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"I must say that after we have begun to pay attention to the diet, it has become clear to me how important it is. You have always known that it was important, but you do not really expect the patients to be undernourished when they are hospitalised" Nurse
|
15363101_p43
|
15363101
|
Divergent attitudes towards intervention
| 1.166071 |
other
|
Other
|
[
0.15350960195064545,
0.4225791096687317,
0.4239112138748169
] |
[
0.004066636320203543,
0.9853611588478088,
0.0022098422050476074,
0.008362356573343277
] |
en
| 0.999997 |
After the intervention the nurses were more conscious of their choice of food rich in energy than " before where they did not pay much attention to the fact that febrile patients constituted a special group at risk of falling into nutritional deficit". The general belief that 'fat is bad' for patients was widespread before the intervention. This belief springs from general dietary recommendations for healthy people. However, the intervention raised consciousness of the fact that public dietary recommendations may be suitable for healthy, but not for ill people.
|
15363101_p44
|
15363101
|
Divergent attitudes towards intervention
| 2.134111 |
biomedical
|
Other
|
[
0.965571939945221,
0.00846470519900322,
0.0259633157402277
] |
[
0.31521841883659363,
0.6754209399223328,
0.006930594332516193,
0.002430061576887965
] |
en
| 0.999999 |
The focus group interviews overall showed that the concept of 'individual nutrition' was not easily introduced in the nutritional practice at the two bed section. The staff was able to offer food five times during 12 hours during a 24-hour period. The duration of the meals was dictated by tight time schedules for maids and the hospital orderly. Lunch and dinner were often served under time pressure. Between the fixed meals, the care providers often lacked the time to offer patients various kinds of between-meals in the form of frozen, heated food. Assuming that nutritional care rests on the efforts of a committed staff, it may be claimed that the very organisation of the food service was counterproductive to individual nutritional care because the staff did not have real opportunities to offer the patients any food outside the fixed meal times. Individual nutritional care was also hampered by the fact that the kitchen ran a 24-hour nutrition schedule. This makes it difficult for the patients themselves to decide which meals they want to eat and hence to involve them in their own nutritional care. This was especially a problem for elderly nibblers.
|
15363101_p45
|
15363101
|
Lack of flexibility during meals
| 3.353988 |
biomedical
|
Study
|
[
0.8015482425689697,
0.18009962141513824,
0.018352126702666283
] |
[
0.912481427192688,
0.07928815484046936,
0.0025836359709501266,
0.005646765232086182
] |
en
| 0.999998 |
The clinical dieticians disseminated knowledge about nutrition to the staff in the bed sections, e.g. knowledge about a change in diet from 'unrestricted diet' to 'normal diet and 'hospital diet'. However, such knowledge dissemination was obstructed in several ways. A large staff turnover in some sections meant that such knowledge did not stay in the sections. The exchange of permanent nursing staff during a seven month period including the intervention was 9% and 46% in intervention section IB and IIB respectively (Information from the administration, Aarhus University Hospital). It was difficult for the clinical dietician to get through to the entire staff, as those who were willing to listen were those who took interest in the patients' diet:
|
15363101_p46
|
15363101
|
Lack of knowledge about nutritional care for the patients
| 1.972653 |
biomedical
|
Other
|
[
0.6902862191200256,
0.2703074812889099,
0.03940628096461296
] |
[
0.4554017186164856,
0.5273181796073914,
0.002592620439827442,
0.014687537215650082
] |
en
| 0.999997 |
"But those we do see are those among the staff who take active interest. It's the old guard turning up" Clinical dietician
|
15363101_p47
|
15363101
|
Lack of knowledge about nutritional care for the patients
| 1.029752 |
other
|
Other
|
[
0.1567297726869583,
0.05035318806767464,
0.7929170727729797
] |
[
0.0026411358267068863,
0.9944304823875427,
0.001341747585684061,
0.0015866172034293413
] |
en
| 0.999998 |
Some care providers found that it was time-consuming to acquire knowledge about nutrition. Thus a member of the health care support staff mentioned that "just learning what a 'normal diet' and a 'hospital diet' is takes so much time".
|
15363101_p48
|
15363101
|
Lack of knowledge about nutritional care for the patients
| 1.599532 |
biomedical
|
Other
|
[
0.775822103023529,
0.08552003651857376,
0.1386578381061554
] |
[
0.02108374610543251,
0.9737291932106018,
0.0019145999103784561,
0.0032724235206842422
] |
en
| 0.999996 |
Along this line, several staff members, especially nursing assistants and health care support staff mentioned that it would be very useful if they had a resource agent they could ask about nutritional issues. It was possible for the care providers to refer the patients to the clinical dieticians. However, they felt that the dieticians were often so busy giving advice to referred patients that they could hardly assume a role in the daily nutritional care. The clinical dieticians, on their side, indicated that they would like the care providers to involve them more so that they could also give advice to patients who had not been referred. However, it was difficult for the clinical dieticians to be allowed to contribute:
|
15363101_p49
|
15363101
|
Lack of knowledge about nutritional care for the patients
| 1.918829 |
clinical
|
Other
|
[
0.1659574657678604,
0.8043398261070251,
0.02970268949866295
] |
[
0.048880685120821,
0.9193216562271118,
0.0031829813960939646,
0.028614716604351997
] |
en
| 0.999997 |
"The nurses think that they can manage the patients' nutritional situation. I think that is what they believe today. But if we were there when a question was raised, then they would use us. That's what I think" Clinical dietician
|
15363101_p50
|
15363101
|
Lack of knowledge about nutritional care for the patients
| 1.292508 |
clinical
|
Other
|
[
0.24362683296203613,
0.6245701909065247,
0.13180294632911682
] |
[
0.006059426814317703,
0.9815799593925476,
0.002219749614596367,
0.010140897706151009
] |
en
| 0.999996 |
Much would be gained, according to the clinical dieticians, if the staff knew that the patients' loss of weight during hospitalisation should be avoided and if such knowledge was used in the nutritional care.
|
15363101_p51
|
15363101
|
Lack of knowledge about nutritional care for the patients
| 1.659837 |
biomedical
|
Other
|
[
0.8188630938529968,
0.15787240862846375,
0.023264477029442787
] |
[
0.006389098707586527,
0.9873260855674744,
0.0011223937617614865,
0.005162383429706097
] |
en
| 0.999999 |
One nurse put forward the view that recommendations for healthy people also applied to patients. But during the intervention she expressed that she had changed her perception, but she found it difficult to manage nutritional requirements of ill patients and at the same time relate to dietary advice to healthy people, which were also used in the nutritional care of hospitalised patients. The clinical dieticians had also noted that many elderly patients were served the 'normal diet' even if they needed 'hospital diet'. These observations could signal the existence of a gap between the knowledge the nurses had and the knowledge actually needed to asses, among others, which diet suited particular patients best. The introduction of two diets caused some confusion and uncertainty among the occupational groups involved.
|
15363101_p52
|
15363101
|
Lack of knowledge about nutritional care for the patients
| 2.518634 |
biomedical
|
Other
|
[
0.5732601881027222,
0.4141383469104767,
0.012601534835994244
] |
[
0.36602783203125,
0.5925165414810181,
0.005955527536571026,
0.03550010547041893
] |
en
| 0.999997 |
The care providers expressed an interest in the patients' nutrition, but also mentioned that they often had to ignore this aspect of care because of their tight work schedule. Some days when they had the time and the resources, they would pay more attention to the patients' nutrition, overseeing for example how much the patients were eating. But on busy days the care providers had to abstain – e.g. from offering the patients an extra portion " because it's nutrition and similar things which we must choose not to include when we are busy".
|
15363101_p53
|
15363101
|
Nutrition – a subordinate part of the care
| 1.674233 |
clinical
|
Other
|
[
0.1277732104063034,
0.7925353050231934,
0.07969151437282562
] |
[
0.03698891028761864,
0.9285654425621033,
0.003557055490091443,
0.03088865429162979
] |
en
| 0.999998 |
Time was a limiting factor in nutritional care. The overall message was that the staff found it difficult to find time for determining the patient's height, calculate BMI, talk with the patient about losing weight, the patient's wishes for diet and his/her possible problems with eating and drinking. Time was hence both a real and an imagined barrier to recording the patients' nutritional status and to including the patients in their own nutritional care.
|
15363101_p54
|
15363101
|
Nutrition – a subordinate part of the care
| 2.091924 |
clinical
|
Other
|
[
0.37732094526290894,
0.604401171207428,
0.01827792264521122
] |
[
0.03127119317650795,
0.9493891596794128,
0.0025776152033358812,
0.01676199585199356
] |
en
| 0.999996 |
In relation to that several care providers in section IB said that the nutritional care was a secondary priority. Hence, it was not perceived as a part of the care and treatment itself, but rather as a service " along with laundering and ironing" , as mentioned by the charge nurse in section IB. Other care providers in section IB also said that serving food and beverages for the patients was not part of their job:
|
15363101_p55
|
15363101
|
Nutrition – a subordinate part of the care
| 1.431215 |
other
|
Other
|
[
0.2318127155303955,
0.26610615849494934,
0.5020810961723328
] |
[
0.037106070667505264,
0.9554425477981567,
0.001552590518258512,
0.0058987075462937355
] |
en
| 0.999997 |
"You feel you are in the catering business in some way when you have to wait on the patients" Nursing assistant
|
15363101_p56
|
15363101
|
Nutrition – a subordinate part of the care
| 1.009883 |
other
|
Other
|
[
0.06032077968120575,
0.055361539125442505,
0.8843176364898682
] |
[
0.004846363328397274,
0.9921543002128601,
0.001053108717314899,
0.0019462505588307977
] |
en
| 0.999995 |
This would seem to suggest that for some care providers, nutritional care and the tasks such care demanded was not perceived as a natural part of their care activities. If a part of the staff defined nutritional care and the task of making sure that the patients got enough to eat as a job function outside the normal realm of their occupation this evidently constituted a barrier to an improvement in the patients' nutritional care.
|
15363101_p57
|
15363101
|
Nutrition – a subordinate part of the care
| 2.145056 |
biomedical
|
Other
|
[
0.7799524664878845,
0.12796548008918762,
0.09208206087350845
] |
[
0.13427622616291046,
0.8591389060020447,
0.0026439675129950047,
0.00394091522321105
] |
en
| 0.999995 |
The patients' nutrition was hence not a priority area within the overall care work performed by the nurses and it was not an active part of the treatment. Inversely, the nurse in charge in section IIB thought that nutrition should be a first line priority to ensure that the work performed by the other occupational groups could have optimal effect. She pointed, among others, to the restoration of physical strength among stroke patients. She was aware that the work routines and the barriers to knowledge dissemination to other occupational groups was a factor limiting the speed with which changes could be implemented. The nurses in charge' attitudes to intervention and nutritional care were reflected in the attitudes of the rest of the staff.
|
15363101_p58
|
15363101
|
Nutrition – a subordinate part of the care
| 1.966821 |
biomedical
|
Other
|
[
0.491870641708374,
0.4587520658969879,
0.04937724769115448
] |
[
0.08326729387044907,
0.8873260021209717,
0.0026030028238892555,
0.02680375427007675
] |
en
| 0.999997 |
The data paradoxically showed that although nutritional care falls within the nurses' competence area, they only engaged in such care when they had the time to do so. When the nurses were busy, which they often were according to themselves, they gave lower priority to nutritional care. However, continuity of nutritional care was particularly important in nibblers according to the clinical dietician:
|
15363101_p59
|
15363101
|
Nutrition – a subordinate part of the care
| 2.203882 |
biomedical
|
Study
|
[
0.8312286138534546,
0.1536850929260254,
0.015086246654391289
] |
[
0.767875075340271,
0.21940508484840393,
0.003640158800408244,
0.009079735726118088
] |
en
| 0.999998 |
"It is not always big science or intricate calculations; it's almost just a simple matter of remembering to serve the food to the patient" Clinical dietician
|
15363101_p60
|
15363101
|
Nutrition – a subordinate part of the care
| 1.462167 |
biomedical
|
Other
|
[
0.7574406862258911,
0.13378393650054932,
0.1087753176689148
] |
[
0.0026023895479738712,
0.9927505254745483,
0.0019306809408590198,
0.002716392744332552
] |
en
| 0.999997 |
The results suggest that the occupational groups involved in the food service had different guidelines. The assistant catering officer from the kitchen declared that she adopted a 24-hour approach to the planning of menus and distribution of energy percentages. The care providers prioritised that patients ate the meals they chose from the menus. However, this target was compromised by constraints of time and choice. The maids stuck meticulously to the diet previously decided by the nurses for each individual patient, while the care providers did not. Moreover, contrary to the clinical dieticians, some care providers thought that overweight patients should lose weight during their admission. The dietary change introduced to make some of the patients lose weight was, however, criticized by some of care providers in section IIB. They found that the change to 'normal diet' was not clear to the patients and was an expression of abuse of power, because the patients did not have any choice.
|
15363101_p61
|
15363101
|
Lack of recognition of responsibility for nutritional care
| 2.310922 |
biomedical
|
Study
|
[
0.8586875796318054,
0.09221742302179337,
0.049094993621110916
] |
[
0.7231407761573792,
0.2683011591434479,
0.0024459126871079206,
0.006112163886427879
] |
en
| 0.999999 |
The data gave no indications that the involved occupational groups shared a common goal as far as nutritional care was concerned. Inversely, the different groups had different priorities and showed neither insight nor any understanding of the professional competences of the other groups. The clinical dieticians also mentioned that a relatively high staff turnover at the bed sections ran counter to continuity of nutritional care and made it difficult to maintain a high, constant level of nutritional knowledge at the bed section derived through instruction and teaching undertaken by the clinical dieticians.
|
15363101_p62
|
15363101
|
Lack of recognition of responsibility for nutritional care
| 2.171769 |
biomedical
|
Study
|
[
0.8472450375556946,
0.1311829388141632,
0.021571960300207138
] |
[
0.8109759092330933,
0.1781928539276123,
0.004103018902242184,
0.006728196982294321
] |
en
| 0.999997 |
Furthermore, the responsibility for the practical aspects of nutritional care could not be precisely located because many different staff groups were involved. This invariably increased the risk that responsibility was diluted, viz. that the individual care provider loses his/her sense of responsibility and overview of the situation. The staff in the bed sections did not see precise definition of responsibility as a central issue as opposed to staff outside the bed sections who would like to see a clear formal distribution of responsibility for nutritional care with a view to improving communication and procedures.
|
15363101_p63
|
15363101
|
Lack of recognition of responsibility for nutritional care
| 1.839073 |
biomedical
|
Other
|
[
0.4076251685619354,
0.2917722761631012,
0.30060258507728577
] |
[
0.04586488753557205,
0.9483931064605713,
0.0018185143126174808,
0.003923584707081318
] |
en
| 0.999998 |
"Nutritional care, distribution and orders should be given priority from above. It should not be the maids who should work for this. They are often having all the problems because the care providers have other duties they must see to; so the maids are sometimes doing as best they can; and what else can they do? But it should be a priority coming from the very top" Assistant catering officer
|
15363101_p64
|
15363101
|
Lack of recognition of responsibility for nutritional care
| 1.099806 |
other
|
Other
|
[
0.01752724125981331,
0.005188426934182644,
0.97728431224823
] |
[
0.0013848711969330907,
0.9975353479385376,
0.000572401040699333,
0.0005073574720881879
] |
en
| 0.999998 |
The data suggested that dilution of responsibility was accompanied by an element of responsibility evasion. The care providers are, theoretically, responsible for the patients' nutritional care, but the maids assumed the lion's share of this responsibility in practice. The maids were employed in the maintenance section and therefore had no occupational responsibility for the patients' nutrition. However, the maids were very committed and felt responsible for the patients' nutrition. They found it difficult to accept that they had no guarantees that other staff members would take responsibility for the patients' diet when they were not at work. When the maids were having their weekends, holidays etc., the substitutes would often take over their function. The maids declared that they would be happy to take a more active role in the patients' nutritional care. Through their teaching at the bed sections, the clinical dieticians had learned that the maids in general were showing much commitment, attention and responsibility towards the issue of the patients' nutritional status. Inversely, several care providers found it difficult so see themselves take a more active role vis-à-vis nutritional care.
|
15363101_p65
|
15363101
|
Lack of recognition of responsibility for nutritional care
| 2.775676 |
biomedical
|
Study
|
[
0.7342530488967896,
0.21583910286426544,
0.04990788549184799
] |
[
0.6122352480888367,
0.3753238618373871,
0.003563549602404237,
0.008877337910234928
] |
en
| 0.999995 |
As a measure intended to counteract the dilution and evasion of responsibility, the assistant catering officer suggested that central hospital management should issue a clear statement that the patients' nutritional status was a high priority area that deserved serious attention from all occupational groups. Such a message could also give impetus to a process of clarifying responsibilities and tasks related to nutritional care in all bed sections.
|
15363101_p66
|
15363101
|
Lack of recognition of responsibility for nutritional care
| 1.345754 |
other
|
Other
|
[
0.09624900668859482,
0.015786122530698776,
0.8879647850990295
] |
[
0.0021931787487119436,
0.9969747066497803,
0.00034029982634820044,
0.0004918539780192077
] |
en
| 0.999995 |
Prior to intervention food ingested during hospitalisation on average met 72% of the patient' protein (table 2 ) and 85% of their energy requirement (table 3 ), and there was no significant difference between the four bed sections. But the intervention targeting the nutritional care had a significantly better effect in bed section IB than in intervention section IIB measured as the extent to which the protein and energy requirements were met. But the quantitative results revealed that the forms designed for assessing the patients nutritional status had been used only to a limited extent. This result was reflected in the results showing that the staff on admission only weighed half of the patients. The outcome of the intervention was probably influenced by the reluctance among the staff in bed section IB to implement the new guidelines, and by the large staff turnover in bed section IIB. Interestingly, the patients' intake of protein- and energy increased significant in bed section IB during the intervention. It cannot be excluded that the focus on the nutritional care coming from an investigator outside of the organization, had led to this paradox that, despite the reluctance identified among the staff, nutritional care was optimised.
|
15363101_p67
|
15363101
|
Discussion
| 4.120617 |
biomedical
|
Study
|
[
0.9954817295074463,
0.003887284081429243,
0.000630965456366539
] |
[
0.9987908005714417,
0.0006453297100961208,
0.00038024832610972226,
0.00018358872330281883
] |
en
| 0.999996 |
Patients who were severely mentally or physically impaired were not included in the study of ethical reasons, although they as 'nibblers' did not receive a different form of nutritional care. So the sample is not representative for all the medical patients. If this group of patients had been included the quantitative results probably would have been lower, as described in an other Danish study .
|
15363101_p68
|
15363101
|
Discussion
| 1.916184 |
biomedical
|
Study
|
[
0.9853227138519287,
0.004444513004273176,
0.010232673957943916
] |
[
0.9516860246658325,
0.046273373067379,
0.0009851340437307954,
0.001055511529557407
] |
en
| 0.999997 |
The average length of the hospital stay for the patients participating in this study was 23 days. The average length for medical patients in the Aarhus County was six days . This significant difference may be ascribed to the fact that patients hospitalised for less than five days were excluded in this study. On the other hand, mentally or physically impaired patients were not included. The official statistics on the length of hospital stays include a large group of patients who are long-term hospitalised. In this study 27% of the patients were hospitalised for more than four weeks. Long-term hospitalisation demands that particular attention be paid to the problem of weight loss. A 24-hour weight loss reaching 154 gram was found before the intervention, which may, indeed, be regarded as a problem during hospitalisation.
|
15363101_p69
|
15363101
|
Discussion
| 2.735371 |
biomedical
|
Study
|
[
0.9784345030784607,
0.015830349177122116,
0.005735267419368029
] |
[
0.9917954802513123,
0.0070989131927490234,
0.00037158079794608057,
0.0007339699659496546
] |
en
| 0.999994 |
The introduction of new diets made a difference both to the patients and the staff at the bed sections. Thus the 'normal diet' had a lower fat energy percentage than the other diets. This meant that patients had to consume a very sizeable diet in order to cover their energy requirement, which was rarely manageable for patients with reduced appetite. The clinical dietician mentioned that they had most frequently met patients with a poor or reduced appetite and a simultaneous need for a diet with a high nutrient density. This observation is corroborated by observations made by other Danish clinical dieticians . The results of this study indicate that it is hardly appropriate to base nutritional care on recommendations intended for healthy individuals if the staff's nutritional knowledge matches that seen in the present study. The consequences seem to be a deterioration of the nutritional status in an even larger fraction of patients.
|
15363101_p70
|
15363101
|
Discussion
| 4.007712 |
biomedical
|
Study
|
[
0.983567476272583,
0.015589524060487747,
0.0008430876769125462
] |
[
0.9959644079208374,
0.002437631133943796,
0.0009440124267712235,
0.0006539481692016125
] |
en
| 0.999997 |
The common understanding and recognition of the integration of nutritional care as part of the overall care among all occupational groups is a key prerequisite in an effort to see nutritional care as part of the care for the individual patient . Another key prerequisite is that responsibility for such care is vested in real professional competence that lies with a single staff group, i.e. that it is backed by knowledge . On this basis it might be possible to establish cooperation and launch a fruitful dialogue.
|
15363101_p71
|
15363101
|
Discussion
| 1.908375 |
biomedical
|
Other
|
[
0.6947425603866577,
0.05570096895098686,
0.2495564967393875
] |
[
0.0011386218247935176,
0.9975995421409607,
0.0007622982375323772,
0.0004995456547476351
] |
en
| 0.999998 |
Nutritional care fell within the competence of the nurses who were therefore able largely to determine to which extent other occupational groups were allowed to contribute with knowledge about nutrition. The clinical dieticians mentioned that they would like a more extensive dialogue with the other care providers about the patients' nutritional status, but these groups did not welcome such cooperation.
|
15363101_p72
|
15363101
|
Discussion
| 1.933639 |
biomedical
|
Other
|
[
0.7819586992263794,
0.1868400126695633,
0.03120134025812149
] |
[
0.06556344032287598,
0.9248420596122742,
0.002835927763953805,
0.006758552510291338
] |
en
| 0.999996 |
One of the nurses in charge found that the intervention had made the nurses pay more attention to nutritional issues including, in particular, patients at increased risk of becoming undernourished. However, it was difficult to translate increased attention into specific nutritional care actions such as recording the patients' nutritional status upon admission by using the special food records. In a study of the relationship between nurses' competences and their knowledge about nutrition and diet in a hospital in the South of England, Lin Perry showed that there was no clear association between the nurses' attitudes, knowledge and actions, as neither knowledge nor attitudes were translated into action . The study also demonstrated discrepancies between what the nurses said they were doing in relation to the patients' nutrition and what was actually documented in the patient records. Perry concluded that nursing care was frustrated by absence or inadequate knowledge among nurses about nutrition or by the failure to communicate such knowledge and a lack of common standards in general.
|
15363101_p73
|
15363101
|
Discussion
| 4.000511 |
biomedical
|
Study
|
[
0.9949719905853271,
0.003163384972140193,
0.0018646777607500553
] |
[
0.9941034913063049,
0.0009381570853292942,
0.004718175623565912,
0.00024017335090320557
] |
en
| 0.999995 |
However, the fact that the staff entertained views on the importance of the food and the food service did not imply that all groups were committed to seeing nutritional care as an element of the overall care effort. And the intervention study was an external project that was not anchored in the bed section's own staff. So that may explain the moderate reluctance to take active part in the study shown by some of the occupational groups . The effect was that the nutritional care was not optimal. Some nurses gave as a reason for this situation that nutritional care was not part of the nursing care and that the time pressures induced by other tasks forced them to give lower priority to nutritional care. In the recommendations of The International Council of Nurses (ICN) the patients' nutritional status is placed second after the first dimension 'ability to breathe' . This implies that a patient's nutritional status is considered an important issue in nursing theory, which is the basis of patient care. This is interesting in the light of the results of the focus group interviews presented here, because it appears that there is no agreement between the guidelines issued by the ICN and the Danish Nurses Organisation as far as the importance of nutrition and the nutritional care the patients receives during hospitalisation is concerned. Several papers in Danish and international nursing journals hence advocate that nurses assume a central role in countering patient under nourishment – a role rarely entertained by nurses today . Yet, the clinical dieticians and the maids found that the nurses took into account neither their knowledge about patient nutrition in general, nor their knowledge of the individual patient's situation. Paradoxically, however, the nurses still claimed that nutritional care fell mainly within their competence.
|
15363101_p74
|
15363101
|
Discussion
| 4.106439 |
biomedical
|
Study
|
[
0.9955158829689026,
0.003296723822131753,
0.001187411486171186
] |
[
0.9971701502799988,
0.0011004558764398098,
0.0015645896783098578,
0.00016476970631629229
] |
en
| 0.999998 |
The clinical dieticians, the maids and the assistant catering officer reported poor communication between patients, nursing staff and kitchen. But the care staff did not share this view.
|
15363101_p75
|
15363101
|
Discussion
| 1.322766 |
biomedical
|
Other
|
[
0.39388853311538696,
0.3597573935985565,
0.2463541179895401
] |
[
0.027476081624627113,
0.9580868482589722,
0.0020051340106874704,
0.012431953102350235
] |
en
| 0.999998 |
The individual bed sections apparently did not have a clear distribution of responsibilities embracing all aspects of nutritional care. On the contrary, the data suggested that dilution of responsibility was accompanied by an element of responsibility evasion.
|
15363101_p76
|
15363101
|
Discussion
| 1.829716 |
biomedical
|
Other
|
[
0.7290652990341187,
0.012869816273450851,
0.25806480646133423
] |
[
0.40532368421554565,
0.5905826091766357,
0.002179978182539344,
0.0019136855844408274
] |
en
| 0.999996 |
The degree to which patients' energy and protein requirements are covered undoubtedly varies from hospital to hospital depending on the menus served and the commitment to the nutritional care shown by the care staff and management. However, any food service involves a long chain of tasks and work processes reaching from the kitchen to the patient, and the food service is essentially organised in the same way and priorities are generally the same in all Danish hospitals. It is therefore likely that the problems associated with insufficient nutritional care are of a similar nature in Danish hospitals and some European hospitals . The perspective for further investigation could be a Health Technology Assessment (HTA) to evaluate the aspect of the patients, the organisation and the economy of the nutritional care of medical inpatients.
|
15363101_p77
|
15363101
|
Discussion
| 2.560192 |
biomedical
|
Other
|
[
0.935192883014679,
0.007332359906286001,
0.057474736124277115
] |
[
0.16741472482681274,
0.8197177648544312,
0.011829436756670475,
0.0010381060419604182
] |
en
| 0.999996 |
The average intake of energy and protein among hospitalised medical patients did not cover their requirements. Prior to intervention, food ingested during hospitalisation on average met 72% of the patients' protein and 85% of their energy requirement. After changing the diets from 'unrestricted diet' to 'normal diet' and 'hospital diet', the diet on average met 61% of the control patients' protein and 75% of their energy requirements. Intervention allowed a significantly better satisfaction of the patients' protein and energy requirements at one of the intervention sections using standard hospital food. However, the implementation of procedures focusing on nutritional care appeared to be difficult, especially at bed sections with a large staff turnover. Consequently, the results of the study call attention to the existence of barriers to efforts aimed at improving the nutritional care of patients.
|
15363101_p78
|
15363101
|
Conclusion
| 4.057288 |
biomedical
|
Study
|
[
0.9976231455802917,
0.0018977082800120115,
0.0004791105166077614
] |
[
0.9989234805107117,
0.00056021090131253,
0.0003829691559076309,
0.00013332620437722653
] |
en
| 0.999997 |
Introduction of nutritional care as part of the overall care met with barriers among the care providers. Focus group interviews identified these barriers as lack of time, lack of knowledge, lack of contact with resource agents concerning nutrition, lack of commitment, resistance towards a additional perceived workload and resistance towards providing service to the patients. Care providers who wished to provide individual nutritional care saw the very organisation of the food service as an obstacle to their freedom of action and flexibility. The effect of this was that it was difficult to accommodate individual patients' requirements.
|
15363101_p79
|
15363101
|
Conclusion
| 2.392769 |
biomedical
|
Study
|
[
0.5999873280525208,
0.36567336320877075,
0.03433926776051521
] |
[
0.625738799571991,
0.3551218807697296,
0.006171913351863623,
0.012967394664883614
] |
en
| 0.999998 |
Occupational groups involved in nutritional care worked on the basis of different perceptions, had no shared target and no clear division of responsibility. Improvement of the nutritional care requires that focus be directed towards the final link in the food service chain.
|
15363101_p80
|
15363101
|
Conclusion
| 1.543732 |
other
|
Other
|
[
0.43523773550987244,
0.006211194209754467,
0.5585510730743408
] |
[
0.00360023882240057,
0.9952241778373718,
0.0008516269153915346,
0.00032405316596850753
] |
en
| 0.999999 |
This study showed that nutritional care was a subordinate rather than a coordinate element in the overall care effort. The failure of coordination hinged on dimensions of organisation, knowledge and resource utilisation and it significantly affected the degree to which patients' nutritional requirements were met. An increase in the priority given to nutritional care by central hospital management and a concomitant general change in attitude towards nutritional care is needed and is probably a precondition for achieving a level of sufficient nutrition among hospitalised patients.
|
15363101_p81
|
15363101
|
Conclusion
| 4.070714 |
biomedical
|
Study
|
[
0.997090220451355,
0.002083520870655775,
0.0008262049523182213
] |
[
0.9982738494873047,
0.0005902317352592945,
0.0009743609116412699,
0.00016148568829521537
] |
en
| 0.999998 |
Karin O. Lassen carried out the research design, the fundraising, coordination of organisational communication, food record planning and implementation, performed the data analysis, drafted the manuscript and is the guarantor of the manuscript. Filip Kruse participated in the designing the focus group interviews, in the data analysis, and as author of the manuscript. Merete Bjerrum participated in the data analysis and as author of the manuscript. Lillian Jensen participate in the planning of the food records, performed the calculation of protein and energy intake and participate in the discussion of the manuscript. Kjeld Hermansen contribute to organisational support and discussion of research design and manuscript. All authors read and approved the final manuscript.
|
15363101_p82
|
15363101
|
Authors' contributions
| 0.915638 |
other
|
Other
|
[
0.026937827467918396,
0.0013399715535342693,
0.9717221260070801
] |
[
0.002031753771007061,
0.9967280626296997,
0.0008167733903974295,
0.00042339268838986754
] |
en
| 0.999996 |
None declared.
|
15363101_p83
|
15363101
|
Competing interests
| 0.828596 |
other
|
Other
|
[
0.19056589901447296,
0.005267829168587923,
0.8041662573814392
] |
[
0.017649320885539055,
0.97890704870224,
0.0020668187644332647,
0.0013767849886789918
] |
it
| 0.999995 |
One of the major clinical problems is how to best evaluate and manage the increasing numbers of patients infected with the hepatitis C virus (HCV) . Liver biopsy is still recommended in most patients . However, numerous studies strongly suggest that due to the limitations and risks of biopsy , as well as the improvement of the diagnostic accuracy of biochemical markers , liver biopsy should no longer be considered mandatory.
|
15387887_p0
|
15387887
|
Background
| 3.641963 |
biomedical
|
Review
|
[
0.9937013387680054,
0.004790012259036303,
0.0015087069477885962
] |
[
0.011088592000305653,
0.33387741446495056,
0.6526603102684021,
0.002373673254624009
] |
en
| 0.999997 |
Among the non-invasive alternatives to liver biopsy , several studies have demonstrated the predictive value of two combinations of simple serum biochemical markers in patients infected with HCV: FibroTest (FT; Biopredictive, Paris, France; HCV-Fibrosure, Labcorp, Burlington, USA) for the assessment of fibrosis; and ActiTest (AT; Biopredictive, Paris, France) for the assessment of necroinflammatory activity (necrosis) . Similar results have not been obtained with other diagnostic tests . Since September 2002 these tests (FT-AT) have been used in several countries as an alternative to liver biopsy. In a recent systematic review, it was concluded that these panels of tests might have the greatest value in predicting fibrosis or cirrhosis . It was also stated that biochemical and serologic tests were best at predicting no or minimal fibrosis and at predicting advanced fibrosis/cirrhosis, and were poor at predicting intermediate levels of fibrosis .
|
15387887_p1
|
15387887
|
Background
| 3.952788 |
biomedical
|
Review
|
[
0.9944573640823364,
0.0026738550513982773,
0.0028687783051282167
] |
[
0.013541797176003456,
0.0007373445550911129,
0.9854540824890137,
0.0002666868385858834
] |
en
| 0.999998 |
The aim of this study was to summarize the diagnostic value of these tests by an overview of the scientific literature and to respond to the following frequently asked questions by performing original new analyses: 1) what is the range of the FT-AT diagnostic values across the different studies? 2) What are the base evidence comparisons between FT-AT and other published biochemical markers? 3) Are there differences in diagnostic values according to HCV genotype or viral load? 4) Are there differences between the FT-AT diagnostic values according to stages and grades? – In other words, is FT better at predicting no or minimal fibrosis (F0 vs F1) or advanced fibrosis/cirrhosis (F3 vs F4) than at predicting intermediate levels of fibrosis (F1 vs F2)? And 5) what is the conversion between FT-AT results and the corresponding fibrosis stages and necrosis grades?
|
15387887_p2
|
15387887
|
Background
| 4.06623 |
biomedical
|
Study
|
[
0.9993594288825989,
0.00038745158235542476,
0.0002531173813622445
] |
[
0.968491792678833,
0.0007430943078361452,
0.030565744265913963,
0.0001993886544369161
] |
en
| 0.999995 |
Between February 2001 and March 2004, a total of 16 publications and 4 abstracts without corresponding publications were identified.
|
15387887_p3
|
15387887
|
Analysis of the literature
| 1.840164 |
biomedical
|
Study
|
[
0.9745703935623169,
0.0035080518573522568,
0.021921489387750626
] |
[
0.8587926030158997,
0.11565765738487244,
0.023370185866951942,
0.002179560484364629
] |
en
| 0.999996 |
For 12 groups of patients detailed in 6 publications , it was possible to assess the prevalence of significant fibrosis and the FT area under receiver operating characteristics curve (AUROC) values, as well as the sensitivity and specificity for the 4 different FT cut offs (Table 1 ). For the diagnosis of significant fibrosis by the METAVIR scoring system, the AUROC ranged from 0.73 to 0.87, significantly different from random diagnosis in each study (Table 1 ), in meta-analysis (mean difference in AUROC = 0.39, random effect model Chi-square = 529, P < 0.001) , or after pooling data in the integrated database (Table 2 ). For the cut off of 0.31, the FibroTest negative predictive value for excluding significant fibrosis (prevalence 0.31) was 91% (Table 2 ).
|
15387887_p4
|
15387887
|
Diagnostic value of FT-AT among published studies
| 4.134188 |
biomedical
|
Study
|
[
0.9993830919265747,
0.00042768646380864084,
0.00018923493917100132
] |
[
0.9988856911659241,
0.0002217830769950524,
0.0008125003660097718,
0.0000800321067799814
] |
en
| 0.999995 |
For four groups of patients detailed in two publications , it was possible to assess the prevalence of significant necrosis and the AT AUROC values, as well as the sensitivity and specificity for 4 different AT cut offs (Table 3 ). For the diagnosis of significant necrosis by the METAVIR scoring system, the AUROC ranged from 0.75 to 0.86, significantly different from random diagnosis in each study (Table 3 ), in meta-analysis (mean difference in AUROC = 0.29, random effect model Chi-square = 556, P < 0.001), or after pooling data in the integrated database (Table 4 ). For the cut off of 0.36, the ActiTest negative predictive value for excluding significant necrosis (prevalence 0.41) was 85% (Table 2 ).
|
15387887_p5
|
15387887
|
Diagnostic value of FT-AT among published studies
| 4.134035 |
biomedical
|
Study
|
[
0.9993152618408203,
0.0004835726576857269,
0.00020119643886573613
] |
[
0.9991474151611328,
0.00021725887199863791,
0.0005553431692533195,
0.00007989435835042968
] |
en
| 0.999996 |
In four studies there was a direct comparison in the same patients of FT versus other biochemical markers, including hyaluronic acid , the Forns index , the APRI index and the GlycoCirrhoTest . All the comparisons were in favor of FT (Table 1 ) , except for the GlycoCirrhoTest, which has a similar AUROC (0.87 vs 0.89 for FT) .
|
15387887_p6
|
15387887
|
Comparison of FT-AT diagnostic values with other biochemical markers
| 4.051831 |
biomedical
|
Study
|
[
0.9994210004806519,
0.0003169021802023053,
0.0002620879968162626
] |
[
0.9973248243331909,
0.00029389027622528374,
0.0023084976710379124,
0.0000728238737792708
] |
en
| 0.999995 |
A total of 1,570 subjects were included in the integrated database. Of these, 1,270 were patients with chronic hepatitis C who tested PCR positive before treatment and who had had a liver biopsy and METAVIR staging and grading performed. Of these patients, 453 were from our center , including 130 patients coinfected with HCV and HIV . Eight hundred and seventy (870) patients were from a multicentre study with a total of 398 patients assessed at inclusion and 419 at the end of follow-up six months after treatment; 352 being investigated twice. Three hundred (300) healthy blood donors were also included .
|
15387887_p7
|
15387887
|
Integrated database
| 4.007176 |
biomedical
|
Study
|
[
0.9977017045021057,
0.002023463835939765,
0.0002748041006270796
] |
[
0.998691976070404,
0.0008644676418043673,
0.0002775496686808765,
0.0001661071291891858
] |
en
| 0.999997 |
There was no difference between the AUROC of FT-AT for the diagnosis of significant fibrosis (F2F3F4) and significant necrosis (A2A3) between 4 classes of genotype (1, 2, 3 and the rarer genotypes 4, 5, 6 grouped together). There was also no difference between the AUROC of FT-AT of patients with high or low viral loads for the diagnosis of significant fibrosis or significant necrosis .
|
15387887_p8
|
15387887
|
Diagnostic value of FT-AT according to HCV genotype and viral load
| 3.956424 |
biomedical
|
Study
|
[
0.9992528557777405,
0.0005003311089240015,
0.00024680615752004087
] |
[
0.9991618394851685,
0.000407023006118834,
0.00035505747655406594,
0.00007612617628183216
] |
en
| 0.999995 |
Among the 13 published studies of FT (detailed in Table 1 ), 9 studies estimated FT and 4 studies compared FT to other non-invasive tests. Among the 9 studies estimating FT, 5 were performed by the same single center (non-independent center), two were performed in totally independent centers, and two were performed in multiple centers, including the non-independent center. The AUROCs for the diagnosis of F2F3F4 versus random AUROCs at 0.50, were all significant and similar between these 3 groups in a meta-analysis: mean difference in AUROC = 0.29 (random effect model Chi-square = 549, P < 0.001), including 0.24 for independent, 0.25 for mixed and 0.36 for dependent studies. In the Callewaert et al. study the AUROC of FT for the diagnosis of F4 was 0.89.
|
15387887_p9
|
15387887
|
Diagnostic value of FT according to the independency of authors
| 4.06125 |
biomedical
|
Study
|
[
0.9994431138038635,
0.0003075469867326319,
0.0002494187792763114
] |
[
0.9904396533966064,
0.0002950002672150731,
0.009153066202998161,
0.00011224241461604834
] |
en
| 0.999996 |
The AUROCs between different stage combinations are given in Table 5 . Between two contiguous stages (one stage difference), the AUROCs were not significantly different and ranged from 0.63 to 0.71. Between patients with a two-stage difference, the AUROCs were not significantly different and ranged from 0.75 to 0.86. Between patients with a three-stage difference, the AUROCs were not significantly different and ranged from 0.87 to 0.95. Between patients with a four- or five-stage difference (blood donors versus F3 or F4, and F0 versus F4), the AUROCs were not significantly different and ranged from 0.95 to 0.99.
|
15387887_p10
|
15387887
|
Diagnostic value of FT-AT according to stage and grade
| 4.005052 |
biomedical
|
Study
|
[
0.9986856579780579,
0.0008319042972289026,
0.0004823861818294972
] |
[
0.9992582201957703,
0.00040758628165349364,
0.0002676763688214123,
0.00006653663876932114
] |
en
| 0.999995 |
The AUROCs between different grade combinations are given in Table 6 . Between two contiguous grades (one grade difference), the AUROCs were not significantly different and ranged from 0.60 to 0.70. Between patients with a two-grade difference, the AUROCs were not significantly different and ranged from 0.75 to 0.86. Between patients with a three-grade difference, the AUROCs were not significantly different and ranged from 0.87 to 0.95. Between patients with a four-grade difference (blood donors versus F3 and F0 versus F4), the AUROCs were not significantly different and ranged from 0.95 to 0.99.
|
15387887_p11
|
15387887
|
Diagnostic value of FT-AT according to stage and grade
| 3.950326 |
biomedical
|
Study
|
[
0.9984203577041626,
0.0009666178375482559,
0.0006130854599177837
] |
[
0.9992203712463379,
0.0004722647718153894,
0.00023673691612202674,
0.00007064178498694673
] |
en
| 0.999999 |
FT-AT is a continuous linear biochemical assessment of fibrosis stage and necroinflammatory activity grade. It provides a numerical quantitative estimate of liver fibrosis ranging from 0.00 to 1.00, corresponding to the well-established METAVIR scoring system of stages F0 to F4 and of grades A0 to A3. Among the 300 controls, the median FT value (± SE) was 0.08 ± 0.004 (95 th percentile, 0.23) and the median AT value was 0.07 ± 0.004 (95 th percentile, 0.26). Among the 1,270 HCV-infected patients, the FT conversion was 0.000 – 0.2100 for F0; 0.2101 – 0.2700 for F0–F1; 0.2701 – 0.3100 for F1; 0.3101 – 0.4800 for F1–F2; 0.4801 – 0.5800 for F2; 0.5801 – 0.7200 for F3; 0.7201 – 0.7400 for F3–F4; and 0.7401 – 1.00 for F4. . The AT conversion was 0.00 – 0.1700 for A0; 0.1701 – 0.2900 for A0–A1; 0.2901 – 0.3600 for A1; 0.3601 – 0.5200 for A1–A2; 0.5201 – 0.6000 for A2; 0.6001 – 0.6200 for A2–A3; and 0.6201 – 1.00 for A3 . The conversions are summarized in Figure 4 .
|
15387887_p12
|
15387887
|
Conversion between FT-AT results and the corresponding fibrosis stage and grade
| 4.155301 |
biomedical
|
Study
|
[
0.9994876384735107,
0.00033860921394079924,
0.00017377744370605797
] |
[
0.9993158578872681,
0.00023872754536569118,
0.0003732720797415823,
0.0000722376789781265
] |
en
| 0.999997 |
Based on the limitations of liver biopsy and the present overview of the diagnostic value of FT-AT, it seems that these non-invasive markers should be used as a first line assessment of liver injury in patients with chronic hepatitis C.
|
15387887_p13
|
15387887
|
Discussion
| 3.649118 |
biomedical
|
Review
|
[
0.9972719550132751,
0.001772076589986682,
0.0009559472091495991
] |
[
0.022282881662249565,
0.045145366340875626,
0.9316539764404297,
0.0009177502943202853
] |
en
| 0.999997 |
Liver biopsy has three major limitations, which are the risk of adverse events , sampling error , and inter- and intra- pathologist variability . An overview of published studies summarizes the risks of liver biopsy as pain (around 30%), severe adverse events (3/1,000) and death (3/10,000) . Sampling variation is the major cause of variability . In a study of patients with chronic hepatitis C that included only good quality biopsies, 30 of 124 patients (24.2%) had a difference of at least one grade, and 41 of 124 patients (33.1%) had a difference of at least one stage between the right and left lobes . In 18 patients (14.5%), an interpretation of cirrhosis was made in one lobe, whereas stage 3 fibrosis was made in the other . Recently, Bedossa et al. observed very high coefficients of variation (55%) and high discordance rates (35%) for fibrosis staging in biopsies measuring 15 mm in length. The variability significantly improved in biopsies measuring 25 mm in length but was still very high with a 45% coefficient of variation and 25% discordance rate; the minimal variability was reached for biopsies, which were 40 mm in length .
|
15387887_p14
|
15387887
|
Discussion
| 4.125134 |
biomedical
|
Study
|
[
0.9994428753852844,
0.0003749102761503309,
0.00018221448408439755
] |
[
0.9719637632369995,
0.0006217681802809238,
0.027178026735782623,
0.00023645570036023855
] |
en
| 0.999996 |
Liver biopsy has also potential advantages. Biopsy could be of diagnostic value for other unrecognized liver disease. These events are probably rare in practice, as we observed no such a case in a prospective study of 537 consecutive patients with chronic hepatitis C . For FT-AT it must be realized that the same predictive values were observed for patients coinfected with HIV , and in patients with other causes of liver fibrosis such as chronic hepatitis B , alcoholic liver disease or non-alcoholic steato-hepatitis .
|
15387887_p15
|
15387887
|
Discussion
| 3.889796 |
biomedical
|
Study
|
[
0.999534010887146,
0.0003366141754668206,
0.00012936310668010265
] |
[
0.9885214567184448,
0.006098982412368059,
0.005060864612460136,
0.0003186172398272902
] |
en
| 0.999997 |
It is possible that biochemical markers such as those described here may provide a more accurate (quantitative and reproducible) picture of fibrogenic and necrotic events occurring within the liver than hepatic biopsy. The greater accuracies of FT-AT, when assessed with biopsy specimens greater than 15 mm versus smaller biopsies, suggest that some discordance between FT-AT and histology were due to biopsy specimen sampling error . Several case reports have observed false negatives of liver biopsy versus biochemical markers . The error was attributable to biopsy because there were overt clinical signs of cirrhosis such as esophageal varices, low platelet counts or a dysmorphic liver on ultrasound. In a recent prospective study we estimated that 18% of discordances between FT-AT and histology were attributable to biopsy failure (mostly due to small length) and 2% to FT-AT failure .
|
15387887_p16
|
15387887
|
Discussion
| 4.11505 |
biomedical
|
Study
|
[
0.9995625615119934,
0.00029802575591020286,
0.0001393840357195586
] |
[
0.9988136291503906,
0.00027069434872828424,
0.0008333493606187403,
0.00008236397115979344
] |
en
| 0.999998 |
The present work allowed frequently asked questions to be answered, the first being whether the diagnostic values of FT-AT had been confirmed in all studies performed to date. A major strength of the studies pertaining to FT-AT is that they were carried out on a large number of patients with chronic hepatitis C, and the results were reproducible in different populations, including patients coinfected with HIV. There was a small variability in the AUROCs, both for the diagnosis of significant fibrosis (0.73 to 0.87) and significant necrosis (0.75 to 0.86).
|
15387887_p17
|
15387887
|
Discussion
| 4.028997 |
biomedical
|
Study
|
[
0.9995179176330566,
0.0002359969075769186,
0.0002460236137267202
] |
[
0.9983269572257996,
0.00018371113401371986,
0.0014281714102253318,
0.00006117753218859434
] |
en
| 0.999997 |
A weakness of this study was that the same group, which developed these tests, performed most of the published studies. However the independent published studies found the same significant diagnostic values than non-independent or multicentre studies. Several recent independent studies confirmed the predictive value of FT-AT .
|
15387887_p18
|
15387887
|
Discussion
| 2.404616 |
biomedical
|
Study
|
[
0.9972264170646667,
0.0006025724578648806,
0.0021709701977670193
] |
[
0.9799817204475403,
0.012842810712754726,
0.006735555827617645,
0.00044000722118653357
] |
en
| 0.999995 |
The second question concerned the comparison of FT-AT to other tests. In their recent review, Gebo et al. concluded that panels of markers might have the greatest value in predicting the absence or no more than minimal fibrosis on biopsy, and in predicting the presence of cirrhosis on biopsy (Evidence Grade B). They pointed out that five studies used large panels of markers and achieved the greatest predictive values. Among these 5 studies were the first FT-AT study and another study developed by the same group (combining age and platelets) . A recent study compared FT-AT to the age and platelets index in the same patients and found that FT-AT was significantly better . Three studies directly compared FT-AT, to hyaluronic acid , the Forns index and the Wai index in the same patients. FT-AT had higher diagnostic values (the AUROC was significantly higher). FT was in particular more sensitive for discriminating between F1 and F2, and more linearly correlated to stages when compared to those 3 other markers . An additional weakness of the Forns index is the inclusion of cholesterol, which varies greatly in patients with genotype 3 . The limitations of these three comparisons are that they were retrospective and were performed by the same group. These comparisons, however, had no evident sources of bias. The comparison with the Forns Index included all patients of the Imbert-Bismut et al. study (n = 323) , as the parameters belong to the routine biochemical tests. The comparison with the APRI index included 249/323 patients (77%) without any difference between included or non-included patients when all characteristics were compared . The comparison with hyaluronic acid included a total of 165 out of the 244 (68%) randomized patients pre-included. The 165 included patients did not differ from the 79 non-included patients according to the main characteristics. Among the 165 patients, the fibrosis index was assessed in 461 samples and hyaluronic acid in 457 samples .
|
15387887_p19
|
15387887
|
Discussion
| 4.113997 |
biomedical
|
Review
|
[
0.9973713159561157,
0.001409526215866208,
0.0012192094000056386
] |
[
0.24980464577674866,
0.0016669983742758632,
0.7479473352432251,
0.0005809377762489021
] |
en
| 0.999996 |
Recently, a study using profiles of serum protein N-glycans found that a profile has a similar AUROC than FT for the diagnosis of compensated cirrhosis. When combined with FT this marker had 100% specificity and 75% sensitivity for the diagnosis of compensated cirrhosis, which is not significantly different from the 92% specificity and 67% sensitivity of the FT . This study was independent and prospectively designed for taking FT as the comparison test. Only 24 patients with cirrhosis were included and no details were given concerning the causes of discordance between biopsy and biochemical markers.
|
15387887_p20
|
15387887
|
Discussion
| 4.035257 |
biomedical
|
Study
|
[
0.9995436072349548,
0.0002728819672483951,
0.00018346622528042644
] |
[
0.9991462230682373,
0.00023301891633309424,
0.0005566307227127254,
0.00006413774099200964
] |
en
| 0.999997 |
However FT-AT is the only panel of markers identified by an independent overview , which has been compared in the same patients with most of the other proposed markers. No studies were found that compared FT-AT with a panel of extra-cellular matrix markers . Compared to other panels, FT-AT also allowed an estimation to be made not only of the fibrosis stage but also the necroinflammatory (histological) activity.
|
15387887_p21
|
15387887
|
Discussion
| 3.476985 |
biomedical
|
Study
|
[
0.9992015957832336,
0.00020745303481817245,
0.0005909704486839473
] |
[
0.9845884442329407,
0.003525233594700694,
0.01170390099287033,
0.00018245067622046918
] |
en
| 0.999996 |
The present analysis of the integrated database demonstrated that the diagnostic value of FT-AT did not depend on HCV genotype or viral load. However, because of the small number of patients included, studies in genotype 4, 5 and 6 would be useful.
|
15387887_p22
|
15387887
|
Discussion
| 2.818959 |
biomedical
|
Study
|
[
0.9988158941268921,
0.0004599583335220814,
0.0007241417188197374
] |
[
0.9968125224113464,
0.0024742751847952604,
0.0005547062610276043,
0.00015848343900870532
] |
en
| 0.999995 |
The present analysis also answered another frequently asked question concerning the predictive values for the intermediate stages of fibrosis. Contrary to the initial hypothesis, the diagnostic values of FT-AT for consecutive stages of fibrosis and grades of necroinflammatory activity were the same for both moderate and extreme stages and grades. Our interpretation is that the same overlap exists between all stages, which is mainly related to the sampling error of the biopsy. It is very reassuring that the medians of FT-AT are linearly associated with stages and grades . The linearity of this association became even more evident as a larger number of patients were included (data not shown).
|
15387887_p23
|
15387887
|
Discussion
| 4.026649 |
biomedical
|
Study
|
[
0.9994533658027649,
0.0002882145927287638,
0.0002584046742413193
] |
[
0.9994357228279114,
0.0002271423873025924,
0.0002849794691428542,
0.00005209771552472375
] |
en
| 0.999995 |
Finally, the integrated database allowed a simple conversion system to be proposed to clinicians between liver injury as estimated by the FT-AT and that as estimated by liver biopsy . One conventional way to express the diagnostic values of FT-AT was summarized using the cutoffs of the distribution by stages and grades (Tables 2 and 4 ). The negative predictive value of FT for excluding significant fibrosis was excellent for the 0.31 cutoff (91%), as was the negative predictive value for excluding significant activity at the 0.36 cutoff of AT (85% negative predictive value). The positive predictive value of the 0.72 cutoff of FT for significant fibrosis was also high at 76%. This, however, may appear lower than the negative predictive value. There is a technical explanation owing to the prevalence of significant fibrosis, which was only 0.31 in this population. According to the excellent specificity (above 0.95), the positive predictive value increased rapidly in populations with more fibrosis (data not shown). We recently observed that the main reason for this was probably because most of the so-called false positives of the FT were in fact false negatives due to the small sampling size of liver biopsies . The same comments can be made concerning the positive predictive value of AT for significant necrosis with 77% at the 0.60 cutoff. Again, it is probable that a large proportion of so-called false positives of AT were in fact false negatives due to liver biopsies which were too small. The ideal study would be one using biopsies measuring 40 mm in length, as two samples of 20 mm each during laparoscopy. Only this very high quality biopsy can be considered as a true gold standard. Obviously this type of biopsy cannot be performed routinely as first line, but it could be recommended for clinical research.
|
15387887_p24
|
15387887
|
Discussion
| 4.171227 |
biomedical
|
Study
|
[
0.9988974332809448,
0.0009149598190560937,
0.00018750200979411602
] |
[
0.9973617196083069,
0.000730841769836843,
0.0017463816329836845,
0.00016108494310174137
] |
en
| 0.999998 |
Based on these results, the use of the biochemical markers of liver fibrosis (FibroTest) and necrosis (ActiTest) can be recommended as an alternative to liver biopsy for the first line assessment of liver injury in patients with chronic hepatitis C. In clinical practice, liver biopsy should be recommended only as a second line test, i.e. , in case of high risk of error of biochemical tests or in transplanted patients. For clinical research, only very high quality liver biopsy (as two samples of 20 mm each) can be considered as a gold standard for validation of new alternatives.
|
15387887_p25
|
15387887
|
Conclusions
| 3.916139 |
biomedical
|
Other
|
[
0.9905825853347778,
0.008862223476171494,
0.000555262784473598
] |
[
0.42549392580986023,
0.42591139674186707,
0.1445026397705078,
0.0040920511819422245
] |
en
| 0.999997 |
We did a search for all publications and communications between February 2001 and March 2004 with the key words "FibroTest" and "ActiTest" in Medline and in the abstract books of hepatology, gastroenterology, internal medicine and infectious diseases annual meetings. Only publications or abstracts concerning FT-AT in chronic hepatitis C were included.
|
15387887_p26
|
15387887
|
Analysis of the literature
| 2.996453 |
biomedical
|
Study
|
[
0.9986515641212463,
0.0005023324047215283,
0.000846024660859257
] |
[
0.9886448383331299,
0.005469769239425659,
0.005587638355791569,
0.0002977796539198607
] |
en
| 0.999995 |
For each study we assessed the diagnostic value for the diagnosis of significant fibrosis (bridging fibrosis or stages F2, F3, F4 according to the METAVIR scoring system) and significant necroinflammatory activity (moderate or severe necrosis, grades A2 or A3 according to the METAVIR scoring system) by the area under the receiver operating characteristics curve (AUROC).
|
15387887_p27
|
15387887
|
Diagnostic value of FT-AT among published studies
| 4.069486 |
biomedical
|
Study
|
[
0.999508261680603,
0.0003206702822353691,
0.00017105383449234068
] |
[
0.9985328912734985,
0.00036042919964529574,
0.001033672713674605,
0.00007302970334421843
] |
en
| 0.999997 |
For several databases it was possible to re-analyze the individual data and we looked at the sensitivity and specificity according to different thresholds (0.10, 0.30, 0.60 and 0.80). When FT-AT was compared to other biochemical tests, we also assessed the corresponding sensitivity and specificity according to several thresholds.
|
15387887_p28
|
15387887
|
Diagnostic value of FT-AT among published studies
| 3.132128 |
biomedical
|
Study
|
[
0.9988369345664978,
0.0004283435409888625,
0.0007348140934482217
] |
[
0.9982854723930359,
0.0012393720680847764,
0.00037711687036789954,
0.00009804427099879831
] |
en
| 0.999997 |
We selected studies using direct comparisons of diagnostic values in the same patients. The AUROCs were compared for the diagnosis of significant fibrosis (F2F3F4) and significant necrosis (A2A3).
|
15387887_p29
|
15387887
|
Comparison of FT-AT diagnostic values with other biochemical markers
| 3.555677 |
biomedical
|
Study
|
[
0.9992596507072449,
0.0003452388336881995,
0.0003951661929022521
] |
[
0.9973883032798767,
0.0009265528642572463,
0.0015884797321632504,
0.00009663045784691349
] |
en
| 0.999998 |
Patients were included in an integrated database if they belonged to a published population of patients with chronic hepatitis C. Liver biopsy was scored using the METAVIR scoring system and FT-AT was assessed using the recommended pre-analytical and analytical procedures . A published population of 300 prospectively analyzed blood donors was included as a control group .
|
15387887_p30
|
15387887
|
Integrated database
| 3.871804 |
biomedical
|
Study
|
[
0.9990285634994507,
0.0007391386898234487,
0.00023230786609929055
] |
[
0.9991627931594849,
0.0004644216678570956,
0.0002823450486175716,
0.00009048047650139779
] |
en
| 0.999995 |
Using the integrated database, we compared the AUROCs of FT-AT for the diagnosis of significant fibrosis (F2F3F4) and significant activity (A2A3) between 4 classes of genotype (1, 2, 3 and the rarer genotypes 4, 5, 6 grouped together). For viral load, only those assessed in the same laboratory were included in the comparison between AUROCs, and the median was used to define low and high viral loads (3,800,000 copies/ml) .
|
15387887_p31
|
15387887
|
Diagnostic value of FT-AT according to HCV genotype and viral load
| 4.044667 |
biomedical
|
Study
|
[
0.9994687438011169,
0.0003263800754211843,
0.00020491342002060264
] |
[
0.999426007270813,
0.00023985133157111704,
0.000270721095148474,
0.00006351210322463885
] |
en
| 0.999997 |
Using the integrated database, we compared the diagnostic values according to different stages or grades. We compared the AUROCs for all possible combinations of stages and grades, including combinations with blood donors. This allowed, for example, a comparison to be made of the diagnostic value of FT for discriminating between F1 and F2 after excluding all other stages of the database.
|
15387887_p32
|
15387887
|
Diagnostic value of FT-AT according to stage and grade
| 3.471688 |
biomedical
|
Study
|
[
0.9986792206764221,
0.00042515911627560854,
0.000895608973223716
] |
[
0.9989277720451355,
0.0007537235505878925,
0.000241457688389346,
0.00007697942783124745
] |
en
| 0.999995 |
In the integrated database, liver biopsies were processed using standard techniques. A pathologist who was unaware of the biochemical markers evaluated fibrosis stage and necrosis grade according to the METAVIR scoring system .
|
15387887_p33
|
15387887
|
Liver biopsies
| 3.93793 |
biomedical
|
Study
|
[
0.9990139007568359,
0.0007962504751048982,
0.00018977596482727677
] |
[
0.996809184551239,
0.0024219979532063007,
0.000577241531573236,
0.000191531129530631
] |
en
| 0.999997 |
Fibrosis was staged on a scale of 0 to 4: F0 = no fibrosis, F1 = portal fibrosis without septa, F2 = few septa, F3 = numerous septa without cirrhosis, F4 = cirrhosis. The grading of activity by the METAVIR system (based on the intensity of necroinflammatory activity, mainly on necrosis) was scored as follows: A0 = no necroinflammatory activity, A1 = mild activity, A2 = moderate activity, A3 = severe activity .
|
15387887_p34
|
15387887
|
Liver biopsies
| 4.044492 |
biomedical
|
Study
|
[
0.9990218877792358,
0.0008039527456276119,
0.00017408748681191355
] |
[
0.9502161741256714,
0.0455368235707283,
0.003535074647516012,
0.0007119861547835171
] |
en
| 0.999998 |
We used the previously validated FT-AT . FT-AT is a non-invasive blood test that combines the quantitative results of six serum biochemical markers [alpha2-macroglobulin, haptoglobin, gamma glutamyl transpeptidase (GGT), total bilirubin, apolipoprotein A1 and alanine aminotransferase (ALT)] with the patient's age and gender in a patented artificial intelligence algorithm (USPTO 6,631,330) to generate a measure of fibrosis stage and necroinflammatory grade in the liver.
|
15387887_p35
|
15387887
|
Biochemical markers
| 4.0337 |
biomedical
|
Study
|
[
0.9995880722999573,
0.0002538331609684974,
0.00015808154421392828
] |
[
0.9983493089675903,
0.0011431167367845774,
0.00040777845424599946,
0.00009990549006033689
] |
en
| 0.999995 |
Corresponding stages and grades were calculated from median scores and 95% confidence intervals were observed in 1,270 patients and 300 healthy blood donors. The AUROC was used as a measure of discrimination, estimated using the empirical (non-parametric) method by DeLong et al. , and were compared using the paired method by Zhou et al. . All analyses are performed on the NCSS software (Kaysville, Utah) .
|
15387887_p36
|
15387887
|
Statistical analysis
| 3.846142 |
biomedical
|
Study
|
[
0.9995410442352295,
0.00018556076975073665,
0.0002735013549681753
] |
[
0.9991806149482727,
0.0005021175020374358,
0.0002608344657346606,
0.00005642297037411481
] |
en
| 0.999995 |
TP and MM conceived the study, performed the statistical analysis, and wrote the manuscript. FIM, BH and DM carried out biochemical analyses. RP, DT, VR, and YB participated in the coordination of the study, and drafted the manuscript. AM participated in the design and coordination of assays in the control group. All authors read and approved the final manuscript.
|
15387887_p37
|
15387887
|
Authors' contributions
| 0.831407 |
biomedical
|
Other
|
[
0.5399187803268433,
0.004459976684302092,
0.4556211829185486
] |
[
0.021792205050587654,
0.9747631549835205,
0.00234416825696826,
0.0011003663530573249
] |
en
| 0.999998 |
The gastrointestinal tract is the initial barrier to dietary constituents and is important in regulating nutrient entry, as well as keeping non-nutrients out. Additionally, the hepatobiliary system acts as an additional filter to rapidly excrete such non-nutrients into bile, thus keeping the net retention of these potential toxins low. Mammals have evolved many mechanisms in the gastrointestinal tract to select out usable dietary constituents from those that maybe potentially toxic to the body. It is apparent that the ATP-binding cassette proteins (ABC proteins/transporters) are the machinery that mediate the ATP-dependent transport of a wide variety of substrates that range from xenobiotics to peptide fragments . A subset of these ABC transporters, located in the canalicular membranes of mammalian liver, play key roles in bile formation and detoxification .
|
15383151_p0
|
15383151
|
Background
| 4.247098 |
biomedical
|
Study
|
[
0.9993705153465271,
0.00025242907577194273,
0.00037700252141803503
] |
[
0.9184085726737976,
0.015960102900862694,
0.06522442400455475,
0.00040697891381569207
] |
en
| 0.999995 |
One of these processes involves the regulation of sterol entry and excretion. Whole body cholesterol homeostasis is a tightly regulated process, involving dietary absorption, de novo synthesis and hepatobiliary secretion. Sitosterolemia, a rare autosomal recessive disorder of sterol metabolism results in the disruption of dietary sterol entry and hepatobiliary sterol secretion . Under normal circumstances, our diets contain equal amounts of plant sterols and cholesterol, but the plant sterols are specifically excluded from our bodies and only regulated amounts of cholesterol are retained. In Sitosterolemia, this exclusion is defective resulting in the retention of non-cholesterol sterols. Mutations in either, but not both, of two ABC transporters, ABCG5 and ABCG8, encoded by a single locus, STSL , are known to cause this disease . Based upon the genetics, as well as in vitro and in vivo data, these 'half-transporters' are proposed to function as obligate heterodimers. In vitro experiments have shown that both proteins are needed to be co-expressed for apical expression and that these may function as mutual chaperones in the ER for maturation . In vivo experiments in mice have not been consistent. Using the Abcg5/Abcg8 double knockout mice, Graf et al has shown that by inoculating them with adenoviral constructs for Abcg5 and Abcg8 that both are required for expression of both proteins . Additionally, Plosch et al and our group have constructed mouse models deficient in either Abcg5 or Abcg8 that show different biliary physiology than that of the Abcg5/Abcg8 double knockout mice. This suggests these proteins may have independent function(s) in addition to their function as heterodimers. However, to date, no reports of characterization and localization of the human proteins have been reported.
|
15383151_p1
|
15383151
|
Background
| 4.671088 |
biomedical
|
Study
|
[
0.9990629553794861,
0.0005644435877911747,
0.00037260010140016675
] |
[
0.9893144369125366,
0.0007324970210902393,
0.009637132287025452,
0.0003159044135827571
] |
en
| 0.999995 |
In this report, we examined the location of these two proteins using cellular fraction and immunohistochemical analyses of human liver, gallbladder and small intestine. We found a general concordance of co-expression of both proteins, but we also noted that ABCG5 and ABCG8 could be found in plasma membranes, as well as in intracellular membrane locations independent of each other. Additionally, deglycosylation of human liver membranes with peptidyl N-glycosidases did not alter the mobility of the proteins after SDS-PAGE, suggesting that these proteins may not be glycosylated in human liver. This differential localization suggests that perhaps ABCG5 and ABCG8 may have functions independent of each other, as well as functioning as heterodimers.
|
15383151_p2
|
15383151
|
Background
| 4.153648 |
biomedical
|
Study
|
[
0.9995085000991821,
0.00030648609390482306,
0.00018505917978473008
] |
[
0.9994612336158752,
0.0002095419040415436,
0.0002555608516559005,
0.00007368727528955787
] |
en
| 0.999998 |
Tissue aquistion. Human liver donated for transplantation, but deemed unsuitable for transplantation on inspection by the transplant service (usually based upon a 'fatty' appearance) was obtained in accordance with IRB approval. As soon as the liver was deemed unsuitable (typically less than 10 h following harvesting) pieces were either snap-frozen in liquid nitrogen and stored at -80°C or liquid nitrogen until use, or placed in ice-cold 2-methylbutane and stored in liquid nitrogen. Samples from more than nine different donors were used in these studies. Additionally, human gallbladders and segments of proximal small intestine were obtained from patients under going either laproscopic cholecystectomy or pancreatoduodenectomy (Whipple procedure). These tissues were directly taken from the operating room in normal saline on ice to be processed directly for frozen sectioning.
|
15383151_p3
|
15383151
|
Methods
| 4.081386 |
biomedical
|
Study
|
[
0.9994122982025146,
0.00039621946052648127,
0.0001914401218527928
] |
[
0.9970511198043823,
0.002444678219035268,
0.0003515807038638741,
0.00015255615289788693
] |
en
| 0.999997 |
Anti-membrin, anti-transferrin, and anti-calnexin antibodies were obtained from Stressgen (Victoria, BC Canada), anti-caveolin antibody from BD Bioscience (San Diego, CA, USA), anti-MDR1 that also detects MDR2/3 (C219) from Centocor Inc. (Malvern, PA, USA), anti-MRP2 (cMOAT) from Chemicon International (Temecula, CA, USA) and secondary antibodies were purchased from Jackson Immuno research (West Grove, PA, USA). Polyclonal rabbit anti-sera to human ABCG5 and ABCG8 peptides were generated in-house, using a 20-peptide immunogen from human ABCG5 and a 22-peptide sequence from human ABCG8 . The anti-sera were further purified using peptide affinity columns and stored at a concentration of 0.8 mg/ml in Immuno Pure Binding Buffer (Pierce, Rockford, IL, USA). For peptide blocking experiments the peptides were dissolved in DMSO (final concentration 30%), incubated with the corresponding peptide for 1 1/2 hours at 37°C then used for immunoblotting as described below.
|
15383151_p4
|
15383151
|
Antibodies
| 3.41512 |
biomedical
|
Study
|
[
0.9989481568336487,
0.0002145316102541983,
0.0008373084128834307
] |
[
0.9800214171409607,
0.01902572438120842,
0.0006638182094320655,
0.0002890095056500286
] |
en
| 0.999995 |
Crude total membrane isolation was carried out with minor modifications as previously described . All the procedures were carried out at 4°C. Three grams of human liver were homogenized in homogenization buffer (5 mM Tris pH7.5, 250 mM sucrose, 1 mM PMSF, 20 μg/μl of leupeptin and 1 μg/μl of aprotinin) by applying 10 strokes with a dounce homogenizer. The homogenate was centrifuged at 1000 g for 10 minutes, the pellet containing any undisrupted cells and nuclear debris were re-homogenized with one-half the initial volume of homogenization buffer, centrifuged at 1000 g for 10 minutes and this process was repeated once more. Supernatants were pooled and subjected to centrifugation at 100,000 g for 40 minutes. The resulting pellet, deemed the crude membrane fraction, was used as the starting material for Western blotting and fractionation experiments.
|
15383151_p5
|
15383151
|
Membrane protein preparation
| 4.110448 |
biomedical
|
Study
|
[
0.9995542168617249,
0.0002512936189305037,
0.00019444187637418509
] |
[
0.998521625995636,
0.00107568537350744,
0.00031517454772256315,
0.00008750813140068203
] |
en
| 0.999997 |
Human liver crude total membrane proteins were re-suspended in 30% Nycodenz solution (Nycodenz in 5 mM Tris-HCl pH 7.5 and 1 mM EDTA). This suspension was loaded on top of a 40% Nycodenz solution cushion in an ultracentrifuge tube, overlaid by consecutive 23%, 20%, 15% and 10% Nycodenz solutions and subjected to centrifugation at 39,000 rpm for 16 hours at 4°C in a SW41 rotor (Beckman Instrument, Palo Alto, CA). After centrifugation, 800–1000 μl fractions were sequentially removed from the top, combined with two volumes of homogenization buffer (see above) and centrifuged at 39,000 rpm at 4°C for 40 minutes to remove the Nycodenz. The resulting pellets were re-suspended in buffer (25 mM Tris-HCl pH 7.5, 150 mM NaCl, 0.1% Triton X-100 and 0.1% SDS, 1 mM PMSF, 20 μg/μl of leupeptin and 1 μg/μl of aprotinin), the protein content determined by the method of Lowry and fractions analysed by SDS-PAGE. Equal amounts of protein (25 μg) per lane were loaded.
|
15383151_p6
|
15383151
|
Nycodenz gradient fractionation
| 4.164185 |
biomedical
|
Study
|
[
0.9994872808456421,
0.00030090019572526217,
0.00021180909243412316
] |
[
0.9985792636871338,
0.0008973954245448112,
0.00043284273124299943,
0.00009052445238921791
] |
en
| 0.999996 |
The procedure for membrane fractionation was essentially as described for the Nycodenz fractionation, except for the homogenization buffer used (25 mM Tris pH6.8, 150 mM NaCl, 1 mM PMSF, 20 μg/μl of leupeptin and 1 μg/μl of aprotinin). The sucrose density gradient fractionation was modified as previously described . Human liver crude membrane proteins were re-suspended in 1% Triton X100 buffer (25 mM Tris-HCl pH6.5, 150 mM NaCl, 1% Triton X100, 1 mM PMSF, 20 μg/μl of leupeptin and 1 μg/μl of aprotinin), adjusted to a final sucrose concentration of 40% and overlaid with a 15–30% linear sucrose gradient. The samples were subjected to centrifugation at 39,000 rpm for 16 hours at 4°C in a SW41 rotor (Beckman Instrument, Palo Alto, CA, USA) and fractions collected from the top as described above. The proteins from fractions 1–4 from top of the tube were precipitated with acetone because these fractions did not contain sufficient protein for direct analysis. After protein concentrations were determined, equal amounts of proteins (20 μg) from each fraction were resolved by SDS-PAGE.
|
15383151_p7
|
15383151
|
Sucrose gradient fractionation
| 4.140928 |
biomedical
|
Study
|
[
0.9995540976524353,
0.000237815867876634,
0.00020800829224754125
] |
[
0.9989013671875,
0.0007162338588386774,
0.0003127274103462696,
0.00006967411900404841
] |
en
| 0.999997 |
Proteins resolved by SDS-PAGE were transferred onto nitrocellulose membranes. Membranes were then blocked for 1 hour in 5% dry milk in PBS-T (Phosphate Buffered saline and 0.1% Tween 20) and incubated with primary antibody against either ABCG5 or ABCG8 in 5% milk in PBS-T overnight at 4°C. Blots were washed three times for 5 minutes in TBS-T (Tris Buffered Saline/0.1% Tween-20) with 150 mM NaCl, incubated with goat-anti-rabbit conjugated HRP antibodies , washed for three times 5 minutes and developed with Western Lightning ® Chemiluminescence Reagent Plus (Perkin Elmer Life Sciences, Inc. Boston, MA, USA).
|
15383151_p8
|
15383151
|
Immunoblotting
| 4.051476 |
biomedical
|
Study
|
[
0.9991255402565002,
0.0004478666523937136,
0.00042668537935242057
] |
[
0.9059597849845886,
0.092131108045578,
0.0013426226796582341,
0.0005664404015988111
] |
en
| 0.999996 |
Snap-frozen liver, gallbladder and intestine tissues were used to cut 8 μm thick frozen sections, air-dried for 30 minutes onto glass slides and kept at -80°C until used. The slides were stained with hematoxylin, rinsed with PBS three times, fixed for 10 minutes with cooled methanol at -20°C and rinsed with PBS three times. The slides were treated with blocking solution (10% donkey serum in 0.1 M glycine/PBS) for 30 minutes at room temperature and incubated with primary antibody overnight at 4°C. The slides were washed with PBS and incubated with secondary antibody (goat-anti-rabbit conjugated with Cy3™ or rhodamine or FITC) for 20–30 minutes at room temperature, rinsed with PBS three times and examined under an Olympus BX-5 confocal microscope with Fluoview.
|
15383151_p9
|
15383151
|
Immunohistochemical analysis and microscopy
| 4.107038 |
biomedical
|
Study
|
[
0.9992928504943848,
0.0004475910682231188,
0.0002596059930510819
] |
[
0.9345465898513794,
0.06334587186574936,
0.0015043597668409348,
0.0006032182718627155
] |
en
| 0.999997 |
Peptide antibodies were raised against human ABCG5 and human ABCG8 and affinity purified prior to use (see Methods). The immunogen peptides used for the antibodies were selected since they were sequences that lay outside of the predicted transmembrane domains and based upon antigenicity.Western blotting experiments showed that both anti-ABCG5 and anti-ABCG8 antibodies bound to ~75 kDa proteins in human liver crude membranes. Pre-immune sera did not detect the ~75 kDa expected bands. Pre-incubation of the immune antibodies with the peptides against which they were raised abolished specific binding . For anti-ABCG5 5 μg of peptide was needed to block 1 μg of antibody and for anti-ABCG8 12.5 μg of peptide was needed to block 1 μg of antibody. Interestingly, a ~60 kDa band was detected using the anti-ABCG8 antibody whose signal is abolished when incubated with the peptide from which the antibody was raised . The significance of this is unclear at present. These antibodies were also tested against mouse and rat liver membrane preparations and no significant cross-reactivity was detected except for faint bands seen with anti-ABCG5 in mouse liver samples . No other bands were detected above the 150 kDa marker in all western blots. Interestingly, while these proteins are predicted to be N-glycosylated , only single bands in the appropriate molecular weight range were detected and no higher molecular bands were observed. To investigate whether these proteins are glycosylated, crude membrane fractions were digested with EndoH, PNGase F and examined for alterations in gel migration by SDS-PAGE . Although the mobility of a known glycoprotein, transferrin, was increased in the same fractions following deglycosylation, there was no change in the mobility of ABCG5 or ABCG8 .
|
15383151_p10
|
15383151
|
Identification of ABCG5 and ABCG8 in crude total membrane preparations of human liver
| 4.289465 |
biomedical
|
Study
|
[
0.9994157552719116,
0.00035885637043975294,
0.00022543882369063795
] |
[
0.9992115497589111,
0.0002287656388944015,
0.00046631350414827466,
0.00009331047476734966
] |
en
| 0.999998 |
Crude total membrane proteins from human liver were fractionated by Nycodenz gradient centrifugation and examined for localization markers by western blot analyses . After Nycodenz gradient centrifugation, ABCG5 (fractions 9–10) and ABCG8 (fractions 6–11) were found to have a broad range of distribution and appeared to be distributed in a pattern similar to calnexin (an ER membrane marker, fractions 5–10), Cytochrome C (a mitochondrial marker, fractions 4–9), transferrin (a plasma membrane marker, fractions 1–11), caveolin (fractions 6–10) and MDR1 (an apical membrane marker, fractions 4–10). ABCG5 and ABCG8 did not co-localize with cis-Golgi markers.
|
15383151_p11
|
15383151
|
Localization of ABCG5 and ABCG8 by Nycodenz and Sucrose gradient fractionation of human liver
| 4.156088 |
biomedical
|
Study
|
[
0.9995235204696655,
0.00024507238413207233,
0.00023134092043619603
] |
[
0.9994307160377502,
0.0002100973651977256,
0.00030541481100954115,
0.0000538341591891367
] |
en
| 0.999997 |
To examine whether ABCG5 and ABCG8 were associated with membrane rafts, total membrane proteins from human liver were solubilized with ice-cold 1% Triton X-100 detergent and fractionated by sucrose density gradient centrifugation . Fractionation resulted in two Triton X-100 insoluble complexes, as judged by the clarity of the gradient fractions. The first was found in the low-density range and the second in the high-density range . Caveolin-rich fractions localized to the low-density range . However, ABCG5 and ABCG8 were detected in the high-density fractions, F10–12, along with transferrin (fractions 5–12) and MDR1 (fractions 9–11). Calnexin or cytochrome C, under these conditions did not co-localize with either ABCG5 or ABCG8. Note that the majority of the ABCG5 and ABCG8 were present in the densest fractions, F11–12. Under these conditions, membrin, a cis-Golgi membrane marker, was also detected in fraction 12.
|
15383151_p12
|
15383151
|
Localization of ABCG5 and ABCG8 by Nycodenz and Sucrose gradient fractionation of human liver
| 4.169538 |
biomedical
|
Study
|
[
0.9994557499885559,
0.0002928696048911661,
0.000251350604230538
] |
[
0.9994106292724609,
0.00023860199144110084,
0.0002920258557423949,
0.00005878566298633814
] |
en
| 0.999995 |
Thus, ABCG5 and ABCG8 have significant overlap with each other suggesting co-localization. However, these proteins did not seem to co-localize with any specific membrane marker except transferrin, when two different methods of fractionation were utilized.
|
15383151_p13
|
15383151
|
Localization of ABCG5 and ABCG8 by Nycodenz and Sucrose gradient fractionation of human liver
| 3.108361 |
biomedical
|
Study
|
[
0.9973904490470886,
0.00030398633680306375,
0.0023055581841617823
] |
[
0.990024209022522,
0.009052548557519913,
0.0007422820199280977,
0.00018104225455317646
] |
en
| 0.999997 |
It has been shown previously that ABCG5 and ABCG8 are expressed only in the liver and intestine . To further characterize the location of ABCG5 and ABCG8 in human liver, immunohistochemical analyses were performed on frozen serial sections of human liver. Pre-immune sera were used as negative controls. The distribution of the two proteins appeared to be divergent not only histologically, but also at the cellular level. From a histological point of view, ABCG5 was detected along sinusoidal tracts whereas ABCG8 was detected within the cells lining the bile ducts . At higher magnification, ABCG5 was detected along bile canaliculi and at the cellular level appeared to be an apically expressed . However, the distribution of ABCG8 at the cellular level appeared more diffuse consistent with plasma membrane expression and perhaps in intracellular membranes . Expression of ABCG5 within intracellular vesicular compartments could not be excluded by the techniques employed. To confirm an apical location of ABCG5 and ABCG8 immunohistochemical co-localization studies were carried out using an antibody against a known apical transporter (MRP2) in the liver. As shown in Figure 4 , ABCG5 and ABCG8 have significant overlap in expression with MRP2 (panels A and B, respectively).
|
15383151_p14
|
15383151
|
Immunohistochemical localization of ABCG5 and ABCG8 in human liver
| 4.207941 |
biomedical
|
Study
|
[
0.9994398951530457,
0.0003090419340878725,
0.00025103159714490175
] |
[
0.9994364380836487,
0.00016815756680443883,
0.0003281886165495962,
0.00006710640445817262
] |
en
| 0.999999 |
Serial sections of human gall bladder were incubated with each antibody and pre-immune serum was used as a negative control. Both ABCG5 and ABCG8 were detected in the epithelium of gall bladder mucosa . At higher magnification, the cellular distribution of the signals detected was similar and showed a diffuse cytoplasmic distribution .
|
15383151_p15
|
15383151
|
Immunohistochemical localization of ABCG5 and ABCG8 in human gall bladder
| 3.983409 |
biomedical
|
Study
|
[
0.9995218515396118,
0.00023849135322961956,
0.0002396091294940561
] |
[
0.9987836480140686,
0.0008583088056184351,
0.0002572497760411352,
0.00010077504703076556
] |
en
| 0.999996 |
Both ABCG5 and ABCG8 were detected in the apical surfaces of the enterocytes in biopsy samples of the small intestine . However, at higher magnification the cellular distribution of ABCG5 appeared more diffuse whereas ABCG8 was expressed apically . This divergent pattern was seen in all of the serial sections analyzed.
|
15383151_p16
|
15383151
|
Immunohistochemical localization of ABCG5 and ABCG8 in human small intestine
| 3.990197 |
biomedical
|
Study
|
[
0.9995341300964355,
0.00022594726760871708,
0.00024000565463211387
] |
[
0.9983495473861694,
0.0012292151805013418,
0.00031628235592506826,
0.00010495621245354414
] |
en
| 0.999998 |
In this study, we report the localization of ABCG5 and ABCG8 in human liver, gall bladder and intestine. Our studies showed that these proteins are highly specific in the cells they are expressed. In the liver, expression is seen in cells lining the hepatobiliary tracts, both hepatocytes and ductal cells. In the intestine, robust expression was seen only in the villus enterocyte layers. In the gall bladder, expression was confined to the epithelial cells lining the lumen. However, some differences in the distribution of ABCG5 and ABCG8 within these tissues were apparent. In the liver, ABCG8 was highly expressed in the hepatocytes lining the bile ducts, whereas ABCG5 was more robustly expressed in hepatocytes lining the cannaliculae. In fractionation studies, using two different methods of separation, the distribution of ABCG5 and ABCG8 was compatible with both proteins potentially acting as heterodimers. However, we also noted that there were fractions where only one of these proteins, but not the other was detected. This could be an artefact, with one antibody being a better reagent, or that this pattern could truly reflect that each of these proteins can also exist independently, perhaps as homodimers. Overall, the distribution patterns of ABCG5 and ABCG8 in these cellular fractionations were similar to that observed with the plasma membrane marker transferrin and apical membrane marker MDR1. Additionally, immunohistochemical analyses show that ABCG5 and ABCG8 are apically expressed in the liver, gall bladder and intestine. In the liver ABCG5 and ABCG8 also appear to co-localize with the known apical protein MRP2. This confirms previous data from Graf et al , using in vitro expression in WIF-B cells , and support the contention that ABCG5 and ABCG8 are plasma membrane proteins.
|
15383151_p17
|
15383151
|
Discussion
| 4.425234 |
biomedical
|
Study
|
[
0.9992571473121643,
0.000503420946188271,
0.0002393794129602611
] |
[
0.9988825917243958,
0.00031297423993237317,
0.0006600167835131288,
0.00014440134691540152
] |
en
| 0.999997 |
These data would suggest that expression of these proteins might not be wholly dependent upon mutual co-expression, as has been reported for the mouse and in in vitro studies . However, one note of caution should be expressed. All of the liver samples analyzed were obtained because they were unsuitable for transplantation. Most livers were considered to be 'fatty' livers. While these livers were not effectively diseased, that fact that they had fatty infiltrates may have influenced the normal expression of these two half-transports. Thus, confirmation in normal human liver samples will be needed, though this may not be feasible.
|
15383151_p18
|
15383151
|
Discussion
| 3.889946 |
biomedical
|
Study
|
[
0.9995113611221313,
0.0001419760228600353,
0.00034666532883420587
] |
[
0.9976803064346313,
0.0016658828826621175,
0.0005573328817263246,
0.00009646067337598652
] |
en
| 0.999998 |
With that reservation in mind, our data do have important implications for sterol trafficking in humans.
|
15383151_p19
|
15383151
|
Discussion
| 2.161022 |
biomedical
|
Other
|
[
0.9919290542602539,
0.0009112853440456092,
0.007159581873565912
] |
[
0.20054616034030914,
0.7866674661636353,
0.010758193209767342,
0.0020281996112316847
] |
en
| 0.999996 |
Firstly, the relatively robust and highly specific expression of ABCG5 and ABCG8 in gall bladder epithelium confirms the important role of this organ in regulating biliary secretion. In addition to the production of bile by the liver, the gall bladder may be able to further regulate the sterol content of bile, via ABCG5/ABCG8 activity. A similar pattern of expression has been reported in canine gall bladder epithelial cell culture and these data confirm these findings in human gall bladder .
|
15383151_p20
|
15383151
|
Discussion
| 4.173119 |
biomedical
|
Study
|
[
0.9996143579483032,
0.00020699595916084945,
0.00017866745474748313
] |
[
0.9989803433418274,
0.0005075854132883251,
0.00043889411608688533,
0.00007322167220991105
] |
en
| 0.999996 |
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