The ‘heart’ of public interventions in historic cities- reflections on the HRIDAY scheme

The paper intends to discuss implemented examples from the Heritage City Development and Augmentation Yojana also commonly known as the HRIDAY scheme in India and how they addressed public spaces in historical cities. HRIDAY (2014-2019) was formulated to provide holistic development and improve infrastructure mainly at pilgrim towns under the Ministry of Urban Development, now the Ministry of Housing and Urban Affairs (MoHUA). The scheme taking into consideration the complexity of dealing with entire historic cities especially for the urban local bodies, focused on only taking into account primarily the core of a city, i.e. its old town centre. Its purview was to revitalise the city’s unique character by ‘encouraging the development of an aesthetically appealing, accessible, informative and secured environment’ (MOUD, 2015). However, as the scheme ended, there remain many historic towns and cities across the country that could benefit from reflections and understanding from its executed projects.  To undertake any further development strategies from the scheme, it was imperative to understand its application specifically in the public space typology. HRIDAY primarily addressed the needs of retaining a cultural identity via improvement of public infrastructure and promoting tourism. The paper will specifically address how public chowks (squares) and market streets fared benefited from the scheme, from secondary sources in two selected cities.  Additions of sanitation or public conveniences, or development of cultural event spaces, in existing public realms and interventions like interpretation centres and improvement of paths will all be considered and guidelines and theories extrapolated. These would be to guide future heritage sensitive urban development in cities and towns across India

Isolated angioedema of the bowel due to C1 esterase inhibitor deficiency: a case report and review of literature

<p>Abstract</p> <p>Introduction</p> <p>We report a rare, classic case of isolated angioedema of the bowel due to C1-esterase inhibitor deficiency. It is a rare presentation and very few cases have been reported worldwide. Angioedema has been classified into three categories.</p> <p>Case presentation</p> <p>A 66-year-old Caucasian man presented with a ten-month history of episodic severe cramping abdominal pain, associated with loose stools. A colonoscopy performed during an acute attack revealed nonspecific colitis. Computed tomography of the abdomen performed at the same time showed a thickened small bowel and ascending colon with a moderate amount of free fluid in the abdomen. Levels of C4 (< 8 mg/dL; reference range 15 to 50 mg/dL), CH50 (< 10 U/mL; reference range 29 to 45 U/ml) and C1 inhibitor (< 4 mg/dL; reference range 14 to 30 mg/dL) were all low, supporting a diagnosis of acquired angioedema with isolated bowel involvement. Our patient's symptoms improved with antihistamine and supportive treatment.</p> <p>Conclusion</p> <p>In addition to a detailed comprehensive medical history, laboratory data and imaging studies are required to confirm a diagnosis of angioedema due to C1 esterase inhibitor deficiency.</p

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

Background and Aims The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases yet standard ERCP is not possible due to surgically altered gastroduodenal anatomy. Laparoscopic-ERCP (LA-ERCP) has been proposed as an option but supporting data are derived from single center small case-series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. Methods This is retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all of the following were achieved: reaching the papilla, cannulating the desired duct and providing endoscopic therapy as clinically indicated. Results A total of 579 patients (median age 51, 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (IQR 109-210) with median ERCP time 40 minutes (IQR 28-56). Median hospital stay was 2 days (IQR 1-3). Adverse events were 18% (laparoscopy-related 10%, ERCP-related 7%, both 1%) with the clear majority (92%) classified as mild/moderate whereas 8% were severe and 1 death occurred. Conclusion Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher due to the added laparoscopy-related events

Pancreatic Cystic Neoplasms: Diagnosis and Management

Pancreatic cancer is one of the most lethal cancers, largely related to the difficulties with early detection, as it typically presents in later stages. Pancreatic cystic neoplasms (PCN) are commonly diagnosed as incidental findings on routine imaging. PCN is becoming more frequently detected with the increasing ease and frequency of obtaining cross-sectional images. Certain subtypes of pancreatic cysts have the potential to progress to malignancy, and therefore, clinicians are tasked with creating a patient-centered management plan. The decision of whether to undergo surgical resection or interval surveillance can be challenging given the criteria, including PCN size, pancreatic duct dilation, presence of a mural nodule, and clinical symptoms that play a potential role in risk stratification. Furthermore, the guidelines available from the major gastrointestinal societies all differ in their management recommendations. In this review, we detail an overview of the different types of PCNs and compare major guidelines for both diagnosis and management. We include emerging evidence for next-generation sequencing as well as confocal needle endomicroscopy to aid in the diagnosis and determination of malignancy potential and diagnosis

Escalating complexity of endoscopic retrograde cholangiopancreatography over the last decade with increasing reliance on advanced cannulation techniques

At our academic tertiary care medical center, we have noted patients referred for endoscopic retrograde cholangiopancreatography (ERCP) who increasingly require advanced cannulation techniques. This trend is noted despite increased endoscopist experience and annual ERCP volume over the same period. To evaluate this phenomenon of perceived escalation in complexity of cannulation at ERCP and assessed potential underlying factors. Demographic/clinical variables and records of ERCP patients at the beginning (2008), middle (2013) and end (2018) of the last decade were reviewed retrospectively. Cannulation approaches were classified as "standard" or "advanced" and duodenoscope position was labeled as "standard" (short position) or "non-standard" ( long, semi-long). Patients undergoing ERCP were older in 2018 compared to 2008 (69.7 ± 15.2 years 55.1 ± 14.7, < 0.05). Increased ampullary distortion and peri-ampullary diverticula were noted in 2018 ( < 0.001). ERCPs were increasingly performed with a non-standard duodenoscope position, from 2.2% (2008) to 5.6% (2013) and 16.1% (2018) ( < 0.001). Utilization of more than one advanced cannulation technique for a given ERCP increased from 0.7% (2008) to 0.9% (2013) to 6.6% (2018) ( 4 cm, pancreatic uncinate mass, and bilirubin > 10 mg/dL predicted use of advanced cannulation techniques ( < 0.03 for each). Complexity of cannulation at ERCP has sharply increased over the past 5 years, with an increased proportion of elderly patients and those with malignancy requiring advanced cannulation approaches. These data suggest that complexity of cannulation at ERCP may be predicted based on patient/ampulla characteristics. This may inform selection of experienced, high-volume endoscopists to perform these complex procedures