A Prospective Study of Comparison Between Fine Needle Aspiration Cytology (FNAC) with Histopathological Diagnosis (HPE) in Neck Masses.

Background: FNAC is easy to perform, is minimally invasive and is economical. It has better patient compliance and the cytological diagnosis can be made before any definitive treatment is planned. Materials and methods: This prospective study was carried out in a tertiary care hospital of a medical college having 100 cases in study. The statistical analysis included sensitivity, specificity, positive predictive value, negative predictive value. Result: On cytological examination, 94/100 were benign, 6 malignant or suspicious. On HPE, 92 were benign while 5 malignant from suspicious and malignant cases leaving 3 discordant cases. Sensitivity, specificity, positive predictive value, negative predictive value which was  71.4%, 98.9%,  83.3%,97.8% respectively in our case series. Conclusion: FNAC is a safe, simple procedure. It gives a reliable pre-operative cytological diagnosis based on which surgical procedures or conservative management can be confidently executed. An attempt is made hereby to compare our results with worldwide documented literature. However pitfalls of this method should be kept in mind with careful observation and adequate clinical suspicion.

Endoscopic Thyroidectomy: A 6-Year Experience from a Tertiary Care Teaching Hospital in Western India.

Background: Minimally invasive and endoscopic surgical techniques have surpassed the conventional open thyroidectomy for the treatment of thyroid nodules. Trans-axillary, Unilateral Axillo-Breast Approach (UABA), Bilateral Axillo-Breast Approach, and Trans-Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) are the most common endoscopic procedures performed currently. This article highlights our experiences with UABA and TOETVA over a period of 6 years. Materials and Methods: Between January 2015 and December 2020, we retrospectively analyzed our experience in Endoscopic thyroidectomy with 119 patients using UABA (n = 72) and TOETVA (n = 47) in our tertiary care teaching hospital. Both approaches used the standard three-port technique. Real time angiography was performed intraoperatively using Indocyanine Green dye to delineate the vessels in all patients. Results: The mean operative time for UABA and TOETVA was 90 and 110 minutes, respectively. Estimated blood loss was 18 mL in the former and 20 mL in the latter. Temporary Recurrent Laryngeal Nerve palsy and Hypoparathyroidism were minimal with TOETVA (5 patients versus 4 patients and 7 patients versus 2 patients). Shorter duration of hospital stay was observed with UABA (3 days versus 5 days). Cosmetic satisfaction was better with TOETVA. Conclusion: Based on our 6-year experience, we propose "JJ Hospital Criteria," which we currently follow to decide which surgical approach will yield best results. UABA and TOETVA are safe, feasible, and give exceptional cosmetic satisfaction. Both approaches should be seen as complementary rather than competitive.

A survey of neurophysiological differentiation across mouse visual brain areas and timescales.

Neurophysiological differentiation (ND), a measure of the number of distinct activity states that a neural population visits over a time interval, has been used as a correlate of meaningfulness or subjective perception of visual stimuli. ND has largely been studied in non-invasive human whole-brain recordings where spatial resolution is limited. However, it is likely that perception is supported by discrete neuronal populations rather than the whole brain. Therefore, here we use Neuropixels recordings from the mouse brain to characterize the ND metric across a wide range of temporal scales, within neural populations recorded at single-cell resolution in localized regions. Using the spiking activity of thousands of simultaneously recorded neurons spanning 6 visual cortical areas and the visual thalamus, we show that the ND of stimulus-evoked activity of the entire visual cortex is higher for naturalistic stimuli relative to artificial ones. This finding holds in most individual areas throughout the visual hierarchy. Moreover, for animals performing an image change detection task, ND of the entire visual cortex (though not individual areas) is higher for successful detection compared to failed trials, consistent with the assumed perception of the stimulus. Together, these results suggest that ND computed on cellular-level neural recordings is a useful tool highlighting cell populations that may be involved in subjective perception.

Does antenatal cholecalciferol supplementation affect the mode or timing of delivery? Post hoc analyses of the MAVIDOS randomized controlled trial.

BACKGROUND: Observational studies relating maternal 25-hydroxyvitamin D status to timing and mode of delivery have reported inconsistent results. We assessed the effect of antenatal cholecalciferol supplementation on the incidence of preterm birth, delivery mode and post-partum haemorrhage (PPH). METHODS: MAVIDOS was a randomized, double-blind, placebo-controlled trial of 1000 IU/day cholecalciferol from 14 weeks' gestation until delivery. Gestational age, mode of delivery [categorized as spontaneous vaginal delivery (SVD), instrumental (including forceps and vacuum extraction) or Caesarean section] and PPH (>500 ml estimated blood loss) were determined from medical records. RESULTS: A total of 965 women participated in the study until delivery. Gestation at birth and incidence of preterm birth (cholecalciferol 5.7%, placebo 4.5%, P = 0.43) were similar between the two treatment groups. SVD (versus instrumental or Caesarean delivery) was more likely in women randomized to cholecalciferol [Relative Risk (RR) 1.13, 95% confidence interval (CI) 1.02,1.25] due to lower instrumental (RR 0.68, 95%CI 0.51,0.91) but similar risk of Caesarean delivery (RR 0.94, 95%CI 0.74,1.19). PPH was less common in women randomized to cholecalciferol [32.1% compared with placebo (38.1%, P = 0.054) overall], but similar when stratified by delivery mode. CONCLUSIONS: Antenatal cholecalciferol supplementation did not alter timing of birth or prevalence of preterm birth but demonstrated a possible effect on the likelihood of SVD.

Influence of claustrum on cortex varies by area, layer, and cell type.

The claustrum is a small subcortical structure with widespread connections to disparate regions of the cortex. However, the impact of the claustrum on cortical activity is not fully understood, particularly beyond frontal areas. Here, using optogenetics and multi-regional Neuropixels recordings from over 15,000 cortical neurons in awake mice, we demonstrate that the effect of claustrum input to the cortex differs depending on brain area, layer, and cell type. Brief claustrum stimulation, producing approximately 1 spike per claustrum neuron, affects many fast spiking (FS; putative inhibitory) but relatively fewer regular-spiking (RS; putative excitatory) cortical neurons and leads to a modest decrease in population activity in frontal cortical areas. Prolonged claustrum stimulation affects many more cortical neurons and can increase or decrease spiking activity. More excitation occurs in posterior regions and superficial layers, while inhibition predominates in frontal regions and deeper layers. These findings suggest that claustro-cortical circuits are organized into functional modules.

Pregnancy Vitamin D Supplementation and Childhood Bone Mass at Age 4 Years: Findings From the Maternal Vitamin D Osteoporosis Study (MAVIDOS) Randomized Controlled Trial.

In the Maternal Vitamin D Osteoporosis Study (MAVIDOS) randomized trial, vitamin D supplementation in pregnancy did not lead to greater neonatal bone mass across the trial as a whole, but, in a prespecified secondary analysis by season of birth, led to greater neonatal bone mass among winter-born babies. Demonstrating persistence of this effect into childhood would increase confidence in a long-term benefit of this intervention. We investigated whether antenatal vitamin D supplementation increases offspring bone mineralization in early childhood in a prespecified, single-center follow-up of a double-blinded, multicenter, randomized controlled clinical trial based in the UK (MAVIDOS). A total of 1123 women in early pregnancy with a baseline 25-hydroxyvitamin D level 25-100 nmol/L from three research centers (2008-2014) were randomized to 1000 IU/d cholecalciferol or matched placebo from 14 weeks of gestation to delivery. Offspring born at the Southampton, UK research center were assessed at age 4 years (2013-2018). Anthropometry and dual-energy X-ray absorptiometry (DXA) were performed (yielding whole body less head [WBLH] bone mineral content [BMC], areal bone mineral density [aBMD], bone area [BA], and body composition). Of 723 children, 564 (78.0%) children attended the 4-year visit, 452 of whom had a useable DXA. Maternal vitamin D supplementation led to greater WBLH aBMD in the children compared with placebo (mean [95% confidence interval {CI}]: supplemented group: 0.477 (95% CI, 0.472-0.481) g/cm2; placebo group: 0.470 (95% CI, 0.466-0.475) g/cm2, p = 0.048). Associations were consistent for BMC and lean mass, and in age- and sex-adjusted models. Effects were observed across the whole cohort irrespective of season of birth. Maternal-child interactions were observed, with a greater effect size among children with low milk intake and low levels of physical activity. Child weight, height, and body mass index (BMI) were similar by maternal randomization group. These findings suggest a sustained beneficial effect of maternal vitamin D supplementation in pregnancy on offspring aBMD at age 4 years, but will require replication in other trials. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Measuring Stimulus-Evoked Neurophysiological Differentiation in Distinct Populations of Neurons in Mouse Visual Cortex.

Despite significant progress in understanding neural coding, it remains unclear how the coordinated activity of large populations of neurons relates to what an observer actually perceives. Since neurophysiological differences must underlie differences among percepts, differentiation analysis-quantifying distinct patterns of neurophysiological activity-has been proposed as an "inside-out" approach that addresses this question. This methodology contrasts with "outside-in" approaches such as feature tuning and decoding analyses, which are defined in terms of extrinsic experimental variables. Here, we used two-photon calcium imaging in mice of both sexes to systematically survey stimulus-evoked neurophysiological differentiation (ND) in excitatory neuronal populations in layers (L)2/3, L4, and L5 across five visual cortical areas (primary, lateromedial, anterolateral, posteromedial, and anteromedial) in response to naturalistic and phase-scrambled movie stimuli. We find that unscrambled stimuli evoke greater ND than scrambled stimuli specifically in L2/3 of the anterolateral and anteromedial areas, and that this effect is modulated by arousal state and locomotion. By contrast, decoding performance was far above chance and did not vary substantially across areas and layers. Differentiation also differed within the unscrambled stimulus set, suggesting that differentiation analysis may be used to probe the ethological relevance of individual stimuli.

Bone turnover in pregnancy, measured by urinary CTX, is influenced by vitamin D supplementation and is associated with maternal bone health: findings from the Maternal Vitamin D Osteoporosis Study (MAVIDOS) trial.

BACKGROUND: The pattern of change in maternal bone turnover throughout pregnancy is poorly characterized. OBJECTIVES: We investigated changes across pregnancy in a marker of maternal bone resorption, urinary C-terminal telopeptide of type I collagen (CTX), the influence of gestational vitamin D supplementation, and associations between CTX and maternal postnatal bone indices. METHODS: MAVIDOS (the Maternal Vitamin D Osteoporosis Study) is a randomized, double-blind, placebo-controlled trial of 1000 IU cholecalciferol/d compared with placebo from 14 weeks of gestation to birth. Maternal second-void urinary α- and ß-CTX were measured (ELISA) at 14 and 34 weeks of gestation; DXA was performed within 2 wk postpartum. The Mann-Whitney Rank Sum test, Spearman's rank correlation, and linear regression were used to compare median CTX values within and between groups from early to late pregnancy, and associations with maternal bone outcomes. RESULTS: In total, 372 women had CTX and 25-hydroxyvitamin D [25(OH)D] measured in early and late pregnancy. CTX at 14 and 34 weeks of gestation were correlated in both placebo (r = 0.31) and cholecalciferol (r = 0.45) groups (P < 0.0001). Median CTX increased from 14 to 34 weeks of gestation in both groups (n = 372 total) [placebo (n = 188): from 223.6 to 449.7 µg/mmol creatinine; cholecalciferol (n = 184): from 222.3 to 419.3 µg/mmol creatinine; P = 0.03 for placebo compared with cholecalciferol difference in CTX at 34 weeks of gestation]. The conditional mean ± SD increase in CTX [z-score (SD)] from early to late pregnancy was greater in the placebo group (n = 188) than in the cholecalciferol group (n = 184) (placebo: 0.16 ± 0.92; cholecalciferol: -0.16 ± 1.06; P-difference < 0.01). Higher CTX at 34 weeks of gestation was associated, similarly in both groups, with lower maternal total hip and lumbar spine bone mineral content and bone mineral density (BMD) (e.g., lumbar spine BMD: ß = -0.02 g · cm-2 · SD-1 increase in CTX; 95% CI: -0.027, -0.002 g · cm-2 · SD-1; P = 0.02, n = 283). CONCLUSIONS: Maternal urinary CTX, a bone resorption marker, rises through pregnancy, although to a lesser degree with gestational cholecalciferol supplementation, and is inversely associated with maternal bone mass postpartum.This trial was registered at www.isrctn.com as ISRCTN 82927713 and eudract.ema.europa.eu as EudraCT 2007-001716-23.

Endoscopic parathyroidectomy: a retrospective review of 27 cases.

BACKGROUND: Primary hyperparathyroidism is a common endocrine disorder with adenomas being the most frequent cause. The condition is conventionally treated by a bilateral neck exploration through a cervical incision with removal of the affected glands. Intra-operative parathyroid hormone (IOPTH) monitoring and pre-operative Tc99m MIBI scans are facilitating focused approaches like minimally invasive video-assisted parathyroidectomy (MiVAP) and totally endoscopic parathyroidectomy (TOEP). METHODS: Patients with primary hyperparathyroidism were tested for location of diseased gland and accordingly selected for endoscopic parathyroidectomy by either trans-vestibular or trans-axillary approach. Those having undergone prior neck surgery or irradiation and those with an enlarged thyroid were excluded. All patients underwent IOPTH measurement to confirm the completeness of diseased gland resection. RESULTS: Eleven cases meeting selection criteria underwent endoscopic trans-vestibular parathyroidectomy and 16 cases underwent endoscopic trans-axillary parathyroidectomy. The mean operative time and blood loss were 104 min and 34 mL in trans-vestibular approach, respectively, while they were 47 min and 68 mL for the trans-axillary approach. All patients had post-operative resolution of hypercalcaemia. A single conversion to cervical approach was performed due to unsatisfactory IOPTH fall. A single patient suffered transient recurrent laryngeal nerve palsy which resolved with steroids. CONCLUSION: Endoscopic parathyroidectomy is a safe and feasible surgical procedure when combined with pre-operative imaging and intra-operative parathyroid hormone monitoring. There is a steady rise in the number of patients with primary hyperparathyroidism, a majority of whom have solitary gland affliction. Focused exploration is the current standard, wherein endoscopic surgery can be an important tool to improve outcomes.

Bochdalek's hernia in an elderly male - A case report.

Diaphragmatic hernia is protrusion of the abdominal contents into the thoracic cavity. It is a congenital defect of the diaphragm. It is most commonly encountered in infancy but rarely in adults. Here, we would like to present a rare case of 75-year-old male with Bochdalek's hernia. The patient had presented for the first time in his life for his symptoms. This case report emphasises the rare presentation of Bochdalek's hernia in an elderly male. The patient was treated using minimal access surgery i.e., laparoscopic approach and hence had a better post-operative outcome.

Combined laparoscopic and thoracoscopic approach for tension gastrothorax in a foramen of Bochdalek hernia.

INTRODUCTION: The incidence of Bochdalek hernias in adults is much more than previously reported. Though most of these are asymptomatic. Tension gastrothorax is a rare complication of these. Literature about the endoscopic management of a tension gastrothorax is extremely sparse. In this case report, we describe how we combined laparoscopy and thoracoscopy in an emergency setting to manage a case of tension gastrothorax with an underlying Bochdalek hernia defect in an adult. PATIENT PROFILE: A 27 year old male presented to our emergency with tension gastrothorax and a gastric volvulus with an underlying Bochdalek hernia defect, exhibiting the classical Borchardt's triad. The patient underwent an emergency surgery, through a minimally invasive approach wherein the herniated contents were reduced, the gastric volvulus detorted and a repair of the diaphragmatic defect was performed. His post-operative course was uneventful. DISCUSSION: Tension gastrothorax, is a diagnostic challenge as an air-fluid level in the thorax on radiology with worsening respiration causes as many as 38% of these cases to be misdiagnosed as tension pneumothorax, hydro-pneumothorax, hemothorax, empyema, effusion or pneumonia. Various techniques of decompression have been described in literature but, employing those, in case of a misdiagnosis may have catastrophic outcomes. CONCLUSION: We strongly recommend employing a combined laparoscopic and thoracoscopic approach for an emergency repair of a tension gastrothorax in a hemodynamically stable patient as, it poses all the advantages of minimal access surgery and is available, at smaller centres, even in an emergency.

Cooperation mitigates diversity loss in a spatially expanding microbial population.

The evolution and potentially even the survival of a spatially expanding population depends on its genetic diversity, which can decrease rapidly due to a serial founder effect. The strength of the founder effect is predicted to depend strongly on the details of the growth dynamics. Here, we probe this dependence experimentally using a single microbial species, Saccharomyces cerevisiae, expanding in multiple environments that induce varying levels of cooperativity during growth. We observe a drastic reduction in diversity during expansions when yeast grows noncooperatively on simple sugars, but almost no loss of diversity when cooperation is required to digest complex metabolites. These results are consistent with theoretical expectations: When cells grow independently from each other, the expansion proceeds as a pulled wave driven by growth at the low-density tip of the expansion front. Such populations lose diversity rapidly because of the strong genetic drift at the expansion edge. In contrast, diversity loss is substantially reduced in pushed waves that arise due to cooperative growth. In such expansions, the low-density tip of the front grows much more slowly and is often reseeded from the genetically diverse population core. Additionally, in both pulled and pushed expansions, we observe a few instances of abrupt changes in allele fractions due to rare fluctuations of the expansion front and show how to distinguish such rapid genetic drift from selective sweeps.

Gestational Vitamin D Supplementation Leads to Reduced Perinatal RXRA DNA Methylation: Results From the MAVIDOS Trial.

We have previously demonstrated inverse associations between maternal 25(OH)-vitamin D status and perinatal DNA methylation at the retinoid-X-receptor-alpha (RXRA) locus and between RXRA methylation and offspring bone mass. In this study, we used an existing randomized trial to test the hypothesis that maternal gestational vitamin D supplementation would lead to reduced perinatal RXRA locus DNA methylation. The Maternal Vitamin D Osteoporosis Study (MAVIDOS) was a multicenter, double-blind, randomized, placebo-controlled trial of 1000 IU/day cholecalciferol or matched placebo from 14 weeks' gestation until delivery. Umbilical cord (fetal) tissue was collected at birth and frozen at -80°C (n = 453). Pyrosequencing was used to undertake DNA methylation analysis at 10 CpG sites within the RXRA locus (identified previously). T tests were used to assess differences between treatment groups in methylation at the three most representative CpG sites. Overall, methylation levels were significantly lower in the umbilical cord from offspring of cholecalciferol-supplemented mothers, reaching statistical significance at four CpG sites, represented by CpG5: mean difference in % methylation between the supplemented and placebo groups was -1.98% (95% CI, -3.65 to -0.32, p = 0.02). ENCODE (Encyclopedia of DNA Elements) evidence supports the functionality of this locus with strong DNase hypersensitivity and enhancer chromatin within biologically relevant cell types including osteoblasts. Enrichment of the enhancer-related H3K4me1 histone mark is also seen in this region, as are binding sites for a range of transcription factors with roles in cell proliferation, response to stress, and growth factors. Our findings are consistent with previous observational results and provide new evidence that maternal gestational supplementation with cholecalciferol leads to altered perinatal epigenetic marking, informing mechanistic understanding of early life mechanisms related to maternal vitamin D status, epigenetic marks, and bone development. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals Inc.

Laparoscopic lateral pancreaticojejunostomy: an evolution to endostapled technique.

BACKGROUND: Chronic pancreatitis (CP) is a debilitating condition resulting in severe pain with progressive deterioration of pancreatic function. "Tropical" pancreatitis represents a variant of the disease with widely dilated ducts, numerous calculi, and few strictures. Traditionally, modified Puestow's procedure has been the treatment of choice for a dilated pancreatic ductal system. However, it has only recently been adapted to laparoscopic approach which is a technically demanding procedure primarily due to need for extensive intra-corporeal suturing. METHODS: Symptomatic cases of CP presenting at our center with minimum 8 mm mean ductal diameter at body and head were selected for laparoscopic modified Puestow's procedure. Those with prior pancreatic surgery, pancreatic head masses, endoscopic pancreatic stenting, and portal hypertension were excluded. Twenty-eight cases meeting selection criteria underwent a laparoscopic procedure. RESULTS: Seven patients (25%) underwent a stapled pancreaticojejunal anastomosis, 17 (60.7%) received a sutured anastomosis. Four patients (14.3%) were converted to open surgery due to failure to localize the pancreatic duct with percutaneous needle aspiration. Of those patients who underwent a successful laparoscopic procedure, a single patient developed a pancreatic fistula which resolved spontaneously; another patient had a difficult post-operative course with prolonged intensive care. We suffered no mortality within the series and no patient had any long-term disability. Anastomotic patency rates of 100% were achieved by the third post-operative month. CONCLUSION: Lateral pancreaticojejunostomy is an effective surgical management for CP with a dilated ductal system. Its laparoscopic adoption is the rational next surgical step. It allows effective duct decompression with low mortality and morbidity. The procedure demands an advanced surgical skill set with an emphasis on intra-corporeal suturing. Those patients suffering from tropical CP with wide ductal dilatation greater than 12 mm are suited to an endostapled anastomosis which helps significantly reduce operative time without any corrosion of outcomes.

Role of indo-cyanine green (ICG) fluorescence in laparoscopic adrenalectomy: a retrospective review of 55 Cases.

BACKGROUND: Indo-Cyanine Green Fluorescence is an emerging technology with more frequent use in laparoscopic and robotic surgery. It relies on near-infrared (NIR) fluorescence to demonstrate tissue perfusion with demarcation of tissue planes and vascular pedicles. The aim of the study is to evaluate the role of this technology in laparoscopic adrenalectomy (LA). METHODS: 55 patients underwent laparoscopic adrenalectomy using NIR Fluorescence enabled laparoscope. All cases received a standard initial dose of 5-mg dye to aid tissue visualization. Surgery proceeded with "fluorescence mode" demonstrating real-time NIR images superimposed on standard white-light imaging. The timing, number of doses were dictated by the operating surgeon, which were recorded and correlated with intra-operative fluorescence visualization. RESULTS: 54 patients underwent successful LA, with one conversion in a case of large pheochromocytoma due to difficult hemostasis. The lag between ICG administration and visualization of adrenal fluorescence varied between 30 and 75 s. The total duration of adrenal parenchymal fluorescence after a single dose did not exceed 15 min in our series. Average total administered dose was 14.4 mg. We suffered no mortality. There were no adverse effects due to the dye. 5 patients suffered Grade I complications, with one patient suffering Grade II and IV complication each, as per Clavien-Dindo Classification. Final histopathology demonstrated pheochromocytoma, adrenocortical adenoma, adrenocortical carcinoma, cushing's adenoma, aldosteronoma, and myelolipoma. CONCLUSION: We describe our initial positive experience with ICG fluorescence in LA, with a detailed description of dye administration in our study. The technology offers real-time differentiation of tissues and identification of vascular structures, providing immediate guidance during surgery. Further evaluation of its role in adrenocortical malignancy is warranted. NIR fluorescence is a safe, useful addition in laparoscopic adrenalectomy which will undergo further refinement over time.

Umbilical Hernia with Evisceration. Two Cases and a Review of the Literature.

BACKGROUND: Evisceration of umbilical hernias is an uncommon occurrence whereby the hernial contents break through the skin overlying the sac and skin. Irrespective of cause, sudden evisceration of an umbilical hernia is associated with deterioration and a poor outcome. CASE REPORTS: Our first case was a 42-year-old woman who presented with sudden outpouring of fluid from the umbilicus with omental evisceration. Further evaluation revealed hepatic decompensation caused by hepatitis C infection belonging to Child-Turcotte-Pugh class C. After stabilizing her hemodynamically, she underwent a partial omentectomy with primary repair of umbilical defect. The patient's postoperative course was challenging. She died of septicemia and acute renal failure after 5 days. Our second case was a 40-year-old man who suffered from alcohol-induced cirrhosis, presenting with omental evisceration, belonging to Child-Turcotte-Pugh class C. We performed a primary repair of the hernial defect with peritoneovenous shunting for his intractable ascites. Upper gastrointestinal endoscopy revealed grade I esophageal varices. The patient succumbed to acute variceal hemorrhage with acute renal failure 18 days later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In an emergent setting with multiple factors influencing final surgical outcome, it is imperative that management be tailored for each patient. Those with severe encephalopathy or cardiovascular instability must be stabilized before surgical intervention. Central venous and blood pressures need to be closely monitored during resuscitation, as fervent fluid administration may predispose to variceal hemorrhage. It may be prudent to follow the principle of hypotensive resuscitation as in acute trauma cases.

When a cure becomes the pathology: mechanical bowel obstruction due to herbal pharmacobezoar. A case report with review of literature.

Bezoars are intra-luminal concretions of ingested material which accumulate within the bowel. They are termed pharmacobezoars when the constituent material is drugs. We report a 64-year-old female with abdominal pain and obstipation for 3 days. Patient had completed anti-tuberculous combination therapy for suspected abdominal tuberculosis 25 years ago. She exhibited features of shock with a right iliac fossa lump. Abdominal X-ray displayed multiple air-fluid levels with densely cluttered radio-opacities in the right lower quadrant. Laparotomy revealed a palpable mid-ileal intra-luminal lump, adherent to the ascending colon and proximal ileum necessitating resection. Ex vivo examination of resected specimen revealed numerous tablets aggregating proximal to an ileal stricture. The patient post-operatively confirmed the tablets resembled the herbal laxatives she had been consuming. Pharmacobezoars can lead to subacute intestinal obstruction. Numerous drugs have been implicated. Patients with partial gastrectomy and vagotomy are at risk. CT is the pre-eminent diagnostic modality. The treatment options for pharmacobezoars include lavage, endoscopic retrieval, in addition to surgery. Pharmacobezoars need a high index of suspicion for pre-operative diagnosis. A detailed history and correlation with radioimaging can offer important cues. One can prevent pharmacobezoars by abstaining from unwarranted medications and identifying those at risk.

Response to Antenatal Cholecalciferol Supplementation Is Associated With Common Vitamin D-Related Genetic Variants.

Context: Single-nucleotide polymorphisms (SNPs) in genes related to vitamin D metabolism have been associated with serum 25-hydroxyvitamin D [25(OH)D] concentration, but these relationships have not been examined following antenatal cholecalciferol supplementation. Objective: To determine whether SNPs in DHCR7, CYP2R1, CYP24A1, and GC are associated with the response to gestational cholecalciferol supplementation. Design: Within-randomization group analysis of the Maternal Vitamin D Osteoporosis Study trial of antenatal cholecalciferol supplementation. Setting: Hospital antenatal clinics. Participants: In total, 682 women of white ethnicity (351 placebo, 331 cholecalciferol) were included. SNPs at rs12785878 (DHCR7), rs10741657 (CYP2R1), rs6013897 (CYP24A1), and rs2282679 (GC) were genotyped. Interventions: 1000 IU/d cholecalciferol from 14 weeks of gestation until delivery. Main Outcome Measure: 25(OH)D at randomization and 34 weeks of gestation were measured in a single batch (Liaison; Diasorin, Dartford, UK). Associations between 25(OH)D and the SNPs were assessed by linear regression using an additive model [ß represents the change in 25(OH)D per additional common allele]. Results: Only rs12785878 (DHCR7) was associated with baseline 25(OH)D [ß = 3.1 nmol/L; 95% confidence interval (CI), 1.0 to 5.2 nmol/L; P < 0.004]. In contrast, rs10741657 (CYP2R1) (ß = -5.2 nmol/L; 95% CI, -8.2 to -2.2 nmol/L; P = 0.001) and rs2282679 (GC) (ß = 4.2 nmol/L; 95% CI, 0.9 to 7.5 nmol/L; P = 0.01) were associated with achieved 25(OH)D status following supplementation, whereas rs12785878 and rs6013897 (CYP24A1) were not. Conclusions: Genetic variation in DHCR7, which encodes 7-dehyrocholesterol reductase in the epidermal vitamin D biosynthesis pathway, appears to modify baseline 25(OH)D. In contrast, the response to antenatal cholecalciferol supplementation was associated with SNPs in CYP2R1, which may alter 25-hydroxylase activity, and GC, which may affect vitamin D binding protein synthesis or metabolite affinity.

Determinants of the Maternal 25-Hydroxyvitamin D Response to Vitamin D Supplementation During Pregnancy.

CONTEXT: Current approaches to antenatal vitamin D supplementation do not account for interindividual differences in 25-hydroxyvitamin D (25(OH)D) response. OBJECTIVE: We assessed which maternal and environmental characteristics were associated with 25(OH)D after supplementation with cholecalciferol. DESIGN: Within-randomization-group analysis of participants in the Maternal Vitamin D Osteoporosis Study trial of vitamin D supplementation in pregnancy. SETTING: Hospital antenatal clinics. PARTICIPANTS: A total of 829 pregnant women (422 placebo, 407 cholecalciferol). At 14 and 34 weeks of gestation, maternal anthropometry, health, and lifestyle were assessed and 25(OH)D measured. Compliance was determined using pill counts at 19 and 34 weeks. INTERVENTIONS: 1000 IU/d of cholecalciferol or matched placebo from 14 weeks of gestation until delivery. MAIN OUTCOME MEASURE: 25(OH)D at 34 weeks, measured in a single batch (Diasorin Liaison). RESULTS: 25(OH)D at 34 weeks of gestation was higher in the women randomized to vitamin D (mean [SD], 67.7 [21.3] nmol/L) compared with placebo (43.1 [22.5] nmol/L; P < .001). In women randomized to cholecalciferol, higher pregnancy weight gain from 14 to 34 weeks of gestation (kg) (ß = -0.81 [95% confidence interval -1.39, -0.22]), lower compliance with study medication (%) (ß = -0.28 [-0.072, -0.48]), lower early pregnancy 25(OH)D (nmol/L) (ß = 0.28 [0.16, 0.40]), and delivery in the winter vs the summer (ß = -10.5 [-6.4, -14.6]) were independently associated with lower 25(OH)D at 34 weeks of gestation. CONCLUSIONS: Women who gained more weight during pregnancy had lower 25(OH)D in early pregnancy and delivered in winter achieved a lower 25(OH)D in late pregnancy when supplemented with 1000 IU/d cholecalciferol. Future studies should aim to determine appropriate doses to enable consistent repletion of 25(OH)D during pregnancy.

Triorchidism: Presenting as Undescended Testis in a Case of Indirect Inguinal Hernia.

Triorchidism is the commonest variety of polyorchidism, an entity with more than two testis is an extremely rare congenital anomaly of the testis. Although excision of the abnormal testis is a safer alternative proposed, recent literature suggests more conservative approach in normal testes with watchful regular follow up to screen for malignancy. This case presented as a left inguinal swelling diagnosed as indirect left inguinal hernia. The left side testis was of smaller size (about half) with normal sperm count, morphology and motility. Intraoperatively indirect inguinal hernia was noted with supernumerary testis at deep ring in addition to normal left testis in left scrotal sac. The ectopic testis were small (2.5×2.5×1 cm) lacking epididymis and with short vas deferens. An evident normal semen analysis and varied anatomy, the decision for orchidectomy of ectopic testis was taken. The histopathological finding was consistent with arrest in germ cell development.