An initial experience with therapeutic drug monitoring of levetiracetam as reported from a pediatric clinical setting in India.

BACKGROUND AND OBJECTIVES: Monitoring of levetiracetam in routine clinical practice is not strongly recommended. The aim of this study was to investigate any difference in serum levetiracetam concentration between patients on enzyme-inducing and -inhibiting antiepileptic co-medication and also to identify any correlation between levetiracetam concentration and clinical response. MATERIALS AND METHODS: This study included pediatric patients with epilepsy from a tertiary care referral hospital in India. Details of antiepileptic co-medication, seizure frequency before and after initiating levetiracetam were recorded. Serum trough levetiracetam concentration was measured. RESULTS: Of the 69 children recruited in the study, 55 children had >50% reduction in seizure frequency compared to baseline seizure frequency. Eight patients showed no improvement. The serum concentration of levetiracetam was more than 10 µg/ml in 78.2% of responders and 75% non-responders. There was no difference in dosing between responders and non-responders. Patients on enzyme-inducing co-medication had lower median serum levetiracetam concentrations (7.3 µg/ml) compared to those on enzyme-inhibiting co-medication (14.4 µg/ml) or those without interfering antiepileptic co-medication (16.6 µg/ml). CONCLUSION: Levetiracetam monitoring has a role in patients on antiepileptic polypharmacy and for confirmation of compliance.

Anthropometric factors and breast cancer risk among urban and rural women in South India: a multicentric case-control study.

Breast cancer (BC) incidence in India is approximately twice as high in urban women than in rural women, among whom we investigated the role of anthropometric factors and body size. The study was conducted at the Regional Cancer Centre, Trivandrum, and in three cancer hospitals in Chennai during 2002-2005. Histologically confirmed cases (n=1866) and age-matched controls (n=1873) were selected. Anthropometric factors were measured in standard ways. Information on body size at different periods of life was obtained using pictograms. Odds ratios (OR) of BC were estimated through logistic regression modelling. Proportion of women with body mass index (BMI)>25.0 kg/m(2), waist size >85 cm and hip size >100 cm was significantly higher among urban than rural women. Risk was increased for waist size >85 cm (pre-menopausal: OR=1.24, 95% CI: 0.96-1.62; post-menopausal: 1.61, 95% CI: 1.22-2.12) and hip size >100 cm (pre-menopausal: OR=1.47, 95% CI: 1.05-2.06; post-menopausal 2.42, 95% CI: 1.72-3.41). Large body size at age 10 (OR=1.75, 95% CI: 1.01-3.03) and increased BMI (OR=1.33, 95% CI: 1.05-1.69 for 25.0-29.9 kg/m(2) and OR=1.56, 95% CI: 1.03-2.35 for 30+ kg/m(2)) were associated with pre-menopausal BC risk. Our data support the hypotheses that increased anthropometric factors are risk factors of BC in India.

Development and validation of limited sampling strategy equation for mycophenolate mofetil in children with systemic lupus erythematosus.

The aim of this study was to establish a limited sample strategy (LSS) to predict the mycophenolic acid (MPA) area under the curve (AUC)(0-12) in children with systemic lupus erythematosus (SLE). Three months after initiation of mycophenolate mofetil (MMF) 26 children with SLE presented for therapeutic drug monitoring of MPA. On the day of the test, 10 specimens were collected, analyzed, and MPA AUC(0-12) was calculated. Using step-wise regression analysis, LSS equations were developed. Using bootstrap validation, the predictive performance was calculated. The measured mean (standard deviation) for the trough concentration and AUC(0-12) were 2.55 (1.57) µg/ml and 62.6 (21.67) mg.h/L, respectively. The range of trough concentrations and AUC(0-12) were 0.7-5.54 µg/ml and 22.1-104.8 mg.h/L, respectively. The interindividual variability (%CV) for dose normalized AUC(0-12) and dose normalized Ctrough was 46.5% and 61.1%, respectively. The correlation between the concentrations at the different time points and MPA AUC(0-12) ranged from 0.05 (1.5 h) to 0.56 (4 h). Two LSS equations that included 4 or 5 time points up to 3 h were developed and validated. The 4 point LSS had a correlation (R2) of 0.88 and the 5 point LSS an R2 of 0.87. With respect to the 4 point and 5 point MPA LSS AUC(0-12), the bias was 1.92% and 1.96%, respectively, and the imprecision was 11.24% and 11.28%, respectively. A 4 point LSS which concludes within 3 h after the administration of the MMF dose was developed and validated, to determine the MPA AUC(0-12) in children with SLE.

Skeletal metastases and bone marrow infiltration from squamous cell carcinoma of the buccal mucosa.

Distant metastasis from head and neck cancer is an extremely rare phenomenon. Squamous carcinomas of the buccal mucosa is not known to spread to distant organs. We report a case of buccal mucosal carcinoma with biopsy proven metastasis to bone and bone marrow.

Angiogenesis during tumor progression in the oral cavity is related to reduced apoptosis and high tumor cell proliferation.

Angiogenesis, the growth of new blood vessels, is believed to aid tumor progression and metastasis. Tumor progression is also influenced by the extent of proliferation and apoptosis. This study, therefore, analyzed in lesions of the oral cavity, the significance of angiogenesis in relation to apoptosis, expression of apoptosis regulatory p53, bax and bcl-2 proteins as well as tissue proliferation defined by cyclin D1 expression. Results from this study suggest that angiogenesis increases as histological abnormality increases in the oral mucosa. The expression of apoptosis regulatory proteins also appears to be altered in a histologically dependent manner. The correlation seen between CD34 expression, cyclin D1 and TUNEL reactive cells suggests that increased angiogenesis, decreased apoptosis and deregulated proliferation occur simultaneously during tumor progression in the oral mucosa. Presence of a mutant p53, increased bcl-2 expression and altered bax expression are also involved in this complex process.

Apoptosis, angiogenesis and proliferation: trifunctional measure of tumour response to radiotherapy for oral cancer.

Local recurrence is a significant problem following radiotherapy in oral carcinoma and hence there is a paramount need for predictive markers. This study therefore analysed the predictive value of pre-treatment status of angiogenesis, apoptosis, expression of apoptosis regulatory p53, bax and bcl-2 proteins as well as tissue proliferation in relation to tumour response to radiotherapy. Sixty-nine histologically defined invasive carcinoma lesions were included in the study. Extent of apoptosis was defined morphologically and by the TUNEL (Tdt-mediated dUTP biotin nick end labelling) assay. Expression of apoptosis regulatory p53, bax and bcl-2 proteins were evaluated by immunocytochemistry. Mutant p53 protein was detected using a mutant p53-specific ELISA. The extent of tissue proliferation was evaluated by cyclin D1 expression. Angiogenesis was evaluated by CD34 antigen expression. All patients were treated with radical radiotherapy and followed up for 36 months. High levels of p53 protein detected by immunocytochemistry were found to be associated with poor response to treatment or disease relapse. Detection of mutant p53 protein also showed significant association with poor prognosis. Low levels of angiogenesis had a correlation with recurrence status. Tumours showing less vascularisation as well as increased apoptosis had a poor prognosis. Expression of p53 and bcl-2 proteins showed direct correlation with angiogenesis. There was no correlation between clinical status and any of the experimental parameters with histopathological grades of invasive lesions. Presence of mutant p53 protein is suggestive of poor tumour response to radiotherapy. Expression of p53 and increased apoptosis in less vascularised tumours is associated with treatment resistance. A predictive assay based on these results designed to analyse individual tumour samples showed presence of apoptotic cells near the vasculature to be indicative of good prognosis, while absence of apoptotic cells or highly proliferative cells and/or expression of bcl-2 protein in cells around the vasculature to be an indicator of poor prognosis.

Case report: malignant mesothelioma of tunica vaginalis testis presenting with spinal metastasis--report of two cases.

Malignant mesotheliomas of tunica vaginalis testis (TVT) are rare tumours with a tendency to disseminate by lymphatic and haematogenous routes. Osseous metastasis is extremely uncommon. We report two cases of malignant mesothelioma of TVT presenting with spinal metastasis.

Primary choriocarcinoma of the ovary. Report of two cases.

Primary choriocarcinoma of the ovary (PCO) is rare. This can be gestational (GCO) or nongestational (NGCO) in origin. It is difficult to differentiate between CGO and NGCO. NGCO carries a worse prognosis than GCO. We present two cases of metastatic GCO who were treated successfully with combination chemotherapy and are alive and disease free at the time of reporting.

Combined approach with therapeutic drug monitoring and pharmacogenomics in renal transplant recipients.

In patients undergoing renal transplantation, dose individualization for tacrolimus is routinely achieved with therapeutic drug monitoring (TDM). The patient started on 5.5 mg/day of tacrolimus had a significantly elevated tacrolimus trough concentration. The tacrolimus dose was regularly reduced following TDM at many time periods in the post transplant period but the tacrolimus concentration was consistently elevated. Genomic analysis done after four years revealed mutations in the genes encoding for CYP3A5 and MDR1 (2677G > T). Pharmacogenomics alongside TDM, will soon emerge as the backbone of dose individualization. But for genomics to be beneficial, it should be advocated in the pre-transplant or early post transplant period.

Mycophenolic acid area under the curve recovery time following rifampicin withdrawal.

Renal transplant patients prescribed mycophenolate mofetil (MMF) may require treatment for tuberculosis with a regimen including the tuberculocidal drug rifampicin. MMF is an ester prodrug which is rapidly hydrolysed to the active compound, mycophenolic acid (MPA). Therapeutic drug monitoring of mycophenolate involves the measurement of MPA area under the curve (MPA-AUC(0-12)). Rifampicin is known to increase the metabolism and decrease enterohepatic recirculation of mycophenolic acid, (MPA). When MPA is monitored after the discontinuation of rifampicin, an important factor is the time required for the MPA area under the curve to return to the pre-rifampicin value. At present this is not known. This report describes one such renal allograft patient, on long term MMF and prescribed rifampicin by a local physician. As expected there was a clinically significant decrease in MPA-AUC(0-12) Three weeks after rifampicin was discontinued the MPA-AUC(0-12) was still only 65% of the pre-rifampicin value and only 55% of the steady state MPA-AUC(0-12) measured six months later.

Stability issues of mycophenolic Acid in plasma: from patient to laboratory.

Although mycophenolate is widely prescribed in India, therapeutic drug monitoring of mycophenolic acid is not performed in most centers. This could be due to many factors such as the large investment and expertise required for high performance liquid chromatography, or the high costs involved as specialized refrigeration is required when transporting patient specimens to the laboratories with the facility to analyze MPA. The Clinical Pharmacology unit of the Christian Medical College Hospital routinely monitors the area under the curve of MPA. In order to determine if this unit could act as a central laboratory for MPA monitoring, the stability of MPA in plasma under a series of storage and transport conditions was assessed. The procedures involved the analysis of plasma specimens from patients on mycophenolate mofetil and blank plasma spiked with MPA reference standard. A range of low and high concentrations were separately analyzed to confirm long term and short term stability. The measured concentrations of MPA showed no significant change over 5 months when stored at -20 degrees or over five days under conditions encountered during transport.

Topical phenytoin solution for treating pressure ulcers: a prospective, randomized, double-blind clinical trial.

STUDY DESIGN: Prospective, randomized, double-blind clinical trial. OBJECTIVES: To evaluate the efficacy of topical phenytoin solution in treating pressure ulcers among patients with spinal cord disorders and to evaluate the systemic absorption of topical phenytoin. SETTING: Physical Medicine and Rehabilitation Unit, Christian Medical College, Vellore, India. METHODS: Twenty-eight patients with stage 2 pressure ulcers were randomized to receive either phenytoin solution (5 mg/ml) or normal saline dressing on their ulcers once daily for 15 days. Efficacy of the treatment was determined by assessing the reduction in Pressure Ulcer Scores for Healing (PUSH 3.0), ulcer volume and ulcer size as on day 16. Serum phenytoin concentrations were estimated to determine the systemic absorption of topical phenytoin. RESULTS: Statistically insignificant but marginally higher reduction in PUSH 3.0 scores and ulcer size were seen with topical phenytoin treatment. Systemic absorption of topical phenytoin was negligible. No adverse drug events were detected during the study. CONCLUSIONS: Phenytoin solution is a safe topical agent that accelerates healing of pressure ulcers. However, its efficacy is only slightly more than normal saline treatment.

A six-hour extrapolated sampling strategy for monitoring mycophenolic acid in renal transplant patients in the Indian subcontinent.

BACKGROUND: Therapeutic drug monitoring for mycophenolic acid (MPA) is increasingly being advocated. The present therapeutic range relates to the 12-hour area under the serum concentration time profile (AUC).However, this is a cumbersome, tedious, cost restricting procedure. Is it possible to reduce this sampling period? AIM: To compare the AUC from a reduced sampling strategy with the full 12-hour profile for MPA. SETTINGS AND DESIGN: Clinical Pharmacology Unit of a tertiary care hospital in South India. Retrospective, paired data. MATERIALS AND METHODS: Thirty-four 12-hour profiles from post-renal transplant patients on Cellcept were evaluated. Profiles were grouped according to steroid and immunosuppressant co-medication and the time after transplant. MPA was estimated by high performance liquid chromatography with UV detection. From the 12-hour profiles the AUC up to only six hours was calculated by the trapezoidal rule and a correction factor applied. These two AUCs were then compared. STATISTICAL ANALYSIS: Linear regression, intra-class correlations (ICC) and a two-tailed paired t-test were applied to the data. RESULTS: Comparing the 12-hour AUC with the paired 6-hour extrapolated AUC, the ICC and linear regression(r2) were very good for all three groups. No statistical difference was found by a two-tailed paired t-test. No bias was seen with a Bland Altman plot or by calculation. CONCLUSION: For patients on Cellcept with prednisolone +/- cyclosporine the 6-hour corrected is an accurate measure of the full 12-hour AUC.

Renal metastasis from squamous cell carcinoma of the lung.

Symptomatic renal metastases from primary malignancy elsewhere in the body is an uncommon feature in disseminated cancer. Postmortem diagnosis is more frequent. A case is reported here of a patient with renal metastasis from lung carcinoma who presented with haematuria.

Testicular germ cell tumors in prepubertal children.

Pediatric testicular germ cell tumors are rare. Fifteen children, all less than 5 years of age, were evaluated and treated during February 1987 to July 1996. The median age was 18 months (range, 4-60 months). All were staged according to the Pediatric Oncology Group/Children's Cancer Study Group staging system. Seven patients had stage III disease. Histologically, 9 patients had pure endodermal sinus tumor, 1 had endodermal sinus tumor with embryonal carcinoma, 1 had embryonal carcinoma alone, 2 had immature teratoma, and 2 had mature teratoma. Six children were kept on surveillance. All others received chemotherapy with cisplatin, bleomycin, and vinblastine. The 10-year actuarial overall survival rate was 86.7%.

Malignant phyllodes tumor.

The study aims to evaluate the survival and prognosis of patients with malignant phyllodes tumor. Between 1982 and 1998, 37 women with malignant phyllodes tumor were treated at the Regional Cancer Center, Trivandrum. Twelve patients were recurrent. Survival was estimated using the Kaplan-Meier method. Patient, disease, and treatment factors were compared using log-rank test. The Cox-proportional hazard model was employed to identify the prognostic factors. Thirty-six patients had surgery. Twenty-five patients received postoperative radiotherapy, and 2 received chemotherapy in addition. The median follow-up was 43 months (range 1-170 months). Eight patients failed locally, and 7 of these were successfully salvaged by surgery. The 5-year overall survival was 74.2% (95% CI, 0.44 to 0.89), whereas 5-year disease-free survival was 59.6% (95% CI, 0.39 to 0.7). The margin of surgical excision was found to be the only independent prognostic factor (p=0.003). However, patients with tumor size more than 5 cm (hazard ratio 2.9) were found to have increased hazard, whereas those receiving adjuvant radiotherapy (hazard ratio 0.6), married women (hazard ratio 0.4), and those women over the age of 35 years (hazard ratio 0.7) showed a decreased hazards. Cystosarcoma phyllodes is a rare malignancy of the female breast. Surgery with adequate margins is the primary treatment. Adjuvant radiotherapy appears to improve the disease-free survival.

De novo programmed cell death in oral cancer.

AIM: The importance of programmed cell death or apoptosis in the maintenance of tissue homoeostasis and the pathogenesis of oral cancer was analysed in relation to apoptosis regulatory proteins, tissue proliferation and tumour histology. METHODS AND RESULTS: The extent of apoptosis was defined by morphological criteria and the TUNEL (terminal deoxy nucleotidyl transferase-mediated dUTP biotin nick end labelling) assay. p53, bax, bcl-2 and cyclin D1 expression was evaluated by immunocytochemistry. The presence of mutant p53 was analysed using a mutant p53-specific ELISA. An inverse correlation was observed between TUNEL reactivity and histology of the lesion (r = -0.555, P = 0.0001). There was also correlation between TUNEL reactivity and immunoreactivity of apoptosis regulatory proteins. p53 (r = 0.641, P = 0.00023), bcl-2 (r = -0.642, P = 0.00014) and bax (r = 0.651, P = 0.00002). The presence of mutant p53 protein showed an inverse correlation to the extent of apoptosis (r = - 0.301, P = 0.00063). Significant correlation was evident between the bax/bcl-2 ratio and TUNEL (r = 0.652, P = 0.00001) as well as between cyclin D1 and TUNEL reactivity (r = 0.577, P = 0.00001). CONCLUSIONS: Results from this study suggest that apoptosis decreases as histological abnormality increases. Apoptotic regulatory proteins are also altered in a histologically dependent manner. Deregulated proliferation occurs simultaneously with decreased apoptosis during tumour progression in the oral mucosa.