Significance of Silver Stained Nucleolar Organiser Region (AgNOR) in Fine Needle Aspiration Smears of Breast Lesions

Background: Breast cancer is the leading cause of cancer - related deaths in Asia. The number of intra-nuclear silver stained structures, termed AgNORs, is significantly higher in malignant cells than in normal, reactive or benign cells. The purpose of this study was to evaluate the AgNOR scores in FNA smears of breast lesions and their correlation with histopathology. Aims & Objective: To establish AgNOR staining as a diagnostic and prognostic tool in management of various breast lesions. Methods: This was a prospective study conducted over a period of 18 months may 2015 to November 2016. A total of 100 cases were included in the study. AgNOR stain was done in both cytology and scoring was done and analysed. Results: In FNAC aspirates, Mean AgNOR count ranged from 5 to 9.9 per high power field with a mean value of 2.888±2.553. The AgNOR dots morphology was homogenous, symmetric with regular contours in FNAC slides of benign breast lesion. In malignant breast lesions, the dots were asymmetric with irregular contours and were aggregated, smaller and more scattered. Conclusions: The present study showed that fine needle aspiration cytology is a useful modality for diagnosis of breast lesions. It has a high concordance with the histopathology . AgNOR count assessment provides a useful objective measure for segregation of different grades of tumor with 100% accuracy for detection of higher grade of lesions, as observed in present study. For differentiation of benign from malignant lesions too it has a high sensitivity as well as specificity. The usefulness of FNAC to evaluate nodal involvement also showed a 90% sensitivity and 95.6% specificity. On the basis of present study, it could be concluded that AgNOR count estimation using fine needle aspiration is a useful method to differentiate and diagnose breast lesions.

Departmental case notes audit: a quality assurance measure in a changing organizational climate

Background: A clinical audit measures practice against standards. It aims to deliver safe and quality care through a systematic approach. The research focuses on the question, "what is the right thing to do?" whereas the audit aims to see if we are doing the right thing in the right way.1-4

Aims and Objectives: To highlight the importance of meticulous record keeping in clinical case notes

Methods: 20 case notes were examined from the dermatology ward. The method of data collection was retrospective. The basis of proposal was local guidelines. The audit type was Process. The standard set was "100%

Results: The result showed 75% compliance with our local guidelines in the analyzed case sets

Antimicrobial and toxicological studies on fruit pulp of Citrullus colocynthis L.

The methanolic extract of dried fruit pulp of Citrullus colocynthis [Cucurbitaceae] has been studied with respect to antimicrobial and toxicological properties. The antimicrobial profile was investigated against thirty bacterial isolates [10 Gram +ve and 20Gram-ve] and five fungal species. None of the bacterial or fungal culture used in the study showed sensitivity against the extract. Acute toxicity studies carried out in Albino mice NMRI indicated the highly toxic nature of the colocynth. A very significant decrease in body weight of test animals was noted at P<0.05. The LD[50] was calculated as 1000mg/kg body weight. Within four days of experimentation mortality was 100%. Histopathological studies confirmed the toxic nature of extract. Gross changes in histology of Heart, Liver and Kidneys were noted. Section of spleen did not exhibit any abnormality

Unusual distribution of bullous pemphigoid lesions in a hemiplegic patient: a case report

Bullous pemphigoid [BP] is an autoimmune subepidermal blistering condition that predominantly affects older patients and characterized by local or generalized tense blister formation. Mucosal involvement with small blisters or erosions may exist in a minority of patients. BP is generally self-limiting with remission in most patients by 5 years. We report an 83-year-old hemiplegic lady with unusual distribution of bullous pemphigoid lesions

Frequency of serum cortisol suppression in patients using 0.05% clobetasol propionate as topical steroid for more than 3 weeks

Objective: To determine the frequency of serum cortisol suppression in patients using 0.05% clobetasol propionate as topical steroid for more than 3 weeks

Study Design: Cross sectional Study

Place and Duration of Study: Both outdoor and indoor patients of Dermatology Department, Military Hospital [MH] Rawalpindi for duration of 6 months i.e. from 18[th] April 2012 to 17[th] October 2012 were selected

Patients and Methods: A total of 189 patients were included in the study. Non-probability purposive sampling technique was used. Early morning [0800 hrs] serum for cortisol levels was taken before starting the treatment and same was repeated after 3 weeks at AFIP. Effect modifiers like age and gender were controlled through stratification. The data was analyzed using SPSS version 10. The quantitative variables like age, duration of illness were calculated by taking standard deviation and mean whereas the qualitative variables like gender, suppression of serum cortisol levels were calculated by taking percentages and frequency. Frequency of serum cortisol suppression was presented according to gender and age groups

Results: Majority of the patients selected were between 31-40 years i.e. 44.98% [n=85]. Gender distribution was 61.90% [n=117] males and 38.10% [n=72] females. Frequency of serum cortisol suppression in patients using 0.05% Clobetasol propionate as topical steroid for more than 3 weeks was seen in 33.33% [n=63]

Conclusion: The frequency of serum cortisol suppression was significantly higher amongst patients using clobetasol propionate 0.05%. Therefore patients prescribed clobetasol propionate 0.05% topically should be checked for serum cortisol suppression regularly if the application is intended to be used for more than 3 weeks

Comparison of efficacy of oral fluconazole with intramuscular meglumine antimoniate in treatment of cutaneous leishmaniasis

Objective: To compare the efficacy of oral fluconazole with intramuscular meglumine antimoniate in patients of cutaneous leishmaniasis

Study Design: Randomized Control Trial

Place and Duration of Study: Study was conducted from 1[st] January 2013 to 30[th] June 2013, at Dermatology department, Military Hospital, Rawalpindi

Patients and Methods: Eighty histopathologically diagnosed patients of cutaneous leishmaniasis were selected. Patients were randomly allocated into two groups. Group-A was given oral fluconazole 200mg/day for six weeks. Group-B was given intramuscular meglumine antimoniate 20 mg/kg/day for 21 days. Status of each lesion was regularly documented and efficacy of drugs was measured at the end of three months. The drug was considered efficacious if there is more than 75% regression in size and induration of lesions

Results: Clinical efficacy was seen in 70% [n=28] in Group-A and 92.7% [n=37] in Group-B at end of three months. When compared by Chi-square test, these results were found to be statistically significant with pvalue 0.010[< 0.05]

Conclusion: Efficacy of Intramuscular meglumine antimoniate is better than oral fluconazole in treatment of cutaneous leishmaniasis

Comparison of in-vitro susceptibility of sarcopties scabieivar hominis to 5% permethrin and 1 % lindane

To measure in-vitro susceptibility of Sarcopties Scabieivar Hominis to 5% permethrin and 1% lindane.Study Design: Randomized controlled trials. Study was carried out at Dermatology Department, Military Hospital, Rawalpindi from January 2012 to June 2012. A total of 60 mites from 60 patients were taken for assay. Mites from every patient were randomly allocated to two groups i.e. group A [5% permethrin] and group B [1% lindane]. Permethrin and lindane were applied in a thin film over a glass slide. Live mites were then gently transferred to the glass slide and covered with a lid. Mites were inspected for leg movements at time interval of 1hr, 2hrs, 3hrs, 4hrs and 5hrs. Death was declared once all leg movements had ceased. All mites which died within 5 hours had been declared as susceptible to drugs, while mites having active leg movements even after 5 hours of drug application were considered as non-susceptible. A total of 93.33% [n=28] of mites in group-A died within 5 hours of application of permethrin [susceptible] and 6.67% [n=2] of mites in group-A were alive after 5 hours of drug application [resistant] While 53.33% [n=16] of mites in group-B died within 5 hours of application of lindane [susceptible] and 46.67% [n=14] of mites in group-B did not die after 5 hours [non-susceptible], [p value < 0.001]. Permethrin is more effective as compared to lindane against Sarcopties Scabei in terms of in-vitro susceptibility

Clinical audit on treatment of mucosal and multiple cutaneous leishmaniasis lesions with pentavalent systemic antimony

Cutaneous leishmaniasis is a parasitic disease spread by the female sandfly occurring throughout the Americas from Texas to Argentina, and in the Old World, particularly the Middle East and North Africa. The condition is diagnosed every year in travelers, immigrants, and military personnel. The treatment mainstay is pentavalent antimony [e.g., sodium stibogluconate]. Not all patients require treatment; many lesions heal spontaneously. The treatment is usually indicated in mucosal, mucocutaneous and multiple active cutaneous lesions. 30 patients of cutaneous leishmaniasis were included from the dermatology ward. The method of data collection was retrospective. The basis of proposal was local guidelines. The audit type was process. The standard set was "100% patients with mucosal and multiple cutaneous leishmaniasis lesions should be treated with pentavalent systemic antimonials"

Workplace-based assessments: the right time to start

Workplace-based assessments [WPBAs] refer to the assessment of working practices based on what doctors actually do in the workplace and is predominantly carried out in the workplace itself [PMETB, 2007]. WPBAs should be recognized as a series of essential educational events along a learning trajectory. WPBAs are an essential part of an assessment system alongside traditional examinations. The primary purpose of WPBAs is to provide constructive feedback to the trainees. The trainer is required to identify trainees not progressing along their structured learning plan so that early remedial action can be initiated. An understanding of the acceptable level of clinical competence required for a particular stage of learning is essential. This will ensure that the patients are safe during training through appropriate supervision and assessment. Stakeholders [trainers, trainees, managers, patients] should actively be involved in the development and implementation of the programme to ensure transparency and understanding of the process

Clinical audit of national institute of clinical excellence [NICE] technology appraisal guidance [TAG] 81 and 82/clinical guidelines [CG57] on atopic eczema in children

To find out how far our current practice complies with the NICE guidelines and to identify any areas in which improvement is needed Patients and methods The audit sample consists of 50 patients. The inclusion criteria include children from birth up to the age of 12 years and diagnosed with atopic eczema 100% patients [n=50] in this audit were treated with topical corticosteroids. 100% cases [n=50] were treated in accordance with NICE recommendations. The drug with lowest acquisition cost was prescribed in 31 [62%] cases. None of the 50 patients was prescribed either tacrolimus or pimecrolimus. The patients in this audit tended to be young. All patients had either mild to moderate eczema with no cases with severe eczema. All patients responded to treatment regimen comprising topical steroids with none requiring topical calcineurin inhibitors i.e. tacrolimus and pimecrolimus

Clinical audit: Baseline investigations for intramuscular meglumine antimoniate in cases of cutaneous leishmaniasis

To see if the baseline investigations for intramuscular meglumine antimoniate in cases of cutaneous leishmaniasis were being carried out in accordance to our local guidelines. 30 case records of patients with cutaneous leishmaniasis were randomly selected from our dermatology ward. These records were reviewed to see if the pre-therapy investigations for meglumine antimoniate were carried out. The method of data collection was retrospective. The result showed 100% compliance with our local guidelines in the analyzed cases. Our audit showed 100% compliance

Clinical audit: a simplified approach

A clinical audit measures practice against standards and performance. Unlike research which poses the question, "what is the right thing to do?" clinical audit asks are we doing the right thing in the right way? An approach for understanding a clinical audit is provided. A basic clinical audit example of a case note audit is presented. A simplified template to help the beginners is included

An unusual skin presentation of necrobiotic xanthogranuloma

A well appearing 73-year-old Caucasian lady presented with a long-standing history of yellowish atrophic lesions on her limbs and trunk. The lesions were asymptomatic. These were found to be consistent with the diagnosis of Necrobiotic Xanthogranuloma [NXG] on histology. The reported patient did not have the characteristic skin changes and instead had unusual lesions reminiscent of morphoea not described in the literature. She reported no associated systemic symptoms

Cutaneous CD30 positive anaplastic large cell lymphoma

An adult Caucasian male presented with a solitary abscess-like lesion on his left thigh. The lesion later on ulcerated and developed a central eschar. The initial differential diagnoses included deep mycosis, insect bite reaction or atypical mycobacterial infection. Histology confirmed it to be a CD30 positive anaplastic large cell lymphoma. Haematologyoncology screen was carried out and the patient started on local field radiotherapy. Localized lymphomatous lesions can be treated with surgical excision or local radiotherapy. Systemic treatments are reserved for generalized disease. The prognosis depends on the extent of involvement

Pharmacokinetic study of cephradine in Pakistani healthy male volunteers

To observe and discuss the difference in the pharmacokinetics of Cephradine in Pakistani population with the reported data of other ethnic origins. A Single group pharmacokinetic study was conducted having six healthy male volunteers of 20-24 years of age. Blood samples were collected at appropriate times up to 7 hours. Plasma concentrations of Cephradine was determined by HPLC technique and pharmacokinetic parameters were determined by both compartmental and noncompartmental methods using Kinetica ver 4.4.1 and Winnonlin ver 5.01. Peak plasma concentration was 11.49 +/- 1.73 microg/ml achieved at 0.76 +/- 0.12 hr, after the administration of 250 mg Cephradine to fasting volunteers. Area under the serum concentration-time curve was found to be 16.4 +/- 1.71 microg.hr/ml. Absorption, distribution, disposition and elimination half lives were calculated as 0.183 +/- 0.038hr, 0.248 +/- 0.143 hr, 2.126 +/- 0.341 hr and 0.441 +/- 0.193 hr respectively where as the volume of central compartment and total body clearance were found to be 9.65 +/- 3.78 L and 15.4 +/- 1.89 L/hr. The plasma concentration time curves showed the absorption rate constant was 3.968 +/- 0.05 hr-1, disposition rate constant was 0.333 +/- 0.05 hr-1, distribution rate constant was 3.64 +/- 2.18 hr-1 and elimination rate constant was 1.738 +/- 0.468 hr-1. The value of micro-constants i.e. K12 [central to peripheral compartment] and K21 [peripheral to central compartment] were found to be 1.529 +/- 1.499 hr-1 and 0.704 +/- 0.44 hr-1 respectively, where as MRT and AUMC were calculated as 2.04 +/- 0.09 hr and 35.92 +/- 1.86 hr[2]x micro g/mL. The findings showed that the results of Pakistani subjects are slightly different when compared with the reported data of other ethnic origin

Antibacterial activity of Elaeagnus umbellata [Thunb.] a medicinal plant from Pakistan

To evaluate the biological activity of Elaeagnus umbellata extracts on standard microorganism strains as well as multi-drug resistant bacteria isolated from hospitals. We carried out this study at the Plant Pathology Laboratory of the University College of Agriculture, Rawalakot Pakistan during the period between September-November 2004. Flowers, leaves, and berries of the plant were extracted in different solvents and tested for their antibacterial activity by disc diffusion method on selected organisms like methicillin resistant Staphylococcus aureus [S. aureus], multi-drug resistant Pseudomonas aeruginosa [P. aeruginosa], and enterohemorrhagic Escherichia coli [E. coli]. The ether extract of flower was found to be highly effective against E. coli, P. aeruginosa, S. aureus, and Bacillus subtilis [B. subtilis]. The alcohol extract of these leaves also demonstrated strong activity against gram positive and negative bacteria. The aqueous extract from the berry strongly inhibited the growth of E. coli and S. aureus whereas, it exhibited a very small zone of inhibition against B. subtilis. Multi-drug resistant P. aeruginosa was found completely resistant to aqueous extract. The acetone extract of the berry showed good activity against P. aeruginosa. The present study reports the antibacterial activity of Elaeagnus umbellata. Most of the extracts displayed broad-spectrum activity, since gram positive bacteria including S. aureus, B. subtilis and gram-negative bacteria including E. coli and P. aeruginosa were inhibited. These preliminary findings may provide the basis for traditional use of this plant in the treatment of infectious diseases

Studies on resistance / sensitivity pattern of bacteria related with urinary tract infections

In order to determine the resistance pattern against five different groups of antimicrobial agents, six different species of bacteria were isolated from among two hundred cases of UTIs. The front line antibiotics for treating urinary tract infection due to Escherichia coli, Klebsiella species, Staphylococcus aureus and Proteus species should include Cephradine, Ofloxacin, Cefaclor, Cephalothin and Pipemidic acid. However, for treating UTI due to Pseudomonas species, the drug of choice must be a member of fluoroquinoline group [norfloxacin, ofloxacin and ciprofloxacin]

Mastocytoses

Mastocytoses are an important group of dermatoses characterized by histological infiltrates predominantly rich in mast cells. The present review focuses on the salient clinical, diagnostic and therapeutic features of different entities included in this group

Application of limulus amebocyte lysate [LAL] test for detecting endotoxin [pyrogen] in large volume parenterals

Screening of twenty five large volume parenterals including dextrose, electrolytes, mannitol, metronidazole infusions, haemodialysis solution, water for injections and distilled water for the determination of pyrogen using Limulus Amebocyte Lysate [LAL] test has been carried out. Out of different preparations only one metronidazole injection exhibited positive LAL test, which was found pyrogen free with USP rabbit pyrogen test