Intrauterine growth retardation refers to a rate of growth of a fetus that is less than normal for the growth potential of a fetus (for that particular gestational age). As one of the leading causes of perinatal mortality and morbidity, intrauterine growth retardation has immense implications for the short term and long term growth of children. It is an important public health concern in the developing countries. Health statistics encompassing parameters for maternal and child health in the Indian subcontinent have shown improvement in the past few years but they are still far from perfect. Maternal health, education and empowerment bears a strong influence on perinatal outcomes including intrauterine growth retardation and should be the primary focus of any stratagem targeted at reducing the incidence of intrauterine growth retardation. A concerted liaison of various medical and social disciplines is imperative in this regard.

Objective: Thyroid storm is a rare life-threatening medical emergency. It is associated with high mortality (10 to 30%). Though there may be mild derangements in liver function tests (LFTs), acute liver failure (ALF) is infrequently reported and its pathophysiology is poorly understood. We hereby report a case of ALF in a patient with thyroid storm. Methods: A 41-year-old female with history of Graves disease (non-compliant with treatment) complicated by multiple episodes of thyroid storm and atrial fibrillation (Afib) presented with exertional dyspnea and productive cough. She was found to be in Afib with rapid ventricular rate and new-onset cardiomyopathy (left ventricular ejection fraction of <20%). She was noted to have a large, nontender thyroid gland with bruit; thyroid function tests were consistent with uncontrolled hyperthyroidism. Results: Two days after initiating treatment with methimazole and propranolol, she became increasingly lethargic, confused, and developed asterixis and icterus. LFTs were consistent with ALF. Methimazole was stopped due to potential hepatotoxicity. Steroids, cholestyramine, and Lugol iodine were started for thyroid storm. Liver ultrasound showed heterogeneous liver texture consistent with acute inflammation. The patient subsequently improved with conservative management and control of thyroid storm. Once clinically stable, she underwent thyroidectomy as a definitive treatment of her Graves disease. Conclusion: The occurrence of ALF in patients with thyroid storm has rarely been reported in the literature and is associated with high mortality. Hyperthyroidism has been hypothesized to injure the liver through several mechanisms which we will discuss in this case report.

Barrett’s esophagus (BE) is a premalignant condition. The incidence of adenocarcinoma in BE has been reported to be between 0.1-3%. Dysplasia in BE is patchy and extensive biopsy sampling is labor intensive, low yield and does not eliminate the sampling error completely. Volumetric laser endomicroscopy (VLE) is expected to enable endoscopists to do targeted biopsy of dysplastic/cancerous lesions (not visible on white light endoscopy) among patients with BE. We reviewed 7 studies with a total of 62 subjects who had undergone VLE. Of 34 patients with available data, VLE correlated with histology in 17 subjects (50%). It missed the underlying diagnosis in one subject (2.9%). VLE led to inadvertent biopsy in 16 patients (47.1%), and led or would have led to upstaging of disease in 11 subjects (32.4%). In the entire cohort, the sensitivity, specificity, positive predictive value and negative predictive value (NPV) of VLE for diagnosis of dysplasia, buried Barrett’s or intramucosal carcinoma was 92.3%, 23.8%, 42.9% and 83.3%, respectively. High sensitivity and NPV can potentially help space out the surveillance intervals. Low specificity does lead to a high number of biopsies, which are likely less than non targeted biopsies. Volumetric laser endomicroscopy is a safe and sensitive test to identify mucosal lesions in patients with BE which are invisible under standard white light endoscopy.Abbreviations: BE: Barrett’s Esophagus; BB: Buried Barrett’s; EAC: Esophageal adenocarcinoma; EDS: Evans Dysplasia Score; EMR: Endoscopic Mucosal Resection; GERD: Gastro-esophageal reflux disease; HGD: High grade dysplasia; IMC: Intra-mucosal adenocarcinoma; LGD: Low grade dysplasia; NBI: Narrow Band Imaging; OCT-SI: Optical Coherence Tomography Scoring Index; RFA: Radiofrequency ablation; SGS: Sub-squamous glandular structures; VLE: Volumetric Laser Endomicroscopy; WLE: White Light Endoscopy.

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