Prevalence and One-year Outcome of Carotid Sinus Hypersensitivity in Unexplained Syncope: A Prospective Cohort Study from South India

Background Carotid sinus syndrome accounts for one third of patients who presents with unexplained syncope. Prevalence of carotid sinus hypersensitivity (CSH) in Indians has not been studied till now. Objectives To assess the prevalence and associations of CSH in symptomatic patients above 50 years and to study its prognostic significance pertaining to sudden cardiac death, syncope, recurrent pre syncope and falls on 1 year follow up. Methods Patients above 50 years who presented with unexplained syncope, recurrent syncope or falls were considered cases and those without these symptoms were considered as controls. All the patients underwent carotid sinus massage and their responses noted. All symptomatic patients were followed up and observed for events like sudden cardiac death, syncope, recurrent pre syncope and falls during 1 year follow up. Patients with recurrent syncope and predominant cardioinhibitory syncope were advised permanent pacemaker implantation. Results A total of 252 patients were screened, 130 patients constituted cases and 49 patients constituted controls. CSH was demonstrable in 32% (n = 42) of cases as compared to 8% (n = 4) in controls (p < 0.001). Cardioinhibitory response was the predominant response (88%, n = 38) followed by mixed response (12%, n = 4). CSH was associated with advancing age, male gender (93%, n = 39, p < 0.001) and history of smoking (63%, n = 27, p = 0.009). Composite outcomes of sudden cardiac death, syncope, recurrent pre syncope and falls were significantly higher in patients with symptomatic CSH than in those without it (45%, n = 16 vs. 6.8%, n = 6; p < 0.001). Conclusions In conclusion, the prevalence of CSH in patients above 50 yrs with unexplained syncope was high in our population. Patients with CSH and baseline symptoms developed recurrent syncope during follow up. Carotid sinus massage should be a part of routine examination protocol for unexplained syncope.

Evaluation of epidermal growth factor receptor mutations based on mutation specific immunohistochemistry in non-small cell lung cancer: A preliminary study.

Background & objectives: Studies have shown that immunohistochemical (IHC) staining using epidermal growth factor receptor (EGFR) mutation specific antibodies, is an easy and cost-effective, screening method compared with molecular techniques. The purpose of present study was to assess the percentage positivity of IHC using EGFR mutation specific antibodies in lung biopsy samples from patients with primary lung adenocarcinoma (ADC). Methods: Two hundred and six biopsies of primary lung ADC were subjected to EGFR mutation specific antibodies against del E746-A750 and L858R. Detection of EGFR mutation done by high resolution melting analysis (HRM) was used as gold standard. A concordance was established between molecular and IHC results. Frequency of IHC positivity was assessed. Results: Of the 206 patients, 129 were male and 77 were female patients, with a mean age of 54.1 yr. Fifty five (26.6%) patients (36 men; 19 women) showed positivity for IHC of del E746-A750 (33) and L858R (22). HRM results were available in 14 patients which showed EGFR mutations in correspondence with del E746-750 or L858R in 64.2 per cent cases. Positive cases on HRM were further confirmed by DNA sequencing and fragment analysis. Three patients showed exon20 variation. Two cases were negative for mutation. The genotype of del E746-750 mutation was more common than L858R. A concordance was established between molecular mutation and IHC in 85.7 per cent cases. Interpretation & conclusions: In this preliminary study from India mutation specific IHC was used for assessment of mutation status of EGFR. Although the number tested was small, a good concordance was observed between molecular EGFR mutation and IHC expression. IHC methodology is a potentially useful tool to guide clinicians for personalized treatment in lung ADC, especially where facilities for molecular analysis are not readily available and for use in small biopsies where material is scant for molecular tests.

Determination of betulinic acid, oleanolic acid and ursolic acid from Achyranthes aspera L. using RP-UFLC-DAD analysis and evaluation of various parameters for their optimum yield.

Achyranthes aspera L. is a well known herb commonly used in traditional system of Indian medicine to treat various disorders, such as cough, dysentery, gonorrhea, piles, kidney stone, pneumonia, renal dropsy, skin eruptions, snake bite, etc. Here, we used RP-UFLC-DAD method for determining triterpenoids betulinic acid (BA), oleanolic acid (OA) and ursolic acid (UA) from A. aspera. Optimum yield of these compounds were studied and evaluated using parameters viz., method of extraction, time of extraction, age of plant and plant parts (leaves, stem and roots). Linear relationships in RP-UFLC-DAD analysis were obtained in the range 0.05-100 µg/mL with 0.035, 0.042 and 0.033 µg/mL LOD for BA, OA and UA, respectively. Of the variables tested, extraction method and parts used significantly affected content yield. Continuous shaking extraction (CSE) at ambient temperature gave better extraction efficiency than exposure to ultra sonic extraction (USE) or microwave assisted extraction (MAE) methods. The highest content of BA, OA and UA were determined individually in leaf, stem and root extracts with CSE. Collective yield of these triterpenoids were higher in leaf part exposed to 15 min USE method. To best of our knowledge, the study newly reports UA from A. aspera and the same was confirmed using ATR-FT-IR studies. This study explains the distribution pattern of these major triterpenoids and optimum extraction parameters in detail.

Computerized tomography guided percutaneous transthoracic fine needle aspiration of lung lesions

Introduction: Computed tomogram guided fine needle aspiration cytology (FNAC) is an important and useful investigation to differentiate between benign and malignant lesions of lungs. With computed tomography (CT) it is possible to perform a biopsy on almost any portion of lung with high degree of safety and minimal morbidity avoiding more invasive techniques. Aim: The present study was designed to assess the efficacy of CT guided fine needle aspiration of lung lesions and to assess the incidence of complications. Materials and methods: 65 cases of both sex and varying age groups referred to radiology department for CT guided lung FNAC from October 2012 to January 2013 were included in this study. Relevant clinical history and investigations were obtained from the patient. Informed and written consent was taken from the patient. The lesions were localized by CT scan and after the needle tip was confirmed to be in the desired location, aspirations were performed. Results: A total 65 cases, 53 cases were male and 12 cases were female with mean age 49.23 years. The most common diagnosis observed following biopsy was malignancy (non small cell carcinoma) in 41 cases (63%), benign lesion in 6 cases (9%) and 3% showed mixed lesions. Among 65 cases, 49 cases (75%) showed adequate material in the aspirate specimen, where as 12 cases (18.4%) showed inadequate tissue for diagnosis. However 4 cases were lost on follow up. Complications observed during procedure include pneumothorax in 11 cases (16.9%) and hemoptysis/pulmonary hemorrhage in 2 cases (3%). Conclusion: CT guided FNAC is well recognized procedure with good efficacy for evaluation of pulmonary lesions with minimal complications, most common being pneumothorax followed by hemoptysis.

Preliminary pharmacognostic screening of Achyranthes coynei stem.

Achyranthes coynei is a rare, endemic perennial shrub reported from Karnataka and Maharashtra states of India. The plant is used to treat various disorders by folk healers and was proven to have antimicrobial and antioxidant properties. The present study was undertaken to evaluate microscopic and macroscopic characters of A. coynei stem, along with its physicochemical parameters. ProgRes® CapturePro and Microsoft Excel were used for statistical analysis. Perennial, shrubby nature and woody stem were the distinguishing morphological characters observed. Transverse section (TS) illustrated quadrangular outline of the stem and showed the presence of two types of trichomes on the thick‑walled epidermis. TS also showed number of rosette calcium oxalates crystals; prismatic and microsphenoid crystals; conjoint, collateral open secondary vascular bundles; and two amphixylic medullary bundles in the pith. Ash and extractive values, micro and macro elements and nutritive factors were estimated in the present study. The presence of alkaloids, saponins and triterpenoids were observed in preliminary phytochemical screening. High‑performance thin layer chromatographic analysis yielded different bands and also indicated the presence of oleanolic acid. The studied parameters for A. coynei stem will be useful for identification and authentication of the plant material.

Monitoring seasonal variation of epicatechin and gallic acid in the bark of Saraca asoca using reverse phase high performance liquid chromatography (RP‑HPLC) method.

Background: Saraca asoca (Roxb.) Wilde (Fabaceae) is a high valued but vulnerable medicinal plant of Western Ghats region. This plant is mainly known for its use in various gynecological disorders. Objective: The objective of the present study was to investigate seasonal variation of the polyphenolic compounds viz., epicatechin and gallic acid in the bark of S. asoca by using Reverse Phase High Performance Liquid Chromatography‑Diode Array Detector (RP‑HPLC‑DAD) method. Materials and Methods: The bark was collected in six different Ritu (season) viz. Varsha (monsoon), Sharad (autumn), hemant (early winter), Shishir (winter), Vasanta (spring), and Grishma (summer) mentioned in Ayurveda. Results: The RP‑HPLC‑DAD analysis indicated that levels of epicatechin and gallic acid in the bark of S. asoca vary seasonally. The highest concentration of epicatechin was observed in Shishir Ritu (3315.19 ± 165.76 mg/100g) and gallic acid during Hemant Ritu (211.90 ± 10.60 mg/100 g). Conclusions: In present study, the ability to synthesize and accumulate both the compounds in bark of S. asoca varied greatly throughout the seasons. It was also observed that the compound epicatechin was present abundantly as compared to gallic acid throughout the seasons.

Total polyphenolic contents and in vitro antioxidant properties of eight Sida species from Western Ghats, India.

Background: Sida L., is a medicinally important genus, the species of which are widely used in traditional systems of medicine in India. Pharmacologically, roots are known for anti‑tumor, anti‑HIV, hepatoprotective, and many other properties. Phenolic antioxidants help in reducing oxidative stress occurring during treatment of such diseases. Objective: The study aimed to evaluate and compare polyphenol contents and antioxidant properties of eight selected species of Sida from Western Ghats, India. Materials and Methods: Methanolic root extracts (10% w/v) of Sida species, viz., S. acuta, S. cordata, S. cordifolia, S. indica, S. mysorensis, S. retusa, S. rhombifolia, and S. spinosa were analyzed. Results: Sida cordifolia possessed highest total phenolic content (TPC: 1.92 ± 0.10 mg Caffeic Acid Equivalent/g and 2.13 ± 0.11 mg Tannic Acid Equivalant/g), total flavonoid content (TF: 2.60 ± 0.13 mg Quercetin Equivalent/g) and also possessed highest antioxidant activities in 2,2‑diphenylpicrylhydrazyl (DPPH) radical scavenging (51.31 ± 2.57% Radical Scavenging Activity, (RSA); Trolox Equivalent Antioxidant Capacity: 566.25 ± 28.31μM; Ascorbic acid Equivalent Antioxidant Capacity: 477.80 ± 23.89 μM) and Ferric Reducing Antioxidant Power assays (TEAC: 590.67 ± 29.53 μM; AEAC: 600.67 ± 30.03 μM). Unlike DPPH and Ferric Reducing Antioxidant Power (FRAP) activity, 2, 2′‑Azinobis (3‑ethyl Benzo Thiazoline‑6‑Sulfonic acid) ABTS+ antioxidant activity was highest in S. indica (TEAC: 878.44 ± 43.92 μM; AEAC 968.44 ± 48.42 μM). It was significant to note that values of AEAC (μM) for all the antioxidant activities analyzed were higher than that of TEAC. Conclusion: The high contents of phenolic compounds in the root extracts of selected Sida species have direct correlation with their antioxidant properties. Conclusively, roots of S. cordifolia can be considered as the potential source of polyphenols and antioxidants.

Tumour morphology after neoadjuvant chemotherapy as a predictor of survival in serous ovarian cancer: an experience from a tertiary care centre in India

Serous ovarian cancer is the most common malignant ovarian tumour. Traditional management consists of surgical resection with postoperative chemotherapy. Currently neoadjuvant chemotherapy is offered to patients with advanced stage disease. The present study aims to analyse the histomorphological alterations in serous ovarian cancer following neoadjuvant chemotherapy. Correlation of these morphological alterations with survival is also presented here. Serous ovarian cancers from 100 advanced stage cases were included; 50 were treated with pre-surgery chemotherapy. Semi-quantitative scoring was used to grade the alterations in tumour morphology. Survival data was correlated with the final morphological score. Tumour morphology was significantly different in cases treated with neoadjuvant chemotherapy (CT group) as compared to cases with upfront surgery. The CT group cases showed more fibrosis, calcification, and infiltration by lymphocytes, plasma cells, foamy and hemosiderin-laden macrophages. The residual tumour cells had degenerative cytoplasmic changes with nuclear atypia. Patients with significant morphological response had a longer median survival, although it did not attain statistical significance in the current study. With the increasing use of neoadjuvant chemotherapy in management, the pathologist needs to be aware of the altered morphological appearance of tumour. Further studies are required to establish a grading system to assess the tissue response which can be helpful in predicting the overall therapeutic outcome and the prognosis of patients.

Leiomyosarcoma of inferior vena cava: A case series of four cases.

Vascular leiomyosarcomas are rare tumors, arising most frequently from inferior vena cava (IVC). They are mostly seen in sixth decade, with a female predominance. Their diagnosis is often challenging, as patients may present with non-specific complaints such as dyspnea, malaise, weight loss, abdominal pain, or back pain, preceding the diagnosis by several years. Leiomyosarcoma of the IVC most frequently occurs in the middle segment. The final diagnosis can be made by an ultrasound or computed tomography guided biopsy. Because of limited experience with this disease, optimal management of IVC leiomyosarcoma is unknown. Curative surgical resection remains the current treatment of choice for primary leiomyosarcoma of IVC. Neoadjuvant therapy may be given to downsize the tumor and increase resectability rates. Nonetheless, when complete resection is not possible, debulking combined with radiation therapy still provides good palliation. We, hereby, report four cases of this rare entity with emphasis on management.

Port site tuberculosis: A case report and review of literature.

Sumrnury: A rare case of port site tubercular infection is reported. A young male patient presented, one month after laparoscopic inguinal hernia repair with discharging sinuses at the port sites. Biopsy of the sinus tract showed features of tuberculosis. Excision of sinus tract was done and the patient was started on anti-tubercular therapy, sinuses healed. Probably, the source of tubercular infection was laparoscopic instruments. Proper sterilization of laparoscopic instruments is necessary.

Anaplastic transformation of metastatic papillary thyroid carcinoma at shoulder mimicking soft tissue sarcoma.

A 52-year-old woman presented with fracture upper end of the left humerus after trivial trauma and aspiration cytology from the lytic lesion in the upper humerus seen on X-ray revealed a metastatic papillary carcinoma from the thyroid. Total thyroidectomy confirmed the papillary carcinoma thyroid. Post-operatively, she was given radioactive iodine (I-131) ablation therapy for 8 years and was asymptomatic during this period; however, for the last 1 year, she has been complaining of swelling in the shoulder, which did not respond to palliative radiotherapy and rapidly increased in size. Disarticulation of the shoulder joint was performed, which showed anaplastic carcinoma on histopathological examination. Anaplastic transformation of papillary carcinoma at the metastatic sites is well documented in the literature and is rare. However, the same has not been reported at the shoulder and from India before. Although soft tissue sarcomas are most common at this site, however, the possibility of anaplastic transformation should be kept in the differential diagnosis of rapidly enlarging painful mass in a known case of metastatic thyroid carcinoma to prevent misdiagnosis.

Thoraco-abdominal mature teratoma in a left diaphragmatic hernia.

This case describes a contiguous mediastinal and retroperitoneal mature teratoma in a congenital diaphragmatic defect, a combination that is hitherto unreported in literature. It substantiates embryological chronology of events during the cephalad migration of the primordial germ cells through the developing diaphragm, prior to its closure.

Mixed gonadal dysgenesis with normal karyotype : A rare case report.

Mixed gonadal dysgenesis (MGD) presents as a unilateral testis, usually intraabdominal, a streak gonad on contralateral side, and persistent mullerian structures. 45X/45XY karyotype is most frequent in such cases with predominance of 45X cells in both peripheral lymphocytes and gonads. We present a rare case of a left undescended testis, normally descended right testis, with penoscrotal hypospadias, who had a normal karyotype and whose histopathological findings were endometrial tissue and fallopian tube in left testicular biopsy. Gonadal dysgenesis should always be kept a possibility in patient with undescended testis and proximal hypospadias. If karyotype reveals a 46XY gonadal dysgenesis, these patients need all the more careful follow-up to screen for gonadoblastoma in remaining normal testis. Subjecting the patients to prophylactic orchidectomy with hormone replacement can be an additional option in such patients.

Diagnosis of Pneumocystis pneumonia by bronchoalveolar lavage cytology: experience at a tertiary care centre in India.

BACKGROUND: Diagnosis of Pneumocystis pneumonia requires morphological demostration of P. carinii (now re-named as P. jiroveci). Although bronchoalveolar lavage (BAL) fluid cytology constitutes a formidable tool for detecting this infection, few studies on the utility of BAL cytology in diagnosing PCP are available from India. The present study reports the clinical spectrum, cytomorphological features and the utility of BAL cytology in diagnosing Pneumocystis infection from a tertiary care centre in India. METHODS: Retrospective study of 13 patients with PCP, diagnosed on examination of BAL fluid. RESULTS: The mean age of the patients was 41.2 years. One patient had human immunodeficiency virus (HIV) infection, while the other 10 were renal transplant receipients on immunosuppressive therapy. The immune status of two patients was unknown. Fever, cough and shortness of breath were the main presenting symptoms. Radiological diagnosis of Pneumocystis pneumonia was offered in only one case. Foamy alveolar casts were present in all cases. Silver methanamine stain enhanced the rounded, helmet or cleft forms of sporozoites. Inflammatory infiltrate was mainly polymorphonuclear. CONCLUSIONS: BAL cytology, thus, constitutes a useful diagnostic modality for morphological documentation and reliable diagnosis of Pneumocystis pneumonia in an immunocompromised host. Pneumocystis pneumonia appears to be a common opportunistic infection in renal transplant receipients in India.

Role of fine needle aspiration cytology in the diagnosis of goiter.

Enlargement of the thyroid gland is a common occurrence in most parts of the world especially in the iodine-deficient goiter belt areas. Vast majority of these lesions are benign but they invariably lead to a series of investigations among which FNAC plays a pivotal role. Although many studies have reported diagnostic accuracy of FNAC in detecting neoplasms, there have been few studies where the role of FNAC in the diagnosis of goiter along with their diagnostic pitfalls has been evaluated. The present study was undertaken to assess the accuracy of FNAC in diagnosis of goiter and to highlight its limitations and diagnostic pitfalls. 771 cases over a five-year period were retrieved from the files of Cytopathology Laboratory, Department of Pathology at the All India Institute of Medical Sciences, New Delhi. They included 733 cases where the cytological diagnosis was goiter or suggestive of goiter along with 38 cases in which the histological diagnosis was goiter while the cytological diagnosis was cystic change or neoplasm. FNAC with minimum of two passes were performed in each case and May Grünwald Giemsa and Papanicolaou stains were done. Histology was available in 192 cases. The cytological and histological concordance was determined and the FNAC smears and histological sections in cases showing discordance were reviewed. There was cytological and histological concordance 130/168 (77.38%) cases. In 34 cases (20.23%) no diagnosis could be offered because of cystic change. A false positive cytologic diagnosis of neoplasm was made in 4 cases. Presence of hurthle cell metaplasia, hyperplastic nodules and papillary hyperplasias were responsible for the false positive diagnoses. In 24 cases neoplasms were initially missed on FNAC of which 10 cases could be detected on review while 5 cases were considered unsatisfactory. Sampling errors were mainly responsible for these false negative diagnoses. FNAC is thus an accurate and reliable diagnostic tool for management of goiters provided strict adherence to adequacy criteria are maintained.

Sclerosing stromal tumour of ovary--a clinicopathological and immunohistochemical study of five cases.

We describe the clinicopathological and immunohistochemical findings in five cases of sclerosing stromal tumours of ovary and compare our findings with other reported cases of this uncommon tumour and with fibromas and thecomas which they may mimic.

Adenomyoepithelioma of the breast: a potential diagnostic pitfall on fine needle aspiration cytology.

Adenomyoepithelioma is a rare myoepithelial cell-rich tumour of the breast. We report a case of adenomyoepithelioma in a 60-year-old female, where it evoked the suspicion of a carcinoma on fine needle aspiration cytology (FNAC) smears and also review the literature on FNAC diagnosis of this rare tumour.

Sertoli Leydig cell tumor with heterologous gastrointestinal epithelium: a case report.

Sertoli Leydig cell tumour (SLCT) of the ovary with the presence of heterologous elements is very unusual. A case of SLCT with virilizing symptoms and androgenic endocrinological profile is presented. The tumor showed presence of heterologous element in the form of mucinous epithelium of the gastrointestinal type.