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Griffin D, Kotecha S, Basu G, Gow P, Lau J, Morrissey CO, Hoy JF. HIV and Solid Organ Transplantation: A 15-Year Retrospective Audit at a Tertiary Australian Transplant Centre. Intern Med J 2021; 52:1780-1790. [PMID: 34139100 DOI: 10.1111/imj.15423] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/21/2021] [Accepted: 06/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The incidence of end-stage organ disease in people living with HIV (PLWH) is increasing, as people live longer due to potent, tolerable antiretroviral therapy. Consequently, the number of PLWH who would benefit from solid organ transplant (SOT) is rising. Solid organ transplantation experience in PLWH in Australia remains limited. The aim of this study was to retrospectively review the outcomes for SOT in PLWH in Victoria, Australia. METHODS A retrospective cohort study of PLWH undergoing SOT over a 15-year period was performed. Adult PLWH over 18 years of age were eligible and identified from the Victorian HIV Service database. Descriptive statistics were used to summarise baseline demographics and clinical data, and outcomes following SOT. RESULTS Nine virologically-suppressed PLWH underwent SOT from HIV-negative donors; 5 kidneys, 2 livers, and 2 bilateral sequential lung transplants. All patients were male, with a median age of 57.3 years (IQR 54.3-60.1), CD4 count of 485 (IQR 342-835) at transplantation, and comorbidities were common at baseline. After a median follow up of 3.9 years (IQR 2.7-7.6), 8 (89%) patents were alive, 7 (78%) had functioning grafts, though 5 (56%) experienced organ rejection. Infections were common. Two patients required modification to their antiretroviral therapy due to significant drug-drug interactions, prior to transplant, while 5 (56%) had modifications post-SOT. No patients experienced HIV virologic failure. CONCLUSION PLWH with end-stage organ disease experience good clinical and functional outcomes, and should be considered for SOT where indicated. However, multidisciplinary planning and care is essential to optomise care in this patient group. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Dwj Griffin
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - S Kotecha
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
| | - G Basu
- Department of Renal Medicine, Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - P Gow
- Department of Gastroenterology, Austin Hospital, Melbourne, Australia
| | - Jsy Lau
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - C O Morrissey
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - J F Hoy
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
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Sampaio RT, Koshy A, Gow P, Clark D, Horrigan M, Farouque O. Feasibility and Safety of Drug-Eluting Stent Implantation in Patients with End-Stage Liver Disease Prior to Liver Transplantation. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.287] [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: 10/20/2022]
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Sampaio Rodrigues T, Koshy A, Gow P, Nerlekar N, Testro A, Lim R, Smith G, Farouque O. Long-Term Prognostic Value of Coronary Artery Disease - Reporting and Data System (CAD-RADS) Score for Cardiovascular Events in Asymptomatic Liver Transplant Recipients. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.229] [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: 10/20/2022]
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Sampaio Rodrigues T, Nerlekar N, Gow P, Testro A, Lim R, Smith G, Farouque O. Risk Factors for Advanced Atherosclerosis Detected on Computed Tomography Coronary Angiography in Patients with Liver Cirrhosis. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.241] [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: 11/17/2022]
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Affiliation(s)
- R Terbah
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, VIC, Australia
| | - P Gow
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, VIC, Australia
- The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - M Sinclair
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, VIC, Australia
- The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - A Testro
- Department of Gastroenterology and Liver Transplant Unit, Austin Health, Melbourne, VIC, Australia.
- The University of Melbourne, Parkville, Melbourne, VIC, Australia.
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Enayati A, Koshy A, Teh A, Gow P, Han H, Cailes B, Weinberg L, Testro A, Lim H, Farouque O. 244 Post-Operative Atrial Fibrillation following Liver Transplantation and Association with Adverse Cardiovascular Events. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.251] [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: 11/28/2022]
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Ko J, Koshy A, Han H, Cailes B, Gow P, Testro A, Weinberg L, Lim H, Farouque O, Teh A. 221 Impact of Liver Transplantation on QT Interval in Patients With Cirrhosis. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.228] [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: 11/29/2022]
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Enayati A, Koshy A, Farouque O, Gow P, Han H, Cailes B, Weinberg L, Testro A, Lim H, Teh A. 229 Long Term Risk of Stroke in Patients with New Post-Operative Atrial Fibrillation After Liver Transplantation. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.236] [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: 10/23/2022]
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McClure T, Chapman B, Hey P, Testro A, Gow P. Long-term continuous terlipressin infusion in cirrhotic patients with hepatorenal syndrome or refractory ascites awaiting liver transplantation is associated with an increase in plasma sodium. United European Gastroenterol J 2019; 7:1271-1273. [PMID: 31700640 PMCID: PMC6826519 DOI: 10.1177/2050640619878996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- T McClure
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia
- Department of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - B Chapman
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia
- Department of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - P Hey
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia
- Department of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - A Testro
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia
- Department of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - P Gow
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia
- Department of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
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Koshy AN, Cailes B, Gow P, Testro A, Sajeev JK, Han H, Ko J, Weinberg L, Lim H, Teh A, Farouque O. P3466Cardiac output in end-stage liver disease increases with the severity of liver dysfunction. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0338] [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] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
End-stage liver disease is associated with significant systemic and haemodynamic alterations that affect cardiac function. Cirrhotic cardiomyopathy remains an ill-defined entity among cardiologists. Understanding the complex interplay between liver dysfunction and cardiac function can lead to a better understanding of the compensatory mechanisms of the heart in liver failure.
Purpose
To investigate whether severity of liver disease affects baseline cardiac output in a large contemporary cohort of patients undergoing liver transplant work-up.
Methods
Consecutive patients that underwent pre-liver transplant (LT) workup between 2010–2017 were included. All patients underwent a resting echocardiogram. Cardiac output (CO) was prospectively recorded at baseline by pulsed-wave Doppler examination of the left ventricular outflow tract from the apical window and systemic vascular resistance (SVR) was calculated as 80 x (mean arterial pressure (MAP)/CO). Severity of liver disease was characterized by the model of end-stage liver disease (MELD) and Child-Pugh scores.
Results
560 patients were included (mean age 57.5±7.7, 74.8% male). Mean MELD score was 19±7 and Child-Pugh Score was 9±3. There was an inverse linear relationship between the severity of liver disease by the MELD score and baseline SVR (rho 0.40, P<0.001). As SVR reduced, there was also a significant rise in baseline CO with a strong inverse correlation between the two variables (rho 0.86, p<0.001). There was a significant linear correlation between the severity of liver disease and baseline CO with both the scores (MELD Score rho 0.42, p<0.001; Child Pugh rho 0.44, p<0.001) (Figure).
Baseline CO in LT Patients by Severity
Conclusions
Baseline CO increased with the severity of liver dysfunction due to a reduced afterload. A higher resting CO may lead to patients encroaching on their cardiac reserve at rest. This provides a pathophysiological insight suggesting a limited role for beta-blockers, particularly in patients with advanced liver cirrhosis.
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Affiliation(s)
- A N Koshy
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - B Cailes
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - P Gow
- Austin Health Hospital, Victorian Liver Transplant Unit, Melbourne, Australia
| | - A Testro
- Austin Health Hospital, Victorian Liver Transplant Unit, Melbourne, Australia
| | - J K Sajeev
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - H Han
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - J Ko
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - L Weinberg
- Austin Health Hospital, Department of Anaesthesia, Melbourne, Australia
| | - H Lim
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - A Teh
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - O Farouque
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
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Cailes B, Koshy AN, Han H, Sajeev JK, Ko J, Weinberg L, Gow P, Testro A, Srivastava P, Lim H, Teh A, Farouque O. P3465Inducible left ventricular outflow tract obstruction is associated with a higher incidence of perioperative cardiac arrest in liver transplantation. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0337] [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] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Inducible left ventricular outflow tract obstruction (LVOTO) is not infrequently encountered in liver transplant (LT) candidates undergoing cardiac workup. While the impact of LVOTO on adverse cardiovascular haemodynamics is well reported, it is unclear whether it predisposes to perioperative cardiovascular complications following LT.
Purpose
To investigate the effect of inducible left ventricular outflow tract obstruction on perioperative cardiovascular complications in a modern cohort of liver transplant patients.
Methods
Consecutive patients undergoing dobutamine stress echocardiography (DSE) were evaluated from a quaternary LT centre between 2010 and 2017. Inducible LVOTO was defined as LVOT gradient ≥36mmHg. Perioperative major adverse cardiovascular events (MACE) at 30 days and all-cause death were recorded from a prospectively maintained transplantation database and augmented by electronic medical record review.
Results
We evaluated 560 patients who underwent DSE as part of a workup for LT. Of these, 319 progressed to transplant. Inducible LVOTO was observed in 68 patients (21.3%). A higher baseline cardiac output (7.7 L/min vs 7.0 L/min, p=0.002) predicted for development of inducible LVOTO. Seventy-seven patients (4.1%) experienced a MACE including five deaths, 19 cases of heart failure, 11 cardiac arrests, 10 acute coronary syndromes and 46 cases of arrhythmias (VT/AF). Overall MACE occurred in 17/68 patients (25.0%) with LVOTO and 60/251 patients (23.9%) without LVOTO (p=0.85). However, there was a significantly increased risk of resuscitated perioperative cardiac arrest in patients with LVOTO (7.4% vs 2.4%, p=0.04). Patients with LVOTO also required significantly greater volumes of fluid intra-operatively (8.37L vs. 6.71L, p=0.043).
Cardiac Arrest in LT Patients with LVOTO
Conclusions
Inducible LVOTO is a frequent finding occurring in 21.3% of LT candidates. Despite higher intraoperative fluid resuscitation, LVOTO increased the risk of a perioperative cardiac arrest. Further studies are required to confirm these findings and to assess whether patients with LVOTO undergoing liver transplantation may benefit from heightened perioperative surveillance.
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Affiliation(s)
- B Cailes
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - A N Koshy
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - H Han
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - J K Sajeev
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - J Ko
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - L Weinberg
- Austin Health Hospital, Department of Anaesthesia, Melbourne, Australia
| | - P Gow
- Austin Health Hospital, Victorian Liver Transplant Unit, Melbourne, Australia
| | - A Testro
- Austin Health Hospital, Victorian Liver Transplant Unit, Melbourne, Australia
| | - P Srivastava
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - H Lim
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - A Teh
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
| | - O Farouque
- Austin Health Hospital, Department of Cardiology, Melbourne, Australia
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Koshy A, Ha F, Gow P, Han H, Amirul-Islam F, Cailes B, Lim H, Teh A, Farouque O. Computed Tomographic Coronary Angiography and Coronary Artery Calcium Score as a Risk Stratification Tool Prior to Non-Cardiac Surgery: A Meta-Analysis. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.256] [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: 11/16/2022]
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13
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Koshy A, Cailes B, Testro A, Ramchand J, Sajeev J, Han H, Calafiore P, Jones E, Srivastava P, Salehi H, Teh A, Lim H, Gow P, Farouque O. Impaired Cardiac Reserve on Dobutamine Stress Echocardiography Predicts Development of Hepatorenal Syndrome. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.014] [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: 11/15/2022]
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14
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Cailes B, Koshy A, Han H, Sajeev J, Ko J, Weinberg L, Gow P, Testro A, Srivastava P, Lim H, Teh A, Farouque O. Inducible Left Ventricular Outflow Tract Obstruction is Associated with a Higher Incidence of Perioperative Cardiac Arrest in Liver Transplantation. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.400] [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: 11/28/2022]
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Cailes B, Koshy A, Sajeev J, Han H, Ko J, Weinberg L, Gow P, Testro A, Lim H, Teh A, Farouque O. Hepatorenal Syndrome in Patients Undergoing Liver Transplantation is an Independent Risk Factor for Perioperative Cardiac Complications. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.391] [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: 11/16/2022]
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Koshy A, Gow P, Cailes B, Sajeev J, Teh A, Lim H, Han H, Jones R, Testro A, Byrne M, Ko J, Clark D, Yudi M, Farouque O. Impact of Cardiovascular Risk Factors on Survival following Liver Transplantation: Results from the Australian & New Zealand Liver Transplant Registry. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.394] [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: 11/17/2022]
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Koshy A, Cailes B, Gow P, Testro A, Han H, Sajeev J, Ko J, Weinberg L, Srivastava P, Lim H, Teh A, Farouque O. Cardiac Output in End-Stage Liver Disease Increases Proportional to the Degree of Liver Dysfunction. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.359] [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: 11/24/2022]
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Koshy A, Gow P, Sajeev J, Cailes B, Ko J, Ramchand J, Lim H, Teh A, Han H, Jones R, Testro A, Byrne M, Clark D, Yudi M, Farouque O. Rise in Proportional Early Cardiovascular Mortality Following Liver Transplantation: Temporal Trends from the Australian & New Zealand Liver Transplant Registry. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.426] [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: 10/26/2022]
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Cailes B, Koshy A, Ko J, Han H, Lim H, Teh A, Weinberg L, Testro A, Gow P, Farouque O. Beta Blocker Use Increases The Risk of Perioperative Cardiac Events in Liver Transplant Patients. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.355] [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: 10/26/2022]
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McCaughan GW, Thwaites PA, Roberts SK, Strasser SI, Mitchell J, Morales B, Mason S, Gow P, Wigg A, Tallis C, Jeffrey G, George J, Thompson AJ, Parker FC, Angus PW. Sofosbuvir and daclatasvir therapy in patients with hepatitis C-related advanced decompensated liver disease (MELD ≥ 15). Aliment Pharmacol Ther 2018; 47:401-411. [PMID: 29205432 DOI: 10.1111/apt.14404] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 06/28/2017] [Revised: 08/14/2017] [Accepted: 10/11/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antiviral therapy for hepatitis C has the potential to improve liver function in patients with decompensated cirrhosis. AIMS To examine the virological response and effect of viral clearance in patients with decompensated hepatitis C cirrhosis all with MELD scores ≥15 following sofosbuvir/daclatasvir ± ribavirin. METHODS We prospectively collected data on patients who commenced sofosbuvir/daclatasvir for 24-weeks under the Australian patient supply program (TOSCAR) and analysed outcomes including sustained viral response at 12 weeks (SVR12), death and transplant. RESULTS 108 patients (M/F, 79/29; median age 56years; Child-Pugh 10; MELD 16; genotype 1/3, 55/47) received sofosbuvir/daclatasvir and two also received ribavirin. On intention-to-treat, the SVR12 rate was 70% (76/108). Seventy-eight patients completed 24-weeks therapy. SVR12 was achieved in 56 of these patients on per-protocol-analysis (76%). SVR12 was 80% in genotype 1 compared to 69% in genotype 3. Thirty patients failed to complete therapy. In patients achieving SVR12, median MELD and Child-Pugh fell from 16(IQR15-17) to 14(12-17) and 10(9-11) to 8(7-9), respectively (P<.001). In those who died, MELD increased from 16 to 23 at death (P=.036). Patients who required transplantation had a significantly higher baseline MELD (20) compared to those patients completing treatment (16) (P=.0010). The odds ratio for transplant in patients with baseline MELD ≥20 was 13.8(95%CI 2.78-69.04). CONCLUSIONS SVR12 rates with sofosbuvir/daclatasvir in advanced liver disease are lower than in compensated disease. Although treatment improves MELD and Child-Pugh in most patients, a significant proportion will die or require transplantation. In those with MELD ≥20, it may be better to delay treatment until post-transplant.
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Affiliation(s)
- G W McCaughan
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - P A Thwaites
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Vic., Australia
| | - S K Roberts
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Vic., Australia
| | - S I Strasser
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - J Mitchell
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Vic., Australia
| | - B Morales
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Vic., Australia
| | - S Mason
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - P Gow
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Vic., Australia
| | - A Wigg
- South Australian Liver Transplant Unit, Flinders Medical Centre, Bedford Park, SA, Australia
| | - C Tallis
- Queensland Liver Transplant Unit, Princess Alexandra Hospital, Woolloongabba, Qld, Australia
| | - G Jeffrey
- Western Australian Liver Transplant Unit, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - J George
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, NSW, Australia
| | - A J Thompson
- St Vincent's Hospital, University of Melbourne, Melbourne, Vic., Australia
| | - F C Parker
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Vic., Australia
| | - P W Angus
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Vic., Australia
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Naka T, Bellomo R, Morimatsu H, Rocktaschel J, Wan L, Gow P, Angus P. Acid-Base Balance during Continuous Veno-Venous Hemofiltration: The Impact of Severe Hepatic Failure. Int J Artif Organs 2018; 29:668-74. [PMID: 16874671 DOI: 10.1177/039139880602900704] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Continuous renal replacement therapy (CRRT) affects acid-base balance but the influence of severe hepatic failure (SHF) on this effect is unknown. Aim To assess the effect of SHF on acid-base balance in patients receiving CVVH. Design Retrospective laboratory investigation. Subjects Forty patients with SHF and acute renal failure (ARF) treated with CVVH and 42 critically ill patients with severe ARF but no liver disease also treated with CVVH (controls). Intervention Retrieval of clinical and laboratory data from prospective unit and laboratory databases. Methods Quantitative acid-base status assessment using the Stewart-Figge methodology. Comparison of findings between the two groups. Results Although CVVH had a major effect on acid base balance in both groups, patients with SHF had a higher mean lactate concentrations (4.8 vs. 3.1 mmol/L; p<0.0005), a greater base deficit compared to controls (-1 vs. 4.1 mEq/L; p<0.0001) and a lower PaCO2 tension (36.8 vs. 42.5 mmHg; p<0.0001), despite the use of bicarbonate replacement fluid. The acidifying effect of hyperlactatemia was slightly worsened by an increased strong ion gap (9.3 vs. 4.9 mEq/L; p<0.0001). It was, however, attenuated by an increased strong ion difference apparent (SIDa) (43.6 vs. 41.9 mEq/L; p<0.05) secondary to hypochloremia (96 vs. 100 mmol/L; p<0.0001) and by hypoalbuminemia, although hypoalbuminemia in SHF patients (26 vs. 23; p<0.005) was less pronounced than in controls. Conclusion The use of CVVH does not fully correct the independent acidifying effect of liver failure on acid-base status. Increased lactate and strong ion gap values maintain a persistent base deficit despite the alkalinizing effects of hypoalbuminemia and hypochloremia. The correction of acidosis in SHF patients may require more intensive CVVH.
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Affiliation(s)
- T Naka
- Department of Intensive Care, Austin Hospital and Melbourne University, Melbourne, Australia
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22
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Naka T, Bellomo R, Morimatsu H, Rocktaschel J, Wan L, Gow P, Angus P. Acid-base Balance in Combined Severe Hepatic and Renal Failure: A Quantitative Analysis. Int J Artif Organs 2018; 31:288-94. [DOI: 10.1177/039139880803100403] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Severe hepatic failure (SHF) commonly leads to major changes in acid-base balance status. However, the direct effects of liver failure per se on acid base balance are poorly understood because this condition is usually associated with acute renal failure (ARF). Aim To assess the effect of SHF on acid-base balance. Design Retrospective laboratory investigation. Subjects Thirty-seven critically ill patients with SHF complicated by ARF, and 42 patients with severe ARF without liver failure prior to renal replacement therapy. Intervention Retrieval of clinical and laboratory data from prospective unit and laboratory databases. Methods Quantitative acid-base assessment using Stewart-Figge methodology. Comparison of findings between the two groups. Comparison of demographic and clinical features. Results Patients with combined SHF and ARF were younger and had significantly higher mean bilirubin, ALT and INR levels (p<0.0001). Their mean lactate concentration was higher (6.4 vs. 2.1 mmol/L; p<0.0001) leading to a greater anion gap (25.8 vs. 16.1 mmol/L; p<0.0001). The ionized calcium concentration (1.00 vs. 1.15 mmol/L; p<0.0001) was lower but the strong ion difference apparent (SIDa) was greater (42.0 vs. 38.0 mEq/L; p<0.005) due to hypochloremia. The albumin concentration was low but higher than in control patients (28 vs. 24 g/L; p<0.01) and the calculated strong ion gap (SIG) was greater (12.6 vs. 9.3 mEq/L; p<0.01). The base excess was similar to controls and the pH was preserved in the near normal range by marked hypocapnea. Conclusions Combined SHF and ARF is a syndrome with unique acid-base changes due mostly to lactic metabolic acidosis and, in smaller part, to the accumulation of unmeasured anions. This acidosis, like that of ARF, is attenuated by hypoalbuminemia, by a unique preservation of the SIDa due to hypochloremia, and by marked hypocapnea.
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Affiliation(s)
- T. Naka
- Department of Intensive Care and Department of Medicine, Austin Hospital, Melbourne - Australia
| | - R. Bellomo
- Department of Intensive Care and Department of Medicine, Austin Hospital, Melbourne - Australia
| | - H. Morimatsu
- Department of Intensive Care and Department of Medicine, Austin Hospital, Melbourne - Australia
| | - J. Rocktaschel
- Department of Intensive Care and Department of Medicine, Austin Hospital, Melbourne - Australia
| | - L. Wan
- Department of Intensive Care and Department of Medicine, Austin Hospital, Melbourne - Australia
| | - P. Gow
- Department of Gastroenterology and Hepatology, Austin Hospital, Melbourne - Australia
| | - P. Angus
- Department of Gastroenterology and Hepatology, Austin Hospital, Melbourne - Australia
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Mgaieth S, Kemp W, Gow P, Fink M, Lubel J, Nicoll A, Gazzola A, Hong T, Ryan M, Knight V, Dev AT, Sood S, Bell S, Paul E, Roberts SK. Impact of viral hepatitis aetiology on survival outcomes in hepatocellular carcinoma: A large multicentre cohort study. J Viral Hepat 2017; 24:982-989. [PMID: 28414893 DOI: 10.1111/jvh.12717] [Citation(s) in RCA: 14] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 02/27/2017] [Indexed: 12/15/2022]
Abstract
While HBV and HCV are risk factors for HCC, uncertainty exists as to whether these viral infections have prognostic significance in HCC. Thus, we compared the overall survival of patients with HBV, HCV and nonviral HCC, and evaluated whether the presence of HBV and HCV predicts patient outcomes. We conducted a multicentre study of HCC cases diagnosed at six Melbourne tertiary hospitals between Jan 2000-Dec 2014. Patient demographics, liver disease and tumour characteristics and patient outcomes were obtained from hospital databases, computer records and the Victorian Death Registry. Survival outcomes were compared between HBV, HCV and nonviral hepatitis cases and predictors of survival determined using Cox proportional hazards regression. There were 1436 new HCC cases identified including 776 due to viral hepatitis (HBV 235, HCV 511, HBV-HCV 30) and 660 from nonviral causes. The median survival of HBV, HCV and nonviral HCC patients was 59.1, 28.4 and 20.9 months, respectively (P<.0001). On multivariate analysis, independent risk factors for survival included HCC aetiology, gender, BCLC stage, serum AFP, total number and size of lesions, and serum creatinine and albumin. After adjusting for these and method of detection, HBV remained an independent predictor of improved overall survival when compared to both nonviral (HR 0.60%, 95% CI 0.35-0.98; P=.03) and HCV-related HCC (HR 0.51%, 95% CI 0.30-0.85; P=.01). In this large multicentre study, HBV is independently associated with improved overall survival compared with HCV and nonviral-related HCC. Further studies are needed to determine the underlying factor(s) responsible.
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Affiliation(s)
- S Mgaieth
- Department of Gastroenterology, Alfred Hospital, Melbourne, Vic., Australia
| | - W Kemp
- Department of Gastroenterology, Alfred Hospital, Melbourne, Vic., Australia
| | - P Gow
- Department of Gastroenterology, Austin Hospital, Heidelberg, Vic., Australia
| | - M Fink
- Department of Surgery, Austin Hospital, Heidelberg, Vic., Australia
| | - J Lubel
- Department of Gastroenterology, Box Hill Hospital, Box Hill, Vic., Australia
| | - A Nicoll
- Department of Gastroenterology, Box Hill Hospital, Box Hill, Vic., Australia.,Department of Gastroenterology, Royal Melbourne Hospital, Parkville, Vic., Australia
| | - A Gazzola
- Department of Gastroenterology, Alfred Hospital, Melbourne, Vic., Australia
| | - T Hong
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Vic., Australia
| | - M Ryan
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Vic., Australia
| | - V Knight
- Department of Gastroenterology, Monash Medical Centre, Clayton, Vic., Australia
| | - A T Dev
- Department of Gastroenterology, Monash Medical Centre, Clayton, Vic., Australia
| | - S Sood
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, Vic., Australia
| | - S Bell
- Department of Gastroenterology, St Vincent's Hospital, Fitzroy, Vic., Australia
| | - E Paul
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - S K Roberts
- Department of Gastroenterology, Alfred Hospital, Melbourne, Vic., Australia
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Burling F, Ng J, Thein H, Ly J, Marshall MR, Gow P. Ethnic, clinical and immunological factors in systemic lupus erythematosus and the development of lupus nephritis: results from a multi-ethnic New Zealand cohort. Lupus 2016; 16:830-7. [PMID: 17895308 DOI: 10.1177/0961203307080225] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The aim of this study was to identify risk factors for lupus nephritis including clinical, laboratory, and ethnic factors in a cohort of lupus patients in New Zealand. A retrospective study of patients from two teaching hospitals in Auckland, New Zealand. Patients were selected if they had attended as either an inpatient, or a rheumatology outpatient between 2000 and 2005. 170 patients had SLE according to ACR classification. Lupus nephritis (LN) was diagnosed according to ACR criteria. Clinical, laboratory, and ethnic data were gathered from the patient notes. Twenty-four patients had LN at diagnosis and 32 patients developed LN after diagnosis. LN was associated with serositis ( P = 0.008), cutaneous vasculitis ( P = 0.026), anaemia ( P = 0.005), CRP elevation >6 months ( P < 0.001), hypocomplementaemia >6 months ( P < 0.0001). Patients with elevated doublestranded DNA (dsDNA) (>5 × normal) were more likely to develop type IV LN ( P = 0.0096). Forty-one percent of patients were Caucasian, 12% Maori, 23% Pacific People, 16% Asian, 6% Indian. Maori patients with SLE (odds ratio (OR) = 8.47, 95% confidence interval (CI) = 2.11—33.96, P = 0.002), and Pacific People (OR = 3.11, 95% CI = 1.29—11.48, P = 0.014) had increased risk for developing LN. Anaemia at presentation (hazard ratio (HR) 3.2, 95% CI = 1.4—7.1, P = 0.004), and low complement >6 months (HR = 3.4, 95% CI = 1.4—8.7, P = 0.008) were independent risk factors for developing LN after SLE diagnosis. In New Zealand, Pacific People and Maori patients with SLE have a higher incidence of LN, and patients with anaemia and hypocomplementaemia are more likely to develop LN after diagnosis. Patients with high dsDNA levels are more likely to develop Type IV lupus nephritis. Lupus (2007) 16, 830—837.
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Affiliation(s)
- F Burling
- Department of Medicine, Middlemore Hospital, Private Bag 93311, Auckland, New Zealand.
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25
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Otter S, Kumar S, Gow P, Dalbeth N, Corkill M, Davies K, Panthakalam S, Rome K. AB0615 Experience of Foot Problems in Patients with Systemic Lupus. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.1767] [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: 11/03/2022]
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26
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Otter S, Kumar S, Gow P, Dalbeth N, Corkill M, Davies K, Panthakalam S, Rome K. SAT0640-HPR Foot Problems in Patients with Systemic Lupus Erythematosus; Under-Recognised and Under-Treated? Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.1925] [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: 11/04/2022]
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27
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Sood S, Haifer C, Yu J, Pavlovic J, Visvanathan K, Gow P, Jones R, Angus P, Testro A. A Novel Immune Function Biomarker Predicts Early Clinical Outcomes Following Liver Transplantation. Transplantation 2014. [DOI: 10.1097/00007890-201407151-00491] [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]
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28
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Gow P, He J. SAT0534 How Healthy Are Our Patients with Gout? A Study of Health Status and Management of Patients with Gout at Two Primary Heath Care Practices. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.1175] [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: 11/03/2022]
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29
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McBryde D, Barnes ME, Berry SA, Gow P, Beere HE, Ritchie DA, Apostolopoulos V. Fluence and polarisation dependence of GaAs based Lateral Photo-Dember terahertz emitters. Opt Express 2014; 22:3234-3243. [PMID: 24663615 DOI: 10.1364/oe.22.003234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
We characterise THz output of lateral photo-Dember (LPD) emitters based on semi-insulating (SI), unannealed and annealed low temperature grown (LTG) GaAs. Saturation of THz pulse power with optical fluence is observed, with unannealed LTG GaAs showing highest saturation fluence at 1.1 ± 0.1 mJ cm(-2). SI-GaAs LPD emitters show a flip in signal polarity with optical fluence that is attributed to THz emission from the metal-semiconductor contact. Variation in optical polarisation affects THz pulse power that is attributed to a local optical excitation near the metal contact.
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Howell J, Angus P, Gow P. Hepatitis C recurrence: the Achilles heel of liver transplantation. Transpl Infect Dis 2013; 16:1-16. [PMID: 24372756 DOI: 10.1111/tid.12173] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 06/12/2013] [Accepted: 08/03/2013] [Indexed: 12/18/2022]
Abstract
Hepatitis C virus (HCV) infection is the most common indication for liver transplantation worldwide; however, recurrence post transplant is almost universal and follows an accelerated course. Around 30% of patients develop aggressive HCV recurrence, leading to rapid fibrosis progression (RFP) and culminating in liver failure and either death or retransplantation. Despite many advances in our knowledge of clinical risks for HCV RFP, we are still unable to accurately predict those most at risk of adverse outcomes, and no clear consensus exists on the best approach to management. This review presents a critical overview of clinical factors shown to influence the course of HCV recurrence post transplant, with particular focus on recent data identifying the important role of metabolic factors, such as insulin resistance, in HCV recurrence. Emerging data for genetic markers of HCV recurrence and their usefulness for predicting adverse outcomes will also be explored.
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Affiliation(s)
- J Howell
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
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31
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Howell J, Sawhney R, Angus P, Fink M, Jones R, Wang BZ, Visvanathan K, Crowley P, Gow P. Identifying the superior measure of rapid fibrosis for predicting premature cirrhosis after liver transplantation for hepatitis C. Transpl Infect Dis 2013; 15:588-99. [PMID: 24028328 DOI: 10.1111/tid.12134] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 03/24/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) recurrence post liver transplant is universal, with a subgroup of patients developing rapid hepatic fibrosis. Various clinical definitions of rapid fibrosis (RF) have been used to identify risks for rapid progression, but their comparability and efficacy at predicting adverse outcomes has not been determined. METHODS Retrospective data analysis was conducted on 100 adult patients with HCV who underwent liver transplantation at a single center. We measured year 1 fibrosis progression (RF defined as METAVIR F score ≥ 1 at 1-year liver biopsy), time to METAVIR F2-stage fibrosis, and fibrosis rate (calculated using liver biopsies graded by METAVIR scoring F0-4; fibrosis rate = fibrosis stage/year post transplant). RF was defined as ≥ 0.5 units/year. RESULTS Multivariate analysis revealed that donor age and peak HCV viral load were significant risks for RF, when fibrosis rate was used to define RF. Advanced donor age was a risk for rapid progression to F2-stage fibrosis, whereas genotype 2 or 3 HCV infection was protective. Fibrosis rate had the strongest correlation with time to cirrhosis development (P < 0.0001, r = -0.76) and was the most accurate predictor of rapid graft cirrhosis (P < 0.0001, area under the curve 0.979, sensitivity 100%, specificity 94%). CONCLUSION Different measures of RF progression identify different risks for RF and are not directly comparable. Fibrosis rate was the most accurate predictor of rapid graft cirrhosis.
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Affiliation(s)
- J Howell
- Victorian Liver Transplant Unit, Austin Hospital, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
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32
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Barnes ME, Berry SA, Gow P, McBryde D, Daniell GJ, Beere HE, Ritchie DA, Apostolopoulos V. Investigation of the role of the lateral photo-Dember effect in the generation of terahertz radiation using a metallic mask on a semiconductor. Opt Express 2013; 21:16263-16272. [PMID: 23938477 DOI: 10.1364/oe.21.016263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Pulses of coherent terahertz radiation can be efficiently generated by a lateral diffusion current after ultrafast generation of photo-carriers near a metal interface on the surface of a semiconductor, this is known as the lateral photo-Dember effect. We investigate how the emission depends on the pump spot position, size, power and how it is affected by the application of an applied external bias. We study the role of the metallic mask and how it suppresses emission from the carriers diffusing under it due to a reduction of available radiation states both theoretically and experimentally.
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Affiliation(s)
- M E Barnes
- School of Physics and Astronomy, University of Southampton, Southampton SO17 1BJ, United Kingdom.
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33
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Sinclair M, Roberts S, Kemp W, Knight V, Dev A, Gow P, Philpott H, Kronborg I, Arachchi NJ, Bell S, Lim L, Gorelik A, Nicoll A. Epidemiology of hepatitis B-associated hepatocellular carcinoma in Victoria. Intern Med J 2013; 43:501-6. [DOI: 10.1111/imj.12068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 12/16/2012] [Indexed: 12/16/2022]
Affiliation(s)
- M. Sinclair
- Department of Gastroenterology and Hepatology; Royal Melbourne Hospital; Heidelberg Victoria Australia
| | - S. Roberts
- Department of Gastroenterology; Alfred Hospital; Heidelberg Victoria Australia
| | - W. Kemp
- Department of Gastroenterology; Alfred Hospital; Heidelberg Victoria Australia
| | - V. Knight
- Department of Gastroenterology; Monash Medical Centre; Heidelberg Victoria Australia
| | - A. Dev
- Department of Gastroenterology; Monash Medical Centre; Heidelberg Victoria Australia
| | - P. Gow
- Department of Gastroenterology; Austin; Heidelberg Victoria Australia
| | - H. Philpott
- Department of Gastroenterology; Austin; Heidelberg Victoria Australia
| | - I. Kronborg
- Department of Gastroenterology; Western Hospital; Melbourne Victoria Australia
| | - N. J. Arachchi
- Department of Gastroenterology; Western Hospital; Melbourne Victoria Australia
| | - S. Bell
- Department of Gastroenterology; St Vincent's Hospital; Melbourne Victoria Australia
| | - L. Lim
- Department of Gastroenterology; St Vincent's Hospital; Melbourne Victoria Australia
| | - A. Gorelik
- Department of Clinical Epidemiology; Royal Melbourne Hospital; Heidelberg Victoria Australia
| | - A. Nicoll
- Department of Gastroenterology and Hepatology; Royal Melbourne Hospital; Heidelberg Victoria Australia
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34
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Howell J, Sawhney R, Skinner N, Gow P, Angus P, Ratnam D, Visvanathan K. Toll-like receptor 3 and 7/8 function is impaired in hepatitis C rapid fibrosis progression post-liver transplantation. Am J Transplant 2013; 13:943-953. [PMID: 23425350 DOI: 10.1111/ajt.12165] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 12/27/2012] [Accepted: 12/30/2012] [Indexed: 01/25/2023]
Abstract
Recurrence of hepatitis C (HCV) postliver transplant is universal, with a subgroup developing rapid hepatic fibrosis. Toll-like receptors (TLRs) are critical to innate antiviral responses and HCV alters TLR function to evade immune clearance. Whether TLRs play a role in rapid HCV recurrence posttransplant is unknown. We stimulated peripheral blood mononuclear cells (PBMCs) from 70 patients with HCV postliver transplant with TLR subclass-specific ligands and measured cytokine production, TLR expression and NK cell function. Rate of fibrosis progression was calculated using posttransplant liver biopsies graded by Metavir scoring (F0-4; R=fibrosis stage/year posttransplant; rapid fibrosis defined as >0.4 units/year). Thirty of 70 (43%) patients had rapid fibrosis progression. PBMCs from HCV rapid-fibrosers produced less IFNα with TLR7/8 stimulation (p=0.039), less IL-6 at baseline (p=0.027) and with TLR3 stimulation (p=0.008) and had lower TLR3-mediated monocyte IL-6 production (p=0.028) compared with HCV slow fibrosers. TLR7/8-mediated NKCD56 dim cell secretion of IFNγ was impaired in HCV rapid fibrosis (p=0.006) independently of IFNα secretion and TLR7/8 expression, while cytotoxicity remained preserved. Impaired TLR3 and TLR7/8-mediated cytokine responses may contribute to aggressive HCV recurrence postliver transplantation through impaired immune control of HCV and subsequent activation of fibrogenesis.
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Affiliation(s)
- J Howell
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Australia
| | - R Sawhney
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Australia
| | - N Skinner
- Innate Immune Laboratory, Monash University, Melbourne, Australia
| | - P Gow
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Australia
| | - P Angus
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Australia
| | - D Ratnam
- Innate Immune Laboratory, Monash University, Melbourne, Australia
| | - K Visvanathan
- Innate Immune Laboratory, Monash University, Melbourne, Australia
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35
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Howell J, Sawhney R, Skinner N, Gow P, Angus P, Ratnam D, Visvanathan K. Toll-like receptor 3 and 7/8 function is impaired in hepatitis C rapid fibrosis progression post-liver transplantation. Am J Transplant 2013. [PMID: 23425350 DOI: 10.1111/ajt.1216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Recurrence of hepatitis C (HCV) postliver transplant is universal, with a subgroup developing rapid hepatic fibrosis. Toll-like receptors (TLRs) are critical to innate antiviral responses and HCV alters TLR function to evade immune clearance. Whether TLRs play a role in rapid HCV recurrence posttransplant is unknown. We stimulated peripheral blood mononuclear cells (PBMCs) from 70 patients with HCV postliver transplant with TLR subclass-specific ligands and measured cytokine production, TLR expression and NK cell function. Rate of fibrosis progression was calculated using posttransplant liver biopsies graded by Metavir scoring (F0-4; R=fibrosis stage/year posttransplant; rapid fibrosis defined as >0.4 units/year). Thirty of 70 (43%) patients had rapid fibrosis progression. PBMCs from HCV rapid-fibrosers produced less IFNα with TLR7/8 stimulation (p=0.039), less IL-6 at baseline (p=0.027) and with TLR3 stimulation (p=0.008) and had lower TLR3-mediated monocyte IL-6 production (p=0.028) compared with HCV slow fibrosers. TLR7/8-mediated NKCD56 dim cell secretion of IFNγ was impaired in HCV rapid fibrosis (p=0.006) independently of IFNα secretion and TLR7/8 expression, while cytotoxicity remained preserved. Impaired TLR3 and TLR7/8-mediated cytokine responses may contribute to aggressive HCV recurrence postliver transplantation through impaired immune control of HCV and subsequent activation of fibrogenesis.
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Affiliation(s)
- J Howell
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Australia
| | - R Sawhney
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Australia
| | - N Skinner
- Innate Immune Laboratory, Monash University, Melbourne, Australia
| | - P Gow
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Australia
| | - P Angus
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Australia
| | - D Ratnam
- Innate Immune Laboratory, Monash University, Melbourne, Australia
| | - K Visvanathan
- Innate Immune Laboratory, Monash University, Melbourne, Australia
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Scott I, Phelps G, Rubin G, Gow P, Kendall P, Lane G, Frost G, Yee KC. Putting professionalism and delivery of value-added healthcare at the heart of physician training and continuing professional development. Intern Med J 2012; 42:737-41. [DOI: 10.1111/j.1445-5994.2012.02835.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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37
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Affiliation(s)
- M Garg
- Gastroenterology and Liver Transplant Unit, Victoria, Australia
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38
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Hutton I, Gamble G, McLean G, Butcher H, Gow P, Dalbeth N. What is associated with being active in arthritis? Analysis from the Obstacles to Action study. Intern Med J 2009; 40:512-20. [PMID: 19460061 DOI: 10.1111/j.1445-5994.2009.01989.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Many adults with arthritis do not achieve physical activity levels recommended for good health. This study aimed to identify factors associated with physical activity participation in people with arthritis. METHODS 1106 out of 8163 adults with self-reported arthritis were identified from the 2003 Obstacles to Action study. Participants were classified as active if they reported 30 min of moderate activity > or = 5 days a week or 20 min of vigorous activity > or = 3 days a week (n = 613), or insufficiently active if they did not (n = 438). Sociodemographic factors, attitudes, self-efficacy, motivators and barriers to being active were analysed. RESULTS Active people with arthritis had a lower burden of chronic disease than insufficiently active people (18% with three or more chronic medical conditions vs 33%, P < 0.0001). Active participants believed more strongly in the benefits of physical activity, reported higher levels of encouragement from others and had greater overall levels of self-efficacy when compared with the less active participants (P for all <0.0001). Arthritis, fatigue and discomfort were ranked by both groups as the top three barriers. However, the active participants reported lower impact scores for these barriers than the inactive group (P for all <0.0001). These findings persisted after adjusting for occupational status, body mass index and comorbidities. CONCLUSION Active adults with arthritis have lower levels of chronic disease, greater self-efficacy and fewer psychosocial barriers. Recognition of such barriers and motivators may be useful when designing intervention programmes to help people with arthritis initiate or intensify physical activity participation.
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Affiliation(s)
- I Hutton
- Counties Manukau District Health Board, Auckland, New Zealand.
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Taylor WJ, Schumacher HR, Baraf HSB, Chapman P, Stamp L, Doherty M, McQueen F, Dalbeth N, Schlesinger N, Furst DE, Vazquez-Mellado J, Mellado JV, Becker MA, Kavanaugh A, Louthrenoo W, Bardin T, Khanna D, Simon LS, Yamanaka H, Choi HK, Zeng X, Strand V, Grainger R, Clegg D, Singh JA, Diaz-Torne C, Boers M, Gow P, Barskova VG. A modified Delphi exercise to determine the extent of consensus with OMERACT outcome domains for studies of acute and chronic gout. Ann Rheum Dis 2007; 67:888-91. [PMID: 18055475 DOI: 10.1136/ard.2007.079970] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To reach consensus with recommendations made by an OMERACT Special Interest Group (SIG). METHODS Rheumatologists and industry representatives interested in gout rated and clarified, in three iterations, the importance of domains proposed by the OMERACT SIG for use in acute and chronic gout intervention studies. Consensus was defined as a value of less than 1 of the UCLA/RAND disagreement index. RESULTS There were 33 respondents (61% response rate); all agreed the initial items were necessary, except "total body urate pool". Additional domains were suggested and clarification sought for defining "joint inflammation" and "musculoskeletal function". Items that demonstrated no clear decision were re-rated in the final iteration. There were six highly rated items (rating 1-2) with four slightly lower rating items (rating 3) for acute gout; and 11 highly rated items with eight slightly lower ratings for chronic gout. CONCLUSIONS Consensus is that the following domains be considered mandatory for acute gout studies: pain, joint swelling, joint tenderness, patient global, physician global, functional disability; and for chronic gout studies: serum urate, gout flares, tophus regression, health-related quality of life, functional disability, pain, patient global, physician global, work disability and joint inflammation. Several additional domains were considered discretionary.
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Affiliation(s)
- W J Taylor
- Department of Medicine, University of Otago, Wellington 6242, New Zealand.
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Steer S, Abkevich V, Gutin A, Cordell HJ, Gendall KL, Merriman ME, Rodger RA, Rowley KA, Chapman P, Gow P, Harrison AA, Highton J, Jones PBB, O'Donnell J, Stamp L, Fitzgerald L, Iliev D, Kouzmine A, Tran T, Skolnick MH, Timms KM, Lanchbury JS, Merriman TR. Genomic DNA pooling for whole-genome association scans in complex disease: empirical demonstration of efficacy in rheumatoid arthritis. Genes Immun 2006; 8:57-68. [PMID: 17159887 DOI: 10.1038/sj.gene.6364359] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
A pragmatic approach that balances the benefit of a whole-genome association (WGA) experiment against the cost of individual genotyping is to use pooled genomic DNA samples. We aimed to determine the feasibility of this approach in a WGA scan in rheumatoid arthritis (RA) using the validated human leucocyte antigen (HLA) and PTPN22 associations as test loci. A total of 203 269 single-nucleotide polymorphisms (SNPs) on the Affymetrix 100K GeneChip and Illumina Infinium microarrays were examined. A new approach to the estimation of allele frequencies from Affymetrix hybridization intensities was developed involving weighting for quality signals from the probe quartets. SNPs were ranked by z-scores, combined from United Kingdom and New Zealand case-control cohorts. Within a 1.7 Mb HLA region, 33 of the 257 SNPs and at PTPN22, 21 of the 45 SNPs, were ranked within the top 100 associated SNPs genome wide. Within PTPN22, individual genotyping of SNP rs1343125 within MAGI3 confirmed association and provided some evidence for association independent of the PTPN22 620W variant (P=0.03). Our results emphasize the feasibility of using genomic DNA pooling for the detection of association with complex disease susceptibility alleles. The results also underscore the importance of the HLA and PTPN22 loci in RA aetiology.
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Affiliation(s)
- S Steer
- Kings College London School of Medicine at Guy's, Department of Rheumatology, King's and St Thomas', London, UK
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Abstract
AIMS This study advances previously performed clinical studies of antifungal prophylaxis and prospectively evaluates the efficacy of low-dose amphotericin B preparations for the prevention of invasive fungal infection (IFI) in high-risk liver transplant (LT) recipients. METHODS High-risk LT patients were recruited and randomised to openly receive intravenously either conventional amphotericin B (amB) at a dose of 15 mg daily, or liposomal amphotericin B (amBisome) 50 mg daily. Prophylaxis was continued until discharge from the intensive care unit (ICU), until patient death, or until time of conversion to high-dose amBisome for treatment of suspected or confirmed IFI. RESULTS During the study period, 360 adult LTs were performed; 132 patients were eligible for 149 recruitment episodes into the trial, and 83 patients were recruited for 92 episodes. Of the 92, 48 patient episodes were randomised to receive amBisome prophylaxis, and 44 to receive amB. IFI was uncommon, diagnosed for 3 patients in the amBisome group, and for 2 in the amB group. Furthermore, Aspergillus was isolated on a single occasion during 92 episodes of prophylaxis. Fungal colonisation scores did not differ significantly between the 2 groups. There was a significant difference in the rates of survival to ICU discharge between the 2 groups (79.6% amBisome vs. 59.5% amB, P=0.038). Renal function measures including creatinine clearance at commencement and conclusion of prophylaxis, and at 12 months post transplant were not statistically different between the 2 groups. CONCLUSION The use of amphotericin B, liposomal or non-liposomal preparations at low doses, for prophylaxis of IFI in high-risk LT patients, is associated with a low incidence of serious fungal infection. In this randomised study, low-dose amBisome prophylaxis was associated with an increased likelihood of successful discharge from the ICU.
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Affiliation(s)
- T Shah
- Liver and Hepatobiliary Unit, Queen Elizabeth Hospital, Birmingham, UK.
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Naka T, Wan L, Bellomo R, Wang BZ, Jones R, Berry R, Angus P, Gow P. Kidney failure associated with liver transplantation or liver failure: the impact of continuous veno-venous hemofiltration. Int J Artif Organs 2005; 27:949-55. [PMID: 15636052 DOI: 10.1177/039139880402701107] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS The short-term outcome of critically ill patients with kidney failure combined with severe liver failure or orthotopic liver transplantation (OLTx) is poor. We sought to test the hypothesis that, with the exclusive use of continuous veno-venous hemofilration (CVVH) with minimal heparin-anticoagulation, the short and long-term outcomes of these patients would be improved. PATIENTS Sixty-six consecutive patients with combined liver and kidney failure SETTING Intensive Care Unit of tertiary hospital DESIGN Retrospective interrogation of prospectively collected databases INTERVENTION Treatment of all patients with continuous veno-venous hemofiltration (CVVH) by protocol with 2L/h of ultrafiltration rate and minimal use of circuit heparinization. Retrieval of specific information on demographic, clinical, therapeutic and outcome details. MEASUREMENTS AND MAIN RESULTS From July 1995 to April 2004, 66 patients with combined liver and renal failure received continuous veno-venous hemofiltration (CVVH). Of these, 26 received liver transplantation and 40 did not. There were no significant differences in age, APACHE II score, bilirubin, ALT, INR or albumin on admission. The average duration of CVVH was 9.5 days for OLTx patients and 5 days for non-transplanted patients (p=0.013). Heparin anticoagulation was used in only 12% of OLTx patients and 20% of non-transplanted patients. ICU mortality was 15% in OLTx patients and 63% in non-transplanted patients (p<0.0005); hospital mortality was 23% compared to 70% (p<0. 001). Mean survival time at follow up was 1,120 days compared to 358 days (p<0.0001). CONCLUSIONS ARF associated with OLTx has a much better outcome than ARF without OLTx. Furthermore, management based on a conservative anticoagulation policy and CVVH as the exclusive form of renal support was associated with the best ICU, hospital and long term survival reported so far.
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Affiliation(s)
- T Naka
- Department of Intensive Care and Surgery, Austin Hospital, Melbourne, Australia
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43
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Delatycki MB, Allen KJ, Gow P, MacFarlane J, Radomski C, Thompson J, Hayden MR, Goldberg YP, Samuels ME. A homozygous HAMP mutation in a multiply consanguineous family with pseudo-dominant juvenile hemochromatosis. Clin Genet 2004; 65:378-83. [PMID: 15099344 DOI: 10.1111/j.0009-9163.2004.00254.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Juvenile hemochromatosis (JH) is an autosomal recessive condition that leads to significant morbidity due to early onset systemic iron overload. The majority of families with JH link to chromosome 1q and were recently found to have mutations in the HFE2 gene encoding hemojuvelin; however, several JH families have been reported to have mutations in the HAMP gene encoding hepcidin. Here, we report a multiply consanguineous family with a father and daughter showing iron overload consistent with JH. Sequence analysis of HAMP revealed homozygosity for amino acid substitution C78T due to a c.233G > A mutation. This mutation disrupts one of eight highly conserved cysteines that are believed to be critical for the function of the active enzyme. This finding adds support to the importance of the role of these conserved cysteines in the activity of hepcidin.
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Affiliation(s)
- M B Delatycki
- Bruce Lefroy Center for Genetic Health Research, Murdoch Childrens Research Institute, University of Melbourne, Department of Paediatrics, Parkville, Victoria, Australia.
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44
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46
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Abstract
BACKGROUND Gout is a common and challenging problem in South Auckland, New Zealand. Allopurinol is widely used but urate reduction remains unsatisfactory. Allopurinol dosing guidelines and a therapeutic range for plasma oxypurinol levels have been published. AIMS We aimed to determine the appropriateness of allopurinol dosing according to current guidelines and to assess the relationship between plasma creatinine, oxypurinol and urate. In addition, we assessed the clinical usefulness of the oxypurinol level. METHODS Thirty-one patients, on a stable dose of allopurinol for at least three weeks, had plasma creatinine, urate and oxypurinol measured as part of routine clinical assessment. Relationships between the various methods were examined using regression analysis. Fisher's exact test was used to test associations with categorical variables. RESULTS Fifty-five per cent of patients were on higher than recommended doses of allopurinol. There was a statistically significant relationship between calculated creatinine clearance and plasma oxypurinol level. Only 50% of patients with a plasma oxypurinol within the therapeutic range (30-100 micromol/L) had a plasma urate < 0.42 mmol/L and this did not increase significantly in the patients with an oxypurinol level > 100 micromol/L. CONCLUSIONS There is poor adherence to the current recommended dosing guidelines for allopurinol. Creatinine clearance rather than plasma creatinine needs to be used to predict the dose of allopurinol. The current role of the oxypurinol level is to identify non-compliers with allopurinol therapy. We need further research to clarify whether increasing the dose of allopurinol outside the recommended dose range to reach an oxypurinol level of close to 100 micromol/L may be of benefit in those who have not had sufficient urate reduction.
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Affiliation(s)
- L Stamp
- Middlemore Hospital, South Auckland, New Zealand
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47
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Abstract
Inpatient discharge surveys at Middlemore hospital, a 600 bed hospital in South Auckland, New Zealand, consistently rate communication and co-ordination of care as parameters in need of improvement. A case management model of care was suggested as a means of achieving this. The objective of this study was to determine the effectiveness of care co-ordination in an acute general medical setting in a pilot study over a 4 week period. A care co-ordinator identified 18 patients with complex problems among 48 patients admitted to a single medical ward under the care of a single multidisciplinary team, with their care being co-ordinated over the entire episode of illness. A control group of 59 similarly complex patients admitted to other wards and teams without care co-ordination over the same period was also studied and the outcomes compared. Communication and co-ordination, discharge information, involvement in discharge planning and information on post-discharge services were rated by the study patients as good or very good by 77, 85, 69 and 77%, respectively, compared with 62, 30, 41 and 45% in the control group. The same parameters were rated as poor or very poor by 13, 30, 36 and 15% of the control patients, compared with 0% in all these measures in the study group. Twenty-one clinical staff involved in the study agreed that there was an improvement in care co-ordination with respect to efficiency, reduction of workload and better communication, with approval ratings being 71, 76 and 76%, respectively. There was no difference in Average Length of Stay between the control and study groups, but three of the patients in the control group may have had their preventable readmissions within 10 days avoided if their care had been co-ordinated during their initial admission.
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Affiliation(s)
- P Gow
- Middlemore Hospital, South Auckland Health, Otahuhu, New Zealand
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48
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Abstract
A major initiative to implement a clinical pathway for myocardial infarction has provided a model on which to further develop pathways within our organization. Two of the primary objectives were to reduce time to thrombolysis and length of stay. Two years after the implementation of the myocardial infarction pathway there has been a reduction in the thrombolysis times from 80 to 49 min and in length of stay from 7.28 to 6.13 days. These results highlight significant improvements in patient and process outcomes. There is heightened awareness about best practice for patients who have sustained myocardial infarctions.
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Affiliation(s)
- D M Smith
- Department of Medicine, Middlemore Hospital, Otahuhu, Auckland, New Zealand
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49
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West MB, Gow P. Ciprofloxacin, bilateral Achilles tendonitis and unilateral tendon rupture--a case report. N Z Med J 1998; 111:18-9. [PMID: 9484431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Williams CJ, Rock M, Considine E, McCarron S, Gow P, Ladda R, McLain D, Michels VM, Murphy W, Prockop DJ. Three new point mutations in type II procollagen (COL2A1) and identification of a fourth family with the COL2A1 Arg519-->Cys base substitution using conformation sensitive gel electrophoresis. Hum Mol Genet 1995; 4:309-12. [PMID: 7757086 DOI: 10.1093/hmg/4.2.309] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- C J Williams
- Department of Biochemistry and Molecular Biology, Thomas Jefferson University, Philadelphia, PA 19107, USA
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