Anticoagulation Therapy in Patients with Liver Cirrhosis is Associated With an Increased Risk of Variceal Hemorrhage

ObjectiveThe belief that cirrhotic patients are “auto-anticoagulated” often results in anticoagulation therapy being withheld in these patients. We aimed to understand patterns of use of anticoagulation and to determine the risk of bleeding complications in cirrhotic patients.MethodsWe retrospectively analyzed 320 cirrhotic patients treated with anticoagulation therapy from July 15, 2014 to January 30, 2018. We performed bivariate and multivariate analyses to identify risk factors for clinically relevant bleeding. We conducted a separate analysis using propensity score matching to compare bleeding rates of a noncirrhotic cohort group on anticoagulation to anticoagulated patients with cirrhosis.ResultsNonalcoholic steatohepatitis (47%) was the most common cause of cirrhosis, and 49% were classified as Child-Pugh class B, a mean model for end-stage liver disease score of 14 and Charlson comorbidity index of 7. Anticoagulation was initiated for atrial fibrillation/atrial flutter in 56% of patients; warfarin was used in 57% of patients and concomitant use of antiplatelet therapy in 25%. Bleeding occurred in 18%, with upper gastrointestinal bleeding (53%) being the most common source. In the propensity-matched cohort, bleeding rates were higher in cirrhotics than in control patients who were matched for baseline characteristics. In multivariate analysis of the cirrhotic patients, the presence of esophageal varices was associated with higher odds of clinically relevant bleeding.ConclusionAnticoagulated cirrhotic patients who have esophageal varices are at an increased risk of bleeding. We recommend that patients with cirrhosis and esophageal varices who require anticoagulation have their varices managed carefully prior to initiation of anticoagulation.     

Utilization of the Iliac Artery as Inflow in the Morbidly Obese During Orthotopic Liver Transplantation: A Case Report

Arterial conduits are a well-recognized technique used in liver transplantation to achieve allograft arterial inflow when conventional hepatic arterial inflow is compromised. Indications for ectopic inflow include native arterial disease at the time of initial transplantation, as well as reconstruction in the setting of thrombotic complications. Although supraceliac or infrarenal aortic reconstructions are preferred approaches, the right common iliac artery represents a viable alternative. We present the case of a morbidly obese patient with occlusive atheromatous plaque at the celiac origin not amenable to preoperative angioplasty who underwent reconstruction with a donor iliac artery conduit to the recipient right common iliac artery. His hepatic arterial inflow remained patent postoperatively with no thrombotic or hemorrhagic complications.     

ERCC6 founder mutation identified in Finnish patients with COFS syndrome

Jaakkola E, Mustonen A, Olsen P, Miettinen S, Savuoja T, Raams A, Jaspers NGJ, Shao H, Wu BL, Ignatius J. ERCC6 founder mutation identified in Finnish patients with COFS syndrome. Cerebro‐oculo‐facio‐skeletal (COFS) syndrome is an autosomal recessive disorder characterized by microcephaly, congenital cataracts, facial dysmorphism, neurogenic arthrogryposis, growth failure and severe psychomotor retardation. We report a large consanguineous pedigree from northern Finland with six individuals belonging into four different sibships and affected with typical COFS syndrome phenotype. Two deceased patients have been published previously in 1982 as the first cases exhibiting cerebral calcifications typical for this disorder. Two living and one of the deceased patients were all shown to possess a novel homozygous mutation in the ERCC6 [Cockayne syndrome B (CSB)] gene, thereby confirming the diagnosis on molecular genetic level even for the earlier published cases. Genealogical investigation showed a common ancestor living in a northeastern village in Finland in the 18th century for all six patients implying a founder effect.     

Acceptability of locally‐produced Ready‐to‐Use Supplementary Food (RUSF) for children under two years in Cambodia: A cluster randomised trial

In Cambodia, existing food products for treating or preventing undernutrition have met with limited success. Therefore, in 2014, alternative ready‐to‐use foods were developed. This trial aimed to assess the acceptability of the novel ready‐to‐use supplementary food (RUSF) as a snack or mixed with borbor (white rice porridge), compared with corn–soy blend plus plus (CSB++) and borbor fortified with micronutrient powder (MNP). The nonblinded, randomised 4 × 4 crossover trial recruited 95 children aged 9–23 months from communities in peri‐urban Phnom Penh. Small quantities (100 g for porridges, 42 g for snack) of each food were offered for three consecutive days at testing sites (homes of health volunteers). Main outcomes were children's consumption, caregivers' assessment of children's preferences, and caregivers' ranking of the foods. Median percentage consumed of the test food servings ranged from 21 to 50% (p = 0.003). The odds of children consuming over 50% were greatest for borbor fortified with MNP versus RUSF snack (unadjusted OR = 6.79, CI = 2.80–16.47, p < 0.001). However, the median energy children received when consuming the RUSF with borbor (57 kcals) or as a snack (48 kcals) was greater than with CSB++ (15 kcals) or borbor fortified with MNP (18 kcals; p < 0.001). Therefore, although children ate less RUSF, it provided approximately three times more kilocalories. Caregivers reported that their children had the highest preference for borbor fortified with MNP. Caregivers themselves ranked the novel RUSF snack highest. Thus, the innovative RUSF was considered sufficiently acceptable to proceed to an effectiveness trial.