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Mellinger JL, Shedden K, Winder GS, Tapper E, Adams M, Fontana RJ, Volk ML, Blow FC, Lok ASF. The high burden of alcoholic cirrhosis in privately insured persons in the United States. Hepatology 2018; 68:872-882. [PMID: 29579356 DOI: 10.1002/hep.29887] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 02/13/2018] [Accepted: 03/01/2018] [Indexed: 12/13/2022]
Abstract
UNLABELLED Alcoholic cirrhosis (AC) is a major cause of liver-related morbidity and mortality in the United States. Rising rates of alcohol use disorders in the United States will likely result in more alcoholic liver disease. Our aim was to determine the prevalence, health care use, and costs of AC among privately insured persons in the United States. We collected data from persons aged 18-64 with AC (identified by codes from the International Classification of Diseases, Ninth and Tenth Revisions) enrolled in the Truven MarketScan Commercial Claims and Encounters database (2009-2015). We determined yearly prevalence, weighted to the national employer-sponsored, privately insured population. Using competing risk analysis, we estimated event rates for portal hypertensive complications and estimated the association between AC and costs as well as admissions and readmissions. In 2015, 294,215 people had cirrhosis and 105,871 (36%) had AC. Mean age at AC diagnosis was 53.5 years, and 32% were women. Over the 7 years queried, estimated national cirrhosis prevalence rose from 0.19% to 0.27% (P < 0.001) and for AC from 0.07% to 0.10% (P < 0.001). Compared to non-AC, AC enrollees were significantly more likely to have portal hypertensive complications at diagnosis and higher yearly cirrhosis and alcohol-related admissions (25 excess cirrhosis admissions and 6.3 excess alcohol-related admissions per 100 enrollees) as well as all-cause readmissions. Per-person costs in the first year after diagnosis nearly doubled for AC versus non-AC persons (US$ 44,835 versus 23,319). CONCLUSION In a nationally representative cohort of privately insured persons, AC enrollees were disproportionately sicker at presentation, were admitted and readmitted more often, and incurred nearly double the per-person health care costs compared to those with non-AC. (Hepatology 2018).
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Affiliation(s)
- Jessica L Mellinger
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Kerby Shedden
- Department of Statistics, University of Michigan, Ann Arbor, MI
| | - Gerald Scott Winder
- Department of Psychiatry, VA Center for Clinical Management Research, Ann Arbor, MI
| | - Elliot Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Megan Adams
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI.,VA Center for Clinical Management Research, Ann Arbor, MI
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Michael L Volk
- Transplantation Institute, Loma Linda University Health, Loma Linda, CA
| | - Frederic C Blow
- Department of Psychiatry, VA Center for Clinical Management Research, Ann Arbor, MI.,VA Center for Clinical Management Research, Ann Arbor, MI
| | - Anna S F Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
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Chhatwal J, Samur S, Bethea ED, Ayer T, Kanwal F, Hur C, Roberts MS, Terrault N, Chung RT. Transplanting hepatitis C virus-positive livers into hepatitis C virus-negative patients with preemptive antiviral treatment: A modeling study. Hepatology 2018; 67:2085-2095. [PMID: 29222916 PMCID: PMC5991982 DOI: 10.1002/hep.29723] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 10/30/2017] [Accepted: 12/07/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED Under current guidelines, hepatitis C virus (HCV)-positive livers are not transplanted into HCV-negative recipients because of adverse posttransplant outcomes associated with allograft HCV infection. However, HCV can now be cured post-LT (liver transplant) using direct-acting antivirals (DAAs) with >90% success; therefore, HCV-negative patients on the LT waiting list may benefit from accepting HCV-positive organs with preemptive treatment. Our objective was to evaluate whether and in which HCV-negative patients the potential benefit of accepting an HCV-positive (i.e., viremic) organ outweighed the risks associated with HCV allograft infection. We developed a Markov-based mathematical model that simulated a virtual trial of HCV-negative patients on the LT waiting list to compare long-term outcomes in patients: (1) willing to accept any (HCV-negative or HCV-positive) liver versus (2) those willing to accept only HCV-negative livers. Patients receiving HCV-positive livers were treated preemptively with 12 weeks of DAA therapy and had a higher risk of graft failure than those receiving HCV-negative livers. The model incorporated data from published studies and the United Network for Organ Sharing (UNOS). We found that accepting any liver regardless of HCV status versus accepting only HCV-negative livers resulted in an increase in life expectancy when Model for End-Stage Liver Disease (MELD) was ≥20, and the benefit was highest at MELD 28 (0.172 additional life-years). The magnitude of clinical benefit was greater in UNOS regions with higher HCV-positive donor organ rates, that is, Regions 1, 2, 3, 10, and 11. Sensitivity analysis demonstrated that model outcomes were robust. CONCLUSION Transplanting HCV-positive livers into HCV-negative patients with preemptive DAA therapy could improve patient survival on the LT waiting list. Our analysis can help inform clinical trials and minimize patient harm. (Hepatology 2018;67:2085-2095).
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Affiliation(s)
- Jagpreet Chhatwal
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA,Harvard Medical School, Boston, MA,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA
| | - Sumeyye Samur
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA,Harvard Medical School, Boston, MA
| | - Emily D. Bethea
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA,Harvard Medical School, Boston, MA,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA
| | - Turgay Ayer
- Department of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Fasiha Kanwal
- Department of Medicine, Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX,Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Chin Hur
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA,Harvard Medical School, Boston, MA,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA
| | - Mark S. Roberts
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA,University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Norah Terrault
- University of California San Francisco Medical Center, San Francisco, CA
| | - Raymond T. Chung
- Harvard Medical School, Boston, MA,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA
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53
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Misconceptions, preferences and barriers to alcohol use disorder treatment in alcohol-related cirrhosis. J Subst Abuse Treat 2018; 91:20-27. [PMID: 29910011 DOI: 10.1016/j.jsat.2018.05.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND While alcohol cessation improves mortality in alcoholic liver disease (ALD), many patients struggle to achieve abstinence. Our aim was to characterize ALD patients' preferences, misconceptions, and barriers to alcohol use treatment options. METHODS This mixed-methods study included outpatients with a history of alcohol-related cirrhosis or alcoholic hepatitis recruited from a hepatology clinic for a survey or an in-depth semi-structured interview. We purposefully sampled men and women, compensated and decompensated patients to ensure adequate representation of gender and severity of liver disease for the qualitative interviews. RESULTS 123 patients completed surveys among which 50% reported having at least one drink within the past year while only 20 patients were in any form of current alcohol treatment. Of the 23 patients reporting drinking within 3 months, only 3 were in AUD treatment currently. 17% had at least one misconception about alcohol use or treatment. An additional 22 ALD patients (10 women, 12 men) completed phone interviews of which two-third self-reported alcohol abstinence. All 22 interview participants had awareness of some form of alcohol treatment, but 13 felt that they did not need treatment with several characterizing it as ineffective or a "waste of time." Misconceptions included inaccurate perceptions of relapse medication side effects, beliefs that the presence of advanced liver disease symptoms means it is too late to treat alcohol use, and a lack of understanding about the chronicity of alcohol use disorders. The most common barriers to treatment included unwillingness to be in treatment, financial/insurance and transportation barriers. CONCLUSIONS Alcohol use treatment was underutilized in many ALD patients, despite active drinking in many. Tailored education and preference sensitive treatment engagement may overcome barriers to alcohol use treatment and promote abstinence.
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54
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Bilal U, McCaul ME, Crane HM, Mathews WC, Mayer KH, Geng E, Napravnik S, Cropsey KL, Mugavero MJ, Saag MS, Hutton H, Lau B, Chander G. Predictors of Longitudinal Trajectories of Alcohol Consumption in People with HIV. Alcohol Clin Exp Res 2018; 42:561-570. [PMID: 29265385 DOI: 10.1111/acer.13583] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 12/12/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Our aim was to describe alcohol consumption trajectories in a cohort of people living with HIV and determine clinical and sociodemographic predictors of each trajectory. METHODS This is a prospective cohort study of 7,906 patients in the 7 Centers for AIDS Research Network of Integrated Clinical Systems sites. Alcohol consumption was categorized as none, moderate, and alcohol misuse. Predictors included age, race/ethnicity, depressive or anxiety symptoms, illicit drug use (opioids, methamphetamines, cocaine/crack), marijuana use, hepatitis C virus (HCV) infection, HIV transmission risk factor, and HIV disease progression. We estimated sex-stratified alcohol consumption trajectories and their predictors. RESULTS We found 7 trajectories of alcohol consumption in men: stable nondrinking and increased drinking (71% and 29% of initial nondrinking); stable moderate, reduced drinking, and increased alcohol misuse (59%, 21%, and 21% of initial moderate alcohol use); and stable alcohol misuse and reduced alcohol misuse (75% and 25% of initial alcohol misuse). Categories were similar in women, except lack of an increase to alcohol misuse trajectory among women that begin with moderate use. Older men and women were more likely to have stable nondrinking, while younger men were more likely to increase to or remain in alcohol misuse. Minorities, people with depressive or anxiety symptoms, HCV-infected individuals, and people who injected drugs were more likely to reduce use. Illicit drug use was associated with a reduction in overall drinking, while marijuana use was associated with stable moderate drinking or misuse. CONCLUSIONS Longitudinal trajectories of increasing alcohol use and stable misuse highlight the need to integrate routine screening and alcohol misuse interventions into HIV primary care.
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Affiliation(s)
- Usama Bilal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Urban Health Collaborative, Drexel Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Mary E McCaul
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Heidi M Crane
- Department of Medicine, UW School of Medicine, University of Washington, Seattle, Washington
| | | | - Kenneth H Mayer
- School of Medicine, Harvard University, Boston, Massachusetts.,School of Public Health, Harvard University, Boston, Massachusetts.,Fenway Health, Boston, Massachusetts
| | - Elvin Geng
- School of Medicine, University of California San Francisco, San Francisco, California
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Karen L Cropsey
- Department of Medicine, University of Alabama, Birmingham, Alabama
| | | | - Michael S Saag
- Department of Medicine, University of Alabama, Birmingham, Alabama
| | - Heidi Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Geetanjali Chander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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55
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Kling CE, Perkins JD, Carithers RL, Donovan DM, Sibulesky L. Recent trends in liver transplantation for alcoholic liver disease in the United States. World J Hepatol 2017; 9:1315-1321. [PMID: 29359014 PMCID: PMC5756720 DOI: 10.4254/wjh.v9.i36.1315] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/07/2017] [Accepted: 12/05/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To examine temporal changes in the indications for liver transplantation (LT) and characteristics of patients transplanted for alcoholic liver disease (ALD).
METHODS We performed a retrospective cohort analysis of trends in the indication for LT using the United Network for Organ Sharing (UNOS) database between 2002 and 2015. Patients were grouped by etiology of the liver disease and characteristics were compared using χ2 and t-tests. Time series analysis was used identifying any year with a significant change in the number of transplants per year for ALD, and before and after eras were modeled using a general linear model. Subgroup analysis of recipients with ALD was performed by age group, gender, UNOS region and etiology (alcoholic cirrhosis, alcoholic hepatitis and hepatitis C - alcoholic cirrhosis dual listing).
RESULTS Of 74216 liver transplant recipients, ALD (n = 9400, 12.7%) was the third leading indication for transplant after hepatitis C and hepatocellular carcinoma. Transplants for ALD, increased from 12.8% (553) in 2002 to 16.5% (1020) in 2015. Time series analysis indicated a significant increase in the number of transplants per year for ALD in 2013 (P = 0.03). There were a stable number of transplants per year between 2002 and 2012 (linear coefficient 3, 95%CI: -4.6, 11.2) an increase of 177 per year between 2013 and 2015 (95%CI: 119, 234). This increase was significant for all age groups except those 71-83 years old, was observed for both genders, and was incompletely explained by a decrease in transplants for hepatitis C and ALD dual listing. All UNOS regions except region 9 saw an increase in the mean number of transplants per year when comparing eras, and this increase was significant in regions 2, 3, 4, 5, 6, 8, 10 and 11.
CONCLUSION There has been a dramatic increase in the number of transplants for ALD starting in 2013.
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Affiliation(s)
- Catherine E Kling
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, United States
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, United States
| | - Robert L Carithers
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Washington, Seattle, WA 98195, United States
| | - Dennis M Donovan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, United States
| | - Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, United States
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56
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Saikia P, Roychowdhury S, Bellos D, Pollard KA, McMullen MR, McCullough RL, McCullough AJ, Gholam P, de la Motte C, Nagy LE. Hyaluronic acid 35 normalizes TLR4 signaling in Kupffer cells from ethanol-fed rats via regulation of microRNA291b and its target Tollip. Sci Rep 2017; 7:15671. [PMID: 29142263 PMCID: PMC5688113 DOI: 10.1038/s41598-017-15760-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 11/02/2017] [Indexed: 02/06/2023] Open
Abstract
TLR4 signaling in hepatic macrophages is increased after chronic ethanol feeding. Treatment of hepatic macrophages after chronic ethanol feeding with small-specific sized hyaluronic acid 35 (HA35) normalizes TLR4 signaling; however, the mechanisms for HA35 action are not completely understood. Here we used Next Generation Sequencing of microRNAs to identify negative regulators of TLR4 signaling reciprocally modulated by ethanol and HA35 in hepatic macrophages. Eleven microRNAs were up-regulated by ethanol; only 4 microRNAs, including miR291b, were decreased by HA35. Bioinformatics analysis identified Tollip, a negative regulator of TLR4, as a target of miR291b. Tollip expression was decreased in hepatic macrophages from ethanol-fed rats, but treatment with HA35 or transfection with a miR291b hairpin inhibitor restored Tollip expression and normalized TLR4-stimulated TNFα expression. In peripheral blood monocytes isolated from patients with alcoholic hepatitis, expression of TNFα mRNA was robustly increased in response to challenge with lipopolysaccharide. Importantly, pre-treatment with HA35 reduced TNFα expression by more than 50%. Taken together, we have identified miR291b as a critical miRNA up-regulated by ethanol. Normalization of the miR291b → Tollip pathway by HA35 ameliorated ethanol-induced sensitization of TLR4 signaling in macrophages/monocytes, suggesting that HA35 may be a novel therapeutic agent in the treatment of ALD.
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Affiliation(s)
- Paramananda Saikia
- Center for Liver Disease Research, Department of Pathobiology, Cleveland, OH, USA.,Department of Molecular Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Sanjoy Roychowdhury
- Center for Liver Disease Research, Department of Pathobiology, Cleveland, OH, USA.,Department of Molecular Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Damien Bellos
- Center for Liver Disease Research, Department of Pathobiology, Cleveland, OH, USA.,Department of Molecular Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Katherine A Pollard
- Center for Liver Disease Research, Department of Pathobiology, Cleveland, OH, USA
| | - Megan R McMullen
- Center for Liver Disease Research, Department of Pathobiology, Cleveland, OH, USA
| | - Rebecca L McCullough
- Center for Liver Disease Research, Department of Pathobiology, Cleveland, OH, USA
| | - Arthur J McCullough
- Center for Liver Disease Research, Department of Pathobiology, Cleveland, OH, USA.,Departments of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Pierre Gholam
- Department of Gastroenterology and Hepatology, University Hospital, Cleveland, OH, USA
| | - Carol de la Motte
- Center for Liver Disease Research, Department of Pathobiology, Cleveland, OH, USA.,Department of Molecular Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Laura E Nagy
- Center for Liver Disease Research, Department of Pathobiology, Cleveland, OH, USA. .,Departments of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA. .,Department of Molecular Medicine, Case Western Reserve University, Cleveland, OH, USA.
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57
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Horvath B, Allende D, Xie H, Guirguis J, Jeung J, Lapinski J, Patil D, McCullough AJ, Dasarathy S, Liu X. Interobserver Variability in Scoring Liver Biopsies with a Diagnosis of Alcoholic Hepatitis. Alcohol Clin Exp Res 2017; 41:1568-1573. [PMID: 28654190 DOI: 10.1111/acer.13438] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/12/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Alcoholic hepatitis (AH) is one of the most severe forms of alcoholic liver disease. Recently, a histologic scoring system for predicting prognosis in this patient cohort was proposed as Alcoholic Hepatitis Histologic Score (AHHS). We aimed to assess interobserver variability in recognizing histologic features of AH and the effect of this variability on the proposed AHHS categories. METHODS Hematoxylin-eosin- and trichrome-stained slides from 32 patients diagnosed with AH with liver biopsies within 1 month of presentation (2000 to 2015) were reviewed by 5 pathologists including 3 liver pathologists and 2 gastrointestinal (GI) pathologists masked to the clinical findings or outcome. Histologic features of AH were assessed, the AHHS was calculated, and an AHHS category (mild, moderate, severe) was assigned. The Fleiss' kappa coefficient (κ) analysis was performed to determine the interobserver agreement. RESULTS A slight-to-moderate level of interobserver agreement existed among 5 reviewers on histopathologic features of AH with κ value ranging from 0.20 (95% confidence interval (CI): 0.03 to 0.46, megamitochondria) to 0.52 [95% CI: 0.40 to 0.68, polymorphonuclear leukocyte (PMN) infiltration]. There was only a fair level of agreement in assigning AHHS category (κ = 0.33, 95% CI: 0.20 to 0.51). While overall fibrosis and neutrophilic inflammation were comparably evaluated by 3 liver pathologists and 2 GI pathologists, bilirubinostasis and megamitochondria were more consistently diagnosed by liver pathologists. Overall, 18 of 32 (56%) were uniformly assigned to an AHHS category by all liver pathologists with a κ value of 0.40 (95% CI: 0.22 to 0.60). CONCLUSIONS In general, features of AH can be recognized with a slight-to-moderate level of interobserver agreement and there was fair interobserver agreement on assigning an AHHS category. Significant interobserver variability among pathologists revealed by the current study can limit its usefulness in everyday clinical practice.
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Affiliation(s)
- Bela Horvath
- Department of Anatomic Pathology , Cleveland Clinic, Cleveland, Ohio
| | - Daniela Allende
- Department of Anatomic Pathology , Cleveland Clinic, Cleveland, Ohio
| | - Hao Xie
- Department of Medicine , Yale University, New Haven, Connecticut
| | - John Guirguis
- Department of Gastroenterology and Hepatology , Cleveland Clinic, Cleveland, Ohio
| | - Jennifer Jeung
- Department of Anatomic Pathology , Cleveland Clinic, Cleveland, Ohio
| | - James Lapinski
- Department of Anatomic Pathology , Cleveland Clinic, Cleveland, Ohio
| | - Deepa Patil
- Department of Anatomic Pathology , Cleveland Clinic, Cleveland, Ohio
| | - Arthur J McCullough
- Department of Gastroenterology and Hepatology , Cleveland Clinic, Cleveland, Ohio
| | - Srinivasan Dasarathy
- Department of Gastroenterology and Hepatology , Cleveland Clinic, Cleveland, Ohio
| | - Xiuli Liu
- Department of Pathology, Immunology and Laboratory Medicine , University of Florida, Gainesville, Florida
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Abstract
PURPOSE OF REVIEW Alcohol consumption is increasing globally, as are complications of alcohol-related liver disease, including the most severe manifestation, alcoholic hepatitis. Despite the increased prevalence, many patients hospitalized with alcoholic hepatitis are either not diagnosed or inadequately treated leading to significant morbidity and high mortality rates. The purpose of this review is to discuss current challenges in the diagnosis and management of this frequently fatal condition. RECENT FINDINGS Recent studies and meta-analyses have improved our understanding of both the evaluation and treatment of alcoholic hepatitis including the diagnostic criteria, appropriate use of glucocorticoids and other therapeutic modalities including novel disease-specific therapeutic agents and indications for considering liver transplantation. SUMMARY Glucocorticoid therapy and enteral nutrition represent the best options for reducing short-term mortality in patients with the severe form of acute alcoholic hepatitis. The efficacy of other medications such as pentoxifylline as currently used does not support a role for use outside clinical trials. While the current management options for alcoholic hepatitis remain insufficient, improvements in diagnosis, determining prognosis and severity and the potential role of novel treatments provides encouragement that outcomes from this devastating condition will improve.
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Heslin KC, Elixhauser A, Steiner CA. Identifying in-patient costs attributable to the clinical sequelae and comorbidities of alcoholic liver disease in a national hospital database. Addiction 2017; 112:782-791. [PMID: 27886658 DOI: 10.1111/add.13702] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/13/2016] [Accepted: 11/21/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS The clinical sequelae and comorbidities of alcoholic liver disease (ALD) often require hospitalization. The aims of this study were to (1) compare the average costs of hospitalizations with ALD and the costs of hospitalizations with other alcohol-related diagnoses that do not involve the liver; and (2) estimate the percentage of the difference in costs between the ALD and non-ALD hospitalizations that may be attributed to ascites, protein-calorie malnutrition and other conditions. DESIGN The 2012 National Inpatient Sample is a population-based cross-sectional database representing more than 94% of all discharges from community hospitals in the United States. SETTING Community hospitals in the United States. PARTICIPANTS The sample included 72 531 hospitalizations with ALD and 287 047 hospitalizations with other alcohol-related diagnoses. MEASUREMENTS The dependent variable was total in-patient costs. We estimated the contribution of ascites, protein-calorie malnutrition and other conditions to the difference in costs between patients with ALD and patients with other diagnoses. FINDINGS Average costs for ALD patients were $3188.4 higher than those for patients with other diagnoses ($13 543 versus $10 355; P < 0.001). Among all conditions in the analysis, protein-calorie malnutrition had the largest impact on costs [$6501; 95% confidence interval (CI) = 5956, 7045; P < 0.001] accounting for 12% of the higher costs of ALD stays. CONCLUSIONS Costs of hospital care for patients with alcoholic liver disease are higher than those for patients with other alcohol-related diagnoses. These increased costs are associated with specific clinical sequelae and comorbidities, with protein-calorie malnutrition-a largely preventable condition-making a substantial contribution.
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Affiliation(s)
- Kevin C Heslin
- Center for Delivery, Organization, and Markets, Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Anne Elixhauser
- Center for Delivery, Organization, and Markets, Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Claudia A Steiner
- Center for Delivery, Organization, and Markets, Agency for Healthcare Research and Quality, Rockville, MD, USA
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60
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Dasarathy S, Brown JM. Alcoholic Liver Disease on the Rise: Interorgan Cross Talk Driving Liver Injury. Alcohol Clin Exp Res 2017; 41:880-882. [PMID: 28295407 DOI: 10.1111/acer.13370] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 03/03/2017] [Indexed: 12/14/2022]
Affiliation(s)
| | - J Mark Brown
- Department of Cellular and Molecular Medicine, Cleveland Clinic, Cleveland, Ohio
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61
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Akinyeke T, Weber SJ, Davenport AT, Baker EJ, Daunais JB, Raber J. Effects of alcohol on c-Myc protein in the brain. Behav Brain Res 2016; 320:356-364. [PMID: 27832980 DOI: 10.1016/j.bbr.2016.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/28/2016] [Accepted: 11/04/2016] [Indexed: 12/18/2022]
Abstract
Alcoholism is a disorder categorized by significant impairment that is directly related to persistent and extreme use of alcohol. The effects of alcoholism on c-Myc protein expression in the brain have been scarcely studied. This is the first study to investigate the role different characteristics of alcoholism have on c-Myc protein in the brain. We analyzed c-Myc protein in the hypothalamus and amygdala from five different animal models of alcohol abuse. c-Myc protein was increased following acute ethanol exposure in a mouse knockout model and following chronic ethanol consumption in vervet monkeys. We also observed increases in c-Myc protein exposure in animals that are genetically predisposed to alcohol and methamphetamine abuse. Lastly, c-Myc protein was increased in animals that were acutely exposed to methamphetamine when compared to control treated animals. These results suggest that in substance abuse c-Myc plays an important role in the brain's response.
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Affiliation(s)
- Tunde Akinyeke
- Department of Behavioral Neuroscience, ONPRC, Oregon Health and Science University, Portland, OR 97239, United States
| | - Sydney J Weber
- Department of Behavioral Neuroscience, ONPRC, Oregon Health and Science University, Portland, OR 97239, United States
| | - April T Davenport
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston Salem, NC 27106, United States
| | - Erich J Baker
- School of Engineering and Department of Computer Science, Baylor University Waco, TX 76978, United States
| | - James B Daunais
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston Salem, NC 27106, United States
| | - Jacob Raber
- Department of Behavioral Neuroscience, ONPRC, Oregon Health and Science University, Portland, OR 97239, United States; Departments of Neurology and Radiation Medicine, Division of Neuroscience, ONPRC, Oregon Health and Science University, Portland, OR 97239, United States.
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62
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Dasarathy S. Nutrition and Alcoholic Liver Disease: Effects of Alcoholism on Nutrition, Effects of Nutrition on Alcoholic Liver Disease, and Nutritional Therapies for Alcoholic Liver Disease. Clin Liver Dis 2016; 20:535-50. [PMID: 27373615 PMCID: PMC4934388 DOI: 10.1016/j.cld.2016.02.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Malnutrition is the most frequent and nearly universal consequence in alcoholic liver disease (ALD) that adversely affects clinical outcomes. Sarcopenia or skeletal muscle loss is the major component of malnutrition in liver disease. There are no effective therapies to prevent or reverse sarcopenia in ALD because the mechanisms are not well understood. Consequences of liver disease including hyperammonemia, hormonal perturbations, endotoxemia and cytokine abnormalities as well as the direct effects of alcohol and its metabolites contribute to sarcopenia in ALD. This article focuses on the prevalence, methods to quantify malnutrition, specifically sarcopenia and potential therapies including novel molecular targeted treatments.
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Affiliation(s)
- Srinivasan Dasarathy
- Departments of Gastroenterology, Hepatology and Pathobiology, Cleveland Clinic, Cleveland, Ohio
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