Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease (NAFLD) defines a condition of hepatic steatosis with or without hepatic injury. NAFLD is increasing in prevalence worldwide and presents a public health burden. Most patients are asymptomatic, although some present with fatigue and right upper quadrant pain. NAFLD is discovered incidentally when patients have elevated liver enzymes or fatty liver is seen on imaging modalities. Imaging studies can confirm fatty deposits in the liver, but needle biopsy is needed to determine degree of inflammation. The mainstay of treatment is weight loss and controlling diabetes and hyperlipidemia. Liver transplantation is considered when disease progresses to cirrhosis.

Fatal pulmonary embolism update: 10 years of autopsy experience at an academic medical center.

OBJECTIVE: To investigate the rate of death caused by pulmonary embolism (PE) and the antemortem performance in diagnosis and treatment of PE. DESIGN: A systematic search of cases involving fatal PE via PowerPath® (Sunquest) followed by chart review. SETTING: An academic medical centre located in San Diego, United States of America. PARTICIPANTS: Postmortem cases with pathological findings of PE. MAIN OUTCOME MEASURES: After data collection and collation, the data were subject to analysis. RESULTS: From 2002 to 2012, PE was identified as the mechanism of death in 108 of 982 cases (11%, 95% CI 9.01-12.99%) at an institution with an average autopsy rate of 30% ± 0.07%. Excluding cases where care was withheld (by advance directive) or unavailable, 29 of 108 were eligible for antemortem treatment for PE. In 31% (nine of 29) of these cases the diagnosis of PE was considered antemortem. Only three of 29 were given thrombolytics despite only one case being contraindicated. CONCLUSION: The rate of PE-related death is consistent with most other autopsy series and major epidemiologic studies despite advances in system wide deep venous thrombosis prophylaxis. The results validate previous studies that this diagnosis is often missed but probably improving compared to historical standards. Even when the diagnosis is considered, however, thrombolytics are not routinely given, even without contraindications. The cause of this failure to treat may require further study with comparison to patients that were treated to determine the utilization of this treatment. It also underscores the continued difficulty in the diagnosis of this disease.

Occult intraocular trauma: evaluation of the eye in an austere environment.

BACKGROUND: Physicians deployed to austere environments often encounter the challenge of needing to make clinical decisions based upon rudimentary history and physical examination. These skills, however, can be difficult for many to rely on, with the many subtleties of examining the eye, when they are normally accustomed to relying on sophisticated modalities to establish diagnosis. OBJECTIVES: This case is a model for evaluating eye trauma in an austere or hostile environment. CASE REPORT: A 25-year-old male U.S. Marine was fired upon at a Mexican Army checkpoint where he sustained glass shrapnel injuries, the most serious being to his right eye. He was taken from a detention facility to a Mexican hospital, where he was evaluated and given the diagnosis of corneal laceration. Twelve hours later, a U.S. Navy physician arrived to evaluate the patient; he was allowed limited access to the patient. His ophthalmologic examination revealed a closed corneal laceration on the right eye, worse than 20/800 vision, absent red reflex, and obscured funduscopic examination. These findings made it impossible to rule out globe penetration. The patient was released 48 h later to a U.S. Naval Hospital, where intraocular foreign bodies were confirmed by imaging and he was taken to emergency surgery. CONCLUSION: This case illustrates that even under austere conditions, a focused history and evaluation can reveal the likelihood of occult intraocular foreign body, thereby triaging the patient for emergency surgery.