The median BMI of the participants was 30.20 (27.8033.30) kg/m2, while 52.63% of them were obese (BMI>30kg/m2). It ranges from 100 to 400 dB/m. A CAP score that is 290 dB/m or higher represents over 67% fatty change in the liver. The serum levels of insulin, C-peptide and thyroid-stimulating hormone (TSH) were determined by using ELISA kit (Monobind Inc., USA). Google Scholar. Treuth, M. S. et al. Factors related to hypermetabolism in individuals with type 2 diabetes mellitus and non-alcoholic fatty liver disease, https://doi.org/10.1038/s41598-023-30945-w. Get the most important science stories of the day, free in your inbox. Salmenniemi, U. et al. 5 0 obj Acquisition of data, M.R.M.T. Advantages of CAP include its ease of measurement, operator-independence and simultaneous availability with LSM for fibrosis assessment. Therefore, this suggests that the elevated protein turnover, among other factors such as systemic inflammatory response, may be contributing to FFM depletion and increase REE levels in subjects with NALFD and diabetes. Herrera-Amante, C. A. et al. Front. Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition. The results of the present study showed a positive association between diastolic blood pressure and hypermetabolism. J. Appl. A stiffer liver is usually indicative of liver damage. CAS Hepatol. Published by Elsevier Ltd. This information will help you understand your FibroScan results. Diabetes Care 31(1), 165169 (2008). 13(9), 849866 (2019). . Diabetologia 35(10), 962966 (1992). Insulin resistance was estimated using the following formula: HOMA-IR=[Fasting insulin (U/mL)fasting glucose (mmol/L)/22.5]. Your healthcare provider will use your liver stiffness result and medical history to find out your fibrosis score. 2019 May;156(6):1717-1730. doi: 10.1053/j.gastro.2019.01.042. A fibrosis score of F4 ( 14 kPa or higher) means late-stage scarring or cirrhosis, where the scarring is permanent and the damage is irreversible. Article We use cookies to help provide and enhance our service and tailor content and ads. Internet Explorer). Diagnostic Accuracy of Noninvasive Markers of Steatosis, NASH, and Liver Fibrosis in HIV-Monoinfected Individuals at Risk of Nonalcoholic Fatty Liver Disease (NAFLD) Google Scholar. Answered 4 years ago Let others know if this answer was helpful Was this answer helpful? PB reports personal fees from EchoSens during the conduct of the study. To the best of our knowledge, this is the first study which evaluated hypermetabolism and its contributing factors in T2DM individuals with NAFLD. Unauthorized use of these marks is strictly prohibited. Liver stiffness measurement (LSM) by FibroScan-determined transient elastography is a noninvasive approach to estimate liver fibrosis severity. Sci Rep 13, 3669 (2023). Fibroscan results? - Liver disease Intensity of resistance exercise determines adipokine and resting energy expenditure responses in overweight elderly individuals. The influence of basal metabolic rate on blood pressure among indigenous Siberians. Am. /ExtGState << The intricate relationship between type 2 diabetes mellitus (T2DM), insulin resistance (IR), and nonalcoholic fatty liver disease (NAFLD). Qi, Y. et al. >> CAPis a quantitative surrogate of liver steatosis expressed in decibel per meter (db/m). Publication Arslanow et al. The .gov means its official. A.M. Study conception and design, Acquisition of data, Analysis and interpretation of data, Drafting of manuscript, Critical revision, S.M. Independent sample t-test, MannWhitney U test or Chi-square (2) test was used for comparison between groups as appropriate. Would you like email updates of new search results? 100(3), 10781087 (2015). The authors declare no competing interests. 1 0 obj 2020 Dec;72(6):2228-2230. doi: 10.1002/hep.31498. Curr. Protein turnover is assumed to account for 20% of REE in healthy subjects41, and elevated protein turnover is associated with increased REE42,43 and loss of FFM43. stream pdf files. However, there is inadequate evidence regarding the threshold of blood glucose in which REE is increased38. Rep. 5(6), 513520 (2003). In combination, these scores can help you understand your overall liver health and how it may change over time with lifestyle or medical interventions. PubMed This is usually caused by heart failure. In the present study, an inverse association between FFM and hypermetabolism was shown. Non-alcoholic fatty liver disease is associated with higher metabolic expenditure in overweight and obese subjects: A case-control study. FibroScan is an imaging-based diagnostic test developed by Echosens that looks at liver fibrosis (stiffness, scarring) and steatosis (fat) using transient-elastography technology. Nursing Informatics: Fibroscan Bnk48 2019 May;156(6):1717-1730. doi: 10.1053/j.gastro.2019.01.042. Arrese, M. & Barrera, F. Concurrent nonalcoholic fatty liver disease and type 2 diabetes: Diagnostic and therapeutic considerations. Mansour, A., Motamed, S., Hekmatdoost, A. et al. FOIA Care 6(1), 5563 (2003). Accuracy of FibroScan Controlled Attenuation Parameter and Liver Stiffness Measurement in Assessing Steatosis and Fibrosis in Patients With Nonalcoholic Fatty Liver Disease. Other studies have also indicated that REE is only elevated in uncontrolled diabetic subjects and diabetic cases who took blood glucose lowering drugs experienced a decrease in REE38,39,40. The site is secure. If you have any questions, contact a member of your care team directly. Adv. A greater CAP result points to a higher degree of fatty change and a more serious level of fatty liver.-The fibrosis result offers evidence of the amount of fibrotic scarring (fibrosis) within the liver, extending from zero to . For instance, bioelectrical impedance can be affected by some factors including the level of body hydration, body geometry, etc., which could result in the incorrect estimation of body composition78. At a cut-off of 283 dB/m, the CAP was 76% sensitive, 79% specific, and had positive and negative predictive values of 87% and 64%, respectively. ISSN 2045-2322 (online). http://creativecommons.org/licenses/by/4.0/. Rathaus, M. & Bernheim, J. A score below 238 dB/m means the amount of fatty change in your liver is not higher than normal. CAPis available on the three FibroScan probes (S+*, M+ and XL+). Conclusions: 318(8), 467472 (1988). ]RH8zBE%4&7\%jo05$. /Filter /FlateDecode KPa score 44.2 CAP score 309 - Living with Fatty - HealthUnlocked JJD, AP, M-HZ, PJE, DAS, ING, and VP declare no competing interests. Although, historically, a negative relationship between obesity and REE has been shown32, recent studies have challenged this finding, indicating that obese individuals have higher BMR or REE33,34. Accurate tools for the noninvasive detection of hepatic steatosis are needed. Then, look at the top of that column to see the fibrosis score. The highest possible result is 75 kPa. Ann. Association between uncoupling protein 2, adiponectin and resting energy expenditure in obese women with normal and low resting energy expenditure. If treated early with diet and lifestyle changes, the disease can be reversible. 105(2), 141150 (2014). The higher level of BMR in obese NAFLD individuals with metabolic syndrome has been to some extent attributed to low-grade, chronic inflammation17. Nutr. Physiol. Hipskind, P. et al. Your healthcare provider will use your FibroScan fibrosis result and your medical history to determine your fibrosis score. The last column tells you how much scarring is in your liver. 2022 Jul;12(Suppl 1):S26-S36. Use of FAST in primary care will require investment in devices and personnel, although there are many examples of such models being introduced successfully. [0 /XYZ 35.2500000 Pursuing basic and translational research across 9 programs and 100+ labs, Focusing on clinical cancer research and population health, Bridging the lab and the clinic through translational research, Fostering interdisciplinary collaborations between laboratory scientists and clinicians, Partnering with other academic and research institutions, Offering state-of-the-art resources for our researchers, Offering a curriculum with a focus on cancer, Connecting college seniors to future careers in biomedicine. MB), Help with N. Engl. The FBS was measured using an autoanalyzer (Cobas c 311, Switzerland). In a casecontrol study matched for sex, age, and body mass index (BMI), NAFLD cases had higher REE when compared to controls16. In accordance with our findings, Ali et al.63 and Snodgrass et al.64 showed a direct relationship between BMR and blood pressure. Examinations with FibroScandevice shall be performed by an operator who has been certified by the manufacturer or its approved local representative. 2020 The Author(s). JFC reports speaker fees/advisory board fees from EchoSens during the conduct of the study; and personal fees from NovoNordisk, Intercept, and Alnylam, outside the submitted work. Correspondence to CAP Score Steatosis grade Portion of your liver affected by fatty change 238 to 260 dB/m S1 Less than (11% to 33%) 260 to 290 dB/m S2 Between and (34% to 66%) 290 to 400 dB/m S3 More than (67%) What is Fibroscan | Testing Preparation & Expectations PubMed Central 26(4), 426433 (2011). Effects of anti-diabetic treatments in type 2 diabetes and fatty liver disease. The results were 4.0 Kpa and CAP score of 179. 13(1), 344348 (2019). SAH reports grants from Conatus, Immuron, Second Genome, and Tobira/Allergan; grants and personal fees from Axcella, Cirius, CymaBay, Galmed, Gilead, HightTide, Intercept, NGM, Novartis, Novo Nordisk, Pfizer, Galectin, Genfit, and Madrigal; and personal fees from Metacrine, 3V Bio, Albereo, Alexion, Blade Therapeutics, Bristol-Myers Squibb, Civi BioPharma, CLDF, Contravir, Consynance, Concept, Echosens, Gelesis, HistoIndex, Innovate, IQVIA, Medpace, Perspectum, Poxel, Pometheus, Prometic, Terns, Akero, and Lipocine, outside the submitted work. J. Clin. Cap Score Liver - What Does Mean By Cap Score In Fibroscan Of | Practo Vitaminol. Nutr. Usui, C. et al. JFC was supported by the NIHR Oxford BRC. an elevated non-alcoholic fatty liver disease activity score, and F2 fibrosis for the . This score will be used by your doctor to grade your steatosis (fatty change). /F6 6 0 R Kao, C. C. et al. The CAP score is measured in decibels per meter (dB/m) and ranges from 100-400. J. Behav. It can be used alone or with other tests (such as blood tests, imaging scans, or biopsies) that also measure scarring or fatty change in your liver. Int. However, the literature represents diverse findings in regard to adiponectin levels and REE. Martin, K. et al. Plasma adiponectin levels are not associated with fat oxidation in humans. F0 = no scarring F1 = mild fibrosis F2 = moderate fibrosis F3 = severe fibrosis F4 = cirrhosis or advanced fibrosis I had a fibroscan done last month with a 17 Kpa (cirrhosis). Diabetes Care 31(1), 128133 (2008). The intercept compares the mean of all predicted risks with the mean observed risk and indicates the extent that predictions are systematically too low or too high. REE was measured by indirect calorimetry using a Fitmate calorimeter (Cosmed, Italy). Your doctor may also order other tests to evaluate your liver, such as blood tests, other imaging scans, or biopsies. /MediaBox [0 0 612 792] A score of less than 1.3 may be considered low-risk, while a Fib4 score of more than 3.25 could mean you're at a high risk for liver fibrosis. Advantages of CAP include its ease of measurement, operator-independence and simultaneous availability with LSM for fibrosis assessment. Your healthcare provider will use your CAP score to find out your steatosis grade. Operators are expressly recommended to carefully read the instructions given in the user manual and on the labelling of these products. Pratley, R. et al. PMC Epub 2019 Jan 25. Google Scholar. Then, look at the top of that column to see the fibrosis score.[3]. PubMed Central The highest possible result is 75 kPa. /Producer ( Q t 4 . /SM 0.02 The continuous variables with normal distribution were presented as meanstandard deviation (SD) and those with non-normal distribution were presented as median (interquartile range [IQR]). Nat. FibroScan will help your healthcare provider learn more about your liver disease. Many people with liver disease(s) have a result that is higher than the normal range. Changes in eating habits and physical activity after COVID-19 pandemic lockdowns in Italy. Delsoglio, M. et al. J. Physiol. 20(1), 18 (2020). Therefore, the objective of the present study was to find the predictive or determining factors that could affect hypermetabolism in subjects with both T2DM and NAFLD. Pediatr. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. [4] Echosens, FDA Approves FibroScan for Non-invasive Liver Diagnosis, April 2013, https://www.prnewswire.com/news-releases/fda-approves-fibroscan-for-non-invasive-liver-diagnosis-203186961.html#:~:text=%2D%20Echosens%E2%84%A2%20is%20pleased%20to,technology%20in%20the%20United%20States. The elasticity modulus of liver in fatty liver rabbits of nonalcoholic and alcoholic groups showed a positive correlation with progression of liver fibrosis (P<0.01). Copyright 2020 The Author(s). J. Clin. Liver Fibrosis: Stages, Treatment, and Symptoms - Healthline The first 5min were excluded from the analysis. Nat Rev Gastroenterol Hepatol. To explain these contradictions, the role of genetics as a factor that can influence both energy expenditure and adiponectin56,57, the use of different populations in studies, and the different methods used to assess energy expenditure must be taken into account. Publication Arslanow et al. The test can also be used to monitor liver health in patients with a history of alcohol abuse and a family history of liver disease. Lifestyle modification improves the hepatic steatosis, and CAPcan be used to detect the improvement of hepatic steatosis during follow-up in patients with NAFLD on lifestyle modification. /PCSp 4 0 R J. Obes. While the present study found no association between inflammatory markers (CRP and TNF-) and hypermetabolism, the effect of inflammatory markers cannot be completely ruled out; this is because, in this study, we did not examine all inflammatory markers such as IL-6, etc. Proportion of NAFLD patients with normal ALT value in overall NAFLD patients: A systematic review and meta-analysis. Engelen, M. P. et al. CAPis a quantitative surrogate of liver steatosis expressed in decibel per meter (db/m). The https:// ensures that you are connecting to the Emerg. Sci Rep. 2022 Dec 19;12(1):21897. doi: 10.1038/s41598-022-25931-7. Article /CSpg /DeviceGray CAS The authors are thanks to the patients who participated in the study. Pract. << 10(5), 524529 (2004). Diabetes Care 40(3), 419430 (2017). ET reports personal fees from Pfizer, Intercept, Gilead, Promethera, and Dr Falk, outside the submitted work. Publication Arslanow et al. Nutrients. Clin. Jouinot, A. et al. 96(5), 945948 (2006). Epub 2020 Dec 16. The FibroScan test result will provide with: Cap Score: The amount of liver with fatty change is measured by CAP score in decibels per meter(dB/m) that corresponds to the stages of steatosis- S1, S2, or S3. This is based on your diagnosis, liver stiffness, and fibrosis scores. the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Follow the row that has your results. Sign up for the Nature Briefing newsletter what matters in science, free to your inbox daily. CAS Understanding NAFLD: From Case Identification to Interventions, Outcomes, and Future Perspectives. Diagnostic performance in the derivation, Diagnostic performance in the derivation cohort of the FAST score for the diagnostic, Calibration plots in external validation, Calibration plots in external validation cohorts (A) French bariatric cohort (n=110). The spleen-strengthening and liver-draining herbal formula treatment of non-alcoholic fatty liver disease by regulation of intestinal flora in clinical trial. 2021 May;36(5):1309-1316. doi: 10.1111/jgh.15358. In those four cohorts, the FAST score overestimates the probability of being NASH+NAS4+F2. /Type /Page World J. Gastroenterol. Mitochondrial dysfunction contributes to the increased vulnerabilities of adiponectin knockout mice to liver injury. Here are some helpful terms to know related to your FibroScan results: Fibrosis and steatosis are measured separately from one another. Hypertens. Deurenberg, P. Limitations of the bioelectrical impedance method for the assessment of body fat in severe obesity. PubMed Furthermore, our small sample size might have affected the results. BMR has been reported to increase by 57% in individuals with T2DM21,22. Why Your Doctor May Order a FibroScan - Northeast Digestive Do handheld calorimeters have a role in assessment of nutrition needs in hospitalized patients? J. Physiol.-Endocrinol. Stefan, N. et al. FAST=FibroScan-aspartate aminotransferase. doi: 10.5005/jp-journals-10018-1364. Nevertheless, among subjects with concurrent T2DM and NAFLD, our findings suggested that the effect of other factors, including FFM, adiponectin, diastolic blood pressure, physical activity and ALT, on REE was greater than that of glycemia and insulin levels. You are using a browser version with limited support for CSS. (E) French NAFLD cohort (n=182). You may have less scarring than your results suggest. Phys. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Nutr. This work was funded by Echosens, who were sponsors of this study, and also the UK National Institute of Health Research (NIHR), who funded staff salaries (chief and principal investigators, clinical research fellows, and research nurses) at the sites in England through grant support from the Biomedical Research Centre (BRC). To assess the health of your liver, your doctor may recommend a FibroScan test, which is an ultrasound of the liver. When the liver gets stiff, the tough get moving - PubMed Ali, N. et al. You can keep reading to learn more about your results. Article The NFSA score was calculated based on age, hyperglycemia, body mass index, platelets, albumin and serum aminotransferase levels. B. et al. Diabetologia 35(8), 753759 (1992). CAP(Controlled Attenuation Parameter) is the non-invasive reference parameter to diagnose and monitor liver steatosis. Int. NASH=non-alcoholic steatohepatitis. After overnight fasting (at least 10h), oxygen consumption and carbon dioxide production were obtained for 20min with the participants lying down, without falling asleep, on a bed in a quiet environment. Validation of controlled attenuation parameter measured by fibroscan as a novel surrogate marker for the evaluation of metabolic derangement. Starling, R. D. Energy expenditure and aging: Effects of physical activity. Past, present and future perspectives in nonalcoholic fatty liver disease. The main causes of fatty liver disease are excessive alcohol consumption and/or poor diet and sedentary lifestyle. According to the results of multivariable logistic regression analysis (Table 2), hypermetabolism was positively associated with adiponectin (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.021.34, p=0.030), physical activity (OR 1.13, 95% CI 1.0021.28, p=0.046), ALT (OR 1.06, 95% CI 1.0061.12, p=0.031) and diastolic blood pressure (OR 1.07, 95% CI 1.011.13, p=0.021). Unauthorized use of these marks is strictly prohibited. /Resources 14 0 R >> FibroScan works similarly to an ultrasound, emitting a small pulse of energy, called a shear wave. Correlation between Fibroscan and laboratory tests in non-alcoholic Finelli, C. & Tarantino, G. What is the role of adiponectin in obesity related non-alcoholic fatty liver disease? A score below 238 dB/m means the amount of fatty change in your liver is not higher than normal. A p-value<0.05 was considered statistically significant. NAFLD=non-alcoholic fatty liver disease. The lower the percentage of your liver with fatty change, the healthier your liver is and the lower your CAP score and steatosis grade from your FibroScan. Kablawi D, Aljohani F, Palumbo CS, Restellini S, Bitton A, Wild G, Afif W, Lakatos PL, Bessissow T, Sebastiani G. Crohns Colitis 360. /Length 13 0 R References are available in our bibliography. FibroScan is a special ultrasound technology that measures liver stiffness (hardness) and fatty changes in your liver. Non-alcoholic fatty liver disease and the interface between primary and secondary care. Patients with chronic liver disease and body mass index (BMI) 28 kg/m(2) underwent biopsy and liver stiffness measurement (LSM) with simultaneous CAP determination using the FibroScan() M probe. Controlled attenuation parameter-insulin resistance (CIR) score to predict non-alcoholic steatohepatitis. CAP value of 300 falls into S2/S3 stage. It uses ultrasound technology to measure the stiffness of your liver tissue. The CAP score is measured in decibels per meter (dB/m). J. Nutr. 2012 Jul;32(6):875-7. doi: 10.1111/j.1478-3231.2012.02824.x. All authors have read the manuscript and approved the manuscript. Scientific Reports J. Appl. What is FibroScan, and How Can It Help With Fatty Liver? CAP Score Steatosis grade Portion of your liver affected by fatty change 238 to 260 dB/m S1 Less than (11% to 33%) 260 to 290 dB/m S2 Between and (34% to 66%) 290 to 400 dB/m S3 More . Find your liver stiffness result in the second column from the left. This can happen if you have: FibroScan may give less accurate results, or no results at all if you have: Your healthcare provider may use imaging tests, such as ultrasound, CT, or MRI, to see your liver. National Library of Medicine Epub 2020 Aug 5. Fontvieille, A. et al. Clin. 8(9), 1387 (2019). If you are looking for a facility where you can get a Fibroscan, choose inSite Digestive Health Care. Resistance training increases total energy expenditure and free-living physical activity in older adults. PNN reports grants and speaker fees/advisory board fees from Novo Nordisk and Boehringer Ingelheim; speaker fees/advisory board fees from Pfizer, Intercept, Gilead, and Poxel; and grants from Pharmaxis, outside the submitted work. Current smoker was attributed to those who had smoked cigarette regularly in the past 6months. /Title ( U n d e r s t a n d i n g Y o u r L i v e r E l a s t o g r a p h y \( F i b r o S c a n \) R e s u l t s | M e m o r i a l S l o a n K e t t e r i n g C a n c e r C e n t e r) Bica, C. et al. Dial. {Wk >=S%ss Basal metabolic rate in morbidly obese patients with non-alcoholic fatty liver disease. At given FAST score cutoffs, it is possible to graphically assess the screen failure rate and missed cases rate together with the proportion of patients above the FAST score who would be given liver biopsy in the context of patients screening in drug trials for NASH. Systolic and diastolic blood pressure of the participants was measured on the left arm after at least 10min of the seated rest. Hepatol. Most patients with the presence of a metabolic syndrome. Endocrinol. Shear wave speed and stiffness, and CAP* may be used as an aid in the clinical management of pediatric patients with liver disease. FibroScan elastography of liver tissue can easily detect patients with cirrhosis and fatty liver. A FibroScan can reveal fatty changes to the liver (steatosis) and scarring. Strength training increases resting metabolic rate and norepinephrine levels in healthy 50-to 65-yr-old men. The rest of this resource explains your FibroScan results in more detail. Mechanisms of altered protein turnover in chronic diseases: A review of human kinetic studies. Expert Rev. The French (E) and Turkish (G) NAFLD external validation cohorts are well calibrated; their calibration curve is nearly linear, their intercept is close to zero (CIs include zero), and their slope is close to one (CIs include one). Typically, a 5-pointscoring system is used to grade the degree of liver fibrosis, from F0-F4. Overall, the mean recruitment agestandard deviation and median (interquartile range) body mass index were 44.695.47years and 30.20 (27.8033.30) kg/m2, respectively. Prevalence and risk factors for biopsy-proven non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in a prospective cohort of adult patients with gallstones. Li, G. & Zhong, L. Genetic variations in adiponectin levels and dietary patterns on metabolic health among children with normal weight versus obesity: The BCAMS study. Sci. The dietary intervention has a positive impact on CAP. Careers. Ravussin, E. et al. Your healthcare provider will use your CAP score to find out your steatosis grade. MathSciNet Melby, C. et al. [ ] 31(1), E24E29 (2008). Non-alcoholic fatty liver disease: A major challenge in type 2 diabetes mellitus. Pharmacol. Lamos, E. M. et al. J. Clin. W-KC reports personal fees from Boehringer Ingelheim, Echosens, and Mylan; grants from Sysmex and Resonance Health; and non-financial support from Endosurgery, outside the submitted work. 2017;15:1120. 53(6), 529535 (2007). One study found that adiponectin concentration had no relationship with energy expenditure among non-diabetic subjects52. Bitz, C. et al. In patients with NAFLD and T2DM, hypermetabolism has a direct association with adiponectin, physical activity, ALT and diastolic blood pressure, but a diverse relationship with FFM. 477.750000 0] Google Scholar. Bloodwork is perfect. Moreover, some studies have indicated serum adiponectin is negatively correlated with REE in Caucasians54 and Pima Indians55. Am. The Controlled Attenuation Parameter (CAP) specifically targets liver steatosis using a process based on transient elastography. Franssila-Kallunki, A. 2012 Feb;36(1):13-20. doi: 10.1016/j.clinre.2011.08.001. The performance of the CAP for diagnosing steatosis compared with biopsy was assessed using areas under receiver operating characteristic curves (AUROC). Gastroenterol. BMC Sports Sci. C(aL}%:f~m5"=&@M*M2*38"% Zhou, M. et al. Ther. All slopes are within an acceptable range (the CI includes one), except for the French bariatric cohort, which seems to be at the limit. Ultrasonography and FibroScan were performed twice and once, respectively ( Table 5 ). endobj In two validation cohorts there was only access to the M probe, so patients with a BMI greater than 32 kg/m. SC reports grants from Echosens to his institution (APHP) during the conduct of the study and speaker fees/advisory board fees from MyGoodLife outside the submitted work.