Leukocytoclastic Vasculitis Associated with Adalimumab Therapy for Crohn's Disease

Leukocytoclastic vasculitis (LCV) is rarely associated with anti-tumor necrosis factor [TNF] α therapy. We report a 22-year-old man with new onset of a pustular rash on his bilateral upper and lower extremities while on adalimumab therapy for Crohn's disease. Skin biopsy of the affected area showed perivascular extravasation of erythrocytes, neutrophils, eosinophils and vascular damage surrounding blood vessels associated with fibrin, consistent with LCV. Patient was treated with topical steroids and subsequently transitioned to ustekinumab therapy with follow-up colonoscopy showing minimal active disease. Our report highlights the association of a unique dermatologic autoimmune manifestation with TNF-targeted therapy in a patient with Crohn's disease.

Cost-Effectiveness Analysis of Screening for Hepatitis B Virus Infection in Patients With Solid Tumors Before Initiating Chemotherapy

BACKGROUND & AIMS

Patients with solid tumors who undergo chemotherapy have an increased risk of hepatitis B virus (HBV) reactivation, but a low proportion of these patients are screened for HBV infection and guidelines make conflicting recommendations. Further, the cost-effectiveness of newer treatments for HBV prophylaxis has not been examined for this population. We aimed to analyze the cost-effectiveness of HBV screening before chemotherapy for patients with solid tumors.

METHODS

We compared 3 HBV screening strategies (screen all, screen only high-risk patients, or screen none) using a Markov model of a population of adults in the United States who initiated chemotherapy for a solid tumor. We modeled use of entecavir prophylaxis for HB surface antigen (HBsAg)-positive patients and surveillance for HBsAg-negative patients who are positive for HBV core antibody. The Markov cycle length was 1 year, with model simulation for up to 5 years.

RESULTS

The screen all strategy was the most cost effective, with an incremental cost-effectiveness ratio of $42,761 compared to screening only high-risk patients. The screen none strategy was less effective and less costly than screening all patients or only high-risk patients. The screen-all strategy was the most cost effective for all estimates of prevalence of HBsAg-positive patients and estimates of HBV reactivation in HBsAg-positive patients. Screening only high-risk patients was the most cost-effective strategy when more than 25% of high-risk patients were screened for HBV infection.

CONCLUSIONS

In a Markov model analysis, we found screening all patients with solid tumors for HBV infection before chemotherapy to be the most cost-effective strategy. Guidelines should consider recommending HBV tests for patients initiating chemotherapy.

Primary Biliary Cholangitis: A Brief Overview

http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-3-reading-louie a video presentation of this article.

Trapped vessel of abdominal pain with hepatomegaly: A case report

Abdominal pain with elevated transaminases from inferior vena cava (IVC) obstruction is a relatively common reason for referral and further workup by a hepatologist. The differential for the cause of IVC obstruction is extensive, and the most common etiologies include clotting disorders or recent trauma. In some situations the common etiologies have been ruled out, and the underlying process for the patient’s symptoms is still not explained. We present one unique case of abdominal pain and hepatomegaly secondary to IVC constriction from extrinsic compression of the diaphragm. Based on this patient’s presentation, we urge that physicians be cognizant of the IVC diameter and consider extrinsic compression as a contributor to the patient’s symptoms. If IVC compression from the diaphragm is confirmed, early referral to vascular surgery is strongly advised for further surgical intervention.

Occurrence and Recurrence of Hepatocellular Carcinoma After Successful Direct-Acting Antiviral Therapy for Patients With Chronic Hepatitis C Virus Infection

Chronic hepatitis C virus (HCV) infection has generally been associated with a slightly increased risk of developing hepatocellular carcinoma (HCC). For the past several decades, most patients with chronic HCV cirrhosis have been treated with pegylated interferon and ribavirin therapies, which were known to achieve sustained virologic response (SVR) but also carried their own side effects and toxicities. The recent implementation of direct-acting antiviral (DAA) treatments revealed an increased efficacy in difficult-to-treat populations and higher adherence rates given the all-oral nature of the regimens. However, while these regimens are excellent in terms of improving the side-effect profile and achieving SVR at a higher rate and in a shorter time frame than interferon and ribavirin, some researchers are now discovering an increased rate of de novo and recurrent HCC in patients with HCV cirrhosis compared to interferon treatment protocols. Although other studies were not able to reproduce similar findings, the question as to the role of DAA therapy in HCC occurrence after achieving SVR in patients with HCV cirrhosis continues to persist. Possible theories as to the mechanisms behind tumor relapse after DAA therapy include alterations of immunosurveillance and gene expression, a protective and antineoplastic effect from inflammation secondary to chronic HCV infection that is then abolished with DAA therapy, and delay in radiographic identification of previously undetectable tumors. This article reviews the current literature regarding concern for the possible increase of HCC after DAA therapy.

Brain-spinal cord interactions stabilize the locomotor rhythm to an external perturbation

Motor networks within the spinal cord of vertebrates are capable of generating rhythmic locomotor output even in the absence of phasic sensory input. In an intact animal these spinal pattern generators are affected by descending inputs from the brain and by sensory inputs. The role of the feedforward-feedback (FF-FB) loops between the brain and the spinal cord in the control of locomotion are not well understood. We hypothesized that the dynamic interaction between the brain and the spinal cord would affect the response of the neural system to external perturbation. We investigated this hypothesis in an in-vitro brain-spinal cord fictive locomotion preparation of a primitive vertebrate, lamprey. In tandem, we analyzed the behavior of a neural network model representing the brain and multiple segments of the spinal cord. Our experimental results indicate that with intact FF-FB loops, phase locked entrainment of the spinal motor activity can be obtained on direct stimulation of the spinal cord. However, the effect is localized with minimal influence on distal spinal segments. The intersegmental coupling strength is strong as indicated by a fast recovery of the perturbed rhythm to the natural frequency on termination of the perturbation. With the FF-FB loop interrupted, the perturbation was capable of altering the motor activity from multiple sites in the spinal cord. Also, upon termination of the perturbation there was a prolonged period before recovery of the original natural frequency. Model analyses support our interpretation of the experimental results. In the neural network model with the brain-spinal cord loops closed there was a localized effect on the oscillatory rhythm and strong intersegmental coupling. Also, the analysis indicated the presence of a smaller entrainment range and many more periodic orbits than with the loops open. The results suggest that the increased variability in the locomotor rhythm and decreased sensitivity to perturbation observed in the presence of intact brain spinal cord connections may be a reflection of a higher dimensional system with many periodic orbits. The higher dimension could allow the system to collectively remain within the attractor space of one of these periodic orbits and thus remain resilient to perturbation.