Hepatitis E is the most common cause of hepatitis worldwide. While originally considered a disease of developing countries, it is increasingly recognised in developed countries, probably related to contaminated pork meat, and where infection is often asymptomatic. However, several non-liver manifestations have become apparent, the most important of which are neurological, including Guillain-Barr e syndrome (acute inflammatory demyelinating polyradiculoneuropathy (AIDP)), neuralgic amyotrophy and meningoencephalitis. We recommend testing all patients with AIDP and neuralgic amyotrophy for hepatitis E and consider testing any patient with an unexplained neurological illness and abnormal liver function tests for the virus.
Background: Anti-drug antibodies are associated with treatment failure to anti-TNF agents in patients with inflammatory bowel disease (IBD).Aim: To assess whether immunogenicity to a patient's first anti-TNF agent would be associated with immunogenicity to the second, irrespective of drug sequence Methods: We conducted a UK-wide, multicentre, retrospective cohort study to report rates of immunogenicity and treatment failure of second anti-TNF therapies in 1058 patients with IBD who underwent therapeutic drug monitoring for both infliximab and adalimumab. The primary outcome was immunogenicity to the second anti-TNF agent, defined at any timepoint as an anti-TNF antibody concentration ≥9 AU/ml for infliximab and ≥6 AU/ml for adalimumab.
IntroductionBoth drug induced liver injury (DILI) and ischaemic hepatitis (IH) present acutely and neither have specific diagnostic tests. Therefore, diagnosis and hence the management relies upon signature pattern of manifestations. We hypothesised that the temporal pattern in the change of bilirubin and alanine transaminase (ALT) may help distinguish those patients with IH compared to DILI.MethodRetrospective single centre analysis of biochemical data from 68 sequential patients with IH over 84 months (mean age 65 ±SEM 1.1 year, 63% male) and 66 patients with DILI (67 ±SEM 1.9 year; 46% male) over a 79 month period. Patients were identified from the hospital biochemistry and outpatient Jaundice Hotline (JHL) databases. The diagnosis of DILI based on the use of established causality assessment methods (RUCAM). IH cases were defined as patients with an ALT level >1000 iu/L and exclusion of those with elevated paracetamol levels, autoimmune or viral hepatitis and DILI on clinical review. Comparative ALT and bilirubin data between the two groups was analysed from 14 days prior to and 35 days after presentation (day 0) using unpaired t tests for unequal variance.ResultsThe IH cohort had a higher rise in index ALT (1321 ±SEM166 iu/l) compared to those with DILI (319±32; p<0.0001) but by day 14 this difference was significantly reversed (79±7 vs 211±44; p<0.006). The mean bilirubin in the DILI vs IH group was significantly higher at presentation (95±11 vs 21±2 umol/L) with a peak at day 14 of 140±23 umol/L with only a slow fall by day 35 to 100±22 umol/L in the DILI group.The data for change in bilirubin and ALT over the study period are shown in Figures 1 and 2.Abstract PWE-087 Figure 1Abstract PWE-087 Figure 2ConclusionThese data support the hypothesis that patients with ischaemic hepatitis demonstrate a rapid rise and fall in ALT following an ischaemic insult and subsequently have a relatively short recovery phase compared to those with DILI. Conversely, patients with severe DILI exhibit a high index bilirubin. These presenting biochemical features and temporal changes may help distinguish DILI from IH.Disclosure of InterestNone Declared
2. Those at high risk of aspiration of gastric feed.Results 8 patients failed to establish adequate NG feeding due to !2 GRVs above 400 ml; all attempted bedside NJT insertion but only 5 were successful. It was noted when more training was provided, 3 NJT were placed within a 2 week period.Delays in NJ placement, medical team shifts and inadequate use of prokinetics (<24h) often led to lower GRVs, excluding patients from NJT placement. This resulted in patients restarting gastric feeding with varied success.Prior to NJ insertion, 7 patients received adequate doses of prokinetics. 1 patient had a reaction to erythromycin. For this patient, metoclopramide was not effective enough except when a higher dose was given (20 mg vs 10 mg). This suggests scope for optimising the prokinetic dose to ensure the success of NJT placement.Mean time between NJ insertion and X-ray position confirmation was 10 hr. This considerably improves nutritional delivery as in the previous service evaluation, patients awaiting endoscopically placed NJT had no nutrition fordays 2 . Conclusions Bedside NJ insertion can be a useful tool to facilitate the provision of enteral nutrition, avoid long gaps in nutrition in critically-ill patients and avoid PN. However, widespread adoption of this protocol requires training and engagement of medical staff and protocol optimisation.
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