A detailed multi-omics analysis of GNB2 gene in human cancers

Abstract The Guanine-nucleotide binding protein 2 (GNB2) encodes for β2 subunit (Gβ2) of the G-protein complex. Keeping in view the increased demand of reliable biomarkers in cancer, the current study was planned to extensively explored GNB2 expression variation and its roles in different cancers using online available databases and diverse methodology. In view of our results, the GNB2 was notably up-regulated relative to corresponding controls in twenty three cancer types. As well, the elevated expression of GNB2 was found to be associated with the reduced overall survival (OS) of the Liver Hepatocellular Carcinoma (LIHC) and Rectum Adenocarcinoma (READ) only out of all analyzed cancer types. This implies GNB2 plays vital role in the tumorigenesis of LIHC and READ. Several additional analysis also explored six critical pathways and few important correlations related to GNB2 expression and different other parameters such as promoter methylation, tumor purity, CD8+ T immune cells infiltration, and genetic alteration, and chemotherapeutic drugs. In conclusion, GNB2 gene has been identified in this study as a shared potential biomarker (diagnostic and prognostic) of LIHC and READ.

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

BACKGROUND

There is limited data from India with regard to presentation, practice patterns and survivals in resected pancreatic ductal adenocarcinomas (PDACs).

METHODS

The Multicentre Indian Pancreatic & Periampullary Adenocarcinoma Project (MIPPAP) included data from 8 major academic institutions across India and presents the outcomes in upfront resected PDACs from January 2015 to June 2019.

RESULTS

Of 288 patients, R0 resection was achieved in 81% and adjuvant therapy was administered in 75% of patients. With a median follow-up of 42 months (95% CI: 39-45), median DFS for the entire cohort was 39 months (95% CI: 25.4-52.5), and median overall survival (OS) was 45 months (95% CI: 32.3-57.7). A separate analysis was done in which patients were divided into 3 groups: (a) those with stage I and absent PNI (SI&PNI-), (b) those with either stage II/III OR presence of PNI (SII/III/PNI+), and (c) those with stage II/III AND presence of PNI (SII/III&PNI+). The DFS was significantly lesser in patients with SII/III&PNI+ (median 25, 95% CI: 14.1-35.9 months), compared to SII/III/PNI + (median 40, 95% CI: 24-55 months) and SI&PNI- (median, not reached) (p = 0.036)).

CONCLUSIONS

The MIPPAP study shows that resectable PDACs in India have survivals at par with previously published data. Adjuvant therapy was administered in 75% patients. Adjuvant radiotherapy does not seem to add to survival after R0 resection.

The elevation of a unique population of Corynosoma strumosum (Acanthocephala: Polymorphidae) from the Caspian seal, Pusa caspica, in the Caspian Sea to Corynosoma neostrumosum n. sp

An isolated population of 700 specimens initially described as Corynosoma strumosum (Rudolphi, 1802) Lühe, 1904 and currently reassigned to Corynosoma neostrumosum n. sp. was collected from one young male Caspian seal, Pusa caspica (Gmelin) in the southern land-locked Caspian Sea in April 2009. Collected worms were morphologically unique compared with those reported by other observers in open waters, especially in shape and distribution of proboscis hooks and trunk spines, dorso-ventral differences in proboscis hooks and their organization, the baldness of anterior proboscis, consistently smaller size of trunk and testes, larger eggs, the rough egg topography, epidermal micropores, and variations in the female gonopore. Molecular data from the internal transcribed spacer region of rDNA and the mitochondrial cox1 gene was also provided to supplement the morphological study of the new species.

Factors predicting 30-day mortality after pancreaticoduodenectomy-the impact of elevated aspartate aminotransferase

PURPOSE

High preoperative bilirubin levels and cholangitis are associated with poor peri-operative outcomes following pancreaticoduodenectomy (PD). However, the impact of deranged preoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels on immediate postoperative outcomes is relatively unexplored. We hypothesized that deranged AST and ALT lead to worse postoperative outcomes after PD. The aim of this study was to assess the factors contributing to postoperative mortality (POM) following PD, and to study the impact of deranged aminotransferases.

METHODS

This is a retrospective analysis of 562 patients. Risk factors for POM were computed using a multivariate logistic regression model.

RESULTS

The rate of POM was 3.9%. On univariate analysis, the American Society of Anaesthesiologists grades, diabetes mellitus, cardiac comorbidity, preoperative biliary stenting, elevated serum bilirubin, AST, elevated serum creatinine, clinically relevant pancreatic fistula (CRPF), and grade B+C post-pancreatectomy hemorrhage (PPH) were associated with 30-day mortality. On multivariate analysis, preoperative elevated AST was independently predictive of 30-day POM (OR = 6.141, 95%CI 2.060-18.305, p = 0.001). Other factors independently predictive of POM were elevated serum creatinine, preoperative biliary stenting, CRPF and grade B and C PPH. The ratio of AST/ALT > 0.89 was associated with 8 times increased odds of POM.

CONCLUSION

Elevated preoperative AST emerged as a predictor of 30-day POM after PD, with an 8-times increased odds of death with an AST/ALT ratio > 0.89.

Revision of Corynosoma australe Johnston, 1937 (Acanthocephala: Polymorphidae) from a North American population using novel SEM images, Energy Dispersive X-ray Analysis, and molecular analysis

We describe a population of the acanthocephalan Corynosoma australe Johnston, 1937 (Polymorphidae) from a California sea lion Zalophus californianus (Lesson, 1828) in California using novel scanning electron microscopy (SEM) images, Energy Dispersive x-ray analysis (EDXA), and molecular analysis for the first time. The taxonomic history of C. australe is replete with accounts using only line drawings some of which proved erroneous. The distribution of ventral spines on the female trunk has been the primary distinction between C. australe and Corynosoma obtuscens Lincicome, 1943, its junior synonym; being continuous in the latter but discontinuous posteriorly in the former species. The distribution of ventral spines is invariably discontinuous in males. Our redescription and SEM images help to resolve this issue further validating the synonymy. Morphological variability has been documented between our California population and others from various host species in California, South Australia, South Shetlands, and the Argentinian coast. Our SEM images document features not previously detectable in line drawings, erroneously reported or missed in previous accounts. The EDXA spectra show high levels of calcium and phosphorous and low levels of sulfur characteristic of C. australe. EDXA for other species of Corynosoma Lühe, 1904 provide support for the diagnostic distinction of C. australe. EDXA spectra were shown to be species specific and have diagnostic value in the taxonomy of the Acanthocephala. Our molecular analysis used amplification of 18S of ribosomal DNA and cytochrome c oxidase 1 (Cox1) gene. Phylogenetic analyses for Cox1 gene revealed a close relationship between Corynosoma hannae Zdzitowiecki, 1984 and C. australe. The phylogenetic trees confirmed that the isolates belonged to C. australe. The haplotype network inferred by Cox1 with C. australe sequences revealed that haplotypes clearly separated from each other and formed clusters related to samples from the Northern Hemisphere (the USA and Mexico), and the second from the Southern Hemisphere (Argentina, Brazil and Peru).

Computational Characterization of Xyloketal B with Human C-Reactive Protein For Management of Kawasaki Disease (KD)

The most common underlying cause of acquired cardiovascular disease in developed countries is Kawasaki disease (KD), a systemic vasculitis. The most serious and common consequence of KD is the growth of coronary artery involvement, however therapy with intravenous gammaglobulin can minimized this issue. There are various limitations of using intravenous gammaglobulin which further make researchers to look for alternative medicine. It has been found that marine natural products and compounds from natural sources are having cardioprotective nature. The present research aims at filling the gap with computational analysis to explore the target ability y of Xyloketal B on human C-Reactive Protein having vital role in Kawasaki disease. It has been found that the marine compound has the ability to inhibit CRP with considerable negative biding energy of-8.47Kcal/mol. The present stdy may aid researchers to explore new invention having the potential for enzymatic and chemical modification of the molecule for the management of KD. Patients having a history of coronary artery disease, involvement are encouraged to have long-term follow-up.

Arthroscopic Debridement for Mucoid Degeneration of Anterior Cruciate Ligament - A Single Institution Experience from Nepal

Background Mucoid degeneration of anterior cruciate ligament is characterized by infiltration of mucoid-like material scattered throughout the anterior cruciate ligament substance. It is an uncommon condition, but previously, underdiagnosed or often misdiagnosed as an anterior cruciate ligament tear. Objective To present our early experiences with mucoid degeneration of anterior cruciate ligament in last five years in terms of clinical presentation and the outcomes of arthroscopic management. Method This was a retrospective descriptive cross-sectional study on patient who received arthroscopic debridement for mucoid degeneration of anterior cruciate ligament in Dhulikhel Hospital over five years period (2017 May to 2022 April). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale that has been translated and validated to be used in local (Nepali) language and context was used for evaluation of outcome evaluation. Result Twenty-one patients of mean age 44.21 years, predominantly females (18), were managed in five years period. The mean Western Ontario and McMaster Universities Osteoarthritis Index score was 16.33±10.47 with a range of 0 to 36 (11.57 to 21.09 at 95% confidence interval). The mean Western Ontario and McMaster Universities Osteoarthritis Index score converted on a scale of 0 to 100 was 17. Thirteen patients had isolated Mucoid degeneration of anterior cruciate ligament whereas nine others had associated either meniscal tear or chondral lesions. Conclusion Mucoid degeneration of anterior cruciate ligament could be a cause of knee pain in middle-aged patients and arthroscopic debridement can improve the patient's symptoms and provide a good functional outcome.

Biofilm assemblage and activity on plastic in urban streams at a continental scale: Site characteristics are more important than substrate type

The fate of plastics in rivers is a key component of the global plastic cycle. Plastics entering freshwater ecosystems are colonized by microbial biofilms, and microbe-plastic interactions can influence ecosystem processes and plastic fate. While literature examining the role of geographic region on plastic biofilms is quickly expanding, research which covers large (i.e., continental) spatial scales and includes freshwater ecosystems is warranted. In addition, most research focuses on bacterial communities, while biofilm eukaryotes are less commonly studied. We assessed biofilm metabolism and community structure on plastic (foamed polystyrene and polyvinyl chloride; PVC) and natural substrates (unglazed ceramic tile) in urban streams spanning a nested geographic gradient in the continental United States. We measured biofilm biomass, community respiration, and chlorophyll a, in addition to assessing marker gene-based community diversity of bacterial, fungal, and algal assemblages. Results demonstrated some substrate-specific trends in biofilm characteristics, including higher biofilm biomass on polystyrene across sites, and lower diversity of bacterial assemblages on both types of plastic litter versus tile. However, there were no differences among substrates for chlorophyll, respiration, and the abundance and diversity of algal and fungal assemblages. Thus, we concluded that the primary driver of biofilm metabolism and community composition were site characteristics, rather than substrate type. Additional studies are needed to quantify which site-specific characteristics drive biofilm dynamics on plastic litter in streams (e.g., water chemistry, light, seasonality, hydrology). These results add to the growing literature on the biofilm 'plastisphere' in aquatic ecosystems, demonstrating that the factors which control the assembly and activity of biofilm communities on plastic substrates (including bacteria, algal, and fungal assemblages together) in urban streams are similar to those driving biofilm dynamics on natural substrates.

Anti-bacterial activity of essential oils against multidrug-resistant foodborne pathogens isolated from raw milk

The presence of pathogenic bacteria in food is considered as a primary cause of food-borne illness and food quality deterioration worldwide. The present study aimed to determine the effectiveness of five essential oils (EOs) against multidrug-resistant foodborne pathogens. In the current study Gram-negative bacteria (Escherichia, Enterobacter, Citrobacter, Proteus, Pseudomonas, and Klebsiella) and the Gram-positive bacteria Staphylococcus were isolated from raw milk and biochemically characterized. The anti-bacterial effect of different antibiotics and EOs (thyme, oregano, lemongrass, mint, and rosemary) was determined using the standard disc diffusion method. The antibiogram study revealed that Gram-negative bacteria were highly resistant to penicillin while Staphylococcus was resistant to streptomycin, amoxicillin, and lincomycin. Moderate resistance was observed to doxycycline, amikacin, enrofloxacin, kanamycin and cefixime. Isolates were found less resistant to gentamycin, chloramphenicol, and ciprofloxacin. EOs showed a broad range of antimicrobial activity against all bacteria except P. aeruginosa. Of these, thyme was more effective against most of the multi-drug resistant bacterial strains and formed the largest zone of inhibition (26 mm) against Escherichia followed by oregano oil (18 mm) against Staphylococcus (p<0.05). Klebsiella spp and Citrobacter spp showed resistance to mint and lemongrass oil respectively. The EOs such as lemongrass, mint and rosemary were less active against all the bacteria. The findings of the recent study suggest the use of EOs as natural antibacterial agents for food preservation.

Can we predict the need for nutritional support following pancreatoduodenectomy?

BACKGROUND

The practice of routine placement of a tube jejunostomy at the time of pancreatoduodenectomy has given way to a more selective approach. However, the indications of establishing enteral access at the time of surgery remain poorly defined. This study aimed to assess the preoperative and intraoperative factors associated with the need for nutritional support after pancreatoduodenectomy, to guide decision-making for the establishment of intraoperative feeding access.

METHODS

Retrospective study, analyzing the data of 562 consecutive patients, who underwent pancreatoduodenectomy between March 2013 to December 2020. Univariate and multiple logistic regression analysis was carried out to ascertain the factors associated with the initiation of and need for nutritional support for more than 7 days postop. The utility of tube jejunostomy was studied in patients in whom it was performed.

RESULTS

Of 562 patients, 105 (18.7%) needed nutritional support. A tube jejunostomy was performed in 46 (8.2%) patients, parenteral nutrition was used in 83 (14.8%), and nasojejunal tube placed in 28 (4.9%) patients. On logistic regression analysis, age, serum albumin <3.0 gm/dl and operative blood loss were independently associated with the initiation of supportive nutrition, while preoperative gastric outlet obstruction (OR 3.105, 95% CI1.201-8.032, p = 0.019) and serum albumin <3.0 gm/dl (OR 2.669, 95% CI 1.131-6.300, p = 0.025) were associated with the need for prolonged nutritional support. The maximal benefit of tube jejunostomy was in patients with mental health disorders (83.3%).

CONCLUSION

Tube jejunostomy for nutritional support after pancreatoduodenectomy can be considered in patients with preoperative gastric outlet obstruction, serum albumin <3.0 gm/dl and mental health disorders.

Optimized biotransformation of acid-treated water melon peel hydrolyzate into ethanol

Today, global focus of research is to explore the solution of energy crisis and environmental pollution. Like other agricultural countries, bulk quantities of watermelon peels (WMP) are disposed-off in environment as waste in Pakistan and appropriate management of this waste is the need of hour to save environment from pollution. The work emphasizes the role of ethanologenic yeasts to utilize significant sugars present in WMP for low-cost bioethanol fermentation. Dilute hydrochloric acid hydrolysis of WMP was carried out on optimized conditions employing RSM (response surface methodology) following central composite design (CCD). This experimental design is based on optimization of ethanologenesis involving some key independent parameters such as WMP hydrolysate and synthetic media ratio (X1), incubation temperature (X2) and incubation temperature (X3) for maximal ethanol yield exploiting standard (Saccharomyces cerevisiae K7) as well as experimental (Metchnikowia cibodasensisY34) yeasts. The results revealed that maximal ethanol yields obtained from S. cerevisiae K7 was 0.36±0.02 g/g of reducing sugars whereas M. cibodasensisY34, yielded 0.40±0.01 g ethanol/g of reducing sugars. The yeast isolate M. cibodasensisY34 appeared as promising ethanologen and embodies prospective potential for fermentative valorization of WMP-to-bioethanol.

Pattern of third molar impactions in north-eastern peninsular Malaysia: A 10-year retrospective study

Background

Third molar impaction, if left untreated, has the potential to cause several complications. The evaluation of surgical difficulty of impacted third molar extraction aids in better formulation of treatment plan by minimizing surgical complications.

Objective

This study aimed to determine the prevalence of third molar impaction and related pathologic conditions in a cohort of patients living in North-eastern Peninsular Malaysia.

Methods

In this retrospective study, 490 orthopantomograms (OPGs) of patients who were referred to the Oral and Maxillofacial Surgery department between January 2010 and December 2019 were assessed. Data including age, gender, ethnicity, frequency of third molar impactions, their angulations and levels of eruption, retromolar space, and associated pathologic conditions were collected. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) version 24.0. The significance level was set to P < 0.05.

Results

A total of 490 patients with a mean age of 28.87 years (range: 20-64) demonstrated 1957 impacted third molars (1022 mandibular + 935 maxillary). Impacted third molars were more likely present in females than males (1:2.20) (p < 0.05); and in Malay-ethnic (44.49%) patients followed by Chinese (34.45%) and Indians (21.02%). Mesioangular was the most common angulation of impaction both in the maxilla (24.68%) and mandible (18.34%). The most common pattern of third molar impaction was IIA (61.67%), and the retromolar space was significantly larger in males (13.6 mm; P < 0.05) than females (11.6 mm). The most frequently occurring pathological condition associated with third molars impaction is dental caries in the second or third molar (15.38%).

Conclusions

This study highlights mesioangular impaction with their occlusal plane at the same level as the occlusal plane of the adjacent tooth being the most prevalent pattern of third molar impaction in North-eastern Peninsular Malaysia.

Successful Outcome of Bariatric Surgery in Living Donor Liver Transplant Recipients With Multidisciplinary Approach: A Preliminary Experience

INTRODUCTION

Liver transplant recipients may develop weight gain, metabolic syndrome, and subsequent nonalcoholic steatohepatitis of the transplanted liver which impairs graft function. Bariatric surgery is an effective modality for management of morbid obesity and metabolic syndrome. Our aim is to review the role of bariatric surgery in such high-risk posttransplant patients not responding to medical management and highlight the important considerations.

METHODOLOGY

We review the management of two cases with posttransplant metabolic syndrome not responding to medical management and discuss the literature available on bariatric surgery in organ transplant patients.

RESULTS

The first patient was a 51-year-old man who underwent living donor liver transplantation 3 years prior, and follow-up ultrasound and fibroscan was suggestive of steatohepatitis of the graft. After liver transplantation, he had gained 30 Kg weight and was on oral hypoglycemic agents with HbA1c of 8%. The second patient was a 65-year-old man, who gained 30 Kg weight with risk of graft impairment 4 years after of combined liver and kidney transplant. Both patients were evaluated thoroughly preoperatively for risk stratification including an upper gastro-intestinal (GI) endoscopy. The immunosuppression was reduced and monitored closely perioperatively. Both patients underwent laparoscopic sleeve gastrectomy (LSG) and were discharged on postoperative day 3. The first patient was evaluated a year after surgery with body mass index (BMI) reduction from 42 to 34 and second at 2 months with BMI reduction from 38 to 33; both patients were free of diabetes and had stable graft functions.

CONCLUSION

Bariatric surgery in liver transplant recipients has significant challenges with higher complication rates as patients are on immunosuppression which often impairs wound healing. LSG is safe and effective in such patients which often requires good coordination between the bariatric team and liver transplant team.

Surgical Oncology Practice in the Wake of COVID-19 Crisis

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome (SARS-CoV-2) outbreak has placed unprecedented challenges globally dismantling healthcare systems and forcing rapid transformations of healthcare services. In patients with cancer, these changes are having profound effects on vital aspects of their care. It has been advised that hospitals discontinue elective surgery and work on triage of nonemergent surgical procedures during the pandemic. The purpose of this article is to highlight the recommendations and adapted workflow from the private and public tertiary level hospitals in India advising on the best practices and views on better patient management, redesigning of SOPs for OR, surgeon, and staff safety and resumption of cancer care especially from surgical perspective. Different concerns are addressed that are necessary to optimize the quality of care provided to COVID-19 patients and to reduce the risk of viral transmission to other patients or healthcare workers.

Elective Gastrointestinal Surgery in COVID Times

With the COVID pandemic claiming deaths the world over, the healthcare systems were overburdened. This led to the cancellation and delay in elective surgical cases which can have far-reaching consequences This study reports our experience of elective gastro-intestinal surgical procedures during the COVID pandemic, after instating preventive strategies and screening protocols to prevent the transmission of COVID infection. This is a case series analysis of elective gastro-intestinal surgical procedures performed from March 24, 2020, to July 31, 2020. During this period, 314 gastro-intestinal surgical procedures were performed; of which, 45% were for malignancies. The median age of patients was 54 years (range 8 to 94 years). Laparoscopy was used in 43% cases. Major postoperative complications (Clavien-Dindo grade 3 and above) were witnessed in 3.5% (11/314) patients, with no statistically significant difference when compared with the rate of major complications last year (45/914, 4.9% vs 11/314, 3.5%, p = 0.3). The 30-day mortality rate was 1% (n = 3). No patient developed COVID in the postoperative period. With preventive and screening strategies and proper patient selection, it is possible to deliver safe GI surgical services during the COVID pandemic, without increasing the risk for major postoperative complications.

Hospital malnutrition in northeast and southeast Asia: A systematic literature review

BACKGROUND & AIMS

Hospital malnutrition is a prevalent yet frequently under-recognised condition that is associated with adverse clinical and economic consequences. Systematic reviews from various regions of the world have provided regional estimates of the prevalence of malnutrition and the magnitude of the associated health and economic burden; however, a systematic assessment of the prevalence and consequences of hospital malnutrition in northeast and southeast Asia has not been conducted.

METHODS

We performed a systematic literature search for articles on hospital malnutrition in 11 Asian countries published in English between January 1, 1997 and January 15, 2018. Studies reporting data on the prevalence, clinical consequences, or economic impact of hospital malnutrition in an adult inpatient population with a sample size ≥30 were eligible for inclusion.

RESULTS

The literature search identified 3207 citations; of these, 92 studies (N = 62,280) met the criteria for inclusion. There was substantial variability in study populations and assessment methods; however, a majority of studies reported a malnutrition prevalence of >40%. Malnutrition was associated with an increase in clinical complications, mortality, length of hospitalisation, hospital readmissions, and healthcare costs.

CONCLUSIONS

Hospital malnutrition is a highly prevalent condition among hospitalised patients in northeast and southeast Asia. Additionally, poor nutritional status is associated with increased morbidity and mortality and increased healthcare costs. Further research aimed at improving the identification and proactive management of hospitalised patients at risk for malnutrition is necessary to improve patient outcomes and alleviate the burden on local healthcare budgets.

Deviations from a clinical pathway post pancreatoduodenectomy predict 90-day unplanned re-admission

Deviations from a post-PD clinical care pathway are common. Poor nutrition and cardiac co-morbidities are associated with an increased likelihood of deviation. As the number of deviations increase, so does the risk of significant complications and interventions, delayed discharge and 90-day re-admission rate.

Pancreatic Exocrine Insufficiency as a Complication of Gastrointestinal Surgery and the Impact of Pancreatic Enzyme Replacement Therapy

BACKGROUND

Pancreatic exocrine insufficiency (PEI) is characterized by inadequate production, insufficient secretion, and/or inactivation of pancreatic enzymes, resulting in maldigestion. The aim of this review was to analyze the prevalence and pathophysiology of PEI resulting from gastrointestinal (GI) surgery and to examine the use of pancreatic enzyme replacement therapy (PERT) for effectively managing PEI.

SUMMARY

A targeted PubMed search was conducted for studies examining the prevalence and pathophysiology of PEI in patients following GI surgery and for studies assessing the effects of PERT in these patients. PEI is a common complication following GI surgery that can lead to nutritional deficiencies, which may contribute to morbidity and mortality in patients. Timely treatment of PEI with PERT can prevent malnutrition, increase quality of life, and possibly reduce the associated mortality. Treatment of PEI should aim not only to alleviate symptoms but also to achieve significant improvements in nutritional parameters. Dose optimization of PERT is required for effective management of PEI, in addition to regular assessment of nutritional status, appropriate patient education, and reassessment if symptoms return. Key Messages: Difficulties in detecting PEI following GI surgery can result in undiagnosed and untreated maldigestion, leading to metabolic complications and increased morbidity. Both are preventable by early administration and monitoring for optimal doses of PERT.

Perioperative antimicrobial therapy in preventing infectious complications following pancreatoduodenectomy

Background & objectives:

Infectious complications have been reported to occur in up to 45 per cent of patients, following pancreatoduodenectomy (PD). The incidence of perioperative infectious and overall complications is higher in patients undergoing preoperative invasive endoscopic procedures. The aim of the study was to compare the role of a carbapenem administered as three-once daily perioperative doses on infectious complications in patients at high risk for these complications versus those at low risk.

Methods:

A retrospective study with some secondary data collected from records was carried out on the data from a prospectively maintained surgical database of patients undergoing PD for pancreatic and periampullary lesions at a tertiary referral care centre, between June 2011 and May 2013. Patients were divided into two groups for comparison based on whether they underwent at least one preoperative endoscopic interventional procedure before PD (high-risk - intervention and low-risk - no intervention). All patients were administered three-once daily doses of ertapenem (1 g).

Results:

A total of 135 patients in two groups were comparable in terms of demographic and nutritional, surgical and histopathological factors. No significant difference between the two groups in terms of the overall morbidity (38.7 vs 35.7%), infectious complications (9.7 vs 4.8%), mortality (2.2 vs 2.4%) and mean post-operative hospital stay (9.2 vs 8.9 days) was observed.

Interpretation & conclusions:

Perioperative three-day course of once-daily administered ertapenem resulted in a non-significant difference in infectious and overall complications in high-risk patients undergoing PD as compared to the low-risk group.

Management of achalasia cardia: Expert consensus statements

Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per-oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short-term to mid-term follow-up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.

Association of Socio-Demographic Profile with Prevalence of Multi Drug Resistant Tuberculosis among Retreated Pulmonary Tuberculosis Patients in North India

Methods: An observational cross sectional study, which includes 116 patients of sputum smear positive pulmonary TB of age 18 or above. Further, detailed history taking regarding different demographic profile was done. Also, they were subjected to CB-NAAT and rifampicin resistant cases were considered as MDR-TB. Results: Proportion of MDR-TB was 31.89% among retreatment TB cases. 56.75 % (n=21) of MDR-TB cases were between the age group of 21-40 years. Proportion of MDR-TB was higher among males (75.67%), married (59.45%) and rural dwellers 59.45%. Proportion was 61.76% among patients with BMI <16; 31.57% with BMI 16-16.99, 28.57% with BMI 17-18.49 and 5.7% with BMI 18.50-24.99. MDRTB proportion was less 29.72% (n=11) in patients with history of TB contact in family. Pulmonary TB including MDR-TB was more common among illiterates (37.83% among MDR). Conclusion: Proportion of MDR-TB was high among retreatment cases in north India. Among them low BMI and education status are modifiable factor and this study signifies that MDR-TB burden can be reduced by improving health and education status of patient.

Magnetite and Green Rust: Synthesis, Properties, and Environmental Applications of Mixed-Valent Iron Minerals

Mixed-valent iron [Fe(II)-Fe(III)] minerals such as magnetite and green rust have received a significant amount of attention over recent decades, especially in the environmental sciences. These mineral phases are intrinsic and essential parts of biogeochemical cycling of metals and organic carbon and play an important role regarding the mobility, toxicity, and redox transformation of organic and inorganic pollutants. The formation pathways, mineral properties, and applications of magnetite and green rust are currently active areas of research in geochemistry, environmental mineralogy, geomicrobiology, material sciences, environmental engineering, and environmental remediation. These aspects ultimately dictate the reactivity of magnetite and green rust in the environment, which has important consequences for the application of these mineral phases, for example in remediation strategies. In this review we discuss the properties, occurrence, formation by biotic as well as abiotic pathways, characterization techniques, and environmental applications of magnetite and green rust in the environment. The aim is to present a detailed overview of the key aspects related to these mineral phases which can be used as an important resource for researchers working in a diverse range of fields dealing with mixed-valent iron minerals.

Extra-mucosal enucleation is still a safe and feasible treatment option of giant esophageal leiomyomas

Esophageal leiomyoma (EL) is rare but still the most common benign tumor of the esophagus. Extra-mucosal enucleation (EME) is the treatment of choice. Many recent reports have favored esophageal resection for giant Esophageal leiomyomas (ELs). The consequence of esophageal resection is well known and it would be radical to consider it as a preferred treatment for giant EL since most of them are still benign. We share case series of five giant ELs managed by EME, avoiding a mucosal breach and hence avoiding potentially morbid esophageal resections.

Maximum surgical blood order schedule for pancreatoduodenectomy: a long way from uniform applicability!

BACKGROUND

Unnecessary preoperative ordering of blood and blood products results in wastage of a valuable life-saving resource and poses a significant financial burden on healthcare systems.

AIM

To determine patient-specific factors associated with intra-operative transfusions, and if intra-operative blood transfusions impact postoperative morbidity.

PATIENTS & METHODS

Analysis of consecutive patients undergoing pancreatoduodenectomy (PD) for pancreatic tumors.

RESULTS

A total of 384 patients underwent a classical PD with an estimated median blood loss of 200 cc and percentage transfused being 9.6%. Pre-existing hypertension, synchronous vascular resection, end-to-side pancreaticojejunostomy and nodal disease burden significantly associated with the need for intra-operative transfusions. Intra-operative blood transfusion not associated with postoperative morbidity.

CONCLUSION

Optimization of MSBOS protocols for PD is required for more judicious use of blood products.

Procamallanus spiculogubernaculus Agarwal, 1958 (Nematoda: Camallanidae) from Stinging catfish, Heteropneustes fossilis in India: morphological characterization and molecular data

The nematode, Procamallanus spiculogubernaculus Agarwal, 1958 was found from the Stinging catfish, Heteropneustes fossilis (Bloch, 1794) from Ghazipur, Delhi, India. Morphological characterization, including scanning electron microscope observation supplemented with DNA sequences is provided. Specimens recently found are characterized by the presence of an unlined buccal capsule having a small basal ring, esophagus muscular and glandular, vulva position is slightly post-equatorial, tail conical, long, and ending in three digit-like processes, phasmids present at about mid-length and cloaca located at the posterior end. In this study the species P. spiculogubernaculus is validated on the basis of molecular data after 47 years from its original description. In the scanning electron microscope examination, the topology of mouth and sensory pits in anterior portion, while the phasmids and digit like processes in posterior portion is clearly observed. Molecular data of the 18S ribosomal RNA and mitochondrial cytochrome c oxidase subunit 1 (cox1) gene were analyzed. Molecular phylogenetic analyses supported the validity of Procamallanus spiculogubernaculus and confirmed the paraphyletic status of the members of Procamallanus, Spirocamallanus, Camallanus and Paracamallanus. Taxonomic status of members of the family Camallanidae are briefly discussed along with the results of the systematic evaluation of P. spiculogubernaculus based on molecular data.

Redescription and phylogenetic analyses of Thaparocleidus gomtius and T. sudhakari (Monogenea: Dactylogyridae) from Wallago attu (Siluriformes: Siluridae) in India

Two species of Thaparocleidus Jain (1952a) were found harboring W. attu from the Ganga River at two localities, Meerut and Farrukhabad, Uttar Pradesh, India, during the period of 2013-2015. Morphology and morphometric study of specimens identified as Thaparocleidus gomtius (Jain, 1952a) Lim, 1996 and T. sudhakari (Gusev, 1976) Lim, 1996. Molecular analyses using the 18S rRNA gene confirmed the validity of T. gomtius and T. sudhakari and demonstrated that both the species clustered with other Thaparocleidus species from different geographical regions. We aim at reassessing the taxonomy and establishing the phylogenetic relationships among these two redescribed species with other representatives of the genus Thaparocleidus.

Role of MMP-7 in the pathogenesis of systemic lupus erythematosus (SLE)

Systemic lupus erythematosus (SLE) is a clinically heterogeneous chronic, inflammatory autoimmune disorder. The association of MMP-7 and disease severity is still unclear. A total of 150 SLE patients and matched healthy controls were recruited for this study. Disease activity was scored according to SLEDAI (98 active and 52 inactive disease). Mean serum MMP-7 levels were significantly higher in SLE patients than controls ( p < 0.001). Patients with active disease showed higher levels (16.24 ± 6.2 ng/ml) as against inactive disease (10.50 ± 3.97 ng/ml) ( p ≤ 0.0001). Mean MMP-7 mRNA expression was significantly higher in patients (RQ = 3.16 ± 0.93) as compared to controls (RQ = 2.21 ± 0.89, p = 0.006). A positive correlation between MMP-7 levels, mRNA expression and SLEDAI score was observed ( r = 0.563, r = 0.427). The MMP-7 -181 G allele was found to be significantly higher among SLE patients ( p < 0.0001). A significant association was noted between MMP-7 -181 A/G +G/G genotypes with renal ( p = 0.0027) and CNS ( p = 0.0031) manifestations and anti-dsDNA autoantibodies ( p = 0.0312). Serum MMP-7 levels and mRNA expression were elevated in advanced stages of SLE, indicating that MMP-7 is associated with disease activity in SLE.

Molecular characterization of three species belongs to the Allocreadioidea, Hemiuroidea and Plagiorchioidea (Platyhelminthes: Trematoda) infecting freshwater fishes in India

Three species of digenetic trematodes are redescribed based on specimens collected from the intestine of freshwater fishes of Hastinapur and Meerut (U.P.), India: Allocreadium handiai (Pande, 1937) Madhavi, 1980 (Allocreadioidea: Allocreadiidae) from Mystus tengara (Hamilton, 1822) (Siluri-formes: Bagridae), Genarchopsis goppoOzaki, 1925 (Hemiuroidea: Derogenidae) and Phyllodistomum chauhaniMotwani & Srivastava, 1961 (Plagiorchioidea: Gorgoderidae) from Channa punctata (Bloch, 1793) (Perciformes: Channidae). The three species were subjected to morphological, morphometric and molecular analyses. The morphological study revealed that A. handiai, G. goppo and P. chauhani can be distinguished by their congeners on the basis of their morphology. Partial nucleotide sequences of the 28S ribosomal RNA gene were obtained from the three trematode species and deposited in the GenBank. A phylogenetic reconstruction based on the 28S rRNA gene placed the three studied species within their respective families and their validity is discussed. For the first time molecular data of newly collected material of these species from India were used for confirmation of their validity and to assess their phylogenetic relationships.

Genome wide array-CGH and qPCR analysis for the identification of genome defects in Williams' syndrome patients in Saudi Arabia

Background

Williams-Beuren Syndrome (WBS) is a rare neurodevelopmental disorder characterized by dysmorphic features, cardiovascular defects, cognitive deficits and developmental delay. WBS is caused by a segmental aneuploidy of chromosome 7 due to heterozygous deletion of contiguous genes at the long arm of chromosome 7q11.23. We aimed to apply array-CGH technique for the detection of copy number variants in suspected WBS patients and to determine the size of the deleted segment at chromosome 7q11.23 in correlation with the phenotype. The study included 24 patients referred to the CEGMR with the provisional diagnosis of WBS and 8 parents. The patients were subjected to conventional Cytogenetic (G-banding) analysis, Molecular Cytogenetic (Fluorescent In-Situ Hybridization), array-based Comparative Genomic Hybridization (array-CGH) and quantitative Real time PCR (qPCR) Techniques.

Results

No deletions were detected by Karyotyping, however, one patient showed unbalanced translocation between chromosome 18 and 19, the karyotype was 45,XX, der(19) t(18;19)(q11.1;p13.3)-18. FISH technique could detect microdeletion in chromosome 7q11.23 in 10/24 patients. Array-CGH and qPCR confirmed the deletion in all samples, and could detect duplication of 7q11.23 in three patients and two parents. Furthermore, the size of the deletion could be detected accurately by both array-CGH and qPCR techniques. Three patients not showing the 7q11.23 deletion were diagnosed by array-CGH to have deletion in chr9p13.1-p11.2, chr18p11.32-p11.21 and chr1p36.13.

Conclusion

Both FISH and array-CGH are reliable methods for the diagnosis of WBS; however, array-CGH has the advantage of detection of genome deletions/ duplications that cannot otherwise be detected by conventional cytogenetic techniques. Array-CGH and qPCR are useful for detection of deletion sizes and prediction of the interrupted genes and their impact on the disease phenotype. Further investigations are needed for studying the impact of deletion sizes and function of the deleted genes on chromosome 7q11.23.

Trial registration

ISRCTN ISRCTN73824458. MOCY-D-16-00041R1. Registered 28 September 2014. Retrospectively registered.

Molecular and ultrastructure characterization of two nematodes (Thelandros scleratus and Physalopteroides dactyluris) based on ribosomal and mitochondrial DNA sequences

The phylogenetic relationships of the nematode species Thelandros scleratus (Oxyurida: Pharyn-godonidae) and Physalopteroides dactyluris (Spirurida: Physalopteridae) were analyzed using the ribosomal 18S rRNAand the mitochondrial cytochrome C oxidase subunit genes. The nematodes were recovered from Brook's house gecko, Hemidactylus brooki (Reptilia: Gekkonidae) from Hast-inapur, Meerut (U.P.), India. The results demonstrated that T. scleratus shows 100% similarity with another sequence available from the same species and a close relationship (98-99%) with species of Parapharyngodon in both 18S rRNAand cox 1 regions. Regarding the nematode Physalopteroides. analysis showed a close phylogenetic relationship between P. dactyluris and several species of Phy-saloptera. This is the first sequence of 18S available for any species of the genus Physalopteroides

The cost of Pancreatoduodenectomy - An analysis of clinical determinants

BACKGROUND

Health care spending is increasing the world over. Determining preventable or correctable factors may offer us valuable insights into developing strategies aimed at reducing costs and improving patient care. The aim of this study was to conduct an exploratory analysis of clinical factors influencing costs of Pancreatoduodenectomy (PD).

METHODS

The financial and clinical records of 173 consecutive patients who underwent PD at a tertiary care referral centre, between January 2013 and June 2015 were analysed.

RESULTS

Complications, by themselves, did not increase costs associated with PD unless they resulted in an increase in the duration of stay more than 11 days. Intraoperative blood transfusion (p-.098) and performance of an end-to-side PJ (p-.043) were independent factors significantly affecting costs. Synchronous venous resections significantly increased costs (p-.006) without affecting duration of stay. Advancing age, hypertension, neurological and respiratory disorders, preoperative endoscopic retrograde cholangiopancreatography (ERCP), performance of a feeding jejunostomy, and surgical complications eg PPH, POPF and DGE significantly increased the duration of stay sufficient enough to influence costs of PD.

CONCLUSIONS

It is not the merely the development, but severity of complications that significantly increase the cost of PD by increasing hospital stay. Strategies aimed at reducing intraoperative blood transfusion requirement as well as minimising the development of POPF can help reduce costs. Synchronous venous resections significantly increase costs independent of hospital stay. This study identified nine factors that may be included in the development of a preoperative nomogram that could be used in preoperative financial counselling of patients undergoing PD.

ID: 64: REVERSIBLE BLINDNESS ASSOCIATED WITH DIABETIC KETOACIDOSIS: A RARE COMBINATION

Introduction

A wide spectrum of ocular diseases is associated with diabetes mellitus (DM) and most of them lead to gradual loss of vision that is almost always irreversible. Sudden vision loss in severe diabetic ketoacidosis (DKA) that is reversible with treatment of the metabolic abnormality is a very rare complication that has been reported three times previously.

Case Presentation

A 59 year-old male with Type 1 DM presented with altered consciousness, epigastric pain, hypothermia and sudden complete bilateral vision loss for three days. He was not complaint with insulin. There was no history or laboratory evidence of ethanol, methanol, ethylene glycol ingestion, head trauma, baseline vision problem, cold or intense bright light exposure.

Physical examination revealed rapid shallow breathing at 55/min, blood pressure 90/60 mm Hg, heart rate 102/min and temperature 90.2F. He was oriented only to place,pupils were dilated and non-reactive to light. No light perception in both eyes. Fundoscopy was normal without any evidence of retinal pallor, retinal detachment, retinal hemorrhages, papilledema or cataract.

Labs revealed blood glucose 1100 mg/dl, pH 6.95,positive serum and urine ketones, pCO2 11 mm Hg and anion gap 36. He received aggressive warm fluid resuscitation, electrolyte replacements and intravenous insulin infusion with close monitoring. 18 hrs later his blood glucose, pH,anion gap and body temperature normalized and vision spontaneously returned to normal. A repeat fundoscopy exam by ophthalmologist and magnetic resonance image (MRI) brain was completely normal; ruling out posterior ischemic optic neuropathy and occipital stroke. He recovered very well, resumed diet, was ambulatory and had an uneventful rest of hospital course.

Discussion

Sudden painless vision loss has a wide differential diagnosis and it is usually caused by ischemia at retinal, ocular or cortical level. No history of methanol ingestion or trauma, normal fundoscopy, normal MRI and rapid return of vision after correction of diabetic ketoacidosis strongly suggests that blindness was related to acidosis.

Alcoholic ketoacidosis has been reported to cause transient reversible blindness in other case reports and correction of acidosis lead to reversal of blindness. Other rare causes of reversible blindness include posterior reversible encephalopathy syndrome, brain tumors, anterior ischemic optic neuropathy and valsalva retinopathy.

The mechanism of acidosis causing blindness is believed to be uncoupling of horizontal cells at pH <7.0 inhibiting photoreceptor transmission as suggested by studies on fish and salamander. Other possible mechanisms include hyperosmolarity causing ischemia or transient lens opacification but in none of the reported cases this was proven. Also lens opacification would have been seen at fundoscopy. Posterior ischemic optic neuropathy is another possibility but it is irreversible. The exact mechanism of blindness remains poorly understood. However irrespective of mechanism of acidosis, its rapid correction to pH >7.0 leads to rapid recovery suggesting a common pathogenesis.

ID: 55: FIBRILLARY GLOMERULONEPHRITIS:LOOKS LIKE AMYLOID BUT ITS NOT!

Introduction

Fibrillary glomerulonephritis is a rare disorder with a prevalence of 1% in renal biopsies.The mean age of presentation is 50 years, proteinurea in 100%, nephrotic syndrome in 70–75%, renal insufficiency (Cr≥1.5) in 50–55%, hypertension 70% and hematuria in 70% cases.Etiology is unknown and diagnosis is established by pathognomonic electron microscopy findings. This case illustrates the presentation, workup and diagnosis of fibrillary glomerulonephritis (FGN).

Case Description

A 49 year-old-female with history of hypertension, obstructive sleep apnea,non-steroidal anti inflammatory drug use for chronic back pain presented with shortness of breath on exertion and bilateral lower extremity swelling.

Vital signs showed temperature 35.6 C, heart rate 75/min, respiratory rate 21/min and blood pressure 112/68 mm Hg.She had mild respiratory distress, bilateral crackles at lung bases and bilateral +2 pedal edema on physical examination.

Complete blood count showed hemoglobin 10.7 g/dl and normal white cell count. Complete metabolic panel showed creatinine 1.1 mg/dl, blood urea nitrogen 21 mg/dl, albumin 2.6 g/dl and normal electrolytes. Urinalysis showed pH 6.0,specific gravity 1.028,+4 proteinuria,+2 hematuria and no casts. 24hour urine collection showed 4.3 g/day nephrotic proteinuria. Lipid profile showed cholesterol 308 mg/dl and non-HDL cholesterol 246 mg/dl.

Hepatitis C, HIV, Goodpasture Disease, Cryoglobulinemia, Systemic Lupus Erythematosus and other autoimmune diseases were ruled out by appropriate tests. Serum and urine protein electrophoresis were without M-spike but with high free Lambda (29.7 mg/dl) and Kappa chains (23.6 mg/dl). A diagnosis of nephrotic syndrome was made due to the presence of edema, proteinuria, hypoalbuminemia and hyperlipidemia.

A renal biopsy was done to evaluate the etiology of nephrotic syndrome. Biopsy showed focal segmental and global glomerulosclerosis with mild to moderate interstitial fibrosis and tubular atrophy. Immunofluorescence showed staining of glomerular capillary walls and mesangium for IgG, kappa and lambda. Electron microscopy showed linear, non-branching fibrils in the mesangium that averaged 20 nm in width (11.7–28.6 nm).Congo red staining was negative.

Discussion

A study of 66 cases identified most common histologic patterns as mesangial, membranoproliferative, endocapillary proliferative, crescentic and necrotizing, membranous and diffuse sclerosing in order of likelihood.This case had focal segmental and global glomerulosclerosis that is a rare finding.

In the same study immunofluorescence staining was positive for IgG in 100%, C3 in 92% and both kappa and lambda in 84% cases. This case also demonstrated positive staining for IgG, kappa and lambda.

The pathognomonic finding is presence of fibrillary deposits in the mesangium and glomerular capillary walls distinct from amyloidosis.The size of fibrils ranges from 8–15 nm in Amyloid and 12–24 nm in FGN. IgG is usually monoclonal in AL Amyloid as compared to polyclonal in FGN. The characteristic difference from amyloid is absence of reaction to histochemical dyes like Congo Red and Thioflavin T in FGN.

One third of FGN cases are associated with malignancy, monoclonal gammopathy and autoimmune disorders. In our case an extensive workup was negative for all these conditions.

Angiotensin inhibitors (ACEI) are used if the glomerular filtration rate is normal and proteinuria is present,to control blood pressure and reduce disease progression. Evidence for use of steroids and immunosuppressants is based on uncontrolled studies with variable success.In our patient a limited trial of corticosteroids with mycophenolate resulted in some improvement in proteinuria alongwith ACEI.