APASL-ACLF Research Consortium-Artificial Intelligence (AARC-AI) model precisely predicts outcomes in acute-on-chronic liver failure patients.

BACKGROUND AND AIMS: We hypothesized that artificial intelligence (AI) models are more precise than standard models for predicting outcomes in acute-on-chronic liver failure (ACLF). METHODS: We recruited ACLF patients between 2009 and 2020 from APASL-ACLF Research Consortium (AARC). Their clinical data, investigations and organ involvement were serially noted for 90-days and utilized for AI modelling. Data were split randomly into train and validation sets. Multiple AI models, MELD and AARC-Model, were created/optimized on train set. Outcome prediction abilities were evaluated on validation sets through area under the curve (AUC), accuracy, sensitivity, specificity and class precision. RESULTS: Among 2481 ACLF patients, 1501 in train set and 980 in validation set, the extreme gradient boost-cross-validated model (XGB-CV) demonstrated the highest AUC in train (0.999), validation (0.907) and overall sets (0.976) for predicting 30-day outcomes. The AUC and accuracy of the XGB-CV model (%Δ) were 7.0% and 6.9% higher than the standard day-7 AARC model (p < .001) and 12.8% and 10.6% higher than the day 7 MELD for 30-day predictions in validation set (p < .001). The XGB model had the highest AUC for 7- and 90-day predictions as well (p < .001). Day-7 creatinine, international normalized ratio (INR), circulatory failure, leucocyte count and day-4 sepsis were top features determining the 30-day outcomes. A simple decision tree incorporating creatinine, INR and circulatory failure was able to classify patients into high (~90%), intermediate (~60%) and low risk (~20%) of mortality. A web-based AARC-AI model was developed and validated twice with optimal performance for 30-day predictions. CONCLUSIONS: The performance of the AARC-AI model exceeds the standard models for outcome predictions in ACLF. An AI-based decision tree can reliably undertake severity-based stratification of patients for timely interventions.

Modified ultrafiltration and postoperative course in patients undergoing repair of tetralogy of fallot.

BACKGROUND: Expected benefits of modified ultrafiltration (MUF) include increased hematocrit, reduction of total body water and inflammatory mediators, improved left ventricular systolic function, and improved systolic blood pressure and cardiac index (CI) following cardiopulmonary bypass (CPB). This prospective randomized trial tested this hypothesis. METHODS: Seventy-nine patients undergoing intracardiac repair of tetralogy of fallot were randomized to conventional ultrafiltration (CUF) + MUF (n = 39) or only CUF group (n = 40). The primary outcome was a change in hematocrit. Secondary outcomes were changes in peak airway pressures, ventilatory support, blood transfusions, time to peripheral rewarming, mean arterial pressure, central venous pressure, inotrope score (IS), and CI. Serum inflammatory markers were measured. RESULTS: Baseline hematocrit was 50.6 ± 10.02 in the only CUF group whereas it was 43.9 ± 5.55 in the CUF + MUF group (p = .36). Following MUF, the CUF + MUF group had higher hematocrit (44.7 ± 0.50 g/dl) compared to the only CUF group (37.2 ± 0.49 g/dl), p ≤ .001 after adjusting for baseline hematocrit. Central venous pressure (mmHg) immediately following sternal closure was 9.27 ± 3.12 mmHg in the CUF + MUF group and 10.52 ± 2.2 mmHg in the only CUF group (p = .04). In the intensive care unit (ICU), they were 11.52 ± 2.20 mmHg in the only CUF group and 10.84 ± 2.78 mmHg in the CUF + MUF group (p = .02). Time to peripheral rewarming was 6.30 ± 3.91 h in the CUF + MUF group and 13.67 ± 3.91 h in the only CUF group (p = .06). Peak airway pressures in ICU were 17 ± 2 mmHg versus 20.55 ± 2.97 mmHg in CUF + MUF group & only CUF group, respectively, p < .001). Duration of mechanical ventilation was 6.3 ± 2.7 h in CUF + MUF group compared to 14.7 ± 3.5 h in the only CUF group (p = .002). IS was 11.52 ± 2.20 in the only CUF group compared to 10.84 ± 2.78 in CUF + MUFs group. Eight of 39 (20.5%) patients in the CUF + MUF group had IS > 10 compared to 22 of 40 (55%) patients in the only CUF group (p = .02). Serum Troponin-T and interleukin-6 levels were lower in the CUF + MUF group; TNF-α and CPK-MB were similar. ICU and hospital stay were similar. CONCLUSION: Patients undergoing a combination of CUF and MUF had higher postoperative hematocrit, decreased duration of mechanical ventilation, lower need for inotropes and lower interleukin-6 and Troponin-T levels. This group had better postoperative outcomes. This study was registered with the Clinical trials registry of India (CTRI/2017/11/010512) before commencement.

Removal of Cr (VI) from aqueous solution by activated charcoal derived from Sapindus trifoliate L fruit biomass using continuous fixed bed column studies.

In this study, the removal of hexavalent chromium from aqueous solution were examined using activated charcoal derived from Sapindus trifoliate L fruit biomass in continuous fixed-bed column studies. The activated S. trifoliate L fruit charcoal was prepared by treating the fruit powder using concentrated nitric acid solution. Experiments were performed to investigate the effect of bed height and initial concentration on the breakthrough and saturation times. The breakthrough and saturation time increases with increase in bed height and initial concentration of chromium solutions. The maximum adsorption capacity of S. trifoliate L charcoal for hexavalent chromium was found to be 1.719 mg/g in the bed height 15 cm and initial concentration 10 mg/L, respectively. Column data required at various conditions were explained using Bohart-Adams and Thomas model. Two models were found to be suitable to describe the definite part of the dynamic behaviour of the column with regard to bed-height and initial concentration of hexavalent chromium. On comparison of Adjusted R2 and estimated standard error, the Thomas model was found to best-fitted model and can be used to predict the adsorption of the hexavalent chromium in fixed-bed column studies. Activated S. trifoliate L fruit charcoal was characterised by SEM-EDX and FTIR analysis.

Drug-Induced Acute-on-Chronic Liver Failure in Asian Patients.

OBJECTIVES: Acute insults from viruses, infections, or alcohol are established causes of decompensation leading to acute-on-chronic liver failure (ACLF). Information regarding drugs as triggers of ACLF is lacking. We examined data regarding drugs producing ACLF and analyzed clinical features, laboratory characteristics, outcome, and predictors of mortality in patients with drug-induced ACLF. METHODS: We identified drugs as precipitants of ACLF among prospective cohort of patients with ACLF from the Asian Pacific Association of Study of Liver (APASL) ACLF Research Consortium (AARC) database. Drugs were considered precipitants after exclusion of known causes together with a temporal association between exposure and decompensation. Outcome was defined as death from decompensation. RESULTS: Of the 3,132 patients with ACLF, drugs were implicated as a cause in 329 (10.5%, mean age 47 years, 65% men) and other nondrug causes in 2,803 (89.5%) (group B). Complementary and alternative medications (71.7%) were the commonest insult, followed by combination antituberculosis therapy drugs (27.3%). Alcoholic liver disease (28.6%), cryptogenic liver disease (25.5%), and non-alcoholic steatohepatitis (NASH) (16.7%) were common causes of underlying liver diseases. Patients with drug-induced ACLF had jaundice (100%), ascites (88%), encephalopathy (46.5%), high Model for End-Stage Liver Disease (MELD) (30.2), and Child-Turcotte-Pugh score (12.1). The overall 90-day mortality was higher in drug-induced (46.5%) than in non-drug-induced ACLF (38.8%) (P = 0.007). The Cox regression model identified arterial lactate (P < 0.001) and total bilirubin (P = 0.008) as predictors of mortality. DISCUSSION: Drugs are important identifiable causes of ACLF in Asia-Pacific countries, predominantly from complementary and alternative medications, followed by antituberculosis drugs. Encephalopathy, bilirubin, blood urea, lactate, and international normalized ratio (INR) predict mortality in drug-induced ACLF.

Elizabethkingia Meningoseptica: An Emerging Nosocomial Pathogen Causing Septicemia in Critically Ill Patients.

Elizabethkingia meningoseptica (E. meningoseptica), is an opportunistic Gram-negative bacteria, normally found in water and soil, notorious for causing nosocomial infections in extremes of ages and immunocompromised patients. It is now emerging as a serious nosocomial pathogen, intrinsically resistant to several commonly used antibiotics (e.g. beta-lactams, aminoglycosides, carbapenems and colistin etc. and a cause of high mortality in critically ill patients in intensive care units (ICUs). We report the first case of E. meningoseptica sepsis in a 5 month old child after open heart surgery for transposition of great arteries, initially on extracorporeal membrane oxygenation, then prolonged mechanical ventilation, with various invasive devices, inotropes and exposed to broad spectrum antibiotics in our ICU. The case highlights the potential risk factors responsible for E.meningoseptica sepsis. Its unusual pattern of resistance to many commonly used antibiotics makes this organism difficult to treat. HOW TO CITE THIS ARTICLE: Sahu MK, Balasubramaniam U et al. Elizabethkingia Meningoseptica: An Emerging Nosocomial Pathogen Causing Septicemia in Critically Ill Patients. Indian J of Crit Care Med 2019;23(2):104-105.

Peritoneal Dialysis in Pediatric Postoperative Cardiac Surgical Patients.

BACKGROUND: We determined the prevalence of acute kidney injury requiring peritoneal dialysis (PD), the factors associated with early PD initiation, prolonged PD and mortality among pediatric postoperative cardiac surgical patients. MATERIALS AND METHODS: The hospital records of 23 children, aged 12 years or younger, who had undergone cardiac surgery and required PD subsequently, during a 1-year period were reviewed. Demographic data, intraoperative variables, and postoperative complications were compared between survivors and nonsurvivors of PD, between the short and long duration PD groups, and between the early and late PD initiation groups. RESULTS: Six hundred and eight pediatric patients who underwent open heart surgery were enrolled in this study. 23 (3.78%) of them required PD. When compared with survivors (n = 11), non survivors (n =12) were more likely to have a higher serum procalcitonin (p = 0.01), higher serum potassium on day 2 (p = 0.001), day 3 (p = 0.04), day of termination of PD (p = 0.001) and a lower urine output on day 3 of PD (p = 0.03). Prolonged PD was associated with time of PD initiation (p = 0.01), a higher postoperative serum creatinine on day 3 (p = 0.01) of PD initiation as well on the day of PD termination (p = 0.01) and the final outcome in terms of survival (p = 0.02). Factors significantly associated with an early PD initiation were CPB time (p = 0.04), sepsis (p = 0.02) and shorter PD duration (p = 0.003). CONCLUSION: PD is very useful mode of renal replacement therapy among pediatric postoperative cardiac surgical patients. The intraoperative and postoperative variables have important association with the time of PD initiation, PD duration and patient survival. HOW TO CITE THIS ARTICLE: Sahu MK, Bipin C, Arora Y, Singh SP, Devagouru V, Rajshekar P, et al. Peritoneal Dialysis in Pediatric Postoperative Cardiac Surgical Patients. Indian J Crit Care Med 2019;23(8):371-375.

A Simple Pre-endoscopy Score for Predicting Risk of Malignancy in Patients with Dyspepsia: A 5-Year Prospective Study.

BACKGROUND: The guidelines for performing endoscopy in dyspeptic patients based on clinical parameters alone have shown variable performance, and there is a need for better prediction tools. AIM: We aimed to prospectively develop and validate a simple clinical-cum-laboratory test-based scoring model to identify dyspeptic patients with high risk of upper gastrointestinal malignancy (UGIM). METHODS: Adult patients with dyspeptic symptoms were prospectively recruited over 5 years. Clinical details including alarm features were recorded, and blood tests for hemoglobin and albumin were done before endoscopy. The presence of UGIM was the primary outcome. Risk factors for UGIM were assessed, and based on the OR of significant factors, a predictive scoring model was constructed. ROC curve was plotted to identify optimal cutoff score. The model was validated using bootstrapping technique. RESULTS: The study included 2324 patients (41.9 ± 12.8 years; 33.4% females). UGIM was noted in 6.8% patients. The final model had following five positive predictors for UGIM-age > 40 years (OR 3.3, score 1); albumin ≤ 3.5 g% (OR 3.4, score 1); Hb ≤ 11 g% (OR 3.3, score 1); alarm features (OR 5.98, score 2); recent onset of symptoms (OR 8.7, score 3). ROC curve had an impressive AUC of 0.9 (0.88-0.93), and a score of 2 had 92.5% sensitivity in predicting UGIM. Validation by bootstrapping showed zero bias, which further strengthened our model. CONCLUSION: This simple clinical-cum-laboratory test-based model performed very well in identifying dyspeptic patients at risk of UGIM. This can serve as a useful decision-making tool for referral for endoscopy.

Hospital-acquired Infection: Prevalence and Outcome in Infants Undergoing Open Heart Surgery in the Present Era.

BACKGROUND: The aim of this study is to evaluate the causal relation between hospital-acquired infection (HAI) and clinical outcomes following cardiac surgery in neonates and infants and to identify the risk factors for the development of HAI in this subset of patients. MATERIALS AND METHODS: After Ethics committee approval, one hundred consecutive infants undergoing open heart surgery (OHS) between June 2015 and June 2016 were included in this prospective observational study. Data were prospectively collected. The incidence and distribution of HAI, the microorganisms, their antibiotic resistance and patients' outcome were determined. The Centers for Disease Control and Prevention criteria were used for defining HAIs. Univariate and multivariate risk factor analysis was done using Stata 14. RESULTS: Sixteen infants developed microbiologically documented HAI after cardiac surgery. Neonatal age group was found to be most susceptible. Lower respiratory tract infections accounted for majority of the infections (47.4%) followed by bloodstream infection (31.6%), urinary tract infection (10.5%), and surgical site infection (10.5%). Klebsiella (36.8%) and Acinetobacter (26.3%) were the most frequently isolated pathogens. HAI was associated with prolonged ventilation duration (P = 0.005), Intensive Care Unit stay (P = 0.0004), and hospital stay (P = 0.002). Multivariate risk factor analysis revealed that preoperative hospital stay (odds ratio [OR] 1.22, 95% confidence interval (CI) 1.6-1.39, P = 0.004), and prolonged cardiopulmonary bypass (CPB) (OR 1.03, 95% CI 1.01-1.05, P = 0.001) were associated with the development of HAI. CONCLUSION: HAI still remains a dreaded complication in infants after OHS and contributing to morbidity and mortality. Strategies such as decreasing preoperative hospital stay, CPB time, and early extubation should be encouraged to prevent HAI.

Adsorption studies of chromium (VI) removal from water by lanthanum diethanolamine hybrid material.

In the present research work, lanthanum diethanolamine hybrid material is synthesized by co-precipitation method and used for the removal of Cr(VI) from synthetic dichromate solution and hand pump water sample. The sorption experiments were carried out in batch mode to optimize various influencing parameters such as adsorbent dose, contact time, pH, competitive anions and temperature. The characterization of the material and mechanism of Cr(VI) adsorption on the material was studied by using scanning electron microscope, Fourier transform infrared, X-ray diffraction, Brunauer-Emmett-Teller and thermogravimetric analysis-differential thermal analysis. Adsorption kinetics studies reveal that the adsorption process followed first-order kinetics and intraparticle diffusion model with correlation coefficients (R2) of 0.96 and 0.97, respectively. The adsorption data were best fitted to linearly transformed Langmuir isotherm with correlation coefficient (R2) of 0.997. The maximum removal of Cr(VI) is found to be 99.31% at optimal condition: pH = 5.6 of the solution, adsorbent dose of 8 g L(-1) with initial concentration of 10mgL(-1) of Cr(VI) solution and an equilibrium time of 50 min. The maximum adsorption capacity of the material is 357.1 mg g(-1). Thermodynamic parameters were evaluated to study the effect of temperature on the removal process. The study shows that the adsorption process is feasible and endothermic in nature. The value of E (260.6 kJ mol(-1)) indicates the chemisorption nature of the adsorption process. The material is difficult to be regenerated. The above studies indicate that the hybrid material is capable of removing Cr(VI) from water.

Asymptomatic portal hypertension incidentally detected during upper gastrointestinal endoscopy.

Esophageal or gastric varices may be incidentally seen during endoscopy for dyspeptic or reflux symptoms. However, the frequency of their occurrence in these patients is unknown. Our center follows the scope and treat strategy for adult patients with dyspeptic or reflux symptoms and this provided us an opportunity to study this. Apart from providing an idea on the etiological spectrum, our data suggests that patients with incidentally detected varices have well preserved liver function which may provide a window for better management.

Removal efficiency of fluoride by novel Mg-Cr-Cl layered double hydroxide by batch process from water.

The fluoride ion removal from aqueous solution using synthesized Mg-Cr-Cl layered double hydroxide has been reported. Mg-Cr-Cl was characterized by X-ray powder diffraction, Fourier-transform infrared, thermo-gravimetric analysis, differential thermal analysis, and scanning electron microscope. Adsorption experiments were carried out in batch mode as a function of adsorption dosages, contact time, pH, and initial fluoride concentration to get optimum adsorption capacity. The adsorption kinetic study showed that the adsorption process followed first order kinetics. The fluoride removal was 88.5% and 77.4% at pH 7 with an adsorbent dose of 0.6 g/100 mL solution and initial fluoride concentration of 10 mg/L and 100 mg/L, respectively. The equilibrium was established at 40 min. Adsorption experiment data were fitted well with Langmuir isotherm with R2 = 0.9924. Thermodynamic constants were also measured and concluded that the adsorption process was spontaneous and endothermic in nature. The removal percentage decreased slowly with increasing pH. This process is suitable for industrial effluents. The regeneration of the material is not possible.

Posttransplant lymphoproliferative disorder in a heart transplant recipient: a case report.

Malignancy in heart transplant recipients is a grave complication. Post-transplant lymphoproliferative disorder (PTLD) is the second most common tumour in adults and commonest in children. The incidence varies with the transplanted organ from 1 to 2% following kidney transplantation to as high as 10% following thoracic organ transplantation due to different immunosuppression intensity. PTLD include a wide spectrum of diseases ranging from benign proliferation of lymphoid tissue to frank malignancy with aggressive behaviour (lymphoma). Epstein-Barr virus (EBV) infection and prolonged immunosuppressant therapy are implicated in the pathogenesis of PTLD. The incidence of PTLD varies from 2.6% at 1 year to 28% at 10 years post-transplant. Seronegativity for EBV in recipients with seropositive donors increases the risk of PTLD in recipients. The majority of early-onset PTLDs (85%) are of B-cell origin and associated with EBV. Timely and accurate diagnosis with histological examination of lymphoid tissue is essential for early intervention. Reduction of immunosuppressive therapy (IST) and rituximab usually are effective in remission of PTLD. In resistant cases, chemotherapy is given with or without rituximab. Adoptive T-cell transfer represents a promising therapeutic approach. Early PTLD respond well to lowering immunosuppression and has a favourable prognosis compared to late PTLD. Five-year survival is 30% for high-grade lymphomas. The prognosis of EBV-negative lymphomas is worse. One out of 40 heart transplant recipients followed up in our centre developed PTLD. He was treated to remission and we describe this case here.

As(III) removal from aqueous solutions using simultaneous oxidation and adsorption process by hierarchically magnetic flower-like Fe3O4@C-dot@MnO2 nanocomposite.

In the present study, a magnetic flower-like Fe3O4@C-dot@MnO2 nanocomposite was synthesized by hydrothermal method and applied for As(III) removal by oxidation and adsorption process. Individual property of the entire material (i.e. magnetic property of Fe3O4, mesoporous surface property of C-dot and oxidation property of MnO2) make the composite efficient with good adsorption capacity for As(III) adsorption. The Fe3O4@C-dot@MnO2 nanocomposite had a saturation magnetization of 26.37 emu/g and it magnetically separated within 40 s. The Fe3O4@C-dot@MnO2 nanocomposite was able to reduce the 0.5 mg/L concentration of As(III) to 0.001 mg/L in just 150 min at pH 3. Pseudo-second-order kinetic and Langmuir isotherm model agreed with experimental data. The uptake capacity of Fe3O4@C-dot@MnO2 nanocomposite was 42.68 mg/g. The anions like chloride, sulphate and nitrate did not show any effect on removal but carbonate and phosphate influenced the As(III) removal rate. Regeneration was studied with NaOH and NaClO solution and the adsorbent was used for repeated five cycles above 80% removal capacity. The XPS studies proposed that As(III) first oxidized to As(V) then adsorb on the composite surface. This study shows the potential applicability of Fe3O4@C-dot@MnO2 nanocomposite to high extent and gives a suitable path for the proficient removal of As(III) from wastewater.

C-reactive protein/albumin and ferritin as predictive markers for severity and mortality in patients with acute pancreatitis.

Introduction: Acute pancreatitis (AP) is a life-threatening gastrointestinal disease with high mortality and morbidity. However, scoring systems or prognostic indicators for assessing AP are cumbersome and expensive, and have not proved accurately to predict outcomes. Aim: We conducted a study with the aim of evaluating the predictive accuracy of C-reactive protein (CRP)/albumin and ferritin regarding outcomes in patients with AP. Material and methods: A prospective study was conducted in a tertiary care referral centre in Odisha from March 2020 to April 2021. A total of 116 consecutive patients of AP were enrolled in the study. CTSI, APACHE II, ferritin, and the CRP/albumin ratio were calculated. Results: The mean age of patients was 40.63 ±5.49 years with a male predominance (73%). Alcohol was most common aetiology (46.6%), and the overall mortality was 18%. Mean ferritin and the CRP/albumin ratio were also significantly higher in severe AP as compared to moderately severe AP and mild AP (p < 0.001). The CRP/albumin ratio (AOR = 1.26, 95% CI: 1.02-1.56, p = 0.02) was found to be independent predictor of mortality in Cox regression multivariate analysis and had the highest AUC for predicting the severity of acute pancreatitis. Serum ferritin had higher AUC (0.89, 0.83-0.91, p < 0.001) for the development of necrosis in acute pancreatitis, but it failed to be proven as an independent predictor of mortality. Conclusions: CRP/albumin is a simple, cheap, and easily available biomarker predicting the development of severe pancreatitis, and it was found to be an independent predictor of mortality in AP.

AARC score determines outcomes in patients with alcohol-associated hepatitis: a multinational study.

BACKGROUND AND AIM: Acute-on-chronic liver failure (ACLF) is a severe form of alcoholic hepatitis (SAH). We aimed to study the natural course, response to corticosteroids (CS), and the role of the Asian Pacific Association for the Study of Liver (APASL) research consortium (AARC) score in determining clinical outcomes in AH patients. METHODS: Prospectively collected data from the AARC database were analyzed. RESULTS: Of the 1249 AH patients, (aged 43.8 ± 10.6 years, 96.9% male, AARC score 9.2 ± 1.9), 38.8% died on a 90 day follow-up. Of these, 150 (12.0%) had mild-moderate AH (MAH), 65 (5.2%) had SAH and 1034 (82.8%) had ACLF. Two hundred and eleven (16.9%) patients received CS, of which 101 (47.87%) were steroid responders by day 7 of Lille's model, which was associated with improved survival [Hazard ratio (HR) 0.15, 95% CI 0.12-0.19]. AARC-ACLF grade 3 [OR 0.28, 0.14-0.55] was an independent predictor of steroid non-response and mortality [HR 3.29, 2.63-4.11]. Complications increased with degree of liver failure [AARC grade III vs. II vs I], bacterial infections [48.6% vs. 37% vs. 34.7%; p < 0.001); extrahepatic organ failure [66.9% vs. 41.8% vs. 35.4%; p < 0.001] respectively. The AARC score better discriminated 90-day mortality. Harrell's C-index was 0.72 compared to other scores. CONCLUSION: Nearly 4 of 5 patients with AH present with ACLF. Such patients have a higher risk of infections, organ failures, lower response to CS, and higher mortality. Patients with AH and ACLF with AARC grade 3 should be considered for an early liver transplant.

Mechanistic insight into the adsorption of mercury (II) on the surface of red mud supported nanoscale zero-valent iron composite.

Recently, nanoscale zero-valent iron (nZVI) particles have been efficiently used in the remediation of many heavy metals, yet potential agglomeration and loss of nZVI remain a critical area of research. In this study, we used red mud as a stable supporting medium to develop red mud modified nZVI to form (RM-nZVI) composite. We assessed its sorptive/reductive removal of mercury (Hg2+) from aqueous solutions. The RM-nZVI was synthesized through the reduction of ferric iron by sodium borohydride (NaBH4) in the presence of red mud. Morphological characterization of RM-nZVI confirmed its diffusion state with lesser aggregation. The RM-nZVI has the BET surface area, pore diameter, and pore volume as 111.59 m2g-1, 3.82 nm, and 0.49 cm3g-1, respectively. Adsorption of mercury (Hg2+) by RM-nZVI exhibits pH-dependent behavior with increased removal of Hg2+ with the increase in pH up to 5, and the removal rate decreased gradually as the pH increased from 5 to 10. Extensive characterization of RM-nZVI corroborated the evidence that the removal of Hg2+ was initially by rapid physical adsorption, followed by a reduction of Hg2+ to Hg0. The adsorption data were best fitted with Langmuir isotherm with R2 (correlation coefficient) > 0.99 with high uptake capacity of 94.58 (mg g-1). The novel RM-nZVI composite with enhanced sorptive and reductive capacity is an ideal alternative for removing Hg2+ from contaminated water.

Effect of energy- and/or protein-dense enteral feeding on postoperative outcomes of infant surgical patients with congenital cardiac disease: A systematic review and meta-analysis.

Infants with congenital heart disease (CHD) are malnourished because of poor dietary intakes and increased requirements. Energy requirements are higher due to increased resting energy expenditure. There are lacunae of nutrition recommendations for these infants. Therefore, this systematic review and meta-analysis was conducted to determine the effect of energy- and/or protein-dense feeds in postoperative CHD infants as compared with the standard feeding. An online literature search was performed on four databases by using different English-language keywords between 2000 and 2020. The inclusion criteria were peer reviewed journals and open access original articles on the feeding practices in infants undergoing congenital heart surgery. Exclusion criteria were editorials, commentaries, discussion papers, conference abstracts, reviews, duplicate studies, and articles on preterm infants and preoperative nutrition. A total of five studies matched the inclusion criteria. The standard mean difference (SMD) of energy intake (SMD = 13.40 kcal, P = 0.001), protein intake (SMD = 2.37 g, P = 0.001), and weight (SMD = 4.99 g, P = 0.001) was significantly higher in the intervention group. The SMD of ventilation duration (SMD = -0.18 h, P = 0.90), intensive care unit (ICU) length of stay (LOS) (SMD = -0.25 d, P = 0.70), and hospital LOS (SMD = -0.20 d, P = 0.67) were not statistically significant between the two groups. Enriched enteral nutrition for the postoperative pediatric patients with cardiac disease helps in achieving energy and protein goals and improves the overall postoperative outcomes (ie, ventilation duration, maintenance of weight, ICU LOS, and hospital LOS).

Acute variceal bleeding portends poor outcomes in patients with acute-on-chronic liver failure: a propensity score matched study from the APASL ACLF Research Consortium (AARC).

BACKGROUND AND AIMS: Limited data exist regarding outcomes of acute variceal bleeding (AVB) in patients with acute-on-chronic liver failure (ACLF), especially in those with hepatic failure. We evaluated the outcomes of AVB in patients with ACLF in a multinational cohort of APASL ACLF Research Consortium (AARC). METHODS: Prospectively maintained data from AARC database on patients with ACLF who developed AVB (ACLF-AVB) was analysed. This data included demographic profile, severity of liver disease, and rebleeding and mortality in 6 weeks. These outcomes were compared with a propensity score matched (PSM) cohort of ACLF matched for severity of liver disease (MELD, AARC score) without AVB (ACLF without AVB). RESULTS: Of the 4434 ACLF patients, the outcomes in ACLF-AVB (n = 72) [mean age-46 ± 10.4 years, 93% males, 66% with alcoholic liver disease, 65% with alcoholic hepatitis, AARC score: 10.1 ± 2.2, MELD score: 34 (IQR: 27-40)] were compared with a PSM cohort selected in a ratio of 1:2 (n = 143) [mean age-44.9 ± 12.5 years, 82.5% males, 48% alcoholic liver disease, 55.7% alcoholic hepatitis, AARC score: 9.4 ± 1.5, MELD score: 32 (IQR: 24-40)] of ACLF-without AVB. Despite PSM, ACLF patients with AVB had a higher baseline HVPG than without AVB (25.00 [IQR: 23.00-28.00] vs. 17.00 [15.00-21.75] mmHg; p = 0.045). The 6-week mortality in ACLF patients with or without AVB was 70.8% and 53.8%, respectively (p = 0.025). The 6-week rebleeding rate was 23% in ACLF-AVB. Presence of ascites [hazard ratio (HR) 2.2 (95% CI 1.03-9.8), p = 0.026], AVB [HR 1.9 (95% CI 1.2-2.5, p = 0.03)], and MELD score [HR 1.7 (95% CI 1.1-2.1), p = 0.001] independently predicted mortality in the overall ACLF cohort. CONCLUSION: Development of AVB confers poor outcomes in patients with ACLF with a high 6-week mortality. Elevated HVPG at baseline represents a potential risk factor for future AVB in ACLF.

Distinguishing Crohn's disease from intestinal tuberculosis--a prospective study.

BACKGROUND: Distinguishing Crohn's disease (CD) from intestinal tuberculosis (ITB) is clinically challenging but important for prognostication and patient management. METHODS: Patients with diagnosis of CD and ITB were prospectively enrolled in the study from January 2006 to October 2007. The patients were followed up for further 15 months to ascertain that the diagnosis had not changed. Clinical, laboratory, serological [IgG anti Saccharomyces cerevisiae antibody (ASCA)], endoscopic and histologic features were compared between the ITB and CD patients. The ASCA titers were estimated in 100 healthy controls. Patients were diagnosed as ASCA positive when their ASCA titers were three standard deviations above mean of controls. RESULTS: Thirty patients with CD (age 33.9 + 15.2 years, 70% males) and thirty with ITB (age 35.1 + 12.2years, 53.3% males) were included in the study. Features commoner in CD were longer duration of symptoms (p < 0.001), blood mixed stool (p = 0.006), presence of longitudinal ulcers (p = 0.005) and skip lesions (p = 0.008) on colonoscopy and more number of colonic segments involved (p = 0.004). Anorexia was commoner in ITB patients (p = 0.008). Positive ASCA was commoner in CD (30%) than ITB (10%) but did not reach statistical significance (p = 0.1). CONCLUSIONS: A combined evaluation of clinical features, endoscopy, histology and response to treatment is the key to differentiate between CD and ITB.