Cannabis use is associated with reduced prevalence of non-alcoholic fatty liver disease: A cross-sectional study

The Effect of Oil-Based Cannabis Extracts on Metabolic Parameters and Microbiota Composition of Mice Fed a Standard and a High-Fat Diet

The prevalence of obesity and obesity-related pathologies is lower in frequent cannabis users compared to non-users. It is well established that the endocannabinoid system has an important role in the development of obesity. We recently demonstrated that prolonged oral consumption of purified Δ-9 Tetrahydrocannabinol (THC), but not of cannabidiol (CBD), ameliorates diet-induced obesity and improves obesity-related metabolic complications in a high-fat diet mouse model. However, the effect of commercially available medical cannabis oils that contain numerous additional active molecules has not been examined. We tested herein the effects of THC- and CBD-enriched medical cannabis oils on obesity parameters and the gut microbiota composition of C57BL/6 male mice fed with either a high-fat or standard diet. We also assessed the levels of prominent endocannabinoids and endocannabinoid-like lipid mediators in the liver. THC-enriched extract prevented weight gain by a high-fat diet and attenuated diet-induced liver steatosis concomitantly with reduced levels of the lipid mediators palmitoyl ethanolamide (PEA) and docosahexaenoyl ethanolamide (DHEA) in the liver. In contrast, CBD-enriched extract had no effect on weight gain, but, on the contrary, it even exacerbated liver steatosis. An analysis of the gut microbiota revealed that mainly time but not treatment exerted a strong effect on gut microbiota alterations. From our data, we conclude that THC-enriched cannabis oil where THC is the main constituent exerts the optimal anti-obesity effects.

The Effect of Orally Administered Δ9-Tetrahydrocannabinol (THC) and Cannabidiol (CBD) on Obesity Parameters in Mice

Prolonged cannabis users show a lower prevalence of obesity and associated comorbidities. In rodent models, Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) from the plant Cannabis sativa L. have shown anti-obesity properties, suggesting a link between the endocannabinoid system (ECS) and obesity. However, the oral administration route has rarely been studied in this context. The aim of this study was to investigate the effect of prolonged oral administration of pure THC and CBD on obesity-related parameters and peripheral endocannabinoids. C57BL/6 male mice were fed with either a high-fat or standard diet and then received oral treatment in ramping doses, namely 10 mg/kg of THC or CBD for 5 weeks followed by 30 mg/kg for an additional 5 weeks. Mice treated with THC had attenuated weight gain and improved glucose tolerance, followed by improvement in steatosis markers and decreased hypertrophic cells in adipose epididymal tissue. Mice treated with CBD had improved glucose tolerance and increased markers of lipid metabolism in adipose and liver tissues, but in contrast to THC, CBD had no effect on weight gain and steatosis markers. CBD exclusively decreased the level of the endocannabinoid 2-arachidonoylglycerol in the liver. These data suggest that the prolonged oral consumption of THC, but not of CBD, ameliorates diet-induced obesity and metabolic parameters, possibly through a mechanism of adipose tissue adaptation.

Factors associated with hospitalizations for co-occurring HIV and opioid-related diagnoses: Evidence from the national inpatient sample, 2009-2017

There has been evidence of rising HIV incidence attributable to opioid misuse within some areas of the U.S. The purpose of our study was to explore national trends in co-occurring HIV and opioid-related hospitalizations and to identify their risk factors. We used the 2009-2017 National Inpatient Sample to indicate hospitalizations with co-occurring HIV and opioid misuse diagnoses. We estimated the frequency of such hospitalizations per year. We fitted a linear regression to the annual HIV-opioid co-occurrences with year as a predictor. The resulting regression did not reveal any significant temporal changes. We used multivariable logistic regression to determine the adjusted odds (AOR) of hospitalization for co-occurring HIV and opioid-related diagnoses. The odds of hospitalization were lower for rural residents (AOR = 0.28; CI = 0.24-0.32) than urban. Females (AOR = 0.95, CI = 0.89-0.99) had lower odds of hospitalization than males. Patients identifying as White (AOR = 1.23, CI = 1.00-1.50) and Black (AOR = 1.27, CI = 1.02-1.57) had higher odds of hospitalization than other races. When compared to co-occuring hospitalizations in the Midwest, the odds were higher in the Northeast. (AOR = 2.56, CI = 2.07-3.17) Future research should explore the extent to which similar findings occur in the context of mortality and targeted interventions should intesify for subpopulations at highest risk of co-occuring HIV and opioid misuse diagnoses.

Should gastroenterologists prescribe cannabis? The highs, the lows and the unknowns

Cannabis, commonly known as marijuana, is a drug extracted from the Cannabis plant known for its psychotropic and medicinal properties. It has been used for healing purposes during ancient times, although its psychoactive components led to its restricted use in medicine. Nonetheless, cannabis is found to have modulatory effects on the endocannabinoid system exhibiting its medicinal role in the gastrointestinal (GI) system. Emerging animal and human studies demonstrate the influential effects of cannabis on a variety of GI diseases including inflammatory bowel disease, motility disorders and GI malignancies. It also has a regulatory role in GI symptoms including nausea and vomiting, anorexia, weight gain, abdominal pain, among others. However, both its acute and chronic use can lead to undesirable side effects such as dependency and addiction, cognitive impairment and cannabinoid hyperemesis syndrome. We will discuss the role of cannabis in the GI system as well as dosing strategies to help guide gastroenterologists to assess its efficacy and provide patient counseling before prescription of medical marijuana.

Nutritional and Lifestyle Therapy for NAFLD in People with HIV

HIV infection and nonalcoholic fatty liver disease (NAFLD) are two major epidemics affecting millions of people worldwide. As people with HIV (PWH) age, there is an increased prevalence of metabolic comorbidities, along with unique HIV factors, such as HIV chronic inflammation and life-long exposure to antiretroviral therapy, which leads to a high prevalence of NAFLD. An unhealthy lifestyle, with a high dietary intake of refined carbohydrates, saturated fatty acids, fructose added beverages, and processed red meat, as well as physical inactivity, are known to trigger and promote the progression of NAFLD to nonalcoholic steatohepatitis, liver fibrosis, and hepatocellular carcinoma. Furthermore, with no currently approved pharmacotherapy and a lack of clinical trials that are inclusive of HIV, nutritional and lifestyle approaches still represent the most recommended treatments for PWH with NAFLD. While sharing common features with the general population, NAFLD in PWH displays its own peculiarities that may also reflect different impacts of nutrition and exercise on its onset and treatment. Therefore, in this narrative review, we aimed to explore the role of nutrients in the development of NAFLD in PWH. In addition, we discussed the nutritional and lifestyle approaches to managing NAFLD in the setting of HIV, with insights into the role of gut microbiota and lean NAFLD.

Impacts of medical and non-medical cannabis on the health of older adults: Findings from a scoping review of the literature

BACKGROUND

Cannabis legalization has enabled increased consumption in older adults. Age-related mental, physical, and physiological changes may lead to differences in effects of cannabis in older adults compared to younger individuals.

OBJECTIVE

To perform a scoping review to map the evidence regarding the health effects of cannabis use for medical and non-medical purposes in older adults.

METHODS

Electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Library) were searched for systematic reviews (SRs), randomized controlled trials (RCTs) and non-randomized/observational studies (NRSs) assessing the health effects and associations of cannabis use (medical or non-medical) in adults ≥ 50 years of age. Included studies met age-related inclusion criteria or involved a priori identified health conditions common among older adults. Records were screened using a liberal accelerated approach and data charting was performed independently by two reviewers. Descriptive summaries, structured tables, effect direction plots and bubble plots were used to synthesize study findings.

FINDINGS

From 31,393 citations, 133 publications describing 134 unique studies (26 SRs, 36 RCTs, 72 NRSs) were included. Medical cannabis had inconsistent therapeutic effects in specific patient conditions (e.g., end-stage cancer, dementia), with a number of studies suggesting possible benefits while others found no benefit. For medical cannabis, harmful associations outnumbered beneficial, and RCTs reported more negative effects than NRSs. Cannabis use was associated with greater frequencies of depression, anxiety, cognitive impairment, substance use and problematic substance use, accidents/injuries, and acute healthcare use. Studies often were small, did not consistently assess harms, and did not adjust for confounding.

DISCUSSION

The effects of medical cannabis are inconsistent within specific patient conditions. For older adults, generally, the available evidence suggests cannabis use may be associated with greater frequencies of mental health issues, substance use, and acute healthcare use, and the benefit-to-risk ratio is unclear. Studies with a balanced assessment of benefits and harms may guide appropriate public health messaging to balance the marketing pressures of cannabis to older adults.

Expanding Research on Cannabis-Based Medicines for Liver Steatosis: A Low-Risk High-Reward Way Out of the Present Deadlock?

Obesity and nonalcoholic fatty liver disease (NAFLD) constitute global and growing epidemics that result in therapeutic dead ends. There is an urgent need for new and accessible treatments to improve and widen both preventive and curative approaches against NAFLD. The endocannabinoid system (ECS) is recognized as a complex signaling apparatus closely related to metabolic disorders and is a key target for treating NAFLD. Despite a lack of conclusive clinical trials, observational and pre-clinical studies highlight putative benefits of phytocannabinoids on liver steatosis through multiple pathways. Owing to both its safety profile and its diversity of active compounds acting primarily (although not exclusively) on the ECS-and its expanded version, the endocannabinoidome, the Cannabis plant should be considered a major prospect in the treatment of NAFLD. However, seizing this opportunity, and intensifying clinical research in this direction, will require overcoming both scientific and nonscientific barriers.

Marijuana use is inversely associated with liver steatosis detected by transient elastography in the general United States population in NHANES 2017-2018: A cross-sectional study

BACKGROUND

The impact of marijuana on the general population is largely unknown. The present study aimed to assess the association between marijuana use and liver steatosis and fibrosis in the general United States population utilizing data from the National Health and Nutrition Examination Survey (NHANES).

METHODS

This cross-sectional study was performed with data from the 2017-2018 cycle of NHANES. The target population comprised adults in the NHANES database with reliable vibration controlled transient elastography (VCTE) results. The median values of the controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) were used to evaluate liver steatosis and fibrosis, respectively. After adjusting for relevant confounders, a logistic regression analysis was used to assess the association between marijuana use and liver steatosis and fibrosis.

RESULTS

A total of 2622 participants were included in this study. The proportions of never marijuana users, past users, and current users were 45.9%, 35.0%, and 19.1%, respectively. Compared to never marijuana users, past and current users had a lower prevalence of liver steatosis (P = 0.184 and P = 0.048, respectively). In the alcohol intake-adjusted model, current marijuana use was an independent predictor of a low prevalence of liver steatosis in people with non-heavy alcohol intake. The association between marijuana use and liver fibrosis was not significant in univariate and multivariate regression.

CONCLUSION

In this nationally representative sample, current marijuana use is inversely associated with steatosis. The pathophysiology is unclear and needs further study. No significant association was established between marijuana use and liver fibrosis, irrespective of past or current use.

Cannabinoids and Chronic Liver Diseases

Nonalcoholic fatty liver disease (NAFLD), alcohol-induced liver disease (ALD), and viral hepatitis are the main causes of morbidity and mortality related to chronic liver diseases (CLDs) worldwide. New therapeutic approaches to prevent or reverse these liver disorders are thus emerging. Although their etiologies differ, these CLDs all have in common a significant dysregulation of liver metabolism that is closely linked to the perturbation of the hepatic endocannabinoid system (eCBS) and inflammatory pathways. Therefore, targeting the hepatic eCBS might have promising therapeutic potential to overcome CLDs. Experimental models of CLDs and observational studies in humans suggest that cannabis and its derivatives may exert hepatoprotective effects against CLDs through diverse pathways. However, these promising therapeutic benefits are not yet fully validated, as the few completed clinical trials on phytocannabinoids, which are thought to hold the most promising therapeutic potential (cannabidiol or tetrahydrocannabivarin), remained inconclusive. Therefore, expanding research on less studied phytocannabinoids and their derivatives, with a focus on their mode of action on liver metabolism, might provide promising advances in the development of new and original therapeutics for the management of CLDs, such as NAFLD, ALD, or even hepatitis C-induced liver disorders.

Cannabinoids and PPAR Ligands: The Future in Treatment of Polycystic Ovary Syndrome Women with Obesity and Reduced Fertility

Cannabinoids (CBs) are used to treat chronic pain, chemotherapy-induced nausea and vomiting, and multiple sclerosis spasticity. Recently, the medicinal use of CBs has attracted increasing interest as a new therapeutic in many diseases. Data indicate a correlation between CBs and PPARs via diverse mechanisms. Both the endocannabinoid system (ECS) and peroxisome proliferator-activated receptors (PPARs) may play a significant role in PCOS and PCOS related disorders, especially in disturbances of glucose-lipid metabolism as well as in obesity and fertility. Taking into consideration the ubiquity of PCOS in the human population, it seems indispensable to search for new potential therapeutic targets for this condition. The aim of this review is to examine the relationship between metabolic disturbances and obesity in PCOS pathology. We discuss current and future therapeutic interventions for PCOS and related disorders, with emphasis on the metabolic pathways related to PCOS pathophysiology. The link between the ECS and PPARs is a promising new target for PCOS, and we examine this relationship in depth.

Cannabis Extract Effects on Metabolic Parameters and Gut Microbiota Composition in a Mice Model of NAFLD and Obesity

Nonalcoholic fatty liver disease (NAFLD) is a major cause of chronic liver abnormalities and has been linked with metabolic syndrome hallmarks. Unfortunately, current treatments are limited. This work aimed to elucidate the effects of three cannabis extracts on metabolic alteration and gut microbiota composition in a mouse model of NAFLD and obesity. Male mice were fed with a high-fat diet (HFD) for 12 weeks. Following the establishment of obesity, the HFD-fed group was subdivided into HFD or HFD that was supplemented with one of three cannabis extracts (CN1, CN2, and CN6) for additional 8 weeks. Metabolic parameters together with intestinal microbiota composition were evaluated. Except for several minor changes in gene expression, no profound metabolic effect was found due to cannabis extracts addition. Nevertheless, marked changes were observed in gut microbiota diversity and composition, with CN1 and CN6 exhibiting microbial abundance patterns that are associated with more beneficial outcomes. Taken together, specific cannabis extracts' addition to an HFD results in more favorable modifications in gut microbiota. Although no marked metabolic effect was disclosed, longer treatments duration and/or higher extracts concentrations may be needed. More research is required to ascertain this conjecture and to establish the influence of various cannabis extracts on host health in general and NAFLD in particular.

THC and CBD affect metabolic syndrome parameters including microbiome in mice fed high fat-cholesterol diet

Background

Nonalcoholic fatty liver disease (NAFLD) is associated with metabolic syndrome, which often includes obesity, diabetes, and dyslipidemia. Several studies in mice and humans have implicated the involvement of the gut microbiome in NAFLD. While cannabis and its phytocannabinoids may potentially be beneficial for treating metabolic disorders such as NAFLD, their effects on liver diseases and gut microbiota profile have yet to be addressed. In this study, we evaluated the therapeutic effects of the two major cannabinoids, delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), on NAFLD progression.

Methods

NAFLD was induced by feeding mice a high fat-cholesterol diet (HFCD) for 6 weeks. During this period, the individual cannabinoids, THC or CBD, were added to the experimental diets at a concentration of 2.5 or 2.39 mg/kg. Profile of lipids, liver enzymes, glucose tolerance, and gene expression related to carbohydrate lipids metabolism and liver inflammation was analyzed. The effect of THC or CBD on microbiota composition in the gut was evaluated.

Results

While not alleviating hepatic steatosis, THC or CBD treatment influenced a number of parameters in the HFCD mouse model. CBD increased food intake, improved glucose tolerance, reduced some of the inflammatory response including TNFa and iNOS, and partially mitigated the microbiome dysbiosis observed in the HFCD fed mice. THC produced a much weaker response, only slightly reducing inflammatory-related gene expression and microbiome dysbiosis.

Conclusions

The results of this study indicate the potential therapeutic effects of individual phytocannabinoids are different from the effects of the cannabis plant possessing a mixture of compounds. While CBD may help ameliorate symptoms of NAFLD, THC alone may not be as effective. This disparity can putatively be explained based on changes in the gut microbiota.

Lower Rates of Hepatocellular Carcinoma Observed Among Cannabis Users: A Population-Based Study

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide and the fourth leading cause of cancer deaths in the world. The association between HCC and cannabis has been identified in mice; however, to our knowledge has not been identified in humans. Therefore, we aim to investigate the relation between HCC and cannabis use in humans.

METHODS

Using data from the National Inpatient Sample (NIS) database between 2002 and 2014, we identified the patients with HCC and cannabis use diagnosis using the International Classification of Disease 9th version codes (ICD-9). Then, we identified patients without cannabis use as the control group. We adjusted for multiple potential confounders and performed multivariable logistic regression analysis to determine the association between cannabis abuse and HCC.

RESULTS

A total of 101,231,036 patients were included in the study. Out of the total, 996,290 patients (1%) had the diagnosis of cannabis abuse versus 100,234,746 patients (99%) in the control group without cannabis abuse. We noticed that patients with cannabis abuse were younger (34 vs 48 years), had more males (61.7% vs 41.4%) and more African Americans (29.9% vs 14.2%) compared with the control group (P<0.001 for all). Besides, patients with cannabis use had more hepatitis B, hepatitis C, liver cirrhosis, and smoking, but had less obesity and gallstones, (P<0.001 for all). Using multivariable logistic regression, and after adjusting for potential confounders, patients with cannabis abuse were 55% less likely to have HCC (adjusted Odds Ratio {aOR}, 0.45, 95% Confidence Interval {CI}, 0.42-0.49, P<0.001) compared with patients without cannabis abuse.

CONCLUSION

Based on our large database analysis, we found that cannabis use patients were 55% less likely to have HCC compared to patients without cannabis use. Further prospective studies are needed to assess the role of cannabis use on HCC.

Serum lipid analysis and isotopic enrichment is suggestive of greater lipogenesis in young long-term cannabis users: A secondary analysis of a case-control study

Cannabis is now legal in many countries and while numerous studies have reported on its impact on cognition and appetite regulation, none have examined fatty acid metabolism in young cannabis users. We conducted an exploratory analysis to evaluate cannabis impact on fatty acid metabolism in cannabis users (n = 21) and non-cannabis users (n = 16). Serum levels of some saturated and monounsaturated fatty acids, including palmitic, palmitoleic, and oleic acids were higher in cannabis users compared to nonusers. As palmitic acid can be derived from diet or lipogenesis from sugars, we evaluated lipogenesis using a de novo lipogenesis index (palmitate/linoleic acid) and carbon-specific isotope analysis, which allows for the determination of fatty acid ¹³ C signature. The significantly higher de novo lipogenesis index in the cannabis users group along with a more enriched ¹³ C signature of palmitic acid suggested an increase in lipogenesis. In addition, while serum glucose concentration did not differ between groups, pyruvate and lactate were lower in the cannabis user group, with pyruvate negatively correlating with palmitic acid. Furthermore, the endocannabinoid 2-arachidonoylglycerol was elevated in cannabis users and could contribute to lipogenesis by activating the cannabinoid receptor 1. Because palmitic acid has been suggested to increase inflammation, we measured peripheral cytokines and observed no changes in inflammatory cytokines. Finally, an anti-inflammatory metabolite of palmitic acid, palmitoylethanolamide was elevated in cannabis users. Our results suggest that lipogenic activity is increased in cannabis users; however, future studies, including prospective studies that control dietary intake are required.

Cannabis use may reduce healthcare utilization and improve hospital outcomes in patients with cirrhosis

INTRODUCTION AND OBJECTIVES

Previous studies reveal conflicting data on the effect of cannabis use in patients with cirrhosis. This research evaluates the impact of cannabis on hepatic decompensation, health care utilization, and mortality in patients with cirrhosis.

MATERIAL AND METHODS

A retrospective analysis of the State Inpatient Database (SID) was performed evaluating patients from Colorado and Washington in 2011 to represent pre-cannabis legalization and 2015 to represent post-cannabis legalization. Multivariable analysis was performed to study the impact of cannabis on the rate of admissions with hepatic decompensations, healthcare utilization, and mortality in patients with cirrhosis.

RESULTS

Cannabis use was detected in 370 (2.1%) of 17,520 cirrhotics admitted in 2011 and in 1162 (5.3%) of 21,917 cirrhotics in 2015 (p-value <0.001). On multivariable analysis, cirrhotics utilizing cannabis after its legalization experienced a decreased rate of admissions related to hepatorenal syndrome (Odds Ratio (OR): 0.51; 95% Confidence Interval (CI): 0.34-0.78) and ascites (OR: 0.73; 95% CI: 0.63-0.84). Cirrhotics with an etiology of disease other than alcohol and hepatitis C had a higher risk of admission for hepatic encephalopathy if they utilized cannabis [OR: 1.57; 95% CI: 1.16-2.13]. Decreased length of stay (-1.15 days; 95% CI: -1.62, -0.68), total charges (-$15,852; 95% CI: -$21,009, -$10,694), and inpatient mortality (OR: 0.68; 95% CI: 0.51-0.91) were also observed in cirrhotics utilizing cannabis after legalization compared to cirrhotics not utilizing cannabis or utilizing cannabis prior to legalization.

CONCLUSION

Cannabis use in patients with cirrhosis resulted in mixed outcomes regarding hospital admissions with hepatic decompensation. A trend towards decreased hospital utilization and mortality was noted in cannabis users after legalization. These observations need to be confirmed with a longitudinal randomized study.

Lean NAFLD: an underrecognized and challenging disorder in medicine

Classically, Non-Alcoholic Fatty Liver Disease (NAFLD) has been thought to be driven by excessive weight gain and obesity. The overall greater awareness of this disorder has led to its recognition in patients with normal body mass index (BMI). Ongoing research has helped to better understand potential causes of Lean NAFLD, the risks for more advanced disease, and potential therapies. Here we review the recent literature on prevalence, risk factors, severity of disease, and potential therapeutic interventions.

Scoping Review and Meta-Analysis Suggests that Cannabis Use May Reduce Cancer Risk in the United States

Introduction: Cannabis smoke contains carcinogens similar to tobacco, in addition to compounds with antitumor activity. Cannabis use reduces the risk of obesity and cannabinoids inhibit chronic inflammation, known causes of cancer. The net effect of Cannabis use on cancer risk is not known. Objective: To examine the association between Cannabis use and cancer risk in the United States. Methods: Identify and analyze published data on cancer risk in Cannabis users. Results: A total of 55 data points, consisting of risk ratios of cancer in Cannabis users and nonusers, were identified from 34 studies. Of these, 5 did not contain data essential for inclusion in the meta-analysis. The remaining data showed a nonsignificant trend to an association with reduced risk (relative risk [RR]=0.90, p>0.06, N=50) although heterogeneity is high (I²=72.4%). Removal of data with high risk of selection bias (defined as those from North Africa and those that failed to adjust for tobacco) and data with high risk of performance bias (defined as those with fewer than 20 cases or controls among Cannabis users) resulted in an RR <1.0 (RR=0.86, p<0.017, N=24) and large effect size (Hedges g=0.66), but did not decrease heterogeneity (I²=74.9). Of all cancer sites, only testicular cancer showed an RR value >1, although this was not significant and had a negligible effect size (RR=1.12, p=0.3, Hedges g=0.02). Following removal of testicular cancers the remaining data showed a decrease in risk (RR=0.87, p<0.025, N=41). Cancers of the head and neck showed a negative association with cancer risk (RR=0.83, p<0.05), with a large effect size (Hedges g=0.55), but high heterogeneity (I²=79.2%). RR did not reach statistical significance in the remaining cancer site categories (lung, testicular, obesity-associated, other). The data are consistent with a negative association between Cannabis use and nontesticular cancer, but there is low confidence in this result due to high heterogeneity and a paucity of data for many cancer types.

Cannabis use and reduced risk of elevated fatty liver index in HIV-HCV co-infected patients: a longitudinal analysis (ANRS CO13 HEPAVIH)

Background: Cannabis use and elevated fatty liver index (FLI≥ 60) (a biomarker of hepatic steatosis in the general population) have been identified as predictors of HCV-related and overall mortality, respectively, in HIV-HCV co-infected patients. However, the relationship between cannabis use and the risk of elevated FLI has never been explored.Methods: Using five-year follow-up data from 997 HIV-HCV co-infected patients (ANRS CO13 HEPAVIH cohort), we analyzed the relationship between cannabis use and FLI using mixed-effects multivariable logistic (outcome: elevated FLI yes/no) and linear (outcome: continuous FLI) regression models.Results: At the last follow-up visit, 27.4% of patients reported regular or daily cannabis use and 27.8% had elevated FLI. After multivariable adjustment, regular or daily cannabis use was associated with a 55% lower risk of elevated FLI (adjusted odds ratio [95% confidence interval]: 0.45 [0.22; 0.94]; p = 0.033) and lower FLI values (adjusted model coefficient: -4.24 [-6.57; -1.91], p < 0.0001).Conclusions: Cannabis use is associated with a reduced risk of elevated fatty liver index in HIV-HCV co-infected patients. Further research is needed to confirm whether and how cannabinoids may inhibit the development of hepatic steatosis or other metabolic disorders in high-risk populations.

Phytocannabinoids-A Green Approach toward Non-Alcoholic Fatty Liver Disease Treatment

Non-alcoholic fatty liver disease (NAFLD) is the most frequent chronic liver disease in adults in developed countries, with a global prevalence as high as one billion. The pathogenesis of NAFLD is a multifactorial and multi-step process. Nowadays, a growing body of research suggests the considerable role of the endocannabinoid system (ECS) as a complex cell-signaling system in NAFLD development. Although increased endocannabinoid tone in the liver highly contributes to NAFLD development, the complex effects and impacts of plant-derived cannabinoids in the aspect of NAFLD pathophysiology are yet not fully understood, and effective medications are still in demand. In our review, we present the latest reports describing the role of ECS in NAFLD, focusing primarily on two types of cannabinoid receptors. Moreover, we sum up the recent literature on the clinical use of natural cannabinoids in NAFLD treatment. This review is useful for understanding the importance of ECS in NAFLD development, and it also provides the basis for more extensive clinical phytocannabinoids testing in patients suffering from NAFLD.

The Therapeutic Potential and Usage Patterns of Cannabinoids in People with Spinal Cord Injuries: A Systematic Review

BACKGROUND

People with spinal cord injuries (SCI) commonly experience pain and spasticity; limitations of current treatments have generated interest in cannabis as a possible therapy.

OBJECTIVES

We conducted this systematic review to: 1) examine usage patterns and reasons for cannabinoid use, and 2) determine the treatment efficacy and safety of cannabinoid use in people with SCI.

METHODS

PubMed, Embase, Web of Science and Cumulative Index to Nursing and Allied Health Literature databases were queried for keywords related to SCI and cannabinoids.

RESULTS

7,232 studies were screened, and 34 were included in this systematic review. Though 26 studies addressed cannabinoid usage, only 8 investigated its therapeutic potential on outcomes such as pain and spasticity. The most common method of use was smoking. Relief of pain, spasticity and recreation were the most common reasons for use. A statistically significant reduction of pain and spasticity was observed with cannabinoid use in 83% and 100% of experimental studies, respectively. However, on examination of randomized control trials (RCTs) alone, effect sizes ranged from - 0.82 to 0.83 for pain and -0.95 to 0.09 for spasticity. Cannabinoid use was associated with fatigue and cognitive deficits.

CONCLUSION

Current evidence suggests that cannabinoids may reduce pain and spasticity in people with SCI, but its effect magnitude and clinical significance are unclear. Existing information is lacking on optimal dosage, method of use, composition and concentration of compounds. Long-term, double-blind, RCTs, assessing a wider range of outcomes should be conducted to further understand the effects of cannabinoid use in people with SCI.

Use of Dietary Supplements in Pediatric Liver Disease and Transplantation

BACKGROUND

Dietary supplements are frequently used by healthy individuals and those with chronic medical conditions but may cause damage to the liver. The aim of this study was to examine the prevalence and attitudes of dietary supplement use, and the frequency of disclosure to healthcare providers among parents/caregivers for children with chronic liver disease.

METHODS

We developed an anonymous survey for parents/caregivers of children (<18 years old) with chronic liver disease or liver transplant recipients and distributed the survey through social media groups organized around pediatric liver diseases.

RESULTS

The survey was completed by 101 parents/caregivers (48 without transplant and 53 posttransplant).Among respondents, 87% agreed they would use dietary supplements to help their child, but parents/caregivers of transplant recipients were less likely to consider use (77% vs 98%; P = 0.01). In the past 12 months, 83% reported dietary supplement use including 47% who used nonvitamin/mineral supplements. In two-thirds of parents/caregivers, use was initiated by their personal belief. Although 77% of respondents disclosed their use to their liver team, disclosure varied depending on the supplement with no individual that used cannabinoid products disclosing the use.

CONCLUSIONS

Dietary supplements are frequently used by children with liver disease and may exceed use in other pediatric conditions. Though most parents report use to their liver team, disclosure may vary depending on the specific supplement. Providers should take extra measures to review use of supplements with their patients and work to develop trust with their families to obtain accurate disclosure of use.

Predictors of venous thromboembolism in hospitalized patients with inflammatory bowel disease and colon cancer: A retrospective cohort study

INTRODUCTION

Venous thromboembolism (VTE) in patients with inflammatory bowel disease (IBD) and colon cancer (CC) increases morbidity and mortality. Risk of thrombosis in IBD and CC is well established. Still, it remains unclear how interaction of thrombotic properties in patients with both diseases predict development of VTE.

MATERIALS AND METHODS

The Nationwide Inpatient Sample was sourced (2005-2014) for data on patients admitted with IBD-CC who developed VTE. The main outcome was predictors of VTE. Secondary outcomes were length of stay and total charge of admission.

RESULTS

7625 adults were admitted from 2005 to 2014 with a co-diagnosis of IBD and CC. 197 (2.6%) were coded to have VTE as a top three diagnosis. Multivariate logistic regression showed that black patients (11.9% vs 6.0%; aOR 2.04, 95% CI = 1.26-3.31, P < 0.004) and patients with metastatic disease (27.9% vs 16.7%; aOR 1.77, 95% CI = 1.27-2.47, P = 0.001) had higher odds of having VTE. Patients with uncomplicated diabetes (8.1% vs 15.5%; aOR 0.48, 95% CI = 0.28-0.84, P = 0.010) had lower odds. Obesity and anemia were significantly associated with VTE in univariate logistic regression, but lost significance after multivariate regression. Additionally, VTE was associated with increased length of stay (8.41 vs 6.87 days, P = 0.006) and admission cost ($64,388 vs $50,874, P = 0.010).

CONCLUSIONS

Patients with IBD and CC likely have unique procoagulant properties that differ from patients with IBD or CC alone. Knowledge of these predictors can assist efforts to risk stratify IBC-CC patients, and can aid development of an individualized approach to DVT prophylaxis in this population.

Liver elastometry and alcohol withdrawal: Median-term follow-up in a psychiatric unit

The measurement of liver stiffness (LS) shows promise as a follow-up tool after alcohol withdrawal, but it has mainly been studied in the early phase or in patients with severe liver disease. A 6-month ancillary study of a specific psychiatric cohort of alcoholic patients without known liver disease followed after withdrawal was conducted (Clinical Trial NCT01491347). Clinical and biological data and LS values were collected every 2 months. A total of 129 patients were included in the study; 93 had an LS assessment within the first 7 days, and 37 had all four LS measurements. Only seven (7.5%) patients had an initial LS > 12.1 kPa, the threshold used to define severe fibrosis. Abstinence was not associated with changes in LS at the various median-term follow-up periods. However, LS of abstinent subjects decreased significantly relative to that of non-abstinent subjects between M0 and M2. CAP™ values were not associated with abstinence. The systematic median-term follow-up of withdrawn patients does not appear to be contributory. However, LS could help to detect relapse in the first 2 months after withdrawal for subjects treated in a psychiatric hospital for dependence. It thus could serve as a motivation tool. Prospective studies with various and higher baseline LS values are warranted for simultaneous longitudinal assessment, including for very short- and long-term LS after withdrawal.

Cannabis use history is associated with increased prevalence of ascites among patients with nonalcoholic fatty liver disease: A nationwide analysis

BACKGROUND

Recent studies have revealed the endocannabinoid system as a potential therapeutic target in the management of nonalcoholic fatty liver disease (NAFLD). Cannabis use is associated with reduced risk for NAFLD, we hypothesized that cannabis use would be associated with less liver-related clinical complications in patients with NAFLD.

AIM

To assess the effects of cannabis use on liver-related clinical outcomes in hospitalized patients with NAFLD.

METHODS

We performed a retrospective matched cohort study based on querying the 2014 National Inpatient Sample (NIS) for hospitalizations of adults with a diagnosis of NAFLD. The NIS database is publicly available and the largest all-payer inpatient database in the United States. The patients with cannabis use were selected as cases and those without cannabis were selected as controls. Case-control matching at a ratio of one case to two controls was performed based on sex, age, race, and comorbidities. The liver-related outcomes such as portal hypertension, ascites, varices and variceal bleeding, and cirrhosis were compared between the groups.

RESULTS

A total of 49911 weighed hospitalizations with a diagnosis of NAFLD were identified. Of these, 3820 cases were selected as the cannabis group, and 7625 non-cannabis cases were matched as controls. Patients with cannabis use had a higher prevalence of ascites (4.5% vs 3.6%), with and without cannabis use, P = 0.03. The prevalence of portal hypertension (2.1% vs 2.2%), varices and variceal bleeding (1.3% vs 1.7%), and cirrhosis (3.7% vs 3.6%) was not different between the groups, with and without cannabis use, all P > 0.05. Hyperlipidemia, race/ethnicity other than White, Black, Asian, Pacific Islander or Native American, and higher comorbidity score were independent risk factors for ascites in the cannabis group. Among non-cannabis users, obesity and hyperlipidemia were independent protective factors against ascites while older age, Native American and higher comorbidity index were independent risk factors for ascites.

CONCLUSION

Cannabis was associated with higher rates of ascites, but there was no statistical difference in the prevalence of portal hypertension, varices and variceal bleeding, and cirrhosis.

Cannabis use is associated with monocyte activation (sCD163) in patients admitted for alcohol use disorder treatment

BACKGROUND

The effect of concomitant cocaine and cannabis use on monocyte activation and inflammation in patients with alcohol use disorder (AUD) is unknown.

METHODS

To analyze the impact of cocaine and cannabis use on levels of markers of monocyte activation (sCD163 and sCD14) and systemic inflammation (interleukin-6 [IL-6]) in AUD patients admitted for hospital treatment between 2013 and 2018. Clinical and laboratory parameters were obtained upon admission. IL-6, sCD163, and sCD14 were measured in frozen plasma samples. We performed logistic regression to detect associations between cocaine and cannabis use and markers of monocyte activation and inflammation in the highest quartile.

RESULTS

A total of 289 patients (77.5 % male) were included (median age = 50 years). The median alcohol intake upon admission was 142 g/day. The median duration of AUD was 20 years. Of the 289 patients with AUD, 76 % were active smokers, 23.1 % and 22.1 % concomitantly used cocaine and cannabis, respectively The median levels of IL-6, sCD163, and sCD14 were 4.37 pg/mL, 759 ng/mL, and 1.68 × 10⁶ pg/mL, respectively. We did not detect associations between cocaine use and inflammation or monocyte activation. Cannabis use was associated with a higher odds of having sCD163 levels in the highest quartile (adjusted odds ratio = 2.34, 95 % confidence interval = 1.07-5.15, p = 0.03). Cannabis use was not associated with inflammation.

CONCLUSION

In this series of AUD patients the concomitant use of cannabis use was associated with sCD163 levels that were in the highest quartile, consistent with monocyte activation.

Associations of marijuana with markers of chronic lung disease in people living with HIV

OBJECTIVES

The relationship between marijuana use and markers of chronic lung disease in people living with HIV (PLWH) is poorly understood.

METHODS

We performed a cross-sectional analysis of the Examinations of HIV-Associated Lung Emphysema (EXHALE) study, including 162 HIV-positive patients and 138 participants without HIV. We modelled marijuana exposure as: (i) current daily or weekly marijuana smoking vs. monthly or less often; or (ii) cumulative marijuana smoking (joint-years). Linear and logistic regression estimated associations between marijuana exposure and markers of lung disease, adjusted for tobacco smoking and other factors.

RESULTS

In PLWH, current daily or weekly marijuana use was associated with a larger forced vital capacity (FVC), larger total lung capacity and increased odds of radiographic emphysema compared with marijuana non-smokers in adjusted models; these associations were not statistically significant in participants without HIV. Marijuana joint-years were associated with higher forced expiratory volume in 1 s and FVC in PLWH but not with emphysema.

CONCLUSIONS

In PLWH, marijuana smoking was associated with higher lung volumes and potentially with radiographic emphysema. No consistently negative associations were observed between marijuana and measures of chronic lung health.

Does Cannabis Intake Protect Against Non-alcoholic Fatty Liver Disease? A Two-Sample Mendelian Randomization Study

Background and Aim

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease. Previous observational studies suggested that cannabis use may be associated with a lower risk for NAFLD but the causal relationship remains unclear. We aim in this study to examine the causal effect of cannabis consumption on the risk of NAFLD using a Mendelian randomization analysis. Clarifying this causal effect is important for cannabis-based drug discovery for NAFLD.

Methods

We used data from the largest-to-date GWAS meta-analysis on lifetime use of cannabis (yes or no) consisting of three cohorts [International Cannabis Consortium (ICC), 23andMe, and the UK Biobank] of European ancestry (total N = 184,765). We also used other GWAS data on cannabis use dependence and cannabis use disorder (CUD). The NAFLD GWAS data were generated from the UK Biobank population (1,122 cases and 399,900 controls). The inverse variance weighted (IVW) method was used to assess the causal impact of cannabis lifetime use on the risk of NAFLD. We also performed a sensitivity analysis using weighted median estimator and MR-Egger.

Results

There was no statistically significant causal effect between either the lifetime cannabis use, cannabis use dependence or CUD and the risk for NAFLD (p > 0.05 for all tests). No significant pleotropic effect was observed based on both MR-PRESSO global test (p = 0.99) and the modified Q’ statistics. However, the study may be underpowered.

Conclusion

Our results demonstrated no evidence that cannabis consumption has a causal effect of protection against the development of NAFLD.

Cannabis Extracts Affected Metabolic Syndrome Parameters in Mice Fed High-Fat/Cholesterol Diet

Introduction: Nonalcoholic fatty liver disease (NAFLD) is associated with metabolic syndrome, which often includes obesity, diabetes, and dyslipidemia. Several studies in mice and humans have implicated the involvement of the gut microbiome in NAFLD. While cannabis may potentially be beneficial for treating metabolic disorders such as NAFLD, the effects of cannabis on liver diseases and gut microbiota profile are yet to be addressed. In this study, we evaluated the therapeutic effects of cannabis strains with different cannabinoid profiles on NAFLD progression. Materials and Methods: NAFLD was induced by feeding mice a high-fat/cholesterol diet (HFCD) for 6 weeks. During this period, cannabis extracts were administrated orally at a concentration of 5 mg/kg every 3 days. Profile of lipids, liver enzymes, glucose tolerance, and gene expression related to carbohydrate lipid metabolism and liver inflammation were analyzed. The effect of cannabis strains on microbiota composition in the gut was evaluated. Results: A cannabidiol (CBD)-rich extract produced an increase in inflammatory related gene expression and a less diverse microbiota profile, associated with increased fasting glucose levels in HFCD-fed mice. In contrast, mice receiving a tetrahydrocannabinol (THC)-rich extract exhibited moderate weight gain, improved glucose response curves, and a decrease in liver enzymes. Conclusions: The results of this study indicate that the administration of cannabis containing elevated levels of THC may help ameliorate symptoms of NAFLD, whereas administration of CBD-rich cannabis extracts may cause a proinflammatory effect in the liver, linked with an unfavorable change in the microbiota profile. Our preliminary data suggest that these effects are mediated by mechanisms other than increased expression of the endocannabinoid receptors cannabinoid receptor 1 (CB1) and CB2.

Different Hospital Readmissions and Outcomes of Acute Pancreatitis

OBJECTIVES

Although acute pancreatitis (AP) is associated with recurrent hospitalizations, the impact of different hospital readmissions (DHR) versus same hospital readmissions (SHR) on outcomes is unknown. We study the burden of DHR among readmissions after survival from AP hospitalizations.

METHODS

Among adult AP patients (Nationwide Readmissions Database), we calculated the prevalence, trends, and predictors of DHR, and its impact on mortality, hospital stay, and charges during 30- and 90-day readmissions.

RESULTS

From 2010 to 2014, 15% and 26% of AP hospitalizations (422,950) were readmitted in 30 and 90 days, respectively. The DHR rates were similar (26.3%, 30 days; 26.4%, 90 days) and unchanged from 2010 to 2014 (Ptrends > 0.10). The predictors of DHR were similar during both readmissions and included younger age category (18-45 years), hospital characteristics (nonteaching, small bed size, nonmicropolitan/metropolitan areas), substance abuse, comorbidities, and nonreception of cholecystectomy and pancreatectomy during index hospitalizations.During readmissions (30 and 90 days), DHR was associated with adjusted odds ratio (95% confidence interval), higher mortality (1.40 [1.19-1.64] and 1.50 [1.32-1.71]), longer hospital stay (1.3 days [1.1-1.7 days] and 1.1 days [0.9-1.3 days]), and higher charges (US $16,779 [US $13,898-US $20,254] and US $14,299 [US $12,299-US $16,623]).

CONCLUSIONS

Targeted measures are needed toward patients at risk for DHR to curb the poor outcomes.

Role of Cannabis and Its Derivatives in Gastrointestinal and Hepatic Disease

Medical and recreational cannabis use has increased dramatically over the last decade, resulting from mainstream cultural acceptance and legalization in several countries worldwide. Cannabis and its derivatives affect many gastrointestinal processes via the endocannabinoid system (ECS). The ECS influences gastrointestinal homeostasis through anti-inflammatory, anti-nociceptive, and anti-secretory effects. Some gastrointestinal disorders might therefore be treated with cannabinoids. Despite numerous studies in cell lines and animals, few human studies have evaluated the therapeutic effects of cannabinoids. Cannabis' schedule 1 drug status has limited its availability in research; cannabis has been legalized only recently, in some states, for medicinal and/or recreational use. Cannabinoids can alleviate chemotherapy-induced nausea and emesis and chronic pain. Studies have demonstrated the important roles of the ECS in metabolism, obesity, and nonalcoholic fatty liver disease and the anti-inflammatory effects of cannabis have been investigated in patients with inflammatory bowel diseases. Despite its potential benefits, undesired or even detrimental effects of cannabis can limit its use. Side effects such as cannabinoid hyperemesis syndrome affect some users. We review the ECS and the effects of cannabis and its derivatives on gastrointestinal and hepatic function in health and disease.

Differential hepatoprotective role of the cannabinoid CB1 and CB2 receptors in paracetamol-induced liver injury

BACKGROUND AND PURPOSE

Protective mechanisms of the endogenous cannabinoid system against drug-induced liver injury (DILI) are actively being investigated regarding the differential regulatory role of the cannabinoid CB₁ and CB₂ receptors in liver fibrogenesis and inflammation.

EXPERIMENTAL APPROACH

The 2-arachidonoylglycerol (2-AG)-related signalling receptors and enzymatic machinery, and inflammatory/fibrogenic factors were investigated in the liver of a mouse model of hepatotoxicity induced by acute and repeated overdoses (750 mg·kg^-1 ·day^-1 ) of paracetamol (acetaminophen), previously treated with selective CB₁ (ACEA) and CB₂ (JWH015) agonists (10 mg·kg^-1 ), or lacking CB₁ and CB₂ receptors.

KEY RESULTS

Acute paracetamol increased the expression of CB₂ , ABHD6 and COX-2, while repeated paracetamol increased that of CB₁ and COX-2 and decreased that of DAGLβ. Both acute paracetamol and repeated paracetamol decreased the liver content of acylglycerols (2-AG, 2-LG and 2-OG). Human liver samples from a patient suffering APAP hepatotoxicity confirmed CB₁ and CB₂ increments. Acute paracetamol-exposed CB₂ KO mice had higher expression of the fibrogenic αSMA and the cytokine IL-6 and lower apoptotic cleaved caspase 3. CB₁ deficiency enhanced the repeated APAP-induced increases in αSMA and cleaved caspase 3 and blocked those of CYP2E1, TNF-α, the chemokine CCL2 and the circulating γ-glutamyltransferase (γGT). Although JWH015 reduced the expression of αSMA and TNF-α in acute paracetamol, ACEA increased the expression of cleaved caspase 3 and CCL2 in repeated paracetamol.

CONCLUSION AND IMPLICATIONS

The differential role of CB₁ versus CB₂ receptors on inflammatory/fibrogenic factors related to paracetamol-induced hepatotoxicity should be considered for designing alternative therapies against DILI.

The relationship of cannabis decriminalization in Colorado and cannabis use in individuals with alcohol use disorders

OBJECTIVE

Over the past decade, cannabis use has become increasingly popular in states that include Colorado. During this time, alcohol use disorders (AUDs) and alcohol-related medical conditions have also been consistently recognized as public health problems with increasing prevalence in the state. Despite the widespread use of cannabis in Colorado, the epidemiology of cannabis use among those with AUDs has been poorly described. Therefore, we sought to examine cannabis use among individuals with likely AUDs and individuals with low-risk alcohol use during a time of major Colorado legislative changes before and after legalization of recreational cannabis in 2012.

METHODS

This study was a secondary data analysis conducted with information from 303 participants (80% male) in the Denver, CO metropolitan enrolled between August 2007 and April 2016 for studies related to alcohol and lung health. Of these participants, 188 (62%) were completing inpatient alcohol detoxification with likely AUDs. All participants completed the Alcohol Use Disorder Identification Test (AUDIT) to establish their likelihood of an AUD, and all had information on current cannabis use assessed by questionnaire and urine toxicology testing.

RESULTS

Individuals with likely AUDs more commonly used cannabis compared to control participants (42% vs 27%, p = 0.007). In multiple logistic regression analyses, participant type (likely AUD versus control), tobacco smoking, and age were significantly associated with cannabis smoking; however, the year of participant enrollment was not. Adjusted odds for cannabis use among participants with likely AUDs were 2.97 (1.51-5.82), p = 0.002, while odds for cannabis use among tobacco smokers were 3.67 (1.94-6.93), p < 0.0001. Among control participants, tobacco smoking increased odds of cannabis use seven-fold.

CONCLUSIONS

Our findings highlight the exceptionally high odds of cannabis use among individuals with likely AUDs undergoing alcohol detoxification at a Colorado treatment facility before and after legalization of recreational cannabis. Targeted investigations into the medical and psychiatric consequences of combined alcohol and cannabis use are urgently needed to define its health impact in these vulnerable individuals.

Cannabis consumption and non-alcoholic fatty liver disease. A three years longitudinal study in first episode non-affective psychosis patients

INTRODUCTION

Increased incidence of obesity and excess weight lead to an increased incidence of non-alcoholic fatty liver disease (NAFLD). Recent evidence indicates a protective effect of cannabis consumption on weight gain and related metabolic alterations in psychosis patients. Overall, patients are at greater risk of presenting fatty diseases, such as NAFLD, partly due to lipid and glycemic metabolic disturbances. However, there are no previous studies on the likely effect of cannabis on liver steatosis. We aimed to explore if cannabis consumption had an effect on hepatic steatosis, in a sample of first-episode (FEP) non-affective psychosis.

MATERIAL AND METHODS

A total of 390 patients were evaluated at baseline and after 3 years of initiating the antipsychotic treatment. Anthropometric measurements and liver, lipid, and glycemic parameters were obtained at both time points. All but 6.7% of patients were drug-naïve at entry, and they self-reported their cannabis use at both time points. Liver steatosis and fibrosis were evaluated through validated clinical scores (Fatty Liver Index [FLI], Fibrosis-4 [FIB-4], and NAFLD).

RESULTS

At 3-year follow-up, cannabis users presented significantly lower FLI scores than non-users (F = 13.874; p < .001). Moreover, cannabis users less frequently met the criteria for liver steatosis than non-users (X² = 7.97, p = .019). Longitudinally, patients maintaining cannabis consumption after 3 years presented the smallest increment in FLI over time, which was significantly smaller than the increment in FLI presented by discontinuers (p = .022) and never-users (p = .016). No differences were seen in fibrosis scores associated with cannabis.

CONCLUSIONS

Cannabis consumption may produce a protective effect against liver steatosis in psychosis, probably through the modulation of antipsychotic-induced weight gain.

Association Between Cannabis Use and Complications Related to Crohn's Disease: A Retrospective Cohort Study

BACKGROUND

Crohn's disease is an idiopathic inflammatory process that is occasionally associated with complications, which cause significant morbidity and mortality. The anti-inflammatory effect of cannabis in intestinal inflammation has been shown in several experimental models; it is unknown whether this correlates with fewer complications in Crohn's disease patients.

AIMS

To compare the prevalence of Crohn's disease-related complications among cannabis users and non-users in patients admitted with a primary diagnosis of Crohn's disease or a primary diagnosis of Crohn's related complication and a secondary diagnosis of Crohn's disease between 2012 and 2014.

METHODS

We used data from the Healthcare Cost and Utilization Project-National Inpatient Sample. Cannabis users (615) were compared directly after propensity score match to non-users, in aspects of various complications and clinical end-points.

RESULTS

Among matched cohorts, Cannabis users were less likely to have the following: active fistulizing disease and intra-abdominal abscess (11.5% vs. 15.9%; aOR 0.68 [0.49 to 0.94], p = 0.025), blood product transfusion (5.0% vs. 8.0%; aOR 0.48 [0.30 to 0.79], p = 0.037), colectomy (3.7% vs. 7.5%; aOR 0.48 [0.29-0.80], p = 0.004), and parenteral nutrition requirement (3.4% vs. 6.7%, aOR 0.39 [0.23 to 0.68], p = 0.009).

CONCLUSION

Cannabis use may mitigate several of the well-described complications of Crohn's disease among hospital inpatients. These effects could possibly be through the effect of cannabis in the endocannabinoid system.

Risk and Outcomes of Clostridium difficile Infection With Chronic Pancreatitis

OBJECTIVES

Chronic pancreatitis (CP) is associated with high rates of recurrent hospitalizations, which predisposes to Clostridium difficile infection (CDI). We investigate the burden of CDI in CP.

METHODS

We identified records of patients with CP from the Nationwide Inpatient Sample (NIS) 2012-2014 and estimated the impact of CDI on their outcomes. We calculated the adjusted odds ratio (AOR) of CP on having CDI (NIS 2014). From NIS 2007-2014, we plotted the trends of CDI and its interaction with CP.

RESULTS

From 2012 to 2014, 886 (2.72%) of the 32,614 CP patients had concomitant CDI, which was associated with poorer outcomes: acute kidney injury (AOR, 2.57 [95% confidence interval {CI}, 2.11-3.13]), length of stay (13.3 vs 7.4 days), and charges (US $127,496 vs US $72,767), but not mortality (AOR, 0.93 [95% CI, 0.28-3.05]). In 2014, CP was associated with an increased risk of CDI (crude odds ratio, 2.10 [95% CI, 1.95-2.26]), which persisted after multivariate adjustment (AOR, 2.03 [95% CI, 1.87-2.19]). From 2007 to 2014, the annual prevalence of CDI was 106.4 cases per 10,000 hospitalizations, increasing from 2007 (95.5/10,000) to 2014 (118.4/10,000), with a 3.7 times higher annual rate of increase among CP versus no-CP patients (13.4/10,000 vs 3.7/10,000 population/year).

CONCLUSIONS

Chronic pancreatitis patients have high burden of CDI and may benefit from CDI prophylaxis.

Lifestyle and Metabolic Syndrome: Contribution of the Endocannabinoidome

Lifestyle is a well-known environmental factor that plays a major role in facilitating the development of metabolic syndrome or eventually exacerbating its consequences. Various lifestyle factors, especially changes in dietary habits, extreme temperatures, unusual light-dark cycles, substance abuse, and other stressful factors, are also established modifiers of the endocannabinoid system and its extended version, the endocannabinoidome. The endocannabinoidome is a complex lipid signaling system composed of a plethora (>100) of fatty acid-derived mediators and their receptors and anabolic and catabolic enzymes (>50 proteins) which are deeply involved in the control of energy metabolism and its pathological deviations. A strong link between the endocannabinoidome and another major player in metabolism and dysmetabolism, the gut microbiome, is also emerging. Here, we review several examples of how lifestyle modifications (westernized diets, lack or presence of certain nutritional factors, physical exercise, and the use of cannabis) can modulate the propensity to develop metabolic syndrome by modifying the crosstalk between the endocannabinoidome and the gut microbiome and, hence, how lifestyle interventions can provide new therapies against cardiometabolic risk by ensuring correct functioning of both these systems.

Prevalence, trends, outcomes, and disparities in hospitalizations for nonalcoholic fatty liver disease in the United States

Background

As the frequency of nonalcoholic fatty liver disease (NAFLD) continues to rise in the United States (US) community, more patients are hospitalized with NAFLD. However, data on the prevalence and outcomes of hospitalizations with NAFLD are lacking. We investigated the prevalence, trends and outcomes of NAFLD hospitalizations in the US.

Methods

Hospitalizations with NAFLD were identified in the National Inpatient Sample (2007-2014) by their ICD-9-CM codes, and the prevalence and trends over an 8-year period were calculated among different demographic groups. After excluding other causes of liver disease among the NAFLD cohorts (n=210,660), the impact of sex, race and region on outcomes (mortality, discharge disposition, length of stay [LOS], and cost) were computed using generalized estimating equations (SAS 9.4).

Results

Admissions with NAFLD tripled from 2007-2014 at an average rate of 79/100,000 hospitalizations/year (P<0.0001), with a larger rate of increase among males vs. females (83/100,000 vs. 75/100,000), Hispanics vs. Whites vs. Blacks (107/100,000 vs. 80/100,000 vs. 48/100,000), and government-insured or uninsured patients vs. privately-insured (94/100,000 vs. 74/100,000). Males had higher mortality, LOS, and cost than females. Blacks had longer LOS and poorer discharge destination than Whites; while Hispanics and Asians incurred higher cost than Whites. Uninsured patients had higher mortality, longer LOS, and poorer discharge disposition than the privately-insured.

Conclusions

Hospitalizations with NAFLD are rapidly increasing in the US, with a disproportionately higher burden among certain demographic groups. Measures are required to arrest this ominous trend and to eliminate the disparities in outcome among patients hospitalized with NAFLD.

Association between long-term NSAID use and opioid abuse among patients with breast cancer

BACKGROUND

Improving survival rates among patients with breast cancer has been associated with an increase in the prevalence of co-morbidities like cancer-related pain. Opioids are an important component in the management of pain among these patients. However, the progression from judicious use to abuse defeats the aim of pain control. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as the first step in cancer-related pain management. Due to their anti-inflammatory, anti-neoplastic and neuroprotective properties, NSAIDs have been shown to reduce the risk of progression of certain cancers including breast cancers. In this study, we assessed whether an association exists between long-term NSAID use and opioid abuse among breast cancer survivors. We also explored the relationship between long-term NSAID use and inpatient mortality and length of stay (LOS).

METHODS

Using ICD-9-CM codes, we identified and selected women aged 18 years and older with breast cancer from the National Inpatient Sample. Our primary predictor was a history of long-term NSAID use. Multivariable regression models were employed in assessing the association between long-term NSAID use and opioid abuse, inpatient mortality and LOS.

RESULTS

Among 170,644 women with breast cancer, 7,838 (4.6%) reported a history of long-term NSAID use. Patients with a history of long-term NSAID use had lower odds of opioid abuse (adjusted odds ratio (aOR) 0.53; 95% CI [0.32-0.88]), lower in-hospital mortality (aOR 0.52; 95% CI [0.45-0.60]) and shorter LOS (7.12 vs. 8.11 days).

DISCUSSION

Further studies are needed to understand the underlying mechanism of the association between long-term NSAID use and opioid abuse.

Predictors, burden and impact of cardiac arrhythmias among patients hospitalized with end-stage liver disease

BACKGROUND

Cirrhotic cardiomyopathy, hyperammonemia, and hepatorenal syndrome predispose to cardiac arrhythmias in End-stage liver disease (ESLD).

OBJECTIVES

Among ESLD hospitalizations, we evaluate the distribution and predictors of arrhythmias and their impact on hospitalization outcomes.

METHODS

We selected ESLD records from the Nationwide Inpatient Sample (2007-2014), identified concomitant arrhythmias (tachyarrhythmias and bradyarrhythmias), and their demographic and comorbid characteristics, and estimated the effect of arrhythmia on outcomes (SAS 9.4).

RESULTS

Of 57,119 ESLD hospitalizations, 6,615 had arrhythmias with higher odds with increasing age, males, jaundice, hepatorenal syndrome, alcohol use, and cardiopulmonary disorders. The most common arrhythmias were atrial fibrillation, cardiac arrest/asystole, and ventricular tachycardia. After propensity-matching (arrhythmia: no-arrhythmia, 6,609:6,609), arrhythmias were associated with 200% higher mortality, 1.7-days longer stay, $32,880 higher cost, and higher rates of shock, respiratory and kidney failures.

CONCLUSIONS

Due to worse outcomes with arrhythmias, there is a need for better screening and follow-up of ESLD patients for dysrhythmias.

Higher odds of irritable bowel syndrome among hospitalized patients using cannabis: a propensity-matched analysis

BACKGROUND

The endogenous cannabinoid system modulates many brain-gut and gut-brain physiologic pathways, which are postulated to be dysfunctional in irritable bowel syndrome (IBS). Herein, we examine the relationship between cannabis use disorder (CUD) and having IBS.

PATIENTS AND METHODS

After selecting patients aged 18 years and above from the 2014 Nationwide Inpatient Survey, we used the International Classification of Diseases, 9th ed. codes to identify individuals with CUD, IBS, and the established risk factors for IBS. We then estimated the crude and adjusted odds ratios of having a diagnosis of IBS with CUD and assessed for the interactions of CUD with other risk factors (SAS 9.4). We confirmed our findings in two ways: conducting a similar analysis on a previous Nationwide Inpatient Survey data (2012); and using a greedy algorithm to design a propensity-scored case-control (1 : 10) study, approximating a pseudorandomized clinical trial.

RESULTS

Out of 4 709 043 patients evaluated, 0.03% had a primary admission for IBS and 1.32% had CUD. CUD was associated with increased odds of IBS [adjusted odds ratio: 2.03; 95% confidence interval (CI): 1.53-2.71]. CUD was related to higher odds for IBS among males compared with females (3.48; 1.98-6.12 vs. 1.48; 0.88-2.50), and Hispanics and Caucasians compared with Blacks (5.28; 1.77-15.76, 1.80; 1.02-3.18 vs. 1.80; 0.65-5.03). On propensity-matching, CUD was associated with 80% increased odds for IBS (1.82; 1.27-2.60).

CONCLUSION

Our findings suggest that CUD is significantly associated with IBS among the general population. Males, Caucasians, and Hispanics might be more impacted by CUD associated IBS. Additional biomedical studies are required to elucidate this relationship.

Protein-Energy Malnutrition and Outcomes of Hospitalizations for Heart Failure in the USA

Chronically elevated cytokines from un-abating low-grade inflammation in heart failure (HF) results in Protein-Energy Malnutrition (PEM). However, the impact of PEM on clinical outcomes of admissions for HF exacerbations has not been evaluated in a national data. From the 2012 to 2014 Nationwide Inpatient Sample (NIS) patient's discharge records for primary HF admissions, we identified patients with concomitant PEM, and their demographic and comorbid factors. We propensity-matched PEM cohorts (32,771) to no-PEM controls (1:1) using a greedy algorithm-based methodology and estimated the effect of different clinical outcomes (SAS 9.4). There were 32,771 (∼163,885) cases of PEM among the 541,679 (∼2,708,395) primary admissions for HF between 2012 and 2014 in the US. PEM cases were older (PEM:76 vs no-PEM:72 years), Whites (70.75% vs 67.30%), and had higher comorbid burden, with Deyo-comorbidity index >3 (31.61% vs 26.30%). However, PEM cases had lower rates of obesity, hyperlipidemia and diabetes. After propensity-matching, PEM was associated with higher mortality (AOR:2.48 [2.31 to 2.66]), cardiogenic shock (3.11[2.79 to 3.46]), cardiac arrest (2.30[1.96 to 2.70]), acute kidney failure (1.49[1.44 to 1.54]), acute respiratory failure (1.57[1.51 to 1.64]), mechanical ventilation (2.72[2.50 to 2.97]). PEM also resulted in higher non-routine discharges (2.24[2.17 to 2.31]), hospital cost ($80,534[78,496 to 82,625] vs $43,226[42,376 to 44,093]) and longer duration of admission (8.6[8.5 to 8.7] vs 5.3[5.2 to 5.3] days). In conclusion, PEM is a prevailing comorbidity among hospitalized HF subjects, and results in devastating health outcomes. Early identification and prevention of PEM in HF subjects during clinic visits and prompt treatment of PEM both in the clinic and during hospitalization are essential to decrease the excess burden of PEM.

Marijuana is not associated with progression of hepatic fibrosis in liver disease: a systematic review and meta-analysis

BACKGROUND

An estimated 22 million adults use marijuana in the USA. The role of marijuana in the progression of hepatic fibrosis remains unclear.

AIMS

We carried out a systematic review and meta-analysis to evaluate the impact of marijuana on prevalence and progression of hepatic fibrosis in chronic liver disease.

PATIENTS AND METHODS

We searched several databases from inception through 10 November 2017 to identify studies evaluating the role of marijuana in chronic liver disease. Our main outcome of interest was prevalence/progression of hepatic fibrosis. Adjusted odds ratios (ORs) and hazards ratios (HRs) were pooled and analyzed using random-effects model.

RESULTS

Nine studies with 5 976 026 patients were included in this meta-analysis. Prevalence of hepatic fibrosis was evaluated in nonalcoholic fatty liver disease (NAFLD), hepatitis C virus (HCV), and hepatitis C and HIV coinfection by two, four, and one studies. Progression of hepatic fibrosis was evaluated by two studies. Pooled OR for prevalence of fibrosis was 0.91 (0.72-1.15), I=75%. On subgroup analysis, pooled OR among NAFLD patients was 0.80 (0.75-0.86), I=0% and pooled OR among HCV patients was 1.96 (0.78-4.92), I=77%. Among studies evaluating HR, pooled HR for progression of fibrosis in HCV-HIV co-infected patients was 1.03 (0.96-1.11), I=0%.

CONCLUSION

Marijuana use did not increase the prevalence or progression of hepatic fibrosis in HCV and HCV-HIV-coinfected patients. On the contrary, we noted a reduction in the prevalence of NAFLD in marijuana users. Future studies are needed to further understand the therapeutic impact of cannabidiol-based formulations in the management of NAFLD.

Cannabis in liver disorders: a friend or a foe?

The recent legalization of recreational marijuana use in some parts of the world, the discovery of new indications for the clinical application of cannabis, and the acceptance of the use of cannabis in practice has been paralleled by extensive research on the active components of cannabis and the endocannabinoid system within the human body. In this review, we evaluate the available evidence on cannabis and its constituents and the application of this evidence in clinical practice, focusing particularly on the liver and liver diseases. Constituents of cannabis, such as cannabidiol and Δ-tetrahydrocannabinol, have shown anti-inflammatory, antioxidant, and hepatoprotective effects both in in vitro and clinical studies, and appear to have potential in the symptom management and treatment of various liver diseases that were previously considered difficult to manage conservatively. In addition, the manipulation of the inherent endocannabinoid response system has found favor in many clinical fields and has generated considerable research and clinical interest. Moreover, evidence with regard to the adverse effects of marijuana use in liver diseases is weak, which has led to raise a question on the prior rules, with regard to a denial of liver transplantation to marijuana users. All in all, the recent trends in research, clinical experiences, as well as the legislature, has opened up new avenues towards the widespread clinical application of cannabis and its derivatives as well as modifiers of the components of the endocannabinoid system. More research is required to fully exploit these new evidences.

Reduced Incidence and Better Liver Disease Outcomes among Chronic HCV Infected Patients Who Consume Cannabis

BACKGROUND AND AIM

The effect of cannabis use on chronic liver disease (CLD) from Hepatitis C Virus (HCV) infection, the most common cause of CLD, has been controversial. Here, we investigated the impact of cannabis use on the prevalence of CLD among HCV infected individuals.

METHODS

We analyzed hospital discharge records of adults (age ≥ 18 years) with a positive HCV diagnosis. We evaluated records from 2007 to 2014 of the Nationwide Inpatient Sample (NIS). We excluded records with other causes of chronic liver diseases (alcohol, hemochromatosis, NAFLD, PBC, HBV, etc.). Of the 188,333 records, we matched cannabis users to nonusers on 1:1 ratio (4,728:4,728), using a propensity-based matching system, with a stringent algorithm. We then used conditional regression models with generalized estimating equations to measure the adjusted prevalence rate ratio (aPRR) for having liver cirrhosis (and its complications), carcinoma, mortality, discharge disposition, and the adjusted mean ratio (aMR) of total hospital cost and length of stay (LOS) [SAS 9.4].

RESULTS

Our study revealed that cannabis users (CUs) had decreased prevalence of liver cirrhosis (aPRR: 0.81[0.72-0.91]), unfavorable discharge disposition (0.87[0.78-0.96]), and lower total health care cost ($39,642[36,220-43,387] versus $45,566[$42,244-$49,150]), compared to noncannabis users (NCUs). However, there was no difference among CUs and NCUs on the incidence of liver carcinoma (0.79[0.55-1.13]), in-hospital mortality (0.84[0.60-1.17]), and LOS (5.58[5.10-6.09] versus 5.66[5.25-6.01]). Among CUs, dependent cannabis use was associated with lower prevalence of liver cirrhosis, compared to nondependent use (0.62[0.41-0.93]).

CONCLUSIONS

Our findings suggest that cannabis use is associated with decreased incidence of liver cirrhosis, but no change in mortality nor LOS among HCV patients. These novel observations warrant further molecular mechanistic studies.

Potential Therapeutic Benefits of Herbs and Supplements in Patients with NAFLD

Our aim is to review the efficacy of various herbs and supplements as a possible therapeutic option in the treatment and/or prevention of nonalcoholic fatty liver disease (NAFLD). We performed a systematic review of medical literature using the PubMed Database by searching the chemical names of many common herbs and supplements with “AND (NAFLD or NASH)”. Studies and medical literature that discussed the roles and usage of herbs and supplements in NAFLD and nonalcoholic steatohepatitis (NASH) from inception until 20 June 2018 were reviewed. Many studies have claimed that the use of various herbs and supplements may improve disease endpoints and outcomes related to NAFLD and/or NASH. Improvement in liver function tests were noted. Amelioration or reduction of lobular inflammation, hepatic steatosis, and fibrosis were also noted. However, well-designed studies demonstrating improved clinical outcomes are lacking. Furthermore, experts remain concerned about the lack of regulation of herbs/supplements and the need for further research on potential adverse effects and herb–drug interactions. In conclusion, preliminary data on several herbs have demonstrated promising antioxidant, anti-inflammatory, anti-apoptotic, and anti-adipogenic properties that may help curtail the progression of NAFLD/NASH. Clinical trials testing the safety and efficacy must be completed before widespread use can be recommended.