Predicting the development of liver cirrhosis by simple modelling in patients with chronic hepatitis C.

BACKGROUND: Data are scarce on the natural history of chronic hepatitis C (CHC) in patients with mild hepatitis C who did not respond to anti-viral therapy. AIM: To predict the risk of progression to cirrhosis, identifying patients with the more urgent need for therapy with effective anti-virals. METHODS: A cohort of 1289 noncirrhotic CHC patients treated with interferon-based therapy between 1990 and 2004 in two referral hospitals were followed up for a median of 12 years. RESULTS: Overall, SVR was achieved in 46.6% of patients. Data from a randomly split sample (n = 832) was used to estimate a model to predict outcomes. Among nonresponders (n = 444), cirrhosis developed in 123 (28%) patients. In this group, the 3, 5 and 10-year cumulative probabilities of cirrhosis were 4%, 7% and 22%, respectively, compared to <1% in the SVR-group (P < 0.05). Baseline factors independently associated with progression to cirrhosis in nonresponders were: fibrosis ≥F2, age >40 years, AST >100 IU/L, GGT >40 IU/L. Three logistic regression models that combined these simple variables were highly accurate in predicting the individual risk of developing cirrhosis with areas under the receiving operating characteristic curves (AUC) at 5, 7 and 10 years of ~0.80. The reproducibility of the models in the validation cohort (n = 457, nonresponders = 244), was consistently high. CONCLUSIONS: Modelling based on simple laboratory and clinical data can accurately identify the individual risk of progression to cirrhosis in nonresponder patients with chronic hepatitis C, becoming a very helpful tool to prioritise the start of oral anti-viral therapy in clinical practice.

Prevalence by sex of preclinical carotid atherosclerosis in newly diagnosed type 2 diabetes.

BACKGROUND AND AIMS: There is clinical trial evidence that only early, intensive risk factor control can reduce cardiovascular disease (CVD) morbidity and mortality in type 2 diabetes (T2DM). However, there is little information regarding preclinical atherosclerosis at diabetes diagnosis. We assessed carotid atherosclerosis in new-onset T2DM and control individuals without prior CVD. METHODS AND RESULTS: In a cross-sectional case-control study, we determined intima-media thickness (IMT) and plaque (IMT ≥1.5 mm) by ultrasound at all carotid sites in new-onset T2DM patients and controls. We assessed 106 T2DM patients, median age 62 years, 46% women, 19% smokers, 54% with hypertension, and 41% with dyslipidemia and 99 non-diabetic subjects matched by age, sex, and cardiovascular risk factors. Compared to controls, T2DM patients had higher common carotid artery (CCA)-IMT (median 0.725 vs. 0.801 mm, p = 0.01), bulb-IMT (0.976 vs. 1.028 mm, p = 0.12), and internal carotid artery (ICA)-IMT (0.727 vs. 0.802 mm, p = 0.04). The prevalence of total plaque (60% vs. 72%, p = 0.06), ICA plaque (20% vs. 42%, p < 0.01), and harboring ≥3 plaques (16% vs. 35% p < 0.01) was also higher in T2DM. Plaque score (sum of maximum plaque heights) was also higher (p < 0.01) in T2DM. Diabetic women showed more advanced carotid atherosclerosis than diabetic men when they were compared with their respective non-diabetic counterparts. CONCLUSIONS: There is a high prevalence of preclinical atherosclerosis (carotid plaque presence and burden) in new-onset T2DM subjects, especially in women. Early, still reversible, preclinical atherosclerosis may explain in part why early intervention is effective to prevent CVD in this patient population.

[Study of satisfaction of testicular prosthesis implantation in children]. / Estudio de satisfacción de la implantación de prótesis testiculares en niños.

UNLABELLED: Testicular absence may cause psychological trauma in children. It can be avoided by placing testicular prosthesis (TP). However there is no consensus on the optimal age of implantation. We evaluate the results of TP implantation and their complications, as well as patient and family satisfaction. MATERIAL AND METHODS: This is a retrospective study of TP implanted between 2004-2010 in our center. Variables analyzed are: age, size and side, indication, surgical technique, complications and comorbidity. Telephone survey was done by a single interviewer to 50 families. DATA COLLECTED: general family satisfaction, characteristics of the prosthesis (size, shape, location and consistency), body image and psychological situation of the child, duration of analgesia after surgery, reoperation rate, and family advice to other parents. Statistical analysis with SPSS-18.0. RESULTS: 107 prostheses were placed (4 bilateral, 64 left and 35 rights) at a mean age of 70,10 +/- 58,6 months. The most common indication was cryptorchidism (48.2%). Initial inguinal approach in 69%, and simultaneous contralateral orchidopexy in 29.9%. Only one patient refused the prostheses. In 71% the mother was interviewed. Parents consider size, shape and position appropriate in 55.6%, 66.7% and 82.22% respectively. Hard consistency of TP was considered in 82.3% of the patients. Psychological problems were absent in 86.7%. Nighty five percent would be willing to replace when it was necessary. Parents would recommend the intervention to parents in the same situation in 86.7%. CONCLUSION: Testicular prosthesis avoids psychological trauma. The lack of satisfaction regarding to the small size and hardness makes necessary to replace the TP in adulthood. An open question remains whether we should consider the placement of TP in early ages, or if we should establish some indications based on a more rational communication with the family.

Estudio de satisfacción de la implantación de prótesis testiculares en niños / Study of satisfaction of testicular prosthesis implantation in children

La ausencia testicular en niños puede ser una experiencia psicológicatraumática, que puede evitarse implantando una prótesis testicular(PT). Sin embargo, no existe un consenso en la edad óptima de intervención. Evaluamos las prótesis testiculares implantadas en nuestro centro y sus complicaciones, así como la satisfacción de los pacientes y familiares. Material y métodos. Estudio retrospectivo de PT colocadas entre2004-2010. Variables analizadas: edad, tamaño, lateralidad, abordaje quirúrgico, complicaciones y comorbilidad asociada. Encuesta telefónica a 50 familiares, por entrevistador único. Datos recogidos: persona entrevistada, satisfacción con las características(forma, tamaño, localización y consistencia), preocupación psicológica del niño, analgesia postcirugía, aprobación de reintervención y recomendación a familiares en situación similar. Análisis estadístico con SPSS 18.0.Resultados. Se colocaron 107 PT (4 bilaterales, 64 izquierdas y35 derechas), a una edad media de 70,1 ± 58,6 meses. El motivo más frecuente fue por criptorquidia (48,2%). El abordaje inicial inguinal en el 69%, el 29,9% con orquidopexia contralateral. Dos pacientes presentaron complicaciones. La madre fue la persona entrevistada en el 71%. Respecto al tamaño, forma y localización, lo consideraron adecuado el 55,6, 66,7 y (..) (AU)

Testicular absence may cause psychological trauma in children. It can be avoided by placing testicular prosthesis (TP). However there is no consensus on the optimal age of implantation. We evaluate the results of TP implantation and their complications, as well as patient and family satisfaction. Material and methods. This is a retrospective study of TP implanted between 2004-2010 in our center. Variables analyzed are: age, size and side, indication, surgical technique, complications and comorbidity. Telephone survey was done by a single interviewer to 50 families. Data collected: general family satisfaction, characteristics of the prosthesis (size, shape, location and consistency), body image and psychological situation of the child, duration of analgesia after surgery, reoperation rate, and family advice to other parents. Statistical analysis with SPSS-18.0.Results. 107 prostheses were placed (4 bilateral, 64 left and 35rights) at a mean age of 70,10 ± 58,6 months. The most common indication was cryptorchidism (48.2%). Initial inguinal approach in 69%,and simultaneous contralateral orchidopexy in 29.9%. Only one patient (..) (AU)

Carotid atherosclerosis and lipoprotein particle subclasses in familial hypercholesterolaemia and familial combined hyperlipidaemia.

BACKGROUND AND AIMS: Familial hypercholesterolaemia (FH) and familial combined hyperlipidaemia (FCH) are common atherogenic disorders with great variability in cardiovascular disease (CVD). No direct atherosclerosis burden comparisons have been performed between FH and FCH in relation to lipoprotein particle distribution. METHODS AND RESULTS: Risk factors and three measures of carotid intima-media thickness (IMT) in both sides were determined in 572 FH, 250 FCH and 200 controls. Lipoproteins were assessed by nuclear magnetic resonance (NMR) spectroscopy. Compared with controls, IMT measures were increased in FH and FCH. FCH had the highest adjusted mean-maximum IMT. FH had twice low-density lipoprotein (LDL) particles than controls, but similar LDL subclass size and distribution. FCH subjects also had increased LDL particles and the highest number of small LDL (1519 ± 731 nmol l(-1) vs. 887 ± 784 nmol l(-1) in FH and 545 ± 409 nmol l(-1) in controls). Age, gender, cholesterol/high-density lipoprotein (HDL) ratio, smoking and systolic blood pressure were independently associated with IMT in FH (r(2) = 0.38). The same variables, except cholesterol/HDL ratio, were associated with IMT in FCH (r(2) = 0.40). Among NMR lipoproteins, only VLDL and chylomicrons increased IMT prediction in FCH by 0.8%. CONCLUSION: FH and FCH subjects show increased carotid atherosclerosis in relation to classical risk factors. Lipoprotein subclasses do not substantially contribute to IMT variability.

Dietary fibre intake is inversely associated with carotid intima-media thickness: a cross-sectional assessment in the PREDIMED study.

OBJECTIVE: To assess the association between the intake of dietary fibre and carotid intima-media thickness (IMT) in a Mediterranean population at high cardiovascular risk. METHODS: Baseline cross-sectional assessment of 457 men and women (average age 67 years) from two different Spanish centres of the PREDIMED trial. A previously validated food frequency questionnaire (137 food items) was administered by trained dieticians in a face-to-face interview. Mean common carotid IMT was measured using B-mode ultrasound imaging of the right and left carotid arteries by four certified sonographers who used a common protocol. Anthropometric and blood pressure measurements were performed and samples of fasting blood were obtained. Participants were categorized into four groups (roughly quartiles: < or =21; >21 to < or =25; >25 to < or =31 and >31 g/day) of energy-adjusted intake of dietary fibre. Multiple linear regression models were used to adjust for age, sex, centre, smoking, body mass index, diabetes, blood pressure, lipid levels and statin use. RESULTS: In the crude analyses, energy-adjusted fibre intake showed a significant inverse correlation with IMT (r=-0.27, P<0.001). In multivariate analyses, a modest, though statistically significant (P=0.03) inverse association between energy-adjusted fibre intake and IMT was also found. The multivariate-adjusted difference in average IMT was -0.051 mm (95% confidence interval: -0.094 to-0.009, P=0.02) for participants whose intake was >35 g/day, (n=47) when compared with those whose intake was <25 g/day (n=224). CONCLUSIONS: Our results suggest that high fibre intake is inversely associated with carotid atherosclerosis.

Impact of carotid atherosclerosis as assessed by B-mode ultrasonography on the evolution of kidney transplantation.

UNLABELLED: Carotid arteriosclerosis is a marker of cardiovascular risk in the general population. Cardiovascular disease is highly prevalent in kidney transplant recipients. This study analyzed the impact of arteriosclerotic carotid lesions on the evolution of renal transplant recipients. METHODS: This prospective study was performed in 70 patients with renal transplantations (mean age 52 +/- 12 years; 67% men (n = 47). High-resolution B-mode ultrasonography (7.5 MHz) of both carotid arteries was performed at baseline to assess carotid caliber, mean and maximum intima-media thickness (IMT), presence of arteriosclerotic plaques (number and maximum height), and percentage stenosis. We analyzed the impact of carotid arteriosclerosis and various donor-recipient clinical covariables on long-term patient and graft survival. RESULTS: Mean follow-up was 9.7 +/- 2.5 years (2-14). Atheroma plaques were detected in 74% of patients (n = 52). The mean number of plaques was 3.96 +/- 2.88 and maximum plaque height was 2.49 +/- 0.97 mm. IMT was 0.71 +/- 0.21 mm (0.4-1.5) with 27% of patients (n = 19) having an IMT value greater than 0.8 mm. Sonographic signs of occlusion were evident in 13% (n = 9) and the mean occlusion was 33 +/- 11% (range 20%-45%). The presence of plaques was significantly associated with age (P = .002), hypertension and diabetes (P = .016), and hypercholesterolemia (P = .01). There was an association between age and arterial wall thickness (P = .042). Acute rejection was an independent risk factor for graft loss (OR 8.14, P = .003). The multivariate study identified carotid wall thickness as an independent risk factor for patient death (OR 12.7, P = .017). CONCLUSION: Carotid arteriosclerosis is highly prevalent among renal transplant recipients. Carotid lesions were an independent risk factor for long-term patient death. High-resolution ultrasound imaging of the carotid arteries was a useful, noninvasive diagnostic technique for accurate assessment of cardiovascular risk in renal transplant recipients.

Treatment and outcome of pancreatic venous graft thrombosis after kidney--pancreas transplantation.

BACKGROUND: Pancreas venous graft thrombosis after transplantation is the main non-immunological cause of graft failure and usually results in pancreatectomy. Duplex Doppler ultrasonography is the primary imaging technique for monitoring vascular patency after pancreas transplantation. This study reports the results of rescue treatments for pancreas graft thrombosis after simultaneous pancreas--kidney transplantation. METHODS: One hundred and ninety-six patients with insulin-dependent diabetes mellitus received a simultaneous pancreas--kidney transplantation. Venous graft thrombosis was diagnosed in 25 of these patients based on Doppler ultrasonographic findings. RESULTS: Total venous graft thrombosis was diagnosed in 20 symptomatic patients, of whom 14 required graft pancreatectomy. Surgical thrombectomy was attempted in six patients with preserved arterial supply and was successful in four. Partial venous graft thrombosis was diagnosed in five asymptomatic patients; one also had partial splenic artery thrombosis. Rescue graft procedures included systemic anticoagulation (one patient), arterial thrombolysis (one) and venous thrombolysis and/or mechanical venous thrombectomy (four episodes in three patients). Graft rescue was achieved in three patients treated by venous thrombolysis/thrombectomy. CONCLUSION: Doppler ultrasonography allows the appropriate selection of rescue treatment based on the findings of total or partial thrombosis.

Stenosis of the suprahepatic inferior vena cava as a complication of transjugular intrahepatic portosystemic shunt in Budd-Chiari patients.

We report 2 patients with Budd-Chiari (BC) syndrome secondary to thrombogenic conditions who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement because of refractory ascites and impending liver failure. After TIPS placement, there was marked symptomatic relief and improvement in liver function, but the courses of both patients were complicated by the development of an inferior vena cava (IVC) syndrome caused by segmental stenosis of the suprahepatic IVC just at the outflow jet of the TIPS at 11 and 9 months later. One patient underwent liver transplantation, and the other patient, caval angioplasty and stenting. Stenosis of the IVC represents an unrecognized complication of TIPS in patients with BC syndrome.

Hydrocolonic sonography for evaluating inflammatory bowel disease.

OBJECTIVE: The purpose of our study was to compare the usefulness of hydrocolonic sonography and (99m)Tc-hexamethylpropyleneamine oxime (HMPAO)--labeled leukocyte scintigraphy in the examination of patients with inflammatory bowel disease, using precise sonographic criteria of bowel involvement. SUBJECTS AND METHODS: Sixty-eight consecutive patients with active inflammatory bowel disease (34 ulcerative colitis and 34 Crohn's disease), 12 with inactive inflammatory bowel disease, and 10 control subjects were prospectively studied. Patients with active disease underwent clinical assessment, hydrocolonic sonography, scintigraphy, and colonoscopy within 72 hr, whereas patients with inactive disease and control subjects underwent clinical examination and hydrocolonic sonography. RESULTS: Involvement of a colonic segment by active inflammatory bowel disease was best defined by mucosal thickness greater than 1.5 mm, bowel wall thickness greater than 4 mm, mucosal irregularity, or the absence of haustra; and involvement of the terminal ileum by bowel wall thickness greater than 4 mm. Using these criteria, hydrocolonic sonography had 100% sensitivity for identifying patients with active inflammatory bowel disease and a greater overall accuracy (87%) than scintigraphy (77%) in the assessment of disease extension. In addition, strong correlation was shown between a hydrocolonic sonography activity index and clinical and endoscopic activity indexes. CONCLUSION: This prospective study provides precise sonographic criteria for the definition of bowel involvement by active inflammatory bowel disease. Hydrocolonic sonography has a greater accuracy than scintigraphy for assessing disease extension and activity. Therefore, hydrocolonic sonography should be considered a first-choice technique to complete the study of inflammatory bowel disease after confirmation of the diagnosis by histology.

Effect of internal carotid artery occlusion on vertebral artery blood flow: a duplex ultrasonographic evaluation.

The aim of this study was to evaluate the effect of unilateral internal carotid artery occlusion on blood flow volume and blood flow velocities in both vertebral arteries using duplex Doppler ultrasonography in the cervical segment. Forty patients with unilateral extracranial internal carotid artery occlusion confirmed by angiography were studied, and the results were compared with those obtained in 57 age-matched patients in whom cervical duplex ultrasonography showed no abnormalities. We measured the diameter, flow velocities, and blood flow volume in both vertebral arteries, and the side-to-side differences were also calculated. Eleven patients (27.5%) with an occluded internal carotid artery had increased peak systolic velocity in the ipsilateral vertebral artery, and 6 (15%) had increased peak systolic velocity in the contralateral vertebral artery. The mean peak systolic velocity and the mean blood flow volume were statistically greater in the ipsilateral vertebral arteries than in the same-side vertebral arteries of the control group (P < .05). We also detected a mean increase of 14.29% of the net blood flow volume in the vertebral arteries compared with the control group. Patients with extracranial unilateral internal carotid artery occlusion may have a compensatory increase in both the peak systolic velocity and the blood flow volume in both vertebral arteries.

Early detection of hepatic artery thrombosis after liver transplantation by Doppler ultrasonography: prognostic implications.

We assessed the usefulness of routine Doppler ultrasonography for early detection of hepatic artery thrombosis after orthotopic liver transplantation and repercussions in patient prognosis. Seventeen confirmed cases of early hepatic artery thrombosis initially diagnosed by Doppler ultrasonography (10 of them before clinical indication) were reviewed. All patients underwent Doppler ultrasonographic studies in the first 3 days after orthotopic liver transplantation. Twelve cases of hepatic artery thrombosis (70.6%) were detected by this early Doppler ultrasonography. All 10 unsuspected cases of hepatic artery thrombosis and 5 of the 7 cases diagnosed after clinical indication were treated by revascularization. Grafts were salvaged in 80% of asymptomatic patients and in 42.8% of symptomatic patients. Furthermore, biliary complications were less serious in the first group. In conclusion, Doppler ultrasonography performed routinely in the first 3 days after orthotopic liver transplantation may permit early detection of hepatic artery thrombosis, even before clinical indications. This allows hepatic artery repermeabilization before liver function damage, improving graft rescue and patient prognosis.

Abdominal sonographic study of autosomal dominant polycystic kidney disease.

PURPOSE: The purpose of this study was to determine whether kidney size in patients who have autosomal dominant polycystic kidney disease (ADPKD) is related to renal function, hypertension, or extrarenal manifestations of the disease and to sonographically evaluate the abdominal manifestations of ADPKD. METHODS: Between 1994 and 1998, 400 individuals from 85 families with a history of ADPKD were examined. There were 213 persons with ADPKD and 187 unaffected family members; there were 182 males and 218 females, 1-82 years old (mean, 39.3 years). We obtained a complete medical history, performed a physical examination, measured the arterial blood pressure and serum creatinine levels, and performed abdominal sonography on each subject. The sonographic features that were studied were renal length and the presence and number of cysts on the kidneys, liver, and pancreas. RESULTS: There was a relationship between kidney size and age (p < 0.05), kidney size and renal function (p < 0.001), and kidney size and hypertension (p < 0.001). The overall prevalence of hepatic cysts in patients with ADPKD was 67%, and the prevalence increased with age. The presence of hepatic cysts was related to the severity of renal disease. Females had more severe polycystic liver disease, and massive polycystic liver disease (ie, hepatomegaly with innumerable cysts) was seen only in females. The prevalence of pancreatic cysts in the 187 persons in whom the pancreas was well evaluated sonographically was 5%. CONCLUSIONS: Kidney size in patients with ADPKD is related to renal function, hypertension, and extrarenal involvement and can be used to predict the outcome of the disease. Hepatic cysts are very common in patients with ADPKD and are related to age and renal function; pancreatic cysts are infrequent in these patients.

Doppler sonography of the intertransverse segment of the vertebral artery.

We assessed the utility of a Doppler ultrasonographic examination of the vertebral artery, limited to the intertransverse segment, in diagnosis of disease at any level of vertebrobasilar circulation. The vertebral artery was identified in all the patients, with a successful evaluation of the presence of disease in 112 of 116 (96.5%) vertebral arteries. All of the occlusions and subclavian steal syndromes were diagnosed. All of the vertebral arteries with abnormal Doppler findings had a pathologic angiographic study. In conclusion, Doppler ultrasonography of the intertransverse segment of the vertebral artery is useful owing to its applicability and accuracy.

Autosomal dominant polycystic kidney disease types 1 and 2: assessment of US sensitivity for diagnosis.

PURPOSE: To estimate the sensitivity and specificity of ultrasonography (US) in the diagnosis of autosomal dominant polycystic kidney disease (ADPKD) types 1 and 2, as compared with those of genetic linkage analysis. MATERIALS AND METHODS: A renal US and DNA analysis for ADPKD was performed in 319 patients who were at risk, 161 of whom were younger than 30 years, from 54 families with ADPKD. The sensitivity of US for diagnosis was estimated by comparing the US results with genotypes inferred from linkage studies. RESULTS: The sensitivity of US in individuals younger than 30 years who were at risk was 95% for ADPKD type 1 but only 67% for ADPKD type 2. The sensitivity of US for either ADPKD type 1 or ADPKD type 2 in individuals aged 30 years or older who were at risk was 100%. The overall sensitivity in individuals younger than 30 years was 93%. For both ADPKD types 1 and 2 in all patients, US demonstrated a sensitivity of 97%, a specificity of 100%, and an accuracy of 98%. CONCLUSION: US is the first-line imaging technique that should be used in the diagnosis of ADPKD. The sensitivity in individuals aged 30 years or older is 100%, but if there is a clinical suspicion of ADPKD type 2 in individuals younger than 30 years, linkage analysis should also be considered.

Wedged hepatic venous pressure adequately reflects portal pressure in hepatitis C virus-related cirrhosis.

Wedged hepatic venous pressure (WHVP) is equivalent to portal venous pressure in patients with alcoholic liver diseases. However, it may underestimate portal pressure in nonalcoholics, which is important because hepatitis C virus (HCV) infection is a frequent cause of chronic liver disease. We investigated the agreement between directly measured portal pressure and WHVP in alcoholic and HCV-related liver diseases. Seventy-one patients with liver disease resulting from HCV infection (n = 32), alcohol (n = 25), or both (n = 14) underwent simultaneous measurements of WHVP (by hepatic vein catheterization) and portal pressure (by direct puncture). In 9 patients, measurements were repeated 20 minutes after acute iv propranolol administration. WHVP showed an excellent agreement with portal pressure in patients with cirrhosis resulting from either HCV, alcohol or both (intraclass correlation coefficient: 0.94, 0.93, and 0.97, respectively; P <.001). A discrepancy of >/=5 mm Hg was observed in 7 cases. WHVP underestimated portal pressure in only 1 case and exceeded portal pressure by >/=5 mm Hg in 6 patients. The WHVP response to propranolol closely and significantly correlated with changes in portal pressure (intraclass correlation coefficient: 0.87; P <.004). The simple and safe measurement of WHVP accurately reflects portal pressure in alcoholic and HCV-related liver disease. This technique also allows us to accurately assess the portal pressure response to propranolol in both alcoholic and HCV-related cirrhosis.