Number of Endoscopic Sessions to Eradicate Varices Identifies High Risk of Rebleeding in Cirrhotic Patients

Background and aims: Risk stratification to identify patients with high risk of variceal rebleeding is particularly important in patients with decompensated cirrhosis. In clinical practice, eliminating gastroesphageal varices thoroughly after sequential endoscopic treatment reduces the rebleeding rate, however, no simple method has been build to predict high risk of variceal rebleeding. We conducted this study to explore the value of the number of endoscopic sessions required to eradicate gastroesphageal varices in identifying high risk of rebleeding.Patients and methods: Consecutive cirrhotic patients received sequential endoscopic therapy between January 2015 to March 2020 were enrolled. Endoscopic treatment was performed every 1-4 weeks until the eradication of varices. The primary endpoint was variceal rebleeding.Results: A total of 146 patients were included of which 60 patients received standard therapy and 86 patients underwent sequential endoscopic treatment alone. The cut-off value of the number of sequential endoscopic sessions is 3.5 times. Variceal rebleeding was significant higher in patients with endoscopic sessions > 3 times vs. ≤ 3 times (61.5% vs. 17.5%, p<0.001). Variceal rebleeding of patients with endoscopic sessions ≤3 times was significant lower than patients with > 3 times in group of standard therapy (19.6% vs. 88.9%, p<0.001) and endoscopic therapy (15.9% vs. 47.1%, p=0.028) respectively. Conclusion: The number of sequential endoscopic sessions required to eradicate the varices is related to the risk of variceal rebleeding in patients with cirrhosis. If three times of endoscopic treatment can not eradicate the varices, a more aggressive treatment such as TIPS should be seriously considered.

Role of Hair Transplantation in Scarring Alopecia—To Do or Not to Do

Alopecia in the scalp region leads to psychosocial embarrassment for an individual. Alopecia could be due to several reasons, including genetic, hormonal, traumatic and infections. Cicatricial alopecias (CAs) are considered as trichological emergency, since their progression is rapid and always results in permanent hair loss. The pathogenesis, disease progression and prognosis of CA are poorly understood, and the treatment process is still evolving. An early diagnosis must be established, and aggressive treatment protocol should be followed in the management of scarring alopecia. This article presents various aspects of CA and determines whether hair transplant (HT) should be done in this condition.

Inflammatory bowel disease in adults

Inflammatory bowel disease (IBD) is an umbrella term used to describe a group of disorders characterised by chronic inflammation of the gastrointestinal tract, of which ulcerative colitis and Crohn’s disease are the most common. It is estimated that 500 000 people in the UK currently live with IBD. There are two peaks of incidence, the first of which is between 15 and 30 years of age, with a second smaller peak between 60 and 80 years of age. Its prevalence is ever increasing, and GPs play an important role in early diagnosis, which is the key in reducing the need for aggressive treatment.

Baricitinib for Refractory Eosinophilic Fasciitis: Myth or Reality?

We read the recent article by Sehgal et al with great interest.1 The authors described a 37-year-old patient with eosinophilic fasciitis (EF) who showed no improvement after an initial aggressive treatment strategy (intravenous [IV] methylprednisolone, prednisone, methotrexate, mycophenolate mofetil, and IVIG). Subsequently, the use of the Janus kinase ( JAK) 1/2 inhibitor baricitinib resulted in considerable improvement in the patient's symptoms and skin appearance. However, there are some details that need further clarification.

Eleven-year Retrospective Study Characterizing Patients With Severe Brain Damage and Poor Neurological Prognosis -Role of Physicians’ Attitude Toward Life-Sustaining Treatment

BackgroundSevere brain hemorrhage/infarction and cardiac arrest constitute the most critical situations leading to poor neurological prognosis. Characterization of these patients is required to offer successful end-of-life care, but actual practice is affected by multiple confounding factors, including ethicolegal issues, particular in Japan and Asia. The aim of this study is to evaluate the clinical courses of patients with severe brain damage and to assess the preference of end-of-life care for these patients in Japanese hospitals.MethodsA retrospective observational study was conducted between 2008 and 2018. All intracranial hemorrhage/infarction and cardiac arrest out-patients (n=510) who were admitted to our two affiliated hospitals and survived but with poor neurologic outcomes were included. Demographic characteristics as well as prognosis and treatment policies were also assessed. Results Patients were divided into two categories; cases with absent brainstem reflex (BSR) (BSR[-]) and those with preserved BSR (BSR[+]). The survival rate was higher and the length of hospitalization was longer in patients with BSR[+] than in those with BSR[-]. Among three life-sustaining policies (i.e., aggressive treatment, withdrawal of treatment, and withholding of treatment), withholding of treatment was adopted to most patients. In BSR[-], the proportion of three treatment policies performed at the final decision did not differ from that at the initial diagnosis on neurological status (p=0.432). In contrast, this proportion tended to be altered in BSR[+] (p=0.072), with a decreasing tendency of aggressive treatment and a modest increasing tendency of withdrawal of treatment. Furthermore, the requests from patients’ families to withdraw life-sustaining treatment, including discontinuation of mechanical ventilation, increased, but actual implementation of withdrawal by physicians was less than half of the requests. ConclusionsBSR constitutes a crucial determinant of mortality and length of hospitalization in comatose patients with severe brain damage. Although the number of withdrawal of life-sustaining treatment tends to increase over time in BSR[+] patients, there are many more requests from patients’ families for withdrawal. Since physicians has a tendency to desist from withdrawing life-sustaining treatment, more in-depth communication between medical staff and patients’ families will facilitate mutual understanding over ethicolegal and religious issues and may thus improve end-of-life care.

Life-threatening complications of streptococcal sepsis: a PICU contemporary series

Background Life-threatening streptococcal sepsis nowadays represents an uncommon event in previously healthy infants and children. Critically ill patients suffering from severe streptococcal sepsis complications may present with pre-antibiotic era clinical pictures and require a timely clinical approach to achieve restitutio ad integrum. Results We report a series of four patient groups affected by an uncommon life-threatening streptococcal sepsis, each of them exhibiting some distinct features. Streptococcus Agalactiae sepsis was associated with cerebral thrombotic/ischaemic lesions, whereas severe cardiogenic shock was prominent in the Streptococcus Viridans group; Streptococcus Faecalis and β-hemolytic group A Streptococcus patients mostly reported lung complications. Conclusions Previous antibiotic treatments should not delay aggressive treatment in the intensive care setting. Early diagnostic suspicion, as well as appropriate and aggressive treatment provided within an intensive care setting are crucial for the clinical outcome.

Prognosis of Aggressive Treatment of Primary Hepatic Angiosarcoma: A Single-Center Experience

Background and Aims: Of all primary liver tumors, primary hepatic angiosarcoma (PHA) is a rare and aggressive malignant vascular tumor. The standard therapeutic care for hepatic angiosarcoma remains unclear. This study compared the survival outcomes of aggressive treatment (resection and liver transplant) and nonaggressive treatment (chemotherapy, transarterial chemoembolization [TACE], and conservative treatments) for patients with PHA and analyzed the prognostic factors influencing survival. Materials and Methods: Data of patients diagnosed as having PHA at our facility were retrospectively reviewed. The primary outcome was survival time. The secondary outcome was calculated baseline characteristics. Results: We included a total of 19 patients, who were divided into 2 treatment groups: aggressive (8 patients had undergone resection or transplants) and nonaggressive (11 patients had undergone TACE, chemotherapy, or conservative treatment). The mean survival time was 233.1 ± 189.7 days in the aggressive treatment group and 146.5 ± 115.8 days in the nonaggressive treatment group. A Kaplan-Meier plot revealed no significant difference in survival time between the 2 treatment groups (P = .3256). Conclusions: The survival time of patients receiving aggressive treatment was longer than that of those receiving nonaggressive treatment. The long term survival time in some selective cases of aggressive treatment will be achieved. Thought a difference was not significant between the groups. Because the number of patients was limited, more cases are required to confirm these findings.

Masson’s Tumour - Case Report of a Malignant Masquerader with Literature Review

Masson’s tumour, an uncommon, benign vascular disorder was first described by Pierre Masson in 1923 as an intravascular papillary proliferation that emerged from an inflamed hemorrhoidal vein of a 68-year-old man and termed it as “Hemangioendotheliome vegetant intravasculaire”.1 He interpreted the lesion as a form of neoplasm, however, Henschen portrayed it as a reactive phenomenon. The current terminology intravascular papillary endothelial hyperplasia (IPEH) was put forward by Clearkin and Enzinger in 1976 considering it as a reactive change occurring secondary to trauma-related vascular stasis.2 The tumour constitutes 2-4 % of all skin and soft tissue tumours. The common locations are head, neck and extremities.3 Masson’s tumour being a benign entity with an excellent prognosis is essential to differentiate from its closer mimic, angiosarcoma which needs aggressive treatment. This case is put up here because of its rarity and its clinical implications.

Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is the most common form of chronic synovial joint inflammation in children. It potentially leads to disability and psychosocial outcomes for children and their families. In the absence of appropriate treatment, this can lead to joint destruction and disability. Thus, early diagnosis and aggressive treatment are essential. With the presentation of new biologic DMARDs, based on understanding the disease pathophysiology and molecular pathogenesis, the course of the disease and its outcome have been changed profoundly. In this chapter, the early diagnosis, appropriate treatment, and outcomes approaches are described. These include the latest diagnosis and management options.

A case series of mucormycosis and aspergillus coinfection in post-covid-19 patient with uncontrolled diabetic

Mucormycosis is an angioinvasive infection caused by fungi Mucorales which mainly occurs in immunocompromised patients. Aspergillosis is also an opportunistic fungal infection caused by Aspergillus species. Coinfection with mucormycosis and aspergillosis is very rare and very few cases were published in the literature till now. There is an increase in the incidence of mucormycosis infection in post-COVID-19 patients. Here, we are going to report a case series of three cases of combined infection of mucormycosis with Aspergillus. All three patients were treated with extensive surgical debridement and intravenous liposomal amphotericin B. Even after aggressive treatment, the mortality rate is high in these types of patients.