Predicting Liver Disease Risk Using a Combination of Common Clinical Markers: A Screening Model from Routine Health Check-Up.

BACKGROUND: Early detection is crucial for the prognosis of patients with autoimmune liver disease (AILD). Due to the relatively low incidence, developing screening tools for AILD remain a challenge. AIMS: To analyze clinical characteristics of AILD patients at initial presentation and identify clinical markers, which could be useful for disease screening and early detection. METHODS: We performed observational retrospective study and analyzed 581 AILD patients who were hospitalized in the gastroenterology department and 1000 healthy controls who were collected from health management center. Baseline characteristics at initial presentation were used to build regression models. The model was validated on an independent cohort of 56 patients with AILD and 100 patients with other liver disorders. RESULTS: Asymptomatic AILD individuals identified by the health check-up are increased yearly (from 31.6% to 68.0%, p < 0.001). The cirrhotic rates at an initial presentation are decreased in the past 18 years (from 52.6% to 20.0%, p < 0.001). Eight indicators, which are common in the health check-up, are independent risk factors of AILD. Among them, abdominal lymph node enlargement (LN) positive is the most significant different (OR 8.85, 95% CI 2.73-28.69, p < 0.001). The combination of these indicators shows high predictive power (AUC = 0.98, sensitivity 89.0% and specificity 96.4%) for disease screening. Except two liver or cholangetic injury makers, the combination of AGE, GENDER, GLB, LN, concomitant extrahepatic autoimmune diseases, and familial history also shows a high predictive power for AILD in other liver disorders (AUC = 0.91). CONCLUSION: Screening for AILD with described parameters can detect AILD in routine health check-up early, effectively and economically. Eight variables in routine health check-up are associated with AILD and the combination of them shows good ability of identifying high-risk individuals.

A multifaceted model for improving the appropriateness of indications for cesarean delivery / Un modelo multifacético para mejorar la adecuación de las indicaciones de cesárea

Background: We evaluated the effectiveness of a multifaceted strategy to improve the appropriateness of the indications for cesarean delivery in 41 hospitals belonging to the Spanish National Health Service. Methods: We implemented indications for emergency and elective cesareans and analyzed their appropriateness prospectively. We provided staff with feedback and training courses and allocated the necessary resources. The results were published. A pre-post design without a control group was used. Results: The total number of deliveries in both periods was 23,711 and 29,627; of these, 5,380 and 6,371, respectively, were cesarean deliveries. The general cesarean rate decreased by 1.19 percentage points, and the overall appropriateness rate increased by 15.45% (95%CI, 13.78-17.13): 8.65% (95%CI, 6.24-11.07) for elective cesarean and 20.15% (95%CI, 17.93-22.36) for emergency cesareans. Appropriateness improved across all 5 indications for emergency cesarean, ranging from 10.87% (95%CI, 6.85-14.89) for fetal distress to 29.97% (95%CI, 24.49-35.45) for cephalopelvic disproportion. Conclusion: This strategy appears to be effective for increasing the appropriateness of the indications for cesarean delivery and reducing the complications and costs associated with the cesarean deliveries avoided

Objetivo: evaluar la efectividad de una estrategia dirigida a mejorar la adecuación de las indicaciones de cesáreas en 41 hospitales del Sistema Nacional de Salud. Métodos: implantación de un protocolo de las indicaciones de cesáreas urgentes y programadas, el análisis prospectivo de su adecuación, retroalimentar a los profesionales, impartir cursos de formación, asignar recursos necesarios y difundir los resultados. Se utilizó un diseño pre-post sin grupo control. Resultados: el número de partos en los periodos pre y post fue 23.711 y 29.627, y el de cesáreas, 5.380 y 6.371, respectivamente. El porcentaje global de cesáreas descendió 1,19, y el de adecuación global aumentó 15,45 (IC 95%: 13,78-17,13); 8,65 (IC 95%: 6,24-11,07) en el conjunto de programadas y, 20,15 (IC 95%:17,93-22,36) en el conjunto de las urgentes. La mejora en la adecuación se observó en las cinco indicaciones de cesáreas urgentes y osciló entre 10,87 (IC 95%: 6,85-14,89) en el grupo de riesgo de pérdida de bienestar fetal y 29,97 (IC 95%: 24,49-35,45) en el de desproporción pelvifetal. Conclusión: esta estrategia parece ser efectiva para aumentar la adecuación de las indicaciones de cesáreas y reducir las complicaciones y los costes asociados con las cesáreas evitadas

Overall and Multiphasic Findings of the Prostate, Lung, Colorectal and Ovarian (PLCO) Randomized Cancer Screening Trial.

BACKGROUND: Screening tests are typically evaluated for a single disease, but multiple tests for multiple diseases are performed in practice. The Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial assessed testing for four cancers simultaneously and can be viewed as a multiphasic cancer intervention. This paper presents overall and multiphasic findings of this trial. METHODS: The PLCO trial was a randomized multi-center trial conducted at ten screening centers in the US. Participants were 76,682 men and 78,215 women ages 55 - 74 and free of the target cancers at trial entry. Screening tests were PSA and digital rectal examination for prostate cancer, chest x-ray for lung cancer, flexible sigmoidoscopy for colorectal cancer, CA125 and transvaginal ultrasound for ovarian cancer. Outcomes and harms of screening were assessed including compliance, test results, incidence, mortality, false positives and overdiagnosis. RESULTS: Screening compliance was 82%, 72,820 (8%) of 906,064 exams were positive, the overall PPV was 4.2% and the cancer detection rate was 3.38/1000. A mortality reduction was observed only for colorectal cancer (RR 0.72, 95% CI 0.61 - 0.85) with no effect on all-cause mortality. Ninety-six percent of positive exams were falsely positive and there was a suggestion of overdiagnosis of prostate and possibly ovarian cancers. Multiphasic testing resulted in 7374 men and 2748 women experiencing multiple false positive results from multiple types of tests. CONCLUSION: Multiphasic cancer screening led to reduced mortality for one target cancer and imposed a burden on the health care system that included substantial false positives and likely overdiagnosis.

Analysis of a Screening System for Diabetic Cardiovascular Autonomic Neuropathy in China.

BACKGROUND The aim of this study was to create a screening system for diabetic cardiovascular autonomic neuropathy (DCAN) in diabetic patients. MATERIAL AND METHODS A Chinese cohort of 455 diabetic participants was recruited between 2011 and 2013. Short-term heart rate variability testing was used to evaluate cardiovascular autonomic function. A simple model was developed using multiple variable regression to include only significant risk factors that were simple and easily assessed. A DCAN score was determined based on the coefficients of the multiple variable model. This score was tested on the entire cohort of 455 diabetic patients and another independent, external cohort of 115 diabetic patients. RESULTS The screening system consisted of age, body mass index, duration of diabetes mellitus, and resting heart rate, and these factors were significantly (P<0.05) associated with DCAN. Receiver operating characteristic (ROC) curve analysis was done. The areas under the ROC curve were 0.798, 0.756, and 0.729 for the total sample, validation cohort, and external set, respectively. A cutoff DCAN score of 12 out of 25 produced optimal results for sensitivity (80.36%), specificity (58.27%), and percentage of patients that needed subsequent testing (43.55%) for the validation set. CONCLUSIONS The study concludes that a simple and practical DCAN screening can be applied for early intervention to delay or prevent the disease in the Chinese population.

Hepatitis C Screening Rate Among Underserved Adults With Serious Mental Illness Receiving Care in California Community Mental Health Centers.

Although HCV is more prevalent among people with severe mental illness (SMI; e.g., schizophrenia, bipolar disorder) than in the general population (17% vs 1%), no large previous studies have examined HCV screening in this population. In this cross-sectional study, we examined administrative data for 57 170 California Medicaid enrollees with SMI to identify prevalence and predictors of HCV screening from October 2010 through September 2011. Only 4.7% (2674 of 57 170) received HCV screening, with strongest predictors being nonpsychiatric health care utilization and comorbid substance abuse.

Poor Collateral Circulation Assessed by Multiphase Computed Tomographic Angiography Predicts Malignant Middle Cerebral Artery Evolution After Reperfusion Therapies.

BACKGROUND AND PURPOSE: Collateral circulation (CC) has been associated with recanalization, infarct volume, and clinical outcome in patients undergoing acute reperfusion therapies. However, its relationship with the development to malignant middle cerebral artery infarction (mMCAi) has not been evaluated. Our aim was to determine the impact of CC using multiphase computed tomographic angiography (during the acute stroke phase in the prediction of mMCAi. METHODS: Patients with consecutive acute stroke with <4.5 hours who were evaluated for reperfusion therapies and presented with an M1-MCA or terminal internal carotid artery occlusion by CTA were included. CC was evaluated on 6 grades by multiphase CTA according to the University of Calgary CC Scale; CC status was defined as poor (grades, 0-3) or good (grades, 4-5). The mMCAi was defined according to clinical and radiological criteria. Recanalization was assessed with transcranial Doppler at 24 hours and final Thrombolysis in Brain Ischemia score≥2b in patients undergoing endovascular reperfusion treatment. RESULTS: Eighty-two patients were included. Mean age was 65.1±13.83 years, median baseline National Institutes of Health Stroke Scale score was 18 (interquartile range, 13-20), and 67.9% M1 and 32.1% terminal internal carotid artery occlusions. Fifty-three patients received endovascular reperfusion treatment. Fifteen patients developed mMCAi. In the univariate analysis, patients with mMCAi had lower CC scores (2.29 versus 3.71; P=0.001). Endovascular reperfusion treatment was associated with lower rate of mMCAi development than only intravenous reperfusion treatment (9.4% versus 29.6%; P=0.028). Patients with poor CC had higher risk of developing mMCAi (13% versus 2%; P=0.001). On the multivariate analysis adjusted by age, vessel occlusion, baseline National Institutes of Health Stroke Scale, and recanalization, the presence of poor CC by multiphase CTA was the only independent predictor of mMCAi (P=0.048; odds ratio, 9.72; 95% confidence interval, 1.387-92.53). CONCLUSIONS: CC assessment by multiphase CTA independently predicts malignant MCA infarction progression. In patients with persistent occlusion after reperfusion therapies, the presence of poor CC may improve the early mMCAi detection and management.

Enhancement patterns of intrahepatic mass-forming cholangiocarcinoma at multiphasic computed tomography and magnetic resonance imaging and correlation with clinicopathologic features.

OBJECTIVE: Incidence of intrahepatic mass-forming cholangiocarcinoma (IMCC) is increasing worldwide, especially in patients with chronic liver disease. The small and the histologically well-differentiated IMCCs in chronic liver disease could be arterially hypervascular lesions with/without washout on computed tomography (CT) and magnetic resonance imaging (MRI), mimicking typical hepatocellular carcinoma (HCC). The aim of this work is to evaluate contrast enhancement (CE) patterns of IMCCs at quadri-phasic multidetector CT (4-MDCT) and MRI, using imaging-clinicopathologic correlation. PATIENTS AND METHODS: The 4-MDCT and MR images of 56 histologically confirmed IMCCs were retrospectively evaluated for tumor morphology and enhancement features. Enhancement pattern was defined according to the behavior of the nodule in arterial (AP), portal venous (PVP) and equilibrium phases (EP), and dynamic pattern was described according to enhancement progression throughout the different phases. Arterial and dynamic enhancement patterns were correlated with chronic liver disease, tumor size and histological differentiation. RESULTS: Most of the nodules were peripherally hyperenhancing (50%) on AP, and partially hyperenhancing on PVP (67.9%) and EP (80.3%). Forty-six (82.1%) IMCCs showed progressive CE, 7 (12.5%) stable CE and 3 (5.4%) wash-out. In normal liver there were 34 nodules with progressive and 3 with stable CE, whereas in chronic liver disease there were 12 IMCCs with progressive, 4 with stable and 3 with washout pattern (p = 0.01); IMCCs with progressive CE were more differentiated than IMCCs with stable CE and wash-out (p = 0.02). CONCLUSIONS: The most prevalent enhancement pattern of IMCCs was arterial rim enhancement followed by progressive and concentric filling. The stable and the washout patterns were more frequent in poorly differentiated IMCCs. Contrast washout was observed only in IMCCs emerging in chronic liver disease with a risk of misdiagnosis with HCC.

High resolution multi-arterial phase MRI improves lesion contrast in chronic liver disease.

PURPOSE: To determine the reliability of arterial phase capture and evaluate hypervascular lesion contrast kinetics with a combined view-sharing and parallel imaging dynamic contrast-enhanced acquisition, DIfferential Sub-sampling with Cartesian Ordering (DISCO), in patients with known chronic liver disease. METHODS: A retrospective review of 3T MR images from 26 patients with known chronic liver disease referred for hepatocellular carcinoma surveillance or post-treatment follow up was performed. After administration of a gadolinium-based contrast agent, a multiphasic acquisition was obtained in a 28 s breath-hold, from which seven sequential post-contrast image volumes were reconstructed. RESULTS: The late arterial phase was successfully captured in all cases (26/26, 95% CI 87-100%). Images obtained 26 s post-injection had the highest frequency of late arterial phase capture (20/26) and lesion detection (23/26) of any individual post-contrast time; however, the multiphasic data resulted in a significantly higher frequency of late arterial phase capture (26/26, p=0.03) and a higher relative contrast (5.37+/-0.97 versus 7.10+/-0.98, p < 0.01). CONCLUSION: Multiphasic acquisition with combined view-sharing and parallel imaging reliably captures the late arterial phase and provides sufficient temporal resolution to characterize hepatic lesion contrast kinetics in patients with chronic liver disease while maintaining high spatial resolution.

A U-shaped Association between Body Mass Index and Psychological Distress on the Multiphasic Personality Inventory: Retrospective Cross-sectional Analysis of 19-year-old Men in Korea.

Objective personality tests, such as the Minnesota Multiphasic Personality Inventory (MMPI), might be more sensitive to reflect subclinical personality and be more state-dependent in an individual's lifetime, so they are good scales to predict the psychological distress regarding certain states. The aim of this study was to identify the specific pattern between body mass index (BMI) and psychological distress using the objective personality test. For this study, we investigated BMI and the Korean Military Multiphasic Personality Inventory (MPI). A retrospective cross-sectional study was conducted with 19-yr-old examinees who were admitted to the Military Manpower Administration in Korea from February 2007 to January 2010. Of 1,088,107 examinees, we enrolled 771,408 subjects who were psychologically apparent healthy possible-military-service groups. Afterwards, we reviewed and analyzed directly measured BMI and MPI results. In terms of the validity scales, the faking-good subscale showed an inverted U-shaped association, and faking-bad and infrequency subscales showed a U-shaped association with BMI groups. In terms of the neurosis scales, all clinical subscales (anxiety, depression, somatization, and personality disorder) also showed a U-shaped association with BMI groups. For the psychopath scales, the schizophrenia subscale showed a U-shaped association, and the paranoia subscale showed a near-positive correlation with BMI. In conclusion, a specific U-shaped pattern was observed between BMI and the MPI in 19-yr-old men in Korea. Underweight and obesity are related to psychological distress, so supportive advice and education are needed to them.

Triple-modality screening trial for familial breast cancer underlines the importance of magnetic resonance imaging and questions the role of mammography and ultrasound regardless of patient mutation status, age, and breast density.

PURPOSE: To evaluate the breast cancer screening efficacy of mammography, ultrasound, and magnetic resonance imaging (MRI) in a high-risk population and in various population subgroups. PATIENTS AND METHODS: In a single-center, prospective, nonrandomized comparison study, BRCA mutation carriers and women with a high familial risk (> 20% lifetime risk) for breast cancer were offered screening with mammography, ultrasound, and MRI every 12 months. Diagnostic performance was compared between individual modalities and their combinations. Further comparisons were based on subpopulations dichotomized by screening rounds, mutation status, age, and breast density. RESULTS: There were 559 women with 1,365 complete imaging rounds included in this study. The sensitivity of MRI (90.0%) was significantly higher (P < .001) than that of mammography (37.5%) and ultrasound (37.5%). Of 40 cancers, 18 (45.0%) were detected by MRI alone. Two cancers were found by mammography alone (a ductal carcinoma in situ [DCIS] with microinvasion and a DCIS with < 10-mm invasive areas). This did not lead to a significant increase of sensitivity compared with using MRI alone (P = .15). No cancers were detected by ultrasound alone. Similarly, of 14 DCISs, all were detected by MRI, whereas mammography and ultrasound each detected five DCISs (35.7%). Age, mutation status, and breast density had no influence on the sensitivity of MRI and did not affect the superiority of MRI over mammography and ultrasound. CONCLUSION: MRI allows early detection of familial breast cancer regardless of patient age, breast density, or risk status. The added value of mammography is limited, and there is no added value of ultrasound in women undergoing MRI for screening.

A U-shaped Association between Body Mass Index and Psychological Distress on the Multiphasic Personality Inventory: Retrospective Cross-sectional Analysis of 19-year-old Men in Korea

Objective personality tests, such as the Minnesota Multiphasic Personality Inventory (MMPI), might be more sensitive to reflect subclinical personality and be more state-dependent in an individual's lifetime, so they are good scales to predict the psychological distress regarding certain states. The aim of this study was to identify the specific pattern between body mass index (BMI) and psychological distress using the objective personality test. For this study, we investigated BMI and the Korean Military Multiphasic Personality Inventory (MPI). A retrospective cross-sectional study was conducted with 19-yr-old examinees who were admitted to the Military Manpower Administration in Korea from February 2007 to January 2010. Of 1,088,107 examinees, we enrolled 771,408 subjects who were psychologically apparent healthy possible-military-service groups. Afterwards, we reviewed and analyzed directly measured BMI and MPI results. In terms of the validity scales, the faking-good subscale showed an inverted U-shaped association, and faking-bad and infrequency subscales showed a U-shaped association with BMI groups. In terms of the neurosis scales, all clinical subscales (anxiety, depression, somatization, and personality disorder) also showed a U-shaped association with BMI groups. For the psychopath scales, the schizophrenia subscale showed a U-shaped association, and the paranoia subscale showed a near-positive correlation with BMI. In conclusion, a specific U-shaped pattern was observed between BMI and the MPI in 19-yr-old men in Korea. Underweight and obesity are related to psychological distress, so supportive advice and education are needed to them.

Dynamic enhancement pattern of HCC smaller than 3 cm in diameter on gadoxetic acid-enhanced MRI: comparison with multiphasic MDCT.

BACKGROUND & AIMS: The dynamic enhancement pattern of HCCs smaller than 3 cm in diameter on gadoxetic acid-enhanced magnetic resonance imaging (MRI) have not been extensively investigated. We aimed to evaluate the dynamic enhancement patterns of small HCCs (≤3 cm) on gadoxetic acid-enhanced magnetic resonance imaging (MRI) and compare enhancement patterns with multiphasic multidetector computed tomography (MDCT) based on tumour cellular differentiation and size. METHODS: We retrospectively included 55 patients with 67 surgically confirmed small HCCs (≤3 cm) who underwent multiphasic MDCT and gadoxetic acid-enhanced MRI. Dynamic enhancement patterns were analysed according to tumour cellular differentiation and size. Hepatobiliary phase images were also analysed to assess their additional value. RESULTS: The proportion of small HCCs demonstrating the typical enhancement pattern differed depending on tumour cellular differentiation on both MRI (P = 0.001) and MDCT (P = 0.001), but differed depending on tumour size only on CT (P = 0.008). Gadoxetic acid-enhanced MRI more sensitively depicted the typical enhancement pattern than CT for all tumours (P = 0.001), for moderately or poorly differentiated HCCs (P = 0.021) and for HCCs ≤2 cm (P = 0.001). 80% of tumours with atypical enhancement could be diagnosed as HCC based on tumour size and hepatobiliary phase images. CONCLUSIONS: On both gadoxetic acid-enhanced MRI and multiphasic CT, the dynamic enhancement patterns of small HCCs (≤3 cm) differed according to tumour cellular differentiation. Gadoxetic acid-enhanced MRI more frequently demonstrated the typical HCC enhancement pattern than CT in small HCCs.

Reliability and predictive validity of Inlow's 60-Second Diabetic Foot Screen Tool.

OBJECTIVE: : The purpose of this study was to assess Inlow's 60-Second Diabetic Foot Screen Tool to ascertain consistency of risk recognition for development of ulceration independent of specific assessor and practice setting. Screening tools that assist clinicians in identifying risk require validation. The objectives were to determine the intrarater reliability, interrater reliability, and predictive validity of Inlow's 60-Second Diabetic Foot Screen Tool in 2 healthcare settings. DESIGN: : Following ethics board approval, a prospective observational study was completed. SETTING AND PARTICIPANTS: : A convenience sample of 69 persons with diabetes was recruited: n = 26 from an acute care setting (dialysis) and n = 43 from long-term-care (LTC) setting. MAIN OUTCOME MEASURES: : The screening tool was administered by 2 assessors independently to determine interrater reliability and later the same day by one of the assessors to determine intrarater reliability. Occurrence of foot ulcers or amputation was noted 1 to 5 months later to determine predictive validity. MAIN RESULTS: : Reliability is reported per setting using the intraclass correlation coefficient (2.1) and 95% confidence intervals. Intrarater reliability: LTC 0.96 (0.93-0.98) right foot, 0.97 (0.95-0.98) left foot; dialysis 1.00 right and 1.00 left foot. Interrater reliability: LTC 0.92 (0.86-0.96) right foot, 0.93 (0.87-0.96) left foot; dialysis 0.83 (0.65-0.92) right foot and left foot. Predictive validity: Two subjects had events-1 ulcer and 1 amputation-that were associated with high Inlow's screening tool scores. CONCLUSION: : This study demonstrates excellent interrater and intrarater reliability and provides preliminary information about predictive validity.

Adding ductus venosus blood flow as a categorical variable to the Combined and Integrated tests in Down's syndrome screening.

Ductus venosus blood flow, expressed as a pulsatility index (DVPI) has been shown to improve the performance of the Combined and Integrated antenatal screening tests for Down's syndrome using previously published data. The use of ductus venosus blood flow as a categorical marker (reversed or absent end diastolic blood flow indicating a positive result) is less discriminatory but simpler, so is sometimes preferred over DVPI. For example, with the Integrated test the false-positive rate for a 90% detection rate was 1.5% as a categorical marker compared with 1.1% expressed as DVPI.  We here provide the necessary algorithm and parameters for using ductus venosus blood flow as a categorical marker with the Combined and Integrated tests.