Survival and prognostic indicators in compensated and decompensated cirrhosis

Six-year survival of cirrhosis was assessed in a series of 1155 consecutive patients (751 men, 404 women). Among the men, 33% were alcoholics and 18% were HB_sAg positive; corresponding figures for the women were 15% and 6%, respectively. Features of decompensation at first presentation were observed in 63% of the patients. Six-year survival was 54% in compensated and 21% in decompensated patients. No significant differences in survival were found between alcoholics and nonalcoholics. Leading causes of death were liver failure (49%), hepatocellular carcinoma (22%), and bleeding (13%). The prognostic role of 21 variables was evaluated separately in compensated and decompensated patients by the Cox's regression model. The following variables were found to be significant predictors of death risk in compensated patients: male sex, HB_sAg positivity, age, prothrombin time prolongation, and esophageal varices. In decompensated disease the significant indicators of death risk were: hepatocellular carcinoma, encephalopathy, hemorrhage, SGOT, esophageal varices, gamma globulins, prothrombin time prolongation, continued abuse of alcohol, HB_sAg positivity, gamma glutamyl transpeptidase, and cholinesterase. A simple prognostic index based upon the relative risk coefficient of the significant variables is suggested.Members of the Liver Study Group are: Maria Caltagirone, Gabriella Filippazzo, Giovanni Gatto, Gandolfo Giannuoli, Silvio Margin, Guiseppe Malizia, Lorenzo Maniaci, Maria Pia Marcenó, Alberto Maringhini, Rocco Micciolo, Salvatore Orsini, Fabio Pace, Ugo Palazzo, Linda Pasta, Giuseppina Russo, Rosa Giovanna Simonetti, Mario Spinello, Mario Traina, Mario Valenza, Maria Vinci, Giovanni Vizzini.     

Alcoholism Diagnoses for Convicted Drinking Drivers Referred for Alcoholism Evaluation

The types and extent of alcohol-related problems were determined for a sample of 461 convicted drinking drivers who were referred to an alcoholism treatment facility for evaluation and possible treatment. Using responses to questionnaire and structured interview questions on alcohol-related problems, DSM III diagnoses are constructed; approximately three-quarters of the sample are diagnosed with sufficient severity for a DSM III diagnosis of abuse or dependence. Self-reported consumption levels and drinking/driving incidents increase as the level of the alcohol problem increases; persons in the Alcohol Abuse category are heavier consumers and drive more frequently after drinking than are persons who are not diagnosed by the DSM III as having an alcohol problem. Persons in the Alcohol Dependence category are heavier consumers than either the Alcohol Abuse or Undiagnosed Problem categories and report more drinking/driving incidents. The DSM III provides useful subcategories of convicted drinking drivers referred for alcoholism evaluation and distinguishes groups differing in quality, frequency, and self-reported DWI measures, independent of basic demographics. These analyses suggest that drinking/driving countermeasures should include intervention efforts to address alcohol-related problems. Serious alcohol problems exist among some drinking drivers, and drinking/driving incidents are more frequent among these individuals.     

MECHANISMS OF HYPOPHOSPHATAEMIA IN ALCOHOLIC PATIENTS

The aim of our study was to determine the possible pathophysiological mechanisms of hypophosphataemia in a group of 127 patients admitted to hospital for alcohol-related causes. Blood and fresh urine specimens were taken to determine acid-base and electrolyte parameters. Thirty-seven patients (29.1%) had hypophosphataemia (serum phosphorus <0.77 mmol/l) with a range of serum phosphorus of 0.32-0.74 mmol/l. In 17 hypophosphataemic patients inappropriate phosphaturia (FEP04 >20%, TmPO₄/GFR<0.80 mmol/l) was evident, possibly due to hypomagnesaemia, metabolic acidosis, metabolic alkalosis, or a proximal tubular defect in phosphate transport. The causes of hypophosphataemia in the remaining 20 patients were alcohol withdrawal syndrome, respiratory alkalosis and diarrhoea. Patients with hypophosphataemia were more often found to have hypomagnesaemia and respiratory alkalosis than normophosphataemic patients. In conclusion, hypophosphataemia is frequently observed in alcoholic patients due to various pathophysiological mechanisms, such as inappropriate phosphaturia, increased phosphorus entry into cells and increased gastrointestinal loss of phosphate.     

Comparative effectiveness of allergy testing method in driving immunotherapy outcomes

Background

Skin‐prick testing (SPT), in vitro testing (IVT), and intradermal‐dilutional testing (IDT) are methods to detect patient sensitivities to specific allergens and direct immunotherapy dosing. We used objective and subjective measures of improvement to compare outcomes based on test method.

Methods

Patients underwent 1 of 3 protocols: SPT, screening SPT followed by IDT, or IVT. We used institution billing data to do a cost analysis of these tests. The time to maintenance (TTM) therapy was analyzed and patients were stratified into high and low reactors. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was used to quantify symptoms pre‐maintenance and post‐maintenance.

Results

Of 177 patients (SPT, n = 40; IVT, n = 91; IDT, n = 46), 115 (SPT, n = 35; IVT, n = 39; IDT, n = 41) were high reactors. Out of 90 patients (SPT, n = 17; IVT, n = 37; IDT, n = 36) reaching maintenance, 58 were high reactors (SPT, n = 15; IVT, n = 12; IDT, n = 31). Overall, SPT, IVT, and IDT median TTM were 542, 329, and 578.5 days, respectively. IDT TTM was shorter compared to IVT overall and in high reactors (hazard ratio [HR] = 1.91, p = 0.02; HR = 2.12, p = 0.03), but was not significant compared to SPT high reactors (p = 0.33). The IDT cost was $62.66, translating to an incremental cost‐effectiveness ratio of $0.23 per day of shortened TTM. Median RQLQ change for the SPT, IVT, and IDT groups was 6.5, 1, and 1.5, respectively, but was not significant (p = 0.60).

Conclusion

IDT reached maintenance immunotherapy quicker than IVT but there was no difference compared to SPT. TTM did not correlate with improvements in patient symptoms between testing methods. This study represents a novel comparison of outcomes based on initial allergy testing method.