October is National Liver Awareness Month, a reminder to focus on liver health through education, screenings, and advocacy. Our partners at Ohio Gastro have shared a physician’s guide to two of the most prevalent chronic liver diseases worldwide. 

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Metabolic dysfunction-associated steatotic liver disease (MALSD) and metabolic associated steatohepatitis (MASH) have emerged as the most prevalent chronic liver disease worldwide and represents a major public health challenge contributing significantly to global morbidity and mortality.  There was a nomenclature change in 2023 regarding this disease. MASLD and MASH were previously known as nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), respectively. We now have an affirmative name and diagnosis without using stigmatizing language. 

Causes, Risks, and Stages 

MASLD and MASH require early diagnosis, risk stratification, and comprehensive management. MASLD is now defined by the presence of hepatic steatosis in conjunction with one or more cardiometabolic risk factors, excluding harmful alcohol intake.  This reclassification underscores the multisystem nature of MASLD and its close association with obesity, type 2 diabetes (T2DM), dyslipidemia, and hypertension.  In fact, T2DM is the most impactful risk factor for the development of steatotic liver disease (SLD), fibrosis progression, and HCC in this population of patients. However, MASLD can occur in lean individuals, highlighting the importance of metabolic risk factors beyond obesity.  

There are also less common causes of steatotic liver disease including hypobetalipoproteinemia, lysosomal acid lipase deficiency, celiac disease, Wilson’s disease, nutrient deficiency (eg, carnitine, choline, anorexia, bypass patients, short gut) as well as medications (eg, steroids, methotrexate, amiodarone, tamoxifen, 5-FU) 

The disease spectrum ranges from simple steatosis, steatohepatitis, progressive fibrosis, and finally cirrhosis, which then can be complicated by portal hypertension and hepatocellular carcinoma. However, MASLD is a multisystem disorder, conferring increased risk for cardiovascular disease, chronic kidney disease, and extrahepatic malignancies. The economic and healthcare burden is substantial, with impaired quality of life and high resource utilization. 

The pathophysiology of MASLD is multifactorial and arises from a complex interplay of genetic, epigenetic, and environmental factors that disrupt hepatic lipid homeostasis. Insulin resistance is a key driver, leading to increased free fatty acids in the liver, enhanced lipogenesis, and impaired fatty acid oxidation. These processes result in hepatocellular lipid accumulation, mitochondrial dysfunction with resultant oxidative stress further triggering inflammation and fibrosis. However, genetic predisposition, dysregulated nuclear receptor signaling, and gut microbiota alterations further modulate disease progression. Also, as already stated, MASH can occur in individuals with normal body weights, underscoring the heterogeneity of the disease and the importance of metabolic dysfunction beyond obesity alone.  

 The diagnostic criteria for MASLD enables earlier identification and intervention, which is important since MASLD follows a variable course, with most patients remaining asymptomatic until advanced stages. Progression from MASLD to MASH is marked by hepatic inflammation and fibrosis. The presence and severity of fibrosis are the strongest predictors of liver-related outcomes and mortality.  Therefore, early diagnosis is critical for preventing advanced fibrosis and its complications.   

When to screen for SLD 

Providers should screen for MASLD and MASH in all patients with cardiometabolic risk factors. It is important to not solely rely on elevated liver enzymes to initiate screening as liver enzymes can often be normal in patients with SLD.  

Risk factors include diabetes, prediabetes, obesity, or two or more metabolic risks factors such as dyslipidemia, hypertension or increased waist circumference. Patients with persistently elevated aminotransferases for at least 6 months without an etiology or incidental findings of steatosis on radiological imaging should also be screened for MASH.  

Screening for SLD 

The initial screening step to assess disease severity is to calculate a Fibrosis-4 index (FIB-4), which is based on aspartate aminotransferase, alanine aminotransferase, platelets and age. The FIB-4 calculator is readily available online, in medical apps, or can be incorporated into electronic health record smartphrase calculators.  

FIB-4 categorizes patients as low risk (<1.30), indeterminate risk (1.30-2.67), or high risk (>2.67). Patients with high risk should be referred to Hepatology. Those with indeterminate risk require further noninvasive testing (eg, the enhanced liver fibrosis (ELF) test, transient elastography) for fibrosis staging. Those with low risk may be monitored in primary care annually and counseled extensively on lifestyle changes. Patients with MASLD or MASH rarely require liver biopsies now and liver biopsies are typically only reserved for selected cases where diagnosis or staging remain uncertain. 

Managing SLD 

The cornerstone of MASLD management is comprehensive lifestyle modification with diet, weight loss, physical activity, and optimal control of metabolic comorbidities. A diet containing excess calories, particularly excess saturated fats, refined carbohydrates, and sugar-sweetened beverages, is associated with obesity and MASLD. Excessive fructose consumption in particular increases the risk of SLD and advanced fibrosis independent of calorie intake. The Mediterranean diet has evidence for improving hepatic and cardiometabolic outcomes in this population. Coffee consumption (3 or more cups/day), independent of caffeine content, has been associated with less advanced liver disease as well. 

Both aerobic and resistance exercise are beneficial, with effects proportional to engagement and intensity and ideally should be done for at least 30 minutes per day. A goal weight loss of at least 10% of the body weight is ideal and can lead to steatosis, inflammation, and fibrosis improvements. There are also now pharmacologic options for patients with MASH and are indicated for patients with MASH that have significant fibrosis (stage F2-F3). Resmetirom (thyroid hormone receptor beta agonist) is an oral tablet, and the first FDA-approved agent for noncirrhotic MASH with moderate-to-advanced fibrosis (F2 or F3) and has been shown to improve steatohepatitis and fibrosis. This medication is still recommended in conjunction with lifestyle modifications including diet, exercise and weight loss. Semaglutide (GLP-1 receptor agonist ideally 2.4 mg weekly) subcutaneous injection is also approved for noncirrhotic MASH with moderate-to-advanced fibrosis (F2 or F3) and has been shown to improve steatohepatitis and fibrosis.  

This is an exciting time for MASH management since there are multiple other agents currently in clinical trials. Other agents currently under investigation include more GLP-1 receptor agonists, SGLT2 inhibitors, fibroblast growth factor 21 analogs, and PPAR agonists, which target both hepatic and metabolic pathways. These potential future treatment options will allow us to target MASH at different metabolic pathways through potential combination therapy. Bariatric surgery and endoscopic interventions may also be considered in select patients with severe obesity and refractory disease. 

Given the multisystem nature of MASLD and MASH, multidisciplinary care is essential. Cardiovascular disease remains the leading cause of mortality in this population, highlighting the need for integrated management of both hepatic and extrahepatic complications. Statins are safe in patients with SLD including compensated cirrhotics and can be used in decompensated cirrhotics with close monitoring who are at high risk for cardiovascular disease. Therefore, collaboration among hepatologists, gastroenterologists, endocrinologists, dietitians, pharmacists, cardiologists, behavioral health specialists, and primary care providers optimizes management of hepatic and extrahepatic complications. 

Early identification and intervention, particularly in high-risk populations, are essential to prevent progression of disease and improve overall morbidity and mortality in this population. The integration of lifestyle modifications, pharmacologic, and potential surgical therapies, alongside management of metabolic comorbidities, offers the best opportunity to improve outcomes. Continued research into the pathophysiology and therapeutic targets of MASLD and MASH will be critical to addressing the growing global burden of this disease.  

By The Institute at MagMutual®

A malpractice claim can be sudden, disorienting and deeply personal. For many physicians, it’s not just the legal implications that cause stress, it’s the emotional fallout — the anxiety, shame and sense that their professional reputation and identity are on the line.

These feelings are incredibly common. Most if not all physicians experience emotional distress at some point during the litigation process. Some develop physical symptoms like headaches or fatigue. Others withdraw from their social lives or begin questioning whether they should continue practicing at all.

These Responses Are Valid — And Manageable
Just because you find yourself facing a lawsuit doesn’t mean that the rest of your life stops, and certainly not your medical practice. As with any sudden adversity, you need to keep moving. Part of that involves making small but intentional choices to support your well-being. Prioritize basic self-care: get enough rest, stay physically active and eat well. Avoid self-isolation, even when you feel like shutting down. Carve out time for things that restore you, whether that’s family dinners, a hobby or simply stepping outside for a walk.

You might also benefit from speaking with someone who can help you process your emotions — a therapist, a trusted friend or a peer who has also been through a lawsuit. While legal rules may prevent you from discussing the details of the case, your personal response is not off-limits. In fact, verbalizing it may be the most effective way to ease its grip.

Finally, give yourself grace. Medicine is a profession filled with complexity, and sometimes, despite our best efforts, things go wrong. That doesn’t make you less skilled or less dedicated. Learning to separate your identity from a legal process can be one of the most powerful ways to keep going.

MagMutual Can Help You Move Forward
For physicians going through this difficult process, MagMutual offers support designed with the emotional demands of litigation in mind. From our Peer2Peer physician network to concierge trial assistance and mental health resources, we’re here to ensure you have the tools—and the human connection — you need to weather the storm and come through stronger. Learn more about the range of services available to MagMutual policyholders who experience unanticipated outcomes.

Take the Next Step Toward Optimal Outcomes

• Request a quote to become a MagMutual policyholder and gain access to our unmatched defense services
• Follow MagMutual on LinkedIn for more physician-focused insights and updates

Disclaimer: The information provided in this article does not constitute legal, medical or any other professional advice. No attorney-client relationship is created and you should not act or refrain from acting on the basis of any content included in this article without seeking legal or other professional advice. 

In today’s fast-paced work environment, many employees find themselves settling into routines that can often lead to complacency.  Complacency can be defined as, doing the same task for so long without incident that you assume nothing will ever happen.  While familiarity with tasks can create a sense of comfort, it can also pose significant risks, especially concerning workplace safety.  It’s crucial to understand how complacency can lead to accidents and what can be done to mitigate these risks. Complacency can affect anyone at any age, regardless of their experience, so it is important to train all employees on how to spot complacency among themselves and other employees.

Let’s take an example of a person who performs a daily safety inspection before production starts.  The purpose of the inspection is to identify any potential safety hazards.  This daily routine occurs for months even years without incident.  But, because “an incident has never occurred”, the employee decides to skip an inspection one day and no injuries resulted.  So, the employee skips another one, then another, and soon inspections are rarely being conducted.     Until something happens.  Skipping important safety steps due to complacency could result in serious injury to the employee or fellow workers.

Usually, the best person to spot complacency is the employee themselves, but complacency can mean they don’t see the dangers right in front of them.  To overcome this, teach employees to spot signs of complacency in their co-workers first.  The more they learn how to recognize these signs in others, the easier it will be to recognize it in themselves.  

Keep an eye out for the following situations that may indicate complacency is setting in:

• Dissatisfaction with work and/or lack of motivation
• Taking short cuts in work processes, safety procedures or inspections
• Increased frequency of near-misses or incidents
• Changes in attitude 
• Noticeable increase or decrease in communication 
• Tardiness for meetings or shifts

Increased employee engagement is a great way to help workers get out of the rut of complacency.  Actions workers can take include:

• Consciously focusing on the task at hand.  
• Identifying distractions when they come up and dismissing them.
• When conducting repetitive tasks, be on the lookout for procedural improvements that can help break up the monotony.
• Understanding the greater purpose of their job, such as the finished product or report, and interacting with team members regularly.  

Identifying and addressing complacency is a team effort.  Not only is it key for employees, but the employer can assist by implementing best practices such as:

• Share the Mission— Remind employees of the company’s purpose and goals so they maintain a connection to the larger missions and emphasize that their behaviors have an impact.
• Minimize Routines—Since repetition is related to complacency, consider job rotation or change up some of the work tasks to add variety to an employee’s job.  Providing differing work tasks can help maintain focus and keep employees from falling into “cruise control” mode.
• Encourage observation of others - Have employees briefly stop work and observe the actions of others as they work.  Observing others raises one’s own awareness, as well as the awareness of their co-workers.
• Correct poor performance - Mentoring programs and coaching can help employees identify and correct poor work practices and potential problems before an injury occurs.
• Conduct safety discussions and tool box talks – Make safety talks part of a daily routine and get employees involved and engaged with team members.
• Share Knowledge – Have employees identify and share the steps they perform to complete a job.  Having another set of eyes or someone else’s ideas may help improve the process.   

Complacency can be a dangerous thing, and everyone is susceptible.  It can lead to underperformance, low job satisfaction, workplace accidents and low morale.  But with a team effort and employee engagement, complacency doesn’t have to run the workplace.

If you would like to know more about Sedgwick’s safety services or would like to schedule a confidential consultation, please contact Andy Sawan at andrew.sawan@sedgwick.com or 330.819.4728.