HISTOMORPHOLOGICAL FINDINGS AND CLINICO-RADIOLOGICAL CORRELATION OF INTESTINAL ATRESIA AT A TERTIARY CARE CENTRE

Background: An atresia is a congenital defect of a hollow viscus that results in complete obstruction of the lumen. Intestinal atresia is one of the most frequent causes of bowel obstruction in the newborn and can occur at any point in the gastrointestinal tract. This study was undertaken to study the histomorphological findings of intestinal atresia and to correlate it with different subtypes and clinico-radiological feature. Material and methods: This was a prospective observational study conducted in 24 months on the resected gastrointestinal tract of 40 neonatal intestinal obstruction cases admitted in Pediatric surgery ward received in the Department of Pathology, Indira Gandhi Institute of Medical Sciences, Patna. Control Group- A total of 5 cases of vitello-intestinal duct patency were taken as control and compared with the study group. Results: With respect to total 40 cases, there were six, i.e. 15.0% female babies and 34, i.e. 85.0% male babies studied. Out of that, 15 i.e. 37.50% were full term and 25, i.e. 62.5% were premature. Mucosa showed oedema, ulceration and flattening in 9 cases. Apart from flattening and oedema, mucosa was denuded at some places and also showed congestion and extravasated blood in 6 cases each. Abnormal villus configuration, calcium deposition in 4 cases each and hypertrophied mucosa were found in 3 cases. Luminal narrowing, loss of mucosa, duplication of mucosa and gangrenewere found in one case each. Sub mucosal changes showed congestion in 33 cases, oedema in 15, Fibrosis in 4, thickened submucosa in 2 cases and dilated irregular branching blood vessels, extravasted blood, calcification in 1 case each. Muscularispropria having changes i.e. thinning in 16 cases, congestion, hypertrophy in 4 cases each, focal loss in 3 cases, calcification in 2 cases and thinning in 2 cases. Similarly, histopathological changes in serosa shows serositis in 16 cases, congestion in 11 cases and thinning in 3 cases. Oedema and congestion were present in 2 cases, hypertrophy and calcification in 1 case each. Conclusion:In this study spectrum of histomorphological changes in the atretic segment has been described. Histomorphological changes at atretic segment can be valuable to surgeons in deciding the type of surgery and minimizing the postoperative intestinal dysmotility, which remains the most common complication of intestinal atresia.

A Fatal Case of Severe Acute Organophosphorus Pesticide Poisoning Complicated with Secondary Hemophagocytic Lympho-Histiocytosis, Severe Lower Intestinal Hemorrhage and Intestinal Mucormycosis

A man in his 50’s, under influence of alcohol, accidentally ingested a pesticide, and was referred for further management and admitted to our hospital. An empty can of Curacron® was found at the site in his farm where he took the alleged pesticide. This raised the suspicion of organophosphorus pesticide poisoning and he was managed at two medical centres before getting admitted to our hospital. His hospital course was complicated with multiorgan dysfunction, shock, respiratory failure and intermediate syndrome. On day five he developed secondary hemophagocytic lymphohistiocytosis (sHLH) and had hematochezia on day six. Colonoscopy revealed multiple circumferential ulcerations in descending and sigmoid colon with luminal narrowing. Biopsy of colonic tissue showed evidence of intestinal Mucormycosis. The clinical presentation of organophosphorus pesticide poisoning in this patient was complicated with multiple issues and included sHLH, chemical gastroenteritis, hemorrhagic ulcers and intestinal zygomycosis. The organophosphorus pesticide ingested by the patient was a 50% emulsifiable concentrate of profenofos along with vegetable oil, soyabean oil and polyglycol ether alkyl aryl sulphate calcium salt 5.25% w/w as an emulsifier/spreading agent. The management of the patient is discussed. Due to the possibility of the emulsifier adhering to the gastrointestinal tract and causing mucosal injury, it is necessary to identify the drug composition and ingredients of the pesticide as soon as possible when managing organophosphorus poisoning.

Lymphoma presented as dysphagia: a diagnosis hard to swallow

An 18-year-old woman presented with progressive oesophageal dysphagia, weight loss and night sweats over a 6-month period. Oesophagogastroduodenoscopy revealed a diffuse luminal narrowing with normal mucosa, whose biopsies were inconclusive. A cervical and thoracic CT scan showed a thickening of the upper oesophagus, densification of the mediastinal fat, several adenopathies and a 4.3×2.4 cm mass with infiltrative appearance and heterogeneous enhancement in right cervical paravertebral location. Positron emission tomography-CT showed marked increased fluorodeoxyglucose uptake in supradiaphragmatic lymph nodes, pleuropulmonary tissue, paraspinal musculature and bone marrow. Imaging-guided and surgical incisional biopsies of the paravertebral mass were inconclusive. During hospitalisation, she developed right cervicobrachial paraesthesia. Only excisional biopsy of the mass allowed the diagnosis of high-grade B-cell lymphoma not otherwise specified, Ann Arbor stage IV-B. The patient underwent chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone), followed by R-EPOCH (rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin hydrochloride). Follow-up at 12 months revealed complete response.

“A STUDY OF ATHEROSCLEROSIS OF RIGHT CORONARY ARTERY AND THORACIC AORTA IN POST MORTEM CASES”

Background: Atherosclerosis is a chronic disease which primarily affects the intima of large and medium sized muscular arteries, commonly involving aorta, coronary arteries and cerebral arteries. The contribution of atherosclerosis in morbidity and mortality of young adults is on the rise. Objective: To demonstrate histopathological spectrum of atherosclerotic lesions in Right Coronary Artery and Thoracic aorta and to compare the age, gender and BMI variation in prevalence of atherosclerotic lesions. 150 specime Materials And Methods: ns of heart with intact coronary arteries and thoracic aorta received by Department of pathology, Shimoga Institute of Medical Sciences, Shivamogga. Heart was grossly examined and sections were taken from Right Coronary Artery and Thoracic Aorta which were processed and stained with Haematoxylin and Eosin. Microscopically typing of the atherosclerotic lesion was made using American Heart Association classication of atherosclerosis. Of the Results: 150 cases, males 91% and females 9% were affected. Majority of the cases were in the age group of 30-40 years (33.33%) and BMI range of 18.6- 24.9 (72.67%). Commonest type of atherosclerosis in Right coronary artery was type 5 (Fibroatheroma) (25.33%) and in Thoracic aorta was type 3 (Preatheroma) (30%). Grade 1 Luminal narrowing (1-25% obstruction) was most commonly seen in Right coronary Artery (50% cases). Conclusion: Due to increase in cardiac death rates screening of cardiovascular risk factors, preventive measures, life style modication and having healthy dietary habits should be implemented early in 3rd decades of young Indians to retard the progression of atherosclerosis.

CT-angiography and Doppler ultrasonography in the evaluation of carotid artery stenosis: a comparative study

Background and purpose Management of carotid artery stenosis is primarily based on the degree of luminal narrowing. The aim of this study is to compare the results of carotid doppler ultrasound (US) and CT angiography (CTA) for grading of carotid stenosis and for plaque characterization in symptomatic patients. Methods This is a cross sectional study with a total number of 35 consecutive patients having 70 carotid arteries for comparison. Grading of carotid stenosis was based on the NASCET criteria for CTA and the carotid consensus panel criteria for US. Each investigator was blinded to the results of the other modality. Results The majority of patients were aged from 60 to 69 years with male to female ratio of 3:2. Males were more commonly affected than females. The most common presenting symptom was recent stroke. Risk factors included; diabetes mellites and hypertension. Atherosclerotic ischemic heart disease was a present association. The carotid bulb and proximal ICA were the most common location for carotid plaques. Kappa analysis with 95 % confidence intervals (CIs) was utilized to determine US – CTA agreement. Both modalities showed overall good agreement (kappa = 0.63) and the concordance was better for moderate and higher grades of stenosis than for non-significant stenosis. The disagreement did not exceed one grade difference in our study sample. There was also good agreement as regards plaque morphology, while CTA was more sensitive than US in the detection of calcifications and plaque ulceration. Conclusion Doppler ultrasound when performed by an experienced sonographer can be used as a reliable first line modality for carotid stenosis grading and to categorize patients as medical and potentially surgical cases. CTA can be used as a confirmatory method for patients with borderline stenosis, for presurgical planning and for patients with suspected stenosis of the intracerebral circulation.

Endoscopic features for early decision to evaluate superior mesenteric artery syndrome in children

Background Diagnostic delay of superior mesenteric artery syndrome (SMAS) is common due to its rarity and lack of index of clinical suspicion. Early diagnosis under suspicion is pivotal for adequate treatment. Present study aims to explore the endoscopic features for early decision to evaluate SMAS in children. Methods In case controlled observation study, the recruitment was limited to patients who had endoscopic finding I or finding 1 plus more as follows: a pulsating vertical or oblique band or slit like luminal narrowing of the third part of the duodenum without no expansion over one third during air insufflation for at least 15 s (finding I), a marked dilation of the duodenal first and second part during air insufflation at the third part of the duodenum (finding II), a bile mixed fluid collection (bile lake) in the stomach (finding III). SMAS was confirmed with UGI series or hypotonic duodenography in enrolled patients. We analyzed positive endoscopic findings related with SMAS. Results The enrolled 29 patients consisted of 18 (62.1%) with SMAS and 11 (37.9%) without SMAS. The three most common presenting symptoms were abdominal pain, postprandial discomfort, and early satiety. The clinical impressions based on history and physical examination before endoscopy were functional dyspepsia (34.6%), gastritis or gastric ulcer (31.0%), and SMAS (17.3%). The constellation of three endoscopic findings (finding I + II + III, feature D) observed in 13 (72.2%) patients of SMAS group and 3 (27.3%) patients of non SMAS group (P = 0.027). Of 16 patients with features D, SMAS was diagnosed in 13 patients (81.2%) and not detected in 3 patients (18.8%) on UGI series or hypotonic duodenography. Conclusions Endoscopic examination to the third part of the duodenum can provide a clue making a decision to evaluate SMAS, which consists of features of three endoscopic findings as follows: a pulsating vertical or oblique band or slit like luminal narrowing of the third part of the duodenum without no expansion over one third during air insufflation for at least 15 s, a marked dilation of the first and second part of the duodenum, and a bile lake in the stomach.

Focal Geometry and Characteristics of Erosion-Prone Coronary Plaques in vivo Angiography and Optical Coherence Tomography Study

Objective: This study compared focal geometry and characteristics of culprit plaque erosion (PE) vs. non-culprit plaques in ST-segment elevated myocardial infarction (STEMI) patients in whom optical coherence tomography (OCT) identified PE as the cause of the acute event.Background: Culprit PE is a distinct clinical entity with specific coronary risk factors and its own tailored management strategy. However, not all plaques develop erosion resulting in occlusive thrombus formation.Methods: Between January 2017 and July 2019, there were 484 STEMI patients in whom OCT at the time of primary percutaneous intervention identified culprit lesion PE to be the cause of the event; 484 culprit PE were compared to 1,132 non-culprit plaques within 1,196 imaged vessels.Results: Culprit PE were highly populated at “hot spots” within the proximal 40 mm in the left anterior descending artery (LAD) and tended to cluster proximal to a nearby bifurcation mainly in the LAD. Minimal lumen area (MLA) <2.51 mm2 and AS (area stenosis) >64.02% discriminated culprit PE from non-culprit plaques. In the multivariable analysis, focal geometry (LAD location, distance from coronary ostium <40 mm, and location proximal to a nearby bifurcation), luminal narrowing (MLA <2.51 mm2, AS > 64.02%), and TCFA phenotype were independent predictors of culprit PE overall. Cholesterol crystals were predictive of culprit PE with underlying LRP morphology while the absence of calcification and microchannels were risk factors for culprit PE with an underlying non-LRP. Similarities and differences in predictors of culprit PE were found between males and females; distance from coronary ostium <40 mm, MLA <2.51 mm2, TCFA, and less spotty calcium were risk factors of culprit PE in males, but not in females while smaller RVD was associated with culprit PE only in females.Conclusions: Irrespective of underlying lesion substrates and patient risk factors, there are lesion-specific and OCT-identifiable predictors of developing culprit PE in erosion-prone vulnerable patients.

Immunomodulation of IL-33 and IL-37 with Vitamin D in the Neointima of Coronary Artery: A Comparative Study between Balloon Angioplasty and Stent in Hyperlipidemic Microswine

Inflammation is a major contributor to the development and progression of atherosclerosis. Interleukin (IL)-33 and IL-37, members of the IL-1 family, modulate inflammation, with IL-33 having a pro-inflammatory effect and IL-37 having anti-inflammatory properties. IL-37 is constitutively expressed at low levels but upregulated in inflammatory contexts. The aim of this study was to evaluate the effect of vitamin D on the expression of IL-33, IL-37, macrophages, and caspase-1 in the neointimal tissue of coronary artery in Yucatan microswine with vitamin D deficient, sufficient, and supplemented status. The intimal injury was induced by balloon angioplasty and stenting in the coronary artery, and tissues were harvested after 6 months. The expression of various proteins of interest was evaluated by immunostaining. Increased expression of IL-33 and IL-37 in the neointimal tissue of the vitamin D deficient, as compared to the sufficient and supplemented microswine, as revealed by histological evaluation and semi-quantitative analysis, suggested the immunomodulatory effect of vitamin D on the expression of IL-33 and IL-37. The minimal expression or absence of IL-33 and IL-37 expression in stented arteries is suggestive of an attenuated inflammatory response in stented arteries, compared to balloon angioplasty. The decreased IL-33 expression in the sufficient and supplemented microswine could be a potential mechanism for controlling the inflammatory process and neointima formation leading to attenuated luminal narrowing of the coronary artery. Overall, these results support supplementation of vitamin D to attenuate inflammation, neointima formation, and restenosis.

Atherosclerosis: immunopathogenesis and strategies for immunotherapy

Atherosclerosis, a chronic inflammatory condition in which atheroma accumulates within the intima of the arterial wall, is a life-threatening manifestation of cardiovascular disease, due to atheroma rupture, chronic luminal narrowing and thrombosis. Current knowledge of the role of a protective immune response in atherosclerotic lesions has provided promising opportunities to develop new immunotherapeutic strategies. In particular, Tregs exert an atheroprotective role by releasing anti-inflammatory cytokines (IL-10/TGF-β) and suppressing autoreactive T lymphocytes. In vivo animal experiments have shown that this can be achieved by developing vaccines that stimulate immunological tolerance to atheroma antigens. Here, we present an overview of the current knowledge of the proatherogenic immune response, and we discuss the strategies currently used as immunoregulatory therapy.

Coronary CT angiography for suspected acute coronary syndrome: sex-associated differences

Aim The optimal diagnostic test in the work-up of suspected acute coronary syndrome (ACS) may differ between men and women. The aim of this study was to compare sex-associated differences between using a diagnostic strategy including early coronary computed tomography angiography (CCTA) and standard of care (SOC). Methods In total, 500 patients who presented with symptoms suggestive of ACS at the emergency department were randomised between a diagnostic strategy supplemented with early CCTA and SOC. Results Women were generally older than men (mean ± standard deviation 56 ± 10 vs 53 ± 10 years, p < 0.01) and were less often admitted to hospital (33% vs 44%, p = 0.02). Obstructive coronary artery disease on CCTA (> 50% luminal narrowing) was less frequently seen in women (14% vs 26%, p = 0.02), and ACS was diagnosed less often in women (5% vs 10%, p = 0.03). Women underwent less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS (p = 0.008). Conclusion Women had a lower incidence of obstructive CAD on CCTA and were less often admitted to hospital than men. They were subjected to less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS.