Deep Inspiration breath Hold facilitates surgical cavity registration on cone beam imaging for Partial breast irradiation.

BACKGROUND AND PURPOSE: The quality of the Cone Beam Computed Tomography (CBCT) images used for patient set-up is essential to avoid geographical miss when narrower margins or shorter fractionation are used for example in Accelerated Partial Breast Irradiation (APBI). This study evaluates deep inspiration breath hold (DIBH) with skin guided radiotherapy as a tool for image improvement reducing motion artifacts. MATERIALS AND METHODS: Daily CBCT images of left and right breast cancer patients with well-defined surgical cavity on CT simulation were used for this study. Only left sided CBCT were acquired with DIBH. Trained and experienced radiation therapists were asked to evaluate the image quality using a cavity visualization score (CVS), an image quality Likert score, and to perform registration shifts. Images were anonymized and therapists were blinded to the use of DIBH. RESULTS: Images from 21 patients, with 15 CBCT each, were evaluated by 6 radiation therapists, generating 4,015 evaluation points. Statistically significant improvements were observed in CVS and image quality (p < 0.001) with DIBH. Also, the rate of surgical cavity identification increased to 76 % with DIBH compared to 56 % without (p < 0.001). DIBH significantly reduced the inter-observer variability in registration shift corrections (p < 0.001) CONCLUSION: Utilizing DIBH for motion control improves both the image quality and the surgical cavity identification. This results in a decrease in registration variability, which is important for APBI accuracy.

Incidence of bone metastasis in head and neck malignancy: A retrospective study.

Aim: The retrospective analysis was done to describe the characteristics and frequency of bone metastases and prognosis of head and neck cancer patients with bone metastases. Materials and Methods: We investigated total 16209 patients of which 3620 were head and neck cancer patients entering our oncology outpatient department from January 2010 to December 2019. Of 3620 patients, 29 of them developed solitary or multiple bone metastases during the progression of the disease. Results: The overall incidence of bone metastases was found to be 0.8% (29 cases) in head and neck cancers. Bone metastasis was observed in solitary or multiple bones which includes vertebrae 12 (41.37%), hip 9 (31.03%), femur 3 (10.34%), and involve sternum, ribs, clavicle and orbits in few cases. All the patients had few months of survival after developing bone metastasis. Conclusions: With the recent advancement in technology, the survival rate and quality of life of patient suffering from head and neck carcinoma had increased. Distant metastasis to bones was rarely observed in these cancers. Bone dissemination is associated with poor outcome; thus it must always be taken into consideration when contemplating intervention in these patients. So, for early diagnose of this metastasis in complete responders' appropriate measures should be taken during follow-up.

Dosimetric effects of repeat computed tomography scan during radiotherapy planning in esophagus carcinoma.

Aim of Study: The aim was to assess the potential reduction in the doses to organs at risk (OARs) and target organ volume by doing replanning on repeat computed tomography (CT) scan during the 4th week of radiation therapy (RT). Materials and Methods: Twenty-four histologically proven patients of inoperable esophagus carcinoma were studied. All patients received induction chemotherapy followed by concurrent chemotherapy and radiotherapy. CT simulation with proper immobilization was done, and images were transferred to the treatment planning system. Delineation of target volumes and OARs was done, and two plans were generated for 60 Gy in 30 fractions and 40 Gy in 20 fractions with intensity-modulated RT keeping the doses to OARs within the tolerance limits. Replanning for 20 Gy in 10 fractions was done on repeat CT scan during the 4th week of radiotherapy treatment, and potential reduction in doses to OARs and target organ volume was assessed. Results: A total of 24 cases were analyzed for the adaptive plan with the coverage of the 95% prescription isodose for planning target volume. Statistical analysis was done by t-test. The difference in the doses received by the OARs was analyzed and was seen that due to re CT scan, the doses were reduced to the left lung V20 (mean 19.23 Gy vs. 17.35 Gy) and Dmean (mean 16.03 Gy vs. 14.25 Gy), right lung V20 (mean 18.38 Gy vs. 16.66 Gy) and Dmean (mean 15.70 Gy vs. 13.97 Gy), heart V25 (mean 38.72 Gy vs. 35.32 Gy) and Dmean (mean 26.40 Gy vs. 22.74 Gy), and spine 1% volume (mean 36.54 Gy vs. 33.39 Gy) and Dmax (mean 39.81 Gy vs. 34.34 Gy), gross tumor volume (GTV) (mean 67.37 cm 3 vs. 24.58 cm 3) and were all significantly smaller for the adaptive plan. Conclusion: By doing adaptive radiotherapy in the 4th week of treatment using repeat CT scan, along with the response evaluation, there is a significant reduction in the volume of GTV, and replanning of treatment on repeat CT scan also helps us in reducing doses to the OARs resulting in reduced toxicity.

Use of misoprostol before tandem application for intracavitary brachytherapy in patients of carcinoma cervix: An institution study.

Aim: To investigate the ease of tandem application and external os identification by giving sublingual misoprostol before initiation of intracavitary brachytherapy in cancer cervix patients. Materials and Methods: 36 patients with cervical cancer stage IIIB which were supposed to undergo intracavitary brachytherapy(ICBT) were randomly divided into 2 subgroups, group A patients receiving misoprostol and group B not receiving misoprostol.Misoprostol 400 mcg was given sublingually 3 hrs prior to the procedure. The efficacy of the drug was measured as per the ease of identification of os and easier tandem application and amount of bleeding during procedure. Results: Application of tandem and identification of external os was easier and amount of bleeding was also less in patients that were administered sublingual misoprostol. Conclusion: Sublingual Misoprostol given before ICBT helps in cervical ripening and thus leads to easier os recognition and central tandem application and reduce overall anaesthesia time.

Quadruple metachronous primary cancer in a single patient: A rare case report.

Multiple primary cancer is a condition where multiple occurrences of different malignancies occur in the same individual. As there is a rise in the long-term survival of patients, multiple primary cancer is now not a rare entity. To see four different tumors in the same patient is very rare, and here, we report the case of a 60-year-old female patient with quadruple primary cancer of bilateral breast, esophagus, and sarcoma of the leg.

Higher Medication Adherence and Lower Opioid Use Among Individuals with Autoimmune Disease Enrolled in an Adalimumab Patient Support Program in the United States.

INTRODUCTION: Opioid use is prevalent among patients with autoimmune conditions, despite not being a recommended treatment. Tumor necrosis factor inhibitor (anti-TNF) therapy is an effective treatment for these autoimmune conditions, and patient support programs (PSPs) have been developed to help patients manage their prescribed treatments. This study was conducted to evaluate the impact of PSPs on anti-TNF adherence and opioid use using data on adalimumab (ADA), an anti-TNF. METHODS: The study used insurance claims data linked to ADA PSP data on patients who initiated ADA after 01/2015, were commercially insured, and had data coverage for 1 year before and after (i.e., during the follow-up period) ADA initiation. Patients with opioid use in the 3 months before ADA initiation were excluded. PSP patients enrolled in the PSP within 30 days of ADA initiation and had 2+ PSP nurse ambassador interactions; non-PSP patients had no PSP engagement. ADA adherence [proportion of days covered (PDC), persistence], opioid initiation, 2+ opioid fills, and opioid supply during follow-up were compared between cohorts using regression models that controlled for patient characteristics. RESULTS: Results were obtained for 1952 PSP and 728 non-PSP patients. PSP patients demonstrated better adherence to ADA than non-PSP patients, including higher PDC and persistence (all p < 0.001). PSP patients were 13% less likely to initiate opioids and 26% less likely to have at least 2 fills than non-PSP patients, and they had fewer days of opioid supply (all p < 0.01). CONCLUSIONS: This study supports the benefit of PSPs and suggests that the ADA PSP is associated with improved adherence and potentially lower opioid use.

Inflammatory Bowel Disease: Pathophysiology and Current Therapeutic Approaches.

Inflammatory bowel diseases, most commonly categorized as Crohn's disease and ulcerative colitis, are immune mediated chronic inflammatory disorders of the gastrointestinal tract. The etiopathogenesis is multifactorial with different environmental, genetic, immune mediated, and gut microbial factors playing important role. The current goals of therapy are to improve clinical symptoms, control inflammation, prevent complications, and improve quality of life. Different therapeutic agents, with their indications, mechanisms of action, and side effects are discussed in this chapter. Anti-integrin therapy, a newer therapeutic class, with its potential beneficial role in both Crohn's disease and ulcerative colitis is also mentioned. In the end, therapeutic algorithms for both diseases are reviewed.

Gastric heterotopia in the rectum. A rare cause of ectopic gastric tissue.

Gastric heterotopia refers to the discovery of normal gastric tissue at foreign, unexpected sites. It has been described anywhere in the alimentary tract, even in the mediastinum, scrotum, and spinal cord. It is not uncommonly seen in the oesophagus or small intestine. However, large bowel lesions are rare, with the most common location of colonic lesions is the rectum. Although it is a rare entity, it may be the source for significant problems such as rectal bleeding, abdominal pain, deep rectal pain, and malignancy. Here, we report an additional case of gastric heterotopia in the rectum of a 56year old gentleman, and review the literature.

Preventive health measures in inflammatory bowel disease.

We aim to review the literature and provide guidance on preventive health measures in inflammatory bowel disease (IBD). Structured searches were performed in PubMed, MEDLINE, EMBASE, Web of Science and Cochrane Library from January 1976 to June 2016 using the following keywords: (inflammatory bowel disease OR Crohn's disease OR ulcerative colitis) AND (health maintenance OR preventive health OR health promotion). Abstracts of the articles selected from each of these multiple searches were reviewed, and those meeting the inclusion criteria (that is, providing data regarding preventive health or health maintenance in IBD patients) were recorded. Reference lists from the selected articles were manually reviewed to identify further relevant studies. Patients with IBD are at increased risk of developing adverse events related to the disease course, therapeutic interventions, or non-adherence to medication. Recent studies have suggested that IBD patients do not receive preventive services with the same thoroughness as patients with other chronic diseases. Preventive health measures can avert morbidity and improve the quality of life of patients with IBD. Gastroenterologists and primary care physicians (PCPs) should have an up to date working knowledge of preventive health measures for IBD patients. A holistic approach and better communication between gastroenterologists and PCPs with explicit clarification of roles will prevent duplication of services and streamline care.

Environmental risk factors for inflammatory bowel diseases: Evidence based literature review.

AIM: Advances in genetics and immunology have contributed to the current understanding of the pathogenesis of inflammatory bowel diseases (IBD). METHODS: The current opinion on the pathogenesis of IBD suggests that genetically susceptible individuals develop intolerance to dysregulated gut microflora (dysbiosis) and chronic inflammation develops as a result of environmental insults. Environmental exposures are innumerable with varying effects during the life course of individuals with IBD. Studying the relationship between environmental factors and IBD may provide the missing link to increasing our understanding of the etiology and increased incidence of IBD in recent years with implications for prevention, diagnosis, and treatment. Environmental factors are heterogeneous and genetic predisposition, immune dysregulation, or dysbiosis do not lead to the development of IBD in isolation. RESULTS: Current challenges in the study of environmental factors and IBD are how to effectively translate promising results from experimental studies to humans in order to develop models that incorporate the complex interactions between the environment, genetics, immunology, and gut microbiota, and limited high quality interventional studies assessing the effect of modifying environmental factors on the natural history and patient outcomes in IBD. CONCLUSION: This article critically reviews the current evidence on environmental risk factors for IBD and proposes directions for future research.

Safety of Long-term Treatment With Certolizumab Pegol in Patients With Crohn's Disease, Based on a Pooled Analysis of Data From Clinical Trials.

BACKGROUND & AIMS: Treatments for Crohn's disease (CD) have been linked to serious infections, malignancies, and dermatologic complications. We pooled and analyzed clinical trials of certolizumab pegol, a pegylated humanized Fab' fragment against tumor necrosis factor, to quantify safety events in patients with CD. METHODS: We collected data from 5 placebo-controlled trials, 9 open-label studies, and 1 dose-regimen study, conducted globally through April 2014. A total of 2570 patients with moderate to severe CD were treated with certolizumab pegol, with 4378.1 patient-years of exposure. Data were analyzed in 2 groups: patients from placebo-controlled (PC) trials treated with placebo (n = 875) or certolizumab pegol (n = 919) for 6 to 38 weeks (the PC group) or all patients exposed to certolizumab pegol (n = 2570), for durations of 6 to 362 weeks (the all-studies group). Incidence rates (IRs; incidence/100 patient-years) of adverse events (AEs) were calculated from first dose through 70 days (approximately 5 half-lives) after the last dose. RESULTS: In the PC group, IRs for serious AEs were similar among patients given certolizumab pegol (31.35/100 patient-years) vs placebo (24.33/100 patient-years). IRs of serious infections or malignancies were low among patients receiving short-term treatment with certolizumab pegol (8.49/100 patient-years and 1.01/100 patient-years, respectively, in the PC group) and did not increase with long-term treatment (6.47/100 patient-years and 0.80/100 patient-years, respectively, in the all-studies group). IRs of psoriasis or psoriasiform dermatitis were low in the PC group (1.01/100 patient-years and 0/100 patient-years, respectively); in the placebo group, these IRs were 0.38 per 100 patient-years and 0 per 100 patient-years, respectively. IRs of psoriasis or psoriasiform dermatitis did not increase with long-term treatment (0.93/100 patient-years and 0.09/100 patient-years, respectively, in the all-studies group). CONCLUSIONS: Based on an analysis of data pooled from 15 trials of patients with CD, the safety profile for long-term therapy with certolizumab pegol therapy is similar to that reported from short-term studies. Overall rates of AEs, serious infections, malignancies, and psoriasis did not increase with long-term treatment, suggesting a favorable risk-benefit ratio with long-term certolizumab pegol therapy in CD. Clinicaltrials.gov identifiers: NCT00291668, NCT00152490, NCT00152425, NCT00308581, NCT00349752, NCT00552058, NCT00329550, NCT00329420, NCT00160524, NCT00160706, NCT00297648, NCT00333788, NCT00307931, NCT00356408, and NCT00552344 (https://www.clinicaltrials.gov/ct2/search).

Iron deficiency anemia in inflammatory bowel disease.

Anemia is a common extraintestinal manifestation of inflammatory bowel disease (IBD) and is frequently overlooked as a complication. Patients with IBD are commonly found to have iron deficiency anemia (IDA) secondary to chronic blood loss, and impaired iron absorption due to tissue inflammation. Patients with iron deficiency may not always manifest with signs and symptoms; so, hemoglobin levels in patients with IBD must be regularly monitored for earlier detection of anemia. IDA in IBD is associated with poor quality of life, necessitating prompt diagnosis and appropriate treatment. IDA is often associated with inflammation in patients with IBD. Thus, commonly used laboratory parameters are inadequate to diagnose IDA, and newer iron indices, such as reticulocyte hemoglobin content or percentage of hypochromic red cells or zinc protoporphyrin, are required to differentiate IDA from anemia of chronic disease. Oral iron preparations are available and are used in patients with mild disease activity. These preparations are inexpensive and convenient, but can produce gastrointestinal side effects, such as abdominal pain and diarrhea, that limit their use and patient compliance. These preparations are partly absorbed due to inflammation. Non-absorbed iron can be toxic and worsen IBD disease activity. Although cost-effective intravenous iron formulations are widely available and have improved safety profiles, physicians are reluctant to use them. We present a review of the pathophysiologic mechanisms of IDA in IBD, improved diagnostic and therapeutic strategies, efficacy, and safety of iron replacement in IBD.

Penetrating Disease, Narcotic Use, and Loop Ostomy Are Associated with Ostomy and IBD-related Complications After Ostomy Surgery in Crohn's Disease Patients.

BACKGROUND: For medically refractory or obstructive Crohn's disease (CD), ostomy surgery remains an important therapeutic option. Outcomes and complications of this approach have not been well described in the era of biological therapies. Our study aims to characterize CD patients undergoing ostomy creation and assess outcome predictors. METHODS: We performed a retrospective chart review of CD patients who underwent ostomy creation in our center from 2011 to 2014. Data collected include patient demographics, detailed disease- and surgery-related variables, and clinical outcomes after 26 weeks of follow-up. RESULTS: Of the 112 patients, 54 % were female, the median age was 39 years (range 19-78), the median disease duration was 13 years (range 0-50), 54 % had ileo-colonic disease, 55 % had stricturing phenotype, and 59 % had perianal disease. Sixty-two percent received end ostomies, and 38 % received loop ostomies. The leading indications for surgery were stricturing, fistulizing, and perianal disease (35 %). Forty-three (38 %) patients had 76 major complications, including dehydration (22 cases), intra-abdominal infection (16), and obstruction (14). Increased major postoperative complications correlated with penetrating disease (p = 0.02, odds ratio [OR] = 5.52, 95 % confidence interval [CI] = 1.25-24.42), the use of narcotics before surgery (p = 0.04, OR = 2.54, 95 % CI = 1.02-6.34), and loop ostomies (p = 0.004, OR = 4.2, 95 % CI = 1.57-11.23). CONCLUSIONS: Penetrating phenotype, the use of narcotics before surgery, and loop ostomies are associated with major complications in CD patients undergoing ostomy creation. These findings may influence risk management of CD patients needing ostomies.

Effect of hyoscine N-butylbromide on adenoma detection rate: meta-analysis of randomized clinical trials.

BACKGROUND AND AIM: Anti-spasmodic drugs may facilitate mucosal inspection during colonoscopy. The impact of hyoscine N-butylbromide (HBB) on polyp detection rate (PDR) and adenoma detection rate (ADR) is unclear. METHODS: We conducted a reproducible literature search of multiple databases. Two reviewers independently compared manuscripts for PDR, ADR, advanced adenoma detection rate (AADR), and rates of complications. Pooling was conducted by fixed-effects and random-effects models. Relative risk (RR) estimates were calculated (95% confidence interval). I(2) index assessed heterogeneity. RESULTS: Patient demographics were comparable. The pooled analysis showed a trend toward improving PDR and ADR among the HBB group compared with the placebo group but failed to reach statistical significance, (46% vs 43%, RR = 1.08 [0.94, 1.25], P = 0.27), (31% vs 28%, RR = 1.12 [0.97, 1.29], P = 0.11) respectively. CONCLUSION: HBB during colonoscopy may provide marginal improvements in ADR and PDR. However, heterogeneity in the available data precludes firm conclusions at this time.

Sleep disturbances and inflammatory bowel disease.

With an estimated 70 million Americans suffering, sleep disorders have become a global issue, and discovering their causes and consequences are the focus of many clinical research studies. Sleep is now also considered to be an important environmental and behavioral factor associated with the process of inflammation and the immune system. Increased sleepiness is considered part of the acute phase of response to tissue injury, and sleep loss activates inflammatory cytokines such as interleukin (IL)-1 and tumor necrosis factor (TNF)-α. Clinical studies in many immune-mediated diseases, such as systemic lupus erythematosus, rheumatoid arthritis, and ankylosing spondylitis, have revealed an association of sleep disturbances with disease activity. Recent research suggests that individuals with sleep abnormalities are also at greater risk of serious adverse health, economic consequences, and most importantly increased all-cause mortality. The importance of sleep in inflammatory bowel disease has recently gained attention with some published studies demonstrating the association of sleep disturbances with disease activity, subclinical inflammation, and risk of disease relapse. A comprehensive review of sleep physiology and its association with the immune system is provided here. Experimental and clinical studies exploring this relationship in inflammatory bowel disease are reviewed, and the clinical implications of this relationship and future directions for research are also discussed.

Assessment of Physicians' Perceived Risk of Inflammatory Bowel Disease Medications in Pregnant Patients.

UNLABELLED: Many female patients with inflammatory bowel disease (IBD) are affected during their reproductive years, and the benefits of continuing medical therapy to maintain remission during pregnancy generally outweigh the risks of therapy cessation. Knowledge of the current guidelines is important to maximize maternal and fetal outcomes. METHODS: A total of 116 practitioners (family medicine [FM], n = 35; internal medicine [IM], n = 22; obstetrics/gynecol-ogy [Ob/Gyn], n=23; gastroenterology [GI], n = 36) responded to a survey. Respondents were asked about the US Food and Drug Administration classifications of common IBD drugs, the need for caution when administering live vaccines to neonates exposed to biologic agents in utero, and 2 scenarios of patients with IBD who wanted to become pregnant. RESULTS: Compared with GI physicians, FM + IM physicians were less likely to correctly identify infliximab (Remicade, Janssen Biotech) as a pregnancy category B drug (67% vs 30%; P=.0005). Among all respondents, 38% were unaware of the need to delay administration of live vaccines to infants exposed to anti-tumor necrosis factor agents in utero. GI specialists were more likely to advise patients to continue their IBD regimen (biologic agents and thiopurines) during pregnancy than non-GI (IM, FM, and Ob/Gyn) physicians (biologic agents: 86% vs 46%; P<.0001 and thiopurines: 69% vs 15%; P<.0001). Overall, 78% of non-GI physicians said that they would change their practice based on the survey. CONCLUSION: Practitioners caring for pregnant patients may lack awareness regarding the safety and management of IBD drugs during pregnancy. Bringing awareness through education may increase the number of physicians following best practice guidelines.

Assessment of the relationship between quality of sleep and disease activity in inflammatory bowel disease patients.

PURPOSE: Poor sleep quality is associated with adverse health consequences. Sleep disturbances can impact the immune function and process of inflammation. The relationship between sleep quality and the inflammatory bowel disease (IBD) has not been well studied. METHODS: A prospective observational cohort study was performed to assess the correlation of the quality of sleep and disease activity in IBD. We used the Pittsburgh Sleep Quality Index (PSQI) to measure sleep quality. IBD disease activity was measured by using the Harvey-Bradshaw Index or Modified Mayo Score. RESULTS: Forty-one patients were enrolled with mean age of 37 ± 15.4 years and 27 (66%) women. Abnormal PSQI was present in all 23 (100%) of the clinically active patients and in 13 (72%) of those with inactive disease (odds ratio = 2.8, P = 0.007). All 30 patients with histologic evidence of inflammation on recent ileocolonoscopy also had abnormal PSQI scores, which were independent of their clinical disease activity status. Only 6 of 11 patients with histologically quiescent disease had abnormal PSQI scores (odds ratio = 6.0, P < 0.0001). There was no difference in disease type, use of steroids, the presence of depression or anxiety, and body mass index between the patients with normal and abnormal sleep. An abnormal PSQI had a positive predictive value for histologic inflammatory activity of 83%. CONCLUSIONS: Our data show a strong association between clinically active IBD and poor sleep quality and demonstrate that patients in clinical remission with abnormal sleep have a high likelihood of subclinical disease activity.

Clinical use of anti-TNF therapy and increased risk of infections.

Biologics such as antitumor necrosis factor (anti-TNF) drugs have emerged as important agents in the treatment of many chronic inflammatory diseases, especially in cases refractory to conventional treatment modalities. However, opportunistic infections have become a major safety concern in patients on anti-TNF therapy, and physicians who utilize these agents must understand the increased risks of infection. A literature review of the published data on the risk of bacterial, viral, fungal, and parasitic infections associated with anti-TNF therapy was performed and the clinical presentation, diagnostic tests, management, and prevention of opportunistic infections in patients receiving anti-TNF therapy were reviewed. Awareness of the therapeutic potential and associated adverse events is necessary for maximizing therapeutic benefits while minimizing adverse effects from anti-TNF treatments. Patients should be adequately vaccinated when possible and closely monitored for early signs of infection. When serious infections occur, withdrawal of anti-TNF therapy may be necessary until the infection has been identified and properly treated.