Early clinical exposure through a vertical integration programme in physiology.

Background: Early clinical exposure is likely to be beneficial during the preclinical year. This pilot programme aimed to define a learning framework of introducing first year medical students to early clinical exposure through a vertical integration programme in the physiology course. The intent was to enhance the understanding of theoretical concepts and practical applications of physiology. Student and faculty perceptions were evaluated. Methods: First year MBBS students (n = 60) had bedside clinics conducted by 5 clinical departments, where the clinical context and applied physiological concepts were emphasized. Clinical sessions were synchronized with pedagogic highlights on related physiological concepts. The student's perceptions were recorded through a semi-structured questionnaire, while qualitative feedback was obtained from the faculty. Results: All students ( 100%) reported that the programme was relevant and did not interfere with their physiology course. Most (91%) appreciated the synchronization of classroom knowledge with clinical exposures, and thought that integrated teaching helped in better understanding of practical applications of physiology (94%) with adequate discussions during the sessions (91 %). Fifty-nine (98%) students preferred integrated teaching over the isolated traditional classroom teaching. The clinicians involved also felt that the early clinical exposure was relevant. The students achieved a mean (SD) score of 13 (2.98) of 25 in the quiz consisting of multiple-choice questions that attempted to test their learning through early clinical exposures. Conclusion: This pilot exercise showed the utility of early clinical exposure integrated into the physiology course. It will be worthwhile to replicate this exercise at other institutions and among a larger student strength.

Liver failure determines the outcome in patients of acute-on-chronic liver failure (ACLF): comparison of APASL ACLF research consortium (AARC) and CLIF-SOFA models.

BACKGROUND AND AIMS: Acute-on-chronic liver failure (ACLF) is a progressive disease associated with rapid clinical worsening and high mortality. Early prediction of mortality and intervention can improve patient outcomes. We aimed to develop a dynamic prognostic model and compare it with the existing models. METHODS: A total of 1402 ACLF patients, enrolled in the APASL-ACLF Research Consortium (AARC) with 90-day follow-up, were analyzed. An ACLF score was developed in a derivation cohort (n = 480) and was validated (n = 922). RESULTS: The overall survival of ACLF patients at 28 days was 51.7%, with a median of 26.3 days. Five baseline variables, total bilirubin, creatinine, serum lactate, INR and hepatic encephalopathy, were found to be independent predictors of mortality, with AUROC in derivation and validation cohorts being 0.80 and 0.78, respectively. AARC-ACLF score (range 5-15) was found to be superior to MELD and CLIF SOFA scores in predicting mortality with an AUROC of 0.80. The point scores were categorized into grades of liver failure (Gr I: 5-7; II: 8-10; and III: 11-15 points) with 28-day cumulative mortalities of 12.7, 44.5 and 85.9%, respectively. The mortality risk could be dynamically calculated as, with each unit increase in AARC-ACLF score above 10, the risk increased by 20%. A score of ≥11 at baseline or persisting in the first week was often seen among nonsurvivors (p = 0.001). CONCLUSIONS: The AARC-ACLF score is easy to use, dynamic and reliable, and superior to the existing prediction models. It can reliably predict the need for interventions, such as liver transplant, within the first week.

Large villous adenoma of the duodenum.

A 27-year-old man, who had symptoms of gastric outlet obstruction, was found on endoscopy to have a large duodenal polyp which on histology was diagnosed as villous adenoma. The tumor was resected surgically and the patient remained asymptomatic until two years later.

Post-transplant lymphoproliferative disorders following liver transplantation: incidence, risk factors and survival.

This study investigates retrospectively the incidence, risk factors and mortality of post-transplant lymphoproliferative disorders (PTLD) in adult orthotopic liver transplant (OLT) recipients. Among 1206 OLT recipients at a single institution, 37 developed a PTLD. The incidence of PTLD was highest during the first 18 months and relatively constant thereafter with cumulative incidence of 1.1% at 18 months and 4.7% at 15 years. The risk of PTLD was approximately 10% to 15% of the risk of death without PTLD. During the first 4 years following OLT, PTLD were predominantly related to EBV, while afterward most PTLD were EBV negative. Significant risk factors for PTLD in OLT recipients were transplantation for acute fulminant hepatitis during the first 18 months following OLT (HR=2.6, p=0.007), and rejection therapy with high-dose steroids (HR=4.5, p=0.049) and OKT3 (HR=3.9, p=0.016) during the previous year. Therapy with high-dose steroids or OKT3 (HR=3.6, p=0.0071) were also significant risk factors for PTLD-associated mortality. OLT recipients remain at risk for PTLD years after transplantation. The strong association of PTLD with rejection therapy and the worse post-PTLD prognosis among recipients of rejection therapy indicate the need to balance the risk of immunosuppression against the risk of PTLD following rejection treatment.

Clinical, colonoscopic, and histological profile of colonic tuberculosis in a tertiary hospital.

BACKGROUND AND STUDY AIMS: Colonic tuberculosis is not uncommon in developing countries. As emigration to the West increases, it is worthwhile to recall the clinical, colonoscopic, and histopathological features of this condition. PATIENTS AND METHODS: The clinical, colonoscopic and histopathological findings were evaluated in 43 patients with colonic tuberculosis. RESULTS: Abdominal pain, weight loss, diarrhea, fever, and a lump in the abdomen were the commonest symptoms. Extraintestinal tuberculosis was present in 11 patients (26 %). Colonoscopy revealed ulcers in 30 patients (70 %), nodules in 24 (56 %), a deformed cecum and ileocecal valve in 17 (40 %), strictures in 10 (23 %), polypoid lesions in six (14 %), and fibrous bands forming mucosal bridges in three (7 %). The cecum and ascending colon were the commonest sites involved. Segmental tuberculosis was seen in six of the 32 patients (19 %) in whom full-length colonoscopy could be performed. Two or more sites were involved in 19 patients (44 %). Histopathology revealed well-formed granulomas in 23 patients (54 %). Fourteen of the above patients (61 %) had caseation and 11 (48 %) had confluence of the granulomas. Acid-fast bacilli were present in the biopsies from two patients (5 %). Ill-formed granulomas were seen in seven patients (16 %) and chronic inflammatory changes in 13 (30 %). Despite the various histopathological findings, all of the patients responded to antitubercular treatment and continued to remain asymptomatic during the follow-up period. CONCLUSIONS: Colonoscopy with biopsy is a useful method for diagnosing colonic tuberculosis. Even in the absence of the classic histopathological features, a therapeutic trial may be indicated in a given clinical and colonoscopic setting. Follow-up is essential.

Idiopathic benign biliary strictures in surgically resected patients with presumed cholangiocarcinoma.

OBJECTIVE: Distinguishing between malignant and benign biliary strictures remains problematic. The aim of this study was to compare and contrast the clinical features of patients with benign and malignant biliary strictures. METHODS: Medical records of patients who underwent surgical resection for presumed cholangiocarcinoma were reviewed. Immunohistochemistry for hypoxia inducible factor-1-alpha (HIF-1-alpha) was performed on all bile ductule samples. RESULTS: Twelve patients with benign strictures (group I) were compared to 26 patients with cholangiocarcinoma (group II). Group I was predominantly female (ratio 2: 1), (p<0.01), whereas the gender ratio was 1: 1 in patients in group II. Bismuth-Corlette type strictures in group I were more likely to be type I/II, whereas type III strictures predominated in group II. The CA 19-9 was <100 U/ml in 6 and >100 U/ml in 1 patient of group I and <100 in 13 and >100 in 11 patients in group II. Half of the patients in group I had positive immunoreactivity for HIF-1-alpha in bile ductules. CONCLUSION: Benign biliary strictures masquerading as cholangiocarcinomas occur more often in women, are less often Bismuth-Corlette type III, have serum CA 19-9 values <100 U/ml, and hypoxia may play a role in a subset of these strictures.

Tuberculous chylous ascites: pathognomonic CT findings.

The computed tomographic (CT) appearance of chylous ascites is usually that of water with corresponding attenuation coefficients. This case report depicts the fat-fluid level sign on CT (shown by supine and decubitus scans), which is pathognomonic of chylous ascites.