An aerobic exercise intervention to improve metabolic health among people living with HIV with at-risk alcohol use: the ALIVE-Ex research study protocol.

BACKGROUND: Effective antiretroviral therapy (ART) in people living with HIV (PLWH) has improved life expectancy and increased risk of age-associated cardiometabolic comorbidities. At-risk alcohol use is more frequent among PLWH and increases the risk of health challenges. PLWH with at-risk alcohol use are more likely to meet criteria for prediabetes/diabetes and this is associated with impaired whole-body glucose-insulin dynamics. METHODS: The Alcohol & Metabolic Comorbidities in PLWH: Evidence Driven Interventions Study (ALIVE-Ex Study, NCT03299205) is a longitudinal, prospective, interventional study to determine the effects of an aerobic exercise protocol on improving dysglycemia among PLWH with at-risk alcohol use. The intervention is a moderate intensity aerobic exercise protocol implemented 3 days per week for 10 weeks at the Louisiana State University Health Sciences Center-New Orleans. Participants who have a fasting blood glucose level between 94 and 125 mg/dl will be enrolled in the study. Oral glucose tolerance tests, fitness assessments, and skeletal muscle biopsies will be performed pre- and post-exercise intervention. The primary outcome is to determine whether the exercise protocol improves measures of whole-body glucose-insulin dynamics, cardiorespiratory fitness, and skeletal muscle metabolic and bioenergetic function. Secondary outcomes are to determine whether the exercise intervention improves cognitive function and overall quality of life. Results generated will demonstrate the effect of exercise on glycemic measures in PLWH with subclinical dysglycemia and at-risk alcohol use. CONCLUSIONS: The proposed intervention will also have the potential to be scalable to promote lifestyle changes among PLWH, particularly in underserved communities.

Skeletal muscle bioenergetic health and function in people living with HIV: association with glucose tolerance and alcohol use.

At-risk alcohol use is prevalent and increases dysglycemia among people living with human immunodeficiency virus (PLWH). Skeletal muscle (SKM) bioenergetic dysregulation is implicated in dysglycemia and type 2 diabetes. The objective of this study was to determine the relationship between at-risk alcohol, glucose tolerance, and SKM bioenergetic function in PLWH. Thirty-five PLWH (11 females, 24 males, age: 53 ± 9 yr, body mass index: 29.0 ± 6.6 kg/m2) with elevated fasting glucose enrolled in the ALIVE-Ex study provided medical history and alcohol use information [Alcohol Use Disorders Identification Test (AUDIT)], then underwent an oral glucose tolerance test (OGTT) and SKM biopsy. Bioenergetic health and function and mitochondrial volume were measured in isolated myoblasts. Mitochondrial gene expression was measured in SKM. Linear regression adjusting for age, sex, and smoking was performed to examine the relationship between glucose tolerance (2-h glucose post-OGTT), AUDIT, and their interaction with each outcome measure. Negative indicators of bioenergetic health were significantly (P < 0.05) greater with higher 2-h glucose (proton leak) and AUDIT (proton leak, nonmitochondrial oxygen consumption, and bioenergetic health index). Mitochondrial volume was increased with the interaction of higher 2-h glucose and AUDIT. Mitochondrial gene expression decreased with higher 2-h glucose (TFAM, PGC1B, PPARG, MFN1), AUDIT (MFN1, DRP1, MFF), and their interaction (PPARG, PPARD, MFF). Decreased expression of mitochondrial genes were coupled with increased mitochondrial volume and decreased bioenergetic health in SKM of PLWH with higher AUDIT and 2-h glucose. We hypothesize these mechanisms reflect poorer mitochondrial health and may precede overt SKM bioenergetic dysregulation observed in type 2 diabetes.

Improved method for calculating hepatic steatosis using the hepatorenal index.

OBJECTIVES: Marshall et al (AJR Am J Roentgenol 2012; 199:997-1002) initially demonstrated that the hepatorenal index is an effective and noninvasive tool to screen patients for hepatic steatosis. The aim of this study was to determine whether the hepatorenal index can be accurately calculated directly from a picture archiving and communication system (PACS) quickly and efficiently without the need for the multiple steps and specialized software used to calculate hepatorenal index in the study by Marshall et al. METHODS: We evaluated 99 of the 101 patients included in the study by Marshall et al: patients being followed by hepatologists with plans for liver biopsy. The hepatorenal index was calculated by using Digital Imaging and Communications in Medicine (DICOM) images from a PACS and a markup region-of-interest tool. We compared this value to the value that Marshall et al derived by using specialized software and to standard histologic estimates. We created similar subgroups: patients with steatosis based on histologically estimated intracellular fat exceeding 5% and patients without steatosis. RESULTS: The mean hepatorenal index ± SD for those with steatosis according to histologic findings was 1.87 ± 0.6, and for those without, it was 1.14 ± 0.2. A hepatorenal index of 1.34 or higher had 92% sensitivity for identifying fat exceeding 5%, 85% specificity, a 94% negative predictive value, and a 79% positive predictive value. Substantial agreement was found between the hepatorenal index calculated from DICOM images and macrovesicular fat categorized at the cut point of 1.34 or higher (κ = 0.76; 95% confidence interval, 0.62-0.88; P < .001). CONCLUSIONS: The hepatorenal index can be quickly and accurately calculated from DICOM images directly on a PACS without supplementary software.

Interventional radiologic techniques for screening, diagnosis and treatment of patients with renal artery stenosis.

Renal artery stenosis resulting in renovascular hypertension or renal ischemia is a potentially treatable condition that results in increased morbidity and mortality, especially among older individuals. Sophisticated imaging techniques are used for screening and identification of affected patients to guide therapy. Treatment guidelines recommend intervention in patients with significant renal artery stenosis, although recent evidence has questioned the benefit of intervention in certain populations. Current research focuses on improving the specificity of imaging techniques and determining which imaging modalities best identify patients who will benefit from intervention.

Hepatorenal index as an accurate, simple, and effective tool in screening for steatosis.

OBJECTIVE: The hepatorenal index has been reported to be a sensitive and noninvasive test to quantify steatosis, but it is cumbersome and time-consuming and requires specialized software. The aim of this study was to improve and simplify the hepatorenal index calculation and determine whether it is an effective tool for differentiating patients with steatosis from those without steatosis, thereby eliminating the need for biopsy in a large number of patients. MATERIALS AND METHODS: One hundred one patients who had undergone ultrasound-guided percutaneous liver biopsy at our institution were selected from a patient database. Patients with renal disease, patients with liver masses, and patients whose liver and right kidney were not included on the same image were excluded. Images were acquired with high-resolution ultrasound, and the hepatorenal index was calculated using freeware based on comparison of hepatic and renal brightness. RESULTS: Of the 101 patients, 63 had 5% or less steatosis and 38 had more than 5% steatosis. Using freeware available online from the National Institutes of Health, we calculated hepatorenal index values for all patients. Our data showed a strong correlation between the hepatorenal index and percentage of fat (r = 0.71, p < 0.0001). A hepatorenal index of 1.28 or greater had a 100% sensitivity for identifying more than 5% fat, 54% specificity, 0.57 positive predictive value, and 1.0 negative predictive value. If this method had been used prospectively to select patients for biopsy in our sample, 34% of biopsies could have been avoided. CONCLUSION: The hepatorenal index is a simple, reliable, and cost-effective screening tool for identifying patients who should not undergo liver biopsy for evaluation of steatosis.

Selective versus nonselective embolization versus no embolization in pelvic trauma: A multicenter retrospective cohort study.

BACKGROUND: Traumatic hemorrhage from pelvic fractures is a significant challenge, and angioembolization has become standard. Optimal treatment is undefined in two clinical scenarios. The first is in the presence of a negative angiogram. Can arterial embolization treat venous bleeding by decreasing the arterial pressure head? If the angiogram is positive, is nonselective embolization (NSE) or selective embolization (SE) better? The purpose of this study is to determine if embolization after a negative angiogram aids in hemorrhage control and when the angiogram is positive, which level of embolization is superior? METHODS: A multicenter retrospective review was conducted including blunt trauma patients with pelvic fractures who underwent angiography. Demographic and clinical data were compiled on all subjects. NSE refers to an intervention at the level of the internal iliac artery and SE is defined as any distal intervention. Theoretical complications of pelvic embolization are those thought to arise from decreased pelvic blood flow and will be referred to as embolization-related complications. Thromboembolic complications included deep vein thrombosis or pulmonary embolism. RESULTS: One hundred ninety-four patients met inclusion criteria. Of the 67 patients with a negative angiogram, 26 (38.8%) were embolized. In those patients requiring transfusion, the units given in the first 24 hours were decreased in the embolization group (7.5 vs. 4.0, p = 0.054). Embolization-related complications occurred more frequently in those not embolized (11.4% vs. 6.0%, p = 0.414).One hundred forty-five patients were embolized, 99 (68.3%) NSE and 46 (31.7%) SE. There were no significant differences in mortality or transfusion requirements. There was no difference in the rate of embolization-related complications (4.1% vs. 2.1%, p = 0.352). There was a significantly increased rate of thromboembolic complications in the NSE group (12.1% vs. 0, p = 0.010). CONCLUSION: Embolization in the face of a negative angiogram may aid in hemorrhage control for those patients being actively transfused. If embolized, then selective occlusion of more distal vessels rather than of the main internal iliac artery should be performed. LEVEL OF EVIDENCE: Therapeutic, level IV.

Feasibility of Intraoperative Nerve Monitoring in Preventing Thermal Damage to the "Nerve at Risk" During Image-Guided Ablation of Tumors.

PURPOSE: To assess feasibility of intraoperative neurophysiologic monitoring (IONM) during image-guided, percutaneous thermal ablation of tumors. MATERIALS AND METHODS: From February 2009 to October 2013, a retrospective review of all image-guided percutaneous thermal ablation interventions using IONM was performed and data was compiled using electronic medical records and imaging studies. RESULTS: Twelve patients were treated in 13 ablation interventions. In 4 patients, real-time feedback from the monitoring neurologist was used to adjust applicator placement and ablation settings. IONM was technically feasible in all procedures and there were no complications related to monitoring or ablation. All nerves at risk remained intact and of the 11 patients who could be followed, none developed new nerve deficit up to a minimum of 2 months after ablation. CONCLUSION: IONM is safe and feasible for use during image-guided thermal ablation of tumors in the vicinity of nerves. Outcomes in this study demonstrate its potential utility in image-guided ablation interventions.