Endovascular and percutaneous transabdominal embolisation of pseudoaneurysms in pancreatitis: an experience from a tertiary-care referral centre.

AIM: To analyse the technical challenges, clinical success, and associated complications of endovascular and percutaneous embolisation of pancreatitis-related pseudoaneurysms. MATERIALS AND METHODS: A retrospective study of patients referred for embolisation of pancreatitis-related pseudoaneurysms between January 2014 and March 2019 was conducted. Computed tomography angiography (CTA) was performed to assess the morphology of the aneurysms prior to any intervention. Percutaneous or endovascular embolisation was performed. Details of CTA and methods of embolisation were recorded. Technical success, clinical success, and complications were reported. RESULTS: A total of 80 patients (mean age, 40.69 ± 13.41 years, 73 male) underwent embolisation during the study period. Pseudoaneurysms were related to chronic pancreatitis (CP) in 44 (55%) patients and acute pancreatitis (AP) in 36 (45%) patients. Pseudoaneurysms were detected in 65 (81.2%) patients on CTA. The most common site of pseudoaneurysms was gastroduodenal artery (GDA) followed by splenic artery. Seven patients were treated with percutaneous thrombin injection and five were treated with percutaneous glue injection under ultrasound/fluoroscopy guidance. The remaining patients (n=68) underwent catheter angiography with endovascular embolisation. Technical success was achieved in 4/7 (57%) percutaneous thrombin cases and in all the cases (5/5, 100%) with percutaneous glue or endovascular (68/68,100%) embolisation. CONCLUSION: Endovascular or percutaneous embolisation of pseudoaneurysms has high technical success with an excellent safety profile.

Efficacy of generic oral directly acting agents in patients with hepatitis C virus infection.

Novel direct-acting antivirals (DAAs) are now the standard of care for the management of hepatitis C virus (HCV) infection. Branded DAAs are associated with high sustained virological response at 12 weeks post-completion of therapy (SVR12), but are costly. We aimed to assess the efficacy of generic oral DAAs in a real-life clinical scenario. Consecutive patients with known HCV infection who were treated with generic-oral DAA regimens (May 2015 to January 2017) were included. Demographic details, prior therapy and SVR12 were documented. Four hundred and ninety patients (mean age: 38.9 ± 12.7 years) were treated with generic DAAs in the study time period. Their clinical presentations included chronic hepatitis (CHC) in 339 (69.2%) of cases, compensated cirrhosis in 120 (24.48%) cases and decompensated cirrhosis in 31 (6.32%) cases. Genotype 3 was most common (n = 372, 75.9%) followed by genotype 1 (n = 97, 19.8%). Treatment naïve and treatment-experienced (defined as having previous treatment with peginterferon and ribavirin) were 432 (88.2%) and 58 (11.8%), respectively. Generic DAA treatment regimens included sofosbuvir in combination with ribavirin (n = 175), daclatasvir alone (n = 149), ribavirin and peginterferon (n = 80), ledipasvir alone (n = 43), daclatasvir and ribavirin (n = 37), and ledipasvir and ribavirin (n = 6). Overall SVR12 was 95.9% (470/490) for all treatment regimens. SVR12 for treatment naïve and experienced patients was 97.0% (419/432) and 87.9% (51/58), respectively, P = .005. High SVR12 was observed with various regimens, irrespective of genotype and underlying liver disease status. There were no differences in SVR12 with 12 or 24 weeks therapy. No major adverse event occurred requiring treatment stoppage. Generic oral DAAs are associated with high SVR rates in patients with HCV infection in a real-life clinical scenario.

Per a 10 protease activity modulates CD40 expression on dendritic cell surface by nuclear factor-kappaB pathway.

Serine protease activity of Per a 10 from Periplaneta americana modulates dendritic cell (DC) functions by a mechanism(s) that remains unclear. In the present study, Per a 10 protease activity on CD40 expression and downstream signalling was evaluated in DCs. Monocyte-derived DCs from cockroach-allergic patients were treated with proteolytically active/heat-inactivated Per a 10. Stimulation with active Per a 10 demonstrated low CD40 expression on DCs surface (P < 0·05), while enhanced soluble CD40 level in the culture supernatant (P < 0·05) compared to the heat-inactivated Per a 10, suggesting cleavage of CD40. Per a 10 activity reduced the interleukin (IL)-12 and interferon (IFN)-γ secretion by DCs (P < 0·05) compared to heat-inactivated Per a 10, indicating that low CD40 expression is associated with low levels of IL-12 secretion. Active Per a 10 stimulation caused low nuclear factor-kappa B (NF-κB) activation in DCs compared to heat-inactivated Per a 10. Inhibition of the NF-κB pathway suppressed the CD40 expression and IL-12 secretion by DCs, further indicating that NF-κB is required for CD40 up-regulation. CD40 expression activated the tumour necrosis factor (TNF) receptor-associated factor 6 (TRAF6), thereby suggesting its involvement in NF-κB activation. Protease activity of Per a 10 induced p38 mitogen-activated protein kinase (MAPK) activation that showed no significant effect on CD40 expression by DCs. However, inhibiting p38 MAPK or NF-κB suppressed the secretion of IL-12, IFN-γ, IL-6 and TNF-α by DCs. Such DCs further reduced the secretion of IL-4, IL-6, IL-12 and TNF-α by CD4(+) T cells. In conclusion, protease activity of Per a 10 reduces CD40 expression on DCs. CD40 down-regulation leads to low NF-κB levels, thereby modulating DC-mediated immune responses.

Spectrum of imaging findings on MDCT enterography in patients with small bowel tuberculosis.

Abdominal tuberculosis (TB) is the sixth most common extrapulmonary site of involvement. The sites of involvement in abdominal tuberculosis, in descending order of frequency, are lymph nodes, genitourinary tract, peritoneal cavity, and gastrointestinal tract. The radiological armamentarium for evaluating tuberculosis of the small bowel (SBTB) includes barium studies (small bowel follow-through, SBFT), CT (multidetector CT, CT enterography, and CT enteroclysis), ultrasound (sonoenteroclysis), and magnetic resonance imaging (MRI; enterography and enteroclysis). In this review, we illustrate the abnormalities at MDCT enterography in 20 consecutive patients with SB TB and also describe extraluminal findings in these patients. MDCT enterography allows non-invasive good-quality assessment of well-distended bowel loops and the adjacent soft tissues. It displays the thickness and enhancement of the entire bowel wall in all three planes and allows examination of all bowel loops, especially the ileal loops, which are mostly superimposed. The terminal ileum and ileocaecal junction are the most common sites of small bowel involvement in intestinal TB. The most common abnormality is short-segment strictures with symmetrical concentric mural thickening and homogeneous mural enhancement. Other findings include lymphadenopathy, ascites, enteroliths, peritoneal thickening, and enhancement. In conclusion, MDCT enterography is a comprehensive technique for the evaluation of SB TB.

Comparison of Chemotherapy Combined with Percutaneous Electroporation and Chemotherapy Alone in the Management of Locally Advanced Gallbladder Carcinoma (GBC): A Study Protocol.

PURPOSE: This study aims to evaluate the feasibility and efficacy of chemotherapy combined with irreversible electroporation (IRE) in patients with locally advanced gallbladder carcinoma (GBC) presenting as gallbladder masses. MATERIALS AND METHODS: Patients with unresectable GBC masses of size greater than 2 cm and less than 6 cm without evidence of distant metastases and with no contraindication to general anaesthesia will be enrolled in the study. They will be randomized using computer generated table into two arms with 1:1 allocation ratio to include 15 patients in each group. Group I will be the chemotherapy alone arm and Group II will be the combined image-guided irreversible electroporation of the tumour and chemotherapy arm. The primary outcome assessed shall be the clinical benefit rate (complete response, CR; partial response, PR and stable disease, SD) based on the mRECIST criteria and overall survival. The secondary outcome shall be feasibility and safety of the procedure and quality of life pre and post procedure. The quality of life will be assessed by a questionnaire as given by EORTC-Quality of Life Group before starting therapy and 4 weeks after completion of therapy. EXPECTED GAIN OF KNOWLEDGE: The combined local and systemic effects of irreversible electroporation and systemic chemotherapy respectively may improve the outcomes in inoperable cases of gallbladder carcinoma. TRIAL REGISTRATION: Clinical Trials Registry - India ( https://ctri.nic.in/Clinicaltrials/advancesearchmain.php ). Identifier: CTRI/2021/05/033803. Primary Register of the International Clinical Trials Registry Platform (WHO ICTRP) ( http://www.who.int/ictrp/search/en/ ).

Serine protease Per a 10 from Periplaneta americana bias dendritic cells towards type 2 by upregulating CD86 and low IL-12 secretions.

BACKGROUND: Serine protease activity of Per a 10 from Periplaneta americana induces airway inflammation and systemic Th2 response towards self and bystander allergen. OBJECTIVE: In the present study the effect of proteolytic activity of Per a 10 allergen on dendritic cells (DCs) polarization and consequent T cell response was investigated. METHODS: Non-atopic subjects with no family history of asthma/allergy were recruited for the study. CD14(+) peripheral blood monocytes were purified, differentiated to immature DCs and stimulated with proteolytically active/inactivated native or recombinant Per a 10. DCs phenotype was analysed with flow cytometry and antigen presenting function assessed by co-culturing with autologous CD4(+) T cells. Cytokine levels were determined using ELISA. RESULTS: Immature DCs differentiated into mature CD14(-)CD83(+)HLA-DR(+) cells after incubating with proteolytically active/inactivated or recombinant Per a 10. Proteolytically active Per a 10 induced significant CD86 up-regulation on DCs compared to inactivated or recombinant Per a 10 lacking enzymatic activity. Proteolytic activity of Per a 10 showed dose-dependent effect on expression of CD80, CD86, CD83, CD1a and HLA-DR. However, no significant differences were observed phenotypically in active or inactive forms except for CD86. Active Per a 10 stimulated DCs secreted significantly low IL-12 (P < 0.01) and high IL-6, compared to inactive forms of Per a 10. Naive CD4(+) T cells primed with active Per a 10 pulsed DCs also secreted significantly less IL-12 (P < 0.01) and high IL-4, IL-5 plus IL-6 (P < 0.01); in contrast to DCs pulsed with inactivated or recombinant Per a 10. CONCLUSION AND CLINICAL RELEVANCE: Proteolytic activity of Per a 10 modulates DCs towards type 2 by CD86 up-regulation, high IL-6 and reduced IL-12 secretions. Proteolytically inactive Per a 10 can be further explored for immunotherapy.

Hypnosis and progressive muscle relaxation for anxiolysis and pain control during extraction procedure in 8-12-year-old children: a randomized control trial.

INTRODUCTION: Hypnosis (H) and Progressive Muscle Relaxation (PMR) have proven to be effective in a variety of medical settings; there is a paucity of their practical application in paediatric dentistry. The study aimed to comparatively evaluate the role of H and PMR on anxiety, heart rate (HR), oxygen saturation (SPO2), blood pressure (BP), pain, and analgesic requirement during extraction in children. MATERIALS AND METHODS: Sixty children aged 8-12 years undergoing primary molar extractions were randomly allocated to three groups-H, PMR, and control (C). The anxiety (proposed Visual Facial Anxiety scale), HR, and SPO2 were measured pre/post-operatively with/without interventions (H, PMR, C) at 4 intervals. The BP and pain (Wong-Baker faces pain scale) were recorded pre- and post-operatively. Need for analgesic post-operatively was assessed. RESULTS: Statistically significant reduction in anxiety was noted post-extraction in H (0.30 ± 0.80), PMR (0.50 ± 0.69) (p < 0.001*). HR showed a statistically significant drop after H, PMR application. (p < 0.001*) No significant difference in SPO2 was noted in the three groups (p > 0.05). Pain control was well achieved using H (85%), PMR (70%); BP was well-regulated in the H, PMR compared to C group (p < 0.001*). Need for analgesics was reduced in H (45%), PMR (50%) versus C (100%). Both techniques H, PMR were comparable in all measures. CONCLUSION: Hypnosis and PMR are effective techniques for anxiolysis and pain control in paediatric dental patients.

Coexistent hepatic and pulmonary epitheloid hemangioendothelioma.

Epitheloid hemangioendothelioma (EHE) is a rare neoplasm of vascular origin known to arise in soft tissue, liver and lung. We describe a case of coexistent hepatic and pulmonary epitheloid hemangioendothelioma, proven on autopsy, and review the histological and radiological features of epitheloid hemangioendothelioma. The coexistence of hepatic with pulmonary EHE has been reported in only a few cases. Large confluent masses, peripheral location with capsular retraction, hypertrophy of uninvolved liver, invasion of portal and hepatic veins, enhancing margins and delayed enhancement and dense calcification are the typical features which provide a clue to diagnosis of hepatic EHE. In patients with both hepatic and pulmonary EHE it is difficult to say whether the tumor arose primarily in the lung or liver, or began simultaneously in both organs.

Radio-pathological Correlation of 18F-FDG PET in Characterizing Gallbladder Wall Thickening.

AIM: Thick-walled gallbladder is difficult to characterize on conventional imaging. 18F-FDG PET was used to differentiate benign and malignant wall thickness and compared with histopathology. METHODS: Thirty patients with gallbladder (GB) wall thickening (focal > 4 mm and diffuse > 7 mm), underwents uspected on  ultrasound, or CT scan, and underwent 18F-FDG PET. Histopathology of the specimen was compared with imaging findings. RESULTS: The mean age was 48.22 ± 31.33 years with a M:F 1:4 ratio. Twenty patients had diffuse and 10 had focal thickening. On 18F-FDG PET, lesion was benign in 12, malignant in 13, and indeterminate in 5. Histopathology was malignancy in 12; benign in 18-chronic cholecystitis in 11, xanthogranulomatous in 4, IgG4 related in 2, and polyp in 1. The mean GB wall thickness was 7.79 ± 3.59 mm (10.34 malignant and 6.10 in benign, p = 0.001). At a cutoff of 8.5 mm, the sensitivity and specificity of detecting malignancy was 94% and 67%. The mean SUV uptake was 7.46 (benign 4.51, malignant 14.26, p = 0.0102). At a cutoff of 5.95, the sensitivity and specificity of detecting malignancy was 92% and 79%. For 18F-FDG PET, overall sensitivity was 91%, specificity 79%, PPV 77%, NPV 92%, and diagnostic accuracy was 84%. CONCLUSION: 18F-FDG PET is a reliable method of differentiation between benign and malignant thickening of the gallbladder particularly when wall thickness and SUV value is taken into account.

Role of CD10 immunochemistry in differentiating hepatocellular carcinoma from metastatic carcinoma of the liver.

BACKGROUND: Differentiation of hepatocellular carcinoma (HCC) from metastatic carcinoma in liver may be difficult on fine needle aspiration cytology (FNAC), especially when both appear as moderate to poorly differentiated tumours. A panel of immunocytochemical stains is frequently used in case of diagnostic difficulty. Recently, CD10 immunostain with a canalicular staining pattern has been shown to be a specific marker for hepatocytic differentiation. OBJECTIVE: The present study was designed to assess the value of CD10 immunostain in distinguishing HCC from metastatic carcinoma in material obtained by FNAC of liver masses. MATERIALS AND METHODS: Formalin-fixed, paraffin-embedded cell blocks of 22 cases (7 cases of HCC and 15 cases of metastatic carcinoma), direct acetone-fixed smears and destained smears of 28 cases (18 cases of HCC and 10 cases of metastatic carcinoma) prepared from FNAC of the liver were immunostained using monoclonal antibody against CD10. RESULTS: Seventeen (68%) of twenty-five cases of HCC were positive for CD10 with a canalicular staining pattern. Among them 7 (70%) of 10 cases were well-differentiated HCC and 10 (66%) of 15 cases were moderate to poorly differentiated HCC. Of 25 cases of metastatic carcinoma, four (16%) were positive for CD10 with a cytoplasmic (three cases) and membranous staining (one case) pattern. CONCLUSION: CD10 immunostaining is useful in discriminating HCC and metastatic carcinoma of the liver and is easily applied on cell blocks as well as FNAC smears.

Regulation of oxidative stress-mediated apoptosis by diallyl sulfide in DMBA-exposed Swiss mice.

Diallyl sulfide, a sulfur-containing volatile compound present in garlic (Allium sativum), exerts anticarcinogenic activity in various rodent tumor models. In the present study, apoptosis-inhibiting effects of diallyl sulfide against a carcinogenic polycyclic aromatic hydrocarbon, 7,12-dimethyl benz(a)anthracene (DMBA), in Swiss albino mice were observed. The animals were given either 250 microg/mouse or 500 mug/mouse of diallyl sulfide for 1 week after a single intragastric dose of 7,12-dimethyl benz(a)anthracene (50 mg/kg body weight). Results showed that diallyl sulfide supplementation effectively protects against 7,12-dimethyl benz(a)anthracene-induced oxidative stress, characterized by restored antioxidant enzyme levels (up to 64%) and lipid peroxidation (up to 25%). Flow cytometric analysis showed a reduction in apoptotic cell population in hypodiploid region in diallyl sulfide-supplemented animals. Inhibition of apoptosis was preceded by decrease in reactive oxygen species levels and restoration of mitochondrial transmembrane potential followed by decreased DNA fragmentation. In 7,12-dimethyl benz(a)anthracene-exposed animals, downregulation approximately 30%) of antiapoptotic Bcl-2 and upregulation (approximately 60%) of pro-apoptotic Bax proteins were observed. These alterations were restored significantly by diallyl sulfide supplementation, indicating inhibition of apoptosis. Thus, these results show that diallyl sulfide provides protection against oxidative damage induced by 7,12-dimethyl benz(a)anthracene in mouse liver and may be an effective chemopreventive and therapeutic agent by modulating expression of cell-growth regulatory proteins.

Coexistent neurocysticercosis and Japanese B encephalitis: MR imaging correlation.

BACKGROUND AND PURPOSE: An increased incidence of intestinal helminthic infections has been observed in patients with viral encephalitis in endemic areas. Both Japanese B encephalitis (JE) and neurocysticercosis (NCC) share some common socio-demographic and ecologic factors, and pigs act as the intermediate carrier for both. Our purpose was to show the coexistence of JE and NCC in brain on MR images and highlight the possible role of NCC as an amplifier of JE. METHODS: MR images from 10 cases of coexistent JE and NCC were studied retrospectively. T1-weighted axial and sagittal, proton T2-weighted axial and coronal, and T2-weighted fluid-attenuated inversion recovery axial and coronal sections of the brain were evaluated. NCC was diagnosed on the basis of neuroimaging. Diagnostic serologic testing for JE was conducted using paired blood and CSF samples. RESULTS: The JE changes were bilateral and asymmetrical and were more severe on the side harboring the solitary cyst or the side bearing the greater number of cysts or lodging the degenerating cyst. In each of nine of 10 cases, at least one degenerating cyst was found on the side of predominant JE pathologic abnormality. CONCLUSION: The study suggests that the co-occurrence of JE and NCC is not just a chance coincidence. NCC apparently predisposes a person to JE infection and is a positive modulator of the encephalitic process. The study shows a spectrum of MR imaging findings of coexistent JE and NCC.

Spiracular indices in Anopheles stephensi: a taxonomic tool to identify ecological variants.

Thoracic spiracle length and its index was examined for their ability to discriminate two ecological variants, type form and mysorensis, of Anopheles stephensi in the adult stage. The type form is exclusively domestic in all seasons, whereas the mysorensis variant occupies the outdoor niche during monsoon and postmonsoon seasons, with spillover into domestic sites during summer ecological stress periods. A statistically significant co-relation was established between the ridge count of the egg and two adult measurements, the thoracic spiracle length, and the spiracular index. In An. stephensi type form, average spiracle length was 0.11-0.12 mm and average spiracular index was 8.09-9.23, whereas in mysorensis, the corresponding figures were 0.09-0.10 mm and 6.82-7.60. These parameters showed consistent variations in population of mosquitoes that emerged during monsoon and summer season. The thoracic lengths in both variants remained constant, and only spiracular lengths showed fluctuations in three seasonal populations. These measures provide discrimination of adult variants--identifications that are essential in malaria control programs.

Anaerobic flora in endodontic infections.

Microbiological and clinical data from 56 patients with endodontic infections were evaluated. Samples were collected using autoclaved paper points. Specimens were processed for isolation of aerobic and anaerobic bacteria. Antimicrobial sensitivity and resistance profiles of the recovered isolates was also performed. Forty nine positive cultures (87.5%) were obtained from the 56 consecutive necrotic root canal systems which were sampled. A total of 69 aerobic bacteria and 21 anaerobic bacteria were recovered. Aerobic bacteria were isolated from 35 patients (72%), anaerobic bacteria from 3 (6%) and mixed aerobic and anaerobic bacteria from 11 patients (22%). The most common aerobic isolate was Klebsiella pneumoniae. The predominant anaerobic isolate was Bacteroides species. One isolate was recovered from 25 patients (51%) whereas in the remaining 24 patients (49%) more than 1 isolate were recovered. These data illustrate the polymicrobial nature of endodontic infections in half the patients studied and the role of anaerobic bacteria in a quarter of them.

Effect of potassium salts and distillery effluent on carbon mineralization in soil.

Distillery effluent, a rich source of potassium, is used for irrigation at many places in the world. A laboratory experiment was conducted to study the influence of potassium salts present in post-methanation distillery effluent (PME) along with two other salts, KCl and K2SO4, on mineralization of carbon in soil. PME oxidized with H2O2, raw PME, KCl and K2SO4 solutions containing K equivalent to 10%, 20%, 40% and 100% of K present in PME were added to the soil separately, maintaining four replications for each treatment and control. Addition of salts up to a certain concentration stimulated C mineralization but a decline was noticed at higher concentrations. All the levels of salts caused higher CO2 evolution than the control suggesting that the presence of K salts enhanced the microbial activity resulting in increased CO2 evolution. The influence of K2SO4 was significantly higher than KCl in stimulating C mineralization in soil. Oxidized effluent had a higher stimulating effect than inorganic salts, showing the influence of other salts accompanying K in the PME. Raw PME, which contained excess organic C, increased CO2 evolution even at the highest salt level (100% PME) signifying the effect of added C on alleviating the salt stress on microbial activity.

CT features of acute phlegmonous gastritis.

One case of phlegmonous gastritis is presented. Radiological diagnosis of this condition is difficult. In the setting of a clinical suspicion of this condition, computed tomography (CT) is the imaging modality of choice.