Proton pencil beam scanning craniospinal irradiation (CSI) with a single posterior brain beam: Dosimetry and efficiency.

This study explores the feasibility and potential dosimetric and time efficiency benefit of proton Pencil Beam Scanning (PBS) craniospinal irradiation with a single posterior-anterior (SPA) brain field. The SPA approach was compared to our current clinical protocol using Bilateral Posterior Oblique brain fields (BPO). Ten consecutive patients were simulated in the head-first supine position on a long BOS frame and scanned using 3 mm CT slice thickness. A customized thermoplastic mask immobilized the patient's head, neck, and shoulders. A vac-lock was used to secure the legs. PBS proton plans were robustly optimized with 3mm setup errors and 3.5% range uncertainties in the Eclipse V15.6 treatment planning system (n = 12 scenarios). In order to achieve a smooth gradient dose match at the junction area, at least 5 cm overlap region was maintained between the segments and 5 mm uncertainty along the cranial-cauda direction was applied to each segment independently as additional robust optimization scenarios. The brain doses were planned by SPA or BPO fields. All spine segments were planned with a single PA field. Dosimetric differences between the BPO and SPA approaches were compared, and the treatment efficiency was analyzed according to timestamps of beam delivery. Results: The maximum brain dose increases to 111.1 ± 2.1% for SPA vs. 109.0 ± 1.7% for BPO (p < 0.01). The dose homogeneity index (D5/D95) in brain CTV was comparable between techniques (1.037 ± 0.010 for SPA and 1.033 ± 0.008 for BPO). Lens received lower maximum doses by 2.88 ± 1.58 Gy (RBE) (left) and 2.23 ± 1.37 Gy (RBE) (right) in the SPA plans (p < 0.01). No significant cochlea dose change was observed. SPA reduced the treatment time by more than 4 minutes on average and ranged from 2 to 10 minutes, depending on the beam waiting and allocation time. SPA is dosimetrically comparable to BPO, with reduced lens doses at the cost of slightly higher dose inhomogeneity and hot spots. Implementation of SPA is feasible and can help to improve the treatment efficiency of PBS CSI treatment.

Examination of an Intergenerational Summer Meal Program for Children and Older Adults.

Unreliable access to a sufficient quantity of affordable, nutritious food in the U.S. is a persistent public health threat significantly impacting households with children (15%) and older adults (20%). Well-established nutrition assistance programs serve children and seniors independently, yet few programs utilize an intergenerational meal program model. The aim of this mixed methods study is to examine the impact of an intergenerational meal program administered through a partnership between a local school district and a county Senior Nutrition Program. Participating older adults completed surveys to assess food security and program attendance, and examine their understanding and utilization of community-based food resources. Interviews with a subsample of participants explored perceptions of the intergenerational meal program and community-level food security. Older adults (n = 83) completed surveys in English (59%), Spanish (25%), and Mandarin (16%). They identified primarily as Asian (44%), Latinx (30%), White (21%), and multi-racial (5%). Forty-eight percent of participants indicated low or very low food security at some time in the last 12 months. The subsample of interview participants (n = 24; Spanish 46% and English 54%) revealed key insights: 1) perceived benefits of an intergenerational meal program; 2) community-level food insecurity and struggles of older adults to make ends meet; and 3) importance and challenge of obtaining nutritious foods for those with limited budgets and medical comorbidities. Implementation of this intergenerational meal program highlights the opportunity to support the nutritional needs of children and older adults while leveraging a new interdisciplinary partnership and existing organizational capacity.

Papanicolaou-Stained Cytosmear Preparations in the Evaluation of Leucocytospermia: A Tertiary Centre Experience and Assessment of Utility.

Objectives Leucocytospermia is a rare cause of infertility with a variable incidence in infertile men. In many andrology laboratories, semen analysis is primarily centered on analyzing basic parameters (sperm count, motility, and viability). We examined the role of cytomorphological analysis on Papanicolaou (PAP)-stained smears in the work up of male infertility, with special reference to leukocytospermia and assessed the morphological features of sperms in these cases. Materials and Methods All cases signed out as "leukocytospermia" between November 2017 and January 2018 were evaluated. Cases showing pus cells (≥ 1/5hpf) on cytosmear evaluation were also analyzed. Parameters obtained on modified Neubauer's chamber, wet mount preparations, and autoanalyzer SQA-IIC-P (Medical Electronic Systems, Israel) were tabulated. PAP-stained smears were examined to assess morphological defects and other findings, if any. Results Out of 348 semen samples, 6 (1.72%) were diagnosed as leukocytospermia, all displaying pus cells on cytomorphological evaluation. Five cases having white blood cells < 1 × 10 9 /L were analyzed, which displayed the presence of pus cells (≥ 1/5 hpf) on cytosmear preparations (1.43%). Nine cases (81.8%) showed reduced motile sperm concentration, functional sperm concentration, and sperm motility index. Morphological evaluation of the PAP-stained smears showed mid-piece defects in 18.1% cases. Conclusion Diligent cytomorphological evaluation of semen is essential to diagnose leukocytospermia, assess morphological defects, and serve as a quality control measure.

Chronic Liver Disease Presenting as Immune Hemolytic Anemia: The Challenges of Diagnosis in the Critically Ill in a Resource-Limited Health Care Setting.

Immune hemolytic anemia is very rarely associated with chronic liver disease. Diagnosis is often complicated in critically ill patients, where an etiological diagnosis can be elusive, especially in routine health care settings. A 48-year-old man presented with jaundice for three months. Ultrasonography showed features of chronic liver disease. Fibroscan showed increased parenchymal stiffness suggesting cirrhosis. Investigations revealed immune hemolytic anemia and thrombocytopenia. A percutaneous liver biopsy was not performed due to worsening thrombocytopenia. Isolated protein C deficiency and portal vein thrombosis were noted in subsequent testing. The patient eventually succumbed to illness. Coagulopathy such as protein C and D-dimer elevation discovered in subsequent rounds of testing may be misleading in rapidly deteriorating patients, emphasizing the need for timely coagulation workup and imaging. Despite comprehensive testing, lack of liver biopsy, as seen herein, may hamper clinical management. Training residents in the skill of transjugular liver biopsy is necessary to manage critical patients at secondary health care facilities.

Finish before the start: Analyzing preanalytical sample errors in a tertiary care hematology laboratory.

AIMS: (a) To evaluate the types and frequencies of preanalytical errors occurring in a tertiary care hematology diagnostic center and (b) To evaluate differences if any, across groups [outpatient data (OPD) vs inpatient data (IPD), type of test requested [complete blood count (CBC) vs coagulation] and laboratory (routine vs emergency). SETTINGS AND DESIGN: A prospective study was conducted over a period of nine months (August 2017-April 2018) to address the above objectives. All samples received in the clinical hematology division of our institute were included in the analysis. MATERIALS AND METHODS: Categories of preanalytical errors were defined. This included insufficient, clotted, diluted, and lipemic samples. Clerical errors such as wrong/absent sample labeling, requisition form-sample mismatch, and wrong vacutainer selection were also documented. IPD and OPD data, as well as data pertaining to samples sent for different tests [complete blood count (CBC)/coagulation] and in the routine and emergency laboratories, were segregated. STATISTICAL ANALYSIS USED: All errors in each category were recorded as numbers and corresponding percentages (proportions). The two-tailed z-test was applied to assess the significance of the difference in proportions across all groups. Statistical significance was kept at P < 0.05. RESULTS: A total of 189,104 samples were received in the clinical hematology laboratory during the aforementioned period, out of which preanalytical errors were found in 4052 (2.14%) samples. Inadequate sample quantity (ISQ) comprised the bulk of preanalytical errors in our laboratory (1.11% of total samples) followed by sample clots (0.88%). There was no significant difference in the error frequencies in OPD and IPD (P = 0.1031). The proportion of errors was higher in routine vis-à -vis emergency samples and also in samples sent for coagulation analysis vis-à -vis CBC.

Critical analysis of two cases of major crossmatch incompatibility in tertiary care hospital in Delhi.

Rh blood group is one of the most complexes of the human blood groups system. RHD gene encodes the D antigen, and the RHCE encodes the C, c, E, and e antigens. Out of these, Rh D antigen is the most immunogenic while e antigen is the least immunogenic. Rh antibodies are produced in Rh-negative individuals following sensitization which occurs either through pregnancy or during blood transfusion. We hereby report two cases of anti-e antibody, both presenting as major crossmatch incompatibility.

Critical evaluation of donor direct antiglobulin test positivity: Implications in cross-matching and lessons learnt.

Direct Antiglobulin Test is a method of demonstrating the presence of antibody/ complement bound to red cell membrane by using AHG to form a visible agglutination reaction. DAT positivity is seen in immune mediated haemolytic anaemias, however rarely non immune mediate haemolytic anaemias also show DAT positivity. DAT positivity predictive of 83% of autoimmune haemolytic anaemia and 1.4% cases without haemolytic anaemia. Screening of blood donors for DAT is usually not recommended traditionally by any guidelines. However DAT positivity is reported in 0.008% of donors. On extensive search of literature we could find only very few studies on DAT positivity in donors. We report two cases of DAT positive donors with no clinical or laboratory evidence of hemolysis.

Case Marking in Hindi as the Weaker Language.

Does language dominance modulate knowledge of case marking in Hindi-speaking bilinguals? Hindi is a split ergative language with a rich morphological case system. Subjects of transitive perfective predicates are marked with ergative case (-ne). Human specific direct objects, indirect objects, and dative subjects are marked with the particle -ko. We compared knowledge of case marking in Hindi-English bilinguals with different dominance patterns: 23 balanced bilinguals and two groups of bilinguals with Hindi as their weaker language: 24 L2 learners of Hindi with age of acquisition (AoA) of Hindi in adulthood and 26 Hindi heritage speakers with AoA of Hindi since birth in oral production and acceptability judgments. The balanced bilinguals outperformed the English-dominant bilinguals; the L2 learners and the heritage speakers, who showed similar lower command of the Hindi case marking system, with the exception of -ko marking as a function of specificity with direct objects. We consider how dominant language transfer, AoA of Hindi, and input factors may explain the acquisition and knowledge of morphology in Hindi as the weaker language.

Reporting adverse transfusion reactions: A retrospective study from tertiary care hospital from New Delhi, India.

CONTEXT: Blood transfusion services have achieved newer heights in the last decade, with developments in cellular techniques, component separation, and integration of molecular methods. However, the system of recording and reporting of the adverse events related to blood transfusion is developing countries like India is grossly inadequate and voluntary in nature. AIMS: This study was undertaken to analyze the retrospective data on adverse events related to blood transfusions in our hospital. SUBJECTS AND METHODS: This retrospective study was done to examine all the transfusion related adverse events reported in a Regional Blood Bank Transfusion Centre of North India over a period of 9 years. Adverse transfusion events related to whole blood, red cell concentrates (RCCs), and all other components were analyzed and classified on the basis of their clinical features and laboratory tests. Average rate of transfusion reactions with the components was also assessed. STATISTICAL ANALYSIS USED: Categorical variables were analyzed using the Chi-square test. P < 0.05 was taken to indicate a significant difference. RESULTS: During this period, a total of 1,60,973 blood/blood component units were issued by our blood bank to various departments of the hospital and 314 immediate transfusion events were reported. The rate of immediate transfusion reactions during the study was 0.19%. Average transfusion reaction rate with RCC was 0.25% with febrile nonhemolytic reactions being the most common type of adverse event (37.2%). CONCLUSIONS: Awareness should be increased among clinicians to correctly prevent, identify, and report transfusion-related adverse events. These measures should be implemented to increase blood transfusion quality and safety.

Critical appraisal of stromal CD10 staining in fibroepithelial lesions of breast with a special emphasis on expression patterns and correlation with WHO grading.

BACKGROUND: Fibroepithelial lesions of the breast are classified into fibroadenoma and phyllodes tumor (PT). Although WHO has established a well-defined grading system for PT, dilemma of discriminating borderline from malignant PT still exists. Stromal CD10 is a known poor prognostic factor in invasive breast cancer, its expression in fibroepithelial lesions of the breast is not well-documented. Till date, only one study has correlated the CD10 staining score with tumor grade in PT. OBJECTIVE: To evaluate whether the differences in expression patterns of CD10 and staining intensity correlate with the degree of malignancy in fibroepithelial tumors of the breast. MATERIALS AND METHODS: This is a retrospective study in which stromal CD10 expression was studied in 75 cases of fibroepithelial lesions of the breast using immunohistochemistry. Statistical analysis was performed using Chi-square test. RESULTS: There was a statistically significant trend of increasing stromal expression of CD10 with increasing degree of malignancy (P = 0.001). CONCLUSIONS: CD10 staining pattern and its scoring can assist the pathologist to accurately grade the PT of the breast for adequate treatment and can also be used as a target for the development of novel therapies.

Congenital Acute Myeloid Leukaemia with Pseudo-Chediak-Higashi Like Granules: A Case Report.

Congenital leukaemia is a very rare entity comprising 0.8% of all childhood leukaemias. Pseudo-Chediak-Higashi Anomaly (PCHA) in acute leukaemia is a rarely described entity. However, co-existence of congenital myeloid leukaemia with PCHA is a very rare entity and to the best of our knowledge has not been described in literature till date. A full term new-born presented on the 27th day of life with severe gastroenteritis. Complete blood counts and peripheral smear examination revealed leucocytosis with presence of 76% blast cells. Approximately 15% of these blast cells showed presence of pseudo-Chediak-Higashi like granules. The diagnosis of acute myeloid leukaemia was confirmed by flow cytometry. The case report is presented due to its rarity and to highlight the differential diagnosis and clinical implications of this entity.

An unusual large abdominal malakoplakia following trauma: Diagnosed on FNAC.

Malakoplakia is a rare chronic granulomatous inflammatory disease, related to immune deficiency and impaired bactericidal macrophage activity. Common sites of involvement include urinary bladder and kidney followed by gastrointestinal tract. We present an unusual case of abdominal malakoplakia diagnosed preoperatively on ultrasound-guided fine-needle aspiration cytology (FNAC). It presented as a large locally aggressive mass with extensive involvement of multiple bowel loops in an 18-year-old boy following blunt trauma to the abdomen. The demonstration of calcified laminated intracytoplasmic Michaelis-Gutman bodies in histiocytes is a reliable diagnostic feature of malakoplakia on FNAC smears, which can guide an appropriate medical management.

Can threshold for MPO by flow cytometry be reduced in classifying acute leukaemia? A comparison of flow cytometric and cytochemical myeloperoxidase using different flow cytometric cut-offs.

Objectives Myeloperoxidase (MPO) detection either by enzyme cytochemistry (cMPO) or flow cytometry (fMPO) plays a major role in acute leukaemia (AL) diagnosis as per World Health Organization (WHO) 2008 classification. Although 3% cMPO was recommended as positivity, no specific cut-off had been mentioned by WHO for fMPO. Various authors recommend different cut-offs ranging from 3 to 28% for fMPO. The aim of this study was to analyse fMPO cut-offs ranging from 3 to 10% in classifying AL and to assess whether a new cut-off could be suggested. Methods Totally, 216 cases of AL were retrospectively analysed for fMPO ranging from 3 to 10% and compared with gold standard. Presence of cMPO (≥3%) and/or expression of two or more pan-myeloid markers (CD13, CD33, and CD117) in the absence of CD19 and CD3 were kept as gold standard for diagnosis of acute myeloid leukaemia (AML). Results Sensitivities for classifying AL as AML/mixed phenotypic acute leukaemia (MPAL) at 3, 5.4, and 10% were 98.3, 98.3, and 96.6%, respectively, whereas specificities at this cut-off were 22.2, 91, and 71%, respectively. Discussion Only few studies have been done in this aspect to define a consistent cut-off for fMPO for proper classification of acute leukaemias. This was one of the largest and few studies available till date in this regard. Conclusion The newer cut-off for fMPO (5.4%) emerged out from our study with best sensitivity and specificity for accurately classifying AL cases into acute lymphoblastic leukaemia, AML, and MPAL.

Mesenchymal hamartoma mimicking hepatoblastoma: A cytological pitfall.

The case of a 9-month-old infant who presented with an abdominal mass since birth is discussed here. Fine-needle aspiration (FNA) cytology of this mass was performed, from which it was thought to be a small round tumor, possibly a hepatoblastoma (HB). Histopathologically, however, it was found to be a mesenchymal hamartoma (MH). This case report thus highlights this cytological limitation.