bluuebunny/crossref_metadata_2025 huggingface dataset:
976 Fibroscan™, FIB-4, and NAFLD Fibrosis Score as Point of Care Non-Invasive Tests for Management of Non-Alcoholic Fatty Liver Disease and Other Chronic Liver Diseases
Authors: Younossi Zobair , Stepanova Maria , Felix Sean , Jeffers Tom , Younossi Elena , Allawi Hossain , Cable Rebecca , Lam Brian , Racila Andrei , Younossi Issah , Henry Linda , Ranagan Jane , Nader Fatema
Published: October 2019

INTRODUCTION:

Fibroscan™ (FS) is a clinically useful tool for non-invasive assessment of fibrosis in patients with chronic liver disease (CLD). We aimed to assess the performance of FS as a point-of-care testing in real clinical practice of gastroenterology/hepatology.

METHODS:

During routine outpatient visits, patients with various etiologies of CLD had FS administered and laboratory tests collected. Advanced fibrosis was defined as a liver stiffness of ≥11.4 kPa and advanced steatosis as a controlled attenuation parameter (CAP) ≥ 260 dB/m. Non-invasive test (NIT) scores were calculated for fibrosis: FIB-4 (advanced fibrosis in patients with the score ≥ 2.67), AST-to-Platelet Ratio (APRI; advanced fibrosis ≥ 1.0), NAFLD Fibrosis Score (NFS; advanced fibrosis ≥ 0.676). Patients with advanced fibrosis status by NITs and a subgroup with liver biopsy data were used for concordance assessment (Cohen’s kappa statistic; Table 1) with FS for each major CLD etiology. Another subgroup of patients had FS administered twice (median period 12 months); these data were used to assess test-retest concordance of FS.

RESULTS:

There were 416 patients included: 28 with chronic hepatitis B (CHB), 32 with chronic hepatitis C (CHC), 270 with non-alcoholic fatty liver disease (NAFLD). Patients were 53.4 ± 12.7 years old, 47% male, 59% white, 12% black, 10% Hispanic, 10% Asian, 33% with type 2 diabetes. Patients with CHC had the highest mean liver stiffness (12.8 ± 13.4 kPa vs. 7.9 ± 7.0 kPa in others, P = 0.0006) while patients with NAFLD had the highest CAP (308 ± 51 dB/m vs. 258 ± 64 dB/m, P < 0.00001). The test-retest concordance for advanced fibrosis by FS was substantial [kappa = 0.70 (0.43–0.97),agreement in 45 out of 49 patients] and moderate for advanced steatosis [kappa was 0.41 (0.12–0.79),agreement in 38/49 patients]. In patients with CHC, the highest concordance of advanced fibrosis by FS was by FIB-4 [kappa = 0.58 (0.25–0.91)] and APRI [0.46 (0.12–0.81)]. Similarly, in patients with NAFLD, the highest concordance of advanced fibrosis by FS was with the stage of histologic fibrosis by liver biopsy [N = 66: kappa = 0.55 (0.35–0.74)] and NFS [kappa = 0.50 (0.32–0.67)].

CONCLUSION:

Non-invasive tests such as Fibroscan™, NFS, and FIB-4 provide useful information for assessment of advanced fibrosis in clinical practice of patients with CLD.
986 The Risk of Depression in Patients With Nonalcoholic Fatty Liver Disease
Authors: Sarmini Muhammad Talal , Fahad Hamna , Asfari Mohammad Maysara , Alomari Mohammad , Al-Khadra Yasser , Singh Amandeep , Dasarathy Srinivasan , McCullough Arthur J.
Published: October 2019

INTRODUCTION:

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the United States. The association of depression with chronic liver disease is reported in the literature, but the previous studies that established this association were limited in size. Therefore, we aimed in this study is to evaluate the association between NAFLD and depression using very large database.

METHODS:

Using data from the National Inpatient Sample (NIS) database between 2002 and 2014, we identified all patients who were diagnosed with NAFLD using appropriate ICD 9 coding. The control group was the patients who did not have a diagnosis of NAFLD. We then performed multivariate logistic regression analysis for the association between NAFLD and depression.

RESULTS:

The total population was comprised of 101,231,036 patients, of which 365,701 (0.36%) were diagnosed with NAFLD. Patients in the NAFLD group were older (53 vs 48), less likely to be females (57.7% vs 58.4%) and African American (9.3% vs 14.3%) (P < 0.001 for all). In addition, NAFLD patients had more obesity (26.2% vs 6.9%), smoking (13.9% vs 9.5%), hypothyroidism (12.2% vs 7.8%) and diabetes mellitus (DM) with or without complications (5.6% vs 3.2%) and (30.7% vs 14.1%) respectively, (P < 0.001 for all). Using Multivariate logistic regression, and after adjusting for potential cofounding factors including: (age, gender, race, obesity, smoking, DM and hypothyroidism), NAFLD group had a statistically significant higher rate of depression (Odds Ratio [OR] 1.75, 95% confidence interval [CI] 1.73–1.77, P < 0.0001) compared with the non-NAFLD group.

CONCLUSION:

Our analysis of very large nationwide database showed that patients with NAFLD were more likely to have depression compared to patients without NAFLD. This finding highlights the importance of depression screening in patients with NAFLD which can help improve their quality of life.
991 BALAD and BALAD-2 Predict Survival of Hepatocellular Carcinoma Patients: A North American Cohort Study
Authors: Wongjarupong Nicha , Negron Gabriela , Ahn Keun Soo , Yang Ju Dong , Giama Nasra H. , Mara Kristin , Harmsen William S. , Therneau Terry , Roberts Lewis R.
Published: October 2019

INTRODUCTION:

The discontinuous BALAD and continuous BALAD-2 scores derived from bilirubin, albumin, alpha-fetoprotein (AFP), Lens culinaris agglutinin-reactive AFP (AFP-L3), and des-gamma-carboxyprothrombin (DCP) are effective in predicting HCC patient mortality, but have not been validated in North America. We validated the BALAD and BALAD-2 scores in North America.

METHODS:

Data from 148 HCC patients seen from 2000–2015 with results for all five biomarkers at diagnosis were abstracted. Hazard ratios (HR) and C-statistics were calculated.

RESULTS:

75 of the 148 patients died during a median follow-up of 33 months (0.3-145 months),. The 1-year and 3-year survival rates were 70.8% and 47.6%, respectively. 114 (77%) patients had cirrhosis with a median MELD of 9.5 (range 6.4-29.5). HCC etiologies were HCV (34%), NASH (34%), alcohol (14%), and HBV (10%). Primary treatments were liver transplant, 21 (14%), surgical resection, 32 (22%), local ablation, 10 (7%), transarterial chemoembolization or radioembolization, 47 (32%), chemotherapy, 11 (7%), best supportive care, 9 (6%), and unknown treatment, 18 (12%). MELD, tumor size (cm), ≥2 tumors, tumor number, and neutrophil-lymphocyte ratio >4 significantly increased mortality with HR (95%CI) of 1.12 (1.06–1.18) per unit increase in MELD, 1.06 (1.0004–1.12) per cm increase in size, 1.21 (1.03–1.43) per number of tumor, and 1.93 (1.16–3.24). For the BALAD score analysis, 12, 49, 40, 31, 16 and 0 patients had BALAD scores of 0–5 respectively. The HR (95%CI) for death were 1.24 (0.42–3.67), 1.79 (0.61–5.26), 2.83 (0.95–8.38), and 7.19 (2.26–22.91) for BALAD scores 1, 2, 3, and 4 vs. BALAD 0. For the BALAD-2 analysis, 58, 35, 33, and 22 patients were BALAD-2 classes 1, 2, 3, and 4. The HR (95%CI) for death were 1.25 (0.65–2.40), 1.75 (0.94–3.23), and 6.20 (3.29–11.68) for BALAD-2 classes 2, 3, and 4 vs. BALAD-2 class 1. A multivariate model incorporating maximal tumor diameter, tumor number, neutrophil-lymphocyte ratio and BALAD had HR of 1.43 (1.14–1.81) per increase of 1 BALAD score. A similar multivariate model with BALAD-2 had HR of 1.50 (1.18–1.90) per increase of 1 BALAD-2 class. BALAD, BALAD-2 and BCLC had similar C-statistics of 0.69, 0.68, and 0.67.

CONCLUSION:

The BALAD score and BALAD-2 class at HCC diagnosis can predict survival of HCC patients in North America. AFP, AFP-L3, and DCP in the BALAD models incorporate HCC tumor biology and make the BALAD model distinguish from other previous predictive models.
992 Venous Thromboembolism Prophylaxis in Hospitalized Patients With Chronic Liver Disease and the Bleeding and Thrombosis Risk: A Systematic Review and Meta-Analysis
Authors: Wongjarupong Nicha , Laoveeravat Passisd , Udompap Prowpanga , Vantanasiri Kornpong , Bakker Caitlin
Published: October 2019

INTRODUCTION:

Patients with chronic liver disease, especially cirrhosis have an increased risk in both venous thromboembolism (VTE) and bleeding. Most of hospitalized chronic liver disease patients, however, were not given the VTE prophylaxis during admission.

METHODS:

A systematic search was conducted for studies published up to May 2019 using MEDLINE, EMBASE, and Cochrane Library. We included cohort studies of patients with chronic liver disease who were hospitalized for ≥48 hours which compared patients with and without VTE prophylaxis. Study quality was assessed using Newcastle-Ottawa scale (NOS). A random-effects model was used to determine relative risk (RR) with 95% confidence interval (CI) for bleeding and thrombotic events.

RESULTS:

After screening 2462 abstracts, 188 potentially studies were assessed. Seven retrospective cohorts met the criteria and were included in this meta-analysis. Only one study matched intervention group and controls and was done with propensity score. In total, there were 1,855 patients who received VTE prophylaxis and 2,915 patients who did not receive VTE prophylaxis. Regarding bleeding events, there were 76 patients (4.0%) and 231 patients (7.9%) in prophylaxis and no prophylaxis group, respectively. There was no increase of bleeding event in the VTE prophylaxis compared to the no-VTE prophylaxis group with pulled RR of 0.70 (0.30–1.64, I2 = 87%). Regarding thrombosis risk, there were 34 patients (1.8%) and 68 patients (2.3%) in prophylaxis and no prophylaxis group, respectively. There was no increase of thrombosis event in the VTE prophylaxis compared to the no-VTE prophylaxis group with pulled RR of 0.76 (0.44-1.31, I2 = 17%). When included only patients with INR ≥ 1.4 or with cirrhosis, the RR of patients with VTE prophylaxis for bleeding was 0.73 (0.31–1.69, I2 = 74%) and thrombosis was 1.13 (0.67–1.92, I2 = 0%).

CONCLUSION:

This meta-analysis found no difference of bleeding and thrombosis events between chronic liver disease patients with and without VTE prophylaxis. The similar results were seen with subgroup analysis of patients with elevated INR or cirrhosis. However, with limitation of retrospective study, the patients who received prophylaxis tended to have less advanced liver disease, which potentially had less risk of bleeding and risk of thrombosis. Further study with liver disease staging and coagulopathy risk matched for intervention and control groups is warranted.
993 Trends of Portal Vein Thrombosis Comorbidities Among Decompensated Cirrhosis in a Nationwide Inpatient Cohort
Authors: Fan Xiaowen , Hershman Melissa , Weisberg Ilan
Published: October 2019

INTRODUCTION:

Portal vein thrombosis (PVT) is commonly associated with cirrhosis. Previous studies showed increasing PVT prevalence but declining PVT mortality in decompensated cirrhosis. However, the trends of PVT associated comorbidities have not been well studied in this population.

METHODS:

We conducted a retrospective cohort study utilizing the 2000-2014 National Inpatient Sample (NIS) Database. Patients older than 18 years with decompensated cirrhosis were included, defined by an ICD-9-CM coding for cirrhosis plus a decompensating event or portal hypertensive sequelae. Those who had liver transplantation or hepatocellular carcinoma were excluded. We further grouped patients with alcoholic cirrhosis vs non-alcoholic cirrhosis. The primary outcomes included the trends of esophageal variceal bleeding, acute kidney injury (AKI), and mesenteric ischemia. The secondary outcome was trend of transjugular intrahepatic portosystemic shunt (TIPS) in cirrhosis with PVT. Analysis was performed using Cochran-Armitage test and further adjusted by patients' age, sex, and race.

RESULTS:

The total number of hospitalizations with decompensated cirrhosis and PVT was 51,925. During years 2000 to 2014, among all-cause decompensated cirrhosis with PVT, AKI prevalence increased from 12.6% to 33.3% (OR 1.09, P < 0.001), mesenteric ischemia prevalence increased from 5.5% to 9.2% (OR 1.06, P < 0.001), esophageal variceal bleed prevalence declined from 27.7% to 13.0% (OR 0.96, P < 0.001), and TIPS rate declined from 8.7% to 4.2% (OR 0.96, P = 0.001). These results remained statistically significant after adjusting for patients’ age, sex, and race. Subgroup analysis showed similar trends in alcoholic and non-alcoholic cirrhosis, though the declining prevalence rates of esophageal variceal bleed and TIPS in alcoholic cirrhosis did not reach statistical significance after adjustment.

CONCLUSION:

Among decompensated cirrhosis complicated by PVT, prevalence of AKI and mesenteric ischemia was found to be rising. Advancements in radiologic imaging technologies may explain increased detection of mesenteric ischemia. Esophageal variceal bleeding and TIPS prevalence were found to be decreasing, likely due to widespread utilization of endoscopy for primary and secondary prophylaxis of variceal hemorrhage. Given ongoing evidence supporting the safety of direct oral anticoagulants for treatment of PVT in cirrhosis, the utilization of TIPS for therapy of nonocclusive and localized PVT is likely to decline.
996 Disease Characteristics of Acute Hepatic Porphyria Patients: ENVISION, a Phase 3 Global, Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial
Authors: Anderson Karl , Balwani Manisha , Sardh Eliane , Gouya Laurent , Rees David , Stein Penelope , Stolzel Ulrich , Aguilera Paula , Bissell D. Montgomery , Bonkovsky Herbert , Keel Sioban , Parker Charles , Phillips John , Silver Samuel , Windyga Jerzy , D'Avola Delia , Ross Gayle , Stewart Peter , Ritchie Bruce , Oh Jeeyoung , Harper Pauline , Wang Jiaan-Der , Langendonk Janneke , Ivanova Aneta , Horie Yutaka , Minder Elisabeth , Vassiliou Daphne , Kubisch Ilja , Guillen-Navarro Encarna , Coman David , Wang Bruce , Kuo Hung-Chou , Scalera Sushama , Penz Craig , Hua Zoe , Simon Amy , Ko John J. , Ventura Paolo
Published: October 2019

INTRODUCTION:

Acute Hepatic Porphyria (AHP) is a family of rare genetic diseases due to enzyme deficiencies in heme biosynthesis in the liver that can lead to neurovisceral attacks and chronic symptoms. (1, 2) AHP is also associated with multiple long-term complications, including neuropathy (3,4), hypertension (5,6), chronic kidney disease (7), and hepatocellular carcinoma (8,9).

METHODS:

ENVISION (NCT03338816) was a Phase 3 global, multicenter, randomized, double-blind, placebo-controlled trial with an open label extension to evaluate the efficacy and safety of subcutaneous givosiran in AHP. Eligible patients had an AHP diagnosis and ≥2 attacks within the prior 6 months. At baseline detailed medical history and laboratory assessments were obtained.

RESULTS:

Ninety-four AHP patients enrolled, median (range) age 37.5 (19-65) years, 89% female, and median (range) of 6.5 (0.1–43) years since diagnosis. Patients had a median of 4 composite attacks in the preceding 6 months and 40% were on hemin prophylaxis prior to study. Half the patients experienced daily chronic symptoms and 29% used opioids daily/most days between attacks. Comorbidities reported on medical history included neuropathy (38%), central venous access complications (71%), iron overload (33%), liver disease (28%), and chronic kidney disease (18%). At baseline 17% of patients had liver transaminases > ULN and 34% had an eGFR < 60 mL/min/1.73m2.

CONCLUSION:

The baseline disease characteristics of the Phase 3 study population are consistent with findings reported in the AHP literature, underscoring the high rate of liver disease and central venous access complications in these patients, and highlighting the multi-systemic nature of AHP and the medical challenge it presents for diagnosis and treatment.
1000 Older Adults With Hepatocellular Carcinoma Are More Likely Than Younger Adults to Receive Curative Treatment but Have Worse Overall Survival
Authors: Rich Nicole E. , Murphy Caitlin C. , Yopp Adam C. , Marrero Jorge A. , Singal Amit G.
Published: October 2019

INTRODUCTION:

Hepatocellular carcinoma (HCC) incidence rates are increasing among older adults in the U.S. Age-related disparities in prognosis and treatment receipt have been described in other cancers; however, there are limited data examining outcomes in older adults with HCC. Our study's aim was to evaluate age-related differences in HCC treatment receipt and prognosis.

METHODS:

We performed a retrospective study of patients diagnosed with HCC between 2008 and 2017 at 2 U.S. hospital systems. Older and younger adults were defined as ≥65 and <65 years old, respectively. Curative therapy was defined as liver transplantation, surgical resection, or local ablation. We used multivariable logistic regression to identify factors associated with curative treatment receipt and Cox proportional hazard models to identify factors associated with overall survival (OS).

RESULTS:

Of 1110 patients with HCC, 261 (23.5%) were ≥65 and 849 (76.5%) were <65 years old; the cohort was racially/ethnically diverse (33.3% white, 32.4% black, 27.5% Hispanic). A higher proportion of older adults had non-viral cirrhosis compared to younger adults (46.1% vs 21.8%, P < 0.001). A similar proportion of HCC were detected by surveillance in both groups (41.0% vs 40.0%, P = 0.80), but a higher proportion of older adults presented with early stage HCC (BCLC 0/A; 44.8% vs 40.6%, P < 0.001) compared to younger adults; further, a higher proportion of older adults had Child A cirrhosis (61.1% vs 43.4%, P < 0.001) compared to younger adults. Among treated patients (n = 750), older adults were more likely to receive curative therapy (OR 1.71, 95% CI 1.06–2.77) even after adjusting for sex, race, Child Pugh score, BCLC stage and ECOG performance status; there was no significant difference in complete response rates (31.0% vs 28.9%, P = 0.58) between older and younger adults. Among those who received curative therapy, median OS was significantly lower among older compared to younger adults (37.9 vs 57.5 months, P = 0.04) while survival was similar among older and younger adults receiving palliative HCC therapy (12.6 vs 12.2 months, P = 0.46) and best supportive care (1.6 vs 2.4 months, P = 0.05). Older adults had higher mortality than younger adults (HR 1.28, 95%CI 1.05–1.56) after adjusting for sex, race, Child Pugh score, BCLC stage and ECOG performance status.

CONCLUSION:

Despite being more likely than younger adults to receive curative treatment, older adults with HCC had worse overall survival, independent of BCLC stage or cirrhosis severity.
1001 Significant Differences in Liver Transplant (LT) Waitlist Mortality, Receiving LT, and Post-LT Survival Among Adults With Primary Sclerosing Cholangitis, Primary Biliary Cholangitis, and Autoimmune Hepatitis in the U.S.
Authors: Bayable Asnakech , Liu Benny , Bhuket Taft , Wong Robert
Published: October 2019

INTRODUCTION:

Given few studies specifically focusing on waitlist (WL) and liver transplant (LT) outcomes among adults with autoimmune liver diseases, there is a need to better understand epidemiology and outcomes among patients with primary sclerosing cholangitis (PSC), primary biliary cholangitis (PBC), and autoimmune hepatitis (AIH). We aim to evaluate disparities in LT outcomes among adults with PSC, PBC, and AIH using data from a comprehensive U.S. LT registry.

METHODS:

We retrospectively evaluated U.S. adults (age ≥18 y) listed for LT using the 2004-2017 United Network for Organ Sharing database, focusing on patients with PSC, PBC, and AIH. Overall WL survival, probability of receiving LT, and post-LT survival were evaluated using Kaplan Meier methods and adjusted multivariate Cox proportional hazards models.

RESULTS:

Among 11,742 patients listed for LT (34.7 % PSC, 32.9 % PBC 32.2 % AIH), PSC patients had higher proportion of male patients (69.3% vs. 14.3% in PBC and 26.9% in AIH, P < 0.001), and PBC patients were older at time of WL registration (mean age: 46.7 PSC vs. 56.5 PBC vs. 48.1 AIH, P < 0.001). While majority of patients were non-Hispanic white, AIH patients had higher proportion of African Americans, and PBC and AIH had higher proportion of Hispanics compared to PSC. Compared to PSC, those with PBC had lower risk of WL death (HR 0.76, 95% CI 0.63-0.92, P < 0.01). Compared to non-Hispanic whites, Asians had significantly higher risk of WL death (HR 1.61 95% CI 1.05-2.45, P < 0.03). When evaluating probability of receiving LT, AIH patients had lower likelihood of receiving LT compared to PSC (HR 0.82, 95% CI 0.76-0.89, P < 0.001). Hispanics had lower likelihood of LT compared to non-Hispanic whites (HR 0.77, 95% CI 0.70-0.85, P < 0.001). Among LT recipients, AIH patients had significantly higher risk of death post-LT compared to PSC patients (HR 1.29 95% CI 1.09-1.51, P < 0.01). African Americans had significantly higher risk of death post-LT compared to non-Hispanic whites.

CONCLUSION:

Compared to U.S. adults with PSC listed for LT, PBC patients had significantly lower risk of WL death and AIH patients had significantly lower likelihood of receiving LT. Among patients that underwent LT, AIH patients had significantly higher risk of post-LT death compared to PSC. While the majority of patients were non-Hispanic white, comparatively, Asians had significantly higher risk of WL death and African Americans had significantly higher risk of post-LT death.
1002 Clostridioides difficile Infection in Liver Transplant Recipients
Authors: Brindise Elizabeth , Kobeszko Matthew , Kuruvilla Aneesh , Elkhatib Imad , Silva Rogelio
Published: October 2019

INTRODUCTION:

Clostridium Difficile Infection (CDI) has been increasing in prevalence within the United States. The CDC estimates that approximately half a million people are infected every year. Patients with liver transplantation tend to require more hospitalizations with increased frequency of antibiotics and higher risk for CDI. We sought to evaluate outcomes of patients with liver transplantation developing CDI.

METHODS:

The study population was derived from the HCUP-National Inpatient Sampling (NIS) database for the years 2010 to the third quarter of 2015. ICD-9 codes were used to identify patients with history of liver transplant and CDI. In-hospital all-cause mortality, total cost of hospitalization, mean length of stay and outcomes rates were assessed. Propensity score matching was used to adjust for baseline confounders.

RESULTS:

A total of 8,567 individuals had a history of liver transplantation and co-existing CDI. Age and race were similar between the two groups; 43.7% of the CDI cohort were female. Patient’s in the control group had higher baseline clinical risk (Table 1). All-cause mortality (3.2% vs 1.7%, P < 0.0001), length of stay (10.4 ± 15.4 vs 5.5 ± 7.4, P < 0.0001), cost of hospitalization ($88,866 ± 166,834 vs $50,724 ± 94,482, P < 0.0001) and blood transfusion rates (13.6% vs 19%, P < 0.001) were higher in the CDI and liver transplant population. Colonoscopy and bowel resection were also performed significantly more frequently in the CDI and liver transplantation cohort (7.1% vs 2.9%, P < 0.0001 and 0.8% vs 1.1%, P = 0.012, respectively) (Table 2). After propensity score matching analysis, these statistically significant differences remained; bowel resection rates were similar between the two groups (1.3% vs 1.1%, P = 0.324). (Table 3).

CONCLUSION:

CDI in liver transplant recipients is associated with significantly higher rates of in-hospital mortality, blood transfusions, length of stay and total cost of hospitalization. Colonoscopy is used more frequently in the management of this population.
1006 Non-Alcoholic Fatty Liver Disease Is an Increasing Reason for Referral to Gastroenterology
Authors: Aggarwal Pankaj , Thomas Aaron , Andrews Christine , Kundrotas Leon , Govani Shail
Published: October 2019

INTRODUCTION:

Non-Alcoholic Fatty Liver Disease (NAFLD) is increasing in prevalence. In integrated healthcare systems with limited clinic access, prior studies have utilized care pathways to triage patients to clinic in situations of suspected advanced fibrosis. Our aim was to study clinic utilization for NAFLD over time and assess how many patients could avoid specialty care using predictive scores such as the FIB4 and NAFLD fibrosis score (NFS).

METHODS:

Consecutive consultations to GI, 200 from 2012 and 300 from 2017, at a large Veterans Administration Hospital in Texas were retrospectively reviewed to determine reason for consultation, final diagnosis, additional workup, and follow up utilization. Weight 1 year after consultation was compared to the initial weight. Chi square testing and Student’s t test were used to compare categorical and quantitative data, respectively, using R.

RESULTS:

Among the 500 patients, the mean age was 57.4 years (+/- 13.9), 86.2% were male and 18.4% Hispanic. Of the 200 consults in 2012, 18 (9.0%) were for NAFLD compared to 53 (17.7%) of 300 consults from 2017 (P < 0.01). Comparatively, the number of consultations for Hepatitis C was not significantly different from 2012 to 2017 (19.5% vs. 16.7%, P = 0.42). Neither liver biopsy (27.8% vs. 17.0%, P = 0.32) nor MR elastography (11.1% vs. 28.9%, P = 0.20) use was significantly different between 2012 and 2017. Using the FIB4 score, 31 (43.7%) were classified as low risk and 11 (15.5%) were classified as high risk for advanced fibrosis. Using the NFS, 18 (25.4%) were classified as both low and high risk. 27 patients underwent MR elastography or liver biopsy and 13 (48%) were found to have advanced fibrosis. The performance characteristics of NFS and FIB4 compared to results of liver biopsy or MR elastography is presented in Table 1 and 2, respectively. Mean weight change 1 year later was -0.8% (+/-4.7%). There was no difference in weight change between those found to have advanced fibrosis or not (-0.3% [95%CI: -3.0- 2.3%] vs. -2.0% [95%CI:-4.1- 0.1], P = 0.29).

CONCLUSION::

One of every 6 consultations to gastroenterology is for NAFLD, now exceeding Hepatitis C referrals in 2017. Using the NFS could save 25% of these referrals without missing cases of advanced fibrosis. GI care was not associated with weight loss. Prospective studies are needed to determine the efficacy of these strategies to triage NAFLD patients for specialty care.
1014 The Majority of Patients With Primary Biliary Cholangitits Do Not Achieve the Ideal Treatment Response in a Real World Clinical Practice
Authors: Cummings-John Oladuni D. , Geistweidt Stephenie , Ritchie Michael , Angueira Candice , Okubote Toluwalase C. , Ascher Bartlett Johanna M. , Filo Jean , Barbara Mary , Lawitz Eric , Hanouneh Ibrahim , Alkhouri Naim
Published: October 2019

INTRODUCTION:

The currently accepted criteria to define therapeutic response to primary biliary cholangitis (PBC) consists of alkaline phosphatase (ALP) (<180 U/L) and bilirubin (<1.0 mg/dL). New data suggests that normalization of ALP (<120 U/L) and bilirubin (<0.5 mg/dL) is associated with better overall outcomes. PBC patients are usually maintained on first line therapy of ursodeoxycholic acid (UDCA), obeticholic acid (OCA) or combination of both agents. The aim of the study was to determine the percentage of PBC patients that achieve the accepted (ALP < 180, bilirubin < 1) and ideal (ALP < 120, bilirubin < 0.5) treatment responses in a real-world setting.

METHODS:

All adult patients in this multi-center study had a diagnosis of PBC via ICD-9 and ICD-10 codes. Other chronic liver disease cases and those with significant alcohol consumption were excluded. Baseline demographics, clinical characteristics and laboratory data were collected. Therapy starting time was noted, assessing their lab values at baseline compared to a recent workup. A two-sided t test was done to compare continuous variables and a P value < 0.05 was considered statistically significant.

RESULTS:

76 adult PBC patients were included in the final analysis. The mean age at the last follow up was 61.8 years (±11.3). 96% were female, 47% were White and 51% were of Hispanic ethnicity. 93% were on UDCA therapy alone with daily dosages between 750-1500 mg. Only 7% received both UDCA and OCA. The mean baseline ALP was 286 U/L and the mean follow up ALP was 172 U/L (±84.6), 52 U/L above the ideal value (P < 0.05). The mean baseline bilirubin was 1.04 mg/dL and the mean follow up bilirubin was 0.8 mg/dL (±1.2), 0.3 mg/dL above the ideal value (P < 0.05). 62% reached the accepted ALP value, 86% reached the accepted bilirubin value, and 57% reached the accepted level. 30% of patients achieved the ideal ALP value and 26% achieved the ideal bilirubin level with 20% reaching the ideal response. The rates for accepted and ideal responses were 80% and 40%, respectively, for those on UDCA and OCA.

CONCLUSION:

The majority of PBC patients in real-life settings did not achieve the ideal treatment response of ALP < 120 U/L and bilirubin < 0.5 mg/dL. Furthermore, a significant percentage did not achieve the accepted treatment response of ALP < 180 U/L and bilirubin < 1.0 mg/dL. Only a small percentage received combination therapy with UDCA/OCA. There's a need to increase awareness among healthcare providers on the optimal responses to PBC treatment.
1024 A Retrospective Analysis of Hepatitis-B Reactivation in Hepatitis-C Patients Treated With Direct-Acting Antivirals Therapy
Authors: Tahir Muhammad , Gopalakrishnan Ravikumar Naveen Prasad , Chathura Wijewardena , Martinez Anthony
Published: October 2019

INTRODUCTION:

Hepatitis B virus/hepatitis C virus (HBV/HCV) co-infection has a prevalence of 5%-10% in patients with chronic HCV patients. Direct-acting antiviral agent (DAA) have replaced Interferon (IFN)-based treatment for HCV infection given the increased HCV sustained virological response (SVR). However, the Food and Drug Administration (FDA) has issued warnings about HBV reactivation (HBV-R) in chronic HCV patients treated with DAA. We aimed to assess the HBV reactivation rate in our chronic HCV patient population treated with DAA (Ledipasvir / Sofosbuvir).

METHODS:

We conducted a retrospective study involving HCV patients treated with DAA at our outpatient hepatology clinic located in Erie county medical center. The goal as discussed above was to find the HBV reactivation which was defined as reverse seroconversion of HBsAg-negative patients at baseline becoming HBsAg-positive post DAA therapy with a DNA level >0 IU/mL. Patient characteristics and laboratory results at baseline and at the end of follow-up were retrospectively analyzed from electronic medical records. A chart review was completed for a total of 260 patients fulfilling the inclusion criteria. The mean age of the study population was 56.5 years. Inclusion criteria: 1-DAA therapy for HCV with confirmed SVR. 2-HBsAg-negative/HbcAb+. 3-HBV/HCV coinfection. Exclusion criteria: 1- Coinfection of HAV/HDV/HEV. 2- Decompensated cirrhosis with CPT class B/C. 3- Active HBV coinfection. 4- Undergoing immunosuppressive therapy or chemotherapy.

RESULTS:

Post-treatment serum samples of 260 patients were analyzed. Of these, 19.60% (51/260) of the total population was positive for HbcAb. Out of these 51 patients, 13 post-DAA treatment patients were checked for hepatitis-B DNA level to rule out the concern for reactivation. None of the patients showed any elevation in Hepatitis-B virus DNA level, i.e. undetectable. Also, no seroconversion to HbsAg+ was noticed in our population post-DAA therapy. Further detailed results will be presented in the poster during meeting.

CONCLUSION:

To conclude, we found no hepatitis-B virus reactivation or seroconversion to HBsAg positive state in our cohort. Our study supports the latest literature that although it has been observed in the past, HBV reactivation in exposed patients with HbcAb without positive HbsAg is very rare.
1034 Efficacy and Safety of Saroglitazar in Nonalcoholic Fatty Liver Disease Patients at 1 Year: An Investigator Initiated Study
Authors: Dadhich Sunil K.
Published: October 2019

INTRODUCTION:

Currently there is no drug or therapy approved for NAFLD. Although there are many drugs which have been explored for their usage in NAFLD/NASH. Saroglitazar is one of such novel dual peroxisome proliferator-activated receptors-α/γ agonist drug approved for diabetic dyslipidemia in India and is being investigated for treatment of NAFLD. In this current observational study we have tried to explore the efficacy of Saroglitazar in NAFLD patients with dyslipidemia.

METHODS:

This is a single centre, single arm, open label study of Saroglitazar conducted in northern India. Obese/overweight patients having Fatty Liver (on USG), elevated transaminases and dyslipidemia with or without type 2 diabetes were enrolled. All the patients were given Saroglitazar 4 mg once daily for at least 1 year. Patients with concomitant liver disease due to other etiologies (alcohol, viral etc.) were excluded. The laboratory parameters and LSM reports at baseline and 1 year were compared using t test.

RESULTS:

A total of 64 patients with mean age of 41.95 ± 8.56 years were enrolled in the study. The ratio of male to female was 84.38 (N:54): 15.62 (N:10). Out of 64 patients 17 Diabetic, 30 Non- diabetic and 17 were Prediabetic. The baseline and follow up of aspartate aminotransferase (AST), alanine aminotransferase (ALT), Total Cholesterol, triglycerides (TG) and liver stiffness measurement values were given in Table 1. There was a consistent and significant reduction in Total Cholesterol, TG, ALT, AST and LSM. There were no reported adverse events pertaining to Hypoglycemia.

CONCLUSION:

Saroglitazar was found to be safe and effective in management of NAFLD patients in this interim analysis of 12 months follow up. It is a potential option and need further exploration for management of dyslipidemia and NAFLD in non diabetic patients.
1040 Quality Improvement Initiative to Improve Receipt of Timely Surveillance Endoscopy After Variceal Bleeding
Authors: Moon Andrew M. , Kim Hannah P. , Barritt A. Sidney , Darling Jama , Arora Shifali
Published: October 2019

INTRODUCTION:

Among patients with cirrhosis who develop esophageal variceal bleeding, surveillance endoscopy (EGD) with variceal ligation within 4 weeks of index bleed decreases the risk of re-bleeding. However, many of these patients do not receive timely surveillance EGD. Therefore, we aimed to assess the rates of timely surveillance EGD after an episode of variceal hemorrhage (VH) before and after a quality improvement (QI) initiative to improve provision of surveillance EGD.

METHODS:

We identified patients with cirrhosis hospitalized at the University of North Carolina Medical Center from 7/1/2017-6/30/2018 with variceal bleeding. We excluded all patients with a transjugular intrahepatic portosystemic shunt placement or death during hospitalization, discharge to hospice, or patient preference for local follow-up. Following the initial EGD, we determined if surveillance EGD was ordered and scheduled, and if scheduled, whether or not patients underwent timely surveillance EGD, defined as <4 weeks from the initial EGD. Based on these results, we designed a QI intervention to reserve two open scheduling slots dedicated to surveillance EGD after VH. Post-intervention surveillance EGD rates were then calculated for hospitalized patients with cirrhosis who underwent EGD for VH from 12/1/2018-4/15/2019.

RESULTS:

We identified 33 patients with cirrhosis hospitalized from 7/2017-6/2018 with VH. Of these patients, 5 (15%) patients underwent surveillance EGD within 4 weeks from initial EGD. Of the 28 patients who did not undergo timely surveillance, the most common reason was the EGD being scheduled for a date >4 weeks after the index bleed (75%). Other reasons included inability to contact the patient (14%), cancellations/no-shows (7%), and failure to place an EGD order (4%). In the post-intervention period, 18 patients had a VH and met other inclusion criteria. Of these patients, 8 (44%) underwent timely surveillance EGD. The reasons for failure to undergo timely surveillance EGD were cancellations (50%), EGD scheduled >4 weeks from initial bleed (40%), and failure to place an EGD order (10%).

CONCLUSION:

A QI intervention to reserve post-VH scheduling slots was associated with a 29% absolute increase in timely surveillance EGDs. Steps to further increase procedure capacity and improve both patient and scheduler education on the importance of surveillance EGDs within 4 weeks of VH may further increase rates of timely surveillance EGDs.
1053 Hepatocellular Carcinoma (HCC) Diagnosis, Treatment and Outcome in a Primarily African American Population
Authors: Jan Jenny , Benjaram Sindhuri , Rutledge Brian , Kutaimy Raya , Philip Philip , Ehrinpreis Murray N. , Mutchnick Milton , Naylor Paul
Published: October 2019

INTRODUCTION:

HCC is the most common primary liver cancer and five-year survival of HCC depends on the extent of disease and liver reserve. The objective of this study was to determine the impact of racial disparity in identification, treatment and outcome in HCC patients seen in a predominately African American (AA) population.

METHODS:

From a database of HCC patients diagnosed between 2009 and 2017, 227 patients had a sufficient number of visits to identify treatment and outcomes. Date of diagnosis was defined by definitive imaging or biopsy. Tumor size (small = < 5 cm) was used as a surrogate for calculating Child’s-Pugh score in these predominately Hepatitis C cirrhotic patients. Outcomes was determined as death or transfer to hospice, while survival was defined by death only. Patients being sent to transplant (9 AA and 1 Non-AA ) were excluded from the analysis since transplant was at a different institution.

RESULTS:

There were 194 AA and 33 non-AA patients and hepatitis C was the dominant risk factor (n = 192; 85%). Only 29 patients (13%) were diagnosed under even a minimal surveillance protocol defined as a normal ultrasound within 6-12 months prior to diagnosis. AA patients were more likely to have a large tumor burden as compared to non-AA (AA = 74% and Non-AA = 51 %; P < 0.01). A variety of treatments for the HCC were use in the 61% of patients who received treatment. The remaining 39% of patients either died in the hospital prior to treatment or were sent to hospice for palliative care. Median outcome was better for patients with a small tumor at diagnosis, treated patients and for non-HCV patients (Table 1). When survival was evaluated, results were similar (44 months for small tumors vs 10 months for large tumors P < 0.001). Race did not have a major impact on overall outcome (AA = 16 months vs Non-AA = 20 months, P = 0.33) or survival (20 months vs 34 months P = 0.35).

CONCLUSION:

Most patients diagnosed with HCC in this urban medical center presented with large tumors with AA patients likelier to have large tumor burden. Outcome was better for patients with small tumors or who were treated regardless of tumor size. However, overall outcome was similar regardless of race. Our study reaffirms the potential importance of surveillance of high-risk individuals to identify early HCC tumors and thus increase survival in our AA population. Moreover, addressing the major risk factor of HCV by treatment with highly effective DAA would also impact the development of HCC especially in our AA population.
1055 Results of a Hepatitis C Outreach Initiative and Identification of Barriers to Treatment
Authors: Pogosky Alexandra , Wungjiranirun Manida , Molino Janine , Callahan Marlene , Furtado Christina , Shittu Yetunde , Promrat Kittichai
Published: October 2019

INTRODUCTION:

Over 80% of veterans born between 1945-1965 in the Veterans Affairs system have been tested for hepatitis C (HCV). In December 2016 the Providence VA Medical Center implemented an outreach initiative that targeted veterans who were untreated for HCV. The purpose of this study is to evaluate the impact of the outreach program on HCV treatment initiation rates. The study also aims to identify factors associated with successful linkage to care and barriers to treatment.

METHODS:

Veterans with HCV viremia were targeted for outreach. Outreach entailed mailing letters to patients offering treatment, followed by telephone calls. The outreach team collaborated with primary care providers (PCP), social workers, the homeless clinic, and addiction services. Medical records were reviewed for demographics, disease characteristics and co-morbidities. The primary outcome was initiation of HCV treatment. Differences in characteristics between treated and untreated patients were studied to identify potential treatment barriers.

RESULTS:

334 patients were treated for HCV prior to the start of the outreach initiative in December 2016. The outreach program targeted 175 patients with untreated HCV. Among these 175 patients, 116 (66.3%) were initiated on treatment, while 59 (33.7%) were not. Characteristics associated with treatment initiation include presence of psychiatric co-morbidities (P = 0.055), history of substance use (P = 0.03), and having a PCP located in-state (P = 0.02). Patients treated before the outreach initiative had higher rates of cirrhosis (P = 0.001), and higher APRI (P = 0.01), FIB-4 (P = 0.001), and Fibroscan scores (P = 0.001).

CONCLUSION:

The outreach program successfully initiated treatment in two-thirds of targeted patients. Prior to the program, HCV treated patients had higher rates of cirrhosis and more advanced liver disease based on non-invasive markers. This disparity may be related to increased screening in high-risk populations or a higher likelihood of establishment in the hepatology clinic. These findings suggest that outreach may improve access for patients who do not see a hepatologist. Higher rates of substance use and psychiatric disease in patients who were treated highlight the impact of coordinating care with mental health and addiction specialists. The data also shows that having a PCP out-of-state or not having a PCP listed is associated with non-treatment. Training more local providers in HCV management may aid in increasing treatment rates.
1056 Incorporation of Obesity Management into the Care of Patients With Nonalcoholic Steatohepatitis: The Yale Fatty Liver Disease Model
Authors: Mankash M. Salah , Kelly Maureen , Dean Jessica , Duffy Andrew J. , Mehal Wajahat Z. , Do Albert
Published: October 2019

INTRODUCTION:

Nonalcoholic fatty liver disease (NAFLD) is fundamentally a disease of excess weight and is worsening in tandem with the obesity epidemic. Nonalcoholic steatohepatitis (NASH) places patients at risk for advanced fibrosis and cirrhosis and the most effective treatment is weight loss, but there is limited efficacy data of clinical care models incorporating obesity management into hepatology practice. We aim to report clinical characteristics and outcomes from the Yale Fatty Liver Disease Program which incorporates all aspects of medical and surgical weight loss into the management of patients with NASH.

METHODS:

Patients from local and community practices were referred to the Yale Fatty Liver Disease Program, which provides comprehensive hepatology as well as nutritional, medical, and surgical care for obesity. We included patients seen for initial evaluation from 7/1/2018 to 10/31/2018, and extracted data on clinical characteristics, care provision, and changes in weight and alanine aminotransferase (ALT) levels.

RESULTS:

62 patients diagnosed with NASH, who were followed for median 112 days: 32 (52%) males, average age 55 ± 10.6 years, and body mass index (BMI) 35.4 ± 6.1 kg/m2, 4 (12%) had a new diagnosis of cirrhosis. Obesity related comorbidities were prevalent: 38 (62%) hypertension, 33 (53%) dyslipidemia, 11 (18%) diabetes mellitus, 19 (31%) obstructive sleep apnea. In this cohort, 40 (64%) received referral to a dietitian, 4 (6%) initiated meal replacement therapy, 14 (23%) were prescribed weight loss medications, and 19 (31%) were referred to bariatric surgery. Of those referred to bariatric surgery, 8 (13%) received surgery, 5 (8%) declined surgery, and 6 (10%) are currently undergoing evaluation. Average weight loss was as follows: Overall 5.1 ± 6.4 lbs, lifestyle alone 8.8 ± 16.7 lbs (paired t-test comparing start with final P = 0.008), WLM 10.8 ± 19.6 lbs (P = 0.003), bariatric surgery 52 ± 5.5 lbs (P = 0.008). On last follow up, average serum ALT decreased by average 33 ± 47 U/l (P = 0.008).

CONCLUSION:

A hepatology clinic incorporating the full range of weight loss options can provide effective treatment of NASH when additional modalities such as weight loss medications and bariatric surgery are utilized. Further study of this practice model would inform specific measures hepatologists can undertake to optimize weight loss while concurrently treating chronic liver disease.
1062 Improvement in Reliability of Acoustic Radiation Force Impulse Elastography Studies Using Feedback and Benchmarking: A Single Center Experience
Authors: Rahman Asad Ur , Zahid Effa , Wasser Elliot
Published: October 2019

INTRODUCTION:

Periodic feedback and use of standardized benchmarks has historically been used to improve quality of various diagnostic studies including screening colonoscopy. Acoustic radiation force impulse (ARFI) elastography is utilized as an important non invasive test to quantify the degree of liver fibrosis. Since this is dependent on obtaining accurate and reliable readings from radiology technicians, we aimed to improve the reliability of clinically significant studies which are defined as at least ten readings with an interquartile range of <0.3.

METHODS:

We initially did a retrospective analysis of all ARFI elastography studies performed at our center over the course of January and February 2018 in order to assess baseline performance. We subsequently shared individual data with each radiology technician in March 2018. We also recommended that technicians who performed with < 50% reliability should shadow their colleagues who were able to get reliable readings beyond 75%. We then longitudinally followed the quality of studies over the ensuing few months. We repeated the same intervention in July 2018 to see if there was any attrition in response. Follow up was then done up until December 2018 to assess performance of studies.

RESULTS:

186 ARFI studies were completed over the course of 12 months. 12 radiology technicians were involved in performed these studies (range 5-25 exams). Average BMI of patients undergoing the exam was 29.2 (range 16.3 to 45.2). No difference was seen in terms of reliability in obese patients. The proportion of reliable studies (10 or more readings with IQR < 0.3) was 44% in January. After the first session of feedback, this proportion increased to 78% in April. However, it decreased to 43% in July at which point a second formal session of feedback was done. A subsequent increase was noticed with reliable studies going up to 70% in August. However, this improvement did not remain sustained with decline in performance to 43% in December.

CONCLUSION:

Based on this study spanning a total of 12 months, we demonstrate that providing feedback to individual technicians and tutorials by high performing technicians leads to improvement in overall performance. Albeit, this effect is not sustained if provided intermittently. This calls for regular feedback and follow up over longer duration to assess for more sustained improvement. This would in turn translate into a diminished need for repeat testing which would curtail cost and patient time as well as need for liver biopsy.