Digestive Disease Sciences

A 35-year-old healthy male with no history of any past medical illness developed severe headache, vomiting and drowsiness while at high altitude (4,572 m) in the eastern Himalayan ranges. He was evacuated to a tertiary-care hospital where he was diagnosed to have cerebral sinus venous thrombosis (CSVT) on magnetic resonance imaging, with deep vein thrombosis (DVT) of his right popliteo-femoral vein on color Doppler study. Investigation for thrombophilia revealed protein S (PS) deficiency in this patient. Family screening revealed low levels of PS in two elder brothers. One brother had a history of 'stroke in young' at the age of 20 years with the other being asymptomatic. This established the hereditary nature of PS deficiency. We are not aware of any previously published report on hereditary PS deficiency combined with CSVT and DVT occurring at high altitude. However, 1 case of protein C deficiency with CSVT has been reported previously.

Background: HBV DNA quantitation is used extensively world wide for the diagnosis and monitoring of treatment of Hepatitis B virus (HBV) infection. However, it has still to be popular in India. The aim of this study was to quantitate HBV-DNA by Real time-PCR method in Hepatitis B and in immuno-compromised patients, to compare the results with HBeAg detection and to monitor the response to therapy of chronic Hepatitis B patients to antivirals. Methods: Ninety one serum samples of Hepatitis group of patients (all HBsAg positive), 41 samples from immuno-compromised patients (all HBsAg negative) and 49 patients of Chronic Hepatitis B group (all HBsAg positive) were the subjects of this first ever study in Armed Forces. Twenty serum samples from healthy volunteers and non-hepatitis B patients served as negative controls. The amplification detection was carried out in a Rotor-Gene 2000-sequence detector. Results : Amongst Hepatitis B group, 33% (30/91) of the samples were positive for HBV-DNA and 26% (24/91) of samples were positive for HBeAg. In the immuno-compromised group of patients 14.6% (6/11) of samples were positive for HIV-DNA and 9.7% (4/41) were positive for HBeAg. Of the Chronic Hepatitis B patients on treatment, all (100%) were positive by HBV-DNA, whereas 29/49 (59.2%) were positive by HBeAg before treatment. After treatment with antivirals, 06/49 (12.2%) were positive by both tests and 11/49 (22.5%) were positive only by HBV-DNA. 32/49 (65.3%) patients became negative serologically after therapy. Conclusion : HBeAg status did not necessarily reflect HBV-DNA level in the serum, as 10/91 (11%) in the Hepatitis B group, 2/41 (4.9%) in the immuno compromised group and 20/49 (40.8%) patients in the Chronic Hepatitis B group were positive for HBV-DNA but negative for HBeAg. HBV-DNA was not found to be positive amongst any of the negative controls. Real time-PCR is a sensitive and reproducible assay for HBV-DNA quantitation and may be started in Armed Forces referral centers in the near future.

The estimated prevalence of hepatitis C virus (HCV) infection in India is between 0.5 and 1.5% with hotspots showing much higher prevalence in some areas of northeast India, in some tribal populations and in certain parts of Punjab. Genotype 3 is the most prevalent type of infection. Recent years have seen development of a large number of new molecules that are revolutionizing the treatment of hepatitis C. Some of the new directly acting agents (DAAs) like sofosbuvir have been called game-changers because they offer the prospect of interferon-free regimens for the treatment of HCV infection. These new drugs have not yet been approved in India and their cost and availability is uncertain at present. Till these drugs become available at an affordable cost, the treatment that was standard of care for the whole world before these newer drugs were approved should continue to be recommended. For India, cheaper options, which are as effective as the standard-of-care (SOC) in carefully selected patients, are also explored to bring treatment within reach of poorer patients. It may be prudent to withhold

Hepatitis C Virus infection is a global problem that leads to development of chronic hepatitis, cirrhosis and hepatocellular carcinoma. So far this infection was being treated with interferon and ribavirin combination which has a large number of adverse effects. Last few years have seen availability of a large number of new molecules that are revolutionising the treatment of hepatitis C. Some of these newer drugs like sofosbuvir have been called game changer because they have changed the way we think of HCV treatment. The cost and availability of these newer drugs in India remains a problem so far. Efforts are on to bring these drugs within the reach of people at an affordable cost, but it is not clear as to how much time it will take. Till then, in our setting, we may continue to recommend the treatment that was standard of care for whole world before these game changers came in. In fact we also explore cheaper options, which are equally effective to make treatment within reach of poorer patients. It may be prudent to withhold treatment for patients with low levels of fibrosis (F1 or F2, with genotype 1 or 4 infection), and for patients who are nonresponders to initial therapy, Interferon intolerant, those with decompensated liver disease, and patients in special populations such as stable patients after liver and kidney transplantation, HIV co-infected patients and those with cirrhosis of liver.

GT 8 RESUMO: O presente estudo tem como proposta identificar as concepções e estratégias de um grupo de professores que atuam diretamente com o aluno no âmbito da aprendizagem formal da leitura, no processo do ato de ler. Conhecer as práticas pedagógicas que são desenvolvidas na sala de aula, as explicações para o sucesso e o insucesso na aprendizagem da leitura. Para atender aos objetivos pretendidos, foram realizadas entrevistas semi-estruturadas, sustentadas por roteiros, com 10 professores em duas escolas públicas municipais do ciclo fundamental na cidade de Aracaju. Os achados deste estudo nos fazem pensar que o professor munícipe precisa rever seus métodos e processos de educação, sem os quais continuaremos a assistir um sistema educacional desmotivado e indiferente ao desenvolvimento de competências e capacidades críticas no processamento da aprendizagem da leitura no primeiro ano do Ciclo Básico.

A few months back the Editor-in-Chief of this journal asked me to write a contemporary piece on 'the future of hepatology in India'. He said, ''You have touched some of these issues as an outgoing president, just put it in writing''. I was very reluctant to take up this task in the beginning. My lack of enthusiasm stemmed from two main reasons. Firstly, I was aware that three doyens of Hepatology in India namely Dr. Subrat K. Acharya, Dr. Yogesh K. Chawla and Dr. Shiv K. Sarin, (in alphabetical order), had delivered exquisite discourses on this issue some time back. And then, given my service background, I was insulated from the forces that have led to chaotic development of this specialty in India. But possibly what I did have was the best ringside view, to be able to introspect and comment on the development of Hepatology in India during the last few decades. In the Armed Forces, we often spend considerable time in planning and in trying to ensure careful execution of the agreed plan. I am still not clear if such an exercise was ever done in India for Hepatology. We are far from having a clear plan as to how many Hepatologists does our country need? How are we going to get so many doctors to specialize in Hepatology? If we do manage the required numbers, how would we employ them to have best results for our people? Most leading hepatologists of India have said that the future of Hepatology in this country is very promising. There have been tremendous advances in the management of liver disease. Liver transplantation outcomes are as good as the best in the world. 1 Research in India is now to be reckoned with. Publications by Indian investigators in peerreviewed international journals, which were few and far between earlier, are now commonplace. 2-19 Emphasis on Hepatology training is increasing and regular postdoctoral training courses (DM in Hepatology) are now running in at least two institutes and are likely to commence soon in two more. National task forces are studying Indian problems in details. There have been excellent studies in

Eighty patients with various thyroid disorders and 20 controls were investigated to determine antibodies against thyroglobulin and microsomal antigens by haemagglutination and immunofluorescent techniques. They were also tested for immunoglobulin profile by radial immunodiffusion methods. Patients with Hashimoto's disease, idiopathic hypothyroidism, and Grave's disease showed significant elevations of IgG. None of the patients with toxic nodular goitre or thyroid adenoma showed any thyroid antibodies while 69.2% patients with Grave's disease, 16% with euthyroid goitre, 58.3% with hypothyroidism and all the patients with Hashimoto's disease had microsomal antibodies by immunofluorescent test. Similarly, all the cases of Hashimoto's disease, 41.6% of those with hypothyroidism, 30% of Grave's disease patients and none of the patients with toxic nodule or thyroid adenoma had thyroglobulin antibodies by haemaglutination test. Evaluation for auto-antibodies may aid...

Background: Recurrent hepatitis C virus (HCV) has been a serious problem after liver transplantation (LT). We report our experience of 24-week therapy with sofosbuvir (SOF) and ribavirin (RBV) in post-LT recurrent HCV in living donor liver transplantation (LDLT) setting in South Asia. Methods: Data from all patients treated for post-transplantation HCV recurrence in a single center were analyzed. Treatment regimen was 24 weeks of SOF 400 mg daily and RBV (starting at 800 mg daily, increased as tolerated). Sustained virological response (SVR) was assessed 12 weeks and 24 weeks after completion of treatment. Results: 63 patients (median age 52 [range 30-69] years; 80% males) were treated. Most (76.2%) were treatment experienced and predominant HCV genotype was 3 (77.7%) followed by 1 (20.6%). Median transient elastography (Fibroscan) score was 7 (range 3-11) kPa and none of the patients had cirrhosis. SVR12 was achieved in 60 of 63 patients (95.2%) while SVR24 was noted in 59 (93.7%). SVR12 rates were as good in genotype-3 as in genotype-1. Older age, longer period after transplantation, higher Fibroscan value and higher need for erythropoietin were likely to be associated with relapse. Adverse effects were noted in 34 patients and weakness and fatigue were the commonest side effects. Significant drop in hemoglobin (<8 g/dL) was seen in 6 patients. Conclusions: SOF + RBV combination therapy for 24 weeks was safe and effective in treatment of for post-LT recurrent HCV in a single LT center and remains relevant due to its low cost and lack of drug interactions.

Objectives: To assess toxicity and efficacy of intensity-modulated radiation therapy (IMRT) for anal cancer. Methods: Records of 152 patients were reviewed retrospectively from multiple institutions. Data on disease control and toxicity were collected as well as patient and treatment characteristics. Acute (< 6 mo) and late (Z6 mo) severe toxicity (grade Z3) were graded. Four patients were excluded due to the presence of metastatic disease or stage TX. Late toxicity data were available for 120 patients. Results: Median cumulative IMRT dose was 51.25 Gy (median, 28 fractions). All but 2 patients received chemotherapy. With median follow-up of 26.8 months, local control at 3 years was 87%, worse for patients with T3-T4 than T1-T2 disease on univariate analysis (79% vs. 90%; P = 0.04). Regional control, distant control, and overall survival were 97%, 91%, and 87%, respectively, at 3 years. Nodal status was associated with regional control, distant control, and overall survival (P < 0.01 for each). Most common severe acute toxicity was hematologic (41%), skin (20%), and gastrointestinal tract (11%). Two grade 5 toxicities occurred (hematologic and gastrointestinal tract). Severe late toxicity affected skin (1%) and gastrointestinal tract (3%). Conclusions: IMRT with chemotherapy resulted in excellent local control. Although T stage predicted worse local control, most T3-T4 disease was controlled with IMRT. Nodal status predicted regional and distant control and overall survival. Severe toxicity was acceptable.

The outcome of liver transplantation has continued to improve because of effective immunosuppressants, improved preservation techniques, and enhanced modalities to treat postoperative complications (1-3). However, hepatic allograft rejection remains an important problem following liver transplantation necessitating increased immunosuppression. Indeed, complications related to the administration of immunosuppressive therapy are still the predominant cause of morbidity and mortality in the liver transplant recipients (4). Early acute rejection, occurring within three months from transplant, is a common event which may affect as many as two-thirds of liver transplant recipients (5, 6). Early acute rejection is usually of lesser significance with respect to prognosis and responds well to additional immunosuppression (7-10). Late acute rejection (LAR) has been variably defined in published reports as occurring more than one, three, or six months from transplant and affects 7-23% of transplant patients (7-9, 11). LAR has been described as more refractory to rescue treatment. Poor compliance is one factor that has long been associated with LAR (7, 12, 13). However, the identification of clinical risk factors for LAR and the impact of LAR on subsequent patient outcome, remain poorly defined. In this study, we evaluated the

See leading article pp. 591-593 Aims The role of various treatments for variceal haemorrhage is currently being evaluated. The purpose of this study was to analyse the impact of the use of endoscopic variceal sclerotherapy (EVS), variceal band ligation (VBL) and transjugular intrahepatic portosystemic stent-shunt (TIPSS) for secondary prophylaxis on the outcome of cirrhotic patients with the first episode of variceal haemorrhage presenting to a single centre. Methods Between 1986 and 1996, data from 225 consecutive patients with the first episode of variceal haemorrhage were analysed. The modality of treatment for secondary prophylaxis between 1986 and 1991 was EVS (group I: n 83; Child class C, 29%; mean follow-up 36 6 3 months), between 1991 and 1993 VBL (group II: n 56; Child class C, 38%; mean follow-up 24 6 3 months), and between 1995 and 1996 TIPSS (group III: n 86; Child class C, 60%; mean follow-up 17 6 1 months). Half of the patients between 1993 and 1995 underwent VBL and the other half had TIPSS. Data regarding rebleeding, mortality and encephalopathy were analysed using the Kaplan-Meier method. Cox's proportional hazard regression was used to test the significance of prognostic factors. Results Seventy-five per cent of patients re-bled in group I, 40% in group II, and 16% in group III (P < 0.0001). Mortality was significantly lower in the patients with Child class C disease in group III patients compared with those in groups I and II (P < 0.02). TIPSS was associated independently with reduced early mortality and rebleeding. Conclusion The results of this study suggest that TIPSS improves survival in patients with advanced liver disease and variceal haemorrhage, and should be considered for secondary prophylaxis in high-risk patients.

PurposeA retrospective study was undertaken to analyse set-up variations in patients being treated with post-operative radiation therapy for carcinoma of gall bladder by image-guided radiotherapy (IGRT) using cone-beam computed tomography (CBCT) scans and paired kilovoltage beam portals (kVps).Materials and methodsThree consecutive patients receiving post-operative radiation therapy for carcinoma of gall bladder were studied. A total of 32 imaging studies were performed. The immobilisation system was an all-in-one system along with a thermoplastic mask, with knees either resting on the knee rest or in a vacuum cushion. The CBCT scans and kVps were reviewed in an off-line mode. The surrogate markers used for matching during co-registration were 12th rib, coeliac trunk, vertebral bodies and canal. Individual readings were used to calculate mean shifts (m); the mean of these means (M) was calculated to arrive at the systematic error in each direction and its standard deviation (Σ) was ...

2 cases of portal, splenic and superior mesenteric vein thromboses related to prolonged stay at high altitude are presented. Both presented initiaUy with innocuous appearing vague pain in abdomen with no physical signs. Later hepatosplenomegaly, and pleural effusion (left) was also detected. Diagnosis was based on CT scan and colour Doppler study showing thrombosed veins and porto-systemic coUateral. 1 patient developed a large splenic haernatoma requiring splenectomy. Both were managed with early anticoagulation and have done well in the short follow up.