Autochthonous hepatitis E is more common than previously recognized, and should be considered in the differential diagnosis in patients with hepatitis, whatever their age or travel history. It carries a significant morbidity and when seen in the context of chronic liver disease carries an adverse prognosis.

SUMMARY BackgroundLocally acquired hepatitis E is an emerging infection in developed countries and can be misdiagnosed as drug-induced liver injury.

Drug-induced liver injury (DILI) encompasses a spectrum of clinical disease ranging from mild biochemical abnormalities to acute liver failure. The majority of adverse liver reactions are idiosyncratic, occurring in most instances 5-90 days after the causative medication was last taken. The diagnosis of DILI is clinical, based on history, probability of the suspect medication as a cause of liver injury and exclusion of other hepatic disease. DILI can be hepatocellular (predominant rise in alanine transaminase), cholestatic (predominant rise in alkaline phosphatase) or mixed liver injury. An elevated bilirubin level more than twice the upper limit of normal in patients with hepatocellular liver injury implies severe DILI, with a mortality of approximately 10% and with an incidence rate of 0.7-1.3 per 100,000. Although acute liver failure is rare, 13-17% of all acute liver failure cases are attributed to idiosyncratic drug reactions. Response to drug withdrawal may be delayed up to 1 year with cholestatic liver injury with occasional subsequent progressive cholestasis known as the vanishing bile duct syndrome. Overall, chronic disease may occur in up to 6% even if the offending drug is withdrawn. Antibiotics and NSAIDs are the most common cause of DILI. Statins rarely cause significant liver injury whereas antiretroviral therapy is associated with hepatotoxicity in 10% of treated patients. Multiple mechanisms of DILI have been implicated, including TNF-alpha-activated apoptosis, inhibition of mitochondrial function and neoantigen formation. Risk factors for DILI include age, sex and genetic polymorphisms of drug-metabolising enzymes such as cytochrome P450. In patients with human immunodeficiency virus, the presence of chronic viral hepatitis increases the risk of antiretroviral therapy hepatotoxicity. Over the next decade, the combination of accurate case ascertainment of DILI via clinical networks and the application of genomics and proteomics will hopefully lead to accurate prediction of risk of DILI, so that pharmacotherapy can be optimised with avoidance of adverse hepatic events.

In areas with endemic hepatitis E virus (HEV), acute liver failure secondary to hepatitis E infection is common in pregnancy and associated with a mortality rate of up to 20%. However, there is little information on the clinical course of severe hepatitis E infection during pregnancy in non-endemic areas such as the UK. Here we describe two cases of severe hepatitis E in pregnancy in patients returning from the Indian subcontinent. These cases were diagnosed by the detection of IgM anti-HEV antibody using an enzyme immunoassay with recombinant hepatitis E viral antigens. The first case describes acute hepatic failure, with coagulopathy and encephalopathy, warranting intensive therapy and elective ventilation. In the other case, the patient had severe hepatitis with coagulopathy. Both cases spontaneously resolved with no foetal loss. These cases highlight the need for suspicion of HEV infection in patients returning from endemic areas and presenting with acute non-A non-B hepatitis, especially when pregnant. Furthermore, the intensive treatment of acute liver failure caused by HEV may reduce the high mortality reported in Asia.

8.1% patients with no biliary obstruction and jaundice had a drug-induced and predominantly antibiotic-related aetiology particularly affecting an elderly population. We recommend that all patients receiving co-amoxiclav and flucloxacillin should be counselled before the therapy regarding the potential risk of jaundice and that an alternative antibiotic to co-amoxiclav is used if possible in men over the age of 60 years.

S, Lodge P, O'Grady JG, Losowsky MS. Effects of orthotopic liver transplantation on body composition.Abstract: Airns/Background: The effects of orthotopic liver transplantation on body composition are unclear. We aimed to assess changes in body composition after transplantation using dual energy x-ray absorptiometry and total body potassium. Methods: Dual energy x-ray absorptiometry and total body potassium counting to assess muscle mass were performed in 55 patients before and up to 24 months after liver transplantation and the results expressed as paired data before and at time intervals after transplantation. Results: The results showed that total body weight fell by 3.6? 1.3 kg @<0.02) at 1 month, with a maximal fall in lean tissue mass at 2-5 months of 4.82 1.2 kg @<0.003). Thereafter, no change in lean tissue mass was recorded, although there were increases at 12 and 24 months of total body weight (1 1.5k2.4 kg, 7.823.1 kg; p<0.03, respectively) and fat mass (12.952.2 and 10.522.7 kg; p<0.003). A fall in total body potassium was seen at 1 month (118212 mmol; p<0.003) and 2-5 months (17659.9 mmol; p<0.03), which mirrored the fall in lean mass. Conclusions: After liver transplantation there is an initial fall in body weight due to a loss of lean mass. Lean mass does not recover after transplantation, although there is an increase in fat mass that leads to the observed increase in total body weight.

The establishment of prospective registries for DILI has provided valuable data on the pathogenesis and outcome of DILI. Drug-specific computerised causality assessment tools should improve the diagnosis of DILI. The clinical utility of genetic polymorphisms associated with drug-specific DILI is limited.

Background: Minimally invasive surgery (MIS) is increasingly being used for bunion correction, but limited patient outcome data have been reported for third-generation minimally invasive chevron/Akin (MICA) techniques. The aim of this study was to report on radiographic outcomes, pain control, satisfaction, learning curve, and complication rates in a consecutive series of 94 patients undergoing MICA procedures for hallux valgus. It also describes strategies for avoiding perioperative complications that may arise with MIS bunionectomies. Methods: The treating surgeon’s first 94 MICA procedures were included in the study. Radiographs were reviewed to measure pre- and postoperative intermetatarsal angles (IMAs), hallux valgus angles (HVAs), and soft tissue/bony foot width. Outcome measures, including visual analog scale (VAS) scores and Coughlin satisfaction scores, were obtained. Complication rates were retrospectively assessed though chart review. Statistical analysis was performed using Student t test for continuous variables and χ2 test for categorical variables. Average patient follow-up was 11.2 months. Results: VAS scores dropped 1 week postoperatively, from 5.2 preoperatively to 2.4 ( P < .001). IMA improved from 12.6 degrees to 5.7 degrees at final follow-up ( P < .001), while HVA improved from 26.8 degrees to 10.3 degrees ( P < .001). Bony foot width improved from 92.4 mm to 87.2 mm ( P < .001), and soft tissue foot width improved from 104.1 mm to 100.1 mm ( P < .001). The reoperation rate was 5%, including 3 hardware removals, 1 irrigation and debridement, and 1 neurolysis. Ninety-four percent of patients reported good or excellent satisfaction with the procedure. Complication rates and patient satisfaction scores were similar between the first and second half of patients ( P > .05), suggesting the learning curve was not a factor. Conclusion: In our experience, the MICA osteotomy was a safe and reproducible technique, associated with rapid improvement in pain scores, early weightbearing, significant deformity correction, high patient satisfaction, and low frequency of complications. In addition, the learning curve for the procedure was not as steep as previously reported. Level of Evidence: Level III, retrospective comparative series.