Diagnostic accuracy and clinical impact of MRI-based technologies for patients with non-alcoholic fatty liver disease: systematic review and economic evaluation.

Background: Magnetic resonance imaging-based technologies are non-invasive diagnostic tests that can be used to assess non-alcoholic fatty liver disease. Objectives: The study objectives were to assess the diagnostic test accuracy, clinical impact and cost-effectiveness of two magnetic resonance imaging-based technologies (LiverMultiScan and magnetic resonance elastography) for patients with non-alcoholic fatty liver disease for whom advanced fibrosis or cirrhosis had not been diagnosed and who had indeterminate results from fibrosis testing, or for whom transient elastography or acoustic radiation force impulse was unsuitable, or who had discordant results from fibrosis testing. Data sources: The data sources searched were MEDLINE, MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Database of Controlled Trials, Database of Abstracts of Reviews of Effects and the Health Technology Assessment. Methods: A systematic review was conducted using established methods. Diagnostic test accuracy estimates were calculated using bivariate models and a summary receiver operating characteristic curve was calculated using a hierarchical model. A simple decision-tree model was developed to generate cost-effectiveness results. Results: The diagnostic test accuracy review (13 studies) and the clinical impact review (11 studies) only included one study that provided evidence for patients who had indeterminate or discordant results from fibrosis testing. No studies of patients for whom transient elastography or acoustic radiation force impulse were unsuitable were identified. Depending on fibrosis level, relevant published LiverMultiScan diagnostic test accuracy results ranged from 50% to 88% (sensitivity) and from 42% to 75% (specificity). No magnetic resonance elastography diagnostic test accuracy data were available for the specific population of interest. Results from the clinical impact review suggested that acceptability of LiverMultiScan was generally positive. To explore how the decision to proceed to biopsy is influenced by magnetic resonance imaging-based technologies, the External Assessment Group presented cost-effectiveness analyses for LiverMultiScan plus biopsy versus biopsy only. Base-case incremental cost-effectiveness ratio per quality-adjusted life year gained results for seven of the eight diagnostic test strategies considered showed that LiverMultiScan plus biopsy was dominated by biopsy only; for the remaining strategy (Brunt grade ≥2), the incremental cost-effectiveness ratio per quality-adjusted life year gained was £1,266,511. Results from threshold and scenario analyses demonstrated that External Assessment Group base-case results were robust to plausible variations in the magnitude of key parameters. Limitations: Diagnostic test accuracy, clinical impact and cost-effectiveness data for magnetic resonance imaging-based technologies for the population that is the focus of this assessment were limited. Conclusions: Magnetic resonance imaging-based technologies may be useful to identify patients who may benefit from additional testing in the form of liver biopsy and those for whom this additional testing may not be necessary. However, there is a paucity of diagnostic test accuracy and clinical impact data for patients who have indeterminate results from fibrosis testing, for whom transient elastography or acoustic radiation force impulse are unsuitable or who had discordant results from fibrosis testing. Given the External Assessment Group cost-effectiveness analyses assumptions, the use of LiverMultiScan and magnetic resonance elastography for assessing non-alcoholic fatty liver disease for patients with inconclusive results from previous fibrosis testing is unlikely to be a cost-effective use of National Health Service resources compared with liver biopsy only. Study registration: This study is registered as PROSPERO CRD42021286891. Funding: Funding for this study was provided by the Evidence Synthesis Programme of the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 10. See the NIHR Journals Library website for further project information.

Non-alcoholic fatty liver disease includes a range of conditions that are caused by a build-up of fat in the liver, and not by alcohol consumption. This build-up of fat can cause inflammation. Persistent inflammation can cause scar tissue (fibrosis) to develop. It is important to identify patients with fibrosis because severe fibrosis can cause permanent liver damage (cirrhosis), which can lead to liver failure and liver cancer. In the National Health Service, patients with non-alcoholic fatty liver disease undergo tests to determine whether they have fibrosis. The test results are not always accurate and multiple tests can give conflicting results. Some of the tests may not be suitable for patients who have a very high body mass index. In the National Health Service, a liver biopsy may be offered to patients with inconclusive or conflicting test results or to those patients for whom other tests are unsuitable. However, liver biopsy is expensive, and is associated with side-effects such as pain and bleeding. Magnetic resonance imaging-based testing could be used as an extra test to help clinicians assess non-alcoholic fatty liver disease and identify patients who may need a liver biopsy. We assessed two magnetic resonance imaging-based diagnostic tests, LiverMultiScan and magnetic resonance elastography. LiverMultiScan is imaging software that is used alongside magnetic resonance imaging to measure markers of liver disease. Magnetic resonance elastography is used in some National Health Service centres to assess liver fibrosis; however, magnetic resonance elastography requires more equipment than just an magnetic resonance imaging scanner. We reviewed all studies examining how well LiverMultiScan and magnetic resonance elastography assess patients with non-alcoholic fatty liver disease. We also built an economic model to estimate the costs and benefits of using LiverMultiScan to identify patients who should be sent for a biopsy. Results from the model showed that LiverMultiScan may not provide good value for money to the National Health Service.

Utilidad de la proteína C-reactiva para determinar la gravedad de infección por SARS-CoV-2 en Perú

Introducción: En los últimos años se han estudiado diversos biomarcadores para determinar los casos graves de COVID-19. La proteína C-reactiva (PCR) ha mostrado alta sensibilidad en la identificación de pacientes con enfermedad grave y utilidad comparable a la tomografía. Objetivo: Determinar la utilidad de la PCR para predecir gravedad de la infección por SARS-CoV-2 en pacientes hospitalizados en el Centro Médico Naval del Perú durante el periodo enero-septiembre del año 2021. Métodos: Se empleó un diseño de tipo cuantitativo, observacional, analítico, retrospectivo, y de tipo prueba diagnóstica. Se calculó un tamaño muestral de 503 pacientes, quienes fueron divididos en dos grupos de acuerdo a su gravedad. Resultados: Se determinó un punto de corte óptimo de 10,92 mg/L de los valores de PCR para el diagnóstico de enfermedad grave por COVID-19. Se calculó un área bajo la curva (AUC) de 0,762 y se obtuvieron valores de sensibilidad, especificidad, valores predictores positivo, negativo y precisión diagnóstica de 78,88%, 66,4%; 41,42%; 87,01%; y 67,27%, respectivamente. El normograma de Fagan mostró una probabilidad posprueba de 41%. En el modelo ajustado fueron significativas la PCR (ORa = 4,853; IC95% 2,987-7,886; p = 0,001), además de la ferritina (ORa = 1,001; IC 95%: 1,001-1,002; p = 0,001) e hipotiroidismo (OR ajustado = 4,899; IC 95%: 1,272-18,872; p = 0,021). Conclusiones: El presente estudio mostró la asociación entre la PCR y la gravedad de infección por SARS-CoV-2 en un modelo ajustado, mostrando su potencial utilidad y contribuyendo a determinar el punto de corte de la PCR en población peruana y su comparación a nivel internacional.

Background: Recently, many biomarkers have been studied to determine severe cases of COVID-19. C-reactive protein (CRP) has shown high sensitivity in identifying patients with severe disease and utility comparable to computed tomography. Aim: To determine the usefulness of CRP to predict the severity of SARS-CoV-2 infection in patients hospitalized at the Naval Medical Center of Peru during the period January-September in the year 2021. Methods: A quantitative, observational, analytical, retrospective, and diagnostic test type design was used. A sample size of 503 patients was calculated, which were divided into two groups according to their severity. Results: An optimal cut-off point of 10.92 mg/L for CRP levels was determined for the diagnosis of severe COVID-19. An area under the curve (AUC) of 0.762 was calculated and sensitivity, specificity, positive and negative predictive values and diagnostic accuracy values of 78.88%, 66.4%; 41.42%; 87.01%; and 67.27%; respectively. Fagan's normogram showed a post-test probability of 41%. In the adjusted model, CRP (aOR = 4.853; 95% CI 2.987-7.886; p = 0.001), ferritin (aOR = 1.001; 95% CI: 1.001-1.002; p = 0.001) and hypothyroidism (adjusted OR = 4899; 95% CI: 1272-18872; p = 0.021) showed significance. Conclusions: The present study showed an association between CRP and the severity of SARS-CoV-2 infection in an adjusted model, showing its potential utility and contributing to determine the cut-off point of CRP in the Peruvian population and its international comparison.

A Quantitative Study of the Decision Threshold for the Diagnosis of Infectious Mononucleosis.

BACKGROUND: Ordering a serologic test for infectious mononucleosis (IM) in all young patients with sore throat is costly and impractical. The test threshold to determine when to order a diagnostic test for IM based on the patient's symptoms has not been previously studied. OBJECTIVE: To determine the test threshold for IM in the management of patients with sore throat. DESIGN AND SETTING: Online surveys were sent to a convenience sample of US primary care clinicians regarding their decision making about whether or not to order a test for IM in a patient with sore throat. METHOD: 7 clinical vignettes were created, each with a different combinations of symptoms and signs. The probability of IM for each vignette was estimated by the investigator based on the number of symptoms present to generate a plausible range of disease probabilities. Clinicians were then asked to decide whether to test or not test for IM, and mixed-effect logistic regression was used to determine the test threshold for IM where half of physicians chose to test and half chose not to test. RESULTS: A total of 117 clinicians provided responses for a total of 819 clinical vignettes. The overall test threshold for IM as estimated using the logistic regression was 9.5% (95% CI: 8.2% to 10.9%). The test threshold for clinicians practicing greater than 10 years was significantly higher than for those practicing less or equal to 10 years (10.5% vs 7.3%, P = .02). No significant differences between specialties and practice sites were found with respect to the test threshold. CONCLUSION: This study identified a test threshold for IM of approximately 10% based on realistic clinical vignettes. This threshold was stable regarding the clinician's specialty and practice sites and could be used in the development of a clinical prediction rule to determine the cutoff for low- versus high-risk groups.

Neurochemical Monitoring of Traumatic Brain Injury by the Combined Analysis of Plasma Beta-Synuclein, NfL, and GFAP in Polytraumatized Patients.

Traumatic brain injury (TBI) represents a major determining factor of outcome in severely injured patients. However, reliable brain-damage-monitoring markers are still missing. We therefore assessed brain-specific beta-synuclein as a novel blood biomarker of synaptic damage and measured the benchmarks neurofilament light chain (NfL), as a neuroaxonal injury marker, and glial fibrillary acidic protein (GFAP), as an astroglial injury marker, in patients after polytrauma with and without TBI. Compared to healthy volunteers, plasma NfL, beta-synuclein, and GFAP were significantly increased after polytrauma. The markers demonstrated highly distinct time courses, with beta-synuclein and GFAP peaking early and NfL concentrations gradually elevating during the 10-day observation period. Correlation analyses revealed a distinct influence of the extent of extracranial hemorrhage and the severity of head injury on biomarker concentrations. A combined analysis of beta-synuclein and GFAP effectively discriminated between polytrauma patients with and without TBI, despite the comparable severity of injury. Furthermore, we found a good predictive performance for fatal outcome by employing the initial plasma concentrations of NfL, beta-synuclein, and GFAP. Our findings suggest a high diagnostic value of neuronal injury markers reflecting distinct aspects of neuronal injury for the diagnosis of TBI in the complex setting of polytrauma, especially in clinical surroundings with limited imaging opportunities.

Three-Dimensional Super-Resolved Imaging of Paraffin-Embedded Kidney Samples.

Background: Diseases of the glomeruli, the renal filtration units, are a leading cause of progressive kidney disease. Assessment of the ultrastructure of podocytes at the glomerular filtration barrier is essential for diagnosing diverse disease entities, providing insight into the disease pathogenesis, and monitoring treatment responses. Methods: Here we apply previously published sample preparation methods together with stimulated emission depletion and confocal microscopy for resolving nanoscale podocyte substructure. The protocols are modified and optimized in order to be applied to formalin-fixed paraffin-embedded (FFPE) samples. Results: We successfully modified our protocols to allow for deep three-dimensional stimulated emission depletion and confocal imaging of FFPE kidney tissue with similar staining and image quality compared with our previous approaches. We further show that quantitative analysis can be applied to extract morphometrics from healthy and diseased samples from both mice and humans. Conclusions: The results from this study could increase the feasibility of implementing optical kidney imaging protocols in clinical routines because FFPE is the gold-standard method for storage of patient samples.

Receiver operating characteristic curve: overview and practical use for clinicians.

Using diagnostic testing to determine the presence or absence of a disease is essential in clinical practice. In many cases, test results are obtained as continuous values and require a process of conversion and interpretation and into a dichotomous form to determine the presence of a disease. The primary method used for this process is the receiver operating characteristic (ROC) curve. The ROC curve is used to assess the overall diagnostic performance of a test and to compare the performance of two or more diagnostic tests. It is also used to select an optimal cut-off value for determining the presence or absence of a disease. Although clinicians who do not have expertise in statistics do not need to understand both the complex mathematical equation and the analytic process of ROC curves, understanding the core concepts of the ROC curve analysis is a prerequisite for the proper use and interpretation of the ROC curve. This review describes the basic concepts for the correct use and interpretation of the ROC curve, including parametric/nonparametric ROC curves, the meaning of the area under the ROC curve (AUC), the partial AUC, methods for selecting the best cut-off value, and the statistical software to use for ROC curve analyses.

The Value of Routine Tests before Pediatric Eye Surgery: A 10-Year Experience at a Tertiary Care Hospital.

Background: Routine tests before ophthalmologic surgery in adult patients are no longer recommended. However, there are limited data on the utility of routine preoperative tests for children. Aims: We aimed to describe the effect of routine preoperative tests on systemic perioperative complications by hospital discharge or by day 30 following eye surgery. Settings and Design: This was a single-center, observational, and descriptive study. Subjects and Methods: We examined all patients ≤ 17 years old for whom ophthalmologists consulted with anesthesiologists before eye surgery under general anesthesia in an academic teaching tertiary care hospital from January 2010 to December 2019. Results: A total of 708 pediatric patients were analyzed. The mean patient age was 8.5 ± 4.6 years. The most frequently performed procedure was strabismus surgery in 433 patients (61.2%). Following anesthetic consultations, 15 patients (2.1%) underwent surgery postponed due to abnormalities at the physical examination. Routine tests identified that the two patients (0.3%) required additional evaluations due to elevated serum creatine kinase and electrocardiographic abnormalities. However, further examinations found that these abnormalities were unremarkable. The remaining 691 patients (97.6%) underwent surgery as scheduled. Substantial intraoperative blood loss was observed only in three patients with malignant tumors or trauma. The incidence of systemic complications was 0 (0%; 95% confidence interval, 0%-0.05%). Conclusions: These data indicated that the development of systemic perioperative complications following pediatric ophthalmic surgery is rare. Preoperative tests should be requested only if they are clinically indicated or before potentially bleeding procedures, such as malignancy or trauma surgery.

Dissolved air flotation as potential new mechanism for intestinal parasite diagnosis in feces.

The parasitological examination of feces is recommended for the laboratory diagnosis of intestinal parasites due to its practicality, low-cost, and moderate diagnostic sensitivity. Dissolved Air Flotation (DAF) is an efficient technical principle used in other areas to separate dispersed solids. This study sought the preliminary evaluation of a proof-of-concept prototype as a tool for detecting species of parasites by adjusting DAF. Two DAF prototype units were developed to evaluate microbubbles' generation amidst fecal suspension and parasites' capture. For this evaluation, samples were screened and processed by the TF-Test technique (Control) and simultaneously by DAF device. The dimensional and attachment characteristics in the formation of the microbubbles were evaluated, and the percentage of parasitic recovery in floated and not-floated regions compared by Student's t-test. The second prototype unit proved to be more efficient in forming microbubbles with diameters between 34 and 170µm. The flotation tests showed a recovery of 73.27%, 58.12%, 37.85%, and 91.89% for Ascaris lumbricoides, Hymenolepis diminuta, Giardia duodenalis, and Strongyloides stercoralis, respectively. This study confirmed the selective interaction between microbubbles and parasite eggs and larvae during the flotation process using the DAF principle for the first time through imaging.

Limited Utility of Routine Tests Prior to Ophthalmologic Surgery: An Observational Study in a Japanese Hospital.

INTRODUCTION: Routine preoperative testing for low-risk surgeries without a clinical indication should be avoided; however, such tests are still frequently performed in Japan. This study was performed to assess the impact of routine preoperative tests in low-risk surgery in a Japanese medical setting. METHODS: We performed a retrospective chart review to examine the utility of routine tests with respect to anesthetic management and postoperative complications in all patients aged ≥ 18 years whom ophthalmologists consulted with anesthesiologists before ophthalmologic surgery under general anesthesia. RESULTS: During the 10-year study period, 1,234 anesthetic consultations and 1,211 routine preoperative tests (laboratory tests, chest X-rays, and electrocardiograms) were performed in Toyama University Hospital. In total, 59 patients (4.8% of the study population) canceled surgery after a battery of preoperative evaluation. Among them, 10 patients had incidental abnormalities that necessitated additional tests, and only three patients (0.2%) canceled surgery. In-hospital postoperative complications developed in nine patients (0.7%) whose routine test results made it difficult to predict development of these adverse events. No severe life-threatening events were noted in this survey. CONCLUSIONS: Routine tests prior to eye surgery for adults were of low value for perioperative management and prediction of development of in-hospital complications in this Japanese medical setting. Anesthesiologists and ophthalmologists should selectively order preoperative tests based on the medical interview and physical examination.

Clinical Application of Liver Imaging Reporting and Data System for Characterizing Liver Neoplasms: A Meta-Analysis.

The Liver Imaging Reporting and Data System (LI-RADS) is a comprehensive system for standardizing liver imaging in patients at risk of developing hepatocellular carcinoma (HCC). We aimed to determine the diagnostic performance of LI-RADS category 5 (LR5) for diagnosing HCC and LI-RADS category M (LRM) for characterizing other non-HCC malignancies (OM) using contrast-enhanced ultrasound (CEUS) and computed tomography (CT)/magnetic resonance imaging (MRI). Multiple databases were searched for articles evaluating the diagnostic accuracy of CEUS LI-RADS and/or CT/MRI LI-RADS. A random-effects model was adopted to synthesize the summary estimates of the diagnostic accuracy of LR5 for diagnosing HCC and LRM for characterizing OM using CEUS and CT/MRI. The pooled sensitivity and specificity of CEUS LR5 for the diagnosis of HCC were 69% and 93%, respectively. The pooled sensitivity was 67% and the specificity, 93% of CT/MRI LR5 for HCC diagnosis. There was no significant difference between the overall diagnostic accuracy for HCC diagnosis of CEUS LR5 and that of CT/MRI LR5 in terms of diagnostic odds ratio (DOR) (p = 0.55). The sensitivity was 84% with a specificity of 90% in the CEUS LRM for characterizing OM, while the sensitivity and specificity of CT/MRI LRM for characterizing OM was 63% and 95%. The DOR of CEUS LRM for characterizing OM was higher than that of CT/MRI LRM without significant difference (50.59 vs. 36.06, p = 0.34). This meta-analysis indicated that CEUS LI-RADS is qualified to characterize HCC and OM and may provide complementary information on liver nodules to CT/MRI LI-RADS.

Routine Blood Chemistry Predicts Functional Recovery After Traumatic Spinal Cord Injury: A Post Hoc Analysis.

BACKGROUND: Spinal cord injury (SCI) leads to various degrees of lifelong functional deficits. Most individuals with incomplete SCI experience a certain degree of functional recovery, especially within the first-year postinjury. However, this is difficult to predict, and surrogate biomarkers are urgently needed. OBJECTIVE: We aimed to (1) determine if routine blood chemistry parameters are related to neurological recovery after SCI, (2) evaluate if such parameters could predict functional recovery, and (3) establish cutoff values that could inform clinical decision-making. METHODS: We performed a post hoc analysis of routine blood chemistry parameters in patients with traumatic SCI (n = 676). Blood samples were collected between 24 and 72 hours as well as at 1, 2, 4, 8, and 52 weeks postinjury. Linear mixed models, regression analysis, and unbiased recursive partitioning (URP) of blood chemistry data were used to relate to and predict walking recovery 1 year postinjury. RESULTS: The temporal profile of platelet counts and serum levels of albumin, alkaline phosphatase, and creatinine differentiated patients who recovered walking from those who remained wheelchair bound. The 4 blood chemistry parameters from the sample collection 8 weeks postinjury predicted functional recovery observed 1 year after incomplete SCI. Finally, URP defined a cutoff for serum albumin at 3.7 g/dL, which in combination with baseline injury severity differentiates individuals who regain ambulation from those not able to walk. Specifically, about 80% of those with albumin >3.7 g/dL recovered walking. CONCLUSIONS: Routine blood chemistry data from the postacute phase, together with baseline injury severity, predict functional outcome after incomplete SCI.

Low diagnostic yield and time to diagnostic confirmation results in prolonged use of antimicrobials in critically ill children.

Background: Broad-spectrum antimicrobial therapy is a key driver of antimicrobial resistance. Here, we aimed to review indications for antimicrobial therapy, determine the proportion of suspected bacterial infections that are confirmed by culture, and assess the time taken for microbiology test results to become available in the paediatric intensive care unit (PICU). Methods: A single-centre prospective observational cohort study of 100 consecutive general PICU admissions from 30 October 2019 to 19 February 2020. Data were collected from the hospital medical record and entered into a study database prior to statistical analysis using standard methods. Results: Of all episodes of suspected infection, 22% of lower respiratory tract infection, 43% of bloodstream and 0% of central nervous system infection were associated with growth on microbiology culture. 90% of children received antimicrobial therapy. Hospital-acquired infection occurred less commonly than primary infection, but an organism was grown in a greater proportion (64%) of cultures. Final laboratory reports for negative cultures were issued at a median of 120.3 hours for blood cultures and 55.5 hours for endotracheal tube aspirate cultures. Conclusions: Despite most critically children receiving antimicrobial therapy, infection was often not microbiologically confirmed. Novel molecular diagnostics may improve rationalisation of treatment in this population.

Acute brainstem encephalitis associated with Mycoplasma pneumoniae in an adult: a case report.

Brainstem encephalitis (BE) associated with Mycoplasma pneumoniae in adults is rare, and the diagnosis is challenging. We describe an uncommon case of BE in an immunocompetent patient. A 43-year-old, otherwise healthy woman visited our emergency department with high fever and a sore throat, and 3 days later she returned with an altered drowsy mental status. Magnetic resonance imaging displayed diffuse swelling in bilateral cerebral regions involving the bilateral pons. The sera tested positive for the immunoglobulin (Ig) M antibody against M. Pneumoniae as detected by an enzyme immunoassay (EIA), and on hospital day 10, the level of IgM index against M. pneumoniae further increased from 1.5 to 2.1. We changed the antibiotic regimen from vancomycin and ceftriaxone to clarithromycin based on detection of M. pneumoniae, and we added intravenous immunoglobulin. After one month, the patient fully recovered from the neurological deficits. A follow-up brain magnetic resonance imaging was performed, which showed completely resolved lesions. Particle agglutination assay (PA) and EIA are both largely used to diagnose M. pneumoniae. Compared to the PA test, the EIA test could be a reliable tool because it separately measures IgM and IgG antibodies. We diagnosed BE associated with M. pneumoniae through EIA with an increasing level of IgM in the acute and subacute paired sera. Early treatment with macrolide antibiotics resulted in a good outcome.

Citric Acid-Containing Dialysate and Survival Rate in the Dialysis Outcomes and Practice Patterns Study.

Background: Metabolic acidosis is a common threat for patients on hemodialysis, managed by alkaline dialysate. The main base is bicarbonate, to which small amounts of acetic, citric, or hydrochloric acid are added. The first two are metabolized to bicarbonate, mostly by the liver. Citric acid-containing dialysate might improve dialysis efficiency, anticoagulation, calcification propensity score, and intradialytic hemodynamic stability. However, a recent report from the French dialysis registry suggested this dialysate increases mortality risk. This prompted us to assess whether citric acid-containing bicarbonate-based dialysate was associated with mortality in the international Dialysis Outcomes and Practice Patterns Study (DOPPS). Methods: Detailed patient-based information on dialysate composition was collected in DOPPS phases 5 and 6 (2012-2017). Cox regression was used to model the association between baseline bicarbonate dialysate containing citric acid versus not containing citric acid and mortality among DOPPS countries and phases where citric acid-containing dialysate was used. Results: Citric acid-containing dialysate was most commonly used in Japan, Italy, and Belgium (25%, 25%, 21% and of patients who were DOPPS phase 6, respectively) and used in <10% of patients in other countries. Among 11,306 patients in DOPPS country and phases with at least 15 patients using citric acid-containing dialysate, patient demographics, comorbidities, and laboratories were similar among patients using (14%) versus not using (86%) citric acid-containing dialysate. After accounting for case mix, we did not observe a directional association between citric acid-containing dialysate use (any versus none) and mortality (HR, 1.14; 95% CI, 0.97 to 1.34), nor did we find evidence of a dose-dependent relationship when parameterizing the citric acid concentration in the dialysate as 1, 2, and 3+ mEq/L. Conclusions: The use of citric acid-containing dialysate was not associated with greater risk of all-cause mortality in patients on hemodialysis participating in DOPPS. Clinical indications for the use of citric acid-containing dialysate deserve further investigation.

Peripheral Insulin Resistance Is Associated with Copeptin in Patients with Chronic Kidney Disease.

Background: Insulin resistance is associated with cardiovascular disease risk and worsened kidney function. Patients with CKD have higher levels of insulin resistance. Elevated levels of copeptin (a surrogate for vasopressin levels) have been associated with an increased incidence and progression of CKD, and with incident diabetes mellitus. The purpose of our study was to examine the relationship between insulin resistance, copeptin, and CKD. Methods: We performed a cross-sectional study to investigate if insulin resistance was associated with higher copeptin levels in nondiabetic patients with stage 3-4 CKD versus controls. We measured plasma copeptin levels and used data from 52 patients with stage 3-4 CKD and 85 controls (eGFR ≥60 ml/min per 1.73 m2) enrolled in the Insulin Resistance in Chronic Kidney Disease (IRCKD) study. We then used a multivariable linear-regression model to assess the independent relationship between peripheral or hepatic insulin resistance and copeptin across levels of eGFR. Results: We found that in patients with CKD (eGFR of 30-60 ml/min per 1.73 m2), but not in controls, peripheral insulin resistance was significantly correlated with higher levels of log copeptin (r=-0.21, P=0.04). In patients with CKD, when adjusted for age, sex, BMI, serum osmolality, log IL6, and log leptin/adiponectin ratio, each 1 SD decrease in insulin sensitivity was associated with a 39% increase in serum copeptin levels. The relationship between hepatic insulin resistance, copeptin, and eGFR is similar between controls and patients with reduced eGFR. Conclusion: Peripheral insulin resistance is associated with elevated copeptin levels in nondiabetic patients with stage 3-4 CKD. Further research into how the interaction between peripheral insulin resistance and elevated vasopressin affects CKD progression could be of interest.

Inappropriate screening of obstructive coronary artery disease during pre-anesthesia assessment of candidates for non-cardiac surgery

Preoperative evaluation in elective surgeries has been associated with successful surgical treatment. However, there is no solid scientific evidence that screening for coronary artery disease (CAD) reduces surgical risk. The aims of this study were to describe the frequency of inappropriate investigation of obstructive CAD induced by pre-anesthetic assessment in individuals without cardiovascular symptoms (candidates for low- to intermediate-risk surgeries) and to evaluate predictors of this conduct. We performed a retrospective evaluation of medical records of anesthesiology services from patients undergoing pre-anesthesia assessment between May 2015 and May 2016, including those with functional capacity ≥4 metabolic equivalents without a diagnosis of heart disease. A total of 778 medical records (47±16 years of age, 62.6% female) were studied. A private hospital performed 50.1% of the surgeries and 60.4% were of intermediate risk. Only 2.7% (95%CI: 1.7-4.1%) were screened for CAD, and 91% of these requests were mediated by cardiology consultations performed during pre-anesthetic testing visits. Factors associated with screening for CAD were hypertension, diabetes, moderate systemic disease (ASA III), cardiac consultation, previous diagnosis of CAD, and admission to a private hospital. Independent predictors were private hospitals (OR: 3.9; 95%CI: 1.3-11.0), ASA III (OR: 5.3; 95%CI: 1.7-16.2), and hypertension (OR: 3.8; 95%CI: 1.5-9.8). The frequency of inappropriate requests for CAD screening in asymptomatic individuals without untreated systemic diseases was low in pre-anesthetic visits. Although infrequent, screening for CAD is more common in the private setting, in patients with poorer health status, and is usually prescribed during cardiology consultation.

HIV serology false positivity among expatriates from Africa: a screening dilemma.

HIV prevalence in Oman is low (<5 %); however, 45 % of the population are expatriates, including a portion originating from countries with high HIV prevalence (>5 %). HIV screening is performed at regional public health laboratories as part of a medical fitness programme for residency applicants. We conducted a retrospective evaluation of indeterminate serology results from 11 females of African origin, aged 21-43 years. Serology testing for HIV was conducted according to the national Oman algorithm: fourth-generation immunoassays (Bio-Rad GS HIV Combo Ag/Ab EIA, Siemens Enzygnost HIV Integral 4, Abbott ARCHITECT HIV Ag/Ab Combo, Roche Elecsys HIV Combi PT, bioMérieux VIDAS HIV DUO QUICK), confirmatory assays (Geenius HIV 1/2 Confirmatory, INNO-LIA HIV I/II Score) and PCR testing. Confirmatory testing to resolve indeterminate results was conducted with available samples for five patients using a combination of immunoassays, confirmatory assays, PCR/PERT and pro-viral DNA levels, at three external laboratories; Roche Diagnostics (Germany), Swiss National Laboratory (Switzerland) and Barts Health NHS Trust (UK). Nineteen serum, 15 plasma and two whole-blood samples were analysed. Nine of ten patients analysed on Bio-Rad and Siemens immunoassays were highly reactive; seven were highly reactive on the Abbott assay. Eight of nine patients tested with the Roche assay were negative. Three of four patients tested on the bioMérieux assay were negative. Five patients underwent confirmatory testing at external laboratories; all were negative by HIV-RNA or pro-viral DNA testing. In conclusion, HIV-RNA and pro-viral DNA testing is recommended for HIV screening of individuals from high-prevalence regions coming to low-prevalence regions.

Detrusor overactivity is missed by stopping urodynamic investigation at a bladder volume of 500 mL.

OBJECTIVES: To investigate whether detrusor overactivity (DO) is missed in a relevant percentage of patients if the urodynamic investigation (UDI) is stopped at a filling volume of 500 mL due to the fear of bladder overdistention, in patients with lower urinary tract symptoms and high bladder capacity. PATIENTS AND METHODS: A consecutive series of 1598 patients with a bladder capacity of >500 mL in the bladder diary undergoing UDI due to lower urinary tract dysfunction (LUTD) was prospectively investigated. UDI was performed according to Good Urodynamic Practices recommended by the International Continence Society. UDI was stopped at strong desire to void or in case of autonomic dysreflexia, vesico-uretero-renal reflux, bladder pain or discomfort. RESULTS: Of the 1598 patients (594 women, 1004 men), 1282 (80%) and 316 (20%) had neurogenic and non-neurogenic LUTD, respectively. Overall, DO was detected in 66% (1048/1598), in 71% (910/1282) with neurogenic and in 44% (138/316) with non-neurogenic LUTD. DO occurred in 16% (263/1598, 95% confidence interval [CI] 14.7-18.4%) only at a bladder volume >500 mL. This phenomenon was significantly (P < 0.001) more frequent in patients with neurogenic (18% [236/1282], 95% CI 16.4-20.6%) compared with non-neurogenic (9% [27/316], 95% CI 5.9-12.1%) LUTD. CONCLUSIONS: In both neurological and non-neurological patients with high bladder capacity, we strongly recommend not to stop UDI at a bladder volume of 500 mL, as DO might be missed in a relevant percentage leading to inappropriate patient treatment.

Diagnostic Accuracy of Dual-Energy CT for Evaluation of Renal Masses: Systematic Review and Meta-Analysis.

OBJECTIVE: The purpose of this study is to determine the diagnostic accuracy of dual-energy CT (DECT) using quantitative iodine concentration in patients with renal masses using histopathologic analysis or follow-up imaging as the reference standard. The secondary objective is to compare the accuracy of DECT (using iodine concentration) to that of conventional CT (using Hounsfield unit measurements). MATERIALS AND METHODS: We searched the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases for studies evaluating the accuracy of DECT for renal mass characterization (1947-2018). To be included, studies had to evaluate quantitative iodine concentrations in human patients with indeterminate renal masses. Risk of bias and applicability were assessed using quality assessment of diagnostic accuracy studies-2. A bivariate random-effects model was used to determine pooled sensitivity and specificity. Variability was assessed by subgroup analyses (DECT technique and risk of bias) and metaregression using test type and threshold applied as covariates. RESULTS: Of 201 studies identified, five were included (367 patients). Pooled sensitivity and specificity for DECT were 96.6% (95% CI, 85.9-99.3%) and 95.1% (95% CI, 90.7-97.5%), respectively. Metaregression evaluating the influence of the test type (DECT vs conventional CT) did not identify differences in accuracy (p = 0.06). No differences in accuracy based on risk of bias or DECT technique were identified. Limitations include the small number of studies, most of which were at risk of bias. CONCLUSION: DECT with iodine quantification shows sensitivity and specificity greater than 95% for evaluation of renal masses and may be an alternative to conventional CT for assessment of renal masses. Larger scale trials are needed to corroborate our findings.

Carcinoma de uraco, una neoplasia maligna poco frecuente / Urachal carcinoma, a rare malignant neoplasm / Carcinoma de úraco, uma neoplasia maligna pouco frequente

El carcinoma de uraco es una neoplasia maligna poco frecuente de predominio masculino entre la quinta a sexta década de la vida. Se localizan típicamente en la cúpula de la vejiga, con patrón histopatológico predominante de adenocarcinoma en el 90% de los casos. Tiene un curso indolente con manifestaciones clínicas en etapas tardías caracterizadas por hematuria, dolor abdominal, disuria, mucosuria, entre otros. El diagnóstico se basa en el hallazgo de la lesión por métodos endoscópicos e imagenológicos. Dado lo infrecuente de esta patología, se describe el caso de una paciente en su cuarta década de vida con infección de vías urinarias recurrente, en quien se documentó por medio de urografía por tomografía computarizada multicorte (UROTAC) de pólipo vesical resecado por resección transuretral (RTU) con reporte histológico de adenocarcinoma de tipo entérico.

Urachal carcinoma is a rare malignant neoplasm of male predominance between the fifth to sixth decade of life. It is typically located in the dome of the bladder, with a predominant histopathological pattern of adenocarcinoma in 90% of cases. It has an indolent course with clinical manifestations in late stages characterized by hematuria, abdominal pain, dysuria, mucosuria, among others. Diagnosis is based on the finding of the lesion by endoscopic and imaging techniques. Given the infrequent nature of this pathology, we describe the case of a female patient in her fourth decade of life with recurrent urinary tract infection, who was documented by MSCTU of bladder polyp resected by TURP with a histological report of enteric-type adenocarcinoma.

O carcinoma de úraco, é uma neoplasia maligna pouco frequente, predominantemente masculina que se manifesta entre a quinta e a sexta década de vida. Sua localização típica é a cúpula vesical e em 90% dos casos sua histologia corresponde a adenocarcinomas. Apresenta evolução indolente com manifestações clínicas nas etapas tardias caracterizadas por hematúria, dor abdominal, disúria, mucosúria, entre outros. O diagnóstico está baseado no achado da lesão por métodos endoscópicos e de imagens. Considerando a baixa frequência desta patologia, descreve-se o caso de uma paciente de sexo feminino em sua quarta década de vida com infecção recorrente das vias urinarias, na qual foi registrado, através de UROTAC, um pólipo vesical ressecado por RTU com laudo histológico de adenocarcinoma de tipo entérico.