Goals: To investigate the effect of obesity on the stages of fibrosis discordance between FibroScan and liver biopsy. Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of liver disease worldwide. Accurate fibrosis assessment is essential in MASLD patients for prognosis and treatment. Vibration-controlled transient elastography using FibroScan can overestimate liver fibrosis in obese patients. Study: This retrospective study included 245 MASLD patients who underwent FibroScan and liver biopsy. Participants were included with FibroScan controlled attenuation parameter (CAP) 250+, 10 liver stiffness measurements (LSM) with IQR/med ≤30%, and 10+ portal tracts on biopsy. Discordance was defined as a ≥2 stage difference between FibroScan and liver biopsy. Participants were stratified by BMI and obesity class to assess their association with discordance. We conducted a post hoc analysis to determine the implication of discordance on resmetirom eligibility. Data was entered into SPSS v28. Results: Among 245 patients, 29.4% exhibited a ≥2 stage discordance between FibroScan and biopsy. Class 3 obesity was significantly associated with discordance (38.6%) compared with class 2 obesity (24.6%) and class 0 to 1 obesity (18.4%). FibroScan suggested cirrhosis in 66 (57.9%) participants with class 3 obesity, however, liver biopsy confirmed cirrhosis in only 16 (24.2%) subjects and identified 28 (42.4%) subjects with stages 2 to 3 fibrosis, making them potentially eligible for resmetirom. Conclusions: FibroScan significantly overestimates advanced fibrosis and cirrhosis in class 3 obesity. A second noninvasive test is warranted for accurate liver-directed therapeutic allocation and to minimize unnecessary biopsies in MASLD management.

GOALS:To investigate the effect of obesity on the stages of fibrosis discordance between FibroScan and liver biopsy. BACKGROUND:Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading cause of liver disease worldwide. Accurate fibrosis assessment is essential in MASLD patients for prognosis and treatment. Vibration-controlled transient elastography using FibroScan can overestimate liver fibrosis in obese patients. STUDY:This retrospective study included 245 MASLD patients who underwent FibroScan and liver biopsy. Participants were included with FibroScan controlled attenuation parameter (CAP) 250+, 10 liver stiffness measurements (LSM) with IQR/med ≤30%, and 10+ portal tracts on biopsy. Discordance was defined as a ≥2 stage difference between FibroScan and liver biopsy. Participants were stratified by BMI and obesity class to assess their association with discordance. We conducted a post hoc analysis to determine the implication of discordance on resmetirom eligibility. Data was entered into SPSS v28. RESULTS:Among 245 patients, 29.4% exhibited a ≥2 stage discordance between FibroScan and biopsy. Class 3 obesity was significantly associated with discordance (38.6%) compared with class 2 obesity (24.6%) and class 0 to 1 obesity (18.4%). FibroScan suggested cirrhosis in 66 (57.9%) participants with class 3 obesity, however, liver biopsy confirmed cirrhosis in only 16 (24.2%) subjects and identified 28 (42.4%) subjects with stages 2 to 3 fibrosis, making them potentially eligible for resmetirom. CONCLUSIONS:FibroScan significantly overestimates advanced fibrosis and cirrhosis in class 3 obesity. A second noninvasive test is warranted for accurate liver-directed therapeutic allocation and to minimize unnecessary biopsies in MASLD management.

Vibration-controlled transient elastography (VCTE) is used for the noninvasive assessment of liver fibrosis. We present a case of significant weight loss over 1 year, resulting in a marked improvement in liver stiffness suggesting a decrease in liver fibrosis from stage 4 (cirrhosis) to stage 2 (moderate fibrosis) notably without a change in the grade of hepatic steatosis. The improvement in two stages of fibrosis over this short time frame is due to the overestimation of liver stiffness in a subject with class 3 obesity and not due to the resolution of fibrosis. Therefore, this case highlights that BMI, due to excess subcutaneous abdominal adipose tissue and not intrahepatic lipid accumulation, can cause a significant overestimation of liver fibrosis with VCTE.

Introduction: Studies have compared the group-averages of liver stiffness measures (LSMs) from multiple rib spaces by vibration-controlled transient elastography (VCTE) to stage liver fibrosis. No previous study has assessed within-individual liver stiffness variation from two rib spaces in individuals with metabolic-dysfunction associated steatotic liver disease (MASLD). Methods: We evaluated within-individual LSM variation according to body weight classification and its clinical implication. From October 2019 to March 2024, VCTE was performed on MASLD patients or those at high risk, in accordance with FibroScan guidelines. The LSMs were categorized into stages: <5 kPa (stage 0), 5–7.99 kPa (stage 1), 8–9.99 kPa (stage 2), 10–13.99 kPa (stage 3), and 14+ kPa (stage 4). Measurements with 10 values and IQR/median ≤ 0.30 were included, using SPSS V25.0 for analysis. Results: Among 1107 subjects (age 54.4 ± 13.9 years, 56.9% female), 7.7% were normal weight, 20.7% overweight, 28.9% class 1 obesity, 21.3% class 2 obesity, and 21.2% class 3 obesity. Significant within-individual variation was noted: 67% (0–2 kPa) variation, 23.4% (2.1–6 kPa), and 10% (≥6.1 kPa). Class 3 obese individuals had the maximum variation. Comparing the group-average of LSM at each ICS site showed that 95% of individuals were within one fibrosis stage. Conclusions: While LSM group-averages at different rib sites provides reliable fibrosis staging, significant within-individual variability exists especially in class 3 obesity. This should be considered when serial LSM assessments are used to assess medical therapeutic efficacy.

Background: The American Gastroenterology Association (AGA) guidelines for metabolic dysfunction -associated steatotic liver disease (MASLD) recommend screening for fibrosis in high -risk subjects with either type 2 diabetes, two or more metabolic risk factors, or steatosis on imaging. The 2021 AGA guidelines recommend calculating a fibrosis -4 index (FIB -4) score, and patients with scores above low -risk require further workup with FibroScan to assess liver stiffness measurement (LSM), a surrogate for liver fibrosis. However, FIB -4 scores have been suggested to be less accurate in patients with type 2 diabetes. The aim of our study was to identify the prevalence of significant to advanced fibrosis in subjects with a low -risk FIB -4 value with FibroScan's LSM in type 2 diabetes. Methods: A total of 1,153 subjects were referred to our liver center between August 2019 and September 2022; 1,114 subjects met MASLD criteria with data to calculate FIB -4 values. Subjects were categorized into age adjusted low -risk FIB -4 groups. Diagnosis of diabetes was determined by medical history. Results: Low -risk age -adjusted FIB -4 scores were observed in 68.3% of older subjects and 73.4% of younger subjects (P = not significant (NS)). In the older group and younger cohorts, a LSM >= 10 kPa was noted in 21% suggesting advanced liver fibrosis. Seventy-one point six percent of older diabetic subjects had low FIB -4 values, similar to 67.2% of young diabetic subjects with low FIB4 values. Overall, 72% of subjects would not have been referred for FibroScan per AGA criteria. Despite low -risk FIB -4 scores, 257 subjects had LSM greater than or equal to 8 kPa and 148 underwent a liver biopsy. Forty-eight percent of patients with biopsies had significant fibrosis (F2-4), predominately affecting subjects with type 2 diabetes. Conclusions: Diabetic subjects, despite having a low -risk FIB -4 tests, were four -fold more likely to demonstrate significant to advanced fibrosis, highlighting the limitations of FIB -4 in these individuals.

Background Fibroblast growth factor 21 (FGF21) regulates metabolism and protects cells against stress. Efruxifermin is a bivalent Fc-FGF21 analogue that replicates FGF21 agonism of fibroblast growth factor receptor 1c, 2c, or 3c. The aim of this phase 2b study was to assess its efficacy and safety in patients with non-alcoholic steatohepatitis (NASH) and moderate (F2) or severe (F3) fibrosis.Methods HARMONY is a multicentre, randomised, double-blind, placebo-controlled, 96-week, phase 2b trial that was initiated at 41 clinics in the USA. Adults with biopsy-confirmed NASH, defined by a non-alcoholic fatty liver disease activity score (NAS) of 4 or higher and scores of 1 or higher in each of steatosis, ballooning, and lobular inflammation, with histological stage F2 or F3 fibrosis, were randomly assigned (1:1:1), via an interactive response system, to receive placebo or efruxifermin (28 mg or 50 mg), subcutaneously once weekly. Patients, investigators, pathologists, site stall, and the sponsor were masked to group assignments during the study. The primary endpoint was the proportion of patients with improvement in fibrosis of at least 1 stage and no worsening of NASH, based on analyses of baseline and week 24 biopsies (liver biopsy analysis set [LBAS]). A sensitivity analysis evaluated the endpoint in the full analysis set (FAS), for which patients with missing biopsies were considered non-responders. This trial is registered with ClinicalTrials.gov, NCT04767529, and is ongoing.Findings Between March 22, 2021, and Feb 7, 2022, 747 patients were assessed for eligibility and 128 patients (mean age 54 center dot 7 years [SD 10 center dot 4]; 79 [62%] female and 49 male [38%]; 118 [92%] white; and 56 [41%] Hispanic or Latino) were enrolled and randomly assigned to receive placebo (n=43), efruxifermin 28 mg (n=42; two randomised patients were not dosed because of an administrative error), or efruxifermin 50 mg (n=43). In the LBAS (n=113), eight (20%) of 41 patients in the placebo group had an improvement in fibrosis of at least 1 stage and no worsening of NASH by week 24 versus 15 (39%) of 38 patients in the efruxifermin 28 mg group (risk ratio [RR] 2 center dot 3 [95% CI 1 center dot 1-4 center dot 8]; p=0 center dot 025) and 14 (41%) of 34 patients in the efruxifermin 50 mg group (2 center dot 2 [1 center dot 0-5 center dot 0]; p=0 center dot 036). Based on the FAS (n=128), eight (19%) of 43 patients in the placebo group met this endpoint versus 15 (36%) of 42 in the efruxifermin 28 mg group (RR 2 center dot 2 [95% CI 1 center dot 0-4 center dot 8]; p=0 center dot 033) and 14 (33%) of 43 in the efruxifermin 50 mg group (1 center dot 9 [0 center dot 8-4 center dot 3]; p=0 center dot 123). The most frequent efruxifermin-related adverse events were diarrhoea (16 [40%] of 40 patients in the efruxifermin 28 mg group and 17 [40%] of 43 patients in efruxifermin 50 mg group vs eight [19%] of 43 patients in the placebo group; all events except one were grade 1-2) and nausea (11 [28%] patients in the efruxifermin 28 mg group and 18 [42%] patients in the efruxifermin 50 mg group vs ten [23%] patients in the placebo group; all grade 1-2). Five patients (two in the 28 mg group and three in the 50 mg group) discontinued due to adverse events. Serious adverse events occurred in four patients in the 50 mg group; one was defined as drug related (ulcerative esophagitis in a participant with a history of gastroosophageal reflux disease). No deaths occurred. Interpretation Efruxifermin improved liver fibrosis and resolved NASH over 24 weeks in patients with F2 or F3 fibrosis, with acceptable tolerability, supporting further assessment in phase 3 trials.

BACKGROUND:Non-alcoholic fatty liver conditions in adolescence are associated with premature mortality in adulthood. Effective screening could impact the population burden of this disease.OBJECTIVES:We sought to determine which adolescents should be screened for non-alcoholic fatty liver using vibration-controlled transient elastography.METHODS:We simulated a non-alcoholic fatty liver screening program of 938 adolescents from the National Health and Nutritional Examination Survey of 2017/2018. We stratified subjects by body mass index and metabolic parameters and analyzed our data using standard diagnostic statistical measures.RESULTS:The weighted prevalence of non-alcoholic fatty liver and non-alcoholic fatty liver disease was 24.4%, and 3.8%, respectively. For all subjects with obesity (21.8% of the population), screening identified 61.8% of the non-alcoholic fatty liver cases. In a category of all subjects with obesity and overweight subjects with metabolic abnormalities (26.7% of the population), screening identified 71.2% of non-alcoholic fatty liver cases.CONCLUSIONS:The two groups most likely to benefit by transient elastography screening are adolescents with obesity and overweight adolescents with one metabolic abnormality. These criteria reduce the number of individuals to be tested by approximately 80% (from an approximate 32 million adolescents to 6-7.5 million adolescents), while retaining a diagnostic accuracy of 84%-85%.

Management of massive non-variceal upper gastrointestinal bleeding (NV-UGIB) can be challenging. Transarterial Embolization (TAE) is often the first therapeutic approach when endoscopic therapy fails before surgery. The purpose of this study is to analyze the technical success, and outcome for our patients with an NV-UGIB referred for TAE. This retrospective analysis included 74 consecutive patients with an NV-UGIB in whom TAE was performed after endoscopic treatment between February 2016 to May 2019 at Prisma Health-Upstate Greenville Memorial Hospital. TAE was 98.7

AbstractObjective:To explore whether individuals who consume higher amounts of ultra-processed food (UPF) have more adverse mental health symptoms.Design:Using a cross-sectional design, we measured the consumption of UPF as a percentage of total energy intake in kilo-calories using the NOVA food classification system. We explored whether individuals who consume higher amounts of UPF were more likely to report mild depression, more mentally unhealthy days and more anxious days per month using multivariable analyses adjusting for potential confounding variables.Setting:Representative sample from the United States National Health and Nutrition Examination Survey between 2007 and 2012.Participants:10 359 adults aged 18+ without a history of cocaine, methamphetamine or heroin use.Results:After adjusting for covariates, individuals with the highest level of UPF consumption were significantly more likely to report at least mild depression (OR: 1·81; 95 % CI1·09, 3·02), more mentally unhealthy (risk ratio (RR): 1·22; 95 % CI 1·18, 1·25) and more anxious days per month (RR: 1·19; 95 % CI 1·16, 1·23). They were also significantly less likely to report zero mentally unhealthy (OR: 0·60; 95 % CI 0·41, 0·88) or anxious days (OR: 0·65; 95 % CI 0·47, 0·90).Conclusions:Individuals reporting higher intakes of UPF were significantly more likely to report mild depression, more mentally unhealthy and more anxious days and less likely to report zero mentally unhealthy or anxious days. These data add important information to a growing body of evidence concerning the potential adverse effects of UPF consumption on mental health.

Objectives Lifestyle behaviors relevant to cardiovascular health are learned during childhood and continued into adulthood. Children and adolescents who participate in unhealthy behaviors have a higher lifetime risk of cardiovascular disease in adulthood. Public health institutions publish behavior and clinical recommendations designed for adolescents to reduce their lifetime cardiovascular risk. We assessed the prevalence and trends of cardiovascular-relevant behaviors and clinical tests among early adolescents using a nationally representative database. Methods In 2020, we compared the prevalence of cardiovascular risk factors among 1408 adolescents surveyed from 1988 to 1994 with that of 1812 adolescents surveyed from 2011 to 2016 by obtaining and comparing measures on physical activity, diet, body mass index, smoking status, cholesterol levels, hemoglobin A1c, sodium intake, and blood pressure. Results The prevalence of adherence to the current recommendations regarding physical activity, diet, and body weight declined over time. Conversely, the prevalence of adhering to recommendations to avoid smoking increased. Clinical indicators, including blood pressure control and normal measures of hemoglobin A1c and total serum cholesterol, showed mixed results, with more individuals showing signs of hyperglycemia, fewer showing signs of hypercholesterolemia, and the percentage of individuals with abnormal blood pressure remaining the same. The use of cardiometabolic medications also increased during the study period. Finally, the number of adolescents with all seven cardiovascular protective factors declined significantly during the study period, from 27.6% to 9.6%. Conclusions Modern American teenagers aged 12 to 16 years have more cardiovascular risk factors relating mostly to diet, exercise, and obesity than those of a prior generation; however, smoking rates have also declined precipitously.

Acute fatty liver of pregnancy (AFLP) is a rare obstetric condition that classically presents in the third trimester or early postpartum period and can lead to liver failure and death. Only six second trimester AFLP cases have been reported in the English literature. We present the earliest case of AFLP at 15 weeks of gestation confounded by a high titer anti-nuclear antibody (ANA >1 : 1280) and concern for autoimmune hepatitis. Our patient had intrauterine fetal demise with prompt dilation and evacuation. Sepsis and multisystem organ failure ensued, and she was transferred to a liver transplant center where she expired without further intervention.

Nonalcoholic fatty liver disease (NAFLD) is common in overweight adolescents, and screening with serum alanine transaminase (ALT) levels is recommended by the American Academy of Pediatrics. We sought to determine if ALT is an accurate adolescent screening measure for NAFLD in a nationally representative sample of overweight adolescents. Diagnosis of NAFLD was determined using vibration-controlled transient elastography. Analyses were performed to calculate the sensitivity, specificity, positive predictive value, negative predictive value, and Youden’s index at various serum ALT cutoff levels. Receiver operating curves were generated in order to determine ALT’s discrimination capability. Males and females were analyzed separately. While average measures (mean and median) of ALT were higher in subjects with NAFLD, ALT provided only minimal discrimination with AUROC (area under the receiver operating characteristic) values of .66 in males and .67 in females. In a nationally representative sample of overweight and obese adolescents, serum ALT level functioned inadequately as a screening test to detect NAFLD.

BACKGROUND:Immune checkpoint inhibitors (ICIs) have significantly changed the oncologic treatment landscape for a wide array of cancers over the past few decades. While these medications can produce a durable remission for patients they also come with a risk of inflammatory toxicities. With the widespread use of immune checkpoint inhibitors there have been increased reports of immune-related adverse events (irAEs) including severe gastrointestinal toxicities such as colitis. While multiple studies have assessed ICI colitis in tertiary care settings little is reported on the characteristics and treatment outcomes of ICI colitis in a community-based population. Additionally, the utility of gastroenterologists in the diagnosis and management of ICI colitis is poorly defined. The aim of this study is to report the characteristics and treatment outcomes of ICI colitis in a community-based hospital system.METHODS:This is a single-center retrospective case-series of patients with ICI colitis. Charts were reviewed from patients in the Prisma Health Upstate Network from 2/1/2016 to 12/31/2020. Potential cases of ICI colitis were identified using a diagnosis code of "toxic colitis", "indeterminate colitis", "unspecified colitis", and "noninfective gastroenteritis and colitis" (ICD-10 K52.1, K 52.3, K 52.89 and K52.9) as well as a prior infusion (within 12 months) of pembrolizumab, nivolumab, cemiplimab, atezolizumab, avelumab, durvalumab, or ipilimumab. Charts were abstracted for demographics, tumor type, checkpoint inhibitor used, mode of colitis diagnosis, endoscopic severity of inflammation, and treatments used. Study was approved by the Institutional Review Board at Prisma Health Upstate.RESULTS:The mean (±SD) age for the 37 patients was 64.1 ± 13.2 years. The patient population was predominantly male (62%) and Caucasian (100%). The cancer type in the patient population were melanoma (43.2%), non-small cell lung cancer (18.9%), renal cell carcinoma (10.8%), and other (27%). Patients with ICI colitis were most-commonly treated with ipilimumab (35.1%), nivolumab (35%), pembrolizumab (10.8%), and other (13.5%). The mean time to colitis onset was 25.7 ± 29.7 weeks. Over 56% of the patient population reported abdominal pain and 45.9% were hospitalized. Only 64.8% were evaluated by a gastroenterologist. Cross sectional abdominal imaging by computed tomography (CT) was obtained in 20 (54.0%) and showed colitis in 13. 54% obtained a colonoscopy with inflammation severity stratified into normal (25.0%), mild (40.0%), moderate (20.0%) and severe (15.0%). Endoscopic extent showed proctitis (0%), left-sided disease (5.0%), right-sided disease (5.0%), pancolitis (55.0%), and isolated ileal disease (25%). Histology showed 90.0% with active inflammation and 10.0% with microscopic colitis. Outcomes were resolution with steroids (64.8%), antibiotics (5.4%), biologic (10.8%), surgery (5.4%), hospice (8.1%). Of those that received biologic therapy, 6 received infliximab and 1 received vedolizumab.CONCLUSION:As immune checkpoint inhibitors gain approval in more cancer treatment ICI-colitis is being seen in a community-based setting. The most common treatment were steroids and often required a prolonged course. Biologic use in our series (18.9%) was much lower than prior reports from academic tertiary referral centers (>50%). Only 64.8% of patients saw a gastroenterologist for ICI-colitis symptoms. Early gastroenterology referral in the community setting could help to identify more severe disease and patients necessitating escalation to biologic therapy.

INTRODUCTION: Acute non-variceal GI bleeding (GIB) may warrant arterial embolization (AE) therapy. We report the clinical characteristics and outcomes of our series of patients referred for AE over three years. METHODS: We retrospectively reviewed patients admitted to Greenville Memorial Hospital with a GIB sent for AE from 1/2016 to 5/2019. Patients were identified in EPIC using ICD-10 codes for GIB and those with transcatheter AE procedures. Patient demographics, clinical and radiologic characteristics, outcomes, and mortality were manually extracted and coded by two individuals. SPSS version 25.0 was used for statistical analysis. RESULTS: 85 subjects underwent AE for a GIB (see Table 1). All 61 pts with an UGIB had an EGD, active bleeding noted in 36(59%). Only 11/24 LGIB underwent a colonoscopy, and 4 were actively bleeding. Nuclear-RBC scan, computed tomography angiography, and catheter angiography (CA) was performed in 25, 33, and 85 pts, respectively. CA best identified the site of bleeding. Angiographic contrast extravasation was slightly greater in LGIB 19/24(79.2%) vs UGIB 35/61(57.3%) P = 0.06. AE controlled bleeding in 77/85(90.6%) pts, UGI 55/61(90.2%) and LGI 22/24(91.7%). AE with coils controlled GIB in 47/48(97.9%), gelfoam in 4/8(50%), coils and gelfoam in 24/27(88.9%), and glue 2/2(100%). Contrast extravasation and directed AE controlled GIB in 51/54(94.4%) and was not significantly different from empiric AE 26/31(83.9%). UGIB embolization of the gastroduodenal/pancreaticoduodenal arteries (GDA/PDA) controlled GIB in 45/46(97.7%) compared to only 9/15 pts(60%) undergoing left gastric artery embolization (LGA) (P = 0.0001). 30-day mortality occurred in 5/8(62.5%) pts with uncontrolled bleeding, compared to 3/77(3.9%) pts with controlled GIB (P = 0.0001). Mortality in AE of LGA was 6/15(40%) compared to 2/46(4.3%) GDA/PDA (P = 0.0001). Univariate analysis for mortality was significant for AE bleeding control, hemoglobin nadir, and number of units of transfused blood, fresh frozen plasma, and platelets; however, on multivariate analysis, only successful AE predicted mortality. CONCLUSION: An UGIB was more frequently referred for AE. 90% of GIB was successful irrespective of directed vs. empiric AE. Gelfoam alone was less successful than other agents but was infrequently used. The only predictor of mortality was AE success. Interestingly, LGA embolization had greater bleeding failures and mortality warranting future investigations.Table 1

A breath-holding spell (BHS) is a common clinical entity where a young child involuntarily holds their breath until they lose consciousness. An estimated 0.1% to 4.6% of the children younger than the age of 2 years have had one or more episodes of BHS.1,2 Affected children often begin having such episodes in the first year of life and continue to have them regularly until approximately 4 years of age. BHS episodes are associated with crying and emotional or painful triggers. During the process of breath-holding, a child can turn cyanotic, stiffen, and can jerk their body prior to losing consciousness. The child generally awakens within a minute, is not disoriented, and does not appear postictal.1,3 Clinically, BHSs are distinguished from other causes of consciousness loss including cardiovascular or neurological problems by history, electrocardiogram, and electroencephalogram. The course of the disorder is generally considered benign and children develop normally without sequela.1 A strong association of anemia and BHS was first reported in 1963 and has since been confirmed by others.1,4,5 An estimated 23.5% to 69% of children with BHS are iron deficient, and many have anemia.6 Clinical studies aimed at treating the iron deficiency of subjects with BHS have been performed but have been limited by small sample sizes and inconsistent methodology. We therefore sought to combine these studies into a meta-analysis.

INTRODUCTION: Acute fatty liver of pregnancy (AFLP) is a rare and potentially fatal condition characterized by microvesicular steatosis and liver failure. It typically presents in the third trimester or early postpartum period, but several cases have been described in the second trimester, with the earliest reported case at 18 weeks gestation. Diagnosis is based on the Swansea Criteria, though liver biopsy can be performed under certain circumstances. Treatment involves supportive care and prompt fetal delivery, with recovery expected over the ensuing days to weeks. We present the earliest known case of AFLP at 15 weeks gestation and detail how its clinical course masqueraded as autoimmune hepatitis (AH). CASE DESCRIPTION/METHODS: A 41-year-old G4P2103 with morbid obesity was transferred to our institution with jaundice, scleral icterus, and vomiting after laboratory testing revealed AST 51 IU/L, ALT 88 IU/L, ALP 191 IU/L, and TB 15 mg/dL. On admission she was alert and oriented with stable vital signs. Laboratory testing was notable for an ANA with >1:1280 titer. Additional autoantibodies, anti-cardiolipin, and ADAMTS13 were negative. Blood smear showed no hemolysis. On day 2 an abdominal ultrasound revealed intrauterine fetal demise, so dilation and evacuation were performed. There was no evidence of preeclampsia or hemolysis with elevated liver enzymes and low platelets, so she was treated with methylprednisolone out of concern for AH. She did not improve with steroids so liver biopsy was performed which revealed mixed micro- and macrovesicular steatosis consistent with AFLP and nonalcoholic fatty liver disease (NAFLD). She was transferred to a liver transplant center where she expired without further intervention. DISCUSSION: This case was challenging because AFLP has never been reported in the early second trimester and the presence of high ANA titers suggested an autoimmune etiology. The biopsy showed mixed micro- and macrovesicular steatosis with cytoplasmic ballooning, mild inflammation, and no fibrosis. AH was excluded due to the lack of interface hepatitis, rosettes, plasma cell inflammatory changes, or improvement with steroids. Although NAFLD is associated with autoantibodies it does not cause acute liver failure, which this patient experienced despite receiving the standard of care. Therefore, based on the patient's clinical course and biopsy we present the earliest case of AFLP complicated by concomitant NAFLD.Figure 1.: Low power, hematoxylin and eosin (H&E) stained section showing mild steatosis in a zonal pattern, primarily involving zone 3. The inflammation is mild with a lobular predominance, composed principally of lymphocytes and plasma cells with smaller populations of neutrophils and eosinophils.Figure 2.: High power, hematoxylin and eosin (H&E) stained section showing cytoplasmic ballooning of hepatocytes with the presence of Mallory's Hyaline (arrows).Figure 3.: High power, hematoxylin and eosin (H&E) stained section of microvesicular (arrowheads) and macrovesicular (asterisk) steatosis.

INTRODUCTION:Leading public health institutions recommend participation in several evidence-based behaviors, including exercise, a healthy diet, and maintenance of a normal BMI while simultaneously avoiding cigarette smoking and excessive alcohol consumption. The investigators attempted to evaluate the collective adherence to these recommendations and population trends in these behaviors by evaluating nationally representative surveys over a period of 12 years.METHODS:In 2019, the data from 26,194 National Health and Examination Survey participants who provided answers to survey questions regarding diet, physical activity, and usage of cigarettes and alcohol were analyzed. BMI was obtained from the examination data. Adherence to each behavior and the constellation of all 5 behaviors was assessed and tracked over a 12-year timeframe.RESULTS:The smoking rates (p=0.01) and adherence to a healthy BMI declined over time (p=0.03). The total percentage of subjects who participated in all 5 behaviors ranged from 4.4% to 6.3%, whereas subjects who performed 2 or fewer behaviors ranged from 45.4% to 48.3%. Greater education (p<0.0001), higher SES (p<0.0001), and being a female participant (p<0.0001) predicted higher behavior scores.CONCLUSIONS:Only 1 in 5 Americans engage in 4 or more healthy behaviors, whereas almost half of them participate in fewer than 3 healthy behaviors. Increased participation in numerous healthy behaviors can decrease premature mortality, decrease the burden of chronic diseases, improve life quality, and provide substantial economic benefits. A public health practice of targeting a constellation of behaviors as opposed to individual behaviors is needed.