Optimising the care of patients with cirrhosis and gastrointestinal haemorrhage: a quality improvement study.

BACKGROUND: Patients with cirrhosis and gastrointestinal haemorrhage are a complex group with high thirty-day mortality rates. AIM: To evaluate the quality of care delivered to patients admitted with gastrointestinal (GI) haemorrhage to a tertiary care centre before and after implementing a quality improvement initiative for better adherence to practice standards. METHODS: This is a prospective cohort study. All patients admitted to a tertiary care centre with a GI haemorrhage and known or suspected chronic liver disease were evaluated before and after the quality improvement initiative was implemented. Interventions to improve quality of care included the delivery of educational sessions for medical practitioners, and creation and implementation of standardised admission order sets. Quality of care measures included delivery of prophylactic antibiotics (PAs) within 24 h of admission, delivery of a somatostatin analogue (SA) and use of a proton pump inhibitor (PPI); optimal care was defined as receiving all three. Secondary outcomes included hospital length of stay (LOS) and 30-day readmission rate. RESULTS: In comparing the preintervention and postintervention groups, we found significant gains in delivering PAs (57% vs. 75%, P=0.05), SAs (54% vs. 76%, P=0.013) and overall optimal care (41% vs. 65%, P=0.008). Use of PPIs did not change and remained in accordance with guidelines (90% vs. 87%, P=0.67). Hospital LOS remained similar between the two groups (6.8 vs. 7.1, P=0.88), whereas the 30-day readmission decreased (41% vs. 13%, P=0.001). CONCLUSION: Implementation of quality improvement initiatives, such as targeted educational efforts and standardised order sets, can improve the quality of care delivered and patient outcomes in patients with cirrhosis and GI haemorrhage.

A noninvasive imaging technique to evaluate therapeutic efficacy after injection of n-butyl-2- cyanoacrylate tissue adhesive into gastric varices: a case report.

A novel use of multidetector computed tomographic intravenous (MDCT IV) portography in the evaluation of gastric varices treated with tissue adhesive is described. A 55-year-old man presented with upper gastrointestinal hemorrhage as a result of bleeding gastric varices. The patient was stabilized and the gastric varices were treated with n-butyl-2-cyanoacrylate (two injections, total 7.5 mL). MDCT IV portography performed after injection revealed thrombosis of all but one of the submucosally based gastric varices. The endoscopist who performed repeat endoscopy three weeks later was then able to direct therapy at the remaining patent submucosally based gastric varix. This represents the first reported use of MDCT IV portography in the evaluation of treatment adequacy in a patient with gastric varices treated with n-butyl-2-cyanoacrylate.

FDG-PET in inflammatory bowel disease.

Accurate, inexpensive, non-invasive studies in evaluation of inflammatory bowel disease (IBD) would represent a significant advancement in identifying and measuring disease activity. There is new evidence that positron emission tomography (PET) scanning can fulfill many of these criteria. The aim of this review is to report the studies pertaining to the use of PET in IBD and provide an evidence-based approach on how to use PET clinically in IBD. Searching Medline and the Cochrane Database of Clinical Trails on July 18, 2008 identified 12 relevant manuscripts for review. Types of studies of PET in IBD include the incidental identification of IBD during studies performed for other indications, the evaluation of suspected IBD and the assessment of known IBD. PET has been studied in both children and adults and has shown excellent sensitivity for detecting active bowel inflammation, but with poor specificity in some studies. PET alone appears sufficient for the evaluation of ulcerative colitis, but PET/computed tomography provides considerably more information over PET alone in the evaluation of Crohn's disease. Current clinical applications for PET in IBD include its use in the early evaluation of IBD, especially in children who may not tolerate an invasive test such as colonoscopy; and its use in differentiating between a flare of IBD versus the onset of a non-inflammatory process causing similar symptoms in patients with known IBD. Many unanswered questions remain, but PET appears to be a promising tool in the non-invasive evaluation of IBD.

Regulation of Na(+) reabsorption by the aldosterone-induced small G protein K-Ras2A.

Xenopus laevis A6 cells were used as model epithelia to test the hypothesis that K-Ras2A is an aldosterone-induced protein necessary for steroid-regulated Na(+) transport. The possibility that increased K-Ras2A alone is sufficient to mimic aldosterone action on Na(+) transport also was tested. Aldosterone treatment increased K-Ras2A protein expression 2.8-fold within 4 h. Active Ras is membrane associated. After aldosterone treatment, 75% of K-Ras was localized to the plasma membrane compared with 25% in the absence of steroid. Aldosterone also increased the amount of active (phosphorylated) mitogen-activated protein kinase kinase likely through K-Ras2A signaling. Steroid-induced K-Ras2A protein levels and Na(+) transport were decreased with antisense K-ras2A oligonucleotides, showing that K-Ras2A is necessary for the natriferic actions of aldosterone. Aldosterone-induced Na(+) channel activity, was decreased from 0.40 to 0.09 by pretreatment with antisense ras oligonucleotide, implicating the luminal Na(+) channel as one final effector of Ras signaling. Overexpression of K-Ras2A increased Na(+) transport approximately 2.2-fold in the absence of aldosterone. These results suggest that aldosterone signals to the luminal Na(+) channel via multiple pathways and that K-Ras2A levels are limiting for a portion of the aldosterone-sensitive Na(+) transport.