This document summarizes a presentation on non-invasive methods for evaluating liver disease severity and prognosis, focusing on measurement of liver stiffness. It discusses two main complementary approaches: biomarkers and physical measurements. For physical measurements, transient elastography (FibroScan) and acoustic radiation force impulse imaging (ARFI) are presented. While transient elastography is well validated and recommended, its applicability is limited in 20% of cases by obesity, operator experience, and other technical factors. The XL probe improves applicability in obese patients but appropriate cut-offs need validation. Food intake and other clinical factors can impact liver stiffness measurements. Reliable interpretation requires considering pre-test probability, confidence intervals, and contextual clinical factors. ARFI
New Data on Resistance to DAAs and Implications for Therapy.2015hivlifeinfo
In this downloadable slideset, Nezam H. Afdhal, MD, FRCPI, provides guidance on testing for and management of resistance in HCV-infected patients treated with DAA therapy.
Format: Microsoft PowerPoint (.ppt)
File size: 1.39 MB
Date posted: 10/30/2015
New Data on Resistance to DAAs and Implications for Therapy.2015hivlifeinfo
In this downloadable slideset, Nezam H. Afdhal, MD, FRCPI, provides guidance on testing for and management of resistance in HCV-infected patients treated with DAA therapy.
Format: Microsoft PowerPoint (.ppt)
File size: 1.39 MB
Date posted: 10/30/2015
Clinical Impact of New Data From AASLD 2015hivlifeinfo
In this downloadable slideset, David R. Nelson, MD, and Norah Terrault, MD, MPH, review key HCV studies presented at the 2015 Annual Meeting of the European Association for the Study of the Liver.
Format: Microsoft PowerPoint (.ppt)
File size: 2.19 MB
Date posted: 12/2/2015
Susanna Naggie, M.D., M.H.S., of Duke Clinical Research Center, presents "HIV/HCV Co-Infection: The Journey of a Special Population" at AIDS Clinical Rounds
A slideshow for my collegues in hospitals on 2014 Oct 15th.
This presentation is about a case who developed resistance to lamivudine, an anti-HBV agent, during treatment. We discussed about how resistance develop, how to interpret resistance result, and how to optimize the therapy in lamivudine-resistant settings. Time to stop anti-viral agents is also discussed.
High efficacy of grazoprevir/elbasvir in HCV genotype 1, 4, and 6-infected pa...Илья Антипин
Rockstroh J. и др. «High efficacy of grazoprevir/elbasvir in HCV genotype 1, 4, and 6-infected patients with HIV co-infection: the phase 3 C-EDGE co-infection study» 8th IAS Conference on HIV Pathogenesis, Treatment, and Prevention, Vancouver, 2015. TUAB0206.
David Wyles, M.D., of the UC San Diego AntiViral Research Center, presents "HCV in 2015: New Medication Approvals and Innovative Studies...Including a One-Shot Cure?" at AIDS Clinical Rounds
This lecture is about Treatment of HCV Genotype 4 presented by Dr. Tamer Elbaz, Assistant professor of Hepatology & Gastroenterology, Cairo University.
The lecture was presented in the scientific meeting of Internal and Tropical Medicine departments, Ahmed Maher Teaching Hospital titled (Towards Eradication of HCV in Egypt) in celebration of World Hepatitis Day on July 28, 2016.
https://www.facebook.com/AMTH.IM
https://www.facebook.com/events/1072758396145209/
http://www.no4c.com
Suppléance hépatique : comment et pour qui ?
Pr Didier Samuel et Pr Saliba Faouzi
Les journées du Centre Hépato-Biliaire - JCHB 2019
Journées de l'hépatologie
Clinical Impact of New Data From AASLD 2015hivlifeinfo
In this downloadable slideset, David R. Nelson, MD, and Norah Terrault, MD, MPH, review key HCV studies presented at the 2015 Annual Meeting of the European Association for the Study of the Liver.
Format: Microsoft PowerPoint (.ppt)
File size: 2.19 MB
Date posted: 12/2/2015
Susanna Naggie, M.D., M.H.S., of Duke Clinical Research Center, presents "HIV/HCV Co-Infection: The Journey of a Special Population" at AIDS Clinical Rounds
A slideshow for my collegues in hospitals on 2014 Oct 15th.
This presentation is about a case who developed resistance to lamivudine, an anti-HBV agent, during treatment. We discussed about how resistance develop, how to interpret resistance result, and how to optimize the therapy in lamivudine-resistant settings. Time to stop anti-viral agents is also discussed.
High efficacy of grazoprevir/elbasvir in HCV genotype 1, 4, and 6-infected pa...Илья Антипин
Rockstroh J. и др. «High efficacy of grazoprevir/elbasvir in HCV genotype 1, 4, and 6-infected patients with HIV co-infection: the phase 3 C-EDGE co-infection study» 8th IAS Conference on HIV Pathogenesis, Treatment, and Prevention, Vancouver, 2015. TUAB0206.
David Wyles, M.D., of the UC San Diego AntiViral Research Center, presents "HCV in 2015: New Medication Approvals and Innovative Studies...Including a One-Shot Cure?" at AIDS Clinical Rounds
This lecture is about Treatment of HCV Genotype 4 presented by Dr. Tamer Elbaz, Assistant professor of Hepatology & Gastroenterology, Cairo University.
The lecture was presented in the scientific meeting of Internal and Tropical Medicine departments, Ahmed Maher Teaching Hospital titled (Towards Eradication of HCV in Egypt) in celebration of World Hepatitis Day on July 28, 2016.
https://www.facebook.com/AMTH.IM
https://www.facebook.com/events/1072758396145209/
http://www.no4c.com
Suppléance hépatique : comment et pour qui ?
Pr Didier Samuel et Pr Saliba Faouzi
Les journées du Centre Hépato-Biliaire - JCHB 2019
Journées de l'hépatologie
This presentation was held by dr. Antonio Pio Masciotra - italian radiologist - on Novembre 2012 at Prato.
It concerns about neoplastic tissue's elasticity and breast elastography.
Ultrasound Elastography is a new imaging technique that allows a noninvasive estimation and imaging of tissue elasticity distribution within biological tissues using conventional, Real Time Ultrasound equipment with modified software. It can be viewed as an electronic palpation of tissues. Introduced by Ophir et al in 1991, it subsequently evolved into a Real Time Imaging tool.
Clinical Impact of New NAFLD/NASH Data From San Francisco 2018hivlifeinfo
Expert faculty summarize key NAFLD/NASH studies from this important annual conference. Use these slides to review data on noninvasive screening, clinical outcomes, emerging treatments.
Ira M. Jacobson, MD
Philip N. Newsome, PhD, FRCPE
Format: Microsoft PowerPoint (.ppt)
File Size: 421 KB
Released: December 3, 2018
ShearWave™ Elastography in Chronic Liver Diseases: Clinical Research Literatu...Joel Gay
By the end of 2016, SuperSonic Imagine’s proprietary ShearWave™ Elastography (SWE™) reached a track record of over 100 peer-reviewed publications focusing on the evaluation of liver fibrosis severity in patients with chronic liver diseases. Therefore, it has become the most clinically studied shear-wave based elastography technique for liver fibrosis assessment.
In this all new webinar, we will walk you through a literature review that will help you to familiarize yourself with clinical research results related to the use of ShearWave™ Elastography (SWE™) within the field of chronic liver diseases.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
1. Laurent CASTERALaurent CASTERA
Service d’Hépatologie,Service d’Hépatologie,
Hôpital Beaujon, Université Paris VIIHôpital Beaujon, Université Paris VII
Alternatives à la PBH :Alternatives à la PBH :
mesure de lmesure de l’’élasticitéélasticité
hépatiquehépatique
DU Hépatites Virales Cytokines et AntivirauxDU Hépatites Virales Cytokines et Antiviraux
Pitie, Paris, 12 Janvier 2016Pitie, Paris, 12 Janvier 2016
4. Non-invasive
tests for evaluation
of liver disease
Severity and
prognosis
Tests non invasifs:Tests non invasifs:
le temps des recommandationsle temps des recommandations
Chairmen:
Laurent Castera & Henry Lik Yuen Chan (EASL)
Marco Arrese (ALEH).
Panel members:
Nezam Afdhal (US), Pierre Bedossa (Fr),EASL-ALEH Clinical practice Guidelines. J Hepatol 2015; 63: 237-64.
8. %
-5
0
5
Depth(mm)
Time (ms)
0 20 40 60
10
20
30
40
50
60
E = 3.0 kPa
F0
Sandrin et al. UMB 2003; 12: 1705-13
VS = 1.0 m/s
E = 27.0 kPa
F4
VS = 3.0 m/s
PrincipePrincipe
“Plus le foie est dur, plus l’onde se propage vite”Plus le foie est dur, plus l’onde se propage vite”
9. Mesure de l’élasticité hépatique
75 kPa3
15 655.5
Normale
Roulot et al. J Hepatol 2008; 48: 606-13
10. FibroScan en pratiqueFibroScan en pratique
Indolore
Rapide (5 min)
Lit du malade/
consultation
Résultats immédiats
Formation courte
(100 exam.)
13. PBH: un « gold » standard imparfait
Mehta et al. J Hepatol 2009; 50: 36-41.Bedossa & Carrat. J Hepatol 2009; 50: 1-3.
0.99
14. « Spectrum bias »
Ransohoff & Feistein. N Engl J Med 1978; 299: 926-230
Problems of Spectrum and Bias in Evaluating
the Efficacy of Diagnostic Tests
David F. Ransohoff, M.D., and Alvan R. Feinstein, M.D.
15. Poynard et al. Clin Chem 2007; 53: 1615-22.
AUROC standardisation
according to fibrosis prevalence
16. AUROC standardisation
according to fibrosis prevalence
Poynard et al. Clin Chem 2007; 53: 1615-22.
DANA = (2+3+4)/3 – (0+1)/2 = 2,5
F0 20%; F1 20% ; F2 20%; F3 20%; F4 20%
ANA
DANA = (F2+F3+F4)/3 – (F0+F1)/2
DANA = Difference between Advanced
& Non Advanced fibrosis
17. AUROC standardisation
according to fibrosis prevalence
Poynard et al. Clin Chem 2007; 53: 1615-22.
DANA = (2+3+4)/3 – (0+1)/2 = 2,5
F0 20%; F1 20% ; F2 20%; F3 20%; F4 20%
ANA
DANA = (F2+F3+F4)/3 – (F0+F1)/2
18. AUROC standardisation
according to fibrosis prevalence
Poynard et al. Clin Chem 2007; 53: 1615-22.
DANA = (2+3+4)/3 – (0+1)/2 = 2,5
F0 20%; F1 50% ; F2 50%; F3 20%; F4 20%
ANA
DANA = (2+0+0)/1 – (0+1)/1 = 1
19. AUROC standardisation
according to fibrosis prevalence
Poynard et al. Clin Chem 2007; 53: 1615-22.
DANA = (2+3+4)/3 – (0+1)/2 = 2,5
F0 50%; F1 50% ; F2 50%; F3 20%; F4 50%
ANA
DANA = (0+0+4)/1 – (0+0)/1 = 4
20. Poynard et al. Clin Chem 2007; 53: 1615-22.
DANA = 1
DANA = 4
AUC = 0.67
AUC = 0.98
AUROC standardisation
according to fibrosis prevalence
24. Utilisation en première intentionUtilisation en première intention
des tests non invasifs chez les patients VHCdes tests non invasifs chez les patients VHC
EASL-ALEH Clinical practice Guidelines. J Hepatol 2015; 63: 237-64.
25. Evaluation non invasiveEvaluation non invasive
FibroScan: 28.0 kPa (IQR: 18.5)
FibroTest: 0.85
Ces résultats vous surprennent-ils ?
Ces résultats vous satisfont-ils ?
26. How to interpret FibroScan resultsHow to interpret FibroScan results
manufacturer’s recommendationsmanufacturer’s recommendations
Success rate > 60%
10 validated measures
IQR < 30% median
Castera, Forns & Alberti. J Hepatol 2008; 48: 835-47
27. Applicability of transient elastographyApplicability of transient elastography
Unreliable 15.8%
IQR/LSM > 30%
9.2%
SR < 60%
8.1%
VS < 10
3.1%
Failure 3.1%
Valid shot =
0
Castéra et al. Hepatology 2010; 51: 828-35Castéra et al. Hepatology 2010; 51: 828-35
FibroScan
not applicable
in 20%
of cases
N=13669 examinationsN=13669 examinations
ObesityObesity OperatorOperator
experienceexperience
28. Unreliable
IQR/LSM > 30%
SR < 60%
VS < 10
Failure
Valid shot =
0
XL Probe:XL Probe:
Does it really overcome the limitations of M probe ?Does it really overcome the limitations of M probe ?
XL vs. M
probe:
1% vs. 16%
N= 276 patients with BMI > 28 kg/m2
Myers et al. Hepatology 2012;Myers et al. Hepatology 2012; 55:199-208.
XL vs. M probe:
27% vs. 50%
29. XL Probe:XL Probe: the cut-off issuethe cut-off issue
N= 65 NAFLD patients Myers et al. Hepatology 2012;Myers et al. Hepatology 2012; 55:199-208.
7.8 vs. 6.4 kPa
M vs. XL
30. Boursier et al. Hepatology 2013; 57: 1182-91Boursier et al. Hepatology 2013; 57: 1182-91
N=1165 patients with CLD; 70% HCVN=1165 patients with CLD; 70% HCV
P=NS
How does applicability translatesHow does applicability translates
into accuracy?into accuracy?
31. Boursier et al. Hepatology 2013; 57: 1182-91Boursier et al. Hepatology 2013; 57: 1182-91
N=1165 patients with CLD; 70% HCVN=1165 patients with CLD; 70% HCV
How does applicability translatesHow does applicability translates
into accuracy?into accuracy?
32. Influence of food intakeInfluence of food intake
Arena et al. Hepatology 2013; 58: 65-72Arena et al. Hepatology 2013; 58: 65-72
Mederacke et al. Liver Int 2009; 29: 1500-6Mederacke et al. Liver Int 2009; 29: 1500-6
TE should be performed
in fasting patients
33. Confounders of liver stiffnessConfounders of liver stiffness
summary for clinical practicesummary for clinical practice
Tapper, Castera, Afdhal. Clin Gastroenterol Hepatol 2015;
39. Mr A… 55 ans VHC+
• FibroTest ininterprétable
• Ne veut pas de biopsie hépatique…
• FibroScan interprétable, en faveur d’une cirrhose
40. Elastométrie : méta-analysesElastométrie : méta-analyses
Chon et al. PLoS ONE 2012
Talwalkar et al. CGH 2007Friedrich-Rust et al. Gastroenterology 2008
Tsochatzis et al. J Hepatol 2011Stebbing et al. APT 2010
41. 14.6
Elastométrie pour le diagnosticElastométrie pour le diagnostic
de cirrhosede cirrhose
3 75
Bien classés 92 %
Ganne-Carrié et al. Hepatology 2006; 44: 1511-7
F = 4
74%
4.5%
misclassified
17%
3.5 %
misclassified
F < 4
96%
83%
(n=1007 patients with various CLD, 165 with cirrhosis)
42. N=1307 patients with viral hepatitis; pre-test probability: 14%
Posttestprobabilitiesofcirrhosis
Degos et al. J Hepatol 2010; 53: 1013-21
64-80%
10%
0-3%
27%
< 7kPa >17kPa12 kPa
Le diagnostic de cirrhose
doit être contextualisé
(probabilités pré-test et post-test)
47. ARFI: Comparison with TEARFI: Comparison with TE
Meta-analysis: significant fibrosisMeta-analysis: significant fibrosis
Bota et al. Liver Int 2013; in press
N= 1063 patients with CLD; 13 studies
ARFI TE
Se = 74%
Low Low Low Low Low Low
Low Low High Low Low Low
Low Low Low Low Low Low
Unclear Low Unclear Unclear Low Unclear
Low Unclear High Low Low Unclear
Low Unclear Unclear Low Low Low
Low Low Low Low Low Low
Unclear Low Unclear Low Low Low
Low Low Low Low Low Low
TE compared to ARFI elastography. Thisisof relevance show that the correla
(A)
(B)
Fig. 2. Summary sensitivity and specificity of elastographic methodsfor predicting significant fibros
elastography (ARFI) and (B) Transient elastography (TE).
Se = 78%Sp = 83%
Low Low Low Low Low
Low High Low Low Low
Low Low Low Low Low
Low Unclear Unclear Low Unclear
Unclear High Low Low Unclear
Unclear Unclear Low Low Low
Low Low Low Low Low
Low Unclear Low Low Low
Low Low Low Low Low
TE compared to ARFI elastography. Thisisof relevance show that the correlation of LS asses
(A)
(B)
Fig. 2. Summary sensitivity and specificity of elastographic methods for predicting significant fibrosis(A) Acoustic radi
elastography (ARFI) and (B) Transient elastography (TE).
Sp = 84%
48. ARFI: Comparison with TEARFI: Comparison with TE
Meta-analysis: cirrhosisMeta-analysis: cirrhosis
Bota et al. Liver Int 2013; in press
N= 1063 patients with CLD; 13 studies
ARFI TE
Se = 87%
Bota et al.
Se = 89%
(A)
(B)
Fig. 3. Summary sensitivity and specificity of elastographic methodsfor predicting cirrhosis(A
(ARFI) and (B) Transient elastography (TE).
Sp = 87%
Bota et al.
Sp = 87%
(B)
Fig. 3. Summary sensitivityand specificityof elastographicmethodsfor predicting cirrhosis(A) Acoustic radiatio
(ARFI) and (B) Transient elastography (TE).
Failure: 2.1% vs. 6.6 % (p<0.001)
49. Challenger for measuring liver stiffnessChallenger for measuring liver stiffness
Supersonic shear Imaging (AixplorerSupersonic shear Imaging (Aixplorer®®))
Muller et al. UMB 2009; 35: 219-29
Bavu et al. UMB 2011;37: 1361-73
50. Supersonic shear Imaging (AixplorerSupersonic shear Imaging (Aixplorer®®))
Comparison with TE in Hepatitis B & CComparison with TE in Hepatitis B & C
Ferrraioli et al. Hepatology 2012; 56: 2125-33N= 121 HCV patients
Significant fibrosis
P=0.002
Leung et al. Radiology 2013; 269: 910-8
N= 226 HBV patients
52. Comparaison SWE, TE et ARFI
Cassinoto et al. J Hepatol 2014; 61: 550-7N= 349 patients with CLD
Failure rate
P=NS
AUROC pour cirrhose
53. Challengers for measuring liver stiffnessChallengers for measuring liver stiffness
Advantages & disavantagesAdvantages & disavantages
• Can be implemented on a
regular US machine
• High applicability
• Performance close to TE
• Advantages
ARFI
• Disadvantages
• Further validation needed
• Narrow range of values
• Quality criteria not defined
• Can be implemented on a
regular US machine
• High range of value (2-150 kPa)
• Performance higher than TE ?
• Advantages
SWE
• Disadvantages
• Further validation needed
• Quality criteria?
• Limited data on
reproducibility
Berzigotti & Castera. J Hepatol 2013; 59: 180-2
54. Challengers for measuring liver stiffnessChallengers for measuring liver stiffness
Magnetic resonance elastographyMagnetic resonance elastography
Muthupillai et al. Science 1995; 269: 1854-7
Huwart et al. Gastroenterology 2008; 135: 32-40
55. Huwart et al. Gastroenterology 2008; 135: 32-40.
MR elastography vs. TE
AUROC
0.84 vs 0.99
N= 96 patients with CLD
F≥2 54%; F4 19%
Bohte al. Eur Radiol 2014; 24: 638-48.
N= 85 patients with HBV & HCV
F≥2 30%
AUROC
0.91 vs 0.91
58. Tests non invasifsTests non invasifs
pour le suivi de la cirrhosepour le suivi de la cirrhose
++
59. 1. Fibroscopie pour dépistage VO
2. Echographie 6 mois pour dépistage CHC
3. Traitement antiviral
4. Rien ou autre
Que faites vous ?Que faites vous ?
60. Prédiction HTP & VOPrédiction HTP & VO
Elastométrie : méta-analyseElastométrie : méta-analyse
Shi et al. Liver Int 2013; 56: 62-71
18 studies; N= 3644 patients
HTP VO LVO
AUC: 0.93 AUC: 0.84 AUC: 0.78
68. 1. FibroScan
2. Serum markers
3. Both
4. None or other
How do you monitor liver fibrosisHow do you monitor liver fibrosis
during antiviral treatment ?during antiviral treatment ?
69. Hezode et al. Aliment Ther Pharmacol 2011; 34: 656-63.
N=91 HCV patients with a prospective follow-up in 5 French centers
Non réponse Eradication virale
Liver stiffness kinetics
during antiviral treatment
BL W4 W12 EOT W24W12
PEG-IFN + RBV 24 or 48 W
70. Non response
Hezode et al. Aliment Ther Pharmacol 2011; 34: 656-63.
N=91 HCV patients with a prospective follow-up in 5 French centers
SVR
Liver stiffness kinetics
during antiviral treatment
Limited value of liver stiffness
monitoring during antiviral treatment
Limited value of liver stiffness
monitoring during antiviral treatment
71. 1. FibroScan
2. Serum markers
3. Both
4. Liver biopsy
5. None or other
How do you monitor liver fibrosisHow do you monitor liver fibrosis
after SVR?after SVR?
72. D’Ambrosio et al. Hepatology 2012; 56: 532-43
Before therapy After SVR
Regression of cirrhosis after SVR
73. Maylin et al. Gastroenterology 2008; 135: 821-9
N=126 HCV patients with SVR and paired liver biopsies pre-post ttt
Regression of cirrhosis after SVRRegression of cirrhosis after SVR
74. N=38 IFN-treated HCV patients with SVR with paired biopsies
D’Ambrosio et al. Hepatology 2012; 56: 532-43
Regression of cirrhosis after SVRRegression of cirrhosis after SVR
75. Kim et al. J Hepatol 2012; 57: 556-63
The Laennec scoring system
Thickness of Septa / Size of Nodule
4a
All cirrhosis are not alike!All cirrhosis are not alike!
4b 4c
Courtesy of Pr P Bedossa
76. Kim et al. J Hepatol 2012; 57: 556-63
N=175 patients with CLD median follow-up: 52.4 mo
Clinical relevance
All cirrhosis are not alike!
77. Kim et al. J Hepatol 2012; 57: 556-63
The Laennec scoring system
Thickness of Septa / Size of Nodule
4a
All cirrhosis are not alike!All cirrhosis are not alike!
4b 4c
Courtesy of Pr P Bedossa
78. Ogawa et al. Antiviral Res 2009; 83: 127-34.
Significant decrease of liver stiffness
values after SVR
N=145 HCV patients (126 ttt) with 4 LSM: BL, EOT, W48, and W96
79. Vergniol et al. J Viral Hepat 2009; 16: 132-40.
N=416 HCV patients (112 ttt) with 3 FibroScan + Fibrotest: BL, EOT, W24.
and last scan is indicated in Fig. 2 according to the viro-
logical response.
The median percentage change between the first and last
Fibrotest in untreated patients and in SVR, RR and NR
Facto
Fibrot
Table
Scan
interv
FibroS
therap
Scan
associ
95% C
betwe
FibroS
Fac
shown
HCV i
initial
rin co
fall in
and 3
10
FibroScan
Fibrotest
%
–5
0
5
0
2.61
–4.7
–15
–10
–10.29
–25
–20
–24.52
–16.77
–30
Untreated NR RR SVR
–29.51
8.67
Fig. 2 Median % changes in FibroScan and Fibrotest values
between the beginning and end of the study in treated
LSM and FT values decrease (%)
according to treatment response
80. Stasi et al. DLD 2013; 45: 840-3.
Decrease of liver stiffness after SVR
in hepatitis C
N=74 HCV patients with a 3 years follow-up
81. N=33 Cirrhotic HCV patients with SVR with paired biopsies
D’Ambrosio et al. J Hepatol 2013; 59: 251-6
Diagnostic accuracy of LSM for fibrosis
regression after SVR in HCV-cirrhosis
Sensitivity 61%
Specificity 95%
82. What do we measure ?What do we measure ?
Confounders of liver stiffnessConfounders of liver stiffness
Tapper, Castera & Afdhal. Clin Gastroenterol Hepatol 2015; 13:60-7
83. Variability of repeated liver stiffness
measurements
Nascimbeni et al. Clin Gastroenterol Hepatol 2015;13: 763-771.e6
531 paired liver stiffness measurements < 1 year from 452 patients
84. RecommandationsRecommandations
Suivi de la cirrhose après guérisonSuivi de la cirrhose après guérison
EASL-ALEH Clinical practice Guidelines. J Hepatol 2015; 63: 237-64.
85. “ Quand le foie est dur
le pronostic est mauvais ”
Un peu d’histoire
Socrate (Vème
siècle av J.C)
87. OV grade II / IIIOV grade II / III
2727
AscitesAscites
4949
HCCHCC
5454
BleedingBleeding
6363 kPakPa1212 7575
Foucher et al. Gut 2006; 55: 403-8.
Complications de la cirrhose
711 patients with liver diseases
F3F4 144
88. Liver stiffnessLiver stiffness
Relationship with liver-related eventsRelationship with liver-related events
diagnosed if coincide
the tumor did not
performed. When
examination was rep
Statistical analyses
Data are expresse
median (range), or n(
patientswith and wit
the chi-squared and
predictors of LRE
multivariate Cox pr
used. Hazard ratios
intervals (CIs) are in
characteristic (ROC)
were used to calcul
prediction of LRE d
sensitivity and speci
were expressed in pe
HCC were calculat
value, 0.05 on a t
significant. Statistica
Figure 2. Cumulative incidence rates of LREs based on
stratified LSM values (Kaplan-Meier plot). Patients with LSM
value . 19 kPa were at a significantly greater risk of LREs development
Kim et al. PloSOne 2012;Kim et al. PloSOne 2012; 7: e36676
N=128 HBV patientsF3-F4N=128 HBV patientsF3-F4
89. Liver stiffnessLiver stiffness
Relationship with liver-related eventsRelationship with liver-related events
Kim et al. PloSOne 2012;Kim et al. PloSOne 2012; 7: e36676
N=128 HBV patientsF3-F4N=128 HBV patientsF3-F4
ues in patients with F3 and F4
of patients with F3 and F4 were 9.0
ge, 4.4–57.1) kPa, respectively and
osis stage were significantly higher
15.86 8.8 kPa, P, 0.001). LSM, liver
Figure 4. Incidence of LREs according to fibrosis stage and LSM
values. The incidence of LREs was similar between patients with F3
fibrosis stage and those with F4 (22.2% vs. 13.6%, P= 0.472) whereas it
Fibroscan for Predicting Liver-Related Events
90. Elasticité hépatiqueElasticité hépatique
survie sans complicationssurvie sans complications
Robic et al. J Hepatol 2011;Robic et al. J Hepatol 2011; 55: 1017-24
N=100 patients CLDN=100 patients CLD
99. Take Home messages (1)Take Home messages (1)
Les méthodes non invasives sont désormais prêtes pour le
« prime time » pour prioriser les patients atteints d’hépatite
C naïfs pour les nouveaux traitements antiviraux.
Elles doivent être interprétées par des spécialistes en
fonction du contexte clinique et des critères de qualité.
L’élastométrie est la technique la plus utilisée car la mieux
validée et la plus performante pour le diagnostic de cirrhose
(meilleure pour l’éliminer que pour le confirmer)
100. Take Home messages (2)Take Home messages (2)
La principale limite de l’élastométrie est sa moins bonne
applicabilité chez les patients obèses.
Les nouvelles techniques comme l’ARFI et la SWE,
permettant de passer outre cette limite, sont prometteuses
avec des performances équivalentes.
Chez les patients ayant une cirrhose virale C guérie, le
suivi par élastométrie n’est pas recommandé dans l’état
actuel des connaissances.
Editor's Notes
an ultrasound transducer probe is mounted on the axis of a vibrator
vibrations of mild amplitude and low frequency are transmitted by the transducer. inducing an elastic shear wave that propagates through the underlying tissues
Results are expressed in kPa.
The median
Only procedures with 10 validated measurements and a success rate of at least 60% and a IQR &lt; 30% of the median value are considered reliable.
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage
Plusieurs paramètres contribuent à la valeur pratique de la biopsie hépatique sont : a) la représentativité de l’échantillon ; b) le conditionnement de l’échantillon ; c) les techniques anatomopathologiques ; d) l’interprétation par l’anatomopathologiste.
La représentativité de l’échantillon tissulaire dépend de la taille et de la fragmentation de l’échantillon. du type d’aiguille utilisée et de la pathologie concernée.
Le bon de demande d’examen anatomopathologique doit comporter des informations clinico-biologiques pertinentes. adaptées à la situation clinique afin de guider le pathologiste dans la prise en charge de la biopsie et son interprétation.
milieu de conservation spéciaux (congélation. formol pour immuno-marquage