Nationwide practices in the use of central venous catheters for therapeutic plasma exchange in the inpatient setting.

INTRODUCTION: Therapeutic plasma exchange (TPE) is often impacted by difficulties in obtaining an adequate and safe vascular access. This study evaluated the rates, predictive factors, and clinical outcomes associated with central venous catheter (CVC) use during the inpatient TPE procedures. METHODS: The Nationwide Readmissions Database, 2016 to 2017 was used to identify hospitalizations with TPE with and without CVC insertion. RESULTS: During the study period, there were 35 429 hospitalizations with TPE (pediatric 6.1%, mean ± standard deviation (SD) age 50.9 ± 20.0 years, female 52.7%). CVC insertion was documented in 24 414 (73.4%) adult and 1596 (73.5%) pediatric hospitalizations. In pediatric patients, age >15 years, higher disease severity, and private insurance were associated with higher odds of CVC insertion. In adults, female sex, obesity, concurrent hemodialysis, and higher disease severity were associated with CVC insertion. Adults with private insurance and both adult and pediatric hospitalizations at the teaching hospitals had lower odds of CVC placement. All patients with CVC insertion had longer length of hospital stay, and adults with CVC insertion also had higher hospital charges, higher in-hospital mortality, and lower likelihood of being discharged to home. CONCLUSION: CVC insertion is performed for the majority of inpatient TPE procedures and CVC use appears to correlate with worse clinical outcomes.

Platelet transfusion practices in immune thrombocytopenia related hospitalizations.

BACKGROUND: The role of platelet transfusions in management of Immune Thrombocytopenia (ITP) remains controversial. Current guidelines recommend that platelet transfusions in ITP be reserved for catastrophic hemorrhage or invasive surgical procedures. This study assesses the nationwide platelet transfusion practices in hospitalized children and adults with ITP. STUDY DESIGN AND METHODS: We studied hospitalizations with ITP as the primary admitting diagnosis from 2010-2014 in National Inpatient Sample (NIS), the largest all-payer inpatient database. Univariate and multivariable logistic regression analyses were used to determine factors predicting platelet transfusions. Sampling weights were applied to generate nationally representative estimates. Propensity score matching was used to perform sensitivity analyses. RESULTS: From 2010 to 2014, there were 78,376 admissions with ITP as the primary admission diagnosis (mean ± SD age: 45 ± 27 years; females 56%, children [age < 18 years] 22%) and 282,285 with ITP as one of all the admission diagnoses. Overall, 27% admissions with ITP as primary (children 4%) and 15% admissions with ITP as one of all the diagnoses documented at least one platelet transfusion. On multivariable adjustment the following factors were associated with worsening disease severity and a higher odds of platelet transfusion, adult age (adjOR = 9.03, 95% CI = 7.40-11.02), male gender (adjOR = 1.21, 95% CI = 1.11-1.31), bleeding occurrence (intracranial/gastrointestinal/genitourinary/epistaxis) (adjOR = 1.78, 95% CI = 1.61-1.96), admission to rural non-teaching hospital (adjOR = 1.85, 95% CI = 1.52-2.22), and small bed-size hospital (adjOR = 1.23, 95% CI = 1.05-1.45). Of admissions reporting platelet transfusions, only 26% reported a bleeding complication, and 11% had a major operating-room surgery/procedure. Overall, 65% of transfused patients had neither bleeding nor a major operative procedure during the hospitalization. Admissions with platelet transfusions had a significantly longer mean length of hospitalization 2.2 days (95% CI = 1.96-2.41, p < 0.001), and accrued higher mean total hospital charges; $31,150 USD (95% CI = 27,644-34,656, p < 0.001). However, platelet transfusions were not associated with in-hospital mortality (adjOR = 1.02, 95% CI = 0.73-1.45, p = 0.892). CONCLUSION: Platelets are administered to a small fraction of the hospitalized ITP patients. In a majority of these cases however, platelet usage does not appear to be concordant with the current guidelines or associated with improvement in clinical outcomes.

Intermediate-risk differentiated thyroid carcinoma patients who were surgically ablated do not need adjuvant radioiodine therapy: long-term outcome study.

OBJECTIVE: The mute question is whether patients with DTC of intermediate risk of recurrence, second most common presentation, who were surgically ablated in the first place, ever needed adjuvant RAI therapy? This study exclusively evaluated the long-term outcome in intermediate-risk patients with DTC. DESIGN: Two-arm retrospective cohort study conducted between years 1991 and 2012. SETTING: Institutional practice. PATIENTS: Intermediate-risk DTC patients, with pathologically proven T1/2 N1 M0, T3 with/without N1 M0 disease, with a minimum follow-up of 12 months, were included. Of 254 patients who fulfilled the inclusion/exclusion criteria, 125 patients were surgically ablated (Gr-I) and 129 patients had significant remnant and/nodal disease (Gr-II). No radioiodine in Gr-I and adjuvant RAI therapy was administered in Gr-II patients. MEASUREMENTS: Baseline characteristics were compared and overall survival, event-free survival, disease-free survival/overall remission rates and recurrence rates were calculated for both the groups. RESULTS: All baseline patient characteristics were comparable except 24-h RAIU between two groups. Depending on adjuvant radioiodine therapy outcome, Gr-II patients were subclassified as Gr-IIa (ablated) and Gr-IIb (not ablated). With a median follow-up duration of 10·3 years (range: 1-21 years), 12/125 (9·6%) patients had disease recurrence and 10 (8%) showed persistent disease in Gr-I. In Gr-IIa, 6/102 (5·9%) patients recurred but only one of them was successfully ablated with (131) I, and 5 (4·9%) had persistent disease. However, in Gr-IIb, 27 patients who failed first-dose adjuvant RAI therapy, 8/27 (29·6%) showed persistent disease (P = 0·000). Overall survival was 100%; however, disease-free survival rates were 92% and 90%, in Gr-I and Gr-II, respectively. CONCLUSION: Intermediate-risk surgically ablated patients do not need adjuvant RAI therapy and patients who failed to achieve ablation with first dose of (131) I may be dynamically risk stratified as high-risk category and managed aggressively.

Mortality among homeless women who remain unclaimed after death: An insight.

BACKGROUND: Some homeless people remain unclaimed after death. Although women constitute a minor proportion among the homeless, they represent a more vulnerable section. We reviewed the major autopsy characteristics and causes of death among women whose bodies remained unclaimed after death. METHODS: We analysed the autopsy records and inquest papers of unclaimed bodies of women for the period 2006-12 at the Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, New Delhi. RESULTS: Most women whose bodies were unclaimed were 21 to 60 years old with a mean age of 45 years. Natural events (53.5%), largely attributable to acute/chronic lung diseases, were identified as the most common cause of death. Accidental deaths were predominant among the unnatural causes. Most bodies of women were found on the footpath besides the road (56.1%). CONCLUSION: The problems of physical/sexual abuse, acute chest infections and road traffic accidents are all aggravated in the situation of homelessness. More affordable shelters are needed to preferentially accommodate women. Also, awareness about the existing medical facilities needs to be increased.

Lung metastases from differentiated thyroid carcinoma: prognostic factors related to remission and disease-free survival.

OBJECTIVE: Distant metastases, although rare, account for maximum disease-related mortality in differentiated thyroid cancer (DTC). Lungs and bones are the most frequent sites of metastases. We sought to identify the prognostic factors in adult DTC patients presenting with pulmonary metastases at initial diagnosis. DESIGN: Retrospective cohort study. PATIENTS: From the medical records of 4370 patients, 200 patients aged more than 21 years who were identified to have pulmonary metastases at the time of diagnosis were included in the analysis. RESULTS: The sites of metastases were lungs alone in 133 (67%) patients, and additional sites in remaining 67 (33%) patients were as follows: bones in 59, liver in 4, brain in 2 and both bone and liver in two patients. During the mean follow-up of 61 months (range, 12-312 months), 76 patients achieved remission, 121 (60·5%) patients had biochemically and/or structurally persistent disease and three patients showed disease progression. Multivariate analysis revealed presence of macro-nodular (chest X-ray positive) pulmonary metastases and concomitant skeletal metastases as independent factors decreasing the likelihood of remission. Of the 76 patients with remission, 16 (21%) developed subsequent recurrence. Patient age >45 years and follicular histopathology were independently associated with greater hazards of developing recurrence. CONCLUSION: This study suggests that the patients with macro-nodular lung metastases and/or concomitant skeletal metastases have reduced odds of achieving remission. Moreover, significant number of patients recur even after complete remission with RAI treatment, hence strict surveillance is recommended especially in patients with age >45 years and/or with follicular histology of DTC.

Epidemiology of heart failure with preserved ejection fraction.

The prevalence of heart failure (HF) and its subtype, HF with preserved ejection fraction (HFpEF), is on the rise due to aging of the population. HFpEF is convergence of several pathophysiological processes, which are not yet clearly identified. HFpEF is usually seen in association with systemic diseases, such as diabetes, hypertension, atrial fibrillation, sleep apnea, renal and pulmonary disease. The proportion of HF patients with HFpEF varies by patient demographics, study settings (cohort vs. clinical trial, outpatient clinics vs. hospitalised patients) and cut points used to define preserved function. There is an expanding body of literature about prevalence and prognostic significance of both cardiovascular and non-cardiovascular comorbidities in HFpEF patients. Current therapeutic approaches are targeted towards alleviating the symptoms, treating the associated comorbid conditions, and reducing recurrent hospital admissions. There is lack of evidence-based therapies that show a reduction in the mortality amongst HFpEF patients; however, an improvement in exercise tolerance and quality of life is seen with few interventions. In this review, we highlight the epidemiology and current treatment options for HFpEF.

Anaplastic Multiple Myeloma With a Novel Proliferation of Pleomorphic Binuclear Plasma Cells.

This study describes an unusual case of multiple myeloma that progressed to anaplastic multiple myeloma in the pleural fluid. The Wright-stained cytospin of the pleural fluid showed a predominant population of mononuclear plasma cells with pleomorphic nuclei, characterized by both small and large nuclei, which is typical of anaplastic multiple myeloma. However, there were also more binuclear plasma cells with pleomorphic nuclei. Morphometric analysis showed that the mean nuclear length was 1.9-fold and 2.3-fold higher in the large nuclei compared to the small nuclei for the mononuclear plasma cells and binuclear plasma cells, respectively (p<0.001). The patient received B cell maturation antigen chimeric antigen receptor T cell (CAR-T) therapy for relapsed disease, with a significant reduction of the serum monoclonal paraprotein level at day 51 post-therapy. Pathologists should be aware that pleomorphic binuclear plasma cells can be part of the morphologic spectrum in anaplastic multiple myeloma.

Application of the International Consensus Classification and World Health Organization 5th edition classification to a series of myeloid neoplasms.

OBJECTIVES: Two new classifications of myeloid neoplasms have recently been published: the International Consensus Classification (ICC) and the 5th edition of the World Health Organization classification (WHO5). We sought to examine the real-world impact of dueling classifications on patient diagnoses. METHODS: Our institutional pathology database was searched, and 237 specimens with a diagnosis of myeloid neoplasia were randomly selected. For each case, a classification based on the WHO5 and the ICC was assigned. The WHO5 and ICC diagnoses were compared to determine their degree of concordance. RESULTS: After applying the WHO5 and ICC diagnostic criteria, 134 (56.5%) cases were classified as concordant, 63 (26.6%) cases had terminological differences, 37 (15.6%) cases had minor diagnostic discrepancies, and 3 (1.3%) cases had major diagnostic discrepancies. Cases with minor diagnostic discrepancies included 25 cases of myelodysplastic syndrome (MDS), 10 cases of acute myeloid leukemia (AML), and 2 cases of myeloid precursor lesions. Cases with major diagnostic discrepancies included 2 cases that were diagnosed as MDS, not otherwise specified (NOS), according to the ICC but classified as AML with NPM1 alteration and AML with RBM15::MRTFA according to the WHO5 and 1 case that was characterized as chronic myelomonocytic leukemia according to the ICC and as AML with NPM1 alteration according to the WHO5. CONCLUSIONS: This study confirms that a majority of cases are classified similarly using the 2 systems. Given the overall similarity of the systems, future harmonization of the classifications should be pursued to avoid confusion and multiple diagnoses.

Systematic Evaluation of Hematologic Parameters and Blood Smear Findings in Patients With SARS-CoV-2 vs Other Viral Respiratory Infections.

OBJECTIVES: We evaluated and compared the peripheral blood findings in patients with acute COVID-19 vs other viral respiratory infections. METHODS: We retrospectively reviewed peripheral blood counts and smear morphology in patients with a positive viral respiratory panel (VRP) or SARS-CoV-2 test. RESULTS: A total of 97 peripheral blood samples (COVID-19 infection, 53; VRP positive, 44) from 50 patients (mean [SD] age, 45.8 [20.8] years; females 52%) were reviewed. There were no statistically significant differences in the demographic characteristics between the 2 groups. The most common peripheral blood abnormalities were anemia, thrombocytopenia, absolute lymphopenia, and reactive lymphocytes. The following peripheral blood findings were significantly associated with other viral respiratory infections compared with COVID-19 infection: low red blood cell count, low hematocrit, high mean corpuscular volume, thrombocytopenia, low mean platelet volume, high red cell distribution width, band neutrophilia, and toxic granulation in neutrophils. CONCLUSIONS: Our study showed that there are several peripheral blood count and morphologic abnormalities seen in patients with COVID-19, but most of these findings lack specificity as they are also seen in the other viral respiratory infections.

In-Hospital Outcomes and Recurrence of Acute Ischemic Stroke in Patients With Solid Organ Malignancy.

OBJECTIVE: To evaluate the influence of solid organ malignancies on the in-hospital outcomes and recurrent strokes among patients hospitalized with acute ischemic stroke (AIS). METHODS: Adult hospitalizations with a primary diagnosis of AIS were identified from the Nationwide Readmissions Database 2016-2018. Logistic regression was used to compare the differences in the utilization of acute stroke interventions and clinical outcomes in patients with and without malignancy. Survival analysis was used to evaluate the risk of readmission due to recurrent stroke after discharge. RESULTS: There were 1385840 hospitalizations due to AIS (mean±SD age 70.4±14.0 years, female 50.2%). Of these, 50553 (3.7%) had a concurrent diagnosis of solid organ malignancy. The five most common malignancies included lung cancer (24.6%), prostate cancer (13.2%), breast cancer (9.3%), pancreatic cancer (6.5%), and colorectal cancer (6.2%). After adjustment for baseline differences, patients with malignancy were more likely to have intraparenchymal hemorrhage (IPH) [odds ratio (OR): 1.11, 95% confidence interval (CI): 1.04-1.19], in-hospital mortality (OR: 2.15, 95% CI: 2.04-2.28), and discharge disposition other than to home (OR: 1.70, 95% CI: 1.64-1.75). Patients with malignancy were less likely to receive intravenous thrombolysis (tPA) and were more likely to undergo mechanical thrombectomy (MT). Among the subgroups of patients treated with tPA or MT, the outcomes were comparable between patients with and without malignancy, except patients with lung cancer remained at a higher risk of mortality and adverse disposition despite these acute stroke interventions. Patients with malignancy were at a higher risk of readmission due to recurrent AIS within 1 year of discharge (hazards ratio: 1.18, 95% CI: 1.11-1.25), and this risk was specifically driven by the lung and pancreatic cancers. CONCLUSION: While patients with malignancy generally have worse in-hospital outcomes as compared to those without, there is considerable variation in these outcomes according to the different cancer types and the use of acute stroke interventions. The use of tPA and MT is generally safe for eligible patients with an underlying malignancy. Patients with lung and pancreatic cancers have a higher early risk of recurrent stroke and might need more intensive surveillance and careful institution of the optimal secondary prevention measures.

Data on the Relationships of Signal-To-Cutoff Ratios of Elecsys HIV Antigen/Antibody and Elecsys Syphilis Assays to Subsequent Confirmatory Testing at an Academic Medical Center.

Immunoassays are widely used as screening tests for HIV and syphilis in clinical, public health, and research settings. For syphilis, immunoassays are used in 'reverse syphilis algorithms' that start with treponemal tests such as syphilis IgG or syphilis total antibodies for the initial screen. Many screening immunoassays for HIV and syphilis use signal-to-cutoff (S/CO) values for determining positivity, with a cutoff value such as 1.0 differentiating positive from negative. Published literature indicates that the S/CO value often correlates with the likelihood of subsequent confirmation of HIV and syphilis infections, with low S/CO values barely exceeding the cutoff more likely to represent false positive screens. The data in this article present results from the Roche Diagnostics Elecsys HIV combi PT Assay and the Elecsys Syphilis Assay. The data include 19,368 syphilis total antibody screening results on 15,764 unique patients and 28,952 HIV screening results on 24,556 unique patients, S/CO values, clinical area where testing was ordered, sex, and age. For samples with positive syphilis total antibody screens, the data also include results of RPR (the immediate next step in the reverse algorithm), Treponema pallidum particle agglutination (TP-PA; for those samples in which RPR was non-reactive in the testing cascade), and clinical information and other testing related to diagnosis of syphilis. For positive HIV screens, the data also include HIV antibody differentiation results, HIV-1 PCR or HIV-2 results results (if performed), and clinical information related to diagnosis of HIV. The distributions of S/CO values relative to confirmation status were analyzed.

Utility of Flow Cytometry and Fluorescence In Situ Hybridization in Follow-up Monitoring of Plasma Cell Myeloma.

OBJECTIVES: We sought to investigate the clinical utility of flow cytometry (FC) and fluorescence in situ hybridization (FISH) in the workup of myeloma. METHODS: We retrospectively reviewed the reports of bone marrow biopsies received for myeloma evaluation between October 2015 and January 2019. RESULTS: A total of 1,708 biopsy specimens from 469 myeloma patients (mean age, 64.5 years [SD, 9.3]; female, 41.4%) were reviewed. Both FC and FISH had comparable detection rates at the time of initial diagnosis (97.6% vs 98.8%) and for follow-up cases (28.6% vs 28.2%). FC and FISH results were concordant in 98.8% of the initial diagnosis cases and 89.6% of the follow-up cases. The FISH-positive (FISH+)/FC-negative (FC-) discordance and FISH-/FC+ discordance occurred among 81 (5.0%) and 87 (5.4%) follow-up cases. In comparison with all concordant cases, FISH+/FC- discordant cases were more likely to have received treatment with daratumumab (P < .05). CONCLUSIONS: Plasma cell-enriched FISH and FC have comparable abnormal plasma cell detection rates, and approximately 10% of the follow-up cases have discordant FISH and FC results in which residual disease is detected by only one of these modalities. FISH testing should be considered for cases with negative FC, especially in patients who have received treatment with daratumumab or in cases in which there is concern about specimen adequacy.

Machine Learning-Based Multiparametric Magnetic Resonance Imaging Radiomics for Prediction of H3K27M Mutation in Midline Gliomas.

OBJECTIVE: H3K27M mutation in gliomas has prognostic implications. Previous magnetic resonance imaging (MRI) studies have reported variable rates of tumoral enhancement, necrotic changes, and peritumoral edema in H3K27M-mutant gliomas, with no distinguishing imaging features compared with wild-type gliomas. We aimed to construct an MRI machine learning (ML)-based radiomic model to predict H3K27M mutation in midline gliomas. METHODS: A total of 109 patients from 3 academic centers were included in this study. Fifty patients had H3K27M mutation and 59 were wild-type. Conventional MRI sequences (T1-weighted, T2-weighted, T2-fluid-attenuated inversion recovery, postcontrast T1-weighted, and apparent diffusion coefficient maps) were used for feature extraction. A total of 651 radiomic features per each sequence were extracted. Patients were randomly selected with a 7:3 ratio to create training (n = 76) and test (n = 33) data sets. An extreme gradient boosting algorithm (XGBoost) was used in ML-based model development. Performance of the model was assessed by area under the receiver operating characteristic curve. RESULTS: Pediatric patients accounted for a larger proportion of the study cohort (60 pediatric [55%] vs. 49 adult [45%] patients). XGBoost with additional feature selection had an area under the receiver operating characteristic curve of 0.791 and 0.737 in the training and test data sets, respectively. The model achieved accuracy, precision (positive predictive value), recall (sensitivity), and F1 (harmonic mean of precision and recall) measures of 72.7%, 76.5%, 72.2%, and 74.3%, respectively, in the test set. CONCLUSIONS: Our multi-institutional study suggests that ML-based radiomic analysis of multiparametric MRI can be a promising noninvasive technique to predict H3K27M mutation status in midline gliomas.

The Neurologic Manifestations of Coronavirus Disease 2019.

The coronavirus disease 2019 (COVID-19) is an ongoing global pandemic that has so far affected 216 countries and more than 5 million individuals worldwide. The infection is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While pulmonary manifestations are the most common, neurological features are increasingly being recognized as common manifestations of the COVID-19, especially in the cases of severe infection. These include acute cerebrovascular disease, encephalitis, and Guillain-Barre syndrome (GBS). Here, we review the neuropathogenesis of SARS-CoV-2 and the central and peripheral nervous system manifestations of COVID-19.

Presurgical detection of brain invasion status in meningiomas based on first-order histogram based texture analysis of contrast enhanced imaging.

OBJECTIVE: Invasion of brain parenchyma by meningioma can be a critical factor in surgical planning. The aim of this study was to determine the diagnostic utility of first-order texture parameters derived from both whole tumor and single largest slice of T1-contrast enhanced (T1-CE) images in differentiating meningiomas with and without brain invasion based on histopathology demonstration. METHODS: T1-CE images of a total of 56 cases of grade II meningiomas with brain invasion (BI) and 52 meningiomas (37 grade I and 15 grade II) with no brain invasion (NBI) were analyzed. Filtration-based first-order histogram derived texture parameters were calculated both for whole tumor volume and largest axial cross-section. Random forest models were constructed both for whole tumor volume and largest axial cross-section individually and were assessed using a 5-fold cross validation with 100 repeats. RESULTS: In detection of brain invasion, random forest model based on whole tumor segmentation had an AUC of 0.988 (95 % CI 0.976-1.00) with a cross validated value of 0.74 (95 % CI 0.45-0.96). For differentiation of grade I meningiomas from grade II meningiomas with brain invasion, the AUC was 0.999 (95 % CI 0.995-1.00) and 0.81 (95 % CI 0.61-0.99) in the training and validation cohorts, respectively. Similarly, when using only the single largest slice, the cross-validated AUC to distinguish BI versus NBI and BI versus grade I meningiomas was 0.67 (95 % CI 0.47, 0.92 and 0.78 (95 % CI 0.52, 0.95) respectively. CONCLUSION: Radiomics based feature analysis applied on routine MRI post-contrast images may be helpful to predict presence of brain invasion in meningioma, possibly with better performance when comparing BI versus grade I meningiomas.

Sulphuric acid marketed in water bottle in India: A cause for fatal accidental poisoning in an adult.

Corrosive acid ingestion is a rare but serious health hazard with fatal complications. Cases of suicidal and accidental acid ingestion have been documented in the scientific literature. Accidental acid poisoning due to a mistaken identity of the bottle containing sulphuric acid is a matter of grave concern especially in a household set-up. We hereby report a fatal case of accidental sulphuric acid ingestion in an adult, who unsuspectingly swallowed about 50 ml of 'toilet-cleaner' at his residence. The bottle containing the acid was recently purchased from a local vendor and placed with water bottles in the kitchen. The autopsy and toxicological findings of this case are discussed in this paper with discussion of medico-legal issues on the sale and use of such corrosive acids in illegal bottles and its subsequent health hazards in India.

Medico-legal autopsy of abandoned foetuses and newborns in India.

Foeticide and the abandonment of newborns are important, albeit frequently neglected, issues. Concealment of childbirth is often seen in the setting of unwanted pregnancy which has been recognised as one of the most important factors in both cases. This study highlights the medico-legal autopsy findings of 238 abandoned foetuses and newborns over a period of 17 years (1996-2012) from the region of South Delhi, India. There was no sex predilection. The majority of the cases were full term. Nearly 35% of the foetuses were still born, about 29% were live born and the remainder were non-viable. Among the live born, death by homicide was more common than a natural death and most were left by the roadside. The abandoning and killing of newborns needs urgent attention, and strict measures are needed to save thousands of innocent lives.

Does Hepatocyte Paraffin 1 expression stand a role in determining the site origin of an adenocarcinoma from unknown gastrointestinal primary?

BACKGROUND: Hepatocyte Paraffin 1 (Hep Par 1) was being extensively used to recognize the hepatocellular carcinomas, until recognition of its expression in tumors without hepatocellular differentiation. AIMS AND OBJECTIVES: The aim of this study was to analyze if Hep Par 1 stain can serve as a specific marker of the small intestinal (SI) adenocarcinomas, versus other gastrointestinal tract (GIT) primary tumors. MATERIALS AND METHODS: In this retrospective cross-sectional study, normal GIT mucosa (n - 60), corresponding adenocarcinomas (n - 60) and nodal metastatic foci (n - 60) from the same patients, including 10 cases each from the esophagus, stomach, SI periampullary region, colon, rectum, and gall bladder were included. H-score was calculated by multiplying the stain distribution and intensity scores. The H-scores were compared with other clinical and histological parameters. RESULTS: While normal SI mucosa showed diffuse strong Hep Par 1 staining, normal esophageal and gastric epitheliums were negative and normal colon, rectal, and biliary epithelium showed weak focal positivity. Adenocarcinomas from all these sites, however, showed Hep Par 1 expression, irrespective of the tumor type, site or origin, and tumor stage. The corresponding metastatic sites also showed variable Hep Par 1 positivity, without any site specificity. CONCLUSION: Hep Par 1 stain cannot help to determine the exact site of origin of primary GIT tumors. Its expression in adenocarcinomas across the GIT and their metastatic foci proves that it cannot be regarded as a marker of SI differentiation, especially in malignancy.

Perioperative Management of Juvenile Nasopharyngeal Angiofibroma: A Retrospective Analysis of 56 Patients From a Single Tertiary Care Institute.

The present study was undertaken with the primary aim to analyze a large number of surgically treated patients with juvenile nasopharyngeal angiofibroma (JNA) in respect to preoperative embolization, different surgical procedures, and JNA stages. Ages of the patients ranged between 8 and 31 years. Mean blood loss was 1,240 mL (range, 50-6,000 mL). Preoperative embolization was performed in 23 patients (41%). Mean blood loss in patients who underwent embolization was not significantly different from those who did not; 1,580.4 mL vs 910.4 mL. Mean blood loss in stage IIB and above was more than 1 L. Intraoperatively 15 patients (37%) required 2 U of packed red blood cells. Postoperatively only 22 patients (39%) required packed red blood cells compared with 38 (67%) intraoperatively. The trachea was kept electively intubated in 46 patients (82%). We conclude that most of the JNA surgeries do not require replacement of more than 2 U of blood intraoperatively. Only 1 intravenous line is required in stages IB and IIA because of less blood loss. Not all patients need to be kept intubated electively in the postoperative period.