A Systematic Review and Meta-Analysis of Inpatient Mortality Associated With Nosocomial and Community COVID-19 Exposes the Vulnerability of Immunosuppressed Adults.

Background: Little is known about the mortality of hospital-acquired (nosocomial) COVID-19 infection globally. We investigated the risk of mortality and critical care admission in hospitalised adults with nosocomial COVID-19, relative to adults requiring hospitalisation due to community-acquired infection. Methods: We systematically reviewed the peer-reviewed and pre-print literature from 1/1/2020 to 9/2/2021 without language restriction for studies reporting outcomes of nosocomial and community-acquired COVID-19. We performed a random effects meta-analysis (MA) to estimate the 1) relative risk of death and 2) critical care admission, stratifying studies by patient cohort characteristics and nosocomial case definition. Results: 21 studies were included in the primary MA, describing 8,251 admissions across 8 countries during the first wave, comprising 1513 probable or definite nosocomial COVID-19, and 6738 community-acquired cases. Across all studies, the risk of mortality was 1.3 times greater in patients with nosocomial infection, compared to community-acquired (95% CI: 1.005 to 1.683). Rates of critical care admission were similar between groups (Relative Risk, RR=0.74, 95% CI: 0.50 to 1.08). Immunosuppressed patients diagnosed with nosocomial COVID-19 were twice as likely to die in hospital as those admitted with community-acquired infection (RR=2.14, 95% CI: 1.76 to 2.61). Conclusions: Adults who acquire SARS-CoV-2 whilst already hospitalised are at greater risk of mortality compared to patients admitted following community-acquired infection; this finding is largely driven by a substantially increased risk of death in individuals with malignancy or who had undergone transplantation. These findings inform public health and infection control policy and argue for individualised clinical interventions to combat the threat of nosocomial COVID-19, particularly for immunosuppressed groups. Systematic Review Registration: PROSPERO CRD42021249023.

Volumetric MRI-guided, high-intensity focused ultrasound ablation of uterine leiomyomas: ASEAN preliminary experience.

PURPOSE: We sought to present our preliminary experience on the effectiveness and safety of magnetic resonance imaging (MRI)-guided, high-intensity focused ultrasound (HIFU) therapy using a volumetric ablation technique in the treatment of Association of Asian Nations (ASEAN) patients with symptomatic uterine leiomyomas. METHODS: This study included 33 women who underwent HIFU treatment. Tissue characteristics of leiomyomas were assessed based on T2- and T1-weighted MRI. The immediate nonperfused volume (NPV) ratio and the treatment effectiveness of MRI-guided HIFU on the basis of the degrees of volume reduction and improvement in transformed symptom severity score (SSS) were assessed. RESULTS: The median immediate NPV ratio was 89.8%. Additionally, the median acoustic sonication power and HIFU treatment durations were 150 W and 125 min, respectively. At six-month follow-up, the median leiomyoma volume had decreased from 139 mL at baseline to 84 mL and the median transformed SSS had decreased from 56.2 at baseline to 18.8. No major adverse events were observed. CONCLUSION: The preliminary results demonstrated that volumetric MRI-guided HIFU therapy for the treatment of symptomatic leiomyomas in ASEAN patients appears to be clinically acceptable with regard to treatment effectiveness and safety.

The novel appearance of low rectal anastomosis on contrast enema following laparoscopic anterior resection: discriminating anastomotic leaks from "dog-ears" on water-soluble contrast enema and flexible sigmoidoscopy.

PURPOSE: Interpretation of water-soluble contrast enema following laparoscopic low anterior resection can be very challenging for both radiologists and colorectal surgeons. Discriminating the radiological appearances secondary to anastomotic configuration from those caused by actual anastomotic dehiscence is a common problem and may be made worse with the advent of laparoscopic surgery. The aim of this study is to identify potential novel appearances of the water-soluble contrast enema (WSCE) images of rectal anastomosis following laparoscopic low anterior resection to radiologists and surgeons. METHODS: We enrolled 45 patients who underwent laparoscopic low anterior resection with proximal de-functioning loop ileostomy within a specialized colorectal unit. The water-soluble contrast enema reports were reviewed. Two blinded colorectal radiologists independently reviewed the images of patients suspected of anastomotic leak. All of these patients also underwent a flexible sigmoidoscopy to confirm or exclude anastomotic leak before reversal of loop ileostomy. Inter-observer concordance was calculated. RESULTS: Seven out of eighteen patients (38.9%) were found to have true anastomotic leaks on flexible sigmoidoscopy (15% overall leak rate). In the remaining eleven patients the image appearances were attributed to the appearance of the anastomotic 'dog-ear effect', created by the anastomotic configuration due to multiple firing of the intra-corporeal laparoscopic stapling device. Radiologist inter-observer concordance was 83%. Sensitivity was 100%, specificity 71%, positive-predictive value (38.9%) and negative-predictive value (100%). CONCLUSIONS: The novel appearances of laparoscopic-stapled rectal anastomoses in WSCE can be mistaken for anastomotic leak. To avoid delay in reversal of ileostomy, a flexible sigmoidoscopy can be used to confirm or exclude a leak.

A project to reduce the rate of central line associated bloodstream infection in ICU patients to a target of zero.

Central venous catheters (CVCs) are life-saving and the majority of patients in intensive care units (ICUs) have them placed in order to receive medicine and fluids. However, the use of these catheters can result in serious bloodstream infections. The rate of Central Line Associated Blood Stream Infection (CLABSI) in Adult Intensive Care Units (ICUs) at King Abdulaziz Medical City Jeddah (KAMC-J) at the start of the project was 2.0/1000 line days in 2008. The Central Line (CL) Bundle by the Institute of Healthcare Improvement (IHI) was implemented at the same time with monitoring of compliance to the CL Bundle. The compliance to CL Bundle was very low at 37% in the same period. A multidisciplinary team was created to improve the compliance to the CL bundle which was expected to have an impact on the rate of CLABSI to achieve zero CLABSI events. The team continued to monitor and evaluate the progress on the compliance to the bundle as well as monitoring the CLABSI events using National Healthcare Safety Network diagnostic criteria. The real reduction in the rate of CLABSI was achieved in 2010 with 0.7/1,000 device days when the compliance to CL Bundle reached up to 98% in that year and 100% in the next two subsequent years. The project still continued and the rate continued to drop and the ultimate target of zero CLABSI was achieved in the year 2014 and maintained in the year 2015 with a sustained compliance of 100% to the CL Bundle. Successful implementation of CL Bundle can help in reducing the rates of CLABSI and achieving zero CLABSI events for a sustained period.

MicroRNA-122 as a Novel Non-Invasive Marker of Liver Fibrosis in Hepatitis C Virus Patients.

BACKGROUND: Noninvasive evaluation of hepatic fibrosis is a growing scientific effort in medicine and is of particular interest as early diagnosis is important for the timely prevention and treatment of liver fibrosis and cirrhosis. Non-invasive markers of liver fibrosis have recently been developed as an alternative to liver biopsy. Aim of the work: The aim of this study was to assess the diagnostic value of serum microRNA 122 in Egyptian chronic hepatitis C virus infected patients. This may be a useful tool as a non invasive diagnostic test to detect early stages of fibrosis in comparison to 4 non invasive indexes (APRI, Forns, FIB-4, and FI) vs. control and their ability to differentiate between mild and moderate fibrosis stages. METHODS: This study was conducted on 40 chronic hepatitis C patients diagnosed by liver biopsy and PCR and 20 apparently healthy volunteers who served as control group (III). Liver fibrosis was staged according to the METAVIR scoring system and consequently patients were classified in two groups of liver fibrosis: mild fibrosis (I) and moderate fibrosis (II). RESULTS: The mean expression level of microRNA-122 was significantly higher in both patient groups (I and II) as compared to the control group (III) (p < 0.001 for each). While there was no statistically significant difference in serum miR-122 expression level between group I compared to group II, microRNA 122 and 4 non invasive indexes (APRI, Forns, FIB-4, and FI) were statistically significant for prediction of fibrosis. MicroRNA 122 had the best performing ROC curve for prediction of fibrosis followed by APRI, FI, Forns, and FIB-4. The AUROCs ranged from 0.912 for FIB-4 to 1 for microRNA 122. While FIB-4 and Forns were statistically significant in differentiating mild and moderate fibrosis, FIB-4 had a better AUROC than Forns (0.75 and 0.71, respectively). CONCLUSIONS: The study concluded that there was increased expression of mcroiRNA-122 in Egyptian chronic hepatitis C virus (CHCV) infected patients. MicroRNA 122 has a strong potential to serve as one of the novel noninvasive markers of early liver fibrosis.

Synthesis and reactivity of indium(I) 1-carba-closo-undecachlorododecaborate.

The arene-solvated indium(I) species [In(C7H8)3][CHB11Cl11] (1) and [In(C6H5Br)1.5][CHB11Cl11] (2) were obtained by a redox reaction involving the silver salt Ag[CHB11Cl11] and indium powder at 80 °C in a toluene or bromobenzene solution. These thermally stable compounds react with triphenylphosphine and the N-heterocyclic carbene 1,3-bis(2,6-diisopropylphenyl)imidazol-2-ylidene under reduction of indium(I) to indium metal and oxidation of the ligands to phosphonium and imidazolium cations contrary to the more commonly observed disproportionation reactions. The presence of 2 equiv of carbene led to deprotonation of the anion to give the dianion [CB11Cl11](2-). Interactions of In(+) with soft donor ligands such as phosphines, olefins, alkynes, and aromatics are weak, and a crystalline solid was only obtained with the nonvolatile phosphinoacetylene Mes2PC≡CPh (Mes = 2,4,6-Me3C6H2). The structure of this compound displays In···C interactions involving the triple bond and the π system of one mesityl group but no In···P contact. Solutions of 2 in fluorobenzene also showed moderate activity as the catalyst for intramolecular hydroamination of primary and secondary aminopentenes. The new compounds were characterized by multinuclear NMR spectroscopy and X-ray diffraction for compounds 1, 2, and 4-6.

Transanal Endoscopic Microsurgery (TEM) for Rectal Cancer: University Hospital of North Tees Experience.

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique that is increasingly being used to treat early rectal cancer (T1/T2). We studied the outcomes of TEM for rectal cancer at our institution looking at the indication, recurrence rate, need for further radical surgery, 30-day and 12-month mortality and complication rate. We performed a retrospective analysis of prospectively collected data of cases between 2008 and 2012: 110 TEM procedures were performed during this period: 40 were confirmed rectal cancers and 70 were benign. We analysed the data for the 40 patients with confirmed rectal cancer. Thirty (75 %) of the subjects were male with a mean age of 71 ± 10 years (range 49-90 years) and 19 (48 %) patients were ASA 3 and 4. Nineteen (48 %) of cancers were pT1, eighteen (45 %) were pT2, two (5 %) were pT3 and one was yPT0. Mean specimen size was 66 ± 20 mm (range 33-120 mm) with a mean polyp size of 41 ± 24 mm (range 18-110 mm). The mean cancer size was 24 ± 13 mm (range 2-50 mm). Average distance from the anal verge was 70 ± 37 mm (range 10-150 mm), and the mean operating time was 72 ± 22 min (range 40-120 min), with an average blood loss of 28 ± 15 ml (range 10-50ml). Median hospital stay was 2 ± 1 days (range 1-7 days). Complete excision (R0) was achieved in 37 (93 %) patients. Minor post-operative complications included urinary retention in two and pyrexia in three patients. There were no 30-day or 12-month mortalities. Mean follow-up was 13 ± 11 months, range (3-40 months) Local recurrence occurred in two (5 %) patients, both underwent redo TEM. Twelve (30 %) patients underwent laparoscopic radical resections (seven AR and five APER) post-TEM. Post-operative histology confirmed pT0N0 in 7/12 patients. Three were lymph node-positive (T0N1), one was pT3N1 and the fifth was pT3N2. TEM is associated with quicker recovery, shorter hospital stay and fewer complications than radical surgery. It is a good alternative to radical surgery in early rectal cancer, especially for high-risk patients. Recurrent tumours can be treated with redo TEM.

Solubilities of carbon dioxide and oxygen in the ionic liquids methyl trioctyl ammonium bis(trifluoromethylsulfonyl)imide, 1-butyl-3-methyl imidazolium bis(trifluoromethylsulfonyl)imide, and 1-butyl-3-methyl imidazolium methyl sulfate.

Ionic liquids (ILs) are being considered as solvents for gas absorption processes as they have the potential, in general, for improved efficiency of gas separations, as well as lower capital and operating costs compared to current commercial processes. In this study the solvent properties of ILs are investigated for use in the absorption of carbon dioxide (CO2) and oxygen (O2). The absorption of these gases in ILs was measured in the temperature range 303.15-333.15 K and at pressures up to 1.5 MPa by gravimetric analysis. The ILs used were methyl trioctyl ammonium bis (trifluoromethylsulfonyl) imide ([MOA][Tf2N]), 1-butyl-3-methyl imidazolium bis (trifluoromethylsulfonyl) imide ([BMIM][Tf2N]), and 1-butyl-3-methyl imidazolium methyl sulfate ([BMIM][MeSO4]). The measurement technique employed in this study is fast and accurate, and requires small quantities of solvent. The results indicated that absorption of both gases increased with a decrease in operating temperature and an increase in pressure. [MOA][Tf2N] had the highest CO2 and O2 solubility. [BMIM][Tf2N] was determined to have the highest selectivity for CO2 absorption. [BMIM][MeSO4] achieved the lowest CO2 absorption with a moderate O2 absorption, revealing this IL to be the least desirable for CO2 and O2 absorption. Calculation of Henry's law constants for all systems confirmed the deductions made from absorption data analysis. Calculation of enthalpy and entropy of absorption for each system revealed CO2 absorption in [MOA][Tf2N] to be the least sensitive to temperature increases. The absorption data was modeled using the generic Redlich-Kwong cubic equation of state (RK-EOS) coupled with a group contribution method.

Dynamic QTL analysis and candidate gene mapping for waterlogging tolerance at maize seedling stage.

Soil waterlogging is one of the major abiotic stresses adversely affecting maize growth and yield. To identify dynamic expression of genes or quantitative trait loci (QTL), QTL associated with plant height, root length, root dry weight, shoot dry weight and total dry weight were identified via conditional analysis in a mixed linear model and inclusive composite interval mapping method at three respective periods under waterlogging and control conditions. A total of 13, 19 and 23 QTL were detected at stages 3D|0D (the period during 0-3 d of waterlogging), 6D|3D and 9D|6D, respectively. The effects of each QTL were moderate and distributed over nine chromosomes, singly explaining 4.14-18.88% of the phenotypic variation. Six QTL (ph6-1, rl1-2, sdw4-1, sdw7-1, tdw4-1 and tdw7-1) were identified at two consistent stages of seedling development, which could reflect a continuous expression of genes; the remaining QTL were detected at only one stage. Thus, expression of most QTL was influenced by the developmental status. In order to provide additional evidence regarding the role of corresponding genes in waterlogging tolerance, mapping of Expressed Sequence Tags markers and microRNAs were conducted. Seven candidate genes were observed to co-localize with the identified QTL on chromosomes 1, 4, 6, 7 and 9, and may be important candidate genes for waterlogging tolerance. These results are a good starting point for understanding the genetic basis for selectively expressing of QTL in different stress periods and the common genetic control mechanism of the co-localized traits.

The relationship between nonalcoholic fatty liver disease and colorectal cancer: the future challenges and outcomes of the metabolic syndrome.

Nonalcoholic fatty liver disease (NAFLD) is closely related to insulin resistance, metabolic syndrome, obesity, type 2 diabetes, and dyslipidaemia. Obesity and metabolic syndrome are associated with an increased cancer risk, and recent evidence demonstrated an association between NAFLD and colorectal cancer (CRC). The mechanism of how NAFLD can be associated with increased risk of CRC is not fully understood; however, NAFLD represents a condition of profound insulin resistance and a proinflammatory state. Insulin and insulin-like growth factors may promote the development of CRC through their proliferative and antiapoptotic effects. Patients with NAFLD have reduced expression of adiponectin, an adipokine with anti-inflammatory effects. Importantly, hypoadiponectinemia is associated with an increased risk of CRC. Decreased levels of adiponectin lead to increased insulin levels due to marked insulin resistance and in turn increased insulin growth factor-1 (IGF-1). Insulin binds to IGF-1 receptors and plays an important role in cell proliferation, apoptosis, and increased production of vascular endothelial growth factor, an angiogenic factor that supports cancer growth. Further studies are needed to establish (i) the pathophysiology of NAFLD with colorectal cancer, (ii) the benefit of early screening of CRC in NAFLD patients, and (iii) the impact of treatment of NAFLD in the modulation of the risk of colorectal cancer.

Emergency colectomy for fulminant Clostridium difficile colitis: Striking the right balance.

The number of reported cases of Clostridium difficile (CD) infections has increased markedly worldwide. CD causes a spectrum of clinical syndromes, ranging from mild diarrhea to a very severe illness in the form of pseudomembranous colitis (PMC), toxic megacolon, leading to colonic perforation, peritonitis, and even death. In today's practice, toxic megacolon is more often caused by pseudomembranous colitis than ulcerative colitis. There is urgent need to establish clear guidelines about how and when to refer patients with fulminant CD colitis to surgeons. Furthermore, there is no strict protocol for the timing of surgical intervention. The aim of this review is to review the available evidence about the criteria for referral to surgeons and timing for surgery. Medline search was carried out for articles published on fulminant CD colitis with emergency colectomy from 1966 to 2010. There were no prospective randomized trails. All retrospective cohort and case control studies were included. We excluded case reports, letters, and studies with less than five patients. Our search showed that patients with confirmed or suspected CD who failed to respond to maximum medical therapy and develop three of the following should be referral for surgical assessment: abdominal pain, abdominal distension, localized tenderness, pyrexia >38°C, and tachycardia >100 beats per minute. In addition to the above, if the patient is above 65 years old and develops four of the following, they should be considered for an emergency colectomy: WBC >16 × 109/l, lactate >2.2 mmol/l, albumin <30 g/l, blood pressure <90 mm Hg, CT/endoscopy evidence of severe colitis in spite of maximum anti-clostridial therapy. Colectomy still carries a high mortality rate; however, timely surgical intervention in fulminant CD colitis (FCDC) prevents many deaths in selected cases. In the absence of published prospective multicenter trial, we suggest that our criteria may enhance early diagnosis and consideration of early referral for surgery. Ultimately, this may reduce the significant morbidity and mortality associated with FCDC.

Concentrations of trace elements [corrected] and organochlorines in Mutton bird (Puffinus griseus).

The Sooty Shearwater (Puffinus griseus, commonly known as Mutton bird) is a migratory wild seabird, annually harvested for food by certain native groups in New Zealand and Australia and in many parts of the world. The concentrations of 22 elements and several organochlorine pesticides [2,2-bis(chlorophenyl)-1,1,1-trichloroethane (DDT), its derivatives dichlorodiphenyldichloroethene (DDE) and dichlorodiphenyldichloroethane (DDD), aldrin, chlordane, dicofol, lindane, and methoxychlor] in Mutton bird were determined over two consecutive years to evaluate its safety for human consumption. Twenty bird carcasses were purchased in each of 2007 and 2008 from a local source. No significant year effect (P>0.05) was found in the following nine trace elements: Al, As, Cd, Co, Cr, Cu, Ni, Pb and Se. The concentrations of Hg, Li and Na were higher (P<0.05) in 2008 samples compared to 2007. The toxic trace elements (mg/kg wet weight) in all the samples were below the maximum residual level (MRL). The concentration of Fe, Ca and Se in Mutton bird was higher than that in domestic land animal meats reported in literature. The residual organochlorine concentrations were all below the recommended MRL. Thus Mutton bird meat is high in essential nutrient elements and of low toxicological risk. Due to active use of agrochemical in New Zealand, a monitoring program for contaminants in Mutton birds is recommended.

Preoperative axillary staging in breast cancer-saving time and resources.

This study was performed to assess the feasibility and accuracy of ultrasound guided fine needle aspiration biopsy for axillary staging in invasive breast cancer. Data were collected prospectively from June 2005 to June 2006. In all, 197 patients with invasive breast cancer and clinically nonsuspicious axillary lymph nodes were included. Patients with suspicious nodes on ultrasound had fine needle aspiration biopsy. Those with fine needle aspiration biopsy positive for malignancy were planned for axillary nodes clearance otherwise they had sentinel node biopsy. Patients (41) had ultrasound guided fine needle aspiration biopsy. Three cases were excluded for being nonconclusive. Postoperative histology showed 18/38 cases (47.4%) axillary lymph nodes positive and 20/38 cases (52.6%) axillary nodes negative. Ultrasound guided fine needle aspiration biopsy was positive in 8/38 cases (21.1%), negative in 30/38 cases (78.9%). The sensitivity of ultrasound guided fine needle aspiration biopsy was found to be 47.1%, specificity 100%, positive predictability 100%, negative predictability 70%, and overall accuracy 76.3%. Ultrasound guided fine needle aspiration biopsy was found to be more accurate and sensitive when two or more nodes were involved, raising the sensitivity to 80% and negative predictability to 93.3%. Preoperative axillary staging with ultrasound guided fine needle aspiration biopsy in invasive breast cancer patients is very beneficial in diagnosing nodes positive cases. These cases can be planned for axillary lymph nodes clearance straightaway therefore saving patients from undergoing further surgery as well as time and resources.

Venous gangrene and cancer: a cool look at a burning issue.

Venous gangrene (VG) is defined as a clinical triad of skin necrosis and discolouration, documented evidence of venous thromboembolism (VTE) and presence of palpable or doppler-identifiable arterial pulsation. Venous gangrene is rare condition which is associated with poor prognosis in cancer patients. The pathogenesis of VG is multifactorial and could paradoxically be due to warfarin treatment. Heparin Induced Thrombocytopenia (HIT) associated venous gangrene develops when heparin therapy is discontinued and warfarin therapy initiated or continued. It has been reported that the presence of anticardiolipin antibodies appears to double the risk of thrombo-embolic events in cancer patients in comparison with those who are anticardiolipin antibody negative. The presence of anticardiolipin antibodies is therefore a warning sign for venous gangrene in cancer patients. Hypercoagulable state associated with malignancy, cancer treatment, prolonged immobilisation, surgical operations and metabolic syndrome are all associated with increased risk of VTE and VG. The current evidence suggests that cancer patients are at increased risk from recurrent venous thrombosis and venous gangrene, and LMWH provides potential promise as a safe and effective measure in the management of such patients.

Effect of pretreatment with insulin on the response of buffaloes with inactive ovaries to gonadotrophin-releasing hormone agonist treatment in summer.

The aim of the present study was to evaluate the effect of a pretreatment with insulin on the response of buffalo cows with inactive ovaries to gonadotrophin-releasing hormone agonist (GnRHa) treatment during hot summer months (July and August). Thirty-six Egyptian buffalo cows with inactive ovaries were randomly allocated into three groups: (1) group treated with GnRHa (G1, n = 16) in which each buffalo received an intramuscular injection of 250 mg of GnRHa (Day 0; gonadorelin, Fertagyl); (2) group treated with insulin before the GnRHa injection (G2, n = 8) in which each buffalo received a subcutaneous injection of biphasic insulin at a dose of 0.25 IU kg(-1) bodyweight once daily starting at Day -3 for 3 consecutive days, followed by an intramuscular injection of 250 mg of GnRHa on Day 0; and (3) the control group (G3, n = 12) in which each buffalo cow received an intramuscular injection of 2.5 mL of sterile saline on Day 0. The ovaries of all animals were examined by trans-rectal ultrasonography (5 MHz) on Days -7, -3 and 0 and continued thereafter at 4-day intervals until oestrus or the end of the experiment. On the same days that ultrasound examinations were performed blood samples were collected to measure the progesterone concentrations. Administration of insulin for 3 days before GnRHa injection (G2) significantly (P < 0.05) increased the diameter of the largest follicle from 6.85 +/- 0.64 to 12.4 +/- 0.88 mm. There was a significant (P < 0.01) increase in the oestrous induction rate in G2 compared with both G1 and G3 during the first 12 days after the treatment interval. It is concluded that pretreatment with insulin for 3 days before GnRHa injection increases the diameter of the dominant follicle and therefore the oestrous induction rate of acyclic buffaloes.

Tamoxifen-induced non-alcoholic steatohepatitis: where are we now and where are we going?

Tamoxifen is a cheap and effective estrogen-receptor antagonist, used as the adjuvant hormonal treatment of choice in women with estrogen-receptor-positive breast cancer. Tamoxifen-induced non-alcoholic steatohepatitis (NASH) may increase the demand on oncologists, not only with regard to screening for diabetes, but also for the suggested link of NASH with high incidence of coronary heart disease. At present, there is no guideline for treatment of hyperlipidaemia associated with tamoxifen-induced NASH. However, exemstane (and other aromatase inhibitors) has been shown to lower triglyceride and have a neutral effect on low-denisty lipoprotein and cholesterol levels. These may be alternative agents if severe progressive liver disease or hyperlipidaemia were encountered with tamoxifen administration. Other lipid-lowering medications may have potential benefits in the treatment of tamoxifen-induced NASH and is discussed in this article.