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.

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.

Hatemongers ride on echo chambers to escalate hate speech diffusion

Recent years have witnessed a swelling rise of hateful and abusive content over online social networks. While detection and moderation of hate speech have been the early go-to countermeasures, the solution requires a deeper exploration of the dynamics of hate generation and propagation. We analyze more than 32 million posts from over 6.8 million users across three popular online social networks to investigate the interrelations between hateful behavior, information dissemination, and polarized organization mediated by echo chambers. We find that hatemongers play a more crucial role in governing the spread of information compared to singled-out hateful content. This observation holds for both the growth of information cascades as well as the conglomeration of hateful actors. Dissection of the core-wise distribution of these networks points towards the fact that hateful users acquire a more well-connected position in the social network and often flock together to build up information cascades. We observe that this cohesion is far from mere organized behavior; instead, in these networks, hatemongers dominate the echo chambers-groups of users actively align themselves to specific ideological positions. The observed dominance of hateful users to inflate information cascades is primarily via user interactions amplified within these echo chambers. We conclude our study with a cautionary note that popularity-based recommendation of content is susceptible to be exploited by hatemongers given their potential to escalate content popularity via echo-chambered interactions.

Mental Health Impacts of Quarantine: Insights from the COVID-19 International Border Surveillance Study in Toronto, Canada

Introduction

Nations thorughout the world are imposing mandatory quarantine on those entering the country. While such measures may be effective in reducing the importation of COVID-19, the mental health implications remain unclear.

Objectives

This study sought to assess mental well-being and factors associated with changes in mental health in individuals subject to mandatory quarantine following travel.

Methods

Travellers arriving at a large urban international airport completed online questionnaires on arrival and days 7 and 14 of mandated quarantine. Questionnaire items such as travel history, mental health, attitudes towards COVID-19, and protection behaviours were drawn from the World Health Organization Survey Tool for COVID-19.

Results

There was a clinically significant decline in mental health over the course of quarantine among the 10,965 eligible participants. Poor mental health was reported by 5.1% of participants on arrival and 26% on day 7 of quarantine. Factors associated with greater decline in mental health were younger age, female gender, negative views towards quarantine measures, and engaging in fewer COVID-19 prevention behaviours.

Conclusions

While the widespread use of quarantine may be effective in limiting the spread of COVID-19, the mental health implications are profound and have largely been ignored in public policy decision-making. Psychiatry has a role to play in contributing to the public policy debate to ensure that all aspects of health and well-being are reflected in decisions to isolate people from others.

Disclosure

No significant relationships.

Particle composition and morphology over urban environment (New Delhi): Plausible effects on wheat leaves

Particulate matter (PM) deposition on leaves adversely affects physical, chemical and biological nature of agricultural crops resulting in their loss of productivity and yield. Wheat being a staple food in major parts of Northern India and around the World, has been selected for research purpose by designing a study to explore the probable effects of PM deposition on wheat leaves and wheat crops to ensure the food security. PM₅ (Particulate matter with aerodynamic diameter <5 μm) and Dry Deposited Particulate Matter (DDPM) on wheat leaves (Leaf_DDPM) were collected from the wheat crop field in Indian Agriculture Research Institute (IARI), New Delhi for growing and harvesting season of wheat crops (i.e. December 2014 to April 2015). The EDS (Energy Dispersive Spectroscopy) analysis was used for this study and the individual particle analysis revealed the presence of both acidic and alkaline components like C, Al, Si, Fe, Ca, K, S and Mg. The offline characterization tool i.e. SEM (Scanning Electron Microscope) was utilized for obtaining the micrographs which clearly showed the presence of some angular, sharp-edged and spherical particles consisting of both smooth and rough texture. Apart from that, prevalence of slightly non-spherical particles with aspect ratio of range (>1.20-1.40) and CIR (>0.70-0.80) for both PM₅ and leaf_DDPM were observed. The size distribution of individual particles for both PM₅(#194 particles) and Leaf_DDPM(#657 particles) revealed that Surface Equivalent Radius (SER) and Volume Equivalent Radius (VER) of particles observed to be 0.40-0.80 μm while surface area to be 0-1 μm². These particles may easily block stomatal openings (with typical diameter range: 42-51 μm) of wheat leaves and damage internal leaf tissues while particle VER determines the interaction of incoming solar radiation with leaf surfaces. Average PM₅ concentrations ± Standard deviations (μg/m³) were reported to be 231.05 ± 113.03. The XRF (X-Ray Fluorescence) spectrometer analysis of bulk PM₅ revealed the concentrations of non-carbonaceous elements (μg/m³) as N (67.34 ± 16.09), Si (27.44 ± 11.01), Al (7.79 ± 3.37), S (3.88 ± 2.24), Na (2.29 ± 0.94), Mg (1.65 ± 0.62), K (0.51 ± 0.26), Ca (0.60 ± 0.26), Fe (0.54 ± 0.26), Cr (1.10 ± 0.70), Zn (0.05 ± 0.03), P (0.10 ± 0.03), Cu (0.07 ± 0.06). The dominant elemental oxides were calculated as SiO₂, Al₂O₃, SO₄^2-, Na₂O, MgO, K₂O, CaO, Fe₂O₃, Cr₂O₃, ZnO, P₂O₅, Cu₂O with variable concentrations. In high humid conditions, with relative humidity (~85%) during the vegetative and flowering growth stages of wheat crops, presence of C and S rich acidic and hygroscopic particles may cause the corrosion of wheat leaves that ultimately affect the wheat crops.

HELF (Haptic Encoded Language Framework): a digital script for deaf-blind and visually impaired

PURPOSE

Digital media has brought a revolution, making the world a global village. For people who are visually impaired and people with visual and hearing impairment, navigating through the digital world can be as precarious as moving through the real world. To enable them to connect with the digital world, we propose a solution, Haptic Encoded Language Framework (HELF), that uses haptic technology to enable them to write digital text using swiping gestures and understand the text through vibrations.

METHOD

We developed an Android application to present the concept of HELF and evaluate its performance. We tested the application on 13 users (five visually impaired and eight sighted individuals).

RESULTS

The preliminary exploratory analysis of the proposed framework using the Android application developed reveals encouraging results. Overall, the reading accuracy has been found to be approximately 91%, and the average CPM is found to be 25.7.

CONCLUSION

The volunteering users of the HELF Android application found it useful as a means of using the digital media and recommended its usage as an assistive technology for the visually challenged. The results of their performance of using the application motivate further research and development in the proposed work to make HELF more usable by people who are visually impaired and people with visual and hearing impairment.

Practical consensus recommendations regarding the management of hormone receptor positive early breast cancer in elderly women

Breast cancer is a leading cause of death among women, and its incidence increases with age. Currently the treatment of breast cancer in older patients is almost identical to their younger counterparts. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists regarding the management of early breast cancer specifically in elderly women.

Performance evaluation of light weight gas sensor system suitable for airborne applications against co-location gas analysers over Delhi

In the present work, we discuss the light-weight gas sensor system (LWGSS) [350 g, 7″ ∗ 3″] originally developed at CSIR-National Physical Laboratory. This instrument is equipped with low-cost electrolytic gas sensors for quantifying major gaseous pollutants present in the atmosphere. Alphasense electrochemical gas sensors were used to measure gas pollutant species such as CO, SO₂, NO₂, O₃ and H₂S. In our experiment, we focus on the observation of CO, SO₂, NO₂, O₃ using this system. LWGSS has been designed for vertical observations using balloons or unmanned aerial vehicles (UAVs) to study the gaseous concentration in the atmospheric boundary layer (ABL). But, before using such instruments in field campaigns, there is a strong need for the inter-comparison of these instruments with that of the collocated high-end gas analysers. Thus, the inter-comparisons were performed between LWGSS and other high-end analysers during 6-7, March 2017 and 26-27, April 2017. The LWGSS system comprising all the sensors was compared against high-end analyser present at CSIR-NPL for ozone and other gas analysers present at IMD, New Delhi. The ozone sensor deployed in LWGSS showed good correlation (i.e. R² = 0.83, slope = 0.93) against the high-end ozone gas analyser, which was calibrated with primary ozone facility (SRP43) available at CSIR-NPL. Inter-comparisons performed for NO₂, SO₂ and CO showed different results. While the NO₂ gas sensor showed medium correlation (R² = 0.75; slope = 0.49), the SO₂ and CO gas sensor showed a poor correlation (and R² = 0.44; slope = 0.98; R² = 0.28, slope = 0.79) respectively, when compared with co-location gas analysers present at IMD, New Delhi. Comparisons were performed for LWGSS data during 1-28 February 2018 with data collected at CPCB station (Shadipur, Delhi) and IMD station (Pusa, Delhi). The comparison results showed variations in LWGSS CO and SO₂ data whereas LWGSS O₃ and NO₂ results were in accordance with data collected at aforementioned monitoring stations.

Deep tubewell microbial water quality and access in arsenic mitigation programs in rural Bangladesh

The objective of this paper is to determine whether deep tubewells installed through arsenic mitigation efforts in rural Bangladesh provide better drinking water microbial quality compared to shallow tubewells. We conducted a stratified random cross-sectional survey of 484 households to assess microbial contamination of deep tubewell water at source and at point of use (POU) compared to shallow tubewell water using the Compartment Bag Test. In addition, we measured storage time, distance, travel time and ownership status among both sets of users to assess deep tubewell efficacy and under what conditions they offer poorer or better water quality. Differences in tubewell characteristics were compared using non-parametric Mann-Whitney U tests and two-proportion Z-tests. Prevalence ratios of microbial contamination stratified by water quality, storage time and distance to tubewells and ownership were estimated using unadjusted Mantel-Haenszel tests. There was no significant difference in microbial contamination between shallow and deep tubewells at source. The presence of POU water microbial contamination in storage containers in deep tubewell households was 1.11 times the prevalence in shallow tubewell storage containers (95% CI = 0.97-1.27). Deep tubewell users stored water longer and walked significantly farther to obtain water compared to shallow tubewell users. Among deep tubewell households, those residing farther away from the source were 1.24 times as likely to drink contaminated water from storage containers compared to those located nearby (95% CI = 1.04-1.48). Our findings suggest that deep tubewells have comparable water quality to shallow tubewells at source, but increasing distance from the household exacerbates risk of microbial contamination at POU.

Study of efficacy and safety of modified adjuvant intraperitoneal chemotherapy regimen in carcinoma ovary

OBJECTIVE

It has been demonstrated in few trials that intraperitoneal and intravenous (IP/IV) chemotherapy improves survival in advanced stage ovarian cancer (OC). However, in view of high treatment-related toxicities, various modifications in treatment schedules have been tried. In this study, response and tolerability of IP paclitaxel on day 8 with IV paclitaxel on day 1 and IV cisplatin day 2 in carcinoma ovary were evaluated.

PATIENTS AND METHODS

In this prospective observational study, from March 2013 to December 2015, the efficacy and tolerability of adjuvant IP/IV chemotherapy in optimally cytoreduced Stage III epithelial OC (EOC) patients were assessed.

RESULTS

Totally, sixty patients were enrolled. The median age of patients was 53 years (32-67 years). Out of a total of 360 IP cycles, 316 cycles (88%) were completed. Forty-five patients (76%) received all the 6 cycles by IP route. Eight out of those 45 patients had one or more adjustment including delay or dose reduction. After median follow-up of 22 months, eight patients (14%) had local or systemic recurrence. Median progression-free survival not reached yet. Catheter block was seen in five cases. Two cases had needle displacement and extravasations of drug around the port chamber. Six patients had Grade 3 abdominal pain and cramp. Grade 3/4 leukopenia was experienced by thirty patients (50%), but febrile neutropenia occurred in only 6 (10%) patients. Renal complication present in 4 (7%) patients.

CONCLUSIONS

In Indian patients, adjuvant chemotherapy with day 8 I/P paclitaxel in optimally cytoreduced EOC is associated with comparable survival outcomes, less side effects and high treatment completion rate relative to literature published from Western countries.

Efficacy and toxicity of cetuximab with chemotherapy in recurrent and metastatic head and neck cancer: A prospective observational study

BACKGROUND

In squamous cell carcinoma of the head and neck (SCCHN), epidermal growth factor receptor is expressed at very high levels. Hence, we have done this study to assess the response and tolerability of cetuximab and platinum-based chemotherapy in recurrent and metastatic (R/M) head and neck squamous cell cancer (HNSCC) in view of paucity of data from the Indian subcontinent.

MATERIALS AND METHODS

In this prospective study, patients of R/M SCCHN were randomly enrolled from September 2012 to April 2015. Chemotherapy (cisplatin/carboplatin/5-fluorouracil) and cetuximab-based treatment were administered up to 6 cycles or unacceptable toxicity. The response rates (RRs), progression-free survival (PFS), and overall survival (OS) were analyzed.

RESULTS

In total, fifty patients were enrolled. The median age was 51.0 years. A total of 255 cycles of treatment were administered (median = 6 cycles/patient). Four patients (8.0%) experienced complete response and 21 (42.0%) experienced partial response. Twenty-one patients (42.0%) had stable disease and four patients (8.0%) experienced progressive disease. The disease control rate was 92.0%. Median PFS was 5.3 months (95% confidence interval [CI]: 4.52-6.14 months). Median OS was 9.933 months (95% CI: 8.58-11.28 months). There was statistically significant correlation between overall response and Eastern Cooperative Oncology Group performance status (P = 0.014), site of tumor (P = 0.027), and histological grade of tumor (P = 0.001). The main Grade 3/4 side effects seen were hematological in 44 (88%) and gastrointestinal in 28 (56%) patients.

CONCLUSIONS

The RR of cetuximab plus chemotherapy of> 45% and the promising PFS rates are strong arguments for clinically testing this combination and this treatment schedule further in R/M HNSCC.

Primary renal primitive neuroectodermal tumor

Primitive Neuroectodermal Tumor of the kidney is a rare entity. Very few cases of primary renal PNET have been reported to date. Most literature about rPNET is isolated case reports. We report a case of rPNET in a 39-year-old male with a pre-operative diagnosis of renal cell carcinoma with renal vein thrombosis. The patient underwent radical nephrectomy with thrombolectomy, and histopathological examination revealed a highly aggressive tumor composed of monotonous sheets of round cells. Tumor cells were positive for CD 99 and FLI-1, hence confirming the diagnosis of Primitive Neuroectodermal Tumor. Post-surgery, patient was given VAC/IE-based adjuvant chemotherapy. In view of highly aggressive nature of this tumor, prompt diagnosis and imparting effective chemotherapy regimen to the patient is required, and it is important to differentiate PNET from other small round-cell tumors because of different therapeutic approach.

The development and validation of a meta-tool for quality appraisal of public health evidence: Meta Quality Appraisal Tool (MetaQAT)

OBJECTIVES

Most quality appraisal tools were developed for clinical medicine and tend to be study-specific with a strong emphasis on risk of bias. In order to be more relevant to public health, an appropriate quality appraisal tool needs to be less reliant on the evidence hierarchy and consider practice applicability. Given the broad range of study designs used in public health, the objective of this study was to develop and validate a meta-tool that combines public health-focused principles of appraisal coupled with a set of design-specific companion tools.

STUDY DESIGN

Several design methods were used to develop and validate the tool including literature review, synthesis, and validation with a reference standard.

METHODS

A search of critical appraisal tools relevant to public health was conducted; core concepts were collated. The resulting framework was piloted during three feedback sessions with public health practitioners. Following subsequent revisions, the final meta-tool, the Meta Quality Appraisal Tool (MetaQAT), was then validated through a content analysis of appraisals conducted by two groups of experienced public health researchers (MetaQAT vs generic appraisal form).

RESULTS

The MetaQAT framework consists of four domains: relevancy, reliability, validity, and applicability. In addition, a companion tool was assembled from existing critical appraisal tools to provide study design-specific guidance on validity appraisal. Content analysis showed similar methodological and generalizability concerns were raised by both groups; however, the MetaQAT appraisers commented more extensively on applicability to public health practice.

CONCLUSIONS

Critical appraisal tools designed for clinical medicine have limitations for use in the context of public health. The meta-tool structure of the MetaQAT allows for rigorous appraisal, while allowing users to simultaneously appraise the multitude of study designs relevant to public health research and assess non-standard domains, such as applicability.

Effect of Red Bull energy drink on muscle performance: an electromyographic overview

AIM

The present study was aimed at investigating the effect of Red Bull Energy drink (RB) on muscle endurance and fatigue.

METHODS

Twenty students of second year MBBS (males N.=10, females N.=10) were involved in a cross over design separated by 7 days, where they received either RB (caffeine at 2 mg/kg body weight) or isoenergetic, isovolumetric, noncaffeinated control drink (CD). After one hour of intake of the drink, maximum isometric force (MVC) and electromyogram (EMG) (flexor carpi radialis) were recorded from the dominant hand using Biopac Systems. After MVC, all subjects performed a sustained isometric contraction at 75% of MVC to fatigue. The Root mean square amplitude (RMS) and mean frequency (MNF) were calculated from the EMG data. Statistical analysis was done using r within and across groups.

RESULTS

Following consumption of RB, the fatigue task showed a decreased tendency to fatigue based on the MNF value for both the drinks. However the EMG index with reference to RMS was inconclusive to interpret any delaying effect on fatigue. There was no significant difference between the two drinks in the parameters assessed during MVC and endurance time.

CONCLUSION

The Red Bull energy drink (caffeine at 2 mg/kg body weight) was no better than CD at significant delaying effect on fatigue during isometric contraction.

Ruptured Gall Bladder containing Stones following Blunt Trauma Abdomen: A Rare Presentation of Hemodynamic Instability

Gall bladder injuries are seen in 2% of patients undergoing laparotomy for blunt trauma abdomen. Isolated gall bladder injury is a rare event with associated presence of stones is even rarer. The associated visceral injuries lead to intraoperative identification in most cases. Here we present a case of 30 years old male with isolated gall bladder laceration following blunt abdominal trauma. The diagnosis of gallbladder perforation after blunt injury may be suspected in patients with signs of an acute abdomen and hypotension that is not explained by blood loss. Early suspicion and prompt exploration is imperative. Cholecystectomy is an adequate treatment for the condition.

Role of the right prefrontal cortex in ill-structured planning

We tested an architect with a lesion to the right prefrontal cortex in a real-world architectural design/planning task that required him to develop a new design for our lab space and compared his performance to an age- and education-matched architect. The patient understood the task and even observed that "this is a very simple problem." His sophisticated architectural knowledge base was still intact and he used it quite skilfully during the problem structuring phase. However, the patient's problem-solving behaviour differed from the control's behaviour in the following ways: (1) he was unable to make the transition from problem structuring to problem solving; (2) as a result preliminary design did not start until two thirds of the way into the session; (3) the preliminary design phase was minimal and erratic, consisting of three independently generated fragments; (4) there was no progression or lateral development of these fragments; (5) there was no carry-over of abstract information into the preliminary design or later phases, and (6) the patient did not make it to the detailing phase. This suggests that the key to understanding our patient's deficit is to understand the cognitive processes and mechanisms involved in the preliminary design phase. We appeal to a theory of design problem solving (Goel, 1995) that associates cognitive processes involved in preliminary design with "lateral" state transformations and argues that "ill-structured" representational and computational systems are necessary to support these transformations. We conclude that the neural basis of this system is selectively damaged in our patient.

Persistent Müllerian duct syndrome with transverse testicular ectopia presenting as an incarcerated inguinal hernia

The presence of both of the testes in one scrotal sac is one of the very rare presentations of testicular ectopia, which is known as transverse testicular ectopia (TTE) and is also known as crossed testicular ectopia. The presence of the uterus and fallopian tubes in a normally virilized male is termed as persistent Müllerian duct syndrome (PMDS). We report a case of an adult male who had a unique combination of both TTE and PMDS presenting as an incarcerated inguinal hernia.

Changes in neurohormonal gut peptides following bariatric surgery

The rising prevalence of obesity has reached pandemic proportions, with an associated cost estimated at up to 7% of health expenditures worldwide. Bariatric surgery is currently the only effective long-term treatment for obesity and obesity-related co-morbidities in clinically severely obese patients. However, the precise physiological mechanisms underlying the postsurgical reductions in caloric intake and body weight are poorly comprehended. It has been suggested that changes in hormones involved in hunger, food intake and satiety via the neurohormonal network may contribute to the efficacy of bariatric procedures. In this review, we consider how gastrointestinal hormone concentrations, involved in appetite and body weight regulation via the gut-brain axis, are altered by different bariatric procedures. Special emphasis is placed on neurohormonal changes following Roux-en-Y gastric bypass surgery, which is the most common and effective procedure used today.

Results of invasive cervical cancer patients undergoing inadvertent hysterectomy followed by salvage radiotherapy

15034

Background: Ca cervix is the leading gynecologic malignancy in India. Conventional treatment consists of radical hysterectomy or primary radiotherapy. Due to inadequate preop workup, invasive ca cervix has been incidentally found in surgical specimens after simple hysterectomy. Extrafascial hysterectomy is not curative as paracervical, paravaginal soft tissues & vaginal cuff are not removed. It is technically difficult to perform adequate radical surgery after a previous simple hysterectomy. It is critical that these patients receive postop RT immediately after surgery; otherwise the prognosis is much worse. Methods: Retrospective analyses of 68 patients of ca cervix referred to our Institute after simple hysterectomy for presumed benign or preinvasive cervical disease was done. The median age was 44 yrs (35–65). 18 pts (26.5%) were pre menopausal while 50 (73.5%) were post menopausal. Exact postop staging was not possible; however 40 pts (59%) had residual growth at vault, 4 had involvement of vagina and in 18 cases parametrial infiltration was evident. Postop USG showed median tumor size of 4.4 cm, hydronephrosis in 17.6% & bladder infiltration in 5.8% pts. Histopathology was squamous cell carcinoma in 97% cases. Results: All patients were treated with EBRT to whole pelvis (dose 50 Gy/25 Fr to 50.4 Gy/28 Fr) over 5-weeks, followed by central vaginal surface HDR brachytherapy (Dose 21 Gy/3 Fr). At an average follow up of 18 to 24 months post RT residual disease was present in 2 (2.9%), local recurrence in 6 (8.6%), scar recurrence in 2 (2.9%) and distant failures in 4 patients (5.8%). Radiation proctitis developed in 2, SAIO in 2, RVF in one and VVF in one patient. All local and distant failures were seen in patients with residual disease before starting RT. Poor response to RT was seen in patients elder than 40 years and when OTT was more than 75 days. No significant correlation was seen between local response rate and type or grade of tumor. Conclusion: Survival for patients with no residual cancer after simple hysterectomy is favorable; & poor for those with gross disease at the start of post hysterectomy treatment. EBRT combined with one or two fractions of intravaginal brachytherapy in the immediate postop period can achieve satisfactory disease control.

No significant financial relationships to disclose.

Impact of prolongation of overall treatment time and timing of brachytherapy on outcome of radiation therapy in carcinoma of uterine cervix

15032

Background: Studies have described decreased pelvic control & survival rates in invasive ca cervix when overall time in definitive RT is prolonged. We evaluated impact of timing of brachytherapy on outcome. Methods: Retrospective analysis of 338 patients of ca cervix treated with radical RT from Jan 2002 to Dec 2002 at Mahavir Cancer Sansthan Patna. The median age was 50 yrs (23–80 yrs). 73% patients were postmenopausal. Histopathology was Squamous Cell in 97% patients. Most common presenting complaints were bleeding P/V (92%) & discharge P/V (82%); with stage I (3%), II (35%), III (43%), IV (5%), unknown stage in 14% cases. Results: Records of 338 patients (Stage IB to III) treated with definitive irradiation (combination of EBRT & ICRT) were reviewed with reference to loco regional control, distant failure and its correlation with patient and tumor variables including OTT. Out of 302 patients who received complete RT, 24 received 60 Gy in 30 fractions as they were found to be unsuitable or were unwilling for ICRT. The rest received a dose of 50 Gy/25 Fr to 50.4 Gy/28 Fr over a median duration of 37 days. 30 patients received concomitant chemo radiation (cisplatin 40 mg/m2/4 cycles). 276 patients received ICRT (dose 21 Gy in 3 Fractions with a median gap of 43 days (range 5–111) after completion of ERT. The median OTT for completion of ERT & ICRT was 75 days (range 54–177). At an average follow up of 18- 24 months residual disease was seen in 2 cases (0.6%), local recurrence in 14 cases (4%) & distant failure in 14 cases (4%). Post RT complications were seen in 4.7% cases and included small bowel obstruction in 6 cases, VVF in 4 & RVF in 6 cases. Significant correlation was seen between OTT and rate of loco regional recurrences. All local recurrences were seen when OTT was more than 75 days. No significant correlation could be drawn between age, Hemoglobin, tumor histology, & bulky vs. non bulky tumor on loco regional and distant failure. Conclusions: Longer radiotherapy completion time was found to be associated with diminished survival outcomes for patients treated radically for carcinoma cervix. The significance of this observed association requires further investigation & correction to keep OTT as short as possible.

No significant financial relationships to disclose.

Stress, social support, and emotional distress in a community sample of pregnant women

Emotional distress in women during pregnancy has been shown to increase the risk of adverse outcomes for women and newborns. Increasingly, assessment and management of mood and anxiety problems during pregnancy entail consideration of life stress and interpersonal relationships with partners, friends, and family members. This study describes cross-sectional relations between life stress, perceived social support, and symptoms of depression and anxiety as well as the mediating influence of social support on relations between stress and symptoms. A community sample of women (N = 2,052) provided self-report data during their second trimester of pregnancy. Empirical fit was found for a structural equation model that depicted the combined influences of sociodemographic factors (i.e., socioeconomic status, age, parity), stress (partner conflict and life events), and social support on symptoms of depression and anxiety, chi2 (df 51) = 310.65, p <.05; CFI=.91. Women who reported low levels of social support showed stronger relations between stress and symptoms than women who reported high levels of social support--indicative of a mediating effect of social support. Consistent with previous studies, results suggest that dyadic psychosocial assessment of pregnant women and their partners may facilitate interventions to augment support networks, thereby reducing the risk of emotional distress.

Efficacy of a standardized echinacea preparation (EchinilinTM) for the treatment of the common cold: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Recently, echinacea has regained popularity as one of the treatments chosen most commonly by consumers with the expectation that it will reduce the severity and duration of the common cold. However, the results from a limited number of clinical trials for this application have thus far been inconclusive. This incongruity may be the result of investigators utilizing poorly standardized echinacea products, likely devoid of sufficient quantities of active constituents necessary to exert a definitive clinical effect. Therefore, a formulation containing alkamides, cichoric acid, and polysaccharides at concentrations of 0.25, 2.5, and 25 mg/mL, respectively, was prepared from freshly harvested Echinacea purpurea plants (commercially available as Echinilin, Natural Factors Nutritional Products, Inc., Vancouver, BC, Canada). The objective of this study was to test the efficacy of this highly standardized formulation in reducing the severity and duration of symptoms of a naturally acquired common cold.

METHODS

In a randomized, double-blind, placebo-controlled trial, 282 subjects aged 18-65 years with a history of two or more colds in the previous year, but otherwise in good health, were recruited. The subjects were randomized to receive either echinacea or placebo. They were instructed to start the echinacea or placebo at the onset of the first symptom related to a cold, consuming 10 doses the first day and four doses per day on subsequent days for 7 days. Severity of symptoms (10-point scale: 0, minimum; 9, maximum) and dosing were recorded daily. A nurse examined the subjects on the mornings of days 3 and 8 of their cold.

RESULTS

A total of 128 subjects contracted a common cold (59 echinacea, 69 placebo). The total daily symptom scores were found to be 23.1% lower in the echinacea group than in placebo in those who followed all elements of the study protocol (P<0.01). Throughout the treatment period, the response rate to treatments was greater in the echinacea group. A few adverse event profiles were observed in both groups.

CONCLUSIONS

Early intervention with a standardized formulation of echinacea resulted in reduced symptom severity in subjects with naturally acquired upper respiratory tract infection. Further studies with larger patient populations appear to be warranted.