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Cases of alcohol-associated liver disease (ALD) are increasing at a steady rate in the United States with more patients presenting with alcohol-associated hepatitis and alcohol-associated cirrhosis. While alcohol use has increased across many demographic groups, women are suffering from a greater increase in alcohol use disorder (AUD), and are at a greater risk of ALD due to pathophysiological differences which include absorption of alcohol, first pass metabolism, and hormonal differences. Differences across race have also been found with Native Americans and Hispanics suffering from some of the largest increases in ALD rates. Younger adults are heavily impacted by rising rates of both AUD and ALD. Comorbidities such as obesity and NASH have been shown to augment the deleterious effects of AUD and ALD, resulting in more advanced liver disease. Finally, COVID-19 and policies related to the pandemic have resulted in increased AUD across many cohorts, which have resulted in marked increases in ALD. In conclusion, ALD rates are rising, with young people and women particularly impacted. [ABSTRACT FROM AUTHOR]

Despite the mortality benefits of alcohol cessation and alcohol treatment, few patients with alcohol-related liver disease (ALD) get such treatment. To understand reasons for low treatment rates, we performed a qualitative mental models study to explore how ALD patients understand factors influencing alcohol cessation, relapse and their liver health. Using a mental models framework, we interviewed experts in alcohol use disorder (AUD) and ALD to determine factors influencing alcohol cessation, risk of relapse and liver health. An expert influence diagram was constructed and used to develop a patient interview guide. We recruited participants with ALD enrolled in hepatology or transplant clinics at a single tertiary-care center. We conducted interviews either face-to-face or by phone, per participant preference. We transcribed all interviews verbatim and analyzed them using combined deductive coding schema based on both the interview guide and emergent coding. 25 (10 women, 15 men) participants with a mean age of 57 years completed interviews. 68 % had decompensated cirrhosis. Major omissions included gender (as a factor in alcohol use or liver disease) and the influence of benzodiazepines/opioids on relapse. Misconceptions were common, in particular the idea that the absence of urges to drink meant participants were safe from relapse. Conceptual differences from the expert model emerged as well. Participants tended to view the self as primary and the only thing that could influence relapse in many cases, resulting in a linear mental model with few nodes influencing alcohol cessation. Participants' risky drinking signals (i.e., elevated liver enzymes) differed from known definitions of hazardous or high-risk drinking, which largely emphasize dose of alcohol consumed irrespective of consequences. Finally, participants sometimes viewed stopping on one's own as the primary means of stopping alcohol use, not recognizing the many other nodes in the influence diagram impacting ability to stop alcohol. Patients with ALD had critical misconceptions, omissions, and conceptual reorganizations in their mental models of the ability to stop alcohol use. Attention to these differences may allow clinicians and researchers to craft more impactful interventions to improve rates of alcohol abstinence and AUD treatment engagement. • Patients with ALD frequently do not access alcohol treatment and struggle to stop drinking. • Misconceptions about alcohol use and treatment are common • ALD patients often emphasize the ability to stop alcohol use on their own. • Perceptions of relapse risk can form barriers to AUD treatment. [ABSTRACT FROM AUTHOR]

Background & Aims: Bariatric surgery is common, but alcohol misuse has been reported following these procedures. We aimed to determine if bariatric surgery is associated with increased risk of alcohol‐related cirrhosis (AC) and alcohol misuse. Methods: Retrospective observational analysis of obese adults with employer‐sponsored insurance administrative claims from 2008 to 2016. Subjects with diagnosis codes for bariatric surgery were included. Primary outcome was risk of AC. Secondary outcome was risk of alcohol misuse. Bariatric surgery was divided into before 2008 and after 2008 to account for patients who had a procedure during the study period. Cox proportional hazard regression models using age as the time variable were used with interaction analyses for bariatric surgery and gender. Results: A total of 194 130 had surgery from 2008 to 2016 while 209 090 patients had bariatric surgery prior to 2008. Age was 44.1 years, 61% women and enrolment was 3.7 years. A total of 4774 (0.07%) had AC. Overall risk of AC was lower for those who received sleeve gastrectomy and laparoscopic banding during the study period (HR 0.4, P <.001; HR 0.43, P =.02) and alcohol misuse increased for Roux‐en‐Y and sleeve gastrectomy recipients (HR 1.86 and 1.35, P <.001, respectively). In those who had surgery before 2008, women had increased risk of AC and alcohol misuse compared to women without bariatric surgery (HR 2.1 [95% CI: 1.79‐2.41] for AC; HR 1.98 [95% CI 1.93‐2.04]). Conclusions: Bariatric surgery is associated with a short‐term decreased risk of AC but potential long‐term increased risk of AC in women. Post‐operative alcohol surveillance is necessary to reduce this risk. [ABSTRACT FROM AUTHOR]

Although alcohol-associated liver disease has long been a major component of the liver disease landscape, it was overshadowed by chronic hepatitis C until recently. Nevertheless, with the declining incidence of hepatitis C in the wake of highly effective antiviral therapy, attention has shifted to the increasing burden of alcohol-associated liver disease. The incidence of advanced alcohol-associated liver disease, including acute alcoholic hepatitis and alcohol-associated cirrhosis, is rising in parallel with increasing rates of alcohol use disorders. As a result, alcohol-associated liver disease is now one of the most common indications for liver transplantation. Rates of liver transplantation for acute alcoholic hepatitis are rising as well in spite of the sparse guidance regarding candidate selection, counseling, postoperative care, long-term follow-up, and other best practices. To this day, liver transplant for acute alcoholic hepatitis remains a hotly debated clinical controversy. [ABSTRACT FROM AUTHOR]

Background: The burden of alcohol‐associated cirrhosis (AC) is high, and though alcohol cessation improves mortality, many patients fail to engage in alcohol use disorder (AUD) treatment and continue drinking. Our aim was to determine rates, predictors, and outcomes of AUD treatment utilization in AC patients with private insurance. Methods: We collected data from persons with AC (diagnosed by ICD‐9/ICD‐10 codes), aged 18 to 64 years, enrolled in the Truven MarketScan Commercial Claims and Encounters database (2009 to 2016). We determined rates and predictors of substance abuse treatment visits as well as rates of alcohol relapse prevention medication prescriptions, weighted to the national employer‐sponsored insured population. Effects of AUD treatment utilization on decompensation rates were calculated using proportional hazards regression with propensity score adjustment. Results: A total of 66,053 AC patients were identified, 32% were female, and mean age at diagnosis was 54.5 years. About 72% had insurance coverage for substance abuse treatment. Overall, AUD treatment utilization rates were low, with only 10% receiving a face‐to‐face mental health or substance abuse visit and only 0.8% receiving a Food and Drug Administration (FDA)‐approved relapse prevention medication within 1 year of index diagnosis. Women were less likely to receive a face‐to‐face visit (hazard ratio [HR] 0.84, p < 0.001) or an FDA‐approved relapse prevention medication (0.89, p = 0.05) than men. AC patients who had a clinic visit for AUD treatment or used FDA‐approved relapse medication showed decreased risk of decompensation at 1 year (HR 0.85, p < 0.001 for either). Conclusions: AUD treatment utilization is associated with lower decompensation rates among privately insured patients with AC. Women were less likely to utilize AUD treatment visits. Efforts to reduce gender‐specific barriers to treatment are urgently needed to improve outcomes. Access to alcohol use treatment is critical for those with alcohol‐associated liver disease as alcohol cessation improves outcomes. In this study of a large population of privately insured US adults with alcohol‐associated cirrhosis, access to alcohol use treatment was low, and access to all forms of alcohol use treatment was lower in women compared to men. Those who received treatment were less likely to experience symptoms of cirrhosis. Future studies should determine how to improve rates of alcohol use treatment for those with alcohol‐associated cirrhosis. [ABSTRACT FROM AUTHOR]

Background: While alcohol cessation improves mortality in alcoholic liver disease (ALD), many patients struggle to achieve abstinence. Our aim was to characterize ALD patients' preferences, misconceptions, and barriers to alcohol use treatment options.Methods: This mixed-methods study included outpatients with a history of alcohol-related cirrhosis or alcoholic hepatitis recruited from a hepatology clinic for a survey or an in-depth semi-structured interview. We purposefully sampled men and women, compensated and decompensated patients to ensure adequate representation of gender and severity of liver disease for the qualitative interviews.Results: 123 patients completed surveys among which 50% reported having at least one drink within the past year while only 20 patients were in any form of current alcohol treatment. Of the 23 patients reporting drinking within 3 months, only 3 were in AUD treatment currently. 17% had at least one misconception about alcohol use or treatment. An additional 22 ALD patients (10 women, 12 men) completed phone interviews of which two-third self-reported alcohol abstinence. All 22 interview participants had awareness of some form of alcohol treatment, but 13 felt that they did not need treatment with several characterizing it as ineffective or a "waste of time." Misconceptions included inaccurate perceptions of relapse medication side effects, beliefs that the presence of advanced liver disease symptoms means it is too late to treat alcohol use, and a lack of understanding about the chronicity of alcohol use disorders. The most common barriers to treatment included unwillingness to be in treatment, financial/insurance and transportation barriers.Conclusions: Alcohol use treatment was underutilized in many ALD patients, despite active drinking in many. Tailored education and preference sensitive treatment engagement may overcome barriers to alcohol use treatment and promote abstinence. [ABSTRACT FROM AUTHOR]

Aims: Alcohol-related liver disease (ALD) is the second leading cause of liver transplantation performed in the USA and Europe. We aimed to provide a narrative review of the major ethical issues governing transplantation for ALD. Methods: We performed a narrative review of the ethical concepts in organ allocation for ALD, including alcoholic hepatitis. Results: Ethical concerns regarding organ allocation for ALD involve issues of urgency, utility and justice. Post-transplant outcomes for ALD patients are good and ethical considerations limiting organs solely because of alcohol etiology do not bear scrutiny. Conclusion: ALD will continue to be a major cause for liver failure. The main criteria for transplant in ALD should be the patient's risk of return to harmful drinking, alongside standard assessments of physical and psychosocial fitness for transplant. [ABSTRACT FROM AUTHOR]

Aims Alcohol-related liver disease (ALD) is the second leading cause of liver transplantation performed in the USA and Europe. We aimed to provide a narrative review of the major ethical issues governing transplantation for ALD. Methods We performed a narrative review of the ethical concepts in organ allocation for ALD, including alcoholic hepatitis. Results Ethical concerns regarding organ allocation for ALD involve issues of urgency, utility and justice. Post-transplant outcomes for ALD patients are good and ethical considerations limiting organs solely because of alcohol etiology do not bear scrutiny. Conclusion ALD will continue to be a major cause for liver failure. The main criteria for transplant in ALD should be the patient's risk of return to harmful drinking, alongside standard assessments of physical and psychosocial fitness for transplant. [ABSTRACT FROM AUTHOR]

Understanding the role of modest alcohol consumption in patients with non-alcohol induced fatty liver disease (NAFLD) remains a significant challenge, with no clear guidance on counselling regarding alcohol use. Conventionally, the strong association of alcohol excess and development of complications related to chronic liver disease, including hepatocellular carcinoma, has led practitioners to advocate complete abstinence to those with NAFLD. New evidence published in this issue of the Red Journal challenges the historic paradigm by showing that modest, non-binge wine consumption (<70 g/week) associates with significantly lower risk of advanced hepatic fibrosis on biopsy compared with complete abstinence across a well-characterised single centre cohort of nearly 200 patients with NAFLD. [ABSTRACT FROM AUTHOR]

Background & Aims Non-alcoholic fatty liver disease (NAFLD) is highly prevalent and is associated with development of metabolic disease including atherosclerotic cardiovascular disease (CVD). Our aim is to examine the association of hepatic steatosis with prevalent clinical and subclinical CVD outcomes in a large community-based sample, the Framingham Heart Study. Methods Hepatic steatosis was measured in 3529 participants using multidetector computed tomography scanning. Multivariable logistic regression was used to determine whether hepatic steatosis is associated with prevalent CVD adjusted for covariates. We also tested whether associations were independent of other metabolic diseases/traits. The primary clinical outcome was composite prevalent clinical CVD defined by prior non-fatal myocardial infarction, stroke, transient ischemic attack, heart failure, or peripheral arterial disease. Subclinical cardiovascular outcomes were coronary artery calcium (CAC) and abdominal artery calcium (AAC). Results 3014 participants were included (50.5% women). There was a non-significant association of hepatic steatosis with clinical CVD (OR 1.14 [ p = 0.07]). Hepatic steatosis was associated with both CAC and AAC (OR 1.20 [ p <0.001] and OR 1.16 [ p <0.001], respectively). Associations persisted for CAC even when controlling for other risk factors/metabolic diseases, but for AAC, the associations became non-significant after adjustment for visceral adipose tissue. The association between hepatic steatosis and AAC was stronger in men than in women ( p sex interaction = 0.022). Conclusion There was a significant association of hepatic steatosis with subclinical CVD outcomes independent of many metabolic diseases/traits with a trend towards association between hepatic steatosis and clinical CVD outcomes. The association with AAC was stronger in men than in women. [ABSTRACT FROM AUTHOR]

Background: Alcohol cessation improves mortality in alcohol-associated liver disease (ALD), but access to treatment is limited. To address this gap, implementation and early feasibility and outcomes of a multidisciplinary ALD clinic are described.Methods: The clinic comprised a hepatologist, psychiatrist, psychologist, nurse, and social worker. Patients included those with alcohol-associated cirrhosis or acute alcoholic hepatitis who were not in the transplant evaluation process, who had less than 6 months' sobriety and willingness to engage in alcohol use treatment. Psychosocial metrics in addition to routine hepatic function labs were collected. Treatment plans were tailored based on patient preferences and needs after multidisciplinary discussion.Results: 89 patients were referred from both inpatient and outpatient settings, with 51 seen during the initial year. 38 remained active in clinic (4 died, 6 discharged, 3 moved to transplant clinic). 55% were women, 88% were white, 61% had private insurance. 49% had alcoholic hepatitis. 71% were decompensated. 80% had severe alcohol use disorder (AUD) and 84% had at least 1 comorbid psychiatric or substance use disorder. 63% chose one-on-one AUD treatment, 57% were prescribed relapse prevention medications. Mean MELD-Na score improved from baseline of 14 (SD 6.6) to 11.3 at 6 months (p=0.01). Hospital utilization significantly declined when comparing 6 months before to 6 months after initial visit (emergency department visits: 0.51 to 0.20 per person-month; inpatient admission: 0.34 to 0.14 per person-month; (β= -0.89, 95% CI -1.18 to -0.60).Conclusions: A multidisciplinary ALD clinic was feasible with encouraging early outcomes. Further research should explore ways to expand this model and increase clinic capacity. [ABSTRACT FROM AUTHOR]

Alcohol-related liver disease (ALD) is the medical manifestation of alcohol use disorder, a prevalent psychiatric condition. Acute and chronic manifestations of ALD have risen in recent years especially in young people and ALD is now a leading indication of liver transplantation (LT) worldwide. Such alarming trends raise urgent and unanswered questions about how medical and psychiatric care can be sustainably integrated to better manage ALD patients before and after LT. Critical evaluation of the interprofessional implications of broad and multifaceted ALD pathophysiology, general principles of and barriers to interprofessional teamwork and care integration, and measures that clinicians and institutions can implement for improved and integrated ALD care. The breadth of ALD pathophysiology, and its numerous medical and psychiatric comorbidities, ensures that no single medical or psychiatric discipline is adequately trained and equipped to manage the disease alone. Early models of feasible ALD care integration have emerged in recent years but much more work is needed to develop and study them. The future of ALD care is an integrated approach led jointly by interprofessional medical and psychiatric clinicians. [ABSTRACT FROM AUTHOR]

This article provides practical advice for gastroenterologists on optimizing care for patients with alcohol-associated liver disease (ALD) and alcohol use disorder (AUD). It emphasizes the importance of addressing AUD in patients with ALD and suggests implementing alcohol screening, brief interventions, and referral to treatment. The article also discusses the use of pharmacotherapy and psychotherapy for AUD treatment, including the caution needed when using Naltrexone in patients with liver disease. It concludes by providing resources for locating AUD treatment and highlighting the role of gastroenterologists in providing education, counseling, and referrals for at-risk patients. [Extracted from the article]

Background: Little is known about patient choice in treatment of eosinophilic esophagitis (EoE).Aim: Determine motivators and barriers to using common EoE therapies and describe patient-reported shared decision making (SDM) and satisfaction with treatment.Methods: We developed and administered a Web-based survey on factors influencing EoE treatment choice, SDM, and satisfaction. Adults with EoE and adult caregivers of pediatric EoE patients were recruited via patient advocacy groups and at two centers. Descriptive statistics of multiple response questions and multivariable logistic regression were performed to identify predictors of SDM and satisfaction with treatment.Results: A total of 243 adults (mean age 38.7 years) and 270 adult caregivers of children (mean age 9.5 years) completed the survey. Preventing worsening disease was the most common motivator to treat EoE. Barriers to topical steroids were potential side effects, cost, and preferring a medication-free approach. Inconvenience and quality of life were barriers to diet. Potential adverse events, discomfort, and cost were barriers to dilation. Nearly half (42%) of patients experienced low SDM, but those followed by gastroenterologists were more likely to experience greater SDM compared to non-specialists (OR 1.81; 95% CI 1.03-3.15). Patients receiving more SDM were more satisfied with treatment, regardless of provider or treatment type (OR 2.62, 95% CI 1.76-3.92).Conclusions: Patients with EoE pursue treatment mostly to prevent worsening disease. Common barriers to treatment are inconvenience and financial costs. SDM is practiced most by gastroenterologists, but nearly half of patients do not experience SDM, indicating a substantial area of need in EoE. [ABSTRACT FROM AUTHOR]

Alcohol use treatment such as medication-assisted therapies (MATs) and counseling are available and effective in promoting alcohol abstinence. We sought to explore the cost-effectiveness of different alcohol use treatments among patients with compensated alcohol-related cirrhosis (AC). We simulated a cohort of patients with compensated AC receiving care from a hepatology clinic over their lifetimes. We estimated costs (in 2017 US$) and benefits in terms of quality-adjusted life years (QALYs) gained from healthcare and societal perspectives. Transition probabilities, costs, and health utility weights were taken from the literature. Treatment effects of FDA-approved MATs (acamprosate and naltrexone) and non-FDA approved MATs (baclofen, gabapentin, and topiramate) and counseling were based on a study of employer-insured patients with AC. We calculated incremental cost-effectiveness ratios (ICERs) and performed one-way and probabilistic sensitivity analyses to understand the impact of parameter uncertainty. Compared to a do-nothing scenario, MATs and counseling were found to be cost-saving from a healthcare perspective, which means that they provide more benefits with less costs than no intervention. Compared to other interventions, acamprosate and naltrexone cost the least and provide the most QALYs. If the effectiveness of MATs and counseling decreased, these interventions would still be cost-effective based on the commonly used $100,000 per QALY gained threshold. Several sensitivity and scenario analyses showed that our main findings are robust. Among patients with compensated AC, MATs and counseling are extremely cost-effective, and in some cases cost-saving, interventions to prevent decompensation and improve health. Health policies (e.g. payer reimbursement) should emphasize and appropriately compensate for these interventions. Alcohol use treatments, including physician counseling and medication-assisted therapies (MATs), improve the outcomes of patients with compensated alcohol-related cirrhosis, though use and access have remained suboptimal. In this study, we found that counseling and MATs are extremely cost-effective, and in some cases cost-saving, interventions to help patients with alcohol-related cirrhosis abstain from alcohol and improve their health. Wider use of these interventions should be encouraged. [Display omitted] • Alcohol use treatments improve outcomes in patients with alcohol-related cirrhosis. • Medication-assisted therapies and counseling are cost-effective or cost-saving. • Different assumptions on costs and effectiveness do not shift main findings. • Wider use of these interventions should be encouraged. [ABSTRACT FROM AUTHOR]

Interprofessional teamwork (IPT) is a well-established idea spanning multiple professional fields and supported by decades of literature. IPT is underemphasized in the medical literature despite its known impact on patient safety and care delivery. While many transplant teams adeptly work together, little has been written about team dynamics in organ transplantation and less on how IPT principles apply to transplant psychosocial clinicians. This editorial summarizes IPT principles, extrapolates key elements to psychosocial work in organ transplantation, flags potential barriers, collates practical strategies for teamwork enhancement, and identifies areas for future study. [ABSTRACT FROM AUTHOR]