Real-world comparison of terlipressin vs. octreotide as an adjuvant treatment in the management of variceal bleeding.

Variceal bleeding is a major complication and the leading cause of death in patients with cirrhosis and portal hypertension. This study aims to compare the efficacy and safety of terlipressin vs octreotide as an adjuvant to endoscopic management of patients with esophageal variceal bleeding in a real-time scenario. We reviewed the medical records of patients with esophageal variceal bleeding from January 2005 to December 2020 at our tertiary care Aga Khan University Hospital. Mortality was assessed after 6 weeks. A total of 842 patients with variceal bleed were evaluated. 624 patients (74.1%) and 218 patients (25.9%) received Terlipressin and Octreotide respectively. On multiple regression analysis, cardiac events during hospital stay (OR: 11.22), presence of Porto-systemic encephalopathy (OR: 3.79), and elevated bilirubin levels at the time of presentation were found to be independent risk factors for increased six weeks mortality. Moreover, cardiac events during hospital stay (OR: 3.26), Porto-systemic encephalopathy at presentation (OR: 3.06), and octreotide administration (OR: 1.80) were identified as independent risk factors for increased length of hospital stay. Terlipressin and Octreotide have similar outcomes in terms of control of bleeding, hospital stay, mortality, and side effects when used as adjuvant therapy for the management of variceal bleeding.

Epidemiology of functional gastrointestinal disorders using ROME III adult questionnaire, a population based cross sectional study in Karachi-Pakistan.

OBJECTIVE: Functional Gastrointestinal Disorder (FGIDs) are a heterogenous group of disorders, with Irritable Bowel Syndrome (IBS) and Functional Dyspepsia (FD) being the most common disorders worldwide. The purpose of this study was to identify the spectra of FGIDs classified according to the ROME III criteria amongst an adult Pakistani population. It also aimed to correlate the psychosocial alarm symptoms with the prevalence of FGIDs and report the overlap of all FGID. DESIGN: This was a community based cross-sectional study. Multi-stage cluster sampling technique was applied, and 1062 households were initially randomly chosen using systematic sampling technique. Only one person from each household was enrolled in the study. After eligibility screening, 860 participating individuals were requested to fill out a structured ROME III interview questionnaire, administered to them by a trained interviewer. RESULTS: FGIDs were diagnosed in 468 individuals (54.4%), out of 860 participants. FD was found to be the most prevalent (70.2%), followed by Functional Heartburn (58.9%) and Functional bloating (56.6%). Amongst a total of 468 participants diagnosed with FGIDs, 347 (74.1%) had overlapping disorders. There was also a higher incidence of psychosocial alarm symptoms including higher pain severity (62.6% vs 46.4%) and being victimized at some point in their lives (26.1% vs 6.6%) amongst FGID patients. CONCLUSION: There is a high disease burden of FGIDs in this study population, with approximately half of the population suffering from at least one type of FGID. Overlapping disorders are also common in this part of the world.

Carvedilol reduces the risk of decompensation and mortality in patients with compensated cirrhosis in a competing-risk meta-analysis.

BACKGROUND & AIMS: Whether non-selective ß-blockers can prevent decompensation of cirrhosis warrants clarification. Carvedilol might be particularly effective since its intrinsic vasodilatory activity may ameliorate hepatic vascular resistance, a major mechanism of portal hypertension in early cirrhosis. We assessed whether carvedilol may prevent decompensation and improve survival in patients with compensated cirrhosis and clinically significant portal hypertension (CSPH). METHODS: By systematic review we identified randomized-controlled trials (RCTs) comparing carvedilol vs. control therapy (no-active treatment or endoscopic variceal ligation [EVL]) in patients with cirrhosis and CSPH without previous bleeding. We performed a competing-risk time-to-event meta-analysis using individual patient data (IPD) obtained from principal investigators of RCTs. Only compensated patients were included. Primary outcomes were prevention of decompensation (liver transplantation and death were competing events) and death (liver transplantation was a competing event). Models were adjusted using propensity scores for baseline covariates with the inverse probability of treatment weighting (IPTW) approach. RESULTS: Among 125 full-text studies evaluated, 4 RCTs were eligible. The 4 provided IPD and were included, comprising 352 patients with compensated cirrhosis, 181 treated with carvedilol and 171 controls (79 received EVL and 92 placebo). Baseline characteristics were similar between groups. Standardized differences were <10% by IPTW. The risk of developing decompensation of cirrhosis was lower with carvedilol than in controls (subdistribution hazard ratio [SHR] 0.506; 95% CI 0.289-0.887; p = 0.017; I2 = 0.0%, Q-statistic-p = 0.880), mainly due to a reduced risk of ascites (SHR 0.491; 95% CI 0.247-0.974; p = 0.042; I2 = 0.0%, Q-statistic-p = 0.384). The risk of death was also lower with carvedilol (SHR 0.417; 95% CI 0.194-0.896; p = 0.025; I2 = 0.0%, Q-statistic-p = 0.989). CONCLUSIONS: Long-term carvedilol therapy reduced decompensation of cirrhosis and significantly improved survival in compensated patients with CSPH. This suggests that screening patients with compensated cirrhosis for CSPH to enable the prompt initiation of carvedilol could improve outcomes. PROSPERO REGISTRATION NUMBER: CRD42019144786. LAY SUMMARY: The transition from compensated cirrhosis to decompensated cirrhosis is associated with markedly reduced life expectancy. Therefore, preventing decompensation in patients with compensated cirrhosis would be associated with greatly improved patient outcomes. There has been controversy regarding the use of non-selective ß-blockers (portal pressure-lowering medications) in patients with cirrhosis and elevated portal blood pressure (portal hypertension). Herein, using a competing-risk meta-analysis to optimize sample size and properly investigate cirrhosis as a multistate disease and outcomes as time-dependent events, we show that carvedilol (a non-selective ß-blocker) is associated with a reduced risk of decompensating events and improved survival in patients with cirrhosis and portal hypertension.

Ergonomics of gastrointestinal endoscopies: Musculoskeletal injury among endoscopy physicians, nurses, and technicians.

BACKGROUND: Musculoskeletal injuries (MSI) have plagued endoscopists and ancillary staff for decades without any innovative and strong ergonomic guidelines. It has placed a physical and mental strain on our endoscopists and ancillary staff. We have very have limited data supporting this claim in our region and most data is supported by western literature. AIM: To document the prevalence of MSI, and awareness and practices of ergonomics by endoscopists and ancillary staff. METHODS: This is an observational cross-sectional study, conducted in Karachi, a city that boasts the maximum number of daily endoscopies in the country. An eleven-point self-administered questionnaire was distributed and used to evaluate MSI and ergonomic adjustments amongst three tertiary care setups in Karachi. An onsite survey via a 13-point checklist for endoscopy suite facilities was used to assess the ergonomically friendly conveniences at five tertiary care setups in Karachi. A total of 56 participants replied with a filled survey. RESULTS: There were 56 participants in total with 39 (69.6%) males. Pain and numbness were documented by 75% of the patients, with pain in the neck (41.1%), lower back (32.1%), shoulder (21.4%), thumb (12.5%), hand (23.2%), elbow (8.9%), and carpal tunnel syndrome (CTS) (7.1%). Of those, 33.3% attributed their symptoms to endoscopy, 14.2% said that symptoms were not caused by endoscopy, and 52.4% were not certain whether endoscopy had caused their symptoms. Twenty-one point four percent of patients had to take time off their work, while 33.9% took medications for pain. Ergonomic modifications to prevent musculoskeletal injury, including placement of endoscopic monitor at eye level and the cardiac monitor in front, stopping the procedure to move patients, sitting while performing colonoscopy, and navigating height-adjustable bed were used by 21.4%. Nine out of 13 ergonomic facilities were not present in all five tertiary care hospitals. Conveniences, such as anti-fatigue mats, height-adjustable computer stations, and time out between patients were not present. CONCLUSION: Three-fourth of our endoscopists reported MSI, of which more than half were not sure or attributed this problem to endoscopy. The prevalence of MSI warrants urgent attention.

Impact of Gastrointestinal Diseases on Health-Related Quality of Life of Patients in Pakistan.

Objective This study aimed to evaluate the impact of gastrointestinal (GI) diseases on health-related quality of life (HRQoL) in Pakistani patients. Methods A cross-sectional study was conducted from 1st January 2019 to 15th February 2019 at a tertiary care hospital in Pakistan by employing a self-administered questionnaire called Gastrointestinal Quality of Life Index (GIQLI). Questionnaires were distributed among the patients presenting to outpatient gastroenterology clinics to evaluate their HRQoL. Results A total of 199 patients were included in this study, and their mean GIQLI score was 87.8 ± 17.8. Results showed that more severe core symptoms can lead to a poorer QoL. Overall GIQLI scores and most of its domain scores were lower in females as compared to males (p-value: 0.02). Obese patients had an overall lower mean GIQLI score including in the GI, psychological, and social domains while advanced age was associated with a higher disease-specific GIQLI score. Conclusion Based on our findings, GI diseases negatively impact the HRQoL in patients. Physicians need to consider the different domains of QoL as part of a holistic approach to treating these patients.

Impact of coronavirus disease 2019 on prevention and elimination strategies for hepatitis B and hepatitis C.

The coronavirus disease 2019 (COVID-19) pandemic has resulted in significant morbidity and mortality since its first case was discovered in December 2019. Since then, multiple countries have witnessed a healthcare system collapse due to the overwhelming demand for COVID-19 care. Drastic measures have been taken globally in order to curb the spread of the virus. However, those measures have led to the disruption of other aspects of healthcare, increasing the burden due to other medical conditions. We have also stepped back in achieving the ambitious goal set in place by World Health Organization to eliminate viral hepatitis as a public threat by 2030. Hepatitis B and C are chronic conditions with a significant worldwide burden, and COVID-19 has resulted in many hepatitis elimination programs slowing or stopping altogether. In this review, we elucidate the impact of the ongoing COVID-19 pandemic on the interventions targeted towards the elimination of hepatitis B virus and hepatitis C virus. Some of the salient features that we have covered in this review include hindrance to screening and diagnostic tests, neonatal vaccinations, the transmission dynamics affecting hepatitis B virus and hepatitis C virus, role of limited awareness, restrictions to treatment accessibility, and disparity in healthcare services. We have highlighted the major issues and provided recommendations in order to tackle those challenges.

Diagnostic Accuracy of the Forns Score for Liver Cirrhosis in Patients With Chronic Viral Hepatitis.

Introduction Liver cirrhosis is an irreversible and end-stage disease. It results from chronic liver damage characterized by the replacement of normal liver tissue by fibrosis, leading to the progressive loss of liver function. Making an early diagnosis of cirrhosis is important for patients with chronic hepatitis because early antiviral therapy can prevent the progression of cirrhosis and even induce regression. There have been efforts to develop surrogate markers for liver cirrhosis as the biopsy is invasive, costly, and difficult to standardize. Methods This was a cross-sectional study conducted at the Section of Chemical Pathology, the Department of Pathology and Laboratory Medicine in Collaboration with the Section of Gastroenterology, Department of Medicine, the Aga Khan University, from January to December 2018. A total of 90 patients (>18 years of age) with a history of chronic viral hepatitis, who were attending the FibroScan® (Echosens, Paris, France) clinic were included. Patients with a history of autoimmune liver diseases and hepatocellular carcinoma were excluded from the study. Blood samples withdrawn were analyzed on ADVIA Centaur® (Siemens Healthineers, Erlangen, Germany), and Forns scores were calculated based on the following four parameters: patient age, total cholesterol, gamma-glutamyl transferase (GGT), and platelet count. Results The median age of the patients was 38.5 years [interquartile range (IQR): 21]. Among the study population, 59 (65.6%) were males and 31 (34.4%) were females; 26 patients showed reactivity for hepatitis B surface antigen (HBsAg), and 63 patients were found chronic with hepatitis C virus (HCV). The proportion of HCV was observed to be higher as compared with that of Hepatitis B virus (HBV). Nineteen patients were found to have jaundice and only one patient had ascites. An Area Under the Receiver Operating Curve (AUROC) was generated to determine the diagnostic accuracy of the Forns score. It was observed that the Forn score value of >7.110 had an AUROC of 0.9928 (95% CI: 0.9821-1.003, p-value: <0.001) with a sensitivity of 100% (95% CI: 91.19-100.0%) and specificity of 94% (95% CI: 83.45-98.75%), with a higher positive likelihood ratio of 16.67. Conclusion This study found the Forns score to be sensitive and specific in diagnosing liver cirrhosis in patients with chronic hepatitis. The Forns score at a cutoff of 7.11 is highly sensitive as well as a specific noninvasive method that can be used to ascertain the status of fibrosis in chronic hepatitis patients.

Minimal Hepatic Encephalopathy: Effect of H. pylori infection and small intestinal bacterial overgrowth treatment on clinical outcomes.

The effect Helicobacter pylori (Hp) infection and small intestinal bacterial over growth (SIBO) in minimal hepatic encephalopathy (MHE) is not well understood. The aim of the study was to determine the effect of eradication of Hp infection and SIBO treatment on MHE in patients with cirrhosis. Patients with cirrhosis were enrolled and MHE was determined by psychometric tests and critical flicker frequency analysis. Hp infection and SIBO were assessed by urea breath and Hydrogen breath tests respectively in patients with cirrhosis and in healthy volunteers. Patients with Hp infection and SIBO were given appropriate treatment. At six weeks follow-up, presence of Hp infection, SIBO and MHE status was reassessed. Ninety patients with cirrhosis and equal number of healthy controls were included. 55 (61.1%) patients in the cirrhotic group were diagnosed to have underlying MHE. Among cirrhotic group, Hp infection was present in 28 with MHE (50.9%) vs. in 15 without MHE (42.8%) (p = 0.45). Similarly, SIBO was present in 17 (30.9%) vs. 11 (31.4%) (p = 0.95) in patients with and without MHE respectively. In comparison with healthy controls, patients with cirrhosis were more frequently harboring Hp and SIBO (47.7% vs. 17.7% (p < 0.001) and 31.1% vs. 4.4% (p < 0.001) respectively. On follow-up, all patients showed evidence of eradication of Hp and SIBO infection. Treatment of SIBO significantly improved the state of MHE in cirrhotics, however eradication of Hp infection did not improve MHE significantly. Additionally, patients with low Model for End-Stage Liver Disease (MELD) score and belonging to Child class B had significantly better improvement in MHE. A large number of patients with cirrhosis had either active Hp infection or SIBO with or without MHE, compared to healthy controls. Treatment of SIBO significantly improved MHE in patients with cirrhosis, whereas eradication of Hp did not affect the outcome of MHE in these patients.

Drug induced liver injury is associated with high mortality-A study from a tertiary care hospital in Pakistan.

BACKGROUND AND AIM: In light of few established drug induced liver injury (DILI) registries, this study aims to evaluate the clinical spectrum and predictors of mortality and morbidity of hospitalized patients with suspected DILI. PATIENTS AND METHODS: DILI cases were identified and categorized on basis of COIMS/RUCAM score and the exclusion of other liver diseases. Clinical and laboratory parameters were analyzed to identify the predictors of morbidity (prolonged hospital stay > 5 days) and mortality. RESULTS: Out of 462 patients, there were 264 (57.6%) males and the mean age of the cohort was 50.83 years (range: 20-94 years). DILI was classified as definite or highly probable in 31.1%, probable in 62.5%, and possible in 7.4% of cases. Pattern of liver injury was hepatocellular in 25.1%, cholestatic in 56.17%, and mixed in 18.72% of patients. Anti-tuberculosis drugs (ATDs) were found to be the most common category of drugs causing DILI, in 295 (63.9%) patients. Clinically, encephalopathy was present in 21.6% patients; other presenting symptoms included abdominal pain (57.1%), vomiting (57.1%), jaundice (54.1%) and pruritus (42.3%). In-hospital mortality was 26.5% and prolonged hospital stay (> 5 days) was observed in 35.93% of patients. Mortality was significantly greater in patients with encephalopathy, male gender, hepatocellular pattern of DILI, increased INR and use of ventilator support. CONCLUSION: In our study, the most frequent cause of DILI in hospitalized patients was ATDs. More than a quarter of patients died during hospital stay. A close control of clinical and biochemical parameters are required to prevent and monitor DILI, especially in patients taking ATDs in our region.

Spectrum and Clinical Outcome of Motility Disorders on High-Resolution Esophageal Manometry: A Study From a Tertiary Center on Patients With Dysphagia in Pakistan.

Objective This study aimed to evaluate the outcome of high-resolution esophageal manometry (HRM) in the diagnosis of esophageal motility disorders in a Pakistani population. It also evaluates the outcomes of management of patients with esophageal dysphagia and no structural abnormality on endoscopy. Methods This is a cross-sectional study. Patients with symptoms of dysphagia with normal endoscopy were subjected to esophageal manometry and to barium swallow as a part of routine workup. Esophageal motility disorders diagnosed by HRM were compared to barium swallow findings. A follow-up of these patients was done after a one-year interval to evaluate improvement in their symptoms. Results A total of 202 patients underwent HRM. There were abnormal findings in 160 patients (79.2%) with achalasia being the most common diagnosis in 35.6% of the total patients. Out of 72 patients diagnosed to have achalasia on HRM, only 46 (32.6%) had similar findings on barium esophagram and this difference is statistically significant, p < 0.001). Among achalasia patients, laparoscopic surgery was performed in 22 (30.5%) patients with 59% patients reporting a good to excellent improvement (>50%) in their symptoms, balloon dilatations were done in 47 (65.27%) patients with a good to excellent improvement in symptoms in 55% patients. Only three patients (5.5%) were given botulinum toxin injections, and two of them had an improvement of >50% in their symptoms. Patients with motility disorders other than achalasia were treated with a combination of proton pump inhibitors (PPIs), calcium channel blockers and selective serotonin reuptake inhibitors (SSRIs). Conclusion Achalasia was the most common esophageal motility disorder in our population. HRM can diagnose significantly more patients with achalasia compared to barium swallow. Likewise, HRM was helpful in detecting other esophageal motility disorders and planning their management.

Understanding Constipation: A Cross-sectional Study from a Developing Country Setting.

A cross-sectional study was conducted in the Gastroenterology Clinics of The Aga Khan Hospital and Jinnah Postgraduate Medical Centre in Karachi. All patients complaining of constipation were included. Patients with alarm features were excluded. Interviews were conducted by trained doctors using a structured Rome III based pre-tested questionnaire and Bristol Stool Form Scale. Out of 396 participants, 186 (47.0%) had FC and 209 (52.7%) had IBS-C. Based upon Bristol Stool Form Scale, only 214 (54%) reported to have slow transit constipation (BSS <2). A higher proportion of women reported severe form of constipation as compared to men (81.5%, n=150 vs. 65.1%, n=138 p<0.001). However, a higher percentage of men reported using medications to treat their symptoms (71.2%, n=151 vs. 57.1%, n=105 p=0.003). Proper understanding of patient's symptoms is essential for optimizing individual patient management.

Functional gastrointestinal disorders and gut-brain axis: What does the future hold?

Despite their high prevalence, lack of understanding of the exact pathophysiology of the functional gastrointestinal disorders has restricted us to symptomatic diagnostic tools and therapies. Complex mechanisms underlying the disturbances in the bidirectional communication between the gastrointestinal tract and the brain have a vital role in the pathogenesis and are key to our understanding of the disease phenomenon. Although we have come a long way in our understanding of these complex disorders with the help of studies on animals especially rodents, there need to be more studies in humans, especially to identify the therapeutic targets. This review study looks at the anatomical features of the gut-brain axis in order to discuss the different factors and underlying molecular mechanisms that may have a role in the pathogenesis of functional gastrointestinal disorders. These molecules and their receptors can be targeted in future for further studies and possible therapeutic interventions. The article also discusses the potential role of artificial intelligence and machine learning and its possible role in our understanding of these scientifically challenging disorders.

Polycythaemia Vera Presenting As A Porta Hepatis Mass.

Polycythaemia Vera (PV) is a myeloproliferative disorder in which bone marrow has increased production of red blood cells, white blood cells and platelets. The hallmarks of the disease are veno-occlusive events, secondary to increased blood viscosity. Polycythaemia Vera rarely presents with portal vein thrombosis below age of 55 years especially in absence of any chronic liver disease. We report a case of 30-years-old South Asian male presenting with abdominal pain, weight loss and vomiting for 3 months. On evaluation, he was found to have oesophageal varices. Furthermore, CT scan showed infiltration at porta-hepatis and portal venous thrombosis. Polycythaemia Vera was diagnosed with a positive JAK2 mutation and increased haemoglobin. Laparoscopy was done to perform biopsy of the porta-hepatis mass. Biopsy showed engorged vessels with no sign of malignancy. Patient underwent repeated sessions of upper GI endoscopy for band ligation and multiple sessions of venous phlebotomy which drastically improved his blood indices. He was started on lifelong aspirin and was advised regular follow-ups. With early recognition and prompt management patients can be prevented from potential complications which can prove to be detrimental.

Findings from a large Asian chronic hepatitis C real-life study.

There is a paucity of information on chronic hepatitis C (CHC) patients treated with direct antiviral agents (DAAs) in Asia. We invited Asia-Pacific physicians to collate databases of patients enrolled for CHC treatment, recording baseline clinical, virologic and biochemical characteristics, sustained virologic response at week 12 (SVR12) and virologic failure. SVR12 outcome was based on intention to treat (ITT). Multivariate analysis was used to assess independent risk factors for SVR12 using SPSS version 20. A total of 2171 patients from India (n = 977), Myanmar (n = 552), Pakistan (n = 406), Thailand (n = 139), Singapore (n = 72) and Malaysia (n = 25) were collected. At baseline, mean age was 49 years, 50.2% were males, and 41.8% had cirrhosis. Overall, SVR12 was 89.5% and by genotype (GT) based on ITT and treatment completion, respectively, was 91% and 92% for GT1, 100% and 100% for GT2, 91% and 97% for GT3, 64% and 95% for GT4, 87% and 87% for GT6 and 79% and 91% for GT untested. Patients with cirrhosis had SVR12 of 85% vs 93% for noncirrhosis (P < 0.001) (RR 2.1, 95% CI 1.4-3.1, P = 0.0002). Patients with GT1 and GT3 treated with sofosbuvir/ribavirin (SR) had 88% and 89% SVR12, respectively, but those GT6 treated with sofosbuvir/ledipasvir (SL) had only 77.6% SVR12. Multivariate analysis showed absence of cirrhosis was associated with higher SVR12 (OR 2.0, 95% CI 1.3-3.1, P = 0.002). In conclusion, patients with GT1 and GT3 with/without cirrhosis had surprisingly high efficacy using SR, suggesting that Asians may respond better to some DAAs. However, poor GT6 response to SL suggests this regimen is suboptimal for this genotype.

Impact of direct acting antivirals on occurrence and recurrence of hepatocellular carcinoma: Biologically plausible or an epiphenomenon?

Hepatocellular carcinoma (HCC) is a major cause of morbidity and mortality worldwide. Chronic hepatitis C virus infection (HCV) is the most common cause of HCC in many European countries, Japan and Pakistan. Introduction of the new direct acting antivirals (DAAs) has revolutionized the management of HCV worldwide, with high rates of sustained virologic response in patients who could not have tolerated the previous interferon based treatments. However, recently there have been reports raising caution about the long term effects of DAAs, particularly a possible increased risk of HCC. Therefore this review explores the current molecular studies as well as clinical data that investigate the impact of DAAs on occurrence and recurrence of HCC.

Training in emerging advances in chronic hepatitis C infection in Pakistan: the Teach - Pak project.

PURPOSE: Viral hepatitis B and C represent the primary health challenge confronting Asia and Pakistan. With direct-acting antiviral therapy for hepatitis C, patients will be treated by general physicians (GPs) and will need training through continuing medical education (CME). Blended learning is a combination of didactic teaching with online, self-paced learning, and it has not been evaluated as a CME tool for general physicians. We aimed to compare the change in physician's knowledge about chronic viral hepatitis following a blended learning educational program. METHODS: Participants enrolled in a 6 week blended learning program comprising three modules, each of 2 weeks duration. These were: 1) epidemiology and prevention of viral hepatitis; 2) diagnosis and assessment of hepatitis; and 3) treatment of hepatitis. Activities were primarily web based with some face-to-face interactive sessions. All study material was available on the Teach - Pak website. Discussions, questions, and comments were encouraged. An overall pre-and postintervention knowledge assessment was performed, in addition to individual module assessments. RESULTS: A total of 48 participants completed the program; 39 passed (81.25%). The participants were from diverse backgrounds with variable previous training. The pass rate rose from 16.1% at the start of the program to 81.2% at the conclusion. The mean pretest score was 26.0 (standard deviation =4.36), while the mean posttest score was 34.6 (standard deviation =5.15), showing an increase in the mean score of 8.56 points. Eighty four percent had completed at least one credit hour for CME as compared to those who did not pass the posttest (44.4% p-value =0.02). No significant differences in results of posttest were observed in the categories of participant's age, years since graduation, or years of experience. The participants were satisfied with the blended learning mode of teaching. CONCLUSION: Blended learning is an efficient way to impart hepatitis CME to a diverse group of postgraduate physicians.

Impact of sepsis and non-communicable diseases on prognostic models to predict the outcome of hospitalized chronic liver disease patients.

AIM: To evaluate the impact of sepsis and non-communicable diseases (NCDs) on the outcome of decompensated chronic liver disease (CLD) patients. METHODS: In this cross-sectional study, medical records of patients with CLD admitted to the Gastroenterology unit at the Aga Khan University Hospital were reviewed. Patients older than 18 years with decompensation of CLD (i.e., jaundice, ascites, encephalopathy, and/or upper gastrointestinal bleed) as the primary reason for admission were included, while those who were admitted for reasons other than decompensation of CLD were excluded. Each patient was followed for 6 wk after index admission to assess mortality, prolonged hospital stay (> 5 d), and early readmission (within 7 d). RESULTS: A total of 399 patients were enrolled. The mean age was 54.3 ± 11.7 years and 64.6% (n = 258) were male. Six-week mortality was 13% (n = 52). Prolonged hospital stay and readmission were present in 18% (n = 72) and 7% (n = 28) of patients, respectively. NCDs were found in 47.4% (n = 189) of patients. Acute kidney injury, sepsis, and non-ST elevation myocardial infarction were found in 41% (n = 165), 17.5% (n = 70), and 1.75% (n = 7) of patients, respectively. Upon multivariate analysis, acute kidney injury, non-ST elevation myocardial infarction, sepsis, and coagulopathy were found to be statistically significant predictors of mortality. While chronic kidney disease (CKD), low albumin, and high Model for End-Stage Liver Disease (MELD)-Na score were found to be statistically significant predictors of morbidity. Addition of sepsis in conventional MELD score predicted mortality even better than MELD-Na (area under receiver operating characteristic: 0.735 vs 0.686; P < 0.001). Among NCDs, CKD was found to increase morbidity independently. CONCLUSION: Addition of sepsis improved the predictability of MELD score as a prognostic marker for mortality in patients with CLD. Presence of CKD increases the morbidity of patients with CLD.