T. M. Rahman

Chronic Liver Disease—An Increasing Problem: A Study of Hospital Admission and Mortality Rates in England, 1979–2005, with Particular Reference to Alcoholic Liver Disease

AIMS To determine time trends in hospital admissions for chronic liver disease in England between 1989/1990 and 2002/2003, mortality rates in England and Wales between 1979 and 2005, and the influence of alcohol-related disease on these trends. METHODS Hospital episode statistics for admissions in England were obtained from the Information Center for Health and Social Care and mortality data for England and Wales from the Office for National Statistics. RESULTS Hospital admission rates for chronic liver disease increased by 71% in males and 43% in females over the study period. This increase was largely due to alcoholic liver disease, admission rates for which more than doubled between 1989/1990 and 2002/2003. While there was a smaller rise for chronic viral hepatitis B and C, admission rates declined for hepatitis A, autoimmune hepatitis, and primary biliary cirrhosis. Mortality rates for chronic liver disease more than doubled between 1979 and 2005. Two thirds of these deaths were attributable to alcohol-related liver disease in 2005. The highest rate of alcoholic liver disease mortality was in the 45-64 age group, and the largest percentage increase between 1979 and 2005 occurred in the 25-34 age group. CONCLUSIONS Hospital admissions and mortality in England from chronic liver disease are increasing. The underlying reasons are complex, but alcohol-induced liver disease makes a major contribution. There are clear social and health implications if the trend continues and addressing alcohol-related liver disease should be a public health priority.

Outcomes of critically ill patients with cirrhosis admitted to intensive care: an important perspective from the non-transplant setting.

Aliment Pharmacol Ther 2010; 32: 233–243

Clostridium difficile infection and inflammatory bowel disease

Abstract The importance of Clostridium difficile (C. difficile) infection amongst patients with inflammatory bowel disease (IBD) is increasingly being recognized. Recent studies have demonstrated a concerning trend towards increased rates of infection, morbidity, mortality and health costs, and guidelines now promote testing for C. difficile in IBD patients experiencing a relapse. This critical review focuses on the epidemiology, risk factors, pathogenesis, treatment options and outcomes associated with C. difficile infection in patients with IBD.

Clostridium difficile-Associated Disease Acquired in the Cardiothoracic Intensive Care Unit

OBJECTIVES To determine the prevalence, severity, and outcome associated with Clostridium difficile-associated disease (CDAD) acquired while in the cardiothoracic intensive care unit (CTICU). DESIGN A 5-year retrospective study. SETTING The CTICU. PARTICIPANTS All CTICU patients with a positive C difficile stool toxin assay 48 hours after admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The results of all CTICU patients with a positive C difficile stool toxin assay were obtained from the Microbiology Department. Each patients medical notes and charts then were reviewed in turn. A total of 27 of 5,199 (0.5%) CTICU patients acquired CDAD. The median age was 74 years (IQR 68-77), and 17 (63%) patients were male. There were 21 (78%) surgical patients; 13 (62%) were elective admissions. The most frequent diagnosis on admission was valvular heart disease (10 [37%] patients). Sixteen (59%) patients underwent coronary artery bypass graft (CABG) surgery and/or valvular heart surgery. The median interval between CTICU admission and CDAD diagnosis was 10 days (IQR 5-18). Previously identified risk factors for ICU-acquired CDAD included age >65 years (23), antibiotic use (26), and medical device requirements (27). At the time of diagnosis, 14 (52%) patients had moderate CDAD. After treatment initiation, 8 (30%) patients developed worsening CDAD. The 30-day in-hospital mortality rate for CTICU-acquired CDAD was 26% (7 patients). CONCLUSIONS C difficile-associated disease rarely is acquired in the CTICU. Approximately one third of patients may experience disease progression, and just over a quarter may die within 30 days of diagnosis. The implementation of recommended severity definitions and treatment algorithms may reduce complication rates and merits prospective evaluation.

Review article: towards a considered and ethical approach to organ support in critically-ill patients with cirrhosis

Increasing numbers of patients are being admitted to hospital with decompensated chronic liver disease in the UK. A significant proportion will develop complicating extra‐hepatic organ dysfunction, but the selection of those who should be admitted to intensive care is complex and challenging. Alcohol‐related liver disease also presents complex ethical dilemmas.

A study of muscle tissue oxygenation and peripheral microcirculatory dysfunction in cirrhosis using near infrared spectroscopy.

Background: The circulatory dysfunction associated with cirrhosis is well described. Reduced systemic vascular resistance and high cardiac output are the main features of the hyperdynamic state, but involvement of the peripheral microcirculation in this process is poorly understood. Near infrared spectroscopy (NIRS) has been used to assess muscle tissue oxygenation (StO2) in haemorrhagic and septic shock. Vascular occlusion testing (VOT) can produce dynamic changes in StO2 which represent tissue oxygen extraction, delivery, and hence, surrogate markers of microvascular function.

Proteomic approaches in the search for biomarkers of liver fibrosis

Chronic liver diseases (CLDs) can cause progressive hepatic fibrosis culminating in cirrhosis. Fibrosis staging requires liver biopsy, which is invasive, expensive and frequently poorly tolerated by patients. Serum-based panels of fibrosis biomarkers have been developed as alternatives to biopsy. Recent advances in high-throughput proteomic methods have the potential to optimise combinations of biomarkers for the diagnosis of liver fibrosis. Here, we review the key recent developments in the field of proteomics and their application to this important clinical question. We critically discuss the challenges and priorities for future research that are of critical importance to clinical hepatology.

Urine output on an intensive care unit: case-control study

Objective To compare urine output between junior doctors in an intensive care unit and the patients for whom they are responsible. Design Case-control study. Setting General intensive care unit in a tertiary referral hospital. Participants 18 junior doctors responsible for clerking patients on weekday day shifts in the unit from 23 March to 23 April 2009 volunteered as “cases.” Controls were the patients in the unit clerked by those doctors. Exclusion criteria (for both groups) were pregnancy, baseline estimated glomerular filtration rate <15 ml/min/1.73 m2, and renal replacement therapy. Main outcome measures Oliguria (defined as mean urine output <0.5 ml/kg/hour over six or more hours of measurement) and urine output (in ml/kg/hour) as a continuous variable. Results Doctors were classed as oliguric and “at risk” of acute kidney injury on 19 (22%) of 87 shifts in which urine output was measured, and oliguric to the point of being “in injury” on one (1%) further shift. Data were available for 208 of 209 controls matched to cases in the data collection period; 13 of these were excluded because the control was receiving renal replacement therapy. Doctors were more likely to be oliguric than their patients (odds ratio 1.99, 95% confidence interval 1.08 to 3.68, P=0.03). For each additional 1 ml/kg/hour mean urine output, the odds ratio for being a case rather than a control was 0.27 (0.12 to 0.58, P=0.001). Mortality among doctors was astonishingly low, at 0% (0% to 18%). Conclusions Managing our own fluid balance is more difficult than managing it in our patients. We should drink more water. Modifications to the criteria for acute kidney injury could be needed for the assessment of junior doctors in an intensive care unit.

Seasonal variability and meteorological factors: retrospective study of the incidence of pulmonary embolism from a large United kingdom teaching hospital.

BACKGROUND: Seasonal variations in the incidence of pulmonary embolism (PE) have been reported. It has been suggested that changes in meteorological factors may explain this variation. Previous studies have provided inconsistent results, possibly as a result of a small number of observations, in some studies and confounding factors. OBJECTIVE: To investigate whether there is a seasonal variation in the incidence of idiopathic PE and to investigate its relationship with atmospheric pressure, humidity, and temperature. METHODS: A large retrospective study was conducted. All confirmed cases of PE at our institution over a 9-year period were included, except for those patients with a major risk factor for PE. Meteorological data were obtained from a local weather station. Days when there was at least one episode of PE (event day) were compared with days when there were no episodes of PE (non-event day). RESULTS: There were a total of 640 episodes of PE. There was a statistically significant lower percentage of event days in spring (13.8%), compared with the rest of the year (18.3%) (P = .003). The incidence of PE was related to decreased atmospheric pressure and increased temperature. For atmospheric pressure the relationship was most significant for the mean atmospheric pressure for the 2 days preceding clinical presentation with PE (P = .02). For temperature the relationship was most significant for the mean temperature for the 5 days preceding clinical presentation with PE (P = .04). CONCLUSIONS: The results confirm the presence of seasonal variations in episodes of idiopathic PE and an association between decreased atmospheric pressure and increased temperature.

Upper gastrointestinal haemorrhage in the acute cardiac care setting: antiplatelets and endoscopy

Upper gastrointestinal haemorrhage (UGIH) in cardiac patients receiving antiplatelets presents a difficult management problem. The aim of this study was to describe a series of cardiac inpatients receiving antiplatelets who underwent endoscopy for an acute UGIH. Cardiac inpatients receiving antiplatelets and requiring endoscopy for UGIH over an 18-month period were followed up. Forty-one patients were studied. Most patients (25 [61%]) presented with melaena. Antiplatelets were withheld in 34 (83%) patients; predominantly in those with higher pre-endoscopy Rockall scores (median, 4; interquartile range [IQR], 3–5 versus median, 3; IQR, 2–4; P < 0.05). Positive findings were identified at endoscopy in 80%. Duodenal ulcers were the most common lesion and adrenaline the most common method of haemostasis. Median time to first endoscopy was 0 (IQR, 0–1) days. Seven (17%) patients re-bled, median Rockall score was six (IQR, 4–8). Three (7%) patients experienced procedural complications, two patients became hypoxic and one patient died. Following endoscopy, antiplatelets were restarted after a median of three (IQR, 3–5) days. On discharge, 27/28 (96%) patients continued with antiplatelet and proton-pump inhibitor therapy. Thirty-day inpatient mortality was 7% (3 patients). One patient re-bled within six months of discharge. Endoscopy helped assess the risk of re-bleeding and timing of antiplatelet re-introduction in cardiac inpatients experiencing UGIH.