The Impact of Metabolic Syndrome on the Prognosis of High-Risk Alcoholic Hepatitis Patients: Redefining Alcoholic Hepatitis.

Background: Alcoholic hepatitis (AH) is characterized by acute symptomatic hepatitis associated with heavy alcohol use. This study was designed to assess the impact of metabolic syndrome on high-risk patients with AH with discriminant function (DF) score ≥ 32 and its effect on mortality. Methods: We searched the hospital database for ICD-9 diagnosis codes of acute AH, alcoholic liver cirrhosis, and alcoholic liver damage. The entire cohort was categorized into two groups: AH and AH with metabolic syndrome. The effect of metabolic syndrome on mortality was evaluated. Also, an exploratory analysis was used to create a novel risk measure score to assess mortality. Results: A large proportion (75.5%) of the patients identified in the database who had been treated as AH had other etiologies and did not meet the American College of Gastroenterology (ACG)-defined diagnosis of acute AH, thus had been misdiagnosed as AH. Such patients were excluded from analysis. The mean body mass index (BMI), hemoglobin (Hb), hematocrit (HCT), and alcoholic liver disease/non-alcoholic fatty liver disease index (ANI) were significantly different between two groups (P < 0.05). The results of a univariate Cox regression model showed that age, BMI, white blood cells (WBCs), creatinine (Cr), international normalized ratio (INR), prothrombin time (PT), albumin levels, albumin < 3.5, total bilirubin, Na, Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), MELD ≥ 21, MELD ≥ 18, DF score, and DF ≥ 32 had a significant effect on mortality. Patients with a MELD greater than 21 had a hazard ratio (HR) (95% confidence interval (CI) of 5.81 (2.74 - 12.30) (P < 0.001). The adjusted Cox regression model results showed that age, Hb, Cr, INR, Na, MELD score, DF score, and metabolic syndrome were independently associated with high patient mortality. However, the increase in BMI and mean corpuscular volume (MCV) and sodium significantly reduced the risk of death. We found that a model including age, MELD ≥ 21, and albumin < 3.5 was the best model in identifying patient mortality. Our study showed that patients admitted with a diagnosis of alcoholic liver disease with metabolic syndrome had an increased mortality risk compared to patients without metabolic syndrome, in high-risk patients with DF ≥ 32 and MELD ≥ 21. A bivariate correlation analysis revealed that patients with AH with metabolic syndrome were more likely to have infection (43%) compared to AH (26%) with correlation coefficient of 0.176 (P = 0.03, CI: 0.018 - 1.0). Conclusion: In clinical practice, the diagnosis of AH is inaccurately applied. Metabolic syndrome significantly increases the mortality risk in high-risk AH. It signifies that the presence of features of metabolic syndrome modifies the behavior of AH in acute settings, warranting different therapeutic strategies. We propose that in defining AH, patients overlapping with metabolic syndrome may need to be excluded as their outcome is different with regard to risk of renal dysfunctions, infections and death.

New precontoured long locking plate for proximal metadiaphyseal fractures of the humerus: a cadaveric study for its use with the minimally invasive technique.

BACKGROUND: The purpose of this study was to identify nerves at risk when using a minimally invasive plate osteosynthesis precontoured long proximal humerus locking plate and to evaluate the risk of injury to deltoid insertion and brachialis muscle. METHODS: Ten cadaveric upper limb specimens were used. A transdeltoid anterolateral approach was performed proximally and a second anterior approach was performed distally. A 14-hole "low" long precountored ALPS locking plate (Biomet Trauma; Zimmer Biomet, Warsaw, IN, USA) was used. Subsequently, anatomic dissection to measure the anatomic relationship of the plate with the deltoid insertion, with the brachialis muscle, and with the axillary, radial, and musculocutaneous nerves was performed. RESULTS: The mean humeral length was 302 mm (standard deviation 52.3, 99% confidence interval: 259.3-344.6). In 6 specimens, the axillary nerve was located at the level of the third row of holes of the plate; in 3 specimens, at the level of the fourth row; and in one specimen, at the level of the second row. The distance between the plate and the musculocutaneous nerve was on average 10.2 mm (standard deviation 4, 99% confidence interval: 6.9-13.5) and between the plate and the radial nerve was on average 7.9 mm (standard deviation 4.7, 99% confidence interval: 4-11.8). The plate pierced the anterior distal fibers of the deltoid in all specimens. In 8 specimens, no brachialis muscle fibers were located under the plate. CONCLUSIONS: The use of the long precontoured 14-hole ALPS locking plate with the minimally invasive plate osteosynthesis technique, previously identifying the axillary and musculocutaneous nerves, is feasible; however, the distances between the plate and the nerves remain low, so caution should be maintained. Despite the curved design of the plate, the deltoid insertion is partially compromised in all cases.

Knee Examination under Anesthesia: Development of a Predictive Score for Partial Anterior Cruciate Ligament Tears.

PURPOSE: To determine the accuracy of knee examination under anesthesia (EUA) and develop a prognostic score for partial anterior cruciate ligament (ACL) tears. MATERIALS AND METHODS: A total of 229 patients with an ACL injury were included. Knee EUA was performed using the Lachman test, pivot shift test and arthrometric maximum manual side-to-side difference (AMMD) test. The arthroscopic examination is the gold standard for the diagnosis of partial and complete ACL tears, which was compared with EUA findings. Multivariate logistic regression was estimated, and the significant variables were used to develop a predictive score. RESULTS: The relative risk for a complete tear with Lachman 2+ was 8.55 (range, 3.5 to 20.7) and 53.04 (range, 6.7 to 417) with Lachman 3+, compared to Lachman 1+. Negative pivot shift was reported in 23 cases in the partial tear group (76.7%) and in 22 in the complete tear group (11.1%). The AMMD was 3.5 mm in the partial tear group and 5.4 mm in the complete tear group (p＜0.05). A prognostic score of less than five suggested the presence of a partial ACL tear. The score showed 81.1% sensitivity and 68.7% specificity. CONCLUSIONS: Partial ACL tears can be differentiated from complete tears with Lachman test, pivot shift test, and AMMD test.

Prevalence and risk factors of acute-on-chronic liver failure in a single center from Argentina.

AIM: To study the prevalence, characteristics, risk factors and mortality at 28 d of acute-on-chronic liver failure (ACLF). METHODS: A total of 100 cirrhotic patients admitted to our hospital for more than one day were included during the period between June 2013 and December 2015. We used the European Association for the Study of the Liver-Chronic Liver Failure-Consortium diagnostic criteria for ACLF, considering it as the acute decompensation of cirrhosis associated with the presence of one or more organ failure. For the diagnosis of organic failure the Chronic Liver Failure-Sequential Organ Failure Assessment score was used. Our population was divided into patients with and without ACLF. Clinical characteristics, presence of precipitating events, potential risk factors for developing ACLF and causes of mortality were analyzed. Mortality at 28 d was evaluated. RESULTS: Twenty-nine patients (29%) developed ACLF criteria. Alcoholism, detected in 58 patients (58%), was the major etiological agent of cirrhosis. Bacterial infections were recognized as a precipitating event in 41.3% of cases and gastrointestinal bleeding in 27.5%. No precipitating event was identifiable in 27.5% of patients with ACLF. Comparing patients with and without ACLF, statistically significant risk factors were: Child Pugh score 10.2 ± 2.1 vs 8.4 ± 1.6 (P ˂ 0.0001), MELD score 20.7 ± 8.5 vs 12.3 ± 4 (P ˂ 0.0001), presence of ascites 27 (93%) vs 43 (60.5%) (P = 0.001), leukocytosis 15300 ± 8033 per cubic millimeter vs 10770 ± 5601 per cubic millimeter (P ˂ 0.0001), and high plasma levels of C reactive protein values 50.9 ± ​​46.4 mg/L vs 28.6 ± 23.4 mg/L (P ˂ 0.0019). Mortality rate was 62% (18 patients) vs 5.6% (4 patients), respectively (P < 0.0001). CONCLUSION: We observed that the ACLF is a frequent entity in this group of patients and has a significantly higher mortality rate.

Hybrid Repair of Aortic Arch Aneurysms with Endografting of the Ascending Aorta.

BACKGROUND: Different "hybrid" techniques that combine open debranching of the supra-aortic vessels with endografting of the aortic arch have emerged as alternatives to the open arch repair in high-risk patients. This study aims to review the early and mid-term results of single-stage hybrid arch repair with ascending aorta stent graft deployment for aortic arch aneurysms and dissections. METHODS: Between June 2006 and May 2015, five consecutive patients, with an age range of 54-78 years, with complex aortic arch diseases, were treated with a hybrid approach in which the endograft had a proximal landing zone in the ascending aorta. Indications included: acute and chronic type A aortic dissections and three arch aneurysms associated with distal aortic pathology. Length of postoperative clinical and imaging follow-up ranged from 10 to 121 months and was completed in all patients. RESULTS: Technical success of the endografting was achieved in all cases. There was one in-hospital mortality secondary to pulmonary embolism, one case of retrograde type A aortic dissection (RTAD) detected before discharge and one case of late type Ib endoleak that required an endografting procedure. No postoperative stroke or transient or permanent spinal cord ischemia occurred. CONCLUSION: Hybrid arch repair with endograft landing in zone 0 may decrease mortality and morbidity in high-risk patients. doi: 10.1111/jocs.12735 (J Card Surg 2016;31:341-347).

A rare case intractable diarrhea secondary to Clostridium difficile and cytomegalovirus coinfection.

PATIENT: Male, 63 FINAL DIAGNOSIS: Cytomegalo virus (CMV) infection Symptoms: Diarrhea Medication:- Clinical Procedure:- Specialty: Infectious Diseases. OBJECTIVE: Unusual clinical course. BACKGROUND: Coinfection with cytomegalovirus in a patient with Clostridium difficile persistent diarrhea and colitis can lead to a delay in diagnosis and treatment. CASE REPORT: A 63-year-old man with squamous cell carcinoma of the lower lip, status post surgical resection and currently on chemoradiation presented with intractable diarrhea and abdominal pain. Initial workup showed Clostridium difficile diarrhea with pancolitis. Diarrhea persisted despite being on antibiotics and bacteriological cure for C. difficile. Further noninvasive work up revealed associated cytomegalovirus infection, and patient had a dramatic response to ganciclovir without any relapse. CONCLUSIONS: Physicians should be cognizant about other causes of diarrhea and colitis in immunocompromised patient when treatment for primary diagnosis fails to resolve their symptoms.

Internal mammary artery dilatation in a patient with aortic coarctation, aortic stenosis, and coronary disease. Case report.

The ideal surgical approach is unclear in adult patients with coarctation of the aorta that is associated with other cardiovascular pathologies that require intervention. Standard median sternotomy allows simultaneous, coronary revascularization surgery, valve replacement and repair of aortic coarctation. However the collateral circulation and the anatomy of the mammary arteries must be determined, to avoid possible complications. We report a case of a 69 year-old man with aortic coarctation, aortic stenosis, coronary artery disease and internal mammary artery dilatation who underwent concomitant surgical procedures through a median sternotomy.

Pulmonary embolism due to biological glue after repair of type A aortic dissection.

Biological glue is increasingly used in cardiac surgery. We report a case of type A aortic dissection repair that was complicated by subsequent pulmonary embolism due to BioGlue(®) (Cryolife Inc, Hennesaw, GA, USA). To our knowledge this is the first report of a case with this complication.