A practical approach to bladder preservation with hypofractionated radiotherapy for localised muscle-invasive bladder cancer

Bladder preservation with trimodality treatment (TMT) is an alternative strategy to radical cystectomy (RC) for the management of localised muscle invasive bladder cancer (MIBC). TMT comprises of transurethral resection of the bladder tumour (TURBT) followed by radiotherapy with concurrent radiosensitisation. TMT studies have shown neo-adjuvant chemotherapy with cisplatin-based regimens is often given to further improve survival outcomes. A hypofractionated radiotherapy regimen is preferable due to its non-inferiority in local control and late toxicities. Radiosensitisation can comprise concurrent chemotherapy (with gemcitabine, cisplatin or combination fluorouracil and mitomycin), CON (carbogen and nicotinomide) or hyperthermic treatment. Radiotherapy techniques are continuously improving and becoming more personalised. As the bladder is a mobile structure subject to volumetric changes from filling, an adaptive approach can optimise bladder coverage and reduce dose to normal tissue. Adaptive radiotherapy (ART) is an evolving field that aims to overcome this. Improved knowledge of tumour biology and advances in imaging techniques aims to further optimise and personalise treatment.

Artificial drainage devices for glaucoma surgery: an overview

Artificial drainage devices (ADD) create an alternative pathway for aqueous drainage from the anterior chamber of an eye through a tube to the subconjunctival bleb connected to an equatorial plate under the conjunctiva. The ADDs, both valved and non-valved, are available for end stage or refractory glaucoma. Currently, some of these devices, particularly the Express shunt, are recommended for the primary treatment of glaucoma. In this article, we highlight various ADDs, their indications and contraindications, surgical techniques and associated complications.

Pulmonary complications in the non-HIV immunocompromised patient

The incidence of non-HIV immunocompromised patients is increasing. This is primarily due to improved immunosuppressive regimes for autoimmune diseases and also increases in stem cell transplantation. Pulmonary complications are a major cause of morbidity and mortality in these patients. Imaging is frequently used to assess these complications and to streamline therapies, as microbiological and/or pathological diagnosis can often be difficult, invasive, or protracted. This review provides the reader with a structured approach to interpret the imaging findings and differentiate between different infective and non-infective complications in these patients.

In situ forming polymeric drug delivery systems

In situ forming polymeric formulations are drug delivery systems that are in sol form before administration in the body, but once administered, undergo gelation in situ, to form a gel. The formation of gels depends on factors like temperature modulation, pH change, presence of ions and ultra violet irradiation, from which the drug gets released in a sustained and controlled manner. Various polymers that are used for the formulation of in situ gels include gellan gum, alginic acid, xyloglucan, pectin, chitosan, poly(DL-lactic acid), poly(DL-lactide-co-glycolide) and poly-caprolactone. The choice of solvents like water, dimethylsulphoxide, N-methyl pyrrolidone, triacetin and 2-pyrrolidone for these formulations depends on the solubility of polymer used. Mainly in situ gels are administered by oral, ocular, rectal, vaginal, injectable and intraperitoneal routes. The in situ gel forming polymeric formulations offer several advantages like sustained and prolonged action in comparison to conventional drug delivery systems. The article presents a detailed review of these types of polymeric systems, their evaluation, advancements and their commercial formulations. From a manufacturing point of view, the production of such devices is less complex and thus lowers the investment and manufacturing cost.

In Vitro Anticancer Activity of the Root, Stem and Leaves of Withania Somnifera against Various Human Cancer Cell Lines

Withania Somnifera Dunal know as Ashwagandha belong Solanaceae family. It is extensively used in most of the Indian herbal pharmaceuticals and nutraceuticals. The current study, evaluate in vitro cytotoxicity in 50% ethanol extract of root, stem and leaves of Withania Somnifera against five human cancer cell lines of four different tissues i.e. PC-3, DU-145 (prostrate), HCT-15 (colon), A-549 (lung) and IMR-32 (neuroblastoma). Root, stem and leaves extracts showed cytotoxicity activity ranging 0-98% depending on the cell lines but maximum activity was found in 50% ethanol extract of leaves of Withania Somnifera. Ethanol extract of leaves obtained from treatments T2, T3, T4 and T5 showed strong activity against PC-3 and HCT-15 with 80-98% growth inhibition, while the 50% ethanol extract of leaves from T1 treatment showed a minimum of 39% and T3 treatment showed a maximum of 98% growth inhibition against HCT-15. This investigation is the first report of the anticancer activity in various parts of Withania Somnifera cultivated in fly ash amended soil.

A novel metered dose transdermal spray formulation for oxybutynin

The objective of the present work was to develop a metered dose spray formulation for transdermal delivery of oxybutynin and to carry out the in vitro characterization of the optimized formulation. Oxybutynin release from a series of ethanol/acetone/methylal based formulations was assessed in vitro and the developed formulation was used for delivery from a metered dose spray. Various qualitative and quantitative parameters like spray pattern, particle size distribution, pH, evaporation time, pump seal efficiency test, average weight per metered dose, content per spray and content uniformity were evaluated. The different film forming agents were assessed and carbopol (0.5%) and lutrol (0.1%) were found to give good clarity of solution, evaporation rate, spray pattern and tackiness of the film. Diffusion studies of the optimized formulations through the semipermeable membrane showed the release of drug to the extent of almost 50% over a period of 24 h. Stability studies were conducted as per ICH guidelines and indicated that formulations were stable. Skin irritation studies were performed using rabbit as an animal model. The results obtained show that the metered dose transdermal spray formulation can be a promising and innovative therapeutic system for the transdermal administration of oxybutynin.

Isolation and characterization of a Pseudomonas sp. strain IITR01 capable of degrading α-endosulfan and endosulfan sulfate

AIM

To isolate bacteria capable of degrading endosulfan (ES) and the more toxic ES sulfate and to characterize their metabolites.

METHODS AND RESULTS

A Pseudomonas sp. strain IITR01 capable of degrading α-ES and toxic ES sulfate was isolated using technical-ES through enrichment culture techniques. No growth and no degradation were observed using β-ES. Thin-layer chromatography and gas chromatography-mass spectrum analysis revealed the disappearance of both α-ES and ES sulfate and the formation of hydroxylated products ES diol, ether and lactone. We show here for the first time the formation of aforementioned metabolites in contrast to ES hemisulfate yielded by an Arthrobacter sp. Metabolism of α-ES and endosulfate was also observed using the crude cell extract of IITR01. The molecular mass of protein induced during the degradation of α-ES and sulfate as substrate was found to be approximately 150 kDa as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE).

CONCLUSION

We describe characterization of bacterium capable of degrading α-ES and ES sulfate but not β-ES. Genetic investigation suggests that a gene nonhomologous to the reported esd may be present in the strain IITR01.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study describes toxic ES degradation by a Pseudomonas species that may be utilized for the bioremediation of the industrial soils contaminated with ES residues.

Bilateral retinoblastoma in early infancy: a case report

Retinoblastoma is the most common primary intraocular tumour of childhood. Though congenital, it is not diagnosed at birth, and is usually seen between 1-2 years of age. We here report a case of bilateral retinoblastoma with early presentation at the age of one month.

Intravenous urography for diagnosing synchronous upper-tract tumours in patients with newly diagnosed bladder carcinoma can be restricted to patients with high-risk superficial disease

AIM

To determine the incidence of synchronous upper-tract transitional cell carcinomas (TCCs) in patients with newly diagnosed bladder cancer and to evaluate the need for performing intravenous urography (IVU) in these patients.

MATERIALS AND METHODS

Imaging data on 330 consecutive patients who were diagnosed with TCC of the bladder over a 2-year period were retrospectively reviewed. Only 233 out of the 330 patients had IVU at presentation. The IVU results were recorded as normal, abnormal, or equivocal. The follow-up radiological or urological investigations in the patients who had an equivocal IVU were reviewed. Clinical follow-up data on all 330 patients were also recorded.

RESULTS

Only 233 out of the 330 patients had an IVU at presentation. Four of these (1.7%) patients were found to have synchronous upper-tract tumours. Twenty-two patients were reported to have equivocal findings on IVU. Nine of these patients had follow-up imaging [computed tomography (CT)=5, IVU=4], which were reported as normal. Retrograde urography was performed in two patients, which was normal. The remaining 11 patients did not have any evaluation of the upper tracts despite the equivocal findings on IVU, but routine clinical follow-up did not reveal any significant disease. Three patients with high-risk superficial disease developed upper-tract tumours that were detected on follow-up.

CONCLUSION

IVU for diagnosing synchronous upper-tract tumours in patients with newly diagnosed bladder carcinoma can be restricted to patients with high-risk superficial disease.

Induction-intubation response--smokers vs non-smokers--

BACKGROUND AND OBJECTIVES

Tobacco smoking has been established to be a hazardous activity. Changing social attitude is bringing a decline in tobacco consumption but a significant proportion of patients presenting for surgery still continues to smoke, putting themselves at risk of perioperative complications. We evaluated induction-intubation response in 40 male patients (ASA-I) divided into two groups of 20, each consisting of smokers and non-smokers.

METHODS

All patients received standard premedication and general anesthesia. Heart rate, blood pressure and rate-pressure product were measured prior to induction, just before intubation and at 1, 3, 5 and 10 minutes after intubation. Continuous electrocardiography (EKG lead II) monitoring was done. Carboxyhemoglobin and total hemoglobin were estimated at the time of securing venous access. Arterial blood gases were analysed 5 minutes before and after the tracheal intubation.

RESULTS

Incidence of arrhythymias (30%) was higher in smokers compared to non-smokers (10%). Mean carboxyhemoglobin (COHb) level in smokers was 3.81 +/- 2.17 gdL(-1) as compared to 2.95 +/- 1.33 gdL(-1) in non-smokers. Four patients who continued to smoke till the day of surgery had higher COHb levels (8.2, 5.9, 6, 8.8 gdL(-1)). PaO2 and PaCO2 levels were comparable in both groups.

CONCLUSIONS

During induction-intubation period, heart rate; systolic, diastolic and mean arterial pressure and rate-pressure product showed more pronounced fluctuations in smokers than in non-smokers (p < 0.05).

Pre-operative anxiety. Effect of early or late position on the operating list

The influence of the relative position on the operating list on pre-operative anxiety was studied in 60 adult female ASA 1 patients undergoing major surgery. Thirty patients were placed first on the operating list (group 1) and 30 were given a time 4-5 h later (group 2). Each patient was visited on the evening prior to surgery and again on the morning of surgery. Anxiety was measured at each visit by objective criteria and part 1 of the State-Trait Anxiety Inventory questionnaire. The pulse rate, systolic blood pressure and the State-Trait Anxiety Inventory questionnaire scores were higher on the second visit than on the first (p < 0.001) in all patients. This increase was greater in group 2 than in group 1 (p < 0.05). The evening anxiety scores were not correlated with those on the morning visit and could not predict them.

Spinal tuberculosis: atypical observations at MR imaging

PURPOSE

To evaluate atypical magnetic resonance (MR) imaging features of spinal tuberculosis.

MATERIALS AND METHODS

Between 1990 and 1993, five of 11 consecutive patients with spinal tuberculosis (two men and three women, aged 30-57 years) had MR findings more suggestive of neoplasm than infection. One patient, a European immigrant, had acquired immunodeficiency syndrome (AIDS).

RESULTS

Areas involved with tuberculosis were hypointense on T1-weighted images and hyperintense on T2-weighted images, and became enhanced with gadopentetate dimeglumine. In two patients, tuberculosis affected only a single vertebral body without paraspinal abscesses or involvement of the end plates and disk spaces. In two other patients, only a single spinous process was replaced with tuberculous abscess. In the remaining patient, the sacrum and multiple lower lumbar vertebrae were affected, but the intervertebral disk spaces were not affected. More typical findings of spinal tuberculosis include destruction of two adjacent vertebral bodies and opposing end plates, destruction of intervening disk space, and/or occurrence of paravertebral abscesses.

CONCLUSION

Neither clinical examination nor MR findings may be reliable in helping differentiate spinal infections from one another or from neoplasm. Adequate biopsy is essential for early diagnosis and prompt treatment.

Isosorbide dinitrate spray. Attenuation of cardiovascular responses to laryngoscopy and intubation

We evaluated the efficacy of isosorbide dinitrate buccal spray (Isomack) in attenuating the cardiovascular response to laryngoscopy and tracheal intubation in 60 patients undergoing elective surgery under general anaesthesia. Patients were allocated to one of three groups of 20 patients each. Group 1 patients were administered placebo buccal spray 90 s before induction of anaesthesia. Groups 2 and 3 had isosorbide dinitrate spray 30 and 90 s before induction of anaesthesia. Systolic, diastolic and mean arterial pressures and heart rate were monitored. After the spray, group 3 patients had a significant decrease in systolic arterial pressure (p less than 0.01). At 1 min after intubation, systolic, diastolic and mean arterial pressures showed a significant increase in group 1 patients (24.9 mmHg, 14.2 mmHg and 18.7 mmHg respectively). In contrast, groups 2 and 3 showed a significant decrease in these parameters (p less than 0.01). Although significant tachycardia was present following intubation in all the three groups, the degree of tachycardia was greater in groups 2 and 3 (p less than 0.01).

The effect of music on ketamine induced emergence phenomena

The purpose of this investigation was to assess the influence of music on emergence phenomena after ketamine anaesthesia. Fifty ASA 1 patients undergoing minor gynaecological procedures were randomly divided into two equal groups. Patients in the treated group were played music of their choice through headphones from 5 min before induction of anaesthesia to 15 min postoperatively. Although the incidence of emergence phenomena was similar in both groups the effects tended to be more pleasant and acceptable in those to whom music was played. The majority of patients in the study group (80%) expressed their willingness to have a similar anaesthetic in the future compared to 52% in the control group (p less than 0.05).

A comparison of morphologic and angiographic findings in long-term internal mammary artery and saphenous vein bypass grafts

Internal mammary artery grafts are currently considered the conduits of choice for myocardial revascularization. Comparisons of long-term morphologic changes in internal mammary artery grafts and saphenous vein grafts and correlation with premortem angiography have not been reported. Eighteen internal mammary artery and 15 saphenous vein grafts that had been in place for 12 to 118 months (mean 56) in 18 patients were removed either surgically or at necropsy and examined histologically. Premortem angiograms were performed within 1 month of histologic study in 15 of these patients. Fibrointimal proliferation was more frequent in internal mammary artery than in saphenous vein grafts 8 [( 44%] of 18 versus 4 [27%] of 15; p = NS). In contrast, atherosclerosis was common in saphenous vein grafts but was extremely rare in internal mammary artery grafts (10 of 15 versus 1 of 18; p = 0.01). A good correlation was noted between the degree of narrowing estimated by angiographic and histologic measurements in both internal mammary artery grafts (d = 0.90) and saphenous vein grafts (d = 0.71). Accelerated atherosclerosis did not occur in internal mammary artery grafts, but was common in saphenous vein grafts. Fibrointimal proliferation was commonly associated with graft narrowing in internal mammary artery grafts and may be an important factor in late graft closure. This study also confirms that internal mammary artery grafts have greater longevity compared with saphenous vein grafts.

Preservation of endothelial cell structure and function by intracoronary perfluorochemical in a canine preparation of reperfusion

To determine the effect of intracoronary perfluorochemical on endothelial cell structure and function, 16 dogs were randomized to receive either low-dose (15 ml/kg) intracoronary perfluorochemical (Fluosol-DA) or saline after 90 min of proximal occlusion of the left anterior descending coronary artery (LAD). The animals underwent reperfusion for 60 min with the introduction of perfluorochemical or saline 5 to 10 min after the onset of reperfusion. Endothelium-dependent coronary vasodilatory reserve was determined in vivo both at baseline and 1 hr after reperfusion by infusion of acetylcholine and then serotonin into the distal LAD bed in 12 animals (six in each group). Both agonists significantly increased regional flow measured by 133Xe washout in the two groups before occlusion, but at 1 hr after reperfusion only animals given perfluorochemical demonstrated a significant increase in flow. Vasodilatory reserve was assessed in vitro with cumulative dose-response curves to acetylcholine on LAD rings proximal and distal to the snare in all animals. These studies demonstrated a significant reduction in endothelial cell-mediated relaxation of epicardial arterial segments in the ischemic segment of control but not treated animals. Light microscopy revealed the presence of neutrophils within vessels in the ischemic zones in control animals only. Electron microscopy showed capillary obstruction by endothelial cell protrusions and neutrophil and red cell plugging in control animals in the ischemic region but an intact endothelium and predominantly unobstructed capillaries in treated animals. These findings suggest that the structural and functional endothelial damage after reperfusion may be prevented by the administration of intracoronary perfluorochemical after the onset of reperfusion.

Pulmonary and bilateral retinochoroidal cryptococcosis

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