase/irregularities studies Simultaneous scintillation, auroral arc, and electron precipitation are observed.

Working channel endoscope in lumbar spine surgery

Percutaneous endoscopic lumbar discectomy (PELD) is a well established modality in the treatment of patients with herniated lumbar discs. Since the time of its inception towards the end of 20th century, this technique has undergone significant modifications. With better understanding of the patho-anatomy and development of instrumentation the indications for PELD are on the rise. In the modern era of knowledge exchange there have been considerable variations among different endoscopic surgeons about classical indications and the implications of a particular technique pertaining to those indications. During last 15 years of experience in practicing endoscopic surgery, Choi has published many articles, regarding the techniques of PELD, across many scientific journals. In our practice there has been considerable shift from central debulking to discectomy to selective fragmentectomy. With further advancements the span of this technique is definitely on the rise. Here, we wish to share all the published data along with my current practice trends in more precise manner to help newer endoscopic spine surgeons understand the implications and limitations of a working channel endoscope in lumbar spine pathologies.

Health care seeking among individuals with cough and tuberculosis: a population-based study from rural India

SETTING

Ujjain district, Madhya Pradesh, India.

OBJECTIVE

To describe and compare health care seeking among men and women with cough of >3 weeks, with special focus on the utilisation of private and public health care.

DESIGN

A population-based cross-sectional survey including 45 719 individuals aged > or = 15 years.

RESULTS

The prevalence of cough was respectively 2.8% and 1.2% among men and women. The majority of men and women reported seeking health care for their symptoms (69% vs. 71%), but only 23% visited a public provider at some point during their illness. A similar health care seeking pattern was found for patients diagnosed with tuberculosis (TB) in our survey. No significant differences in health care seeking were found between men and women. Only 13% of those seeking care reported having had a sputum smear examination since the onset of cough. Factors associated with sputum examination were history of TB, haemoptysis and visiting a public provider.

CONCLUSION

The low utilisation of public health care services and the few sputum examinations reported in this rural Indian setting illustrate the need for improved diagnostic practices as well as involvement of private providers in TB control activities.

Diltiazem overdose haemodynamic response to hyperinsulinaemia-euglycaemia therapy: a case report

A 59-year-old woman was admitted to the intensive care unit after ingesting 5.76 g of an extended release preparation of diltiazem. The patient was hypotensive and bradycardic and was treated initially with intravenous fluids, adrenaline, noradrenaline, vasopressin and standard insulin doses to maintain the blood glucose levels between 6-10 mmol/L. As the patient remained inotrope dependent the insulin dose was increased to 25 U/hr with an infusion of 50% dextrose to maintain the blood glucose levels between 6-8 mmol/L. Within 30 minutes, the mean arterial pressure increased from 65 mmHg to 80 mmHg and within 60 minutes all vasoactive agents were discontinued. A right heart catheter inserted before the increased dose of insulin revealed that the predominant haemodynamic effect of the hyperinsulinaemia-euglycaemia therapy appeared to be an increase in the peripheral vascular resistance.

Candida parapsilosis fungaemia treated unsuccessfully with amphotericin B and fluconazole but eliminated with caspofungin: a case report

A case of Candida parapsilosis Hickman catheter infection with fungaemia presenting with severe hypoxia, lactic acidosis and renal failure is described. Four months previously, the Hickman catheter had become infected with Candida parapsilosis (sensitive to fluconazole and amphotericin B) with blood cultures remaining positive despite an intravenous course of fluconazole 200 mg 12-hourly increasing to 400 mg-12-hourly. Subsequently, treatment with an amphotericin B infusion (30 mg over 24 hours) for five days was associated with a progressive increase in serum creatinine from 0.042 mmol/L to 0.278 mmol/L with blood cultures remaining positive. While arrangements were being made to remove and replace the catheter via a thoracotomy, the patient developed severe hypoxia, lactic acidosis and renal failure and was admitted to the intensive care unit for further management. An intravenous course of caspofungin (70 mg over 1 hour followed by 50 mg over 1 hour, daily) was associated with negative blood cultures and a normal plasma C-reactive protein for the first time in four months. The hypoxia was managed with spontaneous ventilation and high inspired oxygen concentrations, and the anaemia was treated with red blood cell transfusions. A rapid reversal of the respiratory failure and lactic acidosis occurred and the patient was discharged home from the intensive care unit after 10 days to continue the caspofungin infusions for a total of 6 weeks. She has subsequently remained well with negative blood cultures two months later.

Isolated fluvoxamine poisoning presenting with hypertonia and seizures: a case report

Pharmacological management of depressed patients has often relied upon the use of agents that are toxic when taken in large quantities. The recent introduction of selective serotonin reuptake inhibitors (SSRIs) has represented a major advance in the management of depression. While a 'serotonin syndrome' may develop if these drugs are taken in association with other agents, these drugs are believed to have minimal toxicity when taken as an isolated overdose. A case of fluvoxamine poisoning presenting with hypertonicy and seizures is described, highlighting the fact that the SSRI's may not be harmless when taken in isolation, particularly when taken in large amounts.