Reference Charts of Fetal Biometric Parameters at Different Gestational Age Groups in Indian Population

To develop, a reference charts of fetal abdominal circumference and femur length in normal pregnant women by using ultrasonography for Indian population. Further comparison of our findings with data derived from different population. This retrospective cross-sectional study included 300 normal singleton pregnancies and was carried out in the department of Anatomy, All India Institute of Medical Sciences, Jodhpur (Rajasthan), India from September 2017 to April 2019. Ultrasonography measurements included Abdominal circumference (AC) and Femur length (FL). Reference charts with mean AC and FL for corresponding Gestational age (GA) in weeks were developed. Also reference centiles (10th, 50th, 90th and 95th) were derived from this model and compared with similar studies done on different population. There was no statistically significant difference in age distribution of pregnant women (p=0.87). Both AC and FL were found to have statistically significant linear relationship with advancing gestational age (p=0.0005 & p=0.0003 respectively). There is significant difference observed between the values obtained in present study with studies concluded on Chinese and European population. Measurement of AC and FL are used to predict gestational age of fetus by using various regression formulae, also AC is known to be good predictor of nutritional status of fetus in utero. A separate chart is required for every different population because ethnicity, nutrition and environmental factor can have impact on normal values. Therefore, a reference chart for these parameters according to Indian population standards is essential to avoid misinterpretation of data. This would help to avoid misdiagnosis of intrauterine growth retardation or macrosomia during prenatal and perinatal period.

Exocrine and endocrine functions and pancreatic volume in patients with pancreatic trauma

INTRODUCTION

Injury to the pancreas may lead to significant morbidity and mortality. We aim to assess pancreatic endocrine and exocrine functions and evaluated morphological regenerations of pancreas following partial pancreatectomy in patients with pancreatic trauma.

METHODS

The study was performed between June 2016 and December 2017. Endocrine functions were assessed at the time of admission and at 6 months follow-up with 75 g oral glucose tolerance test (OGTT), serum insulin and C-peptide levels and HbA1c estimation and exocrine functions were assessed with fecal elastase test. Pancreatic volumetry was done with imaging scan at 1 month and 6 months post discharge.

RESULTS

Twenty patients were studied with a median age of 30 years (range18-48) at the time of injury. All the patients were normoglycemic on admission; only one patient who underwent pancreatic resection developed diabetes mellitus at follow-up. Eight patients (40%) were found to be prediabetic by American Diabetes Association (ADA) criteria. Eleven patients (55%) had pancreatic exocrine insufficiency. Pancreatic volume increment, from the mean pancreatic volume of 48.65 to 54.29 cm³, was noted in patients who underwent partial pancreatectomy.

CONCLUSIONS

Patients with pancreatic trauma may develop biochemical endocrine and exocrine insufficiencies following pancreatic resection. Pancreatic volume increment requires further research in a larger study.

Acute pancreatitis and nosocomial COVID-19: Cause specific host responses may determine lung injury

BACKGROUND

Coronavirus disease 2019 (COVID-19) presents with myriad extra-pulmonary manifestation and a high mortality in patients with comorbidities. Its effect on patients with pre-existing acute pancreatitis is not known.

METHODS

We hereby, present 3 cases with severe acute pancreatitis with persistent respiratory failure who acquired nosocomial COVID-19 during their hospital stay after recovery from respiratory failure. Their clinical course is highlighted which reflects on pathophysiology of organ dysfunction in these 2 disease states.

RESULTS

None of the 3 patients with severe acute pancreatitis who developed nosocomial COVID-19 redeveloped respiratory failure due to COVID-19 despite having recently recovered from pancreatitis induced acute hypoxemic respiratory failure. Only one patient developed SARS-CoV2 induced moderate pneumonia.

CONCLUSION

These cases highlight that host responses and mechanisms of lung injury might be different in severe acute pancreatitis and COVID-19.

Percutaneous Endoscopic Step-Up Therapy Is an Effective Minimally Invasive Approach for Infected Necrotizing Pancreatitis

BACKGROUND

Infected pancreatic necrosis (IPN) is a major complication of acute pancreatitis (AP), which may require necrosectomy. Minimally invasive surgical step-up therapy is preferred for IPN.

AIM

To assess the effectiveness of percutaneous endoscopic step-up therapy in patients with IPN and identify predictors of its success.

METHODS

Consecutive patients with AP hospitalized to our tertiary care academic center were studied prospectively. Patients with IPN formed the study group. The treatment protocol for IPN was percutaneous endoscopic step-up approach starting with antibiotics and percutaneous catheter drainage, and if required necrosectomy. Percutaneous endoscopic necrosectomy (PEN) was performed using a flexible endoscope through the percutaneous tract under conscious sedation. Control of sepsis with resolution of collection(s) was the primary outcome measure.

RESULTS

A total of 415 patients with AP were included. Of them, 272 patients had necrotizing pancreatitis and 177 (65%) developed IPN. Of these 177 patients, 27 were treated conservatively with antibiotics alone, 56 underwent percutaneous drainage alone, 53 required underwent PEN as a step-up therapy, 1 per-oral endoscopic necrosectomy, and 52 required surgery. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully-34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died due to organ failure-7 after PEN and 4 after surgery. Independent predictors of mortality were > 50% necrosis and early organ failure.

CONCLUSION

Percutaneous endoscopic step-up therapy is an effective strategy for IPN. Organ failure and extensive pancreatic necrosis predicted a suboptimal outcome in patients with infected necrotizing pancreatitis.

Estimation of Fetal Weight: An Ultrasonography Study in Indian Population

To create a reference chart for estimated fetal weight (EFW) in normal pregnancy for use in Indian population and compare it with reference chart from other population. This retrospective cross-sectional study included 300 normal singleton pregnancies coming for routine antenatal ultrasonography examination and was carried out at All India Institute of Medical Sciences, Jodhpur from September 2017 to April 2019. Ultrasonographic measurements included fetal biparietal diameter (cm), head circumference (cm), abdominal circumference (cm) and femur length (cm). Estimated fetal weight was calculated by using Hadlock algorithm which is already fed into ultrasonography machine. Reference chart with mean EFW for corresponding Gestational age (GA) in weeks was developed. Also Reference centiles (10th, 50th, 90th and 95th) were derived from this model. There was no statistically significant difference in age distribution of pregnant women (p=0.87). Statistically significant linear relationship found between EFW and advancing gestational age (p=0.0004). Maximum gain in EFW (34.05%) was observed after second trimester (28 week). Maximum and minimum fetal weight at 38 weeks of GA in our study found to be 3389 grams and 2567 grams respectively, which has significant difference. This could be due to huge difference in socio-economic and nutritional status among Indian population which might have impacted on maternal and fetal health. Estimated fetal weight was found to be at lower range in Indian population compared to reference chart developed into western population. Fetal weight to their corresponding GA is an important factor in determining growth and development in fetus. In normally developing fetus the EFW has linear correlation with advancing GA. A separate reference chart is required for every different population because ethnicity, nutrition and environmental factor can have impact on normal EFW values. This would help to avoid misdiagnosis of intrauterine growth retardation or macrosomia in fetuses and hence unnecessary medical interventions can be prevented during prenatal and perinatal period.

Pulmonary complications of acute pancreatitis

Introduction: Acute pancreatitis is an inflammatory condition of the pancreas, which runs a severe course in 20% of patients, wherein it is associated with high mortality. It is associated with several pleuro-pulmonary complications with variable severity that may occur either in isolation but are frequently present in combination. Clinicians need to be aware of these complications for early and appropriate management.Areas covered: We performed a systematic search of the PUBMED database (1970-2019) to identify relevant articles focusing on pleuro-pulmonary complications that may occur in patients with acute pancreatitis. We also retrieved articles describing the pathophysiological mechanisms and treatment approach of the various complications.Expert opinion: Acute pancreatitis is usually a self-limiting disease, but the development of organ failure during the course worsens the clinical outcome. Pulmonary complications usually occur early in the course of acute pancreatitis. Clinicians need to recognize the various pulmonary complications of acute pancreatitis, early during the disease, and manage them appropriately and aggressively to improve outcomes.

Endoscopic versus laparoscopic drainage of pseudocyst and walled-off necrosis following acute pancreatitis: a randomized trial

BACKGROUND

Pancreatic fluid collections (PFC) may develop following acute pancreatitis (AP). Endoscopic and laparoscopic internal drainage are accepted modalities for drainage of PFCs but have not been compared in a randomized trial. Our objective was to compare endoscopic and laparoscopic internal drainage of pseudocyst/walled-off necrosis following AP.

PATIENTS AND METHODS

Patients with symptomatic pseudocysts or walled-off necrosis suitable for laparoscopic and endoscopic transmural internal drainage were randomized to either modality in a randomized controlled trial. Endoscopic drainage comprised of per-oral transluminal cystogastrostomy. Additionally, endoscopic lavage and necrosectomy were done following a step-up approach for infected collections. Surgical laparoscopic cystogastrostomy was done for drainage, lavage, and necrosectomy. Primary outcome was resolution of PFCs by the intended modality and secondary outcome was complications.

RESULTS

Sixty patients were randomized, 30 each to laparoscopic and endoscopic drainage. Both groups were comparable for baseline characteristics. The initial success rate was 83.3% in the laparoscopic and 76.6% in the endoscopic group (p = 0.7) after the index intervention. The overall success rate of 93.3% (28/30) and 90% (27/30) in the laparoscopic and endoscopic groups respectively was also similar (p = 1.0). Two patients in the laparoscopic group required endoscopic cystogastrostomy for persistent collections. Similarly, two patients in the endoscopic group required laparoscopic drainage. Postoperative complications were comparable between the groups except for higher post-procedure infection in the endoscopic group (19 vs. 9; p = 0.01) requiring endoscopic re-intervention.

CONCLUSIONS

Endoscopic and laparoscopic techniques have similar efficacy for internal drainage of suitable pancreatic fluid collections with < 30% debris. The choice of procedure should depend on available expertise and patient preference.

An international, multi-institution survey of the use of EUS in the diagnosis of pancreatic cystic lesions

Background and Objectives:

Currently, pancreatic cystic lesions (PCLs) are recognized with increasing frequency and have become a more common finding in clinical practice. EUS is challenging in the diagnosis of PCLs and evidence-based decisions are lacking in its application. This study aimed to develop strong recommendations for the use of EUS in the diagnosis of PCLs, based on the experience of experts in the field.

Methods:

A survey regarding the practice of EUS in the evaluation of PCLs was drafted by the committee member of the International Society of EUS Task Force (ISEUS-TF). It was disseminated to experts of EUS who were also members of the ISEUS-TF. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized.

Results:

Fifteen questions were extracted and disseminated among 60 experts for the survey. Fifty-three experts completed the survey within the specified time frame. The average volume of EUS cases at the experts' institutions is 988.5 cases per year.

Conclusion:

Despite the limitations of EUS alone in the morphologic diagnosis of PCLs, the results of the survey indicate that EUS-guided fine-needle aspiration is widely expected to become a more valuable method.

Incidental Coronary Artery Calcification Seen on Low-Dose Computed Tomography Is a Risk Factor for Obstructive Coronary Artery Disease in Patients Undergoing Liver Transplant

Incidental arterial calcification (Ca) on low-dose computed tomography (CT) prior to liver transplant (LT) may help identify those at risk for obstructive coronary artery disease (CAD). A single-center retrospective study of 358 consecutive patients who had undergone LT was performed. Of the 296 patients who met inclusion criteria, 193 patients (65.2%) had CT Ca. Aortic Ca was seen in 116 (39.2%), coronary Ca in 141 (47.6%), and peripheral Ca in 8 patients (2.7%). Patients with coronary Ca were assigned ordinal coronary artery Ca scores and classified as mild, moderate, and severe. All-cause mortality was higher in patients with Ca in any location (14.5% vs 6.8%, P = .05). Of the patients who underwent coronary angiography, those with obstructive CAD were more likely to have aortic and coronary Ca than patients with nonobstructive or no CAD (85.7% vs 50.0%, P = .02 and 92.9% vs 37.9%, P = < .001, respectively). Severe coronary artery Ca scores were more frequent in patients with obstructive CAD (35.7% vs 0%, P < .001). Any severity coronary Ca had an odds ratio of 11.57 (95% CI, 1.61-244.92; P = .04) for obstructive CAD. In conclusion, incidental coronary Ca seen on low-dose CT is a risk factor for obstructive CAD in patients undergoing LT.

Infected Pancreatic Necrosis due to Multidrug-Resistant Organisms and Persistent Organ failure Predict Mortality in Acute Pancreatitis

Background

Organ failure determines outcome in acute pancreatitis (AP). It is controversial if infected pancreatic necrosis (IPN) is also an independent determinant of mortality. We hypothesized that the predictors of mortality in AP might have changed with advances in management and consequent decline in mortality over the past decades. Our objective was to study the predictors of mortality in patients with AP.

Methods

Consecutive patients with a first episode of AP hospitalized from January 2015 to December 2016 were included in an observational study. Patients with IPN were treated with a conservative first approach followed by intervention. Necrosectomy, if required, was delayed beyond 4 weeks and done primarily employing minimally invasive techniques. The primary outcome measure was independent predictors of in-hospital mortality.

Results

Of 209 patients with AP, 81 (39%) had persistent organ failure (OF) and 108 (52%) developed IPN. Overall, 46/209 (22%) patients died. Independent predictors of mortality were OF (odds ratio [OR]19; 95% CI: 6.1–58.8), and IPN due to infection with multidrug resistant (MDR) organisms (OR: 8.4; 95% CI:3.1–22.5). Infected pancreatic necrosis by itself was not found to be a significant predictor of mortality (OR 2; 95% CI: 0.4–9.5).

Conclusion

Persistent OF and complicated IPN due to MDR infection were independent predictors of mortality in patients with AP. Renewed efforts to prevent MDR infection with antibiotic stewardship and strategies for early control of sepsis are urgently required.

Recurrent Acute Pancreatitis: Current Concepts in the Diagnosis and Management

PURPOSE OF REVIEW

There have been significant developments in the diagnosis, clinical approach, and management of patients with recurrent acute pancreatitis (RAP) in the last decade. This review systematically summarizes our current understanding of RAP.

NEW FINDINGS

Gallstones and alcohol are common causes of RAP. Non-alcohol non-biliary RAP (nAnB RAP) is a difficult group of patients after excluding these two causes because extensive workup is required to elucidate the etiology. Idiopathic RAP is diagnosed after excluding all the known causes and recurrence is noted to be higher in such patients. Patients with non-biliary RAP are prone to develop chronic pancreatitis (CP) suggesting a continuum from acute to recurrent to chronic pancreatitis. Often, patients destined to develop CP present at an earlier stage with RAP. Endoscopic ultrasound and magnetic resonance cholangiopancreatography (MRCP) are the investigations of choice to detect microlithiasis, choledocholithiasis, ductal abnormalities, peri-ampullary malignancies, and early changes of chronic pancreatitis. The role of pancreas divisum, sphincter of Oddi dysfunction, and anomalous pancreatobiliary union in causing RAP is controversial. Genetic testing may be advisable in younger patients.

CONCLUSION

With a focused approach and appropriate investigations, the etiology of RAP can be identified in a significant proportion of patients. Therapeutic options are limited and future research is needed to improve understanding of the disease.

Interleukin-6 significantly improves predictive value of systemic inflammatory response syndrome for predicting severe acute pancreatitis

BACKGROUND

Predicting severe acute pancreatitis (AP) is important for triage, prognosis, and designing therapeutic trials. Persistent systemic inflammatory response syndrome (SIRS) predicts severe AP but its diagnostic accuracy is suboptimal. Our objective was to study if cytokine levels could improve the predictive value of clinical variables for the development of severe AP.

METHODS

Consecutive patients with AP were included in a prospective cohort study at a tertiary care center. Serum levels of IL-6, TNF-α, IL-10, MCP-1, GM-CSF and IL-1β were measured at day 3 of onset of AP. Variables such as age, co-morbidity, etiology, SIRS, and cytokines were modeled to predict severe AP by multivariable regression analysis. Genotyping was done to correlate IL-6, TNF-α and MCP-1 gene polymorphisms with cytokine levels.

RESULTS

Of 236 patients with AP, 115 patients admitted within 7 days of onset formed the study group. 37 of the 115 (32%) patients developed organ failure. Independent predictors of organ failure were persistent SIRS (OR 34; 95% CI: 7.2-159) and day 3 serum IL-6 of >160 pg/ml (OR 16.1; 95% CI:1.8-142). IL-6 gene (-174 G/C) GG genotype was associated with significantly higher levels of IL-6 compared to CC/CG genotype. Serum IL-6 >160 pg/ml increased the positive predictive value of persistent SIRS from 56% to 85% and specificity from 64% to 95% for predicting OF without compromising its sensitivity and negative predictive value.

CONCLUSION

Serum IL-6 of >160 ng/ml added significantly to the predictive value of SIRS for severe AP.

Fasting and post-glucose load measures of insulin resistance and risk of incident atrial fibrillation: The Cardiovascular Health Study

BACKGROUND AND AIMS

Existing literature in individuals without diabetes has not demonstrated a relationship between IR and incident AF; however, data are limited and only fasting glucose measures of IR were assessed. We evaluated the relationship of both fasting and post-glucose load IR measures with the development of atrial fibrillation in nondiabetic older adults.

METHODS AND RESULTS

Among Cardiovascular Health Study participants, a population-based cohort of 5888 adults aged 65 years or older enrolled in two waves (1989-1990 and 1992-1993), those without prevalent AF or diabetes and with IR measures at baseline were followed for the development of AF, identified by follow-up visit electrocardiograms, hospital discharge diagnosis coding, or Medicare claims data, through 2014. Fasting IR was determined by the homeostatic model of insulin resistance (HOMA-IR) and post-glucose load IR was determined by the Gutt index. Cox proportional hazards models were used to determine the association of IR with risk of AF. Analyses included 3601 participants (41% men) with a mean age of 73 years. Over a median follow-up of 12.3 years, 1443 (40%) developed AF. After multivariate adjustment, neither HOMA-IR nor the Gutt index was associated with risk of developing AF [hazard ratios (95% confidence intervals): 0.96 (0.90, 1.03) for 1-SD increase in HOMA-IR and 1.03 (0.97, 1.10) for 1-SD decrease in the Gutt index].

CONCLUSIONS

We found no evidence of an association between either fasting or post-glucose load IR measures and incident AF.

Primary and Secondary Organ Failures Cause Mortality Differentially in Acute Pancreatitis and Should be Distinguished

OBJECTIVE

The aim of this study was to study the development of early and late organ failure (OF) and their differential impact on mortality in patients with acute pancreatitis (AP).

METHODS

Consecutive patients (N = 805) with acute pancreatitis were included in an observational study. Organ failure was categorized as primary if it occurred early due to pancreatitis per se and secondary if it occurred late due to infected pancreatic necrosis (IPN). Primary outcome was a relative contribution of primary OF, secondary OF, and IPN to mortality.

RESULTS

Of the 614 patients (mean age, 38.8; standard deviation, 14.6 years; 430 males) in a derivation cohort, 274 (44.6%) developed OF, with 177 having primary OF and 97 secondary OF due to sepsis. Primary OF caused early mortality in 15.8% and was a risk factor for IPN in 76% of patients. Mortality in patients with primary OF and IPN was 49.5% versus 36% in those with IPN and secondary OF (P = 0.06) and 4% in those with IPN but without OF (P < 0.001). The results of the 191 patients in the validation cohort confirmed the relative contribution of primary and secondary OF to mortality.

CONCLUSION

Primary and secondary OF contributed to mortality independently and are distinct in their timing, window of opportunity for intervention, and prognosis.

Assessment of safety and efficacy of an indigenous self-expandable fully covered esophageal metal stent for palliation of esophageal cancer

BACKGROUND

Patients with unresectable esophageal cancer require palliation for dysphagia. Placement of a self-expandable metal stent (SEMS) is the procedure of choice for palliation of dysphagia.

OBJECTIVE

To evaluate the safety and efficacy of an indigenous fully-covered SEMS in patients with esophageal cancer.

METHODS

Eligible patients with unresectable esophageal cancer requiring palliation for dysphagia were included in the study. An indigenous fully covered SEMS of appropriate length was placed under endoscopic and fluoroscopic guidance. Outcome measures assessed were adverse events and improvement in dysphagia.

RESULTS

Twenty one patients (mean age 57.71±13.14 years; 17 males) were included. After stenting, dysphagia score decreased from 3.2+0.4 to 0.35+0.74 at 4 weeks. Adverse events included retrosternal pain, respiratory distress and aspiration pneumonia in 12, 2 and 1 patients respectively. Five patients required repeat stenting due to stent migration in 4 (following radiotherapy in 3) and tumour ingrowth in 1. There was primary stent malfunction in one patient. The median survival of patients was 140 (76-199) days, which was higher in those who received radiotherapy.

CONCLUSION

The stent was reasonably safe and effective to relieve dysphagia due to unresectable esophageal cancer.

A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction

Background and Objectives:

EUS-guided biliary drainage (EUS-BD) was shown to be useful for malignant biliary obstruction (MBO). However, there is lack of consensus on how EUS-BD should be performed.

Methods:

This was a worldwide multi-institutional survey among members of the International Society of EUS conducted in February 2018. The survey consisted of 10 questions related to the practice of EUS-BD.

Results:

Forty-six endoscopists of them completed the survey. The majority of endoscopists felt that EUS-BD could replace percutaneous transhepatic biliary drainage after failure of ERCP. Among all EUS-BD methods, the rendezvous stenting technique should be the First choice. Self-expandable metal stents (SEMSs) were recommended by most endoscopists. For EUS-guided hepaticogastrostomy (HGS), superiority of partially-covered SEMS over fully-covered SEMS was not in agreement. 6-Fr cystotomes were recommended for fistula creation. During the HGS approach, longer SEMS (8 or 10 cm) was recommended. During the choledochoduodenostomy approach, 6-cm SEMS was recommended. During the intrahepatic (IH) approach, the IH segment 3 was recommended.

Conclusion:

This is the first worldwide survey on the practice of EUS-BD for MBO. There were wide variations in practice, and randomized studies are urgently needed to establish the best approach for the management of this condition.

Evolving management of insulinoma: Experience at a tertiary care centre

BACKGROUND & OBJECTIVES

Since our previous study in 2006, several new modalities for localization of cause of endogenous hyperinsulinemic hypoglycaemia such as multiphasic computed tomography (CT), multiphasic magnetic resonance imaging (MRI), endoscopic ultrasound (EUS), intraoperative ultrasound, and intra-arterial calcium infusion with arterial stimulation venous sampling (ASVS) have become available. Therefore, to evaluate the relative usefulness of various imaging modalities to guide future management in terms of diagnosis and patient care, we analyzed presentation and management of patients of endogenous hyperinsulinemic hypoglycaemia.

METHODS

In this retrospective study, medical records of patients admitted with endogenous hyperinsulinemic hypoglycaemia were retrieved. Data pertaining to clinical features, diagnosis, imaging, surgery and patient outcome were extracted. The localization of insulinoma by preoperative imaging techniques was compared with the findings at surgery to assess the accuracy of localization.

RESULTS

Fasting hypoglycaemia was present in all, and post-prandial hypoglycaemia (plasma glucose ≤50 mg/dl within four hours of meal) in 25.8 per cent. Mean duration of symptoms before reaching a diagnosis of hyperinsulinemic hypoglycaemia was 3.9 years. Mean duration of provocative fast was 21.8 h (range 6-48 h). Among the currently used imaging modalities, the sensitivity of localizing tumour was 79.3 per cent for multiphasic CT, 85 per cent for multiphasic MRI and 95 per cent for EUS. EUS detected tumour missed by both CT and MRI. All, except one of the operated patients, were cured by surgery.

INTERPRETATION & CONCLUSIONS

Our results suggest that patients with insulinoma have a varied presentation. Multiphasic contrast-enhanced MRI/CT scan, EUS and ASVS may be complimentary in pre-operative localization.