Clinical practice guidelines on the management of variceal bleeding

Gastroesophageal variceal bleeding occurs in 30 - 50% of patients of liver cirrhosis with portal hypertension, with 20-70% mortality in one year. Therefore, it is essential to screen these patients for varices and prevent first episode of bleeding by treating them with β-blockers or endoscopic variceal band ligation. Ideally, the patients with variceal bleeding should be treated in a unit where the personnel are familiar with the management of such patients and where routine therapeutic interventions can be undertaken. Proper management of such patients include: initial assessment, resuscitation, blood volume replacement, vasoactive agents, prevention of associated complications such as bacterial infections, hepatic encephalopathy, coagulopathy and thrombocytopenia, and specific therapy. Rebleeding occurs in about 60% patients within 2 years of their recovery from first variceal bleeding episode, with 33% mortality. Therefore, it is mandatory that all such patients must be started on combination of β-blockers and band ligation to prevent recurrence of bleeding. Patients who required shunt surgery/TIPSS to control the acute episode do not require further preventive measures. These clinical practice guidelines (CPGs) have been jointly developed by Pakistan Society of Hepatology (PSH) and Pakistan Society of Study of Liver Diseases (PSSLD)

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial

12 hours post admission troponin T levels are consistent with the infarct size in patients with ST segment elevation myocardial infarction.

Background: Current guidelines recommend the use of Troponin T as biomarker of choice for the diagnosis of AMI. Data revealing relationship between TNT and infarct size in patients with STEMI are limited. Objective: To evaluate the relationship between cardiac TnT levels with infarct size measured by ECG and Echo in patients with STEMI. Methods: It is a prospective analysis of 116 consecutive patients with STEMI who were brought to the CCU. Their ECGs were recorded at the time of admission and Troponin T levels were measured at 12 hours of their presentation to the hospital. Their Echo was done 48 hours post admission. The relationship between infarct size and TnT levels was studied. Results: A total of 116 consecutive patients (age, 58 ± 17 years; 18% women) with STEMI were studied. The areas of infarction determined by ECG Vs Echo were IWMI in 37% Vs 36%, ASMI in 19% Vs 20%, ALMI in 18% & Extensive anterior in 13% Vs ALMI 36%, PWMI in 4% Vs IPMI in 5% respectively and 2% were global in location on ECG. Regarding levels of TnT, 48% had high positive i,e \u3e2.0ng/ml, 52% had quantitative readings (20% had 1.51-2.0ng/ml, 18% had 1.0-1.50ng/ml and 14% had 0.51-1.0ng/ml). None of them had low positive value i,e \u3c0.1ng/ml. The mean value of Troponin T in PWMI is 1.11ng/ml, IWMI is 1.23ng/ml, LWMI is 1.33ng/ml, ASMI is 1.62ng/ml and for ALMI, Extensive MI and global MI is \u3e2.0ng/ml Conclusion: TnT is a reliable and cost effective tool at 12 hours post STEMI to aid in quantification of infarct size measured by ECG and Echo. It can also gives us a clue of bedside evaluation of post MI LV function which can later be revealed by much expensive cardiac MRI and SPECT Myocardial perfusion imaging scans. Keywords: ASMI- Anteroseptal Myocardial Infarction, ALMI- Anterolateral Myocardial Infarction, IWMI-Inferior Myocardial Infarction, IPMI- Infero-posterior M

Hypertension in alone and in combination with other stroke risk factors is associated with increased incidence of in-hospital mortality

Objective: To determine the outcome of hypertension alone and in combination with additional risk factors in a hospitalized stroke patient. Material & Methods: A retrospective analysis of 87 stroke patients who presented to Medical Unit-I of Lahore General Hospital, Lahore from January- March 2013. These patients were enrolled and the data was analyzed on SPSS version19 on which relevant details were noted and descriptive statistics like frequency mean and percentages were calculated. Overall frequency of isolated or multiple risk factors like Hypertension, Diabetes Mellitus, Smoking, Previous Stroke, and Ischemic Heart Disease, Valvular Heart Disease contributing to mortality was determined by age, gender and CT scan findings. Results: Out of 87 patients, 65.5%(n=57) were discharged healthy and 34.5%(n=30) died during their hospital stay. The mean age of the group died was 62.4 years with a range of 28-90 years having 50%(n=15) males and 50%(n=15) females. Out of 30 deaths 40% (n=12) were having multiple co-morbidities like HTN, DM and IHD, 20%(n=6) were having HTN, DM and Smoking, 16.7%(n=5) with HTN and DM, 16.7%(n=5) with HTN and smoking and only 6.7%(n=2) with HTN. Of these patients, Intracerebral Hemorrhage 56.7%(n=17) and Cerebral Infarct 43.3%(n=13) were the CT scan findings. The patients reaching the hospital for more than 24 hours of symptoms onset were 62% (n=19), between 18-24 hours were 18%(n=5), between 12-18 hours were 10%(n=3), between 3-12 hours were 7%(n=2) and less than 3 hours were 3%(n=1) Conclusion: Majority of old aged patients with multiple risk factors and arriving late to the tertiary care centre had high risk of In-Hospital mortality with Hypertension in alone as well as with other co-morbidities is the leading risk factor in stroke related deaths. Keywords: HTN- Hypertension, IHD- Ischemic Heart Disease, DM- Diabetes Melitus, ICH- Intracerebral Hemorrhag

Correlation of Gastroesophageal Reflux Disease Symptoms with Body Mass Index

<b>Background/Aim:</b> To find a correlation between symptoms of gastroesophageal reflux disease (GERD) and body mass index (BMI). <b> Materials and Methods:</b> A total of 603 patients who presented at Ghurki Trust Teaching Hospital and Surgimed Hospital Lahore with symptoms of GERD, were included and interviewed according to a validated GERD questionnaire. It included questions regarding GERD symptoms and their severity/frequency. Symptoms were defined: "frequent" if occurred daily; "occasional," if weekly; and "severe," if they were sufficiently intense to change lifestyle. Height and weight were also recorded and their BMI calculated. We used logistic regression analysis was performed to assess the association between the presence of each specific GI symptom and BMI. The odds ratios (OR) for a given specific symptom and 95&#x0025; confidence intervals (CI) were computed from the coefficients in logistic regression models. <b> Results:</b> The prevalence of obesity was 25.3&#x0025;, while 38.1&#x0025; were overweight. There was an increase in reporting of GI symptoms in obese individuals compared to those with normal BMI who were taken as reference group. Frequent nausea, vomiting, early satiety, epigastric pain, heart burn, regurgitation, postprandial fullness, and dysphagia were present in 10.4, 5.6, 8.9, 17.2, 10.2, 22.1, 23.5, and 21.7&#x0025;, respectively, of obese subjects compared to 7.9, 1.2, 6.5, 3.5, 4.4, 11.4, 17.1, and 16.6&#x0025; of normal BMI subjects. BMI showed a positive relationship with frequent vomiting (<i> P</i> = 0.02), epigastric pain (<i> P</i> = 0.03), regurgitation of food (<i> P</i> = 0.02), heart burn (<i> P</i> = 0.002), and postprandial fullness (0.01). <b> Conclusion:</b> The majority of GERD symptoms have a greater likelihood of occurring with increasing BMI

Dengue virus serotype 2 (DEN-2): the causative agent of 2011-Dengue epidemic in Pakistan

Abstract Introduction: Dengue virus (DENV) is an arthropod-borne virus that belonged to the Flaviviridae viral family. Four known serotypes DEN-1 through DEN-4 do exist and circulate in diverse geographical regions of the world causing epidemics. The management of dengue patients, and especially dengue hemorrhagic fever (DHF)/Dengue shock syndrome (DSS) cases, has been a challenge in Pakistan now days. Method: We have carried out a comprehensive study of the current outbreaks of dengue virus infection on molecular level with the aim to find out the common serotype/s of DENV responsible for this outbreak using PCR, real-time PCR and nucleotide sequencing targeting the C-prM gene junction. For this purpose total 1129 serum samples received between from start of August till end of November 2011 from all the major hospitals of Lahore, Punjab at Division of Molecular Virology, National Centre of Excellence in Molecular Biology (CEMB) University of the Punjab Lahore were utilized for the DENV diagnosis and serotypes/genotypes analysis. Results: Male female ratio of the suspected dengue patients was 2.4:1. Their mean age were 31.14 + 16.03 (SD) years ranging from 9 months to 90 years. Out of these 1129 serum samples, total 930 (82.37%) were found infected with DENV. Out of the 930 DENV RNA positive samples, 893 (96.02%) had DEN-2 Am. J. Biomed. Sci. 2012, 4(4), 307-315; doi: 10.5099/aj120400307 © 2012 by NWPII. All rights reserved. 308 and 37 (3.97%) sample had concurrent infection with serotypes 2 and 3. Conclusion: Based on the results of this study we conclude that DEN-2 is the responsible genotype for the current dengue epidemic that started from the beginning of year 2011 and is continuing till now. The additional serotype detected in the current study was serotype 3 that remained in very low frequency in Pakistan for last several decades

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

BackgroundTranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding.MethodsWe did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124.FindingsBetween July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98).InterpretationWe found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial.</div