Atherosclerosis is a multi-factorial disease involving the interplay of genetic and environmental factors. Studies highlighting the public health importance of risk factors like chronic infections causing acute myocardial infarction (AMI) in the Indian context are scarce. This study was undertaken to study the association of socio-demographic and life-style factors with acute myocardial infarction in central India.
Materials and Methods:
The cases and controls were group-matched for age, gender, and socio-economic status. A blinded research associate administered the study questionnaire. We performed an unconditional multiple logistic regression analysis.
The case-control study included 265 cases of AMI and 265 controls. The results of final model of logistic regression analysis for risk factors of AMI included 11 risk factors at α = 0.05. They were waist hip ratio, body mass index, stress at home in last 1 year, hypertension, family history of CHD, past history of gingival sepsis, tobacco smoking, raised total serum cholesterol, Chlamydia pneumoniae, Helicobacter pylori and raised C-reactive protein.
The findings confirm the role of conventional risk factors for cardiac disease and highlight need for research into the association between chronic infections with AMI.
Atherosclerosis; acute myocardial infarction; risk factors
Models of the diffusion-weighted signal are of strong interest for population studies of the brain microstructure. These studies are typically conducted by extracting a scalar property from the model and subjecting it to null hypothesis statistical testing. This process has two major limitations: the reported p-value is a weak predictor of the reproducibility of findings and evidence for the absence of microstructural alterations cannot be gained. To overcome these limitations, this paper proposes a Bayesian framework for population studies of the brain microstructure represented by multi-fascicle models. A hierarchical model is built over the biophysical parameters of the microstructure. Bayesian inference is performed by Hamiltonian Monte Carlo sampling and results in a joint posterior distribution over the latent microstructure parameters for each group. Inference from this posterior enables richer analyses of the brain microstructure beyond the dichotomy of statistical testing. Using synthetic and in-vivo data, we show that our Bayesian approach increases reproducibility of findings from population studies and opens new opportunities in the analysis of the brain microstructure.
Microstructure; Diffusion Imaging; Bayesian Inference
Health systems globally are experiencing a shortage of competent public health professionals. Public health education across developing countries is stretched by capacity generation and maintaining an adequate ‘standard’ and ‘quality’ of their graduate product. We analyzed the Indian public health education scenario using the institutional and instructional reforms framework advanced by the Lancet Commission report on Education of Health Professionals. The emergence of a new century necessitates a re-visit on the institutional and instructional challenges surrounding public health education. Currently, there is neither an accreditation council nor a formal structure or system of collaboration between academic stakeholders. Health systems have little say in health professional training with limited dialogue between health systems and public health education institutions. Despite a recognized shortfall of public health professionals, there are limited job opportunities for public health graduates within the health system and absence of a structured career pathway for them. Public health institutions need to evolve strategies to prevent faculty attrition. A structured development program in teaching–learning methods and pedagogy is the need of the hour.
public health education in India; public health education reforms; future of public health education; public health professionals; education of health professionals
Imaging and delineation of the optic radiations (OpR) remains challenging, despite repeated attempts to achieve reliable validated tractography of this complex structure. Previous studies have used varying methods to generate representations of the OpR which differ markedly from one another and, frequently, from the OpR’s known structure. We systematically examined the influence of a key variable that has differed across previous studies, the tractography seed region, in 13 adult participants (9 male; mean age 31 years; sd. 8.7 years; range 16–47). First we compared six seed regions at the lateral geniculate nucleus (LGN) and sagittal stratum based on the literature and known OpR anatomy. Three of the LGN regions seeded streamlines consistent with the OpR’s three ‘bundles’ while a fourth seeded streamlines consistent with each of the three bundles. The remaining two generated OpR streamlines unreliably and inconsistently. Two stratum regions seeded the radiations. This analysis identified a set of optimal ROI for seeding OpR tractography and important inclusion and exclusion ROI. An optimized approach was then used to seed LGN regions to the stratum. The radiations, including streamlines consistent with Meyer’s Loop, were streamlined in all cases. Streamlines extended 0.2±2.4mm anterior to the tip of the anterior horn of the lateral ventricle. These data suggest some existing approaches likely seed representations of the OpR that are visually plausible but do not capture all OpR components, and that using an optimized combination of regions seeded previously allows optimal mapping of this complex structure.
Diffusion-weighted MRI; DWI; tractography; optic radiations; Meyer’s Loop
The purpose of this study was to examine the relationship between language pathways and autism spectrum disorders (ASDs) in patients with tuberous sclerosis complex (TSC). An advanced diffusion-weighted magnetic resonance imaging (MRI) was performed on 42 patients with TSC and 42 age-matched controls. Using a validated automatic method, white matter language pathways were identified and microstructural characteristics were extracted, including fractional anisotropy (FA) and mean diffusivity (MD). Among 42 patients with TSC, 12 had ASD (29%). After controlling for age, TSC patients without ASD had a lower FA than controls in the arcuate fasciculus (AF); TSC patients with ASD had even a smaller FA, lower than the FA for those without ASD. Similarly, TSC patients without ASD had a greater MD than controls in the AF; TSC patients with ASD had even a higher MD, greater than the MD in those without ASD. It remains unclear why some patients with TSC develop ASD, while others have better language and socio-behavioral outcomes. Our results suggest that language pathway microstructure may serve as a marker of the risk of ASD in TSC patients. Impaired microstructure in language pathways of TSC patients may indicate the development of ASD, although prospective studies of language pathway development and ASD diagnosis in TSC remain essential.
arcuate fasciculus; diffusion tensor imaging; neuroanatomy; tractography; white matter
In this article, the authors aim to introduce the nonradiologist to
diffusion tensor imaging (DTI) and its applications to both clinical and
research aspects of tuberous sclerosis complex. Tuberous sclerosis complex is a
genetic neurocutaneous syndrome with variable and unpredictable neurological
comorbidity that includes refractory epilepsy, intellectual disability,
behavioral abnormalities and autism spectrum disorder. DTI is a method for
modeling water diffusion in tissue and can noninvasively characterize
microstructural properties of the brain. In tuberous sclerosis complex, DTI
measures reflect well-known pathological changes. Clinically, DTI can assist
with detecting the epileptogenic tuber. For research, DTI has a putative role in
identifying potential disease biomarkers, as DTI abnormalities of the white
matter are associated with neurocognitive morbidity including autism. If indeed
DTI changes parallel phenotypical changes related to the investigational
treatment of epilepsy, cognition and behavior with mTOR inhibitors, it will
facilitate future clinical trials.
autism spectrum disorders; behavior; cognition; diffusion tensor imaging; epilepsy; MRI; mTOR serine–threonine kinases; tuberous sclerosis complex
Diffusion-weighted imaging (DWI) enables investigation of the brain microstructure by probing natural barriers to diffusion in tissues. In this work, we propose a novel generative model of the DW signal based on considerations of the tissue microstructure that gives rise to the diffusion attenuation. We consider that the DW signal can be described as the sum of a large number of individual homogeneous spin packets, each of them undergoing local 3-D Gaussian diffusion represented by a diffusion tensor. We consider that each voxel contains a number of large scale microstructural environments and describe each of them via a matrix-variate Gamma distribution of spin packets. Our novel model of DIstribution of Anisotropic MicrOstructural eNvironments in DWI (DIAMOND) is derived from first principles. It enables characterization of the extra-cellular space, of each individual white matter fascicle in each voxel and provides a novel measure of the microstructure heterogeneity. We determine the number of fascicles at each voxel with a novel model selection framework based upon the minimization of the generalization error. We evaluate our approach with numerous in-vivo experiments, with cross-testing and with pathological DW-MRI. We show that DIAMOND may provide novel biomarkers that captures the tissue integrity.
Human basal-like breast cancer (BLBC) is an enigmatic and aggressive malignancy with a poor prognosis. There is an urgent need to identify therapeutic targets for BLBC because current treatment modalities are limited and not effective. The forkhead box transcription factor FOXC1 has recently been identified as a critical functional biomarker for BLBC. However, how it orchestrates BLBC cells was not clear. Here we show that FOXC1 activates the transcription factor NF-κB in BLBC cells by increasing p65/RelA protein stability. High NF-κB activity has been associated with estrogen receptor-negative breast cancer, particularly BLBC. The effect of FOXC1 on p65/RelA protein stability is mediated by increased expression of Pin1, a peptidyl-prolyl isomerase. FOXC1 requires NF-κB for its regulation of cell proliferation, migration, and invasion. Notably, FOXC1 overexpression renders breast cancer cells more susceptible to pharmacologic inhibition of NF-κB. These results suggest that BLBC cells may rely on FOXC1-driven NF-κB signaling. Interventions of this pathway may provide modalities for the treatment of BLBC.
basal-like breast cancer; FOXC1; NF-κB; p65/RelA; Pin1; protein stability
In planning for a potentially curative resection of the epileptogenic zone in patients with pediatric epilepsy, invasive monitoring with intracranial EEG is often used to localize the seizure onset zone and eloquent cortex. A precise understanding of the location of subdural strip and grid electrodes on the brain surface, and of depth electrodes in the brain in relationship to eloquent areas is expected to facilitate pre-surgical planning.
We developed a novel algorithm for the alignment of intracranial electrodes, extracted from post-operative CT, with pre-operative MRI. Our goal was to develop a method of achieving highly accurate localization of subdural and depth electrodes, in order to facilitate surgical planning. Specifically, we created a patient-specific 3D geometric model of the cortical surface from automatic segmentation of a pre-operative MRI, automatically segmented electrodes from post-operative CT, and projected each set of electrodes onto the brain surface after alignment of the CT to the MRI. Also, we produced critical visualization of anatomical landmarks, e.g. vasculature, gyri, sulci, lesions or eloquent cortical areas, which enables the epilepsy surgery team to accurately estimate the distance between the electrodes and the anatomical landmarks, which might help for better assessment of risks and benefits of surgical resection.
Electrode localization accuracy was measured using knowledge of the position of placement from 2D intra-operative photographs in ten consecutive subjects who underwent intracranial EEG for pediatric epilepsy. Average spatial accuracy of localization was 1.31±0.69mm for all 385 visible electrodes in the photos.
In comparison to previously reported approaches, our algorithm is able to achieve more accurate alignment of strip and grid electrodes with minimal user input. Unlike manual alignment procedures, our algorithm achieves excellent alignment without time consuming and difficult judgements from an operator.
Pediatric Epilepsy; Intracranial EEG; Electrode Localization; Epilepsy Surgery Planning
Refractory status epilepticus is a potentially life-threatening medical emergency. It requires early diagnosis and treatment. There is a lack of consensus upon its semantic definition of whether it is status epilepticus that continues despite treatment with benzodiazepine and one antiepileptic medication (AED), i.e., Lorazepam + phenytoin. Others regard refractory status epilepticus as failure of benzodiazepine and 2 antiepileptic medications, i.e., Lorazepam + phenytoin + phenobarb. Up to 30% patients in SE fail to respond to two antiepileptic drugs (AEDs) and 15% continue to have seizure activity despite use of three drugs. Mechanisms that have made the treatment even more challenging are GABA-R that is internalized during status epilepticus and upregulation of multidrug transporter proteins. All patients of refractory status epilepticus require continuous EEG monitoring. There are three main agents used in the treatment of RSE. These include pentobarbital or thiopental, midazolam and propofol. RSE was shown to result in mortality in 35% cases, 39.13% of patients were left with severe neurological deficits, while another 13% had mild neurological deficits.
Midazolam; pentobarb; propofol; refractory status epilepticus; status epilepticus
Magnetoencephalography (MEG) is the measurement of the magnetic field generated by the electrical activity of neurons. It is usually combined with a magnetic resonance imaging to get what is called magnetic source imaging. The technology that has helped record these minute magnetic fields is super-conducting quantum interference detector which is like a highly sensitive magnetic field meter. To attenuate the external magnetic noise the MEG is housed inside a magnetically shielded room. The actual sensors recording magnetic fields are magnetometers and/or gradiometers. MEG fields pass through the head without any distortion. This is a significant advantage of MEG over electroencephalography. MEG provides a high spatial and temporal resolution. The recording and identification information should be according to the American Clinical Magnetoencephalography Society guidelines published in 2011. MEG currently has two approved indications in the United States, one is for pre-operative brain mapping and the other is for use in epilepsy surgery. MEG studies have shown functional brain tissue inside brain tumors.
Cortical mapping; epilepsy; magnetic source imaging; magnetoencephalography
India faces a formidable burden of neonatal deaths, and quality newborn care is essential for reducing the high neonatal mortality rate. We examined newborn care services, with a focus on essential newborn care (ENC) in two districts, one each from two states in India. Nagaur district in Rajasthan and Chhatarpur district in Madhya Pradesh were included. Six secondary-level facilities from the districts─two district hospitals (DHs) and four community health centres (CHCs) were evaluated, where maximum institutional births within districts were taking place. The assessment included record review, facility observation, and competency assessment of service providers, using structured checklists and sets of questionnaire. The domains assessed for competency were: resuscitation, provision of warmth, breastfeeding, kangaroo mother care, and infection prevention. Our assessments showed that no inpatient care was being rendered at the CHCs while, at DHs, neonates with sepsis, asphyxia, and prematurity/low birthweight were managed. Newborn care corners existed within or adjacent to the labour room in all the facilities and were largely unutilized spaces in most of the facilities. Resuscitation bags and masks were available in four out of six facilities, with a predominant lack of masks of both sizes. Two CHCs in Chhatarpur did not have suction device. The average knowledge score amongst service providers in resuscitation was 76% and, in the remaining ENC domains, was 78%. The corresponding average skill scores were 24% and 34%, highlighting a huge contrast in knowledge and skill scores. This disparity was observed for all levels of providers assessed. While knowledge domain scores were largely satisfactory (>75%) for the majority of providers in domains of kangaroo mother care and breastfeeding, the scores were only moderately satisfactory (50-75%) for all other knowledge domains. The skill scores for all domains were predominantly non-satisfactory (<50%). The findings underpin the need for improving the existing ENC services by making newborn care corners functional and enhancing skills of service providers to reduce neonatal mortality rate in India.
Clinical competence; Health facilities; Health personnel; Newborn care; Process assessment; India
The cerebellum plays an important role in motor learning and cognition, and structural cerebellar abnormalities have been associated with cognitive impairment. In tuberous sclerosis complex, neurological outcome is highly variable, and no consistent imaging or pathological determinant of cognition has been firmly established. The cerebellum calls for specific attention as mouse models of tuberous sclerosis complex have demonstrated a loss of cerebellar Purkinje cells and cases of human histological data have demonstrated a similar loss in patients. We hypothesized that there might be a common cerebellar finding in tuberous sclerosis complex that could be measured as morphometric changes with magnetic resonance imaging. Using a robust, automated image analysis procedure, we studied 36 patients with tuberous sclerosis complex and age-matched controls and observed significant volume loss among patients in the cerebellar cortices and vermis. Furthermore, this effect was strongest in a subgroup of 19 patients with a known, pathogenic mutation of the tuberous sclerosis 2 gene and impacted all cerebellar structures. We conclude that patients with tuberous sclerosis complex exhibit volume loss in the cerebellum, and this loss is larger and more widespread in patients with a tuberous sclerosis 2 mutation.
Papillary carcinoma of the breast is a very rare entity accounting for approx 1 % of all breast carcinomas. The diagnosis is difficult due to different clinical and radiological features. Pathological diagnosis is conclusive. Being aware of the diagnostic difficulties and differences in management from the more commonly reported IDC, makes it easier to treat these patients. Because this is an uncommon disease, we report here 2 cases recently diagnosed and treated in our hospital. We have also reviewed the literature regarding the diagnosis, treatment and prognosis of these patients.
Papillary; Carcinoma; Breast
The aim of this study was to see the biochemical effects of pesticides on sprayers of grape gardens before and after 15 days of vitamin E supplementations in Western Maharashtra (India), who were occupationally exposed to various pesticides over a long period of time (about 5 to 15 years). Blood samples were collected from all study group subjects for biochemical parameters assays before and after 15 days of vitamin E supplementation. Sprayers of grape gardens were given 400 mg of vitamin E tablet/day for 15 days. After 15 days of vitamin E supplementation to sprayers of grape gardens, we observed significantly decreased aspartate transaminase (10.88 %, P < 0.05, r = 0.88), alanine transaminase (25.92 %, P < 0.01, r = 0.46) and total proteins (3.32 %, P < 0.01, r = 0.33), whereas, no statistically significant change was found in serum acetyl cholinesterase, C-reactive proteins, albumin (ALB), globulins and ALB/globulin ratio as compared to before vitamin E supplementation. Sprayers of grape gardens, who received vitamin E supplementation, showed significantly decreased serum lipid peroxide (LP) (18.75 %, P < 0.001, r = 0.63) and significantly increased RBC-superoxide dismutase (SOD) (12.88 %, P < 0.001, r = 0.85), RBC-Catalase (CAT) (24.49 %, P < 0.001, r = 0.70), plasma ceruloplasmin (CP) (4.6 %, P < 0.01, r = 0.80), serum zinc (4.57 %, P < 0.01, r = 0.83) and serum copper (4.37 %, P < 0.01, r = 0.79) as compared to values before vitamin E supplementation. These results showed that vitamin E supplementation has ameliorating effects on these transaminase enzymes, suggesting that it may have a protective effect on liver, from pesticides induced damage. In this study vitamin E supplementation might have decreased LP levels by breaking chain reaction of lipid peroxidation. Present results indicate that vitamin E plays a crucial role in restoring the antioxidant enzymes such as SOD, CAT and CP, in population exposed to pesticides. This helps to enhance its antioxidant ability. Therefore, it is suggested that farmers, pesticide applicators, workers in the pesticide industry and other pesticide users, who come in regular contact with pesticides, may be benefited by supplementation with vitamin E.
Acetylcholinesterase; C-reactive proteins; Aspartate transaminase; Alanine transaminase; Lipid peroxidation; Superoxide dismutase; Catalase; Ceruloplasmin; Glutathione-S-transferase
To assess changes in apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values in brainstem gliomas in children and to observe the temporal evolution of changes in the white matter tracts following therapy using diffusion tensor imaging (DTI) analysis.
Serial ADC and FA measurements were obtained in 3 patients with newly diagnosed brainstem gliomas on two approved treatment protocols. Values were compared with a set of normative ADC, FA, and eigenvalues of age-matched children of the corticospinal, transverse pontine and medial lemniscal tracts. Fiber tracking of the tracts coursing through the brainstem was performed using standard diffusion tractography analysis.
We found increased ADC values within tumor at baseline compared to age-matched controls, with subsequent drop following treatment and subsequent increase with recurrence. Correspondingly, FA values were reduced at presentation, but transiently recovered during the phase of tumor response to treatment, and finally decreased significantly during tumor progression. These changes were concordant with the tractography analysis of white matter tracts in the brainstem. Based on these results, we suggest that initial changes in ADC and FA values reflects tract infiltration by tumor, but not complete disruption, whereas tumor progression results in complete loss of anisotropy possibly due to tract disruption.
Serial changes in ADC and FA values and tractography data in pediatric brainstem gliomas suggest initial tumor infiltration, with transient improvement on treatment and subsequent loss of tract anisotropy during tumor progression. This technique may have potential use in assessing response to treatment regimens for pediatric brainstem gliomas.
MRI; diffusion tensor imaging; brainstem glioma; pediatrics
Rationale and Objectives
Tuberous Sclerosis Complex (TSC) is a genetic neurocutaneous syndrome in which cognitive and social-behavioral outcomes for patients vary widely in an unpredictable manner. The cause of adverse neurological outcome remains unclear. We investigated the hypothesis that disordered white matter and abnormal neural connectivity are associated with adverse neurological outcome.
Materials and Methods
Structural and diffusion magnetic resonance imaging was carried out in 40 subjects with TSC (age range 0.5 – 25 years, mean age 7.2 and median age 5 years), 12 of whom had autism spectrum disorders (ASD), and in 29 age-matched controls. Tractography of the corpus callosum was used to define a 3-dimensional volume of interest. Regional averages of four diffusion scalar parameters of the callosal projections were calculated for each subject. These were the average fractional anisotropy (AFA) and average mean, radial and axial diffusivity (AMD, ARD, AAD).
Subjects with TSC had significantly lower AFA and higher AMD, ARD and AAD values compared to controls. Subjects with TSC and ASD had significantly lower AFA values compared to those without ASD, and compared to controls. TSC subjects without ASD had similar AFA values compared to controls.
Diffusion tensor scalar parameters provided measures of properties of the three-dimensional callosal projections. In TSC, changes in these parameters may reflect microstructural changes in myelination, axonal integrity, or extracellular environment. Alterations in white matter microstructural properties were associated with TSC and larger changes were associated with TSC and ASD, thus establishing a relationship between altered white matter microstructural integrity and brain function.
The Indian guidelines on following up sputum smear-negative Pulmonary tuberculosis (PTB) patients differ from the current World Health Organization (WHO) guidelines in that the former recommends two follow up sputum examinations (once at the end of intensive phase and the other at the end of treatment) while the latter recommends only one follow up sputum smear microscopy examination, which is done at the end of the intensive phase. This study was conducted to examine if there was any added value in performing an additional sputum smear examination at the end of treatment within the context of a national TB program.
This study was a descriptive record based review conducted in nine tuberculosis (TB) units in Delhi, India. All consecutive new sputum smear-negative PTB patients registered in these nine TB units from 1st January 2009 to 31st December 2009 were included in the study.
Of 2567 new sputum smear-negative TB patients, 1973 (90%) had sputum specimens examined at the end of the intensive phase, of whom 36 (2%) were smear-positive: the majority (n = 28) successfully completed treatment with either the same or a re-treatment regimen. At treatment completion, 1766 (85%) patients had sputum specimens examined, of whom 16 (0.9%) were smear-positive: all these were changed to a re-treatment regimen. Amongst the sputum-positive patients identified as a result of follow up (n = 52), four were diagnosed with multi-drug resistant TB (MDR-TB), three of whom were detected after smear examination at the end of treatment.
Given the high burden of TB in India, a 0.9% additional yield of smear-positive sputum smears at the end of treatment translates to 3,297 cases of smear-positive PTB. End-of-treatment smear is a low-yield strategy for detection of smear-positive TB cases, although further studies are needed to determine its population-level impact and cost, particularly in relation to other TB control interventions.
Usually patients receive healthcare services from multiple hospitals, and consequently their healthcare data are dispersed over many facilities’ paper and electronic-based record systems. Therefore, many countries have encouraged the research on data interoperability, access, and patient authorization. This study is an important part of a national project to build an information exchange environment for cross-hospital digital medical records carried out by the Department of Health (DOH) of Taiwan in May 2008. The key objective of the core project is to set up a portable data exchange environment in order to enable people to maintain and own their essential health information.
This study is aimed at exploring the factors influencing behavior and adoption of USB-based Personal Health Records (PHR) in Taiwan.
Quota sampling was used, and structured questionnaires were distributed to the outpatient department at ten medical centers which participated in the DOH project to establish the information exchange environment across hospitals. A total of 3000 questionnaires were distributed and 1549 responses were collected, out of those 1465 were valid, accumulating the response rate to 48.83%.
1025 out of 1465 respondents had expressed their willingness to apply for the USB-PHR. Detailed analysis of the data reflected that there was a remarkable difference in the “usage intention” between the PHR adopters and non-adopters (χ2 =182.4, p < 0.001). From the result of multivariate logistic regression analyses, we found the key factors affecting patients’ adoption pattern were Usage Intention (OR, 9.43, 95%C.I., 5.87-15.16), Perceived Usefulness (OR, 1.60; 95%C.I., 1.11-2.29) and Subjective Norm (OR, 1.47; 95%C.I., 1.21-1.78).
Higher Usage Intentions, Perceived Usefulness and Subjective Norm of patients were found to be the key factors influencing PHR adoption. Thus, we suggest that government and hospitals should promote the potential usefulness of PHR, and physicians should encourage patients' to adopt the PHR.
Personal Health Records (PHR); Technology Acceptance Model (TAM); Adoption, Behavior, Taiwan
Carnivorous plants match their animal prey for speed of movements and hence offer fascinating insights into the evolution of fast movements in plants. Here, we describe the mechanics of prey capture in aquatic bladderworts Utricularia stellaris, which prey on swimming insect larvae or nematodes to supplement their nitrogen intake. The closed Utricularia bladder develops lower-than-ambient internal pressures by pumping out water from the bladder and thus setting up an elastic instability in bladder walls. When the external sensory trigger hairs on their trapdoor are mechanically stimulated by moving prey, the trapdoor opens within 300–700 μs, causing strong inward flows that trap their prey. The opening time of the bladder trapdoor is faster than any recorded motion in carnivorous plants. Thus, Utricularia have evolved a unique biomechanical system to gain an advantage over their animal prey.
carnivorous plants; Utricularia; high-speed videography
Patients with Stage IV melanoma have limited therapeutic options with few long term survivors. Our goal was to study the impact of metastasectomy on survival in these patients.
Patients with Stage IV melanoma were identified from the Surveillance, Epidemiology and End Results (SEER) database (1988–2006). Those who had metastasectomy performed were compared with patients that did not.
The median age of the study population (n= 4229) was 63 years and median survival was 7 months. Patients who underwent metastasectomy (33.6%) had an improved median and 5-year overall survival as compared to patients who did not; 12 months vs. 5 months and 16% vs. 7%, p <0.001). In patients with M1a disease (n= 1994), this improvement of survival following metastasectomy was enhanced; median survival of 14 months vs. 6 months and 5-year overall survival of 20% vs. 9% (p <0.001). Younger age and diagnosis from 2001–2006 were predictors of metastasectomy. Metastasectomy was an independent and significant predictor of survival for the entire cohort (HR 0.59, 95% CI 0.55– 0.63).
Metastasectomy in patients with Stage IV melanoma may improve long term survival. The true therapeutic benefit, if any, of metastatectomy needs to be determined by a randomized trial.
Stage IV melanoma; metastasectomy; survival
Rise of diphtheria cases in adults is a cause of concern worldwide. Pertussis is also now affecting adults. We assessed serum levels of tetanus, diphtheria and pertussis antibodies in 62 adults in Pune, India, who had missed their primary immunization. All adults were then given three doses of tetanus-diphtheria (Td) vaccine at 0, 1, and 6 months. All adults were immune to tetanus but 78% had long-term protection. For diphtheria, 88% were protected but only 9% had long term immunity. Only 60% were immune to pertussis. After three doses of the vaccine, long term immunity to both tetanus and diphtheria increased to 87% and 97%, respectively (P < 0.05). Geometric mean titres (GMT) of both antibodies also increased significantly. The vaccine caused minor local reactions and mild fever in a few subjects. There is need of three doses of Td vaccination in those Indian adults, who missed their primary immunization. Susceptibility to pertussis also needs to be further explored.
Currently, no data from randomized controlled clinical trials are available to guide the depth of resection for intermediate-thickness primary cutaneous melanoma. Thus, we hypothesized that substantial variability exists in this aspect of surgical care. We have summarized the literature regarding depth of resection and report the results of our survey of surgeons who treat melanoma. Most of the 320 respondents resected down to, but did not include, the muscular fascia (extremity, 71%; trunk, 66%; and head and neck, 62%). However, significant variation exists. We identified variability in our own practice and have elected to standardize this common aspect of routine surgical care across our institution. In light of the lack of evidence to support resection of the deep muscular fascia, we have elected to preserve the muscular fascia as a matter of routine, except when a deep primary melanoma or thin subcutaneous tissue dictates otherwise.
Extra-anatomical bypass grafting is a recognised method of lower limb re-vascularisation in high-risk patients who cannot tolerate aortic cross clamping, or in those with a hostile abdomen. We present a single surgeon series of such procedures and determine relevant outcomes.
PATIENTS AND METHODS
A retrospective review was performed on a prospectively maintained database of patients undergoing femoro-femoral or axillo-femoral bypass surgery between 1986 and 2004.
Patency rates for femoral (n = 28; 32%) versus axillary (n = 59; 68%) bypass procedures at 1 month, 1, 3 and 5 years were (92% vs 93%), (69% vs 85%), (60% vs 72%) and (55% vs 67%), respectively. Patient survival rates for the corresponding procedures and time intervals were (96% vs 90%), (96% vs 67%), (85% vs 45%) and (73% vs 38%) and revealed a significantly lower survival rate in those undergoing axillary procedures (P = 0.002). Limb salvage rates were calculated at (100% vs 91%), (96% vs 84%), (96% vs 81%) and (92% vs 81%) with no statistically significant difference found between the two groups (P = 0.124). Two-thirds of the patients who required major amputation died within 12 months of surgery.
Acceptable 30-day morbidity, long-term primary patency and survival rates are obtainable in patients suitable for extra-anatomical bypass surgery despite having significant co-morbidities. We have shown 5-year patency rates in those that survive axillary procedures to be as good as those undergoing femoral procedures. Furthermore, surviving patients who evade amputation within a year have an excellent chance of long-term limb salvage.
Extra-anatomical bypass grafting; Femoro-femoral; Axillo-femoral; Limb salvage