No safe level of alcohol consumption - Implications for global health

Voucher-based contingency management to promote treatment engagement in comorbid alcohol use disorder and alcohol-related liver disease: A pilot theory-informed qualitative study with service users

BACKGROUND

Effective interventions for the management of alcohol-related liver disease (ARLD) remain a gap in clinical practice, and patients' engagement with alcohol services is suboptimal. Based upon the principles of operant conditioning, contingency management (CM) is a psychosocial intervention th at involves gradual, increasing incentives upon completion of treatment-related goals such as treatment attendance.

METHODS

A pilot feasibility trial was conducted with 30 adult patients recruited from an inpatient clinical setting. Consecutive sampling was used to recruit patients presenting comorbid alcohol use disorder (AUD) and ARLD. Participants were randomized to integrated liver care (ILC), receiving hepatology and AUD care, or ILC with a voucher-based CM intervention (intervention arm). A longitudinal qualitative approach was adopted to explore anticipated (Stage 1) and experienced acceptability (Stage 2). The Theoretical Framework of Acceptability (TFA) guided semi-structured in-depth interviews and deductive analysis.

RESULTS

Thirty participants were enrolled in the pilot trial, and interviews were conducted with 24 participants at Stage 1 and seven at Stage 2. Over half of the cohort (54.2%, n = 13) presented decompensated liver disease, and an average of 179 units of alcohol were consumed per week. Overall positive views toward voucher-based CM were noted, and explanatory data emerged across five TFA domains (intervention coherence, ethicality, self-efficacy, perceived effectiveness, and affective attitude). The core aspects of the voucher-based CM intervention matched participants' preferences and needs. Participants regarded CM as having a symbolic value and strengthening the therapeutic alliance with healthcare providers.

CONCLUSION

The data support the scope of voucher-based CM intervention to promote engagement with treatment services, and its potential to address the gaps in the care continuum in ARLD. The findings are of practical significance for developing person-centered, tailored interventions for this clinical population. The outcomes of this investigation can inform decision-making among stakeholders and healthcare providers and improve health outcomes for this clinical population.

Protective effect of short-chain fructo-oligosaccharides from chicory on alcohol-induced injury in GES-1 cells via Keap1/Nrf2 and NLRP3 inflammasome signaling pathways

Numerous studies have demonstrated that polysaccharides derived from chicory possess the ability to regulate host signaling and modify mucosal damage. Yet, the effect and mechanism of short-chain fructo-oligosaccharides (scFOS) on gastric mucosa remain unclear. Hence, the protective effect of three scFOS (1-Kestose, Nystose, and 1F-Fructofuranosylnystose) against ethanol-induced injury in gastric epithelial (GES-1) cells, and the underlying molecular mechanism involved was investigated in this study. Treatment with 7% ethanol decreased the cell viability of GES-1 cells, resulting in oxidative stress and inflammation. However, pretreatment with scFOS exhibited significant improvements in cell viability, and mitigated oxidative stress and inflammation. scFOS markedly elevated the protein expression of Nrf2, HO-1, SOD1 and SOD2, while suppressing the expression of Keap1. scFOS pretreatment could also maintain mitochondrial membrane potential balance and reduce apoptosis. In addition, scFOS was observed to reduce the protein level of NLRP3, Caspase-1 and ASC. In conclusion, scFOS served a preventive function in mitigating oxidative stress and inflammation in ethanol-exposed GES-1 cells through modulation of the Keap1/Nrf2 and NLRP3 inflammasome signaling pathways. Collectively, the results indicated that scFOS could significantly mitigate ethanol-induced gastric cell damage, suggesting its potential for safeguarding gastrointestinal health.

AlcoChange: A digital therapeutic for patients with alcohol-related liver disease

Background & Aims

Maintenance of abstinence in alcohol-related liver disease (ARLD) is a major unmet therapeutic need. Digital therapeutics can deliver ongoing behavioural therapy, in real-time, for chronic conditions. The aim of this project was to develop and clinically test AlcoChange, a novel digital therapeutic for ARLD.

Methods

AlcoChange was developed using validated behaviour change techniques and a digital alcohol breathalyser. This was an open-label, single-centre study. Patients with ARLD, ongoing alcohol use (within 1 month) and possession of a suitable smartphone were eligible. Patients were recruited from inpatient and outpatient settings, and received AlcoChange therapy for 3 months. The primary outcome was reduction in alcohol use from baseline to 3 months, measured by timeline follow-back. Secondary outcomes included: (i) compliance with the AlcoChange app, (ii) alcohol-related and all-cause hospital re-admissions up to 1 year, (iii) qualitative analysis to determine factors associated with compliance.

Results

Sixty-five patients were recruited, of whom 41 completed the study per protocol. Patients compliant with the intervention (>60 logins over 3 months) had a significant reduction in alcohol use from baseline compared to non-compliant patients (median [IQR]: -100% [100% to -55.1%] vs. -57.1% [-95.3% to +32.13%], p = 0.029). The proportion attaining abstinence at 3 months was higher in the compliant group (57.1% vs. 22.2%, p = 0.025). The compliant group had a significantly decreased risk of subsequent alcohol-related re-admission up to 12 months (p = 0.008). Qualitative analysis demonstrated that receiving in-app feedback and the presence of a health-related 'sentinel event' were predictors of compliance with the intervention.

Conclusions

Use of the novel digital therapeutic, AlcoChange, was associated with a significant reduction in alcohol use and an increase in the proportion of patients with ARLD attaining abstinence. Definitive randomised trials are warranted for this intervention.

Impact and implications

Alcohol-related liver disease (ARLD) is an increasing health problem worldwide. The main cause of death and disability in ARLD is ongoing alcohol consumption, but few patients receive medications or talking therapy to maintain abstinence. This study demonstrated that a digital therapeutic, linked to a smartphone, may help reduce alcohol consumption and alcohol-related hospital admissions in these patients. If validated in larger, randomised, trials, digital therapeutics may have a role in the primary and secondary prevention of complicatons from ARLD.

Binge-pattern alcohol consumption and genetic risk as determinants of alcohol-related liver disease

Alcohol-related liver disease (ARLD) represents a major public health burden. Identification of high-risk individuals would allow efficient targeting of public health interventions. Here, we show significant interactions between pattern of drinking, genetic predisposition (polygenic risk score, PRS) and diabetes mellitus, and risk of incident ARLD, in 312,599 actively drinking adults in UK Biobank. Binge and heavy binge drinking significantly increase the risk of alcohol-related cirrhosis (ARC), with higher genetic predisposition further amplifying the risk. Further, we demonstrate a pronounced interaction between heavy binge drinking and high PRS, resulting in a relative excess risk due to interaction (RERI) of 6.07. Diabetes consistently elevates ARC risk across all drinking and PRS categories, and showed significant interaction with both binge patterns and genetic risk. Overall, we demonstrate synergistic effects of binge drinking, genetics, and diabetes on ARC, with potential to identify high-risk individuals for targeted interventions.

Landscape of alcohol-related hepatocellular carcinoma in the last 15 years highlights the need to expand surveillance programs

BACKGROUND & AIMS

Alcohol abuse and metabolic disorders are leading causes of hepatocellular carcinoma (HCC) worldwide. Alcohol-related aetiology is associated with a worse prognosis compared with viral agents, because of the lower percentage of patients diagnosed with HCC under routine surveillance and a higher burden of comorbidity in alcohol abusers. This study aimed to describe the evolving clinical scenario of alcohol-related HCC over 15 years (2006-2020) in Italy.

METHODS

Data from the Italian Liver Cancer (ITA.LI.CA) registry were used: 1,391 patients were allocated to three groups based on the year of HCC diagnosis (2006-2010; 2011-2015; 2016-2020). Patient characteristics, HCC treatment, and overall survival were compared among groups. Survival predictors were also investigated.

RESULTS

Approximately 80% of alcohol-related HCCs were classified as cases of metabolic dysfunction-associated fatty liver disease. Throughout the quinquennia, <50% of HCCs were detected by surveillance programmes. The tumour burden at diagnosis was slightly reduced but not enough to change the distribution of the ITA.LI.CA cancer stages. Intra-arterial and targeted systemic therapies increased across quinquennia. A modest improvement in survival was observed in the last quinquennia, particularly after 12 months of patient observation. Cancer stage, HCC treatment, and presence of oesophageal varices were independent predictors of survival.

CONCLUSIONS

In the past 15 years, modest improvements have been obtained in outcomes of alcohol-related HCC, attributed mainly to underuse of surveillance programmes and the consequent low amenability to curative treatments. Metabolic dysfunction-associated fatty liver disease is a widespread condition in alcohol abusers, but its presence did not show a pivotal prognostic role once HCC had developed. Instead, the presence of oesophageal varices, an independent poor prognosticator, should be considered in patient management and refining of prognostic systems.

IMPACT AND IMPLICATIONS

Alcohol abuse is a leading and growing cause of hepatocellular carcinoma (HCC) worldwide and is associated with a worse prognosis compared with other aetiologies. We assessed the evolutionary landscape of alcohol-related HCC over 15 years in Italy. A high cumulative prevalence (78%) of metabolic dysfunction-associated fatty liver disease, with signs of metabolic dysfunction, was observed in HCC patients with unhealthy excessive alcohol consumption. The alcohol + metabolic dysfunction-associated fatty liver disease condition tended to progressively increase over time. A modest improvement in survival occurred over the study period, likely because of the persistent underuse of surveillance programmes and, consequently, the lack of improvement in the cancer stage at diagnosis and the patients' eligibility for curative treatments. Alongside the known prognostic factors for HCC (cancer stage and treatment), the presence of oesophageal varices was an independent predictor of poor survival, suggesting that this clinical feature should be carefully considered in patient management and should be included in prognostic systems/scores for HCC to improve their performance.

"Harm per litre" as a concept and a measure in studying determinants of relations between alcohol consumption and harm

The term "harm per litre" has been increasingly used in alcohol research in recent years as a concept and a comparative measure of alcohol-attributable harm in comparisons between environments, circumstances, and patterns of drinking. This essay discusses the origins of the term in connection with analyses in terms of patterns as well as levels of drinking and with concerns about differential harms from drinking different beverage types. Also discussed is the term's current primary usage, in the context of epidemiological concerns about differentially severe harms for poorer persons who drink. It is noted that these same concerns have been discussed, particularly in Britain, using the phrase "alcohol harm paradox". "Harm per litre" was initially most often used in comparisons between rates of alcohol-attributable harm by beverage type. After 2010, the expression was applied more broadly, particularly after its use in various World Health Organization-related discussions and documents. In addition, and especially from 2018 onwards when most of the papers using this term were published, it has been used in comparisons by socioeconomic status at the individual level, and by level of socioeconomic development at the country level. Almost all the findings indicate that people with lower socioeconomic status, and countries with lower average income, e.g., low income and lower-middle income countries, incur considerably higher harm per litre (with harm being expressed in disease burden and mortality) than upper middle-income and high-income countries. "Harm per litre" is a practicable and easy-to-understand concept to compare groups of individuals or countries, and to quantify health inequalities. The next important step will need to be elucidating a better causal understanding of the processes underlying these inequalities, with an emphasis on factors which can be most easily changed by interventions.

Global cirrhosis prevalence trends and attributable risk factors-an ecological study using data from 1990-2019

BACKGROUND AND AIMS

Cirrhosis is a major public health issue worldwide with significant morbidity and mortality. We aimed to explore the time series associations between varying levels of risk factors and cirrhosis prevalence and predict the cirrhosis prevalence under alternative scenarios to consolidate evidence for further intervention plans.

METHODS

We collected data of cirrhosis and its risk factors from 1990 to 2019 across 178 countries and used a generalized linear mixed model to explore the time series associations between cirrhosis and risk factors. We simulated scenarios with varying levels of risk factors and investigated benefits gained from the control of risk factors compared with the status quo.

RESULTS

The global cirrhosis prevalence varied geographically, with the highest observed in East and Southeast Asia, mainly due to high hepatitis prevalence. Our study revealed that each 1% increase in prevalence of hepatitis B and C, cirrhosis prevalence would correspondingly increase 0.028% and 0.288%. There would be approximately 392.15 million fewer cirrhosis patients if the goals of a 65% reduction in prevalence of hepatitis and a 10% reduction in alcohol consumption were achieved.

CONCLUSIONS

Given that cirrhosis prevalence has different risk factors depending on geography, it is important to identify an appropriate set of interventions for cirrhosis that are adapted to the epidemiological situation in a specific country. Interventions targeting hepatitis may have a significant impact on global cirrhosis prevalence, therefore, the adoption of specific interventions for hepatitis in high-burden regions and high-risk groups is warranted to lower the global burden of cirrhosis.

Association between usual alcohol consumption and risk of falls in middle-aged and older Chinese adults

Background

Previous studies exploring usual alcohol consumption and falls risk were scarce in China. In addition, the dose–response relationship has not been explored so far. This study aims to estimate the association between usual alcohol consumption and risk of falls among middle-aged and older Chinese adults based on data from the China Health and Retirement Longitudinal Study (CHARLS), which is representative of the population of the entire country.

Methods

Baseline survey data in 2015 and follow-up data in 2018 in CHARLS were utilized. Alcohol consumption was calculated in grams per day (gr/day) according to self-reported drinking data and categorized accordingly to The Dietary Guidelines for Chinese Residents (DGC) 2016. Fall was obtained from self-reported information. Multivariable logistic regression analyses were performed to estimate the association of usual alcohol consumption with risk of falling. The dose–response relationship was also explored using restricted cubic splines.

Results

A total of 12,910 middle-aged and older participants were included from the CHARLS 2015, of which 11,667 were followed up in 2018. We found that former, moderate, and excessive drinkers were at higher fall risk compared to never drinkers (former: OR, 1.24; 95% CI, 1.05–1.46; moderate: OR, 1.22; 95% CI, 1.06–1.41; excessive: OR, 1.36; 95% CI, 1.15–1.61) in the longitudinal analysis. Similarly, individuals with moderate and excessive alcohol consumption were at increased risk of falling in the cross-sectional analysis (moderate: OR, 1.18; 95% CI, 1.02–1.37; excessive: OR, 1.32; 95% CI, 1.11,1.57). No significant increased risk of falls was found for former drinkers (former: OR, 1.13; 95% CI, 0.96–1.34). We observed a significant non-linear relationship.

Conclusions

Our study suggests that usual alcohol consumption was associated with a higher risk of falls, highlighting the key role of alcohol intake on the fall risk, which needed consideration in developing intervention and prevention strategies for reducing falls among middle-aged and older Chinese adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03429-1.

Deep Convolutional Neural Network Regularization for Alcoholism Detection Using EEG Signals

Alcoholism is attributed to regular or excessive drinking of alcohol and leads to the disturbance of the neuronal system in the human brain. This results in certain malfunctioning of neurons that can be detected by an electroencephalogram (EEG) using several electrodes on a human skull at appropriate positions. It is of great interest to be able to classify an EEG activity as that of a normal person or an alcoholic person using data from the minimum possible electrodes (or channels). Due to the complex nature of EEG signals, accurate classification of alcoholism using only a small dataset is a challenging task. Artificial neural networks, specifically convolutional neural networks (CNNs), provide efficient and accurate results in various pattern-based classification problems. In this work, we apply CNN on raw EEG data and demonstrate how we achieved 98% average accuracy by optimizing a baseline CNN model and outperforming its results in a range of performance evaluation metrics on the University of California at Irvine Machine Learning (UCI-ML) EEG dataset. This article explains the stepwise improvement of the baseline model using the dropout, batch normalization, and kernel regularization techniques and provides a comparison of the two models that can be beneficial for aspiring practitioners who aim to develop similar classification models in CNN. A performance comparison is also provided with other approaches using the same dataset.

Protective effect of rosmarinic acid-rich trichodesma khasianum clarke leaves against ethanol-induced gastric mucosal injury in vitro and in vivo

BACKGROUND

Although gastroprotective drugs have been used for peptic ulcer disease prevention and treatment, side effects have been observed. Finding a safe and effective treatment strategy is important.

PURPOSE

Edible Trichodesma khasianum (T. khasianum) Clarke leaves are considered to protect against peptic ulcers. However, scientific evidence of this effect of T. khasianum Clarke leaves remains limited.

STUDY DESIGN/METHODS

In this study, we aimed to evaluate the effect of T. khasianum Clarke leaves on ethanol-induced gastric injury and gut microbiota using RAW 264.7 cells, RGM-1 cells, and BALB/c mice, respectively.

RESULT

The rosmarinic acid was identified as the major component of T. khasianum Clarke leaves extracted by 80% ethanol (80EETC). The results showed that 80EETC suppressed inflammatory mediator protein levels in LPS-induced RAW 264.7 cells. Additionally, heat shock protein expression, antiapoptotic ability, and wound healing migration capability were increased by 80EETC pretreatment in RGM-1 cells with the ethanol-induced injury. Remarkably, pretreatment with 80EETC (150 mg/kg b.w.) promoted gastric mucosal healing by decreasing oxidative stress, inflammatory response, proapoptotic protein expression, and gastric mucosa damage in ethanol-induced gastric injury in mice. Crucially, no liver or kidney toxicities were observed by 80EETC oral gavage. Moreover, 80EETC increased gut microbiota diversity and short-chain fatty acid production.

CONCLUSION

Our results illustrated the remarkable gastroprotective effect by 80EETC treatment in vitro and in vivo. These findings are the first to demonstrate the powerful protective effect of T. khasianum Clarke leaves against gastric mucosal injury development.

Contemporary Epidemiology of Chronic Liver Disease and Cirrhosis

BACKGROUND & AIMS

Accurate estimates for the contemporary burden of chronic liver disease (CLD) are vital for setting clinical, research, and policy priorities. We aimed to review the incidence, prevalence, and mortality of CLD and its resulting complications, including cirrhosis and hepatocellular carcinoma (HCC).

METHODS

We reviewed the published literature on the incidence, prevalence, trends of various etiologies of CLD and its resulting complications. In addition, we provided updated data from the Centers for Disease Control and Global Burden of Disease Study on the morbidity and mortality of CLD, cirrhosis, and hepatocellular carcinoma (HCC). Lastly, we assessed the strengths and weaknesses of available sources of data in hopes of providing important context to these national estimates of cirrhosis burden.

RESULTS

An estimated 1.5 billion persons have CLD worldwide and the age-standardized incidence of CLD and cirrhosis is 20.7/100,000, a 13% increase since 2000. Similarly, cirrhosis prevalence and mortality has increased in recent years in the United States. The epidemiology of CLD is shifting, reflecting implementation of large-scale hepatitis B vaccination and hepatitis C treatment programs, the increasing prevalence of the metabolic syndrome, and increasing alcohol misuse.

CONCLUSIONS

The global burden of CLD and cirrhosis is substantial. Although vaccination, screening, and antiviral treatment campaigns for hepatitis B and C have reduced the CLD burden in some parts of the world, concomitant increases in injection drug use, alcohol misuse, and metabolic syndrome threaten these trends. Ongoing efforts to address CLD-related morbidity and mortality require accurate contemporary estimates of epidemiology and outcomes.

Perceived Social Discrimination, Socioeconomic Status, and Alcohol Consumption among Chinese Adults: A Nationally Representative Study

Perceived social discrimination in China has significant effects on drinking behavior. This finding was reached through multivariate logistic regression analysis of a sample of 22,566 adults in the 2016 China Family Panel Studies (CFPS). This was a cross-sectional study conducted with computer-assisted face-to-face interviews to assess alcohol drinking problems and associated factors among Chinese adults. The proportion of adults prone to alcoholism tends to be higher in eastern than central China, and higher in central than western China. Furthermore, gender discrimination and delays in government interactions as a result of unfair treatment have a positive and significant effect on individuals’ drinking. The alcohol consumption rate among Chinese men is about 13 times that of Chinese women. Additionally, older people have a stronger tendency to drink alcohol. In terms of education, those with lower education levels are more prone to alcoholism than those with higher education levels. Regarding marital status, those who are married are more prone to alcoholism than those who are not. Further, those who have been diagnosed with a chronic disease within the past six months are less prone to alcoholism than those without such diagnosis. People with an annual income between 50,000 and 150,000 yuan are more prone to alcoholism than those with an income under 50,000 yuan. Groups that have experienced unequal treatment in public services are also more prone to alcoholism than those who do not suffer such unequal treatment.

Hepatology through the crystal ball

The rapidity of the increase in the global burden of liver disease covered in this review with estimates worldwide of 2 million deaths from cirrhosis and with no signs of effective controls being introduced for two of the main causes, namely, excess alcohol consumption and obesity, is of great concern. The 25% prevalence of non-alcoholic fatty liver disease in many population groups and the recent description of primary hepatocellular cancer (HCC) in obese subjects without underlying severe fibrosis/cirrhosis also raises many questions. In addition, covered in this review are more encouraging areas including techniques for machine preservation of donor organs enabling previously marginal organs to be used for transplantation. Greater knowledge of gut microbiome and gut bacterial translocation is defining the inflammatory reaction underlying multi-organ failure in decompensated cirrhosis. The gut microbiome also influences the response of HCC patients to the new check-point inhibitor drugs which restore immunological responses of its host.

My own personal hell: approaching and exceeding thresholds of too much alcohol

Objectives: Government guidelines aim to promote sensible alcohol consumption but such advice is disconnected from people's lived experiences. This research investigated how people construct personal thresholds of 'too much' alcohol. Design and measures: One hundred fifty drinkers completed an online survey (M_age = 23.29(5.51); 64.7% female). Participants were asked whether they had an intuitive sense of what constitutes too much alcohol. They wrote open-ended descriptions of how that threshold had been established and how it felt to approach/exceed it. These qualitative accounts were coded using thematic analysis and interpreted with an experiential theoretical framework. Results: Personal thresholds were based on previously experienced embodied states rather than guidelines, or health concerns. Describing the approach to their threshold, 75% of participants fell into two distinct groups. Group 1's approach was an entirely negative embodied experience (nausea/anxiety) and Group 2's approach was an entirely positive, embodied experience (relaxed/pleasurable). These groups differed significantly in awareness of alcohol's effects, agency and self-perceptions, but not on alcohol consumption. Exceeding their threshold was an entirely negative embodied experience for all. Conclusion: These findings illustrate that people are guided by experientially grounded conceptions of consumption. Interventions could target different groups of drinker according to their embodied experience during the approach to 'too much' alcohol.