Low yield but high levels of multidrug resistance in urinary tract infections in a tertiary hospital, Nepal

SETTING

There are concerns about the occurrence of multidrug resistance (MDR) in patients with urine tract infections (UTI) in Nepal.

OBJECTIVE

To determine culture positivity, trends in MDR among Escherichia coli and Klebsiella pneumoniae infections and seasonal changes in culture-positive UTI specimens isolated from 2014 to 2018 at the B P Koirala Institute of Health Sciences, Dharan, Eastern Nepal.

DESIGN

This was a cross-sectional study using secondary laboratory data.

RESULTS

Among 116,417 urine samples tested, 19,671 (16.9%) were culture-positive, with an increasing trend in the number of samples tested and culture positivity. E. coli was the most common bacteria (54.3%), followed by K. pneumoniae (8.8%). Among E. coli and K. pneumoniae isolates, MDR was found in respectively 42.5% and 36.0%. MDR was higher in males and people aged >55 years, but showed a decreasing trend over the years. The numbers of isolates increased over the years, with a peak always observed from July to August.

CONCLUSION

Low culture positivity is worrying and requires further work into improving diagnostic protocols. Decreasing trends in MDR are a welcome sign. Information on seasonal changes that peak in July-August can help laboratories better prepare for this time with adequate buffer stocks to ensure culture and antibiotic susceptibility testing.

Clinical application of biological variation data to facilitate interpretation of canine and feline laboratory results

Interpretation of laboratory results is based on comparison of the patient's own results against established decision thresholds or reference intervals in the context of the clinical presentation and history. Blood measurand analysis has pre-analytical, analytical and physiological sources of variation, which may complicate interpretation of results. Biological variation describes the physiological random fluctuation of blood measurands around a homeostatic set point, which varies within and between individuals. This article reviews the practical applications of biological variation in the everyday clinical setting. Examples are offered to highlight how biological variation can be used to: (1) assess the usefulness of subject-based reference intervals, (2) determine measurand homeostatic set points, (3) interpret single or serial results for diagnosis of disease and (4) evaluate changes in serial results during monitoring.

Histopathological analysis of hysterectomy specimens: one year study

Backgound: The uterus is prone to develop several non-neoplastic and neoplastic conditions during the life time of a woman. The aim of this study is to study the histopathological features of varied uterine lesions, their profile and distribution of different lesions in relation of age.Materials and Methods: This is a histopathological database analysis of hysterectomy specimen of one year 2011/12 in Patan Hospital. The variables studied were age and histopathological diagnosis. SPSS version 16 was used as an analytical tool.Results: A total of 3576 histopathology samples were received in this period. There were 1173 gynaecology samples during this period out of which 22% (261 cases) were that of hysterectomy. Histopathology diagnosis showed Leiomyoma in 48.6% (127 cases), Adenomyosis was seen in 10.3% (27 cases), Endometrioid Adenocarcinoma was seen in 1.14% (3 cases).Conclusion: A large number of hysterectomy specimens had no significant findings. However, adenomyosis, leiomyomya and adenocarcinoma are also found which may be the cause of abnormal uterine bleeding. 

Malignant transformation arising in mature cystic teratoma

Background: The prognosis of patients with malignant transformation arising within mature cystic teratoma is poor. However, preoperative diagnosis is dif cult due to its rarity. The aim of this study was to evaluate the clinical and histopathological characteristics of such malignancies. Materials and Methods: A retrospective cross sectional study on a series of cases was performed in the Department of Pathology, Patan Academy of Health Sciences, Patan Hospital, Lalitpur, Nepal from April 2011 to March 2016. Data from the histopathology database were analyzed using SPSS version 16.0. Results: Mature cystic teratoma comprised 230 cases (57.6%) out of total 399 cases of ovarian neoplasms. Malignant transformation was noted in 7 (3%) of the mature cystic teratoma. The mean age at diagnosis of patients with malignant transformation of mature cystic teratoma was 47.57 years. The size of the tumors ranged from 7-14cm. The mean diameter of tumor was 10.28cm. There was signi cant difference in age between mature cystic teratoma and malignant transformations arising within mature cystic teratoma. No signi cant association was noted in tumor size. Torsion was noted in a single case. Squamous cell carcinoma was the most common malignant tumor seen in 5 cases. The TNM stage distribution was T1aNx for 4 cases, T2aNx for one case and T3aNx for 2 cases. Conclusion: Squamous cell carcinoma is the most common malignancy arising in mature cystic teratoma. Advanced age is a signi cant risk factor for malignant transformation in mature cystic teratoma. 

Hand Hygiene: Do we follow it seriously?

The importance of hand hygiene was highlighted in the nineteenth century during the first trial done by Ignaz Philipp Semmelweis, an obstetrician practicing in Vienna, now known as an early pioneer of antiseptic procedures. He was able to reduce maternal mortality rate in his hospital by 90% by just applying the protocol of washing hands in chlorinated lime solution before examining the patients. Semmelweis's hypothesis was largely ignored, rejected, or ridiculed. He was dismissed from the hospital for political reasons and harassed by the medical community in Vienna, being eventually forced to move to Budapest. Semmelweis's practice earned widespread acceptance, when Louise Pasteur confirmed the germ theory and Joseph Lister, pioneered antiseptic surgery. Lister practiced and operated using hygienic methods with great success.There are many national and international guidelines which emphasize the practice of hand hygiene in reducing the incidence of hospital acquired infections (HAI). With all the evidence of decreasing the HAIs the practice of hand hygiene compliance should have been a 100% in all healthcare facilities. However, various studies done in different countries show that the compliance of hand hygiene amongst the healthcare workers is not satisfactory, ranging only 40 to 50% even in the developed nations.Why Not?Inaccessible hand washing facilities: This is one of the major factors due to which the compliance to wash hands is compromised.Wearing Gloves: The misconception amongst the healthcare workers that wearing gloves will prevent transmission of germs is another major factor.Scepticism about the value of hand hygiene: CMEs, lectures, demonstrations and evidence based studies on hand hygiene should be kept in top priority to disseminate the knowledge which will reduce the scepticism.Lack of concept of IPAC, motivation and role model: Many healthcare centres do not have IPAC committee; hence the concept of IPAC is not present in these facilities. If a healthcare worker is not motivated to wash hands she/he will never do it. This is a human behaviour.Being a physician: Last but the most important point is: Do the physicians, the leaders in any healthcare facilities practice correct hand hygiene?Yes to Hand Hygiene:Widely accessible hand washing facilities or Alcohol based hand rub.Multifaceted approach to improve the hand hygiene like CME, training, feedback.Financial incentives, praises from the administrative level.Reminders like posters and pamphlets in the workplace to wash hands.In an era of multi-resistant bacteria, it is now time to implement national IPAC guidelines, create IPAC committees in every healthcare facility, and organize more trainings, CMEs and demonstrations to all healthcare workers. If these measures are not taken in time we may have the MDR organisms engulfing our wards which will definitely increase the healthcare cost as well as morbidity and mortality.

Ethics and Professionalism in Pathology

Pathologists spend most of their professional lives beyond direct view of the public, mostly inside the four walls of the lab. It is the clinicians who face the wrath of the public when something goes wrong. However, with the growing awareness of the public into the decisive role played by the Pathologists in the definitive diagnosis of the disease, the pathologists will soon be the target of the aggrieved patients and relatives.1 The issue of ethics can be dealt when professionalism comes before profession. "Professionalism in medicine requires that physician serve the interests of the patient above his or her own selfinterest." Professionalism aspires to philanthropy, answerability, excellence, duty, service and respect for others. "Professionalism in Pathology is based on the same tenets, but has additional dimensions."The qualities of professionalism for pathologists include 1. Communication with the patients and the clinicians. A small phone call with the clinician will solve most of the clinical mysteries not written in the lab requisition forms; 2. Empathy and Compassion towards patients', colleagues', and laboratory personnel's culture, age, gender, and disabilities; 3. Demonstration of passion, respect and understanding towards the patients; 4. Adherence to guidelines and regulations of the regulatory and accrediting bodies; and 5.Profeciency and knowledge in one's work is valued by the patients more than the credentials, which also enables one to identify deficiencies in peer performance. The basic competencies of professionalism are vital to every pathology report, which in turn is the mirror of the ethics practiced by the pathologist. Evaluating oneself is perhaps the most important tool in maintaining professionalism in the practice of pathology. One colleague recently defined professionalism as “all the things one does when no one is watching,” thus placing personal integrity at the top of the list.

Organizational culture and its implications on infection prevention and control

The hospital acquired infections are becoming common in our hospitals lately. These infections are difficult to treat and maybe life threatening. Hospital acquired infection  can be minimized or eradicated by good Infection Prevention and Control guidelines and good hand hygiene practices. The success of Infection Prevention and Control guidelines program in any hospital is largely impacted by the organizational culture.  In any health care setting the management is challenged by the organizational culture to change of any kind. Where implementation of Infection Prevention and Control guidelines program is easily implemented in some hospitals it is very difficult in others. Moreover, hand hygiene is not only biomedical practice but also has more behavioral factors. 

Histopathology of orodental biopsies

Background: Tissue diagnosis is an essential step to come to a confirmed diagnosis in oral lesions where clinical examination alone can often be difficult and inaccurate. The aim of this study was to assess the use of histopathological services by the dental department and to correlate the clinicopathological diagnosis.Materials and Methods: This is an histopathological database analysis of dental biopsies in 23 years from 1989 to 2012 in Patan Hospital. The variables studied were age, sex, clinical and histopathological diagnosis. SPSS version 16 was used as an analytical tool.Results: Out of 396 dental biopsies 203 (51.3%) were females and 193 (48.7%) were males with  mean age 34.34 years and standard deviation of 17.9 years. The neoplastic and non neoplastic conditions were 44% and 56% respectively.Conclusion: Most diagnoses were benign in nature and had an inflammatory etiology.

In vitro and in vivo evaluation of 2-chloroethylnitrosourea derivatives as antitumor agents

AIM

To evaluate potential of Naphthal-NU, Napro-NU and 5-Nitro-naphthal-NU, 2-chloroethylnitrosourea compounds with substituted naphthalimide in the pre-clinical studies.

MATERIALS AND METHODS

In vitro cytotoxicity of three nitrosoureas was determined in human and mouse tumor cell lines by MTT assays. In vivo anti-tumor potential was evaluated in Sarcoma-180 (S-180) and Ehrlich's carcinoma (EC) solid tumors. Apoptosis in S-180 cells was analyzed by using Annexin V-Propidium Iodide (PI). Histological analysis of liver and kidney was performed at optimum dose (50 mg/kg). Expression status of CD4(+), CD8(+) and CD25(+) cells in treated mouse were also examined.

RESULTS

Significant tumor growth retardation by the compounds was noted in early and advanced disease groups, as the life span of drug treated mice increased considerably. Drug induced killing was observed by induction of apoptosis. Naphthal-NU and 5-Nitro-naphthal-NU were effective to normalize the tumor induced structural abnormalities of liver and kidney. The compounds have no immunotoxic effect on CD4(+) and CD8(+) T cells and down regulate CD4(+)CD25(+) regulatory T cells.

CONCLUSION

Overall data holds promise for the antitumor activity with lower toxicity of the compounds that can be utilized for the treatment of human malignant tumors.

Pathology Laboratories and Infection Prevention and Control

Laboratory health care workers are vulnerable to infection with the Hospital Acquired Infections (HAIs) while receiving, handling and disposing biological samples. Ideally the infrastructure of the lab should be according to the best practices like good ventilation, room pressure differential, lighting, space adequacy, hand hygiene facilities, personal protective equipments, biological safety cabinets etc. Disinfection of the environment, and specific precautions with sharps and microbial cultures should follow the protocols and policies of the Infection Prevention and Control Practices (IPAC). If Mycobacterium tuberculosis or Legionella pneumophila are expected, diagnostic tests should be performed in a bio-safety level 3 facilities (for agents which may cause serious or potentially lethal disease in healthy adults after inhalation). Laboratory access should be limited only to people working in it.Along with the advent of new technologies and advanced treatment we are now facing problems with the dreadful HAIs with Antimicrobial Resistant Organisms (AROs) which is taking a pandemic form. According to WHO, hundreds of millions of patients develop HAI every year worldwide and as many as 1.4 million occur each day in hospitals alone. The principal goals for hospital IPAC programs are to protect the patient, protect the health care worker (HCW), visitors, and other persons in the health environment, and to accomplish the previous goals in a cost-effective manner like hand hygiene, surveillance, training of the HCWs, initiating awareness programs and making Best Practices and Guidelines to be followed by everyone in the hospital.The initiation for the best practices in the Pathology Laboratories can be either Sporadic or Organizational. Sporadic initiation is when the laboratories make their own IPAC policies. It has been seen that in few centres these policies have been conceptualized but not materialized. Organizational initiation is much more effective since the best practices are the same for all hospitals and this helps in standardizing the policies. There are organizations which work in promoting IPAC through education, standards, and advocacy and consumer awareness. Examples of organizations working in this field are IPAC Canada, Centers for Disease Control and Prevention (CDC) USA, Infection Prevention Society UK, Asia Pacific Society of Infection Control (APSIC), World Health Organization (WHO). In Nepal organizational initiation to address the issues of IPAC has been recently taken by Healthy Life Foundation Nepal (HELF Nepal) which is an organization with the mission to inform, promote and implement best practices of IPAC to prevent HAIs in the patients as well as the healthcare workers in all healthcare settings in Nepal.In Nepal awareness on IPAC in Pathology Laboratories can be brought about by initiating trainings, surveillance, regular CMEs and demonstration of techniques to the Lab personnel. Administration will have to be involved in initiating the program and maintaining it with administrative resources and financial support. Before it is too late we have to address the issues of HAIs, AROs and safety in our laboratories.DOI: http://dx.doi.org/10.3126/jpn.v4i8.11603

Outbreak of cholera in Tilathi VDC Saptari Nepal

BACKGROUND

On 2011, Cluster of cholera cases was reported in the Tilathi VDC of Saptari, Nepal.

OBJECTIVE

The outbreak was investigated to identify the etiological agent and possible source of infection and guiding the prevention and control measures.

METHODS

Demographic and clinical details were collected from the suspected case-patients, and the outbreak was described by time, place, and person. Focus group discussion and Key informant interview were conducted to assess the practice of sanitation, source of drinking water and probable cause of diarrheal disease. Five stool samples and 10 water samples of tube well and ponds were collected and microbiological study was done in BPKIHS Dharan.

RESULTS

A total of 111 persons suffered with diarrhea and 02 died of it (attack rate 3.05%, case fatality rate 1.8%). All age groups were affected with disease (median age 26 yrs) and males were affected more than females. Descriptive epidemiology suggested the clustering of cases were around the pond where they clean utensils, take bath and wash clothes. The Vibrio cholerae 01 El Tor, Ogawa serotype was isolated in 03 out of 05 suspected stool samples and in all three of the pond water samples. They reported that most of the houses do not have the toilet and people do not wash their hands regularly with soap and water after defecation.

CONCLUSION

Vibrio cholerae was the causative agent behind the outbreak and probable source of infection was the problematic pond water which they used for different purpose. Immediate chlorination of the pond was recommended to halt further spread of the epidemics.

Idiopathic myelofibrosis mimicking hemolytic anemia

Idiopathic Myelofibrosis is an infrequent chronic myeloproliferative disorder characterized by varying degrees of bone marrow fibrosis and extra medullary hematopoiesis, with the fibrosis being a reactive phenomenon to a neoplastic proliferation of a pluripotent hematopoietic stem cell. Idiopathic Myelofibrosis is heterogeneous in presentation and clinical course, with anemia being one of the most important problems. We present a case of a 59 year old male who presented with severe anemia, the peripheral blood picture mimicking hemolysis with numerous schistocytes and teardrop cells.Journal of Pathology of Nepal (2012) Vol. 2, 323-327DOI: http://dx.doi.org/10.3126/jpn.v2i4.6888

Surface-modified cobalt oxide nanoparticles: new opportunities for anti-cancer drug development

The development of smart nanoparticles that can exhibit the anti-cancer activity, introduces better efficacy and lower toxicity for treatment. The present study was aimed to evaluate the anti-cancer activity of surface functionalized CoO nanoparticles against Jurkat (T-cell lymphoma) and KB (oral carcinoma) cell lines. The nano-sized cobalt oxide nanoparticles (CoO) was prepared by thermal decomposition method followed by surface modification using phosphonomethyl iminodiacetic acid (PMIDA). The PMIDA-coated CoO nanoparticle was characterized by X-ray diffraction, dynamic light scattering, and transmission electron microscopy; and the conjugation was analyzed by Fourier transform infrared spectroscopy. The resultant nanoparticles with an average size less than 100 nm measured by dynamic light scattering and transmission electron microscopy. Cytotoxicity study, flow cytometric analysis and scanning electron micrographs have been revealed that PMIDA-coated nanoparticles significantly enhances the cellular uptake of the nanoparticle and thus facilitates apoptosis of cancer cell (Jurkat and KB). For the application of PMIDA-coated CoO nanoparticles in the medical field, doxorubicin, a potent anti-cancer drug, has been used in similar fashion in this experimental design and all these effects or patterns were observed.

In vitro activity of cefoperazone-sulbactam combination against gram negative bacilli

Cefoperazone is a â-lactam antimicrobial and Sulbactam is an irreversible â-lactamase inhibitor. The objective of this study was to know the susceptibility pattern of gram negative bacilli (GNB) towards cefoperazone-sulbactum. All GNB isolated from different clinical samples during the period of May, 2010 to Aug, 2010 were tested for susceptibility to cefoperazone-sulbactum, meropenem, ceftazidime, cefotaxime, ceftriaxone, chloromphenicol, cotrimoxazole, ampicillin, amikacin, nalidixic acid, ciprofloxacin, carbenicillin and piperacillin using standard Kirby-Bauer disc diffusion antimicrobial susceptibility testing method. The susceptibilities were recorded according to CLSI guidelines. A total of 406 GNB were isolated (urine: 66.7%, pus: 19.2%, and blood: 7.9%). Escherichia coli (54.4%) was most frequently isolated organisms followed by Acinetobacter species (17.7%), Klebsiella pneumoniae (9.1%) and Pseudomonas species (6.1%). Overall, 11.8% of isolates showed resistance to cefoperazone-sulbactam. Frequencies of isolates showing resistance to meropenem and amikacin were 14.7% and 26.25% respectively. Only 3.9% of Escherichia coli isolates showed resistance to cefoperazone-sulbactam. For other organisms, their lowest frequency ranging from 0-20%, exhibited resistance to meropenem. In Pseudomonas spp, in-vitro activity of amikacin was also better as only 11.1% isolates showed resistance to it. This study demonstrated the in-vitro synergistic effect of cefoperazonerazone-sulbactam and meropenem having good activity against GNB compared to the activity of other commonly tested antimicrobials. Cefoperazone-sulbactam can be recommended for the clinical practice against GNB exhibiting resistant to other antimicrobials as it is cheaper alternative to meropenem. Our results also focused on the continuous surveillance of the trends and features of resistance of common antimicrobials.

High lipemic serum: a case report

Hypertriglyceridemia is the condition in which the triglyceride level in the blood is elevated. Triglycerides (TGs) are the major source of energy stored in the body. In this case a 66 years old gentleman has consumed pork with alcohol. A milky white serum was observed due to high triglyceride level. However, he had no other lipid disorders. The increased triglyceride level was purely of dietary origin last night. The subject was perfectly fine with lipid profile and other biochemical investigations performed one week later.

Diagnosis of feline haemoplasma infection in Australian cats using a real-time PCR assay

A total of 147 cats from the Sydney area of Australia that had blood samples submitted to veterinary laboratories were tested using a real-time polymerase chain reaction (PCR) assay able to detect and distinguish the two feline haemoplasma species. This sample number included two cats diagnosed with feline haemoplasma infection by routine blood smear examination. Statistical analysis was performed to evaluate associations between haemoplasma infection, age, sex, breed, haematocrit (HCT) values and anaemia status. One hundred and six cats (72.1%) were negative. Thirty-four cats (23.1%) were positive for 'Candidatus M. haemominutum', six cats (4.1%) were positive for M. haemofelis and one cat (0.7%) was positive for both species. Older, male, non-pedigree cats, with lower HCT values were more likely to be infected with 'Candidatus M. haemominutum'. Significant inverse correlation was found between the amount of M. haemofelis DNA present in the blood and the HCT value. This report documents the existence of, and prevalence of, both haemoplasma species in a sample of cats in Australia and is the first to use quantitative real-time PCR in a prevalence study for haemoplasma infection.

Murine monoclonal anti-idiotypic antibody as a surrogate antigen for human Her-2/neu

The anti-idiotypic (Id) monoclonal antibody (MAb) 520C9-6b (IgG1k), raised in syngenic mice against the murine anti-Her2/neu MAb 520C9 (Ab1), functionally mimics a human Her2/neu epitope and serves as a surrogate for the protein antigen. Immunization of allogeneic C57BL/6 mice and rabbits with 520C9-6b (Ab2) induced anti-Her2/neu-specific antibodies that react with antigen-positive SKBr3 cells by ELISA and FACS analysis. The immune sera inhibited binding between Ab1 and Ab2 and vice versa (binding of Ab2 to Ab1), indicating that it was a true anti-anti-Id (Ab3) antibody. The Ab3 sera or purified Ab3 specifically lysed Her2/neu-positive SKBr3 cells, but no significant lysis was observed in antigen-negative LS174T cells in an antibody-dependent cellular cytotoxicity assay. An Id-specific cellular immune response was also demonstrated in an in vitro lymphocyte proliferation assay. Furthermore, a panel of tumor tissues and tumor cells was screened for the presence of the Her2/neu epitope by its reactivity with Ab1 and Ab3 using immunohistochemistry and FACS analysis. Identical results were obtained using either Ab1 or Ab3 (Ab1'). The data indicated that anti-Id 520C9-6b can induce Her2/neu-specific antibody in experimental animals and may serve as a potential network antigen for the treatment of patients bearing Her2/neu-positive tumors.

Co-overexpression of p53 and c-myc proteins linked with advanced stages of betel- and tobacco-related oral squamous cell carcinomas from eastern India

Epidemiological evidence suggests that heavy consumption of betel quid and tobacco with areca nuts is the cause of high incidence of oral cancer in eastern part of Indian population, which is distinctly different from the etiology of oral squamous cell carcinomas (SCCs) in western countries. Here, expression of p53 and c-myc protein was studied in oral SCCs from this etiologically distinct population by immunohistochemistry. Out of 48 specimens of oral SCCs, 22 (45.8%) exhibited p53 positivity and 27 (56.3%) showed immunoreactivity with c-myc antibody. Considering the p53/c-myc expression pattern, either alone or in combination, the population was divided into four groups, i.e., both p53 and c-myc positive; p53 positive-c-myc negative; c-myc positive - p53 negative; and both p53 and c-myc negative. Tumours with both p53 and c-myc positivity were in advanced stages of the disease (poorly differentiated, tumour stage 3, nuclear grade III), whereas earliest stage of oral SCCs was detected in tumours with neither p53 nor c-myc immunoreactivity. Tumours of remaining two groups were generally restricted to early to moderate stages. These observations suggest that rapid progression of the betel- and tobacco-related oral SCCs may be associated with a simultaneous involvement of these two oncoproteins. The study also attempted to find out the relationship of p53/c-myc expression with spontaneous apoptosis. More apoptotic cells were found in c-myc positive but p53 negative tumours. This preliminary observation requires further molecular investigation of the role of p53 and c-myc genes for the progression of this epidemiologically distinct oral carcinogenesis.

Antibody responses in melanoma patients immunized with an anti-idiotype antibody mimicking disialoganglioside GD2

We initiated a clinical trial for patients with advanced malignant melanoma treated with an anti-idiotype antibody that mimics the disialoganglioside GD2. We report the clinical and immune responses of the first 12 patients entered into this trial. Patients received 1-, 2-, 4-, or 8-mg doses of the anti-idiotype antibody mixed with 100 microg of QS-21 adjuvant every other week, four times, and then monthly. Twelve patients have been on trial for 2-23 months, and all of them have generated immune responses. Patients were removed from the study if they demonstrated disease progression. Hyperimmune sera from all 12 patients revealed an anti-anti-idiotypic Ab3 response, as demonstrated by the inhibition of Ab2 binding to Ab1 by patients' immune sera. To further test the anti-anti-idiotypic response, patients' Ab3 antibodies were affinity purified on Sepharose 4B columns containing adsorbed immunizing anti-idiotype immunoglobulin. Purified Ab3 of all patients studied inhibited binding of Ab1 to a GD2-positive cell line. Purified Ab3 also inhibited binding of Ab1 to purified GD2, in a manner comparable to equal quantities of purified Ab1. The patient Ab3 was truly an Ab1' because it specifically bound to purified disialoganglioside GD2. The isotypic specificity of the Ab3 antibody was predominantly IgG, with only minimal IgM. The predominant IgG subclass was IgG1, with approximately equal quantities of IgG2, IgG3, and IgG4. These Ab3 antibodies reacted specifically with tumor cells expressing GD2 by immune flow cytometry and immunoperoxidase assays. Five patients' Ab3 antibodies studied for antibody-dependent cellular cytotoxicity were positive. One patient had a complete clinical response, with resolution of soft tissue disease, and six patients had stable disease, ranging from 9 to 23 months, and are being continued on vaccine therapy. Toxicity consisted of local reaction at the site of the injection, including induration and pain that generally resolved within a few days. Mild fever and chills were observed in 75% of the patients but rarely required acetaminophen. There was no additional toxicity, including abdominal pain that was previously seen with infusion of murine monoclonal anti-GD2 antibody. Current trials include patients with stage III melanoma and small cell lung cancer. Future trials will attempt to enhance the antitumor response by the addition of interleukin 2, granulocyte macrophage colony-stimulating factor, and other cytokines, together with the 1A7 vaccine.

A comparative study on expression of mucin related antigens in preneoplastic and neoplastic rat colorectal mucosa

A polyclonal antibody (PAb35) defined antigen (Ag) was characterized in association with two monoclonal antibody (MAbM1 and MAb660) defined mucin M1 and 660 Ags in colorectal mucosa during 20-methylcholanthrene-induced rat carcinogenesis in the same organ. Immunohistochemistry and ELISA revealed that these three antibodies were reactive with most of the colorectal carcinomas. MAbM1 and MAb660 were reactive with preneoplastic colorectal mucosa in rats with no detectable carcinoma, in contrast to non-reactivity with PAb35. PAb35 reacted with preneoplastic mucosa, present adjacent to the cancerous tissues only. Staining was mainly localized in the cytoplasm of cancer cells, goblet cells and luminal mucous deposits. In control rats, M1 and 660 Ags were present in gastric mucosa, but not in colorectum. PAb35 defined Ag was absent in gastrointestinal mucosa of controls. ELISA revealed 82% reduction in reactivity, when PAb35 was reacted with 2-mercaptoethanol (2ME) treated colorectal mucosal extracts. Ninety percent reduction was seen in the case of MAbM1. However, 50% reduction was demonstrated when MAb660 was reacted with 2ME treated extracts.

A case of creatine kinase isomer anomaly in relation to the diagnosis of acute myocardial infarction

Creatine kinase (CK) isomers have recently been suggested to be of value in the diagnosis of acute myocardial infarction (AMI). The aim of this report was to determine whether measurement of CK isomers, especially the MM isomer and the cardio-specific marker MB isomer, is practical in the diagnosis of AMI. A 64-year-old female with consistently high values for total CK showed an electrophoretic pattern which suggested AMI. We ruled out all possible causes of increased CK, and its MB isomer, including IgGBB, beta-LP (lipoprotein) and mitochondrial complexes as well as myocarditis, muscular disorders, and myoglobinuria. Regardless of the source of the anomaly, the fact remains that CK macroanomaly cases can be an obstacle in the diagnosis of AMI. CK isomers have proven to be accurate markers in AMI and valuable in doubtful cases, such as non Q-AMI. However, in light of this particular case of CK macroanomaly, isomers are not 100% accurate (specific) in the diagnosis of AMI.

Role of MB isoforms (isomers) in the early diagnosis of acute myocardial infarction

In addition to electrocardiogram (ECG), analysis of creatinine phosphokinase (CPK), lactate dehydrogenase (LDH) and their isoenzymes is commonly employed to diagnose acute myocardial infarction (AMI). The aim of this study was to observe the efficiency of isomers of CPK for early diagnosis of AMI. ECG, though useful in many ways, is not 100% sensitive. The drawback involved with CPK and LDH isoenzymes is the time lag factor in diagnosing AMI early enough for interventional therapy. Recently the subunits of these isoenzymes, namely MM and now the MB isomers are being tested for their effectiveness in the early diagnosis of AMI. In our experience MB isomers were found to be accurate markers in the early diagnosis of AMI. They were especially valuable in diagnosing myocardial infarction not detectable by ECG in cases such as non-Q AMI, cardiomyopathy, and bundle branch block among other such cases.

Alterations in large gut associated lymphatic tissues (LGALT) during experimental colorectal carcinogenesis

Alterations in large gut associated lymphatic tissues (LGALT) were studied histologically during 20-methylcholanthrene (MCA) induced colorectal carcinogenesis. Precancerous changes in LGALT included hyperplasia, hyperchromasia of lymphocytes and enlargement of lymphoid follicles. In addition, follicular invasion in muscular layer and cellular disorganization of diffuse lymphatic tissues were observed in neoplasia. Since, LGALT showed remarkable changes during carcinogenesis, this aspect may be considered during assessment of preneoplastic lesions, along with other histologic features of early neoplasia.

Glomus tumor of uncertain malignant potential

Glomus tumors closely resemble the normal glomus body and have a predilection for skin and subcutaneous tissue. Clinically, Glomus tumors are present on the nail bed and are of less than 1 cm. We report a case of a male who presented with a 3 month history of swelling in the left thumb which was mildly tender. The swelling measured 6 x 6.5 cm. On microscopy the tumor showed mild atypia with increased mitotic activity. These features, by current definition, would suggest uncertain malignant potential. Keywords: Glomus tumor; Glomangioma; Merkel cell carcinoma.DOI: 10.3126/jpn.v1i1.4457 Journal of Pathology of Nepal (2011) Vol.1, 66-68  

Acute appendicitis: a 2- year review of clinical presentation and histopathology

Background: Acute appendicitis is the most common surgical emergency. Obstruction of the lumen by fecolith is the usual cause of acute appendicitis.The aim of the study was to analyze clinical presentation of acute appendicitis and its histopathological correlation. Materials and Methods: A retrospective study of acute appendicitis was done in the Department of Surgery of Helping Hands Community Hospital from January 2009 to December 2010. Three hundred forty five patients out of 415 patients with clinical diagnosis of appendicitis underwent operative treatment. The histopathological reports were reviewed and correlated with clinical diagnosis. Results: Out of 345 patients who underwent operative procedure 98% (n= 338) came with chief complaint of pain in the periumbilical region migrating to the right iliac fossa. The mean age of presentation was 42 years. Increased leucocyte count was seen in only 65% cases. Acute appendicitis was more commonly seen in male patients (214 cases, 62%). The most common per operative finding was acutely inflammed appendix (84%) followed by perforated appendix (7.5%), gangrenous appendix (3.5%) and appendicular lump (1.5%). However, histopathological diagnoses were acute appendicitis (91.9%), resolving appendicitis (3.5%), lymphoid hyperplasia (2.6%), mucocele (0.3%) and carcinoid (0.3%). Normal histology was seen in 1.4% cases. Conclusion: Though there are other causes of acute abdomen, acute appendicitis still stands first amongst all the emergencies. Histopathological examination of appendectomy specimen should not be omitted in order to see the incidence negative appendectomy rate and to avoid complications relating to malignant conditions. Keywords: Acute appendicitis; Appendectomy; Appendicular perforation; Histopathology DOI: http://dx.doi.org/10.3126/jpn.v1i2.5402 JPN 2011; 1(2): 104-107

Oral cavity lesions: A study of 21 cases

Background: Development of lesions in the oral cavity is strongly linked with smoking and alcohol consumption. Non neoplastic lesions are mainly inflammatory conditions. It has been seen that the benign lesions are more common than malignant. Materials and methods: This was a retrospective study carried out in the Department of Histopathology of Helping Hands Community Hospital during a period of one and a half years from January 2009 to June 2010. The study included 21 cases of oral cavity lesions. Results: The most common site was lip with 9 cases (42.8%) followed by buccal cavity with 5 cases (23.8%). Out of the 21 cases of oral cavity lesions, 20 cases (95.2%) were benign and 1 case (4.8%) was malignant. The malignant lesion was a case of squamous cell carcinoma of soft palate. Conclusion: Any oral cavity lesion should have a tissue diagnosis for rational management of the case and to avoid mutilating surgery. Keywords: Oral cavity; Fibroma; Mucocele DOI: 10.3126/jpn.v1i1.4452 Journal of Pathology of Nepal (2011) Vol.1, 49-51

Intestinal infection with multiple parasites including Balantidium coli

Balantidium coli is only parasitic ciliate and infrequent pathogen for human beings. The infection fundamentally affects the colon and causes variable clinical pictures, from asymptomatic to serious dysenteric forms. We present a case of diarrhea and abdominal discomfort with multiple parasites including B. coli in a patient from Sunsari, Nepal. DOI: 10.3126/hren.v9i1.4362Health Renaissance, 2011: Vol.9 No.1:45-46

Histopathological pattern of endometrial samples in abnormal uterine bleeding

Background: Histological characteristics of endometrial biopsy material as assessed by light microscopy remain the diagnostic standard for the clinical diagnosis of endometrial pathology. Management of abnormal uterine bleeding is not complete without tissue diagnosis. The aim of the study was to find out the histopathological pattern of the endometrium in abnormal uterine bleeding. Materials and Methods: Endometrial biopsy specimens received from Jan 2007 to Nov 2010 were studied retrospectively in the Department of Histopathology, Helping Hands Community Hospital, Kathmandu. The specimens were routinely processed and the hematoxyllin and eosin stained slides were studied. Results: A total of 300 specimens were analyzed. In the group of patients less than 40 years of age, 73 (50%) were normal, 34(23%) had abnormal physiologic changes and 13 (9%) had pregnancy related complications and benign changes. In the age group between 40 – 55 years, abnormal physiological changes, benign conditions and normal physiological changes were 45 (32%), 41 (29%) and 37 (26%) respectively. In the age group > 55 years, there were 3(21%) malignant and 3(21%) benign conditions. There were 5(36%) unsatisfactory samples in this age group. Conclusion: It is important to know the histological pattern of the endometrium in abnormal uterine bleeding in different age groups since it will help in the management of the cases. In this study endometrial hyperplasias were seen in 55 cases (18.8%). The importance of studying the histological pattern of endometrium in abnormal uterine bleeding in different age group is to help in correctly managing the cases. Keywords: Endometrium; Simple hyperplasia; Complex hyperplasia; Endometritis; Endometrial Carcinoma. DOI: 10.3126/jpn.v1i1.4443 Journal of Pathology of Nepal (2011) Vol.1, 13-16