Sentinel lymph node biopsy in melanoma: Which hot nodes should be harvested and is blue dye really necessary?

OBJECTIVES: The '10% rule' has become widely accepted by surgeons performing sentinel lymph node biopsy (SLNB) for melanoma. The purpose of this study was to compare the '10% rule' with alternative node harvesting criteria. In particular, we were interested to see whether the use of blue dye had any impact on the sensitivity of the test and whether it is necessary to remove all hot nodes. METHODS: We reviewed 537 SLNBs performed for primary melanoma from 2009-2015. SLNB was offered to all patients with 1-4 mm Breslow thickness melanoma and sentinel nodes were harvested according to the '10% rule'. RESULTS: One hundred sixteen patients (22%) had at least one positive sentinel node and there were 45 positive nodal basins from which more than one sentinel node had been harvested. Excluding blue dye and sampling only hot nodes would have enabled a 5% reduction in nodes harvested, without any compromise in the sensitivity of the test. However, applying harvesting criteria whereby not all hot nodes are taken was associated with a loss of sensitivity, with positive sentinel nodes being missed and patients understaged. CONCLUSIONS: Our data do not support the continued use of blue dye in SLNB for melanoma, as it does not improve the sensitivity of the test. This series adds to growing evidence, suggesting that the '10% rule' with the inclusion of blue nodes should be reconsidered and that radiocolloid tracer alone is sufficient for sentinel node localisation.

Body fat reference percentiles on healthy affluent Indian children and adolescents to screen for adiposity.

BACKGROUND: Indian children and adolescents have higher body fat percentage at a given body mass index than their Western counterparts. OBJECTIVE: To create gender-specific percentile curves for total body fat percentage (TBFP), total body fat mass (TBFM), fat mass index (FMI) and android:gynoid (A:G) ratio for screening adiposity in healthy Indian children. METHODS: Data on body composition by dual-energy X-ray absorptiometry were obtained from a cross-sectional study conducted from May 2006-July 2010 on 888 (462 boys) apparently healthy children from affluent area schools and colleges in Pune city, India. Reference percentile curves were derived for boys and girls for TBFP, TBFM, FMI and A:G ratio. These percentile curves were validated using data on metabolic syndrome risk components in separate sample of 332 (148 boys) children. RESULTS: The median TBFP increased little (4%) from 5 to 18 years of age in boys compared with that in girls (19%). TBFP percentiles showed plateau after 13 years of age in boys, whereas a steady increase was seen till 18 years in girls. The median TBFM increased less (7 kg) from 5 to 18 years in boys compared with that in girls (13.4 kg). The curve for median FMI in boys was relatively flat with FMI remaining near 3 kg m(-2) after 13 years of age, whereas in girls median FMI increased with age till about 15 years of age. A:G ratio curves increased with age in both boys and girls up to 18 years of age. In a separate sample of 332 children, according to percentiles developed in the current study, children with TBFP/TBFM/FMI percentiles between 85th and 95th or >95th percentile had significantly higher metabolic risk parameters as compared with those with <85th percentile (P<0.05). CONCLUSIONS: Percentile curves developed in the current study would be useful in assessment of adiposity and thus cardiometabolic risk in Indian children.

Knowledge and practices regarding oral rehydration therapy among mothers in rural area of Vasind, India.

The oral rehydration therapy is the keystone of National Diarrhoeal Disease Control Programme. The packets of oral rehydration salts (ORS) are available at the Primary health centres as well as in chemist shops. There are depot holders of ORS packets in the community too. Most of the times the health care workers do not emphasise the role, benefits and method of preparation of ORS. As a result of this mothers do not know the right method of preparation of ORS and do not understand the need to give ORS to the child. To study awareness about ORS, depot holders of ORS and importance of ORS. To study knowledge about preparation of ORS solution. Mothers whose children were in the age group of 0-5 years were interviewed. One hundred forty five (89%) of mothers were aware about ORS. Only 39.31% of mothers knew that ORS replenishes the water lost during diarrhoea. 31.72% mothers felt that ORS stops loose motions. In spite of having correct knowledge of preparation many of them followed wrong practice of preparation. Demonstration of correct preparation of ORS solution should be inbuilt in the health education package of the Oral Rehydration Therapy for Diarrhoeal diseases. Health care providers must emphasise about the role of ORS in prevention of dehydration so that mothers give ORS to the child.

Efficacy of a continuous metabolic syndrome score in Indian children for detecting subclinical atherosclerotic risk.

OBJECTIVE: To evaluate the continuous metabolic syndrome score (cMetS) in Indian children and to investigate its relationship with the risk of carotid arterial stiffness. METHODS: Data on weight, height, mean arterial pressure, serum lipids, insulin, glucose, carotid intima-media thickness and stiffness parameters, that is, pulse wave velocity (PWV), elasticity modulus (Ep), stiffness index (ß) and arterial compliance (AC), were assessed in 236 children (6-17 years) from Pune city, India. cMetS was computed using standardized Z-scores for metabolic syndrome (MS) components. cMetS cutoff was obtained by receiver operating characteristic curve analysis across MS components. RESULTS: cMetS was lowest (-3.6±2.0) in normal children and highest (3.3±2.4) in MS children. cMetS increased progressively with number of risk components. The cutoff of cMetS yielding maximal sensitivity (80%) and specificity (94%) for predicting the presence of MS was -0.8 (area under the curve=0.921 (95% CI: 0.877-0.964)). In children with cMetS above -0.8, average PWV (4.3±0.6 m s(-1)), ß (3.8±1.2) and Ep (50.4±14.5 kPa) were significantly higher than the respective values (3.7±0.5 m s(-1); 3.4±0.8; 37.0±10.0 kPa) in children with cMetS below -0.8, whereas AC was lower (1.2±0.5 mm(2) kPa(-1)) in children with cMetS above -0.8 as against AC (1.4±0.3 mm(2) kPa(-1)) in children with cMetS below -0.8 (P<0.05), demonstrating the risk of stiffness with increasing score. Pearson's correlation coefficients of cMetS with PWV (r=0.575), ß (r=0.347), AC (r=-0.267) and Ep (r=0.530) were statistically significant (P<0.01). CONCLUSION: Results demonstrate the usefulness of cMetS over individual MS components as a better tool for assessment of atherosclerotic risk in children.

Is age a predictor of mortality in a U.K. medical high dependency unit?

BACKGROUND: The population aged older than 65 yr is set to increase by 32% by 2033. In resource-limited environments, difficult decisions regarding access to high dependency care for the elderly are increasingly important. The aim of this study was to determine whether age is a predictor of mortality in patients admitted to an open medical high dependency unit (MHDU). METHODS: Prospective observational cohort study of 100 consecutive patients admitted to an MHDU with a primary medical diagnosis over a 3 month period. The primary endpoint was 30 day mortality. RESULTS: Overall mortality at 30 days was 21% (n=21). Patients aged <65 yr were 41%, 29% were 65-74 yr, and 30% were aged 75 yr and above. There were no significant differences in mortality between groups (12%, 31%, and 23%, respectively). When considering Acute Physiology and Chronic Health Evaluation scores ≥25, there was no significant difference in mortality between age groups [35% <70 yr (7/20) vs. 29% ≥70 yr (4/14), P=1.000]. The final model at multivariable regression analysis identified that ≥2 organ support (odds ratio 10.84, 95% confidence interval 3.28-35.84) and pre-admission moderate/nursing home care [4.44 (1.05-18.70)] were significantly associated with worse outcome. The majority of survivors (88%) were discharged at their pre-admission functional status; those who declined in function were not significantly older than those who did not. CONCLUSIONS: Age does not predict the outcome from an MHDU. Those requiring ≥2 organ support, higher levels of pre-admission home support, or both had higher mortality. Selected elderly medical patients should not be denied high dependency unit care.

Oxygen uptake in relation to group size in the juveniles of a climbing perch, Anabas testudineus (Bloch).

The present work reports oxygen uptake in relation to group size in the juveniles (body weight: 0.70 to 1.30 g) of a climbing perch, Anabas testudineus (Bloch). The experiments were conducted at 21.5 +/- 1.0 degrees C using a cylindrical glass respirometer having continuous water flow system. With an increase in the number of fish at an interval of 5 from 5 to 40 in each fourth subsequent experiment, the weight specific aquatic oxygen uptake of a fish decreased from 0.192 +/- 0.030 to 0.800 +/- 0.006 ml O2 x g(-1)x(h(-1). When compared with a controlled fish, there was a reduction of 27.80% in the oxygen uptake in a group of 5 but 58.39% in a group of 40. A negative and significant correlation (r = 0.8411, p < 0.01) was calculated between oxygen uptake and group size of fishes. The investigation showed that probably due to shoaling behaviour, the aquatic oxygen uptake in the juveniles of A. testudineus always remained high in controlled fish or a fish in isolation than when they were in a group.

Malignant melanoma with neuroendocrine differentiation: clinical, histological, immunohistochemical and ultrastructural features of three cases.

AIM: To document the clinical, histological, immunohistochemical and ultrastructural features of three malignant melanomas showing neuroendocrine differentiation. METHODS AND RESULTS: Three patients, two with primary cutaneous melanoma and one with nasal mucosal melanoma, subsequently developing or simultaneously presenting with metastatic malignant melanoma, were studied by conventional histological technique, immunohistochemistry of formalin-fixed paraffin-wax embedded tissues, and electron microscopy of epoxy-resin-embedded tumour tissue. Tumours showed either small cell or conventional malignant melanoma cell morphology. One of the three primary melanocytic lesions (the nasal melanoma) exhibited neuroendocrine differentiation immunohistochemically. All three metastatic malignant melanomas showed, in varying combinations, immunohistochemical and ultrastructural evidence for neuroendocrine differentiation: they were positive for the melanocytic markers, S100 protein, HMB-45, Melan-A and tyrosinase, and the neuroendocrine markers chromogranin, synaptophysin and neurofilament protein. Ultrastructural study in two of the metastases revealed neuroendocrine granules but no lattice-bearing melanosomes. CONCLUSIONS: The cases described are the most comprehensively investigated malignant melanomas showing neuroendocrine differentiation to date, and the first to document neuroendocrine differentiation ultrastructurally in these tumours. Malignant melanoma with neuroendocrine differentiation therefore needs to be recognized among the other, better known variants of malignant melanoma.

Profile of bone marrow examination in HIV/AIDS patients to detect opportunistic infections, especially tuberculosis.

Morphological evaluation of 140 bone marrow aspirations received in haematopathology laboratory with serologically established HIV infection, along with other relevant special haematological tests, was done during 1st Jan 1999 - 31st Dec 2002 at state government run tertiary care General Hospital in Maharashtra state, India. Out of 140 cases: 118 (84.28%) patients had anaemia, 25 (17.86%) had leukopenia, while 13 (9.28%) were thrombocytopenic. Dyserythropoiesis was present in 18 (12.86%) cases, dysmyelopoiesis 37 (26.43%) and micromegakaryocytes were noted in 44 (31.43%) cases. Haemophagocytosis was evident in 8 (5.71%) cases. Plasmacytosis encountered in 120 (85.71%) cases was a common feature. Based on clinical profile and results of other investigations 56 (40%) patients were clinically diagnosed to be of Mycobacterium tuberculosis (TB). Of these, 18 (12.86%) bone marrow aspirates were positive for AFB, Mycobacterium tuberculosis. In 4 cases cryptococci were demonstrated (Mucicarmine stain). There was one case each of Histoplasma capsulatum and leishmaniasis. One patient showed dense parasitemia with Plasmodium falciparum. One patient had immunoblastic lymphoma and showed bone marrow infiltration. Findings in this study strongly indicate that in HIV/AIDS, AFB stain should be done on each marrow aspirate to rule out tuberculosis in countries like India; where TB and AIDS are marching together.

Neonatal outbreak of Salmonella worthington in a general hospital.

This is a report of an outbreak of Salmonella worthington in neonates at Sassoon General Hospitals, Pune, which occurred during August and September 2000. A total of 148 blood, 4 CSF and 6 stool specimens were received from neonates admitted to the hospital. Salmonella worthington could be isolated from 17 clinical specimens [15 blood (10.8%), 1 CSF (25%) and 1 stool (16.6%) sample]. Environmental swabs were also processed. An attempt was made to detect carriers in health care personnel. However, no source or carrier of Salmonella worthington in the hospital environment could be identified. Intensive cleaning measures and fumigation were undertaken. All these measures succeeded in aborting the outbreak.

A pilot study on CD4 & CD8 cell counts in healthy HIV seronegative pregnant women.

CD4 and CD8 counts are widely used prognostic markers to assess the degree of immune impairment in HIV seropositive individuals and to monitor anti-retroviral therapy (ART). Pregnancy is considered as a physiologically immunocompromised state, hence alterations in T lymphocyte subsets may occur during pregnancy. There is a need to establish base-line values of these counts, especially in healthy pregnant women. One hundred healthy HIV seronegative pregnant women (mean age 22.5 +/- 2.99 yr) in their third trimester of pregnancy and 30 non-pregnant women (mean age 22.7 +/- 3.01 yr) were tested for their CD4 and CDS counts. In pregnant women, the CD4 and CD8 cell counts/microl were 764 +/- 249 and 547 +/- 196 and the CD4 and CD8 per cent were 56.49 +/- 8.3 and 38.03 +/- 7.2 respectively. In the non-pregnant women CD4 and CD8 counts/microl were 965 +/- 267 and 639 +/- 211 whereas the CD4 and CD8 per cent were 55.27 +/- 5.99 and 36.17 +/- 6.44 respectively. Absolute counts were significantly lower (P < 0.05) in the pregnant group as compared to the controls. A wide variation was seen in the CD4 and CD8 counts in both the groups. However, the variations in the mean CD4 and CD8 per cent were much smaller. Thus CD4 and CD8 per cent may be considered as a useful indicator of immune function rather than absolute counts, in pregnant women.

Detection of antibodies to Brucella abortus in animal handlers.

1. Our study showed a prevalence of 5.33% in animal handlers working in an urban city like Pune. The prevalence would definitely be higher in a population from a rural area. 2. All these cases who showed presence of antibodies to B. abortus, had varied clinical manifestations, characteristic of the protean manifestations in brucellosis. Likewise in our study we had cases ranging from arthritis, abortions and genito urinary manifestations. 3. All the antibody positive cases had significant antibody titres. The clinicians miss many cases of brucellosis because it is not considered as an alternative diagnosis. The clinician should keep in mind the possibility of an occupational or environmental exposure in cases of P.U.O. It would also be worthwhile to create awareness of the disease in such professions so that necessary precautions and periodic screening of such occupationally exposed people can be done. Studies are needed to assess the role of brucellosis as a cause of morbidity in India, which had not received the attention it deserved. Prevention of human brucellosis focuses mainly on elimination of infection in cattle along with hygiene, vaccine, and effective heating and pasteurization of dairy products and related foods.

Prevalence, identification and distribution of various species of enterococci isolated from clinical specimens with special reference to urinary tract infection in catheterized patients.

Various clinical specimens were processed to find the prevalence rate of enterococci and to identify the species of clinical isolates of enterococci. Screening of various clinical specimens revealed that enterococci were prevalent in 22.19% of the total specimens, with Foley's catheters and burn wounds to be the major site of isolation. High rate of colonization was noted as opposed to infection. Conventional test scheme proposed by Facklam and Collins were successfully used to speciate enterococcal strains. Seven species of enterococci were identified in the study from a set of 202 cultures, with E.faecalis (49.50%) and E. faecium (35.64%) predominating. E. avium (9.40%), E. hirae (2.47%), E. raffinosus (1.98%) and one isolate each of E.gallinarum and E. casseliflavus were the other members of Enterococcus species identified. Urinary tract infection (UTI) by enterococci due to catherisation was found in 8.92% of the patients and is probably the result of high rate of colonization of Foley's catheters and use of broad-spectrum antibiotics.

Clinical and morphological variants of cutaneous tuberculosis and its relation to Mycobacterium species.

Cutaneous tuberculosis forms a small proportion of extrapulmonary tuberculosis. The incidence of cutaneous tuberculosis has fallen from 2% to 0.15% in India whereas it is rare in developed countries. The present study is an attempt at finding out the Mycobacterium species associated with cutaneous tuberculosis. A total of 51 cases of clinically suspected cutaneous tuberculosis were studied over a period of 18 months from July 1997 to December 1998. Of these, 32 (62.75%) were Scrofuloderma cases, 12 (23.52%) cases of Lupus vulgaris and 7 (13.73%) were Tuberculosis verrucosa cutis (TBVC) cases. Twenty nine mycobacterial isolates from 51 specimens gave an isolation rate of 56.86%. These were subjected to a battery of biochemical tests for identification to species level. Twenty six out of 29 isolates were identified as Mycobacterium tuberculosis, two were identified as Mycobacterium Scrofulaceum and one Mycobacterium avium complex was isolated. Sixteen Mycobacterial isolates were recovered from Scrofuloderma cases, 9 were isolated from Lupus vulgaris and 4 from TBVC cases. The three atypical mycobacterial isolates were recovered from Scrofuloderma cases. Though Mycobacterium tuberculosis was the most common isolate, Mycobacterium scrofulaceum and Mycobacterium avium complex were also isolated in the present study.

Comparative pathogenicity of trichomonas vaginalis isolated from symptomatic & asymptomatic cases.

Pathogenicity of 19 isolates of T.vaginalis obtained from vaginal specimens were studied in the murine model by intraperitoneal route. Sixteen isolates were recovered from the females with various clinical conditions and 3 isolates were from normal healthy females. Pathogenicity level of these isolates were studied by inoculating 5 mice per isolates through intraperitoneal route and the animals were sacrificed on tenth day post-inoculation. In general, all the isolates recovered produced infection in mice. On comparison with the reference strain obtained from Hoechst India Ltd., seven isolates recovered from symptomatic cases and one strain from healthy females produced severe infection in mice. Though variation in pathogenicity level was observed among the isolates, a definite correlation between clinical picture in natural host and pathogenicity in mice was not observed.

Prevalence of VDRL sero-positivity in women in reproductive age group in an urban slum community in Bombay.

A cross sectional survey was carried in an Urban Slum Community in Bombay having a population of 60,000. A total of 393 women in reproductive age group were screened for VDRL reactivity. The highest prevalence was in 15 to 29 years of age group. The sero-positivity rate at 1:8 dilution and above was 0.50%. The seropositivity rate can be further brought down by properly planned and implemented STD (Sexually Transmitted Diseases) Control activities at a community level.

Comparative pathogenicity of Trichomonas vaginalis isolated from symptomatic and asymptomatic cases.

Pathogenicity of 19 isolates of Trichomonas vaginalis obtained from vaginal specimens were studied in the murine model by intraperitoneal inoculation. Sixteen isolates were recovered from the females with various clinical conditions and 3 isolates were from normal healthy females. Pathogenicity level of these isolates were studied by inoculating 5 mice per isolate through intraperitoneal route and the animals were sacrificed on the 10th day post-inoculation. In general, all the isolates recovered produced infection in mice. On comparison with the reference strain obtained from Hoechst India Ltd., seven isolates recovered from symptomatic cases and one strain from healthy females produced severe infection in mice. Though variation in the pathogenicity level was observed among the isolates, a definite correlation between the clinical picture in the natural host and pathogenicity in mice was not observed.