Systemic inflammation and acute-on-chronic liver failure: too much, not enough

ACLF is a specific, but complex and multifactorial form of acute decompensation of cirrhosis and is characterized by an extraordinary dynamic natural course, rapidly evolving organ failure, and high short-term mortality. Dysbalanced immune function is central to its pathogenesis and outcome with an initial excessive systemic inflammatory response that drives organ failure and mortality. Later in its course, immuno-exhaustion/immunoparalysis prevails predisposing the patient to secondary infectious events and reescalation in end-organ dysfunction and mortality. The management of patients with ACLF is still poorly defined. However, as its pathophysiology is gradually being unravelled, potential therapeutic targets emerge that warrant further study such as restoring or substituting albumin via plasma exchange or via albumin dialysis and evaluating usefulness of TLR4 antagonists, modulators of gut dysbiosis (pre- or probiotics), and FXR-agonists

Clinical outcomes and cost effectiveness of computerâ guided versus conventional implantâ retained hybrid prostheses: A longâ term retrospective analysis of treatment protocols

BackgroundComputerâ guided systems were developed to facilitate implant placement at optimal positions in relation to the future prosthesis. However, the time, cost and, technique sensitivity involved with computerâ guided surgery impedes its routine practice. The aim of this study is to evaluate survival rates and complications associated with computerâ guided versus conventional implant placement in implantâ retained hybrid prostheses. Furthermore, longâ term economic efficiency of this approach was assessed.MethodsPatients were stratified according to implant placement protocol into a test group, using computerâ guided placement, and a control group, using traditional placement. Calibrated radiographs were used to measure bone loss around implants. Furthermore, the costs of the initial treatment and prosthetic complications, if any, were standardized and analyzed.ResultsFortyâ five patients (149 implants in the test group and 111 implants in the control group) with a minimum followâ up of 5 years, and a mean followâ up of 9.6 years, were included in the study. While no significant difference was found between both groups in terms of biologic and technical complications, lower incidence of implant loss was observed in the test group (P  0.05).ConclusionsComputerâ guided implant placement for an implantâ supported hybrid prosthesis is a valid, reliable alternative to the traditional approach for implant placement and immediate loading. Computerâ guided implant placement showed higher implant survival rates and comparable longâ term cost to nonâ guided implant placement.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/145504/1/jper10157.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/145504/2/jper10157_am.pd

Daily reduction of oral malodor with the use of a sonic tongue brush combined with an antibacterial tongue spray in a randomized cross-over clinical investigation

Abstract The objective of this clinical investigation was to test the effectiveness on breath odor of a newly designed sonic tongue brush (TongueCare+, TC). It consists of a soft silicone brush optimally designed based on the tongue's anatomy to remove bacterial biofilm from the tongue's complex surface, and it is coupled with a sonic power toothbrush handle. TC was used in combination with an antibacterial tongue spray (BreathRx, BRx) containing 0.09% cetylpyridinium chloride and 0.7% zinc gluconate. A total of 21 participants with oral malodor exceeding the threshold for recognition took part in this cross-over clinical investigation, which consisted of a single use of four treatment arms with one week washout period in between. The treatments consisted of: (1) TC  +  BRx, (2) TC  +  water, (3) BRx and (4) water. Malodor levels and bacterial density were monitored up to 6 h by organoleptic scoring and selective plating, respectively. The organoleptic score and bacterial density were significantly lower after using TC  +  BRx compared to all alternative treatments at all time points. A significant decrease in both parameters was detected after a single use of TC  +  BRx, from levels characteristic of high oral malodor, to barely noticeable levels after treatment and this was maintained up to 6 h. Moreover, we identified a significant positive correlation between bacterial density and organoleptic score, confirming that bacterial tongue biofilm is the root cause of oral malodor in these subjects. The results of this clinical investigation demonstrated that the combined treatment of a sonic tongue brush with the antibacterial tongue spray is able to deliver more than 6 h of fresh breath following a single use. The clinical investigation was registered at the ISRCTN registry under study identification number ISRCTN38199132

Genetic variants of innate immunity receptors are associated with mortality in cirrhotic patients with bacterial infection

BACKGROUND & AIMS: Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation of cirrhosis (AD), organ failure(s) and high risk of short-term mortality with bacterial infection frequently as precipitating event. Innate immune pattern recognition receptors and members of the lectin pathway of complement activation are crucial to the innate immune response to pathogens. The aim of this study was to investigate whether single nucleotide polymorphisms (SNPs) of innate immune components are associated with the occurrence of bacterial infections or mortality in patients with cirrhosis hospitalized for AD or ACLF. METHODS: Twenty-one innate immunity SNPs with known functional implications were genotyped in 826 AD/ACLF patients included in the CANONIC study. Associations between baseline characteristics of the patients, the occurrence of bacterial infections and survival rate at 90 days of follow-up in relation to the innate immunity genetic variants were analysed. RESULTS: The NOD2-G908R genetic variant was associated with mortality (HR 2.25, P = .004) independently of age and MELD Score. This association was also found in a predefined subgroup analysis in patients with bacterial infections (HR 2.78, P < .001) along with MBL_Yx (HR 1.72, P = .008) and MASP2_371 (HR 1.67, P = .012) genetic variants. None of the analysed SNPs were significantly associated with the occurrence of acute bacterial infections or spontaneous bacterial peritonitis in particular. CONCLUSIONS: Innate immune system-specific NOD2-G908R, MBL_Yx and MASP2_371 genetic variants were independently associated with increased risk of short-term mortality in AD/ACLF patients with bacterial infection

The CLIF Consortium Acute Decompensation score (CLIF-C ADs) for prognosis of hospitalised cirrhotic patients without acute-on-chronic liver failure

BACKGROUND & AIMS: Cirrhotic patients with acute decompensation frequently develop acute-on-chronic liver failure (ACLF), which is associated with high mortality rates. Recently, a specific score for these patients has been developed using the CANONIC study database. The aims of this study were to develop and validate the CLIF-C AD score, a specific prognostic score for hospitalised cirrhotic patients with acute decompensation (AD), but without ACLF, and to compare this with the Child-Pugh, MELD, and MELD-Na scores. METHODS: The derivation set included 1016 CANONIC study patients without ACLF. Proportional hazards models considering liver transplantation as a competing risk were used to identify score parameters. Estimated coefficients were used as relative weights to compute the CLIF-C ADs. External validation was performed in 225 cirrhotic AD patients. CLIF-C ADs was also tested for sequential use. RESULTS: Age, serum sodium, white-cell count, creatinine and INR were selected as the best predictors of mortality. The C-index for prediction of mortality was better for CLIF-C ADs compared with Child-Pugh, MELD, and MELD-Nas at predicting 3- and 12-month mortality in the derivation, internal validation and the external dataset. CLIF-C ADs improved in its ability to predict 3-month mortality using data from days 2, 3-7, and 8-15 (C-index: 0.72, 0.75, and 0.77 respectively). CONCLUSIONS: The new CLIF-C ADs is more accurate than other liver scores in predicting prognosis in hospitalised cirrhotic patients without ACLF. CLIF-C ADs therefore may be used to identify a high-risk cohort for intensive management and a low-risk group that may be discharged early

Systemic inflammation in decompensated cirrhosis: Characterization and role in acute-on-chronic liver failure.

Acute‐on‐chronic liver failure (ACLF) in cirrhosis is characterized by acute decompensation (AD), organ failure(s), and high short‐term mortality. Recently, we have proposed (systemic inflammation [SI] hypothesis) that ACLF is the expression of an acute exacerbation of the SI already present in decompensated cirrhosis. This study was aimed at testing this hypothesis and included 522 patients with decompensated cirrhosis (237 with ACLF) and 40 healthy subjects. SI was assessed by measuring 29 cytokines and the redox state of circulating albumin (HNA2), a marker of systemic oxidative stress. Systemic circulatory dysfunction (SCD) was estimated by plasma renin (PRC) and copeptin (PCC) concentrations. Measurements were performed at enrollment (baseline) in all patients and sequentially during hospitalization in 255. The main findings of this study were: (1) Patients with AD without ACLF showed very high baseline levels of inflammatory cytokines, HNA2, PRC, and PCC. Patients with ACLF showed significantly higher levels of these markers than those without ACLF; (2) different cytokine profiles were identified according to the type of ACLF precipitating event (active alcoholism/acute alcoholic hepatitis, bacterial infection, and others); (3) severity of SI and frequency and severity of ACLF at enrollment were strongly associated. The course of SI and the course of ACLF (improvement, no change, or worsening) during hospitalization and short‐term mortality were also strongly associated; and (4) the strength of association of ACLF with SI was higher than with SCD. Conclusion: These data support SI as the primary driver of ACLF in cirrhosis