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.

Unlocking India's Potential in Managing Endocrine-Disrupting Chemicals (EDCs): Importance, Challenges, and Opportunities.

Endocrine-disrupting chemicals (EDCs) are a prime concern for the environment and health globally. Research shows that in developing countries such as India both the environment and human populations are severely exposed to EDCs and consequently experience rising incidents of adverse health effects such as diabetes and cancers. In this paper, we discuss the current EDC management approach in India, critically assess its limitations, and describe opportunities for potential improvements. Foremost, current EDC management actions and interventions in India are fragmented and outdated, and far behind the modern and comprehensive approaches adopted in the European Union and other developed countries. Strong and well-planned actions are required on various fronts of science, policy, commerce, and public engagement. These actions include the adoption of a dedicated and modern regulatory framework for managing EDCs, enhancing capacity and infrastructure for EDC monitoring in the environment and human population, employing public-private partnership programs for not only managing EDCs but also in the sectors that indirectly contribute toward the mismanagement of EDCs in the country, and raising awareness on EDCs and promoting health-preserving consumption habits among the public. As India hosts a large proportion of the global human population and biodiversity, the success or failure of its actions will substantially affect the direction of global efforts to manage EDCs and set an example for other developing countries.

Dyspepsia with alarm symptoms in patients aged less than 60 years: Is upper gastrointestinal endoscopy justified in Indian scenario?

BACKGROUND: Newer American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) guidelines do not suggest endoscopy to investigate alarm features for dyspepsia patients under the age of 60 to exclude upper gastrointestinal (GI) neoplasia. The validity of this recommendation has not been evaluated in our population. So, this study was conducted to assess the utility of upper GI endoscopy to investigate alarm features in dyspepsia patients less than 60 years of age to exclude upper GI neoplasia. METHODS: This prospective observational study evaluated consecutive patients of dyspepsia between 18 and 60 years of age, with at least one or more of the alarm symptoms (unintentional weight loss; loss of appetite; GI bleeding; anemia; recurrent or persistent vomiting; dysphagia with predominant epigastric pain; and family history of upper GI cancer) with upper GI endoscopy to exclude any organic lesion and malignancy. RESULTS: Of total 294 patients evaluated with endoscopy, 34.7% (n=102) had normal endoscopy (functional dyspepsia [FD]) while 65.3% (n=192) had abnormal endoscopic findings (organic dyspepsia [OD]). Of 192 patients with OD, 146 patients (49.6% of the total study population) had benign abnormality (benign OD) while 46 patients (15.6% of the total study population) had malignancy of the upper GI tract (malignant OD). CONCLUSION: The investigation of alarm features in dyspepsia patients less than 60 years of age with upper GI endoscopy leads to detection of organic lesion (65.3%) including malignancy (15.6%) in a significant percentage of patients.

Clinicopathological Profile and Outcome of a Large Cohort of Patients with Nonalcoholic Fatty Liver Disease from South Asia: Interim Results of the Indian Consortium on Nonalcoholic Fatty Liver Disease.

Background: Previous data from South Asia and India had shown that patients with nonalcoholic fatty liver disease (NAFLD) have mild liver disease severity. There are no data regarding long-term clinical outcomes in patients with NAFLD from South Asia. The aim of the study was to evaluate the clinicopathological profile, severity of NAFLD, and clinical outcomes in a large cohort of patients with NAFLD from South Asia. Methods: In an ongoing real-life study [Indian Consortium on nonalcoholic fatty liver disease (ICON-D)], interim data captured across 23 centers in India over 18 months was analyzed for clinicopathological profile, severity of NAFLD, and hepatic/extrahepatic events on follow-up. Results: Of 4313 patients (mean age 45 ± 12.2 years, males 52%), data on metabolic risk factors in 3553 (82.3%) patients revealed that 378 (10.6%) were lean, 575 (16.2%) overweight, 2584 (72.7%) obese; metabolic syndrome in 1518 (42.7%) and at least one metabolic risk factor in 3292 (92.6%) patients. Evidence of significant or advanced fibrosis assessed with [aspartate transaminase to platelet ratio index (APRI), n = 3196 (74%)], [fibrosis-4 (FIB-4), n = 3554 (82.4%)], [NAFLD fibrosis score (NFS), n = 1924 (44.6%)], [Fibroscan, n = 2475, (57.3%)], and histology [n = 267 (6.2%)] was present in 682 (21.3%), 676 (19%), 397 (20.6%), 715 (29%), and 41 (15.4%) patients, respectively; 246 (10%) patients on Fibroscan and 22 (8.2%) on histology had evidence of cirrhosis. On a mean follow-up 43.5 months, hepatic and extrahepatic events recorded in 1353 (31.3%) patients showed that patients with compensated cirrhosis [71 (5.2%)] had more hepatic [26 (36.7%)] and extrahepatic events [8 (11.3%)] in comparison with those without cirrhosis (P < 0.0001). Conclusion: Around one fifth of patients with NAFLD in South Asia have significant liver disease. Both hepatic and extrahepatic events on follow-up are observed more commonly in patients with nonalcoholic steatohepatitis-related compensated cirrhosis.

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.

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.

Four percent formalin application for the management of radiation proctitis in carcinoma cervix patients: An effective, safe, and economical practice.

CONTEXT: Radiotherapy is a very effective treatment modality for pelvic malignancies such as carcinoma of the cervix. However, it is quite common for chronic radiation proctitis (CRP) to manifest after radical radiotherapy. CRP is a source of significant morbidity, and there is a lack of effective treatment modalities. There also exists a general lack of guidelines on management of CRP. AIMS: To assess the benefit from 4% formalin application for the treatment of Grade >2 CRP among patients previously treated with radical radiotherapy for cervical carcinoma. SETTINGS AND DESIGN: This retrospective descriptive study involved 29 eligible patients who were treated from November 2010 - November 2015 for CRP with 4% formalin application. MATERIALS AND METHODS: Of the 1864 patients of carcinoma cervix treated during the said patients, 29 patients fulfilled the eligibility criteria. Eligible patients were invited telephonically for follow-up and were assessed for response and complications of the procedure. RESULTS: The treatment of hemorrhagic radiation proctitis with local formalin instillation is effective, well tolerated and safe procedure. The procedure is inexpensive, technically simple and can be done on an outpatient basis. 62% patients had complete freedom from rectal bleed, while 34.5% patients had partial benefit. Only one patient required diversion colostomy for persistent bleeding.

The diagnostic accuracy of colonoscopic brush cytology in diagnosis of colorectal malignancies: A study of 49 patients.

AIMS: To find the spectrum and frequency of lower gastrointestinal malignancies and diagnostic accuracy of colonoscopic brush cytology in their diagnosis. MATERIALS AND METHODS: This was a prospective study carried out on 49 patients in the Department of Pathology over 1 year. Brushing material was smeared directly onto at least two clean glass slides. The air dried smears were stained with May Grunwald Giemsa stain. The endoscopic biopsies were examined grossly and were fixed in 10% formalin, processed and stained with Hematoxylin and Eosin stain, respectively. Special stains were used wherever required. OBSERVATION AND RESULTS: The study was done on 49 patients presented with colorectal and anal lesions. Age of the patients ranged from 17 to 72 years with male to female ratio being 1.57:1. On statistical analysis, the sensitivity of colonoscopic brush cytology was found to be 85.71% and specificity 61.53%. The accuracy came out to be 79.16%. CONCLUSION: Brush cytology is a reliable, safe, inexpensive, and rapid method of diagnosing gastrointestinal lesions. Since brushing is a relatively noninvasive procedure, routine use of brushings of colonoscopically visible lesions should be done, in addition, to biopsy to increase the diagnostic yield.

Spatial gradients of polycyclic aromatic hydrocarbons (PAHs) in air, atmospheric deposition, and surface water of the Ganges River basin.

Polycyclic aromatic hydrocarbons (PAHs) are ubiquitous semi-volatile organic pollutants. Their environmental occurrence is of global concern as some of them are carcinogens, mutagens, and teratogens. In this study, concentrations and distributions of 16 priority PAHs (∑PAHs) were measured in air, atmospheric deposition, and surface water at various locations in Himalayan, Middle, and Lower Reaches of the Ganges River, covering a spatial transect of 2500km, during two seasons (pre-monsoon and monsoon). The concentration of ∑PAHs ranged between 2.2 and 182.2ngm-3 in air, between 186 and 8810ngm-2day-1 in atmospheric deposition, and between 0.05 and 65.9ngL-1 in surface water. Air concentrations were strongly correlated with human population density. In the Middle and Lower Reaches of the Ganges River, atmospheric PAHs were mainly attributed to fossil fuel combustion sources. In the Himalayan Reach the influence of forest fire or biomass combustion was evident during the dry pre-monsoon season. Seasonality in concentrations of PAHs in river water was evident in the Himalayan Reach of the river, as a probable consequence of climate-modulated secondary source intensity (i.e. releases from glacier melting). Seasonality faded in the Middle and Lower Reaches of the Ganges where water contamination is expected to mainly reflect anthropogenic primary sources. Ambient air concentrations were used to calculate the probabilistic incremental lifetime cancer risk (ILCR). It was expectedly found to be higher in the Middle and Lower Reaches compared to the Himalayan Reach. The strong correlation between population density and air concentrations suggests population density may be used as a surrogate variable to assess human health risk in data-sparse regions such as the Ganges River basin.

Unusual presentation of adult Marfan syndrome as a complex diaphragmatic hiatus hernia.

Marfan syndrome is multisystem connective tissue disorder that primarily involves the skeletal, cardiovascular, and ocular systems. The gastrointestinal complications in Marfan syndrome are rare, with only a few case reports described in the literature. We present a 25-year-old woman who presented with acute abdominal pain for 1 day. The imaging features revealed complex diaphragmatic hiatus hernia with organoaxial gastric volvulus. This is a unique case report about an adult patient with Marfan syndrome who presented with symptomatic paraesophageal hernia and organoaxial gastric volvulus.

Diagnostic accuracy of endoscopic brush cytology in malignancies of upper gastrointestinal tract: A prospective study of 251 patients in North India.

AIM: To find the spectrum and frequency of upper gastrointestinal malignancies and diagnostic accuracy of endoscopic brush cytology in their diagnosis. MATERIALS AND METHODS: This study was a prospective study carried out on 251 patients over 1-year in the Department of Pathology. Brushing material was smeared directly on to at least two clean glass slides and was stained with May-Grunwald-Giemsa stain. The endoscopic biopsies were examined grossly and were fixed in 10% formalin, processed, and stained with hematoxylin and eosin stain. OBSERVATION AND RESULTS: The age range of the patients varied from 8 to 90 years, with the mean being 56 years. Male to female ratio was 2.5:1. On brush cytology, out of 251 cases, 110 had benign lesions and 97 had malignant lesions. Forty-four samples were considered suspicious of malignancy. On histopathology, benign lesions were present in 105 patients while malignant lesions were seen in 139 patients. In seven cases, results were inconclusive due to inadequate/superficial biopsy. STATISTICAL ANALYSIS: Statistical analysis revealed the overall sensitivity of upper gastrointestinal brush cytology as 83.45% and specificity 80.95%. The accuracy of brush cytology came out to be 82.37% in upper gastrointestinal tract. CONCLUSION: Brush cytology is a reliable, safe, inexpensive, and rapid method of diagnosing upper gastrointestinal lesions. Although endoscopic biopsies are established gold standard for diagnosing gastrointestinal malignancy, use of both biopsy and brushing together increases the diagnostic accuracy.

Perfluoroalkyl substances (PFAS) in river and ground/drinking water of the Ganges River basin: Emissions and implications for human exposure.

Many perfluoroalkyl substances (PFAS) are ubiquitous environmental contaminants. They have been widely used in production processes and daily-use products or may result from degradation of precursor compounds in products or the environment. India, with its developing industrialization and population moving from traditional to contemporary lifestyles, represents an interesting case study to investigate PFAS emission and exposure along steep environmental and socioeconomic gradients. This study assesses PFAS concentrations in river and groundwater (used in this region as drinking water) from several locations along the Ganges River and estimates direct emissions, specifically for PFOS and PFOA. 15 PFAS were frequently detected in the river with the highest concentrations observed for PFHxA (0.4-4.7 ng L(-1)) and PFBS (

Neuroprotective Effects of Agomelatine and Vinpocetine Against Chronic Cerebral Hypoperfusion Induced Vascular Dementia.

Chronic cerebral hypoperfusion (CCH) has been considered as a critical cause for the development of cognitive decline and dementia of vascular origin. Melatonin receptors have been reported to be beneficial in improving memory deterioration. Phosphodiesterase-1 (PDE1) enzyme offers protection against cognitive impairments and cerebrovascular disorders. Aim of this study is to explore the role of agomelatine (a dual MT1 and MT2 melatonin receptor agonist) and vinpocetine (selective PDE1 inhibitor) in CCH induced vascular dementia (VaD). Two vessel occlusion (2VO) or bilateral common carotid arteries ligation method was performed to initiate a phase of chronic hypoperfusion in mice. 2VO animals have shown significant cognitive deficits (Morris water maze), cholinergic dysfunction (increased acetyl cholinesterase -AChE) activity alongwith increased brain oxidative stress (decreased brain catalase, glutathione, as well as superoxide dismutase with an increase in malondialdehyde levels), and significant increase in brain infarct size (2,3,5- triphenylterazolium chloride-TTC staining). Treatment of agomelatine and vinpocetine reduced CCH induced learning and memory deficits and limited cholinergic dysfunction, oxidative stress, and tissue damage, suggesting that agomelatine and vinpocetine may provide benefits in CCH induced VaD.

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.

Intrarectal application of formalin for chronic radiation proctitis: a simple, cheap and effective treatment.

BACKGROUND: Chronic radiation proctitis is known to be a difficult to treat condition. Argon Plasma Coagulation (APC) though being effective requires prolonged sessions and has limited availability. Formalin, by virtue of its chemical cauterizing effects, has been found to be effective in patients with bleeding radiation cystitis and hemorrhagic proctitis. Our goal was to study the effectiveness of 4% formalin instillation in resistant patients of chronic hemorrhagic radiation proctitis. METHODS: 13 patients with chronic radiation proctitis were treated with instillation of 50 mi 4% formalin into the rectum (3 minutes for 3 times). The total mucosal contact time was approximately 10 minutes. Their clinical response, tolerance to treatment and complications were assessed. Patients who did not have complete response were given another session(s) a week later. RESULTS: The mean (SD) age of patients was 48.62 +/- 11.66 years. Twelve patients (92%) were female who received radiotherapy for carcinoma cervix and 1(08%) was male with carcinoma prostate. The overall clinical response rate was 100%; eight patients (61.5%) had complete cessation of bleeding while 5 patients (38.5%) had significant cessation of bleeding. Eight patients needed only one session, four needed 2 sessions and one patient needed 3 sessions for the clinical response. Serious complications were not observed. No recurrence of symptoms was seen during follow-up. CONCLUSION: The treatment of hemorrhagic radiation proctitis with local formalin instillation is effective, well tolerated, inexpensive, technically simple and safe procedure.

Topological descriptors in modeling the agonistic activity of human A3 adenosine receptor ligands: the derivatives of 2-chloro-N(6)-substituted-4'-thioadenosine-5'-uronamide.

The human A(3) adenosine receptor agonistic activity of 2-chloro-N(6)-substituted-4'-thioadenosine-5'-uronamides has been analyzed through Combinatorial Protocol in Multiple Linear Regression (CP-MLR) using 488 topological descriptors obtained from DRAGON software for the energy minimized 3D-structures of these molecules. Among the various descriptor classes considered in the study, the human A(3) adenosine receptor agonistic activity is correlated with simple topological descriptors (TOPO), Modified Burden eigenvalues (BCUT) and functional group (FUNC) classes of descriptors. The average valence connectivity index of order zero, X0Av, the sum of topological distances between O and Cl, T (O...Cl) from the TOPO class, the lowest eigenvalue n.2 of Burden matrix/weighted by atomic masses, BELm2, from the BCUT class and the number of secondary aliphatic amides, nCONHR, from FUNC class have contributed significantly in the development of a statistical sound models. The models developed and the participating descriptors suggest that the substituent groups at N(6)-position and/or 5'-uronamide of 2-chloro-N(6)-substituted-4'-thioadenosine-5'-uronamide derivatives hold scope for structural modification in the optimization of activity.

Facial palsy as first presentation of acute myeloid leukemia.

Granulocytic sarcoma or chloroma is a tumor composed of myeloblast or monoblast. These tumors may be found in any location of the body and occur in 5% of acute myeloid leukemia (AML) cases and are more common in pediatric patients. In this report we describe the case of a 27-year-old male who developed lower motor neuron seventh nerve palsy followed by swelling of the parotid gland. Fine-needle aspiration cytology (FNAC) of the soft tissue swelling revealed scattered blasts, and peripheral smear and bone marrow aspirate examination suggested AML. This is a rare presentation of a granulocytic sarcoma leading to a diagnosis of AML.