Explore the vast range of titles available.

INTRODUCTION:Critically ill patients with cirrhosis admitted to the intensive care unit (ICU) are usually on broad-spectrum antibiotics because of suspected infection or as a hospital protocol. It is unclear if additional rifaximin has any synergistic effect with broad-spectrum antibiotics in ICU patients with acute overt hepatic encephalopathy (HE).METHODS:In this double-blind trial, patients with overt HE admitted to ICU were randomized to receive antibiotics (ab) alone or antibiotics with rifaximin (ab + r). Resolution (or 2 grade reduction) of HE, time to resolution of HE, in-hospital mortality, nosocomial infection, and changes in endotoxin levels were compared between the 2 groups. A subgroup analysis of patients with decompensated cirrhosis and acute-on-chronic liver failure was performed.RESULTS:Baseline characteristics and severity scores were similar among both groups (92 in each group). Carbapenems and cephalosporin with beta-lactamase inhibitors were the most commonly used ab. On Kaplan-Meier analysis, 44.6% (41/92; 95% confidence interval [CI], 32-70.5) in ab-only arm and 46.7% (43/92; 95% CI, 33.8-63) in ab + r arm achieved the primary objective (P = 0.84).Time to achieve the primary objective (3.65 ± 1.82 days and 4.11 ± 2.01 days; P = 0.27) and in-hospital mortality were similar among both groups (62% vs 50%; P = 0.13). Seven percent and 13% in the ab and ab + r groups developed nosocomial infections (P = 0.21). Endotoxin levels were unaffected by rifaximin. Rifaximin led to lower in-hospital mortality (hazard ratio: 0.39 [95% CI, 0.2-0.76]) in patients with decompensated cirrhosis but not in patients with acute-on-chronic liver failure (hazard ratio: 0.99 [95% CI, 0.6-1.63]) because of reduced nosocomial infections.DISCUSSION:Reversal of overt HE in those on ab was comparable with those on ab + r.

BackgroundTinospora cordifolia (giloy) is a commonly used herbal supplement mentioned in Indian alternative medicine for its action as an immune booster. During the COVID 19 pandemic many commercial preparations of giloy became popular and gained widespread use among the public to prevent severe COVID 19 infections. Some of these patients developed a liver injury with varying clinical manifestations, such as acute hepatitis, acute liver failure (ALF), and acute on chronic liver failure (ACLF). In this study, we aim to analyze the clinical presentation, histological features and outcomes of Giloy-induced liver injury.MethodsThis is a retrospective observational study done at the Asian Institute of Gastroenterology, India, over a period of 1 year, from February 2021 to January 2022. All patients ages more than 18 years presenting with new-onset liver dysfunction (AST, ALT more than 3 times the upper limit of normal or total bilirubin of more than 3mg/dl) with a history of consumption of Giloy for more than 2 weeks duration were included after ruling out other potential causes of liver dysfunction after a thorough etiological evaluation and liver biopsy.ResultsOut of 16 patients that were diagnosed with Giloy-induced liver injury, 7 were males. The mean age of these patients was 48.3±14 years. The most common symptom was jaundice found in all patients. The results of the study are described in IDDF2022-ABS-0185 Table 1. Ten patients underwent liver biopsy out of which five were suggestive of drug-induced liver injury, and another five showed features of autoimmune hepatitis changes possibly triggered by giloy, and one showed intrahepatic cholestasis (IDDF2022-ABS-0185 Figure 1. Liver biopsy showing intrahepatic cholestasis [white arrow mark indicating cholestasis]). However, these five patients did not have any relapses on follow-up after stopping treatment. Three denied liver biopsy and were diagnosed after exclusion of other liver diseases. Three showed immediate improvement with N-acetyl cysteine infusion and liver biopsy was withheld. Ten patients responded with oral steroids. Three steroid non-responders underwent plasma exchange. One patient who developed progressively worsening jaundice and vanishing bile duct syndrome is listed for a liver transplant.Abstract IDDF2022-ABS-0185 Table 1Clinical characteristics of patients with Giloy-induced liver injury Characteristics Number of patients (Total-16 patients) Gender Male 7 (43.75%) Female 9 (56.25%) Age (mean ± SD) 48.3±14 years Presentation type Acute hepatitis 6 (37.5%) ACLF 10 (62.5%) Mean duration for symptom onset after consumption of giloy 84.3±35 days Mean BMI 23.23±3 kg/m2 Comorbidities Type 2 diabetes 9 (56.25%) Interstitial lung disease (on inhalational steroids) 2 (12.5%) Hypertension 1 (6.25%) None 5 (31.25%) NAFLD 2 (6.25%) Symptoms Jaundice 16 (100%) Ascites 8 (50%) Fatigue 12 (75%) Pruritus 4 (25%) Liver function tests Peak total bilirubin (Mean ± SD) 17 ± 9.4 mg/dl Peak ALT (mean ± SD) 365± 219 U/L Peak AST (mean ± SD) 558 ± 475 U/L Peak ALP (mean ± SD) 186 ± 114 U/L Peak serum IgG (mean ± SD) 2400 ± 1213 mg/dl Peak INR (mean ± SD) 2.63 ± 1.05 AIH serology ANA 1(6.25%) ASMA - Anti LKM1 - AMA - Seronegative (biopsy proven) - Liver biopsy 10 (62.5) Drug induced liver injury 5 (31.25%) Features of AIH 5 (31.25%) Treatment N-Acetyl Cysteine infusion+Ademetionine 3 (18.75%) Steroids 10 (62.5%) Plasma Exchange 3 (18.75%) Outcome Alive 16 (100%) One listed for liver transplant Mean duration for recovery 37 ± 16 days Abstract IDDF2022-ABS-0185 Figure 1ConclusionsGiloy, a commonly used immunity booster, can produce drug-induced liver injury, which often mimics autoimmune hepatitis and responds to steroids.

BackgroundSteroid therapy is the standard of care for severe alcoholic hepatitis (sAH) at most centres. However, steroids are associated with an increased risk of infections. Therefore, we aimed to compare the outcomes of patients receiving concomitant norfloxacin (NFX) with steroids in patients with sAH.MethodsIn this double-blind, randomized study, acute-on-chronic liver failure (ACLF) patients without sepsis, hepatic encephalopathy, or SBP were assigned to receive oral NFX 400mg or matched placebo (PBO) once daily for 30 days along with standard medical therapy. 143 ACLF patients were included (CTRI/2019/10/021548). On subgroup analysis, 20 in the NFX group and 13 patients in the PBO group received concomitant steroid therapy for sAH. The primary objective was to assess the incidence of infections at days 30, 90, and the secondary was to evaluate the transplant-free survival (TFS) at days 30, 90.ResultsBaseline characteristics were similar in both the groups (MELD-NFX-27.8±3.79 vs. PBO-29.62±4.66; P=0.229). The incidence of infection was lower with NFX (10%) than PBO (38.5%) at day 30 (P=0.066). The incidence of infection at day 90 was lower with NFX (30%) than PBO (69.2%) (P=0.027) (IDDF2021-ABS-0089 Figure 1. Kaplan Meier analysis of infection incidence at days 30, 60 and 90). TFS was similar in both groups at day 30 (NFX-85% vs. PBO-77%; Log-Rank test: P=0.524). However, TFS at day 90 was better with NFX (85%) than placebo (53.8%) (Log-Rank test: P=0.059). The most common source of infection was the urinary tract (NFX - 3 vs. Placebo-4). E. coli was the commonly isolated organism in both groups. Candida albicans were isolated in two patients in NFX group, while none in the PBO group developed fungal infection. Sepsis was the common cause of mortality (NFX-2; PBO-4). Further, one patient in NFX group succumbed to post-TIPS liver failure (for variceal bleed). There were no drug-related adverse events in this sub-group of patients.Abstract IDDF2021-ABS-0089 Figure 1ConclusionsPrimary norfloxacin prophylaxis is safe and effective in reducing infections in patients with sAH receiving steroid therapy.

Background Liver transplantation (LT) is associated with excellent survival in patients with acute-on-chronic liver failure (ACLF). There is a lack of data assessing the healthcare utilization and outcomes of patients with APASL-defined ACLF undergoing living donor liver transplantation (LDLT). Our aim was to assess pre-LT healthcare utilization and post-LT outcomes in such patients. Methods Patients with ACLF who underwent LDLT at our center between 1st April 2019 and 1st October 2021 were included. Results Seventy-three ACLF patients willing to undergo LDLT were listed; eighteen patients died within 30 days. Fifty-five patients underwent LDLT (age:38.05 ± 14.76 years; alcohol:52.7%; males:81.8%). Most were in grade II ACLF (87.3%) at the time of LDLT (APASL ACLF Research Consortium [AARC] score: 9.05 ± 1; MELD NA: 28.15 ± 4.13). Survival rate was 72.73%; mean follow-up period of 925.21 days; 58.2% (32/55) developed complications during the first year post-LT; 45% (25/55) and 12.7% (7/55) developed infections within and after 3 months. Pre-LT, each patient required a median of 2 (1–4) admissions for 17 (4–45) days. Fifty-six percent (31/55) of patients underwent plasma exchange pre-LDLT. A median amount of Rs. 8,25,090 (INR 26,000–43,58,154) was spent to stabilize the patient (who were sicker and waited longer to undergo LDLT); though post-LT survival benefit was not observed. Conclusions LDLT was associated with 73% survival and, thus, is a viable option in those with APASL-defined ACLF. There was a pre-LT high healthcare resource utilization of plasma exchange, with the intention of optimization, while survival benefit has not been demonstrated.

•Non-response to inactivated and recombinant vaccines is similar among healthy controls (8%), non-cirrhosis CLD patients (16%), and compensated cirrhosis patients (17%).•Cellular immunity was similar among healthy controls, NCCLD, and compensated cirrhosis groups.•Approximately 34% and 59% of decompensated cirrhosis patients and liver transplant recipients were non-responders.•Decompensated cirrhosis and liver transplant recipients demonstrated poor humoral (lower antibody levels) and cellular response. Recent studies have reported poor humoral immune response to mRNA vaccines in patients with chronic liver disease (CLD). However, the immunogenicity of ChAdOx1 (vector-based) and BBV152 (inactivated virus) vaccines in patients with CLD and liver transplant recipients (LTRs) is unknown. Therefore, we aimed to assess the immunogenicity of ChAdOx1 and BBV152 vaccines in patients with CLD (including cirrhosis patients) and LTRs. In this single-center prospective study, consecutive completely vaccinated (ChAdOx1 or BBV152) non-cirrhosis CLD patients, those with cirrhosis, and LTRs were compared with matched healthy controls for anti-spike antibody and cellular response. Sixty healthy individuals, 50 NCCLD patients, 63 compensated and 50 decompensated cirrhosis, and 17 LTRs were included. The proportion of non-responders was similar among the healthy control (8 %), non-cirrhosis CLD (16 %), and compensated cirrhosis groups (17.5 %;p = 0.3). However, a higher proportion of patients with decompensated cirrhosis (34 %) and LTRs (59 %) were non-responders than the healthy controls (p = 0.001). Cluster of differentiation (CD) 4-effector cells were lower in patients with non-cirrhosis CLD and compensated cirrhosis. CD4-naïve, CD4-effector, B, and B-memory cells were lower in the decompensated cirrhosis group. Although the central memory cells were higher in the decompensated cirrhosis group, they could not differentiate into effector cells. CD4- and CD8-naïve cells were higher in the marrow in the LTRs, while the CD4-effector memory cells and CD4- and CD8-effector cells were lower in the LTRs. Furthermore, B cells were more deficient in the LTRs, suggesting poor antibody response. Patients with decompensated cirrhosis and LTRs demonstrated suboptimal humoral and cellular immune responses against recombinant and inactivated COVID-19 vaccines.

Background and Objectives Human albumin (HA) solution is currently recommended only for patients with spontaneous bacterial peritonitis (SBP) and acute kidney injury (AKI). However, its use in hospitalized patients is quite frequent. The objective was to compare the outcomes of patients receiving HA in recommended (Gr. A) vs. non-recommended (Gr. B) indications. Methods In this prospective study, consecutive hospitalized patients who received HA were included. Apart from comparing the proportion of patients achieving resolution of hyponatremia, infection and hepatic encephalopathy among Gr. A and Gr. B, we also compared the in-hospital survival and performed a sub-group analysis of patients with the European Association for the Study of the Liver (EASL) acute-on-chronic liver failure (ACLF) and decompensated cirrhosis (DC). Results Of the 396 hospitalized patients who received HA, 180 had AKI and/or SBP (Gr. A), and 216 received albumin for non-recommended indications (Gr. B). The mean age, sex and etiology distribution were similar. The total dose of HA was higher (88 ± 61.62 g vs. 71.31 ± 488.17 g; p  = 0.003) and the duration longer (4 ± 2.37 vs. 3.4 ± 1.82 days; p  = 0.005) in Gr. A than B. The resolution of infection and HE was similar among both groups, while hyponatremia resolution was significantly higher in Gr. B (94.7%) than Gr. A (75.6%; p  < 0.001). On Kaplan-Meier analysis, survival was significantly higher in Gr. B (94%) than Gr. A (78.9%; p  < 0.001). The incidence of albumin-induced fluid overload was comparable (2.8% vs. 1.4%; p  = 0.32). Patients with ACLF were sicker with a higher incidence of microbiologically proven infection, hepatic encephalopathy (HE) and hyponatremia than in the DC group. Resolution of infection and hyponatremia and in-hospital survival was significantly lower in the ACLF group (72.5%) than in the DC group (92.7%; p  < 0.001). Eighty-six per cent of patients achieved resolution of ACLF. Conclusions HA infusion is safe and effective even in patients without AKI and SBP and leads to the resolution of infection, hyponatremia, HE and ACLF. Graphical abstract

Patients with cirrhosis are susceptible to infections, especially by multidrug-resistant organisms (MDROs). There are limited data on the incidence of culture-positive infections and the validity of Sepsis 3-criteria in patients with cirrhosis admitted to the intensive care unit (ICU) in India, which we aimed to assess.BACKGROUNDPatients with cirrhosis are susceptible to infections, especially by multidrug-resistant organisms (MDROs). There are limited data on the incidence of culture-positive infections and the validity of Sepsis 3-criteria in patients with cirrhosis admitted to the intensive care unit (ICU) in India, which we aimed to assess.In this prospective study, we included consecutive patients with cirrhosis admitted to the ICU between November 1, 2021, and April 30, 2022. The primary objective was to compare the outcomes of patients with microbiologically proven infections with those without proven infections. The secondary objective was to assess the predictors of infections and mortality and the impact of drug-resistant organisms.METHODSIn this prospective study, we included consecutive patients with cirrhosis admitted to the ICU between November 1, 2021, and April 30, 2022. The primary objective was to compare the outcomes of patients with microbiologically proven infections with those without proven infections. The secondary objective was to assess the predictors of infections and mortality and the impact of drug-resistant organisms.A total of 298 patients (9.4% women) were included. The incidence of microbiologically proven infection was 34% (101/298; 95%CI=27.6-41.2). Most patients (61%) had healthcare-associated infections, Gram-negative organisms accounted for 75.3%, and bacteremia was the commonest site. Drug-resistant organisms accounted for 52.5% (53/101; 95%CI=39.3-68.7), of which 39.6% were multidrug-resistant (MDR) and 12.8% were extensively drug-resistant (XDR). Mortality was significantly higher in patients with proven infections than those without (61.4% vs. 44.2%; P=0.007). The sequential organ failure assessment (SOFA) score (OR=1.91; 95%CI=1.04-3.52; P<0.001) and presence of fever and/or positive quick SOFA (qSOFA; OR=1.91;1.04-3.52; P=0.03) were associated with an increased risk of infections. The SOFA score (OR=1.06;95%CI=1.002-1.12; P=0.04), MELD NA score (OR=1.08;95%CI=1.05-1.12; P<0.001), and presence of fever and/or positive qSOFA (OR=2.19; 95%CI=1.27-3.76; P=0.005) predicted mortality.RESULTSA total of 298 patients (9.4% women) were included. The incidence of microbiologically proven infection was 34% (101/298; 95%CI=27.6-41.2). Most patients (61%) had healthcare-associated infections, Gram-negative organisms accounted for 75.3%, and bacteremia was the commonest site. Drug-resistant organisms accounted for 52.5% (53/101; 95%CI=39.3-68.7), of which 39.6% were multidrug-resistant (MDR) and 12.8% were extensively drug-resistant (XDR). Mortality was significantly higher in patients with proven infections than those without (61.4% vs. 44.2%; P=0.007). The sequential organ failure assessment (SOFA) score (OR=1.91; 95%CI=1.04-3.52; P<0.001) and presence of fever and/or positive quick SOFA (qSOFA; OR=1.91;1.04-3.52; P=0.03) were associated with an increased risk of infections. The SOFA score (OR=1.06;95%CI=1.002-1.12; P=0.04), MELD NA score (OR=1.08;95%CI=1.05-1.12; P<0.001), and presence of fever and/or positive qSOFA (OR=2.19; 95%CI=1.27-3.76; P=0.005) predicted mortality.One-third of the patients with cirrhosis admitted to the ICU had microbiologically proven infection, and the mortality rate in such patients was high. SOFA, qSOFA, and fever can predict microbiologically proven infections and mortality in patients with cirrhosis.CONCLUSIONSOne-third of the patients with cirrhosis admitted to the ICU had microbiologically proven infection, and the mortality rate in such patients was high. SOFA, qSOFA, and fever can predict microbiologically proven infections and mortality in patients with cirrhosis.

[...]KQA is often credited with having aroused interest and curiosity about quizzing among the city's youth. Panda cites a question from a MELA (Music, Entertainment, Literature and Arts) Quiz he hosted recently by way of example: 'Certain components of Spanish acoustic guitars were originally made from the small intestine of sheep and it was only in World War 2 that the production material was switched to nylon, as all of the material was being used to create surgical thread for treating wounded soldiers. Chattopadhyay says: \"The answer is Lois Lane, which is very easy to figure out because when you start thinking of alternate names of roads, you think of lane; and since it's a comic book store, Lois Lane is the first name that comes to mind!\" Venkatesh Srinivasan, committee member of KQA and co-founder and CEO of Nexus Consulting (they've been in the business of quizzing/content/knowledge development for the last four years and work with schools and corporates) says that they work on authentic questions which are both interesting and accessible without relying on just Wikipedia or a random newspaper article.

For Kavita Dambal, mother to 19-year-old Anmol (who was first misdiagnosed with Attention-deficit/hyperactivity disorder (ADHD) before finally been diagnosed with autism, at age four-and-a-half, the shock was so severe that she went into depression. Sarbani Mallick, founder-director and managing trustee, Bubbles Centre for Autism and Pragati Vocational Skill Centre, says mothers confide in her that they cannot even get a minute off for themselves - sometimes not even being able to have the privacy for a change during their period. [...]they hesitate to ask for help,\" she says. The litmus test is that it has been loved by Ayush. Because when she showed him the book, he - intensely non-verbal and uncommunicative - gave her a spontaneous kiss and a hug, the instances of which she can \"count on my fingers\".

[...]Singh stayed back in India for four months and took care of all relocation documentation, moving to the UK along with the pets only in January 2017. [...]she says she has conducted an informal survey and found that about 40 per cent of people relocating to different countries take their pets along, while another 40 per cent are on the cusp - they don't know enough about the process and simply require some push to relocate their pets. [...]they decided to move everyone despite the cost and the enormous documentation. For the UK, the process required a Rabies Titer Test, as the UK is a rabies-free country. Since India is unlisted for pet relocation in the UK, the test needs to be taken at least a month after the rabies vaccination is given, and the pet needs to stay in India (or a government quarantine in the UK) for 90 days before being cleared to live in the UK.