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Association between body mass index and liver stiffness measurement using transient elastography in patients with non-alcoholic fatty liver disease in a hepatology clinic: a cross sectional study. 肝内科门诊非酒精性脂肪肝患者瞬态弹性成像测量体重指数与肝脏硬度之间的关系:一项横断面研究
IF 3 4区 医学 Q1 Medicine Pub Date : 2023-01-01 DOI: 10.21037/tgh-22-1
Harish Gopalakrishna, Oluwaseun E Fashanu, Gayatri B Nair, Natarajan Ravendhran

Background: Transient elastography (TE) is an FDA approved, non-invasive tool to estimate liver stiffness measurement (LSM) in patients with non-alcoholic fatty liver disease (NAFLD). Our aim was to analyze if body mass index (BMI) would predict the severity of liver stiffness using TE scores.

Methods: We performed a cross-sectional study of patients with NAFLD who presented to the hepatology clinic between January 2019 through January 2021. Fibrosis severity was divided into the following categories: F0 to F1 (2-7 kPa), F2 (>7 to 10 kPa), F3 (>10 to 14 kPa) and F4 (>14 kPa). We used ordered logistic regression models to determine the odds ratio (OR) and 95% confidence interval (CI) of having a higher LSM severity compared to lower associated with BMI. Models were adjusted for patient demographics and comorbidities.

Results: Among 284 patients, 56.7% were females, and the median (interquartile range, IQR) age was 62 [51-68] years and BMI 31.9 (28.1, 36.2) kg/m2; 47% of patients were in the F0 to F1 stage, 24% F2, 16% F3, and 13% F4. The correlation between BMI and TE score was 0.31 (P<0.001). With 1 kg/m2 increase in BMI there was 1.10 times higher odds of having a higher LSM severity (adjusted OR, 1.10; 95% CI: 1.05-1.14). Compared to patients with BMI <25 kg/m2, the adjusted OR (95% CI) of having a higher fibrosis stage was 1.82 (0.61-5.44), 5.93 (2.05-17.13), and 8.56 (2.51-29.17) for patients with BMI of 25 to <30, 30 to <40, and ≥40 respectively.

Conclusions: BMI correlates with the severity of LSM using TE scores in NAFLD patients even after adjusting for potential confounding variables. This suggests TE as an appreciable study for liver stiffness even in obese individuals.

背景:瞬时弹性成像(TE)是FDA批准的非酒精性脂肪性肝病(NAFLD)患者肝脏硬度测量(LSM)的非侵入性工具。我们的目的是分析身体质量指数(BMI)是否可以用TE评分预测肝脏僵硬的严重程度。方法:我们对2019年1月至2021年1月期间在肝病学诊所就诊的NAFLD患者进行了横断面研究。纤维化严重程度分为F0 ~ F1 (2 ~ 7 kPa)、F2 (>7 ~ 10 kPa)、F3 (>10 ~ 14 kPa)、F4 (>14 kPa)。我们使用有序逻辑回归模型来确定与BMI相关的低LSM严重程度相比,LSM严重程度较高的比值比(OR)和95%置信区间(CI)。模型根据患者人口统计学和合并症进行了调整。结果:284例患者中,女性占56.7%,年龄中位数(四分位间距,IQR)为62[51-68]岁,BMI为31.9 (28.1,36.2)kg/m2;F0 ~ F1期占47%,F2期占24%,F3期占16%,F4期占13%。BMI与TE评分的相关性为0.31 (BMI增加P2, LSM严重程度高的几率为1.10倍(调整OR为1.10;95% ci: 1.05-1.14)。与BMI为2的患者相比,BMI为25的患者纤维化分期较高的调整OR (95% CI)分别为1.82(0.61-5.44)、5.93(2.05-17.13)和8.56(2.51-29.17)。结论:即使在校正了潜在的混杂变量后,使用NAFLD患者TE评分,BMI与LSM严重程度相关。这表明TE是一项有价值的研究,即使在肥胖个体中也是如此。
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引用次数: 1
Impact of immune tolerance mechanisms on the efficacy of immunotherapy in primary and secondary liver cancers. 免疫耐受机制对原发性和继发性肝癌免疫治疗疗效的影响。
IF 3 4区 医学 Q1 Medicine Pub Date : 2023-01-01 DOI: 10.21037/tgh-23-11
Kamya Sankar, Ashley N Pearson, Tejaswi Worlikar, Matthew D Perricone, Erin A Holcomb, Mishal Mendiratta-Lala, Zhen Xu, Neil Bhowmick, Michael D Green

The liver is a functionally unique organ with an immunosuppressive microenvironment. The liver is the sixth most common site of primary cancer in humans and is a frequent site of metastasis from other solid tumors. The development of effective therapies for primary and metastatic liver cancer has been challenging due to the complex metabolic and immune microenvironment of the liver. The liver tumor microenvironment (TME) in primary and secondary (metastatic) liver cancers is heterogenous and consists of unique immune and stromal cell populations. Crosstalk between these cell populations and tumor cells creates an immunosuppressive microenvironment within the liver which potentiates cancer progression. Immune checkpoint inhibitors (ICIs) are now clinically approved for the management of primary and secondary liver cancer and can partially overcome liver immune tolerance, but their efficacy is limited. In this review, we describe the liver microenvironment and the use of immunotherapy in primary and secondary liver cancer. We discuss emerging combination strategies utilizing locoregional and systemic therapy approaches which may enhance efficacy of immunotherapy in primary and secondary liver cancer. A deeper understanding of the immunosuppressive microenvironment of the liver will inform novel therapies and therapeutic combinations in order to improve outcomes of patients with primary and secondary liver cancer.

肝脏是一个功能独特的器官,具有免疫抑制微环境。肝脏是人类原发癌症的第六大常见部位,也是其他实体肿瘤转移的常见部位。由于肝脏复杂的代谢和免疫微环境,开发有效的治疗原发性和转移性肝癌的方法一直具有挑战性。原发性和继发性(转移性)肝癌的肝肿瘤微环境(TME)是异质的,由独特的免疫和基质细胞群组成。这些细胞群和肿瘤细胞之间的串扰在肝脏内创造了一个免疫抑制的微环境,从而加速了癌症的进展。免疫检查点抑制剂(ICIs)现已被临床批准用于原发性和继发性肝癌的治疗,并且可以部分克服肝脏免疫耐受,但其疗效有限。在这篇综述中,我们描述了肝脏微环境和免疫治疗在原发性和继发性肝癌中的应用。我们讨论了利用局部和全身治疗方法的新兴联合策略,这可能会提高原发性和继发性肝癌免疫治疗的疗效。对肝脏免疫抑制微环境的深入了解将为新的治疗方法和治疗组合提供信息,从而改善原发性和继发性肝癌患者的预后。
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引用次数: 0
Identifying optimal therapies in patients with advanced hepatocellular carcinoma: a systematic review and network meta-analysis. 确定晚期肝细胞癌患者的最佳治疗方法:系统回顾和网络荟萃分析。
IF 3 4区 医学 Q1 Medicine Pub Date : 2022-10-25 eCollection Date: 2022-01-01 DOI: 10.21037/tgh-20-318
Zhenyu Yang, Yao Tong, Lin Yang, Xianli He, Guoqiang Bao, Xilin Du

Background: Recently, increasing literature has been reported on optimal therapies in patients with advanced hepatocellular carcinoma (HCC) and many therapeutic modalities have been proposed to improve the survival rate. However, the results are not consistent due to different research protocols, small sample sizes and different study endpoints and there is no standard treatment protocol has been defined. Therefore, it is very important to explore the optimal bonding mode and to evaluate the efficacy and safety of the optimal sequential therapy for those patients.

Methods: We searched available databases through January 2020 for relevant studies. The main outcome measure was 1-year overall survival (OS) and overall response rate (ORR); the secondary outcome measure was a composite of toxic effects retrieved grade 3 or 4 adverse events (AEs) from all included studies. Statistical analyses were conducted using STATA version 15 and GeMTC package in the R statistical software.

Results: After a detailed review, 8 randomized controlled trials (RCTs) and 20 retrospective studies involving 3,675 advanced HCC patients were included for network meta-analysis. Indirect comparisons showed that hepatic arterial infusion chemotherapy (HAIC) plus radiofrequency ablation (RFA) was highest probability of obtaining the best OS rate of 1 year [surface under the cumulative ranking (SUCRA), 0.95] and ORR (SUCRA, 0.86) when compared with other potential optimal therapies and which had ranked the first in all treatment regimens, followed by HAIC (SUCRA, 0.75). Direct and indirect comparison of 1-year OS and ORR with all treatment regimens each other showed that for all treatment regimens, patients showed significant clinical benefit when compared with transcatheter arterial chemoembolization (TACE) or sorafenib alone. However, the incidence of treatment-related AEs of grade 3 or 4 occurred in patients who have received targeted drug sorafenib therapy (SUCRA, 0.51) compared with other interesting regimens.

Conclusions: HAIC may be a valuable therapeutic strategy for advanced HCC patients to prevent recurrence and metastasis after RFA, as well as in improving patient prognosis and quality of life. Meanwhile, HAIC combined with RFA is a safe and effective treatment in patients with advanced HCC, and this combination therapy can significantly prolong 1-year survival rate when compared with other optimal sequential therapies.

Trial registration: This study is registered with PROSPERO, number CRD42020176149.

背景:近年来,越来越多的文献报道了晚期肝细胞癌(HCC)患者的最佳治疗方法,并提出了许多治疗方法来提高生存率。然而,由于研究方案不同,样本量小,研究终点不同,且没有标准的治疗方案,结果并不一致。因此,探索最佳的结合模式,评估最佳序贯治疗对这些患者的疗效和安全性是非常重要的。方法:我们检索了截至2020年1月的可用数据库,以获取相关研究。主要结局指标为1年总生存期(OS)和总缓解率(ORR);次要结局指标是从所有纳入的研究中检索到的3级或4级不良事件(ae)的毒性效应的综合。采用R统计软件中的STATA version 15和GeMTC包进行统计分析。结果:经过详细回顾,纳入8项随机对照试验(rct)和20项回顾性研究,涉及3,675例晚期HCC患者,进行网络meta分析。间接比较显示,肝动脉灌注化疗(HAIC) +射频消融(RFA)与其他潜在的最佳治疗方法相比,获得1年最佳OS率的概率最高[表面下累积排名(SUCRA), 0.95]和ORR (SUCRA, 0.86),在所有治疗方案中排名第一,其次是HAIC (SUCRA, 0.75)。直接和间接比较所有治疗方案的1年OS和ORR均显示,与经导管动脉化疗栓塞(TACE)或单独使用索拉非尼相比,对于所有治疗方案,患者均表现出显著的临床获益。然而,与其他有趣的方案相比,接受靶向药物索拉非尼治疗的患者发生3级或4级治疗相关不良事件(SUCRA, 0.51)。结论:HAIC可能是一种有价值的治疗策略,可预防晚期HCC患者RFA后复发和转移,改善患者预后和生活质量。同时,HAIC联合RFA治疗晚期HCC是一种安全有效的治疗方法,与其他最佳序期治疗相比,该联合治疗可显著延长1年生存率。试验注册:本研究已在PROSPERO注册,注册号为CRD42020176149。
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引用次数: 3
Azithromycin versus erythromycin infusions prior to endoscopy in upper gastrointestinal bleeding. 上消化道出血内镜检查前输注阿奇霉素与红霉素。
IF 3 4区 医学 Q1 Medicine Pub Date : 2022-10-25 eCollection Date: 2022-01-01 DOI: 10.21037/tgh-20-51
Danny Issa, Sanjeev Solomon, Jonathan Hillyard, Brian Di Pace, Christopher Young, Patricia Uber, Adam Sima, Reem Sharaiha, George Smallfield

Background: Intravenous erythromycin prior to endoscopy for upper gastrointestinal bleeding (GIB) improves outcomes but requires immediate preparation delaying administration in emergency cases. Azithromycin is readily available and does not require prolonged preparation. The aim of the study was to assess the effect of azithromycin in improving the quality of endoscopic visualization in upper GIB compared to erythromycin.

Methods: Patients admitted with upper GIB who received erythromycin or azithromycin before urgent endoscopy were included. Primary outcome of the quality of visualization was assessed by two gastroenterologists, blinded to the choice of infusion, using a scoring system ranging from 0 to 8, with a maximum of 2 points assigned to the fundus, body, antrum and bulb.

Results: Sixty-six patients were included; 25 received azithromycin and 41 received erythromycin. Mean total visualization score was significantly higher with azithromycin compared to that with erythromycin (6.8±1.4 vs. 5.5±2.2, respectively; P=0.01) and remained significant after adjusting for confounders (Diff: 0.01, 1.88; P=0.05). Secondary outcomes analyses showed a shorter LOS when given azithromycin compared to erythromycin [6 (3 to 9) vs. 8 (7 to 16) days, respectively, 95% CI: 1.03, 3.89; P=0.04]. Time between initiating the infusion and endoscopy was longer with azithromycin (Diff: 40.64 min; 95% CI: 7.23, 74.05; P=0.02). Need for second look endoscopy, procedure time, blood transfusion requirements and procedure-related complications did not differ between the groups.

Conclusions: Azithromycin infusion before endoscopy for upper GIB was associated with better visualization than that of erythromycin. Randomized trials are needed to validate these findings.

背景:上消化道出血(GIB)内镜检查前静脉注射红霉素可改善预后,但需要立即准备,延迟急诊病例给药。阿奇霉素容易获得,不需要长时间制备。本研究的目的是评估阿奇霉素与红霉素相比,在改善上GIB内镜显示质量方面的效果。方法:纳入急诊内镜检查前接受红霉素或阿奇霉素治疗的上GIB患者。可视化质量的主要结果由两名胃肠病学家评估,他们不知道输注方式的选择,使用评分系统从0到8,眼底、体、胃窦和球最多2分。结果:纳入66例患者;阿奇霉素25例,红霉素41例。阿奇霉素组的平均总可视化评分显著高于红霉素组(分别为6.8±1.4分和5.5±2.2分);P=0.01),调整混杂因素后仍然显著(差异:0.01,1.88;P = 0.05)。次要结局分析显示,与红霉素相比,给予阿奇霉素的LOS更短[分别为6(3至9)天和8(7至16)天,95% CI: 1.03, 3.89;P = 0.04)。阿奇霉素组从开始输注到内镜检查的时间较长(Diff: 40.64 min;95% ci: 7.23, 74.05;P = 0.02)。两组间复查内镜、手术时间、输血需求和手术相关并发症均无差异。结论:上GIB内镜检查前输注阿奇霉素比红霉素有更好的视觉效果。需要随机试验来验证这些发现。
{"title":"Azithromycin versus erythromycin infusions prior to endoscopy in upper gastrointestinal bleeding.","authors":"Danny Issa,&nbsp;Sanjeev Solomon,&nbsp;Jonathan Hillyard,&nbsp;Brian Di Pace,&nbsp;Christopher Young,&nbsp;Patricia Uber,&nbsp;Adam Sima,&nbsp;Reem Sharaiha,&nbsp;George Smallfield","doi":"10.21037/tgh-20-51","DOIUrl":"https://doi.org/10.21037/tgh-20-51","url":null,"abstract":"<p><strong>Background: </strong>Intravenous erythromycin prior to endoscopy for upper gastrointestinal bleeding (GIB) improves outcomes but requires immediate preparation delaying administration in emergency cases. Azithromycin is readily available and does not require prolonged preparation. The aim of the study was to assess the effect of azithromycin in improving the quality of endoscopic visualization in upper GIB compared to erythromycin.</p><p><strong>Methods: </strong>Patients admitted with upper GIB who received erythromycin or azithromycin before urgent endoscopy were included. Primary outcome of the quality of visualization was assessed by two gastroenterologists, blinded to the choice of infusion, using a scoring system ranging from 0 to 8, with a maximum of 2 points assigned to the fundus, body, antrum and bulb.</p><p><strong>Results: </strong>Sixty-six patients were included; 25 received azithromycin and 41 received erythromycin. Mean total visualization score was significantly higher with azithromycin compared to that with erythromycin (6.8±1.4 <i>vs.</i> 5.5±2.2, respectively; P=0.01) and remained significant after adjusting for confounders (Diff: 0.01, 1.88; P=0.05). Secondary outcomes analyses showed a shorter LOS when given azithromycin compared to erythromycin [6 (3 to 9) <i>vs.</i> 8 (7 to 16) days, respectively, 95% CI: 1.03, 3.89; P=0.04]. Time between initiating the infusion and endoscopy was longer with azithromycin (Diff: 40.64 min; 95% CI: 7.23, 74.05; P=0.02). Need for second look endoscopy, procedure time, blood transfusion requirements and procedure-related complications did not differ between the groups.</p><p><strong>Conclusions: </strong>Azithromycin infusion before endoscopy for upper GIB was associated with better visualization than that of erythromycin. Randomized trials are needed to validate these findings.</p>","PeriodicalId":23267,"journal":{"name":"Translational gastroenterology and hepatology","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2022-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/e6/5f/tgh-07-20-51.PMC9468987.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40431624","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 2
Ascitic calprotectin and lactoferrin for detection of spontaneous bacterial peritonitis: a systematic review and meta-analysis. 用于检测自发性细菌性腹膜炎的腹水钙蛋白和乳铁蛋白:系统综述和荟萃分析。
IF 3 4区 医学 Q1 Medicine Pub Date : 2022-10-25 eCollection Date: 2022-01-01 DOI: 10.21037/tgh-20-323
Kishan P Patel, Parker M Korbitz, John P Gallagher, Cynthia Schmidt, Thammasin Ingviya, Wuttiporn Manatsathit

Background: Spontaneous bacterial peritonitis (SBP) is a common bacterial infection in cirrhotic patients associated with a high mortality rate. Prompt diagnosis and early antibiotic administration are crucial in minimizing adverse outcomes. Although detection of ≥250 polymorphonuclear leukocytes (PMN) in ascitic fluid is the current gold standard to diagnose SBP, consideration for rapid detection with biomarkers is warranted.

Methods: A literature search for studies evaluating ascitic calprotectin and lactoferrin for detection of SBP was performed using PubMed, Embase, Scopus, Google Scholar, Cochrane library, and Clinical Trial Registries. Summary sensitivity, specificity, log diagnostic odds ratio (LDOR), and area under the summary receiver operating curve (AUC) were calculated.

Results: In total, 12 and 13 studies evaluated ascitic calprotectin and lactoferrin, respectively, for detection of SBP. Summary sensitivity, specificity, and LDOR for calprotectin were 0.942 (95% CI, 0.916, 0.967), 0.860 (95% CI, 0.799, 0.935), and 4.250 (95% CI, 3.504, 4.990), respectively. AUC for calprotectin was 0.91. Summary sensitivity, specificity, and LDOR for lactoferrin were 0.954 (95% CI, 0.930, 0.979), 0.890 (95% CI, 0.836, 0.945), and 4.630 (95% CI, 3.800, 5.452), respectively. AUC for lactoferrin was 0.958.

Conclusions: The overall performance of ascitic calprotectin and lactoferrin was substantial, potentially serving as a screening tool or an alternative to manual cell count. However, a variety of manufacturers, cut-off values, and significant heterogeneity between studies should be noted. Point-of-care testing for calprotectin and lactoferrin may resolve disadvantages associated with the current methods. Future studies on this topic are, therefore, needed.

背景:自发性细菌性腹膜炎(SBP自发性细菌性腹膜炎(SBP)是肝硬化患者常见的细菌感染,死亡率很高。及时诊断和及早使用抗生素对减少不良后果至关重要。虽然检测腹水中≥250 个多形核白细胞(PMN)是目前诊断 SBP 的金标准,但仍需考虑使用生物标记物进行快速检测:方法: 我们使用 PubMed、Embase、Scopus、Google Scholar、Cochrane 图书馆和临床试验登记处对评估腹水钙蛋白和乳铁蛋白检测 SBP 的研究进行了文献检索。计算了灵敏度、特异性、对数诊断几率比(LDOR)和接收器工作曲线下面积(AUC):共有 12 和 13 项研究分别评估了腹水钙蛋白和乳铁蛋白在检测 SBP 方面的作用。钙蛋白的灵敏度、特异性和LDOR分别为0.942(95% CI,0.916,0.967)、0.860(95% CI,0.799,0.935)和4.250(95% CI,3.504,4.990)。钙黏蛋白的 AUC 为 0.91。乳铁蛋白的灵敏度、特异性和 LDOR 分别为 0.954(95% CI,0.930,0.979)、0.890(95% CI,0.836,0.945)和 4.630(95% CI,3.800,5.452)。乳铁蛋白的 AUC 为 0.958:腹水钙蛋白和乳铁蛋白的总体性能相当可观,可作为筛查工具或人工细胞计数的替代方法。但应注意的是,不同的生产商、临界值和不同研究之间存在明显的异质性。对钙粘蛋白和乳铁蛋白进行床旁检测可能会解决目前方法的缺点。因此,今后需要对这一主题进行研究。
{"title":"Ascitic calprotectin and lactoferrin for detection of spontaneous bacterial peritonitis: a systematic review and meta-analysis.","authors":"Kishan P Patel, Parker M Korbitz, John P Gallagher, Cynthia Schmidt, Thammasin Ingviya, Wuttiporn Manatsathit","doi":"10.21037/tgh-20-323","DOIUrl":"10.21037/tgh-20-323","url":null,"abstract":"<p><strong>Background: </strong>Spontaneous bacterial peritonitis (SBP) is a common bacterial infection in cirrhotic patients associated with a high mortality rate. Prompt diagnosis and early antibiotic administration are crucial in minimizing adverse outcomes. Although detection of ≥250 polymorphonuclear leukocytes (PMN) in ascitic fluid is the current gold standard to diagnose SBP, consideration for rapid detection with biomarkers is warranted.</p><p><strong>Methods: </strong>A literature search for studies evaluating ascitic calprotectin and lactoferrin for detection of SBP was performed using PubMed, Embase, Scopus, Google Scholar, Cochrane library, and Clinical Trial Registries. Summary sensitivity, specificity, log diagnostic odds ratio (LDOR), and area under the summary receiver operating curve (AUC) were calculated.</p><p><strong>Results: </strong>In total, 12 and 13 studies evaluated ascitic calprotectin and lactoferrin, respectively, for detection of SBP. Summary sensitivity, specificity, and LDOR for calprotectin were 0.942 (95% CI, 0.916, 0.967), 0.860 (95% CI, 0.799, 0.935), and 4.250 (95% CI, 3.504, 4.990), respectively. AUC for calprotectin was 0.91. Summary sensitivity, specificity, and LDOR for lactoferrin were 0.954 (95% CI, 0.930, 0.979), 0.890 (95% CI, 0.836, 0.945), and 4.630 (95% CI, 3.800, 5.452), respectively. AUC for lactoferrin was 0.958.</p><p><strong>Conclusions: </strong>The overall performance of ascitic calprotectin and lactoferrin was substantial, potentially serving as a screening tool or an alternative to manual cell count. However, a variety of manufacturers, cut-off values, and significant heterogeneity between studies should be noted. Point-of-care testing for calprotectin and lactoferrin may resolve disadvantages associated with the current methods. Future studies on this topic are, therefore, needed.</p>","PeriodicalId":23267,"journal":{"name":"Translational gastroenterology and hepatology","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2022-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/81/9e/tgh-07-20-323.PMC9468990.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40452587","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Surveillance imaging in primary sclerosing cholangitis (PSC): evidence, patient preference and physician autonomy. 原发性硬化性胆管炎(PSC)的监测成像:证据、患者偏好和医生自主。
IF 3 4区 医学 Q1 Medicine Pub Date : 2022-10-25 eCollection Date: 2022-01-01 DOI: 10.21037/tgh-21-87
Philip A Berry, Sreelakshmi Kotha
Transl Gastroenterol Hepatol 2022;7:43 | https://dx.doi.org/10.21037/tgh-21-87 Rabiee and Silveira’s recent article on primary sclerosing cholangit i s (PSC) comments on survei l lance for cholangiocarcinoma, and highlights an area of ongoing controversy (1). They write, ‘Though guidelines do not universally recommend surveillance for CCA a retrospective study including 79 patients with PSC who developed hepatobiliary cancer revealed that patients who underwent surveillance had a significantly improved 5-year survival compared to the nosurveillance group (68% vs. 20%).’ Current guidelines in the United Kingdom advise a conservative approach, with magnetic resonance imaging (MRI) recommended only if clinical condition changes (2). Clinicians have argued against this, citing studies suggestive of clinical benefits from routine surveillance and contradictory advice from international societies (3). As in other areas of medicine, decisions around surveillance need to take into account overall clinical and economic factors. If hundreds of thousands of patients with a certain condition require surveillance annually, the threshold at which this should commence will have a huge impact on resources. Correspondingly, a physician who elects to scan their patients annually because they interpret the evidence differently could be criticised. Despite this, there is enough latitude in most health systems for doctors and patients to settle on an approach that is comfortable for them. Given that PSC is rare, but carries a risk of cholangiocarcinoma in 10–15% of patients, the economic argument may be less relevant, justifying a more individualised approach. During the COVID-19 pandemic the ‘precautionary principle’ has been used to justify the wearing of masks in the absence of strong evidence (4). The public are now more aware of the evidence-based practice and guidance, and of the difficulties that waiting for large, well-designed trials presents. Are present dangers and associated unknowns sufficient to overthrow evidencebased principles? What if we deny a generation of patients’ surveillance now, but learn in ten years’ time that lives could have been saved? And where do patients’ preferences come into this debate? Uncertainty about prognosis is associated with morbidity in PSC (5). Patients have expressed strong desires to the authors of this letter to have regular scans, in order to know how their disease is progressing and perhaps have some sense of control. Conversely, we know that surveillance can be associated with physical and psychological harms. Presently, hepatologists and patients are caught in a conflicted, uncertain zone; together they must find a path between guidance, patient preference and physician autonomy. While research continues into the effectiveness of surveillance in PSC, patient preferences and the effect on well-being should be studied in parallel.
{"title":"Surveillance imaging in primary sclerosing cholangitis (PSC): evidence, patient preference and physician autonomy.","authors":"Philip A Berry,&nbsp;Sreelakshmi Kotha","doi":"10.21037/tgh-21-87","DOIUrl":"https://doi.org/10.21037/tgh-21-87","url":null,"abstract":"Transl Gastroenterol Hepatol 2022;7:43 | https://dx.doi.org/10.21037/tgh-21-87 Rabiee and Silveira’s recent article on primary sclerosing cholangit i s (PSC) comments on survei l lance for cholangiocarcinoma, and highlights an area of ongoing controversy (1). They write, ‘Though guidelines do not universally recommend surveillance for CCA a retrospective study including 79 patients with PSC who developed hepatobiliary cancer revealed that patients who underwent surveillance had a significantly improved 5-year survival compared to the nosurveillance group (68% vs. 20%).’ Current guidelines in the United Kingdom advise a conservative approach, with magnetic resonance imaging (MRI) recommended only if clinical condition changes (2). Clinicians have argued against this, citing studies suggestive of clinical benefits from routine surveillance and contradictory advice from international societies (3). As in other areas of medicine, decisions around surveillance need to take into account overall clinical and economic factors. If hundreds of thousands of patients with a certain condition require surveillance annually, the threshold at which this should commence will have a huge impact on resources. Correspondingly, a physician who elects to scan their patients annually because they interpret the evidence differently could be criticised. Despite this, there is enough latitude in most health systems for doctors and patients to settle on an approach that is comfortable for them. Given that PSC is rare, but carries a risk of cholangiocarcinoma in 10–15% of patients, the economic argument may be less relevant, justifying a more individualised approach. During the COVID-19 pandemic the ‘precautionary principle’ has been used to justify the wearing of masks in the absence of strong evidence (4). The public are now more aware of the evidence-based practice and guidance, and of the difficulties that waiting for large, well-designed trials presents. Are present dangers and associated unknowns sufficient to overthrow evidencebased principles? What if we deny a generation of patients’ surveillance now, but learn in ten years’ time that lives could have been saved? And where do patients’ preferences come into this debate? Uncertainty about prognosis is associated with morbidity in PSC (5). Patients have expressed strong desires to the authors of this letter to have regular scans, in order to know how their disease is progressing and perhaps have some sense of control. Conversely, we know that surveillance can be associated with physical and psychological harms. Presently, hepatologists and patients are caught in a conflicted, uncertain zone; together they must find a path between guidance, patient preference and physician autonomy. While research continues into the effectiveness of surveillance in PSC, patient preferences and the effect on well-being should be studied in parallel.","PeriodicalId":23267,"journal":{"name":"Translational gastroenterology and hepatology","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2022-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/22/a3/tgh-07-21-87.PMC9468984.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40452592","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Could immune activation cause pancreatitis in COVID-19 patients? 免疫激活会导致COVID-19患者的胰腺炎吗?
IF 3 4区 医学 Q1 Medicine Pub Date : 2022-10-25 eCollection Date: 2022-01-01 DOI: 10.21037/tgh-21-21
Gabriela Gama Freire Alberca, Naiane Samira Souza Cardoso, Ricardo Wesley Alberca
{"title":"Could immune activation cause pancreatitis in COVID-19 patients?","authors":"Gabriela Gama Freire Alberca,&nbsp;Naiane Samira Souza Cardoso,&nbsp;Ricardo Wesley Alberca","doi":"10.21037/tgh-21-21","DOIUrl":"https://doi.org/10.21037/tgh-21-21","url":null,"abstract":"","PeriodicalId":23267,"journal":{"name":"Translational gastroenterology and hepatology","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2022-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/5b/65/tgh-07-21-21.PMC9469009.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40452595","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Erratum to a primer to image enhanced endoscopy. 对图像增强内窥镜的初级读物的勘误。
IF 3 4区 医学 Q1 Medicine Pub Date : 2022-10-25 eCollection Date: 2022-01-01 DOI: 10.21037/tgh-22-78

[This corrects the article DOI: 10.21037/tgh-2020-07.].

[这更正了文章DOI: 10.21037/tgh-2020-07。]
{"title":"Erratum to a primer to image enhanced endoscopy.","authors":"","doi":"10.21037/tgh-22-78","DOIUrl":"https://doi.org/10.21037/tgh-22-78","url":null,"abstract":"<p><p>[This corrects the article DOI: 10.21037/tgh-2020-07.].</p>","PeriodicalId":23267,"journal":{"name":"Translational gastroenterology and hepatology","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2022-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/a9/72/tgh-07-22-78.PMC9468981.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40431622","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Filling the diagnostic gap in follow-up after liver transplantation. 填补肝移植术后随访诊断空白。
IF 3 4区 医学 Q1 Medicine Pub Date : 2022-10-25 eCollection Date: 2022-01-01 DOI: 10.21037/tgh-20-284
Christoph Eisenbach
{"title":"Filling the diagnostic gap in follow-up after liver transplantation.","authors":"Christoph Eisenbach","doi":"10.21037/tgh-20-284","DOIUrl":"https://doi.org/10.21037/tgh-20-284","url":null,"abstract":"","PeriodicalId":23267,"journal":{"name":"Translational gastroenterology and hepatology","volume":null,"pages":null},"PeriodicalIF":3.0,"publicationDate":"2022-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/d6/2b/tgh-07-20-284.PMC9468982.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40452590","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
COVID-19 and the liver: a narrative review of the present state of knowledge. 2019冠状病毒病与肝脏:对目前知识状况的叙述性回顾。
IF 3 4区 医学 Q1 Medicine Pub Date : 2022-10-25 eCollection Date: 2022-01-01 DOI: 10.21037/tgh-20-243
Ragesh B Thandassery, Jonathan A Dranoff, Abhilash Perisetti, Tamar Taddei

Novel corona virus disease (COVID-19) is an ongoing pandemic that has spread across the globe. The virus primarily infects type-2 pneumocytes in alveoli and causes lung disease, with severity ranging from mild pneumonia to acute respiratory distress syndrome. The virus also invades gastrointestinal epithelial cells, hepatocytes, and biliary epithelial cells. Derangement of liver function tests is noted in about one third of patients and appears to correlate with more severe disease. There are multiple mechanisms by which the virus can cause liver injury; immune-mediated inflammation and direct viral cytotoxicity are believed to be the predominant mechanisms. Liver injury appears to be transient, usually recovering with resolution of illness. Limited available studies and experience from prior corona virus pandemics seem to suggest that immunosuppressed patients have similar outcomes compared to non-immunosuppressed patients. Age and comorbid conditions seem to influence outcome, irrespective of immune status. Additionally, patients with preexisting comorbid conditions are more prone to acquire infection and should strictly adhere to travel and social distancing advisories. Telemedicine should be utilized to provide uninterrupted care for patients with liver disease, and clinic or hospital visits should be advised only in sick patients with advanced liver disease. In conclusion, liver dysfunction is not uncommon in COVID-19, it generally improves with resolution of disease, and patients with chronic liver disease (CLD) need continued follow up, uninterrupted by the ongoing pandemic, preferably in virtual clinic settings.

新型冠状病毒病(COVID-19)是一种正在全球蔓延的大流行病。该病毒主要感染肺泡中的2型肺细胞,引起肺部疾病,严重程度从轻度肺炎到急性呼吸窘迫综合征不等。病毒也侵入胃肠道上皮细胞、肝细胞和胆道上皮细胞。大约三分之一的患者出现肝功能检查紊乱,似乎与更严重的疾病有关。该病毒可通过多种机制导致肝损伤;免疫介导的炎症和直接的病毒细胞毒性被认为是主要的机制。肝损伤似乎是短暂的,通常随着疾病的消退而恢复。有限的现有研究和以往冠状病毒大流行的经验似乎表明,与非免疫抑制患者相比,免疫抑制患者的结果相似。无论免疫状态如何,年龄和合并症似乎都会影响结果。此外,既往存在合并症的患者更容易感染,应严格遵守旅行和保持社交距离的建议。应利用远程医疗为肝病患者提供不间断的护理,只建议晚期肝病患者到诊所或医院就诊。总之,肝功能障碍在COVID-19中并不罕见,通常随着疾病的缓解而改善,慢性肝病(CLD)患者需要持续随访,不受持续大流行的影响,最好是在虚拟诊所环境中进行随访。
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引用次数: 1
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