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\u27s 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\u27s 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

Association of awareness about hepatitis C infection with patterns of health seeking behavior among hepatitis C patients in Karachi, Pakistan

Background: Hepatitis C infection is one of the significant causes of morbidity and mortality throughout the world. In Pakistan, hepatitis C infection rate is 4.8%, which is the second highest prevalence rate among all developing countries. This study aimed to identify the association between awareness about hepatitis C infection and pattern of health seeking behavior among patients living with hepatitis C in Karachi, Pakistan. Methods: A descriptive, cross-sectional study was conducted among 250 hepatitis C patients who were recruited from the Aga Khan University Hospital and the Civil Hospital Karachi, Pakistan between March and May 2013. Data were collected through a modified questionnaire on ‘awareness about hepatitis C and patterns of health seeking behavior among hepatitis C patients’. Results: We did not find any association between participants’ awareness of hepatitis C infection and their primary contact with a health care provider. However, this study found that only half of the study participants (52%) had correct knowledge of hepatitisC. The patterns of health seeking behavior showed that a majority of the study participants approached a medical doctor (n=368), followed by spiritual healers (n=206), and a few participants approached traditional healers (n=39) and homeopaths (n=11). Conclusions: The study did not find any association between the patients’ level of awareness about hepatitis C infection and their primary contact with health careproviders. However, it has been found that patterns of health seeking behavior are strongly related to the patients’ cultural practices and beliefs, which affect their choiceof health care providers. This study has provided a basis for planning interventional studies aimed at improving patients’ level of awareness about hepatitis C and their health seeking behavior

Viral hepatitis - The road traveled and the journey remaining

Hepatitis is defined as inflammation of the liver and is commonly due to infection with The hepatotropic viruses - hepatitis A, B, C, D and E. Hepatitis carries one of the highest disease burdens globally and has caused significant morbidity and mortality among different patient populations. Clinical presentation varies from asymptomatic or acute flu-like illness to acute liver failure or chronic liver disease, characterized by jaundice, hepatomegaly and ascites among many other signs. Eventually, this can lead to fibrosis (cirrhosis) of the liver parenchyma and carries a risk of development into hepatocellular carcinoma. Hepatitis B and C are most notorious for causing liver cirrhosis; in 2019, an estimated 296 million people worldwide had chronic hepatitis B infection and 58 million are currently estimated to have chronic hepatitis C, with 1.5 million new infections of both hepatitis B and C, occurring annually. With the help of latest serological biomarkers and viral nucleic acid amplification tests, it has become rather simple to efficiently screen, diagnose and monitor patients with hepatitis, and to commence with appropriate antiviral treatment. More importantly, the development of vaccinations against some of these viruses has greatly helped to curb the infection rates. Whilst there has been exceptional progress over the years in the management of viral hepatitis, many hurdles still remain which must be addressed in order to proceed towards a hepatitis-free world. This review will shed light on the origin and discovery of the hepatitis viruses, the global epidemiology and clinical symptoms, diagnostic modalities, currently available treatment options, the importance of prevention, and the journey needed to move forward towards the eradication of its global disease burden

Perception and knowledge about dietary intake in patients with liver cirrhosis and its relationship with the level of education

Objective: To determine patients perception and knowledge regarding diet in cirrhosis and its relationship with the level of patients education. Study Design: Cross-sectional observational study. Place and Duration of Study: This study was conducted at Gastroenterology Outpatient Clinics at the Aga Khan University Hospital, Karachi, the Aga Khan Health Services, Malir, Karachi and Hamdard University, Karachi, from January to December 2010. Methodology: Consecutive adult patients with compensated cirrhosis were enrolled. Demographic data, level of education, type and reason of food restriction as well as the source of dietary information was asked. Baseline laboratory test were performed, and nutritional status was assessed by BMI normogram. Results: Ninety patients, 58% male were enrolled. Mean age of the patient was 49 11 years. Overall 73% of the patients were restricting fat, meat, fish and eggs in their diet; 53% were in uneducated group and 47% were in educated group (CI, 0.24-1.62, p-0.34). Twenty two patients (62.8%) in uneducated and 21 in educated group (68%) were restricting diet on the advice of their doctors, whereas 13 in uneducated group (37%) and 11 in educated group (32%) believed these dietary components to be harmful for the liver. Thirty two of uneducated patient (71.1%) and 28 of educated patients (62.2%) believed that vegetables, fruits and sugarcane had a beneficial effect on the liver. Main source of dietary information to the patients was the doctor. On sub-group analysis those who restricted diet irrespective of their educational level, had more patients with BMI less than 18.5 kg/m2, (CI 0.01-0.94, p-0.001), haemoglobin less than 12 g/dl (CI 0- 0.03, p-0.001) and serum albumin less than 3 g/dl (CI 0.1- 03, p-0.001). Conclusion: Both educated and uneducated classes of the patients have improper knowledge and perception of diet in cirrhosis. Patients with cirrhosis who restricted diet, had relatively low BMI, haemoglobin and albumin as compared to those who did not restrict. Main source of dietary information to cirrhotic patients were health care personnels

The patterns of health seeking behavior among patients with hepatitis C in Karachi, Pakistan

Background: The study aimed to assess the patterns of health seeking behavior and the level satisfaction with the health care providers among hepatitis C patients in Karachi, Pakistan. Methodology: A descriptive, cross-sectional study was conducted among 250 hepatitis C patients, who were recruited from the Aga Khan University Hospital and the Civil Hospital Karachi, Pakistan, between March and May 2013. Results: The patterns of health seeking behavior showed that a majority of the study participants approached a medical doctor (n=359), followed by spiritual healers (n=103), and a few participants approached traditional healers (n=38) and homeopaths (n=11). The pattern of health seeking behavior also revealed that the participants were taking treatment from more than one health care provider at the same time. Participants who visited doctors had effective treatment outcomes and they were satisfied with their doctors. However, those participants who visited homeopaths, traditional healers and spiritual healers had ineffective treatment outcomes and they were not satisfied with these health care providers. Conclusion: The patterns of health seeking behavior are strongly related to the patients\u27 cultural practices and beliefs, which affect their choice of health care providers. This study has provided a basis for planning interventional studies aimed at improving patients\u27 health seeking behaviors

Nutritional status in patients with Hepatitis C

OBJECTIVE: To assess the nutritional status via the SGA (subjective global assessment) screening tool of patients at all stages of hepatitis C virus (HCV) liver disease. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Out-patient Clinics of the Aga Khan University Hospital, Karachi, conducted from October 2009 to January 2011. METHODOLOGY: Patients with hepatitis C virus infection and their HCV-negative attendants were enrolled from the outpatient clinics, and categorized into 4 groups of 100 patients each: healthy controls (HC), those with chronic hepatitis C infection (CHC), compensated cirrhotics (CC) and decompensated cirrhotics (DC). The validated subjective global assessment (SGA) tool was used to assess nutritional status. RESULTS: A total of 400 patients were enrolled. Most of the patients in the HC group were class \u27A\u27 (best nutritional status). In contrast, the majority (64%) in the DC group were in the class \u27C\u27 (worst status). The compensated cirrhosis (CC) group showed that 90% of patients were malnourished, while 98% of all patients were malnourished in the DC group, predominantly class \u27C\u27. Most importantly, 14% of patients with chronic hepatitis C (CHC) also scored a \u27B\u27 on the SGA; which when compared to HC was statistically significant (p=0.005). As the groups progressed in their disease from CHC to DC, the transition in nutritional status from \u27A\u27 to \u27C\u27 between groups was statistically significant. CONCLUSION: Malnutrition occurs early in the course of HCV, and progresses relentlessly throughout the spectrum of HCVdisease

Banti\u27s syndrome: case report and review of literature.

In 1898 Banti described a disorder characterized by splenomegaly and hypersplenism, resulting in portal hypertension and anemia in the absence of hematological disease. 1 Banti\u27s syndrome is also known as non-cirrhotic portal hypertension (NCPH) in India and Idiopathic Portal Hypertension (IPH) in Japan. Hepatoportal sclerosis seems to be its counterpart in the United States. 2,3 Banti\u27s syndrome is a disorder of unknown etiology, clinically characterized by portal hypertension (varices and portosystemic collateral vessels), splenomegaly, and anemia (hypersplenism). 3 It has been reported from Indian subcontinent. 4-6 In a Pakistani case series of portal hypertension, 18 out of 37 patients were found to have IPH as the etiology. 6 We report a case of Banti\u27s syndrome in an 20-year old girl presenting to us with anemia and splenomegaly

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication