Progression of fibrosis in liver transplant recipients with hepatitis C before and after sustained virologic response.

BACKGROUND: Liver transplant (LT) recipients with untreated hepatitis C (HCV) are at risk for cirrhosis graft failure. The advent of direct acting antiviral agents (DAA) has improved outcomes in HCV. AIMS: We aim to examine liver transplant outcomes and allograft fibrosis development/progression after sustained virologic response (SVR). METHODS: We performed a retrospective cohort study of 226 consecutive liver transplant recipients with HCV from 2007 to 2018. The cohort was split into transplants pre (Group A) and post (Group B) 2014 to reflect the introduction of DAAs. Fibrosis was monitored with liver biopsy and non-invasive imaging. RESULTS: Group B had significantly improved HCV treatment rates and earlier SVR compared to Group A, with a cumulative incidence rate of SVR at 2 years of 86.7% versus 15.4% (HR = .11, p < .001). Prior to achieving SVR, Group A demonstrated worsening of fibrosis stage per year (+.21, p < .001) whereas Group B showed minimal change on protocol annual biopsy (-.02, p = .80). After SVR, most patients were followed non-invasively and demonstrated stable or improved fibrosis stage over time. Patients undergoing transient elastography showed regression in fibrosis stage per year (-.19, p < .001). CONCLUSION: HCV patients undergoing LT after 2014 had higher rates of SVR and improved clinically relevant transplant outcomes, namely less graft loss and death relating to HCV. Fibrosis progression halted or improved after SVR in both cohorts, suggesting that LT recipients with SVR do not require fibrosis monitoring even with established fibrosis prior to SVR.

Assessment of Knowledge of Gluten-Free Diet Amongst Food Handlers in Hospitals.

Purpose: When admitted to the hospital, individuals with celiac disease rely on food handlers for provision of safe, uncontaminated gluten-free meals. We aimed to assess the knowledge of gluten-free diet (GFD) amongst individuals involved in meal preparation for patients.Methods: A questionnaire with 10 demographic and 35 test items to assess knowledge of GFD, including workplace scenarios encountered in meal preparation, was administered to food handlers including cooks, utility workers, dietary technicians, and supervisors in 2 tertiary care, university-affiliated hospitals. A score of ≥28 of 35 (≥80%) was considered a "pass".Results: A total of 72 individuals completed the study, mean age 40.3 ± 1.6 years, 75% female. Only 42 (56.8%) scored ≥80% and achieved a pass. The average score was 75.9% ± 13.4%, range 25.7%-100%. The supervisors had significantly higher scores (87.9% ± 11.4%) than utility workers (73.0% ± 11.4%; P = 0.01) and cooks (71.7% ± 14.5%; P = 0.01). Cooks had the lowest scores with 80% scoring <80%. Females scored higher than males (77.8% vs. 68.8%; P = 0.02).Conclusions: There are significant differences in GFD knowledge amongst various groups involved in food preparation in hospitals. The gaps identified in knowledge can potentially compromise the safety of patients with celiac disease. Targeted interventions to educate hospital food handlers about GFD are warranted. Registered Dietitians can play an important role in providing this education.

Assessment of Nutritional Adequacy of Packaged Gluten-free Food Products.

PURPOSE: There is concern about the nutritional quality of processed gluten-free (GF) products. The aim was to investigate the nutrient composition and cost of processed GF products compared with similar regular products. METHODS: Product size, price, caloric value, and macro- and micronutrient composition were compared between foods labeled "Gluten-free" and comparable regular products in 5 grocery stores in 3 Canadian cities. Data were calculated per 100 g of product. RESULTS: A total of 131 products were studied (71 GF, 60 regular). Overall, calories were comparable between GF and regular foods. However, fat content of GF breads was higher (mean 7.7 vs. 3.6 g, P = 0.003), whereas protein was lower (mean 5.0 vs. 8.0 g, P = 0.001). Mean carbohydrate content of GF pasta was higher (78 vs. 74 g, P = 0.001), whereas protein (7.5 vs. 13.3 g, P < 0.001), fibre (3.3 vs. 5.8 g, P = 0.048), iron (9% vs. 25%DV, P < 0.001), and folate content (5% vs. 95%DV, P < 0.001) were lower. Mean price of GF products was $1.99 versus $1.23 for regular products (P < 0.001). CONCLUSIONS: Some commonly consumed packaged GF foods are higher in fat and carbohydrates and lower in protein, iron, and folate compared with regular products. GF products are more expensive. Dietitians should counsel patients on the GF diet regarding its nutritional and financial impact.

The role of video-assisted feedback sessions in resident teaching: A pre-post intervention.

This article was migrated. The article was marked as recommended. Purpose: Despite providing a large component of teaching to trainees, internal medicine residents receive little feedback on their teaching ability. Methods: This was a single-center, mixed methods study of 19 senior internal medicine residents in Canada. Classroom-based teaching sessions delivered by the participants were individually video recorded. The individual recording was then watched by the participant and by two feedback facilitators, who then met for face-to-face feedback. Participants completed a self-reflective exercise after this intervention. Audience members of the recorded session and a post-feedback teaching session completed an evaluation form. Scores from the evaluation forms from each phase were analyzed with the Wilcoxon Signed-Rank Test. Inductive coding was performed for qualitative data from the feedback sessions and reflective exercises. Results: 19 residents participated. There was no statistical difference in the evaluation form scores between the pre-intervention and post-intervention teaching sessions. Mean scores varied from 4.6 to 5.0 out of 5.0 on combined pre-and post-intervention evaluations. 89% of participants found viewing their recorded session useful. 94% of residents stated the intervention was worth continuing. Common themes of feedback and self-evaluation included "time-management," "organization," "communication," and "environment." Conclusion: Video-assisted feedback of teaching improved self-perception of a resident's teaching ability.

Ramipril-associated cholestasis in the setting of recurrent drug-induced liver injury.

Aim: Angiotensin-converting enzyme inhibitors (ACEIs) are commonly used to treat hypertension. Although generally well tolerated, the adverse effects of ACEIs include hypotension, cough, acute kidney injury and hyperkalemia. Rare reports of ACEI-induced hepatotoxicity have been described, most notably a cholestatic pattern of injury related to captopril. A 67-year-old male presented to the emergency department with a three-week history of jaundice, pruritis and weakness. Eight weeks before, he began taking ramipril and clopidogrel. His past medical history was significant for previous acute cholestatic liver injury approximately 20 years earlier, which was attributed to methimazole. Abnormal blood work demonstrated aspartate aminotransferase (AST) 47 U/L, alanine aminotransferase (ALT) 46 U/L, total bilirubin 230 µmol/L, direct bilirubin 176 µmol/L, and alkaline phosphatase (ALP) 470 U/L. Abdominal ultrasound and magnetic resonance cholangiopancreatography showed no bile duct obstruction. Further work-up was negative for infectious, autoimmune, or other causes. Percutaneous liver biopsy showed marked cholestasis. With discontinuation of ramipril, the patient demonstrated prolonged cholestasis with partial biochemical improvement and was discharged after six weeks in hospital. This case represents the first described cross reactivity between ramipril and methimazole, illustrating the complex and poorly understood nature of DILI. Despite the relatively few instances of ACEI-induced liver hepatotoxicity, consideration should be given to discontinuation of ramipril in situations of unknown liver damage.

Duodenal Villous Atrophy in a TTG-Negative Patient Taking Olmesartan: A Case Report and Review of the Literature.

Olmesartan, an angiotensin II receptor antagonist used to treat hypertension, is associated with few adverse effects. Here, a case of severe sprue-like enteropathy and acute kidney injury is described in a 68-year-old male taking olmesartan for 3-4 years. He presented to hospital with a five-week history of diarrhea, vomiting, and a 20 lb weight loss. Anti-TTG was negative with a normal IgA. Biopsies of the distal duodenum and duodenal cap revealed marked blunting of the villi with near complete villous atrophy of the biopsies from the bulb. There was an increase in intraepithelial lymphocytes as well as neutrophils in the surface epithelium. The patient's diarrhea improved upon discontinuation of olmesartan and he returned to his previous weight. Repeat endoscopy four months later demonstrated complete resolution of inflammatory change with normal villous architecture. Long-term olmesartan use is associated with severe sprue-like enteropathy. The mechanism of intestinal injury is unknown. Duodenal biopsy results may mimic other enteropathies such as celiac disease. Physicians should consider medications as potential etiologies of enteropathy.