Features and Outcomes of 899 Patients With Drug-Induced Liver Injury: The DILIN Prospective Study

BACKGROUND & AIMS

The Drug-Induced Liver Injury Network is conducting a prospective study of patients with DILI in the United States. We present characteristics and subgroup analyses from the first 1257 patients enrolled in the study.

METHODS

In an observational longitudinal study, we began collecting data on eligible individuals with suspected DILI in 2004, following them for 6 months or longer. Subjects were evaluated systematically for other etiologies, causes, and severity of DILI.

RESULTS

Among 1257 enrolled subjects with suspected DILI, the causality was assessed in 1091 patients, and 899 were considered to have definite, highly likely, or probable DILI. Ten percent of patients died or underwent liver transplantation, and 17% had chronic liver injury. In the 89 patients (10%) with pre-existing liver disease, DILI appeared to be more severe than in those without (difference not statistically significant; P = .09) and mortality was significantly higher (16% vs 5.2%; P < .001). Azithromycin was the implicated agent in a higher proportion of patients with pre-existing liver disease compared with those without liver disease (6.7% vs 1.5%; P = .006). Forty-one cases with latency ≤7 days were caused predominantly by antimicrobial agents (71%). Two most common causes for 60 DILI cases with latency >365 days were nitrofurantoin (25%) or minocycline (17%). There were no differences in outcomes of patients with short vs long latency of DILI. Compared with individuals younger than 65 years, individuals 65 years or older (n = 149) were more likely to have cholestatic injury, although mortality and rate of liver transplantation did not differ. Nine patients (1%) had concomitant severe skin reactions; implicated agents were lamotrigine, azithromycin, carbamazepine, moxifloxacin, cephalexin, diclofenac, and nitrofurantoin. Four of these patients died.

CONCLUSIONS

Mortality from DILI is significantly higher in individuals with pre-existing liver disease or concomitant severe skin reactions compared with patients without. Additional studies are needed to confirm the association between azithromycin and increased DILI in patients with chronic liver disease. Older age and short or long latencies are not associated with DILI mortality.

Effect of varying contrast material iodine concentration and injection technique on the conspicuity of hepatocellular carcinoma during 64-section MDCT of patients with cirrhosis

OBJECTIVES

The aim of this study was to compare the intraindividual effects of contrast material with two different iodine concentrations on the conspicuity of hepatocellular carcinoma (HCC) and vascular and hepatic contrast enhancement during multiphasic, 64-section multidetector row CT (MDCT) in patients with cirrhosis using two contrast medium injection techniques.

METHODS

Patients were randomly assigned to one of two groups with an equal iodine dose but different contrast material injection techniques: scheme A, fixed injection duration (25 s), and scheme B, fixed injection flow rate (4 ml s(-1)). For each group, patients were randomised to receive both moderate-concentration contrast medium (MCCM) and high-concentration contrast medium (HCCM) during two CT examinations within 3 months. Enhancement of the aorta, liver and portal vein and the tumour-to-liver contrast-to-noise ratio (CNR) were compared between MCCM and HCCM.

RESULTS

30 patients (mean age 59 years; range 45-80 years; 16 patients in scheme A and 14 in scheme B) with a total of 31 confirmed HCC nodules were prospectively enrolled. For scheme B, the mean contrast enhancement of the aorta and tumour-to-liver CNR were significantly higher with HCCM than with MCCM during the hepatic arterial phase (+350.5 HU vs +301.1 HU, p = 0.001, and +7.5 HU vs +5.5 HU, p = 0.004). For both groups, there was no significant difference between MCCM and HCCM for all other comparisons.

CONCLUSION

For a constant injection flow rate, HCCM significantly improves the conspicuity of HCC lesions and aortic enhancement during the hepatic arterial phase on 64-section MDCT in patients with cirrhosis.

Neuropsychological and psychiatric sequelae of pallidotomy for PD: clinical trial findings

OBJECTIVE

To evaluate the neuropsychological and psychiatric sequelae of unilateral posterior pallidotomy for treatment of PD.

METHODS

Patients with idiopathic PD completed baseline and 3- and 6-month assessments after random assignment to an immediate surgery (n = 17) or medical management (n = 16) group.

RESULTS

Compared with the medical management group, the immediate surgery group with single lesions centered on the posterior internal pallidum showed superior naming and response inhibition, better verbal recall at 6 months, but greater distractibility, a tendency toward lower phonemic fluency, and a transient (3 months' only) semantic fluency deficit. The group with left lesions had more neuropsychological deficits than the group with right lesions or the medical management group, although these occurred mainly at 3 (but not 6) months. At 6 months, the patients with left lesions showed better verbal memory retention than the patients with right lesions. On most measures, the pattern of individual clinical change did not differ as a function of surgery or lesion laterality, with the exception of a higher frequency of decline in phonemic fluency in the patients with left lesions at 6 months. Although psychiatric status did not change overall, a history of depression tended to increase the risk of a depressive episode following surgery.

CONCLUSIONS

Well-targeted, uncomplicated, unilateral pallidotomy does not produce overall neuropsychological or psychiatric change, although there are subtle changes on specific measures sensitive to frontal lobe function.

The impact of lesion laterality on neuropsychological change following posterior pallidotomy: a review of current findings

This paper reviews seven studies evaluating the impact of lesion laterality on the neuropsychological sequelae of posterior pallidotomy for treatment of Parkinson's disease. Left lesions of the internal globus pallidus (GPi) were associated with subtle deficits on measures sensitive to frontal lobe function. The findings of a randomized clinical trial including a patient control group indicated that many of these deficits were transient, resolving by 6 months following surgery. Right GPi lesions were not consistently associated with neuropsychological deficit, except in one study that included a significant proportion of demented patients. It is hypothesized that when neuropsychological decline is present following surgery, this reflects impingement of posterior GPi lesions into proximal regions such as anterior GPi or the external pallidum that participate in cognitive basal ganglia-thalamocortical circuits. The findings from neuroimaging will be important for elucidating the relationship between lesion locus and neuropsychological sequelae.

Early childhood nutrition, education and fertility milestones in Guatemala

Data on fertility milestones were collected in 1994 and linked to information collected in a trial conducted in eastern Guatemala between 1969 and 1977, to examine whether early childhood nutrition was associated with the timing of fertility milestones. In the original trial, two pairs of villages were randomly allocated to receive either a high energy, high protein supplement (Atole) or a low energy, no-protein supplement (Fresco). Mean age at follow-up was 23.47 y (n = 240). About 62% of women had experienced first birth (median age at first birth = 19.83 y). The median intervals from menarche to first intercourse and from first intercourse to first birth were 5.67 and 0.95 y; they were 1.68 and 0.06 y shorter, respectively, for the Atole group than for the Fresco group. Women who had received Atole in utero and/or during early childhood experienced earlier milestones even after adjusting for socioeconomic status (SES), education and age at the prior event. Median age at first birth was 1.17 y earlier for the Atole group. Better growth during early childhood (not severely stunted) led to earlier milestones (median age at first birth was 1.04 y earlier), primarily among women with illiterate fathers. Completion of primary school significantly delayed fertility milestones; the median age at first birth was 4.27 y later for those who completed primary school compared with those who did not (P < 0.05). In sum, improved nutrition during early childhood results in earlier fertility milestones, but the effects of schooling in delaying fertility milestones are greater in magnitude. Intervention programs that improve early childhood nutrition should be accompanied by investments in education that ensure that girls complete primary school.

Epidemiological study of Campylobacter spp. in broilers: source, time of colonization, and prevalence

From October 1993 to August 1994, broiler chickens in four grow-out houses, two previously used (houses 1 and 2) and two newly constructed (houses 3 and 4), were used in a study to determine the source, time of infection, and prevalence of Campylobacter spp. Cecal droppings and cecal samples were obtained from the broilers. Samples were also obtained from water, feed, litter, soil, fans, and workers' boots. Samples were obtained from domestic animals and wildlife species (rectal swabs), including insects, on or near the premises. Broilers in houses 2, 3, and 4 became infected in the second or third week and were fully colonized by day 42. Campylobacter appeared in house 1 during week 2 in a low percentage of the birds, disappearing by the fourth week. Isolates were also recovered from domestic pigs and water on this farm. In house 3, the organism was isolated from workers' boots and a wild bird prior to isolation from the broilers. Following isolation from cecal droppings, the organism was isolated from water, feed, litter, feathers, flies, cattle, feces, and wild animals. In house 2, Campylobacter was isolated from cattle feces and wild birds prior to week 5, when the broilers first became infected, and thereafter from water, feed, insect, and wildlife, and cecal droppings. It was subsequently isolated from workers' boots, cattle feces, feathers, insects, and other wildlife. All ceca taken from 20 birds each from houses 2 and 3 were positive at time of slaughter (day 49). All ceca from house 1 were negative. No ceca were collected from birds originating in house 4. No specific source could be identified from the samples obtained, although apparently the organism permeates the environment and several potential sources are discussed in this paper.

Self-report benefits of Tai Chi practice by older adults

Older persons who are willing to begin exercise programs are often not willing to continue them. At the Atlanta FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) site, individuals aged 70+ were randomized to Tai Chi (TC), individualized balance training (BT), and exercise control education (ED) groups for 15 weeks. In a follow-up assessment 4 months post-intervention, 130 subjects responded to exit interview questions asking about perceived benefits of participation. Both TC and BT subjects reported increased confidence in balance and movement, but only TC subjects reported that their daily activities and their overall life had been affected; many of these subjects had changed their normal physical activity to incorporate ongoing TC practice. The data suggest that when mental as well as physical control is perceived to be enhanced, with a generalized sense of improvement in overall well-being, older persons' motivation to continue exercising also increases.

Calcium, phosphorus, and magnesium contents of human milk during early lactation

Early milk samples from 102 American mothers were examined for Ca, P, and Mg contents in relation to stage of lactation, intake of prenatal mineral supplements, maternal age, parity, and previous history of lactation. A total of 415 samples were collected at three stages of lactation: early transitional (4-7 days postpartum); transitional (10-14 days postpartum); and mature (30-45 days postpartum). No diurnal variations in element concentrations were observed in representative samples of late evening (PM) and early morning (AM) feedings collected during the transitional and mature stages. The mean concentrations for the major elements were highest in early transitional milk and in some cases decreased significantly (p less than 0.05) as lactation progressed. Ca, P, and Mg contents (means +/- SEM) were 26.3 +/- 0.6, 14.6 +/- 0.4, 5.3 +/- 0.1 mg/100 g in early transitional milk and 26.2 +/- 0.5, 13.3 +/- 0.3, and 5.0 +/- 0.1 in mature milk, respectively. Increasing uniformity in the elemental content of milk was noted among the mothers as lactation became established. No significant relationship was found between intake of dietary supplements containing Ca and Mg and levels of these elements in milk. Also, no significant correlations were found between maternal age, parity, or previous history of lactation and the elemental content of milk. From these data, it was estimated that fully breast-fed infants would receive approximately 33, 18, and 6.5 mg/kg/day of Ca, P, and Mg, respectively, during the neonatal period.

Copper, iron, and zinc contents of human milk at early stages of lactation

The Cu, Fe, and Zn contents of early milk from 102 American mothers were examined in relation to stage of lactation, intake of prenatal mineral supplements, maternal age, parity, and previous history of lactation. A total of 412 samples was collected at three stages of lactation: early transitional (4 to 7 days postpartum); transitional (10 to 14 days postpartum); and mature (30 to 45 days postpartum). For the transitional and mature stages, representative samples of late evening (PM) and early morning (AM) feedings were collected. Diurnal variation in concentration was observed only for Fe. Concentrations of all elements decreased significantly at successive stages of lactation with Zn showing the greatest decline. Cu, Fe, and Zn contents (means +/- SEM) were 104.1 +/- 5.4, 96.5 +/- 6.5, and 520 +/- 20 micrograms/100 g in early transitional milk; 93.9 +/- 3.6, 85.4 +/- 4.5, and 410 +/- 10 micrograms/100 g in transitional milk, and 84.7 +/- 3.8, 76.1 +/- 3.8, and 290 +/- 10 micrograms/100 g in mature milk, respectively. No significant relationship was found between levels of Cu and Zn in milk and whether mothers had taken dietary supplements containing these elements. In addition, no significant correlations were found between maternal age, parity, or previous history of lactation and the elemental content of milk. Based on these data, it was estimated that fully breast-fed infants would receive approximately 0.11, 0.10, and 0.50 mg/kg per day of Cu, Fe, and Zn, respectively, during the neonatal period.