Mixed Aetiologies Research Articles

Psychovegetative features at sick of the cirrhosis

Complex kliniko-tool, laboratory, psychovegetative investigation of 139 various aetiologies sick by a cirrhosis (virus, alcoholic, mixed) is carried and severity levels on Childs-Pugh. The comparison group has been presented by 104 sick chronic hepatitises virus, alcoholic and mixed aetiologies. The control group included 30 healthy the person comparable floor and age. At sick of a cirrhosis, also as at sick of a chronic hepatitis, emotionally-labile, neurotic lines and high personal uneasiness prevailed. The tendency to sympathicotonia depended on weight of defeat of a liver. Prevalence of a tone and reactance of sympathetic department of vegetative nervous system is a compensatory strengthening of adaptive mechanisms.

Microbial aetiology of community-acquired pneumonia and its relation to severity

BackgroundThe distribution of the microbial aetiology and mortality of community-acquired pneumonia (CAP) was investigated in relation to the clinical setting and severity scores (pneumonia severity index (PSI) and confusion, blood...

Measuring perceived difficulty in post-acute brain injury rehabilitation: The Sister Kenny Symptom Management Scale

Primary objective: Patients’ perceptions of difficulty managing symptoms contribute to disability after brain injury. This study introduces the Sister Kenny Symptom Management Scale (KSMS) and reports on its factor structure, reliability, validity and clinical value.Method: Archived data from (overlapping) samples of patients with brain injuries of mixed aetiologies, seen at an outpatient clinic over 16 years were used in development and validation studies of the KSMS. Comparison measures included the Profile of Mood States (POMS), neuropsychological test scores and employment.Results: Factor analysis of 34 items (n = 328) identified five sub-scales with satisfactory internal consistency and test–re-test stability representing difficulty with executive functions, language, recent memory, aggressive behaviour and physical symptoms. A pattern of correlations (n = 336) with Profile of Mood States (POMS) sub-scales of similar and different content supported the concurrent validity of KSMS sub-scales. Only the Memory sub-scale correlated with its test index. The Language score and test index approached significance. The Executive sub-scale did not. Hierarchical regression analysis (n = 102) that included ratings of mood and symptom management showed that employment after discharge was only predicted by post-treatment ratings of difficulty with cognitive functions.Conclusion: Self-assessments of difficulty managing symptoms can be reliably assessed and may contribute to understanding patients’ disability, treatment response and future prospects.

M1060 Do Gastroenterologists Advise Their Susceptible Patients Appropriately About Immunization?

Introduction There is evidence-based guidance, including from the Department of Health, supporting vaccination of patients with susceptible gastroenterological conditions. The recent pandemic flu has also raised the profile of vaccination programmes for at-risk patients. Anecdotally, Gastroenterologists rarely advise vaccinations for these patients. Methods We aimed to assess current uptake of vaccination in at-risk Gastroenterology patients. We prospectively audited vaccination uptake in the preceding 12 months, against influenza and pneumococcal disease among 100 consecutive eligible gastroenterology patients on immunomodulators or with chronic liver disease (CLD) seen in clinics or wards. Hepatitis A and B vaccination uptake were also assessed in CLD patients. The underlying diagnoses, type of immunomodulators and Child-Pugh scores were recorded. Patients who received vaccinations were also asked who advised their vaccination. Results We identified 57 males and 43 females with a mean age of 51 (range 19–83). 52% were on immunomodulators (31 Azathioprine, 9 Infliximab, 1 Adalimumab, 1 6-Mercaptopurine, 10 Combination) while 48% had CLD. Indications for immunomodulators include Crohn9s disease (56%), UC (25%), autoimmune hepatitis (15%) and post-liver transplant (4%). Diagnoses for CLD patients include ALD (59%), HCV infection (13%), PBC (6%), NAFLD (4%), autoimmune hepatitis (4%), haemochromatosis (4%), HBV infection (2%) and mixed aetiologies (8%). Only 10% of patients had both influenza and pneumococcal vaccines, while 27% had influenza vaccination alone. Of the eligible CLD patients, only 2/46 (4%) patients had both HAV and HBV vaccinations while 1/46 (2%) had HBV vaccination only. Of the 38 patients who had at least one vaccination, 73% were advised to by their general practitioner, 11% by the gastroenterology team, 11% via self-referral and 5% via other secondary care teams. Conclusion Despite national guidance, only about one third of our susceptible gastroenterology patients are receiving all or some of the appropriate vaccinations. Of the patients receiving vaccination, most do not receive all the recommended vaccinations. This suggests a failure to disseminate guidance rather than a lack of patients9 willingness to receive them. Most patients receiving vaccination were advised by their GPs. Few patients were advised by the Gastroenterology department, despite Gastroenterologists initiating immunomodulators and caring for susceptible patients. A departmental guideline is being created to ensure recommendations to receive all appropriate vaccinations are made to patients and their GPs. These findings may be similar in many UK hospitals and our findings may be more widely applicable.

PTH-073 Do gastroenterologists advise their susceptible patients appropriately about immunisation?

<h3>Introduction</h3> There is evidence-based guidance, including from the Department of Health, supporting vaccination of patients with susceptible gastroenterological conditions. The recent pandemic flu has also raised the profile of vaccination programmes for at-risk patients. Anecdotally, Gastroenterologists rarely advise vaccinations for these patients. <h3>Methods</h3> We aimed to assess current uptake of vaccination in at-risk Gastroenterology patients. We prospectively audited vaccination uptake in the preceding 12 months, against influenza and pneumococcal disease among 100 consecutive eligible gastroenterology patients on immunomodulators or with chronic liver disease (CLD) seen in clinics or wards. Hepatitis A and B vaccination uptake were also assessed in CLD patients. The underlying diagnoses, type of immunomodulators and Child-Pugh scores were recorded. Patients who received vaccinations were also asked who advised their vaccination. <h3>Results</h3> We identified 57 males and 43 females with a mean age of 51 (range 19–83). 52% were on immunomodulators (31 Azathioprine, 9 Infliximab, 1 Adalimumab, 1 6-Mercaptopurine, 10 Combination) while 48% had CLD. Indications for immunomodulators include Crohn9s disease (56%), UC (25%), autoimmune hepatitis (15%) and post-liver transplant (4%). Diagnoses for CLD patients include ALD (59%), HCV infection (13%), PBC (6%), NAFLD (4%), autoimmune hepatitis (4%), haemochromatosis (4%), HBV infection (2%) and mixed aetiologies (8%). Only 10% of patients had both influenza and pneumococcal vaccines, while 27% had influenza vaccination alone. Of the eligible CLD patients, only 2/46 (4%) patients had both HAV and HBV vaccinations while 1/46 (2%) had HBV vaccination only. Of the 38 patients who had at least one vaccination, 73% were advised to by their general practitioner, 11% by the gastroenterology team, 11% via self-referral and 5% via other secondary care teams. <h3>Conclusion</h3> Despite national guidance, only about one third of our susceptible gastroenterology patients are receiving all or some of the appropriate vaccinations. Of the patients receiving vaccination, most do not receive all the recommended vaccinations. This suggests a failure to disseminate guidance rather than a lack of patients9 willingness to receive them. Most patients receiving vaccination were advised by their GPs. Few patients were advised by the Gastroenterology department, despite Gastroenterologists initiating immunomodulators and caring for susceptible patients. A departmental guideline is being created to ensure recommendations to receive all appropriate vaccinations are made to patients and their GPs. These findings may be similar in many UK hospitals and our findings may be more widely applicable.

PTU-058 Histological liver collagen proportionate area predicts decompensation in patients with liver cirrhosis of mixed aetiologies

<h3>Introduction</h3> Histological scoring systems diagnose cirrhosis, but not severity of cirrhosis. Computer assisted digital image analysis (DIA) of Sirius red stained sections measures fibrosis morphologically, using segmentation of digital images to measure the relative areas of collagen and of tissue, producing a fibrosis ratio or collagen proportionate area (CPA).1 CPA could have staging and prognostic value for histological cirrhosis. The aim of this study is to evaluate CPA in cirrhosis of mixed aetiology and its relationship with liver decompensation. <h3>Methods</h3> We evaluated 118 consecutive patients with histological cirrhosis retrospectively: 76 males, mean age 53(±12.31), follow-up mean of 41.6 (±22.03) months after biopsy. At biopsy 63 were compensated (no ascites, bleeding episodes, encephalopaty). <h3>Results</h3> The mean CPA value in compensated patients was 17.2 (±8.3), in decompensated patients 27.9 (±10.7) (p&lt;0.0001). Mean time to first decompensation was 47(± 21) months. The AUROC for CPA to future decompensation in the compensated group was 0.80 (95% CI 0.71 to 0.88). The best cut-off was 20.1 (80% sensitivity and 78%specificity). Decompensation within 24 months had an AUROC of 0.79 (95% CI 0.63 to 0.96) and best cut-off was 18.1 (80% sensitivity and 80% specificity). Cox regression for time to decompensation was evaluated using INR, bilirubin, albumin, sodium, creatinine, Child score and CPA. Indipendently associated variables were CPA (OR 1.13, 95% CI 1.06 to 1.22, p=0.001) and albumin (OR 0.13, 95% CI 0.03 to 0.54, p=0.005). <h3>Conclusion</h3> CPA increases with worsening cirrhosis and is able to predict decompensation in compensated cirrhosis of mixed aetiologies. This suggests that severity of cirrhosis can be assessed histologically and that it correlates with clinical outcome.

Attentional enhancements and deficits in deaf populations: An integrative review

The literature on visual attention in deaf individuals presents two competing views. On one hand, the deficit view proposes that auditory input is necessary for the development of visual attention; on the other hand, the compensation view holds that visual attention reorganizes to allow the individual to compensate for the lack of auditory input. While apparently contradictory, we suggest that these views shed complementary light on the cross-modal reorganization of visual attention after early deafness. First, these two fields of inquiry look at different aspects of attention. The deficit view is mostly supported by studies of allocation of attention in time, whereas the compensation view is backed by studies measuring the allocation of attention across space. Second, they focus on groups of different age and different background. Deficits have been documented mostly in children with mixed hearing loss aetiologies, whereas reorganization has been documented in a less representative, but more homogenous group of Deaf adults. We propose a more integrative view in which early auditory deprivation does not result in better or worse visual attention. Rather, selected aspects of visual attention are modified in various ways along the developmental trajectory as a result of early deafness.

A functional promoter polymorphism in the chitinase-like protein gene (CH3L1) is associated with liver fibrosis in a FibroScan staged cohort

Introduction: Cartilage glycoprotein-39 (YKL-40) is supposed to be involved in tissue remodelling and degradation of extracellular matrix. Recently a functional promoter variant (-131G&gt;C) of the corresponding gene CH3L1 has been associated with advanced liver fibrosis in patients with chronic hepatitis C virus (HCV) infection (Berres et al. J Hepatol 2009;50:370–376). We aimed to verify this association in a cohort of patients with mixed aetiologies of chronic liver disease and in a subgroup of patients with ongoing HCV infection.

Stress trajectories in mothers of young children with Down syndrome

In this study, we investigated the early development of stress in mothers of children with Down syndrome, compared with mothers of children with developmental disabilities of mixed aetiologies. Growth modelling analyses were used to explore: (1) whether mothers of children with Down syndrome demonstrated distinct patterns of stress during their children's early development, compared with mothers of children with other developmental disabilities; and (2) whether there was a relation between child behavioural characteristics and the level and rate of change in stress observed in each population. The stress trajectories of mothers of young children with Down syndrome (n = 25) and a mixed-aetiology comparison group (n = 49) were estimated, using growth modelling on data collected at ages of 15, 30 and 45 months. On average, stress in the mixed comparison group was higher at Time 1 and remained unchanged over time, while stress in the Down syndrome group was lower at Time 1 but increased steadily. After taking diagnostic group membership into account, more advanced cognitive-linguistic functioning and lower levels of maladaptive behaviours at all time points were associated with lower levels of maternal stress. CONCLUSIONS; These findings suggest that the cognitive-linguistic and behavioural trajectory observed in early development in Down syndrome may contribute to the changes in maternal stress levels observed throughout these early years. Implications for developing targeted and time- sensitive family interventions for families of children with Down syndrome are discussed.

Patients with ischaemic, mixed and nephrotoxic acute tubular necrosis in the intensive care unit – a homogeneous population?

IntroductionAcute tubular necrosis (ATN) is usually studied as a single entity, without distinguishing between ischaemic, nephrotoxic and mixed aetiologies. In the present study we evaluated the characteristics and outcomes of patients with ATN by aetiological group.MethodWe conducted a retrospective comparison of clinical features, mortality rates and risk factors for mortality for the three types of ATN in patients admitted to the general intensive care unit of a university hospital between 1997 and 2000.ResultsOf 593 patients with acute renal failure, 524 (88%) were classified as having ATN. Their mean age was 58 years, 68% were male and 52% were surgical patients. The overall mortality rate was 62%. A total of 265 patients (51%) had ischaemic ATN, 201 (38%) had mixed ATN, and 58 (11%) had nephrotoxic ATN. There were no differences among groups in terms of age, sex, APACHE II score and reason for ICU admission. Multiple organ failure was more frequent among patients with ischaemic (46%) and mixed ATN (55%) than in those with nephrotoxic ATN (7%; P < 0.0001). The complications of acute renal failure (such as, gastrointestinal bleeding, acidosis, oliguria and hypervolaemia) were more prevalent in ischaemic and mixed ATN patients. Mortality was higher for ischaemic (66%; P = 0.001) and mixed ATN (63%; P = 0.0001) than for nephrotoxic ATN (38%). When ischaemic ATN patients, mixed ATN patients and all patients combined were analyzed by multivariate logistic regression, the independent factors for mortality identified were different except for oliguria, which was the only variable universally associated with death (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.64–5.49 [P = 0.0003] for ischaemic ATN; OR 1.96, 95% CI 1.04–3.68 [P = 0.036] for mixed ATN; and OR 2.53, 95% CI 1.60–3.76 [P < 0.001] for all patients combined]).ConclusionThe frequency of isolated nephrotoxic ATN was low, with ischaemic and mixed ATN accounting for almost 90% of cases. The three forms of ATN exhibited different clinical characteristics. Mortality was strikingly higher in ischaemic and mixed ATN than in nephrotoxic ATN. Although the type of ATN was not an independent predictor of death, the independent factors related to mortality were different for ischaemic, mixed and all patients combined. These data indicate that the three types of ATN represent different patient populations, which should be taken into consideration in future studies.

Neonatal seizures: Have we got the treatment right?

Neonatal seizures: Have we got the treatment right?

Community-acquired pneumonia: new management strategies for evolving pathogens and antimicrobial susceptibilities

Community-acquired pneumonia (CAP) is still one of the leading causes of mortality and morbidity. The most common bacterial cause of CAP is Streptococcus pneumoniae. The increase in antimicrobial resistance has raised concerns about the efficacy of available therapies, and a call for the reassessment of both existing and newer therapeutic agents. Although microbiological breakpoints are useful for monitoring the emergence of resistance, the current National Committee for Clinical Laboratory Standards (NCCLS) guidelines make no distinction between clinical and microbiological breakpoints. Recent changes in NCCLS breakpoints for extended spectrum cephalosporins have provided a more meaningful approach to susceptibility testing and to consideration of the site of infection. Further controversy surrounds the clinical guidelines relating to CAP in terms of which antimicrobial agents should be given empirically to which types of patients. Within this review, the role of monotherapy versus the need for combination antimicrobial therapy, which often includes a macrolide and an extended spectrum cephalosporin such as ceftriaxone, is discussed. This review also discusses the various aspects of antimicrobial susceptibilities of S. pneumoniae, the drivers and influences of increasing resistance, the clinical relevance of this resistance and possible therapeutic options in the face of changing susceptibilities and mixed bacterial aetiologies. New guidelines from the IDSA attempt to embrace these changes.

Brain natriuretic peptide: is it a predictor of cardiomyopathy in cirrhosis?

Subtle cardiac abnormalities have been described in patients with cirrhosis. Natriuretic peptide hormones have been reported to be sensitive markers of early cardiac disease. We postulate that plasma levels of N-terminal pro-atrial natriuretic peptide and brain natriuretic peptide could be used as markers of cardiac dysfunction in cirrhosis. The aim of the study was to evaluate the levels of N-terminal pro-atrial natriuretic peptide and brain natriuretic peptide and their relationship with cardiac structure and function in patients with cirrhosis. The study population comprised 36 patients with cirrhosis of mixed aetiologies, but with no cardiac symptoms; 19 of the patients had ascites and 17 did not. The subjects underwent (i) trans-thoracic two-dimensional echocardiography, and (ii) radionuclide angiography for measurements of cardiac structural parameters, diastolic and systolic function. Levels of N-terminal pro-atrial natriuretic peptide and brain natriuretic peptide were also measured. The results were compared with those from eight age- and sex-matched healthy volunteers. Compared with the controls, the baseline mean ejection fraction was increased significantly in both patient groups (P=0.02), together with prolonged deceleration times (P=0.03), left atrial enlargement (P=0.03) and interventricular septal thickening (P=0.02), findings that are compatible with diastolic dysfunction. Levels of N-terminal pro-atrial natriuretic peptide and brain natriuretic peptide were significantly higher in all patients with cirrhosis with ascites (P=0.01 and P=0.05 respectively), but in only some of the pre-ascitic cirrhotic patients, compared with controls. All high levels of brain natriuretic peptide were correlated significantly with septal thickness (P<0.01), left ventricular diameter at the end of diastole (P=0.02) and deceleration time (P<0.01). We conclude that elevated levels of brain natriuretic peptide are related to interventricular septal thickness and the impairment of diastolic function in asymptomatic patients with cirrhosis. Levels of brain natriuretic peptide may prove to be useful as a marker for screening patients with cirrhosis for the presence of cirrhotic cardiomyopathy, and thereby identifying such patients for further investigations.

Breakthrough Cancer Pain

Breakthrough pain is the relatively new term applied to describe acute episodes of severe pain superimposed upon a background of otherwise well controlled chronic pain. Surveys of patients with cancer who have pain suggest that breakthrough pain is very common, affecting the majority of patients several times a day on average. The cause of breakthrough pain is tumour related in most cases, and is fairly evenly distributed among somatic, visceral, neuropathic and mixed aetiologies. Not unexpectedly, the incidence and prevalence of breakthrough pain increase with advancing disease. About half of all breakthrough pain episodes are attributable to a specific inciting event or activity, and so these types of pains have been categorised as incident pain. Another subcategory of breakthrough pain is end-of-dose failure, caused by pain that ‘breaks through’ around-the-clock medication because of declining blood concentrations of analgesic near the end of the administration interval. The remainder of breakthrough pain episodes, classified as spontaneous pain, are unpredictable in occurrence.

Natural history of recurrent erosion syndrome—a 4 year review of 117 patients

AIMS/BACKGROUNDRecurrent erosion syndrome encompasses a group of mixed aetiologies for which there are a number of methods of management which may influence the course of the disease.METHODSThe outcomes of a...

Clinical Experience with Cefadroxil in Upper and Lower Respiratory Tract Infections

Cefadroxil is a new semisynthetic oral cephalosporin with a broad spectrum of activity against both Gram-positive and Gram-negative organisms. Absorption of cefadroxil is unaffected by food, its serum levels are prolonged and it is excreted in the urine at a relatively slow rate compared to cephalexin. In the treatment of 108 patient with upper or lower respiratory tract infections, cefadroxil effected 93% complete cures. Fifty-five of the patients had upper respiratory tract infections and fifty-three had lower respiratory tract infections; among them cefadroxil acheived clinical success rates of 100% and 96%, respectively. Cefadroxil was clinically successful in eight (89%) out of nine patients whose infections were caused by mixed aetiologies. The principal causative agents were Staphylococcus aureus, beta-haemolytic streptococci, Streptococcus pneumoniae and Klebsiella pneumoniae. Overall bacterial eradication produced by cefadroxil was 112 (91%) of 123 organisms isolated from 108 patients. Reports of mild and transient side-effects in only 3.7% of the patients showed that the drug was well tolerated.