We present here the first update of the 2013 EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) Guidelines and Recommendations on the clinical use of elastography with a focus on the assessment of diffuse liver disease. The short version provides clinical information about the practical use of elastography equipment and interpretation of results in the assessment of diffuse liver disease and analyzes the main findings based on published studies, stressing the evidence from meta-analyses. The role of elastography in different etiologies of liver disease and in several clinical scenarios is also discussed. All of the recommendations are judged with regard to their evidence-based strength according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence. This updated document is intended to act as a reference and to provide a practical guide for both beginners and advanced clinical users.

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EFSUMB Guidelines and Recommendations on the Clinical Use of Liver Ultrasound Elastography, Update 2017 (Long Version)

The gut-liver axis in liver disease: Pathophysiological basis for therapy.

BACKGROUND In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients. METHODS We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3‐hour bundle of care for patients with sepsis (i.e., blood cultures, broad‐spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3‐hour bundle and risk‐adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid. RESULTS Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3‐hour bundle completed within 3 hours. The median time to completion of the 3‐hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3‐hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk‐adjusted in‐hospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P=0.21). CONCLUSIONS More rapid completion of a 3‐hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk‐adjusted in‐hospital mortality. (Funded by the National Institutes of Health and others.)

Supplement to: Time to treatment and mortality during mandated emergency care for sepsis.

Enoxaparin Prevents Portal Vein Thrombosisand Liver Decompensation in Patients With Advanced Cirrhosis.

Low-grade inflammation is the hallmark of metabolic disorders such as obesity, type 2 diabetes and nonalcoholic fatty liver disease. Emerging evidence indicates that these disorders are characterized by alterations in the intestinal microbiota composition and its metabolites, which translocate from the gut across a disrupted intestinal barrier to affect various metabolic organs, such as the liver and adipose tissue, thereby contributing to metabolic inflammation. Here, we discuss some of the recently identified mechanisms that showcase the role of the intestinal microbiota and barrier dysfunction in metabolic inflammation. We propose a concept by which the gut microbiota fuels metabolic inflammation and dysregulation. Here, the authors describe how metabolic disorders, such as type 2 diabetes and nonalcoholic fatty liver disease, are driven by alterations in the composition of the intestinal microbiota and its metabolites, which translocate from the gut across a disrupted intestinal barrier and contribute to metabolic inflammation.

The intestinal microbiota fuelling metabolic inflammation

Reply to: "The clinical advantage of fixed 8-mm diameter VCX stents over underdilated VTS stents is not established in refractory ascites".

To report the safety and efficacy of percutaneous transfemoral venous recanalization of occluded intrahepatic portosystemic stents (TIPS) in cases where the transjugular approach is not feasible.Between 2000 and 2020, 8 patients with occluded TIPS underwent recanalization via a percutaneous transfemoral venous access. Prior recanalization via a typical transjugular approach was attempted in all cases. Primary technical success was defined as successful crossing of the occlusion. Secondary technical success was defined as the rate of successful TIPS recanalization. Periprocedural complications were evaluated to assess procedural safety.In 8/8 patients transfemoral venous TIPS recanalization was successful. No procedure-related complications were observed.The transfemoral venous approach is a safe and efficient alternative for TIPS recanalization in cases where the transjugular approach is not feasible. 

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Transfemoral recanalization of occluded TIPS

Efficacy and safety of vaccination againts SARS-CoV-2 in patients with vascular liver disease

Abstract Background and aims Liver-associated complications still frequently lead to mortality in people with HIV (PWH), even though combined antiretroviral treatment (cART) has significantly improved overall survival. The quantification of circulating collagen fragments released during collagen formation and degradation correlate with the turnover of extracellular matrix (ECM) in liver disease. Here, we analysed the levels of ECM turnover markers PC3X, PRO-C5, and PRO-C6 in PWH and correlated these with hepatic fibrosis and steatosis. Methods This monocentre, retrospective study included 141 PWH. Liver stiffness and liver fat content were determined using transient elastography (Fibroscan) with integrated CAP function. Serum levels of formation of cross-linked type III collagen (PC3X), formation of type V collagen (PRO-C5) and formation type VI collagen (PRO-C6), also known as the hormone endotrophin, were measured with ELISA. Results Twenty-five (17.7%) of 141 PWH had clinical significant fibrosis with liver stiffness ≥ 7.1 kPa, and 62 PWH (44.0%) had steatosis with a CAP value &gt; 238 dB/m. Study participants with fibrosis were older (p = 0.004) and had higher levels of AST (p = 0.037) and lower number of thrombocytes compared to individuals without fibrosis (p = 0.0001). PC3X and PRO-C6 were markedly elevated in PWH with fibrosis. Multivariable cox regression analysis confirmed PC3X as independently associated with hepatic fibrosis. PRO-C5 was significantly elevated in participants with presence of hepatic steatosis. Conclusion Serological levels of cross-linked type III collagen formation and endotrophin were significantly associated with liver fibrosis in PWH receiving cART and thus may be suitable as a non-invasive evaluation of liver fibrosis in HIV disease. 

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Circulating levels of endotrophin and cross-linked type III collagen reflect liver fibrosis in people with HIV

Neuromyelitis optica (NMO) or Devic´s syndrome is an inflammatory, demyelinating disease of the central nervous system leading to optical neuritis and myelitis. Etiology of NMO is unknown, although autoimmune disorders involving IgG autoantibodies specific for aquaporin 4 are suspected. These autoantibodies are associated with 73% sensitivity 93% specificity for NMO helping to distinguish NMO from other demyelinating disorders. Some cases of NMO are reported in association with systemic lupus erythematosus and Sjogren`s syndrome. Here we report a patient presenting with NMO and concomitantly occurring rapid progressive crescentic intra- and extracapillary crescentic glomerulonephritis.

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Michael Praktiknjo

Papers

Reply to: "The clinical advantage of fixed 8-mm diameter VCX stents over underdilated VTS stents is not established in refractory ascites".

Transfemoral recanalization of occluded TIPS

Efficacy and safety of vaccination againts SARS-CoV-2 in patients with vascular liver disease

Circulating levels of endotrophin and cross-linked type III collagen reflect liver fibrosis in people with HIV

Crescentic glomerulonephritis in a patient with neuromyelitis optica (Devic´s syndrom)