Are buccal cancers in India and Canada any different?

BACKGROUND AND OBJECTIVE: To compare the treatment outcomes of squamous cell carcinoma (SCC) of buccal mucosa in India and Canada. METHODS: We compared the outcome of 169 patients with SCC of buccal mucosa treated at Tata Memorial Hospital (TMH), India with 64 matched patients from Cancer Care Manitoba (CCMB), Canada. Overall and cause specific survivals for the two geographical groups were calculated by Kaplan-Meir method and compared using log rank test. Cox regression analysis was used to see impact of independent variables. RESULTS: At 5 years, CCMB patients had lower over all survival (57.4% vs. 67.1%; P = 0.002) than TMH ones but similar cause specific survival (76.4% vs. 74.2%; P = 0.690). Age had an independent influence on both over all and cause specific survival. After adjusting for the age confounding in the Cox proportional hazard model there was no difference in the overall survival of the two groups (HR = 0.84; 95% CI = 0.51, 1.40; P = 0.509). Radiated patients had three times higher risk of dying of disease than surgically treated ones (HR = 3.03; 95% CI = 1.64, 5.60; P < 0.001). CONCLUSIONS: There was no difference in the cause specific survival between the two groups. Apparent difference in the overall survival was due to the difference in the age of presentation.

Changes in the conformational structure, microscopic and macroscopic pK(a)s of meloxicam on complexation with natural and modified cyclodextrins.

Spectroscopic and phase solubility techniques have been used to study the complexation of neutral meloxicam (Mel) with alpha-, beta-, gamma- and HP-beta-cyclodextrins (CDs). The results indicate that neutral Mel has two conformational structures, enol and zwitterions, with the latter more dominant in water. The two pK(a)s of Mel were found to change in the presence of beta-CD, where a blue shift in lambdamax was observed but not in the presence of alpha, HP-beta- and gamma-CD. Rigorous analysis of phase solubility diagrams indicate that beta- and HP-beta-CD form 1:2 Mel/beta-CD type complexes with Mel while alpha- and gamma-CD form only 1:1 complexes. The fact that the overall 1:2 Mel/CD complex formation constant (beta12) was found significantly higher for beta-CD than for HP-beta-CD, combined with further spectroscopic studies, indicate that beta-CD favors inclusion of the neutral enol form over the zwitterion. Unlike alpha-, HP-beta- and gamma-CDs, the hydrophobic microenvironment of a tight 1:2 Mel/beta-CD complex was found to mimic those of organic solvents, thus favoring inclusion of the enol rather than the zwitterion, and hence shifting the tautomerization equilibrium towards the enol conformer.

Prognostic implications of mandibular invasion in oral cancer.

BACKGROUND: Mandibular invasion alters the clinical staging and management of oral epidermoid carcinoma on the assumption that underresection of mandibular bone invaded by tumor can result in disease progression and poor outcome. METHODS: Cox's proportional hazard model was used to assess the effect of mandibular invasion on recurrence-free survival in 107 patients with squamous cell carcinoma of the oral cavity after controlling for the potential confounding effect of positive margins, tumor size, nodal status, and type of resection. RESULTS: Mandibular invasion was characterized as none (n = 59), focal (n = 25), or deep (n = 23). Relapse-free survival at 60 months by the Kaplan Meier product limit method for the none, focal, and deep invasion groups was 61%, 73%, and 46% respectively (p =.28). Variables influencing disease recurrence were positive margins, size >2 cm, N2 and N3 nodal disease, and marginal vs segmental mandibular resection. Mandibular invasion was not a significant risk factor for disease recurrence with an adjusted hazard ratio for deep invasion vs focal or no invasion of 1.0 (95% CI = 0.5, 2.2; p = 1.00). CONCLUSIONS: Detection of bone invasion, particularly in small tumors, may not be as critical to surgical planning as previously expected. The necessity for and extent of bone resection should be determined by the objective of achieving an adequate surgical margin and not the presence of bone invasion per se.

P-glycoprotein as a prognostic indicator in pre- and postchemotherapy ovarian adenocarcinoma.

P-glycoprotein (P-gp) is a plasma membrane efflux transporter that maintains the intracellular concentration of chemotherapeutic agents at low levels. Since the clinical outcome of ovarian adenocarcinoma depends largely on its response to chemotherapy, an objective assessment of P-gp expression could serve as a prognostic indicator. Eighty-five patients were studied. Available tissue sections from the primary tumor (n = 75) and persistent or recurrent lesions (n = 19) were tested with anti-P-gp (JSB-1) monoclonal IgG. Multivariate survival analysis using Cox regression was performed controlling for fixed covariates (age, surgical stage, and presence of residual tumor) and included occurrence of postchemotherapy tumors and P-gp positivity in postchemotherapy neoplasms as time-dependent variables. P-gp was expressed in 49 prechemotherapy (65.3%) and 14 postchemotherapy (73.7%) tumors. After controlling for potentially confounding factors, patients with P-gp-positive postchemotherapy neoplasms were at three times greater risk of dying within 2 years than their counterparts with P-gp-negative tumors (hazard ratio = 3.1: 95% confidence interval = 1.2, 9.1; p < 0.05). Detection of P-gp-expressive subclones can serve as an independent poor prognostic indicator for patients with postchemotherapy tumors.

A retrospective comparison of treatment outcome in the posterior and anterior tongue.

BACKGROUND: The perceived poor survival for tongue base cancer compared with the anterior tongue influences selection of treatment. METHODS: Treatment outcome is compared in patients with epidermoid carcinoma of the tongue base (n = 112) and anterior tongue (n = 188). A multivariate Cox's proportional hazard model is used to assess the independent effect of tumor location on survival. RESULTS: Seventy-one percent of patients with tongue base tumors had advanced stages of disease (Stages III & IV) at presentation compared with 32% for the anterior tongue (P = .000). Disease-specific survival at 5 years for the tongue base was 26%, and for the anterior tongue was 64%. Significant risk factors for disease relapse included age > 50 years, advanced stages of disease, and radiotherapy as a single treatment modality. The adjusted hazard ratio for disease relapse for the tongue base compared with the oral tongue was 1.2 (95% CI = 0.83, 1.74; P = .332). CONCLUSIONS: Treatment response for tongue base and anterior tongue tumors is similar. The pessimism that besets the management of cancer of the tongue base may not be justified in all patients.

The impact of primary health care services on under-five mortality in rural Niger.

BACKGROUND: Despite large investments in basic primary health care in sub-Saharan Africa over the past two decades, quantifying the contribution of national programme efforts to the reduction of infant/child mortality in the region has proven difficult. This study takes advantage of the phased implementation of the national Rural Health Improvement Program in Niger and conveniently timed survey data to reassess programme impact on under-five mortality during the 1980-1985 period. METHODS: Health service use and under-five mortality rates for children born in the 5 years prior to the 1985 survey are compared for three groups of villages: villages served by a dispensary, villages served by village health teams (VHT), and villages without access to modern primary care services. Multi-level regression analyses using both household- and community-level variables are undertaken in estimating the magnitude of effects. RESULTS: Children residing in villages proximate to health dispensaries were approximately 32% less likely to have died during the study period than children without access to modern health services. Village health teams were not, however, associated with significantly lower mortality probabilities. Formal test for endogeneity indicated that these effects were not the result of non-uniform/non-random allocation of resources. CONCLUSIONS: The findings are largely supportive of the key premise underlying selective primary health care interventions - that packages of basic services can be effectively mounted nationally in poor countries and have a significant impact over a short time period. In Niger, less than optimal implementation of VHT appears to have reduced the magnitude of the impact achieved.

PIP: The phased implementation of Niger's Rural Health Improvement Program, in conjunction with a 1985 Ministry of Health survey, facilitated quantification of the contribution of primary health care interventions to the reduction of infant and child mortality. During 1978-84, over 8000 health workers were trained and deployed to unserved villages; in addition, 45% of rural villages were provided with primary care services through dispensaries or village health teams. The 35 rural clusters covered in the survey were grouped into three categories: 1) villages located 5 km or less from a dispensary; 2) those located over 5 km from a dispensary, but with a village health team; and 3) villages located more than 5 km from a dispensary and with no health team. Mothers residing near a dispensary were two to five times more likely than their counterparts in the other two groups to have received prenatal care for the most recent birth, had the delivery attended by trained health personnel, received nutrition and health education, and know how to prepare oral rehydration solution. Children in the dispensary-proximate villages were three times more likely to have been at least partially immunized and to have a health card and twice as likely to have had their most recent diarrhea episode treated by a health worker. The unadjusted proportions of infants and children who died in the five years preceding the survey were 0.191 in villages served by a dispensary, 0.203 in villages served by a health team, and 0.267 in villages with neither resource. Multivariate analyses indicated that significantly lower mortality was associated with the presence of a dispensary, maternal literacy, and the existence in the community of farm machinery or access to seeds to plant the next crop. Overall, these findings confirm the significance of primary health care services, especially treatment of infantile diarrhea and tetanus, to reducing under-five mortality in sub-Saharan Africa.

Radical hysterectomy for stage IB cervical cancer: recurrence interval as a predictor of survival.

Two hundred patients with stage IB carcinoma of the cervix were treated with radical hysterectomy. We evaluated the impact of recurrence interval on survival and determined its relationship to other prognostic factors. Thirty-one patients (15.5%) had recurrence, with a median follow-up of 2.8 years (range, 1 to 5 years). Multivariate analysis, using the Cox proportional hazard regression model, showed the impact of recurrence interval on survival and its relationship to other prognostic factors. Patients were 19 times more likely to die during follow-up if recurrence occurred shortly after the operation. However, the risk of death from recurrence decreased exponentially as recurrence interval increased, by a multiple of 0.93 m where m is recurrence interval in months. We conclude that in patients with stage IB carcinoma of the cervix treated initially with radical hysterectomy, the shorter the recurrence period after operation, the greater the likelihood the patient would die during 5-year follow-up. This information may help clinicians determine a patient's prognosis after confirmed recurrence.

Intracerebroventricular growth-hormone-releasing peptide-6 stimulates eating without affecting plasma growth hormone responses in rats.

The purpose of this study was to determine the effect of intracerebroventricular (i.c.v.) injections of a synthetic, opioid-related hexapeptide, growth-hormone-releasing peptide-6 (GHRP-6), on stimulation of eating by rats and to correlate this aspect of feeding behavior with the peripheral plasma growth hormone (GH) response to the administered peptide. GHRP-6 dissolved in 5 microL of saline was injected into the lateral ventricles of sated, adult, male, Sprague-Dawley rats in doses from 0 pmol (saline only) to 1000 pmol. For 1 hour after injection, the occurrence of eating was noted, and specimens of arterial blood were collected at 0, 15, 30, and 60 minutes. The plasma was assayed for GH. A nearly linear, statistically significant (p < 0.01) dose-response relationship between the dose of GHRP-6 and the incidence of eating was noted. The mean change from baseline of plasma GH during the 60 minutes after injection was not dose-related (p > 0.2, p > 0.1, and p > 0.1 at 15, 30, and 60 minutes, respectively). We conclude that GHRP-6 given intracerebroventricularly to sated, adult, male, Sprague-Dawley rats stimulates eating and suggest that it does so by some mechanism that is independent of its GH-releasing property.

Correlation between infection and the onset of the giant cell (temporal) arteritis syndrome. A trigger mechanism?

OBJECTIVE: To assess for a correlation between infection and the onset of the giant cell (temporal) arteritis (GCA) syndrome. METHODS: A matched case-control study design was used. Records of 100 patients with biopsy-proven GCA and 100 patients undergoing corrective surgery for hip fracture who did not have GCA were retrospectively reviewed. Non-GCA patients were sex-matched with GCA patients and were as old or older in age. The review period for GCA patients was up to 4 months before and during the occurrence of symptoms (median 2 months), and for non-GCA patients, it was up to 7 months before hip fracture. The prevalence of infection was compared using matched-pairs odds ratios and their 95% confidence intervals. RESULTS: Infections were 3 times more likely to occur in GCA patients than in non-GCA patients (P < 0.05). CONCLUSION: A correlation between the occurrence of infection and the onset of GCA is strongly suggested. We speculate that infection may act as a trigger mechanism in the pathogenesis of this syndrome.

Interpretation of multiple isolate urine cultures in adult male patients.

A retrospective analytical study examined the records of 220 adult males (mean age 64.9 years) to determine the relative probability that multiple urine culture isolates (MUI) represent urinary tract infection (UTI) versus contamination or colonization. Nonculture laboratory data were used to determine the likelihood of UTI. Patients were classified into three categories: group 1 (those with single isolate cultures; n = 110), group 2 (those with MUI and either symptomatic UTI or an underlying pathologic condition; n = 71) and group 3 (those with MUI and either surgically altered urinary passages or absence of UTI symptoms; n = 39). Nonculture laboratory data suggested UTI in 48.2% of patients in group 1, 46.5% in group 2, and 23.1% in group 3. Patients in groups 1 or 2 with cultures yielding isolate counts of 10(5) colony forming units/mL were 6.2 times more likely to be classified as having a UTI (by nonculture laboratory data) compared with patients having only one or more of these two criteria. This study proposes a more objective approach to interpretation of MUI cultures using the results of nonculture laboratory data, clinical profiles, and colony counts.

Surgical management of esophageal cancer. A decade of change.

OBJECTIVE: To examine trends for use of transhiatal esophagectomy (THE) and to relate outcome variables to changes in use, controlling for preoperative risk. BACKGROUND: High operative morbidity and mortality rates are reported with conventional transthoracic esophagectomy (TTE). Transhiatal esophagectomy has been proposed as an alternative but is controversial. METHODS: In this retrospective study divided into early and late time periods, outcome variables were subjected to univariate and multivariate analyses. RESULTS: Use of THE increased significantly in the late period (p < 0.0001). Patients who had THE had significantly higher American Society of Anesthesiologists (ASA) risk scores (p < 0.001). By the late period, 92% of patients with ASA III/IV scores were resected by THE. Postoperative morbidity decreased significantly and operative mortality decreased from 15% to 0% (p < 0.01) between the early and late time periods. By multivariate analysis, ASA > or = III and TTE were associated with adverse surgical outcome. Pathologic stage determined disease-free survival, which was 37% at 3 years for all survivors. CONCLUSIONS: Increased use of THE results in better operative outcome and does not adversely affect disease-free survival.

Intra-household correlations in maternal-child nutritional status in rural Guinea: implications for programme-screening strategies.

It is commonly assumed in public health practice that households in developing country settings are relatively homogeneous with respect to nutritional status. To the extent that this assumption is valid, nutritional assessments of mothers or individual children would provide an effective screening mechanism for household-level maternal-child nutritional risk. However, there has been no confirmation of the strength of intra-household correlations in nutritional status among women and children. Using data from a cross-sectional survey undertaken in 1990 in rural central Guinea, the present study investigates the nature of within-household relationships in maternal and child nutritional status and considers the implications for programme screening strategies. Mothers and their surviving children under 5 years of age are the focus of the analysis. Correlations between maternal and child nutritional levels are assessed and the performance of maternal-child nutritional indicators as screening tools for household nutritional risk are formally evaluated by analysing the sensitivity, specificity, and positive-negative predictive values of various indicators.

PIP: The authors explore to what extent households may be identified as being at risk of maternal-childhood malnutrition on the basis of a nutritional assessment of one household member. Cross-sectional survey data collected in 1990 from the central Guinean provinces of Labe, Tougue, Lelouma, Dolaba, and Pita, on 780 mothers and their 1118 surviving children under 5 years of age are the focus of the analysis. The survey had been conducted to obtain baseline data on nutrition and health problems in the region. Investigators assessed correlations between maternal and child nutrition, and formally evaluated the performance of maternal-child nutritional indicators as screening tools for household nutrition risk. Although significant intra-households correlations were found with regard to nutritional status among women and children, the data clearly indicate the inefficiency of screening for household-level maternal-child nutritional risk on the basis of anthropometric indicators for mothers and/or individual children under age five years.

Prognostic utility of epidermal growth factor receptor overexpression in endometrial adenocarcinoma.

BACKGROUND: Overexpression of epidermal growth factor receptor (EGFR) has been reported in endometrial adenocarcinoma. METHODS: A retrospective analytic study was designed to investigate its prognostic utility. Sixty-nine patients were studied with cell types that included endometrioid (n = 45), papillary serous (n = 16), and clear cell (n = 8). Patients' medical charts and survival data were reviewed. Assessment of EGFR overexpression was done at the protein level by the use of an anti-EGFR polyclonal antibody that reacts with the cytoplasmic membrane glycoprotein receptor in paraffin-embedded tissues. RESULTS: EGFR was overexpressed in 34 (49%) patients in whom immunoreactivity was limited to neoplastic cells. Initial bivariate analysis revealed significant correlations between EGFR immunoreactivity and histologic grade (r = 0.44, P < 0.001), metastasis (r = 0.38, P < 0.001), cell type (r = 0.30, P < 0.01), myometrial invasion (r = 0.30, P < 0.01), and patient age (r = 0.30, P < 0.01). Multiple logistic regression analyses showed that EGFR overexpression and nonendometrioid cell types are two independent statistically significant markers for the presence of metastases. EGFR immunoreactivity can significantly predict myometrial invasion, but after controlling for the histologic grade, its ability of significantly predict invasion was lost. EGFR overexpression was shown to be a statistically significant predictor of survival, even after controlling for patient age, histologic grade, and cell type. CONCLUSIONS: Expression of this oncoprotein may serve as an independent prognostic indicator and a guide to therapy in patients with endometrial cancer.

Socioeconomic, environmental, demographic and behavioral factors associated with occurrence of diarrhea in young children in the Republic of Congo.

This study is the result of a cross-sectional survey undertaken in five regions of the Republic of Congo. A sample of 612 women having children under 3 years of age was interviewed to determine the socioeconomic, environmental, demographic and behavioral factors associated with the occurrence of diarrhea in young children. Logistic regression analysis was used to determine which variables predict the occurrence of diarrhea in a multivariable context. Most of the statistically significant variables were those suggesting behaviorally mediated modes of transmission. These include: type of weaning food fed to the child, maternal age, sex of the child, maternal sickness and method of refuse disposal. Male children had a more than two-fold odds of experiencing recent diarrhea than did female children among those greater than 1 year of age. Although breastfeeding status was not statistically significantly associated with diarrheal disease, children under 1 year of age who were already weaned had a greater odds of disease than those who were still breasted. Due to the pattern of extended breastfeeding in this population, this relationship was difficult to assess. Urban residence also was highly associated with diarrheal disease occurrence. Urban residence is likely to reflect a host of socioeconomic, environmental and behavioral factors. These findings underscore the potential impact of educational interventions on the occurrence of diarrheal disease among young children.