History Of Heavy Alcohol Intake Research Articles

Spur Cell Anemia: A Rare and Under-Diagnosed Cause of Anemia in Alcoholic Patients with Advanced Liver Disease

Anemia in patients with alcohol use disorder (AUD) has a wide range of differential diagnoses, which can be challenging to interpret. It is often multifactorial, such as due to blood loss with or without coagulopathy, direct toxic effect of alcohol on hematopoietic cells, chronic inflammation, abnormalities in red blood cells (RBC) membranes, and nutritional deficiencies. Alcohol-induced liver disease may contribute to anemia through coagulopathy, splenomegaly, and hypersplenism. Macrocytosis is a common finding in patients with AUD due to B12 or folate deficiency or RBC membrane abnormality due to changes in lipid composition of RBC membranes. Patients with cirrhosis may have low haptoglobin due to impaired synthetic liver function. However, non-autoimmune hemolytic anemia and concomitant alcohol-induced liver damage should raise suspicion for spur cell anemia (SCA) and Zieve's syndrome. These medical conditions tend to be underreported or misdiagnosed. We describe a 44 year old male patient with a past medical history of AUD who presented with alcohol intoxication and was found to have newly diagnosed decompensated cirrhosis with severe macrocytic anemia with Hgb of 5.9 g/dl. Patient denied overt bleeding. Initial workup revealed high absolute reticulocyte count of 10.8% with retic index of 3, low haptoglobin of <15 mg/dl, elevated LDH of 275 u/l, negative Coombs test consistent with non-autoimmune hemolytic anemia, normal folate and B12 levels, and mixed direct and indirect hyperbilirubinemia. Peripheral blood smear showed anisopoikilocytosis, macrocytes, many spur cells, increased reticulocytes, but no schistocytes. Endo-colonoscopy showed grade 1 esophageal varices without evidence of recent bleeding. Given the history of heavy alcohol intake and cirrhosis, combined with Coombs-negative hemolytic anemia and peripheral blood smear findings of numerous spiculated red cells, our patient was diagnosed with SCA. At the time, due to active alcohol use, the patient was deemed not to be a candidate for liver transplant. This case report aims to aid physicians with the recognition of acute hemolytic anemia in patients with alcoholic liver injury and consideration of SCA and Zieve's syndrome as potential underlying causes. Prompt recognition and differentiation between these medical conditions are crucial as prognosis and treatment are different. Early recognition of SCA and timely consideration of liver transplantation can significantly improve patient outcomes.

P26 Felty’s syndrome as the first presentation of rheumatoid arthritis

Abstract Introduction Felty's syndrome (FS) is a rare, autoimmune disease occurring in < 1% of patients with rheumatoid arthritis (RA) and comprising a triad of persistent idiopathic neutropenia, splenomegaly and RA. In some affected individuals, FS may develop when the symptoms and signs of RA have subsided or are absent. In this case, FS may remain undiagnosed. In rare instances, the development of FS may precede the development of the clinical manifestation of RA. Case description A 73-year-old Caucasian gentleman presented in October 2017 with pancytopenia and splenomegaly. He was investigated by the haematology team with multiple bone marrow biopsies showing no underlying haematological causes for his pancytopenia. He was also investigated by the hepatologists for the possibility of liver cirrhosis as he had a heavy alcohol intake. His liver ultrasound showed fatty liver with splenomegaly, his fibro-scan showed fibrosis with no evidence of cirrhosis and his OGD showed no oesophageal varies. At this point, he was treated with blood transfusions, weekly erythropoietin and filgrastim as needed under the haematologists. In October 2022, he was admitted with febrile neutropenia and he gave a 20-year history of palindromic rheumatism with no evidence of synovitis or previous DMARD treatment. His rheumatoid factor (RF) was >120 iu/ml, anti-cyclic citrullinated peptide (ACCPA) was >340 u/ml and ANA by CIA was weakly positive (20.6 CU) with Hep-2 IFF being homogenous. ENA and dsDNA were negative. His hand X-ray showed evidence of osteoarthritis with no erosion. He subsequently had multiple admissions due to infections. CT chest, abdomen, and pelvis showed splenomegaly with portal vein dilatation suggestive of portal hypertension, normal liver appearance, and left lower lung bronchiectasis. Liver biopsy showed non-specific portal and sinusoidal inflammation, mild fibrosis, and architectural features suggestive of nodular regenerative hyperplasia indicative of FS. Furthermore, his HLA-DRB1*04 was positive. Together, these factors allowed us to diagnose FS. He was started on a tapered course of prednisolone, 30mg daily decreased by 10mg every two weeks, and methotrexate (10mg orally weekly) with careful blood monitoring. Two weeks later, he developed a mild rise in the ALT and alkaline phosphatase. Therefore, the methotrexate dose was reduced to 5mg weekly. Four weeks later, he reported feeling much better, with improvement in all his cell counts and liver function. Discussion While persistent idiopathic neutropenia and splenomegaly (present in 90% of FS patients) are salient features of FS, patients can also present with other extra-articular manifestations such as rheumatoid nodules (74%), hepatomegaly (68%), lymphadenopathy (42%), Sjögren's syndrome (48%), pulmonary fibrosis (50%), pleuritis (22%), peripheral neuropathy (14%) and leg ulcers (16%). Systemic symptoms include fever and weight loss. They also present with idiopathic non-cirrhotic portal hypertension, which can lead to variceal bleeding. The exact pathophysiology of FS is unclear, making the diagnosis and treatment of FS very challenging. A large multi-central cohort study found that FS is associated with HLA-DRB1*0401 and, in two other studies into the pathophysiology of FS, they found that 73% of patients with FS had IgG Anti-G-CSF and autoantibodies that bind to deaminated histones and neutrophil extracellular chromatin traps (NETs), leading to neutrophil sequestration. Therefore, treatment aims to control the underline RA, improve the neutrophil count, and prevent infection. The first challenge, in this case, was to confirm the diagnosis of FS in the absence of any obvious RA joint involvement and a history of heavy alcohol intake. Following an extensive investigation, we discussed his case at the Rare Disease MDT meeting and liaised with the haematology, hepatology, and histopathology teams to exclude the other differential diagnoses. The clues to the diagnosis of FS were the strongly positive RF and ACCPA, the positive HLA-DRB1*04, the liver biopsy, and the exclusion of other causes of neutropenia. The second challenge in this case was to safely start methotrexate, given his mild liver fibrosis and recurrent infections. With close blood test monitoring and follow-up, he achieved improvement in his cell count (WBC from 0.8 to 1.1x10 9/L, HB from 86 to 104 g/L, platelet from 70 to 91X109/L) with stable liver function. Key learning points Rheumatoid arthritis is a multisystem disease with variable presentations. Rarely, FS can occur in the absence of clinical manifestations of the erosive joint involvement of RA. In this situation, careful, thorough investigation to exclude other causes of neutropenia and prove the diagnosis of FS is imperative to justify immunosuppressive treatment. A multidisciplinary team working across specialties was pivotal in the safe diagnosis and treatment of this gentleman.

High prevalence of liver fibrosis among general population: a Romanian population-based study.

Cirrhosis can be present undected for years prior to a symptomatic presentation. Early detection may result in improved outcomes. Data are lacking, however, regarding the yield of screening in many populations. We aimed to determined prevalence of significant liver fibrosis diagnosed by vibration-controlled transient elastography (VCTE) in apparently healthy Romanians. Between December 2021 and March 2022, we prospectively screened 1,027 subjects from different counties of Northeastern Romania using VCTE and B-mode ultrasonagraphy after a comprehensive medical history questionnaire. Participants with abnormal liver stiffness measurement values were further evaluated by laboratory tests to identify the severity and etiology of chronic liver disease. Overall, 17.9% of subjects had liver stiffness measurments (LSM) ≥8 kpa, including 55 with LSM ≥13.0 kpa. Among these subjects, 26.1% had a history of heavy alcohol intake, 22.3% tested positive for hepatitis B and/or C infection, and 49.5% were diagnosed with NAFLD. The prevalence of elevated LSM was highest among older subjects (>60 y old) and those with diabetes. Among those with LSM ≥13 kPa and ≥9.6 kpa, FIB-4 was <2.67 in 46.9% and 87.5% respectively. There is high prevalence of significant liver fibrosis in the Romanian general population. VCTE is a usefool tool for early detection of liver disease and appears more sensitive than FIB-4.

Polychlorinated biphenyl serum levels in subjects with hepatocellular carcinoma as compared with the general population

Background. Polychlorinated biphenyls (PCBs) have been recognized as human carcinogens and cause liver cancer in animal experimental studies. However, no study investigated their association with hepatocellular carcinoma (HCC) so far. This study aimed to evaluate the serum PCB concentration in HCC patients and in healthy subjects of the general population living in Brescia, North Italy, a highly industrialized area with heavy PCB environmental pollution due to the presence of a PCB producing factory.&#x0D; Methods. Lipid-adjusted PCB concentrations, computed as the sum of 24 congeners, were measured in the serum of 101 HCC patients and in 101 healthy subjects of the same age and gender.&#x0D; Results. Hepatitis B and C virus infection and history of heavy alcohol intake were found, alone and combined, in 87% of HCC patients. No difference was found in PCB serum concentration of HCC patients with and without, and according to, the major risk factors for liver disease. No significant difference was observed in serum total PCB concentration between HCC patients (median: 1081; range: 287.0-3182.0 ng/g lipid) and healthy subjects (median: 1199.3; range: 225.7-22825 ng/g lipid). PCB congeners 118, 138, 153, 156, 180 and 194 were the only ones found over the detection limit in at least 30% of HCC patients. The serum level of PCB 118, but not that of other congeners, was higher in HCC patients than in healthy subjects.&#x0D; Conclusion. These findings do not support the hypothesis that PCBs play an important role in HCC development, although a contribution by some specific congeners cannot be ruled out

Steatohepatitic hepatocellular carcinoma: imaging findings with clinicopathological correlation

To evaluate the clinicopathological and computed tomography (CT) and magnetic resonance imaging (MRI) findings of steatohepatitic hepatocellular carcinoma (SH-HCC). Clinicopathological and radiological features were evaluated in 20 patients with SH-HCC. The diagnosis of SH-HCC was made histologically if the tumour had four of the following five characteristics: steatosis (>5% tumour cells), ballooning, Mallory-Denk bodies, interstitial fibrosis, and inflammation. All patients underwent dynamic CT and MRI. CT and MRI images were reviewed for morphological features including tumour size, presence, and distribution of fat, and patterns and degree of contrast enhancement. Obesity, hypertension, and history of heavy alcohol intake were common clinical findings observed in 10 (50%), 13 (65%), and 11 (55%) of the 20 patients, respectively. Steatosis and steatohepatitis were pronounced in the background liver in 12 (60%) and 10 (50%) patients, respectively. SH-HCC was moderately differentiated in 18 patients (90%) and well differentiated in two (10%). Pathologically, steatohepatitic features were diffuse in 12 (60%) of the 20 tumours and focal in eight (40%). Tumour size and the percentage of intratumoural steatosis were not correlated (r=0.17, p=0.47). On CT, 16 (80%) patients showed arterial phase enhancement and delayed washout. On MRI, 16 (80%) of 20 tumours showed prominent fatty deposition (10 diffusely, six focally) with arterial phase enhancement. SH-HCC is likely to show prominent fatty deposits with arterial phase enhancement on CT and MRI. A hypervascular lesion with prominent fatty change should raise the diagnostic suspicion of SH-HCC.

Daily tea drinking is not associated with newly diagnosed non-alcoholic fatty liver disease in Chinese adults: the Tianjin chronic low-grade systemic inflammation and health cohort study

BackgroundPrevious studies have reported that tea extract supplementation has potential benefits on the risk factors of non-alcoholic fatty liver disease (NAFLD); however, no study has investigated the direct effect of daily tea consumption on the prevalence of NAFLD in the general population. This cross-sectional study aimed to evaluate the associations between tea consumption and the prevalence of newly diagnosed NAFLD among Chinese adults.MethodsThe present cross-sectional study was based on the Tianjin Chronic Low-grade Systemic Inflammation and Health Cohort Study. In total, 19,350 participants were enrolled in the analyses. Tea consumption was assessed via a self-administered food frequency questionnaire. NAFLD was diagnosed via liver ultrasonography and no history of heavy alcohol intake. Logistic regression analysis was used to estimate the associations between tea consumption and the prevalence of NAFLD.ResultsConsumption of green tea, oolong tea, and black tea were positively associated with the prevalence of newly diagnosed NAFLD before adjustments. Compared with the participants who never drink tea, the odds ratios (95% confidence interval) of newly diagnosed NAFLD in the highest categories (≥ 1 cup/day) of green tea, oolong tea, black tea, and jasmine tea were 1.48 (1.33, 1.65), 1.50 (1.33, 1.68), and 1.28 (1.13, 1.46), and 1.36 (1.20, 1.54) before adjustments, respectively. However, no significant association was found between tea consumption and the prevalence of NAFLD after adjusting for socio-demographic, behavioural, anthropometric, dietary, and clinical confounding factors.ConclusionThere is no significant association between daily tea drinking and newly-diagnosed NAFLD in general Chinese adults.

2354 Massive Hematochezia Due to Bleeding Cecal Varices in a 35-Year-Old

INTRODUCTION: Bleeding from cecal varices is a rare complication of portal hypertension. We present a case of bleeding cecal varices manifesting as massive hematochezia in a 35 year-old woman with alcoholic cirrhosis. CASE DESCRIPTION/METHODS: A 35yo woman with chronic alcoholism presented with hematochezia, hypotension, and syncope. She endorsed a 15-year history of heavy alcohol intake, with no known liver disease or prior GI bleeding. Vital signs included HR 112 bpm and BP 83/48 mmHg. Labs indicated hemoglobin 6.6 g/dL, platelet count 58 K/uL, BUN 12 mg/dL, INR 1.5. Upper endoscopy showed no esophageal varices or blood. Colonoscopy showed red blood in the entire colon causing impaired visualization of underlying mucosa. The patient had continued hematochezia and hypotension requiring massive transfusion. CT angiography revealed active bleeding in the cecum and proximal ascending colon with abnormal surrounding vascularity, consistent with bleeding cecal varices (Figure 1). Arteriography demonstrated rectal, splenic, gastric, and small esophageal varices. The patient underwent transhepatic intravenous portosystemic shunt (TIPS) with an associated portosystemic gradient decrease from 24mmHg to 14mmHg. She had no further bleeding and was started on Nadolol for further reduction in portosystemic pressure. The patient was discharged in stable condition. DISCUSSION: Bleeding colonic varices are an uncommon manifestation of portal hypertension, with an incidence of 0.07%. Specifically, bleeding cecal varices are far more rare, and have been reported in less than 20 cases in the literature. This report describes a case of bleeding cecal varices in a 35 year-old with alcoholic cirrhosis; there is only one other report of bleeding cecal varices in a younger patient. Hemorrhage from these lesions is life threatening and requires robust knowledge of diagnostic and therapeutic options. Diagnosis is often attempted with colonoscopy, however can be difficult due to visual obscuration by bleeding. Mesenteric angiography is most effective in diagnosis. Endoscopic and radiologic interventions include cyanoacrylate injection, endoscopic variceal ligation, coil embolization, balloon occluded retrograde transverse obliteration (BRTO), and TIPS. In our case, the decision to pursue TIPS was made due to complicated superior mesenteric artery anatomy precluding coil embolization. Aggressive resuscitation and collaboration between gastroenterology, surgery, and radiology made for a successful outcome for this young patient.

Endoscopy Upper

Endoscopy Upper

Peritoneal tuberculosis as a cause of ascites in a patient with cirrhosis

A 59-year-old Portuguese Caucasian man with a history of heavy alcohol intake and no significant medical history presented with ascites, weight loss and general malaise. The ascitic fluid analysis showed...

Prediction of Poor Response to Modified Neuroleptanalgesia with Midazolam for Endoscopic Submucosal Dissection for Esophageal Squamous Cell Carcinoma

Background/Aims: Modified neuroleptanalgesia (m-NLA) with midazolam is often used for sedation and analgesia during endoscopic submucosal dissection (ESD) for gastrointestinal neoplasia. However, interruption due to poor response to midazolam is often experienced during ESD for esophageal squamous cell carcinoma (ESCC) because most patients with ESCC have a history of heavy alcohol intake. We examined the incidence and risk factors for poor response to m-NLA with midazolam and pethidine hydrochloride. Methods: This retrospective cross-sectional study was conducted at a single institution. Between April 2007 and July 2013, 151 patients with superficial ESCC who underwent ESD under sedation using m-NLA with midazolam and pethidine hydrochloride were enrolled. Poor response to sedation was defined as the use of a second drug when Ramsay Sedation Score 1-2. Results: Poor response to sedation occurred in 66.2% patients. Most cases of poor response were controlled by using additional flunitrazepam. Multivariate logistic regression analysis showed that cumulative alcohol intake and major specimen size were independent risk factors for poor response to sedation (OR 3.63, 95% CI 1.20-10.99, and OR 3.23, 95% CI 1.26-8.25). Conclusion: Our study indicated that cumulative alcohol intake and major specimen size were associated with poor response to m-NLA with midazolam and pethidine hydrochloride.

Role of aetiology, diabetes, tobacco smoking and hypertension in hepatocellular carcinoma survival

BackgroundAim of this study was to investigate the role of aetiology, diabetes, tobacco smoking and hypertension in the survival of patients with hepatocellular carcinoma. MethodsA prospective cohort of 552 patients (81.5% males, mean age 64.4 years) first diagnosed with hepatocellular carcinoma in 1995–2001 in Brescia, Italy, was retrospectively analyzed. Data on the presence of diabetes mellitus, hypertension, heavy alcohol intake and tobacco smoking were obtained from patients’ clinical charts or interviews. Survival analysis was performed using univariate and multivariate methods (Cox proportional hazards model). Results33% had a history of heavy alcohol intake, 24.3% had viral hepatitis and 33.5% had both aetiologies. Diabetes, hypertension and tobacco smoking were found in 29.9%, 37.9% and 35.9%, respectively. During follow-up (median 19.9 months), the median survival was 19.9 (95% confidence interval [CI] 16.7–22.8) months. Using multivariate Cox regression models, alcohol-related liver disease and diabetes were found to be associated with mortality, with hazard ratios of 1.32 (95% CI 0.99–1.75) and 1.25 (95% CI 1.02–1.54), respectively. Hypertension and smoking habit did not influence survival. ConclusionsAlcohol aetiology and the presence of diabetes were positively associated with patient mortality with hepatocellular carcinoma, whereas tobacco smoking and hypertension were not.

Intragastric Stapled Pancreatic Pseudocystgastrostomy Under Endoscopic Guidance

Drainage of cystic contents is the standard treatment for case of pancreatic pseudocyst (PP) with symptoms, complications, or enlargement of the cyst itself. Here, we report an intragastric stapled pancreatic pseudocystgastrostomy involving a combination of laparoscopy and transoral endoscopy. The patient was a 56-year-old man with a history of heavy alcohol intake. He complained of abdominal pain and high fever during hospitalization because of pancreatitis. Diagnostic imaging revealed a large pseudocyst expanding from the pancreatic parenchyma to the anterior abdominal wall. Intragastric stapled pancreatic pseudocystgastrostomy under endoscopic guidance was performed for relief of compression and continuous fever. A 12-mm port was inserted into the peritoneal cavity in the subumbilical region to create a pneumoperitoneum. Initially, an endoscope was inserted transorally into the stomach to identify the region of the posterior gastric wall compressed by the cyst. Two 12-mm ports were created in the stomach using a Funada-style percutaneous endoscopic gastrostomy kit. After penetrating the gastric wall and the PP with laparoscopic coagulating shears, 950 mL of cyst fluid was aspirated. A cystgastrostomy was then accomplished using an Endo-GIA linear stapler. A 5-mm port was added, and reinforcement of the connection between the posterior gastric wall and the PP was performed by hand sewing. There were no intraoperative complications, and all wounds were closed from the outside. Oral intake was started on postoperative day 3, and the postoperative course was uneventful. There was no recurrence during a follow-up period of 36 months. As intragastric stapled pancreatic pseudocystgastrostomy under endoscopic guidance is safe and effective, it can be considered a useful alternative procedure for treatment of symptomatic PP.

Management of platinum-based chemotherapy-induced acute nausea and vomiting: is there a superior serotonin receptor antagonist?

The last decade has witnessed the great impact of 5-hydroxytryptamine-3 receptor (5-HT(3))antagonists in revolutionizing the management of platinum-based chemotherapy-induced acute nausea and vomiting (CINV). However, despite the availability of a variety of 5-HT(3) antagonists, little data is published to support superiority of one drug over another, leaving the choice of serotonin receptor antagonist largely empirical. The National Comprehensive Cancer Network and American Society of Clinical Oncology guidelines for management of chemotherapy-associated nausea and vomiting cleary endorse the use of serotonin receptor antagonist; however, no single agent is preferred over the rest. Data for patients (n=159) receiving platinum-based chemotherapy regimens were retrospectively collected . Patients getting 5-HT(3) antagonists without steriods or those with known history of brain metastasis, gastroparesis, and intestinal obstruction were not eligible for the study. Patient characteristics including age, gender, primary diagnosis, history of heavy alcohol intake, chemotherapy regimen administered , number of cycles, and Eastern Cooperative Group performance status at the start of therapy were noted. Primary outcome was the complete control of platinum-induced acute nausea and vomiting. Secondary outcome measures included control of > or = grade 1 nausea or vomiting, comparison of two doses of dexamethasone, and antiemetic eficacy among various platinum drugs. National Cancer Institute Common Toxicity Criteria version 2.0 was used to assess toxicity. A total of 126 patients received 369 cycles of platinum-based therapy. Dolasetron ( n=157), granisetron ( n=81), and ondansetron ( n=131) achieved complete control of vomiting in 89.8, 95.5, and 92.3% (p=0.67) of cycles, respectively. Respectively, complete nausea control was observed in 68.1, 75.3 and, 69.4% (p=0.50). Dexamethasone 20 mg was not superior to 10 mg in complete control of nausea and vomiting ( p= 0.15 and p=0.63, respectively). However, complete nausea control was signinficantly better in the subgroup of patients getting cisplatin-compared with carboplatin-based regimens (78.8% vs. 67.7%, p<0.05). No significant difference exists in the antiemetic efficacy of the three 5-HT(3) antagonists studied in controlling CINV when administered in combination with dexamethasone. Choicce of antiemetic regimen should therefore be based on drug cost.

Diabetes mellitus increases the risk of hepatocarcinogenesis in patients with alcoholic cirrhosis: A preliminary report

Diabetes mellitus (DM) has been reported to increase the risk of hepatocellular carcinogenesis in chronic liver diseases. This study aims to elucidate whether DM is an independent risk factor for the appearance of hepatocellular carcinoma (HCC) in patients with alcoholic cirrhosis. Forty-seven patients with alcoholic cirrhosis were retrospectively observed for a median of 6.8 years. The patients showed a history of heavy alcohol intake of 500 kg or more until the diagnosis of cirrhosis, and no patients had hepatitis B surface antigen, hepatitis B virus DNA measured by nested polymerase chain reaction, or antihepatitis C virus. During the observation period, HCC developed in nine patients (19.1%). Cumulative appearance rates of HCC were 10.5%, 23.8% and 33.3% at the end of the fifth, 10th and 15th years, respectively. When they were divided into two groups according to the association of diabetes, carcinogenesis rates in patients with (n = 11) and without (n = 36) DM, cumulative carcinogenesis rates were 32.7% and 3.2% at the end of fifth year, 32.7% and 20.2% at the tenth year, and 66.3% and 20.2% at the 15th year, respectively. Crude carcinogenesis rate in the patient with DM was significantly higher than that of patients without DM (P = 0.0034). Multivariate analysis disclosed a higher age (hazard ratio 28.1, P = 0.007), and association of DM (hazard ratio 21.7, P = 0.006) significantly affected future carcinogenesis rate. DM seemed to be an independent risk factor for hepatocarcinogenesis in the cohort study of patients with alcoholic cirrhosis.

Relative efficacy of various 5- hydroxytryptamine receptor antagonists in the prevention and control of acute nausea and vomiting associated with platinum-based chemotherapy

8623 Background: The introduction of 5-Hydroxytryptamine-3 receptor (5-HT3) antagonists has represented a significant clinical advance in the prevention and treatment of chemotherapy-induced nausea and vomiting (CINV), particularly for patients receiving highly emetogenic platinum-based regimens. However no study to date has compared the relative efficacy of Dolasetron, Granisetron, Ondansetron and Palonosetron with Dexamethasone in the prevention and control of acute CINV in patients undergoing platinum-based therapy. Methods: Retrospective data were reviewed for 207 consecutive patients receiving Platinum-based chemotherapy in our infusion center between November 1999 and August 2005. Patients receiving 5-HT3 antagonists without Dexamethasone (n=11) were not eligible for the study. Further 15 patients were excluded because of no documentation of CINV. The remaining 181 patients constitute the subject of this study. Patient characteristics including age, sex, race, diagnosis, history of heavy alcohol intake, chemotherapy regimen administered, number of cycles, and performance status at the start of therapy were noted. Primary outcome measure was complete control of acute CINV. National Cancer Institute Common Toxicity Criteria version 2.0 was used to assess toxicity. Results: The 181 patients received 572 cycles of platinum-based therapy. Dolasetron (n=157), Granisetron (n=81), Ondansetron (n=131) and Palonosetron (n=203) (each given with Dexamethasone) achieved complete control of vomiting in 89.8%, 95.5%, 92.3% and 88.1% (ρ=0.86) of cycles respectively. Respectively, complete nausea control was observed in 68.1%, 75.3%, 69.4% and 73.3% (ρ=0.35). DEX 20 mg was not superior to 10mg in complete control of nausea and vomiting (ρ=0.06 and ρ=0.67 respectively). Similarly complete control of nausea and vomiting (ρ=0.12 and ρ=0.10 respectively) was not significantly different in patients getting cisplatin compared to carboplatin based regimens. Conclusion: This study does not demonstrate a significant difference in the efficacy of the four 5-HT3 antagonists in controlling acute CINV. The higher dose of Dexamethasone confers no added benefit over the lower 10mg dose. No significant financial relationships to disclose.

Alcoholic Hepatitis With Leukemoid Reaction After Surgery

Alcoholic hepatitis (AH) is a clinicopathologic syndrome resulting from an excessive intake of alcohol. Leukemoid reactions (LRs) are characterized by a strikingly elevated granulocyte count over 40,000-50,000 cells/mm(3). Although a leukocytosis of 15,000-18,000 cells/mm(3) is frequently seen in AH, LRs are rare in this context. AH-associated LRs are a sign of poor prognosis and have a high mortality. A 64-year-old male with a history of heavy alcohol intake underwent a right hemicolectomy for cecal carcinoma. Preoperative laboratory data were normal with the exception of an albumin of 2.1 g/dL. Liver biopsies that were taken because of a nodular appearance revealed micronodular cirrhosis, steatohepatitis, and Mallory bodies. Postoperatively, the patient developed a leukocytosis that progressively increased to 72.6 cells/mm(3). He also developed signs of impaired hepatic and renal function. Extensive workup failed to reveal a source of infection. A trial of intravenous antibiotics had no impact on the leukocytosis. Methylprednisolone at a dose of 40 mg IV daily was started on postoperative day 9. The patient experienced a progressive decline in white blood count (WBC), which reached 25.2/mm(3) on postoperative day 14. However, he died on postoperative day 16. We conclude that the patient had AH-associated LR in the postoperative period, but died despite successful treatment of the LR with steroids.

Comparative Safety of Atorvastatin 80 mg Versus 10 mg Derived from Analysis of 49 Completed Trials in 14,236 Patients

Atorvastatin has been shown to reduce coronary events and revascularization procedures in patients with multiple risk factors for coronary heart disease. Recent studies with atorvastatin 80 mg support the overall safety of this dose during long-term treatment. However, physicians appear reluctant to use high doses of statins. A retrospective analysis of pooled data from 49 clinical trials of atorvastatin in 14,236 patients treated for an average period of 2 weeks to 52 months was conducted. The study compared the safety of atorvastatin 10 mg (n = 7,258), atorvastatin 80 mg (n = 4,798), and placebo (n = 2,180) and included analyses on treatment-associated adverse events; nonserious and serious adverse events related to the musculoskeletal, hepatic, and renal systems; the incidence of elevations of creatine kinase >10 times the upper limit of normal (ULN); and hepatic transaminases >3 times ULN. Percentages of patients experiencing > or =1 adverse event were similar across all 3 groups. Withdrawals due to treatment-related adverse events were observed in 2.4%, 1.8%, and 1.2% of patients in the atorvastatin 10 mg, atorvastatin 80 mg, and placebo groups, respectively. Serious adverse events were rare and seldom led to treatment withdrawal with any dose. Treatment-associated myalgia was observed in 1.4%, 1.5%, and 0.7% of patients in the atorvastatin 10 mg, atorvastatin 80 mg, and placebo groups, respectively. No cases of rhabdomyolysis were reported in any group. Persistent elevations in hepatic transaminases >3 times ULN were observed in 0.1%, 0.6%, and 0.2% of patients in the atorvastatin 10 mg, atorvastatin 80 mg, and placebo groups, respectively. The incidence of treatment-associated adverse events for atorvastatin 80 mg was similar to that of atorvastatin 10 mg and placebo. In conclusion, the results of this analysis support the positive safety profile of atorvastatin at the highest dose.

Human-immunodeficiency-virus-negative, Human-herpes-virus-8-negative Abdominal Cavity Primary Effusion Lymphoma

Primary effusion lymphoma (PEL) is an unusual class of non-Hodgkin's lymphoma, which is characterised by lymphomatous effusions in body cavities, but no associated mass lesions. It is usually associated with an immunodeficient state most often with the human immunodeficiency virus (HIV). We describe a case of a man with HIV-negative, human-herpes-virus-8 (HHV8)-negative PEL, with a history of heavy alcohol intake. The abdominal cavity was the only area involved; no solid tumour masses were observed on scanning, and the bone-marrow investigations were normal. The ascites contained numerous pleomorphic lymphoid, lymphoplasmacytoid cells of B-cell origin. The immunophenotyping was moderately positive for CD 38 and 138, and strongly positive for Ki 67. It is postulated that the immunosuppressed state in this patient may have been caused by the long history of heavy alcohol intake.

Large B‐cell lymphoma of the leg

A 74‐year‐old Mexican man presented with an 18‐month history of multiple, violaceous, coalescing, firm, tender nodules with an ulcer in the anterior aspect of the right leg (Fig. 1) and slightly infiltrated, ill‐defined erythematous plaques affecting the left leg and both forearms. He had not received any treatment for his condition. Past medical history was relevant for noninsulin‐dependent diabetes mellitus and hypertension without formal treatment and a history of heavy alcohol intake in his youth. A biopsy specimen of both plaque‐type lesions of the forearm and tumorous lesions of the leg showed a diffuse, nonepidermotropic mononuclear infiltrate throughout the dermis and extending to the subcutis. The infiltrate was composed of pleomorphic, atypical, large mononuclear cells (Fig. 2). Immunostaining with CD20 was positive for the atypical cells while CD3 was positive for normal appearing lymphocytes, characterized as reactive T cells. Additional laboratory and image studies ruled out extracutaneous involvement. The diagnosis of primary cutaneous large B cell lymphoma of the leg (LBCLL) was made. The patient was initiated on radiotherapy localized to the right leg with a very good initial response, nevertheless resolution was not achieved and the plaques in the rest of the limbs remained unchanged. Thus, the patient started chemotherapy with CHOP (Cyclophosphamide, Vincristine, Doxorubicin, Prednisone). He has currently finished his fourth cycle with this chemotherapy regimen. The tumorous lesions involuted leaving only residual hyperpigmentation (Fig. 3) and the plaques in the rest of the limbs disappeared, the area of the ulcer diminished considerably. There is still no evidence of extracutaneous involvement.Nodules and ulcer in the anterior aspect of the right legimageAtypical lymphocytes, with large, pleomorphic nuclei and multiple nucleoles. Positivity for CD20 antigen was demonstrated by immunohistochemical analysis (hematoxylin and eosin; X 600)imageResidual hyperpigmentation and granulation tissue after chemotherapyimage

Risk factors for hepatocellular carcinoma in Turkey.

The contribution of hepatitis B, hepatitis C, and excess alcohol intake to the development of hepatocellular carcinoma in Turkey was assessed. The study was conducted through a questionnaire sent to seven major medical referral centers in different regions of Turkey and is based on 207 patients seen in the period 1994-1997. Of the seven centers, two were located in West Turkey (54 patients), two were in Central Turkey (85 patients), and two were in south and southeast Turkey (68 patients). In 196 of the 207 patients (94.7%), there was a history of chronic liver disease, and in 180 patients (87%) liver cirrhosis was documented. Of the 207 patients, 116 (56%) had hepatitis B, 48 (23.2%) had hepatitis C, and 33 (15.9%) had a history of excess alcohol intake. Anti-delta testing was available in 69 of 116 patients with hepatitis B, and anti-HDV was positive in 13 of these patients (13/69, 18.8%). Of the 33 patients with a history of heavy alcohol intake, 18 had concomitant chronic viral hepatitis infection, and alcohol alone was the etiology of hepatocellular carcinoma in only 15 cases (7.2%). The distribution of etiologic factors was not homogenous in different geographical regions in Turkey. In central, south, and southeastern Turkey, the predominant etiology of hepatocellular carcinoma was hepatitis B, whereas in western Turkey the impact of hepatitis B, hepatitis C, and alcohol was similar. This study indicates that hepatitis B virus infection is the leading cause of hepatocellular carcinoma in Turkey, followed by hepatitis C infection and alcoholic liver disease.