From diagnosis to treatment of hepatocellular carcinoma: An epidemic problem for both developed and developing world

Hepatocellular carcinoma(HCC) is the most frequent primary liver malignancy and the third cause of cancer-related death in the Western Countries. The well-established causes of HCC are chronic liver infections such as hepatitis B virus or chronic hepatitis C virus, nonalcoholic fatty liver disease, consumption of aflatoxins and tobacco smocking. Clinical presentation varies widely; patients can be asymptomatic while symptomatology extends from right upper abdominal quadrant paint and weight loss to obstructive jaundice and lethargy. Imaging is the first key and one of the most important aspects at all stages of diagnosis, therapy and follow-up of patients with HCC. The Barcelona Clinic Liver Cancer Staging System remains the most widely classification system used for HCC management guidelines. Up until now, HCC remains a challenge to early diagnose, and treat effectively; treating management is focused on hepatic resection, orthotopic liver transplantation, ablative therapies, chemoembolization and systemic therapies with cytotocix drugs, and targeted agents. This review article describes the current evidence on epidemiology, symptomatology, diagnosis and treatment of hepatocellular carcinoma.

Penetrating ectopic peptic ulcer in the absence of Meckel's diverticulum ultimately presenting as small bowel obstruction

我们这里报导渗透消化性溃疡的一个异种话题怎么进行了在一个病人引起小肠阻塞与多重以前的否定调查。这个案例的临床的演讲， X 光线照相术的特征和病理检查所见被描述，与接受的突出的教训一起。在如此的情形的无线的囊内视镜检查法(WCE ) 的增加的价值被辩论。

Systemic Inflammatory Markers and Disease Severity in Chronic Obstructive Pulmonary Disease—The Effect of Acute Exercise and Pulmonary Rehabilitation

Background: Decreased physical capacity and increased systemic inflammatory response are frequently observed in patients with chronic obstructive pulmonary disease (COPD). The relationship between the inflammatory response and disease severity and the immunological response to exercise were addressed in COPD. Objective: The first objective was to identify systemic biomarkers and their relationship with COPD severity. The second objective was to examine the effect of both acute exercise and pulmonary rehabilitation on these biomarkers. Methods: Forty subjects participated in the study. Thirty-two patients with moderate or severe COPD and 8 healthy non-smokers completed the study. Spirometry was preformed. Physical capacity was determined by a progressive symptom-limited cycle ergo meter (incremental) test. Blood samples were analyzed for C-reactive protein (CRP), pro-inflammatory cytokines (IL-6, TNF-α), pro-fibrotic cytokines (TGF-β) and oxidative burst in circulating leukocytes before and after exercise, and before and after pulmonary rehabilitation. Results: IL-6, CRP, WCC and TGF-β were higher in COPD (p α, CRP and TGF-β were negatively related to forced expiratory volume in 1 s (FEV1) (r = 0.4054, 0.3221, 0.1528, 0.1846 and 0.1187, respectively). Acute exercise increased circulating leucocytes and oxidative stress in both groups (p = 0.000, 0.0049 respectively), while IL-6 was increased in COPD group ((p = 0.0115) and circulating TNF-α in healthy control (p = 0.0369). Pulmonary rehabilitation didn’t modify the levels of inflammatory mediators. Conclusions: Reduced lung function is associated with increased levels of systemic inflammatory markers and acute exercise can further increase this inflammatory response. However pulmonary rehabilitation is unlikely to exacerbate systemic inflammation in COPD.

A systematic review of dedicated models of care for emergency urological patients

Objective:To systematically evaluate the spectrum of models providing dedicated resources for emergency urological patients(EUPs).Methods:A search of Cochrane,Embase,Medline and grey literature from January 1,2000 to March 26,2019 was performed using methods pre-published on PROSPERO.Reporting followed Preferred Reporting Items for Systematic Review and meta-analysis guidelines.Eligible studies were articles or abstracts published in English describing dedicated models of care for EUPs,which reported at least one secondary outcome.Studies were excluded if they examined pathways dedicated only to single presentations,such as torsion,or outpatient solutions,such as rapid access clinics.The primary outcome was the spectrum of models.Secondary outcomes were time-to-theatre,length of stay,complications and cost.Results:Seven studies were identified,totalling 487 patients.Six studies were conference abstracts,while one study was of full-text length but published in grey literature.Four distinct models were described.These included consultant urologists allocated solely to the care of EUPs(“Acute Urological Unit”)or dedicated registrars or operating theatres(“Hybrid structures”).In some services,EUPs bypassed emergency department assessment and were referred directly to urology(“Urological Assessment Unit”)or were managed by other dedicated means.Allocating services to EUPs was associated with reduced time-to-theatre,length of stay and hospital cost,and improved supervision of junior medical staff.Conclusion:Multiple dedicated models of care exist for EUPs.Low-level evidence suggests these may improve outcomes for patients,staff and hospitals.Higher quality studies are required to explore patient outcomes and minimum requirements to establish these models.

Olanzapine-induced acute necrotising pancreatitis leading to recurrent multiple organ dysfunction syndrome

SUMMARY A married mother in her 50s acutely developed vomiting,diarrhoea and severe epigastric pain 2 weeks following discharge from an acute psychiatric inpatient unit.She presented to the emergency department complaining of a 2-day history of the above symptoms.Blood tests revealed neutrophilia,grossly raised inflammatory markers and amylase levels triple the normal range.Based on radiological investigations,she was treated for necrotising pancreatitis that quickly escalated to multi-system organ failure and a lengthy intensive care unit admission.Common causes of pancreatitis,including cholelithiasis,alcohol and other drugs,were ruled out.Despite this,she suffered recurrent episodes of pancreatitis with significant morbidity.Olanzapine,started during her psychiatric admission,was determined to be the offending agent.Two years following the discontinuation of olanzapine,the patient has had no further episodes of acute pancreatitis.

First Masquerading as Gallstones, Pulmonary Hypertension Mimics PE

Patients presenting to emergency and urgent care centers with calf pain after long and short-haul flights are a common presentation throughout Europe. Patients fitting an epidemiological risk profile for cholelithiasis and presenting with right upper quadrant abdominal pain can also be a common presentation fitting of a specific patient profile. However, pulmonary hypertension can present in a nuanced and possible missed chronic and acute presentation. The patient case we present profiles a mildly obese 54-year-old Caucasian woman and recent holiday maker with unilateral calf pain and shortness of breath after traveling on a long-haul flight with tertiary symptoms of indigestion and epigastric discomfort indicative of gastroenteritis. This case highlights the required diligence for emergency physicians to maintain a high index of suspicion and broad differential diagnosis in the undifferentiated patient with seemingly common or classic presentations. We find that a serendipitous definitive diagnosis is made by following a systematic and organized approach.

Obesity Paradox in Chronic Liver Diseases:Product of Bias or a Real Thing?

In recent years,evidence supporting the theory of obesity paradox has increased,showing that obese/overweight people with prevalent chronic diseases experience lower mortality compared with patients of normal weight.So far,evidence is most comprehensive in cardiovascular and chronic renal diseases;however,published studies are prone to many biases,enabling us to reach a definite conclusion.Available data in chronic liver disease is scarce and ambiguous.Obesity is traditionally associated with nonalcoholic fatty liver disease and steatosis in viral hepatitis and as such one would not expect the obesity paradox to be a real possibility in liver disease.Yet,there seem to be new data indicating the opposite-the obesity paradox exists in severe and end-stage liver cirrhosis,which could be attributed to a better lean mass in patients with higher body mass index,meaning that sarcopenia,as one of the most important prognostic factors of survival,is less likely to be present.Nonetheless,the problem of various methodological problems addressing the association between body weight and mortality,which is present both in liver disease and other chronic diseases,are preventing us from attaining an unanimous conclusion.Still,we should be aware that the obesity paradox might be true,especially in severe and end-stage illness.This suggests focusing our efforts toward preserving or building up fat-free mass and decreasing infiammatory activity responsible for catabolism and sarcopenia,and implying that the underlaying cause should be treated.

A metapopulation network model for the spreading of SARSCoV-2: Case study for Ireland

We present preliminary results on an all-Ireland network modelling approach to simulate the spreading the Severe Acute Respiratory Syndrome CoronaVirus 2(SARS-CoV-2),commonly known as the coronavirus.In the model,nodes correspond to locations or communities that are connected by links indicating travel and commuting between different locations.While this proposed modelling framework can be applied on all levels of spatial granularity and different countries,we consider Ireland as a case study.The network comprises 3440 electoral divisions(EDs)of the Republic of Ireland and 890 superoutput areas(SOAs)for Northern Ireland,which corresponds to local administrative units below the NUTS 3 regions.The local dynamics within each node follows a phenomenological SIRX compartmental model including classes of Susceptibles,Infected,Recovered and Quarantined(X)inspired from Science 368,742(2020).For better comparison to empirical data,we extended that model by a class of Deaths.We consider various scenarios including the 5-phase roadmap for Ireland.In addition,as proof of concept,we investigate the effect of dynamic interventions that aim to keep the number of infected below a given threshold.This is achieved by dynamically adjusting containment measures on a national scale,which could also be implemented at a regional(county)or local(ED/SOA)level.We find that-in principle-dynamic interventions are capable to limit the impact of future waves of outbreaks,but on the downside,in the absence of a vaccine,such a strategy can last several years until herd immunity is reached.

Encephalitis associated with autoantibodies binding toγ-aminobutyric acid-A,γ-aminobutyric acid-B and glycine receptors:immunopathogenic mechanisms and clinical characteristics

Recent,discoveries of neural antibodies have facilitated the diagnosis of immune-mediated,immunotherapy-responsive neurologic disorders.Antibodies that target inhibitory central nervous system receptors,such asγ-aminobutyric acid-B,γ-aminobutyric acid-A,and glycine receptors,disrupt inhibitory regulatory synaptic functions,and lead to neuronal hyperexcitability.The myriad of neurologic,manifestations associated with these antibodies includes seizures,encephalopathy,muscle rigidity and stiffness.This article provides a review of the immunopathogenic mechanisms and the clinical and therapeutic implications of autoimmune encephalitis associated with these antibodies that target inhibitory receptors.