The Prediction of In-Hospital Mortality in Decompensated Cirrhosis with Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is a condition in cirrhosis associated with organ failure (OF) and high short-term mortality. Both the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) and North American Consortium for the Study of End-Stage Liver Disease (NACSELD) ACLF definitions have been shown to predict ACLF prognosis. The aim of this study was to compare the ability of the EASL-CLIF versus NACSELD systems over baseline clinical and laboratory parameters in the prediction of in-hospital mortality in admitted patients with decompensated cirrhosis. Five NACSELD centers prospectively collected data to calculate EASL-CLIF and NACSELD-ACLF scores for admitted patients with cirrhosis who were followed for the development of OF, hospital course, and survival. Both the number of OFs and the ACLF grade or presence were used to determine the impact of NACSELD versus EASL-CLIF definitions of ACLF above baseline parameters on in-hospital mortality. A total of 1031 patients with decompensated cirrhosis (age, 57 ± 11 years; male, 66%; Child-Pugh-Turcotte score, 10 ± 2; Model for End-Stage Liver Disease [MELD] score, 20 ± 8) were enrolled. Renal failure prevalence (28% versus 9%, P < 0.001) was more common using the EASL-CLIF versus NACSELD definition, but the prevalence rates for brain, circulatory, and respiratory failures were similar. Baseline parameters including age, white cell count on admission, and MELD score reasonably predicted in-hospital mortality (area under the curve, 0.76). The addition of number of OFs according to either system did not improve the predictive power of the baseline parameters for in-hospital mortality, but the presence of NACSELD-ACLF did. However, neither system was better than baseline parameters in the prediction of 30- or 90-day outcomes. The presence of NACSELD-ACLF is equally effective as the EASL-CLIF ACLF grade, and better than baseline parameters in the prediction of in-hospital mortality in patients with cirrhosis, but not superior in the prediction of longer-term 30- or 90-day outcomes.

Comparison of mortality risk in patients with cirrhosis and COVID-19 compared with patients with cirrhosis alone and COVID-19 alone: multicentre matched cohort

OBJECTIVE

Comorbid conditions are associated with poor prognosis in COVID-19. Registry data show that patients with cirrhosis may be at high risk. However, outcome comparisons among patients with cirrhosis+COVID-19 versus patients with COVID-19 alone and cirrhosis alone are lacking. The aim of this study was to perform these comparisons.

DESIGN

A multicentre study of inpatients with cirrhosis+COVID-19 compared with age/gender-matched patients with COVID-19 alone and cirrhosis alone was performed. COVID-19 and cirrhosis characteristics, development of organ failures and acute-on-chronic liver failure (ACLF) and mortality (inpatient death+hospice) were compared.

RESULTS

37 patients with cirrhosis+COVID-19 were matched with 108 patients with COVID-19 and 127 patients with cirrhosis from seven sites. Race/ethnicity were similar. Patients with cirrhosis+COVID-19 had higher mortality compared with patients with COVID-19 (30% vs 13%, p=0.03) but not between patients with cirrhosis+COVID-19 and patients with cirrhosis (30% vs 20%, p=0.16). Patients with cirrhosis+COVID-19 versus patients with COVID-19 alone had equivalent respiratory symptoms, chest findings and rates of intensive care unit transfer and ventilation. However, patients with cirrhosis+COVID-19 had worse Charlson Comorbidity Index (CCI 6.5±3.1 vs 3.3±2.5, p<0.001), lower presenting GI symptoms and higher lactate. Patients with cirrhosis alone had higher cirrhosis-related complications, maximum model for end-stage liver disease (MELD) score and lower BiPAP/ventilation requirement compared with patients with cirrhosis+COVID-19, but CCI and ACLF rates were similar. In the entire group, CCI (OR 1.23, 95% CI 1.11 to 1.37, p<0.0001) was the only variable predictive of mortality on multivariable regression.

CONCLUSIONS

In this multicentre North American contemporaneously enrolled study, age/gender-matched patients with cirrhosis+COVID-19 had similar mortality compared with patients with cirrhosis alone but higher than patients with COVID-19 alone. CCI was the only independent mortality predictor in the entire matched cohort.

Nonpharmacologic Management of Hepatic Encephalopathy: An Update

Research increasingly shows that the gut-liver-brain axis is a crucial component in the pathophysiology of hepatic encephalopathy (HE). Due to the limitations of current standard-of-care medications, non-pharmacological treatments that target gut dysbiosis, including probiotics, nutritional management, and fecal microbiota transplants, are being considered as alternative and adjunct therapies. Meta-analyses note that probiotics could offer benefits in HE treatment, but have not shown superiority over lactulose. Emerging literature suggests that fecal microbiota transplants could offer a novel strategy to treat gut dysbiosis and favorably impact HE. Finally, liver support devices and liver transplantation could offer a last-resort treatment option for persistent HE.

Lessons about Motor Learning: How Is Motor Learning Taught in Physical Therapy Programmes Across Canada?

Purpose: This article describes the content of and delivery methods for motor learning (ML) education and the attitudes and beliefs of instructors with regard to how ML is taught in Canadian physical therapy (PT) programmes. Method: A qualitative descriptive design was employed, using an online questionnaire and semi-structured telephone interviews. A descriptive content analysis was used to develop codes and themes. An online search of PT programme Web sites was conducted to supplement missing data and collect information from schools that did not participate in the online questionnaire or interview. Results: Eight individuals representing seven schools completed the questionnaire; six of the eight also completed the interview. Responses conveyed the fact that ML content was fairly consistent across schools and was predominantly situated in the neurological curriculum. Schools differed in the delivery methods used for clinical application of ML content. Respondents believed that ML underlies PT practice and should be integrated throughout the programme. Conclusion: Current instruction may deliver adequate ML content but may not provide optimal opportunities to apply ML principles in a clinical context. Continuing education emerged as one suggestion for remediating clinicians' knowledge-practice gap and facilitating student learning on placement. Only half the eligible PT schools participated, and all were English-language programmes; thus, the findings may not be generalizable to all Canadian programmes. Future work should explore how ML can be integrated into the PT curriculum to promote the application of ML principles across different fields. Students' perspectives on their understanding of ML and ML principles and self-efficacy for entry to practice should also be explored.

Is K-O Tab 1-2-3((R)) long lasting on non-polyester mosquito nets?

Many societies use locally sourced mosquito nets made from a variety of materials. For protecting against malaria these require regular re-treatment with insecticide. K-O Tab 1-2-3 is a 'dip-it-yourself' long-lasting formulation with time-limited interim recommendation from WHO for treatment of washed white and coloured polyester nets for up to 15 washes. To determine wash-resistance on different fabrics, nets made of polyester, polyethylene, cotton or nylon were treated with K-O Tab 1-2-3 and washed up to 20 times using standard WHO washing procedures. Efficacy was assessed using cone and cylinder bioassays and tunnel tests, and deltamethrin content using high-pressure liquid chromatography. Polyethylene and cotton nets treated with K-O Tab 1-2-3 and washed 20 times achieved the WHO threshold of >80% mortality in tunnel tests. Polyethylene matched the performance of polyester in all bioassays in contrast to cotton and nylon which produced low mortality and knock-down in cone and cylinder bioassays. After 20 washes 16.5% of the loading dose of deltamethrin remained on the polyester nets compared with 28.7% on polyethylene, 38.9% on cotton and 2.2% on nylon. Cotton nets retained a high concentration of insecticide but the relatively poor performance in terms of knock-down and mortality suggest most insecticide is bound within the cotton fibres rather than on the surface. K-O Tab 1-2-3 renders insecticide wash fast on polyethylene nets, less so on cotton and nylon. Nets made from polyethylene can be treated in the home to render the insecticide long lasting.

Complementary practitioners' views of treatment for inflammatory bowel disease

A substantial number of patients with inflammatory bowel disease use complementary therapies to manage their disease, including chiropractic and herbal therapies. The objective of this study was to explore whether providers of these therapies see patients with inflammatory bowel disease and recommend therapies, and to determine their opinions about the treatments that they recommend. The study sample comprised 66 chiropractors, 19 pharmacists, 16 herbalists and 15 health food store employees in Calgary, Alberta. A structured questionnaire containing two patient scenarios (a patient with active ulcerative colitis and a patient with inactive Crohn's disease) was completed either by an in-person interview or by a mailed questionnaire. Most respondents had seen patients with ulcerative colitis, and at least 80% of each group except pharmacists (only 10%) would treat these patients or recommend treatment. Almost all chiropractors used spinal manipulation, whereas herbalists and health food store employees suggested a wide range of different treatments. Chiropractors rated their treatment as moderately effective; herbalists and health food store employees viewed their recommendations as very effective. The results with respect to the second scenario were very similar. The wide range of treatment recommendations by practitioners, who differ greatly in terms of skills, knowledge and experience, has important implications for physician-patient communication, information provision and education regarding complementary and alternative therapies.