Medium chain acyl-CoA dehydrogenase deficiency in a premature infant

Medium-chain acyl-CoA dehydrogenase deficiency (MCADD) is identified by newborn screening (NBS). The natural history of MCADD includes metabolic decompensation with hypoglycemia, hyperammonemia, seizures, coma, and death. NBS enables expectant management thus severe symptoms are rare in managed patients. We report premature birth of an MCADD affected infant and resultant management challenges. Nutritional support advanced from parenteral nutrition at 24 hours to enteral feeds. A NBS sample was collected day 2, positive results for MCADD was reported day six, and diagnostic tests were performed day seven. Lab results confirmed MCADD; however, representation of pathologic analytes was so extreme that ingestion of medium chain triglycerides was suspected and subsequently confirmed. Diet was adjusted and reflected in moderation of pathologic analytes. This case emphasizes the need for prompt review NBS results in premature infants. Implementing informatic intervention within electronic medical records, when a disorder requiring special nutritional intervention is identified, will protect premature infants in this vulnerable setting. Standard of care management provided premature infants may be contraindicated in the context of a comorbid inborn error of metabolism.

Progression of trunk imbalance in adolescent idiopathic scoliosis with a thoracolumbar/lumbar curve: is it predictable at the initial visit?

OBJECTIVE Progression of trunk imbalance is an important finding during follow-up of patients with adolescent idiopathic scoliosis (AIS). Nevertheless, no factors that predict progression of trunk imbalance have been identified. The purpose of this study was to identify parameters that predict progression of trunk imbalance in cases of AIS with a structural thoracolumbar/lumbar (TL/L) curve. METHODS This study included 105 patients with AIS and a structural TL/L curve who were followed up at an outpatient clinic. Patients with trunk imbalance (trunk shift ≥ 20 mm) at the initial visit were excluded. All patients were followed up for more than 2 years. Patients were divided into the following groups according to progression of trunk imbalance: 1) Group P, trunk shift ≥ 20 mm at the final visit and degree of progression ≥ 10 mm; and 2) Group NP, trunk shift < 20 mm at the final visit or degree of progression < 10 mm. Radiological parameters included Cobb angle, upper end vertebrae and lower end vertebrae (LEV), LEV tilt, disc wedge angle between LEV and LEV+1, trunk shift, apical vertebral translation, and apical vertebral rotation (AVR). Each parameter was compared between groups. Radiological parameters were assessed at every visit using whole-spine standing anteroposterior radiographs. RESULTS Among the 105 patients examined, 13 showed trunk imbalance with progression ≥ 10 mm at the final visit (Group P). Multivariate logistic regression analysis identified a lower Risser grade (p = 0.002) and a greater initial AVR (p = 0.020) as predictors of progressive trunk imbalance. A change in LEV tilt during follow-up was associated with trunk imbalance (p = 0.001). CONCLUSIONS Risser grade and AVR measured at the initial visit may predict progression of trunk imbalance. Surgeons should consider the risk of progressive trunk imbalance if patients show skeletal immaturity and a greater AVR at the initial visit.

Association between serum soluble CD14 and IL-8 levels and clinical outcome in primary biliary cholangitis

BACKGROUND & AIMS

Primary biliary cholangitis (PBC) is an autoimmune liver disease characterized by portal inflammation and immune-mediated destruction of intrahepatic bile ducts that often leads to liver decompensation and liver failure. Although the biochemical response to ursodeoxycholic acid (UDCA) can predict disease outcome in PBC, few biomarkers have been identified as prognostic tools applicable prior to UDCA treatment. We therefore sought to identify such indicators of long-term outcome in PBC in the Japanese population.

METHODS

The prebiopsy serum samples and subsequent clinical data of 136 patients with PBC treated with UDCA were analysed over a median follow-up period of 8.8 years. Serum levels of biomarkers related to microbial translocation (sCD14, EndoCAb and I-FABP) were measured along with those of 33 cytokines and chemokines and additional auto-antibodies. Associations between the tested parameters and the clinical outcomes of liver decompensation and liver-related death/liver transplantation were evaluated using the Cox proportional hazards model with stepwise methods and Kaplan-Meier analysis.

RESULTS

Elevated levels of serum IL-8, and sCD14 before UDCA therapy were significantly associated with both liver decompensation and liver-related death/liver transplantation. In multivariate analyses, IL-8≥46.5 pg/mL or sCD14≥2.0 μg/mL at enrolment demonstrated the same results. Kaplan-Meier analysis also revealed IL-8 and sCD14 to be significantly associated with a poor outcome. sCD14 was significantly correlated with IL-8. EndoCAb and I-FABP were not related to disease outcome.

CONCLUSIONS

Serum IL-8 and sCD14 levels before UDCA therapy represent noninvasive surrogate markers of prognosis in patients with PBC.

Hepatocellular Carcinoma: An Unusual Complication of Longstanding Wilson Disease

Wilson disease is caused by the accumulation of copper in the liver, brain or other organs, due to the mutation in ATP7B gene, which encodes protein that helps in excretion of copper in the bile canaliculus. Clinical presentation varies from asymptomatic elevation of transaminases to cirrhosis with decompensation. Hepatocellular carcinoma is a known complication of cirrhosis, but a rare occurrence in Wilson disease. We present a case of neurological Wilson disease, who later developed decompensated cirrhosis and hepatocellular carcinoma.

Automated low-flow ascites pump for the treatment of cirrhotic patients with refractory ascites

Cirrhotic patients with refractory ascites (RA) can be treated with repeated large volume paracentesis (LVP), with the insertion of a transjugular intrahepatic portosystemic shunt (TIPS) or with liver transplantation. However, side effects and complications of these therapeutic options, as well as organ shortage, warrant the development of novel treatments. The automated low-flow ascites pump (alfapump^®) is a subcutaneously-implanted novel battery-driven device that pumps ascitic fluid from the peritoneal cavity into the urinary bladder. Ascites can therefore be aspirated in a time- and volume-controlled mode and evacuated by urination. Here we review the currently available data about patient selection, efficacy and safety of the alfapump and provide recommendations for the management of patients treated with this new method.

[Proinsulin as a diagnostic biochemical marker of decompensated diabetes mellitus type II.]

The proinsulin is one of indices reflecting functional activity of pancreas. Under insulin-independent diabetes ration proinsulin/insulin increases. The study was carried out to evaluate content of proinsulin and other biochemical indices of blood serum depending on stage of compensation of diabetes mellitus type II. The content of proinsulin in blood serum was detected using "sandwich"-technique enzyme-linked immunosorbent assay (BioVender, Czechia). The concentration of proinsulin in blood serum of control group comprised 2,56 ± 0,23 nmol/l. No gender and age differences were established concerning content of proinsulin in blood serum of patients. The concentration of proinsulin was twice higher than control level in group of patients. Two main groups were singled out: one with high content (concentration thrice exceeded average value in control group) and another with low content of proinsulin (within standard value). The patients with stages of compensated and sub-compensated diabetes (n=35) retained low concentration of proinsulin. At the stage of decompensation of diabetes (n=40) concentration of proinsulin was thrice higher than standard value. This group was characterized by increasing of concentration of glucose, fructosamine and decreasing of concentration of C-peptide. At the stage of decompensation concentrations of triglycerides, total cholesterol and atherogenicity index increased reliably. The concentration of proinsulin at the stage of decompensation positively correlated with level of glucose and concentration of triglycerides. Therefore, measurement of concentration of proinsulin can be used as an important diagnostic criterion permitting to judge about degree of decompensation of diabetes and development of its complications.

Decompensation: A Novel Approach to Accounting for Stress Arising From the Effects of Ideology and Social Norms

To date, research that has drawn on Meyer's (2003) minority stress model has largely taken for granted the premises underpinning it. In this article we provide a close reading of how "stress" is conceptualized in the model and suggest that aspects of the model do not attend to the institutionalized nature of stressors experienced by people with marginalized identities, particularly lesbian, gay, bisexual, and transgender individuals. As a counter to this, we highlight the importance of a focus on the effects of ideology and social norms in terms of stress, and we argue why an intersectional approach is necessary to ensure recognition of multiple axes of marginalization and privilege. The article then outlines the concept of decompensation and suggests that it may offer one way to reconsider the effects of ideology and social norms. The decompensation approach centers on the need for social change rather than solely relying on individuals to be resilient.

Management of severe skeletal Class III malocclusion with bimaxillary orthognathic surgery

Orthognathic surgery in conjunction with fixed orthodontics is a common indication for interdisciplinary management of severe skeletal Class III malocclusion. A thorough analysis of pretreatment investigations and development of a surgical visual treatment objective is essential to plan the type of surgical technique required. Bimaxillary orthognathic surgery is the most common type of surgical procedure for severe skeletal discrepancies. The present case report is a combined ortho-surgical team management of a skeletally Class III patient. The severity of the case required bilateral upper first premolar extraction for dentoalveolar decompensation and simultaneous "Two-jaw surgery" with maxillary advancement of 4 mm and mandibular setback of 7 mm. Postsurgery, a pleasing good facial profile was achieved with Class II molar relation and positive overjet.

Acute Hepatitis E: Two Sides of the Same Coin

The relevance of acute hepatitis E virus (HEV) infections has been underestimated for a long time. In the past, HEV infection had been interpreted falsely as a disease limited to the tropics until the relevance of autochthonous HEV infections in the Western world became overt. Due to increased awareness, the incidence of diagnosed autochthonous HEV infections (predominantly genotype 3) in industrialized countries has risen within the last decade. The main source of infections in industrialized countries seems to be infected swine meat, while infections with the tropical HEV genotypes 1 and 2 usually are mainly transmitted fecal-orally by contaminated drinking water. In the vast majority of healthy individuals, acute HEV infection is either clinically silent or takes a benign self-limited course. In patients who develop a symptomatic HEV infection, a short prodromal phase with unspecific symptoms is followed by liver specific symptoms like jaundice, itching, uncoloured stool and darkened urine. Importantly, tropical HEV infections may lead to acute liver failure, especially in pregnant women, while autochthonous HEV infections may lead to acute-on-chronic liver failure in patients with underlying liver diseases. Immunosuppressed individuals, such as transplant recipients or human immunodeficiency virus (HIV)-infected patients, are at risk for developing chronic hepatitis E, which may lead to liver fibrosis and cirrhosis in the long term. Importantly, specific treatment options for hepatitis E are not approved by the regulation authorities, but off-label ribavirin treatment seems to be effective in the treatment of chronic HEV-infection and may reduce the disease severity in patients suffering from acute liver failure.

The Enhanced liver fibrosis score is associated with clinical outcomes and disease progression in patients with chronic liver disease

BACKGROUND AND AIMS

Current tools for risk stratification of chronic liver disease subjects are limited. We aimed to determine whether the serum-based ELF (Enhanced Liver Fibrosis) test predicted liver-related clinical outcomes, or progression to advanced liver disease, and to compare the performance of ELF to liver biopsy and non-invasive algorithms.

METHODS

Three hundred patients with ELF scores assayed at the time of liver biopsy were followed up (median 6.1 years) for liver-related clinical outcomes (n = 16) and clear evidence of progression to advanced fibrosis (n = 18), by review of medical records and clinical data.

RESULTS

Fourteen of 73 (19.2%) patients with ELF score indicative of advanced fibrosis (≥9.8, the manufacturer's cut-off) had a liver-related clinical outcome, compared to only two of 227 (<1%) patients with ELF score <9.8. In contrast, the simple scores APRI and FIB-4 would only have predicted subsequent decompensation in six and four patients respectively. A unit increase in ELF score was associated with a 2.53-fold increased risk of a liver-related event (adjusted for age and stage of fibrosis). In patients without advanced fibrosis on biopsy at recruitment, 55% (10/18) with an ELF score ≥9.8 showed clear evidence of progression to advanced fibrosis (after an average 6 years), whereas only 3.5% of those with an ELF score <9.8 (8/207) progressed (average 14 years). In these subjects, a unit increase in ELF score was associated with a 4.34-fold increased risk of progression.

CONCLUSIONS

The ELF score is a valuable tool for risk stratification of patients with chronic liver disease.

Professionals' perception on the management of patients with dual disorders

BACKGROUND

There is a need to evaluate the professionals' perception about the consequences of the lack of therapeutic adherence in the evolution of patients with co-occurring disorders.

METHODS

An online survey, released on the Socidrogalcohol [Spanish Scientific Society for Research on Alcohol, Alcoholism and other Drug Addictions] and Sociedad Española de Patología Dual [the Spanish Society of Dual Pathology] web pages, was answered by 250 professionals who work in different types of Spanish health centers where dual diagnosis patients are assisted.

RESULTS

Most professionals perceived the existence of noncompliance among dual diagnosis patients. Almost all of these professionals (99%) perceived that noncompliance leads to a worsening of the progression of the patient's disorder, in both the exacerbation of mental disorders and the consumption of addictive substances. Most of the professionals (69.2%) considered therapeutic alliance as the main aspect to take into account to improve the prognosis in this population. The primary purpose of treatment must be the improvement of psychotic-phase positive symptoms, followed by the control of behavior disorders, reduction of craving, improvement of social and personal performances, and reduction of psychotic-phase negative symptoms.

CONCLUSION

Most professionals perceived low adherence among dual diagnosis patients. This lack of adherence is associated with a worsening of their disease evolution, which is reflected in exacerbations of the psychopathology and relapse in substance use. Therefore, we propose to identify strategies to improve adherence.

Clinical outcomes of chronic hepatitis C patients related to baseline liver fibrosis stage: a hospital-based linkage study

BACKGROUND AND AIMS

Rates of long-term clinical outcomes of chronic hepatitis C in patients with none, mild or severe liver fibrosis are required to determine benefits of anti-viral therapies. This study evaluated long-term outcomes for chronic hepatitis C stratified by all Metavir fibrosis stages.

METHODS

Clinical outcomes were determined using population-based data linkage methodology for 880 hepatitis C patients who had a liver biopsy performed from 1992 to 2012.

RESULTS

During 9386 person-years of follow up, 28 patients developed hepatocellular carcinoma, 58 developed liver decompensation and 122 died or underwent liver transplantation. There was no significant difference in liver-related death for those with F0-F2 with an 18-year survival probability >94%. Hazard ratio of liver-related death for F3 compared with F0-F2 was 4.24 (P = 0.003), with no significant difference in the first 13-year follow up. The 15-year decompensation-free survival for F0, F1 and F2 was 100%, 96% and 94% respectively and for hepatocellular carcinoma-free survival was 100%, 99% and 98%. Hazard ratio of liver complication (hepatocellular carcinoma or decompensation)-free survival for F3 compared with F0-F2 was 3.22 (P = 0.001), with no significant difference during the first 7-year follow up. F4 had significantly higher risk of liver-related death, decompensation and hepatocellular carcinoma than F3 (P < 0.001).

CONCLUSIONS

Chronic hepatitis C patients with F2 or less had few liver complications after 15 years. For F3 patients, the significant increase in liver-related death occurred after 13 years and for liver complications after 7 years.

Medical Problems in Obstetrics: Inherited Metabolic Disease

An increasing number of women with rare inherited disorders of metabolism are becoming pregnant. Although, in general, outcomes for women and their children are good, there are a number of issues that need to be considered. Currently, limited specific guidance on the management of these conditions in pregnancy is available. Prepregnancy counselling with information on inheritance, options for reproduction, teratogenicity risk, potential impact on maternal health and long-term health of children should be offered. With appropriate specialist management, the teratogenic risk of conditions such as maternal phenylketonuria (PKU) can be eliminated, and the risk of metabolic decompensation in disorders of energy metabolism or intoxication significantly reduced. Multidisciplinary management, and close liaison between obstetricians and other specialists, is required for those women in whom there is cardiac, renal, respiratory, joint or other organ involvement.

Liver stiffness and the prediction of clinically significant portal hypertension and portal hypertensive complications

OBJECTIVE

Clinically significant portal hypertension (CSPH) is associated with increased risk of liver disease complications, but its identification requires invasive methods. Liver stiffness (LS) measurement via transient elastography correlates with the presence of CSPH. We, therefore, evaluated LS as a noninvasive tool in the prediction of CSPH and portal hypertensive complications.

MATERIAL AND METHODS

Ninety-five consecutive patients successfully underwent measurement of hepatic venous pressure gradient (HVPG) and LS on the same day. Recent laboratory tests were correlated. Patients were followed up for development of portal hypertensive complications. Predictors of CSPH and complications were identified.

RESULTS

Seventy-six (80%) were male and mean age was 56.8 ± 9.3 years. Ninety-three percent and 72% of patients had cirrhosis and esophageal varices, respectively. Only LS (r(2) = 0.38; p < 0.0001) and international normalized ratio (r(2) = 0.21; p = 0.02) were independently associated with HVPG. An LS >29.0 kilopascal (kPa) predicted CSPH with 71.9% sensitivity, 100% specificity, 100% positive predictive value (PPV), and 56.0% negative predictive value (NPV). An LS <25.0 kPa in those with platelet count >150 × 10(9)/L excluded CSPH with 91.7% sensitivity, 100% specificity, 100% PPV, and 90% NPV. Ninety patients were followed up for a median duration of 15.1 months. CSPH and LS >34.5 kPa predicted portal hypertensive complications with 100% and 75.0% sensitivity, 40.3% and 69.4% specificity, 43.1% and 52.5% PPV, and 100% and 86.2% NPV, respectively.

CONCLUSION

LS shows promise as a noninvasive marker of CSPH and portal hypertensive complications. Combining LS with platelet count improves diagnostic accuracy in the exclusion of CSPH.

Increased delayed mortality in patients with acute-on-chronic liver failure who have prior decompensation

BACKGROUND AND AIM

Patients with acute-on-chronic liver failure (ACLF) represent a complex population with differential prognosis. The aim of the study was to categorize ACLF according to the severity of underlying chronic liver diseases.

METHODS

A total of 540 ACLF patients were recruited, including 127 with prior decompensated cirrhosis and 413 without prior decompensation (PD) including 193 with underlying chronic hepatitis and 220 with prior compensated cirrhosis. The clinical characteristics and prognosis of subgroups were compared. Cox proportional hazard model and multinominal logistic regression analysis were performed to identify significant prognostic parameters.

RESULTS

The 28-day, 3-month and 1-year survival of ACLF patients with or without PD were 58.9% versus 61.4%, 36.2 versus 52.5%, and 29.1% versus 49.6%, respectively. On multinominal logistic regression analysis or time-to-death analysis by Cox proportional hazard model, PD was significantly associated with post-28-day mortality but not within-28-day mortality. On multivariate time-to-death analysis, older age, high international normalized ratio (INR) and serum bilirubin, low levels of serum sodium and platelet count, and presence of hepatic encephalopathy (HE), upper gastrointestinal bleeding, and respiratory or circulation dysfunction were predictors of within-28-day mortality in patients without PD, whereas the risk factors in patients with PD were high INR, creatinine, presence of HE, and respiratory or circulation dysfunction.

CONCLUSION

ACLF patients with or without PD had comparable short-term prognosis but differential 1-year mortality. ACLF patients with PD were distinct from those without PD in age, types of acute insults, severity of hepatic damage, and distribution of complications, and the former group was characterized by increased delayed mortality.

Pregnancy in women with inherited metabolic disease

An increasing number of women with rare inherited disorders of metabolism are becoming pregnant. Whilst, in general, outcomes for women and their children are good, there are issues that need to be considered. Due to the rarity of many conditions, there is limited specific guidance available on best management. Prepregnancy counselling with information on inheritance, options for reproduction, teratogenicity risk, potential impact on maternal health and long-term health of children should be offered. With appropriate specialist management, the teratogenic risk of conditions such as maternal phenylketonuria (PKU) can be eliminated, and the risk of metabolic decompensation in other disorders of intoxication or energy metabolism significantly reduced. Newer therapies, such as enzyme replacement therapy, appear to be safe in pregnancy, but specific advice should be sought. Multidisciplinary management, and close liaison between obstetricians and other specialists is required for women in whom there is cardiac, renal, respiratory, joint or other organ involvement.

Imaging Congestion With a Pocket Ultrasound Device: Prognostic Implications in Patients With Chronic Heart Failure

BACKGROUND

Venous congestion is common in patients with chronic heart failure (HF). We used a pocket-sized ultrasound imaging device (PID) to assess the patients' congestive status and related our findings to prognosis.

METHODS AND RESULTS

One hundred four consecutive outpatients from an HF outpatient clinic were studied. Interstitial lung water (ILW), pleural effusion (PE), and the diameter of the inferior vena cava (VCI) were assessed with the use of a PID. ILW was assessed by demonstration of B-lines (comet tail artifact (CTA). Out of the 104 patients, 28 had CTA and 8 had PE. Median VCI diameter was 18 mm (interquartile range 14-22 mm). Each of these parameters correlated weakly (r = 0.26-0.37; P < .05) with the HF biomarker N-terminal pro-B-type natriuretic peptide (NT-proBNP). During the median follow-up time of 530 days, 18 hospitalizations and 14 deaths were registered. Findings of CTA, PE, or both increased the risk of death or hospitalization (hazard ratio 3-4; P < .05). After adjustment for age, cardiac systolic function, and NT-proBNP, this difference remained significant for CTA alone and CTA + PE combined, but not for PE alone.

CONCLUSIONS

With the use of a handheld ultrasound device, signs of pulmonary congestion could be demonstrated. When found, these had a significant prognostic impact in clinically stable HF.

Long-term outcomes of chronic hepatitis B virus infection in the era of antiviral therapy in Korea

BACKGROUND AND AIMS

Chronic hepatitis B (CHB) can progress to cirrhosis, hepatocellular carcinoma (HCC), and ultimately liver-related deaths. Recently, owing to potent antiviral therapy with minimal side-effects, sustained suppression of hepatitis B virus replication can be achieved, thereby preventing such complications. We aimed to reappraise clinical courses regarding disease progression in the era of antiviral therapy.

METHODS

Between 2001 and 2005, treatment-naïve Korean CHB patients without cirrhosis were enrolled and followed up for at least 5 years. During follow up, antiviral therapy was commenced according to Korean Association for the Study of the Liver guidelines, if eligible, and ultrasonography and laboratory and clinical assessment were performed regularly. Primary end-points were development of cirrhosis, hepatic decompensation, HCC, or liver-related deaths.

RESULTS

Of 360 patients, 323 (89.7%) received antiviral therapy such as lamivudine (70.6%), entecavir (8.7%), or telbivudine (6.5%). During follow up, cirrhosis developed in 29 (8.1%), hepatic decompensation in 4 (1.1%), and HCC in 15 (4.2%) patients. Annual incidences of cirrhosis, hepatic decompensation, and HCC were 1.05%, 0.14%, and 0.53% per person-year, respectively. Age was an independent predictor for developing cirrhosis (hazard ratio [HR] 1.075, 95% confidence interval [CI] 1.037-1.116; P < 0.001), whereas age (HR 1.060, 95% CI 1.012-1.111; P = 0.014) and cirrhosis (HR 17.470, 95% CI 5.081-60.063; P < 0.001) were those for developing HCC.

CONCLUSIONS

In the era of antiviral therapy, overall clinical courses have been much improved since introduction of lamivudine in 1999. However, patients with older age or cirrhosis are still subject to HCC development despite appropriate antiviral therapy, necessitating cautious surveillance.

Monitoring hemodynamic and metabolic alterations during severe hemorrhagic shock in rat brains

RATIONALE AND OBJECTIVES

Our long-term goals are to identify imaging biomarkers for hemorrhagic shock and to understand how the preservation of cerebral microcirculation works. We also seek to understand how the damage occurs to the cerebral hemodynamics and the mitochondrial metabolism during severe hemorrhagic shock.

MATERIALS AND METHODS

We used a multimodal cerebral cortex optical imaging system to obtain 4-hour observations of cerebral hemodynamic and metabolic alterations in exposed rat cortexes during severe hemorrhagic shock. We monitored the mean arterial pressure, heart rate, cerebral blood flow (CBF), functional vascular density (FVD), vascular perfusion and diameter, blood oxygenation, and mitochondrial reduced nicotinamide adenine dinucleotide (NADH) signals.

RESULTS

During the rapid bleeding and compensatory stage, cerebral parenchymal circulation was protected by inhibiting the perfusion of dural vessels. During the compensatory stage, although the brain parenchymal CBF and FVD decreased rapidly, the NADH signal did not show a significant increase. During the decompensatory stage, FVD and CBF maintained the same low level and the NADH signal remained unchanged. However, the NADH signal showed a significant increase after the rapid blood infusion. FVD and CBF rebounded to the baseline after the resuscitation and then declined again.

CONCLUSIONS

We present for the first time simultaneous imaging of cerebral hemodynamics and NADH signals in vivo during the process of hemorrhagic shock. This novel multimodal method demonstrated clearly that severe hemorrhagic shock imparts irreversible tissue damage that is not compensated by the autoregulatory mechanism. Hemodynamic and metabolic signatures including CBF, FVD, and NADH may be further developed to provide sensitive biomarkers for stage transitions in hemorrhagic shock.

Longitudinal changes in isovolumetric bladder pressure in response to age-related prostate growth in 1,020 healthy male volunteers

AIM

To non-invasively study if compensation and decompensation occurs in the urinary bladder of healthy male volunteers in response to benign prostatic enlargement (BPE) using the condom catheter method.

METHODS

Between 2001 and 2010, 1,020 healthy male volunteers were included in a longitudinal study based on three non-invasive urodynamic examinations during a 5-year follow-up. Inclusion criteria were an informed consent, the ability to void in a normal standing position and a minimum free flow rate of 5.4 ml/sec. Study parameters were prostate volume (PV), maximum free urinary flow rate (Q(max)) and bladder contractility, quantified by the maximum isovolumetric bladder pressure, measured in the condom (P(cond.max)). Volunteers also completed the International Prostate Symptom Score Form (IPSS).

RESULTS

Within limitations, the included volunteers had a flat age distribution between 38 and 72 years. This made it possible to combine longitudinal analysis in a 5-year observation interval, with cross sectional analysis in a 35-year age range. Longitudinal analysis showed that with increasing age, PV increased with 1.9% per year, whereas Qmax decreased with 1.1% per year. IPSS increased with 1.1% per year when volunteers were older than 55 years. P(cond.max) increased during the 5-year longitudinal follow-up, but not in the cross sectional analysis.

CONCLUSIONS

The difference between cross sectional and longitudinal results of the P(cond.max) may have been caused by compensation of the urinary bladder resulting in a selection effect. This would imply that compensation is a relatively fast process, taking approximately 5 years.

Direct-acting antiviral agents in patients with hepatitis C cirrhosis

Patients with cirrhosis who are infected with hepatitis C virus (HCV) are the most in need of antiviral treatment. Virologic cure improves fibrosis and quality of life while reducing liver-related morbidity and mortality. In mid-2011, the addition of direct-acting antiviral agents (DAAs)-the protease inhibitors boceprevir (Victrelis, Merck) and telaprevir (Incivek, Vertex)-to pegylated interferon α-2a/b and ribavirin revolutionized the treatment of HCV infection by increasing cure rates across all fibrosis scores in patients with genotype 1 HCV infection. However, patients with advanced fibrosis or cirrhosis are the most difficult to treat, and the addition of DAAs increases treatment side effects as well as potency. Five phase III DAA trials have been published to date, but they contain limited data on patients with cirrhosis. This review will examine the available data and will describe the evolution of HCV therapy in patients with cirrhosis from the standard-of-care therapy of the past decade into the new era of DAAs.

Surgical-orthodontic treatment of a skeletal class III malocclusion

For patients whose orthodontic problems are so severe that neither growth modification nor camouflage offers a solution, surgery to realign the jaws or reposition dentoalveolar segments is the only possible treatment option left. One indication for surgery obviously is a malocclusion too severe for orthodontics alone. It is possible now to be at least semiquantitative about the limits of orthodontic treatment, in the context of producing normal occlusion as the diagrams of the “envelope of discrepancy” indicate. In this case report we present orthognathic treatment plan of an adult female patient with skeletal class III malocclusion. Patient's malocclusion was decompensated by orthodontic treatment just before the surgery and then normal jaw relationship achieved by bilateral sagittal split osteotomy.

Integrating innovative sensors

Introduction

Heart failure is a significant and growing health problem. To enable a preventative health care system in heart failure, a move is required from the current, intermittent episodical treatment to continuous and ubiquitous access to medical excellence. Home telemonitoring systems that monitor vital body signs and symptoms with wearable technology, have been proposed to enhance treatment and anticipation of adverse events in heart failure patients (decompensation).

Aims and objectives

We investigated whether the data recorded in a home telemonitoring system using innovative sensors had predictive value in detecting heart failure related events.

Methods

In the MyHeart observational clinical trial, 148 heart failure patients were followed daily for up to one year using an innovative telemonitoring system recording symptoms questionnaires, basic parameters such as body weight and blood pressure, as well as advanced information provided by a bed sensor monitoring night heart rate and activity and a thorax bioimpedance (BIM) device, designed to monitor fluid accumulation in the lungs. The area under the receiver operator characteristic curve (AUC) was used to evaluate the predictive value for heart failure related events of single and combined telemonitoring measurements.

Results

The telemonitoring system including innovative sensors was rated positively by the patients, which is further supported by the reasonable compliance rates (>65%) measured. The most predictive variables 14 days preceding an event were thoracic bioimpedance (area under the curve of 0.70), night breathing rate and some symptoms. The initial multiparametric analysis achieved a mean accuracy of 80.6% but would require more data to confirm its generalisation ability.

Conclusions

The measurements performed during the MyHeart trial with 148 patients and 12 months’ follow-up provided evidence supporting the development of predictive algorithms of decompensation to support heart failure management at home. An innovative wearable monitor of thoracic congestion by means of bioimpedance was tested and showed the highest predictive value for heart failure decompensation among a large set of monitored vital signs and symptoms.

YKL-40 genetic polymorphisms and the risk of liver disease progression in patients with advanced fibrosis due to chronic hepatitis C

BACKGROUND/AIMS

The aim of this study was to explore the association of a functional YKL-40 promoter polymorphism (rs4950928) with baseline disease stage, response to antiviral therapy and risk of liver disease progression in a group of patients with chronic hepatitis C (CHC).

METHODS

YKL-40 promoter polymorphisms were determined in 456 Hepatitis C Antiviral Long-term Treatment against Cirrhosis (HALT-C) Trial patients with bridging fibrosis or cirrhosis entering a prerandomization lead-in peginterferon/ribavirin 24-week treatment phase and in 462 patients followed for a mean of 3.8 years after randomization to maintenance peginterferon or observation.

RESULTS

Mean patient age was 49.5 years, 70.4% were men and 71.2% were Caucasian. The 17% frequency of the YKL-40 minor allele (T) was similar to that reported in the general population. YKL-40 genotype was associated significantly with baseline serum YKL-40 levels but was not associated with the likelihood of a virological response following 24-48 weeks of peginterferon/ribavirin therapy. Serum YKL-40 levels remained significantly lower during follow-up in the randomized TT homozygotes compared with CT heterozygotes and CC homozygotes (P < 0.001). Despite this association, YKL-40 genotype was not associated with the risk of clinical or histological liver disease progression.

CONCLUSIONS

A reduced frequency of the protective YKL-40 promoter polymorphism was not observed in the HALT-C Trial patient population. The absence of an association between YKL-40 promoter polymorphisms and baseline liver disease severity as well as with the risk of liver disease progression over time suggests that this polymorphism is not associated with disease progression in CHC patients with established fibrosis.