Medical education in India: Moments of pensive introspection.

India has 262 medical colleges, producing over 29,000 doctors a year. Nearly half of these medical colleges have recently risen in the private sector. As a result, there is an acute shortage of medical teachers. Teaching in medical colleges was once considered immensely important. It is, however, no longer an attractive career option for a young doctor now. With private practice permitted in most colleges, teaching remains low on the priority scale for most doctors. There is quite naturally a visible effect on the quality of doctors being produced if you may, and on the young doctor’s approach to this profession. It is perhaps time for us to decide then if we are indeed moving towards the light.

Treatment of chronic hepatitis B: will entecavir and telbivudine do the trick?

Rapid evolution and development in the treatment strategy of chronic hepatitis B (CHB) has taken place in the last decade. Six agents have been so far approved by the FDA for the management of HBV infection including two parenteral drugs (interferon alpha2b and pegylated interferon alpha-2a) and four oral nucleotide/nucleosides (lamivudine, adefovir dipivoxil, entecavir, and telbivudine). The two parenteral drugs have significant side effects and limited rates of HBeAg seroconversion. Lamivudine and Adefovir have been plagued by significant levels of drug resistance.The newer drugs entecavir and telbivudine have been in focus recently with claims of increased potency, with low side effects and lesser drug resistance. While these new drugs are definitely a welcome addition to the family of antiviral drugs against HBV, they are not necessarily a cure for all the evils of their predecessors.

Protein-c deficiency presenting with subacute intestinal obstruction due to mesenteric vein thrombosis.

We describe a patient with protein C deficiency who presented with subacute intestinal obstruction due to ischaemic small bowel stricture. The patient also had left sided ileofemoral thrombosis. Venous thrombosis at unusual sites especially if associated with deep vein thrombosis of lower limb warrants a thorough screen for underlying thrombophilia. This, however, is a rare cause for ischaemic small bowel stricture.

Gastrointestinal problems at high altitude.

Gastrointestinal (GI) problems at high altitude are commonplace. The manifestations differ considerably in short-term visitors, long-term residents and native highlanders. Ethnic food habits and social norms also play a role in causing GI dysfuntion. Symptoms like nausea and vomiting are common manifestations of acute mountain sickness and are seen in 81.4% short-term visitors like mountaineers. Anorexia is almost universal and has a mutifactorial causation including effect of hormones like leptin and cholecystokinin and also due to hypoxia itself. Dyspepsia and flatulence are other common symptoms. Diarrhoea, often related to poor hygiene and sanitation is also frequently seen especially among the short-term visitors. Peptic ulceration and upper gastro-intestinal haemorrhage are reported to be common in native highlanders in the' Peruvian Andes (9.6/10000 population per year) and also from Ladakh in India. A hig h incidence o f gastriccarcinoma is also reported, especially from Bolivia (138.2 cases per 10000 population per year). Megacolon and sigmoid volvulus are common lower GI disorders at high altitude. The latter accounted for 79% of all intestinal obstructions at a Bolivian hospital. Thrombosis of the portosystemic vascultature and splenic hematomas has been reported from India. Malnutrition is multifactorial and mainly due to hypoxia. Fat malabsorption is probably significant only at altitudes > 5000m. Neonatal hyperbilirubinemia was found to be four times more common in babies born at high altitude in Colorado than at sea level. Gall stones disease is common in Peruvian highlands. A high seroprevalence of antibodies to H pylori (95%) has been found in Ladakh but its correlation to the prevalence of upper gastro-intestinal disease has not been proven.

Impact of hepatitis C virus infection in renal transplant recipients.

OBJECTIVES: The impact of hepatitis C virus (HCV) infection on the success of renal transplant is controversial. We assessed the effect of HCV infection on graft and patient survival in renal allograft recipients. METHODS : We retrospectively analyzed medical records of renal allograft recipients who were transplanted between June 1990 and March 2004. Patients were divided into those positive and negative for anti-HCV antibody. Graft and patient survival were compared between the groups. RESULTS : Of 126 patients studied (median age 34.5 years, range, 16-60; 111 men), 35 were positive for anti-HCV antibody. In seven patients, the antibodies were detected for the first time after renal transplant. Mean patient and graft survival duration in the anti-HCV negative group was longer (55 [SD 2] months [95% CI, 51-58]) than in the anti-HCV positive group (50 [SD 4] months [95% CI, 43-58]) (p< 0.05). Twenty-two patients died - 8 (22.8%) in the anti-HCV positive group and 14 (15.3%) in the negative group. In the anti-HCV positive group, infections were the cause of death in 5 patients and 3 patients died of liver cell failure. In the anti-HCV negative group, corresponding figures were 13 and one. CONCLUSION: HCV infection is a bad prognostic indicator for patient and graft survival duration in renal transplant recipients. Infections are the commonest cause of death in renal transplant recipients.

Should one vaccinate patients with chronic liver disease for hepatitis A virus in India?

BACKGROUND: Hepatitis A virus (HAV) vaccination is recommended worldwide for patients with chronic liver disease to prevent decompensation due to superinfection with HAV. India being endemic for HAV, the prevalence of pre-existing antibodies against HAV due to subclinical exposure to the virus in childhood among patients with chronic liver disease may be high and, therefore, vaccination may not be needed. However, little data are available on the prevalence of HAV antibody among patients with chronic liver disease in India. METHODS: All patients with chronic liver disease seen at Gastroenterology Center, Army Hospital R and R, New Delhi during the year 2002 and diagnosed to have either chronic liver disease were tested for the presence of IgG anti-HAV antibody in their sera (using a commercial ELISA kit). All patients with acute exacerbation or rapid deterioration of a preexisting chronic liver disease were separately studied for presence of IgM anti-HAV. In addition, a matched number of patients who attended the center due to diseases other than liver disease were also studied as controls. RESULTS: One hundred and eighty seven patients of chronic liver disease and 89 controls were studied. Mean age of these two groups was 38.6 and 42.1 years and 153 (81.8%) and 78 (87.6%) of them were males respectively. Etiology of chronic liver disease was HBV infection in 91(48.7%), HCV infection in 62 (33.2%), autoimmune chronic hepatitis in 3 (1.6%), PBC in seven (3.7%) and cryptogenic 24 (12.8%). Of these 179 (95.7%) patients tested positive for IgG anti-HAV. A total of 37 hospitalisations in 29 patients were noted during the study period due to acute exacerbation of pre-existing chronic liver disease. None of these were positive for IgM anti-HAV, while 28 were positive for IgG anti-HAV. Among the controls, 87 controls (94.6%) were positive IgG anti-HAV. The prevalence of anti-HAV positivity was similar among patients with various etiologies. CONCLUSION: Vaccination against HAV is not routinely required among patients with chronic liver disease in India as there is a very high prevalence of pre-existing antibodies in these patients. HAV superinfection as a cause of acute exacerbation of chronic liver disease was not seen in this.

Bioartificial liver support for fulminant hepatic failure.

Mortality from fulminant hepatic failure (FHF) is high (50%-80%), although survivors have absolutely normal liver function. The only treatment option that is curative is liver transplantation. However, because of shortage of cadaveric organ donors and/or delay in their availability, only 10% of FHF patients ultimately receive a transplant. This has led to development of artificial liver support systems with an idea to bridge the time to transplantation and/or recovery from FHF. Initial support systems were based on the principles of hemodialysis, hemofiltration, plasma-exchange, and hemoperfusion through adsorbent media (e.g., charcoal). However, lack of clinical efficacy, problems of bioincompatibility and fear of loss of circulating hepatocyte-regeneration factors led to the search for alternate strategies. With the successful long-term propagation and culturing of human and pig hepatocytes, and the development of adequate biocompatible microcarrier modules, it is now possible to achieve sufficient density of hepatocytes per unit volume to develop bioartificial liver systems. These can be implanted transperitoneally but are subject to early destruction because of inadequate vascularization and immune attack from the host. Thus the major thrust is now to develop bioreactors, e.g., Extracorporeal Liver Assist Device (ELAD), Bioartificial Liver (BAL), etc. These contain human or pig hepatocytes implanted on hollow-fiber ultrafiltration cartridges. The patient's blood or plasma circulates through these bioreactors and after clearance of toxic compounds (via ultrafiltration and metabolism in hepatocytes) and addition of synthesized products, is returned to the patient. This article reviews the genesis, the pros and cons, and the clinical experience of BAL support for FHF.