Inpatient healthcare utilisation in patients with alcoholic liver disease: what are the costs and outcomes?

BACKGROUND: Alcoholic liver disease (ALD) carries a significant cost burden and often leads to inpatient care. It is unclear whether inpatient care for ALD is any more costly than admission for other reasons. AIMS: To compare the costs and outcomes of inpatient care for ALD to two groups: a control group of matched cases admitted in the same time frame and people admitted for other chronic liver diseases (CLD). METHODS: All admissions for ALD and other CLD in a 3-month period were retrospectively identified. Five randomly identified gender- and age-matched contemporaneously admitted controls were allocated. Length of stay (LoS), mortality, inpatient costs, blood product utilisation and discharge destination were compared. RESULTS: Of the 71 admissions due to CLD, ALD was the most frequent cause (53/71, 75%). ALD admissions cost more (median $10 100 vs $5294; P = 0.0012) and had greater LoS (median LoS 7.2 days (interquartile range (IQR) 0.2-40.7)) than controls (2.6 days (IQR 1.1-6.8); P = 0.0001). A larger proportion of the ALD cohort required blood transfusion and had a higher mortality than controls (24.5 vs 6.4%, P = 0.002 and 13.2 vs 0.2%; P < 0.0001 respectively). Self-discharge was more common in the ALD group (13.2 vs 1.1%, P < 0.0001). CONCLUSIONS: ALD inpatient hospital admissions have greater median total cost, longer LoS, greater blood product utilisation, higher mortality and greater rate of discharge against medical advice than age- and gender-matched controls. These data emphasise the large inpatient care burden, high mortality and suboptimal engagement in those with ALD, which justifies the more active provision of services for ALD.

Clonal expansion of hepatocytes with a selective advantage occurs during all stages of chronic hepatitis B virus infection.

Hepatocyte clone size was measured in liver samples of 21 patients in various stages of chronic hepatitis B virus (HBV) infection and from 21 to 76 years of age. Hepatocyte clones containing unique virus-cell DNA junctions formed by the integration of HBV DNA were detected using inverse nested PCR. The maximum hepatocyte clone size tended to increase with age, although there was considerable patient-to-patient variation in each age group. There was an upward trend in maximum clone size with increasing fibrosis, inflammatory activity and with seroconversion from HBV e-antigen (HBeAg)-positive to HBeAg-negative, but these differences did not reach statistical significance. Maximum hepatocyte clone size did not differ between patients with and without a coexisting hepatocellular carcinoma. Thus, large hepatocyte clones containing integrated HBV DNA were detected during all stages of chronic HBV infection. Using laser microdissection, no significant difference in clone size was observed between foci of HBV surface antigen (HBsAg)-positive and HBsAg-negative hepatocytes, suggesting that expression of HBsAg is not a significant factor in clonal expansion. Laser microdissection also revealed that hepatocytes with normal-appearing histology make up a major fraction of the cells undergoing clonal expansion. Thus, preneoplasia does not appear to be a factor in the clonal expansion detected in our assays. Computer simulations suggest that the large hepatocyte clones are not produced by random hepatocyte turnover but have an as-yet-unknown selective advantage that drives increased clonal expansion in the HBV-infected liver.

Results of a randomized trial of end-to-side portacaval shunt and distal splenorenal shunt in alcoholic liver disease and variceal bleeding.

Since 1976, we have compared the end-to-side portacaval shunt (PCS) with the distal splenorenal shunt (DSRS) in patients with alcoholic liver disease and recurrent variceal bleeding. Fifty-four patients were randomly assigned to receive either shunt procedure. There were 27 patients in each group and both groups were highly comparable in clinical and laboratory characteristics. Median follow-up was 31 mo in each group. Postoperative complications and operative mortality (7% after PCS, 12% after DSRS) were comparable. Spontaneous portasystemic encephalopathy developed in 32% of the patients at risk after PCS and in 39% after DSRS. Rebleeding from varices occurred in 4% of the patients after PCS and in 27% after DSRS. Cumulative survival was not significantly different between groups (5-yr survival: 31% after PCS, 43% after DSRS). We have failed to demonstrate superiority of DSRS in our patients with alcoholic liver disease with respect to postoperative encephalopathy or survival, and have experienced an unusually high rate of variceal rebleeding after DSRS.

Traumatic gastric ulceration.

A case of acute gastric ulceration is described which resulted from direct blunt trauma to the stomach. This produced significant haemorrhage ten days after the injury which was successfully managed by conservative means.

Profound hypocalcaemia associated with oestrogen treatment of carcinoma of the prostate.

A case of profound hypocalcaemia which occurred in a patient with osteoblastic metastatic carcinoma of the prostate after treatment with oestrogens is reported. Although there may have been other contributory factors, it was felt that the administration of oestrogens was the most important causative element. Treatment with high doses of oestrogens in patients with osteoblastic metastatic carcinoma of the prostate should be accompanied by frequent measurements of plasma calcium levels.

Gastrointestinal endoscopy: some perspectives.

Remarkable technological advances of fibreoptic endoscopy in the past two decades have produced important improvements in diagnosis and treatment of gastrointestinal and hepatobiliary disorders. These advances must be kept in perspective; continuing, critical assessment of their contribution to the management of patients is desirable. Endoscopy can have adverse effects on the total performance of departments of gastroenterology, on gastroenterology as a discipline, and even on the status of the medical profession in the community. Gastroenterologists need to show proficiency of performance and integrity of practice. Control may be achieved by certification delineation of privileges, peer review, public accountability, and realistic financial returns for procedures. Records of a department of gastroenterology indicate that some control may be achieved by insistence on a consultation before decision on endoscopy. This may be a desirable alternative to endoscopy on demand. Undue emphasis on technology runs some risk of destroying the proper practice of consultant medicine.