Comparing surgical outcomes: Craniotomy versus decompressive craniectomy in acute subdural hematoma - A systematic review and meta-analysis

Introduction

Acute subdural hematomas (SDH) pose a significant health risk, often resulting from traumatic head injuries. The choice between surgical interventions, craniotomy, and decompressive craniectomy, remains a subject of debate. This meta-analysis aims to compare outcomes and guide clinical decision-making.

Methods

Following PRISMA guidelines, a comprehensive literature search was conducted in databases such as Ovid Medline, PubMed, and Cochrane, up to December 2023. Selection criteria included studies comparing craniotomy and decompressive craniectomy for acute SDH. Data extraction utilized the Newcastle-Ottawa Quality Assessment Tool, and statistical analysis employed the random-effects model.

Results

The meta-analysis included 17 studies and 6848 patients. Craniotomy demonstrated a significant reduction in mortality rates (RR 0.80, 95% CI 0.73-0.89, P < 0.0001). GCS scores favored craniotomy for severe cases. GOS outcomes showed a trend favoring craniotomy, particularly in good recovery (RR 1.34, 95% CI 1.04-1.74, P = 0.03). Additional factors explored included co-existing sub-epidural hematoma, mydriasis, extracranial injuries, residual SDH, revision rates, and intracranial pressure.

Conclusion

The meta-analysis suggests that craniotomy may be a favorable surgical strategy for acute SDH, displaying a significant decrease in mortality rates and a lower risk of raised intracranial pressure. However, the nuanced nature of outcomes emphasizes the need for a tailored approach, considering broader clinical contexts. Future research should address limitations and provide a basis for well-informed clinical decision-making.

Japanese encephlu emergence in Australia: the potential population at risk

Japanese encephalitis virus (JEV), an RNA virus transmitted by Culex mosquitoes, primarily cycles between aquatic birds and mosquitoes with pigs as amplifying hosts, posing a significant global encephalitis threat. The emergence and spread of the JEV in new epidemiological regions, such as recent cases in Australia and nonendemic areas like Pune, India, raise significant concerns. With an estimated 68 000 clinical cases and 13 600 to 20 400 deaths annually, JEV poses a substantial global health threat. The virus primarily affects children, with a case-fatality ratio of 20-30% and long-term neurological sequelae in survivors. The changing epidemiology, influenced by factors like bird migration, climate change, and increased urbanization, contributes to the geographic expansion of JEV. The recent outbreaks underscore the potential for the virus to establish itself in nonendemic regions, posing a threat to populations previously considered at low-risk. With limited treatment options and high rates of neurological complications, continued surveillance, traveler vaccination, and research into treatments are crucial to mitigate the impact of JEV on human health. The evolving scenario necessitates proactive measures to prevent and control the spread of the virus in both endemic and newly affected areas.

"Efficacy and safety of oteseconazole in recurrent vulvovaginal candidiasis (RVVC) - A systematic review and meta-analysis"

Background

Recurrent Vulvovaginal Candidiasis (RVVC) is defined as 3 or more episodes of symptomatic Vulvovaginal Candidiasis (VVC) within a year. Out of 75 % of women with VVC, this debilitating infection is experienced by 9 % of women. Although standard guidelines recommend oral and topical fluconazole as its treatment regimen, approval of another drug Oteseconazole has drawn the attention because of its better safety profile and lower recurrence rate by its use.

Aim

The purpose of our Meta-analysis is to evaluate the safety and efficacy of Oteseconazole (Vivjoa) (VT-1161) in the treatment of Recurrent Vulvovaginal Candidiasis (RVVC).

Methodology

Four databases namely PubMed, Google Scholar, Cochrane CENTRAL and Clinical Trial.gov were used from inception till June 2023. Studies that met the predefined inclusion criteria were statistically analyzed on RevMan (Version 5.4). A random effect model was used to pool the studies. A p value of less than 0.05 was considered significant and results were presented as Odds ratio with 95 % Confidence Intervals (CIs).

Result

The pooled analysis of our selected studies showed that Oteseconazole was associated with significantly reduced incidence of Recurrent Vulvovaginal Candidiasis (OR = 0.07; 95 % CI = 0.05-0.11; p < 0.00001, I2 = 0 %) through week 48. Additionally, Vivjoa has also been shown by our analysis to reduce incidence of RVVC through week 24. (OR = 0.05; 95 % CI = 0.03-0.09; p < 0.00001, I2 = 0 %) Furthermore, Oteseconazole was non-significantly associated with developing serious adverse effects during the treatment for Recurrent Vulvovaginal Candidiasis in comparison to the placebo (OR = 0.79; 95 % CI = 0.33-1.89; p = 0.60, I2 = 0 %).

Conclusion

The available evidence suggests Oteseconazole to be safer and more efficacious. However, limited patient population points towards the need of further large and dedicated trials for definitive conclusion.

Emerging autophagic endo-lysosomal targets in the management of Parkinson's disease

Synucleopathies, specifically Parkinson's disease, are still incurable and available therapeutic options are scarce and symptomatic. The autophagy-lysosomal-endosomal system is an indigenous mechanism to manage the proteome. Excess/misfolded protein accumulation activates this system, which degrades the undesired proteins via lysosomes. Cells also eliminate these proteins by releasing them into the extracellular space via exosomes. However, the sutophagy-lysosomal-endosomal system becomes unfunctional in Parkinson's disease and there is accumulation and spread of pathogenic alpha-synuclein. Neuronal degeneration results Owing to pathogenic alpha-synuclein. Thus, the autophagy-lysosomal-endosomal system could be a promising target for neuroprotection. In the present review, we discuss the autophagy-lysosomal-endosomal system as an emerging target for the management of Parkinson's disease. Modulation of these targets associated with the autophagy-lysosomal-endosomal system can aid in clearing pathogenic alpha-synuclein and prevent the degeneration of neurons.

Revolutionising Impacts of Artificial Intelligence on Health Care System and Its Related Medical In-Transparencies

The application of artificial intelligence (AI) in the field of medicine has revolutionised various sectors of the health care system, including robotics surgery, biotechnology, pharmaceutical, evidence-based medicine and advanced research and transplantation techniques. By offering improved 3D imagery of the various organs involved in surgery and perfectly minimising the chances of error, AI aid made complicated surgical procedures more efficient and highly effective, requiring less hands-on. Further, the AI tool helps plastic surgery and aesthetic surgeons in anticipating prognostic surgical markers and post-operative consequences. In addition to enhancing accurate and rapid diagnosis, AI has played a pivotal role in the development and discovery of new drugs. Nevertheless, the application of AI in health care also raises significant challenges and concerns. Incorrect drug recommendations, failure to identify tumours and lesions on imaging modalities and potential bias in data entry and its automatic can risk the life of patients on a large scale. Additionally, breaching patient data privacy may raise concerns about cybersecurity issues, further compromised by growing dependency on AI which can result in massive unemployment. In short, AI has played a pivotal role in health care; however, addressing the in-transparencies is critical to ensure safe, ethical and more effective implementation in the dynamic field of medicine.

Tirzepatide (Mounjaro) - a novel Pharmacotherapeutic Agent for Obesity

Obesity and its consequential morbidities are a major global burden. with Pakistan having a national obesity risk of  6.5/10.(1) Raised BMI (body mass index-an index of weight to height ratio) along with obesity is one  the  prime risk factors that lead to numerous other non-transmissible diseases like heart diseases, Type 2 diabetes, osteoarthritis and certain carcinomas (Breast, ovarian, colon, liver, prostate, gall bladder). Lifestyle interventions can only produce modest (~5-10%) weight loss, necessitating other antiobesity interventions. Therefore, pharmacological approaches to losing weight are in the limelight. The  U.S. (FDA) Food and Drug Administration has also authorized pharmacological treatment as a new treatment option to incorporate into weight management programme with concomitant dietary and physical behavioral remodeling in patients having 27 kg/m2 or higher BMI along with incidence of any of the following obesity-related comorbidities: T2DM, hypertension, or hypercholesterolemia (2).As of 2021 around 5 antiobesity  medications (AOMs) have been approved by FDA so far but a recent randomized,  placebo controlled double blind trial has incredibly unveiled the potential effects of tirzepatide as an antiobesity drug. Tirzepatide (Mounjaro) is an exclusive and the only dual receptor agonist the mimicking actions of glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) and therefore referred as “twincretin”. This drug, originally used to treat T2DM, has now been incredibly effective in treating obesity. According to a recent randomized control trial, 85% of participants with a 5.0 mg dose, 89% participants with a 10 mg dose and 91% participants with a  15 mg dose showed a significant reduction in weight(3) which is a corroborating evidence supporting tirzepatide as antiobesity drug. According to SURPASS-2 clinical trial, comparing efficacy of tirzepatide to semaglutide (a selective GLP-1 receptor agonist), tirzepatide was proven to reduce body weight and A1C levels more effectively than semaglutide demonstrating it to be better in treating not only diabetes but obesity(4). The SURMOUNT-1 trial, depicting the efficacy of tirzepatide, showed significant weight reduction of up to 22.5 % in obese adults (5) Some of the adverse effects noted with its use were gastrointestinal events like nausea, vomiting and diarrhea. A few contraindications are gallbladder disease, pancreatitis, genetic predisposition of medullary thyroid carcinoma and MEN (multiple endocrine neoplasia) Type 2. ---Continue

Beating Corona Virus Disease (COVID-19) in Newborns, Infants and Toddlers

Madam, Corona Virus Disease (COVID-19), a pandemic, has been a global concern and it is a highly contagious respiratory illness that has been fatal to around 6 million lives. Although everyone is prone to get infected by COVID-19, the fact that is often overlooked is that newborns, infants and toddlers are as likely to get COVID-19 as adults. Babies  younger  than one year old might have a  higher chance to get COVID-19 than older children. (1) According to a case report by Alzamora et al. mother infected with COVID-19 can also, in sporadic  cases, pass the disease to her baby. (2) Infants are also at risk of getting infected shortly after birth, reason being exposure to sick caregivers.  Most newborn, infants and toddlers who fall prey to COVID-19 have mild or no symptoms engendering many new cases, but serious cases have also occurred leading to hospitalization. Hospitalization is associated more with the omicron variant than the delta variant. According to Morbidity and Mortality Weekly Report (MMWR) by the Centrs for Disease Control and Prevention (CDC), hospitalization of U.S. infants and children aged 0-4 years was five times more during omicron predominance than during delta surge. (3) To overcome such cases, CDC recommends COVID-19 vaccine and backs Pfizer’s and Moderna’s COVID-19 shots for children aged six month to five years. (4) These vaccines can prevent complications like Multisystem Inflammatory Syndrome and Long COVID, which can be debilitating for young children. Vaccination can also protect children, which in turn minimize the possibility of transmission of disease to others. Furthermore, U.S. Food and Drug Administration (FDA) has also expanded the approval of the COVID-19 treatment Velkury (Remdesivir) to include pediatric patients 28 days of age and older weighing at least 3 kilograms with positive results of direct SARS-CoV-2 viral testing. (5) With COVID-19 rearing its head again in Pakistan, vaccination of vulnerable populations like newborns, infants and toddlers must be an urgent step to stem the spread of virus because tomorrow may be too late. Besides, Remdesivir, which was previously approved for certain adults, can now be put to good use for treating infants as young as 28 days old so that progression in hospitalization and critical illness in pediatric patients of Pakistan be cut down.

Understanding administrative abdominal aortic aneurysm mortality data

OBJECTIVE

Administrative data in the form of Hospital Episode Statistics (HES) and the Scottish Morbidity Record (SMR) have been used to describe surgical activity. These data have also been used to compare outcomes from different hospitals and regions, and to corroborate data submitted to national audits and registries. The aim of this observational study was to examine the completeness and accuracy of administrative data relating to abdominal aortic aneurysm (AAA) repair.

METHODS

Administrative data (SMR-01 returns) from a single health board relating to AAA repair were requested (September 2007 to August 2012). A complete list of validated procedures; termed the reference data set was compiled from all available sources (clinical and administrative). For each patient episode electronic health records were scrutinised to confirm urgency of admission, diagnosis, and operative repair. The 30-day mortality was recorded. The reference data set was used to systematically validate the SMR-01 returns.

RESULTS

The reference data set contained 608 verified procedures. SMR-01 returns identified 2433 episodes of care (1724 patients) in which a discharge diagnosis included AAA. This included 574 operative repairs. There were 34 missing cases (5.6%) from SMR-01 returns; nine of these patients died within 30 days of the index procedure. Omission of these cases made a statistically significant improvement to perceived 30-day mortality (p < .05, chi-square test). If inconsistent SMR-01 data (in terms of ICD-10 and OPCS-4 codes) were excluded only 81.9% of operative repairs were correctly identified and only 30.9% of deaths were captured.

DISCUSSION

The SMR-01 returns contain multiple errors. There also appears to be a systematic bias that reduces apparent 30-day mortality. Using these data alone to describe or compare activity or outcomes must be done with caution.

Colonic perforation secondary to migrated biliary stent. Case report of an unusual complication, and literature review

Endoscopic stents are widely used to facilitate biliary drainage in hepatic, biliary and pancreatic conditions. Migration of the stent is a potentially serious complication. We report a case of migration of a biliary stent to the sigmoid colon at which point the stent perforated the colon and become lodged subcutaneously. The patient was managed successfully by local exploration to retrieve the stent without bowel resection. We also review the literature on complications caused by migrated biliary stents.

Duodenal Dieulafoy's Lesion: A Case Report

Dieulafoy's lesion is an uncommon but important cause of recurrent upper gastrointestinal bleeding. Extragastric location of Dieulafoy's lesion is extremely rare. We report a case of upper gastrointestinal haemorrhage due to Dieulafoy's lesion of the duodenum and discuss the management of this extremely uncommon entity.

Outcome of adult acute lymphoblastic leukemia: a single center experience

OBJECTIVE

To study the outcomes of adult patients with acute lymphoblastic leukemia.

SETTING

Tertiary care hospital.

STUDY DESIGN

Retrospective analysis.

METHODS

Fifty eight adult patients (age >14 years) diagnosed as cases of acute lymphoblastic leukemia were studied with respect to their clinical, morphological and immunopathological features at presentation and their relationship with treatment outcomes.

RESULTS

Forty five (77.5%) of the patients belonged to younger age group with male preponderance. The median age was 20 years and mean age was 25.1 years. Male to female ratio was 3:1. Common presenting signs were lymphadenopathy (17.2%), hepatomegaly (32.7%) and splenomegaly (62%). Laboratory features at presentation revealed: hemoglobin > or = 10 gm/dl in 18 (31%), WBC >50 x 10E9 / L in 18 (31%), LDH more than 1000 IU/L in 44 (75.8%) of patients. Morphology revealed that FAB L1 was seen in 21(37.2%) and L2 in 62 (32.7%). Immunophenotyping showed that 26 (61.9%) were early pre-B ALL, 6 (14.2%) were pre-B ALL and T-ALL were 10 (23.8%). Univariate analysis showed age more than 30 years, male gender, total leucocyte count >50 x 10(9)/L and hemoglobin more than 10 gm/dl to be risk factors for poor outcome. Multivariate analysis revealed age more than 30 years, male sex and total leucocyte count > 50 x 10(9)/L are independent risk factors for poor survival. Patients were treated according to the MRCUKX and XII adult protocols. Thirteen (22.4%) patients died during induction therapy secondary to sepsis and progressive disease whereas 42 (72.4%) patients achieved complete remission. Median survival was 18.6 months and 42% patients were alive at 5-years.

CONCLUSION

Overall survival and disease free survival were comparable to those reported in literature. However, age more than 30 years, male gender and total leucocyte count >50 x 10(9)/L had an adverse impact on overall survival.

Male breast cancer

OBJECTIVE

To review cases of male breast cancer.

SETTINGS

Histopathology Section, Department of Pathology, The Aga Khan University, Karachi.

METHOD

Fifty one cases of male breast cancer specimens, received during a period of 10 years, routinely processed and stained with Haematoxylin and Eosin were analyzed. Special stains and Immunohistochemistry were used in difficult cases.

RESULTS

Male breast cancer affected individuals in the sixth and seventh decades of life with a mean age of 56.2 years. Infiltrating ductal carcinoma (IDC) was the predominant type. Skin involvement was seen in 27.45% of the cases. Breast lump was the most common presenting symptom followed by skin ulceration. At the time of presentation 43.13% patients had a tumour size of more than 3 cm.

CONCLUSION

Male breast cancer is a rare disease. Most of our findings correspond to the published local and international data.

Clinical, pathological and molecular factors predicting axillary node involvement in primary breast cancer in Pakistani women

BACKGROUND

Axillary lymph node involvement in primary breast cancer is one of its most important prognostic features. Thus any factors that may predict axillary lymph node involvement in this setting could be potentially helpful in treatment planning and other interventions.

OBJECTIVE

The objective of this study was to evaluate clinical, pathological and immuno-histochemical markers in univariate and multivariate analysis, which may be helpful predictors of axillary lymph node involvement in breast cancer.

METHOD

A retrospective analysis of 555 cases. Of these 58% had axillary nodal positivity and 42% were negative.

CONCLUSION

Factors of no significance included patient's age, height, weight, age of first pregnancy, parity, marital status, menopausal status, family history of breast cancer, side of tumor. In univariate analysis the age of menarche, duration of symptoms, tumor size, site in outer quadrant, S phase and skin and nipple involvement all predicted axillary nodal involvement. The length of breast-feeding, increased intraductal component and increased PCNA were inversely proportional to nodal involvement. In multiple regression analysis however only size of the tumor, involvement of the skin and nipple and disease in the outer quadrant of breast were the factors, which assumed significance.

Lack of benefit of granulocyte macrophage or granulocyte colony stimulating factor in patients with febrile neutropenia

OBJECTIVES

To compare the clinical benefits of granulocyte-colony stimulating factor (G-CSF) or granulocyte macrophage-colony stimulating factor (GM-CSF) plus standard supportive care to supportive care alone among cancer patients with febrile neutropenia.

METHODS

Clinical data were collected retrospectively from 148 consecutive cancer patients with neutropenia and fever. Patients had hematologic (i.e., acute leukemias or lymphoproliferative disorders) or non-hematologic malignancies (i.e., solid tumors including carcinoma of breast, lung, or colon). Clinical variables analyzed included: age and sex; underlying malignancies; chemotherapy regimens; symptoms at time of presentation; duration of fever prior to study enrollment; days from chemotherapy until administration of GM-CSF or G-CSF; number of previous neutropenic episodes; duration of fever and day of defervescence; absolute neutrophil count on day of defervescence; duration of neutropenia; number and types of antibiotics used; day amphotericin B begun; number of culture-documented infective episodes involving bloodstream, lung, pleura, urinary tract, gastrointestinal tract, intravenous cannulae, or skin; types of antimicrobial isolates; cost of cytokine therapy; length of hospital stay and clinical outcome.

RESULTS

The use of myeloid growth factors increased the number of circulating peripheral white blood cells, but no significant effect was noted in terms of duration of neutropenia or fever, number of culture-proven infections (except pneumonia; p < 0.04), length of hospital stay, or survival.

CONCLUSION

In areas with limited health care resources, expensive treatment with GM-CSF or G-CSF should be reserved for patients with complicated febrile neutropenia where the expected risk of infection is high and the duration of neutropenia is prolonged, or those with documented infections that are refractory to antibiotic treatment.

Complications of in-dwelling venous access devices: a single institution experience

OBJECTIVE

To determine the complications of venous access devices (VADs) in cancer patients.

SETTING

Retrospective study in a tertiary referral center with specialist hematology and oncology services.

SUBJECTS

First one hundred consecutive patients who were implanted a VAD. All patients had an underlying cancer and the devices were inserted by the same surgeon. The duration of use of VADs and causes of their premature removal were noted.

RESULTS

One hundred VADs (55 port-a-caths and 45 Hickman's lines) were inserted in a total of 89 patients over a 7.5 year period. Majority of patients had acute myeloid leukemia (22) gastrointestinal malignancies (20) breast cancer (19) and genito-urinary cancers (15). The mean duration of use was 110 days; 157 days for the port-a-cath and 53 days for the Hickman's line. Nineteen devices (10 port-a-caths and 9 Hickman's lines) had to be removed prematurely. Two Hickman's lines got removed accidentally. The causes of premature removal included device failure (9), exist site infection (4), luminal infection (3) and tunnel infection (3).

CONCLUSION

The mean duration of use and the complication rates are comparable with studies reported in the literature.

Nitric oxide inhibitors ameliorate indomethacin-induced enteropathy in rats

The role of nitric oxide (NO) synthase inhibitors in indomethacin (INDO) -induced enteropathy was investigated in male Sprague-Dawley rats. Rats were subcutaneously administered 5% sodium bicarbonate (controls), two doses of INDO 7.5 mg/kg, and three different inducible NO synthase (iNOS) inhibitors at various concentrations 24 hr, apart; aminoguanidine (AG), guanidinoethyldisulfide (GED), and n-(3-aminomethyl)benzylacetamidine (1400W). Rats were killed four days after the initial injection and small intestinal mucosa was assayed for myeloperoxidase (MPO) activity and iNOS expression by western blot analysis. Serum nitrite/nitrate (NOx) concentration was measured colorimetrically. INDO produced acute ulcers along the mesenteric border from the ileum to proximal jejunum. Rats treated with AG (25 and 50 mg/kg), GED (2.5 mg/kg), and 1400W (0.1 mg/kg) showed decreased total ulcer length and MPO activity by 51, 72, 53, and 61% and by 58, 88, 68, and 70%, respectively, compared to INDO alone. All inhibitors similarly reduced INDO-enhanced serum NOx concentrations to its basal levels. Significant iNOS expression was detected in INDO-treated rats, but the inhibitors did not alter iNOS expression. Our data suggest that NO derived from iNOS may be a key factor in the pathogenesis of acute INDO-induced enteropathy in rats.

Radiological features of hepatocellular carcinoma in Southern Pakistan

We describe the radiological features of 201 patients diagnosed as having hepatocellular carcinoma (HCC) in Southern Pakistan. The cases of biopsy-proven HCC were analysed retrospectively for years 1994-1998. Age, sex, underlying cirrhosis, hepatitis markers, and radiological description were recorded. The mean age was 56 years. There were 149 males and 52 females. 82% patients had underlying cirrhosis. The tumour size was measured in at least two dimensions, and the maximum mean tumour size at the time of diagnosis was 8.3 +/- 4.0 cm. Of the tumours 79.5% were more than 5 cm; 56% of primary HCC were multifocal; 51% involved the right lobe only; 15% involved the left lobe; 34% involved both lobes of liver. Portal vein thrombosis was detectable in 17%. There were no significant differences in the radiological patterns amongst patients who had hepatitis B virus related and hepatitis C virus-related HCC except for age.

Lack of correlation between alpha-fetoprotein and tumor size in hepatocellular carcinoma

OBJECTIVE

To determine whether there was a correlation between tumor size and alpha feto-protein (alpha-FP) levels in hepatocellular carcinoma.

SETTING

Retrospective study in tertiary referral center with specialist Oncology services in Southern Pakistan.

SUBJECTS

Consecutive patients with biopsy-proven hepatocellular carcinoma diagnosed between January 1994 and June 1998.

MAIN OUTCOME MEASURES

Correlation between alpha-FP levels and maximum tumor diameter.

RESULTS

The mean tumor size was 8.3 +/- 4.2 cm. The mean alpha-FP level was 17,027 ng/ml. Twenty four percent patients had an alpha-FP level which was within the normal limits (< 10 ng/ml). There was no correlation between tumor size and alpha-FP levels (r = -0.155; p = 0.129).

CONCLUSION

There was no correlation between the tumor size and alpha-FP levels.

A survival analysis of metastatic breast cancer in Pakistani patients

OBJECTIVE

To determine the overall survival of metastatic breast cancer in the Pakistani patients and compare it with published information.

METHOD

The design was a retrospective analysis of metastatic breast cancer patients from breast cancer database. A total of 137 patient based information was available for review and analysis.

RESULTS

An overall median survival of 2.83 years was noted in metastatic breast cancer patients.

CONCLUSION

This survival figure in this study compares favorably to those published in the literature.

DNA ploidy analyses in 218 consecutive Pakistani breast cancer patients: does it add anything?

An analysis was made to evaluate the significance of DNA ploidy in the biology and prognosis of breast carcinoma. This was done by estimating the correlation of DNA ploidy with other established prognostic markers of breast cancer, namely tumor size, tumor grade, lymph node metastasis and S-phase fraction. From 1995 up to year 2000 ploidy analysis was performed on 218 consecutive cases of infiltrating breast carcinoma by flow cytometry using formalin fixed paraffin embedded material. From the laboratory record, data regarding other pathological variables was retrieved. No correlation could be found between DNA ploidy and tumor grade, nor could there be found a correlation with tumor size. For lymph node metastasis there was a significant difference between the proportion of aneuploids and diploids having metastasis in more than 4 lymph nodes. However, no significant difference was found in axillary lymph node positive and negative groups when number of positive lymph nodes was not taken into account. The mean value of S-phase fraction for the aneuploids and the diploids was also insignificantly different. In conclusion DNA ploidy alone did not add much to predict tumor behaviour in terms of known pathologic variables.

Pain on intramuscular injection of bupivacaine, ropivacaine, with and without dexamethasone

BACKGROUND AND OBJECTIVES

We wished to determine which long-acting local anesthetic would produce the least pain on injection for treatment of myofascial pain disorders. We compared the pain on intramuscular injection of bupivacaine, ropivacaine, bupivacaine with dexamethasone, ropivacaine with dexamethasone, and needle placement alone.

METHODS

Thirty volunteers received 5 injections each: (1) needle only, (2) bupivacaine 0.5%, (3) ropivacaine 0.5%, (4) bupivacaine 0.5% with dexamethasone 0.13 mg/mL, and (5) ropivacaine 0.5% with dexamethasone 0.13 mg/mL. The injections were made in the volunteers' upper trapezius muscles; there was a 15-minute interval between injections. The sequence of injections was randomized by Latin square design. The intensity of pain was rated on a 0 to 10 cm visual analogue scale (VAS) score. Neither the investigator nor the volunteer was aware of the nature of the injectate. The pH of the injected solutions was checked to determine if differences in the intensity of pain on injection were due to differences in the pH of the solutions.

RESULTS

The VAS pain scores were 3.1 +/- 2.4 for needle only, 4.4 +/- 2.8 for bupivacaine, 2.5 +/- 2.0 for ropivacaine, 4.7 +/- 2.7 for bupivacaine/dexamethasone, and 3.7 +/- 2.2 for ropivacaine/dexamethasone. The pain on injection of ropivacaine was significantly less than the pain on injection of bupivacaine or bupivacaine/dexamethasone. The pH values of the solutions were as follows: (1) bupivacaine, 5.50; (2) ropivacaine, 5.57; (3) bupivacaine/dexamethasone, 6.64; and (4) ropivacaine/dexamethasone, 6.60.

CONCLUSIONS

The pain on intramuscular injection of bupivacaine is significantly more intense than with ropivacaine. The difference in the intensity of the pain on injection between bupivacaine and ropivacaine does not appear to be related to differences in pH. The results of our study have implications on the choice of the local anesthetic used in trigger point injections.

The histopathology of routine tonsillectomy specimens: results of a study and review of literature

Controversy continues to attend the routine histologic examination of tonsillectomy specimens. We performed a retrospective evaluation of 400 tonsil specimens removed from 200 patients. We found that 68.3% of the specimens contained reactive lymphoid hyperplasia, 13.5% had follicular hyperplasia, 10.0% represented acute or chronic tonsillitis, and 7.5% were normal. Only one case of malignancy was detected: a non-Hodgkin's lymphoma in one tonsil of a patient who was a cigarette smoker and who had asymmetric tonsils. The results of our study, taken in combination with data already published in the literature, indicate that routine histologic examination of tonsillectomy specimens is unnecessary and results only in added costs and a loss of man-hours. However, in patients who have certain preoperative risk factors, a histopathologic evaluation of tonsillar specimens remains mandatory.

Increased levels of multiple forms of dihydrofolate reductase in peripheral blood leucocytes of cancer patients receiving haematopoietic colony-stimulating factors: interim analysis

The precise mechanism whereby granulocytes proliferate when haematopoietic colony stimulating factors (CSFs) are used in neutropenic cancer patients is poorly understood. The purpose of this study was to investigate whether these cytokines bring about leucocyte proliferation by increasing the levels of multiple forms of dihydrofolate reductase (DHFR). Blood samples were collected from 36 cancer patients (25 males and 11 females) with chemotherapy-induced neutropenia. One sample of blood from each patient was obtained before therapy either with CSF, such as granulocyte colony stimulating factor (G-CSF) and granulocyte-macrophage colony stimulating factor (GM-CSF) or with placebo, and another one at the time of resolution of neutropenia. Peripheral blood leucocytes in these blood samples were counted, separated and lysed. From lysates, cytoplasmic samples were prepared and analyzed for active DHFR by a methotrexate-binding assay and for total immunoreactive DHFR by an enzyme linked immunosorbent assay. The increase in total leucocyte count (TLC) was most prominent (P < 0.005) in the CSF group and less so (P < 0.05) in the placebo group. The mean +/- SD concentration values of active DHFR before and after stimulation with GM-CSF found were to be 0.34 +/- 0.4 ng/mg protein and 0.99 +/- 0.82 ng/mg protein, respectively, and in the group treated with G-CSF, 0.24 +/- 0.32 ng/mg protein and 1.18 +/- 2.4 ng/mg protein, respectively. This increase in active DHFR after stimulation with CSF was statistically significant (P < 0.05). Similarly, concentration values of immunoreactive but nonfunctional form of DHFR (IRE) were 110 +/- 97 ng/mg protein and 605 +/- 475 ng/mg protein before and after stimulation with GM-CSF, and 115 +/- 165 ng/mg protein and 1,054 +/- 1,095 ng/ mg protein before and after stimulation with G-CSF. This increase in concentration of IRE after stimulation with GM-CSF or G-CSF was statistically significant (P < 0.005). In the control group, there was an increase in the concentration of both active DHFR and IRE after treatment with placebo. However, this was not statistically significant. Resolution of neutropenia was quicker in the groups treated with CSF compared to the control group. Results of this study indicate that colony stimulating factors (G-CSF and GM-CSF) induce white cell proliferation by increasing the levels of multiple forms of DHFR.

The clinical pattern of HER-2/neu oncogene overexpressing breast cancer in Pakistani patients at initial presentation: an analysis of HER-2/neu positive versus negative disease--a preliminary report

BACKGROUND

HER 2/new oncogene is an important prognostic marker in Breast Cancer and has implications in therapy planning.

OBJECTIVE

To describe the clinical features of HER 2/new positive and negative Breast Cancer in the Pakistani patient population and note clinical differences between the two groups if any.

DESIGN

A retrospective analysis of Breast Cancer cases at the Aga Khan University, Hospital.

METHOD

Immunochemical staining on formation fixed paraffin embedded tissue using oxidase antiperoxidase method. A total of 152 Breast cancer tissue samples were tested for HER-2/neu gene presence. Of these 43 (39%) samples tested positive and 109 (61%) tested negative. A comparison of the two groups revealed that only a few factors tested for either significance or borderline statistical significance between the two groups. These factors included the estrogen receptor status and the number of lymph nodes involved in the axilla. The progesterone receptor status was of borderline significance.

CONCLUSION

Given the large number of factors tested it appears that there is no consistent defining feature which helps to separate HER-2/neu positive versus HER-2/neu negative cases with Breast Cancer.

Spectrum of Hodgkin's disease in children and adults: impact of combined morphologic and phenotypic approach for exclusion of "look-alikes"

OBJECTIVE

To determine the prevalence of Hodgkin's disease (HD) and its various subtypes in children and adults and assess the use of immunohistochemical (IHC) studies in confirming HD cases and excluding its close mimicries/look-alikes.

MATERIAL AND METHODS

All 265 Hodgkin's disease cases diagnosed at The Aga Khan University Hospital, Karachi over the last 6 years (July 1991-July 1997) were included. Of these 219 were diagnosed on routine H&E examination while in the remaining 46 cases, diagnosis was made after a thorough IHC workup. (This group initially included 161 cases labelled as lymphoproliferative disorder with HD as one of the differentials).

RESULTS

Out of a total of 265 HD cases (206) 78% were males and (59) 22% were females in a ratio of 3.5:1.26% (69) cases were < 15 years while 74% (196) were > 15 years old. In both age groups, the commonest subtype proved to be Mixed Cellularity (MC) (60% of < 15 years old and 40% of > 15 years old) followed by Nodular Sclerosing (NS) (20% of < 15 years old and 27% of > 15 years old). Lymphocyte Predominant (LP) and Lymphocyte Depleted (LD) were seen less frequently. With the help of IHC studies performed on 161 cases in which HD was part of the differential diagnosis, 46 were conclusively diagnosed as HD. In the rest of the cases the main different was Non-Hodgkin's Lymphoma (NHL) that accounted for 72 of the cases.

CONCLUSION

This study shows that the most common sub-type of HD in our series in MC followed by NS. This study also suggests reasons why the more aggressive sub-type MC is predominant in Third world countries like ours compared to the better prognostic NS seen more in developed countries and why LP and LD are less and less commonly diagnosed.

The spectrum of bacterial infections in febrile neutropenic patients: effect on empiric antibiotic therapy

The aim of this retrospective analysis was to look at the spectrum of bacterial isolates and their resistance patterns to the commonly used antibiotics in the setting of febrile neutropenia. A total of 127 bacteria were isolated from patients with acute leukemias, lymphoproliferative disorders, aplastic anaemia and various solid tumours. Fifty-four percent organisms were gram negative; while the rest were gram positive. E. coli, pseudomonas aeruginosa, staphylococcus aureus, enterococcus and streptococci were the commonly isolated organisms. Forty-eight percent organisms were isolated from blood, 16% from urine, 13% from wounds and superficial abscesses and 11% from respiratory tract. E. coli exhibited a great degree of resistance to the commonly used antibiotics, such as pipericillin (70%), ofloxacin (50%) and aztreonam (50%). Pseudomonas and klebsiella also showed varying degree of resistance against the antibiotics. Staphylococcus aureus and staphylococcus epidermidis were almost universally resistant to penicillin and showed a variable degree of resistance to other antibiotics too. Compared to the previous reports, the pattern of bacterial isolates and their resistance to antibiotics has changed over the past years. Aminoglycosides and third generation cephalosporins seem to be the choice of antibiotics for the upfront management of febrile neutropenic patients.

Bacterial isolates from neutropenic febrile pediatric patients and their sensitivity patterns to antibiotics

Patients on cytotoxic therapy often develop neutropenia and fever. Our interest was to identify the common pathogens isolated from such patients and to study the sensitivity patterns of these organisms to the antibiotics used in their treatment. Thus, guidelines can be established by hospitals to identify which antibiotics can be used in the treatment of these patients when the results of cultures and sensitivities are not available. We conducted a retrospective study of neutropenic pediatrics presenting to AKUH from July, 1990 to June, 1996. A total of 153 isolates in 35 different patients were studied. Samples for culture were taken from the sites at risk. The majority of samples consisted of blood, stool, pus and urine. Twenty stool samples were also sent for microscopy. Malignancies were both hematological and non-hematological. Gram negatives were isolated in 52.9%, gram positives in 33.9% and parasites in 13.2%. Salmonella paratyphi B was the most commonly isolated organism, followed by Pseudomonas aeroginosa, Giardia lamblia was the most common parasite. Sensitivity patterns of these organisms to antibiotics studied showed that Escheria coli had the lowest sensitivity rate being only 40% sensitive to Aztreonam and 64% sensitive to Ofloxacillin. A comparison was made between our findings and those reported in literature, as well as the risk factors for developing neutropenia. A guide to management is also discussed.

Effect of chronic peritoneal fluid eosinophilia on peritoneal membrane function

This study was undertaken to evaluate the effects of long-term persistent peritoneal fluid eosinophilia on the peritoneal membrane as reflected by a change in dialysis function. This was a prospective study undertaken at a community-based peritoneal dialysis unit, where thirty-one patients were enrolled over a 9-month period. Chronic, long-term peritoneal fluid eosinophilia was noted in 12/31 (38.7%) patients. Significant differences were not noted between values of creatinine clearance, D/P urea and Kt/V, compared to their baseline values. This study shows that long-term peritoneal fluid eosinophilia does not significantly affect peritoneal membrane function in patients on maintenance peritoneal dialysis.

Hepatitis A and cytomegalovirus infection precipitating acute hemolysis in glucose-6-phosphate dehydrogenase deficiency

A 34-year-old man presented with acute hemolytic anemia secondary to acute viral hepatitis A and a coexisting acute cytomegalovirus infection. This association has not been described previously in patients with glucose-6-phosphate dehydrogenase deficiency and is the subject of this report.

Doxorubicin cardiomyopathy in lung cancer patients

Doxorubicin is cardiotoxic and its use must be monitored carefully. Incidence of refractory cardiac failure is shown to increase once the cumulative dose exceeds 450 mg/m2. However, significant decline of ejection fraction (EF) may occur even at lower dose levels. EF was monitored using Multigated Radionuclide Angiography (MUGA) scan of all consecutive lung cancer patients, treated with Doxorubicin based regimens. Thirteen of 82 patients showed a significant (more than 15%) decline of left ventricular EF. The dose of doxorubicin producing this decline ranged between 91-180 mg/m2. Actual decline in EF ranged between 16-45%. Only 5 of 13 patients developed symptoms attributable to the cardiac disease. Doxorubicin can alter EF significantly in lung cancer patients at levels well below which are considered 'safe'. The reason for massive decline in ejection fraction in these patients has been hypothesized.

Ultrastructure of the May-Hegglin anomaly

Ultrastructural features of the leucocytes in two patients suffering from the May-Hegglin anomaly were studied using electron microscopy. In both the cases, electron dense material parallel to the long axis of the inclusions were noted. Platelet ultrastructure was normal. A review of the literature indicates that the May-Hegglin anomaly is a heterogeneous condition both ultrastructurally and clinically.

Epidemiology of blood-borne viruses: a study of healthy blood donors in Southern Pakistan

There are only a few published reports regarding the prevalence of hepatitis B virus, hepatitis C virus and human immunodeficiency virus in Pakistani blood donors. The true extent of the prevalence of these viral infections in healthy adults in unclear. We examined blood donors attending the Aga Khan University Hospital and blood donation camps in the cities of Karachi and Hyderabad, Pakistan for the presence of hepatitis B surface antigen (HBsAg), antibodies to hepatitis C virus (anti-HCV) and human immunodeficiency virus (anti-HIV). Relationship of anti HCV to the surrogate marker alanine aminotransferase (ALT) was also examined. Prevalence of HBsAg was found to be 2.28% (1,173/51,257), anti HCV was 1.18%(198/16,705) and that of anti HIV to be 0.02% (10/51,257). Higher rate of prevalence of HBsAg and anti HCV was observed in the younger age group of 21 to 30 years. Male to female ratio for HBsAg was 2.5:1 and for anti HCV 1:1. Seropositivity for HBsAg was significantly greater than anti HCV (p < 0.0001). No clear relationship was found between high ALT (>55 U/l) and anti HCV positivity. Further examination of seropositive samples for HIV revealed only one donor to be positive by Western blot also. Prevalence of hepatitis B and C in the adult blood donor population in Southern Pakistan is higher than western countries but is similar to regional countries. This study also suggested that high ALT is not a useful surrogate marker for hepatitis C virus. Prevalence of HIV in this donor population is very low and is comparable to the western countries.

A pilot study of chronic recombinant interferon-alfa 2a for diabetic proliferative retinopathy: metabolic effects and opthalmologic effects

The objective of this study was to evaluate the metabolic effects and opthalmologic effects of alpha-interferon therapy in diabetes mellitus patients with proliferative diabetic retinopathy (PDR). Three volunteer patients [insulin-dependent diabetes mellitus (IDDM), insulin requiring non-insulin-dependent diabetes mellitus (NIDDM), and maturity onset diabetes of the young (MODY)] threatened with blindness due to progressive PDR were treated with alpha interferon for 4 months and were evaluated at intervals of 1-2 weeks to monitor the drug effects on carbohydrate tolerance and possible beneficial therapeutic effects on the preexisting PDR. Metabolic studies included basal and postsustacal glucose, c-peptide and glucagon, fasting serum cortisol, free fatty acids, growth hormone, insulin-like growth factor-1, and urinary microalbumin excretion. Ophthalmologic studies included visual acuity, slit lamp examination, gonioscopy, fluorescein angiography, and standard colored fundus photographs. In all subjects, hyperglycemia worsened with duration of increasing dosage of interferon therapy, requiring progressively higher daily insulin requirements of 17%-68% above pretreatment values. Lowered levels of stimulated C-peptide were observed in the NIDDM and MODY subjects. The counterregulatory hormones (cortisol, growth hormone, and glucagon) were elevated during the 4 months of interferon therapy. In all subjects, visual acuity appeared to stabilize. No new retinal hemorrhages occurred during the 4 months of interferon administration, although all subjects experienced hemorrhage within 6 weeks of termination of the drug. Although only three subjects were investigated, the 1-2 week frequency of metabolic and opthalmologic studies permit some conclusions. The metabolic effects of alpha interferon in our diabetic subjects were consistent worsening of carbohydrate tolerance associated with impaired beta-cell secretion and increased insulin resistance. The extensive opthalmologic investigation suggested protection from retinal hemorrhage while receiving interferon, but further studies are indicated to validate these proposed and antiangiogenic properties.

Comparison of survival. Chemotherapeutically treated and untreated older patient with acute myeloid leukemia

Survival of older patients with acute nonlymphocytic leukemia treated with chemotherapy was compared with those given only supportive care. The treated group was younger and had better survival. The benefits which measure in months must be balanced against socioeconomic cost, toxicity of therapy, patient wishes, and evolving information about the standards of management in the older leukemia patient.

Subclinical cognitive deficits in cancer patients: a preliminary P300 study

A preliminary study of event related potentials (P300) in a group of 16 cancer patients, without cerebral metastases or focal neurological deficits, is being reported. As compared to a group of 28 normal adults, 9 out of 16 cancer patients were found to have prolonged P300 latencies, and 6 made more than two errors in their cognitive performance. These subclinical cognitive impairments in cancer patients may be related to some remote effects of cancer. These patients had not undergone any chemotherapy or radiation therapy prior to P300 studies. Further studies in a larger group of patients with gynecological cancer are being conducted.