The combination of more hospitalizations and reduced in-hospital mortality rates suggests that evidence-based care may be translating into clinical benefits. In R788 contrast, the pattern of hospitalizing older patients requiring discharge to nursing-based care also raises the specter of frequent yet unplanned hospital readmission. The

severity of illness or variations in the quality of care are likely to influence readmission in this respect. Further studies are needed to identify the reasons for increased hospital use because emerging alternatives such as telemonitoring4 for high-risk patients could have significant implications for managing this disease nationally. Jayant A. Talwalkar M.D., M.P.H.*, * Advanced Liver Diseases Study Group, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN. “
“We wish to comment on the article entitled “Pathologic Criteria for Nonalcoholic Steatohepatitis: Interprotocol Agreement and Ability to Predict Liver-Related Mortality” by Younossi et al.,1 selleck screening library which was recently published in HEPATOLOGY. The stated goals of the study were 2-fold: (1) to compare the results of biopsy interpretations made according to three previously published

histological scoring systems2-4 and a previously unpublished system1 for the histopathological diagnosis of nonalcoholic steatohepatitis (NASH) and (2) to compare the use of these systems for the prediction of long-term mortality. The study cohort consisted of patients with biopsy-proven nonalcoholic fatty liver disease

(NAFLD) who had at least 5 years of follow-up. Details of the utilization of the previously described histological scoring systems provide insight into our concerns. Matteoni et MCE al.2 described a system for the categorization of the spectrum of diseases in NAFLD and classified cases into four types: (1) steatosis, (2) steatosis plus inflammation, (3) steatosis plus ballooning, and (4) steatosis plus Mallory-Denk bodies or fibrosis. This classification system was not used to identify the presence or absence of NASH in the original study according to Younossi et al. The degree of inflammation and its location (portal or lobular) were not specified in the system, nor was the degree of fibrosis or its zonality (perisinusoidal or portal). On the other hand, the Brunt proposal3 for grading and staging NASH was just that: a proposal, published in the same year as the Matteoni classification system, that followed the same paradigm used in chronic hepatitis for separating grading (activity) and staging (fibrosis). This proposal was, however, not intended for establishing a diagnosis of NASH. This system was applied to liver biopsy samples only after NASH had been diagnosed and not to cases with steatosis only or steatosis and inflammation.