Body composition predicts mortality and decompensation in compensated cirrhosis patients: A prospective cohort study.

BACKGROUND & AIMS: Body composition, particularly sarcopenia, is associated with mortality in patients with decompensated cirrhosis undergoing transplant evaluation. Similar data are limited for non-transplant eligible or compensated patients. METHODS: A total of 274 patients with cirrhosis were followed prospectively for ≤5 years after a CT scan. We utilized Analytic Morphomics® to measure body composition (fat, muscle, and bone) which was rendered into relative values (percentiles) in relation to a reference population. The model for end-stage liver disease (MELD) score was used as a reference model for survival prediction. We validated our models in a separate cohort. RESULTS: Our cohort had a mean Child-Pugh score of 7.0 and a mean MELD of 11.3. The median follow-up time was 5.05 years. The proportion of patients alive at 1, 3 and 5 years was 86.5%, 68.0%, and 54.3%; 13 (4.6%) underwent liver transplantation. Child-Pugh B/C (vs. A) cirrhosis was associated with decreased muscle, subcutaneous, and visceral fat area but increased subcutaneous/visceral fat density. Decreased normal density muscle mass was associated with mortality (hazard ratio [HR] 0.984, p <0.001) as well as visceral and subcutaneous fat density (HR 1.013 and 1.014, respectively, p <0.001). Models utilizing these features outperformed MELD alone for mortality discrimination in both the derivation and validation cohort, particularly for those with compensated cirrhosis (C-statistics of 0.74 vs. 0.58). Using competing risk analysis, we found that subcutaneous fat density was most predictive of decompensation (subdistribution HR 1.018, p = 0.0001). CONCLUSION: The addition of body composition features to predictive models improves the prospective determination of prognosis in patients with cirrhosis, particularly those with compensated disease. Fat density, a novel feature, is associated with the risk of decompensation. LAY SUMMARY: Am I at high risk of getting sicker and dying? This is the key question on the mind of patients with cirrhosis. The problem is that we have very few tools to help guide our patients, particularly if they have early cirrhosis (without symptoms like confusion or fluid in the belly). We found that how much muscle and fat the patient has and what that muscle or fat looks like on a CT scan provide helpful information. This is important because many patients have CT scans and this information is hiding in plain sight.

Body Composition Predicts Survival in Patients with Hepatocellular Carcinoma Treated with Transarterial Chemoembolization.

PURPOSE: The prognosis of patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE) is often uncertain. We aimed to utilize analytic morphomics, a high-throughput imaging analysis, to assess if body composition is predictive of post-TACE survival. MATERIALS AND METHODS: We included patients from a single center (Ann Arbor VA)who had TACE as the primary treatment forHCC and had a pre-treatment computed tomography scans. Univariate analysis and multivariate conditional inference tree analysis were utilized to identify the morphomic characteristics predictive of 1-year survival. Results were validated in an external cohort(University of MichiganHealth System) ofHCC patientswho underwent TACE as their primary treatment. RESULTS: In the 75 patients in the derivation cohort, median survival was 439 (interquartile range, 377 to 685) days from receipt of TACE, with 1-year survival of 61%. Visceral fat density (VFD) was the only morphomic factor predictive of overall and 1-year survival (p < 0.001). Patients with VFD above the 56th percentile had a 1-year survival of 39% versus 78% for those below the 56th percentile. VFD also correlated with 1-year survival in the external validation cohort (44% vs. 72%, p < 0.001). In a secondary analysis, patients with higher VFD were significantly more likely to experience hepatic decompensation after TACE (p < 0.001). CONCLUSION: VFD served as an objective predictor of mortality in patients undergoing TACE, possibly through its ability to predict hepatic decompensation. VFD may serve as a radiographic biomarker in predicting TACE outcomes.

Intra-arterial Thrombolysis for Extremity Frostbite Decreases Digital Amputation Rates and Hospital Length of Stay.

PURPOSE: To report outcomes of intra-arterial thrombolysis versus non-thrombolytic management of severe frostbite with respect to digital amputation rates and hospital length of stay (LOS). MATERIALS AND METHODS: Seventeen patients with severe frostbite were identified from 2000 to 2017. Eight (47%) patients with mean age of 40 years underwent intra-arterial thrombolysis and served as the treatment group. Nine (53%) patients with mean age of 53 years received non-thrombolytic management and served as the control group. 2/8 (25%) treatment and 3/9 (33%) control patients had underlying vascular comorbidities (p = 0.25). Number of digits at risk, duration of thrombolysis, thrombolytic agents used, digits amputated, hospital LOS, and complications were recorded. RESULTS: Seven upper and nine lower extremities for a total of 80 digits were at risk in the treatment cohort. Eight upper and 12 lower extremities for a total of 100 digits were at risk in the control group. Mean duration of thrombolysis was 26 h. All treatment patients received tissue plasminogen activator in addition to systemic heparin. 4/16 (25%) limbs received intra-arterial alprostadil, 2/16 (13%) received nitroglycerin, and 2/16 (13%) received nicardipine. 12/80 (15%) treatment digits and 77/100 (77%) control digits required amputation (p = 0.003). Average hospital LOS was 14 days in the treatment group and 38 days in the control group (p = 0.011). No major complications occurred in the treatment group; however, 2/9 (22%) patients in the control group required extended hospitalizations secondary to amputation complications. CONCLUSIONS: Intra-arterial thrombolysis reduces digital amputation rates and hospital LOS in the setting of severe frostbite.

Use of analytic morphomics of liver, spleen, and body composition to identify patients at risk for cirrhosis.

BACKGROUND & AIMS: A diagnosis of cirrhosis can be made on the basis of findings from imaging studies, but these are subjective. Analytic morphomics uses computational image processing algorithms to provide precise and detailed measurements of organs and body tissues. We investigated whether morphomic parameters can be used to identify patients with cirrhosis. METHODS: In a retrospective study, we performed analytic morphomics on data collected from 357 patients evaluated at the University of Michigan from 2004 to 2012 who had a liver biopsy within 6 months of a computed tomography scan for any reason. We used logistic regression with elastic net regularization and cross-validation to develop predictive models for cirrhosis, within 80% randomly selected internal training set. The other 20% data were used as internal test set to ensure that model overfitting did not occur. In validation studies, we tested the performance of our models on an external cohort of patients from a different health system. RESULTS: Our predictive models, which were based on analytic morphomics and demographics (morphomics model) or analytic morphomics, demographics, and laboratory studies (full model), identified patients with cirrhosis with area under the receiver operating characteristic curve (AUROC) values of 0.91 and 0.90, respectively, compared with 0.69, 0.77, and 0.76 for aspartate aminotransferase-to-platelet ratio, Lok Score, and FIB-4, respectively, by using the same data set. In the validation set, our morphomics model identified patients who developed cirrhosis with AUROC value of 0.97, and the full model identified them with AUROC value of 0.90. CONCLUSIONS: We used analytic morphomics to demonstrate that cirrhosis can be objectively quantified by using medical imaging. In a retrospective analysis of multi-protocol scans, we found that it is possible to identify patients who have cirrhosis on the basis of analyses of preexisting scans, without significant additional risk or cost.

Contemporary outcomes with percutaneous vascular interventions for peripheral critical limb ischemia in those with and without poly-vascular disease.

Given the very ill nature of patients with critical limb ischemia (CLI), the use of percutaneous vascular interventions (PVIs) for limb salvage may or may not be efficacious; in particular, for those with polyvascular arterial disease. Herein, we reviewed large, multi-institutional outcomes of PVI in polyvascular and peripheral arterial disease (PAD) patients with CLI. An 18-hospital consortium collected prospective data on patients undergoing endovascular interventions for PAD with 6-month follow-up from January 2008 to December 2011. The patient cohort included 4459 patients with CLI; of those, 3141 patients had polyvascular (coronary artery disease, cerebrovascular disease and PAD) disease, whereas 1318 patients suffered from only PAD. All patients were elderly and with significant comorbidities. The mean ankle-brachial index (ABI) was 0.44 and was not different between those with and without polyvascular disease. Polyvascular patients had more femoropopliteal and infra-inguinal interventions and less aortoiliac interventions than PAD patients. Pre- and post-procedural cardioprotective medication use was less in the PAD patients as compared with polyvascular patients. Vascular complications requiring surgery were higher in PAD patients whereas other access complications were similar between groups. At 6-month follow-up, death was more common in the polyvascular group (6.7% vs 4.1%, p<0.001) as was repeat PVI, but no difference was found in the amputation rate. Considering the group as a whole at the 6-month follow-up, predictors of amputation/death included age (HR=1.01; 95% CI=1.002-1.02), anemia (HR=2.6; 95% CI=2.1-3.2), diabetes mellitus (HR=1.6; 95% CI=1.3-1.9), congestive heart failure (HR=1.6; 95% CI=1.4-1.9), and end-stage renal failure (HR=1.9; 95% CI=1.5-2.3), while female sex was protective (HR=0.7; 95% CI=0.6-0.8). In conclusion, from examination of this large, multicenter, multi-specialist practice registry, patients with polyvascular disease had higher 6-month mortality than PAD patients, but this was not a factor in 6-month limb amputation outcomes. This study also underscores that PAD patients still lag in cardioprotective medication use as compared with polyvascular patients.

Predictors of mortality in patients with hepatocellular carcinoma undergoing transarterial chemoembolization.

BACKGROUND/AIM: Transarterial chemoembolization (TACE) is the recommended treatment for patients with Barcelona stage B hepatocellular carcinoma; however, community practice varies from these American Association for the Study of Liver Diseases guidelines. In this study, we sought to assess factors determining outcome after TACE and examine adherence to guidelines. METHODS: From January 2006 to December 2012, 308 patients with newly diagnosed HCC were treated at the Veterans Affairs (VA) Ann Arbor Healthcare System. Of these, 109 patients underwent TACE. The primary outcome measured mortality. Kaplan-Meier analysis was used to determine the cumulative probability of death. Cox regression was used to assess the predictors of mortality. RESULTS: The median age of the 109 patients was 60 years (48-90), 97 % were males and 82 % had chronic HCV infection. The median size of the largest lesion was 4 cm, 51 % were multifocal, and portal vein thrombosis was present in 3.6 %. Sixty-two patients died after median 333 days from the index TACE treatment. Median overall survival from index TACE was 11.2 months. Unadjusted 1-, 2-, and 3-year survival was 64, 35, and 24 %, respectively. CTP score (B vs. A: HR 2.51, p = 0.002; C vs. A: HR 7.96, p < 0.0001) and presence of complete response to TACE (HR 0.51, p = 0.004) were independent predictors of mortality. Barcelona stage (p = 0.88) and performance status as measured by ECOG (p = 0.98) were not associated with mortality after TACE. CONCLUSIONS: In this community based, single VA center study, we found a significant number of patients beyond Barcelona stage B were treated with TACE. Advanced TNM stage, poor liver synthetic function and achieving CR with TACE were better predictors of mortality than guideline-directed decisions based on Barcelona stage. These factors may be useful to guide future patient selection for TACE.

Best practices consensus protocol for peritoneal dialysis catheter placement by interventional radiologists.

Peritoneal dialysis (PD) catheters can be placed by interventional radiologists, an approach that might offer scheduling efficiencies, cost-effectiveness, and a minimally invasive procedure. In the United States, changes in the dialysis reimbursement structure by the Centers for Medicare and Medicaid Services are expected to result in the increased use of PD, a less costly dialysis modality that offers patients the opportunity to receive dialysis in the home setting and to have more independence for travel and work schedules, and that preserves vascular access for future dialysis options. Placement of PD catheters by interventional radiologists might therefore be increasingly requested by nephrology practices, given that recent publications have demonstrated the favorable impact on PD practices of an interventional radiology PD placement capability. Earlier reports of interventional radiology PD catheter placement came from single-center practices with smaller reported experiences. The need for a larger consensus document that attempts to establish best demonstrated practices for radiologists is evident. The radiologists submitting this consensus document represent a combined experience of more than 1000 PD catheter placements. The authors submit these consensus-proposed best demonstrated practices for placement of PD catheters by interventional radiologists under ultrasonographic and fluoroscopic guidance. This technique might allow for expeditious placement of permanent PD catheters in late-referred patients with end-stage renal disease, thus facilitating urgent-start PD and avoiding the need for temporary vascular access catheters.

Immobilization of actively thromboresistant assemblies on sterile blood-contacting surfaces.

Rapid one-step modification of thrombomodulin with alkylamine derivatives such as azide, biotin, and PEG is achieved using an evolved sortase (eSrtA) mutant. The feasibility of a point-of-care scheme is demonstrated herein to site-specifically immobilize azido-thrombomodulin on sterilized commercial ePTFE vascular grafts, which exhibit superior thromboresistance compared with commercial heparin-coated grafts in a primate model of acute graft thrombosis.

Phenyltins in surface sediments of the Visakhapatnam harbour, India.

Twenty-two surface sediment samples were collected from Visakhapatnam harbour, east coast of India, and analysed for monophenyltin (MPT), diphenyltin (DPT), triphenyltin (TPT), total bacteria, and TPT tolerant bacteria. Concentrations of MPT, DPT and TPT varied between 1-26, 3-28, and 0.31-145 ng Sn g(-1) dry wt, respectively. Phenyltin concentrations were influenced by ship related activities, agricultural waste and sewage. These phenyltin concentrations indicate sediments are contaminated. Abundance of TPT tolerant bacteria was strongly influenced by the levels of phenyltins.

Development of a quantitative method for the diagnosis of cirrhosis.

OBJECTIVE: To develop a novel non-invasive, quantitative approach utilizing computed tomography scans to predict cirrhosis. MATERIALS AND METHODS: A total of 105 patients (54 cirrhosis and 51 normal) who had CT scans within 6 months of a liver biopsy or were identified through a Trauma registry were included in this study. Patients were randomly divided into the training set (n = 81) and the validation set (n = 24). Each liver was segmented in a semi-automated fashion from a computed tomography scan using Mimics software. The resulting liver surfaces were saved as a stereo lithography mesh into an Oracle database, and analyzed in MATLAB(®) for morphological markers of cirrhosis. RESULTS: The best predictive model for diagnosing cirrhosis consisted of liver slice-bounding box slice ratio, the dimensions of the liver bounding box, liver slice area, slice perimeter, surface volume and adjusted surface area. With this model, we calculated an area under the receiver operating characteristic curve of 0.90 for the training set, and 0.91 for the validation set. For comparison, we calculated an area under the receiver operating characteristic curve of 0.70 for our dataset when we used the lab value based aspartate aminotransferase-platelet ratio index, another reported model for predicting cirrhosis. Last, by combining the aspartate aminotransferase-platelet ratio index and our model, we obtained an area under the receiving operating characteristic of 0.95. CONCLUSION: This study shows "proof of concept" that quantitative image analysis of livers on computed tomography scans may be utilized to predict cirrhosis in the absence of a liver biopsy.

A contemporary comparison of aortofemoral bypass and aortoiliac stenting in the treatment of aortoiliac occlusive disease.

BACKGROUND: Although aortofemoral bypass (AFB) has historically been the treatment of choice for aortoiliac occlusive disease (AIOD), rates of AFB have declined, while utilization of aortoiliac angioplasty and stenting (AS) has increased dramatically. The objective of the current study was to determine the effect of these trends on treatment outcomes in a contemporary single-institution experience with AIOD. METHODS: Between 1997 and 2007, 118 AFB and 174 AS procedures were performed in 161 men (55.1%) and 131 women at a single university teaching hospital. Patient outcomes were retrospectively reviewed and analyses were performed using chi-squared/Fisher's exact test and ANOVA. Ankle-brachial index (ABI) interactions between procedure type and Trans-Atlantic Inter-Society Consensus (TASC) category were calculated using a General Linear Model. A reduced Cox model was used to determine the impact of patency, presenting symptoms, duplex surveillance, and procedure type on amputations and revisions. Kaplan-Meier estimates for survival, freedom from amputation, and freedom from revision were used to evaluate long-term outcomes. RESULTS: There was no difference between AFB and AS groups with respect to 30-day mortality (0.8% and 1.1%, p=0.64), myocardial infarction (1.7% and 1.1%, p=0.53), cerebrovascular accident (0.0% and 1.1%, p=0.35), or renal failure requiring hemodialysis (3.4% and 1.2%, p=0.19). AFB was associated with increased surgical complication rates including the need for emergency surgery (6.8% and 1.7%, p=0.029), infection/sepsis (16.1% and 2.3%, p<0.001), transfusion (16.1% and 5.7%, p=0.004), and lymph leak (8.5% and 0.6%, p=0.001). The difference between preprocedural and postprocedural ABI was greater for AFB than AS (R, 0.39 and 0.18, p<0.001; L, 0.41 and 0.15, p<0.001). This difference was maintained when patients were stratified by TASC category. CONCLUSION: There were no differences between the AFB and AS groups with respect to long-term rates of mortality, amputation, or revision procedures. AFB continues to be performed safely, despite the case numbers in this series correlating with a lower-volume hospital. Morbidities associated with major open surgery in this series were counterbalanced by greater improvements in ABI. Patients and practitioners should continue to entertain both procedure types as viable alternatives for the treatment of AIOD.

Changes in the abundance and composition of zooplankton from the ports of Mumbai, India.

Zooplankton abundance, biomass, and composition from the ports of Mumbai, India, were studied by selecting 14 stations in and around the area during three different periods between 2001 and 2002 (Nov 01, Apr 02, and Oct 02). The results are compared with the records available since the 1940s. Copepod species such as Canthocalanus sp., Paracalanus arabiensis, Cosmocalanus sp., Euterpina acutifrons, Nannocalanus minor, and Tortanus sp. which were not reported in the earlier studies were observed during the present investigation. Purely herbivorous forms like Nannocalanus minor, Paracalanus sp., and Temora discaudata were in reduced abundance during Apr 02 sampling which was coupled with reduction in the diatom population. Whereas increased abundance of some carnivorous and omnivorous forms during Apr 02 sampling can be related to the changes in the food web dynamics.

Aripiprazole treatment of Asperger's syndrome in the acute psychiatric setting: case report.

Asperger's syndrome (AS) is under-recognized and may be misdiagnosed as schizophrenia in adults because of symptom overlap. Pharmacological treatment usually targets associated behavioral and mental symptoms rather than the actual core features of AS. We report a middle-aged male patient who, after many years of previous contact with mental health services, and on account of his psychotic symptoms and diagnosis of schizophrenia, was admitted to an inner-city acute psychiatric unit, where a primary diagnosis of AS was established for the first time in his life. His impairing clinical features of AS improved markedly following treatment using aripiprazole, a novel atypical antipsychotic that acts as a partial agonist at dopamine D(2) receptors. As well as sharing clinical features, there is an overlap in underlying neurobiology of AS and schizophrenia, including dopamine dysfunction, that provides a rationale for using antipsychotics of this class in the clinical management not only of associated psychotic symptoms but also of the core features of AS itself.

Butyltins in the sediments of Kochi and Mumbai harbours, west coast of India.

Surface sediment samples were collected from various locations in the Mumbai and Kochi harbours, west coast of India, to assess the presence of butyltin compounds. Tributyltin (TBT) and dibutyltin (DBT) varied from 16 to 16,816 ng/g dry wt. and from undetected to 469 ng/g dry wt., respectively, of the sediment in Kochi harbour. In Mumbai harbour, the values of TBT and DBT ranged between 4.5 and 1193 ng/g dry wt. and from undetected to 131 ng/g dry wt. of the sediments, respectively. The concentrations of both TBT and DBT showed strong seasonal variation probably due to the effect of tides and currents. Nevertheless, the levels of butyltin compounds were generally higher at sites influenced by shipping activities such as navigation, dry dock and ship-building activities. The presence of DBT indicates the abiotic or microbiological degradation of TBT. Compared to TBT, DBT was relatively less abundant, suggesting either fresh inputs of TBT and/or less degradation of TBT. The concentrations of TBT showed significant positive relationships with organic carbon and lipid, implying that both lipophilic and ionic interactions were probably involved in controlling the abundance of TBT at these sediments. The observed levels of butyltin compounds are much higher than those required to induce toxic effects on marine organisms, suggesting that these sediments were contaminated with butyltin compounds.