How are medical schools supporting student’s mental wellbeing during the COVID-19 pandemic?

Introduction

The COVID-19 pandemic has impacted medical students in many ways. They are not exempt from personal struggles caused by the health crisis, and many have faced similar challenges adapting to a new learning experience. The University of East Anglia (UEA) has initiatives in place to support medical students including the society Headucate UEA and the Wellbeing Champions scheme established by Norwich Medical School (NMS).

Objectives

Headucate aims to improve mental wellbeing by educational online webinars and social events aimed at university students. NMS Wellbeing Champions offer support and signpost students to resources and the wider student support system at the UEA.

Methods

Headucate was established in 2012 by NMS students that began running workshops at local secondary schools. Their work has expanded to include wellbeing workshops, social events for students and mental health first aid training, so members can provide peer support. Wellbeing Champions are medical student representatives responsible for completing mental health first aid training, communication between students and faculty, providing resources and signposting, creating mental health bulletin newsletters, and running socials exclusively for medical students.

Results

100% of Headucate workshop attendees who completed anonymous feedback agreed that they enjoyed it and that it was useful. No feedback has been collected regarding the success of the Wellbeing Champions. This should be carried out to assess and enhance the project further.

Conclusions

More data is needed to establish the success of the initiatives at NMS and their impact on medical student’s wellbeing.

Disclosure

No significant relationships.

The Success of Headucate: The Student-Led Mental Health Society

Introduction

Headucate: University of East Anglia, a university student-led society, was founded almost 10 years ago by medical students to promote mental health education and raise awareness and funds for mental health causes.

Objectives

Headucate aims to spread mental health awareness and reduce stigma by working with schools, universities, other societies and charities internationally.

Methods

Headucate delivers workshops for children aged 4-18 in primary and secondary schools, community and youth groups and university students. These sessions were delivered in-person pre-COVID and online as interactive webinars since 2020, to spark discussion around mental health, and provide information about the variety of supports available for young people.

Results

In the past decade, Headucate UEA has grown to become one of UEA’s largest student-led groups boasting over 175 members in 2020-2021 from all courses. Within the online world, Headucate’s events have reached worldwide. The initiative has received national recognition, won national student awards and has expanded to set up three further Headucate branches nationwide. Outreach has accelerated and the school workshops reached over 1,000 students in the past year.

Conclusions

Headucate has grown from strength to strength and has plans to continue to develop, with passionate student drivers behind the project. Expansion of the project could include a national mental health university directory, bringing together like-minded mental health advocate students around the country and creating new Headucate branches across the country. To further develop, Headucate could expand outreach to the elderly community as discussed by previous committee.

Disclosure

No significant relationships.

Is TikTok increasing the number of self-diagnoses of ADHD in young people?

Introduction

TikTok is a free mobile application, that enables users to create short videos. TikTok has an estimated one billion monthly active users, comprised of a mostly younger audience. There has been a noticed rise in content discussing ADHD – hashtag ADHD on TikTok has 6.3 billion views. The discussions continue on Twitter, where users are reporting watching TikTok content explaining ADHD symptomatology, subsequently relating to the condition and requesting referrals to specialist psychiatry services. This study aims to identify key themes in discussions around TikTok and ADHD, and its ramifications.

Objectives

This study’s objective is to discuss the relationship between viewing ADHD content of TikTok and self-diagnoses of ADHD in young people.

Methods

In our study, Twitter posts were identified with the words ‘ADHD’ and ‘TikTok’ and established key themes relating to self-diagnosis of ADHD.

Results

Numerous tweets were found discussing individual’s experiences of self-diagnosis of ADHD after watching TikTok videos and relating with the symptomology. Furthermore, many users discussed their efforts to seek diagnosis from psychiatrists. These posts highlighted positive discussion of mental health, and the improvement in quality of life since diagnosis.

Conclusions

Many young people are self-diagnosing ADHD after viewing TikTok videos. This may improve mental health stigma, however the expertise of the video creators should be scrutinised. Furthermore, the impact on already stretched waiting lists should be considered, with individuals who’s perceived ADHD traits are not impacting on their quality of life.

Disclosure

No significant relationships.

The impact of COVID-19 on mental health charity fundraising: An account from the perspective of fundraisers

Introduction

The dawn of COVID-19 brought new rules, restrictions, and lockdowns but this led to the unlikely fall of many sectors, including the charitable sector. There has been a significant decline in funding received by mental health charities, especially during the pandemic. This study looks at the subsequent impact on fundraisers and mental health promotion during COVID-19.

Objectives

The main aim was to uncover how the COVID-19 pandemic has affected the way that mental health charities fundraise, raise awareness, and promote mental health. This aimed to look at the impact of the COVID-19 pandemic on fundraisers supporting mental health charities and their opinion on whether fundraising has either helped or hindered mental health promotion.

Methods

Accounts from fundraisers and local representatives for mental health charities during the COVID-19 pandemic were analysed. Common themes looked at the impact, adaptation, and reasons why fundraisers decided to help during a tough period for the charitable sector.

Results

Mental health charities expressed difficulty in sourcing funds to support their users, especially in a vulnerable time. Fundraisers tried innovative ways to promote mental health and raise money for charities.

Conclusions

Altruism and understanding how precious services such as mental health charities are for the population was the main driver for fundraisers. Mental health charities adapted by turning to online communication and reached out to fundraisers to continually highlight the importance of mental health to their users and fundraisers.

Disclosure

No significant relationships.

The impact of Gender Identity Clinic waiting times on the mental health of transitioning individuals

Introduction

Waiting times for gender identity services, even before the Covid-19 pandemic, have been a cause of concern. Despite the waiting time standard for planned elective care in the NHS being a maximum of 18 weeks, the average waiting time for a first appointment with a gender identity clinic is 18 months. This study aims to analyse the effect that these timings have on the transgender community, and whether they impact the risk of developing mental health conditions such as depression or anxiety.

Objectives

This study’s main aim is to analyse the correlation between waiting times and mental health burden in the transgender community.

Methods

A literature review and analysis on a transgender individual’s mental health and waiting times for Gender Identity Clinics; looking at any key themes and conclusions. Research papers were taken from MEDLINE, The International Journal of Transgender Health, Oxford Academic, SpringerLink and Emerald Insight, with studies publishing date ranging from 2014 – 2021.

Results

The transgender population were found to have higher rates of suicidal ideation, depression and self harm compared to the general population. Longer waiting times were found to contribute to feelings of low mood and suicidal ideation, as well as decreasing overall quality of life.

Conclusions

Longer waiting times can decrease a transgender individual’s quality of life and impact their overall mental wellbeing: especially with the impact of COVID-19 and the rise in referrals.

Disclosure

No significant relationships.

Taking Mental Health into Schools: The work of Headucate Student Society

Headucate: University of East Anglia (UEA) is a student-led organisation aiming to raise awareness around Mental Health through their workshops and events. Events in the last year have included a 24-hour live stream TV fundraiser, UEA’s first Psychiatry and Mental Health conference, a mental health themed stand-up show, mental health assistance workshops, a suicide prevention evening and a variety of panels. Headucate has also collaborated with Beat, the UK’s leading eating disorder charity, to run training aimed at Norwich Medical School students, other healthcare students and Professionals. Headucate provides opportunities for their members, including research, education within the medical community, organising group projects, hosting poster competitions and by collaborating with likeminded initiatives. Workshops were designed to include common mental health conditions; wellbeing; advice regarding looking after yourself and others; ways to get for support and the impact of COVID-19 on our mental health. They are arranged and delivered by our members to school children and university students; they have been adapted to an online platform, which allowed us to reach a wider audience. Outcome measures demonstrating the impact of Headucate’s work were analysed via verbal, written and rated feedback, obtained from participants of workshops and events. Headucate workshops can help to improve mental health awareness and education in schools; however, it is only a local initiative. To educate schools outside of Norfolk, Headucate’s repeatable model can be used to create new branches of organisations that can spread nationwide; so mental health education in schools can be promoted across the UK.

The diagnosis and management of Gaucher disease in pediatric patients: Where do we go from here?

Gaucher disease (GD) is an autosomal recessive inherited lysosomal storage disease that often presents in early childhood and is associated with damage to multiple organ systems. Many challenges associated with GD diagnosis and management arise from the considerable heterogeneity of disease presentations and natural history. Phenotypic classification has traditionally been based on the absence (in type 1 GD) or presence (in types 2 and 3 GD) of neurological involvement of varying severity. However, patient management and prediction of prognosis may be best served by a dynamic, evolving definition of individual phenotype rather than by a rigid system of classification. Patients may experience considerable delays in diagnosis, which can potentially be reduced by effective screening programs; however, program implementation can involve ethical and practical challenges. Variation in the clinical course of GD and an uncertain prognosis also complicate decisions concerning treatment initiation, with differing stakeholder perspectives around efficacy and acceptable cost/benefit ratio. We review the challenges faced by physicians in the diagnosis and management of GD in pediatric patients. We also consider future directions and goals, including acceleration of accurate diagnosis, improvements in the understanding of disease heterogeneity (natural history, response to treatment, and prognosis), the need for new treatments to address unmet needs for all forms of GD, and refinement of the tools for monitoring disease progression and treatment efficacy, such as specific biomarkers.

Staphylococcus Aureus Endocarditis associated with Injecting New Psychoactive Substances

Background

Staphylococcus aureus infective endocarditis (IE) associated with injection of new psychoactive substances (NPS) in Edinburgh from 2014 to 2016 was observed. We compared these infections with a series of S. aureus IE cases in a non-injecting population within Edinburgh.

Methods

NPS-associated S. aureus IE diagnosed between 1 January 2014 and 31 May 2016 in persons who inject drugs (PWID) were compared with a series of S. aureus IE cases from non-PWID.

Results

There was a fourfold increase in the annual incidence of S. aureus IE, mainly due to NPS use in PWID. A larger vegetation diameter was seen on echocardiogram in PWID vs non-PWID (median 1.7 cm vs 0.65 cm; p = 0.009) with more embolic complications in PWID (15 PWID vs 1 non-PWID; p = 2.1 x 10-7) but no difference in 90-day mortality (2 PWID vs 4 non-PWID; p = 0.39).

Conclusions

NPS-associated S. aureus IE correlated with complications, such as deep organ embolic abscesses, that were different from non-PWID S. aureus IE. The alarming increase in incidence resolved with targeted public health and legislative measures.

The colorectal surgeon's personality may influence the rectal anastomotic decision

AIM

Colorectal surgeons regularly make the decision to anastomose, defunction or form an end colostomy when performing rectal surgery. This study aimed to define personality traits of colorectal surgeons and explore any influence of such traits on the decision to perform a rectal anastomosis.

METHOD

Fifty attendees of The Association of Coloproctology of Great Britain and Ireland 2016 Conference participated. After written consent, all underwent personality testing: alexithymia (inability to understand emotions), type of thinking process (intuitive versus rational) and personality traits (extraversion, agreeableness, openness, emotional stability, conscientiousness). Questions were answered regarding anastomotic decisions in various clinical scenarios and results analysed to reveal any influence of the surgeon's personality on anastomotic decision.

RESULTS

Participants were: male (86%), consultants (84%) and based in England (68%). Alexithymia was low (4%) with 81% displaying intuitive thinking (reflex, fast). Participants scored higher in emotional stability (ability to remain calm) and conscientiousness (organized, methodical) compared with population norms. Personality traits influenced the next anastomotic decision if: surgeons had recently received criticism at a departmental audit meeting; were operating with an anaesthetist that was not their regular one; or there had been no anastomotic leaks in their patients for over 1 year.

CONCLUSION

Colorectal surgeons have speciality relevant personalities that potentially influence the important decision to anastomose and could explain the variation in surgical practice across the UK. Future work should explore these findings in other countries and any link of personality traits to patient-related outcomes.

Postnatal Pancraniosynostosis in a Patient With Infantile Hypophosphatasia

Hypophosphatasia is a rare metabolic bone disorder that predisposes patients to craniosynostosis. Typically, patients born with hypophosphatasia will exhibit fused cranial sutures at birth. This is the first reported case of delayed onset of pancraniosynostosis in a patient with infantile hypophosphatasia. The severity of onset and delayed presentation in this patient are of interest and should give pause to those care providers who treat and evaluate patients with hypophosphatasia.

Rapid recontamination with MRSA of the environment of an intensive care unit after decontamination with hydrogen peroxide vapour

Meticillin-resistant Staphylococcus aureus (MRSA) persists in the hospital environment and conventional cleaning procedures do not necessarily eliminate contamination. A prospective study was conducted on an intensive care unit to establish the level of environmental contamination with MRSA, assess the effectiveness of hydrogen peroxide vapour (HPV) decontamination and determine the rate of environmental recontamination. MRSA was isolated from 11.2% of environmental sites in the three months preceding the use of HPV and epidemiological typing revealed that the types circulating within the environment were similar to those colonising patients. After patient discharge and terminal cleaning using conventional methods, MRSA was isolated from five sites (17.2%). After HPV decontamination but before the readmission of patients, MRSA was not isolated from the environment. Twenty-four hours after readmitting patients, including two colonized with MRSA, the organism was isolated from five sites. The strains were indistinguishable from a strain with which a patient was colonized but were not all confined to the immediate vicinity of the colonized patient. In the eight weeks after the use of HPV, the environment was sampled on a weekly basis and MRSA was isolated from 16.3% sites. Hydrogen peroxide vapour is effective in eliminating bacteria from the environment but the rapid rate of recontamination suggests that it is not an effective means of maintaining low levels of environmental contamination in an open-plan intensive care unit.

Fracture of the hydroxyapatite-ceramic-coated JRI-Furlong femoral component

We describe three cases of fracture of the titanium JRI-Furlong hydroxyapatite-ceramic (HAC)-coated femoral component. We have examined previous case reports of failure of this stem and conclude that fracture may occur in two places, namely at the neck-shoulder junction and at the conical-distal cylindrical junction. These breakages are the result of fatigue in a metallurgically-proven normal femoral component. All the cases of failure of the femoral component have occurred in patients with a body mass index of more than 25 in whom a small component, either size 9 or 10, had been used.

In patients with a body mass index above normal size 9 components should be avoided and the femoral canal should be reamed sufficiently to accept a large femoral component to ensure that there is adequate metaphyseal fixation.

Correlation of surrogate markers of Gaucher disease. Implications for long-term follow up of enzyme replacement therapy

BACKGROUND

The excessive storage of cellular debris in the lysosomal storage disorders triggers a variety of cellular responses. Some of these responses are maladaptative and result in the pathology of these diseases. To some extent, cellular responses are specific to the stored material, which influences the pathophysiology of the disease and results in some of its characteristic features.

METHODS

A large body of data has been collected for three biochemical (surrogate) markers of Gaucher Disease: angiotensin converting enzyme (ACE), tartrate-resistant acid phosphatase (TRAP) and chitotriosidase (CHITO) using currently available enzyme analysis. Follow up data was gathered in a group of 18 patients.

RESULTS

The three markers are correlated between each other and are useful indicators of the disease progress and its response to enzyme replacement therapy (ERT). Retrospective analysis of clinical records and comparison of chitotriosidase values with the baseline Severity Score Index (SSI) allowed prediction of the response patterns for this marker when long-term ERT (>24 months) was evaluated.

CONCLUSIONS

The less severely affected patients are more likely to normalize their chitotriosidase activities after long term ERT.

Mobility of the spine after spinal surgery in acute spinal cord injury

STUDY DESIGN

Retrospective study of mobility of the spine.

OBJECTIVES

To study the relation between mobility of the spine, operation and length of surgical stabilisation.

SETTING

The National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK.

METHOD

Questionnaires were sent to 99 consecutive acute traumatic spinal cord-injured patients (UK residents) admitted in 1990-1994. All had acute spinal surgery. A total of 68 responded. Their replies, medical records and radiographs were reviewed.

RESULTS

(1) In all, 63 patients had surgery in the cervical, thoracolumbar or lumbar spine; 11 of them had more than two functional spinal units (FSUs) stabilised, 10 of these 11 (91%) had less than satisfactory results in terms of metal failure, improper placement of the implant or functional restriction of spinal mobility (FROSM). A total of 35 had 1-2 FSUs stabilised. None of them had metal failure or improper placement of implant, but 14 (40%) had less than satisfactory result due to FROSM; 17 had laminectomy alone, four of these had FROSM. (2) Five patients had surgery in the thoracic spine. Three of these who had 5-7 FSUs stabilised had no FROSM. Two had laminectomy alone, one of whom had FROSM.

CONCLUSION

(1) Long surgical stabilisation in the cervical, thoracolumbar and lumbar spines was likely to result in either metal failure or FROSM. (2) Long surgical stabilisation of the thoracic spine was not associated with either metal failure or FROSM. (3) A small proportion of patients had laminectomy alone. One of them who had multiple injuries had FROSM.

Interleukin 17 induces cartilage collagen breakdown: novel synergistic effects in combination with proinflammatory cytokines

OBJECTIVE

To investigate whether interleukin 17 (IL17), derived specifically from T cells, can promote type II collagen release from cartilage. The ability of IL17 to synergise with other proinflammatory mediators to induce collagen release from cartilage, and what effect anti-inflammatory agents had on this process, was also assessed.

METHODS

IL17 alone, or in combination with IL1, IL6, oncostatin M (OSM), or tumour necrosis factor alpha (TNFalpha), was added to bovine nasal cartilage explant cultures. Proteoglycan and collagen release were determined. Collagenolytic activity was determined by bioassay. Chondroprotective effects of IL4, IL13, transforming growth factor beta1 (TGFbeta1) and insulin-like growth factor-1 (IGF1) were assessed by inclusion in the explant cultures.

RESULTS

IL17 alone stimulated a dose dependent release of proteoglycan and type II collagen from bovine nasal cartilage explants. Suboptimal doses of IL17 synergised potently with TNFalpha, IL1, OSM, and IL6 to promote collagen degradation. This collagen release was completely inhibited by tissue inhibitor of metalloproteinase-1 and BB-94 (a synthetic metalloproteinase inhibitor), and was significantly reduced by IL4, IL13, TGFbeta1, and IGF1. In IL17 treated chondrocytes, mRNA expression for matrix metalloproteinase (MMP)-1, MMP-3, and MMP-13 was detected. Moreover, a synergistic induction of these MMPs was seen when IL17 was combined with other proinflammatory cytokines.

CONCLUSIONS

IL17 can, alone and synergistically in combination with other proinflammatory cytokines, promote chondrocyte mediated MMP dependent type II collagen release from cartilage. Because levels of all these proinflammatory cytokines are raised in rheumatoid synovial fluids, this study suggests that IL17 may act as a potent upstream mediator of cartilage collagen breakdown in inflammatory joint diseases.

Postural sway of subjects wearing the U.S. Army chemical protective ensemble after functional activity

BACKGROUND

This study assessed the effects of wearing the chemical protective clothing ensemble (CPE) vs. the battle dress uniform (BDU) on postural sway after 18 min of simulated field activity. Postural sway is a measure of static balance where a person maintains his/her center of gravity over his/her base of support by swaying fore to aft usually around the ankle joint axis.

HYPOTHESES

Subjects' postural sway would increase more post-exercise while wearing the CPE vs. the BDU. The increase in postural sway while wearing the CPE would be due to decreased visual and somatosensory inputs.

METHODS

Static balance was measured on 25 subjects pre- and post-exercise on the NeuroCom SMART Balance Master using the Sensory Organization Test protocol. Following a test-retest, repeated measures design, each subject completed the protocol twice, once while wearing only the BDU and once while wearing the CPE.

RESULTS

A 2 x 2 repeated measures, multivariate analysis of variance revealed no significant difference between the static balance of subjects wearing the CPE vs. wearing the BDU pre- or post-exercise.

CONCLUSIONS

The authors suggest that the wearing of the CPE does not affect static balance, even after completing 18 min of functional tasks. Future research should objectively quantify the amount of fatigue postexercise and employ a protocol that has been previously shown to increase postural sway.

The effects of pulsatile versus nonpulsatile perfusion on blood viscoelasticity before and after deep hypothermic circulatory arrest in a neonatal piglet model

Blood trauma increases blood viscoelasticity by increasing red cell aggregation and plasma viscosity and by decreasing cell deformability. During extracorporeal circulation, the mode of perfusion (pulsatile or nonpulsatile) may have a significant impact on blood trauma. In this study, a hydraulically driven dual chamber pulsatile pump system was compared to a standard nonpulsatile roller pump in terms of changes in the blood viscosity and elasticity during cardiopulmonary bypass (CPB) and pre and post deep hypothermic circulatory arrest (DHCA). Piglets, with an average weight of 3 kg, were used in the pulsatile (n = 5) or nonpulsatile group (n = 5). All animals were subjected to 25 min of hypothermia, 60 min of DHCA, 10 min of cold reperfusion, and 40 min of rewarming with a pump flow of 150 ml/kg/min. A pump rate of 150 bpm, pump ejection time of 120 ms, and stroke volume of 1 ml/kg were used during pulsatile CPB. Arterial blood samples were taken pre-CPB (36 degrees C), during normothermic CPB (35 degrees C), during hypothermic CPB (25 degrees C), pre-DHCA (18 degrees C), post-DHCA (19 degrees C), post-rewarming (35 degrees C), and post-CPB (36 degrees C). Viscosity and elasticity were measured at 2 Hz and 22 degrees C and at strains of 0.2, 1, and 5 using the Vilastic-3 Viscoelasticity Analyzer. Results suggest that the dual chamber neonate-infant pulsatile pump system produces less blood trauma than the standard nonpulsatile roller pump as indicated by lower values of both viscosity and elasticity during CPB support.

Mechanical ventilation

In this article Nigel Henderson discusses the nursing role in the mechanical ventilation of patients. He describes the different ventilator modes, and the physical and psychological care required by ventilated patients.

Behavioral phenotypes of inbred mouse strains: implications and recommendations for molecular studies

Choosing the best genetic strains of mice for developing a new knockout or transgenic mouse requires extensive knowledge of the endogenous traits of inbred strains. Background genes from the parental strains may interact with the mutated gene, in a manner which could severely compromise the interpretation of the mutant phenotype. The present overview summarizes the literature on a wide variety of behavioral traits for the 129, C57BL/6, DBA/2, and many other inbred strains of mice. Strain distributions are described for open field activity, learning and memory tasks, aggression, sexual and parental behaviors, acoustic startle and prepulse inhibition, and the behavioral actions of ethanol, nicotine, cocaine, opiates, antipsychotics, and anxiolytics. Using the referenced information, molecular geneticists can choose optimal parental strains of mice, and perhaps develop new embryonic stem cell progenitors, for new knockouts and transgenics to investigate gene function, and to serve as animal models in the development of novel therapeutics for human genetic diseases.

Influence of cyclic guanosine monophosphate changes on hemodynamics after reperfusion in liver transplantation

Orthotopic liver transplantation (OLT) is often associated with hemodynamic instability upon reperfusion, recognized as postreperfusion syndrome. Changes in vascular tone due to humoral factors released upon reperfusion of the graft have been suggested as a possible mechanism. In this study, we looked at the perioperative changes in cyclic guanosine monophosphate (cGMP), a mediator of vascular smooth muscle relaxation, and investigated its relationship with hemodynamic parameters. cGMP was measured in the plasma of 14 patients undergoing OLT by radioimmunoassay serially at the preanhepatic and anhepatic phases, and after reperfusion at 30, 60, and 120 min. Hemodynamic data recorded were systemic and pulmonary arterial pressures, cardiac output, and pulmonary and systemic vascular resistance. cGMP decreased markedly after reperfusion from a baseline level of 5.33+/-0.7 ng/ml to 1.63+/-0.5 ng/ml (P<0.01). Pulmonary arterial pressure increased from 17+/-1.21 mmHg to 23.5+/-1.9 mmHg (P<0.05), and pulmonary vascular resistance increased from 62.8 +/-12.9 dynes/sec/cm5 to 135+/-42.7 dynes/sec/cm5 (P<0.01). Changes in cardiac output and systemic vascular resistance were not significant. The changes in cGMP correlated with pulmonary arterial pressure (r=0.74, P=0.005) and pulmonary vascular resistance (r=0.7, P=0.01). These data confirm the occurrence of hemodynamic changes during OLT, and provide evidence to suggest that the reduction in cGMP after reperfusion may mediate the vascular changes.

Mechanisms of changes in renal handling of sodium following transjugular intrahepatic portal systemic stent-shunt (TIPSS)

BACKGROUND AND AIMS

Transjugular intrahepatic portosystemic stent-shunt (TIPSS) reduces the portal pressure gradient and leads to better control of ascites. The aim of this study was to evaluate (1) changes in renal handling of sodium following TIPSS and (2) the mechanism of these changes.

DESIGN

Prospective study.

SETTING

Tertiary referral centre for liver diseases.

METHODS

Eighteen patients with ascites undergoing TIPSS for recurrent variceal haemorrhage (16) (3 or more hospital admissions because of variceal haemorrhage whilst being treated endoscopically) or refractory ascites (2) were studied. Urinary sodium (UNa), creatinine clearance (CrCl), plasma renin activity (PRA), atrial natriuretic peptide (ANP), cyclic guanosine monophosphate (cGMP), Angiotensin II (AII) and lithium clearance (LiCl) were measured before and 3 months after TIPSS when portography was performed and the portal pressure gradient (PPG) also measured. All patients were haemodynamically stable and had received no diuretics for at least 1 week before blood sampling.

RESULTS

Improvement in ascites was achieved in all patients in whom TIPSS was inserted successfully (reduction in PPG to < 12 mmHg). PPG was reduced from a mean of 19 (+/-6) to 8.8 (+/-3.4) mmHg (P < 0.001). Urinary sodium and creatinine clearance improved significantly following TIPSS (P < 0.001, P < 0.001, respectively). PRA, All, cGMP and LiCl were abnormal before TIPSS and improved significantly following TIPSS (P < 0.007, P < 0.001, P < 0.001 and P < 0.01, respectively). ANP was not significantly different from normal controls and did not change significantly following TIPSS. Changes in UNa did not correlate with the Pugh score or the change in PPG.

CONCLUSION

The results of this study show that TIPSS is associated with significant improvement in UNa, CrCl, PRA, AII, cGMP and LiCl. The change in UNa following TIPSS was independent of the severity of underlying liver disease or the change in PPG.