APASL clinical practice guidelines on the management of acute kidney injury in acute-on-chronic liver failure.

Acute-on-chronic liver failure (ACLF) is a syndrome that is characterized by the rapid development of organ failures predisposing these patients to a high risk of short-term early death. The main causes of organ failure in these patients are bacterial infections and systemic inflammation, both of which can be severe. For the majority of these patients, a prompt liver transplant is still the only effective course of treatment. Kidneys are one of the most frequent extrahepatic organs that are affected in patients with ACLF, since acute kidney injury (AKI) is reported in 22.8-34% of patients with ACLF. Approach and management of kidney injury could improve overall outcomes in these patients. Importantly, patients with ACLF more frequently have stage 3 AKI with a low rate of response to the current treatment modalities. The objective of the present position paper is to critically review and analyze the published data on AKI in ACLF, evolve a consensus, and provide recommendations for early diagnosis, pathophysiology, prevention, and management of AKI in patients with ACLF. In the absence of direct evidence, we propose expert opinions for guidance in managing AKI in this very challenging group of patients and focus on areas of future research. This consensus will be of major importance to all hepatologists, liver transplant surgeons, and intensivists across the globe.

Exploring the association between early childhood caries, malnutrition, and anemia by machine learning algorithm.

OBJECTIVE: The objective of this study was to determine the prevalence of early childhood caries in children with severe acute malnutrition (SAM) and also the hierarchy of association if any with malnutrition, anemia, and other risk factors with ECC using machine learning algorithms. METHODS: A hospital-based preventive and interventional study was conducted on SAM children (age = 2 to <6 years) who were admitted to the malnutrition treatment unit (MTU). An oral examination for early childhood caries status was done using the deft index. The anthropometric measurements and blood examination reports were recorded. Oral health education and preventive dental treatments were given to the admitted children. Three machine learning algorithms (Random Tree, CART, and Neural Network) were applied to assess the relationship between early childhood caries, malnutrition, anemia, and the risk factors. RESULTS: The Random Tree model showed that age was the most significant factor in predicting ECC with predictor importance of 98.75%, followed by maternal education (29.20%), hemoglobin level (16.67%), frequency of snack intake (9.17%), deft score (8.75%), consumption of snacks (7.1%), breastfeeding (6.25%), severe acute malnutrition (5.42%), frequency of sugar intake (3.75%), and religion at the minimum predictor importance of 2.08%. CONCLUSION: Anemia and malnutrition play a significant role in the prediction, hence in the causation of ECC. Pediatricians should also keep in mind that anemia and malnutrition have a negative impact on children's dental health. Hence, Pediatricians and Pediatric dentist should work together in treating this health problem.

Early Versus Standard Initiation of Terlipressin for Acute Kidney Injury in ACLF: A Randomized Controlled Trial (eTerli Study).

BACKGROUND AND AIMS: Terlipressin infusion is effective in hepatorenal syndrome (HRS-AKI). However, its efficacy for HRS-AKI resolution in acute-on-chronic liver failure (ACLF) patients has been suboptimal. Progression of AKI is rapid in ACLF. We investigated whether early initiation of terlipressin(eTerli) can improve response rates. METHODS: Consecutive ACLF patients with stage II/III AKI despite albumin resuscitation (40 g) were randomized to receive terlipressin at 2 mg/24 h plus albumin at 12 h (ET, n = 35) or at 48 h as standard therapy (ST, n = 35). (June 22, 2020 to June 10, 2022). The primary end-point was AKI reversal by day7. RESULTS: Baseline parameters including AKI stage and ACLF-AARC scores in two arms were comparable. Full AKI response at day 7 was higher in ET [24/35 (68.6%)] than ST arm [11/35 (31.4%; P 0.03]. Day3 AKI response was also higher in ET arm [11/35 (31.4%) vs. 4/35 (11.4%), P 0.04]. Using ST compared to ET [HR 4.3; P 0.026] and day 3 serum creatinine > 1.6 mg/dl [HR 9.1; AUROC-0.866; P < 0.001] predicted HRS-AKI non-response at day 7. ET patients showed greater improvement in ACLF grade, mean arterial pressure, and urine output at day 3, and required lower albumin within 7 days than ET arm (149.1 ± 41.8 g vs. 177.5 ± 40.3 g, P 0.006) and had lower 28-day mortality: 40% vs. 65.7%, P 0.031]. Early use of terlipressin than ST [HR 2.079; P 0.038], baseline HE [HR 2.929; P 0.018], and AKI persistence at day 3 [HR 1.369; P 0.011] predicted 28-day mortality. Fifteen (21.4%) patients had treatment related adverse effects, none was life threatening. CONCLUSION: In ACLF patients, early initiation of terlipressin for AKI persisting after 12 h of volume expansion with albumin helps in reduced short-term mortality and early AKI reversal with regression of ACLF stage. These results indicate need for change in current practice for terlipressin usage in HRS-AKI.

Dissociation in hepatic vein pressure gradient, liver stiffness measurement and complications in histological subtypes of porto-sinusoidal vascular disease.

BACKGROUND AND AIMS: Portosinusoidal vascular disease (PSVD) is a broad term encompassing varied histological patterns with changes in portal tracts and sinusoids without cirrhosis. We aimed to assess whether there is any clinical and pathological difference among the various histological categories of PSVD. PATIENTS AND METHODS: This study included liver biopsy cases classified as PSVD (2020-2022). Clinical and laboratory parameters were obtained from the electronic records. PSVD cases were histologically categorised as obliterative portal venopathy (OPV), OPV with fibrosis (OPV-F), incomplete septal cirrhosis (ISC), nodular regenerative hyperplasia (NRH), mega sinusoids with fibrosis (MSF) and unclassified. Follow-up complications were recorded. RESULTS: PSVD categories were OPV (45 (26%)), OPV-F (37 (21.4%)), ISC (20 (11.6%)), NRH (19 (11%)), MSF (19 (11%)) and unclassified (33 (19%)). Elevated hepatic venous pressure gradient (HVPG) was noted in OPV-F (10 (IQR: 12-14.7)) and ISC (12 (IQR: 9-14)) mm Hg with higher fibrosis quantity in liver tissue and elevated procollagen III aminoterminal propeptide, which correlated with HVPG. On immunohistochemistry, OPV-F and ISC showed lesser expression of ADAMT13 in liver biopsies (p<0.001). On follow-up, ascites development was more in OPV-F and ISC than in other categories (p=0.001). Higher liver stiffness measurement (LSM) values were recorded in MSF and NRH, compared with other categories, but it did not correlate with fibrosis in liver biopsy. CONCLUSIONS: OPV-F and ISC had higher HVPG, fibrosis, and more ascites development on follow-up than the other categories of PSVD, and all are not the same. In contrast, MSF and NRH have spuriously high LSM.

Real-Time Shear Wave Elastography for Determining the Ideal Site of Liver Biopsy in Diffuse Liver Disease.

Objectives The objective of the study was to identify accurate site of liver biopsy under ultrasound and elastography guidance and compare the shear wave elastography (SWE) and transient elastography (TE) diagnostic accuracy with histopathological correlation. Methods This was a prospective single-center study where patients scheduled for nonfocal liver biopsy were divided into two groups (group U: ultrasound; group E elastography) by sequential nonrandom selection of patients. Elastography was performed before the biopsy and biopsies from the maximum stiffness segment were taken. Results There was no significant difference of intersegmental liver stiffness with mean velocity; however, biopsy segment velocities show significant difference with mean liver stiffness suggestive of heterogenous distribution of fibrosis. The rho ( r ; Spearman's correlation) value between biopsy segments and mean velocities shows excellent correlation. The diagnostic performance of TE was good for fibrosis stages F2, F3, and F4, while SWE was fair for the diagnosis of fibrosis stages F1 and F2 and fairly equal for the diagnosis stages F2 and F3. Area under the curve (AUC) values in differentiating mild (F1) or no fibrosis from significant fibrosis (≥F2) were 95.5 with cutoff value of at least 1.94 m/s. Conclusions The diagnostic performance of SWE is comparable with TE in liver fibrosis staging and monitoring. Fibrosis is heterogeneously distributed in different segments of the right lobe liver. Therefore, elastography at the time of biopsy may help in defining the accurate site for biopsy and improve histopathological yield in detecting liver fibrosis in patients with chronic liver disease. Advances in Knowledge Elastography-guided biopsy is helpful to determine the ideal site of biopsy.

A retrospective study of life skills promotes healthy Internet use among adolescents.

Background: Since the beginning of COVID-19 pandemic, studies highlight the augmentation in the use of Internet and smartphone, especially among the adolescents. However, little is known about the effect of technology addiction on adolescent mental health following reopening of the schools. Aim: The study aims to assess the level of technology addiction, life skills, and mental health impact among adolescents during the COVID-19 pandemic in India. Materials and Methods: A cross-sectional research was conducted from July 2021 to October 2022. A nonprobability convenience sampling was used to collect the data from 352 adolescents using an Internet addiction test, smartphone addiction scale, life skills scale, and patient health questionnaire. Results: More than half of the adolescents were moderately addicted to the Internet and Smartphone. Three-fourth of the adolescents had mild-to-moderate depression. Those with moderate life skills were found to be moderately addicted to the Internet and Smartphone. Religion was found to be associated with Internet addiction. Age, religion, and parental monthly income were significantly associated with smartphone addiction among adolescents. Furthermore, class and life skills were significantly associated with depression among adolescents. Conclusion: Early-life skills training can help to prevent dysfunctional Internet use and mental and psychological problems among adolescents in schools and colleges.

Performance Evaluation of an Improved HBsAg Assay (HBsAg NEXT) for the Detection of HBsAg Levels.

Objectives Detection of hepatitis B surface antigen (HBsAg) plays an important role in the screening and diagnosis of hepatitis B virus (HBV) infections. There is a need of highly sensitive assays with an improved lower limit of detection (LoD). Here, we evaluate the performance characteristics of the HBsAg NEXT (HBsAg new) assay in the detection of HBsAg in clinical samples. Materials and Methods This was a cross-sectional study conducted at a tertiary care liver center in North India. The study included 439 clinical samples. The HBsAg new assay was compared to the conventional chemiluminescence-based assay (HBsAg old assay, Architect, Abbott Diagnostics, United States). The analytical sensitivity of the HBsAg new assay was evaluated by checking its performance with the second World Health Organization (WHO) international standards for HBsAg. Results Out of 439 blood samples that were retrieved from the departmental repository stored at -80°C, 100 samples were positive and 339 samples were negative for HBsAg as per the HBsAg old assay. The HBsAg new assay showed incremental detection of HBsAg in 11 additional samples. Out of these, 5 samples were confirmed as occult HBV infection and the remaining 6 were classified as "exposed-to-virus" samples (HBV core total antibody-positive). The HBsAg new assay demonstrated a high positive significant correlation with the HBsAg old assay ( r = 0.881, p -value < 0.001). The HBsAg new assay could effectively detect the second WHO international standards to the level of 0.0033 IU/mL. Conclusion The HBsAg NEXT assay is a highly sensitive assay with an improved lower LoD.

SpeckleCam: high-resolution computational speckle contrast tomography for deep blood flow imaging.

Laser speckle contrast imaging is widely used in clinical studies to monitor blood flow distribution. Speckle contrast tomography, similar to diffuse optical tomography, extends speckle contrast imaging to provide deep tissue blood flow information. However, the current speckle contrast tomography techniques suffer from poor spatial resolution and involve both computation and memory intensive reconstruction algorithms. In this work, we present SpeckleCam, a camera-based system to reconstruct high resolution 3D blood flow distribution deep inside the skin. Our approach replaces the traditional forward model using diffuse approximations with Monte-Carlo simulations-based convolutional forward model, which enables us to develop an improved deep tissue blood flow reconstruction algorithm. We show that our proposed approach can recover complex structures up to 6 mm deep inside a tissue-like scattering medium in the reflection geometry. We also conduct human experiments to demonstrate that our approach can detect reduced flow in major blood vessels during vascular occlusion.

Efficacy of video-based relaxation technique to minimize stress in young adults during the COVID-19 pandemic.

The uncertainty of the pandemic and rapid changes brought forth stressors for young adults as learning shifted to the online mode and most recreational activities required screen time. The objective was to evaluate the effectiveness of video-based diaphragmatic breathing relaxation technique in reduction of stress levels amongst young adults during COVID-19 pandemic. A quasi-experimental design with a sample size of 30 young adults undertook pre- and post-tests of subscale of Depression, Anxiety, and Stress Scale 21-items (DASS-21), negative emotion questionnaire, and hair cortisol concentration through enzyme-linked-immunosorbent assay technique. The findings indicate that there was a reduction in stress levels as majority of the items on the stress subscale of DASS-21 revealed lower stress at significant level. In addition, post-intervention participants reported a reduction in experience of negative emotions. Therefore, indicating that the diaphragmatic focused video-based intervention was effective in lowering stress and negative emotions.

Nursing students' perceptions regarding well-being and healthy use of digital technology: A qualitative thematic analysis.

BACKGROUND: The health and well-being of nursing students are of the utmost importance. Well-being is affected by many factors, ranging from day-to-day hassles to severe stressors in students' college lives. In addition to many other challenges, one new component is added with the advancement of technology, that is, the use of digital technology. The objectives of the study were to explore the perceptions of nursing students regarding well-being, its associated factors, digital technology usage and association between well-being and digital technology use. MATERIALS AND METHODS: A qualitative descriptive design using focus group discussion (FGD) was adopted in this study. A purposive sampling technique was followed for selecting the participants. Five nursing colleges in the city of Bengaluru from Karnataka state (Central Government-1, State Government-2, and Private-2) were selected based on their willingness to allow their students to be a part of the study. Around 12-15 students from each college who might provide potentially rich data were invited to participate in the study. Six FGDs were conducted during June-August 2018 with a total of 80 participants. All the participants were informed about the study. Written informed consent was obtained. All FGDs were audio recorded, and audiotapes were transcribed. Thematic analysis was done using Atlas.ti software. RESULTS: The emerging themes were clustered under the following broad categories: understanding the concept of well-being and associated factors; understanding digital technology; ways to healthy use of digital technology; strategies to maintain well-being; and a felt need for professional help. CONCLUSION: This study provides an insight into the experiences of well-being, stress, and use of digital technology among undergraduate nursing students. The findings have led to elicit the components required to develop an intervention program that may help the undergraduate nursing students to enhance well-being as well as promote healthy use of digital technology.

An Integrated Yoga and Cognitive Behavioral Therapy Intervention for Managing Excessive Use of Internet among the Youth: A Case Series.

Background: Internet addiction is a behavioral problem that is managed by pharmacological and nonpharmacological methods. The nonpharmacological methods focus on enhancing skills for healthy use of technology and promoting mindfulness and mental relaxation. Yoga therapy is an effective tool to reduce psychological stress and promote self-regulation and mindfulness. Thus, present work focused on developing an integrated yoga and cognitive behavioral therapy intervention (Y-CBT) for the management of excessive use of technology amongst adolescents and young adult students. Methods: Feasibility of the Y-CBT program was tested by implementing 10 sessions of yoga and 6 sessions of CBT program for 2 weeks by certified Yoga therapist and psychologist, respectively. This was followed by online booster sessions once a week, and post assessments were conducted at 12 weeks. A total of 4 college-going students with the excessive use of technology were recruited from tertiary specialty service for promotion of healthy use of technology. Each participant was assessed using short-version of internet addiction test (s-IAT), Smartphone Addiction Scale-Short Version, Kessler's Psychological distress scale for baseline, and follow-up assessment after completion of the program. Results: The Y-CBT program was found feasible and useful in reducing internet use, smart phone use, and psychological distress. There were no reported side-effects. A trend was observed for increase compliance toward treatment at follow-up. Future studies should explore this further with robust methodology.

Outcome of capacity building in mental health for well-being volunteers.

Introduction: Volunteering is any activity in which time is given to assist another individual, group, or organization. It assists people who want to get involved in philanthropic programs that help volunteers develop awareness and lead healthier personal and social lives. Several volunteers have received specialized training in the fields in which they volunteer, such as health, mental health, education, or emergency rescue. Volunteers are rendering intervention in different areas in mental health. They are providing psychosocial support to the individuals, groups, community, promoting mental health through conducting various mental health awareness programs in the community. There is a growing concern about mental health in India due to the inaccessibility of services. The National Institute of Mental Health and Neuro Sciences (NIMHANS) being a premier institute for mental health, is devising innovative approaches to mental health care to reach the unreachable. One such initiative was to build the capacity of volunteers in the community who are interested in working for the cause of mental health. Methods: The objective of this study was to evaluate the outcome of the well-being volunteer program. This study used a descriptive cross-sectional research design, wherein all the 136 trained well-being volunteers (WBVs) were included as the study sample. The data was collected from the volunteers who attended the WBV program, which was initiated by NIMHANS Centre for Well-being (NCWB) and the Department of Psychiatric Social Work NIMHANS. A questionnaire on the outcome of the Well Being Volunteers program was developed for the study, and the Volunteer Motivation Inventory scale was used to collect the data from the WBVs. SPSS software was used to analyze the data. Ethical clearance was sought from the Institute Ethics Committee of NIMHANS. Results: The WBV program enhanced volunteers' knowledge of mental health and benefited the volunteers in their personal and social life. They were also able to implement a satisfactory level of mental health-related volunteer activities in the community. Conclusion: Results of present study and the available literature suggest that engaging in voluntary services improves mental health knowledge. WBV program has provided opportunity to Volunteers to participate in mental health delivery system at different levels.

Antiproliferative Activity of New Pyrazole-4-sulfonamide Derivatives: Synthesis and Biological Evaluation.

Pyrazole and sulfonamide constitute an important class of drugs, with several types of pharmacological agents. Facile synthesis of two new series of 3,5-dimethyl-1H-pyrazole-4-sulfonamide and 1,3,5-trimethyl-1H-pyrazole-4-sulfonamide derivatives was designed and synthesized. These pyrazole-4-sulfonamide derivatives are characterized by Fourier transform infrared (FT-IR), 1H NMR, 13C NMR, and elemental analysis, and their biological evolution data are presented. This paved way for the development of new pyrazole-4-sulfonamide derivatives. These compounds are tested for their in vitro antiproliferative activity against U937 cells by the CellTiter-Glo Luminescent cell viability assay using Mitomycin C. Cytotoxicity detection is based on the measurement of LDH activity, while these compounds did not exhibit cytotoxic activity on these cells. Half maximal inhibitory concentration (IC50) was calculated by Graph Pad Prism software for each dose. Their structure-activity relationships were obtained and discussed.

Development and validation of an instrument for the assessment of internet use in the Indian context.

Background: Internet usage is increasing in the young population. Over 560 million internet users, India is the second-largest online market globally, which necessitates the development of an Internet use assessment tool in the Indian context. Methods: Samples of 560 individuals aged from 16 to 40 years participated. Data were coded in excel sheet for STATA 14.0 analysis evolved to item response theory. Cronbach's alpha was used to determine the internal consistency; concurrent validity was performed using the "Internet Addiction Test." Descriptive statistics, analysis of variance, confirmatory factor analysis, and Pearson's correlation were also determined. Results: The developed instrument has the Cronbach's alpha reliability value (25 items) of 0.893, which indicates high internal consistency and has a concurrent value of 0.800. Factor analysis of 23 items revealed that the variance of 64.481 revealed all the items loaded in the rotated component matrix. The final 18 items got the item discrimination index was >1.0 with three-factor structure. Conclusion: The developed reliable and valid instrument can be used for identifying the patterns of internet usage across various settings (research, educational, mental health/clinical, and workplace).

Development of a Technology-Based Intervention to Improve Help-Seeking in Distressed Non-Treatment-Seeking Young Adults With Common Mental Health Concerns.

Background There is a dearth of interventions aimed at improving help-seeking for common mental health concerns among distressed young adults, particularly in the urban Indian context. Availability of cost-effective, targeted intervention for improving appropriate help-seeking can pave the way for reducing the treatment gap. This could prove especially beneficial in low-resource settings. This study describes the guiding principles, underlying theory, and development process of a simple technology-based help-seeking intervention for distressed non-treatment-seeking young adults. Methods Several models of professional help-seeking behavior were examined to ascertain a suitable theoretical framework for the development of the intervention to enable help-seeking among distressed non-treatment-seeking young adults. Pilot work was carried out before the development, along with content validation of the intervention by field experts. Results Help-seeking intervention was developed based on the preferences of young adults and literature review. Eight core intervention components and one optional component were developed, which were built on selected theoretical frameworks. These components have been postulated to enhance awareness of common mental health problems, the utility of self-help, and support of significant others, and to increase the skills to understand when it may be appropriate to step up to professional help-seeking. Conclusion Help-seeking interventions delivered beyond the traditional clinic and hospital setups prove useful as low-intensity interventions acting as gateways to seek mainstream mental health services. Further research will evaluate the feasibility, acceptability, and effectiveness of the intervention in reducing perceived barriers and enhancing inclination to seek professional help and help-seeking behavior among distressed non-treatment-seeking young adults.

Gaming among female adolescents: profiling and psychopathological characteristics in the Indian context.

Objectives: Gaming is a predominant leisure time activity among adolescents, and the literature suggests that unrestrained gaming behavior might lead to gaming disorder. ICD-11 and DSM-5 have recognized gaming disorder as a psychiatric condition and grouped it under the behavioral addiction category. Research on gaming behavior and addiction is largely based on data from the male population, and problematic gaming has largely been understood from the male perspective. In this study, we are attempting to bridge the existing lacuna in the literature by exploring gaming behavior, gaming disorder, and its related psychopathological characteristics among female adolescents in India. Methods: The study was conducted on a sample of 707 female adolescent participants who were contacted through schools and academic institutes in a city in Southern India. The study adopted a cross-sectional survey design, and data were administered using the mixed modality of online and offline data collection. The participants filled out the following set of questionnaires: socio-demographic sheet, Internet Gaming Disorder Scale-Short-Form (IGDS9-SF), Strength and Difficulties Questionnaire (SDQ), Rosenberg self-esteem scale, and Brief sensation-seeking scale (BSSS-8). The data gathered from the participants were then statistically analyzed using SPSS software version 26. Results: The descriptive statistics revealed that 0.8% of the sample (i.e., five participants out of 707) obtained scores meeting gaming addiction criteria. Correlation analysis demonstrated a significant relationship between all the psychological variables with total IGD scale scores (p < 0.05). Total SDQ, total BSSS-8, and domain scores of SDQ, such as emotional symptoms, conduct, hyperactivity, and peer problems, were positively correlated, whereas total Rosenberg scores and domain scores of prosocial behaviors of SDQ were negatively correlated. The Mann-Whitney U-test was employed to compare "with gaming disorder" and "without gaming disorder" categories of female participants. Comparing these two groups revealed significant differences in emotional symptoms, conduct, hyperactivity/inattention, peer problem, and self-esteem scale scores. Furthermore, quantile regression was computed, showing that conduct, peer problem, and self-esteem displayed trend-level prediction for gaming disorder. Conclusion: Female adolescents prone to gaming addiction can be identified through psychopathological characteristics of conduct, peer problem, and low self-esteem. This understanding can be useful in developing a theoretical model focusing on early screening and preventive strategies for at-risk female adolescents.

Hand Foot Mouth Disease During the SARS-CoV-2 Pandemic: A Multicentric Study.

OBJECTIVES: This prospective observational study aimed to identify the current trend of the circulating viral strains responsible for HFMD outbreak in four tertiary care centers in Rajasthan, amidst the COVID-19 pandemic (April-October 2022). METHODS: Cases with suspected HFMD, presenting to our skin outpatient department were assessed clinically and serologically (IgM antibodies against coxsackie virus (CV) A6, A16 and enterovirus 71) for evidence of the disease. RESULTS: We identified 718 new HFMD patients (161 adults) with peaks in May and August, 2022. Male:female ratio decreased with increasing age. Most children were asymptomatic. A total of 385/409 patients assessed serologically, were found positive, most commonly against CV-A6. CONCLUSION: Though HFMD typically affects young children, an unusually higher proportion of adults were affected during the current pandemic. There were some subtle differences between pediatric and adult presentation of HFMD.