Pyoderma gangrenosum: A clinico- therapeutic profile of patients attending a tertiary care hospital in Nepal

Pyoderma gangrenosum (PG) is a primarily sterile inflammatory neutrophilic dermatosis characterized by recurrent cutaneous ulcerations with mucopurulent or hemorrhagic exudate. In many cases, PG is associated with inflammatory bowel disease, rheumatic disorder or neoplasia. The peak of incidence occurs between the ages of 20 to 50 years with women being more often affected than men. To study the clinical and therapeutic profile of patients with pyoderma gangrenosum. All patients diagnosed as pyoderma gangrenosum in the department of dermatology from July 14th 2003- July 12th 2008 were included in the study. Demographic profile, clinical features as well as relevant investigations, treatment and follow-up were noted. A total of 8 patients with pyoderma gangrenosum were diagnosed over a 5 year period. There were 3 males and 5 female patients whose ages ranged from 32 to 80 years. Lower limbs were the commonest site to be involved in 6 patients (75%). Recurrent episodes were noted in 4 patients (50%) and among them 3 patients (75%) had multiple ulcers. Histopathological confirmation of the diagnosis was done in 7 patients (87.5%). Association with ulcerative colitis was seen in 2 patients (25%). All patients were treated with dapsone and systemic steroids which showed resolution of the lesions in all patients. Pyoderma gangrenosum was seen more frequently in females and association with ulcerative colitis was seen in 25% of the patients. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-1, 29-35 DOI: http://dx.doi.org/10.3126/jcmsn.v8i1.6823

A retrospective analysis of Sweet's syndrome in a tertiary care hospital in Nepal: A BPKIHS perspective

Sweet's syndrome (the eponym for acute febrile neutrophilic dermatosis) is characterized by a constellation of clinical symptoms, physical features, and pathologic findings which include fever, neutrophilia, tender erythematous skin lesions (papules, nodules, and plaques), and a diffuse infiltrate consisting predominantly of mature neutrophils that are typically located in the upper dermis without vasculitis. To study the clinico-pathological features, clinical course and treatment of patients with sweets syndrome. A retrospective observational analysis of 12 diagnosed cases of sweet’s syndrome attending and admitted in the Department of Dermatology from June 2003- April 2009 were considered in this study. The study comprised of 9 females and 3 males (3:1) between the age group of 22-73 years. Typical lesions of sweets syndrome were present in all cases and the duration of illness ranged from 3-8 days. Constitutional symptoms of fever, pain and malaise were present in all and the extremities were the most common site of involvement 12 (100%). Leucocytosis was present in 7 (58.3%), raised ESR in 9 (75%) and raised C reactive protein in 7(58.3%) patients. Characteristic histological features were recorded in specimens of all patients. 9 (75%) patients responded promptly to systemic oral corticosteroids while 3 (25%) were treated with intravenous steroids. Complete Response was seen in 7 (58.3%), partial response in 5 (41.6%) and recurrence in 1(8.3%) patient after therapy. Characteristic skin lesion, histopathological diagnosis and relevant abnormal laboratory parameters can act as a useful diagnostic tool in patients with sweet’s syndrome. DOI: http://dx.doi.org/10.3126/jcmsn.v7i3.6703 Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-3, 17-23

MRE11 expression is predictive of cause-specific survival following radical radiotherapy for muscle-invasive bladder cancer

Radical radiotherapy and surgery achieve similar cure rates in muscle-invasive bladder cancer, but the choice of which treatment would be most beneficial cannot currently be predicted for individual patients. The primary aim of this study was to assess whether expression of any of a panel of DNA damage signaling proteins in tumor samples taken before irradiation could be used as a predictive marker of radiotherapy response, or rather was prognostic. Protein expression of MRE11, RAD50, NBS1, ATM, and H2AX was studied by immunohistochemistry in pretreatment tumor specimens from two cohorts of bladder cancer patients (validation cohort prospectively acquired) treated with radical radiotherapy and one cohort of cystectomy patients. In the radiotherapy test cohort (n = 86), low tumor MRE11 expression was associated with worse cancer-specific survival compared with high expression [43.1% versus 68.7% 3-year cause-specific survival (CSS), P = 0.012] by Kaplan-Meier analysis. This was confirmed in the radiotherapy validation cohort (n = 93; 43.0% versus 71.2%, P = 0.020). However, in the cystectomy cohort (n = 88), MRE11 expression was not associated with cancer-specific survival, commensurate with MRE11 being a predictive marker. High MRE11 expression in the combined radiotherapy cohort had a significantly better cancer-specific survival compared with the high-expression cystectomy cohort (69.9% versus 53.8% 3-year CSS, P = 0.021). In this validated immunohistochemistry study, MRE11 protein expression was shown and confirmed as a predictive factor associated with survival following bladder cancer radiotherapy, justifying its inclusion in subsequent trial designs. MRE11 expression may ultimately allow patient selection for radiotherapy or cystectomy, thus improving overall cure rates.

Need for improvement of medical records

INTRODUCTION

A medical record is a systematic documentation of a patient's medical history and care for legal and future use. A poor quality medical record can negatively affect patient care and safety. The study aims to assess the adequacy of medical records in Bir Hospital, a central hospital.

METHODS

A cross-sectional study was conducted by analyzing consecutive discharge summaries of patients admitted during a 6 month period in a single unit of a tertiary care center. The discharge summary format of the hospital was taken as the standard and evaluation for adequacy of data entered was assessed. Descriptive statistics were used to analyze various statistical discrepancies.

RESULTS

Patient's condition at discharge was missing in 86 (66.15%). Patient's address was missing in 21 (16.1%) cases. Almost all the discharge sheets lacked mailing address. Total 96 (73.8%) had use of abbreviations diagnosis. Age and sex were missing in 1 (0.76%). Doctor's signature was illegible in 103 (79.3%) and missing in 2 (1.5%) summaries. Doctor's name and their level/position were missing in 118 (90.76%) and 125 (96.1%) respectively. Total 126 patients (96.9%) were not given any instructions on discharge.

CONCLUSIONS

The discharge summaries analyzed were seen to be inadequate especially in documenting course during the hospital stay, condition at discharge, appropriate instructions and the treating physician's details. These can probably be addressed by introducing electronic medical records if feasible. Otherwise, the discharge summary should be standardized and doctors should be trained to write legible, complete discharge summaries.

Antiviral activity of some plants used in Nepalese traditional medicine

Methanolic extracts of 41 plant species belonging to 27 families used in the traditional medicine in Nepal have been investigated for in vitro antiviral activity against Herpes simplex virus type 1 (HSV-1) and influenza virus A by dye uptake assay in the systems HSV-1/Vero cells and influenza virus A/MDCK cells. The extracts of Astilbe rivularis, Bergenia ciliata, Cassiope fastigiata and Thymus linearis showed potent anti-herpes viral activity. The extracts of Allium oreoprasum, Androsace strigilosa, Asparagus filicinus, Astilbe rivularis, Bergenia ciliata and Verbascum thapsus exhibited strong anti-influenza viral activity. Only the extracts of A. rivularis and B. ciliata demonstrated remarkable activity against both viruses.

Leiomyosarcoma of the spermatic cord: case report and literature review

A 51-year-old man presented with a 2-year history of painless lump in the left hemiscrotum. Scrotal examination demonstrated a 3-cm, firm-to-hard mass attached to the left spermatic cord. Scrotal ultrasound scan revealed a heterogeneous mass separate from the left testis and epididymis. An orchidectomy was recommended to the patient; however, he declined surgery and underwent excision biopsy of the lesion with preservation of the left testis. Histology suggested a leiomyosarcoma of the spermatic cord and positive margins. Following a normal staging CT scan, the patient was referred to the regional sarcoma clinic. He was treated with an orchidectomy. Microscopic examinations showed fibrosis in the spermatic cord and negative margins. The patient has been followed up for 12 months with CT scans and shows no signs of recurrence.

The stability of gingerol and shogaol in aqueous solutions

Gingerols, pungent principles of ginger (the rhizome of Zingiber officinale), are biologically active components that may make a significant contribution towards medicinal applications of ginger and some products derived from ginger. Gingerols, however, are thermally labile due to the presence of a beta-hydroxy keto group in the structure, and undergo dehydration readily to form the corresponding shogaols. This study investigated the stability of [6]-gingerol [5-hydroxy-1-(4-hydroxy-3-methoxyphenyl)decan-3-one] at temperatures ranging from 37 to 100 degrees C in aqueous solutions, at pH 1, 4, and 7. Quantitative measurements of [6]-gingerol and its major degradation product [6]-shogaol [1-(4-hydroxy-3-methoxyphenyl)decan-4-ene-3-one] were performed by HPLC. Kinetics of [6]-gingerol degradation was characterized by least square fitting of a rate equation. It was found that gingerol exhibited novel reversible kinetics, in which it undergoes dehydration-hydration transformations with shogaol, the major degradation product. Degradation rates were found to be pH dependent with greatest stability observed at pH 4. The reversible degradation of [6]-gingerol at 100 degrees C and pH 1 was relatively fast and reached equilibrium within 2 h. Activation energies for the forward and reverse reactions for [6]-gingerol were calculated from the Arrhenius equation using reaction rates obtained at temperatures ranging from 37 to 100 degrees C.

Effectiveness of training of basic health workers in Leprosy Control Programme

This study was undertaken in two adjacent districts (Rautahat and Parsa) in Nepal to measure the impact of training of basic health workers on Leprosy Control Programme. Knowledge, attitude and leprosy service delivery by them were studied before and after training. There was an improvement in all the three components after training. However, improvement was also seen in the control group as well. Possible reasons for this are discussed. Improper selection of the area and an inadequate methodology were the identified drawbacks of the study.

Phyllodes tumor of the breast. A cytohistologic study of 80 cases

OBJECTIVE

To study the cytologic features of phyllodes tumor (PT) of the breast and determine the accuracy of their subclassification in fine needle aspirates.

STUDY DESIGN

Eighty cases of histologically diagnosed PT between 1982 and 1997 with a previous fine needle aspiration (FNA) were evaluated. The FNA smears of each case were reviewed without knowledge of the initial cytologic diagnosis and subclassified into benign, borderline or malignant PT.

RESULTS

Benign PTs were characterized by a dimorphic mixture of stromal and epithelial cells. The stromal fragments showed mild to moderate cellularity with absent to minimal pleomorphism and no mitosis. There were occasional, if any, single stromal cells. Borderline PTs had stromal fragments with moderately cellular stroma exhibiting moderate pleomorphism. Two additional features were the presence of single stromal cells and an occasional mitosis in the stromal fragments/single cells. Aspirates from malignant PT were very cellular, with a high stromal/epithelial ratio and marked stromal cellularity. The stromal cells were highly pleomorphic, with frequent mitosis and atypical single stromal cells in the background. Fifty-seven of the 80 histologically documented cases (71.3%) were diagnosed as PT on FNA (40 benign, 10 borderline and 7 malignant). In 81% (46 of 57 PTs), good cytohistologic correlation (32 benign, 8 borderline and 6 malignant) was observed. In another eight cases, one grade differentiation between cytologic and histologic grade was observed. Six of the nine malignant PTs on histology were correctly subclassified on cytology. There were one false positive and two false negative cases.

CONCLUSION

Cytologic diagnosis and grading of PT on FNA is possible. Special care should be undertaken in interpreting phyllodes fragments, cellularity of stroma, pleomorphism and mitosis. Single stromal cells are also important morphologic criteria for subclassification. Multiple-site aspiration is advisable to avoid diagnostic errors.

Ocular extramedullary myeloid cell tumour in children: an Indian study

Thirty-two children with extramedullary myeloid cell tumour (EMT) who constituted 41 per cent of children with acute myeloid leukaemia (AML) were studied to ascertain their laboratory characteristics and potential problems in diagnosis. The diagnosis, established by peripheral blood smear and/or bone marrow examination, was AML (n = 29) and refractory anaemia with excess blasts in transformation (RAEB-t; n = 3). The six referred patients in whom the diagnosis had been missed, and two cases wrongly reported as histiocytosis on aspiration cytology, were those in whom a peripheral blood smear had not been examined. It is concluded that diagnostic work-up of proptosis must include a full haemogram, meticulous peripheral blood smear examination, repeated if necessary, and bone marrow examination where relevant. RAEB-t cases with extramedullary myeloid cell tumour should be classified as acute myeloid leukaemia.

Ethno-medicinal Plants Used by the People of Nawalparasi District, Central Nepal

Despite new advances in modern medicine, the cultural use of plant in traditional medicine continues from ancient time to this day all over the world. The present research seeks to explore ethnomedicinal plants used by the local people of Nawalparasi district for primary healthcare. Local healers were interviewed regarding the detail uses of plants. When convenient a jungle or forest walk was also conducted, accompanying local healers for plant collection and detailed information gathering. A rich and unique diversity of 94 ethnomedicinal plant species belonging to 49 families under 86 genera were documented. In Nawalparasi, the expense of modern medical treatment combined with the poor economic status of indigenous people and a strong belief in the traditional medicine and traditional medical practitioners are the main reasons for the persistence of the traditional healing system. In addition, we have also documented a lack of continuation and flow of indigenous knowledge from the elders to the younger generation. Youth tend to be attracted by the wave of modernization and do not appreciate the importance of conservation of traditional knowledge. The use of plants in Nawalparasi is an old tradition and the exploration of such unique cultures should be completed thoroughly so that the oral traditions are not lost forever. Immediate conservation and management approaches of valuable medicinal plants with the involvement of local indigenous people of Nawalparasi district will encourage the sustainable conservation of both biological and cultural diversity.Key words: Traditional medicine; Local healers; Healthcare; Conservation; NawalparasiDOI: 10.3126/on.v7i1.2555Our Nature (2009) 7:82-99

Spectrum of cutaneous manifestations in lupus erythematous -a dermatologist perspective

Background: The cutaneous manifestations of lupus erythematosus (LE) specific skin disease consists of acute cutaneous LE (ACLE), Subacute cutaneous (SCLE) and Chronic cutaneous (CCLE). Objective: To evaluate the spectrum of cutaneous manifestation in patients of LE. Methods: A case series of 41 clinically diagnosed cases of LE attending the outpatient department of Dermatology, BPKIHS were evaluated for the specific and non-specific skin changes. Results: All the patients enrolled in the study were female,with the age ranging from 14-64 years. ACLE was detected in 22/41(78.04%). Malar rash was the frequent skin lesion. CCLE was seen in 6/41 (14.63%) patients with classical discoid lesions (localized and generalized) in 4/6(66.66%) and 2/6(33.33%) respectively. Non specific skin lesions were found in 30/ 41(73.17%) of patients. Mucosal ulcers were seen in 23/41(56.09%), Facial telangiectasias 20/41(48.78%), Raynaunds phenomena 22/41(53.65%), Chronic urticaria 9/41(21.95%), Nail changes 12/41(29.26%) and non scarring alopecia was seen in 6/41(14.63%) patients. Eye involvement was seen in 3/41(7.3%), cutaneous vasculitis in 5/41(12.19%) and scaring alopecia in 3/41(7.3%) patients. Conclusion: The cutaneous manifestations of patients with lupus erythematosus (LE) are very frequent, show a great variety and can occur at any stage of the disease. DOI: http://dx.doi.org/10.3126/hren.v10i1.5999 HREN 2012; 10(1): 8-11