Infectious aetiology of jaundice among pregnant women in Angola

The contribution of viral hepatitis, human immunodeficiency virus (HIV) infection and malaria to jaundice among pregnant women in Luanda, Angola, was studied. 20 pregnant women with jaundice (cases) were identified in 2 large maternity hospitals and compared with 40 pregnant women without jaundice (controls). Among the cases 6 patients died, whereas no death occurred in the control group (p < 0.001). Five spontaneous abortions and 6 stillbirths were also noted among the cases, implying foetal loss in 55% and stillbirth in 30%. One stillbirth was registered among control women. Of the cases 40% had anti-hepatitis E virus antibodies compared with 13% of the controls (p = 0.02). Plasmodium falciparum parasitaemia occurred in 47.5% and 5% of cases and controls, respectively (p < 0.001). There was no difference in the prevalence of antibodies against hepatitis C or HIV among cases and controls. The carriership of hepatitis B surface antigen was 10% in both groups. In conclusion, jaundice during pregnancy is often associated with maternal mortality in Luanda, women suffering from jaundice during pregnancy have an extremely high case fatality rate, and P. falciparum and hepatitis E are associated with jaundice in the setting studied.

Severe jaundice in Sweden in the new millennium: causes, investigations, treatment and prognosis

BACKGROUND

The aims of the study were to assess the causes of jaundice in Gothenburg, Sweden, to study the types of investigations applied in cholestatic and hepatocellular types of jaundice and treatment and to evaluate the prognosis of these patients up to a year from the diagnosis.

METHODS

Over a 3-month period, all adult patients with bilirubin > 100 micromol/l were identified by the clinical chemistry laboratory serving all three hospitals in Gothenburg. Relevant clinical information was obtained from medical records. Follow-up was performed 9-12 months later.

RESULTS

A total of 173 patients were identified; 40% were under surgical care while 38% were in the care of internists. The most common cause of jaundice was malignancy in 58 patients, liver metastases in 20, cholangiocarcinoma in 16, pancreatic cancer in 13, cancer of papilla Vateri in 2 and primary liver cancer in 7. Alcoholic liver disease was the second most common cause, found in 29 patients, followed by bile duct stones (28 patients). Only 3% had viral hepatitis. Ultrasound and/or CT were performed in 95% of those with cholestasis and ultrasound had been performed in 75% of those with hepatocellular type and CT in almost 50%. Thirty-two patients were operated on, 27 patients were treated endoscopically and 17 patients required liver transplantation. Total mortality was 51% and in malignancy 82%.

CONCLUSION

Malignancy and alcoholic liver disease are the most common causes of severe jaundice, whereas viral hepatitis is a rare cause. Many patients are under surgical care, probably due to historical reasons as surgery is rarely indicated.

Jaundice noted in the first 24 hours after birth in a managed care organization

OBJECTIVE

To investigate the significance of jaundice noted in the first 24 hours after birth in a community setting.

DESIGN

Supplementary analyses of a nested case-control study.

SETTING

Northern California Kaiser Permanente Medical Care Program.

PATIENTS

Six hundred thirty-one randomly selected newborns (controls) and 140 cases with total serum bilirubin levels of 25 mg/dL (428 micro mol/L) or higher from a cohort of 105 384 newborns of at least 2000 g birth weight and at least 36 weeks' gestational age, born between January 1, 1995, and December 31, 1998.

MAIN OUTCOME MEASURES

Notations of jaundice in the medical record, timing and results of bilirubin testing, use of phototherapy, and development of bilirubin levels of 25 mg/dL or higher.

RESULTS

Among the controls, the cumulative probability of a notation of jaundice (corrected for early hospital discharge using survival analysis) was 2.8% within 18 hours and 6.7% within 24 hours. In these newborns, cumulative proportions that had bilirubin levels measured were 38% within 12 hours and 43% within 24 hours of when jaundice was first noted. About 40% of bilirubin levels measured within 24 hours were above the estimated 95th percentile for age. Compared with newborns not noted to be jaundiced on the first day, newborns noted to be jaundiced within 24 hours were more likely to receive phototherapy (18.9% vs 1.7%; relative risk, 10.1; 95% confidence interval, 4.2-24.4) and to develop a bilirubin level of 25 mg/dL or higher (odds ratio, 2.9; 95% confidence interval, 1.6-5.2), but the absolute risk increase for total serum bilirubin levels of 25 mg/dL or higher was 0.2%.

CONCLUSION

Jaundice noted in the medical record in the first 24 hours after birth was uncommon and often clinically significant in this setting, but other factors also need to be considered in determining its importance.

Outbreak of jaundice and hemorrhagic fever in the Southeast of Brazil in 2001: detection and molecular characterization of yellow fever virus

Between January and March 2001, an outbreak of jaundice and hemorrhagic fever occurred in the state of Minas Gerais, Southeast region of Brazil, in which a mortality rate of 53% was reported. Seroconversion, virus isolation, histopathological and immunohistochemical findings, and reverse transcription-polymerase chain reaction (RT-PCR) identified yellow fever virus (YFV) as the etiological agent responsible for the outbreak. Partial nucleotide sequence analysis from a fragment of the YFV genome spanning parts of nonstructural (NS) 5 gene and 3' noncoding region (3' UTR) showed that the YFV involved in this outbreak belongs to South American genotype I and differs from the Brazilian virus identified in 1996.

Choledochal cysts: age of presentation, symptoms, and late complications related to Todani's classification

PURPOSE

The aim of this study was to compare presentation, complications, diagnosis, and treatment of choledochal cysts in pediatric and adult patients.

METHODS

Forty-two patients were analyzed after subdivision into 3 groups: group A, less than 2 years (n = 10); group B, 2 to 16 years (n = 11); group C, greater than 16 years (n = 21).

RESULTS

The cysts were classified as extrahepatic (n = 33), intrahepatic (n = 5), and combined (n = 4). Seventy-six percent of patients presented with abdominal pain, (20 of 21 group C), and 57% with jaundice, (10 of 10 group A). Cholangiocarcinoma occurred in 6 patients, 4 of whom had previously undergone internal drainage procedures. Excision of the extrahepatic cyst was performed in 27 of 37 patients. Five patients, of whom, 4 had cholangiocarcinoma, were beyond curative treatment at the time of diagnosis. Six patients had died at the closure of this study, 5 of them had carcinoma.

CONCLUSIONS

Presenting symptoms are age dependent with jaundice prevailing in children and abdominal pain in adults. In view of the high risk of cholangiocarcinoma, early resection and not internal drainage is the appropriate treatment of extrahepatic cysts. Patients who had undergone internal drainage in the past still should undergo resection of the cyst.

[Survival in patients with liver cirrhosis at the Durango, IMSS Regional General Hospital]

INTRODUCTION

In Mexico, hepatic cirrhosis mortality exhibits important regional differences.

AIM

To analyze global survival of cirrhotic patients, according to etiology and functional status.

MATERIAL AND METHODS

Between March 1990 to August 1998, newly diagnosed patients with hepatic cirrhosis were included in a follow-up study. Subjects were analyzed monthly. Information on clinical evolution, complications, and dates of events (death) and complications were registered. Survival was estimated using Kaplan-Meier method.

RESULTS

Ninety nine subjects were included in the survival analysis, 66 with alcoholic and 33 with viral cirrhosis (HCV and HBV in 24 and nine patients, respectively). Ninety seven percent of patients were decompensated at diagnosis, and 81% had ascites. Probabilities for survival in the entire series were 69.7, 37.6 and 23.6% at 24, 48, and 60 months, respectively. There were no significant differences in the survival of patients grouped according to etiology. When survival was analyzed by Child-Pugh score, it was slightly higher in the alcoholic cirrhosis group.

CONCLUSIONS

In this study survival probability of patients with viral cirrhosis was lower than in patients with alcohol cirrhosis.

Jaundice as an early diagnostic sign of urinary tract infection in infancy

OBJECTIVE

Urinary tract infections (UTIs) are a common clinical problem in febrile infants younger than 8 weeks old, with a prevalence between 5% and 11%. Previous studies have noted that jaundice may be one of the first signs of a bacterial infection in infants. Our goal was to determine the incidence of UTIs in asymptomatic, jaundiced infants younger than 8 weeks old and to determine which historical and laboratory parameters are associated with UTIs.

METHODS

We prospectively evaluated asymptomatic, jaundiced infants younger than 8 weeks old for evidence of a UTI (defined as >10 000 colony-forming units per milliliter of a single pathogen, obtained by bladder catheterization). A serum fractionated bilirubin level was obtained on all study patients. Detailed questionnaires were completed, which included demographic information, prenatal, intrapartum, and postnatal events.

RESULTS

Twelve (7.5%) of 160 infants had a UTI (95% confidence interval: 3.9%-12.7%). Isolated organisms included Escherichia coli, Enterobacter cloacae, Enterococcus, Klebsiella pneumoniae, group B Streptococcus, Streptococcus viridans, and Staphylococcus aureus. Patients with the onset of jaundice after 8 days of age had a higher incidence of UTI, 6 (50%) of 12 infants in the positive culture group, versus 15 (10%) of 148 infants in the negative culture group. Abnormal urinalysis and microscopy results were noted in 5 (42%) of 12 infants with a UTI, and 6 (55%) of 11 infants had abnormal renal ultrasound results.

CONCLUSION

A UTI was found in 7.5% of asymptomatic, afebrile, jaundiced infants younger than 8 weeks old. In addition, infants with the onset of jaundice after 8 days of age or patients with an elevated conjugated bilirubin fraction were more likely to have a UTI. Therefore, we recommend that testing for a UTI be included as part of the evaluation in asymptomatic, jaundiced infants presenting to the emergency department.

Hepatitis A virus infections in the United States: model-based estimates and implications for childhood immunization

OBJECTIVE

The high prevalence of antibody to hepatitis A virus (HAV) in the US population suggests that the incidence of infection is much higher than reported, but the infection rate is difficult to measure directly because of anicteric infection and underreporting. We present a model that reconciles the reported incidence of hepatitis A with the observed prevalence of antibody to HAV and provides an estimate of the true incidence of HAV infection.

METHODS

In the model, reported incidence of hepatitis A in the United States was adjusted to account first for anicteric infection and then for underreporting and declining incidence over time such that the prevalence predicted by the model approximated that observed in 2 nationwide surveys.

RESULTS

The model showed incidence in the susceptible population declining by 4.5% per year. As incidence declined early in the 1900s, the average age at infection increased, leading to a paradoxical increase in the incidence of icteric infection followed by a slow decline. The model estimated approximately 270 000 (range: 190 000-360 000) infections annually from 1980 to 1999, 10.4 times the number of hepatitis A cases actually reported during this period. More than half of these infections occurred in children who were younger than 10 years, most of which would have been clinically unrecognizable as hepatitis.

CONCLUSIONS

These results suggest a large reservoir of infection in children and that interruption of transmission in children may substantially reduce incidence of hepatitis A overall.

Troglitazone (Rezulin) and hepatic injury

PURPOSE

Analyze US rates of reported severe liver disease for the oral hypoglycemic agent troglitazone from March 1997 through February 2000 and the possible effects of publicity on reporting.

METHODS

The number of troglitazone reports with liver failure and or hospitalization with jaundice or hyperbilirubinemia, made to the FDA and/or Parke-Davis are used as numerators. The denominators are numbers of patients and person-time estimates of exposure. Additionally, the amount of publicity about troglitazone during its marketing is quantified.

RESULTS

Approximately 1.92 million patients were treated with troglitazone from March 1997 through the end of February 2000 resulting in 1.6 million person-years of exposure. Reports of 83 cases of liver failure associated with troglitazone were received (1 in 23,000 patients or 1 in 20,000 person-years). Of the 83 cases, only 49 (59%) were classified by a hepatologist to be 'possibly' or 'probably' attributed to troglitazone. For the first, second, and third years of marketing, rates of reported hepatic failure per 100,000 person years exposure to troglitazone were 8.3, 5.3, and 2.7 respectively. Rates of reported liver disease involving hospitalizations with mention of jaundice and hyperbilirubinemia per 100,000 person-years were 16.0, 6.1, and 3.6 respectively for these years. During the 3-year marketing history of troglitazone, there were 470 lay press and 158 medical literature articles with mentions of hepatotoxicity for the drug.

CONCLUSIONS

Rates of reported severe liver disease declined substantially during the second and third years of marketing of troglitazone. The decline followed increasingly stringent requirements for liver function test monitoring and may have been due to improved patient selection and management as a result of the widely publicized association between troglitazone and hepatotoxicity.

Risk factors resulting in conversion of laparoscopic cholecystectomy to open surgery

BACKGROUND

Laparoscopic cholecystectomy has become the standard treatment for symptomatic gallbladder diseases. However, there still is a substantial proportion of patients in whom laparoscopic cholecystectomy cannot be successfully performed, and for whom conversion to open surgery is required.

METHODS

In this study, 1,000 laparoscopic cholecystectomies performed at Ankara Numune Hospital, Fourth Department of Surgery, from March 1992 to July 1999 were prospectively analyzed. The patients studied included 804 women (80.4%) and 196 men (19.6%) with a mean age of 43.8 years (range, 30-80 years). From the data collected, only factors available to the surgeon preoperatively were considered for analysis. These factors included age, gender, history of acute cholecystitis, jaundice or pancreatitis, previous abdominal surgery, obesity and concomitant disease, white blood cell (WBC) count, preoperative liver function tests, ultrasound findings of the gallbladder, preoperative endoscopic retrograde cholangiopancreatography (ERCP), and suspicion of common bile duct stones. Also we analyzed the case numbers as a measure of institutional experience.

RESULTS

Of the 1,000 patients in whom laparoscopic cholecystectomy was attempted, 48 (4.8%) required conversion to open surgery. The most common reason for conversion was inability to define anatomy in patients with inflamed contracted gallbladder (n = 34). Significantly independent predictive factors for conversion were male gender, previous abdominal surgery, acute cholecystitis, thickened gallbladder wall on preoperative ultrasonography, and suspicion of common bile duct stones.

CONCLUSIONS

An appreciation for the aforementioned predictors of conversion will allow appropriate planning by the patient, the institution, and the surgeon.

Serious adverse events associated with yellow fever 17DD vaccine in Brazil: a report of two cases

BACKGROUND

The yellow fever vaccine is regarded as one of the safest attenuated virus vaccines, with few side-effects or adverse events. We report the occurrence of two fatal cases of haemorrhagic fever associated with yellow fever 17DD substrain vaccine in Brazil.

METHODS

We obtained epidemiological, serological, virological, pathological, immunocytochemical, and molecular biological data on the two cases to determine the cause of the illnesses.

FINDINGS

The first case, in a 5-year-old white girl, was characterised by sudden onset of fever accompanied by headache, malaise, and vomiting 3 days after receiving yellow fever and measles-mumps-rubella vaccines. Afterwards she decompensated with icterus and haemorrhagic signs and died after a 5-day illness. The second patient-a 22-year-old black woman-developed a sore throat and fever accompanied by headache, myalgia, nausea, and vomiting 4 days after yellow fever vaccination. She then developed icterus, renal failure, and haemorrhagic diathesis, and died after 6 days of illness. Yellow fever virus was recovered in suckling mice and C6/36 cells from blood in both cases, as well as from fragments of liver, spleen, skin, and heart from the first case and from these and other viscera fragments in case 2. RNA of yellow fever virus was identical to that previously described for 17D genomic sequences. IgM ELISA tests for yellow fever virus were negative in case 1 and positive in case 2; similar tests for dengue, hantaviruses, arenaviruses, Leptospira, and hepatitis viruses A-D were negative. Tissue injuries from both patients were typical of wild-type yellow fever.

INTERPRETATION

These serious and hitherto unknown complications of yellow fever vaccination are extremely rare, but the safety of yellow fever 17DD vaccine needs to be reviewed. Host factors, probably idiosyncratic reactions, might have had a substantial contributed to the unexpected outcome.

A survey on community perceptions of jaundice in east Delhi: implications for the prevention and control of viral hepatitis

Using senior health professionals as interviewers, a 30-cluster sampling survey was carried out to investigate community perceptions of pilia (the local word for jaundice) in east Delhi (India). Of 416 persons (mostly mothers of children aged < 2 years) interviewed, 339 (81%) were aware of pilia as an illness. Only 322 (77%), 164 (39%), 73 (18%) and 71 (17%) people knew about correct symptoms, dangers, causes and prevention of pilia. Most of the correct responses were related to the faeco-orally transmitted viral hepatitis. Literate respondents were significantly more aware of pilia (chi 2 52.81, P < 0.0001), its symptoms (chi 2 48.88, P < 0.0001), causes (chi 2 39.34, P < 0.0001), dangers (chi 2 19.3, P = 0.0007), and prevention (chi 2 60.8, P < 0.0001). However, age of the respondents had no significant bearing (P > or = 0.05) on the correctness of responses. About 293 (70%) subjects considered pilia as a treatable illness; of them, 193 (66%) and 77 (26%) respectively expressed their preference for the 'modern' and indigenous systems of medicine for its treatment. In contrast, 110 (38%) respondents said that they would prefer faith healers for the treatment of pilia. Although only 31 (7%) persons were aware of a vaccine against pilia (hepatitis B vaccine), virtually all agreed to have their children immunized if such a vaccine were made available. The study underscores the usefulness of pilia in lay-reporting of viral hepatitis and epidemiological studies on jaundice-associated illnesses and the need for educating the community about its causes and prevention to increase people's participation in controlling viral hepatitis and other diseases that mainly manifest as jaundice.

[Increased frequency of icterus in parenterally fed patients after a change of lipid emulsion]

Parenteral nutrition is associated with liver enzyme abnormalities. Until 1993 the incidence of icterus was low in both academic hospitals in Amsterdam, the Netherlands (Academic Medical Centre (AMC) and Academic Hospital of the Free University (AZVU)). In 1993 Intralipid in the nutrition was replaced by Endolipid in the home total parenteral nutrition programme (AMC) and by Lipofundin S in AZVU. Fifty per cent of the patients in the home programme developed severe fatigue, jaundice and thrombocytopenia. These signs and symptoms disappeared over months when parenteral nutrition without fat was given. After reintroduction of Intralipid these signs and symptoms never recurred. In AZVU the incidence of jaundice increased from 21% in 1992 to 79% in 1993 (p = 0.0002). After reintroduction of Intralipid in 1994 the incidence of jaundice decreased to 16%.

CONCLUSION

Although the lipid emulsions are equivalent according to the product specification, the described observation suggests that Lipofundin S and Endolipid cause more icterus than Intralipid, possibly caused bij an impurity in the fat emulsion.

Hepatitis D infectivity profile among hepatitis B infected hospitalised patients in Calcutta

450 hospitalised cases of hepatic and non hepatic disorders and 100 normal individuals were examined for serum Hepatitis B Surface antigen and Delta Virus antigen by ELISA to find out its association with different clinical disorders. 105 patients (23.3%) and 2 control (2%) were positive for HBsAG. 60 cases with jaundice (26%) were HBsAg positive. 65% of HBsAg positive jaundiced patients had serum bilirubin level more than 2 mg per dl with a mean SGPT level of 488 iu/L. Only two cases were positive for HDV antigen among 60 HBsAg positive jaundice patients indicating a lower rate of prevalence of infection (3.3%). 62 (59%) out of 105 HBsAg positive cases did not show any history of blood transfusion or surgical interference indicating a positive HBV transmission through needle prick during investigative procedures.

Acute jaundice in Vientiane, Lao People's Democratic Republic

Analysis of serum samples from patients with acute jaundice by means of enzyme-linked immunosorbent assay and polymerase chain reaction testing provided the first profile of this condition in Vientiane, Lao PDR, in 1995 and 1996. In a case-control, hospital-based study, evidence of acute infections due to hepatitis A and B viruses was found in 14% and 10% of cases, respectively. Hepatitis E virus, however, did not appear to contribute to clinically recognized acute jaundice. Similarly, antibody to hepatitis C virus was recognized in almost equal proportions of cases (8%) and controls (6%), thus representing probable background infections. The detection of hepatitis G virus marks the first report of this virus in Lao PDR. The large proportion (21%) of new leptospiral infections in cases without acute hepatitis A or B was notable. This finding suggests significant regional underreporting of leptospirosis as a cause of acute jaundice. The limited laboratory diagnostic capabilities for confirming a differential diagnosis of leptospirosis contribute to the lack of attention paid to this important health problem.

Hepatitis in falciparum malaria

BACKGROUND

Hepatocellular jaundice occurring in patients with falciparum malaria has been called as malarial hepatitis.

METHODS

We studied 95 consecutive patients admitted with falciparum malaria. Of these 20 had evidence of malarial hepatitis. Their clinical presentation, complications and response to treatment was compared with that of patients without evidence of malarial hepatitis.

RESULTS

The clinical presentation of these patients was not different from those without hepatitis. However, the incidence of complications such as renal failure (60% vs 25%; X2 = 8.47, p < 0.01), Adult Respiratory Distress Syndrome (35% vs 3%; X2 = 18.13, p < 0.001) and septicemia (20% vs 6%; X2 = 4.01, p < 0.05) was significantly higher. The mortality also was higher in the group of patients with malarial hepatitis (40% vs 17%; X2 = 4.85, p < 0.05).

CONCLUSIONS

We conclude that the presence of hepatitis in patients with falciparum malaria indicates a more severe illness with a higher incidence of complications and a poor prognosis.

Hepatitis C and hepatitis E in acute sporadic non-A non-B hepatitis in hospital patients of Delhi (India)

Non-A, non-B hepatitis (NANBH) has been considered to be the commonest cause of acute sporadic viral hepatitis in India. Serological studies (Macro ELISA) were conducted on 477 such patients from 9 hospitals of Delhi for markers of hepatitis A and acute hepatitis B (Anti-HAV-IgM,HBsAg and anti-HBc-IgM) and 49.7% of these were found to be due to NANBH. On further testing of NANBH sera it was found that both hepatitis C and hepatitis E contribute significantly to acute sporadic jaundice in Delhi, the latter more than the former.

Serological diagnosis of jaundice epidemics in India

Enterically transmitted non-A, nonB- hepatitis (ET-NANBH) is a major public health problem in India, where the endemicity of this disease is high and poor public sanitation coupled with compromised quality of drinking water leads to major and minor outbreaks. Sophisticated technics for characterization of hepatitis E virus (HEV) are not easily available/affordable, resulting in continuation of the diagnosis of NANBH for most epidemics. This study attempts to serologically determine the etiology of epidemics of NANBH in India. Eighteen outbreaks of jaundice occurring in various regions of India over a period of twenty months were selected for this laboratory based study. Representative cases of each outbreak were subjected to detailed serological investigation for immunological markers of viral hepatitis. Each serum sample was tested for the immunological markers of acute or recent infection with hepatitis A or B viruses (anti-HAV-IgM, HBsAg and anti-HBc-IgM) by Macro ELISA (Abbott). The sera found to be negative for these three markers ie non-A, non-B hepatitis (NANBH) sera were further tested for anti-HEV by Macro ELISA (anti-HEV EIA, Abbott). A highly significant number of NANBH sera were reactive for anti-HEV in case of almost all the outbreaks. The lowest figure for anti-HEV positivity in NANBH sera of outbreak was compared with anti-HEV positivity in the controls and found to be significantly high. It was concluded that anti-HEV is an important marker revealing probability of the NANBH outbreak being due to HEV.

An analysis of perioperative cholangiography in one thousand laparoscopic cholecystectomies

BACKGROUND

We undertook this retrospective study to ascertain the proper role of perioperative cholangiography in the management of 1002 patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis.

METHODS

Nine hundred forty-one patients were categorized as being at high or low risk for choledocholithiasis according to the presence or absence of jaundice, pancreatitis, elevated bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, or radiographic evidence of common bile duct stones (CBDSs).

RESULTS

Intraoperative cholangiography (IOCG) and preoperative endoscopic retrograde cholangiopancreatography (ERCP) were equivalent in the detection of CBDSs, and laparoscopic common bile duct exploration (CBDE) was successful in 12 of the 21 patients (57%) in whom it was attempted. The ducts of the other 52 patients with CBDSs were successfully cleared by preoperative or postoperative ERCP.

CONCLUSIONS

Laparoscopic IOCG is successful in detecting CBDS in high-risk patients and half of these ducts can be cleared laparoscopically. The incidence of CBDS in low-risk patients is 1.7%, a risk that does not warrant routine cholangiography. These data suggest ERCP should be reserved for those at-risk individuals in whom IOCG or laparoscopic duct clearance has been unsuccessful.

HCV infection in Egyptian patients with acute hepatitis

The diagnostics of community-acquired acute HCV hepatitis in an endemic area was studied in 110 Egyptian patients with acute jaundice. In the first week of the jaundiced period 30 of 110 patients (27.3%) had anti-HCV antibodies. The majority already showed high levels of anti-HCV IgG (25/30), associated with anti-HCV IgM in nine of them. Five patients showed only an HCV IgM reactivity. Seven had also anti-HEV and/or anti-HBV: their jaundice could then be related to an acute infection caused by those viruses. All patients were infected with genotype 4a, in three associated with the 3a. During the follow-up five patients seroconverted for IgG, while their anti-HCV IgM did not show a uniform pattern of reactivity. Patients with positive serology suspected of an acute HCV infection were older than the patients with other acute hepatitis and showed a lower peak of ALT level. Seroconversion during acute hepatitis strongly indicated HCV as the etiologic agent. However, the detection of anti-HCV IgG antibodies in the jaundiced period showed that the majority of patients had already seroconverted to anti-HCV antibodies; in most of them it is possible to hypothesize a reactivation of a chronic HCV infection.

High-performance liquid chromatographic analysis of bilirubin and biliverdin from jaundiced broilers

A sensitive and rapid high-performance liquid chromatographic (HPLC) method was developed and used for the simultaneous determination of bilirubin and biliverdin in pericardial fluid samples collected from broilers at a poultry inspection site. A photodiode array detector distinguishing the bilirubin (UV 450 nm) and biliverdin (365 nm) was used as an analytical detector for HPLC system. An internal-surface reversed-phase silica support column was used, and the mobile phase consisted of acetonitrile: 0.5 M Tris HCl buffer (20:80, pH 7.2). Bilirubin was detected from all of the jaundiced pericardial fluid samples, and a small amount of biliverdin was detected with bilirubin in some samples. These jaundiced broilers had hepatic or bile duct lesions similar to those found in edible animals. From these results, a working definition of jaundiced broilers for poultry inspection sites was suggested: bilirubin is detectable from pericardial fluid and the carcass is in a state of yellow color change.

Halothane hepatitis in a South African population--frequency and the influence of gender and ethnicity

AIM

To review post-anaesthetic hepatitis in a South African population, given that halothane use is restricted in other countries because of the high mortality and morbidity of its associated type II (idiosyncratic) hepatitis, even though it is still widely used in South Africa.

STUDY DESIGN

Descriptive, retrospective analysis.

PATIENTS AND METHODS

Hepatitis cases that occurred after inhalational anaesthetic use were identified by means of a computer search of Groote Schuur Hospital records, 1980-1994. Cases of hepatitis caused by circulatory failure and viral hepatitis were excluded.

RESULTS

Twenty-six episodes occurred in 22 patients (mean age 49.05 years, range 32-65 years), of whom 15 were women. This gave an estimated incidence of 3.53/100,000 anaesthetics (95% confidence interval 2.06-5.0/100,000). All had pyrexia (mean 38.7 +/- 0.72 degrees C), malaise, anorexia or nausea and vomiting, with onset a mean of 4.27 +/- 3.5 days after exposure. Jaundice occurred in 86%, rash in 13.6%; 17 patients (77%) were obese. Alanine and aspartate aminotransferase levels were raised 47.49 +/- 61.8 and 55.9 +/- 54.5 times the upper limit of normal. Seven patients died and 1 underwent liver transplantation. Hepatitis occurred after the first exposure in only 2 patients (9%). Men and women had a similar risk, but the estimated relative risk for whites v. black or coloured patients was 3.33 (95% confidence interval 1.45-7.23; P = 0.003) controlling for gender. Awareness of the condition was suboptimal, and in 3 patients re-exposure to halothane occurred after an initial episode of typical halothane hepatitis.

CONCLUSION

Halothane hepatitis remains a major cause of morbidity and mortality in South Africa. It is more common in whites, but there was no gender-related excess risk.

[Euricterus. A European database on icterus with emphasis on the Danish contribution]

Clinical and biochemical data were collected prospectively from 8032 jaundiced patients to form a database as part of a EU-supported project on computer-aided diagnosis. Patients were recruited prospectively from centres in all EU-countries and some other countries as well. Five hundred and twenty-eight jaundiced patients were collected from four centres in Denmark. Alcoholic cirrhosis, acute alcoholic liver disease and malignancy of the pancreas or the biliary tract were more common in the Danish data base: 49% of cases in Denmark as compared to 30% of cases in the international database. Viral hepatitis was underrepresented in Denmark, 16% as compared to 23% in the international group. A crude Bayesian diagnostic programme on the total database with 17 diagnostic groups achieved 63% accuracy. For the 528 Danish cases the diagnostic accuracy was 64% when the European data base was used, whereas it increased to 81% when only the Danish data base was taken as basis for the calculations. In conclusion, we found a drop in diagnostic accuracy for the Danish patients when using the large European data base instead of the national one.

Epidemiology of endemic viral hepatitis in an urban area of India: a retrospective community study in Alwar

In a community study during a reference period of 1 year, 192 cases of jaundice were detected in an urban population of 69,440 in Alwar, Rajasthan. Detected by paramedics and confirmed by physicians, these cases gave an annual incidence of 2.76 (95% CI: 2.37-3.15) per 1000 population. At least one of these patients died, giving a case fatality ratio of 0.6%. The jaundice cases occurred in all areas investigated, and affected all socioeconomic strata. About 94% of the affected families had only single cases. Although cases occurred throughout the year, more than 59% occurred during June-September, which are the summer and monsoon months. The incidence was highest (5.23 per 1000) among under-5-year-olds and declined progressively and significantly thereafter. Males had a higher incidence than females at all ages; the differences were not significant. Blood samples from 56 cases who had jaundice in the last 3 months of the reference period were tested for markers of viral hepatitis. Of these, 18 (32.1%), 1 (1.8%), 0, 2 (3.6%), and 4 (7.1%) were found to have hepatitis A, B, C, D and E, respectively. The etiology of the remaining 31 cases (55%) could not be established; previously, they would have been included in the NANB (non-A, non-B) category, inflating its proportion. Hepatitis A (HA) was the predominant type; being comparatively mild, it is perhaps underrepresented in hospital-based data. Many HA cases were in adults, which may be the beginning of an age shift of HA to the right owing to improvements in living standards of the study population. Five cases were carriers of hepatitis B virus (HBV), indicating the importance of HBV infection in India as well. Finally, the study found the annual incidence of laboratory-supported cases of viral hepatitis to be 1.24 (95% CI: 0.98-1.5) per 1000 population, which suggests that it is a major public health problem in India.

Severe and complicated falciparum malaria in Melanesian adults in Papua New Guinea

Severe falciparum malaria usually occurs in children, but also occurs in nonimmune migrants or partially immune adults in areas of unstable transmission. We have studied prospectively 70 adult patients with strictly defined severe malaria from the south coast of Papua New Guinea where malaria transmission is not intense. Only 19 (27.1%) were migrants from areas where malaria transmission does not occur; many other patients were periurban dwellers who had become infected after visits to their home villages. The most common clinical features were jaundice or hepatic dysfunction, impaired consciousness, renal failure, cerebral malaria, and anemia. Hypoglycemia was common following treatment with quinine. The overall case fatality rate was 18.6%; renal failure and cerebral malaria in particular were associated with a poor outcome. Reduction in mortality might be achieved by aggressive therapy of renal failure with earlier institution of dialysis; the use of preventive measures for immigrants or urban dwellers returning to high transmission areas might reduce the incidence of this dangerous disease.

Hepatitis E antibodies in Egyptian adolescent females: their prevalence and possible relevance

Hepatitis E virus has been implicated as a frequent cause of acute sporadic hepatitis among Egyptian children. Moreover, an extraordinarily high seroprevalence rate was previously reported in a semiurban Nile Delta population. A conspicuous feature of hepatitis E is the high morbidity and mortality it can cause among infected pregnant women. We therefore evaluated the prevalence of HEV antibodies in adolescent females using a solid-phase enzyme linked immunoassay based on two recombinant hepatitis E virus antigens. A high prevalence rate (38.9%) was found in 95 apparently healthy adolescent females. The mean age of the study subjects was 21.81 +/- 2.5 (SD) range 16-25 years. Eighty (84.2%) subjects resided in Alexandria, while 15 (15.8%) came from semiurban villages of Alexandria Governorate. An increased prevalence was noted with age, as anti-HEV antibodies were detected in 32.1% and 41.8% of study participants in the second and third decades of life, respectively. Similarly, those illiterate or having received less than primary education exhibited a higher HEV prevalence than those with higher education (46.3% vs 29.3%). The majority of subjects having serological evidence of HEV infection denied previous history of jaundice which shows that HEV infection was subclinical in those cases. Ten (55.6%) pregnant females participating in the study, as well as 48 (62.3%) non pregnant females lacked serological evidence of HEV infection; i.e., 60.01% (10 + 48 out of 95) of women in the childbearing age may be susceptible to infection. This report suggests that HEV is endemic in Alexandria, Egypt; the epidemiologic risk factors associated with HEV infection need further exploration.

Jaundice due to anti-tuberculous drugs--a dose related phenomenon

Data of 429 cases proved to have tuberculosis and on anti-tuberculous short course chemotherapy was analysed to find the incidence of jaundice due to anti-tuberculous drugs. The group included 257 males and 172 females (M : F ratio of 3 : 2), aged 7 to 75 years. 336 patients received short course chemotherapy for a duration of 6 months, while 93 patients were cases of relapse and hence received treatment for 9 months duration. Of these, 7 patients developed drug induced jaundice; 2 each in the age group of 21 to 35 years, and 36 to 50 years while 3 patients were in the age group of 51-65 years. All of these patients developed jaundice within 2 months of treatment and 6 of these 7 patients were receiving drugs in doses which were not adjusted as per the weight of the patient. None of these 6 patients redeveloped jaundice when the drugs were started in doses adjusted accurately as per the weight of the patients, in accordance with IUAT recommendations. One patient (0.21%), who was staredon weight adjusted dosage of anti-TB drugs developed jaundice which was probably due to isoniazed hypersensitivity.

Risk factors for hepatitis A infection in France: drinking tap water may be of importance

The prevalence of serologic markers for hepatitis A was investigated in 936 French male military recruits from October 1992 to June 1993. Data were collected in order to assess the evolution of seroprevalence level according to the decline observed for several years and to appreciate the importance of potential risk factors. The overall prevalence of antibody against hepatitis A virus was 16.3%. The prevalence was higher among those with high number of siblings and whose Father's occupation falls into low professional class categories. Multivariate analysis found that high level of seroprevalence was also associated with tap water consumption (odd ratio (OR) = 1.56; p < 0.04), overseas travels (OR = 2.26; p < 0.001) and was higher for recruits reporting an history of clinical jaundice (OR = 2.27; p < 0.01). Together with more anticipated factors, tap water consumption may be of importance in France and this study points out the potential part taken by chlorinated water.

Hepatitis B in health workers in Italy

In Italy, a vaccination campaign against hepatitis B was launched in 1985. It was strongly recommended for health care workers. Over the period 1986-91 the incidence rate of acute B hepatitis in the general population declined from 12/100,000 in 1986 to 5/100,000 in 1991. The corresponding figures among hospital workers were 42.5/100,000 (RR 3.5; 95% CI 2.55-4.92) in 1986 and 14.5/100,000 (RR 2.9; 95% CI 2.03-4.14) in 1991, respectively. The proportion of HBV cases with jaundice was about the same in the general population (77.6%) and in the health care staff (74.2%). Nearly 6% of hospital workers cases had completed the schedule of HBV vaccine. Despite the fact that vaccination against HBV has been strongly recommended for hospital workers, the incidence of infection in this job category has continued to be higher than that in the general population, probably as a consequence of poor vaccine coverage. These findings reiterate the need for aggressive vaccination programmes in hospital workers.

Illness in returned travellers

International travel is an integral and increasing part of modern life. Travel-related illness is common, diverse and associated with varying incubation periods. A travel history should routinely be taken from every patient with a diagnostic problem, particularly if fever is present. This article focuses on common problems among returned Australian travellers.

Hepatitis-C virus antibodies (anti HCV) in haemodialyzed vs non-dialyzed patients

Anti HCV was checked using Enzyme Immuno assay (EIA) (C100-3-Abbott) in 68 patients with chronic renal failure (CRF) who were on maintenance haemodialysis and 48 patients on conservative management. Mean age of the patients was 50 years. The duration of illness ranged from 3 months to 18 years (mean 3 years). All patients were Hepatitis B surface antigen (HBsAg) negative. In haemodialyzed group 31 (46%) and in conservative group only 3 (6%) were Anti HCV positive. High Frequency of Anti HCV positivity in haemodialyzed group was related to period on dialysis (1 year) and number of blood transfusions (>4 units). Patients in whom dialyzer was re-used showed 60% positivity as compared to only 17% in those with single use. Anti HCV positivity predominated in females as compared to males, 42.6% vs 20.3%. Nine out of 10 patients with a history of jaundice and six out of 8 patients with raised transaminase levels were Anti HCV positive. Fifteen of 37 Anti HBc (IgG) positive cases were Anti HCV +ve.

Safety of nonsteroidal anti-inflammatory drugs with respect to acute liver disease

OBJECTIVE

To examine the magnitude of the risk of acute hepatitis associated with the use of nonsteroidal antiinflammatory drugs.

METHODS

We calculated the annual incidence rate of hepatitis resulting in hospitalization and then performed a case-control study using 1980 to 1987 Medicaid billing data from Michigan and Florida. The 107 cases included patients with symptomatic acute hepatitis without an identifiable cause of liver disease. Four controls per case were randomly selected and were matched for age, sex, and state. Antecedent drug exposure was assessed 30 days prior to the onset of the disease in the cases and during the same period in the controls.

RESULTS

The annual incidence rate (95% confidence interval) of acute idiopathic symptomatic hepatitis resulting in hospitalization was 2.2 (2.0 to 2.4) per 100,000 persons per year. Nine cases (8.4%) and 26 controls (6.1%) were exposed to nonsteroidal anti-inflammatory drugs, yielding an odds ratio of 1.4 (0.6 to 3.1). After adjustment for potential confounding variables, the odds ratio was 1.2 (0.5 to 2.8).

CONCLUSIONS

Acute symptomatic idiopathic liver disease severe enough to result in hospitalization is uncommon, and no association was evident between nonsteroidal anti-inflammatory drugs and acute hepatitis. This study was large enough to exclude a relative risk of 2.8. These data suggest that acute symptomatic liver disease from nonsteroidal anti-inflammatory drugs is not a frequent clinical problem.

An investigation of an outbreak of viral hepatitis in a residential area of Delhi

Epidemiological investigation of a focal outbreak of jaundice in the KD block of Pitampura, Delhi during February-March 1992 revealed that 7.0 per cent of the population of the block suffered from viral hepatitis. There was no age or sex predilection. Epidemiological findings and Serological studies suggest that the epidemic was due to Hepatitis E (Enterically transmitted Non A and Non B) virus.

Epitope mapping in proteins of hepatitis E virus

A series of synthetic peptides derived from proteins encoded by open reading frames 2 and 3 (ORF2 and ORF3) of the hepatitis E virus was used in an enzyme immunoassay to determine the localization of epitopes in these proteins. Five peptides spanning almost the entire ORF3 protein sequence and 12 peptides from the ORF2 protein were synthesized. Serum samples collected from outbreaks in three different regions of the world (Turkmenistan, Kenya, and Mexico) were analyzed by a peptide-based enzyme immunoassay. Primary analysis of the peptides was accomplished with the use of serum samples obtained from Middle Asia. Four of 5 peptides from the ORF3 protein and 4 of 12 peptides from the ORF2 protein specifically reacted with antibody from sera of HEV-infected patients. Peptides representing immunodominant epitopes were used for the analysis of serum samples from outbreaks in Kenya and Mexico. The data indicate that these synthetic peptides may be used to develop a diagnostic test to detect antibody to the hepatitis E virus.

Epidemiology of a jaundice outbreak in Rairangpur town in Orissa

A jaundice epidemic broke out in Rairangpur town of Orissa during December 1989 to January 1990. The attack rate was 1.2 per cent with 89.8 per cent cases among 11-40 years age group. Male-female ratio of cases was 2.3:1. The source of infection was traced to contamination of drinking water from leakage in the pipe line which was confirmed by a subsequent case control study. The outbreak was due to enterically transmitted Non A Non B hepatitis virus.

Tattooing as a risk of hepatitis C virus infection

The association of hepatitis C virus (HCV) infection and tattooing was studied in 87 tattooed and 126 tattoo free healthy young men who did not engage in intravenous drug use or multiple sexual activity. Antibody against HCV (anti-HCV) was tested in serum specimens by enzyme immunoassay with C100-3, NS3, and core antigens; 11 of the 87 (12.6%) tattooed and 3 of the 126 (2.4%) tattoo free subjects were positive for anti-HCV (odds ratio = 5.9, 95% CI = 1.6-22.0). A relationship was demonstrated by an increased risk for HCV infection with an increasing number of tattooed site (P(trend) = 0.002). All but one of the 87 tattooed subjects had been infected by hepatitis B virus (HBV) and 25 were carriers of hepatitis B surface antigen (HBsAg). None of the 25 HBsAg carriers was positive for anti-HCV whereas 11 of the 62 HBsAg non-carriers had anti-HCV, suggesting a negative association between the HBsAg carriage and the long lasting anti-HCV (P = 0.02, Fisher's exact). The status of the tattooer was also an important determinant for HCV infection; the risk was higher if tattooing was done by a non-professional friend than by a professional tattooist. Tattooing, probably with improperly sterilized needles, can clearly pose an increased risk for HCV infection in Taiwan. This study indicates the need for legal standards for hygienic tattooing as part of preventive measures for the control of parenterally transmitted infections.

The Epping jaundice outbreak: a 24 year follow up

STUDY OBJECTIVE

The aim was to trace 84 cases of jaundice that occurred following accidental ingestion of methylene dianiline (MDA) in Epping in 1965, and to look at long term health effects.

DESIGN

The original case notes of the cases were used to identify the patients. Subsequent tracing procedures included local general practitioners, the Central NHS Registry, electoral rolls, and company records.

SETTING

This was a community based survey.

MAIN RESULTS

The health status of 68 (81%) of the group was established with 18 deaths. Of the 50 cases known to be alive, 58% completed a health questionnaire. The causes of death were unremarkable except for one case of carcinoma of the biliary tract. Two surviving cases had suffered retinal pathology. Four other surviving cases had had a further, perhaps unrelated, episode of jaundice.

CONCLUSIONS

Although the dose and route of administration in the epidemic differed from occupational exposure, this follow up study a generation on provides little, if any, evidence of long term health sequelae. Nevertheless, in the absence of well documented exposure and health effects data, such accidental poisonings with proven animal carcinogens warrant long term follow up. The identified cohort will be the subject of further study.

Non-icteric pancreas head carcinoma fares worse than icteric pancreas head carcinoma

A total of 22 patients with non-icteric pancreas head carcinoma were retrospectively compared with 61 patients with icteric pancreas head carcinoma. No significant difference was found regarding age, sex, greatest diameter, macroscopic type, microscopic type, stage, lymphatic permeation, perineural infiltration, venous invasion, lymph node metastasis, and the presence of cancer cells at the surgical margins. The main location of pancreas head carcinoma could be divided into two sites: the superior (pericholedochal), and inferior or distal (excholedochal) areas of the pancreas head. Sixteen (73%) of the 22 non-icteric pancreas head carcinomas were located in the inferior or distal area (excholedochal), while 28 (46%) of the 61 icteric pancreas head carcinomas were situated in the superior portion (pericholedochal) (P less than 0.05). One (5%) of the 22 non-icteric pancreas head carcinomas was small pancreas carcinoma, compared with 11 (18%) of the 61 icteric pancreas head carcinomas. The cumulative 2-year and 4-year survival rates of the 22 patients with non-icteric pancreas head carcinoma were significantly worse than those of the 61 patients with icteric pancreas head carcinoma [7.9% vs. 24.6% (P less than 0.05) and 0% vs. 13.4% (P less than 0.01)]. These findings suggest that non-icteric pancreas head carcinomas normally arise in an area far from the biliary tree, and include a greater number of large tumors. Any resulting difficulty and delay in the diagnosis and treatment of this disease will usually lead to a worsening of the clinical course of non-icteric pancreas head carcinoma.

Malarial hepatitis: a heterogeneous syndrome?

BACKGROUND

The incidence of malarial hepatitis in patients with Plasmodium falciparum infection and jaundice is not known and it is not clear whether the condition is a single entity or a heterogeneous syndrome.

METHODS

We prospectively studied the natural history of all patients with falciparum malaria and jaundice admitted to military hospitals in Northeast India from 1988 to 1991. A possible drug or viral cause for the hepatitis was excluded by the history, serological tests and liver histology.

RESULTS

Of the 732 patients admitted with falciparum malaria, 39 had jaundice but only 18 had malarial hepatitis indicated by a rise in their serum glutamate pyruvate transaminase levels to more than three times the upper limit of normal and an absence of clinical or serological evidence to suggest drug or viral hepatitis. The liver in these patients was always enlarged. Their mean age was 27.6 years and 85% were males. The mean serum bilirubin was 12.7 +/- 10.3 mg/dl, serum glutamate oxaloacetate transaminase was 212.8 +/- 144.9 IU, serum glutamate pyruvate transaminase was 287.1 +/- 206.2 IU and the serum alkaline phosphatase was 20.4 +/- 10.1 KA. Clinically, 2 groups of patients were seen. Thirteen patients who presented with a severe form of disease had coma, deep jaundice and renal failure. The other 5 patients had a relatively mild illness with only fever, headache and vomiting for 2 days. Four patients with severe disease died. Liver histology (studied in 5 patients) showed Kupffer cell hyperplasia and deposition of malarial pigment. Plasmodium falciparum was demonstrated in sinusoidal red blood cells in only 2 cases.

CONCLUSIONS

Malarial hepatitis occurred in 18 out of 39 patients with jaundice and falciparum malaria. It is a heterogeneous syndrome with at least two clinical subsets and the severe disease should not be mistaken for fulminant hepatic failure as there is a better response to therapy.

Jaundice

Jaundice is a disorder of bilirubin metabolism and has many causes. History and physical examination help establish the diagnosis in 70 to 80 percent of patients. Elevation of alkaline phosphatase and gamma-glutamyl transpeptidase suggests cholestasis, either intrahepatic (e.g., medication reactions) or extrahepatic (e.g., choledocholithiasis), whereas markedly elevated serum aminotransferases are indicative of hepatocellular damage from infection, toxins or ischemia. Ultrasound examination is a useful initial procedure when extrahepatic obstruction is suspected. Endoscopic retrograde cholangiopancreatography and computed tomography may be better used to diagnose obstruction at the level of the pancreas or distal common bile duct. The treatment is based on the etiology of jaundice and includes removal of offending medications or toxins, therapy for underlying liver disease or surgery for extrahepatic obstruction.

[Clinico-epidemiological and laboratory indices in icteric forms of viral hepatitis B and C]

Icteric form of acute viral hepatitis B (VHR) and C (VHC) were characterized by similar epidemiological data and clinical symptoms, frequency of concomitant diseases, disorders of biochemical values of the blood serum. VHC as distinct from VHB was more frequent in women and was characterized by a short incubation period, prevalence of mild forms. The duration and frequency of revealing blood serum markers of viral hepatitis B are of major importance for differentiation between VHC and VHB.

Direct bilirubin measurements in jaundiced term newborns. A reevaluation

To investigate the usefulness of measuring direct bilirubin in jaundiced term newborns, we reviewed the outcome of 5255 such measurements on 2877 term (37 weeks' gestation) newborns in two hospitals. Direct bilirubin tests were ordered 15 times as often per infant at the University of California, San Francisco, as at Stanford (Calif) University, and the reported results were more than twice as high. In most of the 149 infants with high (greater than 95th percentile) direct bilirubin levels, the high levels remained unexplained (52% of cases) or were due to apparent laboratory errors (21% of cases). Forty infants (27%) had conditions sometimes associated with high direct bilirubin levels. Elevation of direct bilirubin levels contributed to the diagnosis in only four of these infants. All had minor laboratory abnormalities that resolved spontaneously. Because of their low yield and poor specificity, direct bilirubin tests are seldom helpful in evaluating jaundice in term newborns.

Prevalence of the type of hepatitis virus in hospitalized jaundiced individuals

The prevalence of different types of hepatitis virus was estimated in 185 hospitalized jaundiced patients. It was found that 41.08% were positive for HBs Ag by ELISA method. The jaundiced group was also tested for IgM antibody and for total antibodies (IgG and IgM) to HAV infection by ELISA method and 5.40% were found to be positive. All patients in the jaundiced group had serum bilirubin above normal values. It was, therefore, assumed that the rest 52.92% were suffering from Non A Non B virus infection.

Acute sporadic hepatitis in Sudanese children

Eighty consecutive cases of acute viral hepatitis and 80 controls selected from a public pediatric clinic were entered into a study of acute sporadic hepatitis in Khartoum, Sudan. Study subjects were 14 years of age or younger and were mainly from a low socioeconomic level. Non-A, non-B hepatitis was diagnosed by exclusion in 35 (43.8%) patients, hepatitis A in 27 (33.8%), acute hepatitis B in 8 (10.0%), possible Epstein-Barr virus (EBV) hepatitis in 1 patient; and dual hepatitis A and B infection in 1 patient. Eight acute cases were positive for HBsAg but negative for anti-HBc IgM and anti-HAV IgM. Delta hepatitis was not identified in any study subject. A household case of jaundice and acquaintance with an individual outside of the household with jaundice during the prior 6 months were associated with non-A, non-B hepatitis. There was no association between parenteral exposure and non-A, non-B hepatitis. These findings suggest that enterically transmitted non-A, non-B hepatitis may be a major cause of acute sporadic hepatitis in children in this area, as well as a cause of epidemic hepatitis.

Use of haemostatic parameters as a diagnostic and prognostic index in persistent jaundice: a Zaria experience

Haemostatic parameters (PT,KCCT and platelet counts) were measures in conjunction with other biochemical tests in 80 consecutive jaundiced patients here in Zaria. The investigations were performed on admission and within 72 hours after parenteral vitamin K therapy. The prothrombin time and kaolin cephalin clotting time remained prolonged after the administration of vitamin K in cases of liver cirrhosis. Prothrombin times in obstructive jaundice returned to normal after the administration of vitamin K. The prothrombin time, therefore, differentiates between the jaundice of liver cirrhosis from obstructive jaundice.

Decline of incidence of A, B and non-A, non-B hepatitis in Italy. Results of four years surveillance (1985-88). SEIEVA collaborating group

A specific surveillance system for acute viral hepatitis which uses weekly notification of cases and a standard risk factor questionnaire was started in Italy in 1984. From 1985 to 1988 153 Health Departments (27% of Italian population) joined the system. Estimated incidence of reported viral hepatitis was 30 per 100,000 in 1985 and 14 in 1988. The decline was impressive for hepatitis A, particularly in the south. Reduction of incidence was also evident for hepatitis B and Non-A, Non-B hepatitis, particularly in young adults. The decrease of viral hepatitis in Italy is consistent with recent seroepidemiological data. Shellfish consumption was the most frequent risk factor reported for hepatitis A cases at all ages. Hospitalization, surgical intervention, dental therapy and other percutaneous exposures still play a role in the transmission of parenteral hepatitis in Italy. Blood transfusions seem to be important only for Non-A, Non-B. Interventions other than vaccination to prevent B and Non-A, Non-B hepatitis due to hospitalization, surgical intervention, other percutaneous exposures and dental therapy are needed and can further contribute to the decline of hepatitis virus infection rates in Italy.

Spectrum of digestive tract diseases 1985-1987 at the Pediatric Gastroenterology Outpatient Clinic of Dr. Pirngadi General Hospital, Medan

A retrospective study has been done on infants and children attending to the Pediatric Gastroenterology Outpatient Clinic of Dr. Pirngadi General Hospital in Medan, from 1985 through 1987. During the study there were 874 patients, 477 (54.58%) suffered from diarrhea, 209 (23.91%) had bloody stool, 20 (2.99%) jaundice, 57 (6.52%) abdominal pain, 48 (5.49%) abdominal distention, 30 (3.43%) vomiting, 13 (1.49%) constipation, and 20 (2.29%) others. Of all cases with diarrhoea, watery diarrhoea were found in only 319 (66.88%), diarrhoea with vomiting 84 (17.61%), and bloody diarrhoea 74 (15.51%). Stool examination in patients with diarrhoea revealed 144 (30.19%) cases with Candida albicans, while 16 (3.35%) of them with steatorrhoea. Of 63 patients with diarrhoea on which the clinitest had been performed, sugar intolerance were found in 30 (47.62%) cases.