Hepatitis C infections in the hospitalized patients requiring the interventions – Concern, attitude and care of the health care workers providing the services, How can we address them?

It is estimated that nearly 100,000 people die annually in India from HCV infection and co-morbidities. Around 25% of 18 million HCV patients in India are infected by Hepatitis-C genotype 1 virus. This has become a concern in many hospitals, health care workers and more so in dialysis centers, trauma care centers and intensive care units, who frequently deal with blood and blood products during the course of the treatments.

Source of Hepatitis C infection

This is a complex issue observed in the state run hospitals with limited resources and at the same time the risks of operating on such patients with chronic hepatitis C infection can’t be ruled and one needs to organize themselves for these special situations with special provisions and protection measures.

“Who would like to get exposed to the risk of acquiring hepatitis C infection while operating on patients with chronic hepatitis C infections in our elective operation theaters?”  Said an anesthetist, defending his stand of cancelling an operation in a government run tertiary care hospital. The patient and the surgeon were left with no other option. The patient was asked to choose another hospital which can take up such operations. The fear of Hepatitis C infection, is significant due to the lack of availability of appropriate and affordable treatment within reach of the hospitals. Similar situation was there in the past for the patients infected with HIV.

This is a complex issue observed in the state run hospitals with limited resources and at the same time the risks of operating on such patients with chronic hepatitis C infection can’t be ruled and one needs to organize themselves for these special situations with special provisions and protection measures.

 

In the recent past the hope of curing hepatitis C infection is on the cards in many countries with introduction of the new drug treatments. Harvoni, the fixed-dose combination of ledipasvir-sofosbuvir of 90mg and 400mg, respectively, is an improved version of Gilead’s Hepatitis-C drug Sovaldi or sofosbuvir, seems to be playing a major role in the coming years. Biocon will be selling the generic Harvoni under brand name CIMIVIR-L. The potential market size for these drugs could be Rs.500 crore or even Rs. 1,000 crores in the foreseeable future. This type of treatment would cost Rs.63 lakhs in USA today for one individual. But the Indian company is determined to supply this medicine at an affordable price (< Rs. 70,000). In the absence of vaccination for the Hepatitis C infection, there should be provision for the supply of these medicines with the help of insurance to the health care workers. Hospital management should take a lead and assure the health care workers that there is support for them in any exposed gets hepatitis C infection during their service.

Pinjala R K

 

Should we worry about the renal function loss in patients undergoing endovascular therapies?

This paper published in Jl of Vascular Surgery, needs attention from all those who would like to do Endovascular procedures for all the vascular lesions in the patients! 

http://www.jvascsurg.org/article/S0741-5214(16)00822-3/abstract

Loss of kidney function in patients with critical limb ischemia treated endovascularly or surgically

Tim A. Sigterman, MD et al

Background  Acute kidney injury after the administration of contrast material during endovascular procedures for peripheral arterial disease generally recovers with supportive treatment. However, long-term effects of endovascular procedures for critical limb ischemia on renal function remain to be investigated.Methods : This retrospective observational cohort study included all patients who newly presented to the vascular surgery outpatient clinic with Rutherford class 4 to class 6 peripheral arterial disease and who were treated with either endovascular or surgical interventions. Changes in estimated glomerular filtration rate (eGFR) after 1 year were compared between the two types of intervention. Multivariate linear regression analysis was done to correct for potential confounders.Results: One year after treatment, eGFR was reduced by 15.0 mL/min (95% confidence interval [CI], 13.1-17.0; P < .001) after endovascular interventions (n = 209) and by 7.6 mL/min (95% CI, 5.1-10.0; P < .001) after surgical therapy (n = 81). Although eGFR rates decreased in both groups, loss of renal function was significantly greater in patients after endovascular interventions (P < .001). Furthermore, 77% of patients receiving endovascular interventions experienced fast renal decline (defined as >4 mL/min loss of eGFR within 1 year) compared with 54% of patients treated surgically (P < .001). After correction for potential confounders, endovascular intervention was associated with 7.4 mL/min (95% CI, 5.4-9.3; P < .001) greater loss of renal function compared with patients treated surgically.Conclusions:  Endovascular procedures for critical limb ischemia are associated with clinically relevant permanent long-term loss of kidney function. This loss of renal function is greater than in comparable patients who were treated with open surgery.

Supervised exercise program for the claudicants

Claudication is the common symptom in peripheral arterial disease. It can be progressive or stable. In those patients with stable claudication medical managements and supervised exercise programs may be helpful. But in our hospitals there are very few such programs encouraging the patients to follow these practices. Doctors tell their patients about the benefits of regular walking, but rarely they are able supervise such measures. Even in the physiotherapy departments there is no such provision in many hospitals. Very few trials are conducted in India in this direction. The Angioplasty and Stenting of superficial femoral artery, popliteal artery is advocated in some places to save the limbs. Open surgery is performed to bypass the occluded FP segments in some centers.

Common site of Claudication in Femoral-Popliteal disease

A systematic review of the uptake and adherence rates to supervised exercise programmes in patients with intermittent claudication was conducted by A.E. Harwood et al from Hull Royal infirmary and published in Annals of vascular surgery.  
They said that reporting of SEP trials was poor with regard to the numbers of subjects screened and reasons for exclusions. Only approximately 1 in 3 screened IC patients was suitable for and willing to undertake SEP. Levels of adherence to SEPs and definitions of satisfactory adherence were also lacking in the majority of the current literature. Current clinical guidelines based upon this evidence base may not be applicable to the majority of IC patients and changes to SEPs may be needed to encourage/retain participants.
This type of papers should encourage us to do more detailed study on supervised exercise programs in Indian hospitals. This may help our patients and reduce burden of angioplasty or bypass surgery in Peripheral arterial disease patients. 

Reference
http://www.annalsofvascularsurgery.com/article/S0890-5096(16)30174-1/abstract