Female gender, hyperphosphatemia, high alkaline phosphatase, and low serum albumin are risk factors for calciphylaxis. Calciphylaxis is associated with a very high mortality.

The presence of at least one underlying chronic health condition, such as long-term care facility residence, malnutrition, immunosuppression, or prosthetic device use, are well known factors increasing infection risks and progression to severe sepsis. Furthermore, some degree of cardiovascular dysfunction occurs in the majority of septic patients and this prognostic significance has become increasingly recognized. Since septic shock carries the highest mortality risk on the sepsis spectrum, it is important to evaluate the cardiovascular risk impact on mortality in this subset of patients. METHODS METHODS The retrospective parent study contributing these electronic health record data was IRB approved and conducted across four hospital intensive care units within the authors' Michigan healthcare system. Patients with cardiopulmonary arrest or transfers from an outside facility were excluded. The authors evaluated the presence of modifiable and non-modifiable cardiovascular risk factors in septic shock patients upon admission to an emergency department. RESULTS RESULTS The authors' final analytic sample included n = 109 adults who were discharged alive compared to those who died during hospitalization. Those patients who died were more often male with an underlying history of hypertension, congestive heart failure, coronary artery disease, or peripheral arterial diseases, were taking pre-admission beta-blocker medications, and had higher APACHE II scores at admission compared to the patients who survived to discharge. Significantly higher mortality risks were found in sample patients with increased troponin levels on admission and atrial fibrillation. CONCLUSIONS CONCLUSIONS Appropriate triage and prompt treatment of these patient groups with tailored therapy to stabilize and improve cardiac dysfunction in the emergency department could potentially lead to improved survival outcomes. Clinicians need more studies to determine therapeutic targets most impacting underlying pathophysiologic mechanisms such as elevated troponin and atrial fibrillation that greatly increase mortality risks.

Patient: Male, 21Final Diagnosis: AVM intestinal bleedingSymptoms: MelenaMedication: —Clinical Procedure: EGD/colonoscopy/enteroscopySpecialty: Gastroenterology and HepatologyObjective:Congenital defects/diseasesBackground:Isolated congenital asplenia is a poorly understood and rare form of primary immunodeficiency, often associated with life-threatening infections.Case Report:We encountered a unique case of a 22-year-old asplenic male who presented with severe iron-deficiency anemia secondary to occult gastrointestinal bleeding since age 15. Our extensive work-up confirmed jejunal arteriovenous malformations as the source of the bleed. Six months after the treatment, the patient has reported no further episodes of gastrointestinal bleeding and his hemoglobin has remained stable.Conclusions:A comprehensive literature review confirmed that this is the first reported case of adult congenital asplenia associated with arteriovenous malformation in the United States. The relationship of isolated congenital asplenia and arteriovenous malformation-associated bleeding remains unknown at this time; we postulate that this may be a congenital syndrome on its own.Obscure bleeding in the presence of rare anomalies such as asplenia should be investigated as one of the important causes of unexplained intestinal arteriovenous malformations.

INTRODUCTION: The impact of direct-acting antivirals (DAAs) for hepatitis C virus (HCV) on burden of cirrhotic and noncirrhotic hepatocellular carcinoma (HCC) has not been examined. We assessed recent trends in liver disease etiologies of HCC and proportion of noncirrhotic HCC since DAAs introduction. METHODS: Clinical characteristics including presence or absence of underlying cirrhosis were collected from 2,623 patients diagnosed with HCC between 2009 and 2019 at 2 large US centers. Logistic regression was performed to investigate the annual trends of HCC due to different liver diseases and proportions of noncirrhotic cases. RESULTS: In the DAA era (2014–2019), annual decline in HCV-HCC (odds ratio [OR] = 0.93, 95% confidence interval [CI] 0.88–0.99, P = 0.019), without change in trends of other liver diseases–related HCC, was observed. Annual increase in noncirrhotic HCC (OR 1.13, 95% CI 1.03–1.23, P = 0.009) and decline in cirrhotic HCC (OR 0.89, 95% CI 0.81–0.97, P = 0.009) along with similar trends for HCV-HCC—increase in noncirrhotic cases (OR 1.35, 95% CI 1.08–1.69, P = 0.009) and decrease in cirrhotic cases (OR 0.92, 95% CI 0.86–0.98, P = 0.012)—were observed during the DAA era. Compared with the pre-DAA era, HCC resection rate increased (10.7% vs 14.0%, P = 0.013) whereas liver transplantation rate decreased (15.1% vs 12.0%, P = 0.023) in the DAA era. DISCUSSION: Since introduction of DAAs, proportions of cirrhotic HCC have decreased, whereas proportions of noncirrhotic HCC have increased. These new trends were associated with change in utilization of liver resection and transplantation for HCC. The impact of changing patterns of DAA use on these trends will require further study.

SummaryBackgroundSeveral prognostic tests for primary sclerosing cholangitis (PSC) have been developed, including biochemical models, elastography and magnetic resonance imaging scores.AimTo conduct a systematic review of non‐invasive prognostic tests for PSC.MethodsA systematic review was conducted from 1987 to 2020 of blood tests, biochemical models, elastography and imaging scores associated with outcomes in PSC.ResultsForty studies of prognostic tests that collectively included 16 094 subjects with PSC were reviewed, of which 26 studies of non‐invasive tests including 13 759 subjects with PSC were included. Normalisation or reduction of alkaline phosphatase with or without therapy was associated with transplant‐free survival and reduced risk of hepatobiliary cancers but cut‐off values for alkaline phosphatase were not consistent among studies. The most studied prognostic biochemical model was the Mayo Risk Score (MRS) evaluated in 18 studies with a c‐statistic from 0.63 to 0.85 for clinical outcomes. One study demonstrated that the UK‐PSC score outperforms MRS for predicting clinical outcomes with a c‐statistics of 0.81and 0.75 respectively. A transient elastography score greater than 11.1 kPa is associated with survival and liver‐related complications. The Anali score, derived from specific MRI and MRCP features, is associated with the development of cholangiocarcinoma and decompensated cirrhosis. Promising prognostic models include the enhanced liver fibrosis (ELF) score, ELF test and PREsTo scores.ConclusionMRS is the most studied prognostic score for clinical outcomes in PSC but the UK‐PSC score and PREsTo have better test performance. Further studies comparing MRS to UK‐PSC score, PREsTo or ELF with elastography or imaging‐based scores are warranted.