Factors Influencing the Status of the Surgical Margin in the Resection of Oral Squamous Cell Carcinoma

Abstract

Aim: Surgical margin status in the resection of oral squamous cell carcinoma (OSCC) is a significant prognostic indicator of recurrence and long term outcome. We sought to investigate the factors (patient, tumour and surgical) at time of surgery that influenced the ability to achieve adequate surgical margins.

Method: We retrospectively reviewed patients who had undergone primary resection of OSCC. Over a 4-year period (2012-2015) 100 patients were surgically treated. Histological derived margins were classified as clear (≥5mm), close (<5mm) or involved (tumour present at resection margin).

Results: Overall, 49%, 45% and 6% had clear, close and involved margins respectively. Of the 100 patients, 28 had stage I, 21 stages II, 7 stages III and 44 stage IV diseases. No relationship was evident between margin status and sex, age (<65), surgical access or individual surgeon. Maximum tumour diameter and depth of invasion were significant factors relating to poorer margins (p=0.015 and 0.021). Tumour site appeared to have no impact upon margin status. The histological feature of bone invasion had a significant impact upon poorer margins (p=0.015), as did a positive node status (p=0.0054). We were unable to correlate lymphovascular or perineural invasion with margin status.

Discussion: We highlight tumour factors which appear to influence the margin status of resected OSCC, notably tumour size and depth, nodal spread and bone invasion. These all correlate to advanced stage disease being more difficult to treat. Our findings further stress the importance of being able to identify and delineate tumour mass intra-operatively to facilitate a clear resection margin.

Keywords: Head and Neck cancer; Oral squamous cell carcinoma; Surgical margin; Tumour Resection

Introduction

Recently published UK data stated a 5-year disease-free survival of 74% and a local recurrence rate of 10% for patients with surgically treated oral squamous cell carcinoma (OSCC) [1]. Whilst several factors account for poor outcomes within the treatment of OSCC, surgical margin clearances a recognised negative prognostic indicator of local recurrence with mixed evidence of its impact upon long-term survival [2-8]. Current UK guidelines set the goal of 10mm as the gold standard for macroscopic margin clearance [9]. Allowing for specimen shrinkage this relates to a 5mm pathological margin. In the oral cavity, arguably more so than other sites, this may be difficult or indeed impossible taking into account the need to preserve nearby vital structures.

Furthermore, the ability to compare data on surgical margin significance is marred by the lack of clarity of what defines an ‘involved’, ‘close’ and ‘clear’ margin. The involved margin can either be considered as<1mm [10] or the presence of frank tumour at the resection edge [11]. The widely accepted definition of a close margin is that of <5mm clearance [9]. The importance of the definition of the close and involved surgical margin is paramount when determining the need for adjuvant radiotherapy. With such emphasis placed on the determination of this characteristic and the potential for post-operative morbidity, several authors have argued for 4mm [12] or even 3mm [8] to be considered a close margin, to better guide adjuvant treatment. Whilst studies have identified factors that influence the adequacy of the surgical margin, including tumour site [2,13], advanced T-stage [2,13,14], tumour size [2,14], depth of invasion [14] and histological features [2], few have drawn a direct comparison of these variables to the adequacy of the resection margin. With this in mind we sought to investigate what factors (patient, tumour and surgical) influence the surgical margin when resetting OSCC and the potential impact this has upon surgical management.

Method

Our inclusion criteria were defined as all head and neck cancer patients who had undergone surgical resection for primary oral SCC. From the period 2012-2015, 100 patients met our inclusion criteria and were included within the study. All patients had been seen through a designated head and neck oncology clinic and investigated as appropriate with biopsy and imaging, and MDT discussion. Four Consultant surgeons operated during the 4-year period. The following datasets were collected: demographics (age, sex), clinical (stage, site, surgeon, surgical access) and pathological (margin status, histological features). Histological assessment was performed according to a standardized protocol producing a consistent OSCC dataset, with specimens examined by a Consultant Pathologist.

In line with previously published reports of a similar nature [2] and to allow comparison, we used the following definition of surgical margins: Clear-No evidence of tumour at 5mm or greater from the margin, Close-Tumour within 5mm of margin, Involved- Evidence of frank tumour at margin. Univariate analysis was used to compare the aforementioned variables to the three margin groups. Chi-square test was used to analyse contingency tables and the Mann-Whitney U Test was used to compare nominal variables (margin status) to continuous variables (tumour depth). A p-value of <0.05 was considered statistically significant.

Results

Of the 100 patients, 28 had stage I, 21 stages II, 7 stages III and 44 stage IV diseases. Forty-nine patients had clear margins, 45 had close margins and the remaining 6 patients had involved margins. In all involved cases the deep margin was the site of involvement. With regard close margins, 40% (18) were close on the deep margin, 42.2% (19) on the lateral/mucosal margin and 17.8% (8) close on both margins. The study cohort consisted of 54 male and 46 female patients. For the purpose of categorising age, a cut off of 65 was used, with 61 patient’s ≥ 65 years of age. No significant correlation was found between margin status and gender or age.

The most commonly used surgical approach was per oral (86%), with lip split (2%), Weber-Ferguson (4%) and Transcervical (8%) approaches also utilised. No association was found between surgical access and margin status. Furthermore, no significant difference was found between operating surgeon and margin status. Seventy-three patients underwent micro vascular reconstruction and 74 patients received modified radical neck dissection. There was no significant difference in surgical margin status between the micro vascular and non- micro vascular cohorts. For the purposes of data continuity, when no neck dissection was performed in the clinically node negative neck then nodal metastasis and extracapsular spread was recorded as not present (N0). Thirty-five percent of patients received post-operative radiotherapy.

With regard tumour site, the majority were tongue cancers (45%), followed by cancers of the alveolus (21%). No association was found between site and margins status. Whilst tongue cancers exhibited the majority of involved margins, this was likely skewed due to higher patient numbers in this group. Tumours of the lower alveolus appeared to have proportionately more close margins and all palatal tumours were excised with close margins. Tumours of a greater maximum diameter exhibited poorer margins (p=0.015), with the majority lying in the T2 category of 21-40mm and almost all of those >40mm in size demonstrating close or involved margins. Average depth of invasion for clear vs. close/involved margins was 7.5mm and 11.7mm respectively. To evaluate tumour depth, as no clear validated categories are available, the Mann Whitney U test was used to compare clear vs. close/involved margins to depth of invasion on a continuous scale. A greater depth of invasion was significantly associated with close/involved margins (p=0.021). When evaluating nodal status, there was a significant relationship between patients with nodal metastases and extra capsular spread, and inadequate margins (p=0.014).

Histopathological data revealed a significant relationship between bone invasion and inadequate margins (p=0.015). There was no significant association between margin status and the other histological variables of lymphovascular invasion, perineural invasion, severe dysplasia, and non-cohesive growth front and tumour differentiation. Using descriptive analysis, tumours with perineural and/or lymphovascular invasion had a greater proportion of close margins compared to other histological variables. The majority of tumours appeared to have a moderately differentiated non-cohesive invasive tumour front (75% and 86%), which may explain why the low numbers in other categories negated any clear trend in these variables towards margin status.

Discussion

If the adequacy of the resection margin for OSCC is an indicator of outcome and need for adjuvant therapy, then the aim of this study was to identify what factors, present at the time of surgery, both impact and are within our control to influence the quality of our resection. Our involved margin status of 6% is in line with previously reported figures (4.5-22%), but forming a direct comparison is difficult. Whilst those studies that use the definition of an involved margin as tumour at the resection have an average of approximately 5-10%, those that state <1mm as involved exhibit skewed data with figures as high as 24% [6]. Perhaps for this reason, recent research has focused on the definition of the close surgical margin, as this is seen as the ‘grey’ area of deciding whether adjuvant treatment is required [5,8].

It was our hypothesis that we would discover that larger tumours and those more posterior in the mouth would have a higher frequency of close or involved margins, due in part to difficulty in surgical access and resection. However, from our data, tumour site does not appear to influence adequacy of resection margin. In a series of 110 patients, Lawaetz et al. reported that floor of mouth cancers had significantly poorer margins when compared to tongue cancers [13] and this finding was mirrored by Nason et al. who found that in 277 patients, tongue cancers had significantly clearer margins than other sites [8]. The ability to manoeuvre the tongue within the mouth when compared to other ‘fixed’ anatomical sites potentially explains these previous findings. Like Sutton et al., we were unable to find this correlation between site and margin status [2], perhaps due to a disproportionately large number of tongue tumours compared to other sites.

Evaluating surgical factors, the surgeon and complexity of the procedure had no impact upon the margin status. The majority of our resections were performed via oral access, which leaves us unable to fully analyse the impact of more complex surgical approaches. Within our cohort, tumours of increasing diameter and depth of invasion had significantly poorer margins (p = 0.015 and 0.021), supporting the findings of Sutton et al. and Girardi et al. We assume these relationships relate to difficulty in surgical resection, whereby either the surgeon identified the tumour margin and chose to perform a close resection to preserve nearby vital structures, or was unable to accurately assess the tumour margin in the first instance and performed a normal wide excision, as may be the case with a deep irregular infiltrating tumour. As in other studies [2], the presence of nodal metastases was significantly correlated to poorer margins (p=0.0054), with 5 of the 6 patients with involved margins demonstrating nodal metastases.

However, the presence of extra capsular spread did not appear to have a correlation to margin status. The above findings draw the conclusion that tumours with increased aggression and metastatic potential demonstrated poorer surgical margins. These findings are further highlighted when comparing overall stage of disease to margin status. Those with early stage I and II disease had a significant trend towards clearer margins when compared to late stage III and IV disease (p=0.02). Whilst previous research has reported a strong link between inadequate margins and the features of the invasive tumour front and perineural and vascular invasion [2], like Lawaetz et al. and Girardi et al. we were unable to replicate these findings [13,14]. Of all the histological characteristics we analysed, the presence of bone invasion was the only variable significantly associated with inadequate margin status.

In resections of large tumours infiltrating bone, the desire is undoubtedly to preserve as much hard tissue as possible to broaden reconstructive options, which may explain this finding. Sutton et al. noted that given the correlation between pathological findings and margin status, then resection clearance “should be regarded as a product of aggressive tumour behaviour in addition to, or even rather than, inadequate surgical resection”. Their suggestion was the potential use of larger initial biopsies, to better identify those pathological characteristics and prepare the surgeon for a wider excision. This notion is obviously balanced against the surgical morbidity in resection and reconstruction and the desire to preserve vital structures. One option is the use of intra-operative frozen sections, but its clinical application is contentious for reasons of cost and reliability [15].

If our findings are applied to clinical practice, the conclusion is that the only parameters we are able reliably to use to predict margin status are those of the already adoptedpre-operative staging assessment of tumour size, depth of invasion and nodal metastasis. McMahon et al. discussed the importance of using an ‘anatomical approach’ in the resection of OSCC [16]. When comparing surgical margin adequacy between 2 cohorts a decade apart, they demonstrated that the use of modern imaging and in particular post-acquisition processing to better define tumours reduced the involved margin rate from 37% to 5%. A similar approach was taken by Ota et al., who used a combination of US, CT and MRI to evaluate buccal SCC cancers and define them preoperatively into 3 categories based upon depth of invasion in relation to the buccinators muscle [17]. They reported increased local control and long term survival when compared to previous surgical methods. As the deep aspect was responsible in all of our involved margins, and over half of the close margins, such a technique may be applicable to other sites in the mouth. Whilst the above enhanced pre-operative assessment can improve outcomes, the ability of the operating surgeon to better visualise and delineate the tumour mass intra-operatively is the gold standard.

To these effect agents such as Toluidine blue [18] and Lugol’s Iodine [19] have been suggested, with apparent positive outcomes. The use of Lugol’s iodine is currently the topic of a UK based multicentre RCT [20]. Perhaps the most exciting advancement is the use of 3D navigation to improve tumour resection rates. Using this technology the surgeon is able to define the tumour on preoperative imaging and set a tumour “distance wall” correlating to a safe resection margin in relation to nearby vital structures, this is then used intra-operatively to guide the exact resection [21]. This dataset represents the beginning of an evolving head and neck database within our unit. As such we accept that the most significant limitation of our study is the absence of any recurrence or long term survival data, and relatively low patient numbers.

Conclusion

If we accept that surgical margin status is a significant negative prognostic indicator of outcome in the treatment of OSCC, then efforts should continue to better identify factors relating to and methods to improve the standard of resected margins. Our findings add weight to the evidence that the characteristics of tumour invasion to deep tissues and bone together with nodal metastases correlate to the adequacy of surgical margins, regardless of tumour site or surgical procedure complexity. It remains to be seen how we can better improve surgical margins by delineating tumour mass intra-operatively.

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Economics and Importance of Beekeeping

Opinion

Apiculture or Beekeeping is the art and science of collecting, processing honeybee colonies of desired species having them in specified and standard boxes, installing at appropriate sites, managing optimum number of colonies scientifically round the year and harnessing both direct and indirect benefits of the activities. As such a degree or high qualification is not essential in order to work in this profession. Apiarists can be developed and trained to handle the enterprise. There is vast potential and scope from diversification in Apiculture i.e. besides honey its offers scope for production and marketing of other bee products like bee pollen, bee propels, bee way bee venom and Royal selling. Honeybees can also be managed as and when required for pollination of field and Horticultural crops and for hybrid seed production in vegetables and other bee pollination crops technologies for the production of different products i.e. Royal jelly, bee pollen, bee porpoise, bee venom, Queen bees, package bees etc. now available in India Thakur 2008.

In Haryana state, commercial beekeepers are keeping Apis mellifera L.. bee whose queen is highly prolific and lay about 1500-2000 eggs per day during honey flow season. Therefore the colonies always remain in good strength. At present Haryana state is one of the leading state in India in honey production in the year 2004-05 there were only 28,000 colonies from which about 275mt of honey (years 2015-16) about 3,05,000 bee colonies from which about 4100mt honey in produced annually. Haryana has vast resources of bee flora, there is a great scope for further expansion of beekeeping in the state. In Haryana, where land holding is less than 0.75ha beekeeping can provide better food, balanced nutrition and employment to small and marginal farmers. It can also provide the unemployed and underemployed persons with full employment and extra income. A honey bee is member of the genus Apis, primarily distinguished by the production and storage of honey and the construction of perennial, colonial nests from wax Table 1.

Table 1: Economics of Beekeeping.

Currently only 7 species of honeybee are recognized the best known honey bee species Apis mellifera L. (western honey bee) which has domesticated for honey production and crop pollination. Honey bees present only a small fraction of roughly 20,000 known species of bees. But only members of the genial Apis are true honey bees. Two species of honey bee Apis mellifera L. and Apis cerana indica F. (Indian Honey bee) are often maintained fed and transported by beekeepers. Modern bee hives also enable beekeepers to transport bees, moving from field to field as the crop needs pollinating and allowing the beekeeper to charge for the pollination services. They provide, revising the historical role of the self employed beekeeper and favoring large scale commercial operations Table 2.

Table 2: Economics of Honey production and returns.

Bee Keeping Industry

Beekeeping is an ideal activity which provides supplementary income to a large number of rural, hilly and tribal production and also for horticulturists, agriculturists, hobbyist etc. because of the rich flora available in abundance in the country. Any beginner who wants to start beekeeping should known some of the aspects of beehives, tools, locations where honey bees can be kept with its attempt to known honey bee and its start with one should known and learn more about honey bee and its requirement in order to make honey bee work for beekeeper. Most valuable return of the industry is the honey, wax and pollination service rendered by bees which increase yield of many of the agricultural and horticultural crops.

*¹Total of 60,000+42,000+20,000+10,000=1,32,000

*² Total of 1,32,000+17,500=1,49,500

Return expenses = Honey production-Net profit

272000-149500=1, 22,500 Rs/-

Bee’s increase (25×1800) = 45,000 Rs/-

Net profit annual =1, 67,500 Rs. Which is excellent profit?

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Kienbock Disease, a Tertiary Care Experience from the Developing World

Abstract

Introduction: Kienbock’s disease is a form of osteonecrosis of lunate, first described in 1910 by Robert Kienbock. It occurs most commonly in men aged 20 to 40 years of age. Its exact etiology is still under study but most hand surgeons believe to be a multi-factorial origin and some time establishing the diagnosis is a challenge especially in unaccustomed hands. Management of Kienbock’s disease is focused on alleviating pain and halts the worsening disease process [1]. Our study aims to determine the functional and radiological outcome after surgery for Kienbock’s disease.

Objective: To determine the functional and radiological outcome after surgery for Kienbock’s disease.

Methods: The retrospective review of patients managed operatively for Kienbocks disease at Aga Khan University Hospital Karachi. Kienbock disease was classified according to Lichtman and Ross Classification. Patients underwent various procedures including surgical decompression and vascular bone grafting, etc. Radiological variables and outcomes were assessed.

Results: Of the 7 patients, 3 (42.9%) were men and 4 (57.1%) women. The right side was involved in 5(71.4%) patients, and 2(28.6%) had a left sided Kienbock disease. Duration of symptoms ranges from 8 months to 84 months with mean 31.12 +/- 26.63. Post operative x-rays 6 months follow up which showed Ståhl index minimum 0.29 to maximum 0.45 with mean 0.36 (sd .055), Nattrass index ranges from 0.76 to 1.74 with mean 1.4 (sd 0.31) and Radioscaphoid angle varies from 46.3 to 60.6 with mean 51.7 (sd 5.4).

Conclusion: We concluded that revascularization procedures are effective treatment in stage II and IIIa. Limitation was limited number of patients which encourage multi-centre trial to prove the efficacy of treatment.

Introduction

Kienbock’s disease is a form of osteonecrosis characteristically affecting the lunate, first described in 1910 by Robert Kienbock who identified the changes in the proximal portion of the lunate and affecting the radiolunate articulation [2]. It is characterized by lunate sclerosis, cystic changes, fragmentation and articular surface collapse on plain radiograph [3,4]. It occurs most commonly in men aged 20 to 40 years of age. Its exact etiology is still under study but most hand surgeons believe to be a multi-factorial origin and some time establishing the diagnosis is a challenge especially in less experienced hands [5]. Litchman et al. [6] provided four progressive radiological stages of the disease which can be used access the progression of disease. Management of Kienbock’s disease is focused on alleviating pain and halt the worsening disease process [7]. Various standard modalities are used to treat this disease, including nonsurgical management, vascularised bone graft (VBG), joint levelling procedures, intercarpal arthrodesis, proximal row carpectomy and total wrist arthrodesis [8,9]. Gupta et al in 2014 presented their experience in 12 patients and found improvement in the functional outcome after treatment [3]. Our study aims to determine the functional and radiological outcome after surgery for Kienbock’s disease.

Patients and Methods

The retrospective review of patients managed operatively for Kienbocks disease from January 2005 to December 2015 at Aga Khan University Hospital Karachi. All adult patients with radiological evidence of Kienbocks disease were included. Kienbock disease was classified according to Lichtman and Ross Classification of Lunate osteonecrosis. Patients underwent various procedures including surgical decompression and vascular bone grafting, carpel fusion and iliac bone grafting, radial shortening, and external fixator. Radiological variables and outcomes were assessed by viewing appropriate pre-operative, post-operative and 6 month follow-up radiographs. Stahl index, Nattrass index and Radioscaphoid angle were calculated. Data was analyzed using SPSS 20.

Results

Of the 7 patients, 3 (42.9%) were men and 4 (57.1%) women. The right side was involved in 5 (71.4%) patients, and 2 (28.6%) had a left sided Kienbock disease. Duration of symptoms ranges from 8 months to 84 months with mean 31.12±26.63. According to Lichtman and Ross Classification of Lunate osteonecrosis, stage II had 3, stage IIIA had 1, stage IIIB had 2 and stage IV had 1 patient. Three patients with stage II were underwent decompression of lunate bone and vascular bone grafting, in stage IIIB one patient had radial shortening and vascular bone grafting and 2nd patient underwent lunate decompression and bone grafting with unilateral external fixator application, stage IV patient had wrist reconstruction with carpel fusion with iliac bone grafting. Postoperatively patients were immobilized with splint for 6 weeks with exception of patient with external fixator (Tables 1 & 2).

Table 1: Characteristics of patients in the present study (n = 7).

Table 2: Radiological outcomes of patients in the present study (n = 7).

Post operative 6 months follow up x-rays which showed Ståhl index minimum 0.29 to maximum 0.45 with mean 0.36 (sd .055), Nattrass index ranges from 0.76 to 1.74 with mean 1.4 (sd 0.31) and Radioscaphoid angle varies from 46.3 to 60.6 with mean 51.7 (sd 5.4). One of our patient developed persistent wrist pain and later on diagnosed as Osteoid osteoma. Two and half years later we did curettage with bone grafting. Patient treated with no recurrence.

Discussion

Kienbock disease though very rare but presents with agonizing wrist pain affecting the life of working individual. Situation would be more worrisome if they end up in primary care physicians. The radiographic findings don not correlate to the severity of symptoms [1]. A recent meta analysis showed subjective pain relief in all patients whereas object improvement in grip strength and range of movement in all patients treated surgically either joint levelling surgeries or VBG [1]. Our study also showed improvement with joint levelling procedures for negative ulnar varience. Impairment of vascularity is also thought be part of disease process and vascularised bone grafting, which could be expected to restore the biological environment. In our study 5 patients who received vascularised bone grafting showed improvement [10]. One of our patient developed persistent wrist pains one year post operatively and later on diagnosed to be Osteoid osteoma. He was managed by curettage with bone grafting. Due to very limited disease volume evaluation of multicentre data may help enhance better understanding of the disease. Though the present study is small case series we found decompression and vascularised bone grafting has provided promising results.

Conclusion

We concluded that revascularization procedures are effective treatment in stage II and IIIa. Limitation was limited number of patients which encourage multi-centre trial to prove the efficacy of treatment.

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The Impact of the Multi-Disciplinary Team Approach In Managing Palliative Head and Neck Cancer Patients: A Review

Abstract

End of life care in head and neck cancer (HNC) is a complex process, addressing symptomatic, functional and psychosocial needs. In order to provide a high level of care the role of each member of the palliative care multi-disciplinary team (MDT) is vital. This review article discusses end of life care in HNC and the palliative care pathway. We highlight the contribution of each palliative care MDT member and the role of the head and neck surgeon in end of life care.

Introduction

The World Health Organisation define palliative care as: “an approach that is aimed at improving the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”[1]. For the head and neck cancer patient who presents with advanced, incurable or recurrent disease, the role of palliative therapy is vital to ensure both quality of life and quality of dying, with as far as possible a symptomless end of life. Current estimates are that 60% of patients with head and neck cancer present with stage I or II disease, and of those 40% presenting with advanced disease, 10% will have metastatic “incurable’ disease at presentation [2]. Furthermore, as five-year survival data for head and neck cancer approaches two thirds [3], it should be at the forefront of the head and neck surgeons mind that one third of patients will require some form of palliative care. This essay will discuss the impact of the specialist palliative multi-disciplinary team (MDT) upon the head and neck cancer patient, briefly describing non-oncological palliative care treatment modalities and their application by various members of the palliative MDT.

Why the Need for Specialists in Palliative Care medicine and the MDT?

It is paramount for the modern surgeon to appreciate the needs of the palliative head and neck cancer patient; hence having a thorough understanding of the reasoning behind specific palliative care interventions. Palliative interventions are directed by patient presenting signs and symptoms (Table 1). However, palliative care of head and neck cancer is further complicated by site specific squeal that arise in the location of the tumour. Such symptoms are dysphagia, oral problems, and airway obstruction with feeding and communication difficulties. Tumour fumigation, fistula formation and hemorrhage are serious end-stage consequences [4,5]. As can be seen, these are complex and distressing outcomes that require specialist input. In 1987, palliative medicine was recognized as a medical specialty [6]. Palliative medicine provides care relating to symptom management, management of complex psychosocial and spiritual issues, terminal care, and decision making in uncertain progressive situations [6]. In the UK, palliative care services are offered in hospital, community (including hospice care), and outpatient clinic/day therapy settings.

Table 1: Palliative care problems experienced by head and neck cancer patients.

This palliative care service is delivered as part of a specialist MDT, co-operating with numerous other specialties, including head and neck surgery. According to the NHS England Cancer Quality Improvement Network System and the Royal College of Physicians, the palliative care MDT comprises of ‘core/specialist’ and ‘extended’ members [6,7]. Core/specialist members include the palliative medicine team, palliative clinical nurse specialists (CNSs), specialist physiotherapist, specialist occupational therapists and specialist social workers. Several extended members, together with the primary surgeon and oncologist make up the MDT (Table 2). The need for such a diverse MDT becomes apparent when one considers the medical, ethical and psychosocial challenges that arise in end of life care [8]. As Schuman [8] state, palliative care requires “proactive consideration of quality of life, functionality, symptom control and other patient-centered objectives” [8]. At times these factors can be in conflict and the ‘team approach’ is essential to balance needs of care.

Table 2: Members of the specialist palliative care MDT.

The palliative Care Pathway

The palliative needs of a patient should be addressed at initial treatment planning and regularly throughout on-going phases of treatment [2]. If not already involved, the onus is on the surgeon to seek help from a CNS and/or Consultant in palliative medicine [9]. Roland and Bradley listed factors that influence the palliative care decision-making process for head and neck cancer patients. They separated these into patient, tumour and clinician related (Table 3) [2]. With these factors in mind, the planning and provision of palliative care should begin as soon as incurable head and neck cancer is diagnosed, and continue until death; utilizing a MDT approach. The palliative care pathway begins with surgical or nonsurgical oncological treatment to prolong life, followed by terminal non-oncological symptom control and progression onto the end of life pathway (Figure 1). The National Institute for Health and Care Excellence (NICE) describes 6 steps for end of life care to ensure all needs of the patient and family are met with co-ordination of relevant services (Figure 2). In the UK, the Liverpool Care Pathway currently guides end of life care.

Table 3: Factors that influence the palliative care decision making process for head and neck cancer patients.

Figure 1: The palliative care pathway.

Figure 2: NICE 6 steps for end of life care.

Where and when to Provide Palliative Care

The location where terminal patients receive treatment should enable a pain free, peaceful and dignified death, with relatives presents [10]. Ideally, the patient should be allowed to decide where they wish to die. The location may also govern the quality of care patients receive and the provisions in place to ensure this care is delivered; such as access to palliative care specialists in hospices, or Macmillan CNSs at home. A recent study by Kamisetty et al. [11] found that for UK oral cancer patients treated with palliative intent, 34% died in hospital, 22% in a hospice, 22% in their own home, and 22% in a nursing, residential or old people’s home. In a similar study, assessing UK head and neck cancer patients, Ethunandan et al. [10] reported 63% died in hospital, 19% in a hospice and 16% at home. Despite long held social opinion that dyeing at home is preferable, this group argued that the shift to hospital deaths is due in part to a societal change in pastoral and family support. They also noted that the reliance, especially in complex head and neck cancer patients, on technology may be driving palliative care towards the hospital setting. Whilst a hospice setting arguably provides the best access to technology and the palliative MDT, this group reported 53% of patients requiring emergency admission in the final month of life that led to terminal events.

The establishment of specialist centers and specialist palliative care networks is a requirement of the NHS National Cancer Peer Review Programme [12]. Such ‘Expert Centers’ can provide improved psychosocial support to patients and families and better contact between head and neck surgeons with patients and families [13]. Kwon et al. [33] described the characteristics of patients attending a ‘supportive care centre’ (this name was chosen because the term ‘palliative’ was seen as a barrier to referral from physicians) [14]. They grouped patients into ‘early referrals’ (expected survival > 2years) or ‘late referrals’. A significantly greater proportion of early referral patients had head and neck cancer, compared to the late referral patient group (67% vs 6%). These patients were younger, less likely to be married, more likely to suffer from alcoholism and attended services more regularly. This data has ramifications for head and neck surgeons, and the early attendance and referral of such patients to palliative services. The outcome of the above findings is that while head and neck surgeons should respect patient’s wishes regarding location of palliative treatment, they should be increasingly prepared to facilitate and partake in the palliative pathway in hospital as these numbers increase. Furthermore, as Kwon et al [33]. Demonstrate, head and neck cancer patients are more likely to seek palliative care earlier, and thus may present to the head and neck outpatient clinic with palliative needs.

The Impact of Palliative Clinical Nurse Specialists

In the UK, we are fortunate to have access to head and neck oncology and Macmillan palliative CNSs. These nurses are based either in hospital or the community and play a significant role in specialist palliative services in the UK [16]. In a qualitative descriptive study, Howell. Investigated the activities and patient interactions of community palliative care CNSs [17]. They described how palliative CNSs act as ‘liaison points in a complex health service’ and were involved in the assessment, care planning, intervention and evaluation of terminal patients. In such a difficult time for both patients, careers and relatives, CNSs require the ability to make real-time decisions, co-ordinate care in complex situations, and communicate between several teams. Furthermore, CNSs provide the emotional care and support for cancer patients, often overlooked and not delivered elsewhere [18]. CNSs appear to have key roles both in the hospital setting and the hospice/community. CNSs have been reported as acting as triage leaders for the hospitalbased palliative care team; improving the triage process, team efficiency and timely access to care for patients and families [19]. In a similar leadership role, Brockis examined the function of a palliative CNS in the emergency department and acute medical unit [20]. They found that for patients with palliative and end of life needs, 15% were assessed early by the CNS and avoided admission with discharge back home or directly to a hospice. In addition they were able to reduce hospital stay and provide early provision of specialist palliative care for those patients admitted. In the hospice environment, in addition to routine care, CNSs have a key managerial role to facilitate palliative care meetings and adhere to the palliative care ‘gold standards framework’ [21]. While the above roles of CNSs seem generic to all cancer patients, these interactions will overlap with head and neck cancer patients. Furthermore, as previously mentioned, the location of head and neck cancer creates specific palliative symptoms related to airway and eating/speaking difficulties. Macmillan and palliative CNSs receive education, often at a postgraduate level, specific to their field and are therefore experts in managing terminal head and neck cancer patients [22]. It can be seen from the above, that CNSs are truly the lynch pin in the delivery of specialist palliative care. They will be the first port of call for patients in outpatient head and neck cancer services [23], and will assess and co-ordinate both hospital and community based palliative care for head and neck cancer patients.

Allied Healthcare Professionals in the Palliative MDT

As described, the palliative care MDT comprises of extended members. In this section we discuss the role of several of these teams. Specialist dietitians are able to provide nutritional counseling and provide oral nutritional supplements to palliative head and neck cancer patients. As Ardillo states of head and neck cancer patients: “the unique set of side effects of the disease process and treatment cause the patient to develop nutritional challenges” [24]. In a recent review, Hayward and Shea listed factors relating to nutritional issues in head and neck cancer patients (Table 4) [25]. It can be seen that the impact of these issues upon the nutritional needs of head and neck cancer patients can be complex, requiring calculation of protein, calorific and fluid requirements, and may require supplemental feeding [22]. The SALT team plays a key role in the assessment and recommendation of treatment for head and neck cancer related dysphagia. The SALT team can also provide screening before treatment (such as radiotherapy) to provide information on the impact of this therapy upon swallowing and communication [26]. In the palliative patient, this may involve the prescription of food thickeners, or referral for a gastrostomy tube. It is the responsibility of the head and neck surgical team to be able to recognize swallowing difficulties and refer appropriately to SALT. For the terminal head and neck cancer patient, the outcome may be conservative management, nonetheless the SALT team can provide practical advice and support for such patients. For this purpose, Zuydam et al. [27] have described the use of the University of Washington Quality of Life swallowing domain and the MD Anderson Dysphagia Inventory, as useful tools to grade when a referral to SALT is required and to grade the impact of swallowing difficulties upon the patients QOL [27]. Physical exercise and physical therapy have been shown to have beneficial effects for palliative cancer patients: improving quality of life, physical and psychosocial functioning [28]. Treatments that are offered by palliative physiotherapists include: physical exercise (standing, walking, etc), relaxation therapy (massage) and breathing treatment. In a randomized clinical trial of terminally ill cancer patients, a combination of massage and physical exercise was shown to significantly reduce pain and improve mood [29]. Further evidence exists for the overall psychosocial benefit of physical therapy to promote coping with symptom burden [26].

Table 4: Nutritional issues affecting head and neck cancer patients.

Palliative Drug Therapy

One of the mainstays of care delivered by the specialist palliative team takes the form of various drug therapies. For this reason palliative drug therapy is discussed below. Palliative drug therapy commonly includes a variety of analgesics, combined with other symptom controlling medication such as anti-emetics, cough suppressants and corticosteroids [30]. One of the most common symptoms experienced by terminal patients with head and neck cancer is pain [4,5,30]. WHO guidance is clear regarding the analgesic ‘pain ladder’ and the escalation from non-opiod drugs, through to weak and then strong opioids. Whilst this assumption of cancer pain needing appropriate analgesics in the palliative phase is straightforward, evidence exists that both environment and healthcare worker education impacts upon the amount and thus adequacy of palliative pain control. Lin et al. [5] demonstrated that morphine doses significantly increased when head and neck cancer patients were admitted to a hospice. As the level of education of staff increased, so did morphine doses; noting a continued misunderstanding and fear of strong analgesics among health professionals. Furthermore, they stated that the education level of patients impacted upon correct opioid dosage, with those of a low education level fearful of ‘the myth of addiction’. Interestingly, in their patient cohort, tongue cancer required higher doses of morphine than laryngeal, oropharyngeal and floor of mouth cancer. The key finding from this study was that survival time significantly increased with change in morphine dosage. To evaluate the impact of drug therapy upon palliative treatment in head and neck cancer patients, Bisht et al. [30] assessed quality of life (QOL) at baseline and then 1 and 2 months after the initiation of treatment [30]. Most frequently prescribed drugs were analgesics, but patients also received cough suppressants, anti-emetics, multivitamins, anti-ulcer agents, corticosteroid and antibiotics. Patients received a mean 8.7 different drugs. They demonstrated a statistically significant improvement in QOL and reduction in pain score, with the use of correct palliative drug therapy in this cohort. Especially important in head and neck cancer patients, is the method of drug administration, taking into account the symptoms of dysphagia and other oral difficulties [10]. Devices such as syringe drivers provide continuous infusions, often of multiple drug cocktails, and can facilitate an easier transition from hospital care to the home environment. Clearly, as surgeons and members of the palliative MDT, we should be educated and able to competently prescribe palliative drugs and recognize patients with increased needs. In this aspect of care the palliative medicine team and pain team can be very valuable.

Psychosocial Support

Treatment for head and neck cancer, both the surgical and palliative/terminal phase have a profound impact upon the psychosocial well being of the patient. It is established that head and neck cancer impacts upon several facets of quality of life [31,32] and the psychosocial challenges faced by head and neck cancer patients are many and complex (Table 5) [33]. For the terminal patient, manifestations of psychological distress, such as depression and anxiety, can have an adverse outcome on the quality of dying. In a study of 481 terminal cancer patients and 381 carers, Chang et al. reported that the level of ‘burden of care’ was the factor that most predicted satisfaction about overall care in both patient and carer groups [34]. For these reasons, the psychosocial support provided by the specialist palliative care team is invaluable for the terminal head and neck cancer patient. Palliative medicine doctors and especially CNSs are experienced in dealing with these patients and their emotional needs [18]. When required, psychologists and psychiatrists can be added to the extended MDT to deliver psychological therapy and/or medication.

Table 5: Psychosocial issues experienced by patients with head and neck cancer (issues pertinent to terminal patients highlighted in bold).

Involvement of Family and Carers

Despite not being part of the formal MDT, the involvement of family and carers in the care of the terminal head and neck cancer patient should not be overlooked. Specifically the care provided, but also the impact of the cancer upon the family and carers. Family members often assume the role of a carer, feeling enormous responsibility and emotional burden. The demands of care lead to significant practical life changes, and induce financial and psychological effects upon the family [35]. Interestingly, it is often the carers that feel a greater burden of care than the patients [34]. Verdonckde Leeuw demonstrated that 20% of partners of head and neck cancer patients had clinically significant levels of emotional distress; this was related to the presence of feeding tubes, feeling worried and incapable of taking action, and due to disruption in daily living [36]. Furthermore, the patients themselves perceive this burden of care. In a recent survey of 386 head and neck cancer patients, Precious et al. [36] identified nearly half of patients having family members as carers, with one third feeling that their care was a considerable burden and ‘very hard’ for their careers [37]. The palliative care team should be aware of the limitations of care that families can provide and the impact of this care giving upon their lives. For the surgical team, the awareness of such a caregiver burden is imperative. As the clinician seeing the palliative patient regularly, in the outpatient or inpatient setting, we are best placed to offer support. Providing clear information related to the cancer and the specific care requirements of the terminal patient can be useful for carers to understand the care provided and the overall process of dying. Furthermore, self-help groups can be recommended or carers directed for further support, often from the palliative care CNS.

How Can the Head and Neck Surgeon Contribute to the Palliative Pathway?

The above sections have described the members of the palliative MDT and the care they provide, with the aim of highlighting areas where the surgeon can interact and assist this process. It can be seen that the head and neck surgeon is most likely to be involved in the palliative and terminal phases of care. However, other specific roles are worth mentioning. Firstly, as surgeons with a knowledge of oral pathology we are best placed to deliver guidance when managing the oral problems experienced by palliative patients [2]. As listed in Table 1, these include dry mouth, mucositis, candidacies and oral ulcers. The surgeon can also influence the patient perception of psychosocial support. Ledeboer et al. [13] reported a positive relationship between a single surgeon attending to patient care and higher levels of psychosocial support [37]. They also reported that communication between the surgeon, MDT and patient/family was poor and an MDT logbook to improve continuity of care resulted in a reduction of psychological problems. Finally, surgeons are arguably best placed to evaluate the impact of palliative care interventions upon QOL, from the beginning of treatment to the terminal phase. Thus, we have a key role in ongoing palliative care research.

Conclusion

In summary, palliative care should be thought of as an on-going continuum during head and neck cancer treatment once active therapy has ceased, not just end-of-life care. The head and neck surgeon should be aware of the problems facing terminal head and neck cancer patients, with knowledge of how to treat and when to refer such patients. Where possible, involvement of the specialist palliative team should be sought early in the palliative pathway. Furthermore, an understanding of the members of this team and the extended members of the MDT is crucial in meeting the diverse and complex needs of palliative and terminal head and neck cancer patients. Finally, the needs of family and carers should always be borne in mind, with the confidence to involve clinical nurse specialists or other support groups/resources. Upon writing this essay I am reminded of the favorite saying of my former Consultant in Clinical Oncology: “palliative and end of life care is the most important care you will you will ever deliver to a patient, unlike other areas of medicine you only get one chance to get it right!”. Head and neck surgeons and all members of the palliative MDT would do well to remind ourselves of this.

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Bio sorption Studies of Chromium Ions with Modified Chicken Feathers

Abstract

Modified chicken feather has been used as biosorbent for removing chromium ions from aqueous solution. The adsorption capacity tests were performed on an equilibrium batch basis. The parameters such as contact time, biosorbent dose, pH etc were optimized and were found to be 2 hrs, 100 mg & pH 6.0. Equilibrium isotherms were analyzed for the adsorption process and Freundlich adsorption isotherm model was found to fit the data well. The kinetics of adsorption followed pseudo-second order model.

Keywords: Modified Chicken Feather; Bio sorption; Chromium ions; Freundlich isotherm; Pseudo second order

Introduction

Heavy metals such as Hg, Pb, As, Cr, etc are harmful to soil, water bodies and aquatic life. They are leached out mainly from industrial wastes, mines and research labs [1]. They produce acute toxicity in plants, animals and micro organisms. Due to bio accumulation and bio magnification through food chain they cause chronic effects even at lower concentrations. Heavy metals are generally removed from environment by precipitation, reverse osmosis, coagulation, flocculation etc [2-7]. These processes have many drawbacks, which include selective or partial removal of metal ions and high operational cost. Bio sorption can be used for effective removal of the heavy metals from environment. The major advantages of biosorption are low cost, high efficiency, regeneration, metal recovery etc. Bio sorption is largely influenced by pH, the concentration of biomass and the interaction time.

A very big problem of the agriculture industry is managing the enormous amount of waste generated by poultry processing enterprises. The scientific usage of feathers as a renewable material offers both economic and environmental benefits. The adsorbing ability of chicken feathers (CF) as potential biosorbent for the removal of hazardous substances from effluents is due to their high surface area and several reactive functional groups [8-11]. CF consists of keratinous proteins with many functional groups such as -COOH, -NH₂, S-S- which can be treated with suitable chemical reagents to get chemically modified CF biosorbent.

Experimental

The reagents used were ethanol, methanol and HCl and were of analytical grade. UV-Visible spectrophotometer (shimadzu-1800), Mechanical shaker (Rotek, Model number REC27255A2), pH meter, XRD (Rigaku Miniflex X-ray Diffractometer with Cu Kα radiation) etc were used.

Preparation of Biosorbent: The chicken feathers (CF) collected from poultry farms were cleaned, washed in water and ethanol and cut into pieces of size 5mm. CF was modified using an equimolar mixture of methanol and HCl for two hours. 10 g CF was mixed with 6% (v/v) CH₃OH and 2% (v/v) HCl in a 250 ml double necked flask and placed on a hot plate at 80 0C with constant stirring for 3 hours. The reaction mixture was filtered, washed with distilled water and kept for drying [12]. Modified CF biosorbent was characterized by XRD & FTIR [13].

Preparation of Adsorbate: The stock solution of chromium metal ion was prepared in the range (1-10) × 10⁻⁵ M.

Batch Adsorption Experiments: The adsorption studies were carried out in batches in different conditions of pH, contact time, amount of adsorbent, temperature etc to check the propensity of adsorption process. In each 100 ml conical flasks, 25 ml of chromium solution was taken along with 100 mg of adsorbent and shaken for 2 hours in an orbital shaker which was then kept for 24 hours for saturation. Thereafter supernatant liquid was filtered through Whatmann Filter Paper No.42 and the amount of chromium ion adsorbed was determined spectrophotometrically at λ_max 540 nm. The amount of chromium ion adsorbed per unit biosorbent (mg metal/g of biosorbent) was calculated using Equations (1) & (2)

Equation 1:

Where C_o & C_e represent initial and final equilibrium concentrations (mg/L), V is the volume of Adsorbate taken, W is the weight of the biosorbent and q_e is the amount of dye adsorbed at equilibrium.

Results and Discussion

Characterization of the Biosorbent

Chemical modification of chicken feather was carried out with methanol as shown in Figure 1. Modified CF was characterized using XRD and FTIR. IR showed peaks in the range 1600-1700 cm-1 is due to -NH and -C=O stretching vibrations of the amide group. In the case of modified CF, this peak becomes sharp at 1653 cm-1 due to the formation of random coils at the expense of a α-helix and β-pleated sheets .The appearance of intense peak at 1740 cm-1 is due to the -C=O stretching vibration of the aliphatic ester of the modified CF [13]. XRD patterns of CF and modified CF are shown in Figure 2. The peak at 9.9 indicates α- helix configuration and a peak at 19 is due to stranded secondary structure. The modified CF peaks show decreased intensity. The slight shift of 2ϴ values confirms the decrease of the β-sheet content and partial cleavage of α- helix network [13] (Figures 1 & 2).

Figure 1: Chemical modification of chicken feather was carried out with methanol.

Figure 2: XRD patterns of CF and modified CF.

Adsorption Studies

Figure 3 shows the variation of adsorption efficiency of CF with pH for chromium ions it was found that maximum adsorption occurs at pH 6.0. The effect of variation of contact time on the adsorption of metal solution was also studied and optimum time was found to be 2 hours as shown in Figure 4. From Figure 5 we can see that adsorption of the metal by modified CF also depends on the amount of sorbent used and the optimum amount was found to be 100 mg.

Figure 3: Variation of adsorption efficiency of CF with pH for chromium ions.

Figure 4: Effect of contact time on adsorption of matal.

Figure 5: Optimum time was found to be 2 hours.

Adsorption kinetics

Figure 6 shows the effect of contact time on adsorption of chromium onto modified CF at 100 mg/L. Ho’s pseudo-second order model (Eq. 3) was used.

Figure 6: Effect of contact time on adsorption of chromium onto modified CF at 100 mg/L.

Equation 2:

Kinetic studies show that the data fits well in the pseudosecond order plot and is shown in Figure 7.

Figure 7: Kinetic studies show that the data fits well in the pseudo-second order plot.

Equilibrium Studies

The Freundlich adsorption isotherm was applied for the adsorption of metal on modified CF.

The Freundlich equation is represented as:

Equation 3:

Figure 7 is the plot of equilibrium isotherm for the sorption of chromium ions on chemically modified CF. The data fits well in the Freundlich isotherm. It also shows the dependence of temperature on the adsorption of chromium ions on the sorbent which confirms the endothermic nature of biosorption.

Conclusion

This study showed that modified chicken feather could be used as a potential biosorbent for the removal of Cr (VI) ions from aqueous solution. The biosorption process was affected by contact time, temperature, p^H and biosorbent dosage. The thermodynamic studies indicated the endothermic nature of the biosorption process. The Freundlich isotherm model was found to be the most suitable in describing the equilibrium of the biosorption process. The kinetics of adsorption followed pseudo-second order model.

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Affording Visual Causal Epistemologies in Epidemiology

Mini Review

One of the challenges of 21^st Century sciences is how to deal with and manage huge amounts of raw data [1] Using several computational tools, scientists are able to capture, process and, finally, to understand that data. The visual aspects of this understanding process are of the utmost importance due to the specific cognitive mechanisms that make possible human thinking [2]. Epidemiology is a very complex research field devoted to the study of health and the causes of illness [3]. The difficulty of establishing sound statistical relationships between sets of events and some causal outcomes [4] has been the main source of debates within the field [5-7] Although epidemiologists and physicians have tried to avoid philosophical debates [8] about causality, it has been impossible to not be aware of the intrinsic and insurmountable problem of working with so complex amounts of data. From the simple one-hit paradigm of early epidemiology [9,10] to current multi-causal webs of determinants [11], new challenges have emerged. A possible solution for the management of such sets of data has been to invest into visual causal methods: directed acyclic graphs (henceforth, DAG). These methods have allowed a visual quantitative approach to epidemiology [12-14] that fits perfectly with the current research trends in cognitive sciences which defend the power of extended and enhanced ways of using informational tools, which afford new and sound ways of processing information.

In this brief mini report I suggest several interesting corollaries of the implementation of such techniques:

a. The necessity of the enhancement of visual argumentative methods in scientific practices. A few examples, such as Venn diagrams or Feynman’s diagrams [15,16] have still not reached a full implementation of Western scientific cultures dominated by classic written methods.

b. The power that these visual methods give to not only human analysis but to the more fruitful interactions between human thinking and machine thinking in data-mining processes [17].

c. The epistemic reliability and soundness of visual reasoning, beyond the classic critics to these methods.

d. The necessity of more analysis on the culturally embedded values into visual thinking (related on traditions on spatial uses during writing processes, to prevent some possible mistakes as well as to define better this new thinking space [18-20].

Taking into account these ideas, we’ll be able to define a new reasoning scenario for epidemiological researchers that could even be exported to other domains, not only from classic sciences but also to social sciences or even humanities. This new visual quantitative methodologies may make possible a new set of scenarios for the advancement of knowledge thanks to the implementations of tools which impulse the cognitive creativity, closer to naturalized and easily affordable ways to deal with information.

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Factors Contributing to Low Productivity and Food Insecurity in Bungoma County, Kenya

Abstract

Food insecurity within households is a risk to people’s livelihoods. If not addressed in good time it could results into a disaster that will require foreign intervention for that affected community. Households in Bungoma county of Kenya were noted to be vulnerable to food insecurity due to low productivity and this state threatened peoples livelihoods. The objective of this study was to examine the physical, economic, environmental and social factors that led to low food production in Bungoma County, Kenya. A cross-sectional survey design was used in the study and a cluster (multi-stage random) sample size of 384 households was selected. Tools used for data collection were questionnaires, interview guides, focus group discussions and observation checklists. Data was analyzed using descriptive and inferential statistics. The study found that land size was small; the road network was poor and disorganized market systems. The cost of farm inputs was high as well as high poverty levels.

Climatic variability affected crops and animal production. Social support, traditional beliefs and culture which discriminated against women were key risk factors that contributed to low farm production, making households vulnerable to food insecurity. Based on the findings, the study concluded that low farm productions were attributed to physical (Poor road networks and small land size), economic (poverty and high cost of farm inputs), environmental (climate variability and deforestation) and Social (cultural belief and negative attitude) factors. The study recommended that costs of farm inputs should be subsidized, improve road network system and sensitize people on positive cultural practices and attitude change to allow both gender participation on issues of food security.

Key words: Farm productivity; Household food insecurity; Bungoma County

Introduction

Background

Food is a basic necessity of life. It is a basic means of sustenance and key for healthy and productive life. If Kenya is to continue to cut down on health costs and compete in a global economy, it should ensure adequate food security and nutrition within households. Food insecurity within households is a risk to people’s livelihoods. If not addressed in good time it could result into a disaster that will require foreign intervention for that affected community. The economic development of any nation is dependent on the productive capacity of human resources which is however a function of how well fed they are. Poor farmers have little or no access to credit, particularly short-term seasonal credit for farming Audsley et al. [1]. Under such circumstances, households lack economic capacity and therefore are at a risk of being vulnerable to food insecurity. Crucial information on the type of interventions that can be most effective in increasing productivity, reducing hunger, targeting the most needy, informing preparedness and developing contingencies is lacking in most communities in Kenya Lautze et al. [2].

Problem Statement

Available literature indicates that Bungoma County is food insecure and also records a poverty index of 52.9% compared to the National index of 46%, while the food poverty stands at 43% KNBS [3]. There is documentary evidence that Bungoma County has many stakeholders dealing with food security issues being led by the County Government GOK [4]. This would give an impression high production and food sufficiency at household level but it is not the case. Food situation reports dating way back to 2011, show insufficient food stocks among households in Kenya GOK [5]. Records of studies done in Bungoma county revealed household food insecurity NALEP [6], Muyesu [7], KARI [8] and Ndienya et al. [9]. Many families in Bungoma County take one meal a day, in contrast to the recommended three meals per day UNICEF [10]. Due to this controversy, the study was set up with the objective to examine factors that led to low productivity within households, making them vulnerable to food insecurity despite the County’s interventions.

Objective: The objective of this study was to examine physical, economic, environmental and social factors that led to low productivity and made households vulnerable to food insecurity in Bungoma County, Kenya

Contribution to the Field: The study will give recommendations to guide policy makers on issues of food security. This paper contributes to the knowledge bank important for scholars. It is arguable that findings of this study with a focus on Bungoma County will inform similar studies in other counties in the entire country.

Significance of Work: The outcome of the study will guide decision-makers at all levels in formulating food policies. Reliable and timely information on the incidence and causes of low productivity, food insecurity and malnutrition will be documented. Recommendations from the study is expected to assist households understand the crucial factors of production and risks of food insecurity and be able to appropriately plan their farming schedules.

Research Methods and Design

Materials: The study targeted household heads whose food security depended on farming. Community groups (women groups, men groups, youth groups and self-help groups) were targeted for focus group discussions. Opinion leaders, Non-Governmental Organizations, Community Based Organizations/Non-State actors, Faith Based Organizations and Government officials were selected as key informants.

Setting: This study was done in four sub-counties of Bungoma County; they included Bumula, Bungoma West, Mt. Elgon and Bungoma North. The County is located on the Southern slopes of Mt. Elgon, and lies between latitude 0⁰ 28¹ and latitude 10 301 North of the equator, and longitude 34⁰ 20¹ East and 35⁰ 15¹ East of the Greenwich Meridian.

Procedure: The research work adopted a cross-sectional survey research design and the variables examined were physical, environmental, social and economic factors. The population for the study was household heads, key informants and formal organized groups. A cluster (multi-stage random) sample size of 384 households- calculated using a formula from the book of Mugenda [11] was selected from household’s population of 1,553,655 KNBS [12]. This study utilized both primary data collected from the field and secondary data from archival sources. Data was collected using semi-structured questionnaires administered to the selected household heads. Four (4) Focus Group Discussions were held and each group was composed of eight to twelve (8-12) members of mixed gender. Twenty (20) key informants purposely chosen from opinion leaders, Government departments, Faith based organizations, Non-governmental organizations were interviewed. More information was obtained from observation checklists [13,14].

Analyses: The quantitative data were organized, coded and edited by a process called data cleaning Punch [15-17]. The statistical package for social sciences (SPSS) was used to analyze data. Two analyses were made. Descriptive analyses was done by use of means, modes, standard deviations, variance, percentages, and frequencies) while inferential analyses was by use of chi-square test and Spearman rank order correlation analysis.

Results and Discussion

Physical Factors and Vulnerabilities to Food Insecurity

Various physical factors were identified as contributors to low productivity. These included small land size for farming, non use of fertilizer and certified seeds. The soil was infertile and this led to low yields, poor infrastructure, and disorganized marketing system [18]. Chi-square tests revealed a significant relationship between physical factors and production levels in the county (p-value = 0.035; < 0.05). It was also established that markets were few and far apart from farmers. The distribution of farm produce outlet included; farm gate level, neighbors, local or open markets and others. International markets fetches better prizes but unfortunately, all households interviewed had no idea of existence of export market. Very little produce was sold to supermarkets, meaning low incomes that could not enable farmers to purchase certified seeds or other food items not produced on the farm [19,20]. The seasonal roads as well as lack of means of transport made farmers to sell their produce at low prices on the farm. Besides this, farmers did not have government permits and certificates of operation to enable them penetrate the supermarkets in the country.

Economic Factors

In order to earn a living and be food secure households engaged in the following activities: Dairy production, maize farming, horticulture, banana farming and petty trade. Most of the households depended on farming with some shifting from subsistence to business farming to raise income. Similar views were found by Makhanu et al. [21] working in the same region; this shift in attitude to do farming as a business reflects current trends of blending specialization and diversification to reap optimal benefits by smallholder farmers. This was also observed by similar studies as captured by government policy initiatives in Agriculture GOK [22]. The economic factors that contributed to low productivity and food insecurity were listed as high levels of poverty and high cost of farm inputs. Due to high cost of farm inputs like fertilizers and certified seeds, majority of the farmers planted uncertified maize seeds (number name) and without fertilizer. As a result of planting uncertified seeds, the cereal yields were so low that it hardly sustained a household for three months after harvest. Horticulture farming was affected due to non-use of chemicals to control pests and disease [23-25].

Environmental Factors

Environmental factors contributing to food insecurity were found to be natural calamities like drought, floods, hailstones and inadequate / unreliable rainfall. Crops on farms were at the risk of natural calamities like hail stones [26-28]. Too much rainfall led to floods which damaged both properties and livelihoods. Human activities like cutting of trees led to deforestation and this resulted into soil erosion. Erosion made soil unproductive as the soil nutrients are washed downstream, hence food insecurity for such households. Other factors established were pests anddisease outbreaks which were a risk to both crops and animals [29]. This finding is comparable to a study done by Ahmed et al. [30], which revealed that increasing vulnerable environmental conditions such as diminished biodiversity, soil degradation or growing water scarcity can easily threaten food security for people dependent on the products of the land, forests, pastures, and marine environments for their livelihoods. These findings also support Kenya Government recommendations for adapting to climate change like; conservation farming, right land use practices that reduce emissions of greenhouse gases GOK [31].

Social Factors

A key social factor contributing to vulnerability was the gender of the household head. The study established that 80% households were headed by men while 20% were women. All decisions in the household were made by men. In many cases men were found to be the cause of food disasters in their own homes. Women had no say in decision making concerning food issues where men were heads [32-34]. Men made final decisions in relation to land allocation for different crops, when to market farm produce and the use of cash from sale of farm produce. The study further revealed that women were in the same category with children, so they could not be allowed to make final decisions in the households. One Man, during focus group discussion quoted the Holy Bible (Genesis 2:18) [35] where he said ‘women were made to assist men), therefore they should always be subordinates to us’. This notion made households vulnerable to food insecurity as productive ideas from women may not be adopted. The findings were similar to the study done by Lautze et al. [2] who found out that positive traditional value, customs and ideological beliefs contributed to social vulnerability of any given household.

Focus group discussions recorded that culture prohibited working on the farm during bereavement and this contributed to low productivity incase funeral occurred during planting season. Farming activities may be stopped for periods exceeding three weeks. This can be crucial as even a small period of time lost affects agricultural production Africa Progress Report [36], Delgado [37]. Laziness, idleness among the youth and theft of farm produce while in the farm and store were mentioned as contributing factors to food insecurity. Key informants quoted lack of knowledge on production and storage as factors making households vulnerable to food insecurity. This was also revealed by household interview results, where 61% of the household heads only attained primary level of education, meaning they were limited in knowledge and the level of understanding of new farming technologies [38,39].

Conclusion and Recommendations

Farm production by Households in Bungoma County were found to be low and hence making them vulnerable to food insecurity because of the following factors; physical (Poor road networks and markets), economic (poverty and high cost of farm inputs), environmental (climate variability and deforestation) and Social (cultural belief and negative attitude). The study recommended that the County Government of Bungoma should subsidize costs of farm inputs and make it accessible to farmers, the road network system should be improved to ease transportation to access markets for farm produce, people should be sensitize on positive culture practices and attitude change to allow both gender participation on issues of food security.

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Comparative Evaluation of the Bleaching Efficacy of Colgate Visible White, Close-Up Diamond Attraction Compared With Pola Office Plus

Abstract

Bleaching is very common and costly procedure for whitening of teeth. As the aesthetic concern of the patient’s increases these days, the introduction of wide range of less costly whitening products in the market also increases which promises whitening in few applications.

Aim: The objective of this in vivo study is to check the bleaching efficacy of Colgate Visible White, Close-up Diamond Attraction compared with Pola Office Plus.

Materials & Methods: 15 patients were selected and randomly divided into three groups according to whitening agents used. Each group contains five patients i.e. n=5.The application time is as per recommended by the product instructions. For the evaluation of shade selection – color of both canines in upper jaw was evaluated visually before and after bleaching. Tooth shade was evaluated using VITA classical shade guide.

Results: After statistical analysis a significant difference was seen in shade change between pre and post treatment in each group. However, no significant difference was found between all the three groups.

Conclusion: Tooth whitening using minimally invasive techniques is enjoyable for the clinician and allows the patients to smile with confidence.

Key words: Bleaching; Colgate visible white; Close up diamond attraction; Pola office plus

Introduction

Patients increasingly seek to have an attractive smile, as it is considered to be synonymous with health. This growing demand for an enhanced esthetic appearance has led to great development of bleaching products. The color of teeth is influenced by a combination of their intrinsic color and the presence of any extrinsic stains that may form on the tooth surface. Tooth discoloration can be treated professionally with in office or home bleaching. Pola Office+ is the advanced version of the well known in-office tooth-whitening system, Pola Office, which has been used successfully for several years. Pola office +contain desensitizing agents, such as potassium nitrate, to reduce postoperative sensitivities in vital teeth. Also, the whitening tooth pastes have gained in popularity for treating extrinsic stains. The effectiveness of toothpastes at reducing or removing extrinsic dental stain has improved with the introduction of more whitening toothpastes onto the market [1]. A key feature of whitening toothpastes is that they include proteolytic enzymes that remove extrinsic stains from teeth. It is claimed that some whitening toothpastes also remove pellicle (external membrane) from a tooth surface [2].

Apart from containing whitening agents, whitening toothpastes also commonly contain bicarbonates and fluoride to promote caries protection. In Turkey, it has been suggested that further clinical studies are required to help clinicians decide exactly which whitening toothpaste(s) to recommend to patients [3]. A cursory appraisal of the ingredients suggests that most whitening toothpastes are formulated to control extrinsic dental stain rather than to change the natural colour through a bleaching action [4]. The market continues to expand as more tooth whitening dentifrices become available and clearly it is important to evaluate these products. Many clinical techniques such as the Lobene Stain Index (1968) [5], the Shaw and Murray Stain Index (1977) [6], and the comparison of tooth colour with a Vita shade guide have been used to investigate the reduction of extrinsic staining of teeth. Many clinical studies into the whitening effect of dentifrices have been reported, with study periods differing from two weeks to six months [7].

Aim of the Study

The objective of this in vivo study is to check the bleaching efficacy of Colgate Visible White, Close-up Diamond Attraction compared with Pola Office Plus.

Materials and Methods

An initial sample of 15 patients aged from 18 to 30 years was selected from patients who came to our department for tooth bleaching. A randomized, single-blind (examiner-blinded) trial was conducted. The examiner and all staff were blind to the treatment assigned throughout the study. Study inclusion criteria (evaluated at a first examination) were as follows: age ≥18 years, absence of gingival recession or restorations in upper-front teeth, good oral hygiene and gingival health, no previous tooth bleaching procedure, tooth shade of A2 or above on the Vita ClassiÊl Shade Guide scale (Vident, Brea, Calif, USA.) ordered by value, and, in the case of females, not being pregnant or in breast-feeding period. Subjects were excluded if they used tobacco products, had aesthetic restorations, which could become discolored, or were already taking chromogenic oral products, such as chlor hexidine, or medications that could stain the dentition. Before the bleaching treatments, baseline numerical shade values were obtained for central incisors and canines of both hemiarches in accordance with the Vita Classical Shade Guide (Figure 1 & 2). Shade tabs were arranged in the sequence recommended by the manufacturer, assigning each tab with a number from 1 to 16 (B1, A1, B2, D2, A2, C1, C2, D4, A3, D3, B3, A3.5, B4, C3, A4, C4). The shade was recorded by two independent examiners not otherwise involved in the study (K coefficient = 0.85, standard error = 0.09), who were blinded to the materials used. Group 1(n-5) patients were assigned Colgate visible white tooth paste. Group 2 (n-5) were assigned Close up diamond attraction toothpaste. Subjects were instructed to brush their teeth twice a day, in the morning after breakfast and in the evening before sleeping. Subjects were not given any instructions about drinking and eating, and were allowed to follow their previous patterns for these activities. In Group 3 (n-5) patients bleaching was performed by Pola office +. The dual-barrel syringe system of Pola Office+ always delivers a consistent mixture of freshly activated gel that can be easily applied with a fine applicator tip, even in hard-toreach areas .Excess gel was removed with a cotton pellet. A thin layer of gel was applied on the vestibular surface of the tooth. The gel was left on the tooth for eight minutes and then removed using a surgical aspirator tip. The application steps were repeated up to three times, so that the material is on the tooth for a maximum of four times for 8minutes (32minutes in total) in one session.

Results

Fifteen patients completed the study protocol, with a mean age of 23.8 years (range, 18-30 years). No adverse effects on soft tissue were reported by the patients or observed by the examiners. After statistical analysis, a significant difference was seen in shade change between pre and post treatment in each group. (Table 1 & 2) However, no significant differenc was found between all the three groups (Figure 1-4).

Figure 1: Values Were Obtained.

Table 1: N Par Tests.

Table 2: Wilcoxon Signed Ranks Test.

Discussion

In this study, whitening scores were evaluated to assess the validity of whitening toothpaste advertisement sclaiming that whitening will be observed after four weeks’ use of whitening toothpaste. The whitening effects of the toothpastes were compared during this short period. Visual assessment with shade guides, computer analysis of digital images, colorimetry, and spectrophotometry can all be successfully used to measure the color change of teeth in longitudinal tooth bleaching studies [8]. Digital images offer an objective shade difference value, but the light and positioning of the subject must be standardized and a robust mathematical transformation algorithm must be used [9]. We used the Vitapan Classical shade guide ordered by value, considered a valid and reliable method for color assessment [10], and applied in previous investigations [1,11-13]. Other more sophisticated measurement systems are available [10,17,18] but do not offer a more reliable accuracy, since different color measurements can be obtained for the same tooth according to the positioning of the probe tip of the device [14].The Vita shade visual assessment has previously been used successfully in many clinical studies [12-15]. It was therefore used in this study.

Previous studies have reported that whitening dentifrices produce a greater reduction and/or inhibition in extrinsic staining of natural teeth than standard commercial toothpaste formulations [16-18]. The active ingredients of toothpastes either include enzymes that dissolve pellicle proteins and inhibit staining, or contain chelating agents that have stain-dissolving properties. Alumina, dicalcium phosphate dihydrate, and silica are some of the abrasives that are included in whitening toothpastes [19]. In the present study, two whitening toothpastes were evaluated. Colgate visible white was used which consists of silica and polyphosphates that removes and prevent stains on teeth. The high cleaning silica in this toothpaste is similar to the abrasive materials used for cleaning and polishing teeth to remove surface stains. The polyphosphates are widely used to prevent surface staining due to plaque formation. Other toothpaste used was close up diamond attraction based on blue light technology.

It consists of sorbitol, hydrated silica, trisodium phosphate. Hydrated silica has been shown to have great cleaning and stainremovalability [20]. It has been suggested that another factor for whitening effect of toothpaste is pH Price. Reported that whitening toothpastes had a mean pH of 6.83 (range 4.22 to 8.35) [21]. The abrasive in toothpastes should ideally provide stain removal without causing wear of the tooth [22]. Lima. Reported that the enamel wear caused by these dentifrices still needs to be assessed before they are recommended for routine use [23-30]. In future studies, this criterion may be added for the evaluation of whitening toothpastes. In the present study Pola Office + was used which showed significant difference in pre and post treatment results. With SDI’s new in-office system, Pola Office+, patients can have whiter and brighter teeth in less than one hour. The easy-to-handle, dual barrel and auto-mixing syringe system is economical and optimizes the workflow of the practice. In addition, the desensitizing agents and neutral pH make Pola Office + the ideal tooth-whitening material for vital and non-vital teeth. The active ingredient of Pola Office+ is 37.5 % hydrogen peroxide and the gel rapidly releases peroxide ions upon contact with the tooth, enabling a shorter contact time compared with its competitors

Results

Tooth-whitening toothpastes are effective for removal of superficial stains and for providing a whitening effect. Tooth whitening using minimally invasive techniques is enjoyable for the clinician and allows the patients to smile with confidence.

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Anti-Microbial Peptides and Their Speculative Role in Periodontitis

Abstract

Antimicrobial Peptides (AMPs) are present in the oral cavity in the form of defensins and human cathelicidin LL-37 (from neutrophil granules) and histatins along with pdefensins 1 and 2 (from salivary glands and gingival epithelial cells). The oral micro flora organisms that play an important role in the pathogenesis of periodontal disease are opportunistic pathogens, that are highly proteolytic and this activity is known to contribute to nutrient acquisition, tissue destruction and de-regulation of inflammatory responses. Furthermore, the production of proteases enables oral bacteria to evade killing by antimicrobial peptides, thus contributing to the virulence of such opportunistic pathogens, which could have implications for the use of antimicrobial peptides as therapeutic agents to treat periodontal disease. Hence, this review summarizes the suggestive role of AMPs in periodontal disease.

Key words: Immunity; Anti-Microbial Peptides; Periodontitis

Abbreviations: AMPs: Antimicrobial Peptides, LAP: Lingual Antimicrobial Peptide, HNP: Human Neutrophil Peptide; hBD: Human Beta- Defensins

Introduction

Humans often require a multilayered defense mechanism to function smoothly and combat micro-organisms and pathogens. The fundamental guarding complex for almost all human organisms comprises of innate immunity [1]. It is this defense mechanism that helps discern a wide variety of agents, known as pathogens, and distinguish them from the organism’s own healthy tissue [1]. The oral cavity is a manifold interaction where sundry organisms, both commensal and destructive types, intercommunicate and escalate in the environment [2]. The noteworthy quality of the oral cavity lies in the presence of specialized interaction between tooth (hard tissue) presenting itself from the underlying gingival epithelium (soft tissue).

Ideally in the oral cavity, the tooth structure often encompasses a layer of pathogenic biofilm termed “Dental plaque,” that compromises the surrounding epithelium via its incessant exposure to microorganisms [3]. This is when the comeback of the epithelium to these insults determines the overall condition of the gingival sulcus. It is evident that the oral epithelium works in several ways for the conservation of the underlying tissues. As a physical barricade, it can counter unbroken microbial oppositions from dental plaque by the production of chemokines, cytokines, and antimicrobial peptides (AMPs), which enhance inflammation and immune response in oral epithelial tissues [4]. These epithelial antimicrobial peptides are considered to be paramount for the innate immunity of the host [5].

AMPs are also prime contributors that enable the stabilization between health and disease in this complex ecosystem [6]. Exhibiting a wide spectrum of antimicrobial activity against grampositive and gram-negative bacteria, yeasts and certain viruses, they possess the ability to prevent various oral periodontal diseases including bacteria, fungal and viral infections [7]. The reaction involving multiple AMPs to a single pathogen of infection prevents the consequences of antimicrobial resistance. Several families of antimicrobial peptides have been studied in the oral cavity which includes α-defensins, β-defensins, calprotectin, adrenomedullin, histatins, and cathelicidin [8]. The aim of this review paper is to view the crucial role of these molecules against periodontal diseases and its function in host immunity. The article also sheds light on the mechanism of action and the types of identified AMPs.

Types of Anti-Microbial Peptides involved in Periodontitis

The AMPs react to the periodontopathogenic bacteria in a synergistic manner, whereby they secrete chemical innate immunity signal molecules like interleukin, chemokine and cytokines that attract neutrophils at the site and caution the host response [7]. Conducive with the amount of microbial exposure, they also produce natural AMPs and proteins. By acting as an integral part of the hosts natural innate environment, the oral epithelium, polymorph nuclear leukocytes (neutrophils) and saliva, all concurrently and solitarily bestow to this response [9,10]. These responses involve several salivary antimicrobial peptides, the β-defensins manifested in the epithelium, the α-defensins expressed in neutrophils, and the cathelicidin, LL-37, in both epithelium and neutrophils [11-13].

Defensins

The first AMPs identified in the oral epithelium were defensin, Lingual Antimicrobial Peptide (LAP) [14]. The defensin families are prominent AMPs that reside in the host environment, which include the alpha-defensins (human neutrophil peptide; HNP) and human beta-defensins (hBD) [15]. Defensins are stored in secretory granules, with expanding levels observed during periodontitis (Figure 1). Their mechanism of action involves destroying phagocytosed bacteria upon fusion with the secretory granules from the phagocytic vacuoles they reside in [16]. Being a part of the host’s natural environment, expressed in gingiva, tongue, salivary glands and mucosa, they are present in conditions like oral inflammation, carcinomas, etc. Defensins have also shown to inhibit LPS-stimulated inflammatory responses in host cells, which is a primary causal mechanism in the pathogenesis of periodontal disease [16]. Defensins are allocated into subfamilies of α- and β-defensins. Human beta-defensins (hBD) are elementally revealed in epithelial cells, while alpha-defensin are predominantly expressed in neutrophils [17]. Segregated in terms of their cysteine motifs, dually both of them share a homogenous secondary structure, and are opulent in cationic residues [18,19].

Figure 1: Mode of activation of hNPs in periodontal tissues.

In the α-defensin subfamily, four of the six α-defensins, human neutrophil peptide -1, -2, -3, and -4, are fabricated and gathered in neutrophil granules while the other two α-defensins, HD-5 and -6, are synthesized and stored in the granules of paneth cells, specialized epithelial cells at the crypts of Lieberkuhn of the small intestine [17,20,21]. In the β-defensin subfamily only hBD -1, -2 and -3 are substantially expressed in the oral cavity [16,22]. hBD-3 along with the respective three mentioned above are markedly expressed in epithelial cells that encrust some tissues and organs, fundamentally skin [23]. In non-inflamed gingival tissues and gingival crevicular fluid, hBD-1 and hBD-2 have been expressed, with maximum levels at gingival margin [22]. Elevated levels of HNP1-3 have been noted in cases of periodontal infections, indicating a strong correlation See Table 1 for summary.

Table 1: Summary of the role of defensins.

Cathelicidin (LL-37)

Used markedly as one of the predominant identifying tools in inflammatory periodontal disorders, this class of AMPs incorporates a mature peptide and cathelin domain. It is a multifunctional peptide, comprising of 37 amino acids [24]. Active against gram positive and gram negative bacterias, it directly binds to the LPS of bacterial cells, and is native to the oral cavity in several sites, including the buccal and tongue mucosa, gingival crevicular fluid [24]. By activating antigen-presenting cells, it presents as a hemoattractant for immune cells, including monocytes, T cells, etc. There is a specific correlation amongst multiplication in LL-37 levels and periodontal inflammation [25-28]. It is also known to cause an elevation in mucosal thickness in the gingiva. Furthermore, studies have also demonstrated its tissue specific effects on cancer cells [27,28]. Their mode of action involves intracellular killing of the phagosomes after phagocytosis of the bacteria, where the AMP in the neutrophil is severed into a fully developed peptide (Table 2).

Table 2: Summary of the role of Cathelicidin.

Histatins

These AMPs are exclusively resided in the salivary glands, i.e. parotid and submandibular salivary duct cells. Histamine 1, 3 and 5 are found to be predominant of the total histatin proteins (85%) in the saliva [29-32]. They have a major role in fungicidal activity, having a noteworthy role in oral candidiasis restraint, especially histatin-5, which is the most significantly active against candida species as well as bactericidal activities against Porphyromonas gingivalis and Streptococcus mutans, which play a key role in the etiopathogenesis of periodontal disease and dental caries ,respectively [30,32]. Significant linkage occurs between xerostomia and oral candidiasis. It is also noteworthy that the antifungal action is shared between alpha-defensin and histatin, which require ATP transport found in active mitochondria.

Secretory Leuko Protease Inhibitor (SLPI)

Another AMP identified from the parotid salivary gland is SLPI. Manifested in neutrophils, epithelial cells and salivary glands, this protein suggests anti-inflammatory action at the site of infection [33]. Supplementary to having fungicidal action, it has shown to inhibit contamination of human monocytes and is also conveyed in oral tumor tissues as well as inhibition of the HIV virus [34,35]. SLPI is associated with wound repair and its expression is elevated following wound healing [35,36]. The elevated quantity of SLPI following periodontal treatment is an evidence of inflammation resolution activities [36].

Summary

The capacity of these inborn antibiotics is only at its inception of its recognition, as amplified natural announcement or as novel relieving agents [8,37]. This class of proteins is a captivating target for periodontal diseases [37]. In times of periodontal disease, AMPs amalgamate with other inflammatory proteins and maintain inflammatory molecules and pathways. It can be concluded that salivary AMPs have a prospective capacity to be recognized as initial markers of periodontal infections [38]. Thus, a dual approach is mandatory to comprehend the task of hosts’ immunity in response to, against periodontitis [37]. This involves more comprehensive statistics about HNP and hBD, LL-37, and other oral antimicrobial peptides and proteins, along with their mode of action and clinical significance [38-50]. These peptides are peculiar in keeping the level of bacteria in control, having distinctive as well as dual roles in maintaining oral health. Not only can they act as diagnostic or prognostic biomarkers, but also the enhancement of new peptide agents can be a signaling method for future investigation and testing (Table 3).

Table 3: Significance of AMPs.

Moreover, Antimicrobial peptides are potentially important as novel therapeutic agents against periodontal disease diagnosis and potential treatment and probably show most immediate promise for development as topical adjuvant agents in conjunction with conventional periodontal therapy in the treatment of periodontal disease. This makes them promising for oral diseases, as topical application of antimicrobial agents is easy and appropriate, and their use would not contribute to resistance to antibiotics normally used in treatment of more life-threatening bacterial infections. All these findings will have direct implications for new understanding of oral innate immune responses and the development of potential new and innovative therapeutic interventions for periodontal disease.

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Periosteal Osteosarcoma of Radius Mimicking Synovial Sarcoma

Abstract

Periosteal osteosarcoma is a rare surface osteosarcoma. It has a benign course with good prognosis. We report a case of periosteal osteosarcoma in an old lady arising around the elbow and mimicking like synovial sarcoma with calcification in the periarticular tissue. The mass biopsied proved osteosarcoma with osteoid matrix. Patient underwent definitive treatment and followed up for five years with no evidence of recurrence.

Key words: Periosteal osteosarcoma; Calcification; Synovial sarcoma

Abbreviations: ESR: Erythrocyte Sedimentation Rate; CRP: C-Reactive Protein; MRI: Magnetic Resonance Imaging; PET: Positron emission tomography; IHC: Immuno Histo Chemistry

Introduction

Periosteal osteosarcoma belongs to the group of surface osteosarcoma. It is a rare tumour representing 1-2% of surface osteosarcoma. The tumour can mimic various benign pathological conditions when it arises around the joint and cause diagnostic dilemma. We report such a case.

Case Report

63 year old female presented with right elbow swelling which was insidious onset and progressive of 6 months duration. Dull aching pain followed swelling. Pain present at night and not relieved with analgesics. No significant loss of weight. Systemic examination appeared normal. A solitary globular swelling of dimension 5x5x4cm present over the right elbow extending from proximal to mid forearm. Skin over the swelling was stretched with irregular surface. Swelling was firm to hard in consistency. Plane of swelling was deep to the muscle. Elbow range of motion was 50-80 degree with thumb drop and metacarpal drop. Blood investigations showed normal ESR and CRP ruling out the possibility of infection. Radiological evaluation revealed a large ill-defined lobulated lytic lesion with osteoid matrix noted within the soft tissue on volar and radial aspect of the proximal forearm. Presence of cortical destruction in the neck (metaphysis) and proximal shaft (diaphysis) of radius due to infiltration of tumour (Figure 1). MRI scan showed a large soft tissue component with mineralization and calcification. Periosteal breach with infiltration of tumour into the radial metaphysis, adjacent muscles and posterior interosseous nerve (Figure 2). Differential diagnosis of synovial sarcoma was considered. Incisional biopsy was inconclusive between low grade osteosarcoma (surface variety) and spindle cell synovial sarcoma (Figure 3). Immuno-histochemistry markers proved negative for synovial sarcoma. PET scan showed no evidence of metastasis or skip lesions. Patient counseled and opted for amputation over limb salvage. Wide local excision with above elbow amputation was performed. Tumour margins were negative and hence postoperative chemotherapy wasn’t started. Now post op 5 years with no evidence of recurrence or metastasis (Figure 4).

Figure 1: Radiograph of right elbow anterior-posterior(A) and lateral(B) views showing a large ill-defined roughly lobulated, lytic lesion with osteiod matrix noted within the soft tissue of volar and radial aspect of proximal right forearm. Infiltration of tumour is seen into the neck (metaphysis) of radius.

Figure 2: MRI(1.5 Tesla) of right elbow Axial T2 weighted (A) and Coronal T2 weighted (B) section showing T2 hyper-intensity in the metaphysis and in the soft tissue with cortical discontinuity. Focal T2 hypo-intensity in the soft tissue suggesting calcification.

Figure 3: Microscopy slide of low power 10X (A) and High power 40X (B) showing pattern less sheets of tumour cells with ill-defined cytoplasm with moderate aniso-nucleosis. Delicate seams of osteiod with calcification are seen among the tumour cells.

Figure 4: Anterior-posterior radiograph of the right humerus with amputation stump at follow up (5 years) showing no recurrence.

Discussion

Periosteal osteosarcoma is defined as a tumour with its epicenter outside medulla. Stippled calcification present in the tumour with or without medullary involvement [1]. Tumour commonly involves in the 3rd and 4th decade. Incidence is more common in tibia, femur and humerus. In our case, tumour is seen involving the proximal radius which is an uncommon site. Radiologically synovial sarcoma was considered as a differential because of its para-articular involvement and presence of diffuse calcification. Microscopy proved negative for synovial sarcoma because of the absence of monophasic or biphasic pattern. IHC markers were negative for cytokeratin and epithelial membrane antigen. Central medullary osteosarcoma was also excluded due to absence of a central destructive lesion with periosteal reaction. Characteristic sunburst and codman triangle with varying osteoid matrix in the soft tissue was absent [2]. Periosteal osteosarcoma has a good prognosis with high ten year survival. Primary concern of recurrence is because of positive margins and inadequate tumour resection. Lung metastasis is a problem when there is invasion of the vascular system. Presence of a meta-chronous lesion increases the frequency of metastasis. Treatment options are amputation, loco-regional control and limb salvage. Regular follow up is needed because periosteal osteosarcoma is prone for recurrence. Metachronous lesions are to be watched for, if genetic mutations are suspected [3]. Treatment for recurrence is chemotherapy and palliative radiotherapy.

Conclusion

Periosteal osteosarcoma follows a slow course and its occurrence in uncommon sites can mimic various pathological lesions. Swellings with para-articular involvement and diffuse calcification should be investigated with biopsy and IHC markers to institute prompt management. Adequate surgical clearance with chemotherapy is needed to prevent recurrence.

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