Laryngotracheal Resection in Thyroid Cancer - Experience from a Single Centre Series of 22 Cases.

Involvement of the aerodigestive tract is reported in one-third of patients with locally invasive thyroid cancer. It is associated with significant morbidity and mortality, with airway obstruction being the immediate cause of death in 50% of patients who die of thyroid cancer. Management is challenging and includes the risks of extensive surgery as well as decisions regarding the type of surgery and adjuvant therapy. Retrospective cohort study, reporting institutional experience with patients who underwent laryngotracheal resection for invasive thyroid cancer over the past 10 years. Twenty-two patients were included in the study. All patients had Shin stage 4 disease. The median follow-up was 18 months. Five patients had systemic metastasis at diagnosis. Nineteen patients underwent tracheal resection and end to end anastomosis, and 3 underwent laryngectomy. The mean length of the resected trachea was 2.94 cm. Tracheal releasing manoeuvres were utilized in 11 patients. Three patients required a tracheostomy postoperatively. Other complications included a temporary vocal cord palsy in 5 patients, temporary hypocalcemia in 6 and permanent hypocalcemia in 1 patient. Adjuvant radiotherapy was utilized in 9 patients and I-131 therapy in 13 patients. Three patients died during follow-up. Two patients developed thyroid bed recurrence, two patients developed systemic metastasis on follow-up. Most patients survived for a prolonged period with only biochemical evidence of disease persistence and three with no evidence of disease. Laryngotracheal resection with primary anastomosis is a safe and effective option, providing adequate symptomatic relief as well as prolonged survival in carefully selected patients with invasive Shin stage 4 disease.

The utility of indocyanine green (ICG) for the identification and assessment of viability of the parathyroid glands during thyroidectomy.

We conducted this study to evaluate the ability of indocyanine green (ICG) and near infra-red fluorescence (NIRF) camera to aid in the identification and assessment of viability of parathyroid glands during thyroid surgery. A prospective observational study was conducted between May and October 2020 among 50 consecutive patients who underwent total thyroidectomy at a single institution. Parathyroid glands were identified under white light during thyroidectomy following which reconstituted ICG was injected through a peripheral vein and the location of parathyroid glands was confirmed. The perfusion to the parathyroid gland was assessed by documenting the fluorescence intensity score (FIS) and the parathyroid angiogram score (PAS). There was no difference in the number of parathyroid glands seen on visual inspection 147 (73.5%) when compared to under NIRF camera, 146 (73%). Though the rate of postoperative hypoparathyroidism was lower in the cohort with FIS 3 (14.2%) compared to score 2 and 1 (28.5% and 100%, respectively), this was not significant (p = 0.35). A significant correlation was noted between a delayed flow on PAS and the development of post-thyroidectomy hypoparathyroidism (p = 0.01). PAS had a sensitivity of 100%, specificity of 88.6%, NPV of 100% and PPV of 55.6% to predict the development of post-thyroidectomy hypoparathyroidism. In this study, there was no additional benefit of ICG and NIRF camera in the identification of parathyroid glands. However, ICG angiogram seems to be a good adjunct for the intraoperative assessment of the viability of the parathyroid glands and accurately predicts the development of postoperative hypoparathyroidism.

Sentinel Lymph Node Biopsy in Early Breast Cancer Using Methylene Blue Dye Alone: a Safe, Simple, and Cost-Effective Procedure in Resource-Constrained Settings.

Sentinel lymph node biopsy (SLNB) is done by different techniques in clinically node-negative patients with early breast cancer. In this study, we aim to estimate the identification rates, positivity rates, cost-effectiveness, and outcomes for patients who underwent sentinel node biopsy using methylene blue dye alone. This was a retrospective review of 172 patients with early breast cancer (cT1-3, N0) who underwent SLNB using methylene blue dye alone between January 2014 and December 2018 including their follow-up details until December 2019. The mean age was 51 ± 10.3 (range: 28 to 76) years. There were 63 (36.6%) patients with cT1 tumor, 108 (62.7%) with cT2, and only 1 patient with cT3 tumor. Breast conservation surgery was performed in 62 (36%) while the remaining 110 (64%) underwent simple mastectomy. Sentinel nodes were successfully identified in 165 (95.9%) with a positivity rate of 23.6%. There was no dye-related adverse reactions intra-operatively. The mean duration of follow-up was 26.68 ± 15.9 months (range: 1-60). Chronic arm pain was present in 7 (4%) while none of the patients had lymphedema or restriction of shoulder joint motion. There were no documented axillary nodal recurrences in this cohort. Eight (4.65%) patients were detected to have systemic metastasis. One patient died of brain metastasis from bilateral breast cancer. The mean disease-free survival was 57 months (95% CI: 55-59). Sentinel lymph node biopsy using methylene dye alone is a safe, simple, and cost-effective alternative to isosulfan blue or radio isotope technique in surgical centers with resource constraints.

INASL Position Statements on Prevention, Diagnosis and Management of Hepatitis B Virus Infection in India: The Andaman Statements.

Hepatitis B Virus (HBV) infection is one of the major causes of morbidity, mortality and healthcare expenditure in India. There are no Indian consensus guidelines on prevention, diagnosis and management of HBV infection. The Indian National Association for Study of the Liver (INASL) set up a taskforce on HBV in 2016, with a mandate to develop consensus guidelines for diagnosis and management of HBV infection, relevant to disease patterns and clinical practices in India. The taskforce first identified contentious issues on various aspects of HBV management, which were allotted to individual members of the taskforce who reviewed them in detail. A 2-day round table discussion was held on 11th and 12th February 2017 at Port Blair, Andaman & Nicobar Islands, to discuss, debate, and finalize the consensus statements. The members of the taskforce reviewed and discussed the existing literature threadbare at this meeting and formulated the 'INASL position statements' on each of the issues. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong: 1, weak: 2) thus reflects the quality (grade) of underlying evidence (A, B, C, D). We present here the INASL position statements on prevention, diagnosis and management of HBV in India.

Etiology and mode of presentation of chronic liver diseases in India: A multi centric study.

There is a paucity of health policy relevant data for chronic liver disease from India, impeding formulation of an interventional strategy to address the issue. A prospective, multicentric study to delineate the etiology and clinical profile of chronic liver disease in India is reported here. A centrally coordinated and monitored web-based data repository was developed (Feb, 2010 to Jan, 2013) and analyzed. Eleven hospitals from different parts of India participated. Data were uploaded into a web based proforma and monitored by a single centre according to a standardized protocol. 1.28% (n = 266621) of all patients (n = 20701383) attending the eleven participating hospitals of India had liver disease. 65807 (24·68%) were diagnosed for the first time (new cases). Of these, 13014 (19·77%, median age 43 years, 73% males) cases of chronic liver disease were finally analyzed. 33.9% presented with decompensated cirrhosis. Alcoholism (34·3% of 4413) was the commonest cause of cirrhosis while Hepatitis B (33·3%) was predominant cause of chronic liver disease in general and non-cirrhotic chronic liver disease (40·8% out of 8163). There was significant interregional differences (hepatitis C in North, hepatitis B in East and South, alcohol in North-east, Non-alcoholic Fatty Liver Disease in West) in the predominant cause of chronic liver disease. Hepatitis B (46·8% of 438 cases) was the commonest cause of hepatocellular Cancer.11·7% had diabetes. Observations of our study will help guide a contextually relevant liver care policy for India and could serve as a framework for similar endeavor in other developing countries as well.

Assessment of Disease Severity and Role of Cytomegalo Virus Infection in Patients with Ulcerative Colitis.

INTRODUCTION: Course of Ulcerative Colitis is characterized by intermittent flares interposed between variable periods of remission. Identification of exacerbating factors and appropriate assessment of disease activity are crucial in deciding the choice of treatment. AIM: To evaluate various clinical, endoscopic and histological parameters in assessing disease activity and to find out various risk factors involved in the exacerbation of ulcerative colitis especially the role of Cytomegalo Virus (CMV) infection. MATERIALS AND METHODS: It was a prospective study of patients diagnosed as ulcerative colitis presenting with acute exacerbation of symptoms (cases) and those who were in remission (controls). A detailed evaluation of the disease history including personal history, treatment compliance and clinical disease severity were noted. Investigations including blood routine, endoscopic examination with biopsy, histopathological examination and immunohistochemistry for CMV were done on the biopsy sample. RESULTS: A total of 58 patients with ulcerative colitis were studied which included 37 cases and 21 controls. Out of the various clinical and demographic parameters, Good treatment compliance (p =0.0003) and Perceived Stress Scale (PSS) score (p=0.0001) showed significant difference between cases and controls. Basic laboratory parameters {Haemoglobin level, Total Leucocyte Count (TLC) and Erythrocyte Sedimentation Rate (ESR)}, clinical disease severity predictors (Truelove and Witt's criteria, Mayo score and endoscopic disease severity grade) and Geboes histological scoring showed significant difference between cases and controls. The prevalence of CMV colitis in our study was only 5.4% (two cases). CONCLUSION: Clinical and endoscopic disease severity indicators can be used as predictors of histological activity in ulcerative colitis. Poor treatment compliance and stress are important risk factors for acute exacerbation of ulcerative colitis. Clinicians should be aware of the possibility of concurrent CMV infection while treating patients with acute exacerbation of ulcerative colitis not responding to the conventional management. Reduced prevalence of CMV colitis in cases of acute exacerbation of ulcerative colitis in our study may be due to the small sample size, reduced number of steroid dependent cases or reduced severity of our cases.

Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance.

PURPOSE: To investigate the impact of the primary (PSA) and secondary (SSA) spherical aberration terms on visual performance (VP) in presbyopes, as measured using multifocal (MFCL) soft contact lenses on eye. METHODS: Seventeen presbyopes (age: 55.1 ± 6.9 years) wore seven commercial lenses (four center-near (MFCL N), one center-distance (MFCL D), one bifocal, and one single vision control). Unaided and with each lens on eye, the PSA and SSA terms were obtained with an aberrometer, the BHVI-EyeMapper (low illumination, natural and 4 mm pupil diameter). High- and low-contrast distance visual acuity, contrast sensitivity, high-contrast visual acuities at near, and range of clear vision were measured. In addition, subjective VP variables included clarity of vision at distance and near, ghosting, and overall vision satisfaction. Pearson's correlation was used to determine the association between the PSA and SSA terms and the VP variables. RESULTS: PSA (natural pupil) was more negative (P < .05) with the MFCL N (mean PSA = -0.053 ± 0.080 µm) and bifocal (PSA = +0.005 ± 0.067 µm) lenses and more positive with the MFCL D lens (PSA = +0.208 ± 0.160 µm) than the control (+0.067 ± 0.072 µm). SSA (natural pupil) was significantly more positive for the MFCL N lenses (mean SSA = +0.025 ± 0.029 µm) compared to the control (SSA = -0.001 ± 0.017 µm). PSA and SSA terms were significantly (P < .05) correlated with 78% and 56% of VP variables, respectively, but the correlation coefficients were weak, ranging between |0.210| and |0.334|. Although distance variables showed improved VP with more positive PSA or negative SSA, most near variables showed improved VP with more negative PSA. Range of clear focus was greater for more negative PSA terms. CONCLUSIONS: The amount and direction of PSA and SSA terms, as measured with different MFCLs on eye, can affect VP at different distances. Results of this study may provide useful information when designing new or optimize existing MFCLs for improved VP at specific distances.

Short-term visual performance of soft multifocal contact lenses for presbyopia / Desempenho visual de curto prazo de présbitas usando diferentes lentes de contato multifocais hidrofílicas

ABSTRACT Purpose: To compare visual acuity (VA), contrast sensitivity, stereopsis, and subjective visual performance of Acuvue® Oasys® for Presbyopia (AOP), Air Optix® Aqua Multifocal (AOMF), and Air Optix® Aqua Single Vision (AOSV) lenses in patients with presbyopia. Methods: A single-blinded crossover trial was conducted. Twenty patients with mild presbyopia (add ≤+1.25 D) and 22 with moderate/severe presbyopia (add ≥+1.50 D) who wore lenses bilaterally for 1 h, with a minimum overnight washout period between the use of each lens. Measurements included high- and low-contrast visual acuity (HCVA and LCVA, respectively) at a distance, contrast sensitivity (CS) at a distance, HCVA at intermediate (70 cm) and near (50 cm & 40 cm) distances, stereopsis, and subjective questionnaires regarding vision clarity, ghosting, overall vision satisfaction, and comfort. The test variables were compared among the lens types using repeated-measures ANOVA. Results: Distance variables (HCVA, LCVA, and CS) were significantly worse with multifocal lens than with AOSV lens (p≤0.008), except for AOMF lens in the mild presbyopia group in which no significant difference was observed (p>0.05). Multifocal lenses had significantly greater HCVA at 40 cm than AOSV lens (p≤0.026). AOMF lens had greater intermediate HCVA than AOP lens (p<0.03). AOP lens demonstrated greater improvements in stereopsis than AOMF and AOSV lens in the moderate/severe presbyopia group (p≤0.03). Few significant differences in subjective variables were observed, with no significant difference in the overall vision satisfaction observed between lens types (p>0.05). The proportions of patients willing to buy AOSV, AOMF, and AOP lenses were 20%, 40%, and 50%, respectively, in the mild presbyopia group and 14%, 32%, and 23%, respectively, in the moderate/severe presbyopia group; however, these differences were not statistically significant (p≥0.159). Conclusions: Further development of multifocal lenses is required before significant advantages of multifocal lenses over single vision lens are observed in patients with presbyopia.

RESUMO Objetivo: Comparar a acuidade visual, sensibilidade ao contraste, estereopsia e desempenho visual subjetivo de présbitas usando lentes de contato Acuvue Oasys para presbiopia (AOP), Air Optix Aqua Multifocal (AOMF) e Air Optix Aqua Single Vision (AOSV). Método: Foi realizado estudo mascarado simples, cruzado. Vinte pacientes com presbiopia baixa (adição ≤+1,25 D) e 22 com presbiopia média/alta (adição ≥+1,50 D) usaram cada lente bilateralmente durante 1 hora, com descanso mínimo de uma noite entre as diferentes lentes. As medições incluíram acuidade visual para distância em alto e baixo contraste (HCVA, LCVA), sensibilidade ao contraste para distância (CS), HCVA para distância intermediária (70 cm) e para perto (50 cm e 40 cm), estereopsia e questionários subjetivos sobre nitidez visual, fantasmas, satisfação visão geral e conforto. As variáveis foram comparadas entre os tipos de lentes, utilizando medidas repetidas ANOVA. Resultados: As variáveis para distância (HCVA, LCVA, CS) foram significativamente piores com as multifocais em relação a AOSV (p≤0,008), exceto para AOMF no grupo de baixa adição, que não foi significativamente diferente (p>0,05). As multifocais foram significativamente melhores do que a AOSV para HCVA em 40 cm (p≤0,026). AOMF superou AOP para HCVA intermediária (p<0,03). AOP superou AOMF e AOSV em relação à estereopsia no grupo de presbiopia médio/alto (p≤0,03). Houve poucas diferenças significativas nas variáveis subjetivas, mas a satisfação visual global não foi significativamente diferente entre as lentes (p>0,05). A disposição para comprar lentes AOSV, AOMF e AOP foi: 20%, 40%, 50%, respectivamente, no grupo de presbiopia baixa; 14%, 32%, 23% no grupo de presbiopia média/alto, mas essas diferenças não foram estatisticamente significativas (p≥0,159). Conclusões: Melhorias futuras parecem ser necessárias para produção de uma lente multifocal que forneça aos présbitas uma vantagem significativa sobre a lente de visão única.

Association Analysis of PRSS1-PRSS2 and CLDN2-MORC4 Variants in Nonalcoholic Chronic Pancreatitis Using Tropical Calcific Pancreatitis as Model.

OBJECTIVE: Association of PRSS1-PRSS2 (rs10273639) and CLDN2-MORC4 (rs12688220 and rs7057398) variants with alcohol-related chronic pancreatitis (CP) is established but with nonalcoholic CP is unclear. We addressed this inconsistency using tropical calcific pancreatitis (TCP) as model. METHODS: We sequenced 5'-UTR of PRSS1 and genotyped CLDN2-MORC4 variants in 555 patients with TCP and 801 controls and performed association analysis. Gene-gene interaction between PRSS1 and CLDN2-MORC4 variants and with p.Asn34Ser SPINK1 and p.Leu26Val CTSB was also evaluated. RESULTS: We observed significant association of rs10273639/rs4726576 in PRSS1-PRSS2 (odds ratio [OR] = 0.72; P = 3.50 × 10) and CLDN2-MORC4 variants, rs12688220 (OR = 1.54; P = 1.22 × 10) and rs7057398 (OR = 1.50; P = 1.22 × 10) with TCP. Patients carrying p.Asn34Ser SPINK1 were significantly younger than those with rs4726576 risk genotype (30.0 vs 38.0 years; P = 0.015) and those carrying both were even younger (22.0 years; P = 0.001). Presence of risk allele at rs12688220 in patients carrying p.Asn34Ser SPINK1 delayed the age of onset (32.0 vs 24.0 years; P = 0.013). CONCLUSIONS: Our study establishes strong association of PRSS1-PRSS2 and CLDN2-MORC4 variants with TCP and thus with nonalcoholic CP. These variants independently interact with p.Asn34Ser SPINK1 and influence the age of onset in TCP. However, latter results need to be replicated in other cohorts.

Comprehensive screening of chymotrypsin C (CTRC) gene in tropical calcific pancreatitis identifies novel variants.

OBJECTIVE: In a previous study, the authors have shown that rather than variants in trypsinogen gene(s), mutations in pancreatic secretory trypsin inhibitor (encoded by SPINK1) and cathepsin B (CTSB) are associated with tropical calcific pancreatitis (TCP). Recently, chymotrypsin C (CTRC) variants that diminish its activity or secretion were found to predict susceptibility to chronic pancreatitis (CP). The authors analysed CTRC variants in a large, ethnically matched case-control TCP cohort. DESIGN: The authors sequenced all eight exons and flanking regions in CTRC in 584 CP patients (497 TCP, 87 idiopathic CP) and 598 normal subjects and analysed the significance of association using χ(2) test. The authors also investigated interaction of CTRC variants with p.N34S SPINK1 and p.L26V CTSB mutations. RESULTS: The authors identified 14 variants in CTRC, of which non-synonymous variants were detected in 71/584 CP patients (12.2%) and 22/598 controls (3.7%; OR 3.62, 95% CI 2.21 to 5.93; p=6.2 × 10(-8)). Rather than the commonly reported p.K247_R254del variant in Caucasians, p.V235I was the most common mutation in Indian CP patients (28/575 (4.9%); OR 7.60, 95% CI 2.52 to 25.71; p=1.01 × 10(-5)). Another pathogenic variant, p.A73T was identified in 3.1% (18/584) patients compared with 0.3% (2/598) in controls (OR=9.48, 95% CI 2.19 to 41.03, p=2.5 × 10(-4)). The authors also observed significant association for the synonymous variant c.180C>T (p.(=)) with CP (OR 2.71, 95% CI 1.79 to 4.12, p=5.3 × 10(-7)). Two novel nonsense mutations, p.G242AfsX9 and p.W113X were also identified exclusively in CP patients. No interaction between CTRC variants and p.N34S SPINK1 or p.L26V CTSB mutations was observed. CONCLUSION: This study on a large cohort of TCP patients provides evidence of allelic heterogeneity and confirms that CTRC variants play a significant role in its pathogenesis.

Hepatitis B virus subgenotype A1 predominates in liver disease patients from Kerala, India.

AIM: To molecularly characterize hepatitis B virus (HBV) isolates from Kerala and to relate them to the clinical manifestation of infection. METHODS: Sera and clinical data were collected from 91 patients diagnosed with chronic HBV infection and HBV-related hepatocellular carcinoma (HCC). HBV from 44 HCC, 22 cirrhotic and 25 chronic hepatitis patients were genotyped by sequencing of the complete S region or by restriction fragment length polymorphism assays. The basic core promoter/precore region was sequenced. The complete surface DNA sequences were assembled and aligned manually, and then compared with the sequences of HBV of genotypes (A-J) from GenBank. The evolutionary history was inferred using the Neighbor-Joining method and the evolutionary distances computed using the Kimura 2-parameter method. Bootstrapping was performed using 1000 replicates. The TaqMan BS-1 probe was used to quantify HBV DNA at a lower detection limit of approximately 20 IU/mL. Continuous variables were compared using an independent Student's t test. The χ² test or Fisher's exact test was used to compare categorical variables. The differences were considered statistically significant at P < 0.05. RESULTS: Irrespective of disease status, the predominant genotype was A (72%); 95% belonging to subgenotype A1, followed by genotypes D (27%) and C (1%). HCC patients infected with subgenotype A1 were significantly younger than those infected with D. Mutation A1762T/G1764A was significantly associated with HCC in both genotypes A and D. Mutation G1862T was more frequent in subgenotype A1 (P < 0.0001), and in combination with A1762T/G1764A, it was significantly associated with HBV from HCC patients. Mutation C1766T/T1768A was significantly associated with genotype A (P = 0.05) and HCC (P = 0.03). The preS2 start codon M1T/I mutation was unique to genotype A strains (15.6%) from all disease groups and occurred at a higher frequency in isolates from HCC patients (P = 0.076). A higher frequency of preS deletion mutants (33.3%) was observed in genotype A from HCC compared with non-HCC patients, but did not reach statistical significance. The preS2:F22L mutation was found in genotypes A and D. CONCLUSION: Kerala is the first Indian state in which subgenotype A1 has been found to predominate in liver disease patients who developed HCC at a relatively young age.

Isolated rectal tuberculosis in an AIDS patient masquerading as malignancy.

Tuberculosis may involve any region of the gastrointestinal tract but involvement of the rectum is rare. The literature concerning rectal tuberculosis in AIDS patients is limited. We report the case of rectal tuberculosis mimicking malignancy, both clinically and endoscopically, in an AIDS patient. Histopathology confirmed the diagnosis. Treatment was initiated with antituberculous drugs and highly active antiretroviral therapy (HAART). The patient developed drug-induced hepatitis, his general condition deteriorated and he finally succumbed to his illness.

Chronic pancreatitis. A prospective nationwide study of 1,086 subjects from India.

CONTEXT: Chronic pancreatitis is common in India. However, its risk factors are not clear. There is sparse data on the current prevalence of tropical pancreatitis in India. OBJECTIVE: To undertake a prospective nationwide study of the risk factors and clinical profile of chronic pancreatitis. SETTING: Thirty-two major centers from different regions of India contributed data on 1,086 patients to a common online website (www.ipans.org). MAIN OUTCOME MEASURES: Risk factors, clinical features complications and treatment of chronic pancreatitis. RESULTS: Of the 1,086 subjects, complete data on risk factors were available for 1,033 subjects. Idiopathic pancreatitis was the most common form of pancreatitis (n=622; 60.2%) and alcoholic chronic pancreatitis accounted for about a third of the cases (n=400; 38.7%); the rest (n=11; 1.1%) had rare risk factors. Smoking and cassava intake were documented in 292 (28.3%) and 189 (18.3%) subjects, respectively. Using well-defined criteria, only 39 (3.8%)cases could be labeled as 'tropical pancreatitis'. Pain occurred in 971 patients (94.0%). Four hundred and eighteen (40.5%) subjects had diabetes mellitus. Of alcohol consumers, alcoholism and female gender were independent risk factors for diabetes in subjects with chronic pancreatitis (OR=1.48, P=0.003; and OR=1.75, P<0.001, respectively). The most common complications were pseudocysts (15.8%) and biliary obstruction (8.2%). Pancreatic cancer occurred in 42 subjects (4.1%). Ultrasound detected calculi in 69.7%, ductal dilatation in 63.4% and atrophy in 27.3%. The majority of patients were on medical therapy (n=849; 82.2%); endotherapy and surgery accounted for the rest. About 50% percent of the patients with diabetes required insulin (198/418). CONCLUSIONS: In this first nationwide prospective survey of chronic pancreatitis in India, idiopathic pancreatitis was the most common form, followed by alcoholic pancreatitis. The classical form of tropical chronic pancreatitis is becoming less common.

TCF7L2 gene polymorphisms do not predict susceptibility to diabetes in tropical calcific pancreatitis but may interact with SPINK1 and CTSB mutations in predicting diabetes.

BACKGROUND: Tropical calcific pancreatitis (TCP) is a type of chronic pancreatitis unique to developing countries in tropical regions and one of its important features is invariable progression to diabetes, a condition called fibro-calculous pancreatic diabetes (FCPD), but the nature of diabetes in TCP is controversial. We analysed the recently reported type 2 diabetes (T2D) associated polymorphisms in the TCF7L2 gene using a case-control approach, under the hypothesis that TCF7L2 variants should show similar association if diabetes in FCPD is similar to T2D. We also investigated the interaction between the TCF7L2 variants and N34S SPINK1 and L26V CTSB mutations, since they are strong predictors of risk for TCP. METHODS: Two polymorphisms rs7903146 and rs12255372 in the TCF7L2 gene were analyzed by direct sequencing in 478 well-characterized TCP patients and 661 healthy controls of Dravidian and Indo-European ethnicities. Their association with TCP with diabetes (FCPD) and without diabetes was tested in both populations independently using chi-square test. Finally, a meta analysis was performed on all the cases and controls for assessing the overall significance irrespective of ethnicity. We dichotomized the whole cohort based on the presence or absence of N34S SPINK1 and L26V CTSB mutations and further subdivided them into TCP and FCPD patients and compared the distribution of TCF7L2 variants between them. RESULTS: The allelic and genotypic frequencies for both TCF7L2 polymorphisms, did not differ significantly between TCP patients and controls belonging to either of the ethnic groups or taken together. No statistically significant association of the SNPs was observed with TCP or FCPD or between carriers and non-carriers of N34S SPINK1 and L26V CTSB mutations. The minor allele frequency for rs7903146 was different between TCP and FCPD patients carrying the N34S SPINK1 variant but did not reach statistical significance (OR = 1.59, 95% CI = 0.93-2.70, P = 0.09), while, TCF7L2variant showed a statistically significant association between TCP and FCPD patients carrying the 26V allele (OR = 1.69, 95% CI = 1.11-2.56, P = 0.013). CONCLUSION: Type 2 diabetes associated TCF7L2 variants are not associated with diabetes in TCP. Since, TCF7L2 is a major susceptibility gene for T2D, it may be hypothesized that the diabetes in TCP patients may not be similar to T2D. Our data also suggests that co-existence of TCF7L2 variants and the SPINK1 and CTSB mutations, that predict susceptibility to exocrine damage, may interact to determine the onset of diabetes in TCP patients.

Randomized controlled trial of DOTS versus conventional regime for treatment of ileocecal and colonic tuberculosis.

There is limited information regarding the efficacy of 'directly observed treatment short course' (DOTS) in the treatment of intestinal tuberculosis. We randomized patients with ileocecal or colonic tuberculosis to receive daily tuberculosis chemotherapy (Group A) or DOTS (Group B). Patients received isoniazid, rifampicin, pyrazinamide and ethambutol daily for two months in group A and thrice weekly for 2 months in group B, followed by isoniazid and rifampicin daily for 7 months in group A and thrice weekly for 4 months in group B. Patients were followed up at 2 and 4 weeks and monthly thereafter until the end of treatment. Follow up colonoscopy was done at 2 and 6 months after starting treatment. The improvement in clinical symptoms was not different between Groups A (24) and B (23) at 2 and 6 months. Mean increase in weight was 5.1 (0.5) Kg and 5.7 (0.6) Kg at 2 months and 7.1 (1.7) Kg and 6.9 (1.9) Kg at 6 months in Group A and B, respectively. Complete healing of ulceration was noted in 75% of Group A patients and 79% of Group B patients at 2 months and in all patients in both groups at 6 months. We conclude that DOTS and daily chemotherapy are equally effective for treating ileocecal and colonic tuberculosis.

Videoanoscopy: useful technique in the evaluation of hemorrhoids.

BACKGROUND AND AIM: Rigid proctoscopy, the gold standard for detecting hemorrhoids, has become a neglected procedure in the era of flexible endoscopy. Evaluation of hemorrhoids is often done with the retroflexed fiberoptic colonoscope. The aim of this study was to evaluate the technique of videoanoscopy in comparison with retroflexion of colonoscope in the rectum to detect hemorrhoids and to correlate objective findings of hemorrhoids and their relation to bleeding. METHODS: In total, 544 patients were screened and 358 patients were evaluated by the technique of videoanoscopy and retroflexion of colonoscope in the rectum. The video images of both the procedures were independently analyzed by two observers for the presence or absence of hemorrhoids. The videoanoscopy images were also analyzed for number of columns of hemorrhoids, size and presence of red-color sign. RESULTS: Videoanoscopy detected hemorrhoids in a significantly higher number of subjects when compared with retroflexion of colonoscope in the rectum by both observers (P < 0.05). The average kappa value was 0.637 and 0.779 for retroflexed colonoscopy and videoanoscopy, respectively. Red-color sign was present in 80.5% of patients with bleeding compared with only 30.3% in the non-bleeding group. The majority (71%) of patients in the bleeding group had larger hemorrhoids. Red-color sign and size of hemorrhoidal columns correlated with bleeding (P < 0.05). CONCLUSION: Videoanoscopy is a simple technique with increased sensitivity to detect hemorrhoids compared with intrarectal retroflexion of colonoscope and yields valuable objective information about the presence and condition of hemorrhoids. It should be performed as an extension of standard colonoscopy.

Endoscopic abnormalities in the oesophagus after variceal sclerotherapy--a long-term follow up study.

Endoscopic sclerotherapy is a well-established treatment modality for oesophageal varices. Various local, regional and systemic complications occur after sclerotherapy. Altered endoscopic appearances of the oesophagus have been observed on follow-up of patients after sclerotherapy. 171 consecutive patients with extra-hepatic portal venous obstruction on follow up after achieving variceal eradication by sclerotherapy during the period from January 2004 to June 2005 were enrolled in this study. The oesophagus was closely observed for mucosal abnormalities and the endoscopic findings were recorded. Out of 171 patients, 95 (55.5%) patients had no specific endoscopic changes in the oesophagus. The most common finding was mucosal neovascularization which was seen in 56 (32.7%) patients. Oval or oblong depressed areas were seen in 41 (23.9%) patients. Mucosal tags and polypoidal lesions were seen in 37 (21.6%) patients. 25 (15.6%) patients had stenosis of the lower oesophagus and 3 (1.7%) patients had mucosal bridges. On multivariate analysis, these abnormal endoscopic findings in the oesophagus correlated with the total volume of sclerosant injected when compared with those patients without similar findings on endoscopy (p value < 0.001). Endoscopic sclerotherapy leads to various abnormalities at the injection sites like neovascularization, oval or oblong depressed areas, mucosal tags, polypoidal lesions, stenosis and mucosal bridges. Endoscopic abnormalities correlated with the total volume of sclerosant used. The long-term significance of these changes is not known at present and further follow-up studies will be required.

Profile of colonic polyps in a southern Indian population.

BACKGROUND: In Western countries, colonic polyps are usually adenomatous in nature, are evenly distributed along the entire colon in asymptomatic per-sons and show a left-sided predominance in symptomatic patients. There is dearth of such literature from India. METHODS: We retrospectively analyzed reports of colonoscopies done in our institution during the period 2001 to 2005. Clinical features, colonoscopic description and histologic findings of all patients with polyps were noted. Association of the degree of dysplasia with the size, site and type of polyps and the person's age was assessed. RESULTS: Polyps were seen in 124 (5.1%) of 2412 complete colonoscopies. Mean age of patients with polyps was 58.1 (SD 19.9) years; ninety were men. A majority of polyps (92%) were located in the left colon. They were adenomatous in 99 (79.8%), juvenile in 12 (9.8%), hyperplastic in 11 (8.8 %), inflammatory in 1 (0.8%) and Peutz-Jegher's polyp in 1 (0.8%). Dysplasia was severe in large (>2 cm) polyps compared to small (< 1 cm) ones (p< 0.001). Age of patient and location of polyp had no association with degree of dysplasia. CONCLUSIONS: In southern Indian adults, most colonic polyps are adenomatous and are in the left colon. Large polyps are associated with severe dysplasia.