Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Basal Cell Carcinoma in Cases with or without Xeroderma Pigmentosum

Introduction: Basal cell carcinoma is the most common form of cancer in humans and comprises the vast majority of skin cancers. It predominantly affects fair-skinned individuals, and its incidence is rapidly increasing. The objective of the study is to identify the epidemiology, its topography and different histological subtypes of basal cell carcinoma in patients with or without Xeroderma Pigmentosum. Methods: A cross-sectional descriptive study was conducted at Manipal Teaching Hospital, Pokhara from Jan 2009 to Dec 2016. Ethical approval was taken from MEMG/IRC/GA. The study included patients with a confirmed diagnosis of basal cell carcinoma irrespective of their age and sex. Results: This study showed 77 individuals with 91 biopsies of BCC including 5 cases of Xeroderma Pigmentosum. The predominant histological subtype was nodular with 41 (53.94%) cases, followed by the 14 (18.42%) cases of pigmented and 10 (13.15%) cases baso-squamous subtype. The most frequent sites of involvement were the head and neck, with predominance in the nasal and orbital region. The mean age was 57.68 years but the basal cell carcinoma in cases of Xeroderma Pigmentosum was seen more in younger age groups. There were 43 (55.84 %) male patients and 34 (44.16 %) female patients with a male to female ratio of 1.26:1. Conclusions: Nodular and pigmented varieties were the most frequent subtypes with nose being the commonest site of involvement. Basal cell carcinomas in cases of Xeroderma Pigmentosum were noted in younger age group with multiple lesions. Keywords:   basal cell carcinoma; recurrence; topography; xeroderma pigmentosum.

Squamous cell carcinoma arising in familial gingival fibromatosis-a rare case report

Familial gingival fibromatosis is a rare hereditary condition due to chromosomal abnormality which can occur as an isolated disease or as part of a syndrome and has an incidence of 1:350 000. This condition leads to esthetic, functional, psychological and masticatory disturbance of the oral cavity. Here, we present a case of 21-year-old female with severe enlargement of gums in maxilla and mandible. Deciduous teeth were erupted at normal age but the permanent teeth in the oral cavity were not erupted. Her grandmother, father and younger sister were also affected with the same condition. Incisional biopsy from the chronic ulcerated gingiva showed squamous cell carcinoma. Patient was referred to other cancer institution, where metastases to lung, bone and lymph node was detected on CT scan. The diagnosis was made based on clinical examination, family history and histopathological examination.

Basal Cell Carcinoma in Cases with or without Xeroderma Pigmentosum

INTRODUCTION

Basal cell carcinoma is the most common form of cancer in humans and comprises the vast majority of skin cancers. It predominantly affects fair-skinned individuals, and its incidence is rapidly increasing. The objective of the study is to identify the epidemiology, its topography and different histological subtypes of basal cell carcinoma in patients with or without Xeroderma Pigmentosum.

METHODS

A cross-sectional descriptive study was conducted at Manipal Teaching Hospital, Pokhara from Jan 2009 to Dec 2016. Ethical approval was taken from MEMG/IRC/GA. The study included patients with a confirmed diagnosis of basal cell carcinoma irrespective of their age and sex.

RESULTS

This study showed 77 individuals with 91 biopsies of BCC including 5 cases of Xeroderma Pigmentosum. The predominant histological subtype was nodular with 41 (53.94%) cases, followed by the 14 (18.42%) cases of pigmented and 10 (13.15%) cases baso-squamous subtype. The most frequent sites of involvement were the head and neck, with predominance in the nasal and orbital region. The mean age was 57.68 years but the basal cell carcinoma in cases of Xeroderma Pigmentosum was seen more in younger age groups. There were 43 (55.84 %) male patients and 34 (44.16 %) female patients with a male to female ratio of 1.26:1.

CONCLUSIONS

Nodular and pigmented varieties were the most frequent subtypes with nose being the commonest site of involvement. Basal cell carcinomas in cases of Xeroderma Pigmentosum were noted in younger age group with multiple lesions.

Clinicohematological Study of Pancytopenia in a Tertiary Care Hospital of Western Region of Nepal

Introduction: Pancytopenia is a relatively common hematological entity and is a manifestation of many illnesses which can be life threatening at times. The severity of pancytopenia and the underlying pathology determine the management and prognosis. This study was conducted to evaluate hematological and bone marrow findings in patients presenting with pancytopenia. Methods: It was a prospective study carried out in Department of Pathology, Manipal College of Medical Sciences, Pokhara, Nepal, during the period of January 2011 to December 2016. Clinical and hematological parameters including bone marrow aspiration and biopsy were evaluated in all patients who presented with pancytopenia. Results: Among 138 cases studied, patient’s age ranged from 2 to 82 years with a mean age of 43.95 years, and there was male predominance. Most of the patients presented with generalized weakness, pallor, dypnoea and fever. Hypoplastic marrow was seen in 38(27.5%) cases, followed by megaloblastic anemia 26 (18.8%) cases and acute leukemia 19(13.76%) cases. Other findings included one each case of hemophagocyosis, leishmaniasis, plasmodium vivex malaria and metastatic carcinoma. Conclusions: This study highlights that pancytopenia is a common hematological problem and the study of detailed primary hematological investigations along with bone marrow study in patients with pancytopenia will help to identify the cause for further planning and management. Keywords: hypoplastic marrow; leukemia; megaloblastic anemia; pancytopenia.

Clinicohematological Study of Pancytopenia in a Tertiary Care Hospital of Western Region of Nepal

INTRODUCTION

Pancytopenia is a relatively common hematological entity and is a manifestation of many illnesses which can be life threatening at times. The severity of pancytopenia and the underlying pathology determine the management and prognosis. This study was conducted to evaluate hematological and bone marrow findings in patients presenting with pancytopenia.

METHODS

A prospective observational study was conducted in Department of Pathology, Manipal College of Medical Sciences, Pokhara from January 2011 to December 2016. Clinical and hematological parameters including bone marrow aspiration and biopsy were evaluated in all patients who presented with pancytopenia.

RESULTS

Among 138 cases studied, patients' age ranged from 2 to 82 years with a mean age of 43.95 years, and there was male predominance. Most of the patients presented with generalized weakness, pallor, dypnoea and fever. Hypoplastic marrow was seen in 38 (27.5%) cases, followed by 26 (18.8%) cases of megaloblastic anemia and 19 (13.76%) cases of acute leukemia. Other findings included one case each of hemophagocyosis, leishmaniasis, plasmodium vivex malaria and metastatic carcinoma.

CONCLUSIONS

This study highlights that pancytopenia is a common hematological problem and that the study of detailed primary hematological investigations along with bone marrow study in patients with pancytopenia will help to identify the cause for further planning and management.

Clinico-pathological Study of Malignant Melanoma in A Tertiary Care Centre

Introduction: Malignant melanoma, which causes three fourth of all deaths related to skin cancer, is more common in Caucasian population compared to Asian population. There is no reliable information about malignant melanoma in Nepal hence an effort has been made to assess the clinical and pathological features of melanoma patients. Methods: This was a retrospective hospital based study done in the department of Pathology. All cases of malignant melanoma diagnosed on biopsy during a period of 13 years were retrieved, reviewed and collated. Results: We had 35 cases with age range from 15 to 84 years with the mean of 51.4 years and M: F of 1.3:1. The predominant site was lower extremities. Most cases were less than 3 cm. Majority of histologic subtypes were nodular melanoma 29 (82.8%) followed by mucosal lentiginous melanoma 3 (8.6%), superficial spreading melanoma 2 (5.7%) and acral lentiginous melanoma 1 (2.9%). Half (50%) of the excisional biopsies were at Clark’s level IV and 75% were at high Breslow thickness. Conclusions: The most frequent site in males and females were lower extremities and trunk respectively in contrast to Western studies where it is opposite. Nodular melanoma was the commonest histologic subtype while in other Asian studies and in Western studies majority were acral lentiginous melanoma and superficial spreading melanoma respectively. Keywords: Breslow thickness; Clark’s level; malignant melanoma; nodular melanoma.

Clinicopathological Study of Malignant Melanoma at Tertiary Care Centre

INTRODUCTION

Malignant melanoma, which causes three fourth of all deaths related to skin cancer, is more common in Caucasian population compared to Asian population. There is no reliable information about malignant melanoma in Nepal hence an effort has been made to assess the clinical and pathological features of melanoma patients.

METHODS

This was a retrospective hospital based study done in the department of Pathology. All cases of malignant melanoma diagnosed on biopsy during a period of 13 years were retrieved, reviewed and collated.

RESULTS

We had 35 cases with age range from 15 to 84 years with the mean of 51.4 years and M: F of 1.3:1. The predominant site was lower extremities. Most cases were less than 3 cm. Majority of histologic subtypes were nodular melanoma 29 (82.8%) followed by mucosal lentiginous melanoma 3 (8.6%), superficial spreading melanoma 2 (5.7%) and acral lentiginous melanoma 1 (2.9%). Half (50%) of the excisional biopsies were at Clark's level IV and 75% were at high Breslow thickness.

CONCLUSIONS

The most frequent site in males and females were lower extremities and trunk respectively in contrast to Western studies where it is opposite. Nodular melanoma was the commonest histologic subtype while in other Asian studies and in Western studies majority were acral lentiginous melanoma and superficial spreading melanoma respectively.

Histopathological Analysis of Non-Neoplastic Superficial Lymphadenopathies

Background Lymphadenopathies are the clinical manifestation of enlargement of lymph nodes which are a common occurrence and are processes of lymph nodes in response to a variety of exogenous and endogenous stimulants. The vast majority of enlarged lymph nodes are non- neoplastic. Objective The objective of the study is to analyze the spectrum of non-neoplastic lesions of superficial lymphadenopathies with their histomorphological features. Method This was a retrospective hospital based study done in the department of Pathology. All cases of superficial lymph node biopsies received during a period of 7 years were retrieved and divided into 2 broad categories: neoplastic and non-neoplastic. The latter group is the material for the present study. The diagnosis was made on morphological basis. Result Of all the 268 superficial lymph node biopsies, 25.4% (68 cases) were neoplastic and 74.6% (200 cases) were non-neoplastic. The non-neoplastic cases were further categorized into non-infectious 60.5% (121 cases) and infectious 39.5% (79 cases). Neck node (70%) was the most common site of involvement. There were 102 male and 98 female patients with male to female ratio 1.04:1. The age range of the patients was 2 years to 83 years with a mean of 27.16 years and most common being 11-20 years 29% (58 cases). Majority of the cases were non-specific reactive lymphadenitis 84.3% (102 cases) followed by tuberculosis 36.5% (73 cases). Conclusion The major cause for the superficial lymphadenopathy was found to be non-neoplastic etiology with slight male predominance. Reactive lymphadenitis was the leading cause unlike the studies done in other Asian and Tropical countries where tuberculosis was more common.

Cavitation-Induced Fracture Causes Nanocorrugations in Brittle Metallic Glasses

Brittle metallic glasses exhibit a unique and intriguing fracture morphology of periodic nanocorrugations whose spacing and amplitude are of the order of tens of nanometers. We show through continuum simulations that they fail by spontaneous and simultaneous cavitation within multiple weak zones arising due to intrinsic atomic density fluctuations ahead of a notch tip. Dynamic crack growth would then occur along curved but narrowly confined shear bands that link the growing cavities. This mechanism involves little dissipation and also explains the formation of nanocorrugations.

Ovarian Tumors: Pattern of Histomorphological Types- A 10 Years Study in a Tertiary Referral Center and Review of Literature

Background Ovarian cancer accounts for 6% of all cancers in females. Among cancers of female genital tract, the incidence of ovarian cancers ranks below only carcinoma of the cervix and the endometrium. Objective To find the frequency of different types of histomorphological types and their association with age, side and size distribution. Method This study is a hospital based retrospective study carried out in the Department of Pathology, Manipal Teaching Hospital over a time period from Jan. 2006 to Sep. 2015. Specimens were received from the Manipal Teaching Hospital and other hospitals within the Himalayan valley of Pokhara. All the clinical and histolpathological data were retrieved from the departmental data bank and were analyzed. Result A total of 409 cases of ovarian tumors have been reported in the same period. Among them, 215 cases were of surface epithelial origin including 172 benign, 07 borderline and 36 malignant cases. Among the surface epithelial tumors, the commonest was serous cystadenoma (119 cases) followed by mucinous cyst adenoma (40 cases). There were 176 cases of tumors with germ cell origin which included 170 cases of teratoma, four dysgerminoma and one each case of choriocarcinoma and yolk sac tumor. Among seven metastatic tumors, one case was of Krukenberg tumor. Age range was 12 to 90 years and the size range from 3 to 36 cm. Conclusion In our study, we analyzed all the spectrum of ovarian tumors diagnosed on morphological bases and most of the findings were similar to other national and international studies. However, we have reported increased percentage of mucinous tumors and less sex cord stromal tumors.

Tablet in the bronchus--an unusual cause for persistent cough in a 64 year old gentleman

Foreign body aspiration in adults without any background risk factors is uncommon. We report a 64 year gentleman evaluated for persistent cough incidentally detected to have a foreign body (FB) in the left main bronchus (LMB), which after removal by rigid bronchoscopy turned out to be a tablet. This demonstrates the possible risk of silent aspiration of solid foreign bodies and in our case presenting as a persistent cough after months of aspiration. Bronchoscopic evaluation should be carried out in the differential diagnosis of persistent or recurrent pulmonary symptoms.

Clinicopathological features of pilomatricoma cases: Analysis of 21 cases

Background: Pilomatricoma is a slow-growing, asymptomatic tumour originating from outer sheath cells of hair follicle. In this study, we describe the clinical presentation and histopathological features of pilomatricoma. Materials and Methods: This was a hospital based retrospective study carried out in all patients who were diagnosed as pilomatricoma over a period of January 2001 to December 2013. The study was done in department of pathology, Manipal Teaching Hospital, Nepal. Results: A total of 21 cases of pilomatricoma were reported with age range of 9-53 years (mean age 23.7) and male female ratio of 1:1.1. The most common site of occurrence was neck and preauricular region. The size of the tumour ranged from 0.3 to 4.7cm with a mean of 1.2cm. Multiple occurrences were seen in 3 patients and ossifying pilomarticoma was seen in 4 cases. Conclusion: Pilomatricoma is a benign skin neoplasm of hair follicle matrix cells. Calcification is a common finding while dystrophic ossification also can occur in the tumour. Histopathology gives the definite diagnosis as fine needle aspiration cytology and clinical impression may be misleading. DOI: http://dx.doi.org/10.3126/jpn.v4i7.10293 Journal of Pathology of Nepal (2014) Vol. 4, 530-533

A case of concomitant Hodgkin's lymphoma with tuberculosis

Tuberculosis (TB) presenting with Hodgkin's Lymphoma is a rare and difficult clinical situation for any physician to identify and to manage because of very similar clinical presentation. Herein we report a case of 29 year old woman who presented with enlarged lymph nodes, diagnosed and initiated on therapy for TB, based on the cervical node biopsy that showed granulomatous lymphadenitis suggestive of TB. Despite being on regular isoniazid, rifampicin, pyrazinamide and ethambutol regimen, she did not improve but worsened clinically! After an extensive work up that included endobronchial ultrasound (EBUS) and mediastinoscopy, a diagnosis of Hodgkin's disease of nodular sclerosis type was made. She was treated with chemotherapy and radiotherapy along with her TB therapy. Patient showed significant improvement following therapy.

Ovarian Germ Cell Tumor – Histopathological and statistical analysis

Background: Ovarian cancers are common among females. The ovarian tumors are classified according to its histogenesis. In the present study, we analyzed the germ cell ovarian tumors reported in our institute. Materials and Methods: This study was a hospital based retrospective study. All ovarian germ cell tumor reported from Jan 2001 to Feb 2013 were retrieved and analyzed. The specimens were routinely processed and the slides were stained with H&E and special stains wherever required. Results: A total of 340 cases of ovarian tumors were reported and 150 cases (44%) were of germ cell origin. We had 137 cases of benign and 13 cases of malignant germ cell tumors. Most common subtype was mature cystic teratoma comprising 125 cases. Among the malignant cases, the most common was immature teratoma (5 cases). Age range in our series was from 8 to 82 years (mean 28 years). The most common age group affected was 21-30 years. Most of the malignant cases (76.9%) were in less than 30 years. Among the malignant cases majority (84.6%) were more than 10 cm in size. None of the malignant germ cell tumors were bilateral. Conclusion: Among germ cell tumors of ovary, mature cystic teratoma is the most common tumor and malignant subtypes are uncommon. Malignant tumors tend to occur in younger age group. DOI: http://dx.doi.org/10.3126/jpn.v3i6.8990 Journal of Pathology of Nepal (2013) Vol. 3, 441-446

The role of pleuroscopy in undiagnosed exudative pleural effusion

Aims:

To find the diagnostic yield of a pleuroscopic pleural biopsy and to find the complication rates.

Settings and Design:

Institutional based prospective study.

Materials and Methods:

Sixty-eight consecutive patients who had undiagnosed exudative pleural effusion were recruited for pleuroscopy from September 2007 to August 2010.

Results:

A total of 68 patients (55 males and 13 females; mean age 49 years) underwent pleuroscopy. Malignancy was diagnosed in 24 patients, 22 patients had non-specific inflammation, tuberculosis was found in 16 patients, empyema was found in 2 patients, 1 patient had sarcoidosis, 1 patient had normal pleura and it was non-diagnostic in 2 patients. The diagnostic yield was 97%. There were no major complications, only four patients had minor complication like subcutaneous emphysema (three patients) and prolonged air leak (one patient).

Conclusions:

Pleuroscopy is a safe, simple, and valuable tool in the diagnosis of undiagnosed exudative pleural effusion with minimal complication rates.

Value of image-guided fine-needle aspiration cytology-a study of 500 cases

Guided Fine-Needle Aspiration Cytology (FNAC) as the first line investigation is not only useful in diagnosis of space occupying lesions but can also help in choosing appropriate management. This technique is most useful in diagnosing metastasis but is also helpful in excluding malignancy in some cases. Aim of this study is to analyze the spectrum of cytological diagnosis, adequacy, and clinicoradiological correlation of guided FNAC. The study was carried out in the departments of pathology and radiology for a period from January 2000 to November 2011. All the data were retrieved from hospital medical record section and departmental data bank and were analyzed. We have performed a total of 500 FNACs, including 234 under CT guidance and 266 under USG guidance. Among the CT-guided FNACs, 87.6% (205 cases) had adequate material which included 152 malignant cases, 38 inflammatory cases and 15 benign cases. Among the cases under USG, 91.7% (244 cases) had adequate material comprising of 112 malignant cases, 44 inflammatory cases, and 88 benign lesions. It was noted that increased number of inadequate aspirate was from lesions with smaller size and increased depth. Out of total 264 malignant cases diagnosed on FNAC, 160 cases were identified as malignant on clinical and radiological findings. Guided FNAC is useful in deep seated lesions as well as in suspicious superficial lesions and is a safe diagnostic tool. If performed properly and correlated well with clinical and radiological findings, FNAC provides correct diagnosis in most cases.

Patterns of hematological and non-hematological malignancies in bone marrow in a tertiary care hospital in Nepal--11 years study

Developing countries bear more than half of the global cancer burden and the leukemia comprises of 3% of all malignancies with an incidence of 300,500 per year. The patterns of subtypes of leukemias vary in different populations and geographic areas. Here, we analyze both the hematological and non-hematological malignancies in the Western region of Nepal. This is a retrospective study done from Janauary 2000 to June 2011. All cases of bone marrow malignancies including leukemias, multiple myeloma and infiltration/metastasis to bone marrow were included in the study. Morphological subtypes {FAB (French, American and British) classification}, gender, age at diagnosis and peripheral blood counts of all the cases were analyzed. A total of 155 cases of hematological and non-hematological malignancies were reported during this period. Age ranged from 1 year to 82 years. Among 123 leukemia cases, acute myeloid leukemia (AML) was the commonest (80 cases) followed by chronic myeloid leukemia (CML) (20 cases), acute lymphoid leukemia (ALL) (16 cases) and chronic lymphoid leukemia (CLL) (7 cases). The commonest childhood leukemia below 15 years was AML followed by ALL. The commonest subtypes of AML and ALL were M2 and L2 respectively. CML cases in our study were less common and females were more affected than other parts of the country. There were 23 cases of multiple myeloma and 9 cases of infiltration/metastasis to marrow. Males were more affected by multiple myeloma in our study. Our data reflects bone marrow malignancies in the Western region of Nepal which is more comparable to the Central than Eastern region of Nepal.

Atomic scale fluctuations govern brittle fracture and cavitation behavior in metallic glasses

We perform atomistic simulations on the fracture behavior of two typical metallic glasses, one brittle (FeP) and the other ductile (CuZr), and show that brittle fracture in the FeP glass is governed by an intrinsic cavitation mechanism near crack tips in contrast to extensive shear banding in the ductile CuZr glass. We show that a high degree of atomic scale spatial fluctuations in the local properties is the main reason for the observed cavitation behavior in the brittle metallic glass. Our study corroborates with recent experimental observations of nanoscale cavity nucleation found on the brittle fracture surfaces of metallic glasses and provides important insights into the root cause of the ductile versus brittle behavior in such materials.

Whole lung lavage for pulmonary alveolar proteinosis

A 26-year-old male presented with complaints of dry cough of six months and progressive breathlessness of three months duration. He was coughing out milky white sputum for two months and had lost 12 kg weight in two months. He had an evening rise in temperature of one month duration. Clinically, the patient was in respiratory distress and the respiratory system examination revealed bilateral velcro crackles. High resolution computed tomography chest showed bilateral diffuse reticulonodular opacities and "Crazy Paving" pattern suggestive of alveolar proteinosis. Broncho alveolar lavage showed eosinophilic granular material, which was periodic acid-Schiff positive. Open lung biopsy was done to confirm the diagnosis and the histopathologic examination revealed eosinophilic secretions with granular appearance suggestive of pulmonary alveolar proteinosis. Subsequently, patient underwent bilateral sequential whole lung lavage under general anesthesia. Patient showed marked clinical and radiological improvement after sequential whole lung lavage.

Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India

Background:

The biological behavior of endometrial carcinoma differs in epidemiology, presentation, and prognosis, suggesting that there are two fundamentally different pathogenic types of disease: type I (estrogen related, endometrioid type) and type II (non-estrogen related, non-endometrioid type). Untreated hyperplasia can develop into an endometrioid type of adenocarcinoma, hence, it is important to recognize the former type. In contrast to cervical cancers, there are limited studies with respect to the biology of hyperplastic lesions documented from India. This was a 16-year retrospective study, carried out to determine the nature and outcome of proliferative lesions of the endometrium in a referral center from south India.

Materials and Methods:

A histopathological diagnosis of the endometrial hyperplasia, polyp, and carcinoma, on endometrial biopsy and hysterectomy specimens, over a 16 year period (1983 to 1999), were recorded in a computer and the case slides were reviewed. Using the computer software Foxpro, the patients who had come more than once for a subsequent or previous biopsy were identified. An attempt was made to look for progression, regression or a static nature of the lesion in the follow-up cases.

Results:

A total of 1778 cases were studied, and only 74 patients with endometrial hyperplasia and five cases of benign endometrial polyp had follow-up endometrial histopathology. Hyperplasia cases included 59 cases of simple hyperplasia, 10 cases of complex hyperplasia without atypia, and five cases with atypia. The predominant age for patients with all types of hyperplasias was 41 – 50 years. Progression to a higher grade was seen in 8.10%, regression to a lower grade was seen in 9.45%, lesions reverted to a normal pattern in 10.81% cases, and lesions persisted in 70.27% of the cases. A mixed pattern was seen in 54 cases, with predominant coexistent lesion being simple and complex hyperplasia without atypia.

Conclusion:

The fate of the hyperplastic lesion of the endometrium showed a varied pattern. Follow-up cases predominantly showed persistence of the lesion, possibly resulting from a fluctuating but higher level of estrogenic stimulus. Hence, it was not only the high levels of estrogen that influenced the biology, but its sustenance for a prolonged period.

Delay in surgery for acute appendicitis

BACKGROUND

The present study investigates the effect of delay in appendicectomy on the outcome of surgery and also examines the contribution of patient and physician related delay to the stage of appendicitis.

METHODS

During a 12-month period, 114 consecutive adult patients undergoing appendicectomy for acute appendicitis were monitored prospectively. Time of onset of symptoms, presentation to the hospital, surgery consultation, decision to operate and starting of surgery were all noted. The stage of the appendicitis was identified based on operative findings and pathology reports. Postoperative events were recorded. The stage of appendicitis and outcome were related to the prehospital and in-hospital delay of each patient.

RESULTS

There were three (2.6%) normal, 62 (54.4%) early inflamed and 49 (43%) cases of advanced appendicitis. The total delay from onset of symptoms to performance of appendicectomy was 2.4 times longer in the advanced appendicitis group than in the early inflamed appendicitis group. There was no significant difference in the in-hospital delay between the two groups. Delay in the resumption of oral feed and total hospital stay were significantly higher in the advanced appendicitis group.

CONCLUSIONS

The present prospective study concludes that morbidity caused by acute appendicitis correlates directly with delay in treatment. In the majority of cases the delay in treatment is predominantly caused by patient related factors. The negative appendicectomy rate can be reduced by close observation of cases with clinical uncertainty without increasing the morbidity.

Tuberculin reactivity in tuberculous meningitis

OBJECTIVE

To study tuberculin reactivity in childhood tuberculous meningitis both in clinical and histopathological (HP) context.

METHODOLOGY

Children with tuberculous meningitis (TBM) were given tuberculin test by Mantoux technique, which was read at the end of 72 hours after the placement of skin test. Histopathological examination of the punch biopsy specimen of the tuberculin test site was performed and histopathological grading of the tuberculin reaction was compared with clinical reaction and clinical parameters.

RESULTS

Of the 50 children studied, 68% of them were malnourished and 42% had BCG scar. Tuberculin test was positive in 22 (44%) cases. Spearman analysis showed negative correlation between stage of TBM and the size of tuberculin reaction. BCG status did not affect the size of tuberculin reaction. Histopathological grade of the tuberculin reaction was found to be directly proportional to the size of the tuberculin reaction and it was not affected by the stage of TBM.

CONCLUSION

Tuberculin positivity is low in TBM irrespective of the nutritional status. At least some degree of inflammatory reaction can be seen at the site of tuberculin administration. In tuberculin negative cases, varying grades of cellular response in the absence of clinical induration can be seen in histopathology.

Extra-Articular Pigmented Villonodular Synovitis

Villonodular synovitis are a group of idiopathic lesions that affect the synovial surfaces of joints, tendon sheaths, and bursae, causing tumor-like lesions. Pigmented villonodular synovitis rarely affects the tendon sheaths; its occurrence in extra-articular sites is uncommon. This case is presented for the rarity of occurrence. The literature is also reviewed.

Laboratory testing protocol to identify critical factors in bacterial compliance monitoring

This research focused on providing guidelines for water utilities on the collection and handling of routine bacteriological samples and in developing scientifically-based approaches in selecting the most representative sampling locations. A laboratory-scale pilot distribution system was designed comprising two parallel loops, one using unlined cast-iron pipe and one using PVC pipe. Each loop contained six sampling ports, including (1) a distribution main dead end faucet, (2) one long (5.5 m; 18 feet) and (3) one short (0.3 m; 1 foot) household copper service line with threaded hose-bibb taps, (4) one hose-bibb with welded faucet, (5) one dedicated sampling port (modeled after a manufacturer's specifications) and (6) one laboratory-style (PVC) stop-cock sampling port. Residual chlorine concentrations were maintained at 0, 0.5, 1.5 and 2.0 mg/L stages during the course of the experiment. Bacterial samples were collected from the different sampling ports and assayed by membrane filtration and/or spread plate. Nutrient and R2A agars were used for heterotrophic plate counts (HPC), m-Endo agar for total coliform (TC) counts and Chromocult agar for injured bacterial analyses. Several methods of sample collection were tested using various combinations of flushing and tap disinfection, including "first flush" (no flushing, without tap disinfection), flushing only, tap disinfection only (using alcohol or hypochlorite solution) and flushing coupled with tap disinfection. The results indicated that the bacterial counts in samples drawn from dead ends were not significantly different from counts in samples from the other sample port configurations. First flush samples consistently produced the highest bacterial count results. Bacterial counts in samples from the long household copper service line were typically three orders of magnitude higher than in samples from the other sample ports. Thus, there is evidence that long copper household service connections may be unsuitable sample tap configurations for collecting samples intended to represent microbial quality in the distribution system.

Effect of erythromycin and cisapride on emptying of the vagally denervated intrathoracic stomach

BACKGROUND

Subsequent to esophagectomy and reconstruction among patients with esophageal cancers, the intrathoracic denervated stomach acts as a passive conduit without peristalsis.

OBJECTIVE

The study was designed to assess the impact of two prokinetic drugs viz. erythromycin and cisapride on the emptying of vagally denervated intrathoracic stomach.

METHODS

Twenty consecutive patients of carcinoma esophagus, who had undergone one stage transhiatal oesophagectomy with cervical esophagogastrostomy and were disease free at three months postoperative follow-up, were included in the study. These patients were randomised into two groups of ten each. The patients in group A received erythromycin, while patients in group B received cisapride. The gastric emptying was studied by scintigraphy, using a standard test meal containing 99m Tc sulphur colloid labelled 'IDLIS' [rice based radio labelled food] before and after the drug treatment.

RESULTS

The pre and post treatment mean gastric half emptying time of the patients in the erythromycin group was 52.6 min and 49.7 min (p > 0.1) and in cisapride group it was 53.76 and 26.4 min respectively (p < 0.05). Intergroup comparison of the difference was not statistically significant.

CONCLUSION

Cisapride is an effective prokinetic agent in the treatment of gastric stasis of the vagally denervated intrathoracic stomach.

A unique case of metastatic penile basal cell carcinoma

Basal cell carcinoma rarely arises in the penis and metastasizes infrequently. This article presents probably the first case report of a metastatic penile basal cell carcinoma.

Microbial Dynamics in Oil-Impacted Prairie Soil

A remote site in the Tallgrass Prairie Preserve (Osage County, OK) was contaminated with crude oil by a pipeline break in 1992. In 1996, the contaminated soil was bioremediated by blending with uncontaminated soil, prairie hay, buffalo manure, and commercial fertilizers, and spreading in a shallow layer over uncontaminated soil to create a landfarm. The landfarm was monitored for two years for aerobic and anaerobic bacteria, soil gases indicative of microbial activity, and for changes in the concentration of total petroleum hydrocarbons (TPH). Levels of hydrocarbon degraders and soil gas indicators of aerobic degradation were stimulated in the landfarm during the first warm season relative to uncontaminated prairie soil. However, these same indicators were less conclusive during the second warm season, indicating depletion of the more easily degradable hydrocarbons, although the landfarm still contained 6,800 mg/kg TPH on the average at the beginning of the second warm season. Methane formation and methanogen counts were clearly stimulated in the first warm season relative to uncontaminated prairie soil, indicating that methanogenesis plays an important role in the mineralization of hydrocarbons even in these shallow soils.

Wuchereria bancrofti microfilariae in the dentigerous cystic fluid: an unusual presentation

An unexpected and unusual presence of Wuchereria bancrofti microfilariae in the cystic fluid of a maxillary dentigerous cyst in an 8-year-old boy is being reported for the first time. This was an incidental finding during routine fine-needle aspiration cytological examination.

Fine-needle aspiration cytology in the diagnosis of superficial lymphadenopathy: an analysis of 2,418 cases

During a period of 5 yr, 2,418 fine-needle aspirations (FNA) were performed on 2,216 patients with superficial lymphadenopathy. Chronic nonspecific lymphadenitis was the commonest inflammatory lesion followed by tuberculosis. Among malignant lesions, metastatic tumors were most common followed by non-Hodgkin's lymphoma. The FNAC findings were correlated with subsequent histopathological diagnosis in 1,041 cases. The sensitivity rates of FNAC in tuberculosis, metastatic tumors, Hodgkin's disease, and non-Hodgkin's lymphoma were found to be 83.3, 97, 30, and 80.3%, respectively, the specificity being 94.3, 98.9, 98.6, and 95.4% in the same order. Immunocytochemical tests performed on the aspirated material helped in classifying the metastatic poorly differentiated tumors and confirming the diagnosis of non-Hodgkin's lymphomas. Effects of FNA on subsequent biopsy in 81 lymph nodes with benign hyperplasia were studied and showed that aspiration does not interfere with subsequent histologic assessment. Thus FNAC is a simple, inexpensive procedure, and when complemented by appropriate immunocytochemical studies is accurate and reliable for routine diagnosis of lymphadenopathy.

Cutaneous lymphoma mimicking seborrhoeic dermatitis

A case of non Hodgkins lymphoma presenting with cutaneous lesions mimicking seborrhoeic dermatitis is reported. Clinician should have a high index of suspicion to diagnose lymphoma in its early stage, since it can mimic many benign dermatoses.

Accuracy of fine needle aspiration cytology of abdominal masses without radiological guidance

This study was undertaken to evaluate the accuracy of FNAC of abdominal masses without the help of radiological guidance and to determine factors which affect the outcome of the procedure. Five hundred consecutive patients were studied. FNAC was reported by a single cytopathologist without knowledge of subsequent histology. In calculating indices of accuracy of FNAC only those patients in whom both FNAC and histology reports were available (N = 383) were considered. The overall incidence of unsatisfactory specimens was 5.6%. Consistency of the mass did not affect accuracy of FNAC. However, age (below 12 years) plane of the swelling, mobility of mass and size of the swelling, all significantly affected the adequacy of cytological yield. The overall true positive rate was 100.0% and there were no false positives. The true negative rate was 40.2% and false negative rate was 70.9%. The high false negative rates in hepatic and pancreatic lesions can be reduced by imaging techniques. Luminal organs had poor accuracy rates. The overall accuracy rate was 73.5%, comparable to that reported in literature. A positive diagnosis of malignancy had a 100% predictive value. Overall, it appears that nonguided FNAC is as accurate as guided FNAC except for very small lesions or discrete lesions such as hepatic secondaries where guidance may be useful.

Coexisting tuberculosis and carcinoma of the colon

Four cases of coexisting tuberculosis and carcinoma of the colon (CTCC) are reported. All the patients were female and the mean age was 49 +/- 11 years. The tumour involved the right colon in three patients and the distal transverse colon in the other. The two lesions coexisted at the same site in two patients. Mucinous carcinoma was the predominant type seen in three patients. The characteristics of patients with CTCC were compared with those of 54 patients who had carcinoma of the colon (CC) and 17 patients with tuberculosis of the colon (TC) seen during the same period. All the four CTCC patients were female, compared with 13 of 54 patients with CC (P less than 0.001). These two groups were similar in mean age, anatomic sites and histopathological tumour types. The CTCC patients were significantly older than the TC patients (49 +/- 11 years vs 34 +/- 10 years, P less than 0.05). The sex distribution of TC patients was similar to that of CTCC patients, 14 of 17 patients being female. All TC lesions were confined to the right colon. The present study showed a high frequency of carcinoma in patients with colonic tuberculosis, signifying the need for epidemiological and histopathological investigations into the aetiological relationship between the two diseases, the possibility of which was suggested recently by Japanese researchers. The relevant literature on 58 previously reported patients with CTCC was reviewed.

Role of fine needle aspiration cytology in the management of thoracic lesions

Fine needle aspiration cytology was performed on 121 occasions in 100 patients with various thoracic lesions. The investigation was performed chiefly with the help of straight and lateral chest skiagrams regardless of the size or depth of the lesion. The cellular yield was 87.6%. Positive diagnosis of malignancy could be made in 50 cases. The histopathological correlation in malignant cases was 80%. Non-malignant cytology including neoplastic and inflammatory pathology was also found useful in patient management. This report highlights the versatile role of this procedure in arriving at a diagnosis and planning the treatment for malignant as well as non-malignant thoracic diseases.