Search

Nonalcoholic fatty liver disease (NAFLD) affects 30% of adults in the United States and is characterized by accumulation of excess triglycerides in the liver (Younossi et al. 2016). NAFLD is also a common problem worldwide, affecting an estimated 1 billion or more people (Loomba et al, 2018). NAFLD can present as simple hepatic steatosis (i.e., nonalcoholic fatty liver (NAFL)), or as nonalcoholic steatohepatitis (NASH); the more advanced subtype, where inflammation, fibrosis, and histologic evidence of hepatocyte injury [e.g., ballooning] can be present. NASH, especially in those who have developed stage 2 or 3 fibrosis, can progress to cirrhosis, end-stage liver disease, liver transplantation, hepatocellular carcinoma, and death (Tong et al, 2022). The identification of patients with NASH and who are at risk for progression to cirrhosis and clinically meaningful adverse outcomes, and the development of effective therapies for these patients are public health priorities. NAFL is asymptomatic, and NASH is asymptomatic until advanced disease is present; these conditions cannot be readily diagnosed, or distinguished from each other clinically, or by routine laboratory testing. Diagnosis and staging of NASH therefore currently rely on liver biopsy with histologic assessment. However, liver biopsy is invasive and painful, and it carries a non-zero risk of catastrophic complication, including death. Further, histologic evaluation of liver biopsy is limited by moderate accuracy, sampling variability due to the small amount of material gathered for examination relative to the size of, and histologic diversity within the liver, and interpretation variability. Although biopsy is being used as the reference standard for diagnosis and staging of NASH in drug development clinical trials, and clinically, it has imperfect accuracy and precision. There is widely-recognized need to aid, improve, or augment liver biopsy acquisition and interpretation, or to develop non-invasive biomarkers to replace liver biopsy, or both. Ultrasound shear wave elastography (SWE) is an imaging based method to assess liver stiffness, a known surrogate marker for liver fibrosis. This imaging technology has emerged recently, but is now widely available clinically. However, there is a critical lack of consensus on diagnostic thresholds which vary widely based on hardware, context of use, and fibrosis level. The primary goal of this review is to synthesize the existing literature on ultrasound shear wave elastography and provide optimal thresholds for the diagnosis of clinically significant liver fibrosis (stage ≥ F2) and at-risk NASH via meta-analysis. SWE is a subset of ultrasound elastography imaging techniques, of which there are four. Strain elastography is a semi-quantitative elastographic technique that generates a relative tissue stiffness map. As this is non-quantitative, it will not be considered for this review. Vibration controlled transient elastography (VCTE), also known as Fibroscan, uses a vibrating probe tip to generate shear waves and ultrasound to measure tissue stiffness. This device does not generate traditional B-mode ultrasound images, is primarily used in gastroenterology clinics, and will not be included in this review. 2D-SWE and point-SWE are the two SWE techniques; they utilize an acoustic radiation force impulse (ARFI), a focused ultrasound pulse, to generate shear waves and high resolution B-mode imaging to estimate liver stiffness. This technology is deployed within radiology imaging centers and is often performed in conjunction with diagnostic ultrasound imaging. The test output is an estimate of liver stiffness reported in kPa (representing Young’s modulus) or m/s (representing shear wave speed). These values are interconvertible algebraically. Determining the diagnostic threshold for these two SWE techniques will be the focus of this review.

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide, and prevalence of NAFLD is increasing owing to upward trends of obesity and diabetes (24042449). Nonalcoholic steatohepatitis (NASH) is an advanced stage of NAFLD with a higher risk of progression to complications related to cirrhosis, is currently the second most common indication for liver transplantation in the United States, and is expected to become the leading cause in the near future (24768810, 25461851, 25920090). Despite the large societal burden of NASH, there is no safe, effective medication approved by the United States Food and Drug Administration (FDA) (27646933). Most clinical trials for NASH require as an eligibility criterion the presence of ‘at-risk NASH’, defined as diagnosed NASH, NAFLD activity score (NAS) ≥ 4 and significant fibrosis (F≥2). The rationale is that these patients are at substantial risk for progression to complications of cirrhosis, and so might benefit from participating in NASH drug development clinical trials. By comparison, patients without NASH, with NAS ≤ 3, or with F

Gender inequities are deeply rooted in our society and have significant negative consequences. Female physicians experience numerous gender-related inequities (e.g., microaggressions, harassment, violence). These inequities have far-reaching consequences on health, well-being and career longevity and may result in the devaluing of various strengths that female emergency physicians bring to the table. This, in turn, has an impact on patient healthcare experience and outcomes. During the 2021 Canadian Association of Emergency Physicians (CAEP) Academic Symposium, a national collaborative sought to understand gender inequities in emergency medicine in Canada.We used a multistep stakeholder-engagement-based approach (harnessing both quantitative and qualitative methods) to identify and prioritize problems with gender equity in emergency medicine in Canada. Based on expert consultation and literature review, we developed recommendations to effect change for the higher priority problems. We then conducted a nationwide consultation with the Canadian emergency medicine community via online engagement and the CAEP Academic Symposium to ensure that these priority problems and solutions were appropriate for the Canadian context.Via the above process, 15 recommendations were developed to address five unique problem areas. There is a dearth of research in this important area and we hope this preliminary work will serve as a starting point to fuel further research. To facilitate these scholarly endeavors, we have appended additional documents identifying other key problems with gender equity in emergency medicine in Canada as well as proposed next steps for future research.RéSUMé: OBJECTIFS: Les inégalités entre les sexes sont profondément ancrées dans notre société et ont des conséquences négatives importantes. Les femmes médecins subissent de nombreuses inégalités liées au genre (par exemple, microagressions, harcèlement, violence). Ces inégalités ont des conséquences considérables sur la santé, le bien-être et la longévité de la carrière et peuvent entraîner la dévalorisation des différents atouts que les femmes médecins urgentistes apportent à la table. Ceci, à son tour, a un impact sur l’expérience et les résultats des soins de santé des patients. Au cours du Symposium académique 2021 de l’Association canadienne des médecins d’urgence (ACMU), une collaboration nationale a cherché à comprendre les inégalités entre les sexes en médecine d’urgence au Canada. MéTHODES: Nous avons utilisé une approche en plusieurs étapes basée sur l’engagement des parties prenantes (en utilisant des méthodes quantitatives et qualitatives) pour identifier et classer par ordre de priorité les problèmes d’équité entre les sexes en médecine d’urgence au Canada. À partir d’une consultation d’experts et d’une revue de la littérature, nous avons élaboré des recommandations visant à apporter des changements aux problèmes les plus prioritaires. Nous avons ensuite mené une consultation nationale auprès de la communauté canadienne de médecine d’urgence par le biais d’un engagement en ligne et du symposium universitaire de l’ACMU afin de nous assurer que ces problèmes prioritaires et ces solutions étaient adaptés au contexte canadien. CONCLUSION: Grâce au processus ci-dessus, 15 recommandations ont été élaborées pour traiter 5 domaines problématiques uniques. Il existe un manque de recherche dans ce domaine important et nous espérons que ce travail préliminaire servira de point de départ pour alimenter d’autres recherches. Pour faciliter ces efforts de recherche, nous avons annexé d’autres documents identifiant d’autres problèmes clés en matière d’équité entre les sexes en médecine d’urgence au Canada, ainsi que des propositions d’étapes pour de futures recherches.