Prevalence of significant liver disease in human immunodeficiency virus-infected patients exposed to Didanosine: A cross sectional study

AIM: To identify significant liver disease [including nodular regenerative hyperplasia (NRH)] in asymptomatic Didanosine (DDI) exposed human immunodeficiency virus (HIV) positive patients. METHODS: Patients without known liver disease and with > 6 mo previous DDI use had liver stiffness assessed by transient elastography (TE). Those with alanine transaminase (ALT) above upper limit normal and/or TE > 7.65 kPa underwent ultrasound scan (U/S). Patients with: (1) abnormal U/S; or (2) elevated ALT plus TE > 7.65 kPa; or (3) TE > 9.4 kPa were offered trans-jugular liver biopsy (TJLB) with hepatic venous pressure gradient (HVPG) assessment. RESULTS: Ninety-nine patients were recruited, median age 50 years (range 31-70), 81% male and 70% men who have sex with men. Ninety-five percent with VL 9.4 kPa. Seventeen (17%) met criteria for TJLB, of whom 12 accepted. All had HVPG < 6 mmHg. Commonest histological findings were steatosis (n = 6), normal architecture (n = 4) and NRH (n = 2), giving a prevalence of previously undiagnosed NRH of 2% (95%CI: 0.55%, 7.0%). CONCLUSION: A screening strategy based on TE, liver enzymes and U/S scan found a low prevalence of previously undiagnosed NRH in DDI exposed, asymptomatic HIV positive patients. Patients were more likely to have steatosis highlighting the increased risk of multifactorial liver disease in this population

Twin pregnancy in a liver transplant recipient with HIV infection

We are not aware of a report detailing the complex obstetrical and medical management of twin pregnancy in the context of HIV infection and early post-liver transplantation period. Here we describe the successful outcome of a twin pregnancy in a 28-year-old HIV-positive female receiving antiretroviral therapy and immunosuppressive therapy who was the recipient of a liver transplant for previous drug-induced liver failure

Endoscopy management algorithms: role of cyanoacrylate glue injection and self-expanding metal stents in acute variceal haemorrhage

Mortality from acute variceal bleeding (AVB) has improved markedly over the last 2–3 decades due to increased specialisation and standardisation of medical and endoscopic practice culminating in the production of consensus guidance based on expert opinion. Nonetheless, despite greater exposure, training and endoscopic practices, 30-day mortality still remains high at around 30%. This is a reflection of the high morbidity with liver disease, and limited endoscopic experience and/or endoscopic techniques used by the majority of general endoscopists. Clinical necessity defines our drive for further endoscopic innovation to improve ‘best practice’ and, therefore, clinical outcomes accordingly. Sclerotherpy, variceal band ligation and/or rescue balloon tamponade have been entrenched in most treatment algorithms over the decades. However, in recent years and albeit limited to specialised liver centres, cyanoacrylate glue injection therapy (for oesophageal and gastric varices), and the placement of a self-expanding metallic stent for oesophageal varices have begun to offer improved endoscopic care in experienced hands. Yet even in specialised centres, their application is sporadic and operator dependent. Here, we discuss the evidence of these newer endoscopic approaches, and hope to propose their inclusion in endoscopic therapy algorithms for ‘best practice’ management of AVB in all appropriately supported endoscopy units

Albuterol metered dose inhaler performance under hyperbaric pressures

Comparative Medicine - OneHealth and Comparative Medicine Poster SessionINTRODUCTION: The stimulus for this presentation was an asthma attack suffered on the first dive by a victim of a severe industrial electrical burn. The patient's response to albuterol metered dose inhaler (MDI) treatment given at depth was felt to have been poor. We thus wondered what the output of these devises (chlorofluorocarbon or CFC) was at therapeutic depth versus normobaria. As the current MDIs were being phased out of use we also wondered what the comparable output characteristics of the replacement MDIs (hydrofluoroalkane or HFA) would be. MATERIALS AND METHODS: The dose and aerosol particle size and number delivered by MDIs were measured in a hyperbaric chamber at pressures ranging from one atmosphere absolute (1 ATA, 0 feet of seawater, fsw, 101 kPa) to three ATA (66 fsw, 304 kPa). Mass delivered was measured by a Sartorius B120 analytical balance, and particle size analysis by a TSI 3080L electrostatic classifier with a TSI 3776 ultrafine condensation particle counter. RESULTS: Dose delivery per actuation by CFC and long canister HFA powered MDIs was 13±1% and 12±1% less, respectively, at 3 ATA compared to 1 ATA. However, dose delivery by short canister HFA MDIs was not significantly changed with pressure. The geometric mean diameters of nano particles from the CFC and short canister HFA MDIs decreased from 50 nm at 0 fsw to 32 nm at 66 fsw whereas the long canister HFA aerosol diameters were not affected. The numbers of nanometer size particles delivered at 66 fsw were only 4-7% of those delivered at 0 fsw for the CFC and long canister HFA MDIs; whereas for the short canister HFAs it was 26%. CONCLUSIONS: The doses of albuterol and the sizes and numbers of aerosol particles emitted from albuterol MDIs actuated in a hyperbaric environment vary by canister type; CFC MDI loss is probably unimportant

Review article: the role of the microcirculation in liver cirrhosis

BACKGROUND: Intrahepatic microvascular derangements and microcirculatory dysfunction are key in the development of liver cirrhosis and its associated complications. While much has been documented relating to cirrhosis and the dysfunction of the microcirculation in the liver parenchyma, far less is known about the state of the extrahepatic microcirculation and the role this may have in the pathogenesis of multiple organ failure in end stage liver cirrhosis. AIM: To provide an update on the role of the microcirculation in the pathophysiology of cirrhosis and its associated complications and briefly discuss some of the imaging techniques which may be used to directly investigate the microcirculation. METHODS: A Medline literature search was conducted using the following search terms: ‘cirrhosis’, ‘microcirculation’, ‘circulation’, ‘systemic’, ‘inflammation’, ‘peripheral’, ‘hepatorenal’ and ‘hepatopulmonary’. RESULTS: Significant heterogeneous microvascular alterations exist in patients with cirrhosis. Data suggest that the systemic inflammation, associated with advanced cirrhosis, induces microcirculatory dysregulation and contributes to haemodynamic derangement. The resultant vasoconstriction and hypoperfusion in the systemic extrahepatic microvasculature, is likely to be instrumental in the pathophysiology of organ failure in decompensated cirrhosis, however the mechanistic action of vasoactive agents used to correct the circulatory disturbance of advanced cirrhosis is poorly understood. CONCLUSIONS: Further research into the role of the microcirculation in patients with liver cirrhosis, will improve physicians understanding of the pathophysiology of cirrhosis, and may provide a platform for real time evaluation of an individual's microcirculatory response to vasoactive mediators, thus guiding their therapy

The accuracy of respiratory rate assessment by doctors in a London teaching hospital: a cross-sectional study

Respiratory rate (RR) is one of the most sensitive markers of a patient condition and a core aspect of multiple clinical assessment tools. Doctors use a number of methods to assess RR, including formal measurement, and 'spot' assessments, although this is not recommended. This study aimed to assess the accuracy of the methods of RR measurement being used by doctors. A cross-sectional study assessing the accuracy (range, bias, and imprecision) of doctors' 'spot' and 'formal' respiratory rate assessments, using videos of mock patients. 54 doctors in a London teaching hospital participated. Both methods showed high levels of inaccuracy, though formal methods were more accurate than 'spot' assessments. 52 and 19 % of doctors did not identify the respiratory rates shown as abnormal, using 'spot' and formal assessment methods respectively. We observed a trend towards decreasing accuracy of 'spot' assessments with increasing clinical experience (p = 0.0490). Current methods of RR assessment by doctors are inaccurate. This may be significantly delaying appropriate clinical care, or even misguiding treatment

Validation of the Baveno Vi Criteria to Identify Low Risk Cirrhotic Patients not Requiring Endoscopic Surveillance for Varices

BACKGROUND: The Baveno VI guidelines propose that cirrhotic patients with a liver stiffness measurement (LSM) 150000/μL can avoid screening endoscopy as their combination is highly specific for excluding clinically significant varices. The aim of the study was to validate these criteria. METHODS: Transient elastography data was collected from two institutions from 2006-2015. Inclusion criteria were a LSM ⩾10kPa and an upper gastrointestinal endoscopy within 12 months, with a diagnosis of compensated chronic liver disease. Exclusion criteria were porto-mesenteric-splenic vein thrombosis and non-cirrhotic portal hypertension. Varices were graded as low risk (grade 150) are at low risk of having varices and do not need a screening endoscopy. Varices are a complication of cirrhosis, confer a risk of serious bleeding, and can be diagnosed and treated by endoscopy. Our study reviewed the clinical records of patients who have had liver stiffness scans and endoscopy over a 9 year period at two hospitals. The results show that only about 2% of patients who meet the Baveno VI criteria will be miss classified as not having varices

Neurogenic diabetes insipidus presenting in a patient with subacute liver failure: a case report

<p>Abstract</p> <p>Introduction</p> <p>To the best of our knowledge, this is the first report in the literature of development of neurogenic diabetes insipidus in a patient with subacute liver failure.</p> <p>Case presentation</p> <p>A 25-year-old man presented with subacute liver failure. While awaiting a liver transplant, the patient developed cerebral edema, which resulted in neurogenic diabetes insipidus secondary to cerebral edema. The patient died before the liver transplantation could be carried out.</p> <p>Conclusion</p> <p>Neurogenic diabetes insipidus is well recognized in the neurosurgical population as a consequence of cerebral edema and increased intracranial pressure, both of which occur commonly in patients with subacute liver failure.</p

Structure and assembly of the S-layer determine virulence in C. difficile

Many bacteria and archaea possess a cell surface layer – S-layer – made of a 2D protein array that covers the entire cell. As the outermost component of the cell envelope, S-layers play crucial roles in many aspects of cell physiology. Importantly, many clinically relevant bacterial pathogens possess a distinct S-layer that forms an initial interface with the host, making it a potential target for development of species-specific antimicrobials. Targeted therapeutics are particularly important for antibiotic resistant pathogens such as Clostridioides difficile, the most frequent cause of hospital acquired diarrhea, which relies on disruption of normal microbiota through antibiotic usage. Despite the ubiquity of S-layers, only partial structural information from a very limited number of species is available and their function and organization remains poorly understood. Here we report the first complete atomic level structure and in situ assembly model of an S-layer from a bacterial pathogen and reveal its role in disease severity. SlpA, the main C. difficile S-layer protein, assembles through tiling of triangular prisms abutting the cell wall, interlocked by distinct ridges facing the environment. This forms a tightly packed array, unlike the more porous S-layer models previously described. We report that removing one of the SlpA ridge features dramatically reduces disease severity, despite being dispensable for overall SlpA structure and S-layer assembly. Remarkably, the effect on disease severity is independent of toxin production and bacterial colonization within the mouse model of disease. Our work combines X-ray and electron crystallography to reveal a novel S-layer organization in atomic detail, highlighting the need for multiple technical approaches to obtain structural information on these paracrystalline arrays. These data also establish a direct link between specific structural elements of S-layer and virulence for the first time, in a crucial paradigm shift in our understanding of C. difficile disease, currently largely attributed to the action of potent toxins. This work highlights the crucial role of S-layers in pathogenicity and the importance of detailed structural information for providing new therapeutic avenues, targeting the S-layer. Understanding the interplay between S-layer and other virulence factors will further enhance our ability to tackle pathogens carrying an S-layer. We anticipate that this work provides a solid basis for development of new, C. difficile-specific therapeutics, targeting SlpA structure and S-layer assembly to reduce the healthcare burden of these infections.