Prospective Cohort Study to Evaluate Toxicity and Cosmesis between Interstitial APBI and Ultra-Hypo-Fractionated Whole Breast Irradiation in Patients with Early Breast Cancer

PURPOSE/OBJECTIVE(S)

Both interstitial multi-catheter brachytherapy based accelerated partial breast irradiation (APBI) and ultra-hypo-fractionated whole breast irradiation (WBI) with 5 fractions can complete treatment in a short time and result in lower treatment-related costs. Although data are available on their toxicity compared with conventional and hypo-fractionated regimens, there are few data directly comparing these two techniques.

MATERIALS/METHODS

This prospective cohort study enrolled early breast cancer patients with negative ink margin, T1 or T2 stage, and tumor size of 3 cm or less, with 0 to 3 positive lymph nodes after adequate axillary dissection or negative sentinel lymph node biopsy (N0-1), regardless of receptor status (ER, PR, HER2neu). Of the total 31 patients, 15 received APBI with multi-catheter interstitial brachytherapy (35 Gy in10 fractions over 5 days with a minimum interval of 6 hours between fractions) and 16 patients received WBI (27 Gy in 5 fractions over 5 days) with either 3DCRT or VMAT technique. Acute toxicity was assessed using the RTOG toxicity grading and breast cosmesis was assessed using the Harvard breast cosmesis score. Toxicity and cosmesis were assessed immediately after treatment, after one month, and after three months of treatment. Results were compared between groups using the Mann Whitney U test.

RESULTS

All patients completed a 3-month follow-up after completion of treatment. There was no statistically significant difference between the 2 groups in terms of highest grade toxicity (p = 0.97) and acute toxicity immediately after RT (p = 1.0) and after 1 month of RT (p = 0.91). However, at 3 months, more patients in the WBI group had a residual skin reaction than in the APBI group (p = 0.03). There was no statistically significant difference in breast cosmesis scores at any time point. 53.3%, 6.6% had grade 1 and 2 skin toxicities respectively immediately after RT in the APBI group and 62.5% of patients had grade 1 skin toxicity in WBI group. After 1 month 26.6%, 26.6% & 13.3% patients had grade 2, grade 1 and grade 3 toxicities respectively. In the WBI group, at 1 month, 50%, 18.7% and 12.5% patients had grade 1, 3 and 2 skin toxicities respectively. At 3 months, 42.8% and 7.1% of patients in the APBI group had grade 1 and grade 2 toxicities, respectively. In the WBI group, 78.5% and 7.1% of patients had grade 1 and 2 skin toxicities respectively.

CONCLUSION

In this study, no difference in acute toxicity or breast cosmesis was demonstrated between APBI-based interstitial brachytherapy and ultra-hypo-fractionated WBI. Since both regimens can be administered within 5 days, the decision between them is challenging for both physicians and patients. This study can be considered hypothesis-generating and used for further planning of equivalence or noninferiority studies.

Patient-Reported Outcomes Evaluating the Impact of Hypo-Fractionated Palliative Quadshot Radiotherapy and Concurrent CDDP Treatment on Health-Related Quality of Life in Patients with Locally Advanced Squamous Cell Carcinoma of the Head and Neck

PURPOSE/OBJECTIVE(S)

In locally advanced squamous cell carcinoma of the head and neck (LAHNSCC), the main goal of treatment remains survival while improving quality of life (QOL). In recent decades, there has been a paradigm shift in the measurement of clinical outcomes in patients diagnosed with cancer, focusing on the patient perspective by incorporating patient-reported outcomes (PROs). The primary objective of this study was to evaluate the improvement in quality of life with the use of cyclic hypo-fractionated palliative QUAD SHOT radiotherapy (RT) with concurrent cisplatin (CDDP) in previously untreated patients with incurable LAHNSCC.

MATERIALS/METHODS

In this prospective interventional phase- II study, 60 patients with locally advanced squamous cell carcinoma of the head and neck, majority stage IVB, ECOG PS ≤ 3, were treated with QUAD SHOT RT (14 Gy/4 fractions/2 days - BD with 6-hour interval and concurrent CDDP at 6 mg/m2. This treatment was repeated at 4-week intervals for 2 additional cycles if tumor progression did not occur. Serial changes in HR -QoL were assessed using EORTC QLQ C-30 and H&N-35) at 4 different time points. Statistical methods such as the Wilcoxon signed-rank test and Friedman test were used to compare QoL values at different time points with Bonferroni correction for multiple comparisons to control for type I errors.

RESULTS

The median global health score (GHS) at baseline was 41.667, with an initial increase in score at 4 weeks (50.00) and at 8 weeks (54.167) that did not continue at 12 weeks (41.667). Symptoms related to toxicities (speech, social contact, sticky saliva, dry mouth, senses in H&N 35) were lower after 4 weeks. Application of the Friedman test for four time points revealed significant improvement in role function at 4 weeks, which remained constant at 8 weeks but was not sustained at 12 weeks. Comparison of HN-35 symptom scores between the four time points showed improvement in symptoms such as pain, swallowing, and mouth opening at 4 and 8 weeks. The mean QLQ C30 summary score for these patients improved at four weeks but did not remain constant at 8 and 12 weeks.

CONCLUSION

Our study showed significant improvement in quality-of-life parameters and reduction in symptom burden at 4 and 8 weeks due to disease control and symptom palliation by QUADSHOT CTRT, while quality-of-life scores worsened and symptom scores were not maintained at 12 weeks due to disease progression and occurrence of acute toxicities. This phase II study may serve as the basis for designing a phase III randomized control trial to compare quality of life changes with QUADSHOT CTRT and other palliative CTRT regimens.

Role of Stereotactic Body Radiation Therapy in Portal Vein Tumor Thrombosis in Hepatocellular Carcinoma: A Prospective Single Institute Experience

PURPOSE/OBJECTIVE(S)

Patients diagnosed with Hepatocellular carcinoma (HCC) complicated with portal vein tumor thrombosis (PVTT) have a limited number of treatment options available and are associated with an overall poor prognosis. With the recent developments in the field of radiation therapy, the role of radiotherapy particularly Stereotactic Body radiotherapy (SBRT) has increased as a loco-regional therapy for HCC. This study was planned to evaluate the role of SBRT in Locally advanced HCC complicated with PVTT and its role as loco-regional therapy.

MATERIALS/METHODS

We conducted a prospective study that included patients diagnosed with HCC complicated with PVTT Child-Turcotte Pugh (CTP) Class A/B with a maximum score of 7, diagnosed on triple phase Contrast-Enhanced - MRI unsuitable for other ablative procedures. Patients with Bilirubin levels > 4 mg/dl, active Hepatitis, CTP score >7, normal liver volume <700cc or history of prior radiotherapy were excluded from the study. Patients underwent a contrast enhanced 4D-CT simulation with abdominal compression and were planned for SBRT using VMAT technique. Patients were followed-up as per Institute protocol. CECT or MRI for a radiological response was done for response assessment using mRECIST criteria version 1.1. A baseline MRI was done at one-month post-SBRT to understand any RT changes in the liver and to differentiate from tumor progression during the response assessment at three months.

RESULTS

A total of 22 patients with HCC were recruited and received SBRT to PVTT, with a dosage between 30-42 Gy over 6 fractions treated on alternate days. Patients were assessed post-treatment with triphasic CE-MRI every 3 months as per institute protocol. Five patients had achieved Complete response in form of Portal vein recanalization. Three patients had Partial response to the treatment. Seven patients maintained stable disease status whereas six patients had disease progression during the entire course of treatment. The response rate (CR+PR) to treatment was 36.3% at the time of analysis. The Overall Response rate (CR+PR+SD) was 69%. No grade 3 or 4 toxicities were observed and treatment was tolerated well by patients. Kaplan-Meier method was applied to calculate the survival probability at various follow-up intervals. The median time for overall survival was 25 months ((95% CI: 15-35). Out of the 22 subjects included in the study, 6 patients died. There was a 78% survival probability at 12 months and a 68% survival probability at 18 months of follow-up.

CONCLUSION

This prospective single-arm study demonstrated the vital role of SBRT in the treatment of Hepatocellular carcinoma with Portal vein tumor thrombosis and its efficacy in terms of achieving excellent local control with relatively lesser toxicities compared with existing treatment modalities. Patients have shown benefit post-treatment in terms of thrombus reduction and restoration of Portal vein flow making them suitable for further treatment like Resection or TACE.

Multiple Sessions vs. Single Session Image-Based Intracavitary Brachytherapy for Locally Advanced Cervical Cancer: A Randomized Control Trial

PURPOSE/OBJECTIVE(S)

The objectives of this study are: 1) To compare the acute toxicity caused in the treatment of locally advanced cervical cancer (LACC) treated with weekly multiple applications vs. a single application for image-guided intracavitary High Dose Rate (HDR) brachytherapy (BT) after External Beam Radiation Therapy (EBRT) 2) To compare the loco-regional control of cancer at six months in the two arms MATERIALS/METHODS: In a prospective study, 40 patients with biopsy-proven LACC with FIGO-2018 stage IIB-IIIC1 disease, underwent EBRT to the pelvis at a dose of 50.4 Gy/ 28 fractions over 5.5 weeks with weekly concurrent cisplatin. After completion of EBRT, they were randomized into two arms with 20 patients each. In the Control arm (Arm-A), BT sessions were given with weekly 3 applications whereas, in the experimental arm (Arm-B), all the sessions were given with a single application at 6-12 hours intervals with aim of the high-risk clinical target volume receiving >80 Gy EQD2 and 2 cm3 of the bladder and rectum/sigmoid receiving <85 Gy and <75 Gy, respectively. The OAR contouring was done on CT RESULTS: All 40 patients were treated as per protocol. The mean duration of treatment including EBRT and BT was 73.15 days [95% CI 68.63-77.66] in Arm A and 55.85 days [95% CI 52.11-59.58] in Arm B which was significant. After 6 months, 37 patients came for follow-up, all 19 patients in Arm A had Grade 1 or Grade 2 rectal toxicity. In Arm B as well all 18 patients had Grade 1 or Grade 2 rectal toxicity. Bladder toxicity was Grade 1 or Grade 2 in 18 patients and Grade 3 severity in 1 patient among Arm A. Among 18 patients of Arm B, bladder toxicity of Grade 1 or Grade 2 was seen in 16 patients, and 2 patients had grade 3 toxicity. 2 patients in Arm A and 3 in Arm B complained of Grade 1 urinary incontinence. Moreover, Abdominal pain at 6 months was of Grade 1 in around 6 patients in Arm A but 14 patients had abdominal pain in Arm B which was of Grade 1 in 8, 4 had grade 2 and 2 patients had grade 3 severity abdominal pain. In the monthly analysis of acute toxicity, none of the patients showed Grade 3 or 4 toxicity at the 1st, 2nd, or 3rd month of completion of treatment. When comparing local control in both arms at 6 months, 2 patients had treatment failure in the Experimental Arm compared to only 1 patient in the Control Arm CONCLUSION: Single Application Multiple Fraction Intracavitary Brachytherapy post concurrent CTRT is a safe option for the treatment of locally advanced cervical cancer. When compared to the weekly application arm, single-application ICRT showed a comparable acute toxicity profile and comparable local control rates as well. Some patients in Single Application Arm showed abdominal pain which needs to be investigated with further trials. The overall treatment time in the single application arm is significantly lower than the standard weekly application arm.

Biological Response Assessment in Hepatocellular Carcinoma Post Stereotactic Body Radiotherapy

PURPOSE/OBJECTIVE(S)

Biological Response in Hepatocellular carcinoma (HCC) is measured in terms of serum alpha-fetoprotein (AFP) which is elevated in nearly 60% HCC patients at baseline and is directly related to the severity of the disease. This biological response is defined as the reduction of more than 50% from the baseline levels and is associated with an increased percentage of tumor necrosis and is directly related to increased loco-regional control. Patients diagnosed with HCC have very limited treatment modalities. With the recent advances in the field of radiation therapy and the development of Stereotactic Body radiotherapy (SBRT), the role of radiotherapy has increased as a loco-regional modality for HCC. In this single-arm prospective study, we evaluated the biological response post-SBRT in patients diagnosed with HCC.

MATERIALS/METHODS

We conducted a prospective study that included patients diagnosed with HCC with baseline elevation of serum AFP, Child-Turcotte Pugh (CTP) Class A/B with a maximum score of 7. Patient's serum AFP levels were recorded at baseline, pre-treatment, and post-treatment. The biological response was measured at 3 months post-treatment and compared with the baseline serum AFP levels using Wilcoxon signed rank test.

RESULTS

A total of 14 patients with HCC were recruited and received SBRT to the target lesion, with a dose between 30-42 Gy over 6 fractions treated on alternate days. Patients were assessed post-treatment at one month with triphasic CEMRI and serum AFP levels. 12 out of 14 patients (85.71%) had a biological response at 3 months follow-up and levels showed further decline unless a progression was found. The median (IQR) serum AFP level was 1131 ng/ml (359-5668 ng/ml) at baseline. Post-treatment serum AFP levels had a median (IQR) value of 156 ng/ml (15-372 ng/ml) showing a near reduction of 86% from baseline, which was significant. 2/14 pts (14.28%) showed no reduction or even increase in serum AFP levels post-treatment.

CONCLUSION

This prospective single-arm study demonstrated the vital role of SBRT in the treatment of HCC and its importance in achieving a better disease control. The response was achieved in 86% of patients with marked reduction of nearly 90% in serum AFP levels as compared to the baseline and increased median OS and PFS as compared to patients not receiving radiotherapy. Further prospective studies are warranted to confirm our findings.

Hypo-Fractionated Palliative QUADSHOT Radiotherapy and Concurrent CDDP in Patients with LAHNSCC: Toxicities and Clinical Outcomes

PURPOSE/OBJECTIVE(S)

Shorter palliative hypo-fractionated radiotherapy regimens given concurrently with chemotherapy, preferably cisplatin (radiosensitizer), increase response rates with acceptable toxicity, leading to better compliance of patients with locally advanced squamous cell carcinoma of the head and neck (LAHNSCC) in whom late toxicities due to chemoradiotherapy are less relevant. This single institution prospective interventional phase II study was conducted with the goal of achieving high rates of locoregional control with acceptable treatment-related toxicity.

MATERIALS/METHODS

In this prospective interventional phase- II study, 60 patients with LAHNSCC (treatment naive), the majority in stage IVB and ECOG PS ≤ 3, were treated with QUAD SHOT RT using the conventional 2D technique (14Gy in 4 fractions on 2 consecutive days twice daily with a 6-hour interval between the two fractions) and concurrent cisplatin (CDDP) at a dose of 6 mg/m2. This treatment was repeated at 4-week intervals for 2 additional cycles if tumor progression did not occur. The Kaplan-Meier method was used to determine survival probability for progression-free survival (PFS) and overall survival (OS). Descriptive statistics with number and percentage were used for each toxicity and tumor response at different time points. A P value of less than 0.05 was considered significant.

RESULTS

In our study, all patients received at least one cycle of QUADSHOT chemoradiotherapy (CTRT), while 35 and 18 patients received the 2nd and 3rd QUADSHOT CTRT, respectively. Of the patients who completed the first cycle of QUADSHOT CTRT, 27 (45%) patients had a partial response (PR) and 22 (36.7%) had stable disease (SD). Of the patients who completed the second cycle QUADSHOT CTRT, 77.2% had SD, while 11.4% had PR and 11.4% had PD. After the 3rd QUADSHOT CTRT, 72.2% had SD, while 11.1% had PR and 16.7% had PD. The overall response rate (SD +PR) in our study was 81%, 88.6%, and 83% after the 1st, 2nd, and 3rd QUADSHOT CTRT, respectively. After the 3rd QUADSHOT CTRT, no patient showed grade 4 toxicity. Most patients had grade I/ II toxicities e.g., skin (grade I -83%), mucositis (grade II -50%), salivary gland toxicity (grade II -50%), grade I laryngitis (83.3%). Grade- III oral mucositis and pharyngitis were seen in 27% and 6.7% of patients, respectively. Median OS and PFS were 7.9 months and 6.2 months, respectively.

CONCLUSION

Concurrent chemotherapy acts as a radiosensitizer and provides a synergistic effect when coupled with hypo-fractionated radiation, resulting in more effective control of locoregional disease in locally advanced head and neck tumors with acceptable toxicities. This study is hypothesis-generating and may serve as a basis for developing optimal CTRT regimens for patients with LAHNSCC who are not suitable for curative treatment.

842 Safety and Efficacy of Tranexamic Acid to Minimise Perioperative Bleeding in Extrahepatic Abdominal Surgery: A Systematic Review

Introduction

Perioperative bleeding is a major risk during and after surgery, which can result in increased mortality and morbidity. Tranexamic acid (TXA), in the setting of trauma, minimises perioperative bleeding and its associated risks. However, there is a lack of evidence of its use in elective abdominal surgery. This meta-analysis of randomised controlled trials (RCTs) evaluated the effectiveness and safety of TXA in elective extrahepatic abdominal surgery.

Method

A comprehensive search of PubMed, Embase, and Clinicaltrial.gov databases was undertaken to identify RCTs from January 1947 to May 2020. The primary outcomes of intraoperative blood loss, and the secondary outcomes of need for perioperative blood transfusion, thromboembolic events, and mortality were extracted from included studies. Quantitative pooling of data was based on the random effects model.

Results

Nineteen studies reporting on 2205 patients were included. TXA reduced intraoperative blood loss (weighted mean difference (WMD) -188.35mL; 95% CI -254.65 to -121.72) and the need for perioperative blood transfusion (odds ratio (OR) 0.43; 95% CI 0.28 to 0.65). Importantly, TXA had no impact on the incidence of thromboembolic events (OR 0.49; 95% CI 0.18 to 1.35). There were no reported deaths in any of the studies.

Conclusions

TXA reduces intra-operative blood loss without an increase in complications.

Safety and efficacy of tranexamic acid in minimizing perioperative bleeding in extrahepatic abdominal surgery: meta-analysis

BACKGROUND

Perioperative bleeding is associated with increased morbidity and mortality in patients undergoing elective abdominal surgery. The antifibrinolytic agent tranexamic acid (TXA) has been shown to reduce perioperative bleeding and mortality risk in patients with traumatic injuries, but there is a lack of evidence for its use in elective abdominal and pelvic surgery. This meta-analysis of RCTs evaluated the effectiveness and safety of TXA in elective extrahepatic abdominopelvic surgery.

METHODS

PubMed, Embase, and ClinicalTrial.gov databases were searched to identify relevant RCTs from January 1947 to May 2020. The primary outcome, intraoperative blood loss, and secondary outcomes, need for perioperative blood transfusion, units of blood transfused, thromboembolic events, and mortality, were extracted from included studies. Quantitative pooling of data was based on a random-effects model.

RESULTS

Some 19 studies reporting on 2205 patients who underwent abdominal, pelvic, gynaecological or urological surgery were included. TXA reduced intraoperative blood loss (mean difference -188.35 (95 per cent c.i. -254.98 to -121.72) ml) and the need for perioperative blood transfusion (odds ratio (OR) 0.43, 95 per cent c.i. 0.28 to 0.65). TXA had no impact on the incidence of thromboembolic events (OR 0.49, 0.18 to 1.35). No adverse drug reactions or in-hospital deaths were reported.

CONCLUSION

TXA reduces intraoperative blood loss during elective extrahepatic abdominal and pelvic surgery without an increase in complications.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Outcomes of surgery for post-cholecystectomy bile duct injuries: An audit from a tertiary referral center

AIM OF THE STUDY

Bile duct injury (BDI) after cholecystectomy is a serious complication. It often requires surgical repair. The aim of this study was to report on the short and long-term outcomes of surgery for post-cholecystectomy BDI.

PATIENTS AND METHODS

All the patients, who underwent surgery for post-cholecystectomy BDI between August 2007 and September 2017, were retrospectively reviewed. McDonald grading system was used to assess the long-term outcome. The risk factors for unsatisfactory long-term outcome were analyzed by univariate and multivatiate logistic regression analysis.

RESULTS

In total, 228 patients had a Roux-en-Y hepaticojejunostomy. Open cholecystectomy was the major cause of BDI (61%). The median time from injury to definitive repair was 6 months. The types of BDI were as follows: E1 in 13 (5.7%), E2 in 68 (29.82%), E3 in 108 (47.36%), E4 in 28 (12.28%), and E5 in 11 (4.82%) patients respectively. Postoperative morbidity and mortality were 25% and 1.31% respectively. After a median follow-up of 58 months, 90% patients had excellent to good outcome. Recurrent stricture developed in 6 (3%) patients. On multivariate analysis, long injury-repair interval and previous attempt at repair were independent predictors for unsatisfactory long-term outcome.

CONCLUSION

Surgical reconstruction affords excellent to good results for majority of the patients with post-cholecystectomy BDI. As longer delay in definitive repair and previous attempt at repair were associated with unsatisfactory long-term outcome, early referral to a specialized hepatobiliary surgery unit is recommended.

QSAR modelling on a series of arylsulfonamide-based hydroxamates as potent MMP-2 inhibitors

Matrix metalloproteinase-2 (MMP-2) is a lucrative therapeutic target as far as anticancer drug discovery is concerned. Overexpression of MMP-2 is found to facilitate tumour propagation through the involvement of vascular endothelial growth factor (VEGF). However, even after different techniques, finding a target-specific MMP-2 inhibitor with respectable pharmacodynamic properties is still a challenging task. Regression-dependent quantitative structure-activity relationship (QSAR) strategies might be among the possible drug design methods to explore the essential structural features that would be valuable to find a suitable MMP-2 inhibitor. In this paper, 72 molecules were explored using the PaDEL descriptors and stepwise multiple linear regression (S-MLR). The partial least squares (PLS) method was also used to create a viable statistical model with an acceptable metric related to these models. The final statistical models were formed with statistical parameters within acceptable range (r² = 0.797, Q² = 0.725 and r²_pred = 0.643 for the MLR model, and r² = 0.780, Q² = 0.685 and r²_pred = 0.666 for the PLS model). The models were analysed and compared with those already published on the same endpoint.

Transpectoral Anterior Approach to the Axilla for Lymph Node Dissection in Association with Mastectomy Preserving Both Pectoral Muscles and Their Neurovascular Bundles

In Patey's mastectomy, which is still the most common operation for breast cancer, axillary node dissection (AND) is performed through the base of the axilla after retracting the pectoralis major muscle and excising the pectoralis minor muscle (some surgeons preserve the latter). This has the disadvantage of inadequate exposure of the axilla and the risk of damage to the neurovascular bundles supplying the pectoral muscles, which in the long run may lead to atrophy of these muscles. A transpectoral anterior approach to the axilla for AND in association with mastectomy was attempted in 115 cases to obviate the above-mentioned disadvantages. The approach included: 1) splitting of the pectoralis major between the clavicular and sternal fibers; 2) mobilization and swinging of the pectoralis minor into different directions by means of a sling to facilitate AND at selected levels. The major advantages of this approach were: 1) total preservation of both pectoral muscles with their neurovascular bundles maintained the normal anatomy and function of the shoulder; 2) the axilla was directly approached through the anterior wall instead of through the base; in this way the axillary contents were exposed almost at surface level; 3) the dissection plane could be limited to anterior to and below the axillary vein and the risk of postoperative lymphedema could thus be minimized; 4) change of position of the ipsilateral arm was not necessary; 5) the duration of surgery was reduced. Monoblock ablation of significant and suspected tissues, maintaining the normal anatomy and function of the shoulder, could be easily accomplished with this approach.

Aggregates of quadrupolar dyes for two-photon absorption: the role of intermolecular interactions

We present a theoretical investigation of small aggregates of quadrupolar (A-π-D-π-A or D-π-A-π-D) charge-transfer dyes, with attention focused on the role of intermolecular interactions in determining their optical properties. We tackle the theoretical issue by adopting essential-state models (ESMs), which describe an isolated molecule in terms of a minimal number of electronic states, corresponding to the resonance structures. ESMs quite naturally describe intermolecular interactions relaxing the dipolar approximation and accounting for molecular polarizabilities. The approach is applied to curcuminoid and squaraine dyes, two families of chromophores with weak and strong quadrupolar character, respectively. The method is validated against experiment and for curcuminoids also against time-dependent density functional theory. ESMs rationalize the strong ultra-excitonic effects recurrently observed in the experimental optical spectra of aggregates of highly polarizable quadrupolar dyes, offering a valuable tool to exploit the supramolecular design of material properties.

AxGxE: Using Flies to Interrogate the Complex Etiology of Neurodegenerative Disease

Progressive and late-onset neurological disorders such as Parkinson's disease and Alzheimer's disease affect up to 50 million people globally-a number postulated to double every 20 years in a continually aging population. While predisposing allelic variants in several genes clearly confer risk, individual age and specific environmental influences are equally important discriminators of disease onset age and progression. However, none of these factors can independently predict disease with significant precision. Therefore, we must actively develop models that accommodate contributions from all factors, potentially resulting in an A × G × E (age-gene-environment) metric that reflects individual cumulative risk and reliably forecasts disease outcomes. This effort can only be enabled by a deep quantitative understanding of the contribution of these factors to neurodegenerative disease, both individually and in combination. This is also an important consideration because neuronal loss typically precedes clinical presentation and disease-modifying therapies are contingent on early diagnosis that is likely to be informed by an accurate estimation of individual risk. Although epidemiological studies continue to make strong advances in these areas with the advent of powerful "omics"-based approaches, systematic phenotypic modeling of AxGxE interactions is currently more feasible in model organisms such as Drosophila melanogaster where all three parameters can be manipulated with manageable experimental burden. Here, we outline the advantages of using fruit flies for investigating these complex interactions and highlight potential approaches that might help synthesize existing information from diverse fields into a cogent description of age-dependent, environmental, and genetic risk factors in the pathophysiology of neurological disorders.

Natural resolution or intervention for fluid collections in acute severe pancreatitis

BACKGROUND

Revisions in terminology of fluid collections in acute pancreatitis have necessitated reanalysis of their evolution and outcome. The course of fluid collections in patients with acute pancreatitis was evaluated prospectively.

METHODS

Consecutive adults with acute pancreatitis, who had contrast-enhanced CT (CECT) within 5-7 days of symptom onset, were enrolled in a prospective cohort study in a tertiary-care centre. Patients were treated according to standard guidelines. Follow-up transabdominal ultrasonography was done at 4-week intervals for at least 6 months. CECT was repeated at 6-10 weeks, or at any time if there were new or persistent symptoms. Asymptomatic collections were followed until spontaneous resolution. Risk factors for pancreatic pseudocysts or walled-off necrosis (WON) were assessed in multivariable analyses.

RESULTS

Of 122 patients with acute pancreatitis, 109 were analysed. Some 91 patients (83·5 per cent) had fluid collections at baseline. Eleven of 29 with interstitial oedematous pancreatitis had acute peripancreatic fluid collections, none of which evolved into pseudocysts. All 80 patients with acute necrotizing pancreatitis had at least one acute necrotizing collection (ANC); of these, five patients died (2 after drainage), three underwent successful drainage within 5 weeks, and collections resolved spontaneously in 33 and evolved into WON in 39. By 6 months' follow-up, WON had required drainage in eight patients, resolved spontaneously in 23 and was persistent but asymptomatic in seven. Factors associated with increased risk of WON were blood urea nitrogen 20 mg/dl or more (odds ratio (OR) 10·96, 95 per cent c.i. 2·57 to 46·73; P = 0·001) and baseline ANC diameter greater than 6 cm (OR 14·57, 1·60 to 132·35; P = 0·017). Baseline ANC diameter over 6 cm was the only independent predictor of either the need for drainage or persistence of such collections beyond 6 months (hazard ratio 6·61, 1·77 to 24·59; P = 0·005).

CONCLUSION

Pancreatic pseudocysts develop infrequently in oedematous acute pancreatitis. Only one-quarter of ANCs either require intervention or persist beyond 6 months, whereas more than one-half of WONs resolve without any intervention within 6 months of onset. Baseline diameter of ANC(s) is an important predictor of outcome.

Neurodevelopmental disorders: mechanisms and boundary definitions from genomes, interactomes and proteomes

Neurodevelopmental disorders such as intellectual disability, autism spectrum disorder and schizophrenia lack precise boundaries in their clinical definitions, epidemiology, genetics and protein-protein interactomes. This calls into question the appropriateness of current categorical disease concepts. Recently, there has been a rising tide to reformulate neurodevelopmental nosological entities from biology upward. To facilitate this developing trend, we propose that identification of unique proteomic signatures that can be strongly associated with patient's risk alleles and proteome-interactome-guided exploration of patient genomes could define biological mechanisms necessary to reformulate disorder definitions.

A novel flavonoid C-glucoside from Ulmus wallichiana preserves bone mineral density, microarchitecture and biomechanical properties in the presence of glucocorticoid by promoting osteoblast survival: a comparative study with human parathyroid hormone

PURPOSE

6-C-β-D-glucopyranosyl-(2S,3S)-(+)-5,7,3',4'-tetrahydroxydihydroflavonol (GTDF) is a novel compound isolated from Ulmus wallichiana, reported to have bone anabolic action in ovariectomized rats. Here, we studied the effect of GTDF in glucocorticoid (GC)-induced bone loss and its mode of action.

METHODS

Osteoblasts were cultured from rat calvaria or bone marrow to study apoptosis and differentiation by dexamethasone (Dex), methylprednisolone (MP), GTDF, quercetin and rutin. Female Sprague Dawley rats were treated with Dex or MP with or without GTDF or PTH. Efficacy was evaluated by bone microarchitecture using microcomputed tomography, determination of new bone formation by fluorescent labeling of bone and osteoblast apoptosis by co-labeling bone sections with Runx-2 and TUNEL. Serum osteocalcin was determined by ELISA.

RESULTS

GTDF preserved trabecular and cortical bones in the presence of Dex and MP and mitigated the MP-mediated suppression of serum osteocalcin. Co-administration of GTDF to MP rats increased mineral apposition, bone formation rates, bone biomechanical strength, reduced osteoblast apoptosis and increased osteogenic differentiation of bone marrow stromal cells compared to MP group, suggesting in vivo osteogenic effect of GTDF. These effects of GTDF were to a great extent comparable to PTH. GTDF prevented GC-induced osteoblast apoptosis by inhibiting p53 expression and acetylation, and activation of AKT but did not influence transactivation of GC receptor (GR).

CONCLUSIONS

GTDF protects against GC-induced bone loss by promoting osteoblast survival through p53 inhibition and activation of AKT pathways but not as a GR antagonist. GTDF has the potential in the management of GC-induced osteopenia.

Sociodemographic and substance use correlates of repeated relapse among patients presenting for relapse treatment at an addiction treatment center in Kolkata, India

BACKGROUND

In India, substance abuse has infiltrated all socio-cultural and economic strata causing loss of productivity. Prevention of relapse is crucial for its control.

OBJECTIVES

To find out the pattern of substance use, relapse rate, its association with various socio-demographic factors and treatment related issues.

METHODS

An observational study with cross-sectional design during April 2009-March 2010 at a de addiction centre was conducted among consecutive 284 clients admitted with relapse. They were detoxified earlier in the same centre. Data were collected by interviewing clients with schedule and clinical examination.

RESULTS

Brown sugar (an adulterated form of Heroin) was primary drug of abuse in urban area contrary to alcohol in rural area. Commonest age of initiation was between 15-20 years. Polydrug abusers (59.1%) were common. Only 31.3% of the relapse cases took regular follow up. Common psychiatric illnesses were anxiety (44.7%) and depression (30.6%). Peer pressure (77.8%) was commonest cause of relapse. Significantly higher relapse episodes were present with increasing age, Muslim religion, ever marriage, poor literacy, current unemployment, living in nuclear rather than joint family, early age of initiation, longer duration of abuse and no follow up.

CONCLUSION

Regular follow up with family, peer and social support are essential along with vocational rehabilitation to prevent relapse.

Niacin and laropiprant

Nicotinic acid (niacin) is one of the oldest drugs used to treat dyslipidemia. In addition to modestly lowering low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a), niacin is currently the most effective available agent for raising high-density lipoprotein cholesterol (HDL-C). Despite its well-documented beneficial effects on lipids, the clinical use of niacin has been limited by its side effect profile, notably flushing. This sensation of cutaneous vasodilatation and burning has limited patient compliance and is a frequent cause of discontinuation of the drug. While pretreatment with nonsteroidal anti-inflammatory agents, such as aspirin, may reduce the incidence of flushing, present-day niacin still results in flushing in many patients. Recent studies have elucidated what we currently understand as the molecular mechanism that mediates niacin-induced flushing, specifically that niacin acting through its receptor stimulates the production of several prostaglandins, including prostaglandin (PG) I(2), PGE(2) and PGD(2). Laropiprant is a potent, highly selective prostaoid DP(1) receptor antagonist that decreases the incidence and intensity of niacin-induced flushing without affecting its beneficial lipid effects. Thus, laropiprant, when used in conjunction with niacin, can improve the tolerability of niacin and aid in medication compliance. This paper reviews the data suggesting the importance of raising HDL with niacin, describes the pharmacology of the drug, and examines the potential beneficial effects of combining niacin with laropiprant.

Atypical sarcoidosis masquerading as neutropenia

Sarcoidosis is a systemic granulomatous disease of unknown etiology. Gastrointestinal involvement in sarcoidosis is rare and so are its hematological manifestations. We report an unusual case of sarcoidosis with isolated gastric involvement and concomitant B12 and iron deficiency, leucopenia and severe neutropenia. The diagnosis of GI tract sarcoidosis is difficult and other causes of GI tract granulomas should be excluded. Patients can have unusual manifestations like B12 deficiency and one should be aware of this possibility. Careful follow-up and frequent reevaluation of the patient may be a sound strategy in equivocal cases with unusual presentation.

Bromocriptine induced hypoprolactinemia and accessory reproductive glands response to testosterone in castrated male rats

Testosterone stimulates the Accessory Reproductive Glands (ARG) and may increase the serum titres of prolactin in castrated male rats. Bromocriptine antagonizes the testosterone-induced alteration of ARG responses; the testosterone antagonistic action of bromocriptine depends on the degree of serum prolactin depletion.

A randomized, placebo-controlled study of the effects of naproxen, aspirin, celecoxib or clopidogrel on gastroduodenal mucosal healing

BACKGROUND

Many individuals with gastroduodenal ulcers require on-going, non-steroidal anti-inflammatory drug (NSAID) or anti-platelet therapy.

AIMS

To evaluate the effects of these agents on gastroduodenal mucosal healing.

METHODS

Helicobacter pylori-negative volunteers were randomized to receive naproxen, celecoxib, aspirin, clopidogrel or placebo. Antral and duodenal lesions were created endoscopically with a biopsy forceps. After 7 days of medication dosing, each lesion was scored [from 0 (low) to 8 (high)] using a validated methodology. The primary endpoint was the mean injury score. The secondary endpoint was the percentage of subjects with > or = 1 unhealed lesion.

RESULTS

In all, 108 subjects completed the study. Naproxen impaired antral lesion healing more than placebo, clopidogrel, aspirin or celecoxib (mean injury score of 4.3 vs. 3.0, 2.7, 3.2, and 3.2, respectively, P < 0.05). Naproxen impaired duodenal lesion healing more than placebo, clopidogrel or aspirin (mean injury score of 4.0 vs. 2.4, 2.6, and 2.2, respectively, P < 0.05). More subjects taking naproxen than placebo or clopidogrel had > or =1 unhealed antral lesions (72.2% vs. 36.0% and 32.0%, respectively, P < 0.05) and unhealed duodenal lesions (61.1% vs. 16.0% and 28.0%, respectively, P < 0.05).

CONCLUSIONS

Naproxen may impair gastroduodenal healing more than aspirin or celecoxib in H. pylori negative subjects. Clopidogrel did not impair mucosal healing.

DNA repair and cyclin D1 polymorphisms and styrene-induced genotoxicity and immunotoxicity

1-SO-adenine DNA adducts, DNA single-strand breaks (SBs), chromosomal aberrations (CAs), mutant frequency (MF) at the HPRT gene, and immune parameters (hematological and of humoral immunity) were studied in styrene-exposed human subjects and controls. Results were correlated with genetic polymorphisms in DNA repair genes (XPD, exon 23, XPG, exon 15, XPC, exon 15, XRCC1, exon 10, XRCC3, exon 7) and cell cycle gene cyclin D1. Results for biomarkers of genotoxicity after stratification for the different DNA repair genetic polymorphisms showed that the polymorphism in exon 23 of the XPD gene modulates levels of chromosomal and DNA damage, HPRT MF, and moderately affects DNA adduct levels. The highest levels of biomarkers were associated with the wild-type homozygous AA genotype. The exposed individuals with the wild-type GG genotype for XRCC1 gene exhibited the lowest CA frequencies, compared to those with an A allele (P < 0.05). Cyclin D1 polymorphism seems to modulate the number of leukocytes and lymphocytes in the analyzed subjects. The number of eosinophiles was positively associated with XPD variant C allele and negatively with XRCC1 variant A allele (P < 0.05) and XPC variant C allele (P < 0.05). Immunoglobulin IgA was positively associated with an XRCC3 variant T allele (P < 0.01) and negatively with XPC variant C allele (P < 0.05). Both C3- and C4-complement components were lower in individuals with XRCC3 CT (P < 0.05) and TT genotypes (P < 0.01). Adhesion molecules sL-selectin and sICAM-1 were associated with XPC genotype (P < 0.05). Individual susceptibility may be reflected in genotoxic and immunotoxic responses to environmental and occupational exposures to xenobiotics.

Variation in the menstrual characteristics in adolescents of West Bengal

INTRODUCTION

Like other biological phenomena, menstrual characteristics also vary with different age groups, socioeconomic status, and lifestyles. This study aimed to find out the variation in the menstrual characteristics among adolescents of different age groups, and the significant predictors of a menstrual outcome.

METHODS

260 adolescent Bengali-speaking Hindu girls of three different age groups (early, middle and late adolescence) were selected from the district of 24 Parganas (North), West Bengal, India. Data on the socioeconomic conditions and menstrual characteristics were collected via a pre-tested questionnaire.

RESULTS

Significant differences exist between these three age groups in characteristics such as irregularity in the cycle, skipping of the cycle, duration of menstrual discharge, absenteeism from school because of pain and discomfort related to menstruation, and the prevalence of white discharge. Logistic regression showed that socioeconomic variables such as the occupations of the parents and educational levels of the parents and the subjects have a significant relationship with some menstrual outcomes (irregularity in the menstrual cycle, premenstrual problems, and duration of menstrual discharge) and with consultation of doctors due to some morbid conditions. Some of the other menstrual characteristics such as duration of menstrual discharge, number of days of peak discharge and absence of pain at the time of menstrual discharge, can be significantly predicted by age group of the individuals and other menstrual features.

CONCLUSION

Menstrual characteristics vary among the adolescents of different age groups, and some of the menstrual characteristics can be predicted by some socioeconomic factors and other menstrual variables.

Studies on sodium and potassium metabolism and subsequent influence on electrocardiogram in unilaterally adrenalectomized black Bengal goat (Capra hircus)

Unilateral adrenalectomy was performed in six black Bengal goat (Capra hircus)to study electrocardiograph in connection with mineral metabolism with special reference to sodium and potassium and some other factors of physiological importance. The parameters were studied at every 12 hrs interval upto 120 hrs and 24 hrs interval from 120 to 240 hrs. Physiological parameters, like body weight and rectal temperature, changed non-significantly (p < 0.05) after adrenalectomy. Among minerals, plasma sodium (p < 0.01) and plasma potassium (p < 0.05) concentration were changed significantly between hours leaving impression in ECG as widening of QRS complex and peaked T wave with increased amplitude found after unilateral adrenalectomy. Heart rate also increased significantly (p < 0.01) between hours.

Analysis of conditional paralytic mutants in Drosophila sarco-endoplasmic reticulum calcium ATPase reveals novel mechanisms for regulating membrane excitability

Individual contributions made by different calcium release and sequestration mechanisms to various aspects of excitable cell physiology are incompletely understood. SERCA, a sarco-endoplasmic reticulum calcium ATPase, being the main agent for calcium uptake into the ER, plays a central role in this process. By isolation and extensive characterization of conditional mutations in the Drosophila SERCA gene, we describe novel roles of this key protein in neuromuscular physiology and enable a genetic analysis of SERCA function. At motor nerve terminals, SERCA inhibition retards calcium sequestration and reduces the amplitude of evoked excitatory junctional currents. This suggests a direct contribution of store-derived calcium in determining the quantal content of evoked release. Conditional paralysis of SERCA mutants is also marked by prolonged neural activity-driven muscle contraction, thus reflecting the phylogenetically conserved role of SERCA in terminating contraction. Further analysis of ionic currents from mutants uncovers SERCA-dependent mechanisms regulating voltage-gated calcium channels and calcium-activated potassium channels that together control muscle excitability. Finally, our identification of dominant loss-of-function mutations in SERCA indicates novel intra- and intermolecular interactions for SERCA in vivo, overlooked by current structural models.

Acute induction of conserved synaptic signaling pathways in Drosophila melanogaster

Analyses of early molecular and cellular events associated with long-term plasticity remain hampered in Drosophila by the lack of an acute procedure to activate signal transduction pathways, gene expression patterns, and other early cellular events associated with long-term synaptic change. Here we describe the development and first use of such a technique. Bursts of neural activity induced in Drosophila comatosets and CaP60A Kumts mutants, with conditional defects in N-ethylmaleimide-sensitive fusion factor 1 and sarco-endoplasmic reticulum Ca2+ ATPase, respectively, result in persistent (>4 hr) activation of neuronal extracellular signal-regulated kinase (ERK). ERK activation at the larval neuromuscular junction coincides with rapid reduction of synaptic Fasciclin II; in soma, nuclear translocation of activated ERK occurs together with increased transcription of the immediate-early genes Fos and c/EBP (CCAAT element binding protein). The effect of "seizure-stimulation" on ERK activation requires neural activity and is mediated through activation of MEK (MAPK/erk kinase), the MAPKK (mitogen-activated protein kinase kinase) that functions upstream of ERK. Our results (1) provide direct proof for the conservation of synaptic signaling pathways in arthropods, (2) demonstrate the utility of a new genetic tool for analysis of synaptic plasticity in Drosophila, and (3) potentially enable new proteomic and genomic analyses of activity-regulated molecules in an important model organism.