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MBBS, MD (Pathology),
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Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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Aug 2018




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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
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Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : EC06 - EC09 Full Version

Hepatitis Activity Index and its Clinical and Biochemical Parameters in Liver Diseases- A Retrospective Study


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55827.16485
Prema Devi Elangovan, Subashree Kannan, Rajesh Haridass, D Prathiba

1. Associate Professor, Department of Pathology, Sri Muthukumaran Medical College Hospital, Chennai, Tamil Nadu, India. 2. Associate Professor, Deparment of Pathology, Sri Venkateshwara Medical College, Puducherry, India. 3. Associate Professor, Department of Pathology, Tagore Medical College, Chennai, Tamil Nadu, India. 4. Professor, Department of Pathology, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India.

Correspondence Address :
Dr. Prema Devi Elangovan,
Associate Professor, Department of Pathology, Sri Muthukumaran Medical College Hospital, Chennai, Tamil Nadu, India.
E-mail: premadevie@gmail.com

Abstract

Introduction: Hepatitis Activity Index (HAI) is a scoring system devised by Ishak K et al., for grading and staging chronic hepatitis. The HAI provides a numerical score that is both objective and reproducible, it may be useful as either an alternative or supplement to the use of conventional pathological terminology in the study and management of chronic hepatitis patients.

Aim: To assess the efficiency of HAI scoring in the non neoplastic liver diseases by relating it with the clinical and biochemical parameters.

Materials and Methods: This retrospective study was conducted in the Department of Pathology at Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India, from 2010 to 2015. A total of 57 (58%) neoplastic cases and 41 (42%) non neoplastic cases were retrieved. The data was reassessed, HAI score and grade was noted and compared with the clinical and biochemical parameters. Chronic liver disease was classified as chronic viral hepatitis {Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV)} or cirrhosis. Alkaline phosphatase levels, Serum Glutamic Oxaloacetic Transaminase (SGOT) levels , Serum Glutamic Pyruvic Transaminase (SGPT) levels were analysed. Descriptive analysis was done and the data was represented as frequency and percentage in Microsoft Excel.

Results: Among the non neoplastic cases, 21 (51%) belonged to hepatitis and cirrhosis and 20 (49%) belonged to others. In patients with high alkaline phosphatase levels, the predominant HAI score was 4. In cases with high SGOT levels, the predominant HAI score was 5 and 6. In cases with high SGPT levels, the HAI score was 5,6, and 7.

Conclusion: The HAI is useful in assessing the extent of active inflammation. It gives an objective guideline to the treating physician. The HAI score in combination with clinical and biochemical parameters offers a better insight into disease severity.

Keywords

Cirrhosis, Fibrosis, Ishak scoring, Inflammation, Management, Neoplastic

It is reported that around 400 million people are suffering from chronic Hepatitis B Virus (HBV) infection worldwide and in up to 40% of these cases cirrhosis has set in and the patients have progressed to end stage liver disease (1),(2).

Chronic Active Hepatitis (CAH) is a “necro-inflammatory lesion of the liver diagnosed by characteristic pathologic changes in the liver biopsy specimen.” In the early reports of these patients the clinical and biochemical alterations often accompanying this disease were emphasized; they described the poor prognosis associated with severe CAH, and also provided an outline of the treatment regimens; however, they were associated with significantly decreased mortality and morbidity (3),(4),(6). Recent reports suggest that severe CAH patients represent only a small percentage of the total population whose liver biopsy specimens are interpreted as having CAH (7),(8). Many of these patients are completely free of any clinical symptoms and are reported to have only mild alterations in serum aminotransferases, y-globulin, and bilirubin. The natural history of asymptomatic CAH is yet to be understood totally and any guidelines for treatment have yet to be established.

Chronic hepatitis is needs to be graded, based on the degree of inflammation and hepatocellular injury; this condition may lead to the fibrosis stage. The end stage of chronic hepatitis is cirrhosis with clinical decompensation (9),(10).

Hepatitis Activity Index (HAI) grading and staging are two vital scores that determine the mild, moderate or the severe nature of the disease (11). Though several scoring systems have been developed and are in use Ishak scoring system is more popular (12). Conventional clinical and pathological descriptions of histology of serial liver biopsy specimens do not readily provide definitive endpoints for statistical analysis. The HAI provides a numerical score that is both objective and reproducible, it may be useful as either an alternative or supplement to the use of conventional pathological terminology in the study and management of chronic hepatitis patients in whom histological changes in serial liver biopsy specimens may be the only prognostic indicator available for evaluation.

This study was performed to assess the efficiency of HAI scoring in the non neoplastic liver diseases by relating it with the clinical and biochemical parameters.

Material and Methods

A retrospective study was performed with the liver biopsy data reported in the Department of Pathology over a period of 5 years from 2010 to 2015.This study was conducted in Sri Ramachandra Medical College and Research Institute, Chennai, Tanil Nadu, India. The Institutional Ethical Committee approved the conduct of the study (Ref: CSP-MED/13/JUN/07/35).

Inclusion and Exclusion criteia: The non-neoplastic cases of hepatitis and cirrhosis were identified, reassessed, HAI score and grade noted as per Ishak scoring system (12), and compared with the clinical and biochemical parameters. All non-neoplastic cases were identified and included in the study. All neoplastic cases were excluded from the study.

Procedure

Liver biopsy samples were embedded in paraffin. Sections were stained with Hematoxylin and Eosin (H&E), Perls, and Reticulin stain. Because half of the liver sample is frozen for virologic studies, the mean sizes of the initial and final biopsy specimens were 15.6±7.5 mm and 17±6.5 mm. Chronic liver disease was classified as chronic viral hepatitis {Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV)} or cirrhosis. The cirrhosis cases were further confirmed using the special stain- Massons Trichome (Table/Fig 1). Necro inflammatory activity and fibrosis were semi quantitatively assessed according to the HAI score. Histologic analyses were performed by the same pathologist using current technical conditions.

• Clinical parameters such as age, gender, aetiology of hepatitis were recorded.
• Biochemical parameters such as alkaline phosphatase levels, Serum Glutamic Oxaloacetic Transaminase (SGOT) levels, Serum Glutamic Pyruvic Transaminase (SGPT) levels were recorded.
• Hepatitis Activity Index (HAI) grading and staging are two vital scores that determine the mild, moderate or the severe nature of the disease (11). Though several scoring systems have been developed and are in use Ishak K et al., scoring system is more popular (12).

Statistical Analysis

Hepatitis activity index score was considered as outcome variable of interest. The descriptive analysis was done and the data was represented as frequency and percentage. Microsoft Excel was used for statistical analysis.

Results

The mean age of the patient’s studied was 42.1 years. Among the 98 evaluated cases of liver biopsy, 57 cases were neoplastic (58.16%) and 41 cases were non neoplastic (41.84%). Among the non neoplastic cases, chronic liver diseases like hepatitis and cirrhosis in which HAI scoring was done were 21 cases (51%) and cases with infectious aetiology, vascular lesions, and storage disorders constituted the other 20 (49%) cases (Table/Fig 2). In the chronic liver diseases, majority of the cases (n=6) were due to alcohol intake, followed by three cases of Hepatitis B, two cases of biliary cirrhosis, and one case of Hepatitis C.

Biochemical markers: Alkaline phosphatase levels were less than 200 in 14 cases and more than 300 in four cases. Serum Glutamic Oxaloacetic Transaminase (SGOT) levels were below 100 in 14 cases and ≥100 in seven cases. Serum Glutamic Pyruvic Transaminase (SGPT) levels were less than 100 in 17 cases and ≥100 in four cases (Table/Fig 3). In cases with high alkaline phosphatase levels (n=6) the predominant HAI score was 4. In cases with high SGOT levels (n=6) the predominant HAI score was 5 and 6. In cases with high SGPT levels (n=3) the HAI score was 5,6, and 7. The predominant HAI scores were score 2 and 3 and the predominant HAI stage was stage 4. The total HAI score was 2 and 3 among 19.05% respectively. Based on HAI staging, 50% of the participants had stage IV i.e. cirrhosis (Table/Fig 4). The management of the patients based on the HAI scoring has been mentioned in (Table/Fig 5).

Discussion

This study evaluated liver biopsy specimens using HAI scoring system. The study’s findings proved that HAI scoring system can aid in assessing the severity of the disease and in the diagnosis and management.

In this current study, 21 out of the total 98 liver biopsy showed hepatic cirrhosis. Among the 21 samples, 42.86% aetiology was not identified, followed by 28.57% alcoholic aetiology and 14.29% had hepatitis B viral aetiology. Among them, 66.67% had alkaline phosphatase levels less that 200 and SGOT less than 100 respectively. The SGPT was less than 100 in 80.95% of the specimens.

In most forms of chronic liver diseases, the pathologists are expected to assign a grade and stage as part of the evaluation of the liver biopsy as it will help in predicting the patient outcome (13). There are many simple grading systems like International Association for the Study of the Liver (IASL), metavir activity score,and Batts-Ludwig score but the information conveyed to the clinician from these systems are limited and hence in the present study we have used the Ishak hepatitis activity index (HAI) score as it provides more information than the other scoring systems (14),(15),(16).

The HAI scoring is done based on four major histopathological parameters. First, Periportal of interface hepatitis graded as absent, mild (focal, few), moderate and severe with scores ranging from 0 to 4. Second, confluent necrosis (Table/Fig 6) graded as absent, focal, zone 3 necrosis in some area, necrosis in most area, necrosis with occasional portal central bridging, necrosis with multiple bridging and panacinar necrosis with scores from 0 to 4. Third, Focal lytic necrosis graded as one focus, two foci, five to ten and more than ten foci in 10 power objectives with score range 0 to 4. Lastly, portal inflammation as mild, moderate, sever and marked with scores 0 to 4. Based on this scoring and grading in this current study, periportal or periseptal interface hepatitis (Table/Fig 7) was seen in majority of cases (42.86%) with score 1, the Confluent necrosis in majority of the cases (80.96%) was score 0, the focal lytic necrosis, apoptosis and focal inflammation in majority of cases (61.90%) was score 0 and portal inflammation in majority of cases (38.10%) was score 1. The predominant HAI score in the present study was score 2 and 3 and the predominant stage in this study was stage 4 (10 cases).

This current study related the HAI score with the biochemical markers. In cases with high alkaline phosphatase levels six cases the predominant HAI score was 4. In cases with high SGOT levels (six cases) the predominant HAI score was 5 and 6. In cases with high SGPT levels (three cases) the HAI score was 5,6 and 7. Highest HAI score in patients with elevated liver enzymes was 7. Highest HAI Score in patients with cirrhosis was 9.5. Cirrhosis cases had low serum enzyme levels. Eleven patients with low serum enzymes had HAI score ≥2.

The management in the current study was done based on the HAI scoring system. Patients in stage 0 was advised for follow up, stage 1 and 2 patients were managed with medical intervention, stage 3 patients with both medical and surgical intervention and stage 4 with surgical intervention. Hence, the management of the condition can be done based on this scoring.

Previous studies in literature have insisted on the need for using a histopathological scoring system in diagnosing chronic hepatitis and cirrhosis (12),(13),(14). The scoring can also aid in determining the prognosis of the patients. Patients with initial high scores were observed to have guarded prognosis (17). The HAI score should be related with the aetiology of the disease and the biochemical parameters.

Limitation(s)

The limitation of the current study is its retrospective nature, hence clinical follow up of the patients was not possible. Large prospective studies with clinical and biochemical correlation is recommended in further.

Conclusion

Based on this study findings, HAI score in combination with the clinical and biochemical parameters can give more information for the therapeutic intervention and management of patients. Hence, utilization of HAI score in routine reporting of liver biopsy is recommended.

Acknowledgement

Authors would like to acknowledge the department staffs.

References

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DOI and Others

DOI: 10.7860/JCDR/2022/55827.16485

Date of Submission: Feb 21, 2022
Date of Peer Review: Mar 31, 2022
Date of Acceptance: Apr 21, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 24, 2022
• Manual Googling: Mar 03, 2022
• iThenticate Software: Apr 19, 2022 (8%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
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