Association of follow-up imaging frequency with temporal incidence and patterns of distant failure following (chemo) radiotherapy for HPV related oropharyngeal cancer

OBJECTIVES

Emerging data supports radical intent therapy for oligometastatic (OM) relapsed human papilloma virus (HPV+) related oropharyngeal cancer (OPC). We assess the association of follow-up imaging frequency amongst HPV + OPC, with temporal and spatial patterns of distant relapse, to inform rationalisation of routine post-treatment imaging.

MATERIALS AND METHODS

A retrospective single centre cohort study was carried out of consecutive HPV + OPC patients treated with radical intent (chemo)radiotherapy ((CT)RT) between 2011 and 2019. OM state was defined as ≤ 5 metastasis, none larger than 3 cm (OMs) or, if interval from last negative surveillance imaging > 6-months, then ≤ 10 metastasis, none larger than 5 cm, (OMp). Patients not meeting OMs / OMp criteria were deemed to have incurable diffuse metastatic disease (DMdiffuse).

RESULTS

793 HPV-OPC patients were identified with median follow-up 3.15years (range 0.2-8.9). 52 (6.6 %) patients had radiologically identified DM at first failure and were considered for analysis. The median time to recurrence was 15.1 months (range: 2.6-63 months). 87 % of distant metastasis (DM) occurred in the first two years after treatment. Twenty-seven (52 %) patients had OM (OMs or OMp) at time of failure, with 31 % having OMs. The median time from completion of treatment to diagnosis of DMdiffuse vs OM was 22.2 months (range: 2.6-63.1 months) vs 11.6 months (range: 3.5-32.5 months). The probability of being diagnosed with OM vs DMdiffuse increased with reducing interval from last negative surveillance scan to imaging identifying DM (≤6 months 88.9 %, 7-12 months 71.4 %, 13-24 months 35 %, > 24 months 22.2 %).

CONCLUSION

We demonstrate that a reduced interval between last negative imaging and subsequent radiological diagnosis of DM is associated with increased likelihood of identification of OM disease. Consideration of increased frequency of surveillance imaging during the first two years of follow up is supported, particularly for patients at high risk of distant failure.

Temporal Incidence and Patterns of Distant Failure for Human Papillomavirus (HPV) Related Oropharyngeal Cancer

PURPOSE/OBJECTIVE(S)

HPV related oropharyngeal cancer (HPV-OPC) enjoys improved treatment outcomes relative to non-HPV related disease but suffers from similar rates of distant metastases (DM) following treatment. Emerging data supports radical intent therapy for oligometastatic relapsed HPV-OPC, suggesting early diagnosis of DM may be beneficial to outcome. We assess temporal patterns in distance relapse to investigate rationalization of post treatment imaging.

MATERIALS/METHODS

A retrospective single center cohort study was carried out of consecutive HPV-OPC treated with radical intent (chemo)radiotherapy ((CT)RT) between 2011 and 2020. Electronic records were reviewed to identify location and timing of development of DM. Oligometastatic (OM) state was defined as

RESULTS

A total of 793 HPV-OPC patients were identified with median follow-up 3.15 years (range 0.2-8.9). The median time to recurrence was 15.1 months (range: 2.6-63 months). 87% of DM occurred in the first two years after treatment. Pattern of failure by stage are shown in table 1. Indications for scans performed identifying DM alone were symptoms (66%), follow-up imaging based on previous radiological findings (15%), disease response assessment imaging (15%), and incidental findings (4%). Sites of distant metastasis were lung (64%), thoracic nodes (36.5%), bone (27%), visceral (23%), brain (4%) and skin (2%). The sites of visceral metastasis involvement included liver (92%), Adrenal (18%), kidney (18%), and spleen (9%). Treatment offered to patients with OM alone was best supportive care (46%), palliative chemotherapy (15.4%), palliative RT (23%), immunotherapy (8%), and one patient lost to follow up (8%). SBRT was not available during time period. Median survival following diagnosis was 17.5 months (range 4.4-85.4 months).

CONCLUSION

Despite no routine imaging beyond initial treatment response assessment, we identify a small minority of HPV OPC patients with OM recurrence that is associated with better outcome and occasional long-term cure from aggressive therapy. The majority (69%) of DM occur in the thorax/upper abdomen of patients in the first two years post treatment. This finding supports the potential utility of regular imaging of thorax/upper abdomen during early follow.

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Affiliation(s)

J Gaffney The Christie NHS Foundation Trust, Manchester, United Kingdom
A Ramzan Department of Radiology, The Christie NHS Foundation Trust, Manchester, United Kingdom
T Dinizulu Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
D O Onamusi The University of Manchester, Manchester, United Kingdom
G Motamedi-Ghahfarokhi The University of Manchester, Manchester, United Kingdom
H Mistry The University of Manchester, Manchester, United Kingdom
G Price The Christie NHS Foundation Trust, Manchester, United Kingdom; The University of Manchester, Manchester, United Kingdom
K Garcez Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
C Hughes Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
D D Thomson The Christie NHS Foundation Trust, Manchester, United Kingdom
L W Lee Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
Y Jain Department of Radiology, The Christie NHS Foundation Trust, Manchester, United Kingdom
J M Price Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
A McPartlin Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada

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Abiraterone acetate plus prednisolone with or without enzalutamide for patients with metastatic prostate cancer starting androgen deprivation therapy: final results from two randomised phase 3 trials of the STAMPEDE platform protocol

BACKGROUND

Abiraterone acetate plus prednisolone (herein referred to as abiraterone) or enzalutamide added at the start of androgen deprivation therapy improves outcomes for patients with metastatic prostate cancer. Here, we aimed to evaluate long-term outcomes and test whether combining enzalutamide with abiraterone and androgen deprivation therapy improves survival.

METHODS

We analysed two open-label, randomised, controlled, phase 3 trials of the STAMPEDE platform protocol, with no overlapping controls, conducted at 117 sites in the UK and Switzerland. Eligible patients (no age restriction) had metastatic, histologically-confirmed prostate adenocarcinoma; a WHO performance status of 0-2; and adequate haematological, renal, and liver function. Patients were randomly assigned (1:1) using a computerised algorithm and a minimisation technique to either standard of care (androgen deprivation therapy; docetaxel 75 mg/m² intravenously for six cycles with prednisolone 10 mg orally once per day allowed from Dec 17, 2015) or standard of care plus abiraterone acetate 1000 mg and prednisolone 5 mg (in the abiraterone trial) orally or abiraterone acetate and prednisolone plus enzalutamide 160 mg orally once a day (in the abiraterone and enzalutamide trial). Patients were stratified by centre, age, WHO performance status, type of androgen deprivation therapy, use of aspirin or non-steroidal anti-inflammatory drugs, pelvic nodal status, planned radiotherapy, and planned docetaxel use. The primary outcome was overall survival assessed in the intention-to-treat population. Safety was assessed in all patients who started treatment. A fixed-effects meta-analysis of individual patient data was used to compare differences in survival between the two trials. STAMPEDE is registered with ClinicalTrials.gov (NCT00268476) and ISRCTN (ISRCTN78818544).

FINDINGS

Between Nov 15, 2011, and Jan 17, 2014, 1003 patients were randomly assigned to standard of care (n=502) or standard of care plus abiraterone (n=501) in the abiraterone trial. Between July 29, 2014, and March 31, 2016, 916 patients were randomly assigned to standard of care (n=454) or standard of care plus abiraterone and enzalutamide (n=462) in the abiraterone and enzalutamide trial. Median follow-up was 96 months (IQR 86-107) in the abiraterone trial and 72 months (61-74) in the abiraterone and enzalutamide trial. In the abiraterone trial, median overall survival was 76·6 months (95% CI 67·8-86·9) in the abiraterone group versus 45·7 months (41·6-52·0) in the standard of care group (hazard ratio [HR] 0·62 [95% CI 0·53-0·73]; p<0·0001). In the abiraterone and enzalutamide trial, median overall survival was 73·1 months (61·9-81·3) in the abiraterone and enzalutamide group versus 51·8 months (45·3-59·0) in the standard of care group (HR 0·65 [0·55-0·77]; p<0·0001). We found no difference in the treatment effect between these two trials (interaction HR 1·05 [0·83-1·32]; p_interaction=0·71) or between-trial heterogeneity (I² p=0·70). In the first 5 years of treatment, grade 3-5 toxic effects were higher when abiraterone was added to standard of care (271 [54%] of 498 vs 192 [38%] of 502 with standard of care) and the highest toxic effects were seen when abiraterone and enzalutamide were added to standard of care (302 [68%] of 445 vs 204 [45%] of 454 with standard of care). Cardiac causes were the most common cause of death due to adverse events (five [1%] with standard of care plus abiraterone and enzalutamide [two attributed to treatment] and one (<1%) with standard of care in the abiraterone trial).

INTERPRETATION

Enzalutamide and abiraterone should not be combined for patients with prostate cancer starting long-term androgen deprivation therapy. Clinically important improvements in survival from addition of abiraterone to androgen deprivation therapy are maintained for longer than 7 years.

FUNDING

Cancer Research UK, UK Medical Research Council, Swiss Group for Clinical Cancer Research, Janssen, and Astellas.

Centralised RECIST Assessment and Clinical Outcomes with Lenvatinib Monotherapy in Recurrent and Metastatic Adenoid Cystic Carcinoma

Simple Summary

Adenoid cystic carcinoma (ACC) is a rare cancer of the head and neck. Initial treatment may involve surgery and/or radiotherapy with the aim of removing the cancer and preventing spread to other parts of the body. In patients in whom ACC has recurred or spread, systemic therapies such as chemotherapy or immunotherapy have been shown to have minimal benefit and there are currently no recommended standard systemic treatment options. More recently, the targeted therapy lenvatinib has shown promising results in treating ACC patients. We aimed to summarise the real-world experience of lenvatinib use in ACC patients in the UK and found that although some patients obtained clinical benefit, there were no significant responses on radiological imaging by centralized assessment.

Abstract

Adenoid cystic carcinoma (ACC) is a rare cancer of secretory glands. Recurrent or metastatic (R/M) ACC is generally considered resistant to cytotoxic chemotherapy. Recent phase II studies have reported improved objective response rates (ORR) with the use of the multi-kinase inhibitor lenvatinib. We sought to evaluate real-world experience of R/M ACC patients treated with lenvatinib monotherapy within the UK National Health Service (NHS) to determine the response rates by Response Evaluation Criteria of Solid Tumour (RECIST) and clinical outcomes. Twenty-three R/M ACC patients from eleven cancer centres were included. All treatment assessments for clinical decision making related to drug therapy were undertaken at the local oncology centre. Central radiology review was performed by an independent clinical trial radiologist and blinded to the clinical decision making. In contrast to previously reported ORR of 12–15%, complete or partial response was not observed in any patients. Eleven patients (52.4%) had stable disease and 5 patients (23.8%) had progression of disease as the best overall response. The median time on treatment was 4 months and the median survival from discontinuation was 1 month. The median PFS and OS from treatment initiation were 4.5 months and 12 months respectively. Multicentre collaborative studies such as this are required to evaluate rare cancers with no recommended standard of care therapy and variable disease courses.

Commissioning and quality assurance of HalcyonTM 2.0 linear accelerator

BACKGROUND

Varian Medical Systems has introduced a new medical linear accelerator called HalcyonTM 2.0, which is based on the ring delivery system (RDS). It is a true IGRT machine having 6MV FFF photon energy. In addition to the planar and MV-CBCT imaging techniques it also has an option of ultra-fast kV-iCBCT which enhances the image reconstruction and improves the visualization of soft tissue. The field portals are shaped by a unique dual layer MLC with special stacked and staggered design which enables high modulation with low radiation leakage. Recently, we have commissioned our first Halcyon 2.0 machine. The aim of this work was to systematically investigate various parameters of a newly installed HalcyonTM 2.0 linear accelerator.

MATERIALS AND METHODS

Detailed measurements were conducted as per various guidelines. Also, the measurements were performed to fulfil the national regulatory requirements. Commissioning data of Halcyon 6 MV-FFF beam was performed in a water tank. For absolute measurements, a 0.6-cc waterproof Farmer chamber and electrometer were used. All relative measurements (PDDs, in-line, cross-line and angular profiles) were performed with 0.0125 cc point chamber.

RESULTS

All the tests were within the acceptable limit. Measured data were compared with factory data as well as the existing medical linear accelerator of the same category. The obtained results were quite satisfactory.

CONCLUSIONS

This study summarizes the commissioning experience with Halcyon linear accelerator. Evaluation of mechanical, radiation safety and dosimetric parameters were performed. The obtained parameters were well below the specified tolerance limits.

Risk factors for early mortality in patients with pulmonary tuberculosis admitted to the emergency room

BACKGROUND AND OBJECTIVES

Mortality of patients with pulmonary tuberculosis (TB) admitted to emergency departments is high. This study was aimed at analysing the risk factors associated with early mortality and designing a risk score based on simple parameters.

METHODS

This prospective case-control study enrolled patients admitted to the emergency department of a referral TB hospital. Clinical, radiological, biochemical and microbiological risk factors associated with death were compared among patients dying within one week from admission (cases) and those surviving (controls).

RESULTS

Forty-nine of 250 patients (19.6%) experienced early mortality. Multiple logistic regression analysis showed that oxygen saturation (SaO₂) ≤90%, severe malnutrition, tachypnoea, tachycardia, hypotension, advanced disease at chest radiography, severe anaemia, hyponatremia, hypoproteinemia and hypercapnia were independently and significantly associated with early mortality. A clinical scoring system was further designed to stratify the risk of death by selecting five simple parameters (SpO₂ ≤ 90%, tachypnoea, hypotension, advanced disease at chest radiography and tachycardia). This model predicted early mortality with a positive predictive value of 94.88% and a negative predictive value of 19.90%.

CONCLUSIONS

The scoring system based on simple parameters may help to refer severely ill patients early to a higher level to reduce mortality, improve success rates, minimise the need for pulmonary rehabilitation and prevent post-treatment sequelae.

Endoscopic pilonidal abscess treatment: a novel approach for the treatment of pilonidal abscess

INTRODUCTION Pilonidal abscess is a common surgical emergency. Conventional treatment with incision and drainage is associated with significant postoperative morbidity. We report our initial experience of using minimally invasive endoscopic technique for the treatment of pilonidal abscesses, referred to as endoscopic pilonidal abscess treatment (EPAT). MATERIALS AND METHODS A prospective database of all patients undergoing EPAT between January 2015 and March 2016 at Whiston Hospital was maintained. Data regarding patient demographics, peroperative variables and postoperative follow-up were recorded. RESULTS Nineteen patients were included, male to female ratio was 53 : 47 and median age of the cohort was 24 years (interquartile range 22-25 years). EPAT was the primary procedure for 10 patients and 9 had EPAT for recurrent pilonidal abscesses. There were no readmissions and none needed further surgery within 6 weeks of having the procedure. In all patients, complete wound healing was achieved within 6 weeks; all reported minimal postoperative pain (median postoperative visual analogue scale score 1) and immediate return to the activities of daily life. Four of the nineteen patients (21%) required definitive intervention for pilonidal disease in the follow-up period. CONCLUSIONS EPAT is a novel, minimally invasive technique for the treatment of acute pilonidal abscesses. It is safe, associated with reduced postoperative morbidity, recurrence rate and quick wound healing. Initial encouraging results require further investigations on a larger group of patients in a multicentre setting.

Is dual-phase abdominal CT necessary for the optimal detection of metastases from renal cell carcinoma?

AIM

To determine whether dual-phase abdominal computed tomography (CT) detected more metastases than portal-phase CT alone in patients with renal cell carcinoma (RCC).

MATERIALS AND METHODS

Audit committee approval was obtained. A retrospective audit was undertaken in 100 patients who underwent both arterial and portal phase CT. The CT images were independently reviewed by two consultant radiologists. The presence of metastases in the liver, pancreas, and contralateral kidney were recorded for each phase of contrast enhancement.

RESULTS

Metastases were identified in the liver in 27 patients, pancreas in 12, and contralateral kidney in 23 patients. Nine of the 27 (33%) liver metastases, three of the 12 (25%) pancreatic metastases, and two of the 23 (9%) renal metastases were only detected in the arterial phase, whilst four of the 27 (15%) liver metastases, three of the 12 (25%) pancreatic metastases, and two of the 23 (9%) renal metastases were only detected in the portal phase. Nine patients (9%) had metastases only visualized in the arterial phase, and six (6%) only in the portal phase. Detection of metastases only visible in the arterial phase led to a change of management in two patients (2%).

CONCLUSION

The audit results support our current standard of dual-phase abdominal CT for optimal detection of RCC metastases.

Anti-microbial resistance stratified by risk factor among Escherichia coli strains isolated from the urinary tract at a rural clinic in Central India

BACKGROUND

The failure of empirical therapy is frequently observed, even in community-acquired urinary tract infections. We, therefore, conducted a prospective, clinic-based study in 2004-2005 to document anti-microbial resistance rates and correlate them with possible risk factors to assist empirical decision-making.

MATERIALS AND METHODS

Symptomatic patients with pyuria underwent urine culture. Isolates were identified using standard methods and anti-microbial resistance was determined by disk-diffusion. Ultrasonography was used to detect complicating factors. Patients were stratified by the presence of complicating factors and history of invasive procedures for comparison of resistance rates. STATISTICAL METHOD USED: Chi-square or Fisher exact tests, as appropriate.

RESULTS

There were 156 E. coli isolates, of which 105 were community-acquired. Twenty-three community-acquired isolates were from patients with complicating factors while 82 were from patients without any. Fifty-one isolates were from patients who had recently undergone invasive procedures on the urinary tract. Thirty-two community-acquired isolates from reproductive-age women without apparent complicating factors had resistance rates of 50% or above against tetracyclines, Co-trimoxazole, aminopenicillins, Nalidixic acid, Ciprofloxacin and 1 st generation cephalosporins. Resistance rates were significantly higher among isolates from patients subjected to invasive procedures, except against Co-trimoxazole, tetracyclines and Amikacin.

CONCLUSION

High rates of anti-microbial resistance in community-acquired uropathogens have made antimicrobial sensitivity testing necessary even in a rural, primary-care setting.

Technique to prevent post-operative CSF leak in the translabyrinthine excision of vestibular schwannoma

Cerebrospinal fluid (CSF) leak following VS removal is a challenging complication. With experience, it can be seen that anatomical factors such as the extent of pneumatization of the petrous temporal bone and posterior wall of the internal auditory canal play animportant role in contributing to CSF leak. Nevertheless, the risk of post-operative CSF leak remains a major concern for both the surgeon and patient. This paper describes a technique, which we have used since 1994, and which has helped us to achieve the lowest reported rate of post-operative CSF leak in translabyrinthine excision of vestibular schwannoma in the world literature.

Canalplasty for severe external auditory meatus exostoses

Exostoses of the external auditory meatus is a well known condition which infrequently requires surgical correction. However, the stenosis caused by severe exostosis can affect quality of life considerably and may require surgical intervention. Canalplasty, in such a situation, is a valid and effective management option. In our series the commonest indication for surgery was recurrent otitis externa. The detailed surgical technique is described and a retrospective analysis of 65 such procedures is presented. There were only two significant complications, both post-operative stenosis, requiring further corrective surgery. In conclusion, canalplasty for the exostosis of the external auditory meatus is a safe surgical option.

Comparison of task performance of the camera-holder robots EndoAssist and Aesop

BACKGROUND

Two robotic laparoscopic camera-holders, Endo Assist and Aesop 3000, are compared from a system design viewpoint measuring the time taken to perform certain tasks by the operator.

METHODS

EndoAssist and Aesop 3000 robots were tested in a simulated environment. EndoAssist was controlled via a headset-mounted motion axis selection sensor, while Aesop was voice activated. A series of simple and complex tasks were performed moving the camera to different targets. The performance of each task was video taped, and the time from onset to the end of the task was taken from the recording.

RESULTS

The results showed the EndoAssist robot to be significantly quicker for most of the tasks studied. This was attributed to increased accuracy of movement in EndoAssist in comparison to the voice recognition errors evident while operating Aesop.

CONCLUSION

The time taken to perform tasks yields significantly more information about the integrated human-robot system than simply studying the speed of movement of the robot.

Glomus tympanicum tumour: an alternative surgical technique

Glomus tympanicum tumour is one of the commonest neoplasms of the middle ear. It is more common in females. The most common presenting symptom is pulsatile tinnitus. A retrotympanic mass is found in the middle ear in all the cases. Computed tomography (CT) scan is the investigation of choice, however in difficult cases magnetic resonance imaging (MRI) can be helpful. Surgery is regarded as the gold standard of treatment in spite of the fact that radiation therapy has also been advocated in the literature. In this series 17 cases of glomus tympanicum treated at Gruppo Otologico Piacenza - Rome (Italy) were analysed retrospectively. A simple and safe technique has been described. All the cases were female and treated by surgery. The tumour was removed completely in all the cases and the ossicular chain kept intact. Recurrence was encountered in only one case after nine years. Surgical removal of the tumour is recommended as the treatment of choice with the following advantages: complete removal, a low complication rate, a low recurrence rate, acceptable hearing level and minimum morbidity.

Is axillary temperature an appropriate surrogate for core temperature?

The ideal technique for measuring temperature should be rapid, painless, reproducible and accurately reflect the core temperature. While axillary temperature is commonly used because of convenience and safety, there are conflicting reports about its accuracy. To determine whether axillary temperature can act as a surrogate for oral/rectal temperatures, a prospective comparative study was conducted. The axillary and rectal temperatures (Group 1: infants < 1 year age) and axillary and oral temperatures (Group 2: children 6-14 years age) were compared using mercury-in-glass thermometers. Various tests of agreement were applied to the data obtained. Rectal and axillary temperatures for infants agreed well; the mean difference (95% limits of agreement) between the two being 0.6 degree C (-0.3 degree C, 1.4 degrees C). Similarly, the mean difference (95% limits of agreement) between oral and axillary measurements for children aged 6-14 years was observed to be 0.6 degree C (-0.4 degree C, 1.4 degrees C). Axillary temperature appears to be an acceptable alternative to rectal/oral temperature measurements in children.

Granular acute lymphoblastic leukemia with hypereosinophilic syndrome

A four-year-old boy presented with marked peripheral blood eosinophilia (absolute eosinophil count of 54 x 10(9)/1), features of hypereosinophilic syndrome, and acute lymphoblastic leukemia (ALL-L2), the latter characterized by the presence of granular blasts. Blasts were negative for myeloperoxidase, non-specific esterase, acid phosphatase, periodic-acid Schiff stain, and toluidine blue. They exhibited an early pre-B immunophenotype (TdT, CD19, CD10, CD20 and CD22 positive) and stained negative for T (CD7, CD2, CD5 and CD3) and myeloid markers (MPO, CD33 and CD13). Chromosomal analysis revealed a normal karyotype. To the best of our knowledge, this case represents the first report of the coexistence of granular ALL and hypereosinophilic syndrome.

Neutropenic enterocolitis in children with acute lymphoblastic leukemia

Neutropenic enterocolitis is an acute, life-threatening inflammation of the small and large bowel, often seen in children with malignancies during periods of prolonged or severe neutropenia. During the period 1990-1995, 180 children were treated at the authors' center for acute lymphoblastic leukemia using a standard chemotherapy protocol. Among them, 11 children (6.1%) aged 4 to 12 years, were diagnosed clinically to have neutropenic enterocolitis. Eight had severe neutropenia (absolute neutrophil count < 10(8)/L and 5 had prolonged neutropenia (> 7 days duration). The symptoms included diffuse abdominal pain (10 children), oral mucositis (7), hematochezia (7), diarrhea (6), hematemesis (5), and right lower quadrant tenderness (4). Three children had radiological evidence of free intraperitoneal gas and an additional 3 children were found on surgical exploration to have cecal perforation. Laparotomy was performed on 8 children (73%), 4 of whom survived. Among the 3 children managed conservatively, 1 died awaiting surgical exploration, while the other 2 did well. The overall survival was 55%. The authors recommend an approach to management that respects the heterogeneity of the disease.

An indigenously developed nitrite kit to aid in the diagnosis of urinary tract infection

OBJECTIVE

To evaluate the utility of an indigenously developed nitrite kit for the rapid diagnosis of urinary tract infection (UTI) METHODS: 1018 urine specimens were collected from all cases where there was clinical suspicion of UTI. Samples were cultured as per standard microbiological protocol. Presence of nitrites was indicated by the development of purple color on addition of color developing solution and compared with the set of graded positive and negative controls also provided in the Kit.

RESULTS

The results of the nitrite kit were compared with the semi-quantitative urine culture as the gold standard. The sensitivity, specificity, positive predictive and negative predictive values were 47%, 87%, 31% and 93%, respectively.

CONCLUSION

Nitrite kit as a screening test can decrease the work load in the clinical bacteriology laboratory. More importantly in a field set up that is devoid of culture facilities, it can be used to correctly predict the absence of UTI.

Dengue haemorrhagic fever in children in the 1996 Delhi epidemic

An epidemic of dengue haemorrhagic fever (DHF) occurred in Delhi in 1996. A total of 240 children between the age of 4 months to 13 years of either sex, admitted in one hospital, were evaluated. Two hundred and sixteen (90%) children were from Delhi. A clinical diagnosis of dengue fever (DF) was made in 25 (10%), dengue fever with unusual bleeding (DFB) in 22 (9%), DHF in 80 (33%) and dengue shock syndrome (DSS) in 113 (47%) of the children strictly according to the WHO classification. The age peaked at 8 years. There was no association between various grades of severity of illness and age-groups though girls suffered from more severe illness. No association between severity of malnutrition and severity of illness was observed. Tourniquet test was positive in 40% with DF, 18% with DFB, 62% with DHF and 64% with DSS. In DSS haematemesis was present in 55 (49%), epistaxis in 39 (35%), melaena in 27 (24%) and ecchymosis in 34 (30%) patients. Children diagnosed as DFB had haematemesis and epistaxis in 12 (55%) and 10 (45%) respectively. Intravenous fluid requirement was clearly less in DFB patients than in DHF/DSS patients. Unusual clinical features in the form of jaundice were present in 7 (6%), hepatic encephalopathy in 6 (5%) and dengue encephalopathy in 6 (5%) patients. Dengue 2 virus was isolated from 10 of the 50 patients for whom viral culture was done on C6/36 clone of Aedes albopictus cell line. Eighteen patients suffering from DSS died giving an overall case fatality of 7.5%. The mortality rate in DHF/DSS was 9.3%. It is further suggested that DFB is a distinct entity. Most patients could be classified by the WHO classification if a retrospective packed cell volume was used to assess haemoconcentration. We suggest that development of area-specific criteria for diagnosis and management is desirable.

Ocular extramedullary myeloid cell tumour in children: an Indian study

Thirty-two children with extramedullary myeloid cell tumour (EMT) who constituted 41 per cent of children with acute myeloid leukaemia (AML) were studied to ascertain their laboratory characteristics and potential problems in diagnosis. The diagnosis, established by peripheral blood smear and/or bone marrow examination, was AML (n = 29) and refractory anaemia with excess blasts in transformation (RAEB-t; n = 3). The six referred patients in whom the diagnosis had been missed, and two cases wrongly reported as histiocytosis on aspiration cytology, were those in whom a peripheral blood smear had not been examined. It is concluded that diagnostic work-up of proptosis must include a full haemogram, meticulous peripheral blood smear examination, repeated if necessary, and bone marrow examination where relevant. RAEB-t cases with extramedullary myeloid cell tumour should be classified as acute myeloid leukaemia.

Dengue hemorrhagic fever: clinical manifestations and management

Dengue virus infection may remain asymptomatic or manifest as nonspecific viral infection to life threatening dengue hemorrhagic fever (DHF)/dengue shock syndrome (DSS). Patients with DHF/DSS have fever, hemorrhagic manifestations along with thrombocytopenia and hemoconcentration. Thrombocytopenia and hemoconcentration are distinguishing features between DHF/DSS and dengue fever (DF). Some patients with dengue fever may have significant bleed and mild thrombocytopenia but no hemoconcentration. These patients are labelled to have dengue fever with unusual bleeds. Laboratory findings in DHF/DSS include rising hematocrit, thrombocytopenia and transformed lymphocytes on peripheral smear. There may be increased transaminases, hyponatremia, transient increase in blood urea nitrogen and creatinine. In severe disease there may be lab evidence of dissemination intravascular coagulation. X-ray film of the chest may show pleural-effusion. Ultrasonogram of abdomen may detect thickened gall bladder wall with hepatomegaly and ascitis. In some patients there may be abnormality in electrocardiogram and echocardiogram. The diagnosis of DHF/DSS is based on typical clinical findings. For confirmation of dengue virus infection viral culture can be done on blood obtained from patients during early phase of illness. In later part of illness antibodies against dengue virus can be demonstrated by various techniques. The treatment of DF is symptomatic. For control of fever nonsteroidal anti-inflammatory drugs should be avoided. DHF/DSS are managed by intravenous fluid infusion with repeated monitoring of vital parameters and packed cell volume (PCV).

Myocardial dysfunction in children with dengue haemorrhagic fever

BACKGROUND

Dengue fever/dengue haemorrhagic fever/dengue shock syndrome is a serious health problem in tropical countries. Intravascular fluid depletion due to capillary leak is presumed to be the cause of hypotension in dengue haemorrhagic fever. The treatment guidelines of the World Health Organization lay stress primarily on monitoring and fluid replacement therapy. During the 1996 epidemic in New Delhi, we observed problems in fluid management of such children and prospectively looked for myocardial dysfunction as an additional factor for hypotension.

METHODS

Fifty-four children (< 12 years old) admitted to the All India Institute of Medical Sciences, New Delhi after 15 October 1996 with various grades of the disease, who were fit to be shifted to the echocardiography laboratory, were examined clinically and subjected to a detailed M-mode, 2-dimensional and colour doppler echocardiography. Ejection fractions (Teichholz/Modified Simpson's) and shortening fractions were calculated.

RESULTS

Ejection fraction by modified Simpson's rule was reduced (< 50%) in 9/54 (16.7%) children; 2 of these had significant reductions (< 35%). These 9 children belonged to all stages of clinical severity. Three of these 9 children who had a repeat echocardiogram within 2 months of the illness had improved ejection fractions.

CONCLUSION

The role of myocardial dysfunction remains to be defined as there was no correlation with clinical severity. Myocardial functions need to be assessed in patients with this disease, especially those who have persistent hypotension in spite of adequate hydration.

Juvenile dermatomyositis

The clinical profile of 7 children and their follow-up is described. There was female preponderance with mate to female ratio of 1:6. The median age of onset was 6 years. All the patients had skin rash, muscle weakness and abnormal enzyme profile. Muscle biopsy was performed in 6 and was abnormal in all of them. The electromyogram (EMG) was performed in 6 and was found abnormal in five. All the children responded well to corticosteroids. Two children received intravenous dexamethasone bolus and showed good response.

Clinico-immunological profile in juvenile rheumatoid arthritis--an Indian experience

From a Pediatric Rheumatology Clinic 361 children diagnosed as juvenile rheumatoid arthritis (JRA) according to American Rheumatism Association-JRA criteria were studied retrospectively for their clinico-immunological profile. The mean age of onset in systemic, pauciarticular and polyarticular onset, JRA subtypes were 5.2, 6.8 and 7.2 years respectively. There was male preponderance in systemic and pauciarticular JRA. In seropositive polyarticular JRA, girls outnumbered boys. The frequency of occurrence of systemic, pauciarticular and polyarticular disease was 87 (24%), 108 (30%) and 166 (46%) respectively. The systemic onset disease was dominated by extra-articular manifestations in terms of fever (100%), rash (57%), hepatomegaly (51%) and lymphadenopathy (25%). The pauci- and polyarticular illnesses were commonly dominated by joint involvement, morning stiffness, and in few patients, by extra-articular manifestations also. The joints were involved symmetrically. Most commonly involved joints in order of decreasing frequency were knee, ankle, wrist and elbow in all the subtypes. Anemia and leucocytosis were observed in majority with higher frequency in systemic onset JRA. The rheumatoid factor (RF) was present in 15% of polyarticular JRA. RF was also present in 7 and 9% of patients with pauciarticular and systemic subtypes respectively. The antinuclear antibody was positive in only 3 out of 66 patients in whom the test was carried out. The demographic profile and trends in clinical features were similar to the studies reported on caucasian population with difference in the actual frequency of various clinical features.

Unusual radiological manifestations of Lemierre's syndrome: a case report

Lemierre's syndrome is an uncommon clinical entity characterized by oropharyngeal infection followed by septic thrombophlebitis of the jugular vein with embolization to the lungs and other organs. The organism is a gram-negative anaerobic bacterium, Fusobacterium necrophorum. We report a case of Lemierre's syndrome in an 8-year-old child who presented with septic arthritis of the left hip joint. Roentgenograms and computed tomography demonstrated gas in the joint and adjacent soft tissues, along with a dislocated hip. Sonography of the neck coupled with the colour Doppler technique did not reveal any abnormality in the jugular veins. A blood culture grew Fusobacterium necrophorum, confirming the diagnosis of Lemierre's syndrome.

Tubercular lymphadenitis: clinical manifestations

One hundred and thirteen children suffering from tubercular lymphadenitis proven histopathologically, were studied for clinical and laboratory features. Age distribution was equal in all age groups except during infancy when it was rare. Sex ratio indicates a male preponderance with male to female in the ratio of 1.5:1 (67:46). Family history of contact with known tuberculous patient was positive in 19 (17%) children, 44 (40%) had received BCG, and 98 (88%) were either normal nourished or had mild malnutrition. Cervical, axillary and inguinal nodes were found in 90 (80%), 14 (12%), and 8 (7%) children respectively. Epitrochlear node was found in only 1 child. 11 (10%) children had discharging sinus, all being in cervical group. The consistency of nodes was firm in 98 (87%), fluctuation was present in 15 (13%). In 87 (77%) lymph nodes were matted. Hepatomegaly of more than 2 cm was present in 13 (11%) and spleen was enlarged (> 2 cm) in 4 (4%) only: Mantoux test was positive in 96 (85%) children and chest X-ray was abnormal in 25 (22%) cases. Findings suggest that tubercular adenitis occurs in all age groups with equal frequency. It can occur in vaccinated children also. It may be a sole manifestation of tubercular infection. The cervical nodes are predominantly involved. There is no typical location of nodes in individual groups but multiplicity and matting of nodes are characteristic features of tubercular adenitis in children.

Hematological manifestations of congenital cytomegalovirus infection

Nine infants suffering from congenital cytomegalovirus infection were studied for clinical features with special reference to hematological manifestations. The mean age of appearance of first clinical symptom of disease was 14 days and mean age at presentation was 58 days. Significant pallor, thrombocytopenia and evidence of hemolysis were present in 8 (89%), 4 (44%) and 4 (44%) patients respectively out of three bone marrow examination performed, paucity of erythroid and megakaryocytic cells were seen in two. The other clinical features included hepatomegaly in a (100%) splenomegaly in 6 (66%) each, petachial rash in 5 (55%), Hepatitis in 4 (44%) optic atrophy and corneal opacities in one patient each. Two patients died. Remaining patients showed symptomatic improvement without specific therapy.

Juvenile chronic myelocytic leukemia--report of 10 cases

Ten children (five boys and five girls) with juvenile chronic myelocytic leukemia were seen over a period of 12 years (1980-1991) at the All India Institute of Medical Sciences, New Delhi. With the exception of one who was aged 4.5 years, all children were below 4 years of age (mean age 20.4 months). The presenting features included fever, bleeding secondary to thrombocytopenia, marked hepatosplenomegaly, and skin rash. The striking hematological features were anemia, thrombocytopenia, peripheral blood monocytosis, and normoblastemia. There was no significant myeloid proliferation in the bone marrow aspirate (mean M:E = 5:1), while erythroid proliferation was prominent along with monocytosis (mean 11.2%). Fetal hemoglobin was raised in 8 of the 10 patients (mean 14.1%). Long-term survival was poor, with maximum survival being 18 months in one case. New modalities of management of this rare entity are discussed.