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BACKGROUND & AIMS: There is limited knowledge regarding the longitudinal utility of biomarkers of fibrosis, such as the nonalcoholic fatty liver disease (NAFLD) fibrosis score (NFS) or the fibrosis-4 score (FIB-4) score. We examined longitudinal changes in the NFS and the FIB-4 score in patients with NAFLD, with and without clinically significant fibrosis (CSF). METHODS: We performed a retrospective study of 230 patients with NAFLD, collecting clinical and laboratory records to calculate NFS and FIB-4 scores at 6 monthly intervals for 5 years before hepatology assessment of fibrosis. Linear mixed models with random intercept and slope and adjusted for age at baseline were used to assess the progression of NFS and log-transformed FIB-4 scores over time in subjects with and without CSF, determined by liver stiffness measurements of 8.2 kPa or greater. RESULTS: Patients had a median of 11 (minimum, 10; maximum, 11) retrospective observations over a median time period of 5 years (minimum, 4.5 y; maximum, 5 y). Of patients with low baseline NFS and FIB-4 scores, 31.11% and 37.76%, respectively, had CSF at the time of hepatology assessment. There was a correlation between NFS and log10 FIB-4 over time (repeated measure r = 0.55; 95% CI, 0.52-0.59). The rate of increase in NFS and log10 FIB-4 was significantly higher in patients with than without CSF (both P < .001). Predicted NFS increased by 0.17 and 0.06 units per year in subjects with and without CSF, respectively. Predicted log10 FIB-4 score increased by 0.032 and 0.0003 units per year in subjects with and without CSF, respectively. CONCLUSIONS: Noninvasively measured fibrosis scores increase progressively in patients with NAFLD and CSF. Further studies are needed to determine whether repeated measurements can identify patients at risk for CSF.
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Hepatopatia Gordurosa não Alcoólica , Aspartato Aminotransferases , Humanos , Cirrose Hepática , Hepatopatia Gordurosa não Alcoólica/complicações , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is a common cause of incidental liver test abnormalities. General practitioners (GP) have a key role in identifying people with NAFLD at risk of significant liver disease. Recent specialist guidelines emphasise the use of fibrosis algorithms or serum biomarkers rather than routine liver tests, to assess advanced fibrosis. AIM: To evaluate primary care clinicians' current approach to diagnosis, management and referral of NAFLD. METHODS: A cross-sectional survey of primary care clinicians was undertaken through a structured questionnaire about NAFLD. A convenience sample of general practice clinics and general practice conferences in Metropolitan Brisbane and regional south east Queensland was selected. RESULTS: A total of 108 primary care clinicians completed the survey (participation rate 100%). Fifty-one percent of respondents considered the prevalence of NAFLD in the general population to be ≤10%. Twenty-four percent of respondents felt that liver enzymes were sufficiently sensitive to detect underlying NAFLD. Most respondents were unsure whether the Fibrosis 4 score (62.7% unsure) or Enhanced Liver Fibrosis score (63.7% unsure) could help to identify advanced fibrosis or cirrhosis. Although 47% of respondents said they would refer a patient to a Gastroenterologist/Hepatologist if they suspect the patient has NAFLD, 44.1% do not make any referrals. Of concern, 70.6% of clinicians said they were unlikely to refer a patient to Hepatology unless liver function tests are abnormal. CONCLUSION: Our findings demonstrate that many primary care clinicians underestimate the prevalence of NAFLD and under-recognise the clinical spectrum of NAFLD and how this is assessed.
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Atitude do Pessoal de Saúde , Cirrose Hepática/diagnóstico , Cirrose Hepática/epidemiologia , Hepatopatia Gordurosa não Alcoólica/diagnóstico , Hepatopatia Gordurosa não Alcoólica/epidemiologia , Médicos de Atenção Primária , Biomarcadores/sangue , Estudos Transversais , Feminino , Humanos , Cirrose Hepática/sangue , Testes de Função Hepática/tendências , Masculino , Hepatopatia Gordurosa não Alcoólica/sangue , Médicos de Atenção Primária/tendências , Queensland/epidemiologia , Encaminhamento e Consulta/tendênciasAssuntos
Adenocarcinoma , Doença de Crohn , Adenocarcinoma/diagnóstico , Adenocarcinoma/diagnóstico por imagem , Constrição Patológica/diagnóstico por imagem , Constrição Patológica/patologia , Doença de Crohn/diagnóstico , Doença de Crohn/diagnóstico por imagem , Humanos , Intestino Delgado/diagnóstico por imagem , Intestino Delgado/patologiaRESUMO
Primary achalasia is a motility disorder of the esophagus involving impaired relaxation of the esophageal sphincter and, in later stages, dilatation and aperistalsis of the tubular esophagus. Endoscopic botulinum toxin injection to the lower esophageal sphincter is an effective and safe option in the treatment algorithm of achalasia, particularly in high-surgical-risk patients. In the present case report, we describe a rare complication of esophageal perforation following botulinum injection, resulting in associated inflammatory mediastinitis and formation of a pseudoaneurysm in the descending aorta. To the authors' knowledge, this is the first report in the literature of this rare complication of endoscopic botulinum injection. A contributing factor might have been the use of an injecting device with a significantly longer adjustable needle. Endoscopists should remain clinically vigilant to the potential complications associated with this common procedure.
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Falso Aneurisma/etiologia , Aneurisma da Aorta Torácica/etiologia , Toxinas Botulínicas/administração & dosagem , Acalasia Esofágica/tratamento farmacológico , Esfíncter Esofágico Inferior/lesões , Esofagoscopia/efeitos adversos , Mediastinite/etiologia , Idoso , Falso Aneurisma/diagnóstico , Aneurisma da Aorta Torácica/diagnóstico , Humanos , Injeções/efeitos adversos , Masculino , Mediastinite/diagnóstico , Neurotoxinas/administração & dosagem , RupturaAssuntos
Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico/métodos , Cisto Pancreático/patologia , Idoso , Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico/instrumentação , Humanos , Achados Incidentais , Masculino , Pâncreas/patologia , Cisto Pancreático/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: Orbital compartment syndrome (OCS) is a time critical condition, with ischaemic complications occurring after 90-120 min. In the prehospital setting, the diagnosis and management of OCS is challenging due to complex environmental considerations, competing clinical priorities, and limited equipment. This study aims to provide learning points on performing lateral canthotomy and cantholysis (LCC) in the prehospital setting. METHODS: We performed a retrospective audit of LCC in our service from January 2016 to December 2020 by retrieving demographic and clinical details from LifeFlight Retrieval Medicine electronic database using 'OCS' and 'LCC' as keywords. RESULTS: Three cases out of 7413 trauma missions were identified over the 5-year period. LCC was performed at the primary scene in two cases, while one patient underwent LCC at a rural hospital near the scene of injury. Clinical findings, aeromedical considerations, and radiological findings at the receiving facility, along with visual outcomes at time of discharge are discussed. CONCLUSION: Prehospital LCC is rare. The Australian aeromedical context often involves lengthy transfers of trauma patients. Clinical diagnosis and management of OCS are highly challenging in the prehospital setting. It is important that prehospital physicians have access to appropriate equipment to perform LCC. They should be provided with suitable training and supported by a standard operating procedure.
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Síndromes Compartimentais , Serviços Médicos de Emergência , Austrália , Síndromes Compartimentais/etiologia , Síndromes Compartimentais/cirurgia , Descompressão Cirúrgica/efeitos adversos , Humanos , Estudos RetrospectivosRESUMO
Radiofrequency cardiac ablation is increasingly performed for the management of dysrhythmias. Bleeding is a well-known complication of this procedure. We present a rare case of a near-fatal iatrogenic hepatic hemorrhage after cardiac catheter ablation. (Level of Difficulty: Advanced.).
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BACKGROUND: The understanding of non-radiographic axial spondyloarthritis (nr-axSpA) has accelerated over the last decade, producing a number of practice-changing developments. Diagnosis is challenging. No diagnostic criteria exist, no single finding is diagnostic, and other causes of back pain may act as confounders. AIM: To update and expand the 2014 consensus statement on the investigation and management of non-radiographic axial spondyloarthritis (nr-axSpA). METHODS: We created search questions based on our previous statements and four new topics then searched the MEDLINE and Cochrane databases. We assessed relevant publications by full-text review and rated their level of evidence using the GRADE system. We compiled a GRADE evidence summary then produced and voted on consensus statements. RESULTS: We identified 5145 relevant publications, full-text reviewed 504, and included 176 in the evidence summary. We developed and voted on 22 consensus statements. All had high agreement. Diagnosis of nr-axSpA should be made by experienced clinicians, considering clinical features of spondyloarthritis, blood tests, and imaging. History and examination should also assess alternative causes of back pain and related conditions including non-specific back pain and fibromyalgia. Initial investigations should include CRP, HLA-B27, and AP pelvic radiography. Further imaging by T1 and STIR MRI of the sacroiliac joints is useful if radiography does not show definite changes. MRI provides moderate-to-high sensitivity and high specificity for nr-axSpA. Acute signs of sacroiliitis on MRI are not specific and have been observed in the absence of spondyloarthritis. Initial management should involve NSAIDs and a regular exercise program, while TNF and IL-17 inhibitors can be used for high disease activity unresponsive to these interventions. Goals of treatment include improving the frequent impairment of social and occupational function that occurs in nr-axSpA. CONCLUSIONS: We provide 22 evidence-based consensus statements to provide practical guidance in the assessment and management of nr-axSpA.
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Perineal hernias are rare, protruding through a defect, congenital or acquired, of the pelvic floor musculature with intraperitoneal or extraperitoneal content. Anatomically they can be classified as anterior and posterior based on the position relative to the superficial transverse perineal muscle. We present a case of a rare primary posterior perineal hernia that was identified incidentally on computed tomography.
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Hérnia/diagnóstico por imagem , Períneo , Tomografia Computadorizada por Raios X , Idoso , Diagnóstico Diferencial , Feminino , Humanos , Achados IncidentaisRESUMO
OBJECTIVE: We tested the discriminatory capacity of diffusion-weighted magnetic resonance imaging (DWI) and its potential as an objective measure of treatment response to tumor necrosis factor inhibition in ankylosing spondylitis (AS). METHODS: Three cohorts were studied prospectively: (1) 18 AS patients with Bath Ankylosing Spondylitis Disease Activity Index > 4, and erythrocyte sedimentation rate > 25 and/or C-reactive protein > 10 meeting the modified New York criteria for AS; (2) 20 cases of nonradiographic axial spondyloarthritis (nr-axSpA) as defined by the Assessment of Spondyloarthritis international Society (ASAS) criteria; and (3) 20 non-AS patients with chronic low back pain, aged between 18 and 45 years, who did not meet the imaging arm of the ASAS criteria for axSpA. Group 1 patients were studied prior to and following adalimumab treatment. Patients were assessed by DWI and conventional magnetic resonance imaging (MRI), and standard nonimaging measures. RESULTS: At baseline, in contrast to standard nonimaging measures, DWI apparent diffusion coefficient (ADC) values showed good discriminatory performance [area under the curve (AUC) > 80% for Group 1 or 2 compared with Group 3]. DWI ADC values were significantly lower posttreatment (0.45 ± 0.433 before, 0.154 ± 0.23 after, p = 0.0017), but had modest discriminating capacity comparing pre- and posttreatment measures (AUC = 68%). This performance was similar to the manual Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system. CONCLUSION: DWI is informative for diagnosis of AS and nr-axSpA, and has moderate utility in assessment of disease activity or treatment response, with performance similar to that of the SPARCC MRI score.
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Imagem de Difusão por Ressonância Magnética/métodos , Dor Lombar/diagnóstico por imagem , Articulação Sacroilíaca/diagnóstico por imagem , Espondilartrite/diagnóstico por imagem , Espondilite Anquilosante/diagnóstico por imagem , Adulto , Sedimentação Sanguínea , Feminino , Humanos , Dor Lombar/sangue , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Espondilartrite/sangue , Espondilite Anquilosante/sangue , Adulto JovemAssuntos
Dor Lombar , Humanos , Dor Lombar/diagnóstico , Dor Lombar/terapia , Padrão de Cuidado , Atenção à Saúde , AustráliaAssuntos
Dor Lombar , Humanos , Dor Lombar/terapia , Padrão de Cuidado , Atenção à Saúde , AustráliaAssuntos
Dor Lombar , Humanos , Dor Lombar/terapia , Padrão de Cuidado , Atenção à Saúde , AustráliaRESUMO
Noninvasive serum biomarkers (nonalcoholic fatty liver disease fibrosis score [NFS], fibrosis 4 score [FIB-4], or enhanced liver fibrosis [ELF] test) are recommended as first-line tools to determine the risk of advanced fibrosis in nonalcoholic fatty liver disease. We aimed to assess the utility of a pragmatic approach to screening for clinically significant fibrosis in primary care and diabetes clinics. We recruited 252 patients from an endocrine clinic or primary care facility. Anthropometric measurements, ELF test, ultrasound, and liver stiffness measurements (LSMs) were performed. Clinically significant fibrosis was defined as LSM ≥8.2 kPa or ELF ≥9.8. A subgroup of patients underwent liver biopsy (n = 48) or had imaging diagnostic of cirrhosis (n = 14). Patients were 57.3 ± 12.3 years old with a high prevalence of metabolic syndrome (84.5%), type 2 diabetes (82.5%), and body mass index (BMI) ≥40 kg/m2 (21.8%). LSM met quality criteria in 230 (91.3%) patients. NFS and FIB-4 combined had a high negative predictive value (90.0%) for excluding LSM ≥8.2 kPa. However, 84.1% of patients had indeterminate or high NFS or FIB-4 scores requiring further assessment. LSM ≥8.2 kPa and ELF ≥9.8 were present in 31.3% and 28.6% of patients, respectively. Following adjustment for age, BMI, sex, and presence of advanced fibrosis, older age was independently associated with ELF ≥9.8 (adjusted odds ratio, 1.14; 95% confidence interval, 1.06-1.24), whereas increasing BMI was independently associated with LSM ≥8.2 kPa (adjusted odds ratio, 1.15; 95% confidence interval, 1.01-1.30). Concordant LSM <8.2 kPa and ELF <9.8 and concordant LSM ≥8.2 kPa and ELF ≥9.8 had a high negative predictive value (91.7%) and positive predictive value (95.8%) for excluding and identifying clinically significant fibrosis, respectively. Conclusion: Simple scoring tools alone lack accuracy. LSM accuracy is influenced by severe obesity, whereas age impacts the ELF test. Further studies are required to confirm whether combining LSM and ELF may enhance accuracy and confidence in identifying clinically significant fibrosis. (Hepatology Communications 2018; 00:000-000).
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AIMS: To examine the relationship between steatosis quantified by controlled attenuation parameter (CAP) values and glycaemic/metabolic control. METHODS: 230 patients, recruited from an Endocrine clinic or primary care underwent routine Hepatology assessment, with liver stiffness measurements and simultaneous CAP. Multivariable logistic regression was performed to identify potential predictors of Metabolic Syndrome (MetS), HbA1câ¯≥â¯7%, use of insulin, hypertriglyceridaemia and CAPâ¯≥â¯300â¯dB/m. RESULTS: Patients were 56.7⯱â¯12.3â¯years of age with a high prevalence of MetS (83.5%), T2DM (81.3%), and BMIâ¯≥â¯40â¯kg/m2 (18%). Median CAP score was 344â¯dB/m, ranging from 128 to 400â¯dB/m. BMI (aOR 1.140 95% CI 1.068-1.216), requirement for insulin (aOR 2.599 95% CI 1.212-5.575), and serum ALT (aOR 1.018 95% CI 1.004-1.033) were independently associated with CAPâ¯≥â¯300â¯dB/m. Patients with CAP interquartile rangeâ¯<â¯40 (68%) had a higher median serum ALT level (pâ¯=â¯0.029), greater prevalence of BMIâ¯≥â¯40â¯kg/m2 (pâ¯=â¯0.020) and higher median CAP score (pâ¯<â¯0.001). Patients with higher CAP scores were more likely to have MetS (aOR 1.011 95% CI 1.003-1.019), HBA1câ¯≥â¯7 (aOR 1.010 95% CI 1.003-1.016), requirement for insulin (aOR 1.007 95% CI 1.002-1.013) and hypertriglyceridemia (aOR 1.007 95% CI 1.002-1.013). CONCLUSIONS: Our data demonstrate that an elevated CAP reflects suboptimal metabolic control. In diabetic patients with NAFLD, CAP may be a useful point-of-care test to identify patients at risk of poorly controlled metabolic comorbidities or advanced diabetes.