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Dhir V.,Global Hospitals | Itoi T.,Tokyo Medical University | Perez-Miranda M.,University of Valladolid | Khashab M.A.,Johns Hopkins University | And 4 more authors.
Gastrointestinal Endoscopy | Year: 2015

Background EUS-guided biliary drainage (EUS-BD) has emerged as an alternative rescue method in patients with failed ERCP. Opportunities for teaching and training are limited because of a low case volume at most centers. Objective To evaluate a stereolithography/3-dimensional (3D) printing bile duct prototype for teaching and training in EUS-BD. Design Prospective observational feasibility study. Setting Tertiary referral center. Subjects Twenty endosonographers attending an interventional EUS workshop. Intervention A prototype of a dilated biliary system was prepared by computer-aided design and 3D printing. The study participants performed guidewire manipulation and EUS-BD procedures (antegrade procedure and/or choledochoduodenostomy) on the prototype. Participants were scored with the device on a scale of 1 to 5 via a questionnaire. Participants' success rate for various steps of the EUS-BD procedure was noted. Main Outcome Measurements Subjective and objective evaluation of the prototype regarding its overall applicability, quality of radiographic and EUS images, and 4 steps of EUS-BD procedure (needle puncture, guidewire manipulation, tract dilation, stent placement). Results Fifteen participants returned the questionnaire, and 10 completed all 4 steps of EUS-BD. The median score for overall utility was 4, whereas that for EUS and US views was 5. Participants with experience in performing more than 20 EUS-BD procedures scored the prototype significantly lower for stent placement (P =.013) and equivalent for needle puncture, tract dilation, and wire manipulation. The success rate of various steps was 100% for needle puncture and tract dilation, 82.35% for wire manipulation, and 80% for stent placement. The mean overall procedure time was 18 minutes. Limitations Small number of participants. Conclusion The 3D printing bile duct prototype appears suitable for teaching of and training in the various steps of EUS-BD. Further studies are required to elucidate its role. © 2015 American Society for Gastrointestinal Endoscopy.


Itoi T.,Tokyo Medical University | Ishii K.,Tokyo Medical University | Ikeuchi N.,Tokyo Medical University | Sofuni A.,Tokyo Medical University | And 5 more authors.
Gut | Year: 2016

Surgical gastrojejunostomy (GJ), which has been the standard palliative treatment for malignant gastric outlet obstruction (MGOO), is associated with good functional outcome and the long-term relief of symptoms. Endoscopic placement of a metal stent for MGOO treatment has been gaining popularity as an alternative to surgical GJ because of its high technical success rates and less invasiveness. Interestingly, several investigators have attempted endoscopic GJ as 'endoscopic bypass' for longer efficacy while maintaining a less invasive procedure.1 We previously reported on the feasibility and safety of EUS-guided GJ (EUS-GJ) using a lumen-apposing metal stent (LAMS)2 3 and a special double-balloon enteric tube in an animal model and a pilot clinical study.3 Herein, we describe the first prospective clinical study of EUS-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) using a LAMS (figure 1). We performed EPASS in 20 patients with MGOO. The double-balloon tube (figure 2) was correctly inserted into the jejunum across from the stomach in all cases. The technical success rate of stent placement was 90%.


Jothimani D.,Global Hospitals | Cramp M.E.,Plymouth Hospitals | Cross T.J.S.,University of Liverpool
Journal of Clinical and Experimental Hepatology | Year: 2014

Background: Eighty percent (80%) of patients with Autoimmune hepatitis (AIH) respond to a combination ofprednisolone and Azathioprine (AZA). Choice of treatment is limited for those who do not respond to this standard therapy. We evaluated the role of Mycophenolate mofetil (MMF) as a second line therapy in AIH. Method: A retrospective observational study was carried out on all patients who received MMF for AIH. Results: Twenty out of 117 patients with AIH received MMF due to AZA intolerance (18 patients) or refractory disease (2 patients). Median age of the study patients was 56 (18-79) years, Male, n=3 (15%) and Female, n=18 (85%). After a median follow-up period of 47 (5-83) months, 14 (73.6%) patients were still on MMF with biochemical remission, including 4 out of 5 patients with cirrhosis. One patient was lost to follow-up. Three patients were intolerant of MMF due to adverse events, and two had disease refractory to MMF. Both these patients with refractory disease to MMF were initially unresponsive to AZA therapy. Conclusion: MMF is a safe second line agent in patients with autoimmune hepatitis including those with cirrhosis. © 2014 INASL.


Joshi L.,Bhagwan Mahavir Medical Research Center | Chelluri L.K.,Global Hospitals | Gaddam S.,Bhagwan Mahavir Medical Research Center | Gaddam S.,Osmania University
Archivum Immunologiae et Therapiae Experimentalis | Year: 2015

Multi-drug-resistant (MDR) tuberculosis is a major public health problem worldwide. Drug resistance arises due to non-compliance of antibiotic therapy. Herein, we explored the therapeutic options available ranging from conservative treatment approaches to alternate adjunct therapies such as mesenchymal stromal cell (MSC) therapy interventions. It is attractive to understand the scientific rationale of using cells as drugs, in particular mesenchymal stem/stromal cells. The review dwells and attempts to analyze the mechanistic approaches of the current treatment modalities to modern therapies. MSCs have demonstrated profound capacity to regenerate and repair. They appear to modulate that the activities of dendritic cells regulate T cells, both in vivo and in vitro. While there seems to be some benefit of such therapies, its use warrants further research. The merits and de-merits of autologous therapy/allogeneic therapy are ill understood. The challenges of requirement of large number of cells for infusion, the route of administration, choice of timing are complex issues that need to be addressed. Furthermore, the host immune responses, environmental factors and epigenetic mechanisms compound the problem. Although, clinical studies are being performed using autologous MSCs in different inflammatory models, it is important that such an intervention should be based on sound scientific rationale. The current review examines the immunomodulatory properties of MSCs, its interactions with other cell types, in assessing the basis for autologous/allogeneic cell-based therapies in the treatment of XDR/MDR tuberculosis. © 2015, L. Hirszfeld Institute of Immunology and Experimental Therapy, Wroclaw, Poland.


Haridas A.K.,International Advanced Research Center for Powder Metallurgy And New Materials | Haridas A.K.,Indian Institute of Technology Hyderabad | Sharma C.S.,Indian Institute of Technology Hyderabad | Sritharan V.,Global Hospitals | Rao T.N.,International Advanced Research Center for Powder Metallurgy And New Materials
RSC Advances | Year: 2014

Polystyrene (PS) submicron fibers of 14 wt% concentration were fabricated by electrospinning using dimethylformamide (DMF)-tetrahydrofuran (THF) solvent system. The surface morphology of PS fibers was modified from smooth to rough by changing the mixing ratio of DMF and THF in the spinning solution. The electrospun PS fibers with smooth and rough surfaces were then amidomethylated by treating with N-hydroxymethyl-2-chloroacetamide. PS fibers with higher roughness incorporated more amidomethyl functional groups on their surface, as confirmed by XPS analysis. This observation was further supported by BET adsorption isotherm results which showed a significant increase in specific surface area of rough PS electrospun fibers. Interestingly, amidomethylation has altered rough electrospun PS submicron fibers from extremely hydrophobic to hydrophilic. These chemically modified electrospun PS fibers with controllable surface roughness and wettability may be utilized as a carrier for proteins, mainly enzymes and antibodies, by covalent linkage through amino groups attached to their surface. © 2014 The Royal Society of Chemistry.


Petla L.T.,Molecular Diagnostics and Biomarkers Laboratory | Chikkala R.,Molecular Diagnostics and Biomarkers Laboratory | Ratnakar K.S.,Global Hospitals | Kodati V.,Durgabai Deshmukh Hospital and Research Center | Sritharan V.,Molecular Diagnostics and Biomarkers Laboratory
Indian Journal of Medical Research | Year: 2013

Pre-eclampsia (PE) is a pregnancy related disorder characterized by hypertension and proteinuria noticeable after 20 wk of gestation. It is a leading cause of maternal and foetal mortality and morbidity worldwide. The aetiology of the disease is unknown, but recent studies have revealed that this disorder appears to originate in placenta and is characterized by widespread maternal endothelial dysfunction. Till date, delivery of placenta is the only cure for the disease. So, there is a need for the identification of highly specific and sensitive biochemical markers that would allow early identification of patients at risk and thus help in providing proper prenatal care. Several promising biomarkers have been proposed, alone or in combination, that may help in predicting women who are likely to develop PE. Maternal serum concentrations of these biomarkers either increase or decrease in PE during gestation. This review focuses on the various biomarkers available and their utility in predicting pre-eclampsia.


Background: Evaluation of the prevalance of cholelithiasis, choledocholithiasis and there management after sleeve gastrectomy, gastric bypass and mini gastric bypass in Indian bariatric patients. Methods: We did a retrospective analysis of our bariatric patient from January 2007 to December 2013 (n = 1397), for prevalence of cholelithiasis and choledocholithiasis. We did synchronous cholecystectomy in all patients planned for bariatric surgery found to have cholelithiasis on USG. Post-operatively, we followed all the patients with gallbladder in situ for minimum of 18–88 months (mean −32.4) and reviewed data for subsequent development of cholelithiasis/choledocholithiasis. Only those patients who were symptomatic underwent intervention. Results: Prevalence of cholelithiasis and choledocholithiasis in our study was 21.76 and 9.63 %, respectively. The incidence of post-bariatric surgery development of cholelithiasis was 10.53 %; individually, it was 8.42 % in LSG group, 13.4 % in LRYGB group and 12.7 % in MGB patients. The incidence of symptomatic cholelithiasis requiring surgery was 1.94 % after LSG, 4.54 % after LRYGB and 4.25 % after MGB. Post-surgery, six patients developed choledocholithiasis. In our post-bariatric group, the 33 patients who developed symptomatic stones had percentage total weight loss of 30.99 + 4.1 (P < 0.001). The average time period for readmission of symptomatic patient was 11.26 + 2.67 months. Conclusions: We recommend routine synchronous cholecystectomy with bariatric procedure. In spite of synchronous cholecystectomy, incidence of cholelithiasis in our post-bariatric patient is 10.53 % of which up to one third were symptomatic and required surgery, and incidence of choledocholithiasis is comparable to that of general population. © 2016 Springer Science+Business Media New York


Shah S.,Global Hospitals | Shukla A.,Global Hospitals | Paunipagar B.,Global Hospitals
Journal of Clinical and Experimental Hepatology | Year: 2014

Present article is a review of radiological features of hepatocellular carcinoma on various imaging modalities. With the advancement in imaging techniques, biopsy is rarely needed for diagnosis of hepatocellular carcinoma (HCC), unlike other malignancies. Imaging is useful not only for diagnosis but also for surveillance, therapy and assessing response to treatment. The classical and the atypical radiological features of HCC have been described. © 2014 INASL.


Nagendranath C.,Global Hospitals | Saravanan M.N.,Global Hospitals | Sridhar C.,Global Hospitals | Varughese M.,Global Hospitals
Techniques in Coloproctology | Year: 2014

Background: In complex fistula-in-ano, preoperative imaging can help identify secondary tracts and abscesses that can be missed, leading to recurrence. We evaluated hydrogen peroxide-enhanced endoanal ultrasound (PEEUS) in the characterization of fistula compared with standard clinical and operative assessment. Methods: Patients with complex fistula-in-ano treated between February 2008 and May 2009 at our institution were prospectively evaluated by PEEUS with recording of the preoperative clinical examination and intraoperative details of the fistula. Of the 135 patients with fistula-in-ano, 68 met the inclusion criteria for complex fistula-in-ano. Correlation of clinical findings and PEEUS to the gold standard intraoperative findings was assessed in characterizing the fistula. The percent agreement between the clinical and PEEUS findings against the gold standard was derived, and the kappa statistic for agreement was determined. Results: The mean age of the cohort was 42.54 ± 10.86 years. The fistula tracts were curvilinear, high, and transsphincteric in 16 (23.53 %), 8 (11.76 %), and 42 (61.76 %) patients, respectively. Secondary tracts and associated abscess cavities were seen in 28 (33.82 %) and 35 (51.47 %) patients, respectively. PEEUS correlated better than clinical examination with regard to site (92.65 vs 79.41 %; p < 0.001) and course (91.18 vs 77.94 %; p < 0.001) of secondary tract and associated abscesses (89.71 vs 80.88 %; p = 0.02). There was a trend of better correlation of PEEUS compared to clinical examination in classifying the primary tract as per Park's system (88.24 vs 79.41 %; p = 0.06), but it did not reach statistical significance. PEEUS and clinical examination were comparable in correlation of the level of the primary tract (kappa: 0.86 vs 0.78; p = 0.22) and the site of internal opening (kappa: 0.97 vs 0.89; p = 0.22). The operative decision was changed in 13 (19.12 %) subjects based on PEEUS findings. Conclusions: PEEUS is a feasible and efficient tool in the routine preoperative assessment of complex fistula-in-ano. © 2013 Springer-Verlag.


Prabhu M.V.,Global Hospitals | Juneja D.,Global Hospitals | Gopal P.B.,Global Hospitals | Sathyanarayanan M.,Global Hospitals | And 3 more authors.
Clinical Journal of the American Society of Nephrology | Year: 2010

Background and objectives: Insertion of dialysis catheters (DCs) is a prerequisite for successful initiation of hemodialysis. We attempted to determine if ultrasonography-guided (USG) insertion was superior and safer than the anatomical landmarkguided technique (ALT) for the femoral vein (FV). Design, setting, participants, & measurements: This was a randomized prospective study on 110 patients requiring FV DCs in a tertiary care hospital. Patients were randomized into two groups: USG and ALT. Data were collected on demography, operator experience, and side of insertion. The USG group had their catheters inserted under USG guidance, whereas the ALT group had their DC inserted by ALT. Outcome measures included successful insertion of DC, number of attempts, and complications. Results: Both groups were comparable regarding age and gender of patients, operator experience, and the side of catheterization. The overall success rate was 89.1%, with 80% using ALT and 98.2% under USG guidance (P = 0.002). First attempt success rate was 54.5% in the ALT group as compared with 85.5% in the USG group (P = 0.000). The complication rate was 18.2% in the ALT group and 5.5% in the USG group (P = 0.039). The odds ratio (OR) for complications with two or more attempts was 10.73 with a relative risk (RR) of 3.2. The OR for successful insertion using USG was 13.5 (95% CI: 1.7 to 108.7). Conclusions: USG significantly improves success rate, reduces number of attempts, and decreases the incidence of complications related to FV DC insertion. Copyright © 2010 by the American Society of Nephrology.

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