Hepatitis associated aplastic anemia (HAAA) is a rare syndrome in which severe aplastic anemia (SAA) complicates the recovery of acute hepatitis (AH). HAAA is described to occur with AH caused by viral infections and also with idiopathic cases of AH and no clear etiology of liver injury. Clinically, AH can be mild to fulminant and transient to persistent and precedes the onset SAA. It is assumed that immunologic dysregulation following AH leads to the development of SAA. Several observations have been made to elucidate the immune mediated injury mechanisms, ensuing from liver injury and progressing to trigger bone marrow failure with the involvement of activated lymphocytes and severe T-cell imbalance. HAAA has a very poor outcome and often requires bone marrow transplant (BMT). The findings of immune related myeloid injury implied the use of immunosuppressive therapy (IST) and led to improved survival from HAAA. We report a case of young male who presented with AH resulting from the intake of muscle building protein supplements and anabolic steroids. The liver injury slowly resolved with supportive care and after 4 months of attack of AH, he developed SAA. He was treated with IST with successful outcome without the need for a BMT.

Introduction. The progression of chronic liver disease to cirrhosis involves both innate and adaptive immune system dysfunction resulting in increased risk of infectious complications. Vaccinations against pneumococcus, hepatitis A virus (HAV), and hepatitis B virus (HBV) are well tolerated and effective in disease prevention and reduction in morbidity and mortality. Prior studies assessing vaccination rates in patients with cirrhosis have specific limitations and to date no study has provided a comprehensive evaluation of vaccination rates in patients with cirrhosis in the United States. Aim. This study assessed vaccination rates for pneumococcus, HAV, and HBV in patients with cirrhosis. Results. Overall 59.7% of patients with cirrhosis received at least 1 vaccination during the study period. Vaccination rates within the same or following year of cirrhosis diagnosis were 19.9%, 7.7%, and 11.0% against pneumococcus, HAV, and HBV, respectively. Trend analysis revealed significant increases in vaccination rates for pneumococcus in all patients with cirrhosis and within subgroups based on age, gender, and presence of concomitant diabetes. Conclusion. The study demonstrated that vaccination rates in patients with cirrhosis remain suboptimal. Ultimately, the use of electronic medical record (EMR) reminders improved communication between healthcare professionals and public health programs to increase awareness are fundamental to reducing morbidity, mortality, and health-care related costs of vaccine preventable diseases in patients with cirrhosis.

Bleeding from gastro-esophageal varices can often present as the first decompensating event in patients with cirrhosis. This can be a potentially life threatening event associated with a 15%-20% early mortality. We present a rare case of new onset ascites due to intra-abdominal hemorrhage from ruptured mesenteric varices; in a 37 years old male with newly diagnosed nonalcoholic steatohepatitis induced cirrhosis as the first decompensating event. The patient was successfully resuscitated with emergent evacuation of ascites for diagnosis, identification and control of bleeding mesenteric varices and eventually orthotopic liver transplantation with successful outcome. Various clinical presentations, available treatment options and outcomes of ectopic variceal bleeding are discussed in this report.

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significantly greater degree of hypoxia than the control subjects. The magnitude of ODI was not different between middle-aged and elderly patients with OSAS.Circulating AM levels in middle-aged and elderly patients with OSAS were significantly greater than in the ageand BMI-matched controls, although neither age nor sex affected them (Table 1). nCPAP treatment significantly decreased the higher levels of circulating AM in the patients irrespective of age and sex. After 3 months of treatment with nCPAP, AM levels in elderly patients (26.5 AE 2.4 pg/ mL) were not different from those of middle-aged patients (24.7 AE 2.1 pg/mL).These results indicated that plasma AM levels were higher in middle-aged and elderly patients with OSAS and could be deceased with nCPAP treatment, regardless of age and sex. The augmented increase in AM caused by severe nocturnal hypoxemia and oxidative stress due to OSA may overcome the age-dependent increase of AM levels in middle-aged and elderly patients with OSAS. Because AM is reported to induce cell surface expression of adhesion molecules, including E-selectin, vascular cell adhesion molecule-1, and intercellular adhesion molecule-1 (ICAM-1), on human endothelial cells, the higher level of AM is one of the mechanisms of higher levels of ICAM-1 in patients with OSAS. 10 The current study also indicates that treatment with nCPAP may be effective for the prevention of cardiovascular complications in elderly patients with OSAS.

Introduction of Direct Acting Antivirals (DAA) to Hepatitis C Virus (HCV) treatment armamentarium has offered a great boost to the providers' confidence to safely and effectively treat HCV infection in the majority of patients. However, the cost of these medications is high and thus access is poor. Medicaid insurance providers have devised stringent eligibility criteria to approve the cost of DAA for its members. We reviewed the criteria among various Medicaid agencies from States of Ohio and Pennsylvania and noticed similarities and differences among them. The prerequisite process demanding clinical, laboratory, radiologic or histologic documentation is quite cumbersome and sometimes confusing. In certain aspects the eligibility requirements for DAA are not in concordance with the clinical evidence provided by the recently updated guidelines. We have addressed the dilemma most of the providers face while planning HCV treatment for the Medicaid insured patients in regards to the needed testing, clinical documentation and liver fibrosis assessment, along with the clinical implications of such requirements. While HCV remains a major public health issue, variable State Medicaid policies may lead to disparity in access to the emerging DAA with subsequent healthcare outcomes. These gaps may compromise long term efforts of the public health HCV initiatives.

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Liver fibrosis represents the repair mechanism in liver injury and is a feature of most chronic liver diseases. The degree of liver fibrosis in chronic viral hepatitis infections has major clinical implications and presence of advanced fibrosis or cirrhosis determines prognosis. Treatment initiation for viral hepatitis is indicated in most cases of advanced liver fibrosis and diagnosis of cirrhosis entails hepatology evaluation for specialized clinical care. Liver biopsy is an invasive technique and has been the standard of care of fibrosis assessment for years; however, it has several limitations and procedure related complications. Recently, several methods of noninvasive assessment of liver fibrosis have been developed which require either serologic testing or imaging of liver. Imaging based noninvasive techniques are reviewed here and their clinical use is described. Some of the imaging based tests are becoming widely available, and collectively they are shown to be superior to liver biopsy in important aspects. Clinical utilization of these methods requires understanding of performance and quality related parameters which can affect the results and provide wrong assessment of the extent of liver fibrosis. Familiarity with the strengths and weaknesses of each modality is needed to correctly interpret the results in appropriate clinical context.