The use of a porcine model to teach advanced abdominal wall dissection techniques.

BACKGROUND: In the era of minimally invasive surgery, it is clear that a robust simulation model is required for the training of surgeons in advanced abdominal wall reconstruction. The purpose of this experimentation was to evaluate whether a porcine model could be used to teach advanced minimally invasive abdominal wall dissection techniques to novice surgeons. Secondary objectives included: time to completion, identification of various anatomical landmarks, to note the difference in porcine and human models and finally, the ability to dock a Da Vinci Xi robotic platform on the porcine model. METHODOLOGY: Two post-fellowship surgeons were given the task of performing an extended total extraperitoneal dissection (ETEP) on one female Landrace pig under the supervision of a surgeon experienced in robotic-assisted ventral hernia repair. This included insertion of ports, developing a retro-rectus plane, crossover from left to right rectus, bilateral transverse abdominus release, and sub-diaphragmatic dissection. A 5-mm vessel sealer was used to facilitate the dissection. The steps of the surgery were given to the trainees, and an experienced hernia surgeon guided the steps of dissection. The emphasis of the tasks was to develop the planes of extraperitoneal dissection to demonstrate that the porcine model could be considered for a viable and realistic model for training. RESULTS: The candidates were able to successfully complete the task and dock a Da Vinci Xi with the porcine model providing a realistic platform for training. CONCLUSION: The porcine model can be a considerable tool in the education of surgeons embarking on learning the art of minimally invasive abdominal wall reconstruction techniques. The advantage of live tissue dissection, similarity in anatomy and the relatively inexpensive availability of porcine models, makes it an unparalleled form of simulation-based training. We believe that this will have transitional capabilities to robotic ETEP education for complex hernia repair.

H pylori eradication therapy reduces gastric cancer in patients with or without gastric neoplasia.

SOURCE CITATION: Ford AC, Yuan Y, Moayyedi P. Helicobacter pylori eradication therapy to prevent gastric cancer: systematic review and meta-analysis. Gut. 2020. [Epub ahead of print]. 32205420.

Rifabutin triple therapy increased H pylori eradication vs. amoxicillin + omeprazole in treatment-naive patients.

SOURCE CITATION: Graham DY, Canaan Y, Maher J, et al. Rifabutin-based triple therapy (RHB-105) for Helicobacter pylori eradication: a double-blind, randomized, controlled trial. Ann Intern Med. 2020;172:795-802. 32365359.

Disposition Kinetics of Amitraz in Lactating Does.

Amitraz, a member of the formamidine pesticide family, commonly used for ectoparasite control, is applied as a dip or low-pressure hand spray to cattle and swine, and the neck collar on dogs. Data on amitraz were generated mainly on laboratory animals, hens, dogs, and baboons. The data on the toxicity and disposition of amitraz in animals and its residues in the milk are inadequate. Therefore, the present study was intended to analyze the disposition kinetics of amitraz and its pattern of elimination in the milk of lactating does after a single dermal application at a concentration of 0.25%. Blood at predetermined time intervals and milk twice daily were collected for eight days post application. The drug concentration was assayed by high-performance liquid chromatography (HPLC). Amitraz was detected in whole blood as early as 0.5 h, which attained a peak concentration at 12 ± 5 h, followed by a steady decline; however, detection persisted until 168 h. Amitraz was present in the blood at its 50% Cmax even after 48 h, and was still detectable after 7 days. The disposition after a single dermal application was best described non-compartmentally. The mean terminal half-life (t1/2), mean residence time (MRT), and area under the curve (AUC0-t) were 111 ± 31 h, 168 ± 39 h, and 539 ± 211 µg/mL/h, respectively. The apparent volume of distribution (Vdarea) was 92 ± 36 mL/g with an observed clearance (Cl) of 0.57 ± 0.33 mL/kg/h. Thus, the drug was well absorbed, widely distributed and slowly eliminated from the animal body. Amitraz achieved milk concentration approximating 0.2 per cent of the total dose after a single exposure and the steady-state elimination of amitraz in milk above the recommended maximum residue limit (MRL) of 0.01 mg/kg can act as a source of public health concern when applied on lactating animals.

A rare case of mullerianosis of the liver and lung mimicking metastatic biliary cystadenocarcinoma.

Anatomically, normal cells found in an abnormal site are known as choristoma. When any two of the three-cell lineage of the mullerian duct, that is endosalpinx, endocervix and endometrium, are found at an abnormal location, it is termed mullerian choristoma or mullerianosis. Mullerianosis histologically reveals glands of varying sizes lined by cervical, tubal and endometrial cells. Individual cell lineages like endometriosis of the ovary, endosalpingiosis and endocervicosis of the urinary bladder are common. But mullerianosis is quite rare, and as per literature, only about 20 cases have been reported. We report a mullerianosis involving the liver and lung in a 41-year-old female that mimicked metastatic biliary cystadenocarcinoma. It is the first case reported in literature where there is simultaneous involvement of the liver and lung by mullerianosis. The diagnosis was made with the help of histopathology and immunohistochemistry in the resected specimens.

A Validation Study of Non-invasive Scoring Systems for Assessing Severity of Hepatic Fibrosis in a Cohort of South Indian Patients With Non-alcoholic Fatty Liver Disease.

Introduction: Liver biopsy is the gold standard for diagnosing and staging non-alcoholic fatty liver disease (NAFLD), but liver biopsy has its limitations. Non-invasive tests (NITs) eliminate many of the drawbacks of liver biopsy. We did a retrospective observational study to validate the NAFLD Fibrosis Score (NFS score) and Fibrosis Score 4 (FIB-4 index) against the gold standard liver biopsy in a cohort of South Indian patients with NAFLD. Aims: The aim of this study was to validate the diagnostic accuracy of non-invasive fibrosis scoring systems (FIB-4 index and NFS), compared to that of liver histology, to predict AF in a cohort of south Indian patients with NAFLD. Material and methods: A retrospective observational analytical study of patients who had a liver biopsy with a diagnosis of NAFLD and had all the data for aetiology assessment and NIT calculation within 4 weeks of biopsy were included in the study. On liver biopsy, NAFLD was scored as per NIH's NASH committee grading system. NFS and FIB-4 index were calculated, and scores more than 0.676 and 2.67, respectively, were taken as the cut-off to predict advanced fibrosis (AF). The sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve for NFS score and FIB-4 score to diagnose AF were calculated. Results: A total of 147 patients were included in the study. Of these, 56 (38.1%) patients had AF (Stage 3, 4). Patients with AF were more likely to be older and have diabetes mellitus (DM). Patients with AF had lower platelet count, higher aspartate aminotransferase (AST), lower albumin, and higher AST/alanine aminotransferase ratio. An NFS of >0.676 had a sensitivity of 68% and specificity of 100%, and an FIB-4 index of >2.67 had a sensitivity of 67% and specificity of 95.6 % in diagnosing AF in our study. Conclusion: The non-invasive scoring systems NFS and FIB-4 index can be used as a bedside tool for diagnosing liver fibrosis in NAFLD allowing liver biopsy to be used in a more targeted manner for patients diagnosed with AF on NITs.

Transfer of Guided Emergence Profile Developed Using Customized Provisional Implant Restoration and Cementation Using an Abutment Replica Technique: A Case Report.

The long-term success of dental implants depends not only upon implant osseointegration, but also on the surrounding soft tissue health and profile. An ideal emergence profile contributes to the aesthetics of an implant restoration. It maintains long-term implant health by preventing potential food accumulation and forming a barrier against bacterial ingress. This article describes a method for obtaining an impression of implants that will capture the custom guided peri-implant soft tissue contours accurately, thus contributing to a final restoration with favorable aesthetics. We also describe a technique for reducing excess cement in a cement retained implant crown, thereby contributing to the health of the peri-implant tissues.

Comparison of the efficiency of photography-assisted shade selection to visual shade selection.

This study sought to compare the efficacy of digital photographs and graphic software for shade matching to that of conventional visual shade selection. Thirty-one postgraduate students were used and shade selection was analyzed through 1 of 4 different techniques: digital spectrophotometer, conventional visual shade selection, visual shade selection assisted by digital photography, and shade selection by color difference formulas and computer software. Shade selection done with digital photography and graphic software using color difference formulas offered better and statistically significant shade matching compared to conventional visual shade selection and visual shade selection assisted by digital photography.

An In vitro Evaluation of Flexural Bond Strength of Indirect Composites Fused to Metal.

With the advent of newer indirect composite resin materials for crown and bridge prosthesis, it has become imperative to evaluate their strength to serve as long term replacements as a substitute to metal ceramic restorations. This study aimed to evaluate and compare the flexural bond strength of three composite resin veneering material to metal, cured by different methods. Specimen were fabricated with pattern resin by duplicating it with machined metal die and divided into three groups. Three composite resin materials were used in this study. Group (A) received Adoro, Group (B) received Targis and Group (C) received Tescera. The bond strength of all specimens was tested with Lloyd's universal testing machine under three point loading. The highest values for fracture resistance were displayed by light, heat and pressure cured composites followed by composites cured using a temperature of 104 °C and composites with curing temperature of 95 °C. The results indicate that there is a significant difference between the three groups, with the Tescera group specimens exhibiting the highest flexural bond strength. Of the other two groups, Adoro group exhibited higher flexural bond strength than Targis group. The results of this study suggest that Tescera group with curing temperature of 130 °C and pressure of 80 Psi, cured with metal halide unit exhibited the highest flexural bond strength when compared to Adoro and Targis groups.

Non-alcoholic fatty liver disease and diabetic retinopathy: Is there an association?

Background: Studies have not proven whether an association exists between diabetic retinopathy (DR) and non-alcoholic fatty liver disease (NAFLD). The reports from various parts of the world have not used uniform criteria, and hence, results are inconclusive. Both DR and NAFLD are common conditions encountered in primary care. Methods: A total of 130 patients with type 2 diabetes from the medical wards of a tertiary care hospital were enrolled. After documentation of clinical and biochemical data, they underwent ultrasonography (USG) of the abdomen and fibroscan grading of liver. Retinopathy was assessed and classified as per the Early Treatment Diabetic Retinopathy Study. Results: The mean age of the patients included in the study was 46.5+/-8.8 with 55% of the participants being male and 45% female. The mean HbA1c was 7.168+/2.4. The association between DR and hepatic fibrosis was assessed by fibroscan (p 0.003) and USG (p 0.001) and was significant on univariate analysis. Multivariate analysis did not confirm this. There was no association between increasing grades of either condition. Although fibroscan and USG significantly concorded in diagnosing NAFLD, fibroscan diagnosed more cases as compared to USG (83 vs 73). Conclusion: Larger studies should be conducted to conclusively determine the association in order to investigate pathogenetic factors and treatment strategies.

Pulmonary Assessment of the Liver Transplant Recipient.

Respiratory symptoms and hypoxemia can complicate chronic liver disease and portal hypertension. Various pulmonary disorders affecting the pleura, lung parenchyma, and pulmonary vasculature are seen in end-stage liver disease, complicating liver transplantation (LT). Approximately 8% of cirrhotic patients in an intensive care unit develop severe pulmonary problems. These disorders affect waiting list mortality and posttransplant outcomes. A thorough history, physical examination, and appropriate laboratory tests help diagnose and assess the severity to risk stratify pulmonary diseases before LT. Hepatopulmonary syndrome (HPS), portopulmonary hypertension (POPH), and hepatic hydrothorax (HH) are respiratory consequences specific to cirrhosis and portal hypertension. HPS is seen in 5-30% of cirrhosis cases and is characterized by impaired oxygenation due to intrapulmonary vascular dilatations and arteriovenous shunts. Severe HPS is an indication of LT. The majority of patients with HPS resolve their hypoxemia after LT. When pulmonary arterial hypertension occurs in patients with portal hypertension, it is called POPH. All other causes of pulmonary arterial hypertension should be ruled out before labeling as POPH. Since severe POPH (mean pulmonary artery pressure [mPAP] >50 mm Hg) is a relative contraindication for LT, it is crucial to screen for POPH before LT. Those with moderate POPH (mPAP >35 mm Hg), who improve with medical therapy, will benefit from LT. A transudative pleural effusion called hepatic hydrothorax (HH) is seen in 5-10% of people with cirrhosis. Refractory cases of HH benefit from LT. In recent years, increasing clinical expertise and advances in the medical field have resulted in better outcomes in patients with moderate to severe pulmonary disorders, who undergo LT.

Macro and microscopic study of a rare case of Papilliferous Keratoameloblastoma using a stereo zoom microscope.

Papilliferous keratoameloblastoma is an extremely rare variant of ameloblastoma, a benign odontogenic tumor, with only seven cases reported in the English language literature. This variant presents with the metaplastic transformation of stellate reticulum-like cells to the extent of forming papillary structures exhibiting superficial keratinization of varying thickness. This paper describes the pathognomonic macroscopic features of this tumor observed during gross examination under the stereo zoom microscope that differentiate it from the other odontogenic tumors which have not been explored in the previously documented cases. Also, in this paper, a detailed comparison of the macroscopic features observed under the stereo zoom microscope during gross examination with the microscopic features of the histologic section has been described proving to be useful in the histological differential diagnosis of the keratinizing variants of ameloblastoma.

Fluoride content in various types of tea used by tea stalls in Salem district - An in vitro cross sectional study.

Background: Tea leaves are natural rich source of fluoride and are known as fluorine absorbants. It is consumed on large scale in India and thus needs to be monitored for its daily fluoride consumption by customers. Tea manufacturers should mention fluoride concentrations on the packages to avoid overdose through unknown consumption by consumers. Objectives: To detect the levels of fluoride in tea at different periods of boiling and to compare the fluoride levels in various brands of tea at different periods of boiling. Methodology: A survey was conducted in 25 tea stalls of Salem on the type of tea and time of boiling black tea. The five most common brands of tea will bought for the study. The stainless-steel vessel will be used in the methodology for boiling tea. Mettur water will be used for the preparation of black tea and 1 g of tea leaves to 100 ml of hot (~95°C) deionized water (1% w/v tea infusion) and allowed the mixture to stand for 5 min in a glass beaker. After 5 min, the infusions were filtered and again left standing until they are cooled to room temperature. All fluoride measurements will be completed within 4 h of the preparation of the infusion. About 2 min and 4 min boiling will be followed. The fluoride present in each brand of tea will be calculated from black tea prepared using 2-(parasulfophenylazo)-1,8-dihydroxy-3,6-naphthalene-disulfonate (SPADNS) calorimetric method. Results: The distribution of mean score of fluoride level in tea powders available in tea shops of Salem when boiled in distilled water was (559.00 ± 112.12). The mean score of fluoride level in tea powders available in tea shops of Salem boiled in Mettur water was (689.05 ± 116.34). To test the significance of difference between the average fluoride in tea powders available in tea shops of Salem when boiled in distilled water and Mettur water, the independent t-test was used. the P value is <0.05, and hence, it is found that there is significant difference between the average fluoride in tea powders available in tea shops of Salem boiled in distilled water and Mettur water. Conclusion: Thus, the study showed tea consists of significant amount of fluoride concentration that is consumed on daily basis. The study also evaluated fluoride concentration in tea preparations using different water. The study shows necessity for regulations of mentioning fluoride concentration on tea packs.

A pilot study on the comparative evaluation of residual periodontal ligament in extracted teeth of chronic periodontitis patients with and without type 2 diabetes - Vital function of an occult dimension.

Background: Periodontitis is the most common type of periodontal condition, primarily affecting middle-aged people and resulting in tooth loss; when combined with diabetes, it becomes a debilitating condition. The aim of this study is to compare the residual periodontal ligament length in periodontitis patients with and without diabetes. Materials and Methods: The cross-sectional observational study was conducted in the department of periodontics over 5 months. The patients in the study were divided into two groups. Group 1 comprised patients with periodontitis without type 2 diabetes and Group 2 comprised patients with periodontitis with type 2 diabetes. A total of 100 teeth 50 from each group were collected. The teeth were stained, and the Residual Periodontal Ligament (RPL) of all tooth aspects and surfaces to a total of 544 were measured. Two points were identified for measuring the RPL. The first point was from the apex of the tooth and the second point was the highest marking of the stain. The length from these two points was recorded as the RPL. Following which, means from Groups 1 and 2 were calculated to determine the rate of destruction. The average of the values for each tooth was calculated to determine the percentage of RPL in each tooth and surface. The Mann-Whitney test was used to compare the RPL of the teeth surfaces and Group 1 and Group 2 and P < 0.05 was considered statistically significant. Results: The RPL was higher in nondiabetic patients, with a mean value of 23.66 mm, when compared to diabetic patients, with a mean RPL of 17.05 mm, implying that diabetic patients showed greater periodontal destruction. Buccal tooth surfaces displayed a mean RPL of 4.24 mm and 6.00 mm, lingual/palatal tooth surfaces with 4.02 mm and 5.91 mm, mesial tooth surfaces with 3.82 mm and 5.64 mm, and distal tooth surfaces showed 4.14 mm and 5.67 mm (diabetic and nondiabetic, respectively) with (P < 0.001) found to be statistically significant. Conclusion: This study observed that the destruction rate of the periodontal ligament was higher in diabetic teeth than in nondiabetic teeth, implying that patients with metabolic diseases such as type 2 diabetes influence the response of periodontal tissues to periodontitis and that hyperglycemia impacts the periodontal ligament either directly or indirectly.

National Liver Allocation Policy-Consensus Document by the Liver Transplantation Society of India for a Nationally Uniform System of Allocation of Deceased Donor Liver Grafts.

Background: Deceased donor liver transplantation (DDLT) is increasing in India and now constitutes nearly one-third of all liver transplantation procedures performed in the country. There is currently no uniform national system of allocation of deceased donor livers. Methods: A national task force consisting of 19 clinicians involved in liver transplantation from across the country was constituted under the aegis of the Liver Transplantation Society of India to develop a consensus document addressing the above issues using a modified Delphi process of consensus development. Results: The National Liver Allocation Policy consensus document includes 46 statements covering all aspects of DDLT, including minimum listing criteria, listing for acute liver failure, DDLT wait-list management, system of prioritisation based on clinical urgency for adults and children, guidelines for allocation of paediatric organs and allocation priorities for liver grafts recovered from public sector hospitals. Conclusion: This document is the first step in the setting up of a nationally consistent policy of deceased donor liver allocation.

Practice Patterns and Survival in Patients with Resected Pancreatic Ductal Adenocarcinomas (PDAC) - Results from the Multicentre Indian Pancreatic & Periampullary Adenocarcinoma Project (MIPPAP) Study.

BACKGROUND: There is limited data from India with regard to presentation, practice patterns and survivals in resected pancreatic ductal adenocarcinomas (PDACs). METHODS: The Multicentre Indian Pancreatic & Periampullary Adenocarcinoma Project (MIPPAP) included data from 8 major academic institutions across India and presents the outcomes in upfront resected PDACs from January 2015 to June 2019. RESULTS: Of 288 patients, R0 resection was achieved in 81% and adjuvant therapy was administered in 75% of patients. With a median follow-up of 42 months (95% CI: 39-45), median DFS for the entire cohort was 39 months (95% CI: 25.4-52.5), and median overall survival (OS) was 45 months (95% CI: 32.3-57.7). A separate analysis was done in which patients were divided into 3 groups: (a) those with stage I and absent PNI (SI&PNI-), (b) those with either stage II/III OR presence of PNI (SII/III/PNI+), and (c) those with stage II/III AND presence of PNI (SII/III&PNI+). The DFS was significantly lesser in patients with SII/III&PNI+ (median 25, 95% CI: 14.1-35.9 months), compared to SII/III/PNI + (median 40, 95% CI: 24-55 months) and SI&PNI- (median, not reached) (p = 0.036)). CONCLUSIONS: The MIPPAP study shows that resectable PDACs in India have survivals at par with previously published data. Adjuvant therapy was administered in 75% patients. Adjuvant radiotherapy does not seem to add to survival after R0 resection.

Hemangiopericytoma of the gingiva - An exemplary differential of a masquerading tumor.

Periodontal diseases are unique as a small number lesions appearing as inflammatory in reality are neoplastic in nature, and it is imperative that an accurate diagnosis be rendered to provide the appropriate treatment and management. One of the most common clinical presentations of gingival lesions is pedunculated soft-tissue swellings. We report the case of a 63-year-old female who presented with a painless swelling on the interdental papilla of 23 and 24 with a history of recurrences. The lesion was excised by wide surgical excision. This article presents a unique case of a vascular tumor that had clinically mimicked a reactive lesion and with detailed history, thorough clinical examination had provided clues to a vascular entity namely hemangiopericytoma which was confirmed by histological diagnosis. Oral lesions, particularly occurring in gingiva, most often appear clinically benign or innocuous thus necessitating the need for careful examination with investigations to render a diagnosis.

Immunosuppressive Drugs in Liver Transplant: An Insight.

Liver transplantation (LT) is the standard of care for end-stage liver failure and hepatocellular carcinoma. Over the years, immunosuppression regimens have improved, resulting in enhanced graft and patient survival. At present, the side effects of immunosuppressive agents are a significant threat to post-LT quality of life and long-term outcome. The role of personalized immunosuppression is to reach a delicate balance between optimal immunosuppression and minimal side effects. Today, immunosuppression in LT is more of an art than a science. There are no validated markers for overimmunosuppression and underimmunosuppression, only a few drugs have therapeutic drug monitoring and immunosuppression regimens vary from center to center. The immunosuppressive agents are broadly classified into biological agents and pharmacological agents. Most regimens use multiple agents with different modes of action to reduce the dosage and minimize the toxicities. The calcineurin inhibitor (CNI)-related toxicities are reduced by antibody induction or using mTOR inhibitor/antimetabolites as CNI sparing or CNI minimization strategies. Post-liver transplant immunosuppression has an intensive phase in the first three months when alloreactivity is high, followed by a maintenance phase when immunosuppression minimization protocols are implemented. Over time some patients achieve "tolerance," defined as the successful stopping of immunosuppression with good graft function and no indication of rejection. Cell-based therapy using immune cells with tolerogenic potential is the future and may permit complete withdrawal of immunosuppressive agents.

Functional and clinical outcome with modified lateral approach total hip arthroplasty in stiff hips with ankylosing spondylitis.

BACKGROUND: Ankylosing spondylitis at total hip arthroplasty (THA) has significant hip stiffness with flexion deformity, restricted mobility, and function. Range of movement (ROM) improvement with good functional outcome is seen following THA in these hips. The modified Hardinge approach without abductor compromise is helpful in these stiff hips with associated flexion deformity. AIM: To assess improvement in ROM and functional outcomes with a modified lateral approach THA in ankylosing spondylitis with stiff hips. METHODS: A total of 69 hips that underwent THA with a modified Hardinge approach in 40 patients were evaluated at a mean follow-up of 38.33 mo. All individuals ambulated with weight-bearing as tolerated and ROM exercises from the 1st postoperative day. Modified Harris hip score and ROM were assessed during follow-up. Quality of life assessments using the 36-item and 12-item short form health surveys were done along with clinical and functional outcomes at follow-up. SPSS 22.0 was used for statistical analysis. The correlation of ROM and functional score change was performed using Pearson's correlation coefficient. RESULTS: Sixty-nine hips with a significant decrease in ROM preoperatively with 32 clinically fused hips showed significant improvement in flexion range. The mean flexion in 69 hips improved from 29.35 ± 31.38 degrees to 102.17 ± 10.48 degrees. The mean difference of 72.82 with a P value < 0.0001 was significant. In total, 45 out of 69 hips had flexion deformity, with 13 hips having a deformity above 30 degrees. The flexion during the follow-up was below 90 degrees in 3 hips. Eleven hips had flexion of 90 degrees at follow-up, while the remaining 55 hips had flexion above 100 degrees. Modified Harris hip score improved from 17.03 ± 6.02 to 90.66 ± 7.23 (P value < 0.0001). The 36-item short form health survey at the follow-up indicated health status in 40 patients as excellent in 11, very good in 20, good in 5, fair in 3, and poor in 1. The mean mental health score was 84.10 ± 11.58. Pain relief was good in all 69 hips. Altogether, 28/40 patients (70%) had no pain, 9 patients (22%) had occasional pain, and 3 patients (8%) had mild to moderate pain with unusual activity. Heterotopic ossification was seen in 21 hips with Brooker class 1 in 14 hips. CONCLUSION: Modified Hardinge approach THA in ankylosing spondylitis with stiff hips with flexion deformity significantly improved ROM, Harris hip score, and quality of life indicated by the 36-item and 12-item short form health surveys.