CEUS detection of biliary ischaemia during the first 4 weeks after liver transplantation predicts non-anastomotic biliary stricture

BACKGROUND: Biliary ischaemia is an important factor in the pathogenesis of non-anastomotic biliary stricture (NAS) after liver transplantation (LT). Contrast-enhanced ultrasound (CEUS) can be used to detect biliary ischaemia, but no study has examined the utility of CEUS in predicting NAS. OBJECTIVE: To evaluate whether repeated CEUS as a non-invasive method of biliary ischaemia can identify NAS. METHODS: Consecutive LT patients who underwent CEUS examinations at 1–4 weeks after LT from September 2012 to December 2015 at our institution were included. The CEUS images and clinical data were analysed. RESULTS: Among 116 eligible LT patients, 39 (33.6%) were diagnosed with NAS within 1 year after LT. The patients with NAS had a significantly higher CEUS score at weeks 2–4 (all P < 0.05) and a higher slope of CEUS score progression (0.480 vs –0.044, P < 0.001). The accuracy of CEUS in identifying NAS improved over time after LT, reaching its maximum at week 4, with a sensitivity of 66.7%, a specificity of 87.9%, a positive predictive value (PPV) of 75.9%, a negative predictive value (NPV) of 82.3%, and an accuracy of 80.2%in the full cohort when a CEUS score≥3 was used as the cut-off. Multivariate analysis identified gamma-glutamyl transpeptidase (GGT), alanine transaminase (ALT) and the CEUS score at week 4 as independent predictors of NAS. In the task of identifying NAS, an NAS score combining the above 3 variables at week 4 showed areas under the receiver operating characteristic curve of 0.88 (95%CI, 0.78–0.99) in the estimation group (n = 60) and 0.82 (95%CI, 0.69–0.96) in the validation group (n = 56). An NAS score cut-off of 0.396 identified 87.2%of NAS cases in the estimation group, with a PPV of 93.3%; and 75.0%of NAS cases in the validation group, with a PPV of 58.8%. CONCLUSIONS: CEUS examination during the first 4 weeks is useful in assessing the risk of NAS within 1 year after LT. In particular, an NAS score combining the CEUS score, GGT level, and ALT level at week 4 can be used to accurately predict the risk of NAS in LT patients.

Evaluation of NAFLD and fibrosis in obese patients – a comparison of histological and clinical scoring systems

Background Non-alcoholic fatty liver disease (NAFLD) is a frequent condition in obese patients and regularly progresses to non-alcoholic steatohepatitis (NASH) and subsequent cirrhosis. Histologic evaluation is the gold standard for grading and staging, but invasive biopsies are associated with obvious risks. The aim of this study was to evaluate different non-invasive tools for screening of NAFLD and fibrosis in obese patients. Methods In a prospective cohort study liver specimens of 141 patients were taken during bariatric surgery. Serological parameters and clinical data were collected and the following scores calculated: NASH clinical scoring system (NCS), aspartate aminotransferase to platelet ratio index (APRI), FIB-4 as well as NAFLD fibrosis score (NFS). Liver function capacity was measured preoperatively by LiMAx test (enzymatic capacity of cytochrome P450 1A2). Intraoperative liver biopsies were classified using NAFLD activity score (NAS) and steatosis, activity and fibrosis (SAF) score. Results APRI was able to differentiate between not NASH and definite NASH with a sensitivity of 74% and specificity of 67% (AUROC 0.76). LiMAx and NCS also showed significant differences between not NASH and definite NASH. No significant differences were found for NFS and Fib-4. APRI had a high sensitivity (83%) and specificity (76%) in distinguishing fibrosis from no fibrosis (AUROC = 0.81). NCS and Fib-4 also revealed high AUROCs (0.85 and 0.67), whereas LiMAx and NFS did not show statistically significant differences between fibrosis stages. Out of the patients with borderline NASH in the histologic NAS score, 48% were classified as NASH by SAF score. Conclusions APRI allows screening of NAFLD as well as fibrosis in obese patients. This score is easy to calculate and affordable, while conveniently only using routine clinical parameters. Using the NAS histologic scoring system bears the risk of underdiagnosing NASH in comparison to SAF score.

Medical Students’ Attitudes Toward Communication Skills Learning in Chitwan Medical College, Nepal

Introduction: Medical students’ attitude towards communication skills is crucial for curriculum planners, teachers and health professionals. Chitwan Medical College (CMC) is a private medical school admitting students mainly from the Nepal. Objective: To assess the attitudes of medical students towards learning communication skills. Methods: A cross-sectional study was conducted among third and fifth year medical (MBBS) undergraduates at Chitwan Medical College (CMC), Nepal in April 2018 using the 26-itemCommunication Skills Attitude Scale (CSAS) developed by Rees, Sheard, and Davies. Participants ‘age, sex, year of study, nationality, religion, relationship status, the occupation of father and mother, place of residence of a family, were noted. The CSAS scores were computed. Student’s t-test and ANOVA test were used to compare the scores among subgroups of participants. Results: The mean positive attitudes scale (PAS), negative attitudes scale (NAS) and overall CSAS scores were 51.77  5.21, 35.68  4.43, and 83.97  5.77 respectively. PAS score was statistically significantly higher among the respondents whose mothers were not in the health-related profession. Whereas NAS score was statistically significantly lower among females, self-rated outstanding students, and good self-reported written communication skills. Conclusion: Medical undergraduates had strong positive attitudes towards learning communication skills, but negative attitudes were also noted. Hence, faculty members need to change these attitudes through improving teaching and assessment strategies.

Η επίδραση της μαστίχας Xίου (Pistacia lentiscus var chia) σε πειραματικό μοντέλο αθηρωμάτωσης

ΣΚΟΠΟΣ. Η Μαστίχα Χίου αποτελεί ένα πολύτιμο Ελληνικό φυσικό προϊόν ευρέως γνωστό για τις αντιοξειδωτικές αλλά και τις καρδιοπροστατευτικές του ιδιότητες. Σκοπός της παρούσας μελέτης ήταν η διερεύνηση του πιθανού μοριακού μηχανισμού δράσης της σε ένα πειραματικό μοντέλο αθηροσκλήρωσης. ΥΛΙΚΟ ΚΑΙ ΜΕΘΟΔΟΣ. Χρησιμοποιήθηκαν συνολικά 30 ενήλικοι αρσενικοί WT μύες και 30 διαγονιδιακοίομόζυγοι PPARα μύες που κατανεμήθηκαν σε 3 ομάδες, αντίστοιχα: Ομάδα Ελέγχου(n=10) που έλαβε standard chow δίαιτα , Ομάδα Αθηροσκλήρωσης(n = 10) που έλαβεδιατροφή υψηλής περιεκτικότητας σε λιπαρά οξέα (45%) για 12 εβδομάδες και Ομάδα Μαστίχας Χίου (n=10 )που έλαβε διατροφή υψηλής περιεκτικότητας σε λιπαρά οξέα και Μαστίχα Χίου μέσω υδατικού διαλύματος σε δοσολογία 40 mg/kg/μέρα. Πραγματοποιήθηκαν μετρήσεις του σωματικού βάρους, των λιπιδίων,των αιμοδυναμικών παραμέτρων καθώς και προφλεγμονωδών κυτοκινών στον ορό του αίματος με την χρήση πρωτεομικής μεθόδου κατά την έναρξη του πειράματος και έπειτα από 4,8 και 12 εβδομάδες. Έπειτα από ευθανασία των μυών, πραγματοποιήθηκε ιστολογική μελέτη του ήπατος. ΑΠΟΤΕΛΕΣΜΑΤΑ. Στο τέλος της μελέτης, η ομάδα των wild type μυών που έλαβε Μαστίχα Χίου παρουσίασε μειωμένα επίπεδα σωματικού βάρους (30 vs 34 g, p<0.01), γλυκόζης (177vs 233.1 mg/dl ,p<0.001), ολικής χοληστερόλης(129.2 vs 148.1 mg/dl ,p<0.001) καιLDL χοληστερόλης(58 vs 82.6, p<0.001) σε σύγκριση με την ομάδα της Αθηροσκλήρωσης. Η χορήγηση Μαστίχας Χίου οδήγησε σε μείωση (p<0.05) των επιπέδων των κυτοκινών CRP, IL1a, CXCL10, MCP2, WVF, CXCL2 στον ορό σε σχέση με την ομάδα Αθηροσκλήρωσης, καθώς και σε διατήρηση των επιπέδων ινσουλίνης και λεπτίνης καθ’ όλη την διάρκεια της μελέτης. Τέλος η ομάδα της Μαστίχας παρουσίασε βελτιωμένο σκορ ηπατικής στεάτωσης και φλεγμονής σε σχέση με την ομάδα Αθηροσκλήρωσης(NAS score 0.525 vs 0.975 , p<0.05). Ωστόσο καμία από τις παραπάνω διαφορές δεν παρατηρήθηκε στην ομάδα των διαγονιδιακών μυών που έλαβαν Μαστίχα σε σύγκριση με την ομάδα Αθηροσκλήρωσης των διαγονιδιακών μυών. Τόσο στην ομάδα των WT μυών, όσο και στην ομάδα των διαγονιδιακών μυών παρατηρήθηκε σημαντική βελτίωση των αιμοδυναμικών παραμέτρων, που διατηρήθηκε κατά την διάρκεια της μελέτης. ΣΥΜΠΕΡΑΣΜΑ. Τα αποτελέσματα της παραπάνω μελέτης ανέδειξαν την ισχυρή υπολιπιδαιμική, αντιφλεγμονώδη και ηπατοπροστατευτική δράση της Μαστίχας Χίου που πιθανώς μεσολαβείται μέσω της ενεργοποίησης των πυρηνικών υποδοχέων PPAR-alpha, αλλά και επιβεβαίωσαν πως η αντιυπερτασική της δράση πιθανώς είναι συνέργεια διαφορετικών μηχανισμών. Περισσότερες μελέτες για την αποσαφήνιση του ακριβούς μηχανισμού δράσης της καθίστανται αναγκαίες πριν την ασφαλή χορήγησής της σε ασθενείς με καρδιαγγειακή νόσο.

A New Scoring System for the Assessment of Neonatal Abstinence Syndrome

Objective This study aimed to evaluate the concordance of a new scoring system for neonatal abstinence syndrome (NAS) and NAS scores to the traditional Modified Finnegan Neonatal Abstinence Scoring Tool (M-FNAST) score. The NAS score is based on the physiology of withdrawal, with equal emphasis on behavior, and neurological signs. Study Design The NAS scores for a control group of 202 healthy, term neonates were compared with those for 45 term neonates with NAS. The NAS and M-FNAST scores obtained simultaneously in 45 term neonates with NAS were compared using correlation, linear regression, and receiver operating characteristic curve analysis to determine the validity, reliability, and specificity of the NAS scores. Results The association between the NAS and M-FNAST scores was high (Spearman's correlation, 83%; linear regression, 83%), with an area under the curve of the NAS score of 1.00 (p < 0.01). A cut-off NAS score ≥4 identified NAS neonates with a sensitivity of 100% and specificity of 96%. The values of intraclass correlation, interrater agreement, and Cronbach's α were 0.63, 0.88, and 0.63, respectively. Conclusion The new NAS scoring system is valid, reliable, physiologically based, and correlates closely with the M-FNAST score. The NAS scores may require further validation before its use in clinical practice.

Aplicação do Nursing Activities Score (NAS) em diferentes tipos de UTI´s: uma revisão integrative

Objective: To compare the nursing workload measured by the Nursing Activities Score (NAS), between intensive care unit general adult ICU, and specialized surgical, cardiologic and trauma type.Methods: A literature review of the integrative type was carried out, searching the databases BDENF, LILACS, MEDLINE, and SCIELO, using the descriptors nursing, Intensive Care Unit, workload and Nursing Activities Score. They met the inclusion criteria 20 articles published in the period 2007 to 2017.Results: They show a high workload in the ICU, both in general ICUs and in all of the cited specificities, the same with a NAS score> 50.00, especially the trauma ICU, which was characterized with higher scores 72.00 and 71.3.Conclusion: In much of the research, the average number of nursing professionals calculated by the NAS is higher than the average number of professionals required by the legislation. It was observed that even in ICUs with the same specificity it was possible to perceive large differences in the mean of the NAS score, in this way, we understand that despite having the same specificity, the profile of the patient as well as that of the institution has its peculiarities requiring time to different assistance and consequently divergences in sizing. Objetivo: Comparar la carga de trabajo de enfermería medida por la Nursing Activities Score (NAS), entre la unidad de cuidados intensivos general de adultosy especializadas de quirúrgico, cardiología y trauma.Métodos: Realización de una revisión de la literatura del tipo integrativa. Búsqueda en las bases de datos BDENF, LILACS, MEDLINE, SCIELO, utilizando los descriptores enfermería, Unidad de Cuidados Intensivos, Carga de trabajo y Nursing Activities Score. Atendieron a los criterios de inclusión 20 artículos publicados en el periodo de 2007 a 2017.Resultados: Evidencian elevada carga de trabajo en UCI, tanto en UCIs general como en todas las especificidades citadas, las mismas con puntuación NAS > 50,00, destacando la UCI de trauma lo que se caracterizó con mayores marcadores 72,00 y 71,3.Conclusión: En gran parte de las investigaciones, la media de profesionales de enfermería calculada por la NAS es superior a la media de profesionales requerida por la legislación. Se observó que incluso en UCIs con la misma especificidad se perciben grandes diferencias en la media de la puntuación NAS, de esta forma, entendemos que a pesar de tener la misma especificidad, el perfil del paciente así como el de la institución tienen sus particularidades demandando tiempo de asistencia diferente y consecuentemente divergencias en el dimensionamiento. Objetivo: Comparar a carga de trabalho de enfermagem medida pelo Nursing Activities Score (NAS), entre unidade de terapia intensiva UTI geral adulto, e especializadas do tipo cirúrgica, cardiológica e trauma.Métodos: Foi realizada uma revisão de literatura do tipo integrativa, com busca nas bases de dados BDENF, LILACS, MEDLINE, e SCIELO, utilizando-se os descritores enfermagem, Unidade de Terapia Intensiva, carga de trabalho e Nursing Activities Score. Atenderam aos critérios de inclusão 20 artigos publicados no período de 2007 a 2017.Resultados: Evidenciam elevada carga de trabalho em UTI, tanto em UTIs geral quanto em todas as especificidades citadas, as mesmas com pontuação NAS > 50,00, destacando-se a UTI de trauma o que caracterizou-se com maiores escores 72,00 e 71,3.Conclusão: Em grande parte das pesquisas, a média de profissionais de enfermagem calculada pelo NAS é superior à média de profissionais requerida pela legislação. Observou-se que mesmo em UTIs com a mesma especificidade pôde-se perceber grandes diferenças na média do escore NAS, dessa forma, entendemos que apesar de possuir a mesma especificidade, o perfil do paciente assim como o da instituição tem suas particularidades demandando tempo de assistência diferente e consequentemente divergências no dimensionamento.

High potency multistrain probiotic improves liver histology in non-alcoholic fatty liver disease (NAFLD): a randomised, double-blind, proof of concept study

ObjectivePharmacological treatment of non-alcoholic fatty liver disease (NAFLD) is still evolving. Probiotics could be a promising treatment option, but their effectiveness needs to be established. The present study aimed to evaluate the efficacy of a high potency multistrain probiotic in adult patients with NAFLD.MethodsThirty-nine liver biopsy-proven patients with NAFLD were randomised in a double-blind fashion to either lifestyle modifications plus an oral multistrain probiotic (675 billion bacteria daily, n=19) or identical placebo (n=20) for 1 year. Lifestyle modifications included regular exercise for all and control of overweight/obesity (with additional dietary restrictions), hypertension and hyperlipidaemia in those with these risk factors. Primary objective of the study was the histological improvement in NAFLD activity score (NAS) and its components and secondary objectives were improvement in alanine transaminase (ALT) and cytokine profile.ResultsThirty (76.9%) out of 39 patients with NAFLD completed the study with 1 year of follow-up. A repeat liver biopsy at 1 year could be done in 10 patients (52.6%) in probiotic group and five patients (25%) in placebo group. In comparison to baseline, hepatocyte ballooning (p=0.036), lobular inflammation (p=0.003) and NAS score (p=0.007) improved significantly at 1 year in the probiotic group. When compared with placebo, the NAS score improved significantly in the probiotic group (p=0.004), along with improvements in hepatocyte ballooning (p=0.05) and hepatic fibrosis (p=0.018). A significant improvement in levels of ALT (p=0.046), leptin (p=0.006), tumour necrosis factor-α (p=0.016) and endotoxins (p=0.017) was observed in probiotic group in comparison to placebo at 1 year. No significant adverse events were reported in the study.ConclusionPatients with NAFLD managed with lifestyle modifications and multistrain probiotic showed significant improvement in liver histology, ALT and cytokines.Trial registration numberThe clinical trial is registered with CLINICAL TRIAL REGISTRYINDIA (CTRI); http://ctri.nic.in, No. CTRI/2008/091/000074