Burden of fatty liver and hepatic fibrosis in persons with HIV: A diverse cross-sectional US multicenter study.

BACKGROUND AIMS: The current prevalence of fatty liver disease (FLD) due to alcohol-associated (AFLD) and nonalcoholic (NAFLD) origins in US persons with HIV (PWH) is not well defined. We prospectively evaluated the burden of FLD and hepatic fibrosis in a diverse cohort of PWH. APPROACH RESULTS: Consenting participants in outpatient HIV clinics in 3 centers in the US underwent detailed phenotyping, including liver ultrasound and vibration-controlled transient elastography for controlled attenuation parameter and liver stiffness measurement. The prevalence of AFLD, NAFLD, and clinically significant and advanced fibrosis was determined. Univariate and multivariate logistic regression models were used to evaluate factors associated with the risk of NAFLD. Of 342 participants, 95.6% were on antiretroviral therapy, 93.9% had adequate viral suppression, 48.7% (95% CI 43%-54%) had steatosis by ultrasound, and 50.6% (95% CI 45%-56%) had steatosis by controlled attenuation parameter ≥263 dB/m. NAFLD accounted for 90% of FLD. In multivariable analysis, old age, higher body mass index, diabetes, and higher alanine aminotransferase, but not antiretroviral therapy or CD4 + cell count, were independently associated with increased NAFLD risk. In all PWH with fatty liver, the frequency of liver stiffness measurement 8-12 kPa was 13.9% (95% CI 9%-20%) and ≥12 kPa 6.4% (95% CI 3%-11%), with a similar frequency of these liver stiffness measurement cutoffs in NAFLD. CONCLUSIONS: Nearly half of the virally-suppressed PWH have FLD, 90% of which is due to NAFLD. A fifth of the PWH with FLD has clinically significant fibrosis, and 6% have advanced fibrosis. These data lend support to systematic screening for high-risk NAFLD in PWH.

Primary Sclerosing Cholangitis Limited to Intrahepatic Bile Ducts Has Distinctly Better Prognosis.

BACKGROUND: There are two sub-phenotypes of large-duct primary sclerosing cholangitis (PSC): isolated intrahepatic PSC (IIPSC) and extrahepatic disease with or without intrahepatic (extra/intrahepatic). AIMS: This study examined the differences in outcomes in patients with IIPSC compared to extra/intrahepatic and small-duct PSC. METHODS: Patients with PSC treated at our institution from 1998 to 2019 were investigated. Biochemistries, clinical events, and survival were assessed by chart review and National Death Index. Cox-proportional hazards were used to determine the risk of clinical outcomes based on biliary tract involvement. RESULTS: Our cohort comprised 442 patients with large-duct PSC (57 had IIPSC, 385 had extra/intrahepatic PSC) and 23 with small-duct PSC. Median follow-up in the IIPSC group was not significantly different from the extra/intrahepatic group [7 vs. 6 years, P = 0.06]. Except for lower age (mean 37.9 vs. 43.0 years, P = 0.045), the IIPSC group was not different from the extra/intrahepatic. The IIPSC group had longer transplant-free survival (log-rank P = 0.001) with a significantly lower risk for liver transplantation (12% vs. 34%, P < 0.001). The IIPSC group had a lower risk of death or transplantation than the extra/intrahepatic PSC group [HR: 0.34, 95% CI: 0.17-0.67, P < 0.001]. No bile duct or gallbladder cancers developed in patients with IIPSC, compared to 24 in the extra/intrahepatic group. The clinical characteristics and outcomes of IIPSC were similar to 23 individuals with small-duct PSC. CONCLUSIONS: Patients with IIPSC have a favorable prognosis similar to small-duct PSC. These data are important for counseling patients and designing therapeutic trials for PSC.

Racial differences in primary sclerosing cholangitis mortality is associated with community socioeconomic status.

BACKGROUND AND AIMS: Natural history and outcomes data in PSC are mostly derived from cohorts where Blacks have been underrepresented. It is unknown if there are differences in mortality between Blacks and Whites with PSC. METHODS: PSC patients seen at our institution from June 1988 to Jan 2019 were identified by merging prospective ERCP hepatology-clinic databases and liver-transplant registry. Data on race, clinical events, and death was obtained through chart review. Data on community health were collected using indices from county health rankings. Cumulative incidence of death was calculated using liver transplant (LT) as a competing risk. RESULTS: Of 449 patients, 404 were White and 45 were Black. The median-duration of follow-up was 7 years (IQR:3, 13). Black patients were younger at presentation than White patients (36.3 vs 42.5 years., P = .013). Disease severity as indicated by Mayo Risk Score categories (low 27% vs 31%, intermediate 54% vs 49% and high 19% vs 19%, P = .690), comorbidity burden and frequency of cirrhosis (42% vs 35%, P = .411) were similar between Blacks and Whites. Cumulative incidence of liver-related death, with LT as a competing risk was significantly higher in Blacks compared to Whites (sHR 1.80, 95%CI 1.25, 2.61, P = .002). There was a significant interaction between race and community socioeconomic factors that attenuated the racial difference in mortality (sHR 1.01, 95%CI 0.99, 1.04, P = .345). CONCLUSIONS: Blacks with PSC present at a younger age with a similar disease severity as Whites but have higher liver related mortality that is mediated in part through community health.

Guidelines for the Diagnostic Cross Sectional Imaging and Severity Scoring of Chronic Pancreatitis.

The paper presents the international guidelines for imaging evaluation of chronic pancreatitis. The following consensus was obtained: Computed tomography (CT) is often the most appropriate initial imaging modality for evaluation of patients with suspected chronic pancreatitis (CP) depicting most changes in pancreatic morphology. CT is also indicated to exclude other potential intraabdominal pathologies presenting with symptoms similar to CP. However, CT cannot exclude a diagnosis of CP nor can it be used to exclusively diagnose early or mild disease. Here magnetic resonance imaging (MRI) and MR cholangiopancreatography (MRCP) is superior and is indicated especially in patients where no specific pathological changes are seen on CT. Secretin-stimulated MRCP is more accurate than standard MRCP in the depiction of subtle ductal changes. It should be performed after a negative MRCP, when there is still clinical suspicion of CP. Endoscopic ultrasound (EUS) can also be used to diagnose parenchymal and ductal changes mainly during the early stage of the disease. No validated radiological severity scoring systems for CP are available, although a modified Cambridge Classification has been used for MRCP. There is an unmet need for development of a new and validated radiological CP severity scoring system based on imaging criteria including glandular volume loss, ductal changes, parenchymal calcifications and parenchymal fibrosis based on CT and/or MRI. Secretin-stimulated MRCP in addition, can provide assessment of exocrine function and ductal compliance. An algorithm is presented, where these imaging parameters can be incorporated together with clinical findings in the classification and severity grading of CP.

Quantitative MR Evaluation of Chronic Pancreatitis: Extracellular Volume Fraction and MR Relaxometry.

OBJECTIVE: The purpose of this study was to determine if extracellular volume fraction and T1 mapping can be used to diagnose chronic pancreatitis (CP). MATERIALS AND METHODS: This HIPAA-compliant study analyzed 143 consecutive patients with and without CP who underwent MR imaging between May 2016 and February 2017. Patients were selected for the study according to inclusion and exclusion criteria that considered history and clinical and laboratory findings. Eligible patients (n = 119) were grouped as normal (n = 60) or with mild (n = 22), moderate (n = 27), or severe (n = 10) CP on the basis of MRCP findings using the Cambridge classification as the reference standard. T1 maps were acquired in unenhanced and late contrast-enhanced phases using a 3D dual flip-angle gradient-echo sequence. All patients were imaged on the same 3-T scanner using the same imaging parameters, contrast agent, and dosage. RESULTS: Mean extracellular volume fractions and T1 relaxation times were significantly different within the study groups (one-way ANOVA, p < 0.001). Using the AUC curve analysis, extracellular volume fraction of > 0.27 showed 92% sensitivity (54/59) and 77% specificity (46/60) for the diagnosis of CP (AUC = 0.90). A T1 relaxation time of > 950 ms revealed 64% sensitivity (38/59) and 88% specificity (53/60) (AUC = 0.80). Combining extracellular volume fraction and T1 mapping yielded sensitivity of 85% (50/59) and specificity of 92% (55/60) (AUC = 0.94). CONCLUSION: Extracellular volume fraction and T1 mapping may provide quantitative metrics for determining the presence and severity of acinar cell loss and aid in the diagnosis of CP.

The Value of Secretin-Enhanced MRCP in Patients With Recurrent Acute Pancreatitis.

OBJECTIVE: The purpose of this study is to assess the additional value of secretin-enhanced MRCP over conventional (non-secretin-enhanced) MRCP in diagnosing disease in patients with recurrent acute pancreatitis. MATERIALS AND METHODS: A retrospective review of a radiology database found 72 patients with recurrent acute pancreatitis who had secretin-enhanced MRCP and ERCP correlation within 3 months of each other between January 2007 and December 2011. Of these patients, 54 had no history of pancreatic tumor or surgery and underwent MRI more than 3 months after an episode of acute pancreatitis. In addition, 57 age- and sex-matched control subjects with secretin-enhanced MRCP and ERCP correlation and without a diagnosis of recurrent acute pancreatitis or chronic pancreatitis were enrolled as the control group. All studies were anonymized, and secretin-enhanced MRCP images (image set A) were separated from conventional 2D and 3D MRCP and T2-weighted images (image set B). Image sets A and B for each patient were assigned different and randomized case numbers. Two blinded reviewers independently assessed both image sets for ductal abnormalities and group A image sets for exocrine response to secretin. RESULTS: There were statistically significantly more patients with recurrent acute pancreatitis with reduced exocrine function compared with patients in the control group (32% vs 9%; p < 0.01) on secretin-enhanced images. Patients with recurrent acute pancreatitis were more likely to have side branch dilation (p = 0.02; odds ratio, 3.6), but not divisum, compared with the control group. Secretin-enhanced images were superior to non-secretin-enhanced images for detecting ductal abnormalities in patients with recurrent acute pancreatitis, with higher sensitivity (76% vs 56%; p = 0.01) and AUC values (0.983 vs 0.760; p < 0.01). CONCLUSION: Up to one-third of patients with recurrent acute pancreatitis showed exocrine functional abnormalities. Secretin-enhanced MRCP had a significantly higher yield for ductal abnormalities than did conventional MRI and should be part of the MRCP protocol for investigation of patients with recurrent acute pancreatitis.

Improved T1, contrast concentration, and pharmacokinetic parameter quantification in the presence of fat with two-point Dixon for dynamic contrast-enhanced magnetic resonance imaging.

PURPOSE: To evaluate the impact of fat and fat-suppression on the quantification of T1, gadolinium concentration, and pharmacokinetic parameters in DCE-MRI. METHODS: T1 values were measured in fat-free phantoms using variable flip angle with no fat suppression, quick or interleaved fat saturation (QFS), or two-point Dixon and were compared with reference values measured with inversion recovery-prepared turbo spin echo. Relaxivity of gadolinium-benzyloxypropionictetraacetate (Gd-BOPTA) was measured in emulsions of Gd-BOPTA solution and fat using Dixon in-phase and water-only images. Liver T1 and pharmacokinetic parameters of 15 patients were calculated from Dixon in-phase and water-only images and were correlated with liver fat signal fraction. RESULTS: T1 values measured using Dixon water-only and non-fat-suppressed images matched the reference values; while T1 values measured using QFS showed large deviations. Relaxivities and Gd measured in the Dixon water-only images were less affected by the fat than those measured in the in-phase images. The correlation between liver fat fraction and the differences in measured pharmacokinetic parameters using Dixon in-phase and water-only images were significant (P < 0.05) for T1, K(trans), and incremental area under the curve, but not Ve (P = 0.1). CONCLUSION: Dixon water-only images provided more reliable estimation of T1, Gd, and pharmacokinetic parameters when fat was present.

Comparison of Dynamic Phase Enhancement of Hepatocellular Carcinoma Using Gadoxetate Disodium vs Gadobenate Dimeglumine.

OBJECTIVE: To determine the differences in enhancement of hepatocellular carcinoma during the first 5 minutes of postcontrast phases with gadoxetic acid (Gd-EOB-DTPA) vs gadobenate dimeglumine. METHODS: Ninety-five cirrhotic patients with hepatocellular carcinoma were examined on a 1.5-T scanner: 74 patients with Gd-BOPTA and 21 patients with Gd-EOB-DTPA. Same magnetic resonance imaging parameters were used for both groups. Gadoxetate isodium was administered at a dose of 0.025 mmol/kg; and Gd-BOPTA, at a dose of 0.1 mmol/kg. RESULTS: Mean contrast-to-noise ratios (CNR) were similar in arterial (P = 0.3), portal venous (P = 0.1), and 5-minute delayed phases (P = 0.73). The CNRs of lesions in the Gd-EOB-DTPA group were lower in arterial phase, although this did not reach statistical significance. The CNRs of Gd-EOB-DTPA during the equilibrium phase was higher (P = 0.006). CONCLUSIONS: Gadoxetate isodium resulted in lower CNR during the arterial phase and higher CNR during the portal venous, equilibrium, and 5-minute delayed phases compared with gadobenate dimeglumine using the Food and Drug Administration-approved doses; however, overall, there was no statistical significance (P = 0.077).

Value of magnetic resonance imaging in evaluating the pancreatic allograft transplant complications.

PURPOSE: To retrospectively investigate the value of magnetic resonance imaging (MRI) in detecting complications following pancreas transplant. MATERIALS AND METHODS: Institutional review board approved this retrospective HIPAA-compliant study and waived informed patient consent. We identified all allograft pancreas transplant patients at our institution from 2001 to January 2014 who had all pertinent post-transplant imaging and clinical data available. Transplant type was documented. Patients were divided into two groups according to post-transplant period (group A; <12 months, group B; ≥12 months). We evaluated the parenchymal enhancement using contrast-enhanced MRI of the allograft and determined the mean percentage of parenchymal enhancement (MPPE) overall and in various abnormalities, the vessel patency, any peripancreatic fluid collection, and the ductal anatomy. We correlated these with clinical results using t test, χ (2), and Fisher's exact test; p < 0.05 was considered significant. RESULTS: 51 patients (34 male, mean age 43.7 years) were identified, 28 (55%) of whom had abnormal imaging findings; transplant rejection-related necrosis (n = 7), fluid collections (n = 7), vascular stenosis (n = 4), isolated venous thromboses (n = 3), acute pancreatitis (n = 3), pancreatic and peripancreatic abscesses (n = 2), pseudoaneurysm (n = 1), and small-bowel obstruction (n = 1). Pre vs. post-contrast pancreatic MPPE at 1 min was 120% in the normal allografts and 115% in the allografts with pancreatitis and without necrosis (p > 0.05). MPPE at 1 min was only 9% in the allografts rejections with necrosis/infarction. More complications were found in group A than group B (p < 0.05). CONCLUSIONS: Contrast-enhanced MRI is useful for the non-invasive assessment of pancreas transplant complications.

Acinarization (parenchymal blush) observed during secretin-enhanced MRCP: clinical implications.

OBJECTIVE: T2 hyperintensity of pancreatic acini during secretin-enhanced MRCP is called "acinarization." We sought to determine the clinical significance of this finding. MATERIALS AND METHODS: Patients were selected if the radiology report included the phrases "acin*" (where * represented a wild card search) or "blush" using the institution's customized lexicon-search software. Sixty-seven consecutive patients without acinarization on secretin-enhanced MRCP who also underwent ERCP were enrolled as the control group. The intensity of acinarization was classified into three groups: grade 0, no visible acinarization; grade 1, barely visible parenchymal hyperintensity; or grade 2, easily visible parenchymal hyperintensity. ERCP findings of ductal abnormalities and basal pancreatic sphincter manometry were recorded. RESULTS: There were higher frequencies of divisum (p = 0.001) and of a clinical history of recurrent acute pancreatitis (p < 0.001) and higher basal pancreatic sphincter of Oddi manometric pressure measurements (p = 0.008) in the acinarization group. There was no difference in the frequency of ERCP-defined chronic pancreatitis (p = 0.10) between the groups. In patients with acinarization, a higher mean sphincter pressure was seen in patients with more intense acinarization than in those with faint acinarization, but this difference was not significant (p = 0.22). Ampullary tumors were found in four patients with acinarization. CONCLUSION: Acinarization probably occurs in patients with a propensity for increased pancreatic ductal pressure (i.e., patients with divisum, elevated basal pancreatic sphincter pressure, ampullary tumor) and adequate exocrine function (absence of severe chronic pancreatitis).

Cystic neoplasms of the pancreas; findings on magnetic resonance imaging with pathological, surgical, and clinical correlation.

Pancreatic cysts are increasingly being identified by cross-sectional imaging studies. Pancreatic cystic lesions comprise a spectrum of underlying pathologies ranging from benign and pre-malignant lesions to frank malignancies. Magnetic resonance imaging with cholangiopancreatography is a non-invasive imaging modality used for the characterization of cystic pancreatic lesions. This article will review the most common pancreatic cystic neoplasms and the utility of MR imaging in the characterization of these cysts.

The utility of secretin-enhanced MRCP in diagnosing congenital anomalies.

PURPOSE: To assess the additional value of secretin-enhanced MRCP (SMRCP) over conventional MRCP in diagnosing divisum. METHODS: Retrospective HIPAA-compliant and IRB-approved review found 140 patients with SMRCP and ERCP correlation within 6 months of each other. All studies were anonymized and the SMRCP images (SMRCP image set) were separated from 2D and 3D MRCP and axial and coronal T2-weighted images (conventional MRI image set). Each image set on each patient was assigned different and randomized case numbers. Two reviewers (R1 and R2) independently reviewed the image sets for divisum vs. no divisum, complete divisum vs. incomplete divisum, and the certainty of diagnosis (1 = definitely certain, 2 = moderately certain, and 3 = unsure). ERCP findings were taken as gold standard. RESULTS: There was no difference in age and gender between the divisum (n = 97, with 13 incomplete divisum) and no divisum (n = 43) groups. In diagnosing divisum anatomy, the sensitivity was higher for SMRCP compared to conventional MRI for R1 (84.5 vs. 72.2, p = 0.02) but not R2 (89.7 vs. 84.4, p = 0.25). The specificity was higher in SMRCP image set compared to conventional MRI (R1: 88.1 vs. 76.2, p = 0.01; R2: 81.4 vs. 65.1, p < 0.001). The mean area under ROC curve was higher for SMRCP image set (R1: 0.86 vs. 0.74, p = 0.01; R2: 0.87 vs. 0.74, p = 0.01). The certainty of diagnosis was higher in SMRCP image set compared to conventional MRI (p = 0.02 for both reviewers). SMRCP was not found to be superior in distinguishing incomplete from complete divisum. The main reasons for erroneous SMRCP diagnosis were the presence of an ansa loop in the main duct and ductal strictures due to chronic pancreatitis. CONCLUSION: Even though the reviewers had more sequences (axial and coronal) to evaluate in the non-secretin image set, there was some improvement in diagnosing divisum with SMRCP.

Usefulness of conventional MRI sequences and diffusion-weighted imaging in differentiating malignant from benign portal vein thrombus in cirrhotic patients.

OBJECTIVE: The objective of our study was to determine the value of diffusion-weighted imaging (DWI) and conventional MRI (non-DWI sequences) in differentiating benign portal vein thrombus (PVT) from malignant PVT in cirrhotic patients. MATERIALS AND METHODS: A retrospective search of the department of radiology's MRI database of examinations performed from October 2006 through December 2010 for "portal vein thrombosis" and "cirrhosis" and "hepatocellular cancer" was performed. Patients who underwent diagnostic DWI and had thrombus shown to be rapidly (< 3 months) increasing in size despite anticoagulation therapy were considered to have malignant PVT (n = 16 cases) and patients with MRI findings showing stability or reduction in the extent of thrombus over a 12-month follow-up were considered to have benign PVT (n = 20 cases). Two blinded and independent reviewers analyzed the DW images and conventional MR images. RESULTS: There was no difference in the distribution of patients by age (p = 0.25) or sex (p = 0.68) between the benign and malignant PVT groups. On multivariate analysis, the only parameter to predict the type of PVT was the size of HCC (p = 0.05); other parameters were excluded from the model. There was substantial overlap in apparent diffusion coefficient (ADC) values and PVT/liver ADC ratios of benign PVT and malignant PVT. The presence of at least two of the three following MRI findings had a sensitivity of 100% and specificity of 90% for the diagnosis of malignant PVT: distance from tumor to PVT of less than 2 cm, HCC size of greater than 5 cm, and arterial enhancement of PVT. CONCLUSION: Signal-intensity characteristics on DWI and measured ADC values do not reliably differentiate benign PVT from malignant PVT. On the other hand, careful assessment of conventional MRI findings may allow this distinction, thus obviating biopsy.

Response criteria in oncologic imaging: review of traditional and new criteria.

There has been a proliferation and divergence of imaging-based tumor-specific response criteria over the past 3 decades whose purpose is to achieve objective assessment of treatment response in oncologic clinical trials. The World Health Organization (WHO) criteria, published in 1981, were the first response criteria and made use of bidimensional measurements of tumors. The Response Evaluation Criteria in Solid Tumors (RECIST) were created in 2000 and revised in 2009. The RECIST criteria made use of unidimensional measurements and addressed several pitfalls and limitations of the original WHO criteria. Both the WHO and RECIST criteria were developed during the era of cytotoxic chemotherapeutic agents and are still widely used. However, treatment strategies changed over the past decade, and the limitations of using tumor size alone in patients undergoing targeted therapy (including arbitrarily determined cutoff values to categorize tumor response and progression, lack of information about changes in tumor attenuation, inability to help distinguish viable tumor from nonviable components, and inconsistency of size measurements) necessitated revision of these criteria. More recent criteria that are used for targeted therapies include the Choi response criteria for gastrointestinal stromal tumor, modified RECIST criteria for hepatocellular carcinoma, and Immune-related Response Criteria for melanoma. The Cheson criteria and Positron Emission Tomography Response Criteria in Solid Tumors make use of positron emission tomography to provide functional information and thereby help determine tumor viability. As newer therapeutic agents and approaches become available, it may be necessary to further modify existing anatomy-based response-assessment methodologies, verify promising functional imaging methods in large prospective trials, and investigate new quantitative imaging technologies.

Secretin-enhanced MR cholangiopancreatography: spectrum of findings.

Magnetic resonance cholangiopancreatography (MRCP) is the most effective, safe, noninvasive magnetic resonance (MR) imaging technique for the evaluation of the pancreaticobiliary ductal system. The MRCP imaging technique has substantially improved during the past 2 decades and is based mainly on the acquisition of heavily T2-weighted MR images, with variants of fast spin-echo sequences. MRCP can also be performed by utilizing the hormone secretin, which stimulates a normal pancreas to secrete a significant amount of fluid while transiently increasing the tone of the sphincter of Oddi. The transient increase in the diameter of the pancreatic duct improves the depiction of the ductal anatomy, which can be useful in patients in whom detailed evaluation of the pancreatic duct is most desired because of a suspicion of pancreatic disease. Improved depiction of the ductal anatomy can be important in (a) the differentiation of side-branch intraductal papillary mucinous neoplasms from other cystic neoplasms and (b) the diagnosis and classification of chronic pancreatitis, the disconnected pancreatic duct syndrome, and ductal anomalies such as anomalous pancreaticobiliary junction and pancreas divisum. In patients examined after pancreatectomy, stimulation with secretin can give information about the patency of the pancreaticoenteric anastomosis. Duodenal filling during the secretin-enhanced phase of the MRCP examination can be used to estimate the excretory reserve of the pancreas. Secretin is well tolerated, and complications are rarely seen. Secretin-enhanced MRCP is most useful in (a) the evaluation of acute and chronic pancreatitis, congenital variants of the pancreaticoduodenal junction, and intraductal papillary mucinous neoplasms and (b) follow-up of patients after pancreatectomy.

A composite score using quantitative magnetic resonance cholangiopancreatography predicts clinical outcomes in primary sclerosing cholangitis.

Background & Aims: Magnetic resonance cholangiopancreatography (MRCP) for evaluation of biliary disease currently relies on subjective assessment with limited prognostic value because of the lack of quantitative metrics. Artificial intelligence-enabled quantitative MRCP (MRCP+) is a novel technique that segments biliary anatomy and provides quantitative biliary tree metrics. This study investigated the utility of MRCP+ as a prognostic tool for the prediction of clinical outcomes in primary sclerosing cholangitis (PSC). Methods: MRCP images of patients with PSC were post-processed using MRCP+ software. The duration between the MRCP and clinical event (liver transplantation or death) was calculated. Survival analysis and stepwise Cox regression were performed to investigate the optimal combination of MRCP+ metrics for the prediction of clinical outcomes. The resulting risk score was validated in a separate validation cohort and compared with an existing prognostic score (Mayo risk score). Results: In this retrospective study, 102 patients were included in a training cohort and a separate 50 patients formed a validation cohort. Between the two cohorts, 34 patients developed clinical outcomes over a median duration of 3 years (23 liver transplantations and 11 deaths). The proportion of bile ducts with diameter 3-5 mm, total bilirubin, and aspartate aminotransferase were independently associated with transplant-free survival. Combined as a risk score, the overall discriminative performance of the MRCP+ risk score (M+BA) was excellent; area under the receiver operator curve 0.86 (95% CI: 0.77, 0.95) at predicting clinical outcomes in the validation cohort with a hazard ratio 5.8 (95% CI: 1.5, 22.1). This was superior to the Mayo risk score. Conclusions: A composite score combining MRCP+ with total bilirubin and aspartate aminotransferase (M+BA) identified PSC patients at high risk of liver transplantation or death. Prospective studies are warranted to evaluate the clinical utility of this novel prognostic tool. Impact and Implications: Primary sclerosis cholangitis (PSC) is a disease of the biliary tree where inflammation and fibrosis cause areas of narrowing (strictures) and expansion (dilatations) within the biliary ducts leading to liver failure and/or cancer (cholangiocarcinoma). In this study, we demonstrate that quantitative assessment of the biliary tree can better identify patients with PSC who are at high risk of either death or liver transplantation than a current blood-based risk score (Mayo risk score).

Non-alcoholic fatty liver disease is not associated with impairment in health-related quality of life in virally suppressed persons with human immune deficiency virus.

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in persons with HIV (PWH) (HIV-NAFLD). It is unknown if HIV-NAFLD is associated with impairment in health-related quality of life (HRQOL). We examined HRQOL in PWH with and without NAFLD, compared HRQOL in HIV- versus primary NAFLD, and determined factors associated with HRQOL in these groups. Prospectively enrolled 200 PWH and 474 participants with primary NAFLD completed the Rand SF-36 assessment which measures 8 domains of HRQOL. Individual domain scores were used to create composite physical and mental component summary scores. Univariate and multivariate analyses determined variables associated with HRQOL in PWH and in HIV- and primary NAFLD. In PWH, 48% had HIV-NAFLD, 10.2% had clinically significant fibrosis, 99.5% were on antiretroviral therapy, and 96.5% had HIV RNA <200 copies/ml. There was no difference in HRQOL in PWH with or without NAFLD. Diabetes, non-Hispanic ethnicity, and nadir CD4 counts were independently associated with impaired HRQOL in PWH. In HIV-NAFLD, HRQOL did not differ between participants with or without clinically significant fibrosis. Participants with HIV-NAFLD compared to those with primary NAFLD were less frequently cisgender females, White, more frequently Hispanic, had lower BMI and lower frequency of obesity and diabetes. HRQOL of individuals with HIV-NAFLD was not significantly different from those with primary NAFLD. In conclusion, in virally suppressed PWH, HRQOL is not different between participants with or without HIV-NAFLD. HRQOL is not different between HIV-NAFLD and primary NAFLD.

Inter- and intra-observer variability of computed tomography-based parenchymal- and ductal diameters in chronic pancreatitis: a multi-observer international study.

PURPOSE: The need for incorporation of quantitative imaging biomarkers of pancreatic parenchymal and ductal structures has been highlighted in recent proposals for new scoring systems in chronic pancreatitis (CP). To quantify inter- and intra-observer variability in CT-based measurements of ductal- and gland diameters in CP patients. MATERIALS AND METHODS: Prospectively acquired pancreatic CT examinations from 50 CP patients were reviewed by 12 radiologists and four pancreatologists from 10 institutions. Assessment entailed measuring maximum diameter in the axial plane of four structures: (1) pancreatic head (PDhead), (2) pancreatic body (PDbody), (3) main pancreatic duct in the pancreatic head (MPDhead), and (4) body (MPDbody). Agreement was assessed by the 95% limits of agreement with the mean (LOAM), representing how much a single measurement for a specific subject may plausibly deviate from the mean of all measurements on the specific subject. Bland-Altman limits of agreement (LoA) were generated for intra-observer pairs. RESULTS: The 16 observers completed 6400 caliper placements comprising a first and second measurement session. The widest inter-observer LOAM was seen with PDhead (± 9.1 mm), followed by PDbody (± 5.1 mm), MPDhead (± 3.2 mm), and MPDbody (± 2.6 mm), whereas the mean intra-observer LoA width was ± 7.3, ± 5.1, ± 3.7, and ± 2.4 mm, respectively. CONCLUSION: Substantial intra- and inter-observer variability was observed in pancreatic two-point measurements. This was especially pronounced for parenchymal and duct diameters of the pancreatic head. These findings challenge the implementation of two-point measurements as the foundation for quantitative imaging scoring systems in CP.