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Alcohol induced liver disease (ALD) is the predominant cause of alcohol-related mortality in the UK. Therefore helping patients with ALD to quit is a primary treatment goal.
The primary aim of this study was to measure the effectiveness and tolerability of Baclofen in maintaining abstinence, and to determine if this resulted in a reduction in standard measures of liver damage.
An observational prospective clinical audit was performed. Patients with ALD were commenced on Baclofen titrated according to tolerability and response up to 30 mg TDS. Primary outcome measures were severity of physical dependence (SADQ score) and biochemical markers of liver damage GGT, ALT, Bilirubin fibroelastography. These were compared at baseline, and 1 year.
Of the 243 patients commenced on Baclofen, 151 (85 female 66 male) have completed 1 year follow-up (F/U) of which 130 (86%) have remained engaged. 10 have died. Comparison of baseline (B/L) and 1 year biochemical markers showed a reduction in GGT (c2= 66.8 P < 0.0001) and Bil (c2= 82.6 P < 0.0001). There was a significant reduction in alcohol consumption (P < 0.0001 95% CI = 10 to 22). And the presence of physical dependence (c<sup>2</sup> = 77.4 P < 0.0001) as categorised by SADQ.
Baclofen is well tolerated in this very difficult to treat, high risk patient group. It has a positive impact on alcohol consumption, and overall measures of liver function and harm. A RCT is needed to confirm the benefit of Baclofen in this patient group.</div>
Alcohol-dependent patients have a significantly increased risk of depression, contributing a cycle of relapse and attendance at acute hospital services seeking help. Care is often focused on the alcohol dependence treatment with little consideration of concomitant psychiatric disorders.
To help bridge this gap in care planning and aim toward multidisciplinary long-term support.
We collected data on all patients referred to our alcohol complex patient MDT. We investigated the range of disciplines involved in patient care. We spoke to our patients about why they had chosen to attend hospital. We then developed a referral system to our alcohol MDT where a bespoke pathways of care was developed with all current and future care providers.
Our patients were often being cared for by multiple services, however much of this work was happening in isolation and was at times conflicting. Importantly, the patients were unclear where to go for what, and were utilizing the ED as a fail-safe when they were troubled.
Of 15 patients referred to MDT, 7 (50%) had a diagnosis of depression (DSM-IV). These patients had an average of 5.1 hospital attendances and 2.2 hospital admissions in the 3 months prior to MDT. At 3 months post-MDT, we were able to demonstrate a reduction in hospital admissions and attendances (average 2.2 & 1.4, respectively).
An MDT for alcohol-dependent patients with depression facilitates effective and collaborative working for the benefit of patients and services.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Given the common view that pre-exercise nutrition/breakfast is important for performance, the present study investigated whether breakfast influences resistance exercise performance via a physiological or psychological effect. Twenty-two resistance-trained, breakfast-consuming men completed three experimental trials, consuming water-only (WAT), or semi-solid breakfasts containing 0 g/kg (PLA) or 1·5 g/kg (CHO) maltodextrin. PLA and CHO meals contained xanthan gum and low-energy flavouring (approximately 122 kJ), and subjects were told both ‘contained energy’. At 2 h post-meal, subjects completed four sets of back squat and bench press to failure at 90 % ten repetition maximum. Blood samples were taken pre-meal, 45 min and 105 min post-meal to measure serum/plasma glucose, insulin, ghrelin, glucagon-like peptide-1 and peptide tyrosine-tyrosine concentrations. Subjective hunger/fullness was also measured. Total back squat repetitions were greater in CHO (44 (sd 10) repetitions) and PLA (43 (sd 10) repetitions) than WAT (38 (sd 10) repetitions; P < 0·001). Total bench press repetitions were similar between trials (WAT 37 (sd 7) repetitions; CHO 39 (sd 7) repetitions; PLA 38 (sd 7) repetitions; P = 0·130). Performance was similar between CHO and PLA trials. Hunger was suppressed and fullness increased similarly in PLA and CHO, relative to WAT (P < 0·001). During CHO, plasma glucose was elevated at 45 min (P < 0·05), whilst serum insulin was elevated (P < 0·05) and plasma ghrelin suppressed at 45 and 105 min (P < 0·05). These results suggest that breakfast/pre-exercise nutrition enhances resistance exercise performance via a psychological effect, although a potential mediating role of hunger cannot be discounted.
Twain’s two most important contemporaries were William Dean Howells and Henry James. Howells was a friend and champion of both writers, although Twain and James expressed distaste toward each other. Each in his own way was an important figure in the emerging literary realism. Although Twain claimed that he preferred reading history and biography over novels and literature, he was an avid reader of his contemporaries’ works, even if he often criticized them. Harriet Beecher Stowe was his next-door neighbor, and he entertained fellow writers in his Hartford mansion. Twain was a champion of some younger writers, although he wearied at the constant demands for advice and help from emerging writers.
Early in a foodborne disease outbreak investigation, illness incubation periods can help focus case interviews, case definitions, clinical and environmental evaluations and predict an aetiology. Data describing incubation periods are limited. We examined foodborne disease outbreaks from laboratory-confirmed, single aetiology, enteric bacterial and viral pathogens reported to United States foodborne disease outbreak surveillance from 1998–2013. We grouped pathogens by clinical presentation and analysed the reported median incubation period among all illnesses from the implicated pathogen for each outbreak as the outbreak incubation period. Outbreaks from preformed bacterial toxins (Staphylococcus aureus, Bacillus cereus and Clostridium perfringens) had the shortest outbreak incubation periods (4–10 h medians), distinct from that of Vibrio parahaemolyticus (17 h median). Norovirus, salmonella and shigella had longer but similar outbreak incubation periods (32–45 h medians); campylobacter and Shiga toxin-producing Escherichia coli had the longest among bacteria (62–87 h medians); hepatitis A had the longest overall (672 h median). Our results can help guide diagnostic and investigative strategies early in an outbreak investigation to suggest or rule out specific etiologies or, when the pathogen is known, the likely timeframe for exposure. They also point to possible differences in pathogenesis among pathogens causing broadly similar syndromes.
Introduction: Undifferentiated hypotension remains one of the most life-threatening presentations to emergency departments (ED) around the world. An accurate and rapid initial assessment is essential, as shock carries a high mortality with multiple unique etiologies and management plans. Point of care ultrasound (PoCUS) has emerged as a promising tool to improve these diagnostic and management challenges, yet its reliability in this setting remains unclear. Methods: We performed a systematic review of Medline, EMBASE, CINAHL, Cochrane, and clinicaltrials.gov databases from inception to June 8, 2018. Databases were reviewed by two independent researchers and all languages were included. The methodological quality of included studies were evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Our primary outcome was diagnostic accuracy of PoCUS in hypotension, with secondary outcomes including patient outcomes and changes to management. Results: Our literature search revealed 5345 articles after duplicates were removed, leaving 235 articles for full article review. Following full article review, 9 studies remained and were included in the systematic review. There were 2 randomized control trials, 6 prospective cohort trials, and 1 retrospective cohort trial. For our primary outcome of diagnostic accuracy, eight studies were included; we extracted Kappa values ranging from 0.70 to 0.971, pooled sensitivity ranging from 69% to 88%, and pooled specificity ranging from 88% to 96%. Four studies reported on management change including results reporting shorter time to disposition, change in diagnostic test ordering (18% to 31%), change in consultation (13.6%), change in admission location (12%) and change in management plan (25% to 40%). Only one study reported on patient outcomes, which revealed no survival or length of stay benefit. Conclusion: When assessing for the diagnostic accuracy of PoCUS in the setting of undifferentiated hypotension presenting to the emergency department, we found fair consistency between PoCUS and final diagnosis with high Kappa values, fair to good pooled sensitivities, and good to excellent specificities. There was no strong evidence indicating improved outcomes. However, the large amount of heterogeneity amongst studies has limited our ability to make a strong conclusion except that future research should focus on a uniform study design and patient focused outcomes.
Introduction: Although use of point of care ultrasound (PoCUS) protocols for patients with undifferentiated hypotension in the Emergency Department (ED) is widespread, our previously reported SHoC-ED study showed no clear survival or length of stay benefit for patients assessed with PoCUS. In this analysis, we examine if the use of PoCUS changed fluid administration and rates of other emergency interventions between patients with different shock types. The primary comparison was between cardiogenic and non-cardiogenic shock types. Methods: A post-hoc analysis was completed on the database from an RCT of 273 patients who presented to the ED with undifferentiated hypotension (SBP <100 or shock index > 1) and who had been randomized to receive standard care with or without PoCUS in 6 centres in Canada and South Africa. PoCUS-trained physicians performed scans after initial assessment. Shock categories and diagnoses recorded at 60 minutes after ED presentation, were used to allocate patients into subcategories of shock for analysis of treatment. We analyzed actual care delivered including initial IV fluid bolus volumes (mL), rates of inotrope use and major procedures. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: Although there were expected differences in the mean fluid bolus volume between patients with non-cardiogenic and cardiogenic shock, there was no difference in fluid bolus volume between the control and PoCUS groups (non-cardiogenic control 1878 mL (95% CI 1550 – 2206 mL) vs. non-cardiogenic PoCUS 1687 mL (1458 – 1916 mL); and cardiogenic control 768 mL (194 – 1341 mL) vs. cardiogenic PoCUS 981 mL (341 – 1620 mL). Likewise there were no differences in rates of inotrope administration, or major procedures for any of the subcategories of shock between the control group and PoCUS group patients. The most common subcategory of shock was distributive. Conclusion: Despite differences in care delivered by subcategory of shock, we did not find any significant difference in actual care delivered between patients who were examined using PoCUS and those who were not. This may help to explain the previously reported lack of outcome difference between groups.
Introduction: Point of care ultrasound has been reported to improve diagnosis in non-traumatic hypotensive ED patients. We compared diagnostic performance of physicians with and without PoCUS in undifferentiated hypotensive patients as part of an international prospective randomized controlled study. The primary outcome was diagnostic performance of PoCUS for cardiogenic vs. non-cardiogenic shock. Methods: SHoC-ED recruited hypotensive patients (SBP < 100 mmHg or shock index > 1) in 6 centres in Canada and South Africa. We describe previously unreported secondary outcomes relating to diagnostic accuracy. Patients were randomized to standard clinical assessment (No PoCUS) or PoCUS groups. PoCUS-trained physicians performed scans after initial assessment. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses including shock category were recorded at 0 and 60 minutes. Final diagnosis was determined by independent blinded chart review. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: 273 patients were enrolled with follow-up for primary outcome completed for 270. Baseline demographics and perceived category of shock were similar between groups. 11% of patients were determined to have cardiogenic shock. PoCUS had a sensitivity of 80.0% (95% CI 54.8 to 93.0%), specificity 95.5% (90.0 to 98.1%), LR+ve 17.9 (7.34 to 43.8), LR-ve 0.21 (0.08 to 0.58), Diagnostic OR 85.6 (18.2 to 403.6) and accuracy 93.7% (88.0 to 97.2%) for cardiogenic shock. Standard assessment without PoCUS had a sensitivity of 91.7% (64.6 to 98.5%), specificity 93.8% (87.8 to 97.0%), LR+ve 14.8 (7.1 to 30.9), LR- of 0.09 (0.01 to 0.58), Diagnostic OR 166.6 (18.7 to 1481) and accuracy of 93.6% (87.8 to 97.2%). There was no significant difference in sensitivity (-11.7% (-37.8 to 18.3%)) or specificity (1.73% (-4.67 to 8.29%)). Diagnostic performance was also similar between other shock subcategories. Conclusion: As reported in other studies, PoCUS based assessment performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test. However performance was similar to standard (non-PoCUS) assessment, which was excellent in this study.
Englerophytum and Synsepalum are two closely related genera of trees and shrubs from the African tropics. Previous molecular studies have shown that these genera collectively form a clade within the subfamily Chrysophylloideae (Sapotaceae). However, little is known about the inter-relationships of the taxa within the Englerophytum–Synsepalum clade. In this study, nuclear ribosomal DNA and plastid trnH–psbA sequences were used to estimate the phylogeny within the clade. Results indicate that the clade consists of six major lineages, two composed solely of taxa from the genus Englerophytum and four composed of taxa from the genus Synsepalum. Each lineage can be distinguished by suites of vegetative and floral characters. Leaf venation patterns, calyx fusion, style length and staminodal structure were among the most useful characters for distinguishing clades. Some of the subclades within the Englerophytum–Synsepalum clade were also found to closely fit descriptions of former genera, most of which were described by Aubréville, that have since been placed in synonymy with Englerophytum and Synsepalum. The clade with the type species of Englerophytum also contains the type species of the genera Wildemaniodoxa and Zeyherella, which are confirmed as synonyms.
The stellar winds of hot stars have an important impact on both stellar and galactic evolution, yet their structure and internal processes are not fully understood in detail. One of the best nearby laboratories for studying such massive stellar winds is the O4I(n)fp star ζ Pup. After briefly discussing existing X-ray observations from Chandra and XMM, we present a simulation of X-ray emission line profile measurements for the upcoming 840 kilosecond Chandra HETGS observation. This simulation indicates that the increased S/N of this new observation will allow several major steps forward in the understanding of massive stellar winds. By measuring X-ray emission line strengths and profiles, we should be able to differentiate between various stellar wind models and map the entire wind structure in temperature and density. This legacy X-ray spectrum of ζ Pup will be a useful benchmark for future X-ray missions.
To investigate the association of policy, systems and environmental factors with improvement in household food security among low-income Indiana households with children after a Supplemental Nutrition Assistance Program-Education (SNAP-Ed) direct nutrition education intervention.
Household food security scores measured by the eighteen-item US Household Food Security Survey Module in a longitudinal randomized and controlled SNAP-Ed intervention study conducted from August 2013 to April 2015 were the response variable. Metrics to quantify environmental factors including classification of urban or rural county status; the number of SNAP-authorized stores, food pantries and recreational facilities; average fair market housing rental price; and natural amenity rank were collected from government websites and data sets covering the years 2012–2016 and used as covariates in mixed multiple linear regression modelling.
Thirty-seven Indiana counties, USA, 2012–2016.
SNAP-Ed eligible adults from households with children (n 328).
None of the environmental factors investigated were significantly associated with changes in household food security in this exploratory study.
SNAP-Ed improves food security regardless of urban or rural location or the environmental factors investigated. Expansion of SNAP-Ed in rural areas may support food access among the low-income population and reduce the prevalence of food insecurity in rural compared with urban areas. Further investigation into policy, systems and environmental factors of the Social Ecological Model are warranted to better understand their relationship with direct SNAP-Ed and their impact on diet-related behaviours and food security.
This chapter discusses a political theory that has come to the fore in the IR discipline since the end of the Cold War. Understanding IR liberalism nevertheless requires acquaintance with the historical context in which the broader political arguments for freedom and toleration were first enunciated. The chapter thus provides a brief historical outline of liberalism's development before surveying some key liberal tenets and their manifestation in IR. It concludes with a discussion of some of the challenges facing contemporary IR liberalism in the current era.
Liberalism is often seen as the characteristic political philosophy of the modern West. Its central principles – freedom, (human) rights, reason, progress, toleration – and the norms of constitutionalism and democracy are deeply embedded in Western political culture. Nonetheless, liberal theories of IR were until recently disdained as utopian by IR scholars no less than by diplomats. The two World Wars and the Cold War seemed to bear out the realist thesis that the international milieu was inevitably subject to the harsh imperatives of power politics.
For a while after the Cold War, however, the world suddenly looked quite different. There was no hostile power threatening the liberal democracies, major inter-state war seemed unthinkable and the international economy was organised in accordance with the norms of the liberal market (Friedman 1999; Fukuyama 1989). The predominant school of liberal IR theory, most strongly represented in the United States, concentrated almost exclusively on this moment of liberal triumph, invoking the insights of democratic peace theory (DPT), US-led institutionalism and the transformative power of the global marketplace as intrinsic to winning the Cold War (Doyle, 1983, 1986; Friedman 1999; Fukuyama, 1989; Kegley, 1993; Keohane, 1984).
In more recent times, this scenario and its dominant theoretical explanations have come under challenge from a variety of sources. In the face of terrorist threats, the crisis in the global capitalist order after 2008, the rise in global inequality and the many problems facing contemporary democratic societies, one sees widespread scepticism concerning the analytical capacity of mainstream IR liberalism to find even adequate explanations, let alone answers, for these contemporary issues from its base in a (mainly) positivist methodology (see Sterling-Folker 2015).