A practical approach to nutritional support in liver disease.

Nutritional problems are very common in patients with liver disease. The underlying liver disease will cause anorexia, nausea, and a poor appetite. In addition, alcohol acts as "cheap calories" and may be an added problem. Physicians taking care of patients with liver disease often place them on restrictive diets that compound the nutritional problem. Patients must be addressed for both the liver disease and the nutritional problems its treatment may create. One very important fact is that the majority of patients with liver disease will tolerate standard formulas that are much more "cost-effective" for the patients. How to calculate caloric and protein needs and how to select certain formulas are addressed. The results that show nutritional support is beneficial in decreasing mortality and morbidity are reviewed.

Current role of the medical director in community-based nursing facilities.

The majority of community-based nursing facilities in the United States have part-time medical directors whose basic training is either in primary care, internal medicine, or family practice. Some medical directors have a Certificate of Added Qualification in Geriatric Medicine. Very few have received formal training in medical direction in long-term care. This article presents information on the demographics of community medical staffs and medical directors, administrative and medical staff relationships, committee responsibilities, policies and procedures, teaching and research, community activities, and resources of value that should enhance the ability of part-time medical directors to perform more effectively and increase the knowledge of other health professionals about the complex role of the medical director in community-based nursing facilities.

Cimetidine drug interactions.

Cimetidine is a widely used antiulcer medication that is also a potent inhibitor of the mixed-function oxidase enzymes in the liver. This effect results in a number of clinically important interactions with other drugs, which are now being appreciated. Other effects of cimetidine, such as raising of gastric pH, alteration of liver blood flow, or alterations in renal secretory mechanisms, may also contribute to or result in clinically significant interactions. Current data document appreciable alterations in the metabolism or excretion of warfarin, theophylline, phenytoin, lidocaine, certain beta-adrenoceptor antagonists, certain benzodiazepines, and probably narcotic analgesics and procainamide. Thus, effects of these drugs and serum levels, where available, should be more closely followed when used in combination with cimetidine. Cimetidine appears to exacerbate the myelosuppressive effects of the nitrosoureas, and may also significantly alter the absorption of ketoconazole. Though other drugs may affect the absorption or elimination of cimetidine, the clinical implication of these effects is uncertain.

Carbamazepine-induced liver injury.

Two patients had carbamazepine-induced liver injury. The clinical, biochemical, and histologic data suggest hepatitis of the idiosyncratic hypersensitivity type with granulomas in one patient; in the other, the liver injury resembles that caused by a hepatotoxin. Both patients showed prompt recovery upon discontinuation of the drug.

Hepatitis-B surface antigen (HBsAg) and antibody (anti-HBs) prevalence among laboratory and nonlaboratory hospital personnel.

HBsAg and anti-HBs positivity was determined in hospital laboratory workers and nonlaboratory hospital workers (controls) matched for race and sex and adjusted for age. The combined prevalence of antigen-antibody positivity among white female technicians was 12% versus 0 of controls (P less than 0.005). The highest prevalence (18%) among laboratory workers was found in chemistry technicians, and significantly elevated frequencies also were noted in histocytologic, hematologic, and general laboratory technicians and blood collectors; this was not explained by a history of previous blood transfusions or hepatitis. Prevalence among pathologists (16%) was significantly greater (P less than 0.05) than among radiologists not routinely performing angiography (2%). Prevalence among black female housekeepers, both laboratory (25%) and nonlaboratory (36 %), was the highest, and was significantly greater (P less than 0.05) than among black female technicians (10%). Positivity was not correlated with current residence census tract socioeconomic indicators in black or white females. The data emphasize the need for continued identification of risks and improved protection measures in hospital workers.