Disease outcomes in a cohort of women in Ireland infected by hepatitis C-contaminated anti-D immunoglobulin during 1970s.

BACKGROUND & AIM: In the mid-1990s, a group of Rh negative women was diagnosed with hepatitis C virus (HCV) genotype 1b infection, following administration of contaminated anti-D immunoglobulin in 1977-79. We aimed to describe their disease history and estimate the effect of selected host and treatment factors on disease progression. METHODS: We conducted a cohort study on the women infected with HCV. Information was collected from records at seven HCV treatment centres on demographics, treatment and health outcomes up to the 31st December 2013. We calculated cumulative incidence, case fatality, and sub hazard ratios (SHR) for disease progression using competing risks regression. RESULTS: Six hundred and eighty-two patients were included in the study. Among the chronically infected patients (n=374), 35% completed interferon-based antiviral treatment; 42% of whom had a sustained virological response. At the end of 2013, 19%, 1.9%, and 4.9% of chronically infected patients had developed cirrhosis, hepatocellular carcinoma, and liver-related death, respectively, compared with 10%, 0.8%, and 2.4% at the end of 2008. At the end of 2013, 321 (86%) of the chronically infected patients remained alive, 247 (77%) of whom were still chronically infected. Factors associated with increased cirrhosis rates included high alcohol intake (aSHR=4.9 [2.5-9.5]) and diabetes mellitus (aSHR=5.0 [2.9-8.8]). CONCLUSIONS: Development of liver-related outcomes accelerated with time, with the risk of cirrhosis, hepatocellular carcinoma, and liver-related death doubling in the last five years of follow-up, particularly in women with high alcohol consumption and diabetes mellitus. We recommend that patients with chronic HCV infection be advised of the additive harmful effect of alcohol, and that data be collected on this cohort after a further five years to analyse the effect of subsequent antiviral treatment during this rapidly evolving period in HCV treatment history. LAY SUMMARY: In the mid-1990s, a group of women were diagnosed with chronic hepatitis C virus (HCV) infection following receipt of contaminated anti-D immunoglobulin between 1977 and 1979 in Ireland. Seventy-two (19%) developed cirrhosis and 18 had died from liver-related causes (5%) after 36years of infection. Disease progression accelerated in the last five years of follow-up, particularly in women with diabetes mellitus and high alcohol consumption. We recommend that patients with chronic HCV infection be advised of the additive harmful effect of high alcohol consumption.

National Acute Medicine Programme--improving the care of all medical patients in Ireland.

BACKGROUND: The National Acute Medicine Programme (NAMP) was established to address the unsatisfactory management of acutely ill medical patients in Ireland. It aimed to improve quality of care and patient safety, streamline access to healthcare, and reduce cost through efficiency gains. METHOD: A model of care was developed to describe 4 distinct clinical pathways for medical patients streamed through acute medical assessment units. A patient flow model was used to build system capacity and predict demand for each hospital. Specific practice changes necessary were identified for each pathway. A performance framework, with national benchmarks that mirrored the model of care, was also developed. The program team met regularly with hospitals and fed back performance information and, using appreciative enquiry, supported local improvement plans. RESULTS: Thirty-two out of 33 Irish hospitals that admit acute medical patients are now operating the program. Process improvement lies at the core of all the success achieved by the program. Available inpatient data were improved and harnessed to support ongoing audit and quality improvement. A reduction of 1.6 days in average length of stay nationally was achieved between 2010 and 2013. CONCLUSION: Despite a 25% increase in hospital discharges and the severe financial constraints experienced during this implementation period, the NAMP achieved significant efficiency gains through process improvements, while ensuring patient safety and likely improving the quality of care delivered to patients in Ireland.

NSAID-induced colopathy. A case series.

The adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs) on the upper gastrointestinal tract and small intestine are well established. The effect of such therapy on the large intestine, so called NSAID colopathy, is less well described. We present four such cases demonstrating the characteristic endoscopic findings. One case in particular is, to our knowledge, the first report of the natural history of this clinical entity, initially presenting with the acute picture of inflammation and ulceration with subsequent progression to the more chronic development of diaphragm-like fibrous strictures. NSAID-induced colonic damage is a clinically significant condition. Two of our patients presented with bloody diarrhoea while the other two patients developed symptomatic anaemia. With the increasing use of enteric coated and sustained release NSAID preparations this condition is likely to become more frequent. Increasing awareness of its clinical presentation and of its spectrum of endoscopic findings facilitates a more prompt diagnosis and appropriate treatment to be established.

Successful outcome of sphincterotomy and 7 French pigtail stent insertion in the management of post-cholecystectomy bile leaks.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is widely used to manage post-cholecystectomy bile leaks. However, the best endoscopic intervention remains controversial. We investigated the success of a 7 French double pigtail stent following sphincterotomy in the management of such bile leaks. METHODS: Between July 1998 and June 2008, 48 patients were referred for ERCP for presumed post-cholecystectomy bile leaks. Leaks were confirmed at ERCP and managed by a combination of sphincterotomy and stent insertion unless contraindicated. RESULTS: Bile duct cannulation was successful in 44 (91.7%) patients. A leak of the cystic duct was demonstrated in 19 (43.2%) patients, the duct of Luschka in 11 (25.0%), and the common hepatic duct in 5 (11.4%). Complete transection of the common bile duct occurred in 4 patients. The remaining patients had no cholangiographic evidence of a leak. Sphincterotomy was performed in 34 patients. A 7 French double pigtail plastic stent was placed in all 35 patients with cholangiographic evidence of a bile leak. No bile leaks were demonstrated at a follow-up of 8-16 weeks and all stents were removed successfully. CONCLUSION: The combination of sphincterotomy and insertion of a 7 French double pigtail stent results in excellent outcomes in the management of post-cholecystectomy bile leaks.