Prevalence and Determinants of Undiagnosed Liver Steatosis and Fibrosis in a Nationally Representative Sample of US Adults

Background Chronic liver diseases account for approximately 1.9 million deaths globally every year and negatively affect health-related quality of life. Early detection of liver disease may enable timely treatment, potentially improving patient outcomes. This study aimed to determine the prevalence and determinants of liver steatosis and fibrosis in US adults with no previously diagnosed liver condition. Methods We conducted an observational, nationally representative, cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) conducted from January 2017 to March 2020. Study participants were 7,391 adults aged 21 and older with no history of diagnosed liver disorders who underwent vibration-controlled transient elastography (VCTE) to determine liver steatosis and fibrosis. Controlled attenuation parameter (CAP) values between 248 and 267 dB/m were classified as mild steatosis, and those over 267 dB/m as advanced steatosis. Liver stiffness measurement (LSM) values between 7.65 and 13 kPa were classified as moderate/severe fibrosis, and those over 13 kPa as cirrhosis. Covariates included age, sex, race, body mass index (BMI), diabetes mellitus, kidney disease, smoking history, alcohol intake, alanine aminotransferase (ALT), aspartate aminotransferase (AST), physical activity, sedentary time, and sleep time. The associations of subject characteristics with liver CAP and LSM were evaluated using survey multivariable linear regression. Shapley Additive Explanations values determined the relative importance of each attribute in the model. The discriminative performance of classification models was assessed using the area under the receiver operating characteristic (AUROC) curve. Results The population prevalence of liver steatosis was 57.2% (10.2% mild; 47.0% advanced). The relative importance of covariates in predicting liver CAP was 63.1% for BMI, 10.7% for ALT, and less than 10% for the other covariates. The prevalence of significant fibrosis was 11.4% (8.3% moderate/severe fibrosis; 3.1% cirrhosis). The relative importance of covariates in predicting LSM was 67.3% for BMI and less than 10% for the other covariates. BMI alone demonstrated acceptable discriminative performance in classifying varying severities of steatosis and fibrosis (AUROC range 72%-78%) at cutoffs between 28 and 33 kg/m2. Conclusions Undiagnosed chronic liver disease based on VCTE findings is highly prevalent among US adults, particularly in obese individuals. Efforts to increase awareness about liver disease and to reconsider existing BMI thresholds for liver disease screening may be warranted.

Determinants of life dissatisfaction among adults in the United States: A cross-sectional analysis of the National Health Interview Survey

The number of Americans who report dissatisfaction with their quality of life has increased over the past several decades. This study investigated social- and health-related determinants of life dissatisfaction among adults in the United States (US). We conducted a cross-sectional observational study using data from the 2021 National Health Interview Survey, a nationally representative sample of adults in the US. We analyzed the association between self-reported life dissatisfaction and independent variables including demographics, family-level information, health status and conditions, functioning and disability, health insurance coverage, chronic pain, occupational variables, socioeconomic indicators, health-related behaviors, and psychological distress indicators. Survey multivariable logistic regression was used to determine the association among social- and health-related determinants and life dissatisfaction. The relative importance of each variable in the final model was determined using Shapley Additive Explanations values (0-100% scale). Among the 253.2 million civilian noninstitutionalized adults, 12.2 million (4.8%) reported life dissatisfaction. Recent psychological distress, unmarried status, poor general health, lack of social/emotional support, and lower food security were independently associated with life dissatisfaction (all P < .001). The relative importance of these variables in predicting life dissatisfaction was 39.3% for recent psychological distress, 22.2% for unmarried status, 18.3% for poor general health, 13.4% for lack of social/emotional support, and 6.9% for lower food security. Additionally, racial inequities were identified in the prevalence of these factors. Life dissatisfaction among adults in the US is associated with social- and health-related factors that are more prevalent in racial minority groups. The study findings suggest that resource prioritization should be targeted towards individuals with these factors, with particular emphasis on racial minority groups. This study aligns with US health policy initiatives and the results may help policymakers address the underlying factors contributing to life dissatisfaction among the US population.

The Impact of Tort Reforms on the Neurosurgical Malpractice Environment: A Systematic Review of Literature

BACKGROUND

Neurosurgeons, especially spine surgeons, have the highest risk of facing a malpractice claim. Average verdicts in spine surgery litigation has been shown to be over USD $1 million/case. This systematic review aimed to clarify the impact of tort reforms on neurosurgical health care environments across the United States, including patient outcomes, practice of defensive medicine, and physician supply aims.

METHODS

A systematic literature search was performed using PubMed, Embase, Cochrane, and Web of Science databases until May 13, 2022. Study quality was assessed using the quality assessment tool for studies reporting prevalence data.

RESULTS

Five studies (all rated as good quality) were included. Two studies found that in higher-risk state malpractice environments, risk of postoperative complications was higher and odds of nonhome discharge were larger (odds ratio 1.1169, 95% confidence interval 1.139-1.200). One study found that neurosurgeons reported practice of defensive medicine by ordering more imaging in a higher-risk environment, while this was not shown in a study examining imaging rates in different medicolegal environments. One study observed that noneconomic damage caps were associated with a 3.9% increase of physician supply in high-risk specialties.

CONCLUSIONS

There was a suggestive association between tort reforms and less practice of defensive medicine among neurosurgeons, improvement in postoperative outcomes in spinal fusion patients, and increase in physician supply. More elaborate studies on the medicolegal environment in neurosurgical practice are needed to give more insight on the current size of the problem that litigation presents in the United States and the effects tort reforms have on neurosurgical health care environments.

Transconjunctival application of mitomycin C in combination with laser sclerostomy ab interno: a long-term morphological study of the postoperative healing process

The precise mechanism whereby mitomycin C enhances IOP reduction in glaucoma filtering surgery still eludes us. Ten rabbits received full-thickness Nd:YAG laser sclerostomy ab interno and adjunctive intraoperative treatment with mitomycin C (MMC) applied topically over the intact conjunctiva (0.5 mg ml-1 for 5 min). A systematic ultrastructural analysis of the fistulas and surrounding tissue was then conducted in conjunction with clinical observations, over the ensuing 10 weeks. In order to investigate also the extent to which MMC impedes fistula occlusion in the absence of percolating aqueous humour, we created non-perforating ('half-thickness') sclerostomies ab interno in three additional rabbits, one with and two without MMC therapy. Transconjunctival MMC application resulted in no serious complications. Eight of the ten full-thickness fistulas remained patent throughout the study, maintaining significant IOP reduction; the other two sclerostomies were compromised by iris incarceration. The MMC-treated, half-thickness canal remained as a tissue-free cul de sac; the two non-treated ones became completely occluded within one week without having recourse to extraocular cell populations. MMC suppressed the migration and proliferation of fibroblasts, macrophages and clump cells from the episclera, sclera, ciliary body and iris root. Repolymerization of heat-damaged collagen was abortive; neosynthesis was not observed. Myofibroblasts were encountered in the vicinity of the sclerostomy canals, and, after the fifth week, these cells were also found to be deployed as a canal-lining layer, delimiting the lumen from the surrounding stroma along most of the fistula length. Towards the external ostium, this layer of myofibroblasts was incomplete or absent. Near the internal ostium, lining cells were derived from the corneal endothelium. The transconjunctival mode of applying MMC appears to be efficient. This antifibrotic drug exerts its inhibitory influence by suppressing not only cell migration and proliferation, but also phagocytic and synthetic activities. However, exposed tissues are not acellular, and amongst the populations present, myofibroblasts are found to dominate the scene. The canal-delimiting cellular lining may play a role in maintaining fistula patency in MMC-treated eyes.

Some aspects of the automation of perimetry

Manual perimetry has certain inherent limitations stemming from both the patient and the examiner. Automated perimetry, if properly developed, can offer the advantages of exact reproducibility of the examination strategy, accuracy achieved through averaging of repeated determinations, and systematic application of previous data to the current examination. The history, concepts and clinical practically of automated perimetry are discussed. Several systems capable of performing functions resembling human intellectual activity are commerically available; one, the OctopusTM, is described in detail.