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Editorial Board:
Emmet B. Keeffe, MD (Chair); |
MAY 2004
CHRONIC HEPATITIS C VIRUS (HCV) INFECTION
Impact of steatosis. Amedeo Lonardo et al recently
reviewed the significance of steatosis in HCV infection. Steatosis may be attributed to a direct
effect of HCV on hepatic lipid metabolism leading to triglyceride accumulation
through inhibition of export proteins required for VLDL assembly and
secretion. Evidence suggests that
steatosis may contribute to progression of fibrosis in HCV infection due to an
increased sensitivity of steatotic livers to oxidative stress and
cytokine-mediated injury. A study by
Heather Patton et al. analyzed biopsies from 574 chronic HCV patients at a
single center to evaluate the impact of steatosis on disease progression and
treatment outcomes. Severity of
steatosis was associated with body mass index, duration of infection, and
genotype 3 HCV infection. In genotype 1
HCV infection, fibrosis was associated with severity of steatosis. HCV genotype 1-infected patients who achieved
a sustained virological response had lesser degrees of steatosis prior to
treatment than responders. In addition,
patients who had an early virologic response (EVR) were more likely to have
grade 0 steatosis prior to the start of therapy compared to those without an
EVR. In an accompanying editorial, Francesco Negro indicated that the data from this large
study adds strong evidence that steatosis is of diagnostic significance in
chronic HCV infection. (Lonardo A, et al. Gastroenterology
2004;126:586-597; Patton HM, et al. J Hepatol 2004;40:484-490; Negro F. J Hepatol 2004;40:533-535)
NONALCOHOLIC STEATOSIS (NASH)
UDCA treatment.
Keith Lindor and colleagues randomized 166
patients with NASH to receive UDCA (13 to 15 mg/kg/day) or placebo for 2 years
in a double-blind study. A total of 126
patients completed 2 years of treatment, and pre- and post-treatment liver biopsies
were available in 107 patients. Serum
liver biochemistry tests were stable or improved in both treatment groups. Liver biopsy changes in steatosis,
necroinflammation, and fibrosis occurred with a similar frequency in the UDCA
and placebo groups. These data indicate
that UDCA is not effective therapy for NASH.
(Lindor KD, et al. Hepatology 2004;39:770-778)
LIVER FAILURE
Minimal hepatic encephalopathy (MHE) impairs fitness to
drive. MHE is a
mild neurocognitive disorder present in patients with cirrhosis that is not
detected by standard neurological examination.
However, the impairment of attention and diminished speed of mental
processing associated with MHE may affect the ability to drive an automobile. Christian Wein et
al evaluated 48 patients with cirrhosis for MHE (Number Connection Test Part A,
Digit Symbol Test, and Complex Choice Reaction Test) and the ability to drive a
car. Fourteen patients were identified
as having MHE. The driving performance
of the 48 patients and 49 control subjects with normal liver findings were
assessed by a professional driving instructor who was blinded to the subject's
diagnosis. The driving scores of
patients with MHE were lower than those of cirrhotic patients without MHE and
controls. The instructor had to
intervene in the driving of 5 MHE patients to avoid an accident. Thus, patients
with MHE are not fit to drive. In an
accompanying editorial, Juan Cordoba and Roy Lucke
recommended that patients with MHE undergo neuropsychologic screening and a
specialized assessment of driving fitness.
(Wein C, et al. Hepatology 2004;39:739-745;
PYOGENIC LIVER ABSCESS
Catheter drainage vs. needle aspiration. Simon Yu et al conducted a study
over a 5-year period that enrolled 64 consecutive patients with pyogenic liver
abscess. The patients were treated with
intravenous antibiotics and were randomized to receive either continuous
catheter drainage or intermittent needle aspiration. Although a statistical difference was not
observed, needle aspiration was associated with a higher treatment success
rate, a shorter duration of hospitalization, and a lower mortality rate than
continuous catheter drainage. These
findings suggest that intermittent needle aspiration is at least as effective
as continuous catheter drainage for the treatment of pyogenic liver abscess and
should be considered as a first-line drainage approach because it is a simple
and relatively inexpensive procedure to perform. (Yu SCH, et al. Hepatology 2004;39:932-938)
CHOLANGIOCARCINOMA
Incidence and risk factors.
Cholangiocarcinoma is associated with a poor prognosis and limited
treatment options. Yasser
Shaib and others used data from the Surveillance
Epidemiology and End Results program to calculate incidence rates for
intrahepatic cholangiocarcinoma (ICC) between the years 1975 and 1999. A total of 2,864 ICC patients were identified
and the incidence of ICC was found to have increased by 165% during the study period. There were no changes detected in the
proportions of patients with early stage disease, thus suggesting a true
increase in the incidence of ICC. While
the 1-year survival rate increased from 15.8% in 1975-1979 to 26.3% in
1995-1999, the 5-year survival rates were observed to be similar (2.6% vs.
3.5%). In a second study, Kelly Burak and associates at the Mayo Clinic (
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