Acute Pancreatitis Complicating Liver Transplantation in a Case of Fulminant Hepatic Failure Due to Yellow Phosphorus Poisoning.

INTRODUCTION: Yellow phosphorus (YP) is a general protoplasmic poison causing hepatic, cardiac, renal, and multiorgan failure. We report an unusual case of fulminant liver failure due to ratol (YP) poisoning complicated by acute pancreatitis postoperatively after liver transplantation. CASE REPORT: A 25-yr-old man presented with alleged consumption of approximately 7 gm of Ratol paste. Serum amylase and lipase levels were 880 and 2423, respectively, and CT imaging of pancreas was normal. He developed fulminant liver failure, fulfilling King's college criteria and an living donor liver transplantation was performed. Intraoperatively fat saponification was seen at the root of mesentery. On postoperative day (POD) 13, he developed incisional wound dehiscence and he underwent laparotomy with extensive slough removal from the lateral aspect of wound. On POD 21, wound showed evidence of burst abdomen. CT abdomen revealed inflamed tail of pancreas with peripancreatic fat stranding and an exploratory laparotomy was performed again. Intraoperatively, walled-off necrotic collection was seen in the tail of the pancreas and necrosectomy was carried out. All the aforementioned re-explorations were carried out under steroid immunosuppression. He was restarted on tacrolimus on POD27. Graft function and cholestatic biochemistry improved progressively, and he was discharged and is on regular follow-up. DISCUSSION: YP is very toxic with rapid absorption and gets accumulated in liver causing acute liver failure. Acute pancreatitis in a patient after liver transplantation for fulminant liver failure owing to Ratol poisoning has not been reported in published English literature. Although clinically relevant pancreatitis is rare in ratol poisoning, despite elevated pancreatic enzymes, it is prudent to meticulously image pancreas before embarking on liver transplantation. In those with pretransplant elevation of pancreatic enzymes, it is desirable to follow up the enzyme values postoperatively.

Naturally occurring fluorescence protects the eutardigrade Paramacrobiotus sp. from ultraviolet radiation.

Naturally occurring fluorescence has been observed in multiple species ranging from bacteria to birds. In macroscopic animals such as birds, fluorescence provides a visual communication signal. However, the functional significance of this phenomenon is unknown in most cases. Though photoprotection is attributed to fluorescence under ultraviolet (UV) light in some organisms, it lacks direct experimental evidence. Here, we demonstrate naturally occurring fluorescence under UV light in a eutardigrade belonging to the genus Paramacrobiotus. Using a natural variant that lacks fluorescence, we show that the fluorescence confers tolerance to lethal UV radiation. Remarkably, the fluorescent extract from Paramacrobiotus sp. could protect the UV-sensitive tardigrade Hypsibius exemplaris and nematode Caenorhabditis elegans from germicidal UV radiation. We propose that Paramacrobiotus sp. possess a protective fluorescent shield that absorbs harmful UV radiation and emits harmless blue light.

Correlation between insulin resistance and liver histology in patients with nonalcoholic steatohepatitis with and without obesity.

INTRODUCTION: Insulin resistance (IR) plays a central role in pathogenesis of nonalcoholic steatohepatitis (NASH). The aim of this study was to correlate histopathological grading and IR in overweight/obese patients with NASH as compared with lean NASH. METHODS: Patients with NASH who underwent liver biopsy between January 2012 and December 2012 were included. Anthropometric, clinical, and biochemical features, necro-inflammatory grades, and fibrosis stage on liver biopsies were scored according to Brunt and non-alcoholic fatty liver disease (NAFLD) activity score (NAS). RESULTS: Of 42 patients, 33 (78.6%) had body mass index (BMI) ≥ 23 kg/m2 (overweight/obese) while 9 had BMI < 23 kg/m2 (lean). Mean fasting blood sugar (FBS) and HbA1c levels in overweight/obese patients with NASH were higher than in lean NASH (p < 0.05). The median homeostatic model assessment-estimated insulin resistance (HOMA-IR) among NASH patients with BMI ≥ 23 kg/m2 was higher than among those with BMI < 23 kg/m2 (3.02 [0.34-17.22] vs. 2 [0.52-5.26]; p = 0.045). However, fasting insulin levels were comparable among lean and overweight/obese patients with NASH. Metabolic syndrome could be predicted with 75% sensitivity and 85.3% specificity at a HOMA-IR cutoff value of 3.9. No significant difference was observed with regard to HOMA-IR levels with Brunt grades, Brunt staging, Brunt grades 1 and 2, Brunt scores < 2 and > 2, and NAS scores, and NAS scores < 4 and > 4. CONCLUSIONS: Although IR was significantly higher in overweight/obese patients with NASH as compared with that in lean patients with NASH, there was no difference in the correlation of HOMA-IR with histology between these groups.

Adrenal insufficiency in decompensated cirrhotic patients without infection: prevalence, predictors and impact on mortality.

BACKGROUND: Relative adrenal insufficiency (RAI) is common in compensated and decompensated chronic liver disease in the presence of sepsis. This study was performed to find out the prevalence of RAI in decompensated cirrhotic patients presenting with hepatic encephalopathy and variceal bleeding without any evidence of infection. METHODS: The study prospectively included 75 cirrhotic patients with signs of decompensation. The short Synacthen test (SST) was performed on all patients after ruling out infection. Patients with positive blood, urine, sputum, ascitic and pleural fluid cultures or evidence of infection on chest X-ray and those with elevated procalcitonin levels (>0.05 ng/ml) were excluded. RAI in critical illness was defined by a delta cortisol level (difference between basal and post-stimulation cortisol) of ≤9 µg/dl after SST. RESULTS: The mean age of the study population was 54 ± 11 years. Upper gastrointestinal bleed and hepatic encephalopathy were seen in 56.6% and 41.5%, respectively, and both were seen in 1.9%. Of the 75 patients, 55 (73%) were in Child-Turcotte-Pugh (CTP) class C and the mean model for end-stage liver disease (MELD) score was 21 ± 7. Forty-five patients (60%) met our criteria for RAI. Those with RAI had lower serum albumin (2.4 ± 0.5 g/dl vs 2.7 ± 0.5 g/dl, p = 0.03) and higher MELD scores (22 ± 7 vs 19 ± 6, p = 0.03). Prevalence of RAI in CTP class C was 65% (36 out of 55 patients) compared to 45% (9 out of 20 patients) in Child-Pugh stage A and B. Similarly, 82% (23 out of 28 patients) with MELD scores >25 had RAI compared to 54% with MELD scores <20. None of biochemical parameters were predictive of RAI on logistic regression analysis. Three-month mortality rate was not significantly different in patients with or without adrenal insufficiency (44% vs 28%, p = 0.11). CONCLUSION: The present study showed RAI to be common in noninfected decompensated cirrhotic patients, but did not predict 3-month mortality. There were no other predictive factors in those with RAI. Hence, in patients with cirrhosis without infection, the clinical utility of routine adrenal function testing needs further elucidation.

Let-7a-regulated translational readthrough of mammalian AGO1 generates a microRNA pathway inhibitor.

Translational readthrough generates proteins with extended C-termini, which often possess distinct properties. Here, we have used various reporter assays to demonstrate translational readthrough of AGO1 mRNA. Analysis of ribosome profiling data and mass spectrometry data provided additional evidence for translational readthrough of AGO1. The endogenous readthrough product, Ago1x, could be detected by a specific antibody both in vitro and in vivo. This readthrough process is directed by a cis sequence downstream of the canonical AGO1 stop codon, which is sufficient to drive readthrough even in a heterologous context. This cis sequence has a let-7a miRNA-binding site, and readthrough is promoted by let-7a miRNA. Interestingly, Ago1x can load miRNAs on target mRNAs without causing post-transcriptional gene silencing, due to its inability to interact with GW182. Because of these properties, Ago1x can serve as a competitive inhibitor of miRNA pathway. In support of this, we observed increased global translation in cells overexpressing Ago1x. Overall, our results reveal a negative feedback loop in the miRNA pathway mediated by the translational readthrough product of AGO1.

Infant and young child feeding practices, sociodemographic factors and their association with nutritional status of children aged <3 years in India: findings of the National Nutrition Monitoring Bureau survey, 2011-2012.

OBJECTIVE: To study infant and young child feeding (IYCF) practices and their association with nutritional status among young children. DESIGN: A community-based, cross-sectional study was carried out in ten states of India, using a multistage random sampling method. Anthropometric measurements such as length/height and weight were conducted and nutritional assessment was done using the WHO child growth standards. SETTING: National Nutrition Monitoring Bureau survey, 2011-2012.ParticipantsChildren aged <3 years and their mothers. RESULTS: Only 36 % of infants received breast-feeding within an hour of birth and 50 % were exclusively breast-fed up to 6 months. Prevalence of underweight, stunting and wasting was 38, 41 and 22 %, respectively. The chance of undernutrition among <3-year-old children was significantly higher among those from scheduled caste/scheduled tribe communities, the lowest-income group, with illiterate mothers and lack of sanitary latrine. Among infants, the chance of undernutrition was significantly higher among low-birth-weight babies, and among children whose mother had not consumed iron-folic acid tablets during pregnancy. Immunization practices and minimum dietary diversity were observed to be associated with undernutrition among 12-23-month-old children. CONCLUSIONS: Undernutrition is still an important public health problem in India and observed to be associated with low socio-economic status, illiteracy of mother, low birth weight and dietary diversity. Improving socio-economic and literacy status of mothers can help in improving maternal nutrition during pregnancy and thus low birth weight. Also, improving knowledge of mothers about IYCF practices will help in improving children's nutritional status.

Stimulation of angiogenesis using single-pulse low-pressure shock wave treatment.

Endothelial cells respond to mechanical stimuli such as stretch. This property can be exploited with caution to induce angiogenesis which will have immense potential to treat pathological conditions associated with insufficient angiogenesis. The primary aim of this study is to test if low-pressure shock waves can be used to induce angiogenesis. Using a simple diaphragm-based shock tube, we demonstrate that a single pulse of low pressure (0.4 bar) shock wave is enough to induce proliferation in bovine aortic endothelial cells and human pulmonary microvascular endothelial cells. We show that this is associated with enhanced Ca++ influx and phosphorylation of phosphatidylinositol-3-kinase (PI3K) which is normally observed when endothelial cells are exposed to stretch. We also demonstrate the pro-angiogenic effect of shock waves of single pulse (per dose) using murine back punch wound model. Shock wave treated mice showed enhanced wound-induced angiogenesis as reflected by increased vascular area and vessel length. They also showed accelerated wound closure compared to control mice. Overall, our study shows that just a single pulse/shot (per dose) of shock waves can be used to induce angiogenesis. Importantly, we demonstrate this effect using a pulse of low-pressure shock waves (0.4 bar, in vitro and 0.15 bar, in vivo). KEY MESSAGES: Low-pressure single-pulse shock waves can induce endothelial cell migration and proliferation. This effect is endothelial cell specific. These shock waves enhance wound-induced angiogenesis in vivo. These shock waves can also accelerate wound healing in vivo.

Embolization of portosystemic shunt for treatment of recurrent hepatic encephalopathy.

Hepatic encephalopathy in the setting of advanced chronic liver disease, occurs following a precipitating factor and generally responds to correction of the precipitating factor and anticoma measures. We report the case of a lady with Child A cirrhosis who presented with frequent episodes of hepatic encephalopathy without any precipitating factors. She was found to be having a large portosystemic shunt. The shunt was obliterated by coil embolotherapy following which there was no further episodes of encephalopathy.

Antitumour activity of Sargassum wightii (Greville) extracts against Dalton's ascites lymphoma.

Seaweeds have been used by mankind as medicine and food for more than 13,000 years. Marine algae are considered to produce a valuable phytoconstituents characterized by a broad spectrum of antitumor activities. The aim of the present study was to explore the effect of different solvent extracts of Sargassum wightii, Greville against Dalton's Ascitic Lymphoma (DAL) in Swiss male albino mice. DAL cells were injected intraperitoneally 1 x10(6) cell to the mice. Two days after cells injection the animals were treated with different solvent extracts of Sargassum wightii at dose of 200 mg kg(-1) for 14 days. 5-fluorouracil (20 mg kg(-1)) was used as reference drug. On day 11, cancer cell number, packed cell volume, decrease in tumour weight of the mice, increase in life span and hematological parameters were evaluated and compared with the same parameters in control. A significant increase in the life span and a decrease in the cancer cell number and tumour weight were noted in the tumour-induced mice after treatment with the extract. The haematological parameters were also normalized by the ethanolic and chloroform extracts in tumour-induced mice. These observations are suggestive of the protective effect of ethanolic extract of Sargassum wightii is comparatively better than other two tested extracts against Dalton's Ascitic Lymphoma (DAL).

Micronutrient deficiency disorders among the rural children of West Bengal, India.

BACKGROUND: Multiple micronutrient deficiencies continue to be a major nutritional problem of public health significance in India. AIM: To assess the prevalence of micronutrient deficiencies among rural children of West Bengal, India. SUBJECTS AND METHODS: A community-based cross-sectional study was carried out on 9228 and 437 pre-school children, respectively, for assessment of vitamin A deficiency (VAD) and anaemia. Iodine deficiency disorders (IDD) were assessed in 3490 children of 6-12 years. RESULTS: The prevalence of Bitot's spots, an objective sign of clinical VAD, was 0.6% and was significantly (p < 0.01) higher among children of 3-5 years. Prevalence of blood vitamin A deficiency ( < 20 µg/dL) was 61% and ∼81% of children were anaemic. About 25% children had both sub-clinical VAD and anaemia. The children of Scheduled Caste and Scheduled Tribe (OR = 2.3: 95% CI = 1.3-3.9) were at higher risk of anaemia, whereas children of Scheduled Tribe (OR = 4.5; 95% CI = 2.1-10.5) and 3-5 years (OR = 1.4; 95% CI = 1.0-2.0) were at risk for VAD. The prevalence of goitre was 9%. CONCLUSIONS: Micronutrient deficiencies were found to be of public health significance among rural children of West Bengal. Therefore, there is a need to initiate sustainable long-term interventions for prevention and control of micronutrient deficiencies in children.

Clinical and sub-clinical vitamin A deficiency among rural pre-school children of Maharashtra, India.

BACKGROUND: Although a national vitamin A prophylaxis programme has been in operation for more than three decades, vitamin A deficiency (VAD) continues to be a major nutritional problem of public health significance in India. AIM: The present study was carried out with the aim of assessing the prevalence of clinical and sub-clinical VAD among rural pre-school children. SUBJECTS AND METHODS: A community-based cross-sectional study was carried out in rural areas of Maharashtra State during 2002-2003. A total of 8646 pre-school children were examined for the presence of signs and symptoms of VAD. A sub-sample (494) of them was used to estimate blood vitamin A levels. RESULTS: The prevalence of Bitot's spots (1.3%) and night blindness (1.1%) was higher than the WHO cut-off levels used to define a public health problem, and it increased significantly (p<0.001) with increase in age. The prevalence of Bitot's spots was 13 times higher among children belonging to the Scheduled Caste (OR=12.8), and 20 times higher among the children of labourers (OR=19.8). The prevalence of sub-clinical VAD (55%) was significantly (p<0.001) high among the children with night blindness (100%) and Bitot's spots (89%). CONCLUSIONS: Increased vitamin A supplementation, health and nutrition education and consumption of vitamin A rich foods are essential to prevent VAD.

Small cell carcinoma occurring in a case of ulcerative colitis.

A 61-year-old man, with an 8-year history of ulcerative colitis, presented with bleeding per rectum for 4 weeks' duration. Colonoscopy revealed polypoidal neoplasm at the rectosigmoid junction. Histopathology depicted small cell carcinoma. On immunohistochemical staining, chromogranin A and synaptophysin were positive. The tumour was diagnosed as undifferentiated small cell carcinoma, which is unusual since generally it is the adenocarcinoma that occurs on a background of ulcerative colitis and there are only three previous reports of small cell carcinoma occurring in UC.

Dissolution of pharmacobezoar using carbonated beverage.

Bezoars are concretion of undigested material found in the upper alimentary tract, particularly the stomach. Physiologic disturbances such as gastrointestinal dysmotility or anatomical derangements have been described as contributory in most cases of pharmacobezoars. Gastric phamacobezoars can be treated with endoscopic fragmentation or surgery. Gastric lavage with carbonated beverage has been successfully used to treat gastric phytobezoars. We report a 67-year-old man with pharmacobezoar successfully treated by infusion and intrabezoar injection of carbonated beverage. Subsequent endoscopy revealed an underlying adenocarcinoma in the stomach.

Gall bladder carcinoid: a case report and review of literature.

Gall bladder carcinoid tumours are rare and usually lack specific symptoms. In most instances, they are incidentally detected after a cholecystectomy and rarely do they manifest with carcinoid syndrome. We report a case of gall bladder carcinoid in a patient who had undergone surgery for rectal carcinoid 10 years back. Occurrence of rectal carcinoid and gall bladder carcinoid in the same patient has not been reported before.

Rapunzel syndrome: a case report and review of literature.

Bezoars consist of ingested foreign material or organic matter which forms a mass in the gastrointestinal tract, usually in stomach. Trichobezoars formed by swallowed hair present with malnutrition, weight loss, abdominal pain with signs of gastrointestinal obstruction. Gastric trichobezoar with a tail reaching the small intestine is called Rapunzel syndrome. Although endoscopic methods are available to remove bezoars, majority of trichobezoars with Rapunzel syndrome undergo surgical removal.

Endoscopic abnormalities in the oesophagus after variceal sclerotherapy--a long-term follow up study.

Endoscopic sclerotherapy is a well-established treatment modality for oesophageal varices. Various local, regional and systemic complications occur after sclerotherapy. Altered endoscopic appearances of the oesophagus have been observed on follow-up of patients after sclerotherapy. 171 consecutive patients with extra-hepatic portal venous obstruction on follow up after achieving variceal eradication by sclerotherapy during the period from January 2004 to June 2005 were enrolled in this study. The oesophagus was closely observed for mucosal abnormalities and the endoscopic findings were recorded. Out of 171 patients, 95 (55.5%) patients had no specific endoscopic changes in the oesophagus. The most common finding was mucosal neovascularization which was seen in 56 (32.7%) patients. Oval or oblong depressed areas were seen in 41 (23.9%) patients. Mucosal tags and polypoidal lesions were seen in 37 (21.6%) patients. 25 (15.6%) patients had stenosis of the lower oesophagus and 3 (1.7%) patients had mucosal bridges. On multivariate analysis, these abnormal endoscopic findings in the oesophagus correlated with the total volume of sclerosant injected when compared with those patients without similar findings on endoscopy (p value < 0.001). Endoscopic sclerotherapy leads to various abnormalities at the injection sites like neovascularization, oval or oblong depressed areas, mucosal tags, polypoidal lesions, stenosis and mucosal bridges. Endoscopic abnormalities correlated with the total volume of sclerosant used. The long-term significance of these changes is not known at present and further follow-up studies will be required.

Gastric lymphoma presenting as phlegmonous gastritis.

Phlegmonous gastritis is an uncommon local or diffuse bacterial infection of the stomach wall. It is an extremely rare disease with a fulminating course and a high mortality rate. A majority of cases are diagnosed only postmortem, and early diagnosis is crucial for survival. This used to be common in the preantibiotic era; a resurgence of cases has occurred of late due to the spread of acquired immunodeficiency syndrome. There are varying local and systemic associations like gastric ulcer, gastric carcinoma, post-therapeutic endoscopy, postsurgery, human immunodeficiency virus infection, malnutrition, Kaposi's sarcoma, myeloma, leukemia, Sjogren's syndrome, and glucocorticoid use. We report a case of phlegmonous gastritis in a 70-year-old lady associated with gastric lymphoma. She succumbed to death on the fifth day of hospitalization despite broad-spectrum antibiotic therapy. She could not be operated upon due to the onset of multiorgan dysfunction syndrome and multiple comorbidities. To our knowledge, gastric lymphoma presenting as phlegmonous gastritis has not been reported in published English literature.