bluuebunny/crossref_metadata_2025 huggingface dataset:
900 Efficacy and Safety of Endoscopic Full-Thickness Resection Device (FTRD) for Gastrointestinal Lesions Full-Thickness Resection: A Meta-Analysis Study
Authors: Fahmawi Yazan , Kumar Manoj , Shapira Gilad , Ludvik Nicholas , Mizrahi Meir
Published: October 2019

INTRODUCTION:

Endoscopic full-thickness resection (EFTR) is an emerging minimally invasive resection procedure for GI lesions not amenable to conventional resection methods. Endoscopic full-thickness resection device (FTRD) is an over-the-scope single-step device that has been developed recently for EFTR. In this meta-analysis, we aim to assess efficacy and safety of FTRD for EFTR of GI lesions.

METHODS:

Methods: A comprehensive literature review was performed. Studies with < 5 cases were excluded. Rates of histologic complete resection (R0), technical success, and complications were extracted. Pooled estimates and the 95% CI were calculated depending on heterogenicity. Heterogenicity was assessed using I2 statistics.

RESULTS:

Nine studies (5 retrospective and 4 prospective) including 480 patients with 489 lesions were included. Indications were difficult adenomas (355), early carcinoma (82), and subepithelial lesions (SEL) (47). Locations of the lesions: stomach (5), duodenum (20), proximal colon (220), distal colon (98), and rectum (141). 57% of patients were male with median of age 66.5 years (range 20-92). Mean size of the lesions was 15.36 mm (range 1-40). Median procedure time was 46.56 minutes (range 3-190). Mean hospital stay was 3.23 days (range 0-11). Pooled overall R0 resection rate and technical success rate were 81.12% (95% CI: 77.63-84.6; I2 56.7%) and 90.39% (95% CI: 87.76-93.00; I2 10.2%), respectively. The pooled R0 resection rate was 81.59% (95% CI: 76.96-85.63) for difficult adenomas, 83.47% (95% CI: 73.19-91.00) for early carcinomas, and 81.59% (95% CI:68.25-91.05) for SELs. For locations; R0 resection rate were 78.42% (95% CI: 72.17-85.50), 76.97% (95% CI: 62.56-87.88), and 80.59% (95% CI: 67.56-90.09) for proximal, distal colon, and rectum, respectively. The complications were as follows: minor bleeding 2.89 (95% CI: 1.60-4.76), major bleeding 0.88 (95% CI: 0.26-2.15), perforation 2.23% (95% CI: 1.12-3.95), postpolypectomy syndrome 1.26% (95% CI: 0.48-2.68), local trauma 0.9% (95% CI: 0.27-2.19), and other complications 1.91% (95% CI: 0.90-3.54). Of 50 patients with peri-appendicular lesion, the rate of appendicitis was 14.29% (95% CI: 6.38-26.23). The rate of complications that required surgery was 1.55 (95% CI: 0.66-3.06). No procedural death related was found. There was no correlation between mean lesion’s size and complications rates

CONCLUSION/DISCUSSION:

FTRD is a safe and effective procedure for lesions not suitable for conventional resection.
908 Diagnostic Value of Semi-Quantitative Endoscopic Ultrasound Elastography in the Evaluation of Mediastinal and Abdominal Lymph Nodes
Authors: Cazacu Irina M. , Singh Ben S. , Gonzalez Graciela Nogueras , Luzuriaga Chavez Adriana A. , Saftoiu Adrian , Bhutani Manoop S.
Published: October 2019

INTRODUCTION:

An accurate differentiation between benign and malignant lymph nodes (LN) is crucial for staging, risk stratification and treatment selection in patients with gastrointestinal malignancies. Endoscopic ultrasound (EUS) elastography can offer additional information that enables a better tissue characterization, enhancing the diagnostic power of EUS. The aim of this study was to evaluate the accuracy of the qualitative elasticity scores (ES) and semi-quantitative strain ratio (SR) for the diagnosis of abdominal and mediastinal LNs.

METHODS:

Consecutive patients referred for EUS evaluation of a mediastinal or abdominal LN by a single endosonographer (MSB) at a tertiary cancer center between January 2018 and May 2019 were included in the study. Elasticity scores (Table 1) and SR were determined during EUS exam. The final diagnosis was obtained by EUS-FNA cytology evaluation, surgical pathologic examination or clinical follow up.

RESULTS:

A total of 45 patients undergoing EUS evaluation of 70 LNs (40 benign, 30 malignant) were included in the analysis. According to the qualitative ES, the elastography images were interpreted as benign in 18 cases, malignant in 33 cases and indeterminate in 19. ES alone had a sensitivity of 100% and a specificity of 60% (Table 1). Based on the ROC curve analysis results, the best cut-off of SR to obtain the maximum area under the curve was 18.9, with a sensitivity of 47% and specificity of 85%. When both ES and SR were considered, the sensitivity was 100% with a specificity of 60% and negative predictive value of 100%.

CONCLUSION:

EUS elastography represents a promising method that allows the differential diagnosis of benign and malignant LN and it is complimentary to EUS-FNA. Given the high negative predictive value, EUS-elastography can decrease the number of unnecessary biopsies. The elasticity score and SR may be useful in patients with negative EUS-FNA results or in case in which a biopsy is not feasible.
915 A Comparison of Endoscopic Submucosal Resection (EMR) vs. Endoscopic Submucosal Dissection (ESD) on Histologic Margins and Pathologic Evaluation for Endoscopically Managed Early Esophageal Adenocarcinoma
Authors: Mehta Neal , Robertson Scott , Young Andrew , Bahdi Firas , Li Feng , Cruise Michael , Vargo John , Jang Sunguk , Murthy Sudish , Bhatt Amit
Published: October 2019

INTRODUCTION:

Accurate histologic determination is important to determine the completeness of endoscopic resection for esophageal adenocarcinoma (EAC) and gauge risk of recurrence. EMR and ESD are both endoscopic resection techniques used for the treatment of early EAC. ESD advocates believe ESD specimens allow for more precise histopathologic analysis than EMR, but this has never been proven. We aim to determine the effect of EMR vs ESD techniques on histologic analysis in endoscopically treated early EAC.

METHODS:

This is a retrospective, single center study of EMR and ESD resection specimens with pathologic confirmation of HGD or T1 EAC between 1/15-12/18. Lesions with suspected invasion into the muscularis mucosa or beyond (T2 carcinoma or higher) were excluded. Endoscopic and histologic characteristics were collected. Pathology slides were re-analyzed by a blinded GI pathologist for typical pathologic features.

RESULTS:

52 patients with early EAC were analyzed (23 ESD;29 EMR) [Table 1]. ESD-resected tumors were larger compared to those resected by EMR (20 mm [20.0, 28.0] vs 11 mm [9.0, 13.0], P < 0.001) [Table 2]. As per Table 3, EMR specimens were more likely to have positive lateral margins compared to ESD (38% vs 13%, P < 0.005) and have lower confidence in determining lateral margins. Reasons for lower confidence in the EMR group included cautery artifact (37.9%) and difficulty in orientation (20.7%). When accounting for differences in specimen thickness, EMR had a higher percentage of cauterized tissue per total tissue thickness (11.8% vs 3.9%, P < 0.001). EMR specimens had cautery effect abutting the lesion while ESD did not (0 μm vs 2259 μm distance of lesion from nearest cautery, P = 0.001). Cautery effect was more likely to interfere with margin evaluation in EMR (38% vs 13%, P = 0.04). ESD specimens were well-oriented compared to EMR (P = 0.011). EMR and ESD had no difference in positive vertical margins (7% vs 9%, P = 0.33), lymphovascular invasion (P = 0.11), or submucosal invasion (P = 0.62).

CONCLUSION:

Cautery effect and the inability to orient the specimens appropriately play a role in limiting the evaluation of EMR specimens. EMR and ESD had similar rates of positive vertical margins but rates of positive lateral margins were significantly higher in EMR, despite a smaller lesion size resected with EMR. We postulate that this is a limitation of EMR technique and there is a certain lateral size that is unsuitable for EMR as it may not be able to resect enough of a “normal” margin to the tumor compared to ESD.
919 Outcomes of Endoscopic Ultrasound Directed Trans-Gastric ERCP (EDGE): A Single Center Experience
Authors: Gutta Aditya , Patel Harsh K. , Watkins James L. , Sherman Stuart , DeWitt John , Lehman Glen , Fogel Evan L. , Easler Jeffrey J. , Gromski Mark A. , Bick Benjamin L. , Al-Haddad Mohammad
Published: October 2019

INTRODUCTION:

ERCP can be difficult in patients with Roux-En-Y foregut anatomy due to difficulty accessing the papilla, where balloon-assisted enteroscopy or laparoscopy based access has been used. Endoscopic ultrasound directed trans-gastric ERCP (EDGE) allows access to the excluded stomach via a lumen apposing metal stent (LAMS) from the gastric pouch, and passage of the duodenoscope in standard anatomical fashion. Early studies demonstrated high technical and clinical success rates of EDGE with few major adverse events (AEs). We aimed at describing rates of technical and clinical success and AEs of EDGE, impact on patients’ weight and incidence of persistent gastro-gastric fistulae (GGF).

METHODS:

This is a single center retrospective analysis of a prospectively collected database. All patients who underwent EDGE from 06/2018 to 05/2019 were included. AEs were defined per ASGE lexicon. Descriptive statistical analysis was used to assess outcomes.

RESULTS:

Nineteen patients were included in the study [mean age 59.4 years (SD = 10.7); 79% females, Table 1]. Two additional patients with spontaneous GGF noted at planned EDGE had no LAMS placed and were excluded. Choledocholithiasis was the most common indication (7/19, 37%), with three associated with cholangitis. Technical success for EUS guided LAMS placement/GGF creation was 100% (Hot AXIOS, 15 mm × 10 mm) with a mean procedure time of 26.8 (SD = 10) minutes and no major AEs. Same session ERCP was done in 2/19 (10%) with LAMS anchoring and 17/29 ERCPs (90%) performed a mean 5.5 (SD = 4.9) days after LAMS placement with a diagnostic duodenoscope (18/19, 95%) most commonly used. Mean ERCP time was 38.7 (SD = 4.9) min with a technical and clinical success of 95% (18/19). Two ERCP-related moderate adverse events occurred managed endoscopically and conservatively. LAMS were removed within 4 weeks of last ERCP, with APC +/- endoscopic suturing in 13/16 (81%) with 100% technical success of endoscopic closure. There was no weight gain noted on a mean follow up of 11.3(SD = 9) weeks. GGF resolution was confirmed in 5/16 with CT (1/5), Upper GI Series (2/5) or upper endoscopy (2/5) done in 6 months of GGF closure with other patients yet to reach the 6-month time-frame (Table 2).

CONCLUSION:

EDGE is an effective procedure for patients with Roux-en-Y foregut anatomy, with acceptable safety profile and low risk of persistent GGF or weight gain in this series. Further prospective studies are needed to assess the long-term safety, in regards to weight gain and persistence of GGF.
930 Same Day Discharge After Peroral Endoscopic Myotomy versus Overnight Observation
Authors: DiJoseph Kara , Manzo Carl , Mathew Abraham
Published: October 2019

INTRODUCTION:

Achalasia is a spastic motility disease of the esophagus, characterized by aperistalsis and a nonrelaxing lower esophageal sphincter. Since this disorder impacts individual’s quality of life drastically, more treatment modalities have emerged to help relieve patients’ discomfort; the most recent palliative treatment discovered being the Peroral Endoscopic Myotomy, a non-invasive procedure to alleviate hypertonicity at with the lower esophageal sphincter. With any new procedure, there is a high risk of complications including perforations and pneumothoraces that could lead to a lengthy post-operative stay. As time goes on, we are learning that this method maybe safer than we originally thought.1,2

METHODS:

Utilizing the electronic medical record and with IRB approval, we analyzed 149 patients who underwent POEM procedure. Readmission rates were compared between patients who were discharged to those who were kept overnight.

RESULTS:

149 patients underwent POEM in the study periodbetween September 23, 2013 and March 1, 2019. Same day discharge was standard in February 2017; 59 of those patients were discharged after the POEM the same day.

CONCLUSION:

POEM has been established as a very successful alternative treatment for severe achalasia that is minimally invasive compared to a surgical myotomy. It comes with many risks including pneumoperitoneum and esophageal perforation as seen in the early studies. This study effectively demonstrated the safety of same day discharge with zero people requiring readmission. In conclusion, same day discharge after a POEM is relatively safe to the general population and does not require post-operative admission for surveillance.2,3
931 Surveillance of Duodenal Carcinoids and the Importance of Tumor Margins: A Single Center Retrospective Study at the Moffit Cancer Center
Authors: Mony Shruti , Klapman Jason
Published: October 2019

INTRODUCTION:

The incidence of gastrointestinal neuroendocrine tumors (GI-NETs) is increasing in recent times reflecting the widespread use of endoscopy, and an increased awareness among clinicians. Duodenal carcinoids are rare and accounting for 1%-3% of primary duodenal tumors. Duodenal carcinoids < 10 mm in size and limited to the submucosal layer are amenable for endoscopic resection. Despite the increase in incidence, the natural history of duodenal carcinoid tumors has not yet been well defined. The aim of our study was to evaluate the recurrence rate following endoscopic resection of well differentiated duodenal carcinoid tumors from 2006-2016 at our institution.

METHODS:

We performed a retrospective analysis on 39 patients who underwent endoscopic resection of duodenal carcinoids from 2006-2016 at the Moffitt Cancer Institute. The indications for endoscopic resection were lesions ≤ 10 mm in diameter, confined to the submucosal layer, and without lymph node or distant metastasis. Endoscopic resection was accomplished using endoscopic mucosal resection (EMR) and biopsy forceps. The patients were followed for a mean of 3 years.

RESULTS:

Among the 39 patients meeting criteria for endoscopic resection, 28 patients underwent surveillance endoscopies post EMR and were included in final analysis . EMR was performed in 12 tumors while biopsy forceps resection in 11 patients. Pathological complete resection(R0) was achieved in 20 patients (71%), without evidence of recurrence in 9 (45%) patients followed for at least 3 years and in the 11(55%) patients followed for lesser than 3 years. On the contrary, in the 8 patients (28%) had recurrence in the 3 year follow up period of which that was recurrence,6 (75%) had either positive lateral or deep margins on initial resection (Table 1). There were no post procedural complications in any of the patients in the follow up period.

CONCLUSION:

Endoscopic resection appears to be a safe and effective treatment for duodenal carcinoid tumors measuring ≤ 10 mm in diameter and confined to the submucosal layer. This retrospective study showed that the main predictor of recurrence is the presence of positive tumor margins at initial resection. Patients with negative and margins had no recurrences in the 3 year follow up period, thus alleviating the need for long term surveillance in this patient population. Larger multicenter studies are required to determine the optimal surveillance stragey in patients undergoing endoscopic resection of duodenal carcinoid tumors.
950 Effects of Probiotics on Intestinal Failure-Associated Liver Disease in Adult Patients Receiving Prolonged Parenteral Support: A Tertiary Care Center Experience
Authors: Alomari Mohammad , Al Momani Laith , Sarmini Muhammad Talal , El Kurdi Bara , Khazaaleh Shrouq , Nehme Fredy , Young Mark , Romero-Marrero Carlos
Published: October 2019

INTRODUCTION:

It has been hypothesized that dysbiosis plays a significant role in the pathogenesis of intestinal failure-associated liver disease (IFALD). Therefore, we aimed to investigate the effect of probiotics on IFALD in patients receiving prolonged parenteral support, namely home parenteral nutrition (HPN) and intravenous fluids (HIVF).

METHODS:

We identified a cohort of patients with intestinal failure (IF) who received HPN or HIVF for >2 weeks at our tertiary center between January 2005 and August 2016. (Table 1) We excluded patients < 18 years of age, patients with other causes of liver disease, patients who used probiotics for < 30 days, patients with < 6 months follow up and those who had long-term antibiotic use ( >30 days). Bivariable and multivariable logistic regression analyses were used in this study.

RESULTS:

A total of 282 patients who received prolonged parenteral support were included. Eighty-five percent of our sample received PN, while the remaining got HIVF. A total of 78 (27.7%) patients used probiotics. The prevalence of IFALD in patients who used probiotic was 35.9% vs. 54.4% in patients who did not use probiotics, P = 0.005. In multivariable analysis, only small bowel length of 10-90 cm and HPN use showed a significant impact on IFALD, OR = 4.114 (95% CI = 1.557-10.874, P = 0.004), OR = 4.164 (95% CI = 1.325-13.087, P = 0.015) respectively (Table 2).

CONCLUSION:

Our data does not support the use of probiotics to prevent IFALD in patients receiving prolonged parenteral support. Only small bowel length of 10-90 cm and prolonged HPN use showed a significant impact on IFALD.
953 Sustained Decline of Noninvasive Fibrosis Index Values in Patients With Chronic Hepatitis C (CHC) With Sustained Virologic Response (SVR) After Receiving Direct-Acting Antiviral Agents (DAAs)
Authors: Prabhakar Vijay , Lutchman Glen , Ahmed Aijaz , Nguyen Mindie H. , Daugherty Tami , Kwo Paul
Published: October 2019

INTRODUCTION:

DAAs for CHC are highly effective at achieving SVR. However, there are limited data on outcomes post-SVR. Our aim was to investigate the temporal effect of DAAs on the outcomes of hepatic fibrosis by non-invasive assessment and incidence of HCC post-SVR.

METHODS:

Retrospective longitudinal study in adults with CHC who received DAAs between 2014 and 2018 and achieved SVR at 12 weeks (SVR12) and/or 24 weeks (SVR24). Data abstracted included demographic data, pre-treatment fibrosis stage, DAA regimen, clinical and laboratory data post-SVR. Fibrosis level was determined post-SVR using APRI and FIB-4. Co-primary study outcomes were FIB-4 values and APRI values post-SVR, and incidence of hepatocellular carcinoma. ANOVA and two-sample t-test statistical analyses were performed using Microsoft Excel.

RESULTS:

A total of 532 patients were identified retrospectively. Median age at the end of treatment was 60 (55–65) years, 306 (57.5%) were men, baseline median APRI was 0.92, baseline median FIB-4 was 2.67, and 230/532 (43%) were F4 pre-treatment (Table 1). Hispanics had a higher level of pretreatment fibrosis than non-Hispanics (P < 0.01) and higher BMI than whites and Asians (P < 0.001). We observed a significant sustained reduction in APRI scores post-treatment at SVR12/24, and 1 and 2 years post-SVR and FIB-4 scores at 2 years post-SVR within all fibrosis groups and all races (Tables 2 and 3). Hispanics in our cohort had significantly higher fibrosis levels at 1 and 2 years post SVR compared to blacks and Asians (P < 0.01 and P < 0.05, respectively) but not whites. 159 (70%) women and 224 men (73%) achieved a normal ALT less than 25 or 33. 72% of whites, 67 % of Asians, 81% of blacks, and 76% of Hispanics achieved normal ALT level. 22 (4.14%) patients developed hepatocellular carcinoma (HCC) post-treatment; all had F4 fibrosis prior to treatment initiation.

CONCLUSION:

In a cohort of HCV patients with high prevalence of advanced fibrosis,treatment with DAAs lead to significant improvement in fibrosis indices, across all initial fibrosis stages and races at 1 and 2 years post-SVR. In our cohort, Hispanics had higher baseline fibrosis levels and BMI yet still had a sustained significant improvement 2 years post-SVR though fibrosis levels still remained higher than Asians and blacks. The risk of HCC post-SVR remains in patients with F4 fibrosis.
956 Kasr Alainy Fibrosis Index (KAFI) - A Novel Score Based on Micro RNAs for Diagnosis of Significant Fibrosis: A Biopsy Controlled Study
Authors: Abdel-Haleem Hanan , Omran Dalia , Zekri Abdel Rahman , Ahmed Ola , Moniem Mostafa Abdel , El Ray Ahmed
Published: October 2019

INTRODUCTION:

Precise identification of HCV induced liver fibrosis is needed for tailoring therapy, monitoring fibrosis regression after sustained virologic response and management of complications. Few studies investigated the role of MicroRNAs in predicting liver fibrosis. The current study evaluated the diagnostic accuracy of circulating miRNAs; miR-122, miR-192, miR-855, miR-375, miR-224, and miR-221 in prediction of hepatic fibrosis and to validate their usefulness against other commonly used noninvasive fibrosis scores using liver biopsy as the gold standard.

METHODS:

Seventy patients with chronic HCV, enrolled from Theodor Bilhariz research institute were included in this study. They were subjected to routine laboratory investigations, HCV-RNA, serum miR-122, 192, 885, 375, 224 and 221 by PCR, ultrasound guided liver biopsy and calculation of the following scores: Fibrosis Index (Fi), Fibro-Alfa , Hui index , aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio (AAR), Biotechnology Research Center (BRC) score, aspartate to platelet ratio index (APRI), Fibro-Q , Gotebörg University Cirrhosis Index) (GUCI) and FIB-4 score.

RESULTS:

There was no statistically significant difference in laboratory parameters except for miR-122 which was significantly lower in patients with significant and advanced fibrosis (P < 0.0001 and P = 0.007, respectively). Univariate analysis identified miR-122, bilirubin and miR-855 as independent predictors of significant fibrosis. The AUC were 0.78, 0.67and 0.63, respectively (Figure 1a,c). Multivariate analysis selected the best overall formula combining miR-122, bilirubin and miR-855 as a novel noninvasive score for predicting significant liver fibrosis. KAFI Score = 4.558 – (miR-122 × 0.089 + miR-855 × 0.051 + bilirubin × 0.366), where 4.558 is a numeric constant. The area under the ROC curve (AUC) of this score for identifying significant fibrosis was 0.83 (Figure 1d). A cut-off of 0.41 had 77% sensitivity, 75% specificity, 65% positive predictive value, 85 % negative predictive value and 76% efficiency for predicting significant liver fibrosis. The AUCs of FI, Fibro- Alfa, Hui, AAR, BRC, APRI, Fibro-Q, GUCI and FIB 4 were 0.46, 0.53, 0.54, 0.60, 0.61, 0.62, 0.62, 0.62 and 0.67; respectively for predicting significant fibrosis. KAFI score yielded AUC 0.83 for predicting significant fibrosis and 0.80 for predicting advanced fibrosis.

CONCLUSION:

KAFI score is better than the current scores in discriminating hepatic-fibrosis in chronic hepatitis C patients
958 Long Term Data on Effect of Mobilized Peripheral Blood Autologous CD34+ Cell Infusion in Patients With Non- Viral Decompensated Cirrhosis
Authors: Sharma Mithun , Mitnala Sasikala , Rao Padaki N. , Kumar Pavan , Jaggaiahgari Shasidhar , Gupta Rajesh , Da Pramod , Kulkarni Annand , Jagtap Nitin , Singh Jagdeesh Rampal , Reddy Duvurr N.
Published: October 2019

INTRODUCTION:

The paucity of organs for liver transplant coupled with rising cost have paved the way for research in alternative cell based therapies as a bridge to liver transplantation. Our initial published work with 6 months follow up have now been followed up for 3 years and the data is presented below

METHODS:

Cirrhotic patients of non-viral etiology were divided into 2 groups – standard of care (control, n = 23) or to receive autologous CD34+ cell infusion through hepatic artery (study group n = 22). Patient in study group were admitted in hospital and received Granulocyte Colony stimulating Factor (G-CSF) injections @ 520µgm per day for 3 consecutive days to mobilize CD34+ cells from the bone marrow. On Day 4, leukapheresis was done and CD34+ cells were isolated using CliniMAC magnetic cell sorter. The isolated CD34+ cells were infused into the hepatic artery under radiological guidance. The control group received standard of care treatment for liver cirrhosis and were worked up for liver transplantation as per protocol of the institute. Both groups were followed up every weekly for 4 weeks and then every month for 3 months and then 6 monthly for 3 years

RESULTS:

In control and study group, the cause of cirrhosis was cryptogenic in 18 (78.2%) and 16 (72.72%) and alcohol related in 5(21.7%) and 6(27.27%) respectively. The mean day 3 cell count (cells/µl) was 27.00 ± 20.43 with a viability (%) of 81.84 ± 11.99. and purity of 80-90%. Primary end point analysis revealed that at 4 weeks, the mean serum albumin in the study group increased significantly (2.83 ± 0.36 vs 2.43 ± 0.42, P = 0.001) when compared with controls. This improvement in albumin was however not sustained at 3 months. However, at the end of 3 months there was a statistically significant improvement in serum creatinine in the study group (0.96 ± 0.33 vs 1.42 ± 0.70, P = 0.01) which translated into a significant improvement in the MELD score (15.75 ± 5.13 vs 19.94 ± 6.68, P = 0.04) . However, when these patients were followed up for 3 years, there was no difference in the MELD score and mortality ( 6/23 vs 5/23 ) between the 2 groups

CONCLUSION:

Autologous CD 34 + cell infusion is safe and effectively improved liver function in the short term. However, when they were followed up for 3 years , no difference could be noted in both the arms. Since cirrhosis is a ongoing process, the possible role of repeated infusions needs to be studied or a combination of mesenchymal and hematopoietic stem cells may be more effective.
959 Cirrhosis Patients Admitted With Ascites Have Longer Length of Stay and Higher 30-Day Readmission Rate
Authors: Serigado Soares Da Costa Joao M. , Taylor Rikera , Scheinberg Andrew , Patel Angeli , Jones Patricia D.
Published: October 2019

INTRODUCTION:

Hospitalizations and readmissions in cirrhosis patients pose a significant economic burden to the health care system. Readmission rates are high for patients with decompensated cirrhosis; 30-day rates are as high as 30–40%. We aimed to identify the frequency and predictors of 30-day readmission rates in patients with decompensated cirrhosis admitted to two academic hospitals.

METHODS:

Using research informatics and validated ICD-10 codes, we identified cirrhosis patients admitted to the University of Miami Hospital (UMH) from 10/1/2017 to 10/1/2018. (Figure 1) After retrospective chart review, we excluded patients without cirrhosis or qualifying admissions. As patients from UMH are often admitted to Jackson Memorial Hospital, those records were also reviewed for admissions during the study period. Univariate analysis was conducted to describe demographics and disease-specific characteristics and identify variables associated with 30-day readmission rates.

RESULTS:

In our sample, 105 patients met inclusion criteria with 208 eligible admissions. Median age was 63 and 67.6% were male. During the index admission, the primary admission diagnosis was ascites in 36 patients, upper GI bleed in 15, and hepatic encephalopathy (HE) in 13. For 41 patients, the reason for admission is listed as other. (Table 1) The average length of stay (LOS) during the index admission was 7 days (±7.5). The readmission rate was 52.7%; the 30-day readmission rate was 25.8%. Twelve patients died during the index admission. Fifty patients had at least one readmission; range (1–8). A higher proportion of ascites patients were readmitted within 30 days, 35.3%, compared to 23.1% in those with GI bleed, 27.7% of HE patients and 17.1% of those with other diagnoses. Those with ascites also had the longest LOS, mean 7.67 days (±10). Noting the above results, we focused on the 47 patients with a primary or secondary diagnosis of ascites. Average time to paracentesis was 2 days. Only one patient with ascites (2.1%) was scheduled for paracentesis prior to discharge; 38 (81.8%) were discharged on diuretics. Fourteen patients (29.8%) were readmitted with a primary diagnosis of ascites (Table 2).

CONCLUSION:

Patients with decompensated cirrhosis are frequently readmitted in less than 30 days; ascites contributed to increased LOS and readmission rates. Additional study is needed to determine if Implementation of core quality measures decreases readmission rates and/or improves quality of life.
965 Safety of Statins in Decompensated Cirrhosis in Patients Listed for Liver Transplantation
Authors: Singh Kevin N. , Mejia Perez Lady Katherine , Singh Amandeep , Carey William
Published: October 2019

INTRODUCTION:

Statins (S) are important for cardiovascular disease risk reduction, including in those with cirrhosis (C). S may also slow progression of C, reduce portal pressure, and risk of hepatocellular carcinoma (HCC). A recent AASLD NAFLD practice guidance reiterated recommendations of the National Lipid Association's Statin Liver Safety Task Force (Bays et al, Journal of Clinical Lipidology, 2014), recommending S avoidance in decompensated cirrhosis (DC). In this study, we sought to determine whether S in DC use was associated with a higher risk of adverse outcomes.

METHODS:

A retrospective case-controlled study examined S use and outcomes in those with DC listed for liver transplant (LT) between January 2000 and December 2017. The S cohort included those who took S for at least 90 days prior to LT (cases). Listed non-S patients (NS) patients served as controls. The primary aim was to determine S safety (side effects, S discontinuation, change in MELD, non-transplant hospitalization, mortality). Secondary outcomes included evidence of possible S benefit (less new or worsening ascites, GI bleed, hepatic encephalopathy, hepatorenal syndrome (HRS), spontaneous bacterial peritonitis (SBP) and hepatocellullar carcinoma (HCC). Univariate and multivariate analysis of demographic data and outcomes were performed using negative binomial and logistic regression with repeated-measured ANOVAs.

RESULTS:

Eleven hundred ninety-one patients with DC were included. Sixteen percent were taking one of 5 different S (Table 1). There was no apparent serious deleterious effect of continued S use as measured by S discontinuation, progression of MELD score, non-transplant hospitalization, or mortality (Table 2). One developed myalgia not requiring S discontinuation. While S users had moderately higher likelihood of worsening HE, there was a trend for reduction in new HE. Potential S benefit is suggested by lower mortality, hospital admissions, new HCC, ascites, SBP, re-bleeding, and HRS in those taking S. Caution is required in interpreting potential S benefit because of important differences in liver disease distributions and co-morbidities in S and Non S patients.

CONCLUSION:

Conclusion: In decompensated cirrhosis: 1. Statin use is safe. There is no need to discontinue statins once C advances from compensated to DC; 2. Statins may have a protective effect in suppressing HCC, new or worsening ascites, and other important outcomes. Additional study is needed to better understand if there is an interaction of S and HE.
968 Lead (Pb) Exposure and Risk of Non-Alcoholic Fatty Liver Disease and Advanced Fibrosis: An Association Modified by Race/Ethnicity and Gender in NHANES 2011-2016
Authors: Reja Debashis , Visaria Aayush , Tawadros Augustine , Pioppo Lauren , Bhurwal Abhishek , Rustgi Vinod K.
Published: October 2019

INTRODUCTION:

NAFLD and NASH are most commonly associated with risk factors such as metabolic syndrome and obesity. Increasing evidence support that environmental toxicants may also play a role. Common sources of Lead (Pb) include paint, dust, waterpipes, and gasoline. In this study we aim to investigate the association of Lead toxicity with NAFLD and advanced fibrosis.

METHODS:

A population of 5,590 non-pregnant individuals age 18–74 were included in this secondary analysis of NHANES 2011-2016. Exclusion criteria: AST/ALT > 500 IU/L, alcohol > 10 drinks/week (females)/ >20 drinks/week (males), transferrin saturation > 50%, positive hepatitis B and C serology. NAFLD was defined by Fatty Liver Index score > 60. Advanced fibrosis was defined by National Fibrosis Score > 0.676. Student’s T-test was used for continuous and Rao-Scott Chi-Square test for categorical variables. Comparison across quartiles were done with simple linear regression for continuous, Rao-Scott Chi-Square test for categorical variables. Demographics and patient confounders were adjusted using multivariate logistic regression (SAS 9.4) for odds of NAFLD/Advanced Fibrosis with respect to Lead quartile.

RESULTS:

Increasing exposure to blood Lead levels is significantly associated with increasing age, male gender, longer education, lower BMI, and increasing Mercury levels (see Table 1). After multivariate adjustment for confounding factors, risk of Advanced Fibrosis significantly increased with Lead exposure, (Quartile 4 OR 5.63, 95% CI 3.17–9.99). Upon stratification analysis, this increased risk was highest in males (Q4 OR 16.67, 95% CI 3.96–70.09), African Americans (Q4 OR 9.96, 95% CI 4.45–22.33), and significant trends were positively correlated across all racial groups. Increased exposure to Lead after the median also showed a positive trend for risk of NAFLD (Q4 OR 1.11, 95% CI 0.64–1.92). This positive association was seen in males and whites, however a negative trend was seen in African Americans (see Table 3).

CONCLUSION:

Our findings show a strong association for Advanced Fibrosis and elevated Lead levels, particularly for African Americans and males. NAFLD is also positively associated with Lead exposure. This study can help identify populations in need of aggressive screening. Further studies are needed.
971 Eradication of Hepatitis C by Increasing Identification Rates of the Hepatitis C Virus (HCV) in Baby Boomers Using the Health Maintenance Tab
Authors: Zafar Yousaf , Elkafrawy Ahmed A. , Galappaththy Suguni Loku , Khan Shahryar , Shah Raj
Published: October 2019

INTRODUCTION:

Chronic HCV is one of the leading causes of cirrhosis and hepatocellular carcinoma in the United States. Current national data shows 75% of HCV infected adults are born between 1945–1965 (baby boomers). The USPSTF recommends one-time screening of this population for HCV. The aim of our study is to assess the impact on the rate of detection of HCV by implementing a screening tool in the health maintenance tab for this subset of high-risk individuals and improving treatment rates

METHODS:

In March 2017, our health center established a Health Maintenance tab for Screening HCV for all baby boomers.Yearly data regarding the number of patients screened, patients who had positive screening, data on confirmatory testing and the number that finally received treatment was collected between March 2012-February 2018. The percentage of patients screened and later confirmed positive was calculated.

RESULTS:

We compared the screening of baby boomers 5 years prior to the health maintenance tab and 1 year after it was introduced. In 2012, a total of 30915 patients were seen in the health facility with 1.83% screened, followed by 2.57% of 30679 patients in 2013, 2.4% from 29614 patients in 2014, 1.8% from 29081 patients in 2015, 1.7% from 28887 patients in 2016 and 7.8% from 29896 in 2017. There was 4.5 times increase in the screening of patients after the intervention. The number of patients who were screened positive with HCV Antibody from March 2012 to Feb 2018 were 15, 15, 55, 73, 64 and 182 in the consecutive years. The number of patients that had confirmatory testing with HCV RNA titers from 2012 to 2018 was 80%, 60%, 83%, 80%, 71.8% and 77.4%. Of those who had HCV RNA titers ordered between 2012 to 2018, the number of patients who were confirmed positive were 9 in 2012, 4 in 2013, 30 in 2014, 35 in 2015, 18 in 2016. The year after the intervention identified 73 patients who had confirmed Hepatitis RNA titers. Of the patients identified as having the infection, 4 were treated in 2012, 2 in 2013, 25 in 2014, 22 in 2015, 18 in 2016 and 52 after the intervention.

CONCLUSION:

Screening baby boomers using the health maintenance tab in the Electronic health record identified more patients who may in fact have Subclinical HCV. Identifying these individuals earlier would help initiate necessary treatment promptly and help prevent chronic complications. However, treatment of identified patients remains a challenge as other socioeconomic problems prevents individuals getting complete eradication of the infection
973 Utility of Gram Stain in the Diagnosis and Management of Spontaneous Bacterial Peritonitis: Promoting High Value Care
Authors: Fahad Hamna , Vozzo Catherine Frakes , Singh Tavankit , McCullough Arthur J.
Published: October 2019

INTRODUCTION:

The diagnostic criteria for spontaneous bacterial peritonitis (SBP) and culture negative neutrocytic ascites depends largely on neutrophil counts of more than 250 cells / mm3. A positive ascitic fluid culture makes the diagnosis of SBP versus CNNA. In general clinical practice gram stain (GS) and culture are routinely sent for suspected SBP. The yield of microbe from ascitic fluid is low possibly because SBP and CNNA are known to happen with very small concentrations of bacteria, whereas bacterial loads as high as 10^5 organisms/ml are required for a positive GS. The aim of this study was to determine the utility of GS in the diagnosis and management of suspected SBP as an impetus to decrease overall burden of healthcare cost and unnecessary testing.

METHODS:

We retrospectively reviewed patients with ascites and cirrhosis, who underwent paracentesis with body fluid analysis at a large tertiary care hospital in a 1-year period. Patients were identified using institutional procedural codes and ICD 9 and ICD 10 codes for ascites and cirrhosis. We included all adult patients with cirrhosis who had underwent paracentesis in 2017 and had both a culture and a GS sent for analysis. We excluded patients who had any evidence of recent or current source of intra-abdominal infection or had partial labs sent. Variables of interest were date of ascitic fluid studies sent, date of GS results, date of culture results, date of initiation of empiric antibiotics and the date and name of the second antibiotic used. Descriptive statistics were used to analyze data. Costs for GS, culture and body fluid cell count & differential were obtained from the coding and reimbursement department.

RESULTS:

767 patients underwent ascitic fluid testing in our study period. 43 had a positive GS (5.6%). 21 of these had SBP (PMN > 250 and positive culture), one patient had CNNA (PMN > 250 and no culture growth), 20 patients had bacteracitis (PMN < 250 and positive culture) and one patient had PMNs < 250 and no culture growth. Management was changed in 3 cases (0.4%) based on GS alone (Table 1). In one of these patients, therapy was changed again after the culture grew a different organism. Total healthcare cost calculated to be at least $36,672 each year at our center based on $48 per ascitic fluid gram stain sample alone.

CONCLUSION:

Carrying out GS on all ascitic fluid samples is not cost effective and rarely leads to changes in management.
981 Spleen Stiffness Using Elastography as Predictor of Esophageal Varices in Cirrhotic Patients
Authors: Tulsi Rani , Ul Haque Muhammad Manzoor , Farid Muhammad , Hanif Farina , Devi Asha , Luck Nasir Hassan , Tulsi Rinkal , Mehmood Nasir , Danish Muhammad
Published: October 2019

INTRODUCTION:

Prediction of EV by the measurement of splenic stiffness (SS) by Transient elastography (TE) in cirrhotic patients has been recently proposed. Splenomegaly and splenic stiffness in cirrhosis can be explained by enlargement and hyper activation of the splenic lymphoid tissue, increased angiogenesis, fibrogenesis and passive congestion due to portal hypertension. Thus, the aim of this study is to assess diagnostic accuracy of spleen stiffness as a predictor for the presence of esophageal varices in liver cirrhosis using EGD as gold standard. Spleen stiffness measurement is non-invasive technique as compared to EGD so this test can be used to stratify the liver cirrhotic patient who need screening EGD compared those who do not need it.

METHODS:

Patients were enrolled from June 2018 to May 2019, all patient with cirrhosis undergoing screening EGD were offered to participate in the study. After fulfilling the inclusion criteria, a blood sample for platelet count, INR, CTP and MELD score was taken. Splenic stiffness was measured by fibroscan by expert radiologist prior to undergoing screening EGD. Exclusion criteria was followed strictly to avoid confounding variables. All information along including age, gender, spleen stiffness, presence or absence of EV were entered in the Performa.

RESULTS:

Total of 97 patients were included in the study, mean age of patients was 41.1 ± 15.1, predominantly were males 61(62.9%), while 55 (56.7%) belonged to urban areas of province. Common etiologies for cirrhosis includes HCV 49(50.5%) followed by HBV 16(16.5%), HBV and HDV coinfection 10(10.3%), autoimmune hepatitis 7(7.2%) and others were 8 (8.2%). Most patients belonged to CTP class A 58(59.8%), Mean MELD score were 11.7 ± 5.5. Mean platelets and albumin of patients were 128 ± 86.3 and 3.3 ± 0.7. Total 25 (25.7%) had ascites and 55 (56.7%) had esophageal varices on screening EGD and 6(6.2%) patient had fundal varix. Student t-test showed a significant association of low platelets (P = 0.0001, 118.3 vs 57.5) and high splenic stiffness (P = 0.0001, 37.9 vs 23.0) with the presence of esophageal varices. Area under ROC was calculated for APRI, FIB-4 and splenic stiffness was 0.81, 0.79 and 0.93 respectively.

CONCLUSION:

Splenic stiffness can more reliably predict the presence of esophageal varices as compare to other noninvasive test like APRI and FIB-4. So it can be used to stratify the patient who needs screening EGD and minimize the false negative results.
982 Development of Hepatocellular Carcinoma After Treatment of Hepatitis C at a Diverse, Urban Center
Authors: Modi Krishna , Mansour Jonathan , Jafri Syed-Mohammed
Published: October 2019

INTRODUCTION:

This study investigates the clinical outcomes for patients treated for chronic hepatitis C, and factors that led to increased development of hepatocellular carcinoma (HCC) and overall mortality.

METHODS:

This is a retrospective study conducted at a single center institution. Inclusion criterion was patients who completed treatment for chronic hepatitis C in 2015. Patients were excluded if they failed to follow up after receiving therapy. The data studied are patient demographics, relevant medical history, HCC screening, and HCC development.

RESULTS:

This study had 367 patients and majority of them were treated with ledipasvir/sofosbuvir (87.7%), and the remainder were also given ribavirin. Most patients had prior treatment for hepatitis C (57.8%). There were 132 patients (36.0%) who had cirrhosis, and 28 patients (7.6%) who underwent liver transplantation. SVR was achieved in 341 patients (92.9%). Screening was continued in 253 patients (68.9%). Of all the cirrhosis patients only 50% of patients continued the screening. A total of 39 patients (10.6%) developed HCC. There was a statistically significant increase in screening for older patients versus than in younger patients (65 versus 61 years old). More patients continued screening if they failed to achieve SVR (69.2% versus 28.0%) or had known cirrhosis (49.6% versus 20.1%). There was a statistically significant increase in development of HCC in patients that did not achieve SVR (50.0% versus 7.4%), underwent liver transplantation (32.1% vs 8.6%), or had known cirrhosis (17.6% versus 6.4%). No significant differences were observed in HCC development between different viral genotypes, history of prior treatment, or whether they received ribavirin during this treatment. Mortality was greater in patients that identified as black (12.0% versus 5.3%), failed to achieve SVR (23.0% versus 7.7%) or developed HCC (23.7% versus 6.4%).

CONCLUSION:

This study shows that patients are more likely develop HCC if fail to reach SVR, have known cirrhosis, or undergo liver transplantation. Patients were more likely to get HCC screening if they failed to reach SVR, and known cirrhosis, but still half the patients with cirrhosis did not get screening. There was no significant difference in HCC development based on viral genotypes, having prior therapy, or whether ribavirin is used. Mortality was noted to be increased in people who identified as Black, failed to achieve SVR, and developed HCC.
987 The Epidemiology and Trend Analysis of Hepatocellular Carcinoma 2002-2014: A Population-Based Study
Authors: Sarmini Muhammad Talal , Asfari Mohammad Maysara , Alomari Mohammad , Romero-Marrero Carlos
Published: October 2019

INTRODUCTION:

Hepatocellular carcinoma (HCC) is one of the most common malignancies and it is considered the fourth leading cause of malignancy related death in the world. Previous studies suggested that the incidence of HCC continues to rise in the United States (US) and worldwide. Hence, we conducted this study to assess the national trend in the US. Further, we wanted to assess all-cause mortality and baseline characteristics of this population using a nationwide inpatient database.

METHODS:

Using data from the National Inpatient Sample (NIS) database between 2002 and 2014, we identified all patients who were diagnosed with HCC using appropriate ICD 9 coding. We examined also the temporal trends of the length of stay (LOS) and all-cause of mortality (ACM) during admission using the Cochrane-Armitage method for this group over the studied period.

RESULTS:

Out of 101,231,036, we identified total of 824,053 (0.8%) of patients with HCC. Patients with HCC admitted 2010-2014, compared to those admitted 2002-2009, were younger (60 vs 61), (P < 0.001). They were also less likely to be females (46.5% vs 53.5%) and more likely to be Caucasians (51.9% vs 48.1%), (P < 0.001 for all). Furthermore, patients in the first group had more smoking (59.6% vs 40.4%), cirrhosis (51.6% vs 48.8%), hepatitis C virus (HCV) (51.2% vs 48.8%) and nonalcoholic fatty liver disease (NAFLD) (65.1% vs 34.9%), (P < 0.001 for all). On the hand, patients admitted 2002-2009 had more hepatitis B virus (HBV) (57.7% vs 42.3%, P < 0.001) compared to patients admitted 2010-2014. Using trend analysis, the annual prevalence of patients admitted with HCC has significantly increased form 39,935 (0.5%) in 2002 to 70,979 (1%) in 2014, (P < 0.001). ACM of patients admitted with HCC improved from 13.4% in 2002 to 9.2% in 2014, (P < 0.001). In addition, the mean LOS for patients admitted with HCC has decreased gradually from 6.46 in 2002 to 5.77 in 2014 during the studied period, (P < 0.001).

CONCLUSION:

The analysis of very large inpatient data showed that the prevalence of HCC has doubled since 2002 through 2014 and this finding requires immediate attention. Our analysis showed that ACM and mean LOS of HCC patients have improved through this period of time. Screening for HCC in high risk patients remains the key for further improvement in outcomes in this population.