Validation of Spleen Shear Wave Elastography for the Screening of High-risk Varices in Patients with Compensated Advanced Chronic Liver Disease

Objectives: Total number of avoided endoscopies using Baveno VI criteria is relatively low. Spleen elastography is an attractive tool and when compared with liver stiffness, it better represents the dynamic changes occurring in portal hypertension. The aim of the study was to evaluate spleen shear wave elastography (SWE) in compensated advanced chronic liver disease (cACLD) patients for ruling out the presence of esophageal high-risk varices (HRV). Methods: A total of 401 patients with cACLD were included in this cross-sectional study. The total sample was split into training set (200 patients) and validation set (201 patients). Spleen stiffness was measured with two-dimensional shear wave elastography (2D SWE). Esophageal HRV were defined as large varices (diameter >5 mm) or small varices with red color signs. In the training set, the receiver operating characteristic (ROC) curve was drawn and the area under the curve (AUC) of spleen SWE was assessed. A cutoff value was chosen (highest sensitivity and negative predictive value). In the validation set, the spleen SWE cutoff score and Baveno VI criteria were validated. Results: The prevalence of HRV was 12% in the training set and 13% in the validation set. Spleen SWE had an AUC of 0.89 in ruling out the presence of high-risk esophageal varices (cutoff value of 48.7 kPa, sensitivity of 100%, and specificity of 53%). Validating spleen SWE ?48.7 kPa in a different cohort of 201 cACLD patients, 55% of screening endoscopies could be avoided without missing any HRV, whereas using Baveno VI criteria only 30% of screening endoscopies could be spared. Conclusion: Spleen SWE ?48.7 kPa was able to identify cACLD patients who could safely avoid screening endoscopy with good accuracy. Spleen SWE could avoid an additional 25% of screening endoscopies compared to the Baveno VI criteria and no HRV were missed.

Barrett’s Esophagus: A Comparison Study between Two Cohorts of Gastroesophageal Reflux Disease

Introduction: Barrett’s esophagus (BE) is a complication of gastroesophageal reflux disease (GERD). It is seen among 15% of GERD patients as per a population-based study by Ronkainen et al. Barrett’s has malignant potential and annual progression to carcinoma depends on the presence or absence of dysplasia. There are various risk factors for the development of BE. We compared two symptomatic cohorts of GERD patients from the same geographical area who were evaluated for the presence of Barrett’s and various factors that can contribute to Barrett’s Materials and methods: Cross-sectional study. Two GERD cohorts, one from Kottayam and the other from Trivandrum were taken. The presence of Barrett’s and the factors contributing to the development of Barrett’s were analyzed between the two groups. Since biopsy data of all patients were not available, endoscopically suspected esophageal metaplasia (ESEM) was taken as Barrett’s Results: 415 patients were enrolled for the study (203 from Trivandrum and 212 from Kottayam). 192 females (99 from Trivandrum and 93 from Kottayam), and 223 males (104 from Trivandrum and 119 from Kottayam). Barrett’s esophagus and especially long-segment Barrett’s were significantly more common in Kottayam than Trivandrum (68 vs 22 and 36 vs 9) (p-value <0.001). Among the factors that were traditionally thought to contribute to the development of Barrett’s esophagus, age (>50 years) was not statistically significant among the two cohorts (mean age of Trivandrum was 48 years and Kottayam was 49 years). Duration of GERD symptoms was significantly more in the Trivandrum cohort compared to Kottayam (p-value <0.001). Hiatus hernia and body mass index (BMI) were more common in Kottayam. There were no statistically significant differences in erosive esophagitis and antral gastritis (%age?) between the two cohorts. Conclusion: Both Trivandrum and Kottayam belong to the same geographical area and are separated by a distance of only 150 km. The Kottayam cohort is more prone to develop distal esophageal carcinoma as the BE is more in Kottayam. This data also suggests the need for GERD registries so that high-risk population can be targeted and early intervention can lead to a decrease in the incidence of distal esophageal carcinomas.

Gift authorship: Look the gift horse in the mouth

Unmerited authorship in research papers is widely acknowledged to constitute research misconduct. In different contexts, it has been called “gift”, “honorary”, or “guest” authorship. Although several attempts have been made to address the issue, it remains a significant problem in research. In this paper, we discuss accepted criteria that qualify a person to be an author on a research publication and define what constitutes “gift authorship”. We also look at the scenario in India and try to identify the circumstances that have fostered this practice in academia in the country. Finally, we discuss the adverse effects of this practice on the research enterprise as a whole, and possible remedial measures.

Assessment of Visceral Fat Volume and Its Correlation with the Severity of Hepatic Fibrosis in Patients with NAFLD

Introduction: Nonalcoholic fatty liver disease (NAFLD) is one of the leading causes of chronic liver disease. The spectrum of NAFLD includes simple steatosis, nonalcoholic steatohepatitis (NASH), advanced fibrosis, and cirrhosis. Our study aimed to calculate visceral fat volume at the L3–L4 vertebral level and its association with hepatic fibrosis assessed by transient elastography. Methods: All patients above 18 years undergoing computed tomography (CT) abdomen in the Department of Radiodiagnosis of Medical College Thiruvananthapuram during the study period with NAFLD were included. Transient elastography was done. Patients were categorized to advanced fibrosis (>10 kPa) and without advanced fibrosis (<10 kPa). The area under the receiver operating characteristic (AUROC) curve was plotted. Results: Sixty-four patients comprised 36 males and 28 females. Thirty-one (46%) were having advanced fibrosis (transient elastography>10 kPa) and 34 (54%) patients were without advanced fibrosis. About 0.733 was the AUROC for visceral fat in predicting advanced fibrosis. The cutoff was 167.5cm3 (sensitivity was 77.4% and specificity was 51.5% in predicting advanced fibrosis). Conclusion: About 0.733 was the AUROC for visceral fat in predicting advanced fibrosis. The cutoff was 167.5cm3 (sensitivity was 77.4% and specificity was 51.5% in predicting advanced fibrosis).

Protein-Energy Supplementation in Early-Life Decreases the Odds of Mental Distress in Later Adulthood in Guatemala

The prevalence of mental health concerns is growing worldwide, along with lack of access to and receipt of needed treatment. Current gaps in treatment provision have led to exploring alternative methods of prevention, with research linking nutrition and mental health, of particular relevance in low- and middle-income countries, with a high prevalence of undernutrition. To examine whether exposure to a protein-energy nutritional supplement during the first 1000 d of life decreased odds of mental distress in adulthood among men and women in Guatemala compared with receiving a low energy-no protein supplement or supplementation outside the 1000-d window. Data from participants (n = 1249) in a longitudinal cohort protein-energy supplementation trial (early-life, supplementation data from 1969 to 1977, ages 0­7 y; life course, outcome data from 2017­2018 follow-up, ages 40­57 y) were analyzed for associations between nutrition in the first 1000 d and mental distress in adulthood (WHO Self- Reporting Questionnaire 20 [SRQ-20]), controlling for early-life variables and current life stress; life course variables (e.g. education) were examined as potential mediators of this relation. Generalized linear mixed models and zero-inflated Poisson generalized linear mixed models were utilized. Both partial and full supplementation with Atole during the first 1000 d were associated with 63% (95% CI: 0.16, 0.87) and 56% (95% CI: 0.19, 1.03) lower odds, respectively, of experiencing mental distress in adulthood. Did not differ by sex. These inverse relations remained relatively unchanged (partial OR = 0.34 [95% CI: 0.14, 0.83]; full OR = 0.38 [95% CI: 0.16, 0.92]) after controlling for early-life and life course variables, including life stress. Protein-energy supplementation during the first 1000 d of life in Guatemala, where undernutrition is prevalent, may reduce the prevalence of later mental distress in adulthood. This effect appears to occur directly, rather than indirectly, through pathways of life course variables such as education, wealth, and marital status. Keywords: early childhood nutrition, protein-energy

Age at childbirth and change in BMI across the life-course: evidence from the INCAP Longitudinal Study

Background: Parity has been associated with both short- and long-term weight gain in women. However, it is not clear if timing of parity across the reproductive age has different associations with BMI. Methods: To prospectively assess the association between age at childbirth and maternal change in BMI, we analyzed data from the ongoing INCAP Longitudinal Study, which started in 1969 in four villages in Guatemala. Cohort women (n=778) provided information on reproductive history and anthropometric measures were measured in 1988-89 (adolescence, 15 to 25y), 2002-04 (early adulthood, 26 to 36y) and 2015-17 (mid adulthood, 37 to 55y). We evaluated the associations of number of live births in the period preceding each study wave (1969-77 to 1988-89, 1988-89 to 2002-04 and 2002-04 to 2015-17) with BMI change in the same period using multivariable linear regression models. Results: Number of live births between 1988 and 89 and 2002-04 was positively associated with increased BMI, while there was not an association between number of live births and BMI in the other intervals. Women who had one, two, or three or more children between 1988 and 89 and 2002-04 had 0.90 (kg/m2, 95% CI: -0.55, 2.35), 2.39 (kg/m2, 95% CI: 1.09, 3.70) and 2.54 (kg/m2, 95% CI: 1.26, 3.82) higher BMI, respectively, than women who did not give birth in the same period. Conclusions: Our findings suggest that women who had three or more children during early adulthood gained more weight compared to women who had no children in the same period. In contrast, women who had children earlier or later in their reproductive lives did not gain additional weight compared to those who did not have children during that period. Childbirth may have different

Fatal meningococcal septicemia without meningeal signs, contribution of the peripheral smear in diagnosis: Report of a case

Acute meningococcemia is characterized by extensive purpurae consisting of both petechiae and ecchymoses. This condition can be rapidly fatal without treatment due to shock and severe consumptive coagulopathy. We report a case of fatal meningococcal septicemia in a military recruit who presented with fever and associated rapidly progressive purpuric rash (purpura fulminans) without any meningeal signs. Evaluation revealed evidence of disseminated intravascular coagulopathy and multiorgan failure. Diplococci were demonstrated in peripheral blood neutrophils and monocytes. On autopsy, extensive hemorrhages were found in both adrenals, lungs, liver, skin, and kidneys with secondary hemophagocytic lymphohistiocytosis in bone marrow. This report highlights useful information obtained from examination of peripheral blood smear in purpura fulminans.

Granulomatosis with Polyangiitis – A case report

Granulomatosis with Polyangiitis (GPA) is a rare multisystem autoimmune disease. It is characterized histopathologically by necrotizing granulomatous vasculitis. The classical clinical triad consists of upper airway involvement (characterized by sinusitis, otitis, nasal mucosa ulcers, bone deformities, and subglottic stenosis), lower respiratory tract involvement (cough, chest pain, hemoptysis) and glomerulonephritis. We reported here a case of Wegener’s granulomatosis presenting as a thick walled cavity.

Community prevalence of hepatitis B infection and modes of transmission in Tamil Nadu, India.

BACKGROUND AND OBJECTIVE: There have been very few community based studies on prevalence of hepatitis B virus (HBV) infection in India. We undertook this study to determine the prevalence of HBV infection in a southern State of India, Tamil Nadu and to describe the important factors related to transmission of the virus in the community. METHODS: Analysis of stored blood samples from a representative population of Tamil Nadu from an earlier community cluster survey on sexually transmitted diseases (STD) prevalence using proportionate to population size (PPS) technique was done. Serum markers of HBV viz., hapatitis B surface antigen (HBsAg), hepatitis B e antigen (HBe Ag) and antibody to surface antigen (anti-HBs) were performed. RESULTS: 1981 subjects were screened in the study. HBsAg prevalence was 5.7 per cent (CI 4.6- 6.8) with 23.5 per cent (25/106) of these having positive HBe-antigen. Community seroprevalence (HbsAg + anti-HBs) of hepatitis B infection was 27.4 per cent (CI: 25.3-29.5) with the highest prevalence of 32.7 per cent (CI: 30.2-35.2) noted in the 15-20 yr age group. Significant independent association (OR 1.4; P=0.006) was detected with family history of exposure to HBV infection by logistic modeling. Other risk factors noted to have significant association were use of disposable needles during injection (OR 0.5; P=0.02) in men, smoking (OR 3; P=0.04) and use of condom (OR 0.6; P=0.08) in women. INTERPRETATION AND CONCLUSION: This community based study shows a high prevalence of hepatitis B infection in the state of Tamil Nadu with the highest prevalence being in the younger (15-20 yr) age group. High prevalence rate in childhood with e-antigenemia seen in 23.5 per cent of HBsAg positive subjects suggest childhood transmission. Poor injection practices and high-risk sexual behavior were found to be additional risk factors for transmission of the disease in the community.

Estimation of ASO titer as an indicator of streptococcal infection precipitating acute adenolymphangitis in brugian lymphatic filariasis.

Recurrent episodes of acute adenolymphangitis (ADL) are important clinical manifestations of lymphatic filariasis which contribute significantly to the progression of lymphedema. It is increasingly being recognized that secondary bacterial infections play an important role in the etiology of ADL. We examined the role of streptococcal infection as a precipitating factor of ADL in brugian filariasis, by determining the anti-streptolysin O (ASO) titers and by isolating the causative organism wherever possible. The study population consisted of 30 patients with filariasis related ADL (Group A), 30 patients with chronic filarial edema (Group B) and 60 age and sex matched healthy adults (Group C). ASO titer was estimated by the latex agglutination method at the time of entry into the study, at the 15th day and at 3, 6 and 12 months. ASO titers were persistently elevated in 90% of patients in Group A and a portal of entry for bacterial infection was detected in all of these patients. In Group B only six patients had persistently elevated ASO titers. These patients had grade III lymphedema and three of them had monilial infections in the affected limb. In the control group none had persistently elevated ASO titers. The elevated ASO titers and the detection of a site of entry for bacteria in patients with ADL supports a streptococcal etiology for this condition.