The interpretation and management of abnormal liver function tests.

Liver function tests (LFTs) are frequently requested as part of routine health assessments on serving members of the Royal Navy (RN). In common with many investigations there are a number of abnormal results in healthy individuals (0.5 - 9% depending on test and study population). There are established patterns of LFT derangement such as cholestatic derangement, hepatocellular derangement, and failure of synthetic function. There can be indicators to the cause of the derangement by assessing the ratios of elevated assays in relation to one another. This article aims to address the definition, potential causes and further investigation of common patterns of LFT derangement found in primary care in the RN.

The management of acute seizures in Naval Service personnel.

Seizures are a relatively common Emergency Department (ED) presentation among young adult populations, considered for the purpose of this report as being aged 15-59. Due to the varied aetiologies involved, understanding of the potential causes and their presentation is key to managing these patients. Although seizure incidence within the United Kingdom (UK) Armed Forces population is generally low, it is not negligible. Therefore, awareness of the initial management is required by all those involved in patient care from the Medical Assistant (MA) at the Role 1 facility, through to the senior doctors at Role 3 establishments. All management should be in line with the Clinical Guidelines for Operations (CGOs) and Advanced Life Support (ALS) principles, with resuscitation, seizure control and patient stabilisation taking precedence initially. Ultimately, the use of laboratory testing and imaging at a Role 3 setting will be required to accurately confirm a diagnosis. Information obtained during these assessments may serve to assist the Naval Service Medical Board of Survey (NSMBOS) in determining suitability for continued Service retention and employment.

Management of starvation in a Role 1 setting.

Historical reports from war and natural disasters first identified the dangers of reintroducing food after a period of starvation or malnutrition. The development of advanced nutritional support for hospitalised patients gave rise to the concept of refeeding syndrome, further highlighting the problems and leading to the development of guidelines and protocols for managing malnutrition. In this paper we present a case of starvation in the maritime setting and review the pathophysiology of starvation and refeeding. We discuss the problems associated with managing acute starvation in a Role 1 setting without access to higher medical care, and present guidance for its management.

Renal replacement in the deployed setting.

We present a case of a UK soldier suffering multiple injuries in Afghanistan including a lacerated liver, complicated by acute anuric renal failure. His condition was stabilised prior to transfer to the UK using continuous venovenous haemofiltration. This is the first deployed use of renal replacement therapy by UK forces for several decades, and raises questions regarding the provision of this high level capability in the deployed setting.

Hepatitis B in a vaccinated soldier: a case report.

Assessing for an adequate immunological response to a pre-exposure course of hepatitis B vaccine is not routinely recommended in all vaccinated individuals. Current UK guidelines advise checking hepatitis B surface antibody titres only in those considered at high occupational risk such as healthcare and laboratory workers. We present a case of an infantry soldier who developed acute hepatitis B despite having a complete course of hepatitis B vaccinations. This case emphasises that hepatitis B is still an important differential diagnosis for all returning military personnel who present with compatible symptoms despite being vaccinated.

Antibiotic prophylaxis for percutaneous endoscopic gastrostomy for non-malignant conditions: a double-blind prospective randomized controlled trial.

BACKGROUND: The use of antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion has been encouraged following development of guidelines by a number of professional societies within the past few years. However, not all evidence supports routine prophylaxis, particularly in patients with 'benign' disease indications for percutaneous endoscopic gastrostomy insertion. AIM: To identify whether prophylactic antibiotic usage is beneficial in patients undergoing percutaneous endoscopic gastrostomy insertion without malignant disease. METHODS: Adult patients without malignant disease who were referred for percutaneous endoscopic gastrostomy insertion at our unit were assessed for participation in this prospective, double-blind, randomized controlled study. Patients were randomized to receive either placebo or 2.2 g co-amoxiclav (or 2 g cefotaxime if penicillin-allergic) at time of percutaneous endoscopic gastrostomy insertion. Clinical endpoints studies were percutaneous endoscopic gastrostomy site or systemic infection and death within 7 days of percutaneous endoscopic gastrostomy insertion. Results : Ninety-nine patients completed the study (51 antibiotics, 48 placebo). Outcomes in the antibiotic and placebo groups respectively were: percutaneous endoscopic gastrostomy site infection, 11% vs. 47% (P < 0.01); systemic infection, 16% vs. 38% (P < 0.05); and death, 8% vs. 15% (P = 0.5). CONCLUSIONS: Antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion reduces both percutaneous endoscopic gastrostomy site and systemic infections in patients without malignant disease.

Effects of nuclear weapons on the gastrointestinal system.

Nuclear weapons have both blast injury and radiation effects on the gut. The successful management of survivors requires a combined medical and surgical approach, and is likely to need at least 5 - 6 weeks of in-patient therapy for gastrointestinal radiation syndrome. It should be remembered that the haemopoietic syndrome is an invariable companion. The chance of survival for people with acute radiation syndrome decreases with increasing radiation dose. Most people who do not recover from ARS will die within a few weeks of exposure. The cause of death in most cases is the destruction of the bone marrow, which results in infections and internal bleeding. For the survivors, the recovery process may last from several weeks up to 2 years. Long-term survivors face an increased solid cancer risk of approximately 47% per sievert.

Inferior response of Asian vs non-Asian hepatitis C genotype 3 infection to combination antiviral therapy.

Racial differences in response to treatment of hepatitis C virus (HCV) have been noted in several trials. In this study, we compared the response rate to treatment of Asian patients infected by genotype 3 HCV with non-Asians treated for the same genotype. Sixteen of 38 (42.1%) Asians achieved a sustained virological response (SVR), compared with 41 of 66 (62.1%) Caucasians (P = 0.063). At baseline prior to treatment, Asians had a higher histological fibrosis stage (P = 0.0014), indicating more advanced disease at presentation. In univariable analysis of baseline factors predicting failure to achieve an SVR, Asian ethnicity, fibrosis stage, higher serum aspartate transaminase, bilirubin and alkaline phosphatase, as well as lower white cell count, haemoglobin and platelet count were statistically significant. None of these factors achieved significance in multivariate analysis, possibly because of the relatively small number of patients studied. We have observed an inferior response to treatment of Asian vs Caucasian patients. The poor response probably reflects the more advanced liver disease at baseline observed for Asian British patients.

Weight loss during pegylated interferon and ribavirin treatment of chronic hepatitis C*.

SUMMARY: Treatment of hepatitis C virus (HCV) infection with interferon (IFN)-alpha, as monotherapy or in combination with ribavirin, is associated with significant side-effects including weight loss. The aim of our study was to describe the evolution of body weight during combination antiviral treatment and to examine the possible determinants of weight loss. This was a retrospective analysis of 126 patients who received combination therapy of pegylated IFN-alpha-2b and ribavirin at our unit. Body weight was recorded at each outpatient attendance during treatment and follow-up, and was expressed as a percentage of baseline value. We observed a decline of body weight during treatment. Median (range) weight values at 4, 12, 24, and 48 weeks (expressed as percentage of baseline weight) were 97.7 (91.5-110.2), 95.4 (84.4-109.4), 93.7 (80.8-106.5), and 91.1 (80.1-103.6) respectively. There was no significant association of increased weight loss with age, gender, pretreatment weight, ethnicity, pretreatment histological stage, cumulative IFN dose (adjusted for body weight), HCV genotype or treatment outcome. Median body weight returned to baseline within 6 months of stopping treatment. Patients experience significant weight loss during combination therapy. Those experiencing greater weight losses during therapy did not benefit from improved antiviral response.

Plasma ghrelin following cure of Helicobacter pylori.

BACKGROUND: In the Western world, the incidence of oesophageal adenocarcinoma has increased over the last 30 years coinciding with a decrease in the prevalence of Helicobacter pylori. Trends of increasing oesophageal adenocarcinoma can be linked causally to increasing gastro-oesophageal reflux disease (GORD) which can be linked to an increasingly obese population. However, there is no plausible biological mechanism of association between H. pylori, obesity, and GORD. Ghrelin, a peptide produced in the stomach, which regulates appetite, food intake, and body composition, was studied in H. pylori positive asymptomatic subjects. METHODS: Plasma ghrelin, leptin, and gastrin were measured for six hours after an overnight fast, before and after cure of H. pylori in 10 subjects. Twenty four hour intragastric acidity was also assessed. RESULTS: After cure, median (95% confidence intervals) integrated plasma ghrelin increased from 1160.5 (765.5-1451) pg/ml x h to 1910.4 (1675.6-2395.6) pg/ml x h (p=0.002, Wilcoxon's rank sum test), a 75% increase. This was associated with a 14% increase in 24 hour intragastric acidity (p=0.006) and non-significant changes in leptin and gastrin. There was a significant positive correlation between plasma ghrelin and intragastric acidity (r(s) 0.44, p=0.05, Spearman's rank correlation). CONCLUSIONS: After H. pylori cure, plasma ghrelin increased profoundly in asymptomatic subjects. This could lead to increased appetite and weight gain, and contribute to the increasing obesity seen in Western populations where H. pylori prevalence is low. This plausible biological mechanism links H pylori, through increasing obesity and GORD, to the increase in oesophageal adenocarcinoma observed in the West.