Metabolic dysfunction-associated steatotic liver disease:A silent pandemic

The worldwide epidemiology of non-alcoholic fatty liver disease(NAFLD)is showing an upward trend,parallel to the rising trend of metabolic syndrome,owing to lifestyle changes.The pathogenesis of NAFLD has not been fully understood yet.Therefore,NAFLD has emerged as a public health concern in the field of hepatology and metabolisms worldwide.Recent changes in the nomenclature from NAFLD to metabolic dysfunction-associated steatotic liver disease have brought a positive outlook changes in the understanding of the disease process and doctor-patient communication.Lifestyle changes are the main treatment modality.Recently,clinical trial using drugs that target‘insulin resistance’which is the driving force behind NAFLD,have shown promising results.Further translational research is needed to better understand the underlying pathophysiological mechanism of NAFLD which may open newer avenues of therapeutic targets.The role of gut dysbiosis in etiopathogenesis and use of fecal microbiota modification in the treatment should be studied extensively.Prevention of this silent epidemic by spreading awareness and early intervention should be our priority.

Longitudinally extensive transverse myelitis associated with scrub typhus:A case report

Rationale:Longitudinally extensive transverse myelitis(LETM)is a rare inflammatory demyelinating disease predominantly associated with autoimmune and inflammatory disorders.Scrub typhus can cause a variety of neurological complications,which may result in poor recovery and long-term disability.This report reveals a rare linkage between LETM and scrub typhus.Patient concerns:A 24-year-old female presented with a history of fever for 10 days associated with progressive quadriparesis.Physical examination revealed bilateral lower limb weakness(grade 0/5)and bilateral upper limb weakness(grade 2/5)with reduced sensation below the T3 dermatome.Diagnosis:Scrub typhus presenting with longitudinally extensive transverse myelitis.Interventions:Steroid pulse therapy with antibiotics supported by early intensive rehabilitation.Outcomes:Complete recovery was achieved.Lessons:This case report highlights the importance of considering scrub typhus as a potential cause of LETM in endemic regions,particularly in patients presenting with febrile illness and neurological symptoms.

Utilising continuous glucose monitoring for glycemic control in diabetic kidney disease

In this editorial,we comment on the article by Zhang et al.Chronic kidney disease(CKD)presents a significant challenge in managing glycemic control,especially in diabetic patients with diabetic kidney disease undergoing dialysis or kidney transplantation.Conventional markers like glycated haemoglobin(HbA1c)may not accurately reflect glycemic fluctuations in these populations due to factors such as anaemia and kidney dysfunction.This comprehensive review discusses the limitations of HbA1c and explores alternative methods,such as continuous glucose monitoring(CGM)in CKD patients.CGM emerges as a promising technology offering real-time or retrospective glucose concentration measure-ments and overcoming the limitations of HbA1c.Key studies demonstrate the utility of CGM in different CKD settings,including hemodialysis and peritoneal dialysis patients,as well as kidney transplant recipients.Despite challenges like sensor accuracy fluctuation,CGM proves valuable in monitoring glycemic trends and mitigating the risk of hypo-and hyperglycemia,to which CKD patients are prone.The review also addresses the limitations of CGM in CKD patients,emphasizing the need for further research to optimize its utilization in clinical practice.Altogether,this review advocates for integrating CGM into managing glycemia in CKD patients,highlighting its superiority over traditional markers and urging clinicians to consider CGM a valuable tool in their armamentarium.

Magnesium oxide(MgO)nanoadsorbents in wastewater treatment:A comprehensive review

Wastewater contamination by heavy metals and synthetic dyes presents a significant environmental challenge,necessitating effective and sustainable separation techniques.This review article provides a detailed examination of magnesium oxide(MgO)nanoparticles as an innovative nanoadsorbent for wastewater treatment,with a specific focus on heavy metal and dye removal.The review comprehensively explores various aspects of MgO nanoparticles,including their structural characteristics and synthesis techniques.The article delves into the morphology and crystallographic arrangement of MgO nanoparticles,offering insights into their structural attributes.Given the complexity of adsorption processes,the review identifies and analyzes parameters influencing the adsorption efficiency of MgO nanoparticles,such as temperature,pH,contact time,initial concentration,and co-existing ions.The interplay between these parameters and the adsorption capability of MgO nanoparticles emphasizes the importance of optimizing operational conditions.Furthermore,the review assesses various synthesis methods for MgO nanoparticles,including sol-gel,hydrothermal,precipitation,green synthesis,solvothermal,and template-assisted techniques.It discusses the advantages,limitations,and resulting nanoparticle characteristics of each method,enabling readers to grasp the implications of synthesis processes on adsorption efficiency.This comprehensive review consolidates current insights into the effectiveness of MgO nanoparticles as a potent nanoadsorbent for removing heavy metals and dyes from wastewater covering a wide spectrum of aspects related to MgO nanoparticles.Moreover,there is a need to investigate the use of MgO in the treatment of actual wastewater or river water,in order to leverage its cost-effectiveness and high efficiency for practical water treatment applications in real-time.

Hepatic pseudotumor:A diagnostic challenge

Hepatic pseudotumors are rare lesions of unknown origin,characterized by the proliferation of fibrous connective tissue and inflammatory cell infiltrates.They mimic malignant lesions clinically,and radiologically,given their non-specific clinical and imaging features.The pathophysiology of hepatic pseudotumor is incompletely understood and there are no standardized criteria for diagnosis.Pseudotumors have been reported to develop in various organs in the body with the lung and liver being the most common site.Hepatic pseudotumors develop in patients with underlying triggers of liver inflammation and injury,including infections,autoimmune liver diseases,bile duct injury,or surgery.Hepatic pse-udotumors respond well to conservative treatment with antibiotics,and steroids and some may regress spontaneously,thus avoiding unnecessary resection.This condition is rewarding to treat.It is important to recognize pseudotumor as a distinct clinical entity and include it in the differential of liver masses with atypical imaging features.

Digital psychiatry in low-and-middle-income countries:New developments and the way forward

Low-and middle-income countries(LMICs)bear the greater share of the global mental health burden but are ill-equipped to deal with it because of severe resource constraints leading to a large treatment gap.The remote provision of mental health services by digital means can effectively augment conventional services in LMICs to reduce the treatment gap.Digital psychiatry in LMICs has always lagged behind high-income countries,but there have been encouraging developments in the last decade.There is increasing research on the efficacy of digital psychiatric interventions.However,the evidence is not adequate to conclude that digital psychiatric interventions are invariably effective in LMICs.A striking development has been the rise in mobile and smartphone ownership in LMICs,which has driven the increasing use of mobile technologies to deliver mental health services.An innovative use of mobile technologies has been to optimize task-shifting,which involves delivering mental healthcare services in community settings using non-specialist health professionals.Emerging evidence from LMICs shows that it is possible to use digital tools to train non-specialist workers effectively and ensure that the psychosocial interventions they deliver are efficacious.Despite these promising developments,many barriers such as service costs,underdeveloped infrastructure,lack of trained professionals,and significant disparities in access to digital services impede the progress of digital psychiatry in LMICs.To overcome these barriers,digital psychiatric services in LMICs should address contextual factors influencing the delivery of digital services,ensure collaboration between different stakeholders,and focus on reducing the digital divide.

Fecal microbiota transplantation in the treatment of hepatic encephalopathy:A perspective

Due to its complex pathogenesis,treatment of hepatic encephalopathy(HE)continues to be a therapeutic challenge.Of late,gut microbiome has garnered much attention for its role in the pathogenesis of various gastrointestinal and liver diseases and its potential therapeutic use.New evidence suggests that gut micro-biota plays a significant role in cerebral homeostasis.Alteration in the gut microbiota has been documented in patients with HE in a number of clinical and experimental studies.Research on gut dysbiosis in patients with HE has opened newer therapeutic avenues in the form of probiotics,prebiotics and the latest fecal microbiota transplantation(FMT).Recent studies have shown that FMT is safe and could be effective in improving outcomes in advanced liver disease patients presenting with HE.However,questions over the appropriate dose,duration and route of administration for best treatment outcome remains unsettled.

Understanding the role of transmembrane 9 superfamily member 1 in bladder cancer pathogenesis

In this editorial we comment on the article by Wei et al,published in the recent issue of the World Journal of Clinical Oncology.The authors investigated the role of Transmembrane 9 superfamily member 1(TM9SF1)protein in bladder cancer(BC)carcinogenesis.Lentiviral vectors were used to achieve silencing or overexpression of TM9SF1 gene in three BC cell lines.These cell lines were then subject to cell counting kit 8,wound-healing assay,transwell assay,and flow cytometry.Proliferation,migration,and invasion of BC cells were increased in cell lines subjected to TM9SF1 overexpression.TM9SF1 silencing inhibited proliferation,migration and invasion of BC cells.The authors conclude that TM9SF1 may be an oncogene in bladder cancer pathogenesis.

Endoscopic ultrasound-guided pancreatic fluid collection drainage: Where are we?

Pancreatic fluid collections(PFCs)result from injury to the pancreas from acute or chronic pancreatitis,surgery,or trauma.Management of these collections has evolved over the last 2 decades.The choice of interventions includes percu-taneous,endoscopic,minimally invasive surgery,or a combined approach.Endoscopic drainage is the drainage of PFCs by creating an artificial communication between the collection and gastrointestinal lumen that is maintained by placing a stent across the fistulous tract.In this editorial,we endeavored to update the current status of endoscopic ultrasound-guided drainage of PFCs.

Hindi translation and validation of the English version of the gastrointestinal symptom rating scale questionnaire:An observational study

BACKGROUND The gastrointestinal symptom rating scale(GSRS)is a questionnaire in English language which is designed to assess the clinical symptoms in patients with irritable bowel syndrome(IBS)and peptic ulcer disease.This validated scale has questions on around 15 items and has been validated in patients with dyspepsia and IBS.AIM To translate and validate the English version of the GSRS questionnaire to the Hindi version.METHODS The purpose of the present work was to create a Hindi version of this questionnaire for use in the Indian population.The process involved various steps as per the World Health Organization methodology including initial forward translation,backward translation,and assessment by an expert committee.Initial pilot testing was followed by testing in healthy and diseased individuals.RESULTS The Hindi translation was pilot tested in 20 individuals and further validated in healthy controls(n=30,15 females)and diseased individuals(n=72,27 females).The diseased group included patients with functional dyspepsia and IBS.Cronbach's alpha for internal consistency on the final translated GSRS questionnaire was 0.715 which is considered adequate.Twelve questions significantly differentiated the diseased population from the healthy population(P value<0.05)in the translated Hindi version of the GSRS.CONCLUSION The translated Hindi GSRS can be used to evaluate gastrointestinal function in clinical trials and community surveys in Hindi speaking populations.

Reference gene panel for urinary exosome-based molecular diagnostics in patients with kidney disease

BACKGROUND Kidney disease is a severe complication of diabetes that often leads to end-stage renal disease.Early diagnosis is crucial for prevention or delay.However,the current diagnostic methods,with their limitations in detecting the disease in its early stages,underscore the urgency and importance of finding new solutions.miRNAs encapsulated inside urinary exosomes(UEs)have potential as early biomarkers for kidney diseases.The need for reference miRNAs for accurate interpretation currently limits their translational potential.AIM To identify consistently expressing reference miRNAs from UEs of controls and patients with type 2 diabetesmellitus(T2DM)and biopsy-confirmed kidney diseases.METHODS miRNA profiling was performed on UEs from 31 human urine samples using a rigorous and unbiased method.The UEs were isolated from urine samples collected from healthy individuals(n=6),patients with T2DM(n=13),and T2DM patients who also had kidney diseases(including diabetic nephropathy,n=5;membranous nephropathy,n=5;and IgA nephropathy,n=2)through differential ultracentrifugation.After characterizing the UEs,miRNA expression profiling using microarray technology was conducted.RESULTS Microarray data analysis identified 14 miRNAs that were consistently expressed in UEs from 31 human samples,representing various kidney conditions:diabetic controls,diabetic nephropathy,membrane nephropathy,IgA nephropathy,and healthy controls.Through in silico analysis,we determined that 10 of these miRNAs had significant potential to serve as reference genes in UEs.CONCLUSION We identified uniformly expressing UE miRNAs that could serve as reference genes kidney disease biomarkers.

Malignant pleural mesothelioma:The disdained member of thoracic oncology!

Pleural mesothelioma is a very aggressive malignancy that arises from the pleural mesothelial cell lining and is linked strongly to prior asbestos exposure.The ban on asbestos has helped to lower the incidence,but in developing countries like India,it is expected to rise.It has an extended latency period usually progressing over decades and presents with nonspecific symptoms.It has a median survival ranging between 10-22 months.The diagnosis of malignant pleural mesothelioma is challenging and is done using computed tomography(CT),magnetic resonance imaging,or positron emission tomography-CT,with the last two predicting the resectability of the tumor better than CT alone.A pleural biopsy along with an array of immunohistochemical markers,such as p16,BRCA1 associated protein 1,and claudin-4,are required for a definitive diagnosis.Several genetic alterations have prognostic significance as well.The current histological subtype identification is indispensable for decision making because of the new therapeutic avenues being explored.The combination of nivolumab and ipilimumab-based immunotherapy outperformed platinum and pemetrexed-based chemotherapy in terms of survival benefit and improved quality of life especially for non-epithelioid subtypes.However,the latter continues to be a robust treatment option for patients with the epithelioid subtype.Surgery is recommended for resectable cases with radiotherapy being indicated in neoadjuvant,adjuvant,and palliative settings along with systemic treatment.This review article provides an overview of epidemiology,etiology,clinical manifestations,diagnostic approaches(including immunohistochemical and genetic markers),staging,and multidisciplinary approaches to current treatment for malignant pleural mesothelioma using surgery,chemotherapy,immunotherapy,and radiotherapy.It also sheds light on some recent studies(EMPHACIS,CALGB30901,Checkmate-743,etc.)that have led to significant developments in recent years with clinically meaningful results.

Parents’s knowledge and awareness about hepatitis B can influence the vaccination of their children

BACKGROUND Birth-dose(Hep-BD)followed by three additional doses(Hep-B3)of hepatitis B virus(HBV)vaccine are key to eliminating HBV by 2030.Unfortunately,Hep-BD and Hep-B3 coverage in our country is poor.AIM To studied the parent’s knowledge and awareness about HBV infection,its prevention,consequences and vaccination.METHODS Parents of 6 months to 8 years old children were interviewed to assess their knowledge&awareness about hepatitis B,its transmission,prevention,illness caused by this,and vaccination.Eighteen close-ended questions were admini-stered,and responses were recorded as‘yes’,‘no’,or‘not sure’.HBV knowledge score was calculated based on the sum of correct answers.Each correct response scored one point and incorrect,missing or‘not sure’responses received no points.Categorical data are presented as number(%)and numerical data are expressed as median.Data were compared using Chi2 tests and level of significance was kept as P<0.05.RESULTS Parents(58.3%mothers)of 384 children(89.9%age<5 years;82%age-appropriately vaccinated)were included.Three hundred and twenty-two(83.9%)children were Hep-B3 vaccinated.94.3%,87.5%,and 29.2%parents knew about polio,tetanus,and hepatitis B vaccine.Overall,41.2%,15.8%,and 23%parents knew about hepatitis B transmission,consequences of infection,and prevention respectively.Only 7.6%parents knew about three-dose schedule of hepatitis B vaccination.Only 23%parents believed that vaccine could prevent HBV,15.7%knew that HBV affects liver.Parents of Hep-B3 vaccinated children were significantly more aware about HBV than the parents of unvaccinated children(P<0.05 for 17/18 questions).CONCLUSION The knowledge and awareness among the parents about hepatitis B is poor.The Increasing knowledge/awareness about HBV among parents may improve Hep-B3 vaccination coverage.

Geogenic Pollution of Groundwater Quality in Gampaha District, Sri Lanka: A Case Study of Groundwater Acidification from Rathupaswala

Over recent decades, Gampaha district, Sri Lanka, has experienced significant urbanisation and industrial growth, increasing groundwater demand due to limited and polluted surface water resources. In 2013, a community uprising in Rathupaswala, a village in Gampaha district, accused a latex glove manufacturing factory of causing groundwater acidity (pH < 4). This study evaluates the spatial and temporal changes in geochemical parameters across three transects in the southern part of Gampaha district to 1) assess the impact of geological formations on groundwater;2) compare temporal variations in groundwater;and 3) explain acidification via a geochemical model. Seventy-two sample locations were tested for pH, electrical conductivity (EC), and anion concentrations (sulphate, nitrate, chloride and fluoride). Depth to the water table and distance from the sea were measured to study variations across sandy, peaty, lateritic, and crystalline aquifers. Results showed pH readings around 7 for sandy and crystalline aquifers, below 7 for peaty aquifers, and below 5 for lateritic aquifers, with significant water table fluctuations near Rathupaswala area. Principal component analysis revealed three principal components (PCs) explaining 86.0% of the variance. PC1 (40.6%) correlated with pH, EC, and sulphate (saltwater intrusion), while PC2 (32.0%) correlated with nitrates and depth to the water table (anthropogenic nutrient pollution). A geochemical transport model indicated a cone of depression recharged by acidic groundwater from peat-soil aquifers, leading to acidic groundwater in Rathupaswala area. Previous attributions of acidic pH to the over-exploitation of groundwater by the latex factory have been reevaluated;the results suggest natural acidification from prolonged water-rock interactions with iron-rich lateritic aquifers. Groundwater pH is influenced by local climate, geology, topography, and drainage systems. It is recommended that similar water-rock interaction conditions may be present throughout the wet zone of Sri Lanka, warranting detailed studies to confirm this hypothesis.

Emerging role of computed tomography coronary angiography in evaluation of children with Kawasaki disease

Coronary artery abnormalities are the most important complications in children with Kawasaki disease(KD).Two-dimensional transthoracic echocardiography currently is the standard of care for initial evaluation and follow-up of children with KD.However,it has inherent limitations with regard to evaluation of mid and distal coronary arteries and,left circumflex artery and the poor acoustic window in older children often makes evaluation difficult in this age group.Catheter angiography(CA)is invasive,has high radiation exposure and fails to demonstrate abnormalities beyond lumen.The limitations of echocardiography and CA necessitate the use of an imaging modality that overcomes these problems.In recent years advances in computed tomography technology have enabled explicit evaluation of coronary arteries along their entire course including major branches with optimal and acceptable radiation exposure in children.Computed tomography coronary angiography(CTCA)can be performed during acute as well as convalescent phases of KD.It is likely that CTCA may soon be considered the reference standard imaging modality for evaluation of coronary arteries in children with KD.

Long term outcomes of Cohen’s cross trigonal reimplantation for primary vesicoureteral reflux in poorly functioning kidney

BACKGROUND Open ureteric reimplantation by cross trigonal technique described by Cohen is considered a common surgical option for correction of vesicoureteral reflux(VUR). There is a lack of evidence in literature though for what happens to such kidneys, in the long run, particularly those which are poorly functioning.AIM To assess the long-term outcomes of ureteric reimplantation in poorly functioning kidneys in children with unilateral primary VUR.METHODS Children with unilateral primary VUR and a relative renal function of less than 35% who underwent open or laparoscopic ureteric reimplantation between January 2005 and January 2017 were included in the study. Patients who had a follow up of less than five years were excluded. Preoperative evaluation consisted of a voiding cystourethrogram and Dimercaptosuccinic acid(DMSA) scan. In the follow-up period, patients underwent a diuretic scan at 6 weeks and 6 months.Follow up ultrasound was done for change in grade of hydronephrosis and retrovesical ureteric diameter. Subsequent follow up was done at 6 monthly intervals with evaluation for proteinuria and hypertension and any recurrent urinary tract infection(UTI). For assessment of cortical function, DMSA was repeated annually for 5 years after surgery. A paired-samples t-test was used to test the mean difference of DMSA between pre-post observations.RESULTS During this period, 36 children underwent ureteric reimplantation for unilateral primary VUR. After excluding those with insufficient follow-up, 31 were included in the analysis. Most of the patients were males(n = 26/31, 83.8%). Patient’s age(mean ± SD, range) was 5.21 ± 3.71, 1-18 years. The grades of VUR were grade Ⅱ(1patient), grade Ⅲ(8 patients), grade Ⅳ(10 patients), and grade Ⅴ(12 patients). The pre and postoperative DMSA was 24.064 ± 12.02 and 24.06 ± 10.93, which was almost the same(statistically equal, paired-samples t-test: P = 0.873). The median(range) follow-up duration was 82(60-120)mo. One patient had persistent reflux after surgery(preoperative: grade Ⅳ, postoperative: grade Ⅲ), and the very same patient developed recurrent UTI. The difference in the preoperative and postoperative DRF was less than 10% in 29 patients. In one patient, the DRF decreased by 17%(22% to 05%) while in another patient, the DRF increased by 12%(25% to 37%) after surgery. None of the patients had an increase in scarring after surgery. 15% of patients were hypertensive before surgery and all of them continued to be hypertensive after surgery while none developed hypertension after surgery. None of the patients had significant proteinuria(> 150 mg/d) during the follow-up period.CONCLUSION Children with unilateral primary VUR and poorly functioning kidney maintain the renal function over the long term in most cases. Hypertension and proteinuria do not progress over time in these patients.

Budd-Chiari syndrome in children:Challenges and outcome

Budd-Chiari syndrome(BCS)is an uncommon disease of the liver,characterised by obstruction of the hepatic venous outflow tract.The etiological spectrum of BCS as well as venous obstruction pattern show wide geographical and demographic variations across the globe.Compared to adults with BCS,children have primary BCS as the predominant etiology,earlier clinical presentation,and hence better treatment outcome.Underlying prothrombotic conditions play a key role in the etiopathogenesis of BCS,though work-up for the same is often unyielding in children.Use of next-generation sequencing in addition to conventional tests for thrombophilia leads to better diagnostic yield.In recent years,advances in radiological endovascular intervention techniques have revolutionized the treatment and outcome of BCS.Various non-invasive markers of fibrosis like liver and splenic stiffness measurement are being increasingly used to assess treatment response.Elastography techniques provide a novel non-invasive tool for measuring liver and splenic stiffness.This article reviews the diagnostic and therapeutic advances and challenges in children with BCS.

Liver or kidney:Who has the oar in the gluconeogenesis boat and when?

Gluconeogenesis is an endogenous process of glucose production from noncarbohydrate carbon substrates.Both the liver and kidneys express the key enzymes necessary for endogenous glucose production and its export into circulation.We would be remiss to add that more recently gluconeogenesis has been described in the small intestine,especially under high-protein,lowcarbohydrate diets.The contribution of the liver glucose release,the net glucose flux,towards systemic glucose is already well known.The liver is,in most instances,the primary bulk contributor due to the sheer size of the organ(on average,over 1 kg).The contribution of the kidney(at just over 100 g each)to endogenous glucose production is often under-appreciated,especially on a weight basis.Glucose is released from the liver through the process of glycogenolysis and gluconeogenesis.Renal glucose release is almost exclusively due to gluconeogenesis,which occurs in only a fraction of the cells in that organ(proximal tubule cells).Thus,the efficiency of glucose production from other carbon sources may be superior in the kidney relative to the liver or at least on the level.In both these tissues,gluconeogenesis regulation is under tight hormonal control and depends on the availability of substrates.Liver and renal gluconeogenesis are differentially regulated under various pathological conditions.The impact of one source vs the other changes,based on post-prandial state,acid-base balance,hormonal status,and other less understood factors.Which organ has the oar(is more influential)in driving systemic glucose homeostasis is still inconclusive and likely changes with the daily rhythms of life.We reviewed the literature on the differences in gluconeogenesis regulation between the kidneys and the liver to gain an insight into who drives the systemic glucose levels under various physiological and pathological conditions.

Development of a protocol for videoconferencing-based exposure and response prevention treatment of obsessive-compulsive disorder during the COVID-19 pandemic

BACKGROUND The existing literature indicates that psychotherapeutic treatment,especially exposure and response prevention(ERP)is efficacious in treating obsessivecompulsive disorder(OCD).The coronavirus disease 2019 pandemic adversely impacted many patients with OCD and disrupted their usual treatment.Moreover,the pandemic forced a global switch to telemental health(TMH)services to maintain the standards and continuity of care.Consequently,clinicians are increasingly using TMH-based psychotherapeutic treatments to treat OCD.However,several challenges have made it difficult for them to implement these treatments in the changed circumstances imposed by the pandemic.AIM To describe the formulation,implementation,feasibility,and usefulness of videoconferencing-based ERP(VC-ERP)treatment for OCD during the coronavirus disease 2019 pandemic.METHODS This prospective,observational study was conducted in the psychiatric unit of a multi-specialty hospital in north India over 12 mo(July 2020-June 2021).All patients with OCD were assessed using the home-based TMH services of the department.The VC-ERP protocol for OCD was the outcome of weekly Zoom meetings with a group of clinicians involved in administering the treatment.After a systematic evaluation of the available treatment options,an initial protocol for delivering VC-ERP was developed.Guidelines for clinicians and educational materials for patients and their families were prepared.The protocol was implemented among patients with OCD attending the TMH services,and their progress was monitored.The weekly meetings were used to upgrade the protocol to meet the needs of all stakeholders.Feasibility and efficacy outcomes were examined.RESULTS All patients were diagnosed with OCD as a primary or a comorbid condition according to the International Classification of Diseases,10th version criteria.Out of 115 patients who attended the services during the study period,37 were excluded from the final analysis.Of the remaining 78 patients,VC-ERP was initiated in 43 patients.Six patients dropped out,and three were hospitalized for inpatient ERP.Eleven patients have completed the full VC-ERP treatment.One patient completed the psychoeducation part of the protocol.VC-ERP is ongoing in 22 patients.The protocol for VC-ERP treatment was developed and upgraded online.A large proportion of the eligible patients(n=34/43;79%)actively engaged in the VC-ERP treatment.Drop-out rates were low(n=6/43;14%).Satisfaction with the treatment was adequate among patients,caregivers,and clinicians.Apart from hospitalization in 3 patients,there were no other adverse events.Hybrid care and stepped care approaches could be incorporated into the VC-ERP protocol.Therefore,the feasibility of VC-ERP treatment in terms of operational viability,service utilization,service engagement,need for additional in-person services,frequency of adverse events,and user satisfaction was adequate.The VC-ERP treatment was found to be efficacious in the 11 patients who had completed the full treatment.Significant reductions in symptoms and maintenance of treatment gains on follow-up were observed.CONCLUSION This study provided preliminary evidence for the feasibility and usefulness of VC-ERP in the treatment of OCD.The results suggest that VC-ERP can be a useful option in resource-constrained settings.

Diabetes mellitus as a consequence of acute severe pancreatitis:Unraveling the mystery

The occurrence of diabetes mellitus(DM)in pancreatitis is being increasingly recognized lately.Diabetes can develop not only with chronic pancreatitis but even after the first episode of acute pancreatitis(AP).The incidence of diabetes after AP varies from 18%to 23%in 3 years and reaches up to 40%over 5 years.The exact pathogenesis of diabetes after AP is poorly understood and various mechanisms proposed include loss of islet cell mass,AP-induced autoimmunity,and alterations in the insulin incretin axis.Risk factors associated with increased risk of diabetes includes male sex,recurrent attacks of pancreatitis,presence of pancreatic exocrine insufficiency and level of pancreatitic necrosis.Diagnosis of post-pancreatitis DM(PPDM)is often excluded.Treatment includes a trial of oral antidiabetic drugs in mild diabetes.Often,insulin is required in uncontrolled diabetes.Given the lack of awareness of this metabolic disorder after AP,this review will evaluate current information on epidemiology,risk factors,diagnosis and management of PPDM and identify the knowledge gaps.