Lean non-alcoholic fatty liver disease (lean NAFLD): characteristics, metabolic outcomes and risk factors from a 7-year prospective, community cohort study from Sri Lanka.

INTRODUCTION: While patients with non-alcoholic fatty liver disease (NAFLD) are mostly overweight or obese, some are lean. METHODS: In a community-based follow-up study (baseline and follow-up surveys performed in 2007 and 2014), we investigated and compared the clinical characteristics, body composition, metabolic associations and outcomes, and other risk factors among individuals with lean (BMI < 23 kg/m2) NAFLD, non-lean (BMI ≥ 23 kg/m2) NAFLD and those without NAFLD. To investigate associations of selected genetic variants, we performed a case-control study between lean NAFLD cases and lean non-NAFLD controls. RESULTS: Of the 2985 participants in 2007, 120 (4.0%) had lean NAFLD and 816 (27.3%) had non-lean NAFLD. 1206 (40.4%) had no evidence of NAFLD (non-NAFLD). Compared to non-lean NAFLD, lean NAFLD was commoner among males (p < 0.001), and had a lower prevalence of hypertension (p < 0.001) and central obesity (WC < 90 cm for males, < 80 cm for females) (p < 0.001) without prominent differences in the prevalence of other metabolic comorbidities at baseline survey. Of 2142 individuals deemed as either NAFLD or non-NAFLD in 2007, 704 NAFLD individuals [84 lean NAFLD, 620 non-lean NAFLD] and 834 individuals with non-NAFLD in 2007 presented for follow-up in 2014. There was no difference in the occurrence of incident metabolic comorbidities between lean NAFLD and non-lean NAFLD. Of 294 individuals who were non-NAFLD in 2007 and lean in both 2007 and 2014, 84 (28.6%) had developed lean NAFLD, giving an annual incidence of 4.1%. Logistic regression identified the presence of diabetes at baseline, increase in weight from baseline to follow-up and a higher educational level as independent risk factors for the development of incident lean NAFLD. NAFLD association of PNPLA3 rs738409 was more pronounced among lean individuals (one-tailed p < 0.05) compared to the whole cohort sample. CONCLUSION: Although lean NAFLD constitutes a small proportion of NAFLD, the risk of developing incident metabolic comorbidities is similar to that of non-lean NAFLD. A PNPLA3 variant showed association with lean NAFLD in the studied population. Therefore, lean NAFLD also warrants careful evaluation and follow-up.

Effect of audio and visual distraction on patients undergoing colonoscopy: a randomized controlled study.

Background and study aims: Colonoscopy can cause anxiety and discomfort in patients. Sedation and analgesia as premedication can lead to complications in the elderly and those with comorbidities. This has led to an interest in the use of audio-visual distraction during the colonoscopy. We compared the effects of audio (AD) versus visual distraction (VD) in reducing discomfort and the need for sedation during colonoscopy. Patients and methods: Consecutive patients undergoing colonoscopy were randomized into three groups: one group was allowed to listen to the music of their choice (AD), the second group was allowed to watch a movie of their choice (VD), and the third group was not allowed either distraction during colonoscopy and acted as a control (C). Patient controlled analgesia and sedation were administered to all three groups. We used 25 mg of pethidine in 5-mg aliquots and 2.5 mg of midazolam in 0.5-mg aliquots. All patients were assessed for perceived pain and willingness to repeat the procedure. Number of "top-ups" of sedation and total dose of pethidine and midazolam were noted. Patient cooperation and ease of procedure were assessed by the colonoscopist. Results: In total, 200 patients were recruited [AD, n = 66 (32 males, median age 57 years); VD, n = 67 (43 males, median age 58 years); C, n = 67 (35 males, median age 59 years)]. The AD group had significantly less pain (P = 0.001), better patient cooperation (P = 0.001) and willingness to undergo a repeat procedure (P = 0.024) compared with VD and C groups. Conclusions: AD reduces pain and discomfort, improves patient cooperation and willingness to undergo a repeat procedure, and seems a useful, simple adjunct to low dose sedation during colonoscopy. STUDY REGISTRATION: SLCTR/2014/031.