Significant liver fibrosis, as assessed by fibroscan, is independently associated with chronic vascular complications of type 2 diabetes: A multicenter study.

AIMS: The aim of this study was to investigate whether controlled attenuation parameter (CAP) and liver stiffness measurement (LSM), as assessed by vibration-controlled transient elastography (VCTE), are associated with chronic vascular complications of diabetes mellitus type 2 (T2DM). METHODS: We studied 442 outpatients with established T2DM, and who underwent VCTE and extensive assessment of chronic vascular complications of diabetes. RESULTS: A quarter of analyzed patients had a previous history of myocardial infarction and/or ischemic stroke, and about half of them had at least one microvascular complication (chronic kidney disease (CKD), retinopathy or polyneuropathy). The prevalence of liver steatosis (i.e., CAP ≥ 238 dB/m) and significant liver fibrosis (i.e., LSM ≥ 7.0/6.2 kPa) was 84.2% and 46.6%, respectively. Significant liver fibrosis was associated with an increased likelihood of having myocardial infarction (adjusted-odds ratio 6.61, 95%CI 1.66-37.4), peripheral polyneuropathy (adjusted-OR 4.55, 95%CI 1.25-16.6), CKD (adjusted-OR 4.54, 95%CI 1.24-16.6) or retinopathy (adjusted-OR 1.81, 95%CI 1.62-1.97), independently of cardiometabolic risk factors, diabetes-related variables, and other potential confounders. Liver steatosis was not independently associated with any macro-/microvascular diabetic complications. CONCLUSIONS: Significant liver fibrosis is strongly associated with the presence of macro-/microvascular complications in patients with T2DM. These results offer a new perspective on the follow-up of people with T2DM.

Screening for nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus using transient elastography - a prospective, cross sectional study.

AIM: To investigate the prevalence and severity of nonalcoholic fatty liver disease (NAFLD) in patients with diabetes mellitus type 2 (T2DM), based on increased controlled attenuation parameter (CAP) and liver stiffness measurements obtained by transient elastography. In addition, we aimed to identify parameters that correlate with increased elastographic parameters of steatosis and fibrosis to provide a better indication when a patient with T2DM should be screened for NAFLD. METHODS: We conducted prospective, cross-sectional study of 679 consecutive adult patients with diagnosed T2DM mean age 65.2±11.6. NAFLD was defined by transient elastography. In 105 patients a percutaneous liver biopsy (LB) was done. RESULTS: The prevalence of NAFLD based on transient elastography was 83.6%. Independent factors associated with increased CAP were higher body mass index, longer T2DM duration, higher serum triglyceride, lower levels of vitamin D, higher C-reactive protein, and higher HOMA-IR. The prevalence of moderate liver fibrosis was 26.9% and advanced liver fibrosis 12.6%. Independent factors associated with moderated fibrosis based on elastography were higher body mass index and higher levels of alanine aminotransferase (ALT), while independent factors associated with advanced fibrosis were female gender, higher body mass index, higher levels of ALT, gama-glutamil transferase and C-reactive protein. Sixty-four (60.9%) of 105 patients with LB had NAFLD activity score ≥5. Regarding the presence and stages of fibrosis based on LB, moderate fibrosis was found in 29.5% of patients, while 29.5% had advanced fibrosis and 6.7% cirrhosis. CONCLUSION: This study supports more aggressive screening for NAFLD and fibrosis in patients with T2DM.

Telemedicine in the sleep laboratory: feasibility and economic advantages of polysomnograms transferred online.

The costs for polysomnography (PSG) and alternative diagnostic procedures for sleep-disordered breathing are challenging public health care systems. We wanted to determine if a telemedicine protocol with online transfer of PSGs from a remote site could be cost-effective and clinically useful while improving patient access to full PSG. Fifty-nine PSGs were performed in 54 pulmonary patients with suspected sleep-disordered breathing at a remote hospital. The data were transferred by File Transfer Protocol (FTP) via the Internet to Walter Reed Army Medical Center (WRAMC) for scoring and interpretation. The results were faxed back to the remote hospital. Clinical utility was assessed by evaluating the reasons for patient referral and the resulting diagnoses. The economic benefits were calculated by comparing direct expenses of the telemedicine protocol with costs for contracting PSGs at outside sleep laboratories. A total of 93% (55) of all PSGs were transferred successfully online. Of the 54 patients, 47 had PSGs performed for diagnosis (including three split-night studies), 8 underwent treatment titration, and 1 patient had both overnight studies. Diagnoses were obstructive sleep apnea in 43 patients, central sleep apnea in 2, and upper airway resistance syndrome in 2. The disease conditions were defined as severe in 27 patients, moderate in 12 patients, and mild in 8 patients. Each PSG cost $700 (including costs for lost transmissions) compared to $1,250 for referral to a private sleep laboratory. A savings of $550 per study was realized with the telemedicine protocol. The online transfer of PSGs from a remote site to a centralized sleep laboratory is technically feasible and clinically useful. Telemedicine offers an effective alternative for cost reduction in sleep medicine while improving patient access to specialized care in remote areas.

Overnight pulse oximetry for sleep-disordered breathing in adults: a review.

Pulse oximetry is a well-established tool routinely used in many settings of modern medicine to determine a patient's arterial oxygen saturation and heart rate. The decreasing size of pulse oximeters over recent years has broadened their spectrum of use. For diagnosis and treatment of sleep-disordered breathing, overnight pulse oximetry helps determine the severity of disease and is used as an economical means to detect sleep apnea. In this article, we outline the clinical utility and economical benefit of overnight pulse oximetry in sleep and breathing disorders in adults and highlight the controversies regarding its limitations as presented in published studies.

REM sleep and catecholamine excretion: a study in elite athletes.

We investigated the potential influence of catecholamines on sleep architecture in endurance-trained athletes. The hypothesis was that endogenous levels of aminergic neurotransmitters influence sleep architecture. Thirteen well-trained male street cyclists (all members of the German national amateur team, mean age 23.9 years, mean body mass index 21.9 kg/m2) completed the protocol. Each subject was studied during training after a race competition (C) and later in a recovery/rest period (R) with no training and no competition. Polysomnography (PSG) was performed for one night (C) and for a second night some weeks later (R). Urinary levels of catecholamines collected during the preceding day and over the night of PSG were used as an index of excretion rate of circulating adrenergic agonists. Nighttime and daytime excretion of epinephrine and norepinephrine was significantly elevated after exercise (C vs R; P<0.01). Rapid-eye-movement sleep (REM) onset latency was significantly increased (P=0.03) and REM was significantly decreased in the first half of the night in the training compared to the resting condition (C vs R, P=0.05). REM latency was correlated with increased epinephrine excretion on the day of exercise (C, r=0.63, P=0.02). The temporal appearance of REM during the night appears to be affected in part by the intense exercise associated with race competition, and urinary catecholamines are markers that are correlated with this alteration in REM appearance.

Application of telemedicine to sleep medicine.

Polysomnograms (PSGs) in specialized sleep centers with physicians and technicians trained in sleep medicine are still considered to be the most accurate form of diagnosis in patients with sleep disorders. But they are also very costly. Internet online transfer of PSGs from nonstaffed to very well-staffed sleep centers might be a solution in the future to reduce costs.

The upper airway resistance syndrome masquerading as nocturnal asthma and successfully treated with an oral appliance.

Over the past 10 years, our ability to recognize, treat, and identify the morbidity associated with the upper airway resistance syndrome (UARS) has improved vastly. The diagnosis of this syndrome is dependent on a high degree of clinical suspicion, and in the presence of an already known pulmonary disease such as asthma, the identification of UARS may be elusive. Treatment of this condition has received more recent attention in the literature, with oral appliance therapy as a viable treatment option in place of the usual positive-pressure ventilation devices.

Transtracheal oxygen catheterization with pneumomediastinum and sudden death.

A 69-year-old man with hypoxemic COPD underwent placement of a transtracheal oxygen (TTO) catheter. At 3 months, the catheter tract appeared mature with minimal erythema and no evidence of infection at the catheter site. The patient and his spouse were taught to remove and reinsert the catheter but were told to delay beginning the procedure due to erythema at the stoma site. Despite instructions not to remove the catheter for cleaning, the spouse removed the TTO catheter and attempted to reinsert it using the flexible metal cleaning rod. Subsequently, the patient suffered an acute episode of subcutaneous air and hemodynamic collapse resulting in death. Necropsy revealed a false catheter tract occluded by clotted blood and a defect in the platysma muscle where oxygen had dissected into the mediastinum. The patient died due to pneumomediastinum and cardiac tamponade.

Asymptomatic extralobar sequestration in a 43-year-old woman.

A 43-year-old white woman had an asymptomatic left lower lobe density on a chest roentgenogram. She had a past history of biopsy-proven sarcoidosis in 1984 that resolved without corticosteroids. A midsystolic click was heard on cardiac examination. Computed tomography (CT) revealed an extralobar pulmonary sequestration in the left base. Rapid sequence CT scanning revealed an arterial supply from the thoracic aorta and venous return to the inferior vena cava. A pleural lining and cystic parenchymal changes were also seen. After a discussion of the risks and benefits of surgical resection, the patient elected only clinical follow-up.

Simultaneous presentation of thrombotic thrombocytopenic purpura and systemic lupus erythematosus.

An 18-year-old woman with thrombotic thrombocytopenic purpura (TTP) had recurrent thrombocytopenia due to antiplatelet antibodies associated with systemic lupus erythematosus (SLE). The simultaneous occurrence of TTP and SLE is rare. We briefly summarize eight previously reported cases in which these two diseases have developed in the same patient within a 12-month period. The possibility of a common pathogenesis is discussed.

Comparison of venography, duplex imaging, and bilateral impedance plethysmography for diagnosis of lower extremity deep vein thrombosis.

Twenty-four consecutively hospitalized patients with clinical evidence of lower extremity deep vein thrombosis (DVT) had blinded ipsilateral ultrasonographic duplex imaging (US), contrast venography (VG), and a one-time bilateral impedance plethysmography (IPG) examination. The cases of eight (33%) of the study patients were thought to be complicated due to a prior history of DVT or the presence of ipsilateral inguinal adenopathy. Interpretable test results were obtained for 100% of the US examinations, 88% of the VG studies, and 75% of the IPGs. One additional subject, included in our study for statistical analysis, had an unblinded false-negative US examination; in this case DVT was shown by VG but could not be seen on US despite the radiologist's prior knowledge. The sensitivities, specificities, and 95% confidence intervals for the three studies were as follows: US, 92% (81% to 103%) sensitivity, 100% (99% to 101%) specificity; VG, 100% (99% to 101%) sensitivity, 75% (58% to 96%) specificity; IPG, 50% (30% to 70%) sensitivity, 83% (68% to 98%) specificity. Of the six indeterminate IPG studies, four (67%) occurred in complicated cases. These data suggest that US should be the first-line noninvasive screening study done for evaluation of suspected DVT, especially in complicated cases.

Pleural effusion in patients with systemic cholesterol embolization.

We evaluated two patients with systemic cholesterol embolization (SCE) associated with the development of pleural effusions. These two patients had evidence of atherosclerosis and presented with livedo reticularis, renal insufficiency, and gangrenous cutaneous changes as manifestations of their SCE. In both cases, closed pleural biopsies demonstrated acute inflammation of the parietal pleura. Our experience with these individuals and a review of the medical literature suggest that pleural injury from atheromatous embolization may occur. Physicians caring for patients with SCE should be aware of the possible association of pleural reactions with this process.