Nonalcoholic Fatty Liver Disease after Liver Transplant.

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease in the world. The rising prevalence of nonalcoholic steatohepatitis (NASH) has led to a 170% increase in NASH cirrhosis as the listing indication for liver transplantation from 2004 to 2013. As of 2018, NASH has overtaken hepatitis C as an indication for liver transplantation in the USA. After liver transplantation, the allograft often develops recurrent NAFLD among patients with known NASH cirrhosis. In addition to recurrent disease, de novo NAFLD has been reported in patients with other indications for liver transplantation. In this review, we will discuss the risk factors associated with recurrent and de novo NAFLD, natural course of the disease, and management strategies after liver transplantation.

Atrial cardiopathy and stroke mortality in the general population.

BACKGROUND: Prior studies examining the link between atrial cardiopathy and stroke risk have focused mainly on non-fatal stroke. AIMS: To examine the association between atrial cardiopathy and stroke mortality. METHODS: This analysis included 8028 participants (60.0 ± 13.4 years, 51.9% women, 49.8% white) from the Third National Health and Nutrition Examination (NHANES III) Survey. Atrial cardiopathy was defined as abnormal deep terminal negativity of the P wave in V1 (DTNPV1 = negative p-wave in V1<-100 µv), an electrocardiographic marker of atrial cardiopathy. Stroke mortality was ascertained using the National Death Index over a median follow-up of 14 years. RESULTS: 2.95% (n = 237) of the participants had atrial cardiopathy, and the prevalence was slightly higher in blacks (4%) versus whites (3%). During follow-up, stroke mortality was more common in those with (5.9%) than those without (2.7%) atrial cardiopathy; p = .004. In a multivariable adjusted model, atrial cardiopathy was associated with a 76% increased risk of stroke mortality (HR (95% CI): 1.76 (1.02-3.04)]. This association was stronger in non-whites than whites (HR (95% CI): 3.50 (1.74-7.03) vs. 0.98 (0.40-2.42), respectively; interaction p = 0.03). Among those with baseline atrial cardiopathy, the annualized stroke mortality rates/1000 participants across CHA2DS2-VASc scores of 0, 1, and ≥2 were 0.0, 2.2, and 7.8, respectively. CONCLUSIONS: Atrial cardiopathy is associated with an increased risk of stroke mortality, especially among non-whites. Among those with atrial cardiopathy, the risk of stroke mortality exponentially increases as the CHA2DS2-VASc score becomes 2 or above. Randomized controlled trials are needed to assess the efficacy of anticoagulation in the prevention of ischemic stroke and thus, stroke mortality in the presence of atrial cardiopathy.

Relation of total bilirubin and QT interval prolongation (from the Third National Health and Nutrition Examination Survey).

OBJECTIVE: The association of bilirubin with cardiovascular disease (CVD) is controversial. We sought to explore the association of total bilirubin (TB) levels with QT interval in a multiracial cohort. METHODS: A total of 6,627 participants (59.0 ± 13.3 years; 52.6% women, 49.7% Non-Hispanic Whites) without CVD from the Third National Health and Nutrition Examination Survey were included in this analysis. QT was automatically measured from digital 12-lead electrocardiogram in a central reading center. A multivariable logistic regression model was used to examine the cross-sectional association between tertiles of TB and prolonged QT interval (≥450 ms in men and ≥460 ms in women). RESULTS: The prevalence of prolonged QT was higher among those with higher levels of TB (prolonged QT prevalence was 4.7%, 6.8%, and 7.0% across TB lower (0-0.4 mg/dl), middle (0.5-1.6 mg/dl), and higher (0.70-4.30 mg/dl) tertiles, respectively). In a model adjusted for potential confounders, participants within the highest TB tertile had significantly greater odds of the prolonged QT interval (Odds ratios [95% confidence interval] 1.53 [1.16-2.02]) compared to those with bilirubin levels in the first tertile. Each 0.29 mg/dl increase in TB levels was associated with a 12% (p-value <.0001) increase in the prevalence of prolonged QT interval. This association was stronger in men than in women (interaction p-value = .04). CONCLUSION: Elevated bilirubin levels are associated with a prolonged QT interval. This finding extends our current knowledge on the relationship between serum bilirubin and CVD by demonstrating a link between higher TB and abnormal cardiac repolarization.

Wake Forest University long-term follow-up of type 2 myocardial infarction: The Wake-Up T2MI Registry.

BACKGROUND: The Wake-Up T2MI Registry is a retrospective cohort study investigating patients with type 2 myocardial infarction (T2MI), acute myocardial injury, and chronic myocardial injury. We aim to explore risk stratification strategies and investigate clinical characteristics, management, and short- and long-term outcomes in this high-risk, understudied population. METHODS: From 1 January 2009 to 31 December 2010, 2846 patients were identified with T2MI or myocardial injury defined as elevated cardiac troponin I with at least one value above the 99th percentile upper reference limit and coefficient of variation of 10% (>40 ng/L) and meeting our inclusion criteria. Data of at least two serial troponin values will be collected from the electronic health records to differentiate between acute and chronic myocardial injury. The Fourth Universal Definition will be used to classify patients as having (a) T2MI, (b) acute myocardial injury, or (c) chronic myocardial injury during the index hospitalization. Long-term mortality data will be collected through data linkage with the National Death Index and North Carolina State Vital Statistics. RESULTS: We have collected data for a total of 2205 patients as of November 2018. The mean age of the population was 65.6 ± 16.9 years, 48% were men, and 64% were white. Common comorbidities included hypertension (71%), hyperlipidemia (35%), and diabetes mellitus (30%). At presentation, 40% were on aspirin, 38% on ß-blockers, and 30% on statins. CONCLUSION: Improved characterization and profiling of this cohort may further efforts to identify evidence-based strategies to improve cardiovascular outcomes among patients with T2MI and myocardial injury.

Association of obesity phenotypes with electrocardiographic subclinical myocardial injury in the general population.

BACKGROUND: As the debate continues about whether obesity in metabolically healthy individuals is associated with poor outcomes or not, investigating the association between the obesity phenotypes and markers of subclinical myocardial injury will help identify those at risk for future cardiovascular events (cardiovascular disease [CVD]). HYPOTHESIS: We hypothesize that obesity phenotypes including metabolically healthy obesity (MHO) is associated with subclinical myocardial injury (SC-MI). METHODS: This analysis included 3423 participants (57.85 ± 13.06 years, 53.3% women) without known CVD from National Health and Nutrition Examination Survey (NHANES) III. Multivariable logistic regression models were used to examine the cross-sectional association between four obesity phenotypes (metabolically healthy nonobese (MHNO) [reference], metabolically unhealthy nonobese (MUNO), MHO, and metabolically unhealthy obese (MUO) with SC-MI. SC-MI was defined from the 12-lead electrocardiogram as cardiac infarction/injury score ≥ 10 units. Metabolic syndrome (MetS) was defined according to the International Diabetes Federation consensus definition. Obesity was defined as body mass index ≥30 kg/m2 . RESULTS: MUO was associated with higher odds of SC-MI compared with MHNO (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.22-1.92, P = 0.0005). This association was stronger in men vs women (OR [95% CI]: 2.20 [1.58-2.07] vs 1.08 [0.79-1.48]), respectively; interaction P-value = 0.002) but was consistent in subgroups stratified by age and race. There was no significant association of MHO or MUNO with SC-MI compared with MHNO, but there was a trend toward higher odds of SC-MI in the MUNO group (P-value for trend across MHNO, MUNO, and MUO = 0.0002). CONCLUSIONS: Our findings suggest that a combination of obesity and MetS confers worse prognosis and early preventive strategies aimed at weight loss and management of MetS components may decrease the risk of future poor outcomes.

Vitamin D deficiency and electrocardiographic subclinical myocardial injury: Results from National Health and Nutrition Examination Survey-III.

BACKGROUND: Association of cardiovascular disease (CVD) with nontraditional risk factors such as vitamin D deficiency has been examined previously. An investigation of the association of vitamin D with subclinical myocardial injury (SC-MI) based on an electrocardiographic score is a simple, cost-effective and innovative way to explore this relationship. HYPOTHESIS: We hypothesize that low vitamin D levels will be associated with prevalent SC-MI independent of traditional CVD risk factors, lifestyle factors, and socioeconomic status. METHODS: This analysis included 6079 participants (58.3 ± 13.1 years; 54.1% women) without CVD from the third National Health and Nutrition Examination Survey. A multivariable logistic regression model was used to examine the association between vitamin D categories (<20, 20-29, and >30 ng/mL (reference) and cardiac injury score. RESULTS: There was an incremental increase in the prevalence of SC-MI across vitamin D categories with the highest prevalence in <20 ng/mL, followed by 20 to 29 ng/mL and then >30 ng/mL (trend P-value <0.0001). There was a statistically significant association between vitamin D deficiency (<20 ng/mL) and SC-MI (odds ratio [OR] (95% confidence interval [CI]): 1.27 (1.04-1.55), P = 0.04). This association was stronger in men than women (OR (95% CI): 1.74 (1.32-2.30) vs 0.94 (0.70-1.25) respectively; interaction P-value 0.002). CONCLUSIONS: Vitamin D deficiency is associated with SC-MI, especially in men. These findings may further highlight the role of nontraditional risk factors in the development of CVD. The value of vitamin D supplementation in the prevention of myocardial ischemia and injury may warrant investigation.

Incidence and risk factors of bacteria causing infectious keratitis.

OBJECTIVE: To study the incidence and risk factors of the bacteria causing infectious keratitis among patients in Qassim province of Saudi Arabia. METHODS: This is a cross sectional study conducted at the Department of Optometry, College of Applied Medical Sciences, Qassim University, Qassim, Kingdom of Saudi Arabia from December 2010 to May 2011. One hundred patients suspected of keratitis were subjected to clinical examinations. A total of 115 corneal swabs from these cases were collected under aseptic conditions for bacteriological examinations. RESULTS: Culture of the corneal swabs revealed Pseudomonas aeruginosa (25.2%), Staphylococcus aureus (15.7%), and unclassified bacteria (13.9%). However, 52 swabs of infectious keratitis cases (45.2%) were negative to bacteria. Contact lens wearing (44.4%) was the most common risk factor among the examined patients, followed by corneal trauma (21.7%), ocular surface disease (11.3%), and corneal surgery (7%). No significant correlation was observed between systemic risk factor and clinical presentation. CONCLUSION: It could be concluded that infectious keratitis was mostly due to Pseudomonas aeruginosa and Staphylococcus aureus. Therefore, strict measures are recommended to control and treat infectious keratitis to avoid visual complications.