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Virtual reality (VR) is an established and effective tool in reducing autonomic and somatic pain. We aimed to examine the analgesic effects of VR distraction during esophagogastroduodenoscopy (EGD).We conducted a randomized controlled trial and enrolled patients who had indication for unsedated EGD with topical anesthesia. Patients were randomly assigned to use Oculus GO with three-dimensional specific software content (standalone VR headset), sham VR or without VR during EGD. The primary outcome was patient pain scores during EGD.A total of 96 patients undergoing diagnostic EGD were randomized to receive VR (n = 32), sham VR (n = 32), and no VR defined as the control group (n = 32). Patients in all groups reported no statistically different pain during esophageal intubation. The mean pain score was 2.7 ± 2.4 in the VR group, 2.7 ± 2.5 in the sham VR and 2.3 ± 2.3 in the control group, (P value = 0.751). No significant difference was observed in heart rate and blood pressure, and the endoscopists reported higher overall satisfaction scores in VR (4.3 ± 0.5) compared with the control group (4 ± 0.8) but without significance (P value = 0.156).Virtual reality-assisted anesthesia during EGD did not significantly reduce patient pain during esophageal intubation. There was no superiority in using VR distraction regarding patient's and endoscopist's satisfaction compared with standard EGD without VR Further studies are required to detect any true clinical advantage of VR distraction during EGD.

Background Controversy remains regarding fluid management strategy, optimal volume and rate of intravenous fluid in mild acute pancreatitis. We performed a randomized controlled trial to compare clinical improvement and inflammatory markers between aggressive and standard fluid management. Methods A single center prospective randomized controlled trial was conducted in a tertiary care hospital. We randomized patients with a diagnosis of mild acute pancreatitis using revised Atlanta classification in two groups, the aggressive (20 ml/kg bolus followed by 3 ml/kg/hr) and standard (10 ml/kg bolus followed by 1.5 ml/kg/hr) intravenous hydration with Lactated Ringer's solution. Primary outcome was clinical improvement at 24 and 36 hours. Results The mean age of patients was 46 years and 34 patients (77%) were male. The average volumes of fluid during the first 24 hours in aggressive and standard groups was 4886 ml (71 ml/kg) and 3985 ml (53 ml/kg), respectively; p-value 0.002. Aggressive intravenous hydration did not significantly improve clinical outcome compared with standard intravenous hydration (45.45% vs. 31.82%, respectively; p-value 0.353). However, subgroup analysis between patients with obese and non-obese status, revealed aggressive intravenous hydration significantly improved clinical outcome within the first 24 hours in obese group. Conclusion Aggressive intravenous hydration with Lactated Ringer's solution did not improve clinical outcome in mild acute pancreatitis but showed statistically significant improvement only in patients with obese status. Future studies should include a larger sample size to confirm these findings.

BACKGROUND Even in the immuno-oncology era, transcatheter arterial chemoembolisation (TACE) is the most effective way to treat intermediate stage hepatocellular carcinoma (HCC). Postembolisation syndrome (PES) is the most common side effect from TACE and there is still no standard prevention guideline. AIM To evaluate the efficacy of single dose intravenous dexamethasone regimen to prevent PES after TACE among patients with HCC. METHODS This study enrolled patients with HCC who had eligible indication for TACE without macrovascular invasion/extrahepatic metastasis. Patients were randomly assigned to either an intravenous single dose of dexamethasone 8 mg or placebo one hour before TACE. The primary outcome was a negative result of PES at 48 h after TACE, which was defined as score < 2 of Southwest Oncology Group toxicity coding criteria using fever, nausea, vomiting and pain to calculated. And the secondary end point was duration of admission between two groups. RESULTS One hundred patients were randomly assigned 1:1. Under intention-to-treat analysis, 49 patients were randomly assigned to the dexamethasone and 51 to the placebo groups. Both groups were similar for baseline characteristics. The negative PES rate was significantly higher in the dexamethasone group than in the placebo group (63.3% vs 29.4%; P = 0.005). Mean Southwest Oncology Group toxicity coding PES was 2.14 (95%CI: 1.41-2.8) vs 3.71 (95%CI: 2.97-4.45) between the dexamethasone and placebo groups, respectively. Cumulative incidence of fever was significantly lower in dexamethasone group with P < 0.001, pain, nausea and vomiting were also lower in the dexamethasone group compared with the placebo group (P = 0.16, P = 0.11, and P = 0.49). The dexamethasone regimen was generally well tolerated by patients with HCC patients including those with hepatitis B virus infection and well-controlled diabetes mellitus. CONCLUSION Single dose dexamethasone was effective at preventing PES among patients with HCC treated with TACE. The study showed no adverse events of special interest related to dexamethasone.

Background and Aim Cystatin C (Cys) is not affected by age, sex, and muscle mass. We evaluated to compare the predictive performance of serum Cys level and model for end‐stage liver disease (MELD) score and developed a new model to predict 90‐day mortality among patients admitted with cirrhosis complications. Methods A prospective cohort study was performed from December 2018 to December 2019. All cirrhotic patients admitted with acute decompensated liver cirrhosis or acute on chronic liver failure had laboratory values measured within 48 h of admission. Results A cohort of 225 patients with cirrhosis was admitted during the study period. Sixty‐five patients were eligible for analysis. Twenty‐seven of these patients (41.4%) died within 90 days of follow‐up. The median of MELD score was 20.5 (15, 24). Serum Cys level of >1.45 mg/L had the highest 90‐day mortality prediction with the sensitivity and specificity of 66.7% and 68.4%, respectively. Cys and MELD scores were predictive of 90‐day mortality: Cys hazard ratio (HR) = 2.04 (95% CI 1.01–4.14, P = 0.048); MELD score HR = 1.01 (95% CI 0.51–2.01, P = 0.970). C‐statistic of Cys, MELD score, model for end‐stage liver disease‐cystatin C (MELD‐Cys) score, combined Cys with MELD‐Cys score to predict 90‐day mortality were 0.67, 0.58, 0.58, and 0.63, respectively. Adding Cys to the MELD score did not improve the predictive of 90‐day mortality. Conclusion Serum Cys is superior to MELD score, and the new MELD‐Cys model is comparable to the MELD score in predicting mortality among patients with cirrhosis admitted with complications., Unlike creatinine, cystatin C (Cys) is not affected by age, sex, muscle mass. Serum Cys can use to predict mortality among patients with cirrhosis admitted with complications.

Effects of linked-color imaging (LCI) on colorectal lesion detection and colonoscopy quality remain controversial. This study compared the detection rates of adenoma and other precursor lesions using LCI vs white-light imaging (WLI) during screening, diagnostic, and surveillance colonoscopies.This randomized controlled trial was performed at 11 institutions in 4 Asian countries/regions. Patients with abdominal symptoms, a primary screening colonoscopy, positive fecal immunochemical test results, or undergoing postpolypectomy surveillance were recruited and randomly assigned in a 1:1 ratio to either the LCI or high-definition WLI group. The primary outcome was adenoma detection rate (ADR). Secondary outcomes were polyp detection rate, advanced ADR, sessile serrated lesion (SSL) detection rate, and the mean number of adenomas per colonoscopy. The recommended surveillance schedule distribution after trial colonoscopy was analyzed.Between November 2020 and January 2022, there were 3050 participants (LCI, n = 1527; WLI, n = 1523) recruited. The LCI group ADR was significantly higher than the WLI group ADR using intention-to-treat (58.7% vs 46.7%; P.01) and per-protocol analyses (59.6% vs 46.4%; P.01). The LCI group polyp detection rates (68.6% vs 59.5%; P.01), SSL detection rates (4.8% vs 2.8%; P.01), and adenomas per colonoscopy (1.48 vs 1.02; P.01) also were significantly higher. However, the LCI group advanced ADR was nonsignificantly higher (13.2% vs 11.0%; P = .06). The LCI group was categorized in significantly shorter recommended surveillance schedules than the WLI group (P.01).Compared with WLI, LCI improved adenoma and other polyp detection rates, including SSLs, resulting in alteration of the recommended surveillance schedule after screening, diagnostic, and postpolypectomy surveillance colonoscopies.UMIN000042432 (https://www.umin.ac.jp/ctr/index.htm).

Related research has found that men who visit public sex environments such as a gay bathhouse engage in unprotected anal intercourse and tend to have multiple sexual partners during their visit. We aimed to assess the risk of hepatitis C virus (HCV) transmission among men attending a gay bathhouse.A prospective study of the prevalence of HCV among men attending a gay bathhouse was conducted in Bangkok, Thailand, from October 2019 to March 2020. HCV risks and risk perceptions were evaluated using a self-administered questionnaire. HCV testing with result notification was provided on site.Of the 40 participants (median age 30 years), one subject (2.5%) was positive for HCV antibody. Bathhouse patrons reported engaging in high-risk sexual behavior, including sexually transmitted infection history and Chemsex experience. The subject tested positive for HCV antibody reported a frequency of attending gay bathhouse of around 2-4 times monthly and had multiple partners while attending a gay bathhouse. Only 15% of subjects realized that hepatitis C can be transmitted through sexual intercourse.Our findings support HCV transmission-reducing guidelines recommending providing selective HCV testing among men who have sex with men (MSM). Bathhouse patrons reported low literacy levels on HCV transmission. Nevertheless, HCV screening should cover a population exhibiting high-risk sexual behaviors such as attending a gay bathhouse.

Gastroesophageal reflux disease (GERD) is one of the most prevalent and bothersome functional gastrointestinal disorders worldwide, including in Thailand. After a decade of the first Thailand GERD guideline, physician and gastroenterologist encountered substantially increase of patients with GERD. Many of them are complicated case and refractory to standard treatment. Concurrently, the evolution of clinical characteristics as well as the progression of investigations and treatment have developed and changed tremendously. As a member of Association of Southeast Asian Nations, which are developing countries, we considered that the counterbalance between advancement and sufficient economy is essential in taking care of patients with GERD. We gather physicians from university hospitals, as well as internist and general practitioners who served in rural area, to make a consensus in this updated version of GERD guideline focusing in medical management of GERD. This clinical practice guideline was constructed adhering with standard procedure. We categorized the guideline in to four parts including definition, investigation, treatment, and long-term follow up. We anticipate that this guideline would improve physicians' proficiency and help direct readers to choose investigations and treatments in patients with GERD wisely. Moreover, we wish that this guideline would be applicable in countries with limited resources as well.

The impact of drug-induced liver injury (DILI) on patients with chronic liver disease (CLD) is unclear. There are few reports comparing DILI in CLD and non-CLD patients. In this study, we aimed to determine the incidence and outcomes of DILI in patients with and without CLD.We collected data on eligible individuals with suspected DILI between 2018 and 2020 who were evaluated systematically for other etiologies, causes, and the severity of DILI. We compared the causative agents, clinical features, and outcomes of DILI among subjects with and without CLD who were enrolled in the Thai Association for the Study of the Liver DILI registry. Subjects with definite, or highly likely DILI were included in the analysis.A total of 200 subjects diagnosed with DILI were found in the registry. Of those, 41 had CLD and 159 had no evidence of CLD in their background. Complementary and alternative medicine (CAM) products were identified as the most common class of DILI agents. Approximately 59% of DILI in the CLD and 40% in non-CLD group were associated with CAM use. Individuals with pre-existing CLD had similar severity including mortality. Twelve patients (6%) developed adverse outcomes related to DILI including seven (3.5%) deaths and five (2.5%) with liver failure. Mortality was 4.88% in CLD and 3.14% in non-CLD subjects over median periods of 58 (8-106) days and 22 (1-65) days, respectively.In this liver disease registry, the causes, clinical presentation, and outcomes of DILI in subjects with CLD and without CLD patients were not different. Further study is required to confirm our findings.

Functional dyspepsia (FD) is a common problem in gastroenterology practice. The study aimed to compare the efficacy of Curcuma longa Linn versus omeprazole and placebo among patients diagnosed with FD.From November 2017 to November 2018, patients diagnosed with FD according to ROME IV criteria were enrolled. Patients were randomized into curcumin, omeprazole, or placebo groups. The Severity of Dyspepsia Assessment (SODA) was used to evaluate clinical effectiveness after 2 and 4 weeks. Health-related quality of life was assessed using the EuroQol-5 Dimension questionnaire.A total of 132 patients were randomized. Forty-five, 43, and 44 patients were in the curcumin, omeprazole, and placebo groups, respectively. At 4 weeks, the mean SODA score change of pain and non-pain symptoms decreased in the curcumin group compared with the placebo group (pain -16.98 ± 8.09 vs -10.53 ± 4.43; P 0.001, non-pain -7.96 ± 3.41 vs -6.05 ± 3.03; P 0.008). No significant difference was observed between curcumin and omeprazole groups (pain -16.98 ± 8.09 vs -14.69 ± 6.41; P = 0.302, non-pain -7.96 ± 3.41 vs -7.07 ± 2.27; P = 0.486). The mean change of the SODA satisfaction score at 4 weeks was higher in the curcumin group compared with the omeprazole group but without statistical significance (9.17 ± 3.88 vs 8.63 ± 3.89, P = 1). The mean change of EQ-5D index at 4 weeks was highest in the curcumin group but not statistically different from other groups (0.12 ± 0.13 vs 0.09 ± 0.10 vs 0.07 ± 0.05; P = 0.055).Curcuma longa Linn can improve dyspeptic symptoms, improve quality of life, and provide satisfaction equivalent to omeprazole in treatment of FD.

Objective To examine whether baseline model for end-stage liver disease (MELD) score in patients with cirrhosis and ascites predicts the future development of first spontaneous bacterial peritonitis (SBP) episode. Methods A retrospective case-control study was performed at three academic centers to select patients admitted with first SBP episode (cases) and those with ascites admitted for decompensation without SBP (controls). Medical records from these centers were reviewed between January 1, 2008, and December 31, 2013. Cases and controls were matched (1:2) for age, sex, and race. Conditional logistic recession models were built to determine whether baseline MELD score (within a month before hospitalization) predicts first SBP episode. Results Of 697 patients (308, 230, and 159 from centers A, B, and C, respectively), cases and controls were matched in 94%, 89%, and 100% at three respective centers. In the pooled sample, probability of SBP was 11%, 31%, 71%, and 93% at baseline MELD scores less than or equal to 10, from 11 to 20, from 21 to 30, and greater than 30, respectively. Compared with MELD score less than or equal to 10, patients with MELD scores from 11 to 20, 21 to 30, and greater than 30 had six- (3- to 11-), 29- (12- to 69-), and 115- (22- to 598-) folds (95% CI) risk of SBP, respectively. Based on different MELD score cutoff points, MELD score greater than 17 was most accurate in predicting SBP occurrence. Analyzing 315 patients (152 cases) with available data on ascitic fluid protein level controlling for age, sex, and center, MELD score but not ascitic fluid protein associated with first SBP episode with respective odds ratios of 1.20 (1.14 to 1.26) and 0.88 (0.70 to 1.11). Conclusion Baseline MELD score predicts first SBP episode in patients with cirrhosis and ascites.

Background: Accurate population-based data are required concerning the rate, economic impact, and long-term outcome from acute on chronic liver failures (ACLF) in hospitalized cirrhosis patients.Objective: We aimed to discover time trends for the epidemiology, economic burden, and mortality of ACLF in Thailand.Methods: We conducted a nationwide, population-based, cohort study which involved all hospitalized cirrhosis patients in Thailand during the period between 2009 and 2013, with data from the National Health Security Office. ACLF was defined by two or more extrahepatic organ failures in cirrhosis patients. Primary outcomes were trends in hospitalizations, hospital costs, together with inpatient mortality. Results The number of ACLF hospitalizations in Thailand doubled between 3,185 in 2009 and 7,666 in 2013. The average cost of each ACLF hospitalization was 3.5-fold higher than for cirrhosis (฿ 61,928 versus ฿ 16,995). The hospital is paid using a diagnosis-related group (DRG) payment system that is only 15% of the average treatment costs (฿ 9,371 from ฿ 61,928). The in-hospital fatality rate was 51% for ACLF while the additional fatality rate was 85% up to 1 year. The ACLF organ failure trends indicated sepsis with septic shock and renal failure as the majority proportion. Age, the number and types of organ failure and male sex were predictors of ACLF death. Conclusions and Relevance Cirrhosis and ACLF both represent substantial and increasing health and economic burdens for Thailand. These data can assist national health care policy stakeholders to target high-risk cirrhosis patients for care.

Background The influence of direct-acting antivirals (DAAs) on the composition of gut microbiota in hepatitis C virus (HCV)–infected patients with or without human immunodeficiency virus (HIV) is unclear. Methods We enrolled 62 patients with HCV monoinfection and 24 patients with HCV/HIV coinfection receiving elbasvir-grazoprevir from a clinical trial. Fecal specimens collected before treatment and 12 weeks after treatment were analyzed using amplicon-based 16S ribosomal RNA sequencing. Results Sustained virological response rates in the monoinfection and coinfection groups were similar (98.4% vs 95.8%). Pretreatment bacterial communities in the patient groups were less diverse and distinct from those of healthy controls. Compared with HCV-monoinfected patients, HCV/HIV-coinfected individuals showed comparable microbial alpha diversity but decreased Firmicutes-Bacteroidetes ratios. The improvement of microbial dysbiosis was observed in responders achieving sustained virological response across fibrosis stages but was not found in nonresponders. Responders with a low degree of fibrosis exhibited a recovery in alpha diversity to levels comparable to those in healthy controls. Reciprocal alterations of increased beneficial bacteria and reduced pathogenic bacteria were also observed in responders. Conclusions This study indicates a short-term effect of direct-acting antivirals in restoration of microbial dysbiosis. The favorable changes in gut microbiota profiles after viral eradication might contribute toward the reduction of HCV-related complications among infected individuals.

For decade, systemic treatments in advanced stage hepatocellular carcinoma (HCC), except sorafenib, were not very effective even though there were tremendous effort in developing new therapy. Until last 2 years, Nivolumab, the new immune check point inhibitor, has shown promising activity in phase I/II study and have been approved by USFDA to treat patients in first and second line due to their benefits on overall survival and the adequate safety profile. Not only nivolumab, but also lenvatinib; multikinase inhibitor, is approved in advanced HCC due to a positive impact on the overall survival. Still sorafenib is the drug that have been used to treat unresectable HCC for over 10 years with best benefits on overall survival and the adequate safety profile in selected patients. Therefore, this article was to reveal all the data about systemic therapies that were used in advanced stage HCC include indication, dosage, patient and drug’s profile and safety. The strategy to precisely select treatment for advanced or unresectable HCC is now more challenging than ever before because there were many promising drugs available in the market. Thus, as a clinician, we are responsible to gather all the important information from patients to choose the best treatment option not only to prolong survival but to achieve complete response in these metastasis liver cancers. Figure 1 ยาที่ได้รับการรับรองจากองค์การอาหารและยาของประเทศสหรัฐอเมริกาในการรักษามะเร็งตับระยะลุกลาม มะเร็งตับระยะ B หมายถึง มะเร็งตับระยะ Intermediated แบ่งตาม Barcelona Clinic Liver Cancer มะเร็งตับระยะ C หมายถึง มะเร็งตับระยะ Advanced แบ่งตาม Barcelona Clinic Liver Cancer

The International Liver CongressTM (ILC) (the 53rd Annual International Liver Congress) of the European Association for the Study of the Liver (EASL) was held in April from 11 - 15th, 2018 in Paris, France. Over 10,000 delegates confirmed the persistent interest in the area of liver disease especially in viral hepatitis field. Although, no new HCV drugs are entering the HCV treatment arena, there was a considerable amount of new data from studies in the hepatitis field showing that there is still a lot to learn and discuss. In addition, the newly revised EASL practice guidelines for HCV management were released and the corresponding publication is now downloadable from the EASL website (http://www. journal-of-hepatology.eu/article/S0168-8278(18)31968-8/fulltext). These European Association for the Study of Liver Recommendations on Treatment of Hepatitis C describe the optimal management of patients with acute and chronic HCV infections in 2018 and onwards.

Background/Objectives Aggressive fluid resuscitation is recommended for initial management of acute pancreatitis. However, there are few studies which focus on types of fluid therapy. Methods We performed a randomized controlled trial in patients with acute pancreatitis. The patients were randomized into two groups. Each group received Normal Saline solution (NSS) or Lactated Ringer's solution (LRS) through a goal-directed fluid resuscitation protocol. Systemic inflammatory response syndrome (SIRS) at 24 and 48 h, mortality, presence of local complications and inflammatory markers were measured. Results Forty-seven patients were included. Twenty-four patients (51%) received NSS and 23 patients received LRS. There was significant reduction in SIRS after 24 h among subjects who resuscitated with LRS compared with NSS (4.2% in NSS, 26.1% in LRS, P = 0.02). However, SIRS reduction at 48 h was not different between groups (33.4% in NSS, 26.1% in LRS, P = 0.88). Mortality was not different between NSS and LRS (4.2% in NSS, 0% in LRS, P = 1.00). CRP, ESR and procalcitonin increased at 24 h and 48 h after admission with no difference between the two groups. Local complications were 29.2% in NSS and 21.7% in LRS (P = 0.74). The median length of hospital stay was not significantly different in the two groups (5.5 days in NSS, 6 days in LRS, P = 0.915). Conclusions Lactated Ringer's solution was superior to NSS in SIRS reduction in acute pancreatitis only in the first 24 h. But SIRS at 48 h and mortality were not different between LRS and NSS.

Cirrhosisis the final pathway of any chronic liver disease and can lead to a number of complications,including hepatocellular carcinoma. Liver fibrosis is the key role of disease progression in cirrhosis. Advanced liver fibrosis and early stage of cirrhosis are not usually clinically detectable or symptomatic.As patients develop more extensive hepatic fibrosis potentially resulting in development of cirrhoticcomplications such as variceal hemorrhage. Prognosis and survival is markedly better in patients with early stage of cirrhosis. Now there are many stages classification of cirrhosis defined by liverhistology, hepatic venous pressure gradient and clinical staging selected by complications. The knowledgeand understanding of the natural history of liver fibrosis can help for staging and early detection ofthe cirrhosis. Remove noxious stimuli, hepato-protectants and decrease hepatic inflammationand cell death are the main treatment modalities for hepatic fibrosis. Figure 1 ระยะโรคตับแข็งแบ่งตามลักษณะการดำเนินโรค (modified from Arvaniti V’s work) (12)*decompensated events เช่น ท้องมาน spontaneous bacterial peritonitisvariceal bleeding หรือโรคสมองเหตุจากโรคตับ; LT, liver transplantation Keywords: cirrhosis, liver fibrosis, liver histology, hepatic venous pressure gradient

Association between obesity and new-onset heart failure (HF) has repeatedly been established. Less is known about the risk of overweight with the development of HF. The aim of this systematic review and meta-analysis was to explore the association between overweight, obesity, and the incidence of new-onset HF. In this study, we systematically searched MEDLINE, MEDLINE In-ProcessOther Non-Indexed Citations, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials from database inception through June 2017. Studies were included if they reported the association between overweight or obesity and new-onset HF compared with normal weight. DerSimonian and Laird random effect meta-analyses were used, and subgroup analyses were performed to explore the potential sources of heterogeneity. Of 2,184 retrieved articles, we identified 21 relevant studies with a total of 525,656 participants with 18,948 HF cases. Compared with the normal body weight index (body mass index 25 kg/m

BACKGROUND AND AIM This study aims to determine the performance of models adding C-reactive protein (CRP) and procalcitonin (PCT) to the model of end-stage liver disease (MELD) score for mortality prediction in patients hospitalized with complications of cirrhosis. METHODS A prospective cohort study was carried out in consecutive cirrhotic patients admitted with complications of cirrhosis between September 2012 and December 2013 at Phramongkutklao Hospital, Bangkok, Thailand. All patients had venous CRP, PCT, and laboratory values for MELD score calculation measured at emergency room or admission. Cox regression analysis and the c-statistic were used to predict mortality. The MELD-CRP score was externally validated in 818 eligible patients from Mayo Clinic, Rochester, using data from 1288 cirrhotic patients diagnosed between 2010 and 2014. RESULTS A cohort of 177 patients with cirrhosis was admitted during the study period. Seventy-one patients were eligible for analysis. The MELD score was predictive of 90-day mortality odds ratio (OR) 1.19 (95% confidence interval [CI] 1.09-1.32). Adding CRP and/or PCT to the MELD score improved the predictive of 90-day mortality: MELD-CRP OR 2.71 (95% CI 1.66-4.99); MELD-PCT OR 2.72 (95% CI 1.66-4.99); MELD-CRP-PCT OR 2.71 (95% CI 1.67-4.92). The c-statistics for MELD, MELD-CRP, MELD-PCT, and MELD-CRP-PCT were 0.81, 0.83, 0.84, and 0.85, respectively. Adding CRP and/or PCT to the MELD score also improved 30-day mortality prediction. Similar results for the MELD-CRP score were obtained from the Mayo Clinic external validation cohort. CONCLUSION The MELD-CRP, MELD-PCT, and MELD-CRP-PCT scores may be superior to the MELD score alone in predicting mortality in patients hospitalized with complications of cirrhosis.

We examined risks for first hospitalization and the rate, risk factors, costs, and 1-year outcome of 30-day readmission among patients admitted for complications of cirrhosis. Data were retrospectively analyzed for adult patients with cirrhosis residing in Minnesota, Iowa, or Wisconsin and admitted from 2010 through 2013 at both campuses of the Mayo Clinic Hospital in Rochester, MN. Readmission was captured at the two hospitals as well as at community hospitals in the tristate area within the Mayo Clinic Health System. The incidence of hospitalization for complications of cirrhosis was 100/100,000 population, with increasing age and male sex being the strongest risks for hospitalization. For the 2,048 hospitalized study patients, the overall 30-day readmission rate was 32%; 498 (24.3%) patients were readmitted to Mayo Clinic hospitals and 157 (7.7%) to community hospitals, mainly for complications of portal hypertension (52%) and infections (30%). Readmission could not be predicted accurately. There were 146 deaths during readmission and an additional 105 deaths up to 1 year of follow-up (50.4% total mortality). Annual postindex hospitalization costs for those with a 30-day readmission were substantially higher ($73,252) than those readmitted beyond 30 days ($62,053) or those not readmitted ($5,719). At 1-year follow-up, only 20.4% of patients readmitted within 30 days were at home. In conclusion, patients with cirrhosis have high rates of hospitalization, especially among men over 65 years, and of unscheduled 30-day readmission. Readmission cannot be accurately predicted. Postindex hospitalization costs are high; nationally, the annual costs are estimated to be more than $4.45 billion. Only 20% of patients readmitted within 30 days are home at 1 year. (Hepatology Communications 2018;2:188-198).

Background As one of the leading causes of death in Thailand, the accurate data about the quality of care, costs and outcome of cirrhotic patients are needed. The aims of this study were to examine the quality of care according to the American Association for the Study of Liver Diseases (AASLD) practice guidelines, costs and outcome in cirrhotic patients in a large university-based hospital. Methods After IRB approved, cohort study was conducted involving all outpatients with cirrhosis in Phramongkutklao hospital during 2017 through 2018. Medical database and records were reviewed. Quality of care parameters; HCC screening and management of cirrhotic complications (secondary prophylaxis for variceal bleeding with Beta-blocker, abdominal paracentesis in the patient with ascites, antibiotic for secondary prevention of SBP, prevention of hepatic encephalopathy) were measured for the proportion of cases where the patient received recommended care according to AASLD practice guidelines. Costs and outcome were analyzed. Results were reported as total outcome and subgroup outcomes. Results For the 1,180 cirrhotic patients, 30% were followed up at gastroenterology out-patient clinic (GI), 33.4% at general internal medicine outpatient clinic (MED), and 36.6% at both clinics. Quality of care parameters were poorly met the standard recommendations especially in MED group (figure 1). There were 223 deaths occurred (18.8% all-cause mortality). The average direct cost was $1,766 per patient-year. The incremental cost-effectiveness ratio (ICER), demonstrated the superiority of GI group over MED group, was $16.7 per one lifesaving per year (figure 1). Conclusions Despite a high economic burden and mortality rate, current practice in cirrhotic patients in this study were poorly met the standard recommendations according to AASLD guidelines. The results founded in this study were the first data established and were relatively similar to those previous data from the US. The outcomes from this study led to the next study ‘A quality improvement initiative for achieving standard of care in cirrhosis’ which is being conducted in Phramongkutklao hospital, Thailand.

Background Acute variceal bleeding (AVB) is a serious complication associated with high mortality. The aim of our study was to investigate mortality predictors and develop a new simple prognostic model using easily verified factors at admission in AVB patient. Methods Between October 2012 and September 2018, 1,144 consecutive patients with AVB from Phramongkutklao hospital in Bangkok and Maharat Nakhon Sri Thummarat hospital in Nakhon Sri Thummarat were included. A simplified prognostic model was developed using multiple logistic regression after identifying significant predictors of 6-week mortality. Mortality prediction accuracy was assessed with area under the receiver operating characteristic (AUROC) curve. We compared the new model to existing models of model for end-stage liver disease (MELD), Child-Pugh scores and Glasgow Blatchford Score. Results The 6-week overall mortality rate was 12.3%. Multivariate analysis showed that Mean Arterial Pressure (MAP), model for end-stage liver disease (MELD), high-risk stigmata of esophageal varices or peptic ulcer on endoscopic finding and the Glasgow Blatchford Score were independent predictors of mortality. A new logistic model using these variables was developed. This model’s AUROC was 0.934, which was significantly higher than that of MELD (0.721), MAP (0.842), and Glasgow Blatchford Score (0.904). Two external validation studies showed that the AUROC of our model was consistently higher than 0.954. (figure 1) Conclusions Our new simplified model accurately and consistently predicted 6-week mortality in patients with acute variceal bleeding using objective variables measured at admission. Our system can be used to identify high-risk acute variceal bleeding patients.

After the Patient Protection and Affordable Care Act or "Obamacare" was signed into law in 2010, the problem of readmission has taken on a new sense of urgency. Hospitals with excess readmissions receive reduced reimbursement because readmission is considered to represent a poor quality measure in the healthcare delivery system. Cirrhosis places a major burden on the healthcare economy. Patients with cirrhosis frequently require hospitalization, and annual admission rates have doubled within 10 years. The costs of hospitalization associated with cirrhosis have also markedly increased. Readmissions create negative consequences for the patient and the family. Several strategies have been proposed to reduce the number of readmissions, but the efficacy of these strategies is questionable. Although the Model for End-Stage of Liver Disease (MELD) score can be a tool for risk stratification, many other factors are also independent risks for readmission. Studies aimed at the reduction of readmission in patients with cirrhosis are very limited, and much research is required before specific recommendations can be made to reduce readmissions.

Patients with cirrhosis are at risk for several complications that require readmission. Readmissions are a direct burden on the patient and the family and are associated with negative outcomes to the patient, family, and health care system. Several recent studies have shown a high rate of readmission in patients with cirrhosis and a trend towards an increase in cost of health care delivery. Physicians and hospitals should recognize the patient at high risk for readmission not only at dismissal from hospital but also at admission. The Model for End-Stage Liver Disease (MELD) score may be used as a tool for risk stratification for readmission among patient with cirrhosis. Frailty, comorbidity, socioeconomic status, and type of health care delivery system are probable independent risk factors. Strategies to prevent readmission should target the high-risk patient.

Background: A shorter sleep duration has been identified as a risk factor for cardiovascular diseases and increased mortality. It has been hypothesized that a short sleep duration may be linked to changes in ghrelin and leptin production, leading to an alteration of stress hormone production. Here, we conducted a systematic review and meta-analysis to investigate the potential relationship between a sleep duration and cardiovascular disease mortality. Methods: We conducted a comprehensive search of Ovid Medline In-Process and other non-indexed citations, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, and Scopus from database inception to March 2017. Observational studies were included if the studies reported hazard ratios or odds ratios of the associations between sleep durations (short and long) and cardiovascular disease mortality. Data were extracted by a reviewer and then reviewed by two separate reviewers. Conflicts were resolved through consensus. Using the DerSimonian and Laird random effects models, we calculated pooled hazard ratios and pooled odds ratios with 95% confidence intervals (CI). Subgroup analyses were performed to explore potential sources of heterogeneity. The quality of the included studies and publication bias were assessed. Results: In total, our meta-analysis included 19 studies (31 cohorts) with a total of 816,995 individuals with 42,870 cardiovascular disease mortality cases. In pooled analyses, both short (risk ratio 1.19; 95% CI 1.13 to 1.26, P2=30.7, Pheterogeneity=0.034), and long (risk ratio 1.37; 95% CI 1.23 to 1.52, P2=79.75, PheterogeneityConclusions: Both short (9 hours) can increase the risk of overall cardiovascular disease mortality, particularly in Asian populations and elderly individuals. Future epidemiological studies would ideally include objective sleep measurements, rather than self-report measures, and all potential confounders, such as genetic variants.

Globally, among infectious diseases, influenza is one of the leading causes of morbidity and mortality. Individuals with chronic conditions, including cardiovascular disease and diabetes, are particularly vulnerable to complications of an influenza infection. The European Society of Cardiology recommended annual influenza vaccinations for patients with cardiovascular disease. Numerous studies have suggested a link between influenza and increased risk of cardiovascular events. Despite its proven benefits, little is known about the reason for the underutilization of influenza vaccination. We present the findings of an assessment of patients’ perception of the influenza vaccine and the reason for its underutilization, by data mining from Twitter.

This study aims to determine the performance of models adding C-reactive protein (CRP) and procalcitonin (PCT) to the model of end-stage liver disease (MELD) score for mortality prediction in patients hospitalized with complications of cirrhosis.A prospective cohort study was carried out in consecutive cirrhotic patients admitted with complications of cirrhosis between September 2012 and December 2013 at Phramongkutklao Hospital, Bangkok, Thailand. All patients had venous CRP, PCT, and laboratory values for MELD score calculation measured at emergency room or admission. Cox regression analysis and the c-statistic were used to predict mortality. The MELD-CRP score was externally validated in 818 eligible patients from Mayo Clinic, Rochester, using data from 1288 cirrhotic patients diagnosed between 2010 and 2014.A cohort of 177 patients with cirrhosis was admitted during the study period. Seventy-one patients were eligible for analysis. The MELD score was predictive of 90-day mortality odds ratio (OR) 1.19 (95% confidence interval [CI] 1.09-1.32). Adding CRP and/or PCT to the MELD score improved the predictive of 90-day mortality: MELD-CRP OR 2.71 (95% CI 1.66-4.99); MELD-PCT OR 2.72 (95% CI 1.66-4.99); MELD-CRP-PCT OR 2.71 (95% CI 1.67-4.92). The c-statistics for MELD, MELD-CRP, MELD-PCT, and MELD-CRP-PCT were 0.81, 0.83, 0.84, and 0.85, respectively. Adding CRP and/or PCT to the MELD score also improved 30-day mortality prediction. Similar results for the MELD-CRP score were obtained from the Mayo Clinic external validation cohort.The MELD-CRP, MELD-PCT, and MELD-CRP-PCT scores may be superior to the MELD score alone in predicting mortality in patients hospitalized with complications of cirrhosis.

Whether you are an avid reader of the Book Thief or a fan of the Blue Oyster Cult, you know that messing with me is serious business. Be warned, that if you want to outwit me, you better come armed with the ability to predict your future.