Occurrence, Source and Dietary Exposure of Toxic and Essential Elements in the Indian Food Basket.

In this study, representative urban and peri-urban Indian food baskets have been studied for the presence of toxic and essential elements. The concentration of target toxic and essential elements was used to estimate dietary intakes (EDIs) and health risks. Across all food matrices, toxic elements like Cd and Pb were dominant. The highest concentrations of the target elements were found in vegetables, with Cd, Pb, and Ni being beyond permissible limits of the Food and Agriculture Organization of the United Nations and the World Health organization (0.05 mg/kg, 0.1 mg/kg, and 1.5 mg/kg, respectively) in okra, spinach, and cauliflower. The sum of concentrations of the toxic elements (As, Ni, Hg, Cr, Cd, Pb) in vegetables had a range of 0.54-12.08 mg/kg, the highest sum was found in spinach (median 12.08 mg/kg), followed by okra (median 1.68 mg/kg). The EDI was observed for vegetables with a contribution as high as 92% for Cd. Dairy products were found with the highest loading for Ni with a dietary intake of 3.1 mg/kg/day for adults and twice as much for children. Carcinogenic risk for Ni was the highest and found above the threshold for all food categories, as was the case with As. Cumulative carcinogenic and non-carcinogenic risks were mostly contributed by milk and vegetables, in particular, spinach.

Gastric Outlet Obstruction: Don't Miss Duodenal Tuberculosis.

We report a case of isolated duodenal tuberculosis (TB) in a patient who presented with features of gastric outlet obstruction. The diagnosis was made on repeat endoscopic duodenal biopsy after initial histopathology failed to reveal the diagnosis. The patient recovered with antitubercular therapy. The index of suspicion has to be high in TB endemic countries as clinical, radiological, and endoscopic features are nonspecific.

Understanding population structure and detection of QTLs for curding-related traits in Indian cauliflower by genotyping by sequencing analysis.

Curd initiation and development are complex traits and highly responsive for different temperature ranges in cauliflower. The present study was aimed to identify QTLs for eight traits associated with curding behaviour in diverse germplasm of Indian cauliflower. For this, 92 genotypes of cauliflower and 2 each of tropical broccoli and cabbage were genotyped through genotyping by sequencing (GBS). It generated ≈302 million reads (9.1226E + 10 bp) and identified 35,381 SNPs, maximum from chromosome 3 (4735) with a mean value of 3981.1 SNPs. Ts/Tv ratio was 1.74, suggesting transition bias. STRUCTURE analysis revealed delta value of K = 4 and four subpopulations and prominence of population admixture. In total, 121 significant SNPs were detected for eight traits, 38 for Delhi (North Indian plain) and 83 for Barapani (North-East India). Twelve QTLs were detected for traits associated with regulation of curd formation and development, five of which were for marketable curd length, curd width, days to 50% curd harvest and marketable curd weight from Delhi region and seven for curd length, curd width, days to 50% curd harvest, gross plant weight, leaf length, marketable/net curd weight and number of leaves per plant for Barapani area of North East India. The SNPs identified will be useful for development of markers for curding-related traits and their use in breeding varieties with wider curding plasticity.

Association of endotoxaemia & gut permeability with complications of acute pancreatitis: Secondary analysis of data.

Background & objectives: In acute pancreatitis (AP) gut barrier dysfunction is considered as an important predisposing factor leading to increased intestinal permeability (IP). In this study a pooled analysis of data published in our previous four studies on various aspects of gut permeability and endotoxaemia in patients with AP was attempted to find an association between increased IP and severity of disease and associated complications. Methods: This study was a pooled analysis of data of four previously published prospective studies on AP. Gut permeability, assessed by lactulose/mannitol excretion in urine and endotoxin core antibodies type IgG and IgM (EndoCab IgG and IgM) were measured on days zero and seven (D0 and D7) of admission. All patients received standard treatment of AP. We studied whether IgG and IgM anti-endotoxin titres and lactulose-mannitol ratio (LMR) at admission and D7 were associated with organ failure, infection and mortality. Results: The titres of anti-endotoxin IgG and IgM were lower in all patients of AP (n=204), both in mild AP (n=24) and severe AP (n=180) in the first week, compared to controls (n=15). There was no significant difference in serum IgG and IgM anti-endotoxin levels and LMR at baseline and at D7 among patients with organ failure, infection and mortality. Interpretation & conclusions: Our findings showed that serum IgG and IgM anti-endotoxin titres and LMR at admission and at day 7 were not associated with organ failure, infection, and death of patients with AP.

Clinical Profile, Severity and Outcome of Acute Upper Gastrointestinal Bleeding in Elderly Patients Compared to Non-elderly Patients: A Prospective Observational Study.

AIM: To determine the clinical profile, severity and outcome of acute upper gastrointestinal bleeding (UGIB) in elderly subjects (>60 years) compared to the non elderly ones (<60 years). METHODS: In a prospective observational study, 380 consecutive adult patients presenting with acute UGIB were enrolled. Patients were divided into two groups: elderly (≥60 years) and non-elderly (<60 years). RESULTS: Out of 380 patients, 254(66.84%) patients were non-elderly and 126(33.15%) patients were elderly. The proportion of patients with co-morbidity and consumption of non-steroidal anti-inflammatory drugs was higher among elderly patients. The commonest mode of presentation was hematemesis and melena in the both groups, while isolated hematochezia (29% vs. 1.9%, p<0.01) was more common in elderly group. The variceal bleeding was significantly higher among non-elderly group (38.1% vs. 18.2%, p<0.01) and bleeding from gastric or duodenal ulcer was the predominant cause of bleeding among elderly group (65% vs. 43% p<0.01). The proportion of patients with tachycardia (68.2% vs. 20%, p<0.01), postural hypotension (29.3% vs. 14.9%, p<0.01) and blood transfusion requirement of 4 units or more (20.2% vs. 10.1%, p<0.01) was significantly higher among elderly group than in non-elderly group. Despite similar re-bleeding rates, mortality rate was significantly higher in elderly patients compared to the non-elderly patients (10.32% vs. 1.94%, p<0.01). CONCLUSION: Nearly 33% of the patients with acute UGIB are over 60 years old. The severity of bleeding and mortality rates was higher in elderly in comparison to non-elderly patients.

Self-Expanding Metallic Stents (SEMS) in Inoperable Esophageal Cancer: A Prospective Analysis of Morbidity and Survival Outcomes.

BACKGROUND: Palliative treatment for inoperable esophageal cancers by self-expanding metallic stents (SEMS) overcomes disease-related symptoms, preserves the quality of life, and prolongs survival. The aim of this study was to determine dysphagia relief, complications, and patient survival after SEMS in patients with inoperable esophageal cancer. METHODS: This is a hospital-based open cohort study conducted over 9 years between January 1, 2009, and December 31, 2017, from the Sub-Himalayan region of the Indian subcontinent. The last patient was recruited on November 16, 2017 and the minimum of follow-up was either death or survival till December 31, 2017. All the patients attending gastroenterology clinic or admitted in medical wards and fulfilling the definition of inoperable esophageal cancer, subsequently treated with SEMS were included. Data were prospectively gathered on demography, dysphagia scores, morbidity, mortality, and survival outcomes. Follow-ups were done during hospital visits or through a telephonic conversation with the patient and/or caregiver. RESULTS: Of 239 patients, 147 (61.5%) were male and 92 (38.5%) were female. Most of the patients (60.7%) are in the age group of 51-70 years. Squamous cell carcinoma (SCC) was diagnosed in 205 (85.7%) and adenocarcinoma (ADC) in 34 (14.2%). Lower one-third was the most common site of tumor and observed in 125 (52.3%) patients. ADC was diagnosed equally in males and females and the mean age of presentation with ADC was equal to SCC. All the patients had dysphagia score 4, which improved to score 1 after SEMS insertion. Females had better survival than that of males. The difference was found to be statistically significant. CONCLUSION: SEMS effectively reduced dysphagia in inoperable esophageal cancer. Better survival rates were observed in females than males.

Clinical Profile and Outcome of Acute Pancreatitis: A Hospital-Based Prospective Observational Study in Subhimalayan State.

Background: Prospective and population-based studies on the incidence of acute pancreatitis (AP) are lacking. We aimed to determine the incidence, etiology, severity, and outcome of AP. Materials and Methods: This was an observational prospective study done on 123 patients with AP during one year period in IGMC, Hospital Shimla. Detailed Clinical history was recorded and examination and lab investigations were done. Severity of AP was assessed using modified Atlanta classification. Results: In this study, 123 patients were included- 89 men (72.35%) and 34 women (27.65%). Median age of presentation was 42 years. The most common presentation was abdominal pain followed by vomiting. The major etiological groups were as follows: alcohol 73 cases (59.3%), gallstones 40, (35.6%); postendoscopic retrograde cholangio-pancreatography 1 (0.8%), hypertriglyceridemia 3 (2.9%), autoimmune 1 (0.8%) and idiopathic 5 cases (4%). Alcohol was the most common cause of AP and followed by gallstone. Mortality was seen in 7(5.7%) patients. Out of seven patients who died in hospital, 5(71.42%) had severe pancreatitis and 2(28.57%) patients had moderately severe pancreatitis. When compared, patients with BMI ≥25, HCT≥44% and CRP ≥150mg/l had an increased risk of developing a severe form of AP. Conclusions: Alcohol and gallstones were the most common etiology of AP. HCT, CRP and BMI done at admission are useful predictors of severe pancreatitis.

A study on the etiology of cirrhosis of liver in adults living in the Hills of Himachal Pradesh, India.

Aim: Cirrhosis of the liver is an important cause of morbidity and mortality in India. Currently no study exists on the disease from Himachal Pradesh, India. The purpose of this study was to evaluate epidemiological data on the etiological profile of cirrhosis of the liver in adults in a tertiary care hospital in a northern hilly state of Western Himalayas. Materials and Methods: A hospital based, cross sectional, observational study was conducted in the department of Medicine and Gastroenterology in a tertiary care centre of Himachal Pradesh, located in northern India from 1st June, 2012 to 31st May, 2013. In total, 178 patients who were diagnosed with cirrhosis on the basis of history, physical examination, biochemistry and radiology, and of age >18 years were included in the study. Detailed history, examination and investigations were carried out in each case as per protocol. Results: Alcohol was the leading cause of cirrhosis in our study (62.9%), hepatitis B was the second(10.1%), Non-Alcoholic Steatohepatitis (NASH) was the third (7.9%), and autoimmune the fourth (3.9%) most common cause for cirrhosis. Hepatitis C was present in 2.8% of patients as a cause of cirrhosis. Wilson disease and cardiac cirrhosis were present in one patient each. In 9.6% the etiology was cryptogenic. Conclusion: The study identified alcohol as the leading cause of cirrhosis among people in the state. Measures for taking care of preventable risk factors are desired.

Acute kidney injury in acute liver failure: A narrative review.

Acute kidney injury (AKI) is a frequent complication of acute liver failure (ALF) and it worsens the already worse prognoses of ALF. ALF is an uncommon disease, with varying etiologies and varying definitions in different parts of the world. There is limited literature on the impact of AKI on the outcome of ALF with or without transplantation. The multifaceted etiology of AKI in ALF encompasses factors such as hemodynamic instability, systemic inflammation, sepsis and direct nephrotoxicity. Indications of renal replacement therapy (RRT) for AKI in ALF patients extend beyond the conventional criteria for dialysis and continuous renal replacement therapy (CRRT) may have a role in transplant-free survival or bridge to liver transplantation (LT). LT is a life-saving option for ALF, so despite somewhat lower survival rates of LT in ALF patients with AKI, LT is not usually deferred. In this review, we will discuss the guidelines' recommended definition and classification of AKI in ALF, the impact of AKI in ALF, the pathophysiology of AKI and the role of CRRT and LT in ALF patients with AKI.

Sarcopenia in cirrhosis: Unraveling the prevalence and relationships with liver disease severity and complications.

BACKGROUND AND OBJECTIVES: Sarcopenia in cirrhosis is associated with poor survival and adverse pre and post-transplant outcomes. The study aimed at determining the prevalence of sarcopenia and its association with the severity, complications and etiology of liver disease. METHODS: As many as 416 cirrhotic patients who met the inclusion criteria underwent muscle strength testing using a dynamometer. As many as 109 probable sarcopenia patients underwent computed tomography (CT) scan to measure skeletal muscle index (SMI) at the L3 vertebral level and gait-speed testing. The gender-specific cut-offs used to define sarcopenia were an SMI of 36.54 cm2/m2 in males and 30.21 cm2/m2 in females. A gait speed ≤ 0.8 m/s was taken as a cut-off to define severe sarcopenia in both genders. RESULTS: The mean age was 54.7 ± 9.51 years and male:female ratio was 2.2:1.The mean body mass index (BMI) was 24.2 ± 1.34 kg/m2. Alcohol and non-alcoholic steatohepatitis (NASH) were the two most common etiologies (45.9% and 31.2%). The proportion of patients belonging to Child-Pugh class A, B and C was 26.6%, 48.6% and 24.8%, respectively. Forty out of 109 (36.7%) patients had a model for end-stage liver disease (MELD) > 14. Ascites, upper gastrointestinal bleeding and hepatic encephalopathy (HE) were present in 59 (54.1%), 60 (55.0%) and 24 (22.0%) patients, respectively. The prevalence of probable sarcopenia, sarcopenia and severe sarcopenia was found to be 26.20%, 10.09% and 6.73%, respectively. Sarcopenia and severe sarcopenia were associated with Child-Pugh class (p < 0.001, p < 0.001), MELD (p = 0.007, 0.002), upper gastrointestinal bleed (p = 0.007, 0.004), ascites (p = 0.038, 0.025) and HE (0.001, < 0.001). CONCLUSION: The prevalence of sarcopenia and severe sarcopenia was found to be 10.09% and 6.73%, respectively. Sarcopenia and severe sarcopenia had a significant association with the severity and complications of cirrhosis. However, no association was observed with etiology of liver disease.

Commercial suitability and characterization of newly developed Erucastrum canariense (Can) sterile cytoplasm based cytoplasmic male sterile (CMS) lines in Indian cauliflower.

The study presents the first to characterize novel Erucastrum canarianse Webb and Berthel (or Can) sterile cytoplasm-based CMS lines in Indian cauliflower (Brassica oleracea var. botrytis L.) and investigating their commercial suitability. Eleven Can-based CMS lines were examined for 12 agro-morphological and yield traits,18 floral traits, four seed yield traits together with three each of the Ogura (source: wild Japanese Radish) and Tour (Source: Brassica tournefortii) cytoplasms. All of the recorded floral and seed traits showed significant (P > 0.05) differences between the CMS lines of each group. Agro-morphological and yield traits in CMS lines and their maintainers, however, were non-significantly different. All the Can- and Ogura-based CMS lines showed flowering and appropriate seed formation by natural cross-pollination. Only two Tour cytoplasm-based CMS lines, Tour (DC-41-5) and Tour (DC-67), produced the smallest malformed flowers and stigma. The highest seed yield per plant in CMS lines was in Ogu (DC-98-4) and the lowest in Tour (DC-67). P14 and P15, two polymorphic mtDNA markers, were discovered for the Can CMS system for early detection. Five primers (ITS5a-ITS4, atpF-atpH, P16, rbeL and trnL), along with their maintainers, were sequenced and aligned to detect nucleotide changes including as additions and or deletions at different positions. The newly introduced E. canariense sterile cytoplasm-based CMS system in cauliflower is the subject of the first comprehensive report, which emphasises their potential as a further stable and reliable genetic mechanism for hybrid breeding.

Hepatitis B in Trans-Himalayan Tribal Population: High Prevalence, High Pediatric Burden, Virologic Patterns, and Implications for Public Health Interventions.

Background/Aims: The prevalence of hepatitis B is higher in tribal populations, compared to non-tribal populations in India. Therefore, this study aimed to investigate the risk factors, virological and biochemical profile of patients with hepatitis B in a tribal population. Methods: This study analyzed data collected from a community-based project conducted in Spiti, Himachal Pradesh, from July 2015 to 2017. The study included adults and children inhabiting 40 cluster villages out of 82 villages in the subdivision. The blood samples were collected for liver panel, hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), Anti-HBe antibody (anti-HBe Ab) and Hepatitis B virus DNA (HBV-DNA). Results: HBsAg was positive in 23.08% of the population (968/4201), with a prevalence of 13.51% in children under 5 years of age. HBeAg positivity was seen in 22.4% of the participants, while anti-HBe Ab positivity was seen in 59.03% of the participants. HBeAg positive infection, HBeAg positive hepatitis, HBeAg negative hepatitis and HBeAg negative infection were seen in 18.06%, 1.98%, 6.17% and 74.01% of the participants, respectively. HBeAg positivity was highest in 2nd decade (40.83% vs 22% overall). Patients with HBeAg positivity exhibited higher levels of HBV DNA [1960 (IQR: 0-108) IU/ml vs 97.2 (IQR: 0-2090) IU/ml, P < 0.001] and alanine transaminase (ALT) [22.5 (IQR: 16-33) U/L vs 19 (IQR: 14-26) U/L, P = 0.003] levels compared to HBeAg negative patients. Conclusion: This study shows a high prevalence of hepatitis B in tribal population, particularly among children under 5 years of age.

A Prospective Randomised Comparative Four-arm Intervention Study of Efficacy and Safety of Saroglitazar and Vitamin E in Patients With Non-alcoholic Fatty Liver Disease (NAFLD)/Non-alcoholic Steatohepatitis (NASH)-SVIN TRIAL.

Background and aim: Vitamin E is widely prescribed for non-alcoholic steatohepatitis (NASH). Saroglitazar, a novel dual peroxisome proliferator-activator receptor ɑ/γ agonist, is approved in India for non-alcoholic fatty liver disease (NAFLD). No head-to-head comparative study for vitamin E and saroglitazar is available. We studied the efficacy and safety of saroglitazar and vitamin E in NAFLD/NASH. Materials and methods: We prospectively randomised 175 NAFLD patients into four arms as Saroglitazar 4 mg daily alone (n = 44), vitamin E 800IU daily alone (n = 41), vitamin E and saroglitazar combination (n = 47), and control arm (n = 43). All the baseline variables including liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) were recorded. Reassessment was done after 24 weeks of treatment. Results: The mean age and body mass index was 45 ± 11 years and 26 ± 3.6 kg/m2, respectively. Compared to control, the decrease in alanine amino transferase levels with saroglitazar, vitamin E, and combination therapy was significant (95% confidence interval [CI]: 6.27-28.25, P = 0.002, 95% CI: -3.39 to 18.88, P = 0.047 and 95% CI: 8.10-29.54, P = 0.001, respectively). The reduction in CAP was significant with saroglitazar and combination therapy (95% CI: -31.94 to 11.99, P = 0.015 and 95% CI: -10.48 to 30.51, P = 0.026, respectively). Only combination therapy shows significant reduction in LSM (95% CI: 0.41-1.68, P = 0.001). Among glycaemic parameters, both saroglitazar alone and combination therapy significantly improved glycosylated haemoglobin levels (P = 0.001 and P = 0.015, respectively), and only combination therapy significantly improved homoeostasis model assessment-estimated insulin resistance (P = 0.047). Saroglitazar alone showed significant reduction in triglyceride and low-density lipoprotein levels (P = 0.038 and P = 0.018, respectively), and combination therapy showed significant increase in high-density lipoprotein levels (P = 0.024). Conclusions: Combination of Saroglitazar and vitamin E showed statistically significant reduction of LSM and CAP along with biochemical, glycaemic, and lipid parameters. Clinical trial registry India no: CTRI/2022/01/039538.

Atrial myxoma: a rare cause of ischemic stroke.

Arial myxoma can present as stroke and should be considered as a differential diagnosis of stroke in young individuals. We present here a 42 years female who presented with sudden loss of conciousness. After extensive work up for young stroke, left atrial myxoma was detected and tumor was removed surgically and histopathological report was consistent with the atrial myxoma.

Intentional Ingestion of a Foreign Body - Why We Need Psychiatrists.

Foreign body ingestions are common medical emergencies. In adults, foreign body ingestions occur in patients with psychiatric disorders and prison inmates. A majority (80-90%) of foreign bodies pass spontaneously. Endoscopic and surgical interventions are required in only 10-20% and 1%, respectively. A plain radiograph may be the only diagnostic test required. A computed tomography scan may be needed when a perforation is suspected. Food boluses are the most commonly ingested foreign bodies. Snare and rat tooth forceps are frequently used accessories for the retrieval of foreign bodies. The focus of the emergency team is on the management of an acute case of foreign body ingestion, and the psychiatric aspect of the disease gets often ignored.

Decoding allelic diversity, transcript variants and transcriptional complexity of CENH3 gene in Brassica oleracea var. botrytis.

Histone proteins play a critical role in the primary organization of nucleosomes, which is the fundamental unit of chromatin. Among the five types of the histones, histone H3 has multiple variants, and the number differs among the species. Amongst histone H3 variants, centromeric histone H3 (CENH3) is crucial for centromere identification and proper chromosomal segregation during cell division. In the present study, we have identified 17 putative histone H3 genes of Brassica oleracea. Furthermore, we have done a detailed characterization of the CENH3 gene of B. oleracea. We showed that a single CENH3 gene exhibits allelic diversity with at least two alleles and alternative splicing pattern. Also, we have identified a CENH3 gene-specific co-dominant cleaved amplified polymorphic sequence marker SNP34(A/C) to distinguish CENH3 alleles and follow their expression in leaf and flower tissues. The gene structure analysis of the CENH3 gene revealed the conserved 5'-CAGCAG-3' sequence at the intron 3-exon 4 junction in B. oleracea, which serves as an alternative splicing site with one-codon (alanine) addition/deletion. However, this one-codon alternative splicing feature is not conserved in the CENH3 genes of wild allied Brassica species. Our finding suggests that transcriptional complexity and alternative splicing might play a key role in the transcriptional regulation and function of the CENH3 gene in B. oleracea. Altogether, data generated from the present study can serve as a primary information resource and can be used to engineer CENH3 gene towards developing haploid inducer lines in B. oleracea.

Etomidate-ketamine versus dexmedetomidine-ketamine for entropy-guided procedural sedation during endoscopic retrograde cholangiopancreatography procedures: A randomized single blind study.

BACKGROUND AND AIMS: The major challenge for the anesthetist in endoscopic retrograde cholangiopancreatography (ERCP) procedures is to provide moderate to deep levels of sedation in prone position with preservation of spontaneous respiratory efforts in shared airway scenario with an endoscopist. These patients have other comorbidities, making them vulnerable to complications during the routinely used sedation with propofol. We compared the entropy-guided efficacy of combination of etomidate-ketamine to dexmedetomidine-ketamine in patients undergoing ERCP. METHODS: This prospective single blind randomized entropy-guided trial was conducted on 60 patients with etomidate-ketamine in group I (n = 30) and dexmedetomidine-ketamine in group II (n = 30). The purpose was to compare etomidate-ketamine versus dexmedetomidine-ketamine for ERCP in terms of intraprocedural hemodynamics with desaturation, onset of sedation, recovery time and endoscopist's satisfaction. RESULTS: Hypotension was observed only in six (20%) patients of group II (p < 0.009). Two patients of group I and three in group II desaturated (Spo2 < 90) briefly during the procedure, but none of the patient required intubation (p > 0.05). The mean time in minutes of onset of sedation was 1.15 in group I and 5.6 in group II (p < 0.001). Endoscopists' satisfaction was better in group I (p ≤ 0.001) and length of recovery room stay was shorter in group I as compared to that in group II (p ≤ 0.007). CONCLUSION: We conclude that entropy-guided intravenous procedural sedation with etomidate-ketamine combination provides faster onset of sedation, stable periprocedural hemodynamics, rapid recovery and fair to excellent endoscopist satisfaction compared to dexmedetomidine-ketamine combination for ERCP.