Efficacy and Safety of Variable Treatment Options in the Prevention of Hepatic Encephalopathy: A Systematic Review and Network Meta-Analysis

There are no guidelines for the most effective medication to reduce hepatic encephalopathy (HE) or the associated mortality. The purpose of this study is to determine the most effective possible treatment among the single treatment options or the combined treatment options for decreasing the morbidity and mortality of HE. We evaluated the outcomes by various parameters such as the quality of life, reduction in ammonia, all causes of mortality, adverse events, reversal of minimal HE, and development of overt HE. We systematically searched PubMed, Cochrane, Web of Science, and Scopus till the 19th of January 2023 for studies that assess various treatment options for HE. Data were extracted from eligible studies and pooled in a frequentist network meta-analysis as standardized mean difference (SMD) and their 95% confidence interval (CI) using the MetaInsight web-based tool. The Cochrane Tool was used to assess the randomized controlled trials' quality (RCT), while the NIH tool was used to assess the quality of the included cohort studies. Utilizing the R software, the network meta-analysis was conducted. In addition to a significant variation in cases of (Lactulose and Rifaximin) compared with Rifaximin (RR= 0.39, 95% CI [0.17; 0.89]), the results demonstrated a significantly lower incidence of overt HE in (Lactulose and Rifaximin) compared with placebo (RR=0.19, 95% CI [0.09; 0.40]). Most arms demonstrated a statistically significant reduction in the incidence of overt HE compared to albumin and placebo. The results also demonstrated a significant reduction in ammonia between L-ornithine-L-aspartate (LOLA) and probiotics (MD= -19.17, 95% CI [-38.01; -0.32]), as well as a significant difference in the incidence of LOLA compared to placebo (MD= -22.62, 95% CI [-39.16; -6.07]). This network meta-analysis has significant data for managing subclinical HE in people without a history of overt HE. Our analysis showed that (Lactulose and Rifaximin), followed by (Rifaximin and L-carnitine), followed by (Lactulose and Rifaximin with zinc) were the best combinations regarding overt HE. LOLA reduced ammonia best, followed by Nitazoxanide and finally Lactulose. (Lactulose and Nitazoxanide) have the least adverse effects, followed by (Rifaximin and L-carnitine), then Probiotics. Yet, all mortality outcomes and quality of life changes yielded no useful findings. Future studies like RCTs must be done to compare our therapies directly.

Role of Plasmapheresis in Hemolysis, Elevated Liver Enzymes and Low Platelets (HELLP) Syndrome

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a rare abnormality comprising a series of symptoms that make up a syndrome. It usually happens during pregnancy or right after delivery. We describe a case of a 31-year-old female G4P2A2 (Gravida 4 Para 2 Abortions 2) who presented to the hospital for normal vaginal delivery but immediately postpartum developed HELLP syndrome. Acute fatty liver of pregnancy was a differential that the patient also met the criteria for. Her condition improved after starting her on plasmapheresis without considering hepatic transplantation. We emphasize distinguishing the overlap of symptoms between HELLP syndrome vs. acute fatty liver of pregnancy and the outcomes of plasmapheresis in managing HELLP syndrome without needing hepatic transplantation.

Impact of Covid-19 on cardiovascular clinics: are we ready for tele-medicine?

Funding Acknowledgements

Type of funding sources: None.

Background

World is facing Coronavirus disease (COVID-19) pandemic since December 2019. [1, 2]. COVID-19 has significantly decreased the influx of patients presenting with cardiovascular diseases at hospitals. The aim of this study was to determine the difficulties faced by patients in visiting the cardiac outpatient department during COVID-19 era and to assess the awareness regarding telemedicine and wiliness to adopt if offered in future.

Methods

This cross sectional study was carried out on patients presenting to the outpatient department in a National Institute of Cardiovascular Diseases. Data was collected after verbal consent from patients. The collected data was entered using IBM SPSS version 21, mean ± SD was calculated for continuous variables and frequency and percentages were calculated for the categorical variables.

Results

A total of 404 patients were interviewed, 42% female and 58% male with 77.5% from urban areas and 22.5% from rural areas. A total of 32.1% patients presented with shortness of breath, 28.8% with chest pain and 19% with palpitations. Regarding cardiovascular diagnosis 69.5% had ischemic heart disease, 38.3% had hypertension, 29.3% suffered from heart failure and 10.3% had valvular heart disease. A total of 26.7% visited the emergency room during the pandemic, 81.9% were compliant with medication and only 66% were compliant with a healthy lifestyle. A total of 52.8% patients found it difficult to attend the out patients department due to limited appointments, 24% due to limited mobility due to lockdown, 18.2% due to financial issues, 14.2% due to fear of acquiring infection from the hospital. Regarding telemedicine, 11.2% of the patients were aware of it and only 4.5% had previously used it, with 41.3% patients willing to opt for telemedicine in future. Regarding barriers to usage of telemedicine, a total of 40.7% of patients had no access to internet, 32.7% did not have a smart device and 11.6% were afraid of being diagnosed incorrectly.

Conclusion

It was found that distancing measures, lockdowns and restricted mobility of the masses has made it difficult for patients to visit the clinics which has led to patients visiting the emergency room. Telemedicine awareness was found to be limited, however many patients were willing to adopt provided their limitations can be overcame.

Using longitudinal survey and sensor data to understand the social and ecological determinants of clean fuels use and discontinuance in rural Ghana

Efforts to reduce the health and ecological burdens of household biomass combustion are underway in Ghana, principally by promoting clean cookstoves and fuels. Recent studies have focused on the sustained use of clean cookstoves, but sometimes household adopt a new cookstove and then end use of that stove. In this study, we introduce a novel framework for understanding and encouraging household transitions to cleaner cooking: clean fuel discontinuance. We leveraged data from the Ghana Randomized Air Pollution and Health Study (GRAPHS) (N = 1412) where pregnant women received either improved biomass (BioLite) or dual burner LPG stoves for free. LPG users were given free LPG refills during GRAPHS. Weekly questionnaires were administered. Stove use monitors tracked a sub-cohort (n = 220) 6 months before and after the fuel subsidy. We examined social and ecological determinants of stove use and discontinuance. Overall intervention stove use adherence was high throughout GRAPHS, with self-reported use at 69% and 86% of participant-weeks for BioLite and LPG arms respectively. Participants used intervention stoves less for meals requiring vigorous stirring. Burns from intervention stoves decreased use among BioLite (RR: 0.96, p = 0.009), but not LPG users. Device breakage was mentioned as an impediment in 18% of free-text responses for LPG users and 1% for BioLite. Tree canopy within a spatial buffer-a plausible proxy for biomass fuels access-was the only variable explaining LPG discontinued stove use in adjusted Cox time-to-event analyses (HR = -0.56, p < 0.001). Future studies should consider the stove use discontinuance framework.

A Case of Pneumatosis Intestinalis With Pneumoperitoneum as a Potential Delayed Adverse Effect of Capecitabine

Ileitis and colitis are known complications of capecitabine when used in patients with gastrointestinal cancers. However, to our knowledge, pneumatosis intestinalis (PI) has not previously been reported with this medication. We present a patient with breast cancer, without any metastases to the gastrointestinal tract, who presented with persistent diarrhea 4 weeks after discontinuing adjuvant capecitabine, which was found to be due to PI. As she had no other risk factors or identifiable causes, her PI was attributed to a delayed reaction to capecitabine. This case highlights the need to consider PI earlier in the differential diagnosis in patients with breast cancer who present with unexplained diarrhea after recent discontinuation of capecitabine.

Cross-sectional studies published in Indian journal of community medicine: evaluation of adherence to strengthening the reporting of observational studies in epidemiology statement

Background:

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement is a set of recommendations about what should be included in a more accurate and complete description of observational studies.

Aim:

The aim was to assess the quality of reporting of cross-sectional studies by evaluating the extent to which they adhere to the STROBE statement.

Materials and Methods:

This study has a cross-sectional design. All the articles published as original articles in Indian Journal of Community Medicine from January 2010 to September 2011 were downloaded from the journal website. A total of 96 articles were downloaded out of which 80 were found to have a cross-sectional design. Variables were: (1) Percentage of STROBE items included in a report and (2) percentage of articles reporting each item in the STROBE checklist. Data analysis was done by descriptive statistics using frequencies and percentages.

Results:

A total of 80 articles were evaluated. About 46% (37/80) articles reported 12–15 items of the STROBE checklist. Bias, nonparticipants and reasons for nonparticipation, other analyses done, generalizability, and source of funding were reported by < 25% of studies. The most frequently reported items of the checklist were summary of what was done and what was found in the abstract, background/rationale, objectives, setting, outcome data, key results in discussion, interpretation of results. None of the articles reported all items of the STROBE checklist.

Conclusion:

This study reveals that the quality of reporting cross-sectional studies in Indian Journal of Community Medicine is not satisfactory and there is room for improvement.

Primary care treatment for child and adolescent neuropsychiatric conditions in remote rural Punjab, Pakistan - a cross-sectional survey

BACKGROUND

Pakistan is one of the most populous regions of the world. Previous work has demonstrated that there is reliance on traditional healthcare systems when seeking psychiatric care; however, there is a lack of information on help seeking for child and adolescent population. The aim of this study was to describe types of treatments and families' perceptions of the effectiveness of those treatments for childhood neuropsychiatric disorders in remote rural Punjab.

METHOD

Cross-sectional survey of consecutive attendees at an advertised mental health consultation day in a remote rural area.

RESULTS

The effectiveness of these treatments, as rated by patients and their families, was variable, with highest reported effectiveness for general practitioner treatments. In families with a past history of care from a general practitioner, those who had epilepsy reported treatments to be more effective than those with mental retardation. Carers and users described consulting five different types of primary healthcare practitioners that used both physical and psychotherapeutic treatments.

CONCLUSIONS

There is considerable variation in treatments available for child and adolescent neuropsychiatric disorders in remote rural areas of Punjab, a large proportion of which are considered ineffective by the users and carers. This highlights the need to develop effective interventions for child and adolescent neuropsychiatric conditions that can be administered by primary health workers. Our data suggest that the need for this is greatest for mental retardation.

Effect of piriformis versus trochanteric starting point on fixation stability of short intramedullary reconstruction nails

Recently, a new, shorter IM nail using two 6 mm reconstruction screws for proximal fixation was introduced in two versions for femoral insertion: piriformis fossa (FAN) and greater trochanter (TAN). These nails were compared experimentally for their fixation stability, proximal load transmission, and failure strength in an unstable intertrochanteric fracture model in cadaveric femurs. Vertical and axial loads were first applied to the intact femurs. Fractures were created, subsequent fixation applied, and the femurs underwent a series of both vertical and axial loading tests. There was no significant difference in strain readings between the nails for either axial loading or cyclical loading. There was no statistically significant difference between the loads to failure for the trochanteric nails and the standard antegrade nails. The average ultimate loadfor the FAN and TAN nails were 3010 N and 2830 N respectively. These two nails performed very similarly throughout our testing.

Midterm clinical and radiographic results with the genesis I total knee prosthesis

The midterm results of primary posterior cruciate ligament-retaining, minimally conforming, cemented modular total knee arthroplasties using the Genesis I prosthesis in 110 knees in 72 patients were reviewed. Patients were evaluated at a mean follow-up of 7.3 years by Knee Society pain and functional scores, radiographic and survivorship analysis, and Western Ontario and MacMaster Universities Osteoarthritis Index (WOMAC) health status questionnaire. Range of motion increased from an average of 96.3 degrees to 112.5 degrees. Knee Society pain and functional scores increased from preoperative averages of 55 and 44 to 92 and 88, respectively. There were 91 excellent, 16 good, 1 fair, and 2 poor results. WOMAC scores were increased significantly in each subcategory examined (pain, stiffness, and physical function). Kaplan-Meier survivorship was 97% at 10 years. An increase in loosening as a result of eccentric stress concentration secondary to the nonconforming design of this prosthesis, theoretically a matter of some clinical concern, was not shown in this investigation.

Efficacy of combined technetium-99m sulfur colloid/indium-111 leukocyte scans to detect infected total hip and knee arthroplasties

The reliability of combined indium-111 leukocyte/technetium-99m sulfur colloid scans, with and without the addition of blood pooling and blood flow studies, in the diagnosis of infected total joint arthroplasty was investigated. Both scans were performed on 58 patients before reoperation of total hip or knee arthroplasty in the period 1996-1999. Results for imaging alone included 100% specificity, 46% sensitivity, 100% positive predictive value, 84% negative predictive value, and 88% accuracy. Inclusion of blood pooling and flow phase data improved results to 66% sensitivity, 89% negative predictive value, and 90% accuracy, with reductions in specificity (98%) and positive predictive value (91%). Routine use of these radionuclide scans is not supported by these data.

Amitriptyline versus bupivacaine in rat sciatic nerve blockade

BACKGROUND

Amitriptyline, a tricyclic antidepressant, is frequently used orally for the management of chronic pain. To date there is no report of amitriptyline producing peripheral nerve blockade. The authors therefore investigated the local anesthetic properties of amitriptyline in rats and in vitro.

METHODS

Sciatic nerve blockade was performed with 0.2 ml amitriptyline or bupivacaine at selected concentrations, and the motor, proprioceptive, and nociceptive blockade was evaluated. Cultured rat GH3 cells were externally perfused with amitriptyline or bupivacaine, and the drug affinity toward inactivated and resting Na+ channels was assessed under whole-cell voltage clamp conditions. In addition, use-dependent blockade of these drugs at 5 Hz was evaluated.

RESULTS

Complete sciatic nerve blockade for nociception was obtained with amitriptyline for 217 +/- 19 min (5 mM, n = 8, mean +/- SEM) and for 454 +/- 38 min (10 mM, n = 7) versus bupivacaine for 90 +/- 13 min (15.4 mM, n = 6). The time to full recovery of nociception for amitriptyline was 353 +/- 12 min (5 mM) and 656 +/- 27 min (10 mM) versus 155 +/- 9 min for bupivacaine (15.4 mM). Amitriptyline was approximately 4.7-10.6 times more potent than bupivacaine in binding to the resting channels (50% inhibitory concentration [IC50] of 39.8 +/- 2.7 vs. 189.6 +/- 22.3 microM) at - 150 mV, and to the inactivated Na+ channels (IC50 of 0.9 +/- 0.1 vs. 9.6 +/- 0.9 microM) at -60 mV. High-frequency stimulation at 3 microM caused an additional approximately 14% blockade for bupivacaine, but approximately 50% for amitriptyline.

CONCLUSION

Amitriptyline is a more potent blocker of neuronal Na+ channels than bupivacaine in vivo and in vitro. These findings suggest that amitriptyline could extend its clinical usefulness for peripheral nerve blockade.