Mortality patterns in childhood lupus--10 years' experience in a developing country

Over the last 10 years we have seen 31 children with systemic lupus: 10 (32%) of these have died. The commonest primary determinant of mortality was uncontrolled disease activity (60%), possibly contributed to by late referrals leading to delays in diagnosis and the institution of therapy. Thromboembolic disease was responsible for two deaths and tuberculosis for one. The major contributory factors were nephritis in two patients and myocarditis, endocarditis, lupus pneumonia and CNS disease in one patient each. Concomitant infections, predominantly nosocomial, occurred in a significant proportion of patients (40%) but were only cofactors in mortality. Autopsies were done in three cases. These patterns of death are significantly different from those seen in the developed world, where disease activity has ceased to be an important factor owing to early recognition of cases. Avoiding late referrals and delays in diagnosis can reduce mortality in childhood-onset lupus.

Imaging features of esophageal leiomyomatosis: a case report

Leiomyomas are the most common benign tumors of the esophagus. However, esophageal leiomyomatosis is a rare pathologic entity that has received little attention in the radiologic literature. We present a case of esophageal leiomyomatosis with imaging features on barium swallow and computed tomography (CT).

Shah Waardenberg syndrome

Intermittent or partial small bowel obstruction in a neonate may be a rare presentation of total aganglionosis. The presence of partial albinism and white forelock should alert the clinician to the possibility of associated Hirschsprung disease as a cause of bowel symptoms. Such a rare association has been called Shah Waardenberg syndrome and is being reported.

Effect of eradication of Helicobacter pylori on gastric antrum histology

BACKGROUND

Helicobacter pylori is a leading cause of gastritis. Some of the histological changes revert after eradication of H. pylori. There is paucity of reports from India.

AIM

To study the effect of H. pylori eradication on the histopathological changes.

METHODS

Endoscopically obtained antral biopsies from 164 consecutive H. pylori positive cases of dyspepsia were analysed before and 4 weeks after completion of treatment.

RESULTS

Treatment for H. pylori resulted in eradication of the organism as confirmed histologically in 123 out of 164 (76.22%) cases. Analysis of histopathological changes in pre and post treatment biopsies from the same patient revealed a significant reduction in neutrophils, eosinophils, chronic inflammatory cells, acute epithelial changes and regenerative foveolar hyperplasia (p < 0.001) There was no difference in these findings in cases where H. pylori eradication failed when compared with their pre-treatment biopsies (p > 0.05). Similarly the pre and post treatment biopsies revealed, no difference in frequency of intestinal metaplasia and gastric atrophy in cases where H. pylori was eradicated or persisted after treatment.

CONCLUSION

There was significant reduction in neutrophils, eosinophils, chronic inflammatory cells, acute epithelial changes and regenerative foveolar hyperplasia, following eradication of H. pylori.

Flow cytometric immunophenotyping and comparison with immunocytochemistry in small round cell tumors

OBJECTIVE

To quantitate different antigens by flow cytometric immunophenotyping (FCI) in small round cell tumors (SRCTs) and to compare the FCI technique with immunocytochemistry (IC).

STUDY DESIGN

IC and FCI were performed on 24 consecutive cases of SRCT on fine needle aspiration biopsy material using a panel of antibodies--e.g., cytokeratin (CK), leukocyte common antigen (LCA), desmin, epithelial membrane antigen, neuron-specific enolase, chromogranin, retinoblastoma gene product, neuroblastoma clone (NB84a (NB), vimentin and Mic-2 gene product. IC was done by indirect immunoperoxidase and FCI by indirect immunofluorescence onflow cytometry.

RESULTS

In Ewing's sarcoma, with the help of FCI, positive results were obtained in an additional 4 samples in CK, 2 samples in actin and 3 samples in desmin. Similarly, one each sample was additional positive regarding Mic-2 and vimentin by IC. In cases of neuroblastoma with the help of FCI, additional positive results were obtained in one each sample of CK, LCA and NB and two in actin. Combined use of FCI and IC helped to show chromogranin positivity in an additional two cases. Divergent differentiation was noted in four cases of Ewing's sarcoma, one neuroblastoma and two peripheral neuroectodermal tumors.

CONCLUSION

FCI technique is sensitive, more objective and quantitative in comparison with manual absorbance-based microscopic detection of enzyme immunohistochemistry products. FCI may determine divergent differentiation in SRCTs.

Automated nuclear image morphometry on fine needle aspiration smears of malignant round cell tumors

OBJECTIVE

To analyze nuclear image morphometry in fine needle aspiration cytology smears of different groups of malignant round cell tumors (MRCTs) to evaluate its diagnostic role.

STUDY DESIGN

In this study there were 55 cases of MRCT, consisting of 18 Ewing's sarcoma (EW), 10 neuroblastoma (NB), 5 non-Hodgkin's lymphoma (NHL), 6 rhabdomyosarcoma (RMS), 4 peripheral neuroectodermal tumor (PNET), 8 Wilm's tumor (WT), 2 retinoblastoma (RB) and 2 undifferentiated round cell tumor (URCT). A Leica image cytometer with Quantimet 600 software (Leica, Cambridge, U.K) was used to measure nuclear area, nuclear diameter, nuclear perimeter, nuclear convex perimeter (CP), nuclear roundness and nuclear convex area on hematoxylin and eosin-stained cytologic smears. At least 100 cells were studied in each case.

RESULTS

The RB group of tumors showed the highest mean nuclear area (NA), convex area (CA), CP, diameter (D), perimeter (P) and roundness (R). RMS had the highest mean CA, and URCT had the highest mean roundness. ANOVA was performed on the tumors and showed significant differences for all the variables in all the groups (P < .000). All the morphometric data (except roundness) were significantly different in RMS versus all other MRCTs except RB. Similarly, morphometric data on WT were also significantly different from that on NHL. Most of the morphometric data (except CA and R) showed significant differences between RB and all other MRCTs except RMS. PNET, EW and NB could not be differentiated with those variables.

CONCLUSION

RMS and RB could successfully be differentiated from all other MRCTs with the help of morphometry. It was not possible to differentiate RMS and RB by image cytometry (ICM) since the ICM data overlapped in those two groups. It was possible to differentiate WT and NHL with ICM. Nuclear ICM was not significantly different in the NB, PNET and ES groups, and probably ICM would not be very helpful to differentiate these groups of MRCT.

Possible role of enhanced microtubule phosphorylation in dichlorvos induced delayed neurotoxicity in rat

The effect of a single subcutaneous dose of 200 mg/kg body weight dichlorvos on neuronal microtubule phosphorylation has been studied in rat following the development of organophosphate induced delayed neurotoxicity (OPIDN). Microtubule associated Ca2+/calmodulin dependent as well as cAMP dependent protein kinases were assayed. Dichlorvos administration led to a consistent increase in the activity of both the kinases at all post exposure intervals (7th, 15th and 21st day) as compared to that of controls. After in vitro phosphorylation using [gamma-32P]ATP, various proteins were resolved on one-dimensional 8% SDS-PAGE, stained with Coomassie Blue and autoradiographed. The amount of 32P incorporated was quantified by microdensitometry. Dichlorvos enhanced the phosphorylation of 55- and 280-kDa proteins. These two proteins were identified as tubulin and microtubule associated protein-2 (MAP-2) by immunoblotting. This study showed that dichlorvos induced hyperphosphorylation of tubulin and MAP-2 which in turn destabilizes microtubule assembly, and may ultimately result in axonal degeneration leading to dichlorvos induced delayed neurotoxicity.

Role of immunocytochemistry and DNA flow cytometry in the fine-needle aspiration diagnosis of malignant small round-cell tumors

In the present study, DNA flow cytometry (FCM) and immunocytochemistry (ICC) with a selected panel of antibodies were performed on 51 cases of malignant tumors which were referred for fine-needle aspiration biopsy (FNAB) to our Department of Cytology for the last 2 yr. Twelve cases were diagnosed as neuroblastoma, 16 as Ewing's sarcoma, 2 as retinoblastoma, 5 as non-Hodgkin's lymphoma (NHL), 5 as rhabdomyosarcoma, 2 as peripheral neuroectodermal tumors (PNETs), and 8 as Wilms' tumor. Eleven of 12 neuroblastomas were diploid by FCM, and 1 was aneuploid, with an S-phase fraction (SPF) of 8.3%. Neuron-specific enolase (NSE) was negative in 3 and positive in 8 cases of neuroblastoma, whereas neuroblastoma marker was positive in 3/11. Sixteen of 17 Ewing's sarcomas were diploid, and 1 showed tetraploid aneuploidy, with an SPF of 10.06%. Eight of 13 Ewing's sarcomas were positive for Mic-2 gene product (Ewing's marker). All 5 NHL were positive for leukocyte-common antigen (LCA). Three of 5 rhabdomyosarcomas were diploid, and 2 cases showed aneuploidy. Rhabdomyosarcoma showed muscle-specific actin positivity in 4 and desmin positivity in 3 cases. All 3 cases of PNET were diploid and positive for the Mic-2 gene product, whereas NSE and vimentin were positive in 2 cases. Both cases of retinoblastoma were diploid. Immunostaining was noncontributory in 1 case, and the other showed positivity for the retinoblastoma gene product, NSE, and chromogranin. Seven of 8 Wilms' tumors were diploid, and 1 showed aneuploid, with an SPF of 11.13%. Seven of 8 Wilms' tumors were positive for cytokeratin (CK), 5 were positive for NSE, 6 were positive for epithelial membrane antigen (EMA), and 5 were positive for vimentin. FNAB diagnosis of malignant round-cell tumors is difficult only by light microscopy. Due to the availability of specific markers for subgrouping tumors, ICC has proved to be more useful these days, while DNA FCM has little diagnostic value, as most of them are diploid. Further ancillary studies, e.g., electron microscopy, image analysis, and other molecular investigations, are required to further categorize these tumors more precisely for better clinical management of these cases.

Epithelioid sarcoma. Report of a case with fine needle aspiration diagnosis

BACKGROUND

Epithelioid sarcoma is a rare type of soft tissue sarcoma affecting the extremities, particularly the hands and fingers. Though it is well described histopathologically, publications regarding its cytologic findings are limited.

CASE

A 52-year-old woman presented with swelling of the left middle finger. Fine needle aspiration was performed. Smears showed oval to polygonal cells with epithelioid features. A diagnosis of soft tissue sarcoma with a possibility of epithelioid sarcoma was suggested. Histopathologic examination and immunohistochemistry confirmed the diagnosis.

CONCLUSION

In the presence of classic cytologic findings, the diagnosis of epithelioid sarcoma can be suggested. Subsequent histologic examination and immunohistochemistry can confirm the diagnosis.

Crescentic glomerulonephritis associated with renal cell carcinoma

Various glomerular lesions are described in association with malignancy. We report a rare case of crescentic glomerulonephritis occurring in association with renal cell carcinoma. A granular deposition of immune complexes and complement strongly suggests a tumor associated immune complex glomerulonephritis.

Renal involvement in multiple myeloma: a 10-year study

Renal involvement in 204 cases with multiple myeloma admitted over a 10-year period to this tertiary care center in north India was retrospectively examined. Renal involvement occurred in 55 cases (27%); the vast majority of whom (94.5%) had presented with renal failure and 7.3% had nephrotic syndrome. The diagnosis of multiple myeloma was made after admission in 51 of the 55 (92.7%) cases. Oliguria was seen in 23.6% and two-third patients required dialysis. Factors precipitating renal failure were identified in 53% and included dehydration (33%), hypercalcemia (24%), nephrotoxic drugs (16%), sepsis (9%), recent surgery (5%) and contrast media (2%), Severe anemia, hypercalcemia, Bence Jones proteinuria and skeletal abnormalities were more frequent in those with renal involvement. Patients with renal involvement were more likely to have a high tumor burden. The myeloma was of light chain type in 68% of those with renal involvement whereas IgG myeloma was commonest (57%) in those without evidence of renal disease. Renal histology was studied in 27 cases with myeloma cast nephropathy seen in over 60%. Tubulointerstitial nephritis was seen in 14% cases, 11% had amyloidosis, 7% had acute tubular necrosis and 3.6% each had nodular glomerulosclerosis and plasma cell infiltration. In 8 cases (14.6%), renal biopsy provided the first clue to the diagnosis of myeloma. Renal function improved in 33% cases. Only 22% of patients on dialysis survived over 6 months. Median survival in those with renal involvement was only 4 months. Development of unexplained renal failure in an elderly individual with normal sized kidneys, in association with disproportionate anemia even in the absence of skeletal lesions should alert the physician to the diagnosis of multiple myeloma.

Ultrasound-guided transthoracic co-axial biopsy of thoracic mass lesions

PURPOSE

To compare the diagnostic yield of fine-needle aspiration biopsy (FNAB) and cutting needle biopsy in thoracic lesions.

MATERIAL AND METHODS

Thirty patients with thoracic mass lesions were subjected to ultrasound-guided co-axial FNAB and cutting needle biopsy using 0.7 mm aspirating and 1.0-mm cutting needles, respectively. The diagnostic yield of the individual modalities was compared with the combined yield.

RESULTS

A conclusive diagnosis was obtained in 76.6% (n=23) of patients by FNAB and in 66.6% (n=20) by cutting needle biopsy. The combined diagnostic yield of FNAB and cutting needle biopsy was 93.3% (n=28) with a significant statistical difference (p<0.03) as compared to cutting biopsy alone. Of the patients, 23.2% (n=7) had benign and 76.6% (n=23) malignant aetiologies. The diagnostic yield of FNAB versus cutting needle biopsy in benign lesions was 57.1% (n=4) and 100% (n=7), respectively. The diagnostic yield of FNAB versus cutting needle biopsy in malignant lesions was 82.6% (n=19) and 56.5%, (n=13). Two patients remained undiagnosed by either modality. There were no complications.

CONCLUSION

FNAB and cutting needle biopsy are complementary to each other and attempts should be made to obtain small tissue cores in addition to routine cytologic specimens in diagnosing thoracic lesions, especially in benign pathologies. US provides a safe guidance modality for lesions abutting the chest wall.

Indigenous knowledge and uses of medicinal plants by local communities of the Kali Gandaki Watershed Area, Nepal

A field survey was conducted in the villages of Ramdi, Malunga, Balam, Beltari, Mirmi, Burgha and Ridi in the Kali Gandaki watershed, Nepal; 48 medicinal plants belonging to 31 families were reported, each with local names, traditional uses, methods of preparation and route of administration. Traditional medicine remains an integral part of the health system in these areas. Local people have remarkable knowledge of species identity and their uses as crude drugs.

Pyelonephritic potential of Pseudomonas aeruginosa in ascending mouse model

The suitability of female BALB/c and Swiss Webster (LACA) strains of mice for an ascending model of pyelonephritis for human uroisolate of Pseudomonas aeruginosa, was assessed. A fresh isolate of Ps. aeruginosa elaborating virulence factors like elastase, protease, phospholipase C, pyochelin and haemolysin was selected and introduced transuretherally in mice without any manipulation of the urinary tract. This isolate was able to colonize and persist in the renal tissue till day 12 post infection. Histopathologically, severe renal lesions i.e., abscesses formation was observed. The LACA strain was found to be more susceptible to infection with the selected Ps. aeruginosa isolate.

Fatal complications of systemic lupus erythematosus--an autopsy study from north India

Systemic lupus erythematosus (SLE) is a multisystem, autoimmune disease with varied clinical manifestations and outcome. It may prove fatal due to disease activity or intercurrent infections. In recent years, earlier diagnosis and better treatment modalities have resulted in a change in the pattern of organ involvement and mode of death in the west. This aspect of the disease is unknown in India. Hence, in this autopsy series of SLE, the organ involvement and cause of death have been studied. Twenty five cases of clinically diagnosed SLE have been analysed retrospectively. Renal involvement was invariably present (96%) with class IV being the commonest lesion in 60% cases. Disease activity was noted in 60% cases. Pleuro pulmonary lesions were seen in 92% cases with infection being the commonest. Pulmonary infections included bacterial pneumonias (13), disseminated tuberculosis (3), pulmonary mucormycosis (1) and aspergillosis (1). Massive pulmonary haemorrhage in 5 cases and acute lupus pneumonitis in one, contributed to the demise of the patient. Vasculitis was evident in single organ in 9 cases, in two or more organs in 3 cases with systemic vasculitis significantly attributing to morbidity in 1 case. Active disease was the cause of death in 60% cases and infection in 40%.

Effect of renal dysfunction in fulminant hepatic failure

BACKGROUND

Effect of renal dysfunction in fulminant hepatic failure is not studied extensively.

METHODS

Fifty consecutive patients of fulminant hepatic failure were studied prospectively to determine the prevalence of renal failure and its effect on survival.

RESULTS

The mean age of these patients was 36 +/- 7.2 years and there were 21 males and 29 females. Twenty two patients (44%) were hepatitis B surface antigen (HBsAg) positive. Renal dysfunction was observed in 19 patients (38%). Acute tubular necrosis was seen in 7 patients (38%) while prerenal azotemia and functional renal failure occurred in six patients each (37%). Renal failure occurred more commonly in patients with jaundice. In these patients it occurred in less than four days and prior to onset of encephalopathy, ascites, and gastrointestinal hemorrhage. Histopathological examination of kidney (done in 8 patients) revealed acute tubular necrosis in 4 patients while patients with functional renal failure and prerenal azotemia had normal histology. A good correlation was observed between biochemical parameters and histology of kidney in all the patients. The survival amongst the patients with FHF was 28% (14 of 50 patients). Poor prognostic indicators were a leukocyte count of more than 16.5 x 10(9)/liter, prothrombin index of less than 34%, a peak serum bilirubin of more than 376 mumol/liter and presence of renal failure. Only 3 of 19 patients with renal failure survived.

CONCLUSIONS

Renal dysfunction is a major indicator of poor prognosis in patients with FHF.

Grading of ductal breast carcinoma by cytomorphology and image morphometry with histologic correlation

OBJECTIVE

To investigate the relevance of image analysis for grading breast carcinoma.

STUDY DESIGN

Twenty-five ductal breast carcinoma cases were chosen randomly from routine fine needle aspiration clinics. The results of cytomorphologic grading and image morphometry were correlated with those of histologic grading. The five image morphometric parameters studied were nuclear diameter, nuclear area, nuclear roundness, nuclear perimeter and grey level to compare with chromatin texture.

RESULTS

Cytologic grading alone had a high correlation with histologic grading. The lowest correlation was found in grade 2 tumors. When cytologic grading was supplemented with image morphometric parameters, the correlation was higher than that of cytologic grading alone.

CONCLUSION

Cytologic grading has a high correlation with histologic grading. The correlation improves further on supplementation with image morphometric parameters.

Effect of growth factors on proliferation of normal, borderline, and malignant breast epithelial cells

Growth factors play an important role in the development and growth regulation of normal breast. They are also known to be autocrine or paracrine stimulators of breast cancer cells. However, their role on cells of proliferative breast disease has not been studied so far. This study was undertaken to quantitate the proliferative effect of various growth factors on "normal," borderline, and malignant breast epithelial cells. For this purpose, epithelial cell lines of histologically normal human breast and histologically proven proliferative breast diseases were established. Cell lines MCF-7 and T47D were used as malignant cells. The growth factors under study include epidermal growth factor, fibroblast growth factors acidic and basic, platelet-derived growth factor, and insulin-like growth factors 1 (IGF-1) and 2 (IGF-2). Their proliferative effect was determined by incubating the cells with growth factors for 24 h after achieving basal conditions in serum-free medium for 72 h, followed by quantitating the S-phase fraction by flow cytometry. All of the growth factors were found to be capable of inducing cellular proliferation on the entire range of mammary epithelia. Epidermal growth factor was consistently found to be a potent mitogen. Fibroblast growth factor acidic had a higher effect compared to fibroblast growth factor basic in inducing the cells to move from G(0)/G(1) to S-phase. Platelet-derived growth factor had a moderate proliferative response. In the family of insulin-like growth factors, IGF-1 was the dominant mitogen for normal cells and IGF-2 was the dominant proliferative stimulus for the cell line MCF-7. In the cell lines of proliferative breast disease and T47D, both were at par as mitogenic agents. These results suggest that the cells of proliferative breast disease develop some of the biological characteristics of malignancy.

Tracheobronchial amyloidosis: a report of two cases

We describe here two patients with tracheobronchial involvement by amyloidosis. One of them had presented with discrete tracheobronchial mass lesions simulating bronchogenic carcinoma. The other had intermittent streaky hemoptysis and was found to have diffuse tracheobronchial involvement at bronchoscopy. Both patients are doing well without any definitive therapy.

Quality of care within the Indian family welfare programme: a review of recent evidence

India's family planning program represents one of the earliest and most ambitious efforts in a developing country to address the issue of high fertility. Despite its more than four decades of existence, little is known concerning how the program is implemented at the field level, especially in relation to the quality of services provided. In this article, empirical evidence on the accessibility and quality of services provided through the Indian family planning program is reviewed and synthesized. The review highlights the serious and systemic shortcomings in quality of care that characterize the Indian program in such areas as restricted method choice, limited information provided to clients, poor technical standards, and low levels of follow-up and continuity of care. The factors constraining higher service quality are subsequently reviewed, and the prospects for improving quality of care within the Indian program are assessed.

Use of the equity implementation model to review clinical system implementation efforts: a case report

This paper presents the equity implementation model (EIM) in the context of a case that describes the implementation of a medical scheduling system. The model is based on equity theory, a well-established theory in the social sciences that has been tested in hundreds of experimental and field studies. The predictions of equity theory have been supported in organizational, societal, family, and other social settings. Thus, the EIM helps provide a theory-based understanding for collecting and reviewing users' reactions to, and acceptance or rejection of, a new technology or system. The case study (implementation of a patient scheduling and appointment setting system in a large health maintenance organization) illustrates how the EIM can be used to examine users' reactions to the implementation of a new system.