Nutrition in decompensated liver disease: A regional trainee-led audit investigating patient nutrition and outcomes following admission with decompensated chronic liver disease.

OBJECTIVE: To conduct a regional audit assessing the prevalence and management of malnutrition in decompensated liver disease. METHOD: All adults admitted with decompensated cirrhosis over one-month period to participating trusts were included. Malnutrition was identified using MUST and Royal Free Hospital-Nutritional Prioritisation Tool (RFH-NPT). RESULTS: 47 patients were identified. The prevalence of malnutrition was 76.6%. This was independent of age (<65 versus ≥65; p = 1) or aetiology of liver disease (alcohol-related versus not; p = 0.55). Screening was significantly higher on Gastroenterology wards than other wards (77% versus 23%; p = 0.012). RFH-NPT identified 76.6% of patients as malnourished whereas MUST identified 55.3%. Supplementation was prescribed to 83% of eligible patients. 80% was oral supplementation and 20% received NG feeding. Median length of stay (9 (2-62) days) was higher in those prescribed supplements (11 vs 7 days, p = 0.041). Readmission rates were similar regardless of supplementation. Mortality was higher in malnourished patients (p = 0.03) and in those prescribed nutritional supplements at 1, 3 and 6 months (p = 0.026, p = 0.026 and p = 0.008) respectively, who were more likely to have severe liver disease. CONCLUSION: Prevalence of malnutrition is high in patients with decompensated cirrhosis but independent of age and aetiology and associated with higher Child-Pugh scores. The RFH-NPT was a more sensitive screening tool than MUST. Increased nutritional screening was noted on gastroenterology wards with more intervention in those with severe liver disease. Despite the study's limitations, once malnourished, nutritional intervention did not appear to impact on patient readmission or mortality rates therefore, we propose addressing malnutrition by utilising specialty dietician involvement at an earlier stage.

Improved transient silencing of gene expression in the mosquito female Aedes aegypti.

Gene silencing using RNA interference (RNAi) has become a widely used genetic technique to study gene function in many organisms. In insects, this technique is often applied through the delivery of dsRNA. In the adult female Aedes aegypti, a main vector of human-infecting arboviruses, efficiency of gene silencing following dsRNA injection varies greatly according to targeted genes. Difficult knockdowns using dsRNA can thus hamper gene function analysis. Here, by analysing silencing of three different genes in female Ae. aegypti (p400, ago2 and E75), we show that gene silencing can indeed be dsRNA sequence dependent but different efficiencies do not correlate with dsRNA length. Our findings suggest that silencing is likely also gene dependent, probably due to gene-specific tissue expression and/or feedback mechanisms. We demonstrate that use of high doses of dsRNA can improve knockdown efficiency, and injection of a transfection reagent along with dsRNA reduces the variability in efficiency between replicates. Finally, we show that gene silencing cannot be achieved using siRNA injection in Ae. aegypti adult females. Overall, this work should help future gene function analyses using RNAi in adult females Ae. aegypti, leading toward a better understanding of physiological and infectious processes.

Urinary volatile organic compounds and faecal microbiome profiles in colorectal cancer.

AIM: Volatile organic compounds (VOCs) are potential biomarkers for diagnosing colorectal cancer (CRC). We characterized urinary VOCs from CRC patients, their spouses/cohabitors (spouses) and first-degree relatives (relatives) to determine any differences. Correlation with stool-derived microbiomes was also undertaken. METHODS: Urine from 56 CRC patients, 45 spouses and 37 relatives was assayed using liquid chromatography, field asymmetric ion mobility spectrometry (FAIMS), mass spectrometer technology. Analysis was performed using five-fold cross-validation and a random forest classifier. Faecal microbiome 16S rRNA was sequenced using Illumina MiSeq protocols and analysed using UPARSE and QIIME pipelines. VOC and microbiome profiles were also compared before and after cancer treatment. RESULTS: Urinary VOC profiles of CRC patients were indistinguishable from either spouses or relatives. When spouses and relatives were grouped together to form a larger non-cancer control group (n = 82), their VOC profiles became distinguishable from those of CRC patients (n = 56) with 69% sensitivity and specificity, area under the curve 0.72 (P < 0.001). Microbiome analysis identified > 1300 operational taxonomic units across all groups. The analysis of similarity R value was 0.067 (P < 0.001), with significantly different bacterial abundances in 82 operational taxonomic units (6.2%) by Kruskal-Wallis testing. CRC patients' VOC or stool microbiome profiles were unchanged after treatment. CONCLUSION: Although CRC patients' urinary VOC profiles cannot be differentiated from those of spouses or relatives they can be differentiated from a larger non-cancer control group. Comparison of the groups' microbiomes confirmed differences in bacterial species abundance. The current FAIMS-based assay can detect a unique, but modest, signal in CRC patients' urinary VOCs, which remains unaltered after treatment.

Improving patient outcomes with inguinal hernioplasty-local anaesthesia versus local anaesthesia and conscious sedation: a randomized controlled trial.

PURPOSE: Conscious sedation is regularly used in ambulatory surgery to improve patient outcomes, in particular patient satisfaction. We hypothesized that the addition of conscious sedation would provide greater patient satisfaction with inguinal hernioplasty compared to local anesthesia alone. METHODS: This trial was a single-centre, randomized, placebo-controlled, double-blinded trial where patients undergoing inguinal hernioplasty using local anaesthesia were randomized to receive local anaesthesia alone versus local anaesthesia and conscious sedation. The primary outcome of patient satisfaction was assessed using the Iowa Satisfaction with Anesthesia Scale (ISAS). The study was powered to detect a significant difference in ISAS scores between groups. Comparisons were made using T test and Chi square tests. A p value of less than 0.05 was considered significant. RESULTS: There were 149 patients randomized: 78 to the local anesthesia (LA) group and 71 to the local anaesthesia and conscious sedation (LACS) group. For the primary outcome measure of patient satisfaction, the mean ISAS score was significantly greater in the LACS group (p = 0.009). The experience of pain and pain severity was greater in the LA group (p = 0.016; p = 0.0162 respectively). No statistically significant difference was found between groups with respect to operative time, time to discharge or postoperative complications. CONCLUSION: The use of conscious sedation with local anesthesia for inguinal hernioplasty is safe, results in less pain experience and severity and is associated with better patient satisfaction. The use of conscious sedation does not delay patient discharge.

Comparing assessment tools for detecting undernutrition in patients with liver cirrhosis.

BACKGROUND AND AIMS: Undernutrition in cirrhotic patients is often poorly recognised until late-stages. The current UK screening tool, the Malnutrition Universal Screening Tool, can miss undernutrition in patients with ascites/fluid retention. A 6-question Liver Disease Undernutrition Screening Tool (LDUST) has been developed in America. METHODS: We sought to compare LDUST with MUST in the detection of undernutrition in 50 inpatients and 50 outpatients with liver cirrhosis in a secondary care setting. This was then validated by a dietitian assessment. RESULTS: Similar patient demographics and liver disease aetiologies were found in the two cohorts. Mean Child-Pugh scores were higher for inpatients, 8.3 (SD 1.9) vs 5.9 (SD 1.2). LDUST detected undernutrition in 45/50 inpatients (90%) and 34/50 outpatients (68%). MUST scores ≥2 were present in 19/50 (38%) inpatients and 9/50 (18%) outpatients. In those with a MUST score <2, LDUST detected undernutrition in 26/31 (84%) inpatients and 27/41 (66%) outpatients. 26 inpatients had undernutrition using LDUST but had a MUST score <2, 20 (76%) of these were deemed to be undernourished by dietetics assessment. LDUST was mostly completed independently or with minimal assistance (80% inpatients, 100% outpatients), with mean completion times of 4 and 3 min for in- and outpatients respectively. CONCLUSION: LDUST is a quick and easy screening tool, which appears better able than MUST to detect undernutrition in cirrhotic patients, including undernutrition missed by MUST. Importantly the tool was validated against dietitian assessments. The high rates of undernutrition among cirrhotic inpatients suggest that screening this cohort is unnecessary, and instead all should undergo dietitian review, with LDUST utilised in an outpatient setting.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Breathomics--exhaled volatile organic compound analysis to detect hepatic encephalopathy: a pilot study.

The current diagnostic challenge with diagnosing hepatic encephalopathy (HE) is identifying those with minimal HE as opposed to the more clinically apparent covert/overt HE. Rifaximin, is an effective therapy but earlier identification and treatment of HE could prevent liver disease progression and hospitalization. Our pilot study aimed to analyse breath samples of patients with different HE grades, and controls, using a portable electronic (e) nose. 42 patients were enrolled; 22 with HE and 20 controls. Bedside breath samples were captured and analysed using an uvFAIMS machine (portable e-nose). West Haven criteria applied and MELD scores calculated. We classify HE patients from controls with a sensitivity and specificity of 0.88 (0.73-0.95) and 0.68 (0.51-0.81) respectively, AUROC 0.84 (0.75-0.93). Minimal HE was distinguishable from covert/overt HE with sensitivity of 0.79 and specificity of 0.5, AUROC 0.71 (0.57-0.84). This pilot study has highlighted the potential of breathomics to identify VOCs signatures in HE patients for diagnostic purposes. Importantly this was performed utilizing a non-invasive, portable bedside device and holds potential for future early HE diagnosis.

Dengue fever mimicking acute appendicitis: A case report.

INTRODUCTION: Dengue fever is an acute viral disease, which usually presents as a mild febrile illness. Patients with severe disease present with dengue haemorrhagic fever or dengue toxic shock syndrome. Rarely, it presents with abdominal symptoms mimicking acute appendicitis. We present a case of a male patient presenting with right iliac fossa pain and suspected acute appendicitis that was later diagnosed with dengue fever following a negative appendicectomy. PRESENTATION OF CASE: A 13-year old male patient presented with fever, localized right-sided abdominal pain and vomiting. Abdominal ultrasound was not helpful and appendicectomy was performed due to worsening abdominal signs and an elevated temperature. A normal appendix with enlarged mesenteric nodes was found at surgery. Complete blood count showed thrombocytopenia with leucopenia. Dengue fever was now suspected and confirmed by IgM enzyme-linked immunosorbent assay against dengue virus. DISCUSSION: This unusual presentation of dengue fever mimicking acute appendicitis should be suspected during viral outbreaks and in patients with atypical symptoms and cytopenias on blood evaluation in order to prevent unnecessary surgery. CONCLUSION: This case highlights the occurrence of abdominal symptoms and complications that may accompany dengue fever. Early recognition of dengue fever mimicking acute appendicitis will avoid non-therapeutic operation and the diagnosis may be aided by blood investigations indicating a leucopenia, which is uncommon in patients with suppurative acute appendicitis.

Mucinous cystadenoma of the appendix presenting with an elevated carcinoembryonic antigen (CEA): Report of two cases and review of the literature.

INTRODUCTION: Despite the fact the mucocoele of the appendix is a rare entity it has been the subject of much interest in the literature. The term mucocoele refers to cystic dilatation of the appendix filled with mucin resulting from proximal obstruction of the appendix lumen. PRESENTATION OF CASE: We report two patients presenting with mucinous cystadenoma of the appendix with elevation of serum carcinoembryonic antigen (CEA), which has rarely been reported. Both patients had mild symptoms and a normal colonoscopy preoperatively. The diagnosis was not suspected in one patient prior to surgery. The elevated CEA prompted additional diagnostic radiologic investigations including ultrasonography, and computed tomography scans. The patients had uneventful appendicectomies with subsequent normalization of their CEA levels. DISCUSSION: Mucinous cystadenoma of the appendix is a rare pathological entity characterized by a dilated mucous filled appendix. The presence of an elevated CEA associated with the presence of this entity is a rare presentation. CONCLUSION: Because the diagnosis is rarely suspected prior to surgery patients with an enlarged appendix with associated elevated CEA levels should have careful investigations to exclude malignancy.

Female Cape sugarbirds (Promerops cafer) modify egg investment both for extra-pair mates and for male tail length.

The differential allocation hypothesis predicts that females should invest more in reproduction when paired with attractive males. We measured egg volume in Cape sugarbirds (Promerops cafer), a sexually dimorphic passerine, in relation to paternity of the offspring and in response to an experimental tail length treatment. We manipulated tail length, after pair formation, but before egg laying: males had their tails either shortened or left unmanipulated. Our manipulation was designed to affect female allocation in a particular breeding attempt rather than long-term mate choice: males with shortened tails would appear to be signalling at a lower level than they should given their quality. We found that egg volume was smaller in the nests of males with experimentally shortened tails but larger when the offspring were the result of extra-pair matings. Both these findings are consistent with the differential allocation hypothesis. We suggest that tail length may be used by females as a cue for mate quality, eliciting reduced female investment when breeding with social mates; and with males with shortened tails.

Actinomycosis of the colon with invasion of the abdominal wall: An uncommon presentation of a colonic tumour.

Actinomycosis is an uncommon chronic suppurative infectious disease that is caused by Actinomycetes organisms, which are gram-positive, microaerophilic, anaerobic bacteria. The most common type causing disease in humans is Actinomyces israelii. This organism is a commensal of the human mouth and is seldom pathogenic. When it does cause disease, however, three main clinical types of involvement are recognized including cervico-facial, thoracic and abdominal actinomycosis.Herein, we present the case of a 79-year-old male patient who underwent surgical exploration following presentation with abdominal pain and an abdominal mass, initially thought to be a malignancy. Pathologic examination confirmed this as a case of abdominal actinomycosis. This diagnosis should always be included in the differential diagnosis of patients who present with an infiltrative abdominal mass.

Finding sex partners on the internet: what is the risk for sexually transmitted infections?

OBJECTIVE: To assess the association between sexual encounters with internet partners and current Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (GC) infections. METHODS: Between August 2006 and March 2008, patients at the Denver Metro Health Clinic were routinely asked about sexual encounters with internet partners. This retrospective case-control study was limited to patients who tested for Ct/GC at their visit. Analyses were stratified by sexual orientation to account for differences in baseline risk behaviours. RESULTS: Of 14 955 patients with a valid Ct/GC test result, 2802 (19%) were infected with Ct/GC. Stratified by sexual orientation, the prevalence of Ct/GC infection was 17% for men who have sex with men (MSM), 21% for men who have sex with women (MSW) and 16% for women. A total of 339 (23%) MSM, 192 (3%) MSW and 98 (2%) women reported having a sexual encounter with a person they met on the internet in the past 4 months. The estimates of the association between recent internet sex partner and current Ct/GC infection were not significant for MSM (risk ratio (RR): 1.12, 95% confidence interval (CI): 0.84 to 1.49) and women (RR: 0.81, 95% CI 0.45 to 1.48). However, the association appeared to be significantly protective among MSW (RR: 0.66, 95% CI 0.44 to 0.98). CONCLUSIONS: Sexual encounters with internet partners did not appear to be associated with increased risk of current Ct/GC infection among people seeking care at a sexual health clinic. Seeking sexual partners on the internet is a complex behaviour and its implications for STI/HIV infection are not fully understood.

Gay men who engage in substance use and sexual risk behaviour: a dual-risk group with unique characteristics.

'Recreational' substances used among men having sex with men, and their association with risky unprotected anal intercourse (RUAI) were examined--for the first time in Israel--in an internet-based questionnaire assessing knowledge, practices and motivation. Between March and May 2005, 2873 participants completed the entire questionnaire. Of the total, 669 (23%) reported RUAI during the last six months, and 1319 (46%) used substances during sex. Use of substance was significantly higher among those performing RUAI than those who did not (31.5% versus 26.4%, P=0.03). Involvement in both substance use and RUAI was reported by 366 participants (13%). HIV rates were higher in this dual-risk group (P<0.01), and individuals reported more partners in the last six months than those not part of this dual risk (11.6 versus 8.2, P=0.02). In multivariate analyses, Tel-Aviv residency, lower education, performing receptive RUAI, misperception of HIV transmission and limited negotiation skills were positively associated with this dual-risk behaviour.

The role of surgeon specialization in improving patient outcomes: a challenge for the Caribbean.

Progressive surgeon specialization has been shown to result in improved patient outcomes for many surgical procedures. This has been demonstrated in improved survival following cancer surgery and improved operative morbidity and mortality for other procedures. Concentrating complex surgical cases in centres where case volume and expertise exist should result in better overall surgical care delivery.

Emergency department thoracotomy in Jamaica: a case controlled study.

Increasing numbers of severely injured patients have been presenting to Emergency Rooms worldwide due to advances in pre-hospital trauma care. Some of these patients may be candidates for Emergency Department Thoracotomy (EDT). Large advisory bodies have identified selection criteria for EDT in Developed Countries, but there are no regional statistics to guide the selection process in Developing Caribbean Nations. This study evaluates outcomes with EDT at the University Hospital of the West Indies in Jamaica in order to determine factors that could predict survival in this setting. A retrospective study was performed over 11 years from January 1995 to January 2006 examining patients who had EDT at the University Hospital of the West Indies. There were 13 procedures performed over 11 years, with two early survivors (15%) and one patient surviving to discharge. The factors that have been found to be significant predictors of mortality include gunshot injuries, extra-thoracic injury location, inadequate pre-hospital resuscitation, prolonged transportation time and the absence of signs of life on arrival to hospital. Several health care limitations have been uncovered in this setting that must be improved if we are to expect improved outcomes. Focused preparation of the Emergency Room is an initial step that can be easily achieved. We also need to define strict management protocols using selection criteria that are tailored to our local environment in order to exclude futile procedures in unsalvageable patients.

Clinicopathologic profile of gastric carcinomas at the University Hospital of the West Indies / Perfil clínico-patológico de los carcinomas gástricos en el Hospital Universitario de West Indies

The objective of this study was to examine the clinicopathologic features of gastric cancer seen at the University Hospital of the West Indies (UHWI) and to compare the findings with other studies. A retrospective study was conducted using data obtained from the surgical pathology reports of all gastrectomies and gastric biopsies during the period January 1993 and December 2002. Additional cases were identified from the Department of Surgery's audit database. Demographic, clinical and pathological features were analyzed. Two hundred and sixteen patients were identified, 126 males and 90 females. One hundred and thirty-six underwent biopsy procedures but no definitive surgery aimed at cancer eradication, while 70 had gastrectomy. The peak age prevalence in both males and females was the 70-79-year age group. While the antrum was the commonest site, there was an overall increase in tumours of the gastro-oesophageal junction and tumours of the entire stomach in the latter five-year period of the review especially in the 50-59-year age group. Epigastric pain and constitutional symptoms were the common presenting features, and the most common gross tumour characteristic was an ulcerating mass, while histologically, the intestinal variety was most common. Lymph node metastases were common. Helicobacter pylori (Hpylori) were present in 16.7while chronic multifocal atrophic gastritis was present in 40. This study indicates that the gastric cancer pattern is typical of developing countries. However, the low prevalence of H pylori in the resected specimens may indicate the importance of other risk factors for gastric cancer development in this population. This warrants further study.

El objetivo de este estudio fue examinar los aspectos clínicopatológicos del cáncer gástrico observados en el Hospital Universitario de West Indies, y comparar nuestros hallazgos con los de otros estudios. Se llevó a cabo un estudio retrospectivo usando datos obtenidos de los reportes patológicos quirúrgicos de todas las gastrectomías y biopsias gástricas durante el período de enero de 1993 y diciembre de 2002. Se identificaron casos adicionales de la base de datos de auditoría del Departamento de Cirugía. Se analizaron aspectos demográficos, clínicos y patológicos. Se identificaron doscientos dieciséis pacientes, 126 hombres y 90 mujeres. Ciento treinta y seis fueron sometidos a procedimientos de biopsia, pero no se realizó ninguna cirugía definitiva encaminada a la erradicación del cáncer, en tanto que a setenta se les practicó gastrectomía. La prevalencia de edad pico tanto en hombres como mujeres fue el grupo de 70–79 años. Si bien el antro gástrico fue el sitio más común, hubo un aumento general en tumores de la unión gastroesofágica y tumores de todo el estómago en el último período quinquenal de la revisión especialmente en el grupo de 50–59 años de edad. El dolor epigástrico y los síntomas constitucionales fueron los síntomas más comunes que se presentaron, y la característica más común del tumor macroscópico fue una masa ulcerosa, mientras que histológicamente la variedad intestinal fue más común. Fueron comunes las metástasis del nódulo linfático. Helicobacter pylori (H pylori) estuvieron presentes en el 16.7 %, en tanto que la gastritis crónica atrófica multifocal estuvo presente en el 40%. Este estudio indica que nuestro patrón de cáncer gástrico es típico de los países en vías de desarrollo. Sin embargo, la baja prevalencia de H pylori en nuestros especímenes resecados, pueden ser un índice de la importancia de otros factores de riesgo tales como fumar, el uso consuetudinario del alcohol, o la dieta, en relación con el desarrollo del cáncer en nuestra población. Esto merece un estudio ulterior.

Selective operative cholangiography in the performance of laparoscopic cholecystectomy.

The objective of this prospective study was to evaluate the role of intraoperative cholangiography (IOC) for patients undergoing laparoscopic cholecystectomy (LC) to determine whether it could be safely omitted for all patients who fit standard criteria, namely normal liver function tests, no history of gallstone pancreatitis, common bile duct (CBD) diameter less than 10 mm or previous history of jaundice. Data were collected prospectively from 194 consecutive patients who had LC for symptomatic gall bladder disease. IOC was not performed in any patient. The conversion rate was 6.1% and one CBD injury occurred. Our experience demonstrates that LC performed without routine IOC does not result in an increased incidence of retained stones in selected patients who have no history of pancreatitis, normal liver function tests and CBD less than 10 mm diameter.