Economic evaluation of implementing a decentralised Hepatitis B virus diagnostic intervention under National Viral Hepatitis Control Programme in Tamil Nadu, South India.

OBJECTIVE: To assess the cost-effectiveness of decentralised diagnostic programme for hepatitis B virus (HBV) implemented in Tamil Nadu, South India with specific focus on a selected key population at increased risk of HBV. METHODS: A combination of decision tree and Markov model was developed to compare cost-effectiveness of the new and standard strategy. Cost and health outcomes were calculated based on the proportion of cohort in each respective health state. Total costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER) of the intervention and comparator strategies were calculated. The model parameter uncertainties were evaluated by sensitivity analysis. RESULTS: Considering decentralised HBV diagnosis followed by early treatment and vaccination for negatives for a cohort of 1000 population resulted in 505 QALYs gained and incremental cost-saving of 180749 ($2620). The decentralised diagnostic strategy could avert 294 deaths, gain 293 life years and reduce out-of-pocket expenditure of 3274 ($47) per person for HBV management. CONCLUSION: Decentralised HBV diagnosis followed by early treatment and vaccination for negatives in Tamil Nadu can save lives and reduce out-of-pocket expenditures compared to standard strategy.

OBJECTIF: Evaluer le rapport coût-efficacité du programme de diagnostic décentralisé du virus de l'hépatite B (VHB) mis en œuvre au Tamil Nadu, dans le sud de l'Inde, avec un accent particulier sur une population clé sélectionnée à risque accru du VHB. MÉTHODES: Une combinaison d'arbre de décision et de modèle de Markov a été développée pour comparer la rentabilité de la stratégie nouvelle et standard. Les coûts et les résultats pour la santé ont été calculés sur base de la proportion de la cohorte dans chaque état de santé respectif. Les coûts totaux, les années de vie corrigées de la qualité (QALY), le rapport coût-efficacité supplémentaire de l'intervention et les stratégies de comparaison ont été calculés. Les incertitudes des paramètres du modèle ont été évaluées par analyse de sensibilité. RÉSULTATS: La prise en compte d'un diagnostic décentralisé du VHB suivi d'un traitement précoce et d'une vaccination des cas négatifs pour une cohorte de 1000 habitants a permis de gagner 505 QALY et d'économiser des coûts supplémentaires de ₹180.749 (2.620 USD). La stratégie de diagnostic décentralisée pourrait éviter 294 décès, gagner 293 années de vie et réduire les dépenses personnelles de ₹3274 (47 USD) par personne pour la prise en charge du VHB. CONCLUSION: Le diagnostic décentralisé du VHB suivi d'un traitement précoce et de la vaccination des cas négatifs au Tamil Nadu peut sauver des vies et réduire les dépenses personnelles par rapport à la stratégie standard.

Prevalence of hepatitis B and hepatitis C infection from a population-based study in Southern India.

OBJECTIVES: This study aims to estimate the prevalence of hepatitis B (HBV) and C (HCV) in the population through field-screening camps conducted by Chennai Liver Foundation, in the southern state of Tamil Nadu, India. This is the largest population-based study from Tamil Nadu. PATIENTS AND METHODS: A total of 75 camps were conducted across 14 districts of Tamil Nadu (2014-2017). Screening was done by rapid point-of-care assays (SD-bioline tests) and confirmed by enzyme-linked immunosorbent assay (Monolisa tests). Those tested negative were offered first dose of HBV vaccine. Positive patients with HBV count of more than 2000 IU/ml or HCV-RNA positive on quantitative analysis were treated. RESULTS: A total of 18 589 people were screened, with HBV infection detected in 303 (prevalence 1.63%) and HCV infection in 56 (prevalence 0.3%), with significant variation among districts. Males contributed to about three-fourths of detected HBV [233/303 (77%)] or HCV [41/56 (73%)] infection. Screening detected a higher overall HBV/HCV infection rate in rural [203 (2.52%) infections in 8047 people] than in urban [156 (1.47%) infections in 10 542 people] areas (P<0.0001). Slum areas had a HBV prevalence of 5%. In a dialysis unit, all patients were found to have either HBV/HCV infection. A total of 162/303 (54%) people with HBV and 27/56 (48%) with HCV infection were treated, and 7704 people received the first dose of HBV vaccine. CONCLUSION: The prevalence of HBV was 1.63% and HCV was 0.30% in Tamil Nadu. Three-fourths of HBV/HCV infected people were males. Prevalence of HBV/HCV was higher in rural areas. Slum area and dialysis unit had high HBV and HCV prevalence.

Tuberculosis in liver transplant recipients: experience of a South Indian liver transplant center.

Tuberculosis (TB) is a serious disease for liver transplant recipients (LTRs). Data on post-liver transplant TB from high-burden countries are scant. The aims of this study were to describe the prevalence of TB in LTRs from a high-prevalence area and to analyze the risk factors for the development of post-liver transplant TB. We performed a retrospective review of our database and a case-control study of identified cases with TB and age-matched LTRs without TB. The overall prevalence of TB in LTRs was comparable to the prevalence of TB in LTRs from low-prevalence countries (5/214 or 2.3%). A low rate of interferon-γ release assay (IGRA) testing before liver transplantation was observed (68/214 or 31%). Most patients were screened clinically and with chest radiography alone before transplantation. TB developed variably after transplantation [median = 72 days, interquartile range (IQR) = 534 days]. The presentation was mostly extrapulmonary and/or disseminated (4/5 or 80%). When cases with posttransplant TB were compared with matched healthy LTRs, the presence of unexplained granulomas in explants (2/5 or 40%, P = 0.01) was the only factor associated with the development of TB. When all explants showing granulomas were reviewed, TB (52.9%) remained the most common cause; however, in almost half (47.1%), other attributable causes were found. Patients were treated with a standard daily regimen for a median of 12 months (IQR = 7.5 months). Posttransplant TB was associated with a high mortality rate (2/5 or 40%). In conclusion, we observed a low prevalence of TB in LTRs from a high-prevalence region. The presence of granulomas suggestive of TB in liver explants warrants isoniazid prophylaxis in the absence of disease. Post-liver transplant TB is associated with a high mortality rate. The roles of routine IGRA testing and isoniazid prophylaxis in a high-prevalence setting urgently need to be studied.

Tacrolimus-related adverse effects in liver transplant recipients: its association with trough concentrations.

BACKGROUND: Tacrolimus is an important immunosuppressant administered to patients following liver transplantation (LT), with a recommended trough concentration of 8 to 11 ng/mL to prevent allograft rejection. We retrospectively examined our data to identify the tacrolimus trough concentration that combined efficacy with minimal adverse effects. METHODS: The case records of LT recipients, who were nondiabetic, nonhypertensive, and with normal renal parameters prior to LT were retrospectively examined for acute cellular rejection (ACR) episodes and three major adverse effects of tacrolimus, i.e. neurotoxicity, nephrotoxicity, and new onset diabetes mellitus (NODM). RESULTS: Thirty-two LT recipients fulfilled the criteria for the study. The mean (±SD) tacrolimus level for the 290 troughs (after 10 days) was 8.5 ± 3.8 ng/mL. At 10 days, 1 month, 3 months, and 6 months, the trough values were 7.3 ± 2.9, 9.7 ± 3.4, 7.9 ± 3.3, and 7.6 ± 2.6 ng/mL, respectively. The mean time taken for stabilization of the blood pressure and biochemical parameters was 7 ± 2 days. Overall, a trough window with the least adverse effect was 7 to 7.9 ng/mL. Neurotoxicity was least in the trough range 5 to <8 ng/mL. Symptoms included headache in four, tremors in three, seizure in one, confusion and psychosis in two, and combination in three. Nephrotoxicity was least in trough 8 to <11 ng/mL. One patient progressed to chronic kidney disease at 6 months. NODM was present in 11 % to 18 % across the various trough range, including the extremes (mean trough level, 8.4 ± 4.4 ng/dL). At 6 months, five recipients were on treatment for NODM. Three recipients developed ACR, two within the first month and one at 7 weeks. The trough levels were 8.5, 9, 15.2 ng/mL, respectively. All recovered with three pulse doses of methylprednisolone. CONCLUSION: Tacrolimus concentration of 5 to <8 ng/mL was associated with least overall toxicity, neurotoxicity, and ACR.

Novel en-bloc resection of locally advanced hilar cholangiocarcinoma: the Rex recess approach.

Loco-regional recurrence after potentially curative resection remains a problem in hilar cholangiocarcinoma. Hilar dissection risks local spillage of tumor cells leading to suboptimal disease free survival. We have developed a new technique of radical resection for hilar cholangiocarcinoma based on the distinctive anatomy of the Rex recess of the liver, which has been assessed in two patients with locally advanced hilar cholangiocarcinoma. This technique included a right hepatectomy with en-bloc resection of the hepatoduodenal ligament and portal venous reconstruction to the left portal vein at the Rex recess. Both patients had R0 resection and have been disease-free for 26 and 38 months, respectively.

Liver retransplantation in adults: a single-centre, 25-year experience.

BACKGROUND: Retransplantation is the only form of treatment for patients with irreversible graft failure. The aim of this study was to analyse a single centre's experience of the indications for and outcomes of retransplantation. METHODS: A total of 196 patients who underwent liver retransplantation using 225 grafts, between January 1982 and July 2007, were included in the study. The following parameters were analysed: patient demographics; primary diagnosis; distribution of retransplantation over different time periods; indications for retransplantation; time interval to retransplantation, and overall patient and graft survival. RESULTS: Of the 2437 primary orthotopic liver transplantations, 196 patients (8%) required a first regraft, 23 patients (1%) a second regraft and six patients (0.25%) a third regraft. Autoimmune hepatitis was the most common primary diagnosis for which retransplantation was required (12.7% of primary transplantations). The retransplantation rate declined from 12% at the beginning of our programme to 7.6% at the end of the study period. The most common indication for retransplantation was hepatic artery thrombosis (31.6%). Nearly two-thirds of the retransplantations were performed within 6 months of the primary transplantation. The 1-, 3-, 5- and 10-year patient survival rates following first retransplantation were 66%, 61%, 57% and 47%, respectively. Five-year survival after second retransplantation was 40%. None of the patients have yet survived 3 years after a third regraft. Donor age of < or =55 years and a MELD (Model for End-stage Liver Disease) score of < or =23 were associated with better outcome following retransplantation. CONCLUSIONS: First retransplantation was associated with good longterm survival. There was no survival benefit following second and third retransplantations. A MELD score of < or =23 and donor age of < or =55 years correlated with better outcome following retransplantation.

Aetiology and outcome of acute liver failure.

BACKGROUND: Acute liver failure (ALF) is a clinical syndrome characterized by the sudden onset of coagulopathy and encephalopathy. The outcome is unpredictable and is associated with high morbidity and mortality. We reviewed our experience to identify the aetiology and study the outcome of acute liver failure. METHODS: A total of 1237 patients who presented with acute liver failure between January 1992 and May 2008 were included in this retrospective study. Liver transplantation was undertaken based on the King's College Hospital criteria. Data were obtained from the units prospectively collected database. The following parameters were analysed: patient demographics, aetiology, operative intervention, overall outcome, 30-day mortality and regrafts. RESULTS: There were 558 men and 679 women with a mean age of 37 years (range: 8-78 years). The most common aetiology was drug-induced liver failure (68.1%), of which 90% was as a result of a paracetamol overdose. Other causes include seronegative hepatitis (15%), hepatitis B (2.6%), hepatitis A (1.1%), acute Budd-Chiari syndrome (1.5%), acute Wilson's disease (0.6%), subacute necrosis(3.2%) and miscellaneous (7.8%). Three hundred and twenty-seven patients (26.4%) were listed for liver transplantation, of which 263 patients successfully had the procedure (80.4%). The current overall survival after transplantation was 70% with a median follow-up of 57 months. After transplantation for ALF, the 1-year, 5-year and 10-year survival were 76.7%, 66% and 47.6%, respectively. The 30-day mortality was 13.7%. Out of the 974 patients who were not transplanted, 693 patients are currently alive. Among the 281 patients who died without transplantation, 260 died within 30 days of admission (26.7%). Regrafting was performed in 31 patients (11.8%), the most common indication being hepatic artery thrombosis (11 patients). CONCLUSION: Paracetamol overdose was the most common cause of acute liver failure. Liver transplantation, when performed for acute liver failure, has good long-term survival.

Long-term outcome after sequential resections of liver and lung metastases from colorectal carcinoma.

BACKGROUND: Surgical resection of colorectal liver metastases (CLM) is an established form of treatment. Limited data exists on the value of sequential hepatic and pulmonary metastasectomy. We analysed patients who underwent sequential liver and lung resections for CLM. METHODS: A total of 910 patients who underwent liver resection for CLM between January 2000 and December 2007, were analysed to identify patients with resectable pulmonary metastases (n= 43; 4.7%). Patient demographics, overall survival and survival difference between synchronous and metachronous pulmonary metastasectomy groups were compared. In addition, outcomes in the 'liver and lung resection' group were compared with a matched group of 'liver resection only' patients (matched for age, primary disease stage, interval to liver resection and liver disease stage). RESULTS: Forty-three patients (median age 62, range 43-83 years, 22 males) underwent sequential liver and lung resection. A total of 36 patients underwent major hepatic resections, 18 patients had bilobar disease and the median number of liver lesions resected was 3 (range 1-5 lesions). Ten patients had synchronous liver and lung metastases. The median interval between liver and lung metastasectomy was 25 months (range 2-88 months). A total of two patients underwent major lobectomies, three patients had bilateral disease and the median number of lung lesions resected was one (range 1-3). The 1-, 3- and 5-year overall survival rates after first metastasectomy were 100%, 87.1% and 53.9%, respectively, with a median survival of 42 months. PATIENTS: Undergoing metachronous pulmonary metastasectomy had better 1-, 3- and 5-year survival rates than those with synchronous disease (100%, 88.9% and 60.9% vs. 100%, 75% and 0%, respectively; P= 0.02, log rank test). There was no significant survival difference between the 'liver and lung resection' and the 'liver resection only' groups. CONCLUSION: Sequential liver and lung resection for CLM is associated with good long-term survival in selected patients, except in those presenting with synchronous lung and liver metastases.

Management of upper limb arterial injury without angiography--Chennai experience.

We present our experience and observations in the management of upper limb arterial injury in a tertiary trauma care centre of a University Hospital in a developing country from January 2000 to January 2002. In this retrospective study, we had treated 27 patients (identified from trauma register) with upper extremity vascular injuries. Clinical examination and Doppler pressure studies were our prime modalities of investigation. Angiography was not employed. Our immediate limb salvage rate was 100%. Two patients developed complications during a mean follow up of 70 days with one requiring amputation. We thereby emphasise the fact that good results can be obtained by thorough clinical examination and Doppler evaluation and prompt surgery without the need for angiography in upper limb vascular trauma.