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A case of multifocal non-Hodgkin's (Diffuse large B cell type) lymphoma of colon in a patient with ulcerative colitis is described. The patient was a 69-year old male treated with azathioprine and methotrexate for ulcerative colitis for 2 years. He was admitted with loose stools and hematochezia. Colonoscopy revealed two deep ulcers in ascending colon and a large ulcer in rectum. Biopsy from both the sites revealed atypical large lymphoid cells, which were CD20 positive. A whole body PET-CT scan showed disease localized to colon with bone marrow examination showing no evidence of lymphoma. The patient was given chemotherapy cycles and recovered well.

Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality, and healthcare expenditure in patients with chronic liver disease in India. The Indian National Association for Study of the Liver (INASL) had published its first guidelines on diagnosis and management of HCC (The Puri Recommendations) in 2014, and these guidelines were very well received by the healthcare community involved in diagnosis and management of HCC in India and neighboring countries. However, since 2014, many new developments have taken place in the field of HCC diagnosis and management, hence INASL endeavored to update its 2014 consensus guidelines. A new Task Force on HCC was constituted that reviewed the previous guidelines as well as the recent developments in various aspects of HCC that needed to be incorporated in the new guidelines. A 2-day round table discussion was held on 5th and 6th May 2018 at Puri, Odisha, to discuss, debate, and finalize the revised consensus statements. Each statement of the guideline was graded according to the Grading of Recommendations Assessment Development and Evaluation system with minor modifications. We present here the 2019 Update of INASL Consensus on Prevention, Diagnosis, and Management of Hepatocellular Carcinoma in India: The Puri-2 Recommendations.

Background:Objective:To simulate a Micromechanical systems (MEMS) based CMUT working as a transmitter with the existing design and provide comparison within the possible architectural geometries.Methods:FEM simulation software COMSOL is used to simulate the 3D model of the transducer radiating in the air. The classical thin-plate theory is employed to solve for CMUT with a circular shape which is sufficient when the ratio of the diameter to thickness of the plate is very large, an aspect common in CMUTs. The Galerkin-weighted residual technique is used to get a solution for thin plate equation with the presumption that the deflections are small in comparison to the thickness of the plate.Results:The resonant frequency of CMUT with different geometries have been calculated. The deflection of membrane with applied DC bias is shown along with collapse voltage calculation. The generated ultrasound is shown with the AC bias superimposed on the DC bias. The capacitance change with the increasing DC voltage is discussed. The deflection of membrane is maximum as the resonance frequency is proved.Conclusion:The review of Capacitive Micromachined Ultrasonic Transducer architectures with different shapes is highlighted. The working behavior of CMUT with suitable dimension is simulated in 3D providing researcher data to wisely choose the CMUT prior to the fabrication. The CMUT is prioritized on various characteristics like wafer area utilization, deflection percentage within the cavity and durability of the transducer.

Liver diseases occurring during pregnancy can be serious and can progress rapidly, affecting outcomes for both the mother and fetus. They are a common cause of concern to an obstetrician and an important reason for referral to a hepatologist, gastroenterologist, or physician. Liver diseases during pregnancy can be divided into disorders unique to pregnancy, those coincidental with pregnancy, and preexisting liver diseases exacerbated by pregnancy. A rapid differential diagnosis between liver diseases related or unrelated to pregnancy is required so that specialist and urgent management of these conditions can be carried out. Specific Indian guidelines for the management of these patients are lacking. The Indian National Association for the Study of the Liver (INASL) in association with the Federation of Obstetric and Gynaecological Societies of India (FOGSI) had set up a taskforce for development of consensus guidelines for management of patients with liver diseases during pregnancy, relevant to India. For development of these guidelines, a two-day roundtable meeting was held on 26-27 May 2018 in New Delhi, to discuss, debate, and finalize the consensus statements. Only those statements that were unanimously approved by most members of the taskforce were accepted. The primary objective of this review is to present the consensus statements approved jointly by the INASL and FOGSI for diagnosing and managing pregnant women with liver diseases. This article provides an overview of liver diseases occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and the recommended treatment options.

Background Acute kidney injury (AKI) in a patient with cirrhosis has high short-term mortality. Midodrine has shown promising results in the treatment of AKI-hepatorenal syndrome (HRS-AKI). Aims To compare midodrine and albumin versus albumin alone for the secondary prophylaxis of HRS-AKI. Patients and method Open labeled, nonrandomized, pilot study. Patients with a diagnosis of HRS-AKI were recruited after complete recovery. Patients were given midodrine daily (15 mg) and injection albumin infusion 20 g weekly in group-A (Gp-A) and injection albumin 20 g weekly with no midodrine in group-B (Gp-B). The primary endpoint was the recurrence of AKI-HRS, and the secondary endpoint was ascites tap in 2-month period. Results A total of 42 patients were enrolled in Gp-A, n = 22, and Gp-B, n = 20. There was no significant difference between the groups (Gp-A vs. Gp-B) in terms of age, model stage liver disease, Child-Turcotte-Pugh score and serum creatinine at inclusion (1.27 ± 0.1 vs. 1.22 ± 0.2 mg/dL). During follow up ten patients (50%) in Gp-B and four patients (18%) in Gp-A develop HRS-AKI (P = 0.04). The mean number of ascites tap was significantly higher in Gp-B compared to Gp-A (2.6 ± 0.5 vs. 1.9 ± 0.5) in 2 months. There was a significant increase in mean arterial pressure in Gp-A compared to Gp-B on days 7, 15, 30, 45 and 60. There was a significant difference in mean arterial pressure at day 7 in patients who developed HRS-AKI versus those who did not develop HRS-AKI [(n = 14, 65.5 ± 5.5) vs. (n = 28,74.6 ± 9.2 mm Hg), P = 0.02]. Conclusions Midodrine along with albumin infusion, is helpful in the secondary prophylaxis of HRS-AKI and reduces the number of ascites tap. However, a large randomized study is required for further validation.

Malnutrition and sarcopenia are common in patients with chronic liver disease and are associated with increased risk of decompensation, infections, wait-list mortality and poorer outcomes after liver transplantation. Assessment of nutritional status and management of malnutrition are therefore essential to improve outcomes in patients with chronic liver disease. This consensus statement of the Indian National Association for Study of the Liver provides a comprehensive review of nutrition in chronic liver disease and gives recommendations for nutritional screening and treatment in specific clinical scenarios of malnutrition in cirrhosis in adults as well as children with chronic liver disease and metabolic disorders.

Hepatitis C virus (HCV) infections are associated with significant morbidity and mortality globally. The diagnosis of HCV is primarily based on indirect serological assays such as enzyme-linked immunosorbent assay (ELISA), chemiluminescence immunoassay (CIA), and rapid diagnostic tests to detect HCV antibodies. Direct tests detect/quantify components of HCV virions, such as HCV ribonucleic acid (RNA) (nucleic acid test or nucleic acid amplification test [NAT]) and HCV core antigen (HCVcAg). The HCVcAg assay (CIA, Abbott ARCHITECT) is an immune assay used for the quantitative determination of the HCVcAg. This test is simple and fast with the potential to be incorporated into diagnostic guidelines and be used in combination with anti-HCV (CIA) as an effective screening test. HCVcAg can also be used as a potential biomarker for treatment initiation and monitoring patients to assess the treatment response. Apart from this, the scope for implementation of the HCVcAg assay in resource limited setting lies in screening of immune compromised patients where anti-HCV serology is not dependable. However, concerns related to lower sensitivity compared to HCV RNA do exist. Nevertheless, the HCVcAg assay can make a significant difference in the measures taken for the control and eradication of hepatitis C and its complications in India.

COVID-19 is characterized by predominant respiratory and gastrointestinal symptoms. Liver enzymes derangement is seen in 15-55% of the patients. Advanced age, hypertension, diabetes, obesity, malignancy, and cardiovascular disease predispose them to severe disease and the need for hospitalization. Data on pre-existing liver disease in patients with COVID-19 is limited, and most studies had only 3-8% of these patients. Patients with metabolic dysfunction-associated fatty liver (MAFLD) had shown a 4-6 fold increase in severity of COVID-19, and its severity and mortality increased in patients with higher fibrosis scores. Patients with chronic liver disease had shown that cirrhosis is an independent predictor of severity of COVID-19 with increased hospitalization and mortality. Increase in Child Turcotte Pugh (CTP) score and model for end-stage liver disease (MELD) score increases the mortality in these patients. Few case reports had shown SARS-CoV-2 as an acute event in the decompensation of underlying chronic liver disease. Immunosuppression should be reduced prophylactically in patients with autoimmune liver disease and post-transplantation with no COVID-19. Hydroxychloroquine and remdesivir is found to be safe in limited studies in a patient with cirrhosis and COVID-19. For hepatologists, cirrhosis with COVID-19 is a pertinent issue as the present pandemic will have severe disease in patients with chronic liver disease leading to more hospitalization and decompensation.

Background Diagnosis of malignant ascites is a clinical challenge. The gold standard method for diagnosis is with cytology; however, it has low sensitivity, is observer-dependent, and may require repeated paracentesis. Recently, some studies showed that high ascitic fluid cholesterol level could be a marker of malignant ascites and thus can differentiate between benign and malignant ascites. This study aimed to assess and evaluate the diagnostic accuracy of ascitic fluid cholesterol level in differentiating malignant from non-malignant ascites. Methods We prospectively studied patients of ascites, who were admitted in from February 2019 to July 2019. Ascitic fluid cholesterol of all patients was sent along with cytology for malignant cells. Malignancy was proven by tissue diagnosis (peritoneal biopsy or EUS guided abdominal lymph node FNA or cytology of ascitic fluid). Patients with spontaneous bacterial peritonitis, tubercular ascites and pancreatic ascites were excluded. Results A total of 50 patients of ascites were included in the study, and of these 11 patients had malignant ascites as proved by peritoneal biopsy or EUS guided abdominal lymph node biopsy or by ascitic fluid cytology. On taking a cut-off of 30 mg/dL of ascitic fluid cholesterol level, it was found that 9 of 11 patients (81%) of malignant ascites had high cholesterol values; however, only 8 of 39 patients (20.5%) of non-malignant ascites had high cholesterol values (p Conclusions Ascitic fluid cholesterol has high negative predictive value for ruling out malignancy-related ascites and thus can be used as an excellent biochemical investigation to rule out malignant ascites.

Background HRS-AKI or HRS -1 carries high short-term mortality in patients with advanced cirrhosis. Recently ICA has proposed new definition criteria for HRS, and at present, we lack literature on the response rate and predictors of response of terlipressin according to this new definition. So, we aimed to evaluate the response rate of terlipressin and factors affecting the response rate according to this new HRS-AKI definition Methods We performed a prospective study on 114 cirrhotic patients with HRS- AKI diagnosed according to ICA definition 2015 from August 2018 to April 2020 using terlipressin and albumin. Baseline clinical and biochemical details were noted. Response was defined as improvement in serum creatinine within 0.3 mg/dl of baseline (if baseline s.cr 1.5 mg/dl). Further responder and non-responder were followed up to 90 days or death. Univariate and multivariate logistic regression was applied to detect predictors of response. Survival analysis was used to determine 90 days of survival. Results Among 114 HRS-AKI patients, the median age was 52.5 years, and 83.3% were male. Response to terlipressin was seen in 70 (61.4%) patients. On subgroup analysis, the response rate in acute decompensation (AD) was seen in 37 (78.7%) patients and in acute on chronic failure (ACLF) was seen in 32 (47.7%) patients. Independent predictive factors of response to therapy were serum creatinine before start of terlipressin therapy (odds ratio, 0.390; 95% confidence interval, 0.195–0.780; P = 0.008) and baseline child-pugh score (CTP) (odds ratio, 0.584; 95% confidence interval, 0.382–0.894; P = 0.013). Response to therapy was associated with improved 90 days of survival compared to patients with non-response (69.56% vs 10%, P Conclusions Serum creatinine before the start of terlipressin and CTP predicts response to terlipressin in HRS-AKI. The response rate was better with the new definition of HRS. The subset of the population with higher grades of ACLF showed poor response. Therefore early transplantation should be considered in patients of HRS with a low likelihood of response (figure 1).

Background Hepatocellular carcinoma (HCC) is the 5th most common malignancy worldwide. Its clinical presentation in terms of its severity is quite variable, and survival in its advanced stages is poor. Neutrophil lymphocyte ratio (NLR) and Platelet lymphocyte ratio (PLR) are the markers which have been proven useful in prognostication of many malignancies. We aimed to evaluate the predictive value of NLR and PLR in prognosticating patients with HCC and to study its association with severity of HCC. Methods Patients with newly diagnosed HCC getting admitted between Aug 2018 and Jan 2020 were included in the study. The imaging features, ECOG status and liver functional status were analyzed, and BCLC staging was done. Patients were given appropriate treatment according to the BCLC stage. Pre-treatment NLR and PLR were calculated from differential leukocyte count. Repeat imaging was done at 1 and 3 months post-treatment. Patients were followed up for 6 months for survival. Optimum cut off values of NLR and PLR were calculated by ROC curve analysis. The OS at 6 months was compared on Kaplan Meier curve using high and low NLR, PLR values. Association between NLR and PLR was also tested with BCLC stages, recurrence-free and progression-free survival. Results The optimum cut off for high NLR and PLR were ≥ 3 and ≥ 102 respectively. Overall survival rates at 6 months in patients with NLR ≥ 3 and Conclusions NLR and PLR are strong markers for predicting survival and severity in patients with HCC. (figure 1).

Nanomaterials have gathered much interest by various researchers in the past few years due to their specific and unique electrical, mechanical, optical, and magnetic properties. These properties make nanomaterials special, and they are used in various applications, such as for production of gas-tight materials where one makes use of nanostructured metallic powder. In gas sensors, due to their enhanced selectivity and sensitivity, nanostructured metal oxide thin films are being used. All such applications lead to the development of nanomaterials using various methods. Nanomaterials deal with the finest structures. This indeed allows researchers to think about different approaches to creating different nanomaterials. Two different approaches may be used to make nanomaterials. One is to assemble atoms together to make the nanomaterial, and the other approach follows the disassemble method by breaking large or bulk solids into small structures till they are constituted of only a few atoms. Different methods used for making nanostructures and nanomaterials include mechanical grinding, sol-gel process, arc discharge method, laser ablation method, and many more. The chapter describes all the possible methods of creating nanomaterials.

Renal dysfunction is very common among patients with chronic liver disease, and concomitant liver disease can occur among patients with chronic kidney disease. The spectrum of clinical presentation and underlying etiology is wide when concomitant kidney and liver disease occur in the same patient. Management of these patients with dual onslaught is challenging and requires a team approach of hepatologists and nephrologists. No recent guidelines exist on algorithmic approach toward diagnosis and management of these challenging patients. The Indian National Association for Study of Liver (INASL) in association with Indian Society of Nephrology (ISN) endeavored to develop joint guidelines on diagnosis and management of patients who have simultaneous liver and kidney disease. For generating these guidelines, an INASL-ISN Taskforce was constituted, which had members from both the societies. The taskforce first identified contentious issues on various aspects of simultaneous liver and kidney diseases, which were allotted to individual members of the taskforce who reviewed them in detail. A round-table meeting of the Taskforce was held on 20–21 October 2018 at New Delhi to discuss, debate, and finalize the consensus statements. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong and weak) thus reflects the quality (grade) of underlying evidence (I, II, III). We present here the INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly spread world over causing morbidity and mortality in affected patients, especially elderly and those with co-morbidities. Inflammatory Bowel Disease (IBD) patients frequently require immunosuppressive therapy and are known to be at risk of opportunistic infections. AREAS COVERED: We hereby review the available literature pertaining to COVID-19 in IBD based on published consensus guidelines, expert opinions, case series, registries and reports. EXPERT OPINION: Preliminary data suggests no increase in incidence of COVID-19 in IBD patients as compared to general population. Morbidity and mortality rates attributable to COVID-19 are also similar in IBD patients as compared to general population. Though exact reason is unknown, some aspects of COVID-19 pathogenesis may explain this paradox. Medications for IBD need to be carefully reviewed during COVID-19 crisis. Steroids may need dose tapering or substitution to avoid complications based on anecdotal evidence. Endoscopic procedures for IBD maybe deferred unless absolutely necessary. General measures recommended for COVID-19 tailored to specific needs of IBD patients maybe the best way to prevent infection. Our understanding of the disease outcomes and optimal management protocols are likely to evolve as we move ahead in this pandemic.

Objectives: To report the diagnostic yield and safety of endoscopic ultrasound-guided fine-needle aspiration (EUS FNA) for the evaluation of proximal bile duct lesions. Materials and methods: A retrospective analysis of data of the patients, who had undergone EUS for proximal bile duct lesions was done. FNA was performed from either the bile duct mass, enlarged node, or liver lesions. Outcome measures were the diagnostic yield of EUS FNA and adverse events. Results: From April 2011 to August 2018, 147 patients with suspected proximal bile duct malignancy underwent EUS. Mass lesion was seen in 133 (90.47%) patients. FNA was performed in 125 (85.03%) patients. The final diagnosis in patients undergoing EUS FNA was malignancy in 118, benign disease in six, and one patient was lost to follow up. EUS FNA confirmed the diagnosis in 103/118 patients with malignancy (sensitivity 87.28%); was false negative in 15/118 cases with malignancy, and was truly negative in all the six patients with benign disease (specificity 100%). Positive predictive value, negative predictive value, and the accuracy of EUS FNA were 100%, 28.57%, 87.90% respectively. No serious adverse event was reported, five patients had self-limiting pain. Conclusion: EUS FNA is a sensitive tool for the evaluation of proximal bile duct lesions. Low negative predictive value warrants further evaluation in patients with non-malignant findings on cytology.

Background Many studies on COVID-19 have reported diabetes to be associated with severe disease and mortality, however, the data is conflicting. The objectives of this meta-analysis were to explore the relationship between diabetes and COVID-19 mortality and severity, and to determine the prevalence of diabetes in patients with COVID-19. Methods We searched the PubMed for case-control studies in English, published between Jan 1 and Apr 22, 2020, that had data on diabetes in patients with COVID-19. The frequency of diabetes was compared between patients with and without the composite endpoint of mortality or severity. Random effects model was used with odds ratio as the effect size. We also determined the pooled prevalence of diabetes in patients with COVID-19. Heterogeneity and publication bias were taken care by meta-regression, sub-group analyses, and trim and fill methods. Results We included 33 studies (16,003 patients) and found diabetes to be significantly associated with mortality of COVID-19 with a pooled odds ratio of 1.90 (95% CI: 1.37–2.64; p, Highlights • This meta-analysis of 33 observational studies (16,003 patients) found that the pooled prevalence of diabetes in patients with COVID-19 is approximately 10%, which may be similar to the baseline prevalence of diabetes in the community. • Patients of COVID-19 who have underlying diabetes have more than two-fold higher risk of developing severe disease, in terms of more ICU requirement, ARDS development or invasive ventilation requirement. • Similarly, these patients also have nearly two-fold higher risk of mortality due to COVID-19 disease. • Whether this association of diabetes with increased severity and mortality of COVID-19 is independent of other comorbidities, needs to be studied further.

BACKGROUND: Sofosbuvir (SOF), a direct acting antiviral, has revolutionized the treatment of chronic Hepatitis C Virus (HCV) infection. However, data is scarce about efficacy of SOF plus Ribavarin (RBV) in Indian patients with decompensated cirrhosis. We evaluated the efficacy of SOF plus RBV in decompensated cirrhosis, and compared the outcome with compensated cirrhosis and non-cirrhotics. PATIENTS AND METHODS: Consecutive decompensated cirrhotic patients of chronic HCV with detectable HCV RNA were treated with 24-week course of SOF (400 mg) plus weight based RBV. Sustained Virological Response (SVR), Child Turcotte Pugh (CTP) and Model for Endstage Liver Disease (MELD) scores were assessed at 36 weeks (i.e. 12 weeks after completion of therapy). Non-cirrhotic chronic hepatitis C patients and patients with compensated cirrhosis treated with SOF plus RBV during the same period were used as controls. During the period of this study ledipasvir and daclatasvir were not available in India. RESULTS: A total of 47 patients [median age 50 (29–82) years, 64% males] with decompensated cirrhosis were included as ‘cases’ in the study; while, 27 patients with compensated cirrhosis and 29 patients with chronic hepatitis were included as ‘controls’. Age, gender, HCV RNA levels, and genotype distribution were similar in cases and controls. The median CTP and MELD scores of cases were 8 (7–12) and 13 (6–25), respectively. Among cases 39 (83%) could complete the therapy, while 1 (2%) was intolerant and 7 (15%) died before completion of therapy. End of Treatment Response (ETR) was achieved in 37/39 (95%) cases. Of these, another 3 died before SVR, and 7 failed to achieve SVR, thus 27/34 (79%) could achieve SVR. Thus according to intention-to-treat analysis, only 27/47 (57%) cases could achieve SVR. In comparison, 24/28 (86%) compensated cirrhotics and 27/28 (96%) of chronic hepatitis achieved SVR. There was a significant improvement in mean CTP score in cases who achieved SVR (P 3.5 g/dL. CONCLUSIONS: A 24-week course of SOF plus ribavirin in decompensated HCV cirrhosis could lead to SVR in only 57% of patients. The failure of therapy in 43% patients was either due to non-response, intolerance, or death. A serum albumin of more than 3.5 is associated with success of antiviral therapy. Thus an early initiation of antiviral therapy is recommended before decompensation sets in as it precludes successful outcome.

Alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) are commonest causes of chronic liver disease in developing as well as developed countries. Their incidence has increased due to widespread easy availability of alcohol and sedentary life style of people. NAFLD is a spectrum which includes fatty liver (NAFL) which is considered benign disease, steatohepatitis (NASH) which indicates ongoing injury to liver and cirrhosis of liver. Similarly, ALD spectrum comprises simple steatosis, alcoholic hepatitis, and cirrhosis and its complications. Most of the time there is significant overlap between these diseases and clinical presentation depends upon the stage of liver disease. Most of the NAFLD patients are asymptomatic and diagnosed to have fatty liver while undergoing routine health check up. ALD requires significant history of alcohol intake which is supportive by radiological and biochemical tests. In both NAFLD and ALD patients, liver enzymes are seldom raised beyond five times the upper limit of normal. Liver biopsy is required for diagnosis of NASH as it is a histological diagnosis and sometimes in alcoholic hepatitis for confirmation if diagnosis is in doubt. Non-invasive markers and prognostic scores have been developed for avoiding liver biopsy in assessment and treatment response of NASH and alcoholic hepatitis patients.

In the present work efforts have been made to develop microheater integrated gas sensors with low power consumption. The design and simulation of a single-cell microheater is carried out using ANSY...

Background The gold-standard for diagnosis is growth of Mycobacterium tuberculosis on ascitic fluid or peritoneal culture. Due to the non-specific signs and symptoms of disease, its early diagnosis is difficult, especially in patients with decompensated cirrhosis. The reported sensitivity of ascitic fluid is low and to obtain tissue for peritoneal biopsy in patients with cirrhosis is difficult. Endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) is a good alternative to obtain peritoneal tissue for establishing the diagnosis of peritoneal TB. Objective To assess the role of EUS-FNA in the diagnosis of peritoneal tuberculosis in patients with decompensated cirrhosis. Methods Consecutive patients with peritoneal thickening, ascites and decompensated cirrhosis underwent EUS-FNA from the thickened omentum. Presence of granuloma or demonstration of acid fast bacilli was diagnostic of peritoneal tuberculosis. Results A total of 5 patients with CLD underwent EUS-FNA from omentum. FNA cytology revealed granuloma with multinucleated cells in all patients (100%) and AFB stain was positive in 2 of them (40%). Conclusion We hereby report the use of EUS guided fine needle aspiration (FNA) of peritoneum as a newer, safe and unexplored technique for diagnosis of peritoneal TB.

Hepatitis B virus (HBV) is one of the most common causes of liver cirrhosis and hepatocellular carcinoma. Despite recent strides in pharmacotherapy, complete cure of HBV infection still remains an enigma. The biggest obstacle in HBV therapy is clearance of covalently closed circular deoxyribonucleic acid (cccDNA). We discuss about the role of cccDNA in HBV life cycle, efficacy and shortcomings of currently available antivirals as well as promising novel targets to achieve ideal HBV cure.

Severe alcoholic hepatitis (AH) is not an uncommon indication for hospital admission in India. However, there is limited data from India on predictors of mortality in patients of severe AH. We analyzed the data on patients with severe AH admitted to our institute and compared various parameters and severity scores in predicting 90-day mortality. In this prospective study, we analyzed patients with severe AH (defined as discriminant function ≥ 32) admitted from January 2015 to February 2017 to our institute. All patients were administered standard treatment according to various guidelines, and their 90-day mortality was determined. Various hematologic, biochemical factors, and severity scores were compared between survivors and patients who died. A total of 183 patients (98% males, median age 41 years [range 20–70 years]) were included in our study. The median model for end-stage liver disease (MELD) was 26 (15–40). Ascites were present in 83% and hepatic encephalopathy in 38%. Only 21 (12%) could be offered steroid therapy, due to contraindications in the remaining. By 90 days, only 103 (56%) patients survived while 80 (44%) died. All patients died due to progressive liver failure and its complications. On multivariate analysis, presence of ascites, hepatic encephalopathy, high bilirubin, low albumin, high creatinine, high INR, and low potassium independently predicted 90-day mortality. All the scores performed significantly in predicting 90-day mortality with no statistically significant difference between them. MELD score had a maximum area under the curve 0.76 for 90-day mortality. A combination of Child class and presence of acute kidney injury (creatinine ≥ 1.35) was good in predicting 90-day mortality. Our patients had severe AH characterized by a median MELD score of 26 and had a 90-day mortality of 44%. Most patients were not eligible to receive corticosteroids. Presence of Child C status and high serum creatinine value (≥ 1.35 mg/dL) accurately predicted mortality. Newer treatment options need to be explored for these patients.

Hepatitis B Virus (HBV) infection is one of the major causes of morbidity, mortality and healthcare expenditure in India. There are no Indian consensus guidelines on prevention, diagnosis and management of HBV infection. The Indian National Association for Study of the Liver (INASL) set up a taskforce on HBV in 2016, with a mandate to develop consensus guidelines for diagnosis and management of HBV infection, relevant to disease patterns and clinical practices in India. The taskforce first identified contentious issues on various aspects of HBV management, which were allotted to individual members of the taskforce who reviewed them in detail. A 2-day round table discussion was held on 11th and 12th February 2017 at Port Blair, Andaman & Nicobar Islands, to discuss, debate, and finalize the consensus statements. The members of the taskforce reviewed and discussed the existing literature threadbare at this meeting and formulated the ‘INASL position statements’ on each of the issues. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong: 1, weak: 2) thus reflects the quality (grade) of underlying evidence (A, B, C, D). We present here the INASL position statements on prevention, diagnosis and management of HBV in India.

Zinc oxide (ZnO) thin films are prepared using sol–gel method for acetone vapor sensing. Zinc acetate dihydrate (Zn(CH3COO)2·2H2O) was taken as starting material and a stable and homogeneous solution was prepared in ethanol by deliquescing the zinc acetate and distinct amount of monoethanolamine as a stabilizing agent. The prepared solution was then coated on silicon substrates by spin coating method and then annealed at 650 °C for preparing ZnO thin films. The thickness of the film was maintained at 410 nm. The structural, morphological and optical studies were done for the synthesized ZnO thin films. The operating temperature and sensor response is considered to be an important parameter for the gas sensing behavior of any material. Therefore, the present study examined the effect of sensing behavior of 3% v/v gold (Au) doped ZnO thin films as a sensor. The response characteristics of 410 nm ZnO thin film for temperature ranging from 180 to 360 °C were determined for the acetone vapors. The reported study provides a significant development towards acetone sensors, where a very high sensitivity with rapid response and recovery times are reported with lowered optimal operating temperature as compared to bare ZnO nano-chains like structured thin films. In comparison to the bare ZnO thin films giving a response of 63 at an operating temperature of 320 °C, a much better response of 132.3 was observed for the Au doped ZnO thin films at an optimised operating temperature of 280 °C for a concentration of 500 ppm of acetone vapors.

The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. With international groups volunteering to join, the “APASL ACLF Research Consortium (AARC)” was formed in 2012, which continued to collect prospective ACLF patient data. Based on the prospective data analysis of nearly 1400 patients, the AARC consensus was published in 2014. In the past nearly four-and-a-half years, the AARC database has been enriched to about 5200 cases by major hepatology centers across Asia. The data published during the interim period were carefully analyzed and areas of contention and new developments in the field of ACLF were prioritized in a systematic manner. The AARC database was also approached for answering some of the issues where published data were limited, such as liver failure grading, its impact on the ‘Golden Therapeutic Window’, extrahepatic organ dysfunction and failure, development of sepsis, distinctive features of acute decompensation from ACLF and pediatric ACLF and the issues were analyzed. These initiatives concluded in a two-day meeting in October 2018 at New Delhi with finalization of the new AARC consensus. Only those statements, which were based on evidence using the Grade System and were unanimously recommended, were accepted. Finalized statements were again circulated to all the experts and subsequently presented at the AARC investigators meeting at the AASLD in November 2018. The suggestions from the experts were used to revise and finalize the consensus. After detailed deliberations and data analysis, the original definition of ACLF was found to withstand the test of time and be able to identify a homogenous group of patients presenting with liver failure. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information and areas requiring future studies are presented here., Article Highlights Updated on the basis of AARC data of >3300 cases enrolled into AARC registry prospectivelyACLF is distinct form Acute Decompensation of cirrhosisNewer sections on DILI-ACLF, AIH-ACLF, PVT/HVOTO–ACLFReversibility of Chronic Liver Disease in ACLFPortal and systemic hemodynamics and their relevance in ACLFAcute Portal Hypertension and Variceal progression in ACLFAARC score as a guide for treatment strategies in ACLFACLF in Children-first consensus on pediatric ACLF

Abnormalities of the walls of the biliary tree with occasional obstruction in patients with mainly extrahepatic portal hypertension leads to an entity defined as portal biliopathy. These patients are generally young, asymptomatic and predominantly from Asian countries. Symptomatic patients with portal biliopathy may present with pain, jaundice and upper gastrointestinal (GI) bleeding. They are difficult to manage and may require both diagnostic and therapeutic endoscopic procedures followed, if necessary, by a lienorenal shunt. After a shunt, the portal biliopathy usually regresses in most patients, but in some, especially those who have undergone endoscopic intervention, the obstruction remains. The reversal of portal biliopathy after portal decompression has been described usually six months after surgery. We report a reversal of portal biliopathy after a splenorenal shunt as early as eight days after the procedure.

Background Non-cirrhotic portal hypertension (NCPH) is a common cause of variceal bleed in developing countries. Transient elastography (TE) using Fibroscan is a useful technique for evaluation of fibrosis in patients with liver disease. There is a paucity of studies evaluating TE in patients with Non-cirrhotic portal fibrosis (NCPF) and none in Asian population. Aim of this study was to evaluate role of TE in NCPF. Methods Retrospective data of consecutive patients of NCPF as per Asian pacific association for the study of liver (APASL) guidelines were noted. All patients had liver biopsy, TE, computed tomography of abdomen and hepatic venous pressure gradient (HVPG). Twenty age and gender matched healthy subjects and forty age matched patients with cirrhosis with Child's A were taken as controls. Results A total of 20 patients with age [median 29.5 (13–50) years], Male:Female=11:9 with a diagnosis of NCPF were enrolled from January 2011 to December 2015. Of 20 patients 18 patients had variceal bleed and required endoscopic band ligation. There was no difference in haemoglobin and platelet count between patients with cirrhosis and NCPF, but total leucocyte count was significantly lower in patients with NCPF compared to patients with cirrhosis (3.2 vs 6.7×10 3 /cumm, P =0.01). TE (Fibroscan) was high in patients with NCPF compared to healthy controls (6.8 vs 4.7kPa, P =0.001) but it was significantly low compared to cirrhotic patients (6.8 vs 52.3kPa, P =0.001). HVPG is significant low in patients with NCPF compared to patients with cirrhosis (5.0 vs 16.0mmHg, P =0.001). Conclusion Transient elastography (Fibroscan) is significantly low in patients with NCPF compared to patients with cirrhosis. It is a very useful non-invasive technique to differentiate between Child's A cirrhosis and non-cirrhotic portal fibrosis.

Background Liver transplantation is the only curative option for patients with decompensated cirrhosis; however, many patients die while awaiting transplantation. Granulocyte colony-stimulating factor (GCSF) has shown promising results in improving outcomes in patients with advanced liver disease. We evaluated the efficacy of GCSF in patients with decompensated cirrhosis in an open-labeled randomized-controlled trial. Methods Consecutive patients with decompensated cirrhosis were randomized to receive either GCSF 300 μg twice daily for 5 days plus standard medical therapy (SMT) (GCSF+SMT group) or SMT alone (SMT alone group). Outcomes were assessed at 6 months from randomization. Results A total of 126 patients [median age: 53 (range: 31-76) years, 85% men] received GCSF+SMT and 127 patients received SMT alone. Baseline characteristics were similar in both the groups. The 5-day GCSF therapy did not lead to any significant adverse effects. At 6 months, in the GCSF+SMT group, 17 patients had died and nine were lost to follow-up, whereas in the SMT-alone group, 30 patients had died and 11 were lost to follow-up. By intention-to-treat analysis, cumulative survival was significantly higher in the GCSF+SMT group (79 vs. 68%; P=0.025). Also, significantly more patients (66%) showed improvement or stability in the Child-Turcotte-Pugh score at 6 months in the GCSF+SMT group compared with the SMT-alone group (51%, P=0.021). Conclusion GCSF therapy improves survival and clinical outcome in patients with decompensated cirrhosis. It may be useful in patients awaiting transplantation to prevent worsening during the waiting period. Further studies are needed to explore whether repeated periodic GCSF courses can further increase the survival and decrease the need for liver transplantation.Clinical trial registered at https://clinicaltrials.gov vide NCT02642003.

The objective of the paper is to design a Microelectronic Mechanical Systems(MEMS) based Capacitive Micromachined Ultrasonic Transducer (CMUT) which has been found to be superior in terms of bandwidth, transduction efficiency and array fabrication as compared to conventional piezoelectric transducers. With the years CMUT has been shown with different element geometries and fabrication techniques, however the optimization techniques and the application areas for the device persist. In this paper CMUT is simulated in COMSOL with Square and Circular diaphragm. FEM analysis is being carried out considering the same area for both the geometries in 3D.CMUT dynamics have been modeled by combining the Electrostatic module, Solid Mechanics Module and Mesh modules in COMSOL. The distributed stress and electric field are measured as function of time. This gives the exact comparison for the Eigen frequency, pull in voltage, deflection with applied DC bias and deflection of the diaphragm with AC superimposed on DC considering the isotropic Silicon as the diaphragm material. This simulation work provides results for the researcher to conclude on the geometry of the device prior to fabrication.

BACKGROUND Use of tourniquet during total knee arthroplasty (TKA) in patients with radiographic arterial calcifications is controversial. Intimal arterial calcifications are feared to be associated with ischemic complications such as delayed wound healing and arterial thrombosis, whereas medial calcifications stiffen the arterial wall, possibly leading to tourniquet failure and increased blood loss. METHODS We conducted a prospective cohort study to determine the incidence of tourniquet failure (inflated up to 300 mm Hg), blood transfusions, wound healing, and ischemic complications in thighs with and without arterial calcifications on preoperative radiographs, in 2548 consecutive primary TKAs conducted in our unit over a 5-year period. Eighty-six thighs showed vascular calcifications: 58 medial and 28 intimal. RESULTS Thighs with vascular calcifications had higher risk of tourniquet failure as compared to those without calcifications (P < .001), but with no significant increase in incidence of blood transfusions. All cases of tourniquet failure in the calcification group occurred in thighs with medial calcifications, whereas all cases of tourniquet failure in the control group occurred in obese patients. There was no difference in wound healing and ischemic complications in limbs with and without arterial calcifications. CONCLUSION The presence of arterial calcifications on preoperative radiographs increases the risk of tourniquet failure at 300 mm Hg in patients undergoing TKA, with no significant increase in rate of blood transfusions, wound healing or ischemic complications.

Background and Aims: Evaluation of significant liver fibrosis is important for treatment decision and treatment response evaluation in patients with chronic hepatitis B. Since liver biopsy is invasive and transient elastography (TE) has limited availability, various non-invasive blood parameters need evaluation for their capabilities for detection of significant fibrosis. Methods: In this retrospective study, records of patients who had undergone liver biopsy for treatment-naïve chronic hepatitis B were evaluated to obtain various non-invasive blood parameters (aspartate aminotransferase-to-platelet ratio index [referred to as APRI], Fibrosis-4 score [referred to as FIB-4], gamma-glutamyl transpeptidase-to-platelet ratio [referred to as GPR], and gamma-glutamyl transpeptidase-to-albumin ratio [referred to as GAR]), in addition to TE, to assess significant liver fibrosis and compare these to fibrosis stage in liver biopsy. Results: A total of 113 patients were included in the study (median age 33 [interquartile range: 11-82 years], 74% males). Most (75%) patients were HBeAg-negative. The liver biopsy revealed significant fibrosis (Ishak ≥3) in 13% of the patients and nil or mild fibrosis (Ishak

Background: Moderate (Haemoglobin (Hb) 7-9.9g/dl) and severe anaemia (Hb

BACKGROUND: COVID-19 is a new disease which has become a global pandemic, and is caused by a novel coronavirus, SARS-CoV-2 The disease is still not very well characterized, and factors associated with severe clinical course are not well known METHODS: The main objectives were to determine the demographic, clinical and laboratory manifestations of COVID-19 and to identify the factors associated with severe clinical course We searched the PubMed for studies published between Jan 1, 2020 and Mar 17, 2020, and included them if they were in English language, published in full, were retrospective or prospective observational or case control study with data on clinical, laboratory and imaging features of adult patients with COVID-19 disease from single or multiple centers Studies that included exclusively pediatric patients were excluded The demographic, clinical and laboratory data was displayed as n (%) or mean (SD) The meta-analysis on factors associated with severe clinical course was performed using the random effects model, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated as the effect sizes FINDINGS: We included 58 studies (6892 patients) for the systematic review on clinical manifestations and 21 studies (3496 patients) for meta-analysis on factors associated with severe clinical course The mean age of patients with COVID-19 is 49 7±16 3 years with a male to female ratio of 1 2:1 Common symptoms and their frequency are: fever (83 4%), cough (60 5%), fatigue (33 8%), sputum (28 9%), dyspnea (22 1%), myalgia (20 6%), chest tightness / pain (16 3%), sore throat (13 5%), headache (11 2%), diarhhea (7 5%), nasal congestion / rhinorrhea (6 7%), nausea / vomiting (5 6%), pain abdomen (4 6%), and hemoptysis (1 7%) The comorbidities associated with COVID-19 are: hypertension (18 4%), diabetes mellitus (9 8%), cardiovascular diseases (8 8%), endocrine diseases (5 8%), gastrointestinal diseases (5%), CLD (3%), and COPD (2 8%) Among the laboratory parameters WBC was low in 27%, high in 9%, platelets were low in 22 9%, creatinine was high in 6 5%, AST was high in 25 3%, ALT was high in 22 7%, bilirubin was high in 8 8%, albumin was low 60 1%, CT chest was abnormal in 89%, CRP was high in 67 5%, LDH was high in 52%, D-dimer was high in 34 8%, CK was high in 14 4%, and procalcitonin was high in 15 4% Factors significantly associated severe clinical course (with their ORs) are as follows: High CRP (5 78), high procalcitonin (5 45), age >60 (4 82), dyspnea (4 66), high LDH (4 59), COPD (4 37), low albumin (4 34), high D-dimer (4 03), cardiac disease (3 88), low lymphocyte count (3 22), any associated comorbidity (3 16), diabetes mellitus (3 11), high WBC count (2 67), high bilirubin level (2 55), high creatinine (2 34), high AST (2 31), hypertension (2 30), low platelets (1 78), High ALT (1 69), high CK (1 66), fever spikes ≥39°C (1 59), diarrhea (1 55), male gender (1 47), and sputum (1 35) INTERPRETATION: Identification of these factors associated with severe COVID-19 will help the physicians working at all levels of healthcare (primary, secondary, tertiary and ICU) in determining which patients need home care, hospital care, HDU care, and ICU admission;and thus, prioritize the scarce healthcare resource use more judiciously Many of these identified factors can also help the public at large in the current COVID-19 epidemic setting, to judge when they should seek immediate medical care Funding Statement: None Declaration of Interests: The authors declare no competing interests

Aim Clinical hunt for the cause of primary or unreferred abdominal pain is guided by either by its visceral or somatic root. Methods A structured clinical examination and conventional imaging leads to localization of the cause of abdominal pain. The pathology is mostly localized to an abdominal visceral content or neighboring reteroperitoneal structure, which are fixed in their location on imaging. Abdominal & peritoneal spaces are free of any freely mobile structures outside the luminal viscera. Even the image picked pathologies, usually urinary tract stones or foreign bodies in gastrointestinal tracts, shift their image positions at a speed dictated by the physiological function of the viscera. Results Any finding of an image that shifts faster than the physiological movement and is extraluminal is a free or loose peritoneal body. These bodies have been found either on autopsies or as incidental findings on exploratory laparotomy for other causes. Conclusion These have a boiled egg appearance and are known as peritoneal mouse. A preoperative diagnosis of these bodies in abdominal pain has not been reported so far.

Hepatocellular carcinoma (HCC) is the 6th most common cancer and the second most common cause of cancer-related mortality worldwide. There are currently no universally accepted practice guidelines for the diagnosis of HCC on imaging owing to the regional differences in epidemiology, target population, diagnostic imaging modalities, and staging and transplant eligibility. Currently available regional and national guidelines include those from the American Association for the Study of Liver Disease (AASLD), the European Association for the Study of the Liver (EASL), the Asian Pacific Association for the Study of the Liver, the Japan Society of Hepatology, the Korean Liver Cancer Study Group, Hong Kong, and the National Comprehensive Cancer Network in the United States. India with its large population and a diverse health infrastructure faces challenges unique to its population in diagnosing HCC. Recently, American Association have introduced a Liver Imaging Reporting and Data System (LIRADS, version 2017, 2018) as an attempt to standardize the acquisition, interpretation, and reporting of liver lesions on imaging and hence improve the coherence between radiologists and clinicians and provide guidance for the management of HCC. The aim of the present consensus was to find a common ground in reporting and interpreting liver lesions pertaining to HCC on imaging keeping LIRADSv2018 in mind.

Background Sarcopenia is an under-recognized complication of cirrhosis which negatively impacts survival and quality of life. There is a paucity of Indian data regarding the prevalence and clinical significance of sarcopenia in cirrhotics. Our aim was to assess the prevalence of sarcopenia and its impact on short-term morbidity and mortality (6 months) of patients with cirrhosis. Methods This was a prospective study of 156 consecutive patients with liver cirrhosis. The cross-sectional area of the right psoas muscle was measured at the level of L3-vertebra and Psoas muscle index (PMI)(mm2/m2) was calculated. Sarcopenia was defined based on the CT study of patients with irritable bowel syndrome (controls), as PMI less than 295 mm2/m2 and 356 mm2/m2 for females and males respectively. Results 74(47.4%) patients had sarcopenia. Sarcopenia was more common in males and patients with alcohol-related liver disease(ALD). 70% of ALD patients had sarcopenia. There was a negative correlation between the PMI and severity of liver disease as assessed by Child and MELD scores (r= -0.591 and -0.465 respectively). Patients with encephalopathy, ascites and coagulopathy had a higher prevalence of sarcopenia (table 1). 55(74.3% v/s 22%) of the patients who had sarcopenia required readmission within 6 months of follow-up as compared to those without sarcopenia (p=0.0001) (figure 1). 6-months mortality was higher among patients with sarcopenia (24.3% v/s 3.7%; p=0.002). MELD score and PMI were independently associated with higher mortality. PMI Cut off value for predicting mortality obtained was 305.9 mm2/m2with a sensitivity of 76.2% and a false positivity of 22.2%. (AUC was 0.805; 95% confidence interval:0.69–0.91,p=0.001). Conclusions PMI for the assessment of sarcopenia is simple, objective and reproducible. Sarcopenia is seen in about half of the patients with liver cirrhosis and more common in patients with alcohol-related liver disease, ascites and encephalopathy. Sarcopenic patients have frequent hospitalizations, lower short-term survival and worse prognosis.

Background Acute mesenteric ischemia (AMI) is a medical emergency and constitutes around 0.09–0.2% of all cases of acute abdomen, with 50% in-hospital mortality. According to Western literature, AMI most commonly occurs in the 7th-8th decade, with 50% mortality, and arterial occlusion being the most common cause. The clinical profile of patients of AMI in India may be different from Western patients; however, the data is lacking. We aimed to study the clinical profile of patients of AMI at a tertiary care centre in northern India. Methods We retrospectively collected data of consecutive patients of AMI admitted our department from March 2014 to Jan 2019. Data regarding epidemiology, clinical presentation, etiology, imaging, treatment and outcome were studied. Results Our study included 59 patients (74% males, median age 52 years). The most common presentation was pain abdomen in 88%, obstipation 40%, gastrointestinal bleeding 17%, and peritonitis 0.5%. Mesenteric Venous thrombosis was seen in 56%, mesenteric artery thrombosis in 30%, mixed thrombosis in 10% and non-occlusive ischemia in 3%. Most (71%) patients required surgical resection. The overall in-hospital mortality was 34%. Conclusions Unlike the Western literature, the AMI in North India is most commonly due to venous thrombosis, presenting in the sixth decade, and has a lower mortality rate than West. Large prospective studies will be required to elucidate the cause of these differences from Western data.