A single tertiary institution review of the international system for serous fluid cytopathology and the impact of cell block and ancillary studies on its performance

INTRODUCTION

We sought to assess the utility of the International System for Serous Fluid Cytopathology (TIS) in the context of our department's routine practice.

MATERIALS AND METHODS

We examined 1028 archived effusion cytology (pleural, peritoneal, and pericardial) cases from 2018 to 2019, and re-classified them along the international system into the following diagnostic categories: nondiagnostic (ND), negative for malignancy (NFM), atypia cells of undetermined significance (AUS), suspicious for malignancy (SFM), and malignant (MAL).

RESULTS

The full distribution of the cases examined was as follows: ND 2.0%; NFM 66.1%; AUS 6.0%; SFM 4.7%; MAL 21.2%. Overall risk of malignancy for each category was calculated as: ND 30.0%; NFM 18.0%; AUS 61.9%; SFM 100%; MAL 94.4%. The overall performance attributes of TIS were as follows: sensitivity 57.1%; specificity 98.3%; positive predictive value 94.4%; negative predictive value 82.0%; diagnostic accuracy 84.5%.

CONCLUSIONS

The new classification was simple and intuitive to use and our results appear to fall within the expected ranges of the new guidelines, with risk of malignancy and accuracy comparable to similar studies. The availability of a cell block allowed for refinement of the diagnosis in a majority of cases with equivocal cytology, though this was dependent on the cell yield.

Epithelial-mesenchymal transition and cancer stem cell interactions in breast phyllodes tumours: immunohistochemical evaluation of EZH2, EZR, HMGA2, CD24 and CD44 in correlation with outcome analysis

AIM

Phyllodes tumours (PTs) categorised as benign, borderline and malignant, account for 1% of all breast tumours. Histological assessment does not always predict tumour behaviour, hindering determination of the clinical course and management.Epithelial-mesenchymal transition (EMT) is an important process during embryogenesis. Dysregulation of EMT causes loss of cell polarity, decreased intercellular adhesion, increased motility and invasiveness, promoting tumour progression. Similarly, cancer stem cells (CSCs) promote tumour growth, resistance and recurrence. The aim of this study is to evaluate expression of CSC markers; enhancer of zeste homolog 2 (EZH2), CD24 and CD44 and EMT associated proteins; ezrin (EZR) and high-mobility group AT-hook 2 (HMGA2) in PTs.

METHOD

Uing tissue microarray sections, immunohistochemistry was performed on 360 PTs. Epithelial and stromal expressions of EZH2, EZR, HMGA2, CD24 and CD44 were evaluated to assess their impact on disease progression and behaviour in correlation with clinicopathological parameters.

RESULTS

Stromal expression of EZH2, EZR and HMGA2 was observed in 73 (20.3%), 53 (14.7%) and 28 (7.8%) of tumours, epithelial expression in 121 (35.9%), 3 (0.8%) and 351 (97.5%) tumours, respectively. CD24 and CD44 staining was absent in both components.

CONCLUSION

Expression of biomarkers correlated significantly with aggressive tumour traits such as stromal hypercellularity, atypia, mitoses and permeative tumour borders.Stromal expression of EZH2 and EZR shortened disease-free survival and overall survival; HMGA2 expression did not alter patient survival. EZH2 and EZR may thus be useful in predicting PT behaviour.

Use of preoperative opioids increases duration of hospital stay following elective lower limb arthroplasty. - A snapshot of UK practice

This study is one of the first in the UK where to assess the link between pre-operative opioid use and length of stay or complications. The primary objective was to test our hypothesis; that low dose pre-operative opioids will not lead to an increase in complications and LOS in lower limb arthroplasty patients. 640 records were found and 625 patients were included whom received elective primary or revision surgery. It was found that Pre-operative opioids >12 MED does increase LOS.

Evaluation of a human in vitro skin test for predicting drug hypersensitivity reactions

The occurrence of drug hypersensitivity reactions (DHRs) following administration of low molecular weight (LMW) drugs is an important health concern. However, in vivo animal models which could be used as tools for the prediction of DHRs are lacking. As a result, research has focused on development of in vitro tools for predicting DHRs. In this study a novel human in vitro pre-clinical skin explant test was used to predict T cell-mediated hypersensitivity responses induced by LMW drugs. Responses in the skin explant test for 12 LMW drugs associated with T cell-mediated hypersensitivity in the clinic (abacavir, amoxicillin, carbamazepine, diclofenac, lamotrigine, lapatinib, lumiracoxib, nevirapine, ofloxacin, phenytoin, propranolol, sulfamethoxazole) were compared with responses for 5 drugs with few/no reports of T cell-mediated hypersensitivity reactions (acetaminophen, cimetidine, flecainide, metformin, verapamil). Changes in skin histology following in vitro exposure to the drugs as well as T cell proliferation and interferon gamma (IFNγ) production were studied. The results of the skin explant assays showed a good positive correlation (r = 0.77, p < .001) between the test outcome (prediction of positive or negative) and the clinical classification of the tested drugs. The T cell proliferation assay showed a correlation of r = 0.60 (p < .01) and the IFNγ assay r = 0.51 (p < .04). The data suggest that the skin explant model could be a useful tool to predict the potential of LMW drugs to induce DHRs.

Cardiac Myxomas: A Histodemographic Analysis

Background: Cardiac myxoma is the most common benign cardiac tumour, accounting for more than half of all primary cardiac tumours. Most myxomas are sporadic and the cause is largely unknown. Familial variants with an autosomal dominant inheritance exist. It is localized generally in the left atrium and typically develops in females. Clinical manifestations can mimic cardiac conditions and depend on the natural behaviour of the tumour and its location within the heart, ranging from being completely asymptomatic to causing sudden death. Establishing an early diagnosis is essential, which is confirmed by histopathology.Objective: The aim was to find the relation between cardiac myxomas with age, sex and cardiac sites.Materials and method: This cross sectional study was done in the pathology department of Delta Hospital Limited, Dhaka, Bangladesh, during the period of January 2014 to July 2016. A total of 24 cases were studied irrespective of age, sex along with clinical diagnosis.Results: Among the study subjects females were predominant (70.83%) and highest frequency of cases occurred in between 41-50 years of age (41.67%). Commonest site was left atrium (83.33%).Conclusion: The present study revealed that cardiac myxoma occurs most commonly in the 5th decade with female predominance and the most common site is left atrium.Delta Med Col J. Jan 2018 6(1): 4-8

An automated staining protocol for seven-colour immunofluorescence of human tissue sections for diagnostic and prognostic use

Multiplex immunofluorescence (mIF) allows simultaneous antibody-based detection and quantification of the expression of up to six markers, plus a nuclear counterstain, on a single tissue section. Recent studies have shown the potential for mIF to advance our understanding of complex disease processes, including cancer. It is important that the technique be standardised and validated to facilitate its transition into clinical use. Traditional approaches to mIF rely on manual processing of sections, which is time-consuming and a source of significant variation between samples/individuals. Here we determined if an automated diagnostic tissue stainer could be used for mIF incorporating tyramide signal amplification (TSA), and how the final image quality compared with sections stained semi-automatically or manually. Using tissue microarrays of fixed human breast tumour sections, we observed comparable antibody labelling between the diagnostic autostainer and manual technique. The diagnostic autostainer produced higher signal intensity with similar spectral unmixing efficiency. We also found that microwave treatment for antibody stripping during TSA labelling could be replaced by the heating option incorporated within the diagnostic-use autostainer. These data show that diagnostic autostainers used for traditional immunohistochemistry protocols can be readily adapted to achieve rapid preparation of high-quality sections using a TSA method for clinical mIF.

Plasma cell-rich acute rejection of renal allograft: an unusual case of acute allograft dysfunction

We report a case of renal allograft dysfunction due to plasma cell-rich acute rejection (PCAR), which is an uncommon clinical entity with a wide range of differential diagnoses. Extensive diagnostic workup, treatment approach and outcome are discussed and we provide a brief summary of the current management dilemma. Nevertheless, the diagnosis of PCAR portends a poor prognosis and therefore timely diagnosis and intensification of treatment is crucial to prevent disease progression.

Three-layer reconstruction of lower third nasal defects using forehead flap, reversed nasolabial flap, and auricular cartilage

The reconstruction of a full-thickness defect of the distal third of the nose requires the restoration of all three anatomical layers. A practical method for three-layer reconstruction of the lower third of the nose and the long-term results of this technique are presented herein. A combined reconstruction technique was utilized, including a reverse subcutaneous pedicled nasolabial flap to restore the nasal mucosa, an auricular cartilage graft for structural support, and a forehead flap for cutaneous coverage of the defect. This technique was applied in 21 patients following the full-thickness excision of basal cell carcinoma of the lower part of the nose. All patients (12 male and nine female; mean age 59.8 years) were treated successfully and were satisfied with the aesthetic and functional outcomes. The wound had to be further revised in three cases for the correction of contour or residual deformities; however, no further complications were experienced. One patient had a wound infection and the cartilage had to be removed. The grafting procedure was repeated successfully after resolution of the infection. Donor site morbidity was unremarkable. Combined flaps from the forehead and nasolabial regions with an incorporated auricular cartilage graft can be used to reconstruct full-thickness defects of the lower third of the nose.

Clinicopathological characteristics of oestrogen receptor negative, progesterone receptor positive breast cancers: re-evaluating subsets within this group

Aims

The presence of oestrogen and progesterone receptors (ER, PR) in breast carcinoma is an important prognostic indicator as well as a predictor of likely response to hormonal treatment. Current ambiguity surrounds ER-negative (–)/PR-positive (+) breast cancer (BC) as to whether this phenotype exists as a distinct entity. The independent predictive value of PR for treatment considerations is also in question, as some investigators believe ER status to be the single most important therapeutic predictive factor in BC. We undertook this study to determine the existence of ER(–)/PR(+) BC and the prognostic effect, if any, of this phenotype.

Methods

We investigated 267 archival documented ER(–)/PR(+) BCs diagnosed between January 1994 and July 2009. Histological slides were retrieved and reviewed. Tissue microarrays were constructed by selecting two 1 mm cores of tumour per case. Repeat immunohistochemistry was performed for confirmation of the ER(–)/PR(+) status. Clinicopathological parameters including age, ethnicity, tumour size, histological grade, histological subtype, associated ductal carcinoma in situ, lymphovascular invasion and lymph node status were evaluated.

Results

On repeat immunohistochemistry, 92 tumours were confirmed as ER(–)/PR(+) BCs. This phenotype accounted for 1.1% of all BC phenotypes and exhibited different clinicopathological features and survival outcome when compared with other phenotypes. ER(–)/PR(+) tumours showed a trend for an early recurrence and poorer overall survival as compared with the patients with ER(+)/PR(+) tumours and similar to ER(–)/PR(–) tumours.

Conclusions

Our findings suggest that ER(–)/PR(+) BCs exist, although rare, with distinct pathological and clinical characteristics from patients with ER(+)/PR(+) BCs.

Ease of insertion of the laryngeal mask airway in pediatric surgical patients: Predictors of failure and outcome

BACKGROUND

Laryngeal mask airway (LMA) is an useful alternative to endotracheal tube for airway management. The risk of life-threatening adverse respiratory events during its use is rare, but we need to know about the risk-adjusted prediction of its insertion failure requiring rescue tracheal intubation and its impact on patient outcome.

MATERIALS AND METHODS

Five hundred patients; 6 months to 12-year-old, American Society of Anesthesiologists I and II scheduled to undergo elective surgical procedures that require general anesthesia were included in this study. LMA was inserted after induction of anesthesia. The insertion conditions, intra, and postoperative events were recorded. Our primary outcome variable was trial success from the first time.

RESULTS

We recorded 426 cases (85.2%) of first trial success with clear airway compared to 46 case (9.2%) of second trial success (P ≤ 0.001). Predictors of failure of first attempt of LMA insertion include abnormal airway anatomy (91%), body weight <16 kg and age below 5 years (44%), the use of LMA size of 1 and 1.5 (3.8%), the intraoperative lateral position (3.8%).

CONCLUSION

The data obtained from this study support the use of the LMA as a reliable pediatric supraglottic airway device, demonstrating relatively low failure rates. Predictors of LMA failure in the pediatric surgical population should be independently considered.

TRIAL REGISTRATION

The study is registered in the Australian and New Zealand clinical trial registry with the allocated trial number: ACTRN12614000994684. Web address of trial: http://www.ANZCTR.org.au/A CTRN12614000994684.aspx.

Spread of carbapenem-resistant international clones of Acinetobacter baumannii in Turkey and Azerbaijan: a collaborative study

Epidemic clones of Acinetobacter baumannii, described as European clones I, II, and III, are associated with hospital epidemics throughout the world. We aimed to determine the molecular characteristics and genetic diversity between European clones I, II, and III from Turkey and Azerbaijan. In this study, a total of 112 bloodstream isolates of carbapenem-resistant Acinetobacter spp. were collected from 11 hospitals across Turkey and Azerbaijan. The identification of Acinetobacter spp. using conventional and sensitivity tests was performed by standard criteria. Multiplex polymerase chain reaction (PCR) was used to detect OXA carbapenemase-encoding genes (bla OXA-23-like, bla OXA-24-like, bla OXA-51-like, and bla OXA-58-like). Pulsed-field gel electrophoresis (PFGE) typing was used to investigate genetic diversity. The bla OXA-51-like gene was present in all 112 isolates, 75 (67 %) carried bla OXA-23-like, 7 (6.2 %) carried bla OXA-58-like genes, and 5 (4.5 %) carried bla OXA-24-like genes. With a 90 % similarity cut-off value, 15 clones and eight unique isolates were identified. The largest clone was cluster D, with six subtypes. Isolates from clusters D and I were widely spread in seven different geographical regions throughout Turkey. However, F cluster was found in the northern and eastern regions of Turkey. EU clone I was grouped within J cluster with three isolates found in Antalya, Istanbul, and Erzurum. EU clone II was grouped in the U cluster with 15 isolates and found in Kayseri and Diyarbakır. The bla OXA-24-like gene in carbapenemases was identified rarely in Turkey and has been reported for the first time from Azerbaijan. Furthermore, this is the first multicenter study in Turkey and Azerbaijan to identify several major clusters belonging to European clones I and II of A. baumannii.

An in vitro human skin test for assessing sensitization potential

Sensitization to chemicals resulting in an allergy is an important health issue. The current gold-standard method for identification and characterization of skin-sensitizing chemicals was the mouse local lymph node assay (LLNA). However, for a number of reasons there has been an increasing imperative to develop alternative approaches to hazard identification that do not require the use of animals. Here we describe a human in-vitro skin explant test for identification of sensitization hazards and the assessment of relative skin sensitizing potency. This method measures histological damage in human skin as a readout of the immune response induced by the test material. Using this approach we have measured responses to 44 chemicals including skin sensitizers, pre/pro-haptens, respiratory sensitizers, non-sensitizing chemicals (including skin-irritants) and previously misclassified compounds. Based on comparisons with the LLNA, the skin explant test gave 95% specificity, 95% sensitivity, 95% concordance with a correlation coefficient of 0.9. The same specificity and sensitivity were achieved for comparison of results with published human sensitization data with a correlation coefficient of 0.91. The test also successfully identified nickel sulphate as a human skin sensitizer, which was misclassified as negative in the LLNA. In addition, sensitizers and non-sensitizers identified as positive or negative by the skin explant test have induced high/low T cell proliferation and IFNγ production, respectively. Collectively, the data suggests the human in-vitro skin explant test could provide the basis for a novel approach for characterization of the sensitizing activity as a first step in the risk assessment process.

A case of small bowel metastasis from spinal Ewing sarcoma causing intussusception in an adult female

Background

Ewing sarcomas are highly aggressive malignant tumours occurring predominantly in the long bones of the extremities in children and young adults. About 20 % of patients will present with metastases at diagnosis with the commonest sites being the lungs, bone and bone marrow. Cases of primary small bowel Ewing sarcomas have been described but are nonetheless exceedingly rare, even more so cases of metastasis to the small bowel.

Case Presentation

We describe a case of vertebral Ewing sarcoma in a 44 year-old female which metastasized to the jejunum causing intussusception.

Conclusions

Ewing’s sarcoma is highly aggressive and presence of metastases, overt or subclinical, is thought to be present in almost all patients at diagnosis. As evidenced by our patient, metastatic disease can progress rapidly to cause further complications and confer a poorer survival. The possibility of metastasis, no matter how rare or unlikely the site is, should be considered and actively investigated to expedite treatment of the primary disease.

Response of first-line antibiotic therapy in patients with febrile neutropenia during treatment of hematological disorders

Patients with hematological disorders develop febrile neutropenia (FN); most of these events remain undetermined in origin. We performed a prospective study to determine the microbiological characteristics of infections and their response to the first-line antibiotic therapy in FN. The study was conducted at National Institute of Blood Disease and Bone Marrow Transplant. Two-hundred episodes of FN were assessed for the bacterial growth, antimicrobial susceptibility pattern and response to the first-line treatment of FN. All patients were given Ceftazidime and Amikacin Bosch Pharmaceutical (Pvt. Ltd), as first-line antibiotic in FN. Out of 200 episodes we had 108 clinically and microbiologically documented infections. The isolated frequencies for gram negative and gram positive organisms were n = 52 and 49 (48 and 45 %) respectively. Among gram negative micro-organisms, Escherichia coli (E. coli) was isolated in 15 (28.8 %), Klebsiella pneumonae in 4 (7.6 %) and Pseudomonas aeruginosa in 10 (19.2 %) were in highest frequencies. Methicillin sensitive staphylococci emerged as the frequently isolated gram-positive bacteria. Eight-one episodes (45.3 %) responded to the first-line treatment and death reported in 20 cases (10 %). Our study showed almost equal trend of gram positive and gram negative bacteria isolated from patients suffering from neutropenic fever. Empirical use of Ceftazidime and Amikacin as first-line antibiotics was able to cover the infection only in 45.3 % of episodes suffering from FN.

Study on serum glucose level among smear positive pulmonary tuberculosis patients in Bangladesh

This case control study was carried out in the Department of Biochemistry, Mymensingh Medical College, Bangladesh in cooperation with the Outpatient Department and Medicine Units of Mymensingh Medical College Hospital, Fulbaria Upazilla Health Complex, Mymensingh and some DOTS centers of BRAC, a non-government organization during the period of July 2006 to June 2007. The aim of the study was to explore the status of serum glucose level in smear positive Bangladeshi pulmonary tuberculosis patients. A total of 120 people of different age groups were included in this study. Subjects were divided into two groups - Group I (Control; n=60) - apparently healthy people selected matching by age, sex and socioeconomic status with the cases and Group II (Case; n=60) - people with smear positive pulmonary tuberculosis. Serum glucose (fasting) was estimated by colorimetric principle. Statistical analysis was done by using SPSS windows package. Among the groups, mean±SD of serum glucose (fasting) in Group II (5.91±1.02mmol/L) was significantly higher (p<0.001) than in Group I (4.87±0.57mmol/L). It is evident from the study that serum glucose level significantly increases in smear positive pulmonary tuberculosis patients.

Predicting the likelihood of additional lymph node metastasis in sentinel lymph node positive breast cancer: validation of the Memorial Sloan-Kettering Cancer Centre (MSKCC) nomogram

AIM

To identify important clinicopathological parameters that are most helpful in predicting additional non-sentinel lymph node (SLN) metastasis among patients with a positive SLN biopsy in the Singapore breast cancer population.

METHODS

A total of 1409 patients who underwent SLN biopsy were reviewed over a 5 year period from July 2004 to October 2009. A Singapore General Hospital (SGH) nomogram was developed from predictors in the Memorial Sloan-Kettering Cancer Centre (MSKCC) nomogram using 266 patients with primary invasive breast cancer and a positive SLN biopsy who subsequently had an axillary lymph node dissection. The SGH nomogram was calibrated using bootstrapped data, while the MSKCC nomogram was calibrated using SGH data. The performance of these two nomograms was compared with the calculation of the area under the receiver-operator characteristics curve and adequacy indices.

RESULTS

The MSKCC nomogram achieved an area under the curve (AUC) of 0.716 (range 0.653-0.779) in our study population, while the SGH nomogram, which used only three pathological parameters, lymphovascular invasion, number of positive and negative SLN biopsies, achieved an AUC of 0.750 (range 0.691-0.808). The SGH nomogram with a higher adequacy index (0.969) provided better estimates compared with the MSKCC nomogram (0.689).

CONCLUSIONS

The use of the MSKCC nomogram was validated in our local patient population. The SGH nomogram showed promise to be equally, if not, more predictive as a model in our own population, while using only three pathological parameters.

Maintaining and restoring cytoplasmic male sterility systems in pepper (Capsicum annuum L.)

We studied the efficiency of maintaining and restoring cytoplasmic male sterility (CMS) systems in pepper (Capsicum annuum L.). An Rf-linked molecular marker was employed to analyze the interaction between 6 CMS lines (A), 5 maintainers (B), and 6 restorers (C). Sterility was maintained in the matings of lines 201A x 200B, 203A x 200B, 206A x 200B, 200A x 201B, 206A x 201B, 200A x 202B, 200A x 203B, 200A x 206B, and 201A x 206B. All 6 restorers restored the fertility of lines 200A, 202A, 203A, and 204A, except that 213C could not restore the fertility of lines 200A and 204A. However, the 6 restorers had diverse restoring abilities in individual CMS lines. The Rf-linked molecular marker was amplified by PCR in lines 207C, 208C, and 213C. This DNA marker was only found in the F1 hybrids M39, M14, M19, M25, M13, M20, and M22. We conclude that the restorers 208C and 207C can transmit the Rf gene or the Rf-linked marker to F1 hybrids.

Serum calcium level among smear positive pulmonary tuberculosis patients in Bangladesh

This case control study was carried out in the Department of Biochemistry, Mymensingh Medical College, Bangladesh in cooperation with the Outpatient Department and Medicine Units of Mymensingh Medical College Hospital, Fulbaria Upazilla Health Complex, Mymensingh and some DOTS centers of BRAC, a non-government organization during the period of July 2006 to June 2007. The aim of the study was to explore the status of serum calcium level in smear positive Bangladeshi pulmonary tuberculosis patients. A total of 120 people of different age groups were included in this study. Subjects were divided into two groups - Group I (Control; n=60) apparently healthy people selected matching by age, sex and socioeconomic status with the cases and Group II (Case; n=60) people with smear positive pulmonary tuberculosis. Serum calcium was estimated by colorimetric principle. Serum calcium was adjusted by serum albumin concentration. Statistical analysis was done by using SPSS windows package. Among the groups, mean±SD of adjusted serum calcium in Group II (2.41±0.15mmol/L) was significantly higher (p<0.001) than that in Group I (1.85±0.11mmol/L). It is evident from the study that serum calcium level significantly increases in smear positive Bangladeshi pulmonary tuberculosis patients.

The pollen wall and tapetum are altered in the cytoplasmic male sterile line RC₇ of Chinese cabbage (Brassica campestris ssp pekinensis)

Cytoplasmic male sterile line RC(7) of Chinese cabbage produces mature anthers without pollen. To understand the mechanisms involved, we examined the ultrastructural changes during development of the microspores. Development of microspores was not affected at the early tetrad stage. During the ring-vacuolated period, some large vacuoles appeared in the tapetum cells, making them larger, extending to the anther sac center during the monocyte period. At the same time, the tapetum degenerated as the microspores aborted, resulting in pollen-deficient anthers. As a result, the locules collapsed and the anthers shriveled. The callose was degraded in the pollen walls; abnormal deposits of electrodense material gave rise to irregular spike-shaped structures, rather than the characteristic rod-like shape of the B7 bacula. The internal intine wall of RC(7) was thinner than that of the B7 type. At the mitosis I microspore stage, the tapetum cells contained multiple plastids, with numerous small spherical plastoglobuli, and lipid bodies. Based on these observations, we suggest that RC(7) abortion may be due to mutated genes that normally regulate development of the pollen wall and cell walls in the RC(7) line.

Exogenous abscisic acid increases antioxidant enzymes and related gene expression in pepper (Capsicum annuum) leaves subjected to chilling stress

To elucidate how physiological and biochemical mechanisms of chilling stress are regulated by abscisic acid (ABA) pretreatment, pepper variety (cv. 'P70') seedlings were pretreated with 0.57 mM ABA for 72 h and then subjected to chilling stress at 10°/6°C (day/night). Chilling stress caused severe necrotic lesions on the leaves and increased malondialdehyde and H(2)O(2) levels. Activities of monodehydroascorbate reductase (DHAR), dehydroascorbate reductase, glutathione reductase, guaiacol peroxidase, ascorbate peroxidase, ascorbate, and glutathione increased due to chilling stress during the 72 h, while superoxide dismutase and catalase activities decreased during 24 h, suggesting that chilling stress activates the AsA-GSH cycle under catalase deactivation in pepper leaves. ABA pretreatment induced significant increases in the above-mentioned enzyme activities and progressive decreases in ascorbate and glutathione levels. On the other hand, ABA-pretreated seedlings under chilling stress increased superoxide dismutase and guaiacol peroxidase activities and lowered concentrations of other antioxidants compared with untreated chilling-stressed plants. These seedlings showed concomitant decreases in foliage damage symptoms, and levels of malondialdehyde and H(2)O(2). Induction of Mn-SOD and POD was observed in chilling-stressed plants treated with ABA. The expression of DHAR1 and DHAR2 was altered by chilling stress, but it was higher in the presence than in the absence of ABA at 24 h. Overall, the results indicate that exogenous application of ABA increases tolerance of plants to chilling-induced oxidative damage, mainly by enhancing superoxide dismutase and guaiacol peroxidase activities and related gene expression.

Pseudomyxoma peritonei - a case report

Pseudomyxoma peritonei (PMP) is rare in our clinical practice. The patient was a lady of 45 years admitted at the department of Obstetrics & Gynaecology in Sir Salimullah Medical College & Mitford Hospital (SSMC & MH) Dhaka with the complaints of swelling of the abdomen for 3 months associated with pain in the same region and weight loss. On examination a large swelling was palpated occupying the umbilical, hypogastric, both iliac, and part of both lumber regions. It was cystic, mildly tender, and immobile with ill defined margins. Computer tomography (CT) showed a cystic mass in the pelvic cavity extending upto the mid abdomen. Huge ascites was also noted. CT guided FNAC showed benign mucinous cystadenoma. Laparotomy was done which showed that the peritoneal cavity was filled up with mucinous material and there was a tumor in the right ovary which was free from adhesion. Left ovary and uterus were atrophic. Hysterectomy with bilateral salpingoophorectomy was done. Abdomen was cleared from the mucinous material as far as possible. Her postoperative recovery was uneventful. Histopathology report showed borderline mucinous cystadenoma of the ovary. She was referred to the oncology department. No chemotherapy was given but kept under follow-up.

Happy ending of life-threatening upper GI bleeding

Strongyloides stercoralis is an intestinal nematode in humans, and estimated about tens of millions of people are infected worldwide. This parasite is endemic in tropical or temperate and subtropical climates like Bangladesh. The authors report a 33-year-old man who presented with recurrent life-threatening upper gastrointestinal bleeding from gastric infection by S stercoralis.

Cutaneous squamous cell carcinoma associated with proliferation of osteoclast-like giant cells

Proliferation of osteoclast-like giant cells in a cutaneous squamous cell carcinoma is a rare phenomenon and so far only four cases have been reported. In previous reports, osteoclast-like giant cells were admixed with sarcomatoid component of squamous cell carcinoma and it is therefore debatable if the osteoclast-like giant cells represent a reactive phenomenon or a part of the malignant tumour. A case of cutaneous squamous cell carcinoma associated with osteoclast-like giant cells is reported. However, sarcomatous component of squamous cell carcinoma was not identified in this case. Morphologically, the osteloclast-like giant cells appeared to be benign. The localization of the squamous cell carcinoma and the osteoclastic-like giant cells were separate from one another. Immunohistochemically, squamous cell carcinoma was positive for high molecular weight cytokeratin, cytokeratin-5 and p63, whereas the osteloclast-like giant cells were positive for histiocyte marker CD68 and vimentin and negative for epithelial markers supporting a reactive nature of osteoclast-like giant cells to the cutaneous malignancy.

HER2/neu revisited: quality and interpretive issues

BACKGROUND

Immunohistochemistry (IHC) and fluorescence in situ hybridisation (FISH) are the only tests currently approved by the US Food and Drug Administration for classifying which patients will benefit from trastuzumab therapy. The accuracy of these two testing methods can be adversely affected by a variety of pre-analytical, analytical and post-analytical factors. According to the latest published recommendations of the panel of the Joint Committee of the American Society of Clinical Oncology and College of American Pathologists for HER2/neu testing, laboratories performing IHC and FISH for HER2/neu status in breast cancer are now required to have a high concordance of at least 95% between IHC and FISH, significantly higher than that in the published literature.

AIM

To perform a retrospective analysis of the concordance of IHC and FISH analysis for HER2/neu at Singapore General Hospital and review potential causes of disparity between these two methods.

METHOD

A retrospective review of a total of 106 invasive ductal carcinomas evaluated for HER2/neu at the Department of Pathology, Singapore General Hospital between 2007 and 2008 were included in the study. The initial HER2/neu immunostained slides were reviewed independently without knowledge of FISH results, and concordance between IHC and FISH was determined.

RESULTS

Concordance between IHC and FISH assay was excellent and within the published range (104/106=98.1%). The discordant cases represent a well-recognised subset of genetic heterogeneity in HER2/neu, which is known to contribute to positive IHC and negative FISH tests.

Bilateral Transverse Facial Cleft as an Isolated and Asyndromic Deformity

Congenital macrostomia or transverse facial cleft is a rare congenital craniofacial anomaly, which affects the esthetics and functions of oral cavity. It is usually associated with deformities of other structures developed from the first and second branchial arches. Bilateral transverse cleft, occurring alone is uncommon. Since the deformity is rare, its treatment has not been commonly described in the literature. We report a case of congenital bilateral macrostomia as an isolated, asyndromic deformity to add one more case in the literature and surgical technique has been discussed here.

Fixed drug eruptions due to cotrimoxazole

This prospective study on Fixed Drug Eruption (FDE) was carried out between January 2003 to December 2006 in Dermatology department of Mymensingh Medical College Hospital & private chambers. This study was carried out with an objective to see the specific site of involvement and other clinical parameters in FDE due to cotrimoxazole. In each case, a detailed history was taken and a thorough physical examination was done by at least one dermatologist. Patients with suspected FDE, who had consented, were included in the study. Oral re-challenge test was done in each case after written or verbal consent of the patient or legal guardian. For oral re-challenge, usually half of the usual therapeutic dose of the suspected drug (s) was given first and reactions were observed and if no reaction, then full therapeutic dose was given and then again reactions were observed. In case of no reaction to one drug, the next drug was tested after 2 to 7 days. Age & sex distribution, number of attacks of FDE, number of lesions, distribution of sites of involvement were determined in each case of FDE. All informations were recorded in pre-tested data sheet. Among 93 patients of suspected FDE, 61 patients were confirmed as FDE with identified causes, of which 36 cases were due to cotrimoxazole (59.02%). Age range of patients was from 5 years to 65 years with mean of 24.92 years. Male was predominantly affected (M:F=6.2:1). In 50% cases presenting attack was the 2nd attack. Rest 50% had 3 to more than 10 attacks. Number of lesions was: 2-5 lesions in 50%, solitary lesion in 16.67%, 6-10 lesions in 13.89% and more than 10 lesions in 19.44% cases. Sites of involvement in cases of FDE due to cotrimoxazole (n=36) were as follows: lips 58.33%, genitalia 33.33%, oral 13.89%, trunk 38.89%, limbs 55.56%, hands 16.67%, feet 19.44%, face 19.44% and conjunctiva 2.78%.

Delayed replantation of avulsed teeth

Dental injuries are very common and their extent has been classified by Ellis. Avulsion of tooth is a grievous injury and ranges from 1-16% among the traumatic injuries, of which maxillary anterior are commonest. Reimplantation of avulsed teeth is a standard procedure. However, it has certain limitations. Most often their management is very challenging. In this case report we are presenting the management of maxillary incisors by replantation after 36 hrs in a 12 year old girl.

Unusual manifestation of a concurrent demodectic and sarcoptic mange in a Zebu-Friesian cross-bred heifer

We describe a rare case of a concurrent demodectic and sarcoptic mange in a 2-year-old heifer in Khartoum, Sudan. The lesions were massive lumps of granulomatous tumour-like dermatitis with thick, nodular folds mainly covering the head, neck and shoulders. Histopathological examination of the lesions revealed the presence of both Demodex bovis and Sarcoptes scabiei. The animal died regardless of the anti-parasitic treatment it received.

Behavioral effects of acute and chronic triazolam treatments in albino rats

Previous behavioral studies on triazolam (TZ), which are small in number, could only speculate about tolerance to the anxiolytic effect of TZ, as the experiments did not cover sufficient time (of 4 to 7 days) for tolerance to develop. Therefore longer time for chronic TZ administration is used. We investigated the effects of TZ on motor activity and exploratory behavior using plus maze and open field. Three experiments were conducted. In the first, five groups of rats were acutely treated with different doses of TZ (0.25 mg/kg-4.0 mg/kg). In the second set of experiments, rats were treated chronically with a single daily dose of TZ (started with 0.25 mg/kg and increased by time to 1.0 mg/kg) for 5 weeks (representing clinical use). In the third, rats were treated chronically with three daily doses of TZ (started with 0.25 mg/kg and increased by time to 0.5 mg/kg) for 20 days (mimicking drug abuse). Acute TZ administration produced dose dependent anxiolytic effects and a decrease in motor activity with higher doses. Chronically treated rats, either once daily or three times daily doses, showed tolerance to both anxiolytic and sedative effects of TZ. It may be concluded that tolerance to the anxiolytic and sedative effects of TZ would develop after chronic administration either with clinical use or its abuse.

Brain glycine levels in triazolam-treated albino rats

The present study investigates the effects of acute and chronic administration of triazolam in albino rats on glycine levels in different brain areas. Three experiments were conducted. In the first, five groups of rats were acutely treated with different doses of triazolam (0.25 mg/kg-4.0 mg/kg i.p.). In the second experiment, rats were treated chronically by a single daily dose of triazolam (started by 0.25 mg/kg and increased by time to 1.0 mg/kg) for 5 weeks, simulating clinical use. In the third, rats were treated chronically three daily doses of triazolam (started by 0.25 mg/kg and increased by time to 0.5 mg/kg) for 20 days, simulating a form of drug abuse. Brain levels of glycine and plasma levels of triazolam were measured using HPLC technique. The acute triazolam administration produced an increase in glycine levels in almost all brain areas studied. The chronic administration of single daily dose of triazolam produced normal glycine levels in most of the brain areas; this indicates the development of tolerance to glycine content increasing action of triazolam. The chronic administration of three daily doses of triazolam produced a decrease in glycine levels in almost all brain regions studied, which might be a prerequisite for oncoming withdrawal syndrome.

Evolution of hepatitis B virus polymerase gene sequence during famciclovir therapy for chronic hepatitis B

Prolonged administration of nucleoside analogues for chronic hepatitis B may result in the emergence of hepatitis B viral polymerase mutants. To gain insight into the mechanism involved in the virus's resistance to famciclovir, the amino acid sequences of the terminal protein and reverse-transcriptase (RT) domains of the viral polymerase were determined during therapy among 28 patients. The antiviral response was independent of viral genotypes, and nonresponse to famciclovir was associated with a complex variability of the RT domain. No mutation in the YMDD motif was observed, whereas an L528M mutation was clearly selected by famciclovir treatment in 2 patients, as well as 14 novel mutations in 7 patients. Clone sequence analysis of the RT domains of patients undergoing retreatment with famciclovir and/or lamivudine showed the selection of a preexisting drug-resistant mutant in one case and indicated that sequential antiviral therapy may allow the rapid selection of resistant strains.

Effects of acute and chronic triazolam treatments on brain GABA levels in albino rats

The present study investigated the effects of acute and chronic intraperitoneal administration of Triazolam on g-aminobutyric acid (GABA) levels in different brain areas of albino rats. Three experiments were conducted. In the first, five groups of rats were acutely treated with different doses of Triazolam (0.25 mg/kg-4.0 mg/kg). In the second experiment, rats were treated chronically with a single daily dose of Triazolam (started with 0.25 mg/kg and increased by time to 1.0 mg/kg) for 5 weeks, simulating clinical use. In the third, rats were treated chronically with three daily doses of Triazolam (started with 0.25 mg/kg and increased by time to 0.5 mg/kg) for 20 days, representing a form of drug abuse. Brain levels of GABA and plasma levels of Triazolam were measured using high performance liquid chromatography (HPLC). The acute Triazolam administration produced an increase in GABA levels in all brain areas studied. The chronic administration of single daily dose of Triazolam produced normal GABA levels in all brain areas except brain stem where the levels were significantly decreased; this indicates the development of tolerance to Triazolam action on increasing GABA content. The chronic administration of three daily doses of Triazolam produced a decrease in GABA levels in all brain regions studied. In conclusion, chronic single daily dose treatment (representing normal use) produces tolerance to Triazolam effects on brain GABA levels, while chronic three daily doses administration (akin to drug abuse) causes a fall in GABA levels.

TRAM flap perforator ligation and the delay phenomenon: development of an endoscopic/laparoscopic delay procedure

Despite its versatility in breast reconstruction, the TRAM flap is at times subject to ischemic compromise, especially in certain high risk populations. A preoperative delay procedure can decrease the likelihood of TRAM flap failure or fat necrosis, but the required extent of this delay procedure is not clearly defined. In an attempt to augment flap vascularity while reducing surgical dissection and morbidity, six distinct delay procedures and a nondelayed control were compared in a rat TRAM flap model (n = 8 for all groups). An important feature that was incorporated into several groups was the ligation of the contralateral rectus perforators through minimal skin incisions (endoscopic analogy, groups 4 to 7). The most effective delay procedure was the combination of contralateral rectus perforator ligation and ipsilateral dominant pedicle ligation (group 7), which was achieved with two minimal skin incisions and no significant flap undermining. This procedure reduced the flap necrosis from 63.2 +/- 5.8 percent (control) to 13.5 +/- 3.3 percent (p < 0.001). After completion of the animal studies, clinical application of a "minimally invasive" TRAM flap delay procedure was then undertaken in eight high risk patients with only modest ischemic compromise. Although the clinical experience is too early to draw definite conclusions, we feel that "endoscopic delay" has potential as a modality that will increase flap vascularity but minimize the morbidity of the preliminary procedure.

Ribavirin monotherapy in patients with chronic hepatitis C: a retrospective study of 95 patients

Ribavirin is a purine nucleoside that inhibits the replication of a variety of RNA viruses and was shown to have a transient efficacy in chronic hepatitis C during short-term therapy. We have analysed retrospectively its efficacy in 95 patients with liver biopsy-proven chronic hepatitis C. Patients received oral ribavirin (600-1200 mg daily) for a mean duration of 11 months. Alanine aminotransferase (ALT) levels returned to normal values in 38 patients (40%) and decreased by more than 50% in 20 other patients (21%). HCV RNA clearance from serum was observed in seven patients (8%). The biochemical response rate was higher in patients with chronic hepatitis (54%) than in those with cirrhosis (24%) (P = 0.003). Clearance of HCV RNA was observed in 10% of the patients with chronic hepatitis vs 4% of the patients with cirrhosis. In non-responders to interferon (IFN) therapy, ALT levels returned to normal values in 11 (26%) and HCV RNA became negative in one (2%), as compared to 48% and 3%, respectively, in those contraindicated for IFN. In 17 patients in whom paired liver biopsy specimens were available, the histology activity index (HAI) improved in 12. Therapy was generally well tolerated although 11 patients had to stop therapy because of side-effects, which were more common in cirrhotic patients. In conclusion, our results suggest that long-term administration of ribavirin is well tolerated and may be beneficial in controlling the progression of chronic hepatitis C. This may represent an alternative therapy in patients who have contraindications for interferon therapy or as a palliative approach in non-responders to IFN.

Scanning electron microscopy of Diplotriaena obtusa, Henry and Ozoux, 1909 (Nematoda: Diplotriaenidae) from Hirundo saviginii in Egypt

Out of 152 Egyptian swallows, Hirundo saviginii, 24 were found infected by the nematode Diplotriaena obtusa Henry and Ozoux (1909). The worms were collected from the body cavity of the host. Male and female worms were described by light and scanning electron microscopes as a first record of this nematode from Egypt. The specific characteristics of the nematode were defined, including; anterior and posterior extremities, cuticular surface of the body.

A new experimental model: the vascular pedicled cutaneous flap over the mid-dorsum of the rat

The cutaneous vascular anatomy of the mid-dorsum in the rat and its role in flap design was studied in the rat. The investigation consisted of anatomic dissection, methylene blue injection into the axial artery, and flap harvesting in live animals. Dissection and injection revealed that the mid-dorsum of the rat derives its blood supply largely from the 10th intercostal artery, here referred to as the middle dorsal artery, which originates from the lateral aspect of the thoracic aorta. The cutaneous vascular territory of the middle dorsal artery was defined as follows: the medial border, midline of the dorsum; the lateral border, midaxillary line; the cephalic border, a line joining the medial and lateral borders midway between the level of the axilla proximally and 1 cm above the base of the rib cage distally; and the caudal border, a line drawn midway between the latter point proximally and the anterior superior iliac spine distally. Both unilateral and bilateral vascular pedicled island cutaneous flaps were harvested in living rats based on and exceeding the vascular territory delimited by methylene blue injection. Flaps limited to this territory with intact middle dorsal arteries showed total survival, while oversized flaps underwent partial necrosis peripherally. Because of its simplicity, reliability, and consistent vascularity, this flap has potential applications in the study of flap hemodynamics.

Timing, magnitude, and utility of surgical delay in the TRAM flap: I. Animal studies

Surgical delay is an effective technique, but the precise timing of the delay effect and the required extent of the delay procedure are uncertain. We endeavored to study flap survival as a function of the duration of the delay period in a rat transverse rectus abdominis myocutaneous (TRAM) flap model. Two specific delay procedures (limited and extensive) were utilized, and flap survival was assessed after delay periods of 3, 7, 10, 14, 21, and 30 days (n > or = 7, all groups). A delay of 7 days or greater resulted in statistically significant improvement in flap survival in all groups. The delay effect appeared to be maximal at 14 days, and in the extensive delay group, a 14-day delay resulted in statistically greater flap survival than a 7-day delay. Improvement in flap survival was greater when an extensive delay procedure was used. Although the model system has limitations, the rat TRAM flap appears to be a suitable model for the study of the delay phenomenon. Possible clinical correlations are addressed in part II.

Basic aspects of GABA-transmission in alcoholism, with particular reference to GABA-transaminase

Neuronal dysfunction is the neurobiological basis for alcoholic behaviour, and ethanol craving seems related to hypofunction of the GABA-ergic activity. Gamma-aminobutyric acid (GABA) is the major inhibitory neurotransmitter in the central nervous system (CNS). In several studies, GABA has been shown to be an important target of ethanol in the CNS, partly, as a consequence of damage to membrane-bound enzymes and receptors. GABA is involved in mediating pre- and post-synaptic inhibition of neuronal activity. It is speculated that the initial excitatory effects of ethanol may be due to inhibition of GABA-ergic activity whereas the sedative effects of the higher doses may be mediated by the activation of this inhibitory system. In the CNS, GABA is synthesised from glutamic acid by the enzyme glutamate decarboxylase (GAD) and catabolized into succinic semialdehyde by the enzyme GABA-transaminase (GABA-T), which are pyridoxal phosphate (PLP) dependent enzymes. Platelet GABA-T was characterized as being similar to central GABA-T. Inhibition of GABA-T with certain potent and selective compounds markedly increases the levels of brain GABA. Experimentally, acute ethanol treatment does not alter GABA-T activity whereas chronic treatment produces an increase in the activity, though, with some reservations since a bimodal effect has been found in chronically ethanol-treated rats. Thus, as it will be discussed below, it may be suggested that GABA-T inhibitors (e.g. vigabatrin) could have a potential role in the treatment of alcoholism and in some of the problems of ethanol withdrawal and of other drugs of abuse. Related studies on metabolism and concentrations of GABA are also promising and show a greater increase in our understanding of the aetiology and treatment of ethanol dependence and withdrawal. In general, this article also reviews both the animal and clinical observations in the field of alcoholism with regard to the GABA system.

Oxygen radical formation during cytochrome P450-catalyzed cyclosporine metabolism in rat and human liver microsomes at varying hydrogen ion concentrations

The role of pH in uncoupling the electron-flux between oxidoreductase and cytochrome P450 (P450) or P450 and cyclosporine (CyA) and resulting in the generation of oxygen radicals was investigated in vitro in rat and human liver microsomal preparations. Since the electron-flux from NADPH to cytochrome c via oxidoreductase showed a fairly constant reduction activity from pH 7.0-9.5, the generation of oxygen radicals at the level of P450-Cyclosporine (instead of oxidoreductase-P450) was investigated. The effects of increasing pH on oxygen radical formation was measured by the thiobarbituric acid assay (TBA) and the adrenochrome reaction. The trends in oxygen radical production were correlated with benzphetamine metabolism (production of formaldehyde) and CyA metabolism (analyzed by high performance liquid chromatography). The TBA assay showed increased MDA-detected lipid peroxidation (unrelated to autooxidation) at pH < 8.0 and pH > 8.0 (rat and human, respectively) while the adrenochrome reaction showed decreased oxygen radical production. When these results were compared to benzphetamine (a substrate of P450 2B and 3A) metabolism and CyA (a substrate of P450 3A) metabolism, increased metabolism followed the pH-dependent trend of MDA-detected lipid peroxidation. Benzphetamine metabolism with formaldehyde production and depletion of parent compound during CyA metabolism were increased at pH < 8.0 in the rat samples and at pH > 8.0 in the human samples. This parallel relation suggests that the increased metabolism of CyA at lower pH in rats and higher pH in humans may be the result of favorable interactions of P450 with Cyclosporine that also result in increased oxygen radical-related lipid peroxidation.

Fc receptors in liver sinusoidal endothelial cells in NZB/W F1 lupus mice: a histological analysis using soluble immunoglobulin G-immune complexes and a monoclonal antibody (2.4G2)

In systemic lupus erythematosus accompanied by the abnormal appearance of circulating immune complexes (ICs), Fc gamma receptor (FcR)-mediated IC handling in macrophages including Kupffer cells has been shown previously. However, sinusoidal endothelial cells (SECs) largely ingest soluble immunoglobulin (Ig) G-ICs through FcRs. In this study, the character, antigenic expression, and activity (i.e., ligand-binding capacity of SEC FcRs in NZB/NZW F1 lupus and NZW nonautoimmune mice) were immunohistochemically analyzed using monoclonal antibody (MAb) 2.4G2 to FcRs and peroxidase-antiperoxidase IgG as a ligand on cryosections. MAb 2.4G2 stained SECs and blocked the ligand binding of SEC FcRs in both mice strains. The staining intensities with MAb 2.4G2 in SECs and the FcR activities in SECs alone and all sinusoidal cells in both mice strains reached their maximum values at the age of 5 months. Staining intensities in NZB/W F1 were significantly higher at 1 and 2 months and lower at 9 months than those in NZW. The number of Kupffer cells detected by MAb F4/80 to macrophages in both mice strains gradually increased until 5 months, but their number in NZB/W F1 at 9 months was twice as large as that in NZW. In conclusion, SEC FcRs in mice are low-affinity FcRs that react with MAb 2.4G2. The data of FcR activity suggest no impairment of the FcR-mediated IgG-IC binding on SECs in NZB/W F1 in early life.(ABSTRACT TRUNCATED AT 250 WORDS)