Predicting survival in patients with 'non-high-risk' acute variceal bleeding receiving β-blockers+ligation to prevent re-bleeding

BACKGROUND & AIMS

Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice for high-risk acute variceal bleeding (AVB; i.e., Child-Turcotte-Pugh [CTP] B8-9+active bleeding/C10-13). Nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation for secondary prophylaxis. We investigated prognostic factors for re-bleeding and mortality in 'non-high-risk' AVB to identify subgroups who may benefit from more potent treatments (i.e., TIPS) to prevent further decompensation and mortality.

METHODS

A total of 2,225 adults with cirrhosis and variceal bleeding were prospectively recruited at 34 centres between 2011-2015; for the purpose of this study, case definitions and information on prognostic indicators at index AVB and on day 5 were further refined in low-risk patients, of whom 581 (without failure to control bleeding or contraindications to TIPS) who were managed by non-selective beta-blockers/endoscopic variceal ligation, were finally included. Patients were followed for 1 year.

RESULTS

Overall, 90 patients (15%) re-bled and 70 (12%) patients died during follow-up. Using clinical routine data, no meaningful predictors of re-bleeding were identified. However, re-bleeding (included as a time-dependent co-variable) increased mortality, even after accounting for differences in patient characteristics (adjusted cause-specific hazard ratio: 2.57; 95% CI 1.43-4.62; p = 0.002). A nomogram including CTP, creatinine, and sodium measured at baseline accurately (concordance: 0.752) stratified the risk of death.

CONCLUSION

The majority of 'non-high-risk' patients with AVB have an excellent prognosis, if treated according to current recommendations. However, about one-fifth of patients, i.e. those with CTP ≥8 and/or high creatinine levels or hyponatremia, have a considerable risk of death within 1 year of the index bleed. Future clinical trials should investigate whether elective TIPS placement reduces mortality in these patients.

IMPACT AND IMPLICATIONS

Pre-emptive transjugular intrahepatic portosystemic shunt placement improves outcomes in high-risk acute variceal bleeding; nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation. This is the first large-scale study investigating prognostic factors for re-bleeding and mortality in 'non-high-risk' acute variceal bleeding. While no clinically meaningful predictors were identified for re-bleeding, we developed a nomogram integrating baseline Child-Turcotte-Pugh score, creatinine, and sodium to stratify mortality risk. Our study paves the way for future clinical trials evaluating whether elective transjugular intrahepatic portosystemic shunt placement improves outcomes in presumably 'non-high-risk' patients who are identified as being at increased risk of death.

Mild ast elevation as an early sign of COVID-19 severity in a multicenter Madrid cohort

INTRODUCTION

Liver enzyme elevation has been reported for SARS-CoV-2 disease (COVID-19) in heterogeneous cohorts, mainly from China. Comprehensive reports from other countries are needed. We dissect the pattern, evolution and predictive value of such abnormalities in a cohort from Madrid, Spain.

METHODS

Retrospective study with prospective 14-day follow-up of 373 patients with confirmed COVID-19 in five Madrid hospitals, including 50 outpatients. COVID-19 severe course was defined as need of mechanical ventilation.

RESULTS

A total of 33.1% hospitalised patients showed baseline AST elevation and 28.5% showed ALT elevation, contrasting with 12% and 8% of outpatients (P≤0.001). Baseline AST, ALT and GGT levels correlated with LDH and C-reactive protein levels (CRP) (r≤0.598, P<0.005). AST elevation was associated with other severity markers such as male sex, lymphopenia and pneumonia on X-ray (P<0.05 all). ALP and Bilirubin levels were rarely increased. Patients with elevated baseline AST displayed progressive normalization of this enzyme and increase in ALT and GGT levels. Patients with normal baseline AST showed a flattened evolution pattern with levels in range. Patients with a severe course of COVID-19 showed more frequently elevated baseline AST than those with a milder evolution (54.2% vs. 25.4%, P<0.001). Age, AST and CRP were independent risk factors for a severe course of COVID-19.

CONCLUSION

Mild liver enzyme elevation is associated with COVID-19 severity. Baseline AST is an independent predictor of severe COVID-19 course, while it tends to normalize over time. ALT and GGT show late elevation.

Prevalence and outcome of portal thrombosis in a cohort of cirrhotic patients undergoing liver transplantation

INTRODUCTION

The prevalence of portal vein thrombosis (PVT) in patients that have undergone liver transplantation (LT) is 9.7% (SD 4.5). The aim of our study was to determine the prevalence, assess the factors that are associated with PVT and clarify their association with prognosis in patients with liver cirrhosis (LC) and LT.

AIMS AND METHODS

From 2005 to 2014, laboratory, radiological and surgical data were collected from patients with LC in our center who had undergone LT for the first time.

RESULTS

One hundred and ninety-one patients were included. The mean age was 55 (SD 9), 75.4% of patients were male and 48.7% had HCV. The Child-Pugh scores were A/B/C 41.9%/35.9%/25.5% and the MELD score was 15 (SD 6). Previous decompensations were: ascites (61.4%), hepatic encephalopathy (34.4%), variceal bleeding (25.4%), hepatocellular carcinoma (48.9%) and spontaneous bacterial peritonitis (SPB) (14.3%). The mean post-transplant follow-up was 42 months (0-113). PVT was diagnosed at LT in 18 patients (9.4%). Six patients were previously diagnosed using imaging tests (33.3%): 2 patients (11.1%) by DU and 4 patients (22.2%) by CT scan. All patients with PVT had DU in a mean time of 6 months before LT (0-44) and 90 patients (47.1%) had a CT scan in a median time of 6 months before LT (0-45). PVT was significantly related to the presence of SBP (33.3% vs 12.6%; p = 0.02) and lower levels of albumin (3.1g/dl vs 3.4g/dl; p = 0.05). MELD was higher in patients with PVT (16.6 vs 14.9; p = 0.3). There were no significant differences with regard to the need for transfusion of blood components. Moreover, the surgery time was similar in both groups. PVT correlated with a higher mortality in the first 30 days (8.8% vs 16.7%; p = 0.2).

CONCLUSION

Prior history of SBP and lower levels of albumin were identified as factors associated with PVT. The pre-transplant diagnosis rate is very low and the presence of PVT may have implications for short-term mortality.

Idiopathic portal hypertension regarding thiopurine treatment in patients with inflammatory bowel disease

INTRODUCTION

The possibility of developing idiopathic portal hypertension has been described with thiopurine treatment despite compromises the prognosis of these patients, the fact its true prevalence is unknown.

MATERIAL AND METHODS

A cross-sectional study was conducted in a cohort of inflammatory bowel disease (IBD) patients followed at our unit, to determine the prevalence of diagnosis of idiopathic portal hypertension (IPH) and its relationship with thiopurine treatment.

RESULTS

At the time of the analysis, 927/1,419 patients were under treatment with thiopurine drugs (65%). A total of 4 patients with IBD type Crohn's disease with idiopathic portal hypertension probably related to the thiopurine treatment were identified (incidence of 4.3 cases per 1,000). Seventy-five percent of patients started with signs or symptoms of portal hypertension. Only one patient was asymptomatic but the diagnosis of IPH because of isolated thrombocytopenia is suspected. However, note that all patients had thrombocytopenia previously. Abdominal ultrasound with fibroscan, hepatic vein catheterization and liver biopsy were performed on all of them as part of the etiology of portal hypertension. In the abdominal ultrasound, indirect portal hypertension data were observed in all patients (as splenomegaly) cirrhosis was also ruled out. The fibroscan data showed significant liver fibrosis (F2-F3).

CONCLUSION

Idiopathic portal hypertension following thiopurine treatment in IBD patients is a rare occurrence, but it must be borne in mind in the differential diagnosis for early diagnosis, especially in patients undergoing thiopurine treatment over a long period. The presence of thrombocytopenia is often the only predictor of its development in the preclinical stage.

[Acute infarction of the right ventricle. Physiopathology, treatment, and prognosis]

A revision of the pathophysiology clinical classification and treatment of the right ventricular infarction (RVI) is presented. For many years it was believed that right ventricular (RV) contraction was neither important nor crucial to the maintenance of systemic circulation. Although non-invasive studies have reported RV dilation and RV wall motion abnormalities in 50% of patients with inferior--posterior--left ventricular myocardial infarction, RV involvement leads to significant hemodynamic compromise in less than half of such cases. When RVI patients are identified, they should be classified in those without RV failure (Class A), those with RV failure (Class B) and those with shock (Class C). Concerning the role of reperfusion therapies, both therapies (TT or PCI) seem beneficial, because a trend in the reduction of mortality has been observed. A decrease in RV failure was noted in class B patients, and PCI appears to be the procedure of choice in class C patients, since it significantly reduced mortality.

[Prevalence of nosocomial infections in children: survey of 21 hospitals in Mexico]

OBJECTIVE

The purpose of this study was to determine the prevalence of nosocomial infections, associated risk factors, microbiology, use of antibiotics, and associated mortality among hospitalized children.

MATERIAL AND METHODS

A 1-day prevalence survey was conducted among 1,183 children hospitalized in a nationwide network of 21 public hospitals caring for children. To attain consistency between hospitals, CDC nosocomial infection definitions were used. Adjusted relative odds of bacteremia were estimated using logistic regression analysis.

RESULTS

The prevalence of nosocomial acquired infection was 9.8% (CI 95%, 8.1-11.6). The more prevalent infections were pneumonia (25%), sepsis/bacteremia (19%), and urinary tract infection (5%). The main microorganism isolated in blood cultures drown from patients with nosocomial infection was K. pneumoniae (31%). The prevalence of antibiotics use was 49% with substantial variation between hospitals (range 3-83%). Using logistic regression analysis, four factors were independently associated with the risk of nosocomial infection: central venous catheters (OR 3.3; CI 95% 1.0-5.9), total parenteral nutrition (OR 2.1; CI 95% 1.0-4.5) mechanical ventilation (OR 2.3; CI 95% 1.2-4.1), and low birth weight (OR 2.6; CI 95% 1.0-6.8). The overall mortality was 4.8%; however, patients with nosocomial infection had two times greater risk to die as compared to non-infected children (OR 2.6; CI 95% 1.3-5.1).

CONCLUSIONS

This rapid assessment survey using a standard methodology allows to document the prevalence of nosocomial infections in children. The results were used to develop targeted programs on central catheters and mechanical ventilation aimed to reduce bacteremia/sepsis and pneumonia, two nosocomial infections characterized by high prevalence and mortality.

[The utility of rapid qualitative determination of troponin T, the MB fraction of creatine phosphokinase and myoglobin in acute ischemic coronary syndromes]

The objective of our study was to validate the diagnostic utility of cardiac troponine T in acute ischemic syndromes, and also in cases of difficult diagnosis. We analyzed its concordance and compare them with conventional enzymatic quantitative methods. We determined sensitivity, specificity, positive and negative predictive values and likelihood ratio. Kappa index was used to know the concordance grade between T troponin and the positive or negative results of the quantitative enzymatic curve. Stochastic significance was valued by Chi square of Mcnemar test. In seventy patients who arrived to the hospital with chest pain who were assigned to five different groups. The sensitivity in quantitative markers was higher than qualitative methods, however the specificity, likelihood ratio was lower. In the total group the concordance analysis between qualitative and quantitative markers was adequate, (kappa index 0.65 p < 0.05). This study suggest that the rapid bedside qualitative test by cardiac Troponin T is a good diagnostic marker compared with conventional quantitative markers to evaluate chest pain in acute ischemic syndromes.

[Effect of chronic altitude hypoxia on the behavior of the respiratory center. Study on normal subjects living at the altitude of Mexico City (2,240 meters)]

Respiratory center (RC) output has been shown to be increased in hypoxemic Chronic Obstructive patients at sea level. In order to asses the separate role of chronic hypoxia on the RC output we studied 30 normal subjects all of them native and residents of Mexico City (altitude: 2,240 m, PaO2: 65-70 torr.). The parameters studied were: occlussion pressure (P0.1), mean inspiratory flow (Vi), and the ratio inspiratory time to total duration of the respiratory cycle (Ti/Ttot). The inspiratory impedance of the respiratory system as well as the minute ventilation (VE) and lastly to ensure isocapnic conditions, the end-tidal CO2 (PECO2), were also measured. These parameters were determined: 1) While breathing room air (RA), 2) after 30 min of breathing an inspired oxygen fraction (FiO2) of 30% and again 3) after 30 min of breathing and FiO2 of 100%. Fifteen of the subjects were studied on supine and the other 15 in the seated position. In most of the subjects the baseline (RA) values of P0.1 were found to be higher than those reported for normals at sea level. In every case, independent of body position, the P0.1 decreased (less than 0.01) to normal sea level values after 30 min of breathing O2 30%. Likewise, Vi and mechanical impedance also decreased (p less than 0.01) and no changes in Ti/Ttot were noted at this FiO2. No further changes occurred after breathing 100%. The above results show that: 1) The RC output in normal people at altitude (i.e. without mechanical abnormalities but with chronic hypoxia) is increased as compared to sea level.(ABSTRACT TRUNCATED AT 250 WORDS)

[Unilateral agenesis of the main branch of the pulmonary artery]

We studied ten patients with unilateral absence of main branch of pulmonary artery (UAMBPA). Six patients with absent right pulmonary artery (ARPA) and four with the left pulmonary artery (ALPA). The presence of either atrial septal defect, ventricular septal defect and patent ductus arteriosus alone or combinated were associated with pulmonary hypertension (mean pressure of the pulmonary artery greater than 48 mm Hg). The patients without associated cardiac defects were asymptomatic and with little elevation of the pulmonary arterial pressure (mean pressure of the pulmonary artery less than 26 mmHg).

[Pulmonary arteriovenous fistula and lateral decubitus anoxia]

The case of a female patient with Rendu-Osler-Weber disease associated with pulmonary arterio-venous fistula localized at the apical segment of the left inferior pulmonary lobe is described. A decrease in the oxygen arterial saturation (SaO2) at adopting the left lateral decubitus position (left-lateral-decubitodeoxia) was found, as well as an increase in the anatomical venoarterial short-circuit (Qs/Qt) in the same position. The resonsible factors of such changes in SaO2 and Qs/Qt related with the body position are analyzed, and the, exceptional in these patients, finding of alteration of pulmonary mechanics is commented.

[Classical interstitial pneumonitis and mixed cryoglobulinemia in a male with Turner phenotype. Report of a case and review of the literature]

We report a male patient, chromosomal complement 44 XY with Turner's phenotype, who has multiple skeletal, genitourinary and mild cardiac abnormalities, without hypogonadism. This patient developed a diffuse infiltrative pulmonary disease which result in pulmonary fibrosis, respiratory insufficiency and cardiac failure. He has also mixed cryoglobulinemia (Type III) with antigammaglobulin antibodies. The relationship among these problems and his phenotype is discussed. Apparently there is only a coincidental association.

[Analysis of empyrical factors for the determination of cardiac output]

With a method by which no recirculation was possible the area of a dilution curve was obtained. On this basis it was searched what percentage represents the forward triangle of the total surface of the curve. The rôle of the V/F of the sampling system on this portion of the curve was studied, surface from which the empirical constants for the estimation of the cardiac output derivates. The data obtained suggest that the forward surface triangle was V/F dependent V/F less than 1 gave smaller forward triangles, the opposite was true with V/F greater than 1. It was also found that V/F greater than 1 subestimate the total surface of the dye curve, which means cardiac outputs higher than the real. The forward surface of the curve was reduced to a minimal percentage of the total curve when a V/F less than 1 was used. Situation that makes this area non useful to obtain from them empirical factors. If an empirical factor is use in order to measure cardiac output it had to be accepted that an important grade of error is introduced.

[Pulmonary thromboembolism. Occlusion of the right branch of the pulmonary artery caused by lung cancer]

A rare case of an oat cell carcinoma is presented. The clinical picture were those of pulmonary thromboembolism and other extrapulmonary symptoms. There were not respiratory symptoms directly related to the lung carcinoma and the chest film remain normal.

[Coexistence of aorto-pulmonary calcification]

The importance of finding in chest roentgenograms the coexistence of aortic and pulmonary artery calcification in emphasized. This radiologic feature is useful in patients which offered difficulty in the clinical diagnosis, it should suggest as a first possibility in the diagnosis patent ductus arteriosus.