Endoscopic Appendectomy for Inverted Appendix: A Case Report and Review of Literature.

Inverted appendix is a very rare anomaly and presents a diagnostic challenge. We report a case of inverted appendix in a 10-year-old boy and its management.

The Indian Network of Drug-Induced Liver Injury: Etiology, Clinical Features, Outcome and Prognostic Markers in 1288 Patients.

BACKGROUND: Etiology of and outcomes following idiosyncratic drug-induced liver injury (DILI) vary geographically. We conducted a prospective study of DILI in India, from 2013 to 2018 and summarize the causes, clinical features, outcomes and predictors of mortality. METHODS: We enrolled patients with DILI using international DILI expert working group criteria and Roussel Uclaf causality assessment method. Follow-up was up to 3 months from onset of DILI or until death. Multivariate logistics regression was carried out to determine predictors of non-survival. RESULTS: Among 1288 patients with idiosyncratic DILI, 51.4% were male, 68% developed jaundice, 68% required hospitalization and 8.2% had co-existing HIV infection. Concomitant features of skin reaction, ascites, and encephalopathy (HE) were seen in 19.5%, 16.4%, and 10% respectively. 32.4% had severe disease. Mean MELD score at presentation was 18.8 ± 8.8. Overall mortality was 12.3%; 65% in those with HE, 17.6% in patients who fulfilled Hy's law, and 16.6% in those that developed jaundice. Combination anti-TB drugs (ATD) 46.4%, complementary and alternative medicines (CAM) 13.9%, anti-epileptic drugs (AED) 8.1%, non-ATD antimicrobials 6.5%, anti-metabolites 3.8%, anti-retroviral drugs (ART)3.5%, NSAID2.6%, hormones 2.5%, and statins 1.4% were the top 9 causes. Univariate analysis identified, ascites, HE, serum albumin, bilirubin, creatinine, INR, MELD score (p < 0.001), transaminases (p < 0.04), and anti-TB drugs (p = 0.02) as predictors of non-survival. Only serum creatinine (p = 0.017), INR (p < 0.001), HE (p < 0.001), and ascites (p = 0.008), were significantly associated with mortality on multivariate analysis. ROC yielded a C-statistic of 0.811 for MELD and 0.892 for combination of serum creatinine, INR, ascites and HE. More than 50 different agents were associated with DILI. Mortality varied by drug class: 15% with ATD, 13.6% with CAM, 15.5% with AED, 5.8% with antibiotics. CONCLUSION: In India, ATD, CAM, AED, anti-metabolites and ART account for the majority of cases of DILI. The 3-month mortality was approximately 12%. Hy's law, presence of jaundice or MELD were predictors of mortality.

Quantification of Liver Fat with mDIXON Magnetic Resonance Imaging, Comparison with the Computed Tomography and the Biopsy.

INTRODUCTION: Accurate, non-invasive method of fat estimation is a valuable test for evaluation of diseases with abnormal hepatic fat. AIM: To determine the accuracy of mDixon MR technique in assessment of liver fat over CT and to correlate the CT and MRI findings with biopsy. MATERIALS AND METHODS: A prospective observational study was conducted at Imaging Services of Narayana Multispeciality Hospital between March 2011- December 2012. Thirty patients who attended the clinic for non-hepatic complaints were included in the study. Patients with known liver disease, cirrhosis, alcoholic liver disease, bleeding diathesis and claustrophobic patients were excluded from the study. Subjects underwent sonography, CT liver and MR examination of liver for fat estimation using mDixon protocol. Biopsy of the liver was performed either by image guidance or by direct biopsy. Liver Attenuation Index (LAI), fat estimation by MR methods were reviewed independently by two observers and compared with biopsy results. The statistical analysis was performed by SPSS. Pearson correlation was used to find the correlation between the left and right lobe of liver segments by CT and histological correlation. RESULTS: There was good correlation between the MR estimation of liver fat and histological grading. Majority (90%) of patients had fat content of less than 10%. Maximal fat content of 28% was observed in one patient. LAI values poorly correlated with the MRI and histological observations. CONCLUSION: MR estimation of the liver using mDixon technique yielded specific information about liver fat, correlated well with the histological grading. Technique is more accurate than CT, does not involve ionising radiation, hence recommended as method of choice.

Alumina/activated carbon nano-composites: Synthesis and application in sulphide ion removal from water.

An investigation of adsorption of sulphide ion (S2-) in water onto carbon/alumina nano-composites synthesized from aluminium carboxylate precursors, in presence of HCl, NaOH, NaCl and surfactant is reported in this paper. A controlled oxygen free pyrolytic technique has been adopted for the synthesis of nano-composites, using acetate, acetyl acetonate, lactate and distearate of aluminium and activated carbon. XRD, SEM and TEM studies of the composites show that they contain clusters made of nano carbon particles of size 50-130nm into which nano alumina particles of size around 10nm are dispersed. While applying the adsorption data in Langmuir, Freundlich, Temkin and Dubinin-Raduskevich isotherm models, the data fit well with Langmuir model. All composites have increased porosity and decreased surface area compared to bare carbon. The adsorption capacity of composites obtained from acetate and lactate are higher and are found to be in the range of 71-200mg/g.

An elderly male with tingly legs and a heavy heart: Persisting with the diagnosis!

Pursuing a diagnosis despite a negative nerve biopsy report requires a strong clinical conviction. Paying attention to clinical details and a diligent review of medical records is needed to solve cases in which the diagnosis is not obvious despite numerous tests. We present once such case of an elderly man with chronic diarrhea, weight loss, and peripheral neuropathy and elaborate on a step by step basis on how the clinical thought process evolved after sifting through the reports of scan and tests done during his work up.

Granulocytic sarcoma of colon in a patient with acute promyelocytic leukemia.

Granulocytic sarcoma in a patient with acute promyelocytic leukemia (APML) has been described often in the relapse setting, however primary presentation of APML as granulocytic sarcoma is rare. We present a case of a 29 year old male who was evaluated for thrombocytopenia with haematochezia and a diagnosis of acute promyelocytic leukemia was established after the colonic biopsy was reported as a granulocytic sarcoma.

A novel framework to classify marginal land for sustainable biomass feedstock production.

To achieve food and energy security, sustainable bioenergy has become an important goal for many countries. The use of marginal lands to produce energy crops is one strategy for achieving this goal, but what is marginal land? Current definitions generally focus on a single criterion, primarily agroeconomic profitability. Herein, we present a framework that incorporates multiple criteria including profitability of current land use, soil health indicators (erosion, flooding, drainage, or high slopes), and environmental degradation resulting from contamination of surface water or groundwater resources. We tested this framework for classifying marginal land in the state of Nebraska and estimated the potential for using marginal land to produce biofuel crops. Our results indicate that approximately 1.6 million ha, or 4 million acres, of land (approximately 8% of total land area) could be classified as marginal on the basis of at least two criteria. Second-generation lignocellulosic bioenergy crops such as switchgrass ( Panicum virgatum L.), miscanthus (Miscanthus giganteus), native prairie grasses, and short-rotation woody crops could be grown on this land in redesigned landscapes that meet energy and environmental needs, without significant impacts on food or feed production. Calculating tradeoffs between the economics of redesigned landscapes and current practices at the field scale is the next step for determining functional designs for integrating biofuel feedstock production into current land management practices.

Monitoring network design for phytoremediation systems using primary and secondary data sources.

Phytoremediation, or contaminant removal using plants, has been deployed at many sites to remediate contaminated soil and groundwater. Research has shown that trees are low-cost, rapid, and relatively simple-to-use monitoring systems as well as inexpensive alternatives to traditional pump-and-treat systems. However, tree monitoring is also an indirect measure of subsurface contamination and inherently more uncertain than conventional techniques such as wells or soil borings that measure contaminant concentrations directly. This study explores the implications for monitoring network design at real-world sites where scarce primary data such as monitoring wells or soil borings are supplemented by extensive secondary data such as trees. In this study, we combined secondary and primary data into a composite data set using models to transform secondary data to primary, as primary data were too sparse to attempt cokriging. Optimal monitoring networks using both trees and conventional techniques were determined using genetic algorithms, and trade-off curves between cost and uncertainty are presented for a phytoremediation system at Argonne National Laboratory. Optimal solutions found at this site indicate that increasing the number of secondary data sampled resulted in a significant decrease in global uncertainty with a minimal increase in cost. The choice of the data transformation model had an impact on the optimal designs and uncertainty estimated at the site. Using a data transformation model with a higher error resulted in monitoring network designs where primary data were favored over colocated secondary data. The spatial configuration of the monitoring network design was similar with regard to the areas sampled, irrespective of the data transformation model used. Overall, this study shows that using a composite data set, with primary and secondary data, results in effective monitoring designs, even at sites where the only data transformation model available is one with significant error.

Pediatric liver transplantation: A report from a pediatric surgical unit.

BACKGROUND: Liver transplantation is well established worldwide as an effective treatment for end-stage liver disease in children. Acceptance in India has been slow because of considerations of cost, infections, inability to support long-term care, and non-availability of expertise. AIM: This study was designed to report our experience with pediatric liver transplantation. MATERIALS AND METHODS: Twenty-eight children underwent liver transplantation. RESULTS: Biliary atresia was the commonest indication (n = 15) followed by metabolic liver disease. Twenty-six children had living donor transplants, mothers being the donors in a majority of these. Common surgical complications included bile leaks (n = 3) and vascular problems (n = 6). Common medical complications included infections, acute rejection, and renal failure. Overall, patient survival was 71%, while that for the last 14 cases was 92%. All survivors are doing well, have caught up with physical and developmental milestones and are engaged in age appropriate activities. CONCLUSIONS: The study demonstrates the feasibility of a successful pediatric liver transplant program in our country.

Lignin and lipid impact on sorption and diffusion of trichloroethylene in tree branches for determining contaminant fate during plant sampling and phytoremediation.

Plants draw all they need from their surrounding environment and in doing so also draw anthropogenic contaminants from their surroundings. Several natural processes (e.g., active transport, diffusion, sorption, and degradation) occur within trees and affect chemical concentrations in tree samples. This study elucidates tree contaminant chemical interactions on equilibrium sorption and diffusion into branch tissue (i.e., wood core and bark), specifically the impacts of lipid and lignin content. Five tree species were selected to span a range of lignin and lipid contents. Linear isotherms were obtained for all sampled species over a limited concentration range (2 microg/ mL < C(gas) < 12 microg/mL), and equilibrium distribution coefficients (K(d)) were linearly correlated to lipid (R2 > 0.83) but not lignin (R2 < 0.4) content. Lipid content was generally higher in bark than in wood cores, so mass concentrated in this tissue. Diffusion into trees was modeled, showing mass transfer resistance in bark was different from wood cores. Diffusion coefficients for bark were 2-10 times less than those for wood cores for all species, and diffusion was linearly related to lipid content (R2 > 0.96) and sorption coefficients (R2 > 0.83). Data from this study and previous research were used to develop the following correlation between the diffusion coefficient and relevant plant and chemical parameters for branch samples: D = (-7 x 10(-11)) x [f(lipid) x 10 (l.48 x logKow+0.54)] + 4 x 10(-8).

Biofuels, land, and water: a systems approach to sustainability.

There is a strong societal need to evaluate and understand the sustainability of biofuels, especially because of the significant increases in production mandated by many countries, including the United States. Sustainability will be a strong factor in the regulatory environment and investments in biofuels. Biomass feedstock production is an important contributor to environmental, social, and economic impacts from biofuels. This study presents a systems approach where the agricultural, energy, and environmental sectors are considered as components of a single system, and environmental liabilities are used as recoverable resources for biomass feedstock production. We focus on efficient use of land and water resources. We conducted a spatial analysis evaluating marginal land and degraded water resources to improve feedstock productivity with concomitant environmental restoration for the state of Nebraska. Results indicate that utilizing marginal land resources such as riparian and roadway buffer strips, brownfield sites, and marginal agricultural land could produce enough feedstocks to meet a maximum of 22% of the energy requirements of the state compared to the current supply of 2%. Degraded water resources such as nitrate-contaminated groundwater and wastewater were evaluated as sources of nutrients and water to improve feedstock productivity. Spatial overlap between degraded water and marginal land resources was found to be as high as 96% and could maintain sustainable feedstock production on marginal lands. Other benefits of implementing this strategy include feedstock intensification to decrease biomass transportation costs, restoration of contaminated water resources, and mitigation of greenhouse gas emissions.

Mass recovery methods for trichloroethylene in plant tissue.

Monitoring expenses form a significant fraction of the costs associated with remediation of contaminated soil and groundwater sites. A novel monitoring method that could result in significant cost savings is the use of plants as monitoring devices; previous work indicates that plant tissue samples, especially trunk (core) and branch samples, can be used to delineate soil and groundwater plumes at phytoremediation sites. An important factor in reducing the uncertainty associated with this sampling method is development of a technique to analyze, both consistently and accurately, the chemicals stored in plant tissue samples. The present research presents a simple, robust, and inexpensive technique to recover most of the contaminant in plant branch tissue, irrespective of the age or species of the plant. Tricholoroethylene (TCE) was the chemical analyzed. A number of headspace and solvent extraction techniques in the literature were evaluated, including headspace extraction at different incubation times and temperatures and solvent extraction using hexane or hot methanol. Extraction using hot methanol was relatively fast, simple, and reliable; this method recovered more than 89% of the TCE present in branches of five different tree species.

Mast cell disease: surgical and anesthetic implications.

Mast cell disease (MCD) is a clonal disorder of the mast cell and its precursor cells. Cardiac surgery in MCD is rarely described. We report an unusual case of a 14-year-old girl who was admitted for atrial septal defect closure and incidentally found to have hepatosplenomegaly with lymphadenopathy who underwent a successful open-heart surgery, after a diagnosis of MCD.