Severity of anemia during interferon and ribavirin therapy in patients with chronic active hepatitis c genotype-3 and its association with risk factors

Hepatitis C is a major public health problem globally. It is one of the commonest cause of chronic liver disease in Pakistan. The prevalent genotype is "3" in our country. The standard of care treatment is combination of interferon and ribavirin. This combination has important adverse effects especially hemolytic anemia

AIMS and OBJECTIVES: This study has been conducted to determine the frequency of anemia [< 10gm/dl] at 4, 12 and 24 weeks of interferon and ribavirin treatment CAH-C Genotype-3patients along with assessment of associated risk factors

PLACE AND DURATION: This study was conducted in department of Gastroenterology and Hepatology, Isra University Hospital, Hyderabad, Sindh from April 2009 to October 2010. STUDY DESIGN: Prospective and case series study

MATERIALS AND METHODS: All patients who fulfilled the inclusion and exclusion criteria were enrolled. The proforma was filled after patients verbal consent, by asking questions .Their BMI was recorded and other demographic characteristics were also noted .Patients were followed at 4,8,12,16,20 and 24 week. Their Blood CP was checked and if Hb fall within the range of 10.1- 11.9 mg/dL then the dose of ribavirin was reduced [200 mg/day reduction] and if Hb was <8.5 g/ dL then both drugs were stopped altogether

RESULTS: A total of 140 patients were remained for final analysis. Male were 73 [52%, n = 140]

Only 18 [13%, n = 140] patients developed anemia at week 4 of treatment. Compared to baseline mean Hb% SD 13.31+1.18 [12 to 17 gm/dl], week 4 post treatment mean Hb +SD [Range] was 11.2 + 1.15 [gm/dl. Almost 76.4% [107] of patients dropped hemoglobin more than two grams at week 4 from baseline. The mean Hb% level at week 12 of treatment was 11.2 gm/dl. There were 31 [22%] patients developed anemia Hb<10.0 gm/dL .It was significantly seen in females. One hundred and seven [76.4%] patients dropped Hb more than 2 gm at week 12

Total of 30 [18%] patients developed anemia [Hb<10.0 gm/dL] at week 24. Mean hemoglobin level at week 24 was 11.1 gm/dl. Anemia at week 4 and 12 were the two strong predicators of anemia at week 24. Other significant factors associated with anemia at week 24, were female sex and body weight less than 60kg at baseline

CONCLUSION: Anemia is a frequent complication of Anti HCV therapy

Secondary gastric varices in hepatic cirrhosis

To determine the frequency of secondary gastric varices after esophageal variceal eradication in patients with cirrhosis of liver and factors associated with their development. Observational study. The Department of Gastroenterology, Liaquat University Hospital, Jamshoro and Isra University Hospital Hyderabad, from September 2007 to July 2009. Consecutive patients with decompensated cirrhosis of liver were subjected to endoscopy for management of varices. Endoscopic variceal band ligation was done in all patients. Secondary gastric varices were noted at surveillance. Receiver-operating characteristic [ROC] curves were used to determine the cut off values of secondary gastric varices and various factors influencing the development of gastric varices after eradication with the best sensitivity and specificity. Of the 162 patients; 46 [28.3%] were females and 116 [71.7%] males. The mean age was 45 +/- 13 years. Fundal varices were present before eradication in 12 [7.4%] patients and after eradication of varices in 38 [23.5%] patients. A strong association was found between gastric varices after eradication and Child Pugh class [p=0.001], grade of varices at the time of presentation [p=0.024], increasing number of sessions for eradication of esophageal varices [p=0.001] and presence of gastric varix at the time of first presentation [p=0.009]. Secondary gastric varices are common in cirrhosis. A significant association with Child-Pugh class, presenting grade, increasing number of ligation session and prior existence was seen in the studied group

MELD Era: is this time to replace the original child-pugh score in patients with decompensated cirrhosis of liver

To compare the predictive value of MELD [Model of end stage liver disease] and Child-Pugh [CP] scores in patients with decompensated cirrhosis of liver. Descriptive study. Medical Department, Liaquat University of Medical and Health Sciences, Jamshoro/ Hyderabad, from August 2006 to October 2007. This study included 110 consecutive patients with decompensated cirrhosis of liver diagnosed either clinically or radiologically were followed-up during hospital stay. Studied variables included demographic data, cirrhosis related complications and investigations. Patients were classified according to original CP classification into A, B and C. MELD score was estimated from serum bilirubin, serum creatinine and INR [International normalized ratio] of the patients. Duration of hospitalization and in-hospital mortality were made as the end points of the study. T-test and Chi-square test were done for continuous and categorical data. Original CP and MELD score were compared by the ROC curve. 0.05 was kept as the level of significance. There were 110 patients with decompensated cirrhosis of liver. Mean age was 46.76 +/- 12.93 years. There were 72 [65%] male and 38 [35%] females patients. Hepatitis C was the most prevalent cause of cirrhosis of liver present in 60/110 [60%] cases. Ascites was present in 93/110 [83%] patients. The mean MELD scores were 2.23 +/- 0.712 [95% CI 2.09-2.36] and for CTP 2.52 +/- 0.586 [95%; CI 2.41-2.63]. The outcome of the patients were 12 deaths [11%]; 54 [49%] remained hospitalized for up to 14 days and 44 [40%] for>14 days. The majority of deaths and prolong hospitalization were found in patients with MELD score>15 as well as with Child-Pugh grade C. The c-statistic was 0.726 [p=0.001] for CP score, and 0.642 for MELD score [p=0.021]. The MELD score was not found to be superior to CTP score for short-term prognostication of patients with cirrhosis in this study

Self expandable metallic stent endoscopic insertion in esophageal cancer

To determine the safety of self expandable metallic stent [SEMS] placement under endoscopic guidance without fluoroscopy. Quasi experimental study. Section of Gastroenterology and Hepatology, Departments of Medicine, Isra University Hospital and Liaquat University of Medical and Health Sciences [LUMHS], Hyderabad, from April 2006 to March 2009. In 80 patients with inoperable carcinoma of esophagus, SEMS made-up of nickel titanium alloy and mesh shaped with distal release system were placed without the use of fluoroscope under endoscopic guidance. Patients with proximal location of tumour in esophagus were excluded. They were followed at one week after deployment. All the complications were recorded. Dysphagia score was assessed before and after stent placement. Mean pre- and poststenting scores were compared using t-test. Fluoroscopy was needed in only 2 patients. In 75 patients the stent was successfully placed with endoscope control only, without fluoroscope. Dysphagia score improved significantly from 4.26 +/- 1.07 before stenting to 1.02 +/- 0.57 later, [p < 0.001]. Minor complications like retrosternal pain occurred in 30 [37.5%] patients and major complications in 8 [10.0%] patients amongst which 4 [5.0%] developed upper gastrointestinal bleeding and 4 patients [5.0%] had aspiration. Insertion of self expandable metallic stent in esophageal carcinoma without fluoroscope was safe and effective in relieving dysphagia at short term follow-up

Validation of three non-invasive markers in assessing the severity of liver fibrosis in chronic Hepatitis C

To compare various biochemical markers i.e. APRI [AST to platelet ratio index], aspartate aminotransferase [AST] alanine aminotransferase [ALT] ratio, FIB-4 [AST, platelet, AST and age] with biopsy for assessing the severity of hepatic fibrosis in patients with hepatitis C. Study Design: Descriptive study. Medical Department, Liaquat University of Medical and Health Sciences, Jamshoro, from July 2005 to March 2007. Consecutive hepatitis C virus RNA positive and previously untreated patients were studied. Liver biopsy with histological evaluation and AST/ALT ratio, AST to platelet ratio index and FIB-4 were assessed in all patients. Receiver operative curves were developed. There were 158 patients [109 males, 49 females]. On histological grounds non-advanced fibrosis [F0-1] was present in 74 [46.5%] of cases, whereas 84 [53.5%] patients had advanced [F2-4] fibrosis. The area under the receiver operating characteristic curves of APRI < 0.05-1 and FIB-4 < 1.45 were 0.7 and 0.74 respectively, which means that APRI < 1 and FIB-4 < 1.45 will exclude advanced fibrosis in 70% and 74% of patients respectively. An APRI of > 1 and FIB-4 will predict advanced fibrosis in 87% and 98% of patients respectively. AST/ALT ratio was inferior to both of these biomarkers. Both APRI and FIB-4 not only exclude minimal fibrosis but can predict advanced fibrosis in the majority of the patients. The simultaneous use of several indirect markers of liver fibrosis does not improve their diagnostic accuracy

Serum zinc and magnesium in Type-2 Diabetic Patients

To assess serum zinc and magnesium level in type-2 diabetic patients and the effect of age, gender, glycemic control and duration of diabetes on these trace elements in comparison with those of control subjects. Non-interventional case control study. Department of Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, Hyderabad, from October 2007 to March 2008. There were 42 diabetic patients and 42 age matched non-diabetic [control] subjects included in this study. Serum zinc, serum magnesium and fasting blood sugar measured among the diabetic and control groups and association of both trace elements were assessed with glycemic status, age, gender and duration of diabetes using SPSS version 16.0 for analysis. Serum zinc level was significantly lower [mean 2.03+0.39 mg/dL] in diabetic patients as compared to control subjects [4.84 +/- 4.217 mg/dL, p = < 0.001]. No significant difference was found in serum magnesium level with mean of 22.67 +/- 24.5 mg/dL in diabetic patients as compared to controls [18.3 +/- 3.4 mg/dL, p = 0.26]. Serum zinc level was significantly lower in type-2 diabetics, whereas no significant difference was found in serum magnesium level when compared with control subjects. There was no association of age, gender, glycemic status and duration of diabetes on the serum concentration of these trace elements in type-2 diabetic patients

Frequency of thyroid disorders during interferon and ribavirin therapy in chronic hepatitis C infection

The objective of this study was to assess the frequency of thyroid dysfunction in response to combination of interferon and ribavirin therapy in chronic hepatitis C [CHC] patients and HCV outcome. Descriptive study. This study was conducted at Outpatient Department of Liaquat University of Medical and Health Sciences, Jamshoro, Hyderabad from September 2005 to September 2007. One hundred cases of CHC, proven by anti-HCV and HCV RNA-positive with baseline TSH, FT[4] and FT[3] within the normal reference range, who were treated with interferon alpha-2b [3 million unit subcutaneously three times per week] and oral ribavirin [1000-1200 mg per day] were included in this study. All patients were assessed for TSH, FT[4], FT[3] levels at 12 weeks and 24 weeks during therapy. Among the 100 patients, overt thyroid disease developed in 13 [13%] and sub-clinical thyroid disease in 5 [5%]. Out of 13 patients of overt thyroid disorders, 11 [84.6%] had hypothyroidism and 02 [15.3%] hyperthyroidism. Four [80%] patients were of sub-clinical hypothyroidism and 01 [20%] patient was of sub-clinical hyperthyroidism. Overall, thyroid disorders developed in 18 [18%] both as overt and sub-clinical thyroid disorders. Ninety one [91%] patients became negative by HCV RNA. Treatment of HCV with IFN-alpha and ribavirin can be safely continued in patients with over and sub clinical hypothyroidism because thyroid disease responds well to treatment

Awareness and attitudes of people with diabetes regarding their disease in Hyderabad and Adjoining areas

Diabetes Mellitus [DM] is a chronic disease, associated with high degree of morbidity and mortality. Together with the advances in management of DM, and the widespread availability of treatment, patient's education and awareness about the disease is equally important for the optimum management of the disease. Hence, this study was designed to explore the prevailing attitudes and awareness of diabetic patients in and around Hyderabad - Sindh. A cross sectional survey. Interviews were made regarding attitude, awareness and education about the disease. Percentage scores were then compared separately among the gender [2 groups: male and female], age of the patients [3 groups; group 1, 18-30 years, group II, 31-50 years and group III 51-80 years], and time since the diagnosis of DM [3 groups; group A, less than 6 months, group B, 6.1 month to 3 years, and group C 3.1 years and more]. Total 127 patients were interviewed including 88[69.3%] men and 39[30.7%] women. Among these, 51.7% men and 51% women had a positive attitude while 55.4% of men and 38.8% women had adequate awareness. Also, 68.8% men and 62.8% women were adequately educated. A positive attitude was observed in 4.8%, 46.8% and 46.1% respectively in group I, II and III patients respectively. Corresponding figures for awareness were 49.6%, 55.1%, 44.4% and for education 63.2%, 69.4% and 65.1%. Regarding relationship to the chronicity of the disease, a positive attitude was observed in 53.8% of group A patients, 47.7% and 41.4% amongst group B and C patients respectively. Corresponding figures for awareness and education were 41.1%, 49.1% and 56.2% and 57.8%, 64.2% and 7.7% and 57.8% respectively. Adequate awareness and education about diabetes is lacking. Some aspects of diabetes education need more emphasis. Diabetes education should be tailored according to the individual patient understanding

audit of indications and complications of percutaneous endoscopic gastrostomy

To evaluate the indications and complication rate in fifty consecutive patients in whom percutaneous endoscopic gastrostomy [PEG] was attempted. A descriptive study. Fifty consecutive adults referred to our unit for consideration for primary percutaneous endoscopic gastrostomy feeding between November 1999 and October 2001 at The Aga Khan University Hospital, Karachi and Isra University Hospital, Hyderabad were evaluated prospectively. PEG insertions were successful in all fifty patients [29 Males, 21 Females]. The indications for PEG were neurogenic [80%], recurrent aspiration, not the gastric contents [8%], head and neck tumors [6%], esophageal tumor [4%] and dermatomyositis [2%]. Ninety six percent of the patients had the procedure as inpatients while 4% were outpatients when the procedure was performed. Eighty percent of the patients had at least one follow-up after the tube insertion. Major complications were peritonitis [2%] and aspiration of gastric contents [4%]. Minor complications were PEG site infection [16%], accidental tube removal [10%], PEG migration [6%] and PEG blockage [4%]. One patient died due to peritonitis. Oral feed was resumed in 12% of the patients and the tube was removed subsequently. PEG is a feasible and safe procedure in our set up. It provides adequate feeding support and has low mortality rate even in patients, debilitated secondary to their underlying disease