A Rare Case of Caroli's Syndrome.

Caroli's syndrome is a rare autosomal recessive congenital disorder of the biliary tree characterized by intrahepatic bile duct dilation and hepatic fibrosis. Very few cases have been encountered in routine day-to-day practice. The patients usually present with features of cholangitis such as pain abdomen and jaundice. They may also present with features of chronic liver disease and portal hypertension. Very rarely, they may develop cholangiocarcinoma and present with jaundice, weight loss, and abdominal mass or ascites. Here, we report one such case of a young female who presented to us with features of cholangitis with sepsis and encephalopathy, which was finally diagnosed as Caroli's syndrome. The aim of presenting this case is to learn that even patients with common symptoms of pain abdomen and jaundice may be harboring some rare congenital disease like Caroli's syndrome, as in our case.

Can Subacute Thyroiditis Be a Cause of Fever of Unknown Origin?

Subacute thyroiditis (SAT) is a self-limiting, painful, non-suppurative thyroid gland inflammation, which usually develops two to eight weeks after viral upper respiratory tract infections, accompanied by pain and fever. The thyroid gland is large, painful, and tender. It presents with fever, myalgia, arthralgia, weakness, and sore throat. A 37-year-old male presented to medical ward with a history of fever for three weeks along with swelling of neck and difficulty in swallowing. The patient had features of hyperthyroidism. High-resolution ultrasonography (HRUSG) and thyroid scan were suggestive of thyroiditis. Later on, on follow-up, the patient developed hypothyroidism. He was managed with antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and glucocorticoids, and he responded well to the above treatment. The index patient presented as a case of fever which on workup was found to be secondary to subacute thyroiditis (SAT).

Riverine landscape dynamics of the Upper Ganga River (Haridwar-Narora), India.

Earth observation data provides an exceptional opportunity to study the temporal dynamics of large rivers. The availability of spatially continuous, synoptic and temporally repetitive satellite data allows the reconstruction of historical dynamics of large rivers along with the identification of the causal factors. An absolute paucity of information on the effect of hydrogeomorphic processes on the dynamics of the Upper Ganga River (UGR), especially upon its entry in the plains, motivated this research. This study aims to analyse morphological changes in the river channel, map temporal changes in the land use/land cover (LULC) within the riverscape and thereby understand the landscape dynamics in the UGR (Haridwar to Narora) during 1993-2017 by means of earth observation data. The analysis showed that the river remains straight with a sinuosity index of < 1; however, the braiding increased considerably (from 3.79 to 4.53). Erosion being more prominent on the left bank in comparison to the right bank with 85.89 km2 eroded on the left bank in comparison to 59.21 km2 eroded along the right bank. Riverine landscape has been observed to have a higher rate of accretion in comparison to erosion (8.09 km2 yr-1 and 6.04 km2 yr-1, respectively). Morphological change has brought a transition in the land use patterns with marked variation in vegetation and agriculture along with built-up. Significant changes in the composition of the LULC are largely due to the manifold increase in the agriculture extent (≈ 12 times), built-up (5 times) and the decrease in vegetation cover from 43.9% in 1993 to just 10.94% in 2017.

Multi-organ dysfunction following honeybee bite-A rare entity.

Honeybee bites have been known to cause localized allergic reactions and anaphylaxis but systemic toxic reactions leading to multiorgan dysfunction is very rare. Serious complications like acute renal failure, acute myocardial infarction (Kounis syndrome) and even death have been reported as the complication of honeybee bite. Herein, we report a case of multiorgan dysfunction following honeybee bite, which was complicated with acute kidney injury, thrombocytopenia, bradycardia, keratitis, and deranged liver function along with localized allergic reaction and pain.

Heavy metal pollution in surface water of the Upper Ganga River, India: human health risk assessment.

To assess the risk on human health, heavy metal contamination was analysed from surface water in the Upper Ganga river, India. Spatial and seasonal distribution of Fe, Mn, Zn, Cr and Pb was evaluated at eight sites during pre-monsoon and post-monsoon season of 2017. Average concentration of heavy metals was high, often exceeding the limits prescribed for surface water by Bureau of Indian Standard (BIS) and the World Health Organization (WHO). Based on heavy metal pollution index (HPI), 87% of the river stretch was classified as medium to highly polluted. Simultaneous assessment of the health risk employing chronic daily intake (CDI) and hazard quotient (HQ) indicates that exposure through ingestion and dermal pathways currently poses no serious threat to human health (CDI < 1, HQ < 1). For the two population groups analysed, HQIngestion values for Cr (adults 0.51, child 0.55) and Pb (adult 0.31, child 0.34) were significantly higher as compared with other heavy metals. HIIngestion varied from 0.85 to 1.64 for adult and 0.92 to 1.77 for child group, indicating health risk to both groups with child group being more risk prone from either of the exposure pathways. In addition, HI values revealed an increased risk to health for both groups during the post-monsoon season. Higher hazard index (HI) values (> 1) in the Upper Ganga river indicate an ever-increasing non-carcinogenic risk to the exposed population within the riverine landscape. The study highlights the impact of heavy metals in degrading the water quality of the Upper Ganga river and also advocates immediate attention towards reducing human health risk.

Persistent cough: An unexpected diagnosis.

Esophageal cancer is the eighth most common cancer and the sixth most common cause of cancer death globally. Esophageal squamous cell carcinoma (ESCC) accounts for 70%-90% of esophageal cancers worldwide, 5% are adenocarcinoma, and 5% represent rare malignancies and metastases from other organs. We present a case where a 54-year-old lady, with multiple readmissions for persistent dry cough and respiratory symptoms, turns out to be an esophageal malignancy. CECT thorax revealed an enhancing wall thickening of the esophagus with paraoesophageal fat stranding, mediastinal lymphadenopathy, and subsegmental right lobe atelectasis, suggestive of a probable esophageal malignancy. An upper gastrointestinal endoscopy showed a circumferential esophageal growth which on biopsy and histopathological examination turned out to be a moderately differentiated squamous cell carcinoma of esophagus.

A clinical dilemma in an unconscious patient.

Snake bite is a major life-threatening emergency seen more commonly in rural tropical countries. In general, about 70% of the bites are nonpoisonous, 15% are dry bites, and only 15% cause envenomation. Venom is the saliva of snake ejected during biting, from the poison apparatus (the modified parotid glands). It can be neurotoxic, vasculotoxic, or myotoxic in its action. The polyvalent antisnake venom is effective against most common poisonous snakes. Prompt diagnosis and timely administration of the polyvalent antisnake venom can reduce mortality and morbidity to a great extent. We present a case which was brought to the emergency department of without any previous forthcoming history of snakebite, with symptom such as abdominal pain, chest pain, vomiting, and respiratory distress followed by loss of consciousness. The patient was timely resuscitated and with prompt use of polyvalent ASV and neostigmine the patient recovered without any neurological symptoms within a week.

Water and sanitation hygiene knowledge, attitude, and practices among household members living in rural setting of India.

BACKGROUND: Rural population in developing countries face water, sanitation, and hygiene-related health issues. To objectively highlight these issues, we studied the knowledge, attitude, and practices-related to drinking water and sanitation facilities among the rural population of Chennai, India. MATERIALS AND METHODS: A cross-sectional study was designed involving individuals over 18 years of age living in Thandalam village, Chennai, India. Basic information about sociodemographic profile and existing drinking water and sanitation related knowledge, attitude, and practices was collected using a modified version of previously validated questionnaire and analyzed. RESULTS: Forty-five percent of the participants were not following any methods of water treatment and among them half of the participants felt that water available to them was clean and did not require any additional treatment. Twenty-five percent of the participants surveyed did not have access to toilets inside their household. CONCLUSION: There is a need for intervention to educate individuals about drinking water treatment methods, sanitation, and hand washing practices.

Exploring Factors that Influence Smoking Initiation and Cessation among Current Smokers.

INTRODUCTION: Worldwide, cigarette smoking kills 5 million people annually, and leads to illness, disability and death. This study aimed to assess the factors influencing smoking initiation and cessation among current smokers in Chennai, India. MATERIALS AND METHODS: This cross-sectional study was conducted in September 2013 in Chennai, India. A convenient sample of 100 current smokers aged >15 years was enrolled. A modified version of Alcohol, Smoking and Substance Involvement Screen Test (ASSIST) questionnaire was used to gather information on socio-demographics, smoking initiation and cessation, expenditure on smoking products and perceptions on incentives for smoking cessation. RESULTS: Surrounding influence (44%), stress (42%) and fun (40%) were major reasons for smoking initiation. Majority of participants (68%) attempted to quit smoking within past 6 months but failed. Health promotion programs (61%) and financial incentives (20%) were perceived to be helpful in smoking cessation. CONCLUSION: Smoking cessation strategies, especially at workplaces, should target the multi-factorial nature of smoking initiation and cessation. There is a need to review national guidelines to evaluate the accessibility and availability of smoking products in and around the workplace.

Urban rural comparisons of polycystic ovary syndrome burden among adolescent girls in a hospital setting in India.

BACKGROUND: Polycystic ovarian syndrome (PCOS) is a multifaceted disorder characterized by varying clinical presentations. OBJECTIVE: The aim of this study was to determine urban and rural differences in the burden of polycystic ovarian syndrome among Indian adolescent females aged 12 to 19 years. METHODS: A pilot cross-sectional study was conducted for a period of one month (August-September 2013) at Balaji Hospital, Vellore, Tamil Nadu, India. The final sample included 126 study participants located in various urban (50%, n = 63) and rural (50%, n = 63) settings. Information was gathered on sociodemographic and anthropometric characteristics, clinical history, occurrence of acne and hirsutism, serum testosterone levels, obstetric history, family history of chronic diseases, menstrual history, physical activity, and dietary intake. RESULTS: Eighteen percent of the participants were confirmed of having PCOS by recent guidelines of Rotterdam Consensus for adolescent diagnosis of PCOS (presence of all three elements). Majority of the individuals with PCOS had an average age of 16 (SD = 2) (P = .02) years with an average age of menarche 12 years (SD = 1). CONCLUSION: The proportion of participants diagnosed with PCOS was higher among urban participants in comparison to rural participants.

Water and sanitation hygiene knowledge attitude practice in urban slum settings.

BACKGROUND: Access to improved drinking water, sanitation and hygiene is one of the prime concerns around the globe. This study aimed at assessing water and sanitation hygiene-related attitude and practices, and quality of water in urban slums of south Delhi, India. METHODOLOGY: This pilot cross sectional study was performed during July 2013 across four urban slums of South Delhi. A convenient sample of 40 participants was enrolled. A modified version of previously validated questionnaire was used to gather information on socio-demographics, existing water and sanitation facilities and water treatment practices. Water quality testing was additionally performed using hydrogen sulphide (H2S) vials. RESULTS: Average age of participants was 36 years (SD=10). 83% of the participants perceived gastrointestinal tract infection as the most important health problem. 75% of the participants did not use any method for drinking water treatment. 45% of the participants consumed water from privately-owned tube well/ bore well. Water shortage lasted two days or more (50%) at a stretch with severe scarcity occurring twice a year (40%). Females aged 15 years and above were largely responsible (93%) for fetching water from water source. 45% of the participants had toilets within their households. 53% of drinking water samples collected from storage containers showed positive bacteriological contamination. DISCUSSION: There is an urgent need to develop family centered educational programs that would enhance awareness about water treatment methods that are cost effective and easily accessible.

Metabolic engineering of bacteria.

Yield and productivity are critical for the economics and viability of a bioprocess. In metabolic engineering the main objective is the increase of a target metabolite production through genetic engineering. Metabolic engineering is the practice of optimizing genetic and regulatory processes within cells to increase the production of a certain substance. In the last years, the development of recombinant DNA technology and other related technologies has provided new tools for approaching yields improvement by means of genetic manipulation of biosynthetic pathway. Industrial microorganisms like Escherichia coli, Actinomycetes, etc. have been developed as biocatalysts to provide new or to optimize existing processes for the biotechnological production of chemicals from renewable plant biomass. The factors like oxygenation, temperature and pH have been traditionally controlled and optimized in industrial fermentation in order to enhance metabolite production. Metabolic engineering of bacteria shows a great scope in industrial application as well as such technique may also have good potential to solve certain metabolic disease and environmental problems in near future.

Determination of 137Cs dosimetry parameters according to the AAPM TG-43 formalism.

Traditional treatment planning systems calculate dose distributions around 137Cs intracavitary sources by interpolating stored dose rate tables or by Sievert-type integrals. Some of the recently introduced planning systems, such as the Varian BrachyVision and Eclipse (Varian Medical Systems, Palo Alto, CA), have discontinued the use of tables and have implemented instead the AAPM TG-43 formalism as a brachytherapy dosimetry calculation algorithm. In this work we present the dosimetry parameters for 137Cs intracavitary sources as determined according to the TG-43 formalism. With the availability of the TG-43 parameters, the commissioning of a 137Cs source in any current brachytherapy planning system is a straightforward task for a clinical physicist.

A dwell position verification method for high dose rate brachytherapy.

Misplacement of dwell positions is a potential source of misadministration in high dose rate brachytherapy. In this work we present a dwell position verification method using fluoroscopic images. A mobile C-arm fluoroscopic machine is used to take a snapshot of the treatment machine's check cable as it reaches the most distal dwell position. This fluoroscopic image is displayed side-by-side with a treatment planning image on a dual monitor relay station at the HDR treatment console. Any discrepancy between the check cable's position on the verification image and the intended dwell position on the planning image can be identified immediately, thus avoiding the possibility of treating the wrong target volume.

Evaluation of two water-equivalent phantom materials for output calibration of photon and electron beams.

Two commercially available water-equivalent solid phantom materials were evaluated for output calibration in both photon (6-15 MV) and electron (6-20 MeV) beams. The solid water 457 and virtual water materials have the same chemical composition but differ in manufacturing process and density. A Farmer-type ionization chamber was used for measuring the output of the photon beams at 5- and 10-cm depth and electron beams at maximum buildup depth in the solid phantoms and in natural water. The water-equivalency correction factor for the solid materials is defined as the ratio of the chamber reading in natural water to that in the solid at the same linear depth. For photon beams, the correction factor was found to be independent of depth and was 0.987 and 0.993 for 6- and 15-MV beams, respectively, for solid water. For virtual water, the corresponding correction factors were 0.993 and 0.998 for 6- and 15-MV beams, respectively. For electron beams, the correction factors ranged from 1.013 to 1.007 for energies of 6 to 20 MeV for both solid materials. This indicated that the water-equivalency of these materials is within +/- 1.3%, making them suitable substitutes for natural water in both photon and electron beam output measurements over a wide energy range. These correction factors are slightly larger than the manufacturers' advertised values (+/- 1.0% for solid water and +/- 0.5% for virtual water). We suggest that these corrections are large enough in most cases and should be applied in the calculation of beam outputs.

On the use of C-arm fluoroscopy for treatment planning in high dose rate brachytherapy.

Treatment planning for brachytherapy requires the acquisition of geometrical information of the implant applicator and the patient anatomy. This is typically done using a simulator or a computed tomography scanner. In this study, we present a different method by which orthogonal images from a C-arm fluoroscopic machine is used for high dose rate brachytherapy treatment planning. A typical C-arm is not isocentric, and it does not have the mechanical accuracy of a simulator. One solution is to place a reconstruction box with fiducial markers around the patient. However, with the limited clearance of the C-arm this method is very cumbersome to use, and is not suitable for all patients and implant sites. A different approach is adopted in our study. First, the C-arm movements are limited to three directions only between the two orthogonal images: the C-orbital rotation, the vertical column, and the horizontal arm directions. The amounts of the two linear movements and the geometric parameters of the C-arm orbit are used to calculate the location of the crossing point of the two beams and thus the magnification factors of the two images. Second, the fluoroscopic images from the C-arm workstation are transferred in DICOM format to the planning computer through a local area network. Distortions in the fluoroscopic images, with its major component the "pincushion" effect, are numerically removed using a software program developed in house, which employs a seven-parameter polynomial filter. The overall reconstruction accuracy using this method is found to be 2 mm. This filmless process reduces the overall time needed for treatment planning, and greatly improves the workflow for high dose rate brachytherapy procedures. Since its commissioning nearly three years ago, this system has been used extensively at our institution for endobronchial, intracavitary, and interstitial brachytherapy planning with satisfactory results.

The linear-quadratic model and fractionated stereotactic radiotherapy.

PURPOSE: To determine the dose per fraction that could be used when gamma knife or linear accelerator-based stereotactic treatments are delivered in 2 or more fractions. METHODS AND MATERIALS: The linear-quadratic (LQ) model was used to calculate the dose per fraction for a multiple-fraction regimen which is biologically equivalent to a given single-fraction treatment. The results are summarized in lookup tables. RESULTS AND CONCLUSION: The tables can be used by practicing clinicians as a guide in planning fractionated treatment. For the large doses used in typical stereotactic treatments and for small fraction numbers, the model is not very sensitive to the value of the alpha/beta ratio in the LQ model. A simple rule of thumb is found that for two-fraction and three-fraction treatments the dose per fraction is roughly two-thirds and one-half of the single-fraction treatment dose, respectively.