A novel echocardiographic risk score predicts prognosis in AL-amyloidosis

Background

Prognosis in light chain (AL) amyloidosis is largely determined by the severity of cardiac involvement. Conventional (Mayo) staging includes 1) hs troponin 2) N-terminal pro-beta natriuretic peptide (NT-pro BNP) and 3)free light chain difference.

Methods

In a retrospective study of 75 AL amyloidosis patients referred to a quaternary amyloid clinic, all patients underwent comprehensive echocardiographic assessment. Echocardiographic parameters included left ventricular (LV) ejection fraction, LV mass, diastolic function, global longitudinal strain (GLS) and indexed left atrial volume (LAVI). Mortality was assessed through review of clinical records.

Results

Over a median follow up of 51 months, 29/75 (39%) of patients died. LAVI, E/e', e', LVGLS, were univariate predictors of mortality (p<0.1). LAVI was the only independent echocardiographic predictor in a multivariable model. Kaplan Meir analysis evaluated LAVI, LVGLS and E/e' using clinical cutoffs as a predictor of survival; only LAVI and LVGLS were significant. A novel “Echo score” comprising of LAVI (>42 ml/m2) and LVGLS (<−12%) was a predictor of mortality with similar prognostic performance as Mayo stage. (Echo score AUC 0.745, 95% CI 0.64–0.85 vs Mayo score AUC 0.752 95% CI 0.66–0.86, p=0.9).

Conclusion

LAVI, a simple, echocardiographic parameter was as an independent predictor of mortality in AL amyloidosis. A composite echocardiographic score combining LAVI and LVGLS stratified AL-amyloidosis patients into 3 distinct groups with similar prognostic power as Mayo stage for all-cause mortality.

Funding Acknowledgement

Type of funding sources: None.

Outcomes of incoming and outgoing second opinions from a UK liver transplant centre

Objective

Second transplant centre opinions (STCOs) for patients declined for liver transplantation are infrequent. We aimed to identify STCOs outcomes from a tertiary transplant centre.

Design

Referrals between 2012 and 2020 to Birmingham Unit were reviewed. Incoming: all referrals from out-of-region centres were collated. Outgoing: patients not listed in Birmingham were reviewed to identify referrals for STCOs to the other UK centres (A–F).

Results

2535 patients were assessed for liver transplantation during the study period. Incoming: among 1751 referrals, 23 STCOs (17 unit A, 3 unit B, 1 unit C, 1 unit D and 1 unit E) were provided by Birmingham. Of the STCOs, 13/23 (57%) patients remained unsuitable for transplantation. Therefore, 10/23 (43%) underwent a second liver transplant assessment, of whom five (50%) were still deemed unsuitable, three (30%) listed (one transplanted) and two (20%) died preassessment. Outgoing: among 426 patients not listed, eight (1.8%) patients were referred for STCO (4 unit E, 2 unit B, 1 unit D, 1 unit A). Three (38%) were listed, two (25%) were assessed and declined, two (25%) were unsuitable for assessment and one (12.5%) died while waiting. Combining incoming and outgoing Birmingham STCOs (n=31), six (19%) of STCOs were listed in a second centre.

Conclusion

Second transplant centre opinions are rare with the majority still deemed unsuitable for liver transplantation. This highlights potential resource implications especially when undergoing a full second formal assessment. A streamlined STCO process with sharing of investigations and use of telemedicine in appropriate patients may allow for greater transparency, quicker decision making and less use of labour-intensive resources.

Van Allen Probes Observations of Symmetric Stormtime Compressional ULF Waves

Previous spacecraft studies showed that stormtime poloidal ultralow-frequency (ULF) waves in the ring current region have an antisymmetric (second harmonic) mode structure about the magnetic equator. This paper reports Van Allen Probes observations of symmetric ULF waves in the postnoon sector during a moderate geomagnetic storm. The mode structure is determined from the presence of purely compressional magnetic field oscillations at the equator accompanied by strong transverse electric field perturbations. Antisymmetric waves were also detected but only very late in the recovery phase. The symmetric waves were detected outside the plasmasphere at L = 3.0-5.5 and had peak power at 4-10 mHz, lower than the frequency of the local fundamental toroidal standing Alfvén wave. During the wave events, the flux of protons was enhanced at energies below ∼5 keV, which appears to be a prerequisite for the waves. The protons may provide free energies to waves through drift resonance instability or drift compressional instability, which occur in the presence of radial gradients of plasma parameters.

Differences in prevalence of hepatitis B virus infection and genotypes between ethnic populations in Suriname, South America

Epidemiological data on hepatitis B virus (HBV) are needed to benchmark HBV elimination goals. We recently assessed prevalence of HBV infection and determinants in participants attending the Emergency Department in Paramaribo, Suriname, South America. Overall, 24.5% (95%CI = 22.7-26.4%) of participants had anti-Hepatitis B core antibodies, which was associated with older age (per year, adjusted Odds Ratio [aOR] = 1.03, 95%CI = 1.02-1.04), Afro-Surinamese (aOR = 1.84, 95%CI = 1.52-2.19) and Javanese ethnicity (aOR = 1.63, 95%CI = 1.28-2.07, compared to the grand mean). 3.2% of participants were Hepatitis B surface Ag-positive, which was also associated with older age (per year, aOR = 1.02, 95%CI = 1.00-1.04), Javanese (aOR = 4.3, 95%CI = 2.66-6.95) and Afro-Surinamese ethnicity (aOR = 2.36, 95%CI = 1.51-3.71). Sex, nosocomial or culturally-related HBV transmission risk-factors were not associated with infection. Phylogenetic analysis revealed strong ethnic clustering: Indonesian subgenotype HBV/B3 among Javanese and African subgenotypes HBV/A1, HBV/QS-A3 and HBV/E among Afro-Surinamese. Testing for HBV during adulthood should be considered for individuals living in Suriname, specifically with Javanese and Afro-Surinamese ancestry.

Basiliximab With Delayed Tacrolimus Improves Short-Term Renal Outcomes Post-Liver Transplantation-a Real-World Experience

BACKGROUND

Acute kidney injury (AKI) is common after liver transplantation (LT). Induction with interleukin-2 receptor antagonists is often used as a "renal-sparing" strategy. The aim of this study was to assess this approach in a real-world setting in an LT center.

METHODS

A retrospective cohort analysis of LTs between 2011 and 2018 was performed to assess the impact of a renal-sparing strategy using basiliximab in conjunction with mycophenolate mofetil and corticosteroids from day 0 post-LT along with delayed introduction of tacrolimus. This was compared with a group receiving tacrolimus, mycophenolate mofetil, and corticosteroids from the outset.

RESULTS

The renal-sparing regimen was associated with significantly lower incidence of all-stage AKI at day 7 post-LT (36% vs 55%, P = .006) and less decline in renal function at 3 months (39% vs 57%, P = .01). No further significant differences in renal outcomes were observed at other time points on follow-up to 1 year post-LT. There was no significant difference in the incidence of acute cellular rejection, inpatient length of stay or graft survival. The decision to adopt a renal-sparing regimen was predominantly made on a clinically reactive basis within the first 24 hours post-LT in 77%, and was preordained in 23%. Cost-effectiveness analysis did not find evidence of a significant cost saving when using a renal-sparing strategy.

CONCLUSION

This study provides real-world analysis of the use of a renal-sparing immunosuppression regimen in LT. Although improvements in incidence of AKI in the short term were demonstrated, this did not translate to cost savings or improved renal outcomes after 3 months.

Liver Transplantation for Acute Intermittent Porphyria

Recurrent attacks of acute intermittent porphyria (AIP) result in poor quality of life and significant risks of morbidity and mortality. Liver transplantation (LT) offers a cure, but published data on outcomes after LT are limited. We assessed the pretransplant characteristics, complications, and outcomes for patients with AIP who received a transplant. Data were collected retrospectively from the European Liver Transplant Registry and from questionnaires sent to identified transplant and porphyria centers. We studied 38 patients who received transplants in 12 countries from 2002 to 2019. Median age at LT was 37 years (range, 18-58), and 34 (89%) of the patients were women. A total of 9 patients died during follow-up, and 2 patients were retransplanted. The 1-year and 5-year overall survival rates were 92% and 82%, which are comparable with other metabolic diseases transplanted during the same period. Advanced pretransplant neurological impairment was associated with increased mortality. The 5-year survival rate was 94% among 19 patients with moderate or no neuropathy at LT and 83% among 10 patients with severe neuropathy (P = 0.04). Pretransplant renal impairment was common. A total of 19 (51%) patients had a GFR < 60 mL/minute. Although few patients improved their renal function after LT, neurological impairments improved, and no worsening of neurological symptoms was recorded. No patient had AIP attacks after LT, except for a patient who received an auxiliary graft. LT is a curative treatment option for patients with recurrent attacks of AIP. Severe neuropathy and impaired renal function are common and increase the risk for poor outcomes. If other treatment options fail, an evaluation for LT should be performed early.

Qualitative analysis of domestic violence detection and response in a tertiary hospital

INTRODUCTION Domestic and family violence is a public health problem of epidemic proportions and a significant issue facing the Australian community. It knows no boundaries, is indiscriminate to geographical location, social class, age, religious or cultural background. AIM This study aimed to analyse the processes currently used to identify and respond to domestic and family violence in a large tertiary hospital in Australia, and to classify the benefits and weaknesses of these existing systems. METHODS A qualitative method used semistructured, face-to-face and telephone interviews with key informants in 16 key areas across the hospital. Thematic analysis of the interviews was used to define the key issues and areas of interest identified by participants. RESULTS There was a dearth of existing guidelines or pathways of care for patients experiencing domestic violence. Several strengths and weaknesses were identified in relation to the protocols and systems used by the hospital, including limited training for staff and a lack of standardisation of processes, workplace instructions and clinical guidelines. With the exception of maternity services, no clinical service area used a guideline or work instruction. Most interviewees highlighted the need for the safety and protection of staff and victims as a priority. DISCUSSION Domestic and family violence is an enormous burden on the health system. However, many staff have little or no guidance on dealing with it or are unaware of existing protocols or guidelines for detection or response. Participants recommended further education and training for staff, consistent guidelines, specialist liaison and more educational and information resources for staff and patients. Further investigation and discussions with patients affected by violence is warranted to provide robust recommendations for policy change.

Changes in mental health and drug use among men who have sex with men using daily and event-driven pre-exposure prophylaxis: Results from a prospective demonstration project in Amsterdam, the Netherlands

BACKGROUND

Gay, bisexual and other men who have sex with men (GBMSM) are at increased risk of mental health disorders and drug use. In GBMSM taking pre-exposure prophylaxis (PrEP) for HIV, the proportion engaging in risk behaviors could increase due to decreased perception in HIV risk. In turn, this could leave them further susceptible to mental health disorders.

METHODS

The AMsterdam PrEP study (AMPrEP) is a demonstration project offering a choice of daily PrEP or event-driven PrEP regimen at the STI clinic of the Public Health Service of Amsterdam. Eligible participants were HIV-negative GBMSM and transgender people at risk of HIV, aged ≥18 years. We assessed anxiety and depressive mood disorders (Mental Health Inventory 5), sexual compulsivity (Sexual Compulsivity Scale), alcohol use disorder (Alcohol Use Disorder Identification Test), and drug use disorder (Drug Use Disorder Identification Test) using yearly self-administered assessments (August 2015-September 2018). The proportion of mental health problems were analyzed and changes over time and between regimen were assessed using a logistic regression model. Variables associated with the development or recovery of disorders were assessed using a multistate Markov model.

OUTCOMES

Of 376 enrolled, we analyzed 341 participants with data at baseline and at least one follow-up visit. During a median follow-up of 2.5 years (IQR=2.3-2.7), the proportion assessed with sexual compulsivity decreased from 23% at baseline to 10% at the last visit (p<0.001) and drug use disorder decreased from 38% at baseline to 31% at the last visit (p = 0.004). No changes occurred in proportion assessed with anxiety/depressive mood disorders (20% at baseline, 18% at last visit, p = 0.358) or alcohol use disorder (28% at baseline, 22% at the last visit, p = 0.106). During follow-up, participants reported significant less use of alcohol (p<0.001), nitrites (p<0.001) and ecstasy (p<0.001). We found no differences between daily and event-driven PrEP users. The development and recovery of disorders during follow-up were highly interrelated.

INTERPRETATION

Mental health disorders are prevalent among those initiating PrEP. We did not find increases in mental health disorders during PrEP use, but rather a decrease in sexual compulsivity and drug use disorders. The initial prevalence of mental health disorders in our study point at the continuous need to address mental health disorders within PrEP programs.

FUNDING

ZonMw, H-TEAM, Internal GGD research funds, Aidsfonds, Stichting AmsterdamDiner Foundation, Gilead Sciences, Janssen Pharmaceutica, M A C AIDS Fund, and ViiV Healthcare.

Nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) among undocumented migrants and uninsured legal residents in Amsterdam, the Netherlands: a cross-sectional study

BACKGROUND

Nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) is associated with an increased risk of infection. Colonization with MRSA is observed in < 1% of the general Dutch population. Increased risk for MRSA carriage is known to occur in several key groups, one of which is asylum seekers. However, little is known about MRSA carriage among undocumented migrants and uninsured legal residents. This study aimed to determine the prevalence of nasal MRSA carriage among these groups in Amsterdam, the Netherlands.

METHODS

In this cross-sectional study, between October 2018 and October 2019, undocumented migrants and uninsured legal residents aged 18 years or older who were able to understand one of the study languages were recruited at an NGO health care facility in Amsterdam, the Netherlands, for general practitioner (GP) consultations. Participants were asked questions on demographics, migration history, antibiotic use and other possible risk factors for MRSA carriage and were screened for nasal MRSA carriage by selective culturing e-swabs. Characteristics of MRSA-negative and MRSA-positive participants were compared using univariable logistic regression analysis with Firth's correction.

RESULTS

Of the 3822 eligible patients, 760 were screened for nasal MRSA carriage (19.9%). Of the 760 participants, over half were male (58%; 442/760) and originated mainly from Africa (35%; 267/760), Asia (30%; 229/760) and North or South America (30%; 227/760). In total, 705/760 participants (93%) were undocumented migrants and 55/760 (7%) were uninsured legal residents of Amsterdam. The overall prevalence of nasal MRSA carriage was 2.0% (15/760) (95%CI 1.1 to 3.2%), with no difference between undocumented migrants (14/705) (2.0, 95%CI 1.1 to 3.3%) and uninsured legal residents (1/55) (1.8, 95%CI 0.1 to 9.7%). Genotyping showed no clustering of the 15 isolates. MRSA carriage was not associated with sociodemographic, migration history or other possible risk factors. Nevertheless, this study had limited power to detect significant determinants. Three participants (3/15; 20%) harbored Panton-Valentine leukocidin (PVL)-positive isolates.

CONCLUSION

Even though our study population of undocumented migrants and uninsured legal residents had a higher prevalence of nasal MRSA carriage compared to the general Dutch population, the prevalence was relatively low compared to acknowledged other high-risk groups.

P309 The use of echocardiographic parameters to predict clinical outcomes in AL-amyloidosis cardiomyopathy

Background

AL-amyloidosis has a rapid clinical progression, with cardiac involvement associated with a particularly poor prognosis. Cardiac amyloidosis is diagnosed by either invasive biopsy or conventional echocardiographic parameters such as increased wall thickness, in the absence of other causes. More recently, novel parameters including 2D longitudinal strain have demonstrated diagnostic utility in a range of infiltrative cardiomyopathies including cardiac amyloidosis.

Aim/Method: We sought to evaluate traditional and novel echocardiographic parameters in their ability to predict adverse outcomes in a cohort of AL-amyloid patients. 80 patients who had transthoracic echocardiograms at a single centre were included. Comprehensive echocardiographic assessment was performed, including left ventricular ejection fraction (LVEF), LV Global Longitudinal Strain (GLS), LV mass (indexed to BSA). The primary endpoint was a composite of of major adverse cardiac events (MACE) and all-cause mortality, that was assessed by interrogation of the medical records on a specified censor date.

Results

At a mean follow-up (time from echo to censor date) of 5.4 ± 2.6years, 38/80 (47.5%) of patients experienced the primary endpoint of MACE or death, of which 25/80 (31%) were deaths. LVEF (59 ± 5.6%vs56 ± 6.4%, p = 0.04), GLS (17.4 ± 3.9%vs14.8 ± 4.9%, p = 0.01) basal longitudinal strain (12.3 ± 3.2%vs9.6 ± 3.9%, p = 0.002), indexed LV mass (107 ± 36g/m2vs130 ± 34g/m2, p = 0.06) and E/E’ (13.7 ± 4.9vs20.6 ± 9.6, p &lt; 0.001) were all significantly different between patients who experienced the primary endpoint and those that didn’t. The strongest predictors of outcome were E/E’ (AUC 0.74), LV mass (AUC 0.73) and the ratio GLS:LV mass (AUC 0.73). An E/E’ of 15 had a sensitivity of 71% and specificity of 69%, while an indexed LV mass of 108 had a sensitivity and specificity of 74% and 67% respectively. GLS to LV mass as a cutoff of 0.16 had a sensitivity and specificity of 70% and 69% respectively.

Conclusion

In a cohort of 80 patients with AL-amyloid cardiomyopathy, almost half (47.5%) reached the primary composite endpoint. Diastolic dysfunction as expressed as E/E’, and LV mass were the most powerful predictors of outcome, while global longitudinal strain and LV basal strain were also reduced, and showed superiority over LV ejection fraction in predicting prognosis.

P1543 The assessment of regional myocardial strain in classifying amyloid cardiomyopathy

Background

An infiltrative cardiomyopathy is a common manifestation of AL-amyloidosis, with cardiac involvement associated with a poor prognosis. Wild-type transthyretin amyloidosis (wt-TTR), is a distinct clinical entity occurring predominantly in men &gt; 65 yrs, that has gained interest recently due to novel treatment options. Regional strain analysis has been shown to discriminate both forms of cardiac amyloidosis from other causes of concentric left ventricular hypertrophy, with a characteristic pattern of ‘apical sparing’. Due to the significant difference in both the course of the disease and treatment options between groups, a non-invasive echocardiographic method of determining subtype would be valuable.

Aim/Method: We sought to compare traditional and novel echocardiographic parameters in a cohort of AL ( n = 80) and wild type (wt-TTR) amyloid ( n = 32) patients. All amyloid patients underwent comprehensive transthoracic echocardiography, including both conventional parameters and LV longitudinal strain. Further novel parameters were computed including the ratio of global longitudinal strain (GLS) to LV ejection fraction (LVEF), as well as GLS to indexed LV mass.

Results

wt-TTR patients had significantly greater LV mass (176 ± 59g/m2vs118 ± 37g/m2, p &lt; 0.001), and worse diastolic dysfunction as expressed as E/E’ (21.5 ± 11vs17 ± 8, p = 0.04). LVEF was significantly lower in wt-TTR patients however remained in the normal range in both groups (53 ± 6%vs57 ± 6%, p = 0.001), whilst GLS was significantly reduced compared to AL-amyloid patients (11.5 ± 3.4%vs16.2 ± 4.6%, p &lt; 0.001). LVEF:GLS was significantly higher in wt-TTR patients (4.93 ± 1.4vs3.87 ± 1.3, p = 0.001) reflecting a more profound reduction in strain with a relatively preserved ejection fraction. Similarly, the ratio of GLS to LV mass was significantly lower in wt-TTR amyloidosis (0.078 ± 0.05vs0.155 ± 0.07, p &lt; 0.001), reflecting a more significant reduction in strain for a given wall thickness in wt-TTR patients. GLS:LV mass was the strongest discriminator between subtypes (AUC 0.82), with a cutoff of 0.09 giving a sensitivity and specificity of 71% and 80% respectively, for detecting wt-TTR.

Conclusion

In this cohort, patients with wt-TTR had significantly greater increase in LV wall thickness and diastolic dysfunction, which may in part reflect their increased age (77vs62). However, GLS was also significantly reduced compared to AL-amyloid, even when accounting for LV ejection fraction and LV mass, suggesting these composite parameters may have value in determining the subtype of cardiac amyloidosis.

Sex, drugs, and sexually transmitted infections: A latent class analysis among men who have sex with men in Amsterdam and surrounding urban regions, the Netherlands

BACKGROUND

Men who have sex with men (MSM) are at high risk for sexually transmitted infections (STI) and often have sex while under the influence of drugs (sexualized drug use). We aimed to identify classes of MSM in Amsterdam and in surrounding urban regions with distinctive patterns of sexualized drug use and their association with STI.

METHODS

In this cross-sectional study, data on MSM were collected at STI clinics in the Netherlands between September-December 2017. Information on drug use, sociodemographics and sexual risk behavior, including lab-confirmed STI (chlamydia, gonorrhea, syphilis and HIV) was collected and compared between Amsterdam and surrounding urban regions. Latent class analysis was used to identify classes with similar drug use patterns, which were then linked to sexual behavior and STI.

RESULTS

We included 4461 MSM who were a median 35 years old (IQR = 27-47) and mostly Dutch (56.9 %). Use of all drugs was more often reported in Amsterdam compared to surrounding regions (p<0.001). We identified four different classes based on sexualized drug use among Amsterdam participants and three classes in surrounding regions. In both regions, polydrug use classes (compared to classes of no drug use; alcohol use; or few, various drugs) were defined by higher numbers of sexual partners (median range 8-15 vs 4-6, respectively) and higher STI prevalence (range 30.5%-31.8% vs 18.6%-22.8%, respectively).

CONCLUSION

Given the high prevalence of risk behavior and STIs, MSM in urban settings partaking in sexualized polydrug use might benefit from tailored outreach, screening, and safe sex and drug use interventions.

The role of stem cells in liver injury and repair

Introduction: Liver disease is an increasing cause of worldwide mortality, and currently the only curative treatment for end-stage liver disease is whole organ allograft transplantation. Whilst this is an effective treatment, there is a shortage of suitable grafts and consequently some patients die whilst on the waiting list. Cell therapy provides an alternative treatment to increase liver function and potentially ameliorate fibrosis. Areas covered: In this review, we discuss the different cellular sources for therapy investigated to date in humans including mature hepatocytes, hematopoietic stem cells, mesenchymal stromal cells and hepatic progenitor cells. Cells investigated in animals include embryonic stem cells, induced pluripotent stem cells and directly reprogrammed cells. We then appraise the experience and evidence base underlying each cell type. Expert opinion: We discuss how this field may evolve in the years to come focusing on opportunities to enhance the intrinsic regenerative response with therapeutic targets and cell therapies. Growing expertise in tissue engineering will likely lead to increasingly complex bio-reactors and bio-artificial livers, which open a further avenue to restore liver function and delay or prevent the need for transplantation.

Diffuse Auroral Electron and Ion Precipitation Effects on RCM-E Comparisons With Satellite Data During the 17 March 2013 Storm

Effects of scattering of electrons from whistler chorus waves and of ions due to field line curvature on diffuse precipitating particle fluxes and ionospheric conductance during the large 17 March 2013 storm are examined using the self-consistent Rice Convection Model Equilibrium (RCM-E) model. Electrons are found to dominate the diffuse precipitating particle integrated energy flux, with large fluxes from ~21:00 magnetic local time (MLT) eastward to ~11:00 MLT during the storm main phase. Simulated proton and oxygen ion precipitation due to field line curvature scattering is sporadic and localized, occurring where model magnetic field lines are significantly stretched on the night side at equatorial geocentric radial distances r 0 ≳8 R E and/or at r 0 ~5.5 to 6.5 R E from dusk to midnight where the partial ring current field has perturbed the magnetic field. The precipitating protons likewise contribute sporadically to the storm time Hall and Pedersen conductance in localized regions whereas the precipitating electrons are the dominate storm time contributor to enhanced Hall and Pedersen conductance at auroral magnetic latitudes on the night and morning side. The RCM-E model can reproduce general features of the Van Allen Probe/MagEIS observed trapped electron differential flux spectrograms over energies of ~37 to 150 keV. The simulations with a parameterized electron loss model also reproduce reasonably well the storm time Defense Meteorological Satellite Program integrated electron energy flux at 850 km at satellite crossings from predawn to midmorning. However, model-data agreement is not as good from dusk to premidnight where there are large uncertainties in the electron loss model.

Clinical and echocardiographic characteristics of cardioembolic stroke

BACKGROUND AND PURPOSE

Ischaemic stroke frequently has a cardioembolic (CE) source. Clinical and echocardiographic parameters associated with CE stroke were evaluated.

METHODS

In all, 93 consecutive ischaemic stroke patients who underwent a transthoracic echocardiogram were retrospectively analysed; strokes were classified by TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Echocardiographic parameters related to CE stroke, including left atrial volumes and function, were compared to 73 healthy controls.

RESULTS

Of 93 patients (mean age 66.1 years, 56% male), nine (10%) had large artery atherosclerosis, 38 (41%) CE stroke, two (2%) small vessel disease, two (2%) other and 42 (45%) undetermined aetiology. Left atrial (LA) maximum volumes (LAVI_max ) and minimum volumes (LAVI_min ) were larger in the CE group than the non-CE group (45 vs. 32 ml/m² , 32 vs. 13 ml/m² , respectively, P < 0.001), whilst LA function indices including LA emptying fraction and LA function index (LAFI) were lower in the CE group (34% vs. 55%, and 0.12 vs. 0.35, respectively, P < 0.001). Adjusting for clinical characteristics, LAFI ≤0.3 was an independent predictor of CE stroke (adjusted odds ratio 5.3, P = 0.001). Additionally, LAVI_max and LAVI_min were larger (61 vs. 44 and 32 vs. 24 ml/m² respectively, P < 0.01) and LAFI significantly lower (0.34 vs. 0.52, P < 0.001) in the undetermined aetiology group versus healthy controls.

CONCLUSIONS

Left atrial enlargement with reduced LA function was associated with CE stroke and LAFI was the best independent predictor. LA parameters were also altered in the undetermined aetiology group, suggesting an underlying LA myopathy in this subset.

Medical liver biopsy: background, indications, procedure and histopathology

Histological analysis of liver tissue continues to play an important role in modern hepatological practice. This review explores the indications for medical liver biopsy in addition to the procedure itself, potential complications, preparation of tissue and routine staining. A broad selection of histological images is included to illustrate the appearance of liver tissue both in health and in several important diseases.

Precore G1896A mutation is associated with reduced rates of HBsAg seroclearance in treated HIV hepatitis B virus co-infected patients from Western Africa

The nucleotide substitution G1896A on the precore (pc) region has been implicated in virological and serological responses during treatment in hepatitis B virus (HBV)-infected patients. Whether this mutation affects the therapeutic course of HIV-HBV co-infected patients, especially from Western Africa, is unknown. In this prospective cohort study, 86 antiretroviral (ARV)-naïve HIV-HBV co-infected patients from Côte d'Ivoire, initiating ARV-treatment containing lamivudine (n = 53) or tenofovir (n = 33), had available baseline pc sequences. Association of the pcG1896A mutation with time to undetectable HBV-DNA, hepatitis B "e" antigen (HBeAg) seroclearance (in HBeAg-positive patients), and hepatitis B surface antigen (HBsAg) seroclearance was evaluated using Cox proportional hazards regression. At ARV-initiation, median HBV-DNA was 6.04 log₁₀ copies/mL (IQR = 3.70-7.93) with 97.7% harbouring HBV genotype E. Baseline pcG1896A mutation was identified in 51 (59.3%) patients, who were more commonly HBeAg-negative (P < .001) and had basal core promotor A1762T/G1764A mutations (P < .001). Patients were followed for a median 36 months (IQR = 24-36). Cumulative proportion of undetectable HBV-DNA was significantly higher in patients with baseline mutation (pcG1896A = 86.6% vs no pcG1896A = 66.9%, P = .04), but not after adjusting for baseline HBV-DNA levels and anti-HBV agent (P = .2). No difference in cumulative proportion of HBeAg seroclearance was observed between mutation groups (pcG1896A = 57.1% vs no pcG1896A = 54.3%, P = .7). Significantly higher cumulative proportion of HBsAg seroclearance was observed in patients without this mutation (pcG1896A = 0% vs no pcG1896A = 36.9%, P < .001), even after adjusting for baseline HBsAg quantification and anti-HBV agent (P < .001). In conclusion, lacking the pcG1896A mutation before ARV initiation appeared to increase HBsAg seroclearance rates during treatment. The therapeutic implications of this mutation need further exploration in this setting.

HIV-positive men who have sex with men are at high risk of development of significant liver fibrosis after an episode of acute hepatitis C

Acute hepatitis C virus infection remains a major health concern in human immunodeficiency virus(HIV)-infected men who have sex with men (MSM). New direct-acting antiviral agent (DAA) combination therapy has not yet been approved for the treatment for acute hepatitis C virus(HCV), thereby potentially causing deferral of HCV treatment. Therefore, we aimed to study the course of liver disease after an episode of acute HCV. This study is a retrospective single-centre cohort of HIV-positive MSM with acute HCV infection. Liver fibrosis was estimated by Fibroscan^® and Fibrotest^® . Liver-related and non-liver-related outcomes were documented. Overall 213 episodes of acute HCV infection in 178 men were documented. Median follow-up for all included patients was 38.7 months. Spontaneous HCV clearance was found in 10.8% of patients, which was significantly associated with older age, lower HCV RNA levels, and higher ALT levels upon initial acute HCV diagnosis. Treatment with interferon-based therapy was initiated in 86.3% of cases, resulting in a sustained virological response(SVR) rate of 70.7%. After 3 years' follow-up, significant liver fibrosis of METAVIR F2 stage or higher was found in 39.4% of patients after first acute HCV diagnosis. Higher age, physician-declared alcoholism, and nonresponse to acute HCV therapy were independently associated with higher fibrosis stages. Ten patients died during the observation period (IR 1.4/100 patient-years) and four during interferon treatment. Significant liver fibrosis is a common finding in HIV-positive MSM following acute HCV infection despite high treatment uptake and cure rates, suggesting the need for close liver disease monitoring particularly if HCV treatment is deferred.

Clinical and microbiological determinants of severe and fatal outcomes in patients infected with Enterobacteriaceae producing extended-spectrum β-lactamase

Although extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae have become a worldwide public health concern, little is known regarding the clinical course of colonized or infected individuals. Our objective was to characterize the determinants of fatal outcomes related to ESBL-producing microorganisms at a large hospital in Paris, France. In 2012-2013, all consecutive patients with clinical samples testing positive for ESBL-producing Enterobacteriaceae at Saint-Antoine Hospital were identified. Patient clinical data were obtained at hospital entry, while information on intensive care unit (ICU) admissions and death were prospectively collected. Risk-factors for fatal 1-year outcomes were assessed using logistic regression. In total, 643/4684 (13%) ESBL-positive samples were observed, corresponding to 516 episodes (n = 206, 40% treated) among 330 patients. Most episodes were nosocomial-related (n = 347/516, 67%) involving Escherichia coli (n = 232/516, 45%) or Klebsiella pneumoniae (n = 164/516, 32%). Empirical antibiotic therapy was adequate in 89/206 (43%) infections, while the median length of hospital stay was 30 days [interquartile range (IQR) = 11-55] and 39/201 (19%) were admitted to the ICU. Overall, 104/241 patients (43%) with available data died within 1 year. In the multivariable analysis, 1-year death was associated with age >80 years (p = 0.01), concomitant comorbidity (p = 0.001), nosocomial-acquired infection (p = 0.002), and being infected rather than colonized (p < 0.001). In this series of patients with identified samples of ESBL-producing Enterobacteriaceae, hospital burden was large and 1-year mortality rates high. Understanding which patients in this setting would benefit from broad-spectrum empirical antibiotic therapy should be further examined.

Abdominal adhesions: A practical review of an often overlooked entity

Formation of intra-abdominal adhesions is a common consequence of abdomino-pelvic surgery, radiation therapy, and inflammatory processes. In a small but clinically significant proportion of patients, adhesive disease may develop, wherein adhesions lead to a variety of chronic symptoms such as abdominal distension, pain, nausea, and abnormal bowel movement pattern which can be daily, intermittent, or episodic. Due to the chronic and troublesome nature of these symptoms, adhesive disease may be life-altering in many patients, particularly when not recognized and appropriately addressed, as is the case not infrequently. In addition, there is a paucity of literature regarding the evaluation and management of patients with suspected abdominal adhesive disease. Therefore, in this concise review, we provide a clinically practical synopsis of the etiopathogenesis, symptoms, differential diagnosis, evaluation, and treatment of abdominal adhesive disease.

Intensification with pegylated interferon during treatment with tenofovir in HIV-hepatitis B virus co-infected patients

In hepatitis B "e" antigen (HBeAg) positive patients with hepatitis B virus (HBV) mono-infection, intensification of nucleos(t)ide analogue treatment with pegylated interferon (PegIFN) could help induce higher HBeAg seroclearance rates. Our aim was to determine the long-term effect of adding PegIFN to tenofovir (TDF)-containing antiretroviral therapy on seroclearance in HBeAg-positive patients co-infected with the human immunodeficiency virus (HIV) and HBV. In this prospective matched cohort study, 46 patients with 1-year PegIFN intensification during TDF-containing antiretroviral therapy (TDF+PegIFN) were matched 1:1 to controls undergoing TDF without PegIFN (TDF) using a time-dependent propensity score based on age, CD4+ count and liver cirrhosis status. Kinetics of HBeAg quantification (qHBeAg) and hepatitis B surface antigen quantification (qHBsAg) were estimated using mixed-effect linear regression and time to HBeAg seroclearance or HBsAg seroclearance was modelled using proportional hazards regression. At baseline, previous TDF exposure was a median 39.8 months (IQR=21.4-59.4) and median qHBeAg and qHBsAg levels were 6.9 PEIU/mL and 3.72 log₁₀ IU/mL, respectively (P>.5 between groups). Median follow-up was 33.4 months (IQR=19.0-36.3). During intensification, faster average declines of qHBeAg (-0.066 vs -0.027 PEIU/mL/month, P=.001) and qHBsAg (-0.049 vs -0.026 log₁₀ IU/mL/month, P=.09) were observed in patients undergoing TDF+PegIFN vs TDF, respectively. After intensification, qHBeAg and qHBsAg decline was no different between groups (P=.7 and P=.9, respectively). Overall, no differences were observed in HBeAg seroclearance (TDF+PegIFN=13.2 vs TDF=12.6/100 person·years, P=.5) or HBsAg seroclearance rates (TDF+PegIFN=1.8 vs TDF=1.3/100 person·years, P=.7). In conclusion, PegIFN intensification in HBeAg-positive co-infected patients did not lead to increased rates of HBeAg or HBsAg clearance, despite faster declines of antigen levels while on PegIFN.