Evidence of a Hardening in the Cosmic Ray Proton Spectrum at around 166 TeV Observed by the GRAPES-3 Experiment

We present the measurement of the cosmic ray proton spectrum from 50 TeV to 1.3 PeV using 7.81×10^{6} extensive air shower events recorded by the ground-based GRAPES-3 experiment between 1 January 2014 and 26 October 2015 with a live time of 460 day. Our measurements provide an overlap with direct observations by satellite and balloon-based experiments. The electromagnetic and muon components in the shower were measured by a dense array of plastic scintillator detectors and a tracking muon telescope, respectively. The relative composition of the proton primary from the air shower data containing all primary particles was extracted using the multiplicity distribution of muons which is a sensitive observable for mass composition. The observed proton spectrum suggests a spectral hardening at ∼166  TeV and disfavors a single power law description of the spectrum up to the Knee energy (∼3  PeV).

Significant enhancement in the cold emission characteristics of chemically synthesized super-hydrophobic zinc oxide rods by nickel doping

The current article presents a huge enhancement in the field emission characteristics of zinc oxide (ZnO) micro/nanorods by nickel doping. The synthesis of pure and nickel-doped zinc oxide (ZnO) micro/nanorods was done by a simple low-temperature chemical method. Both the as-prepared pure and doped samples were analyzed by X-ray diffraction and electron microscopy to confirm the proper phase formation and the developed microstructure. UV-vis transmittance spectra helped in determining the band gap of the samples. Fourier-Transform Infrared Spectroscopy (FTIR) spectra showed the different bonds present in the sample, whereas X-ray Photoelectron Spectroscopy (XPS) confirmed the presence of nickel in the doped sample. Photoluminescence (PL) spectra showed that after doping, the band-to-band transition was affected, whereas defect-induced transition had increased significantly. After the nickel doping, contact angle measurement revealed a significant decrease in the sample's surface energy, leading to a remarkably high water contact angle (within the superhydrophobic region). Simulation through ANSYS suggested that the doped sample has the potential to function as an efficient cold emitter, which was also verified experimentally. The cold emission characteristics of the doped sample showed a significant improvement, with the turn-on field (corresponding to J = 1 μA cm-2) reduced from 5.34 to 2.84 V μm-1. The enhancement factor for the doped sample reached 3426, approximately 1.5 times higher compared to pure ZnO. Efforts have been made to explain the results, given the favorable band bending as well as the increased number of effective emission sites.

Tracking Changes in Global Longitudinal Strain in Lung Cancer Patients Receiving Thoracic Radiation

PURPOSE/OBJECTIVE(S)

Thoracic radiation improves survival in many lung cancer patients. However, radiation-induced cardiotoxicity is a major source of morbidity and mortality in such patients. Global longitudinal strain (GLS), a novel echocardiography (ECHO) method of assessing left ventricular function, has been shown to predict long-term adverse cardiovascular risk in diverse patient populations. We hypothesized that receipt of thoracic radiation is associated with GLS changes in lung cancer patients.

MATERIALS/METHODS

We retrospectively identified patients with lung cancer treated at our institution between 2005-2020 who had ECHOs performed both before and after RT, and in whom GLS was extractable. ECHO Board-Certified cardio-oncologists measured GLS and left ventricular ejection fraction (LVEF) from these ECHOs.

RESULTS

A total of 40 patients met inclusion criteria. Median time to ECHO was 78 days prior and 172 days after RT. Two chamber (2C), 3C, 4C, and average GLS were significantly decreased after RT on paired t-test [mean difference (SD) 2.23 (3.29), 2.99 (2.78), 2.25 (3.63), 2.51 (2.66) respectively, all p < 0.001]. Thirteen patients (32.5%) had abnormal GLS (<18%) prior to RT. 5 of those 13 patients (38.5%) had abnormal LVEF (< 50%). 27/40 patients (67.5%) had an abnormal GLS or clinically significant (≥15%) drop in GLS after RT. This difference (32.5% patients pre-RT vs 67.5% post-RT) was statistically significant (p < 0.01). Among patients (n = 27) who had normal LVEF before RT, 1 patient (3.7%) developed abnormal LVEF (<50%) after RT. Backwards logistic regression showed significant interaction between heart volume receiving 5 Gray and change in GLS.

CONCLUSION

This cohort exhibited a significant decrease in 2C, 3C, 4C, and average GLS after RT. ∼1/3 of patients had abnormal GLS at baseline (suggesting a high-risk group for cardiac complications) and 67.5% of patients had clinically significant decrease in GLS after RT. Among the patients with normal GLS before RT, although 51.9% of patients demonstrated a clinically significant drop in GLS after RT, only 3.7% of patients developed abnormal LVEF, suggesting that this is a late occurrence. GLS changes may serve as a valuable tool for early identification of patients who are at high risk for future cardiac complications after receiving thoracic radiation.

Primary malignant melanoma of the gall bladder masquerading as xanthogranulomatous cholecystitis

Malignant melanoma of the gall bladder is rare. Most cases are metastatic and primary gall bladder melanoma is even more rare. We report a case of primary malignant melanoma of the gall bladder which illustrates the diagnostic challenge posed by this condition. Histopathology and immunohistochemistry play a pivotal role in making a diagnosis and ruling out conditions which mimic it such as xanthogranulomatous cholecystitis and other relatively common epithelial malignancies. We tested for prognostic and predictive markers including BRAF and PD-L1 and immunohistochemistry showed positive staining for BRAF. The tumour cells expressed HMB-45 and were negative for cytokeratin and CD68, favouring a diagnosis of malignant melanoma and excluding the possibility of xanthogranulomatous cholecystitis and carcinoma. On follow-up at 3 months there was no evidence of recurrence of metastasis.

Heterodimerization of cholecystokinin 1 and cholecystokinin 2 receptors in gallbladder cancer: a new mechanism for carcinogenesis

PURPOSE

Cholecystokinin is present in abundance in gallbladder tissue and mediates function through two structurally related receptors, CCK1R and CCK2R. Heterodimerization of these receptors is known to impact cell growth in vitro. However, the significance of these heterodimers in gallbladder carcinogenesis is relatively unknown.

METHODS

Therefore, we evaluated the expression and the dimerization status of CCK1 and CCK2 receptors in human gallbladder carcinoma cell line (GBC-SD) and resected gallbladder tissue from normal (n = 10), cholelithiasis (n = 25) and gallbladder cancer (n = 25) by immunofluorescence/immunohistochemistry and western blot. The dimerization status of CCK1R and CCK2R was evaluated by co-immunoprecipitation. To understand the effect of heterodimerization of these receptors on growth-related signaling pathways, the expression of p-AKT, rictor, raptor and p-ERK was evaluated by western blot.

RESULTS

We demonstrated the expression and heterodimerization of CCK1 and CCK2 receptor in GBC-SD gall bladder carcinoma cell line. Knockdown of CCK1R and CCK2R in the cell line led to significant reduction in p-AKT (P = 0.005; P = 0.0001) and rictor (P < 0.001; P < 0.001) levels. In tissue samples, significantly higher expression of CCK1R and CCK2R was observed in gallbladder cancer when compared to other groups both by immunohistochemistry (P = 0.008 and P = 0.013) and western blot (P = 0.009 and P = 0.003). An increase in heterodimer formation of CCK1R with CCK2R was observed in gallbladder cancer when compared to normal and cholelithiasis tissues. No significant difference in the expression of p-AKT and p-ERK was observed between the three groups.

CONCLUSION

Our results provide the first evidence of heterodimerization of CCK1R and CCK2R in gallbladder tissue, and its association with development of gallbladder cancer. This finding has potential clinical and therapeutic significance.

Synchronous pancreas and gallbladder cancer with concomitant alopecia totalis

A 55-year-old female presented with history of pain in the right hypochondrium along with complete loss of facial and scalp hair over last two months. On evaluation, she was found to have locally advanced, synchronous malignancies of the gallbladder and head of the pancreas. Synchronous malignancy of gallbladder and pancreas is in itself very rare and less than 10 such cases have been reported in the world literature. Alopecia totalis has been classically associated with various autoimmune disorders. However, alopecia totalis as a presenting feature of any abdominal malignancy has never been reported in the medical literature. The present report describes a rare association of synchronous pancreatobiliary malignancies with strange clinical presentation.

Gallbladder perforation: A single-center experience in north India and a step-up approach for management

BACKGROUND

Spontaneous gallbladder perforation (GBP) is an uncommon diagnosis. This study presented the experience of managing spontaneous GBP over nine years at a large, tertiary care university hospital in north India and investigated the outcomes and treatment strategies.

METHODS

A retrospective review of prospectively maintained digital database of consecutive patients was performed. All patients received medical and/or surgical treatment for spontaneous GBP in our department between January 2010 and June 2018.

RESULTS

We identified 151 patients (81 females and 70 males) with mean age of 53 years. Most common presenting features were pain (96.7%), fever (54.3%) and jaundice (31.1%). Most common cause was gallbladder stones (84.8%) followed by common bile duct stones (30.5%), xanthogranulomatous cholecystitis (17.9%) and malignancy (11.9%). As per Niemeier classification, 8.6% had type 1 GBP (free perforation in peritoneal cavity), 76.2% had type 2 GBP (localized perforation) and 13.2% had type 3 GBP (cholecysto-enteric fistula). About 60% of the perforations were diagnosed preoperatively. Type 1 was more common in patients with diabetes and also had the worst prognosis. Surgery was performed in 109 patients (72.2%). Seven patients (4.6%) had a postoperative morbidity of Clavien-Dindo III or higher. There were three mortalities in patients who underwent surgery.

CONCLUSIONS

High index of suspicion is required for preoperative diagnosis of GBP, especially in types 2 and 3. Laparoscopic cholecystectomy can be difficult in these patients and patients may require open or partial cholecystectomy. Early diagnosis and step-up approach for the treatment of GBP is critical.

Natural Orifice Endosonographic Colposuspension With Rectopexy for Combined Pelvic Organ Prolapse: A Feasibility Study

BACKGROUND

We describe a natural orifice technique for simultaneous endoluminal lateral suspension of apical vaginal wall and rectal prolapse fixation with ultrasound and fluoroscopic assistance.

IMPACT OF INNOVATION

The technique is minimally invasive, can be performed under regional anaesthesia, and avoids laparotomy or use of a mesh in addition to preserving the uterus.

TECHNOLOGY MATERIALS AND METHODS

This technique involves suprapubic transvaginal ventral suture colposuspension, fixation of the anterior rectal wall to the undersurface of the anterior abdominal wall and tack fixation of the posterior rectal wall to the underlying sacral promontory through a submucosal tunnel performed endoscopically with fluoroscopic and ultrasound assistance.

PRELIMINARY RESULTS

Seven patients with a mean age of 63 years were followed between 3 to 11 months.

CONCLUSIONS

This is a novel minimally invasive transluminal procedure that repairs concomitant rectal and vaginal prolapse in the same sitting.

FUTURE DIRECTIONS

Improvement in the instrument design and incorporation of endoluminal robotic systems will enhance the technical ease. The study needs validation in larger series of patients with longer follow-up.

Anatomage - the virtual dissection tool and its uses: A narrative review

Advancement in technology has given students and institutes an educational, interactive, and diagnostic aid with virtual reality functionality known as the Anatomage table. This review analyses the various spheres of the medical field where the 3D virtual tool is being used and assesses its acceptability, convenience, and practical application. A search for relevant studies in various databases namely Pubmed, Embase, Wiley Library, and Google Scholar was performed, and the data was compiled to understand the use of the Anatomage table. The search yielded a total of 24 studies that focused on the use of the Anatomage table. Eleven articles focused on using Anatomage as a learning tool and 13 described the perception of the Table. Anatomage table offers an excellent tool for learning anatomy by virtual dissection. The tool is not only used as a teaching aid, but also as a diagnostic and planning tool in residency programs. Adding the tool as an educational aid boosts the existing curriculum and helps to counter the challenges with cadaveric dissection. The equipment cost and its maintenance charges may be a deciding factor for the underutilization of the tool in developing countries.

Role of Epidermal Growth Factor Receptor in Gallbladder Carcinoma and its Association with Various Clinicopathological Parameters: A Cross-sectional Study

Introduction: Carcinoma of gallbladder is an aggressive disease with poor outcome. The Epidermal Growth Factor Receptor (EGFR) is a transmembrane receptor that regulate growth, proliferation and differentiation in cells. Increased EGFR receptor expression has been studied in various cancers like lung, colorectal, breast and pancreatic tumours and antiEGFR antibody has been used successfully for therapeutic and diagnostic purposes. Aim: To evaluate EGFR expression in gallbladder carcinoma and its association with clinicopathological factors to reveal its relation to prognosis. Methods and Methods: The present study was a crosssectional study in which 64 samples were collected of resected specimen of Gallbladder Carcinoma (GBC), from the Department of Pathology, King George’s Medical University, Lucknow, Uttar Pradesh, India, for a period of one year and six months. Haematoxylin-eosin-stained sections were evaluated for tumour type and histopathological grading and TNM staging was done. Immunohistochemistry (IHC) was performed and analysed prospectively using ready to use anti-EGFR as per manufacturer’s protocols. Association between EGFR expression and clinicopathological factors were statistically analysed using Statistical Package for the Social Sciences (SPSS) software version 21.0. Results: EGFR expression was positive in 81.25% (52/64) cases of GBC which showed a highly significant association between tumour grade and stage. About 60% of poorly differentiated GBC displayed strong (3+) staining intensity as compared to 30% of moderately differentiated (3+) and 10% of well differentiated tumours (3+). It suggests that with decreasing differentiation of tumour EGFR staining intensity increases (p<0.001). Positivity rate of EGFR expression were also increased with increase of tumour TNM stage (stage I to stage IV). Strong EGFR expression was associated with decreased overall survival with significant p value (p=0.031, log rank test). Conclusion: EGFR expression is inversely related with tumour differentiation, and overall survival. EGFR expression increases with high TNM staging. So, it can be used as prognostic marker for gallbladder carcinoma and opening a hope towards the new therapeutic options

Expression of Antimicrobial Peptides and Cytokines in Human Omentum Following Abdominal Surgery

Introduction

Omentum can secrete out biological agents like different growth factors, cytokines, and antimicrobial peptides. The aim of our study was to determine the expression of antimicrobial peptides and cytokines in human omentum tissue and its response to intra-abdominal infection.

Methodology

Omentum tissue was obtained from 60 patients: control (n=20) and cases (n=40). mRNA expression of antimicrobial peptides (LL-37, HBD-1, HBD-2, HNP1-3) and cytokines (TNF- α, IL-8, IL-10, IL1β) was evaluated using Real-Time PCR. Protein quantification was done by Immunoblotting and ELISA.

Results

Significantly higher expression of antimicrobial peptides (LL-37, HBD-1, HBD-2, HNP1-3) and cytokines (TNF- α, IL-8, IL-10, IL1β) was observed in cases as compared to control at both the transcriptional and translational level (p<0.0001).

Conclusion

Omentum governs a population of antimicrobial peptides with potent immunologic functions. The expression of antimicrobial peptides and cytokines is inducible and increases with the severity of infection. Omentum is thus an immunologically active and adaptable organ but its complete regulatory mechanism is still elusive.

Missed pancreatic injury in patients undergoing conservative management of blunt abdominal trauma: Causes, sequelae and management

Objective: Pancreas is a less commonly injured organ in blunt abdominal trauma. This study aimed to analyze the management and outcomes of patients in whom the pancreatic injury was missed during the initial evaluation of blunt abdominal trauma.

Material and Methods: We retrospectively (2009-2019) analyzed the details and outcome of patients who underwent conservative management of blunt abdominal trauma, where the diagnosis of pancreatic injury was missed for at least 72 hours following trauma.

Results: A total of 31 patients with missed pancreatic injury were identified. All patients were hemodynamically stable following trauma and most (21) were initially assessed only by an ultrasound. A delayed diagnosis of pancreatic injury was made at a mean of 28 (4 to 60) days after trauma when patients developed abdominal pain (31), distension (18), fever (10) or vomiting (8). On repeat imaging, 18 (58.1%) patients had high grade pancreatic injuries including complete transection or pancreatic duct injury. Seven (22.5%) patients were managed conservatively, seventeen (54.8%) underwent percutaneous drainage of intra-abdominal collections, seven (22.5%) underwent endoscopic or surgical drainage procedure for symptomatic pseudocyst. Eleven (35.4%) patients needed readmissions to manage recurrent pancreatitis, intra-abdominal abscess and pancreatic fistula. Three patients required pancreatic duct stenting for pancreatic fistula. There was no mortality.

Conclusion: Pancreatic injury may be missed in patients who remain hemodynamically stable with minimal clinical symptoms after abdominal trauma, especially if screened only by an ultrasound. In our series, there was significant morbidity of missed pancreatic injury.

Odderon Exchange from Elastic Scattering Differences between pp and pp[over ¯] Data at 1.96 TeV and from pp Forward Scattering Measurements

We describe an analysis comparing the pp[over ¯] elastic cross section as measured by the D0 Collaboration at a center-of-mass energy of 1.96 TeV to that in pp collisions as measured by the TOTEM Collaboration at 2.76, 7, 8, and 13 TeV using a model-independent approach. The TOTEM cross sections, extrapolated to a center-of-mass energy of sqrt[s]=1.96  TeV, are compared with the D0 measurement in the region of the diffractive minimum and the second maximum of the pp cross section. The two data sets disagree at the 3.4σ level and thus provide evidence for the t-channel exchange of a colorless, C-odd gluonic compound, also known as the odderon. We combine these results with a TOTEM analysis of the same C-odd exchange based on the total cross section and the ratio of the real to imaginary parts of the forward elastic strong interaction scattering amplitude in pp scattering for which the significance is between 3.4σ and 4.6σ. The combined significance is larger than 5σ and is interpreted as the first observation of the exchange of a colorless, C-odd gluonic compound.

Predictors and Outcomes of Pancreatic Fistula Following Pancreaticoduodenectomy: a Dual Center Experience

Fistula following leaked pancreatico-enteric anastomosis is a common, potentially lethal complication of pancreaticoduodenectomy (PD). Early assessment and prediction of its occurrence can improve postoperative outcomes. Various perioperative factors were analyzed for its contribution to clinically relevant postoperative pancreatic fistula (crPOPF). Also, the difference in clinical outcomes of patients with and without fistula was studied. Sixty-seven patients undergoing PD for malignancies were analyzed during 3-year period in a dual-institutional study. Various preoperative, intraoperative, and postoperative factors were assessed. The incidence and severity of POPF and its association with the development of other post-PD complications were observed. Patients with and without POPF were divided into groups and compared with univariate and multivariate analyses, to identify significant contributing factors. Clinically relevant POPF was present in 20.9% cases. crPOPF contributed to delayed gastric emptying, albeit insignificant (p = 0.403), but was significantly associated with increased incidence of post-pancreatectomy hemorrhagic (p = 0.005) and infectious complications (p = 0.013). Soft pancreas (p = 0.024), intraoperative blood loss (p = 0.045), blood transfusion (p = 0.024), and fistula risk score (p = 0.001) were significant predictors of crPOPF. First postoperative day (POD1) drain fluid amylase (DFA) values at cut-off of 1336 U/L (AUC = 0.871; p < 0.001) significantly predicted crPOPF with good sensitivity and specificity. POD1 DFA was only factor significant on multivariate analysis (p = 0.014). There was no significant difference in overall survival between groups. crPOPF results in significant post-pancreatectomy hemorrhagic and septic complications, along with increased mortality. It can be accurately predicted by several preoperative and intraoperative factors. POD1 DFA can independently predict crPOPF development.

Thyroid dysfunction and incident heart failure phenotypes among older adults: the atherosclerosis risk in communities (aric) study

Background/Introduction

Abnormal thyroid hormone concentrations have been associated with adverse cardiovascular outcomes, but the relationship between thyroid dysfunction and specific heart failure phenotypes is less clear.

Purpose

To examine the association of thyroid dysfunction with the risk of incident HF in older adults without pre-existing HF.

Methods

We analyzed participants enrolled in the Atherosclerosis Risk in Communities (ARIC) study who attended the visit 5 examination (2011–2013). Participants with previous HF history, and participants treated with amiodarone, levothyroxine, and antithyroid medication were excluded. We used Cox regression models to assess the associations between serum thyroid indices (free thyroxine [FT4], total triiodothyronine [TT3], or thyroid stimulating hormone [TSH]) and incident adjudicated HF with reduced (HFrEF) and preserved (HFpEF) left ventricular ejection fraction. Continuous associations between TT3 and outcome were further assessed via Cox model using restricted cubic spline.

Results

Among 3349 participants (mean age 75±5 years, 56% women, 20% black), subclinical hypothyroidism was prevalent in 12% of participants and low T3 syndrome in 3%. Those with overt hypothyroidism (&lt;1%) or hyperthyroidism (&lt;1%) were not included in the analysis given the low prevalence. Over a median follow-up of 5.5 years, incident HF occurred in 198 subjects (5.9%) at a rate of 11.1 per 1000 person-years. Of these, 86 were HFrEF, 83 HFpEF, and 29 were unclassified HF. We observed an inverse association of TT3 level with risk of incident HFpEF, but not overall incident HF or incident HFrEF, after adjustment for clinical confounders and baseline NT-proBNP levels (HR per 1 SD 0.70, 95% CI 0.54–0.92; P 0.010) (Figure). Similar results were observed for the composite endpoint of incident HFpEF or all-cause death. No statistically significant associations were found between TSH or T4 levels and incident HF. Low T3 syndrome was associated with incident HFpEF, but not overall incident HF or incident HFrEF, after adjustment for clinical confounders (HR 2.71, 95% CI 1.08–6.82; P 0.035); however, its association was significantly attenuated after adjustment with NT-proBNP (HR 2.25, 95% CI 0.87–5.79; P 0.09). No statistically significant association was found between subclinical hypothyroidism and incident HF.

Conclusions

In a contemporary biracial cohort of older adults, serum T3 level was inversely associated with incident HFpEF hospitalization. T3 administration could be considered as a potential target in future clinical trials preventing HFpEF hospitalization.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The Atherosclerosis Risk in Communities Study is performed as a collaborative study supported by National Heart, Lung, and Blood Institute contracts

The role of transoral fine needle aspiration in expediting diagnosis and reducing risk in head and neck cancer patients in the coronavirus disease 2019 (COVID-19) era: a single-institution experience

OBJECTIVE

The global coronavirus disease 2019 (COVID-19) pandemic has necessitated rapid alterations to diagnostic pathways for head and neck cancer patients that aim to reduce risk to patients (exposure to the hospital environment) and staff (aerosol-generating procedures). Transoral fine needle aspiration cytology offers a low-risk means of rapidly diagnosing patients with oral cavity or oropharyngeal lesions. The technique was utilised in selected patients at our institution during the pandemic. The outcomes are considered in this study.

METHOD

Diagnostic outcomes were retrospectively evaluated for a series of patients undergoing transoral fine needle aspiration cytology of oral cavity and oropharyngeal lesions during the COVID-19 pandemic.

RESULTS

Five patients underwent transoral fine needle aspiration cytology, yielding lesional material in 100 per cent, with cell blocks providing additional information. In one case, excision biopsy of a lymphoproliferative lesion was required for final diagnosis.

CONCLUSION

Transoral fine needle aspiration cytology can provide rapid diagnosis in patients with oral cavity and oropharyngeal lesions. Whilst limitations exist (including tolerability and lesion location), the technique offers significant advantages pertinent to the COVID-19 era, and could be employed in the future to obviate diagnostic surgery in selected patients.

Giant stentolith: A rare complication of long-dwelling biliary endoprosthesis

Endoscopic biliary stenting is performed for various indications in routine clinical practice. Plastic stents are indicated primarily for short-term biliary decompression and require removal or exchange after 12-16 weeks. However, patients who become asymptomatic after the procedure may not return for scheduled stent removal and subsequently present with severe complications. We herein present the case of a 57-year-old female who underwent biliary stenting after the endoscopic clearance of bile duct stones. Her symptoms resolved after the intervention, but she was lost to follow-up with the stent remaining in situ. Four years later, she presented with pain in the right hypochondrium and experienced recurrent episodes of cholangitis. Magnetic resonance cholangiopancreatography revealed a retained plastic stent in the proximal bile duct with a large stone cast around the stent-a stentolith. Owing to the large stone size and proximal migration of the retained biliary stent, the patient required open surgical exploration for stentolith removal. Patients with forgotten biliary stents presenting with serious complications are not uncommon in India. Unaware of the complications of long-dwelling biliary stents, patients ignore the advice for the timely removal of biliary stents. Detailed patient counselling, education and documentation are essential to avoid this condition.

Simulation of Brain Response to Noncontact Impacts Using Coupled Eulerian–Lagrangian Method

Finite element (FE) method has been widely used for gaining insights into the mechanical response of brain tissue during impacts. In this study, a coupled Eulerian−Lagrangian (CEL) formulation is implemented in impact simulations of a head system to overcome the mesh distortion difficulties due to large deformation in the cerebrospinal fluid (CSF) region and provide a biofidelic model of the interaction between the brain and skull. The head system used in our FE model is constructed from the transverse section of the human brain, with CSF modeled by Eulerian elements. Spring connectors are applied to represent the pia-arachnoid connection between the brain and skull. Validations of the CEL formulation and the FE model are performed using the experimental results. The dynamic response of brain tissue under noncontact impacts and the brain regions susceptible to injury are evaluated based on the intracranial pressure (ICP), maximum principal strain (MPS), and von Mises stress. While tracking the critical MPS location on the brain, higher likelihood of contrecoup injury than coup injury is found when sudden brain−skull motion takes place. The accumulation effect of CSF in the ventricle system, under large relative brain−skull motion, is also identified. The FE results show that adding relative angular velocities, to the translational impact model, not only causes a diffuse high strain area, but also cause the temporal lobes to be susceptible to cerebral contusions since the protecting CSF is prone to be squeezed away at the temporal sites due to the head rotations.

Complex Obstetric Perineal Injury Reconstruction Using Antropyloric Valve Transposition

Despite significant advancements in the field of medicine, management of complex obstetric perineal injuries remains a challenge. Although several surgical techniques have been described, no techniques have provided satisfactory long-term results. Recently, a perineal transposed antropyloric valve has been used for anorectal reconstruction in patients with damaged or excised anal sphincters. We describe this technique in the case of complex obstetric perineal trauma with extensive tissue loss, presenting with end stage fecal incontinence. The functional outcome after this procedure was evaluated. The patient tolerated the surgery well, and there were no procedure-related upper gastrointestinal disturbances. Short-term functional outcomes were encouraging. At the 36-month follow-up, the patient’s neoanal resting and squeeze pressures were 50 and 70 mmHg, respectively. The postoperative St. Mark’s incontinence score was 7. Perineal antropyloric valve transposition is feasible and can be successfully applied in the management of end-stage fecal incontinence associated with complex obstetric perineal injury.

100 Association of age-related left atrial remodeling with ischemic stroke in patients with normal sinus rhythm

OnBehalf

The ARIC Study

Background

Age-related left atrial (LA) structural/functional abnormalities in elderly patients with normal sinus rhythm and preserved ejection fraction may precede the development of overt atrial fibrillation, and also may be related to stroke.

Purpose

To evaluate the association of 3-dimensional echocardiographic (3DE) atrial contractility parameters with subclinical cerebral infarcts (SCIs), as assessed by brain MRI, and clinically diagnosed stroke

Methods

We studied 407 participants (mean age 76 ± 5 years, 40.5% male) from the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS) without AF and who underwent a brain MRI and a 3DE examination in 2011-13. We defined 3 groups: those with no cerebral infarcts on brain MRI (NCIs, N = 315); those with MRI-diagnosed SCIs (N = 58); and those with clinically diagnosed stroke (N = 34).

Results

While still within the normal range, LA indexed volume significantly increased across the 3 groups (P-trend = 0.01).This was accompanied by an increase in the LA global longitudinal strain (GLS), an echocardiographic index of LA reservoir function (P-trend = 0.004). E/e’ divided by LA GLS—index of atrial stiffness—worsened across groups (P-trend = 0.005) and was independently associated with SCIs and Stroke, pooled together, [OR per 1 %-1, 1.97; 95% CI (1.24, 3.11), P = 0.004], and Stroke [OR per 1 %-1, 2.30; 95% CI (1.23, 4.30), P = 0.009]. LA GLS was marginally associated with an increased odd of SCIs [OR per 1 %, 1.07; 95% CI (1.01, 1.13), P = 0.014].

Conclusions

Among elderly participants with normal sinus rhythm and preserved ejection fraction in a large cohort study, markers of LA function and stiffness are associated with increased odds of subclinical infarcts and stroke. These data suggest that even subtle LA dysfunction, which may contribute to LA stasis, may predispose to subclinical cerebral infarcts and stroke.

Hemoadsorption by extracorporeal cytokine adsorption therapy (CytoSorb®) in the management of septic shock: A retrospective observational study

INTRODUCTION

Sepsis results in immunologic disturbances with the release of various inflammatory mediators such as cytokines. Cytokines can damage the cells, and the continuous release of inflammatory mediators leads to severely impaired immunity. Therefore, the reduction in cytokine levels by hemoadsorption represents a new concept for blood purification. CytoSorb^® as a hemoadsorption device is a detoxification system, which aims to decrease the cytokines levels. This study was conducted to understand any beneficial effects of CytoSorb^® therapy in septic patients.

METHODOLOGY

This was a retrospective and observational study, approved by the scientific and ethics committee of Max Super Specialty Hospital, Patparganj, Delhi, India and conducted in compliance with current International Council for Harmonization, Good Clinical Practice, Schedule Y, and Indian Council of Medical Research guidelines. Subjects of either gender (age > 18 year) were included in the study. The data were presented as mean ± standard deviation and categorical as frequency and percentage (%). A p value less than 0.05 (p < 0.05) was considered to be statistically significant.

RESULTS

A total number of 36 patients were included in the study. Majority of the patients were male with mean age (56.36 ± 14.83). After therapy, procalcitonin and total leucocyte count levels decreased within 24 h. Post therapy, sepsis-related organ failure assessment (SOFA) score of Day (D)1, D2, and D3 reduced to 10.4 ± 3.63, 8.7 ± 4.02, and 7.8 ± 3.67, respectively. The Acute Physiology and Chronic Health Evaluation (APACHE) II score and predicted mortality were lower in the survivor group as compared to the non-survivor group.

CONCLUSION

Hemoadsorption using the extracorporeal adsorption device (CytoSorb^®) might be an effective rescue therapy in stabilizing septic shock patients.

Endoscopic ultrasound-guided anal sphincteroplasty for fecal incontinence in women: A pilot study

Overlapping sphincteroplasty for anal sphincter injury is associated with suboptimal long-term results that can be implicated to incomplete repair and neurovascular damage during dissection. This study was done to evaluate endoscopic ultrasound-guided overlapping sphincteroplasty to ensure completeness of sphincter repair intraoperatively and also to protect the integrity of neurovascular bundles. Between January 2014 and October 2015, 15 consecutive women with damaged anal sphincters, who underwent endoscopic ultrasound-guided overlapping sphincteroplasty, were prospectively evaluated (group 1). A control group of seven women, who had undergone classical sphincteroplasty between August 2012 and December 2013, was retrospectively identified (group 2). Perioperative outcomes, anal manometry findings, and fecal incontinence scores of both the groups were analyzed. Median age of patients in group 1 was 28 years (range 21-45) whereas group 2 patients had a median age of 33 years (range 26-35). Group 1 patients were followed up for a median duration of 44 months (range 37-54), and the median follow up duration in group 2 was 62 months (range 55-70). Postoperative evaluation done at the last follow up revealed a marked improvement in anal squeeze pressures as well as St. Mark's incontinence score in both the groups compared with their preoperative status. However, there was no significant difference in the outcomes of both the groups. Use of intraoperative ultrasound ensures the completeness of sphincter repair and also decreases chances of neurovascular injury. However, no statistically significant difference in the outcome was found with the use of ultrasound-guided sphincteroplasty in the short-term.

Per anal endoscopic rectopexy for treatment of complete rectal prolapse: A preliminary report

We describe Per Anal Endoscopic Rectopexy (PAER), a new treatment for complete rectal prolapse, which involves fixing the anterior rectal wall to the under-surface of the anterior abdominal wall and posterior rectal wall to the sacrum, through a submucosal tunnel (both endoluminally). This is a prospective single-centre pilot study done at a tertiary care centre. A total of 12 patients with a mean age of 48 years underwent the procedure. Constipation and incontinence were present in 8 and 4 patients, respectively and a significant improvement was seen in both following the procedure. A significant decrease in anorectal angle and its descent was also observed on post procedure magnetic resonance defecography. One patient had partial recurrence of prolapse. No major morbidity was observed. PAER is a minimally invasive and safe option for rectal prolapse, which needs to be validated in more patients over a longer follow up period.

Evaluation of a Method to Determine Flavonol Aglycones in Ginkgo biloba Dietary Supplement Crude Materials and Finished Products by High-Performance Liquid Chromatography: Collaborative Study

An interlaboratory study was conducted for evaluation of a method to determine the flavonol aglycones quercetin, kaempferol, and isorhamnetin in Ginkgo biloba products. The method calculates total glycosides based on these aglycones formed after acid hydrolysis. Twelve matrixes were chosen for study by 12 collaborating laboratories in 2 countries. Test materials included crude leaf material, standardized dry powder extract, single and multiple entity finished products, ethanol and glycerol tinctures, and National Institute of Standards and Technology (NIST) standard reference materials (SRMs). Results from 11 laboratories were used for the final calculations. Eight of the 12 matrixes evaluated produced acceptable results for total flavonol glycosides, with HorRat scores ranging from 1.31 to 2.05; repeatability relative standard deviations (RSDr) from 1.46 to 4.14; and reproducibility relative standard deviations (RSDR) from 4.67 to 9.69. These 8 matrixes consisted primarily of simple dosage forms (e.g., dry powder extracts, crude leaf samples, liquid extracts, and SRMs) and a single tablet product (Ginkgo Awareness). Four additional matrixes, consisting of 3 tablets and 1 soft gel product (Ginkgold, Ginkoba, Ginkogen, and Ginkgo Phytosome, respectively), showed greater total flavonol glycoside HorRat scores in comparison, ranging from 2.39 to 5.13, with RSDr values from 2.83 to 8.16, and RSDR values from 8.53 to 20.4. Based on the results presented here, the method is recommended for Official First Action for determination of total flavonol glycosides calculated from quercetin, kaempferol, and isorhamnetin in dry powder extracts, crude leaf material, liquid extracts, and a select finished product, Ginkgo Awareness.

Corrosive Esophageal Strictures: From Dilatation to Replacement: A Retrospective Cohort Study

Endoscopic dilatation is the recommended primary therapy for chronic corrosive esophageal strictures (ES), and surgery is reserved for failed dilatation. Through this study, we intend to analyze the efficacy and long-term outcomes of both endoscopic and surgical interventions in corrosive ES. A retrospective cohort analysis of patients with chronic corrosive ES, managed with endoscopic or surgical procedures at a tertiary teaching institute in North India from December 2009 to December 2016, was performed from a prospectively maintained database. The primary outcome measure was the absence of dysphagia following dilatation or surgery. During the study period, 64 patients with ES underwent surgical or endoscopic treatment. Associated gastric strictures and pharyngeal strictures were present in 39 (60%) and 22 patients (28.9%), respectively. The mean age was 28.8 years and mean BMI was 14.2 kg/m². Acid was the most common corrosive substance. Endoscopic dilatation using Savary-Gilliard (SG) dilators was successful in achieving persistent symptom relief in 46 patients (71.8%) after a total of 358 sessions (mean number of dilatations were 5.2 ± 1.2) of dilatations over 2 years. The dilatation therapy failed in 18 patients (28.1%) including technical failures (15.6%), perforations (3.1%), refractory stricture (1.5%) and recurrent strictures (7.8%). Increasing stricture length (more than 6 cm) was associated with poor outcome of endoscopic dilatation (p < 0.001). Only eleven patients (17%) required esophageal replacement (resection: 0, bypass: 11) for failed dilatations including seven gastric pull-ups and four pharyngo-coloplasty. The stricture rate after surgery was 36.3% (4/11). The median follows up was 32 months. Endoscopic dilatation of corrosive ES is safe and effective therapy and should be the first-line therapy for these patients and surgery should be considered only in patients who have unsuccessful outcome following dilatation therapy.

Vitamin D Receptor and Role of Vitamin D Supplementation in Advanced Gallbladder Cancer: A Prospective Study from Northern India

BACKGROUND

The proposed role of Vitamin D Receptor (VDR) in various cancers underscores the importance of vitamin D compounds as a novel therapeutic agent in the prevention of occurrence and progression of cancer. Vitamin D Receptor (VDR) expression in gallbladder cancer (GBC) has not been widely analyzed yet. In the present study, an attempt has been made to study VDR expression and the role of vitamin D supplementation during palliative chemotherapy in advanced GBC.

METHODS

Expression of VDR was analyzed in benign cholecystectomy specimens (n=11), and GBC specimens (n=32). Thirty patients with advanced GBC were subjected to palliative chemotherapy. Out of them, 19 patients were supplemented with Vitamin D and 11 patients were not. Effect of vitamin D supplementation on the change in vitamin D scores and improvement in quality of life (QOL) were assessed by EORTC QLQ c30 version 3.0. and the difference in outcome between the two groups were studied.

RESULTS

Mean intensity, staining and immunoreactivity scores signifying VDR expression were decreased in the studied population of GBC when compared to benign disease. In palliative setting, vitamin D supplementation significantly improved the quality of life. However, the effect on disease- specific survival, although present, was not statistically significant.

CONCLUSION

VDR expression downregulation is associated with increasing malignant process. Vitamin D may act as sensitizers for tumor cell death besides downplaying potential harmful effects of palliative chemotherapy thus reducing the associated morbidity. This study assumes importance as the first clinical study reporting VDR expression in GBC tissue and the possible role of vitamin D supplementation in patients with advanced disease.

Antibacterial spectrum of human omentum and differential expression of beta defensins

BACKGROUND

Human β defensins (hBD1 and hBD2) are cationic, cysteine-rich peptides and form an integral part of the mammalian innate immune system. hBD1 is constitutively expressed in epithelial cells, whereas hBD2 increases in response to bacterial infection. Human omentum is known for its anti-inflammatory properties and also possesses an antibacterial activity of its own. We hypothesized that antimicrobial peptides, β defensins, may govern host defense mechanism in the microbe-rich environment of the peritoneal cavity. Therefore, we analyzed the expression of hBD1 and hBD2 in omentum tissue in vivo and also studied the antibacterial activity of omentum against common pathogens.

METHODOLOGY

Omentum tissues were obtained from 30 patients (15 cases and 15 controls). Real-time polymerase chain reaction (PCR) was used to evaluate the mRNA expression of hBD1 and hBD2. Protein quantification was done using Western blotting technique. Antibacterial susceptibility was performed to check the antibacterial activity of omentum.

RESULT

Significantly higher expression of hBD2 was observed in cases compared to controls at both the transcriptional and translational levels. In comparison with an array of antibiotics, activated omentum also showed antibacterial property even at lower concentration of its extract.

CONCLUSION

Omentum directly responds to bacterial infection, which may be due to differential expression of hBD1 and hBD2 in human omental tissue. These peptides (hBD1 and hBD2) may be an ideal candidate for novel antibiotic class with a broad-spectrum activity.

Effect of cholangitis on pre-operative evaluation of regional lymphadenopathy by CT in pancreato-biliary malignancies

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Background: Regional lymph nodes metastasis is a poor prognostic factor in pancreato-biliary malignancies. CT findings like lymph node size > 10mm, irregular shape, heterogenous enhancement, conglomeration and infiltration can suggest metastatic involvement. Cholangitis can induce reactive changes in regional lymph nodes. This study aimed to find if episodes of cholangitis interfere with the pre-operative CT evaluation of regional lymphadenopathy in pancreato-biliary malignancies. Methods: Regional lymph nodes metastasis is a poor prognostic factor in pancreato-biliary malignancies. CT findings like lymph node size > 10mm, irregular shape, heterogenous enhancement, conglomeration and infiltration can suggest metastatic involvement. Cholangitis can induce reactive changes in regional lymph nodes. This study aimed to find if episodes of cholangitis interfere with the pre-operative CT evaluation of regional lymphadenopathy in pancreato-biliary malignancies. Results: A total of 41 patients of gallbladder cancer and 20 patients of periampullary cancer were included. A total of 206 lymph node stations were sampled. In gallbladder cancer group, CT finding of lymph node size > 10mm, ill-defined borders and conglomeration; while intra-operative findings were node size > 10mm, hard consistency and necrosis on cut-section significantly predicted metastatic lymphadenopathy on univariate analysis. In multivariate analysis, size > 10mm measured intra-operatively was the only significant predictor of metastatic lymphadenopathy.21.9% patients (9/41) had history of cholangitis pre-operatively. In this subgroup, none of the CT characteristic or intra-operative nodal feature significantly predicted malignant involvement. In periampullary cancer, nodal necrosis on intra-operative cut-section was a significant predictor of malignant involvement in univariate, but not in multivariate analysis. Subgroup analysis of patients with history of cholangitis (10/20) did not reveal any significant pre-operative or intra-operative lymph nodal feature predicting malignant involvement. Conclusions: In patients with gallbladder or periampullary cancer with history of cholangitis, the typical CT characteristics or the intra-operative characteristics of regional lymph nodes cannot be relied on to predict metastatic lymph node involvement. Thus, cholangitis affects the clinical staging of these malignancies.

Expression and heterodimerization of Type A and B Cholecystokinin Receptors in Gallbladder cancer

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Background: Gallbladder cancer is the most common malignancy of the biliary tract and endemic in Northern India. The prognosis of gallbladder cancer remains dismal despite any treatment because of late presentation and aggressive tumor biology. Cholecystokinin (CCK) is present in abundance in gallbladder tissue and mediates function through two structurally related receptors, the type A (CCKAR) and B (CCKBR) receptors. Previously, heterodimerization of CCKAR and CCKBR receptor has been demonstrated in vitro, and was shown to bind natural agonists normally but exhibited agonist stimulated cellular signaling, promoting cell growth. In this study we examined the expression level of CCKAR and CCKBR in resected gallbladder tissue samples and also attempted to determine the dimerization status of CCKAR and CCKBR receptors in gallbladder cancer comparing them to cholelithiasis and normal gallbladder tissue. Methods: Tissue samples from resected normal gallbladder (n = 10), cholelithiasis (n = 25) and gallbladder cancer (n = 25)) were evaluated for the expression of CCKAR and CCKBR by immunohistochemistry. Determination of CCKAR and CCKBR expression was also done by western blot in representative samples from each of these tissue types while their dimerization status was evaluated by immunoprecipitation. Results: By Immunohistochemistry technique, positive CCKAR expression was observed in 80% gallbladder cancer, 84% cholelithiasis, 90% normal gallbladder, P = 0.76. However significantly higher expression of CCKBR was noted in gallbladder cancer (60%) as compared to cholelithiasis (25%) and normal gallbladder (20%), P = 0.013. We also observed progressively increasing level of expression of CCKAR and CCKBR in gallbladder cancer as compared to cholelithiasis and normal gallbladder by western blot. In addition, we also observed a higher level of heterodimer formation in gallbladder cancer compared to cholelithiasis and normal gallbladder using immunoprecipitation technique. Conclusions: Our results provide the first evidence of increasing trend of heterodimerization of CCKAR and CCKBR in gallbladder cancer which has potential clinical and therapeutic significance.

Bile duct injury: to err is human; to refer is divine

A 42-year-old woman sustained complete transection of common hepatic duct during routine laparoscopic cholecystectomy. The surgery was being performed at a rural setting, and the injury was identified intraoperatively. The surgeon sought the opinion of an expert biliary surgeon via telephone and discussed the possibility of an immediate end-to-end bile duct repair. Since he lacked the experience of doing biliary-enteric anastomosis, he was advised to place a subhepatic drain and transfer the patient to the hepatobiliary centre for definitive surgery. At the referral centre, the patient was evaluated and planned an immediate biliary repair. On exploration, she was found to have a major type, Strasberg E5 injury. The transected ducts were small in calibre and required double Roux-en-Y hepaticojejunostomy over transanastomotic stents. The postoperative recovery was uneventful. Transanastomotic stents were removed after 6 months, and the patient remained perfectly well at a follow-up of 1 year.

Blumgart's technique of pancreaticojejunostomy: Analysis of safety and outcomes

BACKGROUND

Blumgart's pancreaticojejunostomy (PJ) has been described with low pancreatic leak rates. This study aimed to evaluate our experience with this technique regarding the pancreatic leak and other perioperative outcomes.

METHODS

We performed a single-center retrospective analysis of a cohort of 81 patients who underwent pancreaticoduodenectomy in our department from January 2011 to February 2018. The primary endpoint was the occurrence of a clinically relevant postoperative pancreatic fistula (CR-POPF) and analysis of its risk factors.

RESULTS

The CR-POPF rate was 12.3%. Fistula risk score (FRS) was the only significant risk factor for the occurrence of overall POPF in multivariate analysis. However, none of the other factors including FRS was found to be significantly associated with CR-POPF risk. A strong positive correlation was found between the CR-POPF and the incidence of delayed gastric emptying, post-pancreatectomy hemorrhage and increased length of hospital stay.

CONCLUSION

Blumgart's technique is a safe technique of pancreatico-enteric anastomosis with low rates of CR-POPF. CR-POPF with this technique is independent of most of the preoperative and intraoperative factors. Therefore, this technique can be used for all types of the pancreas with consistently good results.