Contralateral Nodal Relapse in Well-lateralised Oral Cavity Cancers Treated Uniformly with Ipsilateral Surgery and Adjuvant Radiotherapy With or Without Concurrent Chemotherapy: a Retrospective Study

AIMS

To evaluate the incidence and pattern of contralateral nodal relapse (CLNR), contralateral nodal relapse-free survival (CLNRFS) and risk factors predicting CLNR in well-lateralised oral cavity cancers (OCC) treated with unilateral surgery and adjuvant ipsilateral radiotherapy with or without concurrent chemotherapy.

MATERIALS AND METHODS

Consecutive patients of well-lateralised OCC treated between 2012 and 2017 were included. The primary endpoint was incidence of CLNR and CLNRFS. Univariable and multivariable analyses were carried out to identify potential factors predicting CLNR.

RESULTS

Of the 208 eligible patients, 21 (10%) developed isolated CLNR at a median follow-up of 45 months. The incidence of CLNR was 21.3% in node-positive patients. CLNR was most common at level IB (61.9%) followed by level II. The 5-year CLNRFS and overall survival were 82.5% and 57.7%, respectively. Any positive ipsilateral lymph node (P = 0.001), two or more positive lymph nodes (P < 0.001), involvement of ipsilateral level IB (P = 0.002) or level II lymph node (P < 0.001), presence of extranodal extension (P < 0.001), lymphatic invasion (P = 0.015) and perineural invasion (P = 0.021) were significant factors for CLNR on univariable analysis. The presence of two or more positive lymph nodes (P < 0.001) was an independent prognostic factor for CLNR on multivariable analysis. CLNR increased significantly with each increasing lymph node number beyond two compared with node-negative patients.

CONCLUSION

The overall incidence of isolated CLNR is low in well-lateralised OCC. Patients with two or more positive lymph nodes have a higher risk of CLNR and may be considered for elective treatment of contralateral neck.

Anhedonia in adolescents at transdiagnostic familial risk for severe mental illness: Clustering by symptoms and mechanisms of association with behavior

BACKGROUND

Anhedonia is a transdiagnostic symptom of severe mental illness (SMI) and emerges during adolescence. Possible subphenotypes and neural mechanisms of anhedonia in adolescents at risk for SMI are understudied.

METHODS

Adolescents at familial risk for SMI (N = 81) completed anhedonia (e.g., consummatory, anticipatory, social), demographic, and clinical measures and one year prior, a subsample (N = 46) completed fMRI scanning during a monetary reward task. Profiles were identified using k-means clustering of anhedonia type and differences in demographics, suicidal ideation, impulsivity, and emotional processes were examined. Moderation analyses were conducted to investigate whether levels of brain activation of reward regions moderated the relationships between anhedonia type and behaviors.

RESULTS

Two-clusters emerged: a high anhedonia profile (high-anhedonia), characterized by high levels of all types of anhedonia, (N = 32) and a low anhedonia profile (low-anhedonia), characterized by low levels of anhedonia types (N = 49). Adolescents in the high-anhedonia profile reported more suicidal ideation and negative affect, and less positive affect and desire for emotional closeness than low-anhedonia profile. Furthermore, more suicidal ideation, less positive affect, and less desire for emotional closeness differentiated the familial high-risk, high-anhedonia profile adolescents from the familial high-risk, low-anhedonia profile adolescents. Across anhedonia profiles, moderation analyses revealed that adolescents with high dmPFC neural activation in response to reward had positive relationships between social, anticipatory, and consummatory anhedonia and suicidal ideation.

LIMITATIONS

Small subsample with fMRI data.

CONCLUSION

Profiles of anhedonia emerge transdiagnostically and vary on clinical features. Anhedonia severity and activation in frontostriatal reward areas have value for clinically important outcomes such as suicidal ideation.

Effectiveness, perceptions and environmental benefits of remote consultation for adults referred with recurrent tonsillitis

INTRODUCTION

We evaluate remote consultation for adult patients referred with recurrent sore throat, measuring the effectiveness of the consultation, satisfaction and environmental impact.

METHODS

Eligible patients were invited to telephone clinics, undertaking a satisfaction survey after consultation, focusing on perceived convenience, satisfaction, cost and travel arrangements (used to calculate potential environmental benefit). Provider opinion was also captured.

RESULTS

Forty-eight of 60 patients attended, with 38 (63%) eligible for inclusion. Thirty-six of these 38 patients (95%) had a definitive outcome of tonsillectomy (27/38) or discharge (9/38). Thirty-three of the 38 patients (87%) responded to the survey and reported high satisfaction in all arms of questioning (mean Likert ranking = 4.7/5). A mean of 3.76 hours of missed work and 5.17kg carbon dioxide emission equivalents were saved per patient. Provider responses were positive towards ongoing remote consultation use.

CONCLUSIONS

Telephone consultation for adult patients considered for tonsillectomy is convenient to patients in terms of cost and time, reduces environmental harm and is associated with high patient and provider satisfaction.

Facial nerve communication with ansa cervicalis - An unusual anatomical variation

Neural connections of the seventh cranial nerve with its neighboring nerves are common and well documented; however, communication with ansa cervicalis is as yet unknown. We present a case with such a connection found during cadaveric dissection, with hitherto unknown consequences. In this specimen, after giving the marginal mandibular and cervical branches, the cervicofacial division continued distally to communicate with the distal loop of ansa cervicalis. Presence of such connection may result in facial muscle paralysis on injury to the ansa or strap muscle paralysis on injury to the facial nerve, depending on the direction of nerve fibers. Such unusual connections bring to light the need for extreme care during surgeries in the neck to safeguard any such connections and when using the ansa as donor.

A Comprehensive Review on Nanoparticles as a Targeted Delivery System for the Treatment of Lung Cancer

The second most common type of cancer is lung cancer, impacting the human population. Lung cancer is treated with a number of surgical and non-surgical therapies, including radiation, chemotherapy, and photodynamic treatment. However, the bulk of these procedures are costly, difficult, and hostile to patients. Chemotherapy is distinguished by inadequate tumour targeting, low drug solubility, and insufficient drug transport to the tumour site. In order to deal with the issues related to chemotherapy, extensive efforts are underway to develop and investigate various types of nanoparticles, both organic and inorganic, for the treatment of lung cancer. The subject of this review is the advancements in research pertaining to active targeted lung cancer nano-drug delivery systems treatment, with a specific emphasis on receptors or targets. The findings of this study are expected to assist biomedical researchers in utilizing nanoparticles (NPs) as innovative tools for lung cancer treatment, offering new methods for delivering drugs and reliable solid ligands.

Injection medialisation laryngoplasty: an alternative approach for challenging cases

OBJECTIVE

Conventional injection medialisation laryngoplasty techniques may be compromised by patient-specific factors such as marked kyphosis, an anteriorly positioned larynx or intolerance to nasendoscopy. This paper describes a technique for successful injection medialisation laryngoplasty where conventional methods are precluded, in an 88-year-old man with presbyphonia on a background of Parkinson's disease.

METHODS

After induction of general anaesthesia, a transoral introducing needle, shaped by tactile manipulation to match the curvature of a 'C-MAC' intubating video-laryngoscope 'D-blade' attachment, was introduced until visible above the glottis. The implant material was then injected into the paraglottic space as normal until satisfactory medialisation of the vocal fold was achieved.

RESULTS

When reviewed in the out-patient clinic four weeks later, the patient's post-operative Voice Handicap Index score fell to 6, from a pre-operative score of 21.

CONCLUSION

By utilising commonly available equipment and anaesthetic support to recreate the views and access conventional nasendoscopy and laryngoscopy facilitate, this novel procedure provides a viable and proven alternative in uncommon but challenging cases.

Usefulness of Children's Hospital of Philadelphia ROP (CHOP ROP) model in the prediction of type 1 ROP

Purpose

Children's Hospital of Philadelphia retinopathy of prematurity (CHOP ROP) model can be used to predict ROP, a leading cause of childhood blindness, using risk factors such as postnatal weight gain, birth weight (BW), and gestation age (GA). The purpose of this study was to determine the usefulness of the CHOP ROP for the prediction of treatable ROP.

Methods

This was a prospective observational study. Babies <34 weeks of GA, BW <2000 grams, and GA 34-36 weeks with risk factors such as respiratory distress syndrome (RDS) were included; ROP screening, follow-up, and treatment were performed based on national guidelines. The average daily postnatal weight gain was measured, and the CHOP nomogram was plotted. Babies were categorized as high risk or low risk based on the "CHOP" alarm. The sensitivity and specificity of the CHOP ROP for the detection of treatable ROP were determined. In case of poor sensitivity, a new cutoff alarm level was planned using logistic regression analysis.

Results

Of 62 screened infants, 23 infants did not fulfill the criteria of the CHOP algorithm and were excluded. Thus, in the study on 39 infants, the predictive model with an alarm level of 0.014 had 100% specificity and 20% sensitivity. With the "new" alarm level (cutoff) of 0.0003, the CHOP nomogram could detect all the infants who developed treatable ROP, that is, sensitivity increased to 100% but specificity decreased to 10.5%.

Conclusion

The CHOP ROP model with a cutoff point (0.014) performed poorly in predicting severe ROP in the study. Thus, there is a need to develop inclusive and more sensitive tailor-made algorithms.

Short-course Palliative Hypofractionated Radiotherapy in Patients with Poor-prognosis High-grade Glioma: Survival and Quality of Life Outcomes from a Prospective Phase II Study

AIMS

To report longitudinal quality of life (QoL) outcomes and survival in patients with poor-prognosis high-grade glioma (HGG) treated with palliative hypofractionated radiotherapy.

MATERIALS AND METHODS

Patients with poor-prognosis HGG were accrued on a prospective study of short-course palliative hypofractionated radiotherapy (35 Gy/10 fractions/2 weeks). The European Organization for Research and Treatment of Cancer QoL core questionnaire (QLQ-C30) and brain cancer module (BN20) were used in English or validated Indian vernacular languages (Hindi and Marathi) for QoL assessment at baseline (before radiotherapy), the conclusion of radiotherapy, 1 month post-radiotherapy and subsequently at 3-monthly intervals until disease progression/death. Baseline QoL scores were compared with corresponding scores from a historical HGG cohort. Summary QoL scores were compared longitudinally over time by related samples Friedman's two-way test. Progression-free survival and overall survival were calculated using the Kaplan-Meier method and reported as 1-year estimates with 95% confidence intervals.

RESULTS

Forty-nine (89%) of 55 patients completed the planned course of hypofractionated radiotherapy. Longitudinal QoL data were available in 42 (86%) of 49 patients completing radiotherapy, comprising the present cohort. The median age of included patients, comprised mainly of glioblastoma patients (81%), was 57 years, with an interquartile range (IQR) of 50-66 years and a median baseline Karnofsky score of 60 (IQR = 50-60). Baseline QoL scores were significantly worse for several domains compared with a historical institutional cohort of HGG patients treated previously with conventionally fractionated radiotherapy, indicating negative selection bias. QoL scores remained stable for most domains after palliative hypofractionated radiotherapy, with statistically significant improvements in fatigue (P = 0.032), dyspnoea (P = 0.042) and motor dysfunction (P = 0.036) over time. At a median follow-up of 8 months, Kaplan-Meier estimates of 1-year progression-free survival and overall survival were 33.3% (95% confidence interval 21.7-51.1%) and 38.1% (95% confidence interval 25.9-56%), respectively.

CONCLUSION

Short-course palliative hypofractionated radiotherapy in patients with poor-prognosis HGG is associated with stable and/or improved QoL scores in several domains, making it a viable resource-sparing regimen.

Multiple Sessions vs. Single Session Image-Based Intracavitary Brachytherapy for Locally Advanced Cervical Cancer: A Randomized Control Trial

PURPOSE/OBJECTIVE(S)

The objectives of this study are: 1) To compare the acute toxicity caused in the treatment of locally advanced cervical cancer (LACC) treated with weekly multiple applications vs. a single application for image-guided intracavitary High Dose Rate (HDR) brachytherapy (BT) after External Beam Radiation Therapy (EBRT) 2) To compare the loco-regional control of cancer at six months in the two arms MATERIALS/METHODS: In a prospective study, 40 patients with biopsy-proven LACC with FIGO-2018 stage IIB-IIIC1 disease, underwent EBRT to the pelvis at a dose of 50.4 Gy/ 28 fractions over 5.5 weeks with weekly concurrent cisplatin. After completion of EBRT, they were randomized into two arms with 20 patients each. In the Control arm (Arm-A), BT sessions were given with weekly 3 applications whereas, in the experimental arm (Arm-B), all the sessions were given with a single application at 6-12 hours intervals with aim of the high-risk clinical target volume receiving >80 Gy EQD2 and 2 cm3 of the bladder and rectum/sigmoid receiving <85 Gy and <75 Gy, respectively. The OAR contouring was done on CT RESULTS: All 40 patients were treated as per protocol. The mean duration of treatment including EBRT and BT was 73.15 days [95% CI 68.63-77.66] in Arm A and 55.85 days [95% CI 52.11-59.58] in Arm B which was significant. After 6 months, 37 patients came for follow-up, all 19 patients in Arm A had Grade 1 or Grade 2 rectal toxicity. In Arm B as well all 18 patients had Grade 1 or Grade 2 rectal toxicity. Bladder toxicity was Grade 1 or Grade 2 in 18 patients and Grade 3 severity in 1 patient among Arm A. Among 18 patients of Arm B, bladder toxicity of Grade 1 or Grade 2 was seen in 16 patients, and 2 patients had grade 3 toxicity. 2 patients in Arm A and 3 in Arm B complained of Grade 1 urinary incontinence. Moreover, Abdominal pain at 6 months was of Grade 1 in around 6 patients in Arm A but 14 patients had abdominal pain in Arm B which was of Grade 1 in 8, 4 had grade 2 and 2 patients had grade 3 severity abdominal pain. In the monthly analysis of acute toxicity, none of the patients showed Grade 3 or 4 toxicity at the 1st, 2nd, or 3rd month of completion of treatment. When comparing local control in both arms at 6 months, 2 patients had treatment failure in the Experimental Arm compared to only 1 patient in the Control Arm CONCLUSION: Single Application Multiple Fraction Intracavitary Brachytherapy post concurrent CTRT is a safe option for the treatment of locally advanced cervical cancer. When compared to the weekly application arm, single-application ICRT showed a comparable acute toxicity profile and comparable local control rates as well. Some patients in Single Application Arm showed abdominal pain which needs to be investigated with further trials. The overall treatment time in the single application arm is significantly lower than the standard weekly application arm.

Outcomes of remote versus face-to-face ear, nose and throat outpatient consultation on patient pathways

INTRODUCTION

Remote consultation has potential benefits in increasing patient pathway efficiency and has been found to reduce costs and carbon emissions. Previous studies of remote consultation in ear, nose and throat (ENT) practice have reported mixed results and used relatively small sample sizes. The aim of this article is to study the impact of remote telephone consultation on ENT clinic outcomes and pathway efficiency, compared with in-person review, within new and follow-up patient cohorts and subspeciality, where previous studies demonstrate mixed and inconclusive results.

METHODS

This was a comparison of remote clinic appointment outcomes over a 2-month period from a single ENT referral centre (426) with an equivalent data set of face-to-face clinic appointments over a similar time frame (1,533). Statistical analysis included chi-squared test for clinic outcomes and two-sample t-squared test for mean hand-off between both cohorts (p < 0.05).

RESULTS

For new referrals, remote consultation was associated with statistically significantly greater rates of follow-up (p < 0.00001), investigation (p = 0.00251) and hand-off (p < 0.00013) than patients seen face-to-face - particularly where presenting with head and neck symptoms. For follow-up patients, remote consultation had similar rates of investigation (p = 0.11071) or further follow-up (p = 0.08) and mean hand-off (p < 0.11764) to those seen face-to-face.

CONCLUSIONS

Remote consultation in ENT could become the norm for follow-up patients, but should be used with caution in the initial consultation of new patients.

Conformational Flexibility Is a Key Determinant for the Lytic Activity of the Pore-Forming Protein, Cytolysin A

Several bacterial infections are mediated by pore-forming toxins (PFTs), a subclass of proteins that oligomerize on mammalian cell membranes forming lytic nanopores. Cytolysin A (ClyA), an α-PFT, undergoes a dramatic conformational change restructuring its two membrane-binding motifs (the β-tongue and the N-terminus helix), during pore formation. A complete molecular picture for this key transition and the driving force behind the secondary structure change upon membrane binding remain elusive. Using all-atom molecular dynamics (MD) simulations of the ClyA monomer and string method based free energy computations with path collective variables, we illustrate that an unfolded β-tongue motif is an on-pathway intermediate during the transition to the helix-turn-helix motif of the protomer. An aggregate of 28 μs of all-atom thermal unfolding MD simulations of wild-type ClyA and its single point mutants reveal that the membrane-binding motifs of the ClyA protein display high structural flexibility in water. However, point mutations in these motifs lead to a distinct reduction in the flexibility, especially in the β-tongue, thereby stabilizing the pretransition secondary structure. Resistance to unfolding was further corroborated by MD simulations of the β-tongue mutant motif in the membrane. Combined with the thermal unfolding simulations, we posit that the β-tongue as well as N-terminal mutants that lower the tendency to unfold and disorder the β-tongue are detrimental to pore formation by ClyA and its lytic activity. Erythrocyte turbidity and vesicle leakage assays indeed reveal a loss of activity for the β-tongue mutant, and delayed kinetics for the N-terminus mutants. On the other hand, a point mutation in the extracellular domain that did not abrogate lytic activity displayed similar unfolding characteristics as the wild type. Thus, attenuation of conformational flexibility in membrane-binding motifs correlates with reduced lytic and leakage activity. Combined with secondary structure changes observed in the membrane bound states, our study shows that the tendency to unfold in the β-tongue region is a critical step in the conformational transition and bistability of the ClyA protein and mutants that disrupt this tendency reduced pore formation. Overall, our finding suggests that inherent flexibility in the protein could play a wider and hitherto unrecognized role in membrane-mediated conformational transitions of PFTs and other membrane protein transformations.

Structural Insight on GPR119 Agonist as Potential Therapy for Type II Diabetes: A Comprehensive Review

Diabetes Mellitus (DM) is a long-term metabolic condition that is characterized by excessive blood glucose. DM is the third most death-causing disease, leading to retinopathy, nephropathy, loss of vision, stroke, and cardiac arrest. Around 90% of the total cases of diabetic patients have Type II Diabetes Mellitus (T2DM). Among various approaches for the treatment of T2DM. G proteincoupled receptors (GPCRs) 119 have been identified as a new pharmacological target. GPR119 is distributed preferentially in the pancreas β-cells and gastrointestinal tract (enteroendocrine cells) in humans. GPR119 receptor activation elevates the release of incretin hormones such as Glucagon-Like Peptide (GLP1) and Glucose Dependent Insulinotropic Polypeptide (GIP) from intestinal K and L cells. GPR119 receptor agonists stimulate intracellular cAMP production via Gαs coupling to adenylate cyclase. GPR119 has been linked to the control of insulin release by pancreatic β-cells, as well as the generation of GLP-1 by enteroendocrine cells in the gut, as per in vitro assays. The dual role of the GPR119 receptor agonist in the treatment of T2DM leads to the development of a novel prospective anti-diabetic drug and is thought to have decreased the probability of inducing hypoglycemia. GPR119 receptor agonists exert their effects in one of two ways: either by promoting glucose absorption by β-cells, or by inhibiting α-cells' ability to produce glucose. In this review, we summarized potential targets for the treatment of T2DM with special reference to GPR119 along with its pharmacological effects, several endogenous as well as exogenous agonists, and its pyrimidine nucleus containing synthetic ligands.

Does loneliness before the age of twelve indirectly affect impaired control over drinking, alcohol use, and problems through perceived stress?

Loneliness is the pain of feeling socially isolated from others (Russell et al., 1980). The Stress-Dampening Hypothesis (Marlatt, 1987; Sayette, 1993; Sher, 1987) posits that individuals drink to alleviate negative affect. To date, it has not been determined whether loneliness experienced as a child can indirectly influence at-risk patterns of alcohol use through the mediating mechanism of stress and impaired control. Impaired control over alcohol use (IC) is the difficulty adhering to one's own self-proscribed limits on drinking behaviors (Heather et al., 1993). Impaired control is an at-risk pattern of use that is particularly relevant to emerging adults. Methods: We examined the direct and indirect relationships between childhood loneliness, stress, IC, and alcohol-related problems with a structural equation model. In a college student sample, we utilized a (k = 20,000) bootstrap technique and a model indirect command in Mplus to examine potential mediational pathways. Cisgender sex was included as a covariate. Results: Loneliness was directly linked to stress as well as to alcohol-related problems. Higher levels of loneliness were indirectly linked to both more alcohol use and alcohol-related problems through more stress and in turn, more impaired control over drinking. Conclusions: The current study is consistent with the Stress Dampening Hypothesis (Marlatt, 1987; Sayette, 1993; Sher, 1987). Our findings suggest that therapeutic interventions combating loneliness in childhood may disrupt the stress-dampening pathway to dysregulated alcohol use in emerging adulthood.

788 Caecal Duplication Cyst: An Unexpected Cause of Bowel Obstruction in a 12-Year-Old

We report the case of a rare cause of bowel obstruction in a 12-year-old girl who presented with a short history of abdominal distension and vomiting after a month of unexplained urinary frequency and weight loss. Abdominal radiographs demonstrated small bowel obstruction with an unknown pelvic mass. A raised CA125 suggested a possible ovarian lesion and a magnetic resonance scan was interpreted as supportive of this pathology. Intra-operatively a 120x90x70mm cystic mass was found attached to the caecal serosa, immediately adjacent to the ileocaecal valve. There was an associated 180-degree twist of the terminal ileum and ascending colon. A limited right hemicolectomy was performed, and histopathology confirmed the diagnosis of a caecal intestinal duplication cyst. Post-operatively she has recovered well, with resolution of her obstructive and urinary symptoms. Given the unusual age of presentation, uncommon location of the cyst and the diagnostic challenges incurred, the authors wish to share their experience of managing an atypical duplication cyst.

Genomic Degeneration and Reduction in the Fish Pathogen Mycobacterium shottsii

Mycobacterium shottsii is a dysgonic, nonpigmented mycobacterium originally isolated from diseased striped bass (Morone saxatilis) in the Chesapeake Bay, USA. Genomic analysis reveals that M. shottsii is a Mycobacterium ulcerans/Mycobacterium marinum clade (MuMC) member, but unlike the superficially similar M. pseudoshottsii, also isolated from striped bass, it is not an M. ulcerans ecovar, instead belonging to a transitional group of strains basal to proposed "Aronson" and "M" lineages. Although phylogenetically distinct from the human pathogen M. ulcerans, the M. shottsii genome shows parallel but nonhomologous genomic degeneration, including massive accumulation of pseudogenes accompanied by proliferation of unique insertion sequences (ISMysh01, ISMysh03), large-scale deletions, and genomic reorganization relative to typical M. marinum strains. Coupled with its observed ecological characteristics and loss of chromogenicity, the genomic structure of M. shottsii is suggestive of evolution toward a state of obligate pathogenicity, as observed for other Mycobacterium spp., including M. ulcerans, M. tuberculosis, and M. leprae. IMPORTANCE Morone saxatilis (striped bass) is an ecologically and economically important finfish species on the United States east coast. Mycobacterium shottsii and Mycobacterium pseudoshottsii were originally described in the early 2000s as novel species from outbreaks of visceral and dermal mycobacteriosis in this species. Biochemical and genetic characterization place these species within the Mycobacterium ulcerans/M. marinum clade (MuMC), and M. pseudoshottsii has been proposed as an ecovar of M. ulcerans. Here, we describe the complete genome of M. shottsii, demonstrating that it is clearly not an M. ulcerans ecovar; however, it has undergone parallel genomic modification suggestive of a transition to obligate pathogenicity. As in M. ulcerans, the M. shottsii genome demonstrates widespread pseudogene formation driven by proliferation of insertion sequences, as well as genomic reorganization. This work clarifies the phylogenetic position of M. shottsii relative to other MuMC members and provides insight into processes shaping its genomic structure.

Post-cricoid and Upper Oesophagus Cancers Treated with Organ Preservation Using Intensity-modulated Image-guided Radiotherapy: a Phase II Prospective Study of Outcomes, Toxicity and Quality of Life

AIMS

To prospectively examine the outcomes, toxicity and quality of life (QoL) of patients with post-cricoid and upper oesophagus (PCUE) cancers treated with an organ-preservation approach of (chemo)-radiotherapy using intensity-modulated image-guided radiotherapy (IM-IGRT).

MATERIALS AND METHODS

This phase II prospective study was conducted at a tertiary cancer centre from February 2017 to January 2020. Forty patients with squamous cell carcinoma of PCUE of stage T1-3, N0-2, M0 were accrued. Gross exolaryngeal extension/dysfunctional larynx were major exclusion criteria. Patients received 63-66 Gy in once-daily fractions using volumetric modulated arc therapy with daily IGRT. Outcome measures included disease-related outcomes, patterns of failure, Radiation Therapy Oncology Group toxicities, feeding tube dependency and QoL.

RESULTS

The median follow-up was 22 months. Twenty-six (87.5%) patients had locoregionally advanced disease and 34 (85%) patients received (chemo)-radiotherapy. A complete response was observed in 26 (65%) patients. The 2-year locoregional control, event-free survival and cause-specific survival were 59.6%, 40.2% and 44.8%, respectively. The volume of primary tumour (GTVPvol) exceeding 28 cm³ had inferior overall survival (P = 0.005) on univariate analysis. Multivariable analysis showed GTVPvol and positron emission tomography-computed tomography maximum standardised uptake value to be independently predictive for event-free and overall survival. A feeding tube requirement at presentation was seen in 11 (27.5%) patients, whereas long-term feeding tube dependency at 6 months was seen in 10 (37%) patients. For QoL, a statistical improvement in pain, appetite loss and swallowing was observed over time.

CONCLUSION

Although the outcomes of PCUE cancers remain dismal, the use of state of the art diagnostic modalities, careful case selection and modern radiotherapy techniques improved outcomes as compared with before in this exclusive analysis of PCUE cancers.

Lactobacillus fermentum (MTCC-5898) alleviates Escherichia coli-induced inflammatory responses in intestinal epithelial cells by modulating immune genes and NF-κB signalling

AIM

Dietary intervention using probiotic bacteria has emerged as a promising preventive strategy in addressing foodborne infections or gastrointestinal disorders. This study investigated the immunomodulatory effects of Lactobacillus fermentum (MTCC-5898) on Escherichia coli-induced inflammatory responses in intestinal epithelial cells.

METHODS AND RESULTS

The immune response of intestinal cells (Caco-2) in the presence of probiotic Lact. fermentum was determined during exclusion, competition and displacement of E. coli as the inflammatory agent. To achieve this objective, transcriptional modulation of key immune-related genes (cytokines, pattern recognition receptors and NF-κB), release of cytokines and nuclear translocation of the NF-κB subunit p-65 were studied. Expression of pro-inflammatory cytokines IL-8, TNF-α, IFN-ϒ and IL-23 was high in E. coli-exposed intestinal cells. However, overexpression of these E. coli-induced pro-inflammatory cytokines was prevented by Lact. fermentum during exclusion and competition assays. It also modulated the transcriptional expression of regulatory cytokines (IL-10 and TGF-β), pattern recognition receptors (TLR-2 and TLR-4) and genes associated with master inflammatory regulators (NF-κB and SIGIRR) to reduce E. coli-induced inflammation. The protective effect of Lact. fermentum was further confirmed by suppression of nuclear translocation of cytoplasmic NF-κB subunit (p-65).

CONCLUSION

Lactobacillus fermentum alleviated E. coli-induced inflammatory responses by modulating the NF-κB signalling besides pro-inflammatory and regulatory cytokines expression.

SIGNIFICANCE AND IMPACT OF THE STUDY

Lactobacillus fermentum holds significant promise as a potent nutraceutical that prevents and manages inflammatory gut-associated dysfunctions.

High-dose salvage re-irradiation for recurrent/progressive adult diffuse glioma: healing or hurting?

PURPOSE

To report survival outcomes and identify prognostic factors of salvage re-irradiation (re-RT) in recurrent/progressive glioma.

METHODS

Medical records of patients treated with high-dose re-RT as part of multi-modality salvage therapy for recurrence/progression of adult diffuse glioma from 2010 to 2019 were analyzed retrospectively.

RESULTS

A total of 111 patients developing recurrent/progressive high-grade glioma after adequate upfront treatment at initial diagnosis were included. The first course of radiotherapy (RT) had been delivered to a median dose of 59.4 Gy with an inter-quartile range (IQR) of 54-60 Gy. Median time to recurrence/progression was 4.3 years (IQR = 2.3-7.4 years) while the median time to re-RT was 4.8 years (IQR = 3.6-7.9 years). Re-RT was delivered with intensity-modulated radiation therapy (IMRT) using 1.8 Gy/fraction to a median dose of 54 Gy (IQR = 50.4-55.8 Gy) for a cumulative median equivalent dose in 2-Gy fractions (EQD2) of 104.3 Gy (IQR = 102.6-109.4 Gy). At a median follow-up of 14 months after re-RT, the 1-year Kaplan-Meier estimates of post-re-RT progression-free survival (PFS) and overall survival (OS) were 42.8 and 61.8%, respectively. Univariate analysis identified histological grade at recurrence/progression; histological subtype; disease-free interval (DFI) and time interval between both courses of RT; performance status at re-RT; dose at re-RT and cumulative EQD2; isocitrate dehydrogenase (IDH) mutation; and O⁶-methyl-guanine DNA methyl transferase (MGMT) gene promoter methylation as significant prognostic factors. Preserved performance status, longer DFI, prolonged time interval between both courses of RT, and presence of IDH mutation were associated with significantly improved PFS on multi-variate analysis. However, only performance status retained independent prognostic significance for OS on multi-variate analysis. Post-treatment changes were seen in 33 (30%) patients on follow-up imaging, with higher cumulative dose (EQD2 ≥ 104.3 Gy) being associated with increased risk of post-re-RT pseudo-progression.

CONCLUSION

This clinical audit reports encouraging survival outcomes and identifies key prognostic factors associated with high-dose salvage re-RT in recurrent/progressive glioma.

Mucosal-associated invariant T (MAIT) cells are activated in the gastrointestinal tissue of patients with combination ipilimumab and nivolumab therapy-related colitis in a pathology distinct from ulcerative colitis

The aim of this study was to investigate the pathogenesis of combination ipilimumab and nivolumab-associated colitis (IN-COL) by measuring gut-derived and peripheral blood mononuclear cell (GMNC; PBMC) profiles. We studied GMNC and PBMC from patients with IN-COL, IN-treated with no adverse-events (IN-NAE), ulcerative colitis (UC) and healthy volunteers using flow cytometry. In the gastrointestinal-derived cells we found high levels of activated CD8⁺ T cells and mucosal-associated invariant T (MAIT) cells in IN-COL, changes that were not evident in IN-NAE or UC. UC, but not IN-C, was associated with a high proportion of regulatory T cells (T_reg ). We sought to determine if local tissue responses could be measured in peripheral blood. Peripherally, checkpoint inhibition instigated a rise in activated memory CD4⁺ and CD8⁺ T cells, regardless of colitis. Low circulating MAIT cells at baseline was associated with IN-COL patients compared with IN-NAE in one of two cohorts. UC, but not IN-COL, was associated with high levels of circulating plasmablasts. In summary, the alterations in T cell subsets measured in IN-COL-affected tissue, characterized by high levels of activated CD8⁺ T cells and MAIT cells and a low proportion of T_reg , reflected a pathology distinct from UC. These tissue changes differed from the periphery, where T cell activation was a widespread on-treatment effect, and circulating MAIT cell count was low but not reliably predictive of colitis.

The role of contaminations in ion beam spectroscopy with freestanding 2D materials: A study on thermal treatment

As surface-only materials, freestanding 2D materials are known to have a high level of contamination-mostly in the form of hydrocarbons, water, and residuals from production and exfoliation. For well-designed experiments, it is of particular importance to develop effective cleaning procedures, especially since standard surface science techniques are typically not applicable. We perform ion spectroscopy with highly charged ions transmitted through freestanding atomically thin materials and present two techniques to achieve clean samples, both based on thermal treatment. Ion charge exchange and energy loss are used to analyze the degree of sample contamination. We find that even after cleaning, heavily contaminated spots remain on single layer graphene. The contamination coverage, however, clusters in strand-like structures leaving large clean areas. We present a way to discriminate clean from contaminated areas with our ion beam spectroscopy if the heterogeneity of the surface is increased sufficiently enough. We expect a similar discrimination to be necessary in most other experimental techniques.

Anatomy of scalenovertebral triangle: A vade mecum for clinicians

OBJECTIVE OF THE STUDY

The thorough anatomical knowledge of scalenovertebral triangle or Triangle of the vertebral artery and its contents is crucial in various neurosurgical procedures such as scalenotomy, stellate ganglion block, direct isolation of proximal vertebral artery and proximal brachial plexus repair.

MATERIAL AND METHOD

Thirty scalenovertebral triangles of known age and sex were dissected. The morphometry of the triangle and stellate ganglion was done. Various relevant distances were measured for topographical location of neurovascular structures especially stellate ganglion and vertebral artery within the triangle.

RESULTS

The mean height and width of the scalenovertebral triangle was 21.7+5.1mm and 19.4+4.4mm respectively. Vertebral artery originated from subclavian artery within the triangle except in one case (left side) where it originated from aortic arch. The mean minimum distance of stellate ganglion from phrenic nerve, scalenus anterior and vertebral origin was 12.6+4.5mm, 12.26+4mm and 2.3+1.3mm respectively.

CONCLUSIONS

The origin and proximal part of vertebral artery may not be present within the scalenovertebral triangle, thus topographic anatomy of the stellate ganglion is also affected and may cause complications during stellate ganglion block. Stellate ganglion is never located in the lateral or upper third of triangle. Occasionally, the phrenic nerve may cross the triangle, making it unsafe during stellate ganglion block.

P14.50 Clinicopathological spectrum of intracranial germ cell tumors: an Indian tertiary cancer center experience

BACKGROUND

Incidence of intracranial germ cell tumors (ICGCT) in Western literature is low (0.3–0.6 %) as compared to East Asia (3–4 %), & their clinicopathological features are well documented. However, there are scant studies on ICGCT from India.

MATERIAL AND METHODS

Retrospective observational study of all ICGCT histologically diagnosed in our hospital from 2007–2018. Metastasis were excluded. Clinicopathological features were retrieved from hospital’s electronic medical records.

RESULTS

We diagnosed 82 primary ICGCT, forming approx. 0.54 % of all primary brain tumors, & 3.5% of pediatric brain tumors. Age range: 2 months-32 yrs (Median age 14 yrs). M:F ratio: 1.82:1 (53M,29F). Nearly 80% patients were pediatric (<18 yrs), & 8 very young (<3 yrs, 7M1F). Majority were suprasellar & pineal (31/82, 37% each), with one bifocal presentation. Other rarer sites: posterior fossa (4), midbrain (1), corpus callosum (1) & 11 non midline (4 thalamic, 4 frontal, 2 cerebellar, 1 CP angle). Predominant histology was germinoma (G) (51/82, 62%), while non germinomatous (NGGCT) were 31/82 (38%), of which 9 were mixed. Pure teratoma were 11 (9 immature (IT), 2 mature), & 5 pure yolk sac tumor (YST). Interestingly, all very young age group patients (<3 yrs), showed only NGGCT histology (5/8 IT, 3/8 pure YST). In contrast, G histology formed nearly 70% of all patients >3 yrs. Females were associated mainly with G (21/29, 72%). NGGCT were predominantly seen in males (M:F=2.9:1). Also, pure IT (9) were seen only in males. Posterior fossa tumors were all IT (4/4). Spinal tumors were NGGCT (1 mature teratoma, 1 YST). Majority of suprasellar tumors (25/31, 80.6%), other midline locations like corpus callosal, midbrain, & all thalamic tumors were G. However, pineal tumors showed equal distribution of G (15/31) & NGGCT (16/31). Spine screening was positive in 8 patients (6 G, 2 IT)- 7 on MRI and 1 only on CSF cytology. Serum tumor markers were raised in 13/54 cases- 6/34G(17.6%), vs 7/20 NGGCT (35%). CSF tumor markers were raised in 14/34-10/23 G (43.4%), vs 4/11 NGGCT (36.3%). Follow up was available for 37 patients (Duration 3 months-10 yrs, median 2 yrs). On f/u 6/15 (40%) NGGCT showed progression/death, while only 2/32 G relapsed (6.5%). Four deaths in G group were not directly attributable to the tumor.

CONCLUSION

Frequency of ICGCT in our hospital similar to western data rather than Asian, albeit with less striking male preponderance. ICGCT were tumors of 2nd decade & majority occurred in pineal/suprasellar areas. About 2/3rd were pure G on histology, and showed good prognosis. NGGCT were common in infants, males and in posterior fossa. IT were seen exclusively in males and pure YST mainly in males. Although majority of ICGCT are in midline, rarely non midline involvement also occurs, and it’s essential to exclude metastasis before considering primary ICGCT. Expectedly, NGGCT showed poorer prognosis, compared to pure germinomas.

Randomized controlled study of the prediction of diminutive/small colorectal polyp histology using didactic versus computer-based self-learning module in gastroenterology trainees

BACKGROUND AND AIM

The aim of this randomized trial was to evaluate the performance of self-training versus didactic training in order to increase the diagnostic accuracy of diminutive/small colonic polyp histological prediction by trainees.

METHODS

Sixteen trainees reviewed 78 videos (48 iSCAN-OE and 30 NBI) of diminutive/small polyps in a pretraining assessment. Trainees were randomized to receive computer-based self-learning (n = 8) or didactic training (n = 8) using identical teaching materials and videos. The same 78 videos, in a different randomized order, were assessed. The NICE (NBI International Colorectal Endoscopic) and SIMPLE (Simplified Identification Method for Polyp Labeling during Endoscopy) classification systems were used to classify diminutive/small polyps.

RESULTS

A higher proportion of high-confidence predictions of polyps was made by the self-training group versus the didactic group using both the SIMPLE classification (77.1% [95% CI 73.4-80.3] vs 69.9% [95% CI 66.1-73.5%] [P = 0.005]) and the NICE classification (77% [95% CI 73.2-80.4%] vs 69.8% [95% CI 66-73.4%] [P = 0.006]). When using NICE, sensitivity of the self-training group compared with the didactic group was 72% versus 83% (P = 0.0005), and the accuracy was 66.1% versus 69.1%. The training improved the confidence of participants and SIMPLE was preferred over NICE.

CONCLUSION

Self-learning for the prediction of diminutive/small polyp histology is a method of training that can achieve results similar to didactic training. Availability of adequate self-learning teaching modules could enable widespread implementation of optical diagnosis in clinical practice.

Comparison of Epidemiology and Outcomes in Neuro-Oncology Between the East and the West: Challenges and Opportunities

Although neoplasms of the brain and central nervous system (CNS) are relatively uncommon, comprising only 1-2% of the overall cancer burden, they represent a substantial source of morbidity and mortality worldwide. The age-adjusted annual incidence of CNS tumours is reportedly low; however, there is substantial global variability in its incidence, with nearly a five-fold difference between regions with the highest rates in developed countries in the West and those with the lowest rates in developing countries in South-East Asia, including India, possibly attributable to key differences in environmental factors, genetic susceptibilities and cultural practices, as well as resource constraints in low-middle income countries precluding precise ascertainment and accurate diagnosis. The burden of CNS tumours is further compounded by the fact that they require highly specialised and skilled multidisciplinary care, including access to modern neuroimaging, neurosurgery, neuropathology and molecular biology, radiotherapy, chemotherapy and rehabilitation services, which may not be widely available in an integrated manner in large parts of the world with a large variation in clinical pathways, non-uniformity of care and resultant heterogeneity in clinical outcomes. CNS tumours encompass a heterogeneous spectrum of histopathological entities with differences in presentation, distinct molecular/genetic alterations, diverse biological behaviour and varying clinical outcomes. Survival is highly dependent on histology, grade and molecular biology, but varies widely across continents, even for the same tumour type and grade. In general, survival is higher in children with primary brain tumours than in adults, largely due to the differences in histological distribution across age groups. However, there is widespread variability, with 5-year survival for paediatric brain tumours being <40% in some low-middle income countries compared with 70-80% in the developed world. This review compares the descriptive epidemiology and clinical outcomes of primary brain tumours between the East and the West that pose unique challenges but also provide new opportunities in contemporary neuro-oncological practice.

Clinicopathological profile of paroxysmal nocturnal haemoglobinuria clone-positive aplastic anaemia paediatric patients-A single centre study from North India

INTRODUCTION

There is a paucity of literature related to the prevalence of Paroxysmal Nocturnal haemoglobinuria (PNH) clones in paediatric aplastic anaemia (AA) patients.

METHODS

We performed a retrospective analysis over a period of 42 months to study the prevalence of PNH clones in paediatric (age less than 18 years) AA cases, using Fluorescein-labelled proaerolysin-based flow cytometric screening and analysed their clinico-pathological features.

RESULTS

PNH clone was identified in 100 (33.2%) of the 301 patients screened. These were comprised of 51 cases of non-severe AA, 33 cases of severe AA and 16 cases of very severe AA. The median age was 13 years with an M:F ratio of 2.5:1. The median clone size (taken as the proportion of PNH-positive neutrophils) was 2.15% (range: 0.05%-93.1%). Although a majority of patients (n = 77) had a clone size of less than 10%, a significant proportion (n = 23) did harbour a clone size of more than 10%. Evidence of haemolysis was observed in 3 patients, all of them having a clone size of more than 10%. Interestingly, 1 patient with dural sinus thrombosis harboured a clone size of 1.25% only. Chromosomal breakage analysis was performed in 61 patients, none of which was positive. Complete and partial response to immunosuppressive therapy was found in 55.1% patients (16/29).

CONCLUSION

There is a high prevalence of PNH clones in paediatric AA patients, which in a majority of cases are of small clone sizes. The use of immunosuppressive therapy does not show a better outcome as compared to PNH-negative cases.

The Prevention and Therapy of Osteoporosis: A Review on Emerging Trends from Hormonal Therapy to Synthetic Drugs to Plant-Based Bioactives

Osteoporosis is one of the major health problems worldwide. It is characterized by increased bone fragility and loss of bone matter due to the action of osteoclast cells, which are associated with modified hormone levels and factors such as aging. Bisphosphonates are the primary treatment for osteoporosis. Apart from bisphosphonates, hormone therapy, calcitonin treatment, selective estrogen receptor modulators (SERMs), and strontium ranelate (SR) are some of the other treatments available for osteoporosis. However, these treatments have some side effects, such as oily skin, fluid retention, nausea, long-term toxicity, and even prostate cancer in males, and thus natural therapies that incur fewer side effects are sought. Phytochemicals, antioxidants, and other plant-based bioactives are important in the human diet. They are abundant in fruits and help against various chronic diseases, including bone disorders. Other providers of these important compounds are the medicinal plant parts. In this article, we highlight the various species of plants and herbs that are useful for the treatment of osteoporosis. The prospect of using these plant-based bioactives in amelioration of osteoporosis as an alternative to hormonal and synthetic drug-based therapy is also discussed.

A case series of salvage CCNU in high-grade glioma who have previously received temozolomide from a tertiary care institute in Mumbai

INTRODUCTION

In our center, we routinely use CCNU (Lomustine) as salvage treatment in high-grade glioma patients who cannot afford bevacizumab. This exploratory analysis was done to report the efficacy and toxicity associated with this regimen.

METHODS

Patients who were treated with salvage CCNU (postexposure to temozolomide) between January 2015 and August 2016 were included for this retrospective analysis. SPSS version 16 was used for this analysis. Time-to-event analysis was performed using the Kaplan-Meier method. Progression-free survival (PFS) and overall survival (OS) were estimated. The maximum grade of toxicity during salvage CCNU was noted in accordance with CTCAE version 4.02.

RESULTS

In the stipulated period, 16 patients were selected for the analysis. The median age of patients was 43 years (range 15-63 years), and 12 (80.0%) patients were males. The Eastern Cooperative Oncology Group performance status was 0-1 in 11 patients (73.3%) and 2-4 in 4 patients (26.7%). The tumor histopathology at diagnosis was glioblastoma in ten patients (66.6%), anaplastic astrocytoma in four (26.7%) patients, and anaplastic oligodendroglioma in one patient (6.7%). Grade 3-4 myelosuppression was seen in five patients (33.3%). The median PFS and OS were 192 days (95% confidence interval [CI]: 156.0-227.5 days) and 282 days (95% CI: 190.9-373.1 days), respectively.

CONCLUSION

CCNU is associated with modest treatment outcomes in recurrent/relapsed high-grade gliomas. The high rate of myelosuppression is a concern. Urgent efforts are required to improve upon these results.