Unconjugated Hyperbilirubinemia in Acetaminophen-Related Acute Liver Failure.

BACKGROUND In the absence of liver transplantation, the natural history of acetaminophen-induced liver failure is characterized by a progressive increase of liver function tests, including bilirubin mainly as its conjugated form. The presence of high levels of unconjugated bilirubin is more unusual; its etiology is unclear and its prognostic factor has been poorly investigated. CASE REPORT A 52-year-old man with a history of chronic analgesics, alcohol, and illicit drug abuse developed acute liver failure in relationship with the ingestion of largely supra-therapeutic doses of acetaminophen over the days preceding admission. The patient received the classical N-acetylcysteine treatment regimen for acetaminophen overdose. Clinical course was characterized by a progressive worsening of the neurological condition, evolving to grade IV encephalopathy. Coagulation disorders persisted, with factor V level <10%. He fulfilled the criteria for liver transplantation, but this option was rejected after a careful psychiatric evaluation. Laboratory investigations revealed a progressive increase in serum unconjugated bilirubin until his death. As evidence for hemolysis was lacking, acquired deficit in bilirubin glucuronidation appeared likely and diagnosis of Gilbert's syndrome was excluded. CONCLUSIONS After the exclusion of other causes of high unconjugated bilirubin levels, the progressive increase in unconjugated bilirubin can reflect a persistent defect in bilirubin conjugation in relationship with liver centrilobular injury, but the relationship with acetaminophen-glucuronidation is not known and there are insufficient data to affirm that the ratio unconjugated/conjugated bilirubin could be used as a prognostic factor.

[Usefulness of social and educational approach in adolescents and young adults with cancer: The Lille team's experience]. / Intérêt d'une approche socioéducative dans l'accompagnement des adolescents et jeunes adultes atteints de cancer : l'exemple lillois.

Within the second "Cancer plan" 2009-2013, the French national institute of cancer (INCa) recommended the implementation of programs dedicated to adolescents and youngs adults (AYA) with cancer. In this context and in parallel to the specific medical care developed for AYA, the Oscar-Lambret center created a psycho-social-educational team including among others a social worker (SW) and a special educational teacher (SET), offering multidisciplinary qualifications and views. The social approach, realized as a pair by SW-SET, takes into account every aspect of each AYA (family, academic, career/professional, personal, cultural aspects…). We expose the first 2 years' experience of this special program for AYA through diagnosis to remission time. For this period, 164 AYA were seen by the social professionals, with a total of 602 consultations in the unit. The number of these consultations depended on the needs of AYA and their family. Nevertheless, only 10 AYA required no further intervention (6.1 %). The study highlights that the social interventions are most frequently about scolarity, work and disability recognition. These 2 years of experience of the SW-SET team offered a way to reflect upon our values and our culture, and on the role of the social worker in a medical setting. Each AYA has a personal story, which affects significantly the way to overcome the challenges that come with the disease. Our findings underscore the need for AYA with cancer to have access to personalized supportive care, encouraging them in pursing their personal goals and rewarding themselves.