Alcoholic Hepatitis
Alcoholic hepatitis (AH) is a unique clinical syndrome on the spectrum of alcohol-associated liver disease (ALD). It constitutes a rising epidemic with increasing incidence and major public health implications. In severe AH, 30-day mortality approaches 30%, yet therapeutic options remain limited. Survival benefit from corticosteroids, the mainstay of medical treatment, is short-lived. Among corticosteroid nonresponders, the use of early liver transplantation is heterogeneous across centers and remains limited by significant barriers. Long-term prognosis is largely dictated by abstinence; however, comorbid alcohol use disor...
Source: Medical Clinics of North America - February 20, 2023 Category: Primary Care Authors: Pranav Penninti, Ayooluwatomiwa D. Adekunle, Ashwani K. Singal Source Type: research
Intensive Care Unit Care of a Patient with Cirrhosis
Patients with cirrhosis frequently require admission to the intensive care unit (ICU). Common indications for admission to ICU include one or more reasons of sepsis, shock due to any cause, acute gastrointestinal bleeding, and altered mentation either due to hepatic encephalopathy, alcohol withdrawal/intoxication, or metabolic encephalopathy. The appropriate critical care of an individual can determine the outcomes of these sick patients. The Airway, Breathing, Circulation, Disability (ABCD) approach to a patient admitted to ICU includes airway, breathing, circulation, and disability management. In this review, the authors...
Source: Medical Clinics of North America - February 20, 2023 Category: Primary Care Authors: Mahathi Avadhanam, Anand V. Kulkarni Source Type: research
Sarcopenia and Frailty in Cirrhosis
Sarcopenia and frailty are frequent in cirrhosis, and both contribute to increased morbidity and mortality. The complex pathogenesis of sarcopenia in cirrhosis is mainly determined by hyperammonemia and malnutrition. Sarcopenia/frailty screening and reevaluation should be undertaken in all cirrhotic patients. Frailty tests are useful in the ambulatory setting, whereas the computed tomography scan is the diagnostic gold standard for sarcopenia. To manage sarcopenia/frailty, a multidisciplinary team should develop a personalized comprehensive care plan that includes patient education, protein/calorie intake goals, late eveni...
Source: Medical Clinics of North America - February 20, 2023 Category: Primary Care Authors: Chalermrat Bunchorntavakul Source Type: research
Drug-Induced Liver Injury due to Biologics and Immune Check Point Inhibitors
Biological agents have in the last two decades become very important therapeutic agents, particularly for the treatment of various autoimmune disorders. The most widely used biologics are the tumor necrosis factor-α (TNF-α) receptor antagonists: infliximab, adalimumab, and etanercept. Other commonly used biological agents are interle ukin (IL)-1 receptor antagonist (Anakinra), interleukin (IL)-6 receptor antagonist (tocilizumab), and CD20 surface antigen antagonist (rituximab). The current review will however focus on TNF-α receptor antagonists. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 20, 2023 Category: Primary Care Authors: Fernando Bessone, Einar S. Bj örnsson Source Type: research
Chronic Hepatitis C
Hepatitis C virus (HCV) infection contributes significantly to liver cirrhosis and hepatocellular carcinoma (HCC), often requiring liver transplantation. Introducing direct-acting antiviral agents (DAAs) has radically changed HCV treatment. DAAs achieve high rates of sustained virological response (>98%). Even then, resistant-associated substitution and HCC during or after treatment have become prominent clinical concerns. Further, several clinically significant issues remain unresolved after successful HCV eradication by DAAs, including treating patients with chronic kidney disease or decompensated liver cirrhosis. Extens...
Source: Medical Clinics of North America - February 20, 2023 Category: Primary Care Authors: Saleh A. Alqahtani, Mark S. Sulkowski Source Type: research
Liver Cirrhosis and Portal Hypertension
The understanding of pathogenesis of portal hypertension in patients with liver cirrhosis continues to evolve. In addition to progressive fibrosis, cirrhosis is characterized by parenchymal extinction and vascular remodelling, causing architectural distortion. Existence of prothrombotic state and more recently, intestinal bacterial dysbiosis are recently described in the pathogenesis of portal hypertension. Clinically significant portal hypertension (CSPH) is an important prognostic milestone in patients with liver cirrhosis. This is a pre-symptomatic phase that predicts the development of varices, ascites and importantly ...
Source: Medical Clinics of North America - February 20, 2023 Category: Primary Care Authors: Dinesh Jothimani, Mohamed Rela, Patrick S. Kamath Source Type: research
Hepatic Encephalopathy
Hepatic encephalopathy (HE) is brain dysfunction secondary to liver insufficiency or portosystemic shunting. HE is a major burden on patients and caregivers, impairs quality of life and is associated with higher mortality. Overt HE is a clinical diagnosis while Covert HE, needs specialized diagnostic strategies. Mainstay of treatment of HE is nonabsorbable disaccharides such as lactulose as well as rifaximin; however, investigational therapies are discussed in this review. Better tools are needed to prognosticate which patients will go on to develop HE but microbiome and metabolomic-driven strategies are promising. Here we...
Source: Medical Clinics of North America - February 20, 2023 Category: Primary Care Authors: Bryan D. Badal, Jasmohan S. Bajaj Source Type: research
Liver Transplantation for the Nonhepatologist
Liver transplantation (LT) is a life-saving and evidence-based intervention for patients with acute liver failure and chronic end-stage liver disease. Significant progress has been made in advancing pre-LT management, transplant techniques, post-LT long-term care, and immunosuppression regimes. However, as rates of DC continue to increase, causes of liver disease and indications for LT continue to be investigated to ensure equity and further improve liver allocation models, waitlist outcomes, and post-LT outcomes for all patient populations. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 20, 2023 Category: Primary Care Authors: Bethany Nahri So, K. Rajender Reddy Source Type: research
Inpatient Hepatology Consultation
Cirrhosis is the end-stage of chronic liver disease and constitutes a leading cause of potential years of working life lost, especially in the Americas and Europe. Its natural history is characterized by an asymptomatic phase called compensated cirrhosis, followed by a rapidly progressive phase characterized by liver-related complications termed decompensated cirrhosis. Complications could be related to portal hypertension and/or liver dysfunction, including ascites, portal hypertensive gastrointestinal bleeding, encephalopathy, and jaundice. This review will discuss some of the most important precipitants of hepatic decom...
Source: Medical Clinics of North America - February 20, 2023 Category: Primary Care Authors: Luis Antonio D íaz, Josefina Pages, Victoria Mainardi, Manuel Mendizabal Source Type: research
Hepatology Update for Clinicians
The discipline of Hepatology encompasses a broad spectrum of acute and chronic liver diseases with ultimately some patients requiring and benefiting from liver transplantation. While a remarkable achievement has been of the development of safe and effective chronic hepatitis C therapies, there has been a steady increase in disease burden due to nonalcoholic fatty liver disease and cirrhosis. The rate of hospitalization in those with cirrhosis has steadily increased, and this has led to enormous resource utilization and health care costs. (Source: Medical Clinics of North America)
Source: Medical Clinics of North America - February 20, 2023 Category: Primary Care Authors: Anand V. Kulkarni, K. Rajender Reddy Tags: Preface Source Type: research
Breast Cancer
This review provides an outline of a risk-based approach to breast cancer screening and prevention. All women should be assessed for breast cancer risk starting at age 18 with identification of modifiable and non-modifiable risk factors. Patients can then be stratified into average, moderate, and high-risk groups with personalized screening and prevention plans. Counseling on breast awareness and lifestyle changes is recommended for all women, regardless of risk category. High-risk individuals may benefit from additional screening modalities such as MRI and chemoprevention and should be managed closely by a multidisciplina...
Source: Medical Clinics of North America - February 8, 2023 Category: Primary Care Authors: Elena Michaels, Rebeca Ortiz Worthington, Jennifer Rusiecki Source Type: research
Updates in Cardiovascular Disease Prevention, Diagnosis, and Treatment in Women
Cardiovascular disease (CVD) is the leading cause of death for American women. CVD is preventable although risk reduction goals are not achieved for women compared with men. Considering a woman ’s cardiometabolic profile for prevention counseling and prescribing may help. Coronary artery calcium scores provide additional risk assessment and reproductive and menopause histories identify risk enhancers. Diagnosis of CVD is often delayed, and treatment is less optimal for women compared wit h men. Differences in presentation and underlying CVD etiology (Including spontaneous coronary artery dissection and microvascular dise...
Source: Medical Clinics of North America - February 8, 2023 Category: Primary Care Authors: Sarah Jones, Melissa McNeil, Agnes Koczo Source Type: research
Affirming Care for Transgender Patients
Gender identity is a deeply felt internal sense of self, which may correspond (cisgender) or not correspond (transgender) with the person ’s assigned sex at birth. Transgender, nonbinary, and gender diverse people may choose to affirm their gender in any number of ways including medical gender affirmation. This is a primer on the medical care of transgender individuals which covers an introduction to understanding a common language, history of transgender medical care, creating a welcoming environment, hormone therapy, surgical therapies, fertility considerations, and cancer screening in transgender people. (Source: Medi...
Source: Medical Clinics of North America - February 8, 2023 Category: Primary Care Authors: Rebecca Green, Kristen L. Eckstrand, Morgan Faeder, Sarah Tilstra, Eloho Ufomata Source Type: research
Not a 70-Kilogram Man
The explosion of information about gender-specific conditions in the last two decades highlights the need for providers with an interest and knowledge about conditions unique to women (eg, menopause), more common in women (eg, osteoporosis), or which present differently in women (eg, cardiovascular disease). One has only to look at the changing views regarding hormone therapy (HT) to understand the need for up-to-date practitioners. In 1995, HT was thought to be beneficial for both primary and secondary cardiac prevention, to be effective in reducing osteoporotic fractures, and to pose no increased risk for breast cancer o...
Source: Medical Clinics of North America - February 8, 2023 Category: Primary Care Authors: Melissa McNeil Tags: Preface Source Type: research
Genitourinary Syndrome of Menopause
Introduced in 2014, genitourinary syndrome of menopause (GSM) describes a variety of unpleasant genital, sexual and urinary symptoms that can either be isolated or coexisting and are not related to other medical conditions. GSM is a chronic and progressive condition that requires early recognition and appropriate management to preserve urogenital health. Despite the importance of early detection and treatment, the condition is consistently underdiagnosed and undertreated. Herein, we emphasize how to diagnose GSM in postmenopausal, hypoestrogenic, and hypoandrogenic women and summarize evidence-based treatments focusing on ...
Source: Medical Clinics of North America - February 8, 2023 Category: Primary Care Authors: Shanice Cox, Ryan Nasseri, Rachel S. Rubin, Yahir Santiago-Lastra Source Type: research
