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Association Between Fibrosis Stage and Outcomes of Patients With Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis.
No full textBACKGROUND & AIMS
Biopsy-confirmed liver fibrosis is a prognostic factor for patients with nonalcoholic fatty liver disease (NAFLD). We performed a systematic review to quantify the prognostic value of fibrosis stage in patients with NAFLD and the subgroup of patients with nonalcoholic steatohepatitis (NASH) and to assess the evidence that change in fibrosis stage is a surrogate endpoint.
METHODS
We searched the MEDLINE, Embase, Cochrane Library, and trial registry databases through August 2018 for prospective or retrospective cohort studies of liver-related clinical events and outcomes in adults with NAFLD or NASH. We collected data on mortality (all cause and liver related) and morbidity (cirrhosis, liver cancer, and all liver-related events) by stage of fibrosis, determined by biopsy, for patients with NAFLD or NASH. Using fibrosis stage 0 as a reference population, we calculated fibrosis stage-specific relative risk (RR) and 95% confidence interval (CI) values for mortality and morbidities. We performed fixed-effect and random-effect model meta-analyses. Metaregression was used to examine associations among study design (prospective vs retrospective cohort), overall risk of bias (medium or high), and mean duration of follow-up (in years).
RESULTS
Our meta-analysis included 13 studies, comprising 4428 patients with NAFLD; 2875 of these were reported to have NASH. Compared with no fibrosis (stage 0), unadjusted risk increased with increasing stage of fibrosis (stage 0 vs 4): all-cause mortality RR, 3.42 (95% CI, 2.63-4.46); liver-related mortality RR, 11.13 (95% CI, 4.15-29.84); liver transplant RR, 5.42 (95% CI, 1.05-27.89); and liver-related events RR, 12.78 (95% CI, 6.85-23.85). The magnitude of RR did not differ significantly after adjustment for confounders, including age or sex in the subgroup of NAFLD patients with NASH. Three studies examined the effects of increasing fibrosis on quality of life had inconsistent findings.
CONCLUSIONS
In a systematic review and meta-analysis, we found biopsy-confirmed fibrosis to be associated with risk of mortality and liver-related morbidity in patients with NAFLD, with and without adjustment for confounding factors and in patients with reported NASH. Further studies are needed to assess the association between fibrosis stage and patient quality of life and establish that change in liver fibrosis stage is a valid endpoint for use in clinical trials
Management of acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura, the value of optical coherence tomography: a case report.
No full textBackground
Treating myocardial infarction in the setting of immune thrombocytopenic purpura (ITP) is always a challenge especially if the platelet count is labile. Cardiologists dealing with such patients should keep a delicate balance between thrombotic and bleeding complications.
Case summary
A 50-year-old gentleman with treatment-challenging ITP presented with acute inferior ST elevation myocardial infarction after receiving recent intravenous immunoglobulin. Using optical coherence tomography (OCT) guidance, it was decided to treat him with percutaneous old balloon angioplasty especially with the labile nature of his platelet count. Subsequently, dual antiplatelet therapy was a challenge and he remained on clopidogrel for a period of only 10 weeks.
Conclusion
This case highlights the rare presentation of patients with ITP with thrombotic complications and the usefulness of OCT in formulating a management plan
Mid-term clinical outcomes from use of Sirolimus coated balloon in coronary intervention; data from real world population.
No full textBACKGROUND
Use of drug coated balloons (DCBs) in coronary intervention is escalating. There is a plethora of data on Paclitaxcel-DCB. However, when it comes of stents, Limus-drugs are preferred over Paclitaxel. There is very limited data on Sirolimus coated balloons (SCB). MagicTouch-SCB (Concept Medical, FL) elutes Sirolimus via nano-technology and have been used in our centers since March 2018. We report a mid-term follow-up with this relatively novel-technology.
METHODS AND RESULTS
We retrospectively analyzed all patients treated with MagicTouch-SCB between March-2018 and February-2019. Results are reported as cardiac-death, target-vessel myocardial-infarction (TVMI), target lesion revascularization (TLR) and Major Adverse Cardiac Events (MACE). During the study period, 288-patients (373-lesions) with a mean age of 65.8 were treated with MagicTouch-SCB. 84% (n = 241) were male, 155 (54%) were in the setting of acute coronary syndrome, 38% (n = 110) had diabetes and 62% (n = 233) were in de-novo lesions. Most lesions treated were in the LAD/diagonal-system (n = 170; 46%). Pre-dilatation was performed in 92% (n = 345) of cases. Bailout stenting was required in 9% lesions (n = 35). The mean diameter and length of SCBs were 2.64 ± 0.56 mm and 24 ± 8.9 mm respectively. During a median follow-up of 363 days (IQR: 278-435), cardiac death and TVMI occurred in 5-patients (1.7%) and 10-patients (3.4%) respectively, TLR per-lesion was 12%. The MACE rate was 10%. There were no documented cases of acute vessel closure.
CONCLUSIONS
The results from mid-term follow-up with this relatively new technology SCB is encouraging with a low rates of hard endpoints and acceptable MACE rates despite complex group of patients and lesion subsets
Productivity of Advanced Clinical Practitioners in Emergency Medicine: A 1-year dual-centre retrospective analysis.
No full textBACKGROUND
The ACP role is relatively new in Emergency Medicine (EM) nationally (RCEM, 2017). This work sought to establish the productivity of EM ACPs within our service, to enable evidence-based workforce planning and national benchmarking of this aspect of the role.
METHODOLOGY
Data from 1st January 2018-31st December 2018 was retrospectively collected from two hospitals in the United Kingdom (UK) via electronic patient records. In addition to the number of patients seen by ACPs (attending), the number of patients who were seen by an ACP as a senior review (SR) was collected. The productivity was mapped to ACP experience, with patient acuity and disposal reported.
RESULTS
In the study period 239,951 patients were seen in the Emergency Departments (EDs) of the two study hospitals. Overall 20,442 (8.5%) patients received care from an ACP. Mean productivity was 1.03 patients per hour (attending) and 1.53 patients per hour (attending and senior review).
DISCUSSION
EM ACPs form part of the RCEM future workforce strategy to overcome some of the contemporary challenges in EM (Hassan, 2018). To our knowledge, this is the first study which has examined and reported the productivity of ACPs in UK EM.
CONCLUSION
This paper sets a national benchmark for other EDs by reporting ACP productivity and contributes to the evidence by reporting productivity in other clinician groups. The data presented may be helpful in future national workforce planning for UK EDs
The Collaborative Ocular Tuberculosis Study (COTS) Consensus (CON) Group Meeting Proceedings.
No full textAn international, expert led consensus initiative was set up by the Collaborative Ocular Tuberculosis Study (COTS) group to develop systematic, evidence, and experience-based recommendations for the treatment of ocular TB using a modified Delphi technique process. In the first round of Delphi, the group identified clinical scenarios pertinent to ocular TB based on five clinical phenotypes (anterior uveitis, intermediate uveitis, choroiditis, retinal vasculitis, and panuveitis). Using an interactive online questionnaires, guided by background knowledge from published literature, 486 consensus statements for initiating ATT were generated and deliberated amongst 81 global uveitis experts. The median score of five was considered reaching consensus for initiating ATT. The median score of four was tabled for deliberation through Delphi round 2 in a face-to-face meeting. This report describes the methodology adopted and followed through the consensus process, which help elucidate the guidelines for initiating ATT in patients with choroidal TB
A new definition for metabolic associated fatty liver disease: an international expert consensus statement.
No full textThe exclusion of other chronic liver diseases including "excess" alcohol intake has till now been necessary to establish a diagnosis of metabolic-dysfunction-associated fatty liver disease (MAFLD). However, given our current understanding of the pathogenesis of MAFLD and its rising prevalence, "positive criteria" to diagnose the disease are required. In this work, a panel of international experts from 22 countries propose a new definition that is both comprehensive yet simple for the diagnosis of MAFLD and is independent of other liver diseases. The criteria are based on evidence of hepatic steatosis, in addition to one of the following three criteria, namely overweight/obesity, presence of type 2 diabetes mellitus, or evidence of metabolic dysregulation. We propose that disease assessment and stratification of severity should extend beyond a simple dichotomous classification to steatohepatitis versus non-steatohepatitis. The group also suggests a set of criteria to define MAFLD associated cirrhosis and proposes a conceptual framework to consider other causes of fatty liver disease. Finally, we bring clarity to the distinction between diagnostic criteria and inclusion criteria for research studies and clinical trials. Reaching consensus on the criteria for MAFLD will help unify the terminology (e.g. for ICD-coding), enhance the legitimacy of clinical practice and clinical trials, improve clinical care and move the clinical and scientific field of liver research forward
Development and clinical application of a prednisolone/cortisol assay to determine adherence to maintenance oral prednisolone in severe asthma.
No full textBACKGROUND
Non-adherence to oral prednisolone is an important driver of poor control in severe asthma, and its detection is warranted to guide management.
RESEARCH QUESTION
to study the utility of liquid chromatography and tandem mass spectrometry (LC-MS/MS) in determining the adherence status to oral prednisolone in severe asthma.
STUDY DESIGN AND METHODS
timeline serum levels of prednisolone, cortisol and metabolites were measured using a validated LC-MS/MS assay following observed intake of prednisolone in patients on maintenance oral prednisolone. Patterns of adherence and non-adherence were determined from analysis of peak blood levels. The performance of a spot test for adherence (detectable prednisolone and suppressed cortisol) was assessed in a second cohort of patients on maintenance prednisolone and a control group.
RESULTS
In the prednisolone absorption test 27 patients [mean age 38.6 years (17-63), 24 (83%) females] were included. We identified adherence in 13 (48%), non-adherence in 13 (48%), and malabsorption in 1(3.7%). The median (IQR) peak serum assays (nmol/L) of the adherent compared to the non-adherent groups were; cortisol 36(39.5) vs 295(153), prednisolone 1810 (590) vs 1730(727). The spot test cohort included 111 patients [67 on maintenance prednisolone and 44 control, the mean age was 42.4 years and 79% were females. Non-adherence was detected in 40.3% of patients and comparison of the adherent versus non-adherent groups showed; cortisol 27(48) vs 211(130) and prednisolone 259 (622) vs <20 respectively. The adherent patients had higher mean BMI (38.4±8.7 vs 32±7.5kg/m, p= 0.03), lower median blood eosinophils (90 (310) vs 510 (530) cells/μl, p< 0.001) and a trend towards reduced mean annual severe exacerbations (3.0±2.6 vs 4.3±2.4, p=0.3) than the non-adherent patients.
INTERPRETATION
non-adherence to oral prednisolone is common in severe asthma and can be reliably detected in the clinic using the LC-MS/MS assay
Transplant International Journal of the European Society for Organ Transplantation.
No full textWe write to express our concerns over the recently published paper by Chen et al, "Outcomes in kidney transplantation with mycophenolate mofetil-based maintenance immunosuppression in China: a large-sample retrospective analysis of a national database" and request details of the kidney procurement process in DCD or DCBD donors in relation to the short WIT" (Transplant International 2020, https://doi.org/10.1111/tri.13566)
The epidemiology of aggressive pituitary tumors (and its challenges).
No full textPituitary tumors are not rare if prevalence rates from autopsy or radiological series are considered; approximately 0.5% of all pituitary adenomas will come to medical attention. Less than 0.1% of these pituitary adenomas will become malignant, and probably around 0.5% of all detected adenomas will display an aggressive course. However, the exact incidence of both aggressive pituitary adenomas and pituitary carcinomas is unknown, as most data come from series with selected patients, such as surgically treated patients, which is likely not a reflection of all patients with a pituitary adenoma. An aggressive pituitary adenoma is not well-defined; even though an overarching definition, capturing both immunohistochemical and clinical characteristics is probably not waterproof, adoption of a widely accepted definition will be very helpful to harmonize research and establish more reliable epidemiological data