Is salvage Plug-Assisted Retrograde Transvenous Obliteration (PARTO) safe and effective for bleeding gastric varices ?- A preliminary single-center experience.

BACKGROUND: Vascular plug-assisted retrograde transvenous obliteration (PARTO) obliterates the gastric varices and portosystemic shunt, thus resulting in a lower rebleeding rate than endoscopic glue/sclerotherapy. AIMS: To evaluate the safety and efficacy of PARTO as salvage therapy in liver cirrhosis with gastric variceal bleed (GVB) after failed endotherapy. We assessed the clinical success rate and changes in liver function at 6- months. MATERIALS AND METHODS: Patients who underwent salvage PARTO after failed endotherapy for GVB (between December 2021 and November 2022) were searched and analyzed from the hospital database. Clinical success rate and rebleed rate were obtained at six months. Child-Pugh score (CTP) and Model for end-stage liver disease (MELD) score were calculated and compared between baseline and 6-month follow-up. RESULTS: Fourteen patients (n = 14, Child-Pugh class A/B) underwent salvage PARTO. Nine had GOV-2, and five had IGV-1 varices. The mean shunt diameter was 11.6 ± 1.6 mm. The clinical success rate of PARTO was 100% (no recurrent gastric variceal hemorrhage within six months). No significant deterioration in CTP (6.79 ± 0.98 vs. 6.21 ± 1.52; p = 0.12) and MELD scores (11.5 ± 4.05 vs. 10.21 ± 3.19; p = 0.36) was noted at 6 months. All patients were alive at 6 months. One patient (n = 1, 7.1%) bled from esophageal varices after three days of PARTO and was managed with variceal banding. 21.4% (3/14) patients had progression of esophageal varices at 6 months requiring prophylactic band ligation. Three patients (21.4%) had new onset or worsening ascites and responded to low-dose diuretics therapy. CONCLUSIONS: PARTO is a safe and effective procedure for bleeding gastric varices without any deterioration in liver function even after six months. Patient selection is critical to prevent complications. Further prospective studies with larger sample size are required to validate our findings.

Bloody Bile and Rescue Intervention-A Case Series of Post-PTBD Hemorrhagic Complications With a Review of the Literature.

Percutaneous transhepatic biliary drainage (PTBD) is a routinely performed interventional radiological procedure. A myriad of complications can occur after PTBD, the most important being hemorrhagic complications that require immediate attention. Hemorrhage following PTBD may result from arterial, portal, or hepatic venous injury. A catheter or pull-back cholangiogram often demonstrates the venous injury. A computed tomogram angiogram aids in identifying bleeding sources and procedural planning. Catheter repositioning, upsizing, or clamping often suffice for minor venous bleeding. However, major venous injury necessitates tract embolization, portal vein embolization, or stent grafting. Arterial injury may lead to significant blood loss unless treated expeditiously. Transarterial embolization is the treatment of choice in such cases. Adequate knowledge about the hemorrhagic complications of PTBD will allow an interventional radiologist to take necessary precautionary measures to reduce their incidence and take appropriate steps in their management. This article entails four different hemorrhagic complications of PTBD and their interventional management. It also discusses the various treatment options to manage different kinds of post-PTBD hemorrhagic complications.

Role of Interventional Radiology (IR) in vascular emergencies among cirrhotic patients.

Gastrointestinal hemorrhage remains one of the most common causes of morbidity and mortality among patients with liver cirrhosis. Mostly, these patients bleed from the gastroesophageal varices. However, nonvariceal bleeding is also more likely to occur in these patients. Because of frequent co-existing coagulopathy, cirrhotics are more prone to bleed from a minor vascular injury while performing percutaneous interventions. Ultrasound-guided bedside vascular access is an essential procedure in liver critical care units. Transjugular portosystemic shunts (TIPS) with/without variceal embolization is a life-saving measure in patients with refractory variceal bleeding. Whenever feasible, balloon-assisted retrograde transvenous obliteration (BRTO) is an alternative to TIPS in managing gastric variceal bleeding, but without a risk of hepatic encephalopathy. In cases of failed or unfeasible endotherapy, transarterial embolization using various embolic agents remains the cornerstone therapy in patients with nonvariceal bleeding such as ruptured hepatocellular carcinoma, gastroduodenal ulcer bleeding, and procedure-related hemorrhagic complications. Among various embolic agents, N-butyl cyanoacrylate (NBCA) enables better vascular occlusion in cirrhotics, even in coagulopathy, making it a more suitable embolic agent in an expert hand. This article briefly entails the different interventional radiological procedures in vascular emergencies among patients with liver cirrhosis.

Cladosporium halotolerans: Exploring an Unheeded Human Pathogen.

BACKGROUND: Cladosporium halotolerans is a saprobic fungus, rarely implicated in human infections. The identification is challenging due to non-specific phenotypic features. OBJECTIVE: To decipher clinical spectrum, microbiological and susceptibility profile of clinical and environmental isolates of Cladosporium halotolerans. METHOD: All the isolates identified as Cladosporium halotolerans deposited in National Culture Collection for Pathogenic Fungi (NCCPF), Postgraduate Institute of Medical Education and Research, Chandigarh, India were revived. Phenotypic and molecular characterization targeting internal transcribed spacer (ITS) region of ribosomal DNA, large subunit of ribosomal DNA (LSU; NL1 and NL4), actin (ACT) and beta-tubulin (TUB) was done. Scanning electron microscopy (SEM) was performed to determine any phenotypic variations. Antifungal susceptibility testing (AFST) was carried out for eight antifungal agents as per CLSI M38 Ed3 guidelines. We also performed systematic literature review of all the cases of Cladosporium halotolerans reported till date. RESULTS: A total of four isolates (clinical, n = 3; soil, n = 1) identified as Cladosporium halotolerans were included in the study. The clinical sites were skin, maxillary tissue and nail. All patients were apparently immunocompetent, and history of trauma was recorded in one patient. All patients improved on antifungal therapy. The cultures revealed growth of black mycelial fungus and microscopic examination demonstrated dematiaceous septate hyphae with erect conidiophores and conidia in branched acropetal chains. Based on molecular methods, all the four isolates were identified as C. halotolerans. SEM revealed no variation in length and width of the conidia, conidiophores, ramoconidium and hyphae among the isolates. All molecular targets, such as ITS region, LSU (partially sequenced), ACT and TUB were able to differentiate the isolates. Minimum inhibitory concentrations for antifungals were: triazoles (0.12-2 µg/ml), amphotericin B (4 µg/ml) and echinocandins (2-8 µg/ml). CONCLUSION: We report role of the rarely isolated dematiaceous fungus, C. halotolerans, in causing human infections. The study emphasizes the role of molecular methods in precisely identifying these species. Triazoles are more active against these black fungi compared to polyenes or echinocandins.

Assessment of Serum Zinc Levels in Patients With Decompensated Cirrhosis of the Liver and Its Association With Disease Severity and Hepatic Encephalopathy: A Prospective Observational Study From North India.

Background Zinc, an essential trace element, plays a vital role in cellular metabolism, and the liver is the main organ responsible for its metabolism. Because serum zinc levels are found to be lowered in chronic liver diseases, it has been hypothesized to be a precipitating factor for the development of hepatic encephalopathy. Methodology This prospective, observational study included patients with decompensated cirrhosis of the liver who were admitted to the medical intensive care unit of a tertiary care institute in northern India between September 2021 and April 2023. The diagnosis was based on history and detailed clinical examination. The serum zinc levels of patients were estimated using atomic absorption spectrometry at admission and compared to that of healthy controls. Serum zinc levels were correlated with the severity of liver disease and hepatic encephalopathy among the cases. Results A total of 100 cases of decompensated cirrhosis of the liver and 50 healthy controls were included. The mean serum zinc level of the cases was 40.5 ± 10.0 µg/dL which was significantly lower than the mean serum zinc level (104.0±9.1 µg/dL) of controls (p < 0.0001). Serum zinc level was significantly lower in patients with higher grades of hepatic encephalopathy (p = 0.000). Similarly, serum zinc level was significantly reduced among patients with higher Child-Pugh and Model for End-stage Liver Disease scores. Conclusions Serum zinc level is significantly reduced in patients with decompensated cirrhosis of the liver, and lower serum zinc level is associated with the increased severity of the disease and higher grades of hepatic encephalopathy. In patients with decompensated cirrhosis of the liver, maintenance of adequate serum zinc levels may prevent hepatic encephalopathy.

Oral Localized Lesion on the Tongue in an Immunocompetent Individual: A Report of a Rare Case With a Comprehensive Review of the Literature.

Histoplasmosis (HP) is a sporadic deep fungal disease that rarely shows oral lesions in various clinical forms. It is usually associated with immunocompromised states, but oral HP has also been reported in many immunocompetent individuals. An unusual case of focal oral HP in a 65-year-old immunocompetent male is reported from New Delhi, India (non-endemic region) presenting with oral ulcerative lesions on the floor of the mouth and lateral surface of the tongue. This case report highlights the importance of prompt diagnosis for the success of the treatment of oral HP along with a thorough review of the literature on HP in immunocompetent patients with oral manifestations. The average age of immunocompetent patients with oral HP is 49.65 years with a marked male predilection. The most common intraoral site is the tongue, followed by the gingiva. Also, five intraosseous cases of HP in immunocompetent patients are reported, among which four are seen in patients from Africa and in a much younger age group (mean: 17.25 years).

Insight into molecular interaction between shrimp and white spot syndrome virus through MjsvCL-VP28 complex: an in-silico approach.

White Spot disease is a devastating disease of shrimps caused by White Spot Syndrome Virus in multifarious shrimp species. At present there is no absolute medication to suppress the disease hence, there is an urgent need for development of drug against the virus. Molecular interaction between viral envelope protein VP28 and shrimp receptor protein especially chitins play a pivotal role in ingression of WSSV. In the present study, we have tried to shed light on structural aspects of lectin protein in Marsupenaeus japonicus (MjsvCL). A structural insight to the CTLD-domain of MjsvCL has facilitated the understanding of the binding mechanism between the two proteins that is responsible for entry of WSSV into shrimps. Further, incorporation of molecular dynamics simulation and MMPBSA studies revealed the affinity of binding and certain hotspot residues, which are critical for association of both the proteins. For the first time we have proposed that these amino acids are quintessential for formation of VP28-MjsvCL complex and play crucial role in entry of WSSV into shrimps. Targeting the interaction between VP28 and CTLD of MjsvCL may possibly serve as a potential drug target. The current study provides information for better understanding the interaction between VP28 and MjsvCL that could be a plausible site for future inhibitors against WSSV in shrimps.Communicated by Ramaswamy H. Sarma.

Ewing's sarcoma masquerading as an odontogenic infection.

ABSTRACT: Ewing's sarcoma (ES) is a small, blue, malignant, round cell tumor of unknown origin. ES is the fourth most common malignant bone tumor, whereas among children, it is found to be the second most common primary malignant bone tumor after osteosarcoma. Swelling is usually the first clinical presentation, followed by pain. ES is an aggressive tumor showing rapid growth and metastasis with complex diagnosis. Because mandibular involvement is rare, it can be misdiagnosed as an odontogenic infection/tumor. We report an unusual case of ES in a 13-year-old female treated for an odontogenic infection before a diagnosis of ES was finally made to make the clinicians aware of this rare entity. Emphasis is also given that ES and odontogenic infections/tumors can masquerade each other with delays in diagnosis and the possibility of devastating results.

Maxillary sinus mucocele in a 20-year-old male: a case report of a rare occurrence / Mucocele de seno maxilar en un varón de 20 años: reporte de un caso de rara ocurrencia

Mucocele of Maxillary sinus is a rare entity comprising 2-10% of all mucoceles and develops due to obstruction of drainage ostium. Here, we present a case of maxillary sinus mucocele in a 20-year-old male who presented with diffuse swelling on the left side of his face. Provisional diagnosis of mucocele was made on a computed tomography scan, which was later confirmed on histopathology. The lesion was managed surgically with uneventful healing at 2 weeks and 3 months follow-up.Mucoceles are often misdiagnosed as cysts or tumours of odontogenic origin on the conventional radiograph. Delay in diagnosis can result in complications due to the expansion of mucocele towards adjacent structures such as the nose and orbit. Therefore, it becomes crucial to diagnose it appropriately with the help of higher imaging modalities so that it can be managed well in time. (AU)

El mucocele del seno maxilar es una entidad rara que comprende el 2-10% de todos los mucoceles y se desarrolla debido a la obstrucción del ostium de drenaje. A continuación, presentamos un caso de mucocele del seno maxilar en un hombre de 20 años que presentó una inflamación difusa en el lado izquierdo de la cara. El diagnóstico provisional de mucocele se realizó en una tomografía computarizada, que luego se confirmó en la histopatología. La lesión se manejó quirúrgicamente con curación sin incidentes a las 2 semanas y 3 meses de seguimiento.Los mucoceles a menudo se diagnostican erróneamente como quistes o tumores de origen odontogénico en la radiografía convencional. El retraso en el diagnóstico puede dar lugar a complicaciones debido a la expansión del mucocele hacia estructuras adyacentes como la nariz y la órbita. Por lo tanto, se vuelve crucial diagnosticarlo adecuadamente con la ayuda de modalidades de imágenes superiores para que pueda manejarse bien a tiempo. (AU)

Comedone Extractor with Multiple Variable Sized Holes for Mass Comedone Extraction.

Conventional comedone extractor has only one or two holes of fixed or variable sizes. This conventional extractor is not suitable for mass comedone extraction and that too of variable sizes. We tried to made an attempt to overcome this problem.

Imaging findings of orofacial cysticercosis: report of 5 cases with review of literature.

Cysticercosis, a fatal disease of parasitic aetiology seen in humans, is caused by ingestion of larvae of Taenia solium in form of raw or poorly cooked pork. Commonly seen in developing countries, it affects the brain, muscle, lungs, heart and liver and is rarely found in the maxillofacial region. Sometimes, the only evidence of cysticercosis could be the cystic swellings or nodules in the maxillofacial region. Such solitary clinical presentation can be diagnosed early with the aid of ultrasound (USG) and Magnetic resonance imaging (MRI). Here, we present 5 cases of intramuscular cysticercosis of Orofacial region which were initially diagnosed on ultrasonography and later confirmed by MRI and aspiration cytology. We have conducted a systematic review of PubMed Literature for Intramuscular cysticercosis of orofacial region and highlighted key imaging findings from 18 cases retrieved. Through this case series, we highlight the USG and MRI imaging features of intramuscular cysticercosis which are characteristic and diagnostic of the condition.

On-farm hydro and nutri-priming increases yield of rainfed pearl millet through physio-biochemical adjustments and anti-oxidative defense mechanism.

Seed priming technique has a marvelous potential in enhancing seed germination and crop establishment under limited soil moisture conditions, which ultimately increases yield. Therefore, we investigated the effects of seed priming on physiology, growth, yield and antioxidant defense system of pearl millet (Pennisetum glaucum L.) under rain-fed condition. The experiments were conducted under laboratory as well as field conditions comprising three treatments i.e., non-primed seeds (control, T0), priming with tap water (hydropriming) (T1) and priming with 2% KNO3 2% for 6 hours at 25°C followed by shade drying (T2). The results showed that chlorophyll content (10.37-14.15%) and relative water content (RWC) (12.70-13.01%) increased whereas proline (-19.44 to -25%) and soluble sugar (-15.51 to -29.13%) contents decreased on account of seed priming in pearl millet under field conditions. The seed priming significantly improved the plant height, final plant stand and grain weight which resulted in increased yield. Enhanced activities of superoxide dismutase (SOD) (5.89 to 8.10 unit/g/seed/min), catalase (CAT) (22.54 to 39.67 µmol/min/g/seed) and ascorbate peroxidase (APX) (8.92 to 22.10 µmol/cm/min/g) and concomitant decrease in H2O2 and malondialdehyde (MDA) content suggests their role in imparting oxidative tolerance at initial stages of growth in primed seed. The lab studies suggest that the improved yield might be attributes to increased seed germination and seedling vigor. It is recommended that the hydropriming (tap water) or KNO3 (2%) priming of seeds for 6 hours under ambient conditions is effective to enhance growth and yield of pearl millet under rainfed conditions.

Diagnosing rare intraductal biliary neoplasms - Intraductal papillary neoplasm of the bile duct: A case report with typical imaging findings.

Intraductal papillary neoplasm of the bile duct (IPN-B) is a rare preinvasive intraductal pathology of the biliary tract. It should be differentiated from other more common benign or malignant causes of biliary obstruction and dilatation such as calculi or cholangiocarcinoma because the management and prognosis of this condition differs significantly. This case report describes a case of IPN-B in a 45-year-old female patient who presented with non-specific complaints of chronic abdominal pain without jaundice for three months.

Assessment of APACHE II Score to Predict ICU Outcomes of Patients with AKI: A Single-center Experience from Haryana, North India.

Background: The acute physiology and chronic health evaluation (APACHE) II severity score has shown a good calibration and discriminatory value across a range of disease processes and remains the most widely used source of prognostic information on the risk for death in patients admitted to intensive care units (ICUs). Objectives: To study APACHE II scores in patients of acute kidney injury (AKI) admitted in the ICU and to find its association with outcome. Materials and methods: One hundred patients with AKI aged 18 years or above were admitted in the ICU, department of general medicine, of a tertiary care institute in Haryana, North India, from October 2019 to September 2020, were studied. Patients who had known causes of chronic kidney disease (CKD), on maintenance hemodialysis, and those who underwent renal replacement therapy (RRT) or nephrectomy were excluded. All required investigations were performed, and data were collected. The patients were followed till discharge or in-hospital mortality. Results: The mean age of the patients was 55.92 ± 18.18 years. Male-female ratio was 1.5:1. Thirty-five percent of the admitted patients had an in-hospital mortality. Sepsis (47%) was the most common cause of AKI, and 83% of the patients had underlying comorbid conditions. The mean APACHE II score of the expired patients on admission, i.e., 24.80 ± 13.65, was found to be significantly higher compared to the mean APACHE II score (17.25 ± 10.12) of the discharged patients (p-value <0.001). APACHE II score was found to have 57.14% sensitivity, 86.15% specificity, 69% PPV, 78.9% NPV, and 76% diagnostic accuracy to predict mortality among the AKI patients. Conclusion: APACHE II scoring system has a good discrimination and calibration when applied to ICU-admitted AKI patients and is a good predictor of prognosis in them. How to cite this article: Patel P, Gupta S, Patel H, Bashar MDA. Assessment of APACHE II Score to Predict ICU Outcomes of Patients with AKI: A Single-center Experience from Haryana, North India. Indian J Crit Care Med 2022;26(3):276-281.

Impacts, Tolerance, Adaptation, and Mitigation of Heat Stress on Wheat under Changing Climates.

Heat stress (HS) is one of the major abiotic stresses affecting the production and quality of wheat. Rising temperatures are particularly threatening to wheat production. A detailed overview of morpho-physio-biochemical responses of wheat to HS is critical to identify various tolerance mechanisms and their use in identifying strategies to safeguard wheat production under changing climates. The development of thermotolerant wheat cultivars using conventional or molecular breeding and transgenic approaches is promising. Over the last decade, different omics approaches have revolutionized the way plant breeders and biotechnologists investigate underlying stress tolerance mechanisms and cellular homeostasis. Therefore, developing genomics, transcriptomics, proteomics, and metabolomics data sets and a deeper understanding of HS tolerance mechanisms of different wheat cultivars are needed. The most reliable method to improve plant resilience to HS must include agronomic management strategies, such as the adoption of climate-smart cultivation practices and use of osmoprotectants and cultured soil microbes. However, looking at the complex nature of HS, the adoption of a holistic approach integrating outcomes of breeding, physiological, agronomical, and biotechnological options is required. Our review aims to provide insights concerning morpho-physiological and molecular impacts, tolerance mechanisms, and adaptation strategies of HS in wheat. This review will help scientific communities in the identification, development, and promotion of thermotolerant wheat cultivars and management strategies to minimize negative impacts of HS.

Comparative efficacy of topical aloe vera and low-level laser therapy in the management of oral lichen planus: a randomized clinical trial.

This randomized clinical trial aimed to compare the efficacy of topical aloe vera with low-level laser therapy in patients with oral lichen planus (OLP). A randomized, parallel arm, single-blind study comprising of 60 patients with OLP was randomly divided into two groups. Group A was given topical aloe vera extract gel applied thrice daily for 2 months, and group B was given low-level laser therapy (LLLT) at 980 nm twice weekly for 2 months. Both groups were followed up for 9 months. Patients were assessed for various parameters according to the Escudier scale at baseline, after treatment at 9 months. Results were assessed using the McNemar-Bowker test and the Mann-Whitney U test. Both individual groups showed significant (p < 0.05) results at the end of the treatment period (0-2 months) and the follow-up period (2-7 months). Intergroup comparison showed significant results in the laser group (reduction of VAS by 44.1%, site score by 24.6%, and activity score by 50%) as compared with the aloe vera group (reduction of VAS by 26.7%, site score by 9.2%, and the activity score by 26%) in the treatment period. In the follow-up period, both groups showed insignificant differences in comparison to each other. Within the limitations of the study, LLLT was more effective as compared with topical aloe vera in managing oral lichen planus during the active treatment time, while both were equally effective during the follow-up period. The clinical study was registered under the Clinical Trials Registry India with the registration number CTRI/2018/04/013147.

Novel Treatment Approach of Oral Submucous Fibrosis in a 6-year-old Girl: A Case Report.

BACKGROUND: Oral submucous fibrosis is characterized by stiffness of oral mucosa, blanching and functional limitation, and areca nut predisposition is considered to be one of the main etiological factors. In recent years, there is an increasing prevalence of OSMF in the Indian subcontinent owing to increased consumption of smokeless tobacco products. Very few cases of pediatric OSMF are reported in PubMed literature. Oral submucous fibrosis has a malignant transformation rate of 7-13% and hence, it is important to intervene at an appropriate stage and manage it well in time. AIM AND OBJECTIVE: To report a case of oral submucous fibrosis (OSMF) in a 6-year-old Indian girl along with its management and follow-up. CASE DESCRIPTION: A 6-year-old girl of Indian origin was diagnosed with OSMF and we have used sesame oil pulling as a novel treatment approach and observed good results with long-term follow-up. We have also reviewed PubMed literature for cases of pediatric OSMF reported till date. CONCLUSION: A timely diagnosis and intervention becomes necessary in pediatric OSMF to improve oral function and prevent malignant transformation. CLINICAL SIGNIFICANCE: It is important to report oral potentially malignant disorder (OPMD) cases in pediatric patients and create awareness through health education programs so that parents and children know about the ill effects of consuming tobacco products. HOW TO CITE THIS ARTICLE: Gupta S, Gupta S, Chaudhary C, et al. Novel Treatment Approach of Oral Submucous Fibrosis in a 6-year-old Girl: A Case Report. Int J Clin Pediatr Dent 2021;14(4):575-579.