DCE-MRI and parametric imaging in monitoring response to neoadjuvant chemotherapy in breast carcinoma : a preliminary report

Purpose: Neoadjuvant chemotherapy is recommended in patients with locally advanced breast cancer. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) enables evaluation of the tumour neovasculature that occurs prior to any volume change, which helps identify early treatment failures and allows prompt implementation of second-line therapy. Material and methods: We conducted a prospective study in 14 patients with histopathologically proven breast cancer. DCE-MRI data were acquired using multisection, T1-weighted, 3D vibe sequences with fat suppression before, during, and after IV bolus injection (0.1 mmol/kg body weight, Gadoversetamide, Optimark). Post-processing of dynamic contrast perfusion data was done with the vendor's Tissue 4D software to generate various dynamic contrast parameters, i.e. Ktrans, Kep, Ve, initial area under the time signal curve (IAUC), apparent diffusion coefficient (ADC), and enhancement curve. Patients underwent MRI examinations at baseline, and then after two cycles, and finally at completion of chemotherapy. Results: Based on Sataloff criteria for pathological responses, four patients out of 14 were responders, and 10 were non-responders. At the 2nd MRI examination, IAUC was significantly smaller in responders than in non-responders (p = 0.023). When the results of the first and second MRI examinations were compared, Kep decreased from baseline to the second MRI (p = 0.03) in non-responders and in responders (p = 0.04). This change was statistically significant in both groups. The ADC values increased significantly in responders from baseline to the third MRI (p = 0.012). Conclusions: In our study, IAUC and ADC were the only parameters that reliably differentiated responders from non-responders after two and three cycles of chemotherapy

Portal Vein Aneurysm: Incidental Detection of Uncommon Entity as Cause of Chronic Abdominal Pain

Portal vein aneurysm is an uncommon anomaly. Both congenital and acquired cases are reported. We report a case of idiopathic probably congenital portal vein aneurysm incidentally detected on contrast CT. There was no evidence of any chronic liver disease or portal hypertension in this patient

Tocilizumab induced immunosuppression in a case of adult-onset still’s disease: are these newer biologics double edged sword?

Adult-onset still’s disease (AOSD) is a rare multisystemic inflammatory disorder of unknown etiology characterised by high spiking fever, evanescent skin rash, arthralgias, arthritis, neutrophilic leucocytosis. Initial treatment strategy includes use of hands-on drugs like non-steroidal anti-inflammatory drugs, low dose corticosteroids, conventional DMARDs. But as the disease progresses to severe form, targeted and biologic DMARDs could be the option for management. Interleukin-6 being one among the many cytokines involved in the pathogenesis of AOSD, has made itself a target for the treatment of refractory cases. Tocilizumab, a recombinant humanized anti IL-6 monoclonal antibody, is one such biologic drug available in the market that has proven its therapeutic efficacy in several clinical trials. We are presenting a case of 37-year-old female patient, known case of AOSD for 4 years. Patient was initially maintained on low dose corticosteroid and conventional DMARD like hydroxychloroquine and methotrexate. Flare ups of the disease warranted the use of tocilizumab and tofacitinib in this patient. After clinical as well as pathological improvement with tocilizumab 2 years before, signs of immunosuppression were observed when tocilizumab was reintroduced for the treatment. Patient suffered from acute pyelonephritis, septicemia, shock, oropharyngeal candidiasis and bronchitis which could be owned to immunosuppressive action of tocilizumab. One can reduce the chances of infection and other adverse effects by careful periodic monitoring of various laboratory parameters like total W.B.C., total platelet count and liver enzymes. Cautious selection of the patient is needed for the treatment with newer biologic agents

A case report on angioedema induced by levofloxacin: an unexpected occurrence

Angioedema is an abrupt swelling of the skin, mucous membrane, or both. It can be either food or drug induced. Drug induced Angioedema (allergic or non-allergic) is known with ACE inhibitors, NSAIDs, Beta-lactams. Levofloxacin is a well-tolerated, broad-spectrum fluoroquinolone commonly prescribed for urinary or respiratory tract infections. Common side effects with levofloxacin involve gastrointestinal tract. However, reports on Levofloxacin induced Angioedema are scarce. Hence, we report two cases of Levofloxacin induced Angioedema. In both the cases, patients developed swelling of face following ingestion of Tab. Levofloxacin 500 mg orally BD on previous day. Drug was prescribed for urinary or respiratory infection. After a provisional diagnosis of Levofloxacin induced Angioedema by the dermatologist, both the patients were asked to withdraw the drug immediately. The reaction was treated with Inj. Avil (Pheniramine maleate) 1 cc i.v. stat and Inj. Dexona (Dexamethasone) 2 cc i.v. stat in one patient whereas oral corticosteroid (Tab. Prednisolone 10mg orally OD with tapering dose) was used in second patient. Oral antihistaminics were also prescribed as per the necessity. Both patients recovered within 4-7 days. Both ADRs were uploaded via Vigiflow under Pharmacovigilance Programme of India (PvPI) with likely relationship between suspected drug and ADR. Incidence of Drug induced cutaneous ADRs (CADRs) in India is 2.85%. Instances of hypersensitivity or anaphylactic reactions with fluoroquinolones are much lesser and milder than with NSAIDs or Beta-lactams. These reactions are associated with quinolone-specific Ig E. Existence of cross reactivity with quinolones is also high. This property is due to a similar ring (4-oxo-1, 4-dihydroquinoline ring) possessed by all fluoroquinolones. This allergic angioedema confined to the skin can be treated with antihistaminics or glucocorticoids

Drug utilization pattern and analysis of quality of life in Indian patients of Parkinson’s disease

Background: Parkinson's disease (PD) is a highly debilitating disease characterized by tremors, bradykinesia and rigidity. It leads to lowered self-esteem and psychological consequences which affect quality of life. The aim of this study is to study the drug utilization pattern and assess the quality of life in patients of Parkinson’s Disease.Methods: 40 patients of PD at least 1 month duration and 20 age-based controls were analyzed for quality of life using Parkinson’s Disease Questionnaire-39 (PDQ-39). Drug prescriptions were analyzed.Results: Mean number of anti-Parkinson drugs prescribed is 2.65±1.21. Of 106 anti-Parkinson drugs prescribed, 45% were levodopa and carbidopa combinations, followed by dopamine agonists (18%), anticholinergic drugs (15%), amantadine (12%), MAO inhibitors (5%) and COMT inhibitors (5%). There were significant problems in speech, performance of daily chores and daytime somnolence (p<0.0001). Depression, isolation, cognitive decline and memory loss were noteworthy in the patients as compared to controls (p<0.05). 25% patients felt embarrassed due to their disease; 59% felt affected by others’ opinion, 60% felt difficulty in communicating with others (p<0.05). Almost 2/3rd patients needed help in personal care as compared to the control group (p<0.0001).Conclusions: Quality of life of parkinsonian patients is severely affected in spite of them receiving a large number of drugs. This may be both due to disease progression as well as medication. Levodopa-carbidopa combination is the most prescribed medication. Use of levodopa and carbidopa combination must be evaluated properly. Newer guidelines and interventions are the need of the hour which may provide a better outcome on the quality of life of parkinsonian patients

Cell-Free DNA and Active Rejection in Kidney Allografts

Histologic analysis of the allograft biopsy specimen is the standard method used to differentiate rejection from other injury in kidney transplants. Donor-derived cell-free DNA (dd-cfDNA) is a noninvasive test of allograft injury that may enable more frequent, quantitative, and safer assessment of allograft rejection and injury status. To investigate this possibility, we prospectively collected blood specimens at scheduled intervals and at the time of clinically indicated biopsies. In 102 kidney recipients, we measured plasma levels of dd-cfDNA and correlated the levels with allograft rejection status ascertained by histology in 107 biopsy specimens. The dd-cfDNA level discriminated between biopsy specimens showing any rejection (T cell-mediated rejection or antibody-mediated rejection [ABMR]) and controls (no rejection histologically), P1% indicate a probability of active rejection

Developing a core outcome set for future infertility research : An international consensus development study

STUDY QUESTION: Can a core outcome set to standardize outcome selection, collection and reporting across future infertility research be developed? SUMMARY ANSWER: A minimum data set, known as a core outcome set, has been developed for randomized controlled trials (RCTs) and systematic reviews evaluating potential treatments for infertility. WHAT IS KNOWN ALREADY: Complex issues, including a failure to consider the perspectives of people with fertility problems when selecting outcomes, variations in outcome definitions and the selective reporting of outcomes on the basis of statistical analysis, make the results of infertility research difficult to interpret. STUDY DESIGN, SIZE, DURATION: A three-round Delphi survey (372 participants from 41 countries) and consensus development workshop (30 participants from 27 countries). PARTICIPANTS/MATERIALS, SETTING, METHODS: Healthcare professionals, researchers and people with fertility problems were brought together in an open and transparent process using formal consensus science methods. MAIN RESULTS AND THE ROLE OF CHANCE: The core outcome set consists of: viable intrauterine pregnancy confirmed by ultrasound (accounting for singleton, twin and higher multiple pregnancy); pregnancy loss (accounting for ectopic pregnancy, miscarriage, stillbirth and termination of pregnancy); live birth; gestational age at delivery; birthweight; neonatal mortality; and major congenital anomaly. Time to pregnancy leading to live birth should be reported when applicable. LIMITATIONS, REASONS FOR CAUTION: We used consensus development methods which have inherent limitations, including the representativeness of the participant sample, Delphi survey attrition and an arbitrary consensus threshold. WIDER IMPLICATIONS OF THE FINDINGS: Embedding the core outcome set within RCTs and systematic reviews should ensure the comprehensive selection, collection and reporting of core outcomes. Research funding bodies, the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) statement, and over 80 specialty journals, including the Cochrane Gynaecology and Fertility Group, Fertility and Sterility and Human Reproduction, have committed to implementing this core outcome set. STUDY FUNDING/COMPETING INTEREST(S): This research was funded by the Catalyst Fund, Royal Society of New Zealand, Auckland Medical Research Fund and Maurice and Phyllis Paykel Trust. The funder had no role in the design and conduct of the study, the collection, management, analysis or interpretation of data, or manuscript preparation. B.W.J.M. is supported by a National Health and Medical Research Council Practitioner Fellowship (GNT1082548). S.B. was supported by University of Auckland Foundation Seelye Travelling Fellowship. S.B. reports being the Editor-in-Chief of Human Reproduction Open and an editor of the Cochrane Gynaecology and Fertility group. J.L.H.E. reports being the Editor Emeritus of Human Reproduction. J.M.L.K. reports research sponsorship from Ferring and Theramex. R.S.L. reports consultancy fees from Abbvie, Bayer, Ferring, Fractyl, Insud Pharma and Kindex and research sponsorship from Guerbet and Hass Avocado Board. B.W.J.M. reports consultancy fees from Guerbet, iGenomix, Merck, Merck KGaA and ObsEva. C.N. reports being the Co Editor-in-Chief of Fertility and Sterility and Section Editor of the Journal of Urology, research sponsorship from Ferring, and retains a financial interest in NexHand. A.S. reports consultancy fees from Guerbet. E.H.Y.N. reports research sponsorship from Merck. N.L.V. reports consultancy and conference fees from Ferring, Merck and Merck Sharp and Dohme. The remaining authors declare no competing interests in relation to the work presented. All authors have completed the disclosure form

Air, Air Everywhere‑ A Rare Entity

Upper gastrointestinal (GI) endoscopy is a widely used diagnostic and therapeutic procedure. Gastric perforation causing pneumothorax, pneumomediastinum, pneumoperitoneum, pneumorrhachis, and subcutaneous emphysema after upper GI endoscopy is an extremely rare complication. We present an interesting case of a 58‑year‑old male who presented to the Emergency Department with recurrent vomiting, abdominal pain and diffuse swelling over abdomen, chest, neck bilateral arms, and thighs after undergoing an endoscopy for a gastric mass