Evaluating Liver Steatosis and Stiffness as a Teachable Moment in Patients with Alcohol Use Disorder: Early Results from a Pilot Study (Elisa)

Background: We have seen a concerning rise in alcohol consumption and alcohol-related hospitalizations in the US, especially since the onset of the COVID-19 pandemic. There is a dire need for effective interventions to treat alcohol use disorder (AUD), particularly in young people. Teachable moments (TMs) are health events that can motivate individuals to adopt risk-reducing health behaviors and have been proven effective for cigarette smoking. Bedside interpretation of vibrationcontrolled transient elastography (VCTE) is an opportunity for a TM. Our aim was to evaluate the effects of bedside VCTE and interpretation related to liver health on motivation to reduce alcohol use in patients with AUD. Method(s): This is an investigator-initiated, prospective, proof-of-concept pilot study of VCTE and AUD. Patients without known liver disease were prospectively recruited from inpatient and outpatient substance use units/practices within the Mount Sinai Health System. Four validated questionnaires assessing alcohol use, insight, and readiness to reduce drinking were administered (Alcohol Use Disorders Identification Test [AUDIT-C], readiness ruler tool, stages of change readiness and treatment eagerness scale [SOCRATES-8A] and Hanil Alcohol Insight Scale [HAIS]). VCTE was then performed with FibroScanTM (Echosens), and results interpreted in real-time via pre-scripted explanations. A recent metaanalysis algorithm was used to adjust fibrosis cut-offs based on available liver tests. Questionnaires were repeated immediately afterwards. The primary endpoint was a change in motivation scores after VCTE and the secondary endpoint was self-reported alcohol use at 1, 6, 12 and 24 months. Result(s): Study enrollment began in early 5/2022, with 10 patients screened and 7 eligible candidates identified: 7/7 (100%) consented to the study, 1/7 (14.3%) was excluded because of inaccurate VCTE due to body habitus. The cohort had a mean age of 51.3 (+-11.3) years, with slight male predominance (57%) and ethnically diverse (42.9% African American, 42.9% Caucasian, and 14.2% Hispanic). All had severe AUD with a mean of 16.6 (+-5.9) daily drinks consumed for 17.3 (+-7.7) years. Five of 7 (71.4%) had comorbid psychiatric diagnoses and all had a family history of AUD. Six out of 7 (85.7%) had VCTE results consistent with stage 0-1 fibrosis and 1 had stage 3-4;all had grade 1 steatosis. There was high baseline motivation and insight with a mean score of 9.8 on the readiness ruler tool (possible range 0-10), 13.0 on HAIS (-20 to +20) and 82.7 on SOCRATES-8A (19-95). After VCTE, there was an improvement in readiness to reduce drinking (mean increase of 4.7 [6%] in SOCRATES-8A) with a slight decrease in insight (mean decrease of 1.3 [10%] in HAIS). Conclusion(s): Early results from this pilot study of VCTE as a teachable moment in AUD demonstrate that this is a feasible intervention that may increase motivation to reduce drinking, which requires further study.

A Perfect Storm

Our authors, who direct the Addiction Institute for the Mount Sinai Health System in New York City, address the substance-abuse avalanche brought on by the Covid-19 pandemic.

Mortality from fulminant myocarditis in multi-organ transplant recipient with COVID-19

Purpose: Novel coronavirus infection has been rarely described in multi-organ transplantation. This case highlights the poor prognosis associated with cardiac involvement by SARS-Cov-2 in transplantation, despite resolution of respiratory infection. Methods: Case report from retrospective chart review. Results: The patient is a 48 year old woman with end stage lung and renal disease. In late 2019, the patient underwent a bilateral lung transplant and simultaneous kidney transplant. Postoperative period was noted for multiple readmissions for post-obstructive pneumonia. By early March 2020 she had made a good functional recovery. In late March the patient's husband, who worked as a ride-share driver, developed fevers and cough but continued working. Four days later, the patient developed fevers and a productive cough. This is considered her first day of COVID-19 symptoms. Subsequent days will be referred to as 'post-symptom days' (PSD#). She presented on PSD#4 with a fever of 102.8 F. The patient's COVID test was positive. During her five-day hospitalization, she remained afebrile, and she was weaned off oxygen. Echocardiogram was normal. She continued to do well clinically and was asymptomatic at discharge, with oxygen saturation of 100% on room air. Two days later (PSD#10), the patient returned with hypoxia requiring intubation. She rapidly went into complete heart block, requiring CPR and cardioversion. Her previously normal LVEF was now 25%, with global hypokinesis. Acute phase reactant levels were markedly elevated. Lab-work indicated acute cardiac, liver and kidney injury, consistent with COVID-19-induced fulminant myocarditis and cardiogenic shock. CXR showed patchy bilateral infiltrates concerning for superimposed bacterial pneumonia. Through PSD#13, she required maximal doses of vasopressors. On PSD#14, we administered IV tocilizumab. She had mild clinical improvement. On PSD#16, she suddenly decompensated, developing atrial fibrillation. X-rays showed dilated loops of bowel with pneumatosis. An emergent bedside laparotomy was performed. Her entire small bowel and colon was ischemic, with extensive necrosis. Shortly after, the patient developed asystole and was pronounced dead. Conclusions: Inflammatory or hypoxic disruption of myocardial pericytes in COVID- 19 can result in microvascular dysfunction and cardiac ischemia which can precipitate heart failure. In the setting of a cytokine storm, this can lead to profound systemic shock and multisystem organ failure, with potentially fatal consequences in transplant recipients. (Table Presented).

First report of novel coronavirus infection following abdominal organ transplantation in North America during the covid-19 pandemic

Introduction: The COVID-19 pandemic demands an urgent response from the transplant community in order to protect our vulnerable patient population. We present the rare case of COVID-19 in a combined liver-kidney transplant recipient from the United States. Case Report: The patient is a 77 year-old diabetic woman who presented to our transplant center with decompensated cryptogenic cirrhosis. She underwent combined liver-kidney transplant. Postoperatively, her liver enzymes normalized, and she no longer required dialysis. She was discharged to a rehabilitation facility 12 days after transplant (POD #12). On POD #13, the patient had rehabilitation sessions with an occupational therapist who later tested positive for COVID-19. This day is presumed to be her first exposure, and subsequent days will be referred to as 'post-exposure days' (PEXD). On PEXD #9 (POD #22), the patient developed a fever of 103 degrees, accompanied by chills and nausea. However, no dyspnea, cough, or respiratory complaints were present at presentation. Other than an elevation in alkaline phosphatase of 168 U/L, her liver enzymes and creatinine were normal (Table 1). Chest CT only showed trace right pleural effusion with no pulmonary infiltrates, no ground-glass opacification, and no consolidation (Figure 1). Abdominal CT revealed a 20 x 15 cm fluid collection surrounding the left kidney graft. Mycophenolate mofetil was discontinued, but prednisone and tacrolimus were continued. Tacrolimus dosing was adjusted to achieve a target daily through level range of 6 - 10 ng/mL. The following morning (PEXD #10), the patient underwent percutaneous drainage of her perinephric abscess. Her fever and pain subsided following intervention. On PEXD #11, the patient's COVID-19 test resulted as positive. Isolation precautions were maintained. Chest X ray was clear. She had no dyspnea or cough, and she maintained oxygen saturation of 96-100% on room air. A five-day course of treatment with oral hydroxychloroquine at 400 mg was planned, and started on PEXD #11. However, the patient had a significant elevation in liver enzymes immediately following treatment initiation. The drug was discontinued on PEXD #13. The patient's liver enzymes improved following drug cessation. We decided to initiate treatment with azithromycin on PEXD #15, completing a five-day treatment course. The patient remained asymptomatic and did not require oxygen therapy at any point. On PEXD #23 (hospital day 14, POD# 36), the patient was discharged home. MMF was not restarted. Tacrolimus and steroid taper were continued as scheduled. Allograft function and chest imaging prior to discharge were normal. Conclusions: Calcineurin inhibitors interfere with the cyclophilins and FKBP required by various coronaviridae for replication. Along with steroids, they also dampen the cytokine storm. The antiviral potential of calcineurin inhibitors and steroids warrants further investigation into their role as viable therapy for COVID-19.