Miriam B Vos

Emory University, Atlanta, Georgia, United States

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Publications (51)240.61 Total impact

  • Ran Jin, Miriam B Vos
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    ABSTRACT: The purpose was to summarize recent advances in the understanding of nonalcoholic fatty liver disease (NAFLD) pathophysiology and the role of fructose in NAFLD. Epidemiological studies continue to point to a strong association between high fructose intake and NAFLD and its severity. New studies of NAFLD reveal the importance of upregulated de novo lipogenesis as a key feature in its pathophysiology along with increased visceral adiposity and alteration of gut microbiome. Studies of fructose in NAFLD show how this nutrient may uniquely exacerbate the phenotype of NAFLD. The timing of exposure to fructose may be important with early (in utero) exposure being particularly harmful. Fructose is a potentially modifiable environmental exposure that appears to exacerbate NAFLD through multiple mechanisms. Although larger, longer clinical studies are still needed, it appears that limitation of fructose sources in the diet is beneficial in NAFLD.
    07/2015; DOI:10.1097/MCO.0000000000000203
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    ABSTRACT: Nonalcoholic fatty liver disease (NAFLD) has emerged as the major pediatric chronic liver disease, and it is estimated to affect more than one third of obese children in the U.S. Cardiovascular complications are a leading cause of increased mortality in adults with NAFLD and many adolescents with NAFLD already manifest signs of subclinical atherosclerosis including increased carotid intima-media thickness. Volume of intrahepatic fat was assessed in 50 Hispanic-American, overweight adolescents, using Magnetic Resonance Spectroscopy. Lipoprotein compositions were measured using Nuclear Magnetic Resonance. Plasma triglycerides (TG) (p = 0.003), TG/HDL ratio (p = 0.006), TG/apoB ratio (p = 0.011), large VLDL concentration (p = 0.019), VLDL particle size (p = 0.012), as well as small dense LDL concentration (p = 0.026) progressively increased across higher levels of hepatic fat severity, while large HDL concentration progressively declined (p = 0.043). This pattern of associations remained even after controlling for gender, BMI, visceral fat, and insulin resistance. Our findings suggest that increased hepatic fat is strongly associated with peripheral dyslipidemia and the amount of fat in the liver may influence cardiovascular risk. Further studies are needed to longitudinally monitor dyslipidemia in children with NAFLD and to examine whether the reduction of hepatic fat would attenuate their long-term CVD risk.
    Lipids in Health and Disease 05/2015; 14(1):39. DOI:10.1186/s12944-015-0038-x · 2.31 Impact Factor
  • Miriam B Vos
    Hepatology 03/2015; 61(6). DOI:10.1002/hep.27808 · 11.19 Impact Factor
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    ABSTRACT: Nonalcoholic fatty liver disease (NAFLD), the most common cause of liver disease among US children, may be associated with cardiovascular disease (CVD) risk. The present study sought to determine the prevalence of dyslipidemia in children with NAFLD and assess dyslipidemia by liver histology and histologic changes. Individuals in the Treatment of NAFLD in Children (TONIC) trial were included (N = 173). In the TONIC trial, children with NAFLD were randomized to vitamin E, metformin, or placebo for 96 weeks. Nonalcoholic steatohepatitis (NASH) improved in 56 children. Change in lipid levels from baseline and 96 weeks was compared between patients with and without histologic improvement and with and without NASH. Dyslipidemia was frequent, with low high-density lipoprotein (HDL) (<40 mg/dL) in 61.8%, hypertriglyceridemia (≥130 mg/dL) in 50.3%, hypercholesterolemia (≥200 mg/dL) in 23.7%, elevated low-density lipoprotein (LDL) (≥130 mg/dL) in 21.5%, elevated non-HDL cholesterol (non-HDL-C) (≥145 mg/dL) in 35.2%, and triglycerides/HDL >3.0 in 57.2% of patients. Histologic improvement was associated with significant decreases in cholesterol (-11.4 mg/dL vs -1.9 mg/dL, P = 0.04), LDL (-11.2 mg/dL vs -2.1 mg/dL, P = 0.04), and non-HDL-C (-8.8 mg/dL vs 0.5 mg/dL, P = 0.03) compared with those without improvement. Children with NASH resolution had significant decreases in cholesterol (-10.0 mg/dL vs -0.9 mg/dL, P = 0.02) and non-HDL-C (-7.3 mg/dL vs 1.1 mg/dL, P = 0.01) compared with those without NASH resolution. There was no improvement in triglycerides, HDL level, or triglycerides/HDL ratio in either group. Dyslipidemia is frequent in children with NAFLD. NASH resolution and histologic improvement are associated with improvements in some forms of dyslipidemia.
    Journal of Pediatric Gastroenterology and Nutrition 03/2015; 60(3):360-7. DOI:10.1097/MPG.0000000000000584 · 2.87 Impact Factor
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    ABSTRACT: Background: Childhood obesity in Georgia exceeds the national rate. The state's pediatric primary care providers (PCPs) are well positioned to support behavior change, but little is known about provider perceptions and practices regarding this role. Purpose: The aim of this study was to assess and compare weight-management-related counseling perceptions and practices among Georgia's PCPs. Methods: In 2012-2013, 656 PCPs (265 pediatricians, 143 family practice physicians [FPs], and 248 nurse practitioners/physician assistants [NP/PAs]) completed a survey regarding weight-management-related practices at well-child visits before their voluntary participation in a free training on patient-centered counseling and child weight management. Data were analyzed in 2014. Likert scales were used to quantify responses from 1 (strongly disagree or never) to 5 (strongly agree or always). Responses of 4 and 5 responses were combined to denote agreement or usual practice. Chi-squared analyses tested for independent associations between pediatricians and others. Statistical significance was determined using two-sided tests and p value <0.05. Results: The majority of PCPs assessed fruit and vegetable intake (83%) and physical activity (78%), but pediatricians were more likely than FPs and NP/PAs to assess beverage intake (96% vs. 82-87%; p≤0.002) and screen time (86% vs. 74-75%; p≤0.003). Pediatricians were also more likely to counsel patients on lifestyle changes (88% vs. 71%; p<0.001) and to track progress (50% vs. 35-39%; p<0.05). Though all PCPs agreed that goal setting is an effective motivator (88%) and that behavior change increases with provider encouragement (85%), fewer were confident in their ability to counsel (72%). Conclusions: Our results show that many PCPS in Georgia, particularly pediatricians, have incorporated weight management counseling into their practice; however, important opportunities to strengthen these efforts by targeting known high-risk behaviors remain.
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    ABSTRACT: Atherosclerotic changes associated with dyslipidemia and increased cardiovascular disease risk are believed to begin in childhood. While previous studies have linked added sugars consumption to low high-density lipoprotein (HDL), little is known about the long-term impact of this consumption. This study aims to assess the association between added sugars intake and HDL cholesterol levels during adolescence, and whether this association is modified by obesity. We used data from the National Heart Lung and Blood Institute's Growth and Health Study, a 10-year cohort study of non-Hispanic Caucasian and African-American girls (N=2379) aged 9 and 10 years at baseline recruited from 3 sites in 1987-1988 with biennial plasma lipid measurement and annual assessment of diet using a 3-day food record. Added sugars consumption was dichotomized into low (0% to <10% of total energy) and high (≥10% of total energy). In a mixed model controlling for obesity, race, physical activity, smoking, maturation stage, age, and nutritional factors, low compared with high added sugar consumption was associated with a 0.26 mg/dL greater annual increase in HDL levels (95% CI 0.48 to 0.04; P=0.02). Over the 10-year study period, the model predicted a mean increase of 2.2 mg/dL (95% CI 0.09 to 4.32; P=0.04) among low consumers, and a 0.4 mg/dL decrease (95% CI -1.32 to 0.52; P=0.4) among high consumers. Weight category did not modify this association (P=0.45). Low added sugars consumption is associated with increasing HDL cholesterol levels throughout adolescence.
    Journal of the American Heart Association 12/2014; 3(1):e000615. DOI:10.1161/JAHA.113.000615 · 2.88 Impact Factor
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    ABSTRACT: Background: Despite the well-documented need for multidisciplinary pediatric obesity treatment programs, few programs exist and best practices are not clearly defined. We describe the design and initial quality-related outcomes of the Strong4Life multidisciplinary pediatric obesity treatment program along with some challenges and solutions implemented over the first 2 years. The purpose of this report is to inform others interested in designing similar programs. Program Description: The Strong4Life Clinic obesity program was designed to provide children with the medical care, as well as the behavior change guidance and support needed to reverse their obesity and/or minimize the related health risks. This low-intensity program is designed to provide approximately 6 hours of care over 12 months from a medical provider, psychologist, registered dietitian nutritionist, exercise physiologist, and nurse. Results: Between August 2011 and February 2014, the Strong4Life clinic served 781 high-risk (mean sex- and age-adjusted body mass index [BMI] percentile 98.8) and racially/ethnically diverse (45% non-Hispanic black and 24% Hispanic) patients. Of the 781 patients seen, 66% returned for at least 1 visit. Nearly all returning Strong4Life patients stabilized or improved their BMI (90% of those who participated <6 months, 97% of those who participated 6 to <12 months, and 92% of those who participated ≥12 months). Conclusions: This report describes a low-intensity multidisciplinary weight management program that is feasible. Initial assessment of the program suggests benefit in most patients who participate >6 months, but longer follow-up and assessment of comorbidities are needed.
    Nutrition in Clinical Practice 10/2014; DOI:10.1177/0884533614551839 · 2.06 Impact Factor
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    ABSTRACT: Background. We hypothesized that training in patient-centered counseling would improve self-efficacy and quality of weight management-related counseling provided by pediatric primary care physicians (PCPs). Methods. A total of 36 PCPs attended a brief (2-hour) training and consented to participate in an evaluation. Training impact was assessed using self-administered, pretraining and posttraining surveys and a review of patient charts from prior to and from 6 and 12 months after training for a random subsample of 19 PCPs (10 charts/timepoint per PCP). Results. Self-reported effectiveness at obesity prevention and treatment increased from 16.7% to 44.4% (P = .01) and from 19.4% to 55.6% (P < .001), respectively. Self-efficacy in counseling and motivating patients increased from 44.4% to 80.6% (P < .001) and 27.8% to 63.9% (P < .001), respectively. Goal documentation increased from 3.9% to 16.4% and 57.9% at 6 months and 12 months posttraining, respectively. Conclusions. Brief training in patient-centered counseling appears to increase self-efficacy and the frequency and quality of weight-related counseling provided by PCPs.
    Clinical Pediatrics 10/2014; 54(5). DOI:10.1177/0009922814553432 · 1.26 Impact Factor
  • 2014 American Academy of Pediatrics National Conference and Exhibition; 10/2014
  • Miriam B. Vos
    10/2014; 4(4). DOI:10.1002/cld.422
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    ABSTRACT: In preclinical studies of fructose-induced NAFLD, endotoxin appears to play an important role. We retrospectively examined samples from three pediatric cohorts (1) to investigate whether endotoxemia is associated with the presence of hepatic steatosis; (2) to evaluate postprandial endotoxin levels in response to fructose beverage in an acute 24-hour feeding challenge, and (3) to determine the change of fasting endotoxin amounts in a 4-week randomized controlled trial comparing fructose to glucose beverages in NAFLD. We found that adolescents with hepatic steatosis had elevated endotoxin levels compared to obese controls and that the endotoxin level correlated with insulin resistance and several inflammatory cytokines. In a 24-hour feeding study, endotoxin levels in NAFLD adolescents increased after fructose beverages (consumed with meals) as compared to healthy children. Similarly, endotoxin was significantly increased after adolescents consumed fructose beverages for 2 weeks and remained high although not significantly at 4 weeks. In conclusion, these data provide support for the concept of low level endotoxemia contributing to pediatric NAFLD and the possible role of fructose in this process. Further studies are needed to determine if manipulation of the microbiome or other methods of endotoxin reduction would be useful as a therapy for pediatric NAFLD.
    09/2014; 2014:560620. DOI:10.1155/2014/560620
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    ABSTRACT: Nonalcoholic fatty liver disease (NAFLD) is now thought to be the most common liver disease worldwide. Cardiovascular complications are a leading cause of mortality in NAFLD. Fructose, a common nutrient in the westernized diet, has been reported to be associated with increased cardiovascular risk, but its impact on adolescents with NAFLD is not well understood. We designed a 4-week randomized, controlled, double-blinded beverage intervention study. Twenty-four overweight Hispanic-American adolescents who had hepatic fat >8% on imaging and who were regular consumers of sweet beverages were enrolled and randomized to calorie-matched study-provided fructose only or glucose only beverages. After 4 weeks, there was no significant change in hepatic fat or body weight in either group. In the glucose beverage group there was significantly improved adipose insulin sensitivity, high sensitivity C-reactive protein (hs-CRP), and low-density lipoprotein (LDL) oxidation. These findings demonstrate that reduction of fructose improves several important factors related to cardiovascular disease despite a lack of measurable improvement in hepatic steatosis. Reducing dietary fructose may be an effective intervention to blunt atherosclerosis progression among NAFLD patients and should be evaluated in longer term clinical trials.
    Nutrients 08/2014; 6(8):3187-3201. DOI:10.3390/nu6083187 · 3.15 Impact Factor
  • Miriam B Vos
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    ABSTRACT: Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide and it has overlapping pathogenesis with diabetes and cardiovascular disease. Reviewed here are recent advances in understanding the contribution of diet and selected nutrients to NAFLD. To understand the effect of diet, the microbiome must be considered because it is the interface of diet and the liver. Early studies suggest that the characteristic of the microbiota is altered in NAFLD. Fructose is a lipogenic carbohydrate that contributes to insulin resistance, hypertriglyceridemia and appears to be associated with the severity of NAFLD. Fructose absorption and malabsorption may alter the microbiota and could be mediating effects on the liver. Lipids also have potent microbiome interactions and could contribute to the benefit of diets emphasizing lipid changes. Several new studies demonstrate that the Mediterranean diet and 'lifestyle change' are effective in modestly improving NAFLD. A new study of 'lifestyle' in children showed simultaneous improvement in cardiovascular disease risk measurements and hepatic steatosis. Current data supports limiting sugar in the diet and 'lifestyle change' as a first-line treatment for NAFLD; however, the benefits from these appear to be modest. The effects of diet on the liver are mediated through the microbiome and expansion of research in this area is needed.
    Current opinion in lipidology 12/2013; 25(1). DOI:10.1097/MOL.0000000000000043 · 5.80 Impact Factor
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    ABSTRACT: Purpose: Weight-related bullying is associated with depression, unhealthy weight control efforts, and problems in school. Little is known about the prevalence of this bullying or the extent to which its occurrence varies among demographic subgroups. The purpose of this study was to characterize weight-related bullying as perceived by parents or caregivers and children in Georgia. Methods: In 2011, 497 children and 484 parents/caregivers throughout Georgia participated in a statewide telephone survey funded by Children’s Healthcare of Atlanta, with oversampling of minority, low-income and lower education groups. Odds of perceived weight-related bullying in schools were assessed for parents/caregivers and children by child’s race, sex, age, location, weight class, family income level and parent’s education. Comparisons between parents/caregivers and children within the same household were made using Pearson’s test. Results: 69% of parents/caregivers and 34% of children reported that they believed bullying related to weight was a problem in schools. Hispanic parents/caregivers were overall significantly likely to perceive bullying as a problem (OR 2.45, 95% CI 1.09–5.52) but not for children (OR 1.42, 95% CI 0.68 – 2.95).. Family income and parent’s education were also significantly correlated among parents with perceived bullying, especially among parents of obese children (Table 1). Conclusion: Hispanics are significantly more likely than their white counterparts to report bullying in schools to be a problem. The prevalence of perceived obesity-related bullying was significantly higher among parents/caregivers than children. Closer analysis of the racial/ethnic disparity and the disparity between parental and child reporting of weight-related bullying is needed. Table 1.Odds Ratios for Weight-Related Bullying in Schools as Perceived by Obese Children and Parents/Caregivers of Obese Children #Corresponds to the prevalence of those within the subgroup who perceive weight-related bullying as a serious problem in schools. N is total number in that subgroup. Variable Parents Children N# %# OR (95% C.I.) N# %# OR (95% C.I.) Overall 252 73.8 242 40.0 Child’s Sex Male 152 69.1 0.52 (0.29–0.96) 137 38.0 0.85 (0.51–1.43) Female 100 81.0 1.00 - 105 41.9 1.00 - Child’s Race/Ethnicity White 80 58.8 1.00 - 83 33.7 1.00 - Hispanic 76 90.8 6.92 (2.83–16.95) 44 61.4 3.12 (1.46–6.66) Black 85 69.4 1.59 (0.84–3.03) 104 35.6 1.09 (0.59–1.99) Family Income Level Low Income 142 82.4 5.85 (2.44–14.01) 125 48.0 2.50 (0.98–6.38) Middle Income 82 69.5 2.85 (1.17–6.96) 90 32.3 1.29 (0.49–3.41) High Income 27 44.4 1.00 - 26 26.9 1.00 - Parent’s Education Low Education 42 81.0 3.42 (1.38–8.53) 29 55.2 2.21 (0.93–5.22) Moderate Education 144 80.6 3.34 (1.76–6.33) 131 38.2 1.11 (0.62–1.97) High Education 65 55.4 1.00 - 81 35.8 1.00 -
    2013 American Academy of Pediatrics National Conference and Exhibition; 10/2013
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    ABSTRACT: Giant Cell Hepatitis with Autoimmune Hemolytic Anemia (GCH-AHA) is presumed to be an autoimmune disease, but the mechanism of liver injury is unknown. We proposed that in CGH-AHA the humoral limb of autoimmunity is the dominant force driving progressive liver injury. We studied 6 cases of GCH-AHA and 6 cases of autoimmune hepatitis (AIH) with early childhood onset (3 type-1 and 3 type-2). Liver biopsies were graded for portal and periportal inflammation and for giant cells. Immunohistochemistry characterized cellular inflammation and complement involvement in injury by showing C5b-9 complex in hepatocytes. Clinical and biochemical features at presentation were generally similar. However, the absence of autoantibodies and the presence of Coombs positivity did distinguish GCH-AHA from early onset AIH. Liver biopsy pathology in CGH-AHA showed giant cells and little inflammation, whereas AIH showed the opposite. C5b-9 staining showed high-grade complement-mediated pan-lobular hepatocyte injury in all GCH-AHA cases, whereas little C5b-9 was seen in hepatocytes in AIH cases. Inflammation in GCH-AHA comprised mainly lobular macrophages and neutrophils, whereas portal and periportal T cell and B cell inflammation characterized AIH cases. Most AIH cases responded to therapy with prednisone and azathioprine, whereas most GCH-AHA cases responded only to rituximab. Widespread complement-mediated hepatocyte injury and typical C3a and C5a complement-driven liver inflammation along with Coombs positive hemolytic anemia in GCH-AHA provide convincing evidence that systemic B cell autoimmunity plays a central pathologic mechanism in the disease. Our findings support B cell directed immunotherapy as a first-line treatment of GCH-AHA.
    Journal of pediatric gastroenterology and nutrition 08/2013; 58(1). DOI:10.1097/MPG.0b013e3182a98dbe · 2.87 Impact Factor
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    ABSTRACT: Objective Dietary fructose and copper interaction may play an important role in the pathogenesis of non-alcoholic fatty liver disease (NAFLD). In this study, we investigate whether or not modest fructose consumption (3% fructose, w/v) (which is more closely related to the American lifestyle with regard to sugar beverage consumption) affects copper status, and causes liver injury and fat accumulation in marginal copper deficient rats. Design and Methods Male weanling Sprague-Dawley rats were fed either an adequate copper (6ppm) or a marginally copper deficient (1.6ppm) diet for 4 weeks. Deionized water or deionized water containing 3% fructose (w/v) was given ad lib. Results Modest fructose consumption further impaired copper status in the marginal copper deficient rats and increased hepatic iron accumulation. Liver injury and fat accumulation were significantly induced in the marginal copper deficient rats exposed to fructose. Conclusions Our data suggest that modest fructose consumption can impair copper status and lead to hepatic iron overload, which in turn, may lead to liver injury and fatty liver in marginal copper deficient rats. This study provides important information on dietary fructose and copper interaction, suggesting that dietary fructose induced low copper availability might be an important mechanism underlying fructose induced fatty liver.
    Obesity 08/2013; 21(8). DOI:10.1002/oby.20380 · 4.39 Impact Factor
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    ABSTRACT: Introduction. Given the high prevalence of childhood obesity in the United States, we aimed to investigate youth's understanding of obesity and to investigate gaps between their nutritional knowledge, dietary habits, and perceived susceptibility to obesity and its co-morbidities. Methods. A marketing firm contracted by Children's Healthcare of Atlanta facilitated a series of focus group discussions (FGD) to test potential concepts and sample ads for the development of an obesity awareness campaign. Data were collected in August and September of 2010 with both overweight and healthy weight 4th-5th grade and 7th-8th grade students. We conducted a secondary analysis of the qualitative FGD transcripts using inductive thematic coding to identify key themes related to youth reports of family eating habits (including food preparation, meal frequency, and eating environment), perceived facilitators and barriers of healthy diet, and knowledge about obesity and its complications. Results. Across focus group discussions, mixed attitudes about healthy eating, low perceived risk of being or becoming obese, and limited knowledge about the health consequences of obesity may contribute to the rising prevalence of obesity among youth in Georgia. Most youth were aware that obesity was a problem; yet most overweight youth felt that their weight was healthy and attributed overweight to genetics or slow metabolism. Conclusions. Our analysis suggests that urban youth in Georgia commonly recognize obesity as a problem, but there is less understanding of the link to lifestyle choices or the connection to future morbidities, suggesting a need for education to connect lifestyle behaviors to development of obesity.
    Journal of obesity 07/2013; 2013:670295. DOI:10.1155/2013/670295
  • Miriam B. Vos
    Hepatology 07/2013; 58(1). DOI:10.1002/hep.26389 · 11.19 Impact Factor
  • Miriam B Vos, Joel E Lavine
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    ABSTRACT: Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in adults and children. A number of genetic and environmental factors are known to predispose individualsto NAFLD. Certain dietary sugars, particularly fructose, are suspected to contribute to the development of NAFLD and its progression. The increasing quantity of fructose in the diet comes from sugar additives (most commonly sucrose and high fructose corn syrup) in beverages and processed foods. Substantial links have been demonstrated between increased fructose consumption and obesity, dyslipidemia and insulin resistance. Growing evidence suggests that fructose contributes to the development and severity of NAFLD. In human studies, fructose is associated with increasing hepatic fat, inflammation and possibly fibrosis. Whether fructose alone can cause NAFLD or if it serves only as a contributor when consumed excessively in the setting of insulin resistance, positive energy balance and sedentary lifestyle is unknown. Sufficient evidence exists to support clinical recommendations that fructose intake be limited through decreasing foods and drinks high in added (fructose-containing) sugars. (HEPATOLOGY 2013.).
    Hepatology 06/2013; 57(6). DOI:10.1002/hep.26299 · 11.19 Impact Factor
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    ABSTRACT: Quantitating hepatic steatosis is important in many liver diseases and liver transplantation. Since steatosis estimation by pathologists has inherent intra- and inter-observer variability, we compared and contrasted computerized techniques with magnetic resonance imaging measurements, pathologist visual scoring, and clinical parameters. Computerized methods applied to whole slide images included a commercial positive pixel count algorithm and a custom algorithm programmed at our institution. For all liver samples (n=59), including pediatric, adult, frozen section, and permanent specimens, statistically significant correlations were observed between pathology, radiology, and each image analysis modality (r=0.75-0.97, p<0.0001), with the strongest correlations in the pediatric cohort. Statistically significant relationships were observed between each method and with body mass index (r=0.37-0.56, p from <0.0001 to <0.05) and with albumin (r=0.55-0.64, p<0.05) but not with alanine aminotransferase or aspartate aminotransferase. Although pathologist assessments correlated (r=0.64-0.86, 0.92-0.97, and 0.78-0.91 for microvesicular, macrovesicular, and overall steatosis, respectively), the absolute values of hepatic steatosis visual assessment were susceptible to intra- and inter-observer variability, particularly for microvesicular steatosis. Image analysis, pathologist assessments, radiology measurements, and several clinical parameters all showed correlations in this study, providing evidence for the utility of each method in different clinical and research settings.
    Pathology - Research and Practice 04/2013; DOI:10.1016/j.prp.2013.04.001 · 1.56 Impact Factor

Publication Stats

1k Citations
240.61 Total Impact Points

Institutions

  • 2008–2015
    • Emory University
      • Department of Pediatrics
      Atlanta, Georgia, United States
    • University of Louisville
      Louisville, Kentucky, United States
  • 2009–2014
    • Children's Healthcare of Atlanta
      Atlanta, Georgia, United States
  • 2011–2013
    • Emory Hospitals
      Atlanta, Georgia, United States