Bleeding risk assessment in immune thrombocytopenia

The bleeding risk in immune thrombocytopenia (ITP) is related not only to low platelet count but also to the presence of platelet dysfunction. However, diagnosing a concomitant platelet dysfunction is challenging as most of the available platelet function assays (PFAs) require a platelet count of greater than 100,000/μL. Sonoclot coagulation and platelet function analyzer works on the principle of viscoelastometry, and results remain unaffected by the platelet counts. To assess the platelet function in adult acute ITP patients with the help of sonoclot coagulation and platelet function analyzer and correlate it with the risk of bleeding. Newly diagnosed acute ITP patients with a platelet count less than 20,000/μL were divided into two groups based on WHO bleeding grade: ITP non-bleeder (ITP-NB) group (WHO bleeding grade ≤1) and ITP bleeder (ITP-B) group (WHO bleeding grade ≥2). Platelet function was assessed by sonoclot in both groups. The patients without significant bleeding (ITP-NB) were followed up monthly for six months with the assessment of platelet function during each contact. Eighty patients (30 ITP-B and 50 ITP-NB) were prospectively included in this study. The median age of patients in the two groups was 37 years and 30 years, respectively. The female-to-male ratio was 4:1 and 1:1 in ITP-B and ITP-NB groups. The median platelet count in ITP-B and ITP-NB was 12000/μL (range 1000-19000/μL) and 8000/μL (range 1000-19000/μL), respectively. Mean platelet functions by sonoclot in both groups were lower than the normal cut-off (>1.6). However, the mean platelet function in the ITP-B group (0.2 + 0.17) was significantly lower than the ITP-NB group (1.2 ± 0.52) (p = 0.01). During the follow-up period of 6 months, patients in ITP-NB with a normal platelet function (>1.6) on sonoclot had lesser episodes (one episode) of clinically significant bleeding than patients with a low platelet function (4 episodes). Patients with acute severe thrombocytopenia and bleeding phenotype have a greater abnormality on platelet function by sonoclot than patients with non-bleeding phenotype. This information may help in taking therapeutic decisions in patients with acute ITP.

Simple bedside tests of muscle strength and function correlate with computed tomography-skeletal muscle index for assessment of sarcopenia in cirrhosis

BACKGROUND

Sarcopenia assessment can be done by skeletal muscle index (SMI) or bedside tests such as handgrip strength (HGS) and gait speed (GS).

GOALS

This study evaluated the correlations of HGS and GS with SMI, health-related quality of life (HRQOL) and cognition and assessed them as predictors of mortality.

STUDY

As many as 116 outpatients with cirrhosis were included in this prospective cohort study. Assessment for sarcopenia was done by SMI, HGS and GS. HRQOL was assessed using the chronic liver disease questionnaire (CLDQ) and fatigue severity scale (FSS). Cognition was assessed by mini-mental state examination (MMSE). Correlations of HGS and GS with SMI, HRQOL and cognition were analyzed. Area under the curve (AUCs) were calculated to compare them as predictors of mortality.

RESULTS

Alcoholic liver disease (47.4%) was the commonest etiology of cirrhosis followed by hepatitis C (12.9%). Sarcopenia was diagnosed in 64 (55.2%) patients. A strong correlation was seen between SMI and HGS (ρ = 0.78) and GS (ρ = 0.65). AUCs of GS (0.91 (95% confidence interval [CI], 0.85-0.96) was maximum, followed by HGS (95% CI, 0.86 [0.78-0.93] and SMI [95% CI, 0.8 0.71-0.88]) in predicting mortality (p > 0.05). CLDQ (3.2 vs. 5.6, p < 0.01) and MMSE scores (24.3 vs. 26.3, p < 0.01) were lower, whereas FSS score (5.7 vs. 3.1, p < 0.01) was higher in patients with sarcopenia. CLDQ (ρ = 0.83) and MMSE (ρ = 0.73) showed the strongest correlation with HGS, whereas FSS correlated well (ρ = 0.77) with GS.

CONCLUSIONS

Bedside tests of muscle strength and function, including HGS and GS, correlate strongly with SMI for sarcopenia assessment and prediction of mortality in patients with cirrhosis.

Is mucormycosis the end? A comprehensive management of orbit in COVID associated rhino-orbital-cerebral mucormycosis: preserving the salvageable

BACKGROUND

Rhino-orbital-cerebral mucor mycosis (ROCM) is a relatively rare opportunistic infection caused by the Mucorales species. While ROCM suggests involvement of the paranasal sinuses, orbit and brain ROM (rhino-orbital-Mucormycosis) stands for the fungal invasion in sinuses and orbit sans cerebral involvement. In India with the outbreak of the second COVID wave and the delta variant of the virus, there has been a steep increase in this opportunistic fulminant fungal infection, named COVID-associated Mucor mycosis (CAM). The most critical question in orbital management is when to go ahead with an exenteration. Our study aims to design a pertinent minimal invasive surgical protocol for surgeons to manage such cases based on our surgical experience and mitigate the need for exenteration and save the eyes wherever possible.

METHODS

The study is a retrospective analysis of patients of ROM with and without brain involvement, who underwent minimal surgical management between March 2021 to March 2022 along with their follow-up.

RESULTS

There were 184 eyes of 148 patients diagnosed with CAM. The mean age was 51.7 years with a male predominance of 103 (70%). All patients developed ROM following the COVID-19 infection and the duration between diagnosis of COVID-19 and ROM was 36 ± 23 days. 18 cases (12%) were bilateral. 76 eyes (41%) had no vision at the presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (61%), cavernous sinus involvement (53%), and central nervous system (CNS) involvement (47%). All the patients (100%) were treated with systemic Liposomal amphotericin-B and sinus debridement. Endoscopic debridement of the orbital disease was performed in 45 (30.4%) cases, 15(8.1%) eyes underwent exenteration and were later rehabilitated with a customized ocular prosthesis, 103 (56%) eyes underwent transcutaneous retrobulbar amphotericin-B. At a mean follow-up of 13.1 months; the complete resolution was seen in 25 (17%) cases, the residual stable lesion was seen in 77(52%) of the cases and new lesions were developed in 13(9%) of the cases. Mortality was seen in 33 (22%) patients and all of them had CNS involvement.

CONCLUSIONS

Systemic and protocol-based management can save the life and salvage the eyes.

AARC score determines outcomes in patients with alcohol-associated hepatitis: a multinational study

BACKGROUND AND AIM

Acute-on-chronic liver failure (ACLF) is a severe form of alcoholic hepatitis (SAH). We aimed to study the natural course, response to corticosteroids (CS), and the role of the Asian Pacific Association for the Study of Liver (APASL) research consortium (AARC) score in determining clinical outcomes in AH patients.

METHODS

Prospectively collected data from the AARC database were analyzed.

RESULTS

Of the 1249 AH patients, (aged 43.8 ± 10.6 years, 96.9% male, AARC score 9.2 ± 1.9), 38.8% died on a 90 day follow-up. Of these, 150 (12.0%) had mild-moderate AH (MAH), 65 (5.2%) had SAH and 1034 (82.8%) had ACLF. Two hundred and eleven (16.9%) patients received CS, of which 101 (47.87%) were steroid responders by day 7 of Lille's model, which was associated with improved survival [Hazard ratio (HR) 0.15, 95% CI 0.12-0.19]. AARC-ACLF grade 3 [OR 0.28, 0.14-0.55] was an independent predictor of steroid non-response and mortality [HR 3.29, 2.63-4.11]. Complications increased with degree of liver failure [AARC grade III vs. II vs I], bacterial infections [48.6% vs. 37% vs. 34.7%; p < 0.001); extrahepatic organ failure [66.9% vs. 41.8% vs. 35.4%; p < 0.001] respectively. The AARC score better discriminated 90-day mortality. Harrell's C-index was 0.72 compared to other scores.

CONCLUSION

Nearly 4 of 5 patients with AH present with ACLF. Such patients have a higher risk of infections, organ failures, lower response to CS, and higher mortality. Patients with AH and ACLF with AARC grade 3 should be considered for an early liver transplant.

Whole brain atlas-based diffusion kurtosis imaging parameters for evaluation of minimal hepatic encephalopathy

BACKGROUND AND PURPOSES

Minimal hepatic encephalopathy (MHE) has no recognizable clinical symptoms, but patients have cognitive and psychomotor deficits. Hyperammonemia along with neuroinflammation lead to microstructural changes in cerebral parenchyma. Changes at conventional imaging are detected usually at the overt clinical stage, but microstructural alterations by advanced magnetic resonance imaging techniques can be detected at an early stage.

MATERIALS AND METHODS

Whole brain diffusion kurtosis imaging (DKI) data acquired at 3T was analyzed to investigate microstructural parenchymal changes in 15 patients with MHE and compared with 15 age- and sex-matched controls. DKI parametric maps, namely kurtosis fractional anisotropy (kFA), mean kurtosis (MK), axial kurtosis (AK) and radial kurtosis (RK), were evaluated at 64 white matter (WM) and gray matter (GM) regions of interest (ROIs) in the whole brain and correlated with the psychometric hepatic encephalopathy score (PHES).

RESULTS

The MHE group showed a decrease in kFA and AK across the whole brain, whereas MK and RK decreased in WM ROIs but increased in several cortical and deep GM ROIs. These alterations were consistent with brain regions involved in cognitive function. Significant moderate to strong correlations (-0.52 to -0.66; 0.56) between RK, MK and kFA kurtosis metrics and PHES were observed.

CONCLUSION

DKI parameters show extensive microstructural brain abnormalities in MHE with minor correlation between the severity of tissue damage and psychometric scores.

Liver transplantation and COVID-19 (Coronavirus) infection: guidelines of the liver transplant Society of India (LTSI)

The Liver Transplant Society of India (LTSI) has come up with guidelines for transplant centres across the country to deal with liver transplantation during this evolving pandemic of COVID-19 infection. The guidelines are applicable to both deceased donor as well as living donor liver transplants. In view of the rapidly changing situation of COVID-19 infection in India and worldwide, these guidelines will need to be updated according to the emerging data.

Correction to: Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update

The article Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update, written by [Shiv Sarin], was originally published electronically on the publisher's internet portal (currently SpringerLink) on June 06, 2019 without open access.

Changes in salivary output after induction at high-altitude areas and its effects on dental caries among Indian Army troops

BACKGROUND

This study was aimed to evaluate the changes in salivary output and its effect on dental caries among Indian troops after 6 months of stay at high-altitude area (HAA).

METHODS

All troops undergo mandatory dental checkup during acclimatization phase before deployment at HAA. Two thousand troops who fulfilled inclusion and exclusion criteria were selected, and consent for the study was obtained. Stimulated and unstimulated salivary samples were collected, the decayed, missing, and filled teeth (DMFT) index was evaluated, and required dental treatment was completed. The same salivary samples were collected after 6 months (on deinduction) to evaluate the salivary output. The DMFT index was re-evaluated to check the initiation of caries.

RESULTS

The mean values of unstimulated and stimulated saliva at the initial visit were 4.105 and 17.03 gm, respectively, whereas the mean values of unstimulated and stimulated saliva after 180 days were 3.034 and 15.831 gm, respectively. Salivary flow was found to be significantly decreased after 6 months both in unstimulated and stimulated saliva. The mean DMFT at the time of induction of the study was 6.18 ± 3.03, and on deinduction, it was 7.22 ± 3.45 with p < 0.001, which was highly statistically significant.

CONCLUSION

A decrease in body fluids and changed sympathetic and parasympathetic at HAA lead to decreased salivary secretions. Low water intake, high carbohydrate solid diet, negligible supply of fresh food, difficulty in maintenance of oral hygiene, and overall stress due to loneliness are all contributory factors for an increase in dental caries. It clearly demonstrates that prolonged stay at HAA affects salivary volume outflow, both stimulated and unstimulated, which has a corresponding effect on new caries.

Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update

The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. With international groups volunteering to join, the "APASL ACLF Research Consortium (AARC)" was formed in 2012, which continued to collect prospective ACLF patient data. Based on the prospective data analysis of nearly 1400 patients, the AARC consensus was published in 2014. In the past nearly four-and-a-half years, the AARC database has been enriched to about 5200 cases by major hepatology centers across Asia. The data published during the interim period were carefully analyzed and areas of contention and new developments in the field of ACLF were prioritized in a systematic manner. The AARC database was also approached for answering some of the issues where published data were limited, such as liver failure grading, its impact on the 'Golden Therapeutic Window', extrahepatic organ dysfunction and failure, development of sepsis, distinctive features of acute decompensation from ACLF and pediatric ACLF and the issues were analyzed. These initiatives concluded in a two-day meeting in October 2018 at New Delhi with finalization of the new AARC consensus. Only those statements, which were based on evidence using the Grade System and were unanimously recommended, were accepted. Finalized statements were again circulated to all the experts and subsequently presented at the AARC investigators meeting at the AASLD in November 2018. The suggestions from the experts were used to revise and finalize the consensus. After detailed deliberations and data analysis, the original definition of ACLF was found to withstand the test of time and be able to identify a homogenous group of patients presenting with liver failure. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information and areas requiring future studies are presented here.

Intrapulpal thermal changes during direct provisionalization using various autopolymerizing resins: Ex-vivo study

BACKGROUND

Resin materials used in the fabrication of direct provisional restoration exhibit an exothermic reaction and the extent of damage may also depend on the remaining dentine thickness. An ex-vivo study was envisaged to compare the time related temperature changes in the pulp chamber during the fabrication of fixed partial denture provisional restorations using direct technique. The effect of differently prepared teeth (with varying remaining dentine thickness) on the above mentioned temperature changes were also evaluated.

METHODS

Thermal changes were calculated in pulp chamber of three differently prepared tooth having different amount of remaining dentinal thickness (45 samples) and control with no tooth media (15 samples), using three different types of autopolymerizing provisional restorative materials using Cr/Al thermocouple connected to digital thermometer.

RESULTS

The data for the mean peak temperature rise was subjected to one way ANOVA analysis for relative comparison among subgroups within each main group and across the main groups. The results showed a statistically significant difference across both the subgroups and the main groups (p < 0.001). Then Turkey HSD test was applied to determine the significance of statistical difference between the means, within the groups. The differences in temperature rise were statistically significant for the three resins (p < 0.001).

CONCLUSION

Polymethylmethacrylate (DPI) showed the highest temperature rise value followed by polyethyl methacrylate (Tempron) and Bis-acrylate composite (CoolTemp). The maximum temperature rise was found on molar full veneer preparation followed by molar three quarter preparation and premolar three quarter preparation. Data and results from current study may assist clinicians to select an autopolymerizing provisional restorative resin when employing direct technique of fabricating provisional restorations for a specific tooth preparation which would cause minimal thermal trauma to pulpal tissue.

Comparative study of immediate functional loading and immediate non-functional loading of monocortical implants

BACKGROUND

Attempts to shorten the overall length of treatment have focused on immediate loading, subsequent to implant placement. Prosthetic rehabilitation immediately after implant placement can be either functional or non-functional in nature. There is paucity of literature on the comparative evaluation of immediate functional and immediate non-functional loading of implants. This in-vivo study was undertaken to comparatively evaluate Immediate Functional Loading and Immediate Non-Functional Loading of monocortical implants with a follow-up period of 18 months.

METHODS

50 partially edentulous cases were selected for the study. The cases were divided into two groups. In first group (Group-1), 25 implants were subjected to immediate functional loading. In second group (Group-2), 25 implants were subjected to immediate non-functional loading. The crestal bone loss, clinical stability and degree of osseointegration of these two groups were comparatively evaluated.

RESULTS

The crestal bone loss in both groups was within acceptable limits. The implant stability, which is a reflection of the status of bone-to-implant interface, was comparable in both the groups at different time intervals. Although, the ISQ values in Group-2 were slightly higher than those in Group-1, the results were not statistically significant. Radiodensity indicating degree of osseointegration at different time intervals in both groups was also comparable.

CONCLUSION

Both the IFL and INFL protocols can be undertaken satisfactorily in rehabilitation using endosseous implants; however, the main factors for success in IFL and INFL are case selection, meticulous treatment planning and the precision of technique.

Dimensional accuracy of two rubber base impression materials as a function of spacer design and techniques in custom trays for fixed partial dentures

BACKGROUND

A prostheses can't be better than the cast over which it has been fabricated. To make accurate casts, accurate impressions are mandatory. To get an accurate and dimensionally stable impression, various techniques and materials have been advocated. This study compares the most commonly used techniques and materials for dimensional accuracy. Two types of spacers were designed to compare the addition silicon and polyether and their techniques.

METHODS

A metal die was used to make the impressions. A total of 60 impressions were made using multiple mix and monophasic techniques for addition silicon and polyether in custom trays. A travelling microscope was used to measure the dimensional accuracy of die stone casts retrieved from impressions.

RESULTS

The results were compared using paired t test and SPSS software. The study was highly significant (p < 0.001). The polyether was more accurate than the addition silicon and spacer design I (adapted to the edentulous area) was more accurate than the design II (spacer over the abutments, not adapted to edentulous area). The multiple mix technique was more accurate than the monophasic for addition silicon.

CONCLUSION

The combination of multiple mix technique with spacer design I for addition silicon gave the best accurate results.

Indocyanine green clearance test (using spectrophotometry) and its correlation with model for end stage liver disease (MELD) score in Indian patients with cirrhosis of liver

BACKGROUND

Child Turcotte Pugh (CTP) score and Model for End Stage Liver Disease (MELD) are used commonly to assess the prognosis of liver disease but the disadvantage of these static tests is their inability to identify the functional reserve of the liver. Among all quantitative liver function tests indocyanine green (ICG) clearance test is most widely used and has been used to determine operative risk before hepatectomy and to assess prognosis of patients with cirrhosis.

AIM

To correlate indocyanine green (ICG) clearance test with MELD score in patients with cirrhosis of liver.

METHODS

Forty patients with cirrhosis of liver were included and divided into two groups according to their CTP scores. Group A had 20 patients with CTP class A and group B had 20 patients with CTP class B. After ICG injection, ICG retention at 15 minutes (ICGR 15) and ICG clearance rate were calculated.

RESULTS

In group A, the mean ICGR15 was 32.86% +/- 6.4% while in group B it was 51.08% +/-12.8% (p <0.001). ICG clearance rates were 4.3% +/- 2.8% and 3.5% +/- 3.8% per minute in group A and B respectively. MELD score had a strong positive correlation with ICGR15 but a negative correlation with ICG clearance rate. On ROC curve analysis, AUC for MELD was 0.805 vs. 0.88 for ICGR15 in assessing prognosis of patients with cirrhosis. The sensitivity and specificity of MELD score was 60% and 80% respectively while that of ICGR15 was 85% and 90% respectively.

CONCLUSION

ICGR15 has a higher sensitivity and specificity than MELD score in assessing the prognosis of patients with cirrhosis of liver.

Evaluation of the effect of surface preparation using phosphoric acid and luting cement on the flexural strength of porcelain laminate veneering material

BACKGROUND

Conventionally HF acid has been used for etching ceramic veneer restorations before their cementation. Studies are lacking regarding the effectiveness of phosphoric acid as a substitute for HF acid for etching the ceramic veneers. The purpose of this study was to evaluate the effectiveness of surface preparation of porcelain laminate veneers using phosphoric acid, as compared to HF acid etching in providing the necessary surface roughness conducive to development of an effective bond between the ceramic laminate and the resin luting cement.

METHODS

210 porcelain discs of 15 mm diameter and 0.9 mm thickness were prepared. These study samples were divided into seven groups of thirty samples each. Surfaces of the first (control) and the second group of samples were not prepared. The surfaces of other five groups were prepared with different surface treatments. Further all the groups of specimens were coated with a layer of resin luting cement. Flexural strength of each specimen was determined using universal testing machine and the results were compared.

RESULTS

The combination surface treatment using alumina surface abrasion followed by etching with phosphoric acid provided the highest flexural strength with the mean flexural strength of 101.11 MPa, followed by alumina surface abrasion (95.41 MPa), and phosphoric acid surface etching (81.68 MPa).

CONCLUSION

Laminate veneers surface treated using 50 μm alumina abrasion followed by etching with phosphoric acid showed the highest flexural strengths after resin coating compared to other groups.

Flexible denture base material: A viable alternative to conventional acrylic denture base material

Although clinician's skills and experience play a major role in designing and fabrication of the optimum prosthodontic restorations, the selection of denture resins is equally important, especially when the patient has been using the prostheses since long. Eighteen cases who were not satisfied with their conventional acrylic dentures were selected. They were provided flexible dentures along with a questionnaire to precisely evaluate the advantages of new material. Prosthodontic planning & observations regarding this material are discussed on various parameters.

Clinical evaluation of immediate implants using different types of bone augmentation materials

BACKGROUND

The immediate placement of implants into fresh extraction socket has proven to be a safe and predictable procedure. However, there is lack of scientific evidence regarding the healing pattern and osseointegration associated with immediate implants especially with different grafting materials.

METHODS

A total of 30 patients male or female, with a mean age of 23.1 years ± 6.0 in the age group of 18-38 years, each having at least one tooth indicated for extraction (either maxillary or mandibular anterior teeth) were selected and randomly divided in to two groups. 30 Implants (Xive(®) friadent, Germany) were placed into fresh extraction sockets during this study. Two types of graft materials namely Dembone(®) (freeze-dried bone allograft) for group A and G-Bone(®) (modified hydroxyapatite) for group B were used. After implant placement all implants were evaluated clinically and radiographically at baseline, 3 months, 6 months, 9 months and 12 months. All clinical and radiographic parameters were subjected to statistical analysis. Intragroup comparisons were made with paired 't' test and intergroup comparisons with unpaired 't' test (P > 0.05 NS, ≤0.05 S, ≤0.01 HS).

RESULT

During the 1-year interval, no implant was lost and the mean bone level at the implants was maintained or even improved.

CONCLUSION

Immediate restoration of single tooth implants placed in fresh extraction sockets could be considered a valuable option to replace a missing tooth. The graft materials used in both groups have been found to be equally effective.

Hepatic osteodystrophy is common in patients with noncholestatic liver disease

BACKGROUND

Patients with cirrhosis are more prone to develop metabolic bone disease. Scanty literature data are available on osteodystrophy in patients from India with noncholestatic liver diseases.

METHODS

Patients diagnosed with cirrhosis were prospectively evaluated for bone mineral density (BMD) as measured by dual-energy X-ray absorptiometry at the femoral neck, lumbar spine, and left forearm (distal radius). Correlation of BMD with age, sex, etiology of cirrhosis, Child's class, serum bilirubin, alkaline phosphatase (ALP), albumin, calcium, phosphate, 25-hydroxyvitamin D (25(OH)D), and parathyroid hormone (PTH) was studied.

RESULTS

The study group comprised 115 cirrhotic patients (107 males and 8 females). Etiology of cirrhosis was alcohol in 67 (58.2%) and viral in 48 (41.7%). Hepatitis B was diagnosed in 29 (25.2%) and hepatitis C in 19 (16.5%). Mean age was 49 (± 5.5) years. Prevalence of osteodystrophy was significantly higher in males than in females; 97.1% and 75% respectively (P = .038). Both alcoholic and viral groups had similar baseline characteristics except albumin levels. Child's class was B in 72 patients and C in 43. Low BMD was present in 97% of patients with alcoholic cirrhosis and 93.7% with viral cirrhosis (P > .05). Low BMD was present at the femoral neck in 80.8% of patients, lumbar spine in 77.3%, and forearm in 59.9%. PTH correlated negatively with BMD.

CONCLUSION

Osteodystrophy is common in alcoholic and viral cirrhosis patients.

Prediction of sustained virological response to combination therapy with pegylated interferon alfa and ribavirin in patients with genotype 3 chronic hepatitis C

BACKGROUND

Sustained virological response (SVR) rates in patients with hepatitis C are heterogeneous and are influenced by a wide range of host and viral factors.

AIM

To evaluate the efficacy of combination therapy with pegylated interferon alfa (PEG-IFN-α) and ribavirin (RBV), and document the SVR rates taking into consideration various predictive factors in patients with chronic hepatitis C (CHC) genotype 3.

METHODS

Ninety-seven treatment-naive patients with CHC genotype 3 (mean age 41.46±11.51 years, M:F ratio 79:18), who received a combination of PEG-IFN (α-2a or α-2b) and RBV were retrospectively analyzed (2006-2008) for the early virological response (EVR) at 12 weeks, end of treatment response (ETR), and SVR at 6 months.

RESULTS

Eighty-four (86.6%) patients achieved EVR and 81 (83.5%) achieved ETR, while SVR was achieved in 65 (67.0%) patients. Of the 84 patients who achieved EVR, 77 (91.7%) achieved ETR and 61 (72.6%) achieved SVR at 6 months. Age and body mass index (BMI) were found to be important predictors (*P<0.05) of SVR. CHC patients with a history of alcohol intake showed decreased SVR (52%) (*P=0.035) as compared to nonalcoholics (80%). Cirrhotic versus noncirrhotic patients showed no difference in SVR (54.5% vs. 70.7%) (P=0.157). Serum alanine aminotransferase (ALT) (P=0.169) and hepatitis C virus (HCV) RNA levels (P=0.42) also did not have an influence on the SVR.

CONCLUSION

Combination therapy with PEG-IFN-α and RBV demonstrated good tolerability in CHC genotype 3 infection. Age, BMI, and alcohol consumption play an important role in determining treatment outcome.

Role of Oral Appliances in the Management of Sleep Disorders

BACKGROUND

A study was undertaken with the aim to evaluate the therapeutic and clinical efficacy of oral appliances in the management of upper airway sleep disorders like snoring and obstructive sleep apnea (OSA).

METHODS

Oral appliances were prescribed in eight cases of non - apneic snoring and 42 polysomnography (PSG) diagnosed cases of OSA. The cases were assessed on Epworth Sleepiness Scale (ESS) and Apnea - Hypopnea Index (AHI).

RESULT

62.5% of the non - apneic snoring cases reported gross reduction/cessation of snoring. In the OSA cases, the mean AHI and ESS scores decreased from 51.48 ± 23.70 to 32.78 ± 18.06 and 12.50 ± 3.57 to 7.20 ± 2.917 respectively. A statistically significant (p<0.0001) improvement in AHI and ESS scores was observed.

CONCLUSION

Short term therapeutic efficacy of oral appliances therapy in non-apneic snoring and OSA cases was observed.

Quantification of hypoxia-inducible factor-1α, vascular endothelial growth factor, and angiopoietin-2 expression in hepatocellular carcinoma using a real-time quantitative reverse transcription polymerase chain reaction

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Background: Hepatocellular carcinoma (HCC) is characteristically a hypervascular tumor and its progression is closely related to angiogenesis. Hypoxia inducible factor-1α (HIF-1 α), vascular endothelial growth factor (VEGF), and angiopioetin-2 (Ang-2) are key angiogenic factors in HCC. In this study, expression of HIF-1α, VEGF, and Ang-2 were analyzed and correlated with clinicopathologic features of HCC.

Methods: Expression of HIF-1α, VEGF, and Ang-2 were analyzed by real-time quantitative reverse transcription polymerase chain reaction in 67 HCC patients (23HBV, 22HCV, 22NBNC) with mean age 59.09 ± 11.13 years (60 M: 7 F), 9 cirrhosis patients (2HBV, 2HCV, 5ALD) with mean age 48.33 ± 11.31 years (8 M:1 F), and 14 chronic hepatitis patients (7HBV, 7HCV) with mean age 48.33 ± 7.17 years (10 M: 4 F), respectively. HCC was diagnosed on the basis of EASL (European Association for the Study of the Liver) criteria.

Results: Expression of HIF-1α and VEGF were found to be significantly higher in patients with HCC compared with cirrhosis and chronic hepatitis. Although Ang-2 expression was higher in HCC compared to cirrhosis and chronic hepatitis but the difference was not statistically significant. The difference in the expression of HIF-1α, VEGF, and Ang-2 in cirrhosis and chronic hepatitis were not significant. Tumor size was positively correlated with HIF-1 α(p = 0.268, p = 0.030)and VEGF (p = 0.546, p = 0.0001). A positive correlation was also seen between the HIF-1α and VEGF expression (p = 0.347, p = 0.0001). However no correlation of HIF-1α, VEGF and Ang-2 was seen with portal vein thrombosis, cirrhosis, etiology, AST, ALT, and platelets.

Conclusions: HIF-1α and VEGF were highly expressed in HCC patients and may be responsible for the HCC growth. Further studies with a larger number of patients need to be done.

No significant financial relationships to disclose.

Non-hepatic insults are common acute precipitants in patients with acute on chronic liver failure (ACLF)

INTRODUCTION

Acute-on-chronic liver failure (ACLF) is a newly coined term to describe simultaneous coexistence of two liver conditions, one of them being chronic or long-standing and the other acute or recent. There is limited data on the entity of ACLF. This study was performed to review our experience in ACLF patients from a tertiary care centre.

PATIENTS AND METHODS

ACLF was defined as per the Asian Pacific Association for the Study of the Liver (APASL) criteria, except for including the non-hepatic insults as precipitating events. Based on the type of acute insult, patients were divided into type I (non hepatic injury) and type II (hepatic injury-further divided in to IIA-acute viral hepatitis (AVH) on underlying chronic liver disease (CLD), IIB-other acute hepatitic insults like drugs/toxins and IIC-same disease responsible for worsening). Patients were also analyzed for the mode of presentation, severity of liver illness, presence of acute kidney injury and other organ failure, hospital stay and final outcome.

RESULTS

One hundred two patients with ACLF (85 males, mean age 44 ± 12.5 years) were included in the study; they accounted for 49% of all liver failures and 27% of all admissions during the study period. Sixty patients (59%) had known cirrhosis whereas 42 (41%) patients presented for the first time as ACLF, unaware of the underlying CLD. Sixty-two (60%) patients had type I ACLF while 40 (40%) patients had type II ACLF. Infections (47%) were the most common non-hepatic causes of acute deterioration in type I ACLF. Amongst type II, acute viral hepatitis (IIA) accounted for six patients (4 hepatitis E virus, 2 hepatitis A virus) and type II C was the most common with alcoholic hepatitis accounting for 30 (29%) patients. Acute kidney injury was present in 47 (46%) and hypotension in 36 (35%) patients. Hypoxemia with ventilatory support was required in 22 (21%) patients. Mean hospital stay of patients was 9.7 ± 6 days (2-27 days). Forty-seven (46%) patients either died or left hospital in a very sick state.

CONCLUSION

ACLF is a common problem in our clinical practice. Non-hepatic insults like non-hepatotropic infections/sepsis are common acute precipitating events.

Pregnancy outcome in women with autoimmune hepatitis

INTRODUCTION

Autoimmune hepatitis (AIH) is a chronic disease of unknown cause, characterized by progressive hepatocellular inflammation and necrosis, frequently leading to cirrhosis. AIH usually affects young women and may influence fertility and pregnancy in them. Nearly 200 pregnancies have been reported so far in the world literature in women with AIH, and no definite guidelines have been established. We hereby report our experience of four pregnancies in women with definite diagnosis of AIH.

MATERIALS AND METHODS

We studied the maternal and perinatal outcome of four women with AIH. The medical history was recorded in detail. The pregnancies were allowed to continue with careful fetal and maternal surveillance. Antenatal complications, disease course during pregnancy, intrapartum maternal fetal events, mode of delivery, and perinatal outcome were noted.

RESULTS

All four patients had preterm labor: three had vaginal delivery and cesarean was done in one due to breech presentation with preterm rupture of membranes. All the infants were live born with birth weight appropriate for gestational age and were born with good Apgar scores and no congenital malformation. The incidence of post partum hemorrhage was 25% and so was the maternal mortality.

CONCLUSION

Successful pregnancy outcome in patients with well-controlled AIH seems to be a realistic expectation with careful monitoring jointly by the Obstetricians and Hepatologists, especially in the post partum period. Steroids seem to be the safe alternative as immunosuppressant therapy although azathioprine has also been seen to be generally safe for mother or baby.

Review article: the modern management of portal vein thrombosis

BACKGROUND

Portal vein thrombosis (PVT) is an important cause of portal hypertension. It may occur as such with or without associated cirrhosis and hepatocellular carcinoma. Information on its management is scanty.

AIM

To provide an update on the modern management of portal vein thrombosis. Information on portal vein thrombosis in patients with and without cirrhosis and hepatocellular carcinoma is also updated.

METHODS

A pubmed search was performed to identify the literature using search items portal vein thrombosis-aetiology and treatment and portal vein thrombosis in cirrhosis and hepatocellular carcinoma.

RESULTS

Portal vein thrombosis occurs because of local inflammatory conditions in the abdomen and prothrombotic factors. Acute portal vein thrombosis is usually symptomatic when associated with cirrhosis and/or superior mesenteric vein thrombosis. Anticoagulation should be given for 3-6 months if detected early. If prothrombotic factors are identified, anticoagulation should be given lifelong. Chronic portal vein thrombosis usually presents with well tolerated upper gastrointestinal bleed. It is diagnosed by imaging, which demonstrates a portal cavernoma in place of a portal vein. Anticoagulation does not have a definite role, but bleeds can be treated with endotherapy or shunt surgery. Rarely liver transplantation may be considered.

CONCLUSION

Role of anticoagulation in chronic portal vein thrombosis needs to be further studied.

Midline Fractures in Single Maxillary Complete Acrylic vs Flexible Dentures

BACKGROUND

Patients using single maxillary denture against their natural mandibular teeth face the problem of midline fracture in their routine acrylic dentures. Various techniques have failed over the years to address the problem. In this study, flexible denture material (Lucitone) with injection moulding system has been used and evaluated for midline fracture in these patients.

METHODS

A total of 58 patients in the age group of 38 to 80 years, who had experienced midline fracture in their acrylic maxillary dentures were selected. They were provided with new dentures using flexible denture material. Various parameters, namely, mastication, phonetics, esthetics and comfort level were evaluated.

RESULT

Only two cases reported slight crack in the palatal region of the-maxillary dentures after 18 months of use. Mastication and phonetics were found to be improved with flexible dentures.

CONCLUSION

The flexible denture is a promising material for preventing midline fractures in a single maxillary denture. It is well tolerated by the patients as compared to the methyl meth-acrylate dentures.

Hepatitis E epidemic with bimodal peak in a town of north India

INTRODUCTION

An epidemic of viral hepatitis occurred in Mandi Gobindgarh town of Punjab in northern India during year 2005-06. An attempt was made to study the outbreak clinically, serologically, and etiologically.

METHODS

Line listing and spot mapping of all cases of jaundice presented to civil hospital was done. An active search of cases was made through house-to-house visit with the help of 33 teams and 6 supervisors. Twenty two blood samples collected from acute cases were tested for anti-HAV IgM and anti-HEV IgM by ELISA. HEV specific PCR was also carried out. Sanitary survey was also done and water samples were tested for coliforms.

RESULTS

In house to house survey 3170 cases of jaundice were reported; of them 2171 (68.5%) were males. Mean age was 28.8 years. Overall attack rate was 5.2%. The epidemic continued for more than a year and bimodal peak was observed. Civil hospital campus which has separate water supply had no jaundice case. About 95% blood samples from icteric patients were found to be positive for IgM and IgG antibodies of HEV. Eighteen persons died during the epidemic, mostly in old age group. Case fatality ratio was 0.57%. No deaths occurred among 17 pregnant women who had developed hepatitis.

CONCLUSION

The epidemic was caused by hepatitis E virus, which was transmitted due to faecal contamination of municipal water supply.

Insulin tolerance test is comparable to homeostasis model assessment for insulin resistance in patients with nonalcoholic fatty liver disease

INTRODUCTION

Insulin resistance (IR) is common in patients with nonalcoholic fatty liver disease (NAFLD). We compared the performance of insulin tolerance test and the homeostasis model assessment (HOMA) for measuring IR in such patients.

METHODS

In a prospective study, IR was determined using both insulin tolerance test and HOMA in 22 patients with NAFLD. Rate constant for insulin tolerance test (KITT) was calculated using the formula KITT (%/min) = 0.693/t(1/2), where t(1/2) was calculated from the slope of plasma glucose concentration during 3-15 minutes after administration of intravenous insulin. IR was assessed using HOMA as the product of fasting insulin (microU/L) and fasting plasma glucose (mmol/L) levels divided by 22.5.

RESULTS

All the 22 patients had IR. Results of KITT and HOMA-IR for determining IR showed a fair correlation (r = 0.55; p = 0.03).

CONCLUSIONS

Insulin tolerance test may be a useful method for assessing IR in patients with NAFLD.

Benign recurrent intrahepatic cholestasis (BRIC) in an adult

Benign recurrent intrahepatic cholestasis is a rare hereditary disorder characterised by recurrent episodes ofcholestasis. We report the case of a young male patient with benign recurrent intrahepatic cholestasis who presented to us with recurrent cholestatic jaundice and pruritus with negative work up for all possible aetiologies and a liver biopsy consistent with intrahepatic cholestasis. He improved on treatment with ursodeoxycholic acid and ondansterone and is doing well on follow up.

The clinicopathological profile of Indian patients with nonalcoholic fatty liver disease (NAFLD) is different from that in the West

There are limited data on nonalcoholic fatty liver disease (NAFLD) from India. The clinicopathological profile of Indian patients with NAFLD may be different from that of Western patients. One hundred NAFLD patients with increased liver enzymes were prospectively evaluated for clinical presentation, associated diseases, overweight/obesity, central obesity (n=54), presence of diabetes mellitus, lipid abnormalities, insulin resistance (n=39), metabolic syndrome (n=54), serum iron, serum ferritin, and transferrin saturation (n=60), and HFE gene mutations (n=30). Risk factors for the grade and stage of the disease on histology were studied in 38 biopsy-proven patients. Patients were treated with lifestyle modifications and ursodeoxycholic acid (UDCA). Seventeen nonresponder patients were treated with metformin. The majority of patients were males (n=70). Twenty percent of patients were overweight, 68% had obesity, and 78% had central obesity. Abnormal cholesterol, HDL, and triglycerides were present in 36%, 66%, and 53% of patients, respectively. Twelve percent of patients had diabetes mellitus and 16% patients had various associated diseases. All 22 (100%) patients studied by ITT and all but 1 (98%) studied by HOMA-IR were found to have reduced insulin sensitivity and 50% were found to have metabolic syndrome by the modified ATP III criteria. Two (3%) patients were found to have high serum iron, 4 (7%) patients had high ferritin, 5 (8%) patients had increased transferrin saturation, and 4 (13%) patients were found to be heterozygotes for H63D HFE gene mutation. Twenty patients of 38 (53%) had histological evidence of NASH (class 3=6, class 4=14). The other 18 (47%) qualified for class I (n=1) or class II (n=17) NAFLD. Four (10.5%) patients had bridging fibrosis and none had evidence of cirrhosis liver. Seventy-four (74%) patients achieved a biochemical response to lifestyle modification and UDCA. All 17 patients treated with metformin had a reduction in ALT level and 10 (59%) of them had normalization of their enzymes. We conclude that the clinicopathological profile of NAFLD in Indian patients is different from that in the West.

Frequency of primary iron overload and HFE gene mutations (C282Y, H63D and S65C) in chronic liver disease patients in north India

AIM: To identify the frequency of iron overload and study the three mutations in the HFE gene (C282Y, H63D, and S65C) in patients with chronic liver disorders (CLD) and controls.

METHODS: To identify patients with iron overload (transferrin saturation > 45% in females and > 50% in males and serum ferritin > 1000 ng/mL) we evaluated 236 patients with CLD, including 59 with non-alcoholic steatohepatitis (NASH), 22 with alcoholic liver disease (ALD), 19 of cirrhosis due to viruses (HBV, HCV), and 136 with cryptogenic cirrhosis. Mutations of the HFE gene were analyzed by PCR-RE. hundred controls were screened for iron status and the mutations.

RESULTS: Seventeen patients with CLD showed evidence of iron overload. Fifteen cases of iron overload had cryptogenic cirrhosis and two had ALD. None of the controls showed iron overload. We did not find any individual with 282Y or 65C either in the cases or in the controls. The prevalence of H63D heterozygosity was 12% in normal individuals, 14.8% in 236 patients (16.9% in NASH, 13.6% in ALD, 26.3% in viral and 12.5% in cryptogenic cirrhosis) and the overall prevalence was 13.98%. Only two of the 17 patients with primary iron overload were heterozygous for H63D. One patient with NASH and one normal individual who were homozygous for H63D showed no iron overload.

CONCLUSION: Primary iron overload in Indians is non-HFE type, which is different from that in Europeans and further molecular studies are required to determine the defect in various iron regulatory genes.

Secondary and Delayed Bone Grafting in Alveolar and Anterior Palatal Clefts

BACKGROUND

Surgical repair with suitable bone graft / substitutes plays an important role in rehabilitation of individuals with residual anterior palatal or alveolar defects associated with an oronasal fistula.

METHODS

52 cases were treated by secondary or delayed bone grafting of the alveolar defects in isolation or associated with defects of the anterior palate from July 2002 - Nov 2004. Dimension and the extent of the defects were assessed with the help of radiographs & maxillofacial CT. Cephalometric analysis, presurgical orthodontics and dentofacial orthopedics preceded surgical repair with cancellous graft from the iliac crest, followed by post surgical orthodontics and prosthetic rehabilitation.

RESULT

Satisfactory results were achieved in 49 cases with three cases showing failure of graft acceptance. Postoperative clinical and radiological evaluation for all the patients was done at an interval of one, three and six months. Bone density and trabeculation was comparable to the adjacent bone within six months.

CONCLUSION

Recreating the bony continuity of the maxillary arch followed by orthodontic correction of dental discrepancies achieves a comprehensive orthosurgical correction.

Unconjugated hyperbilirubinemia in nonalcoholic steatohepatitis--is it Gilbert's syndrome?

BACKGROUND

Patients with nonalcoholic steatohepatitis (NASH) have normal liver function tests except for raised transaminases until they have progressed to cirrhosis of liver. The objective of this study was to evaluate patients of NASH for the presence of hyperbilirubinemia at presentation.

METHOD

Sixty-seven patients of NASH were studied for the presence of hyperbilirubinemia at presentation. All patients were worked up for the presence of cirrhosis and hemolytic work up and fasting test were done in those found with unconjugated hyperbilirubinemia.

RESULTS

Five out of 67 patients (7.5%) of NASH were found to have unconjugated hyperbilirubinemia. Though the fasting test was not positive, they all had a negative hemolytic workup and none of them had underlying cirrhosis. Clinical characteristics of patients with unconjugated hyperbilirubinemia were similar to those with normal serum bilirubin levels.

CONCLUSION

Unconjugated hyperbilirubinemia in patients with NASH may suggest an associated Gilbert's syndrome.

Is vaccination against hepatitis A virus required in patients with cirrhosis of the liver?

Hepatitis A virus (HAV) superinfection can cause decompensation in patients with chronic liver disease. The risk of HAV superinfection depends on the endemicity of HAV in that particular population. Recommendations of vaccination against HAV in patients with cirrhosis of the liver in India are lacking. Our aim was to assess the seroprevalence of anti-HAV antibodies in our population of patients with cirrhosis of the liver. In a retrospective analysis, the serum of 55 patients with cirrhosis of the liver was tested for total anti-HAV antibodies by ELISA. In the 35 patients who presented with acute decompensation, the serum was also analysed for IgM anti-HAV antibodies. Fifty-four of the 55 cirrhotics (99%) were positive for total anti-HAV antibodies. All 35 patients with decompensated liver disease were also positive for total anti-HAV antibodies, and none of them tested positive for IgM anti-HAV antibodies. Most of the patients with cirrhosis of the liver in the population studied were already exposed to HAV. Routine vaccination against HAV cannot be recommended in these patients.

Pharmacokinetics of omeprazole in patients with liver cirrhosis and extrahepatic portal venous obstruction

Omeprazole is frequently used in patients with cirrhosis of the liver to treat peptic ulcer disease. It is also used for the healing of mucosal lesions after endoscopic sclerotherapy of esophageal varices in cirrhosis and extraheptic portal vein obstruction (EHPVO). This study was carried out with the aim of determining the pharmacokinetics of omeprazole in different degrees of liver cirrhosis and in patients with EHPVO, compared with healthy volunteers. Ten healthy volunteers, 30 patients with cirrhosis of the liver, divided into 3 groups of 10 depending on severity (according to Child-Pugh classification A, B and C) and ten patients with EHPVO participated in the study. The subjects received an omeprazole 20 mg capsule after an overnight fast. Blood samples were collected at 0, 0.5, 1, 1.5, 2, 2.5, 3, 6, 9 and 24 h after drug administration. Omeprazole level in plasma was estimated by reverse-phase high performance liquid chromatography (HPLC). The elimination half-life was significantly (p < 0.05) increased to 2.38 +/- 0.16, 3.26 +/- 0,12, 3.58 +/- 0.31 and 2.59 +/- 0.22 h in patients with different grades of cirrhosis (A, B and C) and also in patients with EHPVO, respectively, compared with 1.054 + 0.10 h in healthy volunteers. A similar significant increase (p < 0.05) was observed in the AUC(0alpha), while C(max) was significantly increased to 400.40 +/- 27.89 and 602 +/- 55.13 ng/ml in only grade C cirrhosis patients and EHPVO patients, compared with 303.5 +/- 36.42 ng/ml in healthy volunteers. No significant difference was observed in T(max). It was concluded that the metabolism of omeprazole was significantly impaired in both liver cirrhosis and EHPVO in comparison with healthy volunteers.

Hepatitis C virus-associated keratitis

AIM

To study the association between chronic hepatitis C virus (HCV) and Mooren's type keratitis.

METHOD

A total of 50 patients with chronic HCV were screened for any evidence of corneal ulceration. Detailed ocular examination was conducted by slit-lamp biomicroscopy. Patients with history of trauma to the eye or previous herpetic keratitis were excluded from the study.

RESULTS

There were 37 males and 13 females. The age of the patients ranged from 10 to 70 years. There was no evidence of Mooren's ulcer in any of our patients.

CONCLUSION

No association between chronic HCV and Mooren's ulcer was found in our study. Screening therefore in such cases is not necessary.

Magnetic resonance imaging and spectroscopy in hepatic encephalopathy

Hepatic encephalopathy (HE) is a potentially reversible neuropsychiatric syndrome secondary to cirrhosis and other severe liver diseases. Magnetic resonance imaging (MRI) and MR spectroscopy (MRS) have been explored to provide new insight into the pathophysiology, diagnosis and treatment of HE. MRI shows brain atrophy especially in the frontal region. Globus pallidus, putamen and portions of the internal capsule appear hyperintense on T1-weighted images; this is likely to be due to deposition of manganese as a result of portosystemic shunting and liver dysfunction. MRS permits the detection and quantification of certain brain metabolites in vivo. There is decrease in myoinositol and choline concentrations and increase in glutamine concentrations. There is no change in n-acetyl-aspartate. Depletion of myoinositol is the most sensitive and specific spectroscopic marker in HE. Its loss is most likely a compensatory mechanism for the accumulation of glutamine. In conclusion, MRI and MRS examine different aspects of hepatocerebral disease.

Minimal hepatic encephalopathy: natural history, impact on daily functioning, and role of treatment

Cirrhosis of liver is often complicated by minimal hepatic encephalopathy (mHE), which is detected by neuropsychiatric and neurophysiological tests. mHE develops more commonly in cirrhotics with severe liver disease and in those with esophageal and gastric varices. On follow up, these patients more often develop overt encephalopathy as compared to cirrhotics without mHE. mHE may affect daily activities like sleep, driving ability, alertness, social interaction, and communication. It is probably also an independent predictor of survival. The most practical treatment strategy for mHE has not been established; however, it can be treated as effectively as overt encephalopathy with similar agents. Treatment improves mHE in terms of psychometric tests, but improvement in daily functioning has not been well documented.

Helicobacter pylori and hepatic encephalopathy

Several extra-intestinal diseases have been associated with Helicobacter pylori infection. Hepatic encephalopathy has been linked to H. pylori infection because of the ammonia produced by the organism in the stomach. H. pylori infection is commoner in cirrhotic patients with hepatic encephalopathy than in those without. Increased ammonia levels have been observed in the gastric juice and blood more commonly in cirrhotics with H. pylori infection than in those without. Though the amount of ammonia produced by H. pylori may be too small to contribute to hepatic encephalopathy, eradication of H. pylori has been shown to improve the blood ammonia levels and hepatic encephalopathy.