Amna Subhan Butt

Setting a Standard for Helicobacter pylori Management in Pakistan

With the global rise in sedentary lifestyles, obesity, and unhealthy dietary patterns, dyslipidemia has emerged as a leading modifiable risk factor for atherosclerotic cardiovascular disease. Beyond host genetics and diet, the gut microbiota has gained recognition as a critical regulator of lipid homeostasis through mechanisms involving bile acid metabolism, short-chain fatty acid signaling, and microbial modulation of inflammation. Lv et al provide a comprehensive synthesis of the diet microbe-lipid axis and therapeutic strategies, including probiotics, prebiotics, and fecal microbiota transplantation. In this correspondence, we expand on their framework by highlighting underexplored yet clinically relevant dimensions, including circadian rhythm alignment, pharmacotherapy microbe crosstalk, population-specific microbial signatures, and functional microbial phenotyping. Addressing these overlooked aspects could accelerate the translation of microbiome science into precision dyslipidemia management, with the potential to improve cardiovascular outcomes worldwide.

Hepatitis A, a vaccine-preventable liver infection caused by the hepatitis A virus, is undergoing significant epidemiological shifts worldwide. Traditionally considered a disease of childhood in endemic regions, improved sanitation, economic development, and widespread vaccination have led to a decline in incidence, particularly in developed nations. However, this decline has resulted in a growing population of susceptible adults, increasing the risk of severe outbreaks. Additionally, changes in travel patterns, urbanization, and socioeconomic disparities have altered disease distribution, leading to sporadic outbreaks in low-endemicity regions and a rising burden in certain high-risk populations. This review explores the evolving epidemiology of hepatitis A, emphasizing the transition from endemic childhood infections to adult susceptibility. We examine the impact of changing risk factors, including shifting demographics, increased international travel, and regional disparities in vaccination coverage. Furthermore, the review highlights the emergence of new viral strains and their potential implications for disease control. Updated vaccination policies, including targeted immunization strategies and their role in preventing outbreaks, are also discussed. Given these dynamic changes, continued surveillance and public health preparedness tailored to evolving risk groups are crucial for sustained hepatitis A control. By synthesizing recent epidemiological data and policy updates, this review provides insights into the future of hepatitis A prevention and control, offering guidance for clinicians, researchers, and public health professionals.

Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y-anatomy is technically challenging and additional techniques including balloon-assisted enteroscopy, endoscopic ultrasound (EUS) guided, and percutaneous approaches offers only modest success rates. Motorized spiral enteroscopy (MSE)-assisted ERCP (MSE-ERCP) has emerged as a potential alternative. In a retrospective study by Nennstiel et al , MSE-ERCP achieved high success rates for biliary entry (88%) and therapeutic intervention (83%). However, outcomes varied significantly between bilioenteric anastomosis (93%) and native papilla (63%), underscoring the importance of anatomy-driven procedural selection. Despite encouraging efficacy, the global withdrawal of the MSE platform due to serious device-related complications highlights the ongoing balance between feasibility and safety. Future directions should prioritize refinements in device engineering, multicenter prospective trials comparing MSE with balloon-assisted and EUS-guided techniques, and systematic outcome stratification by anatomical subgroup. Such efforts will be critical to defining the role of MSE within the therapeutic algorithm for surgically altered anatomy.

Background Acute-on-chronic liver failure (ACLF) is a rapidly progressive syndrome marked by high short-term mortality. While diabetes mellitus (DM) is known to worsen liver-related outcomes, its specific impact on alcohol-related ACLF (ALD-ACLF) remains underexplored. This study aimed to assess the prognostic impact of DM on 90-day outcomes in ALD-ACLF using data from the APASL ACLF Research Consortium (AARC) database. Methods This observational study involved data from 5612 ACLF patients with documented 90-day outcomes. We identified 2096 patients with ALD-ACLF precipitated by alcoholic hepatitis. Patients with non-ALD etiologies, mixed etiologies, or non-alcoholic precipitants were excluded. Diabetic and non-diabetic patients were compared using 1:2 propensity score matching based on key baseline covariates. Survival outcomes were assessed using Kaplan–Meier analysis and multivariable Cox regression. Results After matching, 109 diabetic patients were compared with 218 well-matched non-diabetic controls. Diabetic patients had significantly lower overall survival (32 vs. 57%) and transplant-free survival (31 vs. 50%) compared to non-diabetics (log-rank p < 0.001). On multivariable Cox regression, DM was independently associated with increased 90-day mortality (HR 1.739, 95% CI 1.262–2.395, p < 0.001), along with elevated serum lactate (HR 1.187 per mmol/L, p < 0.001) and creatinine (HR 1.267 per mg/dL, p < 0.001). Conclusion Diabetes mellitus is a significant independent predictor of mortality in patients with ALD-ACLF. These findings highlight the need for early identification and integrated management of diabetes in ACLF care pathways to improve clinical outcomes.

BACKGROUND For decades, hepatitis A virus (HAV) has been a leading cause of acute hepatitis among children and was less prevalent among adults. However, recently a paradigm shift has been observed in the epidemiology of HAV, as evident by cases of acute hepatitis due to HAV among adults. AIM To estimate frequency of HAV in acute viral hepatitis and compare characteristics in HAV and hepatitis E virus (HEV) infection. METHODS This was a trend analysis conducted at Aga Khan University Hospital Karachi (Sindh, Pakistan) from February 2024 to May 2024. Individuals aged 18 years and older diagnosed with acute viral hepatitis attributed to hepatotropic viruses in 2024 were reviewed. To compare the trend patients admitted with acute hepatitis during 2019-2023 were also reviewed. Data regarding clinical and laboratory parameters were recorded. The yearly trend of acute hepatitis due to HAV and HEV was analyzed, and comparative analysis was done between HAV and HEV cases among adults. RESULTS A total of 396 patients were found to have acute hepatitis during our study duration. HAV was diagnosed in 234 patients (59%) while 157 patients (39.6%) were found to have acute HEV infection. Additionally, acute hepatitis B virus infection was identified in 3 patients (0.7%), whereas acute hepatitis C virus infection was found in 2 (0.5%) cases of acute hepatitis. Yearly trends showed increasing occurrence of HAV infection among adults over last 5 years. The patients with acute HAV were younger than patients with HEV (28 years ± 8 years vs 30 years ± 8 years; P < 0.01). Higher levels of total bilirubin were seen in HEV infection, while higher levels of alanine transaminase were seen in HAV infection. However, a higher proportion of acute liver failure (ALF), coagulopathy, and mortality were observed in HEV. CONCLUSION An increase in acute hepatitis A cases among adults shows less severity than hepatitis E, highlighting the need for better sanitation, hygiene, and adult hepatitis A vaccination programs.

Due to sedentary lifestyle and rising prevalence of obesity, patients with general population and those who are infected with chronic hepatitis B are found to have metabolic dysfunction associated steatotic liver disease (MASLD). Both chronic hepatitis B virus (HBV) infection and MASLD can damage hepatocytes in their own way, but concomitant HBV-MASLD has its own clinical implications. Cherry on top is the presence of diabetes mellitus, hypertension or obesity which added more chances of unfavorable outcomes in these patients. In this article, we comment on the article by Wang et al published in the recent issue. This article provides a comprehensive overview of the complex interaction between HBV-MASLD, HBV alone and MASLD alone patients. We discuss key findings from recent studies, including the promising outcomes observed in patients with concurrent HBV and MASLD, warrants further research. The insights presented here offer renewed understanding of this complex interaction.

INTRODUCTION: 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 Asian Pacific Association for the Study of the Liver-ACLF Research Consortium (AARC registry). The diagnosis of MAFLD-ACLF was made when the treating unit had identified the etiology of chronic liver disease as MAFLD (or previous nomenclature such as non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, or non-alcoholic steatohepatitis-cirrhosis). Patients with coexisting other etiologies of chronic liver disease (such as alcohol, hepatitis B virus, hepatitis C virus, etc.) were excluded. Data were 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 (hepatitis A virus and hepatitis E virus, 32%), drug-induced injury (drug-induced liver injury, 29%), and sepsis (23%). Model for End-Stage Liver Disease-Sodium (MELD-Na) and AARC scores on admission averaged 32 ± 6 and 10.4 ± 1.9. At 90 days, 51% survived. Nonviral precipitant, diabetes, bilirubin, international normalized ratio, 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 nonviral precipitant), and MAFLD-AARC score (+5 for each) were formed. These outperformed the standard scores in both cohorts. DISCUSSION: Almost half of patients with MAFLD-ACLF die within 90 days. Diabetes and nonviral precipitants such as drug-induced liver injury and sepsis lead to adverse outcomes. The new MAFLD-MELD-Na and MAFLD-AARC scores provide reliable 90-day mortality predictions for patients with MAFLD-ACLF.

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. Graphical Abstract

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