Status epilepticus (SE) significantly increases the all-cause mortality according to a review of more than 82,000 hospitalizations and emergency-department visits. Within this large group were 1,296 patients who presented with only SE, 2,136 patients who had post-epilepsy SE, and nearly 79,000 cases of epilepsy only, which served as controls. Angela M. Malek and associates found a mortality rate of 24.9% among SE only cases, compared with 20% in controls (hazard ratio 1.61) after adjustment for demographic and clinical confounding variables. Patients who presented with post-epilepsy SE had a mortality rate of 29.2% but a hazard ratio of only 1.16.

Malek AM, Wilson DA, Martz GU, et al. Mortality following status epilepticus in persons with and without epilepsy. Seizure. 2016;42:7-13.

Status epilepticus (SE) significantly increases the all-cause mortality according to a review of more than 82,000 hospitalizations and emergency-department visits. Within this large group were 1,296 patients who presented with only SE, 2,136 patients who had post-epilepsy SE, and nearly 79,000 cases of epilepsy only, which served as controls. Angela M. Malek and associates found a mortality rate of 24.9% among SE only cases, compared with 20% in controls (hazard ratio 1.61) after adjustment for demographic and clinical confounding variables. Patients who presented with post-epilepsy SE had a mortality rate of 29.2% but a hazard ratio of only 1.16.

Malek AM, Wilson DA, Martz GU, et al. Mortality following status epilepticus in persons with and without epilepsy. Seizure. 2016;42:7-13.

Status epilepticus (SE) significantly increases the all-cause mortality according to a review of more than 82,000 hospitalizations and emergency-department visits. Within this large group were 1,296 patients who presented with only SE, 2,136 patients who had post-epilepsy SE, and nearly 79,000 cases of epilepsy only, which served as controls. Angela M. Malek and associates found a mortality rate of 24.9% among SE only cases, compared with 20% in controls (hazard ratio 1.61) after adjustment for demographic and clinical confounding variables. Patients who presented with post-epilepsy SE had a mortality rate of 29.2% but a hazard ratio of only 1.16.

Malek AM, Wilson DA, Martz GU, et al. Mortality following status epilepticus in persons with and without epilepsy. Seizure. 2016;42:7-13.

Patients who continue to have seizures after epilepsy surgery should be evaluated for psychogenic nonepileptic seizures (PNES), based on a recent retrospective analysis of 1,105 patients. Among this cohort, 697 patients experienced postoperative seizures, and 27 of the 697 had documented PNES, according to Ali A. Asadi-Pooya and associates. Risk factors associated with post–epilepsy surgery PNES included an intelligence quotient (IQ) below 80 and a history of a psychiatric diagnosis.

Asadi-Pooya AA, Asadollahi M, Tinker J, et al. Post–epilepsy surgery psychogenic nonepileptic seizures. Epilepsia. 2016;57(10):1691-1696.

Patients who continue to have seizures after epilepsy surgery should be evaluated for psychogenic nonepileptic seizures (PNES), based on a recent retrospective analysis of 1,105 patients. Among this cohort, 697 patients experienced postoperative seizures, and 27 of the 697 had documented PNES, according to Ali A. Asadi-Pooya and associates. Risk factors associated with post–epilepsy surgery PNES included an intelligence quotient (IQ) below 80 and a history of a psychiatric diagnosis.

Asadi-Pooya AA, Asadollahi M, Tinker J, et al. Post–epilepsy surgery psychogenic nonepileptic seizures. Epilepsia. 2016;57(10):1691-1696.

Patients who continue to have seizures after epilepsy surgery should be evaluated for psychogenic nonepileptic seizures (PNES), based on a recent retrospective analysis of 1,105 patients. Among this cohort, 697 patients experienced postoperative seizures, and 27 of the 697 had documented PNES, according to Ali A. Asadi-Pooya and associates. Risk factors associated with post–epilepsy surgery PNES included an intelligence quotient (IQ) below 80 and a history of a psychiatric diagnosis.

Asadi-Pooya AA, Asadollahi M, Tinker J, et al. Post–epilepsy surgery psychogenic nonepileptic seizures. Epilepsia. 2016;57(10):1691-1696.

Among relatives of patients with epilepsy, the prevalence of depression is greater among those who believe they have an increased risk of epilepsy because they may have inherited an epilepsy-related mutation. Shawn T. Sorge and his colleagues reached that conclusion after surveying 417 individuals in 104 families in which 4 persons per family had the disease on average. On the other hand, individuals with epilepsy seemed less troubled by the diagnosis: The likelihood of having depression was not related to any potential epilepsy-related mutation among persons who already have epilepsy.

Sorge ST, Hesdorffer DC, Phelan JC, et al. Depression and genetic causal attribution of epilepsy in multiplex epilepsy families. Epilepsia. 2016;57(10):1643-1650.

Among relatives of patients with epilepsy, the prevalence of depression is greater among those who believe they have an increased risk of epilepsy because they may have inherited an epilepsy-related mutation. Shawn T. Sorge and his colleagues reached that conclusion after surveying 417 individuals in 104 families in which 4 persons per family had the disease on average. On the other hand, individuals with epilepsy seemed less troubled by the diagnosis: The likelihood of having depression was not related to any potential epilepsy-related mutation among persons who already have epilepsy.

Sorge ST, Hesdorffer DC, Phelan JC, et al. Depression and genetic causal attribution of epilepsy in multiplex epilepsy families. Epilepsia. 2016;57(10):1643-1650.

Among relatives of patients with epilepsy, the prevalence of depression is greater among those who believe they have an increased risk of epilepsy because they may have inherited an epilepsy-related mutation. Shawn T. Sorge and his colleagues reached that conclusion after surveying 417 individuals in 104 families in which 4 persons per family had the disease on average. On the other hand, individuals with epilepsy seemed less troubled by the diagnosis: The likelihood of having depression was not related to any potential epilepsy-related mutation among persons who already have epilepsy.

Sorge ST, Hesdorffer DC, Phelan JC, et al. Depression and genetic causal attribution of epilepsy in multiplex epilepsy families. Epilepsia. 2016;57(10):1643-1650.

The American Academy of Neurology and the American Epilepsy Society have released their guidelines on how to manage an adult patient who has had their first unprovoked seizure. Based on their review of the evidence, they recommend that clinicians base their decision about immediately initiating an antiepileptic drug after a first seizure on an individualized assessment. That evaluation should weigh the risk of a second seizure occurring against the adverse effects of the medication, as well as patient preferences. The risk of a second seizure increases if the patient has already suffered a symptomatic brain insult such as a stroke or head trauma, among other risk factors. The guidelines also point out that immediate treatment with an antiepileptic agent reduces the likelihood of additional seizures for 2 years but does not have an impact on long-term prognosis for seizure remission.

Tao JX, Davis AM. Management of an Unprovoked First Seizure in Adults. JAMA. 2016;316(15):1590-1591.

The American Academy of Neurology and the American Epilepsy Society have released their guidelines on how to manage an adult patient who has had their first unprovoked seizure. Based on their review of the evidence, they recommend that clinicians base their decision about immediately initiating an antiepileptic drug after a first seizure on an individualized assessment. That evaluation should weigh the risk of a second seizure occurring against the adverse effects of the medication, as well as patient preferences. The risk of a second seizure increases if the patient has already suffered a symptomatic brain insult such as a stroke or head trauma, among other risk factors. The guidelines also point out that immediate treatment with an antiepileptic agent reduces the likelihood of additional seizures for 2 years but does not have an impact on long-term prognosis for seizure remission.

Tao JX, Davis AM. Management of an Unprovoked First Seizure in Adults. JAMA. 2016;316(15):1590-1591.

The American Academy of Neurology and the American Epilepsy Society have released their guidelines on how to manage an adult patient who has had their first unprovoked seizure. Based on their review of the evidence, they recommend that clinicians base their decision about immediately initiating an antiepileptic drug after a first seizure on an individualized assessment. That evaluation should weigh the risk of a second seizure occurring against the adverse effects of the medication, as well as patient preferences. The risk of a second seizure increases if the patient has already suffered a symptomatic brain insult such as a stroke or head trauma, among other risk factors. The guidelines also point out that immediate treatment with an antiepileptic agent reduces the likelihood of additional seizures for 2 years but does not have an impact on long-term prognosis for seizure remission.

Tao JX, Davis AM. Management of an Unprovoked First Seizure in Adults. JAMA. 2016;316(15):1590-1591.

Temporal lobe epilepsy (TLE) is believed to disrupt resting state functional connectivity in the brain. To explore this association in more depth, investigators used group independent component analysis (ICA) to identify the brain’s default mode network (DMN). The DMN has been linked to episodic memory, which does not function normally in patients with TLE. The researchers found functional connectivity instability over time among patients with left and right sided TLE, when compared with healthy controls. The instability within the DMN was most consistently detected within the precuneus region of the brain.

Robinson LF, He X, Barnett P et al. The temporal instability of resting state network connectivity in intractable epilepsy. Hum Brain Mapp. 2016; Sept 15 [Epub ahead of print]

Temporal lobe epilepsy (TLE) is believed to disrupt resting state functional connectivity in the brain. To explore this association in more depth, investigators used group independent component analysis (ICA) to identify the brain’s default mode network (DMN). The DMN has been linked to episodic memory, which does not function normally in patients with TLE. The researchers found functional connectivity instability over time among patients with left and right sided TLE, when compared with healthy controls. The instability within the DMN was most consistently detected within the precuneus region of the brain.

Robinson LF, He X, Barnett P et al. The temporal instability of resting state network connectivity in intractable epilepsy. Hum Brain Mapp. 2016; Sept 15 [Epub ahead of print]

Temporal lobe epilepsy (TLE) is believed to disrupt resting state functional connectivity in the brain. To explore this association in more depth, investigators used group independent component analysis (ICA) to identify the brain’s default mode network (DMN). The DMN has been linked to episodic memory, which does not function normally in patients with TLE. The researchers found functional connectivity instability over time among patients with left and right sided TLE, when compared with healthy controls. The instability within the DMN was most consistently detected within the precuneus region of the brain.

Robinson LF, He X, Barnett P et al. The temporal instability of resting state network connectivity in intractable epilepsy. Hum Brain Mapp. 2016; Sept 15 [Epub ahead of print]

Volumetric correlation analysis of the brain can help detect subtle structural changes in patients with temporal lobe epilepsy (TLE). With that in mind, Conrad and associates performed T1 weighted 3T magnetic resonance imaging in 44 drug-resistant patients with unilateral TLE and in 44 healthy controls. They detected increased correlation in the contralateral areas to seizure foci and networks in several areas of the brains of patients with both left-sided and right-sided TLE. The areas, which included limbic, subcortical, and temporal regions, confirmed that there are coordinated volume changes in this population that are not confined to ipsilateral regions.

Conrad BN, Rogers BP, Abou-Khalil B et al. Increased MRI volumetric correlation contralateral to seizure focus in temporal lobe epilepsy. Epilepsy Res. 2016; 126:53-61.

Volumetric correlation analysis of the brain can help detect subtle structural changes in patients with temporal lobe epilepsy (TLE). With that in mind, Conrad and associates performed T1 weighted 3T magnetic resonance imaging in 44 drug-resistant patients with unilateral TLE and in 44 healthy controls. They detected increased correlation in the contralateral areas to seizure foci and networks in several areas of the brains of patients with both left-sided and right-sided TLE. The areas, which included limbic, subcortical, and temporal regions, confirmed that there are coordinated volume changes in this population that are not confined to ipsilateral regions.

Conrad BN, Rogers BP, Abou-Khalil B et al. Increased MRI volumetric correlation contralateral to seizure focus in temporal lobe epilepsy. Epilepsy Res. 2016; 126:53-61.

Volumetric correlation analysis of the brain can help detect subtle structural changes in patients with temporal lobe epilepsy (TLE). With that in mind, Conrad and associates performed T1 weighted 3T magnetic resonance imaging in 44 drug-resistant patients with unilateral TLE and in 44 healthy controls. They detected increased correlation in the contralateral areas to seizure foci and networks in several areas of the brains of patients with both left-sided and right-sided TLE. The areas, which included limbic, subcortical, and temporal regions, confirmed that there are coordinated volume changes in this population that are not confined to ipsilateral regions.

Conrad BN, Rogers BP, Abou-Khalil B et al. Increased MRI volumetric correlation contralateral to seizure focus in temporal lobe epilepsy. Epilepsy Res. 2016; 126:53-61.

Patients with epilepsy who also have intellectual disabilities seem to fare better when they adhere to a self-management program suggests this pilot study. Since individuals with intellectual disabilities are 20 times more likely to have epilepsy, researchers wanted to determine if a self-management program could make a difference. Their review of pilot and randomized controlled feasibility studies suggests that patients find this type of intervention acceptable and that the programs improve seizure frequency and may improve their quality of life.  Although their analysis highlights the potential for self-management programs, the investigators are currently conducting a randomized controlled trial to obtain more definitive results.

Dannenberg M, Mengoni SE, Gates B, Durand M. Self-management interventions for epilepsy in people with intellectual disabilities: A scoping review.  Seizure. 2016;41:16-25.

Patients with epilepsy who also have intellectual disabilities seem to fare better when they adhere to a self-management program suggests this pilot study. Since individuals with intellectual disabilities are 20 times more likely to have epilepsy, researchers wanted to determine if a self-management program could make a difference. Their review of pilot and randomized controlled feasibility studies suggests that patients find this type of intervention acceptable and that the programs improve seizure frequency and may improve their quality of life.  Although their analysis highlights the potential for self-management programs, the investigators are currently conducting a randomized controlled trial to obtain more definitive results.

Dannenberg M, Mengoni SE, Gates B, Durand M. Self-management interventions for epilepsy in people with intellectual disabilities: A scoping review.  Seizure. 2016;41:16-25.

Patients with epilepsy who also have intellectual disabilities seem to fare better when they adhere to a self-management program suggests this pilot study. Since individuals with intellectual disabilities are 20 times more likely to have epilepsy, researchers wanted to determine if a self-management program could make a difference. Their review of pilot and randomized controlled feasibility studies suggests that patients find this type of intervention acceptable and that the programs improve seizure frequency and may improve their quality of life.  Although their analysis highlights the potential for self-management programs, the investigators are currently conducting a randomized controlled trial to obtain more definitive results.

Dannenberg M, Mengoni SE, Gates B, Durand M. Self-management interventions for epilepsy in people with intellectual disabilities: A scoping review.  Seizure. 2016;41:16-25.

Although ectopic tissue in certain regions of the brain has been linked to epilepsy, a recent review of the literature concluded that periventricular nodular heterotopia rarely causes clinical seizures. The review evaluated chronic invasive EEG recordings and found that nodules alone are rarely responsible for seizures. Their onset is more likely to be connected with overlying neocortex or mesial temporal structures. However, the analysis did find that substantial or complete ablation of nodules usually results in more favorable surgical outcomes.

Thompson SA, Kalamangalam GP, Tandon N. Intracranial evaluation and laser ablation for epilepsy with periventricular nodular heterotopia. Seizure. 2016;41:211-216.

Although ectopic tissue in certain regions of the brain has been linked to epilepsy, a recent review of the literature concluded that periventricular nodular heterotopia rarely causes clinical seizures. The review evaluated chronic invasive EEG recordings and found that nodules alone are rarely responsible for seizures. Their onset is more likely to be connected with overlying neocortex or mesial temporal structures. However, the analysis did find that substantial or complete ablation of nodules usually results in more favorable surgical outcomes.

Thompson SA, Kalamangalam GP, Tandon N. Intracranial evaluation and laser ablation for epilepsy with periventricular nodular heterotopia. Seizure. 2016;41:211-216.

Although ectopic tissue in certain regions of the brain has been linked to epilepsy, a recent review of the literature concluded that periventricular nodular heterotopia rarely causes clinical seizures. The review evaluated chronic invasive EEG recordings and found that nodules alone are rarely responsible for seizures. Their onset is more likely to be connected with overlying neocortex or mesial temporal structures. However, the analysis did find that substantial or complete ablation of nodules usually results in more favorable surgical outcomes.

Thompson SA, Kalamangalam GP, Tandon N. Intracranial evaluation and laser ablation for epilepsy with periventricular nodular heterotopia. Seizure. 2016;41:211-216.

Patients experiencing different types of seizures tend to present with distinct hand gestures during the attacks, according to a recent retrospective analysis published in Neurology. To reach that conclusion, researchers analyzed videotaped hand postures in patients with genetic generalized epilepsy, localization-related epilepsy, and non-epileptic attacks. They found that 96% of patients with localized epilepsy presented with index-finger pointing while 91.3% of patients with genetic generalized epilepsy presented with hand fanning, which only occurred at the onset of the seizures. The investigators also discovered that making a fist, fanning and index-finger pointing was more common among patients who were having epileptic seizures, when compared to those who were having non-epileptic attacks (74% vs 32%).  

Siegel J, Tatum, WO. Hand postures in primary and secondary generalized tonic-clonic seizures. Neurology. 2016; Published online Sept 24.

Patients experiencing different types of seizures tend to present with distinct hand gestures during the attacks, according to a recent retrospective analysis published in Neurology. To reach that conclusion, researchers analyzed videotaped hand postures in patients with genetic generalized epilepsy, localization-related epilepsy, and non-epileptic attacks. They found that 96% of patients with localized epilepsy presented with index-finger pointing while 91.3% of patients with genetic generalized epilepsy presented with hand fanning, which only occurred at the onset of the seizures. The investigators also discovered that making a fist, fanning and index-finger pointing was more common among patients who were having epileptic seizures, when compared to those who were having non-epileptic attacks (74% vs 32%).  

Siegel J, Tatum, WO. Hand postures in primary and secondary generalized tonic-clonic seizures. Neurology. 2016; Published online Sept 24.

Patients experiencing different types of seizures tend to present with distinct hand gestures during the attacks, according to a recent retrospective analysis published in Neurology. To reach that conclusion, researchers analyzed videotaped hand postures in patients with genetic generalized epilepsy, localization-related epilepsy, and non-epileptic attacks. They found that 96% of patients with localized epilepsy presented with index-finger pointing while 91.3% of patients with genetic generalized epilepsy presented with hand fanning, which only occurred at the onset of the seizures. The investigators also discovered that making a fist, fanning and index-finger pointing was more common among patients who were having epileptic seizures, when compared to those who were having non-epileptic attacks (74% vs 32%).  

Siegel J, Tatum, WO. Hand postures in primary and secondary generalized tonic-clonic seizures. Neurology. 2016; Published online Sept 24.

BOSTON – Patients with serious liver disease who also had hepato-adrenal syndrome had significantly longer hospital stays; these patients had significantly longer ICU courses as well.

According to a recent study of this under-recognized syndrome, patients with cirrhosis, acute liver failure, or acute liver injury who also had clinically significant adrenocortical dysfunction had longer hospital stays when compared to patients without hepato-adrenal syndrome (HAS).
 

Presenting the study findings at a poster session at the annual meeting of the American Association for the Study of Liver Disease, Christina Lindenmeyer, MD, and her associates noted that the longer stays for HAS patients with serious liver disease held true even after adjustment for gender, blood glucose levels, and Child-Pugh score (median 29 days, HAS; 17 days, non-HAS; P = .001).

Further, the patients with HAS were more likely to have a prolonged ICU stay, after multivariable analysis adjusted for a variety of factors including the need for mechanical ventilation, age, bilirubin level, Model for End-stage Liver Disease (MELD) score, and severity of encephalopathy (13.5 vs. 4.9 days; P = .002).

“Patients with cirrhosis commonly have hypotension, and I think it’s underrecognized that the elevated levels of endotoxin and the low levels of lipoprotein circulating in patients with cirrhosis can lead to adrenocortical dysfunction,” Dr. Lindenmeyer said in a video interview.

The single-center study enrolled ICU patients with cirrhosis, acute liver injury, and/or acute liver failure who had random cortisol or adrenocorticotropin-releasing hormone (ACTH) stimulation test results. From 2008 to 2014, the tertiary care center saw 69 patients meeting these criteria; 32 patients (46%) had HAS. The mean age was 57.4 years, and 63.8% of enrolled patients were male. There were no significant differences in these demographics between the groups. Serum bicarbonate was higher in patients with HAS (21.4 vs. 17.5 mEq/L; P = .020); other blood chemistries, mean arterial pressures, and the MELD and Child-Pugh scores did not differ significantly between groups.

Dr. Lindenmeyer, a fellow in the Cleveland Clinic’s department of gastroenterology and hepatology, said that the accepted definition of HAS is a random cortisol level of less than 15 mcg/dL in “patients who were highly stressed in the ICU, typically with respiratory failure or hypotension,” she said. For non-ICU patients, the random cortisol level should be less than 20 mcg/dL. An alternative criterion is a post-ACTH stimulation test cortisol level of less than 20 mcg/dL.

Though there was no statistically significant difference between in-hospital mortality for those patients meeting HAS criteria, the trend was actually for those patients to have lower in-hospital mortality (44% vs. 51%; P = .53). This was true even after correction for MELD scores and serum potassium levels. Dr. Lindenmeyer said these results were “a little surprising,” and noted that the study didn’t examine 90-day or 1-year mortality. “That would be something interesting to look at,” she said.

“Early recognition and treatment of HAS may improve judicious allocation of critical care and hospital resources,” wrote Dr. Lindenmeyer and her colleagues.

Dr. Lindenmeyer reported no conflicts of interest, and there were no outside sources of funding reported.

[email protected]

On Twitter @karioakes

BOSTON – Patients with serious liver disease who also had hepato-adrenal syndrome had significantly longer hospital stays; these patients had significantly longer ICU courses as well.

According to a recent study of this under-recognized syndrome, patients with cirrhosis, acute liver failure, or acute liver injury who also had clinically significant adrenocortical dysfunction had longer hospital stays when compared to patients without hepato-adrenal syndrome (HAS).
 

Presenting the study findings at a poster session at the annual meeting of the American Association for the Study of Liver Disease, Christina Lindenmeyer, MD, and her associates noted that the longer stays for HAS patients with serious liver disease held true even after adjustment for gender, blood glucose levels, and Child-Pugh score (median 29 days, HAS; 17 days, non-HAS; P = .001).

Further, the patients with HAS were more likely to have a prolonged ICU stay, after multivariable analysis adjusted for a variety of factors including the need for mechanical ventilation, age, bilirubin level, Model for End-stage Liver Disease (MELD) score, and severity of encephalopathy (13.5 vs. 4.9 days; P = .002).

“Patients with cirrhosis commonly have hypotension, and I think it’s underrecognized that the elevated levels of endotoxin and the low levels of lipoprotein circulating in patients with cirrhosis can lead to adrenocortical dysfunction,” Dr. Lindenmeyer said in a video interview.

The single-center study enrolled ICU patients with cirrhosis, acute liver injury, and/or acute liver failure who had random cortisol or adrenocorticotropin-releasing hormone (ACTH) stimulation test results. From 2008 to 2014, the tertiary care center saw 69 patients meeting these criteria; 32 patients (46%) had HAS. The mean age was 57.4 years, and 63.8% of enrolled patients were male. There were no significant differences in these demographics between the groups. Serum bicarbonate was higher in patients with HAS (21.4 vs. 17.5 mEq/L; P = .020); other blood chemistries, mean arterial pressures, and the MELD and Child-Pugh scores did not differ significantly between groups.

Dr. Lindenmeyer, a fellow in the Cleveland Clinic’s department of gastroenterology and hepatology, said that the accepted definition of HAS is a random cortisol level of less than 15 mcg/dL in “patients who were highly stressed in the ICU, typically with respiratory failure or hypotension,” she said. For non-ICU patients, the random cortisol level should be less than 20 mcg/dL. An alternative criterion is a post-ACTH stimulation test cortisol level of less than 20 mcg/dL.

Though there was no statistically significant difference between in-hospital mortality for those patients meeting HAS criteria, the trend was actually for those patients to have lower in-hospital mortality (44% vs. 51%; P = .53). This was true even after correction for MELD scores and serum potassium levels. Dr. Lindenmeyer said these results were “a little surprising,” and noted that the study didn’t examine 90-day or 1-year mortality. “That would be something interesting to look at,” she said.

“Early recognition and treatment of HAS may improve judicious allocation of critical care and hospital resources,” wrote Dr. Lindenmeyer and her colleagues.

Dr. Lindenmeyer reported no conflicts of interest, and there were no outside sources of funding reported.

[email protected]

On Twitter @karioakes

BOSTON – Patients with serious liver disease who also had hepato-adrenal syndrome had significantly longer hospital stays; these patients had significantly longer ICU courses as well.

According to a recent study of this under-recognized syndrome, patients with cirrhosis, acute liver failure, or acute liver injury who also had clinically significant adrenocortical dysfunction had longer hospital stays when compared to patients without hepato-adrenal syndrome (HAS).
 

Presenting the study findings at a poster session at the annual meeting of the American Association for the Study of Liver Disease, Christina Lindenmeyer, MD, and her associates noted that the longer stays for HAS patients with serious liver disease held true even after adjustment for gender, blood glucose levels, and Child-Pugh score (median 29 days, HAS; 17 days, non-HAS; P = .001).

Further, the patients with HAS were more likely to have a prolonged ICU stay, after multivariable analysis adjusted for a variety of factors including the need for mechanical ventilation, age, bilirubin level, Model for End-stage Liver Disease (MELD) score, and severity of encephalopathy (13.5 vs. 4.9 days; P = .002).

“Patients with cirrhosis commonly have hypotension, and I think it’s underrecognized that the elevated levels of endotoxin and the low levels of lipoprotein circulating in patients with cirrhosis can lead to adrenocortical dysfunction,” Dr. Lindenmeyer said in a video interview.

The single-center study enrolled ICU patients with cirrhosis, acute liver injury, and/or acute liver failure who had random cortisol or adrenocorticotropin-releasing hormone (ACTH) stimulation test results. From 2008 to 2014, the tertiary care center saw 69 patients meeting these criteria; 32 patients (46%) had HAS. The mean age was 57.4 years, and 63.8% of enrolled patients were male. There were no significant differences in these demographics between the groups. Serum bicarbonate was higher in patients with HAS (21.4 vs. 17.5 mEq/L; P = .020); other blood chemistries, mean arterial pressures, and the MELD and Child-Pugh scores did not differ significantly between groups.

Dr. Lindenmeyer, a fellow in the Cleveland Clinic’s department of gastroenterology and hepatology, said that the accepted definition of HAS is a random cortisol level of less than 15 mcg/dL in “patients who were highly stressed in the ICU, typically with respiratory failure or hypotension,” she said. For non-ICU patients, the random cortisol level should be less than 20 mcg/dL. An alternative criterion is a post-ACTH stimulation test cortisol level of less than 20 mcg/dL.

Though there was no statistically significant difference between in-hospital mortality for those patients meeting HAS criteria, the trend was actually for those patients to have lower in-hospital mortality (44% vs. 51%; P = .53). This was true even after correction for MELD scores and serum potassium levels. Dr. Lindenmeyer said these results were “a little surprising,” and noted that the study didn’t examine 90-day or 1-year mortality. “That would be something interesting to look at,” she said.

“Early recognition and treatment of HAS may improve judicious allocation of critical care and hospital resources,” wrote Dr. Lindenmeyer and her colleagues.

Dr. Lindenmeyer reported no conflicts of interest, and there were no outside sources of funding reported.

[email protected]

On Twitter @karioakes