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Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper.
No full textThe coronavirus disease 2019 (COVID-19) pandemic poses an enormous challenge to healthcare systems in affected communities. Older patients and those with pre-existing medical conditions have been identified as populations at risk of a severe disease course. It remains unclear at this point to what extent chronic liver diseases should be considered as risk factors, due to a shortage of appropriate studies. However, patients with advanced liver disease and those after liver transplantation represent vulnerable patient cohorts with an increased risk of infection and/or a severe course of COVID-19. In addition, the current pandemic requires unusual allocation of healthcare resources which may negatively impact the care of patients with chronic liver disease that continue to require medical attention. Thus, the challenge hepatologists are facing is to promote telemedicine in the outpatient setting, prioritise outpatient contacts, avoid nosocomial dissemination of the virus to patients and healthcare providers, and at the same time maintain standard care for patients who require immediate medical attention
Should All Men with Type 2 Diabetes Be Routinely Prescribed a Phosphodiesterase Type 5 Inhibitor?
No full textImportant health problems in men such as type 2 diabetes (T2DM), insulin resistance, erectile dysfunction, benign prostatic hyperplasia and depression have been shown to have to share common pathological processes, such as endothelial dysfunction and inflammation. This paper discusses the role of phosphodiesterase type 5 (PDE5) inhibitors, through beneficial effects on endothelial function and mediators of chronic inflammation and the possibility to treat or preventing these common conditions. We explore possible barriers to this approach, namely the lack of multiple product licences to treat each of these conditions and how these can be overcome by involving the patient in personalised decisions. We also discuss how opportunities are lost by patients with multiple medical conditions being referred to specialists, primarily interested in one specific problem, with little motivation to treat or prevent conditions outside their remit. We explore how these problems might be related to time and financial restraints or simply a lack of awareness of evidence published in journals related to other specialities. As specialists, we often pride ourselves on providing "personalised" or "patient centred" care, but we can only truly be doing so if we assess the specific needs of the patient across a range of conditions. As part of personalised care in T2DM, we routinely prescribe statins, angiotensin converting enzyme inhibitors and metformin, often with poor compliance. In this paper we explore whether the licensed daily PDE5 inhibitor tadalafil should be added routinely to this list as it will potentially improve and prevent bothersome symptoms and improve compliance with other medications
The Pathophysiology of Type 2 Diabetes Mellitus in Non-obese Individuals: An Overview of the Current Understanding.
No full textThe pandemic of type 2 diabetes mellitus (T2DM) has been largely attributed to the increasing prevalence of worldwide obesity at a geometric rate. However, the number of non-obese patients with T2DM is also on the rise, and it is as high as 60-80% in some Asian countries. These non-obese individuals have certain peculiarities and have a higher mortality rate compared with obese individuals. The pathophysiology of T2DM in non-obese individuals remains poorly understood, and this has an impact on defining its management. This review discusses the current understanding of the pathophysiology of T2DM in non-obese individuals. The definition of T2DM in non-obese individuals remains controversial because of the limited clinical measurements, and the current definition of obesity using body mass index (BMI) is not very helpful as these individuals have BMIs of <25K g/m3, which is considered normal. Many authors have argued that the so-called non-obese people are actually metabolically obese; however, in terms of the measurements clinically available, they are non-obese. The simplistic understanding of the mechanism of the pathophysiology sees it in terms of the balance between insulin secretion and insulin resistance. The pathogenesis of insulin resistance in a lean patient has been proven to be the same as what is seen in an obese individual, but most studies confirm more severe functional insulin secretory defects in lean individuals compared to the obese phenotype. The mechanism underlying this form of T2DM is still poorly defined, and more research is required to understand the mechanism of sarcopenic obesity, which some studies have revealed
Fecal Calprotectin Thresholds to Predict Endoscopic Remission Using Advanced Optical Enhancement Techniques and Histological Remission in IBD Patients.
No full textBACKGROUND
Fecal calprotectin (FC) is a common surrogate marker of mucosal healing (MH) in patients with ulcerative colitis (UC) and Crohn's disease (CD). We investigated the optimum FC thresholds for defining endoscopic remission (ER) and histological remission (HR) using advanced endoscopic techniques.
PATIENTS AND METHODS
In this cross-sectional study, we collected clinical, endoscopic, histological data, and FC from 76 UC and 41 CD patients. Receiver operating characteristic curves were created to evaluate the optimum cut-off of FC to predict ER evaluated by Mayo Endoscopic Score (MES), Ulcerative Colitis Endoscopic Index of Severity (UCEIS), and modified PICaSSO (Paddington International Virtual Chromoendoscopy Score) for UC patients and Simple Endoscopic Score (SES-CD) in CD patients; and HR was scored by the Robarts Histology Index (RHI) and Nancy Index for UC and modified Riley for CD.
RESULTS
In UC patients, the best thresholds of FC to identify ER calculated with MES, UCEIS, and modified PICaSSO were 112, 148, and 161 mcg/g with accuracy of 86.9% 86.8%, and 81.6%, respectively. The best value of FC to predict HR was 112 mcg/g and 172 mcg/g with accuracy of 84.2% and 81.6% for RHI and Nancy Index, respectively.In CD patients, the best cut-off of FC to predict ER was 96 mcg/g with accuracy of 82.9%. The HR was best predicted by an FC value of 225 mcg/g with accuracy of 75.6%.
CONCLUSIONS
The FC value threshold between 112 and 172 mcg/g could identify ER and HR in UC patients, whereas a value under 225 mcg/g should be considered for CD patients
Local anaesthesia for office hysteroscopy: A systematic review & meta-analysis.
No full textOBJECTIVE
To compare the effects of different types and routes of administration of local anaesthetic for pain control during and after office hysteroscopy.
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METHODS
Medline, Embase, CINAHL and the Cochrane library were searched from inception until October 2019, in order to perform a systematic review and meta-analysis of all randomised controlled trials investigating the use of a local anaesthetic compared to a control, for pain relief in women undergoing diagnostic or operative office hysteroscopy. Average pain scores and data regarding side-effects, feasibility, complications, acceptability and satisfaction were collected.
RESULTS
The literature search yielded 612 citations. A total of 37 studies were included for systematic review, of which data from 20 studies were used for meta-analysis. Local anaesthesia was associated with significantly reduced pain during (SMD -0.57, 95 % CI -0.79 to -0.34) and after (SMD -0.30, 95 % CI -0.54 to -0.06) office hysteroscopy but did not reduce vasovagal episodes (OR 0.73, 95 % CI 0.50-1.09). A reduction in intra-procedural pain was observed regardless of type or route of administration. Local anaesthesia did not significantly reduce the risk of procedural failure (OR 0.72, 95 % CI 0.47-1.11). Insufficient data regarding complications, acceptability and satisfaction were available for meta-analysis.
CONCLUSION
Local anaesthesia via any route of genital tract administration, should be considered when undertaking office diagnostic or operative hysteroscopy to reduce pain during and after the procedure. Further research is needed to understand whether the pain control benefits of local anaesthesia remain apparent with vaginoscopic approaches to office hysteroscopy that avoid genital tract instrumentation
Improved outcomes with allogeneic compared with autologous stem cell transplantation in aggressive T-cell lymphoma.
No full textPeripheral T-cell lymphomas (PTCL) are a rare and aggressive subtype of non-Hodgkin lymphoma (NHL), comprising up to 10% of all newly diagnosed NHL in the UK. The use of hematopoietic stem cell transplantation (SCT) to improve survival is has gained recognition in the up-front and relapsed setting, although evidence is limited for patients with refractory disease
The predictive applicability of liberal versus restrictive intubation criteria in adult patients with suspected inhalation injury - a retrospective cohort study.
No full textBACKGROUND
This study compares the ability of liberal vs. restrictive intubation criteria to detect prolonged intubation and inhalation injury in burns patients with suspected inhalation injury. Emerging evidence suggests that using liberal criteria may lead to unnecessary intubation in some patients.
METHODS
A single-center retrospective cohort study was conducted in adult patients with suspected inhalation injury admitted to intensive care at Queen Elizabeth Hospital, Birmingham between April 2016 and July 2019. Liberal intubation criteria, as reflected in local guidelines, were compared to restrictive intubation criteria, as outlined in the American Burn Association guidelines. The number of patients displaying positive characteristics from either guideline was compared to the number of patients that had a prolonged intubation (more than 48 hours) and inhalation injury.
RESULTS
In detecting a need for prolonged intubation (n=85), the liberal criteria had greater sensitivity (liberal=0.98 [0.94-1.00] vs restrictive=0.84 [0.75-0.93]; p=0.013). However, the restrictive criteria had greater specificity (restrictive=0.96 [0.89-1.00] vs liberal=0.48 [0.29-0.67]; p<0.001). In detecting inhalation injury (n=72), the restrictive criteria were equally sensitive (restrictive=0.94 [0.87-1.00] vs liberal=0.98 [0.84-1.00]; p=0.48) and had greater specificity [restrictive=0.86 [0.72-1.00] vs. liberal=0.04 [0.00-0.13]; p<0.001). In patients who met liberal but not restrictive criteria, 65% were extubated within 48 hours and 90% did not have inhalation injury.
CONCLUSION
Liberal intubation criteria were more sensitive at detecting a need for prolonged intubation, whilst restrictive criteria were more specific. Most patients intubated based on liberal criteria alone were extubated within 48 hours. Restrictive criteria were highly sensitive and specific at detecting inhalation injury
European Resuscitation Council COVID-19 Guidelines Executive Summary.
No full textThese coronavirus disease 2019 (COVID-19) guidelines focus specifically on patients with suspected or confirmed COVID-19. For resuscitation of those who are low risk or confirmed negative for COVID-19, the reader is directed to the standard resuscitation guidelines for adults and children. Where uncertainty exists treatment should be informed by a dynamic risk assessment which may consider current COVID-19 prevalence, the patient's presentation (e.g. history of COVID-19 contact, COVID-19 symptoms), likelihood that treatment will be effective, availability of personal protective equipment (PPE) and personal risks for those providing treatment. These guidelines will be subject to evolving knowledge and experience of COVID-19. As countries are at different stages of the pandemic, there may some international variation in practice
Pediatric Allergic Diseases in the Indian Subcontinent -Epidemiology, Risk Factors and Current Challenges.
No full textINTRODUCTION
India is low middle-income country (LMIC) with a population of 1.3bn, comprising about 20% of the global population. Whilst the high-income western countries faced an 'allergy epidemic' during the last three decades, there has been a gradual rise in prevalence of allergic diseases in India.
METHODS
Narrative review RESULTS AND DISCUSSION: Allergic diseases occur as a consequence of a complex interplay between genetic and environmental factors. There are multiple contrasting determinants that are important to consider in India including high levels of air pollution, in particular PM due to burning of fossil fuels and biomass fuels, diverse aero-biology, tropical climate, cultural and social diversity, religious beliefs/myths, linguistic diversity, literacy level, breastfeeding and weaning, diet (large proportion vegetarian), high incidence rates of TB, HIV, malaria, filariasis, parasitic infestations and others, that not only shape the immune system early in life, but also impact on biomarkers relevant to allergic diseases. India has a relatively weak and heterogeneous healthcare framework and allergology has not yet been recognized as an independent speciality. There are very few postgraduate training programmes and allergic diseases are managed by primary care physicians, organ-based specialists and general pediatricians. Adrenaline auto-injectors are not available, there is patient unaffordability for inhalers, nasal sprays and biologics and this is compounded by poor compliance leading to 40-50% of asthmatic children having uncontrolled disease and high rates of oral corticosteroid use. Standardised allergen extracts are not available for skin tests and desensitization