ORAL METHOTREXATE AS SECOND LINE CHEMOTHERAPY IN PLATINUM-REFRACTORY OR RELAPSED SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK

Purpose: Platinum-refractory or relapsed squamous cell carcinoma of the head and neck (SCCHN) is considered to have poor prognosis. Although cetuximab is currently recommended as category 1 in this group of patients, the use of it is hampered in low- and middle-income countries (LMICs) like Pakistan due to nancial constraints. Further, majority of the population of these countries is unable to tolerate toxicity related to other intravenous chemotherapeutic agents due to lower socioeconomic background with poor nutrition status. The aim of this study is to evaluate the response rate and toxicity of oral methotrexate (MTX) in platinum-refractory or relapsed SCCHN. Methods: Between June 2008 and December 2012, 71 patients received palliative oral MTX either due to recurrent or persistent disease. With a median age of 51 years (range 22–75), there were 68% of males and 32% of females. Site distribution was as following; oral cavity 58%, nasopharynx 25%, hypopharynx 7%, paranasal sinuses 6%, larynx 3%, Oropharynx 1%. Patterns of recurrence; local 32%, regional 07%, loco regional 10%, distant 15% and persistent disease in 36% of the patients. All the patients received oral MTX 10 mg once a day, 4 days a week. To contain the possible side effects associated with MTX, folinic acid 15 mg per oral every 6 hourly on day 5 was prescribed. Response assessment was done on two monthly basis. Response, toxicity, mean response time and mean time to progression were determined. Results: Response to MTX was as following; complete response 3%, partial response 4%, stable disease 11% and progressive disease in 82% of the patients respectively. Toxicity related to oral MTX includes neutropenia Grade III in 1% while mucositis Grade III in 10% of the patients, respectively. None of the patient had Grade IV mucositis or haematological toxicity. Treatment was stopped in 13% of the patients due to poor compliance. Mean response time was 4 months (range 1 – 20) and mean time to progression was 5 months (range 1–23). Conclusion: Oral MTX is a simple, cost-effective and well-tolerated regimen to be used on outpatient basis for palliation in platinum refractory or relapsed SCCHN in LMICs and debilitated patients. This treatment merits further evaluation in large-scale clinical trials. Key words: Oral methotrexate, platinum refractory, relapsed squamous cell carcinoma of head and neck

Multiphoton blockade and antibunching in an optical cavity coupled with dipole-dipole interacting Λ\Lambda-type atoms

We study multiphoton blockade effects in a single-mode cavity interacting with two three-level atoms in $\Lambda$-configuration having position-dependent atom-field coupling. We consider the effects of dipole-dipole interaction (DDI) between the three-level atoms and show how the presence of DDI strongly influences the multiphoton blockade. For symmetric coupling of the atoms with the field, the DDI induces an asymmetry in the emission spectra as a function of pump field detuning. At positive detuning, the single-photon blockade gets stronger as a function of DDI strength, leading to photon antibunching. However, it becomes weaker at negative detuning and can also completely vanish. We show that this vanishing single-photon blockade is associated with a strong two-photon blockade, leading to two-photon bunching. Therefore, by just tuning the frequency of the pump field, we can achieve two very distinct features. We also study the effects of DDI when the atoms are asymmetrically coupled with the field and show that the proposed system exhibits two-photon bunching. We believe our results are important for the experimental realization of such systems where DDI may be present.Comment: 12 pages, 10 figure

Atypical involvement of central nervous system in classic Hodgkin lymphoma: A case report

Background: Hodgkin lymphoma is a systemic disease that commonly involves the cervical, supraclavicular, and mediastinal lymph nodes. The involvement of central nervous system in Hodgkin lymphoma is extremely rare, and diagnosis is usually established using distinct morphological and immunohistochemical staining on the tissue biopsied. Extranodal presentation of HL is a rare occurrence. It has been evident that prognosis is encouraging in patients with disease that is limited to just central nervous system initially or as relapse, compared with involvement of multiple sites of relapse.Case presentation: We herein report a case of a 35-year-old South-East Asian male with relapsed Hodgkin lymphoma. The patient developed a parotid gland lesion, cervical lymphadenopathy with significant weight loss, and intermittent night sweats. Along with spread to the central nervous system, there was a high suspicion of tuberculosis. Upon biopsy of his cervical lymph node, the patient was confirmed to have Hodgkin lymphoma. Immediate treatment began with six cycles of chemotherapy consisting of adriamycin, bleomycin, vinblastine, and dacarbazine. The patient received three cycles of chemotherapy consisting of ifosfamide, carboplatin, and etoposide but then was lost to follow-up. Five years later, the patient suffered a road traffic accident. Upon work-up, a right parietal space-occupying lesion with moderate cerebral edema and midline shift was found on computed tomography of the brain. The patient underwent resection of the space-occupying lesion of brain, with features consistent with classical Hodgkin lymphoma on histopathology examination. It is crucial for such lesions to be investigated meticulously to rule out any secondary disease process.Conclusion: Relapsed Hodgkin lymphoma with central nervous system involvement is relatively rare with just over two dozen cases reported to date and is observed infrequently in developing nations. Therefore, space-occupying lesion should always be investigated, and biopsy of such lesions is gold standard to establish diagnosis. With timely appropriate therapy, complete remission can be achieved. However, large-scale studies would be prudent to explore the presentation, survival, and treatment options for patients with Hodgkin lymphoma involving the central nervous system

Case of undiagnosed pneumocystis pneumonia (PCP

Pneumocystis pneumonia (PCP) is an opportunistic fungal infection that is usually seen in immunocompromised patients, especially those with HIV, malignancies, organ transplants and on drug therapies like chemotherapy and steroids. PCP has subacute presentation in patients with AIDS which if left untreated gets worse and is a significant cause of morbidity and mortality. Here we present a case of PCP went undiagnosed, partially due to the patient being unaware of his HIV positive status and partially because no organism could be found under the microscope

SURVIVAL OUTCOMES IN EARLY GLOTTIC CARCINOMA; A SINGLE INSTITUTION EXPERIENCE

Purpose: Laryngeal cancers are amongst the most common cancers affecting head and neck region. In this study, we analyse the overall survival (OS) following hypofractionated radiotherapy (RT) in early stage glottic carcinoma treated at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore. Methods: Between October 2003 and June 2009, 87 patients with early stage glottic carcinoma were treated with hypofractionated RT. All patients were included in the study. The ratio of male: female is 94%:6%. Mean age was 62 years (range 31–83 years). 66% of the patients were smokers. AJCC stage was T1a in 76%, T1b 20% and T2 in 4% of the patients. Histological distribution was; squamous cell carcinoma 97%, verrucous carcinoma 2% and squamous cell spindle variant 1%. Median follow-up time was 59 months (range 4–122 months). RT dose was 55 Gy in 20 fractions over a period of 4 weeks. Median RT treatment time was 28 days (range 23–35 days). Patients that lost to follow-up were contacted through telephone. Results: The 10-year OS was 83%. Patterns of failure was 7 local and 1 distant while 1 patient had persistent disease. 15 patients were dead at the time of study. Cause of death; 13 patients died due to Ischemic heart disease and 2 due to primary disease. Conclusion: Hypofractionated RT 55 Gy in 20 fractions seems to achieve good OS while offering potential for optimizing resources usage. Key words: Glottic carcinoma, hypofractionated, overall survival, radiotherapy

Association Of Maternal Age And Hemoglobin Level With Apgar Score Of Newborns In A Tertiary Care Hospital Of Suburbs Of Islamabad

Objectives: To determine the association of Apgar score with maternal age and hemoglobin. Methods A cross-sectional study was conducted on mothers (n=306) delivering live, full-term, singleton babies by spontaneous vertex delivery. Women who suffered stillbirths had babies of unknown gestational age or showed co-morbidities were excluded. SPSS version 26 was used for data analysis. Mean + standard deviation, and percentages were calculated. Cross-tabulation and logistic regression were done to see the association between dependent and independent variables. A p-value of <0.05 was statistically significant. Results The ages of women ranged from 20 to 40 years (mean= 25+1.9).  The number of patients aged 24 years with Hb <7g/dl was 6 (37.5%). Out of all, 90 (29.4%) patients had Hb >11g/dl, and their ages were 30 years which was significant (p = 0.000). Apgar score for the neonates showed that 258 (84.3%) had an Apgar score >7 while 48 (15.7%) had a score < 7. Babies of mothers whose age was 26 years had Apgar score < 7(25%) (p = 0.001). Neonatal birth weight, of <2kg was observed in infants born to young mothers of 26 years of age (20%) (p = 0.001), and a weight >3.5kg was recorded in 20 infants (6.5%). The younger mothers had lower Hb, and their babies had low Apgar scores <7 at the time of birth (p = 0.001). Conclusion Women of younger age and lower hemoglobin levels give birth to infants with low Apgar scores and birth weight. Low birth weight in neonates is significantly associated with a low five-minute Apgar score

Quantification of Ion Migration in CH3NH3PbI3 Perovskite Solar Cells by Transient Capacitance Measurements

Solar cells based on organic-inorganic metal halide perovskites show efficiencies close to highly-optimized silicon solar cells. However, ion migration in the perovskite films leads to device degradation and impedes large scale commercial applications. We use transient ion-drift measurements to quantify activation energy, diffusion coefficient, and concentration of mobile ions in methylammonium lead triiodide (MAPbI3) perovskite solar cells, and find that their properties change close to the tetragonal-to-orthorhombic phase transition temperature. We identify three migrating ion species which we attribute to the migration of iodide (I-) and methylammonium (MA+). We find that the concentration of mobile MA+ ions is one order of magnitude higher than the one of mobile I- ions, and that the diffusion coefficient of mobile MA+ ions is three orders of magnitude lower than the one for mobile I- ions. We furthermore observe that the activation energy of mobile I- ions (0.29 eV) is highly reproducible for different devices, while the activation energy of mobile MA+ depends strongly on device fabrication. This quantification of mobile ions in MAPbI3 will lead to a better understanding of ion migration and its role in operation and degradation of perovskite solar cells

The impact of top management support, perceived justice, supplier management, and sustainable supply chain management on moderating the role of supply chain agility

Sustainable supply chain management (SSCM) is a new area of interest to scientists and industrial practitioners through which to maintain productivity, reduce costs, and enhance agility. SSCM is especially important to protect the environment and reduce pollution by heavy industries. It considers the environment the main stakeholder in minimizing the carbon footprint during production, lowering emissions of dangerous gases, and reducing industrial pollution. Considering the aforementioned purposes, the aim of this study was to explore the relationships between top management support, perceived justice, supplier management, and SSCM and assess the moderating role of supply chain agility. This quantitative study was conducted in the vast textile sector in Pakistan. We collected data through a questionnaire and found that top management support, perceived justice, and supplier management are positively and significantly associated with SSCM. However, there was no significant moderating effect of supply chain agility on the independent variables and SSCM. These findings have practical implications for production managers and top management in enhancement of their roles in promoting environmental wellbeing. By developing rules at the organizational and governmental levels that consider the role of top management, perceived justice, and improved supplier management, the sustainability of the supply chain can be improved. This analysis provides academics who study the supply chain a practical prescription and adds to the body of knowledge about the validity of top SSCM pillars

Dengue fever in Northern Pakistan: The Hepatic Implications

Background: To gauge the clinical spectrum of dengue fever in northern Pakistan and to assess its hepatic implications Methods: This prospective study was conducted at Rawalpindi General Hospital (now BBH), Rawalpindi from 1st Oct 2006 to 31st Dec 2008. It included all 264 patients suffering from dengue fever who presented during this period. Dengue infection was suspected if two or more of the following features in addition to fever were present: headache, retro-orbital pain, myalgias/arthralgias, scarlet/maculopapular rash, vomiting/epigastric pain and haemorrhagic manifestations. Blood samples were sent for dengue virus IgM. A blood complete picture, liver function tests, serum urea and creatinine, and urine R/E were also obtained. Specific evidence of liver involvement was also sought on examination. Results: The 264 patients comprised of 146 males and 118 females. Age of patients ranged from 14 to 80 years. 220 patients were seen in the last three months of 2006, the time of the dengue epidemic. Fever and myalgias were present in all patients. Vomiting was seen in 223 (85%) and abdominal pain in 163 (62%) patients. A skin rash was present in 148 (56%) while 56 (21%) complained of joint pains and 53 (20%) of retro-orbital pain. 26 (10%) patients had a bleeding disposition and jaundice was noted in 6 (2%). Leukopenia and thrombocytopenia were present in all patients, while 254 (96%) had proteinuria. ALT was elevated in 163 (62%) and AST was raised in 135 (51%) patients. Conclusion: The liver is affected in a large number of cases of dengue fever. Liver function tests are useful to evaluate the degree of liver damage and markers such as AST and ALT may be used as parameters to assess severit