Diagnostic and prognostic utility of SF-1 in adrenal cortical tumours

Background and Aims: Superior imaging techniques have increased the recognition of adrenal pathology. Distinguishing benign from malignant adrenocortical tumors is not always easy. Several criteria and immunohistochemical markers have been discovered which help to differentiate between adrenocortical adenoma (ACA) and adrenocortical carcinoma (ACC). Our aim here was to evaluate the diagnostic and prognostic role of steroidogenic factor-1 (SF-1) in adult adrenocortical tumors (ACT) diagnosed using the Weiss criteria. In this cohort, we have also analyzed Ki67 and p53 expression and the extent of agreement between SF-1 and Ki-67. Methodology: This was a retrospective, observational study comprising 24 cases of adult ACT over 10 years. Immunohistochemical staining for SF-1, Ki67, and p53 was done in all the cases, and the results correlated with the morphological diagnosis made using Weiss criteria. Results: SF-1 was 100% sensitive and 80% specific as a marker of malignancy. Increased SF-1 expression correlated with worse survival. There was a moderate degree of agreement between Ki-67 labeling-index and SF-1 as a marker of malignancy with the kappa coefficient being 0.75. The sensitivity of p53 was lower than Ki67 in diagnosing ACC. Conclusion: In adult ACTs, SF-1 has diagnostic significance and prognostic implication. SF-1 is a crucial, dosage-dependent survival factor in ACC. There is a moderate extent of agreement between Ki-67 and SF-1 as a marker of malignancy.

Histoplasmosis masquerading as tuberculosis: A report of three cases in immunocompetent children

The most common cause of granulomatous lymphadenitis in countries like ours is mycobactrium tuberculosis followed by atypical mycobacterial infection, fungal infections, parasitic infection, cat scratch disease, lymphogranuloma venereum (inguinal lymphadenopathy), and leprosy Here, we present three cases of lymphadenopathy due to histoplasmosis in immunocompetent children. Two of them presented with fever, lymphadenopathy, initially diagnosed as granulomatous lymphadenitis consistent with tuberculosis on FNAC and were put on antitubercular drugs. However, their condition gradually became worse. As the patients continued to deteriorate, subsequent lymph node biopsies were done and diagnosed as histoplasmosis. Third case presented with acute loss of vision with hepatosplenomegaly and lymphadenopathy. Initially considered as acute leukemia, but eventually established as histoplasmosis. Histoplasmosis should be considered as one of the possible causes of granulomatous lymphadenitis in children.

Retiform hemangioendothelioma: An uncommon vascular neoplasm

Retiform hemangioendothelioma is a rare vascular neoplasm of intermediate grade, the diagnosis of which can be challenging. We report a case of 35-year-old man with swelling in the postauricular region. He had undergone FNAC which had revealed blood only. Microscopic examination showed narrow, arborizing, vascular channels resembling normal rete testis. Evidence of mitoses or cytological atypia were lacking. Immunohistochemistry showed diffuse and strong staining for CD34 along with CD31 positivity. Immunostains for D240 and GLUT1 were negative. A diagnosis of retiform hemangioendothelioma was made. Histologically, it should be distinguished from Kaposiform hemangioendothelioma, Dabska tumor, epithelioid hemangioendothelioma, and angiosarcoma.

Factors limiting the Northeast Indian elderly population from seeking cataract surgical treatment: Evidence from Kolasib district, Mizoram, India

Purpose: Reliable data on the barriers to the uptake of cataract surgical services in the Northeast Indian states are scanty. The purpose of this study was to assess the barriers to uptake of cataract surgical services among elderly patients and suggest appropriate strategies to reduce these. Methods: A cross-sectional study was conducted among patients who failed to avail cataract surgical services, 6–12 months' postinitial diagnosis at a community eye health camp. Validated questionnaire was used to collect information through face-to-face interviews at the residence of the participants. Descriptive statistics and Chi-square tests were conducted to assess the association between the barriers quoted and sociodemographic variables. Results: A total of 140 (89.2%) individuals participated in the study, of whom 56 (40%) were aged between 71 and 80 years. The median age for men and women was 73.5 and 72.5 years, respectively. About 57% of participants were female patients. A total of 66 (47.1%) participants had borderline visual acuity followed by those with poor vision (41.4%, n = 58). “Bad roads/difficult terrain” (P = 0.009), “witnessed bad surgical outcomes in others” and “did not feel important” (P < 0.024), “poor overall health status” (P < 0.001), “lack of information” (P = 0.025) and “no escort” (P = 0.025) were significant barriers reported by this population. Conclusion: Most of the barriers reported in this study seem to be endogenous in nature and appear to be within the purview of the local eye care service provider to remedy. Counseling and targeted awareness and information, education, and communication strategies could nullify many of the barriers reported in this study.

Current Practice of Iron doses for Treatment of Iron Deficiency Anaemia - A Review

Although functional impairment begins with iron deficiency in the absence of anaemia, the development of anaemia heralds a homeostatic dysfunction that impairs daily activity. Iron deficiency anaemia is often the reason for poor physical performance, maternal and child morbidity and referral to a healthcare professional. (1) Women in their reproductive years, pregnant women and children are most vulnerable to develop iron deficiency anaemia (IDA) and will be the focus of this review.

Guidelines for iron supplementation for Prophylaxis of Anemia in a National Programme - A Review

Recent National Family Health Survey-4 data shows that anaemia continues to be a major public health problem in India. In India much of the anaemia is due to iron deficiency, and women and children are at the greatest risk of anaemia. TheMinistry of Health and Family Welfare took a policy decision, in 2013, to develop the National Iron+ Initiative (NIPI) to address the prevailing iron deficiency anaemia. This initiative covered pregnant and lactating women, children and adolescents. However, the guidelines do not match the current World Health Organization (WHO) guidelines for prevention of iron deficiency anaemia in these population groups. The background evidence for the WHO and NIPI is thus reviewed to come to a common consensus on the optimum recommendation of iron supplementation for the population, while taking into consideration the feasibility of the program, without burdening the groups with iron over-dose. However, from the present review, there is a need for increased number of trials in India that could qualify for a high grade of evidence to support the guidelines of NIPI.

Efficacy of stem cell in improvement of left ventricular function in acute myocardial infarction - MI3 Trial.

Background & objectives: Acute myocardial infarction (AMI) is characterized by irreparable and irreversible loss of cardiac myocytes. Despite major advances in the management of AMI, a large number of patients are left with reduced left ventricular ejection fraction (LVEF), which is a major determinant of short and long term morbidity and mortality. A review of 33 randomized control trials has shown varying improvement in left ventricular (LV) function in patients receiving stem cells compared to standard medical therapy. Most trials had small sample size and were underpowered. This phase III prospective, open labelled, randomized multicenteric trial was undertaken to evaluate the efficacy in improving the LVEF over a period of six months, after injecting a predefined dose of 5-10 × 108 autologous mononuclear cells (MNC) by intra-coronary route, in patients, one to three weeks post ST elevation AMI, in addition to the standard medical therapy. Methods: In this phase III prospective, multicentric trial 250 patients with AMI were included and randomized into stem cell therapy (SCT) and non SCT groups. All patients were followed up for six months. Patients with AMI having left ventricular ejection fraction (LVEF) of 20-50 per cent were included and were randomized to receive intracoronary stem cell infusion after successfully completing percutaneous coronary intervention (PCI). Results: On intention-to-treat analysis the infusion of MNCs had no positive impact on LVEF improvement of ≥ 5 per cent. The improvement in LVEF after six months was 5.17 ± 8.90 per cent in non SCT group and 4.82 ± 10.32 per cent in SCT group. The adverse effects were comparable in both the groups. On post hoc analysis it was noted that the cell dose had a positive impact when infused in the dose of ≥ 5 X 108 (n=71). This benefit was noted upto three weeks post AMI. There were 38 trial deviates in the SCT group which was a limitation of the study. Interpretation & conclusions: Infusion of stem cells was found to have no benefit in ST elevation AMI. However, the procedure was safe. A possible benefit was seen when the predefined cell dose was administered which was noted upto three weeks post AMI, but this was not significant and needs confirmation by larger trials.

Negative PressureWound Therapy (NPWT) in open wound management: A study of 16 Cases in Orthopaedic Department of Faridpur Medical College Hospital.

Wound management is a major concern in open fracture cases. Negative Pressure Wound Therapy (NPWT) is an advanced method for managing open wounds. It is a topical treatment using sub-atmospheric pressure to increase blood flow, remove bacteria and increase growth of granulation tissue in the wound. The study was performed to evaluate the results of NPWT in patients with open fracture in lower extremity. Using Aquarium pump as an NPWT device, 16 patients were prospectly treated for open fractures in their inferior extremity. Mean patients' age range was 21 to 60 yrs. The patients under study either had suffered from trauma, fall or had post operative wound infection. Many of them had wounds with underlying tendon or bone exposure. Necrotic tissues were debrided before applying NPWT. Dressings were changed every 3rd or 4th day and treatments were continued for 07 to 28 days. Exposed tendons and bones were successfully covered with healthy granulation tissue in all cases, depth of the wounds reduced as well as surface areas. In 12 cases coverage of granulation tissue were achieved and further managed by skin grafting, 4 cases with wound infections were closed with secondary suture. No significant complications were noted regarding the treatment. NPWT was found to facilitate the rapid formation of healthy granulation tissue on open wounds in lower extremity and thus to shorten healing time and minimize secondary soft tissue defect coverage procedures.

Neo-regeneration of urinary bladder: A desired metaplasia of autologous membrane from rectosigmoid colon containing stem cells of intestinal crypts.

The current management of diseases of urinary bladder requiring resection is by augmentation cystoplasty or transplantation of ureters. Transplantation of ureters is associated with morbidity and mortality. Ideal management will be by regenerating urinary bladder in vivo. Neo-regeneration of tissues and organs like abdominal wall, aponeurosis etc., has been attempted and patented. After neo-regeneration of mesoderm tissues and organs, regeneration of urinary bladder (developed from endoderm) was. In vivo surgical techniques were developed in dogs. It is known that the embryonic morphogenesis of urinary bladder is from uro-genital sinus of hind gut. A membrane, containing endoderm stem cells in crypts of recto-sigmoid colon, was surgically isolated and colonized with remnant of urinary bladder wall after extensive resection. Experimental study was performed in dogs, for 60 days to one and a half year. Regeneration of all the layers of tissues of the wall of urinary bladder was observed. The neo-regeneration phenomenon has been recognized as “desired metaplasia”. The regenerated neo tissue/organ on histological examination and cystometry studies was found compatible with normal urinary bladder. The hypothesis, neo-regeneration and desired metaplasia, is discussed.

Clinical microbiology in the intensive care unit: Strategic and operational characteristics.

Infection is a major cause of morbidity and mortality among patients admitted in intensive care units (ICUs). The application of the principles and the practice of Clinical Microbiology for ICU patients can significantly improve clinical outcome. The present article is aimed at summarising the strategic and operational characteristics of this unique field where medical microbiology attempts to venture into the domain of direct clinical care of critically ill patients. The close and strategic partnership between clinical microbiologists and intensive care specialists, which is essential for this model of patient care have been emphasized. The article includes discussions on a variety of common clinical-microbiological problems faced in the ICUs such as ventilator-associated pneumonia, blood stream infections, skin and soft tissue infection, UTI, infection control, besides antibiotic management.

Comparative evaluation of cefpodoxime versus cefixime in children with lower respiratory tract infections.

OBJECTIVE: The emergence of penicillin and macrolide resistant strains, responsible for Acute Lower Respiratory Tract Infections in children has offered third generation cephalosporins the platform to perform. The aim of the present study was to evaluate two third generation oral cephalosporins for their empirical use in community acquired lower respiratory tract infections in pediatric patients. An assessment of the clinical cure and bacteriological eradication rates and an overall tolerability was made. METHODS: It was a prospective, open, comparative, multicentric study. 776 children (Mean age 10 years) with LRTIs were included and randomly allotted to two groups respectively. A total of 396 children were given cefpodoxime susp 5 mg/kg b.i.d. and 380 patients on cefixime 4 mg/kg b.i.d. for 10-14 days. RESULTS: At the end of therapy, the clinical success with cefpodoxime was 97% as against 86.8% with cefixime. Bacterial eradication was 93.4% with cefpodoxime and 82.9% with cefixime. CONCLUSION: Cefpodoxime has been found to be a well-tolerated and superior alternative to cefixime synergistically documenting the extended spectrum of activity.

Multifocal giant cell tumour of bone in a skeletally immature patient--a case report.

Giant cell tumor of bone is usually seen in adults affecting a single bone. Multiple giant cell tumour of bone occurring in skeletally immature patients is extremely rare. Multifocal giant cell tumor of bone in a ten year old boy involving upper end of humerus and tibia is being reported for its extreme paucity in literature.

Safe motherhood--a long way to achieve.

Maternal mortality ratio (MMR) is the most important index for monitoring the progress of safe motherhood programmes. A retrospective analysis of all maternal deaths at RG Kar Medical College and Hospital, Calcutta from 1st January, 1995 to 31st December, 1997 was carried out. There were 29,563 live births and 203 maternal deaths giving cumulative MMR of 686.67 per 100,000 live births. Among the victims 25.6% were < or = 20 years of age, majority (73.4%) were unbooked, mostly from rural (59.6%) or urban slum (20.2%) and from low socio-economic status (59.6%). Most (60.10%) were multiparous and 50.74% patients died within 24 hours of hospital admission. Direct causes were responsible for 83.25%, indirect causes for 14.78% and unrelated causes for 1.97% of maternal deaths. Toxaemia was the leading cause (53.20%) of maternal mortality. Other important causes were haemorrhage (16.75%), sepsis (12.31%), severe anaemia (6.4%), infective hepatitis (1.47%) and heart disease (3.44%). In comparison to previous years no significant changes in MMR had been found though there were temporary decline in some years. The contribution of toxaemia in maternal deaths is significantly high and is on the rise. The other national and global pictures were reviewed. India is among the countries of high MMR and far away from achieving safe motherhood. Majority of deaths are preventable. The medical causes of maternal deaths are in fact, the end point of a longer chain of many underlying factors like low socio-economic status, poverty, illiteracy, high parity and inadequate or no health care. An active community-based health care system accessible to every mother with strong referral system is the most effective approach to achieve safe motherhood.

Factors regulating the metastatic potential of benign giant cell tumour of bone--study of an unusual case with short review of literature.

Benign giant cell tumour of bone with metastases to other bones and lungs is extremely rare. Benign metastasising giant cell tumour is distinctly separate from multicentric giant cell tumour, primary and secondary malignant giant cell tumour. Factors regulating the local recurrence and metastatic potential of this benign tumour depend on its aggressiveness which can be better assessed by clinical and radiological parameters rather than the histopathological appearance. A benign giant cell tumour of ischium with metastasis to vertebra and lung over an eleven year period is discussed. Extreme paucity of literature prompted to publish the article. A short review of factors determining the recurrence and metastatic spread of benign giant cell tumour of bone is highlighted.

Primary malignant giant cell tumour of bone--a study of two cases with short review.

Primary malignant giant cell tumour of bone is extremely rare. It is distinctly separate from benign metastasising giant cell tumour of bone and secondary malignant giant cell tumour which occurs in response to radiotherapy and repeated curettage of benign giant cell tumor. The tumor has high mortality rate. It usually affects lower end of femur and upper end of tibia. Two usually affects lower end of femur and upper end of tibia. Two cases, on involving upper end of tibia and other in vertebra are discussed. Extreme paucity of literature prompted to publish this article. A short review of radiological appearance, histopathological findings and treatment modalities is highlighted.

Prognostic role of stress thallium test in patients with significant coronary artery disease.

OBJECTIVE: The benign outcome of patients with a normal exercise thallium-201 myocardial perfusion study has been well established. The aim of the study was to examine the prognostic implications of normal exercise tomographic thallium images in medically treated patients with angiographic evidence of coronary artery disease (CAD). METHODS: There were 68 patients in Group A with significant angiographic CAD (54 male and 14 female) aged 52 +/- 12 years, 42 had one, 18 had two and eight had three vessel CAD (50% diameter stenosis 1, Group B had 70 patients who had normal coronary arteries at cardiac catheterization. RESULTS: Exercise test was submaximal in 40 (50.82%) patients, ST segment depression during exercise occurred in 28 patients (41.1%) and angina during exercise in 24 patients (35.2%). Majority of patients (76.47%) were on anti-anginal therapy. During a mean follow up of 30 months only two patients had cardiac events in group A patient. One died of cardiac causes and one had non fatal myocardial infarction (event rate 0.96%/year). None of these 2 patients had positive ST response during exercise. In group B only one patient had non-fatal myocardial infarction. CONCLUSION: Medically treated CAD patients including those with multivessel CAD have a benign prognosis in the presence of normal exercise thallium images. These results have long term important implication in management of such patients and cost of health delivery.

Role of radionuclide perfusion study in cold solitary thyroid nodule for diagnosis of malignancy: a complimentary diagnostic modality to fine needle aspiration cytology.

One hundred and forty eight subjects with euthyroid solitary thyroid nodules (STN) were taken up for radionuclide perfusion study. They were found to have a cold STN on 99mTc thyroid static scan. All had fine needle aspiration cytology (FNAC), and except for subjects with chronic lymphocytic thyroiditis, were subjected to surgery for tissue diagnosis by histopathology. The diagnostic findings in these patients of solitary thyroid nodules were correlated with the histopathology. Radionuclide perfusion study is considered useful to differentiate benign from malignant cold thyroid solitary nodules with high degree of sensitivity (95%) and specificity (87.9%).