Sompal Singh

Platelet indices in diabetes mellitus: indicators of diabetic microvascular complications

Abstract Background and objective: Diabetes mellitus (DM) has been considered as a ‘prothrombotic state’ with enhanced platelet reactivity. Mean platelet volume (MPV) has been evaluated in DM and correlated with retinopathy. This study was aimed at evaluating platelet indices in diabetic versus non‐diabetic patients and assessing their utility as indicators of presence of complications in patients with DM. Methods: This study included 75 subjects with DM (50 with one or more microvascular complications) and 50 non‐selected patients from the hospital as controls. Anticoagulated blood (ethylene diamine tetracetic acid) was collected and analyzed in an automated blood cell counter for platelet count and indices [MPV, platelet distribution width (PDW) and platelet‐large cell ratio]. Results: MPV, PDW and platelet‐large cell ratio were all significantly higher in diabetic patients compared to the control subjects (P<0·05 for all). Among the diabetics, PDW was higher in those with complications as compared to those without (P = 0·006). On stepwise discriminant analysis using age, duration of diabetes, platelet count and platelet indices, ∼78·6% of patients with diabetic complications were accurately classified. Interestingly, only two input variables (PDW and MPV) qualified for the final discriminant model. Conclusion: Platelet indices, especially PDW, are different between diabetics and controls as well as between diabetics with and without microvascular complications. Discriminant analysis using PDW and MPV could classify majority of patients with diabetic complications.

Fine needle aspiration cytology in diagnosis of salivary gland lesions: A study with histologic comparison.

Objectives: Fine needle aspiration cytology (FNAC) has been employed in pre-operative diagnosis of salivary gland lesions for many years. Various studies in the existing literature have shown a wide range of sensitivity and diagnostic accuracy of cytologic diagnosis. This study was aimed at evaluating salivary gland FNAC for sensitivity, specificity and diagnostic accuracy at a tertiary care center. Materials and Methods: This study included 80 patients who underwent pre-operative FNAC followed by surgical procedure and histologic examination. The histologic diagnosis was considered as the gold standard. FNAC diagnosis was compared with the final histologic impression and concordance assessed. Sensitivity, specificity and diagnostic accuracy of FNAC for malignant lesions were calculated. Results: Of the 80 cases, majority (67.5%) involved the parotid gland. Eight cases (10%) were non-neoplastic lesions, comprised of sialadenitis, retention cyst and sialadenosis. Of a total of 72 neoplasms, 58 were benign and 14 were malignant salivary gland tumors. A cyto-histologic concordance of benign diagnosis was achieved in 85.7% of cases and for malignant lesions in 92.8% of the malignant tumors. FNAC showed a sensitivity of 92.8%, specificity of 93.9%, a positive predictive value of 81.2% and negative predictive value of 98.4% for malignant salivary gland tumors. There was one false-negative diagnosis and four false-positive cases diagnosed on FNAC. Conclusion: FNAC continues to be a reliable diagnostic technique in hands of an experienced cytopathologist. The sensitivity of diagnosis of malignant lesions is high, though the rate of tumor type-specific characterization is lower, due to variable cytomorphology. In difficult cases, histologic examination may be employed for accurate diagnosis.

Propofol sedation during endoscopy in patients with cirrhosis, and utility of psychometric tests and critical flicker frequency in assessment of recovery from sedation.

BACKGROUND AND STUDY AIMS Patients with cirrhosis who undergo endoscopy under sedation could be at increased risk of complications. We assessed the utility of the critical flicker frequency (CFF) in the recovery of cognitive function. PATIENTS AND METHODS This was a prospective study in patients with cirrhosis who underwent endoscopy under sedation with propofol in a tertiary care center. The main outcome was deterioration in cognitive function as measured by the number connection test A and B (NCT-A, -B), digit symbol test (DST), serial dotting test (SDT), and line tracing test (LTT) before and 2 h after endoscopy. CFF was recorded before and then every 30 min after endoscopy for the next 2 h. RESULTS In the 108 patients there was no deterioration in results of the psychometric tests after the endoscopy (NCT-A 65.2 ± 44.4 vs. 62.4 ± 43.6 s, P = 0.01; NCT-B 110.4 ± 34.7 vs. 109.6 ± 44.6 s, P = 0.45; DST 26.2 ±1 0.0 vs. 26.7 ± 9.9, P = 0.25; SDT 88.6 ± 47.5 vs. 84.3 ± 44.1 s, P = 0.02; LTT 116.6 ± 55.2 vs. 115.4 ± 51.3 s, P = 0.47.) Patients with minimal hepatic encephalopathy (MHE; n = 64) did not show any deterioration in cognitive function at 2 h (NCT-A 87.7 ± 45.4 vs. 84.3 ± 44.9 s, P = 0.06; NCT-B 134.8 ± 65.4 vs. 132.7 ± 58.8 s, P = 0.46; DST 21.4 ± 8.9 vs. 22.2 ± 8.8, P = 0.09; SDT 107.1 ± 53.0 vs. 102.7 ± 48.5 s, P = 0.03; and LTT 131.5 ± 62.2 vs. 129.6 ± 57.2 s, P = 0.46). There was a significant difference between CFF at baseline and at 30 min and 1 h but no difference thereafter in non-MHE patients, MHE patients, and in controls. A total of 30 patients (28 %) had CFF < 38 Hz. In these patients, CFF at 2 h did not significantly differ from baseline CFF (35.9 ± 1.5 vs. 36.1 ± 2.0 Hz; P = 0.19). A total of 10 patients (9 %) had transient hypoxemia and 18 (17 %) had hypotension during the procedure. The endoscopy was completed in all patients. CONCLUSIONS Propofol is safe in patients with cirrhosis and the CFF is a useful tool for the assessment of recovery from sedation in these patients.

Spindle cell carcinoma of head and neck: an immunohistochemical and molecular approach to its pathogenesis

Background: Spindle cell carcinoma (SpCC) is a rare microscopic type of cancer of the mouth and oropharynx. Although SpCC is thought to arise from squamous cell carcinoma (SCC), it carries a worse prognosis. Aim: To find out the difference in immunohistochemical expression of cytokeratin, vimentin and smooth-muscle actin, and mutational alterations in the K-ras oncogene between the two tumours, in an attempt to characterise SpCC. Methods: Immunohistochemical analysis was performed by standard avidin–biotin complex method in 35 cases each of SpCCs and SCCs. DNA extracted from paraffin wax-embedded tumours was used for PCR followed by single-strand conformation polymorphism for mutational analysis of K-ras exon 1 and exon 2. Results: In the SpCC group, cytokeratin positivity was significantly higher in epithelial areas (52.2%) than in spindle cell areas (16.1%), whereas vimentin was more positive in spindle cell areas (18.7%) than epithelial areas (2.7%). Cells intermediate between epithelial and spindle cell areas were consistently positive for both cytokeratin and vimentin. Cytokeratin was found to be significantly more positive in SCC (72.6%) than the squamous component and spindle cell component of SpCC. In this study, no mutation was detected in the K-ras gene of either the SpCC or SCC group. Conclusions: The spindle cell component of SpCC is intermixed with cells that are morphologically mesenchymal but express dual antigen-positivity characteristic of epithelial (cytokeratin) and mesenchymal (vimentin) cells. These, possibly, are cells in transition suggesting that SpCC may be a sarcomatous metaplasia of SCC.

Role of platelet volume indices in the differential diagnosis of thrombocytopenia: a simple and inexpensive method

Abstract Thrombocytopenia may result from hypoproliferation in marrow, or peripheral destruction of platelets. Distinction between these two categories is usually made by bone marrow examination. Some studies in literature hint that platelet volume indices are differentially altered in various causes of thrombocytopenia. The present study was aimed at investigating the role of platelet volume indices in the differential diagnosis of thrombocytopenia. Sixty healthy controls and 60 patients (study group) with thrombocytopenia (platelet count < 150 × 109/l) were included in the study. The study group was divided into two categories: hypoproliferative (megaloblastic and non-megaloblastic) and destructive thrombocytopenia. Clinical features, platelet counts and platelet indices were studied in both these categories, and statistical analysis was performed. Platelet counts in the three categories of thrombocytopenia were statistically not different. All the three platelet volume indices were significantly higher in megaloblastic group as compared to the non-megaloblastic hypoproliferative category. Platelet distribution width (PDW) was significantly different between destructive thrombocytopenia and non-megaloblastic hypoproliferative groups. In conclusion, we recommend the division of hypoproliferative category of thrombocytopenia into megaloblastic and non-megaloblastic types. Alterations in platelet indices, especially PDW can differentiate non-megaloblastic hypoproliferative category from both the destructive and megaloblastic thrombocytopenia category. These simple indices can be routinely used in the initial evaluation of a patient with thrombocytopenia.

Sclerosing polycystic adenosis of parotid gland: a cytological diagnostic dilemma.

Several lesions of the major salivary glands are morphologically similar to breast lesions. For example, salivary duct carcinoma bears resemblance to mammary ductal carcinoma; salivary epithelialmyoepithelial carcinoma is identical to mammary adenomyoepithelioma; adenoid cystic carcinoma, pleomorphic adenoma and collagenous spherulosis are described in both organs. A recent addition to this tumour similarity is sclerosing polycystic adenosis (SPCA), which is a pseudo-neoplastic lesion of the major salivary glands with histological similarity to fibrocystic disease of the breast. SPCA is a rare entity, with only 40 cases described in the literature. The cytological features and differential diagnoses of this rare lesion have not been well described in the literature. Only one report of aspiration cytology of SPCA was found in the literature. We report a case of SPCA in a male patient with aspiration cytology findings. This rare entity and its various cytological differentials are briefly discussed.

Impact of routine histopathological examination of gall bladder specimens on early detection of malignancy - a study of 4,115 cholecystectomy specimens.

Gall bladder carcinoma is the most common cancer of biliary tree, characterized by rapid progression and a very high mortality rate. Detection at an early stage, however, is indicative of a very good prognosis and prolonged survival. The practice of histopathological examination of gall bladder specimens removed for clinically benign conditions and its usefulness has been a subject of controversy. The present prospective study was carried out over a period of four years in order to find out the incidence of unsuspected gallbladder carcinoma in cholecystectomy specimens received in our histopathology laboratory and to analyze their clinico-pathological features. A total of 4,115 cases were examined. Incidentally detected cases comprised 0.44%, which accounted for 72% of all gall bladder carcinomas detected. The majority were in an early, surgically resectable stage. From the results of this study we recommend that in India and other countries with relatively high incidences of gall bladder carcinoma, all cholecystectomy specimens should be submitted to histopathology laboratory, as this is the only means by which malignancies can be detected at an early, potentially curable stage.

Cytologic diagnosis of fibrous hamartoma of infancy: a case report of a rare soft tissue lesion.

BACKGROUND Fibrous hamartoma of infancy (FHI) is a rare, benign lesion seen in the first 2 years of life. Despite adequate histopathologic descriptions, reports of it in the cytology literature are rare. CASE A 6-month-old male infant presented with an asymptomatic nodule in left anterior axillary fold. The nodule was noticed 6 weeks before presentation. On local examination, it was mobile and rubbery. Considering the endemicity, a presumptive clinical diagnosis of tuberculous lymphadenitis was made. Fine needle aspiration yielded moderately cellular smears composed of short spindle cells in a greasy background admixed with a few adipocytes. No mitosis or abnormal chromatin pattern was seen. In view of the young age of the patient, a cytologic impression of benign lesion or hamartoma was made. Excision of the nodule and histopathologic examination revealed it as FHI. CONCLUSION The cytologist should be aware of the cytologic features of FHI, so that in the proper clinical setting this diagnosis can be made with certainty. The mixture of adipose tissue and bland spindle cells is helpful to differentiate this lesion from other infantile soft tissue lesions.

Conventional and color Doppler sonography in preoperative assessment of ovarian tumors.

Objective: To study the vascular patterns of ovarian tumors by color Doppler imaging (CDI) and compare the findings of conventional sonographic studies and CDI with histopathologic findings for the same tumors. Methods: Fifty nonpregnant women scheduled for elective surgery for ovarian tumors were examined by sonographic scanning and CDI by the same physician. Sonographic morphology scores [SMSs] were used, and the pulsatility index (PI) and resistance index (RI) were calculated after locating vessels in and around the tumors by CDI. Results: It was possible to obtain CDI results in 26 of the 50 women. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 100%, 71.43%, 73.33%, and 100%, respectively, for SMS. With CDI, the sensitivity, specificity, PPV, and NPV were 100%, 85.72%, 95%, and 100% for PI and 100%, 71.43%, 90.48%, and 100% for RI. RI sensitivity and specificity were identical to those of SMS, i.e., 100% and 71.43%, respectively, but PI specificity was better (85.72%). Conclusion: In this study, CDI was definitely better than SMS when color flow could be obtained through the tumors. The overall efficiency in diagnosing the nature of tumors is very high if SMS and CDI are both used in patients having ovarian tumors.

Hematological profile in pyrexia of unknown origin: role of bone marrow trephine biopsy vis-à-vis aspiration.

Abstract Background: Bone marrow examination, by aspiration and/or trephine biopsy, is an important procedure in arriving at a diagnosis for long-duration febrile illness. The role of trephine biopsy in immunocompromised host, especially HIV-positive patients, has been well studied in the literature. However, its utility in immunocompetent patients is still shrouded by controversy. Thus, the authors attempted to evaluate the utility of marrow aspirate vis-à-vis trephine biopsy in establishing a diagnosis in cases of pyrexia of unknown origin in immunocompetent individuals, along with an analysis of haematological alterations in these patients. Materials and methods: Over a period of 8 years, 121 patients with pyrexia of unknown origin underwent both bone marrow aspiration and trephine biopsy as a part of diagnostic work-up. These cases were reviewed for their clinical data and hematological findings, including detailed morphological features in aspiration smears and trephine biopsies. Bone marrow aspiration and biopsy were compared for their diagnostic efficacy in these patients. Results: A wide age range (2–65 years) was noted with a slight male predominance (2 : 1). Anemia was the most common feature in peripheral blood findings, seen in 97·5% of patients. Bone marrow aspiration was diagnostic in only 16·5% of cases, which revealed leishmaniasis or pure red cell aplasia. Granulomas were infrequent in marrow aspiration smears, as only two cases (1·6%) showed ill defined epithelioid cell collections. Compared to this, trephine biopsy offered a diagnosis in 76% of the cases. Granulomas were a frequent finding in the trephine biopsy, being present in 70% of the cases included. Additional cases diagnosed on biopsy (over those diagnosed with aspiration smears) included lymphoma, tuberculosis, fungal infection, sarcoidosis and hypocellular marrow. Conclusion: Bone marrow trephine biopsy is an important adjunct to aspiration in arriving at an aetiological diagnosis of patient with long-duration febrile illness, and should be routinely performed in such cases. The presence of granulomas in trephine biopsy increases the likelihood of an etiologic diagnosis in these patients.