Hepatogenous Diabetes as Compared to Type-2 Diabetes Mellitus and Non-diabetes in Patients With Liver Cirrhosis: Magnitude, Characteristics, and Implications

Aim

Hepatogenous diabetes (HD) is frequently underestimated among cirrhosis patients. The current study assessed the magnitude, clinical characteristics, and implications of HD in cirrhosis patients as compared to the patients with type-2 diabetes mellitus (T2DM) and non-diabetes (ND) cirrhosis.

Methods

In a prospective observational study, 338 consecutive eligible cirrhosis patients were screened for diabetes mellitus. A 2-hour oral glucose tolerance test (OGTT) was used to detect HD. The clinical characteristics, complications, and outcomes were ascertained and compared amongst HD, T2DM, and ND patients.

Results

In the final study cohort of 316 patients, the proportion of HD, T2DM, and ND was 22.5% (n = 71), 26.3% (n = 83), and 51.3% (n = 162), respectively. HD was the predominant form of diabetes (68.9%) in Child-Pugh class-C cirrhosis. The majority (73%) of HD patients had abnormal OGTT without fasting hyperglycaemia. A lower cut-off of 98.5 mg/dl for fasting blood glucose had a modest sensitivity (72%) and specificity (75%) for predicting HD. In comparison to T2DM patients, HD patients were younger, leaner, and had more advanced cirrhosis. In comparison to ND patients, HD patients were leaner but had higher glycemic indices, serum cholesterol, and arterial ammonia levels. During a median follow-up period of 12 (03-21) months, the frequency of hepatic encephalopathy and variceal haemorrhage were higher in HD and T2DM patients compared to that in the ND group.

Conclusions

HD is prevalent in about one fifth of cirrhosis patients. It differs from T2DM and ND in a number of ways, and has association with complications of cirrhosis.

Amebic liver abscess: An update

Amebic liver abscess (ALA) is still a common problem in the tropical world, where it affects over three-quarters of patients with liver abscess. It is caused by an anaerobic protozoan Entamoeba hystolytica, which primarily colonises the cecum. It is a non-suppurative infection of the liver consisting primarily of dead hepatocytes and cellular debris. People of the male gender, during their reproductive years, are most prone to ALA, and this appears to be due to a poorly mounted immune response linked to serum testosterone levels. ALA is more common in the right lobe of the liver, is strongly associated with alcohol consumption, and can heal without the need for drainage. While majority of ALA patients have an uncomplicated course, a number of complications have been described, including rupture into abdomino-thoracic structures, biliary fistula, vascular thrombosis, bilio-vascular compression, and secondary bacterial infection. Based on clinico-radiological findings, a classification system for ALA has emerged recently, which can assist clinicians in making treatment decisions. Recent research has revealed the role of venous thrombosis-related ischemia in the severity of ALA. Recent years have seen the development and refinement of newer molecular diagnostic techniques that can greatly aid in overcoming the diagnostic challenge in endemic area where serology-based tests have limited accuracy. Metronidazole has been the drug of choice for ALA patients for many years. However, concerns over the resistance and adverse effects necessitate the creation of new, safe, and potent antiamebic medications. Although the indication of the drainage of uncomplicated ALA has become more clear, high-quality randomised trials are still necessary for robust conclusions. Percutaneous drainage appears to be a viable option for patients with ruptured ALA and diffuse peritonitis, for whom surgery represents a significant risk of mortality. With regard to all of the aforementioned issues, this article intends to present an updated review of ALA.

Prevalence and risk factors of lymphatic dysfunction in cirrhosis patients with refractory ascites: An often unconsidered mechanism

BACKGROUND

The lymphatic system is crucial in maintaining the body fluid homeostasis. A dysfunctional lymphatic system may contribute to the refractoriness of ascites and edema in cirrhosis patients. Therefore, assessment of lymphatic dysfunction in cirrhosis patients with refractory ascites (RA) can be crucial as it would call for using different strategies for fluid mobilization.

AIM

To assessing the magnitude, spectrum, and clinical associations of lymphatic dysfunction in liver cirrhosis patients with RA.

METHODS

This observational study included 155 consecutive cirrhosis patients with RA. The presence of clinical signs of lymphedema, such as peau d'orange appearance and positive Stemmer sign, intestinal lymphangiectasia (IL) on duodenal biopsy seen as dilated vessels in the lamina propria with strong D2-40 immunohistochemistry, and chylous ascites were used to diagnose the overt lymphatic dysfunctions.

RESULTS

A total of 69 (44.5%) patients out of 155 had evidence of lymphatic dysfunction. Peripheral lymphedema, found in 52 (33.5%) patients, was the most common manifestation, followed by IL in 42 (27.0%) patients, and chylous ascites in 2 (1.9%) patients. Compared to patients without lymphedema, those with lymphedema had higher mean age, median model for end-stage liver disease scores, mean body mass index, mean ascitic fluid triglyceride levels, and proportion of patients with hypoproteinemia (serum total protein < 5 g/dL) and lymphocytopenia (< 15% of total leukocyte count). Patients with IL also had a higher prevalence of lymphocytopenia and hypoproteinemia (28.6% vs. 9.1%, P = 0.004). Seven (13%) patients with lymphedema had lower limb cellulitis compared to none in those without it. On multivariate regression analysis, factors independently associated with lymphatic dysfunction included obesity [odds ratio (OR): 4.2, 95% confidence intervals (95%CI): 1.1-15.2, P = 0.027], lymphocytopenia [OR: 6.2, 95%CI: 2.9-13.2, P < 0.001], and hypoproteinemia [OR: 3.7, 95%CI: 1.5-8.82, P = 0.003].

CONCLUSION

Lymphatic dysfunction is common in cirrhosis patients with RA. Significant indicators of its presence include hypoproteinemia and lymphocytopenia, which are likely due to the loss of lymphatic fluid from the circulation. Future efforts to mobilize fluid in these patients should focus on methods to improve lymphatic drainage.

Gastric Xanthoma: A Rare Case Report

Xanthomas are characterized by the presence of foamy lipid-laden macrophages. The gastrointestinal tract is an uncommon site for xanthoma, with the stomach being the most favored location. They have been associated with various premalignant and malignant conditions of the stomach. We present a case of a 21-year-old female patient with dyspepsia of 4 months duration. Her lipid profile was mildly altered. On upper gastrointestinal endoscopy, multiple discrete yellow patches were found in the antrum, diagnosed as gastric xanthoma on microscopy. Various published literature has emphasized the frequent association of gastric xanthomas with gastritis, gastric atrophy, intestinal metaplasia, and gastric cancer. Hence, there is a necessity for early recognition, treatment of any coexistent pathology, and close clinical follow-up.

Hepatogenous diabetes: Knowledge, evidence, and skepticism

The diabetogenic potential of liver cirrhosis (LC) has been known for a long time, and the name "hepatogenous diabetes" (HD) was coined in 1906 to define the condition. Diabetes mellitus (DM) that develops as a consequence of LC is referred to as HD. In patients with LC, the prevalence rates of HD have been reported to vary from 21% to 57%. The pathophysiological basis of HD seems to involve insulin resistance (IR) and pancreatic β-cell dysfunction. The neurohormonal changes, endotoxemia, and chronic inflammation of LC initially create IR; however, the toxic effects eventually lead to β-cell dysfunction, which marks the transition from impaired glucose tolerance to HD. In addition, a number of factors, including sarcopenia, sarcopenic obesity, gut dysbiosis, and hyperammonemia, have recently been linked to impaired glucose metabolism in LC. DM is associated with complications and poor outcomes in patients with LC, although the individual impact of each type 2 DM and HD is unknown due to a lack of categorization of diabetes in most published research. In fact, there is much skepticism within scientific organizations over the recognition of HD as a separate disease and a consequence of LC. Currently, T2DM and HD are being treated in a similar manner although no standardized guidelines are available. The different pathophysiological basis of HD may have an impact on treatment options. This review article discusses the existence of HD as a distinct entity with high prevalence rates, a strong pathophysiological basis, clinical and therapeutic implications, as well as widespread skepticism and knowledge gaps.

Large Hepatic Subcapsular Hematoma Following Endoscopic Retrograde Cholangiopancreatography: A Case Report

For decades, endoscopic retrograde cholangiopancreatography (ERCP) has been the cornerstone in the treatment of several biliopancreatic diseases. Although it is a relatively safe procedure, there are certain hazards involved. Hepatic subcapsular hematoma (HSH) is an uncommon complication of ERCP, with only a few cases reported in the literature to date. We present here a case of large HSH that developed 48 hours after an otherwise uneventful ERCP for choledocholithiasis. After being apparently well for the first two days post-ERCP, the patient began to develop abdominal pain and restlessness associated with hemodynamic instability and a decline in hemoglobin levels. Computed tomography (CT) confirmed the presence of a large HSH. The patient was managed nonsurgically with vascular angioembolization followed by ultrasound-guided percutaneous catheter drainage of hematoma. This case highlights the necessity of increasing awareness about this complication in order to aid in early diagnosis and management.

Wearable Thermoelectric Devices Based on Three-Dimensional PEDOT:Tosylate/CuI Paper Composites

Thermoelectric composites of organic and inorganic materials exhibit significantly enhanced thermoelectric properties compared with pristine organic thermoelectrics so they might be better suited as core materials of wearable thermoelectric devices. This study describes the development of three-dimensional (3D) paper PEDOT:tosylate/CuI composites that could be shaped as 3 mm thick blocks to convert a temperature difference between their bottom and top sides into power; the majority of organic thermoelectric materials are shaped as thin strips usually on a planar substrate and convert a temperature difference between the opposite edges of the strips into power. The 3D paper PEDOT:tosylate/CuI composites can produce a power density equal to 4.8 nW/cm² (ΔΤ = 6 Κ) that is 10 times higher than that of the pristine paper PEDOT:Tos composites. The enhanced thermoelectric properties of the paper PEDOT:tosylate/CuI composites are attributed to the CuI nanocrystals entrapped inside the composite that increases the Seebeck coefficient of the composite to 225 μV K^-1; the Seebeck coefficient of paper PEDOT:Tos is 65 μV K^-1. A proof-of-concept wearable thermoelectric device that uses 36 blocks of the paper PEDOT:tosylate/CuI composites (as p-type elements) and 36 wires of monel (as n-type elements) can produce up to 4.7 μW of power at ΔΤ = 20 K. The device has a footprint of 64 cm² and can be placed directly over the skin or can be embedded into clothing.

Optomechanic Coupling in Ag Polymer Nanocomposite Films

Particle vibrational spectroscopy has emerged as a new tool for the measurement of elasticity, glass transition, and interactions at a nanoscale. For colloid-based materials, however, the weakly localized particle resonances in a fluid or solid medium renders their detection difficult. The strong amplification of the inelastic light scattering near surface plasmon resonance of metallic nanoparticles (NPs) allowed not only the detection of single NP eigenvibrations but also the interparticle interaction effects on the acoustic vibrations of NPs mediated by strong optomechanical coupling. The "rattling" and quadrupolar modes of Ag/polymer and polymer-grafted Ag NPs with different diameters in their assemblies are probed by Brillouin light spectroscopy (BLS). We present thorough theoretical 3D calculations for anisotropic Ag elasticity to quantify the frequency and intensity of the "rattling" mode and hence its BLS activity for different interparticle separations and matrix rigidity. Theoretically, a liquidlike environment, e.g., poly(isobutylene) (PIB) does not support rattling vibration of Ag dimers but unexpectedly hardening of the extremely confined graft melt renders both activation of the former and a frequency blue shift of the fundamental quadrupolar mode in the grafted nanoparticle Ag@PIB film.

Tryptophan-based styryl homopolymer and polyzwitterions with solvent-induced UCST, ion-induced LCST and pH-induced UCST

A multi-stimuli responsive tryptophan-based styryl homopolymer and polyzwitterions with solvent-induced UCST, ion-induced LCST and pH-induced UCST under different conditions are presented.

A stimuli-responsive methionine-based zwitterionic methacryloyl sulfonium sulfonate monomer and the corresponding antifouling polymer with tunable thermosensitivity

This report describes a dual pH- and thermo-responsive methionine-based zwitterionic methacryloyl sulfonium sulfonate monomer and the corresponding zwitterionic antifouling polymer with ion-induced tunable thermosensitivity.

Tunable doubly responsive UCST-type phosphonium poly(ionic liquid): a thermosensitive dispersant for carbon nanotubes

Poly(triphenyl-4-vinylbenzylphosphonium chloride) synthesized via RAFT polymerization exhibits both tunable halide ion- and thermo-responsiveness (UCST-type) in aqueous solution and acts as a thermosensitive stabilizer for carbon nanotubes.

Solution-processed reduced graphene oxide in light-emitting diodes and photovoltaic devices with the same pair of active materials

In studying the role of GO in LEDs and PVs, a single pair of active materials has been used in both the devices.

In situ synthesis of ultra-small platinum nanoparticles using a water soluble polyphenolic polymer with high catalytic activity

Ultra-small platinum nanoparticles are generated by in situ polymer reduction technique which shows high catalytic activity in water and in organic solvent.