Obesity and ventral hernia in the context of drug addiction and mental instability: a complex scenario successfully treated with preoperative progressive pneumoperitoneum

Surgery in loss of domain hernia can result in high morbidity and mortality. Chronic muscle retraction along with the reduced volume of the peritoneal cavity can lead to potential problems such as abdominal compartment syndrome, ventilatory restriction and an elevated risk of hernia recurrence. This is affected even further by obesity; a high body mass index is strongly associated with poor outcomes after ventral hernia repair. In these individuals, preoperative preparation is vital as it can reduce surgical risks and improve patients’ outcomes. There are many strategies available. Nonetheless, an individualized case approach by a multidisciplinary team is crucial to accurately treat this troublesome pathology. We present the case of a 41-year-old obese patient with a loss of domain ventral hernia. As he had a drug addiction and several psychologic difficulties, a tailored approach was needed to successfully treat the hernia. After preoperative preparation and surgery, the patient underwent full recovery.

Safety and efficacy of endoscopic vacuum therapy for the treatment of perforations and anastomotic leaks of the upper gastrointestinal tract

AIM

To evaluate the efficacy and safety of endoscopic vacuum therapy (EVT) in the management of perforations and anastomotic leaks of the upper gastrointestinal tract.

PATIENTS AND METHODS

This is a retrospective observational study which included patients who underwent EVT due to any upper gastrointestinal defect between April 2017 and February 2019 in three Spanish Hospitals. To this end, we used the only medical device approved to date for endoscopic use (Eso-SPONGEr; B. Braun Melsungen AG, Melsungen, Germany).

RESULTS

11 patients were referred for EVT of an anastomotic leak after esophagectomy (n=7), gastrectomy (n=2), esophageal perforation secondary to endoscopic Zenker's septomiotomy (n=1) and Boerhaave syndrome (n=1). The median size of the cavity was 8×3cm. The median delay between surgery and EVT was 7 days. The median of EVT duration was 28 days. The median number of sponges used was 7 and the mean period replacement was 3.7 days. In 10 cases (91%), the defect was successfully closed. In 9 cases (82%) clinical resolution of the septic condition was achieved. 5 patients presented some adverse event: 3 anastomotic strictures, 1 retropharyngeal pain and 1 case of new-onset pneumonia. The median hospital stay from the start of EVT was 45 days. 1 patient died owing to septic complications secondary to the anastomotic leak.

CONCLUSION

EVT was successful in over 90% of perforations and anastomotic leaks of the upper gastrointestinal tract. Moreover, this is a safe therapy with only mild adverse events associated.

Duodenal perforation after percutaneous fluid drainage, a rare event: a case report

Duodenal perforations can be caused by surgical instruments during operations. These injuries can go initially unnoticed and lead to problematic complications. While uncommon, bowel perforation after percutaneous fluid drainage can severely impact the patient's outcome. These can occur from equipment used for image-guided percutaneous drainage, a technique that has changed the way surgeons handle postoperative fluid collections and has become daily practice. Prompt recognition and timely treatment of these types of complications can minimize the consequences of this dreaded scenario. We present the case of a 29-year-old male, for whom an intra-abdominal collection was detected after laparoscopic cholecystectomy. CT-guided percutaneous drainage was performed, during which the catheter inadvertently punctured the duodenum. Surgical consultation was required and, since the patient remained asymptomatic, conservative management of the duodenal perforation was accomplished without complications. On follow-ups, the patient is doing well.

SAT0577 USE OF CONTRACEPTIVE METHODS IN MEXICAN WOMEN WITH RHEUMATIC DISEASES

Background:

The importance of safe and effective contraception for women with rheumatic diseases has been increasing.1Several studies have demostrated that carefully planned pregnancies are related with better outcomes making the use of contraceptive methods (CM) more significant.

Objectives:

To describe the use of methods of contraception among Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE).

Methods:

A Cross-sectional study where women aged 18-45 followed in our CEER outpatient clinic, at Monterrey, Mexico, were questioned about the use of CM. Sociodemographic data was collected from the medical record.

CM were classified as Ineffective (10-25% pregnant each year), effective (6-9% pregnant each year) and highly effective (<1% pregnant each year). Methotrexate, Mycophenolate, Cyclophosphamide, Thalidomide and Leflunomide were considered as teratogenic drugs.

The statistical analysis was performed using SPSS 24.0. Ap<0.05was taken to indicate statistical significance.

Results:

A total of 91 patients were included, 35 (38.5%) SLE patients with a median age of 30 years (22-39) and 56 (61.5%) RA patients with a median age of 34.5 years (27.25-40). From the total population, 58 (63.7%) reported the use of teratogenic drugs, with a higher use in RA patients (p <.001). Socio-demographic characteristics are listed inTable 1.

Table 1.

Socio-demographic characteristics.

RA(n=56)SLE(n=35)pAge,years, median (IQR)34.5 (27.25-40)30(22-39)Disease duration,years, median (IQR)3.5 (1.25-7.75)4 (1-7)Onset of Sexual activity,n (%)46 (82.1)24 (68.6).135Onset of Sexual activity age, median (IQR)18 (17-20)14 (17-20)Sexually Active,n (%)*34 (60.7)18 (51.4).384Use of teratogenic drugs,n (%)44 (78.6%)14 (40%)<.001

RA, Rheumatoid Arthritis; SLE, Systemic Lupus Erythematosus. *Sexual activity in the last month.

Among the patients that had started sexual activity (SLE=24, RA=46), the most common CM was tubal ligation 26 (28.6%)Graphic 1. In this group, 49 (70%) patients received contraceptive counseling, however, 21 (42%) patients were using innefective CM.Table 2.

According to effectiveness, highly efective were the most frequent method used in patients that had started sexual activity (n=39, 55.7%)Graphic 2.

Conclusion:

Despite highly effective CM were more frequent in patients that had started sexual activity, 42% of patients that received contraceptive counseling reported the use of inneffective methods. It is neccesary to promote the counseling and use of contraception and provide a multidisciplinary support among rheumatoid patients.

Table 2.

Methods according to effectiveness in patients that received contraception counseling.

GRADE OF EFFECTIVENESSn (%)PatientsThat receive Contraceptive counselingInneffectiveEffectiveHigly effectiveRA= 4630 (65.21)12 (40)1(3.3)17 (56.6)SLE= 2419 (79.16)9 (47.3)1 (5.2)9 (47.36)Total = 70 *49 (70)21 (42)2 (4.08)26 (53.06)

RA= Rheumatoid Arthritis; SLE= Systemic Lupus Erythematosus. * Total of patients that have started sexual activity.

References:

[1]Sammaritano, L. R. (2014). Contraception in Rheumatic Disease Patients. InContraception and Pregnancy in Patients with Rheumatic Disease(pp. 201-227). Springer, New York, NY.

Figure 1.

Graphic 1. This graphic shows the frequence in percentage % of contraceptive methods used by Rheumatoid Arthritis (RA) n=56 and Systemic Lupus Erythematosus (SLE) n=35 patients, which are categorized by the grade of effectiveness. Only were included patients that had started sexual activity.

Figure 2.

Graphic 2. This graphic shows the percentage of use according to the effectiveness of contracetive methods. RA, Rheumatoid Arthritis; SLE, Systemic Lupus Erythematosus. Only were included patients that had started sexual activity.

Disclosure of Interests:

None declared

AB0411 COGNITIVE IMPAIRMENT IN PRIMARY SJÖGREN’S SYNDROME: A CASE-CONTROL STUDY

Background:

Neurological symptoms are common in primary Sjögren’s syndrome (pSS) with a prevalence of 8.5 to 70%, focusing on cognitive impairment, information in pSS is scarce.

Many neuropsychological tests are used to diagnose cognitive impairment. The Montreal Cognitive Assessment (MoCA) is a validated, practical, and reliable instrument for screening mild cognitive impairment.

Objectives:

To evaluate the prevalence of cognitive impairment with the MoCA test in pSS and compare it with controls.

Methods:

Patients of a rheumatology clinic in Northeastern Mexico were recruited, who met the pSS AECG 2002 or ACR-EULAR 2016 classification criteria. Controls, matched by demographic characteristics were included for comparison. All subjects took the MoCA. The test has a range of 0-30 points, the highest score reflects better cognitive function, and explores 6 cognitive domains (Table 2).

Table 1.

Demographic and clinical characteristics

≤ 9 years of education≥10 years of educationGroupNmean, SD1Min-maxp-valuenmean, SD1Min-maxp-valueMoCA totalpSS1725.65 (2.17)20 - 290.2484626.67 (2.27)20 - 300.3Control1424.36 (3.85)17 - 303627.22 (2.24)21 - 30VisuospatialpSS173.76 (0.9)1 - 50.505464.17 (1.03)2 - 50.056Control144.07 (1.59)0 - 5364.58 (0.87)2 - 5NamingpSS172.82 (0.39)2 - 30.831462.96 (0.2)2 - 30.711Control142.79 (0.57)1 - 3362.97 (0.16)2 - 3Deyaled recallpSS173.06 (1.34)1 - 50.251463.48 (1.31)0 - 50.921Control142.43 (1.65)0 - 5363.44 (1.68)0 - 5AttentionpSS175 (0.79)3 - 60.041465.37 (0.77)4 - 60.285Control144.29 (1.06)3 - 6365.53 (0.56)4 - 6AbstractionpSS171.71(0.68)0 - 20.464461.89 (0.31)1 - 20.79Control141.86 (0.36)1 - 2362 (0.23)1 - 3OrientationpSS176 (0)6 - 60.999465.93 (0.25)5 - 60.083Control146 (0)6 - 6366 (0)6 - 6LanguagepSS172.41(0.71)1 - 30.741462.61 (0.57)1 - 30.878Control142.5 (0.76)1 - 3362.58 (0.84)0 - 3

1SD: Standard deviation

We defined mild cognitive impairment as a score <26 and moderate-severe cognitive impairment as a score <24 as previously determined in Mexican population.

Results:

Demographic and clinical characteristics are described in Table 1. Mild cognitive impairment was present in 13 (25.4%) in pSS group versus 14 (27%) in control group. Moderate-severe cognitive impairment was present in 9 (17%) of pSS group versus 8 (15%) in control (p> 0.05).

Table 2.

MoCA subtest analysis by years of education in pSS and control group.

CharacteristicspSSn=51Controln=51Age, Mean (SD)56 (10.4)54 (14)SexFemale n (%)47 (92.15)48 (94)Male n (%)4 (7.85)3 (7.3)Disease duration (years), mean (SD)6.38 (6.15)ESSPRI mean (SD)4.94 (2.28)Years of education, median (q25-q75)13 (10-17)12 (10-15)Employment, mean (%)19 (37)29 (56)

Results of the individual domains and comparison between groups are shown in Table 2. Attention was lower in the pSS group with ≤9 years of education compared to the control group (p <0.05).

Conclusion:

We did not found a difference in the prevalence of cognitive impairment, either mild or moderate-severe, in pSS subjects with low disease duration versus controls by MoCA. We found a lower attention score in the pSS group with less than 10 of years of education.

The combination of neuropsychological examining and imaging techniques, such as SPECT or brain MRI, seem a more sensitive way to detect cognitive impairment in earlier stages.

References:

[1]Manzo, C., Martinez-Suarez, E., Kechida, M., Isetta, M. and Serra-Mestres, J. (2019). Cognitive Function in Primary Sjögren’s Syndrome: A Systematic Review. Brain Sciences, 9(4), p.85.

[2]Aguilar-Navarro S, Mimenza-Alvarado A, Palacios-García A, Samudio-Cruz A, Gutiérrez-Gutiérrez L, Ávila-Funes J. Validez y confiabilidad del MoCA (Montreal Cognitive Assessment) para el tamizaje del deterioro cognoscitivo en méxico. Revista Colombiana de Psiquiatría. 2018;47(4):237-243.

Disclosure of Interests:

None declared

THU0644-HPR TRENDS IN DIAGNOSIS AND TREATMENT OF FIBROMYALGIA AMONG MEXICAN PHYSICIANS

Background:

Fibromyalgia (FM) is a disease characterized by widespread pain which affects 2-8% of the population. Previous studies have shown lack of awareness of classification criteria and accompanying symptoms of FM, as well as heterogeneity in the management of these patients among both rheumatologist and non-rheumatologist physicians.

Objectives:

The objective of this study was to explore the trends in diagnosis and management of fibromyalgia among general practitioners, family physicians, psychiatrists, neurologists and rheumatologists in northeastern Mexico

Methods:

We designed an online survey to yield data on perception of FM, knowledge of existing classification criteria including the ACR 1990, ACR 2010, ACR 2010 modified and AATP classification criteria, as well as pharmacologic and nonpharmacologic therapy for the treatment of FM. Participants should have finished their residence at least in 2019. General practitioners, family physicians, psychiatrists, neurologists and rheumatologists were included.

Results:

A total of 236 participants were included, most of the participants were general practitioners, 149 (59.3%). Other specialties included were rheumatologists 21 (8.9%), neurologists 18 (7.6%), psychiatrists 8 (3.4%), and family physicians 49 (20.8%). FM was considered a clinical entity by 208 (88.1%) participants. Participants’ characteristics are shown in Table 1. Twenty-eight (11.9%) participants didn’t know any classification criteria for FM, and 38 (16.1%) participants answered that they didn’t use any classification criteria to make a formal diagnosis of FM. The 1990 ACR classification criteria was used the most, 62 (26.3%); closely followed by the 2010 modified ACR classification criteria, 61 (25.8%). A total of 101 (42.8%) participants made a formal diagnosis of FM in the previous year and 179 (75.8%) referred the patient to another specialist. Most patients were referred to a rheumatologist, 126 (53.4%). One-hundred and fifty-eight (66.9%) participants believe rheumatologist should be the main care providers for patients with FM.

Table 1.

Participants’ characteristics.

VariableAge, median (25p-75p)33 (27-38)Women, n (%)203 (86)Rheumatologists, n (%)21 (8.9)General practitioners, n (%)140 (59.3)Public practice, n (%)113 (47.9)Public and private practice, n (%)51 (21.6)< 5 years of practice, n (%)100 (42.4)> 15 years of practice, n (%)30 (12.7)

Conclusion:

A total of 88.1% of physicians know at least one classification criteria for the diagnosis of FM. In Mexico, rheumatologists are considered the main care providers for patients with FM. Regarding therapies with level 1A evidence for efficacy in the treatment of FM, only cognitive behavioral therapy and patient education were used by more than 50% of physicians. Serotonin-norepinephrine reuptake inhibitor and tricyclic antidepressants (both of which have level 1A evidence) were only used by 20.8 and 29.2%, respectively.

References:

[1]Fibromyalgia: a clinical review. JAMA. 2014 Apr 16;311(15):1547-55.

Table 2.

Pharmacologic and non-pharmacologic treatment of fibromyalgia among physicians.

Variablen (%)Exercise (any kind), n (%)91 (38.6)Aerobic exercise (aerobic), n (%)86 (36.4)Cognitive behavioral therapy, n (%)127 (53.8)Patient education, n (%)142 (60.2)Gabapentinoids, n (%)107 (45.3)Tricyclic antidepressants, n (%)69 (29.2)Selective serotonin reuptake inhibitors, n (%)121 (51.3)Serotonin-norepinephrine reuptake inhibitor, n (%)49 (20.8)Muscle relaxers, n (%)85 (36)NSAID, n (%)137 (58.1)Opioids, n (%)27 (11.4)Mindfulness, n (%)42 (17.8)

Disclosure of Interests:

None declared

AB0410 COGNITIVE DYSFUNCTION IN PRIMARY SJÖGREN’S SYNDROME AND SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Primary Sjögren’s syndrome (pSS) and systemic lupus erythematosus (SLE) share several clinical manifestations including neurological involvement. Cognitive dysfunction is a common neuropsychiatric manifestation in both, but evaluation and diagnosis is often challenging and delayed. The Automated Neuropsychological Assessment Metrics (ANAM) is a computerized cognitive screening tool that does not need specialized personnel to apply and is less time consuming than other tests.

Objectives:

Assess cognitive function of SLE and pSS patients with a computer-based tool (ANAM) in a single rheumatology clinic, compare its performance, and record their clinical and demographic characteristics

Methods:

We recruited patients from the rheumatology clinic of the UANL University Hospital who met the pSS 2002 AECG or ACR-EULAR 2016 classification criteria and SLE patients fulfilling SLICC 2012 criteria. We defined mild cognitive impairment as 1 to 1.9 SD below controls, and moderate-severe cognitive impairment as 2 SD or more below the comparison group (subjects matched by age, sex, ethnicity and educational level by the ANAM program) as previously employed in SLE.

Percentages were used for categorical variables and means (±SD) for numerical ones. To observe differences between groups, chi square and Student´s t were used,p<0.05 was considered significant.

Results:

A significant difference was observed in the total ANAM score between SLE and pSS patients (Table 1). In SLE, the most affected domains were simple reaction time, code substitution and delayed memory; in pSS patients, the most affected domains were inhibition and spatial work memory (Table 2).

Table 1.

Differences in ANAM performance between pSS and SLE.

VariablepSSmean, (SD)SLEmean, (SD)pFemale, %92.293.50.77Age (years)56.25 (10.45)31.99 (13.17)0.001Disease duration (years)6.38 (6.15)5.61 (6.1)0.492ANAM total score-1.43 (0.85)-1.87 (0.96)0.008Simple reaction time25.554.50.001Simple reaction time score148.39 (32.44)144.13 (52.37)0.571Code substitution (Learning)13.79.10.411Code substitution (Learning) score33.39 (8.42)38.61 (14.23)0.001Procedural reaction time-Attention15.727.30.125Procedural reaction time-Attention score70.29 (12.11)73.17 (17.68)0.277Mathematical processing11.8130.838Mathematical processing score17.92 (11.07)15.57 (6.63)0.177Matching to sample-spatial work memory21.67.80.025Matching to sample-spatial work memory score20.08 (7.66)22.26 (8.72)0.139Code substitution-delayed memory15.77.80.161Code substitution-delayed memory score26 (11.57)33.69 (18.99)0.005Simple reaction time21.632.90.165Simple reaction time score148.88 (24.82)166.29 (38.87)0.004Go/No-Go, Inhibition21.65.20.005Go/No-Go, Inhibition score3.41 (1.573.27 (1.68)0.635

Conclusion:

Cognitive impairment was common in both diseases but the cognitive domains affected were different. Rheumatologists should be aware of these differences when evaluating cognitive dysfunction in SLE and pSS patients.

References:

[1]Kurtuluş F, Çay H, Parlak E, Yaman A. Montreal cognitive assessment in primary sjogren’s syndrome. A brief screening tool. Neurosciences. 2019;24(3):199-206.

[2]Tayer-Shifman O, Green R, Beaton D, Ruttan L, Wither J, Tartaglia M et al. Validity evidence supports the use of automated neuropsychological assessment metrics as a screening tool for cognitive impairment in lupus. Arthritis Care & Research. 2019;.

Disclosure of Interests:

None declared

AB1359-HPR PERCEPTION ABOUT FIBROMYALGIA AND ITS ACCOMPANYING SYMPTOMS AMONG MEXICAN PHYSICIANS

Background:

Previous studies showed that 93% of rheumatologists consider fibromyalgia (FM) as a clinical entity. However, accompanying symptoms such as fatigue, widespread pain, sleep disturbance and headache are underrecognized among physicians. According to a previous study, most recognized symptoms by general practitioners are fatigue and widespread pain (72.6%), while about thirty percent of physicians recognize sleep disturbance and depression as symptoms.

Objectives:

To investigate physicians’ point of view of FM accompanying symptoms in northeastern Mexico.

Methods:

We designed an electronic survey about physicians’ perceived importance of depression, fatigue, widespread pain, sleep disturbances, headache and irritable bowel disease symptoms (pain and cramping) in patients with FM. Questions were answered using a 5-point Likert scale: 1, strongly disagree; 2, disagree; 3, neutral; 4, agree; 5, strongly agree. General practitioners, rheumatologists, neurologists, psychiatrists were included.

Results:

A total of 236 physicians were included: general practitioners, 149 (59.3%); rheumatologists, 21 (8.9%); neurologists 18 (7.6%); psychiatrists 8 (3.4%), and family physicians, 49 (20.8%). FM was considered a clinical diagnosis by 208 (88.1%) and most physicians think FM is both a physical and psychological condition, 190 (80.5%). Full results on physicians’ perceptions is shown in Table 1. Fatigue was the symptom which most physicians agreed or strongly agreed was important in FM, 219 (92.7%). Disagreement (any degree) was greater regarding abdominal pain/cramping being an important symptom in FM, 52 (22%). Complete results can be seen in Image 1.

Table 1.

Perceptions’ of physicians about FM.

VariableFM is a clinic diagnostic, n (%)208 (88.1)Unsure FM is a clinical diagnostic, n (%)12 (5)FM is a physical illness, n (%)33 (14)FM is a psychological illness, n (%)11 (4.7)FM is both physical and psychological, n (%)190 (80.5)FM has a negative impact on quality of life, n (%)227 (96.2)FM has a negative impact on life expectancy, n (%)135 (57.2)

Conclusion:

FM was considered a clinical diagnostic and an illness both physical and psychological by most physicians. Headache and abdominal pain/cramping are symptoms less likely to be perceived as important in patients with FM.

References:

[1]Perrot S, Choy E, Petersel D, et al. Survey of physician experiences and perceptions about the diagnosis and treatment of fibromyalgia. BMC Health Serv Res. 2012 Oct 10;12:356.

[2]Kianmehr N, Haghighi A, Bidari A. Are general practitioners well informed about fibromyalgia? Int J Rheum Dis. 2017 Dec;20(12):1917-1921

Figure 1.

Image 1. Perception of accompanying symptoms of fibromyalgia (FM)

Disclosure of Interests:

None declared

AB0263 SEXUAL FUNCTION IN WOMEN WITH RHEUMATOID ARTHRITIS: A CASE-CONTROL STUDY

Background:

Sexual dysfunction is defined as a change in any component of sexual activity, which may cause frustration, pain and decreased sexual intercourse1. Rheumatoid arthritis (RA) is a systemic autoimmune disease, which may lead to decline in joint mobility, pain, and fatigue; these impairments may influence the sexual health of patients2.

Objectives:

The main aim of this study is to determine if there is an altered sexual function in Mexican women with RA and compare if it occurs in a greater proportion than in healthy women.

Methods:

A case-control study that included Mexican women between 18 and 65 years, with RA diagnosis (according to ACR/EULAR 2010 criteria) and age-matched controls was performed. Patients were excluded if they couldn’t answer the questionnaires reliably or were currently pregnant. They were asked about their sexual activity in the last month, and the Arizona Sexual Experiences Scale (ASEX), Hospital Anxiety and Depression Scale (HADS) and Functional Assessment of Chronic Illness Therapy (FACIT) self-questionnaires were applied; disease activity was assessed by DAS-28. Variables were compared between groups with student T test for independent samples and chi-square.

Results:

We included 102 RA patients and 101 controls. Baseline demographic characteristics between groups are shown in Table 1. Women with RA had less sexual activity than controls (48.03% vs. 90.09%, p <0.001). Out of the total women included, the ASEX was applied only to those that had an active sex life, 49 with RA and 91 controls. Sexual dysfunction (> 18 points) was found in 55.1% of women with RA and in 52.74% of controls, with no significant differences (p = 0.860); the prevalence of severe fatigue was higher in RA than in the healthy group (p = 0.009) (Table 2). Women with RA and sexual dysfunction had higher levels of anxiety (p = 0.024) and fatigue (p = 0.008) than those with RA without sexual dysfunction; however, no significant difference was found in age, depression and level of disease activity between these groups.

Table 1.

Comparison of demographic variables between groups.

RA GROUP(n=102)CONTROL GROUP(n=101)P*Age, years (±SD)52.98 (+/-13.36)52.45 (+/- 8.34)0.738Sexual activity in the last month, n (%)49 (48.03%)91 (90.09%)<0.001Civil status0.456Single, n (%)26 (25.5%)18 (17.82%)Married, n (%)43 (42.2%)55 (54.45%)Divorced, n (%)15 (14.7%)11 (10.89%)Domestic partnership, n (%)5 (4.9%)4 (3.96%)Widowed, n (%)13 (12.7%)13 (12.87%)Menopause, n (%)70 (68.6%)72 (71.28%)0.760Has children, n (%)88 (86.3%)83 (82.17%)0.447

T de student or Chi-Square test according to type of variable

Table 2.

Difference in means of survey scores and frequencies of abnormal scores between groups.

RA GROUP(n=49)CONTROL GROUP(n=91)P*ASEX score (±SD)15.65 +/- 4.8215.45 +/- 5.070.819Sexual dysfunction, n (%)27 (55.1%)48 (52.74%)0.860HADS-A, anxiety subscale (±SD)6.53 +/- 3.957.15 +/- 3.980.378HADS- D, depression subscale (±SD)5.34 +/- 4.124.32 +/- 3.200.108Fatigue score (FACIT) (±SD)34.42 +/- 9.5239.21 +/- 8.370.003*Severe fatigue symptoms, n (%)17 (34.69%)13 (14.28%)0.009*

T de student or Chi-Square test according to type of variable

* Statistically significant difference.

High scoresHADS, ASEXand low scores inFACITindicate severity.

Conclusion:

In this study, women with RA have less sexual activity than healthy women, but no greater sexual dysfunction. Patients with RA and sexual dysfunction have more anxiety and fatigue; but they have no difference in age, disease activity and depression than those with RA and normal sexual function.

References:

[1]Henrique P, Queiroz T, Almeida D, et al. Como o reumatologista pode orientar o paciente com artrite reumatoide sobre func, ão sexual. Rev Bras Reumatol. 2014;55(5):458-463.

[2]Zhao S, Li E, Wang J, Luo L, Luo J, Zhao Z. Rheumatoid Arthritis and Risk of Sexual Dysfunction : A Systematic Review and Metaanalysis. 2018;45(10).

Disclosure of Interests:

None declared

The Development and Outcome of Acute-on-Chronic Liver Failure After Surgical Interventions

Acute-on-chronic liver failure (ACLF) is a syndrome with high short-term mortality. Precipitating events, including hemorrhage and infections, contribute to ACLF development, but the role of surgery remains unknown. We investigated the development of ACLF in patients with cirrhosis undergoing surgery. In total, 369 patients with cirrhosis were included in the study. The clinical and laboratory data were collected prior to and on days 1-2, 3-8, and 9-28, and at 3 and 12 months after surgery. Surgery type was classified as limited or extensive, as well as liver and nonliver surgery. A total of 39 patients had baseline ACLF. Surgery was performed during acute decompensation in 35% of the rest of the 330 patients, and 81 (24.5%) developed ACLF within 28 days after surgery. Surrogate markers of systemic inflammation were similar in patients who developed ACLF or not. Age, sex, serum sodium, baseline bacterial infection, and abdominal nonliver surgery were independent predictors for the development of ACLF after surgery. Patients who developed ACLF within 28 days after surgery had a higher mortality at 3, 6, and 12 months. Survival did not differ between patients with ACLF at surgery and those developing ACLF after surgery. Development of ACLF within 28 days after surgery and elevated alkaline phosphatase and international normalized ratio were independent predictors of 90-day mortality. Independent predictors of 1-year all-cause mortality were alkaline phosphatase, Model for End-Stage Liver Disease score, and preoperative hepatic encephalopathy, whereas nonliver surgery was associated with improved survival. ACLF frequently develops in patients with cirrhosis undergoing surgery, especially in those with active bacterial infection, lower serum sodium, and kidney or coagulation dysfunction. Prognoses of ACLF both at and after surgery are similarly poor. Patients with cirrhosis should be carefully managed perioperatively.

Precipitants of Acute-on-Chronic Liver Failure: An Opportunity for Preventative Measures to Improve Outcomes

Acute-on-chronic liver failure (ACLF) is a feared complication that can develop at any stage of chronic liver disease. The incidence of ACLF is increasing, leading to a significant burden to both the affected individual and health care systems. To date, our understanding of ACLF suggests that it may be initiated by precipitants such as systemic infection, alcohol use, or viral hepatitis. The prevalence of these vary significantly by geography and underlying liver disease, and these precipitants have a varying impact on patient prognosis. Herein, we present a review of our current understanding of the precipitants of ACLF, including gaps in current data and opportunities for meaningful intervention and areas of future research.

Balloon Tamponade and Esophageal Stenting for Esophageal Variceal Bleeding in Cirrhosis: A Systematic Review and Meta-analysis

Failure to control variceal bleeding with current recommendations occurs in 10 to 20% of cases. This systematic review and meta-analysis analyzes the experience, results, and complications of "bridge" therapies for failure to control acute variceal bleeding: balloon tamponade and esophageal stents. The main outcomes assessed were failure to control bleeding and mortality in the short-term and medium-term follow-up, and adverse events. Balloon tamponade studies had a pooled rate of short-term failure to control bleeding of 35.5%, and adverse events in over 20% of cases; 9.7% resulting in death. Stenting failed to control bleeding in the short term and medium term in 12.7 and 21.5% of cases of severe or refractory variceal bleeding, respectively, despite stent migration in 23.8% of cases. Medium-term mortality rates were similar in both therapies. Although only one trial compared these treatments, the available evidence consistently supports that stents serve as a better and safer bridge therapy in refractory acute variceal bleeding.

Current Status of Simultaneous Liver-Kidney Transplantation in the United States

On August 10, 2017, a formal policy was enacted in the United States that defined listing criteria for simultaneous liver-kidney transplantation and priority for patients who received a liver transplantation (LT) and subsequently developed significant kidney disease after LT. This article reviews and summarizes the rationale for such policies, the policies themselves, and the potential impact on LT candidates.

Hyponatremia in Cirrhosis: Implications for Liver Transplantation

Hyponatremia in cirrhosis is defined as a serum sodium level ≤130 mEq/L and occurs in approximately 22% of patients with cirrhosis. The appearance of hyponatremia in patients with cirrhosis portends a poor prognosis before liver transplantation (LT), independent of the Model for End-Stage Liver Disease (MELD) score. With the development of the MELD-sodium score, the management of hyponatremia has become more relevant than ever before. Overcorrection of hyponatremia before LT or perioperatively can lead to the devastating neurologic condition known as osmotic demyelination syndrome, which is often irreversible and fatal. Therefore, the most important tenet of hyponatremia is to avoid correcting the serum sodium by ≥8 mEq/L in a 24-hour period. Treatment of hyponatremia is highly challenging. The vast majority of patients with cirrhosis have chronic hypervolemic hyponatremia. Fluid restriction increases serum sodium levels, but tolerance and compliance are significant barriers. Diuretic withdrawal is helpful but contributes to worsening fluid overload. There are limited data to support use of intravenous concentrated albumin solutions. The use of the arginine vasopressin antagonists ("vaptans") is contentious; however, they may have a limited role. Risk factors for intraoperative overcorrection of serum sodium include increased utilization of packed red blood cell and fresh frozen plasma transfusions, which are often unavoidable. Intraoperative management is evolving, and more data are needed in regard to the use of sodium-reduced continuous venovenous hemofiltration and the use of trishydroxymethylaminomethane (Tris) to avoid excess sodium rebound. A thorough discussion of the current treatment options before and during LT is given in this review.

Quality indicators for esophagogastroduodenoscopy: A comparative study of outcomes after an improvement programme in a tertiary hospital

INTRODUCTION

There is an opportunity for improvement in the recording and measuring of quality indicators. However, no previous experiences exist in our field in terms of their compliance in esophagogastroduodenoscopy (EGD).

OBJECTIVE

To analyse compliance with EGD quality criteria and evaluate improvement after conducting a training programme.

PATIENTS AND METHODS

Comparative study of 2 cohorts: one retrospective (control group) and one prospective (intervention group), before and after a training programme consisting of an information session and the report writing improvement programme. The quality indicators proposed by the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology were used.

RESULTS

A total of 1,200 EGDs were included in a sequential manner (600 in each group). Following the training programme, a significant improvement was observed in the following indicators: documented indication (93 vs. 99.8%; P<0.01), documented full examinations (94.7 vs. 97.3%; P<0.01), correct performance (63.7 vs. 87.9%; P<0.01), appropriate biopsies according to protocols (57.9 vs. 83.8%; P<0.01), photo-documentation of described lesions (84.1 vs. 94.9%; P<0.01), photo-documentation per segment (52.9 vs. 70.5%; P<0.01) and correct overall assessment (56,9 vs. 90.5%; P<0.01). Biopsies for coeliac disease, documented indication, full examination and correct performance, if it went ahead, exceeded the recommended standard.

CONCLUSION

A very simple training programme improves EGD quality indicators, with the majority reaching the standards recommended by the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology.

Endoscopic management of bile leaks after liver transplantation: An analysis of two high-volume transplant centers

Background

Bile leak after liver transplantation (LT) is commonly treated with endoscopic retrograde cholangiopancreatography (ERCP); however, there are limited data regarding the optimal treatment strategy.

Objective

We aimed to examine the role of ERCP in LT recipients with bile leaks at two large institutions.

Methods

We reviewed all ERCPs performed in LT recipients with bile leak and duct-to-duct biliary anastomosis at two high-volume transplant centers.

Results

Eighty patients were included. Forty-seven (59%) patients underwent ERCP with plastic stent placement (with or without sphincterotomy) and 33 patients (41%) underwent sphincterotomy alone. Complete resolution was obtained in 94% of the stent group vs. 58% of the sphincterotomy group (p < 0.01). There was no difference in three-month survival among both groups. Percutaneous transhepatic therapy and surgery were required in 4% and 6% in the stent group vs. 12% and 42% in the sphincterotomy group, respectively (p = 0.22 and p < 0.001). The only predictive factor of bile leak resolution was stent placement.

Conclusion

ERCP with plastic stent placement is highly successful and more effective than sphincterotomy alone for post-LT bile leak treatment. These results indicate that ERCP and plastic stent placement should be considered the standard of care for the treatment of bile leaks in LT.

Validation of a Staging System for Acute Kidney Injury in Patients With Cirrhosis and Association With Acute-on-Chronic Liver Failure

BACKGROUND & AIMS

In patients with cirrhosis of the liver, acute kidney injury (AKI) is classified into 3 stages. Recent studies indicate that there are 2 subgroups of stage 1 disease, associated with different outcomes and serum levels of creatinine (SCr): stage 1A (SCr <1.5 mg/dL) and stage 1B (SCr ≥1.5 mg/dL). We performed a prospective study to validate, in a large series of patients with cirrhosis, the association between this new description and patient outcomes, and assess the relationship between AKI stage and the presence of acute-on-chronic liver failure.

METHODS

We collected data from 547 consecutive patients admitted for cirrhosis with acute decompensation to 2 tertiary hospitals (Italy and Spain), from February 2011 through June 2015. A total of 290 patients had AKI (53%; 197 had stage 1 disease); AKI stages were determined based on levels of SCr at diagnosis. Patients were followed up until death, liver transplantation, or for 90 days. The primary outcome was 90-day survival; secondary outcomes were progression and resolution of AKI and association with acute-on-chronic liver failure.

RESULTS

Based on level of sCr at diagnosis, 58 patients had stage 1A disease and 139 had stage 1B disease. Of patients with stage 1A disease, 82% survived for 90 days; of patients with stage 1B disease, 55% survived for 90 days (P = .001). Hepatorenal syndrome and acute tubular necrosis were the most common causes of stage 1B AKI, and hypovolemia was the most common cause of stage 1A AKI. AKI progressed in a higher proportion of patients with 1B than 1A AKI (31% vs 15%; P = .017) and resolved in a higher proportion of patients with 1A disease (90% vs 52% of patients with stage 1B; P < .001). Stage 1B disease, but not 1A, was an independent predictor of AKI progression and mortality. ACLF developed in a significantly greater proportion of patients with stage 1B disease (76%) than stage 1A disease (22%; P < .001), which could account for the poor outcomes of patients with stage 1B disease.

CONCLUSIONS

In a large group of patients with decompensated cirrhosis, we validated the association between AKI stages IA and IB (based on level of sCR) with survival times and AKI progression. We also associated these subgroups of AKI with development of acute-on-chronic liver failure. These findings are important for management of patients with decompensated cirrhosis.

Limited Efficacy of Tolvaptan in Patients with Cirrhosis and Severe Hyponatremia: Real-Life Experience

BACKGROUND

Vaptans, vasopressin selective V2-receptor antagonists, represent the first pharmacologic approach to the treatment of hypervolemic hyponatremia in cirrhosis. However, information on the use of vaptans for patients with cirrhosis and hyponatremia in a real-life scenario is limited. Therefore, this study evaluated the effect of tolvaptan on serum sodium in patients with cirrhosis and severe hypervolemic hyponatremia.

METHODS

Nine patients with cirrhosis and serum sodium ≤125 mEq/L were included.

RESULTS

Only 2 of the 9 patients (22%) gained an increase in serum sodium >130 mEq/L that persisted throughout treatment. In the remaining patients, serum sodium did not change or increased during the first days but decreased thereafter despite continuation of treatment. Only 1 patient developed hyperkalemia as a side effect.

CONCLUSIONS

The efficacy of tolvaptan in patients with cirrhosis and severe hypervolemic hyponatremia seems to be limited.

Can we prevent ischemic-type biliary lesions in donation after circulatory determination of death liver transplantation?

The pool of livers for transplantation consists of an increasingly greater proportion of marginal grafts, in particular those arising through donation after circulatory determination of death (DCD). However, a primary factor limiting the use of marginal livers, and, thereby, the applicability of liver transplantation in general, is concern over the subsequent development of ischemic-type biliary lesion (ITBL). ITBL is a devastating complication of liver transplantation; in its most severe forms, recipients suffer frequent infectious complications that require repeated invasive biliary procedures and ultimately result in either retransplantation or death. In the present review article, we discuss our current understanding of ITBL pathogenesis as it pertains to DCD, in particular. We discuss the most relevant theories regarding its development and provide a comprehensive overview of the most promising strategies we have available today to prevent the appearance of ITBL, strategies that may, furthermore, allow us to transplant a greater proportion of marginal livers in the future. Liver Transplantation 22 1025-1033 2016 AASLD.

Esophageal balloon tamponade versus esophageal stent in controlling acute refractory variceal bleeding: A multicenter randomized, controlled trial

Balloon tamponade is recommended only as a "bridge" to definitive therapy in patients with cirrhosis and massive or refractory esophageal variceal bleeding (EVB), but is frequently associated with rebleeding and severe complications. Preliminary, noncontrolled data suggest that a self-expandable, esophageal covered metal stent (SX-ELLA Danis; Ella-CS, Hradec Kralove, Czech Republic) may be an effective and safer alternative to balloon tamponade. We conducted a randomized, controlled trial aimed at comparing esophageal stent versus balloon tamponade in patients with cirrhosis and EVB refractory to medical and endoscopic treatment. Primary endpoint was success of therapy, defined as survival at day 15 with control of bleeding and without serious adverse events (SAEs). Twenty-eight patients were randomized to Sengstaken-Blakemore tube (n = 15) or SX-ELLA Danis stent (n = 13). Patients were comparable in severity of liver failure, active bleeding at endoscopy, and initial therapy. Success of therapy was more frequent in the esophageal stent than in balloon tamponade group (66% vs. 20%; P = 0.025). Moreover, control of bleeding was higher (85% vs. 47%; P = 0.037) and transfusional requirements (2 vs 6 PRBC; P = 0.08) and SAEs lower (15% vs. 47%; P = 0.077) in the esophageal stent group. TIPS was used more frequently in the tamponade group (4 vs. 10; P = 0.12). There were no significant differences in 6-week survival (54% vs. 40%; P = 0.46).

CONCLUSION

Esophageal stents have greater efficacy with less SAEs than balloon tamponade in the control of EVB in treatment failures. Our findings favor the use of esophageal stents in patients with EVB uncontrolled with medical and endoscopic treatment. (Hepatology 2016;63:1957-1967).

Hyponatremia influences the outcome of patients with acute-on-chronic liver failure: an analysis of the CANONIC study

Introduction

Hyponatremia is a marker of poor prognosis in patients with cirrhosis. This analysis aimed to assess if hyponatremia also has prognostic value in patients with acute-on-chronic liver failure (ACLF), a syndrome characterized by acute decompensation of cirrhosis, organ failure(s) and high short-term mortality.

Methods

We performed an analysis of the Chronic Liver Failure Consortium CANONIC database in 1,341 consecutive patients admitted to 29 European centers with acute decompensation of cirrhosis (including ascites, gastrointestinal bleeding, hepatic encephalopathy, or bacterial infections, or any combination of these), both with and without associated ACLF (301 and 1,040 respectively).

Results

Of the 301 patients with ACLF, 24.3% had hyponatremia at inclusion compared to 12.3% of 1,040 patients without ACLF (P <0.001). Model for end-stage liver disease, Child-Pugh and chronic liver failure-SOFA scores were significantly higher in patients with ACLF and hyponatremia compared to those without hyponatremia. The presence of hyponatremia (at inclusion or during hospitalization) was a predictive factor of survival both in patients with and without ACLF. The presence of hyponatremia and ACLF was found to have an independent effect on 90-day survival after adjusting for the potential confounders. Hyponatremia in non-ACLF patients nearly doubled the risk (hazard ratio (HR) 1.81 (1.33 to 2.47)) of dying at 90 days. However, when considering patients with both factors (ACLF and hyponatremia) the relative risk of dying at 90 days was significantly higher (HR 6.85 (3.85 to 12.19) than for patients without both factors. Patients with hyponatremia and ACLF had a three-month transplant-free survival of only 35.8% compared to 58.7% in those with ACLF without hyponatremia (P <0.001).

Conclusions

The presence of hyponatremia is an independent predictive factor of survival in patients with ACLF. In cirrhosis, outcome of patients with ACLF is dependent on its association with hyponatremia.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0700-0) contains supplementary material, which is available to authorized users.

Signaling pathways involved in neuron-astrocyte adhesion and migration

Astrocytes in the normal brain possess a stellate shape reflecting their non-migratory properties. Alternatively, in neurodegenerative diseases or after injury, astrocytes become "reactive" in a process known as astrocytosis or reactive gliosis, retract their processes, become polarized and acquire front-to-rear asymmetry typical of migratory cells. On the other hand, neuronal migration is a common process during embryonic development, but only few types of neurons can migrate and differentiate during adult life in the central nervous system. Those that do migrate follow tracks made by glial cells and mainly give rise to interneurons. In vitro, molecular mechanisms involved in adhesion of cells to and migration on extracellular matrix proteins have been widely studied; however, signal transduction pathways explaining how particularly neurons and astrocytes, mutually modulate adhesion and migration are less well known. In this review, we describe and discuss how ligand/receptor interactions in astrocytes and neurons trigger signaling events leading to actin and microtubule reorganization, changes in cell morphology, as well as cell adhesion and migration. The biological significance these cell-cell interactions and signaling events might have in the brain are discussed.

Endoscopic retrograde cholangiography for biliary anastomotic strictures after liver transplantation

Biliary complications after liver transplantation (LT) are an important cause of morbidity and mortality. In most cases, an anastomosis of the bile duct is performed as a duct-to-duct reconstruction, which makes endoscopic therapy with endoscopic retrograde cholangiography (ERC) feasible. Biliary anastomotic strictures (AS) are the most common cause of biliary complications. The early detection of an AS, which can sometimes be challenging given that its clinical presentation is often subtle, is of key importance to obtain high treatment success. In this review, we focus on the management of AS after LT with a special emphasis on ERC.

Type-1 hepatorenal syndrome associated with infections in cirrhosis: natural history, outcome of kidney function, and survival

Type-1 hepatorenal syndrome (HRS) is a common complication of bacterial infections in cirrhosis, but its natural history remains undefined. To assess the outcome of kidney function and survival of patients with type-1 HRS associated with infections, 70 patients diagnosed during a 6-year period were evaluated prospectively. Main outcomes were no reversibility of type-1 HRS during treatment of the infection and 3-month survival. Forty-seven (67%) of the 70 patients had no reversibility of type-1 HRS during treatment of the infection. [Correction to previous sentence added March 10, 2014, after first online publication: "Twenty-three (33%)" was changed to "Forty-seven (67%)."] The main predictive factor of no reversibility of type-1 HRS was absence of infection resolution (no reversibility: 96% versus 48% in patients without and with resolution of the infection; P < 0.001). Independent predictive factors of no reversibility of type-1 HRS were age, high baseline serum bilirubin, nosocomial infection, and reduction in serum creatinine <0.3 mg/dL at day 3 of antibiotic treatment. No reversibility was also associated with severity of circulatory dysfunction, as indicated by more marked activity of the vasoconstrictor systems. In the whole series, 3-month probability of survival was only 21%. Factors associated with poor prognosis were baseline serum bilirubin, no reversibility of type-1 HRS, lack of resolution of the infection, and development of septic shock after diagnosis of type-1 HRS.

CONCLUSION

Type-1 HRS associated with infections is not reversible in two-thirds of patients with treatment of infection only. No reversibility of type-1 HRS is associated with lack of resolution of the infection, age, high bilirubin, and no early improvement of kidney function and implies a poor prognosis. These results may help advance the management of patients with type-1 HRS associated with infections.

A modified acute kidney injury classification for diagnosis and risk stratification of impairment of kidney function in cirrhosis

BACKGROUND & AIMS

The Acute Kidney Injury Network (AKIN) criteria are widely used in nephrology, but information on cirrhosis is limited. We aimed at evaluating the AKIN criteria and their relationship with the cause of kidney impairment and survival.

METHODS

We performed a prospective study of 375 consecutive patients hospitalized for complications of cirrhosis. One-hundred and seventy-seven (47%) patients fulfilled the criteria of Acute Kidney Injury (AKI) during hospitalization, the causes being hypovolemia, infections, hepatorenal syndrome (HRS), nephrotoxicity, and miscellaneous (62, 54, 32, 8, and 21 cases, respectively).

RESULTS

At diagnosis, most patients had AKI stage 1 (77%). Both the occurrence of AKI and its stage were associated with 3-month survival. However, survival difference between stages 2 and 3 was not statistically significant. Moreover, if stage 1 patients were categorized into 2 groups according to the level of serum creatinine used in the classical definition of kidney impairment (1.5mg/dl), the two groups had a significantly different outcome. Combining AKIN criteria and maximum serum creatinine, 3 risk groups were identified: (A) patients with AKI stage 1 with peak creatinine ≤ 1.5mg/dl; (B) patients with stage 1 with peak creatinine >1.5mg/dl; and (C) patients with stages 2-3 (survival 84%, 68%, and 36%, respectively; p<0.001). Survival was independently related to the cause of kidney impairment, patients with HRS or infection-related having the worst prognosis.

CONCLUSIONS

A classification that combines the AKIN criteria and classical criteria of kidney failure in cirrhosis provides a better risk stratification than AKIN criteria alone. The cause of impairment in kidney function is key in assessing prognosis in cirrhosis.

Pilot study: miscellaneous therapy is highly successful for Helicobacter pylori eradication

BACKGROUND

Success in H. pylori eradication with conventional therapies has decreased to unacceptable levels (≤80%). New schemes of combined treatment are currently needed.

AIM

To test a miscellaneous therapy for H. pylori eradication.

METHODS/PATIENTS

Open-label, pilot, single-centre and prospective study. Patients received a 15-day treatment scheme that consisted of 5 initial days of lansoprazole 30 mg b.d., amoxicillin 1 g b.d., and metronidazole 500 mg t.d.s.; days 6 to 10: lansoprazole 30 mg q.d.s. and metronidazole 500 mg t.d.s.; days 11 to 15: lansoprazole 30 mg b.d., clarithromycin 500 mg b.d. and metronidazole 500 mg t.d.s. Each patient underwent an upper endoscopy before treatment and a second follow-up endoscopy at least 4 weeks after therapy. Success was defined on the basis of an eradication rate following a per-protocol analysis ≥95%. Biopsies before and after therapy were obtained for histological evaluation and rapid urease test.

RESULTS

One hundred and twenty-two patients were enrolled and 118 patients completed the study. The eradication rate for H. pylori with miscellaneous therapy was 94% (confidence Interval (CI) 95%, 90-98.3%) in the per-protocol analysis (PP) and 91% (95% CI, 86-96%) in the intention-to-treat (ITT) analysis. Adherence to treatment was 96% (113 patients). Among patients who completed treatment, 55% presented adverse events, mainly nausea and abdominal pain.

CONCLUSION

A miscellaneous therapy, based on the combination of multiple medications in high doses for 2 weeks, and with gastric pH elevation, is a highly effective treatment as a first-line therapy for the eradication of H. pylori.

Optical coherence tomography: from research to clinical application

Optical coherence tomography (OCT) has revolutionized intracoronary imaging. The unprecedented spatial resolution of this technique (15 μm) provides unique insights on the microstructure of the coronary wall. Currently, OCT is increasingly used in clinical practice and also constitutes an emerging, highly robust, research tool. OCT allows detailed visualization of atherosclerotic plaques and provides reliable information on plaque composition (lipid, fibrous, calcified) although its limited tissue penetration usually precludes a comprehensive analysis of the total plaque burden. OCT is the only technique allowing accurate measurements of the thickness of the fibrous cap, a classical marker of plaque vulnerability, and readily detects thin-cap fibroatheromas. In patients with acute coronary syndromes, plaque ruptures, with associated red or white thrombus, are nicely identified. OCT is also valuable to assess the results of coronary interventions. Stent expansion can be easily ascertained. In addition, due to its 10-times higher resolution, OCT is superior to intravascular ultrasound in the detection of even minor degrees of strut malapposition, tissue prolapse, residual thrombus and edge dissections. Furthermore, during follow-up OCT has a unique value to unravel the presence of strut coverage and to detect mild amounts of neointimal proliferation that might represent a valid surrogate marker of drug-eluting stent safety and efficacy. Finally, OCT has been used to unravel the underlying mechanisms implicated in stent failure, namely in-stent restenosis and stent thrombosis. Therefore, OCT appears ideally suited to help to move forward our understanding on the pathophysiology of coronary artery disease and to improve clinical decision-making processes, meeting the ever-increasing demand on coronary artery anatomical information from clinicians and researchers.

Hepatic hemodynamics and transient elastography in alcoholic foamy degeneration: report of 2 cases

Alcoholic liver disease (ALD) covers a wide spectrum of pathology ranging from fatty liver disease to acute steatohepatitis to cirrhosis and/or hepatocellular carcinoma. Alcoholic foamy degeneration (AFD) is an uncommon, potentially life-threatening condition that is part of the spectrum of ALD. It is characterized by extensive microvesicular steatosis in the perivenular areas. Since the first description in 1983, few case reports have been described. Here, we report 2 cases of AFD in patients with a previous history of chronic alcohol abuse and histological diagnosis of AFD with typical clinical, biochemical and histological features. In both cases we provide data on the hepatic hemodynamic status, and in one of them we report liver elastography results, which are features that have not been described previously. In both cases there was rapid resolution of biochemical and clinical abnormalities after complete abstinence, which is the mainstay of treatment for AFD.

[Timing of polyethylene glycol administration is a key factor in the tolerability and efficacy of colon preparation in colorectal cancer screening]

INTRODUCTION

The quality and tolerability of antegrade gut lavage bowel preparation are key elements in the success of population-based colorectal cancer screening.

OBJECTIVES

To evaluate cleansing quality and tolerability according to the timing of polyethylene glycol administration in persons undergoing colorectal cancer screening.

METHOD

Participants in colorectal cancer screening were randomized to two groups: a) control group (colonoscopy scheduled at 9-12 h); preparation with polyethylene glycol on the previous afternoon; b) study group (colonoscopy scheduled at 12-15 h): preparation with polyethylene glycol on the morning of the colonoscopy, with the option of a split dose. The quality of cleansing was evaluated with the Boston scale and tolerability through a questionnaire.

RESULTS

A total of 282 participants were included: preparation was carried out the day before the procedure in 134 and on the same day in 148, of which 26 received a split dose. Cleansing was adequate in 95% (n=268) of the participants. The quality of cleansing was higher in the study group (P=.045). The interval between the end of administration and the beginning of the procedure was inversely correlated with the Boston scale score (P=.036; r=-0.125). Tolerability was unrelated to the time of administration (P>.2). Acceptance of the timing of administration was lower in the study group than in the control group (26% vs 10%, respectively; P=.001).

CONCLUSIONS

Preparation as close as possible to the colonoscopy improves the quality of cleansing with no detrimental effects on tolerability, although this option is less comfortable.

Hepatic hydrothorax

Hepatic hydrothorax is defined as a transudative pleural effusion, usually greater than 500 mL, in patients with portal hypertension without any other underlying primary cardiopulmonary cause. It develops most likely because of diaphragmatic defects that allow for passage of fluid from the peritoneal space to the pleural space. Because of the mechanical constraints of the thoracic cavity, this complication of portal hypertension can be challenging to treat because patients will become symptomatic when as little as 500 mL of fluid is present in the pleural space. Treatments include salt restriction, diuretics, thoracentesis, transjugular intrahepatic portosystemic shunt, video-assisted thoracoscopy, and pleurodesis. It is important to note that a chest tube is not a potential treatment option; a hepatic hydrothorax should not be treated with a chest tube unless there is frank pus in the pleural fluid or a pneumothorax is present. The ultimate treatment is a liver transplant; the development of a hepatic hydrothorax thus warrants a referral to a liver transplant center.

Tolvaptan, an oral vasopressin antagonist, in the treatment of hyponatremia in cirrhosis

BACKGROUND & AIMS

Tolvaptan is a vasopressin V2-receptor antagonist that improves serum sodium concentration by increasing renal solute-free water excretion. Specific data on the safety and efficacy of tolvaptan in patients with cirrhosis and hyponatremia has not been exclusively evaluated.

METHODS

This sub-analysis of the Study of Ascending Levels of Tolvaptan trials examined cirrhotic patients with hyponatremia who received 15 mg oral tolvaptan (n=63; increased to 30 or 60 mg if needed) or placebo (n=57) once-daily for 30 days. At baseline, 44% had mild hyponatremia (serum sodium 130-134 mmol/L), 56% had marked hyponatremia (serum sodium <130 mmol/L), 85% had cirrhosis due to alcohol and/or hepatitis B/C, and 80% were Child-Pugh class B/C.

RESULTS

Tolvaptan was effective in raising serum sodium. Average daily area under the curve for serum sodium was significantly greater in the tolvaptan group from baseline to day 4 (p<0.0001) and day 30 (p<0.0001). This superiority was maintained after stratification by baseline hyponatremia (mild and marked), estimated glomerular filtration rate (≤ 60 ml/min and >60 ml/min), or serum creatinine levels (<1.5mg/dl and ≥ 1.5mg/dl). Hyponatremia recurred 7 days after discontinuation of tolvaptan. Mean mental component summary scores of the SF-12 health survey improved from baseline to day 30 in the tolvaptan group but not the placebo group (4.68 vs. 0.08, p=0.02). Major side effects due to tolvaptan were dry mouth and thirst. Gastrointestinal bleeding occurred in 10% and 2% of patients in the tolvaptan and placebo group, respectively (p=0.11). Adverse event rates, withdrawals, and deaths were similar in both groups.

CONCLUSIONS

One month of tolvaptan therapy improved serum sodium levels and patient-reported health status in cirrhotic patients with hyponatremia. Hyponatremia recurred in tolvaptan-treated patients after discontinuation.

Acute kidney injury is an early predictor of mortality for patients with alcoholic hepatitis

BACKGROUND & AIMS

Alcoholic hepatitis (AH) is a severe condition with high mortality. To improve therapeutic strategies, it is important to identify factors that affect survival times. The age, bilirubin, international normalized ratio, and creatinine scoring system (also known as the ABIC scoring system) was developed previously to determine the prognosis of patients with AH. We studied effects of acute kidney injury (AKI) on survival of patients with AH.

METHODS

We retrospectively analyzed data from 103 patients with biopsy-proven AH. AKI was defined as an abrupt reduction (within 48 h) in kidney function that resulted in an absolute increase of at least 0.3 mg/dL (or a 50% increase) in serum levels of creatinine from baseline (the AKI network [AKIN] criteria).

RESULTS

Twenty-nine patients (28%) developed AKI during hospitalization, with a median time to diagnosis of 3 days. Overall 90-day mortality was 23%, which was significantly higher among patients with AKI than those without (65% vs 7%; P < .0001). The age, bilirubin, international normalized ratio, and creatinine score (P < .0001) and development of AKI (P < .0001) were the most accurate independent predictors of 90-day mortality. The presence of systemic inflammatory response syndrome (P < .0001), serum bilirubin (P = .01), and international normalized ratio at admission (P = .03) were the most accurate predictors of AKI. Importantly, the AKIN criteria were more accurate than traditional criteria for renal failure (serum creatinine >1.5 mg/dL) in predicting 90-day mortality (area under the receiver operating characteristic, 0.83 vs 0.70, respectively; P = .02).

CONCLUSIONS

Development of AKI reduces survival of patients with AH, in the short term. The AKIN criteria are useful and more accurate than traditional criteria in predicting mortality. Strategies to prevent AKI therefore should be considered in the management of patients with AH.

Pre operative cardio pulmonary assessment of the liver transplant candidate

Given the severe shortage of liver donors, a carefully evaluation and selection of patients who are likely to obtain a significant survival benefit from liver transplantation (LT) is imperative in order to attain successful outcomes. Cardiovascular and respiratory events remain one of the leading causes of non-graft-related death in LT. A variety of pre-existing cardiac and pulmonary disorders are commonly identified in LT recipients, more so than in the general population. Uncertainties regarding the optimal assessment of cardiovascular and respiratory function in potential transplant candidates have produced a wide variation in the clinical care of tjis population. There is still no consensus on which assessment algorithm confers the best outcomes. Once the diagnosis has been established, the prognosis should be estimated for risk stratification and to confirm the candidacy for LT. Additionally, the challenge remains in knowing how cardiac or respiratory derangements in candidates affect the long-term outcome after LT and which is the magnitude of risk that we as physicians are willing to accept. This article discusses the cardiac and pulmonary aspects of liver disease that may impact recipient selection. Relevant literature focused upon the most common entities in this field is presented in this review.<br />

Utility and interobserver agreement of ultrasound elastography in the detection of malignant thyroid nodules in clinical care

BACKGROUND AND PURPOSE

Malignancy correlates with hardness of tissues and US elastography can potentially analyze the stiffness of lesions. Our aim was to evaluate the utility of US elastography in the detection of malignant nodules and to investigate interobserver agreement with this technique.

MATERIALS AND METHODS

One-hundred three consecutive patients with 106 thyroid nodules were examined prospectively with conventional B-mode sonography and real-time US elastography. All patients were referred for FNAB. Conventional B-mode sonography and US elastographic examinations were performed, and images were separated and independently interpreted by 2 radiologists blinded to pathologic results. US elastogram evaluation was based on a simplified classification of stiffness based on gray-scale patterns, tumor size compared with B-mode, and margins. Interobserver agreement was studied. FNAB was used as the reference standard for the diagnosis of benign nodules, but histopathologic evaluations were performed when results suspicious for malignancy or malignant results were obtained on FNAB as well as in indeterminate lesions.

RESULTS

In our study, pattern of stiffness based on gray-scale and classification proposed were statistically significant and predicted malignancy with 100% sensitivity and 40.6% specificity. Tumor size when compared with B-mode images or margins was not statistically significant in our study. No false-negatives were found, and an NPV of 100% was seen. Interobserver agreement for US elastography was excellent in our study, with a κ index of 0.82 (95% CI).

CONCLUSIONS

We believe that US elastography is a promising technique that can assist in the evaluation of thyroid nodules and can potentially diminish the number of FNAB procedures needed. We believe that it may be useful to introduce US elastography into routine clinical practice.

Management of patients with cirrhosis awaiting liver transplantation

The demand for OLT continues to be on the rise with patients spending a long time on the waiting list; this not only increases the risk of developing further decompensation but also mortality. The complications discussed above may not only lead to removal from the waiting list in some cases but also a poorer outcome following transplantation. Therefore the appropriate prevention, recognition and treatment of the above-mentioned complications of cirrhosis will have a positive impact on the outcome before and after liver transplantation.