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Cardiovascular Implications in Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A State-of-the-Art Review
No full textMetabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is the most prevalent chronic liver disease globally and a key driver of cardiometabolic morbidity. Beyond hepatic manifestations, MASLD significantly elevates the risk of cardiovascular disease (CVD)-including myocardial infarction, ischemic stroke, heart failure, and cardiovascular mortality-through overlapping mechanisms such as visceral adiposity, insulin resistance, inflammation, oxidative stress, and dyslipidemia. Epidemiologic data demonstrate a consistent and independent association between MASLD and adverse cardiovascular outcomes. Subclinical changes in vascular structure and function precedes overt events, underscoring the need for early detection and proactive risk stratification. While glucagon-like-peptide 1 receptor agonists and sodium-glucose co-transporter-2 inhibitors offer dual hepatic and cardiovascular benefits, recent trials have revealed nuances in efficacy across patient populations, particularly in heart failure with preserved ejection fraction and cirrhotic cohorts. Non-invasive diagnostics-including elastography, magnetic resonance elastography, magnetic resonance imaging-derived proton density fat fraction, and machine learning-based tools-are enhancing the precision of MASLD staging and risk assessment. However, implementation remains variable, and cost-effectiveness in CVD screening is underexplored. This review synthesizes current knowledge on the MASLD-CVD interface, critically appraises existing evidence, and identifies gaps in mechanistic understanding, diagnostics, and therapeutics. We advocate for an integrated, multidisciplinary framework combining hepatology and cardiology expertise to optimize patient care in this evolving disease landscape.
Keywords: Cardiovascular diseases; Diagnostic imaging; Fatty liver; Glucagon-like peptide 1 receptor agonists; Risk assessment
Ultrasound evaluation of pediatric lymphadenopathies: diagnostic patterns and pitfalls
No full textPalpable lymph nodes are among the most common indications for ultrasound evaluation in the pediatric population. Ultrasound provides valuable insight into nodal composition by assessing greyscale morphology, color Doppler vascularity, and vascular resistance, with emerging techniques such as elastography and contrast-enhanced ultrasound offering additional diagnostic potential. Although certain sonographic features may suggest a benign or malignant etiology, imaging overlap often exists posing diagnostic challenges. This review provides an overview of the sonographic appearance of the most common pediatric lymphadenopathies, including reactive hyperplasia, bacterial and viral lymphadenitis, necrotizing and granulomatous lymphadenitis, malignant and atypical entities. Characteristic and non-specific imaging features are discussed, along with practical approaches to interpretation and current strategies for diagnosis and management.
Keywords: Child; Lymph node; Lymphadenopathy; Mycobacterium; Ultrasonography
Comparative outcomes of intracardiac versus transesophageal echocardiography for left atrial appendage occlusion
No full textRegional Variation in Early Kidney Transplant Access Across Dialysis Facilities in 4 US Regions
No full textIntroduction: Pretransplant access varies, but whether pretransplant steps vary regionally across dialysis facilities remains unclear.
Methods: We identified 62,467 adults (aged 18-80 years) referred from 2471 dialysis facilities and 27,171 initiating transplant evaluation from 2188 facilities in New England, New York, Southeast, and Ohio River Valley within the Early Steps to Transplant Access Registry (E-STAR) (January 1, 2015-December 31, 2023), linked with US Renal Data System (USRDS) and the Scientific Registry of Transplant Recipients data, followed-up through March 2, 2024. We examined dialysis facility-level proportions of evaluation start within 6 months of referral and waitlisting within 1 year of evaluation start. Descriptive statistics using analysis of variance and chi-square tests summarized outcome distributions and baseline characteristics within tertiles of outcome proportions, overall and by region.
Results: Evaluation start within 6 months across 2471 facilities varied from 0% to 100%; median within-facility proportion was 50% (interquartile range: 33.3%-64.3%), ranging from 33.3% (18.2%-50%) in the Ohio River Valley to 66.7% (50%-76.7%) in New York. Waitlisting within 1 year of evaluation start varied from 0% to 100% across 2188 facilities; median within-facility proportion was 41.2% (26.0%-60%), lowest in the Southeast (31.9% [20%-43.8%]) and similar across other regions (50%). Facilities in the lowest tertile of evaluation start proportions (\u3c 39.13%) more often treated patients from high-poverty neighborhoods (36.8% vs. 29.2%) and were for-profit (82.4% vs. 73.5%) than the highest tertile (\u3e 58.33%). These characteristics varied by region. Facility-level clustering explained 12.2% (95% confidence interval [CI]: 10.5%-13.5%) of variation in evaluation and 8.2% (6.7%-9.2%) in waitlisting.
Conclusion: Substantial regional variation in pretransplant access across dialysis facilities reinforces the need for region-specific strategies to improve access.
Keywords: dialysis facility; evaluation start; kidney; kidney transplantation; waitlisting
Association of Medicaid Accountable Care Organizations and postpartum mental health care utilization
No full textObjective: To examine the association of Massachusetts Medicaid Accountable Care Organization (ACO) implementation with changes in mental health care utilization in the postpartum period.
Study setting and design: We examine care for people with a birth covered by Medicaid or private insurance. We used a difference-in-differences design to compare differences before and after Medicaid ACO implementation for those with Medicaid versus those with private insurance. The primary outcome was a binary measure of having at least one outpatient mental health care visit in the 6 months postpartum. We estimated linear probability models controlling for age, prenatal mental illness, pregnancy complications, birth mode, and ZIP code characteristics.
Data sources and analytic sample: Data are from the Massachusetts All-Payer Claims Database. The analytic sample included Massachusetts residents with a live birth between July 1, 2016, and September 30, 2019, with complete data.
Principal findings: 107,813 births were included (53.0% Medicaid, 47.0% private). 7.8% of these had at least one outpatient mental health visit in the 6 months postpartum, with similar rates among those with Medicaid versus those with private insurance pre-ACO implementation (7.9% Medicaid versus 7.7% private). An increase in utilization among privately insured individuals and a decrease among Medicaid beneficiaries post-ACO implementation was observed. Regression-adjusted difference-in-differences estimates indicate that Medicaid ACO implementation was associated with a 1.3 percentage point [pp] decrease (95% confidence interval: 1.3 pp, -0.5 pp; p \u3c 0.01) in the probability of having an outpatient mental health visit for those with Medicaid.
Conclusions: Medicaid ACO implementation was associated with decreases in use of outpatient mental health care in the postpartum period among people with Medicaid, overall and compared to those with private insurance. Future research should determine whether this increased disparity in mental health care utilization persists with maturation of the ACO delivery model.
Keywords: Massachusetts; Medicaid Accountable Care Organization; behavioral health; insurance; postpartum
Epidemiology and outcomes of patients with cardiac arrest in the emergency department of a lower middle-income country
No full textBackground: Advanced cardiovascular life support (ACLS) for cardiac arrest is a cornerstone of emergency care and yet remains poorly studied in low- and middle-income countries. We characterised the clinical epidemiology and outcomes of cardiac arrest and ACLS in an ED in central Haiti, a lower middle-income country with a nascent emergency care system.
Methods: We conducted a prospective observational study of adult and paediatric patients who suffered cardiac arrest in an academic hospital ED in central Haiti from January 2019 to August 2020. Patients were identified prospectively at the time of clinical care. Data on demographics, comorbidities, clinical presentation, management with or without ACLS and outcomes were extracted from patient charts using a standardised form and analysed in SAS V.9.4. The primary outcome was survival to 24 hours after arrest.
Results: We identified 161 patients who suffered cardiac arrest in the ED. The mean age was 45 years; 55.9% were female, and 82.6% were aged \u3e18. Common presenting diagnoses were pneumonia (16.1%), sepsis (14.9%), congestive heart failure/cardiogenic shock (11.2%) and cerebrovascular accident (10.6%). Few patients were on cardiac or oxygen saturation monitors (23.1%; 63.5%) prior to arrest. 43 (27%) patients received ACLS (two patients missing data). Among these, 58.1% had initial rhythm assessed, and 2/25 (8%) patients had shockable rhythms. The median time to arrest was 23.6 hours. Sustained return of spontaneous circulation was achieved in two patients (4.7%). Among patients for whom ACLS was not initiated, the majority were due to poor prognosis (66.4%) or irreversible cause (22.4%) in the setting of available resources. One patient survived to 24 hours; none survived to hospital discharge.
Conclusion: In this lower middle-income setting, cardiac arrest in the ED was associated with poor survival despite ACLS. Survival may be impacted by limited resources for prearrest monitoring as well as for ongoing critical care.
Keywords: Cardiopulmonary Resuscitation; emergency department; global health; resuscitation
A Quality Improvement Initiative to Optimize Follow-Up in the New England Area for Pediatric Patients With Cardiovascular Implantable Electronic Devices
No full textBackground: The use of cardiac implantable electronic devices (CIEDs) continues to grow. Despite the presence of implanted hardware, patient compliance with in-clinic visits and remote transmissions is poor. We performed a quality improvement (QI) initiative to assess and optimize CIED follow-up in the New England area.
Methods: A regional network of eight pediatric institutions was created. All patients with CIEDs were identified starting in 2016. Noncompliance was defined as: no in-person evaluation within 1 year, or no remote transmission within 6 months. Interventions performed included automated texts/emails, certified letters, and personal phone calls.
Results: A total of 612 patients were identified, with the total number of patients increasing over the 5-year QI period as patients had devices implanted and removed. Initial noncompliance with in-person annual follow-up was 29%. If patients were noncompliant, a personal phone call was made, reminding them to return to clinic. If the patient could not be reached for 3 months, a certified letter was sent. The noncompliance rate decreased to 5% over the first year and remained around this level over the QI period (3%-9%). For remote transmissions, 54% of patients were noncompliant. Interventions were performed on subgroups of patients. Automated texts/emails were trialed in 126; after 6 months, 41% of these patients remained noncompliant. Phone calls were then trialed on 87 patients. Over 6 months, noncompliance decreased to 11%.
Conclusions: Patients with CIEDs have poor compliance with regular follow-up. Patients have a limited response to automated measures (texts/emails). Personal phone calls had the greatest impact in improving compliance.
Keywords: Clinical: Pediatrics – implantable devices
Considerations for more actionable consensus guidance for monitoring individuals with islet autoantibody-positive pre-stage 3 type 1 diabetes. Reply to Mallone R [letter]
No full textIL-33 signaling is dispensable for the IL-10-induced enhancement of mast cell responses during food allergy
No full textBackground: The IL-33/ST2 axis plays a pivotal role in the development of IgE-mediated mast cell (MC) responses during food allergy. We recently demonstrated that the pleiotropic cytokine, IL-10, not only exerts proinflammatory effects on IgE-mediated MC activation, but also promotes IL-33-induced MC responses. However, whether IL-33 is necessary for IL-10\u27s proinflammatory effects has not been examined.
Methods: To therefore determine the role of the IL-33/ST2 axis in this pathway, we assessed the effects of IL-10 on IgE-mediated MC activation and food allergy development in wild-type (WT) and ST2-/- mice.
Results: IL-10 stimulation significantly enhanced IL-33 gene expression, ST2 receptor expression, cytokine production, mMCP-1 secretion, and proliferation in IgE and antigen-activated bone marrow-derived MCs (BMMCs) from WT mice. ST2-/- BMMCs exhibited reduced cytokine secretion in response to IgE-dependent activation. However, IL-10 enhanced cytokine production, mMCP-1 secretion, and proliferation in these cells as well. To further assess the role of IL-10, food allergy was induced in WT and ST2-/- mice subjected to antibody-mediated IL-10 depletion. IL-10-depleted WT mice exhibited a significant attenuation in MC-mediated responses to OVA challenge. While ST2-/- mice also exhibited a profound suppression of MC responses, IL-10 depletion had no additional effects. However, ST2-/-/IL-10-/- mice exhibited further decreases in OVA-IgE and antigen-specific MC activation compared to ST2-/- mice.
Conclusion: Our data demonstrates that IL-10 can enhance MC responses in both WT and ST2-/- mice, further corroborating its proinflammatory effects on MCs and suggesting that they are not regulated by IL-33 signaling.
Keywords: IL-10; IL-33; allergy; food allergy; mast cells
The impact of surgical technique on the number of sentinel lymph nodes removed and its effect on complication rates
No full textPurpose: Sentinel lymph node biopsy (SLNB) is a staging procedure used to guide treatment for patients with breast cancer. Multiple variations in the SLNB technique have been described. We questioned how technique impacts the number of sentinel lymph nodes (SLNs) removed and associated complications.
Methods: Patients with breast cancer who were treated with lumpectomy and SLNB between 2018 and 2023 were analyzed. Patients were excluded if they had prior ipsilateral breast or axillary surgery or chest wall radiation, underwent neoadjuvant chemotherapy or endocrine therapy, or subsequently required ALND. Demographics, surgical technique, and operative and pathological data were collected. Complication rates were compared between more (4+) or fewer (1-3) SLNs removed.
Results: A total of 643 patients were included, with an average of 2.44 LNs removed (range 1-11). The overall complication rate was 19.8%, with a 4.4% lymphedema rate. The lymphedema rate was higher among patients who had more nodes removed. An average of 2.5 LNs were removed with dual mapping vs. 2.0 with technetium alone (p = 0.15). Breast massage had no effect on the number of SLNs removed (p = 0.12) but did impact blue dye uptake (p = 0.001).
Conclusions: Surgical technique did not significantly impact the number of nodes removed. Removing more nodes was associated with a greater risk of lymphedema.
Keywords: Breast cancer; Breast massage; Complications; Lymph nodes; Lymphedema; Sentinel lymph node biopsy