Coconut Water Induces Clinical Remission in Mild to Moderate Ulcerative Colitis: Double-blind Placebo-controlled Trial.

BACKGROUND & AIMS: Coconut water (CW) is anti-inflammatory, can manipulate the gut microbiome, and is a rich source of potassium. Gut microbiome modulation improves outcomes in ulcerative colitis (UC), and potassium possesses in vitro anti-inflammatory property. We evaluated the effect of CW as an adjunct therapy for patients with mild-moderate UC. METHODS: This single-center, double-blind, placebo-controlled trial randomized patients with mild to moderate (Simple Clinical Colitis Activity Index [SCCAI]: 3-9) endoscopically active UC (Ulcerative Colitis Endoscopic Index of Severity [UCEIS] >1) in 1:1 ratio to CW + standard medical therapy (SMT) vs placebo + SMT. Four hundred mL of CW was administered for 8 weeks. Primary outcome measure was clinical remission (SCCAI ≤2), and secondary outcome measures were clinical response (SCCAI decline ≥3) and adverse events at 8 weeks. Microbiome was analyzed at baseline and 8 weeks. RESULTS: Of 121 patients screened, 95 were included for modified intention to treat analysis (CW, n = 49; placebo, n = 46) (mean age, 37.2 ± 11.2 years; males, 54.1%; disease duration, 48 months [interquartile range (IQR), 24-90 months]; pancolitis, 26.1%; SCCAI, 5 [IQR, 4-6]; UCEIS, 4 [IQR, 3-5]). Clinical response (57.1% vs 28.3%; odds ratio [OR], 3.4; 95% confidence interval [CI], 1.4-7.9; P = .01), remission (53.1% vs 28.3%; OR, 2.9; 95% CI, 1.2-6.7; P = .02), and proportion of patients with fecal calprotectin (FCP) <150 µg/g (30.6% vs 6.5%; OR, 6.3; 95% CI, 1.7-23.6; P = .003) were significantly higher in CW. The relative abundance of bacterial taxa that had a significant or trend towards negative correlation with SCCAI, UCEIS, or FCP increased at 8 weeks in CW, and this effect was independent of disease activity and dietary fiber. Adverse events were comparable, and no patient developed hyperkalemia. CONCLUSIONS: CW was more effective than placebo for induction of clinical remission in patients with mild to moderate UC. The trial was prospectively registered on Clinical Trials Registry of India (ctri.nic.in, Number: CTRI/2019/03/01827).

Next generation imidazothiazole and imidazooxazole derivatives as potential drugs against brain-eating amoebae.

Managing primary amoebic meningoencephalitis, induced by Naegleria fowleri poses a complex medical challenge. There is currently no specific anti-amoebic drug that has proven effectiveness against N. fowleri infection. Ongoing research endeavours are dedicated to uncovering innovative treatment strategies, including the utilization of drugs and immune modulators targeting Naegleria infection. In this study, we explored the potential of imidazo[2,1-b]thiazole and imidazooxazole derivatives that incorporate sulfonate and sulfamate groups as agents with anti-amoebic properties against N. fowleri. We assessed several synthesized compounds (1f, 1m, 1q, 1s, and 1t) for their efficacy in eliminating amoebae, their impact on cytotoxicity, and their influence on the damage caused to human cerebral microvascular endothelial (HBEC-5i) cells when exposed to the N. fowleri (ATCC 30174) strain. The outcomes revealed that, among the five compounds under examination, 1m, 1q, and 1t demonstrated notable anti-parasitic effects against N. fowleri (P ≤ 0.05). Compound 1t exhibited the highest anti-parasitic activity, reducing N. fowleri population by 80%. Additionally, three compounds, 1m, 1q, and 1t, significantly mitigated the damage inflicted on host cells by N. fowleri. However, the results of cytotoxicity analysis indicated that while 1m and 1q had minimal cytotoxic effects on endothelial cells, compound 1t caused moderate cytotoxicity (34%). Consequently, we conclude that imidazo[2,1-b]thiazole and imidazooxazole derivatives containing sulfonate and sulfamate groups exhibit a marked capacity to eliminate amoebae viability while causing limited toxicity to human cells. In aggregate, these findings hold promise that could potentially evolve into novel therapeutic options for treating N. fowleri infection.

Increased circulating Th17 cell populations in patients with pancreatic ductal adenocarcinoma.

T-helper 17 (Th17) cells are a subset of CD4+ helper T cells that produce interleukin 17 (IL-17) and play a crucial role in the pathogenesis of inflammatory and autoimmune diseases. Few studies have been conducted to determine the role of Th17 cells in the tumorigenesis and development of pancreatic ductal adenocarcinoma (PDAC); however, its role is still unclear. In this study, the percentage of circulating Th17 cells and serum levels of IL-17A and IL-23 were analyzed using flow cytometry and ELISA, respectively, in 40 PDAC patients, 30 chronic pancreatitis (CP) patients and 30 healthy controls (HC). In addition, the mRNA expression levels of IL-17A, STAT3 and RORγt in tissue samples were quantified by qRT-PCR. The results showed that the percentage of circulating Th17 cells and the concentrations of serum IL-17A and IL-23 were significantly increased in PDAC patients as compared to CP and HC (P < 0.001). In addition, the higher level of IL-17A was significantly correlated with the poor overall survival of the PDAC patients. Furthermore, the frequencies of Th17 cells and IL-17A were significantly higher in stage III+IV PDAC patients versus stage I+II. A significant increase in IL-17A, STAT3 and RORγT mRNA was observed in patients with PDAC. Taken together, these findings suggest that the increased circulating Th17 cells and serum IL-17A may be involved in the development and metastasis of PDAC, and thus represent potential targets for the treatment of PDAC.

Clinical significance of Notch pathway-associated microRNA-107 in pancreatic ductal adenocarcinoma.

Background & aim: MicroRNAs associated with the Notch pathway play a critical role in the progression of pancreatic carcinoma. Our aim was to study the clinical significance of miR-107 and NOTCH2 in pancreatic ductal adenocarcinoma (PDAC). Methods: The circulating miR-107 levels in PDAC and controls were determined by qPCR. NOTCH2 protein (target) expression in tissue of PDAC, periampullary carcinoma, chronic pancreatitis and normal pancreatic tissue was assessed by immunohistochemistry. Results: The circulating miR-107 levels were found to be significantly reduced in PDAC as compared with controls. Additionally, NOTCH2 protein expression was higher in PDAC tissue as compared with controls and was clinically associated with metastasis. Conclusion: Our findings demonstrate the utility of circulating miR-107 as a potential differentiating marker in PDAC.

Embedding patient safety in a scaffold of interprofessional education; a qualitative study with thematic analysis.

BACKGROUND: Regardless of a proliferation of interest in reducing unsafe practices in healthcare, threats to patient safety (PS) remain high. Moreover, little attention has been paid towards the role of interprofessional education (IPE) in enhancing PS. This qualitative study was conducted to unfold the insights of the senior medical, dental and health sciences students at the University of Sharjah (UoS) in the United Arab Emirates (UAE) about PS in an online IPE-based workshop. METHODS: This inductive thematic analysis study was conducted on senior medical and health students at the Colleges of Medicine, Dental Medicine, Health Sciences, and Pharmacy of UoS. During an online workshop, students discussed plausible solutions for four real practice-based clinical scenarios with elements of unsafe healthcare practices. During the breakout rooms, the students exhibited high level of articulation and proactively participated in discussions. The data from the online workshop were transcribed and then coding, categorizing, and labelling of recurrent themes were carried out. Multiple individual deliberations, consolidation, incorporation of the identified preliminary themes, and merging and reorganizing sub-themes led to a final thematic framework. RESULTS: This work delved into the perspectives of 248 students regarding teamwork, communication, problem-solving, and other aspects concerning PS in interprofessional settings in an online workshop. The iterative process of data transcription, curating and qualitative analysis surfaced 32 codes. Later, the inductive themaric analysis yielded five themes with distinct yet interconnected nested subthemes in the context of PS in IPE settings. These themes of information sharing and grounding (problem-solving, social skills), maintaining communication (clinical reasoning, shared mental model), executing interprofessional activities (collaborative practice, collaboration scripts), professional cognitive abilities (cognitive maturity, metacognition), and negotiating professional identities (systematic change, socio-economic scaffolding) emerged as fundamental pillars for enhancing PS in healthcare. CONCLUSION: Our study demonstrated the outcome of an innovative and team-based workshop which embedded PS within a scaffold of IPE environment. This research calls for incorporation of the emerging areas of clinical reasoning, problem solving, collaborative practice, and shared mental model into medical curricula for structured IPE in improving PS domains in medical education. These findings underscore the need for multifaceted dimensions of IPE imperatives for cultivating collaborative competence.

Pancreatic hemorrhage contributes to late mortality in patients with acute necrotizing pancreatitis.

OBJECTIVES: The frequency, risk factors, and impact on survival of hemorrhage into (peri)pancreatic collections in patients with acute pancreatitis (AP) has not been well studied. The study was designed to evaluate the risk factors for hemorrhage, successful hemostasis and its effect on in-hospital mortality. METHODS: In a prospective cohort study for prediction of severity of AP, the incidence, risk factors, and outcomes of pancreatic hemorrhage were analyzed. Patients with significant hemorrhage were managed according to a predefined protocol including endovascular intervention. RESULTS: Out of 363 patients hospitalized during the study-period, 33(9%) patients developed hemorrhage. Median time from onset of AP to hemorrhage was 59(45-68) days. The cause of hemorrhage was arterial in 19(57.5%) patients and unlocalized in 14(42.5%) patients. Hemorrhage was managed by conservative approach in 7 (21.2%), radiographic angioembolisation in 16 (48.5%), radiographic angioembolisation followed by surgery in 3 (9.1%), and surgery in 7 (21.2%) patients. Persistent organ failure [aHR 2.3 (1.1-5.1), p = 0.03], use of large bore (>20 Fr) catheter for initial drainage [aHR 3.9 (1.7-9.1), p = 0.001] and extensive (>50%) necrosis [aHR 3.1 (1.4-6.9), p = 0.005] were significant risk factors for hemorrhage. Hemorrhage was an independent predictor of mortality [aHR 2.0 (1.2-3.4), p = 0.008] in addition to persistent organ failure (aHR 12.1 (5.7-25.8), p < 0.001). In-hospital mortality in patients with hemorrhage was 22/33 (66.7%) vs. 81/330 (25%) in no hemorrhage group [p <0.001]. CONCLUSION: Pancreatic hemorrhage occurs later in the course of acute pancreatitis in relatively sicker group of patients with organ failure and extensive necrosis, and is independently associated with a higher risk of in-hospital mortality.

Use of free jejunal flap as a salvage procedure in the management of high corrosive esophageal re-strictures: an institutional experience and review of literature.

BACKGROUND: High pharyngo-esophageal strictures following corrosive ingestion continue to pose a challenge to the surgeon, particularly in the developing world. With the advancements and increased experience with microsurgical techniques, free jejunal flaps offer a viable reconstruction option in patients with high corrosive strictures with previous failed reconstruction. We review our experience with free jejunal flap in three cases with high pharyngo-esophageal stricture following corrosive ingestion, with previous failed reconstruction. MATERIALS AND METHODS: A total of three patients underwent salvage free jejunal flap after failed reconstruction for high pharyngo-esophageal strictures following corrosive acid ingestion. All the three patients developed anastomotic leak and subsequent stricture, two following a pharyngo-gastric anastomosis and one following a pharyngo-colic anastomosis. The strictured segment was bridged using a free jejunal graft with microvascular anastomosis to the lingual artery and common facial vein. All patients were followed-up at regular intervals. RESULTS AND CONCLUSIONS: The strictured pharyngeal anastomotic segment was successfully reconstructed with free jejunal flap in all the three patients. Patients were able to take food orally and maintain nutrition without the need of jejunostomy feeding. On long-term follow-up (median: 5 years), there was no recurrence of dysphagia and all the patients had good health-related quality of life.

Outcome assessment of biliary stricture repair following cholecystectomy in a tertiary care centre.

PURPOSE: Bile duct injuries (BDIs) are the potential grievous complications of cholecystectomy that result in substantial morbidity and mortality. Outcomes of BDI management depend on multiple factors such as the type and extent of injury, timing of repair, and surgical expertise. The present retrospective study was conducted to analyse the risk factors associated with the BDI repair outcomes. METHODS: The data of patients having primary or recurrent bile duct stricture following BDI from 1985 to 2018 were retrospectively evaluated. RESULTS: A total of 268 patients underwent hepaticojejunostomy (HJ). Of the total, 218 patients had primary bile duct stricture, and 50 patients had HJ stricture. The most commonly performed procedure for primary BDI was Roux-en-Y HJ (RYHJ), followed by right hepatectomy, right posterior sectionectomy, and left hepatectomy. All patients with strictured HJ underwent RYHJ, except one who underwent a right hepatectomy. Outcome assessment using the McDonald grading system showed that 62%, 27%, 5%, and 6% of patients with primary bile duct stricture had grade A, grade B, grade C, and grade D complications, respectively, with a mortality rate of 3.21%, whereas 46%, 34%, and 18% patients with strictured HJ had grade A, grade B, and grade C complications, respectively, with a mortality rate of 2%. High-up biliary strictures, early repair, and blood loss > 350 mL are the surrogate markers for failure of repair. CONCLUSION: Management of BDI needs a multidisciplinary approach. The outcomes of both primary biliary stricture and strictured HJ can be improved with management of patients in a tertiary care centre. However, attempts to repair within 2 weeks of injury, Strasberg E4 and E5, and blood loss of > 350 mL may have an adverse effect on the outcome of HJ.

Evaluation of the integration of social accountability values into medical education using a problem-based learning curriculum.

BACKGROUND: Medical schools have the obligation to direct their education toward addressing the priority health concerns of the societies that they serve. The purpose of this study was to evaluate the integration of the concepts and values of social accountability into the case scenarios that are used in a problem-based learning (PBL) curriculum at a medical school in the United Arab Emirates (UAE). METHODS: A validated "social accountability inventory for PBL" was used for examining 70 case scenarios in a problem-based learning (PBL) medical curriculum. RESULTS: The findings of the study showed that patient gender and age were included in all the 70 case scenarios. Vast majority of the case scenarios had successfully integrated the social accountably values in addressing the following: the major health problems or social health concerns of the UAE (73%), the social determinants of health (70%), the contextual integration of medical professionalism (87%), the evolving roles of doctors in the health system (79%), the healthcare referral system based on the case complexity (73%), the involvement of different stakeholders in healthcare (87%), psychosocial issues rather than only the disease-oriented issues (80%) and the values of health promotion/prevention (59%) cases. On the other hand, the case scenarios were deficient in integrating other social accountability values that related to the importance of treatment cost-effectiveness (91%), consideration of the underserved, disadvantaged or vulnerable populations in the society (89%), patient's ethnicity (77%), multidisciplinary approach to patient management (67%), the socioeconomic statuses of patients (53%), the issues regarding the management of the health system (39%) respectively. There was variability in integrating the social accountability values in case scenarios across different units which are based on organ system. CONCLUSION: Medical educators and healthcare leaders can use this valuable data to calibrate the curriculum content, especially when using a problem-based learning curriculum to integrate the values of social accountability such as relevance, quality, equity and cost-effectiveness to train the future generation of healthcare providers to be ready to address the ever-changing and diverse needs of the societies.

The educational use of social networking sites among medical and health sciences students: a cross campus interventional study.

BACKGROUND: In recent years, social networking sites (SNSs) have evolved beyond connection and networking to become a powerful instructional tool. There is still a dearth of knowledge on the professional use of SNSs for education particularly among students from diverse backgrounds. This study examined the extent and pattern of SNSs usage for education across six institutions and then conducted an interventional workshop to fortify and regulate the educational use of SNSs. METHODS: This multicenter study was done in two phases. In the first phase, an online cross-sectional survey using a validated inventory was administered to determine the prevalence, extent, and preferences of SNSs usage by undergraduate students in medicine, health sciences and dentistry across five centers. Later, the second phase of the study was undertaken in a 75-min guided live workshop about the appropriate use of SNSs in academia. Additionally, pre- and post-test surveys were conducted to assess the impact and outcome of workshop. RESULTS: Of the 1722 respondents, 1553 (90%) reported using SNSs with the frequency of once a month to three to five times per day for education and to stay in touch with others. Most students agreed with the benefits of SNSs for education mainly in terms of information gathering, networking and collaboration. Twitter, Instagram, and Pinterest were noted as the most preferred SNSs for education. Nevertheless, 63% perceived that proper instruction was required for the efficient use of SNSs. Following the guided workshop, there was a significant improvement in web technology understanding, digital professionalism, skills and knowledge on the productive use of SNSs. Students rated the efficient for conceptual learning, connection to community practice, e-portfolio, and collaborative learning as the top four major teaching and learning strategies, respectively, in the post-workshop survey. CONCLUSION: Our study demonstrates that SNSs can be used as learning tools in medical education. However, SNSs usage should be regulated and guided for a more collegial and coherent learning climate in the digital realm. We urge medical educators to integrate SNSs into their courses for a technologically advanced and impactful curriculum.

Revealing oral microbiota composition and functionality associated with heavy cigarette smoking.

BACKGROUND: Heavy tobacco smoking, a hallmark feature of lung cancer, is drastically predominant in Middle Eastern populations. The precise links between nicotine dependence and the functional contribution of the oral microbiota remain unknown in these populations. METHODS: We evaluated the composition and functional capabilities of oral microbiota with relation to cigarette smoking in 105 adults through shotgun metagenomics using buccal swabs. RESULTS: The oral microbiota composition in our study subjects was dominated by the phyla Firmicutes, Proteobacteria, Actinobacteria, and Bacteroidetes, in addition to the genera Prevotella and Veillonella, similar to previously described westernized cohorts. Furthermore, the smoker's oral microbiota represented a significant abundance of Veillonella dispar, Leptotrichia spp. and Prevotella pleuritidis when compared to non-smokers. Within the smoking groups, differential relative abundance testing unveiled relative abundance of Streptobacillus hongkongensis, Fusobacterium massiliense, Prevotella bivia in high nicotine dependent compared to low nicotine dependent profiles based on Fagerström Test for Nicotine Dependence. Functional profiling showed marked differences between smokers and non-smokers. Smokers exhibited an enrichment of Tricarballylate utilization and Lactate racemization when compared to the non-smokers. According to their nicotine dependence, enrichment of Xanthosine utilization, p-Aminobenzoyl-Glutamate utilization, and multidrug efflux pump in Campylobacter jejuni biosynthesis modules were detected in the high nicotine dependent group. CONCLUSIONS: These compositional and functional differences may provide critical insight on how variations in the oral microbiota could predispose to respiratory illnesses and smoke cessation relapse in cigarette smokers. In particular, the observed enrichment of Fusobacterium and Prevotella in the oral microbiota possibly suggests an intriguing linkage to gut and lung cancers.

Altered respiratory microbiota composition and functionality associated with asthma early in life.

BACKGROUND: The microbiota of the respiratory tract has an important role in maintaining respiratory health. However, little is known on the respiratory microbiota in asthmatic patients among Middle Eastern populations. This study investigated the respiratory microbiota composition and functionality associated with asthma in Emirati subjects. METHODS: We performed 16S rRNA and ITS2-gene based microbial profiling of 40 expectorated sputum samples from adult and pediatric Emirati individuals averaging 52 and 7 years of age, respectively with or without asthma. RESULTS: We report bacterial difference belonging to Bacteroidetes, Firmicutes, Fusobacteria and Proteobacteria phyla between asthmatic and non-asthmatic controls. Similarly, fungal difference belonging to Ascomycota, Basidiomycota phyla and other unclassified fungi. Differential abundance testing among asthmatic individuals with relation to Asthma Control Test show a significant depletion of Penicillium aethiopicum and Alternaria spp., among poorly controlled asthmatics. Moreover, data suggest a significant expansion of Malassezia spp. and other unclassified fungi in the airways of those receiving steroids and leukotriene receptor antagonists' combination therapy, in contrast to those receiving steroids alone. Functional profiling from 16S data showed marked differences between pediatric asthmatic and non-asthmatic controls, with pediatric asthmatic patients showing an increase in amino acid (p-value < 5.03 × 10- 7), carbohydrate (p-value < 4.76 × 10- 7), and fatty acid degradation (p-value < 6.65 × 10- 7) pathways, whereas non-asthmatic controls are associated with increase in amino acid (p-value < 8.34 × 10- 7), carbohydrate (p-value < 3.65 × 10- 7), and fatty acid (p-value < 2.18 × 10- 6) biosynthesis pathways in concordance with enterotype composition. CONCLUSIONS: These differences provide an insight into respiratory microbiota composition in Emirati population and its possible role in the development of asthma early in life. This study provides important information that may eventually lead to the development of screening biomarkers to predict early asthma development and novel therapeutic approaches.

Percutaneous Endoscopic Step-Up Therapy Is an Effective Minimally Invasive Approach for Infected Necrotizing Pancreatitis.

BACKGROUND: Infected pancreatic necrosis (IPN) is a major complication of acute pancreatitis (AP), which may require necrosectomy. Minimally invasive surgical step-up therapy is preferred for IPN. AIM: To assess the effectiveness of percutaneous endoscopic step-up therapy in patients with IPN and identify predictors of its success. METHODS: Consecutive patients with AP hospitalized to our tertiary care academic center were studied prospectively. Patients with IPN formed the study group. The treatment protocol for IPN was percutaneous endoscopic step-up approach starting with antibiotics and percutaneous catheter drainage, and if required necrosectomy. Percutaneous endoscopic necrosectomy (PEN) was performed using a flexible endoscope through the percutaneous tract under conscious sedation. Control of sepsis with resolution of collection(s) was the primary outcome measure. RESULTS: A total of 415 patients with AP were included. Of them, 272 patients had necrotizing pancreatitis and 177 (65%) developed IPN. Of these 177 patients, 27 were treated conservatively with antibiotics alone, 56 underwent percutaneous drainage alone, 53 required underwent PEN as a step-up therapy, 1 per-oral endoscopic necrosectomy, and 52 required surgery. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully-34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died due to organ failure-7 after PEN and 4 after surgery. Independent predictors of mortality were > 50% necrosis and early organ failure. CONCLUSION: Percutaneous endoscopic step-up therapy is an effective strategy for IPN. Organ failure and extensive pancreatic necrosis predicted a suboptimal outcome in patients with infected necrotizing pancreatitis.

Preferred teaching styles of medical faculty: an international multi-center study.

BACKGROUND: In the current wave of educational reforms, understanding teaching styles of medical faculty can help modify instructional strategies for effective teaching. Few studies have probed distinctive teaching styles of medical faculty. We compared preferred teaching styles of faculty from seven medical schools in United Arab Emirates, the Netherlands, Saudi Arabia, Malaysia, Pakistan, and Sudan. METHODS: The validated Grasha-Riechmann teaching style inventory was administered online for data collection and used SPSS version 20.0 for statistical analysis. RESULTS: Of the 460 invitees, 248 responded (response rate; 54%). Delegator teaching style was most common with a highest median and mean of 2.38 and 2.45, respectively. There was a significant correlation between expert and authority teaching styles, correlation coefficient 0.62. Similarly, we found a significant correlation between authority teaching style and nature of curriculum, correlation coefficient 0.30. Multiple regression analysis showed that only authority teaching style and male gender had significant correlation. Interestingly, 117 (47%) teachers disagreed with the teaching philosophy of delivering course contents by strictly following learning outcomes. Female teachers (114/248) were more willing to negotiate with their students regarding how and what to teach in their course, while male teachers tended to allow more autonomy by allowing students to set their learning agenda. CONCLUSIONS: This study showed that the medical teachers preferred delegator teacher style that promotes students' collaboration and peer-to-peer learning. Most teachers are conscious of their teaching styles to motivate students for scientific curiosity. These findings can help medical educators to modify their teaching styles for effective learning.

Adenocarcinoma of oesophagus involving gastro-oesophageal junction following mini-gastric bypass/one anastomosis gastric bypass.

Mini-gastric bypass/one anastomosis gastric bypass (MGB/OAGB) is an emerging weight loss surgical procedure. There are serious concerns not only regarding the symptomatic biliary reflux into the stomach and the oesophagus but also the increased risk of malignancy after MGB/OAGB. A 54-year-old male, with a body mass index (BMI) of 46.1 kg/m2, underwent Robotic MGB at another centre on 22nd June 2016. His pre-operative upper gastrointestinal endoscopy was not done. He lost 58 kg within 18 months after the surgery and attained a BMI of 25.1 kg/m2. However, 2-year post-MGB, the patient had rapid weight loss of 19 kg with a decrease in BMI to 18.3 kg/m2 within a span of 2 months. He also developed progressive dysphagia and had recurrent episodes of non-bilious vomiting. His endoscopy showed eccentric ulcerated growth in lower oesophagus extending up to the gastro-oesophageal junction and biopsy reported adenocarcinoma of oesophagus. MGB/OAGB has a potential for bile reflux with increased chances of malignancy. Surveillance by endoscopy at regular intervals for all patients who have undergone MGB/OAGB might help in early detection of Barrett's oesophagus or carcinoma of oesophagus or stomach.

Specific Tumor Characteristics Predict Upstaging in Early-Stage Esophageal Cancer.

BACKGROUND: Early-stage esophageal cancer (stages 0-1) has been shown to have relatively good outcomes after local endoscopic or surgical resection. For this reason, neoadjuvant chemoradiation usually is reserved for higher-stage disease. Some early tumors, however, are found after resection to be more advanced than predicted based on initial clinical staging, termed pathologic upstaging. Such tumors may have benefited from alternate treatment models had their true stage been known preoperatively. This study aimed to identify high-risk features in early esophageal cancers that might predict tumor upstaging and guide more individualized treatment algorithms. METHODS: Through retrospective review of a single-institution foregut disease registry, we evaluated patients who underwent esophagectomy for high-grade dysplasia (Tis) or stage 1 esophageal cancer, searching for factors associated with pathologic upstaging. RESULTS: The review included 110 patients (88% male, median age at diagnosis, 64.5 years) treated between January 2000 and June 2016. Upstaging occurred for 20.9% of the patients, and was more common for patients with angiolymphatic invasion (odds ratio [OR], 11.07; 95% confidence interval [CI], 2.96-41.44; P < 0.001) or signet-ring features (OR, 23.9; 95% CI, 2.6-216.8; P = 0.005). In the absence of other predictors, upstaging was associated with decreased overall survival (P = 0.006). CONCLUSIONS: Approximately 20% of patients with early-stage esophageal cancer may be upstaged at resection. Angiolymphatic invasion and signet-ring features may predict tumors likely to be upstaged, resulting in decreased overall survival.

Diabetes after pancreaticoduodenectomy: can we predict it?

BACKGROUND: There is limited literature about the perioperative factors which can predict endocrine insufficiency after pancreaticoduodenectomy (PD). The primary aim was to correlate percentage pancreatic remnant volume (%RV) after PD in nondiabetic patients with the development of new-onset impaired glucose tolerance/diabetes mellitus (IGT/DM). The secondary aim was to identify the risk factors for new-onset IGT/DM. METHODS: In this prospective study, all consecutive patients with resectable periampullary carcinoma and without IGT/DM were evaluated with fasting and postprandial plasma glucose, HbA1c, insulin, and C-peptide levels preoperatively and at 3 mo postoperatively. After that, all patients were followed up with fasting and postprandial plasma glucose level assessed at 3-mo intervals for 24 mo or till death, whichever occurred earlier. The %RV was determined from computed tomography measurements preoperatively. RESULTS: Of the 50 patients, 11 (22%) patients developed IGT/DM after median follow-up of 32 mo. The patients' with/without IGT/DM were similar in demographic/perioperative variables. The %RV was found to be an independent factor associated with new-onset IGT/DM. A %RV of <48.8% was found to be a predictor of new-onset IGT/DM (sensitivity, 89.7%; specificity, 73.6%). Plasma sugar and glycosylated hemoglobin levels were significantly higher postoperatively after PD than the preoperative levels. Insulin and C-peptide levels were significantly lower after PD, irrespective of new-onset IGT/DM. CONCLUSIONS: The incidence of IGT/DM after PD was 22%, and %RV < 48.8% was found to be a significant risk factor for new-onset IGT/DM. (CTRI/2013/12/004233).

Pancreaticojejunostomy: Does the technique matter? A randomized trial.

BACKGROUND: Despite a large number of studies, the ideal technique of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) remains debatable. We compared the two most common techniques of PJ (duct-to-mucosa and dunking) in a randomized trial. METHODS: This open-label randomized trial was done at a tertiary care center from January 2009 to October 2015. Patients with resectable periampullary tumours with a pancreatic duct diameter ≥2 mm, requiring PD were randomly assigned to one of the two techniques using computer generated random numbers. The primary outcome was postoperative pancreatic fistula (POPF) rate and secondary outcomes were frequency of other postoperative complications. RESULTS: A total of 193 patients were randomized and analyzed (intention-to-treat analysis), 97 in duct-to-mucosa and 96 in dunking group. Both groups were comparable for baseline demographic and clinical profiles. The incidence of POPF in the entire study group was 23.8%. There was no statistically significant difference between the two groups (24.7% vs 22.9%, P = 0.71). Similarly, the incidence of grades B and C (clinically significant) POPF was comparable (16.5% vs 13.5%, P = 0.57). Both groups were comparable with respect to the secondary outcomes. DISCUSSION: The duct-to-mucosa technique of PJ after PD is not superior to the dunking technique with respect to POPF rate. (CTRI/2010/091/000531).

Early colectomy in steroid-refractory acute severe ulcerative colitis improves operative outcome.

PURPOSE: Up to a third of patients with acute severe ulcerative colitis (ASUC) fail to respond to intensive steroid therapy and eventually require a salvage colectomy. We have previously reported that the mortality of emergency colectomy can be decreased by offering it within the first week of intensive medical therapy. We implemented this policy and report the results of our experience. METHODS: The clinical records of all patients with ASUC who underwent emergency colectomy after failure of medical therapy between January 2005 and July 2015 were extracted from a prospectively maintained database. The data were analysed with regard to duration of intensive medical therapy, timing of surgery, in-hospital mortality and post-operative complications. RESULTS: Eighty-eight patients underwent emergency surgery for ASUC after failed medical therapy. Of these, 75 (85.2%) were operated within 7 days of initiation of intensive medical therapy [n = 51 (58%) were operated < 5 days]. One patient who was operated on day 8 following steroid therapy died postoperatively. The current post-operative mortality of 1.1% (1/88) was significantly lower than the mortality noted in the previously recorded retrospective case series [8/51 (15.6%); p = 0.001]. In addition, the incidence of overall (9/13 vs. 23/75; p = 0.012) and clinically significant (12/75 vs. 6/13; p = 0.022) complications was significantly higher in patients operated after 7 days as compared to those operated within 7 days. CONCLUSION: The policy of early colectomy, within 7 days, in patients with ASUC who fail to respond to intensive steroid-based therapy improves perioperative outcomes with significantly low in-hospital mortality and morbidity.

Predictors of long-term outcomes in patients with acute severe colitis: A northern Indian cohort study.

BACKGROUND AND AIM: Knowledge of long-term outcomes following an index episode of acute severe colitis (ASC) can help informed decision making at a time of acute exacerbation especially when colectomy is an option. We aimed to identify long-term outcomes and their predictors after a first episode of ASC in a large North Indian cohort. METHODS: Hospitalized patients satisfying Truelove and Witts' criteria under follow-up at a single center from January 2003 to December 2013 were included. Patients avoiding colectomy at index admission were categorized as complete (≤ 3 non bloody stool per day) or incomplete responders, based upon response to corticosteroids at day 7. Random Forest-based machine learning models were constructed to predict the long-term risk of colectomy or steroid dependence following an index episode of ASC. RESULTS: Of 1731 patients with ulcerative colitis, 179 (10%) had an index episode of ASC. Nineteen (11%) patients underwent colectomy at index admission and 42 (26%) over a median follow-up of 56 (1-159) months. Hazard ratio for colectomy for incomplete responder was 3.6 (1.7-7.5, P = 0.001) compared with complete responder. Modeling based on four variables, response at day 7 of hospitalization, steroid use during the first year of diagnosis, longer disease duration before ASC, and number of extra-intestinal manifestations, was able to predict colectomy with an accuracy of 77%. CONCLUSIONS: Disease behavior of ASC in India is similar to the West, with a third undergoing colectomy at 10 years. Clinical features, especially response at day 7 hospitalization for index ASC, can predict both colectomy and steroid dependence with reasonable accuracy.