Increased accuracy in identifying NAFLD with advanced fibrosis and cirrhosis: independent validation of the Agile 3+ and 4 scores.

BACKGROUND AND AIMS: We explored 2 novel scores, Agile 3+ and 4, to identify advanced fibrosis (≥F3) and cirrhosis (F4), respectively, in NAFLD and compared their diagnostic performances to liver stiffness measurement (LSM) by vibration-controlled transient elastography and fibrosis-4 index (FIB-4) (for Agile 3+). APPROACH AND RESULTS: This multicenter study included 548 NAFLD patients with laboratory testing, liver biopsy, and vibration-controlled transient elastography within 6 months. Agile 3+ and 4 were applied and compared with FIB-4 or LSM alone. Goodness of fit was evaluated using a calibration plot and discrimination using area under the receiver operating curve. Area under the receiver operating curves was compared using the Delong test. Dual cutoff approaches were applied to rule out and rule in ≥F3 and F4. Median (interquartile range) age was 58 (15) years. Median body mass index was 33.3 (8.5) kg/m2. Fifty-three percent had type 2 diabetes, 20% had F3, and 26% had F4. Agile 3+ demonstrated an area under the receiver operating curve of 0.85 (0.81; 0.88) similar to that of LSM [0.83 (0.79; 0.86), p=0.142] but significantly higher than that of FIB-4 [0.77 (0.73; 0.81), p<0.0001). Agile 4's area under the receiver operating curve [0.85 (0.81; 0.88)] was similar to that of LSM [0.85 (0.81; 0.88), p=0.065). However, the percentage of patients with indeterminate results was significantly lower with Agile scores compared with FIB-4 and LSM (Agile 3+: 14% vs. FIB-4: 31% vs. LSM: 13%, p<0.001; Agile 4: 23% vs. LSM: 38%, p<0.001). CONCLUSIONS: Agile 3+ and 4 are novel vibration-controlled transient elastography-based noninvasive scores that increase accuracy in the identification of advanced fibrosis and cirrhosis respectively and are ideal for clinical use due to a lower percentage of indeterminant outputs compared with FIB-4 or LSM alone.

Machine learning models are superior to noninvasive tests in identifying clinically significant stages of NAFLD and NAFLD-related cirrhosis.

BACKGROUND AND AIMS: We assessed the performance of machine learning (ML) models in identifying clinically significant NAFLD-associated liver fibrosis and cirrhosis. APPROACH AND RESULTS: We implemented ML models including logistic regression (LR), random forest (RF), and artificial neural network to predict histological stages of fibrosis using 17 demographic/clinical features in 1370 patients with NAFLD who underwent liver biopsy, FibroScan, and labs within a 6-month period at multiple U.S. centers. Histological stages of fibrosis (≥F2, ≥F3, and F4) were predicted using ML, FibroScan liver stiffness measurements, and Fibrosis-4 index (FIB-4). NASH with significant fibrosis (NAS ≥ 4 + ≥F2) was assessed using ML, FibroScan-AST (FAST) score, FIB-4, and NAFLD fibrosis score (NFS). We used 80% of the cohort to train and 20% to test the ML models. For ≥F2, ≥F3, F4, and NASH + NAS ≥ 4 + ≥F2, all ML models, especially RF, had primarily higher accuracy and AUC compared with FibroScan, FIB-4, FAST, and NFS. AUC for RF versus FibroScan and FIB-4 for ≥F2, ≥F3, and F4 were (0.86 vs. 0.81, 0.78), (0.89 vs. 0.83, 0.82), and (0.89 vs. 0.86, 0.85), respectively. AUC for RF versus FAST, FIB-4, and NFS for NASH + NAS ≥ 4 + ≥F2 were (0.80 vs. 0.77, 0.66, 0.63). For NASH + NAS ≥ 4 + ≥F2, all ML models had lower/similar percentages within the indeterminate zone compared with FIB-4 and NFS. Overall, ML models performed better in sensitivity, specificity, positive predictive value, and negative predictive value compared with traditional noninvasive tests. CONCLUSIONS: ML models performed better overall than FibroScan, FIB-4, FAST, and NFS. ML could be an effective tool for identifying clinically significant liver fibrosis and cirrhosis in patients with NAFLD.

Mycobacterium leprae Induces Neutrophilic Degranulation and Low-Density Neutrophil Generation During Erythema Nodosum Leprosum.

Erythema Nodosum Leprosum (ENL) is a recurrent acute inflammatory complication of leprosy affecting up to 50% of all Borderline Lepromatous and Lepromatous Leprosy (BL/LL) patients. Although ENL is described as an immune reaction mediated by neutrophils, studies demonstrating the direct role of neutrophils in ENL are still rare. One subpopulation of low-density neutrophils (LDNs), present within the fraction of peripheral blood mononuclear cells (PBMC), has been associated with the pathogenesis and severity of diseases like sepsis, lupus, and tuberculosis. We herein analyzed LDNs and high-density neutrophils (HDNs) in terms of frequency, phenotype, and morphology. Serum levels of MMP-9 (a neutrophilic degranulation marker) were evaluated by ELISA; and LDNs were generated in vitro by stimulating healthy-donor, whole-blood cultures. PBMC layers of ENL patients presented segmented/hypersegmented cells that were morphologically compatible with neutrophils. Immunofluorescence analyses identified LDNs in ENL. Flow cytometry confirmed the elevated frequency of circulating LDNs (CD14-CD15+) in ENL patients compared to healthy donors and nonreactional Borderline Tuberculoid (BT) patients. Moreover, flow cytometry analyses revealed that ENL LDNs had a neutrophilic-activated phenotype. ENL patients under thalidomide treatment presented similar frequency of LDNs as observed before treatment but its activation status was lower. In addition, Mycobacterium leprae induced in vitro generation of LDNs in whole blood in a dose-dependent fashion; and TGF-ß, an inhibitor of neutrophilic degranulation, prevented LDNs generation. MMP-9 serum levels of BL/LL patients with or without ENL correlated with LDNs frequency at the same time that ultrastructural observations of ENL LDNs showed suggestive signs of degranulation. Together, our data provide new insights into the knowledge and understanding of the pathogenesis of ENL while enriching the role of neutrophils in leprosy.

Erythema Nodosum Leprosum Neutrophil Subset Expressing IL-10R1 Transmigrates into Skin Lesions and Responds to IL-10.

Erythema nodosum leprosum (ENL) is an inflammatory complication in leprosy. Yet, the involvement of ENL neutrophils in the inflammatory response against Mycobacterium leprae remains poorly explored. Our primary aim was to investigate the utility of the surface expression of neutrophil IL-10R1 as an ENL biomarker and, secondarily, to evaluate whether leprosy or healthy M. leprae-stimulated neutrophils produce cytokines and are able to respond to IL-10. We, in this study, describe a subpopulation of circulating neutrophils of ENL patients that exclusively expressed IL-10R1, providing evidence that IL-10R1+ neutrophils are present in ENL lesions. It was also found that ENL neutrophils, but not those of nonreactional leprosy controls, were able to secret detectable levels of TNF ex vivo and the addition of IL-10 blocked TNF release. It was likewise observed that M. leprae-stimulated, healthy neutrophils expressed IL-10R1 in vitro, and ENL-linked cytokines were released by M. leprae-cultured neutrophils in vitro. Moreover, consistent with the presence of a fully functional IL-10R, the addition of IL-10 prevented the release of M. leprae-induced cytokines. Most importantly, dead M. leprae revealed its superior capacity to induce CCL4 and IL-8 in primary neutrophils over live Mycobacterium, suggesting that M. leprae may hamper the inflammatory machinery as an immune escape mechanism.

Neutrophils in Leprosy.

Leprosy is an infectious disease caused by the intracellular bacillus Mycobacterium leprae that mainly affects the skin and peripheral nerves. One of the most intriguing aspects of leprosy is the diversity of its clinical forms. Paucibacillary patients are characterized as having less than five skin lesions and rare bacilli while the lesions in multibacillary patients are disseminated with voluminous bacilli. The chronic course of leprosy is often interrupted by acute episodes of an inflammatory immunological response classified as either reversal reaction or erythema nodosum leprosum (ENL). Although ENL is considered a neutrophilic immune-complex mediated condition, little is known about the direct role of neutrophils in ENL and leprosy disease overall. Recent studies have shown a renewed interest in neutrophilic biology. One of the most interesting recent discoveries was that the neutrophilic population is not homogeneous. Neutrophilic polarization leads to divergent phenotypes (e.g., a pro- and antitumor profile) that are dynamic subpopulations with distinct phenotypical and functional abilities. Moreover, there is emerging evidence indicating that neutrophils expressing CD64 favor systemic inflammation during ENL. In the present review, neutrophilic involvement in leprosy is discussed with a particular focus on ENL and the potential of neutrophils as clinical biomarkers and therapeutic targets.

Avaliação do índice de conicidade como preditor de risco cardiometabólico e suas associações em pacientes adultos submetidos a atendimento ambulatorial no Sul do Brasil / Evaluation of the conicity index as a predictor of cardiometabolic risk and its associations in adult patients submitted to outpatient care in Southern Brazil

Objetivo: Avaliar índice de conicidade de pacientes adultos atendidos em um Ambulatório de Nutrição, associá-lo com presença de patologias e compará-lo a indicadores antropométricos quanto à sua eficácia como preditor de risco cardiometabólico. Metodologia: Estudo observacional com dados secundários de prontuários. Dados socioeconômicos, antropométricos (peso, índice de massa corporal, circunferência da cintura, do pescoço e índice de conicidade), número de consultas e hábitos de vida, foram obtidos e comparados entre a primeira e última consulta. As análises foram realizadas no pacote estatístico Stata® 11.1, com nível de significância de 5%. Resultados: Amostra constituída por 164 adultos, sendo 114 (70%) mulheres. A maioria apresentava hipertensão (45%), sedentarismo (48%), peso acima do ideal (90%) e valores de CC(82%), CP (82%) e IC (88%) acima do recomendado. A maioria apresentou perda de peso (77%), sendo que 29% perdeu mais de 5% do peso inicial, além de melhora significativa nos hábitos alimentares, principalmente pelas mulheres. O índice de conicidade associou-se significativamente com os indicadores antropométricos analisados; foi mais sensível nas mulheres quanto à classificação de risco de complicações metabólicas e cardiovasculares, e apresentou valores significativamente maiores nos hipertensos e diabéticos. Conclusão: É importante o acompanhamento nutricional para melhoria dos hábitos de vida dos pacientes, assim como a utilização do IC, que associou-se com hipertensão e diabetes,sendo mais sensível nas mulheres em relação ao risco de complicações cardiometabólicas do que a CC e CP, demonstrando ser um bom indicador antropométrico,capaz de possibilitar a detecção precoce da obesidade e da distribuição de gordura (AU)

Objective: Evaluate the conicity index of adult patients treated at a Nutrition Outpatient Clinic, to associate it with the presence of pathologies and to compare with anthropometric indicators as to its efficacy as a predictor of cardiometabolic risk. Methodology: Observational study with secondary data from medical records. Socioeconomic, anthropometric data (weight, body mass index, waist circumference, neck and conicity index), number of visits and life habits were obtained and compared between the first and last visit. The analyzes were performed in Stata® 11.1 statistical package, with a significance level of 5%. Results: Sample of 164 adults, 114 (70%) of whom were women. The majority had hypertension (45%), sedentarism (48%), weight above the ideal (90%) and values of CC (82%), CP (82%) and IC (88%) above recommended. The majority presented weight loss (77%), with 29% losing more than 5% of the initial weight, in addition to a significant improvement in eating habits, mainly by women. The taper index was significantly associated with the anthropometric indicators analyzed; was more sensitive in women regarding the risk classification of metabolic and cardiovascular complications, presented significantly higher values in hypertensive and diabetic patients. Conclusion: It is important nutritional monitoring to improve life habits of patients, as well as the use of HF, which was associated with hypertension and diabetes, being more sensitive in women in relation to the risk of cardiometabolic complications than CC and CP, proving to be a good anthropometric indicator, capable of making possible the early detection of obesity and fat distribution (AU)

Envolvimento da via IL-10/IL-10R na resposta imunológica durante o curso da infecção pelo Mycobacterium leprae / Involvement of the IL-10 / IL-10R pathway in the immune response during the course of Mycobacterium leprae infection

A interleucina-10 (IL-10) possui papel chave no controle das respostas inflamatórias. A atividade biológica da IL-10 é mediada pela ligação da IL-10 com o receptor heterodimérico composto pelas cadeias IL-10R1 e IL-10R2. Estudos anteriores demonstram que neutrófilos circulantes de doadores sadios expressam constitutivamente a cadeia IL-10R2, porém não expressam IL-10R1, e dessa forma não respondem a IL-10 in vitro. A expressão das duas cadeias é essencial para a responsividade a IL-10. Neutrófilos circulantes de pacientes sépticos expressam o receptor IL-10R1 e essa expressão é corroborada com a responsividade à IL-10. O eritema nodoso hansênico (ENH) é uma complicação imunológica grave da hanseníase multibacilar que apresenta aspectos semelhantes à sepse, como leucocitose neutrofílica, febre, mal-estar e inflamação sistêmica. O ENH altera o curso crônico da hanseníase, pois acelera os danos nos nervos periféricos, resultando em incapacidades físicas permanentes. Um dos aspectos marcantes desta reação é a presença de neutrófilos na derme profunda e no tecido subcutâneo nas lesões. Dessa forma, o ENH tem sido caracterizado como uma condição imunomediada por neutrófilos. O objetivo deste trabalho foi investigar o potencial da via da IL-10 na regulação da produção de citocinas produzidas por neutrófilos durante o episódio de ENH.

Nesse estudo, reportamos que neutrófilos de sangue periférico de pacientes acometidos pelo ENH expressam altos níveis de IL-10R1. Além disso, demonstramos que esses mesmos pacientes, quando tratados com a talidomida, possuem níveis ainda mais elevados de IL-10R1 na superfície de neutrófilos circulantes. Observamos também que neutrófilos presentes nas lesões de pele de pacientes acometidos pelo ENH expressam IL-10R1. Ensaios ex vivo revelaram que a IL-10 foi capaz de inibir a produção espontânea de TNF de neutrófilos de pacientes com ENH, e induzir a produção de TGF-1. Por outro lado, neutrófilos de pacientes controle não-reacionais não produzem espontanêamete TNF, porém, assim como neutrófilos de pacientes com ENH, produzem TGF-ß1. Em seguida, demonstramos que o M. leprae foi capaz de induzir a produção de IL-8, IL-1ß, IL-6, MIP-1/CCL4, TGF- e IL-1RA em neutrófilos de doadores sadios in vitro, e que a adição de IL-10 reduziu a produção dessas citocinas, com exceção de TGF-1 que aumentou. Nossas conclusões demonstraram a capacidade do M. leprae em induzir a expressão de IL-10R1 na superfície de neutrófilos sadios. Coletivamente, nossos dados confirmam que neutrófilos participam da inflamação sistêmica associada ao ENH por meio da produção de citocinas. Esses resultados contribuem para o melhor entendimento dos mecanismos patogênicos e apontam para a via da IL-10 como alvo molecular terapêutico e diagnóstico. (AU)

Expression of CD64 on Circulating Neutrophils Favoring Systemic Inflammatory Status in Erythema Nodosum Leprosum.

Erythema Nodosum Leprosum (ENL) is an immune reaction in leprosy that aggravates the patient´s clinical condition. ENL presents systemic symptoms of an acute infectious syndrome with high leukocytosis and intense malaise clinically similar to sepsis. The treatment of ENL patients requires immunosuppression and thus needs to be early and efficient to prevent both disabilities and permanent nerve damage. Some patients experience multiple episodes of ENL and prolonged use of immunosuppressive drugs may lead to serious adverse effects. Thalidomide treatment is extremely effective at ameliorating ENL symptoms. Several mechanisms have been proposed to explain the efficacy of thalidomide in ENL, including the inhibition of TNF production. Given its teratogenicity, thalidomide is prohibitive for women of childbearing age. A rational search for molecular targets during ENL episodes is essential to better understand the disease mechanisms involved, which may also lead to the discovery of new drugs and diagnostic tests. Previous studies have demonstrated that IFN-γ and GM-CSF, involved in the induction of CD64 expression, increase during ENL. The aim of the present study was to investigate CD64 expression during ENL and whether thalidomide treatment modulated its expression. Leprosy patients were allocated to one of five groups: (1) Lepromatous leprosy, (2) Borderline leprosy, (3) Reversal reaction, (4) ENL, and (5) ENL 7 days after thalidomide treatment. The present study demonstrated that CD64 mRNA and protein were expressed in ENL lesions and that thalidomide treatment reduced CD64 expression and neutrophil infiltrates-a hallmark of ENL. We also showed that ENL blood neutrophils exclusively expressed CD64 on the cell surface and that thalidomide diminished overall expression. Patient classification based on clinical symptoms found that severe ENL presented high levels of neutrophil CD64. Collectively, these data revealed that ENL neutrophils express CD64, presumably contributing to the immunopathogenesis of the disease.

3-Bromopyruvic Acid Inhibits Tricarboxylic Acid Cycle and Glutaminolysis in HepG2 Cells.

BACKGROUND/AIM: 3-bromopyruvate (3BrPA) is an antitumor agent able to inhibit aerobic glycolysis and oxidative phosphorylation, therefore inducing cell death. However, cancer cells are also highly dependent of glutaminolysis and tricarboxylic acid cycle (TCA) regarding survival and 3BrPA action in these metabolic routes is poorly understood. MATERIALS AND METHODS: The effect of 3BrPA was characterized in mice liver and kidney mitochondria, as well as in human HepG2 cells. RESULTS: Low concentration of 3-BrPA significantly affected both glutaminolysis and TCA cycle functions, through inhibition of isocitrate dehydrogenase, α-ketoglutarate dehydrogenase and succinate dehydrogenase. Additionally, 3-BrPA treatment significantly decreased the reduced status of thiol groups in HepG2 cells without proportional increase of oxidizing groups, suggesting that these chemical groups are the target of alkylation reactions induced by 3-BrPA. CONCLUSION: This work demonstrates, for the first time, the effect of 3-BrPA in glutaminolysis and TCA cycle. Our results suggest that the combined action of 3-BrPA in glutaminolysis, TCA and glycolysis, inhibiting steps downstream of the glucose and glutamine metabolism, has an antitumor effect.

A formação ética do fisioterapeuta / Physical therapist ethical formation

No passado, havia estreita relação entre a filosofia e os indivíduos que se dedicavam à área de saúde. O avanço tecnológico exigiu ritmo por parte dos profisisonais para dar conta de acompanhar as novidades. Houve o surgimento das especialidades e paralelamente o desinteresse pelas disciplinas voltadas para orientação da conduta. Os próprios currículos já não prestigiam tais disciplinas. Observa-se que a construção do sujeito ético ocorre por meio da educação. Se esta deixa de cumprir este papel, o prejuízo é percebido na própria sociedade, principalmente na área de saúde, onde se lida com angústias e sofrimento. Muito se tem falado em humanização na assistência à saúde, muitos investimentos são feitos em tecnologia, mas o investimento que mais benefícios oferece consiste em formar profissionais éticos

In past there was narrow relation between Philosophy and individuals who was dedicated to health. The technological advance demanded rhythm sped up of the professionals to follow the new features. It had the sprouting of the specialties and parallel the disinterest for discipline that toward orientation of the behavior. The proper curriculum already do not values such disciplines. The construction of ethical citizen occurs by education. If this leaves this paper the damage is perceived in the society, mainly in the health area where if it deals with anguishes and suffering. Much has been said about humanization in health assistance, many investments is done in technology, but the investment that more benefits it offers consists of forming ethical professionals.