AIMTo verify how malnutrition is related to health-related quality of life (HRQL) impairment in patients with cirrhosis.METHODSData was retrospectively abstracted from medical records and obtained by direct interview. We included patients with cirrhosis from any etiology, evaluated at the Liver Clinic from Gastroenterology Department in a tertiary healthcare center, from June 2014 to June 2016. Child-Pugh score, data about complications, and demographic, clinical and anthropometric characteristics of patients were obtained. Nutritional status was evaluated by the Subjective Global Assessment (SGA). HRQL was evaluated through the Chronic Liver Disease Questionnaire. Patients were requested to assess their global HRQL with the following code: 0 = impairment of HRQL, when it was compared with other healthy subjects; 1 = good HRQL, if it was similar to the quality of life of other healthy subjects. To compare the primary outcome between malnourished and well-nourished groups, the χ2 test, Fisher’s exact test or Student’s t-test were used, based on the variable type. Associations between predictor variables and deterioration of HRQL were determined by calculating the hazard ratio and 95% confidence interval using Cox proportional hazards regression.RESULTSA total of 127 patients with cirrhosis were included, and the mean age was 54.1 ± 12.3 years-old. According to Child-Pugh scoring, 25 (19.7%) were classified as A (compensated), 76 (59.8%) as B, and 26 (20.5%) as C (B/C = decompensated). According to SGA, 58 (45.7%) patients were classified as well-nourished. Sixty-nine patients identified HRQL as good, and 76 patients (59.8%) perceived impairment of their HRQL. Multivariate analysis to determine associations between predictor variables and self-perception of an impairment of HRQL found strong association with malnutrition (P < 0.0001). The most important impaired characteristics in malnourished patients were: Presence of body pain, dyspnea on exertion with daily activities, decreased appetite, generalized weakness, trouble lifting or carrying heavy objects, and decreased level of energy (P < 0.0001).CONCLUSIONMalnutrition is a key factor related to impairment of HRQL in patients with cirrhosis.

Acquired (non-Wilsonian) hepatocerebral degeneration (AHD) is a chronic brain disorder caused by liver dysfunction and long-standing portal-systemic shunting. It typically presents with dysathria, ataxia, tremor, involuntary movements and altered mental status, and often does not respond to conventional medical therapy for hepatic encephalopathy. There is scarce and conflicting information regarding the clinical course of AHD after liver transplantation (OLT). We present a case of a 47-year-old woman with hepatitis C (HCV) cirrhosis who developed severe manifestations of AHD after multiple bouts of hepatic encephalopathy. Her first OLT was complicated with primary nonfunction requiring immediate retransplantation. The second OLT led to complete clinical and radiological resolution of the AHD. However the patient developed recurrence of AHD 11 months post-transplant due to recurrent HCV and chronic rejection leading to cirrhosis of the graft. The patient developed severe neurological symptoms, despite mild synthetic graft dysfunction. Neurological manifestations are common in patients with decompensated cirrhosis. In the majority of the patients they are related to hepatic encephalopathy and typically respond to medical treatment and removal of precipitating factors. Acquired (non-Wilsonian) hepatocerebral degeneration (AHD) is a unique neurological disorder, which differs from hepatic encephalopathy and responds poorly to conventional therapy. It characteristically presents with dysathria, ataxia, tremor, involuntary movements and altered mental status, which are often seen in Wilson disease, hence its original name. 1,2 However, AHD is not related to Wilson disease and has been attributed to manganese deposition in the basal ganglia and other areas of brain tissue. [3][4][5][6][7] Since many of the neuropsychiatric symptoms in patients with AHD tend to be irreversible, a few authors raised the question of their response to liver transplantation (OLT). [8][9][10][11][12][13] Unfortunately, the information regarding the effect of OLT on AHD is limited and inconsistent. We herein present a case of a woman with AHD who experienced complete clinical and radiological resolution after OLT, with late recurrence of AHD. CASE REPORTA 47-year-old white female presented to the emergency room with a recent onset of mild confusion, dysarthria, gait instability, and severe choreo-atetotic movements Abbreviations: AHD, acquired (non-Wilsonian) hepatocerebral degeneration; OLT: liver transplantation; HCV, hepatitis C; TIPS, transjugular intrahepatic porto-systemic shunt. Address reprints to Arie Regev,

-Background -Acid suppression has been associated with adverse events; such as, enteric infections. Proton pump inhibitors (PPI) are frequently prescribed in patients with cirrhosis, but is unclear if PPI are associated with the development of bacterial infections in these patients. Objective -To assess the impact of PPI intake on the development of bacterial, viral and fungal infections in patients with cirrhosis. Methods -An observational, retrospective, historic cohort study. The exposed cohort included patients with cirrhosis with chronic use of PPI. The non-exposed cohort had not been using PPI. The follow-up period was 3 years, searching in the medical records for any events of bacterial infection confirmed by bacteriological culture. Results -One hundred and thirteen patients met the selection criteria, 44 (39%) had chronic use of PPI; of them, 28 (63.6%) patients had not a clear clinical indication to justify the prescription of PPI. Twenty four (21.2%) patients developed bacterial infections during the follow-up period. In the univariate analysis, decompensated cirrhosis (Child B/C), presence of ascites, history of variceal bleeding, and chronic consumption of PPI were risk factors related to the development of infections. But, in the adjusted multivariate analysis only the chronic use of PPI was associated with development of infections (RR=3.6; 95% CI=1.1-12.3; P=0.04). Conclusion -There is an over-prescription of PPI without a justified clinical indication. The long-term consumption of PPI in patients with cirrhosis is associated with the development of bacterial infections; therefore these drugs must be carefully prescribed in this specific population. HEADINGS -Proton pump inhibitors, adverse effects. Inappropriate prescribing. Liver cirrhosis. Risk assessment.Declared conflict of interest of all authors: Fátima Higuera-de la Tijera has received fees for serving as a speaker for Laboratorios Liomont. The other authors have not conflict of interest to declare. None of the other researchers involved in this study have received fees for serving as a speaker, consultant or as advisory board member for any organization. Disclosure of funding: no funding received

Granulocytic sarcoma is an extramedullary collection of myeloblasts. Granulocytic sarcomas usually arise during the course of acute myeloid leukemia, although they also occur infrequently in chronic myeloid leukemia and other myeloproliferative disorders. We are reporting a very unusual presentation of granulocytic sarcoma in a patient with poorly differentiated (FAB type M2) acute myeloid leukemia. The patient was in complete remission from leukemia when he presented obstructive jaundice due to a pancreatic mass consisting of myeloblasts. A literature search identified only five previously reported cases of granulocytic sarcoma of the pancreas. Those cases are also reviewed here with emphasis on their clinical characteristics, diagnostic approaches, and management of this interesting and challenging entity.

Hepatitis C virus (HCV) co-infection is common among human immunodeficiency virus (HIV) patients. The incidence and risk factors associated with hepatotoxicity in this population after high active antiretroviral therapy (HAART) is initiated are still not well-understood. We argued to evaluate the incidence and risk factors associated with liver enzyme elevation (LEE) and their clinical significance. A retrospective chart review of patients who started HAART and had follow up at our centre for at least 1 year was undertaken. The frequency and severity of alanine aminotransferase (ALT)/aspartate aminotransferase (AST) elevation after treatment initiation were investigated and searched for clinical manifestations. Between January 1996 and March 2002, 85 HIV-HCV co-infected patients began HAART and continued follow up for at least 1 year. The incidence of severe toxicity [grades 3 + 4 LEE: >5 and >10 times the upper limit of normal (ULN) of ALT or AST] was calculated at 4% per person-years. There were no clinical manifestations of liver toxicity, and patients continued their treatment with a trend towards a decrease of their enzymes. No statistical differences in opportunistic infections or mortality were evident. The variables associated with severe hepatotoxicity were a higher baseline AST, higher international normalized ratio (INR) and lower albumin. A baseline AST < 2.1 ULN had a negative predictive value of 92% of leading to severe hepatotoxicity. In HIV-HCV co-infected patients therefore, the group at a higher risk of developing higher transaminase elevations is the one with a higher baseline AST, higher INR and lower albumin.