Mese: Settembre 2019

  • Hepatitis B and D

    Hepatitis B and D

    Chronic hepatitis B (CHB) remains a major global healthcare challenge with changing epidemiology and increasing morbidity and mortality from the complications of liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis B virus infection can be broadly categorized into four disease phases: (1) hepatitis B e antigen (HBeAg)-positive chronic infection; (2) HBeAg-positive chronic hepatitis; (3) HBeAg-negative chronic infection; and (4) HBeAg-negative chronic hepatitis.

    After hepatitis B surface antigen loss, patients do not require any specific follow-up but they carry a risk of reactivation in the event of immunosuppression. The primary treatment goal in CHB is to improve survival and quality of life by preventing disease progression and the development of HCC. Current treatment regimens are non-curative and, once initiated, treatment is usually of indefinite duration.

    Treatment decisions are made on the basis of disease assessment and risk stratification. All CHB patients, including those on treatment, should be monitored for disease progression and HCC development. Hepatitis B virus/D virus co-infection represents the most severe form of chronic viral hepatitis because of more rapid disease progression and increased risk of cirrhosis and HCC; thus it requires special consideration. In the present review, we summarize the guidance on hepatitis B and D diagnosis and treatment.

    Keywords

    Chronic hepatitis Bhepatitis B virus infectionhepatitis D virus infection

  • New guidelines from the Thrombosis

    New guidelines from the Thrombosis

    Introduction: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular disease and, globally, more than an estimated 10 million people have it yearly. It is a chronic and recurrent disease. The symptoms of VTE are non‐specific and the diagnosis should actively be sought once considered. The mainstay of VTE treatment is anticoagulation, with few patients requiring additional intervention.

    A working group of experts in the area recently completed an evidence‐based guideline for the diagnosis and management of DVT and PE on behalf of the Thrombosis and Haemostasis Society of Australia and New Zealand

    Main recommendations:

    • The diagnosis of VTE should be established with imaging; it may be excluded by the use of clinical prediction rules combined with D‐dimer testing.
    • Proximal DVT or PE caused by a major surgery or trauma that is no longer present should be treated with anticoagulant therapy for 3 months.
    • Proximal DVT or PE that is unprovoked or associated with a transient risk factor (non‐surgical) should be treated with anticoagulant therapy for 3–6 months.
    • Proximal DVT or PE that is recurrent (two or more) and provoked by active cancer or antiphospholipid syndrome should receive extended anticoagulation.

    Changes in management as a result of the guideline: Most patients with acute VTE should be treated with a factor Xa inhibitor and be assessed for extended anticoagulation.

  • Polypharmacy among older Australians

    Polypharmacy among older Australians

    Objective: To estimate the prevalence of polypharmacy among Australians aged 70 years or more, 2006–2017.

    Design, setting and participants: Analysis of a random 10% sample of Pharmaceutical Benefits Scheme (PBS) data for people aged 70 or more who were dispensed PBS‐listed medicines between 1 January 2006 and 31 December 2017.

    Main outcome measures: Prevalence of continuous polypharmacy (five or more unique medicines dispensed during both 1 April – 30 June and 1 October – 31 December in a calendar year) among older Australians, and the estimated number of people affected in 2017; changes in prevalence of continuous polypharmacy among older concessional beneficiaries, 2006–2017.

    Results: In 2017, 36.1% of older Australians were affected by continuous polypharmacy, or an estimated 935 240 people. Rates of polypharmacy were higher among women than men (36.6% v 35.4%) and were highest among those aged 80–84 years (43.9%) or 85–89 years (46.0%). The prevalence of polypharmacy among PBS concessional beneficiaries aged 70 or more increased by 9% during 2006–2017 (from 33.2% to 36.2%), but the number of people affected increased by 52% (from 543 950 to 828 950).

    Conclusions: The prevalence of polypharmacy among older Australians is relatively high, affecting almost one million older people, and the number is increasing as the population ages. Our estimates are probably low, as we could not take over‐the‐counter or complementary medicines or private prescriptions into account. Polypharmacy can be appropriate, but there is substantial evidence for its potential harm and the importance of rationalising unnecessary medicines, particularly in older people.

  • Treatment of Paracetamol Overdose

    Treatment of Paracetamol Overdose

    Objectives: To assess the numbers of paracetamol overdose‐related hospital admissions and deaths in Australia since 2007–08, and the overdose size of intentional paracetamol overdoses since 2004.

    Design, setting: Retrospective analysis of data on paracetamol‐related exposures, hospital admissions, and deaths from the Australian Institute of Health and Welfare National Hospital Morbidity Database (NHMD; 2007–08 to 2016–17), the New South Wales Poisons Information Centre (NSWPIC; 2004–2017), and the National Coronial Information System (NCIS; 2007–08 to 2016–17).

    Participants: People who took overdoses of paracetamol in single ingredient preparations.

    Main outcome measures: Annual numbers of reported paracetamol‐related poisonings, hospital admissions, and deaths; number of tablets taken in overdoses.

    Results: The NHMD included 95 668 admissions with paracetamol poisoning diagnoses (2007–08 to 2016–17); the annual number of cases increased by 44.3% during the study period (3.8% per year; 95% CI, 3.2–4.6%). Toxic liver disease was documented for 1816 of these patients; the annual number increased by 108% during the study period (7.7% per year; 95% CI, 6.0–9.5%). The NSWPIC database included 22 997 reports of intentional overdose with paracetamol (2004–2017); the annual number increased by 77.0% during the study period (3.3% per year; 95% CI, 2.5–4.2%). The median number of tablets taken increased from 15 (IQR, 10–24) in 2004 to 20 (IQR, 10–35) in 2017. Modified release paracetamol ingestion report numbers increased 38% between 2004 and 2017 (95% CI, 30–47%). 126 in‐hospital deaths were recorded in the NHMD, and 205 deaths (in‐hospital and out of hospital) in the NCIS, with no temporal trends.

  • Faecal calprotectin testing

    Faecal calprotectin testing

    Objectives: To assess the clinical effectiveness of faecal calprotectin (FC) testing for distinguishing between organic gastrointestinal diseases (organic GID), such as inflammatory bowel disease (IBD), and functional gastrointestinal disorders (functional GIDs).

    Study design: Studies that assessed the accuracy of FC testing for differentiating between IBD or organic GID and functional GIDs were reviewed. Articles published in English during January 1998 – June 2018 that compared diagnostic FC testing in primary care and outpatient hospital settings with a reference test and employed the standard enzyme‐linked immunosorbent FC assay method with a cut‐off of 50 or 100 μg/g faeces were included. Study quality was assessed with QUADAS‐2, an evidence‐based quality assessment tool for diagnostic accuracy studies.

    Data sources: MEDLINE and EMBASE; reference lists of screened articles.

    Data synthesis: Eighteen relevant studies were identified. For distinguishing patients with organic GID (including IBD) from those with functional GIDs (16 studies), the estimated sensitivity of FC testing was 81% (95% CI, 74–86%), the specificity 81% (95% CI, 71–88%); area under the curve (AUC) was 0.87. For distinguishing IBD from functional GIDs (ten studies), sensitivity was 88% (95% CI, 80–93%), specificity 72% (95% CI, 59–82%), and AUC 0.89. Assuming a population prevalence of organic GID of 1%, the positive predictive value was 4.2%, the negative predictive value 100%. The difference in sensitivity and specificity between FC testing cut‐offs of 50 μg/g and 100 μg/g faeces was not statistically significant (P = 0.77).

  • Leprosy in Far North Queensland

    Leprosy in Far North Queensland

    People with leprosy, a chronic granulomatous disease caused by Mycobacterium leprae, classically present with hypopigmented or erythematous, anaesthetic skin lesions or thickened peripheral nerves. Leprosy can be cured with antibiotics, but severe deformity and long term disability are common if therapy is delayed.

    Leprosy is now very rarely acquired in Australia, but it is still diagnosed; Indigenous Australians in remote locations bear the greatest burden of disease.1,2 Historically, its incidence has been highest in the Northern Territory, but cases are also diagnosed in Far North Queensland (FNQ), a region that adjoins Papua New Guinea (PNG), where leprosy remains endemic.

    Since 1985, Torres Strait Islander Australians and PNG nationals have been able to move freely across the border to pursue traditional activities in the Torres Strait Protected Zone. This arrangement acknowledges the importance of their shared cultural history, but also means that FNQ clinicians may encounter conditions that are rare in temperate Australia. The potential public health implications are also clear.

  • RNA Strands Isolated

    RNA Strands Isolated

    Cereal yellow dwarf virus (CYDV) RNA has a 5′-terminal genome-linked protein (VPg). We have expressed the VPg region of the CYDV genome in bacteria and used the purified protein (bVPg) to raise an antiserum which was able to detect free VPg in extracts of CYDV-infected oat plants. A template-dependent RNA-dependent RNA polymerase (RdRp) has been produced from a CYDV membrane-bound RNA polymerase by treatment with BAL 31 nuclease. The RdRp was template specific, being able to utilize templates from CYDV plus- and minus-strand RNAs but not those of three unrelated viruses, Red clover necrotic mosaic virusCucumber mosaic virus, and Tobacco mosaic virus.

    RNA synthesis catalyzed by the RdRp required a 3′-terminal GU sequence and the presence of bVPg. Additionally, synthesis of minus-strand RNA on a plus-strand RNA template required the presence of a putative stem-loop structure near the 3′ terminus of CYDV RNA. The base-paired stem, a single-nucleotide (A) bulge in the stem, and the sequence of a tetraloop were all required for the template activity. Evidence was produced showing that minus-strand synthesis in vitro was initiated by priming by bVPg at the 3′ end of the template. The data are consistent with a model in which the RdRp binds to the stem-loop structure which positions the active site to recognize the 3′-terminal GU sequence for initiation of RNA synthesis by the addition of an A residue to VPg.

    In vitro RNA-dependent RNA polymerase (RdRp) systems have been established for several plus-strand RNA plant viruses and, along with in vivo methods, have been useful in elucidating the mechanisms of the virus RNA replication. Generally the isolated RdRp complexes are comprised of the virus RdRp per se, other virus replication proteins, and host proteins. In many cases, these RdRps are template specific and are able to initiate RNA synthesis de novo at or near the 3′ end of the template 

  • New Medicine for Sciatica

    New Medicine for Sciatica

    As many as 4 out of every 10 people will get sciatica, or irritation of the sciatic nerve, at some point in their life. This nerve comes from either side of the lower spine and travels through the pelvis and buttocks. Then the nerve passes along the back of each upper leg before it divides at the knee into branches that go to the feet.

    Anything that puts pressure on or irritates this nerve can cause pain that shoots down the back of one buttock or thigh. The sensation of pain can vary widely. Sciatica may feel like a mild ache; a sharp, burning sensation; or extreme discomfort. Sciatica can also cause feelings of numbness, weakness, and tingling.

    Pain may be made worse by prolonged sitting, standing up, coughing, sneezing, twisting, lifting, or straining. Treatment for sciatic pain ranges from hot and cold packs and medications to exercises and complementary and alternative remedies.

  • Age of Nano Kidneys

    Age of Nano Kidneys

    Immunosenescence involves a series of ageing-induced alterations in the immune system and is characterized by two opposing hallmarks: defective immune responses and increased systemic inflammation. The immune system is modulated by intrinsic and extrinsic factors and undergoes profound changes in response to the ageing process. Immune responses are therefore highly age-dependent.

    Emerging data show that immunosenescence underlies common mechanisms responsible for several age-related diseases and is a plastic state that can be modified and accelerated by non-heritable environmental factors and pharmacological intervention. In the kidney, resident macrophages and fibroblasts are continuously exposed to components of the external environment, and the effects of cellular reprogramming induced by local immune responses, which accumulate with age, might have a role in the increased susceptibility to kidney disease among elderly individuals.

    Additionally, because chronic kidney disease, especially end-stage renal disease, is often accompanied by immunosenescence, which affects these patients independently of age, and many kidney diseases are strongly age-associated, treatment approaches that target immunosenescence might be particularly clinically relevant.

  • Alcohol and the liver

    Alcohol and the liver

    Hospital admissions because of alcohol-related liver disease (ArLD) are increasing. The amount of alcohol consumed and pattern of drinking are linked to increased risk of ArLD. However, other factors such as obesity, co-existent liver disease – particularly hepatitis C, gender, nutritional status and genetic factors also play a role.

    The spectrum of ArLD ranges from steatosis to alcoholic hepatitis to established cirrhosis, and the alcohol-related injury involves multiple mechanisms. Chronic, excessive alcohol consumption can cause cirrhosis in the absence of alcohol dependency syndrome or indicators of alcohol abuse. Presentation is variable, and recognition requires the clinician to be aware of the significance of a history of alcohol excess, clinical stigmata of liver disease and compatible laboratory investigations.

    Not all people who drink excess alcohol have alcohol as the cause of their liver disease, and other aetiologies must be excluded. The key to management is long-term abstinence, and interventions should be delivered in conjunction with addiction services. Nutritional issues should also be addressed. Acute alcoholic hepatitis has a high mortality, and patients with the highest risk can benefit from short-term corticosteroids. Cirrhotic patients require hepatoma surveillance and variceal screening; liver transplant should be considered in selected cases.

    Keywords

    Alcoholalcoholic hepatitisalcoholic liver diseasecirrhosis

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