Imaging of Alcohol-Associated Liver Disease

Alcohol-associated liver disease (ALD) continues to be a global health concern, responsible for a significant number of deaths worldwide. Although most individuals who consume alcohol do not develop ALD, heavy drinkers and binge drinkers are at increased risk. Unfortunately, ALD is often undetected until it reaches advanced stages, frequently associated with portal hypertension and hepatocellular carcinoma (HCC). ALD is now the leading indication for liver transplant. The incidence of alcohol-associated hepatitis (AH) surged during the COVID-19 pandemic. Early diagnosis of ALD is therefore important in patient management and determination of prognosis, as abstinence can halt disease progression. The spectrum of ALD includes steatosis, steatohepatitis, and cirrhosis, with steatosis the most common manifestation. Diagnostic techniques including ultrasound, CT, and MRI provide useful information for identifying ALD and excluding other causes of liver dysfunction. Heterogeneous steatosis and transient perfusion changes on CT and MRI in the clinical setting of alcohol-use disorder are diagnostic of severe AH. Elastography techniques are useful for assessing fibrosis and monitoring treatment response. These various imaging modalities are also useful in HCC surveillance and diagnosis. This review discusses the imaging modalities currently used in the evaluation of ALD, highlighting their strengths, limitations, and clinical applications.

Imaging of Fontan-Associated Liver Disease

ABSTRACT

The Fontan procedure is the definitive treatment for patients with single-ventricle physiology. Surgical advances have led to a growing number of patients surviving into adulthood. Fontan-associated liver disease (FALD) encompasses a spectrum of pathologic liver changes that occur secondary to altered physiology including congestion, fibrosis, and the development of liver masses. Assessment of FALD is difficult and relies on using imaging alongside of clinical, laboratory, and pathology information. Ultrasound, computed tomography, and magnetic resonance imaging are capable of demonstrating physiologic and hepatic parenchymal abnormalities commonly seen in FALD. Several novel imaging techniques including magnetic resonance elastography are under study for use as biomarkers for FALD progression. Imaging has a central role in detection and characterization of liver masses as benign or malignant. Benign FNH-like masses are commonly encountered; however, these can display atypical features and be mistaken for hepatocellular carcinoma (HCC). Fontan patients are at elevated risk for HCC, which is a feared complication and has a poor prognosis in this population. While imaging screening for HCC is widely advocated, no consensus has been reached regarding an optimal surveillance regimen.

Safety and accuracy of aortic and periaortic CT-guided percutaneous core needle biopsy

PURPOSE

The purpose of this study was to determine the safety and accuracy of aortic and periaortic computed tomography (CT)-guided percutaneous core needle biopsy performed at a single center over 12 years.

MATERIALS AND METHODS

A retrospective review was conducted of cases performed between February 2010 and August 2022 in which the biopsied region was in direct contact with the aorta or great vessels including the pericardium and common iliac arteries. Clinical notes were reviewed for any early or delayed complications following the procedure, which if present were graded using the National Institute of Health's Common Terminology Criteria for Adverse Events, version 5.0. Pathology results were compared to subsequent outside biopsy results or follow-up surgical pathology, if available, as well as subsequent clinical decision making and/or clinical course, to determine concordance. Sensitivity, specificity, predictive value, and accuracy (indicative of diagnostic yield) were calculated.

RESULTS

32 core needle biopsies were reviewed from 30 patients (average lesion longest diameter 3.1 cm, range 0.5-10.9 cm; average needle proximity to the vessel endothelium or deep side of the pericardium 1.0 cm, range 0.3-1.8 cm). Complications occurred in 46.9% of cases (15/32), 93.3% (14/15) of which were minor and included small amounts of bleeding or pain. One patient developed a small nonemergent pneumothorax. Of biopsies obtained, 96.9% provided adequate tissue for diagnosis (31/32). When evaluating concordance between pathological and final diagnosis, sensitivity was 94.7% and specificity was 83.3%; positive and negative predictive value were 90.0% and 90.9%, respectively. Accuracy (diagnostic yield) of biopsy was 90.3%.

CONCLUSION

CT-guided percutaneous aortic and periaortic core needle biopsies are safe and efficacious procedures with high diagnostic yield.

Fidelity to the healing relationship: a medical student's challenge to contemporary bioethics and prescription for medical practice

As a medical  student, I observed that different physicians had strikingly different attitudes and approaches when caring for patients. The care of one patient in particular continues to challenge my understanding of illness and moral responsibility in the practice of medicine. In this paper, I illustrate the care of this patient in order to evaluate the dominant ethics I was taught in medical school, in theory and in practice, and argue neither principlism nor the ethics of care fully captures the moral responsibility of physicians. Emphasising fidelity to the healing relationship, a core principle derived from Pellegrino's virtue theory, I conclude that this approach to clinical ethics fully explains physician responsibility. Pellegrino deconstructs the practice of medicine to clarify the moral event within the clinical encounter and offers a sufficiently useful and justified approach to patient care.

Outcomes of vertebroplasty compared with kyphoplasty: a systematic review and meta-analysis

Background and purpose

Many studies demonstrate that both kyphoplasty and vertebroplasty are superior to conservative therapy in the treatment of osteoporotic vertebral body compression fractures. We performed a systematic review and meta-analysis of studies comparing the outcomes of vertebroplasty and kyphoplasty, which included prospective non-randomized, retrospective comparative, and randomized studies.

Materials and methods

We searched MEDLINE, EMBASE, and the Web of Science databases for studies of kyphoplasty versus vertebroplasty from 1 January 1990 to 30 November 2014 and compared the following outcomes: procedure characteristics, pain and disability improvement, complications and anatomic outcomes. A subgroup analysis was performed comparing pain outcomes based on the risk of bias.

Results

29 studies enrolling 2838 patients (1384 kyphoplasty and 1454 vertebroplasty) were included. 16 prospective non-randomized studies, 10 retrospective comparative studies, and 3 randomized controlled studies were included. No significant differences were found in mean pain scores between the two groups postoperatively (2.9±1.5 kyphoplasty vs 2.9±1.7 vertebroplasty, p=0.39) and at 12 months (2.7±1.8 kyphoplasty vs 3.2±1.8 vertebroplasty, p=0.64). No significant differences were found in disability postoperatively (34.7±7.1 kyphoplasty group vs 36.3±7.8 vertebroplasty group, p=0.74) or at 12 months (28.3±16 kyphoplasty group vs 29.6±13.9 vertebroplasty group, p=0.70). Kyphoplasty was associated with lower odds of new fractures (p=0.06), less extraosseous cement leakage (p<0.01), and greater reduction in kyphotic angle (p<0.01).

Conclusions

No significant difference was found between vertebroplasty and kyphoplasty in short- and long-term pain and disability outcomes. Further studies are needed to better determine if any particular subgroups of patients would benefit more from vertebroplasty or kyphoplasty in the treatment of vertebral body compression fractures.

Smoking is not associated with recurrence and retreatment of intracranial aneurysms after endovascular coiling

OBJECT

Tobacco smoking is one of the most important risk factors for the formation of intracranial aneurysms and for aneurysmal subarachnoid hemorrhages. Smoking has also been suggested to contribute to the recurrence of aneurysms after endovascular coiling. To improve the understanding of the impact of smoking on long-term outcomes after coil embolization of intracranial aneurysms, the authors studied a consecutive contemporary series of patients treated at their institution. The aims of this study were to determine whether smoking is an independent risk factor for aneurysm recurrence and retreatment after endovascular coiling.

METHODS

All patients who had received an intrasaccular coil embolization of an intracranial aneurysm, who had undergone a follow-up imaging exam at least 6 months later, and whose smoking history had been recorded from January 2005 through December 2012 were included in this study. Patients were stratified according to smoking status into 3 groups: 1) never a smoker, 2) current smoker (smoked at the time of treatment), and 3) former smoker (quit smoking before treatment). The 2 primary outcomes studied were aneurysm recurrence and aneurysm retreatment after treatment for endovascular aneurysms. Kruskal-Wallis and chi-square tests were used to test statistical significance of differences in the rates of aneurysm recurrence, retreatment, or of both among the 3 groups. A multivariate logistic regression analysis controlling for smoking status and for several characteristics of the aneurysm was also performed.

RESULTS

In total, 384 patients with a combined total of 411 aneurysms were included in this study. The aneurysm recurrence rate was not significantly associated with smoking: both former smokers (OR 1.00, 95% CI 0.61-1.65; p = 0.99) and current smokers (OR 0.58, 95% CI 0.31-1.09; p = 0.09) had odds of recurrence that were similar to those who were never smokers. Former smokers (OR 0.78, 95% CI 0.46-1.35; p = 0.38) had odds of retreatment similar to those of never smokers, and current smokers had a lower odds of undergoing retreatment (OR 0.44, 95% CI 0.21-0.91; p = 0.03) than never smokers. Moreover, an analysis adjusting for aneurysm rupture, diameter, and initial occlusion showed that former smokers (OR 0.65, 95% CI 0.33-1.28; p = 0.21) and current smokers (OR 1.04, 95% CI 0.60-1.81; p = 0.88) had odds of aneurysm recurrence similar to those who were never smokers. Adjusting the analysis for aneurysm rupture, diameter, and occlusion showed that both former smokers (OR 0.49, 95% CI 0.23-1.05; p = 0.07) and current smokers (OR 0.82, 95% CI 0.46-1.46; p = 0.50) had odds of retreatment similar to those of patients who were never smokers.

CONCLUSIONS

The results show that smoking was not an independent risk factor for aneurysm recurrence and aneurysm retreatment among patients receiving endovascular treatment for intracranial aneurysms at the authors' institution. Nonetheless, patients with intracranial aneurysms should continue to be counseled about the risks of tobacco smoking.

Racial and health insurance disparities of inpatient spine augmentation for osteoporotic vertebral fractures from 2005 to 2010

BACKGROUND AND PURPOSE

Vertebroplasty and kyphoplasty are frequently utilized in the treatment of symptomatic vertebral body fractures. While prior studies have demonstrated disparities in the treatment of back pain and care for osteoporotic patients, disparities in spine augmentation have not been investigated. We investigated racial and health insurance status differences in the use of spine augmentation for the treatment of osteoporotic vertebral fractures in the United States.

MATERIALS AND METHODS

Using the Nationwide Inpatient Sample from 2005 to 2010, we selected all discharges with a primary diagnosis of vertebral fracture (International Classification of Diseases-9 code 733.13). Patients who received spine augmentation were identified by using International Classification of Diseases-9 procedure code 81.65 for vertebroplasty and 81.66 for kyphoplasty. Patients with a diagnosis of cancer were excluded. We compared usage rates of spine augmentation by race/ethnicity (white, black, Hispanic, and Asian/Pacific Islander) and insurance status (Medicare, Medicaid, self-pay, and private). Comparisons among groups were made by using χ(2) tests. A multivariate logistic regression analysis was fit to determine variables associated with spine augmentation use.

RESULTS

A total of 228,329 patients were included in this analysis, of whom 129,206 (56.6%) received spine augmentation. Among patients with spine augmentation, 97,022 (75%) received kyphoplasty and 32,184 (25%) received vertebroplasty; 57.5% (92,779/161,281) of white patients received spine augmentation compared with 38.7% (1405/3631) of black patients (P < .001). Hispanic patients had significantly lower spine augmentation rates compared with white patients (52.3%, 3777/7222, P < .001) as did Asian/Pacific Islander patients (53.1%, 1784/3361, P < .001). The spine augmentation usage rate was 57.2% (114,768/200,662) among patients with Medicare, significantly higher than that of those with Medicaid (43.9%, 1907/4341, P < .001) and those who self-pay (40.2%, 488/1214, P < .001).

CONCLUSIONS

Our findings demonstrate substantial racial and health insurance-based disparities in the inpatient use of spinal augmentation for the treatment of osteoporotic vertebral fracture.

Potential advantage of student-run clinics for diversifying a medical school class

The purpose of this study was to evaluate the influence of a student-run clinic on the diversification of a medical student class. We distributed a two-page, 20-item, paper survey to students of the University of Missouri School of Medicine (MU SOM) class of 2015 in July of 2011. The survey gathered information on general demographics, opinions on the importance of medical education opportunities, and opinions on the importance of medical school characteristics in applying to and attending MU SOM. A total of 104 students responded to the survey. A majority of the students identified the MedZou Community Health Clinic, a student-run, free health clinic affiliated with MU SOM, and simulated-patient encounters as important educational experiences (81% and 94%, respectively). More than half of the self-identified "non-white" students reported MedZou as an important factor in their choice to apply to (60%; 95% confidence interval [CI], 32 to 88) and attend (71%; 95% CI, 44 to 98) MU SOM, over half of the females reported MedZou as important in their choice to apply (59%; 95% CI, 43 to 76) and attend (57%; 95% CI, 40 to 74), and over half of non-Missouri residents reported MedZou as important in their choice to apply (64%; 95% CI, 36 to 93) and attend (71%; 95% CI, 44 to 98). According to the above results, it can be said that students clearly value both MedZou and simulated-patient encounters as important educational experiences. Women, minorities, and non-Missouri residents value MedZou more highly than their peers who are First Year Medical Students who are Missouri residents, suggesting that MedZou may provide a promising opportunity to advance diversity within MU SOM. These results highlight the need for additional research to further explore MedZou's potential to enhance the recruitment of a diverse medical student class.

[Pharmacokinetics of gentamicin after intratracheal administration in tracheotomy patients]

Seventeen tracheotomy patients were given gentamicin (Gen) into trachea at the dosage of 2 and 4 mg.kg-1. Gen concentration in serum was determined by fluorescence polarization immunoassay. Pharmacokinetic parameters were calculated by micro-computer pharmacokinetic program (MCPKP). T1/2Ka, Tp, and Cmax were 0.6 +/- 0.3 h, 1.7 +/- 0.7 h, and 4.6 +/- 1.8 micrograms.ml-1, respectively in 4 mg.kg-1 group and 0.3 +/- 0.3 h, 0.9 +/- 0.5 h, and 0.4 +/- 0.2 microgram.ml-1, respectively in 2 mg.kg-1 group (P < 0.05). T1/2Kel was 30 +/- 11 h in patients of serum creatine (Cr) > 2 mg% and 6 +/- 5 h in patients of Cr < 2 mg% (P < 0.01). No significant difference could be found between Cmax of different renal function patients (P > 0.05).