Elevated Liver Function Research Articles

TOXOPLASMOSIS: SEROPREVALENCE IN WOMEN OF REPRODUCTIVE AGE AND APPROACH IN PREGNANCY

Objective: Toxoplasmosis is a parasitosis that is mostly asymptomatic or with mild symptoms. It can lead to severe clinical conditions in immunosuppressed patients who had infections that mostly develop through reactivation, or in congenital infections that develop in fetuses infected as a result of vertical transmission. Since it is possible to prevent congenital toxoplasmosis with appropriate follow-up and treatment, our study aimed to determine the susceptible population and seroprevalence of our region and to evaluate the course of infections in this group. Material and Method: Patients of childbearing age who were evaluated in the last five years in our tertiary hospital were included in our study, and Anti Toxoplasma gondii IgM and IgG results in these patients were evaluated. The course of pregnant women who were thought to have primary infection, the follow-up of these patients and the treatments applied were evaluated. In addition, the follow-up of non-pregnant patients examined were also evaluated. Results: The seropositivity rate was found to be 30.7% (n=1703) in 5545 women included in the study, and the seropositivity rate was 31% (n=1399) in 4503 pregnant women. After detailed evaluations, of 16 pregnant women who were thought to have primary infection during pregnancy and were followed up in our hospital; one underwent medical abortion at the request of the family, and only four used the recommended treatment until the end of pregnancy, and congenital toxoplasmosis was not detected in any newborn. Since the many of pregnant women with possible primary infection (n=28) were not referred to the infectious diseases outpatient clinic, this group was not evaluated in detail and could not be monitored. Of the patients included in the study, 26 (0.4%) were examined to investigate the etiology of fever, 37 (0.6%) were examined to investigate the etiology of lymphadenopathy (LAP), and 29 (0.5%) were examined to investigate the cause of elevated liver function tests. Among the patients monitored with LAP, four (10.8%) were diagnosed with acute toxoplasmosis. Conclusion: As a result, it is very important to determine the seroprevalence of toxoplasmosis, to detect possible primary infections, especially in pregnant women, and to prevent congenital toxoplasmosis by clinicians to guide patients correctly so that the follow-up and treatment of this group of patients is not interrupted.

Association Between Insulin Resistance Indices and Liver Function Parameters Among Women With Polycystic Ovary Syndrome.

This study aimed to investigate whether polycystic ovary syndrome (PCOS) status changes the association between insulin resistance (IR) indices and liver function parameters among women. This is a cross-sectional, population-based study. We selected 1101 subjects aged ≥20 years from participants of Tehran Lipid and Glucose Study (TLGS). All of them had known the status of PCOS, and all variables were related to the IR indices and liver function parameters. The main outcome measures were TG/HDL-C and triglyceride-glucose (TyG) and liver function parameters (hepatic steatosis index [HSI], alanine transaminase [ALT] and aspartate transaminase [AST]). In the present study, there was no significant difference between the PCOS and the non-PCOS regarding the presence of liver function abnormalities. A model adjusted by age and BMI showed that the upper tertile of TyG index was positively associated with high AST (OR = 3.04 [95% CI: 1.20-7.68], p < 0.05), high ALT (4.76 [3.07-7.36], p < 0.05) and high HSI (8.44 [1.82-39.17], p < 0.05). Although the history of diabetes had a positive impact on elevated AST (1.66 [1.15, 2.40], p < 0.05), the third tertile of TG/HDL-C was associated with increased odds of elevated ALT (3.35 [2.21-5.06]) and HSI (6.55 [1.17-36.46]), whereas the second tertile of TG/HDL-C (OR = 2.65, CI 95%: 1.74-4.03) was also positively associated with elevated ALT. PCOS had no significant association with elevated liver function tests. The highest tertile of TyG index and the TG/HDL-C ratio as a surrogate of IR might play a role in detecting abnormalities of liver function parameters among women. However, PCOS status cannot change the association between IR and liver dysfunction.

Fitz Hugh Curtis Syndrome in a Patient Presenting with Right Upper Quadrant Pain: A Case Report

Aim: Fitz-Hugh-Curtis is a syndrome whose diagnosis may be missed because it is not a common condition and presents with non-specific right upper quadrant pain. In this article, we aimed to analyze the syndrome in a patient presenting with right upper quadrant pain and elevated liver function tests and to draw a road map for differentiation from other diagnoses. Case: A twenty two year old female patient admitted to the emergency department with right upper quadrant pain and fever. She was found to have elevated KCFT in a previous hospital admission and was referred to us for further diagnosis and treatment. Her medical history revealed that her pain started 20 days ago. Physical examination revealed tenderness in the right upper quadrant. Ultrasonography and tomography showed a small amount of fluid in the perihepatic region and 10 cm of fluid in the douglas cavity. No hepatic or biliary pathology was detected. Elevated KCFT was detected in blood results. Since the patient was sexually active and described vaginal secretions, pelvic inflammatory disease was considered and she was consulted to the Gynecology and Obstetrics department. After hospitalization, antibiotherapy was started with piperacillin tazobactam, but the drug was revised due to persistent pain and fever. Despite this, the patient remained symptomatic and laparoscopy was performed for both diagnosis and treatment. The patient was discharged on the 15th day of hospitalization with control recommendations. Conclusion: It is a syndrome that responds well to treatment when diagnosed. It should be considered in patients presenting to the emergency department with abdominal pain and elevated KCFT when no liver pathology is found. When the diagnosis is suspected, consultation with the Gynecology and Obstetrics department is necessary for both identification of the causative agent and treatment arrangement. Screening tests for other sexually transmitted diseases should also be performed in patients with the diagnosis. Key words: Fitz-Hugh-Curtis Syndrome, Perihepatitis Syndrome, Pelvic Inflammatory Disease

Real-world study of pegylated interferon α-2a to treat mycosis fungoides/Sézary syndrome using time to next treatment as a measure of clinical benefit: an EORTC CLTGstudy.

Mycosis fungoides (MF) and Sézary syndrome (SS) are chronic malignant diseases that typically necessitate diverse strategies to achieve remission. Systemic interferon (IFN)-α (subtypes 2a and 2b) has been used to treat MF/SS since 1984; however, its production was recently stopped. The recombinant pegylated (PEG) form of IFN-α-2a remains the only alternative IFN treatment, although it has not been approved for use in MF/SS. To assess the effectiveness and safety of PEG-IFN-α-2a in monotherapy and in combination with other treatments using time to next treatment (TTNT) as a measure of clinical therapeutic benefit in a real-world setting. We conducted an international, multicentre retrospective study of patients with MF and SS (of any stage) treated with PEG-IFN-α-2a from July 2012 to February 2022. Patients were included across 11 centres in 10 countries. The primary endpoints were to determine the TTNT of PEG-IFN-α-2a and adverse events (AEs) in MF/SS. In total, 105 patients were included [mean (SD) age 61 (13.1) years]; 42 (40.0%) had stage IA-IIA and 63 (60.0%) had stage IIB-IVB disease. PEG-IFN-α-2a was combined with other therapies in 67 (63.8%) patients, most commonly with extracorporeal photopheresis (36%) and bexarotene (22%). Patients with stage I-IIA disease achieved an overall response rate (ORR) of 57%; the ORR in those with stage IIB-IVB disease was 51%. Combination treatment resulted in a median TTNT of 10.4 months (range 0.6-50.7) vs. 7.0 months (range 0.7-52.4) for those who received monotherapy (P < 0.01). Overall, the mean (SD) TTNT was 9.2 (10.6) months and the ORR was 53.3% (n = 56). A complete response was seen in 13% of patients and a partial response in 40%. AEs were described in 68.6% (n = 72) of patients. Flu-like symptoms (n = 28; 26.7%), lymphopenia (n = 24; 22.9%) and elevated liver function (n = 10; 9.5%) were the most frequently reported. Grade 3-4 AEs were reported in 23 (21.9%) patients, mostly related to myelosuppression. PEG-IFN-α-2a for MF/SS resulted in an ORR of 53.3% and a mean (SD) TTNT of 9.2 (10.6) months. Combination regimens were superior to monotherapy and doses of 180 µg PEG-IFN-α-2a weekly were related to a higher ORR.

A 12-month randomised controlled trial using intensive dietary interventions for adolescents with obesity associated complications

Adolescent obesity requires effective and accessible intervention options and there is potential for intensive dietary interventions to be used as adjunctive therapy to behavioural weight management for some individuals(1). The aim of this study was to determine the effect of two novel diet therapies, delivered in the as part of an intensive behavioural weight management intervention, in adolescents with metabolic complications associated with obesity. The Fast Track to Health study (HREC/17/SCHN/164; ACTRN12617001630303) was a multi-site 52-week RCT, conducted 2018 – 2023, comparing a very-low-energy diet (800kcal/day) followed by i) an intermittent energy restricted (IER) diet; and ii) a continuous energy restricted diet (CER), for adolescents (13-17years) with ≥1 obesity associated complication. Interventions were delivered as part of an intensive behavioural weight management intervention by a multidisciplinary team2. Anthropometry, body composition and cardiometabolic health were assessed at baseline and week-52. The primary outcome was change in BMI z-score at week-52. Dyslipidaemia was defined as HDL &lt;1.03mmol/L and/or triglycerides ≥1.7mmol/l, and elevated liver function tests (LFTs) as ALT and/or GGT ≥1.5 upper limit of 30U/L3. The difference in BMI z-score between groups at week-52 (±4) was assessed using a t-test. Mixed models was used to investigate changes over time. Descriptive statistics were used to describe participants above and below clinical cut-points at baseline and week-52. In total, 141 adolescents (70 female) were enrolled and 97 (48 female) completed the intervention. At week-52, BMI z-score reduced by −0.23 [95%CI −0.37 to −0.22], BMI expressed as a percentage of 95th percentile reduced by −8.86 [95%CI −12.46 to −7.47] and Fat Mass Index reduced by −1.49 [95%CI −2.36 to −1.08]. There was no significant difference for weight or cardiometabolic outcomes between diet groups. The occurrence of dyslipidaemia was unchanged between baseline and week-52 (n = 60 [43%] and n = 37 [43%] respectively) and a small improvement in the occurrence of impaired LFTs (n = 37 [27%] to n = 15 [17.2%] respectively). There were no differences in change of occurrence of dyslipidaemia or impaired LFTs between intervention groups. These findings suggest that both IER and CER, delivered as part of an intensive behavioural weight management program, are equally effective for improving weight and cardiometabolic outcomes for adolescents with obesity.

A Diagnostic Paradox: Identifying IgG4-Related Disease in a Patient Previously Diagnosed with Sjogren’s Syndrome

We present the case of a 77-year-old male with a history of rectal adenocarcinoma and Sjogren’s disease who was admitted for severely elevated liver function tests. Cross-sectional imaging demonstrated a dilated bile duct, and eventual biopsy of the area showed fibrosis and lymphocytic infiltrate consistent with IgG4-related disease. The patient was treated with rituximab and a prednisone taper. This case discusses the clinical, laboratory, and imaging hallmarks of this rare disease and illustrates the practical challenges of distinguishing it from other rheumatologic conditions.

잠복결핵에 관한 온라인 건강 상담 현황

The study’s objective is to explore the health information needs of latent tuberculosis patients and their communities by analyzing data from the online health counselling platform, Naver Jisik-iN. Initially, 3,261 questions related to ‘latent tuberculosis’ were collected. Following the removal of duplicates and irrelevant image information, the final dataset for analysis comprised 2,198 questions. Text pre-processing, Latent Dirichlet Allocation (LDA) topic modelling, and Long Short-Term Memory (LSTM)-based text summarization model were used. Manual categorization was added to supplement the unsupervised learning process. Seven topics were identified using LDA, from which five specific topics (‘side effects’, ‘treatment’, ‘army’, ‘interaction’, and ‘infectiousness’) were derived. Subsequently, manual classification was conducted based on these five topics. Manual summary and LSTM-based text summarization results were consistent. Numerous individuals sought information about the potential for curing latent tuberculosis and the risk of tuberculosis development. Moreover, questions related to the interpretation of test results and interactions with other substances were widespread. Concerning side effects, issues predominantly revolved around drug discontinuation due to skin problems and elevated liver function tests. The findings reveal the prevalent concerns and inquiries of society regarding latent tuberculosis. The identified topics offer valuable insights into the key aspects of interest related to this condition.

Assessment of aspartate aminotransferase to Platelet Ratio Index and Fibrosis-4 Index score on women with intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy is a pregnancy-related liver condition that is characterized by elevated liver function tests and/or bile acids in the presence of pruritis. The study aimed to assess the aspartate aminotransferase to Platelet Ratio Index and Fibrosis-4 Index scores in intrahepatic cholestasis of pregnancy. The prospective study was carried out by assessing 142 women: 71 whose pregnancies were complicated by intrahepatic cholestasis of pregnancy and 71 without intrahepatic cholestasis of pregnancy. The Fibrosis-4 Index score and aspartate aminotransferase to Platelet Ratio Index were assessed. Our findings indicate that both aspartate aminotransferase to Platelet Ratio Index and Fibrosis-4 Index scores were reliable indicators of intrahepatic cholestasis of pregnancy, correlating with important complications of the condition. This study provides valuable information to help clinicians better diagnose and perform the management of intrahepatic cholestasis of pregnancy.

Association of metal/metalloids exposure with abnormal liver function among occupational population in a mining area of Hunan Province:a prospective study

To investigate the association of metals/metalloids exposure with risk of liver disfunction among occupational population in Hunan Province, and to explore the potential dose-response relationship. In 2017, a mining area in Hunan Province was chosen as the research site, and eligible workers were recruited as study subjects. General demographic characteristics, levels of 23 metals/metalloids in plasma and urine, and liver function index(total bilirubin(TBIL), alanine amino transferase(ALT), globulin(GLB) and γ-glutamyl transferase(GGT)) were obtained by questionnaire, physical examination and laboratory tests. Participants were followed up in 2018, 2019 and 2020 respectively. Cox proportional risk model was used to evaluate the relationship between metal/metalloids exposure and risk of liver disfunction, and dose-response relationship curves were plotted by using the restricted cubic spline function. A total of 891 employees were recruited in the study, 576(65.0%)were aged ≤45 years, 832(93.4%) were male and 530(59.5%) worked as smelters. After adjusting various factors such as age, gender, BMI, type of work, education, smoking, alcohol consumption, diet, stress, medical history, exercise and tea consumption, positive correlations were found between plasma tungsten(HR=4.90, 95%CI 1.17-20.48) and urinary barium(HR=1.07, 95%CI 1.02-1.12) levels with abnormally elevated TBIL levels. Additionally, a significant association was observed between plasma thallium and the risk of elevated ALT levels(HR=11.15, 95%CI 1.97-63.29). Plasma tungsten and thallium, along with barium found in urine, are risk factors for the development of abnormally elevated liver function indices in occupational groups.

Determination of Demographic Liver Health with Giardia lambila Infection Analysis in Diyala

Background: Giardia lamblia infection is known to affect liver function indicators, yet its correlation with demographic factors remains unclear. This study aimed to investigate this relationship, focusing on sex, age, and residence, to better understand the impact of the parasite on liver health. Objective: The objective was to assess the effect of Giardia lamblia infection on liver function indicators and its association with demographic variables such as sex, age, and residence. Method: Blood samples were collected from 48 Giardia-infected patients at Al-Batool Teaching Hospital and Shahraban General Hospital, with 20 healthy individuals serving as controls. Samples were obtained between February and May 2020. The age range of participants spanned from under two years to 12 years. The Giesse diagnostic kit from Italy was employed to measure liver function indicators. A colorimetric method was used to estimate the activity of aminotransferase enzymes (GOT and GPT) and phosphatase enzyme levels. Results: The study found the highest infection rate among 2-4-year-olds, with males exhibiting a higher infection rate compared to females (54.16% vs. 45.839%). Rural areas showed a higher infection rate (56.25%) compared to urban areas (43.75%). Infected children displayed increased levels of aminotransferase enzymes (GOT, GPT, and ALP) compared to the control group. Conclusion: Giardia lamblia infection correlates with elevated liver function indicators, particularly among children aged 2-4 years and males. Additionally, residence in rural areas appears to be a risk factor for higher infection rates. These findings underscore the importance of early detection and intervention strategies to mitigate the impact of Giardia lamblia on liver health, especially in vulnerable populations.

Medical and Psychiatric Characteristics of Patients Hospitalized for Severe Restrictive Eating Disorders: Analysis of 545 Consecutive Patients with Severe Anorexia Nervosa or Avoidant/Restrictive Food Intake Disorder

BackgroundPeople with severe eating and feeding disorders regularly require hospitalization due to complications inherent to their disease, though formal training regarding this care is limited. MethodsThis retrospective study included 545 patients with severe anorexia nervosa (AN) or avoidant restrictive food intake disorder (ARFID) hospitalized in a medical stabilization unit between 2018 and 2021. Biometrics were obtained throughout hospitalization. Nutrition was increased until patients were gaining 0.2 kg/day. ResultsAverage admission body mass index (BMI) was 13 kg/m2 with diagnoses of 46% AN-R (Restricting), 39% AN-BP (Binge-purge), and 15% ARFID. Average daily Kcals by discharge were 3,343 for females and 3,962 for males; 26% required nasogastric feeding. Hypoglycemia was common until day 7, correlated with elevated liver function tests (LFTs) and low prealbumin. LFTs were abnormal in 31% of patients. Refeeding hypophosphatemia developed in 26% of patients starting day 2 and was associated with lower BMI. Hypokalemia appeared on admission among 39%, twice as common in patients diagnosed with AN-BP. Initial EKGs were abnormal in 50% of patients, usually sinus bradycardia. Average QTc was normal, only 14% prolonged. Bone density testing revealed 70% osteoporosis. History of suicide attempt were present in 19% while 76% and 50% presented with anxiety and depressive disorders respectively. ConclusionsGiven the inextricability of medical complications from severe eating and feeding disorders, familiarity among CL Psychiatrists with the prevalence of frequently observed abnormal findings can inform consultation and prevent adverse events, unnecessary intervention, and facilitate weight restoration and medical stabilization.

HELLP Syndrome and Differential Diagnosis with Other Thrombotic Microangiopathies in Pregnancy.

Thrombotic microangiopathies (TMAs) comprise a distinct group of diseases with different manifestations that can occur in both pediatric and adult patients. They can be hereditary or acquired, with subtle onset or a rapidly progressive course, and they are particularly known for their morbidity and mortality. Pregnancy is a high-risk time for the development of several types of thrombotic microangiopathies. The three major syndromes are hemolysis, elevated liver function tests, and low platelets (HELLP); hemolytic uremic syndrome (HUS); and thrombotic thrombocytopenic purpura (TTP). Because of their rarity, clinical information and therapeutic results related to these conditions are often obtained from case reports, small series, registries, and reviews. The collection of individual observations, the evolution of diagnostic laboratories that have identified autoimmune and/or genetic abnormalities using von Willebrand factor post-secretion processing or genetic-functional alterations in the regulation of alternative complement pathways in some of these TMAs, and, most importantly, the introduction of advanced treatments, have enabled the preservation of affected organs and improved survival rates. Although TMAs may show different etiopathogenesis routes, they all show the presence of pathological lesions, which are characterized by endothelial damage and the formation of thrombi rich in platelets at the microvascular level, as a common denominator, and thrombotic damage to microcirculation pathways induces "mechanical" (microangiopathic) hemolytic anemia, the consumption of platelets, and ischemic organ damage. In this review, we highlight the current knowledge about the diagnosis and management of these complications during pregnancy.

So many measures in ERAS protocol: Which matters most?

ObjectivesEnhanced recovery after surgery (ERAS), which includes multiple measures, has gradually become the standard perioperative management in pediatric surgery. However, it is still unclear which of its many measures affects the outcomes more. MethodsWe retrospectively analyzed the medical records of children with congenital choledochal cysts who underwent surgical treatment in a specialized children's hospital from January 2019 to December 2022. Data including baseline factors, implementation of ERAS interventions, postoperative complications, and postoperative length of stay (PLOS) were collected. Univariate and multivariate analyses were performed to identify the association between PLOS and baseline factors or specific ERAS measures. ResultsThe implementation rate of ERAS measures ranged from 5.02% to 100% in 219 cases who underwent 3 to 14 ERAS measures. Univariate analysis showed that body mass index-for-age z-scores, liver function indicators, and postoperative complications were the significant baseline factors for PLOS. At the same time, the measures with the greatest effect on PLOS were early postoperative feeding and early removal of tubes. Multivariate analysis with different models revealed that postoperative complications, early postoperative feeding, and early catheter removal influenced the PLOS the most. ConclusionsA prolonged PLOS was associated with poor preoperative nutritional status, elevated liver function indexes, and postoperative complications. Early postoperative feeding and removal of tubes appeared more likely with a reduced PLOS than other measures, requiring more attention when implementing the ERAS protocol.

Migraine Duration as a Potential Amplifier of Obesity.

Migraine is a complex neurovascular disorder with obesity as a notable risk factor. This study aimed to investigate an under-researched area of the association between migraine duration and body composition. Patients with migraine from a neurology outpatient department were enrolled and were categorized into four groups based on illness duration: 1 year, 1-5 years, 5-10 years, and >10 years. Patient demographics, blood biochemistry, and body composition data were collected and analyzed statistically. Patients with migraine were predominantly female, with lower education levels, significant work stress, poor sleep, and limited exercise. Longer migraine duration corresponded to increased obesity metrics. Notably, those patients with under 1 year of illness showed elevated blood lipid and liver function levels, whereas those with >10 years showed increased weight, waist circumference, body mass index, and fat content, despite higher physical activity. Significant positive correlation between obesity metrics and migraine duration was seen in patients who had migraine for >1 year. Our findings indicate that protracted episodes of migraine could amplify obesity tendencies, underscoring the imperative of weight regulation in migraine intervention to diminish ensuing adiposity-associated hazards.

Madhuca longifolia-hydro-ethanolic-fraction reverses mitochondrial dysfunction and modulates selective GLUT expression in diabetic mice fed with high fat diet.

Metabolic disorder is characterized as chronic low-grade inflammation which elevates the systemic inflammatory markers. The proposed hypothesis behind this includes occurrence of hypoxia due to intake of high fat diet leading to oxidative stress and mitochondrial dysfunction. In the present work our aim was to elucidate the possible mechanism of action of hydroethanolic fraction of M. longifolia leaves against the metabolic disorder. In the present investigation, effect of Madhuca longifolia hydroethanolic fraction (MLHEF) on HFD induced obesity and diabetes through mitochondrial action and selective GLUT expression has been studied. In present work, it was observed that HFD (50% of diet) on chronic administration aggravates the metabolic problems by causing reduced imbalanced oxidative stress, ATP production, and altered selective GLUT protein expression. Long term HFD administration reduced (p < 0.001) the SOD, CAT level significantly along with elevated liver function marker AST and ALT. MLHEF administration diminishes this oxidative stress. HFD administration also causes decreased ATP/ADP ratio owing to suppressed mitochondrial function and elevating LDH level. This oxidative imbalance further leads to dysregulated GLUT expression in hepatocytes, skeletal muscles and white adipose tissue. HFD leads to significant (p < 0.001) upregulation in GLUT 1 and 3 expression while significant (p < 0.001) downregulation in GLUT 2 and 4 expressions in WAT, liver and skeletal muscles. Administration of MLHEF significantly (p < 0.001) reduced the LDH level and also reduces the mitochondrial dysfunction. Imbalances in GLUT levels were significantly reversed in order to maintain GLUT expression in tissues on the administration of MLHEF.

Jaundice-predominant manifestation of Kawasaki disease in children.

A jaundice-predominant presentation of Kawasaki disease (KD) is atypical. A total of 12 children with KD with a predominant manifestation of jaundice at MacKay Children's Hospital were reviewed, along with 42 cases reported in the literature since 1990. The median age of the 12 patients was 1.85 years (range: 3 months-4 years), and 66.6% were male. All of the patients had elevated liver function at presentation, 50% had hydrops of the gallbladder, and almost 60% had gastrointestinal symptoms and signs. Complete KD was evident in 11 of the 12 patients (91.7%), and two patients (16.7%) had recurrent episodes. All of the patients received intravenous immunoglobulin (IVIG); however, one-third were refractory to treatment. Corticosteroids were used in five (41.7%) of the patients. Three (25%) of the patients had shock, and seven (58.3%) had coronary artery abnormalities, of whom one (8.3%) had persistent coronary artery aneurysm and the others recovered. A review of the 42 cases in the literature showed that the children with a jaundice-predominant presentation of KD had high rates of IVIG-refractory disease (25%), coronary artery abnormalities (25%), shock (13.2%), and corticosteroid treatment (24.2%). Children with KD presenting with a jaundice-predominant manifestation are at a higher risk of IVIG-refractory disease, coronary artery abnormalities, and more recurrent episodes. Physicians should be aware of the risk of shock in this population.

Diagnosis and Management of Amanita Phalloides Toxicity in the Emergency Department Observation Unit: A Case Report.

Mushroom toxicity is an important etiology of acute liver injury in a patient with gastrointestinal symptoms. We present the case of a male patient presenting to the emergency department (ED) with gastrointestinal distress who was placed under ED observation for elevated liver function tests. During his hospital course, it was revealed he had consumed wild mushrooms believed to be Amanita phalloides. While mushroom ingestion and subsequent toxicity are rare, a high index of suspicion in foraging hobbyists is essential to arriving at the correct diagnosis and directing the patient to the appropriate management.

Liver damage profile in COVID-19 pregnant patients

IntroductionSARS-CoV-2 unsparingly impacts all areas of medicine. Pregnant women are particularly affected by the pandemic and COVID-19 related liver damage seems to be another threat to maternal and fetal health. The aim of this study is to define liver damage profile including bile acids serum levels in COVID-19 pregnant patients and to determine predictors of disease aggravation and poor obstetrics outcomes.MethodsThis study has been carried out in the Obstetrics and Gynecology Department, at the National Medical Institute in Warsaw, Poland between 01.02.2021 and 01.11.2022 The study cohort comprises 148 pregnant patients with COVID-19 and 102 pregnant controls who has been tested negative for SARS-CoV-2.ResultsCOVID-19 pregnant patients presented liver involvement at admission in 41,9%. Hepatotoxic damage accounted for 27 (19.85%), cholestatic type was diagnosed in 11 (8.09%) and mixed type of liver injury was presented in 19 (13.97%) of patients. Higher serum levels of AST, ALT, GGT, total bilirubin and bile acids as well as mixed type of liver injury at admission were correlated with severe form of an illness. AST and ALT above upper reference limit as well as hepatotoxic type of liver damage predisposed pregnant patients with COVID-19 to poor obstetrics outcomes.ConclusionHepatic damage in pregnant women with COVID-19 is a common, mild, transaminase-dominant, or mixed type of injury, and often correlates with elevated inflammatory markers. SARS-CoV-2 test should be performed as a part of differential diagnosis in elevated liver function tests. Although bile acids serum levels were commonly elevated they seems to be clinically irrelevant in terms of pregnancy outcomes.DaRpyovs-oA9XgYzu_a_v9Video

Phase I and pharmacodynamic study of arsenic trioxide plus radiotherapy in patients with newly diagnosed glioblastoma.

When arsenic trioxide (ATO) was combined with radiation for treatment of transplanted murine gliomas in the brain, tumor response improved with disrupted tumor blood flow and survival was significantly prolonged. Total of 31 patients with newly diagnosed glioblastoma were accrued to a multi-institutional, NCI-funded, phase I study to determine the maximum tolerated dose (MTD) of ATO administered with radiation. Secondary objectives were survival and pharmacodynamic changes in perfusion on magnetic resonance imaging (MRI). Patients (unknown MGMT and IDH status) received ATO either once or twice weekly during radiation without concurrent or adjuvant temozolomide. Median age: 54.9 years, male: 68%, KPS ≥ 90: 77%, debulking surgery: 77%. Treatments were well-tolerated: 81% of patients received all the planned ATO doses. Dose-limiting toxicities included elevated liver function tests, hypokalemia, and edema. The MTD on the weekly schedule was 0.4mg/kg and on the biweekly was 0.3mg/kg. The median survival (mOS) for all patients was 17.7 months. Survival on the biweekly schedule (22.8 months) was longer than on the weekly schedule (12.1 months) (P = .039) as was progression-free survival (P = .004). Similarly, cerebral blood flow was significantly reduced in patients treated on the biweekly schedule (P = .007). ATO with standard radiation is well tolerated in patients with newly diagnosed glioblastoma. Even without temozolomide or adjuvant therapy, the overall survival of all patients (17.7 months) and especially patients who received biweekly ATO (22.8 months) is surprising and accompanied by pharmacodynamic changes on MRI. Further studies of this regimen are warranted.

Polymyositis concomitant with hepatitis B virus infection: Treatment challenges.

Polymyositis is a chronic autoimmune disease that presents with symmetrical progressive proximal muscle weakness. The cause of this disease due to abnormal activation of macrophages that might be associated with systemic diseases such as other autoimmune diseases, malignancy or viral infections including hepatitis B virus. The aim of this case report was to highlight treatment challenges in a patient with polymyositis concomitant with hepatitis B. A 28-years-old man with history of completed hepatitis B treatment with negative viral load presented with symmetrical progressive weakness on both inferior proximal extremities. The patient complained of pain predominantly in both tights and calves. No dermatological manifestation was observed. Elevated muscle enzymes and liver function were observed. Along with the course of the disease, hepatitis B reactivation was discovered as hepatitis B virus DNA was re-detected. Treatment options of this patient (polymyositis concomitant with hepatitis B viral infection) remain challenging. The main treatment of polymyositis consists of high dose methylprednisolone and this immunosuppressant could worsen the hepatitis B virus infection. The patient was finally treated with combination of mycophenolic acid and methylprednisolone for polymyositis and entecavir for hepatitis B. After one month of treatment, the patient showed a clinical improvement. This case highlights that viral screening must be done prior to starting polymyositis treatment as it could concomitant with viral infections such as hepatitis B. Antiviral prophylaxis must be given 1-2 weeks before immunosuppression starts. Management for both polymyositis and hepatitis B is important with entecavir or tenofovir as the optimal agents against hepatitis B virus.