Post-operative Pancreatitis as a Predictor of Postoperative Pancreatic Fistula in Patients Following Pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula remains the single most important determinant of morbidity and mortality following pancreaticoduodenectomy. A new entity was proposed by Saxon Connor "Post-Operative pancreatitis", which is defined by raised serum amylase more than the upper limit of institutional serum amylase value on Post-Operative day 0 or 1. There has been shown to be an association between postoperative pancreatitis and postoperative pancreatic fistula. We have conducted this study to see the incidence of postoperative pancreatitis and its association with postoperative pancreatic fistula. METHODS: This was a prospective observational study. All patients undergoing pancreaticoduodenectomy at a tertiary care center for one and a half years were included. A cut-off value of serum amylase 80U/L was used to make a diagnosis of postoperative pancreatitis. The patients were followed up for one month. Pancreas specific complications were defined according to the definition given by the International Study Group of Pancreatic Surgery. RESULTS: A total of 49 pancreaticoduodenectomies were done in the given period. The incidence of postoperative pancreatitis was 31(63.3%) and postoperative pancreatic fistula was 19(38.8%). Postoperative pancreatic fistula was seen in 19(61.2%) of patients having postoperative pancreatitis (P<0.001). Post-operative pancreatitis was also significantly associated with post pancreatectomy hemorrhage, increased hospital stay, and mortality. In multivariate analysis, preoperative endoscopic biliary drainage and increased serum amylase on the first postoperative day came out to be an independent predictor of postoperative pancreatic fistula. CONCLUSIONS: Post-operative Pancreatitis was associated with an increased incidence of Post-operative pancreatic fistula and other postoperative complications like Post pancreatectomy hemorrhage and mortality.

Mesenchymal Stem Cell-Derived Extracellular Vesicles for Therapeutic Use and in Bioengineering Applications.

Extracellular vesicles (EVs) are small lipid bilayer-delimited particles that are naturally released from cells into body fluids, and therefore can travel and convey regulatory functions in the distal parts of the body. EVs can transmit paracrine signaling by carrying over cytokines, chemokines, growth factors, interleukins (ILs), transcription factors, and nucleic acids such as DNA, mRNAs, microRNAs, piRNAs, lncRNAs, sn/snoRNAs, mtRNAs and circRNAs; these EVs travel to predecided destinations to perform their functions. While mesenchymal stem cells (MSCs) have been shown to improve healing and facilitate treatments of various diseases, the allogenic use of these cells is often accompanied by serious adverse effects after transplantation. MSC-produced EVs are less immunogenic and can serve as an alternative to cellular therapies by transmitting signaling or delivering biomaterials to diseased areas of the body. This review article is focused on understanding the properties of EVs derived from different types of MSCs and MSC-EV-based therapeutic options. The potential of modern technologies such as 3D bioprinting to advance EV-based therapies is also discussed.

A Prospective Observational Study of Rational Fluid Therapy in Asian Intensive Care Units: Another Puzzle Piece in Fluid Therapy.

INTRODUCTION: Fluid therapy in critically ill patients, especially timing and fluid choice, is controversial. Previous randomized trials produced conflicting results. This observational study evaluated the effect of colloid use on 90-day mortality and acute kidney injury (RIFLE F) within the Rational Fluid Therapy in Asia (RaFTA) registry in intensive care units. MATERIALS AND METHODS: RaFTA is a prospective, observational study in Asian intensive care unit (ICU) patients focusing on fluid therapy and related outcomes. Logistic regression was performed to identify risk factors for increased 90-day mortality and acute kidney injury (AKI). RESULTS: Twenty-four study centers joined the RaFTA registry and collected 3,187 patient data sets from November 2011 to September 2012. A follow-up was done 90 days after ICU admission. For 90-day mortality, significant risk factors in the overall population were sepsis at admission (OR 2.185 [1.799; 2.654], p < 0.001), cumulative fluid balance (OR 1.032 [1.018; 1.047], p < 0.001), and the use of vasopressors (OR 3.409 [2.694; 4.312], p < 0.001). The use of colloids was associated with a reduced risk of 90-day mortality (OR 0.655 [0.478; 0.900], p = 0.009). The initial colloid dose was not associated with an increased risk for AKI (OR 1.094 [0.754; 1.588], p = 0.635). CONCLUSION: RaFTA adds the important finding that colloid use was not associated with increased 90-day mortality or AKI after adjustment for baseline patient condition. CLINICAL SIGNIFICANCE: Early resuscitation with colloids showed potential mortality benefit in the present analysis. Elucidating these findings may be an approach for future research. HOW TO CITE THIS ARTICLE: Jacob M, Sahu S, Singh YP, Mehta Y, Yang K-Y, Kuo S-W, et al. A Prospective Observational Study of Rational Fluid Therapy in Asian Intensive Care Units: Another Puzzle Piece in Fluid Therapy. Indian J Crit Care Med 2020;24(11):1028-1036.

Extra Hepatic Portal Vein Obstruction with Solitary Left Kidney: A Case Report.

Extra Hepatic Portal Vein Obstruction in individual with solitary left kidney is rare occurence. Though there is no etiological association between Extra Hepatic Portal Vein Obstruction and solitary left kidney but the solitary left kidney decides the modality of treatment. Eighteen year lady referred to our institute with menorrhagia for 5 years and ultrasonography finding of splenomegaly and atretic right kidney. Investigations revealed Extra Hepatic Portal Vein Obstruction with multiple cavernoma formation with oesophagogastric varices with right renal agenesis. She successfully underwent splenectomy with devascularisation. Patient with Extra Hepatic Portal Vein Obstruction present mainly with recurrent episodes of variceal bleeding, splenomegaly and hypersplenism. Splenectomy and esophagogastric devascularisation is an effective modality of treatment for patient with Extra Hepatic Portal Vein Obstruction with solitary kidney. Keywords: cavernoma; modified Hassab's operation; Portal vein; unilateral renal agenesis.

Secondary angiosarcoma in a hormone receptor negative breast cancer patient.

Post-irradiation angiosarcoma arising in the irradiated breast after breast-conserving surgery is uncommon though being reported with increasing frequency. Such cases are reported mainly in hormone-receptor positive patients who had received hormonal therapy along with radiation. We describe a rare case of post-irradiation angiosarcoma in a 71-year-old hormone-receptor negative female who did not receive hormonal therapy.

Malignant phyllodes tumor with metastases to lung, adrenal and brain: A rare case report.

BACKGROUND: Phyllodes tumors are spectrum of tumors ranging from benign to malignant. Malignant spectrum pose a management challenge for clinicians due to high risks of recurrence and metastasis. Malignant phyllodes tumor with brain, lung and adrenal metastases at the same time is rare. CASE PRESENTATION: A 37 years-old unmarried female presented with an ulcerated huge lump in left breast with severe bleeding. Trucut biopsy showed necrosis with spindle cell proliferation with atypia for which she underwent modified radical mastectomy with final diagnosis of malignant phyllodes tumor. Three months after surgery, patient presented with headache, which on further evaluation showed masses in lung, right adrenal and brain. CONCLUSION: We presented a rare case of malignant phyllodes tumor with clinical, imaging and histological findings with metastases to multiple sites early in course and poor outcome of the patient despite margin negative resection.

Rare case of bleeding nipple hemangioma in a lactating mother.

Hemangiomas of nipple of the breast are rare lesions and are limited to case reports in the literature. Such pathology in a lactating mother are clearly a hindrance preventing the child from breastfeeding with its benefits. We report a rare case of a bleeding nipple hemangioma in a 24 years old lactating mother with the clinical, imaging and histopathological findings.

Smart self-tightening surgical suture from a tough bio-based hyperbranched polyurethane/reduced carbon dot nanocomposite.

Design and fabrication of a smart bio-based polymeric material with potent biocompatibility and high performance still remain a challenge in the biomedical realm. In this context, a potential smart suture was fabricated from starch modified hyperbranched polyurethane (HPU) nanocomposites with different weight percentages of reduced carbon dots for the first time. The desired mechanical (tensile strength: 32.14 MPa, elongation at break: 1576% and toughness 439.28 MJ m-3) and thermal (286 °C) attributes of the suture were achieved with 2 wt% of reduced carbon dots in an HPU matrix. The non-contact self-tightening behavior was observed just within 15 s at body temperature of 37 °C ± 1 °C with notable shape fixity (99.6%) and shape recovery (99.7%) effects. The nanocomposites displayed in vitro biodegradability and hemocompatibility. Low lactate dehydrogenase activity and minimal red blood cell lysis indicated the anti-thrombogenicity and anti-hemolytic properties of the nanocomposites. The suitability of the fabricated nanocomposites as a smart biomaterial was supported by the inherent biocompatibility as observed by the growth and proliferation of smooth muscle cells and endothelial cells. Furthermore, they exhibited minimal immunogenic response (TNF α release). Thus, the study paves the way to biodegradable HPU nanocomposites as advanced non-contact triggered rapid self-tightening surgical sutures for biomedical applications.

High performance bio-based hyperbranched polyurethane/carbon dot-silver nanocomposite: a rapid self-expandable stent.

Development of a bio-based smart implantable material with multifaceted attributes of high performance, potent biocompatibility and inherent antibacterial property, particularly against drug resistant bacteria, is a challenging task in biomedical domain. Addressing these aspects at the bio-nano interface, we report the in situ fabrication of starch modified hyperbranched polyurethane (HPU) nanocomposites by incorporating different weight percentages of carbon dot-silver nanohybrid during polymerization process. This nanohybrid and its individual nanomaterials (Ag and CD) were prepared by facile hydrothermal approaches and characterized by various instrumental techniques. The structural insight of the nanohybrid, as well as its nanocomposites was evaluated by TEM, XRD, FTIR, EDX and thermal studies. The significant improvement in the performance in terms of tensile strength (1.7 fold), toughness (1.5 fold) and thermal stability (20 °C) of the pristine HPU was observed by the formation of nanocomposite with 5 wt.% of nanohybrid. They also showed notable shape recovery (99.6%) and nearly complete self-expansion (>99%) just within 20s at (37 ± 1) °C. Biological assessment established in vitro cytocompatibility of the HPU nanocomposites. The fabricated nanocomposites not only assisted the growth and proliferation of smooth muscle cells and endothelial cells that exhibited reduced platelet adhesion but also displayed in vitro hemocompatibility of mammalian RBCs. Significantly, the antibacterial potency of the nanocomposites against Escherichia coli MTCC 40 and Staphylococcus aureus MTCC 3160 bacterial strains vouched for their application to countercheck bacterial growth, often responsible for biofilm formation. Thus, the present work forwards the nanocomposites as potential tough infection-resistant rapid self-expandable stents for possible endoscopic surgeries.

Antioxidant and Hepatoprotective Potentiality of Randia dumetorum Lam. Leaf and Bark via Inhibition of Oxidative Stress and Inflammatory Cytokines.

Randia dumetorum Lam. (RD) (Rubiaceae) is traditionally used by some tribes of Assam and Manipur of North East India for the treatment of liver ailments. In this context, to scientifically validate this indigenous traditional knowledge, we have evaluated the antioxidant and hepatoprotective activity of RD leaf and bark. The methanol extracts of RD leaf and bark were evaluated for in vitro antioxidant activity which exhibited good antioxidant activity in terms of reducing power assay, total antioxidant assay and DPPH (1,1-diphenyl-2-picrylhydrazyl) radical scavenging assay. Total phenolic and flavonoid content were found to be 112 ± 3.24 mg and 138 ± 2.46 mg gallic acid equivalents/g extract and 2.6 ± 0.26 mg and 3.34 ± 0.31 mg rutin equivalents/g extract respectively for RD leaf and bark methanol extracts. The in vivo hepato protective activity of the RD leaf and bark extract was evaluated against carbon tetrachloride (CCl4) induced hepatic damage in male wistar rats. CCl4 administration induced hepatic damage in rats resulted in increased levels of aspartate transaminase, alanine transaminase, alkaline phosphatase, lactate dehydrogenase, thiobarbituric acid reacting substances, albumin, bilirubin, TNF-α, IL-1ß and decreased levels of total protein and antioxidant enzymes like superoxide dismutase, catalase, and glutathione reductase. RD leaf and bark methanol extracts pre-treatment exhibited protection against CCl4 induced hepatotoxicity by reversing all the abnormal parameters to significant levels. Histopathological results revealed that RD leaf and bark extracts at 400 mg/kg protects the liver from damage induced by CCl4. The results of this study scientifically validate the traditional use of RD leaf and bark for the treatment of liver ailments.

Presentation and Outcomes of Gastric Cancer at a University Teaching Hospital in Nepal.

BACKGROUND: Gastric cancer is the most common gastrointestinal cancer and a leading cause of cancer mortality in Nepal. Survival of gastric cancer patients depends on the stage at which diagnosis is made. The aim of this study was to analyze the presentation and outcomes of gastric cancer patients treated at a tertiary care hospital in Nepal. MATERIALS AND METHODS: A retrospective analysis of 140 consecutive histologically proven gastric adenocarcinoma cases managed at the Department of Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal for the period of January 2009 to December 2013 was carried out. RESULTS: One hundred forty out of the total 186 patients with histologically proven gastric adenocarcinoma, were admitted for surgery. The mean age was 59.6±12.4 yrs (range 29 to 78 yrs) and the male: female ratio was 2:1. Sixty three (45%) patients featured Tibeto-Burman descent though this ethnic group accounts for only 18% of the Nepalese population. Two-thirds or more patients presented with abdominal pain, anorexia, weight loss and/or vomiting. In 86 (61.5%) of the patients the tumor was located in the lower 3rd of the stomach and in only 15% of the patients the tumor was located at the upper 3rd. Early gastric cancer was diagnosed postoperatively in only 4%. In 54%, the disease was locally advanced and metastatic lesions were found in 14% of the patients. Subtotal (73) or total (11) curative gastrectomies (D1, D1+ or D2) were performed in 84 (60%) patients with average lymph node retrieval of 16.6±8.2. Palliative gastrectomies or procedures were performed in 23% of the patients and no intervention (open and close/biopsy) was employed in 15% of the patients. Perioperative morbidity was seen in 10% and mortality in 4%. Three, four and five year survival rates up to the recent follow-up were 17.9%, 11.9% and 8.3%, respectively. CONCLUSIONS: Gastric cancer in Nepal is usually diagnosed at an advanced stage and has a poor prognosis. Thus, early detection is the key to improve the survival of gastric cancer patients.

Risk factors for surgical site infections in abdominal surgery: a study in Nepal.

BACKGROUND: Surgical site infection (SSI) remains a major clinical problem for developing countries in terms of morbidity, mortality, and hospital cost. Little is known about the epidemiology of SSI in Nepal. We conducted a study in Nepal to identify the various pre- and intra-operative risk factors for SSIs that are accessible to interventions. METHODS: The study was a prospective study done on all eligible patients who underwent abdominal surgery in the surgical wards of Tribhuvan University Teaching Hospital (TUTH) in Kathmandu, Nepal, from January 2011 to June 2011. We evaluated some patient-related as well as intra-operative variables that could be risk factors for SSIs. We assessed the association between these risk factors and SSI with the Fisher exact test and logistic regression analysis. RESULTS: Of the 230 patients included in the study, 53 were identified as having a SSI, resulting in an overall rate of SSI of 23%. Multivariable analysis identified the following factors as independent risk factors for SSI: (1) Low hemoglobin concentrations (<12 g/dL) (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.1-6.1); (2) overweight (OR 7.6; 95% CI 2.1-27.0); and (3) surgery performed by residents (OR 3.4; 95% CI 1.4-8.3). CONCLUSIONS: Surgical site infection is common among patients undergoing abdominal surgery at TUTH. This study identified some preventable risk factors associated with SSI at TUTH. Identification of such risk factors is expected to help surgeons improve patient care and decrease mortality and morbidity as well as the hospital-care cost of surgical patients.

Insilico studies of organosulfur-functional active compounds in garlic.

Garlic has been used medicinally since antiquity because of its antimicrobial activity, anticancer activity, antioxidant activity, ability to reduce cardiovascular diseases, improving immune functions, and antidiabetic activities and also in reducing cardiovascular diseases and improving immune functions. Recent studies identify that the wide variety of medicinal functions are attributed to the sulfur compounds present in garlic. Epidemiological observations and laboratory studies in animal models have also showed anticarcinogenic potential of organosulfur compounds of garlic. In this study, in silico analysis of organosulfur compounds is reported using the methods of theoretical chemistry to elucidate the molecular properties of garlic as it is more time and cost efficient, reduces the number of wet experiments, and offers the possibility of replacing some animal tests with suitable in silico models. The analysis of molecular descriptors defined by Lipinski has been done. The solubility of drug in water has been determined as it is of useful importance in the process of drug discovery from molecular design to pharmaceutical formulation and biopharmacy. All toxicities associated with candidate drug have been calculated. P-Glycoprotein expressed in normal tissues as a cause of drug pharmacokinetics and pharmacodynamics has been examined. Drug-plasma protein binding and volume of distribution have also been calculated. To avoid rejection of drugs, it is becoming more important to determine pK(a), absorption, polar surface area, and other physiochemical properties associated with a drug, before synthetic work is undertaken. The present in silico study is aimed at examining these compounds of garlic to evaluate its possible efficacy and toxicity under conditions of actual use in humans.