Clinical and demographic comparison of celiac disease diagnosed during adulthood versus childhood and adolescence: A single-center experience

Background and Aim

Celiac disease (CeD) is mainly reported from the northern and western parts of India. In central India, it is believed to be a disease of children, with limited data among adults diagnosed for the first time after the age of 18 years. Hence, we aimed to describe CeD's clinical and demographic features among adults and children/adolescents in central India.

Methods

This is a retrospective analysis of a prospectively maintained database of all patients diagnosed for CeD from 2010 to 2019. The disease in adults was confirmed when symptoms developed for the first time after 18 years and had positive anti-transglutaminase antibodies with villous atrophy on duodenal biopsy. It was compared with pediatric patients with CeD diagnosed during the same time period.

Results

Of the 170 patients diagnosed with CeD, 118 were adults and 52 were children or adolescents. The mean age of presentation of adult CeD was 37.3 ± 11.93 years, while in the pediatric and adolescent group it was 9.19 ± 5.4 years. Classical presentation with chronic, painless, small-bowel-type diarrhea was seen in 44.1% of adults compared to 57.7% in the pediatric age group. Among the adult patients, 55.9% presented with nonclassical symptoms, which included abdominal pain (40.7%) and weight loss (36.4%). The common presenting symptom in children other than diarrhea was weight loss (50%) and abdominal pain (34.6%).

Conclusion

CeD is common in central India, with an increasing number of patients being diagnosed for the first time after 18 years of age and presenting more often with nonclassical symptoms.

Evaluation of liver and splenic stiffness by acoustic radiation force impulse for assessment of esophageal varices

BACKGROUND

In routine clinical practice, assessment of portal hypertension (PHT) among patients with liver cirrhosis is done by a upper gastrointestinal endoscopy (UGIE); however, its invasive nature limits its use. Recent advances in ultrasound imaging make it possible to evaluate the tissue stiffness of the liver and spleen reflecting the severity of underlying fibrosis. Liver stiffness and spleen stiffness can be used to predict the presence of esophageal varices/PHT among cirrhotic patients.

AIM

To predict the presence or absence of esophageal varices by measuring the stiffness of the liver and spleen by ultrasonography (USG)-based acoustic radiation force impulse (ARFI).

METHODS

This cross-sectional study included 90 subjects with liver cirrhosis. Liver and splenic stiffness were measured along with the USG abdomen, UGIE and aspartate aminotransferase to platelet ratio index (APRI).

RESULTS

Liver and spleen stiffness were significantly higher in cirrhotic patients compared to chronic hepatitis B. The best cut-off value of liver stiffness (LS) obtained by the receiver operating characteristic (ROC) curve was 2.16 m/s for predicting esophageal varices (AUROC 0.78, p 0.0002). The best cut-off value of splenic stiffness (SS) obtained by the ROC curve was 3.04 m/s for predicting esophageal varices (AUROC 0.698, p 0.0274). When both LS and SS were taken together, the accuracy in predicting esophageal varices increased to 92.22%. An equation to predict "esophageal varices = (0.225 LS + 0.377SS) - 0.555" was derived.

CONCLUSION

LS and SS values of ≥ 2.16 m/s and 3.04 m/s, respectively, predict esophageal varices independently; however, combined assessment is better with 92% accuracy.

Abdominal pain caused by lead toxicity due to over the counter herbal medicines: A case series

In the last three decades, the use of herbal medications has been increasing for the treatment of various chronic disorders. Studies in the past have shown that many of these medicines could contain high levels of heavy metals, including lead. Therefore, we planned this study to evaluate the possibility of lead toxicity as the underlying cause in patients consuming these unnamed herbal medicines among patients presenting with significant abdominal pain. (Unexplained abdominal pain means pain in abdomen in which no etiology could be ascertained after all possible routine and specialized investigations including computerized axial tomography [CT] of the abdomen and upper gastrointestinal [UGI] endoscopy/colonoscopy). This is an observational case series of prospectively maintained data of all patients having unexplained abdominal pain and found to have an elevated blood lead level from 2011 to 2019. Lead toxicity was diagnosed when its blood lead level was >25 μg/dL. Total sixty-six patients with unexplained abdominal pain from 2011 to 2019 were recruited. Out of the sixty-six patients, seventeen had elevated blood lead levels. All seventeen patients had a history of ingestion of herbal medicines for more than 6 months. Among the seventeen patients, eight were taking it for infertility and sexual dysfunction, six for diabetes, two for arthritis and one for hypertension. Basophilic stippling was seen in one patient. Fourteen patients had low hemoglobin with a median value of 9.7 g/dL. Mean serum blood lead level was 87.1 μg/dL. None of them required anti-chelating agent. Lead toxicity owing to herbal medicine is not uncommon cause of unexplained abdominal pain. Most of these patients do not require a chelating agent for treatment. There is a need to bring these herbal medicines under strict regulations for displaying its constituents and their concentrations.

Button battery ingestion in children: An emerging hazard

Button battery ingestion is an emerging hazard. In this retrospective study, we report six cases of lithium button battery ingestion in pediatric age group (mean age 2.8 years). Three button batteries were removed from stomach and three from esophagus. Esophageal site was associated with significant local injury, and one button battery was impacted in the esophagus, requiring rigid esophagoscopy for removal. Small battery size, used batteries, and early removal (<12 h after ingestion) were associated with lesser mucosal injury. No long-term complications were noted. Our study emphasizes that early diagnosis and urgent removal of ingested button battery are the only measures which prevent complications.

Cross-sectional study on rotavirus A (RVA) infection and assessment of risk factors in pre- and post-weaning piglets in India

Rotavirus A (RVA) infections are known to retard the piglets' growth and minimize the profit to the pig farming community. Between August 2014 and July 2017, in a cross-sectional study, we surveyed 13 organized pig farms located in the eight states of India representing northern, north-eastern and southern regions, to identify the risk factors associated with RVA infection in pre- and post-weaning piglets. Faecal samples (n = 411) comprising of non-diarrhoeic (n = 320) and diarrhoeic (n = 91) were collected and screened for RVA infection using VP6 gene-based RT-PCR. RVA positivity of 52.5% (168/320) in non-diarrhoeic and 59.3% (54/91) in diarrhoeic piglets was noticed. Further, 53.3% (120/225) and 54.8% (102/186) of the samples from pre- and post-weaned samples were positive for RVA, respectively. To note, no statistically significant association was noticed between RVA infection, health and weaning status. Additionally, a questionnaire-based survey was conducted to identify the risk factors for RVA infections in piglets. The analysis revealed that good ventilation (OR 0.2, 95% CI 0.15-0.39), use of deep well water (OR 0.2, 95% CI 0.13-0.43) and feeding of commercial feed (OR 0.3, 95% CI 0.18-0.41) were associated with reduced risk of RVA infection compared with poor ventilation, use of shallow well water and feeding of own milled feed, respectively. Contrarily, mixed farms (OR 2.1, 95% CI 1.26-3.37), use of heater or cooler (OR 5.9, 95% CI 3.74-9.30), sheds in different elevation (OR 2.5, 95% CI 1.20-5.01) and weekly and occasional use of disinfectant for surface cleaning (OR 1.8, 95% CI 1.12-2.96) were associated with higher RVA infection. Mitigating the risk factors might help in better health management of piglets and increase the economic return to pig farming community in the country.

Applications of Gas Separation by Adsorption for the Future

The separation and purification of gas mixtures by adsorption has found numerous industrial applications during the past 30 years. The very active research and development in this field is driven by (a) the highly flexible nature of cyclic adsorptive process designs, (b) the availability of many adsorbents for the separation and (c) the multiple choice of adsorbent–process design combinations for achieving the desired separation goals. The trend is to improve the product quality and separation efficiency, as well as to increase the scale of application of this technology. The design of processes using faster cycles and the use of innovative adsorber configurations are two new directions. Hybrid gas separation and production concepts such as adsorbent membranes and simultaneous sorption–reaction schemes are emerging areas that may open new frontiers of application for this technology.

Gas Adsorption Operations: Equilibrium, Kinetics, Column Dynamics and Design

Separation and purification of gaseous mixtures by adsorption has become a valuable tool in the chemical industry. Gas adsorption operations require information on both equilibrium and kinetics. Analytical equations are available to describe the adsorption of pure gases; mixture equilibria can be predicted by thermodynamic methods. Kinetic data suitable for column design can be expressed in terms of overall mass transfer coefficients. Design of columns for thermal swing adsorption (TSA) or pressure swing adsorption (PSA) processes requires the simultaneous solution of the partial differential equations for the material, energy and momentum balances describing the dynamics of adsorption in columns. Numerical solutions are usually required, but some useful analytical solutions are available for special cases.

Liquid-phase Adsorption of Bulk Ethanol–Water Mixtures by Alumina

Separation of ethanol–water liquid mixtures can be carried out by selective adsorption of water on activated alumina. The moderate selectivity and heat of adsorption of water on the alumina permits easier and less energy intensive desorption of the adsorbed water. Experimental binary surface excess isotherms, liquid-phase adsorption kinetics and column dynamics for the adsorption of bulk water–ethanol mixtures on Alcoa H152 alumina are reported. Model analyses of the data are carried out to quantify the selectivity of adsorption, adsorptive mass-transfer coefficients and the properties of the mass-transfer zones in adsorption columns.

The effect of divalent vs. monovalent ions on the swelling of mucin-like polyelectrolyte gels: governing equations and equilibrium analysis

We introduce a comprehensive model of a mucin-like polyelectrolyte gel swelling-deswelling which includes the ion-mediated crosslinking of polymer strands and the exchange of divalent and monovalent ions in the gel. The gel is modeled as a multi-phase mixture which accounts for the polymer and solvent volume fractions and velocities as well as ionic species concentrations. Motion is determined by force balances involving viscous, drag, and chemical forces. The chemical forces are derived from a free energy which includes entropic contributions as well as the chemical and electrostatic interactions among the crosslinked polymer, uncrosslinked polymer, and the ionic solvent. The unified derivation produces all the classical effects (van't Hoff osmotic pressure, Donnan equilibrium potential, Nernst-Planck motion of ions) as well as expressions for Flory interaction parameter and the standard free energy parameters that explicitly depend on the gel chemistry and crosslink structure. For this model, we show how the interplay between ionic bath concentrations, ionic binding, and transient divalent crosslinking leads to a variety of swelled and deswelled phases/phase transitions. In particular, we show how the absorption of divalent ions can lead to a massive deswelling of the gel. We conclude that the unique properties of mucin-like gels can be explained by their ionic binding affinities and transient divalent crosslinking.

Inflammatory bowel disease in central India: a single centre experience over five years

Summary

In this retrospective study, the records of all patients diagnosed with inflammatory bowel disease between 2005 and 2010 were analysed. Ulcerative colitis is far more common than Crohn's disease in our setting. The incidence is similar in both sexes and the age at diagnosis for both is similar. Limited left-sided ulcerative colitis is more common. Crohn's disease is difficult to diagnose and is commonly treated as tuberculosis in our setting.

Acute febrile illness in cirrhosis – thinking beyond spontaneous bacterial peritonitis!

Summary

The aim of this study was to look at the aetiological factors presenting as acute febrile illness in cirrhotic patients. The study group included all cirrhotic patients admitted as inpatients between January and December 2011 with a history of fever of less than seven days duration. Detailed history, clinical examination and investigations, as required, were noted. The data collected were analysed. A total of 42 patients formed the study group. The male-to-female ratio was 9.5:1. The mean age at presentation was 45.09 years (24 –77 years). The aetiological factors for fever were: spontaneous bacterial peritonitis (20), lower respiratory tract infection (8), urinary tract infection (6), lower limb cellulitis (4), acute cholecystitis (2) and malaria (2). The mean MELD (model for end-stage liver disease) score at presentation was 20.4. Three patients with spontaneous bacterial peritonitis (SBP) and a mean MELD score of 31 died during the hospital admission. Febrile illness in cirrhosis is attributable to multiple causes. Outcome is dependent on the severity of underlying liver disease.

Nonlinearity exponent of ac conductivity in disordered systems

We measured the real part of ac conductance Σ(x,f) or Σ(T,f) of iron-doped mixed-valent polycrystalline manganite oxides LaMn(1-x)Fe(x)O(3) as a function of frequency f by varying initial conductance Σ(0) by quenched disorder x at a fixed temperature T (room) and by temperature T at a fixed quenched disorder x. At a fixed temperature T, Σ(x,f) of a sample with fixed x remains almost constant at its zero-frequency dc value Σ(0) at lower frequency. With increase in f, Σ(x,f) increases slowly from Σ(0) and finally increases rapidly following a power law with an exponent s at high frequency. Scaled appropriately, the data for Σ(T,f) and Σ(x,f) fall on the same universal curve, indicating the existence of a general scaling formalism for the ac conductivity in disordered systems. The characteristic frequency f(c) at which Σ(x,f) or Σ(T,f) increases for the first time from Σ(0) scales with initial conductance Σ(0) as f(c) ~ Σ(0)(x(f)), where x(f) is the onset exponent. The value of x(f) is nearly equal to one and is found to be independent of x and T. Further, an inverse relationship between x(f) and s provides a self-consistency check of the systematic description of Σ(x,f) or Σ(T,f). This apparent universal value of x(f) is discussed within the framework of existing theoretical models and scaling theories. The relevance to other similar disordered systems is also highlighted.

Role of intravenous naloxone in severe pruritus of acute cholestasis

Pruritus is a well-known manifestation of various cholestatic disorders. Increased opioidergic tone is one of the mechanisms for this. This prospective, uncontrolled study was done to determine the efficacy of intravenous naloxone in pruritus of acute cholestasis. Twenty-two patients with severe pruritus (based on visual analogue scale [VAS] score of 0-100 and associated symptoms) were treated with intravenous naloxone (0.4 mg every 8 hours) for at least 48 hours. Viral hepatitis E was found to be the most common etiology for cholestatic pruritus (n=12). Eighteen patients (81.8%) patients had significant reduction in VAS after 48 hours of starting naloxone; these patients also showed reduction in alkaline phosphatase and gamma glutamyl transpeptidase. There was no side-effect or 'breakthrough' phenomenon noted in any patient over next 6 weeks. Naloxone is safe and efficacious in symptomatic improvement in cholestatic pruritus.

Chemisorption of carbon dioxide on potassium-carbonate-promoted hydrotalcite

New equilibrium and column dynamic data for chemisorption of carbon dioxide from inert nitrogen at 400 and 520 degrees C were measured on a sample of potassium-carbonate-promoted hydrotalcite, which was a reversible chemisorbent for CO(2). The equilibrium chemisorption isotherms were Langmuirian in the low-pressure region (p(CO(2)) < 0.2 atm) with a large gas-solid interaction parameter. The isotherms deviated from Langmuirian behavior in the higher pressure region. A new analytical model that simultaneously accounted for Langmuirian chemisorption of CO(2) on the adsorbent surface and additional reaction between the gaseous and sorbed CO(2) molecules was proposed to describe the measured equilibrium data. The model was also capable of describing the unique loading dependence of the isosteric heat of chemisorption of CO(2) reported in the literature. The column breakthrough curves for CO(2) sorption from inert N(2) on the chemisorbent could be described by the linear driving force (LDF) model in conjunction with the new sorption isotherm. The CO(2) mass-transfer coefficients were (i) independent of feed gas CO(2) concentration in the range of the data at a given temperature and (ii) a weak function of temperature. The ratio of the mass-transfer zone length to the column length was very low due to highly favorable CO(2) sorption equilibrium.

Cytohistological study of urinary bladder neoplasms

Eighty patients presenting with painless hematuria and 24 patients of transitional cell carcinoma bladder coming for follow up were included in this study to assess the role of exfoliative (voided urine) and lavage (saline lavage) cytology in initial diagnosis and follow up of the patient with carcinoma bladder. Freshly voided urine samples and saline lavage bladder washing samples were collected. A thorough cystoscopic examination was done and biopsy was taken from any apparent growth. Cytological smears were stained with hematoxylene and eosin and PAP's stain, histology sections were stained with hematoxylene and eosin. A statistically significant correlation (p < 0.001) was observed between the increasing grade of malignancy and cytopositivity. A good association was observed between histology and two methods of cytology (p < 0.01). The sensitivity, specificity and overall diagnostic accuracy of lavage cytology was more as compared to exfoliative cytology (71.05%, 56.0%, 78.85% Vs 47.37%, 41.18% and 61.54%). Cystopositivity was more with single large sessile tumour as compared to multiple small pedunculated tumours. Cytohistological discrepancy was observed in patients of transitional cell carcinoma with recurrence. It is concluded that cytology may act as a good adjuvant to histology in picking up early flat lesions and/or follow up of patients with transitional cell carcinoma.

The effect of mutant peptide cofactors on adenovirus protease activity and virus infection

Adenoviruses encode a cysteine protease, adenain, required for uncoating and virion maturation. Adenain activity is regulated by an 11-amino-acid peptide cofactor thiol-bonded distal to the active site. Structural and experimental data suggest that the peptide might stabilize adenain in an optimal conformation for enzyme activity by bridging two noncontiguous regions of the molecule. The sequence requirements for this mechanism were examined both in vitro and ex vivo by means of mutant peptides and databank analysis. The results of in vitro experiments suggested that activation is not an all or nothing mechanism. With the exception of the smallest peptide, the mutant peptides bound to adenain, activated it, and competed with the wild-type peptide, but all of this occurred with reduced efficiency. When added to the medium of infected cells, most of the peptides inhibited infectious virus production to varying degrees in a dose-dependent manner and in accordance with their in vitro activity on adenain. We interpret this inhibition to be due to unscheduled adenain activation. Examination of the activation peptide sequences from 19 adenovirus serotypes revealed a limited number of conserved sequence features. These features were in agreement with the experimental data. We conclude that binding and activation of adenain by pVIc may be reversible and this reversibility may be an integral aspect of the in vivo regulation of enzyme activity in the course of virus assembly. The peptide cofactor binding domain is therefore a potential target for the development of anti-adenoviral agents.

Adenovirus endopeptidase hydrolyses human squamous cell carcinoma antigens in vitro but not ex vivo

The serpins SCCA1 and SCCA2 are highly expressed in the epithelium of the conducting airways, a common site of infection by group C adenoviruses, such as human adenovirus type 2 (Ad2). Based on the common location we examined a possible interaction between them. In vitro experiments with recombinant proteins showed that SCCA1 inhibited the viral protease in a dose-dependent manner. Both serpins were cleaved in a manner consistent with hydrolysis within their reactive site loop, without the formation of an SDS-resistant complex, as in the case of papain. Infection of SCCA1-expressing cells did not result in the cleavage of SCCA1, nor was the yield of infectious virus affected as compared to SCCA1-negative parental cells. This may be due to differential localization, the serpin being cytoplasmic and viral protease being nuclear. Surprisingly, however, virus infection, which tends to inhibit host protein synthesis, caused a significant increase in SCCA1 expression well into the late phase of infection.