Utility of fine needle aspiration cytology in evaluation of lymphadenopathy - An audit from a Cancer Centre in South India

BACKGROUND

Cytological evaluation and diagnosis of lymphadenopathy plays an important role in distinction between reactive hyperplasia and malignancy.Being a tertiary cancer care centre, lymph node enlargement clinically suspected to be due to malignancy constitute the commonest indication for fine needle aspiration cytology (FNAC) at our centre. The aim of this study was to determine the utility of FNAC in evaluating enlarged lymph nodes and to categorizethe causes of lymphadenopathy diagnosed byFNAC at our centre.

MATERIAL AND METHODS

Data was collected from the records of department of Pathology over a period of three months from January to March 2014. The data was analyzed and various parameters studied.

RESULTS

There were 2000 aspirates over a period of three months of which 270 (13.5%) were from lymph nodes. Of these, 130 cases (48.2%) have metastatic deposits.We also came across 16 cases (5.9%) of lymphoma, 5 cases (1.9%) of granulomatous lymphadenitis, 2 cases (0.7%) of suppurative lesion and 99 cases (36.7%) of reactive hyperplasia during this period. In 3 cases (1.1%), the lesion turned out to be of salivary gland origin. Aspirates were suboptimal for diagnosis in 15 cases (5.5%). Aspirates were more in males (181) as compared to females (89). The most common site of aspiration was the cervical lymph node(64.5%),followed by supraclavicular=81(30%), inguinal=33(12.22%), axillary=19(7.04%) sub mental=1(0.37%) and others=7(2.59%). Apart from metastatic carcinomas other metastatic malignancies we came across were malignant melanoma, neuroblastoma, germ cell tumor and synovial sarcoma.

CONCLUSION

FNAC of lymph nodes helps in rapid diagnosis of lymphadenopathy.Categorizingthe cause of lymph node enlargement as metastatic malignancy,lymphoma, reactive change, inflammatory cause,suppuration etc. can be done by FNAC.In patients with known histologically proven malignancy in whom a subsequent enlargement of lymph node occurs,a cytological diagnosis of metastasis helps in avoiding unwanted surgery for confirming metastasis.In patients without a previous diagnosis of malignancy, FNAC not only confirm metastatic deposit but in most conditions give a clue regarding site of primary. The use of immunocytochemistry and cell block preparations have increased the scope of FNAC.

The Revised Sonographic NASCET Index: A New Hemodynamic Parameter for the Assessment of Internal Carotid Artery Stenosis

PURPOSE

A previously described Doppler parameter, the sonographic NASCET index (SNI), was derived to be more directly analogous to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) methodology for assessing carotid artery stenosis. However, this index does not account for complex changes affecting the Doppler waveform. We propose a revised SNI (rSNI) in an effort to improve predicting carotid stenosis.

MATERIALS AND METHODS

25 carotid bifurcations with stenoses ranging from 40 - 92 % were analyzed. For each vessel, the rSNI and original SNI were calculated. The peak systolic velocity (PSV), rSNI, and original SNI were correlated with angiography using linear regression analysis and relative accuracies were compared at two thresholds.

RESULTS

A correlation between rSNI and angiography was found to be significantly better than that between PSV or internal carotid artery-common carotid artery (ICA-CCA) peak velocity ratio and angiography (r² = 0.47 vs. 0.22; r² = 0.47 vs. 0.16). The accuracy of PSV in predicting high-grade stenosis was 68% and 72%, compared with 80% and 88% for rSNI, at each of two thresholds. The original SNI better correlated with angiography compared to the rSNI (r² = 0.55 vs. 0.47), but with slightly lower accuracy in predicting high-grade stenosis (76% vs. 80%).

CONCLUSION

The revised SNI correlates more closely with angiographic stenosis than either the PSV or the ICA-CCA ratio, and is more accurate in predicting high-grade stenosis. However, it is overall comparable to the original SNI, suggesting that the previously unaccounted for effects over the remainder of the cardiac cycle do not significantly improve the ability to sonographically predict significant stenosis.

Unusual self-assembly of a hydrophilic β-cyclodextrin inclusion complex into vesicles capable of drug encapsulation and release

A hydrophilic β-cyclodextrin bis-inclusion complex forms supramolecular vesicles which can be loaded with the anti-cancer drug doxorubicin. The loaded drug can be released upon addition of a competitive inclusion binder such as adamantane carboxylate.

Nonlinear control of voltage source converters in AC-DC power system

This paper presents the design of a robust nonlinear controller for a parallel AC-DC power system using a Lyapunov function-based sliding mode control (LYPSMC) strategy. The inputs for the proposed control scheme are the DC voltage and reactive power errors at the converter station and the active and reactive power errors at the inverter station of the voltage-source converter-based high voltage direct current transmission (VSC-HVDC) link. The stability and robust tracking of the system parameters are ensured by applying the Lyapunov direct method. Also the gains of the sliding mode control (SMC) are made adaptive using the stability conditions of the Lyapunov function. The proposed control strategy offers invariant stability to a class of systems having modeling uncertainties due to parameter changes and exogenous inputs. Comprehensive computer simulations are carried out to verify the proposed control scheme under several system disturbances like changes in short-circuit ratio, converter parametric changes, and faults on the converter and inverter buses for single generating system connected to the power grid in a single machine infinite-bus AC-DC network and also for a 3-machine two-area power system. Furthermore, a second order super twisting sliding mode control scheme has been presented in this paper that provides a higher degree of nonlinearity than the LYPSMC and damps faster the converter and inverter voltage and power oscillations.

Molecular & phenotypic characterization of Staphylococcus epidermidis in implant related infections

BACKGROUND & OBJECTIVES

The discrimination between the Staphylococcus epidermidis colonizing the deep seated indwelling devices and those which are mere commensals has always been a challenge for the clinical microbiologist. This study was aimed to characterize the S. epidermidis isolates obtained from device related infection for their phenotypic and molecular markers of virulence and to see whether these markers can be used to differentiate the pathogenic S. epidermidis from the commensals.

METHODS

Fifty five S. epidermidis isolates from various device related infections such as endophthalmitis following intra-ocular lens (IOL) implantation, intravascular (IV) catheter related sepsis and orthopaedic implant infections, were studied for slime production, biotyping, antibiotic sensitivity; and mec A and ica positivity by the recommended procedures.

RESULTS

Twenty three (41.8%) isolates were multi-drug resistant, 26 (65.2%) were slime producers, 30 (54.5%) were adherent, 23 (41.8%) possessed the intercellular adhesin (ica) gene, and 28 (50.9%) harboured the mec A gene. Biotypes I and III were the commonest, most members of which were multi- drug resistant. Twenty two (73.3%) of the 30 adherent bacteria were slime producers as opposed to only 4 (16%) of the 25 non-adherent bacteria (P<0.001). A vast majority i.e. 21 (91.3%) of the 23 ica positive organisms were adherent to artificial surfaces in contrast to only 9 (28.1%) of the 32 non-ica positive organisms (P<0.001). Twenty (86.9%) of the 23 ica positive bacteria were slime producers, as opposed to only 6 (18.7%) of the 32 ica negative bacteria (P<0.001). Of the 23 multi-drug resistant isolates, 19 (82.6%) carried the mec A gene.

INTERPRETATION & CONCLUSIONS

The present findings showed that ica AB and mec A were the two important virulence markers of S. epidermidis in implant infections and slime was responsible for the sessile mode of attachment on the devices.

Correlation of proteinase production with amphotericin B resistance in fungi from mycotic keratitis

Two hundred fungal isolates (Aspergillus and Fusarium species) from mycotic keratitis were tested for in vitro susceptibilities to amphotericin B and proteinase production. Geometric mean MICs for all fungal species increased fourfold with thousandfold increase in the inoculum. The MIC(50) and MIC(90) values ranged between 3.12-6.25 and 3.12-12.5 microg/ml, respectively. Proteinase production was noted in 113 (56.5%) isolates. Ninety-eight (49%) showed MICs of > or =1.56 microg/ml that was above the criteria of > or =1 microg/ml for amphotericin B resistance (CLSI). Seventy-three (74.5%) of these 98 isolates were proteinase producers, whereas only 40 (39.2%) of the remaining 102 with low MICs (<1.56 microg/ml) were proteinase producers (p < 0.001). Proteinase seems to be an important virulence marker of filamentous fungi in mycotic keratitis, correlating significantly with amphotericin B resistance.

Fungal infections of the eye--laboratory diagnosis and treatment

Infections of the eye give rise to severe ocular morbidity and blindness include keratitis, orbital cellulites, endophthalmitis and dacryocystitis. Corneal blindness, in developing countries is predominantly associated with infections. In India, nearly 30-35% of all culture positive infectious keratitis are caused fungi. Laboratory diagnosis mainly depends upon proper collection and transport of clinical specimens. In fungal keratitis, corneal scraping is the ideal sample, but occasionally corneal biopsy or anterior chamber aspirate may also be needed. Corneal scraping is usually by Kimura spatula, under a slit lamp examination, after anaesthetizing the cornea with topical anaesthetic like 0.4% proparcaine. Corneal biopsy is done by a minor trephining and AC aspirate using a sterile tuberculin syringe. In case of endophthalmitis, 150-200 ìl of aqueous humour is collected. Vitreous fluid (500-1000 ìl), however, is collected by pars plana vitrectomy onto sterile tuberculin syringe, the needle is then fixed to a sterile rubber bung after expelling air from the syringe. The collected sample is immediately transported to the laboratory. Swabs from the regurgitating lacrimnal sacs and wound aspirate/swabs are the ideal specimens for dacryocystitis and orbital cellulites, respectively. These samples are cultured onto SDA slants following standard procedures. The main draw back of culture is its long incubation time (5 to 14 days), though it is indispensable from the view point of the specificity. Direct examination (KOH wet mount, Gram's, Giemsa or calcofluor fluorescent staining methods) of the specimen, however, is quick and immensely helpful for ophthalmologist. The newer rapid methods, such as molecular techniques are also available and the management of patients can be according to the results obtained. With the advent of novel antifungal agents such as newer azoles and cell wall acting antifungals like echinocandins, the clinician has the wider option of selecting the therapeutic modality. In the event of the increasing reports of in vitro drug resistance to much frequently used azoles, polyenes and 5-fluorocytosines, clinical applicability of the newer antifungal agents seems to be quite promising.

Ultrastructural analysis of slime positive & slime negative Staphylococcus epidermidis isolates in infectious keratitis

BACKGROUND & OBJECTIVE

Slime is a major determinant of Staphylococcus epidermidis adherence. The established methods of laboratory detection of slime production by this organism i.e., Christensen's tube method and congo red agar plate method, can both yield inconclusive and/or intermediate results. We, therefore tried to find out electronmicroscopically the localization of slime in relation to the bacterial cell wall and look for the effect, if any of the slime location on the staphylococcal adherence as well as on the quantum of slime production.

METHODS

A total of 132 coagulase negative staphylococci from cases of infectious keratitis were identified as S. epidermidis following the recommended protocol. Slime was detected both by Christensen's tube method and congo red agar plate method. Antibiotic sensitivity testing was performed by standardized disc diffusion method. Adherence of the organisms to artificial surfaces was determined by a quantitative method and transmission electron microscopy was carried out by the conventional techniques.

RESULTS

Of the total 132 isolates, 57 (43.2%) were slime positive and 75 (56.8%) were slime negative. Twenty seven (47.4%) of the 57 slime producing organisms were multi drug resistant as compared to only 12 (16%) of 75 nonslime-producing organisms (P<0.001). A majority i.e., 45 (78.9%) of 57 adherent organisms were slime producers as against 12 (16%) of 75 nonadherent organisms. Electron microscopic study revealed a thick viscid layer of slime anchoring to the bacterial cell wall, especially in adherent organisms and those yielding positive slime test. Some of the organisms showed loose nonadherent slime and those were mostly nonadherent to artificial surfaces.

INTERPRETATION & CONCLUSION

Slime and multi drug resistance were the important virulence factors of S. epidermidis in bacterial keratitis. It was the adherent slime (i.e., slime in intimate association with the bacterial cell wall as shown by electron microscopy) only, which was responsible for resistance to multiple antibiotics and for the adhesion phenomenon observed in the quantitative slime test.

Decidual stromal cell response to paracrine signals from the trophoblast: amplification of immune and angiogenic modulators

During the invasive phase of implantation, trophoblasts and maternal decidual stromal cells secrete products that regulate trophoblast differentiation and migration into the maternal endometrium. Paracrine interactions between the extravillous trophoblast and the maternal decidua are important for successful embryonic implantation, including establishing the placental vasculature, anchoring the placenta to the uterine wall, and promoting the immunoacceptance of the fetal allograph. To our knowledge, global crosstalk between the trophoblast and the decidua has not been elucidated to date, and the present study used a functional genomics approach to investigate these paracrine interactions. Human endometrial stromal cells were decidualized with progesterone and further treated with conditioned media from human trophoblasts (TCM) or, as a control, with control conditioned media (CCM) from nondecidualized stromal cells for 0, 3, and 12 h. Total RNA was isolated and processed for analysis on whole-genome, high-density oligonucleotide arrays containing 54,600 genes. We found that 1374 genes were significantly upregulated and that 3443 genes were significantly downregulated after 12 h of coincubation of stromal cells with TCM, compared to CCM. Among the most upregulated genes were the chemokines CXCL1 (GRO1) and IL8,CXCR4, and other genes involved in the immune response (CCL8 [SCYA8], pentraxin 3 (PTX3), IL6, and interferon-regulated and -related genes) as well as TNFAIP6 (tumor necrosis factor alpha-induced protein 6) and metalloproteinases (MMP1, MMP10, and MMP14). Among the downregulated genes were growth factors, e.g., IGF1, FGF1, TGFB1, and angiopoietin-1, and genes involved in Wnt signaling (WNT4 and FZD). Real-time RT-PCR and ELISAs, as well as immunohistochemical analysis of human placental bed specimens, confirmed these data for representative genes of both up- and downregulated groups. The data demonstrate a significant induction of proinflammatory cytokines and chemokines, as well as angiogenic/static factors in decidualized endometrial stromal cells in response to trophoblast-secreted products. The data suggest that the trophoblast acts to alter the local immune environment of the decidua to facilitate the process of implantation and ensure an enriched cytokine/chemokine environment while limiting the mitotic activity of the stromal cells during the invasive phase of implantation.

Serotype distribution of Streptococcus pneumoniae isolates from ophthalmic and systemic infections and of commensal origin

BACKGROUND AND OBJECTIVES

Information regarding serotype distributions of Streptococcus pneumoniae causing ophthalmic infections is scanty. This study was therefore undertaken to determine the antimicrobial susceptibility status and serotypes of S. pneumoniae isolated from various ophthalmic infections and to compare with those isolated from systemic infections and commensal nasopharyngeal flora.

METHODS

Thirty eight of S. pneumoniae isolates from ophthalmic infections, 9 from systemic infections and 14 from the nasopharynx of apparently healthy school children were biochemically characterized and tested for in vitro antimicrobial susceptibility to various antibiotics. Serotyping of these 61 isolates was done by a rapid co-agglutination method.

RESULTS

All the 61 isolates were sensitive to oxacillin (penicillin) and susceptibility against other antimicrobials was variable. No multidrug resistance was observed. The 38 ophthalmic isolates were distributed in 15 different serotypes. Most prevalent serotypes were 14, followed by 8 and 19F. The 9 systemic and 14 commensal. isolates of S. pneumoniae were distributed in 7 and 11 serotypes respectively. Three of the systemic and six of the commensal serotypes were observed in ophthalmic infections whereas four of the commensal serotypes were observed in systemic infections.

INTERPRETATION AND CONCLUSION

Resistance to penicillin was not observed. In ophthalmic infections, a wide range of serotypes of S. pneumoniae were observed. More than half of the commensal serotypes obtained in the study as well as majority of the systemic serotypes were observed in ophthalmic infections.

Lead in paint and soil in Karnataka and Gujarat, India

Blood lead surveys in several areas of India have found very high percentages of children with elevated blood lead levels. Fifty-three percent of children under 12 years of age in a seven-city screening had blood lead levels equal to or greater than 10 microg/dL, the level currently considered elevated by the U.S. Centers for Disease Control and Prevention (CDC). A number of these surveys focused on populations near lead smelters or in areas with high lead levels from combustion of lead-containing gasoline. There is little information available, however, on the levels of lead in paint in India and in soil. Field portable X-ray fluorescence analyzers were used to determine environmental lead levels in paint, dust, air, soil, and other bulk samples near several lead-using industries and in the residential environments of children with very high blood lead levels, at least four times as high as the CDC limit. Soils near industrial operations, such as secondary lead smelters, and battery dismantling units contained levels up to 100,000 ppm of lead. Four of 29 currently available paints from five manufacturers measured 1.0 mg/cm2 or above--the current U.S. definition of lead-based paint in housing-after the application of a single coat; four others measured at least 1.0 after three coats, and three others likely reached this level after the application of an additional one or two coats. In 5 of 10 homes of the elevated blood lead children, three or more locations in or around the home were found to have lead paint levels of 1.0 mg/cm2 or higher. Soil exceeding the U.S. standard for residential areas (400 ppm) was found at only one of the houses. Other sources of lead exposure, including traditional ayurvedic medicine tablets, were also observed. Similar surveys would be useful elsewhere in India and in other developing countries.

Portable lead analyzer to locate source of lead

OBJECTIVE

To investigate the sources of lead in the environment in children with elevated blood, with the help of a Field Portable X-Ray Fluorescence Analyzer.

METHODS

One hundred and seven school children were chosen for this study on a random basis, from Mangalore and Karnataka. Their blood lead was analyzed. Of the cases analyzed, 10 students whose blood lead level was more than 40 microg/dl were investigated using a field portable X-Ray Fluorescence Analyzer. This is the first time such a device has been available for this purpose in India.

RESULTS

The 'likely' source of lead exposure could be determined in eight cases which was from the immediate environment of the children like 'lead-based' paint on surfaces in the house, on playground and other exterior equipment; lead storage batteries, contaminated dust and soil and other lead-containing substances.

CONCLUSION

The use of an X-Ray Fluorescence Analyser appeared to be useful in determining the source of lead.

Role of cell surface antigens of Vibrio cholerae 01 and non 01 serovars in intestinal adhesion

Decrease in adherence of Vibrio cholerae to rabbit small intestine was observed following treatment with antisera against outer membrane (OM), lipopolysaccharide (LPS) and flagella. Anti LPS antibodies were more efficient than the other two antibodies in inducing adherence inhibition and promoting in vivo protection.

A simple alternative method for rapid detection of slime produced by Staphylococcus epidermidis isolates in bacterial keratitis

BACKGROUND & OBJECTIVES

Slime is a known virulence factor of Staphylococcus epidermidis. The conventional Christensen's method for detection of slime in the laboratory takes at least 48 h. We, therefore, tried to evaluate the efficacy of the Congo red agar method as a routine procedure for detecting slime among isolates from corneal ulcers.

METHODS

A total of 244 isolates from corneal ulcers were identified as S. epidermidis by the standard procedures. Slime was detected both by the conventional Christensen's method as well as by the Congo red agar method.

RESULTS

Ninety two (37.7%) isolates were positive and 86 (35.2%) were negative for slime by both the techniques. Fifty four (22.1%) isolates were positive in Congo red agar, but negative by Christensen's method; whereas only 12 (4.9%) were negative by Congo red but positive by Christensen's method. Detection of slime by Congo red agar method was rapid i.e., all the 146 strains were positive within 24 h of incubation. On the other hand, Christensen's method had a delayed response; 42.3 per cent (44/104) strains being negative during the first 24 h of incubation.

INTERPRETATION & CONCLUSION

Our results suggested that culture on Congo red agar was a sensitive and rapid test for detecting slime. This might help in the quick identification in a routine laboratory of slime positive isolates in bacterial keratitis.

Development and validation of a novel technique for murine first-pass radionuclide angiography with a fast multiwire camera and tantalum 178

BACKGROUND

The use of genetically altered mice as a model system to study cardiovascular disease has created a need for accurate and quantitative assessment of murine ventricular function. To address this very challenging problem, we have developed a technique of murine first-pass radionuclide angiography using pinhole imaging and the short-lived isotope tantalum 178 (Ta-178) with a high-speed multiwire proportional camera (MPC). METHODS AND RESULTS. An MPC was fitted with a pinhole lens of 2-mm-diameter aperture positioned 15 cm from the camera face. The short-lived isotope Ta-178 (half-life 9.3 minutes) was generated from the tungsten 178 (W-178) (half-life 21.7 days)/Ta-178 generator and concentrated on site to an injection volume of 15 to 20 microL. Mice were imaged in the supine position with the chest wall 3 mm from the camera pinhole aperture, and images were acquired at 160 frames per second after a rapid bolus injection of Ta-178. In the absence of a true gold standard, the technology was validated with measurements in control mice and mice with surgically ligated left anterior descending arteries (LADs). In addition, the effects of pharmacologic intervention with verapamil and with dobutamine were observed. Finally, peak aortic velocity measurements obtained with this technology were compared with those obtained with echocardiographic Doppler ultrasonography, the only available quantitative comparator. There was a significant decrease in the mean left ventricular ejection fraction (LVEF) between normal mice (62% +/- 4.6% [mean +/- SEM], n = 12) and mice with experimentally induced myocardial infarction produced by surgical LAD ligation (22% +/- 2.0%, n = 41; P <.01). The LVEF decreased from 51% +/- 5.8% to 37% +/- 3.5% in a group of normal mice receiving verapamil (P <.05, n = 8) and increased from 34% +/- 2.2% to 43% +/- 2.3% in a group of LAD-ligated mice receiving dobutamine (P <.01, n = 48). Peak camera sensitivity during first pass was 25,000 cps/mCi injected. Intraobserver and interobserver variability of LVEF was studied, yielding r = 0.9639 and 0.9529 and SE of the estimate 2.6% and 3.1%, respectively. Reproducibility in serial studies was excellent (r = 0.92, SE of the estimate 5.18).

CONCLUSIONS

This study demonstrates the development and use of a promising new method that uses the short-lived radioisotope Ta-178 and MPC for noninvasive quantification of murine ventricular function, that produces accurate and highly reproducible results, and that can be applied in multiple serial studies.

Retinyl ester secretion by intestinal cells: a specific and regulated process dependent on assembly and secretion of chylomicrons

Retinyl esters (RE) have been used extensively as markers to study chylomicron (CM) catabolism because they are secreted in the postprandial state with CM and do not exchange with other lipoproteins in the plasma. To understand the mechanism of secretion of RE by the intestine under the fasting and postprandial states, differentiated Caco-2 cells were supplemented with radiolabeled retinol under conditions that support or do not support CM secretion. We observed that these cells assimilate vitamin A by a rapid uptake mechanism. After uptake, cells store retinol in both esterified and unesterified forms. Under fasting conditions, cells do not secrete RE but secrete free retinol unassociated with lipoproteins. Under postprandial conditions, cells secrete significant amounts of RE only with CM. The secretion of RE with CM was independent of the rate of uptake of retinol and intracellular free and esterified retinol levels, and was absolutely dependent on the assembly and secretion of CM. The secretion of RE was correlated with the secretion of CM and not with the secretion of total apolipoprotein B. Inhibition of CM secretion by Pluronic L81 decreased the secretion of RE and did not result in their increased secretion with smaller lipoproteins. These data strongly suggest that RE secretion by the intestinal cells is a specific and regulated process that occurs in the postprandial state and is dependent on the assembly and secretion of CM. We propose that RE are added to CM during final stages of lipoprotein assembly and may serve as signposts for these steps.