Risk stratification of patients with nonalcoholic fatty liver disease using a case identification pathway in primary care: a cross-sectional study.

BACKGROUND: Identification of patients with nonalcoholic fatty liver disease (NAFLD) with advanced liver fibrosis in primary care remains an unmet need. Our primary objective was to implement a pathway driven by shear wave elastography (SWE) to facilitate risk stratification of patients with NAFLD within primary care and evaluate whether SWE assessment can reduce referrals of patients with NAFLD at low risk for fibrosis to hepatology. METHODS: A multidisciplinary NAFLD clinical care pathway was codeveloped by hepatologists, radiologists and primary care physicians in Calgary to provide access to SWE-based screening of patients with NAFLD risk factors in primary care. The study outcome measures were estimated NAFLD-related referrals to the hepatology service in Calgary after implementation of the NAFLD pathway and characteristics of patients with NAFLD at risk for advanced fibrosis. The NAFLD pathway was implemented in January 2018 and was made available to all primary care physicians in the Calgary Health Zone. Patients with NAFLD who had liver stiffness (SWE value ≥ 8.0 kPa) or an inconclusive assessment were referred to hepatology. A serum liver fibrosis score was also measured with the fibrosis-4 (FIB-4) index, and performance of an FIB-4 index score of 1.30 or greater to risk stratify patients with NAFLD was evaluated. Demographic, clinical and laboratory characteristics of study groups were compared. RESULTS: Between March and October 2018, 2084 patients with suspected NAFLD were evaluated. Nonalcoholic fatty liver disease was confirmed by ultrasonography in 1958 (94.1%). A majority of the cohort had elevated liver enzyme values (1028 [52.5%]) and obesity (body mass index ≥ 30) (1063/1764 [60.3%]). Most patients with NAFLD (1791 [91.5%]) had an SWE value less than 8.0 kPa and were not referred to hepatology. Sixty-seven patients (3.4%) had an SWE value of 8.0 kPa or more, and 100 (5.1%) had an inconclusive SWE; these patients were referred to hepatology. Using an FIB-4 index score cut-off of 1.30 would have led to hepatology referral of 396/1251 patients (31.6%). INTERPRETATION: Implementation of a primary care-accessible SWE pathway for patients with NAFLD facilitated fibrosis risk stratification and greatly reduced hepatology referrals. Using the FIB-4 index score alone would led to higher rates of referral of patients with NAFLD.

Anaerobic growth of Bacillus subtilis alters the spectrum of spontaneous mutations in the rpoB gene leading to rifampicin resistance.

Spontaneous rifampicin-resistant (RFM(R)) mutants were isolated from Bacillus subtilis 168 cultivated in the presence or absence of oxygen. By DNA sequencing, the mutations were located within Cluster I of the rpoB gene encoding the ß subunit of RNA polymerase. The spectrum of RFM(R) rpoB mutations isolated from B. subtilis cells grown anaerobically differed from aerobically grown cells, not only with respect to the location of mutations within Cluster I but also in the class of mutation observed (transition versus transversion). In the absence of RFM, RFM(R) mutants exhibited poorer growth under anaerobic conditions than did the wild-type strain, indicating their lower fitness in the absence of antibiotic selection.

Reliability and predictability of the centre-edge angle in the assessment of pincer femoroacetabular impingement.

PURPOSE: The aim of the study was to assess the use of the centre-edge (CE) angle in the assessment of pincer femoro-acetabular impingement (FAI) for reliability and predictability in the diagnosis. METHODS: Between 2004 and 2008, 55 patients underwent surgical treatment for FAI. A control group of 30 was identified among patients attending the emergency department with normal radiographs. Radiographs were assessed by two independent observers both before and after the operation. Nine patients with trauma were excluded. The magnetic resonance arthrogram reports of the remaining 46 patients were assessed for pincer FAI. Nineteen patients were identified and underwent repeat radiographic assessment. All underwent surgical dislocation of hip (SDH), acetabular, with/without femoral osteochondroplasty. Acetabular depth and version were also assessed. The intraclass correlation (ICC) was used to assess reliability of the CE angle. The paired t test and independent groups t test were used to assess the difference between the pincer FAI group, both pre-op and post-op and against controls. RESULTS: The control and pincer groups were similar in demographics (p=0.1769). Coxa profunda was present in 14 patients with eight also having retroverted acetabuli. Of the rest two had retroverted acetabuli and one protrusio. The mean CE angle in the control group was 31.4°, in the pre-op pincer group 46.2° and in the post-op pincer group 38.3°. The ICC for intra-observer correlation was 0.977 and 0.992 pre-op and 0.986 and 0.974 post-op. The ICC for inter-observer correlation was 0.960 and 0.957 pre-op and 0.979 and 0.967 post-op.The p value was <0.001 between the controls, the pre-op and post-op pincer groups. The test characteristics using the CE angle ≥ 40 is a reasonably good predictor of FAI, with a sensitivity of 84.2% and a specificity of 100%. CONCLUSIONS: The pincer FAI can be reliably assessed with the CE angle and can be predicted in patients presenting with FAI.

Validation of the spondyloarthritis research consortium of Canada magnetic resonance imaging spinal inflammation index: is it necessary to score the entire spine?

OBJECTIVE: The Spondyloarthritis Research Consortium of Canada (SPARCC) magnetic resonance imaging (MRI) spinal inflammation index has been developed to objectively measure inflammation in ankylosing spondylitis (AS) and to assess change in response to therapeutic intervention. Scoring of the entire spine limits feasibility and a scoring method that records inflammation in only the more severely affected spinal segments may improve feasibility without sacrificing performance. METHODS: MRI films of 68 patients with AS were assessed in random order by 2 blinded readers. Interreader reliability was assessed by intraclass correlation coefficient. Pre- and posttreatment MRI films of 29 patients randomized to placebo or anti-tumor necrosis factor alpha (anti-TNFalpha) therapy were read by readers blinded to chronology, and responsiveness was assessed by effect size and standardized response mean. The performance of scores based on 6, 8, 10, and all 23 spinal discovertebral units (DVU) was compared. RESULTS: The median number of affected spinal levels per patient was 6.0 and 62% of all affected levels were included when analysis was limited to only the 6 most severely affected levels per patient. Comparison of DVU scores that were limited to only the more severely affected DVU (6-, 8-, 10-DVU score) with scores for all 23 spinal DVU showed excellent interreader reliability for status and change scores (Spearman's correlation >0.90) as well as similar construct validity. Responsiveness to anti-TNFalpha therapy was greater when the more limited scoring methods were used and was greatest with the 6-DVU score. CONCLUSION: The SPARCC MRI spinal inflammation index performs better when analysis is limited to a maximum of 6 most severely affected levels compared with assessment of the entire spine. This should improve its feasibility in clinical trials and research.

Intraocular pressure in patients with human immunodeficiency virus and treated with highly active antiretroviral therapy.

PURPOSE: To compare the intraocular pressure (IOP) of patients infected with human immunodeficiency virus (HIV) and treated with highly active antiretroviral therapy (HAART) to a control group and to determine whether HAART reverses the previously reported reduction in IOP associated with HIV infection. DESIGN: Retrospective case control study. METHODS: Review of patients with HIV infection on HAART compared with a matched control group. RESULTS: Among 64 patients and 56 control subjects, no significant difference in IOP was found (P =.520), nor was correlation noted between IOP and either CD4+ T-lymphocyte counts, or viral load. CONCLUSION: When HIV infection is treated with HAART, IOP is not significantly different from that of control subjects.