Preventive strategies in chronic liver disease: part II. Cirrhosis.

Cirrhosis is a diffuse process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules. The modified Child-Pugh score, which ranks the severity of cirrhosis based on signs and liver function test results, has been shown to predict survival. Strategies have been established to prevent complications in patients with cirrhosis. Esophageal varices can be identified by endoscopy; if large varices are present, prophylactic nonselective beta blocker therapy should be administered. Alpha-fetoprotein testing and ultrasonography can be effective in screening for hepatocellular carcinoma. Vaccines should be administered to prevent secondary infections. The use of nonsteroidal anti-inflammatory drugs should be avoided, and patients should maintain a balanced diet containing 1 to 1.5 g of protein per kg per day. An extensive assessment should be performed before patients with cirrhosis undergo elective surgery. Before advanced liver decompensation occurs, patients should be referred for liver transplantation evaluation. If advanced cirrhosis is present and transplantation is not feasible, survival is between one and two years.     

Methadone and antiretroviral medications, part I

The interactions of Methadone with NRTIs and NNRTIs are presented in the first of a two-part article. Methadone is an effective treatment for heroin addiction; however, insufficient information is available on its interactions with HAART. Methadone is metabolized by the cytochrome P450 system, and NRTIs do not appear to be inducers or inhibitors of the cytochrome P450 system. Pharmacokinetics between Methadone and AZT have been studied in detail, and AZT appears to have no effect on plasma Methadone levels. However, NNRTIs do share metabolic pathways with Methadone, indicating that important interactions between Methadone and these drugs are possible, but formal study is still needed. A table of current information is presented on NRTI and NNRTI interactions with Methadone.     

Cirrhosis and chronic liver failure: part I. Diagnosis and evaluation

Cirrhosis and chronic liver failure are leading causes of morbidity and mortality in the United States, with the majority of preventable cases attributed to excessive alcohol consumption, viral hepatitis, or nonalcoholic fatty liver disease. Cirrhosis often is an indolent disease; most patients remain asymptomatic until the occurrence of decompensation, characterized by ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, or variceal bleeding from portal hypertension. Physical examination of patients with cirrhosis may reveal a variety of findings that necessitate a hepatic- or gastrointestinal-based work-up to determine the etiology. Some patients already may have had laboratory or radiographic tests that incidentally uncovered signs of cirrhosis and its comorbidities. No serologic or radiographic test can accurately diagnose cirrhosis. A significant correlation has been demonstrated between persistently elevated liver function tests and biopsy-proven underlying hepatic disease; thus, a more targeted serologic work-up is indicated in patients whose liver function test results are persistently abnormal. Unnecessary medications and surgical procedures should be avoided in patients with cirrhosis. Referral for liver biopsy should be considered only after a thorough, non-invasive serologic and radiographic evaluation has failed to confirm a diagnosis of cirrhosis; the benefit of biopsy outweighs the risk; and it is postulated that biopsy will have a favorable impact on the treatment of chronic liver disease.     

Vitamin and mineral supplements in the management of liver disease.

While pharmacologic doses of specific vitamins or minerals are probably not warranted as a therapy for acute or chronic liver disease, deficiencies of micronutrients among patients with liver disease are extremely common, act to the detriment of the patient, and should be corrected so that normal metabolic processes can allow both regeneration of tissue and resistance to infection.     

Nutritional evaluation and diet therapy of patients with chronic liver disease

Malnutrition is prevalent in patients with advanced chronic liver disease and may be associated with a worse prognosis. Treatments often include many dietary restrictions (regarding fluids, sodium and proteins), which may further limit energy intake in addition to other factors limiting food intake (e.g. anorexia, encefalopathy). Guidelines for an optimal diet therapy in patients with different liver diseases, above all in presence of encefalopathy, are briefly reported.     

Use of diet, nutritional supplements and exercise in HIV-infected patients receiving combination antiretroviral therapies: a systematic review

BACKGROUND: The use of combination antiretroviral therapy (cART) has improved the prognosis of HIV infection, but it has also been linked to a spectrum of body composition changes and metabolic alterations known as the lipodystrophy syndrome. Nutritional status could influence body composition changes. METHODS: We performed a systematic search of published peer-reviewed data on the effects of diet, nutrition support and exercise on body composition and metabolic complications in patients receiving cART. RESULTS: Few controlled studies, most of them with small sample size, were found. Oral nutritional support increases protein and energy intake, and results in body weight and fat mass gains. Resistance exercise, with or without an aerobic component, increases lean mass and can improve insulin resistance. Low-fat diets or exercise can result in loss of fat mass, and they should be used with caution in subjects with lipoatrophy. CONCLUSIONS: Nutritional support and exercise result in small but significant body composition changes and can be used as complementary interventions. There is a need for further research on nutritional interventions in HIV-infected patients receiving cART.     

The liver. Part 4: chronic liver disease

Chronic liver disease and associated signs and symptoms present a challenge for clinical management as liver failure affects all body systems. While this part of the series concentrates on the physical symptoms of chronic liver disease, it needs to be remembered that these can also have many far-reaching implications for the patients' psychosocial well-being.     

Cirrhosis and chronic liver failure: part II. Complications and treatment

Major complications of cirrhosis include ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, portal hypertension, variceal bleeding, and hepatorenal syndrome. Diagnostic studies on ascitic fluid should include a differential leukocyte count, total protein level, a serum-ascites albumin gradient, and fluid cultures. Therapy consists of sodium restriction, diuretics, and complete abstention from alcohol. Patients with ascitic fluid polymorphonuclear leukocyte counts of 250 cells per mm3 or greater should receive empiric prophylaxis against spontaneous bacterial peritonitis with cefotaxime and albumin. Patients who survive an episode of spontaneous bacterial peritonitis should receive long-term prophylaxis with norfloxacin or trimethoprim/sulfamethoxazole. Patients with gastrointestinal hemorrhage and cirrhosis should receive norfloxacin or trimethoprim/sulfamethoxazole twice daily for seven days. Treatment of hepatic encephalopathy is directed toward improving mental status levels with lactulose; protein restriction is no longer recommended. Patients with cirrhosis and evidence of gastrointestinal bleeding should undergo upper endoscopy to evaluate for varices. Endoscopic banding is the standard treatment, but sclerotherapy with vasoconstrictors (e.g., octreotide) also may be used. Prophylaxis with propranolol is recommended in patients with cirrhosis once varices have been identified. Transjugular intrahepatic portosystemic shunt has been effective in reducing portal hypertension and improving symptoms of hepatorenal syndrome, and can reduce gastrointestinal bleeding in patients with refractory variceal hemorrhage. When medical therapy for treatment of cirrhosis has failed, liver transplantation should be considered. Survival rates in transplant recipients have improved as a result of advances in immunosuppression and proper risk stratification using the Model for End-Stage Liver Disease and Child-Turcotte-Pugh scoring systems.     

饮食和运动干预对非酒精性脂肪肝病患者疾病转归的影响

目的探讨饮食和运动干预对非酒精性脂肪肝病(non-alcoholic fatty liver disease,NAFLD)患者疾病转归的的影响。方法对52例NAFLD患者实施饮食和运动干预,干预前后观察患者NAFLD归转情况。结果干预后患者体重指数(body mass index,BMI)、甘油三酯(triglycerides,TG)、胆固醇(total cholesterol,TC)均低于干预前,差异具有统计学意义(均P0.05)。结论饮食和运动干预能有效改善NAFLD患者肝功能指标,促进疾病转归。     

Asthma update: part I. Diagnosis, monitoring, and prevention of disease progression

Despite increased scientific knowledge about asthma and improved therapeutic options, the disease continues to cause significant morbidity and mortality. The National Asthma Education and Prevention Program Expert Panel has updated its clinical guidelines on asthma medications, prevention of disease progression, and patient self-management. Diagnostic criteria have not changed, and identification of the disease relies on the physician's analysis of the patient's symptoms, family history, and spirometric measurements of lung function. Classification of asthma severity also has not changed, but many obstacles remain, including the variability of asthma and the classification system's inability to account for physical activity levels, which may result in significant underestimation of the severity of asthma. The National Asthma Education and Prevention Program recommends the use of written action plans with or without monitoring of peak expiratory flow, although evidence supporting these management techniques is inconclusive. Patients with asthma may benefit from earlier use of inhaled corticosteroids, which have been proven safe in the usual dosages. However, further studies are needed to determine whether inhaled corticosteroids can prevent the progression of asthma.     

Angiotensinogen in chronic liver disease.

The renin substrate angiotensinogen (AGT) belongs to a supergene family of proteins that also includes alpha 1-antitrypsin (AAT) and alpha 1-antichymotrypsin (ACT), acute-phase reactants with known serine proteinase inhibitory (serpin) function. AGT lacks a known inhibitory function but is an acute-phase reactant. In this study we have compared the plasma levels, as analysed by electroimmunoassay, of AGT with AAT in patients with different types of chronic liver disease. AAT levels are regularly elevated in liver disease patients in contrast to AGT, which remains normal until late in the disease course. The AGT levels (mean +/- SD) were: in alcoholic cirrhosis (n = 19) 100 +/- 27.3%, in chronic active hepatitis (n = 14) 100 +/- 23.2%, in primary biliary cirrhosis (n = 18) 106 +/- 26.1% and in non-alcoholic cirrhosis (n = 15) 92 +/- 38.4%. Only occasionally were levels less than 50% of normal seen. In general, AGT levels were unrelated to sex and type of underlying liver disease and did not correlate with degree of hepatocellular impairment. Crossed immunoelectrophoresis showed no abnormal charge heterogeneity of AGT in patients with low levels. Our data are consistent with a dissociate expression of the homologous serpin genes in chronic liver disease. We speculate that the magnitude of the dissociated response is influenced by hormonal factors.     

Guidelines for managing Alzheimer's disease: part I. Assessment

Family physicians play a key role in assessing and managing patients with Alzheimer's disease and in linking the families of these patients to supportive services within the community. As part of comprehensive management, the family physician may be responsible for coordinating assessments of patient function, cognition, comorbid medical conditions, disorders of mood and emotion, and caregiver status. Suggestions for easily administered and scored assessment tools are provided, and practical tips are given for supporting primary caregivers, thereby increasing efficiency and quality of care for patients with Alzheimer's disease.     

Combined diet and exercise intervention in the workplace: effect on cardiovascular disease risk factors.

This study assessed the effectiveness of a 12-week pilot employee wellness program in reducing risk factors for coronary heart disease. Fifty university employees with at least one cardiovascular disease risk factor participated in the program. Interventions focused on diet, exercise, and monthly workshops. Pre- and post-intervention measurements included weight, body composition, blood pressure, total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, total cholesterol/HDL cholesterol ratio, triglycerides, and blood sugar. Twenty-five employees had post-intervention measurements. A survey was administered to assess adherence. The correlation between adherence and improvement in cardiovascular disease risk factors was also tested. Significant differences were observed between pre- and post-intervention measurements of total cholesterol, LDL cholesterol, total cholesterol/HDL cholesterol ratio, triglycerides, and weight. A significant correlation existed between self-reported level of participation in the diet aspect of the program and improvement in LDL levels. This multi-component, 12-week pilot employee wellness program was effective in reducing cardiovascular disease risk.