Kiran K. Thumburu

Diagnosis and Prognostic Significance of Minimal Hepatic Encephalopathy in Patients with Cirrhosis of Liver

Background and AimsMinimal hepatic encephalopathy is the mildest form of the spectrum of hepatic encephalopathy (HE) that impairs health-related quality of life. We assessed (1) the usefulness of psychometric hepatic encephalopathy score and critical flicker frequency for the diagnosis of minimal hepatic encephalopathy, and (2) prognostic significance of minimal hepatic encephalopathy.MethodsOne hundred patients with liver cirrhosis without overt HE were subjected to psychometric hepatic encephalopathy score and critical flicker frequency evaluation. Eighty-three age- and sex-matched healthy volunteers served as controls. Minimal hepatic encephalopathy was diagnosed when the psychometric hepatic encephalopathy score was ≤−5. An age-adjusted Z score <−2 on the critical flicker frequency was considered abnormal.ResultsForty-eight (48%) patients had minimal hepatic encephalopathy as indicated by altered psychometric hepatic encephalopathy score. Critical flicker frequency was altered in 21 patients; 17 also showed impaired psychometric hepatic encephalopathy score thus providing additional information in only 4 patients. Forty-six of 48 patients with minimal hepatic encephalopathy and 48 of 52 patients without minimal hepatic encephalopathy completed the follow-up. Eighteen (39.1%) patients died among those who had minimal hepatic encephalopathy compared to 11 (22.9%) patients who did not have minimal hepatic encephalopathy. Among the several variables analyzed in this study, univariate analyses showed that age, serum bilirubin level, Child-Turcotte-Pugh score and psychometric hepatic encephalopathy score were associated with a poor prognosis. The multivariate analysis identified two variables as significant independent prognostic factors; psychometric hepatic encephalopathy score ≤−6 [hazard ratio 2.419 (95% CI, 1.014–5.769)] and Child-Turcotte-Pugh score ≥8 [hazard ratio 2.466 (95% CI, 1.010–6.023)] predicted poor survival.ConclusionsPsychometric hepatic encephalopathy score is a useful tool for the diagnosis of minimal hepatic encephalopathy in an outpatient setting. Both psychometric hepatic encephalopathy score and Child-Turcotte-Pugh score have prognostic value on survival.

Probiotic VSL#3 Reduces Liver Disease Severity and Hospitalization in Patients With Cirrhosis: A Randomized, Controlled Trial

BACKGROUND & AIMS Little is known about whether probiotics can affect outcomes of patients with cirrhosis and hepatic encephalopathy (HE). We assessed the efficacy of a probiotic preparation in preventing the recurrence of HE (primary outcome) and reducing the number of hospitalizations and severity of liver disease in patients with cirrhosis. METHODS We performed a double-blind trial at a tertiary care hospital in India. Patients with cirrhosis who had recovered from an episode of HE during the previous month were assigned randomly (using computer-generated allocation) to groups given a probiotic preparation (VSL#3, 9 × 10(11) bacteria; CD Pharma India Private Limited, New Delhi, India) (n = 66) or placebo (n = 64) daily for 6 months. RESULTS There was a trend toward a reduction in the development of breakthrough HE among patients receiving the probiotic (34.8% in the probiotic group vs 51.6% in the placebo group; hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.38-1.11; P = .12). Fewer patients in the probiotic group were hospitalized for HE (19.7% vs 42.2%, respectively; HR, 0.45; 95% CI, 0.23-0.87; P = .02) or for complications of cirrhosis (24.2%) than in the placebo group (45.3%) (HR, 0.52; 95% CI, 0.28-0.95; P = .034). Child-Turcotte-Pugh and model for end-stage liver disease scores improved significantly from baseline to 6 months in the probiotic group, but not in the placebo group. There were no adverse events related to VSL#3. CONCLUSIONS Over a 6-month period, daily intake of VSL#3 significantly reduced the risk of hospitalization for HE, as well as Child-Turcotte-Pugh and model for end-stage liver disease scores, in patients with cirrhosis. ClinicalTrials.gov number: NCT01110447.

Distribution of Serotypes, Vaccine Coverage, and Antimicrobial Susceptibility Pattern of Streptococcus Pneumoniae in Children Living in SAARC Countries: A Systematic Review

Introduction Each SAARC nation falls in the zone of high incidence of pneumococcal disease but there is a paucity of literature estimating the burden of pneumococcal disease in this region. Objective To identify the prevalent serotypes causing invasive pneumococcal disease in children of SAARC countries, to determine the coverage of these serotypes by the available vaccines, and to determine the antibiotic resistance pattern of Streptococcus pneumoniae. Methods We searched major electronic databases using a comprehensive search strategy, and additionally searched the bibliography of the included studies and retrieved articles till July 2014. Both community and hospital based observational studies which included children aged ≤12 years as/or part of the studied population in SAARC countries were included. Results A total of 17 studies were included in the final analysis. The period of surveillance varied from 12–96 months (median, 24 months). The most common serotypes country-wise were as follows: serotype 1 in Nepal; serotype 14 in Bangladesh and India; serotype 19F in Sri Lanka and Pakistan. PCV-10 was found to be suitable for countries like India, Nepal, Bangladesh, and Sri Lanka, whereas PCV-13 may be more suitable for Pakistan. An increasing trend of non-susceptibility to antibiotics was noted for co-trimoxazole, erythromycin and chloramphenicol, whereas an increasing trend of susceptibility was noted for penicillin. Conclusion Due to paucity of recent data in majority of the SAARC countries, urgent large size prospective studies are needed to formulate recommendations for specific pneumococcal vaccine introduction and usage of antimicrobial agents in these regions.

Burden of invasive pneumococcal disease in children aged 1 month to 12 years living in South Asia: a systematic review.

Objective The primary objective was to estimate the burden of invasive pneumococcal disease (IPD) in children aged 1 month to 12 years in South Asian countries. Methods We searched three electronic databases (PubMed, Embase and the Cochrane Library) using a comprehensive search strategy, we manually searched published databases (Index Medicus and Current Contents) and we also searched the bibliographies of the included studies and retrieved reviews. The searches were current through June 2013. Eligible studies (community-based and hospital-based) were pooled and a separate analysis for India was also completed. A meta-regression analysis and heterogeneity analysis were performed. The protocol was registered with PROSPERO registration number CRD42013004483. Results A total of 22 studies surveying 36,714 children were included in the systematic review. Hospital-based prospective studies from South Asia showed that 3.57% of children had IPD, and 15% of all bacterial pneumonia cases were due to Streptococcus pneumoniae. Indian studies showed that the incidence of IPD was 10.58% in children admitted to hospitals with suspected invasive bacterial diseases, and 24% of all bacterial pneumonia cases were due to S. pneumonia. Population-based studies from South Asian countries showed that 12.8% of confirmed invasive bacterial diseases were caused by S. pneumonia whereas retrospective hospital-based studies showed that 28% of invasive bacterial diseases were due to S. pneumoniae. Meta-regression showed that there was a significant influence of the antigen testing method for diagnosing IPD on IPD prevalence. Conclusion S. pneumoniae is responsible for a substantial bacterial disease burden in children of South Asian countries including India despite the presence of high heterogeneity in this meta-analysis. Treatment guidelines must be formulated, and preventive measures like vaccines must also be considered.

Neuropathology of acute liver failure

Cerebral edema has been identified in all forms of liver disease and is closely related to the development of hepatic encephalopathy. Cerebral edema is most readily recognized in acute liver failure (ALF), while the main cause of death in patients with ALF is multi-organ failure; brain herniation as a result of intracranial hypertension does remain a major cause of mortality. The mechanisms responsible for cerebral edema in ALF suggest both cytotoxic and vasogenic injury. This article reviews the gross and ultrastructural changes associated with cerebral edema in ALF. The primary cause of cerebral edema is associated with astrocyte swelling, mainly perivascular edema and ammonia still remains the primary neurotoxin involved in its pathogenesis. The astrocytic changes were confined to the gray matter. The other organelles involved in the pathogenesis of ALF include mitochondria, basement membrane, pericytes, microglial cells, blood-brain barrier (BBB) etc. Discrete neuronal changes have recently been reported. Recent studies in animal and humans have demonstrated the microglial changes which have the potential to cause neuronal dysfunction in ALF. The alterations in BBB still remain unclear though few studies have showed disruption of tight junction proteins indicating the involvement of BBB in cellular swelling.

Expression of astrocytic genes coding for proteins implicated in neural excitation and brain edema is altered after acute liver failure.

In vitro and in vivo studies have suggested that reduced astrocytic uptake of neuronally released glutamate, alterations in expression of glial fibrillary acidic protein (GFAP) and aquaporin‐4 (AQP‐4) contribute to brain edema in acute liver failure (ALF). However, there is no evidence to date to suggest that these alterations occur in patients with ALF. We analyzed the mRNA expression of excitatory amino acid transporters (EAAT‐1, EAAT‐2), GFAP, and AQP‐4 in the cerebral cortex obtained at autopsy from eight patients with ALF and from seven patients with no evidence of hepatic or neurological disorders by real‐time PCR, and protein expression was assessed using immunoblotting and immunohistochemistry. We demonstrated a significant decrease in GFAP mRNA and protein levels in ALF patients compared to controls. While the loss of EAAT‐2 protein in ALF samples was post‐translational in nature, EAAT‐1 protein remained within normal limits. Immunohistochemistry confirmed that, in all cases, the losses of EAAT‐2 and GFAP were uniquely astrocytic in their localization. AQP‐4 mRNA expression was significantly increased and its immunohistochemistry demonstrated increased AQP‐4 immunoreactivity in the glial end‐feet process surrounding the microvessels. These findings provide evidence of selective alterations in the expression of genes coding for key astrocytic proteins implicated in central nervous system (CNS) excitability and brain edema in human ALF.

Two or three primary dose regime for Haemophilus influenzae type b conjugate vaccine: meta-analysis of randomized controlled trials

Haemophilus influenzae type b (Hib) is an important cause of meningitis and pneumonia in children. Despite the availability of Hib conjugate vaccine, many countries are still to implement it in their immunization schedule. Before introducing the vaccine in routine immunization programs, it is important to know not only the cumulative efficacy but also the efficacy of each vaccine dose. The primary objective of this review is to find whether two primary dose schedule of Hib vaccine is equally efficacious as the standard three primary dose schedule. A highly sensitive online search was run using the terms ‘Haemophilus Vaccines’ or ‘Haemophilus influenzae type b’ and ‘conjugate vaccine’, and Medline (Ovid), PubMed, Embase, CENTRAL and Scopus were explored for prospective randomized controlled studies. Data were extracted in a predesigned proforma and analyzed using RevMan software. Nine randomized studies were included in the analysis. Pooled vaccine efficacy using a fixed effects model against confirmed invasive Hib disease following the 3, 2 and 1 primary dose schedule were 82% [95% confidence interval (CI) 73-87], 79% (95% CI 54–90) and 65% (95% CI 23–84), respectively, and the overall efficacy was 80% (95% CI 72–85). To conclude, we found that Hib conjugate vaccine is highly efficacious and that the two dose regime is as good as the three dose regime. [The protocol was registered with PROSPERO (CRD42013004490)].

Increased Expression of GLUT 1 in Patients With Acute Liver Failure

Increased expression of GLUT 1 in patients with acute liver failure 1Chopra M, 1Kiran K. Thumburu,2Rakesh K. Vasishta, 3A. Chakraborti, 5Navneet Sharma, 1Ajay Duseja, 1Yogesh Chawla, 1Radha K. Dhiman, Departments of 1Hepatology, 2Histopathology, 3Experimental Medicine and Biotechnology, and 5Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India. Corresponding author: Dr RK Dhiman, Email: rkpsdhiman@hotmail.com Background: Acute liver failure (ALF) resulting in cerebral edema and intracranial pressure has been shown to cause disturbances in brain oxidative metabolites. Spectroscopic and gene expression studies in experimental ALF models reveal that altered brain oxidative glucose metabolism and lactate synthesis may be implicated in the cerebral complications of ALF. Glucose transporter 1 (GLUT 1), a facilitative glucose transporter that transports glucose across the blood brain barrier is required to sustain brain energy metabolism. We investigated to study the GLUT 1 expression in the brains of patients with acute liver failure. Methods: In order to address this issue, dissected samples of cerebral cortex were obtained at autopsy from 8 patients with ALF due to either viral hepatitis or toxic liver injury and from 7 patients with no evidence of liver disease or other neurological disorders (control) matched for gender (ALF, 4 men; control, 4 men) and post-mortem delay intervals [ALF, median 245 minutes (range 180-415); control median 240 minutes (135-870)]. All ALF patients had high grade hepatic encephalopathy and, there was evidence of brain edema on autopsy in all. Expression of GLUT 1 mRNA was investigated by real-time PCR using appropriate molecular probes and protein expression was assessed using both immunoblotting (western) techniques as well as immunohistochemistry using commercially-available polyclonal antibodies. Results: Expression of GLUT-1 at both the mRNA (7.8 folds; P=0.003) and protein levels (3.02±0.24 vs 2.44±0.55; P=0.020) was significantly increased in frontal cortex of ALF patients compared to control material respectively. Immunohistochemical analysis confirmed the increase of GLUT-1 immunoreactivity in endothelial cells in the frontal cortex of ALF compared to control cortex. Conclusion: These results demonstrated that altered expression of GLUT 1 was involved in disturbances in the brain energy metabolism and could contribute to the pathophysiological mechanisms responsible for the neurological complications of ALF

Probiotics for the prevention or treatment of hyperbilirubinaemia in late preterm and term neonates

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To determine the safety and efficacy of probiotics supplementation in preventing hyperbilirubinaemia among late preterm (born at gestational age (GA) 34 weeks to 36 weeks and six days) and term neonates (≥ 37 weeks) To determine the safety and efficacy of probiotics supplementation in treating hyperbilirubinaemia among late preterm (born at 34 weeks to 36 weeks and six days) and term neonates (≥ 37 weeks) Subgroup analyses will include gestational age at birth (term vs late preterm), cause of jaundice (haemolytic vs non-haemolytic jaundice), mode of feeding at the time of enrolment (exclusive breastfeeding vs mixed feeding/formula feeding), and types of probiotics used.

36 INCREASED EXPRESSION OF AQUAPORIN-4 IN PERIVASCULAR ASTROCYTES END-FEET CONTRIBUTE TO THE DEVELOPMENT OF BRAIN EDEMA IN ACUTE LIVER FAILURE

S 20TH ANNUAL CONFERENCE OF INASL, MARCH 2–4, 2012 S22