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Thursz M.,Imperial College London | Forrest E.,Royal Infirmary | Roderick P.,University of Southampton | Day C.,Foundation Medicine | And 19 more authors.
Health Technology Assessment | Year: 2015

Background Alcoholic hepatitis (AH) is a distinct presentation of alcoholic liver disease arising in patients who have been drinking to excess for prolonged periods, which is characterised by jaundice and liver failure. Severe disease is associated with high short-term mortality. Prednisolone and pentoxifylline (PTX) are recommended in guidelines for treatment of severe AH, but trials supporting their use have given heterogeneous results and controversy persists about their benefit. Objectives The aim of the clinical effectiveness and cost-effectiveness of STeroids Or Pentoxifylline for Alcoholic Hepatitis trial was to resolve the clinical dilemma on the use of prednisolone or PTX. Design The trial was a randomised, double-blind, 2 × 2 factorial, multicentre design. Setting Sixty-five gastroenterology and hepatology inpatient units across the UK. Participants Patients with a clinical diagnosis of AH who had a Maddrey’s discriminant function value of ≥ 32 were randomised into four arms: A, placebo/placebo; B, placebo/prednisolone; C, PTX/placebo; and D, PTX/prednisolone. Of the 5234 patients screened for the trial, 1103 were randomised and after withdrawals, 1053 were available for primary end-point analysis. Interventions Those allocated to prednisolone were given 40 mg daily for 28 days and those allocated to PTX were given 400 mg three times per day for 28 days. Outcomes The primary outcome measure was mortality at 28 days. Secondary outcome measures included mortality or liver transplant at 90 days and at 1 year. Rates of recidivism among survivors and the impact of recidivism on mortality were assessed. Results At 28 days, in arm A, 45 of 269 (16.7%) patients died; in arm B, 38 of 266 (14.3%) died; in arm C, 50 of 258 (19.4%) died; and in arm D, 35 of 260 (13.5%) died. For PTX, the odds ratio for 28-day mortality was 1.07 [95% confidence interval (CI) 0.77 to 1.40; p = 0.686)] and for prednisolone the odds ratio was 0.72 (95% CI 0.52 to 1.01; p = 0.056). In the logistic regression analysis, accounting for indices of disease severity and prognosis, the odds ratio for 28-day mortality in the prednisolone-treated group was 0.61 (95% CI 0.41 to 0.91; p = 0.015). At 90 days and 1 year there were no significant differences in mortality rates between the treatment groups. Serious infections occurred in 13% of patients treated with prednisolone compared with 7% of controls (p = 0.002). At the 90-day follow-up, 45% of patients reported being completely abstinent, 9% reported drinking within safety limits and 33% had an unknown level of alcohol consumption. At 1 year, 37% of patients reported being completely abstinent, 10% reported drinking within safety limits and 39% had an unknown level of alcohol consumption. Only 22% of patients had attended alcohol rehabilitation treatment at 90 days and 1 year. Conclusions We conclude that prednisolone reduces the risk of mortality at 28 days, but this benefit is not sustained beyond 28 days. PTX had no impact on survival. Future research should focus on interventions to promote abstinence and on treatments that suppress the hepatic inflammation without increasing susceptibility to infection. Trial registration This trial is registered as EudraCT 2009-013897-42 and Current Controlled Trials ISRCTN88782125. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 102. See the NIHR Journals Library website for further project information. The NIHR Clinical Research Network provided research nurse support and the Imperial College Biomedical Research Centre also provided funding. © Queen’s Printer and Controller of HMSO 2015.

Rajakumar A.,Institute of Liver Disease and Transplantation | Kaliamoorthy I.,Institute of Liver Disease and Transplantation | Reddy M.S.,Institute of Liver Disease and Transplantation | Rela M.,Institute of Liver Disease and Transplantation | Rela M.,Institute of Liver Studies
Indian Journal of Anaesthesia | Year: 2016

Propionic acidemia (PA) is an autosomal recessive disorder of metabolism due to deficiency of the enzyme propionyl-CoA carboxylase (PCC) that converts propionyl-CoA to methylmalonyl-CoA with the help of the cofactor biotin inside the mitochondria. The resultant accumulation of propionyl-CoA causes severe hyperammonaemia and life-threatening metabolic acidosis. Based on the positive outcomes, liver transplantation is now recommended for individuals with recurrent episodes of hyperammonaemia or acidosis that is not adequately controlled with appropriate medical therapies. We report anaesthetic management of two children with PA for liver transplantation at our institution. It is essential for the anaesthesiologist, caring for these individuals to be familiar with the manifestations of the disease, the triggers for decompensation and management of an acute episode. © 2016 Indian Journal of Anaesthesia.

Sigala F.,Clinical Center Mittelbaden | Kontis E.,Institute of Liver Studies | Sassen R.,Clinical Center Mittelbaden | Mickley V.,Clinical Center Mittelbaden
Journal of Vascular Access | Year: 2014

Purpose: Due to their relatively low complication rates autogenous arteriovenous fistulas (AVFs) are the preferred access for hemodialysis. In long-standing AVF, however, aneurysmatic degeneration of the fistula vein can develop. Several treatment options have been published. We evaluated our experience with autologous surgical reconstruction in patients with AVF aneurysms in order to assess complication and patency rates.Methods: Demographics and comorbidities of all patients operated on for true AVF aneurysms in our institution, during a 7-year period, were reviewed. Access function and surgical outcomes were evaluated with pre- and postoperative Doppler ultrasonography. Patient survival, primary and secondary access patency rates are presented.Results: From April 2006 through March 2013, 31 patients presented with access-associated upper extremity venous aneurysms. The mean time from AVF creation to aneurysm formation was 4.9±3.6 years. The most frequent indication for surgery was aneurysm-associated stenosis (n=16) followed by high flow (n=9), complete thrombosis (n=3) and uncontrolled bleeding (n=3). All patients had autologous reconstructions: 5 resections with end-to-end anastomosis and 26 aneurysmorrhaphies. Overall patient survival at 1 and 2 years was 89% and 84%, respectively. The primary (secondary) patency rates at 6 mo, 1 and 2 years were 87%, 81% and 81% (96%, 96% and 90%), respectively.Conclusions: Autologous surgical reconstruction is feasible in the majority of AVF aneurysms. It preserves fistula function and—in contrast to graft interposition and endovascular repair—keeps the advantages of an autogenous access: low complication and high patency rates. © 2014 Wichtig Publishing.

BACKGROUND:: Cardiovascular diseases remain the leading cause of morbidity and mortality among Filipinos and are responsible for a very large number of hospital readmissions. Comprehensive discharge planning programs have demonstrated positive benefits among various populations of patients with cardiovascular disease, but the clinical and psychosocial effects of such intervention among Filipino patients with acute myocardial infarction (AMI) have not been studied. AIMS/OBJECTIVES:: In this study we aimed to determine the effectiveness of a nurse-led structured discharge planning program on perceived functional status, cardiac self-efficacy, patient satisfaction, and unexpected hospital revisits among Filipino patients with AMI. METHODS:: A true experimental (randomized control) 2-group design with repeated measures and data collected before and after intervention and at 1-month follow-up was used in this study. Participants were assigned to either the control (n = 68) or the intervention group (n = 75). Intervention participants underwent a 3-day structured discharge planning program implemented by a cardiovascular nurse practitioner, which is comprised of a series of individualized lecture-discussion, provision of feedback, integrative problem solving, goal setting, and action planning. Control participants received standard routine care. Measures of functional status, cardiac self-efficacy, and patient satisfaction were measured at baseline; cardiac self-efficacy and patient satisfaction scores were measured prior to discharge, and perceived functional status and number of revisits were measured 1 month after discharge. RESULTS:: Participants in the intervention group had significant improvement in functional status, cardiac self-efficacy, and patient satisfaction scores at baseline and at follow-up compared with the control participants. Furthermore, participants in the intervention group had significantly fewer hospital revisits compared with those who received only standard care. CONCLUSION:: The results demonstrate that a nurse-led structured discharge planning program is an effective intervention in improving perceived functional health status, cardiac self-efficacy, and patient satisfaction, while reducing the number of unexpected hospital revisits, among Filipino patients with AMI. It is recommended that this intervention be incorporated in the optimal care of patients being discharged with an AMI. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved

Efe C.,Hacettepe University | Kav T.,Hacettepe University | Aydin C.,Hacettepe University | Cengiz M.,Gazi University | And 8 more authors.
Digestive Diseases and Sciences | Year: 2014

Results: Mean serum 25(OH)D levels were significantly lower in AIH compared to healthy controls (16.8 ± 9.2 vs. 35.7 ± 13.6, p < 0.0001). Low levels of 25(OH)D (<30 µg/L) were independently associated with advance fibrosis and severe interface hepatitis in AIH patients [p = 0.014; odds ratio (OR) 0.12, 95 % confidence interval (CI) 0.02–0.65 and p = 0.020; OR 0.17, 95 % CI 0.04–0.76, respectively]. Severe 25(OH)D deficiency (<10 µg/L) was associated with advance fibrosis, severe interface hepatitis, low platelet counts and sampling time in a univariate analysis. Only interface hepatitis and fibrosis scores were independently associated with 25(OH)D deficiency in a multiple regression analysis (p = 0.005; OR 0.12, 95 % CI 0.03–0.53 and p = 0.022; OR 0.15, 95 % CI 0.03–0.75, respectively). Mean serum 25(OH)D levels were lower in non-responders compared to responders (9.2 ± 4.8 vs. 17.1 ± 9.4, p = 0.015), and 25(OH)D deficiency was more commonly observed in non-responders than the responders (80 vs. 43 %, p = 0.036).Conclusions: Low 25(OH)D levels are associated with advance fibrosis and severe inflammation in AIH. Our study suggests that vitamin D may be a potential biomarker that predicts response to therapy and histological features in AIH.Background and Aim: 25-Hydroxyvitamin D [25(OH)D] has an important role in fibrosis progression and inflammatory response in patients with various etiologies of chronic liver disease. However, its influence on autoimmune hepatitis (AIH) has not been investigated. We evaluated the association of serum 25(OH)D levels with clinical, biochemical and histological features and response to therapy in AIH.Materials and methods: Serum 25(OH)D levels were quantified in 68 therapy naïve AIH patients and 34 healthy controls. © 2014, Springer Science+Business Media New York.

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