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.