The impact of stigma on quality of life and liver disease burden among patients with nonalcoholic fatty liver disease

Background & Aims: Patients with nonalcoholic fatty liver disease (NAFLD)/metabolic dysfunction-associated steatotic liver disease (MASLD) face a multifaceted disease burden which includes impaired health-related quality of life (HRQL) and potential stigmatization. We aimed to assess the burden of liver disease in patients with NAFLD and the relationship between experience of stigma and HRQL. Methods: Members of the Global NASH Council created a survey about disease burden in NAFLD. Participants completed a 35-item questionnaire to assess liver disease burden (LDB) (seven domains), the 36-item CLDQ-NASH (six domains) survey to assess HRQL and reported their experience with stigmatization and discrimination. Results: A total of 2,117 patients with NAFLD from 24 countries completed the LDB survey (48% Middle East and North Africa, 18% Europe, 16% USA, 18% Asia) and 778 competed CLDQ-NASH. Of the study group, 9% reported stigma due to NAFLD and 26% due to obesity. Participants who reported stigmatization due to NAFLD had substantially lower CLDQ-NASH scores (all p <0.0001). In multivariate analyses, experience with stigmatization or discrimination due to NAFLD was the strongest independent predictor of lower HRQL scores (beta from -5% to -8% of score range size, p <0.02). Experience with stigmatization due to obesity was associated with lower Activity, Emotional Health, Fatigue, and Worry domain scores, and being uncomfortable with the term “fatty liver disease” with lower Emotional Health scores (all p <0.05). In addition to stigma, the greatest disease burden as assessed by LDB was related to patients’ self-blame for their liver disease. Conclusions: Stigmatization of patients with NAFLD, whether it is caused by obesity or NAFLD, is strongly and independently associated with a substantial impairment of their HRQL. Self-blame is an important part of disease burden among patients with NAFLD. Impact and implications: Patients with nonalcoholic fatty liver disease (NAFLD), recently renamed metabolic dysfunction-associated steatotic liver disease (MASLD), may experience impaired health-related quality of life and stigmatization. Using a specifically designed survey, we found that stigmatization of patients with NAFLD, whether it is caused by obesity or the liver disease per se, is strongly and independently associated with a substantial impairment of their quality of life. Physicians treating patients with NAFLD should be aware of the profound implications of stigma, the high prevalence of self-blame in the context of this disease burden, and that providers’ perception may not adequately reflect patients’ perspective and experience with the disease

Genişlemiş spektrumlu beta-laktamaz (GSBL) salgılayan escherichia coli ve klebsiella pneumoniae enfeksiyonlarında fataliteyi belirleyen faktörler ve uygun antibiyotik kullanımının rolü

Giriş: Genişlemiş spektrumlu beta-laktamaz (GSBL) salgılayan mikroorganizmaların neden olduğu enfeksiyonlar yüksek fatalite oranlarına sahiptir. Bu çalışmada, kan kültüründe GSBL salgılayan E.coli ve Klebsiella pneumoniae’nın ürediği hastalardaki uygun olmayan başlangıç antibiyotik tedavisinin fatalite üzerindeki etkisini saptamayı amaçladık. Materyal ve Yöntem: Ocak 2007 - Nisan 2010 tarihleri arasında Marmara Üniversitesi Hastanesi Mikrobiyoloji laboratuarında, kan kültüründe GSBL salgılayan E.coli ve K. pneumoniae üreyen hastaların dahil edildiği retrospektif kohort çalışmasıdır. Fataliteyi etkileyen değişkenler olarak uygun antibiyotiğe geçiş günü, uygun olmayan antibiyotik kullanımı, son bir yıldaki hastane yatışları, Charlson komorbidite indeksi ve yoğun bakım ünitesinde yatış seçilmiştir. Farklı GSBL lerin tiplendirilmesinde polimeraz zincir reaksiyonu kullanıldı. Bulgular: Çalışmaya GSBL salgılayan E.coli (n:76) ve K. pneumoniae (n:26) enfeksiyonu olan toplam 102 hasta dahil edilmiştir. Hastaların ortalama yaşı 54 tü ve %45’i kadındı. Malignite en sık görülen altta yatan hastalıktı (%50). İzolatlarda tespit edilen GSBL lerin oranı CTX-M için %72.8, TEM için %2.5, CTX-M+ TEM için %21.9, CTX-M+SHV için %3.7 dir. Tek değişkenli analizde, mortalite ile ilişkili predispozan faktörler olarak santral venöz katater varlığı, yoğun bakıma yatış, steroid kullanımı, idrar sondası varlığı, nötropeni, malignite varlığı ve mekanik ventilasyon uygulanması saptandı (p<0.05). Bir tanesi ölümcül olan iki karbapenem dirençli izolat saptandı. Hastaların %28.5’inde mortalite gözlendi. Lojistik regresyon analizinde, uygun antibiyotiğe geçişteki bir günlük gecikmenin (OR; 1.2, CI; 1.01-1.44) ve mekanik ventilasyon uygulanmasının (OR; 21.9, CI; 4.34-110) toplam fatalitenin önemli öngörüleri olduğu tespit edildi. Farklı GSBL lerin fatalite üzerine önemli bir etkisi yoktu. Sonuç: Uygun antibiyotiğe zamanında geçiş GSBL enfeksiyonu olan hastalarda hayat kurtarıcı olabilir. Anahtar sözcükler: GSBL, bakteremi, fatalite ABSTRACT Objective: Blood stream infections caused by extended-spectrum B-lactamase (ESBL)- producing organisms have a high case fatality rate. We aimed to determine the impact of inadequate initial antimicrobial treatment on fatality among the patients with blood stream infections caused by ESBL-producing E.coli and Klebsiella pneumoniae. Methods: This is a retrospective cohort study performed between January 2007 and April 2010 in a University Hospital, by including all the bacteremic patients, who had infections with ESBL producing E.coli and Klebsiella pneunomoniae. In multivariate analysis for the overall fatality, the predictors included to the model were days for switching to an appropriate antibiotic, inappropriate antibiotic use, hospitalization within a year, Charlson comorbidity index, and stay in intensive care unit (ICU). ESBL types were determined by polymerase chain reaction. Results: In total, 102 bacteremic patients infected with ESBL producing E.coli (n=76) and Klebsiella pneumoniae (n=26) were included. The mean age of the patients was 54, and 45% was female. The proportion of ESBLs found among the isolates was 72.8% for CTX-M, 2.5% for TEM, 21.9% for CTX-M+TEM and %3.7 for CTX-M+SHV. Malignancy was the most common underlying disease (50%). The mortality rate was found to be 28.5 %. Two carbapenem resistant isolates were detected, one was fatal. In univariate analysis prodisposing factors for mortality were found to be stay in ICU, steroid use, central venous cathater, foley cathater, neutropenia, malignancy and mechanic ventilation (p<0.05). In multivariate analysis, one day delay for switching to an appropriate antibiotic (OR; 1.2, CI; 1.01-1.44) and mechanic ventilator (OR; 21.9, CI; 4.34-110) were detected as the significant predictors of the overall fatality. Different ESBLs had no particular impact on the fatality. Conclusion: Timely switching to appropriate antibiotics could be life saving for ESBL infected patients. Keywords: ESBL, bacteremia, fatalit

Pediatric Non-Alcoholic Fatty Liver Disease

Abstract: With the increase in the prevalence of obesity, non-alcoholic fatty liver disease (NAFLD) has become among the leading causes of chronic liver disease in the pediatric age group. Once believed to be a “two-hit process”, it is now clear that the actual pathophysiology of NAFLD is complex and involves multiple pathways. Moreover, NAFLD is not always benign, and patients with non-alcoholic steatohepatitis (NASH) are at increased risk of developing advanced stages of liver disease. It has also been shown that NAFLD is not only a liver disease, but is also associated with multiple extrahepatic manifestations, including cardiovascular diseases, type 2 diabetes, and low bone mineral density. Although the data is scarce in the pediatric population, some studies have suggested that long-term mortality and the requirement of liver transplantation will continue to increase in patients with NAFLD. More studies are needed to better understand the natural history of NAFLD, especially in the pediatric age group

Advances and challenges in the management of advanced fibrosis in nonalcoholic steatohepatitis

Nonalcoholic fatty liver disease (NAFLD) is rapidly becoming the most common type of chronic liver disease worldwide. From the spectrum of NAFLD, it is nonalcoholic steatohepatitis (NASH) that predominantly predisposes patients to higher risk for development of cirrhosis and hepatocellular carcinoma. There is growing evidence that the risk of progression to cirrhosis and hepatocellular carcinoma is not uniform among all patients with NASH. In fact, NASH patients with increasing numbers of metabolic diseases such as diabetes, hypertension, visceral obesity and dyslipidemia are at a higher risk of mortality. Additionally, patients with higher stage of liver fibrosis are also at increased risk of mortality. In this context, NASH patients with fibrosis are in the most urgent need of treatment. Also, the first line of treatment for NASH is lifestyle modification with diet and exercise. Nevertheless, the efficacy of lifestyle modification is quite limited. Additionally, vitamin E and pioglitazone may be considered for subset of patients with NASH. There are various medications targeting one or more steps in the pathogenesis of NASH being developed. These drug regimens either alone or in combination, may provide potential treatment option for patients with NASH

Prevalence, mortality and healthcare utilization among Medicare beneficiaries with Hepatitis C in Haemodialysis units

Hepatitis C (HCV) is more common among patients with end-stage renal disease requiring haemodialysis compared to the general population. Thus, we aimed to assess trends in prevalence, health resource utilization and mortality among Medicare beneficiaries with HCV on haemodialysis. This is a retrospective study of outpatient and inpatient claims for Medicare beneficiaries receiving haemodialysis (2005-2016). A total of 291 663 subjects on haemodialysis were included (67.3 ± 15.2 years, 55% male, 55% white, 49% age-based eligibility). The prevalence of HCV in subjects on haemodialysis was stable and was significantly higher (mean 4.2% in 2005-2016, P = 0.50 for the trend) than in subjects not on haemodialysis

Among Patients With NAFLD, Treatment of Dyslipidemia Does Not Reduce Cardiovascular Mortality

Dyslipidemia is one of the common risk factors for NAFLD and is associated with cardiovascular (CV) mortality, which is the most common cause of death in NAFLD. Lipid‐lowering agents (LLAs) are used to reduce CV events in the general population. Our aim was to assess whether the use of LLAs in patients with NAFLD can reduce the risk of CV mortality. We used the third National Health and Nutrition Examination Survey mortality linked files. Mortality was determined from the National Death Index records through 2011. NAFLD was diagnosed by ultrasound after exclusion of other causes of liver disease. After inclusion and exclusion, the cohort consisted of 2,566 patients with NAFLD (45.8% < 45 years of age, 52.8% male, 75.4% white). Those who were taking LLAs were more likely to be older, non‐Hispanic white, and had significantly higher rates of diabetes mellitus (DM), hyperlipidemia, hypertension, metabolic syndrome, and history of CV disease (CVD) (all P< 0.01). In our multivariate analysis, DM was an independent predictor of overall mortality (adjusted hazard ratio [aHR]: 1.79 [95% confidence interval (CI): 1.40‐2.30]) and CV mortality (aHR: 1.89 [95% CI: 1.08‐3.30]). History of CVD was associated with both overall (aHR: 2.03 [95% CI: 1.57‐2.63]) and CV mortality (aHR: 3.69 [95% CI: 2.23‐6.08]). In contrast, the use of statins and other LLAs was not associated with reduction in overall (aHR = 0.95 [95% CI: 0.37‐2.44] and aHR = 1.43 [95% CI: 0.99‐2.07]) and CV mortality (aHR = 1.20 [95% CI: 0.26‐5.54] and aHR = 1.63 [95% CI: 0.70‐3.76]). Conclusion: The use of statins and other LLAs did not reduce the increased risk of overall or CV mortality in NAFLD

The Prevalence of Parkinson Disease Among Patients With Hepatitis C Infection

Introduction: HCV has been suspected to potentially cause degenerations in the central nervous system. Parkinson's disease is the second most common neurodegenerative disorder. Our aim was to assess the prevalence of Parkinson's disease among patients with HCV infection. Material and methods: For this study, we used Medicare database from 2005-2010. Medicare database contains information on enrollment, coverage, diagnosis recorded with International Classification of Disease, Ninth Revision (ICD-9). From combined inpatient and outpatient files, Parkinson's disease was identified as the first diagnosis by ICD-9 code 332.0. Other study variables were; age, gender, race (White and No White), and Medicare eligibility status. Simple distribution comparison by HCV status examined with t-test for numerical variables and χ2 test for categorical variables in the main analytical cohort as well as in the propensity score matched cohort. Results: A total of 1,236,734 patients (median age 76 years, 41% male, and 85% White) was identified among over 47 million claims. Of these, 6040 patients (0.5%) were infected with HCV. Overall, 0.8% (N = 49) of the HCV group and 1.3% (N = 16,004) of the Non-HCV group had Parkinson's disease (P 0.05). Discussion: This study revealed that, among Medicare population, HCV was not associated with Parkinson disease

Prevalence and long-term outcomes of non-alcoholic fatty liver disease among elderly individuals from the United States

Abstract Background The prevalence and outcomes of non-alcoholic fatty liver disease (NAFLD) among elderly have not been well described. Our aim was to assess the prevalence, risk factors and mortality of NAFLD in individuals older than 60 years. Methods The data from the Third National Health and Nutrition Examination Survey with linked mortality files were utilized. NAFLD was defined by United States Fatty Liver Index in the absence of other causes of liver disease. Cox proportional hazards models were used to assess all-cause and cardiovascular (CV) mortality. All analyses were performed using SAS software. Results Three thousand two hundred seventy-one NHANES-III participants were included. The prevalence rates from NAFLD were 40.3% (95% CI: 37.2–43.5%) and 39.2% (95% CI: 34.4–44.0%) among 60–74 and > 74 years old. Among aged 60–74, the risks for 5-year and 10-year all-cause mortality were associated with presence of NAFLD [adjusted hazard ratios: 1.60 (95% CI: 1.24–1.96) for 5-year and 1.22 (95%CI: 1.01–1.49) for 10-year]. CV mortality were higher in this group were (aHR: 2.12 (95% CI: 1.20–3.75) for 5-year and 1.06 (95%CI: 0.73–1.52) for 10-year]. In contrast, in individuals > 74 years old, diagnosis of NAFLD was not associated with all-cause or CVD mortality. Conclusions NAFLD is common among elderly population. Although NAFLD is associated with increased risk of mortality for 60–74-year-old individuals, this risk was not increased in those older than 74 years