The interplay between diabetes and non-alcoholic fatty liver disease: a cross-sectional study from Pakistan

Background and objectives

Non-alcoholic fatty liver disease (NAFLD) is characterized by ectopic deposition of fat in the liver, in the absence of other secondary causes of fat buildup. The relationship between NAFLD, including alanine aminotransferase (ALT), and glycated haemoglobin (HbA1c), is important for predicting the severity of disease and prognosis. This study aims to investigate the association of HbA1c in type 2 diabetes mellitus (T2DM) patients with NAFLD via measuring the ALT levels.

Materials and methods

This retrospective cross-sectional study enroled 130 patients with T2DM and NAFLD. The association between levels of HbA1c and ALT in patients of NAFLD with controlled and uncontrolled T2DM, respectively, was investigated. Stratification was done based on gender and diabetic control, using HbA1c levels as a marker of glycemic control. Serum ALT levels were also compared in both groups.

Results

The mean age of the participants was 50.2±5.7 years. The total participants were 130, of which 77 (59.3%) were females and 53 (40.7%) were males. The numbers of patients having uncontrolled T2DM (HbA1c>7%), and controlled T2DM (HbA1c <7%) were 78 (60%) and 52 (40%), respectively. Moreover, 46 (35.3%) females and 32 (24.7%) males had uncontrolled T2DM, and 31 (23.8%) females and 21 (16.2%) males had controlled T2DM. The mean ALT level for uncontrolled and controlled T2DM in female patients was found to be 24.6±3.4 and 13.5±2.4, respectively, (P <0.05). For male patients, it was found to be 54.0±4.9 and 29.1±5.4, respectively (P=0.008).

Conclusion

There is a positive association between elevated HbA1c and ALT levels in T2DM patients with NAFLD.

Prevalence of Non-alcoholic Fatty Liver Disease (NAFLD) Among Diabetic Mellitus Patients in Saudi Arabia: Systematic Review and Meta-Analysis

Non-alcoholic fatty liver disease (NAFLD) is a burgeoning global health concern, closely associated with the rising prevalence of type 2 diabetes mellitus (T2DM) and obesity. This systematic review and meta-analysis aim to comprehensively evaluate the prevalence of NAFLD in DM patients in Saudi Arabia, a country undergoing rapid socioeconomic changes. Our multifaceted search strategy identified four high-quality studies conducted between 2003 and 2022, covering hospital and community settings. The aggregate prevalence rate of NAFLD in DM patients was notably high, ranging from 47.8% to 72.8%. However, substantial heterogeneity (I² = 90.6%) was observed, indicating variability attributed to diverse study characteristics. The uniform application of ultrasound for diagnosis was noteworthy but raised concerns regarding sensitivity. This analysis underscores the urgency of public health measures for early detection and management of NAFLD in DM-prone populations in Saudi Arabia.

The Role of Fucoxanthin in Non-Alcoholic Fatty Liver Disease

Chronic liver disease (CLD) has emerged as a leading cause of human deaths. It caused 1.32 million deaths in 2017, which affected men more than women by a two-to-one ratio. There are various causes of CLD, including obesity, excessive alcohol consumption, and viral infection. Among them, non-alcoholic fatty liver disease (NAFLD), one of obesity-induced liver diseases, is the major cause, representing the cause of more than 50% of cases. Fucoxanthin, a carotenoid mainly found in brown seaweed, exhibits various biological activities against NAFLD. Its role in NAFLD appears in several mechanisms, such as inducing thermogenesis in mitochondrial homeostasis, altering lipid metabolism, and promoting anti-inflammatory and anti-oxidant activities. The corresponding altered signaling pathways are the β3-adorenarine receptor (β3Ad), proliferator-activated receptor gamma coactivator (PGC-1), adenosine monophosphate-activated protein kinase (AMPK), peroxisome proliferator-activated receptor (PPAR), sterol regulatory element binding protein (SREBP), nuclear factor kappa B (NF-κB), mitogen-activated protein kinase (MAPK), protein kinase B (AKT), SMAD2/3, and P13K/Akt pathways. Fucoxanthin also exhibits anti-fibrogenic activity that prevents non-alcoholic steatohepatitis (NASH) development.

Is Cirrhotic Cardiomyopathy Related to Cirrhosis Severity?

OBJECTIVE

Cirrhotic cardiomyopathy (CCM) is associated with increased morbidity and mortality in patients with liver cirrhosis. Yet, it remains an under-diagnosed entity. Further, its relation to the severity of cirrhosis is contradictory. We conducted this study on an Indian population to determine the cardiac dysfunctions in cirrhosis of the liver and correlations with etiologies and cirrhosis severity.

METHODS

This study enrolled patients with diagnosed liver cirrhosis without any cardiac disease or conditions affecting cardiac function. All participants were evaluated clinically, electrocardiographically, and echocardiographically. Cirrhosis severity was assessed by scores from the Model for End-stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP) tests. Cirrhotic cardiomyopathy was defined as diastolic dysfunction and/or systolic dysfunction with QT prolongation.

RESULTS

Ninety-six patients were evaluated, and CTP-A stage of cirrhosis was found in 23 (24%), CTP-B in 42 (43.8%), and CTP-C in 31 (32.3%) cases. Systolic dysfunction was most frequent (P=0.014), and left ventricular ejection fraction was significantly reduced (P=0.001) in CTP-C stage of cirrhosis. Cirrhotic cardiomyopathy was found in 39.6% (n=38) of patients; CCM patients had significantly higher CTP scores (9.6±2.6 versus 8.3±2.3, P=0.012) as well as MELD scores (19.72±4.9 versus 17.41±4.1, P=0.015) in comparison to patients without CCM.

CONCLUSION

Cirrhotic cardiomyopathy has a positive relationship with the severity of cirrhosis. Systolic function declines with the severity of cirrhosis, and overt systolic dysfunction can be present, particularly in the advanced stage of cirrhosis of the liver.

Elevated serum ferritin in non-alcoholic fatty liver disease is not predictive of fibrosis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is common with widely ranging severity. Non-invasive risk scores for risk stratification are recommended but misclassify a significant proportion of patients. In situations where non-invasive risk scores do not provide guidance, referral is typically made to a Hepatologist for transient elastography or liver biopsy. Serum ferritin is elevated in many patients with NAFLD related to dysmetabolic and inflammatory hyperferritinemia. Ferritin is widely available and part of a standard workup for chronic liver disease.

METHODS

To explore the association of ferritin and risk of fibrosis in NAFLD, we reviewed patients diagnosed with NAFLD at the hepatology clinic of the Vancouver General Hospital between the years of 2015 and 2018. We collected data on 317 patients retrospectively assessing for a relationship between serum ferritin and elastography score.

RESULTS

Two hundred twenty-four patients were included in the final analysis. Median ferritin was 145 µg/L (IQR 62-311). Median liver stiffness was 5.2 kPa with 14.3% of patients having liver stiffness ≥8.7 kPa and 17.4% ≥ 8.0 kPa. ROC curve analysis using a liver stiffness ≥8.0 kPa as a cutoff for F2 fibrosis showed an AUROC of 0.54 for serum ferritin levels. At a cut-off of both 300 µg/L; and 450 µg/L median liver stiffness did not differ significantly in those with ferritin above the cutoff (ferritin ≥300 µg/L; p = 0.099, ferritin ≥450 µg/L; p = 0.12). Ferritin was significantly higher in male patients (198 versus 91 µg/L; p = 0.0001). There was a weak linear association between AST and ferritin levels.

CONCLUSION

In this cohort of 224 patients with NAFLD, serum ferritin was not predictive of significant liver fibrosis.

Beyond the Paradigm of Weight Loss in Non-Alcoholic Fatty Liver Disease: From Pathophysiology to Novel Dietary Approaches

Current treatment recommendations for non-alcoholic fatty liver disease (NAFLD) rely heavily on lifestyle interventions. The Mediterranean diet and physical activity, aiming at weight loss, have shown good results in achieving an improvement of this liver disease. However, concerns related to compliance and food accessibility limit the feasibility of this approach, and data on the long-term effects on liver-related outcomes are lacking. Insulin resistance is a central aspect in the pathophysiology of NAFLD; therefore, interventions aiming at the improvement of insulin sensitivity may be preferable. In this literature review, we provide a comprehensive summary of the available evidence on nutritional approaches in the management of NAFLD, involving low-calorie diets, isocaloric diets, and the novel schemes of intermittent fasting. In addition, we explore the harmful role of single nutrients on liver-specific key metabolic pathways, the role of gene susceptibility and microbiota, and behavioral aspects that may impact liver disease and are often underreported in clinical setting. At present, the high variability in terms of study populations and liver-specific outcomes within nutritional studies limits the generalizability of the results and highlights the urgent need of a tailored and standardized approach, as seen in regulatory trials in Non-Alcoholic Steatohepatitis (NASH).

Pathology of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) encompasses a spectrum of different conditions which are characterized by hepatic steatosis in the absence of secondary causes. It is currently the most common chronic liver disease worldwide, and its estimated prevalence is about 1.5-6.5%. The only histological finding of steatosis (“simple” steatosis) represents the uncomplicated form of NAFLD, while non-alcoholic steatohepatitis (NASH) is its inflammatory subtype associated with disease progression to cirrhosis and hepatocellular carcinoma (HCC), and represents the major indication for liver transplantation. NASH is still a diagnostic and therapeutic challenge for clinicians and liver biopsy is currently the only accepted method to reliably distinguish NASH from “simple” steatosis. From the histological perspectives, NAFLD and NASH continue to be an area of active interest for pathologists, with a specific focus on better methods of evaluation, morphologic clues to pathogenesis, and predictors of fibrosis progression. This review focuses on histopathology of NAFLD in adults, with the aim to provide a practical diagnostic approach useful in the clinical routine.

Hand Hygiene Compliance and Effectiveness Against Respiratory Infections Among Hajj Pilgrims: A Systematic Review

The role of hand hygiene in the prevention of respiratory tract infections in Hajj pilgrims has not been assessed through a focussed systematic review of the literature. Considering this, a systematic review was undertaken to synthesize the up-to-date literature on the compliance and effectiveness of hand hygiene among Hajj attendees. Major databases, including OVID Medline, were searched by using a combination of MeSH terms and text words for potentially relevant articles. Data from identified articles were abstracted, quality assessed and combined into a summary effect. Twelve observational studies containing data of 6,320 pilgrims were included. The compliance of hand washing with non-alcoholic surfactants was 77.7% (ranged from 31.5% to 90.3% in individual studies) and the compliance of hand cleaning with alcoholic products was 44.9% (ranged from 30.7% to 67.4%). Education was a key influencer of hand hygiene practice. Only three of the six studies that assessed the effectiveness of hand hygiene against clinical disease found the practice to be effective, and only one of the two studies that evaluated its effectiveness against a laboratory-confirmed infection found it to be effective. This systematic review suggests that hand hygiene using non-alcoholic products is generally acceptable among Hajj pilgrims but there is no conclusive evidence on its effectiveness.

Potential Role of Dexamphetamine in the Treatment of Non-alcoholic Fatty Liver Disease: Hopes and Pitfalls

Non-alcoholic fatty liver disease (NAFLD) is one of most frequent causes of chronic liver disease. Global prevalence of NAFLD and nonalcoholic steatohepatitis (NASH) with advanced fibrosis is increasing day by day. Patients with NAFLD are more susceptible to encounter cardiovascular morbidity and mortality. Apart from lifestyle changes and dietary modifications, no effective pharmacotherapy is available to prevent the progression of NAFLD to NASH and advanced stages of hepatic fibrosis and cirrhosis. Dexamphetamine is the d-isomer of amphetamine, which acts by inhibiting monoamine reuptake and direct stimulation of dopamine and noradrenaline release. Presently, dexamphetamine is indicated for the treatment of attention deficit hyperactivity disorder and narcolepsy, but since its use was found to be associated with weight loss, it is also now used as an off-label drug for the treatment of obesity. Direct or indirect evidence is present in the form case reports, case series and from effects of related drugs to support the potential role of dexamphetamine in NAFLD. There is an urgent need to initiate preclinical and clinical studies involving robust methodology and adequate sample sizes to explore the potential of dexamphetamine in patients with NAFLD. In this review, we will discuss the therapeutic potential of dexamphetamine for the treatment of NAFLD.

A Case Report of Wernicke's Encephalopathy Associated With Schizophrenia

Introduction: Wernicke's encephalopathy (WE) is a severe neurological syndrome often associated with alcoholism. Clinicians tend to ignore WE in other non-alcoholic clinical settings related to malnutrition and thiamine deficiency, resulting in delayed diagnosis. The diagnosis becomes more difficult when WE is secondary to psychiatric illnesses as symptoms can be masked by the primary disease. Case Presentation: We present a case of a 56-year-old female patient with schizophrenia who was admitted to the hospital for mental and behavioral disorder, without history of alcohol. She presented symptoms of ophthalmoplegia and high muscular tension, and the brain MRI showed symmetric lesions in the bilateral basal ganglia and third ventricle. She responded well to thiamine and was discharged on hospital day 22. Conclusion: The psychiatrists should be on the alert for starvation-induced WE, especially for patients suffering from malnutrition. WE is a preventable and treatable disease, so once suspected of WE, patients ought to take adequate supplements of thiamine immediately.

Current Functionality and Potential Improvements of Non-Alcoholic Fermented Cereal Beverages

Fermentation continues to be the most common biotechnological tool to be used in cereal-based beverages, as it is relatively simple and economical. Fermented beverages hold a long tradition and have become known for their sensory and health-promoting attributes. Considering the attractive sensory traits and due to increased consumer awareness of the importance of healthy nutrition, the market for functional, natural, and non-alcoholic beverages is steadily increasing all over the world. This paper outlines the current achievements and technological development employed to enhance the qualitative and nutritional status of non-alcoholic fermented cereal beverages (NFCBs). Following an in-depth review of various scientific publications, current production methods are discussed as having the potential to enhance the functional properties of NFCBs and their safety, as a promising approach to help consumers in their efforts to improve their nutrition and health status. Moreover, key aspects concerning production techniques, fermentation methods, and the nutritional value of NFCBs are highlighted, together with their potential health benefits and current consumption trends. Further research efforts are required in the segment of traditional fermented cereal beverages to identify new potentially probiotic microorganisms and starter cultures, novel ingredients as fermentation substrates, and to finally elucidate the contributions of microorganisms and enzymes in the fermentation process.

Lean Patients with Non-Alcoholic Fatty Liver Disease Have a Severe Histological Phenotype Similar to Obese Patients

A small proportion of lean patients develop non-alcoholic fatty liver disease (NAFLD). We aimed to report the histological picture of lean NAFLD in comparison to overweight and obese NAFLD patients. Biopsy and clinical data from 466 patients diagnosed with NAFLD were stratified to groups according to body mass index (BMI): lean (BMI ≤ 25.0 kg/m², n confirmed to be appropriate = 74), overweight (BMI > 25.0 ≤ 30.0 kg/m², n = 242) and obese (BMI > 30.0 kg/m², n = 150). Lean NAFLD patients had a higher rate of lobular inflammation compared to overweight patients (12/74; 16.2% vs. 19/242; 7.9%; p = 0.011) but were similar to obese patients (25/150; 16.7%). Ballooning was observed in fewer overweight patients (38/242; 15.7%) compared to lean (19/74; 25.7%; p = 0.014) and obese patients (38/150; 25.3%; p = 0.006). Overweight patients had a lower rate of portal and periportal fibrosis (32/242; 13.2%) than lean (19/74; 25.7%; p = 0.019) and obese patients (37/150; 24.7%; p = 0.016). The rate of cirrhosis was higher in lean patients (6/74; 8.1%) compared to overweight (4/242; 1.7%; p = 0.010) and obese patients (3/150; 2.0% p = 0.027). In total, 60/466; 12.9% patients were diagnosed with non-alcoholic steatohepatitis (NASH). The rate of NASH was higher in lean (14/74; 18.9% p = 0.01) and obese (26/150; 17.3%; p = 0.007) compared to overweight patients (20/242; 8.3%)). Among lean patients, fasting glucose, INR and use of thyroid hormone replacement therapy were independent predictors of NASH in a multivariate model. Lean NAFLD patients were characterized by a severe histological picture similar to obese patients but are more progressed compared to overweight patients. Fasting glucose, international normalized ratio (INR) and the use of thyroid hormone replacement may serve as indicators for NASH in lean patients.

Association between malignancy and non-alcoholic Wernicke's encephalopathy: a case report and literature review

Background

Wernicke's encephalopathy is a serious medical condition associated with high morbidity and mortality caused by deficiency of thiamine. This disease is classically associated with alcoholism, but is underappreciated in the nonalcoholic population. There is growing acknowledgement of the development of Wernicke's encephalopathy in patients with malignancies.

Methods

We conducted a literature review in PubMed for cases of Wernicke's encephalopathy occurring in patients with malignancy. We also present the case of a 47-year-old woman with recurrent laryngeal cancer and multiple hospital admissions for malnutrition. Neurological examination was notable for pendular nystagmus, severe gait ataxia, confusion, and poor memory consolidation. MRI of the brain was significant for T2-weighted fluid-attenuated inversion recovery hyperintensities in periaqueductal regions, medial thalami, and the tectal plate, typical for Wernicke's encephalopathy. She was treated with thiamine repletion, and had marked improvement in her mental status and some improvement in her vision problems and ataxia, although some nystagmus and significant short-term memory impairment persisted.

Results

The literature review yielded dozens of case reports of Wernicke's encephalopathy in patients with malignancy, dominated by cases of patients with malignancies of the gastrointestinal system, followed by those with hematologic malignancies.

Conclusions

Malignancy is an important risk factor for the development of Wernicke's encephalopathy. This diagnosis is underappreciated and difficult for the clinician to discern from multifactorial delirium. Clinicians should be aware to treat at-risk patients with thiamine immediately, especially if multiple risk factors are present.