A Day-4 Lille Model Predicts Response to Corticosteroids and Mortality in Severe Alcoholic Hepatitis.

OBJECTIVES: Prednisolone therapy increases the risk of infections in patients with severe alcoholic hepatitis (SAH). We evaluated whether the use of the Lille Model at day 4 (LM4) is useful to predict response to prednisolone compared with the classic day 7 (LM7) in order to limit a futile exposure to corticosteroids. METHODS: We performed a retrospective analysis of a large multinational cohort of patients with SAH with Maddrey's discriminant function (DF) ≥32. Response to corticosteroids was assessed with LM4 and LM7, according to the validated cutoff value (CUV>0.45). Receiver operating characteristics (ROC) curves were constructed to determine the optimal CUV for LM4 and to compare accuracy between LM4, LM7, MELD (Model for End-Stage Liver Disease), and ABIC (age, bilirubin, international normalized ratio, and creatinine). Logistic regression models were constructed to predict 28- and 90-day mortality. Cox regression analysis was performed to assess long-term survival. RESULTS: A total of 163 (62.7%) out of 260 patients received corticosteroids. The median DF for the patients treated with corticosteroids was 64.1 (47.9-81.3). Overall 90-day mortality was 35.9%. The median LM4 and LM7 for the patients who received treatment was 0.39 (0.19-0.83) and 0.36 (0.13-0.77). LM4 was a strong independent predictor of 28-day mortality (OR 25.4, (95% confidence interval (CI) 5.1-126.8), P<0.001). By using LM4 with a CUV>0.45, 28- and 90-day survival was significantly higher for responders (90% and 76%) than non-responders (66% and 40%), P<0.001. Importantly, the area under the ROC curve for predicting mortality for LM4 was similar than the classic LM7 (0.77 vs. 0.75, respectively: P=0.558). CONCLUSIONS: LM4 is as accurate as LM7 in predicting response to corticosteroids, as well as 28- and 90-day mortality. Assessing the efficacy of prednisolone at an earlier time point can avoid a more prolonged futile use of this therapy.

Acute suppurative thyroiditis seeded from infective endocarditis and intravenous drug use.

Acute suppurative thyroiditis (AST) is a rare infection of the thyroid gland, and most patients are euthyroid upon presentation. We present an interesting case of a 42-year-old man with a history of intravenous drug use (IVDU) and poorly controlled type 2 diabetes mellitus who was admitted for sepsis and thyrotoxicosis from infective endocarditis (IE), AST, prostate abscess, and pyelonephritis. He suffered from a cerebral vascular accident (CVA) from septic embolic showering. Thyroid-stimulating hormone (TSH) was <0.10 mIU/L, and free thyroxine (T4) levels were>90 pmol/L. Methicillin-resistant Staphylococcus aureus (MRSA) was cultured in the patient's blood and urine. He was treated with prompt intravenous (IV) antimicrobials and source control from a transurethral resection of the prostate. This case demonstrates that AST can be a potential complication of IE and IVDU.

Clinical Review of Antidiabetic Drugs: Implications for Type 2 Diabetes Mellitus Management.

Type 2 diabetes mellitus (T2DM) is a global pandemic, as evident from the global cartographic picture of diabetes by the International Diabetes Federation (http://www.diabetesatlas.org/). Diabetes mellitus is a chronic, progressive, incompletely understood metabolic condition chiefly characterized by hyperglycemia. Impaired insulin secretion, resistance to tissue actions of insulin, or a combination of both are thought to be the commonest reasons contributing to the pathophysiology of T2DM, a spectrum of disease originally arising from tissue insulin resistance and gradually progressing to a state characterized by complete loss of secretory activity of the beta cells of the pancreas. T2DM is a major contributor to the very large rise in the rate of non-communicable diseases affecting developed as well as developing nations. In this mini review, we endeavor to outline the current management principles, including the spectrum of medications that are currently used for pharmacologic management, for lowering the elevated blood glucose in T2DM.

A rare benign intrathoracic mass in a patient with history of rocket explosion.

Thoracic splenosis is rare benign condition that follows trauma leading to diaphragmatic injury. Most of the patients including ours present with a clear traumatic event leading to autotransplantation of spleen in thoracic cavity. Mostly diagnosed incidentally and we need to avoid unnecessary workup including radiological and invasive. It is a very important case which signifies importance of good history taking and initial imaging for making diagnosis and making our pulmonogist and internist aware of this diagnosis.