Evolution of liver fibrosis in diabetic patients with NAFLD in a follow-up study: Hepatoprotective effects of sodium-glucose co-transporter-2 inhibitors.

BACKGROUND AND AIMS: Patients with non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus (T2DM) are at high risk of hepatic fibrosis. To prospectively evaluate changes in fibrosis in diabetic patients with NAFLD, predisposing factors and sodium glucose cotransporter 2 inhibitors (SGLT2i) influence. METHODS: 237 T2DM outpatients (mean age 67 ± 9 years, 54% male) were enrolled and re-evaluated after 52 ± 10 months. At baseline and follow-up NAFLD and liver fibrosis (LSM) were detected by ultrasonography and Fibroscan®. RESULTS: During follow-up an increase in LSM (6.0 ± 2.8 vs 5.8 ± 2.7 kPa, p = 0.02) and in the prescription of SGLT2i (20% vs 6%, p<0.001) was registered, despite stability of diabetic control. LSM worsened in 133(56%) subjects, 92 (39%) with worsening >10% from baseline. Patients with worsening versus non worsening of LSM had higher prevalence of increase in BMI during follow-up (45% vs 32%, p = 0.06) and lower SGLT2i prescription (15% vs 27%, p = 0.034). In multivariate analysis use of SGLT2-inhibitors at follow-up reduced the risk of LSM worsening (HR 0.34, 95% CI 0.13-0.88), even when considered>10% from baseline. CONCLUSIONS: A high prevalence of fibrosis progression was observed in diabetic subjects with NAFLD over a nearly 5-years follow up and SGLT2-inhibitors seem to reduce the risk of worsening of liver stiffness.

Comparison of the severity of metabolic, liver and cardiovascular damage in NAFLD patients attending the hepatology clinic over the last three decades.

BACKGROUND AND AIMS: NAFLD prevalence is increasing worldwide. AIM: to assess whether severity of hepatic, metabolic and cardiovascular (CV) disease changed over time. METHODS: 422 NAFLD patients (388 biopsy proven and 34 clinical cirrhosis) diagnosed between 1990 and 2021 and subdivided according to decade of presentation. Metabolic parameters, early atherosclerosis (carotid plaques at Doppler ultrasound), severity of liver damage (NAS score, NASH, significant fibrosis (≥2) and cirrhosis) and PNPLA3 genotyping were assessed. RESULTS: No difference in age, sex and prevalence of dyslipidemia and hypertension was found across decades (p for trend), whereas a higher prevalence of diabetes (p = 0.02), obesity (p<0.001), histological severe steatosis (p<0.001), NASH (p<0.001), fibrosis ≥2 (p<0.001), cirrhosis (p<0.001) and carotid plaques (p = 0.05) was observed in the last decade compared to the others. A higher prevalence of PNPLA3 GG polymorphism was found over time (p = 0.02). In the whole cohort, age, metabolic alterations and PNPLA3 G homozygosity were independent risk factors for hepatic fibrosis and carotid plaques, independently of the decade considered. CONCLUSION: Over the past 10 years compared to previous decades, NAFLD patients presented to observation with more severe liver disease and subclinical atherosclerosis, paralleling the spread of diabetes and obesity. PNPLA3 unfavorable genotype became more prevalent over time.

Translumbar type II endoleak embolization with a new liquid iodinated polyvinyl alcohol polymer: Case series and review of current literature.

Purpose: To describe our experience with the use of a novel iodized Polyvinyl Alcohol Polymer liquid agent (Easyx) in type II endoleak treatment with translumbar approach. Methods: Our case series is a retrospective review of patients with type II endoleak (T2E) treated with Easyx from December 2017 to December 2020. Indication for treatment was a persistent T2E with an increasing aneurysm sac ≥5 mm on computed tomography angiography (CTA) over a 6-month interval. Technical success was defined as the embolization of the endoleak nidus with reduction or elimination of the T2E on sequent CTA evaluation. Clinical success was defined as an unchanged or decreased aneurysm sac on follow-up CTA. Secondary endpoints included the presence of artifacts in the postprocedural cross-sectional tomographic imaging and post and intraprocedural complications. Results: Ten patients were included in our retrospective analysis. All T2E were successfully embolized. Clinical success was achieved in 9 out of 10 patients (90%). The mean follow-up was 14 3-20 months. No beam hardening artifact was observed in follow-up CT providing unaltered imaging. Conclusion: Easyx is a novel liquid embolic agent with lava-like characteristics and unaltered visibility on subsequent CT examinations. In our initial experience, Easyx showed to have all the efficacy requisites to be an embolization agent for type II EL management. Its efficacy, however, should be evaluated in more extensive studies and eventually compared with other agents.

Interaction between Lifestyle Changes and PNPLA3 Genotype in NAFLD Patients during the COVID-19 Lockdown.

The coronavirus disease 2019 (COVID-19) lockdown dramatically changed people's lifestyles. Diet, physical activity, and the PNPLA3 gene are known risk factors for non-alcoholic fatty liver disease (NAFLD). Aim: To evaluate changes in metabolic and hepatic disease in NAFLD patients after the COVID-19 lockdown. Three hundred and fifty seven NAFLD patients were enrolled, all previously instructed to follow a Mediterranean diet (MD). Anthropometric, metabolic, and laboratory data were collected before the COVID-19 lockdown in Italy and 6 months apart, along with ultrasound (US) steatosis grading and information about adherence to MD and physical activity (PA). In 188 patients, PNPLA3 genotyping was performed. After the lockdown, 48% of patients gained weight, while 16% had a worsened steatosis grade. Weight gain was associated with poor adherence to MD (p = 0.005), reduced PA (p = 0.03), and increased prevalence of PNPLA3 GG (p = 0.04). At multivariate analysis (corrected for age, sex, MD, PA, and PNPLA3 GG), only PNPLA3 remained independently associated with weight gain (p = 0.04), which was also associated with worsened glycemia (p = 0.002) and transaminases (p = 0.02). During lockdown, due to a dramatic change in lifestyles, half of our cohort of NAFLD patients gained weight, with a worsening of metabolic and hepatologic features. Interestingly, the PNPLA3 GG genotype nullified the effect of lifestyle and emerged as an independent risk factor for weight gain, opening new perspectives in NAFLD patient care.

Radioembolization of Hepatocellular Carcinoma with 90Y Glass Microspheres: No Advantage of Voxel Dosimetry with Respect to Mean Dose in Dose-Response Analysis with Two Radiological Methods.

In this confirmatory study, we tested if a calculation that included the non-uniformity of dose deposition through a voxel-based dosimetric variable Ψ was able to improve the dose-response agreement with respect to the mean absorbed dose D. We performed dosimetry with 99mTc-MAA SPECT/CT and 90Y-PET/CT in 86 patients treated 8 instead of 4 days after the reference date with 2.8 times more 90Y glass microspheres/GBq than in our previous study. The lesion-by-lesion response was assessed with the mRECIST method and with an experimental densitometric criterion. A total of 106 lesions were studied. Considering Ψ as a prognostic response marker, having no Ψ provided a significantly higher AUC than D. The correlation, t-test, and AUC values were statistically significant only with the densitometric method and only with post-therapy dosimetry. In comparison with our previous study, the dose-response correlation and AUC values were poorer (maximum r = 0.43, R2 = 0.14, maximal AUC = 0.71), and the efficacy at a high dose did not reach 100%. The expected advantages of voxel dosimetry were nullified by the correlation between any Ψ and D due to the limited image spatial resolution. The lower AUC and efficacy may be explained by the mega-clustering effect triggered by the higher number of microspheres/GBq injected on day 8.

Comparison of admission chest computed tomography and lung ultrasound performance for diagnosis of COVID-19 pneumonia in populations with different disease prevalence.

PURPOSE: Chest computed tomography (CT) is considered a reliable imaging tool for COVID-19 pneumonia diagnosis, while lung ultrasound (LUS) has emerged as a potential alternative to characterize lung involvement. The aim of the study was to compare diagnostic performance of admission chest CT and LUS for the diagnosis of COVID-19. METHODS: We included patients admitted to emergency department between February 21-March 6, 2020 (high prevalence group, HP) and between March 30-April 13, 2020 (moderate prevalence group, MP) undergoing LUS and chest CT within 12 h. Chest CT was considered positive in case of "indeterminate"/"typical" pattern for COVID-19 by RSNA classification system. At LUS, thickened pleural line with ≥ three B-lines at least in one zone of the 12 explored was considered positive. Sensitivity, specificity, PPV, NPV, and AUC were calculated for CT and LUS against real-time reverse transcriptase polymerase chain reaction (RT-PCR) and serology as reference standard. RESULTS: The study included 486 patients (males 61 %; median age, 70 years): 247 patients in HP (COVID-19 prevalence 94 %) and 239 patients in MP (COVID-19 prevalence 45 %). In HP and MP respectively, sensitivity, specificity, PPV, and NPV were 90-95 %, 43-69 %, 96-72 %, 20-95 % for CT and 94-93 %, 7-31 %, 94-52 %, 7-83 % for LUS. CT demonstrated better performance than LUS in diagnosis of COVID-19, both in HP (AUC 0.75 vs 0.51; P < 0.001) and MP (AUC 0.85 vs 0.62; P < 0.001). CONCLUSIONS: Admission chest CT shows better performance than LUS for COVID-19 diagnosis, at varying disease prevalence. LUS is highly sensitive, but not specific for COVID-19.

Qualitative and quantitative chest CT parameters as predictors of specific mortality in COVID-19 patients.

PURPOSE: To test the association between death and both qualitative and quantitative CT parameters obtained visually and by software in coronavirus disease (COVID-19) early outbreak. METHODS: The study analyzed retrospectively patients underwent chest CT at hospital admission for COVID-19 pneumonia suspicion, between February 21 and March 6, 2020. CT was performed in case of hypoxemia or moderate-to-severe dyspnea. CT scans were analyzed for quantitative and qualitative features obtained visually and by software. Cox proportional hazards regression analysis examined the association between variables and overall survival (OS). Three models were built for stratification of mortality risk: clinical, clinical/visual CT evaluation, and clinical/software-based CT assessment. AUC for each model was used to assess performance in predicting death. RESULTS: The study included 248 patients (70% males, median age 68 years). Death occurred in 78/248 (32%) patients. Visual pneumonia extent > 40% (HR 2.15, 95% CI 1.2-3.85, P = 0.01), %high attenuation area - 700 HU > 35% (HR 2.17, 95% CI 1.2-3.94, P = 0.01), exudative consolidations (HR 2.85-2.93, 95% CI 1.61-5.05/1.66-5.16, P < 0.001), visual CAC score > 1 (HR 2.76-3.32, 95% CI 1.4-5.45/1.71-6.46, P < 0.01/P < 0.001), and CT classified as COVID-19 and other disease (HR 1.92-2.03, 95% CI 1.01-3.67/1.06-3.9, P = 0.04/P = 0.03) were significantly associated with shorter OS. Models including CT parameters (AUC 0.911-0.913, 95% CI 0.873-0.95/0.875-0.952) were better predictors of death as compared to clinical model (AUC 0.869, 95% CI 0.816-0.922; P = 0.04 for both models). CONCLUSIONS: In COVID-19 patients, qualitative and quantitative chest CT parameters obtained visually or by software are predictors of mortality. Predictive models including CT metrics were better predictors of death in comparison to clinical model.

NAFLD fibrosis score (NFS) can be used in outpatient services to identify chronic vascular complications besides advanced liver fibrosis in type 2 diabetes.

We demonstrate in 351 diabetic patients with steatosis that NAFLD fibrosis score (NFS), a rapid and affordable score to diagnose hepatic fibrosis, identifies patients at higher risk of advanced fibrosis and vascular diabetic complications (especially peripheral neuropathy), pointing NFS as a first-line vascular and hepatic screening in diabetic patients.

Well-aerated Lung on Admitting Chest CT to Predict Adverse Outcome in COVID-19 Pneumonia.

Background CT of patients with severe acute respiratory syndrome coronavirus 2 disease depicts the extent of lung involvement in coronavirus disease 2019 (COVID-19) pneumonia. Purpose To determine the value of quantification of the well-aerated lung (WAL) obtained at admission chest CT to determine prognosis in patients with COVID-19 pneumonia. Materials and Methods Imaging of patients admitted at the emergency department between February 17 and March 10, 2020 who underwent chest CT were retrospectively analyzed. Patients with negative results of reverse-transcription polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 at nasal-pharyngeal swabbing, negative chest CT findings, and incomplete clinical data were excluded. CT images were analyzed for quantification of WAL visually (%V-WAL), with open-source software (%S-WAL), and with absolute volume (VOL-WAL). Clinical parameters included patient characteristics, comorbidities, symptom type and duration, oxygen saturation, and laboratory values. Logistic regression was used to evaluate the relationship between clinical parameters and CT metrics versus patient outcome (intensive care unit [ICU] admission or death vs no ICU admission or death). The area under the receiver operating characteristic curve (AUC) was calculated to determine model performance. Results The study included 236 patients (59 of 123 [25%] were female; median age, 68 years). A %V-WAL less than 73% (odds ratio [OR], 5.4; 95% confidence interval [CI]: 2.7, 10.8; P < .001), %S-WAL less than 71% (OR, 3.8; 95% CI: 1.9, 7.5; P < .001), and VOL-WAL less than 2.9 L (OR, 2.6; 95% CI: 1.2, 5.8; P < .01) were predictors of ICU admission or death. In comparison with clinical models containing only clinical parameters (AUC = 0.83), all three quantitative models showed better diagnostic performance (AUC = 0.86 for all models). The models containing %V-WAL less than 73% and VOL-WAL less than 2.9 L were superior in terms of performance as compared with the models containing only clinical parameters (P = .04 for both models). Conclusion In patients with confirmed coronavirus disease 2019 pneumonia, visual or software quantification of the extent of CT lung abnormality were predictors of intensive care unit admission or death. © RSNA, 2020 Online supplemental material is available for this article.

Liver fibrosis by FibroScan® independently of established cardiovascular risk parameters associates with macrovascular and microvascular complications in patients with type 2 diabetes.

BACKGROUND & AIMS: Non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus (T2DM) are closely associated, and liver fibrosis has been related to macrovascular complications. We examined whether liver fibrosis, diagnosed by FibroScan® , correlates with chronic vascular complications in a cohort of T2DM. METHODS: We recruited 394 outpatients with T2DM attending five Italian diabetes centres who underwent liver ultrasonography (US), FibroScan® and extensive evaluation of macrovascular and microvascular diabetic complications. RESULTS: Steatosis by US was present in 89%. Almost all patients (96%) were on hypoglycaemic drugs, 58% had at least one chronic vascular complication, 19% a macrovascular complication (prior myocardial infarction and/or ischaemic stroke) and 33% a microvascular one (26% chronic kidney disease [CKD]; 16% retinopathy; 6% neuropathy). In all, 171 (72%) patients had CAP ≥ 248dB/m (ie hepatic steatosis), whereas 83 (21%) patients had LSM ≥ 7.0/6.2 kPa (M/XL probes) (significant liver fibrosis). CAP was not associated with any macro/microvascular complications, whereas LSM ≥ 7.0/6.2 kPa was independently associated with prior cardiovascular disease (adjusted OR 3.3, 95%CI 1.2-8.8; P = .02) and presence of microvascular complications (adjusted OR 4.2, 95%CI 1.5-11.4; P = .005), mainly CKD (adjusted OR 3.6, 95%CI 1.3-10.1; P = .01) and retinopathy (adjusted OR 3.7, CI 95% 1.2-11.9; P = .02). Neither diabetes duration nor haemoglobin A1c differed according to CAP or LSM values. CONCLUSION: Significant fibrosis, detected by FibroScan® , is independently associated with increased prevalence of macrovascular and microvascular complications, thus opening a new scenario in the use of this tool for a comprehensive evaluation of hepatic and vascular complications in patients with T2DM.

Erratum to "Diagnostic imaging of osteoporosis and sarcopenia: a narrative review".

[This corrects the article DOI: 10.21037/qims.2018.01.01.].

Diagnostic imaging of osteoporosis and sarcopenia: a narrative review.

Osteoporosis and sarcopenia represent two major health problems with an increasing prevalence in the elderly population. The correlation between these diseases has been widely reported, leading to the development of the term "osteosarcopenia" to diagnose those patients suffering from both diseases. Several imaging methods for the diagnosis and management of osteoporosis exist, with dual-energy X-ray absorptiometry (DXA) being the most commonly used for measuring bone mineral density (BMD). Imaging technique other than DXA is represented by conventional radiography, computed tomography (CT) and ultrasound (US). Similarly, the imaging technologies used to detect loss of skeletal muscle mass in sarcopenia include DXA, CT, US and magnetic resonance imaging (MRI). These methods differ in terms of reliability, radiation exposure and costs. CT and MRI represent the gold standard for evaluating body composition (BC), but are costly and time-consuming. DXA remains the most often used technology for studying BC, being quick, widely available and with low radiation exposure.

Scrotal migration of inguinal hernia repair mesh: an unusual cause of testicular mass.

Scrotal masses are common findings in primary care and can develop from all anatomical structures of the scrotum. They are usually painless, although pain may be present occasionally. In this report, we present the case of an unusual testicular mass caused by the migration in the scrotum of a mesh used for inguinal hernia repair. The patient was treated conservatively owing to the spontaneous resolution of symptoms.

Free uroflowmetry versus "Do-It-Yourself" uroflowmetry in the assessment of patients with lower urinary tract symptoms.

INTRODUCTION: We investigated the possibility that patients could carry out a urine flow assessment at home by themselves, in comfort, without expense and without the use of equipment. We compared this strategy of "Do-It-Yourself" (DIY) uroflowmetry with traditional, hospital uroflowmetry. MATERIALS AND METHODS: One hundred and twenty patients were enrolled. The patients underwent conventional, free uroflowmetry in hospital. Subsequently, the patients were asked to carry out the following procedure at home: urinate into a graduated container to quantify the total voided volume and determine the flow time by measuring the duration of miction with a stopwatch or simply with the second hand of a clock. This procedure had to be performed three times without preparation. RESULTS: Hundred patients completed the study. The mean age of the patients analysed was 64.12 years. Their free uroflowmetry values were as follows: the mean voiding time was 44.28 s, the mean voided volume was 290.92 ml, the mean Qmax was 15.17 ml/s, the mean Qmean was 7.87 ml/s, and the mean post-void residual volume was 78.44 ml. The mean Qmean measured by the "DIY-uroflowmetry" was 8.33 ml/s, which was not statistically significantly different (P = 0.12). Assuming that pathological hospital uroflowmetry values are equivalent to a DIY-Qmean ≤10 ml/s and that normal hospital values are equivalent to a DIY-Qmean >10 ml/s, the concordance was 100 %. CONCLUSIONS: Our proposed DIY evaluation of urine flow, together with the International Prostatic Symptom Score (IPSS), provides a good estimate of the results of free uroflowmetry, enabling unnecessary hospital investigations to be avoided.