Primary care practitioners survey of non-alcoholic fatty liver disease

The external validation of Dallas Steatosis Index among Asian population: a useful tool for metabolic dysfunction-associated steatotic liver disease identification and prevention

BACKGROUND

The Dallas Steatosis Index (DSI) is a non-invasive tool (NIT) developed to detect the risk of metabolic dysfunction-associated steatotic liver disease (MASLD) in multi-ethnic populations, external validation in Asians has yet to be conducted. Therefore, we evaluated the ability of the DSI with the BMI classification of WPRO (DSI_WPRO) to identify MASLD in the Chinese population. In addition, we investigated the associations between the DSI_WPRO and the risk of MASLD in a longitudinal study.

METHODS

Baseline data from the Dongfeng-Tongji cohort were collected to investigate the ability of the DSI_WPRO to identify MASLD patients by ROC analysis. Furthermore, multivariate logistic regressions were performed to investigate the associations of the DSI_WPRO and MASLD risks in a 5-year follow-up of the DFTJ cohort study.

RESULTS

Among a total of 9,376 MASLD participants and 25,974 non-MASLD participants, the area under the curve (AUC) of the DSI_WPRO reached 0.777 after adjusting BMI classification, which is higher than other NITs in this study. In addition, we redefined the risk category and the screening proposal of MASLD in Asians with the DSI_WPRO. We found that the cutoff point of 0 has the best ability to recognize the presence or absence of MASLD. Furthermore, compared with the low DSI_WPRO (DSI_WPRO < 0), OR (95% CIs) of higher DSI_WPRO (DSI_WPRO ≥ 0) was 3.048 (2.827 ~ 3.285) for MASLD.

CONCLUSION

The DSI is a useful tool for MASLD identification and prevention. After more validation studies, DSI can be generalized in the Asian population.

Estimation of the Eligible Population For Resmetirom Among Adults in the United States for Treatment of Non-Cirrhotic NASH with Moderate-to-Advanced Liver Fibrosis

INTRODUCTION

As of March 2024, resmetirom is the first and only therapy approved in the United States (US) for the treatment of adults with non-cirrhotic nonalcoholic steatohepatitis (NASH) with moderate-to-advanced liver fibrosis (MALF) consistent with stages F2/F3 fibrosis. Estimates of the diagnosed, treatment-eligible NASH population are poorly understood due to diagnostic variability. This study provides a contemporary estimate of the size of the US resmetirom treatment-eligible population.

METHODS

A dynamic population calculator was developed combining literature, screening guidelines, resmetirom study criteria, and analyses of the NHANES 2017-March 2020 cycle. It computes NASH prevalence, proportion non-cirrhotic NASH with MALF, Year 1 diagnosis, and new diagnoses in Years 2 and 3. NASH prevalence was estimated by applying the American Association of Clinical Endocrinology screening algorithm and recommended NIT cut-offs in the NHANES dataset. The proportion of non-cirrhotic NASH with MALF was informed by analyses of the Forian US integrated medical claims database using NASH and cirrhosis-specific ICD-10-CM codes and FIB-4 scores. NASH diagnosis rates were obtained from published estimates and NHANES responses. Treatment-eligible population growth was projected using published incidence data. Estimates were compared to a NASH budget-impact-analysis (BIA) from the Institute for Clinical and Economic Review (ICER).

RESULTS

In the base case, a NASH prevalence of 4.6% was modeled (range 1.3-14.2%). This value was multiplied by the proportion estimated to have non-cirrhotic MALF (i.e., 35%). Published analyses suggest a diagnosis rate of ~ 10% (range 3.3-14.3%) and ~ 16% year-over-year growth in the treatment-eligible population. Assuming a 1-million commercial-member population, the resmetirom treatment-eligible population was estimated as 1255-1699 in Years 1-3 following approval. Sensitivity analyses were conducted and comparison to the ICER BIA was influenced by different diagnosis rates.

CONCLUSION

Estimation of the treatment-eligible population for resmetirom depends importantly on NASH diagnosis rates, which are predicted to be < 15% in the 3 years after drug approval. Nonalcoholic steatohepatitis (NASH) is an advanced form of nonalcoholic fatty liver disease. Previously there were no treatments for NASH in the United States (US), but as of March 2024, the US Food and Drug Administration (FDA) approved resmetirom (REZDIFFRA™), a once-daily, oral therapy, in conjunction with diet and exercise, under accelerated approval for the treatment of adults (aged 18 years or older) with non-cirrhotic NASH with moderate-to-advanced liver fibrosis (MALF), consistent with stages F2-F3. It is not well understood how many diagnosed patients with NASH would be eligible for treatment with resmetirom; thus, this study aimed to estimate the size of the US resmetirom treatment-eligible population. To do so, we created a flexible population calculator that considers how many people have NASH, what proportion would be eligible for resmetirom treatment-i.e., have non-cirrhotic NASH with MALF-and of those how many people would be diagnosed. We used published literature, screening guidelines, resmetirom study criteria, and analyses of national surveys to inform our range of estimates. In the main analysis, we modeled a NASH prevalence of 4.6% (range 1.3-14.2%), which was then limited to the proportion estimated to have non-cirrhotic NASH with MALF (i.e., 35%) and diagnosed (i.e., 10%, range 3.3-14.3%). A year-over-year growth of approximately 16% in the treatment-eligible population was modeled in years following approval. Assuming a population of 1 million commercial insurance enrollees, the resmetirom treatment-eligible population was estimated to be 1255-1699 in Years 1-3 following approval. We assessed alternative scenarios and have compared our results to existing models.

The myth of the stigma of fatty liver: What does the evidence show?

Recent efforts to reclassify non-alcoholic fatty liver disease (NAFLD) as metabolic dysfunction-associated fatty liver disease (MAFLD) and metabolic dysfunction-associated steatotic liver disease (MASLD) are intended to divert attention to the metabolic basis of the disease rather than to alcohol consumption. This reclassification recognizes the role of obesity, sedentary lifestyles and poor dietary habits in the development of the disease, leading to a better understanding of its etiology. Nevertheless, the transition has posed its own challenges, particularly with regard to communication between patient and healthcare professional. Many healthcare professionals report difficulty in explaining the nuanced concepts, especially the term "steatosis". In addition, the change in terminology has not yet removed the stigma, with ongoing debates about the appropriateness of the terms "fatty" and "steatotic". Surveys suggest that while "obesity" may be perceived as more stigmatizing, the medical term "steatotic liver disease" is not considered as stigmatizing, indicating a disconnect in perceptions between healthcare professionals and patients.

Metabolic associated fatty liver disease (MAFLD): assessing the knowledge and practice of primary care doctors in Seremban District, Negeri Sembilan

Introduction

Metabolic-associated fatty liver disease (MAFLD) is the liver manifestation of metabolic syndrome, which is commonly seen in primary care settings. This study aimed to determine the knowledge and practice of primary care physicians regarding MAFLD in Seremban District, Negeri Sembilan.

Methods

This cross-sectional study was conducted among medical officers in 14 health clinics in Seremban District, using a validated, self-administered online questionnaire.

Results

A total of 240 medical officers from 14 health clinics in Seremban District, participated in this study. Most participants (85.4%) passed the knowledge test. Their practice was acceptable, but only a minority were familiar with non-invasive testing of liver fibrosis (e.g. APRI or FIB-4), medication and specific diet for the treatment of MAFLD.

Conclusion

Most primary care physicians in Seremban District are knowledgeable in identifying risk factors and managing patients with MAFLD. However, there are still areas to improve in terms of management, particularly regarding the use of silymarin, vitamin E and pioglitazone.

Practice Recommendations for the Management of MASLD in Primary Care: Consensus Results

BACKGROUND

Despite its high prevalence and impact on health, metabolic dysfunction-associated steatotic liver disease (MASLD) is inadequately addressed in European primary care (PC), with a large proportion of cases going undiagnosed or diagnosed too late. A multi-country European research consortium led a project to design and evaluate a patient-centered, integrated model for MASLD screening, diagnosis, and linkage to specialty care for European PC settings. Based on the lessons from this project, the latest research evidence, and existing guidelines for the management of MASLD, we sought to develop a set of practice recommendations for screening, referral, and management of MASLD in PC.

METHODS

The Rand/UCLA modified Delphi panel method, with two rounds, was used to reach consensus on practice recommendations. The international panel consisted of experts from six countries, representing family medicine, gastroenterology, hepatology, cardiology, and public health. Initially, fifteen statements were drafted based on a synthesis of evidence from the literature and earlier findings from our consortium. Prior to the consensus meeting, the statements were rated by the experts in the first round. Then, in a hybrid meeting, the experts discussed findings from round one, adjusted the statements, and reassessed the updated recommendations in a second round.

RESULTS

In round one, there was already a high level of consensus on 10 out of 15 statements. After round 2, there were fourteen statements with a high degree of agreement (>90%). One statement was not endorsed. The approved recommendations addressed the following practice areas: risk screening and diagnosis, management of MASLD-lifestyle interventions, pharmacological treatment of MASLD/MASH, pharmacological treatment for co-morbidity, integrated care, surgical management, and other referrals to specialists.

CONCLUSIONS

The final set of 14 recommendations focuses on increasing comprehensive care for MASLD in PC. The recommendations provide practical evidence-based guidance tailored to PC practitioners. We expect that these recommendations will contribute to the ongoing discussion on systematic approaches to tackling MASLD and supporting European PC providers by integrating the latest evidence into practice.

Barriers to care linkage and educational impact on unnecessary MASLD referrals

Background

The importance of primary care physicians (PCPs) in managing metabolic dysfunction-associated steatotic liver disease (MASLD) has increased. This study aimed to assess the effectiveness of an online educational program on MASLD among physicians.

Methods

In total, 869 physicians (72 physicians at referral centers and 797 PCPs) participated in this study. They completed an initial survey regarding their clinical practices for patients with MASLD, followed by a second online survey 8 weeks after receiving a series of seven weekly sets of educational materials on MASLD.

Results

In the baseline survey, most PCPs did not routinely evaluate the stage of hepatic fibrosis in MASLD; they typically initiated assessments based on elevated liver enzyme levels. Only a limited number of PCPs used vibration-controlled transient elastography. The main hurdles in managing MASLD were "the absence of a fee for patient education" for PCPs and "short consultation time" for referral-center physicians. In the follow-up survey, the percentage of liver fibrosis assessments using noninvasive tests increased from 7.0 to 11.2%. Additionally, evaluations for cardiovascular disease increased from 3.9 to 8.2%, and the risk of ischemic stroke increased from 13.7 to 16.9%. The percentage of immediate referrals of patients to specialists after an MASLD diagnosis decreased from 15.4 to 12.3%.

Conclusion

The discrepancies in management strategies and viewpoints regarding MASLD between PCPs and referral-center physicians can hinder efforts to mitigate the disease burden. Increasing awareness among PCPs regarding MASLD through a 7-week education program led to a reduction in unnecessary referral rates and an increase in cardiovascular evaluations.

Endothelial dysfunction and cardiovascular risk in non-alcoholic fatty liver disease – a systematic review and meta-analysis

Background

Nonalcoholic fatty liver disease (NAFLD) is a prevalent metabolic disorder that has been associated with an increased risk of cardiovascular diseases. Endothelial dysfunction, characterized by impaired flow-mediated dilation (FMD) of the brachial artery, is a known predictor of cardiovascular risk. However, the relationship between NAFLD and endothelial dysfunction, as well as the impact of NAFLD on clinical cardiovascular events, remains unclear.

Objective

The aim of this systematic literature review was to determine the association between endothelial dysfunction, as measured by FMD of the brachial artery, and NAFLD. Additionally, we aimed to investigate the relationship between NAFLD and clinical cardiovascular events (CVE).

Methods

A systematic search was conducted in PubMed, Scopus, ScienceDirect, and Google Scholar for articles published between 2000 and July 2023. The reference lists of the included studies were also searched to retrieve possible additional studies. Original studies published in English focusing on adults with NAFLD and endothelial dysfunction are included. Editorials, commentaries, letters and studies focusing on pediatric populations and non-NAFLD liver diseases were excluded. The quality of included studies was appraised using the Newcastle–Ottawa scale. Meta-analyses were performed using Review Manager 5.4 software.

Results

The initial search yielded a total of 1792 articles and ultimately only 20 studies met the criteria. A total 6396 NAFLD patients were studied. Meta-analysis showed that individuals diagnosed with NAFLD had significantly lower brachial FMD values compared to their respective control groups (standardized mean difference: -4.63, 95% confidence interval: -5.68 to -3.58, p < 0.0001). Furthermore, NAFLD patients exhibited a significantly higher risk of clinical cardiovascular events compared to controls (odds ratio: 2.61; 95% CI: 1.41–4.83, p < 0.002). Subgroup analysis of studies focusing on non-alcoholic steatohepatitis (NASH) versus pure steatosis demonstrated that individuals with NASH had even lower FMD values than those with pure steatosis (standardized mean difference: -3.84, 95% confidence interval: -7.56 to -0.13, p = 0.03, I2 = 66%).

Limitations, bias and heterogeneity

The review included studies published in English language, over last 23 years and specified database resulted in language bias and might have missed older pertinent studies from another important database. The overall heterogeneity is attributed to variations in study populations, outcome measurements, differences in methodological approaches among included studies, and diverse diagnostic criteria for NAFLD.

Conclusion

Individuals with NAFLD exhibited impaired brachial FMD, indicating compromised endothelial function. Furthermore, NAFLD patients had an elevated risk of clinical cardiovascular events.

Pragmatic strategies to address health disparities along the continuum of care in chronic liver disease

Racial, ethnic, and socioeconomic disparities exist in the prevalence and natural history of chronic liver disease, access to care, and clinical outcomes. Solutions to improve health equity range widely, from digital health tools to policy changes. The current review outlines the disparities along the chronic liver disease health care continuum from screening and diagnosis to the management of cirrhosis and considerations of pre-liver and post-liver transplantation. Using a health equity research and implementation science framework, we offer pragmatic strategies to address barriers to implementing high-quality equitable care for patients with chronic liver disease.

The hidden epidemic: Uncovering incidental fatty liver disease and its metabolic comorbidities by datamining in a hospital data lake - A real-world cohort study

AIMS

To identify individuals with incidental fatty liver disease (FLD), and to evaluate its prevalence, metabolic co-morbidities and impact on follow-up.

METHODS

We leveraged the data-lake of Helsinki Uusimaa Hospital district (Finland) with a population of 1.7 million (specialist and primary care). A phrase recognition script on abdominal imaging reports (2008-2020) identified/excluded FLD or cirrhosis; we extracted ICD-codes, laboratory and BMI data.

RESULTS

Excluding those with other liver diseases, the prevalence of FLD was 29% (steatosis yes/no, N=61,271/155,521; cirrhosis, N=3502). The false positive and negative rates were 5-6%. Only 1.6% of the FLD cases had the ICD code recorded and 32% had undergone full clinical evaluation for associated co-morbidities. Of the 35-65-year-old individuals with FLD, 20% had diabetes, 42% prediabetes and 28% a high liver fibrosis index. FLD was independently predicted by diabetes (OR 1.56, CI 1.46-1.66, p = 2.3 * 10^-41), BMI (1.46, 1.42-1.50, p = 1.7 * 10^-154) and plasma triglyceride level (1.5, 1.43-1.57, p = 3.5 * 10^-68). Alanine aminotransferase level mildly increased (1.12, 1.08-1.16, p = 2.2 * 10^-9) and high age decreased the risk (0.92, 0.89-0.94, p = 4.65*10^-09). Half of the cases had normal ALT.

CONCLUSIONS

The incidental radiological finding of FLD is reliable and associated with metabolic risks but largely ignored, although it should lead to metabolic and hepatic follow-up.

Guideline-based management of metabolic dysfunction-associated steatotic liver disease in the primary care setting

BACKGROUND

The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing worldwide. Primary care providers play a critical role in the screening, diagnosis, and management of MASLD and/or metabolic dysfunction-associated steatohepatitis (MASH), though they can face challenges in this setting, particularly where healthcare resources are limited and barriers to care exist. To address these challenges, several guidelines have been developed to provide evidence-based recommendations for the clinical assessment and management of patients with MASLD/MASH.

AIMS

To provide a unified, simple-to-understand, practical guide for MASLD screening, diagnosis, and management based on current guideline recommendations, for use by primary care providers in daily practice.

METHODS

Evidence-based recommendations from several international guidelines were summarized, focusing on the similarities and differences between them.

RESULTS

Recommendations are broadly aligned across the guidelines, but several key differences are evident. Practical guidance is provided on screening, identifying target populations for risk stratification, initial evaluation of individuals with suspected MASLD, surveillance, risk stratification and referral, as well as approaches to the management of MASLD and associated comorbidities, with specific considerations for the primary care setting.

CONCLUSIONS

Primary care providers are ideally placed to identify at-risk individuals, implement evidence-based interventions to prevent the development of fibrosis and cirrhosis, and effectively manage comorbidities. Equipping primary care providers with the necessary knowledge and tools to effectively manage MASLD/MASH may help to improve patient outcomes and reduce the burden of liver disease.

Improving care for veterans' environmental exposure concerns: applications of the consolidated framework for implementation research in program evaluation

BACKGROUND

Healthcare systems, like the US Department of Veterans Affairs (VA), need policies and procedures for delivering care to special populations including those with environmental exposure concerns. Despite being common and pervasive, especially among Veterans, environmental exposures are largely overlooked by healthcare providers. To successfully implement care for Veterans with military environmental exposure concerns, an understanding of contextual factors impeding care on the provider (e.g., knowledge and beliefs) and organizational (e.g., leadership's priorities) level is needed. Our goal was to conduct an operational needs assessment of providers to examine provider educational needs regarding Veterans' military environmental exposure concerns.

METHODS

In 2020, we surveyed 2,775 VA medical and behavioral health providers. Our cross-sectional assessment was informed by the Consolidated Framework for Implementation Research (CFIR) and assessed barriers and facilitators to the uptake and application of knowledge regarding interdisciplinary care for environmental exposure concerns. The web-based survey was emailed to providers across the United States representing a variety of disciplines and practice settings to reflect the interdisciplinary approach to care for environmental exposures. We used bivariate statistics to investigate the intervention setting, inner setting, and individual characteristics of providers regarding care for environmental exposure concerns.

RESULTS

Approximately one-third of VA medical and behavioral health clinicians report low to no knowledge of environmental exposure concerns. We find 88% of medical and 91% of behavioral health providers report they are ready to learn more about environmental exposures. Half of medical and behavioral health providers report they have access to information on environmental exposures and less than half report care for environmental exposures is a priority where they practice.

CONCLUSIONS

Our findings suggest interdisciplinary providers' knowledge of and discussion with Veterans about environmental exposures may be influenced by contextual factors at the organizational level. Considering individual-level factors and organizational culture is important to consider when supporting care for environmental exposures. Since this needs assessment, VA established targeted programs to improve care related to military environmental exposures in response to legislation; future exploration of these same variables or contextual factors is warranted.

Prevalence of Nonalcoholic Steatohepatitis and Associated Fibrosis Stages Among US Adults Using Imaging-Based vs Biomarker-Based Noninvasive Tests

Introduction: Nonalcoholic fatty liver disease (NAFLD) is believed to be the most common chronic liver disease worldwide. Therapies are under development for nonalcoholic steatohepatitis (NASH), the progressive form of NAFLD, such that the prevalence of NASH with liver fibrosis, which is likely to require treatment, may be of interest to healthcare decision makers. Noninvasive tests are used in initial screening for NASH, as well as in observational studies of NASH prevalence. However, existing evidence does not address how estimated prevalence varies with different noninvasive tests. This analysis estimated the prevalence of NASH among US adults and assessed variation with different noninvasive tests. Methods: A cross-sectional analysis was conducted using the 2017-March 2020 National Health and Nutrition Examination Survey cycle. Participants with presumed NAFLD (steatosis and without alternative causes of liver disease) were identified, among whom NASH was predicted based on FAST score, Fibrosis-4 (FIB-4), and AST-to-Platelet Ratio Index (APRI) cutoffs across 11 scenarios. Among NASH participants, fibrosis stages were explored based on distribution across the spectrum of liver-stiffness measurements. Results: Among participants with complete data for the analysis (N=6969), prevalence of presumed NAFLD was 25.6%. Within presumed NAFLD, prediction of NASH using imaging-based NIT cutoffs yielded estimated prevalence of 1.3%-4.8% (3.3 million-12.2 million) based on FAST score cutoffs from 0.35-0.67. Using biomarker-based NIT cutoffs yielded estimated prevalence of 0.4%-12.3% (1.0 million-14.5 million) based on FIB-4 cutoffs from 0.90-2.67, and 0.1%-1.9% (0.2-5.0 million) based on APRI cutoffs from 0.50-1.50. Conclusion: Prevalence of NASH among US adults was estimated to range from 1.3% to 4.8% when predicted using imaging-based noninvasive test values for participants with presumed NAFLD, generally aligning with estimates in the literature of prevalence of biopsy-confirmed NASH. Use of biomarker-based noninvasive test values for prediction of NASH yielded a wider range of estimates with FIB-4, and a considerably lower range of estimates with APRI.

Modelling the mass consumption potential of Plant Based Meat: Evidence from an emerging economy

The rising demand for plant-based meat (PBM) has the potential to minimize environmental degradation and save the lives of numerous animals. Furthermore, the intention to consume eco-friendly products triggers people to consume PBM. However, it is essential to understand the factors that influence consumer intentions and actual PBM consumption to enhance its adoption. By incorporating the Theory of Consumption Value, this study examines the impact of health consciousness, health motivation, personal innovativeness, perceived critical mass, perceived cost, and perceived product value on the intention to consume PBM. The impact of intention to consume PBM on actual consumption is also analyzed. Furthermore, the mediating role of the intention to consume PBM in the relationship between these factors and actual consumption behavior is investigated. Using a cross-sectional research design, 978 responses were obtained from Indonesia. The data were analyzed using partial least squares structural equation modelling (PLS-SEM). The results showed that health motivation, perceived critical mass perceived cost, and perceived product value were significant predictors of the intention to consume PBM. However, health motivation and personal innovation had insignificant effects on the intention to consume PBM. Moreover, the intention to consume PBM translated into actual consumption behavior. Furthermore, the intention to consume PBM significantly mediated the relationship between actual consumption behavior and factors other than health motivation, personal innovation, and perceived product value. The findings offer valuable insights for industry, policymakers, and producers interested in PBMA markets in developing focused marketing strategies, improving consumer perceptions, and addressing barriers, such as perceived costs to promote PBM consumption, particularly in emerging markets. Integrating the theory of consumption value and PLS-SEM provides a comprehensive understanding of the underlying dynamics and sheds light on the unique factors driving PBM consumption behavior.

Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis: The Patient and Physician Perspective

Diagnosing and managing metabolic dysfunction-associated steatotic liver disease (MASLD) remains a major challenge in primary care due to lack of agreement on diagnostic tools, difficulty in identifying symptoms and determining their cause, absence of approved pharmacological treatments, and limited awareness of the disease. However, prompt diagnosis and management are critical to preventing MASLD from progressing to more severe forms of liver disease. This highlights the need to raise awareness and improve understanding of MASLD among both patients and physicians. The patient perspective is invaluable to advancing our knowledge of this disease and how to manage it, as their perspectives have led to the growing recognition that patients experience subtle symptoms and that patient-reported outcomes should be incorporated into drug development. This review and expert opinion examine MASLD and metabolic dysfunction-associated steatohepatitis from the patient and physician perspective from pre-diagnosis to diagnosis and early care, through to progression to advanced liver damage. Specifically, the paper dives into the issues patients and physicians experience, and, in turn, what is required to improve diagnosis and management, including tips and tools to empower patients and physicians dealing with MASLD.

Challenges in the Management of Non-Alcoholic Fatty Liver Disease (NAFLD): Towards a Compassionate Approach

Representing a growing ‘silent epidemic’, non-alcoholic fatty liver disease (NAFLD) affects around 25–30% of the general population. Alarmingly, NAFLD increases the risk of cardiovascular disease, both independently and through its strong associations with obesity, type 2 diabetes, and metabolic syndrome, whilst posing a substantial burden from an economic and health-related quality of life perspective. Moreover, growing evidence links NAFLD to common mental health disorders including depression, anxiety, and stress. In this context, recent clinical and research attention further focuses on potential additional problems faced by patients with NAFLD, such as perceived stigma, lack of awareness regarding the condition, and possible feelings of loneliness and isolation that might emerge from unmet support needs. To date, despite a wealth of literature on NAFLD, management of the condition remains challenging and not straightforward, with most cases in primary care being treated with lifestyle modification on top of any other comorbidity treatment. However, for many patients with NAFLD, weight loss is hard to accomplish and/or sustain (e.g., patients may lack the skills, confidence, and motivation required to adhere to dietary changes, and/or may have problems limiting opportunities for increased physical activity). Therefore, tailored interventions which are manageable from the perspective of the individual patient with NAFLD could glean greater results. Accordingly, although there is a lack of research exploring the potential benefits of person-centered and compassion-based approaches to the management of NAFLD, in the present review, we draw on evidence from methods utilized in the treatment of other chronic conditions in postulating the view that such approaches might prove beneficial in the future management of NAFLD.

Identifying Patients with Nonalcoholic Fatty Liver Disease in Primary Care: How and for What Benefit?

Despite its increasing prevalence, nonalcoholic fatty liver disease (NAFLD) remains under-diagnosed in primary care. Timely diagnosis is critical, as NAFLD can progress to nonalcoholic steatohepatitis, fibrosis, cirrhosis, hepatocellular carcinoma, and death; furthermore, NAFLD is also a risk factor linked to cardiometabolic outcomes. Identifying patients with NAFLD, and particularly those at risk of advanced fibrosis, is important so that healthcare practitioners can optimize care delivery in an effort to prevent disease progression. This review debates the practical issues that primary care physicians encounter when managing NAFLD, using a patient case study to illustrate the challenges and decisions that physicians face. It explores the pros and cons of different diagnostic strategies and tools that physicians can adopt in primary care settings, depending on how NAFLD presents and progresses. We discuss the importance of prescribing lifestyle changes to achieve weight loss and mitigate disease progression. A diagnostic and management flow chart is provided, showing the key points of assessment for primary care physicians. The advantages and disadvantages of advanced fibrosis risk assessments in primary care settings and the factors that influence patient referral to a hepatologist are also reviewed.

Screening for NAFLD-Current Knowledge and Challenges

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of abnormal liver function tests worldwide, with an estimated prevalence ranging between 19-46% in the general population. Of note, NAFLD is also expected to become a leading cause of end-stage liver disease in the next decades. Given the high prevalence and severity of NAFLD, especially in high-risk populations (i.e., patients with type-2 diabetes mellitus and/or obesity), there is a major interest in early detection of the disease in primary care. Nevertheless, substantial uncertainties still surround the development of a screening policy for NAFLD, such as limitations in currently used non-invasive markers of fibrosis, cost-effectiveness and the absence of a licensed treatment. In this review, we summarise current knowledge and try to identify the limitations surrounding the screening policy for NAFLD in primary care.

Nonalcoholic fatty liver disease from a primary care perspective

Nonalcoholic fatty liver disease (NAFLD) affects up to one-third of the US population. Approximately one-fifth of patients with NAFLD have nonalcoholic steatohepatitis (NASH), characterized by hepatocyte damage and inflammation with or without fibrosis. NASH leads to greater risk of liver-related complications and liver-related mortality, with the poorest outcomes seen in patients with advanced fibrosis. NASH is also associated with other metabolic comorbidities and conveys an increased risk of adverse cardiovascular outcomes and extrahepatic cancers. Despite its high prevalence, NAFLD is frequently underdiagnosed. This is a significant concern, given that early diagnosis of NAFLD is a key step in preventing progression to NASH. In this review, we describe the clinical impact of NASH from the perspective of both the clinician and the patient. In addition, we provide practical guidance on the diagnosis and management of NASH for primary care providers, who play a pivotal role in the frontline care of patients with NASH, and we use case studies to illustrate real-world scenarios encountered in the primary care setting.

Cardiac dysfunction in a cohort of biopsy proven nonalcoholic steatohepatitis in comparison to nonalcoholic fatty liver

Introduction

NAFLD (non-alcoholic fatty liver disease) is increasing worldwide. Inflammation, fibrosis, and steatosis are the three components of NAFLD. Cardiac events are the most common cause of death in NAFLD. It is believed that there is an association between the inflammatory component of NAFLD and cardiac dysfunction. The gold standard for diagnosis of NAFLD is liver biopsy. Based on histology, NAFLD is categorized into two, nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). As biopsy is an invasive procedure, studies comparing cardiac dysfunction in NAFL and NASH are few. The aim of our study is to compare cardiac dysfunction in patients with NAFL and NASH.

Materials and method

This is a cross-sectional study in which all patients who were biopsy proven for NAFLD without stage 4 fibrosis were included. Cardiac dysfunction in these patients was assessed by 2 D ECHO.

Results

Out of the 92 patients, 52 were males and 40 were females (53.5 vs 46.5 %). Among these patients, 48 had NAFL, whereas 48 had NASH. Among the variables analyzed for the study SGOT, SGPT, ALP, Ferritin, ANA, TSH, LVEF, LA diameter, E/e, NAS score, lobular inflammation, ballooning, and steatosis statistically correlated with cardiac diastolic dysfunction. Majority of the patients with NASH had cardiac dysfunction (32/44) while only a few patients with NAFL (4/48) had cardiac dysfunction (p value = 0.002). Among the variables that can cause diastolic dysfunction, i.e., coronary artery disease, dyslipidemia, diabetes mellitus, and hypertension, only diabetes mellitus had an independent association. By binary logistic regression, it was seen that NASH was an independent risk factor for predicting cardiac dysfunction.

Conclusion

The prevalence of cardiac dysfunction is more in NASH than NAFL in patients with NAFLD. NASH is an independent risk factor for cardiac dysfunction. There is no correlation between fibrosis and diastolic dysfunction.

Development and implementation of a continuing medical education program on non-alcoholic fatty liver disease for primary care practitioners in Europe

Background

Primary care has a crucial role to play in the prevention, early detection, referral, and risk factor management of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (NAFLD/NASH). In 2021, a team of European collaborators developed a continuing medical education (CME) program on NAFLD/NASH that consolidates evidence and clinical best practices tailored to the primary care setting. This article reports on the methodology used to design and develop the CME and the results of a feasibility study.

Methods

An expert advisory group representing both European specialists and general practitioners supported the design of the CME to be implemented in three European settings (Greece, Spain, and Netherlands). The CME features four training modules and problem-based learning using clinical case studies. The CME was tested regarding feasibility and acceptability among a sample of primary care providers (PCPs) in Greece (n = 28) with measurements occurring before, immediately after, and 1 month following the training. Outcome measures included satisfaction with the CME, changes in PCPs' knowledge, attitudes, confidence, and self-reported clinical practices related to NAFLD/NASH.

Results

The CME is available as an open-access e-learning course on the European Society for Primary Care Gastroenterology education platform in English, Greek, Spanish, and Dutch. The feasibility study documented high levels of satisfaction, with 96% of PCPs reporting they were extremely or very satisfied with the overall training. Statistically significant increases in PCPs' confidence in NAFLD/NASH-related clinical practices were documented between the pre- and post-assessments. At the follow-up, 62% of GPs reported that the CME had changed their clinical practices related to NAFLD/NASH to a great extent.

Conclusion

This CME intervention developed by experts and tailored to PCPs in European settings may serve as an asset for increasing knowledge, confidence, and practice behaviors related to NAFLD/NASH.

Screening for Liver Fibrosis in the General Population: Where Do We Stand in 2022?

Approximately 30% of the worldwide population has at least one risk factor for liver disease. Identifying advanced liver disease before the occurrence of complications remains a difficult challenge in clinical practice, where diagnosis comes too late for many patients, at the time of liver decompensation or palliative hepatocellular carcinoma, with poor short-term prognosis. Noninvasive, blood- or elastography-based tests of liver fibrosis (NITs) have been developed for the early diagnosis of advanced liver fibrosis. Recent population-based studies evaluating the screening of liver fibrosis with these NITs have provided important information on at-risk groups that should be targeted. New measures based on the sequential use of NITs help to better organize the referral of at-risk patients to the liver specialist. However, energizing these measures will require increased awareness of both chronic liver diseases and the use of NITs among non-specialists.

A Global Survey of Physicians Knowledge About Nonalcoholic Fatty Liver Disease

BACKGROUND & AIMS

Despite rapidly increasing nonalcoholic fatty liver disease (NAFLD) prevalence, providers' knowledge may be limited. We assessed NAFLD knowledge and associated factors among physicians of different specialties globally.

METHODS

NAFLD knowledge surveys containing 54 and 59 questions covering 3 domains (epidemiology/pathogenesis, diagnostics, and treatment) were completed electronically by hepatologists, gastroenterologists (GEs), endocrinologists (ENDOs), and primary care physicians (PCPs) from 40 countries comprising 5 Global Burden of Disease super-regions. Over 24 months, 2202 surveys were completed (488 hepatologists, 758 GEs, 148 ENDOs, and 808 PCPs; 50% high-income Global Burden of Disease super-region, 27% from North Africa and Middle East, 12% Southeast Asia, and 5% South Asian and Latin America).

RESULTS

Hepatologists saw the greatest number of NAFLD patients annually: median 150 (interquartile range, 60-300) vs 100 (interquartile range, 35-200) for GEs, 100 (interquartile range, 30-200) for ENDOs, and 10 (interquartile range, 4-50) for PCPs (all P < .0001). The primary sources of NAFLD knowledge acquisition for hepatologists were international conferences (33% vs 8%-26%) and practice guidelines for others (39%-44%). The Internet was the second most common source of NAFLD knowledge for PCPs (28%). NAFLD knowledge scores were higher for hepatologists than GEs: epidemiology, 62% vs 53%; diagnostics, 80% vs 73%; and treatment, 61% vs 58% (P < .0001), and ENDOs scores were higher than PCPs: epidemiology, 70% vs 60%; diagnostics, 71% vs 64%; and treatment, 79% vs 68% (P < .0001). Being a hepatologist or ENDO was associated with higher knowledge scores than a GE or PCP, respectively (P < .05). Higher NAFLD knowledge scores were associated independently with a greater number of NAFLD patients seen (P < .05).

CONCLUSIONS

Despite the growing burden of NAFLD, a significant knowledge gap remains for the identification, diagnosis, and management of NAFLD.

The Survey of the Health of Wisconsin (SHOW) Program: An Infrastructure for Advancing Population Health

Introduction

The Survey of the Health of Wisconsin (SHOW) was established in 2008 by the University of Wisconsin (UW) School of Medicine and Public Health (SMPH) with the goals of (1) providing a timely and accurate picture of the health of the state residents; and (2) serving as an agile resource infrastructure for ancillary studies. Today, the SHOW program continues to serve as a unique and vital population health research infrastructure for advancing public health.

Methods

SHOW currently includes 5,846 adult and 980 minor participants recruited between 2008 and 2019 in four primary waves. WAVE I (2008–2013) includes annual statewide representative samples of 3,380 adults ages 21 to 74 years. WAVE II (2014–2016) is a triannual statewide sample of 1,957 adults (age ≥18 years) and 645 children (age 0–17). WAVE III (2017) consists of follow-up of 725 adults from the WAVE I and baseline surveys of 222 children in selected households. WAVEs II and III include stool samples collected as part of an ancillary study in a subset of 784 individuals. WAVE IV consists of 517 adults and 113 children recruited from traditionally under-represented populations in biomedical research including African Americans and Hispanics in Milwaukee, Wisconsin.

Findings to Date

The SHOW resource provides unique spatially granular and timely data to examine the intersectionality of multiple social determinants and population health. SHOW includes a large biorepository and extensive health data collected in a geographically diverse urban and rural population. Over 60 studies have been published covering a broad range of topics including, urban and rural disparities in cardio-metabolic disease and cancer, objective physical activity, sleep, green-space and mental health, transcriptomics, the gut microbiome, antibiotic resistance, air pollution, concentrated animal feeding operations and heavy metal exposures.

Discussion

The SHOW cohort and resource is available for continued follow-up and ancillary studies including longitudinal public health monitoring, translational biomedical research, environmental health, aging, microbiome and COVID-19 research.

Awareness of chronic liver diseases, a comparison between diabetologists and general practitioners

BACKGROUNDS AND AIMS

Because of the high prevalence of chronic liver disease (CLD), it is crucial that general practitioners (GPs, in contact with the general population) and diabetologists (in contact with the most at-risk non-alcoholic fatty liver disease population) identify patients with advanced CLD requiring specialized management. The aim of this study was to evaluate CLD and CLD management awareness among diabetologists and GPs.

MATERIAL AND METHODS

A questionnaire was sent to diabetologists within the Francophone Diabetes Society and to GPs in southern and western France. The questionnaire sounded participant characteristics and knowledge of CLD and its management.

RESULTS

678 questionnaires were completed by 500 GPs and 178 diabetologists. CLD prevalence was underestimated by 90% of GPs and 59% of diabetologists (p<0.001). For biological CLD follow-up, liver injury explorations (transaminases) were systematically included whereas severity explorations (prothrombin time, bilirubin) were prescribed for less than 50% of blood samples; GPs were more likely to prescribe severity explorations than diabetologists were (p<0.001). 74% of GPs and 97% of diabetologists (p<0.001) were familiar with non-invasive tests, Fibroscan and Fibrotest being the two most-frequently mentioned of them. In contrast, the simple blood test Fibrosis-4 was cited by less than 15% of GPs and 30% of diabetologists (p<0.001).

CONCLUSION

GPs and diabetologists have limited knowledge of CLD, despite its high prevalence. Continuing medical education among GPs and diabetologists is therefore necessary to enable the discovery of patients with advanced fibrosis and early management for them so as to avoid liver-related complications.

Underrecognition of Nonalcoholic Fatty Liver Disease in Poorly Controlled Diabetes: A Call to Action in Diabetes Care

Individuals with type 2 diabetes (T2DM) are at high risk for nonalcoholic fatty liver disease (NAFLD), and evidence suggests that poor glycemic control is linked to heightened risk of progressive NAFLD. We conducted an observational study based on data from a telehealth trial conducted in 2018-2020. Our objectives were to (1) characterize patterns of NAFLD testing/care in a cohort of individuals with poorly controlled T2DM; and (2) explore how laboratory based measures of NAFLD (eg, liver enzymes, fibrosis-4 [FIB-4]) vary by glycemic control. We included individuals with poorly controlled T2DM (n = 228), defined as hemoglobin A1c (HbA1c) ≥ 8.5% despite clinic-based care. Two groups of interest were (1) T2DM without known NAFLD; and (2) T2DM with known NAFLD. Demographics, medical history, medication use, glycemic control (HbA1c), and NAFLD testing/care patterns were obtained by chart review. Among those without known NAFLD (n = 213), most were male (78.4%) and self-identified as Black race (68.5%). Mean HbA1c was 9.8%. Most had liver enzymes (85.4%) and platelets (84.5%) ordered in the outpatient department over a 2-year period that would allow for FIB-4 calculation, yet only 2 individuals had FIB-4 documented in clinical notes. Approximately one-third had abnormal liver enzymes at least once over a 2-year period, yet only 7% had undergone liver ultrasound and 4.7% had referral to hepatology. Among those with known NAFLD (n = 15), mean HbA1c was 9.5%. Only 4 individuals had undergone transient elastography, half of whom had advanced fibrosis. NAFLD is underrecognized in poorly controlled T2DM, even though this is a high-risk group for NAFLD and its complications.

Poor Awareness of Liver Disease Among Adults With NAFLD in the United States

Population-based studies that estimate awareness of nonalcoholic fatty liver disease (NAFLD) in the United States are scant. We aimed to understand public awareness of NAFLD and its temporal trends. Our study included 11,700 adults (18+ years old) from five National Health and Nutrition Examination Surveys (2007-2016). NAFLD was determined by the improved Fatty Liver Index for the multiethnic U.S. population (US-FLI) in the absence of secondary causes of liver disease. Overall prevalence of NAFLD, hepatitis C virus, and hepatitis B virus were 36.6%, 1.02% and 0.35%, respectively. From 2007-2008 to 2015-2016, awareness of liver disease among adults with NAFLD improved from 4.4% to 6.3% (trend P = 0.026) but 4 to 10 times lower than awareness about viral hepatitis. In 2015-2016, among adults with NAFLD, awareness of liver disease was lower among young adults (aged 18-29 years) compared with those aged ≥ 30 years (0% vs. 6.9%) and lower among non-Hispanic Blacks compared with other races (0.7% vs. 6.6%) (all P < 0.001). In multivariable analysis, young adults (adjusted odds ratio [aOR] = 0.29; confidence interval [CI] 0.10-0.87) and non-Hispanic Blacks (aOR = 0.43; CI 0.20-0.96) were negatively associated with awareness of liver disease among adults with NAFLD, whereas diabetes (aOR = 2.22; CI 1.37-3.58), advanced fibrosis (aOR = 2.34; CI 1.17-4.68), and a higher number of health care visits (aOR = 1.33; CI 1.15-1.50) were positively associated with awareness of liver disease. Nearly 96% of adults with NAFLD in the United States were unaware they had liver disease, especially among young adults and non-Hispanic Blacks. Findings indicate efforts are needed to improve awareness of NAFLD.

Primary care and referring physician perspectives on non-alcoholic fatty liver disease management: a nationwide survey

INTRODUCTION

The optimal approach to screening and risk stratification for non-alcoholic fatty liver disease is challenging given disease burden and variable progression. The aim of this study was to assess primary care physician and referring physician practice patterns regarding non-alcoholic fatty liver disease.

METHODS

An anonymous nationwide survey was administered to primary care physicians, endocrinologists, and cardiologists in a: (1) tertiary academic hospital, (2) community hospital, and (3) the American College of Physicians Insider Panel. Survey domains assessed non-alcoholic fatty liver disease knowledge, recommendations for screening, risk stratification, treatment, and referral patterns.

RESULTS

A total of 440 providers completed the survey (35.2% completion rate; N = 82 academic hospital, N = 21 community hospital, N = 337 American College of Physicians). Half were male (51.7%), 78% from internal medicine, with 5% subspecialists. Providers were knowledgeable regarding prevalence and risk factors for non-alcoholic fatty liver disease. 58% would support screening for non-alcoholic fatty liver disease and used liver enzymes to do so. Only 22.5% used serum biomarkers and 23% used transient elastography for risk stratification. Primary reason for referral was advanced fibrosis/cirrhosis. 80% reported barriers to treating non-alcoholic fatty liver disease. There was no consistent diet recommended.

CONCLUSION

In this nationwide survey, we demonstrated that while overall disease knowledge was good, there was an important disconnect between current guidelines and real-world clinical practice. There is also significant heterogeneity in practice patterns for first-line therapy of non-alcoholic fatty liver disease and the majority of provider's report barriers to treating non-alcoholic fatty liver disease. These findings highlight the potential role for reevaluating screening and risk stratification recommendations in primary care to better align with needs in that setting.

Cross-sectional pilot study to assess primary healthcare workers' knowledge of nonalcoholic fatty liver disease in a marginalized community in Mexico

The registered incidence of nonalcoholic fatty liver disease (NAFLD) in primary healthcare centers is lower than expected, suggesting a lack of awareness by primary care healthcare professionals. The implementation of educational tools for healthcare workers has been found to increase timely referral and treatment of patients. We aimed to determine healthcare workers' knowledge of NAFLD to identify their educational needs in one marginalized region. We performed a cross-sectional survey of 261 healthcare professionals in Tlapa de Comonfort, Guerrero, Mexico from October 2019 to December 2019. We created a questionnaire that assessed domains most relevant to NAFLD knowledge. Two hundred and forty-six questionnaires were completed. Of the respondents, 38.3% were nurses and 63.4% were women. Most nurses identified NAFLD as a prevalent (89%) and preventable (93%) disease. Hypertension (33%) and obesity (84%) were recognized as risk factors. The associations between NAFLD and cancer, cirrhosis and cardiovascular disease were identified by 53%, 67% and 72% of respondents, respectively. The largest gaps were found in diagnostic workup, therapeutic approach and the current treatments. We identify modifiable knowledge gaps in NAFLD. Educational strategies for primary care workers could enhance the identification of patients with NAFLD and prevent complications.

A Canadian survey on knowledge of non-alcoholic fatty liver disease among physicians

BACKGROUND

In Canada, non-alcoholic fatty liver disease (NAFLD) is the most frequently occurring liver disease, affecting one in four Canadians. NAFLD can in turn evolve into non-alcoholic steatohepatitis (NASH) and cirrhosis. No study in Canada has investigated knowledge of NAFLD among physicians.

METHODS

Primary care physicians (PCPs); specialists in internal medicine, gastroenterology, and hepatology; and hepatology nurses who were members of the College of Family Physicians of Canada, Canadian Association for the Study of the Liver, or Canadian Association of Hepatology Nurses were invited to participate in this web-based survey.

RESULTS

Of 650 invited physicians and nurses, 214 (33%) responded and 171 (26%) completed the whole survey. Overall, 51% of the respondents were PCPs, 38% were specialists, and 11% were nurses. Of these, 58% of PCPs, 28% of specialists, and 39% of nurses responded that they were only somewhat familiar or unfamiliar with NAFLD. Moreover, 53% of PCPs, 20% of specialists, and 35% of nurses thought the prevalence of NAFLD in Canada was 15% or less. Also, 42% of respondents thought that NASH could be diagnosed by imaging or blood tests. Finally, more than 40% of PCPs, 22% of specialists, and 33% of nurses thought that metformin and statin were treatments for NASH.

CONCLUSIONS

This survey shows that a significant proportion of Canadian physicians and nurses managing patients with NAFLD are not very familiar with the disease. This study emphasizes the need for further provider education, national practice guidelines, and improved treatment options.

The Survey of the Health of Wisconsin (SHOW) Program: An infrastructure for Advancing Population Health Sciences

PURPOSE

The Survey of the Health of Wisconsin (SHOW) was established in 2008 by the University of Wisconsin (UW) School of Medicine and Public Health (SMPH) with the goals of 1) providing a timely and accurate picture of the health of the state residents; and 2) serving as an agile resource infrastructure for ancillary studies. Today SHOW continues to serve as a vital population health research infrastructure.

PARTICIPANTS

SHOW currently includes 5,846 adult and 980 minor participants recruited between 2008-2019 in four primary waves. WAVE I (2008-2013) includes annual statewide representative samples of 3,380 adults ages 21 to 74 years. WAVE II (2014-2016) is a triannual statewide sample of 1957 adults (age ≥18 years) and 645 children. WAVE III (2017) consists of follow-up of 725 adults from the WAVE I and baseline surveys of 222 children in selected households. WAVEs II and III include stool samples collected as part of an ancillary study in a subset of 784 individuals. WAVE IV consist of 517 adults and 113 children recruited from traditionally under-represented populations in biomedical research including African Americans and Hispanics in Milwaukee county, WI.

FINDINGS TO DATE

The SHOW provides extensive data to examine the intersectionality of multiple social determinants and population health. SHOW includes a large biorepository and extensive health data collected in a geographically diverse urban and rural population. Over 60 studies have been published covering a broad range of topics including, urban and rural disparities in cardio-metabolic disease and cancer, objective physical activity, sleep, green-space and mental health, transcriptomics, the gut microbiome, antibiotic resistance, air pollution, concentrated animal feeding operations and heavy metal exposures.

FUTURE PLANS

The SHOW cohort is available for continued longitudinal follow-up and ancillary studies including genetic, multi-omic and translational environmental health, aging, microbiome and COVID-19 research.

ARTICLE SUMMARY

Strengths and limitations: The Survey of the Health of Wisconsin (SHOW) is an infrastructure to advance population health sciences including biological sample collection and broader data on individual and neighborhood social and environmental determinants of health.The extensive data from diverse urban and rural populations offers a unique study sample to compare how socio-economic gradients shape health outcomes in different contexts.The objective health data supports novel interdisciplinary research initiatives and is especially suited for research in causes and consequences of environmental exposures (physical, chemical, social) across the life course on cardiometabolic health, immunity, and aging related conditions.The extensive biorepository supports novel omics research into common biological mechanisms underlying numerous complex chronic conditions including inflammation, oxidative stress, metabolomics, and epigenetic modulation.Ancillary studies, such as the Wisconsin Microbiome Study, have expanded the utility of the study to examine human susceptibility to environmental exposures and opportunities for investigations of the role of microbiome in health and disease.Long-standing partnerships and recent participation among traditionally under-represented populations in biomedical research offer numerous opportunities to support community-driven health equity work.No biological samples were collected among children.The statewide sampling frame may limit generalizability to other regions in the United States.

From NAFLD to MAFLD: Nurse and allied health perspective

Fatty liver disease associated with metabolic dysfunction is the most prevalent liver disease worldwide, though both patient and health professional still lack awareness of it. An international consensus panel has produced what is sure to be an influential report renaming the disease from non-alcoholic fatty liver disease (NAFLD) to metabolic (dysfunction) associated fatty liver disease (MAFLD) and suggesting how the disease should be diagnosed. This viewpoint explores the call from the perspective of nurse and allied health practitioners. This group have raised serious concerns on the existing nomenclature, which labels the disease as NAFLD, and its diagnostic criteria, including provoking nurse role confusion and representing a major barrier to various key aspects; patient-nurse communications, patient awareness, partnership working, motivation of patients to undertake lifestyle changes and multiple health behaviour change promotion and nurse-led clinics. Therefore, they are enthusiastically supportive of this call to reframe the disease that we believe will ultimately have a positive impact on nurse-patient communication, and through this, improve patient care and quality of life and reduce burden on health system.

Advances in the Epidemiology, Diagnosis, and Management of Pediatric Fatty Liver Disease

PURPOSE

Nonalcoholic fatty liver (NAFL) is a major contributor to pediatric liver disease. This review evaluated the current literature on prevalence, screening, diagnosis, and management of NAFL in children and explored recent advances in the field of pediatric NAFL.

METHODS

A PubMed search was performed for manuscripts describing disease burden, diagnosis, and management strategies in pediatric NAFL published within the past 15 years. Systematic reviews, clinical practice guidelines, randomized controlled trials, and cohort and case-control studies were reviewed for the purpose of this article.

FINDINGS

The prevalence of NAFL in children is increasing. It is a leading cause of liver-related morbidity and mortality in children. Screening and diagnosis of NAFL in children are a challenge. Lifestyle changes and exercise are the cornerstones of the management of NAFL.

IMPLICATIONS

Further research is needed to develop better screening and diagnostic tools for pediatric NAFL, including noninvasive diagnostics. NAFL therapeutics is another area of much-needed, ongoing research.

Nonalcoholic Fatty Liver Disease Screening in Type 2 Diabetes Mellitus Patients in the Primary Care Setting

Nonalcoholic fatty liver disease (NAFLD) is a major public health problem worldwide and the most common chronic liver disease. NAFLD currently affects approximately one in every four people in the United States, and its global burden is expected to rise in the next decades. Despite being a prevalent disease in the general population, only a minority of patients with NAFLD will develop nonalcoholic steatohepatitis (NASH) with advanced liver fibrosis (stage 3-4 fibrosis) and liver-related complications. Certain populations, such as patients with type 2 diabetes mellitus (T2DM), are recognized to be at the highest risk for developing NASH and advanced fibrosis. Both the American Diabetes Association and the European Association for the Study of Diabetes recommend screening of all T2DM for NAFLD. Incorporating a simple noninvasive algorithm into the existing diabetic care checklists in the primary care practice or diabetologist's office would efficiently identify patients at high risk who should be referred to specialists. The proposed algorithm involves a first-step annual fibrosis-4 score (FIB-4) followed by vibration-controlled transient elastography (VCTE) for those with indeterminate or high-risk score (FIB-4 ≥1.3). Patients at low-risk (FIB-4 <1.3 or VCTE <8 kPa) can be followed up by primary care providers for lifestyle changes and yearly calculation of FIB-4, while patients at high risk (FIB-4 ≥1.3 and VCTE ≥8 kPa) should be referred to a liver-specialized center. Conclusion: Patients with T2DM or prediabetes should be screened for NASH and advanced fibrosis. The proposed simple algorithm can be easily incorporated into the existing workflow in the primary care or diabetology clinic to identify patients at high risk for NASH and advanced fibrosis who should be referred to liver specialists.

Readiness for the epidemic: The adult nonalcoholic fatty liver disease toolkit for primary care nurse practitioners

BACKGROUND AND PURPOSE

Nonalcoholic fatty liver disease (NAFLD) prevalence has reached epidemic proportions, and the severe form, nonalcoholic steatohepatitis, can result in cirrhosis and liver failure. The growing prevalence requires primary care (PC) providers to be adept at recognition and management; however, they experience significant knowledge gaps that can result in delayed access to interventions that could improve outcomes. This study's aim was to develop and evaluate a toolkit to improve knowledge gaps and support evidence-based practice (EBP) among PC nurse practitioners caring for patients with NAFLD in a midwestern state.

METHODS AND INTERVENTION

The Adult NAFLD Toolkit was designed using the Knowledge to Action framework and guidelines from the Agency for Healthcare Research and Quality. The success of the toolkit was evaluated by administering the NAFLD survey for general practitioners in a pre-post evaluation design.

RESULTS

Pre-post survey scores (N = 11) were compared for statistically significant change using the Wilcoxon signed rank test for matched pairs and showed improvement in overall knowledge (p = .011), perceived preparedness to care for NAFLD (p = .007), intention to recommend weight loss for management (p = .008), and intention to use the NAFLD fibrosis score for patient monitoring (p = .008).

CONCLUSIONS

The results of this pilot study demonstrate successful implementation and positive outcomes of an EBP toolkit and support its expanded use. Continued evaluation on a larger scale is needed. Health care providers can use the process described in this article to develop and implement toolkits to support EBP of other PC issues.

Case-finding strategies in non-alcoholic fatty liver disease

Among the large population of patients with non-alcoholic fatty liver disease (NAFLD), identifying those with advanced disease remains challenging. Many patients are diagnosed late, following the development of liver-related complications, leading to poor clinical outcomes. Accumulating evidence suggests that using non-invasive tests for liver fibrosis in patients with metabolic risk factors improves the detection of patients in need of specialised management and is cost-effective. Because of the vast number of patients requiring evaluation, the active participation of general practitioners and physicians who manage patients with metabolic disorders, such as diabetologists, is crucial; this calls for the increased awareness of NAFLD beyond liver clinics. Non-invasive case-finding strategies will need to be further validated and generalised for upcoming drug therapies to have the required impact on the worldwide burden of NAFLD.

Providing Care for Fatty Liver Disease Patients: Primary Care Nurse Practitioners' Knowledge, Actions, and Preparedness

The increasing prevalence of nonalcoholic fatty liver disease requires primary care providers to serve on the front lines of care for patients with nonalcoholic fatty liver disease. Knowledge gaps regarding nonalcoholic fatty liver disease exist among primary care physicians, but it is unknown whether primary care nurse practitioners demonstrate similar gaps because they are under-represented in the literature. The purpose of this study was to evaluate primary care nurse practitioners' clinical approaches regarding nonalcoholic fatty liver disease, their knowledge regarding diagnosis and management, and their preparedness level regarding care for patients with nonalcoholic fatty liver disease. Adequate knowledge was demonstrated in some, but not all, areas. The knowledge did not necessarily translate into clinical practice behaviors, however. In addition, only 35% of the participants agreed that they felt prepared to care for patients with nonalcoholic fatty liver disease. Implications are limited by the small sample size but provide some insight into primary care nurse practitioners' preparedness to care for this important epidemic.

Fatigue and Pruritus in Patients with Advanced Fibrosis Due to Nonalcoholic Steatohepatitis: The Impact on Patient-Reported Outcomes

Fatigue and pruritus are common in patients with chronic liver diseases of all etiologies, but clinical awareness is mostly restricted to those with cholestatic liver diseases. We assessed the impact of fatigue and pruritus on patient‐reported outcomes (PROs) of patients with advanced nonalcoholic steatohepatitis (NASH). Specifically, PROs (Short Form–36, Chronic Liver Disease Questionnaire–NASH, Euro‐Qol 5 Dimension, and Work Productivity and Activity Impairment instruments) were assessed at baseline in patients with histologically confirmed bridging fibrosis (F3) or compensated cirrhosis (F4) due to NASH enrolled in STELLAR 3 and 4. Presence of fatigue and pruritus were indicated by a score of 4 or less on the respective items of the Chronic Liver Disease Questionnaire–NASH (scale range, 1‐7). Among the included 1,669 patients with advanced NASH (mean age = 58 ± 9 years, 48% F3, 42% with psychiatric comorbidities), 33% and 27% had fatigue and pruritus, respectively. Patients with NASH with fatigue were younger, more likely to be female, cirrhotic, and diabetic, and had higher body mass index and more comorbidities (all P < 0.05). All PRO scores of patients with fatigue were significantly impaired (mean up to −31% of a PRO range size in comparison to patients without fatigue). In multivariate analysis, predictors of fatigue included diabetes, history of depression or nervous system comorbidities, and lower serum albumin (P < 0.05). Patients with pruritus had demographic characteristics similar to those with fatigue, but a higher prevalence of dermatologic comorbidities. All PROs were impaired (by up to −19% of a range size, all P < 0.01) in patients with NASH with pruritus. Female gender, lower serum albumin, and a history of depression, nervous system, and dermatologic comorbidities were associated with increased risk of pruritus (P < 0.05). Conclusion: Clinically significant fatigue and pruritus are common in patients with advanced NASH, and these symptoms negatively affect PROs.

Low Awareness of Nonalcoholic Fatty Liver Disease in a Population-Based Cohort Sample: the CARDIA Study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the United States, yet little is known about NAFLD awareness in individuals with incidental fatty liver on imaging.

OBJECTIVE

To assess the level of awareness of imaging-defined NAFLD among individuals with and without metabolic risk factors.

DESIGN

Cross-sectional analysis within a prospective longitudinal population-based cohort study conducted in four U.S. cities.

PARTICIPANTS

Adults age 43 to 55 years enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) Study who underwent computed tomography and a personal health questionnaire at the year 25 exam (2010-2011, n = 2788).

MAIN MEASURES

NAFLD was defined as liver attenuation ≤ 51 Hounsfield units after exclusion of other causes of liver fat. Participants were considered "NAFLD aware" if they reported being told previously by a doctor or nurse that they had "fatty liver."

KEY RESULTS

NAFLD prevalence was 23.9%. Only 16 of 667 (2.4%) participants with CT-defined NAFLD were aware of a NAFLD diagnosis. NAFLD aware participants were more likely to be white (81.3% vs. 53.5%, p = 0.03) and have the metabolic syndrome (87.5% vs. 59.3%, p = 0.02) and/or hypertension (75.0% vs. 50.2%, p = 0.05). In multivariable analyses adjusted for demographics, metabolic syndrome and hypertension remained predictive of NAFLD awareness.

CONCLUSION

There is low awareness of NAFLD among individuals with hepatic steatosis on imaging, even among those with metabolic risk factors. These findings highlight an opportunity to raise public and practitioner awareness of NAFLD with the goal of increasing diagnosis and implementing early treatment strategies.

Inhibition of lncRNA HULC improves hepatic fibrosis and hepatocyte apoptosis by inhibiting the MAPK signaling pathway in rats with nonalcoholic fatty liver disease

This study is conducted to investigate the role of long noncoding RNA highly upregulated in liver cancer (lncRNA HULC) on hepatic fibrosis and hepatocyte apoptosis by inhibiting the mitogen-activated protein kinase (MAPK) signaling pathway in rats with nonalcoholic fatty liver disease (NAFLD). The successfully modeled rats were injected with HULC siRNA or small interfering RNA (siRNA) negative control into the tail vein. The expression of HULC in liver tissues was detected by reverse transcription quantitative polymerase reaction chain. The role of HULC in pathological state and liver function-related indexes of liver lipid deposition, the degree of hepatic fibrosis and hepatocyte apoptosis in rats with NAFLD were also investigated through a series of experiments. Increased expression of HULC was found in liver tissue of NAFLD rats. Inhibition of HULC improved the pathological state and liver function-related indexes of liver lipid deposition, improved the degree of hepatic fibrosis, reduced hepatocyte apoptosis, and inhibited the MAPK signaling pathway in the liver tissue of NAFLD rats. The inhibition of p38 and JNK improved the pathological state of liver lipid deposition and liver function to some extent, improved the degree of hepatic fibrosis, and reduced the apoptosis of hepatocytes in NAFLD rats. Collectively, this present study provides evidence that inhibition of lncRNA HULC improves hepatic fibrosis and decrease hepatocyte apoptosis in rats with NAFLD by inhibiting the MAPK signaling pathway.

Impact of a structured lifestyle programme on patients with metabolic syndrome complicated by non-alcoholic fatty liver disease

BACKGROUND

Lifestyle interventions are first-line therapy for non-alcoholic fatty liver disease (NAFLD).

AIMS

To examine the prevalence of NAFLD among participants of the University of Michigan Metabolic Fitness (MetFit) Programme and to assess the impact of this programme on weight, metabolic and liver-related parameters among patients with and without NAFLD.

METHODS

Adults who completed the programme between 2008 and 2016 were included. Clinical and laboratory data were collected at enrolment, and at 12 and 24 weeks. NAFLD was defined based on liver biopsy, imaging or clinical diagnosis.

RESULTS

The cohort (N = 403; 253 12-week, 150 24-week) consisted primarily of middle-aged (median 54 years) white (88%) men (63%) with severe obesity (median BMI 37.4). 47.6% met criteria for NAFLD. At baseline, NAFLD patients were younger (52 vs 55 years), had higher weights and more metabolic derangements (higher fasting insulin and triglyceride, lower high-density lipoprotein-cholesterol). At programme completion, 30% achieved weight reduction ≥5%, 62% resolution of hypertriglyceridaemia, 33% resolution of low HDL, 27% resolution of impaired fasting glucose and 43% normalisation of alanine aminotransferase. Endpoints were unaffected by NAFLD. Longer programme duration (OR 6.7, 95% CI 3.6-12.3) and white race (OR 3.83, 95% CI 1.04-1.76) were independent predictors of ≥5% weight loss.

CONCLUSIONS

Nearly half of the patients referred to a structured lifestyle programme for metabolic syndrome had NAFLD. Although baseline metabolic derangements were more pronounced among NAFLD patients, the programme was equally efficacious in achieving weight loss and resolving metabolic syndrome components. Programme duration was the most important predictor of response.

GPs' experiences and perceptions of early detection of liver disease: a qualitative study in primary care

BACKGROUND

The incidence of liver disease is increasing in the UK and primary care is a key setting where improvement in the detection and management of liver disease is required. Little is known about GPs' understanding and confidence in detecting liver disease.

AIM

To explore GPs' experiences of liver disease with a focus on early detection and interpretation of liver function tests (LFTs).

DESIGN AND SETTING

A qualitative study employing semi-structured interviews of a purposive sample of GPs from five UK primary care study sites.

METHOD

Telephone and face-to-face interviews of GPs were undertaken. Data were analysed thematically, using a constant comparative approach.

RESULTS

From a total of 25 GP interviews (N = 25), four themes were identified from the data: test-requesting behaviour, confidence and challenges in diagnosing disease, access to specialist tests, and guidance and education. Participants' descriptions of how they request and interpret LFTs varied widely. Concern over missing diagnoses was a common reason for requesting blood tests; patients with mildly abnormal LFTs and those at risk of non-alcoholic fatty liver disease (NAFLD) were a particular cause of concern. GPs saw themselves as generalists, with a reluctance to take on specialist investigations. Guidelines promoted confidence for some clinicians, but others felt that liver disease was too complex to be amenable to simple instructions. Most felt that they did not have access to relevant, focused education on liver disease.

CONCLUSION

Liver disease is not perceived as a priority in primary care. If GPs are to take on a greater role in identification and management of liver disease, support is needed to promote awareness, knowledge, and confidence.

Survey on knowledge of non-alcoholic fatty liver disease (NAFLD) among doctors in Sri Lanka: a multicenter study

OBJECTIVES

There has been a global increase in the incidence and prevalence of NAFLD. We assessed the knowledge and awareness of NAFLD among gastroenterology doctors in three state sector hospitals.

RESULTS

80 medical officers and 58 post-graduate trainee doctors/consultants responded. 110 (79.7%) considered NAFLD a major health problem whilst 97 (70.3%) thought the prevalence of NAFLD was 10-40%. 52.9% saw 12-24 patients with NAFLD/year. A vast majority knew the risk factors for NAFLD: 127 (92.7%) diabetes mellitus, 135 (97.8%) Obesity, 132 (95.7%) Dyslipidemia and 87 (63%) PCOS. The methods for diagnosis were recognized by: USS 132 (95.7%), MRI 34 (24.6%), transient elastography 23 (16.7%) and liver biopsy 88 (63.8%) while, 53 (38.4%) recognized the non-invasive methods available for diagnosis. The trends in referral were lower than expected: 85 (61.6%) refer to a Gastroenterologist/Physician, 53 (38.4%) to a Gym, 67 (48.6%) to a weight loss clinic and 45 (32.6%) to a dietician. Significantly more postgraduate trainee doctors: recognized the availability of non-invasive investigations for NAFLD (P = 0.01) and read guidelines on NAFLD (P = 0.02) compared to non-trainee doctors. As a whole, a majority (57.2%) had not attended a lecture or read a guideline on NAFLD. The barriers for management included: lack of confidence 70 (50.7%) and time constraints 58 (42%).

Management of patients with non-alcoholic steatohepatitis (NASH) in real life

Non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) is a prevalent condition that is associated with the development of cirrhosis and hepatocellular carcinoma and with no approved treatment options except for lifestyle changes. Guidelines have been drafted for the management of NAFLD patients in this setting. Because of the lack of real-life cohort data, we will focus on practice surveys on the management of patients with NAFLD/NASH, which included primary care practitioners, gastroenterologists/hepatologists and other specialists from various countries. Practice patterns have been collected from interviews with practitioners or reviews of patient's files. This review discusses the screening, diagnosis and therapeutic management of NAFLD/NASH patients in real life practice, as well as adherence to guidelines.

Specialty Care Access Network-Extension of Community Healthcare Outcomes Model Program for Liver Disease Improves Specialty Care Access

BACKGROUND AND AIMS

To improve subspecialty access, VA Ann Arbor Healthcare System (VAAAHS) implemented the first Specialty Care Access Network (SCAN)-Extension of Community Healthcare Outcomes (ECHO) in chronic liver disease. SCAN-ECHO Liver links primary care providers (PCPs) to hepatologists via secure video-teleconferencing. We aim to describe characteristics of participants (PCPs) and patients (clinical question and diagnosis) in SCAN-ECHO Liver.

METHODS

This is a prospective study of the VAAAHS SCAN-ECHO Liver (June 10, 2011-March 31, 2015). This evaluation was carried out as a non-research activity under the guidance furnished by VHA Handbook 1058.05. It was approved through the Medicine Service at VAAAHS as noted in the attestation document which serves as documentation of approved non-research, quality improvement activities in VHA.

RESULTS

In total, 106 PCPs from 23 sites participated. A total of 155 SCAN-ECHO sessions discussed 519 new and 49 return patients. 29.4% of Liver Clinic requests were completed in SCAN-ECHO Liver. SCAN-ECHO Liver consults were completed an average of 10 days sooner than in conventional clinic. Potential travel saving was 250 miles round-trip (median 255 (IQR 142-316) per patient.

CONCLUSION

SCAN-ECHO Liver provided specialty care with increased efficiency and convenience for chronic liver disease patients. One of three of Liver Clinic consults was diverted to SCAN-ECHO Liver, reducing consult completion time by 20%.

Nonalcoholic fatty liver disease-related cirrhosis is commonly unrecognized and associated with hepatocellular carcinoma

Determination of cirrhosis in nonalcoholic fatty liver disease (NAFLD) is important as it alters prognosis and management. We aimed to examine whether cirrhosis was diagnosed incidentally or intentionally in patients with NAFLD. We reviewed 100 patients with NAFLD cirrhosis to determine mode of cirrhosis diagnosis (incidental or by intent), severity of liver disease at diagnosis, diagnostician, and previous clinical imaging or laboratory evidence of unrecognized cirrhosis. The majority (66/100) of patients with NAFLD cirrhosis were diagnosed incidentally, with the majority of these (74%) diagnosed with NAFLD simultaneously. Those with incidental cirrhosis diagnoses had more deranged platelet and international normalized ratio levels (P < 0.05) and were more likely to have concomitant hepatocellular carcinoma (HCC) (12% versus 0%, P < 0.05). Incidental cirrhosis was diagnosed following imaging (32%) or liver tests (26%) performed for reasons unrelated to liver disease, following unexpected endoscopic finding of varices (21%) or an unexpected surgical finding (14%). Diagnoses by intent were predominantly made by gastroenterologists/hepatologists, whereas general practitioners, surgeons, and physicians tended to diagnose cirrhosis incidentally (P < 0.001). The majority of patients diagnosed incidentally (n = 48/66, 73%) had previous thrombocytopenia, splenomegaly, or high noninvasive fibrosis scores. Following diagnosis, patients diagnosed incidentally were less likely to undergo HCC screening. Conclusion: The majority of patients with NAFLD cirrhosis are diagnosed incidentally. These patients are more likely to have advanced liver disease and HCC. Increased awareness of screening for cirrhosis is needed in patients with NAFLD. (Hepatology Communications 2017;1:53–60)

Novel educational interventions in residency increase knowledge of chronic liver disease and career interest in hepatology

There is an increasing burden of chronic liver disease (CLD) in the United States but a significant shortage of hepatologists. Thus, it is necessary to develop new recruitment strategies to the field of hepatology as well as ensure that non-gastroenterology-trained physicians are able to capably assist in the care of CLD. We established a novel, nonelective, inpatient hepatology rotation that uses required modules in the American Association for the Study of Liver Diseases Curriculum and Training-First Hepatitis B and C curriculums as well as in LiverLearning. A paper-based anonymous assessment was distributed to the inaugural 25 postgraduate years 2 and 3 internal medicine residents before and after the 2-week rotation over the course of 1 year. Both the prerotation and postrotation assessments included validated multiple-choice questions and Likert-type questions, which evaluated self-perceived knowledge and comfort with managing CLD. The mean comfort level (1 = not at all comfortable/strongly disagree, 5 = very comfortable/strongly agree) of managing several common liver diseases increased significantly after completion of the rotation (i.e., cirrhosis 2.8 versus 3.8, P < 0.001; hepatitis B 2.4 versus 3.4, P = 0.001; hepatitis C 2.6 versus 3.7, P = 0.002; nonalcoholic steatohepatitis 3.0 versus 4.0, P < 0.001; liver transplant care 2.1 versus 3.4, P < 0.001). There was also a significantly increased interest in hepatology as a career (2.6 versus 3.0, P = 0.03). Finally, the mean percentage of multiple-choice questions answered correctly on the pretest was 62% and posttest was 77% (P = 0.02).

CONCLUSION

Our novel curriculum and nonelective hepatology rotation has effectively demonstrated improvement in internal medicine residents' comfort with and knowledge of CLD, and increased career interest in hepatology was also observed after completion of the curriculum, which suggests that more exposure to CLD could positively impact recruitment to the workforce; larger, multicenter studies are needed to validate these results. (Hepatology 2016;64:2210-2218).