History Of Excessive Alcohol Use Research Articles

Unique urine and serum metabolomic signature in patients with excessive alcohol use: An exploratory study.

Excessive alcohol consumption has a multifaceted impact on the body's metabolic pathways and organ systems. The objectives of this study were to characterize global metabolomic changes and identify specific pathways that are altered in individuals with excessive alcohol use. This exploratory study included 22 healthy controls with no known history of excessive alcohol use and 38 patients identified as using alcohol excessively. A Fibrosis-4 score was used to determine the risk of underlying alcohol-associated liver disease among the excessive drinkers. We found significantly altered urinary and serum metabolites among excessive drinkers, affecting various metabolic pathways including the metabolism of lipids, amino acids and peptides, cofactors and vitamins, carbohydrates, and nucleotides. Levels of two steroid hormones-5alpha-androstan-3beta,17beta-diol disulfate and androstenediol (3beta,17beta) disulfate-were significantly higher in both the serum and urine samples of excessive drinkers. These elevated levels may be associated with a higher risk of liver fibrosis in individuals with excessive alcohol use. Alcohol consumption leads to marked alterations in multiple metabolic pathways, highlighting the systemic impact of alcohol on various tissues and organ systems. These findings provide a foundation for future mechanistic studies aimed at elucidating alcohol-induced changes in these metabolic pathways and their implications.

Patterns of Alcohol Use in Hispanic Individuals with TBI over the Ten Years Post-Injury: A Model Systems Study.

The study's aim was to examine alcohol consumption patterns and predictors of consumption across time among Hispanics with traumatic brain injury (TBI) in the U.S. within ten years post-injury. This longitudinal cohort study included 1342 Hispanic individuals (77.6% males) from the multi-site, longitudinal TBI Model Systems (TBIMS) database. The main outcome measures were consumption information, demographic, and injury characteristics. Across the full sample, alcohol consumption variables generally demonstrated quadratic movement characterized by an initial increase followed by a plateau or slight decrease over the ten years post-injury. The predictors of higher consumption were being men, single, with a history of excessive alcohol use, with a nonviolent mechanism of injury, shorter duration of PTA, and higher levels of education. Participants had a greater number of 5+ drinks/episode occurrences in the past month if they were men and had had a greater number of 5+ drinks/episode occurrences in the month before injury. There was no differential change in alcohol consumption over time as a function of these predictors. This study identified a profile of at-risk Hispanics with TBI for increased alcohol consumption. These individuals should be identified and targeted for early evidence-based alcohol intervention after TBI when results might be most favorable.

Long term opioid use after burn injury: a retrospective cohort study

BackgroundPatients who have survive a burn injury might be at risk of opioid dependence after discharge. This study examined the use of opioids in patients who suffer burn injury and explored factors associated with persistent opioid use after hospital discharge. MethodsThis retrospective cohort study compared adults admitted with a burn injury from 2009 to 2019 with two matched comparison cohorts from the general population and adults with a diagnosis of acute pancreatitis. Pre-admission prescription opioid use was determined, and a multivariable negative binomial regression analysis used to explore post-discharge opioid use. ResultsA total of 7147 burn patients were matched with 6810 pancreatitis patients and with 28 184 individuals from the general population. Pre-admission opioid use was higher in the burn and pancreatitis cohorts (29% and 40%, respectively) compared with the general population (17%). Opioid use increased in both burn and pancreatitis cohorts after discharge (41% and 53%, respectively), although patients with pancreatitis were at even higher risk of increased opioid use in an adjusted analysis (incidence rate ratio 1.43). Female sex, lower socioeconomic status, ICU admission, pre-injury opioid use, and a history of excess alcohol use were all associated with an increase in opioid prescriptions after discharge. ConclusionsOpioid use is high in those admitted with a burn injury or acute pancreatitis when compared with the general population, increasing further after hospital discharge. Female sex and socioeconomic deprivation are among factors that make increased opioid use more likely, although this phenomenon seems even more pronounced in those with acute pancreatitis compared with burn injuries.

DNA methylation alterations of ADCY5, MICAL2, and PLEKHG2 during the developmental stage of cryptogenic hepatocellular carcinoma.

The aim of this study was to clarify the significance of DNA methylation alterations of cryptogenic hepatocellular carcinomas (HCCs). Using the Infinium assay, we performed genome-wide DNA methylation analysis of 250 liver tissue samples, including noncancerous liver tissue (U-N) and corresponding cancerous tissue (U-T) from patients with cryptogenic HCC without a history of excessive alcohol use and hepatitis virus infection, and whose U-N samples showed no remarkable histological features (no microscopic evidence of simple steatosis, any form of hepatitis including nonalcoholic steatohepatitis, or liver cirrhosis). We identified 3272 probes that showed significant differences of DNA methylation levels between U-N and normal liver tissue samples from patients without HCC, indicating that a distinct DNA methylation profile had already been established at the precancerous U-N stage. U-Ns have a DNA methylation profile differing from that of noncancerous liver tissue of patients with nonalcoholic steatohepatitis-related, viral hepatitis-related, and alcoholic liver disease-related HCCs. Such DNA methylation alterations in U-Ns were inherited by U-Ts. The U-Ns showed DNA methylation alteration of ADCY5, resulting in alteration of its mRNA expression, whereas noncancerous liver tissue of patients with nonalcoholic steatohepatitis-, viral hepatitis-, or alcoholic liver disease-related HCCs did not. DNA methylation levels of MICAL2 and PLEKHG2 in U-Ts were correlated with larger tumor diameter and portal vein involvement, respectively. U-N-specific DNA hypermethylation of ADCY5 may have significance, even from the precancerous stage in liver showing no remarkable histological features. DNA hypomethylation of MICAL2 and PLEKHG2 may determine the clinicopathological features of cryptogenic HCC.

A - 105 Trajectories of Alcohol Use in Hispanic Individuals with TBI over the Ten Years Post-Injury: a Model Systems Study.

To examine alcohol consumption patterns and predictors of consumption across time among Hispanics with Traumatic Brain Injury (TBI) in the United States (U.S.) within ten years post-injury. Longitudinal cohort study. The sample included 1342 Hispanics (77.6% males) from the TBI Model Systems (TBIMS) database who had at least one complete data record at one of the follow-up data collections for average number of drinks consumed per episode of drinking in the previous month and one complete data record for number of times when five or more drinks were consumed in a single episode in the previous month. Across the full sample, alcohol consumption variables generally demonstrated quadratic movement characterized by an initial increase followed by a plateau or slight decrease over the 10years post-injury. Participants were more likely to consume a greater number of drinks per episode over time if they were men, single, with a history of excessive alcohol use, with a nonviolent mechanism of injury, shorter duration of PTA, and higher levels of education. Participants had a greater number of 5+ drinks/episode occurrences in the past month if they were men and had had a greater number of 5+ drinks/episode occurrences in the month before injury. There was no differential change in alcohol consumption over time as a function of these predictors. This study identified a profile of at-risk Hispanics with TBI for increased alcohol consumption. These individuals should be identified and targeted for early evidence-based alcohol intervention after TBI when results might be most favorable.

Prevalence of alcohol consumption among clients of opioid agonist treatment (OAT) centers in Golestan province, Iran.

Opioid agonist treatments (OATs) with methadone and buprenorphine are known to be effective treatments for people with opioid use disorder (OUD). However, concomitant use of other substances such as alcohol can negatively affect OAT outcomes. This study aimed to determine the prevalence of alcohol use among clients of OAT centers in the Golestan province in the northern part of Iran. This is a secondary analysis of a sample of 706 clients who were receiving OATs from certified OAT centers in Golestan province in 2015. They had been on OATs for at least 1 month and were randomly selected for the study. Data were collected via interviews with selected OAT clients. The main indicators studied in the present study were lifetime history of alcohol consumption, alcohol consumption during last month, lifetime history of excessive alcohol use on one occasion, and years of regular alcohol consumption. The prevalence of lifetime history of alcohol consumption was estimated at 39.2%. Prevalence of alcohol consumption during last month and lifetime history of excessive alcohol use on one occasion was 6.9 and 18.8%, respectively. Despite a total ban on alcohol consumption in Iran, a sub-sample of participants admitted past-month alcohol use concurrent with their OATs. The estimated past-month prevalence of alcohol use was lower than the reported prevalence in countries where the production, distribution, and consumption of alcohol are legal.

Validation of scores of PRO-C3 to predict liver-related events in alcohol-related liver disease.

Risk prediction in alcohol-related liver disease (ArLD) is an unmet need. We aimed to assess PRO-C3 models to predict liver-related events (LRE) in patients with a history of excessive alcohol use without an established diagnosis of chronic liver disease. A prospective cohort study of 462 patients with ArLD, split into a derivation cohort of 221 secondary care patients and a validation cohort of 241 primary care patients. Baseline variables, including fibrogenesis marker PRO-C3, were used to develop a prediction model. Prognostic accuracy was compared to enhanced liver fibrosis (ELF), fibrosis-4-index (FIB-4), transient elastography (TE) and ADAPT. In the derivation and validation cohorts, 67 (30%) and 19 (8%) experienced an LRE during a median follow-up of 5.2 years (IQR: 3.2-6.8) and 4.0 years (IQR: 2.7-5.6). On top of PRO-C3 and ADAPT score, we generated a model (ALPACA) of independent predictors of LREs (PRO-C3, AST/ALT, platelets). ALPACA had high prognostic accuracy with a C-statistic of 0.85 in the derivation cohort, comparable to ELF (0.83) and TE (0.84) and significantly higher than FIB-4 (0.78), PRO-C3 (0.80) and ADAPT (0.81). In the validation cohort, all tests had comparable C-statistics. Compared to low-risk patients (ALPACA ≤11), high-risk patients (>11) had a subhazard ratio for LREs of 12.6 (95% CI 5.9-26.8, p < .001) and higher cumulative incidence (57% vs. 7%, p < .001; derivation cohort). We observed similar subhazard ratio in the validation cohort. PRO-C3-based scores are reliable tools to predict LREs in ArLD patients and are suitable for risk stratification in primary and secondary care.

History of alcohol use does not predict HCV direct acting antiviral treatment outcomes.

Hepatitis C virus (HCV) infection and excessive alcohol consumption are leading causes of liver disease worldwide. Direct acting antivirals (DAAs) are well-tolerated treatments for HCV infections with high sustained virologic response (SVR) rates. There are limited data assessing the influence of alcohol use on DAA uptake and cure. We performed a retrospective analysis of patients followed at The Ottawa Hospital Viral Hepatitis Program between January 2014 and May 2020 to investigate the effect of excessive alcohol use history on DAA uptake and SVR rates. Additionally, we evaluated the incidence of concurrent comorbidities and social determinants of health. Predictors of DAA uptake and SVR were assessed by logistic regression. Excessive alcohol use history was reported in 46.0% (733) of patients. Excessive alcohol use did not predict DAA uptake (OR 1.06, 95% CI 0.71 to 1.57), while employment (OR 2.10, 95% CI 1.29 to 3.42) and recreational drug use (OR 0.62, 95% CI 0.40 to 0.94) were predictors. Employment predicted SVR (OR 2.38, 95% CI 1.68 to 3.36) in those starting treatment. Excessive alcohol use history did not predict SVR. History of excessive alcohol use does not influence treatment initiation or SVR. Efforts to improve treatment uptake should shift to focus on the roles of determinants of health such as employment and recreational drug use on treatment initiation.

Serum metabolomic analysis reveals several novel metabolites in association with excessive alcohol use – an exploratory study

Appropriate screening tool for excessive alcohol use (EAU) is clinically important as it may help providers encourage early intervention and prevent adverse outcomes. We hypothesized that patients with excessive alcohol use will have distinct serum metabolites when compared to healthy controls. Serum metabolic profiling of 22 healthy controls and 147 patients with a history of EAU was performed. We employed seemingly unrelated regression to identify the unique metabolites and found 67 metabolites (out of 556), which were differentially expressed in patients with EAU. Sixteen metabolites belong to the sphingolipid metabolism, 13 belong to phospholipid metabolism, and the remaining 38 were metabolites of 25 different pathways. We also found 93 serum metabolites that were significantly associated with the total quantity of alcohol consumption in the last 30 days. A total of 15 metabolites belong to the sphingolipid metabolism, 11 belong to phospholipid metabolism, and 7 metabolites belong to lysolipid. Using a Venn diagram approach, we found the top 10 metabolites with differentially expressed in EAU and significantly associated with the quantity of alcohol consumption, sphingomyelin (d18:2/18:1), sphingomyelin (d18:2/21:0,d16:2/23:0), guanosine, S-methylmethionine, 10-undecenoate (11:1n1), sphingomyelin (d18:1/20:1, d18:2/20:0), sphingomyelin (d18:1/17:0, d17:1/18:0, d19:1/16:0), N-acetylasparagine, sphingomyelin (d18:1/19:0, d19:1/18:0), and 1-palmitoyl-2-palmitoleoyl-GPC (16:0/16:1). The diagnostic performance of the top 10 metabolites, using the area under the ROC curve, was significantly higher than that of commonly used markers. We have identified a unique metaboloic signature among patients with EAU. Future studies to validate and determine the kinetics of these markers as a function of alcohol consumption are needed.

ENDOBRONCHIAL FOREIGN BODY ASPIRATION MIMICKING AN ENDOBRONCHIAL TUMOR

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: Aspiration of foreign body (FB) into the airways may have an indolent presentation in adults. Although the majority of FB aspiration cases can be diagnosed easily and accurately by radiography and bronchoscopy, some patients are misdiagnosed as having endobronchial tumors. We describe an interesting case of bronchus intermedius FB that mimicked an endobronchial tumor. CASE PRESENTATION: A 61-year-old, male long-time heavy smoker with history of excessive alcohol use and stroke with residual left-sided hemiparesis presented with a 3-month history of worsening dry cough, hemoptysis and dyspnea. Chest computed tomography revealed occlusion of the bronchus intermedius with an enhancing lesion highly suspicious for an obstructing bronchial mass, along with moderate pleural effusion and enlarged subcarinal lymphadenopathy. Thoracentesis of the pleural effusion showed exudative fluid with predominantly neutrophilic cells that was negative for malignancy on cytology twice. Flexible bronchoscopy a firm, endobronchial lesion causing near total occlusion of the bronchus intermedius. Forceps endobronchial biopsy of the lesion and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of a subcarinal lymph node revealed no malignant cells. The patient then underwent flexible bronchoscopy with removal of the occluding lesion using cryoablation. The obstructing mass appeared to be freely movable when the cryoprobe was attached to it. A basket was used to retrieve the entire resected mass, which appeared to be an aspirated pill surrounded by granulation tissue on gross examination. Histopathology of the specimen showed no evidence of malignancy but was consistent with FB aspiration. DISCUSSION: Symptoms of FB aspiration in adults may be absent and often delayed, in some reports for up to 26 months. Dysphagia and impaired cough reflex are the main mechanisms for FB aspiration. This was likely the case in our patient with a history of stroke and excessive alcohol use. In case of such an indolent presentation and invisibility of the FB on chest imaging due to formation of granulation tissue, FB aspiration may be overlooked in adults. In our patient, this was further cofounded by the presence of pleural effusion and mediastinal lymphadenopathy, which were concerning lymphadenopathy, but were likely due to post-obstructive pneumonia. Bronchoscopic cryotherapy, which resulted in the correct diagnosis in this patient, has been described in the diagnosis of benign and malignant lesions of the airways and for recanalization. CONCLUSIONS: This case highlights the importance of suspecting FB aspiration when evaluating airway lesions. Choice of a noninvasive method, such as bronchoscopic cryotherapy, for removing an endobronchial lesion, may preclude the need for thoracotomy. REFERENCE #1: 1- Alharthi BJ, et al. Occult foreign body in the lung mimicking bronchogenic carcinoma. BMJ Case Rep. 2014;2014:bcr2014207438. Published 2014 Dec 17. doi:10.1136/bcr-2014-207438 REFERENCE #2: 2- Hewlett JC, et al. Foreign body aspiration in adult airways: therapeutic approach. J Thorac Dis. 2017 Sep;9(9):3398-3409. doi: 10.21037/jtd.2017.06.137. PMID: 29221325; PMCID: PMC5708401. REFERENCE #3: 3- Sehgal IS, et al. Use of cryoprobe for removal of a large tracheobronchial foreign body during flexible bronchoscopy. Lung India. 2016 Sep-Oct;33(5):543-5. doi: 10.4103/0970-2113.188978. PMID: 27625452; PMCID: PMC5006338. DISCLOSURES: No relevant relationships by Omar Abdulfattah, source=Web Response No relevant relationships by Muath Alsharif, source=Web Response No relevant relationships by Traves Crabtree, source=Web Response no disclosure on file for Keivan Shalileh

Abstract 15615: Association of Covid-19 With QTc Prolongation: A Need for Routine Ecg Screening

Introduction: Coronavirus Disease 2019 (COVID-19) has a high risk of death due to respiratory and cardiac complications. Internalization of the virus in the heart may derange myocyte functions such as repolarization, manifesting as QT prolongation on surface electrocardiograms (ECGs). Long QT is associated with cardiac arrhythmias, including sudden arrhythmic death. Previous studies of corrected QT (QTc) in Covid-19 have not controlled for other QTc prolonging comorbidities. Hypothesis: This study investigates whether COVID-19 is associated with prolonged QTc independent of other causes of QTc prolongation. Methods: QTc values were taken from ECGs of 36 patients with COVID-19 admitted to intensive care and 70 healthy age- and gender-matched control subjects. Patients were excluded if they received QTc-prolonging drugs, had hypokalemia, hypocalcemia, or hypomagnesemia, or history of excessive alcohol use. QTc values of COVID-19 patients were compared against normal control subjects. Results: The COVID-19 group included 15 females and 21 males with hypertension (n=11) and diabetes mellitus (n=5) as the most common comorbidities. Electrolytes were normal (K, 3.97 ± 0.41 mEq/L; Mg, 2.41 ± 0.38 mg/dL; and corrected Ca, 10.60 ± 0.60 mg/dL). QTc (msec) was significantly prolonged in COVID-19 compared with control subjects (total 469 ± 36.1 vs 418 ± 17.8; females, 475±29.2 vs 424 ± 11.4, and males 465 ± 40.5 vs 416 ± 19.9; all p&lt;0.001). Conclusions: COVID-19 alone, without an associated QT prolonging etiology, is associated with QTc prolongation. Ventricular arrhythmias may be more likely to affect women with COVID-19 than men with the disease. Therefore, it is recommended that, in COVID-19 patients, electrolytes be maintained within normal limits and QT prolonging drugs be avoided.

SUN-385 A Rare Case of Ectopic ACTH Secretion by Pancreatic Adenocarcinoma

Background Ectopic ACTH secretion caused by pancreatic neuroendocrine tumor is rare, but is responsible for 15% of ectopic Cushing syndrome. Their presentation and treatment are challenging because their preoperatory diagnosis and treatment are difficult due to its divergent and heterogeneous nature. CaseThe patient is a 65year old male with recent diagnosis of pancreatic cancer with liver metastases opting for naturopathic treatment, history of excessive alcohol use, gout, and biliary stent placement, presented to the ED with abnormal labs. On admission he was noted to be bradycardic with heart rate in 50s, WBC slightly elevated at 12.3, potassium 1.6, bicarbonate 50, calcium 6.5, bilirubin 8.8, ALT 79, AST 63, TSH undetectable, and T3-T4 extremely low. Patient also had lower extremity edema, lethargy, and confusion. Initial presentation was concerning for myxedema coma. Ultrasound for DVT was negative.Twelve-lead EKG demonstrated a ventricular rate of 58, sinus bradycardia with second degree AV block . IV Synthroid and replacement protocol was initiated. MRI of the brain was unremarkable. Patient noted to have upper extremity contractures. 24 hour urine free cortisol was 12,000 (normal 7.2-60 pg/mL ); ACTH 719 pg/mL (normal 4.5 - 20 pmol/L); CEA 10.3 (normal <3 ng/mL, CA19-9 762.0 (normal <40 U/mL). Continued hypokalemia as well as tetany and hypocalcemia secondary to metabolic alkalosis over the next few days were largely due to multifactorial reasons, including Keto-alkalione diet, profound weight loss, chronic stooling and recent development of ectopic Cushing’s with mineralocorticoid excess and hyperaldosteronism resulting in increased tubular wasting of potassium. Patient was continued on PO + IV repletion. Hydrocortisone and Synthroid were discontinued. Patient was started on amiloride PO and clindamycin and Bactrim due to intrinsic immunosuppression. No Ketoconazol was given because of transaminitis. The patient and his family opted for hospice care as he was not a candidate for oral chemotherapy or bilateral adrenalectomy for elevated cortisol levels and for his prognosis of <2 months. Conclusion; Exocrine pancreatic tumors are the most common type of pancreatic neoplasm and commonly consist of purely exocrine characteristics. The significance of this case lies in the extreme rarity of pancreatic adenocarcinoma exhibiting endocrine traits with only one previous case in the literature. This case suggests that exocrine pancreatic cancer with endocrine features is a distinct condition and that certain guidelines and protocols may be necessary for this entity. Resources 1. Gullo, L., et al. “Pancreatic Exocrine Carcinoma Producing Adrenocorticotropic Hormone.” Pancreas, vol. 7, no. 2, 1992, pp. 172-176., doi:10.1097/00006676-199203000-00007.

Perceptions of Alcohol Advertising among High Risk Drinkers

ABSTRACTBackground: Individuals who are particularly vulnerable to the influence of alcohol advertising, such as youth, need special protections, yet little research has been done to determine if other vulnerable groups exist. Secondary data analysis was conducted to determine if perceptions of alcohol advertising differ between groups based on their alcohol use and whether the definition of “vulnerable” should be expanded beyond demographic categories. Methods: Students (n = 326) from 2 U.S. colleges viewed 5 alcohol ads and rated them using a scale designed to detect violations of the alcohol industry's self-regulated marketing codes. Individuals with a history of excessive alcohol use, as measured by the Alcohol Use Disorders Identification Test (AUDIT), were considered potentially vulnerable to alcohol advertising and were compared against individuals without a history of excessive alcohol use. Hierarchical linear modeling was used to determine between-group differences in 4 dependent variables (ad appeal, perceived alcohol consumption, perceived excessive drinking, and perceived responsible drinking). All models were adjusted for age, race, ethnicity, sex, and parental alcohol use. Results: AUDIT risk categories were positively associated with ad appeal (p < 0.001), the amount of alcohol perceived to be consumed (p < 0.01), and perceptions of responsible drinking (p < 0.05). There was no significant associated with perceptions of excessive drinking. Conclusions: Individuals with a history of heavy alcohol use perceived greater alcohol consumption in alcohol ads but perceived this consumption, which often met the definition for binge drinking, to be responsible. Stricter regulations may be needed to protect heavy alcohol users from the effects of alcohol advertising.

Multimorbidity in a large district hospital: A descriptive cross-sectional study.

There is substantial research documenting the burden of disease globally and in the South African (SA) primary care context. Few studies address the disease profile and its implications in the SA hospital setting. To describe the disease profile in the internal medicine department of a large district hospital, using variables related to comorbidity and patient length of stay. The study included specific exploration into the HIV/tuberculosis (TB) syndemic, the acuity of HIV disease, and lifestyle risk factors. The sample population consisted of all consecutive admissions to the internal medicine department of a large district hospital in the Cape metropole during May 2015. A retrospective folder review and subsequent data analysis were completed. Hypertension, HIV, type 2 diabetes mellitus, TB and cardiac failure were the five most prevalent diseases. Extensive multimorbidity was observed, with 86.0% of patients suffering from two or more diseases concurrently. The average number of comorbidities per patient was 3.4, although no clear relationship between the number of comorbidities and length of stay was found. Of the various diseases, only TB and HIV were associated with above-average length of stay, particularly among co-infected patients and those who had defaulted from or never received antiretroviral (ARV) treatment. Compared with patients currently receiving ARVs, much higher proportions of patients who had defaulted from or never received ARV treatment had CD4+ counts &lt;200 cells/µL. Of thelifestyle risk factors investigated, a history of excessive alcohol use and/or drug use wasassociated with an increased length of stay.Most patients were discharged home, with 15.7% being referred to other institutions. Chronic conditions, particularly HIV, TB and non-communicable diseases, represented much of the disease profile in the internal medicine department. Of the comorbidities investigated, the greatest contributor to length of stay was HIV/TB co-infection. Factors such as HIV, TB and substance use that increase length of stay cannot be impacted upon by the district hospital staff in isolation. To improve the health of communities, we require partnerships between doctors, community health providers and patients with their families. Multimorbidity was widespread, suggesting the need to include an understanding of multimorbidity, including the patient perspective, in medical education and health system reform.

Hemosuccus Pancreaticus and Hematochezia: An Unusual Presentation of a Rare Disease

Gastrointestinal bleed (GIB) is a major reason of hospitalization and can lead to worsened morbidity and mortality. Hemosuccus pancreaticus (HP) is a rare cause of upper GIB observed in patients with chronic pancreatitis, pancreatic pseudocysts, or pancreatic tumors. Patients with HP usually present with intermittent epigastric pain and GIB, most commonly hematemesis or melena, but rarely, may have hematochezia. We present a patient with recurrent GIB episodes whose evaluation revealed HP. A 52-year-old gentleman with history of excessive alcohol use was evaluated for recurrent abdominal pain and hematochezia. He had undergone esophagogastroduodenoscopy (EGD), colonoscopy, deep anterograde and spiral retrograde endoscopies as well as two Meckel scans with negative evaluation. Finally, intra-operative enteroscopy revealed a few non-bleeding small angioectasias in the jejunum and ileum that were ligated. However, the patient presented again with hematochezia. Initial CT scan of the abdomen was concerning for chronic pancreatitis change and a hypervascular lesion at the junction of the body and tail of the pancreas. He had no prior history of acute pancreatitis. Subsequent CT angiography revealed a 7mm mid-splenic artery saccular aneurysm arising from the inferior wall of the splenic artery, abutting the tail of the pancreas with pancreatic duct dilatation. Selective angiography with embolization was performed at this lesion. The procedure was complicated by downstream migration of the coils into the splenic artery bifurcation resulting in segmental splenic infarction. He has had no further bleeding and his condition and hemoglobin have been stable since the procedure. Follow up endoscopic ultrasound (EUS) showed chronic pancreatitis changes, there was no mass lesion. GIB from HP usually results when a direct communication is established between the blood vessel and pancreatic duct as a result of erosion. Intermittent abdominal pain and GIB are hallmarks for this disease. Abdominal CT usually establishes the diagnosis but it can also be confirmed by MRCP, ERCP or intra-operatively. Angiography with coil embolization is the initial treatment which was also successful in our patient. Our patient was unique in that he presented with recurrent hematochezia, which is uncommon in this rare disorder. This case demonstrates that HP should be considered in patients with GIB, particularly in those with a pancreatic disorder and negative evaluation of more common causes.Figure: Angiogram of splenic artery revealing pseudoaneurysm off of the mid splenic artery.Figure: Angiogram of the splenic artery after successful coil embolization.Figure: CT angiogram reveals mid-splenic artery pseudoaneurysm.

Development and validation of a composite score for excessive alcohol use screening

This study was undertaken to develop a composite measure that combines the discriminant values of individual laboratory markers routinely used for excessive alcohol use (EAU) for an improved screening performance....

Liver Transplantation for Alcoholic and Nonalcoholic Fatty Liver Disease: Pretransplant Selection and Posttransplant Management

Alcoholic fatty liver disease (ALD) and nonalcoholic fatty liver disease (NAFLD) are common causes of chronic liver disease throughout the world. Although they have similar histologic features, a diagnosis of NAFLD requires the absence of significant alcohol use. ALD is seen commonly in patients with a long-standing history of excessive alcohol use, whereas NAFLD is encountered commonly in patients who have developed complications of obesity, such as insulin resistance, hypertension, and dyslipidemia. Lifestyle contributes to the development and progression of both diseases. Although alcohol abstinence can cause regression of ALD, and weight loss can cause regression of NAFLD, many patients with these diseases develop cirrhosis. ALD and NAFLD account for nearly 30% of liver transplants performed in the United States. Patients receiving liver transplants for ALD or NAFLD have similar survival times as patients receiving transplants for other liver disorders. Although ALD and NAFLD recur frequently after liver transplantation, graft loss from disease recurrence after transplantation is uncommon. Cardiovascular disease and de novo malignancy are leading causes of long-term mortality in liver transplant recipients with ALD or NAFLD.

The Wearable Cardioverter Defibrillator in Nonischemic Cardiomyopathy: A US National Database Analysis

BackgroundThe wearable cardioverter defibrillator (WCD) is often used in patients at risk of sudden cardiac death (SCD) who are not yet candidates for an implantable cardioverter defibrillator (ICD). Newly diagnosed cardiomyopathy may be reversible, and a WCD may protect patients during the initial period of risk. We evaluate the benefit and compliance of the WCD in patients with nonischemic cardiomyopathy (NICM). MethodsWe reviewed a national database of patients with NICM who used WCDs and who self-reported a history of excess alcohol use, although other causes of cardiomyopathy could not be excluded. The database contained demographic data, initial ejection fraction (EF), reason for WCD prescription, compliance and use data, any detected arrhythmias, therapies, and reason for discontinuing WCD. Statistical analyses were performed using SAS, version 9.3 (SAS Institute, Cary, NC). ResultsOf the 127 patients, 88% were men with a mean age of 52.6 ± 11.0 years. The mean initial EF was 19.9% ± 7.4%. Patients wore the WCD for a median of 51 days and a median daily use of 18.0 hours per day. The most common reasons for discontinuing the WCD were improvement in EF (33%) or ICD implantation (23.6%). Seven patients (5.5%) had 9 sustained ventricular arrhythmia events, which were successfully treated with 100% conversion. There were 11 deaths (8.6%) during 100 days of follow-up. No deaths resulted from WCD shock failure or undersensing. ConclusionsNICM may have a significant risk of ventricular arrhythmias and death in the first few months. The WCD delivered appropriate therapy in 5.5% of patients. This study suggests that a WCD may be effective temporary prophylaxis for prevention of SCD in patients with newly diagnosed NICM.

The Utility of Commonly Used Laboratory Tests to Screen for Excessive Alcohol Use in Clinical Practice.

This current study was undertaken to carefully assess the accuracy of routinely used laboratory tests in detecting excessive/recent alcohol use. We also determined the kinetics of these markers in subjects who underwent an intensive alcohol rehabilitation program. The study cohort consisted of 210 nonexcessive drinkers, 272 excessive drinkers, and 76 with alcoholic cirrhosis. To determine the kinetics of these markers during alcohol abstinence, we followed 45 subjects with history of excessive alcohol use for 12 weeks during the intensive alcohol treatment program. Percentage of carbohydrate deficient transferrin (%CDT) provided the highest diagnostic performance (area under the curve [AUC] 0.77) followed by gamma-glutamyl transferase (GGT) (AUC 0.68) to detect excessive drinkers. The percentage of excessive drinkers with aspartate aminotransferase:alanine aminotransferase (AST:ALT) > 2 was only 2%, whereas 51% of subjects with alcoholic cirrhosis had AST:ALT > 2. In the multivariate analysis, the levels of GGT and %CDT were associated with the level of alcohol consumed during the past 30 days. The levels of GGT, mean corpuscular volume (MCV), and %CDT were significantly lower compared to those at baseline before alcohol rehabilitation, whereas the AST, ALT, and AST:ALT ratio were unchanged. The percent reduction was ~2.7% (for MCV), 19% (for GGT), and 43% (for %CDT) at the end of the 12-week follow-up compared to the baseline. %CDT are useful markers to screen for excessive alcohol use and for follow-up of abstinence. Most subjects with excessive alcohol use do not have a high AST:ALT ratio. Rather, the AST:ALT > 2 is suggestive of alcoholic cirrhosis. The performance of the %CDT to screen for heavy alcohol use is still not ideal. Further research to identify the noninvasive marker(s) (i.e., using proteomic or metabolomics approach) should be considered.

The Incidence and Management of Nonalcoholic Fatty Liver Disease in Potential Kidney Donors.

Purpose: To determine the incidence and management of NAFLD and NASH in prescreened living kidney donors. Methods: Between January 2010 and December 2013, 399 potential kidney donors were registered and underwent blood and HLA typing at our institution. Of these potential donors, 106 completed the evaluation including computed tomography (CT) scan. Diagnosis of NAFLD was based upon presence of hepatic steatosis on imaging using liver to spleen ratio (L:S ratio, <1.1) criteria, and absence of anti-HCV and HBsAg, and negative history of excessive alcohol use, and secondary causes of hepatic steatosis or other causes of elevated serum ALT or AST (LFTs). 14 patients (13.2%) had elevated ALT, TB or AST, and 10 patients (9.4%%) had hepatic steatosis noted on CT. 6 patients (5.6%) had both abnormal LFTS and hepatic steatosis on imaging. Results: From the group with abnormal LFTs or imaging, 8 patients (44%) proceeded to donation. Patients with mild steatosis and normal BMI and LFTs were allowed to donate (2). 2 patients had normalization of LFTs without intervention. 3 patients with mild transaminase elevation and/or mild steatosis on imaging were counseled about diet and weight loss, and allowed to donate once transaminases normalized. Average weight loss was 8 lbs. A patient with persistent abnormal LFTs, but normal BMI and imaging was referred for a liver biopsy examination. Liver biopsy showed mild (5-10%) steatosis without signs of NASH and he was cleared for donation. 10 patients were not cleared for donation. 4 patients were ruled out for medical or anatomic issues without work up of for liver disease. One patient was referred to hepatology and but had improvement in LFTs after weight loss, however was ruled out due to the presence of nephrolithiasis. 5 patients were excluded based upon on the presence of significant liver disease. One patient was found to have alcohol abuse as likely contributing factor for liver disease. 2 patients did not proceed with their evaluation after being referred to hepatology for further work up and liver biopsy. 2 patients had NASH without cirrhosis on liver biopsy and were excluded from donation. Conclusion: 10 - 13% of healthy potential living kidney donors are found to have NAFLD based upon either elevated ALT/AST or imaging during work up. Patients with mild transaminase elevation or mild steatosis on imaging are likely ok to proceed with donation, especially if diet and weight loss leads to normalization of ALT and AST. Patients with significant steatosis on imaging or persistent elevation