Burnout and Health Related Quality of Life among emergency physicians working at emergency at Tertiary Care Hospital in Lahore Pakistan.

Objective: To determine frequency of burnout in emergency physicians and to identify its impact on their health-related quality of life (HRQOL). Methods: In this cross-sectional study, physicians from departments with emergency cover of Jinnah Hospital Lahore were included. Their burnout and HRQOL scores using Maslach Burnout Inventory (MBI) and Short Form (SF)-36 respectively were determined in March 2022. Burnout scores were graded as low, moderate and high and were correlated with domains of HRQOL using chi X2 and analysis of variance (ANOVA). Results: One hundred fifty physicians were included with mean age 26.2 (±2.59), male to female ratio 0.78:1 (66/84) and House Officer (HO) to Postgraduate Resident (PGR) ratio 1.94:1 (99/51). High burnout was identified in 76 (50.7%) participants while 48 (32%) had moderate and 26 (17.3%) had low burnout. Males scored better than female physicians in vitality (0.008), general mental health (0.004), and mental component summary (0.01) domains of HRQOL. Doctors with high burnout had significantly lower scores in both physical component summary (p-value 0.004) and mental component summary (p-value < 0.0001) domains of HRQOL. Conclusion: Physicians working in emergency settings have high frequency of burnout and it adversely affects their mental and physical health related quality of life.

Predicting common bile duct stones: Comparison of SAGES, ASGE and ESGE criteria for accuracy.

Objective: To determine accuracy of SAGES, ASGE and ESGE criteria for predicting presence of common bile duct (CBD) stones. Methods: In a prospective study at Jinnah Hospital Lahore from March 2021 to February 2022, patients with suspected CBD stone were stratified in High risk (HR), intermediate risk (IR) and low risk (LR) for SAGES, ASGE and ESGE criteria. All patients underwent ERCP and risk strata were analyzed using SPSS 22® for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy. Results: In 90 patients with mean age 45.18(±14.87) and male/female ratio 0.64(35/55), area Under Curve (AUC) for predicting CBD stones was 0.75, 0.81and 0.83 for HR and 0.28, 0.52 and 0.52 for IR group while it was 0.53, 0.81 and 0.53 for absence of stone in LR group of SAGES, ASGE and ESGE criteria respectively. HR groups had accuracy of 81.1%, 86.7% and 87.8% in predicting CBD stone while LR criteria had 68.8%, 86.7% and 68.1% accuracy in predicting absence of CBD stone for SAGES, ASGE and ESGE respectively. Conclusion: HR strata of SAGES, ASGE and ESGE scores have excellent accuracy in predicting CBD stones whereas IR and LR criteria are suboptimal for excluding CBD stones.

Risk of Covid-19 infection during endoscopy: Efficacy of personal protective equipment (PPE) in protecting health professionals.

OBJECTIVES: To correlate compliance to personal protective equipment (PPE) protocols and risk of exposure to SARS-COV-2 infection in endoscopy staff. METHODS: We included 85 endoscopic procedures performed at Lahore General Hospital from May to July 2020. Standard operating procedures (SOPs) were implemented for patient selection, risk stratification and personal protective equipment (PPE) use for endoscopy staff. Patient and endoscopy staff were followed for Covid-19 infection. PPE scores for staff and Covid-19 positivity on follow-up were correlated using student's t test. RESULTS: Following 85 procedures included, 2 (2.3%) patients became Covid-19 positive. PPE score was <9 in 5 (5.8%) procedures for endoscopist and Covid-19 developed in 2 (2.3%) of them, PPE score was <9 during 19 (22.3%) procedures in 1st assistant and 9 (10.5%) developed infection and for 2nd assistant PPE score was <9 in 19(22.3%) endoscopies and 5 (5.9%) tested positive for covid-19. Infectivity of endoscopy staff was 6.2%. Association between PPE score and risk of Covid-19 was not significant. (p value 0.51 for endoscopist, 0.10 for 1st assistant and 0.09 for 2nd assistant). CONCLUSION: Compliance of SOPs for infection control reduces risk of acquiring Covid-19 infection during endoscopy. Proper use of PPE is effective for safety of endoscopy staff.

Bed side teaching: Student's perception and its correlation with academic performance.

OBJECTIVE: To determine student's perception of bedside clinical teaching and to correlate it with their performance in assessment. METHODS: This cross-sectional study of correlational survey was conducted at Services Institute of Medical Sciences in September 2019, involving students of final professional year who filled a proforma to rate their bedside teaching experience during clinical rotations using rating scale. Mean scores of items were determined with score < 3 reflecting dis-satisfaction. Mean scores were compared between high and low performing students using student's t test. RESULTS: Total of 160 students participated. Physical environment domain was assigned lowest scores by students (mean 2.94±0.74) followed by teaching task by teachers (3.04±0.72), group dynamics (3.16±0.81) and patient comfort and attitude towards patient (3.87±0.60). Teaching task by teacher had maximum stems with scores < 3 needing significant improvement. Students with low academic performance were more unsatisfied with group dynamics of bedside teaching (p value 0.009), especially lack of equal opportunities of participation for every member (p value <0.000) in clinical rotations. CONCLUSION: Small size group with adequate space for bedside training and faculty training can enhance learning experience of students. Ensuring active participation of each group member during bedside learning can improve academic performance of students.

Post-ERCP Pancreatitis: Risk factors and role of NSAIDs in primary prophylaxis.

OBJECTIVE: To determine efficacy of diclofenac suppository in reducing post-ERCP pancreatitis (PEP) and identify risk factors for PEP. METHODS: This is a placebo-based prospective study at Department of Medicine & Gastroenterology, Services Institute of Medical Sciences / Services Hospital, Lahore performed from January 2018 to June 2019. Patients were randomized to receive diclofenac suppository or glycerine suppository before ERCP. Both groups were compared for PEP using chi square x2 test while risk factors for PEP were determined using binary logistic regression. RESULTS: Total of 165 patients with mean age 49.1(±15.2) and male to female ratio 1/1.6 (63/102) were included. Among 82 (49.7%) patients in diclofenac group, 8 (9.7%) developed pancreatitis while 19(22.9%) of 83(50.3%) in placebo group had PEP (p value 0.02). After multivariate analysis, age>45 years (p value 0.014, OR 3.2), Bilirubin >3 mg/dl (p value 0.004 OR 3.58), time to cannulation> 5 minutes (p value<0.000 OR 9.2), use of precut (p value< 0.000 OR 4.9), pancreatic duct cannulation (p value 0.000 OR 5.46) and total procedure time >30 minutes (p value 0.01 OR 3.92) were risk factors for PEP. CONCLUSION: Pre-procedure Diclofenac suppository reduces post-ERCP pancreatitis. Age > 45 years, serum bilirubin > 3 mg/dl, cannulation time > 5 minutes, use of precut, pancreatic duct cannulation and procedure time > 30 minutes are risk factors for post-ERCP pancreatitis.

Health Related Quality of Life (HRQOL) and its correlation with academic performance of medical students.

OBJECTIVE: To determine health related quality of life (HRQOL) of medical students and its correlation with their academic performance. METHODS: Cross sectional study at Services Institute of Medical Sciences, included students of 4th and final year MBBS, who filled SF-36 proforma of HRQOL. Scores of 8-domains and of physical component and mental component summary were determined. Marks in all professional examinations were used to stratify students as high performers (≥ 70% marks) and average performing students (< 70%). HRQOL scores was correlated with academic performance using unpaired student's t-test. RESULTS: Among 267 students included, mental health score (56.2±21.3) was lower than physical health component score (69.03±18.5). Role limitation due to emotional health (RE) (44.81), Vitality (VT) (54.19) and general health perception (GH) (58.89) had lower scores among 8-domains of questionnaire. Female students had significantly lower scores in role limitation due to emotional problems (p value <0.04), vitality (<0.05), bodily pain (p value <0.05) and general health perception (p value<0.03) than male students. Physical health and role limitation due to physical health domains were better in high performing students. CONCLUSION: Mental health of medical students is suboptimal, especially among female students. Students with better physical health have better academic performance.

Cephalosporin resistance in community acquired spontaneous bacterial peritonitis.

OBJECTIVE: To determine 3rd generation cephalosporin resistance in patients with community-acquired spontaneous bacterial peritonitis (SBP) using early response assessment. METHODS: This prospective quasi-experimental study was carried out at Doctors Hospital & Medical Center from January 2016 to September 2018. Patients with cirrhosis and SBP were included. Third generation cephalosporins i.e. cefotaxime/ceftriaxone were used for treatment of SBP. Response after 48 hours was assessed and decline in ascitic fluid neutrophil count of < 25% of baseline was labelled as cephalosporin resistant. Carbapenem were used as second line treatment. Recovery and discharge or death of patients were primary end points. RESULTS: Male to female ratio in 31 patients of SBP was 1.2/1 (17/14). Hepato-renal syndrome was diagnosed in 11(37.9%) patients. Cefotaxime was used for 16(51.6%) patients whereas ceftriaxone for 15(48.3%) patients. Early response of SBP was noted in 26(83.8%) patients while 5 (16.2%) were non-responders to cephalosporins. SBP resolved in all non-responding patients with i/v carbapenem. In-hospital mortality was 12.9% and had no association with cephalosporin resistance. High bilirubin (p 0.04), deranged INR (p 0.008), low albumin (p 0.04), high Child Pugh (CTP) score (p 0.03) and MELD scores (p 0.009) were associated with in-hospital mortality. CONCLUSION: Cephalosporin resistance was present in 16.2% of study patients with community-acquired SBP. Mortality in SBP patients is associated with advanced stage of liver disease.

Primary prophylaxis of hepatic encephalopathy in decompensated cirrhosis: Low dose vs. full dose rifaximin.

OBJECTIVE: To compare efficacy of high vs low dose rifaximin for primary prophylaxis of portosystemic encephalopathy (PSE) in decompensated liver cirrhosis. METHODS: In a quasi-experimental double blind randomized study at Services Institute of Medical Sciences (SIMS), Lahore from August 2017 to August 2018, patients of decompensated cirrhosis with no previous PSE were randomized to receive twice daily rifaximin 200mg in Group-A and 550mg in Group-B. Patients were followed for 6 months for development of PSE. RESULTS: In 75 included patients, mean age was 53.8(±10.7) years and male/female ratio was 0.97/1(37/38). After randomization, 34 (45.3%) patients were included in Group-A and 41 (54.7%) patients in Group-B. During 6 month follow up 24 (32%) patients developed PSE, 12 (35.2%) in Group-A and 12 (29.2%) in Group-B, difference was not significant (p value 0.57). In 6 months, 13 (17.3%) patient died, 6 (17.6%) in Group-A and 7 (17.07%) patients in Group-B, difference not significant (p value 0.94). Patients who died had higher bilirubin (p < 0.00), higher serum creatinine (p 0.05), high CTP score (p 0.04) and worse MELD score (p 0.004). CONCLUSION: Rifaximin is not effective for primary prophylaxis of overt hepatic encephalopathy in decompensated cirrhosis patients.

Sofosbuvir based therapy in hepatitis C patients with and without cirrhosis: Is there difference?

OBJECTIVE: To compare sustained viral response to sofosbuvir/ribavirin ±interferon therapy in patients of hepatitis C with and without liver cirrhosis. METHODS: This observational study of chronic hepatitis C patients was carried out at Doctors Hospital and Medical Center (DH&MC). After diagnostic workup, Sofosbuvir/ribavirin for 24 weeks or sofosbuvir/ribavirin/pegylated interferon for 12 weeks were prescribed. Primary outcome was negative HCV RNA by PCR 12 weeks after treatment completion (SVR12). Chi square χ2 and student's t test were used to analyze data. RESULTS: Of 216 patients included, liver cirrhosis was present in 112 (51.9%) patients and 69(31.9%) were treatment experienced. Liver disease was decompensated in 37 (17.1%) patients. Of 206 patient who completed study protocol, 173(83.1%) achieved SVR12, 89.2% (25/28) with triple therapy and 82.2% (148/180) with sofosbuvir/ribavirin therapy. Treatment response was similar between treatment naïve 86.2% (119/138) and treatment experienced 79.4% (54/68) patents. (p value 0.19) SVR12 was inferior in cirrhosis patients 75.4% (80/106) as compared to those with no cirrhosis 93% (93/100) (p value < 0.000). It was even lesser in those with decompensated liver disease 68.8% (24/35) (p value < 0.000). CONCLUSION: Treatment outcome with sofosbuvir/ribavirin combination therapy in cirrhosis patients is suboptimal especially in those with decompensation as compared to patients without liver cirrhosis.

Perception of educational environment: Does it impact academic performance of medical students?

OBJECTIVE: To compare environmental perception as measured by the Dundee Ready Educational Environment Measure of students with high and low academic performance. METHODS: This cross-sectional analytical study was carried out at the Gujranwala Medical College, Gujranwala, Pakistan, and comprised medical students. Dundee Ready Educational Environment Measure questionnaire with 50 items was used to determine students' perception of the institutional environment. Academic performance was based on mean percentage of marks obtained in all professional examinations. High achievers with 70% or more marks were compared with low achievers with <70% marks for Dundee Ready Educational Environment Measure scores using unpaired Student's t-test. RESULTS: Of the 180 students, 153(85%) were included. Of them, 35(22.87%) were boys and 118(77.12%) girls. The overall mean Dundee Ready Educational Environment Measure score was 116.13±18.24. As for the subscales, the mean score for 'perceptions of learning' was 27.97±6.0, 25.76±4.6 for 'perceptions of teachers', 18.67±4.05 for 'academic self-perceptions', 27.76±6.03 for perceptions of atmosphere and 15.97±3.0 for social self-perceptions. The mean dream score was 108.51±17.54 among boys and 118.39±17.90 among girls. The mean score for perception of having successful learning strategies was 1.66±0.9and 2.18±0.9 among low and high achievers (p>0.05) and 1.71±0.98 and 2.18±1.1 for ability to memorise all that was needed (p>0.05). CONCLUSIONS: Environmental perception of the institution was more positive than negative and better performance in examinations was associated with better academic self-perception and social self-perception in students.

Hepatorenal syndrome:Response to terlipressin and albumin and its determinants.

OBJECTIVE: To determine the efficacy of terlipressin and albumin in improving renal functions in patient with hepatorenal syndrome (HRS) and to identify factors determinant of better response. METHODS: In this quasi experimental interventional study patients of liver cirrhosis and ascites with HRS type I were treated with intravenous albumin and incremental dosage of terlipressin based on response with maximum dose of 12mg/day. Decline of creatinine below 1.5mg/dl was defined as complete response. Factors predictive of response to therapy were determined via linear regression analysis. RESULTS: Twenty four patients were included with male to female ratio 3.8/1(19/5) and mean age 53.3 (±10.06). Complete response to terlipressin/albumin was seen in 14 (58.3%)patients, seven (29.2%) achieved partial response with > 25% creatinine decline while three (12.5%) had no response. Lower serum creatinine at diagnosis (P value 0.003), absence of hyperkalemia (p value 0.005) and absence of portal vein thrombosis (p value 0.05) are associated with response to treatment in HRS. Baseline serum creatinine (p value 0.003) was independent predictor of response to therapy in multivariate analysis. CONCLUSION: Terlipressin and albumin is an effective treatment for HRS type I. Patients with lower baseline serum creatinine are more likely to respond to this therapy.

Clinical characteristics, predictors, and survival among patients with hepatopulmonary syndrome.

BACKGROUND: Hepatopulmonary syndrome (HPS) is a complication of advanced liver disease. The impact of HPS on survival is not clearly understood. MATERIAL AND METHODS: A prospective study was carried out at Department of Medicine, King Edward Medical University Lahore from June 2011 to May 2012. Patients with cirrhosis of liver were evaluated for presence of HPS with arterial blood gas analysis and saline bubble echocardiography. All patients were followed for 6 months for complications and mortality. Cox regression analysis was done to evaluate role of HPS on patient survival. RESULTS: 110 patients were included in the study. Twenty-nine patients (26%) had HPS. MELD score was significantly higher (p < 0.01) in patients with HPS (18.93 ± 3.51) as compared to that in patients without HPS (13.52 ± 3.3). Twenty two (75.9%) patients of Child class C, 5 (17.2%) patients of Child class B and 2 (6.9%) patients of Child class A had HPS (P 0.03). The clinical variables associated with presence of HPS were spider nevi, digital clubbing, dyspnea, and platypnea. HPS significantly increased mortality during six month follow up period (HR: 2.47, 95% CI: 1.10- 5.55). Child-Pugh and MELD scores were also associated with increased mortality. HPS was no longer associated with mortality when adjustment was done for age, gender, Child-Pugh, and MELD scores (HR: 0.44, 95% CI: 0.14-1.41). Both the Child-Pugh and MELD scores remained significantly associated with mortality in the multivariate survival analysis. CONCLUSIONS: HPS indicates advanced liver disease. HPS does not affect mortality when adjusted for severity of cirrhosis.

COMPARISON OF SINGLE VERSES MULTIPLE SESSION BAND LIGATION FOR THE TREATMENT OF BLEEDING OESOPHAGEAL VARICES.

BACKGROUND: Cirrhosis of liver is the leading cause of portal hypertension in this part of the globe. Around thirty percent of the patient with portal hypertension develops complications. Oesophageal variceal bleeding is a serious complication of portal hypertension. Oesophageal variceal band ligation (EVBL) has become the standard of care for patients with bleeding oesophageal varices. Multiple sessions of band ligation are cumbersome and expensive. METHODS: Sixty patients with acute variceal bleed were enrolled in this randomized control trial. Patients were randomly assigned to multi-session (group A) or single session (group B) oesophageal variceal band ligation group. All. patients were followed for re-bleeding and mortality up to three months. RESULTS: Re-bleeding occurred (20%) in group A and (17%) in group B patients, respectively. Mortality was 10% in group A and 7% in group B patients. Variceal obliteration was better in group A 63% than group B 24% (p<0.05). CONCLUSION: Single session band ligation was comparable for rates of re-bleeding and mortality to multi-session band ligation.

Response Guided Interferon Therapy for Genotype 3 of Chronic Hepatitis C: Compliance and Outcome.

OBJECTIVE: To determine compliance and improvement in sustained viral response (SVR) by following response guided therapy (RGT) plan of interferon and ribavirin, for genotype 3 in chronic hepatitis C. METHODS: Patients with chronic hepatitis C genotype 3, who were eligible for interferon-ribavirin therapy and consented for RGT, were included. Those with no rapid viral response (RVR), having coarse echotexture of liver or undergoing re-treatment, were advised 48 week treatment whereas, rest had 24 week standard therapy. PCR for HCV RNA checked 6 months after discontinuing treatment, was the primary end point of study. RESULTS: Of 154 patients, included in the study with mean age of 39.9 (±10.84) and male to female ratio 1.4/1 (94/60), majority of patients, 136 (88.4%) were treatment naïve whereas, 18 (11.6%) were being retreated. On ultrasound, 63 (40.9%) patients had coarse liver and 33 (21.4%) had splenomegaly. RVR was achieved in 99 (64.3%) patients. Overall 66(42.8%) patients merited extended duration of therapy as per RGT plan but only 22 (33%) were compliant. Treatment related side effects were the dominant reason for declining RGT in 33 (75%) patients. SVR was noted in 111 (72.1%) patients. Those patients with extended therapy (RGT), had SVR 90.9% (20/22), although, better but statistically not significant than those who stopped therapy at 6 months 77.2% (34/44) (p value 0.11). CONCLUSION: Response guided therapy plan did not improve SVR to pegylatedinterferon and ribavirin therapy in patients with genotype 3 and it has low patient compliance due to treatment related side effects.

Flow control by circular cavities in lateral flow porous membranes.

This research explores the flow penetration in porous media by virtue of capillary action and geometric control of the liquid imbibition rate in microfluidic paper-based analytical devices (µPADs) having applications in food quality management, medical diagnostics, and environmental monitoring. We examine changes in flow resistance and membrane geometry, aiming to understand factors influencing capillary penetration rates for various practical applications. We conducted experiments and simulations using lateral porous membranes and altered the flow resistance by changing the liquids or the paper channel geometry by adding cavities. From experiments, it was revealed that by creating a circular cavity in the paper channel, the penetration rate was sufficiently altered. Moreover, increasing the cavity size and type of liquid (w.r.t. viscosity) also caused a decrease in the flow rate. Imbibition rates were also influenced by the position of the cavities in the paper channel. The maximum delay for water was almost 2 times with a 16 mm circular cavity located at 3 cm from strip bottom edge. Overall, we attained a maximum delay in the case of castor oil which was almost 85 times slower than water and 3.7 times slower than olive oil. A good agreement was observed with CFD analysis. We believe that this research would help in developing advance techniques to enhance the flow control strategies in µPADs and indicators.

Mortality in Patients of COVID-19 Infection: Biochemical Markers and its Cut-off Values for Predicting Outcome.

OBJECTIVE: To determine the efficacy and cut-off values of C-reactive protein (CRP), lactate dehydrogenase (LDH), serum ferritin, and D-dimer for predicting mortality of COVID-19 infection. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Medicine, Jinnah Hospital, Lahore from January to May 2021. METHODOLOGY: Serum CRP, LDH, ferritin, and D-dimer were measured in patients with moderate to severe COVID-19 infection at admission. Patients were followed for in-hospital disease outcome. ROC curve was used to determine area under curve (AUC) and cut-off values of biomarkers, followed by multi-variate analysis by logistic regression. RESULTS: In 386 patients, male to female ratio was 1.47/1 (230/156); and mean age was 54.03 ± 16.2 years. Disease was fatal in 135 (35%) patients. AUC for mortality was 0.730 for LDH, 0.737 for CRP, 0.747 for ferritin and 0.758 for D-dimer. Mortality was higher with LDH ≥400 U/ml, Odds Ratio (OR) 5.37 (95% CI 3.01-9.57: p = 0.001), CRP ≥30 ng/L, OR 4.30 (95% CI 2.11-8.74: p = <0.001), serum ferritin ≥200 ng/ml, OR 4.13 (95% CI 1.05-16.2: p = 0.02), and D-dimer ≥400 ng/ml, OR 2.72 (95% CI 1.06-7.01: p = 0.03) with 2 log likelihood of 131.54 for predicting disease outcome with 71.7% accuracy in multi-variate analysis. CONCLUSION: Elevated serum CRP, LDH, ferritin and D-dimer are associated with higher mortality in patients of COVID-19 infection. Serum CRP ≥30ng/ml, LDH ≥400 U/L, ferritin ≥200 ng/ml and D-dimer ≥400 ng/ml can predict fatal outcome in COVID-19 patients. Key Words: C-reactive protein (CRP), COVID-19 infection, D-dimer, Ferritin, Lactate dehydrogenase (LDH), Mortality.

Concomitant Therapy versus Triple Therapy: Efficacy in H. Pylori Eradication and Predictors of Treatment Failure.

OBJECTIVE: To compare concomitant therapy (CT) and triple therapy (TRT) for success in helicobacter (H.) pylori eradication and identify factors associated with treatment failure. STUDY DESIGN: Quasi-experimental comparative study. PLACE AND DURATION OF STUDY: Department of Medicine and Gastroenterology, Services Institute of Medical Sciences from December 2018 till July 2019. METHODOLOGY: Patients with H. pylori infection were randomly assigned to receive two weeks of either CT or TRT. H. pylori eradication was confirmed by repeat biopsy four weeks post-treatment. Treatment outcome was compared using Chi-square test, while binary logistic regression identified predictors of treatment failure. RESULTS: Two hundred and eleven patients with H. pylori infection, having mean age 40.15 (±13.04) and male/female ratio 0.9/1 (100/111) after randomisation, were treated with CT in 105 patients (49.8%) and TRT in 106 patients (50.2%). H. pylori was eradicated in 84.3% (150/178) patients with completed follow-up. H. pylori eradication was achieved in 91.9% of CT group as compared to 77.2% in TRT group (p = 0.007, OR 3.38: 95% CI 1.3-8.3). Age ≥40 years (p = 0.02), symptoms duration >6 months (p = 0.001), and prior proton pump inhibitor use for >4 weeks (p = 0.01), were identified as independent predictors of treatment failure. CONCLUSION: CT achieves better H. pylori eradication than TRT. Older age, longer duration of illness, and previous proton pump inhibitor use were independent predictors of H. pylori treatment failure. Key Words: Concomitant therapy, Eradication, H. pylori, Triple therapy.

Response to combination therapy in hepatitis virus C genotype 2 and 3.

OBJECTIVE: To determine Sustained Viral Response (SVR) to Interferon (IFN) and ribavirin therapy in chronic hepatitis C patients of genotype 2 and 3. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: The Garden Clinic, Lahore, from June 1997 to August 2007. METHODOLOGY: All patients of both genotypes 2 and 3 receiving combination therapy were included. Standard IFN with ribavirin was started in 648 (90%) patients of genotype 2 and 3, whereas 73 (10%), all genotype 3 received pegylated IFN. Outcome parameters including End of Treatment Response (ETR) [negative PCR at the end of therapy], sustained viral response (SVR) [negative PCR both at the end of treatment and 6 months later] and relapse (PCR negative at the end of treatment but positive 6 months later) were determined. Data were analyzed using student's t-test and Chi-square. RESULTS: A total of 721 patients of genotype 2 and 3 were evaluated with male to female ratio of 1.78:1 and mean age 39.8 +/- 9.17 years. Twenty six (3.6%) patients were of genotype 2, while 695 (96.4%) had genotype 3. Six hundred and ten patients (84.6%) completed therapy, as per protocol, whereas 58 (8.04%) had therapy beyond 6 months. SVR was 72.7% with better outcome in genotype 2 (80%) than in 3 (72%) and in those on pegylated IFN and ribavirin (85%) than patients on standard IFN-based therapy (71.1%). Relapse was seen in 116 (16.1%) and 80 (11.1%) were non-responders. Patients with baseline ALT 2-4 x UNL had better SVR than patients with ALT < 2x UNL (p-value 0.01). CONCLUSION: Genotype 3 was the predominant type of virus in the studied patients. SVR patients was 72.7%. Outcome was better with high baseline ALT and pegylated interferon combination therapy.

Propranolol, isosorbide mononitrate and endoscopic band ligation - alone or in varying combinations for the prevention of esophageal variceal rebleeding.

OBJECTIVE: To compare the efficacy of propranolol, propranolol with nitrate, band ligation, and band ligation with propranolol and nitrate for the prevention of esophageal variceal rebleeding. STUDY DESIGN: A prospective randomized trial. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology, Sheikh Zayed Hospital, Lahore, from November 2003 to July 2005. METHODOLOGY: One hundred and sixty cirrhotic patients with esophageal variceal bleeding were randomized to four treatment groups (propranolol, propranolol plus isosorbide mononitrate, band ligation, band ligation plus propranolol and nitrate) with 40 patients in each group. Patients were followed for 6 months after the enrolment of last patient. Primary end points were recurrence of esophageal variceal bleeding and death. Treatment complications were noted. RESULTS: Four treatment groups were comparable regarding baseline characteristics. Esophageal variceal rebleeding occurred in 22% patients in band ligation plus drugs group, 26% patients in drug combination group, 31% patients in banding group and 38% patients in propranolol group (p=0.41). Difference in mortality rates was also not significant. CONCLUSION: There was no significant difference between treatment groups in prevention of esophageal variceal rebleeding.

Interferon-ribavirin treatment in chronic hepatitis C--the less talked about aspects.

BACKGROUND: Combination therapy with interferon and ribavirin has become the standard of care in the treatment of Chronic Hepatitis C (CHC) infected patients. Treatment response, however, is not 100% and is accompanied with side effects faced by the patient as well as observed in haematologic indices. Studies are focusing on daily or high-dose induction therapy with interferon, the titration of interferon dosing to initial viral load, higher doses of interferon throughout treatment, and adjustment of interferon dosing to the viral responses. The safety and efficacy of these approaches have not been sufficiently established. Objectives were to see the response of 2 different dosage regimens, effects and side effects and to assess the efficacy and side effects of 2 treatment regimens of Interferon and Ribavirin in CHC. METHODS: A total of 32 patients with CHC at Department of Gastroenterology and Hepatology, Shaikh Zayed Postgraduate Medical Institute Lahore from June 2001 to February 2003 were included in the study and were divided into two groups for treatment. Group A (14 patients) received 5 MU of injection Interferon alpha 2 b S/C daily for 2 weeks followed by 3 MU thrice weekly for the next 22 weeks. Group B (18 patients) received injection interferon alpha 2 b 3 MU S/C thrice weekly for 24 weeks. Ribavirin therapy was started at 1200 mg daily in 3 divided doses and later modified according to side effects. Patients were evaluated at 2, 4, 8, 12, 16, 20 and 24 weeks during the therapy and then 24 weeks after the completion of treatment. RESULTS: Out of 32 adult patients included in the study, 18 were males and 14 females. Haemoglobin was more than 12 gm/dl in females and more than 13 gm/dl in males, WBC count was more than 3.0 x 10(9)/L and Platelet count was more than 100 x 10(9)/L. Twenty patients completed 6 months combination treatment, 16 reported with their end of treatment HCV RNA PCR results, 8 from each group. Twelve patients were lost to follow up. End of treatment response (ETR) in group A was 88% and 62.5% in group B. Sustained virological response in group-A was 5/8 (62.5%) and 4/5 (50%) in group-B. The frequency and severity of flu like symptoms like fever, body aches, skin rash, hair loss, cough and psychiatric symptoms were more in group A than in group B. There was no significant difference in the 2 groups for haematologic side effects. CONCLUSIONS: Treatment with 5 MU interferon daily for initial two weeks followed by 3 MU thrice weekly for 22 weeks is more effective than 3 MU thrice weekly for 24 weeks but with more side effects.