First-Year follow-up of Newborns Operated for Esophageal Atresia in a Developing Country: Just Operating is not Enough!

Purpose:

To identify complications, their incidence and risk factors for their occurrence in patients of esophageal atresia (EA) in the 1^st year after discharge following surgery.

Materials and Methods:

Cases of EA discharged after surgical intervention in the period of July 2011–July 2013 were considered a cohort. All data regarding demographics, investigations, surgical procedure, outcome, and follow-up were recorded.

Results:

Seventy-six such patients were discharged in the study period, six of whom were lost to follow-up, and hence, seventy patients were included in the study. Of these 70, 48 (69%) had esophageal continuity restored (46 EA + tracheoesophageal fistula [TEF]; 2 pure EA), while 22 (31%) had been diverted (3 pure EA; 8 EA + TEF following major leak; 11 long gap EA + TEF). Risk of developing any complication (except death) was 48/70 (68%; 95% confidence interval [CI] = 57.4–79.7). Twenty-six of 48 patients with esophageal continuity restored, demonstrated narrowing on contrast study (54%; 95% CI = 39.5–68.7) but only 18 of these 48 (37.5%) had dysphagia. Thirty-one of seventy had an episode of lower respiratory tract infection (LRTI) (44.2%; 95% CI = 32.3%–56.2%). Poor weight gain was observed in 27/70 (37%), and this was significantly common in diverted patients (63% vs. 25%; P = 0.009). Twenty-one of total 70 (30%) patients died within the 1^st year following discharge.

Conclusions:

Sixty-eight percent of cases developed some complication, while 30% succumbed within the 1^st year of life following discharge. The common complications were stricture, LRTI, and poor weight gain. All of these were common in diverted patients.

Spectrum of Colonic Polyps in a South Indian Urban Cohort

Background: The histological nature of polyps by site prevalence and size is unclear. Aim: To determine the prevalence of polyps in patients undergoing routine lower gastrointestinal (LGI) endoscopy and identify the histological types and their characteristics by age, location and size. Materials and Methods: For this retrospective study, patients undergoing ileocolonoscopy or sigmoidoscopy between 2014 and 2016 were included. Data on age, gender, test indication, site and size of polyps and histology type were collected. Results: Two hundred and ninety (12.7%) of 2303 patients who underwent LGI endoscopy had colonic polyps (n= 317; single in 272 patients). The median age was 61.1 years (range 5-99 years) and 223 (76.4%) were men. Polyps were rare <40 years age (7.3%). By site, the polyp frequency in right colon was 6.9%, 3.9% in left colon and 4.6% in the rectum. Two thirds of polyps (64%) were <1cm size. The 3 common polyp types were adenomatous (48.9%), hyperplastic (23.7%), and inflammatory (22.4%). Adenomatous polyps were common above 60 years (p <0.0002), located often in right (35.5%) or left colon (42.6%), large in size (54.2%) and showed low grade dysplasia (89.7%). Hyperplastic polyps were most common in the middle aged and in the rectum (p <0.00001). Inflammatory polyps were the most common type below 40 years age. Almost all hyperplastic and inflammatory polyps were <1cm size (93.3% and 87.3%). Conclusions: Adenomatous polyps were the commonest type; especially >60 years age. High grade dysplasia and carcinoma were rare (10.3%). While two-thirds of polyps <1cm size were inflammatory or hyperplastic, 86% of large polyps were adenomatous.

A Trimodal Imaging Platform for Tracking Viable Transplanted Pancreatic Islets In Vivo: F-19 MR, Fluorescence, and Bioluminescence Imaging

PURPOSE

Combining specific and quantitative F-19 magnetic resonance imaging (MRI) with sensitive and convenient optical imaging provides complementary information about the distribution and viability of transplanted pancreatic islet grafts. In this study, pancreatic islets (PIs) were labeled with positively charged multimodal nanoparticles based on poly(lactic-co-glycolic acid) (PLGA-NPs) with encapsulated perfluoro-15-crown-5-ether and the near-infrared fluorescent dye indocyanine green.

PROCEDURES

One thousand and three thousand bioluminescent PIs were transplanted into subcutaneous artificial scaffolds, which served as an alternative transplant site. The grafts were monitored using in vivo F-19 MR, fluorescence, and bioluminescence imaging in healthy rats for 2 weeks.

RESULTS

Transplanted PIs were unambiguously localized in the scaffolds by F-19 MRI throughout the whole experiment. Fluorescence was detected in the first 4 days after transplantation only. Importantly, in vivo bioluminescence correlated with the F-19 MRI signal.

CONCLUSIONS

We developed a trimodal imaging platform for in vivo examination of transplanted PIs. Fluorescence imaging revealed instability of the fluorescent dye and its limited applicability for longitudinal in vivo studies. A correlation between the bioluminescence signal and the F-19 MRI signal indicated the fast clearance of PLGA-NPs from the transplantation site after cell death, which addresses a major issue with intracellular imaging labels. Therefore, the proposed PLGA-NP platform is reliable for reflecting the status of transplanted PIs in vivo.

Fecal evacuation disorders in anal fissure, hemorrhoids, and solitary rectal ulcer syndrome

The causative factors for hemorrhoids, anal fissure, and solitary rectal ulcer syndrome (SRUS) are poorly understood. The study was done to identify the prevalence of fecal evacuation disorders in patients with anal fissure, hemorrhoids, and SRUS using anorectal manometry (ARM). Retrospective analysis of ARM data from three centers across India was done. Baseline demographic details and symptoms pertaining to bowel movements were noted. Limited colonoscopy details pertaining to hemorrhoids, fissure-in-ano, and SRUS were noted. The patients were divided into two groups-group I (those with fissure, hemorrhoids, or solitary rectal ulcer) and group II (normal study). ARM parameters of resting anal pressure, squeeze pressure, dyssynergic defecation, and abnormal balloon expulsion were compared between the two groups. Sub-analysis was done for ARM metric differences between those with hemorrhoids, chronic fissure, and SRUS. Appropriate statistical tests were used. A p-value of < 0.05 was considered significant. There were more men in group I (87%; p-value 0.01) with a higher resting anal pressure (80 vs. 69 mmHg, p-value 0.03). Functional evacuation disorders (p < 0.0001), dyssynergic defecation (77.2% vs. 46.8%, p < 0.0001) and abnormal balloon expulsion (66.7% vs. 20.3%, p < 0.0001) were significantly higher in group I. These were significantly more common in patients with anal fissure and SRUS compared to those with hemorrhoids (p-value 0.028). Functional evacuation disorders are frequently noted in patients with hemorrhoids, anal fissure, and SRUS.

Bowel Cleansing Agents in Clinical Practice: A Cross-Sectional Study on Safety, Efficacy, and Predictor of Good Bowel Preparation

Background: A good bowel preparation for colonoscopy is the most important factor that has an impact on visualization and outcome of the procedure. Aim: The primary aim of the study was to assess the quality of bowel preparation as reported by the Boston Bowel Preparation Score (BBPS). The secondary aim of the study was to analyze the patient feedback on ease of administration, palatability, and side effects with the bowel preparation. Materials and Methods: Patients undergoing colonoscopy between March 2018 and September 2018 were enrolled in the study. Patients <18 years of age, those with the previous history of colorectal surgery, emergency procedures in an unprepared colon, and those not willing to participate were excluded from the study. Colon preparation of the patient was decided by senior consultants. A predesigned pro forma that included demography, indication for the procedure, preparation details, dietary recommendations the previous day if any, side effects, and patient’s comfort to preparation was completed by two-independent observers. The BBPS was used to assess the bowel preparation. A score of <5 was deemed inadequate. P < 0.05 was considered statistically significant. Results: The study cohort consisted of 141 patients, of which 78 were male (55.3%). Eighty (56.7%) patients received oral sulfate-based preparation and 61(43.4%) polyethylene glycol-based preparation. Nearly one third of cases reported the solution to be non palatable. 15.4% respondents reported nausea, vomiting and bloating as the major side effects of the preparation. The median duration of colonoscopy was 25 min (8–45 min). One hundred and eighteen patients (83.6%) had a BBPS score of ≥5. Sulfate preparation resulted in better bowel cleansing (P = 0.01). Age, gender, and dosing schedule of preparation, including bedtime dosing of stimulant laxative, did not alter the BBPS score. Conclusion: Sulfate- and polyethylene glycol-based preparations are commonly used for cleansing the colon. Bowel cleansing was adequate in most patients and sulfate-based yielded better bowel cleansing. Nearly 15.4% of patients reported side effects to these preparations.

Ultrastructural Study of Rat Testis Following Conventional Phototherapy during Neonatal Period

Introduction

Phototherapy is the most common treatment for neonatal jaundice. This study sought to determine ultrastructural changes in testis, at different time-points, after 48 hours of conventional phototherapy was given to newborn rats.

Methods

Newborn male Wistar rats (n = 36) were divided into two groups as follows - group 1 (G1), control (without phototherapy) and group 2 (G2), exposure to conventional phototherapy for 48 h. Six animals from each group were sacrificed on postnatal days (PND) 70, 100 and 130. The testes were dissected out and processed for Transmission Electron Microscopy (TEM).

Results

TEM showed that G2 on PND 70 and 100 showed damaged organelles, including nuclei, mitochondria, endoplasmic reticulum, vacuoles and electron dense bodies in the testes. Seminiferous Tubule on PND130 showed lesser damage. On PND70 ST wall thickness (STWT) of G2 was significantly higher (P < 0.001) than G1 STWT of G2 was significantly lower than G1 on PND100 (P = 0.047) and on PND130 (P < 0.001). Mitochondrial diameter in spermatogonia was significantly higher in G2 on PND70 (P = 0.001), PND100 (P = 0.031) and PND130 (P = 0.028). Primary spermatocytes in G2 also had larger mitochondria on PND70 (P < 0.001), PND100 (P = 0.007) and PND130 (P = 0.008). Further, spermatids had larger mitochondria in G2 on PND70 (P < 0.001), PND100 (P = 0.044) and PND130 (P < 0.001).

Conclusion

Phototherapy causes degenerative changes in rat testis on PND70 and 100 that partially recover by PND 130.

Chicago Classification normative metrics in a healthy Indian cohort for a 16-channel water-perfused high-resolution esophageal manometry system

BACKGROUND

High-resolution esophageal manometry (HREM) interpretation by the Chicago Classification (CC) derives its normal values from western volunteers using solid-state catheters. There is no normative data for the 16-channel water-perfused HREM system commonly used in India.

AIMS

To determine normal values for a 16-channel water-perfused HREM catheter in supine posture using healthy volunteers and substitute these normal values (if different from CC values) in the CC v3.0 algorithm.

METHODS

After ethics approval and informed consent, 53 volunteers (31 men) with no gastrointestinal (GI) symptoms or medications affecting GI motility underwent HREM by standard protocol. Age, gender, body mass index (BMI), and manometry parameters analyzed using Trace 1.3.3 software were collected. The median, range, and 5, 10, 75, and 95 percentiles (where applicable) were obtained for all HREM metrics. Normal value percentiles were defined as 95th (integrated relaxation pressure [IRP]), 10th-100th (distal contractile integral [DCI]), and minimum (distal latency [DL]).

RESULTS

The mean age was 30 years and the BMI was 24.2 kg m^-2 . Compared to CC, our normal metrics were lower for IRP (13 mm Hg) and DCI (350-4500 mm Hg s cm). DCI >4500 and <70 (<5th percentile) were defined as hypercontractile and failed contraction, respectively. Abnormal DL (<4.5 s) and peristaltic break size (>5 cm) were similar to CC metrics. Applying these metrics, CC diagnoses changed in 15% (8/53) with downgrading of ineffective motility to fragmented peristalsis or normal, due to lower DCI cutoff used.

CONCLUSIONS

This is the first report of normative data for the 16-channel water-perfused system in supine posture. It revealed lower IRP and DCI, necessitating modification of CC cutoffs for this system.

Basal lower esophageal sphincter pressure in gastroesophageal reflux disease: An ignored metric in high-resolution esophageal manometry

Manometry and 24-h pH interpretation have seldom been studied. Our aim was to study these parameters as gold standard in reflux disease and to identify predictors of pathological acid reflux. Retrospective case record review of all patients with reflux disease evaluated using endoscopy, manometry, and 24-h pH testing from 2010 to 2016. Patients were categorized using Johnson-DeMeester score into two groups-group I (score > 14.7, normal study) and group II (< 14.7, normal study). These groups were compared for the above-mentioned parameters. Appropriate statistical tests were applied. P-value < 0.05 was considered significant. The study group includes 94 patients (median age 44 years, 63.8% males). Sixty (63.8%) and 34 patients belonged to groups I and II, respectively, 76.6% patients had normal endoscopy while the remaining had mild esophagitis. Peristalsis was normal in 66%, followed by ineffective esophageal motility (19.1%) and fragmented peristalsis (14.9%). Demography, symptoms, endoscopy findings, and peristalsis characteristics were similar between the two groups. Group II patients had significantly lower basal lower esophageal sphincter (LES) pressure (11.9 vs. 16.6; p < 0.02), lower integrated relaxation pressure (5.7 vs. 7.4; p < 0.01), and larger separation between LES and crural diaphragm (1.7 vs. 1.4 cm; p < 0.003). Basal LES pressure < 10 mmHg had the highest likelihood ratio (2.2) to predict an abnormal pH study. Basal LES pressure, integrated relaxation pressure, and hiatus size correlated with pathological acid reflux. Hypotensive basal lower esophageal sphincter pressure was the best predictor of an abnormal pH study but with negative linear correlation.

Nebulized N-Acetylcysteine for Management of Plastic Bronchitis

BACKGROUND

Plastic bronchitis is characterized by formation of extensive obstructive endobronchial casts and high recurrence rates.

CASE CHARACTERISTICS

Two children (1-year-old girl, 7-year-old boy) who had recurrent episodes of respiratory distress with acute worsening. Bronchoscopy revealed membrane-like casts. Both children were managed with nebulized N-acetylcysteine in addition to management for asthma.

OUTCOME

Symptom-free without recurrence for more than 9 months of follow-up.

MESSAGE

Nebulized N- acetylcysteine may be helpful in prevention of recurrence of plastic bronchitis due to asthma.

Isolated Terminal Ileal Mucosal Changes: When is the Bite Indicated?

Aim: This study aims to determine the clinical presentation, and ileal mucosal changes during colonoscopy for which terminal ileal (TI) biopsies were taken at our center and to determine the specific histopathology which had the best yield for specific colonoscopy findings. Materials and Methods: Retrospective audit of all patients who underwent colonoscopy with ileoscopy between 2012 and 2016. All patients with TI mucosal changes and normal colonic mucosa, who underwent ileal biopsy, were included in this study. Patient data regarding age, gender, indication for ileocolonoscopy (screening for colorectal cancers, inflammatory bowel disease [IBD], or irritable bowel syndrome [IBS]) and histopathology changes were collected. Appropriate statistical tests were used and P < 0.05 was considered statistically significant. Results: One hundred and nine patients had isolated ileal lesions. The median age was 44.1 years (range 8–80 years). Men outnumbered women in a ratio of 82:27. The major clinical indications for ileocolonoscopy were IBS (64.2%), followed by IBD (22%). Ulcers (aphthoid) were the most frequent finding followed by mucosal nodularity and nonspecific findings. Ulcers in ileum were most often reported as chronic ileitis (46.2%), followed by nonspecific changes (35.2%) Biopsy from nodular ileal lesions, were predominantly nonspecific (74.4%), followed by acute (15.4%) and chronic ileitis (10.2%). About 50% of specimens with nonspecific ileal changes had nonspecific histological changes. Ileal ulcers had the highest sensitivity, PPV, and NPV for significant histological findings. Conclusion: Ileal ulcers are the significant colonoscopy findings where tissue biopsy is likely to yield a definitive diagnosis and justify specific management. Biopsies from nonspecific ileal changes and nodularity should be discouraged as it is unlikely to pick up any major abnormality.

Development and mechanistic insight into enhanced cytotoxic potential of hyaluronic acid conjugated nanoparticles in CD44 overexpressing cancer cells

The overexpression of CD44 in cancer cells reroutes number of oncogenic pathways including the central Pi3K/Akt/NF-kB pathway leading to cancer progression and malignancy. Herein, we developed hyaluronic acid-modified poly(dl-lactic-co-glycolic acid)-poly (ethylene glycol) nanoparticles (PLGA-PEG-HA NPs) for targeted delivery of TTQ (thio-tetrazolyl analog of a clinical candidate, IC87114) to CD44 overexpressing cancer cells. The PLGA-PEG co-polymer was synthesized and characterized by NMR and FTIR. The co-polymer based nanoparticles were prepared by solvent evaporation method and hyaluronic acid (HA) was conjugated on to the nanoparticle surface via EDC/NHS chemistry. The PLGA-PEG-HA NPs had a desirable particle size (<200nm) with reduced polydispersibility and exhibited spherical shape under atomic force microscope (AFM). In vitro cytotoxicity and cellular uptake studies demonstrated higher cytotoxicity and enhanced intracellular accumulation of PLGA-PEG-HA NPs compared to PLGA-PEG NPs in high CD44 expressing MiaPaca-2 cells compared to MDA-MB-231 and MCF7 cells. At the molecular level, the PLGA-PEG-HA NPs were found to be inducing premature senescence with increase in senescence associated β-galactosidase activity and senescence specific marker p21 expression through modulation of Pi3K/Akt/NF-kB signaling pathway in MiaPaca-2 cells. These findings collectively indicated that HA-modified nanoparticles might serve as a promising nanocarrier for site-specific drug delivery, and can be explored further to increase the therapeutic efficacy of anticancer drugs via targeting to CD44 over-expressing cancer cells.

Adaptive learning based heartbeat classification

Cardiovascular diseases (CVD) are a leading cause of unnecessary hospital admissions as well as fatalities placing an immense burden on the healthcare industry. A process to provide timely intervention can reduce the morbidity rate as well as control rising costs. Patients with cardiovascular diseases require quick intervention. Towards that end, automated detection of abnormal heartbeats captured by electronic cardiogram (ECG) signals is vital. While cardiologists can identify different heartbeat morphologies quite accurately among different patients, the manual evaluation is tedious and time consuming. In this chapter, we propose new features from the time and frequency domains and furthermore, feature normalization techniques to reduce inter-patient and intra-patient variations in heartbeat cycles. Our results using the adaptive learning based classifier emulate those reported in existing literature and in most cases deliver improved performance, while eliminating the need for labeling of signals by domain experts.

Thermoluminescence kinetic features of Eu3+ doped strontium pyrophosphate after beta irradiation

Strontium pyrophosphate (Sr₂P₂O₇) doped with various concentrations of Eu³⁺ as a doping agent is synthesized using a combustion method and to study the thermoluminescence dosimetry [TLD] and applications.

Histopathological changes at colonic anastomotic site after ischemia reperfusion injury: role of aminoguanidine in experimental model

BACKGROUND

Inducible nitric oxide synthase (iNOS) has a significant role in ischemia reperfusion (I-R) injury. I-R injury impairs the healing at the intestinal anastomotic site. This study was designed to assess the role of aminoguanidine (AG, a selective inhibitor of iNOS), in healing at the colonic anastomotic site after intestinal I-R injury in rats. Methods: Female Wistar rats (n = 60) were divided into three groups. Group I (n = 15): sham operation, Group II (n = 15): I-R injury and anastomosis, and Group III (n = 30): I-R injury + anastomosis + AG-50 mg/kg. On the 7th postoperative day, relaparotomy was done and 4 cm of the colon with an intact area of the anastomosis was resected. Bursting pressure and histology at the anastomotic site were assessed.

RESULTS

The bursting pressure was significantly higher in Group III. In addition, bridging parameters (i.e., mucosal continuity, muscular continuity, re-epithelization, and granulation tissue), collagen pattern, and collagen density were significantly better in Group III. While the polymorphonuclear density was higher in Group II, suggestive of delayed healing.

CONCLUSION

AG, by decreasing inflammation and increasing collagen content in an organized pattern, helped in preventing I-R injury at the site of colonic anastomosis in rats.