Nomenclature and definition of metabolic-associated fatty liver disease: a consensus from the Middle East and north Africa.

With the increasing prevalence of obesity and type 2 diabetes, fatty liver disease associated with metabolic dysfunction is a global health problem, especially because it is one of the earliest consequences of obesity and it precedes diabetes development. Fatty liver disease associated with metabolic dysfunction is of particular concern in the Middle East and north Africa, where its prevalence is greater than that in the rest of the world. Despite the magnitude of the problem, no regional guidelines have been developed to address this disease. This Review describes suggestions of redefining fatty liver disease associated with metabolic dysfunction, including its terminology and criteria for diagnosis. Experts have raised serious concerns on the current nomenclature, which labels the disease as non-alcoholic fatty liver disease (NAFLD), and its diagnostic criteria. The panel reached a consensus that the disease should be renamed as metabolic-associated fatty liver disease (MAFLD) and that the disease should be diagnosed by positive criteria. The aim is now to work with authorities across the region to implement these proposed changes and reflect them in health-care policy and to improve health care for patients in this region.

What's in a name? Renaming 'NAFLD' to 'MAFLD'.

In medicine, language matters and the words used to name and describe a disease can have a profound impact on patients and their families. Over the last two decades, many criticisms have been voiced about the nomenclature and definition of non-alcoholic fatty liver disease (NAFLD) in regards not only to the prominent role that alcohol plays in the definition but also on the negative impacts of the nomenclature including trivialization, stigmatization and less consideration of the disease in health policy. Recently, a consensus of international experts proposed that the disease acronym be changed from NAFLD to metabolic (dysfunction) associated fatty liver disease or 'MAFLD'. This change goes far beyond a mere semantic revision and may be the first step that catalyses the process to better conceptualize the disease for health promotion, patient orientation, case identification, ongoing clinical trials and for health services delivery. Here we review the history of, and definitions of MAFLD in the context of advancing our understanding of the pathogenesis of the disease. We also address the reasons, signals, promises, challenges and the way going forward from the name change from various stakeholder perspectives.

Clinical usefulness of therapeutic drug monitoring of thiopurines in patients with inadequately controlled inflammatory bowel disease.

BACKGROUND: Circulating concentrations of 6-thioguanine nucleotide (6-TGN) and 6-methyl mercaptopurine (6-MMP) are associated with thiopurine efficacy and may predict toxicity. This study aimed to examine retrospectively the utility of measuring metabolite concentrations in patients with inflammatory bowel disease (IBD) who had continuing symptoms despite stable thiopurine treatment. METHODS: Concentrations of 6-TGN and 6-MMP were measured in lysates of washed red cells by high-performance liquid chromatography in peripheral blood drawn from 63 symptomatic patients with IBD (63% men, mean age 37, range 14-74 years, 67% Crohn's disease, 33% ulcerative colitis) treated with azathioprine or 6-mercaptopurine. Short-term clinical outcomes were examined. RESULTS: 6-TGN concentrations weakly correlated with the thiopurine dose (r = 0.28, P = 0.08). On weight-based criteria, 50% of patients were underdosed. However, metabolite patterns suggested 7 (11%) patients were noncompliant, 18 (29%) were being underdosed, 33 (52%) were refractory to treatment with either appropriate (41%) or elevated (11%) metabolite concentrations, and 6 (10%) had a raised 6-MMP:6-TGN ratio consistent with aberrant thiopurine metabolism. The clinical outcome improved in 40 of 46 (87%) of patients in whom the course of action taken was as recommended by a metabolite-directed algorithm, while 3 of 17 patients (18%) improved where discordant actions were taken (P = 0.0001; Fisher's exact test). Fifteen patients (24%) avoided inappropriate escalation of therapy. CONCLUSIONS: Dose-optimization or toxicity-avoidance strategies frequently result from metabolite testing in patients with inadequate efficacy from thiopurines, with evidence of better outcomes. Thiopurine metabolite testing is a potentially powerful tool for optimizing thiopurine usage in IBD.

Hepatitis B infection among patients receiving chronic hemodialysis at the Royal Medical Services in Jordan.

Hepatitis B virus (HBV) infection is a major clinical problem in patients on maintenance hemodialysis (HD) and can lead to many serious consequences. This study was carried out in order to determine the prevalence of HBV infection and the possible risk factors for acquiring it, in patients on maintenance HD. All patients on regular HD in seven hospitals of the Royal Medical Services, Amman, Jordan, were studied during the period between July and December 2006. The medical history and records of these patients were reviewed for the presence of hepatitis B surface antigen (HbsAg), and possible risk factors for acquiring this infection. A total of 430 patients on HD with a mean age of 47.3 years were studied. Three patients, who were positive for HBsAg before starting dialysis, were excluded from the study. The remaining 427 patients, who were HBsAg negative before starting dialysis were included. Of these, 25 (5.9%) became HbsAg-positive during the study period. Being on HD for longer than two years and positive history of blood transfusion(s) were more frequently noticed in the HbsAg-positive group (88% and 60% respectively) compared with the HbsAg-negative group (43% and 56% respectively). Of 379/402 (94%) patients who remained Hbs Ag-negative and 1/25 (4%) of those who converted to Hbs Ag-positive were reportedly vaccinated. Our study suggests that the prevalence of HbsAg positivity in our HD patients was 5.9%. Dialysis for more than two years, but not history of blood transfusions, was noted to be a significant risk factor for acquiring this infection. Vaccination against the HBV gives good protection against this virus.

5-Aminosalicylic acid (mesalazine) use in Crohn's disease: a survey of the opinions and practice of Australian gastroenterologists.

BACKGROUND: The use of 5-aminosalicylate (5-ASA) drugs in Crohn's disease (CD) is controversial, with their continuing apparent widespread use despite high-level evidence indicating marginal benefit at best and international guidelines recommending limited indications. METHODS: In order to understand how clinicians translate the evidence base into clinical practice, we surveyed a cross-section of Australian gastroenterologists to determine opinions and prescribing patterns of 5-ASA drugs in CD. RESULTS: In all, 42% of 285 gastroenterologists who were sent a questionnaire by e-mail responded. Five (4%) never use 5-ASA drugs in CD. The drugs are most commonly prescribed for patients with colonic (96%) or ileocolonic (92%) disease location, inflammatory disease behavior (80%), and mild disease activity (97%). The majority (64%) use a dose of 1-3 g/day, but only 6% use over 4.5 g/day. Less than one-half use 5-ASA drugs as maintenance following surgical resection, but most use it for inducing remission alone (70%) or in combination with other drugs (90%), and continue its use for maintenance. Side effects are thought to be infrequent (62%) or rare (20%) and few common side effects are believed to be serious. Respondents estimated that over 90% of patients were nonadherent to prescribed 5-ASA regimens at least 50% of the time. While 84% believed that 5-ASA drugs were effective in CD, only 58% believed that they were cost-effective. CONCLUSIONS: In Australia 5-ASA drugs are extensively prescribed for CD at relatively low doses without expectation of patient adherence. Current evidence and guidelines has had little apparent impact on clinical practice. The cost implications are considerable.

Endoscopic balloon dilatation of intestinal strictures in Crohn's disease: safe alternative to surgery.

BACKGROUND AND AIM: Endoscopic balloon dilatation (EBD), a non-surgical treatment option for intestinal strictures in Crohn's disease, appears to be applied infrequently, possibly due to the perceived risk of perforation and early recurrence. This study aimed to determine the outcomes of EBD by a single endoscopist using a defined technique. METHODS: The records of all patients with Crohn's disease in whom EBD was attempted over a 12-year period were examined to determine the rate of technical success, complications and outcome. A stricture was defined as that which prevented passage of the 14 mm diameter colonoscope. Technical success was defined as the ability to traverse the stricture postdilatation. Patients were selected on the colonoscopic appearance of the stricture and dilatation was performed using through-the-endoscope balloons. Antibiotics were given during and for 7 days postdilatation. RESULTS: EBD was attempted on 83 strictures (31 anastomotic and 52 primary) in 37 patients (15 males) and was successful in 75 (90%) of 31 patients. A single dilatation only was required in 21 patients who had a median follow-up of 20 months (range 6-122 months). Recurrent symptomatic stricture requiring dilatation (eight patients) or surgery (two patients) occurred 8 (1-112) months after the initial dilatation. The only complication occurred in one patient where an intra-abdominal fistula and abscess were probably related to the dilatation. CONCLUSION: EBD of intestinal strictures associated with Crohn's disease has a low complication rate and leads to prolonged clinical benefit. It should be considered as a real alternative to surgery.