Synchronous pancreatic and scrotal tuberculosis: Double jeopardy.

We describe a patient who presented with scrotal swelling followed by non-healing and discharging scrotal sinuses, following local trauma and was initially suspected to have an infected scrotal hematoma. An evaluation revealed it to be scrotal tuberculosis. He also complained of upper abdominal pain and on transabdominal ultrasonography was detected to have a mass in the head of the pancreas. Evaluation of the pancreatic mass revealed it to be pancreatic tuberculosis. Both lesions responded well to anti-tubercular therapy. This is an unusual case of two rare sites of extrapulmonary tuberculosis presenting simultaneously in the same individual. Care needs to be exercised while evaluating any non-healing ulcers or sinuses and mass lesions in countries endemic for tuberculosis as this disease can be a great masquerader.

Thermostable xylanase derived from Trichoderma citrinoviride increases growth performance and non-starch polysaccharide degradation in broiler chickens.

1. The aim of this trial was to determine the optimal supplementation level of a xylanase enzyme from Trichoderma citrinoviride on growth performance, apparent ileal and total tract nutrient retention, intestinal morphology, and intestinal concentration of volatile fatty acids in broiler chickens.2. A total of 600 broiler chickens (Ross 308) of mixed sex were randomly allotted to four treatments, on the basis of similar body weight. The dietary treatments were made from a corn-wheat-soy based diet supplemented with either 0, 3750, 7500, or 11 250 XU/kg xylanase and were fed to 32 d of age.3. A linear response to increasing dietary xylanase was demonstrated for overall weight gain (P < 0.05) and feed conversion ratio (P < 0.05). The apparent total tract digestibility of dry matter and gross energy, and the coefficient of apparent ileal digestibility (CIAD) of N and soluble non-starch polysaccharides were linearly improved when xylanase was added to the diet (P < 0.05). Moreover, a linear increase (P < 0.05) was observed in the CIAD of Arg, Lys, and Try with increasing dietary levels of xylanase.4. The viscosity of digesta in ileum was linearly decreased when dietary xylanase level increased (P < 0.05).5. An increase in villus height of the duodenum and jejunum were observed with increasing dietary levels of xylanase (linear, P < 0.05).6. Overall, the results showed that the effects of dietary xylanase supplementation on broiler performance was determined through effects on nutrient availability and intestinal morphology.

Clinical and equipment-related factors associated with the adequate peripheral blood stem cell collection in autologous transplant at a tertiary cancer center in Kerala - A retrospective cohort study.

BACKGROUND: PBSC collection using apheresis is the preferred source of hematopoietic stem cells transplantation. However, apheresis procedures fail to harvest adequate CD34 yield in 5 to 40% of patients during the first collection. Therefore, this study aimed to study both the clinical- and equipmentrelated factors influencing CD34 yield among the autologous patients and to compare the collection efficiency of two apheresis equipments(Haemonetics MCS+ and Terumo Spectra Optia). METHODS: Retrospective analysis of 69 patients underwent PBSC collection from 2015 to 2018. Frequency, clinical- and equipment-related factors responsible for adequate CD34+ cells (≥2 x106 cells/kg) yield during the first collection was studied. Factors such as collection efficiency, percentage platelet loss and percentage hemoglobin loss were considered to compare the two apheresis system. RESULTS: Two-third (72%) patients of the study population had adequate CD34 stem cells yield during the first collection. Factors such as exposure to lenalidomide-based pretreatment regimen, peripheral blood WBC count and CD34 count are associated with the adequate CD34 yield. Optia had a slightly better collection efficiency than MCS+ (50 and 44; p=0.37). Optia had lower product volume (237 vs 298 ml) and lesser procedure duration (277 vs 360 min), whereas the median Hb loss (3.0% and 2.3%) and mean platelet loss (49% and 34%) were higher with MCS. CONCLUSION: This study infers that the collection efficiency of both the equipments in collecting CD34 stem cells was similar. However, during PBSC collection, procedures using Optia can be preferred to MCS+ on the patients with risk of anemia and thrombocytopenia.

Prevalence of gastro-esophageal reflux disease in patients with difficult to control asthma and effect of proton pump inhibitor therapy on asthma symptoms, reflux symptoms, pulmonary function and requirement for asthma medications.

BACKGROUND: The hypothesis that GER can trigger or exacerbate asthma is supported by several clinical trials that have shown amelioration in asthma symptoms and/or an improvement in pulmonary function after antireflux therapy. AIMS: To investigate the prevalence of GER in patients with difficult to control asthma and to determine the effect of omeprazole on asthma symptoms, reflux symptoms, pulmonary function and on the requirement of asthma medications. MATERIALS AND METHODS: Patients with difficult to control asthma were recruited into the study. All patients underwent esophageal manometry and 24 hour esophageal pH monitoring. Pulmonary function tests were done before and after treatment. The severity of asthma and reflux was assessed by a 1 week pulmonary symptom score(PSS) and reflux symptom score(RSS) respectively before and after treatment. Those who had an abnormal pH study (pH <4 in the distal esophagus for >5% of the time) underwent anti-GER treatment with lifestyle changes, and a proton pump inhibitor (omeprazole 40 mg, bid) for 3 months. Asthma medications were added or deleted based on severity of asthma. RESULTS: Out of 250 asthmatic patients screened, forty patients fulfilled the inclusion criteria. Twenty eight of 40 patients(70%) were diagnosed to have GERD. Of the patients 28 with GER, 8 patients(28.5%) had no reflux symptoms. On 24 hr pH metry, the percentage time pH <4.0 was 10.81 ± 4.72 and 1.11 ± 1.21; Deemester score was 37.65 ± 14.54 and 4.89 ± 6.39 (p-value is 0.0001) in GERD and non-GERD patients respectively.In GERD group, post treatment reflux symptom score(RSS) improved from 22.39 ± 14.99 to 1.04 ± 1.07, pulmonary symptom score(PSS) improved from 27.14 ± 7.49 to 13.82 ± 4.21 and night time asthma symptom score(NASS) improved from 6.71 ± 1.80 to 3.04 ± 1.23 (p-value <0.0001). After treatment, FEV1 and PEFR increased from 1.38 ± 0.57 and 4.14 ± 1.97 to 1.47 ± 0.54 and 5.56 ± 1.72, respectively (p-value 0.00114). CONCLUSIONS: PPI therapy improves nocturnal asthma symptoms, daytime asthma symptoms, pulmonary function and decreases requirement of asthma medications in these patients.

Hepatitis C virus infection causes cell cycle arrest at the level of initiation of mitosis.

Chronic infection with the hepatitis C virus (HCV) is associated with increased risk for hepatocellular carcinoma (HCC). Chronic immune-mediated inflammation is likely to be an important factor in the development of HCV-associated HCC, but direct effects of HCV infection on the host cell cycle may also play a role. Although overexpression studies have revealed multiple interactions between HCV-encoded proteins and host cell cycle regulators and tumor suppressor proteins, the relevance of these observations to HCV-associated liver disease is not clear. We determined the net effect of these interactions on regulation of the cell cycle in the context of virus infection. Flow cytometry of HCV-infected carboxyfluorescein succinimidyl ester-labeled hepatoma cells indicated a slowdown in proliferation that correlated with abundance of viral antigen. A decrease in the proportions of infected cells in G(1) and S phases with an accumulation of cells in G(2)/M phase was observed, compared to mock-infected controls. Dramatic decreases in markers of mitosis, such as phospho-histone H3, in infected cells suggested a block to mitotic entry. In common with findings described in the published literature, we observed caspase 3 activation, suggesting that cell cycle arrest is associated with apoptosis. Differences were observed in patterns of cell cycle disturbance and levels of apoptosis with different strains of HCV. However, the data suggest that cell cycle arrest at the interface of G(2) and mitosis is a common feature of HCV infection.

Minimally Invasive Approach for Excision of Dorsolumbar Spine Osteoid Osteomas using 3D Imaging and Stealth Navigation: A Report of Two Cases.

Advantages of three-dimensional (3D) computed tomography-based navigation system has recently been used for safe, accurate, reliable spinal tumour excision. This study presents two cases, a 33-year-old male and a 17-year-old male presented in the clinic with mid-back and low back ache, respectively with change in posture. Radiology suggested an osteoid osteoma. Accurate localisation and complete extirpation of the lesion were performed using a translaminar approach with O-arm Navigation. After follow-up of one year, both did not complain of back pain or radiation, scoliosis had improved in both cases and their VAS was 0 and ODI was 0%. 3D navigation with the O-arm system provided an easy and accurate localisation of the lesion, reducing the risk of instability subsequently and avoiding instrumented stabilisation. This technique also provided for histopathological confirmation of the diagnosis.

Atypical histological features of ulcerative colitis.

INTRODUCTION: The diagnosis of ulcerative colitis is based on combination of clinical, endoscopic and pathological findings. However cases have been reported showing atypical endoscopic and histological features in ulcerative colitis. Hence the objective of this study was to determine the atypical features of new onset ulcerative colitis in adult population. METHODS: A total 110 newly diagnosed cases of ulcerative colitis were enrolled in the study over a period of five years. The diagnosis of ulcerative colitis was made by correlating clinical, endoscopic and histological features. Biopsies from representative areas were processed routinely. Endoscopic and histological evaluation was carried out for atypical features. RESULTS: Majority of the patients (75.4%) were between 21-50 years of age with male to female ratio of 2.2:1. A significant number of patients showed atypical endoscopic findings in the form of rectal sparing in 12 (10.9%) and skip lesions in 24 (21.8%) patients. Atypical features noted on histology included normal surface epithelium in 8 (7.3%), predominant polymorphs in 42 (38%), predominant eosinophils in 7 (6.3%), normal crypt architecture in 1 (0.9%) and well preserved goblet cells in 30 (28%) cases. CONCLUSION: A significant number of patients with new onset ulcerative colitis showed atypical pattern of disease endoscopically as well as histologically. Pathologists should be aware of these atypical findings in cases of ulcerative colitis so as to avoid misdiagnosis.

Serum biomarkers as an alternative to vibration controlled transient elastography in liver fibrosis staging in chronic hepatitis C.

Background: Assessment of liver disease severity in chronic Hepatitis C (CHC) is essential both in pretreatment and posttreatment period. We assessed the impact of direct-acting antiviral therapy on liver stiffness regression measured by Vibration Controlled Transient Elastography (VCTE) in patients with CHC and evaluated the diagnostic performance of the APRI and FIB-4 scores compared to VCTE in detecting advanced fibrosis and cirrhosis (F3/F4). Methodology: Retrospective analysis of consecutive patients with CHC who underwent VCTE before and after DAA therapy was done. APRI and FIB-4 scores were compared to VCTE. Results: 88 (56.78%) patients-12 (F3) and 76 (F4) according to VCTE, had advanced fibrosis pretreatment, which reduced to 69 (44.52%) - 10 (F3) and 59 (F4) after 12 weeks DAA therapy. Significant reduction in VCTE value from 14.08 ± 9.05 KPa to 11.84 ± 8.31 KPa (p=0.002) was noted. There is significant reduction in APRI, FIB-4 and GUCI score posttreatment which was not the case with Lok score and Bonacini score. Before therapy, FIB-4 outperformed others to predict advanced fibrosis with score >2.13 (AUC 0.93), having sensitivity 76%, specificity 96% and accuracy 86%. However posttreatment, APRI and GUCI score performed best to predict F3/F4 fibrosis with score >0.63 (AUC 0.97) and >0.64 (AUC 0.96), having sensitivity, specificity and accuracy of 85%, 96.6% and 92% ; 85%, 6.6% and 92% respectively. Conclusion: Before therapy, FIB-4 had the best accuracy in predicting advanced fibrosis whereas APRI and GUCI score were the best indices post-treatment.

Prevalence of nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus.

OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is commonly associated with type 2 diabetes mellitus (DM) though its prevalence is not well studied. We conducted a prospective study of prevalence and risk factors of NAFLD in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: 204 type 2 DM patients attending an out-patient diabetic clinic underwent abdominal sonography. Ninty of 127 patients with fatty infiltration on ultrasound consented for liver biopsy, clinical and biochemical workup. RESULTS: Eighty seven percent had NAFLD on histology with 62.6% steatohepatitis and 37.3% fibrosis. Age, duration of diabetes mellitus, degree of glycemic control, body mass index, waist circumference, family history of diabetes mellitus, did not predict the presence or severity of NAFLD or fibrosis. Serum alanine aminostranferase (ALT) and alkaline phosphatase levels, though within normal limits, were significantly higher in patients with steatohepatitis. Prevalence of NASH increased with increase in the components of the metabolic syndrome. Serum AST/ALT ratio were also significantly higher (p-0.049) in patients with severe fibrosis. All patients with severe fibrosis had metabolic syndrome. CONCLUSIONS: Prevalence of NAFLD and NASH in our cohort of type 2 DM patients is high and increases with multiple components of metabolic syndrome. NASH and advanced fibrosis can occur in diabetic patients without any symptoms, signs or routine laboratory test abnormalities.

Indomethacin dosing strategy and neonatal patent ductus arteriosus closure.

BACKGROUND: Few studies exist that have evaluated the effects of indomethacin dosing frequency as a factor associated with successful patent ductus arteriosus closure in very low birth weight neonates. The objective of this study is to determine if indomethacin dosing strategy is associated with efficacy for initial patent ductus arteriosus management in very low birth weight neonates. METHODS: This retrospective review compared every 12 hour and every 24 hour indomethacin regimens primarily for efficacy in initial patent ductus arteriosus management, defined as an absence of repeat medical and/or surgical treatment, and secondarily for safety in both univariate and multivariate models. RESULTS: One hundred three very low birth weight neonates were included: 56 (54%) received every 12 hour and 47 (46%) underwent every 24 hour indomethacin dosing. Repeat medical and/or surgical patent ductus arteriosus treatment rates were similar between groups. Less ligation of the patent ductus arteriosus occurred with every 12 hour versus every 24 hour dosing (11% vs. 26%, p = 0.05), though this effect was mitigated controlling for birth weight and gestational age. Renal function, respiratory outcomes, feeding outcomes, length of stay, and mortality were similar between groups. CONCLUSIONS: Neither the every 12 hour nor the every 24 hour indomethacin regimen demonstrated inferior efficacy or safety for initial management of patent ductus arteriosus. Further prospective analysis of indomethacin dosing strategy is warranted.

Transjugular liver biopsy using Tru-cut biopsy needle: KEM experience.

BACKGROUND AND AIM: Transjugular liver biopsy is accepted procedure in patients in whom percutaneous liver biopsy is contraindicated. We report our experience with this procedure, its indications, efficacy and safety in Indian population over 5 years. MATERIAL & METHODS: A retrospective study of 145 consecutive patients who had undergone transjugular liver biopsy from May 2002 to Nov. 2007 was done from the database maintained in our department. We evaluated the indications, technical success, complication and impact of histological diagnosis on the management of those patients. RESULTS: 145 Transjugular liver biopsies were performed of which 74 were males and 71 were females aged between 5 and 74 years. Two procedures were abandoned due to failed hepatic vein cannulation because of venous occlusion. Out of 143 biopsies, 4 were inadequate while 139 yielded adequate tissue for histopathological diagnosis. Histopathological examination in our study showed cirrhotic changes in 56, hepatitis including both acute and chronic in 48, periportal fibrosis in 9, Wilson's disease in 5 and obstructive cholangiopathy in 2 patients. The remaining 19 were normal. Minor complications occurred in 2 patients. CONCLUSION: Transjugular liver biopsy is a safe procedure in the trained hands and provides adequate tissue for diagnosis when percutaneous liver biopsy is contraindicated.

Inclusion of dietary ß-mannanase improves performance and ileal digestibility and reduces ileal digesta viscosity of broilers fed corn-soybean meal based diet.

This study was aimed to evaluate the influence of dietary ß-mannanase inclusion on growth performance, apparent ileal digestibility, digesta viscosity, blood metabolites and excreta noxious gas emissions in broilers fed corn-soybean meal based diet. A total of 600 conventional healthy 1-d-old ROSS 308 broilers with body weight 45 ± 0.50 g (mean ± SD) were randomly assigned to 4 dietary treatments with 10 replicates cages, with 15 broilers in each and fed basal diet supplemented to corn-SBM based diets with 0, 2400, 4800, and 7200 MNU ß-mannanase/kg for 35 d feeding trial period. Significant results were observed on improved average daily gain and reduced feed conversion ratio during trial period and also reduced ileal digesta viscosity and improved apparent ileal digestibility of dry matter, nitrogen and energy. However, no significant effects were found on blood urea nitrogen and creatinine, excreta noxious gas emissions. In conclusion, the inclusion of dietary ß-mannanase had potential to improve daily gain and feed efficiency and apparent ileal digestibility while decreasing digesta viscosity of broiler.

Colonic lithobezoar.

We report a four-year-old girl with large number of stones in the colon presenting with subacute intestinal obstruction.

Achalasia cardia dilatation using polyethylene balloon (Rigiflex) dilators.

OBJECTIVE: Results of 20 dilatation sessions in 15 patients with achalasia cardia were assessed to determine the safety and efficacy of polyethylene balloon achalasia dilators (Rigiflex). METHODS: All patients underwent an initial dilatation by inflating a 30 mm balloon to 9 psi for one minute. Need for subsequent dilatations was assessed on symptom assessment; 35 mm balloon was used for repeat procedure. RESULTS: Overall success rate was 93.3%. The 30 mm balloon achieved a satisfactory result in 73.3% and the 35 mm balloon in 75% of the remainder. Only one patient needed surgery. No short-term complications were observed. The only late complication encountered over an average follow-up period of 16.2 months was gastroesophageal reflux in two patients. CONCLUSIONS: Dilatation using Rigiflex dilators is a safe, effective and simple procedure for treating patients with achalasia.

Asymptomatic spinal tuberculosis presenting as esophageal stricture.

Esophageal tuberculosis is rare and is usually due to secondary extension from contiguous structures. We report a patient who presented with dysphagia and was found to have esophageal stricture. Endoscopic biopsy was not suggestive of malignancy or tuberculosis. CT scan of the thorax revealed involvement of the fourth thoracic vertebra with paratracheal lymphadenopathy. The patient responded to anti-tubercular therapy.

Spectrum of liver diseases in HIV infection.

BACKGROUND: Most earlier reports on the spectrum of liver diseases in HIV-infected individuals originated from the West. OBJECTIVE: To study the spectrum of liver diseases in HIV-infected individuals. METHODS: Seventy four consecutive HIV-positive patients (57 men; age range 23-75 years, mean 34) were studied prospectively with clinical evaluation, liver function tests, ultrasonography, radioisotope liver scan, markers of hepatitis B (HBV) and C (HCV) viruses, and liver histology whenever necessary. RESULTS: Thirty four patients (45%) were chronic alcoholics. Mean (SD) absolute lymphocyte count was 2521 (1271)/mm3; count < 2000/ mm3 was present in 20 patients. Serum bilirubin, transaminases and alkaline phosphatase levels were elevated in 13%, 13% and 24% of patients, respectively. Ultrasonography detected an abscess in two patients (tuberculous-1, amebic-1). Evidence of exposure to HBV was present in 81% (HBsAg-12, hepatitis B core and/or surface antibody-48); anti-HCV antibody was positive in 29.7%. Five patients with liver tuberculosis (granuloma-4, abscess-1) had AFB either in liver tissue or lymph nodes. CONCLUSION: Chronic alcoholism, HBV and HCV infection, hepatic tuberculosis, and evidence of other liver disease were common in patients with HIV infection.

PIP: A prospective study of 74 consecutive HIV patients (mean age, 34 years) at a public hospital in Mumbai, India, found evidence of hepatitis B and C virus, hepatic tuberculosis, and other liver disease. Clinical evaluation, liver function tests, ultrasonography, radioisotope liver scan, hepatitis B and C virus markers, and liver histology were performed. 34 patients (45%) were classified as chronic alcoholics on the basis of a history of consumption of at least 80 g of alcohol daily for at least 5 years and test findings. 59 (80%) had a history of multiple sex partners or encounters with commercial sex workers. 12 patients (16%) were hepatitis B surface antigen-positive and 22 (30%) were positive for hepatitis C virus antibody. Bilirubin, transaminases, and alkaline phosphatase were elevated in 13%, 13%, and 24%, respectively. Liver cirrhosis was present in 5 patients. Hepatitis B virus was detected in 4 patients and dual hepatitis B and C infection was found in another patient. Finally, 5 patients had liver tuberculosis. The mean absolute lymphocyte count was 2521/cu. mm; only 20 had a count indicative of immunosuppression (2000/cu. mm). These findings confirm that hepatic effects are a major feature of HIV infection in India.

Primary gastric lymphoma in a boy.

Primary gastric lymphoma is an extremely uncommon entity in children, and diffuse large-cell-type lymphoma in this age group is still rarer. An 11-year-old boy with primary gastric lymphoma who responded to CHOP regime is reported.

Bleeding duodenal varix in splenic vein thrombosis and chronic pancreatitis.

Isolated duodenal varix is rare. We report a patient with bleeding duodenal varix with splenic vein thrombosis due to chronic pancreatitis.

Endoscopic sclerotherapy in children with extrahepatic portal venous obstruction.

BACKGROUND: Extrahepatic portal vein obstruction (EHPVO) is a common cause of variceal bleeding in children in India. There is paucity of data regarding the results of treatment with endoscopic sclerotherapy. METHODS: Fifty-nine children (mean age 11 +/- 3.8 years; range 7 months to 12 years; 36 males and 23 females) were studied from February 1990 to September 1999. EHPVO was diagnosed on the basis of portal cavernoma on ultrasonography in 55 patients and on splenoportovenogram in 4 patients. Endoscopic sclerotherapy was caried out at weekly intervals for the first three weeks and at 3 weekly intervals thereafter till complete or near complete thrombosis was achieved. All patients were followed up with check endoscopy every 3-6 months after thrombosis of oesophageal varices. RESULTS: Over a mean follow up of 25.4 months (range 3 to 87 months) total thrombosis was achieved in 53 (89.8%) of 59 children. The mean number of sclerotherapy sessions required were 7.5 +/- 2.2. The mean number of blood transfusions required per bleeding episode was 3.8 +/- 3.2. Of the 59 children 21 (35.6%) rebled, of which 17 (28.8%) bled during and 4(6.8) after thrombosis of varices. Seven (11.9%) children had more than one episode of bleeding. Once thrombosis of the varices was achieved 15 (26%) of 59 children developed fresh varices on follow up. Gastric varices were detected in 47 (60%) children. In 39 (66%) children it was present at the onset and in 8 (13.5%) children it developed after thrombosis of oesophageal varices. Bleeding from gastric varix occurred in 7(9%) children. Ascites developed in 6(10.6%) children. One child developed oesophageal stricture. There were 3 (5%) deaths. Two died due to upper gastrointestinal bleed while on sclerotherapy schedule and one died due to cerebral abscess. CONCLUSION: EHPVO is an important and common cause of upper gastrointestinal bleeding in children in Western India. EST is safe and useful in controlling oesophageal variceal bleeding in children.