Corrosive Ingestion.

Corrosive ingestion remains a common problem in developing countries, such as India due to the lack of strict laws that regulate the sale of caustics. While appropriate treatment of the acute phase can mitigate tissue damage improper management of the acute corrosive injury is widely prevalent due to the limited experience of the individual physicians in managing this condition. The aim of this review is to summarize the epidemiology and pathophysiology of corrosive ingestion, principles in the management of acute phase injury, long-term effects of caustic ingestion, and prevention of corrosive ingestion. HOW TO CITE THIS ARTICLE: Kalayarasan R, Ananthakrishnan N, Kate V. Corrosive Ingestion. Indian J Crit Care Med 2019;23(Suppl 4):S282-S286.

Long Term Results of Esophageal Bypass for Corrosive Strictures without Esophageal Resection Using a Modified Left Colon Esophagocoloplasty--A Report of 105 Consecutive Patients from a Single Unit Over 30 Years.

BACKGROUND/AIMS: Esophageal stricture due to corrosive ingestion is a common cause of benign esophageal obstruction in developing countries. The immediate and long-term results of surgical bypass using a modification of the left colon conduit, will be reviewed. METHODOLOGY: From 1977 to 2008, 105 patients underwent esophageal bypass for corrosive esophageal strictures using this procedure which has several modifications, detailed in the text, from the conventional left colon conduit. RESULTS: Acids were the most common corrosive implicated (70.5%). Eighty nine patients underwent a bypass based on the left colic vessel through the substernal route. The subcutaneous route was used in the rest for varying reasons. Postoperatively three patients died. Conduit necrosis was seen in only one patient. Postoperative morbidity included pneumothorax in 15, cervical anastomotic stenosis in one, cervical anastomotic leak in 13 (less than 3% the last 75 cases) and recurrent laryngeal nerve palsy in 6 (5.7%). 72 patients had normal swallowing and 33 had only occasional minor difficulty with solid food on follow-up. CONCLUSIONS: Surgical bypass using a modification of the left colon esophagocoloplasty remains a reliable procedure with acceptable morbidity and good relief of dysphagia.

Unresolved conundrum of the role of physical activity in inflammatory bowel disease: What next?

There is considerable controversy on the role of physical activity in irritable bowel disease (IBD) since published reports are conflicting. It is well known that there is known relapse with specific treatment in IBD. This, in addition to onset of extraintestinal symptoms creates a need to think of alternate approaches. In this context, the current article describes the need of a multi-institutional study with standard protocol of physical activity for documenting its effect on both the primary disease and the extra alimentary manifestations. This paper also points out the possibility of using adjuvant complementary medicine such as yoga, whose effects have been documented in other diseases like irritable bowel syndrome. A third approach could be to focus on the intestinal dysbiosis in IBD and concentrate on research on restoring the microbial flora to normal, to see whether the extra-intestinal symptoms are alleviated.

Design and development of an arena blended connected learning model for faculty development in health professions education: A step forward.

Current medical education and clinical practice has led to a need for advanced faculty development for medical teachers to effectively play the role of educators, researchers and administrators. There is large variability in the teaching programmes across countries, which range from a one-time activity to regularly scheduled workshops and seminars, to a highly advanced course spanning a few months to a year. Several healthcare institutes around the world offer faculty training programmes in health professions education, where the curriculum varies in design as they are developed and implemented by their own institutional body or education unit. Following a discussion of arena blended connected (ABC) learning design during a faculty training programme (Postgraduate Diploma in Health Professions Education) and the subsequent move towards an online approach to education due to the pandemic in 2019, the advisory faculty and students started to envision designing the already existing Postgraduate Diploma in Health Professions Education curriculum along the ABC model favouring blended and outcome-based education. Criteria were set for each topic with clearly defined learning levels to be implemented and the frequency of implementation. We describe the design and development of a curriculum for faculty development of health professions education using the ABC model.

Competency-based postgraduate training: Mentoring and monitoring using entrustable professional activities with descriptive rubrics for objectivity- A step beyond Dreyfus.

Background At Sri Balaji Vidyapeeth, a competency-based learning and training (CoBaLT©) model for postgraduate (PG) curriculum, within the regulatory norms, was implemented in 2016 after adequate faculty development programmes. This focused on well-defined outcomes. Methods A review of the outcomes was undertaken in 2018 as part of internal quality assurance receiving feedback from all stakeholders, viz. students, alumni and faculty. Recent publications were also reviewed. A major problem identified was lack of clarity in definition of levels leading to subjectivity in assessment while grading. It was also noted that the process needed to be aligned with the programme outcomes. Further refinements were, therefore, made to align and objectivize formative assessment using entrustable professional activities (EPA) with the aid of descriptive rubrics of sub-competencies and milestones. Addition of detailed rubrics for objectivity takes assessment a step beyond the Dreyfus model, aligning overall to the programme outcomes. Results Achievement of appropriate grades in EPAs by individual candidates ensures entrustability in professional activities by the time of completion of the PG programme. The modification was found more transparent and objective with reference to grading by the teachers and more conducive to reflections by the residents on their performance and how to improve it. Conclusions The use of descriptive rubrics along with EPAs brings transparency and plays a key role as an objective assessment tool, which can lend direction to individual resident learning and entrustability. This is an important component of outcome-based education.

Yoga Therapy in Functional Dyspepsia. A Narrative Review.

Functional dyspepsia (FD) is a common upper gastrointestinal disorder, characterized by bothersome epigastric pain or burning, fullness after meals or early satiety. The precise pathophysiology remains incompletely understood but may include the role of disordered gut-brain communication leading to disturbances in gastro-duodenal physiological functioning. Even if there are several pharmacological treatment options, it is a chronic and relapsing disorder with persistent symptoms that makes its management difficult. Yoga is a fast-spreading complementary and alternative medicine (CAM) specialty, that has gained attention in the medical field for its ability to address the physical, emotional, mental and social aspects of health and disease. Various other CAM therapies are being used for FD with varying efficacy. However, apart from one research study that used yoga therapy on abdominal pain related functional gastrointestinal disorders in children which included a few FD cases as well (11.6%), no other study using yoga therapy has been done in FD as per our best knowledge. Therefore, in the present review, we have summarized the current scientific understanding of the probable effects of yoga on the pathophysiological mechanisms involved in FD (gastric motility, fundic accommodation, hypersensitivity, duodenal inflammation, psychological distress and gut-brain dysfunction). The literature suggests yoga can have a beneficial role in the management of FD. However, rigorous research and clinical trials are required to confirm the same.

Sequential therapy versus standard triple-drug therapy for Helicobacter pylori eradication: a systematic review of recent evidence.

BACKGROUND: Several alternative treatment regimens for Helicobacter pylori eradication have been proposed since the efficacy of standard triple therapy has declined over time, and sequential therapy is one of them. The purpose of this systematic review is to analyze and compare the efficacy, adverse effects and cost of sequential therapy with that of standard triple therapy for H. pylori infection. METHODS: MEDLINE, EMBASE, Google Scholar and Cochrane databases were used to retrieve all relevant articles published in the English language over the last 5 years (January 2008-October 2012). Eligibility criteria were randomized controlled trials (RCTs) comparing sequential and standard triple therapies in patients with documented H. pylori infection. Eligibility and quality of the trials were assessed independently by two reviewers, and the data regarding eradication rate, adverse effects and the cost of therapy were extracted. RESULTS: Of the 17 RCTs included in the analysis (Asia 13, Europe 3, Latin America, 1), 12 reported better eradication rates with the sequential therapy, four did not find a significant difference between the two treatment regimens, and one reported a better eradication rate with standard triple therapy. All except one RCT reported no significant difference in the incidence of adverse effects between standard triple therapy and sequential therapy. Sequential therapy was cheaper than standard triple therapy in all three RCTs where a cost analysis was performed. The limitations of the RCTs included in the systematic review were that the sequential therapy regimen and the duration of standard triple therapy were not uniform. Antibiotic susceptibility tests were performed in only three RCTs. CONCLUSIONS: While the majority of the RCTs have shown superior eradication rates with sequential therapy, the largest RCT from Latin America did not find a significant difference between the two treatment regimens. Sequential therapy has good efficacy; however, further trials other than those from Asia and Italy are required to assess its superiority over existing regimens before recommending sequential therapy as the first line of treatment for H. pylori infection.

Subcutaneous zygomycosis caused by Mucor hiemalis in an immunocompetent patient.

Zygomycosis is an opportunistic fungal infection with a high mortality rate. It is known to cause invasive disease in immunocompromised hosts but it may produce only cutaneous/ subcutaneous infections in immunocompetent hosts. Treatment is difficult due to its fulminant course and lack of effective anti-fungal drugs. Here, we report a rare case of subcutaneous zygomycosis caused by Mucor hiemalis in an immunocompetent patient without any debilitating illness. The patient was successfully treated by aggressive surgical debridement and anti-fungal therapy.

Therapeutic options for management of pharyngoesophageal corrosive strictures.

INTRODUCTION: Pharyngoesophageal strictures due to corrosive injury raise difficult therapeutic problems due to the site of stricture, the possible association with laryngeal injury and the presence of downstream esophageal strictures. We present here our approach to management of 51 consecutive patients with pharyngoesophageal strictures seen over a 30-year period. METHODS: Patients (51) with PES were managed by one of several options depending on the individual case, viz. dilatation alone, dilatation followed by esophagocoloplasty, dilatation after cervical esophagostomy with or without an esophagocoloplasty, pectoralis major or sternocleidomastoid myocutaneous flap inlays with or without esophagocoloplasty, pharyngocoloplasty with tracheostomy, and neck exploration followed by esophagocoloplasty if a lumen was found in the cervical esophagus. RESULTS: The overall results were excellent with satisfactory swallowing restored in 45 out 51 patients (88.2%). There was one death and three incidences of complications, two patients with temporary cervical salivary fistula, and one patient in whom swallowing could not be restored because of lack of suitable conduit. The mean dysphagia score was improved from a pre-operative value of 3.6 to 1.5 post-operatively. CONCLUSION: In conclusion, pharyngoesophageal strictures require considerable expertise in management, and one should be aware of various options for this purpose. The choice of procedure depends on site of stricture, time of presentation after the corrosive injury, relationship of the stricture to the laryngeal inlet, status of the larynx and the airway, length of the stricture, presence or absence of a lumen distal to the stricture in the cervical esophagus, and presence or absence of strictures further downstream. With proper treatment, mortality is negligible and morbidity minimal and is usually restricted to temporary salivary fistula.

Helicobacter pylori eradication prevents recurrence after simple closure of perforated duodenal ulcer.

BACKGROUND AND AIM: Evidence remains inconclusive as to whether eradication of Helicobacter pylori prevents ulcer relapse after simple closure of a perforated duodenal ulcer. This study was conducted to determine the effect of H. pylori eradication using a quadruple drug regimen along with a probiotic on ulcer recurrence after perforation closure. METHODS: A total of 93 patients who had presented with perforated duodenal ulcer and had a simple closure of a duodenal perforation comprised the study group. Three months postoperatively, patients who were found to be positive for H. pylori infection (n = 60) were administered quadruple therapy consisting of omeprazole, clarithromycin, amoxicillin and colloidal bismuth subcitrate for 10 days along with the probiotic Lactobacillus sporogenes for 14 days. Diagnosis of H. pylori was carried out by urease test and histology. Patients were followed for 18 months. Recurrence of ulcer was analyzed for correlation with H. pylori status. RESULTS: Of 60 patients who received H. pylori eradication therapy, 53 were available for subsequent follow up. H. pylori eradication was achieved in 43/53 (81.1%) patients. The ulcer recurrence in the eradicated group was 18.6% (8/43) compared to 70% (7/10) in the noneradicated group (P = 0.003). CONCLUSION: Eradication of H. pylori significantly reduces the relapse of duodenal ulcer after simple closure of perforation. Anti H. pylori therapy must be recommended for all H. pylori positive patients after simple closure of a perforated duodenal ulcer.

Primary cutaneous malignant fibrous histiocytoma: a case report.

BACKGROUND: Malignant fibrous histiocytoma (MFH) is one of the commonest soft tissue sarcomas to occur in the extremities, but presentation as a primary cutaneous lesion is rare. MFH can present as a cutaneous lesion in the form of a primary tumor or as metastasis from MFH at other sites, such as primary MFH of the breast; however, both presentations are very rare. CASE REPORT: We report here a 55-year-old male patient with cutaneous MFH on the right thigh region. The patient presented with two swellings on the outer aspect of the thigh of three months' duration, which ulcerated following the first month. The swellings were non-tender, soft, compressible, and not fixed to underlying structures. Histopathologic examination of the excised tumor revealed highly pleomorphic spindle-shaped cells arranged in sheets and irregular fascicles with a focal storiform pattern. Many thin-walled blood vessels and focal inflammatory cell infiltration with occasional focus of myxoid change was seen. Storiform-pleomorphic type of MFH grade II was diagnosed. Wide local excision was done. The patient made an uneventful recovery. CONCLUSIONS: Although MFH is one of the commonest soft tissue sarcomas, cutaneous presentation is very rare. A high index of suspicion is necessary to keep this possibility in mind, as it can present in different forms, including the pedunculated types, which can be compressible. MFH variants such as atypical fibrous histiocytoma or atypical fibroxanthoma can occur sometimes as cutaneous MFH. Wide local excision is commonly possible in most of the cases for therapy.

Prevalence of Helicobacter pylori in patients with portal hypertensive gastropathy--a study from south India.

BACKGROUND: This study was done to ascertain the prevalence of Helicobacter pylori in patients with PHG and determine whether it contributed to the severity of the disease. MATERIAL/METHODS: A total of thirty-seven consecutive patients who presented with portal hypertensive gastropathy were included in the study. H. pylori status was determined by urease test and histology. The presence of at least one positive test was considered as a positive H. pylori state. Correlation analyses of H. pylori status with age, gender, alcohol consumption, and the site and severity of lesion were done. RESULTS: Sixteen of the 37 patients were positive for H. pylori. A linear trend with age was seen in H. pylori - infected patients. H. pylori positivity was higher in the second and third decades of life, although this did not reach statistical significance. The linear trend with age was similar to that of the control group. There was no association between H. pylori status and alcohol intake or the site of lesion. Twenty-sevenlpatients had endoscopic evidence of mill PHG, 9 had moderate and 1 severe. The H. pylori status was 52%, 22%, and 0% in patients with mild, moderate, and severe gastropathy, respectively, indicating an inverse relatioinship of severity of PHG with H. pylori colonization. CONCLUSIONS: Portal hypertensive gastropathy does not provide a favorable environment for the colonization of H. pylori. The decline in H. pylori positivity with the severity of PHG suggests that this bacterium is unlikely to contribute in the pathogenesis of congestive gastropathy and that hence there might be no need for its routine eradication in patients with PHG.

Erosive gastroduodenitis and Helicobacter pylori infection.

BACKGROUND: This study was aimed at evaluating the role of Helicobacter pylori in erosive gastroduodenitis and the necessity for its eradication. MATERIAL/METHODS: A total of forty-nine consecutive patients who presented with hematemesis and or melena and proved to have erosive gastroduodenitis on endoscopy were included in the study. H. pylori status was determined by urease, histology and serology. The presence of at least two positive tests was considered as positive H. pylori status. The erosion sites were noted and classified according to predominance. Correlation of H. pylori status was done between NSAID users and non-users. RESULTS: 28 males and 21 females comprised the study group. H. pylori positivity was 43% in men and 52% in women (p=0.51); the overall H. pylori positivity rate was 47%. 39 patients had taken NSAIDs and three had taken indigenous drugs, which did not belong to the group of NSAIDs. The H. pylori status of drug users and non-users was 48% and 43% respectively (p=0.57) Erosions were most common in the body of the stomach (61%) compared to the antrum (23%), fundus (10%) and duodenum (6%). CONCLUSIONS: Erosive gastroduodenitis is commonly associated with NSAID intake. The body of the stomach is the most common site of erosions. Only 47% of patients with erosive gastritis have a positive H. pylori status. The H. pylori status between drug users and non-users was not significantly different. Eradication of H. pylori is not indicated in patients with erosive gastroduodenitis.