Neuroimaging in Pediatric Patients with Juvenile Xanthogranuloma of the CNS

BACKGROUND AND PURPOSE

Juvenile xanthogranuloma is a rare clonal, myeloid, neoplastic disorder. Typically, juvenile xanthogranuloma is a self-limited disorder of infancy, often presenting as a solitary red-brown or yellow skin papule/nodule. A small subset of patients present with extracutaneous, systemic juvenile xanthogranuloma, which may include the CNS. The goal of this retrospective study was to evaluate and categorize the neuroimaging findings in a representative cohort of pediatric patients with CNS juvenile xanthogranuloma.

MATERIALS AND METHODS

The brain and/or spine MR imaging data of 14 pediatric patients with pathology-proven juvenile xanthogranuloma were categorized and evaluated for the location; the signal intensity of xanthogranulomas on T1WI, T2WI, DWI, and a matching ADC map for the pattern and degree of contrast enhancement; and the presence of perilesional edema, cysts, or necrosis.

RESULTS

Fourteen pediatric patients (8 girls, 6 boys; mean age, 84 months) were included in the study. Patients presented with a wide variety of different symptoms, including headache, seizure, ataxia, strabismus, hearing loss, facial paresis, and diabetes insipidus. Juvenile xanthogranuloma lesions were identified in a number of different sites, including supra- and infratentorial as well as intracranial and spinal leptomeningeal. Five patients were categorized into the neuroradiologic pattern unifocal CNS juvenile xanthogranuloma; 8, into multifocal CNS juvenile xanthogranuloma; and 1, into multifocal CNS juvenile xanthogranuloma with intracranial and spinal leptomeningeal disease. In most cases, xanthogranulomas were small-to-medium intra-axial masses with isointense signal on T1WI (compared with cortical GM), iso- or hyperintense signal on T2WI, had restricted diffusion and perilesional edema. Almost all xanthogranulomas showed avid contrast enhancement. However, we also identified less common patterns with large lesions, nonenhancing lesions, or leptomeningeal disease. Four cases had an additional CT available. On CT, all xanthogranulomas were homogeneously hyperdense (solid component) without evident calcifications.

CONCLUSIONS

CNS juvenile xanthogranuloma may demonstrate heterogeneous neuroimaging appearances potentially mimicking other diseases, such as primary brain neoplasms, metastatic disease, lymphoma and leukemia, other histiocytic disorders, infections, or granulomatous diseases.

Cause of intrauterine and neonatal death in twin pregnancies (CoDiT): development of a novel classification system

OBJECTIVE

Twin pregnancies have a significantly higher perinatal mortality than singleton pregnancies. Current classification systems for perinatal death lack twin-specific categories, potentially leading to loss of important information regarding cause of death. We introduce and test a classification system designed to assign a cause of death in twin pregnancies (CoDiT).

DESIGN

Retrospective cross-sectional study.

SETTING

Tertiary maternity unit in England with a perinatal pathology service.

POPULATION

Twin pregnancies in the West Midlands affected by fetal or neonatal demise of one or both twins between 1 January 2005 and 31 December 2016 in which postmortem examination was undertaken.

METHODS

A multidisciplinary panel designed CoDiT by adapting the most appropriate elements of singleton classification systems. The system was tested by assigning cause of death in 265 fetal and neonatal deaths from 144 twin pregnancies. Cause of death was validated by another obstetrician blinded to the original classification.

MAIN OUTCOME MEASURES

Inter-rater, intra-rater, inter-disciplinary agreement and cause of death.

RESULTS

Cohen's Kappa demonstrated 'strong' (>0.8) inter-rater, intra-rater and inter-disciplinary agreement (95% CI 0.70-0.91). The commonest cause of death irrespective of chorionicity was the placenta; twin-to-twin transfusion syndrome (TTTS) was the commonest placental cause in monochorionic twins and acute chorioamnionitis in dichorionic twins.

CONCLUSIONS

This novel classification system records causes of death in twin pregnancies from postmortem reports with high inter-user agreement. We highlight differences in aetiology of death between monochorionic and dichorionic twins.

TWEETABLE ABSTRACT

New classification system for #twin cause of death 'CoDiT' shows high rater agreement.

A rare case of phaeohyphomycosis caused by Fonsecaea pedrosoi in a child with nephrotic syndrome

Dematiaceous fungi are the etiological agents of phaeohyphomycosis and are now increasingly being recognized for causing disease in humans. A high level of suspicion and routine fungal cultures are required to identify these cases. There is no consensus regarding their management. Here, an unusual presentation of phaeohyphomycosis (secondary to Fonsecaea pedrosoi) presenting as a disseminated infection in a case of nephrotic syndrome is described.

Differential binding and internalization of Clostridium difficile toxin A by human peripheral blood monocytes, neutrophils and lymphocytes

Colitis due to Clostridium difficile infection is mediated by secreted toxins A and B and is characterized by infiltration by cells from the systemic circulation. The aim of our study was to investigate interactions between fluorescently labelled toxin A and peripheral blood monocytes, neutrophils and lymphocytes. Purified toxin A was labelled with Alexa Fluor® 488 (toxin A(488)) and incubated with isolated human peripheral blood mononuclear cells or washed whole blood cells for varying time intervals at either 37 or 4 °C/ice. The ability of trypan blue to quench cell surface-associated (but not cytoplasmic) fluorescence was also investigated. At 37 °C, toxin A(488) -associated fluorescence in monocytes peaked at 1 h (majority internalized), with subsequent loss associated with cell death. In contrast to monocytes, binding of toxin A(488) in neutrophils was greater on ice than at 37 °C. Studies using trypan blue suggested that over 3 h at 37 °C, most of the toxin A(488)-associated fluorescence in neutrophils remained at the cell surface. Over 48 h (37 °C and ice/4 °C), there was minimal toxin A(488)-associated fluorescence in lymphocytes. These studies suggest major differences in interactions between toxin A and circulating cells that infiltrate the mucosa during colonic inflammation in C. difficile infection.

Sudden vision loss caused by rhino-orbital zygomycosis in diabetic patients: case series

Rhino-orbital zygomycosis is a life-threatening fungal infection generally occurring in patients with an underlying disorder, such as diabetes mellitus with ketoacidosis or with immunocompromising factors, although it may rarely appear in healthy individuals. The study has been undertaken to discuss the clinical presentation, pathogenesis, diagnostic work up and management of this rapidly progressive disease. Four male patients having uncontrolled diabetes and presenting with signs and symptoms of rhino-orbital zygomycosis were studied to illustrate the serious nature of the disease. All the four patients had rapidly deteriorating vision loss either unilateral or bilateral along with other nasal and orbital signs and symptoms. All the patients were put on liposomal amphotericin B and underwent orbital exenteration and pansinusectomy. One patient died, while the other three were successfully treated. Early diagnosis is critical in the prevention of morbidity and mortality associated with the disease. There is need for a high index of clinical suspicion in immunocompromised patients. Timely medical-surgical treatment proves extremely important for prognosis.

Testicular toxicity of chlorpyrifos (an organophosphate pesticide) in albino rat

Organophosphates are among the most widely used synthetic insect pesticides. The widespread use of organophosphates has stimulated research into the possible existence of effects related with their reproductive toxic activity. Present study was therefore, undertaken to assess the effects of chlorpyrifos on testes, the main organ of male reproduction. Chlorpyrifos at the dose levels of 7.5, 12.5 and 17.5 mg/kg b. wt./day was administered orally to male rats of Wistar strain for 30 days to evaluate the toxic alterations in testicular histology, biochemistry, sperm dynamics and testosterone levels. The body weight of animals did not show any significant change, however, a significant reduction was observed in testes. Chlorpyrifos also brought about marked reduction in epididymal and testicular sperm counts in exposed males and a decrease in serum testosterone concentration. Histopathological examination of testes showed mild to severe degenerative changes in seminiferous tubules at various dose levels. Fertility test showed 85% negative results. A significant reduction in the sialic acid content of testes and testicular glycogen was noticed, whereas the protein and cholesterol content was raised at significant levels. All these toxic effects are moderate at low doses and become severe at higher dose levels. From the results of the present study it is concluded that chlorpyrifos induces severe testicular damage and results in reduction in sperm count and thus affect fertility. Small changes in sperm counts are known to have adverse affects on human fertility. Therefore, application of such insecticide should be limited to a designed programme.

The dispersion of natural oils in de-gassed water

Recent studies have demonstrated that pure hydrocarbon oils can be dispersed in water as fine droplets without the use of additives. The high interfacial tension between hydrocarbons and water is expected to cause cavitation between oil droplets during separation. This cavitation is aided by dissolved atmospheric gases present in both the oil and water. Their removal allows oil droplets to be readily dispersed in water. In this paper we report on the effect of the de-gassing process on the dispersion of several natural, water immiscible oils. These natural, mixed oils are eucalyptus, lavender and tea tree oil. Although these oils are mixtures and in some cases not as hydrophobic as those used in the earlier studies, the effect of de-gassing substantially enhances their dispersion, producing micron-sized droplets without the need for additives. Dispersions of these natural oils in pure water have a wide range of uses where purity is an advantage, for example, in skin cleaning products and oral sprays.

A study of satisfaction with dental services among adults in the United Kingdom

OBJECTIVES

To determine satisfaction with dental care services among the UK adult population, and to assess their knowledge regarding the dental complaints procedure.

METHODS

A national survey involving a multi-stage random sampling procedure with face-to-face home interviews of 5,385 UK residents was conducted in 1999.

RESULTS

The response rate was 69% and 3,739 adults took part in this study. Majority of people (89%) were satisfied with the quality of care they received. Only 2% (76) had actually complained, although 10% (388) had felt like complaining in the past. One third (32%, 1,188) did not know to whom to complain if they had a problem. Among those who knew whom to contact, over a third (36%, 1,359) would contact somebody outside the practice, while another third (31%, 1,169) would contact their dentist or dental practice.

CONCLUSION

Overall most people are satisfied with the quality of dental care they receive. However, 2% have complained and 10% have felt like complaining about their dentist/ dental care. In general, knowledge of the complaints procedure and whom to contact appears fragmented.

Unusual presentation of lupus nephritis

We report a male patient who presented with pyrexia, generalized lymphadenopathy, hepatosplenomegaly, and pleural effusion with no cutaneous or musculoskeletal symptoms. Despite extensive investigation, no cause was detected. His initial serology was also negative for autoantibodies. The patient was placed on a trial of antitubercular treatment in view of a positive Mantoux test. His disease evolved into the full clinical picture of systemic lupus erythematosus with nephritis (World Health Organisation class IV) and strongly positive antinuclear antibody and dsDNA over a period of months. He was treated successfully with intravenous cyclophosphamide pulses along with oral prednisolone, and the disease was still in remission after 3 years of follow-up.

Urodynamic profile after Wertheim's hysterectomy

Wertheim 's hysterectomy is likely to cause damage to innervation and anatomical support of the lower urinary tract. Urodynamic assessment was done in twenty patients of histopathologically proven cancer cervix who were about to undergo Wertheim's hysterectomy. The study was performed preoperatively, in the immediate postoperative period and six weeks after surgery. Urodynamic study included uroflowmetry, cystometry and urethral pressure profile. Urinary symptoms were also corelated with the urodynamic profile. It was concluded that the bladder was hypertonic in the immediate postoperative period and urethral closure pressures were low. Some regeneration of damaged nerve fibres was found to occur during the 6-8 weeks after surgery resulting in some improvement in sensory and motor functions of the bladder Post operatively continuous catheter drainage appeared to be the most important part of management of hypertonic bladder and the duration was individualised on the basis of urodynamic investigations.

Lipid peroxidation and vitamin E levels in preeclampsia

Twenty preeclamptic, 25 normotensive pregnant and 25 healthy nonpregnant women were analyzed with regard to serum malonaldehyde (MDA), vitamin E and lipid profile. In preeclampsia, MDA was significantly higher than control. MDA also showed high correlation to the level of blood pressure. Serum cholesterol and triglycerides were increased in normotensive women and still higher in preeclamptic women. A highly significant fall in vitamin E levels in preeclamptic women was noted as compared to control groups. Our study supports the view that an increased lipid peroxidation may be involved in vasoconstriction in preeclampsia.

Superoxide anion formation and glutathione levels in patients with preeclampsia

Increased free radical activity has been implicated in the pathogenesis of preeclampsia. This article investigates the glutathione status in preeclampsia and whether superoxide generation is enhanced in preeclampsia. Venous blood samples were obtained from 30 preeclamptic women and 30 normotensive pregnant women (controls). Superoxide generation and glutathione content were measured. There was a significant increase in superoxide generation and a marked reduction in glutathione content in preeclamptic women as compared to controls (p < 0.001). These results indicate that enhanced superoxide generation and impaired glutathione metabolism may be involved in the pathogenesis of preeclampsia.

AIDS-related apprehensions among nursing students of Delhi

Students from a nursing school of Delhi were surveyed anonymously using a self-administered questionnaire to explore various AIDS-related apprehensions and their possible reasons. The observations revealed that, majority of the students and their families/friends feared that these students were at risk of contracting HIV infection while providing routine patient care. A large number of students also opined that they would feel uncomfortable while talking, hugging, shaking hands, and sharing a room with an HIV positive person. The main reasons for their apprehensions were unsatisfactory anti-AIDS campaigning by the government, non-availability of sufficient protective measures in the health care settings, inadequate professional education related to prevention of HIV infection, and increase in HIV transmission following false sense of security due to excessive condom promotion. Findings of the study imply imparting factual knowledge addressing the concerns and removing misconceptions which influence attitudes and willingness of the nursing students to provide care to the HIV positives/AIDS patients, facts regarding efficacy of various preventive measures, and provision of counselling services in the event of exposure.

Expression and stable germline transmission of neomycin-resistance gene in transgenic mice

Transgenic mice were produced to study the expression of amino-3' glycosyl phosphotransferase gene (neomycin resistance gene) in the embryonic fibroblast cells. A 1.9 Kb linear fragment of neomycin resistance gene under the control of pPGK promoter was microinjected into the pronucleus of mouse embryos. Out of 64 potential founders born, 5 were identified to be transgenic by the polymerase chain reaction (PCR) and southern hybridization. Multiple mice from first and second generation from two transgenic founders (N-10 and N-32) were analysed to determine the germline transmission. It was found to be 24.6 and 71.4% in first and second generation respectively. Results were also further confirmed by RT-PCR, sequencing and in vitro bioassays.

Serum magnesium levels in preterm labour in relation to socioeconomic status

The present study revealed significantly lower levels of serum magnesium in patients with preterm labour without any apparent cause as compared to normal term pregnant women in labour. The values were also lower in women with low socioeconomic status, older age and consuming vegetarian diet. Hence, estimation of serum magnesium levels in pregnancy may be a useful parameter in preterm labour.

Some AIDS-related policy issues and nursing students' willingness to provide AIDS care

Two thirty three diploma students from a Nursing School, in Delhi were surveyed anonymously to seek their opinion on some AIDS-related policy issues and willingness to provide AIDS care. More than one fourth of students opinionated that health personnel should be given a choice to refuse care to the AIDS patients and an equal proportion felt that authorities should be empowered to terminate the services of such personnel. Majority were in favour of making HIV testing compulsory for various high risk groups, indoor patients and health workers. Perceiving the risk of HIV infection, 41.2% students felt that girls might not opt for nursing career, whereas few (10.7%) were considering even to leave the profession. However, majority (58-72%) were willing to nurse the high risk individuals, if adequate training and preventive measures were provided in the health care settings. The study implies framing of an AIDS policy taking in to consideration the views of health professionals and imparting comprehensive training to the nursing students in order to promote a humane approach towards AIDS care.

Heterosexual behaviour and condom usage in an urban population of Delhi, India

A survey conducted among the lower-class urban population of Delhi, India to describe the heterosexual behaviour, condom usage and awareness about STDs/AIDS revealed that 4.4% respondents had sex outside/before marriage. Female commercial sex workers, friends and neighbours were the important sexual partners. Heterosexual activity was significantly higher among males, unmarried, literates and middle/higher income groups. Almost half of those who had sex before/outside marriage never used a condom during the sexual encounter. Though only a small fraction of the population was found to be engaged in extra-/pre-marital sex, the overall impact of this may be multifold, given the nature and modes of HIV transmission. The superficial and inadequate knowledge regarding STDs/AIDS among this population, especially among those having extra-/pre-marital sex, indicates an urgent need for appropriately targeted health education and condom promotion activities in the community with an endeavour to increase awareness about STDs and HIV/AIDS and motivate people towards healthy sexual lifestyles.

Role of low dose aspirin in prevention of pregnancy induced hypertension

In a prospective randomised clinical study 50 primi or multigravidae with history of essential hypertension or pregnancy induced hypertension (PIH) in previous pregnancy were selected from antenatal clinics, on the basis of positive roll over test (ROT) carried out between 28 to 30 weeks of pregnancy. The study group comprised 25 women who received 50 mg aspirin daily from day of positive ROT till 37 weeks of pregnancy. Other 25 women served as control. The incidence of PIH in study and control group was 4% versus 28% and that of pre-term birth was 4% versus 24%. The mean birth weight of newborns in the two groups was 3.04 +/- 0.38 kg and 2.71 +/- 0.48 kg respectively. All these differences were statistically significant. No adverse maternal or neonatal complication due to aspirin was observed.

AIDS awareness among nursing students of Delhi

A total of 233 students of nursing school affiliated to a major hospital of Delhi were surveyed anonymously employing a predesigned, pretested and self-administered questionnaire. Although, 78.6 per cent students knew that AIDS stands for "Acquired Immuno-deficiency Syndrome," 15.5 per cent students were unaware of the fact that AIDS had reached India. Majority of them were aware of various aspects of HIV/AIDS. However, they also had few misconceptions particularly regarding HIV transmission. Contrary to our belief, only one-fourth students acquired AIDS information from scientific journals. One training session on AIDS conducted for a small group of students could not bring any significant change in their knowledge. Findings suggest organization of AIDS-training sessions at regular intervals from the very inception of nursing programme to impart complete and correct knowledge of these future Florence Nightingales regarding various aspects of HIV/AIDS and for removal of misconceptions.

Preventing gastro-enteritis deaths: recommendations based on a 3 years study

Based on epidemiological investigation of 75 gstro-enteritis deaths that occurred in 22 major hospitals of Delhi during 1990-92, this paper deals with the observations pertaining to the role of physicians and health infrastructure in the management of gastro-enteritis patients. Majority of the patients visited private practitioners/clinics in the first instance. Hospital stay in 44% of cases was 6 hours or more, by which time dehydration and/or electrolyte imbalance should have been corrected. Still, in 54.5 percent out of these, dehydration was the cause of death, while in 18.2 percent electrolyte imbalance co-existed. Record maintenance at various hospitals was far from satisfactory. The study, highlighting the need for proper rehydration and timely referral enlists recommendations that might help in preventing gastro-enteritis deaths.

Phase contrast microscopic evaluation of placental pathology in premature gestation

Numerous representative samples taken from forty placentas immediately after delivery from mothers associated with prematurity (i.e. less than 38 weeks), were semiquantitatively studied by phase contrast microscopy. Twenty placentas delivered from mothers without any antenatal complication served as control. Hypoplasia of the syncytium, stromal edema, ischaemia were prominent findings on phase contrast microscopy in the study group. Increased basement membrane thickening and high villous edema scores observed on light microscopy were statistically significant in prematurity as compared to controls. Observations by phase contrast and light microscopy were found complementary to each other. Phase contrast microscopy provided quicker results without disadvantage of fixation artefact and was found distinctly superior over the conventional histological methods.

Teachers' awareness and opinion about AIDS: implications for school based AIDS education

Two hundred thirteen teachers of one secondary and four primary schools of East Delhi were interviewed to assess their knowledge and attitudes about AIDS and their opinions regarding school based AIDS education. Observations revealed that majority of the teachers were aware of various aspects of HIV/AIDS. However, they also had some misconceptions regarding transmission of the disease. Though, most of the teachers opined that they could play an important role in educating the students as well as the community regarding AIDS/STDs, three fourths of them had never discussed AIDS/STDs with their students. Majority of teachers were in favour of starting class room based education on AIDS/STDs, beginning from secondary classes onwards, and more than half opined that class teacher could educate the students better than the doctors or parents. The results suggest that after being properly trained, teachers can be effectively utilized for educating the students.

Knowledge and attitudes of university students regarding HIV/AIDS: an urban--rural difference

A total of 322 students from two colleges of Delhi University, one located in urban and the other in the rural area were surveyed to assess and compare their knowledge, attitudes and beliefs regarding HIV/AIDS. A pretested and self-administered questionnaire containing mostly close ended questions was used. Observations revealed that majority of the students were aware of various aspects of HIV/AIDS. However, they also had some misconceptions particularly regarding transmission of the disease. The science and urban students had significantly more knowledge as compared to their counter parts, there by leading to more positive attitudes among them. Findings suggest intensification of AIDS education campaign focussed on removal of misconceptions and changing negative attitudes, more so amongst rural students. Science students can prove as a potential source of peer communication to the non-science students both in urban as well as rural areas.

An epidemiological profile of gastro-enteritis deaths in Delhi state

This paper describes epidemiological features of 75 gastro-enteritis deaths that occured in 22 major hospitals of Delhi during 1990-92. Three fourth's of deaths were in under five years of age group and more than half were infants. In 84 per cent, diarrhoea was of an acute watery type. Dehydration was the commonest immediate cause of death, while malnutrition was the commonest associated cause. No ORS/SSS/HAF was given to one fourth of the patients. Close relatives of two third's of deceased were either not aware at all about ORS/SSS or had incorrect information. In 87 per cent, food intake was either stopped or had been restricted. The study emphasizes the need for an intensive IEC campaign for prevention, and for better case management in the hospitals coupled with appropriate reorientation training of private practitioners.

Potential relationship between dengue fever and neural tube defects in a northern district of India

A sudden increase in number of births of newborns with neural tube defects (NTD) was observed from June, 1989 to September, 1989 in Medical College and Hospital, Rohtak and various other government and private hospitals of the district of Rohtak. Out of a total 4785 deliveries whose records were collected, there were 87 newborns with NTD with an incidence of 18.18/1000 births which was three times higher than the previous incidence of 6.8/1000 births in the preceding 4 years. There was an epidemic of dengue fever in this area from September, 1988 to December, 1988 affecting almost one member from each family. This coincided with the period of their first trimester. Of these, 18 patients suffered clinically from dengue fever, 21 patients had positive dengue fever history in their family members, 21 patients had positive history in their neighbors. The cluster of NTD appears to be due to dengue virus infection.

Cytotoxicity of eugenol in sealer containing zinc-oxide

In this study two zinc-oxide-based root canal sealers were compared for their tissue toxic response. The sealers tested were zinc-oxide eugenol and zinc-oxide glycerine. Fifteen albino rats were used for the study and were injected subcutaneously in the preset state. The tissue response was assessed by counting the polymorphonuclear cells at Day 1, Day 7 and Day 15 of the study period. The inflammatory response was graded according to the mean polymorphonuclear counts in the five rats for each period. The results showed that the toxicity was greater for the eugenol-containing sealer and increased during the three time intervals. For the non-eugenol sealer the response was milder and reached a peak by 7 days after which it decreased.

Oral ketoconazole and miconazole vaginal pessary treatment for vaginal candidosis

This prospective study was carried out on 250 patients having clinical and mycological evidence of vaginal candidosis. One hundred patients received ketoconazole orally (400 mg/day for 5 days), another 100 patients received miconazole vaginal pessary treatment (one 100 mg tablet locally for 14 days), while the other 50 patients received combination therapy of oral ketoconazole and miconazole vaginal tablets. Although all 3 regimens were significantly effective in relieving patients symptoms and physical signs, the combination therapy gave the best results. There was 98% symptomatic relief with the combination therapy in contrast to 82% and 78% in the oral ketocanozole and vaginal micronazole groups respectively (p less than 0.001). Mycological cure rates were also significantly higher in the combination therapy group (94% versus 80% and 76%). The relapse rate was least in the combination group 2% versus 8% and 12%. The combination therapy is recommended for the best results in vaginal candidosis.

Maternal and perinatal complications in neurofibromatosis during pregnancy

A total of ten patients with lesions of neurofibromatosis during pregnancy were followed up for pregnancy complications. Seven cases (70%) had hypertensive disorders of pregnancy; four had severe PET (pre-eclamptic toxemia) including one case of eclampsia, one had mild PET and the other two had only mild gestational hypertension. A total of 60% had preterm labor and in none of these did the baby survive; thus perinatal mortality was 600/1000. Mean gestation was 33.0 weeks and mean birthweight was only 1.924 kg. Thus, neurofibromatosis during pregnancy is associated with poor obstetrical outcome and requires greater care.