A case control study for factors of Multidrug Resistant Tuberculosis in East Sikkim, India

Background

Tuberculosis (TB) remains a major public health problem in the developing world and India is the highest TB burden country in the world in terms of absolute number of incident cases that occur each year. The emergence of Multidrug Resistant Tuberculosis (MDR TB) is posing threat to global efforts of TB control. The hilly state of Sikkim has the highest proportion of MDR TB cases in India. Hence there is an emerging need to identify the factors for the rapid rise of MDR TB in Sikkim.

Methods

All the MDR TB cases registered under Revised National TB Control Programme in East district of Sikkim in the first & second quarter of 2019 was compared with double the number of matched controls taken from the same geographical area and ethnicity but not from the same family members.

Results

A total of 78 cases and 156 controls were studied. The mean age of the study participants was 43 years (SD ± 14 years). The most statistically significant risk factors were as follows: overcrowding (OR 2.68); household air pollution (OR 2.55); inadequate ventilation (OR 2.05); previous history of tuberculosis (OR 4.03) with history of relapse/failure; known contact of MDR tuberculosis (OR 4.01); having diabetes (OR 3.96); smoking (OR 3.96)

Conclusions

This study shows that clinical and demographic features can be used to indicate higher risks of drug resistance in this setting. Information was obtained on why Sikkim being a small State with very less population and a good per capita expenditure in health has the highest proportion of MDR-TB in India.

Key messages

Sikkim is the smallest state in India with the highest proportion of MDR TB. Previous history of TB with history of relapse/failure, contact of MDR TB emerged as the most significant risk factors.

Impact of health education on preventive therapy with integrated monitoring of Tuberculosis cases

Background

The hilly state of Sikkim has the highest proportion of Tuberculosis (TB) cases in India. Increasing compliance of preventive therapy among paediatric contacts will help to cut down transmission. Separate visits are being made under the current National TB control programme to monitor preventive therapy & treatment of index Tuberculosis cases in the same house. Integrated monitoring for preventive therapy of the contacts & treatment of index cases will ensure compliance of both but at no extra cost.

Methods

It was a prospective study with universal sampling of all the sputum positive TB patients in East Sikkim. Home visits were conducted initially, after 3 months with health education intervention and finally at the end of 6 months. Focus group discussion (FGD) was done amongst the TB home visitors regarding monitoring visits.

Results

Out of the total 124 paediatric contacts, 86 (69.4%) initiated Isoniazid Preventive Therapy (IPT). After 6 months of follow up, 114 (91.9%) children had completed IPT after the health education intervention. In 96.7% of the houses, it was possible to monitor both index cases and the paediatric contacts simultaneously with the same work force. Content analysis of FGD among TB home visitors revealed lack of programme clarity regarding integrated visits for monitoring of both contacts and index cases.

Conclusions

Health education intervention was found to be an effective tool for increasing compliance of IPT. This study had a huge & far-reaching impact in terms of providing the evidence that integrated monitoring for preventive therapy of the contacts along with health education & monitoring of treatment of index cases can be done simultaneously with no extra cost in the ongoing TB Control Programme.

Key messages

Health education intervention increased compliance of IPT. Integrated monitoring for preventive therapy along with health education & monitoring of index cases can be done with no extra cost.

Epidemiological investigation of an outbreak of food poisoning in an officers’ mess

Background: Foodborne infection is a major cause of illness and death worldwide, having long term effects on children’s growth; and considerable illness, heavily affecting healthcare systems. To investigate an outbreak of food poisoning which occurred in an officers’ mess.Methods: A retrospective cross-sectional descriptive study was carried out in the setting of an officers’ mess in an army unit. Standard statistical methods such as calculation of percentage and Chi square were utilized for analysis.Results: It was observed that seven (63.6364%) cases were amongst officers, 3 (27.2727%) cases were among ladies and 1 (9.0909%) case was amongst ORs. 100% cases occurred within 9 to 20 hours of consuming the food.Conclusions: A small scale outbreak of food poisoning occurred in an officers’ mess in a military establishment. Clinically the most likely causative organism was suspected to be Salmonella typhimurium. No microbiological confirmation could be carried out as no food sample was available for the same.

Study of interleukin-6 and interleukin-8 levels in patients with neurological manifestations of dengue

Context:

Pro-inflammatory markers play a key role in the pathogenesis of various Flavivirus infection.

Aim:

In this study, we evaluated the role of these markers in neurological manifestations of dengue.

Settings and Designs:

Consecutive dengue cases with different neurological manifestations who presented between August 2012 and July 2014 were studied in hospital-based case–control study.

Materials and Methods:

Interleukin (IL-6) and IL-8 level were measured in serum and cerebrospinal fluid (CSF) of dengue cases with different neurological manifestations and also in age- and sex-matched controls. Level was analyzed with various parameters and outcomes.

Statistical Analysis:

Statistical analysis was done using SPSS version 16.0 by applying appropriate statistical methods. P < 0.05 considered statistically significant.

Results:

Out of the 40 enrolled cases of dengue with neurological manifestations, 29 had central nervous system and 11 had peripheral nervous system (CNS/PNS) manifestations. In CNS group, both IL-6 and IL-8 (CSF and serum) were significantly elevated (P < 0.001), whereas CSF IL-6 (P = 0.008), serum IL-6 (P = 0.001), and serum IL-8 (P = 0.005) were significantly elevated in PNS group. CSF IL-6, serum IL-6, and IL-8 were significantly elevated in poor outcome patients in CNS group (P < 0.05). CSF IL-6 and IL-8 were significantly elevated in CSF dengue positive cases as compared to CSF negative patients (P < 0.05). Cytokine level was not significantly correlated with neuroimaging abnormality in CNS group. Nine patients died and the remainder recovered.

Conclusion:

Elevated level of IL-6 and IL-8 is associated with different neurological manifestations and poor outcome, but whether they are contributing to neuropathogenesis or simply a correlate of severe disease remains to be determined.

Trends in trauma: a rural experience

In last 20 years a progressive increase in the cases of road traffic accidents is seen in the institution. In this study efforts have been made to study epidemiology of trauma & how to help the trauma victims in a better way. To study the changing trends in incidence & presentation of trauma victims. To recommend preventive measures based on the analysis. The present study was carried out in MGIMS, Sewagram, Wardha from 2001 to 2003. For this study which is retrospective and prospective, a total of 986 cases of surgical trauma were studied. Present study showed that in this rural area accidents account for maximum trauma admissions & major trauma only in 20 %. Out of 986 patients, 78.8 % required repair of wounds, 3.8 % required exploratory laparotomy and 16.3 % had orthopedic interventions. Overall mortality rate was 2.9 %. It was found that general care in wards was good in terms of trauma results of rural areas. These results may vary when compared with specialized trauma centers in cities; however after a period of few years cost effectiveness of trauma centers in terms of benefits needs an assessment*.

Filaria associated clinical manifestations in children in an endemic area and morbidity control by immunomonitoring and optimal DEC therapy: Sevagram experience

Lymphatic filariasis is a major public health problem in India with 412 million people living in bancroftian endemic areas and is a major cause of clinical morbidity. Twenty million people are reported to suffer from chronic disease manifestations such as lymphoedema, hydrocele or elephantiasis. At least twice the number have been shown to suffer from acute and occult filarial infections in an endemic area without diagnosis. Due to non-availability of suitable diagnostic test for confirming filaria aetiology other than parasitological examination, no significant study on filariasis in children has been reported earlier. Studies in our laboratory for more than a decade showed usefulness of microfilarial excretory-secretory antigen in confirming filarial aetiology in acute and occult infections in adults as well as in children. This study reports acute and atypical manifestations such as lymphadenopathy, asthmatic bronchitis, pulmonary eosinophilia, mono-arthritis, recurrent URI, pneumonia, nutritional anemia, pain in abdomen etc. in children living in filaria endemic area having no microfilaraemia but showing filaria aetiology by immunomonitoring for the presence of antibody or antigen and responding to optimal DEC therapy.

Epidemiological Differentials of Hepatitis B Carrier State in the Army : A Community Based Sero-epidemiological Study

BACKGROUND

Most available studies on seroprevalence of Hepatitis B in the Armed Forces and also at the national level are based on hospital patients and blood donors. Hence, there was a perceived need to undertake a seroepidemiological study on an adequately large and representative random sample of the general cross section of Army personnel, with a view to obtain the exact picture of the frequency and distribution of HBV in the Army.

METHODS

A community based cross sectional study with random samples from four groups were drawn, viz recruits from the Army Medical Corps (AMC) and other Arms and Services; AMC personnel and personnel from other Arms and Services who had served for more than 10 years. A structured pretested questionnaire was administered to all participants and blood samples were drawn aseptically subsequently, with separation of serum and testing by ELISA technique for HBsAg. Multivariate analysis using multiple logistic regression procedure was done after appropriate data entry.

RESULTS

The overall seroprevalence was 7.9% (95%CI = 6.5% to 9.26%). The differential seroprevalence in the four groups being 7.72%, 7.92%, 8.28% and 7.75% respectively. There was statistically no significant difference as regards the seroprevalence levels [p > 0.05]. As regards serving medical personnel, the seroprevalence was observed to be higher among personnel involved in direct nursing care. On multiple logistic regression analysis, two risk factors emerged as independent and significant predictors of hepatitis B positivity. These were history of sexual exposure with commercial sex workers (CSWs) (OR = 3.06, p < 0.01) and history of having taken injections from civil sources (OR = 1.92, p < 0.001).

CONCLUSION

The relatively high level of seroprevalence among recruits has led to certain recommendations on testing and further studies in specific groups, based on the findings of the study.

Significance of platelet volume indices and platelet count in ischaemic heart disease

BACKGROUND

Ischaemic heart disease is mainly caused by atherosclerosis and its complications. Platelets and their activity have an important role in initiation of atherosclerotic lesions and coronary thrombus formation. Larger platelets are enzymatically and metabolically more active and have a higher potential thrombotic ability as compared with smaller platelets.

AIMS

To study the changes in platelet volume indices and platelet count in ischaemic heart disease and assess their usefulness in predicting coronary events.

METHODS

This was a comparative study of 180 patients (60 patients with stable angina, 60 with acute coronary syndrome and 60 with non-cardiac chest pain). Blood venous sample were drawn from all subjects after admission (within 30 min) and collected in standardised EDTA sample tubes. Platelet count and volume indices were assayed within 30 min of blood collection, using Sysmex KX21-N autoanalyzer.

RESULTS

The platelet count was significantly lower in patients with acute coronary syndrome (201.28 x 10(9)/l) as compared with patients with stable angina (267.07 x 10(9)/l) and those from the normal population (256.65 x 10(9)/l) (p<0.001). In addition, patients with acute coronary syndrome had higher platelet volume indices (10.97) compared with patients in the stable angina (10.03) and normal population groups (9.12) (p<0.001).

CONCLUSIONS

Patients with acute coronary syndrome had higher platelet volume indices and lower platelet counts compared with those with stable angina and the normal population. Measurements of platelet volume indices and platelet count may be of some benefit in detecting those patients at higher risk for acute coronary events.

Efficacy of Deltamethrin and Cyfluthrin Impregnated Cloth over Uniform against Mosquito Bites

BACKGROUND

The difficulty with insecticide treated mosquito nets is that in military operation, it may not be practical for the personnel to carry mosquito nets with them. In mobile military operations, availability of pre-treated 'patches of cloth' or 'bands', which can be applied over the uniform at strategic sites, could be a feasible alternative.

METHODS

A double blind randomised controlled trial was undertaken among troops deployed in counter-insurgency operations in the northeastern parts of the country, to assess the efficacy of synthetic pyrethroid pretreated patches in reducing man mosquito contact, as compared to conventional repellents.

RESULT

The study indicated that pretreated patches, when affixed over the uniform, provided significantly higher protection from mosquito bites, when used in addition to the conventional repellents.

CONCLUSION

The study recommends that synthetic pyrethroid treated patches be made available to troops operating in highly malarious areas.

Malaria on the Move : Ecological Considerations for the Armed Forces

BACKGROUND

Armed forces personnel deployed in the North Eastern states of India are vulnerable to falciparum malaria. This vulnerability increases during mobilization of troops.

METHODS

Epidemiological case sheet was used for recording individual movement, clinical features and laboratory investigations of each case of malaria. Immunochromotography test (ICT) or Paracheck Pf was used as a rapid test for falciparum malaria at the regimental aid post (RAP). Subsequently, a case control approach was used to ascertain whether the cases of malaria differed significantly from healthy controls in observing antimalaria measures such as the use of mosquito nets, repellants and chemoprophylaxis.

RESULT

Nineteen out of 623 soldiers suffered from falciparum malaria during a short period of ten days during operational mobilization. Use of mosquito nets and repellants was significantly less among the cases as compared to healthy controls. There was no significant difference among the two groups regarding compliance with chemoprophylaxis.

CONCLUSION

A paradigm of "malaria on the move" or "operational malaria" has been proposed.

Is diagnostic review of radiotherapy-planning CT scans important in the conformal therapy era?

OBJECTIVE

Detailed CT scans are often acquired during the radiotherapy planning process. This study was performed to determine the incidence of important benign and cancer-related CT findings on these scans.

SUBJECTS AND METHODS

From December 1998 to December 2000, 162 radiotherapy patients who were to be treated curatively underwent treatment planning CT scans on a helical scanner in the radiology department at Washington Hospital, Fremont, CA. All CT scans were prospectively interpreted relative to diagnoses, and reports were dictated for the medical records. The diagnostic reports and records on all patients were reviewed to determine the incidence of previously unknown benign or cancer-related findings, the impacts of such findings on treatment, and the need for additional radiologic studies or procedures on the basis of the CT interpretations.

RESULTS

Incidental benign findings were noted for 32 patients (20%). Potentially important benign findings were noted for three patients: two with aneurysms and one with a possible deep vein thrombosis. Potentially cancer-related findings were reported in 20 patients: a single liver lesion (four patients), multiple liver lesions (two patients), possible or probable lymphadenopathy (11 patients), abnormal soft tissue (one patient), a small-bowel obstruction (one patient), and a breast mass (one patient). After reviewing prior diagnostic studies and obtaining additional recommended studies, the physicians found that only three of the previously unknown findings required further investigation: two aneurysms, which did not require near-term treatment, and one metastatic neck node.

CONCLUSION

Routine diagnostic interpretation of radiotherapy planning scans resulted in few important medical findings and changed patient care for less than 1% of the patients.

Protracted venous infusion 5-fluorouracil with concomitant radiotherapy compared with bolus 5-fluorouracil for unresectable pancreatic cancer

Radiation therapy (RT) with concurrent 5-fluorouracil (5-FU) administered by protracted venous infusion (PVI) replaced our prior institutional protocol of RT with bolus administration of 5-FU as standard therapy for unresectable pancreatic cancer in 1994. In this article, we compare the treatment intensity, toxicity, and outcome for patients with unresectable pancreatic cancer treated on these sequential protocols. Fifty-four patients, 27 on each protocol, with biopsy-confirmed pancreatic cancer received chemoradiotherapy. The radiotherapy field included the gross tumor volume and regional lymph nodes to a dose of 45 Gy, followed by "boost" to the gross tumor volume to 54 Gy to 60 Gy. From 1987 to 1994, patients received concurrent 5-FU administered by bolus injection, at a dose of 500 mg/m2 on days 1 to 3 and days 29 to 31 of RT. After December 1994, 5-FU was administered by PVI (200-250 mg/m2) beginning on day 1 and continuing until the completion of RT. The chemotherapy treatment intensity was increased in the group receiving 5-FU by PVI, as evidenced by an increased average weekly and cumulative dose of 5-FU (p < 0.01). The radiotherapy treatment intensity was equivalent between the two groups. The incidence of objectively quantified toxicity was not statistically different between treatment groups. Overall survival remained poor in both treatment groups. With a median follow-up of 18 months (range: 3-30 months) for surviving patients, the 6-month, 1-year, and 2-year survivals for the PVI 5-FU-treated group versus the bolus 5-FU-treated group were 56% versus 52%, 34% versus 18%, and 22% versus 13%, respectively (p = 0.9). Radiotherapy with concomitant 5-FU by PVI results in a greater weekly and total dose of chemotherapy. The method of 5-FU administration (bolus versus PVI) did not change the RT treatment intensity, experienced toxicity, or overall survival.

Comparison of the CardioWest total artificial heart, the novacor left ventricular assist system and the thoratec ventricular assist system in bridge to transplantation

BACKGROUND

Device selection has historically been supported by minimal comparative data. Since 1994, we have implanted 43 patients with the CardioWest Total Artificial Heart (CW), 23 with the Novacor Left Ventricular Assist System (N), and 26 with the Thoratec Ventricular Assist System (T). This experience provides a basis for our device selection criteria.

METHODS

We reviewed retrospectively the results for survival, stroke, and infection in the CW, N, and T groups. Statistical methods included the Student's t-test, chi2 analysis, and Kaplan-Meier actuarial survival curves.

RESULTS

The T group patients were younger and smaller sized than the CW or N group. The CW group had the highest mean central venous pressure (CVP) and lowest mean cardiac index. Survival to transplantation was 75% for CW, 57% for N, and 38% for T. Multiple organ failure postimplant caused most deaths in the CW and T groups. Right heart failure and stroke caused most N deaths. Linearized stroke rates (event/patient-month) were 0.03 for CW, 0.28 for N, and 0.08 for T. Serious infections were found in 20% of CW, 30% of N, and 8% of T patients, but linearized rates showed little difference and death from infection was rare.

CONCLUSIONS

The N device should be used in "stable" patients with body surface area (BSA) greater than 1.7 m2 and with minimal right heart failure. Unstable patients with biventricular failure should receive a CW if the BSA is greater than 1.7 m2 or a T if they are smaller.

Unsuspected abnormalities noted on CT treatment-planning scans obtained for breast and chest wall irradiation

PURPOSE

Three-dimensional treatment planning and CT simulation is widely used for the treatment of a variety of cancers. At the Stanford University Medical Center, a treatment-planning CT scan is obtained before breast irradiation to optimize the dose distribution to the treated breast and to limit radiation to the opposite breast, heart, and lung. In this paper, we review the incidental findings discovered on a careful review of these scans.

METHODS AND MATERIALS

Between 1997 and 1999, 153 patients referred for breast or chest wall radiation therapy underwent a treatment-planning CT scan in our department. The planning scans were extended to include not only the breast, but also the neck, thorax, and liver. A resident and attending radiation oncologist carefully reviewed each scan before approving the treatment plan. Any abnormal findings were reviewed by an attending in the department of radiology, and additional diagnostic imaging or other evaluation was obtained as necessary.

RESULTS

One hundred and fifty-three sequential scans were reviewed, and 17 unsuspected abnormalities were noted (11%). The abnormalities involved the lung (n = 4), the liver (n = 3), the gallbladder (n = 4), the esophagus (n = 2), lymph nodes (n = 3), and the breast. All abnormalities were evaluated with additional imaging studies and/or appropriate consultations. Four of these abnormalities represented additional cancer foci (3%) and altered the treatment plan.

CONCLUSIONS

Three-dimensional treatment-planning CT scans for breast cancer should be carefully reviewed. In our institution, 11% of these planning studies contained abnormalities, and 3% demonstrated additional unanticipated sites of involvement by breast cancer.

Radiotherapy, concomitant protracted-venous-infusion 5-fluorouracil, and surgery for ultrasound-staged T3 or T4 rectal cancer

BACKGROUND

A prospective study was undertaken to evaluate the response and toxicity of neoadjuvant chemoradiotherapy for ultrasound-staged T3 or T4 rectal cancer.

PATIENTS AND METHODS

Since 1995, 30 patients (18 males; median age, 56 (range, 25-83) years) have received preoperative chemoradiotherapy for ultrasound-staged T3 or T4 rectal cancer. All patients underwent an endorectal ultrasound, CT scan, and review in our multidisciplinary Gastrointestinal Tumor Board before treatment. All patients had pathology-demonstrated invasive adenocarcinoma of the rectum. Eleven patients were Stage T3N0, 14 were T3N1, and five were T4N1. Patients received radiotherapy to the primary tumor and draining lymph nodes (45 Gy) followed by a tumor boost (50.4-54 Gy). Protracted-venous-infusion 5-fluorouracil (225 mg/m2 per day, seven days per week) was administered throughout treatment. Surgical resection was performed six to ten weeks after completing chemoradiotherapy. Using endorectal ultrasound measurements, the primary tumor was a median of 4 (range, 0-12) cm from the anal verge, encompassed 50 (range, 20-90) percent of the rectal circumference, and was 6 (range, 3-12) cm in diameter.

RESULTS

No Grade 4 toxicity was observed during chemoradiotherapy. Three patients experienced Grade 3 toxicity (diarrhea), and four patients required a treatment interruption of greater than three days. All patients completed at least 90 percent of the prescribed radiotherapy dose. All patients underwent surgical resection. Ninety-four percent had clear surgical margins. All pathologic specimens had significant evidence of necrosis, hyalinization, and fibrosis. Thirty-three percent of the specimens had a complete pathologic response (defined as no evidence of viable tumor cells). Of the 19 patients with ultrasound-staged N1 disease, only five had pathologic evidence of nodal involvement after chemoradiotherapy. Of the 25 patients with ultrasound-staged T3 disease, pathologic staging revealed eight with T0, two with T1, five with T2, and ten with T3 disease. Of the five patients with ultrasound-staged T4 disease, pathologic staging revealed two with T0, one with T2, and two with T3 disease. No patient developed progressive disease while on treatment. Two patients have experienced local failure at 6 and 20 months, and one patient failed in the liver at seven months. Twenty-seven patients remain free of disease with a median follow-up of 20 (range, 3-53) months.

CONCLUSION

Our experience suggests that preoperative chemoradiotherapy is well tolerated, down-stages tumors, and sterilizes regional lymph nodes.

Preoperative chemoradiation for marginally resectable adenocarcinoma of the pancreas

Only 10% to 20% of patients with pancreatic cancer are considered candidates for curative resection at the time of diagnosis. We postulated that preoperative chemoradiation therapy might promote tumor regression, eradicate nodal metastases, and allow for definitive surgical resection in marginally resectable patients. The objective of this study was to evaluate the effect of a preoperative chemoradiation therapy regimen on tumor response, resectability, and local control among patients with marginally resectable adenocarcinoma of the pancreas and to report potential treatment-related toxicity. Patients with marginally resectable adenocarcinoma of the pancreas (defined as portal vein, superior mesenteric vein, or artery involvement) were eligible for this protocol. Patients received 50.4 to 56 Gy in 1.8 to 2.0 Gy/day fractions with concurrent protracted venous infusion of 5-fluorouracil (250 mg/m2/day). Reevaluation for surgical resection occurred 4 to 6 weeks after therapy. Fifteen patients (9 men and 6 women) completed preoperative chemoradiation without interruption. One patient required a reduction in the dosage of 5-fluorouracil because of stomatitis. Acute toxicity from chemoradiation consisted of grade 1 or 2 nausea, vomiting, diarrhea, stomatitis, palmar and plantar erythrodysesthesia, and hematologic suppression. CA 19-9 levels declined in all nine of the patients with elevated pretreatment levels. Nine of the 15 patients underwent a pancreaticoduodenectomy, and all had uninvolved surgical margins. Two of these patients had a complete pathologic response, and two had microscopic involvement of a single lymph node. With a median follow-up of 30 months, the median survival for resected patients was 30 months, whereas in the unresected group median survival was 8 months. Six of the nine patients who underwent resection remain alive and disease free with follow-up of 12, 30, 30, 34, 39, and 72 months, respectively. Preoperative chemoradiation therapy is well tolerated. It may downstage tumors, sterilize regional lymph nodes, and improve resectability in patients with marginally resectable pancreatic cancer. Greater patient accrual and longer follow-up are needed to more accurately assess its future role in therapy.

Adjuvant chemoradiotherapy for "unfavorable" carcinoma of the ampulla of Vater: preliminary report

HYPOTHESES

Adjuvant chemoradiotherapy decreases the risk of local recurrence in patients with adenocarcinoma of the ampulla of Vater and high-risk features. Adjuvant chemoradiotherapy for this population can be administered safely and without much morbidity.

DESIGN

Controlled, prospective, single-arm study.

SETTING

Tertiary care referral hospital.

PATIENTS

From June 1995 to March 1999, 12 patients (7 men and 5 women; median age, 66 years; age range, 38-78 years) with "unfavorable" ampullary carcinoma were treated with adjuvant chemoradiotherapy. All patients underwent pancreaticoduodenectomy, and all pathologic findings were confirmed at Stanford University Medical Center, Stanford, Calif. Unfavorable features were defined as involved lymph nodes (n = 10), involved surgical margins (n = 1), poorly differentiated histological features (n = 3), tumor size greater than 2 cm (n = 6), or the presence of neurovascular invasion (n = 4).

INTERVENTIONS

Four to 6 weeks after undergoing pylorus-preserving pancreaticoduodenectomy with regional lymphadenectomy, patients began adjuvant chemoradiotherapy consisting of concurrent radiotherapy (45 Gy) and fluorouracil by protracted venous infusion (225-250 mg/m(2) per day, 7 days per week) for 5 weeks.

MAIN OUTCOME MEASURES

Local recurrence, distant recurrence, overall survival rate, and treatment-related toxic effects.

RESULTS

All patients completed the prescribed treatment course. Toxic effects were assessed twice a week during treatment and graded according to the National Cancer Institute Common Toxicity Criteria Scale. One patient required a treatment interruption of 1 week for grade III nausea/vomiting. No grade IV or V toxic effects were observed. At median follow-up of 24 months (range, 13-50 months), 8 of 12 patients were alive and disease free. One patient was alive but had disease recurrence. Three patients died of this disease (liver metastases). Actuarial overall survival at 2 years was 89%, and median survival was 34 months. One surviving patient developed a local recurrence and a lung lesion. Actuarial overall survival and median survival were better than in a parallel cohort with resected high-risk pancreatic cancer (n = 26) treated with the same adjuvant chemoradiotherapy regimen (median survival, 34 vs 14 months; P<.004).

CONCLUSIONS

Adjuvant chemoradiotherapy for carcinoma of the ampulla of Vater is well tolerated and might improve control of this disease in patients with unfavorable features.

Isolation of taxoids from cell suspension cultures of Taxus wallichiana

Cell suspension cultures of stem-derived callus of Taxus wallichiana in MS-F culture media were found to produce three C-14 oxygenated taxoids and one regular taxoid. The taxoids were identified as yunnanxane (1), 2 alpha, 5 alpha, 10 beta, 14 beta-tetraacetoxy-4(20),11-taxadiene (2), 2 alpha, 5 alpha, 10 beta-triacetoxy-14 beta-(2-methyl)-butyryloxy-4(20),11-taxadiene (3) and 1 beta-hydroxybaccatin I (4).

Adjuvant radiotherapy and concomitant 5-fluorouracil by protracted venous infusion for resected pancreatic cancer

PURPOSE

To assess the toxicity and clinical benefit from adjuvant chemoradiotherapy consisting of protracted venous infusion 5-fluorouracil (5-FU) and concomitant radiotherapy in patients with resected pancreatic cancer.

METHODS AND MATERIALS

Between 1994 and 1999, 52 patients who underwent pancreaticoduodenectomy received adjuvant chemoradiotherapy. The tumor bed and regional nodes received a dose of 45 Gy in fractions of 1.8 Gy followed by boost to the tumor bed if the surgical margins were involved (total dose, 54 Gy). The patients also received concomitant 5-FU by protracted venous infusion (200-250 mg/m(2)/day, 7 days/week) during the entire radiotherapy course.

RESULTS

Fifty-two patients (30 men, 22 women) were enrolled and treated on this protocol. The median age was 63 years (range, 38-78 years), and the median Karnofsky Performance Status was 80 (range, 70-100). Thirty-five percent had involved surgical margins and 59% had involved lymph nodes. All patients completed therapy, and there were no Grade IV/V toxicities observed. With median follow-up of 24 months (range, 3-52 months) for surviving patients, the median survival is 32 months, and 2-year and 3-year survivals are 62%, and 39%, respectively.

CONCLUSION

Radiotherapy with concomitant 5-FU by protracted venous infusion as adjuvant treatment for resected pancreatic cancer is well tolerated. This approach allows for greater dose intensity with reduced toxicity. The median survival of this cohort of patients compares favorably with our earlier experience and other published series.

Pancreatic tumors show high levels of hypoxia

PURPOSE

Because of the dismal outcomes of conventional therapies for pancreatic carcinomas, we postulated that hypoxia may exist within these tumors.

METHODS AND MATERIALS

Seven sequential patients with adenocarcinomas of the pancreas consented to intraoperative measurements of tumor oxygenation using the Eppendorf (Hamburg, Germany) polargraphic electrode.

RESULTS

All 7 tumors demonstrated significant tumor hypoxia. In contrast, adjacent normal pancreas showed normal oxygenation.

CONCLUSION

Tumor hypoxia exists within pancreatic cancers.

Successful management of an aneurysmal aortoesophageal fistula

We report a case of aortoesophgeal fistula secondary to the aneurysm of the descending thoracic aorta. The patient presented with massive hematemesis with bright red blood. Patient was operated upon emergently and survived without complication. Six other such cases with successful outcome have been reported before, which depends on the prompt diagnosis and early surgical intervention.

Pneumothorax necessitans presenting as a presternal pneumothoracocele

A 31-year-old woman who is an intravenous drug abuser developed sternoclavicular joint infection with mediastinal and subcutaneous tissue abscesses that communicated through an erosion in the manubrium caused by osteomyelitis. Air entrapment from a subsequent apical pneumothorax formed a localized anterior "pneumothoracocele." We referred to this condition as "pneumothorax necessitans," and we suggest including it in the differential diagnosis of anterior chest wall masses.

Immune-deficient bronchiectasis associated with X-linked lymphoproliferative disease

Bronchiectasis may occur with various congenital and acquired immunodeficiency diseases. The association of bronchiectasis and the X-linked lymphoproliferative disease (XLP), also known as Duncan's disease is unknown. We describe the case of a 39-year-old man with XLP, the oldest surviving, who developed chronic bronchiectasis with hemoptysis and required a pneumonectomy to control his symptoms.

Immunomonitoring followed by optimal dec therapy for successful management of clinical filariasis in an endemic area

Lymphatic filariasis continues to be the major cause of clinical morbidity in India and other developing tropical countries. One of the major lacunae in the effective management of clinical filarial cases is the non-availability of a suitable diagnostic test for confirming filaria aetiology in acute, chronic and occult clinical cases where microfilariae (mf) are not usually seen in peripheral circulation. Studies in our laboratory have shown the usefulness of filarial antibody and antigen assays using microfilarial excretory-secretory (mf ES) antigen in detecting microfilaraemic, acute and chronic filarial cases and in confirming filarial aetiology in occult infections. Diethylcarbamazine citrate (DEC) is the drug of choice for lymphatic filariasis. Different regimens of DEC have been explored in the treatment of microfilaraemic cases. Immunomonitoring has shown that the seroconversion of antigen and antibody positivity was found to be very helpful in determining appropriate period of DEC treatment for clinical relief and cure in clinical filarial patients and further they did not have recurrence in most of the cases. Optimal DEC (6mg/kg body wt/day for 21 days each month for 3-12 months) therapy was found to be very effective in acute and atypical clinical manifestations such as asthmatic bronchitis, pulmonary eosinophilia, monoarthritis, recurrent upper respiratory tract infections (URI), pneumonia (super imposed infections) in children and minimal hydrocele, epididymoorchitis, lymphangitis, lymphadenitis, acute abdomen, central serous retinopathy, tenosynovitis, pain and swelling in limbs and joints in adults living in filaria endemic areas.

Surgical filariasis: immunoscreening for filarial IgG antibodies using Wuchereria bancrofti microfilarial excretory-secretory antigen

A clinical study and immunoscreening was conducted on 363 suspected filarial patients attending the surgery out patient division of the MGIMS, Sevegram. The disease was significantly higher in males (86%) than in females (14%). Majority (52.9%) of the cases were in the age group of 11-30 years. The distribution of cases into three different grades of infection showed, 52.6%, 33.3% and 14.1% of the cases having acute (grade I), sub-acute (grade II) and chronic (grade III) stages of infection respectively. While 73% of the cases had genital manifestations, 23% were with lymphatic obstruction in limbs and the rest of the 4% suffered from manifestations like cellulitis, abscesses, haematuria and chyluria. Filarial IgG antibodies against microfilarial excretory-secretory (mf ES) antigen were detected in 89% of cases with genital manifestations, 87% of lymphoedema cases, 67% of lymphadenitis cases and 60% of cases with other clinical manifestations and 3% of endemic normals.

Low-dose interleukin 1 and tumor necrosis factor individually stimulate insulin release but in combination cause suppression

The macrophage-derived cytokines interleukin 1 (IL-1) and tumor necrosis factor (TNF) have direct effects on pancreatic beta cells and have been hypothesized to play important roles in the autoimmune beta cell lesion of type I diabetes because of two major effects on beta cells: altered insulin secretion and beta cell cytotoxicity. High doses of IL-1 are cytotoxic to beta cells and strongly inhibit insulin release; high-dose IL-1 plus TNF acts synergically to suppress further the insulin release. In contrast, we observed that the predominant effect of low-dose IL-1 and TNF when administered separately was the stimulation of insulin release. We therefore asked whether the combination of low-dose IL-1 plus TNF would act synergistically to stimulate or suppress insulin release. Studies were performed on cultured rat islets and both insulin release and cytotoxicity (51Cr release) were measured. After 2 days of culture, increasing doses of IL-1-25, 50, 75 and 100 ng/l--caused progressively increased cytotoxicity and impaired insulin release. In contrast, the lowest dose of IL-1 tested, 10 ng/l, increased insulin release but was still slightly cytotoxic. Tumor necrosis factor at doses of 10, 25, 62.5, 75 and 100 micrograms/l also was slightly cytotoxic but increased insulin release. The augmented insulin release declined progressively with increasing TNF dose. However the combination of insulin stimulatory doses of IL-1 (10 ng/l) and TNF (62.5 micrograms/l) suppressed insulin release. The effects of these two cytokines on insulin release demonstrated a similar pattern after 4 and 6 days of culture.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracavernous papaverine for impotence in spinal cord injured patients

The majority of the spinal cord injury patients in our centre are young healthy males aged between 20 and 40 years. Loss of erection and inability to have coitus and father children have been responsible for inadequate sociosexual rehabilitation. In 1985, under urologist supervision, intracavernosal papaverine injection treatment was started in 101 volunteers, 65 paraplegics and 36 tetraplegics. Satisfactory erection sufficient for coital penetration was possible in 98 patients. Three had prolonged erection lasting beyond 4 hours. Only one required irrigation of the corpus with saline to achieve detumscence. One patient developed cavernosal fibrosis necessitating discontinuing the injection. Administration was under medical supervision so that possible complications of priapism/systemic effects could be promptly managed.

Vivax malaria causing priapism

We report a 14 year old boy who had priapism induced by vivax malaria. The onset was latent and course was protracted, refractory to anti-malarial and conservative treatment, but satisfactory detumescence was achieved after surgical intervention.

Indirect haemagglutination test for the assay of antibodies against Japanese encephalitis viral antigen in human & animal sera

The indirect haemagglutination (IHA) test was standardized for the assay of antibodies against Japanese encephalitis (JE) virus. Glutaraldehyde fixed sheep erythrocytes were sensitized with purified and concentrated JE vaccine (200-300% brain concentration). The JE vaccine made from Nakayama-NIH strain of JE virus was purified by protamine sulphate treatment and by ultracentrifugation in a sucrose gradient. The sensitized cells were quite stable in liquid as well as in lyophilized state both at -70 degrees C and 4-8 degrees C. These cells could be used for two years without much loss (4-8 times loss) in titre. The IHA test was as sensitive as the neutralization (N) test performed by plaque reduction method in chick embryo fibroblasts. The sensitivity of the test was influenced by the source of erythrocytes i.e., from the different sheep from which these were drawn. After standardization of the test, 16 human sera and 18 sera of immunized mice were assayed for antibodies against JE virus by N and IHA tests. There were no significant differences between titres of both human and mice sera determined by N and IHA tests (P greater than 0.05). The correlation coefficient between N and IHA titres for human sera was 0.60 (P less than 0.05) and for mice sera 0.82 (P less than 0.01). The IHA test has been found to be very simple, inexpensive, sensitive and reproducible.

The standardization of the reverse indirect haemagglutination test for the assay of the viral antigen of Japanese encephalitis vaccine

The reverse indirect haemagglutination (RIHA) test has been standardized for the assay of the viral antigen of purified Japanese encephalitis (JE) vaccine. Glutaraldehyde fixed sheep erythrocytes were sensitized with ammonium sulphate purified antibodies to JE vaccine raised in mice. The sensitivity of the erythrocytes fell to about one hundredth of the initial sensitivity in the first two days after preparation. After initial loss in sensitivity the stability of the cells became stabilized and the cells retained their titre for one year at 4-8 degrees C. The initial loss in sensitivity was not reduced by storing the cells at -70 degrees C, but after freeze drying the sensitized cells with a stabilizer one day after their preparation the cells retained their sensitivity. The RIHA test has been found to be a highly reproducible and sensitive method for detecting viral antigen in 5-10 ng of protein nitrogen. The sensitivity of the test was affected by the origins of the erythrocytes, i.e. from the different sheep from which they were drawn. To obtain results more rapidly, goose erythrocytes were used in place of sheep erythrocytes and the sensitized goose erythrocytes gave RIHA results in only 40 min.