Fibrolamellar hepatocellular carcinoma presenting as cholestatic jaundice: An unusual presentation of a rare disease

Fibrolamellar hepatocellular carcinoma is a rare primary hepatic tumor that usually occurs in youth. The common presenting features are vague abdominal pain, nausea, vomiting and weight loss. We present a case report of a young male who presented with cholestatic jaundice and on evaluation was diagnosed to have fibrolamellar hepatocellular carcinoma. He underwent successful surgical resection of the tumor. In young individuals presenting with unexplained cholestasis, fibrolamellar hepatocellular carcinoma should be considered.

Segmental filiform-polyposis in a treated case of ulcerative colitis, colon: An unusual presentation raising a doubt of primary diagnosis?

Inflammatory bowel disease is broadly classified into Crohn's disease and ulcerative colitis. The standard criteria to distinguish between the two is the manner of the involvement of the bowel, with the former showing classical skip lesions and the latter having continuous involvement of the colon, most commonly affecting the rectum. However, some cases exhibit overlapping features. Herein, we report a treated case of ulcerative colitis presenting with patchy involvement of the colon in the form of peculiar segmental filiform polyposis spanned abruptly by an intervening normal mucosa. The clinico-radiologically suspicion of carcinoma colon with Crohn's colitis was considered. The clinicians and pathologists must be aware of such atypical presentations and should not be misled to change the diagnosis from ulcerative colitis to Crohn's colitis on the post-treatment resection specimens or endoscopic biopsies solely in view of the patchy filiform polyposis (FP), which poses a drastic impact on the patient's management.

Plexiform fibromyxoma of the stomach: An underrecognized entity!

Plexiform fibromyxoma (PF) is a recently described rare type of mesenchymal tumor of the stomach with only 123 cases reported in the literature. It is characterized by a peculiar plexiform growth pattern, myxoid stroma with arborizing microvasculature, and spindle-shaped myofibroblastic cells. We herein report a case of gastric PF in a 15-year-old boy, mimicking a gastrointestinal stromal tumor (GIST) due to overlapping clinicoradiological features. Distinct pathological and immunohistochemical features of PF do aid in distinction from GIST and other mesenchymal entities. Diagnosis is crucial as surgical resection is the mainstay of treatment unlike aggressive management in GIST. It is a benign entity with no local recurrence or distant metastasis reported so far, but confirmation of the same requires longitudinal observational studies with a larger sample size.

Implementation of the online learning management system ‘Moodle’ as a blended approach to online teaching

Objectives: Web-based learning is becoming a newly accepted standard in education, more so with COVID-19 pandemic. To use technology to redesign learning experiences, a blend of synchronous and asynchronous approaches was used wherein the routine lectures through MS Teams (synchronous) were integrated with an online learning management system (LMS), ‘Moodle’ (modular object-oriented dynamic learning environment) based, four-quadrant approach (asynchronous). We aimed to determine the student’s engagement, performance and perception of the new online LMS. Materials and Methods: All 170 students of the 1st year MBBS of batch 2020 were enrolled in the course. A module was developed for teaching ‘Physiology of Vision’ with this blended approach. Along with routine online lectures through Microsoft Teams, supplementary materials in the form of multimedia presentations and additional links to useful websites were provided through online LMS. The online activity of students was recorded and assessments were done. A feedback form was filled out by students at the end of the course. Results: A significant positive correlation of examination scores with individual student’s activity logs and significantly better scores in top Moodle users along with significantly higher marks in Moodle-based modules than in other modules confirmed the value of Moodle in improving student performance. Overall feedback from students was clearly in favour of implementing Moodle as a complementary tool to traditional teaching. Conclusion: Moodle improved the quality of learning. It developed interest and motivation among students and has a positive impact on academic outcomes.

Giant hyperplastic gastric polyp: A diagnostic dilemma!!

Gastric hyperplastic polyps (GHP) account for a majority of benign gastric polyps. Most of the GHPs are <2 cm, asymptomatic, and incidentally detected on endoscopy or radiologically. With increasing size, these polyps manifest as upper gastrointestinal bleeding, iron deficiency anemia, and gastric outlet obstruction (GOO). We report an unusual case of giant GHP simulating gastric carcinoma and posing as a diagnostic challenge for the surgeons emphasizing the diagnostic role of histopathology. A 46-year-old female presented with clinical features of progressive GOO for 1 year. Endoscopy revealed an eccentric proliferative lesion in the antrum. Computed tomography showed a polypoidal, enhancing mural thickening involving distal body and antro-pyloric region measuring 8.4 cm × 6.6 cm × 1.8 cm. Subtotal gastrectomy was done in view of clinical features of GOO and having a clinical suspicion of malignancy. Gross examination showed a giant sessile hyperplastic polyp with lobulated surface. Microscopy revealed features of a large, sessile hyperplastic polyp without any evidence of dysplasia. The patient was symptomatically relieved and is on follow-up. To conclude, giant GHPs can mimic gastric carcinoma on endoscopy and radiology. The possibility of giant GHP should be kept in mind in the presence of an intensely contrast-enhancing polypoidal lesion in the gastric antrum. Long-term endoscopic follow-up is recommended.

Mechanistic Investigation On Anti-Nociceptive Potential Of Bartogenic Acid Containing Barringtonia Racemosa Fraction In Experimental Models Of Pain

Barringtonia racemosa (B. racemosa) is a tropical medicinal plant possessing interesting biological activities. B. racemosa fruits are traditionally used in India for the treatment of pain, inflammation, and rheumatic conditions. Earlier, we have reported anti-inflammatory activity of ethyl acetate fraction (BREAF) obtained from B. racemosa fruits in animal models of inflammation and delayed-type hypersensitivity. The present study aimed to assess the anti-nociceptive activity of BREAF. Acetic acid-induced writhing test, and hot plate and tail immersion tests were employed to study the effect of BREAF on peripheral and central pain mechanisms, respectively. The involvement of opioid system was confirmed through naloxone antagonism. Formalin induced pain test was performed to assess the effect of BREAF on neurogenic and inflammatory pain components. Capsaicin induced pain models were used to investigate the involvement of transient receptor potential vanilloid 1 receptor. The BREAF reduced writhing episodes and delayed the onset of acetic acid-induced writhings. The raised percentage maximum protective effects by BREAF in hot plate and tail immersion tests suggest the efficacy of BREAF in pain alleviation. A reversal of the analgesic effect of BREAF following naloxone treatment indicates the involvement of opioid receptors. The BREAF also inhibited inflammatory and neurogenic components of formalin-induced pain. The inhibition of capasaicin induced pain to some extent by the BREAF indicates the possibility of involvement of TRPV1 receptors. This study reinforces the traditional use of B. racemosa in the treatment of painful conditions. However, further studies are reasonable to explore the detailed mechanism(s) of the anti-nociceptive action of BREAF.

Informed consent in psychiatry outpatients

Background & objectives: Comprehension and process of consent are important for persons with mental illness as they may not be impaired in considering research participation. The American Psychiatric Association developed a detailed Cultural Formulation Interview (CFI). The present study was a part of field testing of CFI, aimed to standardize cultural information affecting the patients' management in India. This paper describes the process and conclusions from the consent-seeking process of this study. Methods: The purpose and procedures about field trial of the CFI were introduced and the patient and caregiver were requested for participation. Consent process was carried out step by step, by reading out the consent form to the first new patient of the day in the psychiatry outpatients department of a tertiary care hospital in north India, inviting questions followed by the 'comprehension' questions. The entire process was audiotaped without any personal identifiers. The process was repeated if not comprehended. Results: A total of 67 patients consented, 11 refused and majority were educated more than secondary school. Some concerns shown by the patients and caregivers included risk of participation, loss or benefits of participation, privacy, etc. All types of mentally ill patients participated in the study. Interpretation & conclusions: Translations of consent forms used simple words, consonant with understanding of the potential participants. Patients' belief that participating in this long process would improve their care, and serve humanity, influenced their decision to participate. Except for intoxication and severe psychosis, patients could understand and comprehend issues around consent. Main issues were confidentiality and culture. Our experience in the psychiatry OPD refutes the commonly held belief that mentally ill persons lack comprehension and ability to consent.

Qualitative analyses of lignocellulolytic enzymes produced by Emericella sp strain HST9 under diverse culture conditions

Aim: Optimization of cultural conditions for improved lignocellulolytic enzyme production by an ascomycete HST9 isolated from leaf and litter waste. Methodology: The fungus HST9 was isolated from leaf and litter waste collected from Chaudhary Charan Singh Haryana Agricultural University, Hisar, India. Culture experiments were conducted at different temperature, pH, incubation periods and aeration conditions. Effects of addition of different concentrations of various metal ions, different carbon complexes and nitrogen salts on enzyme production were also studied under submerged culture condition. Enzyme activities were measured by standard protocols using spectrophotometer. Results: HST9 grew well and produced optimum enzymes at 30oC on 7th day of incubation at stationary conditions and pH- 6. Overall enzyme activities decreased after addition of metal salts. Carboxymethyl cellulose (300 mg l-1) and alkali lignin (200 mg l-1) were observed to be the best carbon complexes for cellulolytic and ligninolytic activities. Ammonium sulfate was found to be a better nitrogen source compared to others. Under optimum conditions, different enzyme activities observed were 0.011 IU m l-1 FPase, 0.015 IU ml-1 CMCase, 6.5 IU m l-1 Lac, 57.5 IU m l-1 LiP and 4 IU ml-1 MnP. Molecular phylogenetic analysis of the strain confirmed that strain HST9 showed closeness with genus Emericella. Interpretation: Lignocellulolytic enzyme activity of Emericella isolate HST9 enhanced at optimum culture conditions, signifying that it can be used as a biological agent to degrade lignocellulosic waste.

Identification of novel polymorphism in buffalo stanniocalcin-1 gene and its expression analysis in mammary gland under different stages of lactation

Stanniocalcin-1 (STC1) is secreted by the variety of tissues having a major role in the regulation of calcium ions in the involuting mammary gland. The present work aims to sequence and structural characterization as well as expression profiling of STC1 gene in buffalo. Polymorphism identified in the 3-untranslated region (UTR) was analysed by polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) genotyping in riverine and swamp buffaloes. Expression profiling of STC1 was performed in different lactation stages of mammary gland and peripheral blood mononuclear cells to study the impact of 3'-UTR polymorphism on its expression. Different polymorphic sites were detected in the entire coding and noncoding regions of riverine and swamp buffaloes, including two INDELs. An identified polymorphic nucleotide locus A324G, having target sites for two miRNAs, namely bta-miR-2382 and bta-miR-1343, reported in cattle, was genotyped by PCR-RFLP to reveal variable allelic distribution among swamp and riverine buffaloes. Gene expression profiling across buffalo mammary tissues representing different lactation stages showed maximum expression of the STC1 gene in the involuting mammary gland. Ruminants’ specific genetic variation has been observed in STC1 and its implication in buffalo mammary gland involution as well as coregulation of gene expression throughmiRNA binding in the 3'-UTR is suggested.

Primary Adenocarcinoma of Jejunum: A Case Report

Malignancy of small intestine is a very rare entity. Duodenum is the most common site for intestinal malignancy. The lesions present with stricture mostly. Small intestinal strictures distal to the duodenum are relatively inaccessible by endoscopy. This leads to difficulty in definitive preoperative diagnosis. The symptoms in case of jejunal malignancy are very nonspecific and a high index of suspicion is required for diagnosis.

Primary Adenocarcinoma of Jejunum: A Case Report

Malignancy of small intestine is a very rare entity. Duodenum is the most common site for intestinal malignancy. The lesions present with stricture mostly. Small intestinal strictures distal to the duodenum are relatively inaccessible by endoscopy. This leads to difficulty in definitive preoperative diagnosis. The symptoms in case of jejunal malignancy are very nonspecific and a high index of suspicion is required for diagnosis.

Use of lycopene in the management of oral submucous fibrosis: a clinical study.

Background: Oral Submucous Fibrosis is a potentially malignant disorder well known for its chronic and resistant nature. The conservative drug treatment that is currently available for this disorder is clearly inadequate. Objective: The study was done to evaluate the efficacy of oral lycopene therapy when used in combination with conventional intralesional steroid therapy in the management of oral submucous fibrosis. Methods: Thirty patients with oral submucous fibrosis (grade III and IV) were included and randomly divided into 2 groups consisting of 15 each: Group A (oral lycopene with biweekly intralesional steroids and hyaluronidase), Group B (biweekly intralesional steroids and hyaluronidase alone). Mouth opening and burning sensation were recorded from baseline to 6 weeks. Cases were followed up to 3 and 6 months. Results: We observed a complete relief of burning sensation in all patients of both the groups, There was significant increase in mouth opening among both groups. The patients in the group B had increased moth opening than the group A patients.The results were statistically significant Conclusion: Lycopene in combination with intralesional steroids and Hyaluronidase, is highly efficacious in improving the mouth opening and reducing other symptoms in patients with Oral Submucous Fibrosis. No side effects were reported with its usage.

Perception of quality in a Radiation Oncology Department: Is it different for patients and health care providers.

AIM: Patient satisfaction is increasingly being identified as an important benchmark in health care industry. Studies addressing patients’ perceptions of quality are available but there is paucity of data regarding the perception of health care providers towards their own services. This study was undertaken to compare the satisfaction level between the patients and the staff from a Radiation Oncology Department. MATERIALS AND METHODS: A common 16‑item questionnaire addressing various aspects of patient care was served to 40 patients and 40 staff members. The responses were statistically evaluated to assess the satisfaction level among the two groups and the scores were compared to assess the agreement between two groups. RESULTS: Overall, satisfaction level of both groups regarding quality of services ranged from “good” to “excellent”. A high level of agreement was observed between the two groups. The physician’s ability to give an explanation to patients, helping attitude of the staff and the staff’s concern for patient safety were the most satisfying features of the department while inconvenience during scheduling of appointments, billing and registration process, status of the changing rooms and inter‑department coordination were the least satisfying features. CONCLUSION: A high level of satisfaction may be achieved from the consumers if service providers are trained to assess the needs and expectations of consumers and to critically evaluate themselves. The service provider’s perception regarding their own services may serve as a preliminary indicator of overall quality. Future studies with more participants in different setting may further explore this hypothesis.

Presence of diabetes mellitus in the ‘Dawoodi Bohra youth community’ in Udaipur, Rajasthan.

Background & objectives: Diabetes mellitus is a major public health problem worldwide. With the rising incidence of diabetes in India, it becomes particularly relevant to ascertain its prevalence in various ethnic groups. The objective of this study was to find out the presence of diabetes mellitus in the ‘Dawoodi Bohra youth community’ and also to assess the factors responsible for it. Methods: A house-to-house study was conducted and 2179 subjects were questioned randomly; children below 18 yr of age were excluded. A questionnaire was given to each member and questions were also asked to test their level of awareness regarding diabetes which was graded on a 5-pointer scale where 1 meant ‘very poor’ and 5-‘excellent’. Diabetes was diagnosed using GOD-POD (oxidase-peroxidase) method according to the WHO criteria. Results: Total number of diabetic subjects found was 246 (11.29%) with a mean age of 60.21±10.91 years. The condition was more common in males (58.94%). The highest prevalence was recorded in the age group of 65-69 yr (22.01%) and none had diabetes in the age group 11-24 yr. pPedigree analysis showed that 109 (44.30%) subjects had at least one affected relative and 23 (9.34%) had at least two diabetic family members; 52 were found to have parents with diabetes. On the 5-pointer scale, the overall care in diabetic subjects was 3.76±0.56 as compared to 2.86±0.60 in non-diabetic subjects (p<0.001). Interpretation &conclusions: Our results indicated that the marital alliances, familial aggregation and lifestyle could be the major factors which enhanced the chances of diabetes in this community. This research work also reflected poor awareness among these people regarding their health and diseases.

Inverted papilloma of the hard palate masquerading as a carcinoma.

Inverted papilloma (IP) is a rare, benign tumor of the nose and paranasal sinus. However, it is locally aggressive, the recurrence rate is high and malignant transformation is possible. Until now, IP of the hard palate has rarely been reported in the literature. Here, we reported a case with IP of the hard palate, which clinically presented as a carcinomatous growth. The management of IP is complete surgical excision with a close follow-up to detect early recurrence and/or malignant transformation

Comparison between Allopurinol and Febuxostat in management of gout patients - a prospective study.

Aim:To assesses the efficacy of a relatively new drug-Febuxostat in management of gout and its comparison with allopurinol. Method: A comparative study of both Allopurinol and Febuxostat was done on 100 patients of gout. Both were studied for efficacy. side effects and for gout flare up. Results: Primary efficacy end point (baseline values) - a serum urate concentration of less than 6.0mg per deciliter at the last three measurements was reached by 54 %( 27/50) of group A patients taking 80mgs of febuxostat and 25 %( 12/50) of group B patients taking allopurinol 300mgs per day (P<0.001) Secondary efficacy end point(follow up values)- At first visit( after 2 weeks of onset of study), the proportions of subjects with serum urate concentration of less than 6.0mg/dl was significantly higher in the group A receiving febuxostat than the group B receiving allopurinol(P<0.001)[Tableno-1]. Conclusion: Febuxostat, at a daily dose was more effective than allopurinol at the commonly used fixed daily dose of 300 mg in lowering serum urate. Results of side effects and gout flare up were similar in both groups.

Gummatous ulcer of leg: an uncommon entity in present era.

Gummatous ulcer due to Treponematoses is quite rare in present era of potent antibiotics, increased social awareness and due to improvement in living standards of society .Better hygiene and improved medical care have contributed to containment of late benign syphilis or gummas. However, pockets of endemic treponematoses are still persisting in the underdeveloped, third world countries.