Recurrent early-onset severe obstetric cholestasis in a patient with two variants in the ABCB4 gene.

A 36-year-old patient presented with severe early-onset obstetric cholestasis on a background of having pre-term induction of labor at 33 weeks during her only previous pregnancy. The patient had significantly abnormal liver biochemistry with a bilirubin of 78 µmol/L, ALP of 318 u/L, ALT of 280 µmol/L, and bile acid levels of 420 µmol/L. The patient received ursodeoxycholic acid 750 mg 3 times a day, rifampicin 500 mg twice a day, aspirin 150 mg once a day, and metformin 500 mg 3 times a day. However, despite this, the patient still suffered from intractable pruritus and her bile acid level was still above the 100 µmol/L target that the obstetrics team was aiming for to avoid early delivery at 32 weeks. Due to the nature and severity of her cholestasis, the patient had a number of investigations done postnatally including genetic analysis, which confirmed that the patient was heterozygous for a pathogenic variant of the ATP-binding cassette subfamily B member 4 gene (c.959C>T [p.Ser320Phe]) and also a variant of unknown significance (c.1679C>T [p.Thr560Met]).

Vanishing Bile Duct Syndrome Associated With Non-Hodgkin's Lymphoma and Hepatitis E Virus Infection.

The vanishing bile duct syndrome (VBDS) is a condition secondary to inciting triggers resulting in destruction and eventual disappearance of intrahepatic bile ducts leading to cholestasis. The overall outcome varies and often depends on the nature of the precipitating cause. VBDS has been found to be associated with adverse drug reactions, infectious diseases, autoimmune diseases, ischemia, and humoral factors associated with malignancies and is often irreversible. The objective of this clinical case report is to highlight the need for a broad differential to include VBDS in similar scenarios to aid rapid diagnosis and management. We hope this could lead to a more favourable outcome for patients presenting with VBDS such as the one described in this case report with concurrent non-Hodgkin's lymphoma and infection with hepatitis E virus. To the best of our knowledge, this is the first ever reported case of VBDS associated with non-Hodgkin's lymphoma and hepatitis E virus infection.

COVID-19 Pneumonia: ST-segment Elevation Myocardial Infarction (STEMI) and Myocarditis.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with numerous cardiac complications. We describe a case of type 1 ST-segment elevation myocardial infarction (STEMI) with focal myocarditis unmasked in a patient infected with SARS-CoV-2 with no previous cardiac history, in the hope of increasing understanding of the severity and possible complications of coronavirus disease 2019 (COVID-19) and improving its clinical management.

The Use of CT Coronary Angiography and CT Fractional Flow Reserve in the Investigation of Patients With Suspected Coronary Artery Disease.

Objective To assess the diagnostic performance of CT fractional flow reserve (CT-FFR) and to assess whether its use in addition to CT coronary angiography (CTCA) changed the investigation and management of patients with suspected coronary artery disease (CAD). Method A retrospective case note review was carried out for 200 consecutive patients at Russells Hall Hospital, Dudley, United Kingdom, who had CTCA sent for Heartflow CT-FFR analysis (HeartFlow, Redwood City, CA) between January 2018 and December 2019. Results Patients with CT-FFR > 0.8 were significantly less likely to require further investigation with coronary angiography (p: < 0.00001) than those with CT-FFR < 0.8. The use of CT-FFR significantly reduced need for further functional imaging (6% vs 26%) (p: 0.00012). A total of 15 patients in this study had both a CT-FFR and an invasive FFR measured, with seven (46.66%) of the CT-FFRs correlating with the invasive FFR. Approximately 54% of patients who had a CT-FFR < 0.8 were found to have an invasive FFR of >0.8. Of the 56 patients who underwent coronary angiography, the CT Coronary Artery Disease-Reporting and Data System (CAD-RADS) and angiography CAD-RADS were the same in 66% of the cases with 82% of CT CAD-RADS results being within ±1 of the angiography CAD-RADS. Conclusion The use of CT-FFR alongside CTCA led to a significant reduction in need for coronary angiography and functional testing. Further studies are required to look at the diagnostic accuracy of CT-FFR in direct comparison with invasive FFR.

Retraction: The Use of CT Coronary Angiography and CT Fractional Flow Reserve in the Investigation of Patients With Suspected Coronary Artery Disease.

[This retracts the article DOI: 10.7759/cureus.7908.].

Challenges in implementing the 2015 BASHH guidelines for the appropriate use of post-exposure prophylaxis for HIV following sexual exposure.

The use of post exposure prophylaxis for human immunodeficiency virus (HIV) following sexual exposure (PEPSE) was retrospectively audited in an inner city genitourinary clinic against the 2015 national guidelines by the British Association for Sexual Health and HIV (BASHH). One-hundred out of a total of 101 patients (99%) had a baseline HIV test done. 82.1% (n=83) of patients were given PEPSE prescriptions fitting within recommended indications lower than the 90% target set by BASHH. 84.2% (n=85) of patients had PEPSE administered within 72 hours lower than the 90%. 61.4% (n=62) of patients were known to have completed four weeks of PEPSE lower than the 75% target. 61.4% (n=62) of patients were screened for sexually transmitted infections (STIs) lower than the 90% target. 59.4% (n=60%) of patients had post-PEPSE HIV bloods slightly lower than the 60% target.