Severe Symptomatic Anemia in Gastrointestinal Tract Sarcoidosis.

Sarcoidosis is a systemic granulomatous disease of unknown etiology with the potential to involve many organs of the body. Less than 1% of patients with sarcoidosis have GI manifestations. Here, we report a case of GI tract sarcoidosis that presented with severe symptomatic anemia. A 51-year-old female with a history of pulmonary and liver sarcoidosis presented to the emergency room with a one-week history of chest pain and shortness of breath. A physical exam was significant for conjunctival pallor. On admission, her hemoglobin was 6.9 g/dL. Her iron studies showed anemia of chronic disease. There was no evidence of recurrent pulmonary sarcoidosis on the CT scan of the chest. Transthoracic echo showed no abnormal wall motion movements. A nuclear stress test was negative for perfusion defects. She underwent esophagogastroduodenoscopy (EGD) and colonoscopy to further evaluate potential sources of active GI tract blood loss. Biopsies of gastric mucosa and small bowel revealed non-caseating granulomas. Immunohistochemical stains for acid-fast bacilli and fungus were negative. Random biopsies of erythematous mucosa from the colonoscopy were unremarkable. The patient's history of pulmonary and liver sarcoidosis along with non-caseating granulomas found in the gastric mucosa and small bowel suggest GI tract sarcoidosis manifestations. She was started on corticosteroids with complete resolution of symptoms in five months. Clinical presentation varies widely based on the specific organ involvement, as well as the underlying pathophysiology of the organ damage. The pathogenesis of sarcoidosis is poorly understood and attributable to both genetic and environmental factors. Overall, the treatment of sarcoidosis is not standardized. It is primarily driven by the effect of sarcoidosis on the patient's symptoms and quality of life. However, symptomatic sarcoidosis usually responds well to corticosteroids. We believe that clinicians should maintain a high level of vigilance for patients with a known history of sarcoidosis and new symptoms, as these might signal sarcoid involvement of a new organ and help guide the diagnostic and treatment process.

Acquiring the Diagnosis of an Acquired Tracheoesophageal Fistula with EtCO2: A Case Discussion with Review of the Literature.

Acquired tracheoesophageal fistula (TEF) is a rare complication of esophageal or lung cancer. A 57-year-old male presented with complaints of vomiting, cough, 20 lb weight loss, and progressive dysphagia. Early laryngoscopy and CT chest showed a normal pharynx with an irregular thickness of the thoracic esophagus. The upper gastrointestinal endoscopy (UGIE) and upper endoscopic ultrasound (EUS) revealed a hypoechoic mass evolving as complete obstruction. During the procedure, minimal CO2 was used for insufflation; however, when attempts were made to traverse the obstruction, capnography revealed an end-tidal CO2 (EtCO2) estimating 90 mmHg indicating possible TEF. This case depicts the use of capnography during UGIE in diagnosing an acquired TEF.

Effects of three biochars on copper immobilization and soil microbial communities in a metal-contaminated soil using a metallophyte and two agricultural plants.

Biochar (BC) is a porous, carbonaceous material produced by slow pyrolysis of biomass under oxygen-limited conditions. BC production has been attracting research interest because it modifies soil physicochemical characteristics and improves the growth of plants in problem soils. These benefits may be best actualized for soils contaminated by metals, where remediation is hampered by metal toxicity to both plants and soil microbial communities. The objectives of this study were to evaluate the impact of the addition of chicken manure biochar (CMB), oat hull biochar (OHB), or pine bark biochar (PBB) on copper (Cu) bioavailability in a Cu-contaminated soil, the effectiveness of these BCs promoting plant growth, and its effects on soil microbial communities supporting these plants. A sandy soil (338 mg Cu kg-1) was amended with CMB, OHB, and PBB, and the metallophyte Oenothera picensis or the agricultural species Solanum lycopersicum and Lolium perenne were grown for 3 months. The BCs produced an increase in soil pH, reduced the exchangeable Cu, and increased Cu bound to organic matter and residual fractions. All BCs enhanced the quality of contaminated soil and increased the plant biomass production, notably for S. lycopersicum, which grew until 12 times more than plants in non-amended soil. While BC addition reduced the concentration of Cu in soil pore water, the amendment did not reduce the concentrations of Cu in shoot tissues. BC additions also stimulated soil microorganisms, increasing basal respiration and DHA activity and modifying microbial communities, especially in soils supporting L. perenne. These results indicate that BCs represent an effective tool to remediate Cu-contaminated sandy soils.

Copper immobilization by biochar and microbial community abundance in metal-contaminated soils.

Biochar (BC) is gaining attention as a soil amendment that can remediate metal polluted soils. The simultaneous effects of BC on copper (Cu) mobility, microbial activities in soil using metallophytes have scarcely been addressed. The objective of this study was to evaluate the effects of biochar BCs on Cu immobilization and over soil microbial communities in a Cu-contaminated soil evaluated over a two-year trial. A Cu-contaminated soil (338mgkg-1) was incubated with chicken manure biochar (CMB) or oat hull biochar (OHB) at rates of 1 and 5% w/w. Metallophyte Oenothera picensis was grown over one season (six months). The above process was repeated for 3 more consecutive seasons using the same soils. The BCs increased the soil pH and decreased the Cu exchangeable fraction Cu by 5 and 10 times (for OHB and CMB, respectively) by increasing the Cu bound in organic matter and residual fractions, and its effects were consistent across all seasons evaluated. BCs provided favorable habitat for microorganisms that was evident in increased microbial activity. The DHA activity was increased in all BC treatments, reaching a maximum of 7 and 6 times higher than control soils in CMB and OHB. Similar results were observed in microbial respiration, which increased 53% in OHB and 61% in CMB with respect to control. The BCs produced changes in microbial communities in all seasons evaluated. The fungal and bacterial richness were increased by CMB and OHB treatments; however, no clear effects were observed in the microbial diversity estimators. The physiochemical and microbiological effects produced by BC result in an increase of plant biomass production, which was on average 3 times higher than control treatments. However, despite being a metallophyte, O. picensis did not uptake Cu efficiently. Root and shoot Cu concentrations decreased or changed insignificantly in most BC treatments.

Effects of acidic and neutral biochars on properties and cadmium retention of soils.

In this study, an acidic biochar and a neutral biochar were applied at 5 wt% into two soils for an 11-month incubation experiment. One Ferrosol soil (Ba) was slightly acidic with low organic matter and the other Dermosol soil (Mt) was slightly alkaline with high organic matter. The acidic (pH = 3.25) wood shaving (WS) biochar had no marked impact on nutrient levels, cation exchange capacity (CEC), pH and acid neutralization capacity (ANC) of either soil. By contrast, the neutral (pH = 7.00) chicken litter (CL) biochar significantly increased major soluble nutrients, pH, ANC of soil Ba. In terms of C storage, 87.9% and 69.5% WS biochar-C can be sequestrated as TOC by soil Ba and Mt, respectively, whereas only 24.0% of CL biochar-C stored in soil Ba and negligible amount in Mt as TOC. Biochars did not have significant effects on soil sorption capacity and sorption reversibility except that CL biochar increased sorption of soil Ba by around 25.4% and decreased desorption by around 50.0%. Overall, the studied acidic C rich WS biochar held little agricultural or remedial values but was favourable for C sequestration. The neutral mineral rich CL biochar may provide short-term agricultural benefit and certain sorption capacities of lower sorption capacity soils, but may be unlikely to result in heightened C sequestration in soils. This is the first study comprehensively examining functions of acidic and neutral biochars for their benefits as a soil amendment and suggests the importance of pre-testing biochars for target purposes prior to their large scale production.

Physical and chemical properties of biochars co-composted with biowastes and incubated with a chicken litter compost.

Two experiments were conducted where three biochars, made from macadamia nutshell (MS), hardwood shaving (WS) and chicken litter (CL), were co-composted with chicken manure and sawdust, and also incubated with a chicken litter based commercial compost. Biochars were added at the rates of 5% and 10% in the co-composting and 10% and 20% in the incubation experiment. The rates of biochar had no consistent effect on the change in element contents of composted- or incubated-biochars. The biochar C demonstrated recalcitrance in both composting and incubation systems. Composting increased the CEC of biochars probably due to thermophilic oxidation. The increases in CEC of WS and CL were 6.5 and 2.2 times, respectively, for composting. Translocation of elements, between biochar and compost medium, occurred in both directions. In most cases, biochars gained elements under the influence of positive difference of concentrations (i.e., when compost medium had higher concentration of elements than biochar), while in some cases they lost elements despite a positive difference. Biochar lost some elements (WS: B; CL: B, Mg and S) under the influence of negative difference of concentrations. Some biochars showed strong affinity for B, C, N and S: the concentration of these elements gained by biochars surpassed the concentration in the respective composting medium. The material difference in the biochars did not have influence on N retention: all three netbag-biochars increased their N content. The cost of production of biochar-compost will be lower in co-composting than incubation, which involves two separate processes, i.e., composting and subsequent incubation.

Biochar-induced concomitant decrease in ammonia volatilization and increase in nitrogen use efficiency by wheat.

Ammonia (NH3) volatilization is a major nitrogen (N) loss from the soil, especially under tropical conditions, NH3 volatilization results in low N use efficiency by crops. Incubation experiments were conducted using five soils (pH 5.5-9.0), three N sources such as, urea, di-ammonium phosphate (DAP), and poultry manure (PM) and two biochars such as, poultry litter biochar (PL-BC) and macadamia nut shell biochar (MS-BC). Ammonia volatilization was higher at soil with higher pH (pH exceeding 8) due to the increased hydroxyl ions. Among the N sources, urea recorded the highest NH3 volatilization (151.6 mg kg(-1)soil) followed by PM (124.2 mg kg(-1)soil) and DAP (99 mg kg(-1)soil). Ammonia volatilization was reduced by approximately 70% with PL-BC and MS-BC. The decreased NH3 volatilization with biochars is attributed to multiple mechanisms such as NH3 adsorption/immobilization, and nitrification. Moreover, biochar increased wheat dry weight and N uptake as high as by 24.24% and 76.11%, respectively. This study unravels the immense potential of biochar in decreasing N volatilization from soils and simultaneously improving use efficiency by wheat.

Maturity indices in co-composting of chicken manure and sawdust with biochar.

Several maturity indices were evaluated for in-vessel co-composting of chicken manure and pine sawdust with three different biochars. All the seven mixtures (piles) contained chicken manure and sawdust. Six of these piles contained biochar; each biochar was added at two rates, 5% and 10% wet weight. The maturity of composts was assessed by C/N, dissolved organic carbon (DOC), seed germination, NO3(-)-N/NH4(+)-N, and the Solvita test. The C/N values of finished composts were from 31.5 to 35.7, which were much higher than the optimum value of 21 for matured compost. Nevertheless, the rest of the parameters indicated that the composts were matured. The C/N values were high because of the high amount of recalcitrant carbon present in the feedstocks: biochar and sawdust. Biochar treated piles showed higher respiration as well as decomposition of DOC indicating higher microbial activity. Use of biochar in composting may reduce NH3 emission and nitrate leaching.

Gastroesophageal reflux disease: the case for improving patient education in primary care.

PURPOSE: Gastroesophageal reflux disease (GERD) affects up to 25% of the western population, and the annual expenditure for managing GERD is estimated to be more than $14 billion. Most GERD patients do not consult a specialist, but rather rely on their primary care physician for symptom management. Research has shown that many patients--regardless of diagnosis--do not fully understand what their doctors tell them and remain uncertain as to what they are supposed to do to take care of themselves. To determine if patients are adequately educated in the management of GERD, we conducted a survey. METHOD: We administered a survey to patients with GERD in an outpatient setting and explored their knowledge of such management practices as modification of behavior and diet and use of medication. RESULTS: Of 333 patients enrolled, 66% reported having an in-depth discussion with their primary care physician. Among patients taking a proton pump inhibitor, 85% of those who'd had an in-depth discussion were aware of the best time to take their medication, compared with only 18% of those who did not have an in-depth discussion. In addition, patients who'd had in-depth conversations were significantly more likely than those who didn't to know some of the behavior modification measures that might improve their symptoms. CONCLUSION: Our study underscores the need for primary care providers to fully discuss GERD with their patients to improve overall management of the disease.

The white nipple sign: please do not disturb.

Blood spurting or oozing from a varix confirms the diagnosis of variceal hemorrhage. In most cases of variceal hemorrhage, however, the bleeding has ceased by the time endoscopy is performed. Endoscopists rely on identification of stigmata of recent hemorrhage to determine whether varices are the cause of bleeding and to predict the likelihood of rebleeding. Most of the attention has focused on red color signs, such as red wale markings, described by Beppu et al. [Gastrointest Endosc 1981;27:213-218] and well known to endoscopists. Here we describe our experience with a less recognized stigma of variceal hemorrhage known as the 'white nipple sign', which resulted in active hemorrhage when manipulated.

Novel endoscopic triangulation approach to percutaneous transgastric placement of jejunal extension feeding tube.

In patients who have surgically-altered upper gastrointestinal anatomy, postoperative endoscopic enteral nutrition options can be limited by issues such as bowel stenosis and/or acute angulation. This report details the use of an endoscopic triangulation method combining per-oral and percutaneous transgastric approaches to overcome an efferent gastrojejunostomy limb stenosis, to successfully place a jejunal extension feeding tube through a newly placed PEG site. This description provides an alternative endoscopically feasible option for successful enteral nutrition access, thus obviating the need for additional operations to place surgical feeding tubes or to commit patients to long-term total parenteral nutrition.

Modified midline abdominal wound closure technique in complicated/high risk laparotomies.

OBJECTIVE: To assess the local wound complications in complicated/ high risk laparotomies in terms of wound dehiscence and incisional hernia formation with a modified technique of midline abdominal wound closure. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of General Surgery, Combined Military Hospital, Bahawal Nagar Cantonment, May 2006 to June 2008. METHODOLOGY: Cases of complicated/high risk abdominal conditions, which required laparotomy, were included in the study. A modified midline abdominal wound closure technique was used. Interrupted Smead-Jones sutures with prolene, a non-absorbable suture material for closure of linea alba was combined with mass closure involving all the layers (also with prolene) and drains were placed. Patients were followed-up for 3-23 months. The postoperative wound dehiscence and incisional hernia formation were noted. Other local wound complications were also recorded. RESULTS: Out of the 36 patients undergoing this surgical technique, 20 (55.55%) had inflammatory/intra-abdominal sepsis, 8 (22.22%) had trauma, 7 (19.44%) had neoplasia and 1 (2.77%) had vascular aetiology. Only 1 (2.77%) had partial wound dehiscence and 1 (2.77%) developed incisional hernia. Wound infection was noted in 12 (33.33%) cases; 4 (11.11%) experienced pain over the subcutaneous palpable knots and 3 (8.33%) developed sinus due to the knots. The average follow-up period was 12.47+7.17 months. CONCLUSION: Patients with extensive widespread generalized peritonitis and metastatic abdominal tumours need special attention regarding wound closure. This modified technique of midline abdominal wound closure is associated with low incidence of wound dehiscence and incisional hernia formation.

Open extraperitoneal mesh repair for abdominal wall hernias in females.

OBJECTIVE: To determine the outcome of treatment in terms of infection and recurrence using open extraperitoneal mesh repair technique. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: The department of General Surgery, Combined Military Hospital, Bahawal Nagar Cantonment, from February 2006 to November 2008. METHODOLOGY: Female patients with abdominal wall hernias with defect of 4 cm or more were studied. A history of previous surgery along with clinical findings on examination like size of defect and previous scar were noted. At surgery, hernial sacs were carefully opened and omental and intestinal adhesions were carefully separated. Polypropylene mesh was placed over extraperitoneal space and secured with interrupted vicryl 2/0 sutures. Redivac drains were placed over the mesh and the fascial repair. The patients were discharged on the 3rd - 4th postoperative day and were followed-up at 3 monthly intervals for postoperative sequelae like seroma, haematoma, infection and recurrence. RESULTS: There were 32 cases with a mean age of 41.25 + or - 10.79 years. The mean follow-up period was 15.78 + or - 9.02 months. Previous abdominal surgical intervention was found in 16 (50%) cases. Out of those, 14 (43.7%) had defects through the previous scar. A history of multiple caesarean sections alone, or in combination with either hysterectomy or laparotomy in the last 5 years was present in 7 patients. There were 12 (37.5%) cases of paraumbilical hernia, 4 (12.5%) of a recurrent paraumbilical hernia, 5 (15.6%) epigastric hernia, 2 (6.2%) mix hernia, 7 (21.8%) incisional hernia and 1 (3.1%) each of Spigelian hernia and postlaparoscopic cholecystectomy portal (paraumbilical) hernia. The mean size of the defect was 4.9 cm in primary paraumbilical hernias and 7.2 cm in recurrent paraumbilical hernias. The mean size of the defect in incisional hernias was 9.4 cm, larger than all other types. Superficial wound infection was seen in only 1 morbidly obese (BMI > 30) patient. No case of seroma, haematoma, deep seated abscess or recurrence was noted in the follow-up period. CONCLUSION: Abdominal wall hernias are common in female patients, especially those with previous surgical intervention. Open extraperitoneal mesh repair with placement of redivac drains is an effective method for the management of abdominal wall hernias with a smaller complication rate and less recurrence.

Combined urethrolithotomy with vesicolithotomy in an 18-months old boy.

We present a case of 18 months old male child who reported with acute urinary retention. He had a urethral calculus along with a vesical calculus. He was subjected to combined external urethrotomy and open vesicolithotomy in one sitting. The patient made a smooth post operative recovery and was followed up for 6 months.

Retroperitoneal masses: different clinical scenarios.

We present two cases of retroperitoneal masses with different presentations and outcomes. The first case was a 22 years old primigravida lady who underwent emergency caesarean section for preterm premature rupture of membranes with breach. On the operating table, a large retroperitoneal mass was identified and the biopsy confirmed Burkitt's lymphoma. Post operative chemotherapy did not have a favourable result and the patient had a fatal outcome. The other case was a 15 years old boy who had a progressively increasing retroperitoneal mass. Exploratory laparotomy revealed a hard, fixed, unresectable tumour extending into the mesentery of the small gut, biopsies were taken which showed tuberculosis. Post operative antituberculosis treatment had a marked response and the tumour disappeared after 6 months.