Comparison of 1-Year Morbidity Following Liver Transplant for Acute Alcoholic Hepatitis Versus Alcoholic Cirrhosis

OBJECTIVES

With limited data on the morbidity profile of liver transplant as therapy for alcoholic hepatitis, we compared 30-day and 1-year morbidity in liver transplant recipients with alcoholic hepatitis versus alcoholic cirrhosis.

MATERIALS AND METHODS

We retrospectively reviewed 38 perioperative variables in patients with alcoholic hepatitis (n = 15) and with alcoholic cirrhosis (n = 46). Multivariable analysis was performed to identify factors independently associated with outcomes.

RESULTS

Patients with alcoholic hepatitis were younger (43 vs 58 years; P = .001), with higher pretransplant Model for End-Stage Liver Disease scores (36 vs 29; P = .009) and worse Karnofsky scores (20 vs 50; P < .001). All patients with alcoholic hepatitis received standard criteria deceased donor grafts; however, in the alcoholic cirrhosis group, 64% received standard criteria deceased, 11% living, 11% after cardiac death, 9% extended criteria, and 2% split graft donor organ donations (P > .05). The alcoholic hepatitis group had higher degree of steatosis on explant (P < .005), and the alcoholic cirrhosis group had higher 30-day reoperation rate (P = .001); however, 1-year interventions, vascular and biliary complications, graft and patient survival, and all other variables were similar (P > .05). Rates of alcohol relapse, 1-year infection, and 1-year rejection were higher but not significant (P > .05) in the alcoholic hepatitis group. Thirty-day reoperation (odds ratio of 82.63; 95% CI, 8.02-3338.96; P = .002) and Karnofsky scores (odds ratio of 1.18; 95% CI, 1.08-1.36; P = .006) remained significant on multivariate analysis.

CONCLUSIONS

Our results showed significant differences between our patient groups, including worse functional status in the alcoholic hepatitis group but significantly higher 30-day reoperation rates and more variable grafts in the alcoholic cirrhosis group, although both groups had similar overall 1-year complication and survival rates. Although not significant, patients with alcoholic hepatitis had higher alcohol relapse and 1-year infection and rejection rates. A larger cohort is necessary to confirm the strength of these findings.

Commercial insurance delays direct-acting antiviral treatment for hepatitis C kidney transplantation into uninfected recipients

INTRODUCTION

The advent of direct-acting antivirals (DAAs) has created an avenue for transplantation of hepatitis C virus (HCV)-infected donors into uninfected recipients (D+/R-). The donor transmission of HCV is then countered by DAA administration during the post-operative period. However, initiation of DAA treatment is ultimately dictated by insurance companies.

METHODS

A retrospective chart review of 52 D+/R- kidney recipients who underwent DAA treatment post-transplant was performed. Patients were grouped according to their prescription coverage plans, managed by either commercial or government pharmacy benefit managers (PBMs).

RESULTS

Thirty-nine patients had government PBMs and 13 had commercial PBMs. Demographics were similar between the two groups. All patients developed HCV viremia, but cleared the virus after treatment with DAA. Patients with government PBMs were treated earlier compared to those with commercial PBMs (11 days vs 26 days, P = .01). Longer time to DAA initiation resulted in higher peak viral loads (β = 0.39, R²  = .15, P = .01) and longer time to HCV viral load clearance (β = 0.41, R²  = .17, P = .01).

CONCLUSIONS

D+/R- transplantation offers patients an alternative strategy to increase access. However, treatment can be profoundly delayed by a third-party payer authorization process that may be subjecting patients to unnecessary risks and worsened outcomes.

Ineffective Absorption? Failure of Direct-Acting Therapy for Chronic Hepatitis C in Cirrhotic Patients With Roux-en-Y Gastric Bypass

In this era of direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) infection, treated patients have extremely high rates of sustained virologic response to short courses of therapy regardless of stage of fibrosis. Treatment failure is uncommon and often attributed to medication noncompliance or viral resistance to drug. This report describes 2 Child-Pugh-A cirrhotic patients who failed to clear HCV in response to therapy with DAAs. Each patient had Roux-en-Y gastric bypass (RYGB) surgery preceding DAA therapy. RYGB may create multiple barriers to adequate DAA absorption as a result of changes in gastrointestinal physiology. Treatment monitoring and duration should be carefully considered in this unique patient population.

Transplantation of viral-positive hepatitis C-positive kidneys into uninfected recipients offers an opportunity to increase organ access

The advent of direct-acting antivirals (DAAs) has provided the impetus to transplant kidneys from hepatitis C virus-positive donors into uninfected recipients (D+/R-). Thirty D+/R- patients received DAA treatment. Sustained virologic response (SVR12) was defined as an undetectable viral load in 12 weeks after treatment. An age-matched cohort of uninfected donor and recipient pairs (D-/R-) transplanted during same time period was used for comparison. The median day of viral detection was postoperative day (POD) 2. The detection of viremia in D+/R- patients was 100%. The initial median viral load was 531 copies/μL (range: 10-1 × 10⁸ copies/μL) with a median peak viral load of 3.4 × 10⁵ copies/μL (range: 804-1.0 × 10⁸ copies/μL). DAAs were initiated on median POD 9 (range: 5-41 days). All 30 patients had confirmed SVR12. During a median follow-up of 10 months, patient and graft survival was 100%, and acute rejection was 6.6% with no major adverse events related to DAA treatment. Delayed graft function was significantly decreased in D+/R- patients as compared to the age-matched cohort (27% vs 60%; P = .01). D+/R- transplantation offers patients an alternative strategy to increase access.

Limited Fibrosis Progression but Significant Mortality in Patients Ineligible for Interferon-Based Hepatitis C Therapy

BACKGROUND

Individuals ineligible for interferon-based hepatitis C therapy may have a worse prognosis than patients who have failed or not received treatment.

AIMS

To provide information about the limitations of medical treatment of hepatitis C in real-world patients.

METHODS

We studied 969 treatment-ineligible patients and 403 treated patients enrolled between 1/1/01 and 6/30/06; data were collected until 3/31/13. Treatment barriers were grouped into five categories and classified as health-related or health-unrelated. Fibrosis stage was assessed initially and at the end of follow-up. Mortality was determined by search of the Social Security database. Death certificates of treatment-ineligible patients were reviewed.

RESULTS

Initially, 288 individuals had advanced fibrosis and compensated disease; 87 untreated patients developed advanced fibrosis during follow-up. Health-related treatment barriers were more commonly associated with fibrosis progression and worse survival. During follow-up, 247 untreated patients died: 47% of liver-related and 53% of liver-unrelated causes. Patients with significant comorbid illness had the worst five- (70%) and ten-year (50.5%) survival. Despite high mortality (47%) in persons with decompensated liver disease, no treatment barrier was associated with a greater incidence of liver-related death. Only significant comorbid medical illness was an independent predictor of disease progression; however, it was not associated with a greater incidence of liver-related death. Furthermore, treated patients had better 10-year survival than untreated patients on Kaplan-Meier analysis (80.3% vs. 74.5%, P = 0.005).

CONCLUSION

Many patients with hepatitis C will die of non-liver-related causes and may not be helped by anti-viral treatment.

Expedited liver allocation in the United States: a critical analysis

The fate of donor livers allocated via an out-of-sequence expedited placement (EP) pathway has not been previously examined. We determined the originating and receiving United Network for Organ Sharing (UNOS) regions of all donor livers procured between January 1, 2010 and October 31, 2012 and placed out of sequence with UNOS bypass code 863 (EP attempt) or 898 (miscellaneous). We reviewed the early function of these liver grafts and assessed the effect of EP allocation on wait-listed patients at our center. Registrants at our center were eligible to receive 1298 liver offers during the interval studied: 218 (16.8%) of these liver offers bypassed our center and were allocated to other centers and used in patients lower on the match-run list. During the study interval, 560 livers were allocated in the United States by EP. Regions 1, 5, 7, 9, and 10 used the greatest number of EP-placed grafts. Region 1 (New England) used the greatest proportion of all EP livers (33% of all imported EP livers in the United States, P < 0.001 versus all other regions). Graft function data were available for 560 livers placed by EP: 491 (88%) of these grafts were functioning at a mean of 399.5 days after transplantation. In conclusion, the transplantation of livers allocated by means of an expedited refusal code is asymmetric across regions and, in some instances, results in the bypassing of patients with higher wait-list priority but without notification of the bypassed center. Short-term graft function after EP allocation is excellent. Policies governing EP allocation should be created in order to improve access to available organs.

Prevalence and natural history of alcoholic liver disease

Alcoholic liver disease is a major cause of morbidity and mortality among people who drink excessive amounts of alcohol. There is a spectrum of liver injury that ranges from steatosis to varying stages of hepatic fibrosis and cirrhosis, with subsequent risk for hepatocellular carcinoma. Steatohepatitis can occur at any stage of disease.

Value of noncontrast CT immediately after transarterial chemoembolization of hepatocellular carcinoma with drug-eluting beads

PURPOSE

To retrospectively evaluate the presence and distribution patterns of contrast agent retention in the liver on noncontrast computed tomography (CT) immediately following chemoembolization with drug-eluting beads (DEBs).

MATERIALS AND METHODS

From 2008 to 2010, 95 patients with 224 liver lesions had chemoembolization performed with DEBs and a noncontrast CT examination of the liver performed immediately after embolization. Of these, 85 patients with 193 lesions were included. The postembolization CT scan was reviewed by a diagnostic radiologist, and the presence of contrast agent retention within the lesion was assessed. Varying patterns of contrast agent retention were defined.

RESULTS

Of the 193 lesions included, 146 (76%) retained contrast medium. Aside from some contrast medium in vessels, very little if any contrast medium was seen in the surrounding liver. Various patterns of contrast agent retention were noted within lesions. In a single case, repeat imaging was obtained 6 hours later, which demonstrated washout of contrast agent in a lesion that had retained contrast agent on the postprocedure CT scan. Of significance, 13 additional foci of contrast agent retention were identified on postchemoembolization CT scans that, on retrospective review of preprocedure imaging, represented enhancing lesions not previously identified.

CONCLUSIONS

Noncontrast CT after chemoembolization with DEBs demonstrates contrast agent retention in 76% of cases, without significant contrast medium seen in the adjacent liver parenchyma. The presence or absence of contrast agent retention may prove to be useful in evaluating accurate targeting of a lesion.

Social barriers to listing for adult liver transplantation: their prevalence and association with program characteristics

Social barriers to effective medical care are mandated to be routinely assessed as part of an evaluation for liver transplantation. This study explores how frequently liver transplant programs encounter these barriers in patients undergoing an evaluation and whether programs with higher proportions of Medicaid patients, historically disadvantaged minority patients, and rural patients encounter social barriers more frequently. A survey for assessing patient demographics and social barriers was electronically completed by representatives of 61 of 104 eligible US adult liver transplant programs (59%). Fifty-eight of the 61 programs identified themselves, and their characteristics were similar to those of all 104 US programs according to publicly available data from the Organ Procurement and Transplantation Network. Social barriers were reported to be encountered sometimes (10%-30%) or frequently (>30%) by the 61 programs as follows: inadequate or unstable health insurance (68.9% of the programs), a chaotic social environment (63.9%), a lack of a care partner (60.7%), an inability to obtain transportation (49.2%), a low educational level (36.1%), inadequate housing (23.0%), a language barrier (19.7%), no reliable way of contacting the patient (16.4%), difficulty in obtaining child care (11.5%), and food insecurity (8.2%). The frequencies of perceived social barriers did not differ significantly between programs reporting higher or lower proportions of Medicaid, minority, or rural patients. Our analysis suggests that program-level operational planning for addressing social barriers to transplant listing should be considered regardless of the proportions of Medicaid-insured, racial or ethnic minority, and rural patients in the population.

Effectiveness of hepatitis C treatment with pegylated interferon and ribavirin in urban minority patients

Randomized controlled trials of hepatitis C virus (HCV) therapy with pegylated interferon and ribavirin have demonstrated sustained viral response rates (SVRs) of 54%-63% (efficacy). Treatment results in clinical practice (effectiveness) may not be equivalent. The goal of this study was to assess the effectiveness of HCV treatment with pegylated interferon and ribavirin in a treatment-naïve, human immunodeficiency virus (HIV)-negative, United States urban population with many ethnic minority patients. We evaluated 2,370 outpatients for HCV therapy from 2001 to 2006 in the Faculty Practice of the Albert Einstein College of Medicine or the attending-supervised Montefiore Medical Center Liver Clinic. Care was supervised by one experienced physician under conditions of everyday clinical practice, and appropriate ancillary resources were made available to all patients. Two hundred fifty-five patients were treated with a mean age of 50 years (60% male, 40% female; 58% Hispanic, 20% African American, 9% Caucasian, 13% other; 68% genotype 1, the remainder genotypes 2 or 3). Patients had at least one liver biopsy. Intention-to-treat analysis (ITT) showed SVR in 14% of genotype 1 patients and 37% in genotype 2/3 patients (P < 0.001). SVR was significantly higher in faculty practice (27%) than in clinic patients (15%) by intention-to-treat (P = 0.01) but not per-protocol analysis (46% faculty practice, 34% clinic). 3.3% of 1,656 treatment-naïve, HIV antibody-negative individuals ultimately achieved SVR. Current hepatitis C therapies may sometimes be unavailable to, inappropriate for, and ineffective in United States urban patients. Treatment with pegylated interferon and ribavirin was less effective in this population than is implied by multinational phase III controlled trials. New strategies are needed to care for such patients.

Corticosteroid-responsive cryptogenic chronic hepatitis: evidence for seronegative autoimmune hepatitis

Cryptogenic chronic hepatitis (CCH) is diagnosed in patients with persistently elevated aminotransferase levels of unknown etiology. The workup of CCH patients must include a liver biopsy in order to exclude the largely unrecognized diagnosis of seronegative autoimmune hepatitis (SAIH). Patients with SAIH have demographic, biochemical, and histologic features of autoimmune hepatitis (AIH) and may be treated effectively with corticosteroids. Recognition and treatment of SAIH are necessary to prevent progression to end-stage liver disease. We performed a retrospective review of a database of 3507 patients seen at our institution over a 5-year period. Thirty patients with conventional AIH and an additional six patients with SAIH were identified. The two groups were similar with respect to mean age, gender, and baseline biochemistry. Of the 20 AIH patients who had pretreatment liver biopsies, 85% had moderate to severe interface hepatitis, compared to 83.3% of patients with SAIH. In the SAIH group, 83.3% had advanced fibrosis (stage 3 or 4), versus 40% in the conventional AIH group (P = 0.16). All patients were treated with corticosteroids followed by azathioprine. The mean time to remission (normal ALT) was similar in both groups, 2.6 vs. 2.7 months. Within 3 months, 88.9% of AIH patients and 66.7% of SAIH patients were in remission. We conclude that a trial of corticosteroids is a reasonable therapeutic measure in patients with chronic hepatitis that has features of AIH despite negative autoantibody markers. In most patients, clinical remission will be seen within 3 months, possibly avoiding progression to end-stage liver disease.

Paroxetine for prevention of depressive symptoms induced by interferon-alpha and ribavirin for hepatitis C

BACKGROUND

Whether antidepressants prevent depression during interferon-alpha/ribavirin treatment for hepatitis C virus infection has yet to be established.

AIM

To investigate the use of paroxetine in a prospective, double-blind, placebo-controlled study for this indication.

METHODS

Sixty-one hepatitis C virus-infected patients were randomly assigned to the antidepressant, paroxetine (n = 28), or placebo (n = 33), begun 2 weeks before and continued for 24 weeks during interferon-alpha/ribavirin treatment. Primary endpoints included development of major depression and severity of depressive symptoms measured by the Montgomery Asberg Depression Rating Scale (MADRS).

RESULTS

Rates of major depression during the study were low (17%) and did not differ between groups. Nevertheless, using published MADRS cut-off scores, the percent of subjects who met criteria for mild, moderate or severe depression during interferon-alpha/ribavirin therapy was significantly lower in paroxetine- vs. placebo-treated subjects (P = 0.02, Fisher's exact test). Assignment to paroxetine was also associated with significantly reduced depressive symptom severity. This effect was largely accounted for by participants with depression scores above the median (MADRS > 3) at baseline in whom paroxetine was associated with a maximal reduction in MADRS scores of 10.3 (95% CI: 2.1-18.5) compared with placebo at 20 weeks (P < 0.01). Study limitations included a small sample size and high drop-out rate.

CONCLUSION

This double-blind, placebo-controlled trial provides preliminary data in support of antidepressant pre-treatment in hepatitis C virus patients with elevated depressive symptoms at baseline.

Entry of hepatitis C virus and human immunodeficiency virus is selectively inhibited by carbohydrate-binding agents but not by polyanions

We studied the antiviral activity of carbohydrate-binding agents (CBAs), including several plant lectins and the non-peptidic small-molecular-weight antibiotic pradimicin A (PRM-A). These agents efficiently prevented hepatitis C virus (HCV) and human immunodeficiency virus type 1 (HIV-1) infection of target cells by inhibiting the viral entry. CBAs were also shown to prevent HIV and HCV capture by DC-SIGN-expressing cells. Surprisingly, infection by other enveloped viruses such as herpes simplex viruses, respiratory syncytial virus and parainfluenza-3 virus was not inhibited by these agents pointing to a high degree of specificity. Mannan reversed the antiviral activity of CBAs, confirming their association with viral envelope-associated glycans. In contrast, polyanions such as dextran sulfate-5000 and sulfated polyvinylalcohol inhibited HIV entry but were devoid of any activity against HCV infection, indicating that they act through a different mechanism. CBAs could be considered as prime drug leads for the treatment of chronic viral infections such as HCV by preventing viral entry into target cells. They may represent an attractive new option for therapy of HCV/HIV coinfections. CBAs may also have the potential to prevent HCV/HIV transmission.

Hippocratic Economics (the Physician's Dilemma)

The nature of the medical profession puts physicians in an unusual position. Patients seek out physicians' help because of their expertise in dealing with illnesses, possibly even life-threatening ones. The asymmetry of knowledge in this relationship, the expert physician and the inexpert patient, creates an ethical dilemma for physicians regarding the delivery of care. Physicians determine how much care to offer while receiving remuneration for this care. Here, acting as patients' agents, physicians have immense discretionary power not only with patients' health but also with their pocketbooks. Known as the principal-agency problem, this type of relationship is part and parcel of what business scholars refer to as moral hazard. This article explains the problem of moral hazard and how it affects radiologists and places it in the context of professional and ethical behavior. Its causes and relationship to human nature are explored. The consequences of falling prey to moral hazard in the practice of radiology are discussed.

Factors associated with successful referral for clinical care of drug users with chronic hepatitis C who have or are at risk for HIV infection

The objective of this study was to determine outcomes of referring drug users (DUs) with chronic hepatitis C for clinical evaluation and care. Two hundred twenty-eight persons with detectable hepatitis C virus RNA were given expedited referrals for evaluation and possible treatment of hepatitis C from a prospective study cohort of current and former opiate-addicted DUs. Four outcomes were analyzed: accepted referral, arrived for clinical evaluation, had liver biopsy, and received treatment. One hundred twenty-seven participants (56%) accepted referral, of whom 54 (43%) arrived for evaluation. Of these participants, 12 (22%) had liver biopsy, and 4 (7%) were treated. Multivariate logistic regression revealed that HIV-infected DUs were significantly less likely to accept referral (adjusted odds ratio [O(Radj)], 0.51; 95% confidence interval [CI], 0.30-0.88), and older participants were more likely to keep an appointment (O(Radj), 1.06/y; 95% CI, 1.00-1.12). Of HIV-seropositive participants, those with a history of injection were more likely to accept referral (O(Radj), 3.60; 95% CI, 1.08-11.96), and those with higher HIV load (O(Radj), 0.50/log10; 95% CI, 0.26-0.94) and Hispanic ethnicity (O(Radj), 0.26; 95% CI, 0.07-0.89) were less likely to keep an appointment. Despite expedited referrals for hepatitis C care, only a few participants received an evaluation, and even far fewer were treated. Because increasingly effective treatment is available, better methods are urgently needed to improve evaluation and treatment of HCV-infected DUs, including those coinfected with HIV.

Recombinant human interferon-alpha does not alter reward behavior, or neuroimmune and neuroendocrine activation in rats

Recombinant human interferon-alpha (IFN-alpha) induces depression, and neuroendocrine and neuroimmune activation, in a significant number of patients undergoing treatment for viral illnesses (e.g., hepatitis C), yet these effects have not been consistently reproduced in rodents. As such, we sought to determine the effects of acute or chronic IFN-alpha treatment on basic reward and immobility in the forced swim test (FST), neuroendocrine and neuroimmune activation, and monoamine turnover in brain. In the first experiment, male Wistar rats (N = 7/group) treated with human recombinant IFN-alpha (100,000 IU/kg, i.p.), as compared to saline, did not exhibit alterations to rate of sucrose pellet self-administration or total reinforcers obtained, corticosterone release, plasma IL-6 release, IL-1beta or IL-6 mRNA expression in hippocampus, or monoamine turnover in prefrontal cortex, striatum, nucleus accumbens, or amygdala. However, acute IFN-alpha decreased body weight and produced a trend toward reduced food consumption in the home cage 2 h after injection. In the second experiment, Wistar rats (N=4/group) were subjected to a chronic treatment regimen of saline or IFN-alpha (100,000 IU/kg, i.p.) once daily for 14 consecutive days. The data reveal that animals exposed to chronic IFN-alpha exhibited similar amounts of time immobile and similar latencies to primary immobility in the FST as compared to saline-treated controls. Chronic IFN-alpha did not induce corticosterone release, plasma TNF-alpha, or IL-6 release. Tissue monoamine analysis revealed that chronic IFN-alpha reduced DA levels in prefrontal cortex, and decreased 5-HT levels and increased 5-HT turnover in amygdala. In the third experiment, Wistar rats (N = 4/group) were exposed to either acute or chronic pegylated IFN-alpha (pegIFN-alpha: 3.25, 10 or 75 mg/kg, i.p.) at one of several time points from 1 h to 23 days. The data reveal that neither acute nor chronic pegIFN-alpha induced corticosterone release. Overall, the current report demonstrates that neither acute nor chronic IFN-alpha induced depressive-like behavior and neither IFN-alpha nor peg-IFN-alpha was capable of inducing neuroendocrine or neuroimmune activation. Despite the neurochemical alterations observed in the chronic treatment regimen, the data indicate that recombinant human IFN-alpha does not produce a robust model of depressive-like behavior in rodents.

Sertraline hepatotoxicity: a case report and review of the literature on selective serotonin reuptake inhibitor hepatotoxicity

The causal role of sertraline in rare cases of liver failure in patients taking the drug has not been proven in a manner consistent with usually accepted standards. We describe an individual who developed clinically significant hepatitis while being treated with sertraline. This case is significant because it is the only one of which we are aware in which the diagnosis of sertraline hepatotoxicity was confirmed when inadvertent rechallenge with the medication resulted in recurrent hepatitis. We review this case and the general role of this widely prescribed class of drugs in causing hepatitis.

IFN-induced depression: a role for NSAIDs

Interferon-alpha (IFN) is widely used for the treatment of viral illnesses and other chronic diseases, though its usefulness is hampered by a problematic side-effect profile. In particular, IFN-alpha induces neuropsychiatric and neurotoxic side effects, including depression, anxiety, insomnia, lethargy, confusion, and psychosis. Of particular interest, a number of patients develop full psychiatric syndromes, particularly depressive disorders. Recent evidence suggests that conventional antidepressants (especially selective serotonin reuptake inhibitors) are effective in preventing or reducing IFN-induced side-effects, but even these compounds are not 100% effective in preventing these symptoms. As such, alternative treatments must be considered. Non-steroidal anti-inflammatory drugs (NSAIDs) are known to counteract a number of IFN-induced side effects, including cytokine activation, stress hormone release, and neurochemical alterations (reduced 5-HT [serotonin]). NSAIDs are widely recommended for various aspects of flu-like symptoms or sickness behaviors in humans, including those induced specifically by IFN. In addition, NSAIDs appear to be effective in treating premenstrual dysphoric disorder. These data indirectly specify a role for NSAIDs in syndromes with a prominent depression component. Drawing from an extensive pre-clinical and clinical research base, we hypothesize that pretreatment with NSAIDs will not only reduce the incidence of flu-like symptoms, but also prove effective for the prevention or reduction of IFN-induced depression.

Interferon-alpha-2b and ribavirin for retreatment of chronic hepatitis C

BACKGROUND/AIMS

Subjects with chronic hepatitis C who fail treatment with interferon-alpha are generally divided into two groups: "relapsers" who normalized serum aminotransferase activity and have undetectable viral RNA during treatment and "non-responders" who do not achieve these results. The aim of this study was to examine retreatment of such subjects.

METHODOLOGY

We studied 117 subjects with chronic hepatitis C who failed treatment with interferon-alpha, 87 of whom were "non-responders" and 30 "relapsers." Retreatment was with either interferon-alpha-2b plus ribavirin for 48 weeks or with interferon-alpha-2b plus placebo for 24 weeks followed by 24 weeks of combined therapy.

RESULTS

Sustained response rates, defined as undetectable viral RNA in serum 6 months after retreatment, were 53% in "relapsers" and 10% in "non-responders" (P < 0.005). There was no significant difference if ribavirin was given for 24 or 48 weeks. In "non-responders" infected with genotypes other than type 1, 42% achieved a sustained response compared to 5% infected with genotype 1 (P = 0.027; odds ratio 7.09).

CONCLUSIONS

Treatment with interferon-alpha-2b plus ribavirin is effective in approximately 50% of "relapsers" and "non-responders" infected with non-type 1 genotypes of hepatitis C virus. This therapy is only marginally effective in "non-responders" infected with genotype 1a or 1b.

Ischemic bowel disease in the elderly

The ischemic bowel diseases are a heterogeneous group of disorders usually seen in elderly individuals. They represent ischemic damage to different portions [figure: see text] of the bowel and produce a variety of clinical syndromes and outcomes. Colonic ischemia is the commonest of these disorders and has a favorable prognosis in most cases. In contrast, acute mesenteric ischemia, most commonly caused by a superior mesenteric artery embolus, is a disease with a poor prognosis. Acute mesenteric ischemia secondary to nonocclusive mesenteric ischemia usually is a [figure: see text] catastrophic complication of other severe medical illnesses, most notably atherosclerosis. Proper diagnosis and management of patients with ischemic bowel disease requires vigilance on the part of the physician and a willingness to embark on an aggressive plan of diagnosis and management in the appropriate setting.

Severe liver injury after treatment with the leukotriene receptor antagonist zafirlukast

BACKGROUND

In registration trials, zafirlukast, an asthma medication, caused asymptomatic elevated aminotransferase levels in up to 5% of participants. Until now, however, no cases of severe hepatitis attributed to zafirlukast have been reported.

OBJECTIVE

To report the clinical characteristics of three patients with severe hepatitis due to zafirlukast.

DESIGN

Case report.

SETTING

One community hospital and two university hospitals.

PATIENTS

Three middle-aged women taking zafirlukast, 20 mg twice per day.

INTERVENTION

Discontinuation of zafirlukast therapy in three patients, steroid therapy in two patients, and orthotopic liver transplantation in one patient.

MEASUREMENTS

Serum aminotransferase and bilirubin levels, standard blood tests for causes of hepatitis other than drug toxicity, and liver biopsy in two patients.

RESULTS

Patient 1 recovered spontaneously, had a severe relapse after inadvertent rechallenge with the medication, and ultimately made a complete recovery. Patient 2 developed subfulminant hepatic failure and required liver transplantation. Patient 3 developed severe hepatitis that improved after treatment with corticosteroids. Liver tissue was available from two patients and showed histologic changes commonly associated with drug reactions.

CONCLUSION

Patients receiving zafirlukast may develop severe liver injury and should be observed for signs and symptoms of hepatitis.

Comparison of clinical features and liver histology in hepatitis C-positive dialysis patients and renal transplant recipients

OBJECTIVE

Liver biopsies in hepatitis C virus (HCV)-positive end stage renal disease (ESRD) patients before or after renal transplantation were compared to study the effect of transplant-related immunosuppression.

METHODS

In this prospective study all patients on the active transplant list and all patients with functioning renal transplants at our hospital were tested for HCV antibody (ELISA-2) over a 30-month period. HCV infection was confirmed by polymerase chain reaction in most patients. All HCV-positive patients were asked to undergo liver biopsy without regard to serum transaminase levels. Patients were interviewed, examined, and had detailed chart review. By protocol, liver histology was evaluated according to stage and inflammatory activity in a blinded fashion.

RESULTS

There were 129 HCV-antibody-positive patients, of 795 tested. Sixty-seven agreed to liver biopsy. Of these, 22 patients had never been transplanted and 45 had received transplants. Mean transplant duration before biopsy was 41.2 months (range, 1-204 months). Transplant patients had significantly longer duration of ESRD and estimated duration of HCV infection than patients not transplanted. Dialysis patients had significantly more portal inflammatory activity and lymphoid follicles on biopsy whereas transplant patients had more piecemeal necrosis and steatosis. However, the total histological activity score and stage were similar between groups. Multivariate analysis confirmed the association between transplant and steatosis. But independent variables including transplant duration, HCV infection duration, and ESRD duration were not correlated with histological findings.

CONCLUSION

Renal transplantation may not be associated with an increased risk of progressive liver disease in HCV-positive patients, compared with ESRD patients receiving chronic dialysis. Long-term studies with serial liver biopsies are needed to resolve this issue.

Comparison of sonograms and liver histologic findings in patients with chronic hepatitis C virus infection

Gray scale ultrasonographic images of the liver were correlated with histologic findings in patients with chronic hepatitis C virus infection. The gray scale patterns of 64 livers with chronic hepatitis C virus infection were categorized as normal, fatty, fibrofatty, fibrotic, or inflammatory and were graded as mild, moderate, or severe. Liver biopsy specimens also were analyzed for the presence of fat, inflammation, and fibrosis and graded similarly. No correlation was found between fatty and fibrofatty sonographic findings with any of the three histologic patterns. Correlations were found between fibrotic sonographic findings and both fibrotic and inflammatory histologic findings (r = 0.27; P = 0.03). Although some pathologic features of liver disease were detected by ultrasonography, no useful correlation was noted between results of sonography and histologic examination.

Results of a survey to evaluate whether vaginal delivery and episiotomy lead to perineal involvement in women with Crohn's disease

OBJECTIVE

Crohn's disease frequently affects the perineum, but it is unknown if such involvement poses a heightened risk to a woman with Crohn's disease undergoing vaginal delivery and possibly episiotomy. This study attempts to elucidate whether vaginal delivery with or without episiotomy: 1) predisposes to perineal involvement in women with Crohn's disease; 2) reactivates quiescent perineal Crohn's disease; or 3) worsens preexisting perineal Crohn's disease.

METHODS

Data were culled from questionnaires returned by 117 respondents contacted through newsletters of the Crohn's and Colitis Foundation of America. These surveys were then reviewed and tabulated to determine if any temporal and causal relationship existed between perineal Crohn's disease and vaginal delivery.

RESULTS

Four groups were identified: group 1 (n = 56), with 128 pregnancies, had no history of perineal disease or subsequent perineal complication. Group 2 (n = 24) had 51 pregnancies. This group had no preexisting perineal disease, but 67.6% said they developed perineal Crohn's disease postpartum, 60% of which occurred within 2 months of vaginal delivery. Groups 3 and 4 were too small to evaluate (n = 4 and 5, respectively) and represented patients with preexisting perineal disease who had varying results after delivery. Overall, the rate of developing perineal involvement after vaginal delivery, usually with episiotomy, in patients with Crohn's disease and no preexisting perineal involvement (combining groups 1 and 2) was 17.9%.

CONCLUSIONS

A high rate of perineal involvement seems to follow vaginal delivery with episiotomy in patients with Crohn's disease. Although this study has substantial methodological limitations, it does raise questions as to the proper obstetrical management of patients with Crohn's disease and highlights an intriguing relationship that deserves further and more rigorous study.

Recurrent chorioamnionitis and second-trimester abortion because of an enterouterine fistula

BACKGROUND

Chorioamnionitis, a common cause of second-trimester abortion, is usually secondary to an ascending infection. Recurrent chorioamnionitis with second-trimester abortion secondary to an occult enterouterine fistula has not been reported previously.

CASE

A 26-year-old Indian woman, para 0-0-2-0, presented with two spontaneous second-trimester losses. Her third pregnancy carried to 24 weeks, but she delivered after the development of pneumonia, bacteremia, preterm labor, and chorioamnionitis. The patient passed melena containing blood clots after the delivery. After the last pregnancy, laparoscopy and laparotomy revealed an ileal-uterine fistula and a foreign body (necrotic cartilage). The blind loop of bowel was resected and the fistulous tract excised.

CONCLUSION

Our patient's recurrent pregnancy wastage was caused by chorioamnionitis secondary to an enterouterine fistula resulting from foreign body ingestion. A complete reversal of this problem is anticipated.

Lower intestinal hemorrhage

Lower intestinal hemorrhage, defined as bleeding originating below the ligament of Treitz, is a common clinical problem frequently requiring hospital admission. The two chief causes, vascular ectasia and diverticulosis, are degenerative diseases usually found in the elderly. This article focuses on those disease entities that potentially can result in significant lower intestinal blood loss. It also discusses a generalized approach to the diagnostic evaluation leading to specific management of the patient presenting with this problem.

Epidemiologic predictors of hepatitis C virus infection in pregnant women

OBJECTIVE

To identify sensitive epidemiologic predictors of a positive hepatitis C virus antibody test in asymptomatic persons, and to compare the cost of testing only persons with an epidemiologic predictor to that of universal screening.

METHODS

Seventeen hundred consecutive pregnant women were tested by enzyme-linked immunosorbent assay for antibody to hepatitis C virus. Seventy-five subjects tested positive and were compared with 257 pregnant women who tested negative. Cohort and control patients were interviewed and their medical records were reviewed to identify those with chosen predictors of a positive hepatitis C virus antibody test.

RESULTS

Seventy-four of 75 cohort patients and 108 of 257 controls had one or more predictors of a positive antibody test. Cohort patients were significantly more likely (P < .001) to have the following: human immunodeficiency virus infection, a sex partner with a risk factor for hepatitis, age greater than 30 years, and a history of drug use, blood transfusion, sexually transmitted disease, hepatitis, or incarceration. The sensitivity and specificity of a single predictor in identifying a person with a positive test were 99 and 58%, respectively. The cost of finding a single individual with a positive antibody test by universal screening was $674, compared to $303 by selectively screening persons with one or more predictors of a positive antibody test.

CONCLUSIONS

Most individuals with positive hepatitis C virus antibody tests can be identified on the basis of epidemiologic predictors, reducing the cost of testing by 55%. These patients may receive appropriate medical therapy, and their children may be evaluated for possible infection by vertical transmission of hepatitis C virus.

Vascular ectasias and diverticulosis. Common causes of lower intestinal bleeding

Lower intestinal bleeding is an important medical problem frequently responsible for hospital admission in the United States. The two most common causes of this type of bleeding are colonic diverticula and vascular ectasias. Because ectasias are difficult to diagnose and because many older individuals have asymptomatic diverticula, it is often impossible to be certain that one of these lesions is the source of blood loss in a given patient. Fortunately, bleeding from an ectasia or a diverticulum usually stops spontaneously. A conservative approach to therapy, therefore, is strongly recommended. Should a careful evaluation fail to reveal the source of bleeding and treatment become necessary because of recurrent hemorrhage, the patient should undergo an elective right hemicolectomy. The extent of resection is not altered by the presence of diverticulosis in the left colon.

Failure to detect vertical transmission of hepatitis C virus

OBJECTIVE

To search for transmission of hepatitis C virus (HCV) from infected mothers to their infants.

DESIGN

Prospective clinical, serologic, and molecular biologic follow-up (at least 3 months) of the infants of mothers with anti-HCV antibody.

SETTING

A county hospital providing primary and referral care in high-risk obstetrics (perinatology).

PATIENTS

Twenty-three mothers with anti-HCV antibody and their 24 infants.

METHODS

An enzyme-linked immunosorbent assay (EIA) and a four-antigen recombinant immunoblot assay (RIBA) were used to test for anti-HCV antibody; serum HCV RNA was measured in two independent laboratories by reverse transcription and polymerase chain reaction (PCR) using nested primers in the 5'-noncoding region. Infant samples were tested for HCV RNA by PCR at delivery and after 3 to 6 months of follow-up. Each sample was tested at least four times in two independent laboratories.

RESULTS

Twenty-nine of 648 mothers (4.5%; 95% Cl, 3.0% to 6.4%) had anti-HCV antibody; these women had 30 babies. Twenty-three mothers and their 24 babies were followed at least 3 months (mean follow-up, 52 weeks). Of the 23 mothers, 21 (91%; Cl, 72% to 99%) had a reactive RIBA; one woman had an indeterminate RIBA and was positive for HCV RNA by PCR. In 16 of 23 mothers (70%; Cl, 47% to 87%), PCR yielded a positive result in both laboratories. The mean maternal alanine aminotransferase (ALT) level was 1.6 times the normal value. All the babies had anti-HCV antibody in cord-blood samples, but antibody disappeared or diminished in strength in interval samples, and no infant had evidence of active production of anti-HCV antibody. Only 1 of 24 (4%; Cl, 0.1% to 21%) cord-blood samples was HCV RNA positive, and none of 24 (0%; Cl, 0% to 14%) follow-up samples was positive for HCV RNA by PCR in either laboratory. Four mothers and one baby had antibody to HIV.

CONCLUSIONS

Infant anti-HCV antibody is most likely acquired passively in utero, and vertical transmission of HCV is uncommon.

Gastrointestinal malignancy in patients with AIDS

To clarify the prevalence and characteristics of gastrointestinal malignancy in patients with AIDS, we reviewed the demographics and clinical features of patients with AIDS and gastrointestinal neoplasms seen at North Central Bronx Hospital and Montefiore Medical Center during the past 8 yr. Malignant neoplasia complicated AIDS in 108/869 (12%) of the cases in our study. Most common was Kaposi's sarcoma (KS) (60%), followed by lymphoma (35%) and miscellaneous tumors (6.5%). The gastrointestinal tract was involved in 35/108 (32%) of patients with AIDS and neoplasia. Gastrointestinal tract involvement with KS usually was silent, although present, in every patient with KS who underwent autopsy. Lymphoma was most commonly non-Hodgkin's, and often produced symptoms. Uncommonly, the gastrointestinal tract was the primary site of neoplasms other than KS or lymphoma.

Lower intestinal bleeding in the elderly

Lower intestinal bleeding in the elderly is a common problem with numerous and varied causes. Its diagnosis and treatment require a careful, systematic approach by physicians with special expertise. Under the proper circumstances, elderly patients with lower intestinal bleeding do well, even when surgery is required. An individual's age, by itself, should not preclude aggressive medical care.

Upper and lower gastrointestinal bleeding in the elderly

Gastrointestinal bleeding in the elderly is a common problem with numerous and varied causes. Its diagnosis and treatment require a careful, systematic approach by physicians with special expertise. Under the proper circumstances, elderly patients with upper or lower gastrointestinal bleeding do well even when surgery is required, and an individual's age, by itself, should not preclude aggressive medical care.

Ischemic diseases of the bowel

The ischemic bowel diseases are a heterogeneous group of disorders usually seen in elderly individuals. They represent ischemic damage to different portions of the bowel and therefore produce a variety of clinical syndromes and outcomes. Proper diagnosis and management of patients with ischemic bowel disease require vigilance on the part of the physician and a willingness to embark on an aggressive plan of diagnosis and management in the appropriate setting.

Ethanol: relative fuel value and metabolic effects in vivo

A nasogastric formula infusion method was used to evaluate the steady-state fuel value of ethanol relative to that of glucose in eight chronically alcoholic men undergoing a 4- or 5-week balance experiment. Each subject received a maintenance infusion of the formula diet throughout the study. When control formula glucose (week 1) was isocalorically replaced with ethanol [week 2, 30% of kcal; week 3 or 4 (5-week experiment) 40% to 60% of kcal], the following was observed: weight loss; zero energy balance and reduced or negative balances of N, K, P, Mg, and Na; increased urinary urea N and 3-methylhistidine; lowered urinary C-peptide; no change in indirectly or directly measured thermal energy losses; and a blood level related rise in breath and urinary ethanol losses. All of these changes promptly reversed during the middle (week 3 in 5-week experiment) and final control weeks. Accounting for all diet-related energy losses (urine, breath, thermal), the fuel value of the ethanol-containing diet relative to the glucose control formula varied between 0.95 and 0.99, depending upon the blood alcohol level. Hence weight loss during short-term (seven-day) ethanol infusion is unrelated to overall negative energy balance, stems primarily from decrements in protein, minerals, and fluid, and may in part be mediated by the reduction in insulin secretion that accompanies switching from dietary glucose to ethanol.