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Almost 10% of bleeding episodes are refractory to combination of vasoactive agent and endotherapy, and are associated with a mortality up to 50%. Severity of liver disease and high portal pressure are mainly responsible for it. TIPS cannot be used in these patients due to high MELD score. We aimed to evaluate the efficacy of self-expandable DE stents for control of refractory variceal bleeds in patients with ACLF. Acute-on-chronic liver failure patients (n = 88, mean age 47.3 ± 10.9 years) with refractory variceal bleeds received either DE stent (Gr. A, n = 35) or continued with repeat endotherapy and vasoactive drug (Gr.B, n = 53). Matching by propensity risk score (PRS) was done to avoid selection bias. Competing risk Cox regression analysis was done to identify event-specific, i.e., gastrointestinal bleed-related death. Majority (78.4%) of patients were alcoholic with MELD score of 45.9 ± 20.1. Control of initial bleeding was significantly more in the DE stent group as compared to controls in both pre-match (89 vs. 37%; p

Background and Aim There is limited data on predictors of acute kidney injury in acute on chronic liver failure. We developed a PIRO model (Predisposition, Injury, Response, Organ failure) for predicting acute kidney injury in a multicentric cohort of acute on chronic liver failure patients. Patients and Methods Data of 2360 patients from APASL-ACLF Research Consortium (AARC) was analysed. Multivariate logistic regression model (PIRO score) was developed from a derivation cohort (n=1363) which was validated in another prospective multicentric cohort of acute on chronic liver failure patients (n=997). Results Factors significant for P component were serum creatinine[(≥2 mg/dL)OR 4.52, 95% CI (3.67-5.30)], bilirubin [(

BACKGROUND: To study CT and MR findings in xanthogranulomatous cholecystitis (XGC). MATERIAL AND METHODS: Retrospective analysis of 30 histopathologically confirmed cases of XGC. Seventeen patients underwent CECT and 13 underwent MRI. The following features were studied – wall thickness, intramural nodules, pericholecystic stranding, wall thickness, THAD, fat in gallbladder wall, cholelithiasis, infiltration, biliary dilatation, lymph nodes, complications. RESULTS: The majority of cases (22/30) showed discontinuous mucosal lining. Discontinuous mucosal lining was seen in all cases with wall thickness >10 mm, 75% of cases with wall thickness between 3-10 mm and none in normal wall thickness (p=0.03). Diffuse wall thickening was seen in 23 cases, focal thickening in 3 and polypoidal wall thickening in 2 cases. Polypoidal thickening was seen in gallbladder carcinoma. Intramural nodules were present in 87.5% of cases with discontinuous mucosal lining. Pericholecystic stranding was seen in 19, biliary dilatation in 12, liver infiltration in 13 and fat in 7 cases. Lymphadenopathy was seen in 1 case with gallbladder carcinoma. Four cases showed a signal drop in the intramural nodules on chemical shift MRI. CONCLUSIONS: Discontinuous mucosal lining is evident in xanthogranulomatous cholecystitis. Diffuse wall thickening, intramural nodules, continuous or discontinuous mucosal lining and cholelithiasis may indicate XGC rather than gallbladder carcinoma. Based on correlation with pathophysiological findings, we conclude that discontinuous mucosal lining is not an unusual finding in cases of XGC. Advances in knowledge: Being aware of the radiological findings described in this article may be helpful in making preoperative radiological diagnosis of XGC. Mucosal lining may be continuous or discontinuous in XGC.

World Health Organization Global Status 2018 Report on alcohol and health states that global total alcohol per capita consumption has drastically risen from 2005 to 2016. Presence of inherited metabolic traits (MTs) such as diabetes, hypertension, and obesity predisposes to early and more severe liver damage, even with smaller quantity and shorter duration of exposure to alcohol. This editorial highlights the need for screening of individuals with either addiction of alcohol or alcoholic liver disease for personal and family history of diabetes, hypertension, obesity, and other MTs for risk stratification and specific interventions. Health education and awareness regarding deleterious effects of alcohol among those who have a personal or family history of MTs should be ensured.

Medical research is the only reliable way through which our insight can be focused towards the best practices in medicine. The Health Insurance Portability and Accountability Act define medical research as “a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.” Medical research is inevitable for ensuring high quality patient care.

Background: Rheumatoid Arthritis is associated with many extra-articular manifestations including cardiac abnormalities, which increases the risk of morbidity and premature death. Sub-clinical cardiac abnormalities occur many years before their clinically overt manifestations. The objective of the present study is to compare cardiac function abnormality in rheumatoid arthritis patients and healthy controls by echocardiography and to determine its relation with duration of disease.Methods: A hospital based case control study was conducted at a tertiary care centre of northern India including 70 rheumatoid arthritis patients and 70 controls. All subjects were evaluated by Electrocardiography and Trans-thoracic Echocardiography to determine cardiac function abnormalities.Results: ECG abnormalities were detected in 30% of RA cases as compared to only 7.1% of controls. Most common ECG abnormality was LV diastolic dysfunction (p=0.001), followed by pericardial effusion. A weak positive correlation was found between duration of disease and IVRT (r=0.329, p=0.005) indicating worsening of cardiac function with increasing duration of disease.Conclusions: Echocardiographic abnormalities are fairly common among RA patients with LV diastolic dysfunction being most common. Cardiac abnormalities increase with duration and severity of disease.

Background: Humoral immune responses in cytomegalovirus (CMV) are not studied well. Pre-transplant CMV immunoglobulin G (IgG) antibody levels (Pre-Tx IgG) could influence the occurrence of post-transplant CMV infections. Objective: Correlation between pre-Tx IgG and post-Tx risk of acquiring CMV infection was investigated. Materials and Methods: A total of 146 liver Tx recipients, not on CMV prophylaxis, were included. Pre-Tx IgG in donor (D) and recipient (R) were estimated and all the recipients were followed up for 1 year for CMV infections. Results: D+ R+ serostatus was seen in 142 (97.3%) and D− R+ in 4 (2.7%). A total of 113 (77.4%) recipients had pre-Tx IgG of ≥250 AU/ml. Overall, post-Tx CMV infections were seen in 54 (36.9%) recipients. In 32 (59.2%) patients, CMV infection was seen during the 1st month after TX. Incidences of post-Tx CMV infection in recipients with pre-Tx IgG

The aim of this report is to discuss the results of percutaneous endobiliary radiofrequency ablation (RFA) combined with balloon-sweep technique in restoring the patency of occluded self-expandable metallic stents (SEMS) secondary to tumor infiltration. A total of eight patients underwent endobiliary RFA for reopening of occluded SEMS at our institute. After endobiliary RFA, all patients showed restoration of stent patency. After a median follow-up of 6.5 months, four patients had succumbed to the underlying disease at 3, 4, 6, and 7 months. Two of these required reinterventions at 2 and 5 months. One patient died of sepsis and aspiration pneumonia at 3 months. Of the remaining three patients, two required re-intervention after 2 months, while the other remained asymptomatic. The mean duration of stent patency after the first session of RFA was 4 ± 2.1 months, which was comparable to the primary patency of these stents (4.2 months). Our experience suggests that endobiliary RFA with balloon sweep is a safe and useful technique for re-establishing the patency of occluded SEMS.

The extent of fibrosis is a major determinant of the clinical outcome in patients with chronic liver diseases. We undertook this study to explore the degree of fibrosis in baseline liver biopsies to predict clinical outcomes in chronic hepatitis B (CHB) patients. Fibrosis quantification was done by image analysis on Masson's trichrome-stained sections and correlated with clinical and biochemical parameters, liver stiffness and hepatic vein pressure gradient (n = 96). Follow-up information collected related to clinical outcome. A total of 964 cases was analyzed. Median quantitative fibrosis (QF) was 3.7% (interquartile range, 1.6%-9.7%) with substantial variation in various stages. Median QF was F0, 1% (0.7%-1.65%); F1, 3.03% (2.07%-4.0%); F2, 7.1% (5.6%-8.7%); F3, 12.7% (10.15%-16.7%); F4, 26.9% (20.3%-36.4%). QF positively correlated with METAVIR staging, liver stiffness measurement, and hepatic vein pressure gradient. Eighty-nine cases developed liver-related events: decompensation, hepatocellular carcinoma, liver transplantation and death. Cox regression analysis after adjusting for METAVIR staging-QF, albumin, and AST for composite events; QF and albumin for decompensation; and only QF for hepatocellular carcinoma-were found to be significant predictors of clinical outcomes. QF categorized into five stages: QF1, 0%-5%; QF2, 5.1%-10%; QF3, 10.1%-15%; QF4, 15.1%-20%; QF5, >20.1%. In patients with advanced stages of QF, probability of event-free survival found to be low. Quantitative fibrosis in baseline liver biopsy predicts progression of the disease and disease outcome in CHB patients. QF defines the probability of event-free survival in CHB cases.

Background and aims Carvedilol is effective in the primary prophylaxis for large oesophageal varices. We investigated its use in preventing progression of small to large oesophageal varices. Methods Consecutive cirrhotics with small oesophageal varices were prospectively randomised to either carvedilol (n=70) or placebo (n=70) and followed up for a minimum of 24 months. Endoscopy was done at baseline and six monthly intervals. Hepatic vein pressure gradient (HVPG) was measured at baseline and at 12 months. The primary endpoint was development of large varices. Results Baseline characteristics in two groups were comparable. The predominant aetiology of cirrhosis was non-alcoholic fatty liver disease in both the groups. The mean dose of carvedilol administered was 12±1.67 mg/day and the target heart rate achieved was 58±3 bpm. A higher proportion of patients in carvedilol group had non-progression to large varices than placebo (79.4% vs 61.4%; p=0.04); the mean time of non-progression to large varices was 20.8 months (95% CI 19.4 to 22.4) in carvedilol group and 18.7 months (95% CI 17.1 to 20.4) in placebo group (p=0.04). There was a modest reduction of HVPG at 1 year in carvedilol group (−8.64%) compared with placebo (+0.33%) (p=0.22). None of the patients in either group died of variceal bleeding or liver-related causes. No major adverse events were observed in either group. Conclusions Carvedilol is safe and effective in delaying the progression of small to large oesophageal varices in patients with cirrhosis. Trial registration number NCT01196507; post-results.

The article provides a comprehensive review of the current situation of micronutrient deficiencies (MND) among children in India. It provides information of common MND with its prevalence and geographical distribution. The review includes a nationally representative survey, nutritional reports and studies conducted in the different regions of India. Iron deficiency anaemia, Vitamin A deficiency (VAD) and iodine deficiency disorder are found to be the most prevalent MND among children. The prevalence of anaemia ranging from 21% to 59.2%, VAD reported as a maximum of 10.2% in one of the recent Indian studies while the total goitre rate of highest as 21.9%. With the implementation of various nutritional programs for children, these deficiencies are found to be significant mainly among pre-school children. The recommendation on strengthening existing nutritional health programmes with some new intervention strategies to improve the micronutrient status among children and to reduce the economic burden to MND in the coming years.

This article reviews the ongoing initiatives to prevent and control cardiovascular diseases (CVDs) and non-communicable diseases (NCDs) in India and analyses the role of primary health care (PHC) system. The authors note that in last 2 decades, there has been increasing policy recognition of the challenges posed by CVDs and NCDs in India. The review of ongoing government health program in India indicate that while the interventions to tackle CVDs and NCD have also been launched and scaled up, a majority of these initiatives continue to be delivered through district or sub-district levels. Though, there has been plans, the scale up through PHC system is at early stage only. There is sufficient scientific evidence that the effective prevention and control of CVDs need accessible health services and a series of public health interventions through strengthened PHC system. There are learnings from COVID-19 pandemic response in India (in areas such as private sector engagement, effective enforcement of health regulation, community engagement and the use of tele-consultations), which can be useful. The authors conclude that a strengthened and well-functioning PHC system can ensure increased access to CVD and NCD services. As India plans to scale up ongoing health programs and launch a few new initiatives, the learnings from the past, documented in this paper, could be useful. These steps would help India to accelerate progress towards universal health coverage.

Background: Pregnancy-induced hypertension is one of the major health problems leading to maternal mortality. Globally, one woman dies every 7 min due to hypertensive disorders of pregnancy (HDOP). Pre-eclampsia and eclampsia contribute majority of maternal, perinatal morbidity and mortality. The objective of this meta-analysis was to estimate the pooled prevalence of pregnancy-induced hypertension in India. Methods: A systematic search was done through PubMed, Google Scholar, MEDLINE, EMBASE and Scopus for studies conducted on HDOP. All studies that met inclusion criteria published till January 2020 were included and analysed. The analysis was done using STATA 20.0 software (STATA Version 20.0 is sufficient). The pooled prevalence of hypertension in pregnancy was estimated using both mixed-effects and random-effects models. Results: A total of 18 studies with 92,220 study participants (pregnant women) were included in this review. The estimated overall pooled prevalence of HDOP in India was found to be 11% (95% confidence interval, 5%–17%). Most of the included studies were cross sectional and from the southern zone of India. Conclusions: The overall pooled estimate shows high prevalence, i.e., 1 out of 11 women suffers from pregnancy-induced hypertension. High prevalence of hypertension in the study population demands the attention of policymakers and healthcare professionals. Better implementation of early screening of hypertension during pregnancy should be undertaken.

Background: Trastuzumab is now the standard of care in patients with Her-2 positive breast cancer. Despite its availability, high cost of treatment of trastuzumab makes it out of reach for many patients. This study analyses access to trastuzumab and identified potential barriers to its use in a large tertiary care hospital in northern India.Methods: This is a cross- sectional study of all the Her-2 positive breast cancer patients diagnosed and treated in our institute in 2018. These patients were investigated to look into various socio-economic factors for acceptance or non-acceptance of trastuzumab by using a predesigned questionnaire. Chi square test or Fishers exact test was applied.Results: Out of 310 diagnosed cases of carcinoma breast 52 (16%) patients were Her-2 positive. The majority of the trastuzumab recipients belonged to upper/middle socioeconomic status as compared to the non-recipient group (75% vs. 34.4%, P=0.004). Most of the receiver were well-educated (75% vs. 28.2%, P= 0.0009) and belonged to the high-income strata (55% vs. 37.5%, P= 0.22). It was found that the treatment of maximum (84.6%) Her-2 positive patients were met by out- of- pocket expenditure (OOPE) and 71.9% of the patients cited financial issues as the main cause of not taking the drug.Conclusions: The patient’s socioeconomic class and their education level significantly influenced the usage of the drug. Improving patient education as well as the implementation of the government health scheme can improve the availability and usage of this drug.

Introduction: In the recent years, ethephon, 2-chloroethylphosphonic acid, is one of the most commonly used plant growth regulators. At present, it is being used on fruits, vegetables, and cereals for promoting pre- and post-harvest ripening. The effect of artificial ripening has become questionable because of various health-related issues. This study was conducted to note the morphology of liver after ethephon administration as it is the site where chemicals undergo first pass metabolism and probably will be affected by ethephon. Materials and Methods: Adult Wistar albino rats were divided into experimental and control groups (10 each). Ethephon was administered at a dose of 200 mg/kg/day by a gavage tube in the experimental rats for 14 days. The animals were sacrificed within 24 h of the last dose; liver was dissected and processed for light microscopy. Hematoxylin and eosin-stained sections were studied using an image-pro express analyzer. The data obtained from control and experimental groups were statistically analyzed. Results: In the experimental rats, the body weight was found to be significantly decreased. The orderly arrangement of hepatocytes was disrupted and was replaced by blood-filled sinusoids. At sites, hepatocytes appeared to be degenerated. Councilman bodies with pyknotic nuclei and inflammatory infiltrations were seen. The population per unit area of the hepatocytes and Kupffer cells was 29.53 ± 10.65 versus 44.18 ± 10.31 and 25.12 ± 4.41versus 13.05 ± 6.5 in experimental and control groups, respectively. The decrease of hepatocytes and increase of Kupffer cells were found to be statistically significant. Conclusions: The observations in the liver are probably indicative of degenerative changes associated with ethephon. Hence, we can conclude that this plant growth regulator, Fruit and Vegetable Ripener, has hepatotoxic potential. General awareness and regarding the use of such plant growth regulators is must to reduce the intake.

Introduction: Narrowband ultraviolet B phototherapy (NBUVB) is safe and effective treatment for psoriasis. Vitamin D plays an important role in pathogenesis of psoriasis. It is known that psoriasis patients have low serum 25(OH)D levels, which increase after NBUVB. We assessed serum 25(OH)D levels, its correlation with Psoriasis Area and Severity Index (PASI), and the effect of NBUVB on 25(OH)D levels among Indian psoriasis patients. Materials and Methods: A prospective study comprising 30 adults with psoriasis with no major comorbidities (PASI > 10 and off-therapy >4 weeks) was conducted. PASI was estimated at baseline among patients and repeated after receiving 12 weeks of NBUVB therapy. Thirty age and gender-matched healthy controls were recruited to compare 25(OH)D levels at baseline and at 12 weeks. Patient demographic parameters, treatment dose, duration, side effects, and its impact on 25(OH)D levels and PASI were serially evaluated. Results: A total of 30 patients presenting with psoriasis and 30 healthy controls were enrolled in the study. Mean baseline PASI (M: F =19:11) among patients with mean age 36.8 (±7.7) years was 20.5 (±6.3) and all patients were either 25(OH)D deficient (n = 14) or insufficient (n = 16). Their baseline 25(OH)D levels were significantly lower than controls (25.93 nmol/L vs 47.54 nmol/L; P < 0.001). After NBUVB therapy (average cumulative dose 20.76 ± 7.1 J/cm2; average treatment sessions 32.57 ± 1.9), there was a significant improvement in PASI as well as 25(OH)D (P < 0.05). There was no correlation between the mean improvement in PASI and 25(OH)D after 12 weeks of therapy. Twelve (40%) patients had therapy-related side effects [pruritus (n = 8), erythema (n = 4)], none had major side effects. Conclusion: Improvement in PASI and serum 25(OH)D levels after NBUVB in psoriasis is significant but poorly correlated with each other. Vitamin D may not be the lone mediator of the therapeutic effects of NBUVB on psoriasis.

Background & Aims Spontaneous bacterial peritonitis (SBP), in the presence of bacterial resistance or failure of third generation cephalosporins (3rd GC) has poor outcome. Empirical antibiotic(s) options are limited in these scenarios. Methods Consecutive cirrhotics with SBP because of hospital acquired SBP (>48 h of admission), microbial resistance or non-response (no resolution of SBP at 48 h) were randomized to Cefepime (n = 88) or Imipenem (n = 87) plus standard medical therapy. We assessed for ‘response at 48 h’ (reduction in ascitic fluid absolute neutrophil count (ANC) by >25% at 48 h), resolution of SBP (

Introduction: National Family Health Survey (NFHS)-3 documented that nearly 57 million children are undernourished in India, which is one-third of the world's share. We planned a study to identify the prevalence of severe acute malnutrition (SAM) among children aged

Background: Literature regarding safe dose of carvedilol is limited and also safe dose across different child classes of chronic liver disease is not very clear. Aim: We aimed primarily to study, the effect of reasonably safe dose (12.5 mg) of carvedilol in acute reduction of portal pressure and compared it with chronic reduction of portal pressure, after Original Research Article Wani et al.; BJMMR, 7(5): 355-368, 2015; Article no.BJMMR.2015.342 356 proper optimization of dose of carvedilol. Second aim of our study was to define predictors of response for acute and chronic reduction of portal pressure and to assess difference in dose tolerated and response across different child class on chronic basis. Methods: One hundred two consecutive patients of cirrhosis of liver with significant portal hypertension were included and hepatic venous pressure gradient was measured at the base line and after 90 minutes of administration of 12.5 mg carvedilol. After proper dose optimization of carvedilol, hepatic venous pressure gradient was again measured after 3 months to assess the chronic response. Results: The mean age of study population was 58.3±6.6 years. A total of 42.2%, 31.9% and 26.6% patients had child class A, child class B and Child class C cirrhosis, respectively. Mean pre-drug hepatic venous pressure gradient was 16.75±2.12 mmHg which dropped to 13.07±2.32 mmHg after 90 minutes of administration of 12.5 mg of carvedilol. The mean drop of hepatic venous pressure gradient was 4.5±2.2 mmHg and 2.4±1.9 mmHg among responders and non-responders, respectively. Overall, 51% showed acute response while 49% were nonresponders. Low cardiac output and high mean arterial pressure were significantly predicting the acute response, while, low baseline cardiac output was found as an independent predictor. After dose optimization, number of responders increased from 52 to 62. Mean dose of carvedilol was higher in non–responders as compared to responders, though statistically insignificant (p>0.05). Mean reduction of hepatic venous pressure gradient from baseline and after 3 months was 5.5±1.7 mmHg and 2.8±1.6 mmHg among responders and non responders on chronic basis, respectively (p

Extrahepatic portal vein obstruction is a vascular disorder of liver, which results in obstruction and cavernomatous transformation of portal vein with or without the involvement of intrahepatic portal vein, splenic vein, or superior mesenteric vein. Portal vein obstruction due to chronic liver disease, neoplasm, or postsurgery is a separate entity and is not the same as extrahepatic portal vein obstruction. Patients with extrahepatic portal vein obstruction are generally young and belong mostly to Asian countries. It is therefore very important to define portal vein thrombosis as acute or chronic from management point of view. Portal vein thrombosis in certain situations such as liver transplant and postsurgical/liver transplant period is an evolving area and needs extensive research. There is a need for a new classification, which includes all areas of the entity. In the current review, the most recent literature of extrahepatic portal vein obstruction is reviewed and summarized.

Background: Central venous cannulation (CVC) is frequently required during the management of patients with liver disease with deranged conventional coagulation parameters (CCP). Since CVC is known to be associated with vascular complications, it is standard practice to transfuse Fresh-Frozen Plasma or platelets to correct CCP. These CCP may not reflect true coagulopathy in liver disease. Additionally CVC when performed under ultrasound guidance (USG-CVC) in itself reduces the incidence of complications. Aim: To assess the safety of USG-CVC and to evaluate the incidence of complications among liver disease patients with coagulopathy. Setting and Design: An audit of all USG-CVCs was performed among adult patients with liver disease in a tertiary care center. Materials and Methods: Data was collected for all the adult patients (18-60 years) of either gender suffering from liver disease who had required USG-CVC. Univariate and multivariate regression analysis was done to identify possible risk factors for complications. Results: The mean age of the patients was 42.1 ± 11.6 years. Mean international normalized ratio was 2.17 ± 1.16 whereas median platelet count was 149.5 (range, 12-683) × 10 9 /L. No major vascular or non-vascular complications were recorded in our patients. Overall incidence of minor vascular complications was 18.6%, of which 13% had significant ooze, 10.3% had hematoma formation and 4.7% had both hematoma and ooze. Arterial puncture and multiple attempts were independent risk factors for superficial hematoma formation whereas low platelet count and presence of ascites were independent risk factors for significant oozing. Conclusion: Ultrasound guidance -CVC in liver disease patients with deranged coagulation is a safe and highly successful modality.

Childhood obesity has reached epidemic levels in developed as well as in developing countries. Overweight and obesity in childhood are known to have significant impact on both physical and psychological health. Overweight and obese children are likely to stay obese into adulthood and more likely to develop non-communicable diseases like diabetes and cardiovascular diseases at a younger age. The mechanism of obesity development is not fully understood and it is believed to be a disorder with multiple causes. Environmental factors, lifestyle preferences, and cultural environment play pivotal roles in the rising prevalence of obesity worldwide. In general, overweight and obesity are assumed to be the results of an increase in caloric and fat intake. On the other hand, there are supporting evidence that excessive sugar intake by soft drink, increased portion size, and steady decline in physical activity have been playing major roles in the rising rates of obesity all around the world. Childhood obesity can profoundly affect children's physical health, social, and emotional well-being, and self esteem. It is also associated with poor academic performance and a lower quality of life experienced by the child. Many co-morbid conditions like metabolic, cardiovascular, orthopedic, neurological, hepatic, pulmonary, and renal disorders are also seen in association with childhood obesity.

Management of acute kidney injury (AKI) in cirrhotics has undergone a paradigm change. We evaluated the impact of AKI persistence at 48 h on outcome in patients with acute on chronic liver failure (ACLF). Consecutive patients with ACLF (n = 373) were prospectively followed. AKI was defined as increase in serum creatinine of 0.3 mg/dl or 1.5- to 2-fold from baseline. Persistent AKI was defined as nonresponsive AKI at 48 h with respect to admission serum creatinine. AKI at admission was present in 177 (47.5 %) patients. At 48 h, 73 % patients had persistent AKI and 27 % had responsive AKI. High Model for End-Stage Liver Disease (MELD) (≥26) [p, odds ratio (OR), 95 % confidence interval (CI)] [

BackgroundThe coronavirus pandemic (COVID-19) control has now become a critical issue for public health. Many ecological factors are proven to influence the transmission and survival of the virus. In this study, we aim to determine the association of different climate factors with the spread and mortality due to COVID-19.MethodsThe climate indicators included in the study were duration of sunshine, average minimum temperature and average maximum temperature, with cumulative confirmed cases, deceased and recovered cases. The data was performed for 138 different countries of the world, between January 2020 to May 2020. Both univariate and multivariate was performed for cumulative and month-wise analysis using SPSS software.ResultsThe average maximum temperature, and sunshine duration was significantly associated with COVID-19 confirmed cases, deceased and recovered. For every one degree increase in mean average temperature, the confirmed, deceased and recovered cases decreased by 2047(p=0.03), 157(p=0.016), 743 (p=0.005) individuals. The association remained significant even after adjusting for environmental such as sunshine duration as well as non-environmental variables. Average sunshine duration was inveserly correlated with increase in daily new cases (ρ= -2261) and deaths (ρ= -0.2985).ConclusionHigher average temperature and longer sunshine duration was strongly associated with COVID-19 cases and deaths in 138 countries. Hence the temperature is an important factor in SARS CoV-2 survival and this study will help in formulating better preventive measures to combat COVID-19 based on their climatic conditions.

Background Menstruation is a normal physiological process among reproductive age group females. Although some of them show the abnormal menstrual pattern, which is influenced by several factors, including sociodemographic status, psychosocial stress, improper sleep level, etc. The identification of these risk factors associated with abnormal menstrual patterns may permit risk stratification among adolescent girls. This study was planned to determine various factors which depict menstrual cycle pattern among adolescent girls in urban India. Materials and methods A school-based case-control study was carried out in urban India from May to December 2019. Urban locality and schools were randomly selected, and data were collected in two phases. Adolescent girls in the age group of 10-19 years studying in government and private (both Hindi medium and English medium) schools of urban India were screened for the abnormal menstrual pattern. Equal numbers of age-matched controls were also enrolled. Data were collected with the help of self-administered predesigned pretested semi-structured questionnaire. Chi-square test, Fisher's exact test, unpaired t-test, and McNemar tests were used to analyze data using SPSS version 23.0. Results A total of 100 cases and 100 age-matched controls (mean age 14.8 ± 1.5 years) were included in the study, almost half of the cases and controls have normative menarche. Improper sleep patterns increased stress levels, and low education status of mothers show statistically significant (P = 0.047) association with abnormal menstrual patterns. Conclusion More stress, improper sleep levels, and low education status of mothers among school-going adolescent girls were strongly associated with abnormal menstrual patterns with more symptoms during menstruation.

Background: Globally, ocular morbidities are one of the most underdiagnosed, underreported, and undertreated public health concern. Among estimated 39 billion blind in world, India shares major proportions, with majority of them living in rural population. In India, religious festivals like Kumbh Mela that involve mass gatherings are mainly attended by middle and elderly population who are usually susceptible to various ocular diseases. Therefore, we analyzed the data of our eye camp to document pattern and magnitude of ocular morbidities among pilgrims attending a mega religious festive event. Methods: In a cross-sectional, descriptive study, we included all those patients who participated in a mega eye camp “Netrakumbh” from January to March 2019 at Kumbh Mela, Prayagraj, India and were attended by voluntary ophthalmologist from All India Institute of Medical Sciences, Rishikesh. Presenting chief complaints and detailed history were collected from all participants. All patients underwent comprehensive eye examination including visual acuity, slit lamp biomicroscopic examination, tonometry, etc., Data were compiled and analyzed utilizing SPSS 22.0. Results: A total of 47142 eyes of 23571 persons of all age groups (range 5 years to 70 years) with approximate equal gender distribution attending the mega eye camp were examined. The most common ocular morbidity noticed after ocular examination was refractive error with underlying cause majorly as presbyopia, followed by cataract, after cataract, convergence insufficiency, lids, and adnexal disease, etc. Conclusions: This study highlights the changing pattern of common ocular morbidities presently among middle and elderly populations in developing countries like India.

Background: Awareness about disease among tuberculosis (TB) patients plays a crucial role toward successfully achieving targets for control, prevention, and their relatives treatment adherence and is not well studied or documented. This study sought to explore the awareness and perceptions of TB patients in a tertiary care centre in northern India. Methods: This was an exploratory study conducted between January and December 2016 among 1,000 pulmonary TB patients and their relatives. Structured and validated interview schedule was used to assess participants knowledge and perception regarding TB, which comprised of 41 questions. Ethical clearance was taken and written informed consent was obtained from each study participants. Data analysis was done using SPSS 22.0 version. Results: A total of 1,000 study participants (mean age 40.2 ± 9.6 years, females 51%) were enrolled. More than two-third of the study participants were from Uttarakhand. Study participants had highest knowledge score (61.85%) regarding sign and symptoms, followed by scores in the aspect of prevention and treatment of TB (52.7%). However, a lower proportion (51.5%) knew about its causation. Overall knowledge score was 54.8%. Around half of the subjects (49.7%) disagreed that TB is a major health problem. Conclusions: Regardless of non-satisfactory knowledge of participants, their perception regarding TB was better. As to the associated factors, we found that participants' knowledge had significant association with religion, educational status, occupation, family income per month, type of family, and source of health information. Although there was insignificant difference between family monthly incomes, source of health information and perception regarding TB.

Context: Vital parameters including blood oxygen level, respiratory rate, pulse rate, and body temperature are crucial for triaging patients to appropriate medical care. Advances in remote health monitoring system and wearable health devices have created a new horizon for delivery of efficient health care from a distance. Materials and Methods: This diagnostic validation study included patients attending the outpatient department of the institute. The accuracy of device under study was compared against the gold standard patient monitoring systems used in intensive care units. Statistical Analysis: The statistical analysis involved computation of intraclass correlation coefficient. Bland–Altman graphs with limits of agreement were plotted to assess agreement between methods. P 0.9) was noted between the two devices for all the investigated parameters with significant P value (

There is limited data on proportion of Bitot's spots (BS), which could reappear after receiving mega dose of Vitamin A (MDVA), and their complete resolution. A prospective, community-based, cohort study with 12 months follow-up was conducted among children (1-5 years) with BS at a district from North India. On diagnosis, 200,000 IU of vitamin A was administered on the same day, then after 4 weeks and subsequently after 6 months. Out of 262 children with BS, 157 (59.9%, 95% CI: 54.1-65.9) children had shown resolution of BS after the MDVA supplementation. Out of 157 children, 97 (61.8%, 95% CI: 54.2-69.4) had reappearance of BS after complete resolution. Kaplan-Meir analysis found that median duration of reappearance of BS was 5 months (95% CI: 3.8-6.2) after their complete resolution. The reappearance of BS after administration of two MDVA within 12 months suggests that children with possibly adequate serum retinol level status may have reappearance of BS.

ObjectiveIodine is an essential micronutrient needed for the production of thyroid hormones. Pregnant mothers who are deficient in iodine provide less iodine to the fetal thyroid. This results in low production of thyroid hormones by the fetal thyroid, thereby leading to compromised mental and physical development of the fetus. The current study aimed to assess the current status of iodine nutrition among pregnant mothers in Himachal Pradesh, India, a known endemic region for iodine deficiency.DesignThree districts, namely Kangra, Kullu and Solan, were selected.SettingIn each district, thirty clusters (villages) were identified by utilizing the population-proportional-to-size cluster sampling methodology. In each cluster, seventeen pregnant mothers attending the antenatal clinics were included.SubjectsA total of 1711 pregnant mothers (647 from Kangra, 551 from Kullu and 513 from Solan) were studied. Clinical examination of the thyroid of each pregnant mother was conducted. Spot urine samples were collected from ten pregnant mothers in each cluster. Similarly, salt samples were collected from eleven pregnant mothers in each cluster.ResultsTotal goitre rate was 42·2 % (Kangra), 42·0 % (Kullu) and 19·9 % (Solan). The median urinary iodine concentration was 200 μg/l (Kangra), 149 μg/l (Kullu) and 130 μg/l (Solan). The percentage of pregnant mothers consuming adequately iodized salt (iodine content of 15 ppm and more) was found to be 68·3 % (Kangra), 60·3 % (Kullu) and 48·5 % (Solan).ConclusionPregnant mothers in Kullu and Solan districts had iodine deficiency as indicated by a median urinary iodine concentration less than 150 μg/l.

Objectives: To study the difference in the prevalence of hypertension and associated risk factors in urban and rural populations and the association of hypertension with various determinants. Materials and Methods: A community-based cross-sectional study was conducted in 48 villages and 15 urban wards of Jabalpur District of Central India. Nine hundred and thirty-nine individuals aged 20 years and above (624 from rural areas and 315 from urban areas) were included in the study. The prevalence of hypertension and associated cardiovascular risk factors was assessed in the urban and rural populations. A pretested questionnaire was used to collect data on socio-demographic, behavioral, and dietary factors. Anthropometric measurements of weight, height, waist and hip circumference, and blood pressure measurements were taken using the standard methodology. The glucose oxidase-peroxidase and cholesterol oxidase-cholesterol peroxidase methods were used to measure plasma glucose and serum cholesterol, respectively. Bivariate analysis was followed by multivariate analysis to detect the odds of getting hypertension with various risk factors for the urban and rural populations separately. Hypertension was defined as per Joint National Committee (JNC) - VII criteria. Results: The response rate was 97%. Overall prevalence of hypertension was 17%, with 21.4% in the urban population and 14.8% in the rural population. Significantly higher mean values of weight, height, body mass index (BMI), hip circumference (HC), waist circumference (WC), waist hip ratio (WHR), systolic blood pressure (SBP), fasting blood sugar (FBS), and serum cholesterol levels were mapped in the urban population in comparison with the rural population. Multivariate logistic regression analysis identified increasing age, parental history of hypertension, tobacco smoking, tobacco chewing, physical inactivity, high estimated per capita salt consumption, and BMI ≥27.5 kg/m 2 as independent predictors for hypertension in the urban population, while in the rural population, increasing age, physical inactivity, central obesity, tobacco chewing and tobacco smoking were independent predictors for hypertension. Conclusion: The prevalence of hypertension and other cardiovascular risk factors was high in both urban and rural communities. Therefore, there is a need for comprehensive health promotion programs to encourage lifestyle modification.

Familial aggregation of metabolic traits with fatty liver disease is well documented. However, there is scarcity of data regarding such association with non-alcoholic steatohepatitis (NASH)-related cirrhosis. This study was aimed to explore the association of family history of metabolic traits with severity of cirrhosis.In a cross-sectional study, all consecutive patients with NASH-related cirrhosis presenting to our tertiary care centre were included. Family history, personal history, demographic characteristics, medical history, anthropometric measurements and laboratory data were recorded.Of the 1133 cirrhotics (68.1% males, age 51.4±10.9 years); 779 (68.8%) had family history for metabolic traits. These patients had lower age at diagnosis (45.4±10.6 vs 49.6±11.2 years), higher Child-Turcotte-Pugh (CTP) score (7.8±1.9 vs 6.6±1.5), higher model for end stage liver disease (MELD) score (12.9±6.1 vs 10.9±4.1) and more incidence of decompensation in the form of ascites (46.3% vs 25.7%), jaundice (12.1% vs 6.2%) and hepatic encephalopathy (26.1% vs 11.0%). Patients with family and personal history of metabolic traits, had an increased risk of an early diagnosis of cirrhosis at45 years of age (OR: 3.1, 95% CI 2.1-4.4), CTP≥10 (OR: 4.6, 95% CI 2.3-9.1), MELD15 (OR: 6.6, 95% CI 3.8-11.5) with ≥1 features of decompensation (OR: 4.2, 95% CI 2.9-6.1). Family history of diabetes alone, also had higher risk of cirrhosis with MELD15 (OR: 4.3, 95% CI 2.4-5.3, P.001).Family and personal history of metabolic traits are associated with early age at diagnosis of cirrhosis with more severity and decompensation and so, has a prognostic importance in NASH-related cirrhotics.

To determine the association of platelets with hepatocellular carcinoma (HCC) growth and its metastasis. We examined platelets, laboratory, and radiological data of consecutive 420 HCC and 1008 cirrhosis cases. Follow-up information of platelet count in cirrhosis to HCC, pre- to post-therapy, and post-therapy to HCC outcome was analyzed. Cytokine profiling was performed in HCC and cirrhosis (n = 10 each). On the basis of imaging, HCC was divided into six subgroups. Cytosmears of HCC were assessed for platelet clustering around tumor cells. An in vitro Matrigel invasion assay was performed on human HCC cell lines using graded concentration of platelets. Baseline platelet numbers and platelet/lymphocyte ratios (PLRs) were significantly higher (p < 0.001) in HCC than cirrhosis. IL-1, IL-6, FGF, G-CSF, thrombopoietin, and VEGF were higher in HCC than cirrhosis. Platelet counts were increased after HCC conversion of cirrhosis (p < 0.001) and decreased (p < 0.001) after therapy. Platelets and PLR in recurrence cases were higher than in responders at baseline. AFP, PIVKAII, platelets, and PLR increase (p < 0.001 each) with advancement in HCC growth. Multivariate analysis showed platelets (p = 0.002), PLR (p = 0.004), and AFP (p < 0.001) associated with distant metastasis. Platelet clustering seen in 75.7% of HCC group 3, 45% in group 2, and 12.5% in group 1 cases (p < 0.001). Invaded cells in Matrigel assay positively correlated with platelet concentration. Platelets can contribute to the development, growth, invasion, and metastasis of HCC. Rising platelet count after HCC therapy is indicative of incomplete response or recurrence.

Objective: To investigate dual-energy spectral CT in characterization of hepatocellular Carcinoma (HCC) in patients with chronic liver disease. Methods: Dynamic computed tomography (CT) was performed in 3600 patients (2879 males; 721 females, mean age 50.9 ± 11.9 years) with working clinical diagnosis of liver cirrhosis for hepatocellular carcinoma screening and other clinical indications. The study was conducted over a period of 3 years. During dynamic CT scanning, spectral (monochromatic) and routine (polychromatic) CT acquisitions were obtained on a single tube, dual energy, 64 slice multi-detector CT scanner. Imaging findings were studied on routine CT. On the basis of routine CT findings, indeterminate lesions (lesions not showing characteristic hypervascularity followed by washout on dynamic routine CT scan) that were referred for biopsy or surgery were segregated. A retrospective blinded review of the lesions, acquired by the spectral CT acquisitions was done with the help of gem stone imaging (GSI) software to characterize these lesions. All the above lesions were analyzed qualitatively in the arterial phase for lesion conspicuity as well as quantitatively using the monochromatic data sets and nodule Iodine concentration on material density maps, respectively. This data was studied with respect to predictability of HCC using the spectral CT technique. Iodine density of the lesion, surrounding liver parenchyma, and lesion to liver parenchyma ratio (LLR) were derived and statistically analyzed. Histopathology of the lesion in question was treated as gold standard for analysis. Results: It was observed via statistical analysis that the value of iodine density of the lesion on material density sets of ≥29.5 mg/dl, enabled a discriminatory power of 86.5%, sensitivity of 90.5% with 95% confidence Interval (CI) (69.2–98.8%) and specificity of 81.2% with 95% Confidence Interval (54.4–95.9%) in predicting HCC. Qualitative assessment also showed higher lesion conspicuity with spectral CT image sets as compared to routine CT data. Conclusion: This study reveals that spectral imaging is an excellent qualitative as well as a quantitative tool for assessing and predicting hepatocellular carcinoma in cirrhotic patients. Keywords: Hepatocellular carcinoma, Dual energy computed tomography, Material density images, Spectral computed tomography, Functional imaging, Iodine quantification

Background: Chemicals that are commonly used for artificial ripening and to increase the shelf life of fruits and vegetables are ethylene, ethane, calcium carbide, and ethephon. The present study was conducted to study the effect of ethephon on the morphometry of rat liver. Methods: Ethephon was administered by oral gavage tube to 10 adult Wistar albino rats at a dose of 200 mg/kg body weight/day for 14 days. Ten controls were maintained. The animals were sacrificed within 24 h of administering the last dose by perfusion with formal saline under anesthesia. Liver was dissected and processed for paraffin embedding. Histomorphometric studies were done on randomly selected sections of the liver and the data obtained were tabulated and statistically analyzed. Results: In the experimental rats, the hepatocytes had a mean long and short diameter of 15.02 ± 4.20 and 12.08 ± 3.02 μm, respectively. In the control animals, the mean long and short diameters were found to be 16.5 ± 3.59 and 13.9 ± 3.59 μm, respectively. The nucleus of the hepatocytes had a mean long and short diameter of 5.08 ± 1.93 and 5.08 ± 1.93 μm, respectively, in the ethephon-treated rats and 6.15 ± 1.72 and 6.05 ± 1.68 μm, respectively, in the control animals. The decrease in diameters of the hepatocytes and their nuclei was statistically significant. At some sites, the parenchyma showed pyknotic nucleus and inflammatory infiltrations. There was a statistically significant increase in the diameters of the central vein and sinusoids. Dilatation of the bile canaliculi was seen in between the hepatocytes. Conclusion: The plant growth regulator, insecticide, and fruit ripener, ethephon, caused inflammatory and degenerative changes in the liver with associated cholestasis, probably suggestive of toxic hepatitis.

Background & aims Patients with acute-on-chronic liver failure (ACLF) have high mortality. Cirrhotics with acute kidney injury (AKI) have poor outcome but relevance of AKI and response to terlipressin in ACLF is not known. Methods Consecutive ACLF patients with AKI at admission were compared with those without AKI (controls) for mortality at day 7, month 1 and 3, presence of hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP) and acute variceal bleed (AVB). Patients were also compared based on severity of AKI (mild; S.cr 1.5–3 mg/dl and marked; S.cr >3 mg/dl). Response to terlipressin was also evaluated. Results Of 241 ACLF patients, 55 (22.8%) had AKI at admission. Patients with AKI had higher mortality at day 7, 1 and 3 month and more often developed HE [54.1% vs. 30.6%; P = 0.001] and SBP [9.1% vs. 5.9%; P = 0.02]. Patients with marked AKI neither had higher mortality or complications in comparison to mild AKI. Presence of AKI [Odds ratio; OR, 2.4], S.bilirubin >20 mg/dl [OR, 3.1] and INR [OR, 2.9] were independent baseline predictors of mortality. Terlipressin was used in 28 of 55 patients with AKI who were volume non-responsive (hepatorenal syndrome, AKI-HRS). Ten (35.7%) of these showed response (S.Cr < 1.5 mg/dl) [median 4 days] and had lower mortality compared to terlipressin non-responders (10% vs. 50%, P = 0.05). There was no difference in terlipressin response in mild vs. marked AKI. Conclusions Almost one-fourth of the ACLF patients have AKI at admission and presence of AKI, but not its severity predicts complications and high mortality. Terlipressin effectively reverses AKI-HRS within a week in ~35% of ACLF patients resulting in improved survival.

To compare the safety and efficacy of ultrasound guided percutaneous glue (N-butyl-2-cyanoacrylate) embolization with transarterial embolization in the management of iatrogenically injured arteries while performing paracentesis or thoracocentesis in patients with chronic liver disease.Hospital database was searched for cirrhotic patients having abdominal/thoracic wall haemorrhage following paracentesis/thoracocentesis procedure from January 2011 to June 2016. Doppler ultrasound and/or CT angiography were used to localize the site of haemorrhage and patients were treated by transarterial embolization or ultrasound-guided percutaneous glue embolization. Technical success was defined as cessation of haemorrhage as evidenced by angiography/Doppler ultrasound and clinical success was evaluated in terms of stabilization of the vital signs without the need for further transfusion or pressors, and survival. In both groups, the time to "imaging diagnosis of haemorrhage" and "successful embolization" with the outcome was analysed.23 cirrhotic patients had bleeding following a percutaneous procedure, 8 (Group 1) of them underwent transarterial embolization while 15 (Group 2) underwent ultrasound-guided percutaneous glue embolization. Mean time needed for embolization in Group 1 was 41 min while in Group 2 was 9 min (p0.001). Technical success was achieved in all but one case requiring repeat glue embolization. Initial clinical improvement was noted in all cases but the 30-day mortality owing to all causes was not significantly different between treatment groups.The study and its outcome suggest that ultrasound guided percutaneous glue embolization is a quick and effective treatment for iatrogenic haemorrhage following paracentesis/thoracocentesis in cirrhotic patients with comparable results to transarterial embolotherapy. Advances in knowledge: This study details an innovative technique of ultrasound guided percutaneous glue embolization of the iatrogenically injured vessel in the management of active extravasation and pseudoaneurysm developing after paracentesis/thoracocentesis in patients with cirrhosis.