Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Conventional vs Short Duration of Antibiotics in Patients With Moderate or Severe Cholangitis: Noninferiority Randomized Trial

INTRODUCTION

Successful biliary drainage and antibiotics are the mainstays of therapy in management of patients with acute cholangitis. However, the duration of antibiotic therapy after successful biliary drainage has not been prospectively evaluated. We conducted a single-center, randomized, noninferiority trial to compare short duration of antibiotic therapy with conventional duration of antibiotic therapy in patients with moderate or severe cholangitis.

METHODS

Consecutive patients were screened for the inclusion criteria and randomized into either conventional duration (CD) group (8 days) or short duration (SD) group (4 days) of antibiotic therapy. The primary outcome was clinical cure (absence of recurrence of cholangitis at day 30 and >50% reduction of bilirubin at day 15). Secondary outcomes were total days of antibiotic therapy and hospitalization within 30 days, antibiotic-related adverse events, and all-cause mortality at day 30.

RESULTS

The study included 120 patients (the mean age was 55.85 ± 13.52 years, and 50% were male patients). Of them, 51.7% patients had malignant etiology and 76.7% patients had moderate cholangitis. Clinical cure was seen in 79.66% (95% confidence interval, 67.58%-88.12%) patients in the CD group and 77.97% (95% confidence interval, 65.74%-86.78%) patients in the SD group ( P = 0.822). On multivariate analysis, malignant etiology and hypotension at presentation were associated with lower clinical cure. Total duration of antibiotics required postintervention was lower in the SD group (8.58 ± 1.92 and 4.75 ± 2.32 days; P < 0.001). Duration of hospitalization and mortality were similar in both the groups.

DISCUSSION

Short duration of antibiotics is noninferior to conventional duration in patients with moderate-to-severe cholangitis in terms of clinical cure, recurrence of cholangitis, and overall mortality.

Racial differences in healthcare utilization among patients with suspected or diagnosed preeclampsia: A retrospective cohort study

OBJECTIVES

To analyze healthcare resource utilization and severe maternal morbidity (SMM) in Black and White patients with preeclampsia diagnosis versus signs/symptoms.

STUDY DESIGN

This was a retrospective cohort study analyzing data from the IBM® Explorys Database between 7/31/2012-12/31/2020. Demographic, clinical, and laboratory data were extracted. Healthcare utilization and SMM were analyzed during the antepartum period (20 weeks of gestation until delivery) among Black and White patients with signs/symptoms of preeclampsia, with a diagnosis of preeclampsia, or neither (control).

MAIN OUTCOME MEASURES

Healthcare utilization and SMM in those with a preeclampsia diagnosis or signs/symptoms of preeclampsia only were compared with a control group (White patients with no preeclampsia diagnosis or signs/symptoms).

RESULTS

Data from 38,190 Black and 248,568 White patients were analyzed. Patients with preeclampsia diagnosis or signs/symptoms were more likely to visit the emergency room compared to those without diagnosis or signs/symptoms. Black patients with signs/symptoms of preeclampsia had the highest elevated risk (odds ratio [OR] = 3.4), followed by Black patients with a preeclampsia diagnosis (OR = 3.2), White patients with signs/symptoms (OR = 2.2), and White patients with a preeclampsia diagnosis (OR = 1.8). More Black patients experienced SMM (SMM rate 6.1% [Black with preeclampsia diagnosis] and 2.6% [Black with signs/symptoms]) than White patients (5.0% [White with preeclampsia diagnosis] and 2.0% [White with signs/symptoms]). SMM rates were higher for Black preeclampsia patients with severe features than for White preeclampsia patients with severe features (8.9% vs 7.3%).

CONCLUSIONS

Compared with White patients, Black patients had higher rates of antepartum emergency care and antepartum SMM.

Society of Gastrointestinal Endoscopy of India Consensus Guidelines on Endoscopic Ultrasound-Guided Biliary Drainage: Part I (Indications, Outcomes, Comparative Evaluations, Training)

Endoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreaticography (ERCP). However, even in expert hands the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or more commonly percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreatico-biliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates.

EUS-BD, albeit, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD, nor the accessories and stents for EUS-BD have been standardized.

Additionally, different countries and regions have different availability of the accessories making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, the Society of Gastrointestinal Endoscopy India deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD.

Deep Venous Thrombosis in Acute Pancreatitis Is Associated with High Mortality: A Prospective Study

BACKGROUND

Incidence and risk factors for the development of extremity deep vein thrombosis (eDVT) in admitted patients of acute pancreatitis have been rarely explored.

AIMS

To identify the incidence of eDVT and to explore role of clinical scores for predicting eDVT in admitted patients of acute pancreatitis.

METHODS

We prospectively enrolled admitted patients of acute pancreatitis and performed a weekly eDVT screen for the duration of their admission. Well's score and Padua's score were also calculated weekly. The incidence of venous thrombosis (eDVT and splanchnic thrombosis based on contrast-enhanced CT scan abdomen) was noted, and the risk factors were determined using multivariate analysis. The correlation between Well's score, Padua's score, and development of DVT was calculated using Pearson's correlation.

RESULTS

Of the 102 patients of acute pancreatitis enrolled, 73.5% of patients had necrotizing pancreatitis. Total of 46 patients (45.1%) developed thrombosis: 43 patients had splanchnic vein thrombosis; 5 patients had eDVT; and 1 patient had pulmonary embolism. Patients with eDVT had higher BISAP score (2.6 ± 0.9 vs 1.7 ± 0.8; p = 0.039), requirement of mechanical ventilation (60% vs 8.2%; p = 0.008), and mortality (60% vs 12.4%; p = 0.022). Well's score of ≥ 2 had sensitivity and specificity of 80% and 96.9% for prediction of eDVT and it had better correlation with the development of eDVT compared to Pauda's score.

CONCLUSION

Incidence of DVT is 5% in patients with acute pancreatitis requiring admission. It is associated with higher disease severity and mortality. The Well's score is useful to predict the development of eDVT in routine clinical practice.

Outcome of percutaneous transhepatic biliary interventions in the management of biliary enteric anastomotic strictures with hepatolithiasis

AIM

To evaluate percutaneous transhepatic biliary interventions (PTBI) using the ADDFREE (Access-Drain-Dilate-Flush-REpeat periodically-Evaluate and remove) technique and its outcomes in patients with biliary enteric anastomotic strictures (BEAS) and hepatolithiasis.

MATERIAL AND METHODS

A retrospective review was undertaken of patients having hepatolithiasis with BEAS who underwent PTBI with a therapeutic intent (from January 2010 to January 2021) was performed. The technical and clinical successes of PTBI were analysed. Technical success was divided into duct access, crossing of BEAS, stricture resolution, and calculi clearance. Improvement of liver function tests, resolution of leucocytosis and presenting complaints were considered as clinical success. The patients were followed-up for a minimum duration of 6-months.

RESULTS

Eighteen patients received PTBI in form of the ADDFREE technique. Hepatolithiasis was bilobar (44.4%), unilobar in multiple ducts (unilobar-m; 27.8%) and unilobar in a single duct (unilobar-s; 27.8%) along with anastomotic stricture. The average number of sessions of stone clearance for bilobar, unilobar-m, and unilobar-s was 4.4 (±1.6), 3.6 (±2.4), and 1.5 (±0.5), respectively. Clinical success was observed in 14 (77.8%), while one patient had recurrence of calculi and received repeat treatment. Bile culture was positive for bacterial organisms in 17 (94.4%) patients. No major complication were seen while minor complication were seen in five patients consisting of self-limiting haemobilia (n=1), per-catheter bile leak (n=2) and aggravation of cholangitis (n=2).

CONCLUSION

PTBI, consisting of bile duct access, cholangioplasty, and calculi clearance, is a safe and effective technique for the treatment of patients having hepatolithiasis secondary to BEAS.

Barriers for using amoxycillin dispersible tablet in pediatric pneumonia treatment in Bangladesh

 

World Health Organization recommends guideline for integrated management of childhood illnesses (IMCI) where Amoxicillin Dispersible Tablet (DT) appears as the first drug of choice for treating childhood pneumonia. The Government of Bangladesh adopted the IMCI strategy in 1998, and scaled it up nationwide by 2014. But, even today, the use of Amoxicillin DT, either in public or private sector, for managing childhood pneumonia is a rare event in Bangladesh. We conducted this exploratory study to understand the existing barriers, both in public and private sector, those have influences on reduced availability of Amoxicillin DT and non-compliance of health service providers to follow IMCI guideline by using Amoxicillin DT for treating a child with pneumonia, in Bangladesh. We conducted desk review of relevant strategy and policy documents, key informant interviews with 19 key individuals from Ministry of Health and national / international NGOs. Collected information were analyzed and interpreted using thematic analysis method. Identified barriers through this study pointed to inadequate policy level focus on IMCI implementation, non-inclusion of Amoxicillin DT in the national essential drug list, single source of Amoxicillin DT producing pharmaceutical in the country coupled with bureaucracy and procurement procedural complexity, lack of training of health service providers and abundant availability of antibiotic over the counter. Study respondents recommended for policy level strengthening of IMCI program, increasing coverage of training for health care provider, including practicing pediatricians both at public and private sectors, facilitating production and procurement procedures and prohibiting antibiotic sell over the counter.

Key messages

• Facilitation of production and procurement procedure coupled with enforcement of law prohibiting antibiotics availability over the counter are urgent needs.

• Policy level support emphasizing full compliance of service providers for quality of implementation of IMCI program in Bangladesh (and similar other settings) is also important.

A Case of Bilateral Middle Cerebral Artery Stenosis with Unilateral M1 Stenting

Stroke is not only the third leading cause of death in Bangladesh but it also causes a high number of disability adjusted life years loss (485 per 10,000 people). Appropriate treatment of recurrent stroke has to be established. Here we present A 60 year's old male patient with history of recurrent stroke who came in our out patient department. He had progressing bilateral middle cerebral artery atherosclerotic stenosis (100.0% on right side and 52.0% on left side) which was less severs but symptomatic at dominant hemisphere (left). Percutaneous transluminal angioplasty with stenting was done to prevent further ischemia and to increase the blood supply of remaining brain parenchyma. On post stenting follow-up patient did not suffered from any new event of stroke for about 22 months. Percutaneous transluminal angioplasty with stenting is an effective procedure to prevent recurrent stroke for intracranial atherosclerotic disease.

Malignant Neuroendocrine Tumor of Gall Bladder: An Incidental Finding

Neuroendocrine tumor of the gallbladder is a rare gallbladder tumor with aggressive behavior and poor prognosis. Cholelithiasis is the most important risk factor for it. The clinical presentations of most patients are non-specific and vague abdominal pain is the most common initial symptom followed by cholecystitis, with obstructive jaundice, weight loss, ascites, pruritus or palpable mass and occasional associated endocrine manifestations. Surgery remains the main cornerstone for it. In January 2019, in the department of Hepatobiliary, Pancreatic and Liver transplant surgery in Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, a 30-year-old female presented with incidental finding of gallbladder mass. Extended cholecystectomy was performed. Histopathology examination revealed small cell neuroectodermal tumor of the gallbladder.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Perforations from Endoscopic Dilation of Corrosive Strictures in Adults: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Endoscopic dilation is an important therapeutic option for treatment of corrosive strictures. Its safety is unclear with variable perforation rates in previous studies. We aimed to evaluate its safety with regard to perforations and the effect of dilator type to perforation risk.

METHODS

A systematic review of published literature from inception to April 24, 2021, using PubMed and EMBASE databases was conducted. Studies in adult subjects (mean age ≥ 18 years) reporting perforation rates of endoscopic dilation of corrosive esophageal and/or gastric strictures were included. Pooled cumulative perforation rates were computed as primary outcome. Secondary outcomes included, perforation with each dilator subtypes, surgical or conservative modes of management and mortality. Random effect meta-analysis was used to estimate the frequency of each of these outcomes. Variables were reported as percentages with 95% CI.

RESULTS

A total of 712 subjects (N) who underwent 4840 dilations (n) were noted in the 15 studies that were included. Of which, eight were retrospective, while the remaining seven were prospective. On meta-analysis, the cumulative pooled perforation rate was 1% (1-2%) of the number of dilations (n%). The perforation rates with SG (1%, 0-3%) and balloon (1%, 0-5%) dilators were similar (p value < 0.01). 45/64 (59%, 11-94%) perforations were subjected to surgery while the remaining 14/64 (41%, 6-89%) was managed conservatively. Choice of management strategy was biased to the norms of the treating team. About 3/712 patients (0%, 0-2%) succumbed following perforation.

CONCLUSION

Perforation from endoscopic dilation of corrosive strictures occurs rarely, and there is no significant difference in perforation risk related to the type of dilator.

Response evaluation of locoregional therapies in combined hepatocellular-cholangiocarcinoma and intrahepatic cholangiocarcinoma versus hepatocellular carcinoma: a propensity score matched study

AIM

To evaluate the response of locoregional therapy (LRT) on combined hepatocellular-cholangiocarcinoma (cHCC-CC) and intrahepatic cholangiocarcinoma (IHC) and compare their outcomes with propensity matched hepatocellular carcinoma (HCC) patients.

MATERIALS AND METHODS

From January 2011 to July 2020, 13 patients with cHCC-CC (11 men, two women, median age 56 years) and 15 IHC patients (10 men, five women, median age 60 years) were compared with 101 HCC patients (79 men, 22 women, median age 60 years) after LRT. All tumours were proven histologically. Among the 13 cHCC-CC patients, 11 received transarterial chemoembolisation (TACE), one received microwave ablation (MWA) and one received TACE with radiofrequency ablation (RFA). Of 15 IHC patients, eight received TACE, five received RFA, and one received MWA, and one received TACE with RFA. Propensity score matching (PSM) was done with conditional logistic regression adjusted for age, type of LRT, tumour specific features and Child-Pugh score.

RESULTS

After LRT, on univariate analysis an objective response was seen in 30% of cHCC-CC and 53% of IHC patients. PSM analysis demonstrated shorter progression-free survival (PFS; cHCC-CC versus HCC: 1.5 versus 7.5 months; IHC versus HCC: 6 versus 14 months, p<0.05), overall survival (OS; cHCC-CC versus HCC: 12 versus 28 months; IHC versus HCC: 18 versus 34 months, p<0.005), and poor objective response (cHCC-CC versus HCC: 25% versus 91%; IHC versus HCC: 58% versus 88%, p<0.05) in cHCC-CC and IHC patients versus HCC patients. Hypovascular tumour, macrovascular invasion, and infiltrative appearance were independent prognostic factors for OS in IHC patients.

CONCLUSION

cHCC-CC and IHC are aggressive tumours with a poor objective response, greater distant progression of the disease and shorter PFS and OS post LRT as compared to HCC.

Cytomorphological and immunocytochemical diagnosis of an oesophageal mass in a 62-year-old female with dysphagia

Oesophageal schwannoma is an extremely rare benign neoplasm. Cytological diagnosis of oesophageal schwannoma has been sporadically reported in the literature. Herein, we present a case of oesophageal schwannoma in an older woman that could be accurately diagnosed based on endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology accompanied by cell block immunocytochemistry.

Abdominal lymphatic malformation: Spectrum of imaging findings

Lymphatic malformations are congenital vascular malformations with lymphatic differentiation. Although the most common locations for lymphatic malformation are the neck and axilla, they can occur at several locations in the body including the abdomen. The abdominal location is rather rare and accounts for approximately 5% of all lymphatic malformation. Abdominal lymphatic malformation can arise from mesentery, omentum, gastrointestinal tract, and retroperitoneum. Clinical presentation includes an abdominal lump, vague abdominal discomfort, and secondary complications including intestinal obstruction, volvulus, ischemia, and bleeding. There is a broad spectrum of radiological manifestation. In the present review, we discuss the imaging appearance of abdominal lymphatic malformation. The diagnosis of lymphatic malformation in our series was based on the histopathological examination (in cases who underwent surgery) and fine needle aspiration cytology.

Spleen-preserving distal pancreatectomy following grade III pancreatic injury in a delayed presentation: a technical challenge

Pancreatic injuries are often overlooked in view of subtle clinical signs, and high index of suspicion is required to manage these injuries. Management strategies vary depending on the grade of injury and associated solid organ injuries and vascular injuries. Early surgery is advised in patients with duct disruption to avoid complications related to duct disruption. We present a case of 19-year-old man with delayed presentation following pancreatic trauma. During the surgery, changes of pancreatitis were noted and posterior wall of the stomach was adherent to pancreas, and inflammatory changes in vicinity of pancreas posed a significant challenge while dissecting pancreas away from the splenic vein. Spleen-preserving distal pancreatectomty (SPDP) was done. SPDP is time-consuming and technically challenging procedure especially in patients with delayed presentation. It is safe and feasible to consider spleen preservation in pancreatic trauma when patient is haemodynamically stable and expertise is available.

Rupture of portal vein pseudoaneurysm caused by impinging infected walled off pancreatic necrosis (WOPN): a rare complication

We report a case of walled off pancreatic necrosis in a patient with alcoholic pancreatitis who underwent endoscopic ultrasound-guided multiple pigtail catheter drainage. 10 days later patient presented with massive haemorrhage likely due to erosion of portal vein pseudoaneurysm caused by decubitus of pigtails. Patient required emergent portal venorrhaphy to arrest haemorrhage.

An international study of interobserver variability of "string sign" of pancreatic cysts among experienced endosonographers

Background and Objectives:

No single optimal test reliably determines the pancreatic cyst subtype. Following EUS-FNA, the “string sign” test can differentiate mucinous from nonmucinous cysts. However, the interobserver variability of string sign results has not been studied.

Methods:

An experienced endosonographer performed EUS-FNA of pancreatic cysts on different patients and was recorded on video performing the string sign test for each. The videos were shared internationally with 14 experienced endosonographers, with a survey for each video: “Is the string sign positive?” and “If the string sign is positive, what is the length of the formed string?” Also asked “What is the cutoff length for string sign to be considered positive?” Interobserver variability was assessed using the kappa statistic (κ).

Results:

A total of 112 observations were collected from 14 endosonographers. Regarding string sign test positivity, κ was 0.6 among 14 observers indicating good interrater agreement (P < 0.001) while κ was 0.38 when observers were compared to the index endosonographer demonstrating marginal agreement (P < 0.001). Among observations of the length of the string in positive samples, 89.8% showed >5 mm of variability (P < 0.001), indicating marked variability. There was poor agreement on the cutoff length for a string to be considered positive.

Conclusion:

String sign of pancreatic cysts has a good interobserver agreement regarding its positivity that can help in differentiating mucinous from nonmucinous pancreatic cysts. However, the agreement is poor on the measured length of the string and the cutoff length of the formed string to be considered a positive string sign.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Bayesian strategy selection identifies optimal solutions to complex problems using an example from GP prescribing

Complex health problems require multi-strategy, multi-target interventions. We present a method that uses machine learning techniques to choose optimal interventions from a set of possible interventions within a case study aiming to increase General Practitioner (GP) discussions of physical activity (PA) with their patients. Interventions were developed based on a causal loop diagram with 26 GPs across 13 clinics in Geelong, Australia. GPs prioritised eight from more than 80 potential interventions to increase GP discussion of PA with patients. Following a 2-week baseline, a multi-arm bandit algorithm was used to assign optimal strategies to GP clinics with the target outcome being GP PA discussion rates. The algorithm was updated weekly and the process iterated until the more promising strategies emerged (a duration of seven weeks). The top three performing strategies were continued for 3 weeks to improve the power of the hypothesis test of effectiveness for each strategy compared to baseline. GPs recorded a total of 11,176 conversations about PA. GPs identified 15 factors affecting GP PA discussion rates with patients including GP skills and awareness, fragmentation of care and fear of adverse outcomes. The two most effective strategies were correctly identified within seven weeks of the algorithm-based assignment of strategies. These were clinic reception staff providing PA information to patients at check in and PA screening questionnaires completed in the waiting room. This study demonstrates an efficient way to test and identify optimal strategies from multiple possible solutions.

Imaging in chronic pancreatitis: State of the art review

Chronic pancreatitis (CP) is an important gastrointestinal cause of morbidity worldwide. It can severely impair the quality of life besides life-threatening acute and long-term complications. Pain and pancreatic exocrine insufficiency (leading to malnutrition) impact the quality of life. Acute complications include pseudocysts, pancreatic ascites, and vascular complications. Long-term complications are diabetes mellitus and pancreatic cancer. Early diagnosis of CP is crucial to alter the natural course of the disease. However, majority of the cases are diagnosed in the advanced stage. The role of various imaging techniques in the diagnosis of CP is discussed in this review.

Invasive aspergillosis causing gastric necrosis and perforation: A case report

Aspergillosis is an opportunistic infection commonly seen in immunocompromised patients. Patients with hematological malignancies, postorgan transplantation, or those with comorbid conditions are susceptible to the development of invasive aspergillosis. Lungs are the main portal of entry and are thus most commonly involved. Aspergillosis can involve the gut, causing vascular thrombosis leading to ischemia and necrosis of the gut wall, resulting in perforation. Primary gastric involvement has been rarely seen, with few case reports in the literature. We report a rare case of primary invasive gastric aspergillosis in a 60‐year‐old diabetic and cirrhotic woman, who presented with clinical features of perforation peritonitis. Exploratory laparotomy was performed, and a 6 cm × 6 cm perforation with necrotizing inflammation was found in the distal stomach, pylorus, and duodenum. Distal gastrectomy with Billroth II reconstruction was performed. Pathology demonstrated septate fungal hyphae invading the gastric wall transmurally. The morphology was compatible with those of Aspergillus spp. Liposomal amphotericin B was started immediately after surgery based on the presence of unusually large areas of necrosis and perforation with blackish exudate covering the ulcer base. Unfortunately, the patient succumbed to rapidly progressive fungal septicemia despite early surgical intervention and critical care management. We recommend that any large confluent areas of gastric ulceration and necrosis with blackish exudates in an appropriate setting should evoke suspicion of invasive fungal infection. These patients should be started on prophylactic broadspectrum antifungal therapy immediately, which may be switched over to specific therapy once the diagnosis is confirmed.

Intestinal Tuberculosis: A Rare Case of Massive Gastrointestinal Bleed in a Post-Renal Transplant Recipient

Massive rectal bleeding is an uncommon presentation of ileal tuberculosis (TB). We report an uncommon cause of anemia in a post-renal transplant patient due to massive lower gastrointestinal (LGI) bleed. The index case had a normal upper and LGI endoscopy, but the ⁹⁹technetium labeled red blood cell scan showed active bleeding from terminal ileum and caecum. Microscopic examination of the resected specimen revealed tubercular granuloma with acid-fast bacilli. Intestinal TB should be a differential diagnosis for massive LGI bleed in immunosuppressed patients in developing country.

Thoracic complications of pancreatitis

Acute pancreatitis in its severe form may lead to systemic inflammatory response syndrome and multisystem organ dysfunction. Acute lung injury is an important cause of mortality in the setting of severe acute pancreatitis. Besides lung involvement, acute and chronic pancreatitis may also lead to the involvement of other thoracic compartments, including mediastinum, pleura, and vascular structures. These manifestations are an important cause of morbidity and may pose diagnostic and therapeutic challenges. These manifestations have not been discussed in detail in the available literature. In this review, we discuss the thoracic complications of pancreatitis, including lung, pleural, mediastinal, and vascular manifestations.

Benzo(a)pyrene, an Active Product of Cigarette Smoke, Role in PLA2 Isoforms Activation in Colon Cancer

Background and aim: One of the active combustion product of cigarette smoke, Benzo[a]pyrenes, role in pulmonary cancer is clearly understood. However, its role in gastrointestinal cancer including colon cancer is not clearly understood. Methods: In this study, benzo(a)pyrenes was treated to colon cells to evaluate its role in cell viability, cellular ROS, and gene expression of various PLA2 isoforms was evaluated by FACS and PCR. The identified PLA2 was silenced at the gene level to evaluate its role in cell viability and ROS generation. Results: B(a)P treatment at 1 µg/mL for 48 h to HCT-15 male colon cells significantly reduced the cell viability without affecting HT-29 female colon cells. Higher doses and longer treatment duration with B(a)P showed that female colon cells were highly sensitive than male colon cells. Annexin-V/PI staining for preapoptotic detection showed that B(a)P treatment increased the apoptosis in both the cell types in a concentration and time-dependent manner. The cytosolic ROS (cROS) and superoxide radical (SOR) formation in the female colon cells was significantly higher than male colon cells unlike the mitochondrial ROS (mtROS) production which was significantly higher in male colon cells. Treatment with B(a)P significantly upregulated the IID and IVA PLA2 isoform groups in HCT-15 male colon cells, whereas IB was upregulated in HT-29 female colon cells among the various PLA2 isozyme gene studied (IB, IID, III, IVA, IVB, IVC, VI, X, aiPLA2 and iPLA2). Gene silencing experiments targeting PLA2 IID and IVA in the HCT-15 male colon cells and IB in HT-29 female colon cells showed no effect with B(a)P treatment on the cell proliferation, apoptosis, membrane integrity and free radicals (ROS, mtROS, and SOR) generation. Conclusion: Targeting specific PLA2 isozymes in a cell-specific manner abolished the B(a)P-induced PLA2-mediated oxidative damage–related signaling pathways.