Acute Kidney Injury in Patients with Liver Cirrhosis: Prevalence, Predictors, and In-Hospital Mortality at a District Hospital in Ghana.

BACKGROUND: Acute kidney injury (AKI) is one of the most severe complications of cirrhosis and portends an ominous prognosis with an estimated mortality of about 50% in a month and 65% within a year. Infection and hypovolemia have been found to be the main precipitating factors of AKI in liver cirrhosis. Early detection and treatment of AKI may improve outcomes. AKI in patients with liver cirrhosis in Ghana and their impact on inpatient mortality are largely unknown. This study was aimed at determining the prevalence, precipitating factors, predictors, and in-hospital mortality of AKI in patients with liver cirrhosis admitted to a district hospital in Ghana. METHODS: Consecutive hospitalized patients with liver cirrhosis from 1 January 2018 to 30 April 2020 were recruited. Patient's demographic data and clinical features were collected using a standardized questionnaire. Biochemical and haematological tests as well as abdominal ultrasound scans were done for all patients. All patients were then followed up until discharge or death. RESULTS: There were 117 (65.4%) males out of the 179 patients with a mean age of 49.94 and 45.84 years for those with and without AKI, respectively. The prevalence of AKI was 27.9% (50/179). Out of 50 participants with AKI, 64.0% (32/50) died, contributing 41.0% of all in-patient mortality amongst participants. There was a significant association between AKI and death (p ≤ 0.001). The major precipitating factors of AKI were infections (60.0%), hypovolemia (20.0%) due to gastrointestinal bleeding and gastroenteritis, and refractory ascites (16.0%). Alkaline phosphatase, INR, model for end-stage liver disease sodium, sodium, and blood urea nitrogen were independent predictors of AKI. CONCLUSION: AKI was common among patients with liver cirrhosis with high in-patient mortality. Identification of these precipitants and independent predictors of AKI may lead to prompt and targeted treatment with reduction in patient mortality.

Sociodemographic characteristics, complications requiring hospital admission and causes of in-hospital death in patients with liver cirrhosis admitted at a district hospital in Ghana.

BACKGROUND: Chronic liver diseases including liver cirrhosis are a major cause of morbidity and mortality globally. Despite the high burden of liver cirrhosis in Ghana, data on this disease is lacking. OBJECTIVE: To determine the sociodemographic characteristics, reasons for admission, and in-hospital mortality of patients with cirrhosis of the liver seen at a district hospital in Ghana. METHODS: A prospective study was conducted involving one hundred and eighty-six (186) patients admitted on the medical wards in St. Dominic hospital with liver cirrhosis from 1st January 2018 to 24th June 2020. The patient's demographic and clinical features were documented using a standardized questionnaire. Diagnostic biochemical and haematological tests as well as abdominal ultrasound scans were performed for all patients. They were followed up until death or discharge from hospital. RESULTS: One hundred and eighty-six patients (186) with a median age of 46 years were included in the study. HBV was the main etiology of liver cirrhosis (38.7%) followed closely by alcohol consumption (38.3%). In-hospital mortality was 41.3% and the most frequent cause of death was hepatic encephalopathy (68.4%). The following were associated with death; Jaundice, weight loss, elevated bilirubin, international normalized ratio (INR), creatinine, blood urea nitrogen(BUN), Child-Pugh score, model for end-stage liver disease sodium score (MELDNa), and low sodium. However, hepatic encephalopathy, MELDNa, INR and BUN were independent predictors of in-hospital mortality on logistic regression analysis. CONCLUSIONS: In-hospital mortality in cirrhotic patients was high with the leading cause of death being hepatic encephalopathy. Timely diagnosis and adequate management of hepatic encephalopathy are necessary to prevent death from liver cirrhosis.

Management of Secondary Poor Response to Botulinum Toxin in Cervical Dystonia: A Multicenter Audit.

BACKGROUND: Botulinum toxin A (BoNT-A) is an effective treatment for cervical dystonia. Nevertheless, up to 30% to 40% patients discontinue treatment, often because of poor response. The British Neurotoxin Network (BNN) recently published guidelines on the management of poor response to BoNT-A in cervical dystonia, but adherence to these guidelines has not yet been assessed. OBJECTIVES: To assess adherence to and usefulness of BNN guidelines in clinical practice. METHODS: We undertook a retrospective medical notes audit of adherence to the BNN guidelines in 3 United Kingdom tertiary neurosciences centers. RESULTS: Of 76 patients identified with poor response, 42 (55%) had a suboptimal response and, following BNN recommendations, 25 of them (60%) responded to adjustments in BoNT dose, muscle selection or injection technique. Of the remaining 34 (45%) patients with no BoNT response, 20 (59%) were tested for immune resistance, 8 (40%) of whom showed resistance. Fourteen (18%) of all patients were switched to BoNT-B, and 27 (36%) were referred for deep brain stimulation surgery. In those not immune to BoNT-A, clinical improvement was seen in 5 (41%) after adjusting their dose and injection technique. CONCLUSION: Our audit shows that optimizing BoNT dose or injection strategy largely led to improvements in those with suboptimal response and in those reporting no response without resistance. It would be helpful to standardize investigations of potential resistance in those with no therapeutic response.

The Prevalence, Predictors, and In-Hospital Mortality of Hepatic Encephalopathy in Patients with Liver Cirrhosis Admitted at St. Dominic Hospital in Akwatia, Ghana.

Background: Hepatic encephalopathy (HE) is one of the most debilitating complications of cirrhosis leading to death. Decrease in HE mortality and recurrence has been linked with timely identification and early treatment. There is a need to document the burden, predictors, and treatment outcomes of HE in an adult population with liver cirrhosis in our setting as only reports from resource-endowed countries abound in the literature. This study aimed therefore to determine the prevalence, predictors, and treatment outcomes of patients with liver cirrhosis admitted at St. Dominic Hospital (SDH) in Akwatia, Ghana. Materials and Methods: A prospective study was conducted involving one hundred and sixty-seven (167) patients admitted at the medical wards in SDH with liver cirrhosis from January 1st, 2018, to March 24th, 2020. The demographic and clinical features of the patients were collected using a standardized questionnaire. Biochemical, haematological, and abdominal ultrasound scans were done for all patients. Patients were then followed up until discharge or death. Results: There were 109 (65.3%) males out of the 167 patients with a mean age of 45.8 and 47.5 years for those with and without HE, respectively. The prevalence of HE was 31.7% (53/167). Out of 53 participants with HE, 75.5% (40/53) died. There was a strong association between HE and death (p < 0.001). The major precipitating factor of HE was infection (64.2%). Severe ascites (OR = 0.009) were clinical feature independently associated with HE, whereas high creatinine (OR = 0.987), blood urea nitrogen (BUN) (OR = 1.199), Child-Pugh score (CPS) (OR = 5.899), and low platelets (OR = 0.992) were the laboratory parameters and scores independently predictive of HE. Conclusion: HE was common among patients with liver cirrhosis admitted at SDH with high in-patient mortality. The commonest precipitating factor for HE was infection(s). Severe ascites, low platelet count, high creatinine, BUN, and CPS were independent predictors of HE.

Stroke Outcome and Determinants among Patients with and without Diabetes in a Tertiary Hospital in Ghana.

BACKGROUND: Diabetes mellitus, a well-established independent risk factor for stroke, has varied association with stroke outcome from previous studies. This study investigated stroke outcome and determinants among patients with and without diabetes in a tertiary hospital in Ghana. METHODS: A prospective study conducted among stroke patients with and without diabetes admitted in a Ghanaian tertiary hospital. Baseline clinical and biochemical data were documented. Functional stroke outcome was evaluated at 1, 3, and 6 months after stroke using the modified Rankin Scale. RESULTS: Number of participants enrolled were 326 and 105 (32.20%) had diabetes. Higher proportions of diabetes patients had poor functional stroke outcome at 1, 3, and 6 months (79%, 75.23%, 73.33%) compared with those without diabetes (70.13%, 65.16, 61.99) (p>0.05). Stroke patients with diabetes had lower survival compared with those without diabetes (p=0.0745). Mortality at 6 months was more likely among ischaemic stroke patients with diabetes compared with those without diabetes (Odds Ratio 2.037; CI: 1.058-3.923). Determinants of poor functional stroke outcome for diabetes patients were older age (Adjusted Odds Ratio (AOR)-1.07; CI-1.03-1.12), female gender (AOR-3.74; CI-1.26-12.65), and pneumonia (AOR-11.32; CI-1.93-220.05) whereas the determinants for those without diabetes were unemployment (AOR-4.19; CI-1.24-19.50), speech abnormalities (AOR-1.99; CI1.08-3.73), and pneumonia (AOR-4.05; CI-1.83-9.77). High fasting plasma glucose (HR-1.15; CI-1.07-1.23), elevated temperature (HR-1.41; CI-1.11-1.79), and pneumonia (HR-2.25; CI-1.44-3.50) were determinants of low survival among all stroke patients. CONCLUSION: Trends towards poorer functional outcome and reduced survival were found among Ghanaian stroke patients with diabetes compared with those without diabetes. Older age, female gender, pneumonia, elevated temperature, and fasting plasma glucose were determinants of adverse outcome in stroke patients with diabetes.