ABSTRACT
OBJECTIVES: Disease-related malnutrition (MN) is common in patients with liver cirrhosis (LC), short bowel syndrome (SBS), and chronic pancreatitis (CP). Different MN risk screening tools and diagnostic criteria of the European Society for Clinical Nutrition and Metabolism (ESPEN) and Global Leadership Initiative on Malnutrition (GLIM) algorithms were analyzed for their diagnostic accuracy and role as specific drivers to diagnose MN in patients with LC, SBS, and CP. METHODS: A total of 187 patients with LC, SBS, and CP, as well as control patients were prospectively recruited in a multicenter cross-sectional study. MN risk was screened using Nutritional Risk Screening 2002 (NRS-2002), the Malnutrition Universal Screening Tool (MUST), and the Royal Free Hospital Nutritional Prioritizing Tool (RFH-NPT), and diagnosed using the ESPEN, GLIM, and GLIMCRP+ (GLIM incorporating C-reactive protein [CRP] >5 mg/L) algorithms. For each of the individual diagnostic criteria, relative frequency, sensitivity, specificity, as well as positive and negative predictive values were calculated. RESULTS: NRS-2002 was only sensitive in conjunction with ESPEN, while MUST was sensitive additionally with the GLIM algorithm. RFH-NPT worked the best for LC. GLIM and GLIMCRP+ diagnosed MN more frequently than the ESPEN algorithm. Diagnostic criteria were detected at remarkably different relative frequencies starting with reduced food intake/malabsorption and chronic disease/inflammation, followed by weight loss, reduced fat-free mass index, low body mass index, and body mass index <18.5 kg/m². Relative frequencies differed between LC, SBS, and CP. Weight loss in LC and CP and reduced fat-free mass index and food intake in SBS had good diagnostic accuracy, suggesting that these criteria act as specific drivers for MN. CONCLUSIONS: RFH-NPT and MUST performed better in conjunction with the GLIM algorithm than NRS-2002. MN was diagnosed more frequently by GLIM than the ESPEN algorithm in LC, SBS, and CP. Individual criteria acted as specific drivers in MN in chronic gastrointestinal diseases.
Subject(s)
Gastrointestinal Diseases , Malnutrition , Humans , Chronic Disease , Cross-Sectional Studies , Gastrointestinal Diseases/complications , Gastrointestinal Diseases/diagnosis , Liver Cirrhosis , Malnutrition/diagnosis , Malnutrition/etiology , Nutrition Assessment , Nutritional Status , Weight Loss , AlgorithmsABSTRACT
Purpose: For treatment of carpometacarpal thumb joint osteoarthritis, a trapeziectomy with an alternative suspension technique can be performed as the primary surgery or as the secondary after a failed primary surgery. This study evaluates the midterm follow-up (median, 54 months) for this technique using patient-reported outcome measures. Methods: After trapeziectomy, an alternative suspension technique is performed with a flexor carpi radialis tendon strip. Leaving the insertion intact, the strip is tunneled through a drill hole in the base of the first metacarpal and then through a drill hole in the second metacarpal neck and then sutured back onto itself. This suspends the first metacarpal to the shaft of the second metacarpal, creating a strong, V-shaped suspension. As the technique is performed in both the primary and secondary surgery, we analyzed both groups separately. As the primary outcome, we evaluated pain and function with the Patient-Rated Wrist and Hand Evaluation. Further, we evaluated the Disabilities of the Arm, Shoulder and Hand and Short Form 12 questionnaire scores from eligible patients. Finally, we correlated pain and function to quality of life. Results: The median Patient-Rated Wrist and Hand Evaluation score was 16.0 (interquartile range, 1.5-40.4) after the primary surgery and 46 (interquartile range, 34.0-75.5) after the secondary surgery. Patients after the primary surgery also scored better on the Disabilities of the Arm, Shoulder, and Hand questionnaire compared to patients after the secondary surgery. The Short Form 12 questionnaire physical scores were negatively correlated with the Disabilities of the Arm, Shoulder, and Hand questionnaire scores for the primary group (correlation coefficient, -0.468) and negatively correlated with the Patient-Rated Wrist and Hand Evaluation pain scores for the secondary group (correlation coefficient, -0.703). Conclusions: Trapeziectomy with this alternative suspension technique for treatment of carpometacarpal thumb joint osteoarthritis shows good patient-reported outcome measures for primary surgery and poor patient-reported outcome measures after the secondary surgery. Type of study/level of evidence: Therapeutic IV.
ABSTRACT
A 41-year-old female patient was admitted because of febrile jaundice and acute liver failure. The quick and the bilirubin were 21â% and 258âµmol/l, and there was hepatic encephalopathy I°. AST and AP had a maximum of 612 and 215âU/l. Despite a strong left shift in the differential, the CRP had a maximum of 15âmg/l. Because of an atypically presenting systemic lupus erythematosus, she had been treated with Azathioprine, steroids and Tocilizumab until 12 days before admission. The diagnostic workup revealed CMV hepatitis and necrotizing hepatopathy, which was interpreted as toxic hepatitis. At the time of liver biopsy, on day 3 after admission, staining for Ki-67 indicated strong regenerative activity in the liver. Treatment with Valgancyclovir, antibiotics and steroids led to early recovery from liver failure. The case differs from the few described cases of severe acute liver injury related to Tocilizumab. Apparently, the combined immunosuppression (steroid, Azathioprine and Tocilizumab) led to acute liver failure secondary to CMV hepatitis and acute toxic hepatitis, which may have been aggravated by transiently impaired liver regeneration. On the other hand, stimulated liver regeneration was proven by histology despite previous IL6 blockage by Tocilizumab.
Subject(s)
Antibodies, Monoclonal, Humanized , Chemical and Drug Induced Liver Injury , Cytomegalovirus Infections , Hepatitis, Viral, Human , Liver Failure, Acute , Liver Regeneration , Adult , Antibodies, Monoclonal, Humanized/adverse effects , Chemical and Drug Induced Liver Injury/diagnosis , Chemical and Drug Induced Liver Injury/drug therapy , Cytomegalovirus Infections/complications , Female , Hepatitis, Viral, Human/diagnosis , Hepatitis, Viral, Human/drug therapy , Humans , Liver Failure, Acute/diagnosis , Liver Failure, Acute/drug therapy , Liver Regeneration/drug effects , Liver Regeneration/immunology , Lupus Erythematosus, SystemicABSTRACT
This review describes the gasterointestinal entities, their pathophysiology, clinical presentation, diagnostic workup and therapy that typically involve weight loss as the major presenting symptom. The differentiation of malassimilation into maldigestion and malabsorption is clinically mostly not helpful. Instead primary malasssimilation can be distinguished from secondary due to another disease. Celiac disease, lambliasis, small bowel CD, CVIDS and Whipple's disease result in loss of absorptive surface. Chronic intestinal pseudobstruction leads to weight loss through dysmotility and postprandial pain. Microscopic colitis involves some weight loss and needs to be considered because of its high prevalence. Exocrine pancreatic insufficiency and the various protein loosing enteropathies may be primary or secondary syndromes. Dumping, bile acid malabsorption and short bowel syndrome occur after typical operative procedures. Chronic radiation enteritis, chronic intestinal ischemia and intestinal diabetic polyneuropathy are due to chronic intestinal injury.
