bluuebunny/crossref_metadata_2025 huggingface dataset:
990 The Association of Obstructive Sleep Apnea and Nonalcoholic Steatohepatitis: A Nationwide Inpatient Sample Analysis
Authors: Renno Anas , Abdel-Aziz Yousef , Alastal Yaseen , Khuder Sadik , Hasan Syed , Assaly Ragheb , Nawras Ali
Published: October 2019

INTRODUCTION:

Obstructive sleep apnea (OSA) has been suggested to be a potential contributing factor for nonalcoholic steatohepatitis (NASH). The oxidative stress caused by chronic intermittent hypoxia is known to play a vital role in the pathogenesis of NASH. There is conflicting data in the literature regarding the association of OSA and NASH. The primary purpose of this study was to determine the association of OSA and NASH from a large national inpatient sample database.

METHODS:

We conducted a retrospective analysis using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS). NASH patients were identified by ICD-10-CM code K75.81. Non-NASH patients (control) were randomly selected and matched to each NASH patient 4:1 by age and gender. Weighted logistic regression models were used to calculate the association between OSA and NASH for different comorbidities.

RESULTS:

A total of 54,169 patients were included in our analysis, 10,740 cases of NASH were matched to 43,429 controls (non-NASH). NASH was significantly higher in the white population (82.12% vs. 76.64%, P < 0.001). The prevalence of NASH among OSA patients was significantly higher compared to the non-OSA group (15.8% vs. 8.9%; adjusted OR: 1.34, 95% CI: 1.14–1.56, P = 0.0003). Celiac disease and Crohn’s disease were significantly higher in patients with NASH (0.7% vs. 0.2%, P < 0.0002 and 1.28% vs. 0.76%, P < 0.0001). Multiple comorbidities were significantly elevated in the NASH group compared to the non-NASH group including diabetes mellitus (36.0% vs. 17.6%, P < 0.0001), obesity (36.4% vs. 18.2%, P < 0.0001) and metabolic syndrome (0.86% vs. 0.06%, P < 0.0001). Mortality rate was significantly higher in the NASH group (3.8% vs. 2.0%, P < 0.0001).

CONCLUSION:

This is the first study using ICD-10-CM code with a specific search code for NASH. Our large population database results emphasize that there is a significant association between OSA and NASH. This important association should prompt physicians to evaluate for the presence of NASH in OSA patients. Additional studies are needed to evaluate this association and the effect of OSA treatment on NASH.
998 Can You Treat Me Now? An Evaluation of Patient-Centered Resources Discussing Fatty Liver Treatment Options
Authors: Dawit Lillian , Tabbara Nadeem , Clarke Lindsay , Szvarca Daniel , Baumgartner Scott , Basso Jessica , Dave Jenny , Borum Marie
Published: October 2019

INTRODUCTION:

Non-alcoholic fatty liver disease (NAFLD) is an increasingly prevalent liver disorder estimated to occur in up to 46 percent of the U.S. adult population. Management includes optimization of weight, diabetes, dyslipidemia, and vitamin E in selected patients. However, patients may opt to self-treat NAFLD based on internet available information, including therapies such as vitamin E which may be potentially harmful if taken in excess. This study evaluated internet accessible information addressing the treatment choices and management of NAFLD.

METHODS:

The search terms “fatty liver” identified the first 100 websites in the Google search engine. Exclusion criteria for this study included non-accessible websites, video postings without transcripts, or articles discussing veterinary topics. The remaining websites were classified by target audience: patient or professional. Statistical analysis using a two-tailed Fisher’s Exact Test was performed with a P-value set at <0.05.

RESULTS:

88 websites met inclusion criteria with 52 (59.1%) targeting patients and 36 (40.9%) for medical professionals. 71 (80.7%) provided management recommendations, with significantly more patient websites discussing treatment (P = 0.02) compared to professional sites. Patient sites more often discussed lifestyle modifications (P = 0.02) as therapy. There was no significant difference in the discussion of diabetic agents, vitamin E, statins, or bariatric surgery between patient and professional websites. Patient websites preferentially discussed treatment benefits compared to possible side effects (P < 0.0001). Patient-clinician shared decision-making was emphasized on patient websites (57.7%; P < 0.01) and websites focused on management strategies (50.7%; P = 0.01).

CONCLUSION:

Individuals are increasingly using online resources to obtain information about NAFLD management. While patient websites were more likely to discuss lifestyle modification, patient and professional websites did not specifically focus on other potential intervention. Only half the websites recommended shared decision-making, more often occurring in patient websites and in sites addressing management. Across all sites, the benefits rather than potential risks of NAFLD treatment were more frequently discussed. It is important that online websites addressing NAFLD offer treatment options that are evidence-based, promote safe interventions, and encourage discussion with a provider.
1003 Outcomes of Patients With Nonalcoholic Steatohepatitis With Cirrhosis and Low Model for End Stage Liver Disease Score
Authors: Laderian Behnam , Murali Arvind R. , Sanchez Antonio J.
Published: October 2019

INTRODUCTION:

Subsets of patients with cirrhosis from non-alcoholic steatohepatitis and low MELD scores have slow progression of their MELD score over time. These patients may succumb to progressive liver disease prior to receiving a transplant. Early identification of this subset of patients is crucial to improve outcomes.

METHODS:

We retrospectively studied patients with NASH cirrhosis seen at our large tertiary care center. We collected data on demographics, clinical and laboratory variables including MELD score at diagnosis, at decompensation and at death. We recorded mortality, cause of mortality, and liver transplantation if received. Patients with MELD score< 15 at the time of diagnosis were analyzed. We performed Kaplan-Meier survival analysis. Univariate logistic regression analysis was performed to identify factors predicting transplant-free survival in NASH patients with low MELD.

RESULTS:

Two hundred and six patients with NASH cirrhosis and MELD < 15 were identified. Mean age 57.8 (12), 62 (30%) were males. Median MELD was 8 (IQR 6-10). Eight five (41%) patients developed hepatic decompensation, 82 (40%) developed ascites. Median MELD at decompensation was 10 (IQR 8-12). At a mean follow up of 5.4 (4.0) years, 8 (4%) patients had progression of their MELD score and received liver transplantation. Eight (4%) patients died of whom 6 (75%) died of progressive liver disease. Median MELD at the time of death was 18 (IQR 15-21). Kaplan Meier survival of all NASH cirrhosis patients with MELD < 15 was 96% at 3 years, and 92% at 5 years. On univariate analysis, absence of ascites was the single most important predictor of transplant free survival in patients with MELD < 15. Age, sex, creatinine, total bilirubin, and MELD score, were not significant predictors of survival. Kaplan Meier survival of patients with NASH cirrhosis and MELD < 15 with and without ascites was 94% vs 98.9% at 3 years, and 88% vs 98.9% at 5 years respectively (P = 0.02).

CONCLUSION:

A significant proportion of patients (∼40%) with NASH cirrhosis have a low MELD score despite decompensation with ascites and have a poor outcome as compared to NASH patients with low MELD and without ascites. A subset of low MELD NASH cirrhosis patients with ascites die of progressive liver disease at a low MELD score before diseased donor liver transplant (DDLT) can become available. Patients with NASH cirrhosis with ascites and low MELD score should be considered for a living donor or high risk diseased donor liver transplant to improve outcomes.
1008 Diarrhea Is Common Both Early and Late After Liver Transplantation and Rates of C. diff. Remain Elevated
Authors: Young Christopher , Patel Samarth , Siddiqui Mohammad B. , Zhang Emily , Chandrakumaran Anchalia , Faridnia Masoud , Hernandez Jose Roman , Siddiqui Mohammad S. , Smallfield George B.
Published: October 2019

INTRODUCTION:

Diarrhea is a common complication of liver transplant (LT) frequently attributed to immune suppressive therapy. However, there is a dearth of published literature with regards to etiology, management, and time course of diarrhea in LT recipients. The aim of this study was to describe and compare the etiology of diarrhea both in the first 12 months after transplant and in diarrhea arising later after LT.

METHODS:

This is a retrospective examination of 333 consecutive patients who underwent LT at author's institution. Diarrhea was defined as ≥3 loose bowel movements occurring within 24 hours. Charts were reviewed for diagnostic evaluation of diarrhea, causative agent, and management. Diarrhea was described at intervals of within 12 months post-LT, diarrhea occurring after 12 months post-LT, and diarrhea that occurred during both time intervals. Risk factors and etiology of diarrhea were analyzed and described.

RESULTS:

The mean age of the cohort was 52.4 years, 38.1% were female. Patients were followed for up to 5 years after transplantation. 162 patients (48.6%%) developed diarrhea within 5 years of LT. 80 patients (24%) developed diarrhea within 1 year after LT but did not have recurrent episode. 63 patients (18.9%%) first developed diarrhea more than 12 months after LT. 19 patients (5.7%) developed diarrhea both during the first year and after 1 year. Clostridium difficile (C. Diff) infection was the most common diagnosis in all 3 groups, with 23 (28.8%) occurrences in the early group, 16 (26.7%) in the late group, and 5 (26.3%) in the early and late group. Nearly half of those patients that developed diarrhea were admitted to the hospital. 37/80 (46.3%) patients with diarrhea within 12 months were admitted. 29/63 (46.0%) patients in the late group were also admitted. 9/19 (47.3%) patients with diarrhea both within 12 months and after required admission. No significant differences in etiology or admission rate between the groups were found.

CONCLUSION:

Diarrhea is common after liver transplant and occurs both early and late following LT. Hospital admissions are also common in both groups of patients. With the high rates of C. diff infection both early and late post-LT, further study of preventative measures are warranted.
1011 Comparable Response of Intradermal Hepatitis B Vaccination in Dialysis and General Population Non Repsonder to Intra-Muscular Route
Authors: Hanif Farina , Mehmood Nasir , Laeeq Syed Mudassir , Luck Nasir Hassan , Khan Shoaib Ahmed , Kumar Sandeep
Published: October 2019

INTRODUCTION:

Hepatitis B vaccine is extremely potent, however, 5% of healthy population and around 50% of hemodialysis patients do not respond to its intramuscular administration. We aim to determine the effectiveness of intradermal Hepatitis B vaccine in both dialysis and general population, who previously were non responder to its intramuscular form.

METHODS:

All participants were enrolled from January 2010 to 2019, received 5 doses of 10 µgm Hepatitis B vaccine via intradermal route every 2 weeks. Hepatitis Bs antibody (HBsAb) titer were checked 6 weeks after the last dose. Participants were consider as responder if HBsAb titer was more than 10 IU/L and good responder if more than 100 IU/L.

RESULTS:

In 95 participants, majority were female (51.6%) with mean age of 39.0 ± 13.5 years. Forty nine participants (51.6 %) were on maintenance hemodialysis. The risk factors for hepatitis B included intramuscular/intravenous injection in 85 (89.5 %), blood transfusion in 56 (58.9 %) and surgical procedures in 45 (47.4%) subjects. The mean HBsAb titer level was 263.5 ± 350.1 IU/L. Overall, 72 (75.8%) participants responded to vaccination, 42 (44.2%) of which achieved good response. Similar vaccination response was noted between hemodialysis and general population i.e., 75.5% and 76.1%, respectively (P = 1.00). Although a good response was observed more in hemodialysis patients (49%) than in general population (39.1%) however, it was not statistically significant. (P = 0.41).

CONCLUSION:

Intradermal hepatitis vaccination showed good response in those previously unresponsive to intramuscular route. Study participants on maintenance hemodialysis showed a similar response rate as the general population.
1023 Early Treatment of Recurrent Hepatitis C Post-Liver Transplant
Authors: Thiyagarajan Abirami , Romano John , Guo Yuqi , Massoud Omar , Shoreibah Mohamed , Jones DeAnn
Published: October 2019

INTRODUCTION:

The rate of hepatitis C virus (HCV) recurrence after liver transplant (LT) is greater than 95% and chronic recurrence is more aggressive in the setting of immunosuppressive therapy (IS) in LT patients. Sustained viral response (SVR) is associated with lower mortality rates related to hepatic and extrahepatic manifestations of HCV including renal disease. Currently, however, there are no clear guidelines for the timing of HCV treatment post LT. The goal of this study is to examine the effects of early HCV treatment post-LT on kidney function, liver function and IS.

METHODS:

This is a retrospective study of 38 LT patients who received HCV treatment within 1 year between 2015 and 2018. Renal function, hepatic function and immunosuppressive regimens were compared at HCV treatment initiation and when patients achieved SVR post treatment. 86% of patients received a Sofosbuvir based regimen.

RESULTS:

The study included 38 patients with recurrent HCV post LT. Patients were 79% male, 71% Caucasian, with mean age being 57 [range 33-73]. The mean number of days between LT and HCV treatment initiation was 129 days [range 15-321]. All patients were initiated on treatment within the first year of LT. SVR rate was 100% in patients that were compliant with the regimen. No serious side effects were reported. There was no significant difference in mean pre and post-HCV treatment creatinine or number of patients with GFR < 60-pre/post treatment. There was no significant difference between number of patients on Mycophenolate or Tacrolimus before and after treatment. There was no significant difference in the mean dose of steroids, Azathioprine, Mycophenolate or Tacrolimus before and after HCV treatment.

CONCLUSION:

In patients completing treatment for recurrent HCV within 1 year of LT as early as 15 days post LT, treatment was well tolerated and effective with 100% SVR rate. There was no significant change in number of patients with Cr < 60 before and after treatment and no significant change in the dose of IS. Further studies will help compare outcomes and effects of HCV treatment within one year post LT vs later particularly on renal function and IS therapy.
1027 Health Outcomes in Patients With Hepatic Encephalopathy Treated in Community Practice Using a Specialized Pharmacy Team
Authors: Guerrero Richard , Kim Jae , Ramirez Ruben , Mitchell Robert , Van Frank Timothy , Christensen Kimberley , Hinojosa Kim , Landaverde Carmen , Loo Nicole , Rodas Fabian , Wells Jennifer , Alkhouri Naim , Lawitz Eric , Pedicone Lisa D. , Poordad Fred
Published: October 2019

INTRODUCTION:

The prevalence of cirrhosis is on the rise in the US and predisposes patients to multiple costly complications, including hepatic encephalopathy (HE). Hospital readmissions among patients with decompensated cirrhosis are common and ∼1/3 are due to recurrent HE. Recommended treatment of HE is lactulose +/- rifaximin; however, access to rifaximin is sometimes difficult to access due to formulary restrictions or cost. This study assesses health outcomes, the rifaximin approval process and compliance in patients with HE in community GI/hep practices that use a dedicated pharmacy team with expertise in liver disorders.

METHODS:

This IRB-approved, observational protocol captures long-term health outcomes and pharmacy support data every 6 months for up to 10 years. Patients have cirrhosis, at least stage 1 HE and are already receiving or newly starting rifaximin. The concomitant use of lactulose was allowed at the discretion of the physician. Patients from community practices across Texas were included in this patient cohort followed over the first 6 months.

RESULTS:

The first cohort of 744 patients received rifaximin with (45%) or without (55%) lactulose and were insured through Medicare (39%), private (36%) or Medicaid (24%). In this cohort, 99% of rifaximin prescriptions were accepted with the first prior auth request and the majority of patients started treatment <14 days of prescription submission. DDI assessment and dosing compliance were reviewed resulting in 94% medication compliance during Month 1. During the first 6 months, 17.4% had >1 ER/urgent care visit and 4.4% were hospitalized due to an HE-related event. Thirteen patients had a new HCC diagnosis and 9 patients underwent liver transplant. After 6 months, 73% remained on rifaximin, 14% no longer wanted to participate, 8% were lost to follow up and 5% died. Overall medical condition was stable/improved for 90% compared to 6 months prior.

CONCLUSION:

Patients with HE who are treated at community sites with a specialized pharmacy team can receive rifaximin in an expedited manner. Continued patient education and communication with the health care team can lead to high adherence rates which can minimize ER/urgent care visits and hospitalizations. HCV remains the most common underlying disease in this cohort. In spite of rigorous monitoring, a large % of patients with advanced liver disease die or are lost to follow up. Close monitoring through a chronic care management model can lead to early diagnosis and better patient management.
1029 The Utility of the Baveno VI Criteria in a Safety Net Hospital
Authors: Jacobs Jaclyn , Hamid Osama , Calderon Amy
Published: October 2019

INTRODUCTION:

Patients with liver cirrhosis are at risk for life-threatening hemorrhage from esophageal varices. Variceal hemorrhage can be prevented with medical and endoscopic therapies, so identifying patients through a screening process is paramount. Traditionally, screening was offered to all patients with cirrhosis; however, not all patients with cirrhosis are at the same risk to develop variceal hemorrhage. Using the Baveno VI criteria, cirrhotic patients with low risk for esophageal varices can be identified and spared the risks associated with invasive endoscopic screening. Previous studies have not evaluated these criteria in a safety net hospital population.

METHODS:

We enrolled 75 patients with cirrhosis for a retrospective chart review. Inclusion criteria were F3-4 or F4 by transient elastography and esophagogastroduodenoscopy (EGD) within 12 months of the elastography procedure.

RESULTS:

Mean age was 58 years, 54.7% were male and 53% of patients identified as black, African-American, or Hispanic. 67% had hepatitis C, 16% had alcoholic liver disease, and 16% had non-alcoholic fatty liver disease. 42.6% of patients had obesity (BMI > 30) and 56% had metabolic syndrome. 21 patients met Baveno VI criteria and 12 had esophageal varices on upper endoscopy. 4 additional patients had esophageal varices, yet were not identified as a high risk patient per Baveno VI criteria. 16 patients in total had esophageal varices (21.3%). 11 had small esophageal varices (without high risk stigmata) and 5 had high risk varices requiring intervention (large varices or varices with high risk stigmata). For Baveno VI criteria predicting the presence of any varices, the sensitivity was 75% (12/16), specificity was 84.8% (50/59), positive predictive value was 57.1% (12/21), and the negative predictive value was 92.6% (50/54). Baveno VI criteria identified all patients with high risk varices (5/5).

CONCLUSION:

With a robust negative predictive value in a safety net hospital population, Baveno VI criteria seems to be an adequate method for identifying patients who can avoid screening endoscopy for esophageal varices.
1031 Social and Medical Determinants of NASH versus NAFLD Using Liver Histology: A Single Center Experience
Authors: Rastegari Sheila , John Elizabeth S. , Valle Selena , Acharya Priyanka , Mantry Parvez
Published: October 2019

INTRODUCTION:

Non-alcoholic fatty liver disease (NAFLD) is pandemic across the world and has a wide spectrum of presentations. Both NAFLD and its most severe histopathologic subtype, non-alcoholic steatohepatitis (NASH), can progress to cirrhosis, making early diagnosis pivotal. Liver histology is critical for the diagnosis of NASH, however little is known about the association of social and medical factors with its histologic features. We are conducting a retrospective analysis of a large single center database of over 2000 patients with fatty liver disease proven by biopsy. Here we focus on one year of data collected at our institution.

METHODS:

We reviewed 653 liver biopsies from a one-year period at Methodist Liver Institute to identify subjects with NAFLD and NASH based on the NAFLD Activity Score (NAS). NASH was defined as NAS score = >3. Patients under the age of 18, documented significant alcohol use, and without steatosis were excluded. We then collected data on demographics (age, race, insurance, and median income), comorbid disease (diabetes mellitus, hypertension, hyperlipidemia, metabolic syndrome), and medication use (antihypertensives, oral antihyperglycemics, insulin, statins, opioids), and used univariate statistical analysis to compare subjects with and without NASH.

RESULTS:

Of 253 biopsies included, 118 had steatosis without NASH and 145 had steatosis with NASH. Subjects with NASH were significantly younger, and more likely to be of Caucasian race than African American race, have Medicaid than commercial insurance, and have diabetes mellitus with use of oral antihyperglycemics. There was no significant difference between NASH and no NASH groups with regards to BMI, hypertension, hyperlipidemia, metabolic syndrome, or use of antihypertensives, statins, insulin, or opioids (Table 1).

CONCLUSION:

Though histologic confirmation is the gold standard to distinguish NAFLD from NASH, there is a lack of data establishing prognostic factors that may predict the degree of fibrosis. In our analysis having diabetes mellitus or Medicaid instead of commercial insurance correlated with more severe histopathologic disease, suggesting that more aggressive screening and treatment should be promoted in this population. There was no significant difference in socioeconomic factors such as median income or metabolic syndrome. Our study was limited by small size, and data collection is ongoing to determine other factors that may contribute to worsening fibrosis and validate or refute these early findings.
1035 Hepatitis C Virus Screening Practices by Medical Residents in a Federally-Qualified Health Center
Authors: Zakarya Mohamed , Pose Alix , Fekredengel Tizita , Homayounrooz Forugh
Published: October 2019

INTRODUCTION:

Hepatitis C virus (HCV) is the most common chronic blood-borne pathogen in the United States. Treatment for HCV infection is currently available, curative, and with few associated side effects, increasing the importance of identifying HCV-infected individuals. HCV screening guidelines recommend a 1-time screening for baby boomers (individuals born between 1945 and 1965). Baby boomers have a higher risk for HCV-related morbidity and mortality. As of 2015, less than 13% of this population has undergone screening for HCV infection. This study aims at quantifying the baseline screening rates amongst baby boomers in a medical residents’ community clinic and evaluating the impact of resident-targeted interventions on HCV screening rates.

METHODS:

A retrospective chart review of baby boomers seen by medical residents between 7/1/17 and 12/31/18 was performed. Patients had to be seen at least once for a physical exam by the medical resident during the study period, and not screened for HCV infection previously. Baseline screening rates were recorded. Interventions were implemented for a period of 4 months. These included an updated electronic medical record (EMR) reminder for screening based on birth year, an EMR HCV risk assessment tool to identify patients need testing before visit, a link to HCV screening indications and guidelines, and small group teaching sessions about testing and linking patients to appropriate posttest care. A second phase of data collection included a chart review of baby boomers seen between 2/1/19 and 5/31/19 and meeting same criteria. A paired comparison t-test is used to analyze results.

RESULTS:

This investigation includes 502 patients in the first phase and 164 patients in the second phase of data collection. Pre-intervention screening rate was 89/502 (17.7%) compared with 72/164 (43.9%) post-intervention (P value < 0.0001).

CONCLUSION:

This investigation shows the suboptimal baseline HCV screening rate in baby boomers in a residents’ community clinic. Our post-intervention findings highlight the impact of focused resident-targeted education and the effectiveness of integrating appropriate tools into clinic infrastructure to help improve the rate of screening. Subsequently, this can help identify individuals who are in need for medical attention, potentially reducing complications of HCV infection and providing good value for our health care dollar overall.
1037 Safety and Efficacy of Sofosbuvir Plus Ribavirin and Sofosbuvir Plus Daclatasvir With or Without Ribavirin Combinations in Children and Adolescents With Chronic Hepatitis C
Authors: Hassan Adil , Bughio Ubedullah , Bhatti Rehmatullah , Ali Mashooque , Jamali Laraib , Sadik Muhammad
Published: October 2019

INTRODUCTION:

The combination of Sofosbuvir plus Ribavirin and Sofosbuvir plus Ledipasvir are recommended by American Association for the study of Liver Disease for treatment of Chronic Hepatitis C Virus (HCV) infection in adolescents; however, there is no clear recommendations for its use in children age < 12 years. The purpose of this study is to evaluate use of Sofosbuvir plus Ribavirin and Sofosbuvir plus Daclatasvir with or without Ribavirin in children and adolescents with Chronic HCV infection.

METHODS:

An observational (off-label), single-centre study was conducted from January 2016 to December 2018. All Chronic HCV RNA detected, aged between 3 to 17 years of either gender were included. Patients were offered one of two regimes; Sofosbuvir plus Ribavirin for 24 weeks (Regime 1) and Sofosbuvir plus Daclatasvir with or without Ribavirin for 12 weeks (Regime 2), according to their weight i.e. standard dose for patients >34kg, half of standard dose for patients weight between 17 to 34 kg and half of standard dose on alternate day for patients < 17 kg. Patients were closely monitored for any drug related adverse effects and very Rapid Virological Response (vRVR) i.e. undetectable serum HCV RNA by week 2 of treatment, then accordingly till Sustained Virological Response (SVR12) i.e. undetectable serum HCV RNA at 12 weeks after completion of treatment.

RESULTS:

Total 14 patients were included with mean age of 12.36 ± 5.43 years with 6 (42.9%) patients were less than 12 years and 8 (57.1%) were 12 years. Among these 9 (64.3%) were boys and 5 (35.7%) were girls. 13 (92.9%) patients were non-cirrhotic and 1 (7.1%) patient was compensated cirrhotic. 5 (35.7%) patients treated with Sofosbuvir plus Ribavirin (Regime 1) and 9 (64.7%) patients treated with Sofosbuvir plus Daclatasvir with or without Ribavirin (Regime 2). 13 (92.9%) patients achieved vRVR except 1 (7.1%) patient who achieved partial response in Regime 1. SVR12 achieved by all 14 (100%) patients. No any significant adverse effect was observed and normal growth was assessed with CDC Growth Charts.

CONCLUSION:

The combination of Sofosbuvir plus Daclatasvir with or without Ribavirin is not approved by the FDA or EMA for paediatric use, however, it is highly safe and effective in children and adolescents while Sofosbuvir plus Ribavirin combination showed good efficacy and comparable safety profile in age < 12 years.
1038 Outcomes of Non-Alcoholic Steatohepatitis in African American Patients With Human Immunodeficiency Virus (HIV)
Authors: Ajose Taiwo A. , Kagbokue Suaka , Abe Temidayo , Ajose Afolarin , Richter Seth
Published: October 2019

INTRODUCTION:

Non-alcoholic steatohepatitis (NASH) is the hepatic manifestation of metabolic syndrome and is highly prevalent in patients with HIV, ranging from 13% to 55%. According to the center for disease control and prevention (CDC), in 2016 African Americans(AA) had the highest rate of HIV diagnosis (44%).Minorities are disproportionately affected by HIV and have a higher risk of developing NASH and progressive liver disease. Data on the outcomes of NASH in AA patients with HIV and the disease progression is scanty and poorly studied.

METHODS:

We retrieved data from the Nationwide Inpatient Sample (NIS) database for the year 2012.The study group consisted of AA patients between ages 18–75 years with NASH and HIV/AIDS (n = 138). Control group included subjects with NASH alone (n = 3681). Our outcomes of interest were: overall mortality, Ascites, Hepatocellular carcinoma (HCC), End stage liver disease (ESLD), Hepatic encephalopathy (HE), Liver cirrhosis and Portal hypertension. All clinical characteristics were defined as per the International Classification of Disease 9th revision (ICD-9) codes. Logistics regression analysis was used to estimate the adjusted odds ratio (aOR) of outcomes amongst participants with coexisting NASH/HIV while accounting for comorbidities and this was compared to those with NASH alone.

RESULTS:

The mean age sample was 49 ± 12 (61% female, 39% male). The rates of ascites were higher among those with NASH/HIV compared to NASH alone (10.1% vs 4.6%, P < 0.005). After adjusting for comorbidities, the aOR for hepatic encephalopathy 1.232 (0.379-4.009), ascites 1.753 (0.962-3.196) and portal hypertension 2.258 (0.276-18.465) was higher in NASH/HIV group compared to NASH alone. Stratified analysis based on age and sex revealed that females with NASH/HIV have a statistically significant higher odd for ascites; age 18-45, aoR 4.752 (2.155-10.478) and portal hypertension age 46- 75 aoR 19.832 (1.182 - 332.644) compared with NASH alone.

CONCLUSION:

African American female patients with NASH coexisting with HIV were at a higher risk for portal hypertension and ascites when compared to those with NASH alone. Further studies will look to evaluate and mitigate the impact of HIV on NASH in this patient population.
1041 Implementation of a Chronic Hepatitis Panel to Improve Viral Hepatitis Screening in Chronic Liver Disease
Authors: Umapathy Chandraprakash , Pham Jonathan , Stokes Linda , Roytman Marina
Published: October 2019

INTRODUCTION:

In 2015, 40,326 or 12.5 per 100,000 population died from chronic liver disease. Viral hepatitis is associated with 18.5% of chronic liver disease related deaths. The vast majority of patients with liver disease present in the chronic phase, however, Community Regional Medical Center was using an acute hepatitis panel (HAV Ab IgM, HBsAg, HBcAb IgM, and HCV Ab) to evaluate for viral hepatitis. We created and implemented a chronic hepatitis panel (HAV Ab Total, HBsAg, HBsAb, HBcAb Total, and HCV Ab) with the aim of improving screening for chronic viral hepatitis, identifying patients at risk for HBV reactivation and patients in need for HAV and HBV vaccinations.

METHODS:

Baseline clinical and laboratory data including the number of acute hepatitis panels were collected from July 2017 to June 2018. Post-implementation data were collected from November 2018 to April 2019. The primary outcome was the utilization of the appropriate hepatitis panel to the presenting clinical syndrome. Secondary outcomes were vaccination rates for HAV and HBV in the setting of chronic liver disease and healthcare cost utilization of patients with chronic liver disease.

RESULTS:

Of 17,357 patients screened, acute hepatitis panel was ordered in 40.2%, mainly in the emergency department (42%) and inpatient (40%) setting. Of these, 26.9% of acute hepatitis panels were ordered with ALT < 150 or prior to ALT results. 64.7% of patients completed chronic hepatitis panel components afterward. Chronic hepatitis panel components were ordered more than once in 47.4%. Post-implementation data was collected in 6298 patients of which, 14% completed the chronic hepatitis panel. There was a 220% increase in the number of chronic hepatitis panels ordered, from November 2018 to April 2019. The average number of hepatitis labs (panel or components) ordered per patient decreased from 3.4 to 2.2 post implementation of the chronic panel. The cost for the chronic hepatitis panel is $214.20 compared to $325.38 for the acute hepatitis panel, reflecting a cost savings of 34% per panel. This is in addition to the projected savings from the decrease in the inappropriate ordering of labs.

CONCLUSION:

The chronic hepatitis panel can improve screening for chronic viral hepatitis, and potentially improve vaccination rates against Hepatitis A and Hepatitis B, as well as help prevent HBV reactivations, while lowering costs, in chronic liver disease. Longitudinal studies are needed to assess the impact of chronic hepatitis panel on disease outcomes.
1043 Effect of Dose Modification of Ribavirin on SVR 12 in Difficult to Treat Patients on Sofosbuvir, Daclatasvir Based DAA Therapy for Chronic HCV
Authors: Nawaz Arif , Iqbal Haseeb , Khan Zohaib , Riaz Saherish , Chowdhry Asad , Ali Bushra , Nawaz Shahmeer , Chaudhry Hafsa
Published: October 2019

INTRODUCTION:

DAAs are recommended as the first line treatment for chronic HCV with SVR rates >95%. Certain groups of patients, cirrhotics and treatment failures, continue to pose challenges for health care providers. In spite of a relatively poor tolerability, weight based Ribavirin has been recommended in these difficult to treat patients. We conducted a study to determine the effect of Ribavirin dose modification on SVR in these patients.

METHODS:

This was a retrospective chart review of cirrhotic (treatment experienced and naïve) and non-cirrhotic (treatment experienced) HCV patients on Sofosbuvir, Daclatasivir and Ribavirin. Patients aged 18 to 80 were included while those with HCV/ HBV or HCV/ HIV co-infection were excluded. Data was collected using a structured questionnaire and frequencies and percentages were calculated to examine the responses.

RESULTS:

A total of 100 patients (54 M, 46 F) receiving triple combination of Sofosbuvir, Daclatasvir and Ribavirin for HCV were included. There were 65 non-cirrhotic (all treatment experienced) and 35 cirrhotic patients (22 treatment naïve, 6 relapsers and 7 non-responders). In the cirrhotic group 81.6% of patients achieved SVR 12 (84% treatment naïve, 81% treatment experienced and 80% non-responders). .Amongst the treatment naïve cirrhotics, SVR was 100% and 71% respectively in the moderate (600-1000 mg) and low dose groups respectively. All 9 treatment experienced, 4 relapsers and 5 non-responder, received low dose Ribavirin with an SVR of 80% and 62.5% respectively. Amongst the 65 non-cirrhotic patients, SVR 12 was 91% with no patients on low dose Ribavirin. In the relapser group SVR was 100 % in the high dose Ribavirin group that dropped to 50% in the 2 patients having received moderate dose of ribavirin. In the non-responder group (total of 41 patients) 38 patients received high dose (SVR 95%) and 3 patients received moderate dose of ribavirin (SVR 43%)

CONCLUSION:

Ribavirin continues to play an important role in resource constrained countries due to its efficacy as part of the most cost-effective Sofosbuvir/ Daclatasvir based DAA therapy for HCV. Our study reemphasizes the need for treating difficult to treat HCV patients with the maximum possible dose of Ribavirin that can be tolerated by these patients. Dose reduction in these difficult to treat patients compromises the outcome and should be discouraged. Various measures to improve the tolerability of Ribavirin should be instituted in order to achieve higher SVRs.
1045 BMI Is an Independent Predictor for the Occurrence of HCC Following DAA Therapy in HCV Related Cirrhosis
Authors: Shrestha Shreesh , Dhungana Yogesh , Ali Bilal , Satapathy Sanjaya Kumar
Published: October 2019

INTRODUCTION:

Treatment for Hepatitis C Virus (HCV) has made a significant stride with the advent of direct-acting antiviral (DAA) therapy with SVR rates higher than 95%. Despite such a big feat, questions have been raised regarding the rate of occurrence and recurrence of HCC following treatment with DAA, especially in those with cirrhosis.

METHODS:

Using our database, we first identified all patients with liver cirrhosis secondary to HCV with no prior history of HCC, who were treated with DAA between 01/01/2014 to 04/01/2018 at our institution. We then performed a detailed review of their electronic medical records and obtained relevant clinical data. Patients who developed HCC in the follow-up period were identified. HCC screening was carried out every 3-6 months with US or CT abdomen. Categorical variables were calculated as frequencies(percentages), and continuous variables were calculated as median (range). Cumulative incidence of de novo HCC was calculated using the Kaplan-Meier method. Univariate and multivariate Cox regression analysis was performed to identify predictors for the development of HCC.

RESULTS:

We identified 254 patients meeting the criteria mentioned above. The basic demographics and key variables were identified and computed for those with and without the occurrence of HCC, as shown in Table 1. The two groups were quite similar in terms of the different variables that were studied. The patients had a median follow up of 21 months (3-55 months) following the start of DAA therapy. Sixteen patients subsequently developed de novo HCC with an occurrence rate of 6.3%. The cumulative incidence of HCC at 1,2 and 3 years of follow up are 1.6%, 6.6 %, and 11.3 %, respectively (Figure 1). Univariate analysis revealed a higher BMI of > 30, was statistically significant (P value = 0.047) for an association with the occurrence of HCC ( HR of 4.06 with a CI of 0.9-18.19) (Figure 2). The median time to the occurrence of HCC following DAA therapy was 17 months. Multivariate analysis was performed to analyze the interaction between different variables on HCC occurrence, namely BMI, CHILD class, AFP, and Viral load, which did not reveal any significant association.

CONCLUSION:

Of the various risk factors that have been identified for de novo HCC occurrence, our study identified higher BMI as an independent risk factor for HCC occurrence. Further large-scale prospective studies should be performed to identify and confirm these risk factors associated with increased HCC occurrence.
1052 Delayed Paracentesis Is Common for Patients With Spontaneous Bacterial Peritonitis: A Multicenter Retrospective Experience
Authors: Abdu Backer , Akolkar Shalaka , Picking Christopher , Boura Judith , Piper Marc
Published: October 2019

INTRODUCTION:

In cirrhotic patients, spontaneous bacterial peritonitis (SBP) is associated with significant mortality. Additional studies have also shown that delayed diagnosis (due to delayed paracentesis (DP)) has been associated with worse outcomes and mortality. We aimed to assess how often patients with SBP had delayed paracentesis. We also assessed for factors associated with DP.

METHODS:

Retrospectively studied patients who were hospitalized in 4 community hospitals with SBP, using ICD 9/10 codes, between 12/2013 and 12/2018. We excluded patients who were found to have other contributing causes of peritonitis. Delayed paracentesis was defined as a paracentesis that occurred > 12 hours from initial encounter. Data collected included: (1) patient factors (i.e., age, race, gender, etiology of liver disease, history of SBP and MELD; and (2) physician factors (i.e., admission service, shift times, and types of providers performing paracentesis (interventional radiology (IR), emergency department (ED) or other). Multivariable logistic regression analysis was performed to assess for factors associated with DP.

RESULTS:

A total of 119 patients were found to have SBP. Delayed paracentesis occurred 78% of the time (n = 93). The median time to paracentesis for patients with SBP was 26 hours (IQR = 14-57). Of the patients who received DP, 54% were male, 58% were Caucasian and 90% were performed by IR (P < 0.01). In comparison, early paracentesis was more often performed by the ED provider. In regression analysis, the factor most associated with delayed paracentesis was IR service performing paracentesis procedures (OR: 82; 95% CI 7.68 - 883). Factors associated with less DP was a known previous history of SBP (OR: 19.4; 95% CI 1.4 - 266.4).

CONCLUSION:

Previous studies have suggested that DP is associated with increase mortality in patients with SBP. Despite this, DP is common in the community setting and is often due to paracentesis being performed by IR rather than the ED or admitting service. Future studies are needed on how to best implement faster recognition and urgent diagnostic paracentesis in this setting.
1054 Prognostic Value of NIACE Score in Patients With Hepatocellular Carcinoma Undergoing Transarterial Radioembolization
Authors: Lynch Jeffrey M. , Thandassery Ragesh , Beheshti Michael V.
Published: October 2019

INTRODUCTION:

The NIACE score provides prognostic value for hepatocellular carcinoma (HCC) undergoing TACE. We aimed to evaluate the prognostic value of the NIACE score in patients undergoing Transarterial Radioembolization with Yttrium-90 (TARE).

METHODS:

In a retrospective multicenter study from the US, patients with HCC undergoing TARE as their initial intervention between January 2012 and April 2019 were analyzed. The NIACE score was calculated according to the Nodularity, tumor Infiltration, Alpha-fetoprotein level, Child-Pugh score, and ECOG score. Patients were stratified in low (<2.5) medium (2.5 to 3) and high risk (≥4) groups. The prognostic values of NIACE score for overall survival according to individual treatment and the Barcelona clinic liver cancer (BCLC) staging were analyzed.

RESULTS:

A total of 116 patients (85.3% males) were included with a median follow-up of 21.7 (range 78.5) months. Predominant etiology for liver disease was Hepatitis C virus infection (52, 44.8%) followed by alcohol (23, 19.8%). A total of 39 (38.2%), 29 (28.4%), and 33(32.4%) patients had BCLC A, B, and C stages respectively. The median MELD score was 9 and the range is 25. Overall transplant free survival (TFS) was 55.4% (n = 56); BCLC A, B, and C stages had 64.1%, 62.1%, and 39.4% survival respectively. Predictive accuracy of different NIACE score groups and BCLC stages were comparable and showed no significant difference (logrank, P = 0.73). Stratified analysis of NIACE score groups within individual BCLC stages also didn’t reveal any significant difference in TFS (BCLC A, logrank P = 0.47; BCLC B, logrank P = 0.87; and BCLC C, logrank P = 0.15).

CONCLUSION:

In our study of patients with HCC undergoing TARE, the TFS predicted by the NIACE score groups were comparable with BCLC staging system. The proposition that in TARE treated patients NIACE score could aid in treatment allocation by adding additional granularity to BCLC may need further studies.
1059 Effects of HCV Eradication on Glycemic Control in Type 2 Diabetics
Authors: Joshi Tejas V. , Roessler Eric , Das Anushka , Cefalu John , Raines Daniel
Published: October 2019

INTRODUCTION:

A meta-analysis of 34 studies estimated that the risk was increased by almost 70 percent in HCV-infected patients compared with non-infected controls. Insulin resistance has been hypothesized to develop via a multimodal pathway. The virus itself causes this through serine and threonine phosphorylation of insulin receptor substrate-1. Hepatitis creates a ubiquitous inflammatory state by releasing proinflammatory cytokines such as interleukin-6 and tumor necrosis factor-α, which upregulates gluconeogenesis. We aimed to analyze the unique patient population cared for at Louisiana State University diagnosed with DM2 and HCV who have completed direct-acting antiviral treatment with a sustained viral response (SVR). We attempted to establish a connection between a SVR and improved glycemic control and quantify the variations in HbA1C.

METHODS:

Using ICD 9/10/CPT codes the study included all patients with DM2 who underwent HCV treatment with DAA. SVR was achieved in all patients using non-ribavirin and non-interferon based therapies. SVR was defined as viral load below the lower limit of quantification after the completion of treatment. Treatments varied between 8 weeks and 12 weeks. We further divded the patient population into two groups and statistically analyzed patients with Severe Fibrosis/Cirrhosis to those without. Comparative analysis and Fisher’s exact test was performed.

RESULTS:

The F-test for increase in Metavir score correlated with a mean drop of 0.5% in HbA1c gives a P Value of 0.01652. DM2 Pts who achieved SVR had an overal drop in HbA1C of 0.39 (P = 0.009), while Cirrhotics experieces the largest median decrease 0.65% (P = 0.004). SF/Cirrhotic patients experienced the largest drop in median Isulin requirements post-treatment, decrease of 6.32 Units (P = .206). SF/Cirrhotic patients also experienced the largest median decrease in number of classes of anti-diabetic medications (P = .445).

CONCLUSION:

Analysis revealed statistically signficant results in regards to reduction in HbA1C, with the greatest benefits experiened by the SF/Cirrhotic cohort.The improvement in microvascular complications in diabetics with a reduction in HbA1C has been confirmed by multiple studies. An increase in the number of investigations with similar findings can assist insurance companies in completing a risk benefit analysis in providing full treatment compensation to all HCV patients with concomitant DM2.