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Battye N, Patch D, Koch I, Monteith R, Roberts D, O'Connor N, Kueper B, Hulley M, Weber K. Mechanochemical degradation of per- and polyfluoroalkyl substances in soil using an industrial-scale horizontal ball mill with comparisons of key operational metrics. Sci Total Environ 2024; 928:172274. [PMID: 38604365 DOI: 10.1016/j.scitotenv.2024.172274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 04/13/2024]
Abstract
Horizontal ball mills (HBMs) have been proven capable of remediating per- and polyfluoroalkyl substances (PFAS) in soil. Industrial-sized HBMs, which could easily be transported to impacted locations for on-site, ex-situ remediation, are readily available. This study examined PFAS degradation using an industrial-scale, 267 L cylinder HBM. This is the typical scale used in the industry before field application. Near-complete destruction of 6:2 fluorotelomer sulfonate (6:2 FTS), as well as the non-target PFAS in a modern fluorotelomer-based aqueous film forming foam (AFFF), was achieved when spiked onto nepheline syenite sand (NSS) and using potassium hydroxide (KOH) as a co-milling reagent. Perfluorooctanesulfonate (PFOS) showed much better and more consistent results with scale-up regardless of KOH. Perfluorooctanoate (PFOA) was examined for the first time using a HBM and behaved similarly to PFOS. Highly challenging field soils from a former firefighting training area (FFTA) were purposefully used to test the limits of the HBM. To quantify the effectiveness, free fluoride analysis was used; changes between unmilled and milled soil were measured up to 7.8 mg/kg, which is the equivalent of 12 mg/kg PFOS. Notably, this does not factor in insoluble fluoride complexes that may form in milled soils, so the actual amount of PFAS destroyed may be higher. Soil health, evaluated through the assessment of key microbial and associated plant health parameters, was not significantly affected as a result of milling, although it was characterized as poor to begin with. Leachability reached 100 % in milled soil with KOH, but already ranged from 81 to 96 % in unmilled soil. A limited assessment of the hazards associated with the inhalation of PFAS-impacted dust from ball-milling, as well as the cross-contamination potential to the environment, showed that the risk was low in both cases; however, precautions should always be taken.
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Affiliation(s)
- Nicholas Battye
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON, Canada
| | - David Patch
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON, Canada
| | - Iris Koch
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON, Canada
| | | | - Dylan Roberts
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON, Canada
| | - Natalia O'Connor
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON, Canada
| | - Bernard Kueper
- Department of Civil Engineering, Queen's University, Kingston, ON, Canada
| | - Michael Hulley
- Environmental Sciences Group, Department of Civil Engineering, Royal Military College of Canada, Kingston, ON, Canada
| | - Kela Weber
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON, Canada.
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Tripathi D, Patch D, Mehrzad H, Yu D, Aspinall RJ, Armstrong MJ, Stanley A, Ireland H, Travis S, Hayes P, Lomax M, Roslund N, Lam E, Slinn G, Jowett S, Moakes C, Maher A, Brettell E, Sehmi S. Study protocol for a Randomised controlled trial of EArly transjugular intrahepatiC porTosystemic stent-shunt in Acute Variceal Bleeding (REACT-AVB trial). BMJ Open Gastroenterol 2024; 11:e001314. [PMID: 38519049 DOI: 10.1136/bmjgast-2023-001314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/16/2024] [Indexed: 03/24/2024] Open
Abstract
INTRODUCTION In liver cirrhosis, acute variceal bleeding (AVB) is associated with a 1-year mortality rate of up to 40%. Data on early or pre-emptive transjugular intrahepatic portosystemic stent-shunt (TIPSS) in AVB is inconclusive and may not reflect current management strategies. Randomised controlled trial of EArly transjugular intrahepatiC porTosystemic stent-shunt in AVB (REACT-AVB) aims to investigate the clinical and cost-effectiveness of early TIPSS in patients with cirrhosis and AVB after initial bleeding control. METHODS AND ANALYSIS REACT-AVB is a multicentre, randomised controlled, open-label, superiority, two-arm, parallel-group trial with an internal pilot. The two interventions allocated randomly 1:1 are early TIPSS within 4 days of diagnostic endoscopy or secondary prophylaxis with endoscopic therapy in combination with non-selective beta blockers. Patients aged ≥18 years with cirrhosis and Child-Pugh Score 7-13 presenting with AVB with endoscopic haemostasis are eligible for inclusion. The primary outcome is transplant-free survival at 1 year post randomisation. Secondary endpoints include transplant-free survival at 6 weeks, rebleeding, serious adverse events, other complications of cirrhosis, Child-Pugh and Model For End-Stage Liver Disease (MELD) scores at 6 and 12 months, health-related quality of life, use of healthcare resources, cost-effectiveness and use of cross-over therapies. The sample size is 294 patients over a 4-year recruitment period, across 30 hospitals in the UK. ETHICS AND DISSEMINATION Research ethics committee of National Health Service has approved REACT-AVB (reference number: 23/WM/0085). The results will be submitted for publication in a peer-reviewed journal. A lay summary will also be emailed or posted to participants before publication. TRIAL REGISTRATION NUMBER ISRCTN85274829; protocol version 3.0, 1 July 2023.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Homoyon Mehrzad
- Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Dominic Yu
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Richard J Aspinall
- Gastroenterology and Hepatology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Matthew J Armstrong
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | | | - Hamish Ireland
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon Travis
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Peter Hayes
- Hepatology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - Emily Lam
- GI and Liver PPI Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Gemma Slinn
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Sue Jowett
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Catherine Moakes
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Alisha Maher
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Elizabeth Brettell
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Sukhwant Sehmi
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
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P Raman K, Patch D. Tranexamic acid in variceal bleeding revisited. Hepatology 2024:01515467-990000000-00813. [PMID: 38502818 DOI: 10.1097/hep.0000000000000861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/08/2024] [Indexed: 03/21/2024]
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Medda S, Cuadra M, Yu Z, Manzano G, Spitler C, Matuszewski P, Patch D, Pease T, Chen A, Garrard V, Karunakar M. Does Anterior Plating of Pelvic Ring Fractures Increase Infection Risk in Patients With Bladder or Urethral Injuries? J Orthop Trauma 2024; 38:129-133. [PMID: 38117571 DOI: 10.1097/bot.0000000000002745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 12/14/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVES Evaluate the effect of anterior fixation on infection in patients with operative pelvic fractures and bladder or urethral injuries. METHODS DESIGN Retrospective. SETTING Eight centers. PATIENT SELECTION CRITERIA Adult patients with closed pelvic fractures with associated bladder or urethral injuries treated with anterior plating (AP), intramedullary screw (IS), or no anterior internal fixation (NAIF, including external fixation or no fixation). OUTCOME MEASURES AND COMPARISONS Deep infection. RESULTS There were 81 extraperitoneal injuries and 57 urethral injuries. There was no difference in infection between fixation groups across all urologic injuries (AP: 10.8%, IS: 0%, NAIF: 4.9%, P = 0.41). There was a higher rate of infection in the urethral injury group compared with extraperitoneal injuries (14.0% vs. 2.5%, P = 0.016). Among extraperitoneal injuries, specifically, there was no difference in deep infection related to fixation (AP: 2.6%, IS 0%, NAIF: 2.9%, P = 0.99). Among urethral injuries, there was no statistical difference in deep infection related to fixation (AP: 23.1%, IS: 0%, NAIF: 7.4%, P = 0.21). There was a higher rate of suprapubic catheter (SPC) use in urethral injuries compared with extraperitoneal injuries (57.9% vs. 4.9%, P < 0.0001). In the urethral injury group, SPC use did not have a statistically significant difference in infection rate (SPC: 18.2% vs. No SPC: 8.3%, P = 0.45). Early removal of the SPC before or during the definitive orthopaedic intervention did not significantly affect infection rate (early: 0% vs. delayed: 25.0%, P = 0.16). CONCLUSIONS Surgeons should approach operative pelvic fractures with associated urologic injuries with caution given the high risk of infection. Further work must be done to elucidate the effect of anterior implants and SPC use and duration. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Suman Medda
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Mario Cuadra
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Givenchy Manzano
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Clay Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Paul Matuszewski
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - David Patch
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Tyler Pease
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Andrew Chen
- UNC Orthopaedics, University of North Carolina at Chapel Hill, UNC School of Medicine, Chapel Hill, NC
| | - Victoria Garrard
- UNC Orthopaedics, University of North Carolina at Chapel Hill, UNC School of Medicine, Chapel Hill, NC
| | - Madhav Karunakar
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
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Dongelmans E, Erler N, Adam R, Nadalin S, Karam V, Yilmaz S, Kelly C, Pirenne J, Acarli K, Allison M, Hakeem A, Dhakshinamoorthy V, Fedaruk D, Rummo O, Kilic M, Nordin A, Fischer L, Parente A, Mirza D, Bennet W, Tokat Y, Faitot F, Antonelli BB, Berlakovich G, Patch D, Berrevoet F, Ribnikar M, Gerster T, Savier E, Gruttadauria S, Ericzon BG, Valdivieso A, Cuervas-Mons V, Perez Saborido B, Croner RS, De Carlis L, Magini G, Rossi R, Popescu I, Razvan L, Schneeberger S, Blokzijl H, Llado L, Gomez Bravo MA, Duvoux C, Mezjlík V, Oniscu GC, Pearson K, Dayangac M, Lucidi V, Detry O, Rotellar F, den Hoed C, Polak WG, Darwish Murad S. Recent outcomes of liver transplantation for Budd-Chiari syndrome: A study of the European Liver Transplant Registry (ELTR) and affiliated centers. Hepatology 2024:01515467-990000000-00750. [PMID: 38358658 DOI: 10.1097/hep.0000000000000778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/06/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND AND AIMS Management of Budd-Chiari syndrome (BCS) has improved over the last decades. The main aim was to evaluate the contemporary post-liver transplantant (post-LT) outcomes in Europe. APPROACH AND RESULTS Data from all patients who underwent transplantation from 1976 to 2020 was obtained from the European Liver Transplant Registry (ELTR). Patients < 16 years with secondary BCS or HCC were excluded. Patient survival (PS) and graft survival (GS) before and after 2000 were compared. Multivariate Cox regression analysis identified predictors of PS and GS after 2000. Supplemental data was requested from all ELTR-affiliated centers and received from 44. In all, 808 patients underwent transplantation between 2000 and 2020. One-, 5- and 10-year PS was 84%, 77%, and 68%, and GS was 79%, 70%, and 62%, respectively. Both significantly improved compared to outcomes before 2000 ( p < 0.001). Median follow-up was 50 months and retransplantation rate was 12%. Recipient age (aHR:1.04,95%CI:1.02-1.06) and MELD score (aHR:1.04,95%CI:1.01-1.06), especially above 30, were associated with worse PS, while male sex had better outcomes (aHR:0.63,95%CI:0.41-0.96). Donor age was associated with worse PS (aHR:1.01,95%CI:1.00-1.03) and GS (aHR:1.02,95%CI:1.01-1.03). In 353 patients (44%) with supplemental data, 33% had myeloproliferative neoplasm, 20% underwent TIPS pre-LT, and 85% used anticoagulation post-LT. Post-LT anticoagulation was associated with improved PS (aHR:0.29,95%CI:0.16-0.54) and GS (aHR:0.48,95%CI:0.29-0.81). Hepatic artery thrombosis and portal vein thrombosis (PVT) occurred in 9% and 7%, while recurrent BCS was rare (3%). CONCLUSIONS LT for BCS results in excellent patient- and graft-survival. Older recipient or donor age and higher MELD are associated with poorer outcomes, while long-term anticoagulation improves both patient and graft outcomes.
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Affiliation(s)
- Edo Dongelmans
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nicole Erler
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rene Adam
- Department of Hepato-Biliary Surgery, Cancer and Transplantation Unit, Hospital Paul Brousse, Villejuif, France
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, Universitätsklinik Tübingen, Tubingen, Germany
| | - Vincent Karam
- Department of Hepato-Biliary Surgery, Cancer and Transplantation Unit, Hospital Paul Brousse, Villejuif, France
| | - Sezai Yilmaz
- Department of Surgery, Liver Transplant Institute, Turgut Özal Medical Center, Malatya, Turkey
| | - Claire Kelly
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery, Universitaire Ziekenhuizen Leuven, Belgium
| | - Koray Acarli
- Department of Liver and Biliary Tract Surgery, Memorial Hospital, Istanbul, Turkey
| | - Michael Allison
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge NIHR Biomedical Research Center, Cambridge, UK
| | - Abdul Hakeem
- Department of HPB Surgery and Liver Transplantation, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Dzmitry Fedaruk
- Department of Transplantation, Minsk Scientific and Practical Center for Surgery, Transplantology and Hepatology, Minsk, Belarus
| | - Oleg Rummo
- Department of Transplantation, Minsk Scientific and Practical Center for Surgery, Transplantology and Hepatology, Minsk, Belarus
| | - Murat Kilic
- Department of Surgery, Kent Hospital, Izmir, Turkey
| | - Arno Nordin
- Transplantation and Liver Surgery Unit, Helsinki University Hospital, Helsinki, Finland
| | - Lutz Fischer
- Department of Surgery, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Darius Mirza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - William Bennet
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Yaman Tokat
- Department of General Surgery, International Liver Center and Acibadem Health Care Hospitals, Istanbul, Turkey
| | - Francois Faitot
- Department of HPB Surgery and Transplantation, C.H.R.U. de Strasbourg, Strasbourg, France
| | - Barbara B Antonelli
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriela Berlakovich
- Department of Transplantation Surgery, Medical University of Vienna, Wien, Austria
| | - David Patch
- Department of Hepatology and Liver Transplantation, Royal Free Hospital, London, UK
| | - Frederik Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, University Hospital Gent, Ghent, Belgium
| | - Marija Ribnikar
- Department of Gastroenterology, University Medical Center Lubljana, Ljubljana, Slovenia
| | - Theophile Gerster
- Department of Gastroenterology and Hepatology, C.H.U. de Grenoble, Grenoble, France
| | - Eric Savier
- Department of Digestive Surgery and Liver Transplantation, Pitie Salpetriere university hospital, Sorbonne University, Paris, France
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
- Department of Surgery and Medical and Surgical Specialties, University of Catania, Catania, Italy
| | - Bo-Göran Ericzon
- Department of Transplantation Surgery, Karolinska University Hospital, Huddinge, Sweden
| | - Andrés Valdivieso
- Department of HBP Surgery and Liver Transplantation, Cruces University hospital, Bilbao, Spain
| | | | - Baltasar Perez Saborido
- Department of General and Digestive Surgery, Hospital Universitario "Rio Hortega", Valladolid, Spain
| | - Roland S Croner
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, Germany
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, University of Milano-Bicocca, Milan, Italy
| | - Giulia Magini
- Department of Surgery, Hôpital Universitaire de Genève, Geneve, Switzerland
| | - Roberta Rossi
- Department of Gastroenterology and Transplantation, Università Politecnica delle Marche, Ancona, Italy
| | - Irinel Popescu
- Department of Surgery, University of Medicine "Carol Davila", Bucharest, Romania
| | - Laze Razvan
- Department of Surgery, University of Medicine "Carol Davila", Bucharest, Romania
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, University Hospital, Innsbruck, Austria
| | - Hans Blokzijl
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Laura Llado
- Department of Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Christophe Duvoux
- Department of Medical Liver Transplant Unit and Liver, Hôpital Henri Mondor, Creteil, France
| | - Vladimír Mezjlík
- Department of Transplantation, Center of cardiovascular surgery and transplantations, Brno, Czech Republic
| | - Gabriel C Oniscu
- Edinburgh Transplant Center, Royal Infirmary of Edinburgh, Edinburg, UK
| | - Kelsey Pearson
- Edinburgh Transplant Center, Royal Infirmary of Edinburgh, Edinburg, UK
| | - Murat Dayangac
- Center for Organ Transplantation, Medipol University Hospital, Istanbul, Turkey
| | - Valerio Lucidi
- Department of abdominal surgery, Unit of Hepato-biliary surgery and Liver Transplantation, Hôpital Erasme, Cliniques Universitaires de Bruxelles, Brussels, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, Liege, Belgium
| | - Fernando Rotellar
- Department of General and Digestive Surgery, Clinica Universitaria de Navarra, Pamplona, Spain
| | - Caroline den Hoed
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Wojciech G Polak
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Maan R, Lauw MN, China L, Patch D, Baiges A, Garcia-Pagan JC, Hernández-Gea V, Hilleret MN, Tjwa ET, Kounis I, Bureau C, Giguet B, Heurgué A, Ollivier-Hourmand I, Causse X, Nery F, Eshraghian A, Plessier A, Darwish Murad S. Extensive splanchnic vein thrombosis after SARS-CoV-2 vaccination: A Vascular Liver Disease Group (VALDIG) initiative. Hepatology 2024:01515467-990000000-00747. [PMID: 38358465 DOI: 10.1097/hep.0000000000000787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/20/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND AND AIMS Since the introduction of SARS-CoV-2 vaccines, several cases of vaccine-induced immune thrombocytopenia and thrombosis (VITT) have been described, especially cerebral vein thrombosis. We aimed to retrospectively collect all new cases of acute onset first or recurrent splanchnic vein thrombosis (SVT) following a recent SARS-CoV-2 vaccination within the Vascular Liver Disease Group network. APPROACH AND RESULTS New cases of SVT were identified from April 2021 to April 2022; follow-up was completed on December 31, 2022. Criteria to define VITT were derived from previous studies. Data from a pre-COVID cohort of patients with SVT (N=436) were used for comparison of clinical presentation, etiology, and outcome. Twenty-nine patients were identified with SVT occurring with a median of 11 days (range 2-76) after the first (48%), second (41%), or third (10%) vaccination (ChAdOx1 nCov-19 (n=12) or BNT162b2 (n=14), other (n=3) Only 2 patients(7%) fulfilled criteria for definite VITT. Twenty (69%) had SVT at multiple sites, including 4 (14%) with concomitant extra-abdominal thrombosis. Only 28% had an underlying prothrombotic condition, compared to 52% in the pre-COVID SVT cohort ( p =0.01). Five patients (17%) underwent bowel resection for mesenteric ischemia, compared with 3% in pre-COVID SVT ( p <0.001). Two patients died shortly after diagnosis (7%). CONCLUSIONS Although definite VITT was rare, in 72% of cases, no other cause for SVT could be identified following SARS-CoV-2 vaccination. These cases were different from patients with nonvaccine-related SVT, with lower incidence of prothrombotic conditions, higher rates of bowel ischemia, and poorer outcome. Although SVT after SARS-CoV-2 vaccination is rare in absolute terms, these data remain relevant considering ongoing revaccination programs.
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Affiliation(s)
- Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mandy N Lauw
- Department of Hematology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Loise China
- Institute of Liver and Digestive Health, University College London, United Kingdom
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Anna Baiges
- v Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic Barcelona, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona. CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas)
| | - Juan Carlos Garcia-Pagan
- v Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic Barcelona, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona. CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas)
| | - Virginia Hernández-Gea
- v Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic Barcelona, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona. CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas)
| | - Marie-Noelle Hilleret
- Service d'Hépato-Gastroentérologie, CHU Grenoble Alpes, 38043 Grenoble Cedex, France
| | - Eric T Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ilias Kounis
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire ; Inserm, Université Paris-Saclay, Université Paris-Saclay, Inserm, Physiopathogénèse et traitement des maladies du Foie, FHU Hepatinov, Villejuif, France
| | - Christophe Bureau
- University Hospital of Toulouse and Toulouse III Paul Sabatier University, Toulouse, France
| | - Baptiste Giguet
- Liver Disease Department, CHU Rennes, Univ Rennes, Rennes, France
| | | | | | - Xavier Causse
- Department of Hepatology and Gastroenterology, Orleans, France
| | - Filipe Nery
- Centro Hospitalar Universitário de Santo António, Porto, Portugal
- EpiUnit, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
| | - Ahad Eshraghian
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz, Iran
| | - Aurélie Plessier
- Université de Paris, AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Centre de recherche sur l'inflammation, Inserm, Paris, France
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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7
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Patch D, O'Connor N, Vereecken T, Murphy D, Munoz G, Ross I, Glover C, Scott J, Koch I, Sauvé S, Liu J, Weber K. Advancing PFAS characterization: Enhancing the total oxidizable precursor assay with improved sample processing and UV activation. Sci Total Environ 2024; 909:168145. [PMID: 37952659 DOI: 10.1016/j.scitotenv.2023.168145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 11/14/2023]
Abstract
Per- and polyfluoroalkyl substances (PFAS) encompass over 9000 chemicals utilized in various industrial and commercial applications. However, the quantification of PFAS using standard commercial analytical methods is currently limited to <50 selected compounds. To address this issue, the total oxidizable precursor (TOP) assay was developed, allowing for the oxidative conversion of previously undetectable PFAS precursors into measurable PFAS. This study investigated different sample processing methods to address post-oxidation PFAS loss identified in literature. Using PFOS as a probe molecule, up to 50 % loss of PFOS was identified during sample work-up. It was determined that the use of mass-labelled PFOS and methanolic acetic acid to chemically quench the sample post-oxidation improved PFOS recovery and allowed for correction of any remaining PFOS loss. The use of ultraviolet (UV) light was then investigated as an activator in contrast to the standard thermal activation method. A comparative evaluation was conducted to assess the recovery and conversion of perfluorooctanoic acid (PFOA), PFOS, and 6:2 fluorotelomer sulfonate (6:2 FTS) using both the heat-activated and UV-activated TOP assays. Results demonstrated that the UV-activated TOP assay achieved complete (100 %) oxidation of 6:2 FTS within 7.5 min, resulting in a total yield of generated perfluorinated carboxylic acids (PFCAs) at 108 ± 8 %. The study concluded by investigating the UV-activated TOP assay for its application on various aqueous film forming foam (AFFF) formulations and two AFFF samples drained from military aircraft rescue firefighting vehicles (ARFFVs). Analysis of these AFFF samples were supported by high resolution mass spectrometry and an expanded analytical suite, identifying several fluorotelomer precursors. The findings of this study provide compelling evidence that modifications in sample processing, work-up procedures, expansion of initial PFAS calibration standards, and UV-activation methods enhance the TOP assay, positioning it as a more reliable and quantitative analytical tool for PFAS characterization.
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Affiliation(s)
- David Patch
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Natalia O'Connor
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Taylor Vereecken
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Daniel Murphy
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Gabriel Munoz
- Brace Water Center, Department of Civil Engineering, McGill University, Montreal, QB H3A 0G4, Canada
| | - Ian Ross
- CDM Smith, 75 State St #701, Boston, MA 02109, United States of America
| | - Caitlin Glover
- Brace Water Center, Department of Civil Engineering, McGill University, Montreal, QB H3A 0G4, Canada
| | - Jennifer Scott
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Iris Koch
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Sébastien Sauvé
- Département de chimie, Université de Montréal, Montréal, QC H2V 0B3, Canada
| | - Jinxia Liu
- Brace Water Center, Department of Civil Engineering, McGill University, Montreal, QB H3A 0G4, Canada
| | - Kela Weber
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada.
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8
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Tranah TH, Nayagam JS, Gregory S, Hughes S, Patch D, Tripathi D, Shawcross DL, Joshi D. Diagnosis and management of ectopic varices in portal hypertension. Lancet Gastroenterol Hepatol 2023; 8:1046-1056. [PMID: 37683687 DOI: 10.1016/s2468-1253(23)00209-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/29/2023] [Accepted: 07/03/2023] [Indexed: 09/10/2023]
Abstract
Ectopic variceal bleeding is a rare cause of gastrointestinal bleeding that can occur in settings of cirrhotic and non-cirrhotic portal hypertension and is characterised by its development at locations remote from the oesophagus and stomach. Ectopic varices can be difficult to identify and access, and, although a relatively uncommon cause of portal hypertensive bleeding, can represent a difficult diagnostic and therapeutic challenge associated with considerable mortality. Low incidence and variance in variceal anatomy preclude large randomised controlled trials, and clinical practice is based on experience from case reports, case series, and specialist centre expertise. Optimisation of survival outcomes relies on understanding a patient's portal venous anatomy and functional hepatic reserve to guide timely and targeted endoscopic and endovascular interventions to facilitate the rapid control of ectopic variceal bleeding.
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Affiliation(s)
- Thomas H Tranah
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Institute of Liver Studies, King's College Hospital, London, UK.
| | - Jeremy S Nayagam
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Institute of Liver Studies, King's College Hospital, London, UK
| | - Stephen Gregory
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Sarah Hughes
- Department of Gastroenterology and Hepatology, St George's Healthcare NHS Trust, London, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and University College London, London, UK
| | - Dhiraj Tripathi
- Department of Liver and Hepato-Pancreato-Biliary Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Debbie L Shawcross
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Institute of Liver Studies, King's College Hospital, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
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9
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Chowdary P, Agarwal B, Peralta MR, Bhagani S, Lee S, Goldring J, Lipman M, Waqif E, Phillips M, Philippou H, Foley JH, Mutch NJ, Ariëns RAS, Stringer KA, Ricciardi F, Watissée M, Hughes D, Nathwani A, Riddell A, Patch D, Buckley J, De Neef M, Dimber R, Diaz-Garcia C, Patel H, Nandani A, Dissanayake U, Chadwick N, Alkhatip AAAMM, Watkinson P, Raith E, Singh S, Wolff T, Jha R, Brill SE, Bakhai A, Evans A, Gilani F, Gomez K. Nebulized Recombinant Tissue Plasminogen Activator (rt-PA) for Acute COVID-19-Induced Respiratory Failure: An Exploratory Proof-of-Concept Trial. J Clin Med 2023; 12:5848. [PMID: 37762789 PMCID: PMC10531875 DOI: 10.3390/jcm12185848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/31/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
Acute lung injury in COVID-19 results in diffuse alveolar damage with disruption of the alveolar-capillary barrier, coagulation activation, alveolar fibrin deposition and pulmonary capillary thrombi. Nebulized recombinant tissue plasminogen activator (rt-PA) has the potential to facilitate localized thrombolysis in the alveolar compartment and improve oxygenation. In this proof-of-concept safety study, adults with COVID-19-induced respiratory failure and a <300 mmHg PaO2/FiO2 (P/F) ratio requiring invasive mechanical ventilation (IMV) or non-invasive respiratory support (NIRS) received nebulized rt-PA in two cohorts (C1 and C2), alongside standard of care, between 23 April-30 July 2020 and 21 January-19 February 2021, respectively. Matched historical controls (MHC; n = 18) were used in C1 to explore efficacy. Safety co-primary endpoints were treatment-related bleeds and <1.0-1.5 g/L fibrinogen reduction. A variable dosing strategy with clinical efficacy endpoint and minimal safety concerns was determined in C1 for use in C2; patients were stratified by ventilation type to receive 40-60 mg rt-PA daily for ≤14 days. Nine patients in C1 (IMV, 6/9; NIRS, 3/9) and 26 in C2 (IMV, 12/26; NIRS, 14/26) received nebulized rt-PA for a mean (SD) of 6.7 (4.6) and 9.1(4.6) days, respectively. Four bleeds (one severe, three mild) in three patients were considered treatment related. There were no significant fibrinogen reductions. Greater improvements in mean P/F ratio from baseline to study end were observed in C1 compared with MHC (C1; 154 to 299 vs. MHC; 154 to 212). In C2, there was no difference in the baseline P/F ratio of NIRS and IMV patients. However, a larger improvement in the P/F ratio occurred in NIRS patients (NIRS; 126 to 240 vs. IMV; 120 to 188) and fewer treatment days were required (NIRS; 7.86 vs. IMV; 10.5). Nebulized rt-PA appears to be well-tolerated, with a trend towards improved oxygenation, particularly in the NIRS group. Randomized clinical trials are required to demonstrate the clinical effect significance and magnitude.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Banwari Agarwal
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Maria Rita Peralta
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Sanjay Bhagani
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Simon Lee
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - James Goldring
- Respiratory Medicine, Royal Free London NHS Foundation Trust, London NW1 2BU, UK
| | - Marc Lipman
- Respiratory Medicine, Royal Free London NHS Foundation Trust, London NW1 2BU, UK
- UCL Respiratory, University College London, London WC1E 6JF, UK;
| | - Emal Waqif
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Mark Phillips
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Helen Philippou
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
| | | | - Nicola J. Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences & Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Robert A. S. Ariëns
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
| | - Kathleen A. Stringer
- Department of Clinical Pharmacy, College of Pharmacy University of Michigan, Ann Arbor, MI 48109, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Federico Ricciardi
- Department of Statistical Science, University College London, London WC1E 6BT, UK
| | | | - Derralynn Hughes
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Amit Nathwani
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London WC1H 9AX, UK
| | - David Patch
- Department of Hepatology, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Jim Buckley
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Mark De Neef
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Rahul Dimber
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Cecilia Diaz-Garcia
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Honey Patel
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Aarti Nandani
- Clinical Trials Pharmacy, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Upuli Dissanayake
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Nick Chadwick
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Ahmed A. A. M. M. Alkhatip
- Department of Anaesthesia, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
- Department of Anaesthesia, Faculty of Medicine, Beni-Suef University Hospital, Beni-Suef University, Beni-Suef 2721562, Egypt
| | - Peter Watkinson
- NIHR Biomedical Research Centre Oxford, Oxford University Hospitals NHS Trust, University of Oxford, Oxford OX3 9DU, UK
| | - Eamon Raith
- Bloomsbury Institute for Intensive Care Medicine, Department of Experimental and Translational Medicine, University College London, London WC1E 6JF, UK
- Discipline of Acute Care Medicine, School of Medicine, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Suveer Singh
- Department of Respiratory and Critical Care Medicine, Chelsea & Westminster Hospital, London SW10 9NH, UK
- Department of Adult Intensive Care, Royal Brompton Hospital, London SW3 6NP, UK
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK
| | - Tony Wolff
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Rajeev Jha
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Simon E. Brill
- UCL Respiratory, University College London, London WC1E 6JF, UK;
| | - Ameet Bakhai
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Department of Cardiology, Royal Free London NHS Foundation Trust, London NW3 2PS, UK
| | - Alison Evans
- University College London (UCL)/University College London Hospitals NHS Trust (UCLH) Joint Research Office, London WC1E 6BT, UK; (A.E.)
| | - Farhat Gilani
- University College London (UCL)/University College London Hospitals NHS Trust (UCLH) Joint Research Office, London WC1E 6BT, UK; (A.E.)
| | - Keith Gomez
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
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10
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Rowe RK, Barakat FB, Patch D, Weber K. Diffusion and partitioning of different PFAS compounds through thermoplastic polyurethane and three different PVC-EIA liners. Sci Total Environ 2023:164229. [PMID: 37245819 DOI: 10.1016/j.scitotenv.2023.164229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/12/2023] [Accepted: 05/13/2023] [Indexed: 05/30/2023]
Abstract
Perfluorooctanoic acid (PFOA), perfluorooctane sulfonate (PFOS), perfluorobutane sulfonic acid (PFBS), 6:2 fluorotelomer sulfonic acid (6:2 FTS), and GenX are tested for diffusion and sorption through thermoplastic polyurethane (TPU) and three ethylene interpolymer alloy (PVC-EIA) liners (EIA1, EIA2, and EIA3) with decreasing ketone ethylene ester (KEE) contents. The tests were conducted at room temperature (23 °C), 35 °C, and 50 °C. The tests show significant diffusion through the TPU as manifested by a decrease in the source concentration and an increase in the receptor concentrations of PFOA and PFOS over time, especially at higher temperatures. On the other hand, the PVC-EIA liners show excellent diffusive resistance to the PFAS compounds especially at 23 °C. At higher temperatures, the diffusion resistance of the PVC-EIA liner with the lowest KEE content, EIA3, was best at 50 °C followed by EIA1 (highest KEE content) and finally EIA2. Sorption tests showed no measurable partitioning of any of the compounds to the liners examined. Based on 535 days of diffusion testing, permeation coefficients are provided for all the compounds considered for the four liners at three temperatures. In addition, the Pg values for PFOA and PFOS are provided for a linear low density polyethylene (LLDPE) and a coextruded LLDPE - ethylene vinyl alcohol (EVOH) geomembrane based on 1246 to 1331 days of testing and are compared to those estimated for EIA1, EIA2, and EIA3.
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Affiliation(s)
- R K Rowe
- GeoEngineering Centre at Queen's - RMC, Queen's University, Kingston K7L 3N6, Canada
| | - F B Barakat
- GeoEngineering Centre at Queen's - RMC, Queen's University, Kingston K7L 3N6, Canada.
| | - D Patch
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - K Weber
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
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11
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O'Connor N, Patch D, Noble D, Scott J, Koch I, Mumford KG, Weber K. Forever no more: Complete mineralization of per- and polyfluoroalkyl substances (PFAS) using an optimized UV/sulfite/iodide system. Sci Total Environ 2023; 888:164137. [PMID: 37182774 DOI: 10.1016/j.scitotenv.2023.164137] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/06/2023] [Accepted: 05/09/2023] [Indexed: 05/16/2023]
Abstract
As the global issue of PFAS contamination in water continues to grow there exists a need for technologies capable of fully mineralizing PFAS in water, with destruction being measured as both a loss of the initial PFAS and a quantitative recovery of the resultant fluoride ions. This study investigates the use of sulfite and iodide in a bicarbonate-buffered alkaline system activated with ultraviolet (UV) light to destroy PFAS. The UV/sulfite/iodide system creates a reductive environment through the generation of aqueous electrons, which can degrade PFAS. The extent of degradation and defluorination was explored for perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), 6:2 fluorotelomer sulfonic acid (6:2 FTS), and perfluorobutane sulfonic acid (PFBS). An initial UV/sulfite/iodide system achieved 100 % degradation and > 90 % defluorination for PFOS, PFOA, and 6:2 FTS, but was not capable of completely degrading PFBS. Transformation product elucidation experiments were performed for PFOS under different UV systems, and 6:2 FtSaB using the initial UV/sulfite/iodide system. Several transformation products were identified including -nF/+nH PFOS (n = 1-13), -F/+H shorter-chain PFSAs, 6:2 fluorotelomer sulfonamidoamine (6:2 FtSaAm), 6:2 fluorotelomer sulfonamide, and 6:2 fluorotelomer unsaturated sulfonamide. Novel identification of -F/+H perfluoropropane sulfonic acid (PFPS) and -F/+H perfluoroethane sulfonic acid (PFES) following degradation of PFOS confirms CC bond cleavage, and different isomers of -F/+H PFOS confirms the potential for CF bond cleavage to occur throughout the perfluoroalkyl chain. Additional optimization experiments were performed aiming to fully degrade PFBS. The optimal protocol found in this study involved an elevated initial sulfite concentration and adding additional sulfite at regular intervals during UV-activation, achieving >99.9 % destruction and complete quantitative defluorination of PFBS.
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Affiliation(s)
- Natalia O'Connor
- Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - David Patch
- Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Diana Noble
- Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Jennifer Scott
- Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Iris Koch
- Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Kevin G Mumford
- Department of Civil Engineering, Queen's University, Kingston, ON, Canada
| | - Kela Weber
- Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada.
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12
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King JJ, Halliday N, Mantovani A, Gerussi A, Wey EQ, Tan J, Ryan J, Patch D, Tsochatzis E, Westbrook RH. Bacterascites confers poor patient prognosis beyond MELD prediction. Liver Transpl 2023; 29:356-364. [PMID: 36691984 DOI: 10.1097/lvt.0000000000000068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 11/18/2022] [Indexed: 01/25/2023]
Abstract
Spontaneous bacterial peritonitis (SBP) is a well-recognized clinical entity with a poor prognosis. In comparison, the prevalence, microbiological flora, and prognostic significance of bacterascites (BA) (the presence of organism on culture but ascitic PMN <250 cells/mm³) is largely unknown. We, therefore, assessed the prognosis and predictors of outcome in patients with BA in comparison with those with SBP. Ascitic fluid cultures from consecutive patients with cirrhosis from 2008 to 2018 were reviewed retrospectively, and patients with SBP and BA were identified. Baseline demographic, laboratory, and microbiological data were collated and analyzed as prognostic indicators, and clinical outcomes were recorded. Patients were censored at the time of LT, death, or last follow-up. For this study 176 and 213 cases of SBP and BA, respectively, were identified and included. Patients with SBP had significantly higher Model for End-Stage Liver Disease (MELD) ( p =<0.01), peripheral blood WCC ( p < 0.01), and higher rates of Enterobacteriaceae ( p < 0.01) and multi-drug resistant pathogens ( p < 0.01). Survival at 1 and 3 months was lower in patients with SBP ( p < 0.01) when compared with BA but at 6 months and beyond, no significant difference remained. After the exclusion of deaths within 30 days of presentation, survival between SBP and BA was equivocal at all time points. Mortality was substantially higher across all MELD groupings for both SBP and BA when compared with the predicted mortality calculated by the MELD score alone. BA has a negative impact on patient survival above that predicted by the MELD score. It has similar impact to SBP on patient survival beyond 1 month suggesting it should be seen as a poor prognostic marker and prompt consideration of LT where appropriate. Further studies evaluating the role of secondary prophylaxis in this group are required.
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Affiliation(s)
- Ji Jade King
- The Royal Free Hospital, Sheila Sherlock Liver Centre, Pond Street, London, UK
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13
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Abbas N, Fallowfield J, Patch D, Stanley AJ, Mookerjee R, Tsochatzis E, Leithead JA, Hayes P, Chauhan A, Sharma V, Rajoriya N, Bach S, Faulkner T, Tripathi D. Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery. Frontline Gastroenterol 2023; 14:359-370. [PMID: 37581186 PMCID: PMC10423609 DOI: 10.1136/flgastro-2023-102381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
As a result of the increasing incidence of cirrhosis in the UK, more patients with chronic liver disease are being considered for elective non-hepatic surgery. A historical reluctance to offer surgery to such patients stems from general perceptions of poor postoperative outcomes. While this is true for those with decompensated cirrhosis, selected patients with compensated early-stage cirrhosis can have good outcomes after careful risk assessment. Well-recognised risks include those of general anaesthesia, bleeding, infections, impaired wound healing, acute kidney injury and cardiovascular compromise. Intra-abdominal or cardiothoracic surgery are particularly high-risk interventions. Clinical assessment supplemented by blood tests, imaging, liver stiffness measurement, endoscopy and assessment of portal pressure (derived from the hepatic venous pressure gradient) can facilitate risk stratification. Traditional prognostic scoring systems including the Child-Turcotte-Pugh and Model for End-stage Liver Disease are helpful but may overestimate surgical risk. Specific prognostic scores like Mayo Risk Score, VOCAL-Penn and ADOPT-LC can add precision to risk assessment. Measures to mitigate risk include careful management of varices, nutritional optimisation and where possible addressing any ongoing aetiological drivers such as alcohol consumption. The role of portal decompression such as transjugular intrahepatic portosystemic shunting can be considered in selected high-risk patients, but further prospective study of this approach is required. It is of paramount importance that patients are discussed in a multidisciplinary forum, and that patients are carefully counselled about potential risks and benefits.
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Affiliation(s)
- Nadir Abbas
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan Fallowfield
- Centre for Inflammation Research, The University of Edinburgh The Queen's Medical Research Institute, Edinburgh, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Raj Mookerjee
- Institute for Liver and Digestive Health, University College London, London, UK
| | | | - Joanna A Leithead
- Department of Gastroenterology, Forth Valley Royal Hospital, Larbert, UK
- Hepatology, Forth Valley Royal Hospital, Larbert, UK
| | - Peter Hayes
- The Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Abhishek Chauhan
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Vikram Sharma
- GI and Liver Unit, Royal London Hospital, London, UK
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Simon Bach
- Academic Department of Surgery, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Thomas Faulkner
- Department of Anaesthetics, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Dhiraj Tripathi
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- The Liver Unit, University Hospitals NHS Foundation Trust, Birmingham, UK
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14
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Patch D, O’Connor N, Meira D, Scott J, Koch I, Weber K. Parsimonious methodology for synthesis of silver and copper functionalized cellulose. Cellulose (Lond) 2023; 30:3455-3472. [PMID: 36994235 PMCID: PMC9959961 DOI: 10.1007/s10570-023-05099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 02/11/2023] [Indexed: 06/19/2023]
Abstract
UNLABELLED Metal nanomaterials, such as silver and copper, are often incorporated into commercial textiles to take advantage of their Antibacterial and antiviral properties. The goal of this study was to identify the most parsimonious method for the synthesis of silver, copper, or silver/copper bimetallic treated textiles. To accomplish this eight different methods were employed to synthesize silver, copper, and silver/copper functionalized cotton batting textiles. Using silver and copper nitrate as precursors, different reagents were used to initiate/catalyze the deposition of metal, including: (1) no additive, (2) sodium bicarbonate, (3) green tea, (4) sodium hydroxide, (5) ammonia, (6, 7) sodium hydroxide/ammonia at a 1:2 and 1:4 ratio, and (8) sodium borohydride. The use of sodium bicarbonate as a reagent to reduce silver onto cotton has not been used previously in literature and was compared to established methods. All synthesis methods were performed at 80 °C for one hour following textile addition to the solutions. The products were characterized by x-ray fluorescence (XRF) analysis for quantitative determination of the metal content and x-ray absorption near edge structure (XANES) analysis for silver and copper speciation on the textile. Scanning electron microscopy (SEM) with energy dispersive x-ray (EDX) and size distribution inductively coupled plasma mass spectrometry (ICP-MS) were used to further characterize the products of the sodium bicarbonate, sodium hydroxide, and sodium borohydride synthesis methods following ashing of the textile. For the silver treatment methods (1 mM Ag +), sodium bicarbonate and sodium hydroxide resulted in the highest amounts of silver on the textile (8900 mg Ag/kg textile and 7600 mg Ag/kg textile) and for copper treatment (1 mM Cu +) the sodium hydroxide and sodium hydroxide/ammonium hydroxide resulted in the highest amounts of copper on the textile (3800 mg Ag/kg textile and 2500 mg Ag/kg textile). Formation of copper oxide was dependent on the pH of the solution, with 4 mM ammonia and other high pH solutions resulting in majority of the copper on the textile existing as copper oxide, with smaller amounts of ionic-bound copper. The identified parsimonious methods will lend themselves to the efficient manufacturing of antibacterial and antiviral textiles, or the development of multifunctionalized smart textiles. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s10570-023-05099-7.
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Affiliation(s)
- David Patch
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4 Canada
| | - Natalia O’Connor
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4 Canada
| | - Debora Meira
- Argonne National Laboratory, Lemont, IL 60439 USA
| | - Jennifer Scott
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4 Canada
| | - Iris Koch
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4 Canada
| | - Kela Weber
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4 Canada
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15
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Dunne P, Finkel J, Khan F, Lachlan N, Patch D, Tripathi D, Stanley A, Hayes P. Letter: improve survival in variceal bleeding in cirrhosis-place pTIPS as early as possible after index bleed. Authors' reply. Aliment Pharmacol Ther 2023; 57:441-442. [PMID: 36710540 DOI: 10.1111/apt.17372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/19/2022] [Accepted: 12/11/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Philip Dunne
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK.,Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Jemima Finkel
- Institute for Liver and Digestive Health Royal Free Hospital and UCL, London, UK
| | - Faisal Khan
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Neil Lachlan
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - David Patch
- Institute for Liver and Digestive Health Royal Free Hospital and UCL, London, UK
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Adrian Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter Hayes
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
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16
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Polverelli N, Hernández-Boluda JC, Czerw T, Barbui T, D'Adda M, Deeg HJ, Ditschkowski M, Harrison C, Kröger NM, Mesa R, Passamonti F, Palandri F, Pemmaraju N, Popat U, Rondelli D, Vannucchi AM, Verstovsek S, Robin M, Colecchia A, Grazioli L, Damiani E, Russo D, Brady J, Patch D, Blamek S, Damaj GL, Hayden P, McLornan DP, Yakoub-Agha I. Splenomegaly in patients with primary or secondary myelofibrosis who are candidates for allogeneic hematopoietic cell transplantation: a Position Paper on behalf of the Chronic Malignancies Working Party of the EBMT. Lancet Haematol 2023; 10:e59-e70. [PMID: 36493799 DOI: 10.1016/s2352-3026(22)00330-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/25/2022] [Accepted: 10/04/2022] [Indexed: 12/12/2022]
Abstract
Splenomegaly is a hallmark of myelofibrosis, a debilitating haematological malignancy for which the only curative option is allogeneic haematopoietic cell transplantation (HCT). Considerable splenic enlargement might be associated with a higher risk of delayed engraftment and graft failure, increased non-relapse mortality, and worse overall survival after HCT as compared with patients without significantly enlarged splenomegaly. Currently, there are no standardised guidelines to assist transplantation physicians in deciding optimal management of splenomegaly before HCT. Therefore, the aim of this Position Paper is to offer a shared position statement on this issue. An international group of haematologists, transplantation physicians, gastroenterologists, surgeons, radiotherapists, and radiologists with experience in the treatment of myelofibrosis contributed to this Position Paper. The key issues addressed by this group included the assessment, prevalence, and clinical significance of splenomegaly, and the need for a therapeutic intervention before HCT for the control of splenomegaly. Specific scenarios, including splanchnic vein thrombosis and COVID-19, are also discussed. All patients with myelofibrosis must have their spleen size assessed before allogeneic HCT. Myelofibrosis patients with splenomegaly measuring 5 cm and larger, particularly when exceeding 15 cm below the left costal margin, or with splenomegaly-related symptoms, could benefit from treatment with the aim of reducing the spleen size before HCT. In the absence of, or loss of, response, patients with increasing spleen size should be evaluated for second-line options, depending on availability, patient fitness, and centre experience. Splanchnic vein thrombosis is not an absolute contraindication for HCT, but a multidisciplinary approach is warranted. Finally, prevention and treatment of COVID-19 should adhere to standard recommendations for immunocompromised patients.
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Affiliation(s)
- Nicola Polverelli
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy.
| | | | - Tomasz Czerw
- Department of Hematology, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Mariella D'Adda
- Hematology Division, Department of Oncology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Hans Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Markus Ditschkowski
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital of Essen, Essen, Germany
| | - Claire Harrison
- Department of Clinical Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Ruben Mesa
- Mays Cancer Center at UT Health San Antonio, San Antonio, TX, USA
| | - Francesco Passamonti
- Department of Medicine and Surgery, University of Insubria, ASST Sette Laghi, Varese, Italy
| | - Francesca Palandri
- Institute of Hematology L and A Seràgnoli, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Damiano Rondelli
- Blood and Marrow Transplant Program, and Center for Global Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Alessandro Maria Vannucchi
- Center for Innovation and Research in Myeloproliferative Neoplasms, Hematology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marie Robin
- Hôpital Saint-Louis, APHP, Université de Paris Cité, Paris, France
| | | | - Luigi Grazioli
- Department of Radiology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Enrico Damiani
- 2nd Division of General Surgery, Department of Medical and Surgical Sciences, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Domenico Russo
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology Research Program, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Jessica Brady
- Department of Clinical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Slawomir Blamek
- Department of Radiotherapy, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Gandhi Laurent Damaj
- Unit of Hematology, Centre Hospitalier Universitaire de Caen, University of Caen-Normandie, Caen, France
| | - Patrick Hayden
- Department of Haematology, Trinity College Dublin, St James's Hospital, Dublin, Ireland
| | - Donal P McLornan
- Department of Stem Cell Transplantation and Haematology, University College London Hospitals, London, UK
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Dunne P, Finkel J, Khan F, Lachlan N, Patch D, Tripathi D, Stanley A, Hayes P. Effect of time to pre-emptive transjugular intrahepatic portosystemic shunt on patient outcome, a UK multicentre cohort study. Aliment Pharmacol Ther 2023; 57:237-244. [PMID: 36256485 DOI: 10.1111/apt.17252] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/30/2022] [Accepted: 10/01/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Pre-emptive transjugular intrahepatic portosystemic shunt (pTIPSS) should be considered within 72 hours following acute oesophageal variceal bleeding. However, recent studies highlight the difficulty in providing pTIPSS within this narrow timeframe. Delaying pTIPSS beyond 72 hours has not been studied. AIM To determine if the time taken to perform pTIPSS alters patient outcome. METHOD Patients referred to 4 UK tertiary centres for pTIPSS between 01 January 2010 and 31 December 2018 were included. Time from endoscopy to pTIPSS was recorded and pre-defined clinically relevant outcomes were observed relative to two groups: early pTIPSS (<72 h) and late pTIPSS (72 h-28 days). The primary outcome was transplant-free survival at 1-year. Follow-up was until 31 December 2020. RESULTS A total of 83 patients received early pTIPSS and 88 received late pTIPSS. Baseline characteristics were similar with no requirement for propensity score-matched analysis. There was no difference between early and late pTIPSS groups for patient outcomes; 1-year transplant-free survival rate (69.9% vs 71.6%, p = 0.73, HR 0.91, 95% CI 0.52-1.58), long-term survival (p = 0.52, HR 1.132, 95% CI 0.77-1.65), variceal rebleeding (4.82% vs 11.36%, p = 0.09, HR 0.411, 95% CI 0.14-1.17), hepatic encephalopathy (43.93% vs 34.61%, p = 0.26) and new or worsening ascites (16.6% vs 13.46%, p = 0.79). Death due to liver failure was significantly more prevalent in those undergoing early pTIPSS compared to late pTIPSS (44% vs 16%, p = 0.046, HR 2.79, 95%CI 1.02-8.32). CONCLUSION Placement of pTIPSS within 72 hours offered similar short- and long-term survival benefits compared to pTIPSS placed between 72 hours and 28 days. Early pTIPSS may be associated with an increased risk of liver failure-related mortality. Further large, randomised studies are required to evaluate these findings.
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Affiliation(s)
- Philip Dunne
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK.,Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Jemima Finkel
- Institute for Liver and Digestive Health Royal Free Hospital and UCL, London, UK
| | - Faisal Khan
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Neil Lachlan
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - David Patch
- Institute for Liver and Digestive Health Royal Free Hospital and UCL, London, UK
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Adrian Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter Hayes
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
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Patch D, O'Connor N, Koch I, Cresswell T, Hughes C, Davies JB, Scott J, O'Carroll D, Weber K. Elucidating degradation mechanisms for a range of per- and polyfluoroalkyl substances (PFAS) via controlled irradiation studies. Sci Total Environ 2022; 832:154941. [PMID: 35367256 DOI: 10.1016/j.scitotenv.2022.154941] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/19/2022] [Accepted: 03/27/2022] [Indexed: 06/14/2023]
Abstract
Per- and polyfluoroalkyl substances (PFAS) are a challenging class of environmental pollutants due to a lack of available destructive remediation technologies. Understanding the fundamental mechanisms for degradation of PFAS is key for the development of field scalable and in-situ destructive based remediation technologies. This study aimed to elucidate and refine the current understanding of PFAS degradation mechanisms in water through a series of controlled gamma irradiation studies. Gamma irradiation of PFAS was performed using a cobalt-60 source in a batch irradiation up to 80 kGy at the Australian Nuclear Science and Technology Organisation. Perfluorooctanoic acid (PFOA), perfluorooctanesulfonic acid (PFOS), 6:2 fluorotelomer sulfonate (6:2 FTS), and a suite of thirteen different PFAS (including C4-C12 PFCAs, C4, C6, C8 PFSAs, and FOSA) were irradiated to investigate degradation, influence of pH, chain length, and transformation. High resolution mass spectrometry was used to identify more than 80 fluorinated transformation products throughout the degradation experiments. These included the -F/+H, -F/+OH, -F/CH2OH exchanged PFAS and n - 1 PFCA, amongst others. Given the reactive species present (hydroxyl radicals (·OH), hydrogen radicals (·H) and aqueous electrons (e-aq)), and the degradation products formed it was shown that aqueous electrons were the key reactive species responsible for initial PFAS degradation. Most importantly, based on degradation product formation, we found that the initial -F/+H does not have to occur at the α-fluoride (nearest the functional head group), rather occurring throughout the chain length leading to more complex degradation pathways than previously postulated. While our results support some of the reaction steps postulated in the literature, we have developed a unified 16 step and 3 pathway schematic of degradation supported by experimental observations.
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Affiliation(s)
- David Patch
- Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Natalia O'Connor
- Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Iris Koch
- Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Tom Cresswell
- Australian Nuclear Science and Technology Organisation, Australia
| | - Cath Hughes
- Australian Nuclear Science and Technology Organisation, Australia
| | - Justin B Davies
- Australian Nuclear Science and Technology Organisation, Australia
| | - Jennifer Scott
- Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada
| | - Denis O'Carroll
- Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada; School of Civil and Environmental Engineering, University of New South Wales, Sydney, NSW 2052, Australia
| | - Kela Weber
- Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada; School of Civil and Environmental Engineering, University of New South Wales, Sydney, NSW 2052, Australia.
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19
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Patch D, Koch I, Peloquin D, O'Carroll D, Weber K. Development and validation of a method for the weathering and detachment of representative nanomaterials from conventional silver-containing textiles. Chemosphere 2021; 284:131269. [PMID: 34186226 DOI: 10.1016/j.chemosphere.2021.131269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/13/2021] [Accepted: 06/15/2021] [Indexed: 06/13/2023]
Abstract
Nanotoxicology research commonly utilizes pristine nanomaterials for toxicity assessment, which may not be perfectly representative of what is released into environmental systems. The goal of the present study was to develop a method to simulate human weathering of silver-containing textiles. To achieve this goal the roles of physical and chemical stress on X-Static® containing athletic textiles were investigated and compared to data collected from human weathering experiments and literature. Chemical weathering methods (artificial sweat) were used independently and alongside physical weathering methods (3D printed stretching and abrasion instruments). Non-weathered control textiles were found to release 29 ± 11 mg Ag/kg of textile into wash water effluent (ICP-MS), with 16% being released as ionic silver (ICP-MS) and the rest as metallic nanomaterials, nanosheets, and particulates of varying size (SEM/XANES). Real and simulated human weathered textiles released similar amounts of total silver (67 ± 11 mg Ag/kg, 84 ± 13 mg Ag/kg respectively) with the silver released being composed of ionic (1.5%, 2%) and a mixture of metallic and chlorinated nanomaterials, nanosheets, and particulates. The method was shown to effectively detach environmentally representative silver materials from silver-containing textiles and can provide such materials for future studies on the assessment of their fate, transport, and toxicity.
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Affiliation(s)
- David Patch
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON, K7K 7B4, Canada
| | - Iris Koch
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON, K7K 7B4, Canada
| | - Derek Peloquin
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, 37830, USA
| | - Denis O'Carroll
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON, K7K 7B4, Canada; School of Civil and Environmental Engineering, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Kela Weber
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON, K7K 7B4, Canada.
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20
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Mattock R, Tripathi D, O'Neill F, Craig J, Tanner J, Patch D, Aithal G. Economic evaluation of covered stents for transjugular intrahepatic portosystemic stent shunt in patients with variceal bleeding and refractory ascites secondary to cirrhosis. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000641. [PMID: 34429322 PMCID: PMC8386212 DOI: 10.1136/bmjgast-2021-000641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/18/2021] [Indexed: 12/20/2022] Open
Abstract
Objectives Transjugular intrahepatic portosystemic stent shunt (TIPSS) is clinically effective in variceal bleeding and refractory ascites; however, the cost-effectiveness of TIPSS has yet to be evaluated in the UK. This study aimed to establish the cost-effectiveness of (i) pre-emptive TIPSS versus endoscopic band ligation (EBL) in populations with variceal bleeding and (ii) TIPSS versus large volume paracentesis (LVP) in refractory ascites. Methods A cost-utility analysis was conducted with the perspective including healthcare costs and quality-adjusted life years (QALYs). A Markov model was constructed with a 2-year time horizon, health states for mortality and survival and probabilities for the development of variceal bleeding, ascites and hepatic encephalopathy. A survival analysis was conducted to extrapolate 12-month to 24-month mortality for the refractory ascites indication. Uncertainty was analysed in deterministic and probabilistic sensitivity analyses. Results TIPSS was cost-effective (dominant) and cost saving for both indications. For variceal bleeding, pre-emptive TIPSS resulted in 0.209 additional QALYs, and saved £600 per patient compared with EBL. TIPSS had a very high probability of being cost-effective (95%) but was not cost saving in scenario analyses driven by rates of variceal rebleeding. For refractory ascites, TIPSS resulted in 0.526 additional QALYs and saved £17 983 per patient and had a 100% probability of being cost-effective and cost saving when compared with LVP. Conclusions TIPSS is a cost-effective intervention for variceal bleeding and refractory ascites. TIPSS is highly cost-saving for refractory ascites. Robust randomised trial data are required to confirm whether pre-emptive TIPSS is cost saving for variceal bleeding.
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Affiliation(s)
- Richard Mattock
- York Health Economics Consortium, University of York, York, UK
| | - Dhiraj Tripathi
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Joyce Craig
- York Health Economics Consortium, University of York, York, UK
| | | | - David Patch
- Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Guruprasad Aithal
- Faculty of Medicine & Health Sciences, The University of Nottingham, Nottingham, UK
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21
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Hussain A, Patel PJ, Rhodes F, Srivastava A, Patch D, Rosenberg W. Decompensated cirrhosis is the commonest presentation for NAFLD patients undergoing liver transplant assessment. Clin Med (Lond) 2021; 20:313-318. [PMID: 32414722 DOI: 10.7861/clinmed.2019-0250] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) accounts for 10-15% of orthotopic liver transplants (OLTs) in the UK. Index presentations with cirrhotic decompensation represent missed opportunities for preventive treatment leaving OLT or palliation as the only options.We retrospectively reviewed patient records for all NAFLD patients undergoing assessment for OLT between January 2003 and December 2017.Data were available for 81 patients with NAFLD as the primary diagnosis. Fifty-two patients had decompensated cirrhosis at first presentation; 91.7% presented to secondary care compared to 52.7% referred from primary care (p=0.001). Cirrhosis was not suspected at the time of referral to hospital in 24.7% of patients subsequently assessed for OLT. Most patients undergoing assessment for OLT for NAFLD had decompensated cirrhosis at their first diagnosis of chronic liver disease. These data highlight the plight of patients with NAFLD cirrhosis in whom chronic liver disease is diagnosed late.
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Affiliation(s)
- Ahmed Hussain
- UCL Institute for Liver and Digestive Health, London, UK
| | - Preya J Patel
- UCL Institute for Liver and Digestive Health, London, UK
| | - Freya Rhodes
- UCL Institute for Liver and Digestive Health, London, UK
| | | | - David Patch
- UCL Institute for Liver and Digestive Health, London, UK
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22
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Forrest E, Petts G, Austin A, Lloyd K, Wright M, Vergis N, Atkinson S, Masson S, Patch D, Quaglia A, Thursz M, Goldin R. The diagnostic and prognostic significance of liver histology in alcoholic hepatitis. Aliment Pharmacol Ther 2021; 53:426-431. [PMID: 33326633 DOI: 10.1111/apt.16157] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/31/2020] [Accepted: 10/23/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Liver biopsy may be of diagnostic and prognostic value but its role in alcoholic hepatitis (AH) has been controversial. AIM To assess the utility of liver biopsy in the assessment of clinically severe AH METHODS: The histological features of alcoholic steatohepatitis (ASH) were recorded and scored in patients enrolled in the Steroids or Pentoxifylline for Alcoholic Hepatitis (STOPAH) trial who underwent liver biopsy. These features were then assessed relative to outcome and established clinical prognostic scores. RESULTS The STOPAH trial recruited 1068 patients; biopsies were obtained in 182 (17%). One hundred and sixty-one biopsies were adequate for histological assessment and 140 (87%) were diagnostic for ASH. Only three biopsies (2%) did not have histological features of alcohol-related liver injury. In biopsies performed prior to randomisation, ASH was identified in 92.5% of patients meeting clinical trial definitions of severe AH. In biopsies with ASH, taken before or within 48 hours of randomisation, survival differences between Alcoholic Hepatitis Histological Score (AHHS) groups were not significant: comparison of mild / moderate (91%: 21 of 23 patients) with severe (78%: 29 of 37 patients) groups: P = 0.18. The AHHS was not superior to clinical scores of prognosis: area under the curve for 28-day mortality was 0.728, compared with 0.799 for the Glasgow alcoholic hepatitis score and 0.728 for the MELD score. CONCLUSION Liver histology taken before treatment rarely changes the diagnosis in patients meeting strict criteria for a clinical diagnosis of AH. The AHHS is similar to clinical scores in determining prognosis. Clinical trial registration EudraCT reference number: 2009-013897-42. ISRCTN reference number: 88782125. MREC number: 09/MRE09/59. UKCRIN ID 9143.
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Affiliation(s)
- Ewan Forrest
- Glasgow Royal Infirmary and University of Glasgow, Glasgow, UK
| | | | | | | | - Mark Wright
- Southampton University NHS Trust, Southampton, UK
| | | | | | - Steven Masson
- Freeman Hospital Newcastle on Tyne, Newcastle upon Tyne, UK
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23
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Kumar R, Kerbert AJC, Sheikh MF, Roth N, Calvao JAF, Mesquita MD, Barreira AI, Gurm HS, Ramsahye K, Mookerjee RP, Yu D, Davies NH, Mehta G, Agarwal B, Patch D, Jalan R. Determinants of mortality in patients with cirrhosis and uncontrolled variceal bleeding. J Hepatol 2021; 74:66-79. [PMID: 32561318 DOI: 10.1016/j.jhep.2020.06.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Failure to control oesophago-gastric variceal bleeding (OGVB) and acute-on-chronic liver failure (ACLF) are both important prognostic factors in cirrhosis. The aims of this study were to determine whether ACLF and its severity define the risk of death in OGVB and whether insertion of rescue transjugular intrahepatic shunt (TIPS) improves survival in patients with failure to control OGVB and ACLF. METHODS Data on 174 consecutive eligible patients, with failure to control OGVB between 2005 and 2015, were collected from a prospectively maintained intensive care unit registry. Rescue TIPS was defined as technically successful TIPS within 72 hours of presentation with failure to control OGVB. Cox-proportional hazards regression analyses were applied to explore the impact of ACLF and TIPS on survival in patients with failure to control OGVB. RESULTS Patients with ACLF (n = 119) were significantly older, had organ failures and higher white cell count than patients with acute decompensation (AD, n = 55). Mortality at 42-days and 1-year was significantly higher in patients with ACLF (47.9% and 61.3%) than in those with AD (9.1% and 12.7%, p <0.001), whereas there was no difference in the number of endoscopies and transfusion requirements between these groups. TIPS was inserted in 78 patients (AD 21 [38.2%]; ACLF 57 [47.8%]; p = 0.41). In ACLF, rescue TIPS insertion was an independent favourable prognostic factor for 42-day mortality. In contrast, rescue TIPS did not impact on the outcome of patients with AD. CONCLUSIONS This study shows that in patients with failure to control OGVB, the presence and severity of ACLF determines the risk of 42-day and 1-year mortality. Rescue TIPS is associated with improved survival in patients with ACLF. LAY SUMMARY Variceal bleeding that is not controlled by initial endoscopy is associated with high risk of death. The results of this study showed that in the occurrence of failure of the liver and other organs defines the risk of death. In these patients, insertion of a shunt inside the liver to drain the portal vein improves survival.
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Affiliation(s)
- Rahul Kumar
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK; Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Duke-NUS Academic Medical Centre, CGH Campus, Singapore
| | - Annarein J C Kerbert
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK
| | - M Faisal Sheikh
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK
| | - Noam Roth
- Intensive Care Unit, Royal Free Hospital London NHS Foundation Trust, London, UK
| | - Joana A F Calvao
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK; Centro Hospital de Tras-os-Montes e Alto Douro, EPE, Portugal
| | - Monica D Mesquita
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK; Centro Hospital de Tras-os-Montes e Alto Douro, EPE, Portugal
| | - Ana I Barreira
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK; Centro Hospital de Tras-os-Montes e Alto Douro, EPE, Portugal
| | - Haqeeqat S Gurm
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK
| | - Komal Ramsahye
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK
| | - Rajeshwar P Mookerjee
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK
| | - Dominic Yu
- Department of Radiology, Royal Free Hospital London NHS Foundation Trust, London, UK
| | - Neil H Davies
- Department of Radiology, Royal Free Hospital London NHS Foundation Trust, London, UK
| | - Gautam Mehta
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK
| | - Banwari Agarwal
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK; Intensive Care Unit, Royal Free Hospital London NHS Foundation Trust, London, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK.
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Di Battista V, Rowe RK, Patch D, Weber K. PFOA and PFOS diffusion through LLDPE and LLDPE coextruded with EVOH at 22 °C, 35 °C, and 50 °C. Waste Manag 2020; 117:93-103. [PMID: 32818812 DOI: 10.1016/j.wasman.2020.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 06/11/2023]
Abstract
Diffusion of perfluorooctanoate (PFOA) and perfluorooctane sulfonate (PFOS) through 0.1 mm and 0.75 mm LLDPE and 0.1 mm and 0.75 mm LLDPE coextruded with ethyl vinyl alcohol (denoted as CoEx) at room temperature (23 °C), 35 °C, and 50 °C is examined. These tests had negligible source depletion throughout the monitoring period, indicating limited contaminant partitioning and diffusion through the LLDPE. At 483 days, 23 °C receptor PFOA and PFOS concentrations, cr, were <8 μg/L (cr/co < 3.2 × 10-4) for all tests, and at 399 days elevated temperature receptor concentrations were < 0.4 μg/L (cr/co < 1.6 × 10-5) at 35 °C and <0.5 μg/L (cr/co < 2.0 × 10-5) at 50 °C for both PFOA and PFOS. LLDPE partitioning coefficient, Sgf was 0.9-1.4 (PFOA) and 2.8-5.3 (PFOS) based on sorption tests at 23 °C. Based on the best estimates of permeation coefficient, PgCoEx, for CoEx was consistently lower than PgLLDPE. For PFOA, CoEx had PgCoEx < 0.26 × 10-16 m2/s at 23 °C, <11 × 10-16 m2/s (35 °C), and < 10 × 10-16 m2/s (50 °C) while LLDPE had PgLLDPE < 3.1 × 10-16 m2/s (23 °C), <13 × 10-16 m2/s (35 °C), and <19 × 10-16 m2/s (50 °C). For PFOS, CoEx and LLDPE had PgCoEx < 0.55 × 10-16 m2/s and PgLLDPE < 3.2 × 10-16 m2/s (23 °C), PgCoEx < 8.3 × 10-16 m2/s and PgLLDPE < 40 × 10-16 m2/s (35 °C), and PgCoEx < 8.2 × 10-16 m2/s and PgLLDPE < 52 × 10-16 m2/s (50 °C). These values are preliminary and may change (e.g., decrease) as more data comes available over time. The Pg values deduced for PFOA and PFOS are remarkably lower than those reported for other contaminants of concern, excepting BPA, which exhibits similar behaviour.
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Affiliation(s)
- V Di Battista
- GeoEngineering Centre at Queen's - RMC, Queen's University, Kingston K7L 3N6, Canada.
| | - R Kerry Rowe
- GeoEngineering Centre at Queen's - RMC, Queen's University, Kingston K7L 3N6, Canada.
| | - D Patch
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada.
| | - K Weber
- Environmental Sciences Group, Department of Chemistry and Chemical Engineering, Royal Military College of Canada, Kingston, ON K7K 7B4, Canada.
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Benmassaoud A, Roccarina D, Arico F, Leandro G, Yu B, Cheng F, Yu D, Patch D, Tsochatzis E. Sarcopenia Does Not Worsen Survival in Patients With Cirrhosis Undergoing Transjugular Intrahepatic Portosystemic Shunt for Refractory Ascites. Am J Gastroenterol 2020; 115:1911-1914. [PMID: 33156111 DOI: 10.14309/ajg.0000000000000959] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The impact of sarcopenia in patients undergoing transjugular intrahepatic portosystemic shunt (TIPSS) insertion for refractory ascites is unknown. METHODS All adult patients who underwent TIPSS insertion for refractory ascites between 2010 and 2018 were included. Skeletal muscle index at L3 was used to determine sarcopenia status. RESULTS One hundred seven patients were followed for 14.2 months. Sarcopenia was present in 57% of patients. No patient had history of pre-TIPSS hepatic encephalopathy (HE). De novo HE occurred in 30% of patients. On multivariate analysis, only platelet count and L3-SMI predicted de novo HE. On multivariate analysis, age and model for end-stage liver disease with sodium predicted mortality, whereas L3-SMI and sarcopenia did not. In patients with repeat imaging, L3-SMI improved significantly post-TIPSS compared with baseline. DISCUSSION Sarcopenia should not be considered as a contraindication to TIPSS insertion in refractory ascites because it is not associated with de novo HE or increased mortality.
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Affiliation(s)
- Amine Benmassaoud
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
- UCL Institute for Liver and Digestive Health, University College of London, London, UK
| | - Davide Roccarina
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
- UCL Institute for Liver and Digestive Health, University College of London, London, UK
| | - Francesco Arico
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
- UCL Institute for Liver and Digestive Health, University College of London, London, UK
| | - Gioacchino Leandro
- National Institute of Gastroenterology, S. De Bellis Research Hospital, Castellana Grotte, Italy
| | - Becky Yu
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
- UCL Institute for Liver and Digestive Health, University College of London, London, UK
| | - Felix Cheng
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
- UCL Institute for Liver and Digestive Health, University College of London, London, UK
| | - Dominic Yu
- Department of Radiology, Royal Free London NHS Trust, London, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
- UCL Institute for Liver and Digestive Health, University College of London, London, UK
| | - Emmanuel Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
- UCL Institute for Liver and Digestive Health, University College of London, London, UK
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Tripathi D, Stanley AJ, Hayes PC, Travis S, Armstrong MJ, Tsochatzis EA, Rowe IA, Roslund N, Ireland H, Lomax M, Leithead JA, Mehrzad H, Aspinall RJ, McDonagh J, Patch D. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension. Gut 2020; 69:1173-1192. [PMID: 32114503 PMCID: PMC7306985 DOI: 10.1136/gutjnl-2019-320221] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/20/2020] [Accepted: 01/22/2020] [Indexed: 12/15/2022]
Abstract
These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK .,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter C Hayes
- Hepatology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon Travis
- Department if Radiology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Matthew J Armstrong
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Emmanuel A Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre, UCL Institute for Liver and Digestive Health, London, UK
| | | | | | - Hamish Ireland
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Joanne A Leithead
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Homoyon Mehrzad
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Aspinall
- Department of Hepatology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Joanne McDonagh
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, UCL Institute for Liver and Digestive Health, London, UK
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27
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Haddadin Y, Katarey D, Patch D. Upper gastrointestinal bleeding in superior mesenteric vein thrombosis. Clin Med (Lond) 2020; 20:e3. [DOI: 10.7861/clinmed.let.20.2.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Baiges A, Turon F, Simón-Talero M, Tasayco S, Bueno J, Zekrini K, Plessier A, Franchi-Abella S, Guerin F, Mukund A, Eapen CE, Goel A, Shyamkumar NK, Coenen S, De Gottardi A, Majumdar A, Onali S, Shukla A, Carrilho FJ, Nacif L, Primignani M, Tosetti G, La Mura V, Nevens F, Witters P, Tripathi D, Tellez L, Martínez J, Álvarez-Navascués C, Fraile López ML, Procopet B, Piscaglia F, de Koning B, Llop E, Romero-Cristobal M, Tjwa E, Monescillo-Francia A, Senzolo M, Perez-LaFuente M, Segarra A, Sarin SK, Hernández-Gea V, Patch D, Laleman W, Hartog H, Valla D, Genescà J, García-Pagán JC. Congenital Extrahepatic Portosystemic Shunts (Abernethy Malformation): An International Observational Study. Hepatology 2020; 71:658-669. [PMID: 31211875 DOI: 10.1002/hep.30817] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 05/21/2019] [Indexed: 12/27/2022]
Abstract
Congenital extrahepatic portosystemic shunt (CEPS) or Abernethy malformation is a rare condition in which splanchnic venous blood bypasses the liver draining directly into systemic circulation through a congenital shunt. Patients may develop hepatic encephalopathy (HE), pulmonary hypertension (PaHT), or liver tumors, among other complications. However, the actual incidence of such complications is unknown, mainly because of the lack of a protocolized approach to these patients. This study characterizes the clinical manifestations and outcome of a large cohort of CEPS patients with the aim of proposing a guide for their management. This is an observational, multicenter, international study. Sixty-six patients were included; median age at the end of follow-up was 30 years. Nineteen patients (28%) presented HE. Ten-, 20-, and 30-year HE incidence rates were 13%, 24%, and 28%, respectively. No clinical factors predicted HE. Twenty-five patients had benign nodular lesions. Ten patients developed adenomas (median age, 18 years), and another 8 developed HCC (median age, 39 years). Of 10 patients with dyspnea, PaHT was diagnosed in 8 and hepatopulmonary syndrome in 2. Pulmonary complications were only screened for in 19 asymptomatic patients, and PaHT was identified in 2. Six patients underwent liver transplantation for hepatocellular carcinoma or adenoma. Shunt closure was performed in 15 patients with improvement/stability/cure of CEPS manifestations. Conclusion: CEPS patients may develop severe complications. Screening for asymptomatic complications and close surveillance is needed. Shunt closure should be considered both as a therapeutic and prophylactic approach.
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Affiliation(s)
- Anna Baiges
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona, Spain
| | - Macarena Simón-Talero
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, VHIR, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Stephanie Tasayco
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, VHIR, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Javier Bueno
- Pediatric Surgery Department, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Kamal Zekrini
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Aurélie Plessier
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Stéphanie Franchi-Abella
- Service d'Hépatologie et de Transplantation Hépatique et de radiologie Pédiatriques, Groupement Hospitalier Paris Sud (GHUPS), Hôpital Bicêtre, Le Kremlin Bicetre, France
| | - Florent Guerin
- Service d'Hépatologie et de Transplantation Hépatique et de radiologie Pédiatriques, Groupement Hospitalier Paris Sud (GHUPS), Hôpital Bicêtre, Le Kremlin Bicetre, France
| | - Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - C E Eapen
- Hepatology Department, Christian Medical College, Vellore, India
| | - Ashish Goel
- Hepatology Department, Christian Medical College, Vellore, India
| | | | - Sandra Coenen
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Andrea De Gottardi
- Hepatology, Clinic of Visceral Surgery and Medicine, Inselspital and Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Avik Majumdar
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, United Kingdom
| | - Simona Onali
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, United Kingdom
| | - Akash Shukla
- Department of Gastroenterology, Seth G S Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Flair José Carrilho
- Digestive Organ Transplantation Division, Department of Gastroenterology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Lucas Nacif
- Digestive Organ Transplantation Division, Department of Gastroenterology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Massimo Primignani
- A. M. e A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giulia Tosetti
- A. M. e A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Vicenzo La Mura
- A. M. e A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale Emostasi e Trombosi, Milano, Italy
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Peter Witters
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Dhiraj Tripathi
- Liver Unit, Queen Elisabeth Hospital, Birmingham, United Kingdom
| | - Luis Tellez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, CIBERedh, Madrid, Spain
| | - Javier Martínez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, CIBERedh, Madrid, Spain
| | | | | | - Bogdan Procopet
- Department of Gastroenterology, 3rd Medical Clinic, University of Medicine and Pharmacy "Iuliu Hatieganu", Regional Institute of Gastroenterology and Hepatology "O Fodor", Cluj-Napoca, Romania
| | - Fabio Piscaglia
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Barbara de Koning
- Division of Pediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elba Llop
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mario Romero-Cristobal
- Digestive Diseases and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Hospital General Universitario Gregorio Marañón Instituto de Investigación Sanitaria Gregorio Marañón Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Alberto Monescillo-Francia
- Digestive Disease Department, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, España
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Mercedes Perez-LaFuente
- Interventional Radiology Unit, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Segarra
- Interventional Radiology Unit, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona, Spain
| | - David Patch
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, United Kingdom
| | - Wim Laleman
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale Emostasi e Trombosi, Milano, Italy
| | - Hermien Hartog
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dominique Valla
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, VHIR, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona, Spain
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Chung W, Maurice J, Patch D. Twitter debate: controversies in the management of portal hypertension. Frontline Gastroenterol 2020; 12:77-79. [PMID: 33456744 PMCID: PMC7790013 DOI: 10.1136/flgastro-2019-101400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 02/04/2023] Open
Abstract
The latest 'Controversies in…' series for the Frontline Gastroenterology Twitter debates addressed the challenges of managing patients with portal hypertension, facilitated by Hepatologist and Liver Transplant physician Dr David Patch from the Royal Free London. Key topics discussed include basic principles of managing a patient with variceal bleeding, techniques for treating oesophageal and ectopic varices, pitfalls of vasoactive therapy, indications for transjugular intrahepatic portosystemic shunt, and a brief discussion of portal vein thrombosis. This article aims to summarise key areas of discussion from the event.
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Affiliation(s)
- William Chung
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Hampstead, London, UK
| | - James Maurice
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Hampstead, London, UK,Department of Gastroenterology, Barts Health NHS Trust, London, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Hampstead, London, UK
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30
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Benmassaoud A, AlRubaiy L, Yu D, Chowdary P, Sekhar M, Parikh P, Finkel J, See TC, O'Beirne J, Leithead JA, Patch D. A stepwise thrombolysis regimen in the management of acute portal vein thrombosis in patients with evidence of intestinal ischaemia. Aliment Pharmacol Ther 2019; 50:1049-1058. [PMID: 31489698 DOI: 10.1111/apt.15479] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/06/2019] [Accepted: 08/05/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Anticoagulation alone in acute, extensive portomesenteric vein thrombosis (PVT) does not always result in spontaneous clot lysis, and leaves the patient at risk of complications including intestinal infarction and portal hypertension. AIM To develop a new standard of care for patients with acute PVT and evidence of intestinal ischaemia. METHODS We present a case series of patients with acute PVT and evidence of intestinal ischaemia plus ongoing symptoms despite initial systemic anticoagulation, who were treated with a thrombolysis protocol between 2014 and 2019. This stepwise protocol initially uses low-dose systemic alteplase, and in patients with ongoing abdominal pain, and no evidence of radiological improvement, is followed by local clot dissolution therapy (CDT) through a TIPSS. Outcomes and safety were assessed. RESULTS Twenty-two patients were included. The mean age was 44.6 (standard deviation [SD] 16.0) years, and 64% had an identifiable prothrombotic risk factor. All patients had intestinal wall oedema and 77% had complete occlusion of all portomesenteric veins. Systemic thrombolysis was started 18.7 (SD 11.2) days after the onset of symptoms. 55% of patients underwent TIPSS insertion for CDT. At the end of treatment, symptoms resolved in 91% of patients and recanalisation in 86%. Only one patient required resection for intestinal ischaemia, and there were no deaths. Major complications occurred in two patients (9%). CONCLUSIONS Our stepwise protocol is effective, resulting in good recanalisation rates. It can be commenced early while organising transfer to a centre capable of performing local CDT.
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Affiliation(s)
- Amine Benmassaoud
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
| | - Laith AlRubaiy
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
| | - Dominic Yu
- Department of Radiology, Royal Free London NHS Trust, London, UK
| | - Pratima Chowdary
- KD Haemophilia and Thrombosis Centre, Royal Free London NHS Trust, London, UK
| | - Mallika Sekhar
- Department of Haematology, Royal Free London NHS Trust, London, UK
| | - Pathik Parikh
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
| | - Jemima Finkel
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
| | - Teik Choon See
- Department of Interventional Radiology, Addenbrooke's Hospital, Cambridge, UK
| | - James O'Beirne
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK.,Department of Hepatology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | | | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
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De Luca L, Kalafateli M, Bianchi S, Alasaker N, Buzzetti E, Rodríguez-Perálvarez M, Thorburn D, O'Beirne J, Patch D, Leandro G, Westbrook R, Tsochatzis EA. Cardiovascular morbidity and mortality is increased post-liver transplantation even in recipients with no pre-existing risk factors. Liver Int 2019; 39:1557-1565. [PMID: 31233663 DOI: 10.1111/liv.14185] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/09/2019] [Accepted: 06/18/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND/AIMS Post-liver transplant (LT) metabolic syndrome (PTMS) and cardiovascular (CVS) mortality are becoming increasingly prevalent following sustained improvements in post-LT survival. We investigated the prevalence and predictors of PTMS and CVS complications in a cohort of consecutive LT recipients. METHODS We reviewed prospectively collected data of patients (n = 928) who underwent LT (1995-2013) and survived at least 1-year post-LT or died before that due to a major CVS complication. RESULTS Median follow-up was 85 months (IQR = 106). The prevalence of PTMS was 22.4% and it developed de novo in 183 recipients (19.7%). A total of 187 (20.2%) patients developed at least one CVS event post-LT within a median of 49 months (IQR = 85). Overall mortality rate was 22.6% (n = 210). Causes of death were CVS events (n = 45, 21.4%), malignancies (21%), liver-related deaths (20%) and infections (6.7%). Independent predictors of major CVS events were: documented CVS disease pre-LT (Hazard Ratio (HR) = 3.330; 95% CI = 1.620-6.840), DM (HR = 1.120; 95% CI 1.030-1.220), hypertension (HR = 1.140; 95% CI 1.030-1.270), dyslipidaemia (HR = 1.140; 95% CI 1.050-1.240) and creatinine levels at 1 year (HR = 1.010; 95% CI = 1.005-1.013). Among LT recipients without pre-LT CVS disease or MS components (n = 432), 85 recipients developed ≥1 CVS events (19.7%) with independent predictors being DM (HR = 1.150; 95% CI = 1.010-1.320), creatinine levels at 1 year (HR = 1.020; 95% CI = 1.010-1.030) and hypertension (HR = 1.190; 95% CI = 1.040-1.360). CONCLUSIONS Post-LT patients are at increased risk of CVS morbidity even in the absence of pre-existing metabolic risk factors. Renal sparing immunosuppressive protocols might reduce CVS events post-LT.
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Affiliation(s)
- Laura De Luca
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Maria Kalafateli
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Simone Bianchi
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Norah Alasaker
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Elena Buzzetti
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Manuel Rodríguez-Perálvarez
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.,Department of Hepatology and Liver Transplantation, Reina Sofía University Hospital, IMIBIC, CIBERehd, Córdoba, Spain
| | - Douglas Thorburn
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - James O'Beirne
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - David Patch
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Gioacchino Leandro
- National Institute of Gastroenterology "S. De Bellis"Research Hospital, Castellana Grotte, Italy
| | - Rachel Westbrook
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
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32
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Despott EJ, May A, Lazaridis N, Vlachou E, Koukias N, Patch D, Planche K, Hayashi Y, Murino A. Double-balloon enteroscopy-facilitated cyanoacrylate-injection endotherapy of small-bowel varices: an international experience from 2 European tertiary centers (with videos). Gastrointest Endosc 2019; 90:302-306. [PMID: 30980796 DOI: 10.1016/j.gie.2019.03.1171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/28/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Small-bowel varices (SBVs) are an uncommon consequence of portal hypertension. Radiologic intervention is usually considered for first-line management. When radiologic intervention is not possible, management options become very limited. The aim of this study was to evaluate the usefulness of double-balloon enteroscopy (DBE)-facilitated cyanoacrylate-injection endotherapy of SBVs. METHODS This was a retrospective review of DBE-facilitated cyanoacrylate-injection endotherapy of SBVs (December 2015 to October 2016). RESULTS Ten DBEs were performed in 6 patients (4 women; median age, 68.5 years). No radiologic or surgical options were deemed feasible. Thirteen nests of SBVs were identified and injected with cyanoacrylate glue without hemorrhagic or embolic adverse events. At the 30-day follow-up after therapy, only 1 patient had experienced a mild recurrence of mid-gut bleeding; this was managed conservatively. One patient presented with acute GI bleeding 7 months later, and a repeat DBE with cyanoacrylate-injection endotherapy was successfully performed. One patient succumbed to his underlying advanced cholangiocarcinoma after 2 months. The remaining patients had a median follow-up of 12 months without any recurrent GI bleeding. CONCLUSIONS DBE-facilitated cyanoacrylate-injection endotherapy of SBVs appears to be a safe and effective option when other first-line options are not feasible.
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Affiliation(s)
- Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - Andrea May
- Department of Gastroenterology, Sana Klinikum Offenbach GmbH and University of Mainz, Germany
| | - Nikolaos Lazaridis
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - Erasmia Vlachou
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK; NIMTS Army Veterans Hospital, Athens, Greece
| | - Nikolaos Koukias
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - David Patch
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - Katie Planche
- Department of Radiology, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
| | - Yoshikazu Hayashi
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK; Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Alberto Murino
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, UK
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Castellano XC, Craven B, Patch D, Yu D, Abiodun M, De Jesus J, Sekhar M. PF686 HEALTHCARE RESOURCE IMPLICATIONS IN PATIENTS WITH MYELOPROLIFERATIVE NEOPLASMS AND SPLANCHNIC VEIN THROMBOSIS. Hemasphere 2019. [DOI: 10.1097/01.hs9.0000561028.61539.9c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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34
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Maimone S, Saffioti F, Filomia R, Alibrandi A, Isgrò G, Calvaruso V, Xirouchakis E, Guerrini GP, Burroughs AK, Tsochatzis E, Patch D. Predictors of Re-bleeding and Mortality Among Patients with Refractory Variceal Bleeding Undergoing Salvage Transjugular Intrahepatic Portosystemic Shunt (TIPS). Dig Dis Sci 2019; 64:1335-1345. [PMID: 30560334 DOI: 10.1007/s10620-018-5412-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/03/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) has proven clinical efficacy as rescue therapy for cirrhotic patients with acute portal hypertensive bleeding who fail endoscopic treatment. AIMS To investigate predictive factors of 6-week and 1-year mortality in patients undergoing salvage TIPS for refractory portal hypertensive bleeding. METHODS A total of 144 consecutive patients were retrospectively evaluated. Three logistic regression multivariate models were estimated to individualize prognostic factors for 6-week and 12-month mortality. Log-rank test was used to evaluate survival according to Child-Pugh classes and Bureau's criteria. RESULTS Mean age 51 ± 10 years, 66% male, mean MELD 18.5 ± 8.3, Child-Pugh A/B/C 8%/38%/54%. TIPS failure occurred in 23(16%) patients and was associated with pre-TIPS portal pressure gradient and pre-TIPS intensive care unit stay. Six-week and 12-month mortality was 36% and 42%, respectively. Pre-TIPS intensive care unit stay, MELD, and Child-Pugh score were independently associated with mortality at 6 weeks. Independent predictors of mortality at 12 months were pre-TIPS intensive care unit stay and Child-Pugh score. CONCLUSIONS In this large cohort of patients undergoing salvage TIPS, MELD and Child-Pugh scores were predictive of short- and long-term mortality, respectively. Pre-TIPS intensive care unit stay was independently associated with TIPS failure and mortality at 6 weeks and 12 months. Salvage TIPS is futile in patients with Child-Pugh score of 14-15.
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Affiliation(s)
- Sergio Maimone
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK.
- Division of Clinical and Molecular Hepatology, Department of Internal Medicine, University Hospital of Messina, Messina, Italy.
| | - Francesca Saffioti
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberto Filomia
- Division of Clinical and Molecular Hepatology, Department of Internal Medicine, University Hospital of Messina, Messina, Italy
| | - Angela Alibrandi
- Department of Economics, Unit of Statistical and Mathematical Sciences, University of Messina, Messina, Italy
| | - Grazia Isgrò
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
| | - Vincenza Calvaruso
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
- Gastroenterology and Hepatology Unit, Di.Bi.M.I.S., University of Palermo, Palermo, Italy
| | - Elias Xirouchakis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
- Gastroenterology and Hepatology Department, Athens Medical P. Faliron Hospital, Athens, Greece
| | - Gian Piero Guerrini
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
- Department of Surgery, Ravenna Hospital, Ravenna, Italy
| | - Andrew K Burroughs
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
| | - Emmanuel Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
| | - David Patch
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
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Tai D, Timehin C, Patch D, Thorburn D, Westbrook RH. Is the hub-and-spoke model of care delivery a possible answer to geographical variation in liver transplant outcomes? Am J Transplant 2019; 19:1246-1247. [PMID: 30412648 DOI: 10.1111/ajt.15176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- David Tai
- Sheila Sherlock Liver Centre - Royal Free Hospital London, London, UK
| | - Christina Timehin
- Sheila Sherlock Liver Centre - Royal Free Hospital London, London, UK
| | - David Patch
- Sheila Sherlock Liver Centre - Royal Free Hospital London, London, UK
| | - Douglas Thorburn
- Sheila Sherlock Liver Centre - Royal Free Hospital London, London, UK
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36
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Drebes A, de Vos M, Gill S, Fosbury E, Mallett S, Burroughs A, Agarwal B, Patch D, Chowdary P. Prothrombin Complex Concentrates for Coagulopathy in Liver Disease: Single-Center, Clinical Experience in 105 Patients. Hepatol Commun 2019; 3:513-524. [PMID: 30976742 PMCID: PMC6442702 DOI: 10.1002/hep4.1293] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 10/22/2018] [Indexed: 02/06/2023] Open
Abstract
Patients with liver disease frequently develop coagulopathy, and fresh frozen plasma is traditionally used for correction of coagulopathy to manage and prevent bleeding. Prothrombin complex concentrates (PCCs) offer an attractive alternative because they are more readily available and avoid large-volume transfusion. This retrospective, single-center study reviewed clinical use of PCC in patients with acute/chronic liver disease. A total of 105 patients with 194 episodes of PCC administration were reviewed. Data pertaining to indication, dosing, effectiveness, and safety were collected. The effect of PCC on coagulation was analyzed in patients for whom coagulation results were available 7 hours before and after PCC. Data on thromboembolic events and mortality within 4 weeks of PCC administration were captured. Most patients (77%) had chronic liver disease; the remainder had acute liver failure. Indications for PCC were preprocedure prophylaxis and treatment for active/recent bleeding in 48% and 52% of 194 treatment episodes, respectively. The median dose of PCC administered was 22 IU/kg (interquartile range, 16-29 IU/kg). Before PCC administration, 45% of patients had an international normalized ratio (INR) greater than 2.0, and 36% had fibrinogen levels of at least 1.5 g/L. PCC produced statistically significant reductions in prothrombin time and INR (coadministration with fibrinogen or cryoprecipitate: 3.1 versus 1.9; P < 0.001; no coadministration: 2.3 versus 1.8; P < 0.001). Three patients with multiple risk factors developed thrombotic events (hepatic artery thrombosis, incidental bilateral pulmonary embolism, nonocclusive portal vein thrombosis); there were no cardiovascular or cerebrovascular adverse events. Overall, 46 patients died of causes unrelated to PCC treatment. Conclusion: In patients with liver disease, PCC therapy was effective in improving coagulation test results without an excess of thrombotic events. Further assessment of PCC as hemostatic therapy in this setting is required.
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Affiliation(s)
- Anja Drebes
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUnited Kingdom
| | - Marie de Vos
- UCL Institute for Liver Disease and Digestive HealthRoyal Free Hospital and UCLLondonUnited Kingdom
| | - Sunita Gill
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUnited Kingdom
| | - Emma Fosbury
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUnited Kingdom
| | - Sue Mallett
- Department of AnaesthesiaRoyal Free HospitalLondonUnited Kingdom
| | - Andy Burroughs
- UCL Institute for Liver Disease and Digestive HealthRoyal Free Hospital and UCLLondonUnited Kingdom
| | - Banwari Agarwal
- UCL Institute for Liver Disease and Digestive HealthRoyal Free Hospital and UCLLondonUnited Kingdom
- Intensive Care UnitRoyal Free HospitalLondonUnited Kingdom
| | - David Patch
- UCL Institute for Liver Disease and Digestive HealthRoyal Free Hospital and UCLLondonUnited Kingdom
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUnited Kingdom
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Forrest EH, Atkinson SR, Richardson P, Masson S, Ryder S, Thursz MR, Allison M, Gleeson D, Austin A, Patch D, Dhanda A, Shawcross D, Wright M. Application of prognostic scores in the STOPAH trial: Discriminant function is no longer the optimal scoring system in alcoholic hepatitis. J Hepatol 2018; 68:511-518. [PMID: 29175535 DOI: 10.1016/j.jhep.2017.11.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 10/21/2017] [Accepted: 11/01/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS 'Static' prognostic models in alcoholic hepatitis, using data from a single time point, include the discriminant function (DF), Glasgow alcoholic hepatitis score (GAHS), the age, serum bilirubin, international normalized ratio and serum creatinine (ABIC) score and the model of end-stage liver disease (MELD). 'Dynamic' scores, incorporating evolution of bilirubin at seven days, include the Lille score. The aim of this study was to assess these scores' performance in patients from the STOPAH trial. METHODS Predictive performance of scores was assessed by area under the receiver operating curve (AUC). The effect of different therapeutic strategies upon survival was assessed by Kaplan-Meier analysis and tested using the log-rank test. RESULTS A total of 1,068 patients were studied. The AUCs for the DF were significantly lower than for MELD, ABIC and GAHS for both 28- and 90-day outcomes: 90-day values were 0.670, 0.704, 0.726 and 0.713, respectively. 'Dynamic' scores and change in 'static' scores by Day 7 had similar AUCs. Patients with consistently low 'static' scores had low 28-day mortalities that were not improved with prednisolone (MELD <25: 8.6%; ABIC <6.71: 6.6%; GAHS <9: 5.9%). In patients with high 'static' scores without gastrointestinal bleeding or sepsis, prednisolone reduced 28-day mortality (MELD: 22.2% vs. 28.9%, p = 0.13; ABIC 14.6% vs. 21%, p = 0.02; GAHS 21% vs. 29.3%, p = 0.04). Overall mortality from treating all patients with a DF ≥32 and Lille assessment (90-day mortality 26.8%) was greater than combining newer 'static' and 'dynamic' scores (90-day mortality: MELD/Lille 21.8%; ABIC/Lille 23.7%; GAHS/Lille 20.6%). CONCLUSION MELD, ABIC and GAHS are superior to the DF in alcoholic hepatitis. Consistently low scores have a favourable outcome not improved with prednisolone. Combined baseline 'static' and Day 7 scores reduce the number of patients exposed to corticosteroids and improve 90-day outcome. LAY SUMMARY Alcoholic hepatitis is a life-threatening condition. Several scores exist to determine the outcome of these patients as well as to identify those who may benefit from treatment. This study looked at the performance of existing scores in patients who had been recruited to the largest alcoholic hepatitis clinical trial: STOPAH. 'Static' scores are calculable at the start of assessment. The three newer static scores (ABIC, GAHS and MELD) were shown to be superior to the oldest score (DF). ABIC and GAHS could also identify patients who had a survival benefit 28 days after starting prednisolone treatment. 'Dynamic' scores relate to the change in disease over the first week of treatment. Combination of the 'static' scores 'with the 'dynamic' scores or change in 'static' scores allowed identification of patients who could benefit from prednisolone up to 90 days.
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Affiliation(s)
- Ewan H Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, United Kingdom.
| | | | - Paul Richardson
- Liver Unit, Royal Liverpool Hospital, Liverpool, United Kingdom
| | - Steven Masson
- Liver Unit, Freeman Hospital, Newcastle, United Kingdom
| | - Stephen Ryder
- NIHR Nottingham Biomedical Research Centre and Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, United Kingdom
| | - Mark R Thursz
- Liver Unit, Imperial College, London, United Kingdom
| | - Michael Allison
- Liver Unit, Addenbrooke's Hospital, Cambridge Biomedical Research Centre, Cambridge, United Kingdom
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Tavare AN, Wigham A, Hadjivassilou A, Alvi A, Papadopoulou A, Goode A, Woodward N, Patch D, Yu D, Davies N. Use of transabdominal ultrasound-guided transjugular portal vein puncture on radiation dose in transjugular intrahepatic portosystemic shunt formation. Diagn Interv Radiol 2018; 23:206-210. [PMID: 28223261 DOI: 10.5152/dir.2016.15601] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE Transjugular intrahepatic portosystemic shunt (TIPS) creation is used to treat portal hypertension complications. Often the most challenging and time-consuming step in the procedure is the portal vein (PV) puncture. TIPS procedures are associated with prolonged fluoroscopy time and high patient radiation exposures. We measured the impact of transabdominal ultrasound guidance for PV puncture on duration of fluoroscopy time and dose. METHODS We retrospectively analyzed the radiation dose for all TIPS performed over a four-year period with transabdominal ultrasound guidance for PV puncture (n=212, with 210 performed successfully and data available for 206); fluoroscopy time, dose area product (DAP) and skin dose were recorded. RESULTS Mean fluoroscopy time was 12 min 9 s (SD, ±14 min 38 s), mean DAP was 40.3±73.1 Gy·cm2, and mean skin dose was 404.3±464.8 mGy. CONCLUSION Our results demonstrate that ultrasound-guided PV puncture results in low fluoroscopy times and radiation doses, which are markedly lower than the only published dose reference levels.
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Affiliation(s)
- Aniket N Tavare
- Departments of Radiology, Royal Free London NHS Foundation Trust, London, UK.
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Tai D, Dhar A, Yusuf A, Marshall A, O'Beirne J, Patch D, Tsochatzis E, Alexander G, Portal J, Thalheimer U, Thorburn D, Kallis Y, Westbrook R. The Royal Free Hospital ‘hub-and-spoke network model’ delivers effective care and increased access to liver transplantation. Public Health 2018; 154:164-171. [DOI: 10.1016/j.puhe.2017.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/09/2017] [Accepted: 10/19/2017] [Indexed: 01/16/2023]
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Onali S, Kalafateli M, Majumdar A, Westbrook R, O'Beirne J, Leandro G, Patch D, Tsochatzis EA. Non-selective beta-blockers are not associated with increased mortality in cirrhotic patients with ascites. Liver Int 2017; 37:1334-1344. [PMID: 28296047 DOI: 10.1111/liv.13409] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 03/02/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Controversy exists on the impact of non-selective beta-blockers (NSBBs) on survival in patients with ascites. We assessed whether NSBB treatment affects survival in a cohort of 316 consecutive patients with ascites undergoing evaluation for liver transplantation. METHODS Consecutive patients with cirrhosis and ascites assessed for liver transplantation between 2011 and 2014 were retrospectively evaluated. Competing risk Cox regression analysis in the whole population and in propensity score matched patients were performed to identify predictors of survival. RESULTS Three hundred and sixteen patients were evaluated: males 229 (73%), mean age 54 years, median follow-up: 7 months. Refractory ascites was diagnosed in 124 (39%) patients. Patients receiving NSBBs (n=128, 40.5%) had a higher frequency of previous spontaneous bacterial peritonitis (27% vs 17%, P=.025), lower frequency of refractory ascites (32% vs 44%, P=.03) but similar MELD and UKELD scores. Overall 80 (25%) patients died: 20 (16%) in the NSBB group vs. 60 (32%) in the non-NSBB group (P=.002). In multivariate competing risk Cox regression analysis, NSBB use was associated with reduced mortality (HR=0.55, 95% CI=0.33-0.94) along with prophylactic antibiotic use (HR=0.33, 95% CI=0.14-0.74), MELD score (HR=1.10, 95% CI=1.06-1.14) and sodium levels (HR=0.94, 95% CI: 0.89-0.98). No impact on survival was found when considering only patients with refractory ascites (NSBB use: HR=0.43, 95% CI=0.20-1.11). CONCLUSIONS Patients with ascites on NSBBs did not have impaired survival compared to those not receiving NSSBs and interestingly this observation was also confirmed in the subgroup with refractory ascites. Our results suggest that NSBBs are not detrimental, but instead seem safe even in more advanced stages of cirrhosis in patients on a transplant waiting list.
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Affiliation(s)
- Simona Onali
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Maria Kalafateli
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Avik Majumdar
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Rachel Westbrook
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - James O'Beirne
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Gioacchino Leandro
- Gastroenterology I Department, IRCCS De Bellis Hospital, Castellana Grotte, Italy
| | - David Patch
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
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Vergis N, Atkinson SR, Knapp S, Maurice J, Allison M, Austin A, Forrest EH, Masson S, McCune A, Patch D, Richardson P, Gleeson D, Ryder SD, Wright M, Thursz MR. In Patients With Severe Alcoholic Hepatitis, Prednisolone Increases Susceptibility to Infection and Infection-Related Mortality, and Is Associated With High Circulating Levels of Bacterial DNA. Gastroenterology 2017; 152:1068-1077.e4. [PMID: 28043903 PMCID: PMC6381387 DOI: 10.1053/j.gastro.2016.12.019] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/16/2016] [Accepted: 12/03/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Infections are common in patients with severe alcoholic hepatitis (SAH), but little information is available on how to predict their development or their effects on patients. Prednisolone is advocated for treatment of SAH, but can increase susceptibility to infection. We compared the effects of infection on clinical outcomes of patients treated with and without prednisolone, and identified risk factors for development of infection in SAH. METHODS We analyzed data from 1092 patients enrolled in a double-blind placebo-controlled trial to evaluate the efficacy of treatment with prednisolone (40 mg daily) or pentoxifylline (400 mg 3 times each day) in patients with SAH. The 2 × 2 factorial design led to 547 patients receiving prednisolone; 546 were treated with pentoxifylline. The trial was conducted in the United Kingdom from January 2011 through February 2014. Data on development of infection were collected at evaluations performed at screening, baseline, weekly during admission, on discharge, and after 90 days. Patients were diagnosed with infection based on published clinical and microbiologic criteria. Risk factors for development of infection and effects on 90-day mortality were evaluated separately in patients treated with prednisolone (n = 547) and patients not treated with prednisolone (n = 545) using logistic regression. Pretreatment blood levels of bacterial DNA (bDNA) were measured in 731 patients. RESULTS Of the 1092 patients in the study, 135 had an infection at baseline, 251 developed infections during treatment, and 89 patients developed an infection after treatment. There was no association between pentoxifylline therapy and the risk of serious infection (P = .084), infection during treatment (P = .20), or infection after treatment (P = .27). Infections classified as serious were more frequent in patients treated with prednisolone (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.27-2.92; P = .002). There was no association between prednisolone therapy and infection during treatment (OR, 1.04; 95% CI, 0.78-1.37; P = .80). However, a higher proportion (10%) of patients receiving prednisolone developed an infection after treatment than of patients not given prednisolone (6%) (OR, 1.70; 95% CI, 1.07-2.69; P = .024). Development of infection was associated with increased 90-day mortality in patients with SAH treated with prednisolone, independent of model for end-stage liver disease or Lille score (OR, 2.46; 95% CI, 1.41-4.30; P = .002). High circulating bDNA predicted infection that developed within 7 days of prednisolone therapy, independent of Model for End-Stage Liver Disease and white blood cell count (OR, 4.68; 95% CI, 1.80-12.17; P = .001). In patients who did not receive prednisolone, infection was not independently associated with 90-day mortality (OR, 0.94; 95% CI, 0.54-1.62; P = .82) or levels of bDNA (OR, 0.83; 95% CI, 0.39-1.75; P = .62). CONCLUSIONS Patients with SAH given prednisolone are at greater risk for developing serious infections and infections after treatment than patients not given prednisolone, which may offset its therapeutic benefit. Level of circulating bDNA before treatment could identify patients at high risk of infection if given prednisolone; these data could be used to select therapies for patients with SAH. EudraCT no: 2009-013897-42; Current Controlled Trials no: ISRCTN88782125.
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Affiliation(s)
| | - Stephen R. Atkinson
- Imperial College, London, United Kingdom,Reprint requests Address requests for reprints to: Stephen Atkinson, PhD, St Mary’s Hospital, Imperial College, London, W2 1NY, UK. fax: +4420 7724 9369.
| | | | | | | | | | | | - Steven Masson
- Freeman Hospital, The Newcastle Upon Tyne Hospitals, National Health Service Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Anne McCune
- Bristol Royal Infirmary, Bristol, United Kingdom
| | | | - Paul Richardson
- Royal Liverpool University National Health Service Trust, Liverpool, United Kingdom
| | - Dermot Gleeson
- Sheffield Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Stephen D. Ryder
- NIHR Biomedical Research Unit in Gastrointestinal and Liver Diseases at Nottingham University Hospitals National Health Service Trust and The University of Nottingham, Nottingham, United Kingdom
| | - Mark Wright
- Southampton University Hospital, Southampton, United Kingdom
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Chouhan MD, Mookerjee RP, Bainbridge A, Punwani S, Jones H, Davies N, Walker-Samuel S, Patch D, Jalan R, Halligan S, Lythgoe MF, Taylor SA. Caval Subtraction 2D Phase-Contrast MRI to Measure Total Liver and Hepatic Arterial Blood Flow: Proof-of-Principle, Correlation With Portal Hypertension Severity and Validation in Patients With Chronic Liver Disease. Invest Radiol 2017; 52:170-176. [PMID: 27805917 DOI: 10.1097/rli.0000000000000328] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Caval subtraction phase-contrast magnetic resonance imaging (PCMRI) noninvasive measurements of total liver blood flow (TLBF) and hepatic arterial (HA) flow have been validated in animal models and translated into normal volunteers, but not patients. This study aims to demonstrate its use in patients with liver cirrhosis, evaluate measurement consistency, correlate measurements with portal hypertension severity, and invasively validate TLBF measurements. MATERIALS AND METHODS Local research ethics committee approval was obtained. Twelve patients (mean, 50.8 ± 3.1 years; 10 men) with histologically confirmed cirrhosis were recruited prospectively, undergoing 2-dimensional PCMRI of the portal vein (PV) and the infrahepatic and suprahepatic inferior vena cava. Total liver blood flow and HA flow were estimated by subtracting infrahepatic from suprahepatic inferior vena cava flow and PV flow from estimated TLBF, respectively. Invasive hepatic venous pressure gradient (HVPG) and indocyanine green (ICG) clearance TLBF were measured within 7 days of PCMRI. Bland-Altman (BA) analysis of agreement, coefficients of variation, and Pearson correlation coefficients were calculated for comparisons with direct inflow PCMRI, HVPG, and ICG clearance. RESULTS The mean difference between caval subtraction TLBF and direct inflow PCMRI was 6.3 ± 4.2 mL/min/100 g (BA 95% limits of agreement, ±28.7 mL/min/100 g). Significant positive correlations were observed between HVPG and caval subtraction HA fraction (r = 0.780, P = 0.014), but not for HA flow (r = 0.625, P = 0.053), PV flow (r = 0.244, P = 0.469), or caval subtraction TLBF (r = 0.473, P = 0.141). Caval subtraction and ICG TLBF agreement was modest (mean difference, -32.6 ± 16.6 mL/min/100 g; BA 95% limits of agreement, ±79.7 mL/min/100 g), but coefficients of variation were not different (65.7% vs 48.1%, P = 0.28). CONCLUSIONS In this proof-of-principle study, caval subtraction PCMRI measurements are consistent with direct inflow PCMRI, correlate with portal hypertension severity, and demonstrate modest agreement with invasive TLBF measurements. Larger studies investigating the clinical role of TLBF and HA flow measurement in patients with liver disease are justified.
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Affiliation(s)
- Manil D Chouhan
- From the *Centre for Medical Imaging, Division of Medicine, and †Institute for Liver and Digestive Health, Division of Medicine, University College London; ‡Department of Medical Physics, University College London Hospitals NHS Trust; and §Centre for Advanced Biomedical Imaging, Division of Medicine, University College London, London, United Kingdom
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Kalafateli M, Mantzoukis K, Choi Yau Y, Mohammad AO, Arora S, Rodrigues S, de Vos M, Papadimitriou K, Thorburn D, O'Beirne J, Patch D, Pinzani M, Morgan MY, Agarwal B, Yu D, Burroughs AK, Tsochatzis EA. Malnutrition and sarcopenia predict post-liver transplantation outcomes independently of the Model for End-stage Liver Disease score. J Cachexia Sarcopenia Muscle 2017; 8:113-121. [PMID: 27239424 PMCID: PMC4864202 DOI: 10.1002/jcsm.12095] [Citation(s) in RCA: 208] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/23/2015] [Accepted: 11/02/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although malnutrition and sarcopenia are prevalent in cirrhosis, their impact on outcomes following liver transplantation is not well documented. METHODS The associations of nutritional status and sarcopenia with post-transplant infections, requirement for mechanical ventilation, intensive care (ICU) and hospital stay, and 1 year mortality were assessed in 232 consecutive transplant recipients. Nutritional status and sarcopenia were assessed using the Royal Free Hospital-Global Assessment (RFH-GA) tool and the L3-psoas muscle index (L3-PMI) on CT, respectively. RESULTS A wide range of RFH-SGA and L3-PMI were observed within similar Model for End-stage Liver Disease (MELD) sub-categories. Malnutrition and sarcopenia were independent predictors of all outcomes. Post-transplant infections were associated with MELD (OR = 1.055, 95%CI = 1.002-1.11) and severe malnutrition (OR = 6.55, 95%CI = 1.99-21.5); ventilation > 24 h with MELD (OR = 1.1, 95%CI = 1.036-1.168), severe malnutrition (OR = 8.5, 95%CI = 1.48-48.87) and suboptimal donor liver (OR = 2.326, 95%CI = 1.056-5.12); ICU stay > 5 days, with age (OR = 1.054, 95%CI = 1.004-1.106), MELD (OR = 1.137, 95%CI = 1.057-1.223) and severe malnutrition (OR = 7.46, 95%CI = 1.57-35.43); hospital stay > 20 days with male sex (OR = 2.107, 95%CI = 1.004-4.419) and L3-PMI (OR = 0.996, 95%CI = 0.994-0.999); 1 year mortality with L3-PMI (OR = 0.996, 95%CI = 0.992-0.999). Patients at the lowest L3-PMI receiving suboptimal grafts had longer ICU/hospital stay and higher incidence of infections. CONCLUSIONS Malnutrition and sarcopenia are associated with early post-liver transplant morbidity/mortality. Allocation indices do not include nutritional status and may jeopardize outcomes in nutritionally compromised individuals.
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Affiliation(s)
- Maria Kalafateli
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | | | - Yan Choi Yau
- Department of RadiologyRoyal Free Hospital London NHS Foundation TrustLondonUK
| | - Ali O. Mohammad
- Intensive Care UnitRoyal Free Hospital London NHS Foundation TrustLondonUK
- Department of Chest DiseasesMinia UniversityEgypt
| | - Simran Arora
- Nutrition and Dietetics DepartmentRoyal Free Hospital London NHS Foundation TrustLondonUK
| | - Susana Rodrigues
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - Marie de Vos
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | | | - Douglas Thorburn
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - James O'Beirne
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - David Patch
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - Massimo Pinzani
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - Marsha Y. Morgan
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - Banwari Agarwal
- Intensive Care UnitRoyal Free Hospital London NHS Foundation TrustLondonUK
| | - Dominic Yu
- Department of RadiologyRoyal Free Hospital London NHS Foundation TrustLondonUK
| | - Andrew K. Burroughs
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
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Arnold F, Patch D, Yu D, Westbrook RH. When banding fails; investigation hails. Gut 2017; 66:322. [PMID: 27340193 DOI: 10.1136/gutjnl-2016-311515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 06/06/2016] [Accepted: 06/07/2016] [Indexed: 12/08/2022]
Affiliation(s)
| | - D Patch
- Hepatology Department, Royal Free Hospital, London, UK
| | - D Yu
- Radiology Department, Royal Free Hospital, London, UK
| | - R H Westbrook
- Hepatology Department, Royal Free Hospital, London, UK
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Maurice JB, Brodkin E, Arnold F, Navaratnam A, Paine H, Khawar S, Dhar A, Patch D, O'Beirne J, Mookerjee R, Pinzani M, Tsochatzis E, Westbrook RH. Validation of the Baveno VI criteria to identify low risk cirrhotic patients not requiring endoscopic surveillance for varices. J Hepatol 2016; 65:899-905. [PMID: 27388923 DOI: 10.1016/j.jhep.2016.06.021] [Citation(s) in RCA: 155] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 06/05/2016] [Accepted: 06/07/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The Baveno VI guidelines propose that cirrhotic patients with a liver stiffness measurement (LSM) <20kPa and a platelet count >150,000/μl can avoid screening endoscopy as their combination is highly specific for excluding clinically significant varices. The aim of the study was to validate these criteria. METHODS Transient elastography data was collected from two institutions from 2006-2015. Inclusion criteria were a LSM ⩾10kPa and an upper gastrointestinal endoscopy within 12months, with a diagnosis of compensated chronic liver disease. Exclusion criteria were porto-mesenteric-splenic vein thrombosis and non-cirrhotic portal hypertension. Varices were graded as low risk (grade <2) or high risk (grade ⩾2). RESULTS The study included 310 patients (169 (55%) hepatitis C, and 275 (89%) Child-Pugh A). Varices were present in 23% cases, with 5% prevalence of high risk varices. Overall 102/310 (33%) met the Baveno VI criteria. Within this group 11% had varices and 2% had high risk varices, representing 2/15 (13%) of all high risk varices. The Baveno VI criteria gave a sensitivity 0.87, specificity 0.34, positive predictive value 0.06, negative predictive value 0.98, positive likelihood ratio 1.31 and negative likelihood ratio 0.39. The AUROC for LSM and platelet count combined was 0.746. CONCLUSIONS The Baveno VI criteria performed well correctly identifying 98% of patients who could safely avoid endoscopy. LAY SUMMARY This study examines the effectives of a recent set of guidelines published by the Baveno VI conference, which states that patients with chronic liver disease and a low liver stiffness (<20kPa) and high platelet count (>150) are at low risk of having varices and do not need a screening endoscopy. Varices are a complication of cirrhosis, confer a risk of serious bleeding, and can be diagnosed and treated by endoscopy. Our study reviewed the clinical records of patients who have had liver stiffness scans and endoscopy over a 9-year period at two hospitals. The results show that only about 2% of patients who meet the Baveno VI criteria will be miss-classified as not having varices.
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Affiliation(s)
- James B Maurice
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom; Department of Hepatology, Imperial College Healthcare NHS Trust, United Kingdom
| | - Edgar Brodkin
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom
| | - Frances Arnold
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom
| | | | - Heidi Paine
- Department of Hepatology, Imperial College Healthcare NHS Trust, United Kingdom
| | - Sabrina Khawar
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom
| | - Ameet Dhar
- Department of Hepatology, Imperial College Healthcare NHS Trust, United Kingdom
| | - David Patch
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom
| | - James O'Beirne
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom
| | - Raj Mookerjee
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom; Institute for Liver and Digestive Health, University College London, United Kingdom
| | - Massimo Pinzani
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom; Institute for Liver and Digestive Health, University College London, United Kingdom
| | - Emmanouil Tsochatzis
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom; Institute for Liver and Digestive Health, University College London, United Kingdom
| | - Rachel H Westbrook
- Department of Hepatology, Royal Free Hospital NHS Trust, United Kingdom.
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Ramsay I, Snell L, Sharma V, O'Beirne J, Patch D, Marshall A, Imber C, Ijaz S, Dianne Irish, Westbrook RH. Liver transplantation for acute liver failure because of genotype 3 hepatitis E virus infection. Liver Transpl 2015; 21:1557-9. [PMID: 26178234 DOI: 10.1002/lt.24213] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 07/01/2015] [Accepted: 07/02/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Isobel Ramsay
- Department of Virology, Royal Free London, NHS Foundation Trust, London, UK
| | - Luke Snell
- Department of Hepatology, Royal Free London, NHS Foundation Trust, London, UK
| | - Vikram Sharma
- Department of Hepatology, Royal Free London, NHS Foundation Trust, London, UK
| | - James O'Beirne
- Department of Hepatology, Royal Free London, NHS Foundation Trust, London, UK
| | - David Patch
- Department of Hepatology, Royal Free London, NHS Foundation Trust, London, UK
| | - Aileen Marshall
- Department of Hepatology, Royal Free London, NHS Foundation Trust, London, UK
| | - Charles Imber
- Department of Virology, Royal Free London, NHS Foundation Trust, London, UK
| | - Samreen Ijaz
- Infectious Diseases, Gastroenterology, Hepatology, Public Health England, London, UK
| | - Dianne Irish
- Department of Virology, Royal Free London, NHS Foundation Trust, London, UK
| | - Rachel H Westbrook
- Department of Hepatology, Royal Free London, NHS Foundation Trust, London, UK
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Thursz M, Forrest E, Roderick P, Day C, Austin A, O'Grady J, Ryder S, Allison M, Gleeson D, McCune A, Patch D, Wright M, Masson S, Richardson P, Vale L, Mellor J, Stanton L, Bowers M, Ratcliffe I, Downs N, Kirkman S, Homer T, Ternent L. The clinical effectiveness and cost-effectiveness of STeroids Or Pentoxifylline for Alcoholic Hepatitis (STOPAH): a 2 × 2 factorial randomised controlled trial. Health Technol Assess 2015; 19:1-104. [PMID: 26691209 PMCID: PMC4781103 DOI: 10.3310/hta191020] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Alcoholic hepatitis (AH) is a distinct presentation of alcoholic liver disease arising in patients who have been drinking to excess for prolonged periods, which is characterised by jaundice and liver failure. Severe disease is associated with high short-term mortality. Prednisolone and pentoxifylline (PTX) are recommended in guidelines for treatment of severe AH, but trials supporting their use have given heterogeneous results and controversy persists about their benefit. OBJECTIVES The aim of the clinical effectiveness and cost-effectiveness of STeroids Or Pentoxifylline for Alcoholic Hepatitis trial was to resolve the clinical dilemma on the use of prednisolone or PTX. DESIGN The trial was a randomised, double-blind, 2 × 2 factorial, multicentre design. SETTING Sixty-five gastroenterology and hepatology inpatient units across the UK. PARTICIPANTS Patients with a clinical diagnosis of AH who had a Maddrey's discriminant function value of ≥ 32 were randomised into four arms: A, placebo/placebo; B, placebo/prednisolone; C, PTX/placebo; and D, PTX/prednisolone. Of the 5234 patients screened for the trial, 1103 were randomised and after withdrawals, 1053 were available for primary end-point analysis. INTERVENTIONS Those allocated to prednisolone were given 40 mg daily for 28 days and those allocated to PTX were given 400 mg three times per day for 28 days. OUTCOMES The primary outcome measure was mortality at 28 days. Secondary outcome measures included mortality or liver transplant at 90 days and at 1 year. Rates of recidivism among survivors and the impact of recidivism on mortality were assessed. RESULTS At 28 days, in arm A, 45 of 269 (16.7%) patients died; in arm B, 38 of 266 (14.3%) died; in arm C, 50 of 258 (19.4%) died; and in arm D, 35 of 260 (13.5%) died. For PTX, the odds ratio for 28-day mortality was 1.07 [95% confidence interval (CI) 0.77 to 1.40; p = 0.686)] and for prednisolone the odds ratio was 0.72 (95% CI 0.52 to 1.01; p = 0.056). In the logistic regression analysis, accounting for indices of disease severity and prognosis, the odds ratio for 28-day mortality in the prednisolone-treated group was 0.61 (95% CI 0.41 to 0.91; p = 0.015). At 90 days and 1 year there were no significant differences in mortality rates between the treatment groups. Serious infections occurred in 13% of patients treated with prednisolone compared with 7% of controls (p = 0.002). At the 90-day follow-up, 45% of patients reported being completely abstinent, 9% reported drinking within safety limits and 33% had an unknown level of alcohol consumption. At 1 year, 37% of patients reported being completely abstinent, 10% reported drinking within safety limits and 39% had an unknown level of alcohol consumption. Only 22% of patients had attended alcohol rehabilitation treatment at 90 days and 1 year. CONCLUSIONS We conclude that prednisolone reduces the risk of mortality at 28 days, but this benefit is not sustained beyond 28 days. PTX had no impact on survival. Future research should focus on interventions to promote abstinence and on treatments that suppress the hepatic inflammation without increasing susceptibility to infection. TRIAL REGISTRATION This trial is registered as EudraCT 2009-013897-42 and Current Controlled Trials ISRCTN88782125. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 102. See the NIHR Journals Library website for further project information. The NIHR Clinical Research Network provided research nurse support and the Imperial College Biomedical Research Centre also provided funding.
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Affiliation(s)
- Mark Thursz
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ewan Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Paul Roderick
- Primary Care & Population Sciences, University of Southampton, Southampton, UK
| | - Christopher Day
- Institute of Cellular Medicine, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew Austin
- Department of Gastroenterology, Derby Royal Hospital, Derby, UK
| | - John O'Grady
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Stephen Ryder
- Department of Hepatology, Nottingham University Hospitals NHS Trust and National Institute for Health Research Biomedical Research Unit, Queens Medical Centre, Nottingham, UK
| | - Michael Allison
- Department of Hepatology, Addenbrookes Hospital, Cambridge, UK
| | - Dermot Gleeson
- Department of Hepatology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - Anne McCune
- Department of Hepatology, Bristol Royal Infirmary, Bristol, UK
| | - David Patch
- Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | - Mark Wright
- Department of Hepatology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Steven Masson
- Institute of Cellular Medicine, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Paul Richardson
- Department of Hepatology, Royal Liverpool Hospital, Liverpool, UK
| | - Luke Vale
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Jane Mellor
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Louise Stanton
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Megan Bowers
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Ian Ratcliffe
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Nichola Downs
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Scott Kirkman
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Tara Homer
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Ternent
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, Austin A, Ferguson JW, Olliff SP, Hudson M, Christie JM. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015; 64:1680-704. [PMID: 25887380 PMCID: PMC4680175 DOI: 10.1136/gutjnl-2015-309262] [Citation(s) in RCA: 351] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 03/17/2015] [Indexed: 12/12/2022]
Abstract
These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and University College London, London, UK
| | - Charles Millson
- Gastrointestinal and Liver Services, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Homoyon Mehrzad
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Austin
- Department of Gastroenterology, Derby Hospitals NHS Foundation Trust, Derby, UK
| | - James W Ferguson
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon P Olliff
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark Hudson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - John M Christie
- Department of Gastroenterology, Royal Devon and Exeter Hospital, Devon, UK
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Isgro G, Luong T, Andreana L, Garcovich M, Maimone S, Manousou P, Calvaruso V, Tsochatzis E, Patch D, Thornburn D, Dhillon A, Burroughs A. PP-011 Collagen proportionate area: a continuous quantitative of histological collagen has the best correlation with transient elastography. Gut 2015. [DOI: 10.1136/gut.2009.209015c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Affiliation(s)
- Mallika Sekhar
- Department of Haematology, Royal Free London NHS Foundation Trust, London, UK.
| | - David Patch
- Department of Hepatology, Royal Free London NHS Foundation Trust, London, UK
| | - Belinda Austen
- Department of Haematology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Joanne Howard
- Department of Haematology, Basildon and Thurrock NHS Foundation Trust, Basildon, UK
| | - Stephen Hart
- Department of Haematology, Royal Free London NHS Foundation Trust, London, UK
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