Nodular regenerative hyperplasia of the liver and cutaneous T-cell lymphoma: an unreported association.

Nodular regenerative hyperplasia of the liver -a type of noncirrhotic portal hypertension- is a rare condition of unknown etiopathogenesis that has been associated with multiple disorders, including diverse types of hematologic disease. We report the case of a 36-year-old female patient diagnosed with cutaneous T-cell lymphoma of the mycosis fungoides variety, staged as T2N0M0B0, where a transjugular liver biopsy demonstrated the presence of nodular regenerative hyperplasia with a hepatic venous pressure gradient of 15 mm Hg. The study was triggered by the incidental radiologic finding of hepatomegaly with indirect evidence of portal hypertension. We are not aware of any previous reports on the association of nodular regenerative hyperplasia with mycosis fungoides in the medical literature.

Monitoring the natural evolution and response to treatment of post liver transplant recurrent hepatitis C using transient elastography: preliminary results.

OBJECTIVES: To perform a prospective analysis of changes in liver stiffness (LS) using transient elastography (TE) in a consecutive series of patients with post-liver transplant (LT) recurrent hepatitis C, either left to their natural evolution or receiving antiviral treatment. METHODS: We examined the results from 17 comparisons of TE (baseline vs follow-up) from 11 patients. We evaluated: (1) upon inclusion in the study: age, sex, genotype, time transpired since LT, and baseline fibrosis (F0-4; Scheuer), and (2) during the follow-up period: time elapsed between the two TE and either specific treatment (B) or absence of treatment (A). RESULTS: Mean patient age was 56.8 ± 7.9 years, with a male/female ratio of 10:1. Ten of the eleven patients had genotype 1b. The median time transpired between the LT and inclusion in the study was 28 months (range: 6-142 months). The mean time transpired between the two TE was 11.3 ± 4.5 months. In the 11 patients from group A (9 F1/2 F2; 13 "paired" TE), a predictable increase in LS was produced in 10 cases and a paradoxical result was produced in 3 cases. In the four patients in group B (3 F2/1 F1; 4 "paired" TE), a decrease in LS was produced in 3 cases and a paradoxical result in 1 case. CONCLUSIONS: In our study of patients left to their natural evolution, a slow increase of LS was normal. However, antiviral treatment appeared to decrease LS. TE can be very useful as a complementary test to biopsy for monitoring post-LT recurrent hepatitis C. A longer follow-up period and larger sample size could confirm these preliminary results.

Prevalence and characteristics of bone disease in cirrhotic patients under evaluation for liver transplantation.

BACKGROUND: We performed a retrospective study to examine the prevalence of bone disease (BD) among cirrhotic patients being evaluated for liver transplantation (OLT) using bone densitometry dual-energy x-ray absorptiometry in the hip/femoral neck and lumbar spine. The associations of BD with demographic and clinical data, disease etiology and liver function were studied by univariate and multivariate logistic regression analyses. Osteopenia and osteoporosis were defined by World Health Organization criteria. RESULTS: We included 486 patients (79% men of mean age, 53 ± 8.8 years (range, 21-69) who included 62.6% smoker and 23.7% diabetic subjects. Body mass index (BMI) was 28.8 ± 5.7 kg/m(2) (range, 16-43). The liver disease was Child-Pugh class A (22%), B (51%), or C (27%); the Model for End-Stage Liver Disease (MELD) score was 14.6 ± 5.4 (range, 7-33). The disease etiology was alcohol (59%), hepatitis C (32%), hepatitis B (10%), primary biliary cirrhosis (PBC) (2.3%), secondary biliary cirrhosis, (2%) or other causes (10%). In all, 350 patients (72%) had BD in the hip/femoral neck and/or lumbar spine: Global hip, 26% (osteopenia, 22%; osteoporosis, 4%); femoral neck, 48% (osteopenia, 43%; osteoporosis, 5%) and lumbar spine, 63% (osteopenia, 40%; osteoporosis, 23%). Univariate analysis showed the BD risk to increase with the following variables: Female gender (odds ratio [OR], 1.88; P = .023) and lower BMI (OR, 0.95; P = .012). Upon multivariate analysis, female gender (OR, 2.43; P = .004), lower BMI (OR, 0.96; P = .016), and tobacco use (OR, 1.59; P = .043) were significant. PBC showed BD in 100% of cases. By adjusting bone mineral density (BMD) values to age (Z-score) in relation to that defined by T-score, we observed a decrease in BD prevalence in both the femoral neck (20% vs 48%) and the lumbar spine (44% vs 63%). CONCLUSION: BD, especially in the lumbar spine, is common among cirrhotic patients under evaluation for OLT. Cirrhosis is a major BD risk factor that remains even when BMD values are adjusted for age. Female gender, lower BMI, and tobacco consumption are major risk factors for BD in cirrhotic patients. Bone densitometry must be included in the OLT evaluation of all patients.

Response to vaccination against hepatitis B virus with a schedule of four 40-µg doses in cirrhotic patients evaluated for liver transplantation: factors associated with a response.

We performed a retrospective study to evaluate the rate of and factors associated with a response to recombinant hepatitis B virus (HBV) vaccination using 4 intramuscular doses (40 µg) administered at 0, 1, 2, and 6 months among 278 cirrhotic patients being evaluated for orthotopic liver transplantation (OLT). We re-vaccinated 57 non-responders with the same schedule. The 39.2% overall response rate to vaccination included 36% after three and 40.7% after four doses, namely, a median anti-HBs level of 100 IU/mL (range, 10 to 1000 IU/mL). The 51% revaccination response rate achieved a median hepatitis B surface antibody (anti-HBs) level of 99 IU/mL (range, 11 to >1000 IU/mL). Upon univariate analysis, variables associated with a higher response were: better liver function (Child-Pugh class [A, 53.8% B, 33.3%, C, 30.1%; P = .002), Model for End-stage Liver-Disease (MELD) score (11.4 versus 13.6; P = .001]), absence of diabetes (43.6% versus 20.8%; P = .002), presence of isolated hepatitis B core antibody (anti-HBc) positivity (80% versus 37.7%; P = .007), and younger age (< 45 years, 52.2%; range, 45 to 55 years, 40.4%; > 55 years, 34.1%; P = .031). Upon multivariate logistic regression analysis, lower MELD score (odds ratio [OR]: 0.922; P = .046), absence of diabetes (OR:0.359; P = .008) and isolated anti-HBc positivity (OR:5.826; P = .034) were associated with a higher response. No differences were observed to be associated with gender, weight, body mass index, etiology or tobacco consumption. Among the same patient cohort (n = 79), the responses after the third and fourth doses were 36.7% and 51.9% respectively. In conclusion, the response rate to HBV vaccination in cirrhotic patients evaluated for OLT reached more than 35% among those who received at least 3 doses. It was higher among patients who showed isolated anti-HBc positivity, better liver function, younger age, and non-diabetic status. The fourth dose only increased the response rate by 24% over that obtained after the first three doses, whereas a revaccination achieved a 50% response rate, which probably accounts for revaccination after no response to 3 doses. Vaccination should be introduced against HBV in the early stages of the disease.

Prevalence of hepatitis B and A virus markers and vaccination indication in cirrhotic patients evaluated for liver transplantation in Spain.

In the absence of immunity, vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV) is recommended for patients with chronic liver disease and those evaluated for liver transplantation (OLT) HAV and HBV infections after OLT which are frequent in this setting, are associated with a worse prognosis. The aim of this study was to estimate the need for vaccination against HBV and HAV among cirrhotic patients who were candidates for OLT and associations with gender, age, and etiologic factors. HBV and HAV serological markers HBsAg, anti-HBc, antiHBs, immunoglobulin G (IgG)-anti-HAV were investigated among 568 patients, including 75% men. The overall mean age was 53.6 ± 8.9 years range 17-69, and 20% were diabetic. This etiologies were alcohol (68%), hepatitis C virus (35%) or other causes (10.4%). Child-Pugh classes were: A (26%), B (44%), and C (30%). In contrast with 359 patients (63.2%) who had negative HBV markers, 209 (36.8%) were positive: HBsAg (+), 43 (7.6%), isolated anti-HBc (+), 57 (10%), isolated anti-HBs (+), 19 (3.3%), anti-HBc (+)/anti-HBs (+), 90 (15.8%). HBV vaccine indication was performed in 416 patients (73.2%) who either had negative HBV markers or isolated anti-HBc (+). It was more frequently performed in women (82.3% versus 70.3%, P = .005), albeit with no differences according to age or etiology. There were only 8.2% (44/538) IgG-anti-HAV-negative, an indication for vaccination against HAV, which was more frequent affecting patients who were younger [≤ 45 years (27.6%), 46-55 (7.2%), >55 (2.6%); P < .0001)]; nondiabetic (9.5% versus 2.8%, P = .023); nonalcoholic (11.4% versus 6.6%, P = .056); and displayed negative HBV markers (10.2% versus 4.6%, P = .023). Only three patients with IgG-anti- HAV (-) were over 60 years. In conclusion, there is a frequent indication for HBV vaccination among cirrhotic and especially HAV vaccine for under 45 year old patients undergoing evaluation for OLT.

Study of colorectal mortality in the Andalusian population.

OBJECTIVES: to provide up-to-date information and to analyze recent changes in colorectal cancer mortality trends in Andalusia during the period of 1980-2008 using joinpoint regression models. PATIENTS AND METHODS: age- and sex-specific colorectal cancer deaths were taken from the official vital statistics published by the Instituto de Estadística de Andalucía for the years 1980 to 2008. We computed age-specific rates for each 5-year age group and calendar year and age-standardized mortality rates per 100,000 men and women. A joinpoint regression analysis was used for trend analysis of standardized rates. Joinpoint regression analysis was used to identify the years when a significant change in the linear slope of the temporal trend occurred. The best fitting points (the "join-points") are chosen where the rate significantly changes. RESULTS: mortality from colorectal cancer in Andalusia during the period studied has increased, from 277 deaths in 1980 to 1,227 in 2008 in men, and from 333 to 805 deaths in women. Adjusted overall colorectal cancer mortality rates increased from 7.7 to 17.0 deaths per 100,000 person-years in men and from 6.6 to 9.0 per 100,000 person-years in women Changes in mortality did not evolve similarly for men and women. Age-specific CRC mortality rates are lower in women than in men, which imply that women reach comparable levels of colorectal cancer mortality at higher ages than men. CONCLUSIONS: sex differences for colorectal cancer mortality have been widening in the last decade in Andalusia. In spite of the decreasing trends in age-adjusted mortality rates in women, incidence rates and the absolute numbers of deaths are still increasing, largely because of the aging of the population. Consequently, colorectal cancer still has a large impact on health care services, and this impact will continue to increase for many more years.

Neuralgia amiotrófica (síndromede Parsonage-Turner) de presentaciónbilateral en una paciente intervenida por abdomen agudo / Amytrophic neuralgia (Personage-Turner syndrome) with bilateral presentation in a patient operated on account of surgical abdomen

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