Plan dose evaluation of three dimensional conformal radiotherapy planning (3D-CRT) of nasopharyngeal carcinoma (NPC): experience of a tertiary care University Hospital in Pakistan

Background: Radiation therapy is the mainstay of treatment for nasopharyngeal carcinoma. Importance of tumor coverage and challenges posed by its unique and critical location are well evident. Therefore we aimed to evaluate our radiation treatment plan through dose volume histograms (DVHs) to find planning target volume (PTV) dose coverage and factors affecting it.MATERIALS AND Methods: This retrospective study covered 45 histologically proven nasopharyngeal cancer patients who were treated with definitive 3D-CRT and chemotherapy between Feb 2006 to March 2013 at the Department of Oncology, Section Radiation Oncology ,Aga Khan University Hospital, Karachi, Pakistan. DVH was evaluated to find numbers of shrinking field (phases), PTV volume in different phases and its coverage by the 95% isodose lines, along with influencing factors.Results: There were 36 males (80%) and 9 females (20%) in the age range of 12-84 years. Stage IVA (46.7%) was the most common stage followed by stage III (31.1). Eighty six point six-percent received induction, 95.5% received concurrent and 22.2% received adjuvant chemotherapy. The prescribed median radiation dose was 70Gy to primary, 60Gy to clinically positive neck nodes and 50Gy to clinically negative neck regions. Mean dose to spinal cord was 44.2Gy and to optic chiasma was 52Gy. Thirty seven point eight-percent patients completed their treatment in three phases while 62.2% required four to five phases. Mean volume for PTV3 was 247.8 cm3 (50-644.3), PTV4 173.8 cm3 (26.5-345.1) and PTV5 119.6 cm3 (18.9-246.1) and PTV volume coverage by 95% isodose lines were 74.4%, 85.7% and 100% respectively. Advanced T stage, intracranial extension and tumor volume \u3e200 cm3 were found to be important factors associated with decreased PTV coverage by 95% isodose line.CONCLUSIONS: 3D CRT results in adequate PTV dose coverage by 95% isodose line. However advanced T stage, intracranial extension and large target volume require more advanced techniques like IMRT for appropriate PTV coverage

Global Prevalence of Tobacco Use in Adolescents and Its Adverse Oral Health Consequences

BACKGROUND: Smoking is associated with various systemic conditions and contributes to a huge financial burden to economies around the world. AIM: The study aimed to evaluate global data about the prevalence of tobacco use among male and female adolescents and to discuss smoking-related oral complications. METHODS: The prevalence data of tobacco use among adolescents (13-15 years) was retrieved from the World Health Organization (Global Health Observatory). The World Bank’s statistics about gross national income (GNI) per capita were used to categorise low-income, lower-middle-income, upper-middle-income, and high-income countries. PubMed, Web of Science, Scopus, and Embase databases were searched to gather updated evidence about the adverse consequences of smoking on oral health among adolescents. RESULTS: The prevalence of tobacco use was 19.33%, and there were 23.29% of male and 15.35% female smoker adolescents in 133 countries (p < 0.001). The highest prevalence of tobacco use in male (24.76%) and female (19.4) adolescents was found in high-income countries. Significantly higher proportions of male adolescents were smokers than female counterparts in low-income, lower-middle-income, and upper-middle-income (p < 0.001). However, there were no statistically significant differences in tobacco use between male and female adolescents in high-income countries. Low-income countries had the lowest prevalence (14.95%) of tobacco use, while high-income countries had the highest prevalence estimates (22.08). Gingivitis (72.8%), gingival bleeding (51.2%), oral malodor or halitosis (39.6%) is common oral conditions among smoker adolescents. Smoking habit is significantly associated with dental caries, periodontal disease, hairy tongue, smoking-related melanosis, and hyperkeratosis among adolescents. CONCLUSION: There was a high prevalence of tobacco use among male and female adolescents around the globe. Available evidence suggests a strong association between smoking and compromised oral health among adolescents. Globally, measures should be taken to prevent and control the menace of tobacco use to reduce systemic and oral complications

Frequency and severity of acute toxicity of pelvic radiotherapy for gynecological cancer

Objective: To determine the frequency and severity of acute toxicity of pelvic radiotherapy for gynecological cancer.STUDY Design: A case series.PLACE AND DURATION OF STUDY: Department of Oncology, The Aga Khan University Hospital, Karachi, from March 2011 to June 2012.METHODOLOGY: A total of 99 patients with histologically proven uterine and cervical cancer, receiving radiation therapy, were enrolled into the study after informed consent on justification of inclusion and exclusion criteria. Patients were evaluated for the frequency and severity of pelvic radiotherapys side effects according to toxicity criteria based on RTOG/EORTC and CTC version 2 criteria at the start, during and at the end of treatment. The data was analyzed by using SPSS version 16.Results: Out of the 99 enrolled patients, 58 (58.6%) had uterine and 41 (41.4%) had cervical cancer. Mean age was 54.54 ± 10.29 years. Thirty-five (35.4%) patients received chemotherapy with RT. Mean RT dose was 60.72 ± 7.15 Gy. The most common gastrointestinal adverse effect was diarrhea in 64 (64.6%) followed by proctitis in 55 (55.5%), nausea in 33 (33.3%) and vomiting in 16 (16.2%) patients. Grade (G) 1 was the most frequently observed severity. The most common hematological toxicity was anemia in 37.8% (n=31/82) {(G1=18 (21.9%), G2=11 (13.4%), G3=2 (2.4%)} followed by thrombocytopenia in 22.8% (21/92) {(G1=16 (17.3%), G2=2 (2.1%), G3=3 (3.2%)} and neutropenia in 21 (21.2%) {(G1=12 (12.1%), G2=5 (5%), G3=3 (3%), G4=1 (1%)}. Urinary toxicity was observed in 49 (49.5%) patients. On stratification, chemotherapy and higher RT dose were strong predictor of increased hematological and upper gastrointestinal toxicity (p \u3c 0.05) and age \u3e 60 years for diarrhea (p \u3c 0.05).CONCLUSION: The frequency and severity of acute toxicity of pelvic radiotherapy in women with gynecologic cancers was found intermediate to high

A case of finger clubbing associated with nasopharyngeal carcinoma in a young girl, and review of pathophysiology

Hypertrophic osteoarthropathy is characterized by clubbing of the digital tips and periosteal reaction of long bones. Most of the cases are associated with malignancy or other conditions such as congenital heart disease, liver cirrhosis, pulmonary fibrosis, biliary atresia and gastrointestinal polyps. Hypertrophic osteoarthropathy associated with malignancy is rare in children. A few cases of hypertrophic osteoarthropathy in children with nasopharyngeal carcinoma have been reported. This is a case of hypertrophic osteoarthropathy associated with nasopharyngeal carcinoma with lung and bone metastasis in a 16 year old girl. In this case, lung metastases progressed after intensive chemotherapy and hypertrophic osteoarthropathy (Clubbing) persisted

Acute toxicity and local response using three fractions of high dose rate (HDR) brachytherapy for curative treatment of carcinoma cervix

To determine the acute vaginal mucosal toxicity and clinical response of cervical cancer after definitive treatment with external beam radiotherapy (EBRT) and three fractions each of 8 Fray (Gy) high dose rate intracavitary brachytherapy (HDR-BT).Study design: Descriptive study.Place and duration: Radiation Oncology Section, Department of Oncology, The Aga Khan University Hospital, Karachi, Pakistan from January 2008 till December 2015.Methodology: Protocol was formulated for carcinoma cervix to complete treatment in 7 weeks. Patients were treated with chemotherapy and pelvic EBRT to a total dose of 45 Gy/25 fractions, followed by three intracavitary HDR brachytherapy fractions of 8 Gy each. Vaginal toxicity and local clinical response was assessed at the end of treatment, at 4 and 8 weeks.Results: A total of 57 patients were treated with HDR brachytherapy and 49 patients were evaluated for assessment of toxicity and response. According to FIGO staging system, two had stage IB2, one had IIA, thirty-six had IIB, seven had IIIB, one had IVA disease and two had IVB with para aortic nodes. Concurrent gemcitabine and cisplatin were given to 26 (46%); whereas, 28 (49%) received concurrent cisplatin alone. Grade III acute vaginal mucosal toxicity was seen in 52 and Grade IV acute vaginal mucosal toxicity was observed in 08 patients. At completion of treatment, 40 patients had complete clinical response, at 4 weeks follow-up, complete regression of disease was found in 3 more and at 8 weeks none had clinical residual disease.Conclusion: This regimen of HDR brachytherapy treatments is feasible, efficacious, and well-tolerated for carcinoma cervix in a setup with cost constraints. Long term toxicity and disease control remains to be reported with longer follow-up. Key Words: Carcinoma cervix, High dose rate brachytherapy, Acute toxicity, Local response, External beam radiation therapy, Intracavitary brachytherapy

Genotypic response of chickpea (Cicer arietinum L.) for resistance against gram pod borer (Helicoverpa armigera)

Background: Chickpea is an important pulse crop of Pakistan. The pod borer, Helicoverpa armigera (Hubner), is the major pest in most of the chickpea growing areas of the country. A field trial was carried out at Entomological Research Area, Ayub Agriculture Research Institute (AARI), Faisalabad, during growing season of 2012-13 to evaluate the resistance of chickpea genotypes against gram pod borer (Helicoverpa armigera).Methods: Experiments were conducted in randomized complete block design (RCBD) with four replications having plot size of 3 ft × 20 ft. Morphological characters of chickpea like pod trichome, pod wall thickness, pod length, pod breadth, pod area and number of pods per plant were measured. The pod borer larval population/pod infestation was recorded from fifteen randomly selected plants per plot after ten days interval.Results: It was found that the genotypes which had higher trichomes length and density and pod wall thickness were more resistant against Helicoverpa infestation. Significant genetic variation for resistance against Helicoverpa armigera attack was found in chickpea and variety K-70005 showed resistant behavior followed by K-08004 and K-60062.Conclusions: It was concluded from prescribed study that the most susceptible genotypes were K-70005, K-08004 and K-70008 for the attack of Helicoverpa armigera to reduce grain yield

LMBiS-Net: A Lightweight Multipath Bidirectional Skip Connection based CNN for Retinal Blood Vessel Segmentation

Blinding eye diseases are often correlated with altered retinal morphology, which can be clinically identified by segmenting retinal structures in fundus images. However, current methodologies often fall short in accurately segmenting delicate vessels. Although deep learning has shown promise in medical image segmentation, its reliance on repeated convolution and pooling operations can hinder the representation of edge information, ultimately limiting overall segmentation accuracy. In this paper, we propose a lightweight pixel-level CNN named LMBiS-Net for the segmentation of retinal vessels with an exceptionally low number of learnable parameters \textbf{(only 0.172 M)}. The network used multipath feature extraction blocks and incorporates bidirectional skip connections for the information flow between the encoder and decoder. Additionally, we have optimized the efficiency of the model by carefully selecting the number of filters to avoid filter overlap. This optimization significantly reduces training time and enhances computational efficiency. To assess the robustness and generalizability of LMBiS-Net, we performed comprehensive evaluations on various aspects of retinal images. Specifically, the model was subjected to rigorous tests to accurately segment retinal vessels, which play a vital role in ophthalmological diagnosis and treatment. By focusing on the retinal blood vessels, we were able to thoroughly analyze the performance and effectiveness of the LMBiS-Net model. The results of our tests demonstrate that LMBiS-Net is not only robust and generalizable but also capable of maintaining high levels of segmentation accuracy. These characteristics highlight the potential of LMBiS-Net as an efficient tool for high-speed and accurate segmentation of retinal images in various clinical applications

We won\u27t go there: Barriers to accessing maternal and newborn care in district Thatta, Pakistan

Accessibility and utilization of healthcare plays a significant role in preventing complications during pregnancy, labor, and the early postnatal period. However, multiple barriers can prevent women from accessing services. The aim of this study was to explore the multifaceted barriers that inhibit women from seeking maternal and newborn health care in Thatta, Sindh, Pakistan. This study employed an interpretive research design using a purposive sampling approach. Pre-tested, semi-structured interview guides were used for data collection. The data were collected through eight focus group discussions with men and women, and six in-depth interviews with lady health workers and analyzed through thematic analysis. The study identified individual, sociocultural, and structural-level barriers that inhibit women from seeking maternal and newborn care. Individual barriers included mistrust towards public health facilities and inadequate symptom recognition. The three identified sociocultural barriers were aversion to biomedical interventions, gendered imbalances in decision making, and women\u27s restricted mobility. The structural barriers included ineffective referral systems and prohibitively expensive transportation services. Increasing the coverage of healthcare service without addressing the multifaceted barriers that influence service utilization will not reduce the burden of maternal and neonatal mortality. As this study reveals, care seeking is influenced by a diverse array of barriers that are individual, sociocultural, and structural in nature. A combination of capacity development, health awareness, and structural interventions can address many if not all of these barriers

Chemoradiation and the role of adjuvant chemotherapy in lymph nodal-metastatic cervical cancer

Purpose: To report the long-term outcome in lymph nodal-metastatic cervical squamous cell cancer after chemoradiation followed by adjuvant chemotherapy.Patients and Methods: Between 2010 and 2013, five patients were diagnosed with advanced cervical cancer with clinically involved para-aortic lymph nodes (ie, International Federation of Gynecology and Obstetrics stage IVB). These patients were treated with concurrent chemoradiation therapy followed by adjuvant chemotherapy. Concurrent chemoradiation consisted of cisplatin given once per week concomitantly with extended-field radiation therapy followed by high-dose-rate brachytherapy. Adjuvant chemotherapy comprised four courses of carboplatin and paclitaxel given every three weeks. The primary outcomes were local and distant failures.Results: None of the patients had local recurrence or distal failure after a minimum follow-up time of 3 years.Conclusion: Adjuvant chemotherapy after chemoradiation has a probable role in the management of lymph nodal-metastatic cervical cancer