Evaluation of utility of immunohistochemistry markers as a tool for objective diagnosis of low-grade myelodysplastic syndrome in routine reporting: Prospective observational study

Purpose: Diagnosis of myelodysplastic syndrome (MDS) primarily relies on the detection of morphological dysplasia in bone marrow. It is subjective and many studies have reported lack of interobserver agreement in reporting. Biopsy is preferred specimen for megakaryocyte assessment. We studied 43 bone marrow biopsies from 40 suspected MDS patient having persistent undiagnosed cytopenia. Utility of immunohistochemistry (IHC) with CD61 and p53 in detecting low-grade MDS was analyzed over routine morphology. Method and Results: Total number of megakaryocytes and number of dysplastic megakaryocytes seen on CD61 IHC was significantly higher than that on H and E stain (P value < 0.05) Out of total 43 biopsies, 13 [30.2%] cases showed dysplastic megakaryocytes that were confirmed by interobserver agreement after IHC. From 30 cases with no significant dysplasia on morphology, 21/43 [48.8%] cases showed >10% dysplastic megakaryocytes on CD61 (P value 0.0001). Nine cases showed no significant dysmegakaryopoiesis with either H and E or CD61 IHC. Fourteen cases could meet higher cut off (30%) of dysmegakaryopoiesis with CD 61 IHC. Out of total 34 cases showing significant dysplasia 7 cases (20.6%) showed positivity for p53 on IHC, which is little less than that reported in low-grade MDS. Conclusion: CD61 IHC is helpful in making correct diagnosis of MDS in cases with minimal dysplasia and should be performed before excluding possibility of MDS on morphology in a patient with undiagnosed cytopenia. IHC is cost effective tool for MDS diagnosis in developing world where access to extensive flow cytometery and molecular testing is limited.

Association of bull semen protein estimates and SDS-PAGE profiles on semen freezability

It is vital to identify the ejaculate with good freezability by determining the biochemical makeup of the ejaculate at the pre-freeze stage. The present study targeted to assess the use of the protein estimates and profiles at the pre-freeze stage as markers of freezability in Frieswal populations. Storing the proteins for proteomic studies is always tricky in the case of animal studies, where accessibility to liquid nitrogen is limited. Hence alternative storing approaches need to be optimized. The second part of this study examined the protein concentration and protein profiles of RNALater and frozen stored sperm cells to assess the use of RNALater preservation in sperm proteomic studies. Sperm and seminal plasma protein concentrations were quantified using Bradford assay, and total protein quantities were derived. The seminal plasma and sperm protein profiles were generated with SDS-PAGE. The protein estimates and SDS-PAGE profiles of good and poor freeze-groups were similar. Also, sperm and seminal plasma protein concentration were not correlated with the semen volume and sperm count. Even though the yield was comparatively less, the protein profiles of sperm preserved by RNALater were similar to that of frozen sperms. The present study results indicate that the protein estimates and qualitative profiles of sperm and seminal plasma proteins may not be sufficient to reveal the differences in the proteome of good and poor freezable bulls at the macro level. Hence, the protein estimates and profiles of neat semen may not be helpful for the prediction of freezability at the pre-freeze stage. Secondly, this study indicates that RNALater preservation helps store sperms for proteome analysis studies.

Expect the unexpected – Loss of surface CD3 on flow cytometry in hepatosplenic T-cell lymphoma: An eye opener

Hepatosplenic T-cell lymphoma (HSTCL) is a rare extranodal T-cell lymphoma that shows preferential sinusoidal infiltration of spleen and liver. It usually shows bright expression of surface CD3 (sCD3) with restriction for γδ-T cell receptors (TCR). We present a case of a 34-year-old male who presented with hepatosplenomegaly and B symptoms. His peripheral blood and bone marrow (BM) was involved by atypical lymphoid cells that were CD2+, CD7+, CD56+, cytoplasmic CD3+, and sCD3− on immunophenotyping by flow cytometry. As sCD3 is a lineage marker for T-cell lymphomas, the loss of sCD3 posed a diagnostic dilemma. However, typical pattern of sinusoidal BM and liver involvement by CD3+ cells and TCR gene rearrangement positivity led to final diagnosis of HSTCL. The differential diagnosis, workup, and clinical course of the case are discussed. To the best of our knowledge, only one case of de novo HSTCL with negative sCD3 has been reported before in the literature.

Bernard Soulier Syndrome; A Rare Bleeding Disorder

Bleeding syndromes in the newborn are rare, but they may be life-threatening and demand immediate attention. Congenital bleeding disorders especially pose a diagnostic challenge to the clinician because of their rarity and the need to be differentiated from the other common causes of bleeding in children. We present a case of an infant presenting with bleeding symptoms early in his life (since 5 months of age) which was initially thought to be immune thrombocytopenic purpura (ITP) with low platelet count. No response to steroids and further evaluation by platelet aggregometry and flowcytometry led to the correct diagnosis – Bernard soulier syndrome(BSS). Though, there is no specific treatment available for this rare bleeding disorder, however it is imperative to have arrived at correct diagnosis in order to save unnecessary therapy and to take due precautions for prevention of bleeding.

Bernard Soulier Syndrome; A Rare Bleeding Disorder

Bleeding syndromes in the newborn are rare, but they may be life-threatening and demand immediate attention. Congenital bleeding disorders especially pose a diagnostic challenge to the clinician because of their rarity and the need to be differentiated from the other common causes of bleeding in children. We present a case of an infant presenting with bleeding symptoms early in his life (since 5 months of age) which was initially thought to be immune thrombocytopenic purpura (ITP) with low platelet count. No response to steroids and further evaluation by platelet aggregometry and flowcytometry led to the correct diagnosis – Bernard soulier syndrome(BSS). Though, there is no specific treatment available for this rare bleeding disorder, however it is imperative to have arrived at correct diagnosis in order to save unnecessary therapy and to take due precautions for prevention of bleeding.

Amyloidosis Presenting as Severe Bleeding Diathesis

Bleeding is one of the rare presentations of Amyloidosis. The mechanism behind spontaneous or peri- interventional bleeding in patients of amyloidosis is complex and involves multiple co-existing factors like coagulation factor deficiency, abnormal synthesis of coagulation factors due to advanced liver dysfunction, acquired Von Willebrand disease, platelet dysfunction, amyloid angiopathy and other unknown mechanisms. We present a case of middle aged female, presenting with spontaneous retroperitoneal haemorrhage, on further investigations was found to have systemic amyloidosis and secondary severe factor X deficiency (2.7 % of normal by one stage factor assay method). Factor X deficiency (both inherited and acquired) is known to present with the most severe bleeding phenotype. The management option for such acute spontaneous haemorrhage is limited and mostly supportive in nature. Definitive treatment is directed towards the primary pathology and requires chemotherapy and hematopoietic stem cell transplantation.

Amyloidosis Presenting as Severe Bleeding Diathesis

Bleeding is one of the rare presentations of Amyloidosis. The mechanism behind spontaneous or peri- interventional bleeding in patients of amyloidosis is complex and involves multiple co-existing factors like coagulation factor deficiency, abnormal synthesis of coagulation factors due to advanced liver dysfunction, acquired Von Willebrand disease, platelet dysfunction, amyloid angiopathy and other unknown mechanisms. We present a case of middle aged female, presenting with spontaneous retroperitoneal haemorrhage, on further investigations was found to have systemic amyloidosis and secondary severe factor X deficiency (2.7 % of normal by one stage factor assay method). Factor X deficiency (both inherited and acquired) is known to present with the most severe bleeding phenotype. The management option for such acute spontaneous haemorrhage is limited and mostly supportive in nature. Definitive treatment is directed towards the primary pathology and requires chemotherapy and hematopoietic stem cell transplantation.

Infant and young child feeding practices of mothers attending immunisation clinic at a tertiary care hospital of Lucknow

Background: Adequate infant and young child feeding (IYCF) practices are essential to ensure optimal survival, health, growth, development and overall nutritional status of children. Objective: The objective of the present study was to assess the IYCF practices among mothers with children aged 0-23 months attending immunisation clinic at a tertiary care hospital of Lucknow, capital of Uttar Pradesh. Materials and methods: A hospital based cross-sectional study was conducted at immunisation clinic, King George’s Medical University from January 2015 to September 2015. Systematic random sampling was used and a total of 240 mothers with children 0-23 months old attending immunisation clinic were interviewed with the help of pre-designed, pre-tested and semi-structured questionnaire. Results: Breastfeeding (BF) was initiated within one hour of birth in 18.3% of children. Early initiation of BF was significantly associated with educational and socioeconomic status of mother and type of delivery. Pre-lacteal feeds were given to 23.4% of the children, children born at government health facility and with birth order ≤2 received pre-lacteal feeds more often. Colostrum was given by 67.9% of the mothers. Children born at private institutions or home were more likely to receive colostrum (p< 0.05). The prevalence of exclusive breastfeeding for at least 6 months was 53.8%. It was higher in children belonging to low socioeconomic group (p< 0.05). Complementary feeding was initiated at 6 months in 32.8% of children. Children of mothers belonging to upper socioeconomic Shukla M, Tyagi S, Agarwal M. Infant and young child feeding practices of mothers attending immunisation clinic at a tertiary care hospital of Lucknow. IAIM, 2016; 3(1): 58-66. Page 59 class, nuclear family and delivered at government institution through normal delivery were more likely to be started on timely complementary feeding (p<0.05). Conclusion: The study revealed that inadequate IYCF practices are still quite prevalent in the community and therefore emphasis should be given to IYCF education sessions.

Port exteriorization appendectomy: is it the future?

The time honoured surgical procedure open appendectomy seems to be on the decline, it may be replaced in the modern era by laparoscopic appendectomy ("in appendectomy") performed with three trocars, or by the port exteriorization appendectomy ("out appendectomy") which can be done with two ports or even one. These techniques combine the benefits of decreased tissue trauma and operative time in addition to other advantages of minimal invasion. We conducted this study to know the effectiveness of Port Exteriorization Appendectomy, to analyze its complications and to assess the conversion rate. A one year prospective study consisted of fifty cases; a combination of emergency and elective group. They were operated under general anaesthesia and different variables were documented. Mean operative time, conversion rate, hospital stay, complications and patient satisfaction. There were 27 females with the (F: M) ratio of 1.17:1. The operative time of 23.3 mins, conversion in 4 (8.0%) patients and 2.4 days of hospital stay contributed to 86.0% operative success rate. Surgical site infection was seen in 5 (10.0%) patients and one (2.0%) developed pelvic abscess. On analysis of the satisfaction level, 44(93.6%) were completely satisfied and one (2.1%) patient seemed disappointed with the technique for cosmesis though, 42 (89.3%) remained completely satisfied and 5(10.7%) didn't like their scars. Port exteriorization appendectomy's efficacy can be verified by 86.0% success rate, operative time of 23.3 mins, indoor stay of 2.4 days, and minimal undesirable sequlae. However, more authentic results could be obtained if this technique is compared to open or laparoscopic appendectomy in a well designed randomized controlled clinical trial.

Portopulmonary hypertension in a patient of autoimmune hepatitis.

A 35-year-old women presented with breathlessness and features suggestive of pulmonary hypertension. Further investigations revealed that she had autoimmune hepatitis and both portal and pulmonary hypertension. Pertinent literature is reviewed.

Isolated extra-cranial internal carotid artery aneurysm in a young adult with Eale's disease.

A young male patient, a known case of Eale's disease presented with a large isolated aneurysm of the extra-cranial part of internal carotid artery. Detailed investigation failed to establish the etiology of the aneurysm, and it is possible that the underlying pathology may be the same as that of Eale's disease. Eale's disease is an idiopathic vascular disease of the peripheral retina and we hypothesize that aneurysm in this patient may be associated with Eale's disease of the eye.

A study of hepatopulmonary syndrome among patients of cirrhosis of liver and portal hypertension.

OBJECTIVES: Hepatopulmonary syndrome consists of a triad of hepatic dysfunction and/or portal hypertension, intrapulmonary vascular dilatations and hypoxemia. A study of hepatopulmonary syndrome among patients of cirrhosis of liver and portal hypertension was undertaken. METHODS: Thirty patients participated in this study. The diagnosis of cirrhosis of liver was confirmed by liver biopsy. Arterial blood gas analysis, pulmonary function tests, two-dimensional transthoracic air contrast echocardiography were undertaken in all the patients. Those patients in whom contrast echocardiogram showed intrapulmonary vascular dilatations were classified as the positive group while others were labelled as the negative group. RESULTS: Ten patients (33.33%) had a positive contrast echocardiogram; five (16.67%) of them were found to have PaO2<70 mmHg and were qualified for the diagnosis of hepatopulmonary syndrome (HPS); and other five (16.67%) with PaO2>70 mmHg were diagnosed as intrapulmonary dilatations syndrome (IPVDS). Five patients of HPS revealed significant P(A-a)O2 gradient and intrapulmonary shunts of moderate severity computed by a/A ratio. Cyanosis (p=0.001), clubbing (p=0.009) and orthodeoxia (p=0.0024) were significantly commoner in the five patients of hepatopulmonary syndrome. Presence of spider naevi was significantly related with the presence of intrapulmonary vascular dilatations. CONCLUSIONS: The study results showed presence of hepatopulmonary syndrome and intrapulmonary vascular dilatation syndrome among patients of portal hypertension. The presence of cyanosis, clubbing and orthodeoxia were found to be suggestive indicators of hepatopulmonary syndrome. Even though not very specific, spider naevi were found to be a useful clinical indicator for the presence of intrapulmonary vascular dilatations.

Endoluminal treatment of infrarenal abdominal aortic aneurysm with bifurcated stent-graft system.

Atherosclerotic infrarenal aortic aneurysm has been traditionally treated by open surgical repair. We report a high risk case where the aneurysm was successfully treated by the new technique of endoluminal stent graft placement.

Evidence for activation of cellular immune responses in patients with acute hepatitis E.

INTRODUCTION: Although acute hepatitis E virus (HEV) infection is known to induce IgM and IgG humoral host immune responses, little is known about occurrence of cellular responses in this infection. We looked for evidence of lymphocyte sensitization to HEV peptides in patients with acute HEV infection. METHODS: peripheral blood lymphocytes were obtained from patients with acute hepatitis E and healthy controls. Proliferation of these lymphocytes in the presence of each of seven peptides with amino acid sequences corresponding to open reading frames 2 and 3 proteins of HEV (3 and 4 peptides, respectively) were studied; no peptide was added to control wells. Proliferative responses with stimulation indices exceeding 3.0 were taken as positive. RESULTS: More patients showed reactivity to two or more HEV peptides than did controls (11/21 vs 5/22, p<0.05). Reactivity to one peptide corresponding to open reading frame 2 of HEV was more frequent in patients than in controls (7/21 vs 1/22, p<0.05). CONCLUSION: Our results show that lymphocytes of patients with acute hepatitis E show sensitization to HEV peptides. This may have significance in understanding the pathogenetic mechanisms of liver injury in this infection.

Aortoarteritis presenting with hypoparathyroidism.

Clinical manifestations of aortoarteritis (Takayasu's arteritis) are varied, depending on the involved segment of the aorta and its branches. A case of a young Indian woman with aortoarteritis presenting primarily with hypoparathyroidism is reported. Aortogram showed total occlusion of the arch arteries. To the best of our knowledge, the occurrence of hypoparathyroidism in aortoarteritis has not been reported. Possible mechanisms of such an involvement are discussed.

Bacterial adherence to polymethylmethacrylate posterior chamber intra ocular lenses.

PURPOSE: Bacterial adherence to intraocular lenses (IOLs) has been incriminated in the pathogenesis of postoperative endophthalmitis. Staphylococcus epidermidis is the most common organism isolated. We studied the in-vitro adhesion of Staphylococcus epidermidis to Polymethylmethacrylate (PMMA) IOLs and the effect of duration of exposure to adherence. METHODS: Two groups of 10 IOLs each were incubated in Staphylococcus epidermidis suspension for 2 minutes and 20 minutes respectively. Adhesion of bacterial cells was determined by counting the number of viable bacteria attached to IOLs. RESULTS: The mean bacterial adherence with 2 minutes incubation was 12,889 +/- 7,150 bacteria/ IOL and with 20 minutes incubation was 84,226 +/- 35,024 bacteria/IOL (P< 0.01). CONCLUSION: Our results show that Staphylococcus epidermidis adheres to PMMA IOLs in vitro and the degree of adherence is less for shorter duration of exposure. We conclude that viable bacteria irreversibly adherent to IOLs may play a role in the pathogenesis of postoperative endophthalmitis. Shorter duration of operative manipulation and exposure to contaminating sources may decrease the chances of postoperative endophthalmitis.

Transcranial Doppler evaluation of blood flow velocity changes in basal cerebral arteries in cerebral AVMs following embolisation and surgery.

Blood flow velocities in the basal cerebral arteries were evaluated in 41 patients with supratentorial arteriovenous malformation (AVM), using a transcranial doppler 64-B instrument. The AVM was surgically excised in 20 patients and embolised in 21 patients. Blood flow velocities in feeding basal cerebral arteries were found markedly decreased in both the groups, at 24 hours after intervention. On follow up study at 3 months, blood flow velocity in feeding cerebral artery was found to be increased in 47 percent of patients who were embolised, but remained normal in all the patients who underwent surgery.