Response to Ballester et al Deutsch-Link, Sasha; Moon, Andrew M
The American journal of gastroenterology,
07/2023, Letnik:
118, Številka:
7
Journal Article
Recenzirano
...the authors state that ammonia should be understood in the context of age, underlying comorbidities, inflammation, electrolyte status, and severity of liver disease. ...we want to acknowledge that ...blood ammonia testing in clinical practice has not yet demonstrated benefits for patient care in large studies. Efficacy and safety of ornithine phenylacetate for treating overt hepatic encephalopathy in a randomized trial. How to diagnose hepatic encephalopathy in the emergency department.
Gastrointestinal diseases account for considerable health care use and expenditures. We estimated the annual burden, costs, and research funding associated with gastrointestinal, liver, and ...pancreatic diseases in the United States.
We generated estimates using data from the National Ambulatory Medical Care Survey; National Hospital Ambulatory Medical Care Survey; Nationwide Emergency Department Sample; National Inpatient Sample; Kids’ Inpatient Database; Nationwide Readmissions Database; Surveillance, Epidemiology, and End Results program; National Vital Statistics System; Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research; MarketScan Commercial Claims and Encounters data; MarketScan Medicare Supplemental data; United Network for Organ Sharing registry; Medical Expenditure Panel Survey; and National Institutes of Health (NIH).
Gastrointestinal health care expenditures totaled $119.6 billion in 2018. Annually, there were more than 36.8 million ambulatory visits for gastrointestinal symptoms and 43.4 million ambulatory visits with a primary gastrointestinal diagnosis. Hospitalizations for a principal gastrointestinal diagnosis accounted for more than 3.8 million admissions, with 403,699 readmissions. A total of 22.2 million gastrointestinal endoscopies were performed, and 284,844 new gastrointestinal cancers were diagnosed. Gastrointestinal diseases and cancers caused 255,407 deaths. The NIH supported $3.1 billion (7.5% of the NIH budget) for gastrointestinal research in 2020.
Gastrointestinal diseases are responsible for millions of health care encounters and hundreds of thousands of deaths that annually costs billions of dollars in the United States. To reduce the high burden of gastrointestinal diseases, focused clinical and public health efforts, supported by additional research funding, are warranted.
Serum ammonia testing in hepatic encephalopathy (HE) has been long debated in the field of hepatology. Although central to the pathophysiology of HE, serum ammonia testing is fraught with ...complexities that can lead to challenges in laboratory collection and interpretation. Although there is some disagreement across guideline organizations regarding routine testing of ammonia in HE, all acknowledge that normal values, although possible in HE, may warrant reconsideration of the diagnosis. In this study, we propose a nuanced approach to ammonia testing in HE. Serum ammonia testing provides little additional benefit in clinical scenarios with a high or low pretest probability for HE. However, if the pretest probability for HE is uncertain, a low ammonia level may reduce the posttest probability of HE. In this scenario, other etiologies of altered mental status should be explored. Future research should focus on developing a standardized approach to serum ammonia collection, processing, and interpretation.
Our understanding of the hepatic consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its resultant coronavirus disease 2019 (COVID-19) has evolved rapidly since ...the onset of the pandemic. In this Review, we discuss the hepatotropism of SARS-CoV-2, including the differential expression of viral receptors on liver cell types, and we describe the liver histology features present in patients with COVID-19. We also provide an overview of the pattern and relevance of abnormal liver biochemistry during COVID-19 and present the possible underlying direct and indirect mechanisms for liver injury. Furthermore, large international cohorts have been able to characterize the disease course of COVID-19 in patients with pre-existing chronic liver disease. Patients with cirrhosis have particularly high rates of hepatic decompensation and death following SARS-CoV-2 infection and we outline hypotheses to explain these findings, including the possible role of cirrhosis-associated immune dysfunction. This finding contrasts with outcome data in pharmacologically immunosuppressed patients after liver transplantation who seem to have comparatively better outcomes from COVID-19 than those with advanced liver disease. Finally, we discuss the approach to SARS-CoV-2 vaccination in patients with cirrhosis and after liver transplantation and predict how changes in social behaviours and clinical care pathways during the pandemic might lead to increased liver disease incidence and severity.
Background Treatment strategy for acute arterial occlusions due to intracranial atherosclerotic disease (IAD) may differ from those due to embolism (embolic). The aims were to differentiate and ...classify angiographically defined occlusion due to IAD versus embolism and identify baseline clinical factors associated with IAD-related occlusion. Methods Acute ischemic stroke patients with large cerebral artery occlusions on computed tomography angiography who underwent transfemoral cerebral angiography for endovascular treatment were included. Patients were categorized as the embolic (no evidence of focal stenosis after recanalization) or IAD group (significant fixed focal stenosis in the occlusion site, evidenced in the final angiography or during the endovascular treatment procedure) based on transfemoral cerebral angiography findings. Results In total, 158 patients were included. The IAD group patients (n = 24) were younger ( P = .005), more often male ( P < .001) and smokers ( P < .001), and had a higher total cholesterol level ( P = .001) than patients in the embolic group (n = 134). The posterior circulation was more frequently involved in the IAD group ( P = .001). Independent predictors of IAD on multivariable analysis were male sex (odds ratio, 6.42 95% confidence interval, 1.25-32.97, P = .026), posterior circulation involvement (3.57 1.09-11.75, P = .036), and high total cholesterol levels (1.02 1.01-1.03, P = .008). Conclusions Male sex, hypercholesterolemia, and posterior circulation involvement are associated with higher likelihood of underlying IAD as the etiology for the intracranial arterial occlusion. In patients with these characteristics, underlying IAD may have to be considered and the endovascular treatment strategy may have to be modified.
Diffuse myocardial fibrosis is a final end point in most cardiac diseases. It is missed by the cardiovascular magnetic resonance (CMR) late gadolinium enhancement technique. Currently, quantifying ...diffuse myocardial fibrosis requires invasive biopsy, with inherent risk and sampling error. We have developed a robust and noninvasive technique, equilibrium contrast CMR (EQ-CMR) to quantify diffuse fibrosis and have validated it against the current gold standard of surgical myocardial biopsy.
The 3 principles of EQ-CMR are a bolus of extracellular gadolinium contrast followed by continuous infusion to achieve equilibrium; a blood sample to measure blood volume of distribution (1-hematocrit); and CMR to measure pre- and postequilibrium T1 (with heart rate correction). The myocardial volume of distribution is calculated, reflecting diffuse myocardial fibrosis. Clinical validation occurred in patients undergoing aortic valve replacement for aortic stenosis or myectomy in hypertrophic cardiomyopathy (n=18 and n=8, respectively). Surgical biopsies were analyzed for picrosirius red fibrosis quantification on histology. The mean histological fibrosis was 20.5+/-11% in aortic stenosis and 17.1+/-7.4% in hypertrophic cardiomyopathy. EQ-CMR correlated strongly with biopsy histological fibrosis: aortic stenosis, r(2)=0.86, Kendall Tau coefficient (T)=0.71, P<0.001; hypertrophic cardiomyopathy, r(2)=0.62, T=0.52, P=0.08; combined r(2)=0.80, T=0.67, P<0.001.
We have developed and validated a new technique, EQ-CMR, to measure diffuse myocardial fibrosis as an add-on to a standard CMR scan, which allows for the noninvasive quantification of the diffuse fibrosis burden in myocardial diseases.
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