Efficacy and Safety of Reirradiation with Stereotactic Body Radiation Therapy for Locally Recurrent Pancreatic Adenocarcinoma.

AIMS: The purpose of this study was to report on outcomes of a cohort of patients who were treated with reirradiation with stereotactic body radiation therapy (SBRT) for locally recurrent pancreatic adenocarcinoma. MATERIALS AND METHODS: Patients treated with SBRT reirradiation for locally recurrent pancreatic adenocarcinoma from December 2009 to April 2020 were included in the study. Descriptive statistics were used to record patient demographics, tumour and treatment characteristics. Kaplan-Meier analysis was used to evaluate overall survival, local progression-free survival (LPFS), distant metastasis-free survival and progression-free survival (PFS). RESULTS: In total, 27 patients were included in the study. The median follow-up time from local recurrence was 19.7 months (range 4.2-43.1 months). Most patients received five-fraction SBRT (26/27, 96%). The median overall survival after local recurrence treatment was 18.3 months (range 3.0-42.6 months), with 6-month, 1-year and 2-year overall survival rates of 88.5%, 73.1% and 33.6%. The median LPFS after local recurrence treatment was 16.2 months (range 2.3-33.6 months), with 6-month, 1-year and 2-year LPFS rates of 95.8%, 62.9% and 27.2%. Peri-SBRT chemotherapy improved LPFS (median 17.5 versus 8.5 months; P = 0.010) and overall survival (median 19.3 versus 5.5 months; P = 0.049). Tumours ≤ 3 cm in the greatest dimension showed better local control (median LPFS 19.2 versus 10.2 months; P = 0.130). There was one case (4%) of acute grade 3 pain and one case (4%) of late grade 3 gastrointestinal toxicity. CONCLUSIONS: Reirradiation with five-fraction SBRT is safe, but local control remains suboptimal. Patients with smaller tumours experienced improved outcomes, as did patients whose treatment plan included the administration of peri-SBRT chemotherapy.

CTA Evaluation of Basilar Septations: An Entity Better Characterized as Aberrant Basilar Fenestrations.

BACKGROUND AND PURPOSE: A basilar artery intraluminal septation is an exceedingly rarely reported, presumed congenital abnormality. In our clinical practice, we have occasionally noticed an intraluminal band within the inferior aspect of the basilar artery on CTA. Furthermore, we have noticed, at times, the presence of a punctate calcification associated with this finding. We hypothesized that what previous studies have called "basilar septations" in fact represent miniature and thus aberrant basilar fenestrations. MATERIALS AND METHODS: We retrospectively reviewed CTA studies obtained between January 1, 2017, and August 31, 2019. Identified intraluminal basilar abnormalities were classified as either basilar septations or basilar fenestrations. Association with other posterior circulation abnormalities was documented. RESULTS: A total of 3509 studies were examined. A basilar intraluminal abnormality was evident in 80 patients (2.3%). Of these 80 patients, 59 were classified as having a basilar fenestration (1.7%) and 21 were classified as having basilar septations (0.6%). Associated calcification was evident in 3 of the basilar fenestration cases and 13 of the basilar septation cases. CONCLUSIONS: Basilar septations most likely represent and should be referred to as aberrant basilar fenestrations. They should be interpreted as benign congenital incidental findings and should not be misinterpreted as focal dissections or arterial webs. Important variations in the morphology of aberrant basilar fenestrations exist, including areas of thinning, varying thickness, and nodularity. Therefore, when associated with calcification or nodularity, aberrant basilar fenestrations should not be confused with focal intraluminal thrombi or calcified or noncalcified emboli.

Numerical analysis of subcritical Hopf bifurcations in the two-dimensional FitzHugh-Nagumo model.

It had been shown that the transition from a rigidly rotating spiral wave to a meandering spiral wave is via a Hopf bifurcation. Many studies have shown that these bifurcations are supercritical, but, by using simulations in a comoving frame of reference, we present numerical results which show that subcritical bifurcations are also present within FitzHugh-Nagumo. We show that a hysteresis region is present at the boundary of the rigidly rotating spiral waves and the meandering spiral waves for a particular set of parameters, a feature of FitzHugh-Nagumo that has previously not been reported. Furthermore, we present a evidence that this bifurcation is highly sensitive to initial conditions, and it is possible to convert one solution in the hysteresis loop to the other.

ADENOID CYSTIC CARCINOMA MISINTERPRETED AS ANTROCHOANAL POLYP: A RARE PRESENTATION.

Adenoid cystic Carcnoma (ACC) is an uncommon malignant tumour accounting for <1% of all oral and maxillofacial tumors. However, in the sinonasal tract, ACC is the most common salivary gland tumor. The sinonasal ACC is asymptomatic initially or causes non-specific symptoms that are similar to those caused by inflammatory sinus disease and local neurological symptoms such as trigeminal neuralgia in advance stage due to perineural invasion by the tumour.We present a case of 35-year-old female who presented with complaints of nasal obstruction and headache. CT scans revealed an antrochoanal polyp without any bony involvement. The histopathological examination revealed unremarkable respiratory epithelium with underlying sheets and acini of small hyperchromatic cells with hyaline-like material in the lumina, confirming adenoid cystic carcinoma. The highlight of this case is that sinonasal polyps are not always inflammatory in origin, these can be neoplastic also.

Alien chromosome segment from Aegilops speltoides and Dasypyrum villosum increases drought tolerance in wheat via profuse and deep root system.

BACKGROUND: Recurrent drought associated with climate change is a major constraint to wheat (Triticum aestivum L.) productivity. This study aimed to (i) quantify the effects of addition/substitution/translocation of chromosome segments from wild relatives of wheat on the root, physiological and yield traits of hexaploid wheat under drought, and (ii) understand the mechanism(s) associated with drought tolerance or susceptibility in wheat-alien chromosome lines. METHODS: A set of 48 wheat-alien chromosome lines (addition/substitution/translocation lines) with Chinese Spring background were used. Seedling root traits were studied on solid agar medium. To understand the influence of drought on the root system of adult plants, these 48 lines were grown in 150-cm columns for 65 d under full irrigation or withholding water for 58 d. To quantify the effect of drought on physiological and yield traits, the 48 lines were grown in pots under full irrigation until anthesis; after that, half of the plants were drought stressed by withholding water for 16 d before recording physiological and yield-associated traits. RESULTS: The alien chromosome lines exhibited altered root architecture and decreased photochemical efficiency and seed yield and its components under drought. The wheat-alien chromosome lines T5DS·5S#3L (TA5088) with a chromosome segment from Aegilops speltoides (5S) and T5DL.5 V#3S (TA5638) with a chromosome segment from Dasypyrum villosum (5 V) were identified as drought tolerant, and the drought tolerance mechanism was associated with a deep, thin and profuse root system. CONCLUSIONS: The two germplasm lines (TA5088 and TA5638) could be used in wheat breeding programs to improve drought tolerance in wheat and understand the underlying molecular genetic mechanisms of root architecture and drought tolerance.

Anaemia and thyrotoxicosis: The need to look for an alternative cause.

OBJECTIVES: Anaemia and thyrotoxicosis are both relatively common. It is unclear whether thyrotoxicosis results in anaemia in the absence of other causes. The aim of this study was to determine the prevalence and characteristics of anaemia in patients with thyrotoxicosis. DESIGN: A prospective cohort study of patients with thyrotoxicosis. PATIENTS: 353 patients referred to a regional endocrinology centre in New Zealand from March 2013 to November 2014 for new-onset thyrotoxicosis. MEASUREMENTS: Detailed assessment including thyroid function tests, full blood count, inflammatory markers, haematological parameters and coeliac serology. Anaemia was defined as a haemoglobin value <115 g/L (woman) or <130 g/L (men). RESULTS: Anaemia was present in 31 (8.7%) patients at diagnosis. Of these, pre-existing anaemia was present in 10, and a further 11 had one or more identifiable underlying cause(s) for the anaemia. Only 10 patients (2.8% of the entire cohort) had anaemia not clearly attributable to another cause. Median free thyroid hormone levels were higher in those with anaemia of unknown cause compared to patients with thyrotoxicosis alone. The median duration of anaemia was shorter in patients with thyrotoxicosis-associated anaemia compared to those with anaemia due to an underlying cause (1 vs 6 months, P = .001). In all patients with thyrotoxicosis-associated anaemia, the anaemia resolved, either prior to, or on becoming euthyroid. CONCLUSION: Anaemia coexisting with thyrotoxicosis is less common than previously reported and is mild and transient. Patients with thyrotoxicosis and significant anaemia should be investigated for other potential causes, particularly when anaemia persists.

Association of type 2 diabetes with prolonged hospital stay and increased rate of readmission in patients with lower limb cellulitis.

BACKGROUND/AIMS: Lower limb (LL) cellulitis-related hospitalisations are prevalent in type 2 diabetes subjects. We assess its costs and factors associated with length of stay and readmissions. METHODS: A retrospective case-control study at an urban hospital servicing a multi-ethnic population in New Zealand, where 7% of the adult population is estimated to have diabetes. Admissions with LL cellulitis in 2008-2013 were identified using coding records. Subsequent hospitalisations after 1 month with the same diagnosis were classified as readmissions. Glycaemic control was assessed by HbA1c measured within 6 months of the index admission. RESULTS: There were 4600 admissions with LL cellulitis in 3636 patients, including 719 patients (20%) with type 2 diabetes. Hospital stay was longer for type 2 diabetes patients (median 5.3 vs 3.0 days, P < 0.001), independent of age, ethnicity and HbA1c. Accompanying LL ulceration was more frequent in type 2 diabetes patients (50% vs 17%, P < 0.001); however, admissions remained longer for type 2 diabetes patients without ulceration (median 3.4 vs 2.8 days, P < 0.001). Readmission rates were also higher in type 2 diabetes patients compared to non-diabetes patients (HR 1.7, P < 0.001), even in the absence of ulceration (HR 2.2, P < 0.001). Age, HbA1c and ethnicity did not distinguish those prone to readmissions in the type 2 diabetes cohort. Type 2 diabetes patients accounted for a fifth of all admissions and one third of the estimated costs. CONCLUSIONS: A high proportion of patients with type 2 diabetes was admitted with LL cellulitis. They had significantly longer admissions and higher readmission rates. Age, HbA1c and ethnicity did not predict length of stay or recurrence.

Cytological Diagnosis of Primary Thyroid Tuberculosis.

Primary thyroid tuberculosis is an extremely rare disease, even in countries where other forms of tuberculosis are abundant. TT has no age bar but usually affects women in fourth and fifth decade. Hereby, we report a case of 16-years-old girl presented with complaint of progressively increasing, painful thyroid swelling. Diagnosis of TT was made on cytology and there was no evidence of involvement of any other organ by tuberculosis. Despite of its rarity, TT is usually misdiagnosed. So, a clinician should always consider this entity in the differential diagnosis of thyroid swelling. Fine needle aspiration cytology is the best diagnostic method and can result in the avoidance of unnecessary thyroid surgeries.

Nutritional composition of ginger powder prepared using various drying methods.

A study was undertaken to prepare ginger powder using various drying methods and their nutritional evaluation was carried out. Ginger (Zingiber officinale) was dried using shade, solar, oven and microwave drying methods. All the samples were ground in grinder to make fine powder. Sensory analysis indicated that acceptability of all types of ginger powders were in the range of 'liked very much' to 'liked moderately' by the panelists. The mean score obtained for colour was higher in shade dried ginger powder i.e., 8.20 as compared to oven dried (7.60), solar dried (7.70) and microwave dried ginger powder (7.80). Moisture content ranged from 3.55 % in solar dried ginger powder to 3.78 % in shade dried ginger powder. Slightly higher moisture content was found in shade dried ginger powder. Protein, crude fiber, fat and ash contents ranged from 5.02 to 5.82, 4.97 to 5.61, 0.76 to 0.90 and 3.38 to 3.66 %, respectively. ß-carotene and ascorbic acid content was found maximum in shade dried ginger powder i.e., 0.81 mg/100 g and 3.83 mg/100 g, respectively. Polyphenol content was almost similar in all the samples whereas calcium was slightly higher in the shade dried ginger powder i.e., 69.21 mg/100 g. Results have shown that ginger powder prepared from various drying methods had good sensory and nutritional profile.

Slow progressor of human immunodeficiency virus: 20 years follow-up of a case from North India.

A case of human immunodeficiency virus (HIV) infection from North India is described with a 20-year follow-up. Patient first reported in 1993 when he was detected HIV positive, remained healthy without treatment, married in 1999 and did not transmit the disease to his children or his wife and was lost to follow-up. He was thought to be an elite controller. After 15 years of the initial visit, his CD4 cells, however, were found to be low, with a viral load of 10,000/copies/ml. He was negative for human leukocyte antigen B57 and B27 alleles with a normal expression of CCR5 and CXCR4 on CD4 cells. Lymphocytes showed a significant production of tumour necrosis factor alpha and interferon γ, but not of interleukin (IL)-2, IL4 or IL10. It is possible that gut infection, common in India, could have triggered T cell activation in the ensuing years, resulting in activation of HIV. The case illustrates the significance of long-term follow-up of these patients for timely institution of anti-retroviral therapy.

Risk factors and survival analysis of the esophageal cancer in the population of Jammu, India.

OBJECTIVE: To identify the risk factors of esophageal cancer and study their effect on the survival rates patients of Jammu region, India. MATERIALS AND METHODS: Detailed information was collected on socio-demographic, dietary and clinico-pathological parameters for 200 case control pairs. Discrete (categorical) data of 2 independent groups (control and cases) were summarized in frequency (%) and compared by using Chi-square (χ2 ) test. The mean age of two independent groups was compared by independent Student's t-test. To find out potential risk factor (s), the variable (s) found significant in univariate analysis were further subjected to multivariate logistic regression analysis. The association of potential risk factors with patients survival (3-year overall survival) was done by Kaplan-Meier survival curve analysis using Log-rank test. A 2-tailed (a = 2) P < 0.05 was considered statistically significant. RESULTS: Out of the 63 response parameters, seven were found highly significant on multivariate analysis. The mean (± SD) age was 56.74 ± 10.76 years, the proportions of males were higher than females, mostly illiterate and lower income group. Among dietary characteristics, snuff was highest (OR = 3.86, 95% CI = 2.46-6.08) followed by salt tea (OR = 2.53, 95% CI = 1.49-4.29), smoking (OR = 1.97, 95% CI = 1.18-3.30), sundried food (OR = 1.77, 95% CI = 1.10-2.85) and red chilly (OR = 1.76, 95% CI = 1.07-2.89). Probability of survival lowered significantly (P < 0.05 or P < 0.01 or P < 0.001) in those consuming tobacco in the form of snuff (Log-rank c 2 = 24.62, P = 0.000) and smoking (Log-rank c 2 = 5.20, P = 0.023) as compared to those who did not take these. CONCLUSIONS: The analysis finally established snuff (smokeless tobacco) as the most powerful risk factor of esophageal cancer in Jammu region, followed by the salt tea, smoking and the sundried food.

Relevance of opt-out screening for HIV in emergency and pre-surgery patients in a tertiary care center in Northern India: a pilot study.

OBJECTIVE: A preliminary opt-out screening study for HIV was conducted in a tertiary care hospital in India according to Center for Disease Control (CDC) guidelines. A total of 876 cases were screened for HIV during August 2007 to December 2007 using tests approved by the National AIDS Control Organization (NACO). RESULTS: Data indicates that the prevalence of HIV in emergency and pre-surgical setting was 21 per thousand at the tertiary care center. Positivity rate in the pediatric population was 20.9 per thousand while in adults it was 21.4 per thousand. Most patients were totally unsuspected. Nearly 40000 patients seek admission annually to the emergency department alone. Thus nearly 700 to 800 patients may be missed every year if one does not resort to such a practice. CONCLUSION: Since India has the second largest number of HIV cases in the world, opt-out screening program and testing in an emergency setting, as recommended by CDC, is extremely relevant. Logistics of implementation of this policy need to be worked out at a national level.

High incidence of Epstein Barr virus infection in childhood acute lymphocytic leukemia: a preliminary study.

INTRODUCTION: Epstein Barr virus (EBV) has a unique association with several human malignancies, especially lymphoproliferative disorders, mainly lymphomas in adults. There is paucity of data pertaining to EBV association with various cancers in India . OBJECTIVE: The study aims to investigate the association of EBV in childhood leukemia. MATERIAL AND METHODS: Patients attending pediatric oncology services of the referral center have been included in the study. Twenty-five consecutive pediatric patients with acute lymphocytic lukemia (ALL) were subjected to EBV studies employing sensitive polymerase chain reaction followed by hybridization for presence of Bam H1-W region of EBV genome and detection of anti Z EBV replication activator (ZEBRA) antibodies using Western blot. Positive control included a case of Burkitt's lymphoma and infectious mononucleosis each. Raji cells were used as positive control with each test. RESULTS: The PCR for EBV was positive in 8/25 patients of ALL. Western blot test using anti ZEBRA antibodies was positive in 5/25(20%) cases of ALL. Considering PCR as the gold standard, 32% of the children with ALL had evidence of active EBV replication. The positive controls were consistently positive. None of the 30 healthy laboratory controls, 22 age matched disease controls, 12 cases of AML and 15 cases of multiple myeloma were positive either by PCR or Western blots assays (P < 0. 01). There was no statistically significant correlation between duration of therapy and EBV positivity (P > 0.05). CONCLUSION: These studies indicate that a significant number of patients with ALL show evidence of active EBV replication.

Risk factors associated with leptospirosis during an outbreak in Middle Andaman, India.

BACKGROUND & OBJECTIVE: Leptospirosis outbreaks occur frequently in North and South Andaman Islands but not in Middle Andaman. In 2002, an outbreak appeared in Middle Andaman for the first time. Although a study on risk factors was conducted in North Andaman, it used seropositivity to define leptospirosis. Since seropositivity might not indicate current leptospiral infection and as no study on risk factors was conducted in Middle Andaman, we carried out this study to identify the risk factors during the outbreak. METHODS: A suspected outbreak of leptospirosis occurred in Rangat of Middle Andaman during October - November 2002. Suspected cases were screened for leptospirosis using microscopic agglutination test (MAT). Fifty two patients confirmed to have leptospirosis based on rising titres in MAT on paired sera, and 104 age, sex and neighbourhood seronegative matched controls, were included in the study. A conditional multiple regression by backward elimination process was carried out with acute leptospirosis as the dependent factor and various environmental, occupational and behavioural factors as independent factors. A stratified analysis was also carried out. RESULTS: The presence of cattle in the house, drinking stream water, contact with garbage, walking barefoot and standing in water while working were identified as significant factors associated with leptospirosis. Stratified analysis showed a dose response relationship between number of cattle in the house and the risk of leptospiral infection suugesting that cattle could be a source of infection. INTERPRETATION & CONCLUSION: Identification of the potential risk factors would help understand the transmission dynamics of the disease and formulate public health interventions.

A single dose of preoperative gabapentin for pain reduction and requirement of morphine after total mastectomy and axillary dissection: randomized placebo-controlled double-blind trial.

BACKGROUND: Gabapentin has been recently found to be useful for reducing acute postoperative pain when administered preoperatively. Although various dose regimens have been tried in different surgical settings, the minimum effective dose is not established. AIMS: We aimed to evaluate the analgesic efficacy of single low dose gabapentin in patients undergoing total mastectomy and axillary dissection. SETTINGS AND DESIGN: Prospective randomized placebo-controlled double-blind trial in a tertiary care teaching hospital. MATERIALS AND METHODS: Fifty women scheduled for total mastectomy and axillary dissection were randomized to receive either gabapentin 600 mg or placebo orally 1 h preoperatively. The intraoperative and postoperative management was standardized. Postoperative pain was assessed at rest and on movement for 12 h using the numerical rating scale (NRS). Morphine was administered if NRS exceeded 30. Primary outcome measure was total morphine consumption. STATISTICAL ANALYSIS: The morphine consumption was compared using independent t test while pain and sedation scores were analyzed using Mann-Whitney U test. RESULTS: Forty-six patients completed the trial. The postoperative morphine consumption was significantly less (5.8 +/- 4.2 vs. 11.0 +/- 3.4 mg; P 0.001) and the median [IQR] time to first analgesic was significantly longer (90 [37.5-120] vs. 0 [0-90] min; P 0.001) in the gabapentin group than in the placebo group. The incidence of side effects was similar in the two groups. CONCLUSIONS: A single low dose of 600 mg gabapentin administered 1 h prior to surgery produced effective and significant postoperative analgesia after total mastectomy and axillary dissection without significant side effects.

High rate of mutation K103N causing resistance to nevirapine in Indian children with acquired immunodeficiency syndrome.

In north India the number of paediatric cases with acquired immunodeficiency syndrome (AIDS) is on the rise. Most drug combinations used for treatment of AIDS incorporate nevirapine, resistance to which develops very fast if given singly or because of unplanned interruptions. This paper investigates presence of mutations at codon 103 and codon 215 of the HIV pol gene causing resistance to nevirapine and zidovudine (AZT) respectively in 25 children with AIDS. Mutations T215Y and K103N were detected by a nested cum amplification refractory mutation system polymerase chain reaction (ARMS PCR) and the results were confirmed by direct sequencing in five randomly selected cases. Nineteen patients had received nevirapine containing regimen and six were drug naive. Mutation K103N was observed in 56% (14/25) of the children while mutation T215Y was found in none. Two of the six drug naïve children also showed K103N mutation. Thus, Indian children drug naïve or treated with nevirapine containing regimens show a high rate of mutation conferring resistance to nevirapine which calls for a judicious use of nevirapine both in antenatal and postnatal setting.

Serodiagnosis of severe leptospirosis: evaluation of ELISA based on the recombinant OmpL1 or LipL41 antigens of Leptospira interrogans serovar autumnalis.

ELISA based on the recombinant OmpL1 and LipL41 antigens of Leptospira interrogans serovar autumnalis strain N2 have been developed, for the serodiagnosis of the severe pulmonary form of leptospirosis on the endemic Andaman Islands. The recombinant OmpL1 and LipL41 were produced using Escherichia coli expression systems and then purified before each was evaluated in an IgM-ELISA. The sera tested came from 224 patients who had the severe form of leptospirosis and pulmonary pneumonitis as major symptoms, 148 patients who, although clinically suspected to have severe leptospirosis, had been found seronegative for leptospirosis, 528 patients with diseases other than lepstospirosis, and 704 apparently healthy individuals, all from the Andaman Islands. Among the patients with the severe pulmonary form of leptospirosis, the ELISA based on the recombinant OmpL1 achieved a sensitivity of 91.1%, a specificity of 86.5%, a positive predictive value of 91.1%, and a negative predictive value of 86.5%. The corresponding values for the assay based on the recombinant LipL41 were 89.3%, 89.2%, 92.6%, and 84.6%, respectively. The good performance of both ELISA indicates that either may be routinely used for the diagnosis of severe pulmonary leptospirosis which, at least on the Andaman Islands, occurs soon after the patient has become leptospiraemic. The evaluated ELISA may also be useful for early case detection and for monitoring the effects of treatment.

Gastrointestinal histoplasmosis presenting as colonic pseudotumour.

We report a case of gastrointestinal histoplasmosis in a 45-year-old HIV positive man who was misdiagnosed as a case of colonic cancer. The patient presented with low-grade fever, pain in lower abdomen, anorexia and weight loss of six months duration. On examination a lump in the left iliac fossa was detected. Colonoscopy revealed stricture and ulcerated growth in the sigmoid colon. Radiological investigations suggested malignant/inflammatory mass in the sigmoid colon with luminal compromise. Patient was operated and ulcerated tissue was sent for histopathological examination, which revealed numerous intracellular, 2-4 microm, oval, narrow-based budding yeast cells suggestive of Histoplasma capsulatum. Subsequently, the patient developed fluffy opacities on X-ray chest. Examination of sputum revealed presence of acid-fast bacilli and yeast forms of H. capsulatum. Patient was started on amphotericin B but died on the seventeenth postoperative day. The diagnosis of histoplasmosis was made retrospectively. Atypical presentation and rarity of the disease led to this diagnostic pitfall. To the best of our knowledge this is the first report of gastrointestinal histoplasmosis presenting as colonic pseudotumour from India.