Liver stiffness by transient elastography predicts liver-related complications and mortality in patients with chronic liver disease

Background

Liver stiffness measurement (LSM) by transient elastography (TE, FibroScan) is a validated method for noninvasively staging liver fibrosis. Most hepatic complications occur in patients with advanced fibrosis. Our objective was to determine the ability of LSM by TE to predict hepatic complications and mortality in a large cohort of patients with chronic liver disease.

Methods

In consecutive adults who underwent LSM by TE between July 2008 and June 2011, we used Cox regression to determine the independent association between liver stiffness and death or hepatic complications (decompensation, hepatocellular carcinoma, and liver transplantation). The performance of LSM to predict complications was determined using the c-statistic.

Results

Among 2,052 patients (median age 51 years, 65% with hepatitis B or C), 87 patients (4.2%) died or developed a hepatic complication during a median follow-up period of 15.6 months (interquartile range, 11.0–23.5 months). Patients with complications had higher median liver stiffness than those without complications (13.5 vs. 6.0 kPa; P<0.00005). The 2-year incidence rates of death or hepatic complications were 2.6%, 9%, 19%, and 34% in patients with liver stiffness <10, 10–19.9, 20–39.9, and ≥40 kPa, respectively (P<0.00005). After adjustment for potential confounders, liver stiffness by TE was an independent predictor of complications (hazard ratio [HR] 1.05 per kPa; 95% confidence interval [CI] 1.03–1.06). The c-statistic of liver-stiffness for predicting complications was 0.80 (95% CI 0.75–0.85). A liver stiffness below 20 kPa effectively excluded complications (specificity 93%, negative predictive value 97%); however, the positive predictive value of higher results was sub-optimal (20%).

Conclusions

Liver stiffness by TE accurately predicts the risk of death or hepatic complications in patients with chronic liver disease. TE may facilitate the estimation of prognosis and guide management of these patients.

Feasibility and reliability of the FibroScan S2 (pediatric) probe compared with the M probe for liver stiffness measurement in small adults with chronic liver disease

BACKGROUND

The success of liver stiffness measurement (LSM) by transient elastography (TE, FibroScan) is influenced by anthropometric factors. In smaller adults, the M probe may fail due to narrow intercostals spaces and rib interference. We aimed to compare LSM using the FibroScan S2 (pediatric) probe with the M probe in small adults with chronic liver disease.

MATERIAL AND METHODS

In this prospective study, 41 liver disease patients and 18 controls with a thoracic perimeter ≤ 75 cm underwent LSM using the FibroScan M and S2 probes. TE failure was defined as no valid LSMs and unreliable examinations as < 10 valid LSMs, an interquartile range (IQR)/LSM > 30%, or success rate < 60%.

RESULTS

TE failure was not observed and reliability did not differ between the M and S2 probes (86% vs. 95%; P = 0.20). Liver stiffness measured using the M and S2 probes was highly correlated (ρ = 0.81; P < 0.0005) and median liver stiffness did not differ between probes (4.5 vs. 4.4 kPa; P = 0.10). However, in participants with a skin-capsular distance ≥ 15 mm, median liver stiffness was higher using the S2 probe (5.5 vs. 4.9 kPa; P = 0.008). When compared with validated liver stiffness cut-offs, the S2 probe would have overestimated the stage of fibrosis compared with the M probe in 10% of patients.

CONCLUSIONS

The FibroScan S2 probe does not improve the feasibility of LSM in adults of smaller stature and may overestimate liver stiffness compared with the M probe. The FibroScan M probe should remain the preferred tool for LSM in small adults with chronic liver disease.

Stem cells as a treatment for chronic liver disease and diabetes

Advances in stem cell biology and the discovery of pluripotent stem cells have made the prospect of cell therapy and tissue regeneration a clinical reality. Cell therapies hold great promise to repair, restore, replace or regenerate affected organs and may perform better than any pharmacological or mechanical device. There is an accumulating body of evidence supporting the contribution of adult stem cells, in particular those of bone marrow origin, to liver and pancreatic islet cell regeneration. In this review, we will focus on the cell therapy for the diseased liver and pancreas by adult haematopoietic stem cells, as well as their possible contribution and application to tissue regeneration. Furthermore, recent progress in the generation, culture and targeted differentiation of human haematopoietic stem cells to hepatic and pancreatic lineages will be discussed. We will also explore the possibility that stem cell technology may lead to the development of clinical modalities for human liver disease and diabetes.

Safety of newer generation anti-epileptic drugs in non-accidental overdose: an Irish population study

Seven new anti-epileptic drugs (AEDs) have become available in Ireland over the last 10 years; data from animal models and clinical trials suggest that they have a superior safety profile to older AEDs. A specific relationship between epilepsy and psychiatric co-morbidity has long been recognised, including the relationship between epilepsy and suicide. AEDs are common agents taken in intentional drug overdoses. We undertook a study to review the frequency and outcome of non-accidental overdose with seven new AEDS in an Irish population from 1996 to 2000.

METHOD

All reported cases of drug overdoses with AEDs from 1996 to 2000 were reviewed. Data was provided by the National Poisons Information Centre, Beaumont Hospital and the Central Statistics Office. Medical records from Beaumont Hospital were reviewed in specific cases of serious drug toxicities. An extensive review of published literature reviewing the safety profile of these AEDs was performed and medical literature retrieved from the databases of the pharmaceutical industry was similarly reviewed.

RESULTS

Of the 164 reported cases of newer AEDs, there were no fatalities among the cases followed up.

CONCLUSION

The absence of mortalities and serious consequences from deliberate self-poisoning with the newer agents is supportive evidence for the superior safety profile of the newer AEDs.

Carbon monoxide poisoning in the Republic of Ireland

Carbon monoxide (CO) poisoning remains a common preventable cause of morbidity and mortality from poisoning worldwide. Common environmental sources include motor vehicle exhaust, faulty kerosene or gas heaters used in unventilated rooms, and fireplaces with blocked flues. This paper describes the epidemiology of CO poisoning in Ireland, using Hospital Inpatient Enquiry (HIPE) data, Mortality data and data from the National Poisons Information Centre (NPIC). CO poisoning is responsible for over 40 deaths per year in Ireland. Many occur at home as a result of house-fires. Incomplete combustion of domestic fuels is responsible for many cases of non-fatal unintentional CO poisoning. In comparison, most intentional poisonings are caused by motor vehicle exhaust, representing approximately 6.4% of successful suicides. The advent of catalytic converters in cars may lead to a decline in the effectiveness of this method of suicide. This study illustrates the hidden impact of CO poisoning. Most deaths occur at home and thus do not come to the attention of the health services. Those admitted to hospital represent the milder end of the spectrum and generally recover after a short stay. It is important that the public be aware of the risks of CO poisoning and that Public Health action be taken.

Role of C3 cleavage in monocyte activation during extracorporeal circulation

BACKGROUND

We previously demonstrated that inhibiting formation of terminal complement components (C5a and C5b-9) prevents platelet and neutrophil (PMN) but not monocyte activation during simulated extracorporeal circulation (SECC). This study examined whether earlier complement inhibition during SECC, blocking C3a formation, would additionally prevent monocyte activation.

METHODS AND RESULTS

SECC was established by recirculating heparinized whole blood from human volunteers on a membrane oxygenator. CAB-2, a chimeric protein constructed from genes encoding the complement regulatory proteins CD46 and CD55, inactivates the C3/C5 convertases and blocks in vitro generation of C3a, C5a, and C5b-9. CAB-2 was used in 4 experiments at a final concentration of 300 micrograms/mL and 4 experiments at 30 micrograms/mL; 4 control runs used vehicle alone. Samples were assayed for C3a and C5b-9, monocyte activation (CD11b upregulation), PMN activation (CD11b upregulation and elastase release), and platelet activation (P-selectin expression and monocyte-platelet conjugate formation). CAB-2 at both doses significantly inhibited formation of C3a and C5b-9 during SECC. High-dose CAB-2 significantly blocked monocyte and PMN CD11b upregulation and PMN elastase release. CAB-2 also inhibited formation of platelet activation-dependent monocyte-platelet conjugates.

CONCLUSIONS

Blockade of complement activation early in the common pathway inhibited monocyte CD11b upregulation during SECC, suggesting that early complement components contribute most to monocyte activation during SECC. As expected, PMN and platelet activation were blocked by terminal complement inhibition. This investigation further elucidates the relation between complement and blood cell activation during simulated cardiopulmonary bypass.

Development and evaluation of the Rural Trauma and Emergency Care Roadshow

AIMS

To validate the Rural Trauma and Emergency Care (RTEC) Roadshow, an educational programme comprised of 14 skills-based, educational modules in trauma care designed for rural general practitioners and taught as a travelling roadshow in isolated rural areas.

METHOD

The first 31 rural general practitioners to participate in the course completed an extensive participant satisfaction rating form. They also underwent pre-and post-testing of knowledge using a written true/false test, of skills using an OSCE examination and of stress related to being on call using a self-assessment, Likert scale.

RESULTS

Participant satisfaction was high with a mean rating of 4.7 (maximum of 5) for overall course quality and relevance of content. There was a significant increase in skills (from 46 to 73% mean OSCE scores), in knowledge (from 58 to 69% mean true-false test scores) and in confidence in handling major trauma (from 3.9 to 5.3 on a ten point scale) as a result of the course.

CONCLUSION

The RTEC course is effective in increasing the skills and knowledge of general practitioners in trauma care.

Clinical and virologic effects of recombinant human granulocyte-macrophage colony-stimulating factor in patients receiving chemotherapy for human immunodeficiency virus-associated non-Hodgkin's lymphoma: results of a randomized trial

Thirty patients with human immunodeficiency virus (HIV)-associated non-Hodgkin's lymphoma (NHL) receiving chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) were randomized to receive either subcutaneous recombinant human granulocyte-macrophage colony-stimulating factor (rGM-CSF) or no additional therapy. Recombinant rGM-CSF (at a dose of 10-20 micrograms/kg/d) was given on days 1 to 10 (early rGM-CSF) to the first five patients, but was changed to days 4 to 13 (delayed rGM-CSF) of each chemotherapy cycle in subsequent patients. Compared with the control group (N = 10), the delayed rGM-CSF group (N = 11) had higher mean nadirs of the absolute neutrophil count (0.36 v 0.89 x 10(9)/L; P = .009), shorter mean durations of neutropenia (4.9 v 1.3 days; P = .02), fewer chemotherapy cycles complicated by neutropenia and fever (67% v 27%; P = .001), fewer days hospitalized for fever and neutropenia (4.9 v 1.8; P = .004), fewer reductions in chemotherapy dosages, and less frequent delays in chemotherapy administration. No significant differences were observed between patients in the control group and those in the early rGM-CSF group (N = 5). Median levels of serum HIV-1 p24 antigen decreased to 18% and 17% of baseline values in control (N = 4) and rGM-CSF groups (N = 6), respectively, 1 week following administration of the first cycle of chemotherapy. In the third week after chemotherapy, median antigen levels remained below baseline in the control group, but rose to 243% of baseline values in the rGM-CSF group (P = .01), suggesting stimulation of HIV replication. The effect of this change in HIV activity on clinical outcome of treated patients could not be determined, and therefore the clinical significance of this finding remains unclear. Complete response rates of 67%, 70%, and 60% were observed in the control, delayed rGM-CSF, and early rGM-CSF groups, respectively, with corresponding survival times of 9.0, 11.4, and 8.0 months.

The management of diabetes in general practice

Over a period of 3 months 32 general practitioners in the Waikato kept copies of all consultations with patients with noninsulin-dependent diabetes mellitus. Of 229 patients with diabetes known to the practices 189 were seen on a total of 438 occasions. Mean fructosamine level was 2.93 mmol/L. Each consultation was analysed as to history obtained, examinations performed, investigations ordered and referrals made. Overall care was satisfactory except for the low incidence of checking for early signs of peripheral vascular disease or diabetic neuropathy affecting the feet and for diabetic nephropathy.

Lignocaine: its effects on wound healing

In the light of clinical observations that local anaesthetic impairs wound healing, the effect of lignocaine at various concentrations, with and without adrenaline, on the tensile strength of skin wounds in rats 3, 5 and 7 days after operation was studied. Lignocaine had an adverse effect on wound healing at 5 and 7 days, perhaps due partly to the destructive effect of the intra- and subcutaneous injection, but certainly due also to the lignocaine itself. Adrenaline potentiated this effect. It was concluded that it is better to use dilute solutions of lignocaine, preferably without adrenaline, for local anaesthesia.