Impact of Diabetes, Drug-Induced Liver Injury, and Sepsis on Outcomes in MAFLD-Related Acute-on-Chronic Liver Failure.

BACKGROUND: The prevalence of Metabolic dysfunction associated fatty liver disease (MAFLD) and its complication, MAFLD-related acute on chronic liver failure (MAFLD-ACLF), is rising. Yet, factors determining patient outcomes in MAFLD-ACLF remain understudied. METHODS: Patients with MAFLD-ACLF were recruited from the AARC registry. The diagnosis of MAFLD-ACLF was made when the treating unit had identified the etiology of chronic liver disease (CLD) as MAFLD (or previous nomenclature such as NAFLD, NASH, or NASH-cirrhosis). Patients with coexisting other etiologies of CLD (such as alcohol, HBV, HCV, etc.) were excluded. Data was randomly split into derivation (n=258) and validation (n=111) cohorts at a 70:30 ratio. The primary outcome was 90-day mortality. Only the baseline clinical, laboratory features and severity scores were considered. RESULTS: The derivation group had 258 patients; 60% were male, with a mean age of 53. Diabetes was noted in 27%, and hypertension in 29%. The dominant precipitants included viral hepatitis (HAV and HEV, 32%), drug-induced injury (DILI, 29%) and sepsis (23%). MELD-Na and AARC scores upon admission averaged 32±6 and 10.4±1.9. At 90 days, 51% survived. Non-viral precipitant, diabetes, bilirubin, INR, and encephalopathy were independent factors influencing mortality. Adding diabetes and precipitant to MELD-Na and AARC scores, the novel MAFLD-MELD-Na score (+12 for diabetes, +12 for non-viral precipitant) and MAFLD-AARC score (+5 for each) were formed. These outperformed the standard scores in both cohorts. CONCLUSION: Almost half of MAFLD-ACLF patients die within 90 days. Diabetes and non-viral precipitants such as DILI and sepsis lead to adverse outcomes. The new MAFLD-MELD-Na and MAFLD-AARC scores provide reliable 90-day mortality predictions for MAFLD-ACLF patients.

Gender disparities in gastroenterology and hepatology conferences: The journey towards equality.

BACKGROUND: This study scrutinizes gender representation in invited faculty and conference committee leadership at key gastroenterology and hepatology conferences in Pakistan over five years, exploring the impact of the "glass ceiling" and "sticky floor" phenomena on gender diversity within academic medicine. METHODS: This cross-sectional study was conducted between January and March of 2023. The three major national societies of gastroenterology and hepatology in Pakistan that had been established for more than 10 years and the scientific programs of their annual conferences, which were publicly accessible, were included and coded as Society 1, Society 2 and Society 3 to maintain anonymity. The scientific programs for the last five years (2018-2022) were retrieved. The roles of invited faculties were identified as invited speakers, moderators, chairs/panelists, presidents and chairs of organizing or scientific committees and the gender makeup of the faculty was compared. Regression analysis was used to evaluate the trends for female representation over time for each role. RESULTS: Significant gender disparity was evident by an extremely lower cumulative proportion of female invited faculty compared to males (211 [11.9%] vs. 1567 [88.1%], p 0.001). The predominance of invited male faculty was observed across all societies as well as in various roles of invited faculty (p 0.01). A significant disparity has also been observed in leadership positions of all three societies (43 [95.5%] males vs. 2 [4.5%] females, p 0.001), while the trend of women's underrepresentation across all societies remained almost unchanged over time (slope = 0.08, R2 = - 0.078, p-value = 0.875). CONCLUSION: Our study unveils striking gender disparities in women's representation as invited speakers and other roles at the annual scientific conferences of major gastroenterology and hepatology. Additionally, male dominance remains entrenched, notably in leadership positions, necessitating a proactive, multifaceted approach to rectify gender inequities.

Metabolic dysfunction-associated fatty liver disease and low muscle strength: A comment.

The diagnosis of non-alcoholic fatty liver disease (NAFLD) and metabolic dysfunction-associated fatty liver disease only on the basis of laboratory parameter score such as Hepatic Steatosis Index which includes liver enzymes, gender, basal metabolic index, and presence of diabetic mellitus is not sufficient to exclude other causes of deranged liver enzymes especially medications and autoimmune related liver diseases. As the guideline suggests ultrasound is the preferred first-line diagnostic procedure for imaging of NAFLD, as it provides additional diagnostic information and the combination of biomarkers/scores and transient elastography might confer additional diagnostic accuracy and evident from previous similar studies too.

National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma.

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

Gluten Intolerance and Its Association With Skin Disorders: A Narrative Review.

Gluten sensitivity is defined as a chronic intolerance to gluten ingestion in genetically predisposed individuals. The etiology is thought to be immune-mediated and has a variable dermatologic presentation. Celiac disease (CD) is one of the most common forms of gluten intolerance and encompasses a wide range of extra-intestinal pathology, including cutaneous, endocrine, nervous, and hematologic systems. Psoriasis, another long-term inflammatory skin condition, has been linked to significant symptomatic improvement with a gluten-free diet (GFD). Palmoplantar pustulosis (PP), a variant of psoriasis, and aphthous stomatitis, which causes recurrent oral ulcers, have also exhibited beneficial results after the dietary elimination of gluten. In addition to this, dermatitis herpetiformis (DH), another immune-mediated skin disorder, is genetically similar to CD and has, therefore, shown tremendous improvement with a GFD. Another highly prevalent long-term skin condition called atopic dermatitis (AD), however, has revealed inconsistent results with gluten elimination and would require further research in the future to yield concrete results. Hereditary angioedema (HA) has shown an association with gluten intolerance in some patients who had symptomatic benefits with a GFD. Similarly, vitiligo and linear IgA bullous dermatosis have also shown some clinical evidence of reversal with a GFD. On the contrary, rosacea enhances the risk of developing CD. This narrative review emphasizes the potential impact of gluten intolerance on different cutaneous conditions and the potential therapeutic effect of a GFD on various symptomatic manifestations. There is a need for additional clinical and observational trials to further expand on the underlying pathophysiology and provide conclusive and comprehensive recommendations for possible dietary interventions.

Reimagining Healthcare: Unleashing the Power of Artificial Intelligence in Medicine.

Artificial intelligence (AI) has opened new medical avenues and revolutionized diagnostic and therapeutic practices, allowing healthcare providers to overcome significant challenges associated with cost, disease management, accessibility, and treatment optimization. Prominent AI technologies such as machine learning (ML) and deep learning (DL) have immensely influenced diagnostics, patient monitoring, novel pharmaceutical discoveries, drug development, and telemedicine. Significant innovations and improvements in disease identification and early intervention have been made using AI-generated algorithms for clinical decision support systems and disease prediction models. AI has remarkably impacted clinical drug trials by amplifying research into drug efficacy, adverse events, and candidate molecular design. AI's precision and analysis regarding patients' genetic, environmental, and lifestyle factors have led to individualized treatment strategies. During the COVID-19 pandemic, AI-assisted telemedicine set a precedent for remote healthcare delivery and patient follow-up. Moreover, AI-generated applications and wearable devices have allowed ambulatory monitoring of vital signs. However, apart from being immensely transformative, AI's contribution to healthcare is subject to ethical and regulatory concerns. AI-backed data protection and algorithm transparency should be strictly adherent to ethical principles. Vigorous governance frameworks should be in place before incorporating AI in mental health interventions through AI-operated chatbots, medical education enhancements, and virtual reality-based training. The role of AI in medical decision-making has certain limitations, necessitating the importance of hands-on experience. Therefore, reaching an optimal balance between AI's capabilities and ethical considerations to ensure impartial and neutral performance in healthcare applications is crucial. This narrative review focuses on AI's impact on healthcare and the importance of ethical and balanced incorporation to make use of its full potential.

Giant Hyperplastic Polyp at the Gastroesophageal Junction: A Rare Provocateur of Upper Gastrointestinal Bleeding.

Esophageal hyperplastic polyps (HPs) are a rare benign polypoidal growth most commonly resulting from gastroesophageal reflux disease (GERD). The lesion is asymptomatic in most patients unless large enough to cause luminal obstruction or gastrointestinal bleeding. The treatment of choice is endoscopic resection if it becomes symptomatic. Here, we report a case of a 51-year-old woman presenting with dyspeptic symptoms and upper gastrointestinal bleeding. An upper gastrointestinal endoscopy showed a large polyp with active oozing of blood at the gastroesophageal junction (GEJ), which was removed endoscopically after injecting adrenaline at its base. Histopathological analysis was suggestive of HPs.

Rare but critical: Aberrant vascular communication leading to multiorgan ischemia after prophylactic gastroduodenal artery embolization for refractory upper gastrointestinal bleeding.

Upper gastrointestinal bleeding (UGIB) carries a high risk of morbidity and mortality despite recent improvements in diagnosis and management. Many patients failed to respond to initial endoscopic and medical management. Transcatheter arterial embolization (TAE) is now considered the next line of therapy over surgery in refractory UGIB because of its good safety profile and high technical and clinical success rate. We discuss the case of a 66-year-old female patient who presented with massive UGIB and had TAE after endoscopic hemostasis failed. She developed widespread ischemia involving multiple organs following the procedure, including the liver, gallbladder, pancreas, spleen, and small intestine, as a result of an abnormal communication between the gastroduodenal artery (GDA) and superior mesenteric artery (SMA), resulting in PVA particle reflux and widespread ischemic injury. It is important to carefully evaluate the vascular anatomic variations before the procedure to avoid potential complications of ischemia.

INASL-SAASL Consensus Statements on NAFLD Name Change to MAFLD.

There is an ongoing debate on the change of terminology of non-alcoholic fatty liver disease (NAFLD) to metabolic associated fatty liver disease (MAFLD). Experts from the Indian National Association for Study of the Liver (INASL) and the South Asian Association for Study of the Liver (SAASL) involved in diagnosing, managing, and preventing NAFLD met in March 2022 to deliberate if the name change from NAFLD to MAFLD is appropriate, as proposed by a group of experts who published a "consensus" statement in 2020. Proponents of name change to MAFLD opined that NAFLD does not reflect current knowledge, and the term MAFLD was suggested as a more appropriate overarching term. However, this "consensus" group which proposed the name change to MAFLD did not represent the views and opinions of gastroenterologists and hepatologists, as well as perceptions of patients across the globe, given the fact that change of nomenclature for any disease entity is bound to have multidimensional impact on all aspects of patient care. This statement is the culmination of the participants' combined efforts who presented recommendations on specific issues concerning the proposed name change. The recommendations were then circulated to all the core group members and updated based on a systematic literature search. Finally, all the members voted on them using the nominal voting technique as per the standard guidelines. The quality of evidence was adapted from the Grades of Recommendation, Assessment, Development and Evaluation system.

Identifying the early predictors of non-response to steroids in patients with flare of autoimmune hepatitis causing acute-on-chronic liver failure.

BACKGROUND AND AIMS: Early identification of non-response to steroids is critical in patients with autoimmune hepatitis (AIH) causing acute-on-chronic liver failure (ACLF). We assessed if this non-response can be accurately identified within first few days of treatment. METHODS: Patients with AIH-ACLF without baseline infection/hepatic encephalopathy were identified from APASL ACLF research consortium (AARC) database. Diagnosis of AIH-ACLF was based mainly on histology. Those treated with steroids were assessed for non-response (defined as death or liver transplant at 90 days for present study). Laboratory parameters, AARC, and model for end-stage liver disease (MELD) scores were assessed at baseline and day 3 to identify early non-response. Utility of dynamic SURFASA score [- 6.80 + 1.92*(D0-INR) + 1.94*(∆%3-INR) + 1.64*(∆%3-bilirubin)] was also evaluated. The performance of early predictors was compared with changes in MELD score at 2 weeks. RESULTS: Fifty-five out of one hundred and sixty-five patients (age-38.2 ± 15.0 years, 67.2% females) with AIH-ACLF [median MELD 24 (IQR: 22-27); median AARC score 7 (6-9)] given oral prednisolone 40 (20-40) mg per day were analyzed. The 90 day transplant-free survival in this cohort was 45.7% with worse outcomes in those with incident infections (56% vs 28.0%, p = 0.03). The AUROC of pre-therapy AARC score [0.842 (95% CI 0.754-0.93)], MELD [0.837 (95% CI 0.733-0.94)] score and SURFASA score [0.795 (95% CI 0.678-0.911)] were as accurate as ∆MELD at 2 weeks [0.770 (95% CI 0.687-0.845), p = 0.526] and better than ∆MELD at 3 days [0.541 (95% CI 0.395, 0.687), p < 0.001] to predict non-response. Combination of AARC score > 6, MELD score > 24 with SURFASA score ≥ - 1.2, could identify non-responders at day 3 (concomitant- 75% vs either - 42%, p < 0.001). CONCLUSION: Baseline AARC score, MELD score, and the dynamic SURFASA score on day 3 can accurately identify early non-response to steroids in AIH-ACLF.

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.

Frailty in Aging HIV-Positive Individuals: An Evolving Healthcare Landscape.

The life expectancy of people living with HIV (PLWH) has greatly increased due to advancements in combination antiretroviral treatment (cART). However, this longer life has also increased the prevalence of age-related comorbidities, such as frailty, which now manifest sooner in this group. Frailty, a term coined by the insurance industry, has been broadened to include physical, cognitive, and emotional elements and has been recognized as a critical predictor of negative health outcomes. With the median age of PLWH now in the mid-50s, treating frailty is critical given its link to chronic diseases, cognitive decline, and even death. Frailty assessment tools, such as the Frailty Phenotype (FP) and the Frailty Index (FI), are used to identify vulnerable people. Understanding the pathophysiology of frailty in PLWH indicates the role of immunological mechanisms. Frailty screening and management in this group have progressed, with specialized clinics and programs concentrating on multidisciplinary care. Potential pharmacotherapeutic solutions, as well as novel e-health programs and sensors, are in the future of frailty treatment, but it is critical to ensure that frailty evaluation is not exploited to perpetuate ageist healthcare practices. This narrative review investigates the changing healthcare environment for older people living with HIV (OPLWH), notably in high-income countries. It emphasizes the significance of identifying and managing frailty as a crucial feature of OPLWH's holistic care and well-being.

Work-up for Incidentally Detected NAFLD: How Far is It Worth?

The incidence of nonalcoholic fatty liver disease (NAFLD) has seen a steep rise in parallel with the global obesity and metabolic syndrome epidemic. The presence of NAFLD contributes to significant socioeconomic burden due to healthcare costs, progression of liver disease as non-alcoholic steatohepatitis (NASH), and later cirrhosis and hepatocellular carcinoma (HCC). With the advent of widely available imaging, it is also being detected as an incidental diagnosis in individuals with systemic disease like metabolic syndrome, diabetes, chronic cardiac disease, polycystic ovarian syndrome, etc. or in asymptomatic persons on presurgical evaluation or even annual health assessments. Gastroenterologists, hepatologists, physicians and surgeons need to be updated about the new diagnostic criteria of Metabolic (dysfunction)-associated fatty liver disease, noninvasive tests (NITs) of liver fibrosis, new tools of elastography, and identification of those with high-risk disease. In this review, we appraise the relevance of new diagnostic definitions, steatosis and fibrosis estimation tests, advanced imaging like magnetic resonance elastography and proton density fat fraction and discuss the diagnostic algorithm for incidentally detected NAFLD. How to cite this article: Mishra S, Bhujade H, Butt AS, et al. Work-up for Incidentally Detected NAFLD: How Far is It Worth? Euroasian J Hepato-Gastroenterol 2022;12(Suppl 1):S26-S36.

NAFLD vs MAFLD: South Asian NAFLD Patients don't Favor Name Change.

Aim: There have been vociferous attempts to change the name of Nonalcoholic Fatty Liver Disease (NAFLD) to Metabolic Associated Fatty Liver Disease (MAFLD). Of the many arguments put forth in support of this, an important one is the presumed demand by patient groups insisting on the change. However, this claim does not have credible evidence to support it. Therefore, we decided to conduct a survey among South Asian NAFLD patients to understand their perspectives with regard to the change in nomenclature. Materials and Methods: The study was conducted at multiple centers across South Asia from January 2021 to June 2021. Patients were surveyed using an 8-question survey questionnaire and responses were categorized by multiple-choice format. Results: Of 218 patients surveyed, 80.3% of the patients were not aware of the entity "NAFLD" before they were first diagnosed. Although 74.3% of patients admitted to being questioned about alcohol intake at the time of the first diagnosis, 75.9% of female patients were not questioned regarding this. After being labelled NAFLD, 92.1% of patients were never questioned again about alcohol intake. While 86.3% of patients found the term "NAFLD" consoling, 83% did not feel that "Non" in NAFLD trivialized their problem. In addition, only 6.9% of patients were scared of developing cardiovascular disease. Conclusion: The term "NAFLD" destigmatizes patients of the taboo associated with alcohol use. It was found to be consoling to most patients and they did not feel it trivialized their problem. A change of name without considering patients' perspectives and peculiarities specific to different populations will have enormous ramifications for both patients and physicians. Clinical significance: Our survey clearly shows that patients are happy with the term "NAFLD" and it effectively destigmatizes them from the taboo of alcohol. This would lead to higher compliance with management and greater patient participation in future studies and trials. How to cite this article: Singh SP, Anirvan P, Butt AS, et al. NAFLD vs MAFLD: South Asian NAFLD Patients don't Favor Name Change. Euroasian J Hepato-Gastroenterol 2022;12(Suppl 1):S1-S4.

Cisteína oral N-Acetyl versus indometacina retal para prevenção de pancreatite pós-CPRE: um ensaio controlado randomizado multinacional multicêntrico / Oral n-acetyl cysteine versus rectal indomethacin for prevention of post ercp pancreatitis: a multicenter multinational randomized controlled trial

ABSTRACT Background This multicenter multinational RCT designed to compare the efficacy of suppository indomethacin and NAC for prevention of PEP. Methods: During a 6-month period, all of the ERCP cases in seven referral centers were randomly assigned to receive either 1200 mg oral NAC, indomethacin suppository 100 mg, 1200 mg oral NAC plus indomethacin suppository 100 mg or placebo 2 hours before ERCP. The primary outcomes were the rate and severity of any PEP. Results: A total of 432 patients included (41.4% male). They were originally citizens of 6 countries (60.87% Caucasian). They were randomly allocated to receive either NAC (group A, 84 cases), rectal indomethacin (group B, 138 cases), NAC + rectal indomethacin (group C, 115 cases) or placebo (group D, 95 cases). The rate of PEP in groups A, B and C in comparison with placebo were 10.7%, 17.4%, 7.8% vs 20% (P=0.08, 0.614 & 0.01 respectively). The NNT for NAC, indomethacin and NAC + indomethacin was 11, 38 and 8 respectively. Conclusion: Oral NAC is more effective than rectal indomethacin when compared to placebo for prevention of PEP and the combination of NAC and Indomethacin had the lowest incidence of PEP and may have synergistic effect in preventing of PEP (IRCT20201222049798N1; 29/12/2020).

RESUMO Contexto: Este estudo randomizado, controlado multicêntrico e multinacional foi projetado para comparar a eficácia da indometacina supositório e N-acetil cisteína (NAC) para prevenção de pancreatite pós colangiografia endoscópica. Métodos: Durante um período de 6 meses, todos os pacientes submetidos à CPRE em sete centros de referência foram aleatoriamente atribuídos para receber 1200 mg de NAC oral, supositório de indometacina 100 mg, 1200 mg de NAC oral mais supositório de indometacina 100 mg ou placebo 2 horas antes do procedimento. Os resultados primários foram a taxa e a gravidade de qualquer pancreatite pós procedimento (PPP). Resultados: Um total de 432 pacientes foram incluídos (41,4% do sexo masculino). Eram originalmente cidadãos de seis países (60,87% caucasianos). Foram alocados aleatoriamente para receber NAC (grupo A, 84 casos), indometacina retal (grupo B, 138 casos), NAC + indometacina retal (grupo C, 115 casos) ou placebo (grupo D, 95 casos). A taxa de PPP nos grupos A, B e C em comparação com o placebo foi de 10,7%, 17,4%, 7,8% vs 20% (P=0,08, 0,614 e 0,01, respectivamente). Conclusão A NAC oral é mais eficaz do que a indometacina retal quando comparado ao placebo para prevenção de PPP e a combinação de NAC e indometacina teve a menor incidência de PPP e pode ter efeito sinérgico na sua prevenção de PPP. (IRCT20201222049798N1; 29/12/2020).

ORAL N-ACETYL CYSTEINE VERSUS RECTAL INDOMETHACIN FOR PREVENTION OF POST ERCP PANCREATITIS: A MULTICENTER MULTINATIONAL RANDOMIZED CONTROLLED TRIAL.

BACKGROUND: This multicenter multinational RCT designed to compare the efficacy of suppository indomethacin and NAC for prevention of PEP. METHODS: During a 6-month period, all of the ERCP cases in seven referral centers were randomly assigned to receive either 1200 mg oral NAC, indomethacin suppository 100 mg, 1200 mg oral NAC plus indomethacin suppository 100 mg or placebo 2 hours before ERCP. The primary outcomes were the rate and severity of any PEP. RESULTS: A total of 432 patients included (41.4% male). They were originally citizens of 6 countries (60.87% Caucasian). They were randomly allocated to receive either NAC (group A, 84 cases), rectal indomethacin (group B, 138 cases), NAC + rectal indomethacin (group C, 115 cases) or placebo (group D, 95 cases). The rate of PEP in groups A, B and C in comparison with placebo were 10.7%, 17.4%, 7.8% vs 20% (P=0.08, 0.614 & 0.01 respectively). The NNT for NAC, indomethacin and NAC + indomethacin was 11, 38 and 8 respectively. CONCLUSION: Oral NAC is more effective than rectal indomethacin when compared to placebo for prevention of PEP and the combination of NAC and Indomethacin had the lowest incidence of PEP and may have synergistic effect in preventing of PEP (IRCT20201222049798N1; 29/12/2020).

Correction: The diagnostic performance of combined conventional cytology with smears and cell block preparation obtained from endoscopic ultrasound-guided fine needle aspiration for intra-abdominal mass lesions.

[This corrects the article DOI: 10.1371/journal.pone.0263982.].

COVID-19 infection among vaccinated and unvaccinated: Does it make any difference?

OBJECTIVE: There is a probability that vaccination may lead to reduction in the severity and complications associated with COVID-19 infection among hospitalized patients. This study aimed to determine the characteristics, clinical profiles, and outcomes of COVID-19 infection in vaccinated and non-vaccinated patients. DESIGN AND DATA SOURCES: This prospective observational cohort study was conducted at the Aga Khan University Hospital (AKUH) and recruited COVID-19 patients admitted between June 1st and September 30th, 2021. Patients' demographics, date of admission and discharge, comorbid conditions, immunization status for COVID-19 infection, presenting complaints, lab workup and computed tomography (CT) scan findings were obtained from the medical records. The primary outcome of the study was patients' condition at discharge and the secondary outcomes included level of care, length of stay (LOS), requirement of non-invasive ventilation (NIV) and inotropic support. RESULTS: Among a cohort of 434 patients, 37.7% (n = 164), 6.6% (n = 29) and 55.5% (n = 241) were fully vaccinated, partially vaccinated, and unvaccinated, respectively. Around 3% and 42.9% of the patient required inotropic and NIV support respectively; however, there was no discernible difference between them in terms of vaccination status. In case of unvaccinated patients there were significantly increased number of critical care admissions (p-value 0.043). Unvaccinated patients had significantly higher median serum procalcitonin, ferritin, LDH and D-dimer levels. Around 5.3% (n = 23) of the patient required invasive ventilation and it was more common in unvaccinated patients (p-value 0.04). Overall, mortality rate was 12.2% (n = 53) and this was higher (16.2%, n = 39) in unvaccinated patients as compared to fully vaccinated patients (6.1%, n = 10, p-value 0.006). CONCLUSIONS: Through this preliminary data, we can conclude that patient can develop severe and critical COVID-19 infection despite being vaccinated but this proportion is low as compared to unvaccinated population. So, uninterrupted endeavors need to be done to vaccinate as many individuals as possible. Furthermore, more effective vaccinations need to be developed to lessen the high death toll of COVID-19 infection.

Post-traumatic Renal Arteriovenous Malformation Discovered after 2 Years of Blunt Trauma: Diagnosis and Management.

Blunt trauma to the kidney is usually minor and self-limiting. In some cases, the patient may present with intractable hematuria or persistent flank pain and discomfort, which necessitates aggressive management. It is very rare and unusual to find a renal arterio-venous malformation following blunt trauma. This unusual presentation should be kept in mind when a patient presents with hematuria and history of blunt abdominal trauma. We report the case of a young male who suffered blunt abdominal trauma two years back, and continued to have on-and-off hematuria. After extensive work up, a diagnosis of renal arterio-venous malformation was made. His case was managed promptly with renal angio-embolization. Key Words: Blunt trauma, Arterio-venous malformation (AVM), Angio-embolisation, kidney.