Trends in Allogeneic Hematopoietic Cell Transplantation Utilization and Estimated Unmet Need Among Medicare Beneficiaries with Acute Myelogenous Leukemia

Allogeneic hematopoietic cell transplantation (alloHCT) is a resource-intensive procedure and the sole potentially curative treatment available for patients with acute myelogenous leukemia (AML). Although Medicare coverage may help address a major financial barrier to accessing alloHCT, there remains an unmet need for alloHCT owing to sociodemographic disparities. This study examined trends and factors associated with the utilization of alloHCT and the estimated unmet need for alloHCT among Medicare beneficiaries with AML. This retrospective cohort study included patients (age 65 to 74 years) with a diagnosis of AML identified in Medicare claims data from 2010 through 2016. To study trends in utilization, transplantation rates were calculated as the number of patients who underwent alloHCT within 180 days and 1 year of diagnosis (numerator) divided by the total number of patients with AML within each diagnosis year (denominator). A multivariable logistic regression was used to identify factors associated with the likelihood of undergoing alloHCT within 1 year of diagnosis. Two approaches were applied to estimate the unmet need for alloHCT. The first approach used claims data to identify the potential need for alloHCT among patients who achieved complete remission for at least 90 days. The second approach used established National Marrow Donor Program (NMDP) methodology, which considers estimates of risk level, response to treatment, comorbidity, and early mortality, to identify the potential and unmet need for alloHCT. The overall estimated need and unmet need from 2010 to 2015 and over different time periods were evaluated for both approaches. The alloHCT rate within 180 days of diagnosis increased from 8% in 2010 to 15.8% in 2016 (P < .001), and the 1-year alloHCT rate also increased over time, from 11.9% in 2010 to 20.0% in 2015 (P < .001). The likelihood of undergoing alloHCT within 1 year of diagnosis was associated with diagnosis year, age, race, geographic region, Elixhauser Comorbidity Index, and population-level median household income. Between 2010 and 2015, the claims data approach estimated a lower potential need for alloHCT compared with the NMDP methodology estimate (27% versus 36%); both approaches estimated that 43% to 44% of patients with a potential need for alloHCT had an unmet treatment need. Despite the differences in estimated potential need between the 2 approaches, both showed a sustained unmet need but with a downward trend over time. Our data show that utilization of alloHCT has increased over time among Medicare beneficiaries with AML. Two approaches of need analysis were conducted for validation of estimated need and unmet need for alloHCT using claim-identified remission status, given the lack of cytogenetics and molecular information in claims data. Both approaches to estimating the unmet need for alloHCT found a downward trend over time; however, there are differences in utilization of alloHCT by age, race, geographic region, comorbidity, and socioeconomic status, indicating disparities in access to alloHCT among Medicare beneficiaries with AML. This suggests the need for policy efforts, research, and continued education to improve access to alloHCT and to close the gap between the actual utilization of alloHCT and the unmet need.

The epidemiology and clinical features of portal vein thrombosis: a multicentre study

BACKGROUND

Reliable epidemiological data for portal vein thrombosis are lacking.

AIMS

To investigate the incidence, prevalence and survival rates for patients with portal vein thrombosis.

METHODS

Retrospective multicentre study of all patients registered with the diagnosis of portal vein thrombosis between 1995 and 2004.

RESULTS

A total of 173 patients (median age 57 years, 93 men) with portal vein thrombosis were identified and followed up for a median of 2.5 years (range 0-9.7). The mean age-standardized incidence and prevalence rates were 0.7 per 100,000 per year and 3.7 per 100,000 inhabitants, respectively. Liver disease was present in 70 patients (40%), malignancy in 27%, thrombophilic factors in 22% and myeloproliferative disorders in 11%. Two or more risk factors were identified in 80 patients (46%). At diagnosis, 65% were put on anticoagulant therapy. Thrombolysis, TIPS, surgical shunting and liver transplantation were performed in 6, 3, 2 and 8 patients, respectively. The overall survival at 1 year and 5 years was 69% and 54%. In the absence of malignancy and cirrhosis, the survival was 92% and 76%, respectively.

CONCLUSIONS

The incidence and prevalence rates of portal vein thrombosis were 0.7 per 100,000 inhabitants per year and 3.7 per 100,000 inhabitants, respectively. Concurrent prothrombotic risk factors are common. The prognosis is variable and highly dependent on underlying disease.

Laboratory tests as indicators of alcohol consumption in patients with chronic low back pain

The use of laboratory screening tests for the detection of heavy drinking in outpatients implies among other things knowledge about their relation to the degree of alcohol consumption. In this study of 95 patients with chronic low back pain, serum gamma-glutamyltransferase demonstrated the best correlation with the mean daily amount of alcohol consumed (r = 0.74). Adding other serological tests, such as high density lipoprotein cholesterol, aminotransferases and linoleic acid content in lecithin, did not improve this correlation, although these tests also correlated well with the alcohol intake.

Acute liver failure in Sweden: etiology and outcome

OBJECTIVE

To determine the causes and outcome of all patients with acute liver failure (ALF) in Sweden 1994-2003 and study the diagnostic accuracy of King's College Hospital (KCH) criteria and the model for end-stage liver disease (MELD) score with transplant-free deaths as a positive outcome.

RESEARCH DESIGN AND METHODS

Adult patients in Sweden with international normalized ratio (INR) of >or=1.5 due to severe liver injury with and without encephalopathy at admission between 1994-2003 were included.

RESULTS

A total of 279 patients were identified. The most common cause of ALF were acetaminophen toxicity in 42% and other drugs in 15%. In 31 cases (11%) no definite etiology could be established. The KCH criteria had a positive-predictive value (PPV) of 67%, negative-predictive value (NPV) of 84% in the acetaminophen group. Positive-predictive value and negative-predictive value of KCH criteria in the nonacetaminophen group were 54% and 63% respectively. MELD score>30 had a positive-predictive value of 21%, negative-predictive value of 94% in the acetaminophen group. The corresponding figures for the nonacetaminophen group were 64% and 76% respectively.

CONCLUSIONS

Acetaminophen toxicity was the most common cause in unselected patients with ALF in Sweden. KCH criteria had a high NPV in the acetaminophen group, and in combination with MELD score<30 predicts a good prognosis in acetaminophen patients without transplantation.

Elevation of cytokines in peritoneal fluid and blood in patients with liver cirrhosis

BACKGROUND/AIMS

Liver cirrhosis, described as the endstage of a necroinflammatory process, is often accompanied by ascites formation. The rationale for this study was the hypothesis that patients with liver cirrhosis have a low-grade chronic inflammatory response, which leads to an increased amount of proinflammatory cytokines accumulated in ascites. Twenty-five patients with liver cirrhosis complicated by ascites and twelve healthy volunteers were prospectively included in the study.

METHODOLOGY

Ascites and blood samples from the patients were obtained for analysis of inflammatory cytokines using enzyme-linked immunosorbent assay methodology. Blood samples were taken from the healthy volunteers to obtain reference values.

RESULTS

Plasma and ascites concentrations of interleukin-1alpha, interleukin-6, and tumor necrosis factor-alpha were significantly elevated in the patients compared with plasma levels in the group of healthy controls. Significant elevation of interleukin-10 concentrations was found in ascites but not in plasma in the patients. There was no significant difference in interleukin-10 levels between patient and control plasma.

CONCLUSIONS

The findings suggest that elevated cytokine concentrations in ascites and serum could perpetuate an inflammatory reaction that may be a source of preservation of an ongoing systemic inflammatory reaction. This may contribute to the maintenance, and even progress, of the liver dysfunction, leading to exaggerated ascites development.

Subjects with essential hypertension are more sensitive to the inhibition of 11 beta-HSD by liquorice

In this intervention study, we have investigated if hypertensive patients are more sensitive to liquorice-induced inhibition of 11 beta-hydroxysteroid dehydrogenase (11 beta-HSD) type 2 than normotensive (NT) subjects and if the response depends on gender. Healthy volunteers and patients with essential hypertension (HT), consumed 100 g of liquorice daily, for 4 weeks, corresponding to a daily intake of 150 mg glycyrrhetinic acid. Office, 24-h ambulatory blood pressure (BP) and blood samples were measured before, during and after liquorice consumption. Effect on cortisol metabolism was evaluated by determining the urinary total cortisol metabolites and urinary free cortisol/free cortisone quotient (Q). The mean rise in systolic BP with office measurements after 4 weeks of liquorice consumption was 3.5 mmHg (p<0.06) in NT and 15.3 mmHg (p=0.003) in hypertensive subjects, the response being different (p=0.004). The mean rise in diastolic BP was 3.6 mmHg (p=0.01) in NT and 9.3 mmHg (p<0.001) in hypertensive subjects, the response also being different (p=0.03). Liquorice induced more pronounced clinical symptoms in women than in men (p=0.0008), although the difference in the effect on the BP was not significant. The increase in Q was prominent (p<0.0001) and correlated to the rise in BP (p=0.02). The rise in BP was not dependant on age, the change in plasma renin activity or weight. We conclude that patients with essential HT are more sensitive to the inhibition of 11 beta-HSD by liquorice than NT subjects, and that this inhibition causes more clinical symptoms in women than in men.

HLA class II markers and clinical heterogeneity in Swedish patients with primary biliary cirrhosis

Genetic susceptibility to PBC can, at least in part, be ascribed to the major histocompatibility complex. The relevance of immunogenetic markers for the clinical presentation and course, however, is unclear. Thus, the aim of this study was to investigate the contribution of HLA class II genes to susceptibility, clinical presentation and course of disease in PBC patients. HLA genotyping for HLA-DRB1, -DQB1 and -DPB1 was carried out in a total of 99 Swedish PBC patients and 158 controls. Clinical parameters including epidemiologic variables, signs and symptoms of PBC-related liver disease and histologic data were collected and analyzed in 92 patients at study entry and at follow-up five years later. Significant clinical heterogeneity was seen among PBC patients upon study entry. Although a significant disease association was seen for HLA DRB1*08 and DQB1*0402, immunogenetic markers identified neither a particular subset of patients nor an association with the clinical course of the disease. HLA-DRB1*08 and DQB1*0402 provide the strongest immunogenetic influence in PBC. However, this association is not restricted to any particular, clinically defined subgroup of patients and it is not predictive for the course of the disease.

[Therapeutic program for ascites. Recommendations from the Swedish Society of Gastroenterology and Gastrointestinal Endoscopy]

As ascites is related to liver cirrhosis in 80% of the patients, the present therapeutic guidelines are focused on ascites in liver cirrhosis. A combination of spironolactone and furosemide is recommended as first line therapy in patients with mild to moderate ascites and is effective in 90% of patients. In patients with pronounced or tense ascites, first line treatment is total paracentesis with intravenous infusion of human albumin as colloid replacement. Maintenance therapy for the prevention of recurrent ascites is based on spironolactone with or without furosemide. The indications for peritoneovenous shunt, or transjugular intrahepatic stent-shunt (TIPSS), are limited and only recommended in strictly selected patients with refractory ascites. Ascites in liver cirrhosis is a symptom of advanced liver disease, and liver transplantation should always be considered in eligible patients.

Liquorice-induced rise in blood pressure: a linear dose-response relationship

To clarify the dose-response and the time-response relationship between liquorice consumption and rise in blood pressure and explore the inter-individual variance this intervention study was designed and executed in research laboratories at University hospitals in Iceland and Sweden. Healthy, Caucasian volunteers who also served as a control for himself/herself consumed liquorice in various doses, 50-200 g/day, for 2-4 weeks, corresponding to a daily intake of 75-540 mg glycyrrhetinic acid, the active substance in liquorice. Blood pressure was measured before, during and after liquorice consumption. Systolic blood pressure increased by 3.1-14.4 mm Hg (P < 0.05 for all), demonstrating a dose-response but not a time-response relationship. The individual response to liquorice followed the normal distribution. Since liquorice raised the blood pressure with a linear dose-response relationship, even doses as low as 50 g of liquorice (75 mg glycyrrhetinic acid) consumed daily for 2 weeks can cause a significant rise in blood pressure. The finding of a maximal effect of liquorice after only 2 weeks has important implications for all doctors dealing with hypertension. There does not seem to be a special group of responders since the degree of individual response to liquorice consumption followed the normal distribution curve.

Carbohydrate-deficient transferrin in vitreous humour: a marker of possible withdrawal-related death in alcoholics

The possibility of performing reliable post-mortem analysis of carbohydrate-deficient transferrin (CDT) concentration in vitreous humour (VH) by using a commercial assay designed for serum analysis (CDTect(TM)) as well as the usefulness of VH-CDT as a marker of alcohol misuse and possible withdrawal-related death were evaluated in a forensic sample. Detectable VH-CDT was found in 20 of 21 alcoholic subjects and in two of seven controls. By using the detection limit of the CDTect(TM) method (VH-CDT = 5 U/l) as cut-off level for a positive test, the alcoholic group was significantly separated from the control group (P = 0.0024, Fisher's exact test). The sensitivity and specificity of the test was 95% and 71%, giving a positive and a negative predictive value of 91% and 83%, respectively. Time-dependent changes of VH-CDT in the dead body could not unequivocally be excluded, which must be considered when selecting cases suitable for VH-CDT analysis. We conclude that adding VH-CDT analysis to ordinary alcohol tests may become useful in forensic medicine for establishing the so-called 'alcoholic state', which may provide a tool in research dealing with the relation between alcohol withdrawal and various causes of death in alcoholics.

Hepatocellular carcinoma in Sweden: its association with viral hepatitis, especially with hepatitis C viral genotypes

Viral markers of chronic hepatitis were tested for in 95 frozen serum samples from 299 patients from Malmö, Sweden, with hepatocellular carcinoma (HCC), diagnosed between 1977 and 1994. Hepatitis B analysis included anti-HBc, HBsAg and, if anti-HBc positive, HBV DNA. Hepatitis C infection analysis included anti-HCV screening, RIBA, HCV RNA and HCV genotyping. HCV genotyping was also carried out in 9 HCV-viraemic HCC-patients from Gothenburg. HCV genotype distribution in HCC cases was compared with Swedish HCV-infected blood donors. Among the 95 patients from Malmö, 28 (29%) had anti-HBc, but only 5 (5%) were chronic HBV carriers, compared with 16 (17%) with chronic hepatitis C (p = 0.021). HCV-related HCC was more common among immigrants (8/16 vs. 8/79; p < 0.001). Genotyping of 25 HCV-infected cases showed genotype 1a in 6 (24%), genotype 1b in 13 (52%), genotype 2b in 4 (16%), and genotype 3a in 2 (8.0%) patients. Genotype 1b was more common among HCC patients than among blood donors (p < 0.001), but 8 of 13 genotype 1b-infected patients were from countries where genotype 1b is predominant. Among native Swedes there was no difference between the HCV genotypes infecting blood donors and those found in HCC patients.

Incidence, etiologic aspects and clinicopathologic features in intrahepatic cholangiocellular carcinoma--a study of 51 cases from a low-endemicity area

A total of 51 cases (19 males and 32 females) of intrahepatic cholangiocellular carcinoma (CCC) from a low-endemicity area of primary liver cancer was analyzed during the periods from 1958 to 1979 and from 1984 to 1991. The mean annual age-adjusted incidence rate was 0.44 for males and 0.56 for females per 100,000 inhabitants. CCC was diagnosed before death in only 31%. There was a female predominance in patients over 70 years of age (p < 0.05). At presentation, malaise (85%), weight loss (73%) abdominal pain (50%) and hepatomegaly (80%) were common. The median survival time from diagnosis was 2 months. The mean age at the time of death was 72 years (range 41-92). At autopsy, cholelithiasis was found in 61% (81% in patients older than 70 years) and cirrhosis in 30% of patients. Cholelithiasis was more common in CCC (p < 0.01) than in hepatocellular carcinoma cases with the same mean age. Not one case of inflammatory bowel disease was found. The gross appearance of the tumor was predominantly massive (49%) or multinodular (35%). The most common histological features were tubular pattern of growth (82%) and abundant fibrous stroma. Metastases were particularly associated with the lymph nodes (41%), skeleton (26%) and lungs (16%).

Spontaneous regression of hepatocellular carcinoma

AIMS

To determine the clinical and histopathological features of a case of a spontaneous regression of hepatocellular carcinoma (HCC).

CASE DETAILS

HCC was found incidentally in a 73-year-old man during a laparotomy for evaluation of gastric retention. Despite no treatment being given, he improved gradually with no sign of tumour as evidenced by coeliac angiography 15 months later, as well as by explorative laparotomy after another 2 years. The patient died 15 years after the primary diagnosis of HCC, without known evidence of tumour recurrence. The patient's clinical records were reviewed, and paraffin-embedded liver tissue was re-evaluated. Both histological and immunohistochemical features were compatible with the diagnosis of a well differentiated HCC. Conceivable causes of the spontaneous regression of this and other reported cases are discussed, but the phenomenon remains enigmatic.

CONCLUSIONS

This case with a histologically proven HCC and a very long follow-up time confirms that spontaneous regression does occur. Since the case was found incidentally our report also implies that this may not be as rare as reported.

ST-segment changes and catecholamine-related myocardial enzyme release during alcohol withdrawal

ST-segment changes and biochemical signs of myocardial injury, and their relation to sympatho-adrenergic activation and cardiac function, were studied in a case series of 19 alcohol-dependent (DSM-III-R) men undergoing in-hospital treatment for alcohol withdrawal. No patient had any clinically apparent heart disease. Analyses of ST-segment depressions > or = 0.1 mV from 24 h ambulatory electrocardiographic recordings revealed horizontal or downsloping ST-segment depressions in seven of the patients. The serum concentration of creatine kinase (CKMB) the day after admission correlated with the urinary excretion of adrenaline (r = 0.74, P < 0.001) and noradrenaline (r = 0.71, P < 0.001). In the two patients with the highest adrenaline excretion and the highest serum concentrations of CKMB and cardiac troponin T, horizontal ST-segment depressions were detected as well. The left ventricular ejection fraction was > or = 0.65 (range 0.65-0.79) in all of the 17 alcoholic men who were examined by echocardiography. Our study shows that alcohol withdrawal is frequently associated with ST-segment abnormalities in men without impairment of heart function and that sympatho-adrenergic activation during withdrawal seems to influence the release of myocardial enzymes. Alcohol withdrawal should thus be considered a condition in which acute cardiac complications may be expected in susceptible individuals.

Ursodeoxycholic acid treatment in patients with primary biliary cirrhosis. A Swedish multicentre, double-blind, randomized controlled study

BACKGROUND

Ursodeoxycholic acid (UDCA) has been shown to improve serum levels of liver enzymes and bilirubin in primary biliary cirrhosis (PBC). However, it is still uncertain whether UDCA treatment also improves symptoms, liver histology, and survival without liver transplantation.

METHODS

We randomized 116 patients with PBC to receive 0.5 g UDCA (n = 60) or placebo (n = 56) daily for 2 years. During the next 2 years, 80% of the UDCA-treated patients and 65% of the placebo-treated patients continued to take UDCA.

RESULTS

UDCA improved serum enzyme values but not survival, symptoms, serum bilirubin levels, or liver histology. There was no significant difference in response between initially symptomatic and asymptomatic patients.

CONCLUSIONS

UDCA in a dosage of 7.7 mg/kg body weight is of little benefit in PBC. This does not exclude the possibility that larger doses have beneficial effects.

Minor role of hepatitis B and C virus infection in the etiology of hepatocellular carcinoma in a low-endemic area

BACKGROUND

The etiologic role of hepatitis B (HBV) and C virus (HCV) for hepatocellular carcinoma (HCC) in a low-endemicity area is obscure.

METHODS

Patients suspected of having primary liver cancer (PLC) in Göteborg, Sweden (n = 113), were tested serologically for HBV surface antigen and antibodies to HBV surface and core antigens. The presence of HBV surface and core antigens in cancer and non-neoplastic liver tissue in HCC cases was investigated immunohistochemically. Antibodies to HCV were tested by third-generation tests. The prevalence of HBV and HCV infection was compared in 73 patients with HCC and 32 patients with a final diagnosis other than PLC.

RESULTS

No patient had signs of chronic HBV infection. Seven of 64 (11%) HCC patients were anti-HCV-positive, compared with 1 of 31 (3%) without PLC. All seven patients with HCC and HCV infection had liver cirrhosis, and two were alcoholics. Alcoholism was judged the commonest (42%) cause of cirrhosis.

CONCLUSION

Contrary to areas with a high incidence of HCC, chronic viral hepatitis, particularly HBV, seems to play a minor etiologic role for HCC in Sweden compared with alcohol-related cirrhosis.

Fibrolamellar hepatic carcinoma in an area with a low incidence of primary liver cancer: a retrospective study

OBJECTIVE

To assess the incidence and prognosis of fibrolamellar hepatic carcinoma in a defined population.

DESIGN

Retrospective study of histological slides.

SETTING

University hospital, Sweden.

SUBJECTS

The 532 patients (out of a total of 711 who were treated at the university hospital during a 22 year period 1 January 1958-31 December 1979) whose primary hepatocellular carcinoma was confirmed on review of the histological slides.

MAIN OUTCOME MEASURES

Incidence and prognosis of fibrolamellar hepatic carcinoma.

RESULTS

Two patients (women aged 22 and 46) were found to have fibrolamellar tumours and in both they were advanced and the patients died 2 weeks and 9 months, respectively, after exploratory laparotomy. If these are taken as a proportion of the 18 patients who were under the age of 50 at the time of diagnosis then the incidence of the fibrolamellar type of hepatocellular carcinoma is 11%. Since then (in 1993) we have come across one further case, a woman of 39 who was well 22 months after operation though she had metastatic disease.

CONCLUSIONS

The fibrolamellar type of hepatocellular carcinoma is rare, and all three of our cases were young women (under the age of 50). It seems to have a slightly better prognosis than other types of primary hepatic tumours.

Natural history and prognostic factors in 305 Swedish patients with primary sclerosing cholangitis

BACKGROUND/AIMS--The course of primary sclerosing cholangitis (PSC) is highly variable and unpredictable. This study describes the natural history and outcome of PSC. These data were used to construct a prognostic model for patients with PSC. METHODS--A total of 305 Swedish patients with PSC were studied. The median follow up time was 63 (1-194) months and all patients could be traced for follow up. Some 79 patients died or had a liver transplant. The prognostic significance of clinical, biochemical, and histological findings at the time of diagnosis were evaluated using multivariate analysis. RESULTS--The estimated median survival from time of diagnosis to death or liver transplantation was 12 years. Cholangiocarcinoma was found in 24 (8%) of the patients and 134 (44%) of the patients were asymptomatic at the time of diagnosis. The estimated survival rate was significantly higher in the asymptomatic group (p < 0.001). However, 29 (22%) of the asymptomatic patients became symptomatic during the study period. It was found that age, serum bilirubin concentration, and histological stage at the time of diagnosis were independent predictors of a bad prognosis. These variables were used to construct a prognostic model. CONCLUSIONS--This prognostic model developed from a large homogeneous population of PSC patients should be of value for the timing of transplantation and patient counselling in PSC.

Prevalence of Crohn's disease and simultaneous occurrence of extraintestinal complications and cancer. An epidemiologic study in adults

BACKGROUND

Very dissimilar prevalence figures for Crohn's disease (CD) have been reported from different regions of Scandinavia. There are few reports on the occurrence of liver, joint, skin, and eye disease and gastrointestinal cancer in CD.

METHODS

All patients > or = 16 years old with CD living in a well-defined catchment area on 1 March 1990 were identified from the previous 10 years' registers of inpatients and outpatients. The records were screened for evidence of extraintestinal complications and fistulas.

RESULTS

The prevalence of CD was 94/10(5) (95% confidence interval, 84-104) inhabitants > or = 16 years old. Signs of liver disease were encountered in 1 of 10 patients, and other extraintestinal complications and intestinal cancer occurred in 1-3%. The true prevalence of primary sclerosing cholangitis could not be assessed.

CONCLUSION

The prevalence of CD was midway between recent figures from Orebro and Copenhagen. Fistulas and pathologic liver laboratory test results were more prevalent when CD involved both the large and small bowel.

Incidence of primary liver cancer and aetiological aspects: a study of a defined population from a low-endemicity area

The prevalence of primary liver cancer (PLC) varies throughout the world. It has been attributed to variations in incidence of the predominant histological type, hepatocellular carcinoma (HCC). The incidence of PLC types other than HCC such as cholangiocellular carcinoma (CCC) is far less known, especially in low-incidence areas. The aetiology of HCC and other PLC types is obscure, with the exception of the association between HCC and cirrhosis as well as chronic viral hepatitis. The present retrospective incidence and aetiology study concerns a well-defined population from a period with a high autopsy frequency. Preserved biopsy specimens were re-evaluated histopathologically and patient records were studied. Among 590 histologically verified cases of PLC, HCC constituted 90%, CCC 8% and a mixed form of these types 1%. At the end of the study period the annual age-standardised incidence rate of HCC was 3.6 cases per 100,000 inhabitants. Other PLC types were hepatoblastoma (n = 3), fibrolamellar carcinoma (n = 2), angiosarcoma (n = 1) and infantile haemangioendothelioma (n = 1), each constituting less than 1% of the PLC cases. Comparing HCC with CCC we found that cirrhosis (70%) and alcoholism (21%) was significantly more frequent in HCC, and cholelithiasis was significantly more common (60%) in patients with CCC. In the majority of the PLC cases with liver cirrhosis this disorder was unknown before diagnosis of the tumour.

Sampling variability of percutaneous liver biopsy in primary sclerosing cholangitis

AIMS

To study sampling variability of percutaneous liver biopsy in primary sclerosing cholangitis (PSC).

METHODS

One hundred and twelve biopsy specimens (that is, 56 pairs) from 44 patients with PSC, confirmed by cholangiography, were evaluated blindly. Six different features, qualitative grading of four other features and staging according to Ludwig were assessed.

RESULTS

Quantitative sampling variability was confined mainly to just one grade or stage, although 11% (six of 56) of the biopsy specimen pairs differed by more than one stage (7% (one of 15) in pairs > 2 cm in length). Qualitative sampling variabilities were between 18 and 71%. Advanced disease (stages 3 or 4) was missed in 40% (two of five) of the biopsy specimens while cirrhosis was missed in 37%.

CONCLUSION

Paired liver biopsy specimens should be taken in clinical studies of PSC using liver histology for evaluation or prognosis.

Ischemic heart disease and epilepsy: two major causes of out-hospital natural death in male alcoholics

The objectives of this research were to study the distribution of in- and out-hospital deaths and causes of death in male alcoholics and in particular to analyze obscure cases. In a population-based sample of 1123 men treated in one detoxification unit during 1986-1989, 97 patients with alcohol dependence (DSM-III-R) died < or = 1 year after in-hospital detoxification. In each case, the cause and the manner of death were assessed by scrutiny of information in hospital and autopsy records, toxicological examinations, and police reports. The results were that 71 of the 97 men died outside hospital. The overall autopsy rate was 89%. Ischemic heart disease accounted for 18 out of 41 evaluable natural out-hospital deaths. Epileptic seizures were judged to be the cause of death in five cases and could also have contributed to seven out of eight obscure out-hospital deaths. Ethanol in blood or urine was detected in 19 of the 23 deaths attributed to trauma or intoxication, whereas only four out of the 18 out-hospital deaths from ischemic heart disease were ethanol-positive. It was concluded that early detection and adequate treatment of ischemic heart disease and epilepsy might improve prognosis in patients with alcohol dependence. The use of clinical information could be of crucial importance in evaluating possible causes of death, especially in obscure cases.

Colchicine treatment of primary sclerosing cholangitis

BACKGROUND/AIMS

There is no medical treatment of documented benefit in primary sclerosing cholangitis (PSC). Colchicine has been observed to reduce mortality in primary biliary cirrhosis in one study. The aim of this study was to examine the effect of colchicine in PSC.

METHODS

Eighty-four patients with PSC were randomized to receive 1 mg of colchicine daily (n = 44) or placebo (n = 40) in a double-blind 3-year study. The effect of treatment was evaluated through blind scoring of 10 variables in prestudy and poststudy liver biopsy specimens, daily recording of symptoms, and biochemical tests (serum bilirubin, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, albumin, immunoglobulins, ceruloplasmin, alpha 1-antitrypsin, and plasma prothrombin levels) at 6-month intervals.

RESULTS

There was no evidence of a favorable effect of colchicine on survival, symptoms, serum biochemistry, or liver histology in patients with PSC.

CONCLUSIONS

One milligram of colchicine daily is ineffective in PSC.

The prevalence of alcoholism and its relation to cause of hospitalization and long-term mortality in male somatic inpatients

OBJECTIVE

To investigate the prevalence of alcoholism in patients hospitalized because of somatic disorders, and to analyse morbidity, mortality, and causes of death in those alcoholics.

DESIGN

Inception cohort, 7-year follow-up.

SETTING

Primary and secondary care clinics at a community hospital in Göteborg, Sweden.

PATIENTS AND CONTROLS

A convenience sample of all 205 men hospitalized at a medical, surgical, and orthopaedic clinic at a random time-point. The diagnosis of alcoholism was stated or rejected by means of structured interviews about drinking habits and by scrutiny of records from the hospital, psychiatric clinics, and social authorities. In the study of morbidity pattern and mortality in the alcoholics (n = 52), age-matched, non-alcoholic controls were recruited from the same sample.

MAIN OUTCOME MEASURES

Prevalence of alcoholism; distribution of somatic disorders as cause of hospitalization at inclusion; mortality and risk ratio of death using the death hazard function of the groups compared with that of men of the same age-distribution in the Swedish population; causes of death during a 7-year follow-up.

MAIN RESULTS

Fifty-two of the 205 hospitalized men (25%) were alcoholics and 16 of these men (31%) were treated for an alcohol-related disorder. During follow-up, the mortality rate was about 50% both in the alcoholic and in the control groups. The risk of death ratio was 5.0 [95% confidence interval (CI), 2.9 to 8.3] in the alcoholics and 3.9 (95% CI, 2.2 to 6.4) in the controls. Death from trauma, intoxication, and liver failure occurred exclusively in the alcoholics and accounted for almost one-third of the deaths after discharge.

CONCLUSIONS

Alcoholism was found in every fourth male somatic inpatient, and an alcohol-related disorder was the cause of hospitalization in one-third of these men. The long-term prognosis did not differ from that in non-alcoholic patients. In the treatment of alcoholics with somatic disorders, it is important to take measures against alcoholism as well.

Erythrocyte porphobilinogen deaminase activity and primary liver cancer

OBJECTIVES

To study whether primary liver cancer (PLC) could be associated with acute intermittent porphyria (AIP) carriership and whether the activity of erythrocyte porphobilinogen deaminase (PBGD) could be used as a tumour marker for PLC.

DESIGN

Prospective study.

SETTING

Medical and surgical wards in two general hospitals in Göteborg, Sweden.

SUBJECTS

All patients with a strong suspicion of PLC (n = 109) who came to the authors' attention.

MAIN OUTCOME MEASURES

Measurement of PBGD activity in erythrocytes. Comparison of the PBGD activity in groups with various final diagnoses-hepatocellular carcinoma (n = 58), cholangiocellular carcinoma (n = 2), malignancy other than PLC (n = 18), benign liver disorders (n = 11)--and according to presence of cirrhosis.

RESULTS

None of the patients had a clinical or family history of AIP. Four cases with low PBGD activity, suggesting AIP gene carriership, were found, which is more than expected. However, the cases were evenly distributed amongst the groups. The mean activity of PBGD was higher in cirrhotic patients, irrespective of the presence of PLC, than in others.

CONCLUSIONS

(i) Acute intermittent porphyria gene carriership might be associated with an increased risk not only for PLC but also for secondary malignancies and benign tumours in the liver. (ii) High activity of PBGD is not unusual in liver cirrhosis and the reason for this needs to be elucidated, but it seems to be of no clinical value as a tumour marker for PLC.

Metastases in cases with hepatocellular carcinoma in relation to clinicopathologic features of the tumor. An autopsy study from a low endemic area

In order to study clinicopathologic features of hepatocellular carcinoma (HCC) and their relation to metastatic growth, all autopsied cases with confirmed HCC (n = 490) from a period with a high autopsy frequency in a well-defined population were analyzed. Cirrhosis, usually of micronodular type, was found in 72%. The gross appearance of the tumour was predominantly massive (46%) or multinodular (42%). The tumour involved both liver lobes in 72% or the right lobe alone in 20%. Histologically, trabecular growth (79%) and grade II of differentiation (52%) prevailed. Vascular invasion was noted in 56%, whereas involvement of the biliary tract was unusual (4%). Metastases especially involved lymph nodes (42%), lungs (18%) and skeleton (17%). Increased weight of the liver, multinodular appearance, involvement of both liver lobes, low grade of differentiation and vascular invasion were significantly associated with presence of metastases.

Influence of increased adrenergic activity and magnesium depletion on cardiac rhythm in alcohol withdrawal

OBJECTIVE

To investigate the prevalence of arrhythmias in alcoholic men during detoxification and its relation to neuroendocrine activation and electrolyte disturbances.

DESIGN

Consecutive case-control study.

SETTING

Primary and secondary care, detoxification ward.

PATIENTS AND CONTROLS

19 otherwise healthy alcoholic men (DSM-III-R) with withdrawal symptoms necessitating detoxification in hospital. 19 age matched, healthy non-alcoholic men as controls for Holter recordings.

INTERVENTIONS

Treatment with chlomethiazole; additional treatment with carbamazepine in patients with previous seizures.

MAIN OUTCOME MEASURES

Computer based analyses of mean heart rate and arrhythmias from 24 hour Holter recordings, 24 hour urinary excretion of adrenaline and noradrenaline, magnesium retention measured by means of intravenous loading test, and serum concentrations of electrolytes.

RESULTS

The 24 hour mean heart rate was higher in the alcoholic men (97.4 beats/minute, 95% confidence interval (CI) 91.2 to 103.6) than in the controls (69.6 beats/minute, 95% CI 65.4 to 73.8, P < 0.001). However, there was no difference in diurnal heart rate variation. The prevalence of premature supraventricular depolarisations was lower in the alcoholic men (P < 0.05). Neither atrial fibrillation nor malignant ventricular arrhythmias occurred. The sinus tachycardia in the alcoholic men correlated with the concomitant urinary excretion of catecholamines (P < 0.05). The mean serum magnesium concentration was 0.78 mmol/l (95% CI 0.73 to 0.83) in the alcoholic men and 0.83 mmol/l (95% CI 0.81 to 0.85) in a reference population of 55 men aged 40. Magnesium depletion (defined as magnesium retention > 30%) was detected in 10 alcoholic men (53%). Three alcoholic men had serum potassium concentrations < or = 3.3 mmol/l on admission.

CONCLUSION

Increased adrenergic activity, magnesium depletion, and hypokalaemia are often seen after heavy drinking, but in alcoholic men without clinical heart disease these changes were not accompanied by arrhythmias other than sinus tachycardia during detoxification in hospital.

Pregnancy in patients with primary biliary cirrhosis--a case for dissuasion? The Swedish Internal Medicine Liver Club

The medical literature on pregnancy in primary biliary cirrhosis is restricted; it mostly dates from several decades ago and mostly reports a bad prognosis for the fetus as well as for the liver disease. We report experiences based on four pregnancies in three patients with primary biliary cirrhosis which are at variance with those reported earlier.

Lack of correlation between hepatitis B virus infection and the increasing incidence of primary liver cancer in Sweden

The incidence of primary carcinoma of the liver in Sweden has been reported to increase. In order to study the role of chronic hepatitis B virus (HBV) infection for liver cancer development 40 cases with hepatocellular carcinoma (HCC) were examined for the presence of HBV surface antigen and HBV core antigen in the cancer and in the surrounding non-neoplastic liver tissue. It was not possible to demonstrate a single case with tissue HBV antigen, indicating that HBV plays a minor role in the etiology of HCC in Sweden and thus does not seem to be responsible for the increasing incidence of this cancer.

Bacterial overgrowth after high-dose corticosteroid treatment

A 63-year-old man with systemic lupus erythematosus and selective IgA deficiency developed intractable diarrhoea the day after treatment with prednisone, 50 mg daily, was started. The diarrhoea was considered to be caused by bacterial overgrowth and was later successfully treated with doxycycline. Although IgA deficiency is a risk factor for bacterial overgrowth, a further predisposing condition is necessary for development of this disorder but was not present in this case. We therefore suppose that high-dose treatment with corticosteroids might be a hitherto undescribed risk factor for bacterial overgrowth in vulnerable patients.

Primary biliary cirrhosis presenting as idiopathic thrombocytopenic purpura with deterioration after splenectomy

A case of primary biliary cirrhosis (PBC) presenting as idiopathic thrombocytopenic purpura is described. The patient, a 59-year-old woman, had, at the time when thrombocytopenia was first observed, an asymptomatic PBC. She responded only temporarily to corticosteroids, and splenectomy had to be performed later. After this operation the platelet count was normalized, but a marked and rapid deterioration of her previously indolent PBC occurred. The time-relationship indicates that the removal of the spleen may be considered the cause of the disease's progression. Possible mechanisms behind this adverse effect of the splenectomy are discussed. After initiation of azathioprine therapy a good response in clinical and laboratory features of the PBC was obtained, although the histological picture has remained unchanged.

Diagnosis of pyogenic liver abscess via liver scanning with indium-111 labelled granulocytes

An 82-year-old man presented with a history indicating cancer or a developing pyogenic abscess in the liver. The latter diagnosis was established by a liver scan with indium-111 labelled granulocytes, whereas ultrasonography, computed tomography and percutaneous liver puncture were inconclusive.

The predictive value of antimitochondrial antibodies in establishing the diagnosis of primary biliary cirrhosis

Primary biliary cirrhosis (PBC) was diagnosed in 85% of patients with antimitochondrial antibodies (AMA) found in sera routinely analyzed for autoantibodies. In these patients and in those without PBC other autoimmune disorders were common, but the latter patients generally had a low AMA titer, 1:80 or less. It was concluded that a low AMA titer may occur in many patients without PBC. On the other hand, it appears very likely that PBC is present in patients with an AMA titer exceeding 1:80 and an increased activity of alkaline phosphatases without signs of extrahepatic biliary obstruction.

Paracetamol medication and alcohol abuse: a dangerous combination for the liver and the kidney

The clinical pattern of paracetamol-induced acute liver damage was studied with regard to whether the intoxication was acute or due to continuous use. This condition was found to be caused almost as often by accidental chronic medication as by acute intoxication, with annual incidences per 100,000 of 0.8 and 1.2 cases, respectively. The liver damage found in 18% of the cases of acute intoxication was generally mild, probably due to an early antidote treatment. In contrast, in the chronic intoxicated cases the liver damage was more pronounced and often accompanied by a severe renal dysfunction. Since all these patients were alcohol abusers, and the reported paracetamol intake was not remarkably high, it seems reasonable to recommend that paracetamol should be prescribed with great caution to alcoholics, and absolutely not for continuous use.

On the relation between drinking habits and alcohol problems

In clinical practice it is important to consider the possibility of alcohol consumption as an etiologic or contributing factor for disease. Information concerning abuse might be obtained by e.g. interviews or indirectly by use of different abuse registers and/or laboratory screening tests. It was found in the present study that statements made by 95 patients with chronic low back pain on drinking habits correlated well with presence of alcohol related problems. Drinking statements thus appear to be useful, at least in well motivated individuals. In patients without alcohol problems the estimated mean daily ethanol consumption generally did not exceed 15 g. An ethanol intake exceeding 15 g per day more than one per week during the last six months was reported by about every third patient with former or present alcohol problems. Such a reported drinking pattern should make the doctor more vigilant about signs of alcohol abuse.

Haematological findings in chronic alcoholics after heavy drinking with special reference to haemolysis

Haematological abnormalities are frequently found in heavy-drinking chronic alcoholics, but anaemia is generally a rare complication. When present, haemolysis is considered to be one of the most common causes. However, little is known about mild haemolysis without anaemia. The present report on eighteen male chronic alcoholics with a recent heavy debauche but without signs of severe liver disease gave support for the occurrence of a reversible low-degree haemolysis without concomitant gross changes of the erythrocytes. Thus the bone marrow showed an increased erythropoiesis in the absence of iron deficiency and known blood losses. Further, increased reticulocyte counts and low levels of haemopexin were noted in the early abstinence. Finally, during the withdrawal phase haptoglobin and haemopexin increased concomitantly with diminishing values of unconjugated bilirubin. The most likely cause of the proposed diminished red cell survival before the withdrawal is supposed to be a reduced membrane stability.

Changes in fatty acid composition of major glycerophospholipids in erythrocyte membranes from chronic alcoholics during withdrawal

Low-degree haemolysis, seen in alcoholics after debauche, may originate from abnormal lipid and fatty acid composition of the erythrocyte membranes. This hypothesis was tested on 13 chronic alcoholics without signs of severe liver disease after an abuse period of more than 7 days. Erythrocytes were analysed at admittance and during withdrawal after 1 and 2 weeks. In order to evaluate the usefulness of whole erythrocytes instead of purified plasma membranes for these analyses a comparison was made. No differences were found with regard to the fatty acid patterns. Reference values of the fatty acid composition of phosphatidylcholine and phosphatidylethanolamine from erythrocytes were also established in control persons. The fatty acid composition of both phosphatidylcholine and phosphatidylethanolamine in the erythrocytes was significantly different from controls at admission. Polyunsaturated fatty acids were decreased and saturated and monounsaturated fatty acids were increased. In phosphatidylcholine, the proportions of the fatty acids of the linoleic acid series were 24% decreased at admittance and 2 weeks later still 19% lower than in controls. The abnormal fatty acid patterns of erythrocytes correlated with similar aberrations in blood plasma phospholipids at admittance. The pathological levels of fatty acids in erythrocytes normalized slower in erythrocytes than in plasma. We conclude that the abnormal fatty acid composition is induced during erythropoiesis.

On the applicability of statements on drinking and dietary habits for the calculation of risks or organ damage in chronic alcoholics

Data from 12 alcoholics admitted to a detoxication ward on two separate occasions revealed great differences in statements on drinking and dietary habits between the two interrogations. The findings clearly demonstrate that such statements do not give reliable informations on drinking and dietary habits during prolonged periods. Furthermore, data from 61 patients show that a classification into chronic and intermitent drinkers only to some extent improves the possibilities to calculate the alcohol consumption over prolonged periods, since because of e.g. frequent or prolonged hospitalizations many chronic drinkers may be intoxicated during fewer days of the year than intermittent drinkers.

Changes in "routine laboratory tests" during abstinence after heavy alcohol consumption in chronic alcoholics

Standard laboratory tests were studied in 61 male chronic alcoholics admitted for detoxication after a period of heavy alcohol consumption. Results obtained within three days after the end of the last debauche were compared with those obtained one week later. Almost half of the patients was considered to have thrombocytopenia, two thirds of the patients had subnormal serum urea values and more than two thirds of the patients were considered to have increased ASAT values. Abnormal values often normalized within one week after admission. Significant alterations within the reference limits were observed for hemoglobin, erythrocyte sedimentation rate, sodium, potassium and bilirubin. The latter test often showed strikingly low values after one week. Most of the aberrations and the changes could be related to details in the case histories.