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

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

Hypogonadotrophic short statured with anosmia: kallmann's syndrome

Short stature with loss of secondary sex characters can occur due to genetic disorders. One of them is Kallmann's syndrome. The condition has been noted to be present in families. It is associated with anosmia and hypogonadism. We are presenting a case of young boy who was short statured and had anosmia with multiple hormonal deficiencies

Ectopic intestinal varices as a rare cause of lower gastrointestinal haemorrhage

Ectopic intestinal varices are rarely responsible for lower gastrointestinal [GI] haemorrhage. A case of 55 years old male with recurrent melena is being presented, who was found to have scattered varices on small as well as large intestine. Selective review of literature regarding presentation, diagnosis and management of these cases is also part of presentation