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ABSTRACT: Background A nurse practitioner-led dysphagia service was introduced to improve appropriateness of investigations. Objective To determine the clinical outcomes and efficacy of this service. Design and patients A 7-year prospective audit of the first 2000 patients referred for investigation of dysphagia. Setting Royal Cornwall Hospitals NHS Trust. Intervention An innovative nurse practitioner-led telephone dysphagia hotline (DHL) assessment service for all patients and consultant review following investigation prior to discharge. Outcomes Clinical outcomes, service efficiency and cost effectiveness. Results 2000 patients (median age 70 years, 48% male) were referred in less than 7 years, 1775 being managed fully through the DHL. 67% patients had gastroscopy only, 13% barium swallow only and 8.8% both and 11.2% had no investigation. Reflux was the commonest cause (41.3%), 9% had peptic stricture, 10% malignancy 1.9% pharyngeal pouches and 0.8% achalasia. The did not attend rate was reduced from 3.9% to 1.1% and 151 patients either refused or did not require investigation saving a potential £53 040. Although some patients with pharyngeal pouches had gastroscopy as initial investigation, no complications resulted. Conclusions The nurse practitioner-led DHL service has improved efficiency and resulted in a safe prompt service to patients.
Frontline Gastroenterology. 12/2013; 4:102-107.
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ABSTRACT: BACKGROUND: Seronegative hepatitis is a recognized cause of liver failure requiring transplantation. The aetiology is unknown, but might relate to an unidentified virus or immune dysregulation. There are few data on seronegative hepatitis presenting to nontransplant centres. OBJECTIVES: To describe the clinical/laboratory features and natural history of seronegative hepatitis and compare these with viral/autoimmune hepatitis. METHODS: Cases of seronegative, viral and autoimmune hepatitis were identified from 2080 consecutive patients attending a rapid-access jaundice clinic over a 14-year period. RESULTS: Of 881 patients with hepatocellular jaundice, 27 (3%) had seronegative hepatitis, 44 (5%) autoimmune and 62 (7%) viral hepatitis (acute hepatitis A, B, C and E viruses). Fifteen out of 27 (56%) patients with seronegative hepatitis were male, median age 60 years (range 14-74). Peak bilirubin was 63 μmol/l (range 9-363), alanine aminotransferase 932 IU/l (range 503-3807). Duration of illness was 7 weeks (range 4-12). No patients developed liver failure or had further bouts of hepatitis. One patient developed acute lymphoblastic leukaemia shortly after presentation.There was no difference in age/sex of patients with seronegative hepatitis and those with viral hepatitis. Compared with autoimmune hepatitis (age 65 years, range 15-91), patients with seronegative hepatitis were younger (P=0.002) and more likely to be male (P=0.004). Patients with autoimmune hepatitis were more likely (P<0.0001) to have an albumin less than 35 g/l, international normalized ratio greater than 1.2, raised IgG and positive antinuclear/smooth muscle antibody, compared with patients with seronegative hepatitis. CONCLUSION: Seronegative hepatitis presenting to a nontransplant centre is generally a self-limiting illness. The aetiology is more likely to be viral than autoimmune.
European journal of gastroenterology & hepatology 05/2013; · 1.66 Impact Factor
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Alex Harrison,
Linda Scobie,
Claire Crossan,
Rob Parry,
Paul Johnston,
Jon Stratton,
Steve Dickinson,
Vic Ellis,
Jeremy G Hunter,
Oliver R Prescott,
Richie Madden,
Nan X Lin,
William E Henley,
Richard P Bendall, Harry R Dalton
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ABSTRACT: Locally acquired HEV infection is increasingly recognized in developed countries. Anti-HEV IgG seroprevalence has been shown to be high in haemodialysis patients in a number of previous studies, employing assays of uncertain sensitivity. The aim of this study was to investigate anti-HEV IgG seroprevalence in recipients of haemodialysis and renal transplants compared to a control group using a validated, highly sensitive assay. Eighty-eight patients with functioning renal transplants and 76 receiving chronic haemodialysis were tested for HEV RNA and anti-HEV IgG and IgM. Six hundred seventy controls were tested for anti-HEV IgG. Anti-HEV IgG was positive in 28/76 (36.8%) of haemodialysis and 16/88 (18.2%) of transplant patients. HEV RNA was not found in any patient. 126/670 (18.8%) of control subjects were anti-HEV IgG positive. After adjusting for age and sex, there was a significantly higher anti-HEV IgG seroprevalence amongst haemodialysis patients compared to controls (OR = 1.97, 95% CI = 1.16-3.31, P = 0.01) or transplant recipients (OR = 2.63, 95% CI = 1.18-6.07, P = 0.02). Patients with a functioning transplant showed no difference in anti-HEV IgG seroprevalence compared to controls. The duration of haemodialysis or receipt of blood products were not significant risk factors for HEV IgG positivity. Patients receiving haemodialysis have a higher seroprevalence of anti-HEV IgG than both age- and sex-matched controls and a cohort of renal transplant patients. None of the haemodialysis patients had evidence of chronic infection. The reason haemodialysis patients have a high seroprevalence remains uncertain and merits further study. J. Med. Virol. © 2012 Wiley Periodicals, Inc.
Journal of Medical Virology 11/2012; · 2.82 Impact Factor
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ABSTRACT: To determine which features of history and demographics predict a diagnosis of malignancy or peptic stricture in patients presenting with dysphagia.
A prospective case-control study of 2000 consecutive referrals (1031 female, age range: 17-103 years) to a rapid access service for dysphagia, based in a teaching hospital within the United Kingdom, over 7 years. The service consists of a nurse-led telephone triage followed by investigation (barium swallow or gastroscopy), if appropriate, within 2 wk. Logistic regression analysis of demographic and clinical variables was performed. This includes age, sex, duration of dysphagia, whether to liquids or solids, and whether there are associated features (reflux, odynophagia, weight loss, regurgitation). We determined odds ratio (OR) for these variables for the diagnoses of malignancy and peptic stricture. We determined the value of the Edinburgh Dysphagia Score (EDS) in predicting cancer in our cohort. Multivariate logistic regression was performed and P < 0.05 considered significant. The local ethics committee confirmed ethics approval was not required (audit).
The commonest diagnosis is gastro-esophageal reflux disease (41.3%). Malignancy (11.0%) and peptic stricture (10.0%) were also relatively common. Malignancies were diagnosed by histology (97%) or on radiological criteria, either sequential barium swallows showing progression of disease or unequivocal evidence of malignancy on computed tomography. The majority of malignancies were esophago-gastric in origin but ear, nose and throat tumors, pancreatic cancer and extrinsic compression from lung or mediastinal metastatic cancer were also found. Malignancy was statistically more frequent in older patients (aged >73 years, OR 1.1-3.3, age < 60 years 6.5%, 60-73 years 11.2%, > 73 years 11.8%, P < 0.05), males (OR 2.2-4.8, males 14.5%, females 5.6%, P < 0.0005), short duration of dysphagia (≤ 8 wk, OR 4.5-20.7, 16.6%, 8-26 wk 14.5%, > 26 wk 2.5%, P < 0.0005), progressive symptoms (OR 1.3-2.6: progressive 14.8%, intermittent 9.3%, P < 0.001), with weight loss of ≥ 2 kg (OR 2.5-5.1, weight loss 22.1%, without weight loss 6.4%, P < 0.0005) and without reflux (OR 1.2-2.5, reflux 7.2%, no reflux 15.5%, P < 0.0005). The likelihood of malignancy was greater in those who described true dysphagia (food or drink sticking within 5 s of swallowing than those who did not (15.1% vs 5.2% respectively, P < 0.001). The sensitivity, specificity, positive predictive value and negative predictive value of the EDS were 98.4%, 9.3%, 11.8% and 98.0% respectively. Three patients with an EDS of 3 (high risk EDS ≥ 3.5) had malignancy. Unlike the original validation cohort, there was no difference in likelihood of malignancy based on level of dysphagia (pharyngeal level dysphagia 11.9% vs mid sternal or lower sternal dysphagia 12.4%). Peptic stricture was statistically more frequent in those with longer duration of symptoms (> 6 mo, OR 1.2-2.9, ≤ 8 wk 9.8%, 8-26 wk 10.6%, > 26 wk 15.7%, P < 0.05) and over 60 s (OR 1.2-3.0, age < 60 years 6.2%, 60-73 years 10.2%, > 73 years 10.6%, P < 0.05).
Malignancy and peptic stricture are frequent findings in those referred with dysphagia. The predictive value for associated features could help determine need for fast track investigation whilst reducing service pressures.
World Journal of Gastroenterology 08/2012; 18(32):4357-62. · 2.47 Impact Factor
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ABSTRACT: Hepatitis E virus (HEV) was discovered during the Soviet occupation of Afghanistan in the 1980s, after an outbreak of unexplained hepatitis at a military camp. A pooled faecal extract from affected soldiers was ingested by a member of the research team. He became sick, and the new virus (named HEV), was detected in his stool by electron microscopy. Subsequently, endemic HEV has been identified in many resource-poor countries. Globally, HEV is the most common cause of acute viral hepatitis. The virus was not initially thought to occur in developed countries, but recent reports have shown this notion to be mistaken. The aim of this Seminar is to describe recent discoveries regarding HEV, and how they have changed our understanding of its effect on human health worldwide.
The Lancet 04/2012; 379(9835):2477-88. · 38.28 Impact Factor
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Hepatology 01/2012; 55(5):1643; author reply 1644. · 11.66 Impact Factor
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Cara McLaughlin,
Louisa Vine,
Luke Chapman,
Paula Deering,
Sam Whittaker,
John Beckly,
Paul Fortun,
Iain A Murray,
S Hyder Hussaini,
Nick P Michell,
Bill Stableforth,
Peter Thatcher,
Nicola C Hare,
Jo Palmer, Harry R Dalton
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ABSTRACT: Acute upper gastrointestinal haemorrhage is a common medical emergency, initially managed with inpatient care. Bleeding stops spontaneously in over 80% of cases, indicating that patients with low-risk upper gastrointestinal haemorrhage may be more optimally managed in the community, without the need for admission to hospital.
To assess the safety of managing patients with low-risk upper gastrointestinal haemorrhage without admission to hospital.
Prospective/retrospective study of all patients presenting to a UK teaching hospital with low-risk upper gastrointestinal haemorrhage who were managed without admission to hospital over 5 years. Low risk was defined as Glasgow Blatchford Score of 2 or less, age below 70 years, no other active medical problems, not taking warfarin and suspected nonvariceal bleed. Outcome measures were the need for intervention (blood transfusion, endoscopic therapy or surgery) and death.
One hundred and forty-two patients fulfilled the inclusion criteria, and were managed without admission to hospital. No patients required endoscopic intervention, blood transfusion or surgery. The 28-day mortality was nil. Forty-one patients had normal endoscopic examination and 11 had significant endoscopic findings (peptic ulceration=10, oozing Mallory-Weiss tear=1) but did not require intervention.
Patients presenting with a primary upper gastrointestinal haemorrhage aged below 70 years with a Glasgow Blatchford Score of 2 or less are at a low risk, and can be safely managed in the community.
European journal of gastroenterology & hepatology 12/2011; 24(3):288-93. · 1.66 Impact Factor
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Jean-Michel Mansuy,
Richard Bendall,
Florence Legrand-Abravanel,
Karine Sauné,
Marcel Miédouge,
Vic Ellis,
Henri Rech,
François Destruel,
Nassim Kamar, Harry R Dalton,
Jacques Izopet
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ABSTRACT: Using a validated sensitive assay, we found hepatitis E virus (HEV) IgG in 52.5% of voluntary blood donors in southwestern France. This finding suggests HEV is highly endemic to this region. The high HEV prevalence may reflect local dietary practices, such as eating uncooked pork and game products.
Emerging Infectious Diseases 12/2011; 17(12):2309-12. · 6.79 Impact Factor
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ABSTRACT: BACKGROUND: Hepatitis E virus (HEV) infections in immunosuppressed patients can result in chronic hepatitis that rapidly progresses to cirrhosis (1, 2). When immunosuppressed transplant recipients are treated with pegylated -interferon and ribavirin, HEV clears and liver histology improves (2). However, we are not aware of reports about how this therapy works in patients with HIV infection. OBJECTIVE: To describe the clinical and laboratory response to antiviral therapy for chronic HEV infection in a patient also infected with HIV. CASE REPORT: We studied a 48-year-old bisexual male with HIV- 1 infection who was chronically infected with HEV genotype 3a and had several years of painful sensory neuropathy of uncertain cause in the lower limbs (3). He had malaise, persistently abnormal liver function tests, and active inflammation and cirrhosis on liver biopsy (Figure).Before beginning anti-HEV therapy, the patient had an undetectable HIV viral load and a CD4 cell count between 30 and 150 cells/mL for the previous 2 years while receiving combination antiretroviral therapy (abacavir–lamivudine once daily and lopinavir–ritonavir twice daily).
Annals of internal medicine 10/2011; 155(7):479-80. · 16.73 Impact Factor
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Harry R Dalton,
Richard P Bendall,
Mo Rashid,
Vic Ellis,
Rachel Ali,
Rene Ramnarace,
William Stableforth,
William Headdon,
Rose Abbott,
Cara McLaughlin,
Emma Froment,
Katie J Hall,
Nick P Michell,
Peter Thatcher,
William E Henley
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ABSTRACT: In developed countries autochthonous hepatitis E infection is caused by hepatitis E virus (HEV) genotype 3 or 4 and mainly affects middle aged/elderly men. Host factors might explain why older men develop clinically overt disease.
Retrospective review of 53 patients with symptomatic autochthonous hepatitis E infection to determine putative host risk factors. Patients were compared with 564 controls with adjustment for age and sex. Anti-HEV seroprevalence was determined in controls and 189 patients with chronic liver disease.
Mean age of the patients was 62.4 years, 73.6% were men. Compared with controls, patients with hepatitis E were more likely to drink at least 22 U alcohol/week (OR=9.4; 95% confidence interval=3.8-25.0; P<0.001). The seroprevalence of anti-HEV IgG in controls increased with age (P<0.001) but was similar in men and women. There was no association between alcohol consumption and anti-HEV IgG seroprevalence in the control group. There was no difference in the anti-HEV IgG seroprevalence between the controls and patients with chronic liver disease of all aetiologies, but seroprevalence was higher in controls (13.8%) than patients with alcoholic liver disease (4.8%, P=0.04).
Clinically apparent hepatitis E infection is more common in individuals who consume at least 22 U alcohol/week. Patients with established chronic alcoholic liver disease have a low seroprevalence compared with controls. The reason for this observation is uncertain, but patients with alcoholic liver disease have clinically severe disease with a high mortality when exposed to HEV. The low seroprevalence in this group may represent a 'culled' population.
European journal of gastroenterology & hepatology 09/2011; 23(12):1200-5. · 1.66 Impact Factor
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Nassim Kamar,
Richard P Bendall,
Jean Marie Peron,
Pascal Cintas,
Laurent Prudhomme,
Jean Michel Mansuy,
Lionel Rostaing,
Frances Keane,
Samreen Ijaz,
Jacques Izopet, Harry R Dalton
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ABSTRACT: Information about the spectrum of disease caused by hepatitis E virus (HEV) genotype 3 is emerging. During 2004-2009, at 2 hospitals in the United Kingdom and France, among 126 patients with locally acquired acute and chronic HEV genotype 3 infection, neurologic complications developed in 7 (5.5%): inflammatory polyradiculopathy (n = 3), Guillain-Barre syndrome (n = 1), bilateral brachial neuritis (n = 1), encephalitis (n = 1), and ataxia/proximal myopathy (n = 1). Three cases occurred in nonimmunocompromised patients with acute HEV infection, and 4 were in immunocompromised patients with chronic HEV infection. HEV RNA was detected in cerebrospinal fluid of all 4 patients with chronic HEV infection but not in that of 2 patients with acute HEV infection. Neurologic outcomes were complete resolution (n = 3), improvement with residual neurologic deficit (n = 3), and no improvement (n = 1). Neurologic disorders are an emerging extrahepatic manifestation of HEV infection.
Emerging Infectious Diseases 02/2011; 17(2):173-9. · 6.79 Impact Factor
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Nassim Kamar,
Cyril Garrouste,
Elizabeth B Haagsma,
Valérie Garrigue,
Sven Pischke,
Cécile Chauvet,
Jérome Dumortier,
Amélie Cannesson,
Elisabeth Cassuto-Viguier,
Eric Thervet, [......],
Pascal Lebray, Harry R Dalton,
Robert Santella,
Nada Kanaan,
Marie Essig,
Christiane Mousson,
Sylvie Radenne,
Anne Marie Roque-Afonso,
Jacques Izopet,
Lionel Rostaing
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ABSTRACT: Hepatitis E virus (HEV) infection can cause chronic hepatitis in recipients of solid organ transplants. However, the factors that contribute to chronic infection and the outcomes of these patients are incompletely understood. We performed a retrospective analysis of data from 17 centers from Europe and the United States that described the progression, outcomes, and factors associated with development of chronic HEV infection in recipients of transplanted solid organs.
We studied data from 85 recipients of solid organ transplants who were infected with HEV. Chronic HEV infection was defined by the persistent increases in levels of liver enzymes and polymerase chain reaction evidence of HEV in the serum and/or stool for at least 6 months.
Fifty-six patients (65.9%) developed chronic hepatitis. Univariate analysis associated liver transplant, shorter times since transplant, lower levels of liver enzymes and serum creatinine, lower platelet counts, and tacrolimus-based immunosuppressive therapy (rather than cyclosporin A) with chronic hepatitis. On multivariate analysis, the independent predictive factors associated with chronic HEV infection were the use of tacrolimus rather than cyclosporin A (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.49-1.97; P = .004) and a low platelet count at the time of diagnosis with HEV infection (OR, 1.02; 95% CI, 1.001-1.1; P = .04). Of patients with chronic hepatitis, 18 (32.1%) achieved viral clearance after the dose of immunosuppressive therapy was reduced. No HEV reactivation was observed after HEV clearance.
HEV infection causes chronic hepatitis in more than 60% of recipients of solid organ transplants. Tacrolimus therapy is the main predictive factor for chronic hepatitis. Dose reductions of immunosuppressive therapy resulted in viral clearance in more than 30% of patients.
Gastroenterology 02/2011; 140(5):1481-9. · 11.68 Impact Factor
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ABSTRACT: The RNA virus, hepatitis E virus (HEV) is the most or second-most important cause of acute clinical hepatitis in adults throughout much of Asia, the Middle East, and Africa. In these regions it is an important cause of acute liver failure, especially in pregnant women who have a mortality rate of 20-30%. Until recently, hepatitis E was rarely identified in industrialized countries, but Hepatitis E now is reported increasingly throughout Western Europe, some Eastern European countries, and Japan. Most of these cases are caused by genotype 3, which is endemic in swine, and these cases are thought to be zoonotically acquired. However, transmission routes are not well understood. HEV that infect humans are divided into nonzoonotic (types 1, 2) and zoonotic (types 3, 4) genotypes. HEV cell culture is inefficient and limited, and thus far HEV has been cultured only in human cell lines. The HEV strain Kernow-C1 (genotype 3) isolated from a chronically infected patient was used to identify human, pig, and deer cell lines permissive for infection. Cross-species infections by genotypes 1 and 3 were studied with this set of cultures. Adaptation of the Kernow-C1 strain to growth in human hepatoma cells selected for a rare virus recombinant that contained an insertion of 174 ribonucleotides (58 amino acids) of a human ribosomal protein gene.
Proceedings of the National Academy of Sciences 02/2011; 108(6):2438-43. · 9.68 Impact Factor
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New England Journal of Medicine 10/2009; 361(10):1025-7. · 53.30 Impact Factor
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BMJ (Clinical research ed.). 02/2009; 338:b2085.
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BMJ (Clinical research ed.). 02/2009; 338:a3175.
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ABSTRACT: Hepatitis E is endemic in many developing countries where it causes substantial morbidity. In industrialised countries, it is considered rare, and largely confined to travellers returning from endemic areas. However, there is now a growing body of evidence that challenges this notion. Autochthonous hepatitis E in developed countries is far more common than previously recognised, and might be more common than hepatitis A. Hepatitis E has a predilection for older men in whom it causes substantial morbidity and mortality. The disease has a poor prognosis in the context of pre-existing chronic liver disease, and is frequently misdiagnosed as drug-induced liver injury. The source and route of infection remain uncertain, but it might be a porcine zoonosis. Patients with unexplained hepatitis should be tested for hepatitis E, whatever their age or travel history.
The Lancet Infectious Diseases 12/2008; 8(11):698-709. · 17.39 Impact Factor
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BMJ (Clinical research ed.). 02/2008; 337:a1252.
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BMJ (Clinical research ed.). 02/2008; 337:a1481.
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BMJ (Clinical research ed.). 02/2008; 337:a1845.
