Non-alcoholic fatty liver disease (NAFLD) is a burgeoning global health concern. In the subset of NAFLD patients with non-alcoholic steatohepatitis (NASH), the presence of significant fibrosis at index assessment is associated with poor prognosis and increased mortality. Hence, there is a growing need to accurately assess and stage fibrosis. Liver biopsy, the current gold standard, has limitations with sampling error and is invasive, with associated inherent risk. This has led to a host of non-invasive means of assessing fibrosis, which has garnered relevance in a disease that requires serial assessment of fibrosis longitudinally over time. This review discusses, comprehensively, the various tools available to the clinician for the assessment of fibrosis, including the various scoring systems used in liver biopsy, the non-invasive means of serum biomarkers, such as the highly-validated NAFLD fibrosis score, and the imaging-based modalities, such as transient elastography and magnetic resonance elastography.
BackgroundNon-alcoholic fatty liver disease (NAFLD) is a well-established risk factor for cardiovascular disease, with ethnic and regional differences noted. With the recent surge of research within this field, we re-examine the evidence associating NAFLD with subclinical atherosclerosis, and investigate potential regional differences.MethodsThis is a systematic review and meta-analysis. PubMed and EMBASE were systematically searched for publications from January 1967 to July 2020 using standardised criteria. Original, observational studies investigating the association between NAFLD and either carotid intima-media thickness (CIMT) and/or coronary artery calcification (CAC) were included. Key outcomes included differences in mean CIMT, the presence of increased CIMT, the presence of CAC and the development/progression of CAC. Pooled ORs and pooled standard differences in means were calculated using random-effects models. Between-study heterogeneity was quantified using the Q statistic and I². Subgroup analyses stratified by region of study (Asian vs Western) were also conducted.Results64 studies involving a total of 172 385 participants (67 404 with NAFLD) were included. 44 studies assessed the effect of NAFLD on CIMT, with the presence of NAFLD associated with increased CIMT (OR 2.00, 95% CI 1.56 to 2.56). 22 studies assessed the effects of NAFLD on CAC score, with the presence of NAFLD associated with the presence of any coronary calcification (OR 1.21, 95% CI 1.12 to 1.32), and the development/progression of CAC (OR 1.26, 95% CI 1.04 to 1.52). When stratified by region, these associations remained consistent across both Asian and Western populations (p>0.05). The majority (n=39) of studies were classified as ‘high quality’, with the remaining 25 of ‘moderate quality’.ConclusionsThere is a significant positive association between various measures of subclinical atherosclerosis and NAFLD, seen across both Western and Asian populations. These results re-emphasise the importance of early risk evaluation and prophylactic intervention measures to preclude progression to clinical cardiovascular disease in patients with NAFLD.
Background: In line with recent guidance from both ASPEN/ESPEN to cluster care to minimize healthcare team exposure by relying on other providers or telehealth to collect relevant nutrition assessment, our nutrition support team has adopted a modified workflow, leveraging information technology to provide parenteral nutrition (PN) remotely in a safe and timely manner. We aim to compare our prescribing adequacy and PN-related complications before and during COVID-19 outbreak using the modified workflow in non-critically ill patients. Method: This study reviewed a prospectively recruited cohort of adults (>18 years old) started on PN in the general wards or high dependency units from 5 th of December 2019 to 15 th of April 2020. Demographic data, nutrition assessment, PN prescriptions, blood results, electronic notes, capillary blood glucose (CBG) monitoring and CRBSI rates were reviewed for patients who received PN. Result: In our study, we found that patients who started PN during COVID-19 were more malnourished with lower BMI and higher proportion of SGA B/C(52 (92.9%) vs 36 (73.5%) p<0.005). Proportion of patients who achieved target calories within 5 days were similar in both groups. Protein prescription was >1g/kg/day in both groups, though there was a trend of higher protein prescription during COVID-19. Complications were similar in both groups. Conclusion: Our study demonstrates that minimal contact with effective multidisciplinary communication using the modified workflow can allow for safe and timely PN administration.
Background and AimNon‐alcoholic fatty liver disease (NAFLD) is associated with metabolic syndrome. Worryingly, it has been increasingly reported among nonobese patients. This study aims to analyse patient characteristics of biopsy‐proven NAFLD in an Asian cohort and explore differences stratified by body mass index (BMI).MethodsClinical, laboratory, and histological data were collected from 263 adults with biopsy‐proven NAFLD. Patients with and without obesity (BMI cut‐off 25) were compared. The ability to predict advanced liver fibrosis with three non‐invasive scores, the NAFLD Fibrosis score (NFS), Fibrosis‐4 (FIB4), and the aspartate aminotransferase to platelet ratio index (APRI), was compared.ResultsObese subjects had a lower mean age (49.5 ± 12.5 vs 54.0 ± 12.9 years, P = 0.017), a higher prevalence of diabetes (52.4% vs 36.8%, P = 0.037), and a higher waist circumference (113.9 ± 16.0 cm vs 87.0 ± 18.4 cm, P = 0.022). The prevalence of dyslipidaemia (68.0% vs 61.4%, P = 0.353) and hypertension (61.7% vs 49.1%, P = 0.190) was comparable between the two groups. The distribution of non‐alcoholic steatohepatitis (NASH) (63.1% versus 61.4%, P = 0.710) and advanced fibrosis (31.6% versus 26.3%, P = 0.447) were also similar in both groups. All three non‐invasive scores (NFS, FIB4, and APRI) performed poorly in predicting advanced fibrosis in nonobese patients with NAFLD. The FIB4 was the most accurate non‐invasive score in predicting advanced fibrosis in the obese group.ConclusionsObese and nonobese patients are equally at risk of NASH and advanced fibrosis. While the FIB4 is the most accurate non‐invasive score in predicting advanced fibrosis among obese individuals, further research is warranted to develop a nonobese specific score to correctly identify nonobese NAFLD patients with advanced fibrosis.
Introduction Chronic hepatitis B (CHB) remains common in endemic regions, causing significant healthcare burden. Patients with CHB may need to be adherent to nucleoside analogue (NA) for a long period of time to prevent complications. This study aims to investigate the safety, efficacy and patient experience of a virtual monitoring clinic (VMC) in monitoring stable patients taking NA for CHB. Methods Patients on NA and regular follow-up were randomised to either VMC alternating with doctors’ clinic visit or to a control group in which they continued standard follow-up by doctors. Therapy adherence was measured by medication possession ratio (MPR) for NA therapy, incidence of virological breakthrough and hepatocellular carcinoma (HCC) development at two years of follow-up. Patient acceptance was measured on a Likert scale of 1–10. Results A total 192 patients completed follow-up: 94 and 98 patients in the VMC and control groups, respectively. Mean age was 60.6 ± 10.8 years, with 95.3% Chinese ethnicity and 64.1% males. Age, gender, race, educational, employment and financial status were similar in both groups. Upon study completion, the majority of patients – 76 (80.9%) in VMC group and 74 (75.5%) in control group – had MPR ≥0.8; 88.8% were satisfied and rated VMC better than a traditional follow-up clinic with doctors only. More than 85% of patients rated ≥8/10 on the Likert scale for VMC, and preferred VMC over traditional clinic visits. Clinical outcomes observed were HCC development in one (1.1%) in the VMC group and four (4.1%) in the control group ( p = 0.369). Two (2.1%) and one (1.0%) virological breakthroughs were observed in the VMC and control groups, respectively ( p = 0.615). No incidence of HCC or abnormal blood tests were missed in the VMC arm. Discussion VMC is a viable and safe clinical model for monitoring stable CHB patients on NA therapy without compromising patients’ adherence to medications and is preferred by patients.
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Introduction: Reported clinical outcomes for elderly patients with acute intestinal failure receiving parenteral nutrition (PN) in the acute hospital setting is limited. Our study aims to characterize the use of PN in the elderly and compare clinical outcomes against younger patients. Methods: A retrospective review of inpatients administered PN from 1st January 2019 to 31st December 2019 was performed. Demographics, indications for PN, biochemical results and clinical outcomes were compared. Patients were categorized into < 65 (younger) or ≥ 65 years old (elderly). Results: 235 patients were included. There were 103 patients in the elderly group with a mean age of 73.9 years (± 6.9 years) and 132 patients in the younger group with a mean age of 52.4 years (± 12.5 years). There was a significantly higher Charlson Comorbidity Index and comordities and lower Karnofsky score in the elderly group. Indications for PN were similar between both groups. There was more younger patients who required PN for ≥28 days. The elderly group received a significantly lower total calorie, dextrose and protein compared to the younger group (20.8 (7.8) vs 22.8 (6.3) kcal/kg/day ; 3.1 (1.4) vs 3.6 (1.4) g/kg/day ; 1.1 (0.4) vs 1.2 (0.3) g/kg/day ). Mean length of stay was significantly longer in the younger group than in the elderly group (59.8 (± 55.3 ) vs 35.9 (± 21.3) days). There was no significant difference in clinical outcomes: line sepsis, hypoglycemia, hyperglycemia, fluid overload, inpatient mortality and total mortality between the two groups. Conclusion: The usage of PN in elderly patients with acute intestinal failure was not associated with an increased rate of PN related complications nor worse clinical outcomes when compared with younger patients. and hence should not be denied when appropriate indications are present.
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