History of depression is associated with higher prevalence of hepatic encephalopathy in patients with advanced liver disease

INTRODUCTION

Depression and hepatic encephalopathy are common in patients with advanced liver disease. Although these are distinct entities, they share several clinical features. In this analysis, we evaluated whether having a history of depression was associated with developing hepatic encephalopathy in patients with advanced liver disease METHODS: : We performed a retrospective cohort study of patients with cirrhosis referred for liver transplant. Patients were categorized into one of two groups: "history of depression" or "no history of depression." Multivariable logistic regression was used to evaluate history of depression as a potential independent predictor of hepatic encephalopathy RESULTS: : A total of 447 patients were included, of which 158 (35%) had a history of depression and 233 (52%) had experienced hepatic encephalopathy. Hepatic encephalopathy was more common in patients with a history of depression (63% vs. 46%, p<0.01). On multivariate analyses, depression history was independently associated with hepatic encephalopathy (aOR 2.3, 95% CI 1.4-3.6), along with alcohol associated cirrhosis (aOR 2.0, 95% CI 1.3-3.2), history of ascites (aOR 3.5, 95% CI 2.1-5.9) and presence of a trans-jugular intra-hepatic shunt (aOR 9.2, 95% CI 2.6-32.6). The relationship between history of depression and hepatic encephalopathy remained significant in a subgroup of patients with alcohol associated liver disease (p=0.04). Among those with a history of depression, SNRI prescription was more common in the hepatic encephalopathy group (14% vs. 3%), and SNRI prescription was as an independent predictor of hepatic encephalopathy in the multivariable model (OR 4.8, 95% CI 1.0, 24.6) CONCLUSION: : Patients with a history of depression were significantly more likely to experience hepatic encephalopathy. Patients with cirrhosis who have a history of depression should be closely monitored for the development of hepatic encephalopathy. Further research is needed to understand the nuances of this relationship and whether the use of certain psychiatric medications may modify the relationship between depression and hepatic encephalopathy.

The Yucatan miniature swine as a model for post-inflammatory hyperpigmentation

Post-inflammatory hyperpigmentation (PIH) is a hypermelanosis that often occurs secondary to skin irritation or injury, especially in darker skin tones, for which there is currently a lack of effective treatment options. Few preclinical models are available to study PIH. Here, we show that the Yucatan miniature pig consistently develops PIH after skin injuries. Skin wounds were produced on Yucatan pigs by needle punches, full-thickness excisions, or burns. Wound sites were monitored and photographed regularly. Tissue samples were collected after 24 weeks and processed for histology/immunohistochemistry. Skin pigmentation and histologic changes were quantified by computer-assisted image analyses. All injury methods resulted in hyperpigmentation. Melanin content at the histologic level was quantified in the larger (burn and excision) wounds, showing a significant increase compared to uninjured skin. Increased melanin was found for both epidermal and dermal regions. Dermal melanin deposits were primarily clustered around the papillary vasculature, and were associated not with melanocytes but with leukocytes. The Yucatan miniature pig model recapitulates key clinical and histologic features of PIH in humans, including skin hyperpigmentation at both gross and histologic levels, and persistence of dermal melanin subsequent to injury. This model could be used to further our understanding of the etiology of PIH, and for new therapy development.

Gender disparities in isotretinoin prescribing patterns for pediatric patients before and during practice changes introduced by the COVID-19 pandemic

Isotretinoin is a systemic therapy approved for acne and has historically required lab monitoring in addition to adherence to the iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) given the medication's teratogenic effects. The COVID-19 pandemic resulted in the expansion of telemedicine, acceptance of remote pregnancy tests, and relaxation of lab monitoring practices. A retrospective review of 142 pediatric patients was conducted, and multivariate linear regression was performed to examine differences in prescribing patterns pre-COVID and during COVID. Backward elimination identified gender and the interaction between acne severity and number of systemic treatments tried before isotretinoin as significant factors associated with increased number of visits to isotretinoin initiation, with females requiring more visits before starting isotretinoin at every acne severity level and even after accounting for systemic treatments previously tried. While the changes catalyzed by the pandemic may have improved visit-related burdens for patients and caregivers, female patients with acne continue to be delayed in receiving isotretinoin even when adjusting for acne severity and systemic treatments trialed, underscoring persistent gender disparities in prescribing practices for isotretinoin.

The Price of Inequality in Type 1 Diabetes Management

The purpose of this paper is to examine the compounded disparities in diabetes management and how disease burden is amplified by socioeconomic conditions. Access to tools that equip care is explored in relation to income, education, race and insurance coverage. Commentary is also provided from the perspective of a patient who has managed diabetes for 25 years and is currently a third year medical student. From this experience, she understands firsthand the demand and complexity of disease management. Through her observations in the hospital, she also identifies how disparities shape care for individuals managing this challenging disease. Lower socioeconomic status, education level, non-white race and non-commercial insurance are amongst variables that restrict access to technology. The various influences that shape technological access in combination with the observations from a patient managing T1D serve to demonstrate the multifactorial challenges encompassed in care acquisition.