Game Changers

Hepatic encephalopathy (HE) is an impairment of cognition and/or consciousness affecting up to 70% of patients with cirrhosis. Whilst overt encephalopathy (OHE) is associated with a reduction in life expectancy, minimal encephalopathy (MHE) is known to effect quality of life, social interaction and driving capacity. Previously control of HE was restricted to identification and management of potential precipitants (gastrointestinal bleeding, sedatives, infection, constipation) together with the use of non-absorbable disaccharides (lactulose) and agents to lower serum ammonia (L-ornithine-L-aspartate). Rifaximin a non-absorbable antibiotic, initially licensed for traveller's diarrhoea, is effective in the management of both OHE and MHE, received its license in 2013. Rifaximin demonstrated a reduction in breakthrough HE and hospitalisations (4 patients needing 6 months treatment to prevent one episode of OHE and 9 to prevent one admission) 1. In cirrhotics with MHE, rifaximin improves cognitive function, health-related quality of life 2 and reduces driving-related errors 3. Given the majority of those with cirrhosis will develop some degree of HE rifaximin affords significant benefit by improving function and reducing the need for hospitalisation. improves psychometric performance and health-related quality of life in patients with minimal hepatic encephalopathy (the RIME Trial). Diagnosis and treatment of minimal hepatic encephalopathy to prevent motor vehicle accidents: a cost-effectiveness analysis. Accurate staging of lung cancer is vital in planning treatment and informing prognosis. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is now available in several centres in Northern Ireland. In selected cases, hilar and mediastinal lymph nodes can be sampled in a minimally invasive way under ultrasound guidance, improving diagnostic yield and avoiding the need for a mediastinoscopy. The target node or mass is localised using a combination of an endobronchial image, real-time ultrasound image of structures beyond the airway lumen and doppler flow to help avoid vascular structures. Complication rates are low and the procedure is well-tolerated. In a direct comparison with mediastinoscopy, EBUS-TBNA demonstrated significantly greater sensitivity 1. We are looking forward to the initial feedback from the local consultants who are using this exciting new diagnostic tool. of mediastinal adenopathy-real-time endobronchial ultrasound guided needle aspiration versus mediastinoscopy. Multiple sClerosis is a treatable disease. Over the last forty years I have witnessed a transformation from therapeutic nihilism to measured management of MS. In about 90% of people with MS it starts with a relapsing-remitting phase. After 15-20 years a phase of gradual progression of disability emerges (the secondary progressive phase). In about 10%, …