Epidemiology of antenatal depression among women with high-risk pregnancies due to obstetric complications: a scoping review.

PURPOSE: Antenatal depression is a common mental health problem among pregnant women that negatively affects maternal and neonatal outcomes. Women with obstetric complications, defined as high-risk pregnancies, seem to be at particularly increased risk for developing depressive symptomatology. The purpose of this study was to review the prevalence of antenatal depression among pregnant women with obstetric complications and to identify possible associated factors. METHODS: A literature search was performed in the PubMed database and a scoping review was conducted to identify studies with data on the prevalence of antenatal depression and associated factors among high-risk pregnancies due to obstetric complications. The included studies were written in English and published up to 31/12/2018. RESULTS: The prevalence of antenatal depression among pregnant women with high-risk pregnancies ranges from 12.5 to 44.2% among the reviewed studies. The associated factors significantly associated with antenatal depression include maternal age, maternal education, dwelling place, relationship with the partner, previous psychiatric diagnosis, perceived stress, antenatal attachment, abortion thoughts, smoking, diabetes, parity, number of pregnancies, gestational age, threatened preterm labour, preeclampsia and oligohydramnios. CONCLUSIONS: Our findings indicate a high prevalence of depressive disorders in women with obstetric complications, suggesting the need for more rigorous screening among this population. The identification of associated factors also merits clinical attention. Further research is warranted to develop evidence-based effective screening strategies and relevant interventions.

Hepatitis C in patients with ß-thalassemia major. A single-centre experience.

Chronic hepatitis C (CHC) and iron overload are the main causes of liver disease in ß-thalassemia major (ßTM). There is limited data regarding the course of CHC in this population. All patients (n=144) from the thalassemia centre of the University Hospital of Patras were evaluated (January 1981 to June 2012). Patients were classified into group A (n=57), which consisted of patients with CHC, who either had received antiviral treatment (n=49) or not (n=8), and group B which included 87 patients without CHC. Nineteen patients died during follow-up (median: 257.5 months (1-355)). Survival rates were 84.2 % and 88.5 % for group A and B, respectively. The causes of death were heart failure (63.2 %), accident (10.5 %), sepsis (5.3 %), liver failure (5.3 %), hepatocellular carcinoma (HCC) (5.3 %), non-Hodgkin lymphoma (5.3 %) and multiorgan failure (5.3 %). There were no differences in total survival between the two groups (p=0.524). In the multivariate analysis, survival was neither correlated with CHC (p=ns), nor with anti-HCV treatment (p=ns), whereas independent negative predictors were presence of heart failure (p<0.001), presence of malignancy other than HCC (p=0.001) and non-adherence to chelation treatment (p=0.013). Predictive factors for the development of cirrhosis were: CHC (p<0.001), age>35 years (p=0.007), siderosis grade 3/4 (p=0.029) and splenectomy (p=0.001); however, multivariately, only siderosis grade 3/4 was found to be significant (p=0.049). In this study, survival of patients with ßTM was mainly associated with heart failure, presence of malignancy other than HCC and non-adherence to chelation treatment, rather than with liver disease. Multicentre studies need to be designed to define more accurately the indications of antiviral treatment in this population.

Critical illness-related corticosteroid insufficiency in patients with cirrhosis and variceal bleeding.

BACKGROUND & AIMS: Relative adrenal insufficiency (AI) occurs in patients with cirrhosis with sepsis, but not with variceal bleeding. We evaluated adrenal function in cirrhotic patients with and without bleeding. METHODS: Twenty cirrhotic patients with variceal bleeding were evaluated using the short synacthen test (SST) and 10 using the low-dose synacthen test (LDSST) followed by SST. The control group included 60 stable cirrhotic patients, assessed by LDSST (n = 50) or SST (n = 10), and 14 healthy volunteers. AI was diagnosed using SST, based on peak cortisol levels ≤ 18 µg/dL in nonstressed patients or Δmax <9 µg/dL or a total cortisol level <10 µg/dL in stressed patients with variceal bleeding-the current criteria for critical illness-related corticosteroid insufficiency. Using LDSST, diagnosis was based on peak concentrations of cortisol ≤ 18 µg/dL in nonstressed patients and <25 µg/dL (or Δmax <9 µg/dL) in patients with variceal bleeding. We evaluated patients with levels of serum albumin >2.5 g/dL, to indirectly assess cortisol binding. RESULTS: All healthy volunteers had normal results from LDSSTs and SSTs. Patients with variceal bleeding had higher median baseline concentrations of cortisol (15.4 µg/dL) than stable cirrhotic patients (8.7 µg/dL, P = .001) or healthy volunteers (10.1 µg/dL, P = .01). Patients with variceal bleeding had higher median peak concentrations of cortisol than stable cirrhotic patients (SST results of 32.7 vs 21 µg/dL, P = .001; LDSST results of 9.3 vs 8.1 µg/dL; nonsignificant), with no differences in Δmax in either test. These differences were greater with variceal bleeding than in stable cirrhotic patients with AI. Subanalysis of patients with albumin levels >2.5 g/dL did not change these differences. CONCLUSIONS: Cirrhotic patients with variceal bleeding have AI. Despite higher baseline concentrations of serum cortisol and subnormal Δmax values, they did not have adequate responses to stress, and therefore had critical illness-related corticosteroid insufficiency.

Acute Lower Gastrointestinal Bleeding: Characteristics and Clinical Outcome of Patients Treated With an Intensive Protocol.

BACKGROUND: In recent years major advances have been made in the management of patients with acute lower gastrointestinal bleeding. The aim of this study was to investigate the characteristics and clinical outcome of patients with acute lower gastrointestinal bleeding (ALGIB) treated with an intensive protocol. METHODS: We analyzed the medical records of 528 patients with ALGIB. All patients after hemodynamic stabilization underwent colonoscopy during the first 24 h of hospitalization and capsule enteroscopy when needed. Patients with massive ongoing bleeding underwent computed tomography angiography (CTA), and when active bleeding was detected embolization was immediately performed. RESULTS: The mean age of the patients was 70.2 ± 14.6 years and 271 (51.3%) of them were men. At least one comorbidity was present in 464 patients (87.9%), cardiovascular disease in 266 (50.4%), while 158 (30%) patients were on antiplatelet drugs and 96 (18.2%) on anticoagulants. The most common causes of bleeding were diverticulosis (19.7%) and ischemic colitis (19.3%). Thirty-six patients (6.9%) had small intestinal bleeding. In 117 patients (22.2%) active bleeding or recent bleeding stigmata were found and in 82 of them (92.1%) endoscopic hemostasis was applied. Embolization was performed in 10 (1.9%) and was successful in seven (70%) cases, while surgical hemostasis was required in only six (1.1%) cases. Forty-four (8.3%) patients had a rebleeding episode, and 13 patients died with an overall mortality of 2.5%. CONCLUSIONS: Management of ALGIB based on an intensive protocol is safe and effective. The bleeding source can be identified in most cases with a favorable outcome.

Adipokines levels are associated with the severity of liver disease in patients with alcoholic cirrhosis.

AIM: To investigate the adipokine levels of leptin, adiponectin, resistin, visfatin, retinol-binding protein 4 (RBP4), apelin in alcoholic liver cirrhosis (ALC). METHODS: Forty non-diabetic ALC patients [median age: 59 years, males: 35 (87.5%), Child-Pugh (CP) score: median 7 (5-12), CP A/B/C: 18/10/12, Model for End-stage Liver Disease (MELD): median 10 (6-25), follow-up: median 32.5 mo (10-43)] were prospectively included. The serum adipokine levels were estimated in duplicate by ELISA. Somatometric characteristics were assessed with tetrapolar bioelectrical impedance analysis. Pearson's rank correlation coefficient was used to assess possible associations with adipokine levels. Univariate and multivariate Cox regression analysis was used to determine independent predictors for overall survival. RESULTS: Body mass index: median 25.9 (range: 20.1-39.3), fat: 23.4% (7.6-42.1), fat mass: 17.8 (5.49-45.4), free fat mass: 56.1 (39.6-74.4), total body water (TBW): 40.6 (29.8-58.8). Leptin and visfatin levels were positively associated with fat mass (P < 0.001/P = 0.027, respectively) and RBP4 with TBW (P = 0.025). Median adiponectin levels were significantly higher in CPC compared to CPA (CPA: 7.99 ± 14.07, CPB: 7.66 ± 3.48, CPC: 25.73 ± 26.8, P = 0.04), whereas median RBP4 and apelin levels decreased across the spectrum of disease severity (P = 0.006/P = 0.034, respectively). Following adjustment for fat mass, visfatin and adiponectin levels were significantly increased from CPA to CPC (both P < 0.001), whereas an inverse correlation was observed for both RBP4 and apelin (both P < 0.001). In the multivariate Cox regression analysis, only MELD had an independent association with overall survival (HR = 1.53, 95%CI: 1.05-2.32; P = 0.029). CONCLUSION: Adipokines are associated with deteriorating liver function in a complex manner in patients with alcoholic liver cirrhosis.

Efficacy of Interferon A-2b monotherapy in Β-thalassemics with chronic hepatitis C.

BACKGROUND & AIMS: Monotherapy with standard or pegylated interferon (PegIFN) remains the first-line treatment for HCV infection in patients with thalassemia major (ßTM), although its long-term impact is still unknown. We aimed to assess the efficacy of IFN-a2b/PegIFN-a2b (one or multiple treatment sessions) and the predictors for sustained virological response (SVR) in HCV-infected ßTM patients. METHODS: Between 11/1992 and 12/2013 [median follow-up: 165.5 months (8-237)], 48 ßTM HCV-infected patients [19 males, median age: 22 years (12-45)], received IFN-a2b (n=34) or PegIFN-a2b (n=14). Twenty-three patients (47.9%) had a previous splenectomy; 13/40 (32.5%) patients had Ishak stage >/=4 and 21/40 (52.5%) had siderosis grade 3-4. HCV-genotype was available in 36 patients (genotype 1: 47.2%, 2: 5.6%, 3: 25%, and 4: 22%). IL28B genotype was determined in 37 patients by means of in-house real-time PCR (CC: 27%, CT: 62.2%, TT: 10.8%). RESULTS: Totally, 15/48 (31.3%) achieved SVR following the first treatment and 18/48 (37.5%) after multiple courses. Splenectomy (p=0.01) and fibrosis grade >/=4 (p<0.05) were negative predictors for SVR (first course), whereas splenectomy (p<0.05) and age >18 (p<0.02) for SVR after multiple courses. In HCV-genotype 1/4 (n=25), none of the patients with CT or TT IL28B genotype achieved SVR compared to 50% of the CC patients (p=0.004). CONCLUSIONS: Interferon is an effective therapeutic option in HCV-infected ßTM patients. IL28B genotype was a strong predictor for SVR, together with splenectomy, age and fibrosis.

Acceptance of hepatitis B vaccination among health care workers in Western Greece.

Health care personnel are at high risk for hepatitis B virus (HBV) transmission. The aim of the present study was to investigate hepatitis B (HB) knowledge and vaccination acceptance among health care personnel in southwestern Greece, using the Hepatitis B Vaccine Knowledge and Acceptance Questionnaire. One hundred eighty-three employees participated (71 males). Occupation (p < .001), higher education (p < .001), and vaccination (p = .007) were significantly related to HB knowledge. The rate of HBV vaccination coverage was 70.9%. Participants considering themselves at high risk for HBV infection did not report significantly increased vaccination rates. In the multivariate analysis, university personnel (p = .002), occupational category (p < .001), and HB knowledge (p = .049) were significantly associated with vaccination. In conclusion, 29% of hospital personnel were not vaccinated mainly due to negligence. Occupation, education, and knowledge about HB seem to be associated with HBV vaccination.

Endogenous heparinoids detected by anti-Xa activity are present in blood during acute variceal bleeding in cirrhosis. A prospective study.

BACKGROUND & AIMS: Endogenous heparinoids have been detected by thromboelastography and quantified by clotting based anti-Xa activity assays in patients with cirrhosis, but their presence in variceal bleeding has not been established yet. METHODS: Clotting based anti-Xa activity was measured in A) 30 cirrhotics with variceal bleeding, B) 15 non-cirrhotics with peptic ulcer bleeding, C) 10 cirrhotics without infection or bleeding, and D) 10 cirrhotics with hepatocellular carcinoma (HCC). RESULTS: Anti-Xa activity was not detected in ulcer bleeders or in cirrhotics without infection or bleeding but was present in seven (23%) variceal bleeders (median levels: 0.03 u/mL (0.01-0.07)) and was quantifiable for 3 days in six of seven patients. Four of seven variceal bleeders with anti-Xa activity present had HCC (p=0.023). Age, creatinine, platelet count and total infections the second day from admission were significantly correlated with the presence of measureable anti-Xa levels (p=0.014, 0.032, 0.004 and 0.019, respectively). In the HCC group, anti-Xa activity was present in three patients (30%) [median levels: 0.05 u/mL (0.01-0.06)]. CONCLUSIONS: In this study, variceal bleeders and 30% of the patients with HCC had endogenous heparinoids that were detected by a clotting based anti-Xa activity assay, whereas there was no anti Xa activity present in patients with cirrhosis without infection, or bleeding or HCC, nor in those with ulcer bleeding. Thus, the anti Xa activity is likely to be a response to bacterial infection and/or presence of HCC in cirrhosis.

Higher free serum cortisol is associated with worse survival in acute variceal bleeding because of cirrhosis: a prospective study.

BACKGROUND AND AIMS: Critical illness-related corticosteroid insufficiency has been reported in acute variceal bleeding (AVB). In cirrhosis, free serum cortisol (FC) is considered optimal to assess adrenal function. Salivary cortisol (SC) is considered a surrogate for FC. We evaluated FC and its prognostic role in AVB. METHODS: Total serum cortisol, SC, cortisol-binding globulin, and FC (Coolens' formula) were evaluated in AVB (n=38) and in stable cirrhosis (CC) (n=31). A Cox proportional hazards model was evaluated for 6-week survival. RESULTS: In AVB, the median FC and SC levels were higher with worse liver dysfunction [Child-Pugh (CP) A/B/C: 1.59/2.62/3.26 µg/dl, P=0.019; CPA/B/C: 0.48/0.897/1.81 µg/ml, P<0.001, respectively]. In AVB compared with CC, median total serum cortisol: 24.3 versus 11.6 µg/dl (P<0.001), SC: 0.86 versus 0.407 µg/ml (P<0.001); FC 2.4 versus 0.57 µg/dl (P<0.001). In AVB, 5-day rebleeding was 10.5%, and 6-week and total mortality were 21.1 and 23.7%, respectively. Independent associations with 6-week mortality in AVB were FC at least 3.2 µg/dl (P<0.001), hepatocellular carcinoma (P<0.001), CPC (P<0.001), and early rebleeding (P<0.001). Among patients with normal cortisol-binding globulin (n=14) and albumin (n=31), the factors were hepatocellular carcinoma (P=0.003), CP (P=0.003), and FC (P=0.036). SC was also found to be an independent predictor of 6-week mortality (P<0.001). Area under the curve of FC for predicting 6-week mortality was 0.79. CONCLUSION: Higher FC is present in cirrhosis with AVB compared with CC and is associated independently with bleeding-related mortality. However, whether high FC solely indicates the severity of illness or whether there is significant adrenal insufficiency cannot be discerned.

Health-related quality of life in patients with inflammatory bowel disease: a single-center experience.

BACKGROUND: Inflammatory bowel disease (IBD) has a negative impact on health-related quality of life (HRQoL). The aim of the study was to assess HRQoL of IBD patients in South-Western Greece. METHODS: 89 IBD patients [38 (42.7%) Crohn's disease (CD), 51 (57.3%) ulcerative colitis (UC)] were included. HRQoL was assessed using IBD questionnaire (IBDQ), which tests four health domains: bowel symptoms (BS), systemic symptoms (SS), emotional function (EF) and social function (SF). Total score (TS) ranges from 32 to 224. Disease activity was measured using Crohn's Disease Activity Index (CDAI) (CD), and Truelove and Witts classification (UC). The impact of epidemiological and disease-specific characteristics on IBDQ was studied. RESULTS: No statistically significant difference was found in all IBDQ scores between UC and CD patients. No correlation was found regarding age, sex, smoking, anemia, disease duration and use of corticosteroids, 5-aminosalicylates or immunosuppressives with HRQoL. The factors found to have a major negative impact on all IBDQ scores was disease severity both in CD and UC, and education on bowel symptoms in CD. On multivariate analysis, only high disease activity had significant effects on total and dimensional scores of IBDQ in UC (TS, P=0.005; BS, P<0.001; SS, P=0.004; EF, P=0.05; SF, P=0.001), whereas in CD, only CDAI (TS, P=0.001; BS, P=0.004; SS, P=0.001; EF, P=0.003; SF, P=0.003) and education (TS, P=0.047; BS, P=0.004; SS, P=0.03) had significant effects. CONCLUSIONS: IBD patients in remission experience better HRQoL than patients with active disease. Induction of remission should become the mainstay of care regarding improvement in HRQoL.

Surgical repair of umbilical hernias in cirrhosis with ascites.

The most common complications of umbilical hernias in patients with cirrhosis and ascites include leakage, ulceration, rupture and incarceration. If such a complication is present, there is a high mortality rate after surgical repair. Elective repair is the most effective choice, as it prevents complications with a lower mortality. However, the control of ascites before and/or after repair is mandatory but may not always be possible with diuretics and paracentesis. Portal decompression by transjugular intrahepatic portosystemic shunt (TIPS) with better control of ascites may allow these patients to undergo surgery. Patients with cirrhosis and umbilical hernias should be referred for consideration of an elective surgical repair with mesh, preferably after optimal management of ascites. There should be a low threshold for placement of a TIPS to facilitate surgery and reduce the chance of severe recurrence of ascites. If surgery is contraindicated, a TIPS must be considered for control of ascites.