Children with significant cervical lymphadenopathy: clinicopathological analysis and role of fine-needle aspiration in Indian setup

OBJECTIVE

To study the clinicopathological profile of children from India with cervical lymphadenopathy and the role of fine-needle aspiration cytology with special emphasis on tuberculosis as a cause.

METHODS

A total of 89 children in the age group of 10 months to 12 years, presenting to our hospital from April 2004 to March 2005, were included. All the patients underwent thorough clinical and investigational assessment vis-à-vis cervical lymphadenopathy. Outcome measurements included clinical status and ability of conventional tests to categorize different types of lymphadenopathy and their utility in diagnosing tubercular lymphadenitis. Interobserver variability was analyzed measuring kappa test and was found to be in agreement.

RESULTS

Reactive hyperplasia was the most common type of lymphadenitis, followed by granulomatous involvement. Unilateral posterior triangle lymph nodes were the most commonly affected in the tubercular cervical lymphadenopathy group. Fine-needle aspiration followed by Ziehl-Neelsen staining, histopathology and culture in combination were able to perform the diagnosis in 85.7% of cases affected with tubercular etiology.

CONCLUSIONS

Fine-needle aspiration is a valuable diagnostic tool in the management of children with the clinical presentation of enlarged cervical lymph nodes. The technique reduces the need for more invasive and costly procedures, especially in a Third World country. Culture and histopathology, however, should be considered in cases where repeated fine-needle aspiration cytology is non-diagnostic.

Platelet activation, upregulation of CD11b/ CD18 expression on leukocytes and increase in circulating leukocyte-platelet aggregates in Indian women chronically exposed to biomass smoke

The majority of households in rural India still rely on unprocessed solid biomass for domestic energy. The aim of this study was to investigate whether chronic exposure to biomass smoke causes activation of leukocytes and the formation of leukocyte-platelet aggregates. We conducted flow cytometric analysis of beta2 Mac-1 integrin (CD11b/CD18) expression on polymorphonuclear leukocytes (PMN) and monocytes, and P-selectin (CD62P) expression on the platelets of 165 women from eastern India, who cook solely with wood, dung and agricultural wastes, and 155 age- and socio-economic condition-matched control subjects, who used relatively cleaner fuel, liquefied petroleum gas (LPG). Leukocyte-platelet aggregates were defined as CD11b-positive PMN and monocytes co-expressing platelet-specific markers CD41 or CD62P. A significant increase in leukocyte-platelet aggregates was found in women who used biomass as cooking fuel. In addition, they showed increased surface expression of CD11b/CD18 in circulating PMN and monocytes and CD62P expression on platelets. The mean fluorescence intensity (MFI) of CD11b on the surface of circulating monocytes and PMN of biomass users increased by 50 and 68%, respectively. Similarly, a 62 and 48% increase in MFI was observed in CD18 expression on the surface of these cells in biomass users. The results show that chronic biomass smoke exposure activates circulating platelets, PMN and monocytes, and increases the number of leukocyte-platelet aggregates, which are considered a risk factor for thrombosis.

Tuberculosis among healthcare workers in a tertiary-care hospital in South India

It is possible that tuberculosis is transmitted from patients to healthcare workers (HCWs). However, there are few data on this from developing countries. The object of this study was to document the incidence of tuberculosis among HCWs in the Christian Medical College (CMC), Vellore, India during a 10-year period (January 1992-December 2001). Data were collected from records maintained in the staff and students health services of CMC. A total of 125 cases were diagnosed during the period of study. The overall incidence of sputum positive cases was similar to that observed in the general population, during most years. However, it appears that focal outbreaks occur with transmission between HCWs. The chance of developing extra-pulmonary tuberculosis was higher in HCWs compared with the general population.

Comparison of protein carbonyl and antioxidant levels in brain tissue from intracerebral haemorrhage and control cases

BACKGROUND

In an attempt to develop a clearer understanding of the pathological mechanisms underlying intracerebral haemorrhage (ICH), the objective of this investigation was to obtain evidence for free radical-induced oxidative damage in brain tissue following intracerebral haemorrhage.

METHODS

Brain cortex samples were obtained from the ischaemic penumbra (overlying the haematoma) from 10 patients with spontaneous ICH and from six control cases (normal tissue obtained during tumour removal or aneurysm repair). Following extraction via homogenization and subsequent derivatization with dinitrophenylhydrazine (DNPH), tissue samples were analysed for the presence of protein carbonyl moieties (a hallmark of tissue protein oxidation). This procedure involved SDS-polyacrylamide gel electrophoresis and Western immunoblotting using a commercially available primary monoclonal antibody to DNPH, with final visualization of oxidized protein bands via enhanced chemiluminescence.

RESULTS

Samples from ICH cases showed a number (10-15) of well-defined bands of medium to strong staining intensity (not present in nonderivatized samples), corresponding to proteins of molecular mass 25-200 kDa, indicating the presence of oxidatively damaged proteins in these samples. However, tissue samples from control cases also showed the presence of oxidized protein bands, with fractionation patterns for individual ICH or control samples being qualitatively and quantitatively similar. In addition, there was no significant difference in the levels of the following antioxidants (as additional indirect markers of free radical activity) in ICH or control brain tissue: glutathione, glutathione peroxidase, glutathione reductase, catalase, superoxide dismutase, and total antioxidant status.

CONCLUSIONS

It is concluded from the above data that (i) evidence for free radical involvement in ICH based on protein carbonyl analysis should be interpreted with caution, since normal brain tissue contains a surprisingly high proportion of oxidized proteins; (ii) since there is no evidence for increased protein oxidative damage or decreased tissue antioxidant levels in ICH, therapeutic strategies aimed at salvage of potentially viable tissue would not benefit from inclusion of protein protecting antioxidants.

Continuous monitoring of ICP and CPP following ICH and its relationship to clinical, radiological and surgical parameters

Sixty-two patients with a spontaneous supratentorial haemorrhage had continuous Intracranial Pressure (ICP) and Cerebral Perfusion Pressure (CPP) monitoring. In addition to the recordings of physiological data their past medical history, presenting neurological state, Computed Tomograph (CT) findings, daily Glasgow Coma Score (GCS) and outcome were noted. The mean age was 57.6 years (sd 13.3). Onset of recording, after ictus was at a mean of 32.6 hours (sd 26.0). Average length of recording was 62.0 hours (sd 39.8). Thirty-one patients had evacuation of haematoma, 6 insertion of External Ventricular Drain (EVD). Preoperative measures of ICP were significantly related to delayed neurological deterioration, death within three days and Glasgow Outcome Scale (GOS) at neurosurgical discharge. No such relationships existed with preoperative measures of CPP and neither ICP nor CPP was related to outcome at 6 months. Post-operative measures of both ICP and CPP demonstrated a significant relationship with death within three days of ictus and GOS at neurosurgical discharge. Again no relationship existed with these parameters and outcome at six months. Surgical evacuation of haematoma acted to significantly reduce ICP and improve CPP. Given that these factors seem to be related to deterioration, death and early outcome, it would seem that surgery could play a role in reducing mortality and improving outcome following Intra cerebral Haemorrhage (ICH).

Subperiosteal release of the floor of the mouth musculature in two cases of Pierre Robin sequence

Many management approaches have been considered to relieve upper respiratory obstruction in patients with Pierre Robin sequence, but the choice of treatment is determined by the severity of the obstruction. These options include prone positioning, the use of a nasal trumpet, and surgery. One surgical technique is the subperiosteal release of the floor of the mouth musculature. The theory behind this procedure is that this musculature is under tension, and therefore it pushes the tongue upward and backward, resulting in respiratory obstruction. In theory, the release of this musculature from the mandible should alleviate the tension and hence clear the obstruction. In an attempt to objectively evaluate this theory, we performed subperiosteal release surgery on two infants. Our first patient required an emergent tracheostomy on postoperative day 2 because of the onset of surgically induced airway edema. To avoid this complication in the second patient, we performed a tracheostomy at the same time as surgery. Pre- and postoperative magnetic resonance imaging in the second patient revealed only a minimal change in the anatomy of the floor of the mouth musculature. We believe the subperiosteal release of the floor of the mouth musculature requires further evaluation before it can be considered to be effective in the surgical treatment of respiratory obstruction in Pierre Robin sequence.

Surgery in intracerebral hemorrhage. The uncertainty continues

BACKGROUND AND PURPOSE

Primary intracerebral hemorrhage (ICH) accounts for 10% to 20% of stroke but carries the highest rates of mortality and morbidity of all stroke subtypes. Current treatment, however, is varied and haphazard. The most recent Cochrane systematic review refers to 4 prospective, randomized controlled trials. We present a further meta-analysis to include 3 new trials. In addition, we review the trials of Chen et al and McKissock et al and discuss aspects of their quality that, we believe, prevent their inclusion in modern day meta-analysis.

METHODS

Literature databases and articles were searched from 1966 to October 1999. Using the end points of death and dependency, the results of the 7 identified randomized trials were expressed as odds ratios. All available data were then analyzed with meta-analysis techniques. Analysis of relevant subsets of trials was also carried out.

RESULTS

Meta-analysis of all 7 trials shows a trend toward a higher chance of death and dependency after surgery (OR 1.20; 95% CI 0.83 to 1.74). Meta-analysis was also carried out after exclusion of the Chen and McKissock trials for reasons discussed in the text. This meta-analysis suggests a benefit from surgery, with a reduction in the chances of death and dependency after surgical treatment by a factor of 0.63 (OR 0.63; 95% CI 0.35 to 1.14).

CONCLUSIONS

When meta-analysis is restricted to modern-day, post-CT, well-constructed, balanced trials, a trend for surgery to reduce the chances of death and dependency is found. Perhaps, then, in the modern era of CT, good neuroanesthesia, intensive care, and the operating microscope, surgery has a role in the treatment of supratentorial intracerebral hemorrhage. The results of a large, multicenter, randomized controlled trial are urgently needed, and the ongoing International Surgical Trial of Intracerebral Hemorrhage should fulfill this objective.

Paecilomyces fungus infection of the paranasal sinuses

Fungal infections caused by Paecilomyces species are very rare and occur in adult patients with impaired host defences or following foreign body implants. They are found worldwide in soil and decaying vegetation. We describe a case of an 8 year old child who came with complaints of left sided nasal obstruction and discharge, telecanthus, diplopia and epiphora. On examination and investigation he had pansinusitis caused by P. lilacinus. An endoscopic sinus surgery was done and the patient was on oral Itraconazole for 6 months. To our knowledge, this is the first case reported in the paediatric age group.

Magnetic resonance imaging of the facial nerve in children with idiopathic facial paralysis

The role of gadolinium-enhanced MRI (Gd-MRI) in the diagnosis of idiopathic facial paralysis (IFP) in children is not well defined. Fourteen children with IFP were evaluated to assess the use of Gd-MRI for the presence and pattern of enhancement and its usefulness in predicting the recovery of facial function. Six of 14 children had enhancement of the facial nerve on Gd-MRI, whereas 8 had none. Enhancement was noted in the tympanic, mastoid, and most commonly in the distal intracanalicular and labyrinthine segments. The average time from onset of paresis to recovery in patients with enhancement was 19.3 weeks, whereas in those with no enhancement, mean recovery time was 9.5 weeks (P = 0.003, t test). All 14 patients eventually had recovery to House-Brackmann grade I or II. Gd-MRI is not required for all children with IFP but may yield information about the time course of recovery of facial function.

Primary eyelid mucinous adenocarcinoma of eccrine origin

To report a case of mucinous adenocarcinoma of the eyelid. A 70-year-old man presented with a lesion of his lower left eyelid, which had been growing over the past few years. An excisional biopsy was performed. The lesion was incompletely excised and recurrence at the excision site was observed at a 3-month follow-up visit. A histopathological examination of the excised specimen showed it to be a mucinous adenocarcinoma of eccrine origin. Primary mucinous adenocarcinoma of the eye lid is a rare malignant sweat gland tumor with a high incidence of local recurrence. It has to be differentiated from other adenocarcinomas which may rarely metastasize to the skin.

Polymeric chitosan-based vesicles for drug delivery

A simple carbohydrate polymer glycol chitosan (degree of polymerization 800 approx.) has been investigated for its ability to form polymeric vesicle drug carriers. The attachment of hydrophobic groups to glycol chitosan should yield an amphiphilic polymer capable of self-assembly into vesicles. Chitosan is used because the membrane-penetration enhancement of chitosan polymers offers the possibility of fabricating a drug delivery system suitable for the oral and intranasal administration of gut-labile molecules. Glycol chitosan modified by attachment of a strategic number of fatty acid pendant groups (11-16 mol%) assembles into unilamellar polymeric vesicles in the presence of cholesterol. These polymeric vesicles are found to be biocompatible and haemocompatible and capable of entrapping water-soluble drugs. By use of an ammonium sulphate gradient bleomycin (MW 1400), for example, can be efficiently loaded on to these polymeric vesicles to yield a bleomycin-to-polymer ratio of 0.5 units mg(-1). Previously polymers were thought to assemble into vesicles only if the polymer backbone was separated from the membrane-forming amphiphile by a hydrophilic side-arm spacer. The hydrophilic spacer was thought to be necessary to decouple the random motion of the polymer backbone from the ordered amphiphiles that make up the vesicle membrane. However, stable polymeric vesicles for use in drug delivery have been prepared from a modified carbohydrate polymer, palmitoyl glycol chitosan, without this specific architecture. These polymeric vesicles efficiently entrap water-soluble drugs.

Coding of temporal parameters of complex sounds by frog auditory nerve fibers

1. Physiological recordings were made from single auditory fibers in the frog eighth nerve to determine quantitatively how the different behaviorally relevant temporal parameters (the signal rise-fall time, duration, and rate of amplitude modulation) of complex sounds are encoded in the auditory periphery. Individual temporal parameters were varied. Response functions (RFs) were constructed with respect to each of these parameters using each unit's best excitatory frequency (BF) as the carrier. 2. In response to a change in signal rise-fall time, auditory nerve fibers showed little change in the mean spike count or firing rate, i.e., all fibers displayed ALL-PASS RFrfts. But the transient components, particularly the early phasic component, of responses varied with rise-fall times; these components were more pronounced in the responses to stimuli with shorter rise-fall times. 3. In response to an increase in signal duration, auditory nerve fibers showed a corresponding increase in firing duration and thus in the mean spike count, giving rise to HIGH-PASS RFdurs. The shape of response curves differed among fibers; the difference appeared to be related to the fiber's temporal adaptation characteristic. When the firing rate was measured, all fibers displayed higher mean firing rates in response to shorter duration stimuli than they did to longer duration stimuli, thus giving rise to LOW-PASS response functions. 4. To determine the response transfer functions to modulation rate, pulsed (PAM) and sinusoidally (SAM) amplitude-modulated signals were used. These signals differed substantially in terms of their envelopes and how they varied with AM rate. Data were analyzed by 1) plotting spike counts against the AM rate to derive modulation transfer functions (MTFspks) and 2) plotting synchronization coefficients (SCs) against the AM rate to generate MTFscs. 5. In response to PAM stimuli, all fibers showed an increase in mean spike count with modulation frequency over the range examined, giving rise to HIGH-PASS MTFspks. 6. For SAM stimuli, the average energy and duty cycle are independent of AM rate. Most (79%) auditory fibers showed little selectivity for AM rate over a range of 5-400 Hz, giving rise to ALL-PASS MTFspks. The remaining auditory fibers displayed LOW-PASS MTFspks, i.e., there was a distinct decline in the mean spike count with increasing AM rate. 7. In response to PAM stimuli, most fibers showed good response synchrony at low AM rates but the SC declined with an increase in the AM rate (i.e., LOW-PASS MTFscs). The cut-off frequency was typically very high, averaging 90 pulses/s.(ABSTRACT TRUNCATED AT 400 WORDS)