Philip Wong

Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study Of Liver Diseases and the European Association for the Study of the Liver

The AASLD/EASL Practice Guideline Subcommittee on Hepatic Encephalopathy are: Jayant A. Talwalkar (Chair, AASLD), Hari S. Conjeevaram, Michael Porayko, Raphael B. Merriman, Peter L.M. Jansen, and Fabien Zoulim. This guideline has been approved by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver and represents the position of both associations.

Hepatic Encephalopathy in Chronic Liver Disease: 2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases

These recommendations provide a data-supported approach. They are based on the following: (1) formal review and analysis of the recently published world literature on the topic; (2) guideline policies covered by the American Association for the Study of Liver Diseases/European Association for the Study of the Liver (AASLD/EASL) Policy on the Joint Development and Use of Practice Guidelines; and (3) the experience of the authors in the specified topic. Intended for use by physicians, these recommendations suggest preferred approaches to the diagnostic, therapeutic, and preventive aspects of care. They are intended to be flexible, in contrast to standards of care, which are inflexible policies to be

Clostridium difficile colitis: Increasing incidence, risk factors, and outcomes in solid organ transplant recipients

Background Clostridium difficile-associated diarrhea (CDAD) is an increasingly important diagnosis in solid organ transplant recipients, with rising incidence and mortality. We describe the incidence, risk factors, and outcomes of colectomy for CDAD after solid organ transplantation. Methods Patients with CDAD were identified from a prospective transplant database. Complicated Clostridium difficile colitis (CCDC) was defined as CDAD associated with graft loss, total colectomy, or death. Results From 1999 to 2010, we performed solid organ transplants for 1331 recipients at our institution. The incidence of CDAD was 12.4% (165 patients); it increased from 4.5% (1999) to 21.1% (2005) and finally 9.5% (2010). The peak frequency of CDAD was between 6 and 10 days posttransplantation. Age more than 55 years (hazard ratio [HR]: 1.47, 95% confidence interval [CI]=1.16–1.81), induction with antithymocyte globulin (HR: 1.43, 95% CI=1.075–1.94), and transplant other than kidney alone (liver, heart, pancreas, or combined kidney organ) (HR: 1.41, 95% CI=1.05–1.92) were significant independent risk factors for CDAD. CCDC occurred in 15.8% of CDAD cases. Independent predictors of CCDC were white blood cell count more than 25,000/&mgr;L (HR: 1.08, 95% CI=1.025–1.15) and evidence of pancolitis on computed tomography scan (HR: 2.52, 95% CI=1.195–5.35). Six patients with CCDC underwent colectomy with 83% patient survival and 20% graft loss. Of the medically treated patients with CCDC (n=20), the patient survival was 35% with 100% graft loss. Conclusions We have identified significant risk factors for CDAD and predictors of progression to CCDC. Furthermore, we found that colectomy can be performed with excellent survival in selected patients.

Dosimetric evolution of the breast electron boost target using 3D ultrasound imaging.

PURPOSEnTo investigate the effect of treatment planning, patient setup, and interfraction motion errors on the delivered dose for external beam electron boosts for postoperative early stage breast cancer patients.nnnMETHODS AND MATERIALSnFor 5 patients, 10-15 Gy was prescribed and administered via a conventionally defined electron boost treatment field - no dose distribution was calculated. Two computed tomography (CT) data sets were acquired on an average of 47 days apart. Using Monte Carlo techniques the clinically defined electron beams were reconstructed on CT1 and CT2, and a dosimetric comparison between the two data sets was made. Additionally, 3D ultrasound (US) imaging was performed to monitor interfraction motion. 3D US images were acquired concurrently with the CT images, as well as prior to each boost fraction in the treatment room. Taking into account interfraction motion, the dose to the clinical target volume (CTV) was calculated.nnnRESULTSnBased on conventionally determined treatment fields the CT1-based CTV D95 averaged 49% (range 12-89%) of the prescribed dose. Representing setup errors, the CT2-based CTV D95 averaged 47% (range 16-91%) of the prescribed dose. Considering interfraction motion, the average radial displacement was 11 mm, and the resulting CTV D95 was further reduced in 2/5 patients.nnnCONCLUSIONSnPoor initial coverage at the time of planning is exacerbated by breast mobility and interfraction tumour bed motion, increasing the uncertainty in the delivered dose.

The utility of Xenon-133 liver scan in the diagnosis and management of nonalcoholic fatty liver disease

BACKGROUNDnNonalcoholic fatty liver disease (NAFLD) is an important and common condition affecting approximately 20% of the general population. Given the limitation of radiological investigations, diagnosis often requires a liver biopsy.nnnOBJECTIVEnTo compare Xenon-133 (Xe-133) liver scanning with ultrasonography in the diagnosis of NAFLD.nnnMETHODSnFrom January 2003 to February 2007, 258 consecutive patients with suspected NAFLD underwent Xe-133 liver scanning at Royal Victoria Hospital (Montreal, Quebec). Of these, 43 patients underwent ultrasonography and liver biopsy for the evaluation of NAFLD. Patients with other liver diseases and significant alcohol consumption were excluded. Two nuclear medicine physicians assessed liver Xe-133 uptake and measured the grade of steatosis using a standardized protocol. The degree of steatosis was determined from biopsy specimens assessed by two hepatopathologists.nnnRESULTSnNAFLD was identified by liver biopsy in 35 of 43 patients (81.4%). Xe-133 scan demonstrated 94.3% sensitivity (95% CI 81.4% to 98.4%) and 87.5% specificity (95% CI 52.9% to 99.4%) for the presence of NAFLD. The positive and negative predictive values for detection of steatosis by Xe-133 scan were 97.1% (95% CI 85.1% to 99.8%) and 77.8% (95% CI 45.3% to 93.7%), respectively. The positive and negative likelihood ratios were 7.54 (95% CI 1.20 to 47.26) and 0.07 (95% CI 0.02 to 0.26), respectively. Two patients with NAFLD (5.7%) who had a negative Xe-133 scan result had histologically mild steatosis (<10%). The grade of steatosis on liver biopsy was highly correlated with the results of the Xe-133 scan (r=0.87; P<0.001). The sensitivity and specificity of ultrasound in diagnosing steatosis were 62.9% and 75%, respectively.nnnCONCLUSIONnXe-133 liver scan proved to be a safe, reliable, noninvasive method for diagnosing and quantifying hepatic steatosis, and was superior to ultrasound.

Serum fibrosis biomarkers predict death and graft loss in liver transplantation recipients.

Noninvasive serum fibrosis biomarkers predict clinical outcomes in pretransplant patients with chronic liver disease. We investigated the role of serum fibrosis biomarkers and of changes in biomarkers in predicting death and graft loss after liver transplantation (LT). We included 547 patients who underwent LT between 1991 and 2012 and who met the following criteria: patient and graft survival > 12 months; serum fibrosis biomarkers aspartate aminotransferase–to‐platelet ratio index (APRI), fibrosis score 4 (FIB‐4), and nonalcoholic fatty liver disease (NAFLD) fibrosis score available at 1 year after LT; and a minimum follow‐up of 1 year. Delta of fibrosis biomarkers was defined as (end of follow‐up score – baseline score)/follow‐up duration. Baseline and delta fibrosis biomarkers were associated with death: APRI > 1.5 (adjusted hazard ratio [aHR], 2.2; 95% confidence interval [CI], 1.4‐3.3; P < 0.001) and delta APRI > 0.5 (aHR, 5.3; 95% CI, 3.4‐8.2; P < 0.001); FIB‐4 > 3.3 (aHR, 1.9; 95% CI, 1.3‐2.8; P = 0.002) and delta FIB‐4 > 1.4 (aHR, 2.4; 95% CI, 1.4‐4.1; P = 0.001); and NAFLD fibrosis score > 0.7 (aHR, 1.9; 95% CI, 1.3‐2.9; P = 0.002) and delta NAFLD fibrosis score (aHR, 3.7; 95% CI, 2.6‐5.4; P < 0.001). Baseline and delta fibrosis biomarkers were associated also with graft loss. In conclusion, serum fibrosis biomarkers 1 year after LT and changes in serum fibrosis biomarkers predict death and graft loss in LT recipients. They may help in risk stratification of LT recipients and identify patients requiring closer monitoring. Liver Transpl 21:1383‐1394, 2015.

Identifying those infected with hepatitis C virus

The new recommendations by the Canadian Task Force on Preventive Health Care for screening for hepatitis C virus (HCV) infection[1][1] strongly advise against screening those without apparent risks. This can only perpetuate Canada’s low HCV diagnosis rates, leading to the late diagnosis of liver