History Of Chronic Alcohol Consumption Research Articles

Chest wall mass as a sign of ignored hepatocellular carcinoma in an alcoholic cirrhotic patient: a case report.

The authors report a case of a 68-year-old male with a history of chronic alcohol consumption who presented with epigastric pain, abdominal distension, and a hard, tender lump on the right posterolateral aspect of his back. Investigation revealed HCC with isolated metastasis to the posterior thoracic wall. HCC usually develops secondary to chronic hepatitis B and C infection in the background of chronic liver disease. Common presenting symptoms of bone metastasis include local pain, neurological manifestations, palpable subcutaneous masses, and pathological fractures. An immunohistochemistry analysis is important to differentiate HCC from non-HCC metastasis in patients without known underlying HCC. Treatment is often directed towards palliative care as the prognosis is poor. An isolated rib mass can be an initial presentation of metastatic HCC. Thus, HCC with bone metastasis should be considered in the differential diagnosis in patients presenting with painful swelling in the thoracic region.

Most patients with severe obesity has liver fibrosis even without Metabolic Syndrome/ A maioria dos pacientes com obesidade grave apresenta fibrose Hepática mesmo sem Síndrome Metabólica

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is a condition commonly associated with metabolic syndrome (MS). This association is frequently found in people with severe obesity, yet some who are diagnosed with NAFLD do not fulfill the criteria for MS. We aimed to compare the clinical and histological characteristics of NAFLD in patients with obesity with and without MS.METHODOLOGY: Cross-sectional study with patients with severe obesity (BMI ≥35kg/m2) diagnosed with NAFLD on liver biopsy during bariatric surgery between Sep/2014 and May/2015.  Patients with a history of chronic alcohol consumption and other liver diseases were excluded. MS diagnosis was based on the International Diabetes Federation criteria. Statistical analyses were performed using Chi-square and t tests. P0.05 were considered significant. RESULTS: The simple included 170 patients with severe obesity with histological diagnosis of NAFLD. The mean BMI (body mass index) was 43.2±5.3 kg/m2; 60% were female and the mean age was 37.1±10.7 years. Dyslipidemia (81.7%) and arterial hypertension (48.2%) were the most frequent NAFLD risk factor associated with obesity in these patients. A total of 75 of them (44.1%) did not meet the criteria for MS. They were younger than those with MS [33.8 (9.9) vs 39.7 (10.8) years; p0.001], and 68.0% (51) of them had nonalcoholic steatohepatitis (NASH) and fibrosis.  CONCLUSION: The results reinforce the relevance to evaluate NAFLD in people with severe obesity, even those without MS. Despite not presenting MS, these patients with severe obesity already had NASH with fibrosis and can potentially evolve to cirrhosis.

A 57-year-old alcoholic woman with soft neck mass

A 57-year-old woman was diagnosed with an anterior cervical mass (figure 1). No peripheral neuropathy or cervical lymph nodes were detected from the physical examination. The mass has slowly and painlessly grown for 30 years with no dyspnea or dysphagia. She had a history of chronic alcohol consumption and heavy tobacco use for 25 years. No standard medications were taken.
 Multiple symmetric lipomatosis is a disease characterized by the accumulation of multiple, benign, symmetric, and nonencapsulated fatty tissue masses. This is more common in males (15:1) and in the Mediterranean population. Malignancy is rarely observed in this case. Masses can be found on the head and neck, including the upper trunk, shoulders, upper back, mediastinum, perineum, scrotum, and tongue. Besides the aesthetic effects, masses can cause airways or digestive compressive symptoms, as well as limitations in head or neck movements, urinating, or sexual intercourse. The involvement of peripheral nerves can cause neurological symptoms.
  
 Alcohol abuse has been long associated with this disease.  A genetic cause has been suggested, but a hereditary pattern has not been identified in most cases. A link was suggested with liver disease, but there is no mention of liver abscess in the literature.
  
 The diagnostic is based on image finds. Solitary lipoma is a benign soft tissue tumor, rarely found in the neck region. It mostly occurs in females and obese patients, and it is enclosed by a fibrous capsule that helps to differentiate it from other fat aggregations. Liposarcoma represents 1% of neck and head sarcomas. Patients are mostly men and the medium age is 70 years. Familial multiple lipomatosis is a rare autosomal dominant disease that is manifested in the thirties and is more prevalent in females (2:1). In this case, the discrete multiple subcutaneous nodules are movable, painless, and soft and have no associated conditions.
  
 Lipectomy is the concerned treatment, but recurrence is common. Liposuction is an alternative to extensive lipectomy. No medicinal therapy is effective; however, alcohol abstinence can reduce the recurrence frequency.
  
 Clinics must be aware of this uncommon disease in order to diagnose it and treat it appropriately.
  
 Statement of Ethics
 Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
  
 Conflict of Interest Statement
 The authors have no conflicts of interest to declare.
  
 Funding Sources
 The authors had no funding sources in the preparation of data or the manuscript.

Abstract- Poster

Marchiafava - Bignami disease is a progressive alcoholism related neurologic disease characterized by corpus callosum demyelination, necrosis and subsequent atrophy which occasionally occurs in non alcoholics but chronically malnourished. Among the many brain alterations promoted by chronic ethanol consumption, brain shrinkage due to cortical atrophy is the most striking one, it is related to alcoholic dementia and to atrophy of the corpus callosum. Although clearly dependent on age, brain shrinkage is more intense among heavy drinkers. MBD is a rare complication of chronic alcoholism and malnutrition which is most prevalent in men between 40 and 60 years of age. We are presenting here a case of 32year old alcoholic came to us with chief complaints of memory disturbances, decreased selfcare, decreased interaction with family members, provoked anger, sleep disturbances and disoriented to time and place for 2 months, with history of chronic alcohol consumption. A provisional diagnosis of Delirium was made and started him on Tab. Haloperidol 1.5 mg HS, T. Pregabalin 75 mg BD, T. Memantine 5mg OD, Thiamine and folic acid supplements for 7 days which showed no improvement in symptoms, on imaging found to have thinning of Corpus Callosum.

Impact of Short-term Exercise Program on Functional Independence in Patient with Hydropneumothorax: A Case Study

Background: Hydro-pneumothorax is a rare variant of pneumothorax. It occurs when both free fluid and air is present within the pleural space. The goal of the treatment is to relieve the pressure on the lung, allowing it to re-expand. Treatment options may involve solely observation or needle aspiration or intercostal tube drainage (ICD), along with antibiotic cover, all of this anchored with physiotherapeutic management.
 Case presentation: A 54 years old male visited hospital with complaints of dyspnea (MMRC grade II), dry cough and high-grade fever since one month along with a history of chronic alcohol consumption and tobacco chewing since more than 10 years.
 Investigations: Laboratory investigations include Chest X-ray which showed fairly large opacities with fluid level in right side. The costo-phrenic angle on the right side was obliterated, multiple small patchy opacities are also seen in right lower zones. Along with these findings, there was contralateral mediastinal shift.
 Treatment: Physiotherapy intervention included patient education, breathing retraining, airway clearance techniques, positioning, walking program with supplemented oxygen and psychological support. Outcome measures have shown improvement in functional independence and performance of activities of daily living.
 Conclusion: Physiotherapy management showed efficient results in improving the lung function, quality of life, inducing relaxation and early return to pre-disease life in patient with hydro pneumothorax.

Tuberculosis peritoneal, un diagnóstico diferencial para ascitis en cirrosis

Se presenta el caso de un paciente con antecedente de consumo crónico de alcohol, que consultó por dolor abdominal inespecífico, fiebre intermitente no cuantificada y pérdida de peso, con posterior aumento del perímetro abdominal. Se encontró ascitis y hallazgos en imágenes que sugerían cirrosis. El estudio del líquido ascítico fue no hipertensivo con predominio de linfocitos y niveles de adenosina-desaminasa (ADA) elevados. La ecografía y tomografía de abdomen mostraron el engrosamiento del peritoneo y la biopsia peritoneal por laparoscopia fue compatible con enfermedad granulomatosa, con reacción en cadena de la polimerasa (PCR) positiva para Mycobacterium tuberculosis en un paciente sin otras causas de inmunosupresión. Este caso muestra la necesidad de mantener una alta sospecha clínica de TB en patologías abdominales con clínica inespecífica, aun en pacientes sin inmunocompromiso claro.

Alcohol dependence running in a family.

Etiopathogenesis of alcohol dependence syndrome is complex. Multiple interrelated and interacting factors are implicated in causation of alcohol dependence. Family history of alcoholism has been implicated as one of the key risk factors for developing alcohol dependence. Alcohol dependence syndrome is known to run in families, and this familial type of alcoholism has different clinical profile including earlier age of onset of drinking[1] and more severe pattern of drinking.[2] We present a case of alcohol dependence syndrome in family in which alcohol dependence is present in their four generations. A 43-year-old, Hindu, woman educated up to 10th standard, married for 26 years, working as a saloon owner for 10 years, was brought by husband and son-in-law to psychiatry outpatient department with chief complaints of excessive consumption of alcohol since last 2 years, irritable aggressive behavior toward family, decreased concentration at work, and generalized weakness. The patient was apparently alright 2 years ago when due to worries of downsizing of her work due to competition along with worries about her injured son in road traffic accident she started feeling increasingly overwhelmed and helpless about her situation. After the consumption of alcohol in one marriage ceremony, she felt better and relieved of her stressful emotions. After that she started consuming alcohol quite regularly to get relieved of her stress. She gradually increased her consumption of alcohol. She also had decreased concentration at her workplace and increasingly irritable behavior toward her family members. She was noticed and confronted by her husband about her alcohol consumption after which she stopped alcohol consumption for few months and restarted again after that due to irresistible craving. Due to lockdown, she faced unavailability of alcohol after which she involved her son into her alcohol drinking behavior where son used to procure alcohol and bring it to home for his mother and in return son would also get his share of alcohol. Gradually, son also became alcohol dependent. In the last 2 months, consumption of both patient and her son increased to 360 ml of vodka per day each and their drinking pattern also became eye opener type. Their increased consumption of alcohol and behavioral issues related to it was noticed by patient's husband. They were taken to some private psychiatrist but with no improvement. Finally, the patient and her son were brought to our OPD. On further enquiry, there was no significant medical or surgical history, but in family history, patient's mother had a history of chronic alcohol consumption and passed away due to liver failure complications. Furthermore, patient's maternal grandmother had a history suggestive of alcohol dependence. On mental status examination of both patient and her son, apart from mild-to-moderate withdrawal symptoms of alcohol and craving for alcohol other examination was normal. Diagnoses of alcohol use disorder were made in both patient and her son. Both were started on tablet clordiazepoxide 25 mg QID which was later down titrated and stopped. Furthermore, thiamine supplement along with other symptomatic management was given. Motivational enhancement therapy along with family therapy was given to both the patient and her son, currently both are maintaining well with regular follow-ups. The presence of family history of alcohol dependence is a key predictor of development of alcohol dependence in an index person. Researchers have noted that the odds of alcohol dependence increased by 167% when first, second or third degree relative was affected by alcohol dependence.[1] However, this familial effect encompasses both genetic effect and intrafamilial environmental effect. Genetic component plays a significant part in heritability of alcohol dependence syndrome. Twin studies and adoption studies showed this heritability to be 0.49.[3] Some studies have also found out specific genes related to alcohol dependence syndrome such as GABRA2[4] and ADH1B.[5] Other theories supporting inheritability of alcoholism implies that alcoholic behavior is inherited primarily by inheritance of predisposing personality type or inheritance of the metabolism pathways of alcohol which is also under genetic control.[6] However, familial and cultural factors also have been shown to be equally important in causation of alcohol dependence syndrome[7] as these are the factors which actually determine whether person actually consumes alcohol or not. These factors may include decreased intrafamilial communication, decreased parental monitoring, intrafamilial conflicts, and harsh parenting practices.[89] Clinically, familial alcohol dependence also differs from nonfamilial alcohol dependence patients in that they have young age of onset, more sever dependence, childhood history of hyperactivity and conduct disorder, and adulthood antisocial behavior.[10] Thus, from the current evidence, it can be definitely suggested that those who have family history of alcohol dependence are vulnerable for developing alcohol dependence themselves and should approach drinking alcohol more cautiously. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Multiple symmetric lipomatosis with vulvar involvement: a rare case report associated with walking difficulty and urination disorder

Multiple symmetric lipomatosis (MSL)—a rare metabolic condition characterized by diffuse, nonencapsulated, painless fat deposits—remains a challenging condition to treat. In addition, the clinical manifestation of MSL in women has not been fully understood due to the male-dominated prevalence of the disease. Here, we report a rare case of MSL with vulvar involvement and provide a review of the literature to increase the understanding of both the diagnosis and treatment of the disease. A 46-year-old Japanese woman, who had a history of chronic alcohol consumption for over 20 years, presented with bilateral giant enlargement of the labia major and complained of difficulty in walking and urination. Magnetic resonance imaging revealed nonencapsulated fat deposits involving the vulvar region and extending around the rectum. The patient underwent pubic lipectomy followed by episioperineoplasty, which resulted in a good esthetic outcome with sufficient patient satisfaction. The morphological presentation of MSL in women is different from that in men, and clinical expression of MSL in the vulvar region is rare but cannot be overlooked owing to the potential of serious sequelae such as walking difficulty, urination disorder, and sexual dysfunction. In such cases, lipectomy followed by episioperineoplasty is indicated for the treatment of the condition and its sequelae, while ensuring less chance of relapse and better esthetic outcome compared with other treatment strategies.Level of evidence: Level V, therapeutic, diagnostic, risk/prognostic study.

Impact of systemic treatment associated to radiotherapy on quality of life in locally advanced head and neck cancer patients in Brazil: Prospective real-world data study.

e17563 Background: the purpose of this study was to compare quality of life (QoL) and overall survival (OS) in patients with locally advanced head and neck cancer treated with radiotherapy only (RT), chemoradiotherapy with cisplatin (CT-RT) or RT with cetuximab (CET-RT). Methods: in this real-world, multi-institutional and prospective study, QoL outcomes were assessed using EORTC QLQ-C30 and QLQ-H&N43 questionnaires. Patients were treated according to each participating institution’s protocol. The Item Response Theory was used to generate a global QoL score, based on the 71 questions of both forms. Questionnaires were completed before treatment and every three months, thereafter. Survival was calculated using the Kaplan-Meyer method, and groups were compared by the log-rank test. The impact of the treatment modalities on QoL was analyzed using multivariate regression analyses. Results: Six hundred and twenty-six patients, with tumors located at the oral cavity (36%), oropharynx (30%), larynx (21%), hypopharynx (9%) and nasopharynx (4%) were included. Median follow up was 10.2 months. RT was delivered to 39% of the patients while 58% received CT-RT and 3% received CET-RT. Patients submitted to surgery were not included. OS was higher when systemic treatment was added to RT (median OS CET-RT: 21.9 months and CT-RT: 24.3 months, versus 14.2 months with RT, p < 0.05). A decrease in QoL during treatment was observed in all patients’ groups, but CT-RT had a statistically significant negative impact on QoL when compared to CET-RT (p = 0.02). An important limitation of the study is the low number of patients that received this last treatment modality, what is, probably, a result of local policies on reimbursement. Other factors that influenced QoL were alcohol consumption (better QoL for patients with no history of chronic alcohol consumption, p = 0.007) and radiotherapy technique (better QoL for patients treated with intensity-modulated RT, when compared to conformal RT, p < 0.001). Conclusions: We observed, as expected, better OS with systemic therapy, when associated to RT. A decrease in QoL was detected, as well, during treatment, but a less pronounced decrease was seen in patients receiving CET-RT, when compared to CT-RT. More studies are needed to confirm the QoL improvement in patients submitted to this last treatment approach.

Genetics of nonalcoholic fatty liver disease in Asian populations

Nonalcoholic fatty liver disease (NAFLD) is characterized by the accumulation of fat in the liver without any history of chronic alcohol consumption. It encompasses a wide spectrum of diseases that range from simple steatosis to nonalcoholicsteatohepatitis. NAFLD is strongly associated with obesity, insulin resistance / type-2 diabetes mellitus and the metabolic syndrome. NAFLD is a complex disorder; environmental and genetic factors interact with NAFLD manifestation and determine its progression. In this review, an attempt was made to provide current information on the genetic variants of NAFLD in Asian populations. Literature search was performed by using PubMed, Medline and Google Scholar database. Candidate gene, validation and genomewide association studies (GWASs) were included in this review. A total of 41 studies fulfilled inclusion criteria of which 12 candidate gene studies exclusively focussed on the PNPLA3 gene and 17 other studies on other important candidate genes such as NCANCILP2, PPARG,AGTR1, FABP1, APOC3 etc. reported significant association with NAFLD. Eight validation studies identified associations of variants on PNPLA3, LYPLAL1, TM6SF2, ADIPOR2, STAT3, GCKR, SAMM50 etc. with NAFLD. Thus, so far, four GWASs have been conducted in Asian population that reported PNPLA3, SAMM50, PARVB and GATAD2A genes which were significantly associated with NAFLD. Findings indicate that PNPLA3, APOC3, PPARG, NCAN and GCKR genes emerge out to be the important biological markers associated with NAFLD.

“Interferent Detect” on the Intoxilyzer® 8000C in an individual with an elevated blood acetone concentration due to ketoacidosis

ABSTRACTA 72-year-old male was arrested for impaired driving. He had a history of chronic alcohol consumption and limited food intake on the day of his arrest. The Intoxilyzer® 8000C provided the following communication messages during testing: “Interferent Detect”, “Invalid Sample” and then an additional “Interferent Detect.” This information from the Intoxilyzer® 8000C prompted a medical investigation. The individual was taken to the hospital where ketoacidosis was part of the medical diagnosis. Blood samples were collected and analyzed at two hospital laboratories and the Centre of Forensic Sciences. The results from the hospital analyses were serum ethanol concentrations of 172 and 161 mg/100 mL and an acetone concentration of 18 mg/100 mL; the results from the forensic analyses were blood ethanol, acetone, isopropanol and beta-hydroxybutyrate concentrations of 139 mg/100 mL, 21 mg/100 mL, <5 mg/100 mL and 468 mg/L, respectively.

Alcohol Consumption and Nutrition Facts in Breast Cancer: From a Case

A 53-year-old female presents a nodule in the right breast's external inferior quadrant since one month ago, fixed in the subcutaneous tissue and painful. No lymphadenopathy is present in the armpit. She has a personal history of chronic alcohol consumption of 100 mg per week, with a pattern of weekend consumption. Her body mass Index is 33, and she follows a little varied diet, rich in fast food and scarce in vegetables. There is no family history of breast cancer, previous rheumatic diseases, early menopause or other risk factors for breast cancer.

Effects of chronic alcohol consumption on long-term outcomes of thalamic deep brain stimulation for essential tremor

The prevalence of essential tremor (ET) is about 4% above 40years of age. Chronic alcohol consumption is present in around 20% of patients with ET. Our objective was to identify whether chronic alcohol consumption was associated with a negative effect on tremor outcome after thalamic deep brain stimulation (DBS) in ET patients. We conducted a retrospective chart review, from January 2005 to December 2012, from which 23 patients who had ventral intermediate nucleus (Vim)-DBS surgery for ET were identified. Seven patients had a positive history of chronic alcohol consumption. We defined as chronic alcohol users those patients with a habit of drinking alcohol every day in order to suppress tremor. In the overall group of 23 patients, there was a reduction in the median tremor score from 8 pre-operatively, to 1 post-operatively (p<0.0001). The alcohol consumers group experienced a reduction in the median tremor score from 6 pre-operatively to 0 post-operatively (p=0.03). The non-alcohol consumers group had a reduction in the median tremor score from 8 pre-operatively to 1.7 post-operatively (p<0.0001). Both groups of patients experienced significant benefit from thalamic DBS. A larger study may reveal statistically significant differences between subgroups.

A Not-So-Groovy Masquerader: A Case Report of Groove Pancreatitis

Background: Groove pancreatitis is an uncommon and under-recognized form of focal chronic pancreatitis of the area between the pancreatic head and duodenum due to obstruction of pancreatic juice flow in the minor duct. This disease entity creates a diagnostic challenge as clinical, radiographic, and gross pathologic features can mimic pancreatic adenocarcinoma. Case: A 54-year-old male former-smoker with a history of chronic alcohol consumption presented initially with refractory pyrosis and nausea. Esophagogastroduodenoscopy (EGD) demonstrated duodenal wall thickening and a CT scan of his abdomen revealed duodenitis and inflammation of the pancreatic head with fat stranding. He re-presented three years later with worsening epigastric pain and a 60 pound weight loss. Repeat CT scan revealed an infiltrating heterogeneously enhancing process between the descending duodenum and pancreatic head (Figure 1). Magnetic resonance cholangiopancreatography (MRCP) revealed a 2.7 x 2.3 x 2.3cm mass with soft tissue infiltration and narrowing of the distal common bile duct (CBD) concerning for possible malignancy. CA 19-9 and liver function tests were within normal limits. Continued abdominal pain, intolerance to oral intake, persistent nausea and vomiting, and continued weight loss lead to endoscopic ultrasound (EUS). This demonstrated diffuse pancreatic head and genu parenchymal abnormalities, a 10mm CBD, and enlarged peripancreatic lymph nodes. Repeat MRCP on subsequent admission again revealed focal groove-centric changes of acute and chronic pancreatitis with duodenal wall thickening. EGD/EUS with duodenal biopsies demonstrated focal duodenitis with prominent Brunner glands and fine needle aspiration of the mass revealed cellular atypia and chronic inflammation consistent with chronic pancreatitis and a diagnosis of groove pancreatitis was established.Figure 1Discussion: Groove pancreatitis poses a diagnostic challenge due to its malignancy-like presentation and clinical course. Many of the described risk factors and classical findings of groove pancreatitis were present in our patient including chronic tobacco and alcohol use, severe weight loss secondary to duodenal stenosis, sheet-like mass lesion in the periduodenal space, and prolonged time to diagnosis. However, his clinical course demonstrates the complex nature of this disease process, the close resemblance to pancreatic malignancy, and the difficulty in differentiating these two conditions to arrive at a diagnosis.

Pseudoparallel Channel Sign on Ultrasonography in Alcoholic Hepatitis

A 27-year-old male presented with yellowish discoloration of eyes and urine for 1 month with a history of hematemesis 1 month back. He had history of chronic alcohol consumption, of around 80–100 g/day ethanol for last 8 years with last intake 20 days ago. Physical examination revealed pallor, deep icterus, hepatomegaly of 5 cm below right costal margin, smooth and mildly tender and a hepatic bruit on auscultation. There was no splenomegaly and free fluid in the abdomen. Hemoglobin was 8.7 g/dL, total leukocyte count 16,000/mm3, platelet count 174,000/mm3, and prothrombin time was 18 s prolonged with an INR 2.22. Liver function tests revealed total bilirubin of 15 with a conjugated fraction of 8 mg/dL with aspartate aminotransferase level of 223 IU/mL, alanine aminotransferase of 69 IU/mL, alkaline phosphatase of 135 IU/mL and serum albumin of 2.6 g/dL. His renal parameters were normal. His viral markers (hepatitis B surface antigen and antibody to hepatitis C virus) were negative. Upper gastrointestinal endoscopy showed grade II–III esophageal varices with cherry red spots for which variceal band ligation was performed. His Maddrey's discriminant score was 97.8 and model for end stage liver disease score was 27. His ultrasound showed large liver with irregular surface, heterogenous echotexture and splenomegaly. Ultrasonography also demonstrated the findings, which were suggestive of alcoholic hepatitis. The findings are shown in Figures 1–4. Figure 1 Ultrasound of liver showing parallel tubular structures adjacent to each other (pseudoparallel channel sign). Figure 2 Duplex Doppler ultrasound shows the color flow in each of the tubular structure. Red color in the dilated intrahepatic artery and blue color in portal venous branch (pseudoparallel channel sign). Figure 3 Pulsed Doppler waveform is seen in the portal venous branch within the liver. Figure 4 Pulsed Doppler waveform is seen in the left hepatic artery branch within the. Ultrasound of liver showed parallel tubular structures adjacent to each other [pseudoparallel channel sign (PPCS), Figure 1]. Duplex Doppler ultrasound also demonstrated the color flow in each of the tubular structure. Dilated intrahepatic artery demonstrated red color, while portal venous branch showed blue color (Figure 2). Pulsed Doppler waveform was seen in the portal venous branch (Figure 3) and in the left hepatic artery branch within the liver (Figure 4). The sonographic findings of parallel tubular structures in alcoholic hepatitis have been observed in the past resembling the parallel channel sign seen in obstructive jaundice.1–3 This entity of intrahepatic artery dilation has been termed as PPCS by Sumino and coworkers.4 The parallel tubular structures in this entity are formed by a dilated hepatic arterial branch and an adjacent branch of the portal vein. Hepatic arterial buffer response is an intrinsic regulatory mechanism of the liver to maintain total hepatic blood flow when portal perfusion decreases. Increased hepatic arterial blood flow mediated by adenosine washout in the portal triad compensates for the reduced portal blood flow. Histologic studies demonstrate the presence of dense sinusoidal collagen deposits in patients with acute alcoholic hepatitis. The sinusoidal collagen causes increased sinusoidal resistance, impeding blood flow through the hepatic sinusoids. Ultimately, sinusoidal pressure builds until portal blood flow is compromised in a retrograde manner, with marked reduction in portal venous perfusion of the sinusoids. The reciprocal response of hepatic arterial blood flow to reduction in portal venous perfusion is well established. To preserve perfusion to the liver, compensatory dilation of the hepatic artery occurs with subsequent increase in hepatic artery flow. Angiography of hepatic arteries in alcoholic hepatitis demonstrate elongated, stretched and tortuous arteries.5 The marked increase and tortuosity of the hepatic artery is responsible for the characteristic systolic bruit heard on auscultation of the liver surface.6 A significant decrease in the hepatic artery resistive index is seen in acute alcoholic hepatitis compared to controls and chronic viral hepatitis. Ethanol itself may be responsible for hepatic artery dilatation as it has been seen in chronic alcoholic patients without liver damage.7 However progression of alcoholic hepatitis to cirrhosis profoundly impairs the hepatic arterial responsiveness as a result of fibrosis with vascular distortion.7 However coefficients of interobserver and intraobserver variability ranged from 5.2% to 10.1% in this study. Sumino et al observed this finding of PPCS in 90% of patients with acute alcoholic hepatitis and in 23% of patients with other than alcoholic liver disease. However it was not detected in nonalcoholic liver disease and healthy individuals. Liver biopsy was available in 51 patients with alcoholism and PPCS gave a sensitivity of 82%, specificity of 87% and diagnostic accuracy of 84% in diagnosing acute alcoholic hepatitis.4 Sumino et al studied this finding also in Japanese group of patients.8 Duplex Doppler ultrasound modality has been used to study the hemodynamics within the hepatic artery in patients with acute alcoholic hepatitis.9 The mean hepatic artery diameter is larger in patients with acute alcoholic hepatitis than in those with cirrhosis and healthy controls. Peak systolic velocity is higher and mean resistive index is lower in acute alcoholic hepatitis compared to cirrhosis and healthy controls.9 There was no correlation between the Duplex Doppler ultrasound parameters and the severity of liver disease as assessed by Maddrey's discriminant function. The clinical significance of this finding has not been studied however it does demonstrate the pathophysiological alterations in acute alcoholic hepatitis and may serve as a diagnostic sonographic finding in patients with alcoholic hepatitis.

Transaminase [alanine aminotransferase (ALT) and aspartate aminotransferase (AST)] Activity of HIVFemale Patients on Drugs and Female Patients Not on Drugs

Elevated serum transaminase (alanine aminotransferase (ALT) and aspartate aminotransferase (AST)) levels have been reported in human immunodeficiency virus (HIV)-infected patients on combination antiretroviral therapy (cART). 100 female patients referred to Virology department of the Jos University teaching Hospital (JUTH), were randomly selected by their physicians on the basis of the following criteria: documented HIV infection, no alcohol abuse (≤ 20 g alcohol daily and no history of chronic alcohol consumption), no history of hereditary and autoimmune liver disease, no evidence of hemochromatosis. Patients with any contraindication for liver biopsy were excluded. Data on demographics, drug or alcohol use, and history of liver diseases were obtained at first visit. Subjects were then classified into control (30), HIV-infected; not on drugs (35) HIV-infected; on drugs (35);a month-by-month documentation of the prescribed drug combination for patients who started medication, provided an avenue for calculating each patient's individual cumulative drug exposure. The test for HIV antibodies, HBsAg were carried out on day one (at first visit) serum ALT and serum AST were determined three (3) months after detection (day 90; after HIV antigen confirmatory test). Thirty-five (35) patients started medication at day one and 35 decided not to start medication until after confirmatory test (three months later).The serum ALT levels of the HIV infected patients on drugs (M=43.94, SD=4.30) was significantly higher than the serum ALT levels of the control group (M=29.17, SD=6.17), t (63) = 10.72, p < .0001 at p <.005 confidence level. In a similar trend, the serum ALT levels of the HIV infected patients not on drugs (M=41.17, SD=2.06) was significantly higher than the serum ALT levels of the control group (M=29.17, SD=6.17), t (63) =10.05, p < .0001 at p <.005 confidence level. On comparison, the serum ALT levels of the HIV infected patients on drugs (M=43.94, SD=4.30) was significantly higher than the serum ALT levels of the HIV infected patients not on drugs (M=41.17, SD=2.06), t (68) = 3.44, p < .0001 at p <.005 confidence level. The serum AST levels of the HIV infected patients on drugs (M=44.54, SD=4.85) was significantly higher than the serum AST levels of the control group (M=32.23, SD=5.93), t (63) =9.21, p < .0001 at p <.005 confidence level. In a similar manner, the serum AST levels of the HIV infected patients not on drugs (M=39.91, SD=1.67) was significantly higher than the serum AST levels of the control group (M=32.23, SD=5.93), t (63) =7.33, p < .0001 at p <.005 confidence level. On comparison, the serum AST levels of the HIV infected patients on drugs (M=44.54, SD=4.85) was significantly higher than the serum AST levels of the HIV infected patients not on drugs (M=39.91, SD=1.67), t (68) = 5.34, p < .0001 at p <.005 confidence level.A correlation plot between ALT and AST levels showed a non-significant correlation between these transaminases in the three groups. Control group (r = 0.098, p < 0.05), HIV (+ve), and HBV (-ve) patients on drugs (r = -0.038, p < 0.05), HIV (+ve), and HBV (-ve) patients not on drugs (r = 0.201, p < 0.05).It has been observed from the study that a significant elevation of liver transaminase levels (ALT and AST) is a serious risk factor associated with management of HIV management with drugs.

Transaminase [alanine aminotransferase (ALT) and aspartate aminotransferase (AST)] Activity of HIV and HBV Co-Infected Female Patients on Drugs and Female Patients Not on Drugs

Human immunodeficiency virus-1 (HIV) and hepatitis B virus (HBV) co-infection is a major threat, especially to liver damage. 100 female patients referred to Virology department of the Jos University teaching Hospital (JUTH), were selected by physicians on the basis of the following criteria: documented HIV infection, no alcohol abuse (≤ 20 g alcohol daily and no history of chronic alcohol consumption), no history of hereditary and autoimmune liver disease, no evidence of hemochromatosis. Data on demographics, drug or alcohol use, and history of liver diseases were obtained at first visit. A month-by-month documentation of the prescribed drug combination allowed a calculation of each patient's individual cumulative drug exposure. Subjects were then classified into control (30), co-infected; on drugs (35) and co-infected; not on drugs (35). The test for HIV antibodies, HBsAg were carried out on day one (at first visit) serum ALT and serum AST were determined three (3) months after detection (day 90; after HIV antigen confirmatory test). Thirty-five (35) patients started medication at day-one, and 35 decided not to start medication until after confirmatory test (three months later).The serum ALT levels of the HIV-HBV co-infected patients on drugs (M=43.60, SD=1.83) was significantly higher than the serum ALT levels of the control group (M=29.17, SD=6.17), t (63) =12, p< .0001 at p <.05 confidence level. In a similar trend, the serum ALT levels of the HIV-HBV co-infected patients not on drugs (M=37.74, SD=3.70) was significantly higher than the serum ALT levels of the control group (M=29.17, SD=6.17), t (63) =6.5, p< .0001 at p <.05 confidence level. On comparison, the serum ALT levels of the HIV- HBV co-infected patients on drugs (M=43.60, SD=1.83) was significantly higher than the serum ALT levels of the HIV-HBV co-infected patients not on drugs (M=37.74, SD=3.70), t (68) =8.40, p< .0001 at p <.05 confidence level. The serum AST levels of the HIV-HBV co-infected patients on drugs (M=43.54, SD=2.74) was significantly higher than the serum AST levels of the control group (M=32.23, SD=5.93), t (63) =10, p< .0001 at p <.05 confidence level. In a similar manner, the serum AST levels of the HIV-HBV co-infected patients not on drugs (M=37.66, SD=2.11) was significantly higher than the serum AST levels of the control group (M=32.23, SD=5.93), t (63) =5.1, p< .0001 at p <.05 confidence level. On comparison, the serum AST levels of the HIV-HBV co-infected patients on drugs (M=43.54, SD=2.74) was significantly higher than the serum AST levels of the HIV-HBV co-infected patients not on drugs (M=37.66, SD=2.11), t (68) =10.07, p< .0001 at p <.05 confidence level. HIV-HBV infection causes liver damage with more damage caused by drugs taken to manage these infections. A correlation analysis between ALT and AST levels shows a non-significant correlation.

Pellagra Encephalopathy in the Context of Alcoholism: Review and Case Report

The aim of the study was to review and describe the Alcoholic Pellagra Encephalopathy, a severe neuropsychiatric condition caused by a combination of niacin (vitamin B3) deficiency and alcohol abuse. PsychInfo, Medline and Embase databases were searched for peer-reviewed studies addressing this illness. A historical and conceptual review of the psychopathological aspects of this condition is offered, followed by the report of a patient with a history of chronic alcohol consumption showing signs of pellagra, delusions and visual hallucinations, which was treated successfully with niacin. Pellagra encephalopathy should still be considered in the differential diagnosis of acute psychotic disorders seen in the context of chronic alcoholism.

Overwhelming Sepsis after a Cat Bite

In mid-June, a 52-year-old man presented to the emergency department with fever, chills and a rapidly progressing erythema on his right hand without regional lymphadenopathy, a few days after being bitten by his domestic cat. The patient resided in a rural area and had a history of chronic alcohol consumption. The cat lived primarily outdoors and its immunization status was unknown. Pasteurella multocida cellulitis was suspected, oral amoxicillin-clavulanate was prescribed and the patient was discharged. Three days later, the cellulitis regressed completely but the patient sought medical attention for persisting fever and new-onset jaundice and dyspnea. On physical examination, he was hypotensive, exhibited hepatosplenomegaly and presented a centimetric necrotic ulcer on his right hand. The patient’s hematological results revealed leukopenia, thrombopenia and an elevated international normalized ratio. His biochemistry results revealed acute renal and liver failure. His chest radiograph was normal. The patient’s condition rapidly deteriorated to septic shock and multiple organ failure. He required mechanical ventilation, vasopressive support and renal replacement therapy. Intravenous piperacillin-tazobactam and vancomycin were empirically started; he was transferred to a tertiary care hospital the next day. On arrival to the intensive care unit, a septic workup was repeated and the patient’s hand ulcer was surgically debrided and tissue was sent for culture. Antibiotic treatment was switched to intravenous meropenem and vancomycin for sepsis of unknown origin. The patient developed further ascites. A percutaneous cholecystostomy was performed for suspected acalculous cholecystitis. The bile and the cloudy ascitic fluid were also cultured. Despite aggressive medical therapy, the patient’s condition failed to improve during the following two days and the family decided not to further pursue active treatments. At the time of the patient’s death, viral hepatitis serology and all bacterial cultures were negative. The following day, the aerobic blood cultures showed small Gramnegative coccobacilli. What is the diagnosis? DIAGNOSIS After four days of incubation, the plates of aerobic blood cultures grew small grey colonies on chocolate agar and on initial sheep blood agar. The same isolate was identified in all other specimens (necrotic ulcer, bile, ascites and endotracheal secretion). Laboratory technicians were instructed to handle the plates inside the biosafety cabinet because Francisella tularensis was suspected. The Gram stain of the colonies showed the same tiny Gram-negative coccobacilli. The organism was tetramethyl-oxidase negative, weakly catalase positive and nonmotile. The isolate was sent to the provincial reference laboratory, which confirmed the identification of F tularensis. Following the postmortem diagnosis, an investigation headed by the regional public health agency revealed that the cat was still in good health and its serology for F tularensis was negative. Other domestic and wild animals in the area also tested negative. There were no other cases of tularemia reported in the region during the rest of the summer. Nevertheless, informational pamphlets on tularemia were distributed to local small game hunters and warnings were published in regional newspapers to increase public awareness. DISCUSSION

Assessing nonresponse bias at follow-up in a large prospective cohort of relatively young and mobile military service members

BackgroundNonresponse bias in a longitudinal study could affect the magnitude and direction of measures of association. We identified sociodemographic, behavioral, military, and health-related predictors of response to the first follow-up questionnaire in a large military cohort and assessed the extent to which nonresponse biased measures of association.MethodsData are from the baseline and first follow-up survey of the Millennium Cohort Study. Seventy-six thousand, seven hundred and seventy-five eligible individuals completed the baseline survey and were presumed alive at the time of follow-up; of these, 54,960 (71.6%) completed the first follow-up survey. Logistic regression models were used to calculate inverse probability weights using propensity scores.ResultsCharacteristics associated with a greater probability of response included female gender, older age, higher education level, officer rank, active-duty status, and a self-reported history of military exposures. Ever smokers, those with a history of chronic alcohol consumption or a major depressive disorder, and those separated from the military at follow-up had a lower probability of response. Nonresponse to the follow-up questionnaire did not result in appreciable bias; bias was greatest in subgroups with small numbers.ConclusionsThese findings suggest that prospective analyses from this cohort are not substantially biased by non-response at the first follow-up assessment.