Role of Spleen Stiffness Measurement in the Evaluation of Metabolic Dysfunction-Associated Steatotic Liver Disease.

BACKGROUND: Spleen stiffness measurement (SSM) correlates with the severity of portal hypertension. AIMS: We investigated the utility of SSM in individuals with metabolic dysfunction-associated steatotic liver disease (MASLD) for detecting cirrhosis, esophageal varices (EV), and high-risk EV. METHODS: 154 study participants with MASLD underwent simultaneous liver stiffness measurement (LSM) and SSM. 96 (62%) participants had an upper endoscopy (73 participants, i.e., 47% undergoing within a year). The diagnostic performance of SSM, as well as the BAVENO VII proposed SSM cutoffs (≥ 21 kPa, > 40 kPa, and > 50 kPa), was examined. RESULTS: The failure rate for SSM was 19% compared to 5% for LSM. An invalid SSM was statistically significantly associated with a higher body mass index, a larger waist circumference, and a lower fibrosis stage. The area under the receiver operating characteristics for SSM to diagnose cirrhosis, EV, and high-risk EV was 0.78 (95% CI 0.70-0.85), 0.74 (95% CI 0.61-0.84), and 0.82 (95% CI 0.75-0.98), respectively. SSM ≥ 21 kPa cutoff had a sensitivity > 96% for all three outcomes, with a positive predictive value (PPV) of 88% for cirrhosis. In contrast, SSM > 40 kPa and SSM > 50 kPa cutoffs had better diagnostic abilities for identifying EV, particularly high-risk EV (sensitivity of 100% and 93% with NPV of 100% and 96%, respectively). CONCLUSION: SSM has a higher failure rate in individuals who are non-cirrhotic or have a higher BMI, or larger waist circumference. Although useful for diagnosing NASH cirrhosis, SSM is most reliable in excluding EV and high-risk EV.

Small Intestine Varices in Cirrhosis at a High-Volume Liver Transplant Center: A Retrospective Database Study and Literature Review.

INTRODUCTION: Esophageal varices are a well-characterized sequela of portal hypertension; however, less is known about varices arising in ectopic locations. We aimed to describe bleeding small intestine varices (SIV) in patients with cirrhosis and compare characteristics and outcomes to published case reports. METHODS: We performed an institutional chart review using billing codes and natural language processing between 2008 and 2019. Inclusion criteria were adult patients with cirrhosis and SIV verified by endoscopy, video capsule, or imaging. Patients with noncirrhotic portal hypertension and stomal varices were excluded. We examined demographic and clinical factors, characteristics of SIV, bleeding, intervention, and outcomes in our series and collated data from published cases identified during a literature review. RESULTS: We identified 71 patients with cirrhosis and SIV (18 bled). The literature search yielded 76 cases with bleeding SIV. Our series and published cases were matched for age, sex, liver disease etiology, and SIV location. Length of stay and transfusion requirements were similar. Aggregate initial treatments (number, hemostasis rate) included medical (n = 7, 57%), endoscopic (n = 48, 56%), interventional radiology (n = 31, 77%), and surgery (n = 8, 87%). Hospital and overall mortality rates were higher in our series (22% and 38%) compared with the published cases (5.3% and 18.4%), respectively (P = 0.02 and P = 0.07). DISCUSSION: A quarter of patients with cirrhosis and SIV experience bleeding, with high transfusion requirements, frequent need for secondary interventions, and high mortality. These findings highlight the need for a multidisciplinary approach and second-line therapeutic modalities in the timely management of bleeding SIV in cirrhosis.

Do Império à cidade multiétnica: austríacos no sul do Brasil / From Empire to multiethnic city: Austrians in the South of Brazil / Del imperio a la ciudad multiétnica: austríacos en el sur de Brasil

Este artigo enfoca as circunstâncias que configuraram uma identidade específica a imigrantes identificados como "austríacos". O lócus principal da pesquisa é um núcleo de povoamento no interior do Rio Grande do Sul, reunindo dados que vão do final do século XIX ao final do século XX, período que contempla, em termos internacionais, a existência, ainda que a poucas décadas do seu final, do Império Austro-Húngaro e, em nível local, investimentos recentes no memorialismo étnico. Está sendo dado destaque aos agentes que realizam conexões entre mundos e tempos diferentes e aos modos pelos quais são operacionalizadas as representações do passado.

This article focuses the circumstances which shaped the creation of a specific identity forimmigrants recognized as 'Austrians' in the South of Brazil. The main locus of this research is a small settlement in Rio Grande do Sul's inland, as we collected data from the end of the nineteenth century to the end of the twentiethcentury, comprising the finalyears of the Austro-Hungarian Empire, and locally witnessing late investment in ethnic memorialism. We highlight the agents who accomplish connections between distinct worlds and times, as well as the ways in which past representations are put into action.

Este artículo se centra en las circunstancias que dieron forma a una identidad específica para los inmigrantes identificados como austríacos. El lugar principal de la investigación es un asentamiento en el interior de Río Grande del Sur y fueron recolectados datos que van desde finales del siglo XIX hasta finales del siglo XX, un período que contempla, en términos internacionales, la existencia, aunque unas pocas décadas a partir de su fin, del Imperio austrohúngaro y, en lo local, las recientes inversiones en el memorialismo étnico. Se hace hincapié en los agentes que conectan diferentes mundos y tiempos y en las formas en las que las representaciones del pasado se hacen operativas.

Admission plasma uromodulin and the risk of acute kidney injury in hospitalized patients with cirrhosis: a pilot study.

Acute kidney injury (AKI) is a common complication in hospitalized patients with cirrhosis. Uromodulin, a protein uniquely produced by the kidney and released both in the urine and circulation, has been shown to regulate AKI and is linked to tubular reserve. Although low levels of urine uromodulin are associated with AKI after cardiac surgery, it is unclear whether circulating uromodulin can stratify the risk of AKI, particularly in a susceptible population such as hospitalized patients with cirrhosis. Thus, we investigated whether plasma uromodulin measured at the time of admission is associated with subsequent hospital-acquired AKI (defined by a rise in serum creatinine >0.3mg/dL within 48 h or ≥ 1.5 times baseline) in patients with cirrhosis. A total of 98 patients [mean age 54 yr, Model for Endstage Liver Disease Sodium (MELD-Na) score 19, and baseline creatinine of 0.95 mg/dL] were included, of which 13% (n = 13) developed AKI. Median uromodulin levels were significantly lower in patients who developed AKI compared with patients who did not (9.30 vs. 13.35 ng/mL, P = 0.02). After adjusting for age, sex, diabetes, hypertension, albumin, and MELD-Na score as covariates on multivariable logistic regression, uromodulin was independently associated with AKI [odd ratios of 1.19 (95% confidence interval 1.02, 1.37; P = 0.02)]. Lower uromodulin levels on admission are associated with increased odds of subsequent AKI in hospitalized patients with cirrhosis. Further studies are needed to better understand the role of uromodulin in the pathogenesis and as a predictive biomarker of AKI in this population.NEW & NOTEWORTHY In this study, we found that admission plasma uromodulin levels are significantly lower in patients who developed subsequent acute kidney injury (AKI) during their hospital stay compared with patients who did not. Additionally, uromodulin is independently associated with AKI development after adjusting for clinically relevant parameters such as age, sex, diabetes, hypertension, severity of cirrhosis, and kidney function. To our knowledge, this is the first study linking plasma uromodulin with AKI development in patients with cirrhosis.

Targeted Temperature Management for Subarachnoid Hemorrhage: Excellent Outcome After Severe Vasospasm-A Case Series.

Targeted temperature management (TTM) might improve outcome of patients with severe subarachnoid hemorrhage (SAH) in which vasospasm, delayed cerebral ischemia (DCI), and increased intracranial pressure (ICP) are frequent and severe complications. A series of patients (n = 3) with severe aneurysmatic SAH were treated by TTM if they developed ICP crisis and/or severe vasospasm diagnosed by angiography. Once these complications were detected, body core temperature (BCT) was rapidly decreased to 35°C or 33°C, if necessary. BCT induced and maintained by surface cooling remained at the desired level for at least 72 hours. Rewarming was performed by 1°C, only if the target parameters ICP and velocities in the serial Doppler sonography indicating macrovascular vasospasm improved to regular levels. In case of increase of ICP or middle cerebral arteries velocities BCT was decreased again to the last effective level. The patients developed vasospasm between days 6 and 12 after SAH. All aneurysms were treated by coiling. BCT was reduced between days 6 and 12 after SAH. Total duration of BCT <36.5°C was between 5.5 and 8 days. It remained <35°C for 4-6 days, and at 33°C for 3 days on average. ICP could be sufficiently controlled in all patients, because no ICP crisis was observed during TTM and after rewarming. Two patients developed minor DCI. Side effects of prolonged ventilation of 7-18 days included pneumonia for two patients that could be treated sufficiently. Other complications were one case of ventriculitis and two temporary deliriums. Outcome of the patients was good because no focal neurological symptoms could be detected after rehabilitation. TTM represents a promising treatment approach for severe SAH in which standard treatment is often limited and experimental. It deserves further clinical investigation in a larger cohort.

Is Fasting Necessary for Individuals With Nonalcoholic Fatty Liver Disease to Undergo Vibration-Controlled Transient Elastography?

OBJECTIVES: To investigate the effect of meal intake on liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) in patients with biopsy-proven nonalcoholic fatty liver disease undergoing vibration-controlled transient elastography. METHODS: LSM and CAP were assessed at baseline and serially for 6 hours after meal intake in 24 patients. RESULTS: A significant increase in LSM was seen up to the 2-hour time point (26 ± 25%, P = 0.02). The CAP scores changed minimally with a maximal change of 3% (P > 0.1). CONCLUSIONS: Three hours of fasting is necessary before evaluation with vibration-controlled transient elastography.

Most Individuals With Advanced Cirrhosis Have Sleep Disturbances, Which Are Associated With Poor Quality of Life.

BACKGROUND & AIMS: Sleep disturbances are common in patients with cirrhosis, but their determinants and effects on health-related quality of life are not well-understood. We investigated the prevalence of disturbed sleep in these patients, factors associated with sleep disruption, and effects on quality of life. METHODS: We performed a prospective, cross-sectional study of 193 stable ambulatory patients with cirrhosis (154 with decompensated cirrhosis). Participants completed the Pittsburgh Sleep Quality Index (to assess sleep quality), the Chronic Liver Disease Questionnaire (CLDQ), and muscle cramp questionnaires and underwent neurocognitive testing. Actigraphy was performed in a subset of patients with normal and disturbed sleep. We collected serum samples from subjects with normal and disturbed sleep and performed non-targeted metabolomic analyses. RESULTS: Of the study subjects, 157 (81%) had disturbed sleep, with Pittsburgh Sleep Quality Index scores >5. Disturbed sleep was associated with muscle cramps, daytime somnolence, and decreased quality of life on the basis of CLDQ scores. Factors independently associated with disturbed sleep in logistic regression analysis included hypoalbuminemia, opiate therapy, and muscle cramps. Disturbed sleep was independently associated with CLDQ score (correlation parameter, -36.6; 95% confidence interval, -24 to -49; P < .001) on linear regression. Disturbed sleep was associated with neurocognitive impairment and with significantly delayed bedtime and decreased total sleep time, measured by actigraphy. Disturbed sleep was associated with metabolome signatures of alterations to the intestinal microbiome and lipid, arginine, and urea cycle metabolism. CONCLUSIONS: Most patients with advanced cirrhosis (81%) have disturbed sleep. This has negative effects on quality of life and is associated with disruptions of several metabolic pathways, including metabolism by the intestinal microbiota.

Cycloalkene Carbonitriles in Rhodium-Catalyzed 1,4-Addition and Formal Synthesis of Vabicaserin.

Cycloalkenes with exocyclic acceptor substituents still remain challenging substrates for enantioselective rhodium-catalyzed 1,4-addition. Cycloalkene carbonitriles and carboxylates have been investigated, and a highly diastereo- and enantioselective protocol for 1,4-addition to cyclopentene and cycloheptene carbonitrile has been developed. This new asymmetric transformation was subsequently applied in the asymmetric formal synthesis of the drug candidate Vabicaserin.

Intraoperative three-dimensional visualization in microvascular decompression.

OBJECT: The authors systematically analyzed 3D visualization of neurovascular compression (NVC) syndromes in the operating room (OR) during microvascular decompression (MVD). METHODS: A total of 50 patients (26 women and 24 men) with trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GN) were examined and underwent MVD. Preoperative imaging of the neurovascular structures was performed using constructive interference in the steady state magnetic resonance (CISS MR) imaging, which consisted of 2D image slices. The 3D visualization of the neurovascular anatomy is generated after segmentaion of the CISS MR imaging in combination with direct volume rendering (DVR). The 3D representations were stored on a personal computer (PC) that was mounted on a mobile unit and transferred to the OR. During surgery, 3D visualization was applied by the surgeon with remotely controlled plasma-sterilized devices such as a wireless mouse and keyboard. The position of the 3D visualized neurovascular structures at the PC monitor was determined according to the intraoperative findings observed through the operating microscope. RESULTS: The system was stable during all neurosurgical procedures, and there were no operative or technical complications. Interactive adjustment of the 3D visualization guided by the view through the microscope permitted observation of the neurovascular relationships at the brainstem. Vessels covered by the cranial nerves could be noninvasively viewed by intraoperative 3D visualization. Postoperatively, the patients with TN and GN experienced pain relief, and the patients with HFS attained resolution of their facial tics. Vascular compression of nerves was explored in all 50 patients during MVD. Intraoperative 3D visualization delineated the compressing vessels and respective cranial nerves in 49 (98%) of 50 patients. CONCLUSIONS: Interactive 3D visualization by DVR of high-resolution MR imaging data offered the opportunity for noninvasive virtual exploration of the neurovascular structures during surgery. An extended global survey of the neurovascular relationships was provided during MVD in each case. The presented method proved to be extremely advantageous for optimizing microneurosurgical procedures, supporting superior safety and improving the operative results when compared with the conventional strategy. This modality proved to be a very valuable teaching instrument and ensured the improvement of neurosurgical quality.

Classification of neurovascular compression in typical hemifacial spasm: three-dimensional visualization of the facial and the vestibulocochlear nerves.

OBJECT: In this paper, the authors introduce a method of noninvasive anatomical analysis of the facial nerve-vestibulocochlear nerve complex and the depiction of the variable vascular relationships by using 3D volume visualization. With this technique, a detailed spatial representation of the facial and vestibulocochlear nerves was obtained. Patients with hemifacial spasm (HFS) resulting from neurovascular compression (NVC) were examined. METHODS: A total of 25 patients (13 males and 12 females) with HFS underwent 3D visualization using magnetic resonance (MR) imaging with 3D constructive interference in a steady state (CISS). Each data set was segmented and visualized with respect to the individual neurovascular relationships by direct volume rendering. Segmentation and visualization of the facial and vestibulocochlear nerves were performed with reference to their root exit zone (REZ), as well as proximal and distal segments including corresponding blood vessels. The 3D visualizations were interactively compared with the intraoperative situation during microvascular decompression (MVD) to verify the results with the observed microneurosurgical anatomy. RESULTS: Of the 25 patients, 20 underwent MVD (80%). Microvascular details were recorded on the affected and unaffected sides. On the affected sides, the anterior inferior cerebellar artery (AICA) was the most common causative vessel. The posterior inferior cerebellar artery, vertebral artery, internal auditory artery, and veins at the REZ of the facial nerve (the seventh cranial nerve) were also found to cause vascular contacts to the REZ of the facial nerve. In addition to this, the authors identified three distinct types of NVC within the REZ of the facial nerve at the affected sides. The authors analyzed the varying courses of the vessels on the unaffected sides. There were no bilateral clinical symptoms of HFS and no bilateral vascular compression of the REZ of the facial nerve. The authors discovered that the AICA is the most common vessel that interferes with the proximal and distal portions of the facial nerve without any contact between vessels and the REZ of the facial nerve on the unaffected sides. CONCLUSIONS: Three-dimensional visualization by direct volume rendering of 3D CISS MR imaging data offers the opportunity of noninvasive exploration and anatomical categorization of the facial nerve-vestibulocochlear nerve complex. Furthermore, it proves to be advantageous in establishing the diagnosis and guiding neurosurgical procedures by representing original MR imaging patient data in a 3D fashion. This modality provides an excellent overview of the entire neurovascular relationship of the cerebellopontine angle in each case.

The heart-mind connection.

A clear connection exists between mental health and heart disease, which requires assessment, collaboration with other professionals, and behavioral health interventions. Psychosocial factors such as stress, anger, anxiety, and depression promote heart disease. Alternately, the use of mood-enhancing or stress-reducing techniques--such as optimism, meditation, counseling, exercise, and imagery--as well as a lifestyle behavioral change approach can have a positive effect on reducing the incidence of heart disease. Behavioral health treatment can improve medical conditions and quality of life.

Condiçöes de vida: acesso à previdência: assistência médica; aposentadoria / Living conditions: access to social security: medical care; retirement

Além de tratar do acesso à assistência médica, acompanha, a partir de uma pequena cidade, Ijuí, a forma de implantaçäo de um sistema previdenciário nacional.

Condiçöes de vida: acesso à previdência: assistência médica; aposentadoria / Living conditions: access to social security: medical care; retirement

Além de tratar do acesso à assistência médica, acompanha, a partir de uma pequena cidade, Ijuí, a forma de implantaçäo de um sistema previdenciário nacional.(AU)