Decompensated cirrhosis-related admissions in a large urban hospital in Uganda: prevalence,clinical and laboratory features and implications for planning patient management

Background

Cirrhosis-related complications are a major cause of morbidity and mortality in areas where its risk factors are endemic.

Objective

We determined the prevalence of decompensated cirrhosis among patients on the gastroenterology service of Mulago Hospital and described the clinical and laboratory features of these patients.

Methods

All patients admitted to the unit were assessed and their diagnosis documented. Patients with cirrhosis had clinical features of decompensation recorded. History of alcohol consumption was taken and testing for hepatitis B surface antigen (HBsAg) and hepatitis C antibody (anti-HCV) performed.

Results

Between September 2010 and January 2011, we enrolled 482 patients. The majority (53.7%) were male, overall median age 38 years. Decompensated cirrhosis was diagnosed in 85 (17.6%) patients. Of the 85 patients, 47 (55.3%) gave a history of alcohol intake, HBsAg was positive in 23 (27.1%) and anti-HCV in 3 (3.5%). Decompensation was defined by ascites among 81 (95.3%) patients, variceal bleeding in 31 (36.5%), encephalopathy in 20 (23.5%).

Conclusion

Cirrhosis is common in Mulago hospital presenting mainly with ascites and variceal bleeding. Aside from controlling causes of liver diseases, especially alcohol and hepatitis B virus infection, in the interim it is necessary to manage complications in patients who already have cirrhosis.     

Bottom-up analysis of emergent properties of N-acetylcysteine as an adjuvant therapy for COVID-19

N-acetylcysteine (NAC) is an abundantly available antioxidant with a wide range of antidotal properties currently best studied for its use in treating acetaminophen overdose. It has a robustly established safety profile with easily tolerated side effects and presents the Food and Drug Administration's approval for use in treating acetaminophen overdose patients. It has been proven efficacious in off-label uses, such as in respiratory diseases, heart disease, cancer, human immunodeficiency virus infection, and seasonal influenza. Clinical trials have recently shown that NAC's capacity to replenish glutathione stores may significantly improve coronavirus disease 2019 (COVID-19) outcomes, especially in high risk individuals. Interestingly, individuals with glucose 6-phosphate dehydrogenase deficiency have been shown to experience even greater benefit. The same study has concluded that NAC's ability to mitigate the impact of the cytokine storm and prevent elevation of liver enzymes, C-reactive protein, and ferritin is associated with higher success rates weaning from the ventilator and return to normal function in COVID-19 patients. Considering the background knowledge of biochemistry, current uses of NAC in clinical practice, and newly acquired evidence on its potential efficacy against COVID-19, it is worthwhile to investigate further whether this agent can be used as a treatment or adjuvant for COVID-19.     

Hyperbaric oxygen treatment prevents nitric oxide‐induced apoptosis in articular cartilage injury via enhancement of the expression of heat shock protein 70

Heat shock proteins (HSPs), inflammatory cytokines, nitric oxide (NO), and localized hypoxia‐induced apoptosis are thought to be correlated to the degree of cartilage injury. We investigated the effect of hyperbaric oxygen (HBO) on (1) interleukin‐1β (IL‐1β)‐induced NO production and apoptosis of rabbit chondrocytes and (2) healing of articular cartilage defects. For the in vitro study, RT‐PCR and Western blotting were performed to detect mRNA and protein expressions of HSP70, inducible NO synthase (iNOS), and caspase 3 in IL‐1β‐treated chondrocytes. To clarify that the HSP70 was necessary for anti‐iNOS and anti‐apoptotic activity by HBO, we treated the cells with an HSP70 inhibitor, KNK437. For the in vivo study, cartilage defects were created in rabbits. The HBO group was exposed to 100% oxygen at 2.5 ATA for 1.5 h a day for 10 weeks. The control group was exposed to normal air. After sacrifice, specimen sections were sent for examination using a scoring system. Immunohistochemical analyses were performed to detect the expressions of iNOS, HSP70, and caspase 3. Our results suggested that HBO upregulated the mRNA and protein expressions of HSP70 and suppressed those of iNOS and caspase 3 in chondrocytes. KNK437 inhibited the HBO‐induced downregulation of iNOS and casapase 3 activities. The histological scores showed that HBO markedly enhanced cartilage repair. Immunohistostaining showed that HBO enhanced HSP70 expression and suppressed iNOS and caspase 3 expressions in chondrocytes. Accordingly, HBO treatment prevents NO‐induced apoptosis in articular cartilage injury via enhancement of the expression of heat shock protein 70. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31: 376–384, 2013     

Surgical approaches for nonneurogenic elbow heterotopic ossification with ulnar neuropathy

BACKGROUND: Few reports are available concerning elbow heterotopic ossification (HO) and its optimal management in nonneurologic or nonburn patients after repetitive elbow manipulation. The unique anatomic relationship of the ulnar nerve at the elbow renders it rather vulnerable to injury when elbow HO occurs medially or posteromedially and extends into the vicinity of the cubital tunnel. METHODS: A total of 16 consecutive patients without neurologic injury were diagnosed with heterotopic ossification formation in the elbow and referred to the Upper Extremity Unit of Chang Gung Memorial Hospital. All 16 patients were diagnosed with ulnar palsy, and 14 were found to have sensory dysfunction and muscle wasting for an average of 5.2 months. RESULTS: Fourteen of 16 patients achieved functional range of motion or more after surgery. The final gain in range of motion averaged 80.3 degrees. All except one had complete neurologic recovery postoperatively. The patient who had ulnar palsy for 1 year presurgery did not achieve any neurologic recovery. CONCLUSION: Forceful and repetitive manipulation may add further damage to an already stiffened elbow and should be avoided in an elbow after immobilization or surgery. Early surgical resection of HO and ulnar nerve decompression followed by gentle and aggressive physical therapy terminate the vicious cycle and yield encouraging results.     

Non-tuberculous cold abscess of the psoas muscle – an unusual manifestation of colocutaneous fistula

We report here a case of colocutaneous fistula drained from the retroperitoneal space mimicking a cold abscess of the psoas muscle. A 60-year-old diabetic woman with a 6-year history of a chronic draining sinus over her right thigh had been treated intermittently with antibiotics. At presentation, she had no systemic toxic signs nor other constitutional symptoms. The patient was inadequately managed by curettage at first under the tentative diagnosis of tuberculous cold abscess. After the correct diagnosis of colocutaneous fistula, right nephrectomy and right hemicolectomy with ileotransverse colostomy were done. The patient was well 5 years later without recurrence. This is an atypical presentation of enterocutaneous fistula in an immunodeficient patient that should be emphasized to facilitate the correct diagnosis and early treatment.