Bariatric Surgery in Nonalcoholic Fatty Liver Disease (NAFLD): Impact Assessment Using Paired Liver Biopsy and Fibroscan

BACKGROUND

Bariatric surgery is associated with a positive impact on the degree of hepatic steatosis and inflammation in nonalcoholic associated fatty liver disease (NAFLD), although its effect on fibrosis is contentious. The role of Fibroscan in the post-bariatric assessment of hepatic steatosis and fibrosis is unclear.

OBJECTIVES

This work aims to study the impact of bariatric surgery on the course of NAFLD using both invasive (liver biopsy) and non-invasive tests (biochemical parameters and Fibroscan).

METHODS

In this prospective study, the impact of bariatric surgery on the course of NAFLD was assessed using paired liver biopsy (intra-operative and post-bariatric surgery 1-year follow-up). The liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) cutoffs for the assessment of hepatic fibrosis and steatosis, respectively, were calculated in both pre- and post-bariatric settings.

RESULTS

Fifty-eight patients (70.7% females, mean age 39.2 years) underwent paired liver biopsy. Post-bariatric surgery 1-year liver biopsy showed significant improvement in all the histopathological parameters of NAFLD. The mean NAFLD Activity Score declined from 2.81 (± 1.08) to 1.31 (± 1.39) post-bariatric surgery. Thirty (51.7%) patients showed improvement in fibrosis, eighteen (31%) no change, and ten (17.2%) had worsening. Worsening of fibrosis was associated with a higher median age of 44.5 versus 38 years (p value = 0.033). The CAP cutoff values for the various stages of hepatic steatosis were higher pre-operatively as compared with those obtained post-bariatric surgery.

CONCLUSIONS

Bariatric surgery is associated with significant improvement in histopathological parameters of NAFLD. Fibroscan shows good diagnostic accuracy in detecting advanced stage and grade of NAFLD.

Hypoxia aggravates non-alcoholic fatty liver disease in presence of high fat choline deficient diet: A pilot study

AIM

NAFLD is a chronic and progressive disease for which there are no FDA-approved drugs available in the market. Drug discovery is a time-consuming procedure and requires screening of hundreds of small molecules to find new chemical entities (NECs) for a particular disease. Current preclinical NAFLD animal models take a longer time, which enhances the duration and expenses of the screening procedure. Hence to shorten the duration, we have proposed a preclinical animal model for rapid induction of non-alcoholic steatohepatitis (NASH), an advanced stage of NAFLD in rats.

METHODOLOGY

The animals were divided into three groups; control, high fat choline deficient (HFCD) and high fat choline deficient diet with sodium nitrite (40 mg/kg b.w. i.p. per day) (HFCD + NaNO₂) respectively. Four weeks later physical and serum biochemical parameters were assessed, intraperitoneal glucose tolerance test was performed, and histopathology and gene expression were analysed.

KEY FINDINGS

Hypoxic stress aggravates the lipid accumulation, ballooning, lobular inflammation and fibrosis in hepatic tissue in presence of HFCD diet.

SIGNIFICANCE

This novel rodent model could be a useful NAFLD model to screen small molecules rapidly for treatment of NASH.

Digital workflow for treating comminuted anterior mandibular fracture - A technical note

Comminuted mandibular fracture poses a surgical challenge. Extensive comminution and absence of reference adds complexity particularly in anterior region. In this technical note, we describe a novel application of virtual surgical planning combined with 3D printing which grants precise anatomic reduction in such cases. Computed Tomography data (mandible) of another patient of same age and sex was utilized to create reference model by virtual surgical planning. Virtually created model was 3D printed and utilized for precontouring the reconstruction plate which assisted in achieving satisfactory outcome.

Can costochondral grafts fulfil ramus-condyle unit reconstruction goals in children with temporomandibular joint ankylosis?

The purpose of this study was to analyse whether costochondral grafts (CCG) fulfil temporomandibular joint (TMJ) reconstructive goals in children with TMJ ankylosis. A total of 23 patients (12 male, 11 female, aged 3-16 years) with unilateral or bilateral TMJ ankylosis operated on between January 2014 to April 2018 were included in the study. Maximal incisal opening (MIO), frequency of reankylosis, and growth of CCG, were evaluated at one month and six months for one year, and after that once yearly. Mouth opening changes with time were assessed by the Friedman test and growth was compared at follow up and analysed using the paired t test. Mean (range) follow up was 18 (12-48) months. Study results revealed follow up MIO at 12 months was highly significant (p=0.001). Out of 27 CCG studied, only one graft had undergone re-ankylosis. Based on the predetermined criteria using condylion to gnathion (Co-Gn) measurement in the posteroanterior cephalogram, CCG were categorised into optimum, sub-optimum, and overgrowth. However, long-standing TMJ ankylosis cases still displayed mandibular asymmetry at the end of the study, even with "optimal growth" radiographically. Overall comparison between the immediate postoperative and last follow up Co-Gn measurements in either unilateral or bilateral cases was not significant. CCG with functional matrix maintained the growth of the mandible and MIO in TMJ ankylosis. It can be concluded that CCG partially fulfils reconstructive goals; however, patients need to be followed up till the end of puberty for a substantive conclusion.

Safety and Efficacy of Bariatric Surgery in Advanced Liver Fibrosis

BACKGROUND

There is limited data on the safety and efficacy of metabolic and bariatric (MBS) surgery in patients with advanced liver fibrosis.

METHODS

This is a retrospective analysis of data of patients with advanced liver fibrosis undergoing MBS at a tertiary care centre. Weight loss and complications were analysed. Transient elastography and liver biopsy findings 1 year after surgery were compared with baseline.

RESULTS

Twenty-two patients had cirrhosis and 16 had stage 3 fibrosis; all were Child Pugh A. Majority (76%) underwent sleeve gastrectomy. Mean excess BMI loss was 65.8 ± 18.9%. There were no leaks or 30-day mortality. One patient with cirrhosis had late mortality due to liver decompensation. Preoperative and postoperative median LSM were 15.5 kPa (interquartile range IQR = 24.4-11.6) and 10.9 kPa (IQR 19.3-7.6), respectively. Preoperative and postoperative median CAP were 352.5 dB/m (IQR = 372-315.5) and 303 dB/m (IQR 331-269.5), respectively. On follow-up biopsy, nine of twelve patients had improvement in fibrosis, while three had no change. Four out of five patients in the cirrhotic cohort had improvement in fibrosis stage and LSM improved in all of them. Five out of seven patients with stage 3 fibrosis had an improvement in fibrosis stage and none progressed to cirrhosis. LSM improved in three of these five patients.

CONCLUSION

MBS has the potential to ameliorate advanced liver fibrosis, including cirrhosis. Transient elastography can be used as an effective tool for screening and follow-up of liver disease in patients undergoing MBS.

Giant Gastric Polyp in Peutz-Jeghers Syndrome: Report of a Case

Peutz–Jeghers syndrome (PJS) is inherited as an autosomal dominant disorder presenting as hamartomatous polyps in the small bowel, mucocutaneous pigmentation and with a predisposition to develop cancer. We report a case of PJS, with an adenomatous giant gastric polyp. The purpose is to highlight that adenomatous giant gastric polyp may be an extremely rare presentation of PJS. Awareness of this possibility will help us in not missing out these atypical cases of PJS.

Cardiological Society of India: Document on acute MI care during COVID-19

The unprecedented and rapidly spreading Coronavirus Disease-19 (COVID-19) pandemic has challenged public health care systems globally. Based on worldwide experience, India has initiated a nationwide lockdown to prevent the exponential surge of cases. During COVID-19, management of cardiovascular emergencies like acute Myocardial Infarction (MI) may be compromised. Cardiological Society of India (CSI) has ventured in this moment of crisis to evolve a consensus document for care of acute MI. However, this care should be individualized, based on local expertise and governmental advisories.

Why every word counts: towards patient- and people-centered tuberculosis care

Tuberculosis (TB) remains a major public health concern worldwide. To combat the global epidemic, the World Health Organization (WHO) launched the End TB Strategy in 2016. This strategy advocates patient-centered care. The WHO considers 'patients' as 'people' with interests and needs beyond their illness. TB care models centered around people aim to connect affected persons to health services and give support throughout treatment. Nevertheless, studies have shown that patients continue to experience negative attitudes from providers. The disempowering language used to refer to people with TB often place limits on the care that they receive. Common terminologies applied to patients who interrupt treatment perpetuate the 'blame game'. It is a moral obligation of providers to give care free from prejudice and discrimination, as articulated in the Patient's Charter for Tuberculosis Care. Researchers too have a duty to address underlying system barriers to relieve the unfair burden placed on patients. Lessons learned from the compassionate care provided to people living with HIV/AIDS (human immunodeficiency virus/acquired immune-deficiency syndrome) offer opportunities to address treatment adherence challenges. People-centered and patient-centered TB programs are necessary to end the epidemic. It is essential that providers and researchers find creative solutions for engaging patients throughout the care continuum and address health system factors.

Loop mediated isothermal amplification assay for detection of Trichomonas vaginalis in vaginal swabs among symptomatic women from North India

Trichomonas vaginalis is one of the most common curable sexually transmitted pathogens infecting both men and women worldwide. Unlike traditional methods such as microscopy and culture, nucleic acid amplification tests rapidly detect this agent, assisting in treatment. Conventional polymerase chain reaction (PCR), the loop-mediated isothermal amplification (LAMP), and the Xpert TV assay were evaluated using 28 microscopy positive T. vaginalis samples and 125 microscopy negative samples from symptomatic females of reproductive age. The sensitivity of all tests was 100% and the specificity was 100%, 100%, and 99·2% for PCR, Xpert TV, and LAMP, respectively. The inter-rater reliability was excellent for PCR: Xpert TV (kappa-coefficient = 1) and good for LAMP assay: Xpert TV/PCR (kappa-coefficient = 0·98) and conventional PCR: LAMP (kappa-coefficient = 0·98). The study highlights the importance of PCR for screening T. vaginalis in women, particularly in laboratories where the Xpert-TV assay is not available or not affordable. The LAMP assay showed a lower positive predictive value which merits further evaluation. SIGNIFICANCE AND IMPACT OF THE STUDY: Trichomonas vaginalis is a common sexually transmitted pathogen associated with considerable morbidity and risk of complications. Due to the limitations of traditional diagnostic modalities, three molecular assays were compared: conventional polymerase chain reaction (PCR), Xpert TV assay, and loop mediated isothermal amplification (LAMP) assay for detecting T. vaginalis in symptomatic females. All tests had a sensitivity of 100% and the inter-rater reliability was excellent for PCR: Xpert TV, and good for LAMP assay: Xpert TV/PCR. The translational impact of this study lies in the possible use of conventional PCR and LAMP in laboratories where the Xpert TV assay is not available or not affordable.

Cytomorphology of hepatoblastoma with histological correlation and role of SALL4 immunocytochemistry in its diagnosis, subtyping, and prognostication

BACKGROUND

Hepatoblastoma (HB) is the most common malignant pediatric liver tumor, and cytology material is often the only tissue available for evaluation before definitive therapy. Subcategorization of HB based on cytomorphological features thus carries an important role in its prognostication. Spalt-like transcription factor 4 (SALL4), a marker of embryonic stem cells that is also found in the fetal liver, is reactivated in certain liver tumors. Limited studies have evaluated its role in HB. This study was aimed at evaluating the cytomorphological features of HB and assessing the utility of SALL4 immunocytochemistry (ICC) in its subtyping and prognostication.

METHODS

Pretherapy fine-needle aspiration smears from patients diagnosed with HB over a period of 9 years were retrieved. Aspirates were subclassified on the basis of the cytomorphology and were correlated with the histology wherever it was available. ICC for SALL4 was performed in 33 cases, and nuclear staining was considered positive.

RESULTS

A total of 53 HB cases were included with 30 available postchemotherapy resection specimens. All the patients were diagnosed as epithelial HB on cytology, and the cases were subclassified as pure fetal (9 of 53), pure embryonal (2 of 53), or combined epithelial HB (42 of 53). There was good concordance between cytology and histology for subtyping. SALL4 immunostaining displayed strong and diffuse nuclear positivity in the embryonal component while focal and weak to negative staining in fetal cells.

CONCLUSIONS

Fine-needle aspiration cytology serves as a rapid and effective tool for a correct diagnosis of HB before the implementation of chemotherapy, and SALL4 may serve as a useful diagnostic and prognostic marker.

Effect of Helicobacter pylori-eradication therapy on hepatic steatosis in patients with non-alcoholic fatty liver disease: a randomized-controlled pilot study

Background

Helicobacter pylori infection has been associated with insulin resistance and non-alcoholic fatty liver disease (NAFLD). This study was done to evaluate the effect of H. pylori-eradication therapy (HPET) in patients with NAFLD compared to standard management therapy (SMT).

Methods

Eighty NAFLD patients with H. pylori co-infection were randomized into SMT (diet and exercise, n = 36) and HPET (SMT plus amoxicillin, clarithromycin, and pantoprazole, n = 44) groups. The controlled attenuation parameter (CAP), anthropometric parameters, liver enzymes, lipid profile, and glycemic parameters including homeostasis model assessment-insulin resistance (HOMA-IR) were measured and compared between two groups at the baseline and 24 weeks.

Results

Sixty-four participants (SMT group [n = 28] and HPET group [n = 36]) were included in a modified intention-to-treat analysis. Both the SMT group and the HPET group had a significant reduction in CAP scores at 24 weeks (P = 0.002 and P < 0.001, respectively), but the change between the groups was insignificant (P = 0.213). Successful eradication of H. pylori occurred in 68% of the HPET group and led to greater improvement in HOMA-IR at 24 weeks compared to SMT or non-responder patients (P = 0.007). The liver enzymes reduced significantly at 24 weeks in both groups, but the changes between the groups were similar. The lipid parameters remained unchanged within the groups and between the groups at 24 weeks. A significant increase in the levels of reduced glutathione was noted in the HPET group, but the change between the two groups was not statistically different.

Conclusions

HPET was found to be comparable to SMT alone in reducing hepatic steatosis and liver enzymes at 24 weeks in NAFLD patients. However, successful eradication of H. pylori led to greater improvement in HOMA-IR (Trial registration CTRI/2017/05/008608).

Expression and Clinical Implications of Cysteine Cathepsins in Gallbladder Carcinoma

Background: Gallbladder carcinoma (GBC) exhibits poor prognosis due to its detection at an advanced stage. Upregulation of lysosomal cysteine proteases cathepsin L (CTSL) and cathepsin B (CTSB) has been implicated in several tumorigenic processes. However, no such information in GBC was available. Therefore, the present study was planned to investigate the expression and clinical significance of these cathepsins in GBC.

Methods: Activities of CTSL and CTSB were assayed in the gallbladder (GB) tissues obtained from GBC patients (n = 43) and control subjects (n = 69). Protein and mRNA levels were quantified using immunohistochemistry and real-time PCR (qPCR), respectively. Finally, serum levels of CTSL and CTSB were estimated by ELISA. Receiver operating characteristic (ROC) curve analysis was used for the assessment of sensitivity, specificity, and diagnostic accuracy of these cysteine cathepsins in GBC. The association of combined CTSL and CTSB activity with overall survival was assessed using Kaplan Meier survival analysis.

Results: The expression and activity of both CTSL and CTSB were significantly increased (p < 0.050) in tumors of GBC patients as compared to controls. Enzymatic activity of CTSL+B and CTSB exhibited a strong positive association with tumor stage and lymph node involvement in GBC (p < 0.050). Interestingly, the elevated activity of combined CTSL+B was also associated with increased mortality in these patients. Furthermore, significantly enhanced levels of serum CTSL and CTSB were also observed in GBC (p < 0.050) as compared to controls. ROC analysis revealed high diagnostic significance of serum CTSB and CTSL for distinguishing GBC patients from controls with an area under the curve (AUC) of 82 and 77%, respectively.

Conclusion: This study, for the first time, demonstrates the clinical significance of CTSL and CTSB overexpression in GBC. Our findings may help improve the clinical management of this carcinoma.

SPARC expression in desmoplastic and non desmoplastic pancreatic carcinoma and cholangiocarcinoma

BACKGROUND

The pancreatobiliary carcinomas are characterized by presence of desmoplastic stroma. Overexpression of secreted protein acid and rich in cysteine (SPARC), a matrix producing agent has been documented in pancreatic ductal adenocarcinomas, with survival benefits. This study was targeted to see if SPARC expression in pancreatobiliary carcinomas is responsible for stromal desmoplasia and its prognostic significance.

METHODS

In this retrospective study 48 cases of pancreatic cancer and 27 cases of cholangiocarcinoma were analyzed. The expression pattern of SPARC and vascular endothelial growth factor (VEGF) (angiogenic factors) was evaluated by immunohistochemistry on formalin fixed paraffin embedded tissues. Immunoreactivity was scored semi quantitatively based on stain intensity and stain distribution. SPARC expression was correlated with tumor histology, stromal desmoplasia, VEGF expression, various histological parameters and overall survival in patients. Real time polymerase chain reaction was performed in few cases to validate the immunohistochemistry expression pattern.

RESULTS

SPARC expression was high in peritumoral stroma in pancreatic carcinoma than in pancreatic controls; however, SPARC expression pattern was not grossly different in desmoplastic and non-desmoplastic pancreatobiliary carcinomas and in cholangiocarcinomas. No definite correlation was noted between SPARC expression and histological markers of severity and overall survival data.

CONCLUSIONS

The relevance of SPARC expression in pancreato-biliary carcinomas though may still be important for therapeutic decision making, it is not responsible for peritumoral stromal desmoplasia in these tumors and it does not have any significant prognostic implication.

Melanotic neuroectodermal tumour of infancy presenting as a lytic lesion in femur: a rare tumour at a rare site with an unusual behaviour

Melanotic neuroectodermal tumour of infancy (MNTI) is an uncommon tumour, predominantly occurring in head and neck, mostly maxilla, but also in skull and mandible. Although a benign lesion, it is known to recur in 15%-27% of cases, and rarely, may undergo malignant transformation. We present a case of a 5-month-old female patient, who presented with a gradually progressive swelling in the right thigh. On imaging, an osteolytic lesion was seen, involving the metadiaphysis of shaft of right femur. A biopsy was performed, on which diagnosis of MNTI was made. MNTI is rarely seen in extremities. To the best of our knowledge, only six cases have been reported in femur, the present case being the seventh. The tumour showed spontaneous regression on follow-up in our patient, which has rarely been described. A knowledge of characteristic morphology and immunohistochemistry is the key to differentiate it from other tumours.