Effects of sanitation and hygiene perceptions on international travelers' health, travel plans and trip experiences in India.

Background: International travelers often experience travelers' diarrhea. However, there is paucity of data on whether self-reported gastrointestinal symptoms influence travelers' perceptions of adequacy of sanitation and hygiene services encountered during travel, and to what degree their travel plans, and overall trip experience are impacted. Methods: A cross-sectional face-to-face survey was conducted amongst international travelers in India. Data collected included socio-demographics, travel characteristics, self-reported occurrence and frequency/severity of gastrointestinal symptoms, perceptions of sanitation and hygiene encountered, and adverse effects of symptoms on travel plans and trip experiences. Chi-square tests and logistic regression were performed to describe differences and associations between categorical variables. Results: Of the 300 international travelers surveyed, 46.3% experienced diarrhea. At least two thirds of travelers perceived the quality of sanitation (67.0%) and hygiene (70.0%) encountered to be inadequate. Perceptions of inadequate sanitation (adjusted OR = 3.0; 95% CI 1.7-5.5) and poor hygiene (adjusted OR = 7.7; 95% CI 4.1-15.5) were higher among travelers who experienced diarrhea. Additionally, both higher likelihood of travel plans being affected (adjusted OR = 10.7; 95% CI 5.1-23.6) and adverse impacts on overall trip experience (adjusted OR = 2.8; 95% CI 1.4-5.8) were reported among those who experienced diarrhea. Conclusions: More than two thirds of travelers surveyed in India experienced inadequate sanitation and hygiene services, with perceptions influenced by occurrence and frequency of diarrhea. Self-reported diarrhea was also associated with adverse effects on travel plans and overall trip experience. While these results may seem intuitive, they have important implications and suggest that improving sanitation and hygiene standards in India could potentially enhance tourism.

Tumor radiomic features complement clinico-radiological factors in predicting long-term local control and laryngectomy free survival in locally advanced laryngo-pharyngeal cancers.

OBJECTIVE: To study if pre-treatment CT texture features in locally advanced squamous cell carcinoma of laryngo-pharynx can predict long-term local control and laryngectomy free survival (LFS). METHODS: Image texture features of 60 patients treated with chemoradiation (CTRT) within an ethically approved study were studied on contrast-enhanced images using a texture analysis research software (TexRad, UK). A filtration-histogram technique was used where the filtration step extracted and enhanced features of different sizes and intensity variations corresponding to a particular spatial scale filter (SSF): SSF = 0 (without filtration), SSF = 2 mm (fine texture), SSF = 3-5 mm (medium texture) and SSF = 6 mm (coarse texture). Quantification by statistical and histogram technique comprised mean intensity, standard-deviation, entropy, mean positive pixels, skewness and kurtosis. The ability of texture analysis to predict LFS or local control was determined using Kaplan-Meier analysis and multivariate cox model. RESULTS: Median follow-up of patients was 24 months (95% CI:20-28). 39 (65%) patients were locally controlled at last follow-up. 10 (16%) had undergone salvage laryngectomy after CTRT. For both local control & LFS, threshold optimal cut-off values of texture features were analyzed. Medium filtered-texture feature that were associated with poorer laryngectomy free survival were entropy ≥4.54, (p = 0.006), kurtosis ≥4.18; p = 0.019, skewness ≤-0.59, p = 0.001, and standard deviation ≥43.18; p = 0.009). Inferior local control was associated with medium filtered features entropy ≥4.54; p 0.01 and skewness ≤ - 0.12; p = 0.02. Using fine filters, entropy ≥4.29 and kurtosis ≥-0.27 were also associated with inferior local control (p = 0.01 for both parameters). Multivariate analysis showed medium filter entropy as an independent predictor for LFS and local control (p < 0.001 & p = 0.001). CONCLUSION: Medium texture entropy is a predictor for inferior local control and laryngectomy free survival in locally advanced laryngo-pharyngeal cancer and this can complement clinico-radiological factors in predicting prognosticating these tumors. ADVANCES IN KNOWLEDGE: Texture features play an important role as a surrogate imaging biomarker for predicting local control and laryngectomy free survival in locally advanced laryngo-pharyngeal tumors treated with definitive chemoradiation.

Case Reports on Metaplastic Squamous Cell Carcinoma of the Breast and Treatment Dilemma.

Metaplastic squamous cell carcinoma of the breast is a very rare form of breast cancer that consists of both glandular and nonglandular components mixed with epithelial and mesenchymal tissues. Worldwide, the incidence of this tumor is between 0.1 and 2%. Because of the rarity of this tumor and heterogeneous behavior of the tumor cells, it is difficult to establish the standard therapeutic approach. We report 2 cases of metaplastic squamous cell carcinoma of the breast in young patients with different responses to treatment strategies. The first case is a premenopausal female with metaplastic squamous cell carcinoma treated with surgery, chemotherapy, and radiotherapy, and the second case is perimenopausal metaplastic squamous cell carcinoma with sarcomatoid subtype and osteoid matrix production which progressed on chemotherapy and was treated with surgery and radiation.

Uncommon Presentation of Metastatic Squamous Cell Carcinoma of the Skin and Treatment Challenges.

BACKGROUND Squamous cell carcinoma is one of the most common keratinocytic skin cancers, the other being basal cell carcinoma. It is the second most common skin cancer after melanoma. Cutaneous squamous cell carcinoma is mostly a localized disease. The metastatic presentation is rare even in the presence of invasive disease. The metastatic potential depends on the presence of high-risk features at the time of diagnosis. Lung, liver, and bone are the frequent sites of metastasis. Local and locoregional disease undergoes excision with or without adjuvant radiation. However, we lack proper treatment paradigms for this metastatic disease. CASE REPORT We are reporting a case of an elderly female with a history of high-risk localized cutaneous squamous cell carcinoma treated with complete local excision and radiation presenting 5 years later with extensive disease to the lung and liver, abdominal nodes, and spinal fracture. The patient was not a candidate for chemotherapy due to kidney failure. On the basis of ongoing separate trials on different immunotherapies, she was started on nivolumab. CONCLUSIONS Treating metastatic cutaneous squamous cell carcinoma is a challenge considering the absence of phase III trials due to the rarity of this disease. Historically, platinum with or without 5-FU (fluorouracil), bleomycin, doxorubicin, and retinoic acid were used with variable responses. Data on epidermal growth factor receptor (EGFR) inhibitors on EGFR expressing tumors are available. However, even with the most recent reports on immunotherapy in patients with high programmed death-1 expression or high mutation burden, it is difficult to achieve good response.

Multi-catheter interstitial brachytherapy for partial breast irradiation: an audit of implant quality based on dosimetric evaluation comparing intra-operative versus post-operative placement.

PURPOSE: The use of multicatheter interstitial brachytherapy (MIB) for accelerated partial breast irradiation (APBI) in early breast cancer (EBC) patients outside the trial setting has increased. Hence, there is a need to critically evaluate implant quality. Moreover, there is a scarcity of reports using an open cavity technique. We report the dosimetric indices of open and closed cavity MIB techniques. MATERIAL AND METHODS: The dosimetric parameters of 60 EBC patients treated with MIB (open and closed cavity) who underwent three dimensional, computerized tomography (CT) based planning for APBI from November 2011 to July 2015 were evaluated. Coverage Index (CI), Dose Homogeneity Index (DHI), Conformity Index (COIN), Plan Quality Index (PQI), and Dose Non-uniformity Index (DNR) were assessed. RESULTS: Forty-one patients underwent open cavity and 19 patients underwent closed cavity placement of brachytherapy catheters. The median number of planes was 4 and median number of needles was 20. Median dose was 34 Gy with dose per fraction of 3.4 Gy, given twice a day, 6 hours apart. The D90 of the cavity and clinical target volume (CTV) were 105% and 89%, respectively. The median doses to the surgical clips were greater than 100%. The median CI of the cavity and CTV was 0.96 and 0.82, respectively. The DHI and COIN index of the CTV was 0.73 and 0.67. There were no significant differences in the dosimetric parameters based on whether the technique was done open or closed. CONCLUSIONS: Critical evaluation of the dosimetric parameters of MIB-APBI is important for optimal results. While the open and closed techniques have similar dosimetry, our institutional preference is for an open technique which eases the procedure due to direct visualization of the tumor cavity.

Composite risk factors predict survival after transplantation for congenital heart disease.

OBJECTIVE(S): Previous studies have shown that individual risk factors are poor predictors of mortality after heart transplantation in patients with congenital heart disease. We developed composite risk factor groups to better predict mortality after cardiac transplantation. METHODS: We conducted a cross-sectional retrospective analysis of all heart transplants performed for congenital heart disease at a single congenital heart transplant center between 1996 and 2011. Patient, procedural, and hospital course data were obtained through a review of medical records. Univariate analyses were performed using the Fisher exact test for categorical data and the Mann-Whitney U test for continuous variables. Overall mortality was examined using Kaplan-Meier estimates for univariate analysis and Cox regression analysis for multivariate analysis. A comparison of patients with functional single ventricles (SVs) versus biventricular (BV) hearts was performed. Mean follow-up duration for the whole group was 51 ± 43 months (median, 43 months). RESULTS: Forty-six patients underwent heart transplantation during the study period. Mean age at transplant was 9.0 ± 9.1 years; 45% (n = 21) were in the SV group and 55% (n = 25) were in the BV group. The SV group had significantly more previous sternotomies (P = .006) and longer bypass times (266 ± 78 vs 207 ± 64 minutes; P = .001). High panel-reactive antibody levels (>10%) were also more common in the SV group (38% vs 13%; P = .08). Overall hospital mortality was 4.3% (n = 2, both SVs). There was no significant difference in operative mortality (10% SV vs 0% BV; P = .20) or major morbidity (33% SV vs 44% BV; P = .51) between the 2 groups. High-risk groups identified by univariate analysis were patients with an SV diagnosis + dialysis (P < .0005), SV + mechanical assist device (VAD)/extracorporeal membrane oxygenation (ECMO) (P = .026), or VAD/ECMO + renal insufficiency (P = .006)/VAD/ECMO + dialysis (P < .0005), and SV + reoperation (P = .016). By multivariate analysis, preoperative renal insufficiency (P = .038) and the composite SV + dialysis (P = .005) were predictors of overall mortality. Although survival at 2 years was lower in the SV cohort (73% vs 96%; P = .16), this benefit was not apparent (63% vs 69%) at late follow-up. CONCLUSIONS: Preoperative renal insufficiency and SV + dialysis are strong predictors of overall mortality and identify high-risk congenital heart transplant recipients. Although individual risk factors may not predict survival, a composite of factors may be more useful in identifying the high-risk recipient.