Haemobilia in a previously stented hilar cholangiocarcinoma: successful haemostasis after the insertion of fcSEMS

Haemobilia describes blood loss from the biliary tract and classically presents as Quincke's triad: upper gastrointestinal bleeding (UGIB), jaundice and right upper quadrant abdominal pain. We discuss the case of a 70-year-old male with a previously stented Bismuth 1 hilar cholangiocarcinoma who presented with haematemesis. He had a similar presentation a month ago where a forward viewing gastroscope identified fresh and altered blood in the distal stomach but no clear source of bleeding. During this admission, a side-viewing duodenoscope identified bleeding from the periampullary region, which was managed by inserting a fully covered self-expanding metal stent (fcSEMS) within his pre-existing uncovered SEMS to tamponade the haemorrhage. This case highlights the importance of using a side-viewing duodenoscope for patients with UGIB on a background of a stented cholangiocarcinoma and inserting a fcSEMS within an uncovered SEMS is feasible and effective in managing these patients

Pulmonary Echinococcal Cyst with a Filamentous Fungus Co-Infection

Fungal infections are known to colonize the preexisting lung cavities formed as a result of diseases like tuberculosis, sarcoidosis, bronchiectasis and cavitatary neoplasia, mostly encountered in immunocompromised patients. Pulmonary echinococcal cysts have been reported coexistent with cryptococcosis and other saprophytic mycosis, but the coexistence of aspergillosis and echinococcal cyst is extremely rare and occasionally been reported in English literature. Active invasion and proliferation of the fungi in the laminated ectocyst of the echinococcal cyst is very unusual. We report a case of 60 years old immunocompetent female, presented with cough, chest pain and shortness of breath. The chest X- ray showed a large thick walled cavity in the lower and mid zone of right lung with positive water lily sign. Surgical enucleation of the echinococcal cyst revealed aspergilloma involving the cavity with massive invasion of laminated ectocyst by filamentous fungus, morphologically resembling an Aspergillus species and was further treated with Itraconazole for 3 months. This unique coexistence of active pulmonary echinococcosis and aspergillosis is being reported because of its rarity and clinical importance for its management.Keywords: Aspergillosis, echinococcosis, echinococcal cyst, pulmonary, mycosis

Analysis of Box Culvert to Reduce Stress Values

At the time of construction of roads, highways a structure is placed (commonly used) to transfer the traffic, rain water, drainage from one side to another of the road is called a culvert placed beneath the road. Due to the structural use, multiple loads are placed on the box causing various types of stress which occurs on it. The paper tries to reduce the stress occurred in the box by flaring the box partially

Systematic review: Investigating the prognostic performance of four non‐invasive tests in alcohol‐related liver disease

BACKGROUND/AIMS: Mortality of Alcohol-related-Liver-Disease (ArLD) is increasing, and liver fibrosis stage is the best mortality predictor. Non-invasive-tests (NIT) are increasingly used to detect fibrosis, but their value as prognostic tests in chronic liver disease (CLD), and in particular in ArLD is less well recognized. We aimed to describe the prognostic performance of four widely used NITs (FIB4, ELF test, FibroScan and FibroTest) in ArLD. METHODS: Applying systematic-review methodology, four databases were searched from inception to May 2020. Inclusion/exclusion criteria were applied to search using MeSH terms and keywords. First and second reviewers independently screened results, extracted data and performed risk-of-bias assessment using Quality-In-Prognostic-Studies (QUIPS) tool. RESULTS: Searches produced 25,088 articles. After initial screening, 1,020 articles were reviewed independently by both reviewers. Eleven articles remained after screening for eligibility: one on ELF, four on FibroScan, four on FIB4, one on FIB4+FibroScan and one on FibroTest+FIB4. Area-Under-Receiving-Operator-Characteristics-curves (AUROCS) for outcome-prediction ranged from: 0.65-0.76 for FibroScan, 0.64-0.83 for FIB4, 0.69-0.79 for FibroTest and 0.72-0.85 for ELF. Studies scored low-moderate risk of bias for most domains, but high-risk in confounding/statistical reporting domains. The results were heterogeneous for outcomes and reporting, making pooling of data unfeasible. CONCLUSIONS: This systematic-review returned eleven papers, six of which were conference-abstracts and one unpublished manuscript. Whilst the heterogeneity of studies precluded direct comparisons of NITs, each NIT performed well in individual studies in predicting prognosis in ArLD (AUROCs >0.7 in each NIT category), and may add value to prognostication in clinical practice

Is there scope to improve the selection of patients with alcohol-related liver disease for referral to secondary care? A retrospective analysis of primary care referrals to a UK liver centre, incorporating simple blood tests

OBJECTIVES: Twenty per cent of people with alcohol use disorders develop advanced fibrosis and warrant referral to secondary care. Improving outcomes in alcohol-related liver disease (ArLD) relies on its earlier detection in primary care with non-invasive tests (NIT). We aimed to determine the proportion of alcohol-related referrals who were diagnosed with advanced fibrosis in secondary care, the prevalence of both alcohol and fatty liver disease ('BAFLD') and the potential impact of NIT on referral stratification. DESIGN/SETTING: Retrospective analysis of all general practitioner-referrals with suspected ArLD/non-alcoholic fatty liver disease (NAFLD) to a UK hepatology-centre between January 2015 and January 2018. PARTICIPANTS: Of 2944 new referrals, 762 (mean age 55.5±13.53 years) met inclusion criteria: 531 NAFLD and 231 ArLD, of which 147 (64%) could be reclassified as 'BAFLD'. PRIMARY OUTCOME MEASURE: Proportion of referrals with suspected ArLD/NAFLD with advanced fibrosis as assessed by tertiary centre hepatologists using combinations of FibroScan, imaging, examination and blood tests and liver histology, where indicated. SECONDARY OUTCOME MEASURES: Included impact of body mass index/alcohol consumption on the odds of a diagnosis of advanced fibrosis, and performance of NIT in predicting advanced fibrosis in planned post-hoc analysis of referrals. RESULTS: Among ArLD referrals 147/229 (64.2%) had no evidence of advanced fibrosis and were judged 'unnecessary'. Advanced fibrosis was observed in men drinking ≥50 units per week (U/w) (OR 2.74, 95% CI 1.51 to 5, p=0.001) and ≥35 U/w in women (OR 5.11, 95% CI 1.31 to 20.03, p=0.019). Drinking >14 U/w doubled the likelihood of advanced fibrosis in overweight/obesity (OR 2.11; 95% CI 1.44 to 3.09; p<0.001). Use of fibrosis 4 score could halve unnecessary referrals (OR 0.50; 95% CI 0.32 to 0.79, p=0.003) with false-negative rate of 22%, but was rarely used. CONCLUSIONS: The majority of referrals with suspected ArLD were deemed unnecessary. NIT could improve identification of liver damage in ArLD, BAFLD and NAFLD in primary care. Anecdotal thresholds for harmful drinking (35 U/w in women and 50 U/w in men) were validated. The impact of alcohol on NAFLD highlights the importance of multi-causality in chronic liver disease

Temperature driven spin-zero effect in TaAs2_2

The electrical and thermo-electrical transport effects of the TaAs$_2$ semimetal were measured in a magnetic field applied along [-2 0 1] direction. The resulting field dependences of the resistivity as well as the Hall, Seebeck and Nernst coefficient below T ~ 100 K can be satisfactory described within the two-band model consisting of the electron and hole pockets. At low temperature all the measured effects exhibit significant contribution from quantum oscillations. The fast Fourier transform (FFT) of the oscillatory Nernst signal shows two fundamental frequencies, Fa = 105 T and Fb = 221 T, and the second harmonic of the latter (F2b = 442 T). The ratio between FFT amplitudes of Fb and F2b changes with temperature in an unusual way, indicating that we observe the spin-zero effect caused by temperature change. This is likely related to substantial temperature dependence of the Lande g-factor, which in turn can result from non-parabolic energy dispersion or temperature evolution of the spin-orbit coupling.Comment: 30 pages, 14 figure

Severe acute respiratory syndrome coronavirus Orf3a protein interacts with caveolin.

The orf3a (also called X1 or U274) gene is the largest unique open reading frame in the severe acute respiratory syndrome coronavirus genome and has been proposed to encode a protein with three transmembrane domains and a large cytoplasmic domain. Recent work has suggested that the 3a protein may play a structural role in the viral life cycle, although the mechanisms for this remain uncharacterized. Here, the expression of the 3a protein in various in vitro systems is shown, it has been localized to the Golgi region and its membrane topology in transfected cells has been confirmed. Three potential caveolin-1-binding sites were reported to be present in the 3a protein. By using various biochemical, biophysical and genetic techniques, interaction of the 3a protein with caveolin-1 is demonstrated. Any one of the potential sites in the 3a protein was sufficient for this interaction. These results are discussed with respect to the possible roles of the 3a protein in the viral life cycle

Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease.

BACKGROUND & AIMS: We aimed to develop and evaluate a pathway for management of patients with non-alcoholic fatty liver disease (NAFLD) using blood tests to stratify patients in primary care to improve detection of cases of advanced fibrosis and cirrhosis, and avoid unnecessary referrals to secondary care. METHODS: This was a prospective longitudinal cohort study with before-and-after analysis and comparison to unexposed controls. We used a two-step algorithm combining the use of FIB-4 followed by the ELF test if required RESULTS: In total, 3,012 patients were analysed. Use of the pathway detected 5 times more cases of advanced fibrosis (Kleiner F3) and cirrhosis (OR=5.18; 95%CI=2.97 to 9.04; p<0.0001). Unnecessary referrals from primary care to secondary care fell by 81% (OR=0.193; 95%CI 0.111 to 0.337; p<0.0001). Three times more cases of cirrhosis were diagnosed (OR=3.14; 95%CI=1.57 to 24; p=0.00011). Although it was used for only 48% of referrals, significant benefits were observed across all referrals from the practices exposed to the pathway. Unnecessary referrals fell by 77% (OR=0.23; 95% CI=0.658 to 0.082; p=0.006) with a 4-fold improvement in detection of cases of advanced fibrosis and cirrhosis (OR=4.32; 95% CI=1.52 to 12.25; p=0.006). Compared to referrals made before introduction of the pathway, unnecessary referrals fell from 79/83 referrals (95.2%) to 107/152 (70.4%) representing an 88% reduction in unnecessary referrals when the pathway was followed (OR=0.12; 95%CI=0.042 to 0.349; p<0.0001). CONCLUSIONS: The use of non-invasive blood tests for liver fibrosis to stratify patients with NAFLD improves the detection of cases of advanced fibrosis and cirrhosis and reduces unnecessary referrals to secondary care of patients with lesser degrees of liver fibrosis. This strategy improves resource use and benefits patients. LAY SUMMARY: Non-alcoholic fatty liver disease effects up to 30% of the population but only a minority of cases develop liver disease. Our study has shown that established blood tests can be used in primary care to stratify patients with fatty liver disease to reduce unnecessary referrals by 80% and improve the detection of cases of advanced fibrosis 5 fold and cirrhosis 3 fold

Role of Salicylic Acid in Combating Heat Stress in Plants : Insights into Modulation of Vital Processes

Peer reviewe

Large-scale IPM validation in whitefly (Bemisia tabaci)-prone cotton (Gossypium spp.) fields adjoining kinnow orchards

Whitefly [Bemisia tabaci (Gen)] is a serious sucking pest of cotton in the north zone of India. Cotton (Gossypium spp.) fields adjoining kinnow orchards used to have a quite higher incidence of whiteflies compared to the fields away from orchards. Therefore, the study was carried out at ICAR-National Centre for Integrated Pest Management, New Delhi during 2017–19 to implement integrated pest management (IPM) validation trial in cotton fields located adjoining the kinnow orchards in the village Nihalkhera of district Fazilka, Punjab in farmers’ participatory (FP). The IPM strategy consists of weed removal from orchards, timely sowing of recommended cotton hybrid, 4 foliar sprays of 2% potassium nitrate, use of azadirachtin 1500 ppm @5 ml/litre, conservation of natural enemies by avoidance of insecticides that are harmful (IOBC Class-4) to natural enemies and judicious use of safer pesticides (IOBC class1 and 2). The IPM adoption resulted in the successful management of whitefly and other sucking pests along with a two to three-fold increase in predator population compared to FP. IPM recorded a substantial reduction in the use of pesticide active ingredients (86%) and the number of sprays (58%) along with high parasitization (35.32–45.98%) of whitefly nymphs by Encarsia sp. IPM provided a significant increase in yield (23%), net return (57.5%) along with a high benefit cost (B:C) ratio of 2.65