Advanced and Metastatic Gastrointestinal Stromal Tumors Presenting With Surgical Emergencies Managed With Surgical Resection: A Case Series.

Advanced and metastatic gastrointestinal stromal tumors (GISTs) presenting with surgical emergencies are rare. Neoadjuvant imatinib being the treatment of choice for non-metastatic advanced disease with a proven role in downstaging the disease may not be feasible in patients presenting with bleeding and obstruction. We present a case series with retrospective analysis of a prospectively maintained database of patients with advanced and metastatic GISTs presenting with surgical emergencies. Clinical characteristics, imaging and endoscopic findings, surgical procedures, histological findings, and outcomes in these patients were studied. Four patients were included in this case series, with three males and one female (age range: 24-60 years). Two patients presented with melena; one with hemodynamic instability despite multiple blood transfusions underwent urgent exploratory laparotomy for bleeding gastric GIST, while the other underwent surgical exploration after careful evaluation given the recurrent, metastatic disease with a stable metabolic response on six months of imatinib. One patient with metastatic jejunal GIST who presented with an umbilical nodule and intestinal obstruction was given a trial of non-operative management for 72 hours, but due to non-resolution of obstruction, segmental jejunal en bloc resection with the dome of the urinary bladder with reconstruction and metastasectomy was needed. The patient with advanced gastric GIST who presented with gastric outlet obstruction was resuscitated, and an attempt of endoscopic naso-jejunal tube placement was tried, which failed, and exploration was needed. The mean length of hospital stay was 7.5 days. Histopathological examination confirmed GIST in all four patients with microscopic negative resection margins. All patients were started on imatinib with dose escalation to 800 mg in the patient with recurrent and metastatic disease; however, the patient with bleeding gastric GIST experienced severe adverse effects of imatinib and discontinued the drug shortly. All four patients are disease-free on follow-ups of 15 months, 48 months for the patient with advanced non-metastatic disease, and six and 24 months for the patients with metastatic disease. In the era of tyrosine kinase inhibitor (TKI) therapy for advanced and metastatic disease, upfront surgery is usually reserved for surgical emergencies only. Surgical resection, the cornerstone for the treatment of resectable GIST, may also be clinically relevant in metastatic settings, although it requires a careful and individualized approach.

A Novel Potential Treatment for Diabetic Foot Ulcers and Non-Healing Ulcers - Case Series.

INTRODUCTION: Appropriate care and treatment of a wound is the need of the hour whether it is an infected or a non-infected wound. If wound healing is delayed for some reason, it leads to serious complications and further increases the hospital stay and cost of treatment. Herein, we describe a novel antimicrobial wound dressing formulation (VG111), with an objective to generate the preliminary data showing the distinct advantages in various types of wounds. METHOD: This case series involved the treatment of acute cases of wounds or chronic wounds that did not respond well to conventional wound healing treatments with VG111 in patients with different etiologies. Thirteen cases of patients that included patients with diabetes, pressure ulcers, burns, trauma, and others treated with VG111 showed rapid wound healing in all the cases, even obviating the need for a graft when complete skin regeneration occurred RESULT: This was illustrated by clearing of the wound infections, reduction/disappearance of the exudate, appearance of intense granulation, epithelialization, and anti-biofilm activity followed by complete wound closure. This VG111 precludes the need for systemic antimicrobial agents in localized infections and therefore, this single agent is an attempt to address the limitations and the drawbacks of the available products. CONCLUSION: Despite patients belonging to the old age group and having comorbidities like diabetes, still VG111 showed effective rapid wound healing, and that too without any scar formation in hardto-heal, infected, and non-infected wounds

Impact of Tailored-Enhanced Recovery After Surgery Versus Conventional Care in Patients of Gastro-Duodenal Perforation: A Pilot Randomized Control Trial.

BACKGROUND: The enhanced recovery after surgery (ERAS) program established improved clinical outcomes in elective surgery; however, its role in emergencies is uncertain. This study was designed to assess the feasibility, safety, and efficacy of a tailored-ERAS (t-ERAS) protocol in patients undergoing modified Graham's patch closure for gastro-duodenal perforation. METHODS: A single-centre, prospective, parallel-arm, open-label, randomized controlled trial was conducted from February 2021 to December 2021. Patients with gastroduodenal perforation undergoing modified Graham's patch were randomly assigned to either conventional care or the t-ERAS pathway. Patients with refractory septic shock, psychiatric or neurological disorders, pregnancy, multiple perforations, sealed-off perforations, and perforation sizes greater than 1.5 cm were excluded. The primary outcome was to compare the length of hospitalization (LOH). Functional recovery parameters and morbidity were compared in secondary outcomes. RESULTS: Twenty-five patients each were included in conventional care and the t-ERAS group. In the t-ERAS group, LOH was significantly shorter (6.3 SD2.15 days versus 9.56 SD4.33 days, p = 0.001). Patients in the t-ERAS group had significantly early functional recovery (days) with time to first bowel sound (1.8 SD0.41; p 0.002), first flatus (2.52 SD0.65; p = 0.026), first stool (3.04 SD0.68; p < 0.001), first liquid diet (2.24 SD0.60; p = 0.002), and duration of ileus (2.64 SD0.86; p = 0.038). There was no significant difference in morbidity such as post-operative nausea and vomiting, SSI, or pulmonary complications between the two groups. CONCLUSION: Tailored ERAS pathways are safe and effective in reducing the LOH and promoting early functional recovery in patients undergoing emergency closure of gastro-duodenal perforation.

Prospective Validation and Comparison of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) and Site Other Than Lower Limb, Immunosuppression, Age, Renal Impairment, and Inflammatory Markers (SIARI) Scoring Systems for Necrotizing Fasciitis.

INTRODUCTION: Necrotizing fasciitis (NF) is a rapidly progressing infection of the soft tissues associated with high morbidity and mortality and hence it is a surgical emergency. Early diagnosis and treatment are of paramount importance. LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) and SIARI (Site other than lower limb, Immunosuppression, Age, Renal impairment, and Inflammatory markers) scoring systems have been established for early and accurate diagnosis of necrotizing fasciitis. This study compared the two scoring systems for diagnosing NF, predicting management, and elucidating the prognostic performance for re-operation and mortality. METHODS: This prospective study was conducted in PGIMER Chandigarh, India, between February 2020 and June 2021. The study was approved by the Institutional Review Board (No. INT/IEC/2020-90). The clinical presentation, laboratory parameters, and imaging were used to classify patients into NF or severe cellulitis groups. We also calculated the LRINEC and SIARI scores. Demographic variables and mortality were recorded. The area under the receiver operating characteristic was used to express the accuracy of both scores at a cut-off LRINEC and SIARI scores of ≥6 and ≥ 4, respectively. RESULTS: The study comprised 41 patients with NF and 11 with severe cellulitis. Informed written consent was taken from all the participants. At LRINEC score ≥6, the C-statistic for NF diagnosis was 0.839 (95% confidence interval [CI] 0.682-0.995, P 0.001), which was better than SIARI score at ≥ 4, C-statistic of 0.608 (95% CI 0.43-0.787, P 0.297). Both scores accurately predicted 30-day mortality. The LRINEC score showed a C-statistic of 0.912 (95% CI 0.798-1, P 0.001). Simultaneously, the SIARI score showed 70% sensitivity and 77% specificity, with a C-statistic of 0.805 (0.62-0.99, P = 0.017). CONCLUSIONS: LRINEC score is an effective diagnostic tool for distinguishing necrotizing fasciitis from severe cellulitis. Additional research is required to establish the SIARI score's external validity.

Efficient Photodynamic Therapy against Gram-Positive and Gram-Negative Bacteria Using Rose Bengal Encapsulated in Metallocatanionic Vesicles in the Presence of Visible Light.

Significant consumption of antibiotics has generated multidrug resistance in bacteria, which is a major menace to human beings. Antibacterial photodynamic therapy (aPDT) is a progressing technique for inhibition of bacterial infection with minimal side effects. Metals and delivering agents play a major role in aPDT efficiency. Herein, we report a formulation to enrich the antibacterial photodynamic therapy utilizing metallocatanionic vesicles (MCVs) against both Gram-positive and Gram-negative bacteria. These MCVs were synthesized by utilizing iron-based double-chain metallosurfactant [FeCPC(II)] as a cationic surfactant and AOT, a double-chain anionic surfactant. These synthesized MCV fractions were characterized by distinct techniques like DLS, zeta potential, FE-SEM, confocal microscopy, SAXS, and UV-Visible spectroscopy. Polyhedral-shaped MCVs with a size of 200 nm were formed, wherein the charge and size of the catanionic vesicle can be controlled by varying the mixing ratios. Both Gram-positive bacteria, i.e., methicillin-resistant Staphylococcus aureus (MRSA), and Gram-negative bacteria, i.e., Escherichia coli (E. coli), were used for aPDT using Rose Bengal (RB) as a photosensitizer (PS) encapsulated in MCVs in the presence of a 532 nm wavelength laser. The aPDT against bacterial cells was evaluated for both dark and light toxicities. Pure MCVs also exhibited good antibacterial properties; however, much enhancement was observed in the presence of RB encapsulated in MCVs under light, where eradication of bacteria (E. coli and MRSA) was achieved in 30 min. The observations demonstrated that it is the presence of metal that enhances the singlet oxygen quantum yield of RB and MCVs help in retarding self-quenching and enhanced solubilization of RB. The cationic surfactant-rich fraction shows strong adhesion toward bacteria via electrostatic interactions. The outcome of this research shows that these newly fabricated metal-based metallocatanionic vesicles were effective against both Gram-positive and Gram-negative bacteria using aPDT and must be exploited for clinical applications as well as an alternative for antibiotics in the future.

Effect of Calotropis procera (madar) and amprolium supplementation on parasitological parameters of broilers during mixed Eimeria species infection.

AIM: An experiment was conducted on day old 168 broiler chicks to study the effect of 0.4% as well as 0.2% Calotropis procera (madar) leaf powder and 0.0125% amprolium supplementation on parasitological parameters of broilers during mixed Eimeria species infection. MATERIALS AND METHODS: Chicks were randomly divided into seven groups (I-VII) each with two replicates of 12 chicks. On 15th day of experiment, broilers of Group II, IV, VI, and VII were infected with 50,000 sporulated oocysts of mixed Eimeria species. To evaluate the anticoccidial effect of different feed supplements percent fecal score, percent survival, percent weight gain, performance index (PI), average oocyst production, and percent reduction in oocyst production were calculated. RESULTS: It was observed that amprolium supplementation had maximum anticoccidial effect as it gave the best efficacy in terms of all parameters, whereas supplementation of 0.4% madar leaf powder showed nonsignificant difference with amprolium for some parameters such as percent survival, percent weight gain, and PI. CONCLUSION: It can be concluded that madar (C. procera) leaf powder and amprolium had comparable activity against coccidiosis. Hence, madar leaf powder may be used for the prevention and control of mixed Eimeria spp. infection prevalent in field conditions.

Seroprevalence of bovine herpesvirus-1 antibodies in bovines in five districts of Uttarakhand.

AIM: This study was conducted to know the status of bovine herpesvirus-1 (BHV-1) antibodies in the bovines of the selected area of Uttarakhand. MATERIALS AND METHODS: A total of 489 serum samples, 392 of cattle and 97 of buffaloes were randomly collected from the unvaccinated bovine population of five districts viz., Dehradun, Haridwar, Nainital, Pithoragarh, and Udham Singh Nagar and were tested by avidin biotin enzyme-linked immunosorbent assay for BHV-1 antibodies. RESULTS: The overall prevalence was observed to be 29.03%. At district level, the highest prevalence was recorded in Pithoragarh district (40.00%) while it was lowest in district Udham Singh Nagar (16.00%). The prevalence of BHV-1 antibodies was found to be higher in unorganized dairy units (31.02%) compared to organized farms (26.51%) in Uttarakhand. Buffaloes were found to have greater prevalence (38.14%) than cattle (26.78%) while on sex-wise basis; it was found that more females (30.08%) were harboring antibodies to the virus than males (16.21%). CONCLUSION: The study revealed that the population in the area under study has been exposed to BHV-1 and hence prevention and control strategies must be implemented.