Coexistent Alcohol-Related Liver Disease and Alcohol-Related Pancreatitis: Analysis of a Large Health Care System Cohort.

INTRODUCTION: Although coexistence of alcohol-related liver disease (ALD) and pancreatitis (ALP) is seen in clinical practice, a clear understanding of the overlap between these diseases is lacking. Moreover, the relative risks for certain population groups have not been studied. We determined the prevalence and coexistence of ALD and ALP in patients with an alcohol use disorder using retrospective analysis of a large patient cohort from Western Pennsylvania. We specifically emphasized the analysis of underrepresented populations, including women and blacks. METHODS: We identified all unique patients who received care in UPMC health system during 2006-2017 with at least one International Classification of Diseases versions 9 and/or 10 codes for alcohol misuse, ALD and pancreatitis. We noted their sex, race and age of first diagnosis and duration of contact. RESULTS: Among 89,774 patients that fit our criteria, the prevalence of ALD, ALP and coexistent ALD and ALP in patients with alcohol misuse was 11.7%, 7.4% and 2.5%, respectively. Prevalence of ALP in ALD was 16.4%, and ALD in ALP was 33.1%. Prevalence of ALP in ALD was slightly more prevalent in women (18.6% vs. 15.6%, p < 0.001). Prevalence of ALP in ALD was 2-4 folds greater in blacks than other races. DISCUSSION: A sizeable fraction of patients with ALD or ALP has coexistent disease. This is the first study to identify that blacks are at a higher risk for ALP in the presence of ALD. Future studies should define the clinical impact of coexistent disease on clinical presentation and short- and long-term outcomes.

Coexistence of alcohol-related pancreatitis and alcohol-related liver disease: A systematic review and meta-analysis.

BACKGROUND: Available estimates of coexistent alcohol-related pancreatitis (ALP) and alcohol-related liver disease (ALD) vary widely, and factors that determine coexistent disease are largely unknown. We performed a systematic review of published literature with the primary aim to generate robust estimates for coexistent alcohol-related chronic pancreatitis (ACP) and alcohol-related cirrhosis (ALC). METHODS: We searched PubMed, EMBASE, and Web of Science databases from inception until February 2018. Studies included were those in English-language, sample size ≥25 and allowed calculation of the coexistent disease. Pooled estimates were calculated using a random-effects model approach. RESULTS: Twenty-nine (including 5 autopsy studies) of 2000 eligible studies met inclusion criteria. Only 6.9% included patients were female. Fifteen studies enabled calculation of ACP in ALC, and 11 for ALC in ACP. Pooled prevalence of ACP in ALC was 16.2% (95% CI 10.4-24.5) overall, and 15.5% (95% CI 8.0-27.7) when data were limited to clinical studies. Corresponding prevalence for ALC in ACP was 21.5% (95% CI 12.0-35.6) and 16.9% (95% CI 11.5-24.3), respectively. There was significant heterogeneity among studies (I2 - 65-92%). Pooled prevalence for ALP in ALD or ALD in ALP in clinical studies were 15.2% and 39%, respectively. None of the studies reported outcomes in patients with coexistent disease. CONCLUSION: A sizeable fraction of patients with ACP or ALC have coexistent disease. Future studies should define the prevalence of coexistent disease in women and minority populations, and the consequences of coexistent disease on clinical presentation and short- and long-term outcomes.

A Microwave-Induced Thermoacoustic Imaging System With Non-Contact Ultrasound Detection.

Portable and easy-to-use imaging systems are in high demand for medical, security screening, nondestructive testing, and sensing applications. We present a new microwave-induced thermoacoustic imaging system with non-contact, airborne ultrasound (US) detection. In this system, a 2.7 GHz microwave excitation causes differential heating at interfaces with dielectric contrast, and the resulting US signal via the thermoacoustic effect travels out of the sample to the detector in air at a standoff. The 65 dB interface loss due to the impedance mismatch at the air-sample boundary is overcome with high-sensitivity capacitive micromachined ultrasonic transducers with minimum detectable pressures (MDPs) as low as 278 µ Pa rms and we explore two different designs-one operating at a center frequency of 71 kHz and another at a center frequency of 910 kHz. We further demonstrate that the air-sample interface presents a tradeoff with the advantage of improved resolution, as the change in wave velocity at the interface creates a strong focusing effect alongside the attenuation, resulting in axial resolutions more than 10× smaller than that predicted by the traditional speed/bandwidth limit. A piecewise synthetic aperture radar (SAR) algorithm modified for US imaging and enhanced with signal processing techniques is used for image reconstruction, resulting in mm-scale lateral and axial image resolution. Finally, measurements are conducted to verify simulations and demonstrate successful system performance.

Myths and realities about alcohol and smoking in chronic pancreatitis.

PURPOSE OF REVIEW: Alcohol and smoking play an important role in pancreatitis. The present review will address the myths and evidences about alcohol and smoking with pancreatitis to help improve the approach of healthcare professionals when managing of these patients. RECENT FINDINGS: There is a growing recognition that chronic pancreatitis is a multifactorial disease. Eliciting an accurate history of alcohol consumption and smoking from patients, and if necessary, family members, can help determine their contribution to the patient's disease. In the absence of a convincing history, physicians should be open to consideration of other etiologies. The amount and duration of alcohol consumption is the most important determinant in increasing pancreatitis risk. Alcohol sensitizes the pancreas to other insults or injury and promotes disease progression. Smoking is an independent risk factor or chronic pancreatitis and has synergistic pathogenic effects with alcohol. The natural history of chronic pancreatitis is highly variable. A patient with alcoholic pancreatitis can have symptoms, recurrences or exacerbations from disease-related complications or nonpancreatic causes. Novel strategies are needed to enable patients quit smoking. SUMMARY: Obtaining accurate history, appropriate evaluation and management can help to achieve meaningful improvement in symptoms in patients with chronic pancreatitis. Abstinence from alcohol and smoking cessation, when applicable, should be recommended in all patients to prevent disease recurrences and progression.

Resting and Exercise Energy Metabolism After Liver Transplantation for Nonalcoholic Steatohepatitis.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is a leading indication for liver transplantation (LT). We hypothesized that weight gain after LT may be exacerbated by reduced metabolic rates due to the LT procedure, particularly during exercise. We aimed to compare resting and exercise energy expenditure between patients transplanted for NASH and nontransplant nonalcoholic fatty liver disease (NAFLD) subjects. METHODS: NASH LT recipients (>1-year post, n = 14) and NAFLD controls (n = 13) underwent analysis of body composition, resting energy expenditure (REE), and exercise energy expenditure (VO2max), the latter using a ramped-Bruce protocol assessed by expired gas analysis and peak heart rate. RESULTS: Participants were mean 61.5 ± 7.9 years, 48.1% men, and 66.7% white. Baseline comorbidities were similar between groups. Among men, mean REE adjusted for total (17.7 vs 18.8, P = 0.87) and lean body mass (23.5 vs 26.9, P = 0.26), as well as VO2 (20.1 vs 23.9, P = 0.29), was lower in NASH LT recipients compared with NAFLD controls, respectively, although not statistically significant. However, female NASH LT recipients had significantly lower mean REE than NAFLD controls when adjusted for total (14.2 vs 18.9, P = 0.01) and lean body mass (19.3 vs 26.5, P = 0.002), as well as significantly lower VO2max (14.4 vs 20.6, P = 0.017). CONCLUSIONS: NASH LT recipients, particularly women, have lower REE and exercise energy expenditure compared with nontransplant NAFLD patients. More aggressive diet and exercise programs for post-LT NASH recipients to account for reduced resting and exercise metabolic rates may attenuate weight gain in this vulnerable population.

The utility of pulmonary function testing in predicting outcomes following liver transplantation.

Although pulmonary function tests (PFTs) are routinely performed in patients during the evaluation period before liver transplantation (LT), their utility in predicting post-LT mortality and morbidity outcomes is not known. The aim of this study was to determine the impact of obstructive and/or restrictive lung disease on post-LT outcomes. We conducted a retrospective analysis of patients who had pre-LT PFTs and underwent a subsequent LT (2007-2013). We used statistical analyses to determine independent associations between PFT parameters and outcomes (graft/patient survival, time on ventilator, and hospital/intensive care unit [ICU] length of stay [LOS]). A total of 415 LT recipients with available PFT data were included: 65% of patients had normal PFTs; 8% had obstructive lung disease; and 27% had restrictive lung disease. There was no difference in patient and graft survival between patients with normal, obstructive, and restrictive lung disease. However, restrictive lung disease was associated with longer post-LT time on ventilator and both ICU and hospital LOS (P < 0.05). More specific PFT parameters (diffusing capacity of the lungs for carbon monoxide, total lung capacity, and residual volume) were all significant predictors of ventilator time and both ICU and hospital LOS (P < 0.05). Although pre-LT PFT parameters may not predict post-LT mortality, restrictive abnormalities correlate with prolonged post-LT ventilation and LOS. Efforts to identify and minimize the impact of restrictive abnormalities on PFTs might improve such outcomes. Liver Transplantation 22 805-811 2016 AASLD.

Cross-Validation of Single-Stage Treadmill Tests for Predicting Aerobic Fitness in Adolescents with Type I Diabetes.

PURPOSE: Determining fitness is important when assessing adolescents with type 1 diabetes mellitus (T1DM). Submaximal tests estimate fitness, but none have been validated in this population. This study cross-validates the Ebbeling and Nemeth equations to predict fitness (VO2max (ml/kg/min)) in adolescents with T1DM. METHODS: Adolescents with T1DM (n = 20) completed a maximal treadmill test using indirect calorimetry. Participants completed one 4-min stage between 2.0 and 4.5 mph and 5% grade (Ebbeling/Nemeth protocol). Speed and grade were then increased until exhaustion. Predicted VO2max was calculated using the Ebbeling and Nemeth equations and compared with observed VO2max using paired t tests. Pearson correlation coefficients, 95% confidence intervals, coefficients of determination (R²), and total error (TE) were calculated. RESULTS: The mean observed VO2max was 47.0 ml/kg/min (SD = 6.9); the Ebbeling and Nemeth mean predictions were 42.4 (SD = 9.4) and 43.5 ml/kg/min (SD = 6.9), respectively. Paired t tests resulted in statistically significant (p < .01) mean differences between observed and predicted VO2max for both predictions. The association between the Ebbeling prediction and observed VO2max was r = .90 (95% CI = 0.76, 0.96), R² = .81, and TE = 6.5 ml/kg/ min. The association between the Nemeth prediction and observed VO2max was r = .81 (95% CI = 0.57, 0.92), R² = .66, and TE = 5.6 ml/kg/min. CONCLUSION: The Nemeth submaximal treadmill protocol provides a better estimate of fitness than the Ebbeling in adolescents with T1DM.

Effects of moderate-to-vigorous intensity physical activity on overnight and next-day hypoglycemia in active adolescents with type 1 diabetes.

OBJECTIVE: Physical activity (PA) provides many benefits to adolescents with type 1 diabetes; however, these individuals tend to have lower fitness and PA levels than their disease-free counterparts. The purpose of this study was to examine the acute temporal associations between moderate-to-vigorous intensity PA (MVPA) and hypoglycemia (continuous glucose monitor [CGM] reading ≤70 mg/dL). RESEARCH DESIGN AND METHODS: Nineteen participants (53% females) 14-20 years old with type 1 diabetes were recruited. Participant fitness was evaluated via indirect calorimetry using a maximal exercise test; body composition was measured using air displacement plethysmography. An accelerometer was worn continuously (3-5 days) and acceleration data used to estimate MVPA (minutes per day). Blood glucose values were simultaneously tracked using CGM. Controlling for sex, percent body fat (%BF), fitness, and concurrent MVPA, the likelihood of nighttime and next-day hypoglycemia due to MVPA was examined using logistic regression. RESULTS: Participants were of average fitness (females: 43.9 mL/kg/min; males: 49.8 mL/kg/min) and adiposity (females: 26.2%; males: 19.2%); 63.2% met the U.S. federal guideline of accumulating 60 min/day of MVPA. Hypoglycemia was 31% more likely in those who accumulated 30 min/day more MVPA in the previous afternoon than those with less (95% CI 1.05-1.63; P = 0.017). CONCLUSIONS: The results suggest that participating in afternoon MVPA increases the risk of overnight and next-day hypoglycemia, independent of sex, %BF, fitness, and concurrent MVPA. While promoting PA as a healthy behavior, it is important to educate adolescents with type 1 diabetes on prevention of hypoglycemia following PA.

Aerobic fitness and glycemic variability in adolescents with type 1 diabetes.

OBJECTIVE: This study examines the association of fitness on glycemic variability (GV) in adolescents with type 1 diabetes mellitus (T1DM). GV has been associated with high frequency of hyper- and hypoglycemia. METHODS: Nineteen adolescents with T1DM, ages 14 to 19 years, underwent aerobic fitness testing to determine their maximal aerobic capacity (VO2 max). A continuous glucose monitoring (CGM) device was placed on each subject and worn for 3 to 5 days until a return visit when the subjects underwent a 1-hour treadmill exercise session. Mean amplitude of glycemic excursion (MAGE) was calculated from the CGM data collected between the 2 study visits. Metabolic equivalent (MET), a measure of accumulated metabolic workload during the exercise session, was also calculated. RESULTS: Mean VO2 max was 46.6 ± 6.8 mL/kg/min, with a range of 34.8 to 57.0 mL/kg/min. Mean MET during the exercise session was 577.2 ± 102.4 and ranged from 354.3 to 716.2 METs. There was an inverse association between VO2 max and MAGE (r = -0.46; 95% confidence interval [CI], -0.01 to -0.76; P = .048). MET load and MAGE also had an inverse relationship (r = -0.48; 95% CI, -0.03 to -0.77; P = .037). CONCLUSION: GV is inversely associated with fitness and MET load. Aerobic fitness should be promoted in adolescents with T1DM not only because of its multiple beneficial effects but also due to a possible association with GV, leading to fewer extremes in hypo- and hyperglycemia.