The gut-skin axis(GSA)embodies a complex,bidirectional interaction between the gastrointestinal(GI)system and skin,driven by immune modulation,systemic inflammation,and gut microbiota dynamics.Disruptions in gut homeo...The gut-skin axis(GSA)embodies a complex,bidirectional interaction between the gastrointestinal(GI)system and skin,driven by immune modulation,systemic inflammation,and gut microbiota dynamics.Disruptions in gut homeostasis,including dysbiosis and increased intestinal permeability,are increasingly recognized as contributing factors to dermatological conditions such as acne,psoriasis,and atopic dermatitis.For gastroenterologists,appreciating this interplay is essential,as diseases and their treatments frequently present with cutaneous manifestations,offering diagnostic and therapeutic insights.This review explores the underlying mechanisms of the GSA,focusing on the microbiome and its metabolites as key regulators of inflammation and immunity.It underscores the clinical importance of microbiome-targeted therapies,such as probiotics,prebiotics,and dietary modifications,in addressing both GI and dermatological disorders.Furthermore,the review examines the influence of GI conditions,including inflammatory bowel disease and celiac disease on skin health.This article seeks to equip gastroenterologists with practical insights for identifying,diagnosing,and managing skin conditions associated with GI health.The article also highlights the current limitations in knowledge regarding the GSA.The GSA represents a promising avenue for therapeutic advancements,encouraging interdisciplinary collaboration between gastroenterology and dermatology to optimize patient care.展开更多
Portal hypertension is a critical determinant of prognosis in chronic liver disease and a key factor in evaluating candidates for liver transplantation.Traditional methods such as hepatic venous pressure gradient(HVPG...Portal hypertension is a critical determinant of prognosis in chronic liver disease and a key factor in evaluating candidates for liver transplantation.Traditional methods such as hepatic venous pressure gradient(HVPG)measurement have long been considered the gold standard for assessing portal pressure.However,these methods are invasive and carry procedural limitations.Recent advances in endoscopic ultrasound(EUS)-guided techniques have emerged as promising alternatives,offering direct and minimally invasive assessment of portal pressure.EUS-guided portal pressure gradient measurement enables real-time evaluation of haemodynamic through direct access to the portal system.This technique has shown to be as accurate as HVPG,and it has some extra benefits,like the ability to take liver biopsies and check collateral circulation all at the same time.Despite these benefits,the technique poses challenges such as operator dependence,proce-dural complexity,and limited standardization across centres.This minireview highlights the evolution of portal pressure measurement,focusing on the potential of EUS-guided techniques in pre-transplant assessment,risk strati-fication,and monitoring therapeutic outcomes.Furthermore,it discusses the technical challenges,clinical implications,and future directions for integrating these innovations into routine practice.Advances in portal pressure measurement hold significant promise for enhancing decision-making and outcomes in liver transplantation.展开更多
BACKGROUND Septic shock is a severe form of sepsis characterised by deterioration in circulatory and cellular-metabolic parameters.Despite standard therapy,the outcomes are poor.Newer adjuvant therapy,such as CytoSorb...BACKGROUND Septic shock is a severe form of sepsis characterised by deterioration in circulatory and cellular-metabolic parameters.Despite standard therapy,the outcomes are poor.Newer adjuvant therapy,such as CytoSorb®extracorporeal haemoadsorption device,has been investigated and shown promising outcome.However,there is a lack of some guidance to make clinical decisions on the use of CytoSorb®haemoadsorption as an adjuvant therapy in septic shock in Indian Setting.Therefore,this expert consensus was formulated.AIM To formulate/establish specific consensus statements on the use of CytoSorb®haemoadsorption treatment based on the best available evidence and contextualised to the Indian scenario.METHODS We performed a comprehensive literature on CytoSorb®haemoadsorption in sepsis,septic shock in PubMed selecting papers published between January 2011 and March 20232021 in English language.The statements for a consensus document were developed based on the summarised literature analysis and identification of knowledge gaps.Using a modified Delphi approach combining evidence appraisal and expert opinion,the following topics related to CytoSorb®in septic shock were addressed:need for adjuvant therapy,initiation timeline,need for Interleukin-6 levels,duration of therapy,change of adsorbers,safety,prerequisite condition,efficacy endpoints and management flowchart.Eleven expert members from critical care,emergency medicine,and the intensive care participated and voted on nine statements and one open-ended question.RESULTS Eleven expert members from critical care,emergency medicine,and the intensive care participated and voted on nine statements and one open-ended question.All 11 experts in the consensus group(100%)participated in the first,second and third round of voting.After three iterative voting rounds and adapting two statements,consensus was achieved on nine statements out of nine statements.The consensus expert panel also recognised the necessity to form an association or society that can keep a registry regarding the use of CytoSorb®for all indications in the open-ended question(Q10)focusing on“future recommendations for CytoSorb®therapy”.CONCLUSION This Indian perspective consensus statement supports and provides guidance on the use of CytoSorb®haemoadsorption as an adjuvant treatment in patients with septic shock to achieve optimal outcomes.展开更多
Achieving optimal alignment in total knee arthroplasty(TKA) is a critical factor in ensuring optimal outcomes and long-term implant survival. Traditionally, mechanical alignment has been favored to achieve neutral pos...Achieving optimal alignment in total knee arthroplasty(TKA) is a critical factor in ensuring optimal outcomes and long-term implant survival. Traditionally, mechanical alignment has been favored to achieve neutral postoperative joint alignment. However, contemporary approaches, such as kinematic alignments and hybrid techniques including adjusted mechanical, restricted kinematic, inverse kinematic, and functional alignments, are gaining attention for their ability to restore native joint kinematics and anatomical alignment, potentially leading to enhanced functional outcomes and greater patient satisfaction. The ongoing debate on optimal alignment strategies considers the following factors: long-term implant durability, functional improvement, and resolution of individual anatomical variations. Furthermore, advancements of computer-navigated and robotic-assisted surgery have augmented the precision in implant positioning and objective measurements of soft tissue balance. Despite ongoing debates on balancing implant longevity and functional outcomes, there is an increasing advocacy for personalized alignment strategies that are tailored to individual anatomical variations. This review evaluates the spectrum of various alignment techniques in TKA, including mechanical alignment, patient-specific kinematic approaches, and emerging hybrid methods. Each technique is scrutinized based on its fundamental principles, procedural techniques, inherent advantages, and potential limitations, while identifying significant clinical gaps that underscore the need for further investigation.展开更多
Central venous pressure(CVP)serves as a direct approximation of right atrial pressure and is influenced by factors like total blood volume,venous compliance,cardiac output,and orthostasis.Normal CVP falls within 8-12 ...Central venous pressure(CVP)serves as a direct approximation of right atrial pressure and is influenced by factors like total blood volume,venous compliance,cardiac output,and orthostasis.Normal CVP falls within 8-12 mmHg but varies with volume status and venous compliance.Monitoring and managing disturbances in CVP are vital in patients with circulatory shock or fluid disturbances.Elevated CVP can lead to fluid accumulation in the interstitial space,impairing venous return and reducing cardiac preload.While pulmonary artery catheterization and central venous catheter obtained measurements are considered to be more accurate,they carry risk of complications and their usage has not shown clinical improvement.Ultrasound-based assessment of the internal jugular vein(IJV)offers real-time,non-invasive measurement of static and dynamic parameters for estimating CVP.IJV parameters,including diameter and ratio,has demonstrated good correlation with CVP.Despite significant advancements in non-invasive CVP measurement,a reliable tool is yet to be found.Present methods can offer reasonable guidance in assessing CVP,provided their limitations are acknowledged.展开更多
BACKGROUND Total knee arthroplasty(TKA)can improve pain,quality of life,and functional outcomes.Although uncommon,postoperative complications are extremely consequential and thus must be carefully tracked and communic...BACKGROUND Total knee arthroplasty(TKA)can improve pain,quality of life,and functional outcomes.Although uncommon,postoperative complications are extremely consequential and thus must be carefully tracked and communicated to patients to assist their decision-making before surgery.Identification of the risk factors for complications and readmissions after TKA,taking into account common causes,temporal trends,and risk variables that can be changed or left unmodified,will benefit this process.AIM To assess readmission rates,early complications and their causes after TKA at 30 days and 90 days post-surgery.METHODS This was a prospective and retrospective study of 633 patients who underwent TKA at our hospital between January 1,2017,and February 28,2022.Of the 633 patients,28 were not contactable,leaving 609 who met the inclusion criteria.Both inpatient and outpatient hospital records were retrieved,and observations were noted in the data collection forms.RESULTS Following TKA,the 30-day and 90-day readmission rates were determined to be 1.1%(n=7)and 1.8%(n=11),respectively.The unplanned visit rate at 30 days following TKA was 2.6%(n=16)and at 90 days was 4.6%(n=28).At 90 days,the unplanned readmission rate was 1.4%(n=9).Reasons for readmissions included medical(27.2%,n=3)and surgical(72.7%,n=8).Unplanned readmissions and visits within 90 days of follow-up did not substantially differ by age group(P=0.922),body mass index(BMI)(P=0.633),unilateral vs bilateral TKA(P=0.696),or patient comorbidity status(30-day P=0.171 and 90-day P=0.813).Reoperation rates after TKA were 0.66%(n=4)at 30 days and 1.15%(n=8)at 90 days.The average length of stay was 6.53 days.CONCLUSION In this study,there was a low readmission rate following TKA.There was no significant correlation between readmission rate and patient factors such as age,BMI,and co-morbidity status.展开更多
As new COVID-19 strains surface and proliferate over the world,the pandemic is still evolving[1].The FLiRT variants are one such family of variants that have recently drawn notice.They are a family of Omicron sub-vari...As new COVID-19 strains surface and proliferate over the world,the pandemic is still evolving[1].The FLiRT variants are one such family of variants that have recently drawn notice.They are a family of Omicron sub-variants quickly becoming dominant.These FLiRT variants include KP.2 and KP.1.1.Due to certain changes in the virus's spike proteins,these variants have been dubbed"FLiRT."展开更多
Management of acute pancreatitis in pregnancy is based on expert opinion only,due to geographic and ethic variations.Nonbiliary causes should be sought as they are associated with worse outcomes.Alcohol as a cause of ...Management of acute pancreatitis in pregnancy is based on expert opinion only,due to geographic and ethic variations.Nonbiliary causes should be sought as they are associated with worse outcomes.Alcohol as a cause of acute pancreatitis is not rare.Hemoconcentration as a marker of fluid def icit and severity should be predicted with caution and fluid resuscitation should be done carefully by closely monitoring the central venous pressure,cardiac and respiratory system.Hypercalcemia of hyperparathyroidism may be falsely lowered due to hypoalbuminemia or suppressed by magnesium tocolysis.展开更多
Percutaneous nephrolithotomy is a very commonly done procedure for management of renal calculus disease. Establishing a good access is the first and probably themost crucial step of this procedure. A proper access is ...Percutaneous nephrolithotomy is a very commonly done procedure for management of renal calculus disease. Establishing a good access is the first and probably themost crucial step of this procedure. A proper access is the gateway to success. However, this crucial step has the steepest learning curve for, in a fluoroscopy guided access, it involves visualizing a three dimensional anatomy on a two dimensional fluoroscopy screen. This review describes the anatomical basis of the renal access. It provides a literature review of all aspects of percutaneous renal access along with the advances that have taken place in this field over the years. The article describes a technique to determine the site of skin puncture, the angle and depth of puncture using a simple mathematical principle. It also reviews the common problems faced during the process of puncture and dilatation and describes the ways to overcome them. The aim of this article is to provide the reader a step by step guide for percutaneous renal access.展开更多
Cardiovascular disease(CVD) is an important cause of mortality and morbidity in India.Mortality statistics and morbidity surveys indicate substantial regional variations in CVD prevalence and mortality rates.Data from...Cardiovascular disease(CVD) is an important cause of mortality and morbidity in India.Mortality statistics and morbidity surveys indicate substantial regional variations in CVD prevalence and mortality rates.Data from the Registrar General of India reported greater ageadjusted cardiovascular mortality in southern and eastern states of the country.Coronary heart disease(CHD) mortality is greater in south India while stroke is more common in the eastern Indian states.CHD prevalence is higher in urban Indian populations while stroke mortality is similar in urban and rural regions.Case-control studies in India have identified that the common major risk factors account for more than 90% of incident myocardial infarctions and stroke.The case-control INTERHEART and INTERSTROKE studies reported that hypertension,lipid abnormalities,smoking,obesity,diabetes,sedentary lifestyle,low fruit and vegetable intake,and psychosocial stress are as important in India as in other populations of the world.Individual studies have reported that there are substantial regional variations in risk factors in India.At a macro-level these regional variations in risk factors explain some of the regional differences in CVD mortality.However,there is need to study the prevalence of multiple cardiovascular risk factors in different regions of India and to correlate them with variations in CVD mortality using a uniform protocol.There is also a need to determine the 'causes of the causes' or fundamental determinants of these risk factors.The India Heart Watch study has been designed to study socioeconomic,anthropometric and biochemical risk factors in urban populations in different regions of the country in order to identify regional differences.展开更多
We agree that the covered self-expanding metal stents (SEMSs) fare better than the uncovered stents as recurrent dysphagia due to tumor ingrowth is common with uncovered stent. Recent American College of Gastroenterol...We agree that the covered self-expanding metal stents (SEMSs) fare better than the uncovered stents as recurrent dysphagia due to tumor ingrowth is common with uncovered stent. Recent American College of Gastroenterology Practice Guideline on the Role of Esophageal Stents in Benign and Malignant Diseases concludes that SEMSs cannot be routinely recommended in conjunction with chemo-radiation. The comparison of ultraflex and choostent in the Italian study found no difference in the palliation of dysphagia, rate of complications and survival rate.展开更多
Objective:To report our experience with supracostal percutaneous nephrolithotomy(SC-PNL)and evaluate factors which could predict the risk of hydrothorax following SC-PNL.Methods:We reviewed 347 patients who underwent ...Objective:To report our experience with supracostal percutaneous nephrolithotomy(SC-PNL)and evaluate factors which could predict the risk of hydrothorax following SC-PNL.Methods:We reviewed 347 patients who underwent SC-PNL from January 2011 to December 2019.Patients were assessed for demographic characteristics,indication for the supracostal access,level of supracostal access,anatomy of the kidney(normal or malrotated),site of the puncture in relation to the mid-scapular line(medial or lateral),and whether another subcostal tract for stone clearance was required or not.Patients were assessed for the incidence of hydrothorax and requirement of intercostal drain depending on the level of percutaneous access.In addition,a multivariable logistic regression analysis model was developed to identify factors which could predict the occurrence of hydrothorax following SC-PNL.Results:Of the 347 patients with SC-PNL,248(71.5%)underwent a supra-12th rib approach,while the rest needed a supra-11th(n=85;24.5%)or a supra-10th(n=14;4.0%)rib tract.Overall,17(4.9%)patients developed a hydrothorax,while an intercostal-drain was required in seven of these 17 patients for 48 h.None of the patients with a supra-12th rib puncture required an intercostal-drain.More than a third of the patients with a supra-10th puncture developed a hydrothorax(35.7%)and all of them required an intercostal drain.Factors such as anteriorly malrotated kidney(odds ratio[OR]=2.722;95%confidence interval[CI]=1.042-5.617,p=0.03),puncture medial to the mid-scapular line(OR=1.669;CI=0.542-1.578,p=0.03),and an access higher than the supra-12th level(OR=5.265;CI=1.292-9.342,p<0.001)proved to be independent predictors of hydrothorax following a SC-PCNL on multivariable analysis.Conclusion:Incidence of clinically significant hydrothorax requiring an intercostal-drain after SC-PNL is very low.Knowledge of the predicting factors will help to anticipate the risk of hydrothorax in a particular patient and take necessary peri-operative measures.展开更多
Colonoscopic surveillance is advocated in patients with inflammatory bowel disease(IBD) for detection of dys-plasia. There are many issues regarding surveillance in IBD: the risk of colorectal cancer seems to be de-cr...Colonoscopic surveillance is advocated in patients with inflammatory bowel disease(IBD) for detection of dys-plasia. There are many issues regarding surveillance in IBD: the risk of colorectal cancer seems to be de-creasing in the majority of recently published studies, necessitating revisions of surveillance strategy; surveil-lance guidelines are not based on concrete evidence; commencement and frequency of surveillance, cost-effectiveness and adherence to surveillance have been issues that are only partly answered. The traditional technique of random biopsy is neither evidence-based nor easy to practice. Therefore, highlighting abnormal areas with newer technology and biopsy from these areas are the way forward. Of the newer technology, digital mucosal enhancement, such as high-definition white light endoscopy and chromoendoscopy(with magnification) have been incorporated in guidelines. Dyeless chromoendoscopy(narrow band imaging) has not yet shown potential, whereas some forms of digital chromoendoscopy(i-Scan more than Fujinon intelligent color enhancement) have shown promise for colonoscopic surveillance in IBD. Other techniquessuch as autofluorescence imaging, endomicroscopy and endocytoscopy need further evidence. Surveillance with genetic markers(tissue, serum or stool) is at an early stage. This article discusses changing epidemiology of colorectal cancer development in IBD and critically evaluates issues regarding colonoscopic surveillance in IBD.展开更多
Spontaneous bacterial peritonitis （SBP） is a treatable complication of decompensated cirrhosis. Coagulopathy with evidence of hyperfibrinolysis or clinically evident disseminated intravascular coagulation precludes ...Spontaneous bacterial peritonitis （SBP） is a treatable complication of decompensated cirrhosis. Coagulopathy with evidence of hyperfibrinolysis or clinically evident disseminated intravascular coagulation precludes paracentesis. Alcoholic hepatitis with fever, leucocytosis and abdominal pain should be evaluated for SBP. Oral ofloxacin is as effective as parenteral cefotaxime in treatment of SBP except for inpatients with vomiting, encephalopathy, or renal failure. Albumin is superior to hydroxyethyl starch in treatment of SBR展开更多
Rationale: Fever of unknown origin (FUO) is a frequently observed phenomenon in clinical practice. Definite diagnosis of FUO is a great challenge in clinical practice since potential causes for FUO involve more than 2...Rationale: Fever of unknown origin (FUO) is a frequently observed phenomenon in clinical practice. Definite diagnosis of FUO is a great challenge in clinical practice since potential causes for FUO involve more than 200 diseases. Adult-onset Still's disease is a defined clinical entity and a known rare cause of FUO. Patient's concern: A 19-year girl was referred to the clinic with the concern of intermittent fevers and shivering for almost a year despite multiple investigations and consultations. She had undergone intensive serologic, radiologic, laboratory investigations to exclude infectious diseases, connective tissue diseases, and malignancy, and all the investigation showed no conclusive diagnosis. Diagnosis: Adult-onset Stills disease. Intervention: Steroids and supportive treatment. Outcomes:The symptoms were relieved within three days, and the patient became asymptomatic. Lessons: Physicians need to be familiar with the diagnostic criteria of adult-onset Still's disease, or it shall remain a diagnostic dilemma. Besides, all shivers are not infections.展开更多
AIM To ascertain the frequency of hyponatremic hypertensive syndrome （HHS） in a cohort of children with hypertensive emergency in a tertiary pediatric hospital.METHODS A retrospective review was undertaken among chi...AIM To ascertain the frequency of hyponatremic hypertensive syndrome （HHS） in a cohort of children with hypertensive emergency in a tertiary pediatric hospital.METHODS A retrospective review was undertaken among children with hypertensive emergency admitted in our tertiary children hospital between June 2014 and December 2015 with an aim to identify any children with HHS. Three children with HHS were identifed during this period.RESULTS The 3 patients with HHS presented with hypertensive emergency. They were initially managed with Labetalol infusion and thereafter switched to oral anti-hypertensives （combination of Nifedipine sustained release, Hydralazine and Beta Blocker）. All 3 were diagnosed to have unilateral renal artery stenosis. One child was lost to follow up, whereas the other 2 underwent renal angioplasty which was followed with normalization of blood pressure.CONCLUSION Despite activation of renin angiotensin axis secondary to renal artery stenosis, these groups of children have significant hyponatremia. Renal re-vascularisation pro-duces excellent results in most of them.展开更多
BACKGROUND: The present study aimed to compare outcome of primary and secondary Illizarov's fi xator application as a treatment method for type III open tibial fractures in terms of nonunion and wound infection.ME...BACKGROUND: The present study aimed to compare outcome of primary and secondary Illizarov's fi xator application as a treatment method for type III open tibial fractures in terms of nonunion and wound infection.METHODS: This prospective study was done in a tertiary care center. Forty-eight type III tibial fractures were treated with Illizarov's apparatus between 2008 and 2011. The patients were divided into two groups depending on the treatment protocol, timing of wound closure and Illizarov's application, primary(n=28) and secondary(n=20).RESULTS: In the primary group, healing was achieved in all 28 patients. The median time to recovery was 24 weeks, and the median number of operations was 3. There were 6 patients with a bone defect. In the secondary group, complete recovery was achieved in 18 out of 20 patients. The median time to recovery was 30 weeks, and the median number of operations 5. There were 9 patients with a bone defect. The median time to recovery and the number of operations were signifi cantly smaller in patients undergoing primary operation. Union was 100% in the primary group and more than 95% in the secondary group. Chronic osteomyelitis persisted in one patient and below amputation was done in one patient in the secondary group.CONCLUSION: Primary wound closure and Illizarov's fixation required a smaller number of operations and shorter time to recovery than secondary wound closure and Illizarov's fi xation, mostly due to a signifi cantly less number of patients with a bone defect in the primary group.展开更多
Background: Coblation based bipolar plasma devices are designed to operate at a relatively low temperature to gently dissolve and/or shrink target tissue with minimal thermal damage to surrounding healthy tissue. Cobl...Background: Coblation based bipolar plasma devices are designed to operate at a relatively low temperature to gently dissolve and/or shrink target tissue with minimal thermal damage to surrounding healthy tissue. Coblation technology provides ablation, resection, coagulation of soft tissue and hemostasis of blood vessels in one convenient surgical device. Coblation technology can be used in the larynx and trachea for removing or debulking sessile polyps, lesions or tumors. Minimally invasive coblation technology can offer less invasive treatment with quicker recovery and shorter hospitalization. Aim: This case study aims to explore the advantages of coblation combined with microscopy to treat benign laryngeal lesions. Case report: We report the case of laryngeal papilloma treated with minimally invasive coblation resection. Fiberoptic laryngoscopy was done pre-operatively and that showed papillomatous mass at anterior half of right vocal cord involving inferior surface and also extending upto anterior commissure. Mobility of both vocal cords was normal. On the basis of the above findings with normal vocal cords mobility, the microlaryngeal surgery with coblation was planned. After complete pre-op work up, the patient underwent trans-oral microscopic coblation excision of mass under general anaesthesia. Power level was set to 7 for ablation and 3 for coagulation. The PROcise<sup>TM</sup> LW Plasma Wand system was chosen such that it was malleable to reach the papillomatous mass without obstructing the vision. It was totally excised and sent for histopathology examination. Post-operatively after four hours, he was able to take normal diet comfortably. He was followed up after 10 days. Histopathological report confirmed the diagnosis of papilloma. Check laryngoscopy was performed after 3 weeks. Laryngeal examination was absolutely normal with almost normal vocal cords and normal voice post-operatively. Conclusion: Microscopic surgery with coblation has the advantages of less bleeding, short procedure duration, increased completion rate and few complications.展开更多
AIM To investigate the role of a novel minimally invasive endoscopic technique in the management of tight neartotal corrosive strictures of the proximal esophagus involving the hypopharynx.METHODS Two patients with ne...AIM To investigate the role of a novel minimally invasive endoscopic technique in the management of tight neartotal corrosive strictures of the proximal esophagus involving the hypopharynx.METHODS Two patients with near-total corrosive strictures of the proximal esophagus involving the hypopharynx were managed with the novel endoscopic technique. The technique involved passing a 0.025-inch flexible guidewire across the stricture, and stricture dilatation, using 10 F coaxial diathermy and balloon dilators, followed byelectro-incision of the proximal aspect of the residual eccentric stricture by means of a novel approach using a wire-guided sphincterotome.RESULTS Both patients were successfully managed on an outpatient department basis with the complete relief of symptoms and resolution of strictures on endoscopy and an esophagogram. No adverse events were seen during or after the procedure. There was no recurrence of symptoms at a follow-up of over a year in both cases. There was a significant improvement in the body mass index of both patients after the procedure.CONCLUSION We report a novel flexible endoscopic technique for the management of complex hypopharyngo-esophageal strictures. In experienced hands, the procedure is relatively simple, safe and effective with a durable response.展开更多
Sexual dysfunction(SD)is a prevalent but very commonly ignored aspect in the treatment of liver diseases and cirrhosis.The etiology of SD is multifactorial and therefore treatment strategies are complex,especially in ...Sexual dysfunction(SD)is a prevalent but very commonly ignored aspect in the treatment of liver diseases and cirrhosis.The etiology of SD is multifactorial and therefore treatment strategies are complex,especially in females.Phosphodiesterase inhibitors are useful and effective in erectile dysfunction in males but in females,no single drug is available for SD,therefore multimodal treatment is required depending upon the cause.The foremost and fundamental requirement in both genders is to be stress-free and have adequate control of liver diseases.Improved quality of life is helpful in improving SD and vice versa is also true.Therefore,patients suffering from liver diseases should come forward and ask for treatment for SD,and physicians should actively enquire about SD while history taking and evaluating these patients.SD results in deterioration of quality of life,and both are modifiable and treatable aspects of liver diseases,which are never addressed actively,due to social taboos and fears of SD treatment in the presence of liver diseases.The diagnosis of SD does not require costly investigations,as the diagnosis can be established based on validated questionnaires available for both genders,therefore detailed targeted history taking using questionnaires is essential.Data are emerging in this area but is still at an early stage.More studies should be dedicated to SD in liver diseases.展开更多
文摘The gut-skin axis(GSA)embodies a complex,bidirectional interaction between the gastrointestinal(GI)system and skin,driven by immune modulation,systemic inflammation,and gut microbiota dynamics.Disruptions in gut homeostasis,including dysbiosis and increased intestinal permeability,are increasingly recognized as contributing factors to dermatological conditions such as acne,psoriasis,and atopic dermatitis.For gastroenterologists,appreciating this interplay is essential,as diseases and their treatments frequently present with cutaneous manifestations,offering diagnostic and therapeutic insights.This review explores the underlying mechanisms of the GSA,focusing on the microbiome and its metabolites as key regulators of inflammation and immunity.It underscores the clinical importance of microbiome-targeted therapies,such as probiotics,prebiotics,and dietary modifications,in addressing both GI and dermatological disorders.Furthermore,the review examines the influence of GI conditions,including inflammatory bowel disease and celiac disease on skin health.This article seeks to equip gastroenterologists with practical insights for identifying,diagnosing,and managing skin conditions associated with GI health.The article also highlights the current limitations in knowledge regarding the GSA.The GSA represents a promising avenue for therapeutic advancements,encouraging interdisciplinary collaboration between gastroenterology and dermatology to optimize patient care.
文摘Portal hypertension is a critical determinant of prognosis in chronic liver disease and a key factor in evaluating candidates for liver transplantation.Traditional methods such as hepatic venous pressure gradient(HVPG)measurement have long been considered the gold standard for assessing portal pressure.However,these methods are invasive and carry procedural limitations.Recent advances in endoscopic ultrasound(EUS)-guided techniques have emerged as promising alternatives,offering direct and minimally invasive assessment of portal pressure.EUS-guided portal pressure gradient measurement enables real-time evaluation of haemodynamic through direct access to the portal system.This technique has shown to be as accurate as HVPG,and it has some extra benefits,like the ability to take liver biopsies and check collateral circulation all at the same time.Despite these benefits,the technique poses challenges such as operator dependence,proce-dural complexity,and limited standardization across centres.This minireview highlights the evolution of portal pressure measurement,focusing on the potential of EUS-guided techniques in pre-transplant assessment,risk strati-fication,and monitoring therapeutic outcomes.Furthermore,it discusses the technical challenges,clinical implications,and future directions for integrating these innovations into routine practice.Advances in portal pressure measurement hold significant promise for enhancing decision-making and outcomes in liver transplantation.
文摘BACKGROUND Septic shock is a severe form of sepsis characterised by deterioration in circulatory and cellular-metabolic parameters.Despite standard therapy,the outcomes are poor.Newer adjuvant therapy,such as CytoSorb®extracorporeal haemoadsorption device,has been investigated and shown promising outcome.However,there is a lack of some guidance to make clinical decisions on the use of CytoSorb®haemoadsorption as an adjuvant therapy in septic shock in Indian Setting.Therefore,this expert consensus was formulated.AIM To formulate/establish specific consensus statements on the use of CytoSorb®haemoadsorption treatment based on the best available evidence and contextualised to the Indian scenario.METHODS We performed a comprehensive literature on CytoSorb®haemoadsorption in sepsis,septic shock in PubMed selecting papers published between January 2011 and March 20232021 in English language.The statements for a consensus document were developed based on the summarised literature analysis and identification of knowledge gaps.Using a modified Delphi approach combining evidence appraisal and expert opinion,the following topics related to CytoSorb®in septic shock were addressed:need for adjuvant therapy,initiation timeline,need for Interleukin-6 levels,duration of therapy,change of adsorbers,safety,prerequisite condition,efficacy endpoints and management flowchart.Eleven expert members from critical care,emergency medicine,and the intensive care participated and voted on nine statements and one open-ended question.RESULTS Eleven expert members from critical care,emergency medicine,and the intensive care participated and voted on nine statements and one open-ended question.All 11 experts in the consensus group(100%)participated in the first,second and third round of voting.After three iterative voting rounds and adapting two statements,consensus was achieved on nine statements out of nine statements.The consensus expert panel also recognised the necessity to form an association or society that can keep a registry regarding the use of CytoSorb®for all indications in the open-ended question(Q10)focusing on“future recommendations for CytoSorb®therapy”.CONCLUSION This Indian perspective consensus statement supports and provides guidance on the use of CytoSorb®haemoadsorption as an adjuvant treatment in patients with septic shock to achieve optimal outcomes.
文摘Achieving optimal alignment in total knee arthroplasty(TKA) is a critical factor in ensuring optimal outcomes and long-term implant survival. Traditionally, mechanical alignment has been favored to achieve neutral postoperative joint alignment. However, contemporary approaches, such as kinematic alignments and hybrid techniques including adjusted mechanical, restricted kinematic, inverse kinematic, and functional alignments, are gaining attention for their ability to restore native joint kinematics and anatomical alignment, potentially leading to enhanced functional outcomes and greater patient satisfaction. The ongoing debate on optimal alignment strategies considers the following factors: long-term implant durability, functional improvement, and resolution of individual anatomical variations. Furthermore, advancements of computer-navigated and robotic-assisted surgery have augmented the precision in implant positioning and objective measurements of soft tissue balance. Despite ongoing debates on balancing implant longevity and functional outcomes, there is an increasing advocacy for personalized alignment strategies that are tailored to individual anatomical variations. This review evaluates the spectrum of various alignment techniques in TKA, including mechanical alignment, patient-specific kinematic approaches, and emerging hybrid methods. Each technique is scrutinized based on its fundamental principles, procedural techniques, inherent advantages, and potential limitations, while identifying significant clinical gaps that underscore the need for further investigation.
文摘Central venous pressure(CVP)serves as a direct approximation of right atrial pressure and is influenced by factors like total blood volume,venous compliance,cardiac output,and orthostasis.Normal CVP falls within 8-12 mmHg but varies with volume status and venous compliance.Monitoring and managing disturbances in CVP are vital in patients with circulatory shock or fluid disturbances.Elevated CVP can lead to fluid accumulation in the interstitial space,impairing venous return and reducing cardiac preload.While pulmonary artery catheterization and central venous catheter obtained measurements are considered to be more accurate,they carry risk of complications and their usage has not shown clinical improvement.Ultrasound-based assessment of the internal jugular vein(IJV)offers real-time,non-invasive measurement of static and dynamic parameters for estimating CVP.IJV parameters,including diameter and ratio,has demonstrated good correlation with CVP.Despite significant advancements in non-invasive CVP measurement,a reliable tool is yet to be found.Present methods can offer reasonable guidance in assessing CVP,provided their limitations are acknowledged.
文摘BACKGROUND Total knee arthroplasty(TKA)can improve pain,quality of life,and functional outcomes.Although uncommon,postoperative complications are extremely consequential and thus must be carefully tracked and communicated to patients to assist their decision-making before surgery.Identification of the risk factors for complications and readmissions after TKA,taking into account common causes,temporal trends,and risk variables that can be changed or left unmodified,will benefit this process.AIM To assess readmission rates,early complications and their causes after TKA at 30 days and 90 days post-surgery.METHODS This was a prospective and retrospective study of 633 patients who underwent TKA at our hospital between January 1,2017,and February 28,2022.Of the 633 patients,28 were not contactable,leaving 609 who met the inclusion criteria.Both inpatient and outpatient hospital records were retrieved,and observations were noted in the data collection forms.RESULTS Following TKA,the 30-day and 90-day readmission rates were determined to be 1.1%(n=7)and 1.8%(n=11),respectively.The unplanned visit rate at 30 days following TKA was 2.6%(n=16)and at 90 days was 4.6%(n=28).At 90 days,the unplanned readmission rate was 1.4%(n=9).Reasons for readmissions included medical(27.2%,n=3)and surgical(72.7%,n=8).Unplanned readmissions and visits within 90 days of follow-up did not substantially differ by age group(P=0.922),body mass index(BMI)(P=0.633),unilateral vs bilateral TKA(P=0.696),or patient comorbidity status(30-day P=0.171 and 90-day P=0.813).Reoperation rates after TKA were 0.66%(n=4)at 30 days and 1.15%(n=8)at 90 days.The average length of stay was 6.53 days.CONCLUSION In this study,there was a low readmission rate following TKA.There was no significant correlation between readmission rate and patient factors such as age,BMI,and co-morbidity status.
文摘As new COVID-19 strains surface and proliferate over the world,the pandemic is still evolving[1].The FLiRT variants are one such family of variants that have recently drawn notice.They are a family of Omicron sub-variants quickly becoming dominant.These FLiRT variants include KP.2 and KP.1.1.Due to certain changes in the virus's spike proteins,these variants have been dubbed"FLiRT."
文摘Management of acute pancreatitis in pregnancy is based on expert opinion only,due to geographic and ethic variations.Nonbiliary causes should be sought as they are associated with worse outcomes.Alcohol as a cause of acute pancreatitis is not rare.Hemoconcentration as a marker of fluid def icit and severity should be predicted with caution and fluid resuscitation should be done carefully by closely monitoring the central venous pressure,cardiac and respiratory system.Hypercalcemia of hyperparathyroidism may be falsely lowered due to hypoalbuminemia or suppressed by magnesium tocolysis.
文摘Percutaneous nephrolithotomy is a very commonly done procedure for management of renal calculus disease. Establishing a good access is the first and probably themost crucial step of this procedure. A proper access is the gateway to success. However, this crucial step has the steepest learning curve for, in a fluoroscopy guided access, it involves visualizing a three dimensional anatomy on a two dimensional fluoroscopy screen. This review describes the anatomical basis of the renal access. It provides a literature review of all aspects of percutaneous renal access along with the advances that have taken place in this field over the years. The article describes a technique to determine the site of skin puncture, the angle and depth of puncture using a simple mathematical principle. It also reviews the common problems faced during the process of puncture and dilatation and describes the ways to overcome them. The aim of this article is to provide the reader a step by step guide for percutaneous renal access.
基金Supported by Ad hoc research grant from South Asian Society of Atherosclerosis and Thrombosis,Bangalore,India and Min-neapolis,United States
文摘Cardiovascular disease(CVD) is an important cause of mortality and morbidity in India.Mortality statistics and morbidity surveys indicate substantial regional variations in CVD prevalence and mortality rates.Data from the Registrar General of India reported greater ageadjusted cardiovascular mortality in southern and eastern states of the country.Coronary heart disease(CHD) mortality is greater in south India while stroke is more common in the eastern Indian states.CHD prevalence is higher in urban Indian populations while stroke mortality is similar in urban and rural regions.Case-control studies in India have identified that the common major risk factors account for more than 90% of incident myocardial infarctions and stroke.The case-control INTERHEART and INTERSTROKE studies reported that hypertension,lipid abnormalities,smoking,obesity,diabetes,sedentary lifestyle,low fruit and vegetable intake,and psychosocial stress are as important in India as in other populations of the world.Individual studies have reported that there are substantial regional variations in risk factors in India.At a macro-level these regional variations in risk factors explain some of the regional differences in CVD mortality.However,there is need to study the prevalence of multiple cardiovascular risk factors in different regions of India and to correlate them with variations in CVD mortality using a uniform protocol.There is also a need to determine the 'causes of the causes' or fundamental determinants of these risk factors.The India Heart Watch study has been designed to study socioeconomic,anthropometric and biochemical risk factors in urban populations in different regions of the country in order to identify regional differences.
文摘We agree that the covered self-expanding metal stents (SEMSs) fare better than the uncovered stents as recurrent dysphagia due to tumor ingrowth is common with uncovered stent. Recent American College of Gastroenterology Practice Guideline on the Role of Esophageal Stents in Benign and Malignant Diseases concludes that SEMSs cannot be routinely recommended in conjunction with chemo-radiation. The comparison of ultraflex and choostent in the Italian study found no difference in the palliation of dysphagia, rate of complications and survival rate.
文摘Objective:To report our experience with supracostal percutaneous nephrolithotomy(SC-PNL)and evaluate factors which could predict the risk of hydrothorax following SC-PNL.Methods:We reviewed 347 patients who underwent SC-PNL from January 2011 to December 2019.Patients were assessed for demographic characteristics,indication for the supracostal access,level of supracostal access,anatomy of the kidney(normal or malrotated),site of the puncture in relation to the mid-scapular line(medial or lateral),and whether another subcostal tract for stone clearance was required or not.Patients were assessed for the incidence of hydrothorax and requirement of intercostal drain depending on the level of percutaneous access.In addition,a multivariable logistic regression analysis model was developed to identify factors which could predict the occurrence of hydrothorax following SC-PNL.Results:Of the 347 patients with SC-PNL,248(71.5%)underwent a supra-12th rib approach,while the rest needed a supra-11th(n=85;24.5%)or a supra-10th(n=14;4.0%)rib tract.Overall,17(4.9%)patients developed a hydrothorax,while an intercostal-drain was required in seven of these 17 patients for 48 h.None of the patients with a supra-12th rib puncture required an intercostal-drain.More than a third of the patients with a supra-10th puncture developed a hydrothorax(35.7%)and all of them required an intercostal drain.Factors such as anteriorly malrotated kidney(odds ratio[OR]=2.722;95%confidence interval[CI]=1.042-5.617,p=0.03),puncture medial to the mid-scapular line(OR=1.669;CI=0.542-1.578,p=0.03),and an access higher than the supra-12th level(OR=5.265;CI=1.292-9.342,p<0.001)proved to be independent predictors of hydrothorax following a SC-PCNL on multivariable analysis.Conclusion:Incidence of clinically significant hydrothorax requiring an intercostal-drain after SC-PNL is very low.Knowledge of the predicting factors will help to anticipate the risk of hydrothorax in a particular patient and take necessary peri-operative measures.
文摘Colonoscopic surveillance is advocated in patients with inflammatory bowel disease(IBD) for detection of dys-plasia. There are many issues regarding surveillance in IBD: the risk of colorectal cancer seems to be de-creasing in the majority of recently published studies, necessitating revisions of surveillance strategy; surveil-lance guidelines are not based on concrete evidence; commencement and frequency of surveillance, cost-effectiveness and adherence to surveillance have been issues that are only partly answered. The traditional technique of random biopsy is neither evidence-based nor easy to practice. Therefore, highlighting abnormal areas with newer technology and biopsy from these areas are the way forward. Of the newer technology, digital mucosal enhancement, such as high-definition white light endoscopy and chromoendoscopy(with magnification) have been incorporated in guidelines. Dyeless chromoendoscopy(narrow band imaging) has not yet shown potential, whereas some forms of digital chromoendoscopy(i-Scan more than Fujinon intelligent color enhancement) have shown promise for colonoscopic surveillance in IBD. Other techniquessuch as autofluorescence imaging, endomicroscopy and endocytoscopy need further evidence. Surveillance with genetic markers(tissue, serum or stool) is at an early stage. This article discusses changing epidemiology of colorectal cancer development in IBD and critically evaluates issues regarding colonoscopic surveillance in IBD.
文摘Spontaneous bacterial peritonitis （SBP） is a treatable complication of decompensated cirrhosis. Coagulopathy with evidence of hyperfibrinolysis or clinically evident disseminated intravascular coagulation precludes paracentesis. Alcoholic hepatitis with fever, leucocytosis and abdominal pain should be evaluated for SBP. Oral ofloxacin is as effective as parenteral cefotaxime in treatment of SBP except for inpatients with vomiting, encephalopathy, or renal failure. Albumin is superior to hydroxyethyl starch in treatment of SBR
文摘Rationale: Fever of unknown origin (FUO) is a frequently observed phenomenon in clinical practice. Definite diagnosis of FUO is a great challenge in clinical practice since potential causes for FUO involve more than 200 diseases. Adult-onset Still's disease is a defined clinical entity and a known rare cause of FUO. Patient's concern: A 19-year girl was referred to the clinic with the concern of intermittent fevers and shivering for almost a year despite multiple investigations and consultations. She had undergone intensive serologic, radiologic, laboratory investigations to exclude infectious diseases, connective tissue diseases, and malignancy, and all the investigation showed no conclusive diagnosis. Diagnosis: Adult-onset Stills disease. Intervention: Steroids and supportive treatment. Outcomes:The symptoms were relieved within three days, and the patient became asymptomatic. Lessons: Physicians need to be familiar with the diagnostic criteria of adult-onset Still's disease, or it shall remain a diagnostic dilemma. Besides, all shivers are not infections.
文摘AIM To ascertain the frequency of hyponatremic hypertensive syndrome （HHS） in a cohort of children with hypertensive emergency in a tertiary pediatric hospital.METHODS A retrospective review was undertaken among children with hypertensive emergency admitted in our tertiary children hospital between June 2014 and December 2015 with an aim to identify any children with HHS. Three children with HHS were identifed during this period.RESULTS The 3 patients with HHS presented with hypertensive emergency. They were initially managed with Labetalol infusion and thereafter switched to oral anti-hypertensives （combination of Nifedipine sustained release, Hydralazine and Beta Blocker）. All 3 were diagnosed to have unilateral renal artery stenosis. One child was lost to follow up, whereas the other 2 underwent renal angioplasty which was followed with normalization of blood pressure.CONCLUSION Despite activation of renin angiotensin axis secondary to renal artery stenosis, these groups of children have significant hyponatremia. Renal re-vascularisation pro-duces excellent results in most of them.
文摘BACKGROUND: The present study aimed to compare outcome of primary and secondary Illizarov's fi xator application as a treatment method for type III open tibial fractures in terms of nonunion and wound infection.METHODS: This prospective study was done in a tertiary care center. Forty-eight type III tibial fractures were treated with Illizarov's apparatus between 2008 and 2011. The patients were divided into two groups depending on the treatment protocol, timing of wound closure and Illizarov's application, primary(n=28) and secondary(n=20).RESULTS: In the primary group, healing was achieved in all 28 patients. The median time to recovery was 24 weeks, and the median number of operations was 3. There were 6 patients with a bone defect. In the secondary group, complete recovery was achieved in 18 out of 20 patients. The median time to recovery was 30 weeks, and the median number of operations 5. There were 9 patients with a bone defect. The median time to recovery and the number of operations were signifi cantly smaller in patients undergoing primary operation. Union was 100% in the primary group and more than 95% in the secondary group. Chronic osteomyelitis persisted in one patient and below amputation was done in one patient in the secondary group.CONCLUSION: Primary wound closure and Illizarov's fixation required a smaller number of operations and shorter time to recovery than secondary wound closure and Illizarov's fi xation, mostly due to a signifi cantly less number of patients with a bone defect in the primary group.
文摘Background: Coblation based bipolar plasma devices are designed to operate at a relatively low temperature to gently dissolve and/or shrink target tissue with minimal thermal damage to surrounding healthy tissue. Coblation technology provides ablation, resection, coagulation of soft tissue and hemostasis of blood vessels in one convenient surgical device. Coblation technology can be used in the larynx and trachea for removing or debulking sessile polyps, lesions or tumors. Minimally invasive coblation technology can offer less invasive treatment with quicker recovery and shorter hospitalization. Aim: This case study aims to explore the advantages of coblation combined with microscopy to treat benign laryngeal lesions. Case report: We report the case of laryngeal papilloma treated with minimally invasive coblation resection. Fiberoptic laryngoscopy was done pre-operatively and that showed papillomatous mass at anterior half of right vocal cord involving inferior surface and also extending upto anterior commissure. Mobility of both vocal cords was normal. On the basis of the above findings with normal vocal cords mobility, the microlaryngeal surgery with coblation was planned. After complete pre-op work up, the patient underwent trans-oral microscopic coblation excision of mass under general anaesthesia. Power level was set to 7 for ablation and 3 for coagulation. The PROcise<sup>TM</sup> LW Plasma Wand system was chosen such that it was malleable to reach the papillomatous mass without obstructing the vision. It was totally excised and sent for histopathology examination. Post-operatively after four hours, he was able to take normal diet comfortably. He was followed up after 10 days. Histopathological report confirmed the diagnosis of papilloma. Check laryngoscopy was performed after 3 weeks. Laryngeal examination was absolutely normal with almost normal vocal cords and normal voice post-operatively. Conclusion: Microscopic surgery with coblation has the advantages of less bleeding, short procedure duration, increased completion rate and few complications.
文摘AIM To investigate the role of a novel minimally invasive endoscopic technique in the management of tight neartotal corrosive strictures of the proximal esophagus involving the hypopharynx.METHODS Two patients with near-total corrosive strictures of the proximal esophagus involving the hypopharynx were managed with the novel endoscopic technique. The technique involved passing a 0.025-inch flexible guidewire across the stricture, and stricture dilatation, using 10 F coaxial diathermy and balloon dilators, followed byelectro-incision of the proximal aspect of the residual eccentric stricture by means of a novel approach using a wire-guided sphincterotome.RESULTS Both patients were successfully managed on an outpatient department basis with the complete relief of symptoms and resolution of strictures on endoscopy and an esophagogram. No adverse events were seen during or after the procedure. There was no recurrence of symptoms at a follow-up of over a year in both cases. There was a significant improvement in the body mass index of both patients after the procedure.CONCLUSION We report a novel flexible endoscopic technique for the management of complex hypopharyngo-esophageal strictures. In experienced hands, the procedure is relatively simple, safe and effective with a durable response.
文摘Sexual dysfunction(SD)is a prevalent but very commonly ignored aspect in the treatment of liver diseases and cirrhosis.The etiology of SD is multifactorial and therefore treatment strategies are complex,especially in females.Phosphodiesterase inhibitors are useful and effective in erectile dysfunction in males but in females,no single drug is available for SD,therefore multimodal treatment is required depending upon the cause.The foremost and fundamental requirement in both genders is to be stress-free and have adequate control of liver diseases.Improved quality of life is helpful in improving SD and vice versa is also true.Therefore,patients suffering from liver diseases should come forward and ask for treatment for SD,and physicians should actively enquire about SD while history taking and evaluating these patients.SD results in deterioration of quality of life,and both are modifiable and treatable aspects of liver diseases,which are never addressed actively,due to social taboos and fears of SD treatment in the presence of liver diseases.The diagnosis of SD does not require costly investigations,as the diagnosis can be established based on validated questionnaires available for both genders,therefore detailed targeted history taking using questionnaires is essential.Data are emerging in this area but is still at an early stage.More studies should be dedicated to SD in liver diseases.
