The Role of Endoscopic Ultrasound in Early Chronic Pancreatitis.

Chronic pancreatitis (CP) is an irreversible and progressive inflammation of the pancreas that can involve both pancreatic parenchyma and the pancreatic duct. CP results in morphological changes in the gland in the form of fibrosis and calcification along with functional impairment in the form of exocrine and endocrine insufficiency. Studies on the natural history of CP reveal the irreversibility of the condition and the resultant plethora of complications, of which pancreatic adenocarcinoma is the most dreaded one. In Japanese population-based studies by Otsuki and Fuzino et al., CP was clearly shown to reduce lifespan among males and females by 10.5 years and 16 years, respectively. This dismal prognosis is superadded to significant morbidity due to pain and poor quality of life, creating a significant burden on health and health-related infrastructure. These factors have led researchers to conceptualize early CP, which, theoretically, is a reversible stage in the disease spectrum characterised by ongoing pancreatic injury with the presence of clinical symptoms and the absence of classical imaging features of CP. Subsequently, the disease is thought to progress through a compensated stage, a transitional stage, and to culminate in a decompensated stage, with florid evidence of the functional impairment of the gland. In this focused review, we will discuss the definition and concept of early CP, the risk factors and natural history of the development of CP, and the role of various modalities of EUS in the timely diagnosis of early CP.

Strategies to Improve Colonoscopy Preparation in Inflammatory Bowel Disease. A Systematic Review and Network Meta-analysis of Randomized Trials.

BACKGROUND AND AIMS: Colonoscopy has a vital role in the diagnosis of inflammatory bowel disease (IBD), as well as in the estimation of disease severity, monitoring response to therapy, and surveillance for neoplasia. We performed a systematic review of randomised trials of various bowel preparations for colonoscopy in IBD. METHODS: We searched various electronic databases (PubMed, Embase, and CENTRAL) for studies reporting about the use of various strategies to improve colonoscopy preparation in IBD. We included only randomized clinical trials (RCTs). A network meta-analysis was done using a frequentist approach to compare the effectiveness of various bowel preparations. The risk of bias was assessed using Cochrane risk of bias tool 2.0. Other outcome parameters like compliance, tolerance, acceptance, and adverse effects were assessed qualitatively. RESULTS: Seven RCTs reporting about 960 patients were included. On comparison with 4 liter (L) of poliethylen glycol (PEG), oral sulfate solution (OR=1.1, 95%CI: 0.65-1.86); PEG2L/Ascorbate (OR=0.98, 95%CI: 0.65-1.48); PEG1L (OR=1, 95%CI: 0.55-1.81); PEG2L plus bisacodyl (OR=1.08, 95%CI: 0.71-1.65); PEG4L plus simethicone (OR=1, 95%CI: 0.67-1.50); PEG/ sodium picosulfate and magnesium citrate (SPMC) 1.5L (OR=0.99, 95%CI: 0.55-1.78); SPMC 2L (OR=1.09, 95%CI: 0.61-1.97) had similar effectiveness. Three RCTs reported compliance, five RCTs reported tolerance, two studies reported patient acceptance and five RCTs reported data on the willingness of patients to repeat the procedure in the future. Low-volume preparations had better compliance, tolerance, acceptance, and willingness to repeat. No difference in additional outcomes like change in disease activity after colonoscopy, procedure-related outcomes after colonoscopy like cecal intubation rate, and change in electrolyte levels were found. CONCLUSION: Various bowel preparations had similar effectiveness in respect to colonoscopy preparation in IBD patients. Low-volume preparations have better compliance, tolerance, and acceptance. The systematic review was limited by a small number of included RCTs.

Endoscopic ultrasound-guided pancreatic duct drainage: a comprehensive state of the art review.

INTRODUCTION: Endoscopic retrograde pancreatography (ERP) has traditionally been the standard modality for pancreatic endotherapy. However, in certain situations, failure of retrograde ductal access may warrant an alternative modality of drainage. This can occur in various settings like difficult and/or surgically altered anatomy or duodenal obstruction. Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is a relatively newer addition to the armamentarium for endoscopic access to the PD. AREAS COVERED: This comprehensive state-of-art review aims to give an overview of the indications, technical details, different approaches, and outcomes of EUS-PDD, with the latest evidence available in scientific literature. EXPERT OPINION: Akin to its biliary drainage counterpart, EUS-PDD enables an EUS-assisted-ERP using rendezvous technique or EUS-guided drainage through transmural stenting. The technique has evolved over the ensuing years with multitude of accessories, approaches, and devices to optimize the outcomes. However, the technical success and adverse events rates need to be further improved. Additionally, it has a steep learning curve with requirements of advanced technical skill and optimum infrastructure back-up. Meticulous patient selection, precise knowledge of ductal anatomy, appropriate approach, and carefully chosen accessories can improve its clinical outcomes.

Role of Endoscopic Ultrasound in Diagnosis of Pancreatic Ductal Adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) is the most common (90%) type of solid pancreatic neoplasm. Due to its late presentation and poor survival rate, early diagnosis and timely treatment is of utmost importance for better clinical outcomes. Endoscopic ultrasound provides high-resolution images of the pancreas and has excellent sensitivity in the diagnosis of even small (<2 cm) pancreatic lesions. Apart from imaging, it also has an advantage of tissue acquisition (EUS fine-needle aspiration, FNA; or fine-needle biopsy, FNB) for definitive diagnoses. EUS-guided tissue acquisition plays a crucial role in genomic and molecular studies, which in today's era of personalized medicine, are likely to become important components of PDAC management. With the use of better needle designs and technical advancements, EUS has now become an indispensable tool in the management of PDAC. Lastly, artificial intelligence for the detection of pancreatic lesions and newer automated needles for tissue acquisition will obviate observer dependency in the near future, resulting in the wider dissemination and adoption of this technology for improved outcomes in patients with PDAC.

Endoscopic Ultrasound in Pancreatic Duct Anomalies.

Embryological development of the pancreas is a complex phenomenon and, therefore, it can have multiple developmental aberrations. Fortunately, the majority of these pancreatic ductal anomalies are asymptomatic with no clinical relevance and are incidentally detected during diagnostic cross-sectional imaging or endoscopic retrograde cholangiopancreatography (ERCP) or autopsy. Occasionally, pancreatic duct anomalies can result in symptoms like abdominal pain or recurrent pancreatitis. Also, an accurate pre-operative diagnosis of ductal anomalies can prevent inadvertent duct injury during surgery. Conventionally, ERCP had been used for an accurate diagnosis of pancreatic duct anomalies. However, because it is invasive and associated with a risk of pancreatitis, it has been replaced with magnetic resonance cholangiopancreatography (MRCP). MRCP has demonstrated high sensitivity and specificity for the diagnosis of ductal anomalies, which can be further improved with the use of secretin-enhanced MRCP. Endoscopic ultrasound (EUS) is a new diagnostic and interventional tool in the armamentarium of endoscopists and has demonstrated promising results in the detection of pancreatic duct variations and anomalies. Along with the visualization of the course and configuration of the pancreatic duct, EUS can also visualize changes in the pancreatic parenchyma, thereby helping with an early diagnosis of any co-existent pancreatic disease. Absence of the stack sign and crossed duct sign are important EUS features to diagnose pancreas divisum. EUS can also help with the diagnosis of other congenital ductal anomalies like annular pancreas, ansa pancreatica, and anomalous pancreaticobiliary union, although the published experience is limited.

Drug-Resistant Helicobacter pylori: Diagnosis and Evidence-Based Approach.

Helicobacter pylori (H. pylori) is the most common chronic bacterial infection, affecting approximately half of the world's population. H. pylori is a Class I carcinogen according to the World Health Organization, and the International Agency for Research on Cancer (IARC) has linked it to 90% of stomach cancer cases worldwide. The overall pattern points to a yearly reduction in eradication rates of H. pylori with the likelihood of success further decreasing after each unsuccessful therapeutic effort. Antimicrobial resistance in Helicobacter pylori is a major public health concern and is a predominant cause attributed to eradication failure. As a result, determining H. pylori's antibiotic susceptibility prior to the administration of eradication regimens becomes increasingly critical. Detecting H. pylori and its antimicrobial resistance has traditionally been accomplished by time-consuming culture and phenotypic drug susceptibility testing. The resistance of H. pylori to different antibiotics is caused by various molecular mechanisms, and advances in sequencing technology have greatly facilitated the testing of antibiotic susceptibility to H. pylori. This review will summarize H. pylori antibiotic resistance patterns, mechanisms, and clinical implications. We will also review the pros and cons of current antibiotic susceptibility testing methods. Along with a comparison of tailored susceptibility-guided regimens and empirical therapy based on the latest evidence, an evidence-based approach to such situations will be explored.

Comparison of Single Versus Two Non-Compression Miniplates in the Management of Unfavourable Angle Fracture of the Mandible Orginal Research.

Aim: To compare the postoperative complications of fixing Mandibular angle fractures with two non-compression mini plates, on the superior and lateral the aspects of the mandible, to the standard technique of using a single non-compression miniplate on the superior border. Methodology: Fifty patients with MAF were divided equally into two groups. Patients in Group 1 were secured with two mini plates at the lateral and superior border of the MA using an extraoral approach; for patients in Group 2 a single non-compression miniplate was used via an intraoral extended third molar approach as described by Champy et al. The post-operative complications in both groups were compared statistically. Results: The findings of this study revealed that there was no significant difference in postoperative complications between the two groups when fixing MAF with two non-compression mini plates versus the standard technique of using a single non compression miniplate on the superior border of the mandible. However, the surgery time with one miniplate was significantly more than the dual plate approach. Conclusion: We advocate using two mini plates to treat an unfavorable angle fracture.

Meditation as an intervention for cognitive disturbances following total sleep deprivation.

BACKGROUND & OBJECTIVES: Decline in cognitive functions is a major challenge for professionals during sustained wakefulness. We used middle latency response (MLR), event related potentials P300-ERP and contingent negative variation (CNV) and Raven's Advanced Progressive Matrices (RAPM) - a standard neuropsychological test were used to evaluate cognitive impairment after total sleep deprivation (SD); and to study the impact of meditation as an intervention for this impairment. METHODS: Healthy male volunteers (n=10) drawn randomly from the Indian Army participated in a 6-night study design executed before and after two months of meditation practice: night 1-adaptation, night 2-baseline, night 3-24 h SD, night 4-recovery sleep, night 5-24 h SD after 60 days meditation, night 6-recovery sleep after SD. A 36 h SD was obtained by keeping the subject awake for 12 h after 24 h SD. RESULTS: The latency and amplitude of P300 increased after 36 h SD. Amplitudes and latencies of both early and late CNV increased after 24 and 36 h SD, indicating deficient orientation and impairment of attention and perception. Prolonged CNV reaction time after 36 h SD manifested deficient motor response following second (imperative) stimulus. Latency of MLR Na registered significant change following 36 h SD compared to baseline (P<0.01) and recovery (P<0.05). RAPM score showed significant decrease after 36 h of wakefulness indicating impaired analytical ability and difficulty in problem solving. None of these parameters showed any significant alteration after SD, following meditation practice. INTERPRETATION & CONCLUSIONS: The present results showed that SD impaired cognitive performance to graded extents significantly, but this deterioration could be improved to a significant extent using meditation.

Retrieval of Fractured Implant Abutment Screws: A Narrative Review.

Objective: Implant abutment screws can fracture due to various biomechanical factors. Improper fit of the prosthesis, inadequate seating of the abutment, occlusal interference, and manufacturing errors are some of the causes that can result in an abutment screw fracture. Retrieval of the retained fractured abutment screw is quite challenging to the clinician. The objective of this review is to provide information on various fractured abutment screw retrieval techniques reported in literature and to formulate a structured treatment protocol for the management of fractured abutment screws. Materials and Methods: An electronic search of Scopus and PubMed databases was performed for articles between January 1989 and December 2021 using the keywords "Implant screw fracture" and "screw retrieval." Results: Most of the articles were of the opinion that abutment screw fractures occurred due to screw loosening. Both conservative approaches and the use of commercial retrieval kits have been advocated to retrieve the fractured abutment screws. Based on various review articles, an innovative novel technique to retrieve an abutment screw fractured due to excessive torque was devised in our unit. Conclusion: Although clinicians can use various techniques to remove fractured abutment screws, every effort should be made to eliminate the cause of screw fracture. Retrieval of the broken screw fragment should be done judiciously to prevent any internal damage to the implant structure.

Blocking SARS-CoV-2 Delta Variant (B.1.617.2) Spike Protein Receptor-Binding Domain Binding with the ACE2 Receptor of the Host Cell and Inhibiting Virus Infections Using Human Host Defense Peptide-Conjugated Graphene Quantum Dots.

The emergence of double mutation delta (B.1.617.2) variants has dropped vaccine effectiveness against SARS-CoV-2 infection. Although COVID-19 is responsible for more than 5.4 M deaths till now, more than 40% of infected individuals are asymptomatic carriers as the immune system of the human body can control the SARS-CoV-2 infection. Herein, we report for the first time that human host defense neutrophil α-defensin HNP1 and human cathelicidin LL-37 peptide-conjugated graphene quantum dots (GQDs) have the capability to prevent the delta variant virus entry into the host cells via blocking SARS-CoV-2 delta variant (B.1.617.2) spike protein receptor-binding domain (RBD) binding with host cells' angiotensin converting enzyme 2 (ACE2). Experimental data shows that due to the binding between the delta variant spike protein RBD and bioconjugate GQDs, in the presence of the delta variant spike protein, the fluorescence signal from GQDs quenched abruptly. Experimental quenching data shows a nonlinear Stern-Volmer quenching profile, which indicates multiple binding sites. Using the modified Hill equation, we have determined n = 2.6 and the effective binding affinity 9 nM, which is comparable with the ACE2-spike protein binding affinity (8 nM). Using the alpha, beta, and gamma variant spike-RBD, experimental data shows that the binding affinity for the delta B.1.617.2 variant is higher than those for the other variants. Further investigation using the HEK293T-human ACE2 cell line indicates that peptide-conjugated GQDs have the capability for completely inhibiting the entry of delta variant SARS-CoV-2 pseudovirions into host cells via blocking the ACE2-spike protein binding. Experimental data shows that the inhibition efficiency for LL-37 peptide- and HNP1 peptide-attached GQDs are much higher than that of only one type of peptide-attached GQDs.

Electrophysiological correlates of cognition improve with nap during sleep deprivation.

The efficacy of a 30-min nap as a countermeasure in the reduction of cognitive decline following 24 h of sleep deprivation (SD) on subjective sleepiness scales, event-related potential (ERP) P300, and contingent negative variation (CNV) was evaluated. The experiment was performed in three sessions on different days between 7 and 8 a.m. on nine normal, healthy males, of age 25-30 years: Session 1. Baseline recordings; Session 2, after one night's total sleep deprivation, and; Session 3, after 1 week of Session 1, following one night's sleep deprivation along with a 30-min nap opportunity between 1.00 and 3.00 a.m. Subjective sleepiness scores increased after SD as compared to baseline, but reduced significantly after nap (P < 0.05). There was an increase in P3 peak latency of ERP following SD (16%, P < 0.01), which was reduced with nap (10.7%, P < 0.05).There was an increase in CNV M1 peak latency after SD (18%) which decreased with the use of nap (12.5%) (P < 0.01). The CNV reaction time increased following SD (39.3%) and decreased with the use of nap (24%) (P < 0.01). No significant effects on ERP N1, P1, N2 latencies, P2 and P3 amplitudes and CNV N1, P3, M2 peak latencies and M1, and M2 amplitudes were observed. It was concluded that a 30-min nap, between 1.00 and 3.00 a.m. during night SD, reduces the cognitive decline following 24 h of SD in terms of its electro-physiological correlates. The study is of applied value in optimization of cognitive performance in professions demanding night work schedules.

Posttraumatic stress disorder among patients with oral and maxillofacial trauma in a South Indian population.

AIM: To determine the incidence and severity of Post-Traumatic Stress Disorder (PTSD) in maxillofacial trauma patients and to assess the predisposing factors. METHODS AND RESULTS: Post-Traumatic Stress Disorder (PTSD) was assessed as per the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. The PTSD checklist for DSM-5 (PCL-5), was used initially to screen patients for PTSD for a provisional diagnosis. These provisionally diagnosed patients were then subjected to a structured interview by a Clinician Administered PTSD Scale for DSM-5 (CAPS-5). The PTSD status outcome of PCL-5 and CAPS-5 were correlated. PTSD was compared among patients with different types of facial fractures/injuries and also compared based on their anatomic location. The reliability of PCL-5 scale in relation to the structured CAPS-5 was assessed and the specificity was found to be 71.4%. Patients with both aesthetic and functional deformity exhibited greater severity of injury and showed higher incidence of PTSD with higher conversion rate from the 1st month to 3rd month. The frequency of PTSD in deformities with higher severity like zygomaticomaxillary complex injuries was found to be statistically significant. CONCLUSION: A high incidence of PTSD is associated with maxillofacial trauma and early detection is essential.

Implementation of Routine Cognitive Screening in the Preoperative Assessment Clinic.

Traditional systems of anesthesia evaluation do not routinely incorporate cognitive screening into preoperative assessments of vital organ systems. Increasing recognition of the importance of preoperative cognitive assessment of the elderly surgical patient has resulted in a "call to action" from experts in this area. A paradigm shift will be necessary to make this screening routine and not just a research tool. We describe our preliminary experience with developing a training program and implementing routine cognitive screening in a preoperative evaluation clinic. We outline a process showing our successful clinical implementation of sustainable cognitive stratification and documentation of routine cognitive screening.

Efficacy of Buccal Infiltration with or without Palatal Injection for Posterior Maxillary Teeth Extraction - A Split-Mouth Randomized Trial

ABSTRACT Objective: To evaluate the feasibility of posterior maxillary teeth extraction buccal infiltration with or without the use of palatal injection. Material and Methods: A total of 70 patients underwent extraction of bilateral maxillary posterior teeth under 2% lignocaine hydrochloride with 1:2,00000 adrenaline infiltration in this single-centric split-mouth randomized trial. The test side was administered with a buccal infiltration of 2 mL of anesthetic alone. An extended waiting period of 10 minutes was given before the commencement of the procedure. A standard protocol was followed for the control side. A single operator performed all extractions. Results: A total of 140 posterior maxillary teeth were extracted. Patients marked pain perception on a visual analogue scale in three different instances. During the administration of injections for the test side, the pain score was less than that of the control side and was statistically significant. The overall pain during the extraction procedure was comparable and statistically insignificant. The overall success of the method was 90%. Conclusion: Extraction of posterior maxillary teeth was feasible with a single buccal infiltration without palatal injection in most cases using an extended waiting period. Dentists can attempt extraction without palatal injections with optimal success. However, the alternate technique could be used when there is a necessity for rescue palatal anesthesia.