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Background/Aims. Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease that can progress to cirrhosis and hepatocellular carcinoma. This retrospective chart review investigated the incidence of hepatic steatosis in London, Ontario, Canada. Methods. A retrospective chart review was performed on emergency room (ER) patients undergoing nonscheduled computed tomography (CT) imaging over a six-month period in London, Ontario. CT images and reports were examined to determine presence of steatosis. Analyses of the electronic chart for a period of six months following the CT and communication with the patients’ family doctors were used to determine if there was follow-up. Waist circumference, subcutaneous fat depth, and abdominal fat volumes were calculated. Results. 48/450 patients meeting inclusion criteria were identified by radiology as having steatosis, with 34/40 (85%) family physicians unaware of the finding. 24.7% (100/405) of patients met standard CT criteria for steatosis, 40 of which were reported by the radiologist. Waist circumference, subcutaneous adipose tissue depth, subcutaneous adipose tissue volume, and visceral adipose tissue volume were significantly associated with steatosis. Conclusions. The hepatic steatosis prevalence we report is the first reported in a Canadian population. Early identification of steatosis will become more important as new pharmacologic therapies arise.

Sleep disruption has been associated with irritable bowel syndrome (IBS). We hypothesized that residents with greater sleep disruption secondary to intermittent overnight call shifts would have a higher prevalence of IBS. Postgraduate residents completed a Web-based survey including demographic data, frequency and characteristics of call shifts, the Rome III questionnaire, and the IBS-quality of life measure. For every hour of sleep deprivation while on call vs. off call, the odds ratio for an increased likelihood of IBS was 1.32, after adjustment for age and gender. The mean number of calls per block, sleep deprivation while on call, and specialty program vs. family practice each predicted the severity of IBS. Sleep disruption secondary to overnight call in residents was associated with an increased prevalence of IBS.

A computed tomograph of the patient's thorax showed a large lower descending thoracic aortic aneurysm (7.7 × 8.8 cm), with discontinuity of the posterior wall and a large extrapleural fluid collection; these findings were both suggestive of a hemorrhaging ruptured aortic aneurysm (Appendix 1, available at www.cmaj .ca /lookup /suppl/doi:10.1503 /cmaj.130056 /-/DC1). Within an hour, the patient's chest pain became tearing in quality and radiated to his back. Examination showed tachycardia (160 beats/min), a pulse deficit and a large difference in blood pressure between arms (right arm: 160/70 mm Hg; leftarm: 70/30 mm Hg). He eventually became hypotensive with blood pressure of 70/30 mm Hg in his right arm and undetectable blood pressure in his leftarm. Emergency endovascular repair of the ruptured aortic aneurysm was successful.

Background/Aim: In patients with advanced post-transplant hepatitis C virus (HCV) recurrence, antiviral treatment (AVT) with interferon and ribavirin is indicated to prevent graft failure. The aim of this study was to determine and report Canadian data with respect to the safety, efficacy, and spontaneous virologic response (SVR) predictors of AVT among transplanted patients with HCV recurrence. Patients and Methods: A retrospective chart review was performed on patients transplanted in London, Ontario and Edmonton, Alberta from 2002 to 2012 who were treated for HCV. Demographic, medical, and treatment information was collected and analyzed. Results: A total of 85 patients with HCV received pegylated interferon with ribavirin post-liver transplantation and 28 of the 65 patients (43%) with genotype 1 achieved SVR. Of the patients having genotype 1 HCV who achieved SVR, there was a significantly lower stage of fibrosis (1.37 ± 0.88 vs. 1.89 ± 0.96; P = 0.03), increased ribavirin dose (total daily dose 1057 ± 230 vs. 856 ± 399 mg; P = 0.02), increased rapid virologic response (RVR) (6/27 vs. 0/31; P = 0.05), increased early virologic response (EVR) (28/28 vs. 18/35; P = 0.006), and longer duration of therapy (54.7 ± 13.4 weeks vs. 40.2 ± 18.7; P = 0.001). A logistic regression model using gender, age, RVR, EVR, anemia, duration of therapy, viral load, years′ post-transplant, and type of organ (donation after cardiac death vs. donation after brain death) significantly predicted SVR (P < 0.001), with duration of therapy having a significant odds ratio of 1.078 (P = 0.007). Conclusions: This study identified factors that predict SVR in HCV-positive patients who received dual therapy post-transplantation. Extending therapy from 48 weeks to 72 weeks of dual therapy is associated with increased SVR rates. Future studies examining the role of extended therapy are needed to confirm these findings, since the current study is a retrospective one.

Abstract Background Immune-related adverse events can occur after treatment with immune checkpoint inhibitors (ICI), limiting treatment persistence. We aimed to evaluate the clinical course of ICI-mediated hepatitis (IMH) associated with combination ipilimumab and nivolumab treatment. Methods A retrospective cohort study including consecutive patients with metastatic melanoma treated with ipilimumab and nivolumab between 2013 and 2018 was conducted at two tertiary care centres. IMH was defined by the Common Terminology Criteria for Adverse Events (CTCAE). We determined the proportion of patients developing IMH, and compared the duration, treatment patterns and outcomes, stratified by hepatitis severity. Kaplan–Meier survival analysis was used to evaluate time to hepatitis resolution, and a linear mixed-effects model was used to compare longitudinal outcomes by treatment. Results A total of 63 patients were included. Thirty-two patients (51%) developed IMH (34% Grade 1–2, 66% Grade 3–4), at a median of 34 days (IQR 20 to 43.5 days) after the first dose. Baseline FIB4 index ≥1.45 was associated with IMH (OR 3.71 [95% CI: 1.03 to 13.38], P = 0.04). Ninety-four per cent (30/32) of patients had liver enzyme normalization after a median duration of 43 days (IQR 26 to 70 days). Corticosteroid use was not associated with faster IMH resolution or less ICI discontinuation. A total of 24 patients died during the study; no deaths were attributable to hepatitis-related complications. Fifty-three per cent (17/32) of patients resumed anti-PD-1 monotherapy and three patients developed IMH recurrence. Conclusions Approximately half of the patients treated with combination ipilimumab and nivolumab developed IMH in this cohort. However, most patients experienced uncomplicated IMH resolution.

Over 600,000 Americans have advanced liver disease, with cirrhosis accounting for approximately 49,500 deaths annually; it was the eighth leading cause of death in the USA in 2010 (Murray et al., JAMA 310(6):591–608, 2013). Hence, every year a large number of patients with cirrhosis require either elective or emergent surgical procedures. Perioperative mortality and morbidity is typically much higher in patients with cirrhosis as compared to non-cirrhotic patients for many reasons. Therefore, the preoperative assessment and the optimization of perioperative management of cirrhotic patients is essential. Education of cirrhotic patients and their families regarding the complexities and risks of surgery is paramount.

Root branching is critical for plants to secure anchorage and ensure the supply of water, minerals, and nutrients. To date, research on root branching has focused on lateral root development in young seedlings. However, many other programs of postembryonic root organogénesis exist in angiosperms. In cereal crops, the majority of the mature root system is composed of several classes of adventitious roots that include crown roots and brace roots. In this Update, we initially describe the diversity of postembryonic root forms. Next, we review recent advances in our understanding of the genes, signals, and mechanisms regulating lateral root and adventitious root branching in the plant models Arabidopsis (Arabidopsis thaliana), maize (Zea mays), and rice (Oryza sativa). While many common signals, regulatory components, and mechanisms have been identified that control the initiation, morphogenesis, and emergence of new lateral and adventitious root organs, much more remains to be done. We conclude by discussing the challenges and opportunities facing root branching research.