Beta-blocker plus nitrates for secondary prevention of variceal bleeding

This article does not have an abstract

Characterization of naturally occurring and lamivudine-induced surface gene mutants of hepatitis B virus in patients with chronic hepatitis B in India

Background: Besides vaccine escape or immune escape hepatitis B virus (HBV) mutants, naturally occurring and drug-induced mutations have been reported in the surface gene (S-gene) of HBV. Aim: To investigate the frequency and profile of naturally occurring S-gene mutants and the influence of long-term lamivudine therapy in patients with chronic hepatitis B (CHB). Materials and Methods: 57 patients with histologically proven CHB, on lamivudine 100 mg/day for more than 24 months, were included. Viral DNA was extracted at baseline and from on-therapy serum samples. The region encoding the complete major hydrophilic region (MHR) and flanking regions (nucleotides 425-840) of major S-gene that overlapped with the viral polymerase was PCR amplified and sequenced. End-of-therapy response (ETR) was assessed. Results: Two (3.5%) patients had naturally occurring HBV mutants, sP127S and sS143L seen in the 'a' determinant of the S-gene. Following lamivudine therapy, 14 of 57 (24.5%) patients developed 16 types of S-gene mutations (sP120S, sA128V, sS143L, sW182St., sT189I, sV190A, sS193L, sI195M, sW196L, sW196St., sS207R, sI208T, sS210E, sF219S, sF220L and sC221G). Thirteen (81.2%) of these mutations emerged downstream to the MHR. Nine of 16 types of S-gene mutations observed with lamivudine therapy were also associated with the corresponding changes in the polymerase gene. Baseline viral DNA was significantly higher (2,093 vs. 336 pg/ml; p < 0.05) among patients developing S-gene mutants and the ETR in them was significantly lower [3 of 16 (18.8%) vs. 17 of 41 (41.5%); p < 0.05]. Conclusions: Naturally occurring S-gene mutations are uncommon and are restricted to the 'a' determinant region. Mutations develop in about a quarter of the patients on lamivudine therapy, mostly downstream to the MHR. They may contribute to non-response to the antiviral therapy

COVID-19 Rapid Antigen Test: Role in Screening Prior to Gastrointestinal Endoscopy

Background/Aims The severe acute respiratory syndrome coronavirus 2 pandemic has affected the gastrointestinal (GI) endoscopy units globally owing to the risk of transmission. We present our data on the use of rapid antigen test (RAT) as a screening tool prior to endoscopy to prevent the transmission of coronavirus disease (COVID-19). Methods This study was a retrospective analysis of patients who underwent any GI endoscopic procedure from July 2020 to October 2020 at a tertiary referral center in New Delhi, India. All patients underwent screening for COVID-19 using RAT, and endoscopy was performed only when the RAT was negative. The data are presented as numbers and percentages. Results A total of 3,002 endoscopic procedures were performed during the study period. Only one endoscopic procedure was performed in a COVID-19 positive patient. A total of 53 healthcare workers were involved in conducting these procedures. Only 2 healthcare workers (3.8%) were diagnosed COVID-19 positive, presumably due to community-acquired infection, during this period. Conclusions The COVID-19 RAT is easily usable as a simple screening tool prior to GI endoscopy during the COVID-19 pandemic

APASL consensus statements and recommendations for hepatitis C prevention, epidemiology, and laboratory testing

The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on “APASL consensus statements and recommendations for management of hepatitis C” in March 2015 to revise the “APASL consensus statements and management algorithms for hepatitis C virus infection” (Hepatol Int 6:409–435, 2012). The working party consisted of expert hepatologists from the Asian–Pacific region gathered at the Istanbul Congress Center, Istanbul, Turkey on 13 March 2015. New data were presented, discussed, and debated during the course of drafting a revision. Participants of the consensus meeting assessed the quality of the cited studies. The finalized recommendations for hepatitis C prevention, epidemiology, and laboratory testing are presented in this review

Predictors of nonresponse to lactulose for minimal hepatic encephalopathy in patients with cirrhosis

Background/Aims: Minimal hepatic encephalopathy (MHE) impairs health-related quality of life and predicts overt hepatic encephalopathy (HE) in cirrhotic patients. Lactulose is effective in the treatment of MHE. However, not all patients respond to lactulose. We evaluated predictors of nonresponse to lactulose. Patients and methods: Consecutive 110 cirrhotic patients without HE were evaluated for MHE by psychometry, P300 auditory event-related potential (P300ERP), venous ammonia and critical flicker frequency (CFF). MHE was diagnosed by abnormal psychometry and P300ERP (>2 SD). MHE patients were treated with lactulose for 1 month. Response was defined by normalization of the abnormal test parameters (both psychometric tests and P300ERP). Results: Sixty patients (54.5%) were diagnosed as having MHE: 17/39 (44%) in Child's A, 21/42 (50%) Child's B and 22/29 (76%) in Child's C. There was a significant difference between Child's C's vs Child's A's and B's (P<0.05). Abnormal psychometric tests and abnormal P300ERP were seen in 74 (67%) and 74 (67%) patients respectively. Of 60 patients with MHE, after treatment, psychometry remained abnormal in 22 (36.6%) and P300ERP in 21 (35%) patients. CFF was<38 Hz in 34 (57%) and 11 (18%) patients, respectively, before and after treatment in MHE patients. There was a significant difference between the baseline serum sodium level (134.7±2.6 vs 131.1±2.2 mmol/L, P=0.001) and the venous ammonia level (76.6±20.7 vs 113.4±22.8 μmol/L, P=0.001) between responders vs nonresponders. Receiver operating characteristic analysis was performed to identify the cutoff for venous ammonia [cutoff 93.5 mmol/L, area under the curve (AUC) 0.892 (0.814-0.970)] and for the serum sodium level [cutoff 132.5 mmol/L, AUC 0.874 (0.779-0.998)]. Taking a cutoff of 93.5 mmol/L for ammonia patient had a sensitivity of 88.5% and a specificity of 79.4%, respectively, and a cutoff of 132.5 mmol/L for serum sodium patient had a sensitivity of 76.5% and a specificity of 88.5% for nonresponse to lactulose. On univariate analysis and multivariate analysis, serum sodium and venous ammonia were the only two parameters associated with nonresponse to lactulose. Conclusion: The prevalence of MHE was 55% and MHE improved in 57% patients with lactulose. Baseline low serum sodium and high venous ammonia were highly predictive of nonresponse to lactulose therapy

Prevalence of abnormal psychometric tests and critical flicker frequency after clinical recovery of overt hepatic encephalopathy

Background: Abnormal psychometric tests are common in cirrhotic patients without overt encephalopathy. It may seriously impair the patient′s daily functioning and quality of life. Prevalence of abnormal psychometric tests after the clinical recovery of overt encephalopathy has not been studied. Materials and Methods: Consecutive 80 patients (age, 44.5±9.8yr; M: F 66:14) with hepatic encephalopathy (HE) who recovered and met inclusion criteria were evaluated for abnormal psychometric tests ( > 2 SD) and critical flicker frequency (CFF < 38Hz). All patients underwent number connection tests-A and B, figure connection tests -A and B (if illiterate), digit symbol test, object assembly test, CFF and arterial ammonia after one month of clinical recovery of HE. Results: Prevalence of abnormal psychometric tests (> 2SD) was seen in 58 (72.5%) patients. [33 (66%) of 50 patients on lactulose and 25 (83%) of 30 patients not on lactulose, P = 0.12]. Arterial ammonia was significantly higher in patients with abnormal psychometric tests compared to patients without it (86.3±22.2 vs 50.4±11.5 mmol/l, P = 0.01). CFF was < 38Hz in 50 patients (62.5%). Patients with ≥2 abnormal psychometric tests had CFF significantly lower than with normal psychometric tests (35.6±2.3 vs 40.7±2.4 Hz, P = 0.001). CFF sensitivity and specificity in diagnosing ≥2 abnormal psychometric tests was 82 and 83% respectively. CFF was significantly correlated with psychometric tests [NCT-A (-0.672, P = 0.001) and B (-0.743, P = 0.001), digit symbol test (-0.533, P = 0.001), object assembly test (-0.659, P =0.001) and arterial ammonia level (-0.385, P = 0.02)]. Conclusion: About 73% of patients who recovered from HE had abnormal psychometric tests ( > 2SD). CFF is a simple reliable tool to find out the presence of abnormal tests

Natural history of minimal hepatic encephalopathy in patients with extrahepatic portal vein obstruction

Objectives: Minimal hepatic encephalopathy (MHE) leads to deterioration in patient quality of life and could be a marker for future episodes of clinical hepatic encephalopathy (HE) in liver cirrhosis. Whether MHE predicts HE in extrahepatic portal vein obstruction (EHPVO) is not known. We studied the incidence of overt HE in EHPVO patients with MHE. Methods: Consecutive patients (from October 2006 to July 2007) with a diagnosis of EHPVO were followed up at 3-month intervals. MHE was diagnosed by abnormal psychometry (&gt;2 s.d.) and/or P300 auditory event-related potential (P300 ERP) (&gt;2.5 s.d.), and HE was diagnosed as per West-Heaven criteria. Critical flicker frequency (CFF) was also measured at baseline and after 1 year. Results: Thirty-two EHPVO patients (age, 23.210.8 years; M/F 22:10) were followed up for 1 year. Of 32 patients, P300 ERP was prolonged in 8 (25%) (371.813.9 ms), 9 (28%) had abnormal psychometric tests, and CFF was &lt;38 Hz in 8 (25%) patients after a follow-up of 13.52.4 months. Of 12 patients who had MHE at baseline, 9 (75%) patients continued to have MHE, and in 3 (25%) patients it disappeared. One (5%) of the remaining 20 patients developed MHE during the follow-up. Venous ammonia level was higher in patients with MHE (79.717.0 mol/l; range 33-124) compared with patients without MHE (46.619.8 mol/l; range 24-78, P&lt;0.001) on follow-up. Similarly, patients who had spontaneous shunts (n=10) had significantly higher venous ammonia levels (82.420.3 vs. 47.116.7 mol/l; P=0.001) than those who had no shunt (n=22). Neither patients who had MHE nor those who did not have MHE at baseline developed HE. Conclusions: Seventy-five percent of extrahepatic portal vein obstruction patients with MHE continued to have MHE, and new-onset MHE developed in 5% over 1 year. In this small sample, patients with EHPVO and MHE did not progress to overt encephalopathy within the relatively short time frame studied

Secondary prophylaxis of hepatic encephalopathy: an open-label randomized controlled trial of lactulose versus placebo

Background &amp; Aims: Hepatic encephalopathy (HE) is associated with a poor prognosis. Lactulose is used for the treatment of HE. There is no study on the prevention of recurrence of HE using lactulose. Methods: Consecutive cirrhotic patients who recovered from HE were randomized to receive lactulose (HE-L group) or placebo (HE-NL group). All patients were assessed by psychometry (number connection test [NCT-A and B], figure connection test if illiterate [FCT-A and B], digit symbol test [DST], and object assembly test [OAT]), critical flicker frequency test, and blood ammonia at inclusion. Primary end point was development of overt HE. Results: Of 300 patients with HE who recovered, 140 (46.6%) met the inclusion criteria and were included. There was a high prevalence of abnormal psychometry test results (NCT-A, 67.5%; NCT-B, 62.5%; DST, 70%; and OAT, 80%), and FCT-A and B were abnormal in 10 of 14 patients. Critical flicker frequency was &lt;38 Hz in 77 patients (55%). Twelve (19.6%) of 61 patients in the HE-L group and 30 (46.8%) of 64 in the HE-NL group (P = .001) developed HE over a median follow-up of 14 months (range, 1-20 months). Readmission rate due to causes other than HE (HE-L vs HE-NL, 9:6; P = NS) and deaths (HE-L vs HE-NL, 5:11; P = .18) in 2 groups were similar. Recurrence of overt HE was significantly associated with 2 or more abnormal psychometric tests after the recovery of an episode of HE (r = 0.369, P = .02). Conclusions: Lactulose is effective for prevention of recurrence of HE in patients with cirrhosis