Stereotactic Body Radiotherapy for Renal Cell Carcinoma: Oncological and Renal Function Outcomes.

AIMS: To evaluate oncological and renal function outcomes of stereotactic body radiotherapy (SBRT) for medically inoperable patients with localised renal cell carcinoma. MATERIALS AND METHODS: Consecutive patients treated with curative intent SBRT (30-45 Gy in five fractions or 42 Gy in three fractions) were included. Data on local control (Response Evaluation Criteria in Solid Tumors [RECIST] v1.1), distant metastasis, impact on estimated glomerular filtration rate (eGFR) and proportional ipsilateral and contralateral renal functions (measured through renal scans) were collected. Univariate and multivariable analyses were conducted to determine association of variables with oncological and renal function outcomes. RESULTS: Seventy-four patients were analysed. The median follow-up was 27.8 months (interquartile range 17.6-41.7). Fifty-seven per cent had tumours ≥ T1b. One-, 2- and 4-year cumulative incidence of local failure was 5.85, 7.77 and 7.77%, respectively. The cumulative incidence of distant metastasis at 2 years was 4.24%. On multivariable analysis, a lower planning target volume (PTV) mean dose (P = 0.019) and a larger PTV (P = 0.005) were significantly associated with the risk of developing local failure. A lower PTV maximum dose (P = 0.039) was significantly associated with the risk of developing distant metastasis. The median change in global eGFR (ml/min) from pre-SBRT levels was -7.0 (interquartile range -14.5 to -1.0) at 1 year and -11.5 (interquartile range -19.5 to -4.0) at 2 years. The proportion of ipsilateral (differential) renal function decreased over time from 47% of overall renal function pre-SBRT to 36% at 2 years, whereas the proportion of contralateral renal function correspondingly improved. On multivariable analysis, a higher volume of uninvolved renal cortex (P < 0.0001) was significantly associated with a smaller decrease in eGFR over time. CONCLUSION: In this large institutional cohort, oncological outcomes of renal cell carcinoma treated with SBRT were favourable and a longitudinal decline in renal function in the ipsilateral kidney and compensatory increase in the contralateral kidney were observed. Clinical and dosimetric factors were significantly associated with oncological and renal function outcomes.

Socio-demographic characteristics and the three delays of maternal mortality.

OBJECTIVE: To describe the socio-demographic characteristics and the three delays of maternal mortality in a tertiary teaching hospital. STUDY DESIGN: Retrospective, observational study. PLACE AND DURATION OF STUDY: Department of Obstetrics and Gynaecology, Unit III, Civil Hospital, Karachi, from April 2005 to May 2008. METHODOLOGY: One hundred and four consecutive maternal deaths were reviewed. Data regarding age, parity, sociodemographic characteristics, booking status, referral source, cause of death and the three delays was collected on structured proformas, analyzed by the statistical software, SPSS version 13, and presented in the form of frequencies and percentages. RESULTS: The projected maternal mortality ratio was 1650/100,000 live births. The mean age was 28+/-6.2 years and median parity was two. Seventy-one women (68%) were uneducated, 65 (62.5%) belonged to lower socioeconomic class and 60 (58%) had received no antenatal care. Ninety-eight women (94%) had one or more delays, with 70 (71%) having the first delay, 73 (74%) having the second delay and 47 (48%) the third delay. The most frequent reasons for first, second and third delays were lack of awareness in 88.5% women, long distance in 39.7% women and difficulty in getting blood in 49% women respectively. CONCLUSION: The very high maternal mortality ratio suggests lack of access of women to quality healthcare facilities. A majority of these women suffered first and second delays in their management, which could be due to their poor sociodemographic factors.

Obstetric causes of stillbirth at low socioeconomic settings.

OBJECTIVE: To determine the obstetric causes for stillbirth in low socio-economic settings. METHODS: A case-control retrospective study through data analysis was conducted at a tertiary university hospital, from January to June 2008. All pregnant women diagnosed with stillbirth after 28 weeks of gestation were included in the study. They were compared with women who had live birth during the study period. Both groups were identified from the admission, and labour room registers. The risk factors studied were maternal age, parity, gestational age, hypertensive disorders of pregnancy, antepartum haemorrhage, obstructed labour and Prematurity. Stillbirth was defined as foetal death after 28 weeks of gestation. RESULTS: Of the 1011 deliveries in the selected period, there were 100 still births (98/1000 deliveries). Both nulliparity and grand multiparity were significantly associated with stillbirths (p < 0.003 and p < 0.009 respectively). From the binary logistic regression analysis, obstetric factors which were significantly associated with stillbirth were obstructed labour ( OR 16.2, CI 5.5-47), hypertensive disorders (OR 9.6 CI 4-23), abruptio placentae (OR 136, CI 52-356), placenta previa (OR 71, CI 21-230), and preterm labour (OR 15 CI 4-54). Gender was not found significantly associated with stillbirth (p < 0.432) CONCLUSION: Majority of stillbirths were due to risk factors which can be identified in the antenatal period.

Drug-prescribing patterns during pregnancy in the tertiary care hospitals of Pakistan: a cross sectional study.

BACKGROUND: The rationale for use of drugs during pregnancy requires a careful assessment as in addition to the mother, the health and life of her unborn child is also at stake. Information on the use of drugs during pregnancy is not available in Pakistan. The aim of this study was to evaluate the patterns of drug prescriptions to pregnant women in tertiary care hospitals of Pakistan. METHODS: This was a cross-sectional study conducted at five tertiary care hospitals of Pakistan. Copies of outpatient medicinal prescriptions given to pregnant patients attending the antenatal clinics were collected. The drugs were classified according to the pharmacological class and their teratogenic potential. RESULTS: All the pregnant women attending the antenatal clinics received a prescription containing at least one drug. A total of 3769 distinct prescriptions given to different women were collected. Majority of the women who received the prescriptions belonged to third trimester (55.4%) followed by second (33.6%) and first trimester (11.0%). On an average, each prescription contained 1.66 +/- 0.14 drugs. The obstetricians at Civil Hospital, Karachi and Chandka Medical College Hospital, Larkana showed a tendency of prescribing lesser number of drugs compared to those in other hospitals. Anti-anemic drugs including iron preparations and vitamin and mineral supplements (79.4%) were the most frequently prescribed drugs followed by analgesics (6.2%) and anti-bacterials (2.2%). 739 women (19.6%) received prescriptions containing drugs other than vitamin or mineral supplements. Only 1275 (21.6%) of all the prescribed drugs (n = 6100) were outside this vitamin/mineral supplement class. Out of these 1275 drugs, 29 (2.3%) drugs were prescribed which are considered to be teratogenic. Misoprostol was the most frequently prescribed (n = 6) among the teratogenic drugs followed by carbimazole (n = 5) and methotrexate (n = 5). Twenty nine pregnant women (0.8% of all the women studied) were prescribed these teratogenic drugs. CONCLUSION: Less than one percent of the pregnant women attending tertiary care hospitals in Pakistan are prescribed teratogenic drugs. The prescribing practices of Pakistani physicians are similar to those in western countries.

Use of recombinant activated factor VII for massive postpartum hemorrhage.

OBJECTIVE: We hypothesised that patients with massive postpartum hemorrhage (PPH), defined as blood loss >1,500 ml,may benefit from the use of activated recombinant factor VII (rFVIIa). Design. Retrospective cohort study. Setting.Department of Obstetrics & Gynaecology, Dow University of Health Sciences. POPULATION: Thirty-four women with a diagnosis of massive PPH. METHODS: All patients with PPH who were admitted to the Department of Obstetrics &Gynecology and Surgical Intensive Care Unit of Civil Hospital Karachi, Pakistan, were included in the study. From March 2005 to October 2006, 34 patients fulfilled the criteria of massive PPH, of which 18 received rFVIIa to control bleeding, and 16 patients did not. Availability and cost of rFVIIa were the factors in drug allocation. Main outcome measures. Maternal mortality, correction of coagulopathy, the amount of blood products transfused and preservation of fertility. RESULTS: Patients receiving rFVIIa had lower maternal mortality (5/18, 28% versus 8/16, 50%, OR: 0.04 (0.002, 0.83)), and received a lower number of packed red cell transfusions (4.0 ± 4.46 versus 9.61 ± 6.7, p value 0.007), against the comparison group. Patients receiving rFVIIa had lower activated partial thromboplastin (median: 13.0; 25-75th percentile: -25.0, -8.0, signed rank p<0.0001), and lower prothrombin times (median: -8.8; 25-75th percentile: -24.2, -4.8), after administration of drug.There was no significant difference in the rate of hysterectomy between the 2 groups (11/18 (61%) versus 6/16 (38%)). No adverse event attributable to rFVIIa was observed in the study. CONCLUSION: Activated recombinant factor VII can be a lifesaving drug in patients with massive PPH.

Ectopic pregnancy: presentation and risk factors.

OBJECTIVE: To describe the clinical features and risk factors in ectopic pregnancy. DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: The study was conducted in Unit III of the Department of Obstetrics and Gynaecology, Civil Hospital, Karachi from January 2002 to December 2003. PATIENTS AND METHODS: A total of 38 women diagnosed with ectopic pregnancy were included in the study. Data was retrieved from the charts of all the patients diagnosed with ectopic pregnancy through a structured proforma. The variables studied included age, parity, symptoms and signs, risk factors, treatment and associated maternal morbidity. RESULTS: Among the clinical features, the most common presenting symptom was abdominal pain in 37 (97.3%) patients whereas history of amenorrhea and vaginal bleeding were found in 28 (73.6%) and 22 (57.8%) patients respectively. The most common physical sign was tenderness: abdominal tenderness in 28 (73.6%) and pelvic tenderness in 23 (60.5%) patients. Cervical excitation was only present in 19 (50%) patients. Risk factors were present in 23 patients (60.5%), the most frequent being infertility in 9 patients (23.6%). Other risk factors were tuberculosis in 6 patients (15.7%), previous ectopic pregnancy in 3 (7.8%) and previous tubal surgery in 1 (2.6%) patient. History of IUCD was present in 1 (2.6%), injection Depo-provera in 4 (10.5%) and OCP in 3 (7.8%) patients. History of D & C and C-section were present in 7 (18.4%) and 4 (10.5%) patients respectively. CONCLUSION: Abdominal pain was the single most consistent feature of ectopic pregnancy. Risk factors may not always be present. Therefore, ectopic pregnancy should be suspected in every woman of reproductive age who presents with unexplained abdominal pain, irrespective of amenorrhea and vaginal bleeding and whether risk factors were present in the past history or not.

Elevated levels of IL-8 in dengue hemorrhagic fever.

Dengue virus causes dengue fever, a mild febrile illness, and at times dengue hemorrhagic fever (DHF), a severe illness the pathogenesis of which is not fully understood. Given the crucial roles played by interleukin-8 (IL-8) as a chemoattractant cytokine and in inflammatory processes, levels of circulating IL-8 in the sera and IL-8 mRNA in the peripheral blood mononuclear cells (PBMC) were measured in 99 patients of a recent dengue epidemic that occurred in India in 1996 and in 21 normal healthy controls. Twenty-six of the patients had dengue fever (DF) and the remaining 73 were diagnosed as having different grades of DHF. All the control normal sera were negative for IL-8, so were their PBMC for IL-8 mRNA. Increased levels of IL-8 in the sera and IL-8 mRNA in their PBMC were observed in patients with severe illness of DHF grades III and IV. Only two out of 26 patients of DF and one out of 10 DHF grade I patient were positive for IL-8 and all three deteriorated to DHF grade IV within 24 hr. All six patients of DHF grade IV who died had higher serum level of IL-8 above 200 pg/ml, the highest being 5,568 pg/ml in one patient; the presence of mRNA for IL-8 was very high in all patients. A striking correlation was observed between increased levels of IL-8 and severe DHF, with greater levels in patients with increased grade of the disease and death. These results suggest that IL-8 may have an important role and may be an indicator of increasing severity of the disease and death.