Helicobacter pylori outer membrane protein Q genotypes and their susceptibility to anti-adhesive phytotherapeutic agents / 中西医结合学报

<p><b>OBJECTIVE</b>Helicobacter pylori is a Gram-negative organism. Its outer membrane protein Q (HopQ) mediates host-pathogen interactions; HopQ genotypes 1 and 2 are found associating with gastroduodenal pathologies. The authors measured the anti-adhesion effects of the extracts of Abelmoschus esculentus, Zingiber officinale, Trachyspermum ammi, Glycyrrhiza glabra, Curcuma longa and Capsicum annum against HopQ genotypes and H. pylori cytotoxin-associated gene A (CagA).</p><p><b>METHODS</b>DNA was extracted by polymerase chain reaction of the HopQ genotypes (i.e., type 1, type 2 and CagA) from 115 H. pylori strains. The effect of the extracts from selected dietary ingredients was determined using a gastric adenocarcinoma cell line and a quantitative DNA fragmentation assay. The anti-adhesive effect of these extracts on H. pylori was tested using an anti-adhesion analysis.</p><p><b>RESULTS</b>C. annum, C. longa and A. esculentus showed prominent anti-adhesion effects with resultant values of 17.3% ± 2.9%, 14.6% ± 3.7%, 13.8% ± 3.6%, respectively, against HopQ type 1 and 13.1% ± 1.7%, 12.1% ± 2%, 11.1% ± 1.6%, respectively, against HopQ type 2. C. longa (93%), C. annum (89%) and A. esculentus (75%) had better anti-adhesive activity against H. pylori with HopQ type 1 compared to HopQ type 2 with respective values of 70%, 64% and 51%. Extracts of C. annum (14.7% ± 4.1%), A. esculentus (12.3% ± 4.1%) and Z. officinale (8.4% ± 2.8%) had an anti-adhesion effect against CagA-positive H. pylori strains compared to CagA-negative strains.</p><p><b>CONCLUSION</b>The anti-adhesion properties of the tested phytotherapeutic dietary ingredients were varied with HopQ genotypes. HopQ type 1 was found to be more sensitive to extracts of C. annum, C. longa and A. esculentus compared to the HopQ type 2 genotype.</p>

Primary hepatic carcinoid tumor with poor outcome

Primary Hepatic Carcinoid Tumor [PHCT] represents an extremely rare clinical entity with only a few cases reported to date. These tumors are rarely associated with metastasis and surgical resection is usually curative. Herein, we report two cases of PHCT associated with poor outcomes due to late diagnosis. Both cases presented late with non-specific symptoms. One patient presented after a 2-week history of symptoms and the second case had a longstanding two years symptomatic interval during which he remained undiagnosed and not properly worked up. Both these cases were diagnosed with hepatic carcinoid tumor, which originates from neuroendocrine cells. Case 1 opted for palliative care and expired in one month's time. Surgical resection was advised to the second case, but he left against medical advice

Interferon lambda-3 rs12979860 variants and response to pegylated interferon in chronic hepatitis-c genotype-3

Objective: To assess the role of single nucleotide polymorphisms [SNPs] near the interferon lambda-3 [IFNX3] [formal IL-28B] gene rs12979860 in predicting sustained virologic response [SVR] in hepatitis-C virus genotype-3 [HCV-3]

Study Design: Descriptive, analytical study

Place and Duration of Study: Department of Medicine, The Aga Khan University Hospital, Karachi, from July 2012 to June 2014

Methodology: Patients with HCV-3 were classified as sustained virologic response [SVR], relapsers and non-responders. SNP rs12979860 was determined by PCR-RFLP protocol. Differences between categorical variables were assessed by chi-square or Fisher's exact test, while those between continuous variables were evaluated using the Mann-Whitney U-test. Binary logistic regression analysis by forward conditional method was performed by using significant variables with p-values less than 0.05 as the criteria for model inclusion

Results: Out of 115 patients, rs12979860 genotype-CC, CT, TT was found in 37 [32.2%], 70 [60.9%], and 8 [7%] patients. 72 patients were male with median age of 45 years. Cirrhosis was present in 32 patients. Patients with response failures [no response and relapse, n=36 and 29, respectively] had higher baseline gamma glutamyl transferase [GOT] level [p < 0.001], higher alanine aminotransferase [p=0.027] and cirrhosis [p=0.001] than patients with SVR. Genotype-CC was present in 16/65 in response failures compared to 21/50 who achieved SVR [p=0.048]. Rapid virologic response [RVR] [p < 0.001], low GGT [p=0.001] and absence of cirrhosis [p=0.039] were the independent predictive factors for SVR. In patients who could not achieve RVR and in patients with cirrhosis, SVR was seen more in with genotype-CC [p=0.007 and 0.038]

Conclusion: In patients infected with HCV-3, IFNA3 rs12979860, SNP has less impact on SVR

Age and site of colonic neoplastic lesions: implications of screening in south Asia

To evaluate the Age of patients and the site of Colonic Neoplastic Lesions [CNL] and to determine the appropriate screening strategy for Colorectal Carcinoma [CRC] [sigmoidoscopy versus colonoscopy] in our population. This is a cross sectional study. Data of all patients more than 16 years of age who underwent full colonoscopic examination at the Aga Khan University hospital between January 2011 till December 2013 and were diagnosed to have CRC or advanced adenomas [defined as polyp more than 1 cm and/or having villous morphology on histology] was recorded. Lesions found distal to the splenic flexure were characterized as distal lesions and while lesions found between the splenic flexure and the cecum were characterized as proximal lesions. During the study period colonic neoplastic lesions were found in 217 patients; 186 [85.7%] patients had CRC and 31 [14.3%] patients had advanced adenomatous polyps. Mean age was 55.8 +/- 14 years and amongst them 72 [33.2%] patients were less than 50 years of age while 145 [66.8%] were more than 50 years. In 144 [66.4%] patients lesions were located in the distal colon, 65 [30%] had lesions in the proximal colon while in 8 [3.7%] patients the neoplastic lesions were found both in the proximal and distal colon. The predominant symptoms were bleeding per rectum in 39.6% of patients followed by weight loss in 31.8% of patients. Only 3 patients had familial syndromes with multiple polyps. When patients younger than 50 years of age were compared with patients more than 50 years there was no statistically significant difference between the site of neoplastic lesion as well as the presenting symptoms. [p value 0.85]. Colonic Neoplastic Lesions presented at younger age in our study population and one third of the lesions were found in the right sided colon. Hence screening for CNLs should be implied at an earlier age preferably with colonoscopy. More population based data is required to further validate our results

Task-based learning versus problem-oriented lecture in neurology continuing medical education

To determine whether general practitioners learned better with task-based learning or problem-oriented lecture in a Continuing Medical Education [CME] set-up. Quasi-experimental study. The Aga Khan University, Karachi campus, from April to June 2012. Fifty-nine physicians were given a choice to opt for either Task-based Learning [TBL] or Problem Oriented Lecture [PBL] in a continuing medical education set-up about headaches. The TBL group had 30 participants divided into 10 small groups, and were assigned case-based tasks. The lecture group had 29 participants. Both groups were given a pre and a post-test. Pre/post assessment was done using one-best MCQs. The reliability coefficient of scores for both the groups was estimated through Cronbach's alpha. An item analysis for difficulty and discriminatory indices was calculated for both the groups. Paired t-test was used to determine the difference between pre- and post-test scores of both groups. Independent t-test was used to compare the impact of the two teaching methods in terms of learning through scores produced by MCQ test. Cronbach's alpha was 0.672 for the lecture group and 0.881 for TBL group. Item analysis for difficulty [p] and discriminatory indexes [d] was obtained for both groups. The results for the lecture group showed pre-test [p] = 42% vs. post-test [p] = 43%; pre- test [d] = 0.60 vs. post-test [d] = 0.40. The TBL group showed pre -test [p] = 48% vs. post-test [p] = 70%; pre-test [d] = 0.69 vs. post-test [d] = 0.73. Lecture group pre-/post-test mean scores were [8.52 A +/- 2.95 vs. 12.41 A +/- 2.65; p < 0.001], where TBL group showed [9.70 A +/- 3.65 vs. 14 A +/- 3.99; p < 0.001]. Independent t-test exhibited an insignificant difference at baseline [lecture 8.52 A +/- 2.95 vs. TBL 9.70 A +/- 3.65; p = 0.177]. The post-scores were not statistically different lecture 12.41 A +/- 2.65 vs. TBL 14 A +/- 3.99; p = 0.07]. Both delivery methods were found to be equally effective, showing statistically insignificant differences. However, TBL groups' post-test higher mean scores and radical increase in the post-test difficulty index demonstrated improved learning through TBL delivery and calls for further exploration of longitudinal studies in the context of CME

Varied presentation of celiac disease in Pakistani adults

The objective of this retrospective study was to evaluate presentation of celiac disease in adults. It included 77 patients, 41 [53.2%] males with median age 26 years and median body mass index of 18 [16 - 22] kg/m[2]. Typical presentation with gastrointestinal symptoms was seen in 76.6%. Atypical presentation with extra intestinal complaints in 7.8% and silent presentation in 15.6%. Major symptoms were diarrhea in 64.9%, weight loss 36.4%, abdominal pain 35.1%, vomiting 32.5%, pallor 24.7%, and weakness 13%. Iron deficiency was documented in 20.8%, B12 deficiency in 9.1%, folic acid deficiency in 6.5% and vitamin D deficiency in 10.4%. Half of the patients had haemoglobin less than 11 g/dl. Osteoporosis and osteomalacia, hypothyroidism, diabetes and atrophic gastritis were seen in 2.6% each. Raised alanine aminotransferase was documented in 23.4%. Duodenal biopsy, done in 39 patients, revealed increased intraepithelial lymphocytes in 11, along with crypt hyperplasia in 3, partial villous atrophy in 15 and sub-total villous atrophy in 10. In conclusion, celiac disease in adults should be looked for in patients with chronic diarrhea or irritable bowel syndrome like symptoms, underweight, anaemic, or having nutritional deficiencies

Wilson's disease: experience at a tertiary care hospital

Wilson's disease [WD] is a rare autosomal recessive disorder of copper metabolism. Data regarding WD is not available from Pakistan. A cross-sectional study was conducted at The Aga Khan University Hospital, Karachi, and all patients admitted with primary and secondary diagnosis of Wilson's disease were added. A total of 47 patients were seen; 68% [n = 32] were male. The mean age was 26.6 +/- 9.97 years. Most of the patients presented with hepatic, [n = 22, 46.8%], neurological, [n = 17, 36.2%] and psychiatric [n = 8, 17%] symptoms. Mean ceruloplasmin level was 0.17 +/- 0.13 g/dl; it was < 0.25 g/dl in 39 [86.6%] patients. Serum copper [Cu] was reduced in 32 [68.1%] patients and 24-hr-urinary Cu was raised in 22 [47.6%] patients. Slit lamp examination for Kayser-Fleischer [KF] rings was done on 15 [31.9%] patients and 9 [60%] of them had KF rings. Mean serum aspartate transaminase [AST] / alanine transaminases [ALT] ratio was 1.92 and median alkaline phosphatase / total bilirubin ratio was 79.30 [IQR 35.05; 166.50]

Comparison of the virulence markers of helicobacter pylori and their associated diseases in patients from Pakistan and Afghanistan

Helicobacter pylori is a Gram-negative bacteria, which is associated with development of gastroduodenal diseases. The prevalence of H. pylori and the virulence markers cytotoxin-associated gene A and E [cagA, cagE] and vacuolating-associated cytotoxin gene [vacA] alleles varies in different parts of the world. H. pylori virulence markers cagA, cagE, and vacA alleles in local and Afghan nationals with H. pylori-associated gastroduodenal diseases were studied. Two hundred and ten patients with upper gastrointestinal symptoms and positive for H. pylori by the urease test and histology were included. One hundred and nineteen were local nationals and 91 were Afghans. The cagA, cagE, and vacA allelic status was determined by polymerase chain reaction. The nonulcer dyspepsia [NUD] was common in the Afghan patients [P = 0.025]. In Afghan H. pylori strains, cagA was positive in 14 [82%] with gastric carcinoma [GC] compared with 29 [45%] with NUD [P = 0.006], whereas cagE was positive in 11 [65%] with GC and 4 [67%] with duodenal ulcer [DU] compared with 12 [18%] with NUD [P < 0.001 and 0.021, respectively]. The vacA s1a/b1was positive in 10 [59%] of GC compared with 20 [31%] in NUD [P = 0.033]. In Pakistani strains, cagE was positive in 12 [60%] with GC, 7 [58%] with GU, 12 [60%] with DU compared with 11 [16%] with NUD [P < 0.001, 0.004, and < 0.001, respectively]. In Pakistani strains, cagA/s1a/m1 was 39 [33%] compared with Afghans in 17 [19%] [P = 0.022]. Moderate to severe mucosal inflammation was present in 51 [43%] Pakistani patients compared with 26 [28%] [P = 0.033] in Afghans. It was also associated with grade 1 lymphoid aggregate development in Pakistani patients 67 [56%] compared with 36 [40%] [P = 0.016] in Afghans. Distribution of H. pylori virulence marker cagE with DU was similar in Afghan and Pakistan H. pylori strains. Chronic active inflammation was significantly associated with Pakistani H. pylori strains

Nutritional status in patients with hepatitis C

To assess the nutritional status via the SGA [subjective global assessment] screening tool of patients at all stages of hepatitis C virus [HCV] liver disease. Descriptive study. Out-patient Clinics of the Aga Khan University Hospital, Karachi, conducted from October 2009 to January 2011. Patients with hepatitis C virus infection and their HCV-negative attendants were enrolled from the outpatient clinics, and categorized into 4 groups of 100 patients each: healthy controls [HC], those with chronic hepatitis C infection [CHC], compensated cirrhotics [CC] and decompensated cirrhotics [DC]. The validated subjective global assessment [SGA] tool was used to assess nutritional status. A total of 400 patients were enrolled. Most of the patients in the HC group were class A [best nutritional status]. In contrast, the majority [64%] in the DC group were in the class C [worst status]. The compensated cirrhosis [CC] group showed that 90% of patients were malnourished, while 98% of all patients were malnourished in the DC group, predominantly class C. Most importantly, 14% of patients with chronic hepatitis C [CHC] also scored a B on the SGA; which when compared to HC was statistically significant [p=0.005]. As the groups progressed in their disease from CHC to DC, the transition in nutritional status from A to C between groups was statistically significant. Malnutrition occurs early in the course of HCV, and progresses relentlessly throughout the spectrum of HCV disease

Perception and knowledge about dietary intake in patients with liver cirrhosis and its relationship with the level of education

To determine patients perception and knowledge regarding diet in cirrhosis and its relationship with the level of patients education. Cross-sectional observational study. This study was conducted at Gastroenterology Outpatient Clinics at the Aga Khan University Hospital, Karachi, the Aga Khan Health Services, Malir, Karachi and Hamdard University, Karachi, from January to December 2010. Consecutive adult patients with compensated cirrhosis were enrolled. Demographic data, level of education, type and reason of food restriction as well as the source of dietary information was asked. Baseline laboratory test were performed, and nutritional status was assessed by BMI normogram. Ninety patients, 58% male were enrolled. Mean age of the patient was 49 +/- 11 years. Overall 73% of the patients were restricting fat, meat, fish and eggs in their diet; 53% were in uneducated group and 47% were in educated group [CI, 0.24-1.62, p-0.34]. Twenty two patients [62.8%] in uneducated and 21 in educated group [68%] were restricting diet on the advice of their doctors, whereas 13 in uneducated group [37%] and 11 in educated group [32%] believed these dietary components to be harmful for the liver. Thirty two of uneducated patient [71.1%] and 28 of educated patients [62.2%] believed that vegetables, fruits and sugarcane had a beneficial effect on the liver. Main source of dietary information to the patients was the doctor. On sub-group analysis those who restricted diet irrespective of their educational level, had more patients with BMI less than 18.5 kg/m[2], [CI 0.01-0.94, p-0.001], haemoglobin less than 12 g/dl [CI 0- 0.03, p-0.001] and serum albumin less than 3 g/dl [CI 0.1- 03, p-0.001]. Both educated and uneducated classes of the patients have improper knowledge and perception of diet in cirrhosis. Patients with cirrhosis who restricted diet, had relatively low BMI, haemoglobin and albumin as compared to those who did not restrict. Main source of dietary information to cirrhotic patients were health care personnels

Hepatocellular carcinoma in hepatitis D: does it differ from hepatitis B monoinfection?

Hepatitis D virus [HDV] superinfection in patients with chronic hepatitis B leads to accelerated liver injury, early cirrhosis, and decompensation. It may be speculated that hepatocellular carcinoma [HCC] may differ in these patients from hepatitis B virus [HBV] monoinfection. The aim of this study was to compare clinical aspects of hepatocellular carcinoma in patients of hepatitis D with HBV monoinfection. A total of 92 consecutive HCC cases seropositive for antibody against HDV antigen [HDV group] were compared with 92 HBsAg-positive and anti-HDV-negative cases [HBV group]. The features including sex, body mass index, presence of ascites, serum biochemistry, gross tumor appearance, child class, barcelona cancer liver clinic and okuda stages were not significantly different between the 2 groups. Decreased liver size was noticed more in cases of HDV compared with HBV group where the liver size was normal or increased [P=0.000]. HDV patients had lower platelets [P=0.053] and larger varices on endoscopy [P=0.004]. Multifocal tumors and elevated alpha-fetoprotein level>1000 IU/mL were more common in HBV group [P=0.040 and P=0.061]. TNM classification showed more stage III-IV disease in HBV group [P=0.000]. Decreased liver size and indirect evidence of more severe portal hypertension and earlier TNM stage compared with HBV monoinfection indicate that HDV infection causes HCC in a different way, possibly indirectly by inducing inflammation and cirrhosis

Discriminant value of Rome III questionnaire in dyspeptic patients

Rome III criteria has modified the description of functional dyspepsia [FD] and divided this into subgroups. However, the discriminative value of Rome III questionnaire-based diagnosis of FD is yet to be determined. Objectives: To evaluate the Rome III questionnaire for the diagnosis of FD and whether it can discriminate between postprandial distress syndrome [PDS] and epigastric pain syndrome [EPS] in patients with dyspeptic symptoms. Consecutive patients, who were not on proton pump inhibitors [PPI], were asked to participate. Patients who have previously established acid peptic disease or predominantly reflux symptoms or having alarm symptoms such as weight loss and hematemesis were excluded. Rome III questionnaire for FD was used to identify the patients as having FD and divide into its subgroups; PDS or EPS. Gastro-duodenal biopsies, liver function tests and ultrasound were done to establish the diagnosis of FD. Out of 272 patients with upper gastrointestinal [GI] symptoms without alarm features, who were enrolled in the study, a total of 191 [70%] fulfilled the criteria of FD based upon Rome III questionnaire. EPS subgroup was found in 109 [57%], PDS in 17 [9%] patients, overlap between EPS and PDS was present in 56 [29%] patients. Nine [5%] patients remained indeterminate. Diagnosis of FD was established in 136/191 [71%] patients only. Gastritis was present in 116 patients [85%], Duodenitis in 44 [32%] and Helicobacter pylori infection in 70 [51%] patients. Among 55 patients [29%] who had organic diseases, EPS was seen in 35 [64%], PDS in 5 [9%]] and overlap in 15 [27%] patients. Underlying organic causes were gastric or duodenal ulcers in 14 patients, Barrett esophagus in five, chronic liver disease in seven, gall stones in five, Giardiasis and celiac disease in three each. Gastric carcinoma, Crohns disease and gastric polyps were seen in one patient each. This study indicates that 30% of patients who fulfilled the Rome III criteria for FD actually had organic disease. Almost one-third of patients with functioanl dyspepsia did not qualify for one of the two subgroups of FD of Rome III. There is also a need to further define the Rome Ill-based subgroups of FD for research purpose

Size or the number of portal tracts: which matters in a liver biopsy core in chronic hepatitis C?

Liver biopsy has an important role in staging of fibrosis [SoF] and grading of inflammation [GoI] in chronic hepatitis C [CHC] patients. The effect of size and number of portal tracts [NoP] on grading and staging of liver biopsy was evaluated. A total of 150 consecutive liver biopsy core [LBC] of patients with CHC were obtained. There were 98 [65.3%] males. Mean length of LBC was 1.45 +/- 0.48 cm. Mean number of portal tracts [NoP] was 11 +/- 4.6. Mean length of LBC was greater [1.60 +/- 0.45 cm] in stage 4 [n=41; 27.3%] and lesser [1.28 +/- 0.39] in stage 1 [n=23; 15%, p=0.04]. The mean NoP were 8.5, 10.6 and 13.1 in GoI 1, 2 and 3 respectively [p < 0.001]. The mean NoP were 7.6, 11.1, 11.3 and 14.5 in SoF 1, 2, 3 and 4 respectively [p < 0.0001]. There was a good correlation between number of portal tracts and length of LBC [r[2]=0.56]

Small intestinal bacterial overgrowth and lactose intolerance contribute to irritable bowel syndrome symptomatology in Pakistan

The symptoms of irritable bowel syndrome resemble those of small intestinal bacterial overgrowth [SIBO]. The aim of this study was to determine the frequency of SIBO and lactose intolerance [LI] occurrence in patients with diarrhea-predominant irritable bowel syndrome [IBS-D] according to Rome III criteria. In this retrospective case-control study, patients over 18 years of age with altered bowel habit, bloating, and patients who had lactose Hydrogen breath test [H2 BT] done were included. The "cases" were defined as patients who fulfill Rome III criteria for IBS-D, while "controls" were those having chronic nonspecific diarrhea [CNSD] who did not fulfill Rome III criteria for IBS-D. Demographic data, predominant bowel habit pattern, concurrent use of medications, etc., were noted. Patients with IBS-D were 119 [51%] with a mean age of 35 +/- 13 years, while those with CNSD were 115 [49%] with mean age 36 +/- 15 years. Patients in both IBS-D and CNSD were comparable in gender, with male 87 [74%] and female 77 [64%]. SIBO was documented by lactose H2 BT in 32/234 [14%] cases. It was positive in 22/119 [19%] cases with IBS-D, while 10/115 [9%] cases had CNSD [P = 0.03]. LI was positive in 43/234 [18%] cases. Of these, 25/119 [21%] cases had IBS-D and 18/115 [16%] cases had CNSD [P = 0.29]. SIBO was seen in a significant number of our patients with IBS-D. There was no significant age or gender difference in patients with or without SIBO

Factors predicting the recurrence of spontaneous bacterial peritonitis in patients with cirrhosis

To evaluate the frequency of recurrence of spontaneous bacterial peritonitis [SBP] in patients with end stage liver disease and the factors responsible for it. Descriptive study. The Aga Khan University Hospital, Karachi, from November 2008 till November 2009. Patients with cirrhosis who were admitted at AKUH with diagnosis of SBP during the study period were included. Any episode of SBP after resolution of the first index case of SBP within one year was considered as recurrence. Out of 238 cirrhotic patients, 157 [66%] had single, while 81 [34%] had recurrent episodes of SBP. History of using proton pump inhibitors [PPI] and diuretics was found in 113 [47.5%] and 139 [58.4%] patients respectively. Only 58 [24.4%] patients were on prophylactic antibiotic therapy. Univariate analysis revealed that the female gender [52%], and presence of porto-systemic encephalopathy [PSE, 31%] were statistically significant [p=0.03] among those who had recurrent SBP. On multivariate analysis bilirubin level of > 1.0 mg [OR=7.03; 95%CI=1.55-32], protective factor of hepatitis B [OR 0.31; 95%CI=0.13-0.70] and presence of urinary tract infection [UTl] [OR=2.24; 95%CI=0.99-5.09] were significant in patients with recurrent SBP. Recurrent SBP was noticed in 34% patients. Serum bilirubin level of > 1.0 mg, protective factor of HBV and presence of UTl were significant factors present in patients with recurrent SBP

Efficacy of L-ornithine-L-aspartate as an adjuvant therapy in cirrhotic patients with hepatic encephalopathy

To evaluate the efficacy of L-ornithine-L-aspartate [LOLA] as an adjuvant therapy in cirrhotic patients with hepatic encephalopathy [HE]. Randomized placebo controlled study. The Aga Khan University Hospital, Karachi in the year 2003-2004. Patients with HE were randomized to receive LOLA or placebo medicine as an adjuvant to treatment of HE. Number connection test-A [NCT-A], ammonia level, clinical grade of HE and duration of hospitalization were assessed. Out of 120 patients, there were 62 males with mean age of 57 +/- 11 years. Improvement in HE was higher [n=40, 66.7%] in LOLA group as compared to the placebo group [n=28, 46.7%, p=0.027]. In patients with grade I or less encephalopathy, improvement was seen in 6 [35.3%] and 3 [20%] patients in LOLA and placebo groups respectively [p=0.667]. Patients with HE grade II and above showed improvement in 34 [79.1%] and 25 [55.6%] cases in LOLA and placebo group respectively [p=0.019]. On multivariate analysis patients with HE of grade II and above showed prothrombin time, creatinine level and use of LOLA influencing the outcome. Duration of hospitalization was 93.6 +/- 25.7 hours and 135.2 +/- 103.5 hours in LOLA and placebo groups respectively [p=0.025]. No side effects were observed in either groups. In cirrhotic patients with advanced hepatic encephalopathy treatment with LOLA was safe and associated with relatively rapid improvement and shorter hospital stay

Continuing medical education and pharmaceutical industry

Continuing medical education providers' [academia] and industrial relationship is drawing attention all over the world. To date, there are no national commercial support guidelines available in Pakistan to properly regulate cooperation between the two distinct entities. However, the fact is that the future of all continuing medical education depends on pharmaceutical support and the providers are heavily dependent on the pharmaceutical industry to remain in action. It should always be remembered that medical education and profession is regarded as a moral of enterprise based on a blind faith between the physician and the patient. The funding support by the industry should not bind or influence physician's prescription for any reason. To be trusted, medicine must be free of all such dependency; it should be accountable only to the society it serves and to its own professional standards