Regional leptomeningeal collateral score by computed tomographic angiography correlates with 3-month clinical outcome in acute ischemic stroke.

PURPOSE: The aim of the study is to assess the correlation between regional leptomeningeal collateral (rLMC) Scores calculated on computed tomography (CT) angiography following acute anterior circulation ischemic stroke, with 3-month clinical outcome measured as modified Rankin Scale (mRS) and Barthel Index (BI). MATERIALS AND METHODS: A total of thirty patients were studied as per the exclusion and inclusion criteria and after informed consent. Multi-phase CT angiography was carried out within 24 h of stroke onset, and collateral scoring was done using rLMC score along with Alberta stroke programme early CT (ASPECT) scoring. At 3 months, patients were followed up to evaluate the clinical outcome using mRS and BI. Statistical analysis was performed to find out the correlation between rLMC score, ASPECT score, and clinical outcome and for association with demographic parameters and stroke risk factors. RESULTS: A strong correlation was noted between ASPECT and rLMC scores (P < 0.001) and between rLMC scores and clinical outcome at 3 months (mRS and BI). Correlation with mRS (P < 0.001) was nearly as strong as that of BI on follow-up (P < 0.001). The ASPECT score also was a predictor of clinical outcome and showed correlation with mRS (P < 0.001) and BI (P < 0.001). No significant association was found between various stroke risk factors and demographic parameters with rLMC scores. The rLMC scoring system showed substantial inter-rater reliability with Kappa = 0.7. CONCLUSIONS: rLMC score in CT angiography correlates with ASPECT Score and clinical outcome at 3 months. Hence, this scoring system can be used for collateral quantification as may be of use in predicting short-term clinical outcomes.

Joint Indian Chest Society-National College of Chest Physicians (India) guidelines for spirometry.

Although a simple and useful pulmonary function test, spirometry remains underutilized in India. The Indian Chest Society and National College of Chest Physicians (India) jointly supported an expert group to provide recommendations for spirometry in India. Based on a scientific grading of available published evidence, as well as other international recommendations, we propose a consensus statement for planning, performing and interpreting spirometry in a systematic manner across all levels of healthcare in India. We stress the use of standard equipment, and the need for quality control, to optimize testing. Important technical requirements for patient selection, and proper conduct of the vital capacity maneuver, are outlined. A brief algorithm to interpret and report spirometric data using minimal and most important variables is presented. The use of statistically valid lower limits of normality during interpretation is emphasized, and a listing of Indian reference equations is provided for this purpose. Other important issues such as peak expiratory flow, bronchodilator reversibility testing, and technician training are also discussed. We hope that this document will improve use of spirometry in a standardized fashion across diverse settings in India.

Clinicopathological Study of Malignant Melanoma at Tertiary Care Centre.

INTRODUCTION: Malignant melanoma, which causes three fourth of all deaths related to skin cancer, is more common in Caucasian population compared to Asian population. There is no reliable information about malignant melanoma in Nepal hence an effort has been made to assess the clinical and pathological features of melanoma patients. METHODS: This was a retrospective hospital based study done in the department of Pathology. All cases of malignant melanoma diagnosed on biopsy during a period of 13 years were retrieved, reviewed and collated. RESULTS: We had 35 cases with age range from 15 to 84 years with the mean of 51.4 years and M: F of 1.3:1. The predominant site was lower extremities. Most cases were less than 3 cm. Majority of histologic subtypes were nodular melanoma 29 (82.8%) followed by mucosal lentiginous melanoma 3 (8.6%), superficial spreading melanoma 2 (5.7%) and acral lentiginous melanoma 1 (2.9%). Half (50%) of the excisional biopsies were at Clark's level IV and 75% were at high Breslow thickness. CONCLUSIONS: The most frequent site in males and females were lower extremities and trunk respectively in contrast to Western studies where it is opposite. Nodular melanoma was the commonest histologic subtype while in other Asian studies and in Western studies majority were acral lentiginous melanoma and superficial spreading melanoma respectively.

Histopathological Analysis of Non-Neoplastic Superficial Lymphadenopathies.

Background Lymphadenopathies are the clinical manifestation of enlargement of lymph nodes which are a common occurrence and are processes of lymph nodes in response to a variety of exogenous and endogenous stimulants. The vast majority of enlarged lymph nodes are non- neoplastic. Objective The objective of the study is to analyze the spectrum of non-neoplastic lesions of superficial lymphadenopathies with their histomorphological features. Method This was a retrospective hospital based study done in the department of Pathology. All cases of superficial lymph node biopsies received during a period of 7 years were retrieved and divided into 2 broad categories: neoplastic and non-neoplastic. The latter group is the material for the present study. The diagnosis was made on morphological basis. Result Of all the 268 superficial lymph node biopsies, 25.4% (68 cases) were neoplastic and 74.6% (200 cases) were non-neoplastic. The non-neoplastic cases were further categorized into non-infectious 60.5% (121 cases) and infectious 39.5% (79 cases). Neck node (70%) was the most common site of involvement. There were 102 male and 98 female patients with male to female ratio 1.04:1. The age range of the patients was 2 years to 83 years with a mean of 27.16 years and most common being 11-20 years 29% (58 cases). Majority of the cases were non-specific reactive lymphadenitis 84.3% (102 cases) followed by tuberculosis 36.5% (73 cases). Conclusion The major cause for the superficial lymphadenopathy was found to be non-neoplastic etiology with slight male predominance. Reactive lymphadenitis was the leading cause unlike the studies done in other Asian and Tropical countries where tuberculosis was more common.

Cavitation-Induced Fracture Causes Nanocorrugations in Brittle Metallic Glasses.

Brittle metallic glasses exhibit a unique and intriguing fracture morphology of periodic nanocorrugations whose spacing and amplitude are of the order of tens of nanometers. We show through continuum simulations that they fail by spontaneous and simultaneous cavitation within multiple weak zones arising due to intrinsic atomic density fluctuations ahead of a notch tip. Dynamic crack growth would then occur along curved but narrowly confined shear bands that link the growing cavities. This mechanism involves little dissipation and also explains the formation of nanocorrugations.

Prevalence of subscapularis tears and accuracy of shoulder ultrasound in pre-operative diagnosis.

PURPOSE: Subscapularis tears can be difficult to diagnose and their treatment requires advanced arthroscopic skills. The objective of this study was to find the prevalence of subscapularis tears on arthroscopic examination of shoulders with rotator cuff pathology and to determine the accuracy of pre-operative ultrasound in diagnosing these tears. METHOD: Ultrasound and intra-operative reports of 236 patients who underwent shoulder arthroscopy for rotator cuff pathology by the senior author at his institution were compared. Prevalence of subscapularis tear was noted and classified using Lafosse classification system. Ultrasound reports and intra-operative findings were compared to determine the accuracy, sensitivity and specificity of ultrasound in detecting subscapularis tears. RESULTS: The prevalence of subscapularis tears in patients needing rotator cuff repair was found to be 31.4 %. A total of 6.4 % of patients needing a rotator cuff repair had an isolated subscapularis tear. The sensitivity of ultrasound was 39.5 % and specificity 93.1 % in detection of these tears. The overall accuracy of ultrasound was 75.8 %. Sensitivity of ultrasound was low (42.8 %) for smaller (type 1 and 2) tears and higher (79 %) for larger (types 3, 4, 5) tears. The overall positive predictive value of USS was 73.1 % and negative predictive value 76.4 %. CONCLUSION: The shoulder surgeon should be skilled in diagnosing and repairing subscapularis tendon tears arthroscopically and cannot completely rely on pre-operative ultrasound scans in ruling out smaller tears as its sensitivity in diagnosing smaller tears is quite low. Unsettling anterior shoulder pain with a normal ultrasound may need further arthroscopic evaluation to rule out missed subscapularis tears.

Ovarian Tumors: Pattern of Histomorphological Types- A 10 Years Study in a Tertiary Referral Center and Review of Literature.

Background Ovarian cancer accounts for 6% of all cancers in females. Among cancers of female genital tract, the incidence of ovarian cancers ranks below only carcinoma of the cervix and the endometrium. Objective To find the frequency of different types of histomorphological types and their association with age, side and size distribution. Method This study is a hospital based retrospective study carried out in the Department of Pathology, Manipal Teaching Hospital over a time period from Jan. 2006 to Sep. 2015. Specimens were received from the Manipal Teaching Hospital and other hospitals within the Himalayan valley of Pokhara. All the clinical and histolpathological data were retrieved from the departmental data bank and were analyzed. Result A total of 409 cases of ovarian tumors have been reported in the same period. Among them, 215 cases were of surface epithelial origin including 172 benign, 07 borderline and 36 malignant cases. Among the surface epithelial tumors, the commonest was serous cystadenoma (119 cases) followed by mucinous cyst adenoma (40 cases). There were 176 cases of tumors with germ cell origin which included 170 cases of teratoma, four dysgerminoma and one each case of choriocarcinoma and yolk sac tumor. Among seven metastatic tumors, one case was of Krukenberg tumor. Age range was 12 to 90 years and the size range from 3 to 36 cm. Conclusion In our study, we analyzed all the spectrum of ovarian tumors diagnosed on morphological bases and most of the findings were similar to other national and international studies. However, we have reported increased percentage of mucinous tumors and less sex cord stromal tumors.

Granulocyte colony-stimulating factor in severe alcoholic hepatitis: a randomized pilot study.

OBJECTIVES: Severe alcoholic hepatitis has high short-term mortality. The aim of this study was to test the hypothesis that treatment of patients with alcoholic hepatitis with granulocyte colony-stimulating factor (G-CSF) might mobilize bone marrow-derived stem cells and promote hepatic regeneration and thus improve survival. METHODS: Forty-six patients with severe alcoholic hepatitis were prospectively randomized in an open study to standard medical therapy (SMT) plus G-CSF (group A; n=23) at a dose of 5 µg/kg subcutaneously every 12 h for 5 consecutive days or to SMT alone (group B; n=23) at a tertiary care center. We assessed the mobilization of CD34(+) cells on day 6, Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), and modified Maddrey's discriminant function (mDF) scores, and survival until day 90. RESULTS: There was a statistically significant increase in the number of CD34(+) cells in peripheral blood in group A as compared with group B (P=0.019) after 5 days of G-GSF therapy. There was a significant reduction in median Δ change% in CTP, MELD, and mDF at 1, 2, and 3 months in group A as compared with group B (P<0.05). There was marked improvement in survival in group A as compared with group B (78.3% vs. 30.4%; P=0.001) at 90 days. CONCLUSIONS: G-CSF is safe and effective in the mobilization of hematopoietic stem cells and improves liver function as well as survival in patients with severe alcoholic hepatitis.

A case of concomitant Hodgkin's lymphoma with tuberculosis.

Tuberculosis (TB) presenting with Hodgkin's Lymphoma is a rare and difficult clinical situation for any physician to identify and to manage because of very similar clinical presentation. Herein we report a case of 29 year old woman who presented with enlarged lymph nodes, diagnosed and initiated on therapy for TB, based on the cervical node biopsy that showed granulomatous lymphadenitis suggestive of TB. Despite being on regular isoniazid, rifampicin, pyrazinamide and ethambutol regimen, she did not improve but worsened clinically! After an extensive work up that included endobronchial ultrasound (EBUS) and mediastinoscopy, a diagnosis of Hodgkin's disease of nodular sclerosis type was made. She was treated with chemotherapy and radiotherapy along with her TB therapy. Patient showed significant improvement following therapy.

Tablet in the bronchus--an unusual cause for persistent cough in a 64 year old gentleman.

Foreign body aspiration in adults without any background risk factors is uncommon. We report a 64 year gentleman evaluated for persistent cough incidentally detected to have a foreign body (FB) in the left main bronchus (LMB), which after removal by rigid bronchoscopy turned out to be a tablet. This demonstrates the possible risk of silent aspiration of solid foreign bodies and in our case presenting as a persistent cough after months of aspiration. Bronchoscopic evaluation should be carried out in the differential diagnosis of persistent or recurrent pulmonary symptoms.

The role of pleuroscopy in undiagnosed exudative pleural effusion.

AIMS: To find the diagnostic yield of a pleuroscopic pleural biopsy and to find the complication rates. SETTINGS AND DESIGN: Institutional based prospective study. MATERIALS AND METHODS: Sixty-eight consecutive patients who had undiagnosed exudative pleural effusion were recruited for pleuroscopy from September 2007 to August 2010. RESULTS: A total of 68 patients (55 males and 13 females; mean age 49 years) underwent pleuroscopy. Malignancy was diagnosed in 24 patients, 22 patients had non-specific inflammation, tuberculosis was found in 16 patients, empyema was found in 2 patients, 1 patient had sarcoidosis, 1 patient had normal pleura and it was non-diagnostic in 2 patients. The diagnostic yield was 97%. There were no major complications, only four patients had minor complication like subcutaneous emphysema (three patients) and prolonged air leak (one patient). CONCLUSIONS: Pleuroscopy is a safe, simple, and valuable tool in the diagnosis of undiagnosed exudative pleural effusion with minimal complication rates.

Patterns of hematological and non-hematological malignancies in bone marrow in a tertiary care hospital in Nepal--11 years study.

Developing countries bear more than half of the global cancer burden and the leukemia comprises of 3% of all malignancies with an incidence of 300,500 per year. The patterns of subtypes of leukemias vary in different populations and geographic areas. Here, we analyze both the hematological and non-hematological malignancies in the Western region of Nepal. This is a retrospective study done from Janauary 2000 to June 2011. All cases of bone marrow malignancies including leukemias, multiple myeloma and infiltration/metastasis to bone marrow were included in the study. Morphological subtypes {FAB (French, American and British) classification}, gender, age at diagnosis and peripheral blood counts of all the cases were analyzed. A total of 155 cases of hematological and non-hematological malignancies were reported during this period. Age ranged from 1 year to 82 years. Among 123 leukemia cases, acute myeloid leukemia (AML) was the commonest (80 cases) followed by chronic myeloid leukemia (CML) (20 cases), acute lymphoid leukemia (ALL) (16 cases) and chronic lymphoid leukemia (CLL) (7 cases). The commonest childhood leukemia below 15 years was AML followed by ALL. The commonest subtypes of AML and ALL were M2 and L2 respectively. CML cases in our study were less common and females were more affected than other parts of the country. There were 23 cases of multiple myeloma and 9 cases of infiltration/metastasis to marrow. Males were more affected by multiple myeloma in our study. Our data reflects bone marrow malignancies in the Western region of Nepal which is more comparable to the Central than Eastern region of Nepal.

Atomic scale fluctuations govern brittle fracture and cavitation behavior in metallic glasses.

We perform atomistic simulations on the fracture behavior of two typical metallic glasses, one brittle (FeP) and the other ductile (CuZr), and show that brittle fracture in the FeP glass is governed by an intrinsic cavitation mechanism near crack tips in contrast to extensive shear banding in the ductile CuZr glass. We show that a high degree of atomic scale spatial fluctuations in the local properties is the main reason for the observed cavitation behavior in the brittle metallic glass. Our study corroborates with recent experimental observations of nanoscale cavity nucleation found on the brittle fracture surfaces of metallic glasses and provides important insights into the root cause of the ductile versus brittle behavior in such materials.

Whole lung lavage for pulmonary alveolar proteinosis.

A 26-year-old male presented with complaints of dry cough of six months and progressive breathlessness of three months duration. He was coughing out milky white sputum for two months and had lost 12 kg weight in two months. He had an evening rise in temperature of one month duration. Clinically, the patient was in respiratory distress and the respiratory system examination revealed bilateral velcro crackles. High resolution computed tomography chest showed bilateral diffuse reticulonodular opacities and "Crazy Paving" pattern suggestive of alveolar proteinosis. Broncho alveolar lavage showed eosinophilic granular material, which was periodic acid-Schiff positive. Open lung biopsy was done to confirm the diagnosis and the histopathologic examination revealed eosinophilic secretions with granular appearance suggestive of pulmonary alveolar proteinosis. Subsequently, patient underwent bilateral sequential whole lung lavage under general anesthesia. Patient showed marked clinical and radiological improvement after sequential whole lung lavage.

Distribution of interstitial cells of Cajal and nitrergic neurons in normal and diabetic human appendix.

The objective of this study was to determine the distribution of enteric nerves and interstitial cells of Cajal (ICC) in the normal human appendix and in type 1 diabetes. Appendixes were collected from patients with type 1 diabetes and from non-diabetic controls. Volumes of nerves and ICC were determined using 3-D reconstruction and neuronal nitric oxide synthase (nNOS) expressing neurons were counted. Enteric ganglia were found in the myenteric plexus region and within the longitudinal muscle. ICC were found throughout the muscle layers. In diabetes, c-Kit positive ICC volumes were significantly reduced as were nNOS expressing neurons. In conclusion, we describe the distribution of ICC and enteric nerves in health and in diabetes. The data also suggest that the human appendix, a readily available source of human tissue, may be useful model for the study of motility disorders.

Tuberculin reactivity in tuberculous meningitis.

OBJECTIVE: To study tuberculin reactivity in childhood tuberculous meningitis both in clinical and histopathological (HP) context. METHODOLOGY: Children with tuberculous meningitis (TBM) were given tuberculin test by Mantoux technique, which was read at the end of 72 hours after the placement of skin test. Histopathological examination of the punch biopsy specimen of the tuberculin test site was performed and histopathological grading of the tuberculin reaction was compared with clinical reaction and clinical parameters. RESULTS: Of the 50 children studied, 68% of them were malnourished and 42% had BCG scar. Tuberculin test was positive in 22 (44%) cases. Spearman analysis showed negative correlation between stage of TBM and the size of tuberculin reaction. BCG status did not affect the size of tuberculin reaction. Histopathological grade of the tuberculin reaction was found to be directly proportional to the size of the tuberculin reaction and it was not affected by the stage of TBM. CONCLUSION: Tuberculin positivity is low in TBM irrespective of the nutritional status. At least some degree of inflammatory reaction can be seen at the site of tuberculin administration. In tuberculin negative cases, varying grades of cellular response in the absence of clinical induration can be seen in histopathology.

Extra-articular pigmented villonodular synovitis.

Villonodular synovitis are a group of idiopathic lesions that affect the synovial surfaces of joints, tendon sheaths, and bursae, causing tumor-like lesions. Pigmented villonodular synovitis rarely affects the tendon sheaths; its occurrence in extra-articular sites is uncommon. This case is presented for the rarity of occurrence. The literature is also reviewed.