Meta-analysis: the diagnostic accuracy of critical flicker frequency in minimal hepatic encephalopathy

BACKGROUND: Minimal hepatic encephalopathy (MHE) reduces quality of life, increases the risk of road traffic incidents and predicts progression to overt hepatic encephalopathy and death. Current psychometry-based diagnostic methods are effective, but time-consuming and a universal ‘gold standard’ test has yet to be agreed upon. Critical Flicker Frequency (CFF) is a proposed language-independent diagnostic tool for MHE, but its accuracy has yet to be confirmed. AIM: To assess the diagnostic accuracy of CFF for MHE by performing a systematic review and meta-analysis of all studies, which report on the diagnostic accuracy of this test. METHODS: A systematic literature search was performed to locate all publications reporting on the diagnostic accuracy of CFF for MHE. Data were extracted from 2 × 2 tables or calculated from reported accuracy data. Collated data were meta-analysed for sensitivity, specificity, diagnostic odds ratio (DOR) and summary receiver operator curve (sROC) analysis. Prespecified subgroup analysis and meta-regression were also performed. RESULTS: Nine studies with data for 622 patients were included. Summary sensitivity was 61% (95% CI: 55–67), specificity 79% (95% CI: 75–83) and DOR 10.9 (95% CI: 4.2–28.3). A symmetrical sROC gave an area under the receiver operator curve of 0.84 (SE = 0.06). The heterogeneity of the DOR was 74%. CONCLUSIONS: Critical Flicker Frequency has a high specificity and moderate sensitivity for diagnosing minimal hepatic encephalopathy. Given the advantages of language independence and being both simple to perform and interpret, we suggest the use of critical flicker frequency as an adjunct (but not replacement) to psychometric testing

Lipids in liver failure syndromes: a focus on eicosanoids, specialized pro-resolvinglipid mediators and lysophospholipids.

Lipids are organic compounds insoluble in water with a variety of metabolic and non-metabolic functions. They not only represent an efficient energy substrate but can also act as key inflammatory and anti-inflammatory molecules as part of a network of soluble mediators at the interface of metabolism and the immune system. The role of endogenous bioactive lipid mediators has been demonstrated in several inflammatory diseases (rheumatoid arthritis, inflammatory bowel disease, atherosclerosis, cancer). The liver is unique in providing balanced immunotolerance to the exposure of bacterial components from the gut transiting through the portal vein and the lymphatic system. This balance is abruptly deranged in liver failure syndromes such as acute liver failure and acute-on-chronic liver failure. In these syndromes, researchers have recently focused on bioactive lipid mediators by global metabonomic profiling and uncovered the pivotal role of these mediators in the immune dysfunction observed in liver failure syndromes explaining the high occurrence of sepsis and subsequent organ failure. Among endogenous bioactive lipids, the mechanistic actions of three classes (eicosanoids, pro-resolving lipid mediators and lysophospholipids) in the pathophysiological modulation of liver failure syndromes will be the topic of this narrative review. Furthermore, the therapeutic potential of lipid-immune pathways will be described

Metabolic phenotype of skeletal muscle in early critical illness

No commercial use is permitted unless otherwise expressly granted.ZAP was funded by the National Institute of Health Research (UK). Additional funding has been received from the European Society of Intensive Care Medicine, Guy’s & St Thomas’ and King’s College London NIHR Comprehensive Biomedical Research Centre (BRC) and the Whittington Hospital NHS Trust. SDH received support from the Research Councils UK. NH received funding from the NIHR Clinical Research Facility and BRC at Guy’s and St Thomas’ NHS Foundation Trust (GSTT) and King’s College London. HEM was funded by University College London and UCLH BRC. The Clinical Phenotyping Centre is supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Imperial College Healthcare NHS Trust and Imperial College London. MJWM is grateful to the Wellcome Trust for support in the form of a Postdoctoral Training Fellowship for part of this work. YP is grateful to Merz Pharmaceuticals for support in the form of a training fellowship award

The Association of Low-Penetrance Variants in DNA Repair Genes with Colorectal Cancer: A Systematic Review and Meta-Analysis

OBJECTIVES: Approximately 35% of colorectal cancer (CRC) risk is attributable to heritable factors known hereditary syndromes, accounting for 6%. The remainder may be due to lower penetrance polymorphisms particularly of DNA repair genes. DNA repair pathways, including base excision repair (BER), nucleotide excision repair (NER), mismatch repair (MMR), direct reversal repair (DRR), and double-strand break repair are complex, evolutionarily conserved, and critical in carcinogenesis. Germline mutations in these genes are associated with high-penetrance CRC syndromes such as Lynch syndrome. However, the association of lowpenetrance polymorphisms of DNA repair genes with CRC risk remains unclear. METHODS: A systematic literature review of PubMed, Embase, and HuGENet databases was conducted. Pre-specified criteria determined study inclusion/exclusion. Per-allele, pooled odds ratios disclosed the risk attributed to each variant. Heterogeneity was investigated by subgroup analyses for ethnicity and tumor location; funnel plots and Egger’s test assessed publication bias. RESULTS: Sixty-one polymorphisms in 26 different DNA repair genes were identified. Meta-analyses for 22 polymorphisms in 17 genes revealed that six polymorphisms were significantly associated with CRC risk within BER (APE1, PARP1), NER (ERCC5, XPC), double-strand break (RAD18), and DRR (MGMT), but none within MMR. Subgroup analyses revealed significant association of OGG1 rs1052133 with rectal cancer risk. Egger’s test revealed no publication bias. CONCLUSIONS: Low-penetrance polymorphisms in DNA repair genes alter susceptibility to CRC. Future studies should therefore analyze whole-genome polymorphisms and any synergistic effects on CRC risk. TRANSLATIONAL IMPACT: This knowledge may enhance CRC risk assessment and facilitate a more personalized approach to cancer prevention

Incidence and outcomes for patients with cirrhosis admitted to the United Kingdom Critical Care Unitsa

OBJECTIVE: To assess the epidemiology and outcome of patients with cirrhosis following critical care unit admission. DESIGN: Retrospective cohort study. SETTING: Critical care units in England, Wales, and Northern Ireland participating in the U.K. Intensive Care National Audit and Research Centre Case Mix Programme. PATIENTS: Thirty-one thousand three hundred sixty-three patients with cirrhosis identified of 1,168,650 total critical care unit admissions (2.7%) admitted to U.K. critical care units between 1998 and 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ten thousand nine hundred thirty-six patients had alcohol-related liver disease (35%). In total, 1.6% of critical care unit admissions in 1998 had cirrhosis rising to 3.1% in 2012. The crude critical care unit mortality of patients with cirrhosis was 41% in 1998 falling to 31% in 2012 (p < 0.001). Crude hospital mortality fell from 58% to 46% over the study period (p < 0.001). Mean(SD) Acute Physiology and Chronic Health Evaluation II score in 1998 was 20.3 (8.5) and 19.5 (7.1) in 2012. Mean Acute Physiology and Chronic Health Evaluation II score for patients with alcohol-related liver disease in 2012 was 20.6 (7.0) and 19.0 (7.2) for non-alcohol-related liver disease (p < 0.001). In adjusted analysis, alcohol-related liver disease was associated with increased risk of death (odds ratio, 1.51 [95% CI, 1.42-1.62; p < 0.001]) with a year-on-year reduction in hospital mortality (adjusted odds ratio, 0.95/yr, [0.94-0.96, p < 0.001]). CONCLUSIONS: More patients with cirrhosis are being admitted to critical care units but with increasing survival rates. Patients with alcohol-related liver disease have reduced survival rates partly explained by higher levels of organ failure at admission. Patients with cirrhosis and organ failure warrant a trial of organ support and universal prognostic pessimism is not justified

High speed quantitative UPLC-MS analysis of multiple amines in human plasma and serum via pre-column derivatization with 6-aminoquinolyl-N-hydroxysuccinimidyl carbamate: Application to acetaminophen-induced liver failure

A targeted reversed-phase gradient UPLC-MS/MS assay has been developed for the quantification/monitoring of amino acids and amino-containing compounds in human plasma and serum using pre-column derivatization with 6-aminoquinolyl-N-hydroxysuccinimidyl carbamate (AccQTag UltraTM). Derivatization of the target amino-containing compounds reagent required minimal sample preparation and resulted in analytes with excellent chromatographic and mass spectrometric properties. The resulting method, which requires only 10 µl of sample, provides the reproducible and robust separation of 66 analytes in 7.5 minutes, including baseline resolution of isomers such as e.g. leucine and isoleucine. The assay has been validated for the quantification of 33 amino compounds (predominantly amino acids) over a concentration range from 2-20 and 800µM. Intra- and inter-day accuracy of between 0.05-15.6 and 0.78 -13.7 % and precision between 0.91-16.9 % and 2.12-15.9 % were obtained. A further 33 biogenic amines can be monitored in samples for relative changes in concentration rather than quantification. Application of the assay to samples derived from healthy controls and patients suffering from acetaminophen (APAP, paracetamol) induced acute liver failure (ALF) showed significant differences in the amounts of aromatic and branched chain amino acids between the groups as well as a number of other analytes, including the novel observation of increased concentrations of sarcosine in ALF patients. The properties of the developed assay, including short analysis time, make it suitable for high throughput targeted UPLC-ESI-MS/MS metabonomic analysis in clinical and epidemiological environments