Cephalosporin resistance in community acquired spontaneous bacterial peritonitis

Objective: To determine 3rd generation cephalosporin resistance in patients with community-acquired spontaneous bacterial peritonitis [SBP] using early response assessment

Methods: This prospective quasi-experimental study was carried out at Doctors Hospital and Medical Center from January 2016 to September 2018. Patients with cirrhosis and SBP were included. Third generation cephalosporins i.e. cefotaxime/ceftriaxone were used for treatment of SBP. Response after 48 hours was assessed and decline in ascitic fluid neutrophil count of < 25% of baseline was labelled as cephalosporin resistant. Carbapenem were used as second line treatment. Recovery and discharge or death of patients were primary end points

Results: Male to female ratio in 31 patients of SBP was 1.2/1 [17/14]. Hepato-renal syndrome was diagnosed in 11[37.9%] patients. Cefotaxime was used for 16[51.6%] patients whereas ceftriaxone for 15[48.3%] patients. Early response of SBP was noted in 26[83.8%] patients while 5 [16.2%] were non-responders to cephalosporins. SBP resolved in all non-responding patients with i/v carbapenem. In-hospital mortality was 12.9% and had no association with cephalosporin resistance. High bilirubin [p 0.04], deranged INR [p 0.008], low albumin [p 0.04], high Child Pugh [CTP] score [p 0.03] and MELD scores [p 0.009] were associated with in-hospital mortality

Conclusion: Cephalosporin resistance was present in 16.2% of study patients with community-acquired SBP. Mortality in SBP patients is associated with advanced stage of liver disease

Health Related Quality of Life [HRQOL] and its correlation with academic performance of medical students

Objective: To determine health related quality of life [HRQOL] of medical students and its correlation with their academic performance

Methods: Cross sectional study at Services Institute of Medical Sciences, included students of 4th and final year MBBS, who filled SF-36 proforma of HRQOL. Scores of 8-domains and of physical component and mental component summary were determined. Marks in all professional examinations were used to stratify students as high performers [>/= 70% marks] and average performing students [< 70%]. HRQOL scores was correlated with academic performance using unpaired student's t-test

Results: Among 267 students included, mental health score [56.2+/-21.3] was lower than physical health component score [69.03+/-18.5]. Role limitation due to emotional health [RE] [44.81], Vitality [VT] [54.19] and general health perception [GH] [58.89] had lower scores among 8domains of questionnaire. Female students had significantly lower scores in role limitation due to emotional problems [p value <0.04], vitality [<0.05], bodily pain [p value <0.05] and general health perception [p value<0.03] than male students. Physical health and role limitation due to physical health domains were better in high performing students

Conclusion: Mental health of medical students is suboptimal, especially among female students. Students with better physical health have better academic performance

Sofosbuvir based therapy in Hepatitis C patients with and without cirrhosis: Is there difference?

Objective: To compare sustained viral response to sofosbuvir/ribavirin +/- interferon therapy in patients of hepatitis C with and without liver cirrhosis

Methods: This observational study of chronic hepatitis C patients was carried out at Doctors Hospital and Medical Center [DHandMC]. After diagnostic workup, Sofosbuvir/ribavirin for 24 weeks or sofosbuvir/ribavirin/pegylated interferon for 12 weeks were prescribed. Primary outcome was negative HCV RNA by PCR 12 weeks after treatment completion SVR[12]. Chi square Chi[2] and student's t test were used to analyze data

Results: Of 216 patients included, liver cirrhosis was present in 112 [51.9%] patients and 69[31.9%] were treatment experienced. Liver disease was decompensated in 37 [17.1%] patients. Of 206 patient who completed study protocol, 173[83.1%] achieved SVR[12], 89.2% [25/28] with triple therapy and 82.2% [148/180] with sofosbuvir/ribavirin therapy. Treatment response was similar between treatment naïve 86.2% [119/138] and treatment experienced 79.4% [54/68] patents. [p value 0.19] SVR[12] was inferior in cirrhosis patients 75.4% [80/106] as compared to those with no cirrhosis 93% [93/100] [p value < 0.000]. It was even lesser in those with decompensated liver disease 68.8% [24/35] [p value < 0.000]

Conclusion: Treatment outcome with sofosbuvir/ribavirin combination therapy in cirrhosis patients is suboptimal especially in those with decompensation as compared to patients without liver cirrhosis

Hepatorenal syndrome: Response to terlipressin and albumin and its determinants

Objective: To determine the efficacy of terlipressin and albumin in improving renal functions in patient with hepatorenal syndrome [HRS] and to identify factors determinant of better response

Methods: In this quasi experimental interventional study patients of liver cirrhosis and ascites with HRS type I were treated with intravenous albumin and incremental dosage of terlipressin based on response with maximum dose of 12mg/day. Decline of creatinine below 1.5mg/dl was defined as complete response. Factors predictive of response to therapy were determined via linear regression analysis

Results: Twenty four patients were included with male to female ratio 3.8/1[19/5] and mean age 53.3 [ +/- 10.06]. Complete response to terlipressin/albumin was seen in 14 [58.3%] patients, seven [29.2%] achieved partial response with > 25% creatinine decline while three [12.5%] had no response. Lower serum creatinine at diagnosis [P value 0.003], absence of hyperkalemia[p value 0.005] and absence of portal vein thrombosis [p value 0.05] are associated with response to treatment in HRS. Baseline serum creatinine [p value 0.003] was independent predictor of response to therapy in multivariate analysis

Conclusion: Terlipressin and albumin is an effective treatment for HRS type I. Patients with lower baseline serum creatinine are more likely to respond to this therapy

Association between functional dyspepsia and severity of depression

Objective: To determine the association between functional dyspepsia and the severity of depression

Study Design: Cross-sectional study

Place and Duration of Study: Department of Medicine, King Edward Medical University/Mayo Hospital, Lahore, from September 2012 till January 2013

Methodology: After taking informed written consent, patients with symptoms of dyspepsia fulfilling the Rome III criteria were included in the study. All patients were evaluated for depression, using Hamilton depression rating scale [HDRS]. Upper gastrointestinal endoscopy was done. Fischers' exact test and independent t-test were used for determining significance of association

Results: One hundred and one patients with mean age of 35.81 [ +/- 14.81] years and male to female ratio of 1.41:1 [54/47] were included. Predominant symptoms were early satiety [72.3%], epigastric pain [65.3%], bloating [49.5%], postprandial fullness [40.6%], and regurgitation [40.6%]. Alarm symptoms were positive in 44 [43.6%] patients. Dyspepsia were classified as epigastric pain syndrome [EPS, 69.3%], and postprandial distress syndrome [PDS, 30.7%]. Significantly more females had PDS [p=0.04], with positive endoscopic findings in EPS [p=0.03]. Positive endoscopic findings noted were esophagitis in 21.8%, and gastritis in 48.5% patients. All patients except one had depression, mild in 22.8%, moderate in 33.7%, severe in 31.7%, and very severe in 10.9% patients. Severe depression was seen in 32 [45.7%] patients with EPS and PDS; whereas very severe depression was in 11 [15.7%] patients of EPS, while 11 [35.4%] patients of PDS had severe depression but the difference was not significant

Conclusion: Functional dyspepsia is associated with depression, while positive endoscopic findings are more likely in patients with EPS. Very severe depression was only seen with epigastric pain syndrome

Peer-assisted learning: who should be the tutor, fellow student or senior resident?

Objective: To compare student-tutor guided peer-assisted learning [ST PAL] and resident-tutor guided peer-assisted learning [RT PAL] for its impact on performance of students in summative assessment

Study Design: Quasi-experimental study

Place and Duration of Study: Gujranwala Medical College, from February to September 2015

Methodology: Four batches each of final year MBBS students were first trained for clinical skills by resident-tutors for 2 weeks and had a pre-test. Two students with highest marks were selected as student-tutors. Half of the batch had a further 2 weeks skill training by the student-tutors while other half by resident-tutor, post-test was carried out after 2 weeks

Improvement in scores was compared between ST PAL and RT PAL groups, using unpaired student t-test. The batch underwent same intervention for the next month with cross-over of ST PAL and RT PAL groups

Results: Study population was 152 out of expected 188 as batch D underwent the study only once and 13 students were either absent or had decline in scores, so were excluded. Among 74 [48.68%] ST PAL and 78 [51.23%] RT PAL students, median improvement in scores was 8 for ST PAL group as compared to 7 for RT PAL group; the difference was not statistically significant [p= 0.61]

Conclusion: Student-tutor guided peer-assisted learning is as effective as resident-tutor peer assisted learning in improving performance of the students

Predicting prognosis in hepatocellular carcinoma: comparison of staging systems in Pakistani cohort

To determine the clinical, biochemical and radiological prognostic indicators and to compare the performance of six staging systems in patients of hepatocellular carcinoma [HCC]. Descriptive study. Department of Gastroenterology, Doctors Hospital, Lahore, from October 2007 to December 2013. Patients with HCC were included. Baseline clinical, hematological and radiological variables were noted. Patients were followed for 5 years or till death. Survival predictors were identified using Cox proportional hazard analysis and 6 prognostic staging systems were evaluated by determining homogeneity, discriminatory ability and monotonicity. Of the 228 patients included, male to female ratio was 2.6/1 [165/63] and mean age was 56.5 +/- 10.4 years. Majority of patients 189 [82.9%] were anti-HCV positive. Solitary HCC lesion was seen in 121 [53.1%] patients, 16 [7%] had 2 lesions while 73 [32%] had 3 or more lesions. Only 36 [15.8%] patients had palliative therapy for HCC. Survival rate was 45.2%, 25%, 12.3%, 7%, 2.2% and 1% for 6 months, 1, 2, 3, 4 and 5 years respectively. Male gender, portal vein thrombosis, serum albumin < 3.5 g/dl, tumor size >/= 6 cm and alpha fetoprotein [AFP] >/= 147 U/ml were bad prognostic indicators. OKUDA, GRETCH and early stages of CLIP had better homogeneity while CLIP showed superior discriminatory ability and monotonicity for predicting survival. Male gender, presence of portal vein thrombosis, low serum albumin, large tumor size and high AFP level are poor prognostic indicators in patients of HCC. CLIP has better performance in predicting mortality

Response guided interferon therapy for genotype 3 of chronic hepatitis C: compliance and outcome

To determine compliance and improvement in sustained viral response [SVR] by following response guided therapy [RGT] plan of interferon and ribavirin, for genotype 3 in chronic hepatitis C. Patients with chronic hepatitis C genotype 3, who were eligible for interferon-ribavirin therapy and consented for RGT, were included. Those with no rapid viral response [RVR], having coarse echotexture of liver or undergoing re-treatment, were advised 48 week treatment whereas, rest had 24 week standard therapy. PCR for HCV RNA checked 6 months after discontinuing treatment, was the primary end point of study. Of 154 patients, included in the study with mean age of 39.9 [+/-10.84] and male to female ratio 1.4/1 [94/60], majority of patients, 136 [88.4%] were treatment naïve whereas, 18 [11.6%] were being retreated. On ultrasound, 63 [40.9%] patients had coarse liver and 33 [21.4%] had splenomegaly. RVR was achieved in 99 [64.3%] patients. Overall 66[42.8%] patients merited extended duration of therapy as per RGT plan but only 22 [33%] were compliant. Treatment related side effects were the dominant reason for declining RGT in 33 [75%] patients. SVR was noted in 111 [72.1%] patients. Those patients with extended therapy [RGT], had SVR 90.9% [20/22], although, better but statistically not significant than those who stopped therapy at 6 months 77.2% [34/44] [p value 0.11]. Response guided therapy plan did not improve SVR to pegylatedinterferon and ribavirin therapy in patients with genotype 3 and it has low patient compliance due to treatment related side effects

Validity of alpha fetoprotein for diagnosis of hepatocellular carcinoma in cirrhosis

To determine the accuracy of serum alpha fetoprotein [AFP] for diagnosis of hepatocellular carcinoma [HCC] in patients with cirrhosis. Observational study. Department of Medicine, The King Edward Medical University, Lahore, from November 2007 to August 2011. Consecutive patients, diagnosed with HCC by contrast enhanced CT, MRI or biopsy were included as cases. Patients of cirrhosis with no evidence of HCC were enrolled as controls. Demographic, laboratory and radiological data were recorded. Serum AFP was determined in all patients at outset and was analyzed using ROC curve for its accuracy in diagnosing HCC. A total of 275 patients were included; of them 173 had HCC and 102 had cirrhosis. One hundred and thirty nine cases [80.3%] with HCC and 86 [84.3%] without HCC had cirrhosis due to HCV. Stage of liver disease, as determined by Child Turcotte Pugh [CTP] score, was comparable; mean CTP value 7.97 A +/- 2.17 in HCC and 7.75 A +/- 2.21 in control group [p = 0.41]. Area under curve [AUC] for AFP was 0.85 [95%, CI: 0.80 - 0.90] with optimum cut off value of 20.85 ng/ml which showed 72.2% sensitivity, 86.2% specificity, 89.9% positive predictive value, 64.7% negative predictive value and 77.4% overall accuracy in diagnosing patients with HCC. Despite sub-optimal sensitivity, alpha fetoprotein is still a valid screening test for diagnosis of hepatocellular carcinoma till other more sensitive markers are developed. Till then, it should be used in conjunction with ultrasound

Paraneoplastic manifestations of hepatocellular carcinoma- are we different?

Objective: to determine the frequency of paraneoplastic manifestations in patients with hepatocellular carcinoma [HCC] presenting at tertiary care center

Design: descriptive study

Place of study: department of Gastroenterology - Hepatology, Shaikh Zayed Federal Post Graduate Medical Institute, Lahore

Patients and Methods: patients of hepatocellular carcinoma were interviewed for symptoms suggestive of paraneoplastic manifestations of HCC. The patients were subsequently examined and investigated. The frequency of paraneoplastic features was determined using SPSS 13.0

Results: of the total 100 patients included, musculoskeletal involvement with joint pain [11%] and muscle tenderness [4%] was noted. Skin lesions were noted in 2% of patients. On investigation 1% patient had erythrocytosis, 3% had thrombocytosis and eosinophilia was noted in 10% of patients. Calcium and cholesterol level were raised in 7% of patients each

Conclusions: paraneoplastic features are seen in significant number of patients with hepato cellular carcinoma

Response to combination therapy in hepatitis virus C genotype 2 and 3

To determine Sustained Viral Response [SVR] to Interferon [IFN] and ribavirin therapy in chronic hepatitis C patients of genotype 2 and 3. The Garden Clinic, Lahore, from June 1997 to August 2007. All patients of both genotypes 2 and 3 receiving combination therapy were included. Standard IFN with ribavirin was started in 648 [90%] patients of genotype 2 and 3, whereas 73 [10%], all genotype 3 received pegylated IFN. Outcome parameters including End of Treatment Response [ETR] [negative PCR at the end of therapy], sustained viral response [SVR] [negative PCR both at the end of treatment and 6 months later] and relapse [PCR negative at the end of treatment but positive 6 months later] were determined. Data were analyzed using student's t-test and Chi-square. A total of 721 patients of genotype 2 and 3 were evaluated with male to female ratio of 1.78:1 and mean age 39.8 +/- 9.17 years. Twenty six [3.6%] patients were of genotype 2, while 695 [96.4%] had genotype 3. Six hundred and ten patients [84.6%] completed therapy, as per protocol, whereas 58 [8.04%] had therapy beyond 6 months. SVR was 72.7% with better outcome in genotype 2 [80%] than in 3 [72%] and in those on pegylated IFN and ribavirin [85%] than patients on standard IFN-based therapy [71.1%] Relapse was seen in 116 [16.1%] and 80 [11.1%] were non-responders. Patients with baseline ALT 2-4 x UNL had better SVR than patients with ALT < 2x UNL [p-value 0.01]. Genotype 3 was the predominant type of virus in the studied patients. SVR patients was 72.7%. Outcome was better with high baseline ALT and pegylated interferon combination therapy

Propranolol, isosorbide mononitrate and endoscopic band ligation - alone or in varying combinations for the prevention of esophageal variceal rebleeding

To compare the efficacy of propranolol, propranolol with nitrate, band ligation, and band ligation with propranolol and nitrate for the prevention of esophageal variceal rebleeding. A prospective randomized trial. Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from November 2003 to July 2005. One hundred and sixty cirrhotic patients with esophageal variceal bleeding were randomized to four treatment groups [propranolol, propranolol plus isosorbide mononitrate, band ligation, band ligation plus propranolol and nitrate] with 40 patients in each group. Patients were followed for 6 months after the enrolment of last patient. Primary end points were recurrence of esophageal variceal bleeding and death. Treatment complications were noted. Four treatment groups were comparable regarding baseline characteristics. Esophageal variceal rebleeding occurred in 22% patients in band ligation plus drugs group, 26% patients in drug combination group, 31% patients in banding group and 38% patients in propranolol group [p=0.41]. Difference in mortality rates was also not significant. There was no significant difference between treatment groups in prevention of esophageal variceal rebleeding

L-ornithine-L-aspartate infusion efficacy in hepatic encephalopathy

To determine the efficacy of L-ornithine-L-aspartate in treatment of hepatic encephalopathy. Randomized, placebo-controlled trial. Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from February to August 2005. Cirrhotic patients with hyperammonemia and overt hepatic encephalopathy were enrolled. Eighty patients were randomized to two treatment groups, L-ornithine-L-aspartate [20g/d] or placebo, both dissolved in 250mL of 5% dextrose water and infused intravenously for four hours a day for five consecutive days with 0.5 g/kg dietary protein intake at the end of daily treatment period. Outcome variables were postprandial blood ammonia and mental state grade. Adverse reactions and mortality were also determined. Both treatment groups were comparable regarding age, gender, etiology of cirrhosis, Child-Pugh class, mental state grade and blood ammonia at baseline. Although, improvement occurred in both groups, there was a greater improvement in L-ornithine-L-aspartate group with regard to both variables. Four patients in the placebo group and 2 in L-ornithine-L-aspartate group died. L-ornithine-L-aspartate infusions were found to be effective in cirrhotic patients with hepatic encephalopathy

Budd chiari syndrome: a rare complication of renal cancer

A 52 years old lady was admitted with 2 weeks history of abdominal distension and drowsiness. Laboratory workup confirmed the presence of de-compensated liver disease with negative viral serology. Abdominal ultrasound and CT abdomen revealed tumour in right kidney with tumour thrombus extending in inferior vena cava and hepatic vein resulting in Budd Chiari syndrome and ascites. Patient was managed with medications only due to advanced liver disease

Predictive value of rockall score for rebleeding and mortality in patients with variceal bleeding

To validate Rockall scoring system for in-hospital rebleeding and mortality in cirrhotic patients with variceal bleed. Cohort type of case series. It was carried out at the Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from March 2005 to March 2006. All cirrhotic patients presenting with upper GI bleeding and later found to have variceal source of bleeding on endoscopy were included. Clinical and endoscopic features were noted to calculate Rockall score. After giving appropriate pharmacological and endoscopic therapy, patients were followed for rebleeding or death till discharge from hospital. linear regression analysis was used to determine predictive value of score and discrimination was evaluated by calculating the area under the receiver operating characteristic [ROC] curve. A total of 402 patients were included. Mean age was 52.57 [ +/- 11.39] and male to female ratio was 2:1 [269/133]. Esophageal varices were source of bleeding in 340 [84.5%], gastric fundal varix in 44 [11%] and ectopic duodenal varix in 3 [0.9%] patients. Both esophageal and gastric varices were present in 15 [3.6%] patients. In-hospital mortality was 6.7% while 22 [5.5%] patients had rebleeding. Rockall score was found to have good predictive value for mortality [p-value <0.001 and area under curve AUC 0.834] and in-hospital rebleeding [p-value < 0.001 and AUC 0.798]. Rockall scoring system has good predictive and discriminative value for in-hospital rebleeding and mortality in patients with variceal bleeding due to cirrhosis

Shifting proportions of carcinoma stomach: 18 Years experience of Shaikh Zayed Hospital

Objective: To study the demographic, endoscopic and histological features of patients with carcinoma stomach presenting in the Endoscopy suite at the Shaikh Zayed Hospital

Study Design: Cross sectional type of descriptive study

Place of study: Study was carried out at Department of Gastroenterology and Hepatology Shaikh Zayed Post-Graduate Medical Institute Lahore from November 2005 to March 2006

Method and Material: All patients diagnosed to have growth, ulcer or infiltrating lesion in stomach on upper gastrointestinal endoscopy were included from the record of the last eighteen years. Patients were divided in two groups depending on the time of endoscopy, each group comprising of endoscopies performed over nine years time. Both groups were compared using SPSS 11.1

Results: Total number of patients included was 267, male to female ratio was 1.42: 1 [158/109]. Mean age of patients was 52.11 [range 17-85 years] with 39% patients below 45 years of age. Predominant gross appearance was polypoidal, seen in 179 [67%] patients while in 151[56%] patients tumor was located in body of stomach, while 7 1[27%] patients had tumor in antrum and 45[17%] in fundus. Time based analysis oftwo groups of patients revealed no significant change in location, gross appearance or histological diagnosis over 18 years in patients presenting at the Shaikh Zayed Hospital

Conclusion: Gastric carcinoma involves younger age group in our population and is mostly located· in proximal two third of stomach. Features of gastric carcinoma have not shown much change over last 18 years in our population

Effect of band ligation on portal hypertensive gastropathy and development of fundal varices

Use of endoscopic therapies for esophageal varices has resulted in increased prevalence of fundal varices and severe portal hypertensive gastropathy. This study was meant to compare the effect of band ligation and sclerotherapy on development of fundal varices and portal hypertensive gastropathy. Patients with esophageal varices presenting in the endoscopy unit of Shiakh Zayed Hospital, with at least one previous endoscopy were included. Patient's past record was reviewed for findings and type of treatment given for varices during first endoscopy, number of endoscopies till date, number of esophageal varices band ligation [EVBL] or sclerotherapy sessions. All patients underwent upper GI endoscopy and findings were recorded. Type of treatment patient rendered during first endoscopy either EVBL or sclerotherapy was correlated to the presence of fundal varices and severity of portal hypertensive gastropathy observed on present endoscopy, using Chi square test [chi [2]]. Eighty one patients were included. Mean age of patients was 48.7 +/- 12.63. Esophageal varices band ligation was carried out during first endoscopy in 49 [60.5%] patients and sclerotherapy in 31 [38.2%] patients. On fresh endoscopy, fundal varices were seen in 25 [30.8%] patients. Severe portal hypertensive gastropathy was found in 26 [32.1%] and mild in 54 [66.7%] patients. Severity of portal hypertensive gastropathy and presence of fundal varices in recent endoscopy was significantly more in patients with EVBL in first endoscopy. Band ligation of esophageal varices is associated with more frequent development of fundal varices and worsening of portal hypertensive gastropathy compared to sclerotherapy