Indian Himalayan natural Arabidopsis thaliana accessions with abolished miR158 levels exhibit robust miR173-initiated trans-acting cascade silencing.

Small RNAs (sRNAs) such as microRNAs (miRNAs) and small interfering RNAs (siRNAs) are short 20-24-nucleotide non-coding RNAs. They are key regulators of gene expression in plants and other organisms. Several 22-nucleotide miRNAs trigger biogenesis cascades of trans-acting secondary siRNAs, which are involved in various developmental and stress responses. Here we show that Himalayan Arabidopsis thaliana accessions having natural mutations in the miR158 locus exhibit robust cascade silencing of the pentatricopeptide repeat (PPR)-like locus. Furthermore, we show that these cascade sRNAs trigger tertiary silencing of a gene involved in transpiration and stomatal opening. The natural deletions or insertions in MIR158 led to improper processing of miR158 precursors, thereby blocking synthesis of mature miR158. Reduced miR158 levels led to increased levels of its target, a pseudo-PPR gene that is targeted by tasiRNAs generated by the miR173 cascade in other accessions. Using sRNA datasets derived from Indian Himalayan accessions, as well as overexpression and knockout lines of miR158, we show that absence of miR158 led to buildup of pseudo-PPR-derived tertiary sRNAs. These tertiary sRNAs mediated robust silencing of a gene involved in stomatal closure in Himalayan accessions lacking miR158 expression. We functionally validated the tertiary phasiRNA that targets NHX2, which encodes a Na+ -K+ /H+ antiporter protein, thereby regulating transpiration and stomatal conductance. Overall, we report the role of the miRNA-TAS-siRNA-pseudogene-tertiary phasiRNA-NHX2 pathway in plant adaptation.

IL1ß/ TNFα/COX-2/VEGF axis responsible for effective healing potential of C-glucoside xanthone (mangiferin) based ointment in immunocompromised rats.

Present study was conducted to undermine the wound healing potential of mangiferin vis a vis its molecular dynamics in immunocompromised excisional rat model. 120 rats were randomly and equally divided into five groups viz. group I (Healthy control), group II (Immunocompromised control), group III (Immunocompromised group treated with silver sulphadiazine), group IV (Immunocompromised group treated with 2.5 %Mangiferin) and group V (Immunocompromised group treated with 5 %Mangiferin). Immuno compromised state was achieved following intramuscular injection of Hydrocortisone @ 80 mg/kg body weight. Study was conducted for a period of 28 days. Six animals from each group were humanely sacrificed at weekly interval till day 28th of study. Planimetric analysis, biochemical studies viz. hydroxyproline assay, total protein and DNA content, antioxidative potential through LPO assay was done along with molecular studies involving expression profiling of IL1ß, TNFα and COX-2 and Immunohistochemistry of angiogenic marker i.e. VEGF was performed to undermine the pharmacodynamics of mangiferin. Histopathological studies including H&E and Masson's Trichome was also performed to study histoarchitectural changes in wound healing and reparative process following application of mangiferin ointment. Study revealed significant (P ≤ 0.05) reduction in wound area measurement and significant (P ≤ 0.05) increase in wound contraction (%) following mangiferin administration in immunocompromised rats. Hydroxyproline, DNA and total protein showed significant (P ≤ 0.05) increase in skin tissues of mangiferin treated immunocompromised rats. LPO assay revealed significant (P ≤ 0.05) reduction in mangiferin treated animals. Histopathological studies of skin tissues revealed complete restoration advocating grade III of healing in 2.5% mangiferin treated group. Higher expression and strong signal intensity of VEGF was noticed in 2.5% mangiferin treatment group along with significant (P ≤ 0.05) upregulation IL1ß and TNFα on day 7 in 2.5% mangiferin treatment group with significant (P ≤ 0.05) down regulation of COX-2 in mangiferin treatment group as compared to other groups i.e. group II and III. It is concluded from our study that mangiferin facilitates wound healing through improved wound closure, organized deposition of collagen deposition and granulation matrix formation.

Impact of Covid-19 on gastrointestinal cancer surgery: A National Survey.

PURPOSE: To understand the actual impact of the Covid-19 pandemic and frame the future strategies, we conducted a pan India survey to study the impact on the surgical management of gastrointestinal cancers. METHODS: A national multicentre survey in the form of a questionnaire from 16 tertiary care gastrointestinal oncology centres across India was conducted from January 2019 to June 2021 that was divided into a 15-month pre-Covid era and a similar period of active Covid pandemic era. RESULTS: There was significant disruption of services; 13 (81%) centres worked as dedicated Covid care centres and 43% reported suspension of essential care for more than 6 months. In active Covid phase, there was a 14.5% decrease in registrations and proportion of decrease was highest in the centres from South zone (22%). There was decrease in resections across all organ systems; maximum reduction was noted in hepatic resections (33%) followed by oesophageal and gastric resections (31 and 25% respectively). There was minimal decrease in colorectal resections (5%). A total of 584 (7.1%) patients had either active Covid-19 infection or developed infection in the post-operative period or had recovered from Covid-19 infection. Only 3 (18%) centres reported higher morbidity, while the rest of the centres reported similar or lower morbidity rates when compared to pre-Covid phase; however, 6 (37%) centres reported slightly higher mortality in the active Covid phase. CONCLUSION: Covid-19 pandemic resulted in significant reduction in new cancer registrations and elective gastrointestinal cancer surgeries. Perioperative morbidity remained similar despite 7.1% perioperative Covid 19 exposure.

An unusual cause of obstructive jaundice in childhood: Intra-choledochal malignant neuroendocrine tumour.

The extrahepatic biliary apparatus is a rare site for neuroendocrine tumours. A 13-year-old child presented with cholestatic symptoms of jaundice and pruritus with soft hepatomegaly and mild ascites. Magnetic resonance imaging and endoscopic ultrasound revealed a mid-common bile duct mass, and dilated intrahepatic biliary system. An en-bloc resection of the extrahepatic biliary apparatus, showed malignant cells disposed in lobules in a desmoplastic stroma with intramural invasion, staining positive for cytokeratin, chromogranin, synaptophysin and negative for CD56. At 3 months post-resection, whole body positron emission tomography scan was normal with no recurrence at 24 months.

Nitrogen removal in vermifiltration: Mechanisms, influencing factors, and future research needs.

To meet global health and sanitation goals, there is a continued need for sustainable wastewater treatment alternatives that require minimal energy and investment. Vermifiltration, a technology gaining relevance in Africa and Asia, may be an alternative to traditional wastewater treatment systems due to its cost-effectiveness, ease of application and maintenance, and sustainability. However, nitrogen removal in vermifiltration is not well understood since most of the prior research focuses on organics removal. Thus, a state of the art review is necessary to separately focus on the mechanisms associated with nitrogen removal in vermifiltration, along with the factors affecting nitrogen removal. For the first time, this review attempts to present the types of vermifilter based on their flow pattern. The review further discusses the current status of the application of vermifiltration, along with the benefits and limitations associated with the adoption of this technology. It also explores possible strategies that could be adopted to maximize the nitrogen removal potential of vermifilters as optimizing nitrogen removal is critical for improving the performance of vermifiltration based treatment systems.

Response surface methodology and artificial neural network modelling for the performance evaluation of pilot-scale hybrid nanofiltration (NF) & reverse osmosis (RO) membrane system for the treatment of brackish ground water.

Artificial neural network (ANN) and response surface methodology (RSM) were employed to develop models for process optimisation of pilot scale nanofiltration (NF) and reverse osmosis (RO) membrane filtration system for the treatment of brackish groundwater. The process variables for this study were feed concentration, temperature, pH and pressure. The performance of NF/RO was assessed in terms of permeate flux, water recovery, salt rejection and specific energy consumption, which were considered as responses. The experimental design was employed to develop both RSM and ANN models. RSM model was validated for the whole range of experimental levels, while the ANN model was considered for the whole range of experimental design. RSM and ANN models were statistically analysed using analysis of variance (ANOVA). Further, the models were graphically compared for its predictive capacity. Numerical optimisation of NF and RO pilot plant to determine the optimum conditions were verified. Finally, using the optimum conditions, three hybrid configurations of NF and RO were studied to determine the best mode for the treatment of brackish groundwater. It was found that parallel NF-RO had a recovery of 57.18% and rejection of 44.89%, for RO-concentrate-NF (RO-C-NF) recovery was 49.55% and rejection of 38.64% & for NF-concentrate-RO (NF-C-RO), the recovery of 39.53% and rejection of 49.66% was obtained. Results obtained also suggested that the mode of configurations and the feed concentration affect the performance of the hybrid system.

Optimization of bioclogging in vermifilters: A statistical approach.

In the present research, an experiment was conducted with the objective of optimization of the role of earthworms in alleviating the bioclogging of a horizontal subsurface flow vermifilter (HSSFVF), caused due to the application of organics rich brewery wastewater. In this experiment, for the optimization of bioclogging of the vermifilters, the Box-Behnken Design (BBD) and response surface methodology (RSM) were involved. Hydraulic loading rate (HLR), influent COD and earthworm density (EWD) are the variables against which the bioclogging of the HSSFVF has been optimized. EWD of 9475 earthworms/m3, HLR of 1.84 m3/m2-d and influent COD of 3701 mg/L have been observed as the optimized values for the minimum bioclogging in the vermifiltration of brewery wastewater. At this optimum boundary conditions, the reduction in hydraulic conductivity was obtained as 1.49%, against the predicted value of 1.67% based upon the BBD model. The verification of the model against real brewery wastewater yielded insignificant error and thus very strongly portrays the suitability of the derived BBD model. The study indicates that the bioclogging from the vermifilters can be minimized, if the variables are optimized using the response surface methodology.

Vermifiltration as a sustainable natural treatment technology for the treatment and reuse of wastewater: A review.

With increasing urbanization and industrialization, the scarcity of freshwater is becoming rampant. To counteract this, authorities all over the world are forced to consider the treatment and reuse of the wastewater produced by either industries or domestic units. After an extensive literature survey, vermifiltration coupled with/without macrophyte has been identified as one of the best sustainable, natural and eco-friendly technology for the treatment and reuse of wastewater. Till date, it has been successfully applied for treating domestic wastewater. However, the results from very limited industrial applications are also encouraging and proving its worth for industrial wastewater remediation. The present review on vermifiltration deals with the mechanisms involved and its current status for the remediation and reutilisation of the effluents generated from domestic and industrial premises. The review successfully identifies and explicitly discusses the mechanisms involved in the vermifiltration. The review exhaustively discusses the performance of vermifiltration and identifies the factors contributing to the performance of vermifiltration, which could be of help in designing of the field scale vermifilter based treatment plant. The review identifies the limitations associated with the vermifiltration and suggests possible alternatives, aimed to improve its performance and applicability. The aim of this review is to bring the attention of prospective researchers to study each and every aspect related to the vermifiltration so that it may be adopted as a reliable and dependable technology for the remediation of several industrial effluents meeting the concept of "Zero discharge".

A mechanistic review on vermifiltration of wastewater: Design, operation and performance.

With global population explosion, the available water resources are slowly being polluted due to the excessive human interference. To encounter this, it is the need of this hour to find out sustainable pollution remediating technologies to meet the stringent discharge standards for domestic as well as industrial wastewaters. In addition, those techniques should have the capabilities for effective implementation even in developing countries. Based on the available literatures, one such technique, named vermifilter, has been identified which takes care of almost all the sustainable and economical criteria for its effective implementation even in developing countries. The aim of this meta-analysis is to provide a comprehensive review on assessment mechanisms involved, factors affecting the process and performance of vermifiltration under different scenarios. The present review envisages the current state of the knowledge regarding physical, chemical and biological aspects related to the treatment mechanisms and effective functioning of earthworms. This review has also proposed several suggestive plans on its application at any proposed site.

Understanding the role of biofilms and estimation of life-span of a tire derived aggregates-based underground stormwater treatment system.

The importance of biofilm in tire derived aggregates (TDA) based underground systems has been investigated in this paper, to assess the utilization of tire waste as a cost-effective and sustainable resource for stormwater treatment. The primary objective of this study is to look into the role of biofilms in preventing metal leaching from a TDA based stormwater treatment system and to estimate the life span of a TDA based stormwater treatment system. TDA subjected to different influents to promote or limit the growth of biofilms were analyzed for their leaching and adsorption potential for fifteen different metals through 72 flushes, which is representative of roughly 9 years of TDA exposure to storm events in the upper Midwest USA. Biofilm growth on a manufacturing byproduct (wire exposed-TDA) was higher than on the traditional TDA. The presence of biofilm on TDA had a minor impact on orthophosphate adsorption as observed in a previous study conducted by the authors. However, metals such as iron, zinc and copper, which were previously a concern, had substantially lower leaching into the stored runoff. In addition, the orthophosphate removal from runoff by TDA with a biofilm through 72 flushes indicates that TDA based underground systems can have orthophosphate removal life span beyond 8-9 years. Thus, TDA with biofilms in an underground storage/infiltration chamber has the potential to establish itself as a sustainable, cost-effective, and long life-span alternative for stormwater remediation of orthophosphate pollution without leaching of metals.

Readmissions Following Pancreaticoduodenectomy: Experience From a Tertiary Care Center in India.

Background An enhanced recovery approach in surgery helps early postoperative discharge. With the decreasing trend of morbidity and mortality in recent times in patients undergoing complex procedures such as pancreaticoduodenectomy, readmissions are the next major concern. The causes and outcomes of these readmissions should be investigated for their impact on patient care and prevention. Methodology A total of 997 patients discharged after pancreaticoduodenectomy from a tertiary care center in northern India, between 1989 and 2021, were studied retrospectively to assess the readmission rate for sequelae after pancreaticoduodenectomy. The causes, interventions, outcomes, and predictive factors were studied. Results A total of 103 (10.3%) patients required readmission for sequelae after pancreaticoduodenectomy, and 52 (50.4%) patients required interventions. The most common cause for readmission in our study was intra-abdominal collection (n = 23, 22.3%). Of these 103 patients, 63 (61.2%) had good outcomes, 36 (34.9%) had fair outcomes, and four (3.9%) had bad outcomes. Overall, 53 (51.5%) of 103 patients were readmitted within 30 days of discharge, most commonly with intra-abdominal collection (16 of 53, 30.1%). Of these 53 patients, 22 (41.5%) required interventions, 34 (64.1%) had good outcomes, and 27 (50.9%) were readmitted within seven days of discharge. Of these 27 patients, 12 (44.4%) required interventions, with 24 (88.8%) experiencing good outcomes. Of the 103 patients, 12 (11.6%) were readmitted between 31 and 90 days, mostly due to external stent, T-tube, or percutaneous transhepatic biliary drainage-related problems. Overall, 38 (36.9%) of 103 patients were readmitted after 90 days, mostly with incisional hernia and strictured hepaticojejunostomy. Of these 38 patients, 26 (68.4%) required intervention, and 23 (60.5%) had good outcomes. A previous history of cholangitis (odds ratio (OR) = 1.771, 95% confidence interval (CI) = 1.17-2.67, p = 0.007), postoperative fever (OR = 1.628, 95% CI = 1.081-2.452, p = 0.02), wound infection (OR = 2.011, 95% CI = 1.332-3.035, p = 0.001), and wound dehiscence (OR = 2.136, 95% CI = 1.333-3.423, p = 0.002) predicted readmission on univariate analysis. Multivariate analysis showed a previous history of cholangitis (OR = 1.755, CI = 1.158-2.659, p = 0.008) and wound infection (OR = 1.995, 95% CI = 1.320-2.690, p = 0.001) as factors independently predicting readmission. Conclusions Readmitted patients have high intervention rates and good recovery rates. Readmissions should not be considered a scale for poor healthcare. Patient education, proper management of postoperative complications, and a properly designed discharge care system can help tackle this problem.

PD-L1 Expression in Ampullary Adenocarcinoma.

INTRODUCTION: Ampullary adenocarcinoma is a rare neoplasm often treated by the complex Whipple's procedure. Several histological factors predict poor prognosis including pancreatobiliary morphology, presence of lymphovascular, perineural invasion and local or distant metastasis. Systemic therapy with gemcitabine, 5-fluorouracil regimens are given with variable benefits. Immunotherapy checkpoint inhibitors have shown beneficial anti-tumor effects in several carcinomas, the most remarkable being in non-small cell lung cancer. Administration of these novel drugs is based on immunohistochemical expression (which may or may not be indicative of response to therapy) along with meticulous decision making by the multidisciplinary team. Immunohistochemistry (IHC) is an effective means of immune marker demonstration and has been used in various tumor types for predictive and prognostic purposes. METHODS: PD-L1 IHC (clone E1L3N) was applied in 101 cases of ampullary adenocarcinoma. Tumor infiltrating lymphocytes were also evaluated. The immunoreactivity was assessed and categorized into following staining thresholds: <1%, <5%, <10% and ≥10% for tumor cells (membranous and/or cytoplasmic staining pattern), and 5% and 10% cut-offs for immune cells. RESULTS: We found that at a 10% cut-off, 73.3% (74/101) patients were men (P = .006) older than 50 years of age (P < .001) presenting with a tumor measuring <3 cm (P = .001). It was significantly associated with intestinal differentiation (P = .004) and grade 1 tumors (P = .001). Twelve patients presented with recurrence as well (P = .03). CONCLUSION: In the context of ampullary adenocarcinoma, this study highlights the positivity observed with the PD-L1 IHC clone E1L3N at different thresholds, with the particularly stronger associations being evident at a 10% cut-off.

Jaundice in a Child with Sickle Cell Anemia: A Case Based Approach.

Sickle cell anemia (SCA) is an autosomal recessive disorder caused by a mutation in beta globin gene. Hepatobiliary system is affected in 10-40% of patients with SCA and has a multifactorial etiology. The authors present a child with SCA and conjugated hyperbilirubinemia due to biliary obstruction. He underwent endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting, had complications of post sphincterotomy bleed, retroperitoneal hematoma and post laparoscopic cholecystectomy sepsis with acute sickle hepatic crisis. He was managed successfully and is doing well on follow-up. Here authors discuss a stepwise approach in management of jaundice in a patient with SCA. Patients with SCA are prone to develop vaso-occlusive crisis (VOC) during periods of stress. VOC affects the liver as acute sickle hepatic crisis, acute hepatic sequestration or sickle cell intrahepatic cholestasis and is collectively termed as sickle cell hepatopathy. Hemolysis due to sickling results in cholelithiasis with its associated complications. These patients are vulnerable to viral hepatitis and hemochromatosis due to multiple blood transfusions. There may be a concomitant acute viral hepatitis, drug induced liver injury, Budd-Chiari syndrome or other chronic liver diseases. These conditions have considerable clinical overlap and may coexist, making the evaluation more challenging. Detailed history, examination and investigations are required for differentiation of etiology. Periods of stress must be tackled with proper hydration, oxygen supplementation, maintaining hemoglobin >10 g/dL, and a low hemoglobin S fraction. Patients with SCA and conjugated hyperbilirubinemia are "high-risk" and best managed by a multidisciplinary team. Preventive strategies like timely vaccinations, chelation, etc. must be practised.

Post Cholecystectomy Bile Duct Injury in an Acute Setting: Categorization, Triaging, and Management Algorithm.

Background Postcholecystectomy bile duct injury (BDI) is a management challenge with significant morbidity, mortality, and effects on long-term quality of life. Early referral to a specialized hepatobiliary center and appropriate early management are crucial to improving outcomes and overall quality of life. In this retrospective analysis, we examined patients who were managed at our center over the past 10 years and proposed a triage and management algorithm for BDI in acute settings. Methods Patients referred to our center with BDI from January 2011 to December 2020 were reviewed retrospectively. The primary objective of initial management is to control sepsis and minimize BDI-related morbidity and mortality. All the patients were resuscitated with intravenous fluid, antibiotics (preferably culture-based), correction of electrolyte deficiencies, and organ support if required. A triage module and management algorithm were framed based on our experience. All the patients were triaged based on the presence or absence of bile leaks. Each group was further subdivided into red, yellow, and green zones (depending on the presence of sepsis, organ failure, and associated injuries), and the results were analyzed as per the proposed algorithm. Results One hundred twenty-eight patients with acute BDI were referred to us during the study period, and 116 patients had BDI with a bile leak and 12 patients were without a bile leak. Out of bile leak patients, 106 patients (91.38%) had sepsis with or without organ failure (red and yellow zone) and required invasive intervention in the form of PCD insertion (n=99, 85.34%) and/or laparotomy, lavage, and drainage (n=7, 6.03%). Another 10 patients (8.62%) had controlled external biliary fistula (green zone), of which four were managed with antibiotics, four underwent endoscopic retrograde cholangiopancreatography stenting, and only two (1.7%) patients could undergo Roux-en-Y hepaticojejunostomy upfront due to late referral. Among patients with BDI without bile leaks, nine (75%) had cholangitis (red and yellow zones). Out of these, five required PTBD along with antibiotics and four were managed with antibiotics alone. Only three (25%) patients in this group could undergo definitive repair without any restriction on the timing of referral and were sepsis-free at presentation (green zone). A total of nine patients had a vascular injury, and four of them required digital subtraction angiography and coil embolization. There were three (2.34%) mortalities; all were in the red zone of rest and had successful initial management. In total, five patients were managed with early repair in the acute setting, and the rest underwent definitive intervention at subsequent admissions after being converted to green zone patients with initial management. Conclusion The presented categorization, triaging, and management algorithm provides optimum insight to understand the severity, simplify these complex scenarios, expedite the decision-making process, and thus enhance patient outcomes in early acute settings following BDI.

Current Utility of Transgastric Percutaneous Drainage for the Management of Pancreatitis-Related Retrogastric Walled-Off Necrotic Collections: A Prospective Observational Study.

Introduction Pancreatic fluid collection (PFC) is one of the most frequent complications associated with acute pancreatitis. The route of drainage is guided by the size and site of collection. The present study aims to assess the clinical and technical success of transgastric percutaneous drainage (PCD) for managing retrogastric walled-off pancreatic necrosis (WOPN). Materials and methods A total of 44 patients with acute pancreatitis diagnosed with WOPN who underwent transgastric PCD with ultrasound or CT guidance as part of standard clinical management were included in the study. Patients were observed for improvement in clinical parameters, and treatment outcomes were noted in terms of technical success, clinical success, adverse events, need for additional procedures, hospital stay, and duration of placement of all drains. Data for the internalization of transgastric PCD was also observed in the study. Results Technical success during the drain placement was observed in 93% (n=41) of patients.Internalization of the transgastric drain was attempted in 12 patients and successful in 11 (91%). The median duration of hospital stay from the time of placement of the first PCD until discharge and the median duration of all PCDs placed were higher in patients where the transgastric drain was not internalized as compared to patients where the transgastric drain was internalized. Conclusion In WOPN, transgastric drain placement and successful internalization in any form help in the early resolution of peripancreatic and abdominal collections. It also reduces the time to percutaneous catheter removal, which in turn reduces the morbidity and decreases the need for additional interventions or surgery.

Case Reports on Black Fungus of the Gastrointestinal Tract: A New Complication in COVID-19 Patients.

Gastrointestinal mucormycosis is a rare disease with a significant mortality rate, even when promptly diagnosed and treated. An unusual complication was observed in India during the second wave of coronavirus disease 2019 (COVID-19). Two incidences of gastric mucormycosis were found. A 53-year-old male patient with a history of COVID-19 one month earlier came into the intensive care unit. After admission, the patient developed hematemesis, which was initially treated with blood transfusions and digital subtraction angiography embolization. Esophagogastroduodenoscopy (EGD) revealed a large ulcer with a clot in the stomach. During an exploratory laparotomy, the proximal stomach was necrotic. Histopathological examination confirmed mucormycosis. The patient was started on antifungals, but despite rigorous therapy, the patient died on the tenth postoperative day. Another patient, an 82-year-old male with a history of COVID-19, arrived with hematemesis two weeks earlier and was treated conservatively. EGD revealed a large white-based ulcer with abundant slough along the larger curvature of the body. Mucormycosis was verified by biopsy. He was treated with amphotericin B and isavuconazole. He was discharged after two weeks in a stable condition. Despite quick detection and aggressive treatment, the prognosis is poor. In the second case, prompt diagnosis and treatment saved the patient's life.

Surgery for symptomatic hepatic hemangioma: Resection vs. enucleation, an experience over two decades.

Backgrounds/Aims: Hemangiomas are the most common benign liver lesions; however, they are usually asymptomatic and seldom require surgery. Enucleation and resection are the most commonly performed surgical procedures for symptomatic lesions. This study aims to compare the outcomes of these two surgical techniques. Methods: A retrospective analysis of symptomatic hepatic hemangiomas (HH) operated upon between 2000 and 2021. Patients were categorized into the enucleation and resection groups. Demographic profile, intraoperative bleeding, and morbidity (Clavien-Dindo Grade) were compared. Independent t-test and chi-square tests were used for continuous and categorical variables respectively. p-value of < 0.05 was considered significant. Results: Sixteen symptomatic HH patients aged 30 to 66 years underwent surgery (enucleation = 8, resection = 8) and majority were females (n = 10 [62.5%]). Fifteen patients presented with abdominal pain, and one patient had an interval increase in the size of the lesion from 9 to 12 cm. The size of hemangiomas varied from 6 to 23 cm. The median blood loss (enucleation: 350 vs. resection: 600 mL), operative time (enucleation: 5.8 vs. resection: 7.5 hours), and postoperative hospital stay (enucleation: 6.5 vs. resection: 11 days) were greater in the resection group (statistically insignificant). In the resection group, morbidity was significantly higher (62.6% vs. 12.5%, p = 0.05), including one mortality. All patients remained asymptomatic during the follow-up. Conclusions: Enucleation was simpler with less morbidity as compared to resection in our series. However, considering the small number of patients, further studies are needed with comparable groups to confirm the superiority of enucleation over resection.

Carcinosarcoma of Gallbladder with Osteosarcomatous Differentiation - a Case Report with Review of Literature.

A 44-year-old female presented with dull upper abdominal pain. Contrast-enhanced computed tomography (CECT) of the abdomen revealed a well-distended gallbladder with multiple foci of minimally enhancing, intraluminal, soft tissue lesion, and hyperdensity on non-contrast scan measuring 4.3 × 3.5 cm in the fundus with few calculi embedded in it. There was no evidence of extraluminal extension. The patient underwent extended cholecystectomy with liver wedge resection. Histologically, the tumor showed both carcinomatous and sarcomatous components, with prominent osteosarcomatous differentiation. We report this unusual case and present a review of all cases of carcinosarcoma of the gallbladder with sarcomatous differentiation. Despite curative resection, CSGB prognosis remains poor, and thus, the authors recommend to focus their efforts to improve the surgical outcomes.

Machine Learning Algorithms for understanding the determinants of under-five Mortality.

BACKGROUND: Under-five mortality is a matter of serious concern for child health as well as the social development of any country. The paper aimed to find the accuracy of machine learning models in predicting under-five mortality and identify the most significant factors associated with under-five mortality. METHOD: The data was taken from the National Family Health Survey (NFHS-IV) of Uttar Pradesh. First, we used multivariate logistic regression due to its capability for predicting the important factors, then we used machine learning techniques such as decision tree, random forest, Naïve Bayes, K- nearest neighbor (KNN), logistic regression, support vector machine (SVM), neural network, and ridge classifier. Each model's accuracy was checked by a confusion matrix, accuracy, precision, recall, F1 score, Cohen's Kappa, and area under the receiver operating characteristics curve (AUROC). Information gain rank was used to find the important factors for under-five mortality. Data analysis was performed using, STATA-16.0, Python 3.3, and IBM SPSS Statistics for Windows, Version 27.0 software. RESULT: By applying the machine learning models, results showed that the neural network model was the best predictive model for under-five mortality when compared with other predictive models, with model accuracy of (95.29% to 95.96%), recall (71.51% to 81.03%), precision (36.64% to 51.83%), F1 score (50.46% to 62.68%), Cohen's Kappa value (0.48 to 0.60), AUROC range (93.51% to 96.22%) and precision-recall curve range (99.52% to 99.73%). The neural network was the most efficient model, but logistic regression also shows well for predicting under-five mortality with accuracy (94% to 95%)., AUROC range (93.4% to 94.8%), and precision-recall curve (99.5% to 99.6%). The number of living children, survival time, wealth index, child size at birth, birth in the last five years, the total number of children ever born, mother's education level, and birth order were identified as important factors influencing under-five mortality. CONCLUSION: The neural network model was a better predictive model compared to other machine learning models in predicting under-five mortality, but logistic regression analysis also shows good results. These models may be helpful for the analysis of high-dimensional data for health research.