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Treating heart failure (HF) in postoperative congenital cardiac repair in children with an anomalous left coronary artery from the pulmonary artery (ALCAPA) is a daunting task. Regular anti-failure measures with angiotensin-converting enzyme (ACE) inhibitors may become inadequate or resistant in certain situations. Angiotensin receptor-neprilysin inhibitor (ARNI) in place of ACE inhibitors can be an alternative to help these postcardiac surgical children convalesce better. Sacubitril/valsartan is an ARNI-approved treatment for HF in adults, and in pediatric HF patients, it is showing promising benefits. However, in postcardiac surgical children with HF, its effects are not known. We used ARNI successfully in one of our postcardiac surgical infants with ALCAPA repair in HF, and we describe this case here. [ABSTRACT FROM AUTHOR]

Introduction: Day-care procedures has now becoming a popular modality of treatment throughout the world. Day-care procedures means that patient gets admitted, undergoes interventional procedure and gets discharged from the hospital on the same day of the procedure.[1] Anaesthetic agents available now-a-days play an important role in achieving specific criteria for ambulatory anaesthesia. Anaesthestic agents like, propofol and sevoflurane favors the anaesthesiologist to perform successful day case surgeries. Propofol has become the drug of choice for induction of anesthesia in the day care procedures due to its favorable recovery profile and low incidence of side effects.[2] Newer inhaled anaesthetics like desflurane and sevoflurane with low blood gas partition coefficient facilitates rapid induction of anaesthesia and rapid recovery and less adverse effect at the end of anaesthesia, leading to their use in day care surgery.[3] Materials and Methods: One hundred female patients with ASA and MPC grade 1 undergoing fibroadenoma surgery were selected for the study. Each patient was randomly allocated to either the propofol or the sevoflurane group. The groups were named „P? for propofol and „S? for sevoflurane. All the patients in the study were premedicated with inj.Glycopyrrolate 5µg/kg and Fentanyl 2 µg/kg just prior to induction of anaesthesia. Group P Induction with propofol 2mg/kg IV with nitrous oxide and oxygen 4L: 2L ratio. Group S Induction with sevoflurane 4% in nitrous oxide and oxygen 4L: 2L ratio in a closed circuit. Parameters studied, time to loss of consciousness, induction complications,incidence of apnoea, time of Phase 1 and Phase 2 recovery. Results: The mean time to LOC with intravenous propofol induction was significantly shorter when compared to inhalation induction with sevoflurane. Equal incidence of apnoea in both groups. Induction complications were more with sevoflurane group. The time to Phase I and Phase II recovery was comparable in both groups. Incidence of PONV was significantly less in propofol group,postoperative pain was comparable in both groups. Conclusion: The smoother induction and less post operative PONV and pain with propofol make it more ideal for induction and maintenance of anaesthesia in adult day care surgeries. [ABSTRACT FROM AUTHOR]

Depression is associated with hyperactivity of the hypothalamo pituitary adrenal axis. Cortisol is a steroid hormone, released from the adrenal gland and is considered to be a biological marker of stress and anxiety. Serum or plasma cortisol levels have been previously studied in depressive patients but reported contradictory results. The present meta analysis aims to assess the serum or plasma concentration of cortisol in depressive patients compared with controls. We have conducted a systematic review with sequential meta analysis according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Web of Science, PubMed, Scopus, and PsycINFO databases, and published reference lists were searched up to January 2021. We have conducted a systematic review on PubMed for the following search (MeSH) terms ("Hydrocortisone"[Mesh]) AND "Depressive Disorder"[Mesh]). The RevMan 5.3 and Open Meta Analyst software was used with the standard mean difference (SMD) and 95% confidence intervals (CIs). The Jamovi and Open Meta Analyst Software were used to evaluate the publication bias, sensitivity analysis, and meta regression as possible sources of heterogeneity. Seventeen studies having a combined population (n) of 1400 (743 depressive patients and 657 controls) had satisfied the inclusion criteria for serum or plasma cortisol. The pooled SMD of the serum or plasma cortisol levels in depressive patients compared with controls was 1.18, (95% CI: 0.84, 1.52; P < 0.00001) with I2 = 85% (Ph < 0.00001). This meta analysis indicates a statistically significant mean difference in serum or plasma cortisol between depressed patients and controls. Meta analysis concluded that serum or plasma cortisol can differentiate depressed patients from nondepressed controls. [ABSTRACT FROM AUTHOR]

Many gastrointestinal (GI) disorders present to the emergency room with acute clinical presentations, some even life threatening. Common emergencies encountered that require urgent endoscopic interventions include GI hemorrhage (variceal and nonvariceal), foreign body ingestion, obstructive jaundice, postprocedure-related complications such as postpolypectomy bleed or perforation, etc. A major advantage of emergency endoscopy is that it is cost effective and, on many occasions, can be life-saving. The present review will highlight a practical approach on various endoscopic modalities and their use in the GI emergencies. [ABSTRACT FROM AUTHOR]

Background and Aims  The training in esophageal stricture dilation is difficult to obtain and have few simulation models. The aim of the study was to evaluate a novel stricture simulation for training a wire-guided, controlled radial expansile (CRE) balloon dilation. Methods  The study was a pretest–posttest design without a control group involving a novel simulation device for esophageal stricture. The training session involved 12 final year gastroenterology fellows from five different centers. The trainees received 2 hours of education sessions featuring didactic content, a live demonstration of step-by-step demonstration of wire-guided CRE balloon dilation and a study material on the procedure. The simulation device used was a single-use hose pipe along with a red color nonhardening modeling clay with a 5.0-to-8.0-mm hole in the center. Results  All the trainees and instructor uniformly rated the model as excellent or good with simulation device being mild stiffer in haptics than of the real tissue. The mean (%) pretest scores of 39 (21.6%) improved significantly to 160 (88.8%) in mean (%) posttest questionnaire (p  < 0.05). There was a significant improvement in the questionnaire of the dilation procedure after the simulation training episode. Conclusion  The novel stricture simulation model had good performance evaluation and can be used to train CRE balloon dilation procedure. [ABSTRACT FROM AUTHOR]

Background and Study Aims  In the coronavirus disease 2019 (COVID-19) pandemic, patients undergoing esophagogastroduodenoscopy (EGD) and colonoscopy on the same day (bidirectional endoscopy [BDE]) have increased. The aims of the study were to compare the procedure times, benefits, and safety of same-day BDE and conventional serial endoscopic examination (SEE). Patients and Methods  All the patients undergoing evaluation with either BDE or SEE were prospectively enrolled at Ramaiah Medical College and Hospitals, Bangalore, from 1st December 2020 to 31st May 2021. EGD was immediately followed by colonoscopy in BDE. In SEE, EGD was followed by colonoscopy in 1 or 2 days. Clinical data and results were collected and evaluated. Results  Two hundred consecutive patients who consented for BDE were enrolled in the study. The mean ± standard deviation (range) age of the patients was 45 ± 14.5 (22–60) years. Majority (124 [62%]) were men. The outcome measures of Boston Bowel Preparation Scale with the excellent/good preparation score and polyp detection rate were similar in both groups (p  = 0.4). The total procedure time was significantly higher in the SEE group than in the BDE (p  < 0.001). There were no adverse events noted in the study. The overall patient experience and satisfaction were higher in BDE than in SEE without any difference in the quality of the procedures (p  < 0.001). Patients with weight loss and anemia were more likely to have a positive test result than the patients with abdominal pain and diarrhea. Conclusions  In conclusion, same-day BDE is advised for patients with anemia and weight loss which can reduce the number of hospital visits and improve patient satisfaction in COVID times. [ABSTRACT FROM AUTHOR]

Heart transplantation (HTx) is a gold standard for end-stage heart failure (ESHF). Cardiomyopathies form the majority of patients who undergo HTx. Grown-up congenital heart disease, with or without prior palliative surgery, progresses to ESHF requiring HTx. They constitute the least among all heart recipients. The immediate posttransplant management may become challenging due to severe right heart failure, massive ascites, pleural effusion, and cardiac cachexia. Scarce data are available on this subset of patients. We describe one such patient's post-HTx management. A 15-year-old male with Ebstein's anomaly, restrictive cardiomyopathy, severe right ventricular (RV) dysfunction, atrial flutter, left atrial clot, postradiofrequency ablation, New York Heart Association III, and early cardiac cirrhosis underwent HTx successfully. He had significant mediastinal hemorrhage postoperatively, and managed medically; echocardiography showed a good biventricular function with mild tricuspid regurgitation (TR), and he was extubated on the 1st postoperative day. However, progressive RV function deterioration was observed over the next 72 h (tricuspid annular plane systolic excursion of 7 mm with mild TR) with massive worsening ascites and pleural effusion. He was treated with milrinone and furosemide infusion and noninvasive ventilation, but response to optimal diuretic doses was poor, and the ascites did not decrease. Hence, intermittent paracentesis was done, and 10 L of ascitic fluid was removed over 10 days. Then, he responded to diuretics; his RV function improved. His respiratory support and inotropes were discontinued. His immunosuppressants consisted of tacrolimus and prednisolone. Mycophenolate mofetil was withheld due to leukopenia. At 6-month follow-up, his cardiac functions were normal, ascites completely resolved, appetite improved, and he gained weight. [ABSTRACT FROM AUTHOR]

Objective: The objective is to assess the clinical course and outcomes of heart transplant (HTx) recipients affected by COVID-19 disease in a tertiary care health care institution. Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) is a contagious illness with alarming morbidity and mortality. The HTx recipients are chronically immunosuppressed and thus COVID-19 infection in them may result in an unpredictable clinical course. Materials and Methods: HTx recipients in a tertiary care transplant center in North India were retrospectively reviewed from January 2020 to January 2021. Case records of 28 patients of HTx were reviewed, and four (14%) were found to have developed Covid-19 infection. Clinical parameters and outcomes of these four HTx recipients with confirmed SARS-CoV-2 infection are described. Results: Fourteen percent of our HTx patients (4 out of 28 patients under follow-up) developed COVID-19 in the first infection wave. The study population consisted of 3 males and 1 female patient with a median age of 28 years (range 15-39). The most common presenting symptoms were fever (100%), myalgia (100%) and cough (75%). There was no mortality observed in this study. None required intensive care admission or mechanical ventilatory support. Three were managed with hospital admission while one was subjected to home isolation. The mean hospital stay was 13.5 days (12-17 days). Immunosuppressants were modified by reducing tacrolimus and mycophenolate, however, corticosteroids were continued. Conclusion: The dose modification rather than discontinuation of immunomodulatory agents should be established as standard of care for transplant recipients. Steroids may provide added benefit and should be continued. The morbidity and mortality in such cases may be lower than anticipated; however, this needs to be substantiated with larger multicentric studies. [ABSTRACT FROM AUTHOR]

Introduction: Dysregulation of Hypothalamic-Pituitary-Adrenal (HPA) axis can reduce the effects of antidepressants. Salivary cortisol level and Hamilton Depression Rating (HAM-D) score can be used to assess the level of improvement in the HPA axis and depressive disorders. Aim: To evaluate the changes in salivary cortisol level and HAM-D score in patients of Treatment Resistant Depression (TRD) and to investigate the association between them. Materials and Methods: The present prospective cohort study was conducted in the Department of Pharmacology and Psychiatry at Pt. JNM Medical College and Dr. BRAM Hospital Raipur (CG) over a period of one year, from June 2014 to June 2015. The participants were 52 diagnosed cases of TRD according to Diagnostic and Statistical Manual of Mental Disorders (DSM IV) criteria, who were taking antidepressant medications for at least four weeks. The salivary cortisol values and HAM-D scoring were done at baseline and follow-up at 8 weeks and 16 weeks and compared by student's t-test and one-way ANOVA. Results: A significant difference (p<0.001) was noted in the mean salivary cortisol levels (1.15±0.31 and 0.72±0.24) mean HAM-D (29.67±1.43 and 16.26±7.08) scores at baseline and subsequent follow-up respectively. Conclusion: The therapeutic benefit of antidepressants could be due to alteration of HPA axis functioning. [ABSTRACT FROM AUTHOR]

Background: COVID-19 pandemic has stirred an unexpected turmoil in health care worldwide. The strategic conduct of critical care would warrant an effective preparedness plan, thorough knowledge of the disease manifestations, and relevant therapeutic strategy to sail through this crisis. Methods: English medical literature with MeSh database was searched using the key words such as "COVID-19 pandemic," "ICU preparedness," "COVID-19 management," "COVID-19 therapy," and "COVID-19 systemic effects." The relevant studies were included with significant inputs from interdepartmental meetings for the formulation of a plan. Results: The analysis of the respective studies highlighted the requirements of COVID-19 designated intensive care units (ICUs) with special provisions and the therapeutic agents being used in critical patients with emphasis on Remdesivir, Dexamethasone, Convalescent Plasma, and insight into newer agents. The systemic manifestations of COVID-19 requiring ICU care such as acute respiratory distress syndrome, myocardial injury, arrhythmias, hypercoagulable state, and acute renal dysfunction have been highlighted. The need of updating records with research protocols cannot be disregarded. The care of patients should not compromise the health-care personnel requirements. Conclusion: The evidence-based preparedness strategy can curtail the critical care crunch in COVID-19 management; however, institutional specific approach should be formulated. [ABSTRACT FROM AUTHOR]

Background: We determined the prevalence of acute kidney injury requiring peritoneal dialysis (PD), the factors associated with early PD initiation, prolonged PD and mortality among pediatric postoperative cardiac surgical patients. Materials and Methods: The hospital records of 23 children, aged 12 years or younger, who had undergone cardiac surgery and required PD subsequently, during a 1-year period were reviewed. Demographic data, intraoperative variables, and postoperative complications were compared between survivors and nonsurvivors of PD, between the short and long duration PD groups, and between the early and late PD initiation groups. Results: Six hundred and eight pediatric patients who underwent open heart surgery were enrolled in this study. 23 (3.78%) of them required PD. When compared with survivors (n = 11), non survivors (n =12) were more likely to have a higher serum procalcitonin (p = 0.01), higher serum potassium on day 2 (p = 0.001), day 3 (p = 0.04), day of termination of PD (p = 0.001) and a lower urine output on day 3 of PD (p = 0.03). Prolonged PD was associated with time of PD initiation (p = 0.01), a higher postoperative serum creatinine on day 3 (p = 0.01) of PD initiation as well on the day of PD termination (p = 0.01) and the final outcome in terms of survival (p = 0.02). Factors significantly associated with an early PD initiation were CPB time (p = 0.04), sepsis (p = 0.02) and shorter PD duration (p = 0.003). Conclusion: PD is very useful mode of renal replacement therapy among pediatric postoperative cardiac surgical patients. The intraoperative and postoperative variables have important association with the time of PD initiation, PD duration and patient survival. [ABSTRACT FROM AUTHOR]

Background: Self-expandable metallic stents (SEMS) placement is the procedure of choice for palliation of dysphagia in inoperable esophageal malignancies. Aim To evaluate the safety of placement of SEMS in esophageal cancer at two institutes using only endoscopic control without fluoroscopy and to determine efficacy of SEMS in palliation of dysphagia after deployment. Methods: Participants who underwent endoscopy and esophageal SEMS placement at two centers for inoperable esophageal malignancy between 2014 and 2017 were included retrospectively. The indication for the procedure and clinical outcome measures like adverse events and improvement in dysphagia score were recorded on uniform structured data forms. Results: Eighty-three esophageal SEMS placement was performed in 78 patients (mean age 64 ± 10.1 years; 59 men). The indication of SEMS placement was stricture in 72 (92.3%) and in 6 cases SEMS was placed for closure of trachea–esophageal fistula. All the patients in dysphagia score of 3 have improved to lower dysphagia scores post stent deployment. Postprocedure retrosternal pain, respiratory distress, and aspiration pneumonia in 58, 9, and 2 patients, respectively. Five patients required repeat stenting due to tumor ingrowth/granulation tissue during follow-up. The median survival of patients who received SEMS was significantly different from controls who did not receive SEMS (141 [41–360] days versus 98 [30–165 days]; p = 0.01). In 2 cases stent repositioning was done due to distal migration at the time of placement. There was no SEMS migration or stent related complications at follow-up. Conclusions: SEMS can be placed effectively under endoscopic control without fluoroscopic control in palliation of esophageal malignancy. Early SEMS deployment for palliating dysphagia may lead to survival advantage. [ABSTRACT FROM AUTHOR]

Rapid two-stage arterial switch operation (ASO) is very relevant as many patients of transposition of great arteries (TGA) present late to the hospital when primary switch either is not possible or carries a high risk of morbidity and mortality. Hence, other means apart from the traditional methods of left ventricle preparedness should be tried to help this category of patients, who are to undergo rapid two-stage ASO. We successfully used levosimendan and continuous positive airway pressure after 1st stage operation in a patient with dTGA and regressed ventricle, which helped in left ventricular preparedness, and the child underwent rapid two-stage ASO uneventfully. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to evaluate the causal relation between hospital-acquired infection (HAI) and clinical outcomes following cardiac surgery in neonates and infants and to identify the risk factors for the development of HAI in this subset of patients. Materials and Methods: After Ethics committee approval, one hundred consecutive infants undergoing open heart surgery (OHS) between June 2015 and June 2016 were included in this prospective observational study. Data were prospectively collected. The incidence and distribution of HAI, the microorganisms, their antibiotic resistance and patients' outcome were determined. The Centers for Disease Control and Prevention criteria were used for defining HAIs. Univariate and multivariate risk factor analysis was done using Stata 14. Results: Sixteen infants developed microbiologically documented HAI after cardiac surgery. Neonatal age group was found to be most susceptible. Lower respiratory tract infections accounted for majority of the infections (47.4%) followed by bloodstream infection (31.6%), urinary tract infection (10.5%), and surgical site infection (10.5%). Klebsiella (36.8%) and Acinetobacter (26.3%) were the most frequently isolated pathogens. HAI was associated with prolonged ventilation duration (P = 0.005), Intensive Care Unit stay (P = 0.0004), and hospital stay (P = 0.002). Multivariate risk factor analysis revealed that preoperative hospital stay (odds ratio [OR] 1.22, 95% confidence interval (CI) 1.6-1.39, P = 0.004), and prolonged cardiopulmonary bypass (CPB) (OR 1.03, 95% CI 1.01-1.05, P = 0.001) were associated with the development of HAI. Conclusion: HAI still remains a dreaded complication in infants after OHS and contributing to morbidity and mortality. Strategies such as decreasing preoperative hospital stay, CPB time, and early extubation should be encouraged to prevent HAI. [ABSTRACT FROM AUTHOR]

Background and Objectives: Adequate nutritional supplementation in infants with cardiac malformations after surgical repair is a challenge. Critically ill infants in the early postoperative period are in a catabolic stress. The mismatch between estimated energy requirement (EER) and the intake in the postoperative period is multifactorial, predisposing them to complications such as immune deficiency, more infection, and growth failure. This study aimed to assess the feasibility and efficacy of enriched breast milk feed on postoperative recovery and growth of infants after open heart surgery.Methodology: Fifty infants <6 months of age were prospectively randomized in the trial for enteral nutrition (EN) postoperatively from day 1 to 10, after obtaining the Institute Ethics Committee's approval. They were equally divided into two groups on the basis of the feed they received: Control group was fed with expressed breast milk (EBM; 0.65 kcal/ml) and intervention group was fed with EBM + energy supplementation/fortification with human milk fortifier (7.5 kcal/2 g)/Simyl medium-chain triglyceride oil (7.8 kcal/ml). Energy need for each infant was calculated as per EER at 90 kcal/kg/day, as the target requirement. The intra- and post-operative variables such as cardiopulmonary bypass and aortic cross-clamp times, ventilation duration, Intensive Care Unit (ICU), and hospital length of stay and mortality were recorded. Anthropometric and hematological parameters and infection control data were recorded in a predesigned pro forma. Data were analyzed using Stata 14.1 software.Results: The duration of mechanical ventilation, length of ICU stay (LOIS), length of hospital stay (LOHS), infection rate, and mortality rate were lower in the intervention group compared to the control group although none of the differences were statistically significant. Infants in control group needed mechanical ventilation for about a day more (i.e., 153.6 ± 149.0 h vs. 123.2 ± 107.0 h; P = 0.20) than those in the intervention group. Similarly, infants in control group stayed for longer duration in the ICU (13.2 ± 8.9 days) and hospital (16.5 ± 9.8 days) as compared to the intervention group (11.0 ± 6.1 days; 14.1 ± 7.0 days) (P = 0.14 and 0.17, respectively). The LOIS and LOHS were decreased by 2.2 and 2.4 days, respectively, in the intervention group compared to control group. The infection rate (3/25; 5/25) and mortality rate (1/25; 2/25) were lower in the intervention group than those in the control group. The energy intake in the intervention group was 40 kcal more (i.e., 127.2 ± 56.1 kcal vs. 87.1 ± 38.3 kcal) than the control group on the 10th postoperative day.Conclusions: Early enteral/oral feeding after cardiac surgery is feasible and recommended. In addition, enriching the EBM is helpful in achieving the maximum possible calorie intake in the postoperative period. EN therapy might help in providing adequate nutrition, and it decreases ventilation duration, infection rate, LOIS, LOHS, and mortality. [ABSTRACT FROM AUTHOR]

Since the initiation of economic reforms in 1991, India adopted an outward-oriented strategy for development. After the inception of the World Trade Organization (WTO) in 1995, the country initially relied on multilateral trade reforms for export growth, but slow progress of the Doha Round negotiations over the last decade caused it to explore the regional trade agreements (RTAs) route as well from 2003-04 onwards. While in the initial period India focused on deeper trade relationship with Asian partners--namely, the Association of Southeast Asian Nations (ASEAN), Japan, South Korea, etc.--as preferential trade allies, the perceived need to diversify the export markets has led the country to focus on potential trade partners in Africa, Europe, North and Latin America as well in recent times. On the other hand, the economies of East Africa are also embracing the RTA route for their trade promotion, and the growing Indian market offers an opportunity for them as well. The present analysis attempts to understand the trade potential between the five East African Community (EAC) countries and India in the sphere of merchandise and services trade by looking through various trade indices. The empirical results indicate that bilateral trade between the two regions have a strong potential, which can be aided further through policy reforms at both ends. [ABSTRACT FROM AUTHOR]

Background: Nosocomial infections (NIs) in the postoperative period not only increase morbidity and mortality, but also impose a significant economic burden on the health care infrastructure. This retrospective study was undertaken to (a) evaluate the incidence, characteristics, risk factors and outcomes of NIs and (b) identify common microorganisms responsible for infection and their antibiotic resistance profile in our Cardiac Surgical Intensive Care Unit (CSICU).Patients and Methods: After ethics committee approval, the CSICU records of all patients who underwent cardiovascular surgery between January 2013 and December 2014 were reviewed retrospectively. The incidence of NI, distribution of NI sites, types of microorganisms and their antibiotic resistance, length of CSICU stay, and patient-outcome were determined.Results: Three hundred and nineteen of 6864 patients (4.6%) developed NI after cardiac surgery. Lower respiratory tract infections (LRTIs) accounted for most of the infections (44.2%) followed by surgical-site infection (SSI, 11.6%), bloodstream infection (BSI, 7.5%), urinary tract infection (UTI, 6.9%) and infections from combined sources (29.8%). Acinetobacter, Klebsiella, Escherichia coli, and Staphylococcus were the most frequent pathogens isolated in patients with LRTI, BSI, UTI, and SSI, respectively. The Gram-negative bacteria isolated from different sources were found to be highly resistant to commonly used antibiotics.Conclusion: The incidence of NI and sepsis-related mortality, in our CSICU, was 4.6% and 1.9%, respectively. Lower respiratory tract was the most common site of infection and Gram-negative bacilli, the most common pathogens after cardiac surgery. Antibiotic resistance was maximum with Acinetobacter spp. [ABSTRACT FROM AUTHOR]

Background: Levosimendan a calcium ion sensitizer improves both systolic and diastolic functions. This novel lusitropic drug has predictable antiischemic properties which are mediated via the opening of mitochondrial adenosine triphosphate-sensitive potassium channels. This action of levosimendan is beneficial in cardiac surgical patients as it improves myocardial contractility, decreases systemic vascular resistance (SVR), and increases cardiac index (CI) and is thought to be cardioprotective. We decided to study whether levosimendan has any impact on the outcomes such as the duration of ventilation, the length of Intensive Care Unit (ICU) stay, and the hospital stay when compared with the nitroglycerine (NTG), which is the current standard of care at our center.Materials and Methods: Forty-seven patients undergoing elective coronary artery bypass surgery were randomly assigned to two groups receiving either levosimendan or NTG. The medications were started before starting surgery and continued until 24 h in the postoperative period. Baseline hemodynamic parameters were evaluated before beginning of the operation and then postoperatively at 3 different time intervals. N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) levels were also measured in both groups.Results: In comparison to the NTG group, the duration of ventilation and length of ICU stay were significantly less in levosimendan group (P < 0.05, P = 0.02). NT-proBNP level analysis showed a slow rising pattern in both groups and a statistically significant rise in the levels was observed in NTG group (P = 0.03, P = 0.02) in postoperative period when compared to levosimendan group of patients.Conclusion: Levosimendan treatment in patients undergoing surgical revascularization resulted in improved CI, decreased SVR and lower heart rate. And, thereby the duration of ventilation and length of ICU stay were significantly less in this group of patients when compared with NTG group. [ABSTRACT FROM AUTHOR]

In this research work, mesoporous zirconium phosphate (mzrp) and cerium loaded mesoporous zirconium phosphate with different Zr/Ce molar ratios (1 : 0, 1 : 1, 2 : 1, 5 : 1) (Cemzrp) were synthesized and used for the removal of fluoride ions from aqueous solutions. The adsorbents were prepared by a surfactant assisted route and characterized using different instrumental techniques like XRD, N2 adsorption/desorption isotherms, FTIR and SEM. The analysis of results of experimental data indicates the formation of uniform mesopore zirconium phosphate and framework substitution of cerium on it. Adsorption experiments were conducted as a function of adsorbent dose, equilibrium pH, initial fluoride concentration, contact time, kinetics and Langmuir isotherms. The adsorption kinetic studies indicate that the overall adsorption process was best described by pseudo-second-order kinetics. The experimental adsorption isotherm was in good concordance with the Langmuir isotherm model (R2 = 0.999) and based on the Langmuir isotherm model, the maximum adsorption capacity of fluoride ions from aqueous solutions was found to be 20.5 mg g−1. The enthalpy and entropy were found to be 27.73 kJ mol−1 and 96.21 J mol−1 K−1 respectively. The endothermic nature of the adsorption process is ascertained from the result. The results show that cerium loaded mesoporous zirconium phosphate having a Zr to Ce molar ratio of 2 : 1 (Cemzrp2) can be used as an effective adsorbent for the removal of fluoride ions from wastewater. [ABSTRACT FROM AUTHOR]

Severe persistent hypertension is seen infrequently in newborns and infants, but we came across two infants who developed severe paradoxical hypertension after successful coarctation repair. Treatment of systemic hypertension following repair of coarctation of the aorta is always challenging particularly in infants. Dexmedetomidine was used successfully as an adjunct to the established anti-hypertensive drugs in the immediate postoperative period in our cases to treat postoperative paradoxical hypertension. [ABSTRACT FROM AUTHOR]

Recently, nanoscale zero-valent iron (nZVI) particles have been efficiently used in the remediation of many heavy metals, yet potential agglomeration and loss of nZVI remain a critical area of research. In this study, we used red mud as a stable supporting medium to develop red mud modified nZVI to form (RM-nZVI) composite. We assessed its sorptive/reductive removal of mercury (Hg2+) from aqueous solutions. The RM-nZVI was synthesized through the reduction of ferric iron by sodium borohydride (NaBH 4) in the presence of red mud. Morphological characterization of RM-nZVI confirmed its diffusion state with lesser aggregation. The RM-nZVI has the BET surface area, pore diameter, and pore volume as 111.59 m2g−1, 3.82 nm, and 0.49 cm3g−1, respectively. Adsorption of mercury (Hg2+) by RM-nZVI exhibits pH-dependent behavior with increased removal of Hg2+ with the increase in pH up to 5, and the removal rate decreased gradually as the pH increased from 5 to 10. Extensive characterization of RM-nZVI corroborated the evidence that the removal of Hg2+ was initially by rapid physical adsorption, followed by a reduction of Hg2+ to Hg0. The adsorption data were best fitted with Langmuir isotherm with R2 (correlation coefficient) > 0.99 with high uptake capacity of 94.58 (mg g−1). The novel RM-nZVI composite with enhanced sorptive and reductive capacity is an ideal alternative for removing Hg2+ from contaminated water. [Display omitted] • RM-nZVI was more effective to remove Hg(II) ions from aqueous solution. • The removal capacity of Hg(II) by RM-nZVI was 94.58 mg g−1. • Hg2+ is completely reduced to Hg0 via a Hg2+-Fe0 replacement reaction. • Mechanisms of reduction of Hg2+ to Hg0 is explained by XRD, XPS and FTIR. [ABSTRACT FROM AUTHOR]

Introduction: Acute pancreatitis (AP) is a life-threatening gastrointestinal disease with high mortality and morbidity. However, scoring systems or prognostic indicators for assessing AP are cumbersome and expensive, and have not proved accurately to predict outcomes. Aim: We conducted a study with the aim of evaluating the predictive accuracy of C-reactive protein (CRP)/albumin and ferritin regarding outcomes in patients with AP. Material and methods: A prospective study was conducted in a tertiary care referral centre in Odisha from March 2020 to April 2021. A total of 116 consecutive patients of AP were enrolled in the study. CTSI, APACHE II, ferritin, and the CRP/albumin ratio were calculated. Results: The mean age of patients was 40.63 ±5.49 years with a male predominance (73%). Alcohol was most common aetiology (46.6%), and the overall mortality was 18%. Mean ferritin and the CRP/albumin ratio were also significantly higher in severe AP as compared to moderately severe AP and mild AP (p < 0.001). The CRP/albumin ratio (AOR = 1.26, 95% CI: 1.02-1.56, p = 0.02) was found to be independent predictor of mortality in Cox regression multivariate analysis and had the highest AUC for predicting the severity of acute pancreatitis. Serum ferritin had higher AUC (0.89, 0.83-0.91, p < 0.001) for the development of necrosis in acute pancreatitis, but it failed to be proven as an independent predictor of mortality. Conclusions: CRP/albumin is a simple, cheap, and easily available biomarker predicting the development of severe pancreatitis, and it was found to be an independent predictor of mortality in AP. [ABSTRACT FROM AUTHOR]

Abernethy syndrome (congenital extrahepatic portosystemic shunt (CEPS II)) as an etiology of hepatopulmonary syndrome (HPS) is uncommon. The severe hypoxemia and its consequences become incapacitating for the patient. Early shunt closure resolves hypoxemia and clinical symptomatology and prevents irreversible changes in pulmonary vasculature. [ABSTRACT FROM AUTHOR]

Ascarias lumbricoides infestation is endemic in tropical countries. Most infections are asymptomatic, but it can produce a wide spectrum of manifestations including hepatobiliary and pancreatic complications. There are reports of association of biliary ascariasis with bilary malignancies in the past, but same is not known for pancreatic ascariasis. We report a case of association of periampullary malignancy with pancreatic ascariasis. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 43-year-old woman who experienced complications after undergoing an orthotopic heart transplantation (OHT) for her dilated cardiomyopathy. The patient then went for an echocardiography test which showed a mild right ventricle dysfunction and risk of developing hyperkalemia. The article also discusses the drug effectiveness of fludrocortisone as treatment for hyperkalemia.

Elizabethkingia meningoseptica (E. meningoseptica), is an opportunistic Gram-negative bacteria, normally found in water and soil, notorious for causing nosocomial infections in extremes of ages and immunocompromised patients. It is now emerging as a serious nosocomial pathogen, intrinsically resistant to several commonly used antibiotics (e.g. beta-lactams, aminoglycosides, carbapenems and colistin etc. and a cause of high mortality in critically ill patients in intensive care units (ICUs). We report the first case of E. meningoseptica sepsis in a 5 month old child after open heart surgery for transposition of great arteries, initially on extracorporeal membrane oxygenation, then prolonged mechanical ventilation, with various invasive devices, inotropes and exposed to broad spectrum antibiotics in our ICU. The case highlights the potential risk factors responsible for E.meningoseptica sepsis. Its unusual pattern of resistance to many commonly used antibiotics makes this organism difficult to treat. [ABSTRACT FROM AUTHOR]

Introduction: Lung transplant (LTx) is a potential treatment option for all patients with chronic, end‑stage respiratory disease, who are refractory to optimal medical therapy or where no medical therapy exists. In India, LTx is still in its evolving stages and published literature is sparse. The current study was carried out to study the selection criteria for lung transplant and to evaluate the clinical and socio‑economic profile of patients referred for the same at a tertiary health care facility. Methods: The study was a descriptive, prospective, observational study. All adults referred for lung transplant were evaluated for clinical and laboratory profiles. All enrolled patients were assessed for presence of referral criteria, listing criteria, contraindications, and willingness for lung transplant. These patients were followed up for 2 years for transplant‑free survival, and the Cox proportional hazards model was used to determine independent predictors of all‑cause mortality. Results: A total of 103 were included in study. The most common diagnosis was interstitial lung disease (57.2%), followed by bronchiectasis (17.5%) and COPD (13.6%). Most patients were referred for LTx at an advanced stage as 90% met listing criteria. Fifty‑four (52.4%) patients had an absolute or relative contraindication to transplant; however, the majority of those contraindications were modifiable. Patients with a lower socio‑economic status were less likely to be willing for LTx. The median survival was 757 days. A 6‑minute walk distance (6MWD) lesser than 250 m was found to be an independent predictor of mortality. Conclusion: Making patients aware about lung transplant early in their treatment may give them sufficient time to come to terms with their disease and understand the risk and benefits associated. Efforts should be focused on screening and early treatment of reversible contraindications for the eligible patients. Patients with 6MWD < 250 m are at increased risk of mortality. [ABSTRACT FROM AUTHOR]

Background. Left ventricular diastolic dysfunction (LVDD) appears to be the earliest cardiac disturbance in cirrhosis patients. There are many previous reports reporting the significance of severity of LVDD on the outcome of liver transplantation or TIPS insertion, a few Indian studies have addressed the role of LVDD on survival in decompensated cirrhosis. The objective of this study is to assess the effect of LVDD on the survival of decompensated cirrhotic patients. Methods. We prospectively evaluated 92 decompensated cirrhotic patients from April 2015 to March 2017 at IMS and SUM Hospital, Bhubaneswar, India. 2D echocardiography with tissue Doppler imaging was used to evaluate cardiac function, as per the American society of echocardiography guidelines. The primary endpoint was to evaluate the effect of LVDD on overall mortality. Results. Ninety-two decompensated cirrhotic patients were evaluated in this prospective cohort study. Twenty-eight out of 92 patients (30%) died due to liver-related complications after a follow-up of 24 months. The decompensated cirrhotic patients with MELD score ≥ 15 had a significantly higher E / e ′ ratio (11.94 ± 4.24 vs. 8.74 ± 3.32 , p < 0.001) suggesting severe LV dysfunction in advanced cirrhosis. Patients with E / e ′ ratio > 10 had significantly higher MELD score and Child-Pugh score (19.88 ± 7.72 vs. 14.31 ± 5.83 ; 10.25 ± 1.74 vs. 9.02 ± 1.74 , p < 0.01 , respectively) as compared to the E / e ′ ratio < 10 group. In Cox proportional hazard multivariate analysis, E / e ′ ≥ 10 (HR 2.72, 95% CI 1.07-6.9, p = 0.03) and serum albumin (HR 0.32, 95% CI 0.14-0.7, p < 0.01) were found to be independent predictors of mortality in decompensated cirrhotic patients. Conclusion: The presence of LVDD and low serum albumin were independent predictors of mortality in decompensated cirrhotic patients. Hence, LVDD is an indicator of advanced cirrhosis and mortality. [ABSTRACT FROM AUTHOR]

BACKGROUND Left ventricular diastolic dysfunction (LVDD) is the earliest cardiac dysfunction noted in patients with liver cirrhosis, which increases the morbidity and mortality in such patients. There are sparse studies from India evaluating the predictive factors of LVDD in patients with cirrhosis. Hence we undertook this prospective study with an aim to evaluate the factors predicting the development of LVDD in liver cirrhosis. METHODS 104 patients with cirrhosis were enrolled in this prospective study. A detailed cardiac evaluation was done by 2 D echocardiography with tissue Doppler imaging by an experienced senior cardiologist. The severity of liver disease was defined by Model For End-Stage Liver Disease (MELD) and Child-Pugh score. RESULTS The prevalence of LVDD was 46% in our study. Multivariate logistic regression analysis revealed that serum albumin, MELD score, and presence of ascites (OR = 0.1, 95%CI 0.03-0.3,p < 0.001; Or = 1.12, 95%CI 1.03-1.22,p < 0.001; OR = 4.19, 95%CI 1.38-12.65, p < 0.01, respectively) were independent predictors of LVDD in patients with cirrhosis. Diastolic dysfunction was unrelated to age, sex, and etiology of cirrhosis. The patients with cirrhosis and LVDD had significantly higher child Pugh score, MELD score, and lower serum albumin than patients without LVDD. The echocar-diographic parameters like E/e' ratio, Deceleration time (DT), and Left atrial volume index (LAVI) were significantly different in cirrhotic patients with higher MELD and child Pugh score than lower. CONCLUSION The present study showed a significant correlation of diastolic dysfunction with the severity of the liver disease. Low serum albumin, high MELD score, and presence of ascites significantly predict the development of LVDD in patients with cirrhosis. [ABSTRACT FROM AUTHOR]

The relationship between ammonia and liver-related complications (LRCs) in acute-on-chronic liver failure (ACLF) patients is not clearly established. This study aimed to evaluate the association between ammonia levels and LRCs in patients with ACLF. The study also evaluated the ability of ammonia in predicting mortality and progression of LRCs. The study prospectively recruited ACLF patients based on the APASL definition from the ACLF Research Consortium (AARC) from 2009 to 2019. LRCs were a composite endpoint of bacterial infection, overt hepatic encephalopathy (HE), and ascites. A total of 3871 cases were screened. Of these, 701 ACLF patients were enrolled. Patients with LRCs had significantly higher ammonia levels than those without. Ammonia was significantly higher in patients with overt HE and ascites, but not in those with bacterial infection. Multivariate analysis found that ammonia was associated with LRCs. Additionally, baseline arterial ammonia was an independent predictor of 30-day mortality, but it was not associated with the development of new LRCs within 30 days. In summary, baseline arterial ammonia levels are associated with 30-day mortality and LRCs, mainly overt HE and ascites in ACLF patients. [ABSTRACT FROM AUTHOR]

(1) Background: The current study examined the correlations between platelet count (PC), spleen diameter (SD), and their ratio to establish a non-invasive technique for predicting the presence of oesophageal varices in cirrhotic patients. (2) Methods: The current study was an observational study conducted in the Gastroenterology Department at IMS and SUM Hospital from November 2019 to November 2021. Consecutive cirrhotic patients without a history of gastrointestinal bleeding were enrolled in the study, and the esophageal varices were assessed. The patients underwent the necessary tests, including upper gastrointestinal endoscopy, liver function testing, abdominal ultrasonography, and full hemograms. All these parameters were analyzed statistically through SPSS version 23, and p ≤ 0.05 was considered statistically significant. (3) Results: There were significant differences between cases with and without esophageal varices in the following parameters: PC, SD and their ratio, hemoglobin, and ALT level. The PC/SD ratio of ≤ 1400 was associated with a sensitivity of 90.9%, specificity of 80.8%, and a positive predictive value of 82.56% in predicting the presence of oesophageal varices, as per receiver operating curve (ROC) analysis in our study. (4) Conclusions: Esophageal varices can be predicted non-invasively using the platelet count, spleen diameter, and PC/SD ratio. [ABSTRACT FROM AUTHOR]

Fasciolopsis is one of the rarest parasitic infestations in our locality. The usual definitive host is the sheep; humans are accidental hosts in the life cycle of a liver fluke – Fasciola. In the chronic phage of Fasciolopsis, the patient presents with cholestasis and cholangitis. Yet, there is no proof of association of this parasite with carcinoma of the gallbladder. We here present such a case of Fasciolopsis in association with Stage IV gallbladder malignancy. Fasciola worms were extracted on endoscopic retrograde cholangiopancreatography done as a palliative measure for associated obstructive jaundice. The chronic phase of this zoonotic infection can be easily misdiagnosed as any other cause of obstructive jaundice if not properly investigated. The importance of repeated stool examination for parasitic ova and cysts should never be understated as it may help in early diagnosis of such treatable conditions as well as preventing the complications. [ABSTRACT FROM AUTHOR]

This review investigated depth literature survey on the removal of various heavy metals and dyes contamination. The current study is a broad review of the different methods of preparation of biowaste adsorbent from rice husk and rice straw that has been implemented for the adsorption of many hazardous heavy metals and dyes in order to reduce their harmful effect on the environment. The selection of rice waste-based material for the adsorption process was considered due to its cost-effectiveness, easy availability, high adsorption efficiency, and reusability. This study is a comprehensive review of the adsorption of toxic heavy metals and dyes using rice husk and rice straw-based adsorbents either in bare or in modified forms under different physicochemical processes. In addition, some parameters affecting adsorption capability like pH, initial dye concentration, equilibrium time, temperature, adsorbent dosage, and shaking or stirring speed influence the adsorption mechanism have been discussed thoroughly. The applicability of various adsorption isotherm models and adsorption kinetic models for dye adsorption by various rice husk and straw biomass adsorbents is also reported here. Finally, from the literature reviewed conclusions have been drawn and also proposed a few future research suggestions. [ABSTRACT FROM AUTHOR]

Background: Hepatocellular carcinoma (HCC) is leading cause of cancer-related mortality and is categorized among the most common malignancies around the world. It is a heterogeneous tumor, which shows significant degree of histopathological heterogeneity. Despite the apparent histopathological diversity there has been very little distinct correlation between histopathological features and molecular aberrations particularly when it comes to the expression level of Wnt and Hh pathway molecules. The role of Wnt and Hh pathways in relation to HCC behavior viz. histopathological heterogeneity and aggressiveness is not known. Determining the sequential molecular changes and associated histopathological characteristic during HCC initiation, promotion, and progression would probably lead to a better treatment and prognosis. Methods: N-Nitrosodiethylamine (DEN) induced HCC model in male Wistar rats were established to study the expression level of Wnt and Hh pathway molecules during different stages of hepatocarcinogenesis. Their expression levels were checked at mRNA and protein levels at initiation, promotion, and progression stages of HCC. The expression levels of Wnt and Hh pathway molecules were correlated with biospecimens of HCC patients of different stages. Results: In the present study we identified the comprehensive change in the expression pattern of Wnt and Hh pathway molecules in DEN induced rodent hepatocarcinogenesis model. Our results demonstrate that β-catenin /CTNNB1 plays important role in tumor initiation and promotion by stimulating tumor cell proliferation. The activated Wnt signaling in early stage of HCC is associated with well-differentiated histological pattern. The Hh activity although activated during the initiation stage but is significantly increased during the early promotion stage of hepatocarcinogenesis. The increased activity of both Wnt & Hh pathways during promotion stage is associated with moderately-differentiated histological pattern and was simultaneously linked with an increased expression of MMP9. Furthermore, our data demonstrated that during the progression stage Wnt pathway is modestly down-regulated but the Hh pathway activity sustained which in turn is associated with aggressive and invasive phenotype and poorly-differentiated histopathology. Conclusion: Our data uncovers the grade related expression of Wnt and Hh pathway molecules and the potential utility of these molecular signatures in daily clinical practice is to decide best therapy according to patients characteristic. Additionally, our data offer insight into the interaction between Wnt and Hh pathways which triggers HCC development and progression. [ABSTRACT FROM AUTHOR]

Presents an abstract of the article "Anesthetic Management For Thoracoabdominal Aneurysmal Endovascular Stent Graft Implantation," by Pankaj Ingole, Manoj Sahu, Shaileja C. Kale, Vishwas Malik and Sanjeev Sharma.

Background: In anxiety disorders, culture is important in symptom presentation and help-seeking. Most tools for anxiety disorders are not validated in India and thus might not capture culture-specific aspects of anxiety. This study aims to identify and generate culturally specific terms to describe symptoms of anxiety as part of the development of the Kannada version of the Panic and Anxiety National Indian Questionnaire (PANIQ). The PANIQ is a tool under development to identify anxiety and panic in Indian settings. Methods: This study used qualitative methods like focus group discussions (FGDs) and in-depth interviews (IDIs) to identify and generate items related to anxiety and panic in Kannada from stakeholders like individuals with anxiety disorders, their caregivers, healthcare workers, and mental health professionals who treat individuals with anxiety and panic disorders. Five FGDs (n = 28), one triad (n = 3), and 34 IDIs (n = 34) were conducted. Results: The mean age of the participants was 38.9 (standard deviation: 12.28) years; 57.1% were from rural areas. We generated 615 Kannada items. These were classified into 21 domains and facets. Items in domains like Somatic symptoms, Fear, and Impairment in day-to-day life were higher than those noted in existing tools for anxiety that focus more on cognitive symptoms of anxiety. Conclusions: This study generated culturally specific items of anxiety through a qualitative process of tool development incorporating subjective experiences of persons with anxiety disorders and other stakeholders. This is among the first steps toward the development of PANIQ. [ABSTRACT FROM AUTHOR]

In the present study, a magnetic flower-like Fe3O4@C-dot@MnO2 nanocomposite was synthesized by hydrothermal method and applied for As(III) removal by oxidation and adsorption process. Individual property of the entire material (i.e. magnetic property of Fe3O4, mesoporous surface property of C-dot and oxidation property of MnO2) make the composite efficient with good adsorption capacity for As(III) adsorption. The Fe3O4@C-dot@MnO2 nanocomposite had a saturation magnetization of 26.37 emu/g and it magnetically separated within 40 s. The Fe3O4@C-dot@MnO2 nanocomposite was able to reduce the 0.5 mg/L concentration of As(III) to 0.001 mg/L in just 150 min at pH 3. Pseudo-second-order kinetic and Langmuir isotherm model agreed with experimental data. The uptake capacity of Fe3O4@C-dot@MnO2 nanocomposite was 42.68 mg/g. The anions like chloride, sulphate and nitrate did not show any effect on removal but carbonate and phosphate influenced the As(III) removal rate. Regeneration was studied with NaOH and NaClO solution and the adsorbent was used for repeated five cycles above 80% removal capacity. The XPS studies proposed that As(III) first oxidized to As(V) then adsorb on the composite surface. This study shows the potential applicability of Fe3O4@C-dot@MnO2 nanocomposite to high extent and gives a suitable path for the proficient removal of As(III) from wastewater. [ABSTRACT FROM AUTHOR]

Endoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined, and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreatography (ERCP). However, even in expert hands, the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or, more commonly, percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreaticobiliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD, and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates. EUS-BD, however, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD nor the accessories and stents for EUS-BD have been standardized. Additionally, different countries and regions have different availability of the accessories, making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, Society of Gastrointestinal Endoscopy of India (SGEI) deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD. [ABSTRACT FROM AUTHOR]

Endoscopic management of bile duct obstruction is a key aspect in gastroenterology practice and has evolved since the first description of biliary cannulation by McCune et al in 1968. Over many decades, the techniques and accessories have been refined and currently, the first-line management for extrahepatic biliary obstruction is endoscopic retrograde cholangiopancreaticography (ERCP). However, even in expert hands the success rate of ERCP reaches up to 95%. In almost 4 to 16% cases, failure to cannulate the bile duct may necessitate other alternatives such as surgical bypass or more commonly percutaneous transhepatic biliary drainage (PTBD). While surgery is associated with high morbidity and mortality, PTBD has a very high reintervention and complication rate (∼80%) and poor quality of life. Almost parallelly, endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to a substantial therapeutic option in various pancreatico-biliary diseases. Biliary drainage using EUS-guidance (EUS-BD) has gained momentum since the first report published by Giovannini et al in 2001. The concept of accessing the bile duct through a different route than the papilla, circumventing the shortcomings of PTBD and sometimes bypassing the actual obstruction have enthused a lot of interest in this novel strategy. The three key methods of EUS-BD entail transluminal, antegrade, and rendezvous approach. Over the past decade, with growing experience, EUS-BD has been found to be equivalent to ERCP or PTBD for malignant obstruction with better success rates. EUS-BD, albeit, is not devoid of adverse events and can carry fatal adverse events. However, neither the technique of EUS-BD, nor the accessories and stents for EUS-BD have been standardized. Additionally, different countries and regions have different availability of the accessories making generalizability a difficult task. Thus, technical aspects of this evolving therapy need to be outlined. For these reasons, the Society of Gastrointestinal Endoscopy India deemed it appropriate to develop technical consensus statements for performing safe and successful EUS-BD. [ABSTRACT FROM AUTHOR]

Worsening heart failure (WHF) is a distinct under-diagnosed and under-treated condition, independent of location of care. Heart failure (HF) progression is punctuated by repeated WHF events, each resulting in reduced cardiac function. One-third of the patients with HF with reduced ejection fraction experience a decompensation event. These decompensation events often result in the emergency department visits and HF hospitalization. Despite its inclusion in recent guidelines, there is no precise definition of WHF or its various forms. It is worth noting that WHF signals a need for treatment optimization as per guideline-directed medical therapy and the addition of novel drugs like a stimulator of soluble guanylate cyclase that benefit this high-risk patient population. This practical document is based on the expert opinion of cardiologists, cardiothoracic surgeons, and physicians that discussed the definition, assessment, pharmacological management, and monitoring of WHF patients in a hospitalized setting. In addition, there is also a need for an expert opinion for the management of WHF in an outpatient setting. [ABSTRACT FROM AUTHOR]

Introduction: Gastric cancer (GC) is one of the leading causes of cancer-related decimations worldwide. The gastric infection at both the stomach and duodenum with Helicobacter pylori causes inflammation by the tumor necrosis factor-alpha (TNF-α). The aim of the study was to associate and evaluate the three TNF-α gene polymorphisms at positions -308 G/A, -238 G/A, and -857 C/T with the risk of GC. Methods: A total of 156 individuals (consecutively diagnosed 95 GC patients and 61 controls) above the age of 18 years were enrolled in the study. Healthy individuals with normal upper gastrointestinal endoscopy (UGIE) irrespective of their family history of GC or peptic ulcer were included as controls. The cited three TNF-α gene polymorphisms were evaluated using polymerase chain reaction-restriction fragment length polymorphism (RFLP). Results: There was no significant difference in the distribution of gene polymorphisms as genetic factors, TNF-α-308 GA/AA (22.1% vs. 14.8%, p = 0.2), TNF-α-238 GA/AA (21% vs. 19.6%, p = 0.8), and TNF-α-857 CT/TT (8.4% vs. 11.5%, p = 0.5), between GC cases and healthy controls. A subgroup analysis of H. pylori-positive patients showed that there was no significant difference in the distribution of GA/AA polymorphisms in TNF-α-308 (15(45.5%) vs. 3(23%); p = 0.17) and -238 (12(36.3%) vs. 2(15.4%); p = 0.17), and the distribution of TT/CT -857 CT/TT (13(39.4%) vs. 2(15.4%); p = 0.13), among the GC cases and controls. Conclusion: The statistical comparisons of GA/AA vs. GG genotypes at -308 (with OR = 1.6, 95% CI: 0.6-3.8), -238 (OR = 1.09, 95% CI: 0.4-2.4) and TT/CT vs. CC genotypes at -857 (OR = 0.7, 95% CI: 0.2-2.1) did not suggest any association of TNF-α with GC in the population herein. Hence, the TNF-α (-308 G/A, -238 G/A and -857 C/T) may not be the associating factor for GC incidence determined by the PCR-RFLP method. [ABSTRACT FROM AUTHOR]

Human epidermal growth factor receptor 2/neu (HER2/neu) is known to serve as a prognostic and predictive biomarker in several cancers such as breast, gastric and ovarian cancers. In head and neck squamous cell carcinoma, HER2/neu expression is seen but in a fluctuated manner. Hence, its role as a prognostic factor in oral squamous cell carcinoma (OSCC) needs evaluation. To determine the HER 2/neu overexpression in OSCC patients and its association with clinical and pathological parameters. 74 patients of OSCC treated between 2016 and 2018 were included in the study. Immunohistochemistry was done on tissue samples from these patients and HER2/neu expression was measured. Both biopsy and resected specimens were considered for the study. Out of 74 patients, 47.3% (35) were operated and 52.7% (39) were not operated due to loss to follow-up. No significant association was found (p = 0.636, OR = 0.68, CI = 0.14–3.34) between lymphovascular invasion (LVI) and HER2/neu expression. Similar results were seen for perineural invasion (PNI) (p = 0.490, OR = 0.53, CI = 0.88–3.24), depth of invasion (p = 0.21), grade of tumor (p = 0.214), clinical-stage (p = 0.511) and pathological stage (p = 0.091). No significant association existed between HER2/neu expression and LVI, PNI, clinical-stage, the grade of tumor and the pathological stage of oral squamous cell carcinoma. [ABSTRACT FROM AUTHOR]

The article describes the case of a 6-month-old female child with a history of respiratory distress, tachycardia, tachypnea, subcostal retractions and peripheral oxygen saturation. A diagnosis of obstructed supracardiac total anomalous pulmonary venous conncetion (TAPVC) with atrial septal defect (ASD) and severe pulmonary artery hypertension based on the results of transthoracic echocardiography and pre-operative chest X-ray. A single lumen endotracheal (ET) tube (ETT) was placed.

Renewable energy-based smart grids are famous nowadays due to their high intellectual properties. The world is starting new inventions in renewable energy-based electrical power generation systems to reduce global warming. However, a single renewable energy source cannot maintain a proper energy management system and reliability of power towards loads. Hence, integrating two or more systems is very important and can form a smart grid with an appropriate energy management system. Effective energy management system for a 4-wire 1-MW smart grid system is proposed in this paper. The system is composed of three solar plants and three wind farms with a battery bank. The battery energy management system can operate the complete system as a smart grid with the proper design of the controllers. The maximum power points of PV plants are tracked using a hybrid algorithm that merges the merits of Modified Invasive Weed Optimization and Perturb and Observe (P&O). Thus, the maximum power is obtained under partial shading conditions. The P&O algorithm is also developed to track the maximum power of wind farms. All the loads and generation units are connected in a ring-configuration distribution with a centralized battery energy management system. The loads are selected to be unbalanced, nonlinear and reactive to simulate practical cases. TS-Fuzzy based common inverter controller is implemented to maintain acceptable power quality, which is linked to the battery. The proposed inverter controller can work as a reactive power compensator, active power filter, voltage regulator under unbalanced load, and power balancing device between generation and load. Extensive Hardware-in-Loop (HIL) results are presented to validate the effectiveness of the proposed system. [ABSTRACT FROM AUTHOR]