We conducted an individual patient data (IPD) meta-analysis to establish stiffness cut-off values for Magnetic Resonance Elastography (MRE) in staging liver fibrosis and to assess potential confounding factors. A systematic review of the literature identified studies reporting MRE data in patients with non-alcoholic fatty liver disease (NAFLD). Data were obtained from the corresponding authors. Pooled diagnostic cutoff value for the various fibrosis stages was determined in a two-stage meta-analysis. Multilevel modelling methods were used to analyze potential confounding factors influencing diagnostic accuracy of MRE in staging liver fibrosis. Eight independent cohorts comprising 798 patients were included in the meta-analysis. The AUROC for MRE in detecting significant fibrosis was 0.92 (sensitivity: 79%, specificity: 89%). For advanced fibrosis, the AUROC was 0.92 (sensitivity: 87%, specificity: 88%). For cirrhosis, the AUROC was 0.94 (sensitivity: 88%, specificity: 89%). Cut-offs were defined to explore concordance between MRE and histopathology: ≥F2: 3.14 kPa (pre-test probability:39.4%); ≥F3: 3.53 kPa (pre-test probability:24.1%); F4: 4.45 kPa (pre-test probability:8.7%). In generalized linear mixed model analysis, histological steatohepatitis with higher inflammatory activity [OR (95% CI) =2.448 (1.180-5.079), P120U/L) [OR (95% CI) = 3.388(1.577-7.278), P<0.01] were significantly associated with elevated liver stiffness, and thus affecting accuracy in staging early fibrosis (F0-F1). Steatosis, as measured by MRI-PDFF, and body mass index (BMI) were not confounders. MRE has excellent diagnostic performance for significant, advanced fibrosis and cirrhosis in patients with NAFLD. Elevated inflammatory activity and GGT level may lead to overestimation in staging early liver fibrosis, but anthropometric measures such as BMI or the degree of steatosis do not. This individual patient data meta-analysis on 8 international cohorts including 798 patients demonstrated that MRE achieves excellent diagnostic accuracy for significant, advanced fibrosis and cirrhosis in patients with NAFLD. The cut-off values (significant fibrosis: 3.14 kPa, advanced fibrosis: 3.53 kPa, cirrhosis: 4.45 kPa) were established. Elevated inflammatory activity and GGT level may affect the diagnostic accuracy of MRE, overestimating liver fibrosis in early stages. No impact of diabetes, obesity or any other metabolic disorder on the diagnostic accuracy of MRE.

Background: There has been speculation as to whether hormonal changes during pregnancy or pre‐existing conditions of general, oral, and dental health and socio‐cultural background have a greater impact on the development of periodontal disease during pregnancy.Methods: This study evaluates the periodontal status of 130 pregnant women (plaque index, bleeding index, probing depth, and clinical attachment level) and its relationship to demographic (age, professional level, education, and urban or rural residence) and clinical variables (gestation period, previous pregnancy, health status, previous live births, previous periodontal maintenance). The hospital in which the study was conducted was selected during a prior pilot study. All records were compiled by the same trained examiner with a calibrated manual probe. Statistical tests used were ANOVA and ANCOVA.Results: Results showed a mean plaque index of 58.7±2.79%, which increased with statistical significance when the professional level was lower (P <0.014), education was lower (P <0.01), previous periodontal maintenance was less frequent (P <0.00001) and patients lived in rural areas (P <0.0003). The mean bleeding index was 68.8±2.44% and was significant in relation to lower professional level (P <0.025), less frequent previous periodontal maintenance (P <0.029), and an urban residence (P <0.0011). A mean clinical attachment level of 0.84±0.65 mm was observed and was related significantly with age (26 to 30 years) (P <0.001) and the third trimester of gestation period (P <0.0025). The mean probing depth was 1.71±0.3 mm, which related significantly with age (36 to 42 years) (P <0.0002), lower professional level (P <0.0013), rural residence (P <0.0025), 2 or more previous live births (P <0.0001), and non‐attendance for previous periodontal maintenance (P <0.0023). Using ANCOVA testing and adjusting by age, the differences relating to previous live births disappeared.Conclusions: Gingivitis due to accumulation of plaque was the most characteristic periodontal condition in this sample and was related to professional level, level of education, and previous periodontal maintenance. These results illustrate the importance of establishing periodontal preventive measures for pregnant women, even though their demographic and clinical characteristics do not differ from those of the general population. J Periodontol 1999;70:779‐785.

Background: Health information technologies (HITs) such as electronic health records (EHR) and telemedicine services are currently used to assist clinicians provide care to patients. There are many barriers to HIT adoption, including mismatches between investments and benefits, disruptions in the workflow, and concerns about privacy and confidentiality. The lack of HIT training of health professionals as a workforce is an increasingly recognized and understudied barrier. Objective: The purpose of this study is to describe what courses on HIT topics are available at the graduate level for future health professionals in the European Union (EU) and to explore possible determining factors for their exposure to these courses. Methods: A cross-sectional descriptive study of EU medical schools was performed to explore the prevalence of HIT courses. The curricula of all identified higher learning institutions that offer a medical degree were manually explored to identify graduate-level courses that offer specific training on HIT topics. HIT topics were defined as courses or subjects that provided knowledge on the design, development, use, and implementation of HIT. Associations among potential factors such as population, yearly medical graduates, total number of physicians, EHR presence, and gross domestic product (GDP) were explored. Results: A total of 302 medical schools from the 28 member states of the EU were explored. Only about one-third (90/302, 29.80%) of all medical degree curricula offered any kind of HIT course at the graduate level; in the medical schools that offered HIT courses, the courses were often mandatory (58/90, 64.44%). In most EU countries, HIT courses are offered in less than half of the medical schools, regardless of the country’s GDP per capita. Countries with the highest percentages of HIT course presence have the lowest GDP per capita. There seems to be a weak inverse correlation (–0.49) between the two variables (GDP per capita and HIT course presence). There is a trend between the availability of medical human resources and an increase in the presence of HIT courses, with Romania, Croatia, and Greece as outliers in this respect. Conclusions: The current state of medical training in the EU leaves much room for improvement. Further studies are required for in-depth analysis of the content and manner of instruction that would fit present and future needs of HIT.

This is an update of a review previously published in 2009. Chronic angina and advanced forms of coronary disease are increasingly more frequent. In spite of the improvement in the efficacy of available revascularization treatments, a subgroup of patients continue suffering from refractory angina. Transmyocardial laser revascularization (TMLR) has been proposed to improve the clinical situation of these patients. To assess the effects (both benefits and harms) of TMLR versus optimal medical treatment in people with refractory angina who are not candidates for percutaneous coronary angioplasty or coronary artery bypass graft, in alleviating angina severity, reducing mortality and improving ejection fraction. We searched the following resources up to June 2014: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the metaRegister of Controlled Trials database, ClinicalTrials.gov, and the WHO International Clinical Trials Registry. We applied no languages restrictions. We also checked reference lists of relevant papers. We selected studies if they fulfilled the following criteria: randomized controlled trials (RCTs) of TMLR, by thoracotomy, in patients with Canadian Cardiovascular Society or New York Heart Association angina grade III-IV who were excluded from other revascularization procedures. Three authors independently extracted data for each trial about the population and interventions compared and assessed the risk of bias of the studies, evaluating randomisation sequence generation, allocation concealment, blinding (of participants, personnel and outcome assessors), incomplete outcome data, selective outcome reporting, and other potential sources of bias. From a total of 502 references, we retrieved 47 papers for more detailed evaluation. We selected 20 papers, reporting data from seven studies, which included 1137 participants, of which 559 were randomized to TMLR. Participants and professionals were not blinded, which suggests high risk of performance bias. Overall, 43.8% of participants in the treatment group decreased two angina classes, as compared with 14.8% in the control group: odds ratio (OR) 4.63, 95% confidence interval (CI) 3.43 to 6.25), and heterogeneity was present. Mortality by intention-to-treat analysis was similar in both groups at 30 days (4.0% in the TMLR group and 3.5% in the control group), and one year (12.2% in the TMLR group and 11.9% in the control group). However, the 30-day mortality as-treated was 6.8% in the TMLR group and 0.8% in the control group (pooled OR was 3.76, 95% CI 1.63 to 8.66), mainly due to a higher mortality in participants crossing from standard treatment to TMLR. The assessment of subjective outcomes, such as improvement in angina, was affected by a high risk of bias and this may explain the differences found. Other adverse events such as myocardial infarction, arrhythmias or heart failure, were not considered in this review, as they were not predefined outcomes in trials design and they show a high inconsistency across studies. No new trials on transmyocardial laser revascularization have been published in the last ten years and it is very unlikely that new research will be undertaken in this field. This review shows that risks associated with TMLR outweigh the potential clinical benefits. Subjective outcomes are subject to high risk of bias and no differences were found in survival, but a significant increase in postoperative mortality and other safety outcomes suggests that the procedure may pose unacceptable risks.