Latest Updates

Autoimmune Hepatitis/Overlap  Syndromes

Albert J Czaja, MD
    • Autoimmune hepatitis may have laboratory and histological features that resemble PBC or PSC, and PBC and PSC may have features of autoimmune hepatitis. These mixed clinical phenotypes constitute the overlap syndromes, and they may have a variable response to the conventional therapies used for each unmixed classical disease.
    • Clinical judgment and expert interpretation of liver tissue are the principal bases for diagnosing the overlap syndromes, and incompatible manifestations of cholestasis (disproportionate serum AP and GGT elevations, destructive cholangitis or ductopenia in liver tissue) or liver inflammation (disproportionate serum AST and ALT elevations, interface hepatitis, and dense lymphoplasmacytic infiltration in liver tissue) are hallmarks of the diagnosis.
    • Autoimmune hepatitis with cholestatic features that are unassociated with AMA or an abnormal cholangiography suggests the possibility of an overlap syndrome with AMA-negative PBC or small duct PSC.
    • Therapy is guided by the predominant component of the overlap syndrome and consists mainly of prednisone or prednisolone, azathioprine, and low dose UDCA (13 to 15 mg/kg daily) in combination. Management strategies can be tailored to the individual patient and adjusted according to the response. High dose UDCA (28 to 30 mg/kg daily) should be avoided.
    • Management of a nonresponse to the frontline regimen consists mainly of modifying the original treatment by adding corticosteroids or low dose UDCA if not present initially or considering the empirical use of mycophenolate mofetil as a substitute for azathioprine or a calcineurin inhibitor as a substitute for corticosteroids. Salvage drug therapies have had a limited clinical experience. Liver transplantation should be considered for features of liver failure.

Autoimmune Hepatitis/Overlap  Syndromes

Albert J Czaja, MD
    • Autoimmune hepatitis may have laboratory and histological features that resemble PBC or PSC, and PBC and PSC may have features of autoimmune hepatitis. These mixed clinical phenotypes constitute the overlap syndromes, and they may have a variable response to the conventional therapies used for each unmixed classical disease.
    • Clinical judgment and expert interpretation of liver tissue are the principal bases for diagnosing the overlap syndromes, and incompatible manifestations of cholestasis (disproportionate serum AP and GGT elevations, destructive cholangitis or ductopenia in liver tissue) or liver inflammation (disproportionate serum AST and ALT elevations, interface hepatitis, and dense lymphoplasmacytic infiltration in liver tissue) are hallmarks of the diagnosis.
    • Autoimmune hepatitis with cholestatic features that are unassociated with AMA or an abnormal cholangiography suggests the possibility of an overlap syndrome with AMA-negative PBC or small duct PSC.
    • Therapy is guided by the predominant component of the overlap syndrome and consists mainly of prednisone or prednisolone, azathioprine, and low dose UDCA (13 to 15 mg/kg daily) in combination. Management strategies can be tailored to the individual patient and adjusted according to the response. High dose UDCA (28 to 30 mg/kg daily) should be avoided.
    • Management of a nonresponse to the frontline regimen consists mainly of modifying the original treatment by adding corticosteroids or low dose UDCA if not present initially or considering the empirical use of mycophenolate mofetil as a substitute for azathioprine or a calcineurin inhibitor as a substitute for corticosteroids. Salvage drug therapies have had a limited clinical experience. Liver transplantation should be considered for features of liver failure.

Clinical Management of Feeding and Eating Disorders

Anne Marie O’Melia , MD, Patricia Westmoreland, MD
    • Lisdexamfetamine for the treatment of binge eating disorder
    • Novel deep brain stimulation, repetitive transcranial magnetic stimulation, and transcranial direct current stimulation
    • Novel treatments for severe and enduring forms of anorexia nervosa

Viral Hepatitis C: Treatment

Raymond T. Chung, MD, Jacinta A Holmes, MBBS, PhD, Anna Lidofsky, BS, Jay Luther, MD, Stephanie M Rutledge, MBBCh BAO MRCPI
    • Recent advances in treatment of chronic HCV to include interferon-free direct-acting antiviral agent regimens
    • Latest treatment recommendations, including special populations
    • Issues surrounding treatment-emergent resistance-associated variants 

Urologic Infections

Nisa S Atigapramoj, MD, Tatyana Vayngortin, MD
    • UTI evaluation and management varies by age; rapid diagnosis and treatment prevents complications; infants may present solely with fever
    • Most common uropathogen is Escherichia coli (85%). Other pathogens include gram-negative bacteria and more rarely gram-positive bacteria
    • Antibiotic treatment should be based on local antibiograms plus individual patient risk factors and history
    • Indications for inpatient admission include: age under 2 months, sepsis, vomiting/inability to tolerate oral antibiotics, infection with a multidrug-resistant organism, immunocompromised state, a complicated social situation, or risk of no follow up
    • Risk factors for UTI in infants include age <12 months, uncircumcised males, temperature >39°C. Risk factors in adults include pregnancy, sexual activity, immunosuppression, urologic abnormalities or obstruction, long-term urinary catheter, neurogenic bladder, urinary incontinence

Human Trafficking 2: Approach To The Patient

Wendy Macias-Konstantopoulos, MD, MPH
    • The trauma-informed approach to care has been likened to ethics of care, a philosophy that emphasizes fostering attentive, holistic, and competent patient care that is simultaneously responsive to the unique and continually changing needs, wishes, goals, priorities, risks, and vulnerabilities of the individual patient.
    • ED clinicians should inform patients about their rights to privacy and the limits of confidentiality with respect to mandatory reporting laws.
    • Preliminary data analysis from one clinic for trafficking victims and survivors found that 57% of trafficked persons accessed care while trafficked and 76% of them accessed care through the ED.

Human Trafficking 3: Intervention And Therapy

Wendy Macias-Konstantopoulos, MD, MPH
    • As of May 2017, the commercial sexual exploitation or trafficking of a child under the age of 18 is considered a form of child sexual abuse under the law and would require reporting in all 50 states, the District of Columbia, and the US territories.
    • If the ED physician has a concern for an active infection, testing and treatment are indicated, but in the absence of an active STI, clinicians can forego testing and counsel patients regarding presumptive treatment based on updated guidelines for antiretroviral postexposure prophylaxis following a potential sexual, injection drug use, or other nonoccupational exposure to HIV.

Evaluating the Quality of Evidence

Zach W Brown, DO, CDR, MC, USN, Herb A. Phelan, MD, MSCS
    • Well-written articles must identify a clear and novel hypothesis, a relevant topic, valid study methods, and the overall importance of the research.
    • Baseline level of quality is established by the hierarchy of study designs.
    • Overall quality of research can be downgraded based on five criteria identified in the GRADE guidelines: imprecision, inconsistency, indirectness, publication bias, and lack of internal validity.
    • Overall quality of research can be upgraded based on three criteria identified in the GRADE guidelines: when the size of the effect observed is very large, when a dose-response relationship exists, or when plausible confounders or other biases paradoxically increase confidence in the direction or magnitude of the signal.
    • A basic understanding of statistics is helpful for the reader to determine if the author has applied the appropriate statistical tools to interpret and analyze the data correctly. Otherwise, the conclusions may not be valid.
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