Spontaneous Heparin-Induced Thrombocytopenia Presenting as Concomitant Bilateral Cerebrovascular Infarction and Acute Coronary Syndrome

Background:Spontaneous heparin-induced thrombocytopenia is a pro-thrombotic syndrome in which anti-heparin antibodies develop without heparin exposure.Case presentation:A 78-year-old man who underwent a successful lumbar laminectomy presented to the hospital 5 days after discharge for stroke-like symptoms and was found to have acute infarcts of the bilateral frontal lobes.The patient was found to be severely thrombocytopenic and was incidentally found to have an inferior wall myocardial infarction.Further investigation led to the diagnosis of bilateral lower extremity deep vein thromboses.His overall clinical presentation prompted a detailed hematologic workup that indicated positivity for heparin-induced thrombocy-topenia despite no previous exposure to heparin products.Conclusions:This case illustrates a patient with no prior lifetime heparin exposure who underwent laminectomy with subsequent development of acute infarcts of the bilateral frontal lobes,an inferior wall myocardial infarction,and bilateral lower extremity deep vein thromboses,with concern for sequelae of spontaneous heparin-induced thrombo-cytopenia.

Effectiveness of exercise in hepatic fat mobilization in nonalcoholic fatty liver disease: Systematic review

AIM: To investigate the efficacy of exercise interventions on hepatic fat mobilization in non-alcoholic fatty liver disease(NAFLD) patients.METHODS: Ovid-Medline, Pub Med, EMBASE and Cochrane database were searched for randomized trials and prospective cohort studies in adults aged ≥ 18 which investigated the effects of at least 8 wk of exercise only or combination with diet on NAFLD from 2010 to 2016. The search terms used to identify articles, in which exercise was clearly described by type, duration, intensity and frequency were: "NASH", "NAFLD", "nonalcoholic steatohepatitis", "non-alcoholic fatty liver disease", "fat", "steatosis", "diet", "exercise", "MR spectroscopy" and "liver biopsy". NAFLD diagnosis, as well as the outcome measures, was confirmed by either hydrogen-magnetic resonance spectroscopy(H-MRS) or biopsy. Trials that included dietary interventions along with exercise were accepted if they met all criteria. RESULTS: Eight studies met selection criteria(6 with exercise only, 2 with diet and exercise with a total of 433 adult participants). Training interventions ranged between 8 and 48 wk in duration with a prescribed exercise frequency of 3 to 7 d per week, at intensities between 45% and 75% of VO2 peak. The most commonly used imaging modality was H-MRS and one study utilized biopsy. The effect of intervention on fat mobilization was 30.2% in the exercise only group and 49.8% in diet and exercise group. There was no difference between aerobic and resistance exercise intervention, although only one study compared thetwo interventions. The beneficial effects of exercise on intrahepatic triglyceride(IHTG) were seen even in the absence of significant weight loss. Although combining an exercise program with dietary interventions augmented the reduction in IHTG, as well as improved measures of glucose control and/or insulin sensitivity, exercise only significantly decreased hepatic lipid contents.CONCLUSION: Prescribed exercise in subjects with NAFLD reduces IHTG independent of dietary intervention. Diet and exercise was more effective than exercise alone in reducing IHTG.

Advances in cirrhosis: Optimizing the management of hepatic encephalopathy

Hepatic encephalopathy(HE) is a major complication of cirrhosis resulting in significant socioeconomic burden, morbidity, and mortality. HE can be further subdivided into covert HE(CHE) and overt HE(OHE). CHE is a subclinical, less severe manifestation of HE and requires psychometric testing for diagnosis. Due to the time consuming screening process and lack of standardized diagnostic criteria, CHE is frequently underdiagnosed despite its recognized role as a precursor to OHE. Screening for CHE with the availability of the Stroop test has provided a pragmatic method to promptly diagnose CHE. Management of acute OHE involves institution of lactulose, the preferred first-line therapy. In addition, prompt recognition and treatment of precipitating factors is critical as it may result in complete resolution of acute episodes of OHE. Treatment goals include improvement of daily functioning, evaluation for liver transplantation, and prevention of OHE recurrence. For secondary prophylaxis, intolerance to indefinite lactulose therapy may lead to non-adherence and has been identified as a precipitating factor for recurrent OHE. Rifaximin is an effective add-on therapy to lactulose for treatment and prevention of recurrent OHE. Recent studies have demonstrated comparable efficacy of probiotic therapy to lactulose use in both primary prophylaxis and secondary prophylaxis.

Biomechanical Mapping of the Female Pelvic Floor: Prolapse versus Normal Conditions

Background: Quantitative biomechanical characterization of pelvic supportive structures and functions in vivo is thought to provide insight into pathophysiology of pelvic organ prolapse (POP). An innovative approach—vaginal tactile imaging—allows biomechanical mapping of the female pelvic floor to quantify tissue elasticity, pelvic support, and pelvic muscle functions. The Vaginal Tactile Imager (VTI) records high definition pressure patterns from vaginal walls under an applied tissue deformation and during pelvic floor muscle contractions. Objective: To explore an extended set of 52 biomechanical parameters for differentiation and characterization of POP relative to normal pelvic floor conditions. Methods: 96 subjects with normal and POP conditions were included in the data analysis from multi-site observational, case-controlled studies;42 subjects had normal pelvic floor conditions and 54 subjects had POP. The VTI, model 2S, was used with an analytical software package to calculate automatically 52 biomechanical parameters for 8 VTI test procedures (probe insertion, elevation, rotation, Valsalva maneuver, voluntary muscle contractions in 2 planes, relaxation, and reflex contraction). The groups were equalized for subject age and parity. Results: The ranges, mean values, and standard deviations for all 52 VTI parameters were established. 33 of 52 parameters were identified as statistically sensitive (p 0.05;t-test) to the POP development. Among these 33 parameters, 11 parameters show changes (decrease) in tissue elasticity, 8 parameters show deteriorations in pelvic support and 14 parameters show weakness in muscle functions for POP versus normal conditions. Conclusions: The biomechanical mapping of the female pelvic floor with the VTI provides a unique set of parameters characterizing POP versus normal conditions. These objectively measurable biomechanical transformations of pelvic tissues, support structures, and functions under POP may be used in future research and practical applications.

Validation of the chronic liver disease questionnaire in Serbian patients

AIM:To translate into Serbian and to investigate the validity of the cross-culturally adapted the chronic liver disease questionnaire(CLDQ).METHODS:The questionnaire was validated in 103 consecutive CLD patients treated between October 2009 and October 2010 at the Clinic for Gastroenterology,Clinical Centre of Serbia,Belgrade(Serbia).Exclusion criteria were:age < 18 years,psychiatric disorders,acute complications of CLD(acute liver failure,variceal bleeding,and spontaneous bacterial peritonitis),hepatic encephalopathy(grade > 2)and liver transplantation.Evaluation of the CLDQ was done based on the following parameters:(1)acceptance is shown by the proportion of missing items;(2)internal reliabilities were assessed for multiple item scales by using Cronbach alpha coefficient;and(3)in order to assess whether the allocation of items in the domain corresponds to their distribution in the original questionnaire(construction validity),an exploratory factor analysis was conducted.Discriminatory validity was determined by comparing the corresponding CLDQ score/sub-score in patients with different severity of the diseases.RESULTS:The Serbian version of CLDQ questionnaire completed 98% patients.Proportion of missing items was 0.06%.The total time needed to fill the questionnaire was ranged from 8 to 15 min.Assistance in completing the questionnaire required 4.8% patients,while 2.9% needed help in reading,and 1.9% involved writing assistance.The mean age of the selected patients was 53.8 ± 12.9 years and 54.4% were men.Average CLDQ score was 4.62 ± 1.11.Cronbach's alpha for the whole scale was 0.93.Reliability for all domains was above 0.70,except for the domain "Activity"(0.49).The exploratory factor analysis model revealed 6 factors with eigenvalue of greater than 1,explaining 69.7% of cumulative variance.The majority of the items(66%)in the Serbian version of the CLDQ presented the highest loading weight in the domain assigned by the CLDQ developers:"Fatigue"(5/5),"Emotional function"(6/8),"Worry"(5/5),"Abdominal symptoms"(0/3),"Activity"(0/3),"Systemic symptoms"(3/5).The scales "Fatigue" and "Worry" fully corresponded to the original.The factor analysis also revealed that the factors "Activity" and "Abdominal symptoms" could not be replicated,and two new domains "Sleep" and "Nutrition" were established.Analysis of the CLDQ score/sub-score distribution according to disease severity demonstrated that patients without cirrhosis had lower total CLDQ score(4.86 ± 1.05)than those with cirrhosis Child's C(4.31 ± 0.97).Statistically significant difference was detected for the domains "Abdominal symptoms" [F(3)= 5.818,P = 0.001] and "Fatigue" [F(3)= 3.39,P = 0.021].Post hoc analysis revealed that patients with liver cirrhosis Child's C had significantly lower sub-score "Abdominal symptoms" than patients without cirrhosis or liver cirrhosis Child's A or B.For domain "Fatigue",patients with cirrhosis Child's C had significantly lower score,than non-cirrhotic patients.CONCLUSION:The Serbian version of CLDQ is well accepted and represents a valid and reliable instrument in Serbian sample of CLD patients.

Tactile and Ultrasound Image Fusion for Functional Assessment of the Female Pelvic Floor

Introduction: The true etiology of pelvic organ prolapse and urinary incontinence and variations observed among individuals are not entirely understood. Tactile (stress) and ultrasound (anatomy, strain) image fusion may furnish new insights into the female pelvic floor conditions. This study aimed to explore imaging performance and clinical value of vaginal tactile and ultrasound image fusion for characterization of the female pelvic floor. Methods: A novel probe with 96 tactile and 192 ultrasound transducers was designed. Women scheduled for a urogynecological visit were considered eligible for enrollment to observational study. Intravaginal tactile and ultrasound images were acquired for vaginal wall deformations at probe insertion, elevation, rotation, Valsalva maneuver, voluntary contractions, involuntary relaxation, and reflex pelvic muscle contractions. Biomechanical mapping has included tactile/ultrasound imaging and functional imaging. Results: Twenty women were successfully studied with the probe. Tactile and ultrasound images for tissues deformation as well as functional images were recorded. Tactile (stress) and ultrasound (strain) images allowed creation of stress-strain maps for the tissues of interest in absolute scale. Functional images allowed identification of active pelvic structures and their biomechanical characterization (anatomical measurements, contractive mobility and strength). Fusion of the modalities has allowed recognition and characterization of levator ani muscles (pubococcygeal, puborectal, iliococcygeal), perineum, urethral and anorectal complexes critical in prolapse and/or incontinence development. Conclusions: Vaginal tactile and ultrasound image fusion provides unique data for biomechanical characterization of the female pelvic floor. Bringing novel biomechanical characterization for critical soft tissues/structures may provide extended scientific knowledge and improve clinical practice.

Treatment strategies for chronic hepatitis C prior to andfollowing liver transplantation

Hepatitis C virus(HCV)-related liver disease is the leading indication for liver transplantation(LT) worldwide. However, HCV is an independent predictor of lower survival following LT, and recurrence of HCV postLT is virtually universal. The historic standard of care during the interferon era of HCV therapy was expectant management-initiation of antiviral therapy in the setting of documented disease progression following LT. With the advent of new direct acting antiviral(DAA) therapies for HCV, the paradigm of expectant treatment for recurrent HCV infection post-LT is shifting. The safety, tolerability, and efficacy of DAAs, even among the sickest patients with advanced liver disease, enables treatment of HCV in the pre-transplant setting among LT waitlist registrants. Finally, emerging data are supportive of preemptive therapy with DAAs in liver transplant recipients as the preferred approach. Expectant management of HCV following LT can rarely be justified in the modern era of HCV therapy.

Neurodevelopmental outcome in congenital diaphragmatic hernia: Evaluation, predictors and outcome

To review the reported neurodevelopmental outcome of congenital diaphragmatic hernia(CDH) survivors, identify important predictors of developmental disabilities, and describe the pathophysiological mechanisms contributing to adverse outcome. A Medline search was performed for English-language articles cross-referencing CDH with pertinent search terms. Retrospective, prospective, and longitudinal follow-up studies were examined. The reference lists of identified articles were also searched. Neurodevelopmental dysfunction has been recognized as one of most common and potentially most disabling outcome of CDH. Intelligence appears to be in the low normal to mildly delayed range. Neuromotor dysfunction is common during early childhood. Behavioral problems, hearing impairment, and quality of life related issues are frequently encountered in older children and adolescence. Disease severity correlates with the degree of neurological dysfunction. Neurodevelopmental follow-up in CDH children should become standard of care to identify those who would benefit from early intervention services and improve neurological outcomes.

Low Dose Total Skin Electron Beam Radiation in Cutaneous T-Cell Lymphoma: Review

The treatment of advanced stage MF is especially challenging as single agent overall response rates are in the 35% range and chronic recurrence is the rule. The treatment of CTCL across all stages of disease is aimed at the goal of achieving and sustaining remission. Increasingly, low dose total skin electron beam therapy (TSEBT) is being utilized as a skin directed component in combination therapy for advanced stage CTCL. Researchers are seeking to better define the utility of low dose TSEBT as a method of debulking skin disease while simultaneously treating other disease compartments and in combination with sustained maintenance therapies of both the skin directed and systemic varieties. Data exists showing the efficacy of low dose TSEBT in early and advanced disease. There is also data documenting prolonged treatment responses with TSEBT plus adjuvant skin directed therapies such as PUVA and topical nitrogen mustard. Emerging data examining the role of low dose TSEBT in the prestem cell transplant preparation is also promising. This brief review summarizes the utility of low dose TSEBT in multiagent treatment regimens in CTCL.

Mealtime feeding behaviors and gastrointestinal dysfunction in children with classic autism compared with normal sibling controls

Introduction: We compared the frequency and duration of specific mealtime behaviors and GI dysfunction in children with classic autism to typically-developing siblings. Survey Method: A 41-item on-line parent survey. Statistics: Chi square and binomial logistical regression. Results: 79 children with classic autism matched with a normally-developing sibling. Logistic Regression Analysis Revealed: Dislike of new foods and bizarre mealtime mannerisms, were more frequent in those with classic autism (p < 0.01). They also had higher odds ratio of constipation and fecal incontinence (p < 0.01). 40% of children with classic autism had been on GFCF diets (p < 0.01). Only 1% of those children on a gluten-free diet had a biopsy-proven diagnosis of celiac disease. Conclusion: Children with classic autism had more frequent dislike of new foods, bizarre mealtime behaviors, constipation, and fecal incontinence.

Vaccination practices among physicians and their children

The purpose of this study was to identify vaccination patterns of both general pediatricians and subspecialists with regards to their own children and projected progeny. A 14 question survey was sent randomly to 1000 members of the Academy of Pediatrics in 2009. Two categories of questions included 1) how physicians with children vaccinated them in the past, and 2) how all respondents would vaccinate a child in 2009. A comparison was made between the answers of general and specialty pediatricians. 582 valid questionnaires were received (58.2% response rate) of which 431 were general pediatricians and 151 subspecialists. No statistical difference was found between general and specialty pediatricians on how they vaccinated their children up until 2009 (95% vs 93%). When asked about vaccinating a future child, a significant proportion of respondents would deviate from CDC guidelines, specialists more than general pediatricians (21% vs 9%). Generalists were more likely to give a future child Hepatitis A (OR: 3.6;95% CI 1.3 - 10.4), Rotavirus (OR: 2.2;95% CI 1.1 - 4.4), Meningococcal (OR: 9.9;95% CI 3.3-29.9), and influenza (OR: 5.4;95% CI 1.1 - 26.7) vaccines. Specialists were more likely to postpone MMR vaccinetion (OR: 4.4 95% CI 2.3 - 8.6). Safety was listed by both groups as the most common reason for altering the recommended immunization schedule. Until 2009, general pediatricians and pediatric specialists have largely adhered to ACIP recommendations, but due to vaccine safety and other concerns, both groups, albeit a higher percentage of specialists, reported greater numbers willing to diverge from these recommendations.

Pott puffy tumor in an unusual location

Pott puffy tumor is almost always associated with an outward extension of suppurative acute frontal sinusitis. Pathogenesis includes osteomyelitis of the frontal bone with local spread of the infection to the outer cortex and termination of the suppurative process in a frontal subgaleal abscess. An unusual ectopic location of Pott puffy tumor is the tempo-parietal subgaleal space, located exterior to the squamous portion of the temporal bone. In this location, Pott puffy tumor is considered a suppurative complication of otomastoiditis. Reported here is a 4-year-old boy who developed amoxicillin-resistant acute otitis media, silent mastoiditis, temporal bone subperiosteal abscess, subgaleal abscess, and an epidural abscess. He had several fenestra of the tegmen mastoideum as a result of osteiitis of the temporal bone, which we believe permitted spread of the oto-mastoiditis to temporal bone, subgaleal space, and epidural space. Surgical specimens obtained from the middle ear and subgaleal abscess after 24-hours of intravenously-administered combination antibiotic therapy did not reveal any aerobic or anaerobic bacterial pathogens. This is only the second such pediatric case that we found during a careful search of the literature.

Distinct Placenta Increta and Percreta in the Setting of Dichorionic Diamniotic Twin Gestation: A Unique Histological Finding

Multiple gestations have been reported as a risk factor for placenta accreta spectrum (PAS) but the evidence is limited. Previous reports showed that PAS degrees (creta, increta, percreta) were similar in multiple gestation placentas. To our knowledge, there have been no reports of PAS in dichorionic placentas with different degrees of invasion. Here, we report dichorionic diamniotic placentas with two different degrees of invasion, one increta and another percreta.

Delayed Thoracic Radiation Injury

A case of delayed thoracic radiation injury occurring many years after an initial lung insult is presented. This case involves an individual who developed acute respiratory failure due to severe pleural fibrosis or fibrothorax possibly as a result of distant radiation therapy for Hodgkins disease.

Utilization of Artificial Intelligence for Diagnosis and Management of Urinary Incontinence in Women Residing in Areas with Low Resources: An Overview

Urinary incontinence (UI) is a distressing condition involving involuntary loss of urine from the body. Urinary incontinence can negatively impact a person’s overall quality of life and lead them into stages of embarrassment and depression. It is an underrepresented and undertreated condition prevalent in women, especially in low socioeconomic regions where women may not be able to express their concerns due to unawareness of diagnosis and treatment/management options. There are different diagnostic and management protocols for UI;however, utilizing artificially intelligent systems is not standard care. This paper overviews the use of artificial intelligence in women’s health and as a means of cost-effectively diagnosing patients, and as an avenue for providing low-cost treatments to women that suffer from urinary incontinence in low-resource communities. Studies found that these systems, mainly utilizing artificial neural networks (ANNs) and convolutional neural networks (CNNs), served to be an effective method in diagnosing patients and providing an avenue for personalized treatment for improved patient outcomes. A simple artificial intelligence (AI) model utilizing Multilayer Perceptron (MLP) Networks was proposed to diagnose and manage urinary incontinence.

Vaginal Cellular Angiofibroma with Heavy Bleeding: A Case Report

Cellular angiofibroma is a rare mesenchymal tumor that most commonly presents as an asymptomatic well-circumscribed mass in the vulva. Very few cases have been found in the vagina and even fewer presented with vaginal bleeding. A 54-year-old female presented to the emergency department with five months of vaginal bleeding and symptomatic anemia requiring blood transfusion. Upon physical examination, she was found to have a firm 4 cm posterior vaginal mass, distinctly distal to the cervix. The mass was resected and diagnosed as a vaginal cellular angiofibroma on pathologic evaluation. The patient did well post-operatively with recommended follow-up every six months. The common differential diagnosis for a bleeding vaginal mass includes leiomyoma, angiofibroblastoma, aggressive angiomyxoma, squamous cell carcinoma, and adenocarcinoma. In this case, cellular angiofibroma presented as a vaginal mass with heavy bleeding leading to severe anemia. Early involvement of gynecologic oncology can help to optimize patients’ evaluation and management.

Improving the Evaluation and Management of Cystotomy in Gynecologic Surgery with a Cadaver Surgical Curriculum

Objectives: Urinary tract injuries are a known complication of gynecologic surgery, occurring in 0.18% - 0.80% of procedures and most commonly involving the bladder. Appropriate identification, evaluation, treatment, and follow-up by gynecologic surgeons are important to reduce the associated long-term morbidities. The purpose of this study was to implement a comprehensive cadaver curriculum in cystotomy repair for OBGYN residents. Methods: This was a prospective observational cohort study including 10 OBGYN residents (PGY1-3) at a single institution in 2020 (56% of the 18 eligible residents). The curriculum consisted of a one-hour didactic lecture and one-hour hands-on surgical skills training with fresh frozen cadavers. Residents were evaluated in three domains: 1) knowledge, 2) surgical skills, and 3) confidence. Knowledge, confidence, and resident satisfaction were evaluated with pre- and post-surveys. The bladder model, derived from the ACOG Simulation Working Group, was used to evaluate surgical skills at baseline and at completion of the curriculum. Results: Across all three PGY levels, statistically significant improvements were observed in knowledge, surgical skills, and confidence after didactic and cadaver education (p = 0.001, p < 0.02, and p = 0.009 respectively). The largest increases in confidence occurred in residents’ ability to describe and perform cystotomy repairs. Conclusions: Educating and training OBGYN residents to manage and repair cystotomies can be challenging given the low incidence of injury in the operating room. The cadaver surgical skills curriculum was an effective training module and remains an important component of skills training in conjunction with simulation and traditional didactic sessions.

Resection of Vaginal Septum in Obstructed Hemivagina and Ipsilateral Renal Anomaly: Utility of Three Dimensional Intraoperative Ultrasound

Background: Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a rare congenital condition of the female urogenital tract, presenting intraoperative challenges. We demonstrate the utility of three dimensional intraoperative ultrasound to better delineate anatomy and aid in optimal resection of the vaginal septum. Case: A 12-year-old female was referred to pediatric and adolescent gynecology for irregular periods and evaluation of her gynecologic organs. Imaging studies confirmed OHVIRA syndrome. She underwent uncomplicated vaginal septum resection, guided by three dimensional intraoperative ultrasound. Summary and Conclusion: Intraoperative ultrasound can better delineate challenging anatomy. We show that three dimensional intraoperative ultrasound offers significant advantages over traditional two dimensional ultrasound and is a supplement to MRI, which may be helpful in complex anatomical cases like OHVIRA syndrome.

HCV阳性患者未参加医疗保险的比例较高

Background and Goals: There are no published data on the health insurance status of Hepatitis C virus (HCV) positive individuals. To address this issue, we analyzed data from the Third National Health and Nutrition Examination Survey (NHANES III). Study: Individuals 18 years of age and older who participated in NHANES III were included in the study. We determined the rates of health insurance coverage according to HCV status. We also determined healthcare status and health service utilization according to health insurance status among HCV-positive persons. Results: HCV-positive individuals were more likely to be uninsured compared with those who were HCV-negative (29.6% vs. 12.2% , P = 0.0002). Among those with health insurance, HCV-positive individuals were more likely to have government insurance compared with those who were HCV-negative (42.9% vs. 27.6% , P < 0.005). Among HCV-positive individuals, being uninsured was associated with younger age, being unmarried, living in the South, Mexican- American race/ethnicity, and not graduating from high school. Additionally, the uninsured were less likely than their insured counterparts to identify a healthcare facility for sick or routine care, and less likely to have regular contact with a healthcare professional. Conclusions: A high proportion of HCV-positive individuals are uninsured, and many HCV-positive individuals with health insurance have publicly funded insurance. This finding may have implications for access to health care and for liver-related disease outcomes in HCV-positive persons.

非酒精脂肪性肝病疾病谱的基因组与蛋白组学研究

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, and some of its forms are progressive. This study describes the profiling of hepatic gene expression and serum protein content in patients with different subtypes of NAFLD. Liver biopsy specimens from 98 bariatric surgery patients were classified as normal, steatosis alone, steatosis with nonspecific inflammation, and nonalcoholic steatohepatitis (NASH). Microarray hybridizations were performed in triplicate and the microarray expression levels of a selected group of genes were confirmed using real-time quantitative reverse- transcriptase polymerase chain reaction. Serum protein profiles of the same patients were determined by SELDI-TOF mass spectrometry. Of 98 obese patients, 91 were diagnosed with NAFLD (12 steatosis alone, 52 steatosis with nonspecific inflammation, and 27 NASH), and 7 patients without NAFLD served as obese controls. Each group of NAFLD patients was compared with the obese controls, and 22 genes with more than twofold differences in expression levels were revealed. Proteomics analyses were performed for the same group comparisons and revealed twelve significantly different protein peaks. In conclusion, this genomic/proteomic analysis suggests differential expression of several genes and protein peaks in patients within and across the forms of NAFLD. These findings may help clarify the pathogenesis of NAFLD and identify potential targets for therapeutic intervention.