Influence of gut bacteria on development and progression of non-alcoholic fatty liver disease

The intestine of the human contains a dynamic population of microbes that have a symbiotic relationship with the host. In addition, there is an effect of the intestinal microbiota on metabolism and digestion. Non-alcoholic fatty liver disease (NAFLD) is a common cause worldwide of hepatic pathology and is thought to be the hepatic manifestation of the metabolic syndrome. In this review we examine the effect of the human microbiome on the components and pathogenesis of the metabolic syndrome. We are now on the threshold of therapeutic interventions on the human microbiome in order to effect human disease including NAFLD.

Non-alcoholic fatty liver disease - the heart of the matter

Non-alcoholic fatty liver disease (NAFLD) is one of the most common forms of chronic liver disease in the Western world. There is a close association with the metabolic syndrome and NAFLD is considered to be the hepatic manifestation of the metabolic syndrome. The components of the metabolic syndrome include hypertension, obesity and insulin resistance which are well established cardiovascular risk factors. The mortality rate of NAFLD patients from myocardial infarction is higher than that in the general United States population and there is also an increased risk of non-fatal cardiovascular events. This article reviews the cardiovascular complications associated with NAFLD. In order to provide comprehensive care of NAFLD patients, physicians need to be aware of, and search for, the cardiac morbidity associated with NAFLD.

Routine chest X-ray on hospital admission: does it contribute to diagnosis or treatment?

BACKGROUND

In many hospitals a routine chest X-ray is performed on admission. There are, however, scant data regarding its usefulness in contemporary patient populations.

METHODS

We studied consecutive patients admitted during a 2 month period to a single department of medicine, where hospital policy mandates performing an admission CXR. Two senior clinicians not involved in the care of these patients assessed the discharge summaries for a clinical indication to perform CXR on admission, as well as its contribution to patient management (major positive, major negative, minor positive, or no contribution).

RESULTS

There were 675 patients whose mean age was 64.5 +/- 17.2 years. In 19.6% (130 cases) CXR was not performed. Of the 545 CXRs done, 260 (48%) were normal. In only 128 (23.5%) did the admission CXR make a major positive contribution to diagnosis or treatment. In 61 (11.2%) it provided a minor positive contribution and in 153 (28.1%) a major negative contribution. In 184 patients (33.8%) the CXR did not affect either diagnosis or management. It made a major positive contribution to management in patients for whom there was an indication for performing the X-ray (odds ratio 10.3, P < 0.0005) and in those with a relevant finding on physical examination (OR 1.63, P = 0.110). For the 329 patients who had neither a clinical indication for performing a CXR nor an abnormal chest examination the admission CXR contributed to patient management in only 12 cases (3.6%).

CONCLUSIONS

A routine admission CXR has a significant impact on patient management only in those patients in whom there are relevant findings on physical examination or a clear clinical indication for performing the test. There is no need to routinely order CXR on admission to hospital.

Strongyloides hyperinfection in Ethiopian immigrants in Israel

We report four cases of Strongyloides hyperinfection among Ethiopian immigrants, of which three were fatal. Many immigrants from countries in which Strongyloides is endemic settle in developed countries. A high index of suspicion will lead to earlier diagnosis and treatment of this disease. Testing for Strongyloides infestation in this susceptible population by enzyme-linked immunosorbent assay serology, stool testing or duodenal aspiration may prevent the fatal complications of hyperinfection.

The involvement of the liver in systemic diseases

The liver has a double blood supply and plays a central role in the metabolism of proteins, carbohydrates, and many medications. In addition, it has a role in the induction of immune tolerance and may also be a target for immune-mediated damage. For these reasons, the liver may be involved in many systemic diseases. In this review, we discuss the involvement of the liver in granulomatous, rheumatologic, malignant, and circulatory diseases. An understanding of the wide spectrum of liver involvement in systemic diseases will aid in both diagnosis and treatment of patients with a wide range of medical conditions.

[Shared residency training in internal medicine--a need for the 21st century]

The crisis that has enveloped internal medicine over the past decade has resulted in difficulties in attracting the best and brightest graduates to this specialization. Since an increasing number of graduates are female, there is often a conflict between raising a family and completing demanding postgraduate medical training. We suggest that serious consideration be given to part-time training in internal medicine in Israel. This article outlines our proposal and reports experience in other countries that supports the concept of postgraduate training in a part-time position. We suggest that this idea is suited to internal medicine and should be seriously considered by the regulatory authorities.

Routine ultrasound-guided liver biopsy: a time whose idea has come?

Percutaneous liver biopsy is a commonly performed procedure in modern hepatology. Although it is a safe procedure and performed in most cases on an outpatient basis, complications including mortality have been reported. It is widely perceived that the use of ultrasound guiding for the biopsy produces a decrease in complications and is safer. There is now a trend for more centers to adopt a policy of ultrasound-guided biopsies only. There are, however, no official guidelines that recommend such a policy. This trend for ultrasound guidance of invasive procedures is also becoming apparent in other areas such as the insertion of a central venous line in children. The literature in support of such a position is far from conclusive. Because there are medicolegal and economic implications for the policy of routine ultrasound guiding of biopsies, we suggest that there is a need for the major professional organizations to make a clear declaration on this issue.

Hemochromatosis mutations are not linked to dilated cardiomyopathy in Israeli patients

AIMS

Hemochromatosis is a condition in which iron loading impairs the function of many organs, including the heart. Congestive heart failure with left ventricular dilatation is commonly found in patients with hemochromatosis. Two missense mutations (C282Y and H63D) have been shown to be responsible for the majority of cases of hemochromatosis.

METHODS AND RESULTS

We examined 156 patients with congestive heart failure due to dilated cardiomyopathy. Details were recorded of clinical and echocardiographic parameters. DNA was extracted from peripheral blood and checked for the presence of the C282Y and H63D mutations by a commercially available single nucleotide primer extension assay. A control group of 98 healthy blood donors was also checked for the presence of these mutations. Of the 157 patients, 42 (26.75%) had at least one mutation. Five (3.65%) were homozygotic for the H63D mutation and 37 (23.6%) were heterozygotic for the H63D mutation. The C282Y mutation was not present. In a control population of 98 healthy blood donors, 27 (27.6%) were heterozygous for the H63D population and none had the C282Y mutation (no significant difference between the patients with cardiomyopathy and the healthy blood donors, chi(2) test 0.754). There was a non-significant trend to a difference in the prevalence of homozygotic H63D between the cardiomyopathy patients and the healthy blood donors (3.18% vs. 0%, P=0.076, chi(2) test). There was no statistically significant difference between the cardiomyopathy patients with and without the mutations in terms of age, gender, hemoglobin, iron, transferrin, ferritin, presence of diabetes mellitus, hypertension and previous coronary artery bypass grafting.

CONCLUSION

In our population of patients with dilated cardiomyopathy, there was no evidence for hemochromatosis being an important etiology.

Treatment of Clostridium difficile-associated diarrhea

OBJECTIVE

To review the literature related to the treatment and infection control of Clostridium difficile-associated diarrhea (CDAD).

DATA SOURCES

A MEDLINE search (1966-August 2001) of the English literature was conducted.

DATA SYNTHESIS

C. difficile is a leading cause of antibiotic-related diarrhea. The clinical spectrum extends from simple diarrhea to fulminant colitis. Cessation of antibiotic therapy alone is sufficient for mild cases; however, the majority of cases require oral metronidazole as the drug of choice. Vancomycin orally is reserved for patients who have failed to respond to metronidazole, are pregnant, or are severely ill. There is an important role for infection control interventions.

CONCLUSIONS

CDAD is a common infection. Appropriate antibiotic treatment and infection control policies can prevent the spread and reduce the morbidity associated with this disease.

Acute cholestatic hepatitis after exposure to isoflurane

OBJECTIVE

To report a case of acute cholestatic hepatitis following exposure to the inhalational anesthetic isoflurane.

CASE SUMMARY

A 70-year-old healthy woman from Iraq developed acute cholestatic hepatitis 3 weeks following repair of the right rotator cuff under general anesthesia. There was no evidence for viral, autoimmune, or metabolic causes of hepatitis. No other medications were involved except for dipyrone for analgesia. The alanine aminotransferase was elevated to a peak concentration of 1533 U/L and the serum bilirubin reached a peak of 17.0 mg/dL. There was slow improvement over 4 months. Accidental reexposure by the patient to dipyrone was uneventful.

DISCUSSION

The clinical and histologic picture of this case resembles halothane hepatitis, which has a significant mortality rate.

CONCLUSIONS

Isoflurane, a common anesthetic agent, can cause severe cholestatic hepatitis.

Treatment of chronic hepatitis C virus infection

OBJECTIVE

To review the literature on the treatment of chronic hepatitis C virus (HCV) infection.

DATA SOURCES

MEDLINE search (1986-December 1999) using key words such as HCV, hepatitis, non-A and non-B hepatitis, as well as terms regarding treatment during that time period.

DATA SYNTHESIS

HCV infection was initially treated with interferon monotherapy, but only a minority of patients responded to long-term therapy. A higher rate of response in both interferon-naïve patients and interferon-relapsers has been achieved by using the combination of interferon and ribavarin. Other treatment regimens including high-dose interferon protocols, ursodeoxycholic acid, amantadine, and nonsteroidal antiinflammatory drugs have been less promising. Many alternative therapies are being investigated.

CONCLUSIONS

HCV infection is a major public health problem. It is now possible to achieve a cure in nearly 50% of the patients with this infection. Many additional therapies are being evaluated in order to achieve a higher cure rate.

Anticardiolipin autoantibodies in serum samples and cryoglobulins of patients with chronic hepatitis C infection

OBJECTIVE

Chronic hepatitis C virus (HCV) has been linked to extrahepatic autoimmune phenomena. In addition, a variety of autoantibodies are found in patients with HCV. The prevalence, nature, and clinical significance of anticardiolipin (aCL) autoantibodies in serum samples of patients with HCV were therefore investigated.

PATIENTS AND METHODS

A prospective study of 48 consecutive patients with chronic HCV with no evidence of previous hepatitis B virus (HBV) infection or any other autoimmune disorder. Thirty patients with HBV and 50 healthy volunteers matched for age and sex served as control groups. Anticardiolipin antibodies in the serum samples and cryoprecipitates were measured by a sensitive enzyme linked immunosorbent assay (ELISA). The beta(2) glycoprotein I (beta(2)-GPI) dependency was determined by carrying out aCL assays in the presence or absence of fetal calf serum samples.

RESULTS

High levels of IgG aCL antibodies were detected in serum samples of 21/48 (44%) patients with HCV. These autoantibodies showed no beta(2)-GPI dependency. The control groups had much lower levels of aCL antibodies (20% in the patients with HBV and none in the normal volunteers). Cryoprecipitates from four patients with HCV (three aCL positive; one aCL negative) were further isolated. In two of the three aCL positive patients, specific cardiolipin reactivity was shown in the cryoprecipitates. The group of patients with HCV and aCL antibodies in their serum showed significantly higher total IgG levels, a higher incidence of antinuclear antibodies, and viraemia (HCV RNA) than the aCL negative patients. None of the patients with HCV and aCL antibodies showed any clinical manifestations related to those autoantibodies.

CONCLUSIONS

This study clearly shows a high prevalence of IgG aCL antibodies in the serum of patients with HCV and the localisation of these antibodies in some cryoprecipitates. The role of these autoantibodies on the course of HCV infection and their clinical significance has not yet been determined.

Evaluation of carotid arterial plaques after endarterectomy for Helicobacter pylori infection

Chronic inflammation is linked to atherosclerosis and Helicobacter pylori has been suggested to be an etiologic agent, although the evidence is equivocal. In this report, H. pylori was not detected by the polymerase chain reaction in atherosclerotic plaque from carotid endarterectomy samples.

Celiac disease

Celiac disease, or gluten-sensitive enteropathy, classically presents as diarrhea and weight loss in childhood, but it may also have protean manifestations and appear well into adult life. The increasing availability of noninvasive blood tests that are highly sensitive and specific for celiac disease enables primary care physicians to recognize the disorder in a wide variety of clinical situations. The authors believe that the disease is more common than supposed and thus offer this diagnostic review to increase awareness.