A New Potential Strategy for Acute Non-Alcoholic Steatohepatitis (NASH).

BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the United States, and 25% of patients with NAFLD progress to non-alcoholic steatohepatitis (NASH). NAFLD is predicted to be the most common indication for liver transplantation by 2030. Despite associated high morbidity and mortality, there is currently no approved therapy for NASH. PCSK9 inhibitors are approved for reducing LDL in patients who are statin-intolerant or need further LDL reduction. Increased LDL levels are independently associated with an elevated risk of NAFLD. CASE REPORT We present a case of a 39-year-old woman with acute NASH with familial hypercholesterolemia that was refractory to lifestyle modifications and HMG-CoA reductase inhibitors. An episode of rhabdomyolysis warranted a search for alternatives to statin therapy. Results of a liver biopsy showed microvesicular and macrovesicular steatosis with ballooning degeneration, indicating acute NASH. She was started on PCSK9 inhibitors as salvage therapy. Three monthly doses resulted in a more than an 80% reduction in ALT and AST and a 48% reduction in LDL levels. A liver biopsy done 8 months after the first biopsy showed normalization of liver histology. CONCLUSIONS The use of PCSK9 inhibitors showed a dramatic response in this patient who failed conventional therapies, and the encouraging results seen in this case merit further research into the use of PCSK9 inhibitors as first-line therapy for the acute phase of NASH.

The clinical impact of including pictures in Papanicolaou test reports.

INTRODUCTION: Although the inclusion of representative photomicrographic images in pathology reports remains uncommon, the frequency has increased in recent years. The impact of the inclusion of pictures has not previously been examined in peer-reviewed literature. MATERIALS AND METHODS: We compared the Papanicolaou (Pap) test interpretations produced by our laboratory before and after the introduction of a requirement to include pictures in reports with interpretations of low-grade squamous intraepithelial lesion (LSIL); atypical squamous cells, cannot rule out high-grade squamous intraepithelial lesion; high-grade squamous intraepithelial lesion; atypical glandular cells; or carcinoma. Atypical squamous cells of undetermined significance (ASC-US) did not require a picture, creating an incentive to interpret borderline cases as ASC-US instead of LSIL. We compared 1810 Pap tests from before the picture requirement to 1807 after. RESULTS: The number of cases upgraded by the pathologists from a cytotechnologist interpretation of negative or ASC-US to one of the positive interpretations requiring a picture decreased from 99 in the prepicture era to 80 in the picture era (P = 0.19). Conversely, the number of cases downgraded by the pathologists increased from 65 to 98 (P = 0.015). The ASC-US to LSIL (ASC-SIL) ratio for the laboratory went from 0.92 to 1.45. CONCLUSIONS: The introduction of a picture requirement in Pap test reports significantly affected the practice of pathologists in our laboratory. The ASC-SIL ratio of the laboratory shifted toward the national mean in association with this change.

Double lung transplantation for diffuse idiopathic pulmonary neuroendocrine cell hyperplasia.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare cause of obstructive lung disease and a proposed precursor of pulmonary carcinoid tumors. With increased awareness of this disease, an accumulating number of cases have been reported. Patients may have progressive shortness of breath due to small airway obstruction. There is limited information on treatment of the disease, particularly for those with progressive disease. Here we report 2 patients who were treated at our institution with double lung transplantation. Both patients were female nonsmokers with a clinical presentation of cough and dyspnea. Multiple bilateral lung nodules were identified on high-resolution computed tomography and pulmonary function tests showed obstructive pattern in both patients. The diagnoses of DIPNECH were made by histologic evaluation of the explanted native lungs. These 2 patients are in stable condition following double lung transplantation at the time of this report. DIPNECH is increasingly recognized due to improved sensitivity of investigative imaging and increased awareness of the entity. Considering the malignant potential and lack of effective treatment of the disease, lung transplantation could be potentially an effective treatment option for these patients.