ZSFG AM Report-CVG guest blogging 4.21.17

Happy day after 4/20. CVG got lost in the L and D unit at the ZSFG trying to get back from report which is literally my waking nightmare. Anyway, we talked about alc hep. Thanks for the case dave Anderson.

#STOPAH trial: This is one of those trials that literally changed practice during my time in residency. I remember my first wards month at ZSFG giving pentoxifylline to alc hep patients, then a couple years ago this head to head trial of prednisolone vs pentoxi vs pentoxi+pred vs placebo groups in each arm. Prednisolone showed a slight mortality benefit at 28 days compared to placebo (14% of cohort had died, OR=0.72), but at 90d and one year no difference between any groups. This confirms what Dr. Cello had known for years, which is that long-term survival has never really been shown to be impacted by prednisolone/steroids, and that the benefits seem to wash out the further away from the hospital and steroids you get. We do know that transplant has a proven mortality benefit, and according to Dr. Cello women seem to have better outcomes post-transplant than men.

http://www.nejm.org/doi/full/10.1056/NEJMoa1412278

#arterial vs venous ammonia in acute liver failure: The oft-maligned ammonia level does have prognostic value in acute liver failure with regards to cerebral herniation. Geoff Buckle did some agile googling and found the following reference, from a small study, that showed ARTERIAL ammonia levels above 200 portended an increased risk of cerebral herniation. This can be helpful in your triage, when deciding whether to take pts to the unit for hypertonic saline.

http://onlinelibrary.wiley.com/doi/10.1002/hep.510290309/abstract

too da loo!

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