Bibliometric Analysis of Renal Fibrosis in Diabetic Kidney Disease From 1985 to 2020

Background

Diabetic renal fibrosis (DRF) is an irreversible renal pathological change in the end-stage of diabetic kidney disease (DKD), which plays a significant role in the development and deterioration of the disease. However, data for bibliometric analysis of renal fibrosis in DKD is currently missing. This study aimed to provide a comprehensive and visualized view of DRF research and lay the foundation for further studies.

Materials and Methods

Firstly, the data was collected from the Web of Science Core Collection (WoSCC) database. Secondly, the Web of Science analytic tool was performed to analyze publication years, authors, countries/regions, organizations, and citation frequency. Finally, CiteSpace was employed to construct a visualization bibliometric network to reveal the emerging trends and hotspots of DRF.

Results

A total of 3,821 publications from 1985 to 2020 were included in this study. The number of publications has maintained a growth trend since 2003. Cooper is the most prolific author in this field, and the American Journal of Physiology-Renal Physiology ranking as first place compared with other journals. In terms of the number of publications, China contributed the most to DRF. Monash University is the organization that published the most papers. The top 5 clusters of keyword co-appearance are “chronic kidney disease”, “primary biliary cirrhosis”, “receptor”, “TGF-beta”, “renal tubulointerstitium”. The top 5 clusters of reference co-citation are “microRNAs”, “bone morphogenetic protein”, “hypertrophy”, “glomerulosclerosis”, “diabetic kidney disease”. The strongest citation burst of keyword is “diabetic kidney disease” and the strongest burst of cited reference is “Meng, 2016”.

Conclusions

The present study analyzed the research hotspots, Frontiers, and development trend of DRF and have important implications for future research.

Understanding the Renal Fibrotic Process in Leptospirosis

Leptospirosis is a neglected infectious disease caused by pathogenic species of the genus Leptospira. The acute disease is well-described, and, although it resembles other tropical diseases, it can be diagnosed through the use of serological and molecular methods. While the chronic renal disease, carrier state, and kidney fibrosis due to Leptospira infection in humans have been the subject of discussion by researchers, the mechanisms involved in these processes are still overlooked, and relatively little is known about the establishment and maintenance of the chronic status underlying this infectious disease. In this review, we highlight recent findings regarding the cellular communication pathways involved in the renal fibrotic process, as well as the relationship between renal fibrosis due to leptospirosis and CKD/CKDu.

Surveillance of patients with cirrhosis remains suboptimal in the United States

BACKGROUND & AIMS

Regular monitoring/surveillance for liver complications is crucial to reduce morbidity and mortality in patients with cirrhosis. Recommendations from professional societies are available but adherence is not well studied, especially outside of academic centers. We aimed to determine the frequencies and factors associated with laboratory monitoring, and hepatocellular carcinoma (HCC) and esophageal varices (EV) surveillance in patients with cirrhosis.

METHODS

We identified 82,427 patients with cirrhosis (43,280 compensated and 39,147 decompensated) from the Truven Health MarketScan Research Database®, 2007-2016. We calculated the proportion of patients with cirrhosis with various frequencies of procedures/testing: laboratory (complete blood count, comprehensive metabolic panel, and prothrombin time), HCC and EV surveillance. We also used multivariable logistic regression to determine factors associated with having procedures.

RESULTS

The proportions of patients undergoing HCC surveillance (8.78%), laboratory testing (29.72%) at least every 6-12 months, or EV surveillance (10.6%) at least every 1-2 years were suboptimal. The majority did not have HCC (45.4%) or EV (80.3%) surveillance during the entire study period. On multivariable regression, age 41-55 (vs. <41) years, preferred provider organization (vs. health maintenance organization) insurance plan, specialist care (vs. primary care and other specialties), diagnosis between 2013-2016 (vs. 2007-2009), decompensated (vs. compensated) cirrhosis, non-alcoholic fatty liver disease (vs. viral hepatitis), and higher Charlson comorbidity index were associated with significantly higher odds of undergoing procedures/testing every 6-12 months and EV surveillance every 1-2 years.

CONCLUSIONS

Despite modest improvements in more recent years, routine monitoring and surveillance for patients with cirrhosis is suboptimal. Further efforts including provider awareness, patient education, and system/incentive-based quality improvement measures are urgently needed.

LAY SUMMARY

Patients with cirrhosis should undergo health monitoring for liver complications to achieve early detection and treatment. In a large nationwide cohort of 82,427 patients with cirrhosis in the United States, we found a low rate of adherence (well less than half) to routine blood test monitoring and surveillance for liver cancer and esophageal varices (swollen blood vessels in the abdomen that could lead to fatal bleeding). Adherence has increased in the recent years, but much more improvement is needed.

Association of Omental Adipocyte Hypertrophy and Fibrosis with Human Obesity and Type 2 Diabetes

OBJECTIVE

Morphological alterations including adipocyte hypertrophy and fibrosis deposition are important surrogate markers of visceral adipose tissue function, but the relationships between these morphological changes and type 2 diabetes mellitus (T2DM) and impaired insulin sensitivity are poorly defined.

METHODS

Omental adipose tissue was obtained from 66 individuals with obesity but without T2DM (OB group), 93 individuals with both obesity and T2DM (T2DM group), and 15 individuals with normal BMI and normal glucose tolerance (NGT group). Adipocyte diameter and volume were measured through pathological section analysis. Pericellular and perilobular fibrosis was determined through picrosirius red staining and immunochemistry, while fibrosis-related genes were tested through gene expression and hydroxyproline content.

RESULTS

Compared with the NGT and OB groups, individuals from the T2DM group displayed increased adipocyte diameter and volume levels. Increased adipocyte size (diameter and volume) was positively associated with hyperglycemia and insulin resistance and inversely correlated with insulin sensitivity (using the Matsuda whole-body insulin sensitivity index assessment of insulin sensitivity) and β-cell function (disposition index 30 and disposition index 120). The fibrosis levels of the OB group were the highest out of the three groups, whereas the fibrosis levels of T2DM individuals were lower than the OB group but higher than the NGT group. Although fibrosis was negatively correlated with T2DM, fibrosis deposition was not remarkably associated with impaired systemic insulin sensitivity and glucose metabolism.

CONCLUSIONS

Compared with fibrosis deposition, adipocyte hypertrophy is more closely associated with T2DM and impaired systemic insulin sensitivity.

Cobalt exposure increases the risk of fibrosis of people living near E‑waste recycling area

The toxicity of heavy metals is one of the major public health issues leading to hazardous effects on humans. Many studies focus on the adverse effects on people who were working in or living near E-waste recycling. However, little is known to the sustaining effects of E-waste exposure on human health after the recycling factories were shut down. In the present study, we collected the blood of people living near E‑waste recycling facilities after the recycling factories were closed for 2 years. Eight heavy metals were examined in all blood samples. The results revealed that the blood levels of lead (Pb), nickel (Ni), cobalt (Co), mercury (Hg) were significantly higher in the exposed group than in the reference group, and no difference was observed for copper (Cu), zinc (Zn), stannum (Sn), cadmium (Cd). Transforming growth factor-β (TGF-β) and alpha-smooth muscle actin (α-SMA) were analyzed as the important indicators of fibrosis, which were statistically significantly higher in the exposed group than in the reference group. 8-isoprostane (8-I) and malondialdehyde (MDA) as the biomarkers of oxidative stress (OS) were elevated in the exposed group. Furthermore, both Spearman correlation and multiple linear regression showed that Co was positively correlated with TGF-β, α-SMA and 8-I in the exposed group. Accordingly, we speculate that high concentrations of Co dissolved in the blood may increase the risk of tissue fibrosis through stimulating myofibroblast activation and OS involve in the process, which may provide some potential new hints for the intervention for tissue fibrosis in the future.

Sex, HIV Status, and Measures of Cardiac Stress and Fibrosis in Uganda

Background

Biomarkers of myocardial stress and fibrosis are elevated in people living with HIV and are associated with cardiac dysfunction. It is unknown whether sex influences these markers of heart failure risk in sub‐Saharan Africa, where HIV burden is high and where the vast majority of women with HIV live.

Methods and Results

Echocardiograms and 6 plasma biomarkers (suppression of tumorigenicity‐2, growth differentiation factor 15, galectin 3, soluble fms‐like tyrosine kinase‐1, NT‐proBNP [N‐terminal pro‐B‐type natriuretic peptide], and cystatin C) were obtained from 100 people living with HIV on antiretroviral therapy and 100 HIV‐negative controls in Uganda. All participants were ≥45 years old with ≥1 major cardiovascular risk factor. Multivariable linear and logistic regression models were used to assess associations between biomarkers, echocardiographic variables, HIV status, and sex, and to assess whether sex modified these associations. Overall, mean age was 56 years and 62% were women. Suppression of tumorigenicity‐2 was higher in men versus women (P<0.001), and growth differentiation factor 15 was higher in people living with HIV versus controls (P<0.001). Sex modified the HIV effect on cystatin C and NT‐proBNP (both P for interaction <0.025). Women had more diastolic dysfunction than men (P=0.02), but there was no evidence of sex‐modifying HIV effects on cardiac structure and function. Cardiac biomarkers were more strongly associated with left ventricular mass index in men compared with women.

Conclusions

There are prominent differences in biomarkers of cardiac fibrosis and stress by sex and HIV status in Uganda. The predictive value of cardiac biomarkers for heart failure in people living with HIV in sub‐Saharan Africa should be examined, and novel risk markers for women should be further explored.

Risk of arthrofibrosis in anatomical anterior cruciate ligament reconstruction: the role of timing and meniscus suture

BACKGROUND

The optimal timing of anterior cruciate ligament (ACL) reconstruction remains controversial. Several studies have shown that early surgery leads to an increased rate of arthrofibrosis and poorer postoperative function. Other studies found no correlation between time of surgery and arthrofibrosis. The influence of simultaneous meniscus treatment is also discussed. Aim of this study was to ascertain whether the timing of surgery and treatment of meniscus influences the occurrence rate of arthrofibrosis.

METHODS

Two hundred and six patients could be included. These were split into two groups. Group 1: surgery within 6 weeks after ACL rupture (n = 68), group 2: surgery after more than 6 weeks (n = 68). In addition, 2 matched groups were created (n = 138 ). Follow-up was 12 months after surgery. The primary endpoint was the rate of subsequent arthrofibrosis procedures (arthroscopic arthrolysis). Secondary endpoints were knee function (knee osteoarthritis outcome score: KOOS), knee pain (numeric rating scale: NRS) and patient satisfaction measured on a 5 point Likert scale.

RESULTS

In 6 of the 68 patients in group 1 (8.8%) and 3 of the 138 patients in group 2 (2.2%) a subsequent arthroscopic arthrolysis was performed (OR 4.4). A simultaneous meniscal suture was performed in 58 patients (30 of them in group 1). Five of the six patients with subsequent arthrolysis in group 1 received meniscal repair (OR for arthrolysis 3.4). There was no difference between the groups in terms of knee function (KOOS), pain (NRS) and patient satisfaction.

CONCLUSION

The rate of subsequent arthroscopic arthrolysis was higher in the acute surgery group. However, most of these subsequent procedures were associated with meniscal repair at index surgery with a more restrictive rehabilitation protocol than after ACL reconstruction without meniscus repair. This allows the assessment that the meniscal suturing poses an increased risk. Therefore, this allows the conclusion that if using an anatomical surgical technique and considering the signs of inflammation with effusion, pain and movement deficit less than 90° there is no increased risk of arthrofibrosis.

Cirrhosis: An evidence-based approach

ABSTRACT

The role of nurses in managing patients with cirrhosis is increasing due to the growing prevalence of the disease. This article reviews the pathophysiology, diagnosis, complications, and management of patients with cirrhosis, with an emphasis on interdisciplinary collaboration and evidence-based practice.

Association between Markers of Fibrosis and Heart Failure Incidence in Patients with Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) and chronic heart failure (HF) have close association, and several biomarkers have been studied to better understand this association and improve prediction of HF in T2DM. Furthermore, in recent clinical trials, sodium glucose cotransporter 2 inhibitors (SGLT2i), glucose-lowering drugs, improved HF outcomes. The objective of the present study was to evaluate association between circulating biomarkers of fibrosis and incidence of HF with preserved ejection fraction (HFpEF) in patients with T2DM receiving sodium glucose cotransporter 2 inhibitors (SGLT2i). Materials and Methods. At baseline, transthoracic echocardiography and laboratory assessment of N-terminal fragment of the brain natriuretic peptide (Nt-proBNP), soluble suppression of tumorigenesis-2 (sST2), galectin-3 (Gal-3), C-terminal propeptide of procollagen type I (PICP), N-terminal propeptide of procollagen type III (PIIINP), matrix metalloproteinase-9 (MMP-9), and tissue inhibitor of matrix proteinase-1 (TIMP-1) were done. After 3 years of follow-up, information about HF events (hospitalization for HF, established HF in outpatient department by a cardiologist) was obtained. Results. Seventy-two patients were included in the study. The mean age was 57 (49.7; 63.2) years; 44% were female. Most patients had T2DM for more than 4 years. All patients were overweight or had obesity, and 93% patients had arterial hypertension (AH). After 3 years of follow-up, HFpEF was established in 21% patients. Patients were divided into two groups according to the presence of HFpEF, and baseline characteristics were compared. Patients with HF were older and had longer diabetes and AH duration and higher Nt-proBNP, Gal-3, PIIINP, and PICP levels at baseline than patients without HF (all p < 0.05). Gal - 3 > 10 ng/ml (OR = 2.25; 95% CI, 1.88-5.66; p = 0.01) and NT - pro - BNP > 80 pg/ml (OR = 2.64; 95% CI, 1.56-4.44; p = 0.001) were associated with increased risk of HF incidence. Age > 60 years, diabetes duration > 10 years, and presence of abdominal obesity were independent predictors of HFpEF as well. Conclusions. T2DM patients treated with SLGT2i, who developed HFpEF after 3 years of follow-up, had higher PICP, PIIINP, Gal-3, and NT-proBNP serum concentrations at baseline, and Gal-3 level was an independent predictor of HFpEF.

Global prevalence, incidence, and outcomes of non-obese or lean non-alcoholic fatty liver disease: a systematic review and meta-analysis

BACKGROUND

Although non-alcoholic fatty liver disease (NAFLD) is commonly associated with obesity, it is increasingly being identified in non-obese individuals. We aimed to characterise the prevalence, incidence, and long-term outcomes of non-obese or lean NAFLD at a global level.

METHODS

For this systematic review and meta-analysis, we searched PubMed, Embase, Scopus, and the Cochrane Library from inception to May 1, 2019, for relevant original research articles without any language restrictions. The literature search and data extraction were done independently by two investigators. Primary outcomes were the prevalence of non-obese or lean people within the NAFLD group and the prevalence of non-obese or lean NAFLD in the general, non-obese, and lean populations; the incidence of NAFLD among non-obese and lean populations; and long-term outcomes of non-obese people with NAFLD. We also aimed to characterise the demographic, clinical, and histological characteristics of individuals with non-obese NAFLD.

FINDINGS

We identified 93 studies (n=10 576 383) from 24 countries or areas: 84 studies (n=10 530 308) were used for the prevalence analysis, five (n=9121) were used for the incidence analysis, and eight (n=36 954) were used for the outcomes analysis. Within the NAFLD population, 19·2% (95% CI 15·9-23·0) of people were lean and 40·8% (36·6-45·1) were non-obese. The prevalence of non-obese NAFLD in the general population varied from 25% or lower in some countries (eg, Malaysia and Pakistan) to higher than 50% in others (eg, Austria, Mexico, and Sweden). In the general population (comprising individuals with and without NAFLD), 12·1% (95% CI 9·3-15·6) of people had non-obese NAFLD and 5·1% (3·7-7·0) had lean NAFLD. The incidence of NAFLD in the non-obese population (without NAFLD at baseline) was 24·6 (95% CI 13·4-39·2) per 1000 person-years. Among people with non-obese or lean NALFD, 39·0% (95% CI 24·1-56·3) had non-alcoholic steatohepatitis, 29·2% (21·9-37·9) had significant fibrosis (stage ≥2), and 3·2% (1·5-5·7) had cirrhosis. Among the non-obese or lean NAFLD population, the incidence of all-cause mortality was 12·1 (95% CI 0·5-38·8) per 1000 person-years, that for liver-related mortality was 4·1 (1·9-7·1) per 1000 person-years, cardiovascular-related mortality was 4·0 (0·1-14·9) per 1000 person-years, new-onset diabetes was 12·6 (8·0-18·3) per 1000 person-years, new-onset cardiovascular disease was 18·7 (9·2-31·2) per 1000 person-years, and new-onset hypertension was 56·1 (38·5-77·0) per 1000 person-years. Most analyses were characterised by high heterogeneity.

INTERPRETATION

Overall, around 40% of the global NAFLD population was classified as non-obese and almost a fifth was lean. Both non-obese and lean groups had substantial long-term liver and non-liver comorbidities. These findings suggest that obesity should not be the sole criterion for NAFLD screening. Moreover, clinical trials of treatments for NAFLD should include participants across all body-mass index ranges.

FUNDING

None.

Systematic review: medical therapy for fibrostenosing Crohn's disease

BACKGROUND

Medical therapy and/or endoscopic balloon dilation with intralesional therapies are options for the treatment of small bowel fibrostenotic Crohn's disease (CD).

AIM

To perform a systematic review summarising evidence for efficacy of systemic and endoscopic intralesional medical therapy in established small bowel strictures in adult CD patients.

METHODS

A systematic search of MEDLINE, EMBASE, CENTRAL and Scopus was conducted. Primary outcomes were rates of surgical resection and repeat endoscopic dilation. Pooled event rates from random effects models across studies with 95% confidence intervals were reported.

RESULTS

Ten studies describing systemic medical therapy and eight studies of intralesional injection were included. One randomised controlled trial each for systemic therapy and intrastricture injection were identified. Only observational studies were found for systemic biologic therapies, which exclusively included tumour necrosis factor (TNF) antagonists, while intralesional therapies all involved corticosteroids except for one study that evaluated infliximab. Pooled event rates for surgical resection after systemic and intralesional therapy were 28.3% (95% CI: 18.2%-41.3%) and 18.5% (95% CI: 8.3%-36.2%), respectively over a median follow-up of 23 months (range 5.5-105.8), and 21.8 months (range 5-47). Risk of repeat endoscopic balloon dilation in those with intralesional therapy was 58.3% (95% CI: 36.6%-77.3%) over a median follow-up of 21.8 months (range 5-47).

CONCLUSIONS

There are no favoured therapies for patients with stricturing small bowel CD. Data are lacking for ustekinumab and vedolizumab. No endoscopic intralesional medications provided a clear benefit for prevention of repeat EBD or surgery.

Non-Alcoholic Fatty Liver Disease in Patients with Type 2 Diabetes Mellitus: A Position Statement of the Fatty Liver Research Group of the Korean Diabetes Association

This clinical practice position statement, a product of the Fatty Liver Research Group of the Korean Diabetes Association, proposes recommendations for the diagnosis, progression and/or severity assessment, management, and follow-up of non-alcoholic fatty liver disease (NAFLD) in patients with type 2 diabetes mellitus (T2DM). Patients with both T2DM and NAFLD have an increased risk of non-alcoholic steatohepatitis (NASH) and fibrosis and a higher risk of cardiovascular diseases and diabetic complications compared to those without NAFLD. With regards to the evaluation of patients with T2DM and NAFLD, ultrasonography-based stepwise approaches using noninvasive biomarker models such as fibrosis-4 or the NAFLD fibrosis score as well as imaging studies such as vibration-controlled transient elastography with controlled attenuation parameter or magnetic resonance imaging-proton density fat fraction are recommended. After the diagnosis of NAFLD, the stage of fibrosis needs to be assessed appropriately. For management, weight reduction achieved by lifestyle modification has proven beneficial and is recommended in combination with antidiabetic agent(s). Evidence that some antidiabetic agents improve NAFLD/NASH with fibrosis in patients with T2DM is emerging. However, there are currently no definite pharmacologic treatments for NAFLD in patients with T2DM. For specific cases, bariatric surgery may be an option if indicated.

Does the intermittent Pringle maneuver affect the recurrence following surgical resection for hepatocellular carcinoma? A systematic review

BACKGROUND AND AIM

To evaluate the effect of intermittent pringle maneuver (IPM) on the long-term prognosis and recurrence of hepatocellular carcinoma (HCC).

METHODS

Eligible studies were identified by PubMed and other databases from Jan 1st 1990 to Mar 31st 2019. Hazard ratios (HR) with 95% confidence interval (CI) were calculated to evaluate the effects of IPM on the long-term prognosis and recurrence of patients with HCC.

RESULTS

Six studies were enrolled in this meta-analysis. Results showed that there were no differences between IPM group and non-IPM group in the pooled HRs for the overall survival (OS) and disease-free survival (DFS) (HR 1.04, 95%CI 0.84~1.28, P = 0.74; HR 0.93, 95%CI 0.81~1.07, P = 0.29; respectively). However, subgroup analysis showed that the pooled Odd ratios (OR) for the 1-year OS and DFS rates of the IPM group when compared with the non-IPM group were 0.65 (95% CI 0.45~0.94, P = 0.02), 0.38 (95% CI 0.20~0.72, P = 0.003), respectively. In addition, there were no significant differences in the proportions of liver cirrhosis, HBsAg (+), Child-Pugh A class, multiple tumor, vascular invasion, and major hepatectomy between groups of IPM and non-IPM.

CONCLUSION

Since IPM would increase the risk of early-recurrence, it should be used cautiously in the procedure of hepatectomy for resectable HCC. However, the current conclusion needs further validation.

TRIAL REGISTRY NUMBER

CRD 42019124923.

Incidence and risk factors for cyclops syndrome after anterior cruciate ligament reconstruction: A systematic literature review

BACKGROUND

Cyclops syndrome after anterior cruciate ligament (ACL) reconstruction is due to a fibrous nodule that develops in the anterior part of the intercondylar notch and prevents full knee extension. The primary objective of this systematic literature review was to evaluate the incidence of symptomatic cyclops lesion after ACL reconstruction. The secondary objective was to identify risk factors for cyclops syndrome.

HYPOTHESIS

Cyclops syndrome is common after ACL reconstruction and has several risk factors reported in the literature.

METHODS

A systematic literature review was performed by searching the PubMed, Medline, CINAHL, Cochrane, and Embase databases with the key terms 'cyclops' and 'ACL reconstruction'. The data thus retrieved were evaluated independently by two investigators. All articles in English or French that reported the incidence and risk factors of cyclops syndrome after ACL reconstruction were included.

RESULTS

The search retrieved the titles and abstracts of 79 articles, of which 20 were selected to be read in full; among these, 10 were included in the study. The incidence of symptomatic cyclops lesion ranged from 1.9% to 10.9%. Identified risk factors were as follows: pre-operatively, knee inflammation and/or motion restriction at the time of ACL reconstruction; intra-operatively, narrow intercondylar notch and excessively anterior position of the tibial tunnel; and post-operatively, persistent hamstring muscle spasm.

DISCUSSION

Development of a cyclops lesion is common after ACL reconstruction, occurs early, and may require further surgery. The knowledge of the risk factors provided by this study may improve the ability to devise effective preventive measures.

LEVEL OF EVIDENCE

II, systematic literature review.

Nonalcoholic Fatty Liver Disease and Diabetes: An Epidemiological Perspective

Nonalcoholic fatty liver disease (NAFLD) is thought to stem from the body's inability to store excess energy in adipocytes; as such, it is commonly viewed as the hepatic manifestation of metabolic syndrome. The pathogenesis of NAFLD involves ectopic fat accumulation, which also takes place in the liver, muscle and visceral fat. NAFLD is rapidly becoming more widespread in Korea, with an estimated prevalence of 30% in adults. Type 2 diabetes mellitus (T2DM) and NAFLD share insulin resistance as a common pathophysiological mechanism, and each of these two diseases affects the development of the other. Recent studies have suggested that NAFLD is often present as a comorbidity in T2DM patients. The mutual interrelationship between these conditions is shown by findings suggesting that T2DM can exacerbate NAFLD by promoting progression to nonalcoholic hepatosteatosis or fibrosis, while NAFLD causes the natural course of diabetic complications to worsen in T2DM patients. It remains unknown whether one disease is the cause of the other or vice versa. In this review, I would like to discuss current epidemiological data on the associations between NAFLD and T2DM, and how each disease affects the course of the other.

High sex hormone-binding globulin concentration is a risk factor for high fibrosis-4 index in middle-aged Japanese men

Low endogenous testosterone and sex hormone-binding globulin (SHBG) concentrations have been reported to be associated with metabolic syndrome (MetS) and non-alcoholic fatty liver disease (NAFLD). However, little is known about the relationships between testosterone or SHBG and liver fibrosis in NAFLD. Thus, we aimed to clarify the relationships between serum testosterone or SHBG concentration and fibrosis-4 (FIB-4) index, a marker of liver fibrosis. Serum testosterone was assayed in various forms (total testosterone [TT], calculated free testosterone [cFT], calculated bioavailable testosterone [cbT], and SHBG) and metabolic markers were also measured in 363 Japanese men (mean age 51.1 ± 8.7 years) at routine health examinations. We then attempted to identify the factors contributing to liver fibrosis by investigating the associations between the metabolic markers, including testosterone, and FIB-4 index. People with a relatively high FIB-4 index (≥1.3) demonstrated lower cFT, cbT, homeostasis model assessment (HOMA)-β, low-density lipoprotein-cholesterol, and blood urea nitrogen, but higher SHBG, than those with a lower FIB-4 index (<1.3). There were no significant differences in HbA1c, fasting glucose concentration, HOMA-R, or metabolic syndrome prevalence between the two groups. Binary regression analysis revealed that SHBG ≥52 nmol/L and cFT <8.0 ng/dL were statistically significant risk factors for FIB-4 index ≥1.3. Receiver operating characteristic analysis revealed that cFT <7.62 ng/dL (area under the curve [AUC] = 0.639) and SHBG ≥49.8 nmol/L (AUC = 0.649) were the strongest risk factors for FIB-4 index ≥1.3. In contrast to previous findings showing low SHBG concentrations in NAFLD, we provide evidence that high SHBG and low bioactive testosterone are associated with liver fibrosis.

Lowering the upper limit of serum alanine aminotransferase levels may reveal significant liver disease in the elderly

This study sought to determine the prevalence of significant liver disease in those subjects with serum alanine aminotransferase levels in the range between the current and the newly suggested upper limit of normal (termed the delta range). The files of the previous study subjects (who underwent at least one alanine aminotransferase measurement in 2002 and followed to 2012) were reviewed for a diagnosis of chronic liver disease; aspartate aminotransferase/platelet ratio index, FIB-4 and alanine aminotransferase/aspartate aminotransferase ratio were used to evaluate liver fibrosis. The prevalence of significant liver disease, by diagnoses and fibrosis scores was compared between subjects with alanine aminotransferase levels in the delta range (men, 42-45 IU/L; women, 26-34 IU/L) and in the newly suggested normal range (men, 15-42 IU/L; women, 10-26 IU/L). The cohort included 49,634 subjects (41% male, mean age 83±6 years) of whom 2022 were diagnosed with chronic liver disease including 366 with cirrhosis. Compared to subjects with alanine aminotransferase levels in the newly suggested normal range, subjects with alanine aminotransferase levels in the delta range had a significantly higher rate of chronic liver disease (men, 15.3% vs. 4.9%; women, 7.8% vs. 3.3%) and of cirrhosis specifically (men, 4.2% vs. 0.9%; women, 1.5% vs. 0.4%) and also had higher mean fibrosis scores (P <0.001 for all). Lowering the current upper limit of normal of serum alanine aminotransferase may help to identify elderly patients at risk of significant liver disease.

Clinical and endoscopic predictors for intraprocedural mucosal injury during per-oral endoscopic myotomy

BACKGROUND AND AIMS

Mucosal injury (MI) is one of the most common perioperative adverse events of per-oral endoscopic myotomy (POEM). Severe undertreated MI may lead to contamination of the tunnel and even mediastinitis. This study explored the characteristics, predictors, and management approaches of intraoperative MI.

METHODS

A retrospective review of the prospectively collected database at a large tertiary referral endoscopy unit was conducted for all patients undergoing POEM between August 2010 and March 2016. MI was graded according to the difficulty of repair (I, easy to repair; II, difficult to repair). The primary outcomes were the incidence and predictors of intraoperative MI. Secondary outcomes were MI details and the corresponding treatment.

RESULTS

POEM was successfully performed in 1912 patients. A total of 338 patients experienced 387 MIs, for an overall frequency of 17.7% (338/1912). Type II MI was rare, with a frequency of 1.7% (39/1912). Major adverse events were more common in patients with MI than in those without MI (6.2% vs 2.5%, P < .001). On multivariable analysis, MI was independently associated with previous Heller myotomy (odds ratio [OR], 2.094; P = .026), previous POEM (OR, 2.441; P = .033), submucosal fibrosis (OR, 4.530; P < .001), mucosal edema (OR, 1.834; P = .001), and tunnel length ≥13 cm (OR, 2.699; P < .001). Previous POEM (OR, 5.005; P = .030) and submucosal fibrosis (OR, 12.074; P < .001) were significant predictors of type II MI. POEM experience >1 year was a protective factor for MI (OR, .614; P = .042) and type II MI (OR, .297; P = .042).

CONCLUSIONS

MI during POEM is common, but type II injury is rare. Previous POEM and submucosal fibrosis were significant predictors of type II mucosal injury. POEM experience after the learning curve reduces the risk of MI.

Perspectives on the expansion of human precision oncology and genomic approaches to sea turtle fibropapillomatosis

Our recent Communications Biology research article revealed the genomic drivers and therapeutic vulnerabilities of sea turtle fibropapillomatosis tumors. Fibropapillomatosis is a debilitating tumorous disease afflicting populations of green sea turtles globally. While a virus is involved in the development of this disease, it is increasingly understood that the key trigger is linked to anthropogenic disturbances of the environment. The specific environmental co-trigger(s) has yet to be functionally confirmed. Here we outline the next steps required to advance our understanding of this enigmatic disease, to enable us to more effectively clinically combat it and to ultimately tackle its environmental co-trigger to halt and hopefully reverse the spread of fibropapillomatosis.

Co-occurrence of opisthorchiasis and diabetes exacerbates morbidity of the hepatobiliary tract disease

Complications arising from infection with the carcinogenic liver fluke Opisthorchis viverrini cause substantial morbidity and mortality in Thailand and adjacent lower Mekong countries. In parallel, the incidence rate of diabetes mellitus (DM) is increasing in this same region, and indeed worldwide. Many residents in opisthorchiasis-endemic regions also exhibit DM, but the hepatobiliary disease arising during the co-occurrence of these two conditions remains to be characterized. Here, the histopathological profile during co-occurrence of opisthorchiasis and DM was investigated in a rodent model of human opisthorchiasis in which diabetes was induced with streptozotocin. The effects of excretory/secretory products from the liver fluke, O. viverrini (OVES) on hepatocyte and cholangiocyte responses during hyperglycemic conditions also were monitored. Both the liver fluke-infected hamsters (OV group) and hamsters with DM lost weight compared to control hamsters. Weight loss was even more marked in the hamsters with both opisthorchiasis and DM (OD group). Hypertrophy of hepatocytes, altered biliary canaliculi, and biliary hyperplasia were more prominent in the OD group, compared with OV and DM groups. Profound oxidative DNA damage, evidenced by 8-oxo-2'-deoxyguanosine, proliferating cell nuclear antigen, and periductal fibrosis characterized the OD compared to OV and DM hamsters. Upregulation of expression of cytokines in response to infection and impairment of the pathway for insulin receptor substrate (IRS)/phosphatidylinositol-3-kinases (PI3K)/protein kinase B (AKT) signaling attended these changes. In vitro, OVES and glucose provoked time- and dose-dependent effects on the proliferation of both hepatocytes and cholangiocytes. In overview, the co-occurrence of opisthorchiasis and diabetes exacerbated pathophysiological damage to the hepatobiliary tract. We speculate that opisthorchiasis and diabetes together aggravate hepatobiliary pathogenesis through an IRS/PI3K/AKT-independent pathway.

Use of Neuromuscular Electrical Stimulation During Physical Therapy May Reduce the Incidence of Arthrofibrosis After Total Knee Arthroplasty

INTRODUCTION

Arthrofibrosis remains a major complication following total knee arthroplasty (TKA) that negatively impacts patient outcomes and exhausts healthcare resources. The use of neuromuscular electrical stimulation (NMES) has demonstrated the ability to facilitate quadriceps muscle recovery and reduce pain. Therefore, the purpose of this study was to compare TKA patients who received physical therapy (PT) and adjuvant NMES therapy versus physical therapy alone in terms of: 1) rates of manipulation under anesthesia (MUA) to treat arthrofibrosis; and 2) post-therapy range of motion (ROM).

MATERIALS AND METHODS

This was a retrospective review of TKA patients from multiple institutions who underwent physical therapy versus physical therapy and adjuvant NMES therapy following primary TKA. A total of 206 patients were reviewed in the two cohorts that either received PT alone (n=86) or PT and adjuvant NMES therapy (n=120). Data regarding the requirement of MUA postoperatively for treatment of arthrofibrosis were collected for every patient. Additionally, pre- and post-therapy knee ROM data was also collected. Outcomes in both cohorts were then compared and analyzed.

RESULTS

Lower rates of arthrofibrosis requiring MUA were recorded in patients who used NMES therapy and PT when compared to PT alone (7.5% vs. 19.8%; p=0.009). Log regression analysis revealed lower odds of needing MUA in patients who utilized NMES therapy in adjunct with PT (odds ratio [OR]=0.36; 95% CI: 0.115 to 0.875; p=0.023). Patients who received the NMES therapy were shown to have a statistically greater mean improvement in ROM when compared to those patients who did not receive NMES (+2.63, p=0.04). Log regression analysis also demonstrated that post-PT ROM decreased the odds of receiving MUA with a larger ROM (OR=92; 95% CI: 0.824 to 0.9855; p<0.001).

CONCLUSION

This study demonstrated that the use of NMES during PT may reduce the incidence of arthrofibrosis and improve patient ROM. Prospective, randomized controlled, and larger-scale studies are needed to validate these results. Nevertheless, this novel report demonstrated the positive outcomes for a new application of the NMES therapy.

Functional associations of pleuroparenchymal fibroelastosis and emphysema with hypersensitivity pneumonitis

BACKGROUND

Pleuroparenchymal fibroelastosis (PPFE) has been described in hypersensitivity pneumonitis (HP) yet its functional implications are unclear. Combined pulmonary fibrosis and emphysema (CPFE) has occasionally been described in never-smokers with HP, but epidemiological data regarding its prevalence is sparse. CTs in a large HP cohort were therefore examined to identify the prevalence and effects of PPFE and emphysema.

Methods

233 HP patients had CT extents of interstitial lung disease (ILD) and emphysema quantified to the nearest 5%. Lobar percentage pleural involvement of PPFE was quantified on a 4-point categorical scale: 0 = absent, 1 = affecting <10%, 2 = affecting 10–33%, 3 = affecting >33%. Marked PPFE reflected a total lung score of ≥3/18. Results were evaluated against FVC, DLco and mortality.

RESULTS

Marked PPFE prevalence was 23% whilst 23% of never-smokers had emphysema. Following adjustment for patient age, gender, smoking status, and ILD and emphysema extents, marked PPFE independently linked to reduced baseline FVC (p = 0.0002) and DLco (p = 0.002) and when examined alongside the same covariates, independently linked to worsened survival (p = 0.01).

CPFE in HP demonstrated a characteristic functional profile of artificial lung volume preservation and disproportionate DLco reduction. CPFE did not demonstrate a worsened outcome when compared to HP patients without emphysema beyond that explained by CT extents of ILD and emphysema.

CONCLUSIONS

PPFE is not uncommon in HP, and is independently associated with impaired lung function and increased mortality. Emphysema was identified in 23% of HP never-smokers. CPFE appears not to link to a malignant microvascular phenotype as outcome is explained by ILD and emphysema extents.

•

In patients with HP, marked PPFE had a prevalence of 23% in our study cohort.

•

23% of never-smokers with HP demonstrated emphysema on CT imaging.

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Outcome in HP patients with CPFE is explained by CT extents of ILD and emphysema.

•

PPFE is independently associated with a worsened outcome in HP.

[Interrelation between the melatonin level and indicators of aging and fibrosis in men in the European part of the Arctic zone of Russian Federation.]

The results of the correlation analysis between the metabolite melatonin - 6-sulfatoxymelatonin (6-SMT) in the urine and the indicators of aging, interstitial fibrosis, the system of antioxidant protection in men in the Arctic are presented. Negative correlation of medium strength between 6-SMT with calendar age, biological age and molecular marker of aging p16INK4a in leukocytes was noted. A relationship of 6-SMT to fibrosis indices was found. It manifested itself in a negative correlation with sulfated glycosaminoglycans in the urine, with collagen markers: free hydroxyproline, peptide-linked hydroxyproline, and total hydroxyproline. Age-related decrease in the level of 6-SMT may be associated with an age-related increase in interstitial fibrosis in northerners. A positive correlation of medium strength between 6-SMT and hormones: free testosterone level (r=0,53, p=0,0002), total testosterone (r=0,43, p=0,003) and cortisol (r=0,33, p=0,007) was shown. Negative correlations of 6-SMT with the content of ceruloplasmin (r=-0,63, p=0,001) and SCORE scale (r=-0,52, p=0,001) indicate the relationship between melatonin and the antioxidant defense system and the risk of cardiovascular pathology.The results of the correlation analysis between the metabolite melatonin - 6-sulfatoxymelatonin (6-SMT) in the urine and the indicators of aging, interstitial fibrosis, the system of antioxidant protection in men in the Arctic are presented. Negative correlation of medium strength between 6-SMT with calendar age, biological age and molecular marker of aging p16INK4a in leukocytes was noted. A relationship of 6-SMT to fibrosis indices was found. It manifested itself in a negative correlation with sulfated glycosaminoglycans in the urine, with collagen markers: free hydroxyproline, peptide-linked hydroxyproline, and total hydroxyproline. Age-related decrease in the level of 6-SMT may be associated with an age-related increase in interstitial fibrosis in northerners. A positive correlation of medium strength between 6-SMT and hormones: free testosterone level (r=0,53, p=0,0002), total testosterone (r=0,43, p=0,003) and cortisol (r=0,33, p=0,007) was shown. Negative correlations of 6-SMT with the content of ceruloplasmin (r=-0,63, p=0,001) and SCORE scale (r=-0,52, p=0,001) indicate the relationship between melatonin and the antioxidant defense system and the risk of cardiovascular pathology.

Statin Use and Risk of Cirrhosis and Related Complications in Patients With Chronic Liver Diseases: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Statins have been variably shown to decrease risk and complications of chronic liver diseases (CLDs). We performed a systematic review and meta-analysis to evaluate the association between statins and risk of cirrhosis and related complications in patients with CLDs.

METHODS

Through a systematic literature search up to March 2017, we identified 13 studies (3 randomized trials, 10 cohort studies) in adults with CLDs, reporting the association between statin use and risk of development of cirrhosis, decompensated cirrhosis, improvements in portal hypertension, or mortality. Pooled relative risk (RR) estimates with 95% confidence interval (CIs) were calculated using random effects model. Grading of Recommendations Assessment, Development and Evaluation criteria were used to assess quality of evidence.

RESULTS

Among 121,058 patients with CLDs (84.5% with hepatitis C), 46% were exposed to statins. In patients with cirrhosis, statin use was associated with 46% lower risk of hepatic decompensation (4 studies; RR, 0.54; 95% CI, 0.46-0.62; I2 = 0%; moderate-quality evidence), and 46% lower mortality (5 studies; RR, 0.54; 95% CI, 0.47-0.61; I2 = 10%; moderate-quality evidence). In patients with CLD without cirrhosis, statin use was associated with a nonsignificant (58% lower) risk of development of cirrhosis or fibrosis progression (5 studies; RR, 0.42; 95% CI, 0.16-1.11; I2 = 99%; very-low-quality evidence). In 3 randomized controlled trials, statin use was associated with 27% lower risk of variceal bleeding or progression of portal hypertension (hazard ratio, 0.73; 95% CI, 0.59-0.91; I2 = 0%; moderate-quality evidence).

CONCLUSIONS

Based on a systematic review and meta-analysis, statin use is probably associated with lower risk of hepatic decompensation and mortality, and might reduce portal hypertension, in patients with CLDs. Prospective observational studies and randomized controlled trials are needed to confirm this observation.

Population Pharmacokinetics of Paritaprevir, Ombitasvir, and Ritonavir in Japanese Patients with Hepatitis C Virus Genotype 1b Infection

BACKGROUND AND OBJECTIVE

Hepatitis C virus (HCV) infection is of considerable clinical concern in Japan. We modeled the population pharmacokinetics of an oral interferon-free, direct-acting antiviral agent (DAA) regimen (i.e., the 2D regimen) recently approved for the treatment of chronic HCV genotype 1 infection as a new option for affected Japanese patients.

METHODS

Using data from a phase III clinical trial (GIFT-I) that enrolled Japanese patients with HCV genotype 1b infection, population pharmacokinetic models were developed for the drugs that comprise the 2D regimen: paritaprevir, ombitasvir, and ritonavir. Demographic and clinical covariates with potential to influence 2D pharmacokinetics were evaluated for their effects on drug exposures. Proposed models were assessed using goodness-of-fit plots, visual predictive checks, and bootstrap evaluations.

RESULTS

One-compartment models with first-order absorption and elimination adequately described the population pharmacokinetics of paritaprevir, ombitasvir, and ritonavir. On average, patients with cirrhosis had approximately 95-145 % higher, 19-24 % lower, and 58-68 % higher exposures of paritaprevir, ombitasvir, and ritonavir, respectively. Female patients had 58-81 % higher ombitasvir exposures, whereas patients with mild renal impairment (creatinine clearance 75 mL/min) had 9-14 % higher ombitasvir exposures than did patients with normal renal function (creatinine clearance 105 mL/min). The DAA exposure values were comparable between responders and non-responders.

CONCLUSION

Population pharmacokinetic modeling did not reveal any patient-related or clinical parameters that would require dose adjustment of the 2D regimen when used for the treatment of HCV genotype 1b infection in Japanese patients.

Pathophysiology of Aortic Valve Stenosis: Is It Both Fibrocalcific and Sex Specific?

Our understanding of the fundamental biology and identification of efficacious therapeutic targets in aortic valve stenosis has lagged far behind the fields of atherosclerosis and heart failure. In this review, we highlight the most clinically relevant problems facing men and women with fibrocalcific aortic valve stenosis, discuss the fundamental biology underlying valve calcification and fibrosis, and identify key molecular points of intersection with sex hormone signaling.

Distal intestinal obstruction syndrome and colonic pathologies in cystic fibrosis

The management of abdominal pain in cystic fibrosis can be complicated. Distal intestinal obstruction syndrome is a common cause of pain and obstruction in these patients. Knowledge of the diagnosis and management and of similar presenting symptoms is essential for the hospital doctor.

A Prospective Study of the Lymphedema and Fibrosis Continuum in Patients with Head and Neck Cancer

BACKGROUND

The purpose of this study was to determine the prevalence and nature of internal, external, and combined lymphedema and fibrosis in patients with head and neck cancer (HNC).

MATERIALS AND METHODS

We obtained consent from 100 patients newly diagnosed with having cancer of the head and neck for a 4-year, prospective, longitudinal descriptive study. Recruitment began in August 23, 2010, and the study was completed in April 24, 2014. Eighty-three were evaluated at regular intervals from preradiation therapy to 18 months post-treatment. Percentage developing external, internal, or both types of lymphedema and/or fibrosis and trajectories of the severity of external, internal, or both types of lymphedema and/or fibrosis were determined.

RESULTS

Before treatment, lymphedema rates were the following: external: 62.7%, internal: 41.7%, or combined: 29.2%, and/or fibrosis: 42.2%. Ranges of lymphedema late-effect rates were even higher: external: 81.9%-90.1%, internal: 80.4%-89.4%, combined: 70.6%-80.9%, and fibrosis: 66.7%-77.4%. Approximately 75% had a late-effect trajectory characterized by moderate to severe external or internal lymphedema; ∼47% had moderate to severe fibrosis.

CONCLUSION

Lymphatic and soft tissue complications of HNC occur not only post-treatment but also before treatment. They are ubiquitous throughout the first 18 months post-treatment, with greater than 90% of patients in our study experiencing some form of internal, external, or combined lymphedema, and over half of those patients developing fibrosis. Further research regarding these conditions is indicated.

Cost-effectiveness of currently recommended direct-acting antiviral treatments in patients infected with genotypes 1 or 4 hepatitis C virus in the US

OBJECTIVE

This study compared the cost-effectiveness of direct-acting antiviral therapies currently recommended for treating genotypes (GT) 1 and 4 chronic hepatitis C (CHC) patients in the US.

METHODS

A cost-effectiveness analysis of treatments for CHC from a US payer's perspective over a lifelong time horizon was performed. A Markov model based on the natural history of CHC was used for a population that included treatment-naïve and -experienced patients. Treatment alternatives considered for GT1 included ombitasvir/paritaprevir/ritonavir + dasabuvir ± ribavirin (3D ± R), sofosbuvir + ledipasvir (SOF/LDV), sofosbuvir + simeprevir (SOF + SMV), simeprevir + pegylated interferon/ribavirin (SMV + PR) and no treatment (NT). For GT4 treatments, ombitasvir/paritaprevir/ritonavir + ribavirin (2D + R), SOF/LDV and NT were compared. Transition probabilities, utilities and costs were obtained from published literature. Outcomes included rates of compensated cirrhosis (CC), decompensated cirrhosis (DCC), hepatocellular carcinoma (HCC) and liver-related death (LrD), total costs, life-years and quality-adjusted life-years (QALYs). Costs and QALYs were used to calculate incremental cost-effectiveness ratios.

RESULTS

In GT1 patients, 3D ± R and SOF-containing regimens have similar long-term outcomes; 3D ± R had the lowest lifetime risks of all liver disease outcomes: CC = 30.2%, DCC = 5.0 %, HCC = 6.8%, LT = 1.9% and LrD = 9.2%. In GT1 patients, 3D ± R had the lowest cost and the highest QALYs. As a result, 3D ± R dominated these treatment options. In GT4 patients, 2D + R had lower rates of liver morbidity and mortality, lower cost and more QALYs than SOF/LDV and NT.

LIMITATIONS

While the results are based on input values, which were obtained from a variety of heterogeneous sources-including clinical trials, the findings were robust across a plausible range of input values, as demonstrated in probabilistic sensitivity analyses.

CONCLUSIONS

Among currently recommended treatments for GT1 and GT4 in the US, 3D ± R (for GT1) and 2D + R (for GT4) have a favorable cost-effectiveness profile.

Impact of Age-related Comorbidities on Five-year Overall Mortality among Elderly HIV-Infected Patients in the Late HAART Era--Role of Chronic Renal Disease

OBJECTIVES

To identify main prognostic factors for 5-year mortality among age-related comorbidities (ARCs) in older people living with HIV (PLHIV).

DESIGN

A prospective, multicentre cohort study with a 5-year follow-up period in the late HAART era (from January 2008 to December 2012).

SETTING

The Dat'AIDS cohort involving 12 French hospitals.

PARTICIPANTS

All actively followed HIV-1 infected patients aged 60 or older.

MEASUREMENTS

The study endpoint was all-cause five-year mortality. The following ARCs were considered: chronic renal disease, cardiovascular diseases, cancer, chronic pulmonary disease, cirrhosis, diabetes and nutritional status. Hepatitis C (HCV), hepatitis B (HBV) co-infection and sociodemographic characteristics were also evaluated. Cox's Proportional Hazards model was used for multivariate analysis.

RESULTS

Among 1415 PLHIV aged 60 or more patients included, mean age was 66±5.5 years; 154 died (mortality rate 2.47/100 patient-years). The most prevalent ARCs were chronic renal disease (20.1%), diabetes (14.2%) and cardiovascular diseases (12.2%). By multivariate analysis, chronic renal disease (adjusted hazard ratio (aHR)=2.25; 95% confidence interval (CI) [1.58-2.21]; p<10-4), cardiovascular diseases (aHR=2.40; 95%CI[1.64-3.52]; p<10-4), non-HIV related cancer (aHR=1.91; 95%CI[1.20-3.05]; p=0.007), cirrhosis (aHR=2.99; 95%CI[1.68-5.33]; p<10-3), HCV co-infection (aHR=2.00; 95%CI[1.18-3.38]; p=0.009), low body mass index (aHR=2.42; 95%CI[1.46-4.01]; p<10-3) and CD4 cell count < 200 cells/µl (aHR=2.23; 95%CI[1.36-3.65]; p=0.002) were independently associated with 5 year mortality.

CONCLUSION

Due to a high prevalence, chronic renal disease and cardiovascular disease are main prognostic factors for 5-year mortality among aged PLHIV.

Left Ventricular Deformation and Myocardial Fibrosis in Patients With Advanced Heart Failure Requiring Transplantation

PURPOSE

To evaluate potential relationships between different components of left ventricular (LV) function and histopathological evidence for myocardial fibrosis in patients undergoing heart transplantation.

METHODS

The study population included patients with advanced heart failure, referred for an echocardiographic examination before heart transplantation. Traditional LV function measurements and global longitudinal strain (GLS) by speckle tracking echocardiography, averaging all LV segments in 4-, 2-, and 3-chamber views were obtained in all subjects. LV tissue samples were obtained from all patients who underwent heart transplantation. Myocardial fibrosis was assessed using Masson's staining.

RESULTS

Of 106 patients referred for cardiac transplantation, 47 underwent cardiac transplantation and were enrolled in the study. LV myocardial fibrosis and its grade strongly correlated with GLS (r = 0.75, P = .0001), modestly with global circumferential strain and LV torsion (r = 0.61, P = .001 and r = 0.52, P = .01, respectively) and weakly with mitral S' wave (r = -0.41; P = .01) and mitral annular plane systolic excursion (r = -0.35; P = .05) but did not correlate with LV ejection fraction (r = -0.12; P = NS). GLS had the strongest accuracy for detecting LV fibrosis (area under the curve, 0.92). None of the echo parameters correlated with patient's exercise capacity.

CONCLUSION

Global longitudinal strain is the most accurate LV global function measure that correlates with the extent of myocardial fibrosis in patients with advanced systolic HF requiring heart transplantation.

Pleiotropic Effects of Immune Responses Explain Variation in the Prevalence of Fibroproliferative Diseases

Many diseases are differentially distributed among human populations. Differential selection on genetic variants in ancestral environments that coincidentally predispose to disease can be an underlying cause of these unequal prevalence patterns. Selected genes may be pleiotropic, affecting multiple phenotypes and resulting in more than one disease or trait. Patterns of pleiotropy may be helpful in understanding the underlying causes of an array of conditions in a population. For example, several fibroproliferative diseases are more prevalent and severe in populations of sub-Saharan ancestry. We propose that this disparity is due to selection for an enhanced Th2 response that confers resistance to helminthic infections, and concurrently increases susceptibility to fibrosis due to the profibrotic action of Th2 cytokines. Many studies on selection of Th2-related genes for host resistance to helminths have been reported, but the pleiotropic impact of this selection on the distribution of fibrotic disorders has not been explicitly investigated. We discuss the disproportionate occurrence of fibroproliferative diseases in individuals of African ancestry and provide evidence that adaptation of the immune system has shaped the genetic structure of these human populations in ways that alter the distribution of multiple fibroproliferative diseases.

Morphometric analysis of epithelial thickness and blood vessels in different grades of oral submucous fibrosis

BACKGROUND

Oral submucous fibrosis (OSF) is a common oral health problem in the Indian subcontinent. It is characterized by a juxtaepithelial inflammatory reaction followed by fibroelastic changes in the lamina propria. Traditionally, it is said to be associated with marked epidermal atrophy and decreased vasculature as the disease advances.

OBJECTIVE

To assess the changes in epidermal thickness and mucosal vasculature in various stages of the disease.

MATERIAL AND METHODS

Patients with histological diagnosis of OSF were included in the study. Demographic data and oral habits of each patient were collected. The severity of OSF was graded histologically according to Pindborg and Sirsat. Epithelial thickness and subepithelial blood vessel area, diameter and perimeter were measured and analysed using Image analysis software IMAGE PRO PLUS version 6.0.

RESULTS

Thirty-five patients with OSF were studied. 25 (71.4%) were males and 10 (28.6%) were females with a male to female ratio of 1.3:1. Most patients were in the 31-40 yrs age group. The majority of patients (40%) chewed areca nut/dohra. Each grade of the disease was found to display either hyperplastic or atrophic epithelial changes. The mean blood vessel area, diameter and perimeter did not show any sustained change with the increasing severity (grade) of the disease.

CONCLUSION

These findings question the role of ischaemia in the aetiopathogenesis of oral submucous fibrosis.

Relation of burden of myocardial fibrosis to malignant ventricular arrhythmias and outcomes in Fabry disease

The aim of this study was to investigate the impact of myocardial fibrosis in Fabry disease. Seventy-three patients with genetically confirmed Fabry disease were followed for 4.8 ± 2.4 years. In accordance with current guidelines, 57 patients received enzyme replacement therapy (ERT) after study inclusion, whereas 16 did not. At baseline and latest possible follow-up, myocardial fibrosis was assessed noninvasively by cardiac magnetic resonance, and biomarkers of collagen metabolism were determined. Holter electrocardiography and clinical follow-up at yearly intervals were used to monitor malignant ventricular arrhythmias (MVAs; nonsustained and sustained ventricular tachycardia and sudden cardiac death). In total, 48 patients (66%) showed fibrosis assessed by late enhancement (LE) at baseline, and 4 patients developed new LE during follow-up, 2 of them despite ERT. The 2 patients receiving ERT (1.4 ± 1.9% vs 2.5 ± 2.6%, p <0.001) and the patients not receiving ERT (0.5 ± 0.8% vs 0.7 ± 1.0%, p = 0.035) showed a progression of LE during follow-up. None of the patients displayed reductions of LE during follow-up. Collagen biomarkers were elevated in patients with and without LE but did not correlate with LE amount. Thirteen LE-positive patients at the baseline examination had documented MVAs (including 5 sudden cardiac deaths), whereas none of the patients without LE had MVAs. The yearly increase in fibrosis was 0.9 ± 0.6% in patients with MVAs and 0.2 ± 0.3% in patients without MVAs (p <0.001). Logistic multivariate regression analysis revealed that the annual increase in fibrosis during follow-up was the only independent predictor of MVAs. In conclusion, myocardial fibrosis in Fabry disease is progressive, apparently not modified by ERT, and a crucial outcome determinant.

Distal quadricepsplasty in children: 88 cases of retractile fibrosis following intramuscular injections treated in Benin

INTRODUCTION

Retractile fibrosis of the quadriceps (RFQ) is a physical and social handicap in children, and often results from a past history of quadriceps intramuscular injection. The aim of this study was to evaluate the therapeutic results of RFQ treated by distal quadricepsplasty using a modified Thompson-Payr procedure (DQPMTP).

HYPOTHESIS

Functional recovery will be good with DQPMTP.

PATIENTS AND METHODS

This is a descriptive retrospective 10-year study from 2002 to 2011, including 74 children (88 knees) less than 15 years old, admitted for RFQ and treated in Benin. The types of RFQ were: knee flexion loss of motion 16 cases (18.2%), lag of extension 54 cases (61.4%) and associated genu recurvatum, 18 cases (20.5%). Wasting of the thigh was found in all cases. An associated distal femoral osteotomy was performed to correct a bone deformity in 18 cases (20.5%).

RESULTS

There were 16 cases (18.2%) of poorly looking postoperative scars and 2 cases (2.3%) of fracture during physical therapy. Mean flexion ROM after surgery was 77.7°. Mean flexion increased from 77.7° to 108.5° following postoperative rehabilitation or a mean gain of 30.7°. The quadriceps muscle testing scores were at least 3/5. Results of DQPMTP were good in 80.7% of cases, as shown by mean active knee flexion of 108.5° with normal active extension. The results were satisfactory in 17 cases (19.3%).

DISCUSSION

DQPMTP has the advantage of cutting a minimum of blood vessels, thus limiting the risk of hematoma. Laterally placed incisions create less tension reducing the risk of skin necrosis. The clinical and radiological results of this series confirm those in the literature. Treatment of RFQ by DQPMTP provides satisfactory functional rehabilitation in patients, which confirms our hypothesis.

LEVEL OF EVIDENCE

Level IV, retrospective study without comparison.

Accelerated renal fibrosis in cardiorenal syndrome is associated with long-term increase in urine neutrophil gelatinase-associated lipocalin levels

BACKGROUND

Cardiac events are the main cause of death among patients with end-stage renal failure. Even a mild renal disease is currently considered a major risk factor for cardiovascular complications following myocardial infarction (MI). The aim of the present study was to detect histological, sera and urine characteristics of kidney injury in cardiorenal syndrome (CRS) compared to chronic kidney disease (CKD) with an intact cardiac function.

METHODS

We employed a rat model for CRS, in which an acute MI (AMI) was induced 4 weeks after establishment of subtotal nephrectomy. Four weeks later, left ventricular function was assessed by echocardiography and changes in renal performance were examined using histological and biochemical parameters.

RESULTS

Increased interstitial fibrosis as well as renal inflammation were observed in renal sections derived from CRS rats, compared to subtotal nephrectomy (CKD)-only animals. Moreover, we found that even though AMI on the background of CKD was not associated with a further decrease in creatinine clearance or a further increase in sera BUN levels compared to CKD only, a significant long-term elevation in urine neutrophil gelatinase-associated lipocalin (Ngal) levels was detectable post-MI induction.

CONCLUSIONS

AMI in the CKD setting is associated with accelerated renal fibrosis and long-term elevated urine Ngal values, suggesting that cardiac dysfunction contributes to accelerated intrinsic kidney injury in CKD. The data indicate that elevated urine Ngal may potentially serve as an early non-invasive laboratory parameter for a left ventricular dysfunction-related renal injury.

Elevated plasma IL-6 associates with increased risk of advanced fibrosis and cholangiocarcinoma in individuals infected by Opisthorchis viverrini

Opisthorchis viverrini is considered among the most important of the food-borne trematodes due to its strong association with advanced periductal fibrosis and bile duct cancer (cholangiocarcinoma). We investigated the relationship between plasma levels of Interleukin (IL)-6 and the risk of developing advanced fibrosis and bile duct cancer from chronic Opisthorchis infection. We show that IL-6 circulates in plasma at concentrations 58 times higher in individuals with advanced fibrosis than age, sex, and nearest-neighbor matched controls and 221 times higher in individuals with bile duct cancer than controls. We also observed a dose-response relationship between increasing levels of plasma IL-6 and increasing risk of advanced fibrosis and bile duct cancer; for example, in age and sex adjusted analyses, individuals with the highest quartiles of plasma IL-6 had a 19 times greater risk of developing advanced periductal fibrosis and a 150 times greater risk of developing of bile duct cancer than individuals with no detectable level of plasma IL-6. Finally, we show that a single plasma IL-6 measurement has excellent positive predictive value for the detection of both advanced bile duct fibrosis and bile duct cancer in regions with high O. viverrini transmission. These data support our hypothesis that common mechanisms drive bile duct fibrosis and bile duct tumorogenesis from chronic O. viverrini infection. Our study also adds a unique aspect to the literature on circulating levels of IL-6 as an immune marker of hepatobiliary pathology by showing that high levels of circulating IL-6 in plasma are not related to infection with O. viverrini, but to the development of the advanced and often lethal pathologies resulting from chronic O. viverrini infection.

Secular trends of fibrocalculous pancreatic diabetes and diabetes secondary to alcoholic chronic pancreatitis at a tertiary care diabetes centre in South India

CONTEXT

Data on prevalence and trends in diabetes secondary to chronic pancreatitis in developing countries is scarce.

OBJECTIVE

To compare the secular trends in the prevalence of fibrocalculous pancreatic diabetes (FCPD) and diabetes secondary to alcoholic chronic pancreatitis (ACP) at a diabetes centre in south India.

DESIGN

A retrospective analysis was done of all patients registered at Dr. Mohan's Diabetes Specialties Centre, Chennai, India between January 1991 and December 2010.

PATIENTS

A total of 1,079 subjects with diabetes secondary to chronic pancreatitis were identified, of whom 47 were excluded because of difficulty in classification.

MAIN OUTCOME MEASURE

The number of patients with FCPD and diabetes secondary to ACP were calculated as a percentage of the total number of diabetes patients seen at the centre during five year blocks.

RESULTS

Of the total of 1,032 cases of diabetes secondary to chronic pancreatitis, FCPD comprised 898 (87%) and ACP 134 (13%). The prevalence of FCPD decreased from 1.6% during 1991-1995 to 0.2% during 2006-2010 (P<0.001). The prevalence of ACP remained constant at 0.1%. The age at diagnosis of FCPD increased (P=0.002) while that of ACP decreased (P=0.025) during the study period. There was a significant increase in BMI of FCPD P<0.001), but not of ACP (P=0.248) patients.

CONCLUSIONS

At this centre, FCPD continues to be more common than ACP, but there is a decline in its frequency. The age at diagnosis of FCPD has increased, while that of ACP has decreased. The decline in FCPD probably reflects improved nutrition.

Prisoner survival inside and outside of the institution: implications for health-care planning

The life expectancy of persons cycling through the prison system is unknown. The authors sought to determine the 15.5-year survival of 23,510 persons imprisoned in the state of Georgia on June 30, 1991. After linking prison and mortality records, they calculated standardized mortality ratios (SMRs). The cohort experienced 2,650 deaths during follow-up, which were 799 more than expected (SMR = 1.43, 95% confidence interval (CI): 1.38, 1.49). Mortality during incarceration was low (SMR = 0.85, 95% CI: 0.77, 0.94), while postrelease mortality was high (SMR = 1.54, 95% CI: 1.48, 1.61). SMRs varied by race, with black men exhibiting lower relative mortality than white men. Black men were the only demographic subgroup to experience significantly lower mortality while incarcerated (SMR = 0.66, 95% CI: 0.58, 0.76), while white men experienced elevated mortality while incarcerated (SMR = 1.28, 95% CI: 1.10, 1.48). Four causes of death (homicide, transportation, accidental poisoning, and suicide) accounted for 74% of the decreased mortality during incarceration, while 6 causes (human immunodeficiency virus infection, cancer, cirrhosis, homicide, transportation, and accidental poisoning) accounted for 62% of the excess mortality following release. Adjustment for compassionate releases eliminated the protective effect of incarceration on mortality. These results suggest that the low mortality inside prisons can be explained by the rarity of deaths unlikely to occur in the context of incarceration and compassionate releases of moribund patients.

Association between depressive symptoms and fibrosis markers: the Cardiovascular Health Study

OBJECTIVE

Fibrosis plays an important role in heart failure (HF) and other diseases that occur more frequently with increasing age. Depression is associated with an increased risk of heart failure and other age-related diseases. This study examined the association between depressive symptoms and fibrosis markers in adults aged 65 years and above.

METHODS

Fibrosis markers and depressive symptoms were assessed in 870 participants (age=80.9+/-5.9 yrs, 49% women) using a case-control design based on heart failure status (307 HF patients and 563 age- and sex-matched controls, of whom 284 with CVD risk factors (hypertension, diabetes mellitus, or hypercholesterolemia) and 279 controls without these CVD risk factors). Fibrosis markers were procollagen type I (PIP), type I collagen (CITP), and procollagen type III (PIIINP). Inflammation markers included C-reactive protein, white blood cell counts and fibrinogen. Depression was assessed using the Center for Epidemiological Studies-Depression (CES-D) scale using a previously validated cut-off point for depression (CES-D > or = 8). Covariates included demographic and clinical variables.

RESULTS

Depression was associated with higher levels of PIP (median=411.0, inter-quartile range (IQR)=324.4-472.7 ng/mL vs. 387.6, IQR=342.0-512.5 ng/mL, p=0.006) and CITP (4.99, IQR=3.53-6.85 vs. 4.53, IQR=3.26-6.22 microg/L, p=0.024), but not PIIIINP (4.07, IQR=2.75-5.54 microg/L vs. 3.58, IQR=2.71-5.01 microg/L, p=0.29) compared to individuals without depression. Inflammation markers were also elevated in depressed participants (CRP, p=0.014; WBC, p=0.075; fibrinogen, p=0.074), but these inflammation markers did not account for the relationship between depression and fibrosis markers.

CONCLUSIONS

Depression is associated with elevated fibrosis markers and may therefore adversely affect heart failure and other age-related diseases in which extra-cellular matrix formation plays a pathophysiological role.

Prevalence of fibrocalculous pancreatic diabetes in Chennai in South India

CONTEXT

Fibrocalculous pancreatic diabetes is a form of diabetes secondary to chronic pancreatitis found in tropical, developing countries. There is no population based data on prevalence of fibrocalculous pancreatic diabetes.

OBJECTIVE

This paper reports on prevalence of fibrocalculous pancreatic diabetes in Chennai in South India based on the Chennai Urban Rural Epidemiology Study.

RESULTS

The prevalence of fibrocalculous pancreatic diabetes is 0.36% (1:276) of all self reported diabetes and 0.019% (1:5,200) of the general population of Chennai.

CONCLUSION

Although the frequency is low, diagnosis of fibrocalculous pancreatic diabetes must be kept in mind in treating diabetic subjects in developing countries as its management would include management of pain, pancreatic enzyme supplements and periodic surveillance for pancreatic malignancy.

Modelling prevalence and incidence of fibrosis and pleural plaques in asbestos-exposed populations for screening and follow-up: a cross-sectional study

BACKGROUND

CT-Scan is currently under assessment for the screening of asbestos-related diseases. However, to date no consensus exists as to how to select high-risk asbestos-exposed populations suitable for such screening programs. The objective of this study is to select the most relevant exposure variables for the prediction of pleural plaques and asbestosis in order to guide clinicians in their use of CT-Scan.

METHODS

A screening program of non malignant asbestos-related diseases by CT-scan was conducted among asbestos-exposed volunteers in France. Precise assessments of asbestos exposure were obtained by occupational hygiene measurements and a job-exposure matrix. Several parameters were calculated (time since first exposure, duration, intensity and cumulative exposure to asbestos). Predictive parameters of prevalence and incidence were then estimated by standard logistic and a complementary log-log regression models.

RESULTS

1011 subjects were recruited in this screening program among them 474 (46.9%) presented with pleural plaques and 61 (6.0%) with interstitial changes compatible with asbestosis on CT-scan. Time since first exposure (p < 0.0001) and either cumulative or mean exposure (p < 0.0001) showed independent associations with both pleural plaques and asbestosis prevalence and pleural plaques incidence. Modelling incidence of pleural plaques showed a 0.8% to 2.4% yearly increase for a mean exposure of 1 f/ml.

CONCLUSION

Our findings confirmed the role played by time since first exposure and dose but not duration in asbestos-related diseases. We recommend to include these parameters in high-risk populations suitable for screening of these diseases. Short-periodicity of survey of pleural plaques by CT-Scan seemed not to be warranted.

Radiologists’ knowledge and perceptions of the impact of contrast-induced nephropathy and its risk factors when performing computed tomography examinations: A survey of European radiologists

BACKGROUND

The past decade has seen a proliferation in the number of CT procedures. As increasing numbers of elderly patients with multiple comorbidities undergo contrast media (CM)-enhanced procedures, more patients are at risk for contrast-induced nephropathy (CIN).

OBJECTIVES

To understand whether radiologists are sufficiently aware of the incidence, impact and risk factors of CIN, and whether they are taking sufficient measures to prevent CIN among patients undergoing CT.

MATERIALS AND METHODS

A telephone or online survey was conducted in 2005 with 509 radiologists from 10 European countries. Participants had a minimum of 3 years' experience and performed at least 50 CT scans per week.

RESULTS

Most (88%) radiologists believed that CIN is an important issue. While 45% identify that a patient is experiencing CIN when the serum creatinine level increases >25% (0.5mg/dL) from baseline within 48h, the remainder used criteria that might lead to significant under-diagnosis. Most (72%) radiologists believed that CIN is associated with increased morbidity; 56% did not believe that it is associated with increased mortality. Most respondents agreed that pre-existing renal impairment (97%), dehydration (90%) and diabetes (89%) were risk factors for CIN; however, 26%, 30% and 46%, respectively, did not identify advanced age, CM dose or congestive cardiac failure as risk factors. Only 7% of radiologists thought they were always made aware of CIN associated with their cases and 28% never consulted a nephrologist to discuss patients at risk of CIN or who had developed CIN.

CONCLUSION

There is highly variable awareness of the definition, impact and risk factors for CIN among European radiologists. Data regarding the importance of CIN in CT are limited. Improved efforts are required to better educate radiologists and referring physicians and to institute appropriate protocols to identify at-risk patients and prevent CIN.