Effect of herbal extracts and Saroglitazar on high-fat diet-induced obesity, insulin resistance, dyslipidemia, and hepatic lipidome in C57BL/6J mice.

We evaluated the effects of select herbal extracts (Tinospora cordifolia [TC], Tinospora cordifolia with Piper longum [TC + PL], Withania somnifera [WS], Glycyrrhiza glabra [GG], AYUSH-64 [AY-64], and Saroglitazar [S]) on various parameters in a diet-induced obesity mouse model. After 12 weeks of oral administration of the herbal extracts in high-fat diet (HFD)-fed C57BL/6J mice, we analyzed plasma biochemical parameters, insulin resistance (IR), liver histology, and the expression of inflammatory and fibrosis markers, along with hepatic lipidome. We also used a 3D hepatic spheroid model to assess their impact on profibrotic gene expression. Among the extracts, TC + PL showed a significant reduction in IR, liver weight, TNF-α, IL4, IL10 expression, and hepatic lipid levels (saturated triglycerides, ceramides, lysophosphocholines, acylcarnitines, diglycerides, and phosphatidylinositol levels). Saroglitazar reversed changes in body weight, IR, plasma triglycerides, glucose, insulin, and various hepatic lipid species (fatty acids, phospholipids, glycerophospholipids, sphingolipids, and triglycerides). With the exception of GG, Saroglitazar, and other extracts protected against palmitic acid-induced fibrosis marker gene expression in the 3D spheroids. TC + PL and Saroglitazar also effectively prevented HFD-induced insulin resistance, inflammation, and specific harmful lipid species in the liver.

Gastrointestinal complications (gangrene or perforation) after corona virus disease 2019 - A series of ten patients.

During the recent second wave of corona virus disease 2019 (COVID-19) pandemic in India, we managed a series of gastrointestinal complications in patients with COVID-19. We aim to highlight the key presentation and clinical course and emphasize the lessons we learnt from our series of such patients. A case review of ten consecutive patients with either bowel gangrene or perforation who were managed at our centre from March 20, 2021 to June 10, 2021. Clinical-demographic details, possible etiology, radiological findings, management and outcomes have been described. Of the 10 patients, 2 presented with bowel gangrene and 8 with perforation. In our series, all these patients were diagnosed with the help of computed tomography (CT) abdomen during the 3rd week after diagnosis of COVID-19. All had received steroid medication. Both patients with bowel gangrene and 4 of 8 patients with perforation underwent surgery, while 4 were managed non-operatively. Barring one patient, all the operated patients succumbed within 5 days of surgery after rapid clinical deterioration. Non-operative management in selected patients with perforation including placement of percutaneous drains, bowel rest and antibiotics was successful. Emergency surgery for COVID-19 related intestinal gangrene or perforation was associated with high mortality in our series. Non-operative management which avoids the added stress of a major emergency surgery particularly in patients just recovering from COVID-19 may be considered in stable patients in whom perforation appears to be contained.

Successful Outcome of Bariatric Surgery in Living Donor Liver Transplant Recipients With Multidisciplinary Approach: A Preliminary Experience.

INTRODUCTION: Liver transplant recipients may develop weight gain, metabolic syndrome, and subsequent nonalcoholic steatohepatitis of the transplanted liver which impairs graft function. Bariatric surgery is an effective modality for management of morbid obesity and metabolic syndrome. Our aim is to review the role of bariatric surgery in such high-risk posttransplant patients not responding to medical management and highlight the important considerations. METHODOLOGY: We review the management of two cases with posttransplant metabolic syndrome not responding to medical management and discuss the literature available on bariatric surgery in organ transplant patients. RESULTS: The first patient was a 51-year-old man who underwent living donor liver transplantation 3 years prior, and follow-up ultrasound and fibroscan was suggestive of steatohepatitis of the graft. After liver transplantation, he had gained 30 Kg weight and was on oral hypoglycemic agents with HbA1c of 8%. The second patient was a 65-year-old man, who gained 30 Kg weight with risk of graft impairment 4 years after of combined liver and kidney transplant. Both patients were evaluated thoroughly preoperatively for risk stratification including an upper gastro-intestinal (GI) endoscopy. The immunosuppression was reduced and monitored closely perioperatively. Both patients underwent laparoscopic sleeve gastrectomy (LSG) and were discharged on postoperative day 3. The first patient was evaluated a year after surgery with body mass index (BMI) reduction from 42 to 34 and second at 2 months with BMI reduction from 38 to 33; both patients were free of diabetes and had stable graft functions. CONCLUSION: Bariatric surgery in liver transplant recipients has significant challenges with higher complication rates as patients are on immunosuppression which often impairs wound healing. LSG is safe and effective in such patients which often requires good coordination between the bariatric team and liver transplant team.

Acute Suppurative Thyroiditis with Thyroid Abscess by Klebsiella pneumoniae: An Unusual Presentation.

Acute suppurative thyroiditis with thyroid abscess is very uncommon cause of thyroiditis. Thyroid infection in a diabetic patient is commonly labeled to the relative immunosuppressive state of diabetes mellitus. We present a case of a diabetic patient showing clinical symptoms of acute thyroiditis with progressing dysphagia, who was diagnosed as thyroid abscess as a result of Klebsiella pneumoniae. The infection in the absence of other significant history was initially considered de novo; however, on extensive evaluation was associated with other distant primary source of the same microbe. The patient was managed with minimally invasive drainage of abscess and intravenous antibiotics.

Occurrence and Predictors of Depression and Poor Quality of Life among Patients with Type-2 Diabetes: A Northern India Perspective.

BACKGROUND AND AIMS: Globally, depression has been linked to Type-2 diabetes mellitus (T2DM). However, similar data from India are scant. This study evaluated the occurrence and predictors of depression and health-related quality of life (QOL) in patients with T2DM as compared to healthy controls. MATERIALS AND METHODS: One hundred adults with T2DM without prior diagnosis of depression and 100 matched controls were evaluated. Depression was assessed using Patient Health Questionnaire-9. World Health Organization QOL Brief (WHO-QOL-BREF) was used to assess QOL. Demography, anthropometry, biochemical parameters of diabetes control, and microvascular and macrovascular complications in patients were recorded. RESULTS: Depression was significantly more common in T2DM (63%) as compared to controls (48%) (odds ratio [OR] - 1.84 [1.04, 3.24]; P = 0.03). In T2DM, depression was higher in patients with disease duration >5 years (OR = 2.66; P = 0.02), glycated hemoglobin >7% (OR = 3.45; P = 0.004), retinopathy (OR - 3.56; P = 0.03), and nephropathy (OR - 4.11; P = 0.07). Occurrence of depression was significantly higher among the patients with macrovascular complications, namely, coronary artery disease (17.4%; P = 0.000006), cerebrovascular disease (14.2%; P = 0.0006), and peripheral vascular disease (7.9%; P = 0.05). Insulin users had higher depression as compared to patients using only oral antihyperglycemic medications (P = 0.034). Patient with depression had significantly low QOL. The WHO-QOL for all the domains was significantly lower in T2DM with microvascular and macrovascular complications, as compared to those without. CONCLUSION: Indian T2DM had higher prevalence of depression and lower QOL as compared to controls, which was associated with poor glycemic control and higher end-organ damage. Public health measures are required to create more awareness for managing depression in diabetes.

Preoperative evaluation of gastroesophageal reflux disease.

GERD is a common problem. If prolonged therapy is needed, the patient should have at least an endoscopy to assess for complications of GERD. If a surgical treatment is being considered, a thorough preoperative evaluation should be done to confirm the presence of pathologic GERD. Studies that should be done before a procedure include ambulatory pH testing, esophageal function testing, endoscopy, and esophagram. Nonacid ambulatory studies can be done in those who seem to be suffering from nonacid reflux with careful note of symptom correlation. Gastric emptying studies should be done if gastroparesis or gastric outlet obstruction is suspected. Esophageal motility disorders should be assessed with manometry, especially to evaluate for achalasia, which can mimic reflux.

Effect of Sudarshan Kriya on male prisoners with non psychotic psychiatric disorders: a randomized control trial.

OBJECTIVES: To investigate whether Sudarshan Kriya and related practices (SK&P) can lead to increased global assessment of functioning (GAF) and increased feeling of wellness in male prisoners with a non psychotic psychiatric disorder. METHODOLOGY: This is a six month parallel randomized controlled study with sample size of 230 male prisoners. Participants meeting inclusion and exclusion criteria were assigned to a study or control group by simple random allocation in which random allocation sequence was generated using a random number table. Each individual study participant was involved in a daily program of SK&P for six weeks. Each individual control participant was instructed to sit in an armchair with his eyes closed and gentle attention to their breath for duration of six weeks. To be included in this study, a participant must be a male prisoner diagnosed to be suffering from a psychiatric disorder (except psychosis and bipolar affective disorder [BPAD]) by ICD-10 (DCR) criteria with age between 18 and 65 years. RESULTS: Majority of subjects were unemployed married individuals, educated until undermatric level and not having occupational skills of more than an unskilled labor level. Practicing SK&P for six weeks led to improvement in mean±SD score of study participants in GAF, anxiety (ANX), depressed mood (DEP), positive well being (PWB), general health (GH), self control (SC), vitality (VT) and total positive general well being (PGWB). Change in mean±SD score of study participants when compared with control participants was statistically significant in terms of GAF, ANX, DEP, PWB, GH and PGWB. Increase in SC and VT scores was statistically insignificant when compared with control participants. CONCLUSION: Practicing SK&P helps in improving GAF, PWB, GH and total PGWB of an individual. SK&P also causes significant reduction in anxiety and depression levels. Effect of SK&P on SC and VT is insignificant.

Gastroesophageal reflux disease: diagnosis and patient selection.

Gastroesophageal reflux disease (GERD) has a high prevalence worldwide. Recent reports have noted a high prevalence even in Asian countries. GERD significantly affects the quality of life and can present with a wide variety of symptoms. Not all reflux is acid, and non-acid reflux disease can be more difficult to diagnose and can lead to a variety of extra-esophageal symptoms. Although proton pump inhibitors (PPIs) are effective in the majority of patients, but they are not without side effects, and their effect often diminishes with time. For patients who do not desire to be on long-term PPIs or have incomplete symptom resolution with medication, various endoscopic and minimally invasive treatment modalities are now available. The etiology of GERD can be multifactorial including dysfunctional LES, presence of a hiatal hernia, and transient lower esophageal sphincter relaxations (TLESRs). We hence believe that the treatment should be individualized to the cause of the reflux. In the following review, we describe the etiology of reflux disease and attempt to lay a framework for the diagnosis and selection of patients for the various interventions available for treatment, along with their evidence base.

Biliary dyskinesia: how effective is cholecystectomy?

INTRODUCTION: Studies on biliary dyskinesia have been based on short-term surgical follow-up and do not take into consideration that most patients are discharged from surgical follow-up after the first postoperative visit and that for persistent or recurrent symptoms they are frequently seen by primary care providers and subsequently referred to gastroenterologists. We aimed to study this pattern and assess which factors predict patients that will benefit from cholecystectomy. METHOD: This is a retrospective analysis of medical records of patients who underwent cholecystectomy for biliary dyskinesia from February 2001 to January 2010 with a minimum postoperative follow-up of 6 months. RESULTS: At initial surgical follow-up, 19 of 141 (13.4%) patients said they had persistent symptoms. However, when subsequent visits were analyzed, 61 of 141 (43.3%) patients with persistent or recurrent symptoms saw their primary care provider. These symptoms were epigastric or right upper quadrant pain in 43 patients or 30% of those undergoing cholecystectomy. The only factor that distinguished patients with and without resolution of symptoms after cholecystectomy was the pathologic finding of inflammation (p = 0.02). CONCLUSION: Cholecystectomy does not appear to be as effective for biliary dyskinesia when long-term follow-up is evaluated.

Ventral hernia repair: outcomes change with long-term follow-up.

BACKGROUND AND OBJECTIVES: Ventral hernia repairs continue to have high recurrence rates. The surgical literature is lacking data assessing the time trend to hernia recurrence after ventral hernia repairs and whether over time the recurrence rates change with laparoscopic technique compared to open repairs. Our aim was to carry out a long-term comparative analysis of ventral hernia repairs performed at our hospital over the last 10-y period to assess if outcomes change during the follow-up period. METHODS: We conducted a retrospective observational study analyzing electronic medical records of all consecutive patients who had a ventral hernia repair from January 2001 to February 2010 at our hospital. RESULTS: During the study period, 436 ventral hernia repairs were performed: laparoscopic repairs (n=156; 36%), laparoscopic converted to open (n=8; 2%), and open repairs (n=272; 62%). We analyzed the time distribution to hernia recurrence after surgery and found that 85% of recurrences after laparoscopic repairs and 77% of recurrences after open repairs occurred within 2 y of surgery. We did a Kaplan-Meier analysis for the subgroup of patients for whom we had a minimum 4-y follow-up and found that there continued to be a low subsequent yearly recurrence rate for open repairs after the initial 2-y follow-up. CONCLUSION: Most hernia recurrences occur within 2 y after surgery for ventral hernias. There appears to be a continued although low subsequent yearly rate of recurrence for open repairs.

Cervical rib with stroke as the initial presentation.

Cervical ribs rarely become symptomatic. Cerebral ischemia or infarct due to cervical rib is extremely rare and, invariably, these patients have a history of upper limb symptoms before presenting with stroke. We report a young boy with cervical rib who presented with stroke. A right sided cervical rib was noted during angiogram, causing mild stenosis and post stenotic dilatation of right subclavian artery distal to the rib. An abduction angiogram showed complete occlusion of the right subclavian artery and visualization of collaterals. Right carotid angiogram also showed evidence of thromboembolic episodes in the right middle cerebral artery territory.

Selective embolotherapy as a treatment option for lower gastrointestinal haemorrhage following open-heart surgery.

Lower gastrointestinal haemorrhage following cardiac surgery is a rare but potentially life threatening complication. Conservative or endoscopic management often fails to detect and control the bleeding, with surgery, often in the form of a major colonic resection, being the last resort. Surgical intervention, however, is associated with high morbidity and mortality. Our case describes the successful management of small bowel haemorrhage, following coronary artery bypass surgery, with angiographic embolotherapy of a branch of the ileocolic artery. We suggest that selective arterial embolisation is a safe and effective therapeutic option available to hospitals undertaking cardiothoracic surgery and should always be considered in the above context.