Comparison of esophagectomy with and without thoracotomy in a low-resource tertiary care center in a developing country.

Esophageal cancer surgery is traditionally performed by a number of open surgical approaches. Open approaches require thoracotomy and laparotomy. Developments in instrumentation and optics have allowed the use of minimally invasive approaches to esophageal cancer, which had been traditionally managed by open operation. Minimally invasive surgery (MIS) avoids thoracotomy and laparotomy and results in quicker return to normal functions and less morbidity. In this prospective study, we compared the immediate surgical and oncologic outcomes of patients who have undergone MIS with those who have had open surgery. From November 1, 2003 to March 30, 2006, 62 cases of carcinoma esophagus were operated in Surgical unit 3 (MIS unit) in the institute. Out of the 62 patients, 34 (54.8%) underwent minimally invasive esophagectomy (MIE), and the remaining 28 patients (45.2%) underwent open surgery. Both operations were done by the same team of surgeons. The groups were compared in terms of perioperative outcomes, morbidity, mortality, and adequacy of oncologic excision. The average duration for MIS was 312.35 min (60-480 min), which was more than that of open group surgery whose average duration was 261.96 min (60-360 min). This difference was found to be not significant (P < 0.110). The average blood loss was 275.74 mL (200-500 mL) in minimally invasive group compared with 312.50 (200-500 mL) in open group (P-value 0.33). Four patients (11.76%) in MIS group had been converted to open surgery. Average duration of hospitalization was 11.9 (4-24) days in MIS group compared with 12.19 (5-24) days in open group (P-value 0.282). Nine (26.47%) patients in MIS group had developed major or minor morbidity. Similarly, eight (28.57%) patients in open group had morbidity. One patient each expired in each group. The morbidity and mortality rates were not statistically significant. There were four leaks (11.76%) in MIS group and three leaks (10.71%) in open group (P-value 0.85). Regarding the extent of nodal clearance, an average number of 9.5 (0-19) nodes were removed in MIS group compared with an average of 7.26 (0-12) nodes in open group (P-value 0.05). Better visibility and magnification enabled more number of lymph nodes to be removed in MIS group. MIE is oncologically safe compared with open surgery. It has almost similar postoperative course, morbidity pattern, and duration of hospital stay as open surgery. Increased duration of procedure compared with open surgery is a disadvantage of MIS, especially in the early part of learning curve.

Body-mass index, waist-size, waist-hip ratio and cardiovascular risk factors in urban subejcts.

BACKGROUND AND OBJECTIVE: Influence of obesity as determinant of cardiovascular risk factors has not been well studied. To determine association of obesity, measured by body-mass index (BMI), waist-size or waist-hip ratio (WHR), with multiple risk factors in an urban Indian population we performed an epidemiological study. METHODS: Randomly selected adults > or = 20 years were studied using stratified sampling. Target sample was 1800 (men 960, women 840). 1123 subjects (response 62.4%) were evaluated and blood samples were available in 532 men and 559 women (n=1091, response 60.6%). Measurement of anthropometric variables, blood pressure, fasting blood glucose and lipids was performed. Atherosclerosis risk factors were determined using current guidelines. Pearson's correlation coefficients (r) of BMI, waist and WHR with various risk factors were determined. BMI was categorized into five groups: <20.0 Kg/m2, 20.0-22.9, 23.0-24.9, 25.0-29.9, and > or = 30 Kg/m2; waist size was divided into five groups and WHR into six groups in both men and women. Prevalence of cardiovascular risk factors, smoking, hypertension, diabetes, metabolic syndrome and dyslipidaemias was determined in each group and trends analyzed using least-squares regression. RESULTS: There is a significant positive correlation of BMI, waist-size and WHR with systolic BP (r= 0.46 to 0.13), diastolic BP (0.42 to 0.16), fasting glucose (0.15 to 0.26), and LDL cholesterol (0.16 to 0.03) and negative correlation with physical activity and HDL cholesterol (-0.22 to -0.08) in both men and women (p<0.01). With increasing BMI, waist-size and WHR, prevalence of hypertension, diabetes, and metabolic syndrome increased significantly (p for trend <0.05). WHR increase also correlated significantly with prevalence of high total and LDL cholesterol and triglycerides (p <0.05). CONCLUSIONS: There is a continuous positive relationship of all markers of obesity (body-mass index, waist size and waist hip ratio) with major coronary risk factors- hypertension, diabetes and metabolic syndrome while WHR also correlates with lipid abnormalities.

Construction and evaluation of cDNA libraries for large-scale expressed sequence tag sequencing in wheat (Triticum aestivum L.).

A total of 37 original cDNA libraries and 9 derivative libraries enriched for rare sequences were produced from Chinese Spring wheat (Triticum aestivum L.), five other hexaploid wheat genotypes (Cheyenne, Brevor, TAM W101, BH1146, Butte 86), tetraploid durum wheat (T. turgidum L.), diploid wheat (T. monococcum L.), and two other diploid members of the grass tribe Triticeae (Aegilops speltoides Tausch and Secale cereale L.). The emphasis in the choice of plant materials for library construction was reproductive development subjected to environmental factors that ultimately affect grain quality and yield, but roots and other tissues were also included. Partial cDNA expressed sequence tags (ESTs) were examined by various measures to assess the quality of these libraries. All ESTs were processed to remove cloning system sequences and contaminants and then assembled using CAP3. Following these processing steps, this assembly yielded 101,107 sequences derived from 89,043 clones, which defined 16,740 contigs and 33,213 singletons, a total of 49,953 "unigenes." Analysis of the distribution of these unigenes among the libraries led to the conclusion that the enrichment methods were effective in reducing the most abundant unigenes and to the observation that the most diverse libraries were from tissues exposed to environmental stresses including heat, drought, salinity, or low temperature.

99mTcN complexes of tert-butyl dithiocarbamate and methoxyisobutyl dithiocarbamate as myocardial and brain imaging agents.

OBJECTIVE: Two ligands viz. tert-butyl dithiocarbamate (TBDTC) and methoxyisobutyl dithiocarbamate (MIBDTC), which are analogous to the tert-butyl isonitrile (TBI) and sestamibi (MIBI) ligands, were synthesized and labelled with the [99mTcN] core to evaluate their potential as myocardial agents. As these complexes have low molecular weights, and are neutral and lipophilic in nature, they have a tendency to cross the blood-brain barrier and thus deserve evaluation as potential brain perfusion imaging agents. METHODS: The dithiocarbamate ligands were synthesized from their respective amines, i.e., tert-butylamine and methoxyisobutylamine, by reacting with carbon disulfide in dry ether in the presence of crushed sodium hydroxide. The ligands were characterized by elemental analyses. The 99mTc-nitrido intermediate was prepared from 99mTcO(-)4 using commercially available nitrido kits. The complexation was carried out by mixing the freshly prepared 99mTc-nitrido intermediate and the ligand followed by incubation at room temperature for 10 min. These complexes were characterized by high-performance liquid chromatography (HPLC) using a C-18 reversed phase column with acetonitrile:water as the mobile phase, and by paper electrophoresis. Biodistribution studies were carried out in normal Swiss mice. RESULTS: The ligands were synthesized in near quantitative yields. They were radiolabelled in > 95% yields using the 99mTc-nitrido core, at low ligand concentrations of 0.01 mg . ml(-1) (5.8 x 10(-5) M) for TBDTC and 1 mg . ml(-1) (4.8 x 10(-3) M) for MIBDTC, respectively. Both the complexes were found to be neutral and eluted out as single species in HPLC. Both the complexes showed myocardial as well as brain uptake. The 99mTcN(TBDTC)2 complex showed a better heart/blood and heart/lung ratio when compared to 99mTcN(NOEt)2, an agent in phase III clinical trials proposed for myocardial imaging. This complex also showed brain uptake (3.74%ID/g) at 10 min post-injection (p.i.) with brain/blood ratios better than that of the standard agent 99mTc-D,L-HMPAO at all time points studied. 99mTcN(MIBDTC)2 showed myocardial uptake of 6.41%ID/g at 5 min p.i., which decreased to 1.76%ID/g, 60 min p.i. 99mTcN(MIBDTC)2 also showed good brain uptake (3.21%ID/g at 5 min p.i.) but relatively fast washout (1.33%ID/g at 60 min p.i.) from the target organ. CONCLUSION: Both the complexes under study showed myocardial as well as brain uptake. The results obtained with 99mTcN(TBDTC)2 shows promise towards its development as a potential brain imaging agent.

Radiochemical studies of 99mTc complexes of modified cysteine ligands and bifunctional chelating agents.

The synthesis of four novel ligands using the amino-acid cysteine and its ethyl carboxylate derivative is described. The synthetic method involves a two-step procedure, wherein the intermediate Schiff base formed by the condensation of the amino group of the cysteine substrate and salicylaldehyde is reduced to give the target ligands. The intermediates and the final products were characterized by high resolution nuclear magnetic resonance spectroscopy. Complexation studies of the ligands with 99mTc were optimized using stannous tartrate as the reducing agent under varying reaction conditions. The complexes were characterized using standard quality control techniques such as thin layer chromatography, paper electrophoresis, and paper chromatography. Lipophilicities of the complexes were estimated by solvent extraction into chloroform. Substantial changes in net charge and lipophilicity of the 99mTc complexes were observed on substituting the carboxylic acid functionality in ligands I and II with the ethyl carboxylate groups (ligands II and IV). All the ligands formed 99mTc complexes in high yield. Whereas the complexes with ligands I and II were observed to be hydrophilic in nature and not extractable into CHCl3, ligands III and IV resulted in neutral and lipophilic 99mTc complexes. The 99mTc complex with ligand II was not stable and on storage formed a hydrophilic and nonextractable species. The biodistribution of the complexes of ligands I and II showed that they cleared predominantly through the kidneys, whereas the complexes with ligands III and IV were excreted primarily through the hepatobiliary system. No significant brain uptake was observed with the 99mTc complexes with ligands III and IV despite their favorable properties of neutrality, lipophilicity, and conversion into a hydrophilic species. These ligands offer potential for use as bifunctional chelating agents.

Synthesis of heptadentate (N4O3) amine-phenol ligands and radiochemical studies with technetium-99m.

Heptadentate amine-phenol ligands with N4O3 donor atoms for coordination were synthesized by condensing tris(2-aminoethyl)amine with salicylaldehyde or acetophenone and reducing the Schiff bases formed with NaBH4. The ligands were characterized by 1H and 13C nuclear magnetic resonance spectroscopy. Radiochemical studies were carried out with no-carrier-added 99mTc and 99mTc spiked with 0.1-100 microM of 99Tc. Complexation yields were estimated from thin layer chromatography, paper electrophoresis, and solvent extraction studies. 99mTc complexes were formed in yields better than 90% with the amine-phenol ligands. The complexes were found to be neutral and lipophilic. Biodistribution studies of the 99mTc complexes showed that clearance was mainly through the hepatobiliary system.

Tc-99m and Re-186 complexes of tetraphosphonate ligands and their biodistribution pattern in animal models.

The syntheses of four alpha-aminomethyl phosphonates and their complexation studies with (99m)Tc and (186/188)Re are reported. Complexation conditions were standardized to give maximum yields, which ranged from 90-97%. The yields of complexation were estimated by paper chromatography. The (99m)Tc complexes were stable for more than 4 h, while the (186/188)Re complexes were stable for 3-8 days when stored at 4 degrees C. Biodistribution of these complexes in Wistar rats were carried out, and the uptake in bone and other soft tissue are detailed. Bone uptake of the (99m)Tc complexes varied from 40-60% at 30 min postinjection depending on the ligands. The uptake in soft tissue was minimum with all the complexes. A comparison of the biodistribution studies of the (99m)Tc complexes with that of the well-established radiopharmaceutical (99m)Tc-MDP was carried out for the purpose of evaluating the efficacy of the radiopharmaceutical preparation with the complexes of these ligands. The bone uptake of the (186/188)Re complexes varied from 19-28% corresponding to 1.6-3% per g at 3 h postinjection. The residual activity in both (99m)Tc and (186/188)Re complexes showed renal clearance.

[(186/188)Re] rhenium-ethylene dicysteine (Re-Ec): preparation and evaluation for possible use in endovascular brachytherapy.

188ReO(4)(-), (188)Re-MAG(3), and (188)Re-DTPA are currently under investigation as radiation sources in liquid-filled balloons for prevention of restenosis following coronary angioplasty. Because (99m)Tc-labeled ethylene dicysteine (EC) is a well-established agent for renal tubular function imaging, the use of [(188)Re] rhenium-labeled EC as a potential agent for prevention of restenosis after angioplasty is worth evaluation. In this article, the preparation and pharmacological behavior of [(188/186)Re]Re complex of EC are reported. The yield of the Re complex was optimized by varying the parameters of complexation. The complex prepared under the optimized conditions was found to be stable over a period of 7 days when stored at pH 2 and at 4 degrees C. The pharmacological behavior of [(188/186)Re]Re-EC confirms its similarity to (188)Re-MAG(3) and its superiority over (188)ReO(4)(-) for use in endovascular brachytherapy.

186Re-1,4,8,11-tetraaza cyclotetradecyl-1,4,8,11-tetramethylene phosphonic acid: a novel agent for possible use in metastatic bone-pain palliation.

In connection with our work on the development of 186Re-tetra-phosphonates with optimum properties for use in bone pain palliation, a novel cyclic tetraphosphonate derivative, has been synthesized, complexed with 186Re and evaluated with promising results. The ligand, which consists of a cyclic array of tetra-aminomethylphosphonate groups, was synthesized using orthophosphorus acid, 1,4,8,11-tetraazacyclotetradecane and formaldehyde. The labeling conditions with 186Re have been standardized under varying reaction conditions to give maximum yield. In a reaction volume of 1 mL, maximum complexation yield of 98% was observed at pH 2 using 0.1 mg Re (37-370 MBq) for a ligand concentration at 9 x 10(-2) M/L, under heating at 100 degrees C for 30 min with 2 mg of stannous chloride. The complex was found to be stable for 6 days with RC purity remaining approximately 97%. The complex was characterized by paper chromatography in saline and acetone, wherein the R(f) exhibited were 0.9 and 0, respectively. Biodistribution studies of the complex were performed in male Wistar rats. Activity in femur which was observed to be 1.8%/g (equivalent to about 23% of the injected activity in skeleton) at 3 h post injection remained almost constant up to 48 h. Minimum activity was observed in blood and other soft tissues. The complex showed major renal clearance. Scintigraphic images in rabbits after injecting 70-100 MBq of 186Re-CTMP and using a dual head gamma camera were observed to be superior to 186Re-HEDP, prepared by a procedure standardized by us. Insignificant activity was observed in other vital organs. The results suggest the suitability of the complex for further evaluation in higher animals for bone pain palliation.

Synthesis and characterization of (99m)Tc- and (188)Re-complexes with a diamido-dihydroxymethylenephosphine-based bifunctional chelating agent (N(2)P(2)-BFCA).

A diamido-dihydroxymethylenephosphine (N(2)P(2)) bifunction chelating agent (BFCA) was shown to form well-defined (99m)Tc- and (188)Re-chelate structures. The 4, 4-bis [bis-hydroxymethyl-phosphonyl-propylcarbonmoyl]-butyric acid bifunctional chelating agent (N(2)P(2)-BFCA) formed stable complexes with (99m)Tc and (188)Re in >95% yield with high radiochemical purity (RCP). The biodistribution of the (99m)Tc- and (188)Re-N(2)P(2)-BFCAs after intravenous injection studied in normal mice showed the activity was excreted primarily via renal-urinary pathway indicating their use for labeling peptides with (99m)Tc and (188)Re.

Haemangiopericytoma: current status, diagnosis and management.

Haemangiopericytoma (HPC) is a rare tumour, characterized by unidentifiable light microscopic features. Despite first being described over 50 years ago, nothing much was known about this tumour until the early 1980s, when ultrastructural studies and tumour markers made it possible to differentiate it from other mesenchymal tumours. Advancements in radiology and the emergence of MRI technology helped surgeons in better planning. Pre-operative vascular embolization helped to reduce the menace of operative haemorrhage. Improvements in localization and delivery of radiotherapy, coupled with early diagnosis, has tremendously improved the treatment outcome of haemangiopericytoma.

Congenital infantile fibrosarcoma.

Infantile fibrosarcoma is a rare tumour in the paediatric age group. It occurs mainly in children below the age of 5 years. About 200 cases have been reported in the literature so far, very few of them in new-borns. We present here a case of infantile fibrosarcoma in a 27-day-old baby.

Malignant lymphoma of the gastrointestinal tract.

AIMS: The gastrointestinal tract (GIT) is the most common site of extra-nodal lymphoma. Most of these lymphomas arise from mucosa associated lymphoid tissue (MALT). We attempt in this study to define the natural history and treatment outcome of this type of lymphoma. METHODS: We carried out a retrospective study of patients presenting at our centre with histopathological diagnosis of primary GIT lymphoma between 1990 and 1994. RESULTS: Equal numbers of cases of stomach and small bowel lymphoma were found. Vomiting and feeling of fullness were the two most common presenting symptoms. Large cell type and high grade tumours were found to be the commonest histological types. All the patients were treated with surgery followed by chemotherapy. A 5-year disease-free survival (DFS) rate of 73%) was observed with a confidence interval of 0.65-1.35. Survival in stomach cancer was 73.5% (95% CI 0.26-1.74) while it was 76.4% in small bowel tumours (95% CI 0.54-1.46). The difference in survival was not statistically significant. CONCLUSIONS: Although there is no consensus regarding treatment of primary GI lymphoma, surgery and adjuvant chemotherapy yield good survival.

Rupture of a radial keratotomy incision after 11 years during clear corneal phacoemulsification.

We report a case of rupture of a radial keratotomy (RK) incision that occurred during clear corneal phacoemulsification 11 years after the initial surgery. The RK was done in both eyes for correction of high myopia (>8.0 diopters). This was followed by 2 enhancement procedures at 6 month intervals. The patient presented with diminished vision in both eyes. The diagnosis was nuclear cataract in the right eye, and clear corneal phacoemulsification was done. The intraoperative and postoperative courses were uneventful. Nine months later, clear corneal temporal phacoemulsification was done in the left eye. During surgery, 1 of the radial incisions opened to one third its length. The wound was sutured, and the procedure was completed uneventfully. One month later, best corrected visual acuity was 20/20.

Combined topical-peribulbar anesthesia for cataract surgery.

PURPOSE: To evaluate the anesthetic effect of single-point low-volume peribulbar anesthesia supplemented by topical anesthesia. SETTING: Private ambulatory ophthalmic practice. METHODS: Five hundred consecutive patients received 4 cc of lidocaine 2% with 200 units hyaluronidase as 1-point peribulbar anesthesia. This was supplemented by lidocaine 4%, 1 drop every 3 to 5 minutes for 3 instillations. Phacoemulsification and intraocular lens implantation were performed through a scleral tunnel or clear corneal approach. All patients were evaluated for intraoperative akinesia, lid closure, and anesthesia. One hour after surgery, the eye patch was removed and patients were evaluated for pain, discomfort, foreign-body sensation, diplopia, and lid closure. RESULTS: All patients had no pain to mild discomfort during surgery; 34% had total and 58% partial akinesia; 78% had poor orbicularis action (lid closure); 12% had subconjunctival hemorrhage. Postoperatively, 42% of patients had foreign-body sensation caused by conjunctival coaptation by diathermy or corneal edema. Diplopia occurred in 32% of patients but resolved within 1 hour after eye-patch removal, and partial ptosis occurred in 58%, resolving within 2 hours of patch removal. All patients had normal lid closure when the eye patch was removed. CONCLUSIONS: Low-volume 1-point peribulbar anesthesia supplemented by topical anesthesia was safe and effective and provided early visual recovery. Topical therapy can be started 1 hour postoperatively.

Prognostic significance of DNA aneuploidy and p21 ras oncoprotein expression in colorectal cancer and their role in the determination of treatment modalities.

The purpose of the present study was to investigate the prognostic significance of DNA ploidy, S-phase fraction and p21 ras oncoprotein expression in patients with colorectal cancer and to correlate these factors with the clinical behavior of the tumors and their response to therapy. Of 79 patients with colorectal cancer 57% (45/79) had early stage disease. Forty-one percent (32/79) had aneuploid tumors while 30% (24/79) of the tumors had a high (>10%) S-phase fraction. p21ras oncoprotein expression was detected in 38% (30/79) of tumors. Patients with aneuploid tumors had a worse prognosis than patients with diploid tumors (p=0.0002). Similarly, patients with high S-phase fraction tumors had a shorter survival than those with low S-phase fraction tumors (p=0.005). No such difference was found between p21 raspositive and p21 ras-negative tumor subgroups. In early stage colorectal cancer, aneuploidy was closely correlated with disease outcome (p=0.029). Early stage patients with diploid tumors who received radiotherapy and chemotherapy had a better prognosis than patients with aneuploid tumors. In conclusion, DNA ploidy is a significant and independent prognostic factor in colorectal cancer. Aneuploidy and genetic alteration of the p21 ras oncoprotein are important in determining the biological aggressiveness of colorectal cancer. Furthermore, DNA ploidy may identify those subgroups of patients with early stage disease who may benefit from more aggressive treatment.

Milk-of-calcium renal cyst, evaluated by ultrasound and computed tomography.

Milk-of-calcium renal cysts, which when asymptomatic need no treatment, sometimes pose diagnostic problems by conventional radiography. Two such cases are here reported. The first case was further evaluated by ultrasonography only, the second case also by computed tomography and cyst puncture, because of an irregularity in the cyst wall. Both imaging modalities added valuable information.

Clinicopathologic significance of p53 immunostaining in adenocarcinoma of the breast.

Methanol/acetone-fixed frozen sections of 87 breast carcinomas were studied with a panel of three anti-p53 monoclonal antibodies that had specificities for wild-type, mutant, or combined wild-type plus mutant epitopes by using the avidin-biotin method. Nuclear staining was present in 13 (15%) of 87 cases with the mutant-specific antibody. The combined-specificity antibody stained 28 (32%) of 87 cases, including all but one of the tumors that was positive with the mutant-specific antibody. None of the cases reacted with the wild-type-specific antibody. Immunostaining for mutant form p53 was strongly correlated with adverse clinicopathologic factors, including poor differentiation, absence of estrogen receptor protein, nodal metastases, and large tumor size. In groups that were stratified by axillary node status, disease-free survival (52-month mean follow-up) was worse among cases with positive staining for either antibody. This difference was statistically significant in node-positive patients with the combined-specificity antibody (disease free, 22% [p53+] vs recurred, 57% [p53+]). We concluded that (1) immunostaining for mutant forms of p53 characterizes a clinically aggressive subset of breast tumors and may have prognostic utility in some patient populations, and (2) antibody-dependent-staining patterns for p53 may reflect epitope specificities of various mutant forms.

Anterior capsular staining with trypan blue for capsulorhexis in mature and hypermature cataracts. A preliminary study.

PURPOSE: To study the efficacy and safety of 0.1% Trypan Blue dye to stain the anterior capsule for capsulorhexis in mature and hypermature cataracts. METHODS: This preliminary study included 25 eyes of 25 patients with a unilateral mature or hypermature cataract, including one case of traumatic mature cataract. In all these cases 0.2 ml of 0.1% trypan blue dye was used to stain the anterior capsule. The efficacy and safety of the dye was evaluated on the basis of intraoperative and postoperative observations. RESULTS: In all 25 eyes the capsulorhexis was completed. There was peripheral extension of the capsulorhexis in the eye with traumatic cataract and the stained edge of the anterior capsule helped identification and redirection of the capsulorhexis. Successful phacoemulsification with intraocular lens implantation was performed in all eyes. Adverse reactions related to the dye such as raised intraocular pressure, anterior chamber inflammation and endothelial damage were not observed in the immediate postoperative period or at the end of mean follow-up of 3 months. CONCLUSION: Trypan blue dye staining of the anterior capsule appears to be a very useful and safe technique that simplifies capsulorhexis in mature and hypermature cataracts.