Liver injury induced by high-dose methylprednisolone therapy: a case report and brief review of the literature

Corticosteroids are used widely to treat many types of disease. In general, these drugs are considered safe for the liver; however, recent reports have demonstrated that high-dose methylprednisolone (MT) may cause severe liver injury. Here, we report a case of a 24-year-old female who was given pulsed MT therapy for multiple sclerosis. MT induced icteric hepatitis and impaired liver synthetic function. Hepatotoxicity developed several weeks after drug exposure, and the causal association with MT was confirmed by unintentional rechallenge test. A brief review of the literature on corticosteroid-induced hepatotoxicity is presented.     

S-adenosyl L-methionine in CNS diseases

S-adenosyl L-methionine (SAMe) is the natural, universal methyl group donor, participating in transmethylation reactions, known and commonly used as a dietary supplement since 1952. It plays an important role in the synthesis of neuromediators and melatonin and mechanisms of epigenetic regulation. The aim of this article is to review the literature about possibilities of SAMe application in the therapy of CNS diseases: depression, dementia syndromes, schizophrenia and somatic disorders. SAMe is the promising dietary supplement, which may be successfully used as a substance increasing effectiveness of the treatment of depression, with antidepressants in monotherapy in mild depressive states or depressive symptoms. SAMe addition to antipsychotic drug, may lead to the improvement of the quality of life and reduction of aggressiveness of patients. SAMe may be an effective substance in the therapy and prophylaxis of mild cognitive impairments and mild dementia syndrome. SAMe possesses some hepatoprotective action, so it may decrease the risk of the development of neoplasm, alcohol-induced liver disease (ALD) and cirrhosis. SAMe improves the functions of joints and decreases the experience of pain in rheumatoid arthritis (RA).     

Primary small intestine tumour as the cause of gastrointestinal tract occlusion

The following paper presents the case of a 40-year-old patient staying in our Clinic between 2 March 2010 and 12 March 2010 due to the symptoms of permeable occlusion of gastrointestinal tract. This is a patient with a several weeks' history of non-specific abdominal pain, vomiting and significant weight loss (ca 20 kg). Until recently he has not suffered from any serious illnesses. In the performed abdominal ultrasound, gastroscopy and colonoscopy no pathology was affirmed. CT scan with intravenous and oral contrast showed significantly widened intestinal loops with residual liquid matter in the stomach, duodenum and a part of the jejunum without any distinguishing pathological mass, and also single mesenteric lymph nodes and para-aortic nodes enlarged to the size of 12 mm. The patient was qualified for laparatomy. During the surgery, a 4-cm tumour of the jejunum, concentrically narrowing intestinal lumen was found. Segmental resection of the small intestine was performed with side to side anastomosis with the use of a linear stapler. Currently the general condition of the patient is good, without any ailments, and the patient is undergoing systemic treatment.     

Gallstone disease in the elderly: are older patients managed differently?

Background  

This study aimed to describe the differences in the management of symptomatic gallstone disease within different elderly groups and to evaluate the association between older age and surgical treatment.     

Reflex and tonic autonomic markers for risk stratification in patients with type 2 diabetes surviving acute myocardial infarction

OBJECTIVE

Diabetic postinfarction patients are at increased mortality risk compared with nondiabetic postinfarction patients. In a substantial number of these patients, diabetic cardiac neuropathy already preexists at the time of the infarction. In the current study we investigated if markers of autonomic dysfunction can further discriminate diabetic postinfarction patients into low- and high-risk groups.

RESEARCH DESIGN AND METHODS

We prospectively enrolled 481 patients with type 2 diabetes who survived acute myocardial infarction (MI), were aged ≤80 years, and presented in sinus rhythm. Primary end point was total mortality at 5 years of follow-up. Severe autonomic failure (SAF) was defined as coincidence of abnormal autonomic reflex function (assessed by means of heart rate turbulence) and of abnormal autonomic tonic activity (assessed by means of deceleration capacity of heart rate). Multivariable risk analyses considered SAF and standard risk predictors including history of previous MI, arrhythmia on Holter monitoring, insulin treatment, and impaired left ventricular ejection fraction (LVEF) ≤30%.

RESULTS

During follow-up, 83 of the 481 patients (17.3%) died. Of these, 24 deaths were sudden cardiac deaths and 21 nonsudden cardiac deaths. SAF identified a high-risk group of 58 patients with a 5-year mortality rate of 64.0% at a sensitivity level of 38.0%. Multivariately, SAF was the strongest predictor of mortality (hazard ratio 4.9 [95% CI 2.4–9.9]), followed by age ≥65 years (3.4 [1.9–5.8]), and LVEF ≤30% (2.6 [1.5–4.4]).

CONCLUSIONS

Combined abnormalities of autonomic reflex function and autonomic tonic activity identifies diabetic postinfarction patients with very poor prognoses.Diabetes remains one of the leading causes of death in the industrialized world despite considerable recent attention. Diabetic patients with histories of myocardial infarctions (MIs) have particularly poor prognoses (1). A substantial number of deaths in these patients occur suddenly and might thus be preventable by prophylactic implantation of implantable cardioverter defibrillators (ICDs). As implanting ICDs in all diabetic post-MI patients would not be cost-effective, further risk stratification of this patient population is necessary. At present, left ventricular ejection fraction (LVEF) is the gold standard tool for post-MI risk stratification (2). However it is neither specific nor sensitive. This problem is not related to diabetic patients because risk stratification in the general postinfarction population suffers from the same shortcoming. Therefore, additional risk stratification tools, including the assessment of autonomic dysfunction, have been proposed for the general postinfarction population.In diabetic postinfarction patients, autonomic function can be affected by both the infarction, including its complications, and the preexisting cardiac autonomic neuropathy (2–4). This might compromise risk-predictive value of the autonomic markers. Therefore, this study was undertaken to investigate whether markers of autonomic dysfunction are of prognostic value in the clinical setting of acute MI complicated by a preexisting diabetic cardiac neuropathy.Heart rate turbulence (HRT) (5) and deceleration capacity (DC) (6) are Holter-based techniques that capture different aspects of autonomic control. HRT quantifies an autonomic reflex, namely the heart rate response to the transient fall of arterial pressure caused by ventricular premature complexes (VPCs). DC is supposed to be representative of tonic vagal activity. Coincidence of abnormal HRT and DC are suggestive of severe autonomic failure (SAF). In unselected post-MI patients, SAF indicated high risk of subsequent death (7). In the current study of diabetic post-MI patients, we tested the association of SAF with 5-year mortality and the improvement of risk prediction by adding SAF to the LVEF gold standard.     

Interaction between brain chemistry and physiology after traumatic brain injury: impact of autoregulation and microdialysis catheter location

Bedside monitoring of cerebral metabolism in traumatic brain injury (TBI) with microdialysis is gaining wider clinical acceptance. The objective of this study was to examine the relationship between the fundamental physiological neuromonitoring modalities intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain tissue oxygen (P(bt)O(2)), and cerebrovascular pressure reactivity index (PRx), and cerebral chemistry assessed with microdialysis, with particular focus on the lactate/pyruvate (LP) ratio as a marker of energy metabolism. Prospectively collected observational neuromonitoring data from 97 patients with TBI, requiring neurointensive care management and invasive cerebral monitoring, were analyzed. A linear mixed model analysis was used to account for individual patient differences. Perilesional tissue chemistry exhibited a significant independent relationship with ICP, P(bt)O(2) and CPP thresholds, with increasing LP ratio in response to decrease in P(bt)O(2) and CPP, and increase in ICP. The relationship between CPP and chemistry depended upon the state of PRx. Within the studied physiological range, tissue chemistry only changed in response to increasing ICP or drop in P(bt)O(2)<1.33 kPa (10 mmHg). In agreement with previous studies, significantly higher levels of cerebral lactate (p<0.001), glycerol (p=0.013), LP ratio (p<0.001) and lactate/glucose (LG) ratio (p=0.003) were found in perilesional tissue, compared to "normal" brain tissue (Mann-Whitney test). These differences remained significant following adjustment for the influences of other important physiological parameters (ICP, CPP, P(bt)O(2), P(bt)CO(2), PRx, and brain temperature; mixed linear model), suggesting that they may reflect inherent tissue properties related to the initial injury. Despite inherent biochemical differences between less-injured brain and "perilesional" cerebral tissue, both tissue types exhibited relationships between established physiological variables and biochemistry. Decreases in perfusion and oxygenation were associated with deteriorating neurochemistry and these effects were more pronounced in perilesional tissue and when cerebrovascular reactivity was impaired.