Bowel Movement Frequency Is Not Linked With Cognitive Function in Cirrhosis

The spectrum of hepatic encephalopathy (HE) ranges from overt HE (OHE) to cognitive impairment (ie, covert) HE (CHE).¹ The first-line therapy is lactulose, which is titrated to achieve ~2-3 soft/loose daily bowel movements (BM). This metric is considered dogma for practitioners despite erratic results, GI adverse events, and poor tolerance in Western countries.¹ There are logistic barriers for the widespread uptake of rifaximin, the second-line therapy. Moreover, although BM frequency-directed dose titration of lactulose is the usual practice, its impact on objective cognitive performance is unclear. Our aim is to determine the impact of BM frequency on cognition in patients with/without prior OHE.

The Prediction of In-Hospital Mortality in Decompensated Cirrhosis with Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is a condition in cirrhosis associated with organ failure (OF) and high short-term mortality. Both the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) and North American Consortium for the Study of End-Stage Liver Disease (NACSELD) ACLF definitions have been shown to predict ACLF prognosis. The aim of this study was to compare the ability of the EASL-CLIF versus NACSELD systems over baseline clinical and laboratory parameters in the prediction of in-hospital mortality in admitted patients with decompensated cirrhosis. Five NACSELD centers prospectively collected data to calculate EASL-CLIF and NACSELD-ACLF scores for admitted patients with cirrhosis who were followed for the development of OF, hospital course, and survival. Both the number of OFs and the ACLF grade or presence were used to determine the impact of NACSELD versus EASL-CLIF definitions of ACLF above baseline parameters on in-hospital mortality. A total of 1031 patients with decompensated cirrhosis (age, 57 ± 11 years; male, 66%; Child-Pugh-Turcotte score, 10 ± 2; Model for End-Stage Liver Disease [MELD] score, 20 ± 8) were enrolled. Renal failure prevalence (28% versus 9%, P < 0.001) was more common using the EASL-CLIF versus NACSELD definition, but the prevalence rates for brain, circulatory, and respiratory failures were similar. Baseline parameters including age, white cell count on admission, and MELD score reasonably predicted in-hospital mortality (area under the curve, 0.76). The addition of number of OFs according to either system did not improve the predictive power of the baseline parameters for in-hospital mortality, but the presence of NACSELD-ACLF did. However, neither system was better than baseline parameters in the prediction of 30- or 90-day outcomes. The presence of NACSELD-ACLF is equally effective as the EASL-CLIF ACLF grade, and better than baseline parameters in the prediction of in-hospital mortality in patients with cirrhosis, but not superior in the prediction of longer-term 30- or 90-day outcomes.

Microbiome: Emerging Concepts in Patients with Chronic Liver Disease

The gut microbiome is an exciting new area of research in chronic liver disease. It has shown promise in expanding our understanding of these complicated disease processes and has opened up new treatment modalities. The aim of this review is to increase understanding of the microbiome and explain the collection and analysis process in the context of liver disease. It also looks at our current understanding of the role of the microbiome in the wide spectrum of chronic liver diseases and how it is being used in current therapies and treatments.

Nutritional Assessment in Inpatients With Cirrhosis Can Be Improved After Training and Is Associated With Lower Readmissions

Malnutrition is widely prevalent in cirrhosis patients, which can worsen sarcopenia, hepatic encephalopathy (HE), and overall prognosis. We aimed to define the frequency of nutritional assessments of patients with cirrhosis in retrospective and prospective (after educational training) cohorts and to evaluate prospective changes along with their effects on 90-day readmissions. This study was conducted in 2 phases. Retrospectively, records of hospitalized patients with cirrhosis from the university and Veterans Affairs Medical Center (VAMC) settings were reviewed to assess nutritional status, if a nutrition consultation occurred, the number of days patients were nil per os (npo) and received inadequate nutrition, and if nutritional management was guideline directed. In the prospective phase, after dedicated educational efforts directed at the stakeholders regarding nutritional guidelines for patients with cirrhosis, subsequently hospitalized cirrhosis patients had nutritional and 90-day readmission data collected for comparison between groups. In total, 279 patients were included in the retrospective phase (150 university/129 VAMC), and 102 VAMC patients were in the prospective phase. Cirrhosis severity, reason for admission, and hospital course were similar between groups regardless of cohort, ie, prospective versus retrospective or VAMC versus university. The prospective group had significantly more nutritional consultations and assessments (74.5% versus 40.1%; P < 0.001) compared with the retrospective group regardless of comparisons between the VAMC and university cohorts. Both groups had a similar number of days npo, but the prospective group had fewer days of inadequate nutrition. The 90-day readmission rate was significantly lower in the prospective group versus the retrospective group (39.4% versus 28.4%; P = 0.04), which was associated with greater nutrition outpatient follow-up. In conclusion, nutritional consultation rates in inpatients with cirrhosis can be significantly improved after educational intervention and is associated with lower 90-day readmission rates.

Neutrophil-to-Lymphocyte Ratio Associates Independently With Mortality in Hospitalized Patients With Cirrhosis

BACKGROUND & AIMS

The neutrophil to lymphocyte ratio (NLR) is a biomarker of immune dysregulation in patients with cirrhosis and is inexpensive to measure. We investigated the association between NLR and mortality in hospitalized patients with cirrhosis at 4 liver transplant centers, controlling for severity of acute-on-chronic liver failure (ACLF).

METHODS

We performed a retrospective study using data from the North American Consortium for the Study of End-stage Liver Disease on patients with index hospitalizations for cirrhosis from December 2011 through December 2016. We collected data on patient demographics, NLR, model for end-stage liver disease (MELD) scores, serum levels of Na, cirrhosis stages, infections, hepatocellular carcinomas, and ACLF severity (based on number of organ failures). Competing risk regression analysis evaluated mortality within 1 year after hospital discharge, accounting for competing events (liver transplant).

RESULTS

At admission, the patients' mean age was 57 years, mean MELD score was 21, and mean serum level of Na was 134 mmol/L. Sixty-eight patients had no organ failure, 21 patients had 1 organ failures, 7 patients had 2 organ failures, 4 patients had 3 organ failures, and 1 patient had 4 organ failures; 36% of the patients had confirmed or suspected infections. In univariate models, risk of death associated with increasing NLR, up to a value of 8 (hazard ratio [HR]= 1.14; 95% CI, 1.07-1.20; P < .001), and NLR quartile (for NLR range of 3-5, HR = 2.17; for NLR range of >5-9, HR=2.46; for NLR quartile >9, HR=2.84 vs the lowest quartile [NLR<3]) (P ≤ .001). The NLR remained statistically significant in multivariable models, adjusting for age, MELD score, hepatocellular carcinoma, and ACLF severity. Additionally, NLR was a statistically significant independent predictor of length of index hospital stay and mortality within 90 days after discharge.

CONCLUSION

In a retrospective analysis of patients with cirrhosis, we found NLR to associate with death within 1 year after non-elective hospitalization. In these patients, the risk of death associated with acute immune dysregulation persists long after their initial hospitalization.

Assessment of the spectrum of hepatic encephalopathy: A multicenter study

Hepatic encephalopathy (HE) is a major cause of morbidity in cirrhosis. However, its severity assessment is often subjective, which needs to be studied systematically. The aim was to determine how accurately trainee and nontrainee practitioners grade and manage HE patients throughout its severity. We performed a survey study using standardized simulated patient videos at 4 US and 3 Canadian centers. Participants were trainees (gastroenterology/hepatology fellows) and nontrainees (faculty, nurse practitioners, physician assistants). We determined the accuracy of HE severity identification and management options between grades <2 or ≥2 HE and trainees/nontrainees. In total, 108 respondents (62 trainees, 46 nontrainees) were included. For patients with grades <2 versus ≥2 HE, a higher percentage of respondents were better at correctly diagnosing grades ≥2 compared with grades <2 (91% versus 64%; P < 0.001). Specialized cognitive testing was checked significantly more often in grades <2, whereas more aggressive investigation for precipitating factors was ordered in HE grades >2. Serum ammonia levels were ordered in almost a third of grade ≥2 patients. For trainees and nontrainees, HE grades were identified similarly between groups. Trainees were less likely to order serum ammonia and low-protein diets, more likely to order rifaximin, and more likely to perform a more thorough workup for precipitating factors compared with nontrainee respondents. There was excellent concordance in the classification of grade ≥2 HE between nontrainees versus trainees, but lower grades showed discordance. Important differences were seen regarding blood ammonia, specialized testing, and nutritional management between trainees and nontrainees. These results have important implications at the patient level, interpreting multicenter clinical trials, and in the education of practitioners. Liver Transplantation 24 587-594 2018 AASLD.

Integrin-Linked Kinase in Muscle Is Necessary for the Development of Insulin Resistance in Diet-Induced Obese Mice

Diet-induced muscle insulin resistance is associated with expansion of extracellular matrix (ECM) components, such as collagens, and the expression of collagen-binding integrin, α2β1. Integrins transduce signals from ECM via their cytoplasmic domains, which bind to intracellular integrin-binding proteins. The integrin-linked kinase (ILK)-PINCH-parvin (IPP) complex interacts with the cytoplasmic domain of β-integrin subunits and is critical for integrin signaling. In this study we defined the role of ILK, a key component of the IPP complex, in diet-induced muscle insulin resistance. Wild-type (ILK(lox/lox)) and muscle-specific ILK-deficient (ILK(lox/lox)HSAcre) mice were fed chow or a high-fat (HF) diet for 16 weeks. Body weight was not different between ILK(lox/lox) and ILK(lox/lox)HSAcre mice. However, HF-fed ILK(lox/lox)HSAcre mice had improved muscle insulin sensitivity relative to HF-fed ILK(lox/lox) mice, as shown by increased rates of glucose infusion, glucose disappearance, and muscle glucose uptake during a hyperinsulinemic-euglycemic clamp. Improved muscle insulin action in the HF-fed ILK(lox/lox)HSAcre mice was associated with increased insulin-stimulated phosphorylation of Akt and increased muscle capillarization. These results suggest that ILK expression in muscle is a critical component of diet-induced insulin resistance, which possibly acts by impairing insulin signaling and insulin perfusion through capillaries.

Treatment during primary HIV infection does not lower viral set point but improves CD4 lymphocytes in an observational cohort

Objective

To investigate if early treatment of primary HIV-1 infection (PHI) reduces viral set point and/or increases CD4 lymphocytes.

Methods

Analysis of two prospective multi-centre PHI cohorts. HIV-1 RNA and CD4 lymphocytes in patients with transient treatment were compared to those in untreated patients. Time to CD4 lymphocyte decrease below 350/μl after treatment stop or seroconversion was calculated using Kaplan-Meier and Cox-PH-regression analyses.

Results

156 cases of PHI were included, of which 100 had received transient HAART (median treatment time 9.5 months) and 56 remained untreated. Median viral load (563000 cop/ml vs 240000 cop/ml; p < 0.001) and median CD4 lymphocyte (449/μl vs. 613/μl; p < 0.01) differed significantly between treated and untreated patients. Median viral load was 38056 copies/ml in treated patients (12 months after treatment stop) and 52880 copies/ml in untreated patients (12 months after seroconversion; ns). Median CD4 lymphocyte change was +60/μl vs. -86/μl (p = 0.01). Median time until CD4 lymphocytes decreased to < 350/μl (including all patients with CD4 lymphocytes < 500/μl during seroconversion) was 20.7 months in treated patients after treatment stop and 8.3 months in untreated patents after seroconversion (p < 0.01). Cox-PH analyses adjusting for baseline VL, CD4 lymphocytes, stage of early infection and symptoms confirmed these differences.

Conclusions

Treatment during PHI did not lower viral set point. However, patients treated during seroconversion had an increase in CD4 lymphocytes, whereas untreated patients experienced a decrease in CD4 lymphocytes. Time until reaching CD4 lymphocytes < 350/μl was significantly shorter in untreated than in treated patients including patients with CD4 lymphocytes < 500/μl during seroconversion.

[Impairments of action control in the context of neuropsychological findings in schizophrenia]

Based on a review of neurobiological and neuropsychological findings in schizophrenia, we illustrate how experimental neuropsychological research contributes to the understanding of schizophrenia. It is shown that cognitive performance deficits are a central feature of schizophrenia. They are closely connected with changes of brain physiology and appear to reflect disturbances of basic cognitive functions. It is difficult to identify these functions, because task performance usually taps various cognitive processes. However, isolation of functions is possible by experimental variation of tasks that require a small number of well defined processes. To illustrate this, we review several recent studies that experimentally analyzed deficits in the control of fast eye movements (saccades). In the antisaccade task schizophrenia patients show distinct, temporally stable and often replicated performance deficits. The reviewed studies suggest that these deficits predominantly reflect a weakness in the volitional initiation of action.

Epidemiological and clinical features of travel-associated cryptosporidiosis

Data concerning the clinical and epidemiological features of travel-associated cryptosporidiosis are lacking. In order to investigate the impact of this disease on travellers' health, a retrospective study was conducted at the Institute of Tropical Medicine, Berlin. In total, 57 cryptosporidial infections were identified between 2000 and 2004, resulting in a prevalence of 2.9% in patients with travel-associated diarrhoea. Travel to south-central Asia, especially India, was associated with a higher prevalence of infection than was travel to other destinations. Clinically, the disease resembled giardiasis, but fever and arthralgias seemed to occur more frequently.

Male sex workers in three Australian cities: socio-demographic and sex work characteristics

This article describes the socio-demographic and sex work characteristics of sex workers in Sydney, Melbourne, and Brisbane. A total of 185 male sex workers completed the questionnaire component of the study. The results of this study serve to debunk many of the myths surrounding the popular view of the male sex worker (MSW). The respondents in this study were on average 27 years old, and the majority had completed secondary education, with 30% having gained some form of tertiary qualification. Interestingly, those MSWs who had not completed secondary education were mostly street workers and were generally aged under 25 years. The majority of sex workers lived in rented accommodation, with only 6% reporting to be homeless. Half of all respondents identified as being "gay," 31% as "bisexual" and 5.5% as "straight." More than half of the respondents were in a permanent relationship. Only 7.3% of this group reported using heroin daily, although the majority consumed alcohol, tobacco, marijuana, and ecstasy. The majority of sex workers had been in the profession for less than six months, although some had been working in the industry for more than ten years. Most of the sex workers reported having taken an HIV test and a preference to offer safer sex. The article highlights ways in which the work context of MSW can be better understood and supported by education and public policy programs.

A profile of the clients of male sex workers in three Australian cities

OBJECTIVE

This paper describes the profile of clients as reported by 186 male sex workers in three Australian cities.

METHOD

The data were collected using a diary which was completed after each commercial sexual encounter with a male client over a two-week period. The data reported in this study are based on reports from 2,088 sex encounters and a profile of 1,776 clients.

RESULTS

The findings reveal, for example, that the most common source used for recruiting clients was advertisements, followed by escort agencies, although there were differences between the three cities; the majority of the clients were in their 40s but clients of street workers were younger; clients were most often classified as 'middle class', with differences by source of client recruitment; less than half the clients were identified as being gay and a significant number were identified as bisexual or straight; alcohol and drug use took place in a small percentage of the encounters; most workers had some information about their clients, such as occupation and home number; violence was infrequent; and unsafe sex was requested in a minority of the encounters.

CONCLUSION

Overall, the results reveal that clients of male sex workers are a highly heterogeneous group.

IMPLICATIONS

The paper highlights a number of issues which can further promote safety and public accountability in male sex work.

Identification of bacterial isolates from biofilters as Paracoccus alkenifer sp. nov. and Paracoccus solventivorans with emended description of Paracoccus solventivorans

Two groups of strains isolated from biofilters for the treatment of waste gases were assigned to the genus Paracoccus by phylogenetic and chemotaxonomic methods. All type strains of the genus Paracoccus were compared with these groups using 16S rDNA sequence analysis, fatty acid patterns and physiological reaction profiles. For both groups, the nearest related reference species was Paracoccus solventivorans based on 16S rDNA sequence similarity. However, whereas one group of isolates was identified as a member of this species by fatty acid analysis and DNA-DNA hybridization, the other group was proposed as a new species, Paracoccus alkenifer sp. nov. Fatty acid analysis showed the unusual fatty acid 20:1cis13 instead of 19:0 cyclo11-12 for P. alkenifer and P. solventivorans, and 14:1cis7 instead of 12:1cis5 for P. alkenifer and Paracoccus kocurii. By means of a GC-MS method, diaminopimelic acid was detected for P. solventivorans. Based on these results we propose an emended description for the species P. solventivorans.

Biosynthesis of the labdane diterpene marrubiin in Marrubium vulgare via a non-mevalonate pathway

The biosynthesis of the furanic labdane diterpene marrubiin has been studied in plantlets and shoot cultures of Marrubium vulgare (Lamiaceae). The use of [2-14C]acetate, [2-14C]pyruvate, [2-14C]mevalonic acid and [U-14C]glucose incorporation experiments showed that the labelling of sterols in etiolated shoot cultures of M. vulgare was in accordance with their biosynthesis via the acetate-mevalonate pathway. In contrast, the incorporation rates of these precursors into the diterpene marrubiin could not be explained by biosynthesis of this compound via the acetate-mevalonate pathway. Cultivation of etiolated shoot cultures of M. vulgare on medium containing [1-13C]glucose and subsequent 13C-NMR spectroscopy of marrubiin led to the conclusion that the biosynthesis of marrubiin follows a non-mevalonate pathway. All isoprenic units of 13C-labelled marrubiin were enriched in those carbons that correspond to positions 1 and 5 of a putative precursor isopentenyl diphosphate. This labelling pattern from [1-13C]glucose is consistent with an alternative pathway via trioses, which has already been shown to occur in Eubacteria and Gymnospermae. The labdane skeleton is a precursor of many other skeletal types of diterpenes. Therefore it becomes obvious that in connection with the few known examples of a non-mevalonate pathway to isoprenoids the formation of some isoprenoids in plants via a non-mevalonate pathway might be quite common.

Biosynthesis of [14C]geranylgeranyldiphosphate by a prenyl transferase system from a mutant strain of Gibberella fujikuroi

[14C]Geranylgeranyldiphosphate was produced by a prenyl transferase system extracted from the mutant strain SG4 of Gibberella fujikuroi (wild-type strain IMI 58289), which is blocked in carotenoid biosynthesis. The fungus was grown in liquid medium containing only potato-dextrose broth. Crude extracts of 12- to 14-day-old mycelia in Tris buffer, pH 8.5, were centrifuged at 100,000g. The supernatant was desalted and used to produce [4,8,12,16-14C]geranylgeranyldiphosphate from R,S-[2-14C]mevalonic acid. Maximum yield of [14C]geranylgeranyldiphosphate was obtained using mycelia from the stationary growth phase with incubation of the enzyme preparation at pH 8.5 for 5 h. Routinely, 65% of the biogenetic available R-mevalonic acid was converted to [14C]geranylgeranyldiphosphate, which was identified by cochromatography with authentic [1-3H]geranylgeranyldiphosphate by means of radio-TLC, radio-HPLC, and hydrolysis to geranylgeraniol.

Novel nonsteroidal anti-inflammatory drug derivatives with markedly reduced ulcerogenic properties in the rat

BACKGROUND/AIMS

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is limited by their ability to induce gastrointestinal injury. Two NSAIDs were modified by incorporation of an nitroxybutyl moiety. The short-term ulcerogenic and anti-inflammatory properties of these derivatives were compared with the native NSAIDs.

METHODS

Rats were given flurbiprofen, ketoprofen, or their respective derivatives, and the extent of gastric damage and effect on gastric prostaglandin E2 synthesis was assessed. The damage-promoting effects of these compounds were also compared following twice-daily administration for 1 week. Anti-inflammatory properties were examined using a carrageenan-induced paw edema model.

RESULTS

The derivatives of flurbiprofen and ketoprofen caused significantly less short-term gastric mucosal injury at all doses tested, despite producing comparable suppression of prostaglandin synthesis. The NSAID derivatives also showed comparable anti-inflammatory activity to the native compounds. The flurbiprofen derivative inhibited collagen-induced platelet aggregation significantly more than the native NSAID. Plasma nitrate/nitrite levels increased significantly following administration of the flurbiprofen derivative, consistent with release of a nitrogen oxide.

CONCLUSIONS

Addition of a nitroxybutyl moiety to two NSAIDs markedly reduced the ability of these agents to induce short-term gastric injury but did not interfere with their ability to suppress inflammatory processes, inhibit prostaglandin synthesis, or inhibit platelet aggregation. These NSAID derivatives may therefore represent a novel class of anti-inflammatory drugs with markedly less ulcerogenic effects on the stomach.

A diclofenac derivative without ulcerogenic properties

In this study, we assessed the effects of addition of a nitroxybutyl moiety to diclofenac on its ulcerogenic properties. The diclofenac derivative, 'nitrofenac', was examined in terms of its ability to induce acute gastric erosions and chronic-type gastric ulcers in rats and rabbits, respectively. The effects of these compounds on prostaglandin synthesis in the stomach and at a site of peripheral inflammation were also assessed, as were their anti-inflammatory properties in a model of acute inflammation. Diclofenac dose-dependently caused acute gastric mucosal injury in the rat at all doses tested (10-40 mg/kg), that was significantly greater in severity than that observed with the same doses of nitrofenac. In rabbits, twice-daily administration of diclofenac induced penetrating antral ulcers and small intestinal damage. No damage was observed in the stomach or small intestine of rabbits receiving nitrofenac. Diclofenac and nitrofenac exerted similar inhibitory effects on prostaglandin E2 synthesis in the stomach and in a carrageenan-sponge model of peripheral inflammation. These compounds exerted similar inhibitory effects on carrageenan-induced paw edema. Nitrofenac, but not diclofenac, caused a significant increase in plasma levels of nitrate/nitrite. These results suggest that the addition of a nitroxybutyl moiety to diclofenac markedly reduces the ulcerogenic properties of this compound without interfering with its ability to inhibit cyclo-oxygenase activity or to reduce acute inflammation.

Investigation of the visual cytoscreening of conventional gynecologic smears. II. Analysis of eye movement

The perception of visual information in cytoscreening was studied: eye movements were recorded while the cytotechnologist was screening cervical smears by means of a projection screen. Four phases of eye movement could be distinguished: small, aimless movements during the stage movement; a latency period with a duration of about 180 milliseconds; saccadic movement to the position of an object; and fixation on an object. These components explain the two-phase behavior of cytoscreening found in our previous investigations of the stage movement. Visual perception during the period of latency was found to be the most important since only those objects that are recognized by peripheral vision during this period can trigger the necessary saccadic movement before fixation takes place. The scanpath of search in the stationary field of view is determined by the conspicuousness of the objects; the main features of conspicuousness are size and contrast. Even with the comparatively small fields of view (24 degrees and 29 degrees in diameter) used in these experiments, it was found that the detection threshold of peripheral vision increases towards the margin of the field of view. This raises the question of whether the use of large-field binoculars (with 40-degree visual angles) may cause higher false-negative rates for samples with only a few atypical cells.

Investigation of the visual cytoscreening of conventional gynecologic smears. I. Analysis of slide movement

In order to elucidate the process of visual cytoscreening, graphic and electronic recordings of the stage movements in visual screening of conventional gynecologic smears were carried out. More than 400 recordings have been evaluated. The screening consisted of alternating movements, with a mean duration of 180 milliseconds, and stops of about 230 milliseconds. Variations of the screening pattern due to the specimen diagnosis were hidden behind the rather obvious individual behavior and reactions to inhomogenity of material distribution. The detection threshold was found to vary with the diagnostic situation. A lowering of the detection threshold was especially reflected by an increase of the overlap in screening direction and an increased number of fields of view with stop times of more than 350 milliseconds. A substantial part of the specimen was only seen during movements; the fraction of the specimen area covered during the stops was found to vary between 41% and 93% for screenings in the daily routine work.