Liver Function Tests Abnormalities and Hepatitis B Virus & Hepatitis C Virus Co-infection in Human Immunodeficiency Virus (HIV)-infected Patients in India.

BACKGROUND: While highly active anti-retroviral therapy (HAART) has improved survival of HIV-infected patients, there is increasing liver disease and progressive Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) related liver disease. AIMS: To study the liver function tests (LFT) and HBV and HCV co-infection in HIV-infected patients. MATERIAL AND METHODS: All HIV-positive patients presenting to a tertiary level hospital from April 2009 to April 2011 were evaluated. Baseline LFT, CD4/CD8 counts, ultrasound abdomen, HBsAg, IgG anti-HBc, HBVDNA, Anti-HCV and HCVRNA were done in all patients. LFT was repeated monthly or more frequently with anti-tubercular therapy (ATT)/HAART. RESULTS: Abnormal LFT were seen in 143/320 (44.6%) HIV-infected patients (n = 320; M-282, F-38; mean age-35.4 ± 7.3 years). Baseline LFT was abnormal in 48 (15%) [hepatotropic viruses-19, alcohol-24, NAFLD-1, disseminated TB-1, idiopathic-03). Subsequent LFT derangement developed in 95/272 (34.9%). In the majority, the LFT abnormality was mild (119/143-83.2%) and multi-factorial [HAART 132 (76.4%), alcohol 69 (48.2%), ATT 31 (21.7%), HBV 16 (11.2%), HCV 15 (10.4%)]. Using multivariate analysis, abnormal LFT were associated with HAART (OR, 5.92; 95%CI, 2.83-12.37), ATT (OR, 2.06; 95%CI, 1.06-3.99) or HCV infection (OR, 2.54; 95%CI, 1.03-6.26). Significant hepatotoxicity requiring drug modification was seen in only 7 cases. HBV, HCV and HBV + HCV co-infection were seen in 37 (11.6%), 28 (8.8%) and 2 (0.6%) respectively. Occult co-infections were rare [HBV-1 (0.3%); HCV-3 (0.9%)]. CONCLUSION: While LFT abnormalities in HIV are common, they are usually mild and multifactorial. HBV and HCV co-infections were seen in 11.6% and 8.8%, respectively. Occult HBV and HCV infections were rare.

Frequency of Helicobacter pylori and CagA antibody in patients with gastric neoplasms and controls: the Indian enigma.

BACKGROUND: Despite association between H. pylori and gastric neoplasm (GN) from the developed world, studies from India, where infection is more common and acquired early, are scant and contradictory. METHODS: Two hundred and seventy-nine patients with GN from two northern and one eastern Indian centers during the period 1997-2005, 101 non-ulcer dyspepsia (NUD), and 355 healthy volunteers (HV) were evaluated for H. pylori [rapid urease test (RUT), histology and anti-H. pylori, and CagA IgG serology]. RESULTS: Patients with GN [263 gastric carcinoma and 16 (6%) primary gastric lymphoma, 208 male] were older than HV (n = 355, 188 male) and NUD (n = 101, 54 male) patients (53 +/- 12 versus 44 +/- 17 and 43 +/- 13 years, respectively; P < 0.001). Eastern Indian patients with GN (n = 145) were younger than those from northern India (n = 134; 52 +/- 12 versus 55 +/- 12 years; P < 0.007, t-test). In GN and NUD patients H. pylori positivity by RUT [86/225 (38%) versus 46/101 (46%)], anti-H. pylori IgG [154/198 (78%) versus 85/101 (84%)], and histology [136/213 (64%) versus 55/101 (55%)] were comparable (chi(2)-test). Serum IgG anti-H. pylori antibody was more common among HV than among GN patients [300/355 (85%) versus 154/198 (78%); P = 0.04, chi(2)-test]. Intestinal metaplasia was more common in GN than in NUD patients [101/252 (40%) versus 2/98 (2%), P < 0.000, chi(2)-test]. CagAIgG was more common in GN than in NUD patients [124/163 (76%) versus 64/101 (63%)] but comparable to that in HV patients [87/98 (89%), P = NS]. CONCLUSION: Frequency of H. pylori as detected using endoscopy and serology-based tests is not higher among patients with GN as compared with controls in India.

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.

Routine pulse oximetry during methacholine challenges is unnecessary for safety.

BACKGROUND: Methacholine-induced bronchoconstriction is associated with significant hypoxemia, which can be assessed noninvasively by transcutaneous oxygen tension and pulse oximetry. OBJECTIVES: To assess the value of the monitoring of finger pulse oximetry during routine methacholine challenges in a clinical pulmonary function laboratory with regard to both safety and the possibility that a significant fall in oxygen saturation as measured by pulse oximetry (SpO(2)) might be a useful surrogate for determining the response to methacholine. METHODS: Two hundred consecutive patients undergoing diagnostic methacholine challenges in the pulmonary function laboratory of a tertiary-care, university-based referral hospital were studied. Methacholine challenges were performed by the standardized 2-min tidal breathing technique, and the DeltaFEV(1) was calculated from the lowest postsaline solution inhalation to the lowest postmethacholine inhalation value. SpO(2) was measured immediately prior to each spirogram, and the DeltaSpO(2) was measured from the lowest postsaline solution inhalation value to the lowest postmethacholine inhalation value. We examined the data for safety (ie, any SpO(2) value < 90). Based on previous reports, we used a DeltaSpO(2) of > or = 3 as significant and looked at the sensitivity, specificity, and positive and negative predictive values for DeltaSpO(2) > or = 3 vis-à-vis a fall in FEV(1) of > or = 15%. RESULTS: There were 119 nonresponders (DeltaFEV(1), < 15%) and 81 responders. The baseline FEV(1) percent predicted was slightly but significantly lower in the responders (responders [+/- SD], 91.6 +/- 15%; nonresponders, 96.4 +/- 14%; p < 0.05). DeltaSpO(2) was 3.1 +/- 1.6 in the responders and 1.6 +/- 1.8 in the nonresponders (p < 0. 001). There was a single recording in one patient of SpO(2) < 90 (88). A DeltaSpO(2) > or = 3 had a sensitivity of 68%, a specificity of 73%, a positive predictive value of 63%, and negative predictive value of 77% for a fall in FEV(1) > or = 15%. CONCLUSIONS: Pulse oximetry is not routinely useful for safety monitoring during methacholine challenge. DeltaSpO(2) is not helpful in predicting a positive spirometric response to methacholine. However, the negative predictive value is adequate to allow the DeltaSpO(2) to be used as an adjunct in assessing a negative result of a methacholine test in patients who have difficulty performing spirometry.

Principles of steam sterilization.

Moist heat in the form of saturated steam under pressure, is by far the most reliable medium, known for the destruction of all forms of microbial life. Steam sterilisation, therefore, is the most economical, effective and widely used method of seeking sterilisation in hospital practice. This article aims at describing the principle mechanism that makes steam an effective destruction of micro-organisms, the equipment that is most commonly used for the purpose and the practical methods of testing for sterility. The application of these principles, it is hoped, will ensure standardisation and quality control of routine sterilisation practice in hospitals thus, contributing towards the reduction in the incidence of hospital acquired infection.

Planning and organization of the C. S. S. D.

"Central Sterile Supply Department" is a service which caters to the needs of a hospital or a group of hospitals, for the supply of sterilized material. It aims at centralizing the activities of receipt, cleaning, assembly, sterilization, storage and distribution of reliably sterilized material from a central department, where bacteriologically safe sterilization practice is conducted under controlled conditions, adequate managerial and technical supervision and minimum cost. This article aims at describing the planning considerations and principles of organization of a Central Sterile Supply Department. It is hoped that the information thus contained will assist the Hospital Administrators to plan and organize such facilities in their hospitals.