Effectiveness of levofloxacin in the induction of chemotherapy in high-risk acute lymphoblastic leukaemia in children in a developing country.

Background: Infections significantly predominate during induction chemotherapy for acute lymphoblastic leukaemia (ALL) in children. Antibacterial prophylaxis is one strategy that lowers the risk of these infections. This study evaluates the role of levofloxacin prophylaxis on the frequency of infections, febrile neutropenia (FN) and outcomes associated with it along with the development of drug-resistance. Subject and methods: This was a single-centre cohort study in which the data were collected from electronic health records between two cohorts of high-risk ALL patients in the induction phase: the first one before the initiation of levofloxacin prophylaxis and the second was after the implementation of levofloxacin prophylaxis. The variables were compared between both the groups and odds ratios were calculated for clinical outcomes. Results: Out of 227 patients, 115 were given levofloxacin prophylaxis and 112 were in the no prophylaxis group. Both cohorts were similar in demographic factors, treatment regimen and supportive care services. There was a significant difference in total in-patient admissions along with FN admissions (p = 0.026). Microbiologically documented infections and infection-related critical interventions were significantly higher in the no prophylaxis group (p < 0.05). Odds ratios with a 95% confidence interval were applied to both groups for clinical outcomes in patients with and without FN which also illustrated similar results. Overall mortality and drug resistance patterns were similar among both groups. Conclusion: This study emphasised that levofloxacin is effective in reducing inpatient admissions with FN and its complications but did not affect the drug-resistance pattern. Long-term monitoring for antibiotic resistance is mandatory.

Frequency of Occult Hepatitis B Virus (HBV) in Chronic Hepatitis C Patients.

Occult HBV is defined as the presence of HBV DNA in the liver tissue and / or HBV DNA in blood of people with negative HBsAg by currently available assays. The objective of the study was to determine the prevalence of occult HBV in chronic HCV patients. It was a cross-sectional study of one year duration including patients coming to the outpatient department with a positive HCV RNA by PCR from May 2018 to May 2019. Blood samples were taken to test HBsAg. Those cases who were HBsAg negative were checked for HBV DNA using real time PCR. A total of 217 cases were included in the study. Mean age was 41.3 + 14.61 years. All 217 cases of chronic HCV infection, which were positive for HCV RNA by PCR, were found to be negative for both HBsAg and HBV DNA. No occult HBV was detected in cases of chronic HCV infection seeking treatment. Key Words: Occult, Hepatitis B, Chronic hepatitis C.

Comparison of dried blood spots with conventional blood sampling for diagnosis of hepatitis b & c through serological and molecular technique; a pilot study.

OBJECTIVE: To compare the sensitivity and specificity of dried blood spot with conventional blood sampling for serological and molecular testing of hepatitis B and C viruses. METHODS: The case-control study was conducted at the Pakistan Health Research Council Specialised Centre for Gastroenterology and Hepatology, Karachi, from May,2015 to April,2016 and comprised patients who were hepatitis B surface antigen-positive (group 1), anti-hepatitis C virus positive (group 2), hepatitis B virus deoxyribonucleic acid-positive (group 3), and hepatitis C virus ribonucleic acid-positive (group 4). A group of controls had healthy subjects negative for both hepatitis B and C viruses. Blood samples were collected using the conventional as well as the dried blood spot method using finger prick. Relevant tests were run for each subject using both the samples at baseline and after 3 and 6 months of storage. Receiver operative characteristic curve was plotted to determine the ideal cut-off points for dried blood spot testing and corresponding sensitivity and specificity. Data was analysed using SPSS 19. RESULTS: Of the 100 subjects, there were 20(20%) in each of the four patient groups and 20(20%) in the control group. Sensitivity of dried blood spot method was 95.2%, 95%, 80% and 70% for groups 2, 1, 4 and 3 respectively when tested within a week of sampling. Specificity was 100% for all the four groups. There was a significant correlation of the two methods for all the four parameters tested (p<0.01). CONCLUSIONS: Dried blood spot sampling correlated well with the conventional blood sampling method for serological and molecular testing.

Comparison of Rapid Anti-HCV Multi-sure Kit with Gold Standard ELISA.

OBJECTIVE: To compare the diagnostic yield of Multi-sure rapid HCV (hepatitis C virus) kit with ELISA. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Pakistan Health Research Council, specialised research center for gastroenterology and hepatology, from August 2016 to January 2017. METHODOLOGY: A modified rapid anti-HCV kit was compared with ELISA. This rapid kit is multi-parameter qualitative immune chromatographic kit for the in-vitro detection of antibodies to HCV in human blood. Patients who came to PHRC, were tested using anti-HCV ELISA, and their test was run simultaneously on multi-sure HCV rapid kit were included in the study. Each positive and negative sample was included in this study. SPSS software was adapted for data analysis. RESULTS: A total of 420 samples were collected. Among them, 255 (61%) were of male and 165 (39%) were of female patients. Mean age was 35 ± 14.33 years. All the samples run for anti-HCV on ELISA were also run on multi-sure rapid kit. It is evident that 22.4% were reactive on ELISA and 23.6% were reactive on rapid kit, while 75.5% were non-reactive on ELISA and 68.1% were non-reactive on rapid kit. Borderline positive results were seen in 2.1% on ELISA and 5.0% on rapid kit. Sensitivity of rapid kit was 87.2%, specificity 89.3% with 82.8% positive predictive value and 98.9% negative predictive value. CONCLUSION: Multi-sure kit showed significantly, less non-reactive and more borderline results as compared to ELISA. Comparison of multi-sure rapid kit with ELISA showed that core antibody can be used as an alternate marker for ELISA. Other non-structural proteins including NS3, NS4 and NS5 were found to be less significant. So, it is concluded that this rapid kit may not be recommended as an alternative of ELISA, except for places where ELISA is not available.

Treatment of chronic Hepatitis C in Thalassemia major patients.

Treatment of chronic hepatitis C (HCV) is difficult in thalassemics due to the haemolytic side effects of therapy. This study evaluated the treatment response to conventional interferon and ribavirin in HCV patients with thalassemia major. It was conducted at PMRC Research Centre, Jinnah Postgraduate Medical Centre (JPMC) Karachi. At baseline complete blood count, liver function tests, serum protein/ albumin, random blood glucose, serum ferritin, TSH, HCV RNA (quantitative) and genotyping were done. Conventional interferon 3 MIU thrice weekly and ribavirin 400 mg daily was given for 24 or 48 weeks. HCV RNA was done at 1st month (RVR), 3rd month (EVR), 6th month (ETR) and six months post treatment sustained virological response (SVR). A total of 17 Anti HCV positive patients, age range 7-28 years were included.HCV RNA was found in 12. Treatment was completed in 8 patients. Genotype 3(87.5%) was found in 7 patients, 1 had genotype 1. RVR was achieved in 5 (62.5%) cases, negative PCR at 3 and 6 months of treatment (EVR) in 7 (87.5%) patients, one patient was non responder. SVR was achieved in 2(25%) patients. Anaemia was the most common side effect due to which transfusion requirements increased in 4(50%) patients.

Is chlorhexidine-gluconate superior than Povidone-Iodine in preventing surgical site infections? A multicenter study.

OBJECTIVE: To compare the efficacy of povidone-iodine and chlorhexidine gluconate scrubs in preventing surgical site infections. METHODS: The randomised controlled clinical trial was conducted from May 2012 to April 2013 in two public-sector hospitals of Pakistan; one each in Karachi and Islamabad. Patients undergoing clean or clean contaminated surgeries were included and were randomly assigned to one of the two groups: group I comprised patients whose skin was preoperatively disinfected using 10% povidone-iodine, and in group II by 2% chlorhexidine gluconate in 70% alcohol. A predesigned proforma was filled for all patients to record demographic data, diagnosis, surgical procedure and antibiotic used. Patients in both groups were followed up for one month postoperatively to monitor any signs of surgical site infections. SPSS 16 was used for statistical analysis. RESULTS: Of the 388 patients from the two hospitals, 220(57%) were in group I and 168(43%) were in group II. Surgical site infection was observed in 22(10%) cases in group I and 12(7.1%) in group II (p=0.324). Pseudomonas aeruginosa (23.5%) was the predominant pathogen associated with surgical site infections followed by Staphylococcus aureus (17.6%). CONCLUSIONS: Chlorhexidine gluconate was associated with lower infection rates compared to povidone-iodine; but it was not statistically significant.

Clinical, laboratory and bacterial profile of Spontaneous Bacterial Peritonitis in Chronic Liver Disease patients.

OBJECTIVE: To determine the clinical and laboratory features, bacterial profile and antibiotic sensitivity pattern of Spontaneous Bacterial Peritonitis (SBP) in Chronic Liver Disease (CLD) patients presenting at a tertiary care hospital of Karachi. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi, from April 2010 to March 2012. METHODOLOGY: CLD patients with ascites were recruited from PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi. Basic demographics, symptoms and clinical signs of patients were recorded. Patients with the history of antibiotic use within last 3 days or any intra-abdominal source of infection were excluded. Diagnostic paracentesis was done for ascitic fluid detailed report (D/R) and culture. Blood sample was collected for total leukocyte count, serum proteins and billirubin levels. RESULTS: Out of a total 152 CLD patients, 38 (25%) were diagnosed with SBP. Eight (24.2%) patients presented with classical SBP, 20 (52.6%) had culture negative neutrocytic ascites and 10 (26%) had bacterascites. Fever, abdominal tenderness and constipation were common in SBP patients. Ascitic fluid culture was positive in 19 (50%) patients. E. coli (65%) was the predominant pathogen followed by Enterococcus species (15%). Resistance was high against cephalosporins (78%) and fluoroquinolones (69.6%) and least against amikacin (13%) and meropenem (12%). CONCLUSION: Ascitic fluid D/R and culture together can lead to the accurate diagnosis of SBP and can guide for the right antibiotic choice as resistance to commonly prescribed antibiotic is common in such patients.

Dengue fever in patients admitted in tertiary care hospitals in Pakistan.

OBJECTIVES: To assess the gaps in the diagnosis and management of dengue fever cases. METHODS: The retrospective descriptive analytical study was done with a case record analysis of patients with dengue fever admitted from January to December 2010 at five tertiary care hospitals in different Pakistani cities. Using a questionnaire, information was gathered on demography, haematological profile, management, use of blood and platelet transfusions and the outcome. For comparison, data of serologically-confirmed dengue patients from a private laboratory in Islamabad was collected to see the age, gender and month-wise distribution of cases tested over the same period. SPSS 16 was used for statistical analysis. RESULTS: Out of the 841 confirmed dengue cases, 514 (79%) were males and 139 (21%) females. The overall mean age was 31.3 +/- 14.0 years. Dengue fever was seen in 653 (78%) and dengue haemorrhagic fever (DHF) in 188 (22%) patients. Most cases were between 20 and 49 years of age. A gradual increase in dengue fever and dengue haemorrhagic fever was seen from August, with a peak in October/November. Tourniquet test was done only in 20 (2.3%) cases, out of which 11 (55%) were positive and 9 (45%) were negative. Serial haematocrit was not done in any case. Total deaths were 5 (0.6%). CONCLUSIONS: Most cases were seen in October/November with the majority being in the 20-39 age group. Tourniquet test and serial haematocrit were infrequently used. No standard national guidelines were employed.

The evidence of mother to child transmission of hepatitis B virus infection in Pakistan and the need for hepatitis B immunization policy change.

OBJECTIVE: To establish the hepatitis B surface antigen and hepatitis B 'e' antigen seroprevalence of mothers and their children aged 6-36 months and to assess the risk of hepatitis B transmission occurring in infants born to hepatitis B surface antigen positive mothers in Pakistan. METHODS: Mothers and their children were selected from eight districts of three provinces that have been identified as high hepatitis B prevalence areas between May 2010 to February 2011. Ages of the children and their vaccination status were obtained from the lady health workers' registers and also verified from the mothers. Five ml of blood was drawn from all the children and their mothers for testing. All sera were tested for anti-hepatitis B. Those found negative were run for HBsAg the sueface antigen and those positive for it were further run for hepatitis B 'e' antigen All tests were run on Abbott machine using chemiluminesence method. EPI-info 12 was used for statistical purposes. RESULTS: A total of 1561 mothers and their 1612 children were tested. Among the mothers, 590 (37.8%) were hepatitis B antibody positive. Remaining 971 (62.2%) samples were tested for surface antigen and 123 (12.7%) were found positive of which 27 (22%) showed HBeAg positivity. Out of 1612 children tested, 975 (60.5%) were positive. Remaining 637 (39.5%) were tested for surface antigen and 49 (8%) were found positive of which 24 (49%) were HBeAg positive with a perinatal hepatitis B virus transmission rate of 5.4% by 12 months of age. Of the 123 surface antigen positive mothers, 18 (14.6%) had children who were also positive, while of the 1489 children born to the 1438 surface antigen negative mothers, 31 (2.1%) were positive. Children born to surface antigen positive mothers had eight times higher risk of getting hepatitis B virus infection and the risk rose to 17 times if the mother was also HBeAg positive. Hepatitis B vaccination record showed that 1229 (76.25%) children were vaccinated at six weeks with pentavalent vaccine, but despite vaccination 33 (2.6%) became surface antigen positive. No vaccination was received by 320 (19.9%) children and out of these 16 (5%) became surface antigen positive. Moreover, the vaccinated and unvaccinated children born to surface antigen positive mothers were nine and 11 times respectively more likely to be exposed to the risk of hepatitis B virus transmission relative to vaccinated children born to surface antigen negative mothers. CONCLUSIONS: Hepatitis B vaccination given at 6, 10 and 14 weeks of birth is not sufficiently protective, indicating a strong need for the introduction of birth dose into the national immunisation system.

Innovative solution to sharp waste management in a tertiary care hospital in Karachi, Pakistan.

BACKGROUND: Prevalence of hepatitis B and C in Pakistan is 2.5% and 4.5%, respectively. Major cause of these infections is reuse of syringes. OBJECTIVE: To determine a cost-effective, innovative solution to prevent syringe reuse and break the transmission cycle of blood-borne infections. STUDY DESIGN, SETTINGS, AND DURATION: Analytical study in a tertiary care hospital, Jinnah Postgraduate Medical Centre, Karachi, Pakistan, July 2011 to June 2012. METHODS: Healthcare workers from 30 wards included in the study were trained on injection safety, use of needle remover and needle pit, and management of needlestick injuries. Each ward was provided with 2 needle-removing devices, and a pit was constructed for disposal of needles. Usage of the device in wards and pit use were monitored regularly. RESULTS: In 28 (93.3%) wards, sharp containers were accessible by public and were slack. Syringes were recapped using both hands in 27 (90%) cases; needlestick injury was reported by 30% of paramedics, while 25 (83.3%) of the interviewed staff had not received any formal training in injection safety. Vigilant monitoring and information sharing led to healthcare workers in 28 (96.5%) wards using the device. Needle containers were emptied in 27 (93.1%) wards, and needle pits were used in 26 (96.3%) wards. Needlestick injury was nil in follow-up. CONCLUSIONS: Needle removers permanently disable syringes. The needle pit served as a cost-effective, innovative method for disposal of needles. The intervention resulted in reducing the risk of needlestick injury.

Treatment of hepatitis B and C through national programme--an audit.

OBJECTIVES: To evaluate the response to treatment given on a large scale for hepatitis B and C through a nationwide programme. METHODS: Records of patients who received treatment of hepatitis B and C during past 2 years through the Prime Minister's programme for the Prevention and Control of Hepatitis Viral Infection was retrieved randomly from 12 sites after taking consent from the management and the site managers. Data confidentiality was ensured. All data was photocopied and brought to the Pakistan Medical Research Centre at the Jinnah Postgraduate Medical Centre, Karachi, where it was entered and analysed. The inclusion/exclusion criteria and the followup tests that were to be done before, during and after treatment were taken from the National programme manager so that actual data could be matched with the guidelines. Data was analysed through a specially developed programme. RESULTS: A total of 7752 patients received treatment at the 12 sites for hepatitis C. Adherence to inclusion/exclusion criteria or protocol was followed in 7572 (97.6%) patients. Out of 7572 patients, 3440 (45.4%) completed 6 months of interferon therapy, but the polymerase chain reaction test at the end of 6 months was available in 1686 (49%) cases. It was not detected at 6 months in 1133/1686 (67%) cases, while in 553 (33%) cases there was no response. Data for hepatitis B was collected from 8 sites. A total of 454 cases received treatment and 85 (18.72%) fulfilled the inclusion criteria. Treatment was completed by 9 (10.58%) cases, with 3 (3.52%) cases showing Hepatitis B 'e' antigen clearance and anti-HBe (antibody to hepatitis B 'e' antigen) production. CONCLUSION: Poor followup and inadequate documentation of serological/biochemical tests were the major drawbacks in both hepatitis B and C patients, resulting in wastage of huge human and financial resources without proper planning and accountability.

Comparative cost and efficacy trial of Pakistani versus Indian anti snake venom.

OBJECTIVES: To compare the efficacy, safety and cost of Pakistani anti-snake venom with that imported from India METHODS: The comparative cross-sectional study was conducted from June to September 2010 and comprised patients hospitalised following Krait snake bite in Mithi and Umerkot hospitals of Tharparker district who had incoagulable blood test on admission (20-minute whole blood clotting time). Basic demographies of patients, the site of bite and swelling around the bite and joints were entered in a proforma. For blinding, the liquid anti-snake venoms were packed in opaque polythene bags and marked as "A" and "B", and refrigerated. Four ampoules of the venom were mixed in a drip and given over one hour while looking for adverse reactions. In case of milder reactions, the venom was temporarily stopped and anti-histamines and analgesics were given. For more severe reactions intramuscular adrenaline was recommended. Coagulation was again checked after 6 hours and, if blood was still incoagulable, the dose of the venom was repeated after 6 hours. Once coagulation was confirmed on two occasions, the patient was discharged. Total doses of the venom given to achieve coagulation, the reactions and the cost of the venom were analysed at the end to see the response and cost-effectiveness. RESULTS: Of the 80 cases - 40 (50%) from each hospital - 6 (7.5%) had to be excluded for lack of data. Out of the remaining 74 (92.5%) patients, 38 (52.35%) received Pakistani anti-snake venom (A), and 36 (48.64%) received Indian anti-snake venom (B). Immediate reaction to the venom was seen in 23 (60.5%) cases with "A" and 25 (69.4%) with "B". In terms of evenomation, 23 (60.5%) cases with "A" attained restoration of coagulation with the first dose, compared to 13 (36.11%) with "B", showing a significantly better response with "A" (p < 0.035). Mean of 1.66 doses of "A" and 1.94 of "B" were used to neutralise venom, again showing lesser doses of Pakistani anti-snake venom. Cost-wise "A" was 2.5 times cheaper than the imported "B". CONCLUSION: Pakistani anti-snake venom was significantly quicker and better as well as cheaper than the Indian anti-snake venom.

Active disease in chronic hepatitis C patients with normal alanine aminotransferase.

OBJECTIVE: To quantify liver damage using Metavir score, in chronic hepatitis C patients having normal alanine aminotransferase (ALT) to determine active disease requiring treatment. STUDY DESIGN: An analytical study. PLACE AND DURATION OF STUDY: Pakistan Medical Research Centre, JPMC, Karachi, from January 2007 - December 2010. METHODOLOGY: Patients suffering from hepatitis C with positive PCR, having persistently normal ALT on 3 separate occasions over a 6 months period and also having normal platelets and albumin were included in the study. After written consent, all patients underwent a liver biopsy and the degree of damage was assessed using Metavir scoring system. RESULTS: A total of 99 patients suffering from chronic HCV were included in the study. A majority of the patients (55.6%) were females. Using Metavir score, minimal fibrosis of ² 1 was seen in majority (78.8%) of the patients. Only 21.2% patients had fibrosis score ³ 2, with 16 (47.1%) of these also having inflammatory score ³ 2 (p < 0.001). The age of patients (mean 38.1 ± 10.2 years) had a significant association with the severity of liver damage (p < 0.001) as compared to younger age group (mean 33.1 + 9.8 years). CONCLUSION: A large proportion of patients with normal ALT have insignificant fibrosis indicating non active disease and thus questions the blanket use of interferon in all HCV RNA cases. It is strongly recommended that a liver biopsy should be done in all cases with normal ALT before deciding antiviral therapy.

Weight loss with interferon and ribavirin therapy in chronic hepatitis C patients.

Recommended treatment of chronic Hepatitis C virus (HCV) infection is interferon and ribavirin. Most patients develop side effects during treatment. Weight loss is one of the side effects of interferon therapy. Present study was conducted at Pakistan Medical and Research Centre (PMRC), Jinnah Postgraduate Medical Centre (JPMC), Karachi from January 1998 - December 2010, to find out the frequency, extent of weight loss, its recovery after interferon therapy and the impact of weight loss on treatment response. Body weight was recorded on regular outpatient visits i.e initially, then at 1, 3 and 6 months of treatment and six months post treatment. Out of 260 patients, 176 (67.7%) observed statistically significant weight loss (p<0.05), on completion of therapy as compared to initial visit. Weight loss during interferon therapy was found to be independent of age, gender, treatment outcome, serum albumin, haemoglobin, white blood cell (WBC) and platelet count. Body weight returned to baseline within six months after completion of treatment in most cases.

Factors influencing the response of interferon therapy in chronic hepatitis C patients.

OBJECTIVE: To determine factors influencing response of interferon therapy in chronic hepatitis C patients. STUDY DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Pakistan Medical Research Centre, Jinnah Postgraduate Medical Centre, Karachi, from January 1998 to December 2009. METHODOLOGY: Patients of chronic hepatitis C treated with conventional interferon were retrospectively analyzed. End treatment response at 6 months for genotype 2 and 3 and one-year for genotype 1 and 4 was assessed. Sustained virological response was checked after 6 months of cessation of therapy. Non-compliant and incomplete follow-up cases were excluded. Factors influencing the response to therapy were analyzed by univariate and multivariate logistic regression analysis. RESULTS: A total of 932 cases received interferon therapy 103 were lost to follow-up and were excluded. Treatment was completed in 829 cases end treatment response was 74% (615 out of 829 cases). Six months post-treatment follow-up was available in 492 cases. Sustained virological response was seen in 63% (308 out of 492 cases). Univariate logistic regression analysis showed significantly better response in patients with <40 years of age, body weight>70 kg, normal platelet count, serum albumin>4.0 grams, non diabetic patients and those with a normal alanine aminotransferase (ALT) at 1st month of therapy. Multiple logistic regression analysis showed that only age<40 years was significantly important for sustained virological response. CONCLUSION: For conventional interferon therapy, age<40 years is the best predictor for sustained virological response, however, better response can be achieved in patients with <70 kg weight, normal platelet count, serum albumin>4.0 grams, non-diabetics and patients having normal ALT at 1st month of therapy.

Changing trend of viral hepatitis--"A twenty one year report from Pakistan Medical Research Council Research Centre, Jinnah Postgraduate Medical Centre, Karachi".

OBJECTIVE: To determine the frequency and pattern of Hepatitis B and C over the past twenty one years, in a liver research unit of Karachi. METHODS: Retrospective analysis of the records of PMRC, Research Centre, Jinnah Postgraduate Medical Centre, Karachi, from 1987 to 2007 were reviewed. A special flow sheet was made where information of all patients with viral liver disease was entered. Patients having complete information of viral markers were included in the analysis. Cases with HBsAg, Anti HBc IgM positive and raised ALT were considered as acute Hepatitis B. HBs Ag/Anti HBc IgG positive were considered as chronic Hepatitis B. Delta antibody positive with or without HBsAg were considered as Delta Hepatitis. Anti HCV positive and raised ALT more than ten times for less than 6 months were considered as acute Hepatitis C, whereas Anti HCV and HCV-RNA positive with or without raised ALT for more than six months were considered as chronic Hepatitis C. Anti HEV IgM and Anti HAV IgM positive were considered as acute Hepatitis E and A respectively. RESULTS: A total of 5193 cases fulfilling all criteria of viral hepatitis were seen in the past 21 years. Of the total 3247 (62.5%) were males and 1946 (37.5%) females giving a male to female ratio of 1.7 : 1. Hepatitis C was the most common infection seen in 2896 cases (55.8%), followed by Hepatitis B in 1691 cases (32.6%). Seventy five percent cases of Hepatitis B were males and 25% females while 55% Hepatitis C cases were males and 45% females. Hepatitis B was seen a decade earlier in different age groups than hepatitis C. Overall, out of the total 5193 cases, 2294 (44.2%) were of chronic hepatitis, 1430 (27.5%) cirrhosis, 1083 (20.8%) carriers and 346 (6.7%) had acute hepatitis (hepatitis B; 214 (61.8%), hepatitis C; 21 (6.0%). While hepatitis B and hepatitis C both were present in 3 (1.3%). Hepatitis E was 70 (20.2%), hepatitis A 12 (3.5%) and all markers were negative in 26 (7.5%) cases). Forty cases (0.8%) were of Hepatocellular carcinoma. Year wise analysis of proportion of hepatitis B and C showed gradual decline of Hepatitis B and rise of Hepatitis C with a transition period between 1995 and 1996. CONCLUSIONS: Hepatitis C is the most common viral hepatitis, followed by hepatitis B, both are more common in males. Hepatitis B is seen a decade earlier than hepatitis C. Rising trend of hepatitis C and declining evidence of hepatitis B could be due to increased awareness and detection of hepatitis C and effective vaccination for hepatitis B in the country.

Determination of risk factors for hepatitis B and C in male patients suffering from chronic hepatitis.

BACKGROUND: Hepatitis B and C is common in Pakistan and various risk factors are attributable to its spread.One thousand and fifty consecutive male cases suffering from chronic liver disease (327 HBV and 723 HCV) were selected from the OPD of public sector hospital and a private clinic dealing exclusively with the liver patients. To compare the results 723 age and gender matched controls were selected from the blood transfusion services of the public sector hospital. A standard questionnaire was filled for all patients and controls which included the information on possible risk factors. FINDINGS: Family history of liver disease was significantly higher (43% and 34%) in HBV and HCV positive cases as compared to 5% in controls [odds ratio 15.6; 95% Confidence Interval CI: 10.1 - 24.1, 10.9; 95% Confidence Interval CI: 7.3 - 16.4] and same trend was seen for death due to liver disease in the family. Majority 74% hepatitis B positive cases had their shaves done at communal barbers but this practice was equally prevalent amongst controls (68%), thus negating it as a possible risk factor, but there is a significant risk with p < 0.05 associated with HCV in male that get their shave in barber. Very strong association of the disease was found with history of dental treatment (38% HCV 36% HBV and 21% controls) [Odd ratio 2.3; 95% CI: 1.8-3.0, Odd ratio 2.1; 95% CI: 1.5-2.8], surgery (23% HCV cases,14% HBV cases and 12% controls), history of blood transfusion was significantly higher in HCV (6%) as compared to controls (2.1%) [Odd ratio 2.9; 95% CI: 1.5-5.5]. History of taking injections for various ailments by the general practitioners (over 90% patients in both hepatitis B and C cases) was significantly higher as compared to 75% in controls [Odds ratio 3.8, 6.9; 95% CI: 2.4-6.1, 4.5-10.4] but hospitalization was not significant in HBV and HCV cases. CONCLUSION: Injections, surgery and dental treatment appear as major risk factors for the transmission of hepatitis B and C in the community. Massive health care awareness drives need to be done for both health care providers and the public to reduce this menace.

Ovarian reserve and BMI between fertile and subfertile women.

OBJECTIVE: To compare the ovarian reserve and BMI in fertile and subfertile women aged 20-39 years by ultrasonography. STUDY DESIGN: A comparative study. PLACE AND DURATION OF STUDY: The Ultrasound Clinic, PECHS, Karachi, from March to December 2006. METHODOLOGY: Eighty women, 40 fertile and 40 subfertile, were subdivided into age groups of 20-29 and 30-39 years. Total ovarian volume (OV) was determined transabdominally (OV-TA) and transvaginally (OV-TV), antral follicle count (AFC) was performed transvaginally; and BMI was calculated. Unpaired t-test and Pearson correlation tests were used for analysis. RESULTS: In the total and subfertile females, aged 20-39 years, OV-TA obtained was 10.47 +3.81 ml vs. 7.0+2.67 (p=0.015), OV-TA was 12.55+4.53 ml vs. 8.36+2.36 ml (p=0.001); AFC was 7.35+3.02 vs. 5.7+3.57 (p=0.027) and BMI was 23.4+3.9 vs. 26.5+4.7 (p=0.006). In the older group of fertile and subfertile females, aged 30-39 years, OV-TA was 7.92+2.01 ml vs. 6.74+2.38 (p=0.097), OV-TA was 9.97+2.99 vs. 7.73+2.40 (p=0.012), AFC was 5.30+2.05 vs. 3.05+2.46 (p=0.003), and BMI was 24.4+3.8 vs. 27.4+4.80 (p=0.034). A significant negative correlation was present between ovarian volume and BMI in the older fertile women only (p=0.001 r=0.3) whereas no significant correlation was seen in the two parameters in any other group (r=0.1). CONCLUSION: The ovarian reserve decreased with increasing age. The lack of ovarian reserve may lead to subfertility or early ovarian ageing. Ovarian volume showed decrease with an increase in the BMI, indicating the possible decrease in fertility with an increase in a woman's weight.

YMDD mutation in Pakistani patients. The comparison of Eastern response with the Western response.

Lamivudine exhibits potent antiviral activity in chronic hepatitis B. YMDD mutations in west is around 32% (5 years) but reports from East are scarce. To evaluate frequency of lamivudine resistance and compare the results with the West, a total of 100 chronic hepatitis B patients were given Lamivudine 100 mg before breakfast. Out of 81 patients (19 no follow up), (85%) males and (15%) females. Wild type were 69 (85%) and 12 (14.8%) pre-core mutants. At 1 year 25/69 wild type (36.2%) lost their HBeAg and 18 (26%) seroconverted. At 2 years 30 (43.4%) became HBeAg negative and 22(31.8%) had positive anti-HBe. At 3 years 33 (47.8%) became HBeAg negative and 25 (36.2%) sero-converted. Of 12 precore mutants 8 (66.6%) lost HBV DNA within 24 weeks of therapy. At 36 months 44.4% showed sero-conversion with a YMDD mutation rate of 6% which is in contrast to 32% reported from the West.

The correlation between ultrasonic manual and automatic measurements of foetal head and abdominal circumferences.

OBJECTIVE: To assess the correlation between ultrasonic manual and automatic ellipsoid measurements of foetal head and abdominal circumferences. METHODS: This comparative cross-sectional study was conducted at the Ultrasound Clinic, Karachi, from January to July 2004. Seventy two normal pregnant women with gestational ages between 14 to 38 weeks were included. Foetal head and abdominal circumferences were measured by manual method using traditional formulae and by automatic ellipsoid mode incorporated into the real-time ultrasound machines (EcoCee and Power Vision, Toshiba, Japan) using convex probes of 3 and 4.2 MHz frequency. Three readings of each parameter i.e. head circumference (HC) and abdominal circumference (AC) were taken by both methods. Mean values were calculated and compared using paired sample 't' test to assess the correlation between ultrasonic manual and automatic ellipsoid measurements. RESULTS: The mean HC measured through manual method was found to be 20.11 +/- 7.04 cm and was significantly different from that of 19.46 +/- 6.82 cm measured through ellipsoid automatic technique. There was, however, a perfect positive correlation (r = 0.999) between these measurements. In case of AC, there was no statistical difference between the mean values obtained by the manual technique and those measured automatically (16.79 +/- 6.24 vs. 16.74 +/- 6.11; p < 0.44), correlation between these measurements (r = 0.997) was also significantly positive. CONCLUSION: Correlation was found between the mean measurements of the foetal HC and AC by the manual and the automatic method of calculation; and even stronger for the latter. The automatic mode of measurement is a more rapid method than the manual calculation, and its use may be encouraged.