The new digital flexible ureteroscopes: 'size does matter'--increased ureteric access sheath use!

OBJECTIVES

To evaluate whether the use of sheaths to access the ureter has increased after the introduction of new digital ureterorenoscopes in patients undergoing flexible ureteroscopy.

METHODS

140 patients with kidney stones were randomised to be scoped with either an old-generation fibre-optic flexible ureteroscope (DUR-8, Elite, ACMI; distal tip diameter = 6.75 Fr) or a new-generation digital LCD flexible ureteroscope (Invisio D-URD flexible ureteroscope; distal tip diameter = 8.7 Fr). We recorded the necessity to use a sheath to access the ureter, sheath-related and postoperative complications, and whether or not a JJ stent was left behind.

RESULTS

157 (80 fibre-optic and 77 digital) ureterorenoscopies were performed. Ureteral access sheaths were used significantly more frequently with digital scopes (p = 0.00174). Two patients in the digital scope group had a small distal ureteric perforation from the introducer sheath compared with none in the fibre-optic scope group.

CONCLUSIONS

A statistically significant increase in sheath use was observed in the new-generation digital flexible ureteroscopy group. Despite the improvement in image quality, better durability and improved stone clearance, there are some potential drawbacks of these scopes. The increased distal tip diameter can result in increased use of ureteric access sheaths and this may increase morbidity and expense.

Is 46XX karyotype always a female?

A19-year-old man, from a middle east country was referred by his physician to the endocrine department for bilateral gynaecomastia, low libido and sparse facial hair. There was no history of any chronic illness, mumps or traumatic injury to testis. He had clinical features suggestive of gonadotropin deficiency which was confirmed on biochemical testing. On karyotype and fluorescent in situ hybridisation analysis, he was found to have 46XX(SRY+) karyotype.

Neural bases of the foreign accent syndrome: a functional magnetic resonance imaging case study

Foreign accent syndrome (FAS) is a rare disorder characterized by the emergence of a perceived foreign accent following brain damage. Despite decades of study, little is known about the neural substrates involved in this disorder. In this case study, MRI images of the brain were obtained during a speech task for an American English-speaking monolingual female who presented with FAS of unknown etiology and was thought to sound 'Swedish' or 'Eastern European'. On the basis of MR structural imaging, the patient was noted to have frontal lobe atrophy. An fMRI picture-naming task designed to broadly engage the speech motor network revealed predominantly left-hemisphere involvement, including activation of the (1) left superior temporal and medial frontal structures, (2) bilateral subcortical structures and thalamus, and (3) left cerebellum. The results suggest an instance of substantial brain reorganization for speech motor control.

Antenatal diagnosis of bladder/cloacal exstrophy: challenges and possible solutions

OBJECTIVE

To identify the pitfalls in accurate antenatal diagnosis of bladder exstrophy (BE) and cloacal exstrophy (CE), and thus understand the challenges for antenatal counselling.

METHODS

A prospectively maintained bladder exstrophy database of antenatal and live born referrals for BE/CE was used to identify patients. Data were collected about the antenatal scan findings and the outcome of pregnancy.

RESULTS

Between 2003 and 2009, 40 new babies with BE/CE were referred and of them 10 had an antenatal diagnosis. Five patients did not have a diagnosis despite suspicious findings noted on antenatal scans and another three had a wrong diagnosis of BE/CE. Of the 16 referrals with antenatal suspicion of BE/CE, 5 opted for termination. At the 20-week scan, it was possible to identify the gender of the fetus in 3/16 cases only.

CONCLUSIONS

Only a quarter of the babies born with BE/CE had received an antenatal diagnosis. Raising awareness about the condition amongst radiographers, and facilitating further scanning by a specialist fetal management unit if suspicious findings are noted, is crucial for improving the rate of detection. An antenatal diagnosis may not be reliable, and difficulty in identifying gender at the 20-week scan adds to the complexity of antenatal counselling. Magnetic resonance imaging and karyotyping may provide additional helpful information.

Auto-PEEP in respiratory failure

Intrinsic positive end-expiratory pressure (auto-PEEP) is a common occurrence in patients with acute respiratory failure requiring mechanical ventilation. Auto-PEEP can cause severe respiratory and hemodynamic compromise. The presence of auto-PEEP should be suspected when airflow at end-exhalation is not zero. In patients receiving controlled mechanical ventilation, auto-PEEP can be estimated measuring the rise in airway pressure during an end-expiratory occlusion maneuver. In patients who trigger the ventilator or who are not connected to a ventilator, auto-PEEP can be estimated by simultaneous recordings of airflow and airway and esophageal pressure, respectively. The best technique to accurately measure auto-PEEP in patients who actively recruit their expiratory muscle remains controversial. Strategies that may reduce auto-PEEP include reduction of minute ventilation, use of small tidal volumes and prolongation of the time available for exhalation. In patients in whom auto-PEEP is caused by expiratory flow limitation, the application of low-levels of external PEEP can reduce dyspnea, reduce work of breathing, improve patient-ventilator interaction and cardiac function, all without worsening hyperinflation. Neurally adjusted ventilatory assist, a novel strategy of ventilatory assist, may improve patient-ventilator interaction in patients with auto-PEEP.

Nature of feeding practices among children with cleft lip and palate

OBJECTIVE

To find out the nature of feeding practices among children with cleft lip and palate.

MATERIALS AND METHODS

A total of 155 subjects of less than 2 years of age with cleft lip and palate were chosen and divided into three groups according to their chronological age. Group I included 47 subjects (M=35, F=12) who were <6 months old, Group II included 56 subjects (M=36, F=20) aged between 6 months and 1 year, and Group III included 52 subjects (M=28, F=24) of age between 1 and 2 years. Both the parents of the subjects with cleft lip and palate were interviewed and the details of the existing feeding practice were recorded on a standard pro forma. Chi-square test was applied to find out any significant difference in the feeding method between males and females.

RESULTS

Spoon feeding was found as the most common feeding practice method. Breast feeding was the second most common feeding practice method among Group I subjects, whereas bottle feeding was the second most common feeding practice method among Group II and III subjects. The difference in the feeding practice between male and female subjects in all the three groups was very negligible and statistically not significant.

CONCLUSION

Spoon feeding was found as the most common feeding method practiced by the parents of children with cleft lip and palate.

Oral health related quality of life among children with parents and those with no parents

OBJECTIVES

To compare the oral health related quality of life (OHRQoL) and caries status between school children living with their parents and orphan children, and to assess the factors that influence the oral health related quality of life.

METHODS

Study sample consisted of 279 school children living with their parents and 257 orphan children thus making a total sample of 536 school children. Sampling frame comprised of 12-15 year old children attending two upper primary public schools and two special schools for orphan children at Udaipur city, India. Clinical examination for caries status and personal interviews for oral health related quality of life were conducted by a single investigator.

RESULTS

Children without parents presented poor scores for OHRQoL compared to those having parents. Caries status was significantly related to OHRQoL and its domains. Subjects with no caries reported good OHRQoL which deteriorated as the caries score increased. Children who never visited dentist reported poorer OHRQoL than regular visitors and males experienced better oral health quality of life than females. All the four variables (gender, group, dental visits and DMFT) entered the step wise linear regression analysis when the effect of each independent variable was adjusted for all others and were responsible for a variance of 21.6% for OHRQoL; however DMFT constituted the first best predictor which solely explained a variance 15.8%.

CONCLUSIONS

Oral health related quality of life along with its domains differed significantly between children with and without parents. Furthermore, gender, dental visiting habits and caries status significantly influenced the OHRQoL.

Spectrophotometric estimation of ethamsylate and mefenamic Acid from a binary mixture by dual wavelength and simultaneous equation methods

Two simple, accurate, economical and reproducible spectrophotometric methods for simultaneous estimation of two-component drug mixture of ethamsylate and mefenamic acid in combined tablet dosage form have been developed. The first developed method involves formation and solving of simultaneous equation using 287.6 nm and 313.2 nm as two wavelengths. Second developed method is based on two wavelength calculation. Two wavelengths selected for estimation of ethamsylate were 274.4 nm and 301.2 nm while that for mefenamic acid were 304.8 nm and 320.4 nm. Both the developed methods obey Beer's law in the concentration ranges employed for the respective methods. The results of analysis were validated statistically and by recovery studies.

Talon cusp in a primary incisor: a rare entity

This case report describes the presence of a talon cusp in a right primary incisor in a 6-year-old girl. It is a rare entity with only three cases having been reported from the Indian population. The talon cusp showed presence of wear facets along with altered morphology of the involved tooth. No treatment was done apart from sealing the cusp-tooth interface with fissure sealant.

Tuberculosis of nose and palate with vanishing uvula

During the past two decades, tuberculosis - both pulmonary and extrapulmonary - has re-emerged as a major health problem worldwide. Nasal tuberculosis - either primary or secondary to pulmonary tuberculosis or facial lupus - is rare, but it should be considered in the differential diagnosis of nasal granulomas. We describe a case of tuberculosis in an adult male who presented with palatal perforation with vanishing uvula and arch deformity of the palate. The diagnosis was based on histopathology and patient's successful response to antituberculous drug treatment.

Outcome after autologous dermal sling-assisted immediate breast reconstruction

Background

In selected patients undergoing mastectomy and immediate reconstruction, a de-epithelialized skin flap (dermal sling) may be used to complete the submuscular pocket. This study examined the safety and efficacy of an autologous dermal sling in providing inferolateral support to the implant or tissue expander during immediate breast reconstruction.

Methods

Patients were identified from an electronic prospective database. Records of all patients were reviewed for details of management, complications and follow-up. Patient satisfaction and quality of life in the postoperative period were determined using the BREAST-Q© questionnaire.

Results

Between October 2008 and August 2010, 21 patients underwent 28 dermal sling-assisted breast reconstruction procedures. Their median age was 48 (range 30–70) years. Median hospital stay was 5 (range 3–7) days. Drains were removed at a median of 5 (range 3–7) days after surgery. During the operation a median volume of 150 ml was added to the tissue expander. The most common postoperative complication was superficial -junction breakdown in five patients, followed by seroma and infection each in three patients, but no implant required removal. BREAST-Q© responses indicated a high level of satisfaction overall with the reconstructed breast.

Conclusion

Dermal sling-assisted immediate breast reconstruction has a low serious complication rate, provides stable soft tissue cover for the tissue expander and is associated with a high level of patient satisfaction. A larger pocket can be created, permitting more fluid to be added to the expander.

Epitaxial Growth of Oxide Thin Films on (001) Metal Surfaces Using Pulsed-Laser Deposition

The epitaxial growth of CeO2 on various (001) metal surfaces using pulsed-laser deposition is discussed. In particular, the growth of (001) CeO2 on (001) Pd, Ag, and Ni is described. Emphasis is given to the specific deposition conditions which successfully alleviate the formation ornative oxides at the metal/metal oxide interface. The control of the epitaxial relationships between the oriented oxides films and the underlying noble and oxidizing metal surfaces is addressed.

Progressive changes in arch width from primary to early mixed dentition period: a longitudinal study

OBJECTIVE

The present study was conducted to evaluate, on a longitudinal basis, the changes in intercanine and intermolar widths form the primary to the early mixed dentition periods.

MATERIALS AND METHODS

A total of 38 children aged 4-5 years, with normal occlusion without any proximal caries or any dental anomalies, were selected. The impressions were recorded and casts were prepared. Intercanine and intermolar widths were measured on these dental casts with the help of a digital vernier calliper. After 3 years follow-up, the impressions were recorded again and dental casts were prepared. Intercanine and intermolar widths were measured again at this stage and were compared with the baseline data using the paired t-test and the chi square test.

RESULTS

There is a significant increase in the intercanine (3.93 + 1.70 mm) and intermolar width (1.49 + 1.77 mm) during the transition period from primary to early mixed dentition in both the arches and both the sexes. The gender-wise comparison showed a greater increase in males than in females, but this was not statistically significant.

CONCLUSION

A thorough knowledge of growth changes during various stages of the mixed dentition period are important for a pediatric dentist to make an accurate diagnosis and treatment planning during preventive and interceptive orthodontics.

Abstract P6-03-02: Breast Reduction Mammoplasty and Incidence of Occult Carcinoma. A 10 Year Experience

Background: The aim of this study was to report the incidence of cancer in reduction mammoplasty specimens and suggest alternative pragmatic cost-effective way of identifying and treating patients with carcinoma. Methods: All patients who underwent breast reduction surgery at Northern General Hospital over a 10-year period were identified from a prospective database. The histopathology reports and case records of all patients with significant abnormalities were analysed. All breast reduction specimens were sliced at 1 cm intervals and examined macroscopically. At least 3 blocks per breast were examined microscopically in addition to sampling of any grossly abnormal tissue.

Results: Between October 1999 and April 2010, 1,588 patients underwent reduction mammoplasty. The median age of patients was 38 years (range 16-75 years). Indications for surgery were macromastia in 1,194 (75.2%), congenital asymmetry in 182 (11.5%) and contralateral symmetry procedure post breast cancer surgery in 178 (11.2%). 9 specimens showed atypical hyperplasia (0.57%). 5 cancers were detected (0.31%). 4 of the 5 patients had normal mammograms 1-3 years before the reduction operation (not done in 1). Of these cancers, 4 were invasive (3 invasive lobular, 1 invasive ductal) (0.25%) (mean invasive tumour size 9 mm (SD 7.4)) and 1 was DCIS (4mm) (0.06%). A lump was felt macroscopically by the pathologist in 2 of the 4 patients with invasive cancer. The median age of patients with invasive cancer was 56 years (range 47-68 years). Patient found to have DCIS did not undergo further surgery while those with invasive disease underwent mastectomy (3) and axillary nodal staging (4). None of the patients with benign/normal post-reduction breast imaging had residual breast cancer on histology.

Conclusion: The incidence of occult carcinoma in reduction mammoplasty specimens is less than 0.5%. Pre-operative mammogram is not useful as 4 of the 5 patients with cancer had a normal mammogram 1-3 years before surgery and invasive lobular cancers are often not detected on mammogram. Mastectomy may be avoided in patients with no residual breast disease on post-reduction imaging.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-03-02.

Abstract P1-01-01: Learning Sentinel Node Biopsy in the UK: Results of the NEW START Training Program

Background: NEW START-a structured, validated multi-professional surgical training programme, was established to allow rapid transfer of appropriate knowledge and technical skills to ensure safe and competent practice of sentinel lymph node biopsy (SLNB) across the UK.

Methods: Multi-professional teams attended a theory/skills-lab course delivering a standardized educational package, following which they performed SLNB in 30 consecutive patients, either concurrently with their standard axillary staging procedure — mentorship training model-or as stand-alone SLNB — apprenticeship training model. An accredited NEW START trainer mentored the first 5 procedures in the participants’ hospital, or all 30 if stand-alone. Validation standards were a localization rate of ≥90% and in the mentorship program where a minimum of 10 cases were node positive, a false-negative rate of ≥10%. SLNB was performed according to a standardised protocol using the combined technique of isotope (0.05-0.1ml of 99mTc-albumin colloid — Nanocoll®) and blue dye (Patent blue V) injected into the tumour quadrant peri-areolar tissue. Isotope was injected intra-dermally and static scintigraphic images were obtained, blue dye was injected sub-dermally after anaesthetic induction.

Results: From October 2004 to December 2008, 210 SLNB naive surgeons, in 103 centres, performed 6,685 SLNB procedures of which 31% (2,098/6,685) were node positive. The mentorship training model was followed in 87% (5,849/6,685). Scintigraphy identified axillary lymph node drainage in 85% (5,564/6,511) with an overall SLN localization rate of 98.9% (6,610/6,685, 95% CI 98.6% to 99.1%). Node positivity was higher (P&lt;0.001) for failed (58.7%, 44/75) than successful (31.1%, 2054/6610) localizations. The mentorship false negative rate (FNR) was 8.9% (163/1821, 95% CI 7.7% to 10.4%). The median SLN yield was 2.0 (range 1-11).

SLN localization and FNR improved with surgeon caseload so that after 20 procedures the FNR fell below 10% but no statistically significant learning curve was identified. The FNR patients who had one SLN harvested was 14.8%. The FNR rate declined to 9.4%, 6.3%, 4.5% and 4.0% for those patients with 2, 3, 4 and more than 4 SLNs removed.

Conclusion: NEW START demonstrates that a standardized injection protocol and structured multi-professional training can abolish learning curves so ensuring patient safety during national adoption of a new technique. Tumor quadrant injection using both isotope and dye has a high localization rate and low false-negative rate. Failed localization indicates higher probability of axillary nodal involvement. It is not necessary to remove more than 4 SLNs to achieve a FNR of less than 5%.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-01.

Abstract P5-14-03: The Impact of Routine Cavity Margins on Reducing the Need for Re-Excision in Women Undergoing Breast-Conserving Surgery for Invasive or Non-Invasive Breast Cancer

Background: The goal of breast conserving surgery (BCS) in women with invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS) is to remove all malignant cells from the breast or to reduce the residual tumor burden to a level that is likely to be eradicated by adjuvant radiation therapy and/or systemic therapy. Theoretical concerns exist that radiography of lumpectomy specimens and subsequent pathologic processing may lead to artifactually positive lumpectomy margins (LM), and the need for subsequent re-excision. To improve the chances of obtaining negative final margins (FM) (generally defined as 2 mm or greater), a number of surgeons in the US and abroad have adopted a technique in which 4-6 additional margins surrounding the main lumpectomy specimen, so-called “cavity margins” (CM), are routinely obtained. The purpose of this study was to assess the clinical utility of the routine use of CM in reducing the need for re-excision.

Methods: The surgical pathology records at our institution were searched for all cases of BCS with additional complete routine CM sampling performed by a single surgeon between May 2008 and April 2010. Patients in whom additional CM were obtained based on intraoperative findings of grossly close margins were excluded from the analysis. The demographic characteristics of the patients and the histological features of the tumor were recorded. We then tabulated the number of patients who had positive LM, CM, and FM, defined as either DCIS or invasive carcinoma at or less than 2 mm from inked specimen margin. The number needed to treat (NNT) to prevent one re-excision was calculated.

Results: We identified 97 women (74 with IBC and 33 with DCIS-only) who had undergone BCS with routine CM sampling during the study period. Mean patient age was 62. Median specimen volume was 178 cc3. 90% of the IBCs were ductal subtype. Mean IBC size was 1.5 cm. 63% of tumors were ER+, 58% PR+, and 7% HER2+. Of the 97 patients in this study, 64 had +LM and 33 had -LM. Of the 64 with +LM, 38 did not have tumor in the CM and 26 had tumor in the CM. Of these 26, 18 had +FM (re-excision needed) and 8 had -FM (no re-excision needed). The proportion of patients with actual tumor at ink (not just close margins) in the lumpectomy specimen was significantly higher among the group with tumor present in the CM than it was in the group with no tumor present in the CM (14/26 versus 7/38, p = 0.006). The NNT with routine CM compared with standard BCS to prevent one re-excision was 2.0 (95% CI, 1.5 — 2.1).

Discussion: In this study the routine use of CM reduced the need for reexcision in women undergoing BCS for IBC or DCIS; one re-excision was avoided for every two patients treated with this surgical approach. The absence of tumor in the CM in the majority of patients with positive LM suggests that specimen radiography and/or pathologic processing techniques may result in artifactually positive LM. Our results indicate that improved specimen imaging and pathological processing techniques are needed to increase the fidelity of margin assessment. In the meantime, the routine use of cavity margins may reduce the need for re-excision in women undergoing BCS.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-14-03.

Spectrophotometric methods for determination of zolpidem tartrate in tablet formulation

AIM

The study aims to develop simple, sensitive, rapid, accurate and precise spectrophotometric method for estimation of Zolpidem tartrate in tablet dosage forms.

MATERIALS AND METHODS

For method I, II, III and IV in a series of 10 ml volumetric flask, aliquots of standard drug solution (100 µg/ml) in 0.1N HCl were transferred and diluted with same so as to give several dilutions in concentration range of 5-30 µg/ml, 5-30 µg/ml, 10-50 µg/ml and 5-40 µg/ml respectively of zolpidem tartrate. To 5 ml of each dilution taken in a separating funnel, (5 ml of bromo phenol red, bromo cresol purple, bromo cresol green and bromo phenol blue for method I, II, III and IV respectively) reagent and 5 ml of chloroform was added. Reaction mixture was shaken gently for 5 min and allowed to stand so as to separate aqueous and chloroform layer. Absorbance maxima measured at 407 nm, 417 nm, 412 nm and 415 nm for method I, II, III and IV respectively.

RESULTS

The recovery studies were found close to 100 % that indicates accuracy and precision of the proposed methods. The statistical analysis was carried out and results of which were found satisfactory. Standard deviation values were found low that indicated reproducibility of the proposed methods.

CONCLUSION

Based on results the developed methods could be used for routine estimation of zolpidem tartrate from tablet formulations.

Surgical intervention in children with vesicoureteric reflux: are we intervening too late?

BACKGROUND

Vesicoureteric reflux is usually managed medically. When medical management fails, the patient is referred for surgical intervention. The aim is to protect the kidneys from progressive damage. This study investigates if significant kidney damage has occurred during medical treatment prior to surgical intervention.

MATERIALS AND METHODS

Case notes of all children treated with ureteric re-implantation for vesicoureteric reflux in a 5-year period were reviewed. Demographic details, radiological investigations, surgery and follow-up were recorded. Indication for surgery was failure of medical treatment. Kidney damage was defined as the presence of a scar on the DMSA scans and/or kidney function below 45% in one kidney.

RESULTS

Forty-two patients underwent ureteric re-implantation with 24 having a bilateral procedure resulting in a total of 66 renal units. Mean age at surgery was 7.4 years. Thirty-eight kidneys (58%) showed reduced function prior to medical treatment. Twenty-four kidneys (36%) had deterioration of renal function associated with recurrent urinary tract infections during the course of medical treatment with the overall mean function of the worst affected kidney being 28%. Thirty-five patients (83%) demonstrated scarring on their kidneys on DMSA scan prior to surgery.

CONCLUSIONS

More than half of patients who eventually need ureteric re-implantation for vesicoureteric reflux have already suffered kidney damage prior to start of medical treatment. A third will have progressive deterioration of their renal functions. Early referral for medical management coupled with early surgical intervention in selected cases should hopefully reduce the number of children with renal damage due to VUR.

Prone retroperitoneoscopic approach for heminephrectomy: specific advantages relating to access to vascular pedicle

INTRODUCTION

The lateral approach is more widely used in retroperitoneoscopic (RP) heminephroureterectomy (HNU) due to familiar orientation and ease of conversion. The prone approach however gives early and easy access to the vascular pedicle. The main reason for not adopting a prone approach more widely is the perceived difficulty in lower ureteric access. We present a series of 30 HNUs where the prone approach was utilized extremely effectively with no conversions and few complications.

METHODS

Thirty consecutive HNUs performed over a 4-year period (2004-2007) using a prone RP approach were included in the study. Prospectively recorded data and notes were reviewed.

RESULTS

Upper HNU was done in 17 and lower HNU in 13 patients. Mean age was 3.2 years (range 0.9-13.3). There were no transfusions or conversions. Follow-up ultrasound showed healthy remnant moieties in all. Residual ureteric stump was seen in six patients but only one was symptomatic requiring a further procedure.

CONCLUSION

With the prone approach the anatomy can be demonstrated quickly and effectively. Dissection can be done easily without the need for kidney retraction as gravity aids demonstration of the renal vascular pedicle. There is a low risk of complications arising from the residual ureteric stump. We recommend that this approach be considered for RP HNU in all patients, irrespective of age.

Axillary node staging by ultrasonography and fine-needle aspiration cytology in patients with breast cancer

Background

This study evaluated the role of axillary ultrasonography (AUS) and fine-needle aspiration cytology (FNAC) in preoperative staging of the axilla in patients with invasive breast cancer.

Methods

Between October 2006 and March 2009, 502 patients scheduled to undergo surgery for invasive breast cancer had preoperative AUS. All patients with suspicious nodes on ultrasonography underwent FNAC, and those with positive cytology proceeded directly to axillary node clearance. Patients with normal findings on AUS or negative cytology underwent sentinel node biopsy (SNB).

Results

A total of 137 (27·3 per cent) of 502 patients had axillary node metastases on final histology. Thirty-nine (28·5 per cent) node-positive patients were identified by AUS–FNAC and spared unnecessary SNB. AUS–FNAC had a sensitivity of 28·5 per cent and a specificity of 100 per cent for detecting axillary nodal metastases. AUS–FNAC findings were normal in all 15 patients with nodal micrometastases and in 11 patients with isolated tumour cells on histopathology. The sensitivity of AUS–FNAC had a positive correlation with invasive tumour size (odds ratio 1·03) and grade (odds ratio 2·80).

Conclusion

Preoperative AUS–FNAC avoided unnecessary SNB in 28·5 per cent of node-positive patients and in 7·8 per cent of patients overall.

Adverse reactions to patent blue V dye - The NEW START and ALMANAC experience

BACKGROUND

Blue dye with or without isotope has been widely used to identify the sentinel lymph node(s) in breast cancer. Patent blue V is used in the UK while its isomer isosulfan blue is used in the US. The allergic potential of isosulfan blue is well documented (1.4% adverse reactions) but that of patent blue V is less clearly defined.

METHODS

In this paper we review the adverse reactions of patent blue V in 7,917 patients who participated in the NEW START training programme and the ALMANAC trial. All patients underwent sentinel lymph node biopsy for breast carcinoma using patent blue V in combination with (99m)Tc-albumin colloid.

RESULTS

In total, 72 of 7,917 (0.9%) patients experienced adverse reactions : non-allergic reactions were observed in 4 (0.05%) patients, 23 (0.3%) patients had minor grade I allergic skin reactions (urticaria, blue hives, pruritus, or generalised rash) and 16 (0.2%) had grade II reactions (transient hypotension/bronchospasm/laryngospasm). Severe Grade III reactions (severe hypotension requiring vasopressor support and/or change/abandoning of planned procedure and/or HDU/ITU admission) were noted in 5 (0.06%) patients. The type of adverse reaction was not specified in 24 (0.3%) patients. No mortality was recorded.

CONCLUSION

The allergic potential of patent blue V dye compares favourably with isosulfan blue however both the surgeon and anaesthetist need to be alert to the risk of allergic reactions.

Oral fluid, a substitute for serum to monitor measles IgG antibody?

We have analyzed the suitability and potential of Oral Fluid (OF) to substitute serum in estimating measles IgG antibodies, during community surveys, by comparing the Optical Density (OD) of measles IgG antibodies in OF and serum of 100 apparently asymptomatic children. IgG antibody status was determined using commercially available - Measles IgG Capture ELISA. Sensitivity 89.5%, specificity 90.6% Concordance of 89%, coefficient of correlation r is equal to 0.97 (Karl Pearson's) and rho is equal to 0.86 (Spearman's), was found between OD value of OF and serum. The study emphasizes the potential of OF to surrogate serum in estimating Measles IgG antibody among children. The OF collection is advantageous over blood as it is painless. It is suitable for non-technical staff, easy to transport and less bio-hazardous.

Comparison of validity of DIAGNOdent with conventional methods for detection of occlusal caries in primary molars using the histological gold standard: an in vivo study

AIM

This study was conducted to compare the in vivo effectiveness of DIAGNOdent with other conventional methods (visual, tactile and bitewing radiographs) for the detection of occlusal caries in primary molars. Another objective of the study was to calculate new cut-off limits for the detection of caries by DIAGNOdent in primary teeth.

MATERIALS AND METHODS

Eighty-four primary molars in 52 children (aged 8-12 years), which were indicated for extraction, were selected and evaluated for dental caries using DIAGNOdent, visual and tactile examination and bitewing radiographs. Histological examination of the sections, prepared subsequent to extraction of the teeth, served as the gold standard for comparison of the above-mentioned methods.

RESULTS

When considering enamel caries, values obtained for sensitivity, specificity and accuracy were 48.15, 100 and 49.40% for visual examination, 48.15, 100.00 and 49.40% for tactile examination, 49.38, 50.00 and 49.40% for bitewing radiographs, 85.19, 50.00 and 84.34% for DIAGNOdent scores interpreted according to manufacturer's cut-off limits and 81.48, 100.00 and 81.93% for DIAGNOdent scores interpreted according to newly formulated cut-off limits, respectively. At dentin caries cut-off levels, the values of sensitivity, specificity and accuracy for visual examination were 52.78, 89.36 and 73.49%; 50.00, 91.49 and 73.49% for tactile examination; 30.56, 82.98 and 60.24% for bitewing radiographs; 72.22, 76.60 and 74.70% for DIAGNOdent scores when interpreted according to manufacturer's cut-off limits and 77.48, 74.47 and 75.90%, respectively, for the DIAGNOdent scores when interpreted according to the newly formulated cut-off limits.

CONCLUSIONS

DIAGNOdent showed higher sensitivity and accuracy as compared with other conventional methods for detection of enamel caries, whereas for detection of dentinal caries, even though the sensitivity was high, accuracy of the DIAGNOdent device was similar to other conventional caries diagnostic methods.

Proximate Composition and Functional Properties of Mushroom Flours from Ganoderma spp., Omphalotus olearius (DC.) Sing. and Hebeloma mesophaeum (Pers.) Quél. Used in Nasarawa State, Nigeria

The proximate composition and functional properties of three edible mushroom (Ganoderma spp., Omphalotus olearius (DC.) Sing. and Hebeloma mesophaeum (Pers.) Quél.) flours used in Nasarawa state, Nigaria were investigated using standard analytical techniques. The samples contained crude protein in the range of 18.5% in Omphalotus olearius to 21.5% in Ganoderma spp. Crude fat varied with values ranging from 6.9% in Ganoderma spp. to 8.7% in Omphalotus olearius. Other proximate composition values were in the following ranges: moisture content 10.0 - 11.1%, ash 7.3 - 8.3%, crude fibre 2.8 - 3.5% and carbohydrate (by difference) 50.3 - 50.9%. The range values of functional properties were: foaming capacity 101.8 - 131.5%, foaming stability 51.0 - 54.0%, water absorption capacity 260.0 - 390.0%, oil absorption capacity 450 - 480%, oil emulsion capacity 57.3 - 61.0mLg- 1, least gelation concentration 12.0 - 14.0% and bulk density 230.0 - 410.0gmL-1. The results showed that these nutrient rich mushroom flours under investigation may prove useful in the formulation of different food products where foaming, emulsification, retention of flavour and palatability as well as gel formation are required.

Plasma levels of 4-OHT with topical tamoxifen gel (afimoxifene) and therapeutic local antiestrogenic effect in premenopausal women with cyclical mastalgia

e14598

Background: 4-hydroxytamoxifen(4-OHT) is a potent anti-estrogenic metabolite of tamoxifen with a much higher affinity for estrogen receptors than tamoxifen. Methods: Plasma levels of 4-OHT in 19 premenopausal women taking 20 mg/d oral tamoxifen for at least 2 months were compared with those of 16 premenopausal women assigned to apply 4mg 4-OHT in a 0.228% Afimoxifene gel daily for 21 days in a pharmacokinetic(PK) study. To evaluate the clinical effectiveness of the gel, premenopausal women experiencing moderate-to-severe mastalgia were randomized to receive placebo, 2mg or 4 mg of Afimoxifene daily delivered as a transdermal hydroalcoholic gel for 4 menstrual cycles. The primary efficacy parameter was change in mean pain intensity, as measured by the VAS for the 7 worst pain score days within a cycle, from baseline to the 4th cycle. Results: In the PK studies, the 4-OHT plasma levels following oral tamoxifen were 16–18 times higher than 4-OHT levels following 4mg 4-OHT administration by topical gel. At steady state, mean Cmax levels in the Afimoxifene group and oral tamoxifen group were 149+99 pg/mL and 2398+901 pg/mL respectively. The Cave concentrations, derived from AUC0–24h/24, were 117+77 pg/mL (Afimoxifene) and 2078+811 pg/mL (oral tamoxifen). After 4 cycles of gel treatment, significant improvements relative to placebo were seen in mean VAS score in the 4-mg Afimoxifene group (-12.71 mm [95% confidence interval, -0.96 to -24.47; P = 0.034]). Patient global assessment of pain, physician assessment of pain, tenderness on palpation and nodularity following 4 cycles of treatment were significantly improved in the 4-mg group, compared with placebo (P = 0.010 [pain]; P = 0.012 [tenderness]; P = 0.017 [nodularity]). There were no changes in menstrual pattern or plasma hormone levels and no breakthrough vaginal bleeding in patients treated with Afimoxifene. Conclusion: Topical application avoids high systemic exposure to 4-OHT compared with oral tamoxifen, a 16–18-fold difference, thus reducing the risk of systemic side-effects. Afimoxifene is an effective treatment for moderate-to-severe mastalgia and potentially may be used for breast cancer chemoprevention and gynecomastia.

No significant financial relationships to disclose.

Topical tamoxifen gel (afimoxifene) is associated with low plasma levels of 4-OHT while achieving therapeutic local antiestrogenic effect in premenopausal women with cyclical mastalgia

Abstract #2154

Background:4-hydroxytamoxifen(4-OHT) is a potent anti-estrogenic metabolite of tamoxifen with a much higher affinity for estrogen receptors than tamoxifen.We compared the plasma levels of 4-OHT in subjects applying Afimoxifene gel with subjects on oral tamoxifen.We conducted a randomized clinical trial to evaluate the safety and efficacy of topical Afimoxifene gel for the treatment of moderate-to-severe cyclical mastalgia.&#x2028; Methods:Plasma levels of 4-OHT in 19 healthy premenopausal women taking 20 mg/d oral tamoxifen for at least 2 months were compared with those of 16 healthy premenopausal women assigned to apply 4mg 4-OHT in a 0.228% Afimoxifene gel daily for 21 days in a pharmacokinetic(PK) study.Plasma for PK sampling was obtained at multiple time-points.PK parameters of plasma 4-OHT Cmax, and AUC0-24ht were determined.&#x2028; To evaluate the clinical effectiveness of the gel, premenopausal women aged at least 18 years experiencing moderate-to-severe mastalgia were randomized to receive placebo, 2mg or 4 mg of Afimoxifene daily delivered as a transdermal hydroalcoholic gel for 4 menstrual cycles.The primary efficacy parameter was change in mean pain intensity, as measured by the Visual Analog Scale(VAS) for the seven worst pain score days within a cycle, from baseline to the fourth cycle.Plasma levels of 4-OHT were assessed once after the second and the fourth menstrual cycles.&#x2028; All plasma levels of 4-OHT were measured in the same central lab, with a GC-MS method with a lower limit of quantification of 5 pg/mL.&#x2028; Results:In the PK studies, the 4-OHT plasma levels following oral tamoxifen administration were 16-18 times higher than 4-OHT levels following 4mg 4-OHT administration by topical gel. At steady state, mean Cmax levels in the Afimoxifene group and oral tamoxifen group were 149+99 pg/mL and 2398+901 pg/mL respectively. The Cave concentrations, derived from AUC0-24h/24, were 117+77 pg/mL(Afimoxifene) and 2078+811 pg/mL(oral tamoxifen).&#x2028; After 4 cycles of gel treatment, statistically significant improvements relative to placebo were measured in mean VAS score in the 4-mg Afimoxifene group(-12.71 mm[95% confidence interval, -0.96 to -24.47; P = 0.034]).Patient global assessment of pain, physician assessment of pain, tenderness on palpation and nodularity following 4 cycles of treatment were significantly improved in the 4-mg group, compared with placebo(P = 0.010 [pain]; P = 0.012 [tenderness]; P = 0.017 [nodularity]).Systemic exposure was low, with mean 4-OHT plasma levels of 50±64 pg/mL. There were no changes in menstrual pattern or plasma hormone levels and no breakthrough vaginal bleeding in patients treated with Afimoxifene.&#x2028; Conclusion:Topical application avoids high systemic exposure to 4-OHT compared with oral tamoxifen, a 16-18-fold difference, thus potentially reducing the risk of systemic side-effects.Afimoxifene is an effective treatment for moderate-to-severe mastalgia in premenopausal women and has the potential to be used for breast cancer chemoprevention/gynecomastia in the future.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2154.

Early class III occlusal tendency in children and its selective management

Class III malocclusion may develop in children as a result of an inherent growth abnormality, i.e., true class III malocclusion, or as a result of premature occlusal contacts causing forward functional shift of the mandible, which is known as pseudo class III malocclusion. These cases, if not treated at the initial stage of development, interfere with normal growth of the skeletal bases and may result in severe facial deformities. The treatment should be carried out as early as possible with the aim of permitting normal growth. This paper deals with the selection of an appropriate treatment approach from the various current options available for early intervention in children developing class III occlusal tendencies; the different clinical features are depicted in the three case reports.

Evaluation of a mixture of zinc oxide, calcium hydroxide, and sodium fluoride as a new root canal filling material for primary teeth

Endodontic treatment was performed on 25 pulpally involved mandibular primary molars in 4 to 9-year-old children; the root canals were obturated with a new root canal filling material consisting of a mixture of calcium hydroxide, zinc oxide, and 10% sodium fluoride solution, using hand-operated lentulo-spirals. All cases were evaluated clinically every 3 months and also radiographically every 6 months to assess the success of the treatment; we also examined the resorption of the root canal filling material from the root canals and the status of overpushed material, if any, as the tooth resorbed with the passage of time. At 6 months, endodontic treatment in 2 of the 25 teeth had failed and one tooth had exfoliated; the remaining 22 teeth were without any signs or symptoms. At the end of 2 years, 14 teeth could be evaluated; out of these 12 had physiologically exfoliated. It was observed that the rate of resorption of this new root canal obturating mixture was quite similar to the rate of physiologic root resorption in primary teeth. In three cases, where there was an overpush of the mixture, a gradual partial resorption was noted.

Management of inverted impacted primary incisors: an unusual case

The prevalence of impacted primary teeth has been reported to be very rare and it has been reported to occur in 1:10,000 times, most commonly involving the primary second molars. This report discusses the presence of an impacted inverted maxillary primary incisors and their management by surgical intervention in a 5 year old boy. The inverted primary maxillary central incisors were extracted and prosthetic rehabilitation was done to improve the esthetics, speech and psychosocial behaviour of the child. Co-incidentally the permanent maxillary incisors were also found to be hypoplastic although the parents did not give any history of trauma to the maxillofacial complex. It is important for pediatric dental surgeons to carefully monitor the eruption of primary and permanent teeth for early identification and management of developmental anomalies.

Progressive multifocal leukoencephalopathy--as a presenting manifestation of AIDS

Progressive multifocal leukoencephalopathy (PML) is an opportunistic demyelinating disease caused by the ubiquitous, usually non pathogenic JC Polyomavirus. We report a case of PML as a presenting manifestation of AIDS in a forty five year old man on the basis of clinical features and neuroradiology.

Quality of life in lung cancer patients: impact of baseline clinical profile and respiratory status

As cure is attainable in very few cases of lung cancer, the imperative issue is to make quality of life (QOL) as good as possible as part of the palliative care package. The aim of this paper was to evaluate the baseline QOL of lung cancer patients and observe its association with various clinical parameters and overall respiratory status. A total of 101 patients were administered the European Organization for Research and Treatment of Cancer core quality of life (EORTC QLQ-C30, version 3) questionnaire. Clinical profile and measures of respiratory status, including spirometry, measures of dyspnoea, and 6-min walk test, were recorded. Higher Karnofsky Performance Status (KPS) significantly correlated with better global health status (P < 0.001) and healthy level of functioning (P < 0.001). The cumulative symptom burden was significantly associated with global QOL (P = 0.01) and physical, role and cognitive function scales (P < 0.05). All dyspnoea measures negatively correlated with global QOL and functioning scales. Spirometric indices showed a positive correlation with all functional scales (P < 0.05) except social. In conclusion, lung cancer patients have unsatisfactory QOL, with the global health status and physical functions being most affected. Number of symptoms, KPS, dyspnoea and spirometry significantly affect QOL.

Epidemiology of dental caries in Chandigarh school children and trends over the last 25 years

The prevalence of dental caries in 6, 9, 12 and 15-year-old school children of Chandigarh, selected on a randomized basis was evaluated using Moller's criteria (1966) and correlated with the various risk factors. The mean deft was found to be 4.0 +/- 3.6 in 6 year old and 4.61 +/- 3.14 in 9 year old, whereas the mean DMFT in 12 and 15 year old was found to be 3.03 +/- 2.52 and 3.82 +/- 2.85 respectively. The high prevalence of dental caries in these children was attributed to the lack of use of fluoride toothpaste (80% children), lack of knowledge about etiology of dental caries (98%) and frequency of sugar exposures up to more than five times per day (30%).

Functional characterization and mutation analysis of family 11, Carbohydrate-Binding Module (CtCBM11) of cellulosomal bifunctional cellulase from Clostridium thermocellum

The non-catalytic, family 11 carbohydrate binding module (CtCBM11) belonging to a bifunctional cellulosomal cellulase from Clostridium thermocellum was hyper-expressed in E. coli and functionally characterized. Affinity electrophoresis of CtCBM11 on nondenaturing PAGE containing cellulosic polysaccharides showed binding with β-glucan, lichenan, hydroxyethyl cellulose and carboxymethyl cellulose. In order to elucidate the involvement of conserved aromatic residues Tyr 22, Trp 65 and Tyr 129 in the polysaccharide binding, site-directed mutagenesis was carried out and the residues were changed to alanine. The results of affinity electrophoresis and binding adsorption isotherms showed that of the three mutants Y22A, W65A and Y129A of CtCBM11, two mutants Y22A and Y129A showed no or reduced binding affinity with polysaccharides. These results showed that tyrosine residue 22 and 129 are involved in the polysaccharide binding. These residues are present in the putative binding cleft and play a critical role in the recognition of all the ligands recognized by the protein.