Preventing liver disease with policy measures to tackle alcohol consumption and obesity: The HEPAHEALTH II study.

BACKGROUND & AIMS: Chronic liver disease (CLD) causes 1.8% of all deaths in Europe, many of them from liver cancer. We estimated the impact of several policy interventions in France, the Netherlands, and Romania. METHODS: We used a validated microsimulation model to assess seven different policy scenarios in 2022-2030: a minimum unit price (MUP) of alcohol of €0.70 or €1, a volumetric alcohol tax, a sugar-sweetened beverage (SSB) tax, food marketing restrictions, plus two different combinations of these policies compared against current policies (the 'inaction' scenario). RESULTS: All policies reduced the burden of CLD and liver cancer. The largest impact was observed for a MUP of €1, which by 2030 would reduce the cumulative incidence of CLD by between 7.1% to 7.3% in France, the Netherlands, and Romania compared with inaction. For liver cancer, the corresponding reductions in cumulative incidence were between 4.8% to 5.8%. Implementing a package containing a MUP of €0.70, a volumetric alcohol tax, and an SSB tax would reduce the cumulative incidence of CLD by between 4.29% to 4.71% and of liver cancer by between 3.47% to 3.95% in France, the Netherlands, and Romania. The total predicted reduction in healthcare costs by 2030 was greatest with the €1 MUP scenario, with a reduction for liver cancer costs of €8.18M and €612.49M in the Netherlands and France, respectively. CONCLUSIONS: Policy measures tackling primary risk factors for CLD and liver cancer, such as the implementation of a MUP of €1 and/or a MUP of €0.70 plus SSB tax could markedly reduce the number of Europeans with CLD or liver cancer. IMPACT AND IMPLICATIONS: Policymakers must be aware that alcohol and obesity are the two leading risk factors for chronic liver disease and liver cancer in Europe and both are expected to increase in the future if no policy interventions are made. This study assessed the potential of different public health policy measures to mitigate the impact of alcohol consumption and obesity on the general population in three European countries: France, the Netherlands, and Romania. The findings support introducing a €1 minimum unit price for alcohol to reduce the burden of chronic liver disease. In addition, the study shows the importance of targeting multiple drivers of alcohol consumption and obesogenic products simultaneously via a harmonized fiscal policy framework, to complement efforts being made within health systems. These findings should encourage policymakers to introduce such policy measures across Europe to reduce the burden of liver disease. The modeling methods used in this study can assist in structuring similar modeling in other regions to expand on this study's findings.

Perinatal deaths and low birthweight in an urban health centre in the Gambia: A prospective cohort study.

Perinatal deaths (stillbirths after 28 weeks gestation and early neonatal deaths) are rarely reported separately but are the deaths most closely associated with complications during pregnancy, birth and the first days of life. We conducted a prospective cohort study to report perinatal deaths, late neonatal deaths and low birthweight babies as they occur. This cohort of birth outcomes from The Gambia was conducted between 2012 and 2016 and followed 1611 women attending a government-supported health center from the first antenatal visit to 28 days post-delivery. The outcome of the pregnancy was known for 1372 women (85.2%) and included 20 stillbirths and 12 early neonatal deaths. Of 1252 singleton babies with known birthweight 85 weighed less than 2500g (6.8%). Using multivariate analysis it was shown that women who attended the antenatal clinic four times or more were less likely to have a low birthweight baby than women who attended less than four times, OR 0.47 (95% CI:0.273-0.799). We conclude that frequent visits to the antenatal clinic are associated with better outcomes.

Determinants of compliance with the World Health Organisation recommendations for pregnant women in an urban health centre in The Gambia.

In 2001 the World Health Organization drew up recommendations for pregnant women in order to reduce maternal mortality: the first visit to the antenatal clinic to be in the first trimester, at least four visits in total and delivery with a trained birth attendant. This study reports the extent to which pregnant women attending a health centre in The Gambia complied with the recommendations. A cohort of 1611 consecutive pregnant women was recruited. Only 384 (23.9%) women first attended in the first trimester and 568 (41.6%) attended at least four times. Only 15.8% of the women complied with all recommendations. Following multivariate analysis the educational level of the partner was the sole factor associated with both recommendations regarding attendance. This level of compliance reflects widespread ignorance of the value of early antenatal care and frequent visits. Public health programmes require a basic level of education to be effective.

How Could Different Obesity Scenarios Alter the Burden of Type 2 Diabetes and Liver Disease in Saudi Arabia?

INTRODUCTION: Obesity is a major risk factor for type 2 diabetes (T2DM) and liver disease, and obesity-attributable liver disease is a common indication for liver transplant. Obesity prevalence in Saudi Arabia (SA) has increased in recent decades. SA has committed to the WHO "halt obesity" target to shift prevalence to 2010 levels by 2025. We estimated the future benefits of reducing obesity in SA on incidence and costs of T2DM and liver disease under two policy scenarios: (1) SA meets the "halt obesity" target; (2) population body mass index (BMI) is reduced by 1% annually from 2020 to 2040. METHODS: We developed a dynamic microsimulation of working-age people (20-59 years) in SA between 2010 and 2040. Model inputs included population demographic, disease and healthcare cost data, and relative risks of diseases associated with obesity. In our two policy scenarios, we manipulated population BMI and compared predicted disease incidence and associated healthcare costs to a baseline "no change" scenario. RESULTS: Adults <35 years are expected to meet the "halt obesity" target, but those ≥35 years are not. Obesity is set to decline for females, but to increase amongst males 35-59 years. If SA's working-age population achieved either scenario, >1.15 million combined cases of T2DM, liver disease, and liver cancer could be avoided by 2040. Healthcare cost savings for the "halt obesity" and 1% reduction scenarios are 46.7 and 32.8 billion USD, respectively. CONCLUSION: SA's younger working-age population is set to meet the "halt obesity" target, but those aged 35-59 are off track. Even a modest annual 1% BMI reduction could result in substantial future health and economic benefits. Our findings strongly support universal initiatives to reduce population-level obesity, with targeted initiatives for working-age people ≥35 years of age.

Preoperative statins and acute kidney injury after cardiac surgery: utilization of a consensus definition of acute kidney injury.

BACKGROUND: Previous trials investigating preoperative statin use for prevention of acute kidney injury following cardiovascular surgery were limited to patients undergoing a specific procedure and many used nonconsensus definitions of acute kidney injury. OBJECTIVE: To use a consensus definition of acute kidney injury for evaluating the association of preoperative statin use with the development of acute kidney injury following cardiac surgery utilizing cardiopulmonary bypass. METHODS: We retrospectively evaluated a cohort of 667 patients ≥18 years who underwent any cardiac surgery on cardiopulmonary bypass between April 2007 and May 2009 at Mercy Hospital in Scranton, PA. Patients were excluded if they were receiving preoperative renal replacement therapy, had stage 5 chronic kidney disease, or did not have a postoperative serum creatinine level assessed. The primary outcome was the odds of developing acute kidney injury given the use of preoperative statins. Acute kidney injury was defined based on the Acute Kidney Injury Network criteria as either an absolute increase in serum creatinine of ≥0.3 mg/dL or 1.5 times baseline, or the need for postoperative renal replacement therapy. RESULTS: The final analysis included 563 patients; 356 were receiving preoperative statins. The incidence of acute kidney injury was 35.1% in the statin group and 26.1% in the non-statin group. On univariate analysis statins were associated with an increase in the odds of acute kidney injury (OR 1.53; 95% CI 1.05 to 2.24). Multivariate logistic regression did not demonstrate an association of statins with acute kidney injury (OR 1.36; 95% CI 0.904 to 2.05). Repeating the analysis using 312 propensity score-matched patients also showed no association of statins with acute kidney injury (OR 1.17; 95% CI 0.715 to 1.93). CONCLUSIONS: Our findings do not support the hypothesis that preoperative statin use is associated with a decrease in the incidence of acute kidney injury following cardiac surgery utilizing cardiopulmonary bypass.

Enoxaparin dosing in the elderly using adjusted body weight.

We prospectively compared anti-Xa activity in 61 elderly (>65 years) subjects receiving enoxaparin according to standard or adjusted body weight (ABW) dosing. In the ABW dosing group, mean patient age was 76 years, mean weight 80 kg, mean serum creatinine 1.0 mg/dl, and mean CrCl 48 ml/min. ABW dosing resulted in 57% of elderly study subjects achieving anti-Xa activity of 0.5-1.0 IU/ml, and 80% achieving anti-Xa activity of 0.5-1.2 IU/ml. Compared to standard dosing, for all subjects ABW dosing of enoxaparin was associated with a more favorable mean anti-Xa activity (0.98 IU/ml vs. 1.28 IU/ml, P = 0.001), fewer highest-risk (>1.5 IU/ml) supratherapeutic anti-Xa levels (0% vs. 28%, P = 0.001), and more frequent therapeutic levels among women (64% vs. 25%, P = 0.001). ABW dosing of enoxaparin may be beneficial in elderly patients aged 65 and older, and its benefit appears to be more pronounced in female patients.

Improving diabetes care using a multitiered quality improvement model.

The authors report the results of implementing a diabetes mellitus guideline in a group practice in which uniform, technology-generated care processes were produced for patients, clinical staff, and providers. The objective was to increase the annual rate of recommended tests and examinations for patients with diabetes and to reduce levels of glycosylated hemoglobin, blood pressure, and low-density lipoprotein cholesterol. A process change for type 2 diabetes mellitus was implemented that included changes in office visit structure, protocol-driven electronic prompts for nursing and physician staffs, clinical decision support built into a new electronic medical record form, and audit with feedback. Twelve primary care physicians treated a total of 1592 patients with diabetes between January 2007 and January 2008. There were prompt and statistically significant improvements in 5 process measures and 2 outcome measures; a quality summary measure showed 8% overall improvement. Statistically significant improvements with moderate effect size were observed after a multitiered intervention.