Autoimmune Antibodies in Children and Adolescents With Nonalcoholic Fatty Liver Disease.

OBJECTIVES: The clinical significance of autoantibody positivity in nonalcoholic fatty liver disease (NAFLD) in the absence of autoimmune hepatitis (AIH) remains uncertain. We aimed to determine the prevalence of autoantibodies in a pediatric cohort with biopsy-proven NAFLD and investigate the association between autoantibodies and NAFLD histologic grade. METHODS: Single-center, retrospective study of patients ≤21 years with biopsy-proven NAFLD from 2014 to 2019. Clinical and laboratory data were obtained within 90 days of liver biopsy. Autoantibody positivity was defined as serum titer ≥1:80 or units ≥20. Liver biopsies were evaluated for features of AIH, then scored for steatosis, hepatocyte ballooning, lobular inflammation, and NAFLD activity score (NAS) was calculated. Portal inflammation and fibrosis were scored separately. Multivariable logistic regression was used for continuous and binary outcomes. RESULTS: Sixty-seven subjects met inclusion criteria. Positive antinuclear antibody (ANA), antismooth muscle antibody (ASMA), antineutrophil cytoplasmic antibody (ANCA), anti-F-actin antibody (F-actin), anti-liver kidney microsomal (LKM) antibody, or any combination was observed in 43%, 39%, 19%, 13%, 0%, and 66% of subjects, respectively. After controlling for confounders, positive ANA and alanine aminotransferase (ALT) >80 had 4.6 greater odds of having an NAS ≥5 ( P = 0.035; 95% confidence interval [CI], 1.12-19.01). Autoantibody positivity resolution occurred in 10%-50% who underwent serial monitoring. CONCLUSIONS: Autoantibodies, except LKM, were frequently encountered in our pediatric NAFLD cohort in the absence of AIH. ANA positivity with ALT may help clinically stratify pediatric patients with suspected NAFLD targeting those at greater risk for nonalcoholic steatohepatitis (NASH).

Perspectives of adolescents with severe obesity on social Media in Preparation for weight-loss surgery: a qualitative study.

BACKGROUND: Currently the most effective treatment for severe obesity in adolescents is weight-loss surgery coupled with lifestyle behavior change. In preparation for weight-loss surgery, adolescents are required to make changes to eating and activity habits (lifestyle changes) to promote long term success. Social media support groups, which are popular among adolescents, have the potential to augment preoperative lifestyle changes. The purpose of this study was to qualitatively assess the perceived role of social media as a support tool for weight-loss, and to identify motivators and constraints to lifestyle changes and social media use in adolescents preparing for weight-loss surgery. METHODS: Thematic analysis of social media comments from 13 (3 male, 10 female) adolescents aged 16 ± 1.3 years with a body mass index (BMI) 45 ± 7.3 kg/m2 enrolled in a weight-management program preparing for bariatric surgery and who participated in a 12-week pilot social media intervention was performed. Participants commented on moderator posts and videos of nutrition, physical activity, and motivation that were shared three to four times per week. Social media comments were coded using NVivo 11.0 to identify recurrent themes and subthemes. RESULTS: 1) Social media provided accountability, emotional support, and shared behavioral strategies. 2) Motivators for lifestyle changes included family support, personal goals, and non-scale victories. 3) Challenges included negative peers, challenges with planning and tracking, and time constraints. CONCLUSION: Adolescents considering bariatric surgery identified social media as a tool for social support and reinforcement of strategies for successful behavior change. Important motivators and challenges to lifestyle changes were identified.

Update on childhood/adolescent obesity and its sequela.

PURPOSE OF REVIEW: We aim to describe current concepts on childhood and adolescent obesity with a strong focus on its sequela. Childhood obesity is a national epidemic with increasing prevalence over the past three decades placing children at increased risk for many serious comorbidities, previously felt to be only adult-specific diseases, making this topic both timely and relevant for general pediatricians as well as for subspecialists. RECENT FINDINGS: Childhood obesity develops through an interplay of genetics, environment, and behavior. Treatment includes lifestyle modification, and now metabolic and bariatric surgery is more commonly considered in carefully selected adolescents. The off-label use of adjunct medications for weight loss in childhood and adolescent obesity is still in its infancy, but will likely become the next logical step in those with lifestyle modification refractory obesity. Obesity can lead to several comorbidities, which can persist into adulthood potentially shortening the child's lifespan. SUMMARY: Efforts should be focused primarily on reducing childhood and adolescent obesity, and when indicated treating its sequela in effort to reduce future morbidity and mortality in this precious population. VIDEO ABSTRACT: http://links.lww.com/MOP/A36.

Clinical Practice Approach to Nonalcoholic Fatty Liver Disease by Pediatric Gastroenterologists in the United States.

OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is common; however, no information is available on how pediatric gastroenterologists in the United States manage NAFLD. Therefore, study objectives were to understand how pediatric gastroenterologists in the US approach the management of NAFLD, and to identify barriers to care for children with NAFLD. METHODS: We performed structured one-on-one interviews to ascertain each individual pediatric gastroenterologist's approach to the management of NAFLD in children. Responses were recorded from open-ended questions regarding screening for comorbidities, recommendations regarding nutrition, physical activity, medications, and perceived barriers to care. RESULTS: Response rate was 72.0% (486/675). Mean number of patients examined per week was 3 (standard deviation [SD] 3.5). Dietary intervention was recommended by 98.4% of pediatric gastroenterologists. Notably, 18 different dietary recommendations were reported. A majority of physicians provided targets for exercise frequency (72.6%, mean 5.6 days/wk, SD 1.6) and duration (69.9%, mean 40.2 minutes/session, SD 16.4). Medications were prescribed by 50.6%. Almost one-half of physicians (47.5%) screened for type 2 diabetes, dyslipidemia, and hypertension. Providers who spent more than 25 minutes at the initial visit were more likely to screen for comorbidities (P = 0.003). Barriers to care were reported by 92.8% with 29.0% reporting ≥3 barriers. CONCLUSIONS: The majority of US pediatric gastroenterologists regularly encounter children with NAFLD. Varied recommendations regarding diet and exercise highlight the need for prospective clinical trials. NAFLD requires a multidimensional approach with adequate resources in the home, community, and clinical setting.

Liraglutide with Lifestyle Intervention in Adolescents with Overweight/Obesity, Nonalcoholic Fatty Liver Disease, and Type II Diabetes Mellitus.

There is a strong interplay between nonalcoholic fatty liver disease (NAFLD), obesity, insulin resistance, and type II diabetes mellitus (T2DM). Liraglutide, a glucagon-like-peptide-1 (GLP-1) analogue, is FDA approved for T2DM in children 10 years or older and more recently approved for chronic weight management in children 12 years or older with obesity. GLP-1 analogues have also been shown to reduce liver enzymes and improve liver histology. We report two adolescent females with T2DM and biopsy proven nonalcoholic steatohepatitis (NASH) refractory to lifestyle intervention who were safety treated with liraglutide with associated weight loss and liver enzyme improvement. This is the first case series reporting use of liraglutide in pediatric NASH. Liraglutide should be considered in pediatric patients with overweight/obesity, NAFLD, and T2DM.

Utilization of Topiramate as an Adjunct to Lifestyle Intervention for Weight Loss in Pediatric Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease is the most common chronic liver disease in children and has become the leading indication for liver transplantation in adults. The primary treatment modality is lifestyle modification to promote weight loss, which is challenging to achieve and maintain. Adjunctive weight loss medications, such as topiramate, are commonly used off-label in adults and children with obesity and found to be safe and effective. We report an adolescent male with severe obesity and nonalcoholic steatohepatitis refractory to aggressive lifestyle intervention. He was safely treated with topiramate with resultant weight loss, reduction in body mass index z-score, improvement in liver enzymes, and resolution of hepatic steatosis. This is the first report of using topiramate in a pediatric patient with obesity and nonalcoholic steatohepatitis. Topiramate should be considered in pediatric nonalcoholic fatty liver disease to help curb emotional eating and promote satiety in cases refractory to lifestyle intervention alone.

Filipino nursing students' views of their clinical instructors' credibility.

BACKGROUND: Although the concept of clinical credibility has attracted the interest of some researchers in the field, it is interesting to note the substantive paucity of literature on this since the mid 1990s [Fisher, M., 2005. Exploring how nurse lecturers maintain clinical credibility. Nurse Education in Practice 5, 21-29.] specifically from an Asian context. OBJECTIVE: This qualitative study purports to capture how a select group of senior nursing students view their clinical instructors' credibility. METHOD: A total of 22 senior nursing students recruited from a comprehensive university in the capital of the Philippines participated voluntarily in this qualitative study. FINDINGS: With the use of individual indepth interview as a qualitative tool, findings of the study yielded three significant themes that elucidate the essence of credibility from the lens of Filipino nursing students. These include (1) credibility as an image building activity; (2) credibility as a work in progress; and (3) credibility as an influencing agent.