Analysis of prognostic factors for 5 year survival in surgically treated patients with carcinoma cervix stages IB1, IB2 and IIA

Aim: To identify pathological and clinical prognostic factors that best predict 5 year survival among patients with early stage cervical carcinoma treated with radical hysterectomy. Methods: Data from 77 patients diagnosed at Safdarjung Hospital, New Delhi, India with carcinoma cervix were taken from 1997 to 2002. Patients were followed up for 5 years. Survival probability was calculated through Kaplan–Meier method for overall survival at 5 years. Univariate and multivariate analysis with Cox's regression model was used to statistically identify the best combination of these risk factors to predict prognosis. Results: Univariate analysis revealed tumour size, lymph node involvement and parametrial spread as significant prognostic factors for survival. Multivariate analysis showed that lymph node involvement and parametrial spread remained significant prognostic factors. Overall carcinoma with tumour size of less than 4 cms had a higher chance for survival. Conclusion: The presence of lymph node involvement and parametrial spread decreased the chance of survival by two and a half and threefold, respectively. Lack of awareness about the screening, symptoms of disease and non‐availability of early diagnostic facilities such as the Pap smear at a primary health care level are areas of priority. The most pressing need is to spread awareness among sexually active women to undergo Pap tests at regular intervals.     

Inducibility of Atrial Fibrillation After GP Ablations and “Autonomic Blockade”: Evidence for the Pathophysiological Role of the Nonadrenergic and Noncholinergic Neurotransmitters

Autonomic Blockade and Atrial Fibrillation . Background: Recent clinical reports that used cholinergic and adrenergic blockade (CAB) as an alternative to ganglionated plexi (GP) ablation to terminate atrial fibrillation (AF) showed mixed results. We investigated the role of other neurotransmitters in AF inducibility. Methods: In 23 pentobarbital anesthetized dogs, a left and right thoracotomy allowed the attachment of electrode catheters to the left and right pulmonary veins and atrial appendages (AA). Programmed stimulation was used to determine the effective refractory periods (ERP) and AF inducibility, measured by the window of vulnerability (WOV). AF duration in response to acetylcholine (Ach; 100 mM) applied to the AA was measured before and after GP ablation + CAB and with vagus nerve stimulation (VNS). After GP ablation + CAB, Ach induced AF duration was determined in response to vasoactive intestinal peptide (VIP) and its specific antagonist ([Ac‐Tyr1,D‐phe2]‐VIP). Results: GP ablation + CAB significantly prolonged ERP, eliminated WOV, and suppressed the duration of Ach induced AF (P ≤ 0.01 for all). Also slowing of the heart rate by VNS was essentially blocked; however, with Ach 100 mM applied to the AA, VNS, and VIP applied to the AA markedly prolonged AF duration. This effect was blocked by the VIP antagonist. Conclusions: Neither GP ablation nor CAB can fully suppress AF inducibility arising from the atrial neural network. Our findings suggest that other neurotransmitters, such as VIP released during VNS, can promote sustained AF despite GP ablation and “autonomic blockade,” which may further define the substrate for AF outside the pulmonary vein‐atrial junctions. (J Cardiovasc Electrophysiol, Vol. 24, pp. 188‐195, February 2013)     

Successful selection of patients with intractable extratemporal epilepsy using non-invasive investigations

PURPOSE: Patients with intractable epilepsy, operated for extratemporal epileptogenic foci, have often been found to have poorer surgical outcome compared with those with temporal lobe foci. The objective of this study is to assess the surgical outcome in patients with extratemporal foci, operated at the All India Institute of Medical Sciences (AIIMS), New Delhi. METHODS: Patients of intractable epilepsy with extratemporal foci on detailed investigation constituted the study group. They were evaluated by the 'Comprehensive Epilepsy Care Team' at the AIIMS with detailed clinical assessment, interictal EEGs, video-EEG studies, magnetic resonance imaging (MRI) with special sequences tailored for evaluation of the temporal lobes and for cortical dysplasias and single photon emission computerised tomography (SPECT) studies. Intraoperative electrocorticography was obtained in some patients. Outcome was assessed on follow-up, and graded according to Modified Engel's Grading System. RESULTS: Twenty-five patients (18 males, 7 females) with a mean age of 19.7 years (age range 7-45 years) were operated and assessed during the study period, for surgical outcome with a mean follow-up of 16.8 months (range 3 months to 6.5 years). Twenty patients (87%) were found to have a good outcome (Modified Engel's grades I and II), while three had poor outcome, one died and one was lost to follow-up. CONCLUSION: We found a good seizure outcome in patients who underwent resection of extratemporal epileptogenic foci, one of the reasons being presence of a lesion in all patients. Careful patient selection even with non-invasive investigations can aid in obtaining a good outcome in this group of patients.     

Early Clinical Experience with a Minute Ventilation Sensor DDDR Pacemaker

The new DDDR pacemaker META DDDR utilizes a minute veritilation sensor based on transthoracic impedance measurements. The sensor determines the metabolic indicated interval, the atrioventricular (AV) delay and the postventricular atrial refractory period (PVARP). The baseline PVARP must be carefully selected to define nonphysiological tachycardias. If a Pwave falls within the PVARP the pacemaker will automatically switch to the VVIR mode. This behavior prevents tracking of paroxysmal atrial tachyarrhythmias (PAT). Twenty-eight patients with sinus node dysfunction (n = 20), AV junction ablation (n = 5), complete or intermittent AV block (n = 3); who received a META DDDR pacemaker were studied. The mean age was 65 ± 13 years. Results: mode switching (reversion) to VVIR was observed in 57% of the patients. Forty-two percent had episodes of mode switching to VVIR during a stress test four related to PAT, and seven to sinus tachycardia. Fifty percent had episodes of mode switching to VVIR during a 24-hour Holter, four related to PAT, three to retrograde P wave sensing, and two to sinus tachycardia. At the last follow-up, 20 of the 26 patients initially programmed to the DDDR mode remained in the DDDR mode, while five were reprogrammed to the DDD and one to the VVIR mode. Mode switching has a high sensitivity but a low specificity for PAT. It appears to be a useful approach to prevent rapid tracking of atrial tachyarrhythmias. Careful PVARP programming is critical to appropriate reversion behavior, but further modifications of the algorithm are needed to improve its performance.