The transition from fetus to neonate – an endocrine perspective

Gluckman PD, Sizonenko SV, Bassett NS. The transition from fetus to neonate - an endocrine perspective. Acta Pædiatr 1999; Suppl 428: 7–11. Stockholm. ISSN 0803–5326
The transition from fetus to neonate involves three phases: late gestation, parturition and the processes needed to establish independent homoeostatic regulation after separation from the placenta. These phases are regulated by a series of fetal and placental endocrine events. Glucocorticoids have an important role in the preparation for birth, including involvement in lung and cardiac development, and the maturation of enzymes in a variety of pathways. Fetal Cortisol production is, in turn, also under hormonal control. Parturition is a complex process, which is still poorly understood in humans. The final steps are largely dependent on the effect of prostaglandin F_2α on the myometrium associated with increased oxytocin activity. The transition to birth is accompanied by changes in respiration, circulation, glucose homoeostasis, and the onset of independent oral feeding and thermoregulation. Several examples of endocrine components of the transition from fetal to neonatal life are reviewed here: the role of prostanoids, the onset of thermogenesis, and changes in the thyroid hormone and growth hormone axes. The effects of hormone levels on prematurity and growth retardation are also discussed. □ Birth transition, fetus, gestation, hormonal control, neonate, parturition     

INITIAL EXPERIENCE WITH SHOCK WAVE LITHOTRIPSY AT ARMY HOSPITAL (R & R) DELHI CANTT

Army Hospital (R & R) has acquired an Electrohydraulic Lithotripter (DIREX NOVA), the first of its kind in the Armed Forces for the treatment of stone diseases. The first 200 patients who underwent Extracorporeal Shock Wave Lithotripsy (ESWL) have been analysed in this study. This being a pilot study would serve as a beginning of an ongoing experience with this non-invasive procedure and its benefits for the stone population in the Armed Forces.KEY WORDS: ESWL, Lithotripsy     

The effects of oncotype DX recurrence scores on chemotherapy utilization in a multi-institutional breast cancer cohort

The use of clinicopathologic features in decision-making in early stage estrogen receptor (ER)-positive breast cancer (BC) may lead to over or under treatment. We investigated the effect of the Oncotype Dx? (ODX) on chemotherapy (CTX) utilization in two cancer centers. 276 cases of node-negative ER-positive BC had ODX between 2005 and 2009. Age at diagnosis, tumor size, grade, and progesterone receptor (PR) status were abstracted from records and provided to two medical oncologists blinded to the ODX score. A recommendation for or against CTX was made based on clinicopathologic characteristics. Median age was 55 years. Mean tumor size was 1.6 cm. The median 10-year Adjuvant! Online (AO) mortality risk was 8. The median Nottingham Prognostic Index (NPI) was 3.3. The median ODX recurrence score was 17. Without knowledge of the ODX, oncologists were more likely to recommend CTX to younger women (P < 0.0001), women with negative PR status (P < 0.0001), higher NPI (P < 0.012), and tumors > 1 cm (P = 0.033). On average, CTX recommended patients had larger tumors (2.0 vs. 1.2 cm) and higher AO 10-year mortality (11.4 vs. 4.4%). ODX resulted in a change in management for 38% of women. Of 188 total patients who did not receive CTX, 71 had a recommendation favoring CTX by an oncologist blinded to the ODX score. In our multi-institutional cohort, the ODX score had a significant impact on the receipt of adjuvant CTX and altered management for 38% of women.     

Pregnancy after breast cancer: if you wish,ma’am

A growing number of young breast cancer survivors consider reproductive health issues, including subsequent fertility and pregnancy, of great importance, but many questions regarding safety remain unanswered. We conducted a comprehensive literature search and review of published articles, control-matched, population-based, and co-operative group reports that addressed various aspects of pregnancy after breast cancer (patients’ expectations, fertility damage, assessment and preservation, maternal and fetal outcome, breast feeding). Overall, available data support pregnancy and breast feeding after breast cancer as safe and feasible for women at low risk of recurrence. This retrospective and population-based evidence is, however, frequently incomplete; usually not representative of the entire population, it can be biased by patients’ related effects or underpowered and is often not controlled for biological factors and risk determinants in the statistical model used. Before making any definitive assumption on this delicate and fundamental aspect of a woman’s life after breast cancer, we should demonstrate without any reasonable doubt that the scattered information available today is scientifically sound. The Breast International Group and North American Breast Cancer Group are planning a global prospective study in young women with endocrine responsive, early breast cancer who desire pregnancy, to assess both patients’ and pregnancy outcomes. The trial will include an observational phase investigating the feasibility and impact of a temporary treatment interruption to allow conception and an experimental phase investigating the optimal duration of the subsequent endocrine treatment after delivery or the last failed attempt to get pregnant.     

Spinal instability in ankylosing spondylitis

Background:

Unstable spinal lesions in patients with ankylosing spondylitis are common and have a high incidence of associated neurological deficit. The evolution and presentation of these lesions is unclear and the management strategies can be confusing. We present retrospective analysis of the cases of ankylosing spondylitis developing spinal instability either due to spondylodiscitis or fractures for mechanisms of injury, presentations, management strategies and outcome.

Materials and Methods:

In a retrospective analysis of 16 cases of ankylosing spondylitis, treated surgically for unstable spinal lesions over a period of 12 years (1995-2007); 87.5% (n=14) patients had low energy (no obvious/trivial) trauma while 12.5% (n=2) patients sustained high energy trauma. The most common presentation was pain associated with neurological deficit. The surgical indications included neurological deficit, chronic pain due to instability and progressive deformity. All patients were treated surgically with anterior surgery in 18.8% (n=3) patients, posterior in 56.2% (n=9) patients and combined approach in 25% (n=4) patients. Instrumented fusion was carried out in 87.5% (n=14) patients. Average surgical duration was 3.84 (Range 2-7.5) hours, blood loss 765.6 (± 472.5) ml and follow-up 54.5 (Range 18-54) months. The patients were evaluated for pain score, Frankel neurological grading, deformity progression and radiological fusion. One patient died of medical complications a week following surgery.

Results:

Intra-operative adverse events like dural tears and inadequate deformity correction occurred in 18.7% (n=3) patients (Cases 6, 7 and 8) which could be managed conservatively. There was a significant improvement in the Visual analogue score for pain from a pre-surgical median of 8 to post-surgical median of 2 (P=0.001), while the neurological status improved in 90% (n=9) patients among those with preoperative neurological deficit who could be followed-up (n =10). Frankel grading improved from C to E in 31.25% (n=5) patients, D to E in 12.5% (n=2) and B to D in 12.5% (n=2), while it remained unchanged in the remaining - E in 31.25% (n=5), B in 6.25% (n=1) and D in 6.25% (n=1). Fusion occurred in 11 (68.7%) patients, while 12.5% (n=2) had pseudoarthrosis and 12.5% (n=2) patients had evidence of inadequate fusion. 68.7% (n=11) patients regained their pre-injury functional status, with no spine related complaints and 25% (n=4) patients had complaints like chronic back pain and deformity progression. In one patient (6.2%) who died of medical complications a week following surgery, the neurological function remained unchanged (Frankel grade D). Persistent back pain attributed to inadequate fusion/ pseudoarthrosis could be managed conservatively in 12.5% (n=2) patients. Progression of deformity and pain secondary to pseudoarthrosis, requiring revision surgery was noted in one patient (6.2%). One patient (6.2%) had no neurological recovery following the surgery and continued to have nonfunctional neurological status.

Conclusion:

In ankylosing spondylitis, the diagnosis of unstable spinal lesions needs high index of suspicion and extensive radiological evaluation Surgery is indicated if neurological deficit, two/three column injury, significant pain and progressive deformity are present. Long segment instrumentation and fusion is ideal.     

Modalities of Empowerment and Strengthening of Ex-servicemen

Background

Older people including ex-servicemen (ESM) in India are left to fend for themselves due to nuclear family system. Most children are not staying with them due to reasons such as acquiring of education or employment at distant places. These factors, coupled with deteriorating health with advancing age, change in value system and attitude amongst children who give more importance to materialism, it was felt necessary to find modalities to empower and strengthen ESM by available methods of including progressive weight training, yoga and meditation.

Methods

An interventional “Before and After” study was planned for a period of three months for in-patient ESM of a military hospital for common lifestyle diseases namely stroke, diabetes, senile depression, acute myocardial infarction and hypertension. Data of anthropometry, laboratory investigations and Hamilton rating scale for depression (HRSD) were taken before the study. These cases were then subjected to interventions (progressive weight training and spiritual health enhancement by yoga with meditation for three months) followed by same measurements again.

Result

Statistically significant differences were observed before and after study with respect to pulse, respiratory rate, blood pressure, blood glucose, total cholesterol, low density lipoproteins (LDL), very low density lipoproteins (VLDL) and Hamilton depression score (p<0.05). The sleep pattern, sense of well being and posture while sitting to standing and walking with degree of support (stick/other person''s help) improved considerably after the interventions.

Conclusion

ESM are recommended to be trained much before retirement on progressive weight training and yoga in regimental centre/station institute. Provision to be made in existing ex-servicemen contributory health scheme (ECHS) polyclinics for employment of part time trainers for weight training and yoga. The physical and spiritual strengthening results in better capability to deal with old age and its problems.Key Words: Ex-servicemen, Progressive weight training, Yoga, Spiritual health     

Molecular profiling assays in breast cancer: are we ready for prime time?

Breast cancer is a heterogeneous disease with diverse morphologies, molecular characteristics, and clinical behavior. The advances in molecular profiling technologies have changed our understanding of breast cancer and led to the identification of prognostic/predictive gene signatures. Despite the huge quantity of information gleaned from these profiling technologies and the increasing number of gene signatures, their incorporation into clinical decision making is a slow process and is limited in various aspects. The 70-gene assay (MammaPrint, Agendia, Netherlands) and the 21-gene assay (Oncotype DX, Genomic Health, USA) are the most widely used breast cancer multigene classifier assays. A 50-gene assay (PAM50, NanoString, USA) has shown promise but needs further independent validation. In this review, we will present the current data on commercially available molecular profiling assays in breast cancer and discuss the challenges surrounding their incorporation into routine clinical practice as prognostic and predictive tools.