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Background: NASH cirrhosis is predicted to become the leading indication for liver transplantation within the next decade; however, cardiovascular morbidity andmortality is a significant concern in this population. The aim of this study was to assess cardiovascular comorbidities in liver transplant candidates with NASH/cryptogenic cirrhosis with the hypothesis that a significant proportion of patients will not be eligible for transplantation due to prohibitive cardiac risks. Methods: We assessed listing and transplantation rates as well as wait-list mortality in 155 patients with NASH cirrhosis and 169 patients with cryptogenic cirrhosis who were evaluated for liver transplantation at the University of Pennsylvania from February 2000 to August 2011. Data collected focused on cardiac risk factors in both cohorts. Results: Mean patient age in the NASH and cryptogenic cohorts was 59.8 versus 57.3 years. Men accounted for 56% of patients in the NASH cohort versus 57% in the cryptogenic cohort with a mean BMI of 34.3 versus 29.1 respectively. Median MELD score at evaluation was 13 in the NASH versus 14 in the cryptogenic group with a median Child-Turcotte-Pugh score of 9 in both cohorts. Regarding decompensations in the NASH versus cryptogenic cohorts, 61 % versus 53% had encephalopathy, 71% versus 83% ascites, and 28% versus 27% had variceal bleeding respectively. With respect to comorbidities in the NASH versus cryptogenic groups, 77% versus 51% had diabetes, 63% versus 49% hypertension, 38% versus 28% hyperlipidemia, 28% versus 22% coronary artery disease, and 21% versus 15% had pulmonary hypertension respectively. Fifty-nine percent of the NASH cohort was listed and 49% transplanted. Of those patients not listed, a third were excluded due to cardiovascular comorbidities including coronary artery disease, congestive heart failure, cerebovascular accidents or pulmonary hypertension. Of those listed, 20 patients (22%) died, and 20 (22%) were delisted; 3 deaths and 3 delistings were attributable to cardiovascular events. In comparison, 58% of the cryptogenic cohort was listed and 51% transplanted. Of those not listed, 24% were excluded due to cardiovascular comorbidities; 16 listed patients (16%) died, none due to cardiovascular disease, and 19 got delisted (19%), 2 due to cardiovascular events. Conclusion: Coronary artery disease and metabolic risk factors are a significant concern in liver transplant candidates with NASH/cryptogenic cirrhosis, precluding listing and transplantation in a sizeable proportion of patients.

Serratia marcescens is a gram-negative bacillus that has been recognized as a human pathogen since the 1960s [1]. This organism is known to cause a variety of infections including bacteremia, pneumonia, endocarditis, meningitis, and septic arthritis [2]. Communityacquired infections are uncommon and most often occur in immunocompromised or neutropenic persons [2, 3]. Serratia marcescens is also an unusual cause of soft tissue infections such as cellulitis and necrotizing fasciitis [3]. We report a case of community-acquired necrotizing fasciitis secondary to Serratia marcescens infection that occurred in an otherwise healthy woman.

AIM: To examine the association between macronutrient dietary patterns and alcohol consumption using the Third National Health and Nutritional Examination Survey III. METHODS: A total of 9877 subjects (5144 males) constituted the study cohort. Dietary interviews were conducted with all examinees by a trained dietary interviewer in a mobile examination center (MEC). Subjects reported all foods and beverages consumed except plain drinking water for the previous 24-h time period. Physical examination and history of alcohol consumption were obtained. Pearson correlation coefficients were used to evaluate the association of the levels of alcohol consumption and the percentage of energy derived from macronutrients. Univariate and multivariate regression analyses were performed accounting for the study sampling weight to further explore the relationships between alcohol consumption and calories derived from each macronutrient. RESULTS: Subjects who drank were younger than non-drinker controls in both genders (P < 0.01). Alcohol intake was inversely associated with body mass index and body weight in women. Of all macronutrients, carbohydrate intake was the first to decrease with increasing alcohol consumption. In the multivariate analyses, the level of alcohol consumption was found to be an independent predictor associated with lower intake of other macronutrients. CONCLUSION: Our results show that there is an alteration in the daily dietary pattern with increasing alcohol consumption and that energy derived from alcoholic beverages substitutes that from other macronutrients such as carbohydrate, protein, and fat.

Lymphocyte mRNA levels may serve as a surrogate for activity of drug metabolizing enzymes. We conducted a study to examine the relationship between CYP2E1 and CYP3A4 lymphocyte mRNA levels and the clearances (CL) of oral chlorzoxazone (CHZ) and oral and IV midazolam (MDZ), respectively. 20 alcoholics (ALC) (> 140gm of alcohol/wk) and 20 non-alcoholics (N-ALC) (20 African-Americans 20 Caucasians) enrolled in the study. MDZ was given IV (0.05mg/kg over 30 min) and orally (5mg) on consecutive days. CHZ (500mg) was administered orally 8 hr after IV MDZ. mRNA was isolated from blood lymphocytes, CYP3A4 and 2E1 mRNA was quantitated using real time PCR. Serum CHZ and MDZ concentrations were determined by HPLC-UV or LC-MS. There was no significant difference (p>0.05) between ALC and N-ALC for CYP3A4 mRNA, MDZ CLORAL (149.4±87.8 vs 120.3±84.1 L/hr) and CLIV (36.9±12 vs 36.6±14.1 L/hr). No correlation was observed between lymphocytic CYP3A4 mRNA and CYP3A activity. CYP2E1 mRNA levels were not significantly different between ALC and N-ALC. In contrast, CHZ CLORAL was significantly greater (p

Patient preferences for sedation for colonoscopy: propofol vs. fentanyl/midazolam vs. no sedation

Relationship between hepatitis C and microalbuminuria: Results from the NHANES III. Background Hepatitis C infection is associated with diabetes mellitus and insulin resistance and it is suggested that metabolic syndrome is common in patients with hepatitis C. Microalbuminuria is common in patients with diabetes and metabolic syndrome; however, no studies have examined the relationship between microalbuminuria and hepatitis C infection. Methods We conducted a nested case-control study to examine the relationship between nondiabetic subjects with hepatitis C infection and microalbuminuria by using the Third National Health and Nutrition Examination Survey (NHANES III) database. Study cohort consisted of 15,336 adults from the United States who had hepatitis C antibody measured as part of the NHANES III. The prevalence of microalbuminuria and the metabolic syndrome were compared between individuals with positive hepatitis C infection antibody ( N = 362) and matched controls ( N = 995). Additional analyses were conducted to define the association between hepatitis C infection and microalbuminuria. Results Prevalence of microalbuminuria in patients with hepatitis C infection was 12.4% and it was significantly higher than in controls (7.5%) ( P = 0.001). This difference persisted even after excluding diabetics from the analyses (11.4% vs. 6.7%) ( P = 0.001). However, there was no difference in the prevalence of the metabolic syndrome between two groups (19% vs. 19%) ( P = 0.9). After controlling for relevant covariates, hepatitis C infection was independently associated with microalbuminuria in subjects without diabetes (odds ratio 1.99, 95% CI 1.38–2.85) ( P = 0.008). Older age and African Americans were independently associated with microalbuminuria in nondiabetic hepatitis C patients. Conclusion Hepatitis C infection is independently associated with microalbuminuria but not the metabolic syndrome. Older age and African Americans are strongly associated with microalbuminuria in nondiabetic hepatitis C subjects. More research is needed to explore the implications of these observations.

Introduction Though gastrointestinal stromal tumors (GISTs) frequently present with gastrointestinal bleeding, the guidelines for the management and control of bleeding are unclear especially in patients who are not appropriate for surgical resection. Case presentation We report a case of gastric GIST in an elderly patient who presented with bleeding. Homeostasis was achieved initially with the endoscopic placement of a hemoclip followed by treatment with the tyrosine kinase inhibitor, imatinib. Conclusion The management of bleeding GISTs in the elderly pose a challenging task to the gastroenterologist and treatment strategies should be tailored to the expertise of the endoscopist, surgeon and other supportive staff.