A prospective study to assess the predictive factors of radiation-induced oral mucositis in head-and-neck carcinoma and its impact on treatment outcome: Long-term results and lessons learned

Background: Radiation-induced oral mucositis (RIOM) is one of the major dose-limiting toxicities in head-and-neck cancer patients. It is due to normal tissue damage by radiation. It is a potential hazard to treatment delivery as it threatens to alter the therapeutic ratio. The radiation oncologist must find a way to balance between tumor control and sparing of normal mucosa to validate the age-old principle of cancer treatment. The onus lies on them to find the contributory factors to curb them accordingly. Objective: The objective of the study was as follows: (1) To find out the factors associated with RIOM in head-neck squamous cell cancer (HNSCC) and (2) to assess the impact of the RIOM on treatment outcome. Materials and Methods: This was a single-institutional, prospective, non-randomized, and open-label study. All cases were treated after informed consent and tumor board approval. This was an observational study with standard treatment according to the stage of the disease. Results: Tumor site, poor oral hygiene, modality of radiation, addiction, and fractionation appeared to be the significant predictive factors of RIOM in HNSCC. Conclusion: This study helps to identify the contributory factors and gives a comprehensive understanding of the same. More multi-institutional subsite-specific studies are warranted to validate the same.

Comparison of plasma adipocytokines & C-reactive protein levels in healthy schoolgoing adolescents from private & government-funded schools of Delhi, India

Background & objectives: Obesity-mediated chronic inflammatory state is primarily governed by lifestyle and food habits in adolescents and marked by alterations in the level of various inflammatory markers. This cross-sectional study was aimed to compare the inflammatory status of healthy Indian adolescents vis-�-vis their obesity profile. The inflammatory state of urban adolescents attending private and government-funded schools, and the relationship between inflammatory marker levels and anthropometric indices in the study participants from both groups were examined. Methods: A total of 4438 study participants (10-17 yr) were chosen from various schools of Delhi, India, and their anthropometric parameters were measured. Plasma adipocytokines (adiponectin, leptin and resistin) of the study participants were measured by enzyme-linked immunosorbent assay, and plasma C-reactive protein (CRP) levels were assayed by a biochemical analyzer. Metabolic syndrome-related risk factors such as waist circumference, hip circumference (HC), fasting glucose, fasting insulin, Homeostatic Model Assessment of Insulin Resistance, total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol and triglycerides of normal-weight adolescents were also evaluated. Results: The level of leptin and CRP increased with increasing adiposity, whereas adiponectin levels were found to be negatively related to obesity. All plasma cytokine levels (adiponectin, leptin and resistin) were significantly elevated in female than male adolescents. Age-based classification revealed a distinct trend of variability in the levels of all the inflammatory markers among adolescents of varying age groups. Significant differences were observed between private and government schoolgoing adolescents in terms of anthropometric and inflammatory parameters, with higher adiposity indices in the former group. The relationship of plasma adipokine and CRP levels with various adiposity indices was found to be distinctly different between private and government schoolgoing students. Interpretation & conclusions: Inflammatory markers were significantly elevated in overweight/obese adolescents. The socio-economic condition of urban Indian schoolgoing adolescents reflecting lifestyle transition has profound effects on their adiposity indices and inflammatory states. Longitudinal studies in different regions of the country need to be done to further confirm the findings.

Is neo‑adjuvant chemotherapy a better option for management of cervical cancer patients of rural India.

OBJECTIVES: To explore alternate modality of treatment in patients of advanced cancer cervix by neo‑adjuvant chemotherapy (NACT) followed by External Beam Radiotherapy (ERT) and Brachytherapy (BT). Short‑ (6 months) and long‑ (12 months) term follow‑up data from these patients were compared with the retrospective data from an urban cancer centre, where standard protocol of concurrent chemo‑radiotherapy is practiced. MATERIALS AND METHODS: Two hundred patients of advanced cervical cancer, treated at our rural cancer centre between January 2007 and December 2007, were included in the study arm (Group A). These patients received three cycles of neo‑adjuvant chemotherapy with Cisplatin, Bleomycin, and Vincristine before External‑Beam Radiotherapy (EBT) followed by brachytherapy. Patients in the control arm (Group B) of an urban cancer centre, received EBT with weekly concomitant Cisplatin, followed by brachytherapy. Short‑ (6 months) and long‑ (12 months) term follow‑up data from our patients were compared with the retrospective data from the urban cancer centre. RESULTS AND ANALYSIS: Complete response rate was comparatively higher among patients of Group A, also correspondingly proportion of patients showing progressive disease and stable disease was lower among them. Local treatment failure was 87.5% among patients from Group A and 94.4% in Group B patients. Concomitant chemoradiation (CRT) was associated with more GI toxicities. CONCLUSION: Our result suggests NACT arm is as effective as CRT arm in respect of complete response with less pelvic failure and G.I toxicities. Further follow‑up data are needed before arriving at a definite conclusion.

Serum lipoprotein ratios as markers of insulin resistance: A study among non-diabetic acute coronary syndrome patients with impaired fasting glucose.

Background & objectives: Recent data suggest that insulin resistance can predict cardiovascular disease independently of the other risk factors, such as hypertension, visceral obesity or dyslipidaemia. However, the majority of available methods to evaluate insulin resistance are complicated to operate, expensive, and time consuming. This study was undertaken to assess whether serum lipoprotein ratios could predict insulin resistance in non-diabetic acute coronary syndrome (ACS) patients. Methods: Ninety non-diabetic patients with impaired fasting glucose admitted with a diagnosis of ACS were included in the study. At the time of admission fasting glucose and insulin concentrations were measured. The homeostatic model assessment-insulin resistance (HOMA-IR) was used for insulin resistance. The fasting serum total cholesterol (TC), triglycerides (TG) and high density lipoprotein cholesterol (HDL-C) levels were checked, and then TC/HDL-C and TG/HDL-C ratios were calculated. The areas under the curves (AUC) of the receiver operating characteristic (ROC) curves were used to compare the power of these serum lipoprotein ratios as markers. Results: Lipoprotein ratios were significantly higher in patients with HOMA-IR index > 2.5 as compared to patients with index <2.5 (P < 0.05). Both TG/HDL-C and TC/HDL-C ratios were significantly correlated with HOMA-IR (P<0.05). The area under the ROC curve of the TG/HDL-C and TC/HDL-C ratio for predicting insulin resistance was 0.80 (95% CI, 0.67 to 0.93), 0.78 (95% CI, 0.65 to 0.91), respectively. Interpretation & conclusions: The findings of this study demonstrate that serum lipoprotein ratios can provide a simple means of identifying insulin resistance and can be used as markers of insulin resistance and cardiovascular diseases risk in adult non-diabetic patients.

Enteric fever in an HIV/AIDS patient: atypical manifestations

Bloodstream infections with Salmonella typhi, is uncommon in human immunodeficiency virus [HIV]-infected persons. The symptoms in such patients are often non-specific and have a rather insidious onset and progression. We report a patient with sepsis and lower limb gangrene due to Salmonella typhi infection in an HIV-infected patient.

A histopathological study of liver and biliary remnants with clinical outcome in cases of extrahepatic biliary atresia.

Context: The indicators of poor prognosis in cases of extrahepatic biliary atresia (EHBA) continue to remain controversial. Aims: To correlate the histopathological findings of wedge biopsy from liver and tissue obtained from the shaving at the porta hepatis, during hepatic portoenterostomy, with the clinical outcome. Materials and Methods: All cases of EHBA surgically treated in our hospital from 1995 to 2006 have been reviewed. Wedge biopsies of the liver and biopsies from the porta hepatis were analyzed with hemotoxylin-eosin stains and immunohistochemistry. The parameters correlated with clinical outcomes were - presence of large bile ducts ( > 150μm diameter) in the portal tissue plaque, degree of fibrosis (semi-quantitative; graded as mild, moderate and severe), presence of ductal plate malformation (DPM) and age at operation. Results: The proportions of patients with small or large ductal diameter who remained clinically controlled (serum bilirubin < 1.5mg/dl with no evidence of end stage liver failure) were 39% and 66.6% respectively (P=0.44). There was a highly significant correlation between the extent of fibrosis and clinical outcome. Mild, moderate and severe fibrosis resulted in clinical control rates of 78.5%, 34.4% and 24% respectively (P=0.001). Ductal plate malformation was seen in 15% of our cases and was uniformly associated with poor outcome. A non-significant trend towards poorer outcome was seen with increasing age at surgery. Conclusions: Histopathological correl ations with clinical outcome in EHBA have been rarely reported from the Indian subcontinent. A greater degree of fibrosis at the time of hepatic portoenterostomy and presence of ductal plate malformation is associated with a significantly poorer clinical outcome.

Extradigital glomus tumor as a cause of chronic perianal pain.

Glomus tumor is a rare perivascular benign tumor arising from the Sucquet-Hoyer canal of the normal glomus body, most commonly in the digital areas. We report a serving soldier with such a tumor in an atypical site, the perianal region, presenting with episodic shooting pain. Total surgical excision was performed. Histopathology revealed a well-circumscribed tumor composed of clusters of monotonous polygonal cells surrounding capillary-sized blood vessels. Tumor cells also showed immunopositivity for smooth muscle antigen and vimentin. Following excision, the patient was completely relieved of pain and there was no recurrence on follow-up for 6 months.

Hepatitis C virus-related fibrosing cholestatic hepatitis in a renal transplant recipient.

Fibrosing cholestatic hepatitis (FCH) is a severe and progressive form of liver dysfunction seen in organ transplant recipients and immunosuppressed patients; it is usually associated with hepatitis B virus infection. We report 36-year-old man, a renal transplant recipient, also developed FCH with hepatitis C virus infection and succumbed to it.

A study on dyslipidaemia in subclinical hypothyroidism.

Subclinical hypothyroidism is characterised by elevated serum thyroid stimulating hormone (TSH) concentrations in association with normal free thyroid hormones. The aim of the study was to evaluate the prevalence and pattern of serum lipid alterations in patients with stable subclinical hypothyroidism in comparison to age- as well as sex-matched euthyroid group and also subgroup analysis between them in regard to age of presentation, sex, antithyroperoxidase (anti TPO) positivity, and TSH value. In this study, 100 patients of SCH were recruited, age ranged 17-68 years, majority (78%) being females, presenting mainly with non-specific symptoms and compared with 52 euthyroid control regarding lipid parameters. Of the subclinical hypothyroidism patients, only 10% had goitre and anti TPO was positive in 52% cases. Serum lipoprotein (a) above the age of 20 years, and total cholesterol, triglyceride and low density liporpotein cholesterol in the age group of 40-50 years were significantly elevated. In addition, total cholesterol, triglyceride and low density lipoprotein cholesterol levels in anti TPO positive cases and serum triglyceride and low density lipoprotein cholesterol in anti TPO negative patients showed statistically significant higher levels. In males only lipoprotein (a), but in females total cholesterol, triglyceride, low density lipoprotein cholesterol and liproprotein (a)--all were significantly elevated.

Correlation of lipid profile and carotid artery plaque as detected by Doppler ultrasound in ischaemic stroke patients--A hospital-based study.

Stroke is one of the leading causes of morbidity and mortality all over the world. Carotid plaque formation and intima media thickness can be a predictor of ischaemic stroke. In this regard studies from our country, are few and far between. This is a small hospital-based study to look in to this matter. We have assessed the intima media thickness of the common carotid as well as the internal and external carotid arteries by the ultrasound method. The lipid profiles were estimated and correlated with the intima media thickness. Results indicate that in the common as well as in the internal and external carotid arteries, the intima media thickness is a good predictor of ischaemic stroke. This thickness is also well correlated with the lipid levels in blood. Hence this non-invasive method can be used successfully to identify the high risk patients, prone to develop stroke.

Risk factor analysis in ischaemic stroke: a hospital-based study.

Stroke represents a major health burden in our country. Ischaemic stroke has got several risk factors associated with increased chance of atherosclerosis. A small hospital-based study was done to look into the risk factors associated with ischaemic stroke. Forty patients with CT-confirmed cerebral infarction were taken for the study and detailed history and clinical findings were obtained. Investigations like complete haemogram, fasting blood glucose, urea, creatinine, lipid profile, serum Lp(a), homocysteine, fibrinogen, ECG, chest x-ray, echocardiography, MRI/MRA where indicated, were done to identify the risk factors as well. Results indicated that hypertension was the most prevalent (87.5%) risk factor followed by ischaemic heart disease (35%) and diabetes. Dyslipidaemia was also found in a significant number of cases, mostly elevated LDL, low HDL and elevated Lp(a). Fibrinogen and homocysteine were of less significance.

Hepatopulmonory syndrome--an uncommon and severe complication of certain liver diseases.

Hepatopulmonary syndrome (HPS) is charaterised by arterial hypoxaemia found mainly in association with chronic liver disease (most commonly cirrhosis of liver) but also rarely with acute liver diseases like fulminant hepatic failure or Budd-Chiari syndrome. The purpose of this article is to present an uncommon but grave complication mostly associated with cirrhosis of liver and to differentiate this entry from cyanotic heart diseases or certain lung conditions. Investigations include history and physical examination, certain biochemical tests, upper gastro-intestinal (GI) endoscopy, abdominal ultrasonography, liver biopsy and venacavography in appropriate cases. Finally, the suspected cases underwent arterial blood gas (ABG) analysis and contrast enhanced echocardiography (CEE) for confirmation of the diagnosis of HPS. Of the 123 cases of cirrhosis of liver, three cases of HPS (2.4%) were found-all of them being males. Also one male patient with inferior vena cava (IVC) obstruction amongst other causes presenting with HPS was encountered. As of now, no medical treatment has been proved to be useful and liver transplant remains the only hope for this disorder.

Effect of chitosan on lipid levels when administered concurrently with atorvastatin--a placebo controlled study.

In a placebo controlled trialthe lipid lowering effects of chitosan, a unique dietary fibre, was assessed when given along with atorvastatin 10 mg in patients with chronic coronary heart disease. Altogether 100 patients were studied. They were randomly allocated in two groups of 50 patients each. Patients of group A received atorvastatin 10 mg before dinner plus 2 g/day chitosan in two divided doses. The groupB patients received atorvastatin 10 mg plus placebo. Patients were followed up for a period of 6 weeks. There was significant reduction in mean body weight in group A patients (3.14% versus 1,29% of body weight, p<0.05). There was also a significant rise in HDL cholesterol value (3.8% versus 1.07%, p=0.02) in group A patients. However, there was no significant reduction in the mean values of total cholesterol, LDL cholesterol and triglyceride in the two groups, although group A patients showed marginally lower values.

A study on micro-albuminuria--an independent risk factor for vasculopathy in diabetes mellitus.

Diabetes is becoming a serious threat to combat felt among the doctors of the world. India, in partcular is a vulnerable country contributing maximum number of cases to the global diabetic pool. Macro-and microvascular complications are important causes of mortality and morbidity. Micro-albuminuria is a surrogate marker for detetion of vasculopathy for which early detection and aggressive treatment can reduce mortality and morbidity. A small study was conducted to identify the usefulness of this marker in our setting which can be used as a cost-effective tool for detecting the dreadful complication early. This study has demonstrated that in presence of micro-albuminuria the vascular complications of diabetes definitely increase and it is more relevant in cases of type 2 diabetes irrespective of other parameters rendering it to be a independent risk factor. It also indicates that presence of this marker along with vasculopathy is time dependent ie, more the duration of the disease more is the complication.

Carotid intima media thickness: an independent marker for assessment of macrovascular risk in diabetic patients.

In view of the global epidemic of diabetes with India being the hottest reservoir of the disease, it was tried to identify carotid intima media thickness as a surrogate marker for atherosclerosis in diabetic subjects. The study becomes more relevant because diabetes is now considered a disease of the endothelium and a risk equivalent of coronary atherosclerosis (paradigm shift). The study incorporated 41 normotensive patients of diabetes and 31 age and sex matched controls. Plasma glucose and lipid profiles were assessed in all and the carotid intima media thickness was measured. Results were statistically analysed for significance and correlation coefficient between values of plasma glucose and carotid intima media thickness. Results clearly showed that carotid intima media thickness abnormality can pick up atherosclerosis even if the lipid parameters are nearly normal. So it crystallises from this small study that, as a non-invasive test carotid intima media thickness is a better and early predictor of atherosclerosis in diabetic subjects. It also revealed the linear relationship between both fasting and postprandial blood sugar with carotid intima media thickness.

Management of diabetic gastroparesis.

Diabetic gastroparesis is a long term complication of diabetes mellitus which could basically be defined as dysregulated gastric emptying leading to various pathological, biochemical and clinical changes in absence of any structural changes. Symptoms include nausea, vomiting, bloating, epigastric pain, anorexia, weight loss and so on. For symptomatic gastroparesis prokinetic drugs like metoclopramide, domperidone, cisapride, erythromycin and itcopride are used. Itopride is currently emerging as a prokinetic drug of choice. There is also scope of surgery.

Predictive efficacy of Framingham's risk score in Indian scenario--a retrospective case-control study.

To assess the predictive ability of Framingham's risk score in primary prevention in our population, 252 cases and 212 age and sex matched controls were taken up for study. Those patients, who were presenting for the first time with acute coronarysyndrome (ACS) and who did not have any prior manifestations of coronary artery disease (CAD) and whose medical records were available formed the patient group. Framingham's risk score was calculated and the corresponding 10 years risk was assessed in each of them. The patients and controls were divided into two groups--diabetic and non-diabetic. Depending on the 10 years risk, they were further grouped into high risk (10 years risk > 20%), moderately high risk (10 years risk 10 to 20%) and low risk (10 years risk less than 10%). Results were compared and statistically analysed. In the diabetic patients with ACS 14% would have qualified as high risk, 33% as moderately high risk and 53% as low risk whereas in diabetic patients without any manifestation of CAD the distribution was 4% in the high risk, 54% in the moderately high risk and 42% in the low risk. In the non-diabetic subjects, amongst the patients of ACS, 20% would have been in high risk, 39% in moderately high risk and 41% in the low risk. The corresponding figures in the non-diabetic control subjects were 10% in high risk, 22% in the moderately high risk and 68% in the low risk. In the non-diabetic subjects, the mean risk was significantly more in patients than in controls (14.15% versus 8.61%, p <0.01). However, in the diabetic patients there was no significant difference in the mean projected risk between patients with ACS and patients without any manifestation of CAD (11.37% versus 10.41%, p>0.05).

Comparative evaluation of diabetic and non-diabetic stroke--effect of glycaemia on outcome.

Though there are extensive data on diabetic retinopathy, neuropathy and peripheral vascular disease, there are not enough data on diabetic stroke. Present study was carried out to evaluate distinctive feature of diabetic and non-diabetic stroke and to compare early mortality between two groups. Four hundred and fifty consecutive stroke cases categorised into group I of 171 known diabetic and 279 non-diabetics. Reactive hyperglycaemia seen in cases with HbA1c below 7.0% were put into group II. Patients were evaluated clinically. Evidence of peripheral vascular disease, retinopathy and other target organ damage were assessed. Glycaemic parameters monitored include fasting plasma glucose (FPG), random plasma glucose (RPG) and HbA1c. Total serum cholesterol was taken as the main risk factor in both groups though lipid profile was done in all cases. CT scan was done in all cases and a repeat one when needed. Out of 450 cases 171 were diabetic and 279 cases were non-diabetic. There was female preponderance in diabetic. Average age of diabetic stroke was lower than non-diabetic, 51.2 years as against 67 years. History of previous stroke was higher in diabetic (15.8%) than non-diabetic (5.7%). There was higher incidence of transient ischaemic attack in diabetic (22.8%) than non-diabetic (7.5%), which was highly significant (p<0.001). Hypertension and hypercholesterolaemia (> 175 mg/dl) were two important risk factors in 70.9% and 30.9% respectively in group I compared to 47.6% and 21.1 % respectively in group II, both of which are significant (p<0.001). Ischaemic stroke were higher in group I(69%) as compared to group II (45.8%) which was significant (p<0.001). Lacunar infarct were more in group I (73.7%) than group II (61.7%). Haemorrhagic stroke was higher in group II (52.7%) than in group I (30.4%). Apart from recent event CT scan showed evidence of old lacunar infarct in 36.8% cases of group I compared to 21.1% of group II. During follow-up mortality within 4 weeks was higher in haemorrhagic stroke of group I (55.8%) compared to 49.6% in group II which is significant (p<0.05). For ischaemic stroke mortality in group I was 26.3% compared to 14.8% in group II which is very significant (p<0.001). Out of total mortality in group I, 35.08% had high HbA1c. Increased risk of stroke in diabetic is probably related to hypertension and lipid abnormalities. Increased mortality from abnormal glycaemic control needs to be evaluated further.