Treating persistent asthma in rural Rwanda: characteristics, management and 24-month outcomes

SETTING

In 2007, the Rwandan Ministry of Health, with support from Partners In Health, introduced a district-level non-communicable disease programme that included asthma care.

OBJECTIVE

To describe the demographics, management and 24-month outcomes of asthma patients treated at three rural district hospitals in Rwanda.

DESIGN

We retrospectively reviewed electronic medical records of asthma patients enrolled from January 2007 to December 2012, and extracted information on demographics, clinical variables and 24-month outcomes.

RESULTS

Of the 354 patients, 66.7% were female and 41.5% were aged between 41 and 60 years. Most patients (53.1%) were enrolled with moderate persistent asthma, 40.1% had mild persistent asthma and 6.8% had severe persistent asthma. Nearly all patients (95.7%) received some type of medication, most commonly a bronchodilator. After 24 months, 272 (76.8%) patients were still alive and in care, 21.1% were lost to follow-up, 1.7% had died and 0.3% had transferred out. Of the 121 patients with an updated asthma classification at 24 months, the severity of their asthma had decreased: 17.4% had moderate and 0.8% had severe persistent asthma.

CONCLUSION

Our findings show improvements in asthma severity after 24 months and reasonable rates of loss to follow-up, demonstrating that asthma can be managed effectively in rural, resource-limited settings.

The role of the cytopathologist in subtyping and epidermal growth factor receptor testing in non-small cell lung cancer: An institutional experience

OBJECTIVE

Approximately 10% of non-small-cell lung cancer (NSCLC) remains unclassifiable as NSCLC-not otherwise specified (NOS), after using a panel of immunomarkers. The present study was undertaken to assess sensitivity and specificity of immunomarkers in sub-typing NSCLC on fine needle aspiration cytology (FNAC). Epidermal growth factor receptor (EGFR) mutations were also detected in these samples.

METHODS

Sixty cases of NSCLC including 15 squamous cell carcinoma (SCC), 15 adenocarcinomas (ADC) and 30 NSCLC-NOS reported on FNAC were included in the study. A panel of CK7, CK5/6, TTF-1 and p63 was applied in these cases. DNA was extracted from 54 cases including 14 effusion samples, and EGFR mutations were detected.

RESULTS

Classic ADC cases (n=15) showed 73.3% TTF-1 positivity and 100% CK7 positivity. Two cases of ADC showed aberrant expression of p63 and 2 cases showed CK5/6 positivity. 80% of classic SCC cases (n=15) showed strong nuclear p63 positivity and 86.6% were positive for CK5/6. TTF-1 was seen exclusively in ADC cases. Immunohistochemistry (IHC) using two immunomarkers (TTF-1 and p63) helped in subtyping 24/30(80%) cases of NSCLC. EGFR mutations were detected in 9/54 (16.7%) cases, and the most common mutation was short in-frame deletion in Exon 19.

CONCLUSIONS

More than 90% of NSCLC can be sub-typed on cytology samples with the help of immunochemistry. The sensitivity of TTF-1, p63, CK5/6 and CK7 was 73.3%, 80%, 100% and 100%, respectively. The specificity of TTF-1, p63, CK5/6 and CK7 was 100%, 86.6%, 86.6% and 93.3%, respectively. TTF-1 is highly specific, and almost 80% of NSCLC-NOS cases can be sub-typed using TTF-1 and p63. EGFR mutations can be detected in cytology samples, and 16.7% samples were positive for EGFR mutations.

Distribution trends & antibiogram pattern of Salmonella enterica serovar Newport in India

Background & objectives:

Salmonellosis is a major public health concern worldwide. Besides typhoidal salmonellae, infections due to non-typhoidal serovars of Salmonella are also associated with high morbidity and mortality leading to huge economic losses. Among non-typhoidal serovars, Salmonella Newport has been reported as a major cause of foodborne infections resulting in outbreaks due to consumption of contaminated food items. Little data related to this serovar are available from India leading to the scarcity of information on the distribution trends of this important serovar in the country. Therefore, an effort was made in the present study to generate data on distribution trends and antibiogram of S. Newport in the country.

Methods:

S. Newport isolates received at the National Salmonella and Escherichia Centre at Kasauli, India, during January 2010 to December 2013 were analysed for their distribution trends and antibiogram data were also generated using standard methods.

Results:

In the present study, S. Newport isolates were received from eight States and one union territory of the country and highest proportion of S. Newport isolates were found to be from humans (53.61%) followed by animals (27.84%) and food (18.56%). S. Newport isolates exhibited resistance to all drugs used in the present study except chloramphenicol, ciprofloxacin and cefuroxime.

Interpretation & conclusions:

Considering distribution of this important serovar of Salmonalla and its wide range of reservoirs, steps towards formulation and execution of efficient surveillance programmes should be taken.

Position paper on olfactory dysfunction

BACKGROUND

Olfactory dysfunction is an increasingly recognised condition, associated with reduced quality of life and major health outcomes such as neurodegeneration and death. However, translational research in this field is limited by heterogeneity in methodological approach, including definitions of impairment, improvement and appropriate assessment techniques. Accordingly, effective treatments for smell loss are limited. In an effort to encourage high quality and comparable work in this field, among others, we propose the following ideas and recommendations. Whilst the full set of recommendations are outlined in the main document, points include the following: - Patients with suspected olfactory loss should undergo a full examination of the head and neck, including rigid nasal endoscopy with small diameter endoscopes. - Subjective olfactory assessment should not be undertaken in isolation, given its poor reliability. - Psychophysical assessment tools used in clinical and research settings should include reliable and validated tests of odour threshold, and/or one of odour identification or discrimination. - Comprehensive chemosensory assessment should include gustatory screening. - Smell training can be helpful in patients with olfactory loss of several aetiologies.

CONCLUSIONS

We hope the current manuscript will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency and generalisability of work in this field.

Successful Treatment of BK Virus Hemorrhagic Cystitis (HC) Post Allogenic Hematopoietic Stem Cell Transplantation with Low Dose Cidofovir

BK virus (BKV) hemorrhagic cystitis (HC) is a serious cause of morbidity and mortality after allogeneic hematopoietic SCT (allo-HSCT) in patients with hematological malignancies. Around half of allogenic HSCT patients present with BKV viruria at some point after HSCT; about 5-40% of these patients subsequently develop active HC. Supportive care including bladder irrigation, blood transfusions and symptomatic pain management remains the mainstay of therapy; the acyclic nucleoside analogue cidofovir is currently the front-line drug for BKV-HC treatment. Here we report the first case of severe hemorrhagic cystitis from India who was successfully treated with low dose cidofovir therapy.

Further studies of the effects of aging on arginine metabolites in the rat vestibular nucleus and cerebellum

Some studies have demonstrated that aging is associated with impaired vestibular reflexes, especially otolithic reflexes, resulting in postural instability. However, the neurochemical basis of these age-related changes is still poorly understood. The l-arginine metabolic system has been implicated in changes in the brain associated with aging. In the current study, we examined the levels of l-arginine and its metabolizing enzymes and downstream metabolites in the vestibular nucleus complex (VNC) and cerebellum (CE) of rats with and without behavioral testing which were young (4months old), middle-aged (12months old) or aged (24months old). We found that aging was associated with lower nitric oxide synthase activity in the CE of animals with testing and increased arginase in the VNC and CE of animals with testing. l-citrulline and l-ornithine were lower in the VNC of aged animals irrespective of testing, while l-arginine and l-citrulline were lower in the CE with and without testing, respectively. In the VNC and CE, aging was associated with lower levels of glutamate in the VNC, irrespective of testing. In the VNC it was associated with higher levels of agmatine and putrescine, irrespective of testing. In the CE, aging was associated with higher levels of putrescine in animals without testing and with higher levels of spermine in animals with testing, and spermidine, irrespective of testing. Multivariate analyses indicated significant predictive relationships between the different variables, and there were correlations between some of the neurochemical variables and behavioral measurements. Cluster analyses revealed that aging altered the relationships between l-arginine and its metabolites. The results of this study demonstrate that there are major changes occurring in l-arginine metabolism in the VNC and CE as a result of age, as well as behavioral activity.

Prevalence of high-risk human papilloma virus types and cervical smear abnormalities in female sex workers in Chandigarh, India

PURPOSE

Cervical cancer is the most common cancer among women in developing nations. Nearly 90% of the cases have been linked to the presence of high-risk human papillomavirus (hrHPV) types 16 and 18. The risk of cervical cancer may be high in female sex workers (FSWs) due to multiple sexual partners. This study aimed to determine the prevalence of cytological abnormalities and hrHPV types 16 and 18 in FSWs in Chandigarh, North India using the liquid-based cytology (LBC) approach.

MATERIALS AND METHODS

The cervical brush samples were collected from 120 FSW and 98 age-matched healthy controls (HCs). These were subjected to pap smear using conventional method, LBC and the detection of hrHPV types 16 and 18 was carried out using polymerase chain reaction.

RESULTS

The LBC samples showed better cytological details and also reduced the number of unsatisfactory smears from 11% in Pap to 1.5% in the LBC. A significantly higher number of inflammatory smears were reported in FSWs (51.7% vs. 34.7%, P = 0.01). The hrHPV types 16/18 were detected in 33/120 (27.5%) FSW versus 23/98 (23.5%) HCs. The risk of acquiring hrHPV was higher in FSWs, who had age at first sex ≤25 years, higher income and the habit of smoking.

CONCLUSION

The high prevalence of hrHPV among FSWs and HCs suggests the need for the implementation of effective National Screening Programme for early detection of hrHPV types to decrease the burden of cervical cancer, especially in high-risk population.

Abstract P3-03-10: Penfluridol reduces paclitaxel resistance in breast cancer by inhibiting HER2/β-catenin signaling

This abstract was not presented at the symposium.

Abstract P5-16-12: Pertuzumab and trastuzumab in combination with weekly paclitaxel delivers high pCR rates with favourable toxicity profile in neo-adjuvant treatment of Her-2 positive breast cancer

This abstract was not presented at the symposium.

Abstract OT2-03-01: NRG oncology/NSABP B-51/RTOG 1304: A phase III superiority clinical trial designed to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to breast RT post breast-conserving surgery (BCS) will reduce invasive cancer events in patients (pts) with positive axillary (Ax) nodes and convert to ypN0 after neoadjuvant chemotherapy (NC)

Background:

This phase III post-NC trial evaluates if CWRNRT post Mx or whole breast irradiation (WBI) with RNRT after BCS significantly reduces the invasive breast cancer recurrence-free interval (IBC-RFI) rate in pts presenting with positive Ax nodes that are pathologically negative after NC. Secondary aims are OS, LRRFI, DRFI, DFS-DCIS, and second primary cancer, as well as comparing RT effect on cosmesis in reconstructed Mx pts.

Correlative science studies examine RT effect by tumor subtype, molecular outcome predictors for residual disease pts, and predictors for the degree of reduction in loco-regional recurrence.

Methods:

Clinical T1-3, N1 IBC pts with positive Ax nodes (FNA or core needle biopsy) complete ≥8 wks of NC (anthracycline and/or taxane). HER2-positive pts receive anti-HER2 therapy (tx). After NC, BCS or Mx is performed with a sentinel node biopsy (≥2 nodes) and/or Ax dissection with histologically negative nodes. ER/PR and HER2 neu status before NC is required. Pts receive required systemic tx. Radiation credentialing with a facility questionnaire and a case benchmark is required. Randomization for Mx pts is to no CWRNRT or CWRNRT and for BCS pts to WBI or WBI+RNRT.

Statistics:

1636 pts to be enrolled over 5 yrs with definitive analysis at 7.5 yrs. Study is powered at 80% to test that RT reduces the annual hazard rate of events for IBCR-FI by 35% for an absolute risk reduction in the 5-yr cumulative rate of 4.6%. Intent-to-treat analysis with 3 interim analyses at 43, 86, and 129 events, with a 4th/final analysis at 172 events will occur. Accrual as of 6/13/16 is 356. Pt-reported outcomes focusing on RT effect will be obtained from 736 pts before randomization and at 3, 6, 12, and 24 months.

Contacts:

Protocol: CTSU member website https://www.ctsu.org. Questions: NRG Oncology Pgh Clin Coord Dpt: 1-800-477-7227 or ccd@nsabp.org. Pt entry: OPEN at https://open.ctsu.org or the OPEN tab on CTSU member website.

Support: U10 CA-2166; -180868, -180822; -189867; Elekta.

Citation Format: Mamounas EP, Bandos H, White JR, Julian TB, Khan AJ, Shaitelman SF, Torres MA, Vicini FA, Ganz PA, McCloskey SA, Paik S, Gupta N, Li XA, DiCostanzo DJ, Curran, Jr WJ, Wolmark N. NRG oncology/NSABP B-51/RTOG 1304: A phase III superiority clinical trial designed to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to breast RT post breast-conserving surgery (BCS) will reduce invasive cancer events in patients (pts) with positive axillary (Ax) nodes and convert to ypN0 after neoadjuvant chemotherapy (NC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-03-01.

Abstract OT2-03-02: Feasibility of assessing radiation response with MRI/CT directed preoperative accelerated partial breast irradiation in the prone position for hormone sensitive early stage breast cancer

Background: Accelerated partial breast irradiation (APBI) delivers adjuvant radiation (RT) to the 1-2 cm of the breast at highest risk for recurrence surrounding the lumpectomy (L) cavity over 5-8 days and is an alternative to standard whole breast irradiation for hormone sensitive (HS) stage 1 (T1, N0) breast cancer (BC) based on 2 randomized controlled trials. External beam methods for APBI are common but have notable inherent drawbacks that include: inter-fraction inaccuracy due to patient setup based on anatomy, intra fraction error related to patient or respiratory motion, and inaccurate geometric targeting by relying on L cavity position instead of the tumor position. Postoperative RT has other limitations including delivery in the setting of disrupted blood or lymphatic supply that may be suboptimal for radio sensitivity and it eliminates observation of radiation-induced tumor response. MRI is an established tool for measuring BC extent and response from neoadjuvant systemic therapy. It's hypothesized that MRI directed pre-operative APBI using intensity modulated radiotherapy (IMRT) with image guidance (IGRT) will improve RT delivery, and that MRI features can be identified to correlate with pathologic radiation response.

Trial Design: There are 2 cohorts to this single arm prospective trial. The first cohort is for establishing and verifying patient flow and image fusion between MRI, CT and RT planning. In the second cohort eligible patients will receive preoperative APBI 38.5 Gy in 10 fractions BID with IMRT, IGRT in the prone position using MRI defined targets fused to CT treatment planning.

Eligibility: For cohort 1 it is HS Stage 1 BC that has completed CT in prone position for RT planning. Eligibility for cohort 2 requires: age > 60 yo, clinical stage 1 BC, HS, HER2 negative, intending L, clinically negative axilla verified by ultrasound, able to tolerate the prone position, and MRI with contrast.

Specific aims: To determine the reproducibility of MRI directed preoperative APBI based on meeting 3 criteria: ability to define RT targets by MRI, quality of RT plans and completion of treatment (APBI and surgery). Additional aims include assessing toxicity, cosmetic outcome, local regional cancer control and collection of tissue for correlative studies.

Statistical methods: The optimal two-stage design by Simon is used. Sample size for cohort 2 is based on the first endpoint. 19 eligible patients will be required in the first stage; if 3 or more treatments are scored unacceptable, then early stopping will be recommended. Otherwise, accrual will continue to a total accrual of 30. If > 4 of 30 treatments are scored unacceptable, the technique will be considered not reproducible, and a Phase II study will not be pursued. Under the null hypothesis of an 80% reproducibility rate, this two-stage design has an expected sample size of 24.4.

Patient accrual to cohort 1 is 2 and targeted accrual is 3. Patient accrual to Cohort 2 is 0 and targeted accrual is 30.

Contact information: Soyhun Mc Elroy ( Sohyun.McElroy@osumc.edu) or Julia White (Julia.White@osumc.edu)

Funding source: Susan G Komen Breast Cancer Foundation Grant # GRT00035216.

Citation Format: White J, McElroy S, Seykon A, Wei L, Bazan J, Yang X, DiCostanzo D, Gupta N, Knopp M. Feasibility of assessing radiation response with MRI/CT directed preoperative accelerated partial breast irradiation in the prone position for hormone sensitive early stage breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-03-02.

Successful diagnosis of lymphangioleiomyomatosis with transbronchial lung cryobiopsy

A 47-year old female was evaluated in our clinic for an incidental discovery of diffuse cystic lung disease on high-resolution computed tomography (CT) scan of the chest. There was no personal or family history of tuberous sclerosis complex (TSC), sicca symptoms, pneumothorax, or skin or renal tumors. Review of her chest CT scan showed bilateral, round, uniform, thin-walled cysts present in a diffuse distribution characteristic of lymphangioleiomyomatosis (LAM). CT scan of the abdomen and pelvis did not reveal angiomyolipomas, lymphangioleiomyomas, abnormal lymphadenopathy, or chylous fluid collections. Serum vascular endothelial growth factor-D was non-diagnostic. In order to achieve diagnostic confirmation, the patient underwent transbronchial cryobiopsy of the lung, revealing changes consistent with LAM. Our case highlights the utility of transbronchial lung cryobiopsy in the evaluation of patients with suspected LAM and suggests that further investigation of this diagnostic technique is warranted in patients presenting with diffuse cystic lung disease.

Evaluation of the effect of three innovative recyling methods on the shear bond strength of stainless steel brackets-an in vitro study

Background

Orthodontists are commonly faced with the decision of what to do with debonded or inaccurately positioned brackets. An economical option to this dilemma is to recycle the brackets. Many recycling methods have been proposed, but the optimal bond strength of these recycled brackets needs further evaluation. Objectives: To evaluate and compare the effect of three recycling methods: (i) Sandblasting (ii) Sandblasting / direct flaming (iii) Sandblasting /direct flaming /acid bath solution on shear bond strength (SBS) of stainless steel brackets.

Material and Methods

Eighty human premolars were bonded with premolar stainless steel brackets as per manufacturer’s instructions. The teeth were divided into 4 groups (n=20): Recycling and initial debonding was not done in Control group (Group I). After initial bonding, the brackets in the rest of the three experimental groups were debonded and recycled by following methods: (i) Sandblasting (Group II) (ii) Sandblasting /direct flaming (Group III) (iii) Sandblasting /direct flaming /acid bath solution (Group IV). Further the recycled brackets were bonded. The specimens were then subjected to testing in a Universal machine. The evaluation of the variation of the shear bond strength (SBS) among test groups was done using one-way ANOVA test and inter-experimental group comparison was done by Newman-Keuls multiple post hoc procedure.

Results

Group I (8.6510±1.3943MPa) showed the highest bond strength followed by Group II (5.0185±0.9758MPa), Group IV (2.30±0.65MPa) and Group III (2.0455± 0.6196MPa). Statistically significant variations existed in the shear bond strength (SBS) in all groups analyzed except between Group III and Group IV.

Conclusions

The following conclusions were drawn from the study: 1. Shear bond strength of new brackets is significantly higher than the recycled brackets. 2. Brackets sandblasted with 90µm aluminium oxide particle air-abrasion showed significantly higher shear bond strength compared to direct flaming/sandblasting and direct flaming/sandblasting/acid bath solution. 3. Sandblasting with 90µm aluminium oxide particle air-abrasion is the simplest, most efficient and hence, the preferred method of recycling debonded brackets.

Key words:Orthodontic bracket, recycling, shear bond strength.

Simple multiplex RT-PCR for identifying common fusion BCR-ABL transcript types and evaluation of molecular response of the a2b2 and a2b3 transcripts to Imatinib resistance in north Indian chronic myeloid leukemia patients

INTRODUCTION

Chronic myeloid leukemia (CML) is characterized by the Philadelphia chromosome, an abnormally shortened chromosome 22. It is the result of a reciprocal translocation of chromosomes 9 and 22, creating BCR-ABL fusion transcripts, b3a2, b2a2, and e1a2. The aim of our study was to determine the type of BCR-ABL fusion transcripts for molecular diagnosis and investigate the frequency of BCR-ABL fusion transcripts in CML patients by multiplex RT-PCR in CML.

MATERIALS AND METHODS

A single reaction with multiple primers multiplex PCR was used to detect and investigate the type and frequency in 200 CML patients among which 116, 33, and 51 were in CP, AP, and BC phase, respectively.

RESULTS

The study included 200 CML patients, among whom breakpoints in b3a2, b2a2 transcripts were detected in 68% and 24%, respectively, while 8% of the patients showed both b3a2/b2a2. A statistically significant difference was seen between frequency of BCR-ABL fusion transcripts and gender (P = 0.03), molecular response (P = 0.04), and hematological response (P = 0.05). However, there was no correlation found between frequencies of BCR-/ABL fusion transcripts and other clinicopathological parameters like age, type of therapy, thrombocytopenia, and white blood cell count.

CONCLUSION

Multiplex reverse transcriptase-polymerase chain reaction is useful and saves time in the detection of BCR-ABL variants; the occurrence of these transcripts associated with CML can assist in prognosis and treatment of disease.

Primary epiphyseal and metaepiphyseal tubercular osteomyelitis in children A series of 8 case

Clinical series of primary epiphyseal and metaepiphyseal tubercular osteomyelitis are few. The purpose of our study was to retrospectively review the presentation, healing response and functional results of 8 such cases in children.

MATERIAL AND METHODS

The patients were evaluated for pain, deformity, range of motion, limb length discrepancy (if any) and recurrence. Serial radiographs of the region were studied to see remineralization, obliteration of radiological lesions, status of physis and remodeling of the growth plate.

RESULTS

The mean patient age was 7.1 years. Average follow up was 3.7 years. The mean duration of symptom before presentation was 2.9 months (range, 0.5-8 months). Knee region was involved in 4, distal radius in 2, shoulder and distal fibula in 1 patient each. The lesions were either localized or diffuse depending upon physeal involvement and osseous destruction. At the last follow up, the involved joints were painfree and had useful range of motion. Limb length lengthening was seen in all knee patients. The diffuse variety resulted in premature physeal closure. The residual lucencies persisted for several years without any clinical manifestations.

CONCLUSIONS

Primary epiphyseal and metaepiphyseal tuberculosis was relatively uncommon. The clinical outcome was good following curettage and multidrug antitubercular therapy. The epiphyseal and metaphyseal lucencies persisted for several months even after successful treatment. The diffuse variety lead to premature physeal closure. Limb length lengthening was common sequelae of tuberculosis of knee region.

Persistence of Corynebacterium diphtheriae in Delhi & National Capital Region (NCR)

Despite the introduction of mass immunization, diphtheria continues to play a major role as a potentially lethal infectious disease in many countries. Delay in the specific therapy of diphtheria may result in death and, therefore, accurate diagnosis of diphtheria is imperative. This study was carried out at National Centre for Disease Control (NCDC), Delhi, India, on samples of suspected diphtheria cases referred from various government hospitals of Delhi and neighbouring areas during 2012-2014. Primary identification of Corynebacterium diphtheriae was done by standard culture, staining and biochemical tests followed by toxigenicity testing by Elek's test on samples positive for C. diphtheriae. The results showed persistence of toxigenic C. diphtheriae in our community indicating the possibility of inadequate immunization coverage.

Supra-aural gossypiboma: case report of a retained textile surgical sponge in an unusual location

Gossypiboma or retained surgical sponge is an infrequently encountered surgical complication, more so in the head and neck region. A literature search did not reveal a previously reported case of retained or concealed surgical sponge after microscopic ear surgery. We present a unique and previously unreported case of a 25-year-old male who presented with a cystic swelling in the right supra-aural region 5 months post-modified radical mastoidectomy of the right ear. Surgical excision of the swelling revealed a retained surgical sponge. We emphasise the importance of counting surgical sponges after every surgical step to minimise the incidence of such retained surgical items.

Nasopharyngeal teratoma, congenital diaphragmatic hernia and Dandy-Walker malformation - a yet uncharacterized syndrome

An association of congenital diaphragmatic hernia, dandy walker malformation and nasopharyngeal teratoma is very rare. Here, we report a fourth case with this association where chromosomal microarray and whole exome sequencing (WES) was performed to understand the underlying genetic basis. Findings of few variants especially a novel variation in HIRA provided some insights. An association of congenital diaphragmatic hernia, dandy walker malformation and nasopharyngeal teratoma is very rare. Here, we report a fourth case with this association where chromosomal microarray and whole exome sequencing (WES) was performed to understand the underlying genetic basis. Findings of few variants especially a novel variation in HIRA provided some insights.

An Overview of Menopausal Symptoms in A District Hospital of Nepal

INTRODUCTION

Menopause is a universal reproductive phenomenon which confirms the end of fertility of the women. The objectives of this study were to establish the age of natural menopause and to identify the prevalence of menopausal symptoms among the rural women attending district hospital of Nepal.

METHODS

This present study is a hospital based, observational cross-sectional study conducted in Outpatient department of Lamjung District Hospital, Lamjung, Nepal. The study was carried out from January 2014 till June 2014. Fifty four menopausal women were included in the study. A structured questionnaire was used and the data were analyzed using statistical package for social sciences.

RESULTS

There were 54 participants with menopausal symptoms included in the study. Age ranged from 45 to 60 years with mean 51.2 years. Approximately seventy percentages of women were in age group of above 50 years. About two-third of participants had menarche in at 11 to 13 years of age and 32 (59.5%) of females were married before 15 years of age. In the study total 22 different health problems were reported by menopausal women. The most common symptoms were backache, fatigue/tiredness, numbness and tingling of the extremities, mental exhaustion, depressive mood, bladder problems and sexual symptoms.

CONCLUSIONS

The study suggests that rural middle-age and elderly women suffer from variety of health problems related to natural menopause. The health care workers should adopt a holistic approach towards management to improve the quality of life.

Morphometric analysis of endometrial cells in liquid-based cervical cytology samples

BACKGROUND

Exfoliated endometrial cells can be seen in cervical smears in association with a wide variety of conditions ranging from normal proliferative endometrium to endometrial malignancies. It is often difficult to differentiate between benign, atypical and malignant endometrial cells using cytomorphology alone. This study was conducted to evaluate if morphometric analysis of endometrial nuclei on liquid-based cervical samples could be of help in differentiating between these endometrial cells.

MATERIALS AND METHODS

Three groups of cervical samples with histopathological correlation were selected: Group A: showing benign endometrial cells; Group B: showing atypical endometrial cells and Group C: showing malignant endometrial cells. There were 30 cases each in Group A and B and 39 cases in Group C. Image J, NIH, USA was used for selecting the endometrial nuclei and performing the morphometric measurements. MANOVA was used for statistical analysis.

RESULTS

The mean nuclear area and nuclear perimeter were significantly different between the three groups of endometrial cells with a P-value <0.05. However, the mean standard deviation of the nuclear area (SDNA) was not significantly different between atypical and malignant endometrial cells (P = 0.765) and the mean nuclear diameter was not statistically different between benign and atypical cells (P = 0.112). Also, the difference in the mean integrated gray density amongst all three groups was not statistically significant (P = 0.397, 0.844, 0.732).

CONCLUSION

We conclude that the morphometric parameters of the nuclear area and nuclear perimeter are helpful in differentiating between benign, atypical and malignant endometrial nuclei even in liquid-based cervical cytology samples.

Multiple pterygium syndrome: Challenge for anesthesiologist

Multiple pterygium syndrome (MPS) is a very rare autosomal recessive disorder characterized by flexion of joint and digit contractures, skin webbing, cleft palate, deformity of the spine, and cervical spine fusion. Difficult airway is associated mainly due to micrognathia, retrognathia, webbing of the neck, and limitation of the mouth opening and neck extension. We are reporting a case of a 5-year-old female diagnosed with MPS and exhibiting a bilateral club foot and congenital vertical talus. The patient was posted for manipulation and above the knee casting under general anesthesia.

Anesthetic management of a parturient with varicella presenting for cesarean delivery

Varicella (chicken pox) infection is associated with a significant risk of maternal and fetal morbidity and mortality. The choice of anesthetic technique, either neuraxial or general anesthesia, in such patients remains controversial. Anesthetic management depends not only on the extent of disease involvement and associated complications, but also on the indication for cesarean delivery. We present the anesthetic management of a 25-year-old parturient with acute varicella infection who underwent emergency cesarean delivery under spinal anesthesia. The risks and benefits of neuraxial anesthesia in the setting of varicella are discussed.