Is dependent cannabis use in adult hospitalizations with inflammatory bowel disease associated with major adverse cardiovascular and cerebrovascular events? Insights from National Inpatient Sample Analysis

BACKGROUND

Inflammatory bowel disease (IBD) and dependent cannabis use or cannabis use disorder (CUD+) are independent risk factors for cardiovascular diseases. Usage of cannabis for pain increased in IBD patients. However, associated cardiovascular safety remains unclear. This study aims to investigate the major adverse cardiac and cerebrovascular events (MACCE) associated with CUD + in hospitalized IBD patients.

METHODS

We analyzed the National Inpatient Sample 2020 using ICD-10-CM codes; hospitalized IBD patients were identified and divided based on CUD's presence or absence. Multivariable regression models were performed to evaluate MACCE [in-hospital mortality, acute myocardial infarction (AMI), cardiac arrest (CA), and acute ischemic stroke (AIS)] odds after adjusting for baseline demographics, hospital-level characteristics, and relevant cardiac/extra-cardiac morbidities.

RESULTS

Among the 302,770 hospitalized adult IBD patients, 3.1% (9,490) had CUD+. The majority of patients in the CUD + cohort were white (67.7%), male (57.5%), and aged between 18 and 44 years (66.2%). Cardiovascular risk factors like hypertension, diabetes, hyperlipidemia, and prior myocardial infarction were higher in the CUD - cohort (p <0.001) compared to the CUD + cohort. The CUD + cohort had a lower rate of MACCE (3.1% vs. 5.8%), crude in-hospital mortality (0.7% vs. 2.2%), AMI (1.7% vs. 2.6%), CA (0.3% vs. 0.7%), and AIS (0.6% vs. 1.2%) with statistical significance (p <0.001). However, after adjusting for baseline characteristics and comorbidities, the adjusted odds ratios (aORs) did not show a statistically significant difference for MACCE (aOR = 0.9, 95% CI = 0.65-1.25, p = 0.530), CA (aOR = 0.54, 95% CI = 0.2-1.47, p = 0.227), and AIS (aOR = 0.86, 95% CI = 0.43-1.73, p = 0.669).

CONCLUSION

Our study did not find a statistically significant difference in MACCE among hospitalized IBD patients with and without CUD. This emphasizes the need for more extensive prospective studies focusing on the quantity, method, and duration of cannabis use (recreational or medicinal) in patients with IBD.

Proteinaceous Lymphadenopathy Masquerading as Malignancy: a Rare Case Presenting a Diagnostic Dilemma

Proteinaceous lymphadenopathy (PLD) is a rare poorly defined, underrecognized entity of uncertain etiology, characterized by massive deposition of amorphous, acellular, eosinophilic, PAS-positive material within an enlarged lymph node. We report an unusual case of a 46-year-old female with a large abdominal lump in the left lumbar region with inguinal lymphadenopathy. Contrast-enhanced computed tomography (CECT) showed multiple variable-sized lobulated non-enhancing soft tissue attenuated masses showing multiple peripheral and central calcific foci in the right para-aortic, bilateral iliac region, pelvis on the left side and left inguinal region. No evidence of any abnormal hypermetabolic focus was found in the neck, chest, abdomen, and pelvis on fluorodeoxyglucose positron emission tomography. A large, well-defined, non-FDG avid mass lesion with significant central and peripheral calcification in the left iliac fossa, abutting the descending colon, was seen. A biopsy of left-sided inguinal lymph nodes revealed large masses of an amorphous, acellular, eosinophilic material with areas of mature lymphoid cell aggregates interspersed between the pink amorphous materials. A final impression of proteinaceous lymphadenopathy was given. Proteinaceous lymphadenopathy is a benign condition with often a large mass masquerading as malignancy. It is a major therapeutic challenge for pathologists and clinicians. Histopathologists need to be vigilant in such cases and be aware of the morphological appearances in such cases.

Utility of galactomannan diagnostic assay in rhino-orbito-cerebral mycosis in COVID-19 patients

An increasing number of fungal infections were reported post COVID-19 and many of them were caused by fungi of mixed aetiologies. This study was carried out to assess the utility of serum galactomannan (GM) assay in establishing the etiology of acute rhino-orbito-cerebral mycosis caused by Aspergillus spp. Two serum samples were obtained from 41 suspected post COVID-19 rhino-orbito-cerebral mycosis patients to perform GM assay. Serum GM assay was positive in 68.7% of the cases of proven aspergillosis at cut off OD = 1.0. Serum GM assay can be used as a supplementary test in the diagnosis of rhino-orbito-cerebral mycosis caused by Aspergillus spp.

A Correlation of Tumour Budding and Tumour-Stroma Ratio with Clinicopathological Factors in Oral Squamous Cell Carcinoma

Objectives

This study aimed to analyse the association of tumour budding (TB) and tumour-stroma ratio (TSR) with clinicopathological parameters that can be easily viewed on routine haematoxylin and eosin (H&E)-stained slides to provide an easy and cost-effective method for prognosticating oral squamous cell carcinoma (OSCC).

Methods

This study was conducted at the ESIC Medical College and Hospital in Faridabad, India, from July 2022 to October 2022. In patients with histologically diagnosed OSCC, TB and TSR were evaluated via routine H&E-stained sections and correlated with clinicopathological parameters. Statistical analysis was performed using Chi-squared test.

Results

A total of 50 patients were included. The mean age of participants was 61 ± 12.72, and the male-to-female ratio was 7.1:1. Most of the tumours were located on the tongue (46%), followed by the buccal mucosa (26%), gingivobuccal sulcus (12%) and retromolar trigone (8%). The palate and alveolus were the other sites involved, constituting 4% each. TB and TSR were both found to be significantly associated with the tumour grade, lymph node metastasis and tumour size. A highly significant correlation was also found between TB and TSR (P = 0.001).

Conclusions

Both TB and TSR can be easily evaluated on routine H&E sections; they are highly reproducible and were found to be reliable independent prognostic markers in OSCC. Therefore, this simple and cost-effective method of prognostication, which is currently lacking in clinical practice, will help clinicians to identify patients with poor prognosis and thus individualise their treatment plan.

Secretory carcinoma of salivary gland: A rare tumor masquerading as acinic cell carcinoma on cytology

Secretory carcinoma (SC) was originally described as mammary analogue secretory carcinoma (MASC). We present here a case of 33 years old male who came to ENT outpatient department with a complaint of swelling over the left side of his neck for 8 months. On Fine-needle aspiration cytology, an impression of cytomorphological features suggestive of acinic cell carcinoma (Milan category V) was given. Left functional endoscopic sinus surgery was done. On histopathology, a final impression of Secretory carcinoma, the left submandibular gland was given with pathological stage classification as pT2N0Mx. SC of the salivary gland is a rare entity that may pose diagnostic challenges. Awareness of its cytologic features is paramount to achieve an accurate diagnosis. Morphologic interpretation must be supported by an immunohistochemical profile and molecular studies to confirm a diagnosis of SC.

COVID-19-associated mucormycosis - "The Black fungus" with associated invasive aspergillosis and actinomycosis infection: Series of 5 cases in the Indian scenario

COVID-19 caused by SARS-CoV-2 has been studied and reported widely since November 2019, after its first case was detected in Wuhan, China. It has proven to be a fatal disease worldwide. COVID-19 causes severe disease in patients with immunosuppression and has always been associated with high mortality in such patients. Immunocompromised patients are always at a higher risk of getting co-infections too, and the same is true with COVID-19. It predisposes to the development of many fungal infections of which, mucormycosis is one of the most common ones, especially in the Indian population where a large group of the population is predisposed to diabetes mellitus. India has the world's largest population of diabetic patients; therefore, the prevalence of COVID-19-associated mucormycosis (CAM) is also the highest in India. Also, the use of corticosteroids over a long duration of time predisposes the patients to the development of mucormycosis owing to immunosuppression. Hypoxia, low total leukocyte count, and high ferritin are the other predisposing factors that lead to the growth of mucormycosis associated with COVID-19. Here, we present five cases within a span of 2 months, of mucormycosis-associated COVID-19 with mixed infections of aspergillosis and actinomycetes. Four cases had mucormycosis with aspergillosis and one with mucormycosis with Actinomyces. Three patients recovered fully after being treated with intravenous amphotericin B; however, unfortunately, two of our patients could not be saved.

Nonstationary time series forecasting using optimized-EVDHM-ARIMA for COVID-19

The Coronavirus (COVID-19) outbreak swept the world, infected millions of people, and caused many deaths. Multiple COVID-19 variations have been discovered since the initial case in December 2019, indicating that COVID-19 is highly mutable. COVID-19 variation "XE" is the most current of all COVID-19 variants found in January 2022. It is vital to detect the virus transmission rate and forecast instances of infection to be prepared for all scenarios, prepare healthcare services, and avoid deaths. Time-series forecasting helps predict future infected cases and determine the virus transmission rate to make timely decisions. A forecasting model for nonstationary time series has been created in this paper. The model comprises an optimized EigenValue Decomposition of Hankel Matrix (EVDHM) and an optimized AutoRegressive Integrated Moving Average (ARIMA). The Phillips Perron Test (PPT) has been used to determine whether a time series is nonstationary. A time series has been decomposed into components using EVDHM, and each component has been forecasted using ARIMA. The final forecasts have been formed by combining the predicted values of each component. A Genetic Algorithm (GA) to select ARIMA parameters resulting in the lowest Akaike Information Criterion (AIC) values has been used to discover the best ARIMA parameters. Another genetic algorithm has been used to optimize the decomposition results of EVDHM that ensures the minimum nonstationarity and maximal utilization of eigenvalues for each decomposed component.

A Novel DCNN-ELM Hybrid Framework For Face Mask Detection

The Coronavirus disease (2019) has caused massive destruction of human lives and capital around the world. The latest variant Omicron is proved to be the most infectious of all its previous counterparts – Alpha, Beta and Delta. Various measures are identified, tested and implemented to minimize the attack on humans. Face masks are one of those measures that are shown to be very effective in containing the infection. However, it requires continuous monitoring for law enforcement. In the present manuscript, a detailed research investigation using different ablation studies is carried out to develop the framework for face mask recognition using pre-trained deep convolution neural networks (DCNN) models used in conjunction with a fast single layer feed-forward neural network (SLFNN) commonly known as Extreme Learning Machine (ELM) as classification technique. The ELM is well known for its real time data processing capabilities and has been successfully applied both for regression and classification problems of image processing and biomedical domain. It is for the first time that in this paper we have proposed the use of ELM as classifier for face mask detection. As a precursor to this, for feature selection, six pre-trained DCNNs such as Xception, Vgg16, Vgg19, ResNet50, ResNet 101 and ResNet152 are tested for this purpose. The best testing accuracy is obtained in case of ResNet152 transfer learning model used with ELM as the classifier. The performance evaluation through different ablation studies on testing accuracy explicitly proves that ResNet152 - ELM hybrid architecture is not only the best among the selected transfer learning models but also proves so when it is compared with several other classifiers used for the face mask detection operation. Through this investigation, novelty of the use of ResNet152 + ELM for face mask detection framework in real time domain is established.

Hypertensive Crisis-Related Hospitalizations and Subsequent Major Adverse Cardiac Events in Young Adults with Cannabis Use Disorder: A Nationwide Analysis

Background and Objectives: With the growing recreational cannabis use and recent reports linking it to hypertension, we sought to determine the risk of hypertensive crisis (HC) hospitalizations and major adverse cardiac and cerebrovascular events (MACCE) in young adults with cannabis use disorder (CUD+). Material and Methods: Young adult hospitalizations (18−44 years) with HC and CUD+ were identified from National Inpatient Sample (October 2015−December 2017). Primary outcomes included prevalence and odds of HC with CUD. Co-primary (in-hospital MACCE) and secondary outcomes (resource utilization) were compared between propensity-matched CUD+ and CUD- cohorts in HC admissions. Results: Young CUD+ had higher prevalence of HC (0.7%, n = 4675) than CUD- (0.5%, n = 92,755), with higher odds when adjusted for patient/hospital-characteristics, comorbidities, alcohol and tobacco use disorder, cocaine and stimulant use (aOR 1.15, 95%CI:1.06−1.24, p = 0.001). CUD+ had significantly increased adjusted odds of HC (for sociodemographic, hospital-level characteristics, comorbidities, tobacco use disorder, and alcohol abuse) (aOR 1.17, 95%CI:1.01−1.36, p = 0.034) among young with benign hypertension, but failed to reach significance when additionally adjusted for cocaine/stimulant use (aOR 1.12, p = 0.154). Propensity-matched CUD+ cohort (n = 4440, median age 36 years, 64.2% male, 64.4% blacks) showed higher rates of substance abuse, depression, psychosis, previous myocardial infarction, valvular heart disease, chronic pulmonary disease, pulmonary circulation disease, and liver disease. CUD+ had higher odds of all-cause mortality (aOR 5.74, 95%CI:2.55−12.91, p < 0.001), arrhythmia (aOR 1.73, 95%CI:1.38−2.17, p < 0.001) and stroke (aOR 1.46, 95%CI:1.02−2.10, p = 0.040). CUD+ cohort had fewer routine discharges with comparable in-hospital stay and cost. Conclusions: Young CUD+ cohort had higher rate and odds of HC admissions than CUD-, with prevalent disparities and higher subsequent risk of all-cause mortality, arrhythmia and stroke.

Fractional flow reserve versus angiography guided revascularization for patients with multivessel coronary artery disease: a systematic review and meta-analysis of randomized controlled trials

Background

Recently published randomized controlled trials (RCT) have questioned the utility of Fraction Flow Reserve (FFR) to guide revascularization in patients with multivessel coronary artery disease (CAD) as compared to Angiography

Purpose

This current analysis aimed to compare the clinical outcomes associated with FFR guided versus standard angiography-guided revascularization for patients with multivessel CAD using a large number of randomized patients with stable CAD and acute coronary syndrome (ACS)

Methods

We conducted an electronic database search of all published data for RCT that compared FFR versus Angiography for patients with multivessel CAD and reported on subsequent mortality, cardiac death, myocardial infarction, revascularization, and other outcomes of interest. Event rates were compared using a forest plot of odds ratios using a fixed-effects model assuming interstudy heterogeneity.

Results

Eleven RCT (n=6052; FFR = 3043, Angiography = 3027) were included in the final analysis. Mean follow-up period was 1.7 years. In our analysis, FFR guided revascularization as compared to angiography guided revascularization alone was not associated with any significant reduction in overall mortality (OR = 1.10, 95% CI = 0.83–1.47, P=0.47, I2=0), cardiac mortality (OR = 0.95, 95% CI = 0.63–1.45, P=0.42, I2=0), all revascularization (OR = 0.96, 95% CI = 0.80–1.14, P=0.17, I2=31%) or myocardial infarction (OR = 0.99, 95% CI = 0.79–1.23, P=0.33, I2=12%). There was also no difference between two groups in terms of major adverse cardiac or cerebrovascular event [MACCE] (OR = 1.13, 95% CI = 0.90–1.42, P=0.39, I2=5%), major adverse cardiac event [MACE] (OR = 0.86, 95% CI = 0.70–1.07, P=0.55, I2=0), stroke/TIA (OR = 1.61, 95% CI = 0.92–2.82, P=0.36, I2=8%) or target lesion revascularization [TLR] (OR = 0.86, 95% CI = 0.44–1.67, P=0.71, I2=0). Furthermore, sensitivity analysis was conducted to include only studies with ACS patients and studies which used CABG only for revascularization. However, there was no difference between the two groups for any of the above outcomes

Conclusion

There is no difference in clinical outcomes in patients undergoing FFR-guided versus angiography guided revascularization for multivessel CAD

Funding Acknowledgement

Type of funding sources: None.

Evaluation of Cytomorphological Patterns of Fibroadenoma on Cytology: Emphasis on Pattern based approach to avoid misdiagnosis

Background: Fibroadenoma (FA) is a frequently occurring breast lesion diagnosed on fine needle aspiration cytology (FNAC) with a bimodal picture comprising of epithelial and/or stromal component. It can have a gamut of differential diagnosis depending on the predominant cellular features reflected on cytological smears, thereby it is important that the cytologist should be well versed with the various patterns of fibroadenoma to avoid diagnostic errors. Materials and methods: The present study was conducted over a period of two years including all cases of fibroadenoma diagnosed on cytology (n=234). The detailed cytomorphological spectrum was analysed to study the different patterns of fibroadenoma on cytology. Out of these (234), cytohistological correlation was performed in 197 cases. Results: The incidence of fibroadenoma among all the breast FNACs was 50% (234/468). The different patterns observed were: epithelial predominant, stromal predominant, FA with giant cells, apocrine change, cyst macrophages, granuloma, acute inflammation and atypia. Cytohistologic concordance was observed in 173/197 cases (87.8%). Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 98.8%, 92.3%, 87.8%, 94.5% and 88.8% respectively. Conclusion: Although fibroadenoma can be diagnosed with ease on cytology in most of the cases, However, at times in addition to classical features, morphological variations are observed such as giant cells, cyst macrophages, apocrine change, granulomas, acute inflammation and atypia wherein it maybe misdiagnosed as benign phyllodes, hyperplasia, fibrocystic disease etc.. This pattern based approach for the cytological diagnosis of FA is re-emphasized in the index article so as to create awareness about these varied patterns among the young cytopathologists. Bangladesh Journal of Medical Science Vol. 21 No. 03 July’22 Page: 590-595

The arginine methyltransferase PRMT7 promotes extravasation of monocytes resulting in tissue injury in COPD

Extravasation of monocytes into tissue and to the site of injury is a fundamental immunological process, which requires rapid responses via post translational modifications (PTM) of proteins. Protein arginine methyltransferase 7 (PRMT7) is an epigenetic factor that has the capacity to mono-methylate histones on arginine residues. Here we show that in chronic obstructive pulmonary disease (COPD) patients, PRMT7 expression is elevated in the lung tissue and localized to the macrophages. In mouse models of COPD, lung fibrosis and skin injury, reduced expression of PRMT7 associates with decreased recruitment of monocytes to the site of injury and hence less severe symptoms. Mechanistically, activation of NF-κB/RelA in monocytes induces PRMT7 transcription and consequential mono-methylation of histones at the regulatory elements of RAP1A, which leads to increased transcription of this gene that is responsible for adhesion and migration of monocytes. Persistent monocyte-derived macrophage accumulation leads to ALOX5 over-expression and accumulation of its metabolite LTB4, which triggers expression of ACSL4 a ferroptosis promoting gene in lung epithelial cells. Conclusively, inhibition of arginine mono-methylation might offer targeted intervention in monocyte-driven inflammatory conditions that lead to extensive tissue damage if left untreated.

Chronic obstructive pulmonary disease is a progressive and incurable chronic condition that involves accumulation of inflammatory macrophages in the lung tissue. Authors here show in mouse models of lung disease that PRMT7, a protein arginine methyltransferase, is an important regulator of recruitment and the pro-inflammatory phenotype of macrophages.

An unusual case of Essential Thrombocythemia in coexistence with Breast cancer

Essential thrombocythemia (ET) is an extremely rare myeloproliferative neoplasm (MPN) which is characterized by persistent, non-reactive thrombocytosis (> 450 X 109/L) and an increased risk for thrombotic events.These patients have an increased risk of both hematological and non-hematological malignancies however the risk of breast cancer in MPN is not increased in comparison to general population. We hereby present an extremely unusual case of ET in a 38 years old female (diagnosed with breast cancer), which came to light on routine pre-surgical work up of the patient.Diagnosis was confirmed on bone marrow aspiration clubbed with JAK 2 mutation. Patients with ET have an increased risk of thrombosis thereby it becomes challenging for the clinician to operate on a coexistent solid tumor. On extensive literary search, there was a single case of coexistent Breast Cancer and Essential Thrombocythemia and we are reporting second such coexistence to the best of our knowledge. Bangladesh Journal of Medical Science Vol. 21 No. 02 April’22 Page : 463-466

Cellular leiomyoma versus endometrial stromal sarcoma: A report of a rare case presenting a diagnostic challenge on intraoperative frozen section

Endometrial stromal sarcomas (ESSs) account for approximately 0.2% of all uterine malignancies. Cellular leiomyoma (CL) often simulates low-grade ESS due to similar cytology. We report the case of a 34-year-old female with a mass per abdomen. Frozen sections showed a tumor with many thin- and thick-walled vessels along with hyaline material. A differential diagnosis of CL and endometrial stromal tumor was suggested. The index case was diagnostically challenging to pathologists. Paraffin sections supplemented by immunohistochemistry (smooth muscle actin, CD10, and beta-catenin) favored CL. Frozen section sometimes leads to over/underestimation of tumor in view of small sampling area of tumor.

Valorization of Larix decidua Mill. bark by functionalizing bioextract onto chitosan films for sustainable active food packaging

The present study explored the use of chitosan films functionalized with antioxidants extracted from Larix decidua Mill. bark for active packaging. The pristine chitosan and extract-incorporated chitosan films were evaluated for their structural, physico-mechanical, thermal, viscoelastic and antioxidant properties using advanced characterization techniques. The infrared spectroscopy revealed hydrogen bonding between the extract polyphenolic antioxidants and chitosan, whereas the surface microscopy studies indicated good compatibility between them. The addition of bark extract caused a significant increase in color parameters and solubility with reduction in swelling and elongation at break of the films. The thermal analysis indicated a drop in thermal stability of chitosan films modified with the extract. The dynamic mechanical analysis confirmed the extract-polymer interactions and the viscoelastic nature of the films. The incorporation of bark extract caused remarkable enhancement in the antioxidant activity of chitosan films. Overall, larch bark extract-functionalized chitosan films demonstrated promising potential for food packaging.

In vitro antioxidant and antibacterial activities with polyphenolic profiling of wild cherry, the European larch and sweet chestnut tree bark

This study is a comparative investigation of antioxidant and antibacterial properties of tree bark extracts of three common European species, Prunus avium L., Larix decidua Mill. and Castanea sativa Mill. The bioactive compounds present in the bark were recovered in 80% aqueous ethanol using ultrasound as the green extraction method. The antioxidant potential of the extracts was assessed with multiple biochemical assays: total phenol content (TPC) expressed in gallic acid equivalent (GAE), 2,2-diphenyl-1-picrylhydrazyl (DPPH), 2,2′-azino-bis (3-ethylbenzothiazoline-6-sulphonic acid) (ABTS) expressed in trolox equivalent (TE), and ferric reducing ability of plasma (FRAP) expressed in ascorbic acid equivalent (AAE). Sweet chestnut bark extract showed the highest antioxidant activity with TPC of 174.25 ± 16.95 mg GAE/g dry weight, DPPH (IC50) of 2.69 ± 0.03 μg/mL, ABTS of 739.65 ± 24.41 mg TE/g dry weight and FRAP of 207.49 ± 3.62 mg AAE/g dry weight. The antibacterial activity of the extracts was evaluated by disk diffusion test, minimal inhibitory concentration (MIC) assay and bacterial growth curves. Sweet chestnut bark extract gave IC50 values of 0.25 mg/mL and 1.00 mg/mL against E. coli and S. aureus, respectively. The polyphenolic profiling of the bark extracts was performed to identify the major compounds responsible for the bioactivities using high-performance liquid chromatography/tandem mass spectrometry (HPLC–MS/MS). The bark extracts were rich in natural antioxidants, thus holding tremendous potential for use as natural additives in food industry.

Graphic abstract

Evaluation of Tumor infiltrating lymphocytes in breast carcinoma and their correlation with molecular subtypes, tumor grade and stage

BACKGROUND

Tumour infiltrating lymphocytes (TILs) exhibit the local immune response directed against tumor growth and metastasis. TILs have emerged as a tool to assess immune-reactivity in various malignancies including colon, ovary, lung, bladder, breast etc as well as independent marker of favourable prognosis in many tumors. TILs in breast cancer (BC) play a role in tumor response to therapy in the adjuvant and neoadjuvant settings, especially in triple-negative cancers.

MATERIAL & METHODS

This cross sectional study comprised of 101cases of invasive breast carcinoma. For each case, a representative 5 μm H&E stained section was selected and the clinicopathological details were recorded. To establish the molecular subtype of breast cancer, immunohistochemistry for ER, PR and Her2neu was done. Both stromal (sTIL) and intratumoral (iTIL) TILs were assessed based on the recommendations of the International TIL Working Group (ITILWG).

RESULTS

A statistically significant difference was observed in the mean sTIL as well as iTIL scores and tumor grade, size, molecular type and lymph node metastasis. A signification correlation was observed between stromal TIL and tumor grade, lymph node metastasis, molecular subtype and mitosis. Intratumoral TIL showed a significant correlation with tumor size, mitosis, tumor grade, distant metastasis, stage and lymph node metastasis. Moreover, stromal and intratumoral TIL showed a highly significant correlation with each other.

CONCLUSION

The ITILWG recommendations are reproducible and reliable for the evaluation of sTILs and iTILs. TILs, as evaluated on Hematoxylin and eosin (H&E) slides, has been shown in numerous studies now to be a reliable, reproducible, inexpensive and readily available marker of pre-existing antitumor immunity in breast cancer. We suggest that TILs should be evaluated for each case of breast carcinoma and should be part of histopathology report.

Should COVID-19 patients >75 years be Ventilated? An Outcome Study

BACKGROUND

Elderly patients with COVID-19 disease are at increased risk for adverse outcomes. Current data regarding disease characteristics and outcomes in this population are limited.

AIM

To delineate the adverse factors associated with outcomes of COVID-19 patients ≥75 years of age.

DESIGN

Retrospective cohort study.

METHODS

Patients were classified into mild/moderate, severe/very severe and critical disease (intubated) based on oxygen requirements. The primary outcome was in-hospital mortality.

RESULTS

A total of 355 patients aged ≥75 years hospitalized with COVID-19 between 19 March and 25 April 2020 were included.Mean age was 84.3 years. One-third of the patients developed critical disease. Mean length of stay was 7.10 days. Vasopressors were required in 27%, with the highest frequency in the critical disease group (74.1%). Overall mortality was 57.2%, with a significant difference between severity groups (mild/moderate disease: 17.4%, severe/very severe disease: 71.3%, critical disease: 94.9%, P < 0.001).Increased age, dementia, and severe/very severe and critical disease groups were independently associated with increased odds for mortality while diarrhea was associated with decreased odds for mortality (OR: 0.12, 95% CI: 0.02-0.60, P < 0.05). None of the cardiovascular comorbidities were significantly associated with mortality.

CONCLUSION

Age and dementia are associated with increased odds for mortality in patients ≥75 years of age hospitalized with COVID-19. Those who require intubation have the greatest odds for mortality. Diarrhea as a presenting symptom was associated with lower odds for mortality.

Outcomes in patients with severe COVID-19 disease treated with tocilizumab: a case-controlled study

BACKGROUND

COVID-19 is an ongoing threat to society. Patients who develop the most severe forms of the disease have high mortality. The interleukin-6 inhibitor tocilizumab has the potential to improve outcomes in these patients by preventing the development of cytokine release storm.

AIMS

To evaluate the outcomes of patients with severe COVID-19 disease treated with the interleukin-6 inhibitor tocilizumab.

METHODS

We conducted a retrospective, case-control, single-center study in patients with severe to critical COVID-19 disease treated with tocilizumab. Disease severity was defined based on the amount of oxygen supplementation required. The primary endpoint was the overall mortality. Secondary endpoints were mortality in non-intubated patients and mortality in intubated patients.

RESULTS

A total of 193 patients were included in the study. Ninety-six patients received tocilizumab, while 97 served as the control group. The mean age was 60 years. Patients over 65 years represented 43% of the population. More patients in the tocilizumab group reported fever, cough and shortness of breath (83%, 80% and 96% vs. 73%, 69% and 71%, respectively). There was a non-statistically significant lower mortality in the treatment group (52% vs. 62.1%, P = 0.09). When excluding intubated patients, there was statistically significant lower mortality in patients treated with tocilizumab (6% vs. 27%, P = 0.024). Bacteremia was more common in the control group (24% vs. 13%, P = 0.43), while fungemia was similar for both (3% vs. 4%, P = 0.72).

CONCLUSION

Our study showed a non-statistically significant lower mortality in patients with severe to critical COVID-19 disease who received tocilizumab. When intubated patients were excluded, the use of tocilizumab was associated with lower mortality.

Granular Cell Tumor Breast Masquerading as a Malignancy Cytologically: a Rare Case Presenting a Diagnostic Dilemma

Granular cell tumor (GCT) also known as Abrikossoff's tumor is an uncommon soft tissue tumor of neurogenic origin. GCT of the breast accounts for < 0.1% of breast tumors and 6% of all reported cases of granular cell tumor. Although GCT is a benign tumor, malignant GCT can be seen in 1% v of the cases. GCT of the breast is diagnostically challenging as it can imitate carcinoma clinically and radiologically but need to be differentiated from breast malignancy since they have totally different approach in treatment and prognosis. GCT has a great ability to mimic a variety of lesions from benign histiocytic to malignant epithelial/mesenchymal lesions, thereby presenting a diagnostic challenge to the practicing cytopathologist. We report a case of GCT of breast cytologically masquerading as a malignancy in a 45-year-old female. Although, fine needle aspiration (FNA) is a first-line diagnostic tool, the present case reemphasizes the role of histopathology as the gold standard for a definite diagnosis clubbed with ancillary techniques like immunohistochemistry and special stains.

A Clinicopathological Correlation of International Federation of Gynecology and Obstetrics's PALM-COEIN Classification of Abnormal Uterine Bleeding: Indian Scenario

Background

Abnormal uterine bleeding (AUB) is a common problem affecting the women of reproductive age group and may also have a significant impact on their physical, social, and emotional aspects directly affecting their quality of life. The International Federation of Gynecology and Obstetrics (FIGO) devised a universally acceptable system of nomenclature and classification, namely PALM-COEIN classification of AUB in the year 2011. The objective of the present study was to analyze the structural (PALM) and functional (COEIN) component of FIGO system in the Indian scenario.

Materials and Methods

Three hundred patients with complaints of AUB were taken. A clinical diagnosis according to PALM-COEIN system was made after thorough history and clinical examination. Additional investigations if required were done, and endometrial sampling or hysterectomy was done whichever indicated. A histological diagnosis was made, and each case was allocated a category according to PALM-COEIN classification. A clinicopathological correlation was done in the hysterectomy cases for structural causes (PALM).

Results

Leiomyoma (30%) was the most common cause of AUB closely followed by adenomyosis (29.66%) overall. The clinicopathological correlation in hysterectomy cases was good with concordance rate of 85.03%. The concordance between clinical and pathological diagnoses for AUB-L, AUB-A, AUB-M, and AUB-A, L was statistically significant with P < 05 in positive cases. However, additional finding of adenomyosis was diagnosed in 48.2% of the cases apart from primary clinical diagnosis.

Conclusion

A good clinicopathological correlation was seen in the cases when classified according to PALM-COEIN classification. The system also provides for consideration of multiple etiologies contributing toward AUB both clinically and histopathologically. However, histopathology remains the cornerstone in establishing the accurate diagnosis as the cases without specific symptoms can be missed clinically.

Association of coagulation profile with microvascular complications and glycemic control in type 2 diabetes mellitus - a study at a tertiary care center in Delhi

Introduction

Type 2 diabetes mellitus, characterized by insulin resistance, corresponds to approximately 90% of cases of diabetes worldwide. Hyperglycemia in diabetes contributes to hyperfibrinogenemia and activates the coagulation cascade thereby producing atherothrombotic events.

Objectives

This study was designed to evaluate the coagulation profile (activated partial thromboplastin time, prothrombin time and fibrinogen) in Type 2 diabetes and to analyze correlations between body mass index, fasting blood glucose, glycated hemoglobin and duration of diabetes with coagulation parameters.

Methods

This study included 60 type 2 diabetics and 30 controls. Diabetic patients were grouped in two sets based on the presence or absence of microvascular complications. The demographic profile and clinical details were recorded. Fasting blood glucose, glycated hemoglobin, coagulation parameters such as prothrombin time, activated partial thromboplastin time and fibrinogen along with other biochemical parameters were investigated.

Results

There were statistically significant differences in the coagulation parameters between the two groups of diabetics (with and without complications). The present study also found significant correlations between age and the duration of diabetes with and without complications and coagulation parameters such as the activated partial thromboplastin time, which was found to be significantly lower, and fibrinogen, which was found to be significantly higher in subjects with complications compared to subjects without complications.

Conclusion

Clinical tests for prothrombin time, activated partial thromboplastin time and fibrinogen are relatively inexpensive and readily available. The present study shows that shortened prothrombin time, activated partial thromboplastin time and increased fibrinogen levels might be useful hemostatic markers in diabetic patients, especially in those at high-risk for thrombotic complications.

Masood's and Modified Masood's Scoring Index: An Evaluation of Fine Needle Aspiration Cytology of Breast Lesions with Histopathological Correlation

OBJECTIVE

As fine needle aspiration cytology (FNAC) is the primary tool for evaluation of breast lesions, it is essential to segregate lesions with low and high risk of malignancy. To address this, Masood proposed a cytological scoring system for categorization, Masood's Scoring Index (MSI), which was modified later (Modified Masood's Scoring Index [MMSI]). This study analyses the effectiveness of MMSI over MSI and assesses the concordance between cytological scoring and histopathology.

STUDY DESIGN

All breast FNACs over a period of 2 years were categorized based on MSI and MMSI by 2 reviewers independently. The agreement rate along with specificity, sensitivity, positive predictive value, negative predictive value and diagnostic accuracy were calculated. Correlation and concordance analyses between cytological and histopathological categories were conducted.

RESULTS AND DISCUSSION

Out of 415 cases of breast FNACs, histopathology was available for 310 for which MSI and MMSI were evaluated. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 95, 100, 100, 97.6 and 98.3%, respectively. The difference between the concordance rate of MSI and of MMSI for various cytological categories was found to be statistically significant.

CONCLUSION

MMSI has a better concordance with histopathological diagnosis than MSI. MMSI can serve as a uniform standardized scoring system for breast cytology for better categorization of proliferative breast diseases.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Are all Granulomatous Mastitis Cases Tuberculous?: A Study on the Role of Cytology in Evaluation of Granulomatous Mastitis

OBJECTIVE

Granulomatous mastitis is a rare inflammatory condition of the breast clinically mimicking breast carcinoma and pyogenic abscess, thereby creating a diagnostic dilemma. Tuberculous mastitis is a rare clinical entity accounting for approximately 3% of all mammary lesions. All cases of granulomatous mastitis diagnosed cytologically over a period of 3 years were evaluated to ascertain the cases with tuberculous etiology.

MATERIAL AND METHOD

Fine needle aspiration cytology of the breast lump was performed and all the cytological parameters were evaluated. Wherever histopathology was available, the diagnosis was confirmed on Hematoxylin & Eosin stained sections and the Ziehl Neelsen (ZN) stain was applied.

RESULTS

A total of 10 cases of granulomatous mastitis were diagnosed on cytology during the 3-year period. On cytological smears, four cases showed presence of ill-formed granulomas and one case had scattered epithelioid histiocytes; however, the rest of the cases had well-formed granulomas. Finally, four out of ten cases were labeled as tuberculous mastitis based on the ZN stain/Tuberculosis-Polymerase chain reaction (TB-PCR) and the other six cases were granulomatous mastitis.

CONCLUSION

Cytology plays a significant role in the diagnosis of granulomatous mastitis. This study re-emphasizes the role of the cytopathologist in the accurate and early diagnosis of these lesions so that unnecessary surgery can be avoided, and also highlights the fact that all granulomatous mastitis cases are not tuberculous.

IAC standardized reporting of breast fine-needle aspiration cytology, Yokohama 2016: A critical appraisal over a 2 year period

BACKGROUND

Breast cytology is a significant component of the "Triple approach" for pre-operative diagnosis of breast lumps, the other two being clinical assessment and radiological imaging. The role of Fine needle aspiration cytology (FNAC) as a first line investigation in diagnosing breast lesions is well documented, however histopathology is the gold standard. Cyto-histopathological correlation is of great relevance and also increases precision.AIMS \& OBJECTIVES:The present study was conducted with the aim to categorize breast lesions according to the latest standardized reporting system proposed by International academy of cytologists (IAC) in 2016. Evaluation of diagnostic accuracy, sensitivity and specificity of FNAC in diagnosing breast lesions and cyto-histopathological correlation was planned.

MATERIALS AND METHODS

All FNAs of breast lesions over a period of 2 years were included in the study. The cases were grouped into five standardized categories proposed by the International academy of cytology: Category I (Insufficient material), Category II (Benign), Category III (Atypical, probably benign), Category IV (Suspicious, probably in situ or invasive) & Category V (Malignant) respectively. Specificity, sensitivity, diagnostic accuracy, negative and positive predictive value of FNAC were calculated and cyto-histopathological correlation assessed wherever possible.

RESULTS

Out of 468 breast lesions reported on FNAC, the category wise distribution was - Category I, II, III, IV & V accounting for 23(4.9%), 342(73.07%), 7(1.5%), 11(2.35%) and 85(18.16%) respectively. Histopathology was performed in 331/468 cases with cyto histological concordance of 98.4% and a type agreement rate of 90.9%. The sensitivity, specificity, positive and negative predictive value and diagnostic accuracy was 98.90%, 99.16%, 97.82%, 99.58% and 99.09% respectively.

CONCLUSION

FNAC is a simple, reliable, cost effective, first line diagnostic procedure for all breast lumps. In collaboration with physical examination and imaging studies (triple approach), FNAC is a highly sensitive diagnostic tool. Adopting a universally acceptable standardized reporting system for breast cytology can enhance the diagnostic accuracy of FNAC.

A correlation between platelet indices and preeclampsia

Background

Preeclampsia is one of the major health problems causing maternal morbidity and mortality, complicating 3–8% of pregnancies. It has been suggested that the alterations in the coagulation and fibrinolysis play a role in the pathogenesis of preeclampsia. The markers of platelet activation include platelet count, platelet distribution width, mean platelet volume and plateletcrit.

Study design

It was a case-controlled study which included a total of 60 patients (30 cases and 30 controls). Blood samples were collected and the platelet indices – platelet count, plateletcrit, mean platelet volume and platelet distribution width – were evaluated using the Sysmex XN1000 and compared between the two groups.

Results

The MPV and PDW also showed a significant difference (p > 0.05) between the two groups, with a significant positive correlation with increasing blood pressure (MPV – r = +0.6126, p < 0.05 and PDW – r = +0.6441, p < 0.05). The PC and PCT had lower values in the preeclampsia patients, however the difference between the two groups was not statistically significant.

Conclusion

The MPV and PDW showed a significant difference between the two groups and increasing values with increasing BP. However, the PC and PCT in our study did not show a significant correlation with preeclampsia. Thus, the platelet indices, mainly the MPV and PDW, which are economical and easily available, can be reliable in the prediction and early diagnosis of preeclampsia, as well as a marker for the severity of preeclampsia.

A critical appraisal of the Milan system for reporting salivary gland cytology (MSRSGC) with histological correlation over a 3-year period: Indian scenario

BACKGROUND

Fine needle aspiration cytology (FNAC) is the first line investigation for pre-operative diagnosis of salivary gland lesions, but due to its inherent limitations remains a challenge for the cytopathologists. The recently proposed international risk stratification scheme, the Milan System for Reporting Salivary Gland Cytology (MSRSGC) aims to promote and standardise the communication between cytopathologist and clinician thereby improving patient care.

METHODS

A retrospective study of all salivary gland cytology cases was performed over a 3-year period, reviewed by pathologists and categorised into 1 of the 6 diagnostic categories according to MSRSGC, namely, non-diagnostic, non-neoplastic, atypia of undetermined significance (AUS), benign neoplasm, and salivary gland neoplasm of undetermined significance (SUMP), suspicious for malignancy (SFM), and malignant neoplasm. Cyto- histological correlation was done wherever possible. Risk of malignancy (ROM) was calculated for each diagnostic category.

RESULTS

Out of a total of 150 salivary FNAC cases, histopathology was available for 64 cases. The sensitivity of FNAC was 81.8%, specificity was 100% while the diagnostic accuracy was 96.9%. The positive and negative predictive values were 100% and 96.4% respectively. The ROM for non-diagnostic, non-neoplastic, AUS, benign neoplasm, SUMP, SFM, and malignant categories were 0%, 10%, 50%, 2.5%, 50%, 100%, and 100% respectively.

CONCLUSION

MSRSGC fulfils the critical need for a uniform, internationally acceptable reporting system with ROM specified for each category. However, large scale multi centre studies need to be conducted before its reliability and validity is proven.

Encapsulated Follicular Variant of Papillary Thyroid Carcinoma Arising in a Follicular Adenoma: a Diagnostic Dilemma

Papillary thyroid carcinoma (PTC) arising within follicular adenoma is a rare histological subset of papillary carcinoma. A 24-year-old female (euthyroid and asymptomatic) presented with a solitary mass in the right lobe of thyroid for 2 years. Fine-needle aspiration cytology (FNAC) suggested features of hyperplasia of thyroid. Hemithyroidectomy was performed. Histopathological examination revealed two distinct areas and was reported as encapsulated variant of papillary carcinoma along with follicular adenoma. Papillary carcinoma was confirmed by positive immunohistochemistry for HBME-1. CT head and neck region ruled out metastasis and the patient was kept on follow-up. There have been reports of medullary and papillary carcinomas occurring together; however, there is a paucity of literature on co-existing follicular neoplasm and papillary carcinoma. We hereby report a rare case of follicular variant of papillary carcinoma arising within follicular adenoma of the thyroid.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Ultrasound-Assisted Extraction of Cannabinoids from Cannabis Sativa L. Optimized by Response Surface Methodology

Ultrasonication was used to extract bioactive compounds from Cannabis sativa L. such as polyphenols, flavonoids, and cannabinoids. The influence of 3 independent factors (time, input power, and methanol concentration) was evaluated on the extraction of total phenols (TPC), flavonoids (TF), ferric reducing ability of plasma (FRAP) and the overall yield. A face-centered central composite design was used for statistical modelling of the response data, followed by regression and analysis of variance in order to determine the significance of the model and factors. Both the solvent composition and the time significantly affected the extraction while the sonication power had no significant impact on the responses. The response predictions obtained at optimum extraction conditions of 15 min time, 130 W power, and 80% methanol were 314.822 mg GAE/g DW of TPC, 28.173 mg QE/g DW of TF, 18.79 mM AAE/g DW of FRAP, and 10.86% of yield. A good correlation was observed between the predicted and experimental values of the responses, which validated the mathematical model. On comparing the ultrasonic process with the control extraction, noticeably higher values were obtained for each of the responses. Additionally, ultrasound considerably improved the extraction of cannabinoids present in Cannabis.

PRACTICAL APPLICATION

Low frequency ultrasound was employed to extract bioactive compounds from the inflorescence part of Cannabis. The responses evaluated were-total phenols, flavonoids, ferric reducing assay and yield. The solvent composition and time significantly influenced the extraction process. Appreciably higher extraction of cannabinoids was achieved on sonication against control.

Coincidental Finding of Beta Thalassaemia Minor in a Patient of Lacquer Thinner Poisoning Presenting as Methaemoglobinemia

Lacquer thinner, commonly used for removing household paints, is known to contain various aromatic hydrocarbons and naphtha; if ingested, may cause methaemoglobinemia. We report a case of 13-year-old girl who presented with episodes of vomiting, abdominal pain and numbness of limbs. Peripheral blood smear showed few fragmented erythrocytes and 10-12 nucleated red blood cells /100 white blood cells. Reticulocyte count was 15% with presence of Heinz bodies. There was a history of accidental ingestion of lacquer paint thinner. Levels of methaemoglobin were very high along with raised HbA2 levels. An impression of haemolytic anaemia, due to lacquer thinner paint poisoning, with methaemoglobinemia was given. Incidentally High Performance Liquid Chromatography (HPLC) revealed increased HbA2 levels i.e., heterozygous inheritance of beta thalassaemia minor. Patient responded well to methylene blue. Blood transfusion was performed and symptomatic treatment was given.

A rare tumor of salivary gland: Diagnostic Dilemma on fine needle aspiration cytology

Salivary gland cytopathology is a diagnostically challenging area with overlapping cytomorphological features between benign, malignant, and metastatic tumors. We report the case of 45-year-old male who presented with two swellings in right retroauricular and infraauricular region along with a palpable single right cervical lymph node. On ultrasonography of the neck, a possibility of malignant lesion was given. Contrast enhanced computed tomography of the head showed a large well-defined space occupying lesion in right temporooccipital region eroding the skull bone with both extra and intracranial extension. Fine needle aspiration was performed from both swellings and cervical lymph node. Based on cytological features and clinicoradiological examination, a possibility of metastasis from epithelial malignancy (adenocarcinoma) was suggested. The retroauricular region swelling was excised, and a diagnosis of salivary duct carcinoma was given on histopathology. In this article, we discuss the diverse presentation, cytomorphological features, and differential diagnosis of this rare salivary gland tumor.

Parathyroid lesions: Difficult diagnosis on cytology

Cytology of parathyroid lesion (PL) is often confused with that of thyroid lesions. Differentiation between thyroid and PL is very difficult on cytomorphology because of their similar features and close anatomical proximity. Three cases of PLs reported on cytology in last one year were retrieved from archives of cytology department. Their cytomorphological details were studied and were correlated with the available biochemical parameters. Histopathology was available in two cases. Radiological assistance and parathyroid hormone (PTH) assessment in our cases formed the basis of diagnosing PLs on cytology. We discuss the differential diagnosis and pitfalls in cytological diagnosis of PLs. However, histopathology remains the gold standard for diagnosis. Interpretation of PLs on cytology remains problematic due to its rarity and limited available literature. The cytomorphology combined with clinical and biochemical data supported by histopathology are necessary to improve the diagnostic sensitivity of PLs. Diagn. Cytopathol. 2016;44:704-709. © 2016 Wiley Periodicals, Inc.

Trichoepithelioma and Basal Cell Carcinoma with Squamous Differentiation: Is it Causal or Coincidental?

Trichoepitheliomas (TEs) are benign cutaneous tumors that occur either as solitary non-familial or multiple familial. We report a case of multiple familial trichoepithelioma (MFT) in a 55-year-old female patient and her son who came with complaints of single ulcerated mass involving the left nasolabial fold and cheek. She had multiple papules and nodules all over the face and neck since 25 years. Histopathological examination of an ulcerated lesion revealed features of basal cell carcinoma (BCC) with squamous differentiation, which was confirmed by immunohistochemistry. A skin biopsy obtained from the papule on neck showed features of TE. However, whether BCC developed independently or by transformation from TE was uncertain. Her 36-year-old son presented with similar lesions on the face and a skin biopsy showed features of TE. Though malignant transformation of TE is quite rare, awareness of the potential for evolution of carcinoma in patients with MFT is important for management of these patients.

Effect of addition of 2% chlorhexidine or 10% doxycycline on antimicrobial activity of biodentine

Aim:

The purpose of this in vitro study was to determine whether the addition of 2% chlorhexidine gluconate or 10% doxycycline would enhance the antimicrobial activity of Biodentine against Staphylococcus aureus (ATCC-25923), Enterococcus faecalis (ATCC-29212), Candida albicans (ATCC-90028), and Streptococcus mutans (MTCC-497).

Materials and Methods:

Three wells of 4 mm diameter and 4 mm depth on each plate were prepared on the agar medium with standardized suspensions of each microorganism. Biodentine powder mixed with 2% chlorhexidine (0.06 g) or 10% doxycycline (0.30 g) in its liquid or liquid alone was placed to fill each well. Plates were incubated at 37°C as required for microbial growth. A blinded, independent observer measured zones of inhibition. The data were analyzed using independent “t” test to compare the differences among the three cement preparations for different micro-organisms.

Results:

All Biodentine samples inhibited microbial growth. The highest mean diameters of zone of inhibition for all the micro-organisms were found around Biodentine/chlorhexidine (13.417) followed by Biodentine alone (12.236) and Biodentine/doxycycline (11.25).

Conclusion:

In conclusion, adding 2% chlorhexidine gluconate in liquid of Biodentine enhanced the antimicrobial activity of Biodentine against all the tested micro-organisms except Candida albicans, while addition of 10% doxycycline decreased the antimicrobial activity of Biodentine. The differences were significant statistically (P < 0.05).

Prophylactic strategies in recurrent vulvovaginal candidiasis: a 2-year study testing a phytonutrient vs itraconazole

The aim of the present study was to assess the clinical efficacy of a one week/month treatment with a phytocompound with antimycotic properties (K-712, with following 100 mg composition: 10 mg of oleoresin from Pseudowintera colorata at 30 percent concentration in Polygodial together with trace amounts of Olea europea) in recurrent vulvo-vaginal candidiasis (RVVC), as compared to once a week treatment with an azole drug for 24 months follow up. This prospective randomized study involving 122 women (19 to 63 years old) with a history of proven episodes of RVVC in the prior 12 months. Patients were allocated in two treatment groups of 61 patients each and given A) Itraconazole 200 mg orally once a week or B) 1 tab twice a day of K-712 for one week/month. Each treatment schedule was well tolerated with 19 patients in the azole group complaining of transient mild symptoms (nausea, abdominal discomfort, unpleasant taste), while only 3 patients on K-712 reported slight dyspepsia. The number of relapses was significantly lower in the K-712-treated group as compared to the itraconazole-group (22 vs 39, p less than 0.05). Moreover, the former group showed a significantly decreased number of cases resistant or dose-dependent susceptible as compared to group A (p less than 0.05 vs itraconazole) and the same occurred for the occurrence of non-albicans species (group A 64.1 percent vs group B 31.8 percent, p less than 0.05). The overall mycological cure at the end of the 2-year study showed a comparable benefit between the two groups. From these data it appears that the present antifungal phytonutrient is equally effective as itraconazole in the overall treatment of RVVC over a 2-year follow-up, but yielding a significantly better prophylactic effect and also maintenance benefit with lower relapse rate, antifungal susceptibility and growth of azole-resistant species.