Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524191EnglishN2017January7HealthcareCEREBROSPINAL FLUID CYTOLOGY IN CANCER PATIENTS: AN INSTITUTIONAL STUDY WITH 5394 CASES English0105Trupti S. Patel1English Chetan Dharaiya2English Majal G. Shah3English Rujuta A. Shah4EnglishObjectives: Cytological examination of cerebrospinal fluid (CSF) is a routine procedure in the management of patients with malignancies that frequently spread via leptomeninges. Interpretation, understanding and cytological characteristics of these lesions are required. Detection of malignant cells in cerebrospinal fluid in cytology is the diagnostic gold standard for leptomeningeal carcinomatosis (LC). Material and Method: Retrospective analysis of 5394 cases of CSF was done over 5 year’s duration at cancer hospital. Smears were stained with papanicolaou stain and examined. Data were analyzed with clinical detailed. Results: Patient`s age ranged from 1 to 70 years. Out of 5394, 273 cases were positive for malignant cells, and 4 cases had infectious etiology. Acute lymphoblastic leukemia was the commonest malignancy infiltrating CSF in both, followed by retinoblastoma, nonhodgkins lymphoma in pediatric and nonhodgkins lymphoma and metastatic carcinoma in adults. Other rare tumor infiltrating CSF found in our study were myeloid leukemia, medulloblastoma, peripheral neuroectodermal tumor, and space occupying lesion of brain, where primary could not found. Of four infectious cases, one case of Cryptococcus meningitis was found. Conclusion: Correct identification of LC is important as it as therapeutic and prognostic implications. Thus, cytological examinations of the CSF played a decisive role in the diagnosis of LC. EnglishCerebrospinal fluid, Cytology, Meningitis, Cancer, CSFIntroduction Cerebrospinal Fluid (CSF) cytology is principally useful in the identification of malignant cells as the cytological changes in inflammatory and other non-neoplastic disorders are nonspecific. (1,2) It is an important part of a complete neurological evaluation of cancer patients, also important in patients with the acquired immunodeficiency syndrome (AIDS) particularly with neurological symptoms and patients with space occupying lesions (SOL) of brain. It is an essential step in the follow-up of patients with lymphoma and leukemia, round cell tumor and small cell tumor like small cell carcinoma of lung. In recent era of newer therapeutic regimens and advanced diagnostic techniques, survival of cancer patient increase and so, incidence of Leptomeningial carcinomatosis (LC) also increases. Clinically one of the differential diagnoses of LC is infectious meningitis or encephalitis. Diagnosis of LC was given following the identification of malignant cells in the CSF. Diffuse or multifocal seeding of the leptomeninges by metastatic cancer cells was first reported by Eberth in 1870, (3) and the term ‘carcinomatous meningitis’ (CM) was introduced by Beerman in 1912. (4)  It is previously known as CM, a devasting neurological complication of cancer; occurring in 3-8% of all cancer patients. (5) It arises from haematological malignancies or from solid intracranial or extra cranial tumors. Useful tests to establish diagnosis of LC include magnetic resonance imaging (MRI), particularly gadolinium enhanced MRI (gd-MRI) study of the brain and spine, CSF cytology and radioisotope CSF flow studies.(6,7) Among all these diagnostic tests, CSF cytology is the only examination that verifies the presence of malignancy. A number of studies have proven that the cytological identification of malignant cells in the CSF remains the gold standard test for LM. (7,8,9,10) The purpose of the study is to evaluate the importance of cytological examination of CSF as a useful and first line diagnostic technique for diagnosis of LM. Material and methods The study includes retrospective analysis of patients who were admitted to MP Shah Cancer Hospital, Gujarat Cancer and Research Institute, the Cancer referral center of West India, between years 2007 to 2011. Total 5394 CSF specimens were collected during this five year period. Clinical data includes age and gender of patients, sign and symptoms, primary diagnosis, and follow up were noted. Protocol for doing CSF examination at our hospital is as follows: Following newly diagnosed cases had CSF examination at first visit. Acute lymphoblastic leukemia (ALL), retinoblastoma (RB), medulloblastoma, Burkitts lymphoma, lymphoma in HIV positive patient, lymphoma with more than three extranodal sites involved, acute myeloblastic leukemia (AML)-myelomonocytic (M4) type and monoblastic (M5) type and AML with more than 1 lakh count. In remaining cases of malignancy, CSF examination was done when patient presented with clinical signs/ symptoms of meningitis or meningeal irritation during the course of disease. 1-2 ml of CSF collected by lumbar puncture (LP) method in EDTA vacutte. Processing of the specimen was done at cytology department. After physical examination: appearance, quantity and quality of CSF, centrifuge the specimen with cytocentrifuge (Cytospin-3) machine at 800 rpm speed for 3 minutes. A button was formed which provides more concentrated population of cells. Supernatant was preserved in another tube till the final report was given. For each case one slide was prepared. Papanicolaoue stain was done by standard procedure. Whenever required, another slide was formed from the remaining CSF of that particular case. Samples of CSF for biochemistry were sent only in those cases when infectious etiology was suspected by clinician. For suspicious CSF cytology, clinician repeat the CSF only if the patient was clinically normal, not showing any signs/symptoms of meningeal irritation otherwise they considered it as positive and followed the patient for positive protocol of CSF cytology. For positive CSF cytology, intracranial RT and one cycle of intrathecal chemotherapy was given. Biweekly CSF cytology was sent. After three consecutive negative CSF reports, patient was transferred to his/her routine protocol of therapy. If the patient still remains positive for or had suspicious CSF cytology then second cycle of intrathecal chemotherapy was given. Results Diagnoses were divided into positive cases, negative cases, suspicious for malignancy, hemorrhagic aspirate and having infectious etiology. a) Negative for malignant cells when smear was almost acellulr or when few benign lymphocytes, monocytes or macrophages were seen in smear, b) suspicious for malignancy: when few atypical cells seen, in either paucicellular smear or in the background of reactive cells which were not conclusive for the diagnosis of malignancy, c) positive for involvement: when definite malignant cells seen. In 5 years’ period, total 5394 cases were sent to cytology department. In our study, patient`s age was range from 1 to70 years. In pediatric age group, male to female ratio was 3:1 and in remaining age group, it was 1.2:1. Out of 5394, 4985 cases were negative for malignant cells and 273 cases were positive for malignant cells, 110 cases were hemorrhagic, 26 cases were suspicious for malignancy and 4 cases had infectious etiology. Out of 26 suspicious cases, repeat CSF cytology was done in 18 cases in which 11 were become negative and 7 were positive, remaining 8 cases still showed signs/symptoms of meningeal irritation so, they were treated as positive. Out of 288 positive cases, 153 were pediatric and 135 were adults. Distributions of cases were shown in Table-1. In four infectious etiologies, two had acute meningitis, one had Cryptococcus meningitis and last one had chronic meningitis. Out of four cases of SOL brain, one case had liver mass – further details not available, two cases suspected having GI malignancy, and last one was lost to follow-up without any investigation. CSF cytology In general, cytology of CSF reveled the general characteristics of the malignant cells consisted of cells with high nuclear : cytoplasmic (N/C) ratio, scanty to moderate cytoplasm, hyper chromatic nuclei, inhomogeneous or loosely clustered chromatin texture, prominent nucleoli, irregular nuclear membrane and presence of mitosis. CSF involved by leukemia/lymphoma usually had discohesive, relatively monotonous cells with high N/C ratio, thin rim of cytoplasm, irregular nuclear membrane, and presence of nuclear protrusion or folding and large nucleoli. In some cases hand- mirror cells seen. Apoptotic bodies were also seen in few cases. CSF involved by chronic myeloid leukemia (CML), the cell population is heterogeneous, with all stages of granulocytic precursors with or without increase number of blast cells. Retinoblastoma, medulloblastoma and Peripheral neuroectodermal tumor (PNET) were morphologically similar in CSF. In all cases, cells are usually numerous and identified as malignant. The cells vary in size, relatively monotonous, occurs singly, in small clusters or rosettes. The cytoplasm is scanty and nuclei are hyperchromatic. Nuclear molding and apoptotic bodies were seen in many cases. The cytology in CSF of metastatic cancer depends on the type of tumor. (Figure-1 and Figure-2) The recognition of the organ of origin or even tumor type may be extremely difficult in cytological preparation in the absence of clinical history. In general, cells of metastatic carcinomas, even of small size, are larger than transformed lymphocytes.   Discussion Malignant cells infiltrate the leptomeninges or the CSF cavity by direct extension or by haematogenous spread or by lymphatic metastasis. (11, 12) Misdiagnosis of LC occurs frequently because of its diverse clinical symptoms and its association with high mortality and major neurological disability. (5) So, it is of great importance to recognize its presentation and to improve the diagnosis. Lymphoma, leukemia and some carcinoma particularly small cell carcinoma of lung may be associated with treatable occult cerebromeningeal metastasis. Early recognition of this metastasis may be critical in deciding on further therapeutic measures that may significantly alter the course of the disease. One of the useful tests to establish diagnosis of LM is gd-MRI but it showed an approximately 30% incidence of false negative results and so negative imaging does not exclude the diagnosis of neoplastic meningitis (NM).(13) CSF analysis could represent a valid method for diagnosis of NM because of direct demonstration of tumor cells among all these diagnostic tests. Even in lesion that are in contact with CSF, the number of malignant cells observed may be very small, so even a single abnormal cells should be most carefully evaluated as it may prove to be of diagnostic value. The use of liquid based monolayer technology seems to overcome most of these diagnostic difficulties. This procedure provides better cytomorphology, higher cellularity per slide, clean background with easier detection of malignant cells and reproducibility of equivalent shades for immunocytochemistry. Sioutopoulou Do et al. (14) suggested thin preparation is as an alternative method of preparation for CSF specimen. Only in malignant lymphoma and leukemia and rarely in other metastatic tumor, abundant cancer cells consistently present in CSF. The CSF cytology of metastatic cancer depends on the type of primary tumor. In our study commonest malignancy found in CSF was acute leukemia in both adult and pediatric cases, account for 44.5% and 67.5% of cases respectively. Lymphoblastic leukemia was more common in both age groups. In pediatric series ALL is 52.9% followed by Retinoblastoma (25.5 %). Our results correlate well with the study of Payerson et al. (15) Lymphoma accounts 11.7% of cases followed by AML and Medulloblastoma involving similar number of cases (4.7%). In adult, leukemia (44.5%) was followed by epithelial malignancy (28.1%) and lymphoma (22.9%) in positive CSF cytology. In epithelial malignancy most common involvement is by breast carcinoma (16.3%) followed by lung cancer (6.7%). Other sites included were ovary, cervix, colon, and stomach. Two cases of Medulloblastoma were also found in adult. It has been reported in the literature that the most common malignancies associated with LC are breast cancer, lung cancer, melanoma, lymphoma and leukemia.(16,17) Our results were comparable to other studies.(3,4,14,18,19,20,21) All cases of lymphoma involving CSF in our study had systemic spread rather than primary CNS lymphoma. In pediatric, out of 18 positive cases of metastatic NHL, 15 were which lymphoblastic lymphoma and 3 cases of T-cell lymphoma. In adult, out of 31 positive cases, 16 were diffuse large B-cell lymphoma, 8 cases were lymphoblastic lymphoma, 3 were T cell lymphoma, 2 were B cell lymphoma and 2 were Burkitt’s lymphoma. Amongst the breast carcinomas, most of our cases were duct type, only one case was lobular type and in lung carcinoma most cases were adenocarcinoma. Our results correlate with the study of Chuang TY et al. (22) but it contrast to other studies. (23, 24, 25)   Now a day, CSF examination is a routine procedure in acute leukemia of children. It has been shown that leukemic cells may be present in CSF in asymptomatic patients with good response to the therapy, before there are clinical manifestations of meningeal involvement. Thus, CSF cytology serves to monitor the effect of treatment in sequential samples of CSF, particular in children. (26, 27) Several sources of errors in diagnosis of leukemia, lymphoma in CSF were identified like viral and fungal meningitis, viral encephalitis, contamination with peripheral blood in a known case of leukemia and a postsurgical reaction. The errors are avoided by following the strict morphologic criteria of CSF. In case of doubt, additional material should be requested and processed by immunocytochemistry and flow cytometry. Our results suggest that CSF cytology is helpful in the diagnosis of tumor metastasis to leptomeninges. CSF metastasis correlates with worse prognosis and patient survival. Treatment in broad prospective entails radiotherapy (intrathecal) and Systemic chemotherapy.(28) The clinical value of an early and accurate diagnosis of metastatic tumors in CSF is high even in neurologically asymptomatic patients who are in remission from neoplasms that were formerly rapidly fatal, because the effect of treatment contributes to quality of  life, control of neurological symptoms and longer survival. Since the CNS is outside the field of radiation and many chemotherapy agents cannot penetrate the blood brain barrier, these patients may present with relapse in the CNS. Since long, detection of neoplastic cells by cytological examination of CSF has become commonplace in most cytopathology laboratories. This technique will still remain the first-line diagnostic procedure in patients with metastatic tumors, leukemia, lymphoma and primary brain tumors who are suspected of having meningeal spread as well as in patients who present initially with signs of meningeal disease of unknown etiology.  Conclusion The present case series also states that cytological examination of CSF is simple and useful technique even possible at primary health centre still remains the first line diagnostic technique for diagnosis of LM. CSF analysis could also represent a valid method for diagnosis of neoplastic meningitis because of direct demonstration of tumor cells among all other diagnostic tests. Acknowledgement Authors acknowledge the immense help received from the scholars whose article cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. We would like to thank all the paramedical staff who had participated in the study.            Note: In the present study, CSF aspiration procedure performed on the patient as routine diagnostic procedure which was with prior consent of the patients. Ethical committee clearance has not been required as confidentiality of patients’ details has not been published. Financial support: Nil Conflict of interest: Nil Ethical approval: not required Abbreviation Cerebrospinal fluid (CSF) Leptomeningeal carcinomatosis (LC). Acquired immunodeficiency syndrome (AIDS) Space occupying lesions (SOL) Acute lymphoblastic leukemia (ALL), Retinoblastoma (RB), Acute myeloblastic leukemia (AML) Myelomonocytic (M4) type  Monoblastic (M5) type Lumbar puncture (LP) Peripheral neuroectodermal tumor (PNET) Chronic myeloid leukemia (CML), Neoplastic meningitis (NM) Gadolinium enhanced MRI (gd-MRI) Englishhttp://ijcrr.com/abstract.php?article_id=125http://ijcrr.com/article_html.php?did=125 Kaplan JG, DeSouza TG, Farkash A, et al: Leptomeningeal metastases: comparison of clinical features and laboratory data of solid tumors, lymphomas and leukemia. J Neurooncol  1990;9:225-229 Wolfgang G, Marcus D, Ulrike S:  LC: clinical syndrome in different primaries. J Neurooncol  1998;38:103-10 Aboulafia DM, Taylor LP, Crane RD, et al. Carcinomatous meningitis complicating cervical cancer: a clinicopathologic study and literature review. Gynecol Oncol. 1996; 60:313-18. Beerman WF. Meningial carcinomatosis.JAMA;58:1437-9 DeAngelis LM.  Current diagnosis and treatment of leptomeningeal metastasis. J Neurooncol 1998; 38:245–52. Gleissner B, Chamberlain MC. Neoplastic meningitis. The Lancet Neurology.2006; 5:443- 52. Chamaberlain MC, Glantz M, Groves MD, Wilson WH. Diagnostic Tools for Neoplastic Meningitis: Detecting Disease, Identifying Patient Risk, and Determining Benefit of Treatment.  YSONC. 2010;36:535-45 Wasserstrom WR, Glass JP, Posner J: Diagnosis and treatment of leptomeningeal metastases from solid tumors: Experience with 90 patients. Cancer 1982; 49: 759–72 Glass JP, Melamed M, Chernik NL, et al: Malignant cells in cerebrospinal fluid (CSF): The meaning of a positive CSF cytology. Neurology 1979; 29: 1369–1375. An-Foraker SH: Cytodiagnosis of malignant lesions in cerebrospinal fluid. Review and cytohistologic correlation. Acta Cytol 1985; 29: 286–90. Chamberlain MC. Neoplastic meningitis. Oncologist. 2008; 13:967–77. Mammoser AG, Groves MD. Biology and therapy of neoplastic meningitis. Current Oncology Report 2010; 12:41–49. Chamberlain MC, Sandy AD, Press GA. Leptomeningeal metastasis: A comparison of gadolinium-enhanced MR and contrast-enhanced CT of the brain. Neurology. 1990; 40:435–38. Sioutopoulou D.O.,Kampas L.I.,Gerasimidou D.,Valeri R.M.,Boukovinas I.,Tsavdaridis D. Destouni C.T.: Diagnosis of Metastatic Tumors in Cerebrospinal Fluid Samples Using Thin-Layer Cytology. Acta Cytol 2008; 52:304-8. Prayson, Richard A, Fischler, Diana F. Cerebrospinal fluid cytology-An 11 year experience with 5951 specimens. Archives of Pathology and Laboratory Medicine, January 1, 1998           Grossman SA, Krabak MJ: Leptomeningeal carcinomatosis. Cancer Treat Rev 1999;25:103- 19 Jayson GC, Howell A: Carcinomatous meningitis in solid tumors. Ann Oncol 1996; 7:773-86. Grossman SA, Krabak M: Leptomeningeal carcinomatosis. Cancer Treat Rev 1999;25:495-99 Gupta R, Naran S, Lallu S, Fauck R: Cytodiagnosis of neoplasms of the central nervous system in cerebrospinal fluid samples with an application of selective immunostains in differentiation. Cytopathology 2004;15:38-43 Jorda M, Ganjei-Azar P, Nandji M: Cytologic characteristics of meningeal carcinomatosis. Arch Neurol 1998;55:181-84 Fadda G, Rossi ED, Mule A, Miraglia A, Vecchio FM, Capellli A: Diagnostic efficacy of immunocytochemistry of fine needle aspiration biopsies processed by thin layer cytology. Acta Cytol 2006;50:129-35 Tzu-Yi Chuang, Chong-Jen Yu, Jin-Yuan Shih, Pan-Chyr Yang, Sow-Hsong Kuo: Cytologically Proven Meningeal Carcinomatosis in Patients with Lung Cancer: Clinical Observation of 34 Cases. Journal of Forsmosan Medical Association 2008; 107:851-56. Wasserstrom WR, Glass P, Posner JB: Diagnosis and treatment of leptomeningeal metastases from solid tumors: experience with 90 patients. Cancer 1982; 49:759-72.        Liaw CC, Ng KT, Huang JS, et al.: Meningeal carcinomatosis from solid tumors: clinical analysis of 42 cases. J Formos Med Assoc 1992; 91:299-303.   Balm M, Hammack J.: Leptomeningeal carcinomatosis presenting features and prognostic factors. Arch Neurol 1996; 53:626-32. Aaronson AG, Hajdu SI, Melamed MR: Spinal fluid cytology during chemotherapy of leukemia of central nervous system in children. Am J Clin Pathol 1975;63:528-37 Mayer JR, Watson CW: Cytologic monitoring of cerebrospinal fluid in the treatment of histiocytic lymphoma involving the central nervous system. Acta Cytol 1980; 24:26-29. Chowdhary S, Chamberlain M: Leptomeningeal metastases: Current concepts and Management guidelines. J Natl Compr Canc Netw 2005; 3:693-703

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524191EnglishN2017January7HealthcarePERIPHERAL OSSIFYING FIBROMA-  A CLINICO-HISTOPATHOLOGICAL REPORT English0608Kalpana Gokul1English Kamala R.2English Basavaraj N. Kallalli3English Jyothi Zingade4EnglishAim: This article attempts to describethe peripheral ossifying fibroma of gingiva in a 40 year old male patient. Case Report: A 40 year old male patient presented with a growth which was lobulated, sessile, asymptomatic and firm in consistency. Histopathological picture shows hyperparakeratinized epithelium with long and slender rete ridges, with collagen fibresand chronic inflammatory cell infiltrate in connective tissue stroma, suggestive of Peripheral Ossifying Fibroma. Conclusion: Knowledge of the frequency and presentation of the most common oral lesions with its differential diagnosis is beneficial in developing an early clinical diagnosis of such lesions and its management in the primary stage with minimum surgical intervention. EnglishFibrous hyperplasia, Oral mucosal lesion, Peripheral ossifying fibromaINTRODUCTION Oral mucosa is constantly subjected to external and internal stimuli and therefore presents with a spectrum of diseases that range from developmental, reactive, inflammatory and neo­plastic.1,2,3 These lesions present as either generalized or local­ized. Reactive lesions of the gingiva are clinically non-neoplastic nodular swellings that develop in response to chronic and recurrent tissue injury which stimulates an exu­berant or excessive tissue response.2,4 They may present as pyogenic granuloma, fibrous epulis, peripheral giant cell granu­loma, fibroepithelial polyp, peripheral ossifying fibroma, giant cell fibroma, and pregnancy epulis. Such reactive lesions are less commonly present in other intraoral sites such as cheek, tongue, palate and floor of the mouth but very frequently present in re­lation to the gingiva.1,2 Clinically, these reactive lesions often present diagnostic challenges because they appear similar. But they possess distinct histo-pathological features.3,4 Here we present a case of peripheral ossifying fibroma manifesting as inflammatory hyperplasia rather than a true neoplastic lesion of connective tissue origin. CASE REPORT A 40 year old male patient visited to the department of oral medicine and radiology with the chief complaint of growth in the lower front tooth region of jaw since 5 months. Patient gives history of growth which was smaller in size initially and gradually increased to the present size. He had difficulty while brushing and on mastication. Past dental history revealed he visited to the dentist 5 months back for the same complaint and underwent surgical excision. Patient again noticed small growth after 1 week of excision which gradually increased to the present size. Patient had habit of tobacco chewing 3-4 times/day 10 years back but he quit his habit 3 years back. On intraoral examination a single lobulated growth was present on the attached gingiva in relation to 31,32,41 with sessile base. Extending superiorly 2 mm below the incisal edge of 31,41,42 to 2mm above the lower labial vestibule and from mesial of 32 tooth to mesial of 43 measuring about 2x3 cm in size. Overlying mucosa of the growth was, blanched superiorly while the inferior surface was erythematous.Indentations of the 11,12,21 were seen on the superior surface of the growth. No visible surface pulsation, ulcerations, bleeding was seen. On palpation growth was non-tender, firm in consistency and not fixed to the underlying tissue. Bleeding on probing was present. With the history and clinical examination provisional diagnosis was given as Peripheral ossifying fibroma. (Figure 1,2) An intraoral periapical radiograph showing radiopacities suggestive of calcifications.(Figure 3) Haematological investigations were carried out, all the values were within the normal limit. Excisional biopsy of the patient was carried out under local anaesthesia and excised specimen was sent for the histopathological examination. (Figure 4 ) Histopathologically the hematoxylin and eosin stained section revealed hyperparakeratinized stratified squamous epithelium with long and slender rete ridges. Connective tissue stroma showing dense collagen fibres with chronic inflammatory cell infiltration. The overall features suggestive of Peripheral Ossifying Fibroma (Figure 5)  The patient was followed after 15 days, and no recurrence was noticed. (Figure 6) DISCUSSION Fibrous growths of the oral soft tissues are fairly common and include a diverse group of reactive and neoplastic conditions. Tissue enlargement of the oral cavity often presents a diagnostic challenge because a diverse group of pathologic processes can produce such lesions.5,6,7 They are categorized into four subgroups which includes pyogenic granuloma, peripheral ossifying fibroma, peripheral giant cell granuloma and fibrous hyperplasia (Kfir et al).10  Fibro epithelial hyperplasias are reactive/ inflammatory conditions and they give rise to variety of lesions named according to their clinical presentation. Most of these lesions arise on gingiva, reflecting universal presence of inflammation in the interdental papillae.1,3 Lesions are associated with local predisposing factor like mal-aligned teeth, ill-fitting restorations, calculus which prevent removal of bacterial plaque and indirectly induce inflammation.2,11 It is interesting that most reactive hyperplastic lesions occurred in the female gender with female to male ratio of 1.5:1. In a study carried out by Zarei et al and Aghbali et al they were more common in females (male to female ration of 1:1.8 and 1: 1.4).Reactive lesions of the gingiva are clinically and histologically non-neoplastic nodular swellings that develop in response to chronic and recurrent tissue injury which stimulates an exuberant or excessive tissue response.10 Peripheral Ossifying Fibroma is a histological variant of fibroma and a proliferative fibrous lesion of the gingival tissue that causes esthetic and functional problems which need to be evaluated and treated as early as possible.4 The clinical aspects of Peripheral Ossifying Fibroma with calcification and ossification are similar to pyogenic granuloma. Yehoshua Kfir et al in his clinicopathologic study conducted on 741 cases it has been proved that Peripheral Ossifying Fibroma with calcification and ossification affects more commonly young people and female.1 Daley et al suggested that the vascular component of pyogenic granuloma is gradually replaced by fibrous tissue with time and hence, diagnosed as a fibrous hyperplasia or fibroma. Natheer Al- Rawi et al observed that fibrous hyperplasia on the gingiva not only have the same female gender preponderance but occur in the same age group and site as gingival pyogenic granuloma. An inference that fibrous hyperplasia represents a fibrous maturation of pyogenic granuloma especially in lesions with long duration. Fibrous inflammatory hyperplasia may occur on any surface of the oral mucous membrane as either pedunculated or sessile growth. Lesions more than one cm in diameter are rare in cheeks, tongue and floor of the mouth because masticatory stresses restricts their size through necrosis and ulceration.3,4,10 Histopathologically, these lesions shows hyperplastic stratified squamous epithelium, thin finger like rete ridges extend into underlying connective tissue stroma which are fibrocellular. Chronic inflammatory cell infiltrate are seen. These lesions are treated by complete local excision and removal of chronic irritant and low recurrence rate is expected.1,2,5 CONCLUSION Oral lesions are first detected by oral physicians. Knowledge of the frequency and presentation of the most common oral lesions with its differential diagnosis is beneficial in developing an early clinical diagnosis of such lesions and its management in the primary stage with minimum surgical intervention. Although there is female predominance the present case represents a rare reactive lesion in male. It is difficult to differentiate clinically between pyogenic granuloma, peripheral ossifying fibroma, peripheral giant cell granuloma and fibrous hyperplasia. Hence a histopathological investigation is helpful to arrive at accurate diagnosis.   Englishhttp://ijcrr.com/abstract.php?article_id=126http://ijcrr.com/article_html.php?did=126 Gorwade N, Dhalkari CD, Ambulgekar JR. Inflammatory fibro-epithelial hyperplasia with two variants- A report of three cases. Int. J Sci Res 2014;3:1-2 Astekar M, Gupta S, Soumya G. Focal Fibrous Hyperplasia: Report of two Cases. Int J Dent Clin 2011;3:111-112 Suryaprasanna J, Sehrawat S. Fibroepithelial hyperplasia: Rare, self-limiting condition- Two case reports. J Adv Oral Res 2011; 2;70  Reddy V , Saxena S, Saxena S, Reddy V. Reactive hyperplastic lesions of the oral cavity: A ten year observational study on North Indian Population J Clin Exp Dent 2012;4:e136-40. Shafer. Textbook of Oral Pathology. 5ed. New Delhi, Elsevier. 2007:178-180. Regezi JA, Sciubba. Connective Tissue Lesions. Oral Pathology: Clinical Pathologic Correlations. 5 ed. St. Louis, Saunders, Elsevier, 2008:155- 178. Michael Glick. Burket’s Oral Medicine. People’s Medical publishing house; 12th edition.2015 Brad W. Neville, Douglas D. Damm, Carl M. Allen, Jerry E. Bouquet. Text book of Oral and Maxillofacial Pathology.2nd edition. Jafarzadeh A, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review, J Oral Sci 2006; 48: 167-175. Jain K, Singh BD, Dubey A, AvinashA .Fibro-Epithelial Hyperplasia Mimicking Mucocele. Kathmandu Univ Med J 2014;12 :146-148.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524191EnglishN2017January7HealthcareASSESSMENT OF KNOWLEDGE AND AWARENESS ABOUT PERIODONTAL ORAL HEALTH AMONG PREGNANT WOMEN- A QUESTIONNAIRE STUDY English0912Jaiganesh Ramamurthy1English Fathima Irfana2EnglishBackground: Periodontal diseases and systemic diseases are having association and various studies have been done to assess the scientific evidence. There are a lot of scientific data available to explain the association between periodontal diseases, adverse pregnancy outcomes such as preeclampsia and preterm low birth weight deliveries. It is also linked with stillbirth, miscarriage, intrauterine growth retardation. Pregnancy can influence gingival health and also the changes in the hormone level during pregnancy promote inflammation termed as Pregnant Gingivitis and it occurs without any changes in the plaque level. Aim and Objective: To assess and compare the level of knowledge and attitude towards periodontal oral health among pregnant women. Materials and Methods: Awareness of the relationship between oral health and pregnancy, demographics, oral health knowledge, oral hygiene, and dental visits during pregnancy and their willingness for treatment to be surveyed by self administered questionnaire from 100 pregnant females. The data was collected, summarized and statistically analyzed. Results: Knowledge and awareness regarding periodontal disease, and its effect on the pregnancy and birth outcome is very limited. Knowledge and awareness about use of interdental aids, extra care during pregnancy and about premature labour and low birth babies are correlated with periodontal oral health. Conclusion: Most pregnant women need more information about oral health, and prevention of gingival and periodontal diseases as they are more concern about general health and less aware and concern about dental health. EnglishPregnancy, Periodontitis, Oral healthINTRODUCTION: “Periodontal Disease” is a destructive inflammatory disorder of the hard and soft tissues surrounding teeth. Preterm birth, also known as premature birth, is the birth of a baby at less than 37 weeks gestational age(1). The infected periodontium can represent an endocrine like source of potentially deleterious cytokines and lipid mediators which may increase the likelihood of adverse pregnancy outcomes. Pregnancy can influence gingival health. Changes in hormone levels during pregnancy promote an inflammation termed pregnancy gingivitis. This type of gingivitis may occur without changes in plaque levels.Furthermore, pregnancy increases the onset of new periodontal disease. If the pre-existing periodontal disease becomes active during the pregnancy, it may pose a significant concomitant infectious or inflammatory exposure and it can lead to preterm delivery of low birth weight babies(2). Pregnancy is a unique period during a woman's life and is characterised by complex physiological changes, which may adversely affect oral health. Women’s life cycle changes presents unique challenges to the oral health care profession. Hormonal influences associated with the reproductive process alter periodontal and oral tissue responses to local factors creating diagnostic and therapeutic dilemmas. It is imperative, therefore, that clinician recognise, customise and vary periodontal therapy, according to an individual female and the stage of her life cycle(3-5). Maintenance of oral health during pregnancy has been recognised as an important public health issue worldwide. A number of statements and guidelines have been published emphasising improved oral health care during pregnancy. Hormonal changes in pregnancy combined with neglected oral hygiene tend to increase the incidence of oral diseases like gingivitis(6-8). The present study was conducted to assess knowledge and awareness regarding oral health among pregnant women in India. Relevant cross-sectional observational studies were included in the systematic review to assess the level of knowledge and awareness regarding oral health among pregnant women in Chennai. The results obtained would serve as baseline information for planning an oral health education program aimed at improving the oral health of pregnant women receiving care in the hospital. Specifically, it would identify areas of deficiency in the women’s knowledge and this would be helpful in formulating the content of the oral health messages(9-10). MATERIALS AND METHODS: A questionnaire based study was conducted by assessing the responses to selected basic questions about periodontal oral health in the Gynaecology department of shifa hospital, Chennai. The subjects were informed about the purpose of the study and ethical approval was obtained from the chief of the Hospital. The demographic data and a questionnairewith 20 structured questions regarding the knowledge and awareness of periodontal oral health were given to all consenting pregnant women who attended the clinic during the study period.The first section contained questions on the respondent’s socio- demographic characteristics such as age, occupation, monthly income and educational status. The second section comprised of fifteen questions pertaining to awareness of relationship between oral health and pregnancy, oral health knowledge, oral hygiene, dental visits during pregnancy, advice about dental health requirements during pregnancy, history of bleeding gums and what, if any, actions were sought to treat perceived gingival problems and their willingness for treatment. Questionnaire Name: Age: Address: Occupation: Education: Monthly income: Habits if any: Gestational age: Oral Hygiene Status: Do you brush your teeth? A. Yes B. No If no, then do you use any other oral hygiene method?_________ Do you brush your teeth after every meal?                                                                                                         A. Yes           B. No Do you use interdental cleaning aids?                                                                                                               A. Yes       B. No  Do you think that extra care of oral hygiene is needed during pregnancy?                                                     A. Yes        B. No  Are you aware that dental disease and pregnancy are related ?                                                                    A. Yes     B. No  Do you know that Cavities (tooth decay) and gum disease are caused by infection in the mouth?               A. Yes              B. No Do you know about Premature labour and low birth babies ?                                                                         A. Yes          B. No  Premature labour means how many months early ?_________ What will be the weight of low birth babies?________ What do you think is the ideal weight of new born ?                                                                                        a) 2kg b) 2.5kg c) 3kg d) 4 -6kg Have you ever suffered from premature labor or low birth weight babies in the past?                                     A. Yes            B. No Are you aware that gum disease are related with premature labor and low birth weight babies?                       A. Yes           B. No Have you ever visited a dentist during or before your pregnancy?                                                                 A. Yes             B. No Do you know that Pregnancy makes your gums bleed, swell, become red?                                                   A. Yes              B. No Do your gums bleed during tooth brushing after conception?                                                                         A. Yes               B. No If you are found to have periodontal disease (gum disease) now during pregnancy ,will you undergo treatment for the same?                                                                                                                                  A. Yes                B. No If you are diagnosed with periodontal disease (gum disease) after delivery ,will you undergo treatment ?       A. Yes                 B. No Did your gynaecologist recommended oral check up before or during pregnancy?                                       A. Yes                   B. No     RESULTS: The data was collected and the results were tabulated . The results obtained from the periodontal health awareness questionnaire were compiled and were tabulated and graphically represented. Descriptivetabulations were done by age, education and occupation. For the purpose of analysis the level of education was categorised as low (primary education only), middle (secondary education) and tertiary (post secondary education). Thus the results were analyzed.   The commonest oral disease during pregnancy (i.e. Periodontal disease) is preventable by the institution of simple measures such as regular tooth-brushing and flossing.(10-12) However such positive behaviour would be influenced by the individual’s oral health knowledge and attitudes which in turn is influenced by the awareness of an individual. Thus, this study was designed to provide a view of periodontal awareness among pregnant females. CONCLUSION: A majority of the pregnant women has good knowledge and information about general health. But they have limited knowledge and awareness regarding periodontal disease, and its effect on the pregnancy and adverse pregnancy outcomes. Most pregnant women need more information about oral health, and prevention of gingival and periodontal diseases. (13,14) Longitudinal studies are needed to assess the long-term effect of oral health education programs in maternity care centers on dental health knowledge and behavior of pregnant women. Long term studies are required to determine if there is a strong correlation between periodontal disease and premature labor. Also further studies are required to check whether periodontal therapy or prevention can reduce the risk of premature labor. Studies to assess the role of dental hygienists in designing and promoting information regarding periodontal health awareness and practices among pregnant women in maternity care centers. Acknowledgement: The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Conflict of interest: Nil Source of Funding: Nil Englishhttp://ijcrr.com/abstract.php?article_id=127http://ijcrr.com/article_html.php?did=1271. Boggess KA, Urlaub DM, Moos MK, Polinkovsky M, El-Khorazaty J, Lorenz C. Knowledge and beliefs regarding oral health among pregnant women. J Am Dent Assoc. 2011 Nov;142(11):1275-82.  2. Loe H, Silness J. Periodontal Disease In Pregnancy. I. Prevalence And Severity. Acta Odontol Scand. 1963 Dec;21:533-51  3. Jensen J, Lilijmack W, Bloomquist C. The effect of female sex hormones on subgingival plaque. J Periodontol1981;52(10): 599–602.  4. Nuamah I, Annan BD. Periodontal status and oral hygiene practices of pregnant and non-pregnant women. East Afr Med J. 1998 Dec;75(12):712-4.  5. Ferris GM. Alteration in female sex hormones: their effect on oral tissues and dental treatment. Compendium. 1993 ;14(12):1558-64.  6. Zachariasen RD. The effect of elevated ovarian hormones on periodontal health: oral contraceptives and pregnancy. Women Health. 1993;20(2):21-30. 7. Sánchez AR, Kupp LI, Sheridan PJ, Sánchez DR. Maternal chronic infection as a risk factor in preterm low birth weight infants: the link with periodontal infection. J IntAcadPeriodontol 2004. Jul;6(3):89- 8. Al Mullahi A, Mendoza LF, Al Wahaibi MC. Audit on Patient’s Attendance Pattern, Reasons for Failed Appointments and Waiting Time at Oral Health Department. Oman Med J 2012. Jan;(1)(Suppl):75-100 9. Hajikazemi E, et al. The relationship between Knowledge, Attitude and Practice of Pregnant Women about Oral and Dental Care. European Journal of Scientific Research 2008;24(4):556-562 10. American Academy of Periodontology 2010; Baby steps to a healthy pregnancy and on time delivery. 11. Deasy MJ, Vogel RI. Female sex hormonal factors in periodontal disease. Ann Dent 1976;35(3):42- 12. Silk H, Douglass AB, Douglass JM, Silk L. Oral health during pregnancy. AmFam Physician 2008. Apr;77(8):1139-1. 13. Manjushavaradan, Jaiganesh Ramamurthy. Association of Periodontal Disease and Pre-term Low Birth Weight Infants.J Obstet.Gynaecol India 2015. May;65(3):167-171. 14. Misrathbanum A, Jaiganesh Ramamurthy. Periodontitis a risk factor for pre-eclampsia in pregnant women.Int J Pharm Bio Sci. Volume 5, Issue 2, 2014 ( April - June), Pages:736-739.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524191EnglishN2017January7HealthcareNON-INTERCOMMUNICATING ABDOMINOSCROTAL HYDROCELE WITH MULTI-SYSTEM ANOMALIES: A CASE REPORT English1316Gadelkareem R.A.EnglishAim: Presentation of an abdominoscrotal hydrocele case with a very rare association to multiple anomalies and separate abdominal and inguinoscrotal sacs. Case Report: A 21-year-old male patient presented with left-sided abdominoscrotal hydrocele, impalpable right testis, hydrocephalus and cerebral and musculoskeletal deformities. On abdominal ultrasonography, the abdominal and inguinoscrotal components were seen separated by a septum that was confirmed on surgery. Extended inguinal incision was used for repair and the post-operative course was uneventful. Discussion: Abdominoscrotal hydrocele is a rare entity and its simultaneous association to multiple anomalies, like in the current case, is a rarer finding. Non-intercommunication state is another very rare criteria of abdominoscrotal hydrocele which was clinically, sonographically and surgically demonstrated in this case. Extended inguinal incision was indicated and enough to deal with both abdominal and scrotal components. Conclusion: Abdominoscrotal hydrocele is mostly intercommunicating, but it is exceptionally non-intercommunicating and associated to multiple anomalies. Surgical excision via an extended inguinal incision may be indicated for voluminous cases and those with a solitary testis. EnglishAbdominoscrotal Hydrocele, Hydrocephalus, Septum Introduction Abdominoscrotal hydrocele is a simple hydrocele extends into the abdominal cavity forming two intercommunicating sacs (inguinoscrotal and abdominal) in the hourglass fashion[1, 2]. Old and recent reviews described this lesion as an unusual or uncommon entity[1-3]. Initially, it was reported among adults as single case reports [1-4]. However, few case series were published, especially among pediatrics[3].Regarding the nomenclatures, Prather[1] credited the initial term ″l'hydrocèle en bissac″ to Dupuytren in 1834[4] and the more acceptable term ″abdominoscrotal hydrocele″ to Bickle in 1919[5]. However, this latter term was coined, firstly, by Baitcheff in 1903[6]. Only three cases were published from Egypt, a century ago[7-9], and the case reported below is just the fourth one. Case report A 21-year-old male patient presented by a long-standing left inguinoscrotal swelling with a recently developed lower abdominal swelling. Also, he presented by other multiple anomalies and defects including reduced mental capabilities and epilepsy which were diagnosed and managed early in childhood and adolescence. Also, the mother gave a history of previous consultation for treatment of a small scrotal hydrocele and absent right testis, 5 years ago. Laparoscopy was done for the right testis which was diagnosed as atrophied intra-inguinal one. After a missing follow up, however, she returned for treatment because of the increasing swelling size and the patient’s complaint of progressive scrotal heaviness. On physical examination, there were: Left inguinoscrotal mass that seemed to be continuous with another visible lower abdominal mass. The latter mass extended upwards to a level near to the umbilicus and slightly crossed the midline to the right side. The scrotal mass had a smooth surface and looked as a bilocular swelling at site of the deviated median raphe to the right (Fig. 1). The abdominal and scrotal masses were cystic with no cross-fluctuation between them could be elicited, but hardly the gross movement of the scrotal mass could be felt through the abdominal one. Scrotal mass was transilluminable. Both testes could not be palpated. Other multi-system anomalies and lesions: Hydrocephalus: Huge head with exophthalmos, abnormal teeth and senile appearance. Cerebral lesions: Slurred and unclear speech and diminished mental capabilities. Musculoskeletal deformities: Dorsolumbar kyphosis, flat foot, short stature and under body built. Abdominal ultrasound examination revealed a marked left inguinoscrotal anechoic mass with clear fluid content and thin smooth capsule. This mass extended through the left inguinal canal into the abdominal cavity as another large cystic component with measured dimensions as 15 cm x 10 cm x 8 cm at the widest dimensions. A unique finding of a thin septum was noted at the level of the internal inguinal ring separating the two components (Fig. 2). The report described the left testis with absent right one. Preoperative routine laboratory work up and surgical fitness were unremarkable.  Surgery was done through an extended inguinal incision like that described by Roller [10]. The left inguinal canal was opened, the widened internal ring was incised, and the incision extended upwards by cutting the lower abdominal wall muscles. There was a glistening and transparent hydrocele occupying the inguinoscrotal region with intra-abdominal component. A well-defined ring constriction was obvious at the level of the internal inguinal ring (Fig. 3) which mostly corresponds to the sonographically described septum. Abdominal sac was pro-peritoneal reaching above the level of the umbilicus. It had few adhesions with the surroundings and was dissected by sharp and blunt dissections. It was pear-shaped when delivered from the wound (Fig. 3). A fibrous band connection was found at the inferomedial aspect of the sac. Mostly, this band represented the obliterated processusvaginalis and it was ligated and transected. Another finding that confirmed the non-intercommunication state between the two sacs was that the abdominal one remained full after accidental rupture of the inguinoscrotal one. Then the ruptured scrotal sac was drained, dissected, and excised, except the part adherent to the testis. This residue of the tunica was managed like in simple hydrocelectomy where it was reduced and everted around the testis. Drained fluid was clear, greenish yellow, and about 2 to 2.5 liters. The left testis looked larger than normal, fusiform, and was slightly soft in consistency. These slight testicular dysmorphism findings could be attributed to the prolonged compression effect of hydrocele. The lower abdominal wall and inguinal canal were repaired, a drain was inserted in a dependent part, and the scrotum was compressed within a bandage. Post-operative recovery course was uneventful. Discussion Abdominoscrotal hydrocele is an anomaly of the processusvaginalis which originates from a simple (mostly infantile) hydrocele [11, 12]. Its association to other anomalies like cryptorchidism and contralateral herniais encountered frequently[13]. However, the simultaneous association to multiplegenital and extra-genitalanomalies, like the current case, is unusual. Currently, no specific explanation for this association could be speculated. So, it is considered as just a matter of co-existence until studying of more similar cases could prove otherwise. The scrotal and abdominal sacs are connected via the isthmus which is a narrow segment corresponds to the inguinal canal giving them the hourglass appearance[1, 9]. Abdominal sac is usually the larger and may reach up to the costal margins[9, 14, 15]. Its relations to the peritoneum were classified into pro- and retro-peritoneal, but like the current case, it seems to be commonly pro-peritoneal[1, 2]. Also, as I found in this case, its coverings were described to be formed mainly of the transversal is fascia [2]. Free intercommunication between the two components is a constant pathological finding. It is the underlying basis of all the diagnostic clinical and imaging criteria in old and recent literature[2, 16, 17]. However, there were four reported cases with a separation between the abdominal and scrotal components; all were among adults[18-21]. In one of those cases, there was a wide distance between the sacs [21]. In another case, however, the abdominal and scrotal components were adherent, but could be separated surgically [20]. In the current case, absence of cross fluctuation, detected septum by ultrasound and the gross finding of a ring constriction at the level of the internal inguinal ring referred to an abdominoscrotal hydrocele with separate components. This finding was confirmed after delivery of the abdominal component and evacuation of the scrotal one, while the former was remaining full. The septum was very thin and the two components were adherent and non-separable surgically. Roller’s suggestion [10]of an encysted hydrocele of the cord with a vaginal hydrocele as etiology of abdominoscrotal hydrocele is accepted for cases like the current one. However, to withstand the intercommunicating form in this hypothesis, I suggest a possibility of septum recanalization under the effect of increasing internal pressure. Non-communication to the peritoneal cavity is a cardinal feature in most of the reported cases, especially in adults[1, 16]. The present case finding of an obliterated and fibrosed processusvaginalis correlates to this common finding. Tense compressing mass effect of the internal pressure is the reference of many complications as testicular dysmorphism, lymphedema and hydronephrosis[12, 14]. In the current case, there was only one large-volume left testis with hardly detectable dysmorphism. The commonly reported method of treatment is the surgical excision of the sacs(hydrocelectomy), early as can as possible[3]. The gold standard surgical approach is through the inguinal incision [13].It is predominantly used because of its effectiveness in dealing with the both components in adults and pediatrics [15, 22]. Extended inguinal (inguinoabdominal) incision could be employed to facilitate dissection of the large abdominal sac [17]. In the old literature, abdominal and combined abdominal and inguinal or scrotal incisions were employed[8, 9]. Also, dissection of the abdominal sac was claimed to be easy, but some difficulties were reported in few cases of that era[2]. To the best of my knowledge, this case is the first case of abdominoscrotal hydrocele with this number of different anomalies and deformities; the second one to be associated to head deformities after the case of Delmonaco et al. who reported abdominoscrotal hydrocele with macrocephaly [23]; and the fifth one regarding the presence of non-intercommunicating components. Conclusion Abdominoscrotal hydrocele may be associated to multi-system anomalies and deformities, simultaneously. It is commonly intercommunicating two-component hydrocele, but exceptionally, it could be non-intercommunicating. Ultrasonography is sufficient for confirmation of the diagnosis. Extended inguinal incision could be employed, especially in cases with solitary testis and voluminous cases. Acknowledgement I thank my colleagues Mohammed Zewaita and Amr Abdelgawad, the assistant lecturers in our hospital, who assisted me in the surgery of this case. I acknowledge the immense help received from the scholars whose articles are cited and included in reference of this article. I’m grateful to authors / edi­tors / publishers of all those articles and journals from where the literature for this article has been reviewed and discussed. Ethical approval This case study was approved by the ethical committee of the Faculty of Medicine in Assiut University. Informed consent was taken from the patient’s mother. Funding:None Conflict of interest: None Englishhttp://ijcrr.com/abstract.php?article_id=128http://ijcrr.com/article_html.php?did=128 Prather, G.C. Abdominoscrotal Hydrocele - Review of the literature and report of a case. N Engl J Med, 1942 Feb. 226(7): p. 255-260. Currie, J.A. Abdomino-scrotal hydrocele or hydrocele en bissac. S Afr Med J, 1953 Nov. 27(48): p. 1083-1086. Doudt, A.D., Kehoe, J.E., Ignacio, R.C., Christman, M.S. Abdominoscrotal hydrocele: A systematic review. J Pediatr Surg, 2016 Jun. 51(9): p. 1561-1564. Dupuytren, G. De l'hydrocèle et de ses principales variétés. Leçons orales de clinique chirurgicale., ed. G. Bailliêre. Vol. IV. 1834, Paris. p. 444-445. Bickle, L.W. Abdominal or bilocular hydrocele. BMJ, 1919 Jul. 2(3053): p. 13-13. Baïtcheff, I.K. De l'hydrocèle abdomino-scrotale (hydrocèle en bissac de Dupuytren). 1903 May, Delord-Boehm et Martial: Montpellier. p. 48. Richards, O. A case of double abdominal hydrocele. Lancet, 1908 Aug. 172(4434): p. 533-534. Lasbrey, F. A case of abdominal or bilocular hydrocele. BMJ, 1916 Aug. 2(2904): p. 292-292. Coleman, R. Abdominal or bilocular hydrocele. BMJ, 1918 Dec. 2(3023): p. 629-630. Roller, C. Abdominoscrotal hydrocele. JAMA, 1934 Sep. 103(9): p. 671-672. Miyamoto, A.T. Abdominoscrotal hydrocele: a congenital genitourinary tract anomaly diagnosed by ultrasound. J Clin Ultrasound, 1977 Dec. 5(6): p. 407-409. Abel, E.J., Pettus, J.A., Snow, B. Laparoscopic marsupialization before inguinal repair of large abdominoscrotal hydroceles in infants: observation of natural history and description of technique. Urology, 2009 Mar. 73(3): p. 507-509. Nagar, H., Kessler, A. Abdominoscrotal hydrocele in infancy: a study of 15 cases. Pediatr Surg Int, 1998 Mar. 13(2-3): p. 189-190. Mansoori, D. Abdominoscrotal hydrocele presenting as a large abdominal mass in a young man. BJU International 2002 Jun. 90(1cr): p. 139-139. Tiwary, S.K., Kumar, S., Agarwal, A., Khanna, R., Khanna, A.K. Abdomino-scrotal hydrocele in 35 years old: a case report. Kathmandu Univ Med J (KUMJ), 2007 Apr-Jun. 5(2): p. 237-239. Hisamatsu, E., Takagi, S., Nomi, M., Sugita, Y. A case of bilateral abdominoscrotal hydroceles without communication with the peritoneum. Indian J Urol, 2010 Jan-Mar. 26(1): p. 129-130. Garg, P.K., Prasad, D., Agrawal, V., Bhatt, S., Mohanty, D., Dubey, I. Abdominoscrotal hydrocele: an insight into its origin. Hernia, 2011 Oct. 15(5): p. 587-589. Tanzer, R.C. Abdominoscrotal hydrocele. J Urol,1935 Nov. 34(5): p. 447-452. Lysaght, A.C. Multi-locular intra-pelvic scrotal hydrocele. BJU, 1943 Dec. 15(4): p. 140-144. Sood, I.D., Aptekar, S.J. Co-existing abdominal and scrotal hydroceles. J Urol, 1970 Jul. 104(1): p. 141-142. Rekha, A., Ravi, A. Understanding the processus vaginalis! The abdomino scrotal hydrocoele. Intern J Morphol, 2012. 30(1): p. 61-63. Pogoreli?, Z., Juri?, I., Bogdani?, Ž., Krželj, V. Bilateral abdominoscrotal hydrocele in a 5–month-old infant presented with a left leg edema and cyanosis. Hernia, 2013 Aug. 17(4): p. 533-535. Delmonaco, A.G., Gaidolfi, E., Scheper, G.C., et al., A child with macrocephaly: case report of a patient with megalencephalic leukoencephalopathy with subcortical cysts and a compound heterozygosity for two mutations in the MLC1 gene. Minerva Pediatr, 2011 Apr. 63(2): p. 125-129.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524191EnglishN2017January7HealthcarePROGNOSTIC EVALUATION OF CHRONIC LIVER DISEASE PATIENTS WITH VARIOUS SCORING SYSTEMS English1721Showkat Ahmad Malik1English Abdul Qayoom Rather2English Peerzadi Shabeena3English Waseem Raja4EnglishBackground: Prognostic evaluation of patients with chronic liver diseases is an important topic, often challenging the clinician. The number of patients on waiting lists for orthostatic liver transplantation (OLT) is becoming increasingly higher compared with the number of available donor livers. Correct timing of orthostatic liver transplantation can reduce the mortality of patients on waiting lists and improve post-transplantation survival. Objective: To evaluate the short and medium term survival prognosis of chronic liver disease patients by means of various scoring systems. Material and Methods: Our study was a hospital based retrospective study in which 93 chronic liver disease patients of either sex, age > 18 years and of any etiology were included. Medical records of these patients were retrospectively reviewed. Child-pugh, MELD, MELA-Na and updated forms of MELD and MELD-Na were calculated from data. Predictive value of survival at 3 months and 1 year were compared between scores through AUROC (Area under receiver operating characteristics and p value of < 0.05 was considered significant. Results: 23 patients died including 4 who lost follow up, but all where belonging to Child Pugh class C and so considered dead. At both levels of assessment the scores of patient who died where significantly higher than those who survived, but there was no statistically significant difference in prediction of survival between various scores at both times as shown by their AUROC. Conclusion: All these scoring systems are useful for predicting survival of chronic liver disease patients and so more studies are warranted to investigate the superiority of one model over others.. EnglishChild Pugh, MELD, MELD-Na, Updated MELD-Na, AUROCINTRODUCTION The prevalence of chronic liver disease patients is increasing in the world, because of hepatitis B, C, alcoholic and non-alcoholic fatty liver disease (NAFLD), so are the patients on waiting list for orthostatic liver transplantation (OLT). Correct timing and selection for OLT can reduce the mortality and improve post-transplantation survival.1,2 Over the years many clinical and biochemical parameters have been suggested in order to accurately predict the prognosis of cirrhotic patients and correctly access their short and medium term survival. Child Pugh score is still considered the cornerstone in the prognostic evaluation of cirrhotic patients although it has some drawbacks, such as subjectivity of some clinical parameters and limited discriminatory ability.2 In 1999 United Network for Organ Sharing (UNOS) formulated the model for end stage liver disease (MELD) as an objective assessment tool.3 The present study aims to evaluate the prognostic accuracy of the Child Pugh, MELD, MELD-Na and updated forms of MELD and MELD-Na.   MATERIAL AND METHODS Our study was a retro-prospective hospital based study, conducted in SMHS hospital Srinagar (JandK) – a tertiary care teaching hospital. 93 patients of chronic liver disease patients of either gender, age > 18 years and of any etiology were included who visited the hospital from October 2009 to October 2010. The diagnosis of cirrhosis is confirmed on clinical, radiological and or biopsy (wherever feasible), detailed medical history, complete physical examination and laboratory tests (i.e. CBC, prothrombin time and INR, serum urea/creatinine, electrolytes, liver function tests) were performed in all patients at the time of registration and at 3 months and 1 year. Encephalopathy graded according to Zakim and Boyer (1996) classification4. Ascites diagnosed clinically and its degree evaluated by ultrasonic examination. Based on collected data various scores for each patients were calculated. Various scores in each patients were calculated according to following equations: MELD =  3.78 [Ln.Sr.Bil.(mg/dl)+11.2 [Ln.INR] + 9.57 [Ln.Sr.Creat.] + 6.43. MELD-NA = MELD-Na – [0.025 x MELD x (140 – Na) + 140 Updated MELD = 9.39 [Ln.Sr.Bil.mg/dl] + 16.58 [Ln.INR] + 12.66 [Ln.Sr.Creat] + 6.43 Updated MELD-Na = Updated MELD-Na – [0.025xupdated MELD] x [140-Na] + 140 Child Pugh scoring was calculated from following patient parameters. Serum Bilirubin (mg/dl), Sr. Albumin (g/dl), PT/INR, Presence or absence of Ascites or presence or absence of hepatic encephalopathy. Each patients was then allotted a Child class according to his or her score. Class A (5-6); Class B (7-9) and Class C (10-15) scores. RESULTS AND OUTCOME A total of 93 patients were enrolled, 56 were males (60.21%) and 37 were females (39.78%). 15 were belonging to Child Pugh class A, 45 Child Pugh class B, and 33 were belonging to Child Pugh class C. Most common etiology was cryptogenic (48 (51.6%) out of 93) followed by hepatitis B (26 (27.95%) out of 93), hepatitis C (10 (10.73%) out of 93), autoimmune 6 (6.45) out of 93) and least were mixed HBV and HCVG related (3.22%). 23 patients died including 4 who lost follow up, but all where belonging to Child Pugh class C and so considered dead. At both levels of assessment the scores of patient who died where significantly higher than those who survived, but there was no statistically significant difference in prediction of survival between various scores at both times as shown by their AUROC. Comparison of Prognostic Accuracy Between Various Scores To compare the accuracy of various scores as predictors of survival at 3 months and one year. The area under the operating characteristics curve (AUROC) was calculated. 23 patients died over study period of one year, 7 at 3 months and total of 23 at one year including those 4 who lost follow up. The AUROC of Child Pugh MELD, MELD-Na, updated MELD and updated MELD-Na were 0.799, 0.805, 0.806, 0.809 and 0.810 at 3 months and 0.714, 0.791, 0.765, 0.790 and 0.793 at one year. The enhanced efficacy of liver transplantation as a treatment for end stage liver disease has led to a progressive discrepancy between supply and demand for donor livers. As a result, the proportion of patients dying while on the wait list has steadily increased5 in an attempt to reduce wait list mortality, a new allocation policy replacing the CTP with MELD has been adopted since 2002. Indeed, by allowing available grafts to the sick patients, the MELD system has led to a decrease in wait list mortality,6 without impairing the transplant outcome.7 Nevertheless the MELD system does not take into account important prognostic factors. In particular, the role of hyponatremia as an independent predictor of mortality has been convincingly demonstrated8 and some studies assessed the prognostic value of a new scores derived from integration of sodium in the MELD score.9,10 The applicability of sodium based MELD scoring systems in organ allocation has some limitation due to inter-laboratory variability and the potential variability of serum sodium concentration after simple therapeutic maneuvers such as administration of diuretics or intravenous hypotonic fluids or plasma volume expanders. Despite these caveats, Na based MELD scoring system represent a major advance in the prognostic assessment of patients with cirrhosis.11 To date only two studies12,13 with an adequate sample size have evaluated the impact of modified MELD score on wait list mortality, and both reported that the incorporation of Na into the MELD score may enhance prognostic accuracy. One study elaborated the MELD-Na formula on the data from the huge register of U.S. organ procurement and transplantation network14 and other proposed the UKELD score which is currently used to prioritize patients on the liver transplantation wait list in the United Kingdom.12 Recently based on the observation that Na inversely correlated with severity of cirrhosis, another score derived from the ratio between MELD and sodium concentration (MESO) has been proposed, but it was tested and validated in patients not listed for liver transplantation.15,16 Other MELD based models have also been devised that incorporate Na concentration and add either age10 or presence of ascites.17 However the addition of ascites in a MELD based score enhanced its prognostic ability only in patients with low standard MELD17, and its applicability to the entire spectrum of listed patients needs further assessment. To the best of our knowledge, only two studies have compared the performance of different scores. However one study suffered from a small size, whereas the other enrolled patients who were rather old for liver transplantation and mostly had HBV related cirrhosis.18 Our study compared all the latest prognostic scores predicting short term and medium term survival prognosis of chronic liver disease patients, that includes Child-Pugh, MELD, MELD-Na, updated MELD and updated MELD-Na.19 The mean MELD at registration was 15.88+5, the minimal value from the survival benefit at one year has been demonstrated.20 The etiology of cirrhosis did not modify the actual survival rate of listed patients, which then allowed an assessment of the prognostic ability of scores not influenced by the etiology of liver disease. Finally, the issue of assessing the test performances in the entire spectrum of disease severity within our patients was specifically addressed. Our discrimination analysis showed that all scores namely Child-Pugh, MELD, MELD-Na, updated MELD and updated MELD-Na predicted survival or chronic liver disease patients to same degree. The AUROC of Child Pugh, MELD, MELD-Na, updated MELD and updated MELD-Na were comparable, indicating good prognostic accuracy, so our study is in agreement with the studies of Jeong Han Kim et al (2009)19 and Laurence S et al (2009)21. Sharma et al (2009)14 recently tried to improve MELD performance by modifying the three coefficients of the formula, using data from scientific registry of transplant recipients for all listed adult candidates in the United States. However in our study updated MELD and standard MELD had comparable predictive value at 3 and 12 months. In their study such variant results could likely be explained by differences among enrolled patients. Having found that 3 months and 12 months AUROC of Child Pugh, MELD, updated MELD and updated MELD-Na were not significantly different, so any one of these scores can be used for prognostic assessment and allocation of liver transplant in chronic liver disease patients. CONCLUSION All these scoring systems were useful for predicting survival rate of chronic liver disease patients. MELD has been accepted useful mainly for predicting short term prognosis of 3 months. Our results showed that it could be also useful for long term period upto 12 months. But it is difficult to conclude that updated MELD or updated MELD-Na are superior to pre-existing prognostic tools such as MELD, MELD-Na or Child-Pugh scores. So more studies are warranted to investigate superiority of one prognostic model over the other. Acknowledgement: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. 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