Bolus electron conformal therapy for the treatment of recurrent inflammatory breast cancer: a case report

The treatment of locoregionally recurrent breast cancer in patients who have previously undergone radiation therapy is challenging. Special techniques are often required that both eradicate the disease and minimize the risks of retreatment. We report the case of a patient with an early-stage left breast cancer who developed inflammatory-type recurrence requiring re-irradiation of the chest wall using bolus electron conformal therapy with image-guided treatment delivery. The patient was a 51-year-old woman who had undergone lumpectomy, axillary lymph node dissection, and adjuvant whole-breast radiation therapy for a stage I left breast cancer in June 1998. In March 2009, she presented at our institution with biopsy-proven recurrent inflammatory carcinoma and was aggressively treated with multi-agent chemotherapy followed by mastectomy that left a positive surgical margin. Given the patient's prior irradiation and irregular chest wall anatomy, bolus electron conformal therapy was used to treat her chest wall and draining lymphatics while sparing the underlying soft tissue. The patient still had no evidence of disease 21 months after treatment. Our results indicate that bolus electron conformal therapy is an accessible, effective radiation treatment approach for recurrent breast cancer in patients with irregular chest wall anatomy as a result of surgery. This approach may complement standard techniques used to reduce locoregional recurrence in the postmastectomy setting.     

Tourniquet application only during cement fixation in total knee arthroplasty: a double-blind, randomized controlled trial

Background: The functional benefits of tourniquet application for short periods compared with standard duration applications during total knee arthroplasty surgery have not been well explored. We aimed to compare functional outcomes between tourniquet application of short duration (during cement fixation only) and tourniquet application of longer duration (from skin incision to just after cement fixation). Methods: We planned to randomize 230 patients to short and long duration groups. The primary outcome was Oxford Knee Score at 10 weeks post‐surgery. In‐hospital blood transfusion rate was also a primary safety measure. Serial measures of knee function were taken together with knee range, quadriceps lag and timed stair tests. Results: The trial was discontinued after randomization of 65 patients. Interim analysis indicated a higher risk of transfusion (odds ratio 7.38, P= 0.015) in the short duration group. No significant difference was observed in Oxford Knee Score at 10 weeks. There were no between‐group differences in rate of recovery up to 52 weeks for any outcome. Conclusions: Restricting tourniquet application to the period of cementing is associated with a significantly higher risk of transfusion. This approach is impractical if it is not offset by gains in functional recovery.     

A prospective international cooperative information technology platform built using open-source tools for improving the access to and safety of bone marrow transplantation in low- and middle-income countries

Jagriti Innovations developed a collaboration tool in partnership with the Cure2Children Foundation that has been used by health professionals in Italy, Pakistan, and India for the collaborative management of patients undergoing bone marrow transplantation (BMT) for thalassemia major since August 2008. This online open-access database covers data recording, analyzing, and reporting besides enabling knowledge exchange, telemedicine, capacity building, and quality assurance. As of February 2014, over 2400 patients have been registered and 112 BMTs have been performed with outcomes comparable to international standards, but at a fraction of the cost. This approach avoids medical emigration and contributes to local healthcare strengthening and competitiveness. This paper presents the experience and clinical outcomes associated with the use of this platform built using open-source tools and focusing on a locally pertinent tertiary care procedure—BMT.     

Chronic lymphocytic leukemia in India-A clinico-hematological profile

Chronic lymphocytic leukemia (CLL) is the most common form of leukemia in elderly people. The clinico-hematological profile and treatment outcome of patients with CLL were assessed using retrospective case record analysis over 11 years. There were 95 (75 males: 20 females) patients with a median age of 61 years. Thirty patients were aged 55 years or less (young CLL patients) and 65 were more than 55 years of age (elder CLL patients). Sixty percent patients had non-specific complaints, such as weakness, cough and indigestion. Twenty-six (27%) patients had pallor and 24 (25%) had fever as initial presenting manifestation. Bleeding manifestations were seen in 7 patients. Seven patients were diagnosed incidentally. Lymphadenopathy, splenomegaly and hepatomegaly were seen in 52 (55%), 63 (66%) and 60 (63%) patients, respectively. The median white blood cell count and absolute lymphocyte counts were 70,600 and 51,490/μl, respectively. Three patients had autoimmune hemolytic anemia. Twenty-five patients (26%) had anemia with hemoglobin <11 g/dl and thrombocytopenia with platelet count 100 × 10³/mm³ was seen in 17 (18%). Interstitial nodular, mixed and diffuse bone marrow (BM) involvement was seen in 10.2, 67.3, 6.1 and 16.3% cases, respectively. Eighteen (60%) young patients and 35 (54%) older patients required treatment with chlorambucil. The mean time from initial diagnosis to treatment was 4.6 ± 10.7 months. None of our patient attained complete response. Six patients obtained partial response. Median duration of chlorambucil was 7 months (1–86 months). Forty-six patients had stable disease. Three patients died. Median survival of study group was 4 years (8 months–13 years). In older CLL it was 4 years (8 months–11 years) and in young patients, survival duration was 5.5 years (1–13 years).     

Implication of CT Table Sag on Geometrical Accuracy During Virtual Simulation

Computed tomography (CT) scanners are used in hospitals worldwide for radiation oncology treatment simulation. It is critical that the process very accurately represents the patient positioning to be used during the administration of radiation therapy to minimize the dose delivery to normal tissue. Unfortunately, this is not always the case. One problem is that some degree of vertical displacement, or sag, occurs when the table is extended from its base when under a clinical weight load, a problem resulting from mechanical limitations of the CT table. In an effort to determine the extent of the problem, we measured and compared the degree of table sag for various CT scanner tables at our institution. A clinically representative weight load was placed on each table, and the amount of table sag was measured for varying degrees of table extension from its base. Results indicated that the amount of table sag varied from approximately 0.7 to 6.6 mm and that the amount of table sag varied not only between tables from different manufacturers but also between tables of the same model from the same manufacturer. Failure to recognize and prevent this problem could lead to incorrectly derived isocenter localization and subsequent patient positioning errors. Treatment site-specific and scanner-based laser offset correction should be implemented for each patient’s virtual simulation procedure. In addition, the amount of sag should be measured under a clinically representative weight load upon CT-simulator commissioning.     

Chloroquine Psychosis: A Chemical Psychosis?

Psychotic states are mimicked by the use of many drugs including amphetamines, cannabis, lysergic acid diethylamide, psilocybin, mescaline, isoniazid, and L-dopa. A paranoid psychotic picture in a clear sensorium is characteristic of amphetamine psychosis. In developing countries, malaria among other diseases is a frequent indicator of chloroquine administration. The present communication reports a series of chloroquine-induced psychosis in a clear sensorium simulating affective illness, such as mania, mixed affective states, or depression. The psychosis disappeared after cessation of the drug, combined with or without the use of low dosage phenothiazines in excited patients. From our cases, two types of presentation of chloroquine psychosis could be seen: (1) psychic with clear sensorium, mood changes, alteration in motor activity, delusions, and hallucinations; and (2) psycho-organic with clouded sensorium, disorientation, and fleeting hallucinations. The precise nature of the mechanism of the psychosis is not clear because of the limited number of reported cases.     

Metoprolol monotherapy in the treatment of mild hypertension

Metoprolol tartrate (MT) as monotherapy was administered orally in 17 patients with mild hypertension. All other drugs were discontinued 2 weeks prior to MT therapy. The present study group consisted of 10 men and 7 women within the age range of 42 to 71 years (mean ± S.D. = 55.8 ± 8). MT was administered at an initial dose of 50 mg twice daily. Subsequently, the dose of MT was titrated on a biweekly basis for a period of 12 weeks until the diastolic blood pressure was < 90 mmHg or a maximum daily dose of 300 mg was administered. The blood-pressure-lowering effect of MT was found to be clinically satisfactory and statistically significant (P < 0.05). Mild fatigue and swelling of the extremities were seen in two patients each. Mild headache, transient diarrhea, and mild cloudiness of mind were seen in one patient. From this study it is concluded that MT is a safe and effective first-step antihypertensive agent. The long-term effect of MT as a monotherapy in the treatment of mild hypertension needs further clinical evaluation.     

Efficacy of Tinospora cordifolia in allergic rhinitis

The efficacy of Tinospora cordifolia (TC) extract in patients of allergic rhinitis was assessed in a randomized double blind placebo controlled trial. Seventy-five patients were randomly given either TC or placebo for 8 weeks. They were clinically examined and Hb %, TLC, DLC and nasal smear was done. At the end of trial baseline investigations were repeated, drug decoded and results analyzed. With TC treatment 100% relief was reported from sneezing in 83% patients, in 69% from nasal discharge, in 61% from nasal obstruction and in 71% from nasal pruritus. In placebo group, there was no relief in 79% from sneezing, in 84.8% from nasal discharge, in 83% from nasal obstruction, and in 88% from nasal pruritus. The difference between TC and placebo groups was highly significant. TLC increased in 69% patients in drug treated group and in only 11% with placebo. After TC, eosinophil and neutrophil count decreased and goblet cells were absent in nasal smear. After placebo, decrease in eosinophil and neutrophil count was marginal and goblet cells were present. TC significantly decreased all symptoms of allergic rhinitis. Nasal smear cytology and leukocyte count correlated with clinical findings. TC was well tolerated.