Methylphenidate-induced autoimmune hepatitis.
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Alanine Transaminase↗
Biomedical subjects
Carl L Berg
Publications and source records attributed to Carl L Berg.
Resolution of decompensated cirrhosis from Wilson's disease with zinc monotherapy: a potential therapeutic option?
BACKGROUND & AIMS: Wilson's disease is a genetic autosomal-recessive copper deposition disorder often presenting with neurologic or hepatic symptoms. In cases of hepatic presentation, treatment usually is initiated with potentially toxic copper chelators, such as D-penicillamine or trientine. Although multiple studies have introduced zinc as a low-toxicity and low-cost Wilson's disease treatment, its use has been limited to adjunctive or single-agent maintenance options. In this report, we describe the use of zinc monotherapy in a patient with severe hepatic presentation of Wilson's disease. METHODS: Zinc has not been evaluated as a single-agent treatment option for active hepatic Wilson's disease. Zinc monotherapy was initiated for a single patient with fulminant hepatic failure caused by Wilson's disease while awaiting liver transplantation. RESULTS: Over a 1-year period with zinc monotherapy, this patient experienced normalization of hepatic synthetic function and resolution of hypoalbuminemia and coagulopathy. Clinical stabilization of variceal bleeds, ascites, and lower-extremity edema also were observed. The patient is no longer a transplant candidate as a result of clinical recovery and improvement of Model for End-stage Liver Disease and Child-Turcotte-Pugh scores. CONCLUSIONS: This case highlights the potential use of zinc as a low-toxicity and low-cost single-agent treatment in severely decompensated hepatic Wilson's disease. Despite promising results in this case, further clinical evaluation will be necessary to assess fully the clinical efficacy of zinc monotherapy.
Female↗
Coagulopathy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboembolism.
OBJECTIVE: Despite the endogenous coagulopathy of cirrhosis, some patients with cirrhosis experience thrombophilic states. This study aims to determine the incidence and predictors of venous thromboembolism (VTE), such as deep vein thrombosis (DVT) and pulmonary embolism, in hospitalized patients with cirrhosis. METHODS: A retrospective case-control study was performed in a tertiary-care teaching hospital over an 8-yr period. A total of 113 hospitalized patients with cirrhosis with a documented new VTE were compared to controls. Risk factors for VTE were determined using univariate and multivariate statistical analyses. RESULTS: Approximately 0.5% of all hospitalized patients with cirrhosis had a VTE. Traditional markers of coagulation such as INR and platelet count were not predictive of VTE. In the univariate analysis, serum albumin level was significantly lower in cases than controls (2.85 vs. 3.10 g/dL, respectively, p = 0.01). In the multivariate analysis, serum albumin remained independently predictive of VTE, with an odds ratio of 0.25 (95% CI 0.10-0.56). CONCLUSIONS: Approximately 0.5% of admissions involving cirrhosis patients resulted in a new thromboembolic event. Low serum albumin was strongly predictive of increased risk for developing VTE, independent of international normalized ratio or platelet count. Serum albumin deficiency may indicate low levels of endogenous anticoagulants.
Blood Coagulation Disorders↗
Intermittent disconjugate gaze: a novel finding in nonalcoholic steatohepatitis and cryptogenic cirrhosis.
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Fatty Liver↗
Comparison of the grading of esophageal varices by transnasal endoluminal ultrasound and esophagogastroduodenoscopy.
BACKGROUND & AIMS: Esophagogastroduodenoscopy (EGD) is the current standard for evaluating esophageal varices, yet there is no universally accepted system of grading varices endoscopically and several studies have shown interobserver variability of endoscopic grading. High-resolution endoluminal ultrasound 20 MHz (HRES) has been shown to detect varices accurately and can be performed without sedation. Our aim was to compare the detection of esophageal varices by transnasal HRES and EGD. METHODS: We prospectively studied 37 cirrhotic patients being evaluated for esophageal varices. HRES was used to measure the largest esophageal variceal diameter and then EGD was performed. Photographs were taken for both procedures. Three blinded investigators graded the EGD photographs at 2 periods. End points were as follows: (1) the correlation of HRES variceal diameter and EGD grading of varices, and (2) the assessment of interobserver and intraobserver variation in varix grading by EGD. RESULTS: The correlation between the transnasal HRES and EGD was .63, with a 95% confidence interval of .37-.80. The HRES detected early varices that were not seen by EGD. The interobserver correlation for EGD scoring was .87 or greater in all comparisons and the intraobserver correlation was .91 or greater. CONCLUSIONS: In conclusion, there is a significant correlation between transnasal HRES size measurement of esophageal varices and EGD. HRES is much more sensitive in detecting early esophageal varices and may not require sedation, suggesting that it may be more tolerable to patients and is worth further study.
Adult↗
Cost minimization in endoscopy center scheduling: a case-controlled study.
BACKGROUND: Traditional endoscopy center scheduling often results in nonurgent inpatient endoscopic procedures being delayed until late in the day and can prolong length of hospital stay and costs. We report the first controlled study designed to evaluate the effect of an early morning fast-track triage endoscopy unit on the cost and length of stay of a general GI inpatient population. METHODS: A case-control methodology matched a cohort of patients undergoing morning triage procedures with historical controls that underwent standard add-on scheduling endoscopy. Outcome indices and patient quality of care measures were compared between cases and controls. RESULTS: Analysis of patients most likely to benefit from rapid endoscopy showed significant advantage comparing fast-track endoscopy patients to controls in time to endoscopy (0.63 vs. 1.00 days, P = 0.01), length of stay (1.22 vs. 1.78 days, P = 0.05), and hospital costs (2,793 dollars vs. 3,586 dollars, P = 0.02). CONCLUSIONS: When routine endoscopy is the rate-limiting step for hospital discharge in the general GI patient, early morning scheduling with a reserved time and space for inpatient endoscopy is a cost-minimizing factor in a busy endoscopy center that may save significant hospital costs while preserving optimal patient outcomes.
Case-Control Studies↗
Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis.
OBJECTIVE: We sought to determine the ability of the Model for End-Stage Liver Disease (MELD) score to predict 30-day postoperative mortality for patients with cirrhosis undergoing nontransplant surgical procedures. SUMMARY BACKGROUND DATA: The Child-Pugh class historically has been used by clinicians to assist in management decisions involving patients with cirrhosis. However, this classification scheme has a number of limitations. Recently, MELD was introduced. It has been shown to be highly predictive of mortality in a variety of clinical scenarios. METHODS: Adult patients with a diagnosis of cirrhosis undergoing nontransplant surgical procedures between January 1, 1996, and January 1, 2002, at a single center were analyzed. The preoperative MELD score was calculated for all patients, and the MELD's performance in predicting 30-day mortality was determined using multivariate regression techniques. RESULTS: A total of 140 surgical procedures were identified and analyzed. The 30-day mortality rate was 16.4%. The mean admission MELD score for the patients who died (23.3, 95% confidence interval 19.6-27.0) was significantly different from those patients surviving beyond 30 days (16.9, 15.6-18.2), P = 0.0003. The c-statistic for MELD score predicting 30-day mortality was 0.72. Further subgroup analysis of 67 intra-abdominal surgeries showed an in-hospital mortality of 23.9%. The mean MELD score for patients dying (24.8, 20.4-29.3) was significantly different from survivors (16.2, 14.2-18.2), P = 0.0001. The c-statistic for this subgroup was 0.80. CONCLUSIONS: The MELD score, as an objective scale of disease severity in patients with cirrhosis, shows promise as being a useful preoperative predictor of surgical mortality risk.
Adult↗
Identification of a human heme exporter that is essential for erythropoiesis.
FLVCR, a member of the major facilitator superfamily of transporter proteins, is the cell surface receptor for feline leukemia virus, subgroup C. Retroviral interference with FLVCR display results in a loss of erythroid progenitors (colony-forming units-erythroid, CFU-E) and severe anemia in cats. In this report, we demonstrate that human FLVCR exports cytoplasmic heme and hypothesize that human FLVCR is required on developing erythroid cells to protect them from heme toxicity. Inhibition of FLVCR in K562 cells decreases heme export, impairs their erythroid maturation and leads to apoptosis. FLVCR is upregulated on CFU-E, indicating that heme export is important in primary cells at this stage. Studies of FLVCR expression in cell lines suggest this exporter also impacts heme trafficking in intestine and liver. To our knowledge, this is the first description of a mammalian heme transporter.
Apoptosis↗
Recurrent demyelinating myelitis associated with hepatitis C viral infection.
We report a 46-year-old-man who developed recurrent myelitis associated with hepatitis C viral (HCV) infection. Spinal cord biopsy showed acute demyelination without evidence of vasculitis. Antibodies to HCV were present in the CSF; HCV RNA was not detected in the CSF. Neither HCV antigens nor RNA were detected in the spinal cord biopsy, whereas they were found in the liver biopsy. Evaluation for other infectious or autoimmune causes was unrevealing. These observations suggest that recurrent myelitis in this patient is etiologically related to HCV infection, possibly via an immune-mediated mechanism. This is the first report of pathologically proven myelitis associated with HCV infection and we suggest that HCV be considered in the differential diagnosis of the transverse myelitis syndrome.
Antigens, CD↗
Association of primary sclerosing cholangitis and celiac disease: a case report and review of the literature.
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Antibodies↗
Preoperative delta-MELD score does not independently predict mortality after liver transplantation.
Changes in model for end-stage liver disease (MELD) score of > or = 5 points over 30 days (delta-MELD) is an independent predictor for death in patients awaiting liver transplantation. The aim of the current study was to determine if a positive change in MELD score occurring over the 30 days immediately prior to liver transplantation was predictive of posttransplant mortality. MELD scores from the day of transplantation and 30 days prior to transplantation were calculated for 1510 UNOS patients and used to compute a delta-MELD score. Multivariate modeling determined predictors of posttransplant mortality. Patients with a preoperative delta-MELD > or = 5 had higher absolute MELD scores at transplant, shorter mean posttransplant survival and higher mortality. However, multivariate analysis showed that none of the excess mortality was attributable to the high delta-MELD score (p = 0.43 for delta-MELD > or = 5) and the majority of the excess risk was attributable to absolute MELD score (p < 0.001) at the time of transplantation. Mortality of patients with rapidly worsening chronic liver disease who undergo transplantation depends substantially on absolute MELD score at the time of transplantation but not the rate of change immediately preceding transplant. Allocation policymakers should consider that a high delta-MELD in the immediate pretransplant period does not indicate greater posttransplant mortality.
Female↗