Minimal Hepatic Encephalopathy in Cirrhosis- How Long to Treat?

Abstract: Introduction. Minimal hepatic encephalopathy (MHE) can reverse after short-term treatment. However, relapse rate of MHE after stopping treatment has not been studied so far. We aimed to evaluate long-term (9 months) efficacy of a short-term (3 months) treatment of MHE with lactulose/rifaximin, for maintenance of remission from MHE. Material and methods. In this prospective study, consecutive patients with cirrhosis and MHE were treated with lactulose/rifaximin for 3 months. After treatment, they were followed up for 6 months. Psychometric testing for diagnosis of MHE was performed at baseline, 3 months and 9 months. Results. Of the 527 patients screened, 351 were found eligible and tested for MHE. Out of these, 112 (31.9%) patients had MHE (mean age 55.3 years; 75% males). They were randomized to receive Rifaximin (n = 57; 1,200 mg/day) or Lactulose (n = 55; 30-120 mL/day) for three months. At 3 months, 73.7% (42/57) patients in Rifaximin group experienced MHE reversal compared to 69.1% (38/55) in Lactulose group (p = 0.677). Six months after stopping treatment, 47.6% (20/42) in rifaximin group and 42.1% (16/38) patients in lactulose group experienced MHE relapse (p = 0.274). The overt hepatic encephalopathy development rate (7.1% vs. 7.9%) and mortality rate (0.23% vs. 0%) were similar in both groups. The Child-Turcotte-Pugh score and model for end stage liver disease (MELD) scores of patients who had MHE relapse were higher compared to those who didn’t. On multivariate regression analysis, MELD score was an independent predictor of MHE relapse. Conclusion. Of the patients who became MHE negative after short-term (3 months) treatment with rifaximin/lactulose, almost 50% had a relapse of MHE at 6 months follow-up.

Disease Dynamics and Surveillance of Malaria in Malwa Region of Punjab and Evaluation of RDT Test.

Aim: Malaria remains an enormous public health problem. Regular and ongoing surveillance to detect changes in its trends to initiate the control measures is the need of the hour. The present study was undertaken to provide the malaria transmission dynamics using surveillance indicators through active and passive surveillance in district Faridkot. Usefulness of rapid malaria diagnostic test was also evaluated. Methodology: This retrospective study extended over a period of two years (2010-2011). Thick and thin blood smears were prepared from suspected cases of malaria complaining of fever and headache for the last three days (i) of 2 CHC’s, 8 PHC’s and 68 sub centers as a part of active surveillance and (ii) those who visited GGS Medical College & Hospital and civil hospital Faridkot as a part of passive surveillance. Out of all the samples collected during the passive surveillance 995 samples collected at GGS Medical College and Hospital, Faridkot were also subjected to rapid diagnostic test (OptiMAL®). Results: The annual blood examination rate (ABER) was 9.0 and 9.7 in 2010 and 2011 respectively. Annual parasite incidence (API) recorded was < 2 (0.5) in both the years and slide positive rate (SPR) was 0.5 and 0.05 in the two respective years of study. Significant gap in the rate of case detection of active and passive surveillance systems was observed with predominance of passive surveillance. More than 96% of cases were of P. vivax. RDT’s showed an excellent correlation with conventional microscopy. Conclusion: Malaria (P. vivax) is a persistent problem in the Malwa region with variation in its transmission dynamics with in the year. P. vivax is the main species of malarial parasite in the Faridkot district with occasional cases of falciparum malaria. Prevention strategy should be targeted towards on the spot diagnosis by using RDT and hence prompt treatment. It could help to prevent spread of drug resistance and complicated malaria.