Detection of Minimal Hepatic Encephalopathy in Iranian Patients with Cirrhosis.

BACKGROUND Minimal hepatic encephalopathy (MHE) is the mildest type of hepatic encephalopathy in patients with cirrhosis. Patients with MHE have normal clinical and physical examination but they show some neurocognitive dysfunctions that affect their quality of life negatively. The aim of the current study is to diagnose MHE in patients with cirrhosis and its associated factors. METHODS This is a cross-sectional study on 120 known cases of cirrhosis referred to hospitals affiliated to Isfahan University of Medical Sciences during 2014-17. The patients' cirrhosis severity was evaluated using laboratory tests and physical examinations based on MELD (Model for End-stage Liver Disease) and Child-Pugh criteria. The patients' demographics were filled in a checklist. All included patients with cirrhosis were asked to respond to the questions of Psychometric Hepatic Encephalopathy Score (PHES) test. RESULTS Mean age of the patients was 51.2 ± 9.7 years. 62 (51.7%) patients were men and 58 (48.3%) patients were women. The mean score of the patients based on MELD criteria was 14.03 ± 6.09. 26.7% of the patients presented MHE. Mean age of the patients with MHE was statistically less than the patients without MHE (p value < 0.001). Mean score of MELD criteria among the patients with diagnosis of MHE was significantly higher than the other group (p value < 0.001). The patients' Child class was statistically associated with MHE (p value < 0.001). Men were significantly more affected than women (p value = 0.03). CONCLUSION MHE was associated with MELD score and Child class of the patients with cirrhosis. The noticeable point was reversible association of age with MHE. Further studies are recommended.

Effects of cumin on nonalcoholic steatohepatitis: A double blind, randomised, controlled trial.

BACKGROUND: This study was designed to evaluate the effect of cumin on nonalcoholic steatohepatitis (NASH) in compare to placebo. MATERIALS AND METHODS: One hundred patients with histopathological diagnosis NASH in two groups of case and control received oral cumin capsule or placebo thrice daily for 6 months. Clinical and laboratory data were body mass index (BMI), serum triglyceride, serum total cholesterol, alanine aminotransferase (ALT), aspartate aminotransferase (AST), high-density lipoprotein (HDL), low-density lipoprotein (LDL), fasting blood sugar (FBS), steatosis grade, and side-effects and were measured at baseline and after treatment period using standard clinical chemistry techniques. The grade of steatosis was assessed by liver sonography in 3 stages (mild, moderate and severe). RESULTS: Of 100 eligible patients during follow-up 10/50 cases and 9/50 controls were excluded. At baseline and after treatment BMI, triglyceride, cholesterol, ALT, AST, HDL, LDL, and FBS were not statistically significant between groups (P ≥ 0.5). BMI, triglyceride, cholesterol, ALT, AST, LDL, and FBS after treatment decreased compare to baseline but were not statistically significant (P ≥ 0.5). The mean of changes in the level of BMI, triglyceride, cholesterol, ALT, LDL and FBS were not statistically significant (P ≥ 0.5). The mean of changes in AST and HDL between groups was significant (P < 0.05). The grade of steatosis before and after treatment between studied groups was not statistically significant (P ≥ 0.5). Side-effects were not statistically significant among the two groups. CONCLUSION: Findings show that there the effect of cumin in in the treatment of NASH was not significantly different in compare to placebo.

A comparative study of one minute versus five seconds endoscopic biliary balloon dilation after small sphincterotomy in choleducolithiasis.

BACKGROUND: Limited sphincterotomy and endoscopic papillary balloon dilation (EPBD) is a low-risk method for the treatment of choleducolithiasis. Traditionally one minute ballooning time (BT) is applied; however, the effective BT is not clear. In this study, we compare five seconds and one minute ballooning time. MATERIALS AND METHODS: In this single-blind, randomized, clinical trial 60 patients with common bile duct (CBD) stones documented in ultrasonography or magnetic resonance cholangiopancreatography (MRCP), with no severe hepatic, biliary or systemic diseases, enrolled in the study. The patients were randomly assigned to receive EPBD with either five seconds (n = 31) or one minute (n = 29) ballooning time (BT) after endoscopic retrograde cholangiopancreatography (ERCP) and small sphincterotomy. Then stones were retrieved with an extractor balloon. The patients were followed for 48 hours to check the possible complications. RESULTS: Successful CBD stone removal was the same in the five-second and one-minute BT groups (93.5% vs. 96.6%; P = 0.594). Pancreatitis occurred in three (9.7%) patients in the five-second BT group and in six (20.7%) patients in the one-minute BT group (P = 0.233). No hemorrhage or perforation was noted. CONCLUSIONS: After a small sphincterotomy, EPBD in the five-second and one-minute BT groups had a similar efficacy. Small sphincterotomy combined with very short BT is a safe and effective method for CBD stone removal.

Multistrain probiotic and lactulose in the treatment of minimal hepatic encephalopathy.

BACKGROUND: Some evidence has shown benefits of probiotics in the management of minimal hepatic encephalopathy (MHE). We evaluated the efficacy of a multistrain probiotic compound, alone and in combination with lactulose, in the treatment of MHE. MATERIALS AND METHODS: This study has two parts. First, consecutive adult patients with MHE were randomized to receive lactulose (30-60 mL/day) + probiotic (200 million colony forming units of seven bacteria species/day) (Gp-LPr) or lactulose + placebo (Gp-L). In second part, a non-randomized group of patients received probiotic alone (Gp-Pr). Medication duration was for 2 weeks and patients were followed-up for another 8 weeks. Improvement in MHE status was assessed by psychometric hepatic encephalopathy score (PHES). Development of overt encephalopathy, hospitalization, and death were considered as secondary outcomes. RESULTS: Sixty patients (80% male, mean age 38.4 ± 9.6 years) completed the intervention. PHES significantly improved after medication in all the three groups (Gp-LPr: -3.8 ± 3.9 to -1.6 ± 3.0; Gp-L: -4.8 ± 4.1 to -1.6 ± 2.9; and Gp-Pr: -4.9 ± 3.7 to -2.1 ± 2.5, P < 0.001). After 8 weeks follow-up, improvement was maintained in Gp-LPr and Gp-Pr, but there was deterioration in those who did not receive probiotics (Gp-L: PHES score reversed to -4.8 ± 4.2). Two patients (one each in Gp-L and Gp-Pr) experienced overt encephalopathy. One patient was hospitalized due to worsening of ascites (Gp-LPr) and one due to spontaneous bacterial peritonitis (Gp-L). Side effects were mild and not significantly different among the groups. CONCLUSION: Lactulose and probiotics are effective for the treatment of MHE; however, probiotics, but not lactulose, have long-term effects. More studies are required before suggesting probiotics for the standard treatment of MHE.

The effects of multi-strain probiotic compound on symptoms and quality-of-life in patients with irritable bowel syndrome: A randomized placebo-controlled trial.

BACKGROUND: Evidence has shown beneficial effects of probiotics in the treatment of irritable bowel syndrome (IBS); however, there is still a lack of data in this regard. We evaluated the efficacy of a multi-strain probiotic compound on IBS symptoms and quality-of-life (QOL). MATERIALS AND METHODS: Adult IBS patients (n = 132) were randomized to receive a probiotic compound containing seven bacteria species including Lactobacillus strains, Bifidobacterium strains and Streptococcus thermophiles or similar placebo, twice daily after a meal for 14 consecutive days. Improvement of IBS symptoms was assessed in categories of abdominal pain and distension and improvement of bowel habit. Improvement in patients QOL was assessed by the IBS-QOL instrument. Patients were evaluated for symptoms and QOL at baseline and then 1 month after completion of the treatment. RESULTS: After treatment, there was a decrease in abdominal pain and distension severity in both probiotic and the placebo groups (P<0.001), but there was no difference between the two groups in this regard (P>0.05). Improvement in bowel habit was observed in 33.3% of the probiotic and 36.5% of the placebo group (P = 0.910). There was no significant difference between the two groups in QOL after the treatment (P >0.05). CONCLUSIONS: We found no beneficial effects over placebo for a 2-week treatment with the above mentioned multi-strain probiotic compound in the treatment of IBS. Further, trials are yet required before a clear conclusion in this regards.

Premedication with sublingual or oral alprazolam in adults undergoing diagnostic upper gastrointestinal endoscopy.

BACKGROUND AND STUDY AIM: Diagnostic esophagogastroduodenoscopy (EGD) is uncomfortable for most patients. We determined the efficacy of alprazolam, administered orally or sublingually, as premedication for sedation during EGD. PATIENTS AND METHODS: Adult EGD candidates were randomly allocated to four groups (n = 55, each group) and received alprazolam (0.5 mg) sublingually or orally, placebo sublingually or orally at 30 minutes before EGD. Main outcome measures included procedure-related anxiety and pain/discomfort (assessed using 11-point numeric scales), patient overall tolerance (assessed using a 4-point Likert scale), need for intravenous sedation, and willingness to repeat the EGD if necessary. RESULTS: Patients experienced greater reduction in anxiety score after medication with sublingual alprazolam (mean 2.25, standard deviation [SD] 1.73) compared with sublingual placebo (mean 0.10, standard error [SE] 0.15]; P < 0.001) and oral alprazolam (0.63, SE 0.14; P < 0.001). Also, pain/discomfort scores were lower with sublingual alprazolam compared with sublingual placebo (3.29, SE 0.29 vs. 4.16, SD 1.86; P = 0.024), and with oral alprazolam compared with oral placebo (3.48, SD 1.69 vs. 5.13, SD 2.39; P  < 0.001). Patient overall tolerance was better with sublingual alprazolam than with sublingual placebo (P = 0.005) or with oral alprazolam (P = 0.009). Regarding intravenous sedation, there was no difference between sublingual alprazolam and sublingual placebo (10.9 % vs. 10.9 %; P = 0.619) or between oral alprazolam and oral placebo (9.0 % vs. 12.7 %; P = 0.381). Willingness to repeat the procedure was greater with sublingual alprazolam than with sublingual placebo (50.9 % vs. 30.9 %; P = 0.026). CONCLUSIONS: Sublingual alprazolam is an effective premedication for sedation during EGD. It reduces anxiety and pain/discomfort related to EGD and increases patient tolerance and willingness to repeat the EGD if necessary. CLINICAL TRIAL REGISTRATION: NCT01949038 ClinicalTrials.gov.

Statin efficacy in the treatment of hepatitis C genotype I.

BACKGROUND: Lipid metabolism is one of the hepatitis C virus (HCV) life cycle steps. Statins can reduce cholesterol level and finally can decrease HCV replication. Thus, we assessed the effect of Statins in combination with standard antiviral treatment on hyperlipidemic genotype I HCV infected patients. MATERIALS AND METHODS: This study was a prospective clinical trial. 40 patients were selected from those referred to educational and Therapeutic Centers of Isfahan University of Medical Sciences from 2009 to 2010 with confirmed HCV viremia. All patients received Peg-interferon-a2a and ribavirin. 20 hyperlipidemic Patients received 20 mg atorvastatin nightly for 3 months and placebo was prescribed for 20 normolipidemic HCV infected patients as a control group. Liver enzymes and complete blood count were checked monthly and thyroid stimulating hormone was checked every 3 months. We also performed quantitative HCV-ribonucleic acid (RNA) test in 12(th) week of therapy, at the end of treatment and 6 months after therapy for all samples. RESULTS: We didn't find any significant differences in the mean of HCV-RNA numbers between statin and placebo groups in 12(th) week of treatment, in the end of treatment and 6 months after treatment (P > 0.05). CONCLUSION: Atorvastatin has no effect on the mean of HCV viral load when we added it to standard treatment for hepatitis C infection. Further studies are necessary to examine the possible antiviral properties of statins and their potential role as adjuncts to standard HCV therapy.

The effects of multistrain probiotic compound on bismuth-containing quadruple therapy for Helicobacter pylori infection: a randomized placebo-controlled triple-blind study.

BACKGROUND: Evidence has shown benefits of single-strain probiotics for Helicobacter pylori eradication. We investigated the effects of adding a multistrain probiotic compound on bismuth-containing quadruple therapy for H. pylori infection. MATERIALS AND METHODS: Adult patients with peptic ulcer disease and confirmed H. pylori infection (n = 180) were randomized to receive bismuth-containing quadruple therapy (omeprazole, bismuth subcitrate, amoxicillin, and clarithromycin) plus a probiotic compound or placebo for 2 weeks. The probiotic compound contained seven bacterial species including Lactobacillus and Bifidobacterium strains and Streptococcus thermophiles. Eradication of H. pylori was assessed 4 weeks after medication by (13) C urea breath test. Other outcomes were dyspepsia symptoms, therapy-related adverse effects, and patient's tolerance. RESULTS: Eighty-four patients in the probiotic and 86 in the placebo group completed the trial. With per-protocol (intention to treat) analysis, H. pylori was eradicated in 82.1% (76.6%) of the probiotic and 84.8% (81.1%) of the placebo group, p = .392 (0.292). Symptoms were significantly improved with similar trends in both groups. Regarding the adverse effects, diarrhea was less frequent (2.2 vs 11.1%, p = .016), while abdominal pain was more frequent (10 vs 2.2%, p = .029) in the probiotic group. The two groups were similar in treatment tolerance (p = .851). CONCLUSIONS: In overall, our studied multistrain probiotic compound has not beneficial effects in the treatment of H. pylori infection. It might be related to the low dosage of our probiotic regimen and/or high frequency of upper gastrointestinal adverse effects which in turn could decrease the eradication efficacy.