A case of giant colonic lipoma removed endoscopically using a modified hybrid technique.

Colonic lipomas are benign adipose tumors and are mostly asymptomatic. They may cause symptoms when their size becomes more than 2 cm. Giant colonic lipoma (GCL) is a rare finding in endoscopy which presents with or without macroscopic ulceration and may lead to iron deficiency anaemia (IDA). The choice of treatment of symptomatic large colonic lipomas has been controversial. Here we are presenting a case of GCL presenting with occult bleeding causing iron deficiency anaemia (IDA). It was removed endoscopically using a combination of noradrenaline, endoloop ligation, and snare cautery technique (modified hybrid technique). Successful removal of the GCL lead to the resolution of IDA. This case report highlights that even GCL can be removed endoscopically, thus surgery can be prevented. Clinical Significance: GCL is an unusual cause of anemia. Modified hybrid endoscopic removal technique improves safety.

Pattern of liver function test variations in COVID-19 infection & its clinical significance: A study from a dedicated COVID-19 tertiary care centre from India.

Background & objectives: Coronavirus disease 2019 (COVID-19) affects respiratory, gastrointestinal, cardiovascular and other systems disease. Studies describing liver involvement and liver function test (LFT) abnormalities are sparse from our population. This study was undertaken to estimate the LFT abnormalities in patients with COVID-19 in a tertiary care set up in India. Methods: In this retrospective study conducted at a tertiary care centre in Mumbai, India, all consecutive patients with proven COVID-19 by reverse transcriptase-PCR from March 23 to October 31, 2020 were enrolled. Of the 3280 case records profiled, 1474 cases were included in the study. Clinical characteristics, biochemical parameters and outcomes were recorded. Results: Overall 681 (46%) patient had deranged LFTs. Hepatocellular type of injury was most common (93%). Patients with deranged LFTs had more probability of developing severe disease (P<0.001) and mortality (P<0.001). Advanced age (P<0.001), male gender (P<0.001), diabetes mellitus (P<0.001), lower oxygen saturation levels at admission (P<0.001), higher neutrophil-lymphocyte ratio (P<0.001), history of diabetes mellitus and cirrhosiss were associated with deranged LFTs. Acute liver injury was seen in 65 (4.3%) cases on admission and 57 (3.5%) cases during hospital stay. On multivariate analysis for predicting mortality, age >60 yr serum creatinine >2 mg%, PaO2/FiO2 ratio ≤200 and raised AST >50 IU/l (OR: 2.34, CI: 1.59-3.48, P<0.001) were found to be significant. Interpretation & conclusions: In COVID-19, LFT abnormalities were common, and derangement increased as severity progressed. The presence of deranged LFT worsens the clinical outcome and predicts in-hospital mortality.

A comparative study of uncomplicated acute non-A-E hepatitis with acute viral hepatitis and acute onset autoimmune hepatitis.

BACKGROUND AND AIMS: Non-A-E hepatitis (NAEH) not leading to acute liver failure (ALF) is poorly documented. The objective was to compare clinical and laboratory features of uncomplicated acute NAEH with acute viral (AVH) and autoimmune hepatitis (AIH) and histopathology in NAEH and AIH. METHODS: Cases of hepatocellular jaundice were included. These were grouped into AVH, AIH and NAEH based on clinical, laboratory and, when indicated, liver biopsy findings. NAEH and AIH were followed up at three months. RESULTS: Of 336 patients with hepatocellular jaundice, 15 (5%) were NAEH, 25 (7%) acute AIH and 45 (14%) AVH. Among NAEH patients, seven (46.7%) were males with a mean age of presentation 39 years. Jaundice (100%) was the most common presentation of NAEH. Peak bilirubin was 10.7 mg/dL. Peak aspartate and alanine aminotransferase (AST, ALT) were 512 and 670 U/L. Five (33.3%) patients had positive anti-nuclear antibody and one had anti-smooth muscle antibody. Mean immunoglobulin G (IgG) levels were 1829. On liver biopsy, all had ballooning degeneration, four (26.7%) had mild and three (20%) moderate interface hepatitis, four (26.7%) mild lymphoplasmacytic infiltrate, one (6.7%) rosette formation, bridging necrosis in none and stage 1 fibrosis in one. Comparing NAEH with AIH, AIH showed significantly older age at presentation, female predisposition, past history of jaundice, lower ALT, more autoantibodies, higher IgG, higher grade interface hepatitis, lymphoplasmacytic infiltrate, rosette formation and higher bilirubin, AST at three months. NAEH and viral hepatitis had similar features. CONCLUSION: Etiology of NAEH is unlikely to be autoimmune and is probably viral, unidentified as yet. Uncomplicated NAEH likely has self-limiting course even without specific treatment.

Screening depression among university students utilizing GHQ-12 and machine learning.

The escalating incidence of depression has brought attention to the increasing concern regarding the mental well-being of university students in the current academic environment. Given the increasing mental health challenges faced by students, there is a critical need for efficient, scalable, and accurate screening methods. This study aims to address the issue by using the General Health Questionnaire-12 (GHQ-12), a well recognized tool for evaluating psychological discomfort, in combination with machine learning (ML) techniques. Firstly, for effective screening of depression, a comprehensive questionnaire has been created with the help of an expert psychiatrist. The questionnaire includes the GHQ-12, socio-demographic, and job and career-related inquiries. A total of 804 responses has been collected from various public and private universities across Bangladesh. The data has been then analyzed and preprocessed. It has been found that around 60% of the study population are suffering from depression. Lastly, 16 different ML models, including both traditional algorithms and ensemble methods has been applied to examine the data to identify trends and predictors of depression in this demographic. The models' performance has been rigorously evaluated in order to ascertain their effectiveness in precisely identifying individuals who are at risk. Among the ML models, Extremely Randomized Tree (ET) has achieved the highest accuracy of 90.26%, showcasing its classification effectiveness. A thorough investigation of the performance of the models compared, therefore clarifying their possible relevance in the early detection of depression among university students, has been presented in this paper. The findings shed light on the complex interplay among socio-demographic variables, stressors associated with one's profession, and mental well-being, which offer an original viewpoint on utilizing ML in psychological research.

Appraisal of microplastic pollution and its related risks for urban indoor environment in Bangladesh using machine learning and diverse risk evolution indices.

The widespread presence of Microplastics (MPs) is increasing in the indoor environment due to increasing annual plastic usage, which is becoming a global threat to human health. Therefore, this is the first research in Bangladesh to identify, and characterize, MP pollution and its allied threats to human health in the indoor urban environment, where 80 household dust samples were collected from the whole study area. The presence of MPs in household dust of the urban indoor environment was 25.8 ± 6.43 particles/g with a significant variety, whereas the fiber shape (73%), 0.5-1.00 mm ranged MPs size (58%), blue color (21%), and polystyrene polymer (34%) was the most ubiquitous MPs category. The pollution load index (1.61-2.96) indicated significant pollution due to the high abundance of MPs. Besides, other risks evaluating indices including contamination factor (1.00-3.51), and Nemerow pollution index (1.60-3.51) represent moderate to high MP-induced pollution. The polymer hazard index (119.54 ± 70.34) indicated significant risks for the selected polymers to the indoor environment living inhabitants. Machine learning approaches, especially random forest and support random vector machine were effective in predicting the number of MPs, where EC, salinity, pH, OC, and texture classes acted as controlling factors. Children and adults might be ingesting 4.12 ± 1.01 and 2.27 ± 0.57 particles/day through the ingestion exposure route, which has significant health effects. Polymer-associated lifetime cancer risk assessment results show that there are moderate risks for both adults and children, but children tend to be more susceptible to MP risks. The overall study found that Dhaka was the most severely MPs induced risky division among the others. This study reveals that high quantities of MPs in indoor environments could pose a serious health hazard' to different exposure groups.

Application of machine learning and multivariate approaches for assessing microplastic pollution and its associated risks in the urban outdoor environment of Bangladesh.

Microplastics (MPs) are an emerging global concern due to severe toxicological risks for ecosystems and public health. Therefore, this is the first study in Bangladesh to assess MP pollution and its associated risks for ecosystems and human health in the outdoor urban environment using machine learning and multivariate approaches. The occurrences of MPs in the urban road dust were 52.76 ± 20.24 particles/g with high diversity, where fiber shape (77%), 0.1-0.5 mm size MPs (75%), blue color (26%), and low-density polyethylene (24%) polymer was the dominating MPs category. Pollution load index value (1.28-4.42), showed severe pollution by MPs. Additionally, the contamination factor (1.00-5.02), and Nemerow pollution index (1.38-5.02), indicate moderate to severe MP pollution. The identified polymers based on calculated potential ecological risk (2248.52 ± 1792.79) and polymer hazard index (814.04 ± 346.15) showed very high and high risks, respectively. The occurrences of MPs could effectively be predicted by random forest, and support random vector machine, where EC, salinity, pH, OC, and texture classes were the influencing parameters. Considering the human health aspect, children and adults could be acutely exposed to 19259.68 and 5777.90 MP particles/ year via oral ingestion. Monte-Carlo-based polymers associated cancer risk assessment results indicate moderate risk and high risk for adults and children, respectively, where children were more vulnerable than adults for MP pollution risks. Overall assessment mentioned that Dhaka was the most polluted division among the other divisions.

Microplastics in the commercially available branded milk in Bangladesh: An emerging threat for human health.

Microplastics (MPs) are polymer-based particles commonly found in diverse foods that pose serious human health impacts throughout the food chain. Assessment of MPs in different food products is a prime measure to combat MP-related food contamination. Therefore, this study first investigated the identification, characterization, and potential risks of MPs in the commercially available milk brands (19 dry powders and 06 liquid brands) in Bangladesh. The presence of MPs in milk samples was 279.47 ± 134.26 particles/kg and 182.27 ± 55.13 particles/L for powder and liquid milk, respectively, with a significant variety. Study findings displayed miscellaneous colors, fiber shapes (powder=78 %; liquid=81 %), > 0.1 mm sizes (powder=69 %; liquid=65 %), and polyethylene (powder=48 %; liquid=44 %) dominating MPs categories. The pollution load index indicated significant pollution due to the high abundance of MPs. Further, other risk-evaluating indices including contamination factor and Nemerow pollution index represent moderate to high MP-induced pollution for both milk samples. Low to moderate polymeric risks are exhibited by powder and liquid milk samples. Children could be exposed to 3.43 times higher MPs than adults through daily oral ingestion, which has significant health effects. This study found that powder milk was the most severely MPs induced risk than liquid milk. Consequently, this study finding established a reference point for MP contamination in milk, so special attention must be taken during production, storage, and packaging stages to reduce MP contamination.

Characterization of Circulating Tumor Cells Using Imaging Flow Cytometry in Liver Disease Patients.

Background: Hepatocellular carcinoma (HCC) is asymptomatic at an early stage which delays its timely diagnosis and treatment. Circulating tumor cells (CTCs), derived from a primary or secondary tumor, may help in the management of HCC. Here, we evaluate and characterize CTCs in liver disease patients. Methods: In total, 65 patients, categorized into liver cirrhosis (LC) (n = 30) and HCC (n = 35), were enrolled. Using ImagestreamX MkII imaging flow cytometer, CTCs were detected and characterized using biomarker expression of EpCAM, CK, AFP, CD45, and DRAQ5 in LC and HCC patients. Results: CTCs were detected in 33/35 (94%) HCC patients and in 28/30 (93%) LC patients. In the HCC group, the number of biomarker-positive CTCs was higher in BCLC stage D when compared with others. EpCAM + CK was the most expressed biomarker on CTCs in LC versus HCC (83.3% vs. 77.14%), followed by AFP (80% vs. 65.71%), EpCAM (30% vs. 28.57%), and CK (16.6% vs. 14.28%). The EpCAM cell area was significantly associated (P value = 0.031) with the CTC-positive status. The combination biomarker expression of CTCs cell area (EpCAM, CK, and AFP) performed well with the area under the curve of 0.92, high sensitivity, and specificity in detecting early-stage and AFP-negative HCC as well as in AFP-negative LC cases. Conclusion: Enumeration and cell area of CTCs may be used as a biomarker for early detection of HCC and guiding treatment.

Predictors of Severity and Mortality in Chronic Liver Disease Patients With COVID-19 During the Second Wave of the Pandemic in India.

Background Coronavirus disease 2019 (COVID-19) infection in chronic liver disease patients is associated with poor outcomes. In this study, we aimed to evaluate the predictors of severity and mortality in this group of patients during the second wave of the COVID-19 pandemic in India. In addition, we compared cirrhotic patients with COVID-19 with cirrhotic patients from the pre-COVID-19 period. Methodology This was a single-center observational study. We included data from 50 patients with cirrhosis and COVID-19 retrospectively from the discharge/death files. A comparison group of 100 patients with cirrhosis from the pre-COVID period was also analyzed retrospectively. Results The majority of patients had predominantly respiratory symptoms, with fever being the most common symptom (85%). The most common presentation was acute on chronic liver failure (ACLF). The most common form of decompensation was jaundice followed by hepatic encephalopathy. The overall mortality in cirrhotic patients with COVID-19 was double than that in cirrhotic patients from the pre-COVID-19 period. All patients with ACLF succumbed to multiorgan failure. Diabetes was the only comorbidity that was associated with severe infection. Higher creatinine on admission and high D-dimer levels correlated with severity. D-dimer was the only parameter that correlated with severity and mortality on multivariate analysis. None of the comorbidities predicted mortality. Among various composite scores, the Child-Turcotte-Pugh (CTP) score and CURB-65 correlated with mortality. On the area under the receiver operating characteristic analysis, a D-dimer level of >1.1 mg/L was associated with mortality. Conclusions COVID-19 infection in patients with cirrhosis is associated with poor outcomes. D-dimer levels of >1.1 mg/L on admission are a simple parameter to predict mortality. CTP and CURB-65 are composite scores that correlate with mortality in this group of patients.

Normal Values of High-resolution Anorectal Manometry of Healthy Indians.

Background/Aims: High-resolution anorectal manometry (HRAM) measures anal sphincter function and anorectal co-ordination. This study aims to provide normal data for HRAM and evaluate the effect of gender, age, and body mass index (BMI) on anorectal functions in healthy Indian subjects. Methods: HRAM was performed on 93 healthy volunteers using a 20-channel, water-perfused catheter. We evaluated anorectal pressures, rectal sensation, and balloon expulsion time. Measurements were recorded during rest, squeeze, and simulated defecation (push). Results: Median anal resting pressure (88 mmHg vs 94 mmHg, P = NS), anal squeeze pressure (165 mmHg vs 147 mmHg, P = NS) were not significantly different between males and females. Rectal pressure (70 mmHg vs 54 mmHg, P = 0.024) and anal pressure (82 mmHg vs 63 mmHg, P = 0.008) during simulated evacuation without rectal distention, were higher in males. The threshold for the first sensation was lower in females (40 mL vs 30 mL, P = 0.021) but desire to defecate (105 mL vs 90 mL, P = NS) and maximum tolerable volume (160 mL vs 140 mL, P = NS) were not significantly different in males and females. Anal residual pressure (median mmHg 83 vs 71 mmHg, P = 0.025) was higher in subjects < 40 years of age. Maximum anal squeeze pressure (185 mmHg vs 165 mmHg, P = 0.024) and maximum rectal pressure (75 mmHg vs 62 mmHg, P = 0.032) during push higher in BMI < 23 kg/m2. Conclusions: The present study provides normal data for the Indian population that can be used for comparison and further work. Age, gender, and BMI affect anorectal parameters in HRAM and should be considered while reporting.

Adult-onset Kawasaki disease: A great masquerader.

Kawasaki disease is a necrotising small-to-medium vessel vasculitis affecting children between age groups of 6 months and 5 years. Following the first description in Japanese infants, it has been recognised as the single most common cause of non-infectious vasculitis in children worldwide. Presentation in adult age groups, although described, is rare. Herein, we report a case about a 19-year-old female Indian patient diagnosed with Kawasaki disease and managed with antiplatelets and intravenous immunoglobulin, without further sequalae. We aim to highlight the importance of recognising this entity in adult age groups in day-to-day clinical practice.

Acute viral hepatitis E complicated with acute pancreatitis in an immunocompetent adult.

Acute viral hepatitis has been associated with several extrahepatic complications. Fulminant liver failure secondary to acute viral hepatitis may be complicated by acute pancreatitis. However, in the setting of benign viral hepatitis, in the absence of liver failure, association of pancreatitis is uncommon, that too in an otherwise immunocompetent individual. The exact mechanism of hepatitis-related pancreatitis remains elusive. Proposed mechanisms include immune-mediated injury against infected pancreatic acinar cells, oedema of the ampulla of Vater and release of lysosomal enzymes from the liver. A high index of clinical suspicion is needed in any case of viral hepatitis with severe abdominal pain to recognise acute pancreatitis as a possible complication, which may increase both morbidity and mortality if unrecognised. Herein, we report a case of a young man presenting with acute viral hepatitis due to hepatitis E infection, complicated by acute pancreatitis.

Clostridioides difficile-induced diarrhoea following dasatinib therapy.

Dasatinib, an oral tyrosine kinase inhibitor, is approved for therapy of chronic myeloid leukaemia (CML). Common adverse effects of this therapy include myelosuppression, fluid retention and diarrhoea. However, Clostridioides difficile infections (CDIs) in the context of dasatinib therapy, without a history of antecedent antibiotic use, has not been reported previously. We present here a case of a 36-year-old man diagnosed with accelerated phase of CML, who was started on treatment with dasatinib. Two months into therapy, he experienced profuse diarrhoea and abdominal pain. Colonoscopy revealed multiple confluent colonic mucosal ulcerations. Immunoassay study of stool revealed positive C. difficile toxin. The patient was started on oral metronidazole, with discontinuation of all other drugs, including dasatinib. He made a complete uneventful recovery following 2 weeks of antibiotic therapy. Chemotherapeutic agents, such as dasatinib, should be considered as possible etiological agents in the pathogenesis of CDI, even in absence of antibiotic use.

Primary pancreatic tuberculosis with a duodenal fistula in an immunocompetent young man.

Tuberculosis (TB) is a common disease in developing countries that can virtually affect any organ in the body. The abdomen is one of the most common sites for extra-pulmonary tuberculosis. Primary Pancreatic tuberculosis (PPTB) is rare and can be clinically elusive. It is commonly encountered in immunodeficient individuals in regions endemic for TB. However, it is extremely rare in immunocompetent individuals with very few case reports in the literature. We describe a case of PPTB in an immunocompetent young man complicated with duodenal fistula. There was complete resolution of symptoms and the fistulous tract with a significant reduction of the size of the lesion on imaging after 6 months of anti-tubercular therapy (ATT).

Screening of Family Members of Nonalcoholic Fatty Liver Disease Patients can Detect Undiagnosed Nonalcoholic Fatty Liver Disease Among Them: Is There a Genetic Link?

BACKGROUND & AIMS: Nonalcoholic fatty liver disease (NAFLD) has multifactorial origin. Genetic and environmental factors lead to the biology of this complex disorder. In this study, we screened parents of cases with NAFLD and compared them with parents of cases without NAFLD to see its familial aggregation and the role of patatin-like phospholipase domain containing 3 (PNPLA3). METHOD: It was a cross-sectional study. Parents of probands with NAFLD and without NAFLD were screened with abdominal sonography, anthropometry, blood tests, transient elastography, and PNPLA3 polymorphism. RESULTS: We had enrolled 303 individuals: 51 probands with NAFLD, 50 probands without NAFLD, and their 202 parents. Parents of the NAFLD group had significantly higher metabolic risk factors as compared with parents of the non-NAFLD group. They had a significantly higher rate of fatty liver (P = 0.0001), mean serum aspartate aminotransferase levels (P = 0.011), mean serum alanine aminotransferase levels (P = 0.001),raised fasting and postprandial blood sugar levels, lower mean platelets (P = 0.033) and serum albumin levels (P = 0.005), and higher mean liver stiffness (P = 0.001) on transient elastography.Frequency of PNPLA3 polymorphism within NAFLD group was higher compared to the non-NAFLD group (mutant GG-13.3 vs 3.3%). Similarly, parents of NAFLD group had mutant GG in 15 % versus 5% in parents of non-NAFLD group, (P = 0.105, odds ratio 6), though it was not statistically significant but may be relevant. In this study, offsprings of parents with nonalcoholic steatohepatitis were likely to have GG homozygous allele. A NAFLD16 score based on parent's parameters was calculated to predict the probability of NAFLD occurrence in an overweight obese individual. CONCLUSION: Screening of parents of individuals with NAFLD will help in the identification of undiagnosed NAFLD cases and other metabolic risk factors among them as there is a familial aggregation of NAFLD. One can predict the occurrence of NAFLD in the next generation using the NAFLD16 score.

Complete hemogram: simple and cost-effective in staging and predicting outcome in acute pancreatitis.

BACKGROUND: An important goal in management of acute pancreatitis (AP) is early prediction and recognition of disease severity. Various predictive scoring systems are in clinical use with their own limitations and there is always a quest for simple, practical, quantifiable, dynamic and readily available markers for predicting disease severity and outcome. Complete hemogram is routinely ordered in all patients with AP. In recent years red cell distribution width (RDW), neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR) and platelet lymphocyte ratio (PLR) have been found to be independent predictors of prognosis in various benign and malignant conditions. This prospective study evaluated complete hemogram based markers in AP. MATERIAL AND METHODS: Complete hemogram analysis was done and NLR, LMR, PLR values were calculated. Development of organ failure, the need for intensive care unit (ICU) admission and interventions, development of complications (local/systemic) and 100-day mortality were assessed. RESULTS: In this study 160 subjects of AP were included. Complete hemogram analysis was performed within 24 h after admission. C­reactive protein, RDW, NLR, PLR and bedside index of severity in acute pancreatitis (BISAP) values were higher in severe AP than moderate AP group than mild AP group, while LMR values were decreased in the corresponding severe, moderate and mild AP groups (p < 0.001). The NLR performed best for prediction of ICU admission, organ failure, interventions and mortality with area under receiver operating curve (AUROC) were 0.943, 0.940, 0.902 and 0.910, respectively. CONCLUSION: Hemogram based markers are simple, objective, dynamic and readily available. They can be considered in addition to conventional multifactorial scoring systems for prediction of outcome and prognosis of AP.