Proxy War to Proxy Peace; Strategic Insights: v.2, issue 8 (August 2003)

This article appeared in Strategic Insights (August 2003), v.2 no.8During his visit to Kashmir on 18 April 2003, Indian Prime Minister Atal Behari Vajpayee made a new peace offer to Pakistan. Pakistan's Prime Minister Zaffarullah Khan Jamali responded to this offer by making a telephone call to Mr. Vajpayee on 20 April 2003, thereby setting in motion speculation on the possibility of high-level engagement between the two countries. During recent months, both sides have made positive moves toward a fresh rapprochement, including a set of India-centered confidence building measures undertaken by Pakistan, both countries restoring normal diplomatic ties, and also announcing restoration of air and land transportation links between the two countries. Furthermore, both sides have avoided indulging in heightened euphoria about an immediate start of bilateral dialogue, preferring a cautious and weighted approach with a better prospect of leading towards meaningful communication. Despite heightened expectations caused by the talk of talks between the two countries, the progress in that direction has been rather tardy. This Strategic Insight argues that Pakistan's political response to India's peace offer is a proxy response, and that the real stakeholders in Pakistan are still undecided on final contours of the Pakistan-India relationship

Emerging Reconciliation Amidst Continuing Military Impasse ; Strategic Insights, v. 1, issue 6 (August 2002)

This article appeared in Strategic Insights, v.1, issue 6 (August 2002). It appeared with a companion piece, Pakistan's Challenges and the Need for a Balanced Solution" by Brigadier Feroz Hassan Khan. Both pieces appeared under a header: India and Pakistan at the Precipice: Two ViewsHigh level U.S. political engagement during the last two months has resulted in a visible easing of tensions between India and Pakistan. During the visit of U.S. Deputy Secretary of State Richard Armitage to Pakistan on 6 June 2002, Pakistan's President Pervez Musharraf pledged to end cross-border infiltration from Pakistan into Indian-controlled Kashmir on a permanent basis. India responded with a series of diplomatic and military steps, and acknowledged that the level of cross-border incidents had decreased. Pakistan, however, dismissed the steps taken by India as merely "cosmetic." During his visit to India on 12 June, U.S. Secretary of Defense Donald Rumsfeld said that the United States would want to convert this initial positive movement into a virtuous cycle of mutually reinforcing actions that would reduce tensions and create the conditions for political dialogue between the two adversaries.Center on Contemporary Conflict;Department of National Security Affairs;Naval Postgraduate Schoo

Massive Hemolysis Causing Renal Failure in Acute Hepatitis E Infection

Abstract Acute viral hepatitis is usually a self-limiting illness. However, it can lead to complications that can be life-threatening, such as acute liver failure. Glucose 6 phosphate dehydrogenase (G6PD) deficiency in the setting of acute viral hepatitis can lead to a massive hemolysis, manifesting as acute kidney injury and markedly raised bilirubin levels; although cases are rare. Here, we report such a case. The patient had a viral hepatitis E infection and presented with kidney injury requiring dialysis. Examination showed very high mixed hyperbilirubinemia due to massive intravascular hemolysis. The patient experienced a long, protracted course of illness, requiring renal replacement therapy with other supportive management, which led to improvement over a period of four weeks. This case highlights the importance of recognizing associated hemolysis in a patient with viral hepatitis who presents with very high bilirubin levels or associated kidney injury. Such patients will require aggressive supportive care with prompt fluid and electrolyte management

Prognostic signifi cance of diff erentiating necrosis from fl uid collection on endoscopic ultrasound in patients with presumed isolated extrapancreatic necrosis

Abstract Background Extrapancreatic necrosis is diagnosed on computed tomography (CT) as extrapancreatic changes that are more than fat stranding; both fl uid collections and necrosis would have a similar appearance. Th e aim of this study was to determine the prognostic signifi cance of diff erentiating peripancreatic necrosis from fl uid collection on endoscopic ultrasound (EUS) in patients with presumed isolated extrapancreatic necrosis

Endoscopic management of splenic pseudocysts associated with acute and chronic pancreatitis

Background Splenic pseudocysts (SP) are a rare consequence of both acute and chronic pancreatitis. Surgery has been conventional treatment for SP and literature on role of endoscopic treatment is scant. In this study, we retrospectively evaluated SP clinical and radiological characteristics as well as the outcome following endoscopic drainage. Methods Retrospective analysis of SP patients seen at our unit from January 2002 to June 2015. All patients were treated with attempted endoscopic transpapillary drainage with a nasopancreatic drain or stent. Patients not responding underwent endoscopic ultrasound-guided transmural or percutaneous radiological drainage. Results Eleven patients with SP (all male; mean age: 40.5±8.8 years) were studied. Seven patients had chronic pancreatitis and 4 patients had SP following acute pancreatitis. Th e majority (10/11; 91%) had alcohol-related acute or chronic pancreatitis with one patient having coexistent pancreas divisum. Seven (64%) patients were treated successfully with transpapillary drainage only; one (9%) patient needed combined transpapillary and transmural drainage; and 3 (27%) patients needed surgery. Conclusion Endoscopic transpapillary drainage is an eff ective treatment for SP especially when it is not infected and with clear contents, and is associated with partial ductal disruption that can be bridged by an endoprosthesis

Online)

ABSTRACT Context Dieulafoy's lesion is an unusual cause of gastrointestinal bleeding with the most common location being the stomach. A periampullary location is rare for a bleeding Dieulafoy's lesion. Case report We present the case of a 52-year-old female who presented with intermittent painless melena. Her upper gastrointestinal endoscopy and colonoscopy were normal. She was a diagnostic challenge as no definite lesion could be identified on capsule endoscopy. However, as there was presence of fresh blood in the proximal jejunum, a push enteroscopy was performed which revealed the presence of fresh blood in the duodenum and proximal jejunum. But no bleeding lesion could be identified. A side view endoscopy was performed which revealed a bleeding periampullary Dieulafoy's lesion. Immediate hemostasis was achieved with an injection of adrenalin. Other episodes of bleeding occurred and the patient was finally treated surgically. Conclusion A periampullary Dieulafoy's lesion presenting with obscure gastrointestinal bleed is a diagnostic challenge and can be missed on capsule endoscopy

Efficacy and safety of carbon dioxide insufflation for brain protection for patients undergoing planned left-sided open heart valve surgery:protocol for a multicentre, placebo-controlled, blinded, randomised controlled trial (the CO2 Study)

Introduction: Brain injury is common following open heart valve surgery. Carbon dioxide insufflation (CDI) has been proposed to reduce the incidence of brain injury by reducing the number of air microemboli entering the bloodstream in surgery. The CO2 Study will evaluate the efficacy and safety of CDI in patients undergoing planned left-sided open heart valve surgery. Methods and analysis: The CO2 Study is a multicentre, blinded, placebo-controlled, randomised controlled trial. Seven-hundred and four patients aged 50 years and over undergoing planned left-sided heart valve surgery will be recruited to the study, from at least eight UK National Health Service hospitals, and randomised in a 1:1 ratio to receive CDI or medical air insufflation (placebo) in addition to standard de-airing. Insufflation will be delivered at a flow rate of 5 L/min from before the initiation of cardiopulmonary bypass until 10 min after cardiopulmonary bypass weaning. Participants will be followed up until 3 months post-surgery. The primary outcome is acute ischaemic brain injury within 10 days post-surgery based on new brain lesions identified with diffusion-weighted MRI or clinical evidence of permanent brain injury according to the current definition of stroke. Ethics and dissemination: The study was approved by the East Midlands–Nottingham 2 Research Ethics Committee in June 2020 and the Medicines and Healthcare products Regulatory Agency in May 2020. All participants will provide written informed consent prior to undertaking any study assessments. Consent will be obtained by the principal investigator or a delegated member of the research team who has been trained in the study and undergone Good Clinical Practice training. Results will be disseminated through peer-reviewed publications and presentations at national and international meetings. Study participants will be informed of results through study notifications and patient organisations. Trial registration number: ISRCTN30671536

Common variants in CLDN2 and MORC4 genes confer disease susceptibility in patients with chronic pancreatitis

A recent Genome-wide Association Study (GWAS) identified association with variants in X-linked CLDN2 and MORC4 and PRSS1-PRSS2 loci with Chronic Pancreatitis (CP) in North American patients of European ancestry. We selected 9 variants from the reported GWAS and replicated the association with CP in Indian patients by genotyping 1807 unrelated Indians of Indo-European ethnicity, including 519 patients with CP and 1288 controls. The etiology of CP was idiopathic in 83.62% and alcoholic in 16.38% of 519 patients. Our study confirmed a significant association of 2 variants in CLDN2 gene (rs4409525—OR 1.71, P = 1.38 x 10-09; rs12008279—OR 1.56, P = 1.53 x 10-04) and 2 variants in MORC4 gene (rs12688220—OR 1.72, P = 9.20 x 10-09; rs6622126—OR 1.75, P = 4.04x10-05) in Indian patients with CP. We also found significant association at PRSS1-PRSS2 locus (OR 0.60; P = 9.92 x 10-06) and SAMD12-TNFRSF11B (OR 0.49, 95% CI [0.31–0.78], P = 0.0027). A variant in the gene MORC4 (rs12688220) showed significant interaction with alcohol (OR for homozygous and heterozygous risk allele -14.62 and 1.51 respectively, P = 0.0068) suggesting gene-environment interaction. A combined analysis of the genes CLDN2 and MORC4 based on an effective risk allele score revealed a higher percentage of individuals homozygous for the risk allele in CP cases with 5.09 fold enhanced risk in individuals with 7 or more effective risk alleles compared with individuals with 3 or less risk alleles (P = 1.88 x 10-14). Genetic variants in CLDN2 and MORC4 genes were associated with CP in Indian patients