Prevalence of Acanthosis Nigricans in an urban population in Sri Lanka and its utility to detect metabolic syndrome

<p>Abstract</p> <p>Background</p> <p>Insulin resistance (IR) plays a major role in the pathogenesis of metabolic syndrome. Acanthosis nigricans (AN) is an easily detectable skin condition that is strongly associated with IR. The aims of this study were, firstly, to investigate the prevalence of AN among adults in an urban Sri Lankan community and secondly, to describe its utility to detect metabolic syndrome.</p> <p>Findings</p> <p>In a community based investigation, 35-64 year adults who were selected using stratified random sampling, underwent interview, clinical examination, liver ultrasound scanning, and biochemical and serological tests. Metabolic syndrome was diagnosed on revised ATP III criteria for Asian populations. AN was identified by the presence of dark, thick, velvety skin in the neck.</p> <p>2957 subjects were included in this analysis. The prevalence of AN, metabolic syndrome and type 2 diabetes mellitus were 17.4%, 34.8% and 19.6%, respectively. There was a strong association between AN and metabolic syndrome. The sensitivity, specificity, positive predictive value and negative predictive value of AN to detect metabolic syndrome were 28.2%, 89.0%, 45.9% and 79.0% for males, and 29.2%, 88.4%, 65.6% and 62.3% for females, respectively.</p> <p>Conclusions</p> <p>AN was common in our study population, and although it did not have a high enough sensitivity to be utilized as a screening test for metabolic syndrome, the presence of AN strongly predicts metabolic syndrome.</p

Transfusion‐transmitted hepatitis C: A cluster of cases in transfusion‐dependent thalassaemia patients in Sri Lanka

Objectives To report the clinical and virologic epidemiology of a recent epidemic of hepatitis C in thalassaemia patients in Sri Lanka. Background Transfusion‐dependent thalassaemia patients remain at risk for hepatitis C virus (HCV). Here, we report a cluster of recent HCV infections in Sri Lankan thalassaemia patients and examine the phylogenetic relationship of viral sequences. Methods We conducted two prospective cross‐sectional surveys of 513 patients in four Sri Lankan thalassaemia centres in 2014/2015 and re‐surveyed one centre in 2016. We screened for anti‐HCV antibodies using the CTK Biotech enzyme‐linked immunosorbent assay (ELISA) kits and confirmed active infection by reverse transcription‐polymerase chain reaction (RT‐PCR) for HCV‐RNA. HCV genomes were sequenced by unbiased target enrichment. Results Anti‐HCV antibodies were found in 116/513 (22.6%) of patients initially tested. Active hepatitis C infection was found in 26 patients with no cases of active hepatitis B infection. Of 26 patients with HCV, two were infected with genotype 1(a), and the rest had 3(a). In a single centre (Ragama), 122 patients (120 new cases and two previously tested, but negative) were retested for anti‐HCV antibodies. 32/122 (26.2%) patients were seropositive. Twenty‐three (23/122; 18.8%) of these new cases were confirmed by HCV PCR (all genotype 3[a]). Conclusion There is a significant cluster of recent HCV cases in multiply transfused thalassaemia patients in several centres in Sri Lanka. Most of the viruses shared a close phylogenetic relationship. The results are consistent with recent continuing transfusion‐transmitted HCV infection. Routine surveillance for HCV of chronically transfused patients is required irrespective of screening of blood products

Asia–Pacific association for study of liver guidelines on management of ascites in liver disease

The development of ascites is a landmark event in the natural history of cirrhosis. This guidance statement by the Asia–Pacific Association for Study of Liver (APASL) provides an evidence-based approach to managing ascites and its complications in patients with chronic liver disease. These guidelines extensively review the differential diagnosis, diagnostic evaluation, and management of ascites, hyponatremia, hepatic hydrothorax and hepatorenal syndrome (HRS) in patients with cirrhosis and acute-on-chronic liver failure (ACLF). A panel of international experts was invited to formulate the guidelines. The opinions of the experts were collected using two sets of Delphi questionnaires. Then, an online meeting of all the experts was held to discuss the evidence and formulate the final recommendations by consensus. The guidelines were developed using the GRADE system for analysing the level of evidence and strength of recommendation (Table 1). All authors have gone through the guidance document and endorse the same.In this document, we have also covered the grey areas which have been underexplored in previous guidelines and some of the issues which are relatively peculiar to the Asia–Pacific region. Given the high burden of tuberculosis in some of the countries of the Asia–Pacific region, mixed ascites is not uncommon in these patients with liver disease. We discuss the diagnostic approach to mixed ascites and the role of ascitic fluid adenosine deaminase (ADA) and other tests for tuberculosis. In addition, many countries in the Asia–Pacific region are low-middle-income countries, and financial constraints are an essential barrier to liver transplants and other costly therapies like albumin. Hence, we have discussed the role of low-dose albumin in the prevention of paracentesis-induced circulatory dysfunction (PICD) after large-volume paracentesis (LVP) and the prevention of acute kidney injury (AKI) in patients with spontaneous bacterial peritonitis (SBP). We have also reviewed the current evidence of outpatient albumin in managing patients with ascites and have made practical recommendations. We also highlight the timing of albumin infusion concerning LVP. To decrease adverse events and improve patient compliance with diuretic therapy, the guidelines emphasize initiating low-dose diuretics and gradually increasing the dose to the maximum tolerable dose. Non-alcoholic fatty liver disease (NAFLD), also referred to as Metabolic associated fatty liver disease (MAFLD) by some societies has become a significant cause of chronic liver disease worldwide [1]. Many patients with NAFLD/MAFLD related cirrhosis are on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) when they present to a hepatologist or gastroenterologist with ascites. For the first time, we provide guidance statements regarding the use of these drugs in patients with cirrhosis and ascites. For refractory ascites, we have now defined renal dysfunction following the International Club of Ascites (ICA) recommendations on AKI. Lastly, we have highlighted the gaps in our knowledge and have provided directions for future research