bluuebunny/crossref_metadata_2025 huggingface dataset:
1025 Frequency of Diagnosed Acute Intermittent Porphyria in a National Health Care Database
Authors: Silver Samuel , Erwin Angelika L. , Meninger Stephen , Ko John J. , Tkacz Joseph , Noxon Virginia , Conradt Christian
Published: October 2019

INTRODUCTION:

Acute hepatic porphyria (AHP) refers to a family of rare, genetic diseases caused by deficient activity of enzymes involved in the heme biosynthesis pathway in the liver, with acute intermittent porphyria (AIP) being the most common subtype. Accumulation of neurotoxic heme intermediates may result in potentially life-threatening acute attacks and chronic symptoms that negatively impact daily functioning and quality of life. Although AIP-related genetic mutations are relatively common (1:1,700), clinical penetrance of the disease is estimated around 1%. European data suggest that the diagnosed prevalence of AHP is approximately 1 per 100,000 individuals. Epidemiologic data specific to AIP are limited. The study aimed to identify AIP patients diagnosed in a nationally representative health care database to estimate prevalence, commonly reported clinical presentations, and health care resource utilization of AIP in the United States.

METHODS:

This retrospective analysis utilized the IBM® MarketScan® Commercial Claims and Medicare Supplemental Databases. Patients with at least one claim for AIP (ICD-10 diagnosis code E80.21) between October 1, 2015 – June 30, 2018 were selected for analyses. The subset of AIP patients with continuous enrollment for one year preceding and following their first observed AIP diagnosis (index diagnosis) were identified for the measurement of baseline characteristics and outcomes post-index, including healthcare resource utilization (HCRU), medications (including hemin), symptoms, and the frequency of comorbid diagnoses.

RESULTS:

Approximately 37 million patients within the MarketScan® databases had a medical or pharmacy claim between October 1, 2015 and June 30, 2018; a total of 361 of these patients were identified with a diagnosis of AIP. Among these 361 AIP patients, a partial prevalence estimate of AIP on June 30, 2018 was calculated to be 0.98 per 100,000 (214 AIP patients per 21,807,137 people enrolled on June 30, 2018). Sensitivity analyses around claims-based definitions for identifying AIP revealed 140 patients with ≥2 claims for AIP and 31 AIP patients receiving hemin (Table 1).

CONCLUSION:

Results from this national representative healthcare claims database demonstrated the frequency of diagnosed AIP in the United States to be similar to estimations previously published in global and European-specific AIP epidemiology studies.
1033 Quality Metrics Adherence Assessment for Patients With Chronic Hepatitis B Virus Seen in Gastroenterology Clinics
Authors: Kutaimy Raya , Benjaram Sindhuri , Naylor Paul , May Elizabeth , Mutchnick Milton , Ehrinpreis Murray N.
Published: October 2019

INTRODUCTION:

The American Association for the Study of Liver Disease (AASLD) guidelines for hepatitis B management have progressed over time. However, adherence to quality metrics for chronic hepatitis B (CHB) care needs to be evaluated, especially in settings where liver specific clinics are not part of the system. Our study aims to evaluate the adherence to quality of care metrics in CHB patients in a predominately African American patient population general Gastroenterology clinic in an academic medical center.

METHODS:

We performed a cohort chart review on 92 patients with ICD 9 or 10 codes for CHB. Patients co-infected with HIV were excluded from analysis as they were treated by Infectious Disease clinics. We identified 45 patients following up with our Gastroenterology clinic for CHB with a visit between 2017 and 2018. We gathered demographic data. Adherence metrics were collected including HAV vaccination, treatment guideline relevant metrics, timely measurement of alanine aminotransferase (ALT), Aspartate Aminotransferase (AST), platelets and hepatitis B virus DNA level check to monitor for treatment response HBV status. Hepatocellular carcinoma screening measure.

RESULTS:

Our patient population was 65% African American,17% Asian,13% Caucasian and 5% other races. All treated patients had >2000 in HBV DNA levels and high ALT prior to treatment, whereas untreated patients had low HBV DNA and normal ALT with the exception of 1 patient under consideration for treatment. Hepatocellular cancer screening adherence was significantly high in both treated (80%) and untreated (84%) patients with 6 monthly imaging studies. Both treated and untreated patient had relatively high compliance (68%) with HAV vaccination. All the patients had ALT, AST and platelets so that APRI score could be checked every 6 months to provide an indirect assessment of fibrosis. Timely evaluation of fibrosis specific assessments has not been completed in most of the cases, and there was no consensus with respect to the preferred method for assessing fibrosis.

CONCLUSION:

Our finding reflects satisfactory adherence with AASLD guidelines particularly in areas of treatment indications, regular laboratory check, hepatocellular carcinoma screening and compliance with HAV vaccination. However, fibrosis evaluation was suboptimal according to guidelines. Given the access to Fibroscan in our practice, once yearly assessment is being recommended for our patients. Supported in part by an Investigator Initiated Grant from Gilead Sciences.
1046 Quantifying Risk Factors and Comparing Clinical Parameters for Cirrhotic and Non-Cirrhotic Hepatocellular Carcinoma (HCC) in Non-Alcoholic Steatohepatitis (NASH)
Authors: Desai Aakash , Twohig Patrick , Sandhu Sonia , Sandhu Dalbir S.
Published: October 2019

INTRODUCTION:

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third leading cause of cancer-related death in the United States. HCC is historically associated with cirrhosis from Hepatitis B virus, Hepatitis C virus (HCV), and alcohol abuse. Nonalcoholic fatty liver disease (NAFLD) is a key risk factor for the development of HCC. The prevalence of obesity and metabolic syndrome in the United States has likely contributed to the HCC epidemic. Epidemiological data reports that two-thirds of obese people have fatty liver ranging from steatosis to steatohepatitis, which in turn can progress to cirrhosis in 3-15% and eventually to HCC. The primary aim of our study is to ascertain the differences between cirrhotic and non-cirrhotic NASH-HCC patients based on demographics, risk factors, and laboratory abnormalities. Additionally, we wanted to quantify the risk factors that increase the likelihood of HCC in NASH patients.

METHODS:

We performed a retrospective analysis in the IBM Explorys database which has 63781930 unique patient data in the US. Data is reported as counts and percentages and an independent two sample t-test was used to compare epidemiological, clinical and laboratory features between cirrhotic and non-cirrhotic NASH-HCC. Odds ratios were calculated to determine the relationship between NASH-HCC sub-groups and risk factors and converted into Forest plots.

RESULTS:

There were 1120 cases of NASH-HCC of which 1040 were cirrhotic and 80 were non-cirrhotic. Patients with cirrhotic NASH-HCC were more likely to have type 2 diabetes mellitus, chronic kidney disease, coronary artery disease, and elevated alpha fetoprotein, direct bilirubin and INR compared to their non-cirrhotic counterpart. Patients with type 2 diabetes (OR 70, 95%CI 59.4-82.5) had the highest risk for HCC in cirrhotic NASH. Patients with elevated ferritin (OR 25, 95%CI 15.1-41.5) had the highest risk for HCC in non-cirrhotic NASH.

CONCLUSION:

Patients with type 2 diabetes are at the highest risk for HCC in NASH cirrhosis patients compared to other components of metabolic syndrome. Elevated ferritin levels conferred the highest risk for development of NASH-HCC in non-cirrhotic patients. OSA has been shown to promote HCC in early studies and our findings demonstrate similar but notable risk in both sub-groups. Identifying key differences in the epidemiology and disease traits of cirrhotic and non-cirrhotic NASH-HCC could be used to assist with the early identification of patients that are at risk for HCC
1047 Changes in Liver Fibrosis Scores in Patients With New Onset Type 2 Diabetes on Triple Therapy With Exenatide/Pioglitazone/Metformin vs. Conventional Therapy: Year Two Results
Authors: Lavrynenko Olga , Abdul-Ghani Muhammad , Alatrach Mariam , DeFronzo Ralph , Alkhouri Naim
Published: October 2019

INTRODUCTION:

Patients with nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes (T2DM) are at higher risk of developing advanced fibrosis. Certain diabetes medications such as pioglitazone and GLP1 agonists have shown some efficacy against NAFLD in small clinical trials. The Durability of Combination Therapy With Exenatide/Pioglitazone/Metformin vs. Conventional Therapy in New Onset T2DM trial is an ongoing interventional trial assessing the effects of two different approaches to treating T2D (ClinicalTrials.gov Identifier: NCT01107717). The aim of the current study was to evaluate the effects of these two approaches on liver fibrosis scores after two years of treatment.

METHODS:

Newly diagnosed, drug-naïve T2DM patients were enrolled into the study. Medical history, clinical characteristics were obtained, and blood was drawn for the measurement of plasma glucose concentration, HbA1c, CBC, and blood chemistries. Subjects were randomized to receive in an open label fashion an initial combination therapy with metformin (2000 mg) plus pioglitazone (45 mg) and exenatide 10 µg BID (triple therapy) or sequential addition of metformin followed by sulfonylurea and insulin (conventional therapy) to maintain HbA1c < 6.5%. Subjects were seen every 3 months for follow-up visits and at 2 years all baseline measurements were repeated. Liver fibrosis scores that were calculated included AST/ALT ration, APRI, FIB-4 and NFS.

RESULTS:

Baseline characteristics are listed in Table 1; patients were well matched. Liver fibrosis scores at baseline and at 2 years are listed in Table 2. To compare the effect of each therapy on liver fibrosis scores, the ratio between the 2-year values of liver fibrosis scores to the baseline values was compared amongst the two treatment groups with ANOVA. Both therapies significantly reduced liver fibrosis scores but no significant difference was noted between the two treatment arms.

CONCLUSION:

In this randomized trial in patients with new-onset T2D, good control of HbA1c was associated with reduction in liver fibrosis scores at 2 years but the use of pioglitazone and GLP1 agonist did not have an added benefit over conventional therapy. The effects of longer duration of treatment are currently being evaluated in addition to assessment of fibrosis by Fibroscan and MR elastography.
1049 The Palliative Performance Scale Among Patients Evaluated for Liver Transplantation
Authors: Duffey Katherine , Amin Avani , Nahar Ritu , Shen Katie , Shah Mital , Guirguis Shady , Halegoua-DeMarzio Dina
Published: October 2019

INTRODUCTION:

Patients being evaluated for liver transplantation (LT) often suffer from poor health-related quality of life. While several quality measures exist for palliative care in cancer patients, there are limited cirrhosis-specific palliative care tools. The Palliative Performance Scale (PPS) is a prognostication tool that measures a patient’s functional status based on ability to ambulate, activity level, evidence of disease, self-care abilities, oral intake, and level of consciousness, where a patient with a PPS of 100% is functionally healthy. We aim to observe how PPS at initial transplant evaluation relates to patient demographics, decompensation, and transplant outcomes to establish its potential role in the LT population.

METHODS:

We examined the records of patients who completed LT evaluation at our mid-size liver transplant center. Between March and December 2018, we calculated the PPS as a part of new outpatient LT evaluations. Descriptive statistics were used to evaluate relationships between patient PPS scores and MELD, disease characteristics, and outcomes.

RESULTS:

Forty-nine patients completed LT evaluation, of which 71% (N = 35) were male and 80% (N = 39) were white. The average age at the time of evaluation was 63. The most common etiology of cirrhosis was NASH (35%, N = 17), followed by alcohol (29%, N = 14), and HCV (25%, N = 12). Among the three most common etiologies, those with alcoholic cirrhosis had the lowest average PPS scores (76), patients with HCV had the highest (90). During the study period, 8 patients were transplanted. Their average PPS at the time of evaluation was 76 compared to 80 among those who were not transplanted. When compared to men, women had a higher MELD (15 vs 13), and lower PPS (74 vs 82). The rates of decompensation among patients with a PPS of 100, 80, and 70 were 55%, 86%, and 93%, respectively.

CONCLUSION:

This pilot study examines the utility of PPS for patients undergoing LT evaluations, and several trends were elucidated warranting further evaluation. There was not a clear linear relationship between MELD and PPS, indicating that patients with end-stage liver disease have a variable symptom burden even at advanced disease states. The functional status of patients appeared to vary significantly between etiology, gender, and transplantation. Importantly, our data suggests that patients with documented decompensations had lower PPS, indicating a possible role for the PPS to better characterize the functional status and disease burden of these patients.
1051 Association Between Vitamin D Deficiency and Nonalcoholic Fatty Liver Disease (NAFLD)
Authors: Baidoun Firas , Sarmini Muhammad Talal , Alkhadra Yasser , Khoudari George , McCullough Arthur J.
Published: October 2019

INTRODUCTION:

Nonalcoholic fatty liver disease (NAFLD) is the leading cause for chronic liver disease in western countries and a major leading cause of morbidity and mortality in the United States. Vitamin D deficiency has been associated with obesity,diabetes mellitus and metabolic syndrome, all of which are risk factors for NAFLD. The goal of this study was to investigate the association between vitamin D deficiency and NAFLD using a large inpatient date base.

METHODS:

By using the data from the National Inpatient Sample (NIS) database between 2002 and 2014, we identified the patients with the diagnoses of vitamin D deficiency and NAFLD using the International Classification of Diseases 9th version codes (ICD-9). The control group was the patients without vitamin D deficiency using the ICD-9 codes. We performed multivariate logistic regression analysis to calculate the association between vitamin D deficiency and NAFLD.

RESULTS:

The study had total 101,137,145 patients. The vitamin Ddeficiency group had 339,418 patients (0.34%). We noticed that patients with vitamin D deficiency were older (63 vs 48), and more likely to be African American (17% vs 14%) and female (67% vs 58%) (P < 0.001 for all). The vitamin D deficiency group also had more patients with obesity (16% vs 7%), hyperlipidemia (34% vs 13%), hypertension (59% vs 36%) hypothyroidism (19% vs 8%) uncomplicated diabetes mellitus (21% vs 14%) and chronic diabetes mellitus with complications (8% vs 3%) (P < 0.001 for all). Using Multivariate logistic regression, and after adjusting for potential cofounding factors, patients with vitamin D deficiency had a statistically significant higher rate of NAFLD (Odds Ratio [OR], 2.946, 95% confidence interval [CI], 2.859 -3.036, P < 0.001) compared with patients without vitamin D deficiency.

CONCLUSION:

Based on our study we found that patients with vitamin D deficiency have three times higher risk of having NAFLD compared to patients without vitamin D deficiency. These data emphasize the importance of screening for vitamin Ddeficiency in NAFLD patients. Further studies are needed to assess the role of vitamin D supplement in NAFLD progression.
1058 Real World Effectiveness and Safety of Glecaprevir/Pibrentasvir in Adults With Chronic Hepatitis C Virus Infection: A Meta-Analysis
Authors: Cornberg Markus , Negro Francesco , Lampertico Pietro , Turnes Juan , Curry Michael P. , Brown Ashley , Wedemeyer Heiner , Carrion Jose A. , Wick Nicole , Pangerl Andreas , Larsen Lois , Yu Yao , Persico Marcello
Published: October 2019

INTRODUCTION:

Glecaprevir/pibrentasvir (G/P) is approved for adults infected with hepatitis C virus (HCV) genotypes 1–6. In clinical trials, G/P was associated with high rates of sustained virologic response at post-treatment Week 12 (SVR12) and was well tolerated. Currently, real-world evidence (RWE) regarding G/P use is being collected. A systematic review and meta-analysis of RWE reporting the effectiveness and safety of G/P were undertaken.

METHODS:

Biosis, Derwent Drug File, Embase®, International Pharmaceutical Abstracts, Medline®, and SciSearch databases were searched using pre-defined terms for “G/P” and “RWE” to identify real-world prospective/retrospective studies (1 January 2017‒15 October 2018) that reported SVR12 and/or safety parameters in HCV-infected adults (N ≥ 20) treated with G/P. Congress presentations up to 12 November 2018 were included. Random effects meta-analysis was used to determine SVR12 and naïve pooling for adverse event (AE) rates. Intention-to-treat (ITT) SVR12 analyses included all patients dosed with G/P; modified ITT (mITT) excluded those who had non-virologic failure.

RESULTS:

10,048 adults treated with G/P in 16 studies were included; ITT SVR12 rates were reported in 14 studies and mITT SVR12 rates in 11 studies. SVR12 rates overall and by subgroups based on ITT and mITT populations are shown (Table 1). AEs were summarised in 6 studies and reported in 12.7% (724/5685) of patients. Treatment discontinuations due to AEs were summarised in 5 studies and reported in 0.5% (24/4508) of patients. The most frequent AEs were pruritus (4.7%; 126/2698), fatigue (4.4%; 146/3305), and headache (2.7%; 102/3759). SVR12 and safety data will be updated in the final presentation.

CONCLUSION:

Consistent with results observed in clinical trials, RWE indicates that G/P is a well-tolerated and highly effective pangenotypic treatment option for a broad range of HCV-infected patients.
1061 Gender Differences in Characteristics of Hospitalized Patients With Cirrhosis: A Prospective Multicenter Inpatient Cohort Study
Authors: Rubin Jessica B. , Srisengfa Yanin , Albhaisi Somaya , Acharya Chathur , Nangia Gayatri , Shaikh Tahira , Thacker Leroy R. , Reddy Rajender , Tandon Puneeta , Bajaj Jasmohan S. , Lai Jennifer C.
Published: October 2019

INTRODUCTION:

Women with cirrhosis listed for liver transplant have increased waitlist mortality compared with men, but the reasons for this disparity is not well-established. We hypothesized that women with cirrhosis have different comorbidities and reasons for hospitalizations than men - and explored this hypothesis in a large, multi-center cohort of inpatients with cirrhosis.

METHODS:

Our cohort included patients with cirrhosis hospitalized non-electively, prospectively enrolled at 4 academic medical centers 1/2013-2/2017. Data collected included comorbidities, reasons for admission, cirrhosis complications, medications, hospital course, and outcomes. Readmission and mortality rates were compared between women and men using logistic regression.

RESULTS:

Of the 674 hospitalized patients with cirrhosis, 256 (38%) were women. Median age was 56 years; 75% were non-Hispanic White. Women were less likely than men to have cirrhosis from alcohol (34% vs 26%, P < 0.001), and more likely to have NASH (22% vs 15%, P < 0.001). Women and men had similar cirrhosis complications, liver-related medications, MELD (20 vs 20, P = 0.36), and Child-Pugh (9 vs 10, P = 0.36) scores. Women were more likely to have certain non-liver related comorbidities, including insulin-dependent diabetes (23% vs 14%, P = 0.002) and connective tissue disease (4% vs 1%, P = 0.004), as well as to require non-opiate pain medications (14% vs 7%, P = 0.008) or antidepressant/sleep aids (38% vs 28%, P = 0.005). Overall infection rates on admission were similar between women and men (27% vs 22%, P = 0.19), but women were more likely than men to have UTIs (14% vs 4%, P < 0.001) and less likely to have SBP (6% vs 11%, P = 0.04). Rates of other decompensating events were similar between women and men, including GI bleeding, renal dysfunction, and volume overload (P for all > 0.05). There were no differences between women and men in 30d (11% vs 13%, P = 0.60) or 90d (22% vs 27%, P = 0.18) mortality. In logistic regression, female gender was not associated with increased 30d mortality (OR 0.88, 95% CI 0.54-1.43, P = 0.60) or 90d readmission (OR 1.06, 95% CI 0.75-1.48, P = 0.76).

CONCLUSION:

Although women and men hospitalized with cirrhosis have similar severity of liver disease, they differ by their etiologies of cirrhosis, non-liver related comorbidities, infectious complications, and patterns of medication use. Future studies should further explore the role that these non-liver-related factors play in contributing to well-established gender disparities in waitlist outcomes.
1064 Influenza in Cirrhosis Patients: A Multi-Year Nationwide Analysis
Authors: Aloreidi Khalil , Maddika Srikanth , Then Eric O. , Culliford Andrea , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Influenza is an acute and usually self-limited febrile respiratory illness. However, it is associated with increased morbidity and mortality in certain high-risk populations including patients with liver disease. Interestingly, the data on this group has been always limited.

METHODS:

The Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (2010-2014) was used for this analysis. Using with International Classification of Diseases, Ninth Revision, Clinical Modification codes (ICD-9-CM), the patients with a primary discharge diagnosis of influenza were identified. Similarly, the patients with a secondary discharge diagnosis of cirrhosis were identified. Our primary outcome is to assess the effect of cirrhosis on inpatient mortality among patients who were admitted with influenza. Our secondary outcomes include the length of stay and hospitalization charges. Categorical variables were compared using the chi-square test, and continuous variables were compared using Student t-test. All P values were 2 sided, with .05 as the threshold for statistical significance. All analysis was performed with SPSS 25 (IBM, USA).

RESULTS:

There were 36,680 discharges with a primary diagnosis of influenza between 2010 and 2014; 444 of these discharges (1.2%) have a secondary diagnosis of cirrhosis. Patients with influenza with and without Cirrhosis had comparable mean age, sex, and race (Table 1). Cirrhosis among patients with Influenza was associated with a higher mortality rate of 5% compared to 1.8% in patients without cirrhosis (OR 2.85, 95% CI 1.85 to 4.41, P < 0.0001). There was a minor increase in mean length of stay in influenza patients with a history of cirrhosis compared to non-cirrhotics (5.26 days vs 4.48 days, P < 0.0001). The mean hospitalization cost was significantly higher in influenza patients with cirrhosis ($45059.66 vs $32421.75, P < 0.0001). After adjustment for patient characteristics on a multivariable analysis (Table 2), cirrhosis was independently associated with higher mortality among patients with influenza (OR 3.09, 95% CI 1.99 to 4.78, P < 0.0001).

CONCLUSION:

Among the patients who were admitted with influenza, cirrhosis was associated with nearly three times higher mortality compared to non-cirrhotics. The mean length of stay and mean hospitalization cost were also higher in patients with cirrhosis.
1066 Effectiveness of a Nurse-Led Fibroscan Service Towards Enhanced Care in Liver Disease
Authors: Bhandare Anirudh P. , Kendrick Lynne , Coulter Diane , Nadeem Muhammad Iftikhar I.
Published: October 2019

INTRODUCTION:

Fibroscan as a convenient, non invasive tool for classification of Liver Stiffness (KPA) and fat component (CAP) has gained popularity in the hospital as well as community health services .With burden of liver disease significantly affecting the NHS in terms of finances as well as mortality, an accurate measure of the liver parenchyma assists in delivery of safe enhanced care.We present our nurse led fibroscan service in comparison to conventional modalities in the management of liver disease.

METHODS:

273 patients were referred to the Nurse led Fibroscan service from July 2017-18.The Fibroscan readings were then compared to the USS, biochemistry and liver biopsy results. British Society of Gastroenterology(BSG) guidelines were then used to manage these subjects.

RESULTS:

Out of 273 patients referred 30 were excluded due to difficult procedures. Out of 243 screened, 52.68% were female.An average age of 53.9 years was seen (Median 55,IQR 19).The Fibroscan results were classified based on KPA and CAP for different etiology.Mean ALT of 49.22 was seen. Fibroscan results showed , Normal 9.87% ,Fatty Liver = 50.2%,Fibrosis = 22.2%and Cirrhosis 17.69% and compared to USS. Of the 48 subjects with Normal USS, 22 showed fatty liver, 9 had fibrosis and 2 had cirrhosis on fibroscan showing a 68.75% variance in diagnosis indicating a worsening stage of liver disease. Of the 123 that had fatty liver on USS,81 had the same diagnosis on fibroscan too.There was variance in 34.14% with 3 showing a better diagnosis having Normal fibroscan and 23 and 16 subjects showing fibrosis and cirrhosis respectively, indicating a worsening diagnosis. As Per BSG guidelines, fatty liver disease and ALT of below 50 can be discharged back to the care fo GP. 51.2% of these patients were similarly discharged to the GP. 70 subjects had Cirrhosis on USS 45 had a better diagnosis indicating the variance to be 50%. The total variance in diagnosis was noted in 122 (50.2%) from USS to fibroscan, with 41% (n = 50)having a better stage and 72 (59%) showing worse stage of disease. 44 of these subjects underwent liver biopsies which correlated to the above findings in similar percentage.

CONCLUSION:

Nurse led fibroscan service shows effective monetary benefit in good enhanced care of liver disease. It gives a more accurate diagnosis as compared to USS and also helps in avoiding the invasive liver biopsy in majority of the cases. Utilised in a correct manner it can help in appropriate care of the liver disease patients.
1071 Awareness and Barriers to Hepatitis C Screening for Baby Boomers in Internal Medicine Training: A Nationwide Survey
Authors: Khan Ahmad , Cipriani Allison , Kim Jin A. , Singh Shailendra
Published: October 2019

INTRODUCTION:

World Health Organization has determined a goal of 65% reduction in Hepatitis C Virus (HCV) related mortality by 2030. Baby Boomers, born between 1945 to 1965, comprises two-thirds of patients with HCV in the United States (US). Despite one-time screening recommendation by CDC and USPTF, HCV screening remains low in this age group. There is no available data to determine the adherence and awareness of HCV screening in internal medicine (IM) training programs for this birth cohort. The objective of this study was to assess adherence, awareness, and barriers to hepatitis C screening among IM residents.

METHODS:

An electronic medical record query was made for HCV screening in patients, born between 1945 to 1965, and seen in IM resident continuity clinics from January 2018 to June 2019. Later, a national survey of the IM residents was conducted to assess the awareness and barriers to HCV screening. A convenience-based sampling method was adopted, and we created a 15-item survey instrument on REDCaP that was disseminated to residents by reaching out to their program directors/coordinators through email.

RESULTS:

A total of 1207 patients with mean age 62.2 years, and 49% of females met inclusion criteria; however, only 63 patients (4.9%) had their HCV status tested. In contrast to that, the results from 186 survey respondents showed that 73.7 % of residents are familiar with CDC recommendation to screen baby boomers for HCV. The respondents estimated to provide care to a mean of 54 ± 17 patients from this cohort per year in their continuity clinics. The participants also identified that patients who undergo screening; only 36% understands the purpose of the testing. Notably, survey respondents stated that 9.4% of patients associate HCV testing with IV drug use, suggesting potential stigmatization with testing. Most common barriers identified in the survey are knowledge gap (51.76%) at either patient or provider end, lack of EMR alerts (11.76%) and time constraints (9.4%) due to increased patient load, or complexity of the patients’ comorbidities. Nevertheless, 61% of the participants suggested that providers need more education and awareness about HCV screening in baby boomers.

CONCLUSION:

Adherence and awareness of HCV screening among Baby Boomers in IM residency training are low. There is a need to increase awareness and overcome these barriers to improve HCV testing in this vulnerable population.
1072 Rates and Predictors for Readmission in Decompensated Cirrhosis at a Large Rural Tertiary Care Hospital
Authors: Khan Ahmad , Sohail Abdullah , Cipriani Allison , McDaniel Bryce A. , Farooq Junaid , Chowdhry Monica , Kemper Suzanne , Singh Shailendra
Published: October 2019

INTRODUCTION:

Decompensated cirrhosis (DC) is an organ failure state associated with multiorgan involvement. Patients with cirrhosis are frequently readmitted, accounting for a significant portion of the billions of dollars spent annually in hospitalization for chronic liver disease. Various studies involving North American cohorts have reported a varied range of readmissions rates and predictors depending on the location and type of hospital. This study aimed to determine the rates of readmission and validate the predictors of 30 and 90-day readmission at a large rural tertiary care hospital with no liver transplant or hepatology service.

METHODS:

A retrospective chart review of patients with DC discharged from September 2016 to September 2018 was conducted. Patients with DC were identified through ICD- 10 codes listed as primary or secondary discharge diagnosis. Patient demographics, laboratory values, and disease-related risk factors were recorded. Primary outcomes were a 30- and 90-day inpatient readmission. We used multivariate logistic regression to determine predictors of readmission at 30 and 90-days.

RESULTS:

A total of 300 patient charts were selected randomly from a sample of 1500 identified through ICD codes. A total of 180 patients that met the inclusion and exclusion criteria were included for analysis. Mean age of the patients was 60.0 ± 11.8 years and 56.74 %were males. The most common etiology for cirrhosis was alcohol use (42.22%), and the mean MELD-Na score was 17 ± 11.8. Mean length of stay was 7 ± 6.6 days. The 30-day and 90- day readmission rate was 28% and 40% respectively. On multivariate analysis, GI bleed, (OR 8.5, 95% CI 2.7-27.2, P = 0.0003), infection, (OR 8.7, 95% CI 2.0-36.6, P = 0.0003) and electrolyte imbalance, (OR 6.6, 95% CI 1.8-24.6, P = 0.0005) were found to be independent predictors of readmission.

CONCLUSION:

Decompensated cirrhosis is associated with high rates of early and late readmissions at a large rural tertiary care hospital with no liver transplant or hepatology service. The predictors for readmission were also unique. Readmission rates and predictors should be reassessed locally so that structured interventions explicitly targeting the local hospital or region can be taken to prevent these readmissions.
1087 Women and Ethnic Minorities With Alcoholic Hepatitis in the United States Are More Likely to Be Hospitalized in High Safety Net Burden Hospitals
Authors: Ladhani Sanah , Hirode Grishma , Singal Ashwani , Wong Robert
Published: October 2019

INTRODUCTION:

Recurrent hospitalizations due to alcoholic hepatitis (AH) contribute to significant morbidity, mortality, and economic burden. Underserved safety-net populations and ethnic minorities are disproportionately affected by recurrent AH hospitalizations. We aim to evaluate the impact of a hospital’s safety-net burden (SNB) on in-hospital mortality using a large U.S. inpatient database with a focus on ethnicity-specific disparities.

METHODS:

We retrospectively evaluated the 2012-2014 National Inpatient Sample database, the largest publicly available all-payer inpatient healthcare database in the U.S., to evaluate the impact of hospital SNB on in-hospital mortality among adults with AH. Hospital SNB was defined as the percentage of AH hospitalizations per hospital with Medicaid or uninsured payer status and was categorized into 3 groups (low SNB-lowest quartile, medium SNB-2nd and 3rd quartile, high SNB- 4th quartile). AH hospitalizations were identified using ICD-9 codes. Sex- and ethnicity-specific differences by SNB were evaluated with chi-squared testing. The odds of being hospitalized at a high SNB hospital (vs. low/medium) and the impact of SNB on in-hospital mortality were evaluated using adjusted multivariate logistic regression.

RESULTS:

Among 12,519 AH-related hospitalizations (63.2% male, 66.9% non-Hispanic white, 9.9% African American, 11.8% Hispanic), 30.6% were low SNB, 46.3% were medium SNB, and 23.0% were high SNB. Compared to men with AH, women were significantly more likely to be hospitalized at high SNB hospitals (24.1% vs. 22.4%; OR 1.13, 95% CI 1.03-1.25, P < 0.01). Compared to non-Hispanic whites, African Americans (29.6% vs. 21.1%; OR 1.31, 95% CI 1.10-1.57, P < 0.001) were significantly more likely to be hospitalized at a high SNB hospital, and Hispanics demonstrated a trend towards more likely to be hospitalized at a high SNB hospital (29.2% vs. 21.1%; OR 1.18, 95% CI 0.99-1.42, P = 0.067). Overall in-hospital mortality among AH-related hospitalizations was 2.63%. On multivariate regression, there was a trend towards higher odds of in-hospital mortality for AH-related hospitalizations at high SNB hospitals vs. low/medium SNB hospitals (2.78% vs. 2.58%; OR 1.41, 95% CI 0.95-2.08, P = 0.09).

CONCLUSION:

Among hospitalized adults with AH in the U.S., women and ethnic minorities were significantly more likely to be cared for at high SNB hospitals. High SNB hospitals demonstrated a trend towards higher in-hospital mortality for AH patients.
1098 Rapid Fire Hepatology: A Pilot Study of a Near-Peer, Speed-Teaching Hepatology Curriculum on a Dedicated Inpatient Liver Service
Authors: Goldowsky Alexander , Ardolino Eric , Patwardhan Vilas
Published: October 2019

INTRODUCTION:

Near-peer teaching, trainees educating other trainees, is a valuable form of teaching in residency, valued equally or greater to faculty-led sessions. While resident teaching has been shown to improve clinical performance, concern exists over this type of education encroaching on clinical duties. Our study seeks to determine whether a resident-led, speed-teaching hepatology curriculum leads to improvement in resident comfort with independent management and teaching of core hepatology topics.

METHODS:

PGY2&3 residents at an academic liver transplant center received teaching scripts based on published practice guidelines to lead 15-minute teaching sessions on 8 hepatology topics. The curriculum was given to interns and residents (4 per month) over 4 weeks. Anonymous pre- and post-rotation surveys assessing comfort with independent management and teaching on these topics were performed (Likert scale 1-5). Statistical analysis used independent sample T-tests of pre- and post-rotation survey responses.

RESULTS:

A total of 18 residents completed the pre- and post-intervention surveys (N = 11 PGY1, N = 7 PGY2/3). In the intervention cohort, there was significant improvement in comfort with independent management and teaching of all topics between the pre- and post-intervention surveys (all P < 0.05) (Table 1). Post-intervention respondents, including PGY1 and 2 residents, showed no difference in comfort with independent management of core topics compared to graduating PGY3s who did not have the intervention, with the exception of hyponatremia, which graduating residents felt more comfort managing (4.32 vs 3.56; P = 0.03). In addition, the post-intervention group felt more comfort than graduating residents teaching on hepatorenal syndrome (4.11 vs 3.38; P = 0.02) and trended towards increased comfort teaching on post-liver transplant complications (2.89 vs 2.08; P = 0.0502) (Table 1).

CONCLUSION:

Our study shows a near-peer resident-led speed-teaching hepatology curriculum is feasible to implement on a busy hepatology inpatient service and leads to improvement in comfort in independently managing and teaching on core hepatology topics. We also found a mixed resident group including PGY1-2s reported comfort with teaching and management similar to that of graduating residents, suggesting that our near-peer curriculum may lead to more rapid knowledge acquisition and trainee confidence with hepatology.
1101 Study of Outcomes of Nephrectomy in Cirrhotic Patients: A National Analysis From a Large Database
Authors: Vedachalam Srikanth , Porter Kyle , Li Na , Kelly Sean , Conteh Lanla , Hanje James , Michaels Anthony , Black Sylvester , Mumtaz Khalid
Published: October 2019

INTRODUCTION:

Nephrectomy is the definitive treatment of the 9th most common cancer- renal cell carcinomas (RCC). Outcomes of various elective surgeries in patients with cirrhosis depends on its stage-compensated cirrhosis (CC) or decompensated (DC). Small-scale studies have reported nephrectomy to be safe in patients with CC. We studied the 30 day readmission rates and its predictors in cirrhotic patients undergoing nephrectomy. We also studied the index and calendar year mortality and their predictors in the cirrhotic patients.

METHODS:

The National Readmission Database (NRD) was queried using ICD-9 codes to identify 158,443 non-cirrhotic (NC), 942 CC and 212 DC who underwent total or partial nephrectomies, open or laparoscopically from 2010-2014. DC was identified by Baveno IV criteria. Patient demographics, Elixhauser comorbidity index, hospital characteristics, and extent and approach of nephrectomy were collected from the NRD.

RESULTS:

Thirty-day readmission rates were significantly higher in DC (18.3%) compared to NC patients (7.5%), P < 0.001; it was elevated in CC (11.2%) compared to NC (P = 0.28). Predictors of 30-day readmission were DC (OR: 7.12 versus NC; CI: 4.09-12.38) followed by Elixhauser Comorbidity ≥3 (OR 2.94, Cl: 2.77-3.12), Medicare insurance (OR 1.76 versus private insurance, Cl 1.59, 1.95), and open surgery (OR 1.64, Cl 1.49-1.80). Index and calendar year morality were higher in cirrhotics as compared to NC; CC (OR: 3.80; CI:1.86-7.74) and DC (OR: 7.91; CI: 3.30 -18.92) were the main predictors of morality at index admissions. However, only DC (OR: 3.62; 1.26-10.40) had significant increased risk of calendar year mortality compared to NC. CC (80.9%) and DC (85.8%) were more likely to be treated at metropolitan teaching hospitals as compared to NC (64%).

CONCLUSION:

Patients with DC undergoing nephrectomy had seven times the odds of 30-day readmission as compared to NC suggesting increased healthcare utilization. DC increased the odds of early readmission and presence of cirrhosis (CC or DC) increased index admission mortality, despite being predominantly managed at metropolitan teaching units where expertise with cirrhotics is greater. Increased attention to medical optimization and surgeon awareness of inherent risks in patients with cirrhosis undergoing nephrectomy is required to improve outcomes.
1104 Low Rates of Hepatitis A Virus, Hepatitis B Virus, and Hepatitis C Virus Screening Among Adults With Nonalcoholic Fatty Liver Disease at an Ethnically Diverse Safety Net Health System
Authors: Mendoza Brian , Ohikere Kabiru , Liu Benny , Bhuket Taft , Wong Robert
Published: October 2019

INTRODUCTION:

Screening for viral hepatitis among adults with nonalcoholic fatty liver disease (NAFLD) is important to evaluate for possibility of concurrent infection and to assess for opportunities to appropriately vaccinate for hepatitis A virus (HAV) and hepatitis B virus (HBV). We aim to assess viral hepatitis screening rates and rates of susceptibility to viral hepatitis due to lack of immunity among NAFLD patients at an ethnically diverse safety-net health system.

METHODS:

We retrospectively evaluated adults with confirmed diagnosis of NAFLD from August 1, 2017 to April 1, 2019 at a single-center safety-net hospital to determine rates of screening for HAV, HBV, and hepatitis C virus (HCV). HAV and HBV immunity was determined by reactive HAV IgG and reactive HBV surface antibody (HBsAb), respectively. HCV exposure was determined with reactive HCV antibody (HCV Ab). Viral hepatitis screening rates and rates of susceptibility (lack of demonstrated immunity) among those tested were compared using chi-squared testing.

RESULTS:

Among 325 NAFLD patients (67.0% women, mean age 53.3 ± 12.6, 58.3% Hispanic), 25.3% had advanced fibrosis at time of diagnosis. Overall, only 26.9% had prior HAV screening, among which 91.9% demonstrated immunity and 8.1% remained susceptible. 33.1% had prior HBV screening, among which 27.1% demonstrated immunity and 70.8% remained susceptible. 31.5% received prior HCV screening, among which 7.8% had concurrent chronic HCV infection. Compared to women with NAFLD, men were significantly more likely to have received HAV screening (35.2% vs. 28.7%, P < 0.01), HBV screening (40.7% vs. 35.1%, P < 0.01), and HCV screening (41.8% vs. 31.9%, P < 0.01). Compared to NAFLD patients without advanced fibrosis, there was a trend towards higher rates of having received screening for HAV (50.0% vs. 36.2%, P = 0.09) and HCV (56.0% vs. 40.5%, P = 0.06) in NAFLD patients with advanced fibrosis. No race/ethnicity-specific differences in viral hepatitis screening were observed.

CONCLUSION:

Among an ethnically diverse safety-net health cohort of NAFLD patients, less than one-third of adult NAFLD patients had evidence of receiving prior viral hepatitis screening. Among those previously screened, more than 70% remained susceptible to HBV infection and were in need of vaccination. These data highlight the need for greater education and awareness of appropriate viral hepatitis screening and vaccination for those not immune among patients with NAFLD.
1111 Clinical Significance of Isolated Gastric Varices in Liver Cirrhosis Patients: Re-Visited the Unsolved Problem
Authors: Lesmana Cosmas Rinaldi A. , Kalista Kemal F. , Sandra Sharon , Lirendra Mutiara , Aprilicia Gita , Hasan Irsan , Sulaiman Andri S. , Kurniawan Juferdy , Jasirwan Chyntia O. , Nababan Saut H. , Gani Rino
Published: October 2019

INTRODUCTION:

Gastric varices (GV) presents in 10-30% of liver cirrhosis patients with mortality rate up to 45%. Isolated gastric varices rupture is less frequent than esophageal varices (EV) rupture, but the hemorrhage is often more severe, more difficult to control, and have higher risk of recurrent bleeding and mortality. However, there are still debatable and no clear consensus yet about optimal management especially for incidentally discovered IGV.

METHODS:

This was a cohort retrospective endoscopy database study at Dr. Cipto Mangunkusumo National General Hospital from 2016 until 2017. All liver cirrhosis (LC) patients’ database who underwent upper GI endoscopy were included. Patients without the presence of varices, patients with malignancy or uncomplete database were excluded. Patients’ characteristic including MELD score, and Child Pugh score were collected for data analysis. Data analysis was performed using IBM SPSS version 23 for Windows.

RESULTS:

Of 328 patients, there were 153 patients that can be included in this study with the mean age 51 years old. The most prevalent etiology of liver disease is hepatitis B virus. Child Pugh (CP) A was found in 74 (48.36%) patients, CP B was found in 53 (34.64%) patients, and CP C was found in 26 (16.99%) patients. Isolated GV (IGV) was found in 13 (8.49%) patients, meanwhile esophageal varices (EV) found in 112 (73.20%) patients, and both (Gastroesophageal Varices/GOV) in 28 (18.30%) patients. CP C, GV and EV were found to be independent risk factors for variceal bleeding. CP C is still the strongest independent risk factor for variceal bleeding occurrence in bivariate (HR: 10.21, 95% CI:4.15-25.12 P .001) as well as in multivariate analysis (HR: 12.49, 95% CI: 4.95-31.54 0 0.001), whereas the presence of GOV is an independent risk factor associated with bleeding incidence in bivariate analysis (HR: 2.51, 95% CI: 1.26-4.99 P .009) as well as in multivariate analysis (HR: 2.95, 95% CI: 1.40-6.19 P .004) but not IGV. However, CP C score is still the only significant risk factor associated with survival liver cirrhosis patients based on multivariate analysis (HR: 26.77 95% CI: 6.01-119.34 P .001).

CONCLUSION:

The concern of high potential of bleeding occurrence in the presence of IGV sometimes give a clinical dilemma regarding the potential risk and side effect of endoscopic therapy for IGV. Our study results showed that the presence of IGV is not the strongest risk factor for bleeding occurrence as well as patient's survival.
1116 The Role of Perioperative Transjugular Intrahepatic Portosystemic Shunt in Cirrhotic Patients Undergoing Extrahepatic Surgery
Authors: Castillo Michael , Kapila Nikhil , Wakim-Fleming Jamile
Published: October 2019

INTRODUCTION:

The use of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the perioperative period in cirrhotic patients with portal hypertension has been limited to small case series. The aim of this study is to describe a multi-center experience with the use of TIPS prior to abdominal surgery in patients with cirrhosis and portal hypertension.

METHODS:

In a retrospective multi-center case-matched study, we compared outcomes between patients with cirrhosis who received TIPS prior to abdominal surgery and patients who did not. Patients with liver transplantation were excluded. All patients had ascites and were matched 1/1 for same surgical procedure and for similar Model for End Stage Liver Disease (MELD) score. Outcomes evaluated included MELD scores at 30- and 180-day post-surgery, bleeding varices, development of hepatic encephalopathy, medical and surgical complications, 30- and 180-day mortality, length of hospital stay, and 30-day readmission rate. Statistical significance was determined using a paired t test and Fischer’s exact test.

RESULTS:

There were 14 patients in each group. In each group, 5 patients (35.7%) underwent colorectal surgery and the remainder underwent umbilical hernia repair. The majority of patients in both cohorts had advanced cirrhosis as characterized by their pre-operative Child Pugh score B and C. TIPS was performed an average of 18.4 days prior to surgery. In the post-operative period, 4 patients with TIPS had ascites compared to 12 patients without TIPS (P = 0.006). Post-operative hepatic encephalopathy and esophageal variceal bleeding were more common in the non-TIPS cohort. Length of stay was 11.4 days in TIPS patients and 6.6 days in non-TIPS patients (P = 0.19). Five TIPS patients (35.7%) were re-admitted within 30-days compared to 7 non-TIPS patients (50%) (P = 0.7).

CONCLUSION:

Our study indicates that preoperative TIPS significantly improved ascites post TIPS in cirrhotic patients with portal hypertension in comparison with patients who did not receive TIPS. Our study also shows improvement although not statistically significant in 30- and 180-day MELD scores, incidence of esophageal variceal bleeding, incidence of hepatic encephalopathy, post-operative medical and surgical complications, and 180-day mortality. TIPS did not improve length of stay or readmission rates. TIPS appears to have a role in patients with cirrhosis however further studies are required to better characterize the potential benefit of TIPS in the perioperative period.