bluuebunny/crossref_metadata_2025 huggingface dataset:
1063 Clostridioides difficile Infection in Liver Cirrhosis: A Multiyear Nationwide Analysis
Authors: Aloreidi Khalil , Barakat Mohamed , Ramai Daryl , Xie Chencheng , Aamar Ali , Reddy Madhavi
Published: October 2019

INTRODUCTION:

For the past two decades, the incidence and severity of Clostridium Difficile Infection (CDI) have been increasing. Many risk factors have been identified in an effort to explain this phenomenon including broad-spectrum antibiotic therapy, prolonged hospitalization, immunosuppression, multiple comorbidities, and use of proton pump inhibitors (PPIs). Interestingly, all these factors occur frequently in patients with liver cirrhosis.

METHODS:

The Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (2010-2014) was used for this analysis. Patients discharged with a diagnosis of cirrhosis and CDI were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes (ICD-9-CM). Our primary outcomes were the prevalence of CDI and the effects of CDI on inpatient mortality. Our secondary outcomes were 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. The analysis was performed with SPSS 25 (IBM, USA).

RESULTS:

Over the study period, a total of 738,199 patients with liver cirrhosis were identified. Among those, 15,791 had CDI. Cirrhosis patients with CDI and Cirrhosis patients without CDI had comparable mean age, sex, and race (Table 1). The prevalence of CDI was 2.1% among the cirrhosis population compared to 1.1% in the non-cirrhosis population with unadjusted OR of 1.95 (95% CI 1.92 to 1.98, P < 0.0001). CDI among patients with cirrhosis was associated with a higher mortality rate of 12.1% compared to 6.7% in cirrhosis-only patients (OR 1.91, 95% CI 1.82 to 2, P < 0.0001). The mean length of stay was higher in cirrhosis patients with CDI compared to cirrhosis-only patients (12.79 days vs 6.25 days, P < 0.0001). The mean hospitalization cost was also higher in cirrhosis patients with CDI ($117661.51 vs $56241.81, P < 0.0001). After adjustment for patient characteristics on a multivariable analysis (Table 2), CDI was independently associated with higher mortality among patients with cirrhosis (OR 1.88, 95% CI 1.79 to 1.97, P < 0.0001).

CONCLUSION:

The prevalence of CDI is higher for cirrhosis patients compared to non-cirrhotics. CDI among cirrhosis patients was associated with nearly twice the mortality rate compared to cirrhosis-only patients. Similarly, the mean length of stay and mean hospitalization cost were significantly higher in cirrhosis patients with CDI.
1068 Ethnic Minorities With Primary Biliary Cholangitis in the U.S. Are More Likely to Be Hospitalized at Higher Safety-Net Burden Hospitals
Authors: Galoosian Artin , Hirode Grishma , Wong Robert
Published: October 2019

INTRODUCTION:

Primary biliary cholangitis (PBC) is a progressive cholestatic liver disease associated with significant morbidity; its progression to cirrhosis and its complications contributes to significant healthcare resource utilization. Underserved communities, which include safety-net hospital populations, represent a major contributor to healthcare costs in the US. We aim to evaluate ethnic disparities by safety-net burden (SNB) and associated hospitalization costs.

METHODS:

Using the 2012-2014 National Inpatient Sample, we evaluated US adults hospitalized with PBC (using ICD-9 codes). Hospital SNB was defined as percentage of hospitalizations with PBC with Medicaid or uninsured payer status per hospital, and was categorized into two groups: no SNB vs. any SNB. Ethnicity-specific differences by SNB were analyzed with chi-squared testing. Logistic regression was used to analyze odds of being hospitalized at a SNB hospital (vs. no SNB). Multivariate linear regression was performed after logarithmic transformation of the outcome to identify factors associated with mean hospitalization costs, inflation-adjusted to 2014 US dollars. Coefficients were exponentiated to yield percentage change associated with each predictor.

RESULTS:

Among 7,364 hospitalizations with PBC (mean age 64.0 + 14.3 years, 16.1% men, 70.3% non-Hispanic white, 11.8% Hispanic, 5.9% African-American), 65.3% were no SNB and 34.7% with higher SNB. Compared to non-Hispanic whites, Hispanics (30.5% vs 52.1%; OR: 2.49, 95% CI: 2.02-3.05, P < 0.001) and African-Americans (30.5% vs 43.3%; OR: 1.75, 95% CI: 1.38-2.21, P < 0.001) were more likely to be hospitalized at a hospital with SNB. From 2012-2014, the total estimated national burden of PBC hospitalizations was $564 million. On adjusted regression, being admitted to a hospital with SNB (vs. no SNB) resulted in higher mean hospitalization costs (9.0% higher, 95% CI: 2.7%-15.6%, P < 0.001). African-Americans had higher mean hospitalization costs compared to non-Hispanic whites (11.4% higher, 95% CI: 1.6%-22.3%, P = 0.02). Finally, larger (vs. small) and urban (vs. rural) hospitals were more likely to have higher hospitalization costs, and hospitals in the Western region (vs. Northeast) were also more likely to have higher hospitalization costs.

CONCLUSION:

Among hospitalized adults with PBC, ethnic minorities were significantly more likely to be cared for at SNB hospitals. African-Americans and Hispanics had a higher inpatient economic burden compared to non-Hispanic whites.
1070 Hip Fractures in Celiac Disease Patients: A Nationwide Analysis
Authors: Khan Ahmad , Gupta Kamesh , Sohail Abdullah , Goyal Hemant
Published: October 2019

INTRODUCTION:

Autoimmunity associated with Celiac disease (CD) has previously shown to be associated with bone health and hip fracture risk. Literature also supports supplementation of Vitamin D in celiac disease patients to increase bone mineral density. Currently, there is no US national-level study to show the risk of hip fractures in CD patients.

METHODS:

We conducted a cross-sectional study using the National Inpatient Sample (2008 to 2014). We identified patients with a primary diagnosis of HP using diagnosis codes for the neck of femur, intertrochanteric and subtrochanteric fractures or procedure codes for interventions for hip fractures including total hip replacement. The primary outcome was the total number of hospitalizations with secondary outcomes including mortality, length of stay (LOS) and total hospitalization charges. We adjusted outcomes for confounding factors such as age, gender, race, and comorbidities by the univariate and multivariate regression model.

RESULTS:

From 2008-2012, a total of 32,96,442 hospitalizations were identified for hip fractures, of which 3614 (0.1%) had associated celiac disease. CD subgroup had significantly increased number of females, Caucasians, and elderly patients but no differences were noted in the total number of comorbidities. CD + HP was more common in hospitals situated in the northeastern states than only HP group but there were no differences noted in the teaching vs nonteaching hospitals or urban vs rural hospitals. Multivariate analysis with confounding factors showed that patients with CD were more likely to have HP with OR 1.08 (95%CI: 1.003-1.18; P = 0.041). There was no significant difference in mortality or mean length of stay. Patients with CD and hip fractures had higher incidence and odds ratio of osteoporosis than non-CD patients (29% vs 13.1%, OR: 3.71, P = 0.00).

CONCLUSION:

Our study showed that patients with CD are more likely to get hip fractures which is further supported by increased prevalence of osteoporosis in these patients. However, there is no difference in terms of in-hospital mortality and hospital resources utilization in comparison to patients without CD. Our study reinforces the necessity of addressing risk of osteoporosis risk in CD patients with Vitamin D and calcium supplementation, which can likely prevent a gravely morbid event like a hip fracture.
1075 Primary Care and Specialty Physician Perspectives on Non-Alcoholic Fatty Liver Disease (NAFLD) Screening, Diagnosis, and Referral
Authors: Saeed Naba , Tincopa Monica , Mahmood Asadullah , Habbal Heba , Sengstock David , Glass Lisa
Published: October 2019

INTRODUCTION:

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in the developed world. It is associated with cardiovascular risks, malignancy and poor health-related quality of life. It is often under-recognized and undertreated by primary care providers (PCPs), leading to increased morbidity and mortality. Our study aims to assess PCP awareness of NAFLD risk factors, diagnosis and treatments, as well as their referral patterns to specialty care.

METHODS:

An anonymous provider survey was developed by 2 hepatologists, to assess PCPs’ perspectives on NAFLD disease knowledge, diagnosis, management, and referral of patients to sub-specialty care. Primary care and sub-specialty providers from Internal Medicine, Medicine-Pediatrics, Family Medicine, Geriatrics, Cardiology and Endocrinology, who spend >25% of their time in adult clinical care, were included. Descriptive statistics (means for continuous data, percentages for categorical data) were used.

RESULTS:

A total of 438 physicians completed the survey: 83 Michigan Medicine, 18 Beaumont Health and 337 ACP physicians. 99.5% physicians reported most/some of their patients likely have NAFLD, while 19% strongly agreed to the role of screening for NAFLD. Most common associated comorbidities identified by PCPs were diabetes, obesity and hyperlipidemia. Comorbidities prompting screening most often were NAFLD family history, diabetes, and obesity. Hepatic function tests and liver ultrasound were the most frequently used screening tools. Only 22.6% of providers used non-invasive serum-based staging, and 23% used fibroscan. 67% providers referred few/none of their patients to specialists, with mainly advanced fibrosis/cirrhosis patients being referred. Most common barriers to PCP NAFLD evaluation and treatment included uncertainty of NAFLD treatments (47.3%) and low priority (30.8%). 74% providers reported no change in statin prescription.

CONCLUSION:

Despite the high rates of NAFLD in primary care, the rate of NAFLD screening and referral to specialty care is surprisingly low. Additionally, non-invasive tests for staging hepatic fibrosis are underutilized, which means that high-risk NAFLD patients with advanced fibrosis are likely overlooked. Important barriers to be addressed include improving NAFLD recognition, as well as disease assessment and knowledge of NAFLD treatment. Emphasis should be placed on early referral before patients reach advanced cirrhosis.
1077 Liver Cancer in Ethiopia: Presentation, Prognosis, and Therapy
Authors: Sultan Amir , Campos Marilia , Wondifraw Zerihun , Braimoh Grace , Bane Abate , Debes Jose D.
Published: October 2019

INTRODUCTION:

Sub-Saharan Africa exposes one of the largest burdens of morbidity and mortality from Hepatocellular carcinoma (HCC). However, there is little information about HCC presentation and outcomes form the region. In this study we describe clinical characteristics and therapeutic approach to HCC in a single center in Ethiopia.

METHODS:

We retrospectively evaluated clinical charts of individuals that presented with HCC at a major referral clinic in Addis Ababa, Ethiopia from 2016 to 2018. Diagnosis of HCC was performed via biopsy or imaging criteria as established by AASLD guidelines. Survival was determined as date of last visit, and calculated in days from initial diagnosis visit. Those individuals with initial and last visit of less than seven days were removed from survival analysis. Mann-Whitney test was used for survival assessment.

RESULTS:

Forty-six cases are reported. The median age was 54 years (IQR 45-62) and 50% were females. Forty-one percent of individuals had hepatitis B (HBV) as underlying liver disease, 45% had hepatitis C (HCV) and the rest were classified as “other”. There was no association between region of origin and HBV-related HCC. Seventy-eight percent (N:36) of cases had evidence cirrhosis on presentation. Median age of HCC diagnosis was 54 years (IQR 45-62) in all patients and 48 years (IQR 19-38) in those infected with HBV. Median tumor size was 6.5cm (IQR 4.5-6.9) and median MELD score was 12 (IQR 8-17). The median survival in the entire cohort was 68 days (IQR 17-334). The most common treatment modalities were trans-arterial chemoembolization (TACE, 16%), Sorafenib (18%) and Palliative care (31%), with median survival being 351, 94 and 27 days, respectively. There was no correlation between MELD score and survival at 6 months. Twenty percent of all individuals were treated with sorafenib (N:9). Median survival in this group was 92 days (IQR 24-121), despite almost all of them having AFP >400ng/ml. Interestingly, a neutrophil-to-lymphocyte ratio (NLR) of < 2.5 correlated with better survival (109 days vs 68 days for those with NLR >2.5, P = 0.01).

CONCLUSION:

We found younger diagnosis of HCC in individuals infected with HBV. The great majority of patients received non-curative therapy. A small sub-group of individuals showed a reasonable survival benefit with sorafenib.
1078 Impact of GLP-1 Agonist Use on Non-Alcoholic Fatty Liver Disease Among Patients at a Large, Tertiary Care Center
Authors: Aggarwal Soorya , Sullivan Matthew J. , Kloska Michal , Magdaleno Angela , Perilli Gretchen , Wong She-Yan
Published: October 2019

INTRODUCTION:

Non-alcoholic fatty liver disease (NAFLD) is on target to become the leading cause of cirrhosis by 2030. The GLP-1 agonist class of medications, which are highly effective weight loss agents, may result in reducing inflammation and fibrosis in NAFLD. The aim of this study was to evaluate the effects of these medications amongst NAFLD patients.

METHODS:

This was a single center, retrospective study of NAFLD patients who had initiated a GLP-1 agonist between January 2012 and January 2018. Patient demographics, medical co-morbidities and laboratory values were obtained from the electronic medical record. Additionally, the NAFLD fibrosis score (NFS) was calculated before and after initiation of GLP-1 agonist.

RESULTS:

In total 149 patients were studied of which 45% were male and 55% were female. 78.5% of the patients were Caucasian. 60.8% of patients were on Liraglutide and all had a diagnosis of diabetes mellitus. Prior to initiation of GLP-1 agonist, 59% of patients were in the indeterminate NFS category followed by 33.6% in F3-4 and 7.4% in F0-2. Treatment lasted on average of 29.06 months (range of 5 to 80 months). After medication use, there was a statistically significant change in patient’s BMI (P = 0.018), correlating to degree of fibrosis. F3-4 patients who became intermediate stage after GLP-1 use had the largest percent change in BMI of 8.5%. In 71% of initially abnormal ALT ( >30) 17% of those patients, normalized ALT after GLP-1 agonist use. Of the 66% of patients with abnormal triglycerides ( >150), 28% normalized triglycerides after use of these medications. There was no statistically significant change in NAFLD fibrosis score after the use of GLP-1 agonist.

CONCLUSION:

In our study of fatty liver disease in diabetics, we found that over one-third of patients had severe F3-4 stage fibrosis prior to initiation of GLP-1 agonist. In this population, we showed statistically significant improvement in BMI, supporting GLP-1 agonists’ role in weight loss. Additionally, with use of GLP-1 agonist, when fibrosis stage improved, other measures of metabolic syndrome including BMI, triglycerides, and ALT also improved. Although there was no statistically significant change in NFS, this could be explained by the fact that the majority of patients had an indeterminant score prior to GLP-1 agonist use, rendering this interpretation difficult. Future investigation of histopathology with GLP-1 agonist use will help to elucidate these conclusions further.
1080 Bilirubin and QT Interval Prolongation (From the Third National Health and Nutrition Examination Survey)
Authors: Majeed Chaudry N. , Ahmad Muhammad Imtiaz , Anees Muhammad Ali , Soliman Elsayed Z.
Published: October 2019

INTRODUCTION:

The association of bilirubin with cardiovascular disease (CVD) is controversial. We sought to explore the association of total bilirubin levels with QT interval in a multiracial cohort.

METHODS:

A total of 6,627 participants (59.0 ± 13.3 years; 52.6%% women, 49.7% Non-Hispanic Whites) without cardiovascular disease (CVD) from the Third National Health and Nutrition Examination Survey (NHANES-III) were included in this analysis. QT was automatically measured from digital 12-lead electrocardiogram in a central reading center. A multivariable logistic regression model was used to examine cross-sectional association between tertiles of total bilirubin and prolonged QT interval (≥450 ms in men, ≥460 ms in women).

RESULTS:

The prevalence of prolonged QT was higher among those with higher levels of total bilirubin (prolonged QT prevalence was 4.7%, 6.8%, and 7.0% across total bilirubin lower (0-0.4 mg/dl), middle (0.5-1.6 mg/dl) and higher (0.70-4.30 mg/dl) tertiles respectively). In a model adjusted for potential confounders, participants within the highest total bilirubin tertile had significantly greater odds of prolonged QT interval (OR (95% CI): 1.53 (1.16-2.02) compared to those with bilirubin levels in the first tertile. Each 0.29 mg/dl increase in total bilirubin levels was associated with a 12% (P-value < .0001) increase in the prevalence of prolonged QT interval (Table 1). This association was stronger in men than women (interaction P-value = 0.04).

CONCLUSION::

Recent evidence suggests worse cardiovascular (CV) outcomes with high levels of bilirubin but the mechanism behind worse CV events remains to be elucidated. Our study showed that elevated bilirubin levels are associated with prolonged QT interval. QT interval has been consistently associated with increased risk of all-cause and CV death. Thus, finding an association between total bilirubin levels and prolonged QT interval in our study extends our current knowledge on the relationship between serum bilirubin and CVD by demonstrating a link between higher total bilirubin and abnormal cardiac repolarization. To the best of our knowledge, this is the first study to demonstrate the association between bilirubin and prolonged QT. This association was stronger in men than women. Future studies are needed to establish the causal relationship between bilirubin and QT prolongation and how this association between bilirubin and QT interval could be harnessed to improve CVD risk estimation.
1081 Direct-Acting Antiviral Therapy Against Hepatitis C in Patients With Liver Cancer: Is It Safe?
Authors: Kang MItchell , Jung Jeah , Kalidindi Yamini , Riley Thomas
Published: October 2019

INTRODUCTION:

The effect of direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) patients with hepatocellular carcinoma (HCC) has been controversial, as initial studies reported increasing incidence and aggressiveness of HCC post-DAA treatment with more recent literature contradicting this claim. Furthermore, questions remain regarding overall survival in this high risk population after DAA treatment, as previous studies have suffered from small sample sizes of HCC cases.

METHODS:

Data was obtained from the Medicare database on patients diagnosed with HCV and HCC in 2014, and followed for 3 years. Subjects who received DAA therapy were matched to controls based on age, gender, race, and cirrhosis. Outcomes including HCV-related costs, hospitalizations, and mortality rates were measured. Paired t-test was used for independent variables; logistic regression was used to compare outcomes between groups.

RESULTS:

1208 subjects were included in this study. 604 of these had received DAA therapy with HCC and were matched to controls who did not receive DAA therapy with HCC. Baseline characteristics were similar between groups (Table 1). The control group had a total of 445 deaths. Those who received DAA therapy had lower rates of mortality through time, with a total of 94 deaths (see Figure 1 for mortality rates through time). HCV-related hospitalizations for those who received DAA therapy significantly declined through time, with 19.5% requiring hospitalization within the first 6 months and 9.4% at 30 months (P = 0.01), whereas the hospitalization rates for the control group did not significantly change. HCV-related costs (Figure 2) also significantly declined through time for those who received DAA therapy (P = 0.02). The costs for the non-DAA therapy group did not significantly decrease (P = 0.63).

CONCLUSION:

In this largest study to date of HCV patients with HCC, the group selected to receive DAA treatment fared better in the short and long term than those not selected to receive DAA therapy. Patients who received DAA therapy had a low mortality rate over the 3 years of follow up. DAA therapy in the follow up period did not accelerate mortality from baseline. This data supports the paradigm that treating HCV in the setting of HCC is beneficial and is not detrimental either from a mortality or cost perspective. Further investigation including prospective randomized control studies would be warranted to elucidate these findings.
1084 Does Viremia in Patients With Hepatitis C Antibody Positivity Alter Mortality in People Who Inject Drugs With Infective Endocarditis?
Authors: Tom Chloe K. , Kovalic Alexander J. , Huang Glen , Peacock James E. , Majeed Chaudry N. , Davis Kyle A.
Published: October 2019

INTRODUCTION:

Injection drug use [IDU] is a well-known risk factor for both infective endocarditis [IE] and hepatitis C virus [HCV] infections. In parallel with the opioid epidemic, the incidence of both infections has increased in recent years. In this retrospective study, the impact of HCV on mortality of people who inject drugs [PWID] with IE is assessed.

METHODS:

Electronic medical records of adult patients diagnosed with IE according to modified Duke criteria from January 2012 through May 2018 at an academic tertiary medical center were analyzed. Patients were identified as PWID based on IDU documentation within 3 months of admission. The study included all patients with a positive HCV antibody. Patients were then stratified into two groups: “Positive HCV viremia” [positive HCV antibody and viral load] or “Negative HCV viremia” [positive HCV antibody but negative viral load]. Prior HCV treatment, HIV infection, and absence of documented HCV seropositivity precluded study enrollment. Pertinent demographic, clinical, laboratory, microbiologic, and outcome data were recorded and analyzed.

RESULTS:

One hundred and twenty-nine PWID with IE were identified, of whom 110 [85.2%] had a positive HCV antibody. Of these, 23 patients were excluded due to lack of testing for viral RNA. , resulting in 87 HCV study patients [67.4%]. Fifty-three [61.0%] patients had viremia and 34 [39.1%] did not. Of the 87 study patients, 85.1% were Caucasian and 52.9% were female with a median age of 25. Six [6.9%] patients had previous IE. The most commonly injected drug was prescription opioids [69.0%]. The tricuspid valve was involved in 56.3% of patients and the most common pathogen was Staphylococcus aureus [71.3%]. Prescription opioid injection, S. aureus infection, tricuspid valve involvement, and 10-week mortality did not differ between the viremic and non-viremic HCV groups [Table 1].

CONCLUSION:

While several host and clinical factors affect mortality in PWID with IE, HCV viremia does not appear to increase mortality. However, larger, prospective studies will be required to better delineate the significance of HCV viremia among PWID with IE.
1093 Longitudinal Follow-Up of Malnutrition in U.S. Veterans With Decompensated Cirrhosis
Authors: Edwards Jade , Narayanan Shreya , Hiller Lynn D. , Smith Tristan , Kumar Ambuj , Foulis Philip , Vidyarthi Gitanjali
Published: October 2019

INTRODUCTION:

This retrospective cohort study aims to address the overall incidence of formal malnutrition assessments of U.S. veteran patients with decompensated cirrhosis and how these assessments impact clinical outcomes.

METHODS:

All consecutive adult U.S. veteran patients with a diagnosis of decompensated cirrhosis were identified in the James A. Haley VA Computerized Patient Record System using ICD-9 and ICD-10 codes associated with decompensated cirrhosis. Patients were included in the study if they had at least 2 cross-sectional imaging studies (CT or MRI) approximately 2 years apart from one another in order to identify significant changes in skeletal muscle composition and body fat as a primary outcome. These studies were reviewed and compared by one independent radiologist. Demographic and clinical data were also extracted. Malnutrition assessments were evaluated by one registered dietician (RD) based on review of prior dietician consultation notes that documented clinical evidence of malnutrition.

RESULTS:

101 subjects with decompensated cirrhosis met inclusion criteria; 97% were male with a median age of 60 years. The most common etiology of cirrhosis was due to hepatitis C virus. The overall incidence of at least one documented nutritional assessment conducted by a registered dietician (RD) was 69% (70/101). Approximately 41% of those patients evaluated by an RD were confirmed as being malnourished and had significant reductions in the dimensions of their gluteus maximus, erector spinae muscles and flank fat while their BMI and MELD scores were relatively unchanged over a 2-year period. Cirrhotic veterans that were not evaluated by an RD had similar reductions in fat and muscle mass compositions. Only 17% of malnourished subjects that were evaluated by an RD had a billing code (ICD-9 or ICD-10) in their medical record that corresponded to their malnutrition.

CONCLUSION:

Nearly one-third of U.S. veterans with decompensated cirrhosis had a documented diagnosis of malnutrition. There were significant reductions in skeletal muscle mass and fat mass over a 2-year time period that correlated with their chronic disease-related malnutrition. Interestingly, the presence or absence of an RD evaluation had no significant impact on these reductions. Corresponding ICD-9/ICD-10 billing codes associated with malnutrition were underreported, which may be a potential barrier in identifying and optimally treating malnutrition in U.S. veteran patients with decompensated cirrhosis.
1107 Novel Therapy for Hepatocellular Carcinoma: Immunotherapy
Authors: Jones Patricia D. , Gmunder Kristin , McLaughlin Jeremy , Martin Paul M. , Herrera Cristina , Feun Lynn
Published: October 2019

INTRODUCTION:

Over 50% of patients with hepatocellular carcinoma (HCC) present with advanced disease for which therapeutic options have been limited to locoregional therapy and/or systemic chemotherapy. Since 2017, three multi-kinase inhibitors and two checkpoint inhibitors have received FDA approval, expanding the treatment armamentarium for advanced HCC. We aimed to describe our early institutional experience with immunotherapy including response to treatment and frequency of adverse events.

METHODS:

We identified patients diagnosed with HCC (C22.0) from the Cancer Registry and Electronic Data Warehouse at the University of Miami /Jackson Memorial Hospitals and identified those who were treated with immunotherapy (IT). We used bivariate and Pearson’s chi-squared analyses to describe participant characteristics.

RESULTS:

Forty patients have been treated with immunotherapy to date. Median age at diagnosis was 65; 87.5% were male. Cirrhosis was present in 70%; 17 patients had hepatitis C, 5 had hepatitis B, 7 had alcoholic liver disease and 9 had non-alcoholic fatty liver disease. At diagnosis, 17 patients were Barcelona Clinic Liver Cancer (BCLC) Stage 0/A, 16 were BCLC B and 6 were BCLC C. Four had metastasis at presentation and 2 had tumor thrombus. At diagnosis, median AFP was 44 ng/mL. Median MELD score was 7. See Table 1 for baseline characteristics. Prior to receiving IT, patients received a median of 3 other treatment modalities. (Figure 1) Median time from diagnosis to first treatment was 48.5 days. Prior to IT, 3 patients were BCLC B, 36 were BCLC C and 1 was BCLC D. Median time from diagnosis to IT was 834.5 days. Twenty-eight patients received pembrolizumab and 12 received nivolumab. Patients received a median 5 doses of IT; side effects occurred in 85%. However, only 6% had treatment discontinuation due to patient intolerance of side effects. Elevated liver enzymes occurred in 40%; of these, 2 developed autoimmune-type hepatitis and 1 experienced significant liver dysfunction. Fatigue occurred in 37.5% and rash in 27.5%. Prednisone was used to treat side effects in 22 patients. At present, 21 are alive and 8 are still receiving IT. See Table 2 for IT characteristics. There were no significant baseline or survival differences comparing pembrolizumab vs. nivolumab.

CONCLUSION:

Although IT is promising in the treatment of advanced HCC, future research must identify which patient characteristics predict treatment response and development of side effects.
1113 Epidemiological Study of Liver Cancer Incidence in the U.S.-Mexico Border Region
Authors: Robles Alejandro , Contreras Alberto , Chavez Luis O. , Deoker Abhizith
Published: October 2019

INTRODUCTION:

Liver cancer is the fifth most common cause of cancer-related death in men and the seventh most common in women, accounting for 7% and 4%, respectively, of all cancer-related deaths. In the United States, the incidence of liver cancer has more than tripled since 1980, and it continues to increase by about 3% per year in women and 4% per year in men. Mortality rates from liver cancer have also increased at a faster pace than all other cancer sites. The rising trend of liver cancer is likely attributed to an aging population with chronic hepatitis C virus infection and the increasing prevalence of diabetes, obesity, metabolic syndrome, and NAFLD; risk factors that are amenable to intervention. In this study, we investigate the burden of liver cancer in persons living near the U.S.-Mexico border.

METHODS:

Incidence statistics for liver cancer in counties along the U.S.-Mexico border were obtained from the NIH National Cancer Institute, State Cancer Profiles. Incidence rates (per 100,000 population) were compared by race (non-Hispanic white and Hispanic) and gender from 2011 to 2015. Variability in rates and changes in trends over the period were reported with 95% confidence intervals. Only descriptive data was reported - a statistical trend test was not used to analyze incidence rates over time.

RESULTS:

Incidence rates of liver cancer are higher in states that border Mexico. In general, Hispanics have higher average annual incidence rates of liver cancer than non-Hispanic whites, and this finding is even more noticeable in those living in counties along the U.S.-Mexico border, where rates of liver cancer in Hispanic men and women are higher than the state and national averages for Hispanics. Furthermore, an upward trend in liver cancer incidence was noted in Hispanic men living in El Paso County and Hispanic women living in San Diego County (Figure 1).

CONCLUSION:

Hispanics have the highest incidence rates of liver cancer, and this finding is more pronounced in those living near the U.S.-Mexico border; where the prevalence of known risk factors are higher. Increasing awareness and targeting preventive practices are needed to reduce the future impact imposed by liver cancer.
1114 The Effect of Metabolic Syndrome on Acetaminophen-Induced Acute Liver Injury/Failure - Morbidity and Mortality: A Single Liver Transplant Center Experience
Authors: Ghanimeh Mouhanna Abu , Baltarowich Lydia , Miller Joseph , Varma Adarsh , Brown Kimberly
Published: October 2019

INTRODUCTION:

Acetaminophen (N-acetyl-p-aminophenol; APAP) toxicity is a major cause of acute liver injury in USA. Several risk factors could increase the risk and severity of APAP-induced acute liver injury/failure (APAP-ALI/ALF), including malnutrition, chronic hepatitis C, alcoholism, hepatic cytochrome P450-inducing medications, and pre-existing liver disease. Whether metabolic syndrome affects the risk or the severity of APAP-ALI/ALF has not been definitively confirmed. Clinical and animal studies show conflicting results. We aim to assess the effect of pre-existing metabolic syndrome on the natural history of APAP-ALI/ALF, including morbidity and mortality

METHODS:

This was a retrospective study performed at a tertiary care liver transplant center. A collective database of all patients with APAP-ALI/ALF from 2001-2012 was reviewed. Primary outcomes were 28-day mortality and the need for liver transplantation. Secondary outcomes were the degree of liver injury and elevation of biochemical markers

RESULTS:

A total of 327 patients were evaluated with APAP-ALI/ALF. A subset of 219 patients who had a recorded BMI in the medical record were included for analysis. There were 151 females and 68 males, with a mean age of 39.1 years old. Benzodiazepine or opioid co-ingestion occurred in 116 patients. A total of 60 patients were obese (BMI > 30 Kg/m2) with a mean BMI of 38.3 Kg/m2, and 21 were morbidly obese (BMI > 40 Kg/m2). 58 patients died (24 obese and 34 non-obese). Liver transplantation was performed in 4 out of the 7 patients who were listed. There was a statistically significant association between obesity and the 28-day mortality, OR 2.451 (95% CI 1.291-4.651) and P 0.005. No significant association was found between obesity and either listing for liver transplantation or liver transplantation (P 0.351 and 0.916 respectively). Maximum total bilirubin and INR were slightly higher in obese patients; however, this was not statistically significant (P 0.08 and 0.823, respectively). Pearson correlation showed a weak association between rising BMI and a higher maximum total bilirubin and INR, but this was not statistically significant (r 0.08, P 0.201 for total bilirubin and r 0.07, P 0.307 for INR)

CONCLUSION:

Our study demonstrates that obesity is associated with a higher mortality in patients with APAP-ALI/ALF. Preexisting hepatocyte lipid accumulation, CYP2E1 induction, reduced hepatic glutathione stores as well as mitochondrial dysfunction have been proposed as risk factors that may be contributing.
1115 Spontaneous Bacterial Peritonitis: We Are Still Behind
Authors: Numan Laith , Tomaw Andrew , Elkafrawy Ahmed A. , Kaddourah Osama , Saeed Lyla , Zafar Yousaf , Al-Sayyed Leen
Published: October 2019

INTRODUCTION:

Spontaneous bacterial peritonitis (SBP) is an infection in the ascitic fluid when there is no evidence of intra-abdominal surgically treatable source of infection. It has an estimated in-hospital mortality rate of 20%. Despite the published guidelines, inappropriate diagnosis of SBP is frequent. In this study, we aim to measure the percentage of inappropriate diagnosis and treatment of SBP.

METHODS:

A retrospective study was conducted between Jan-2015 and Jan-2018. Based on the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of Liver (EASL) two authors judged the adherence to the guidelines in diagnosis and management of SBP. A third author resolved conflicts. Data was analyzed by chi-square analysis/Mann Whitney U Tests, ANOVA, and t-tests.

RESULTS:

One hundred six patients were included in the study. 93.3% (98/106) of them were hospitalized. Mean age was 56.9 years (range 32-87). 58.5% (62/106) of the patients were males. Caucasian was the most common ethnicity, with 86.8% (92/106). Smoking use was present in 41.5%, and alcohol use was present in 28.3% of our sample. Alcohol was the most common cause of cirrhosis in 50% of the patients, and viral hepatitis was the second (21.7%). Prior SBP was found in 24.5% of the population. Mean WBC 11.1, Mean MELD-Na score 23.5 (range 8-42), and mean Albumin 2.8 (1.6-4.9). Polymorphonuclear neutrophils (PMN) was neutrocytic (>250) in 54.8% (46/106). 81.8% of the ascitic cultures were negative. 16.2% of the cultures grew one organism, and 1.9% of them were polymicrobial. Albumin was given in 62.1%, and 52.4% on day 1 and day 3, respectively. Hepatology was consulted on 80.2% of the patients. Authors judged that only 52.4% of patients were appropriately diagnosed, and only 67.3% were managed with appropriate treatment. Inpatient mortality documented in 5 patients. The readmission rate was 29.3%.

CONCLUSION:

SBP is a common complication of cirrhosis, that can be easily managed if we adhere to the published guidelines. In our population, nearly half of the patients were diagnosed and treated inappropriately; this was mostly due to misdiagnosis of SBP with secondary peritonitis or non-neutrocytic bacteriascites, starting antibiotics before performing the paracentesis, and even given broader antibiotics when it is not needed. Further efforts should stress to adopt the guidelines in clinical practice.
1117 Same Day, Walk-In Ultrasound Appointments Improve Hepatocellular Carcinoma Screening Rates in Patients With Cirrhosis at a Veterans Affairs Center
Authors: Ward Christopher , Tse Chung Sang , Shittu Yetunde , Promrat Kittichai
Published: October 2019

INTRODUCTION:

The incidence of hepatocellular carcinoma (HCC) is rapidly increasing in the United States and 80% have pre-existing cirrhosis. It is imperative to implement effective screening programs to detect clinically silent or early stage HCC in patients with cirrhosis to improve cancer-related mortality. The 2018 American Association for the Study of Liver Diseases (AASLD) Guidelines recommends surveillance using ultrasound (US), with or without alpha fetal protein (AFP), every 6 months. Prior studies have shown low HCC surveillance rates of approximately 20% among eligible patients in clinical practice. Our aim is to improve the HCC surveillance rate at our local Veterans Affairs Medical Center (VAMC).

METHODS:

We developed a process map and an apparent cause analysis (fishbone) to identify the barriers to HCC screening. We implemented a quality improvement initiative and collected the HCC screening compliance rates on a monthly basis on all eligible patients with cirrhosis seen at a local VAMC between January 2018 and February 2019.

RESULTS:

Based on our process map (Figure 1) and apparent cause analysis (Figure 2), the barriers to HCC screening at our local VAMC included the lack of a set protocol in our radiology department for limited ultrasound scans which limited patient access and compliance, such as the schedulers’ inability to reach patients for ultrasound appointments and patients’ no-show on ultrasound appointments. Our primary intervention was to institute same day walk-in ultrasounds, such that patients could go directly from their liver clinic appointment to the radiology department for a dedicated HCC screening ultrasound, without the need for patients to fast or return on a different date. At the start of the study period in January 2018, the HCC screening compliance rate was 39.6%, with 195/324 patients overdue. The same day walk-in ultrasound was implemented on 31 July 2018, at a time when the compliance rate was 42.1%. Six months after the intervention, the compliance rate in February 2019 was 66% with just 90/215 patients overdue for their ultrasounds. (Figure 2)

CONCLUSION:

It is standard of care to provide biannual screening ultrasounds for HCC surveillance in patients with cirrhosis. At our local VAMC, providing patients with same day walk-in ultrasounds to coincide with their liver clinic appointment days eliminated a number of barriers to HCC screening and lead to an increase in compliance.
1119 Assessment of Utility of Prognostic Models for Predicting Short-Term Mortality of Patients With Acute-on-Chronic Liver Failure
Authors: Margaret Teng Li Peng , Phyo Wah Wah , Lee Guan Huei
Published: October 2019

INTRODUCTION:

Acute-on-chronic liver failure (ACLF) is a clinical syndrome associated with high short-term mortality. Numerous models have been proposed to predict outcomes in ACLF patients, including novel ones by Asian Pacific Association for the Study of the Liver (APASL) ACLF Research Consortium (AARC), but their utility in a heterogeneous population of ACLF patients remains inconclusive. The study aims to assess the performance of established and newer models for predicting mortality of ACLF patients.

METHODS:

A retrospective study of 96 patients fulfilling either APASL or European Association for the Study of the Liver (EASL) criteria for ACLF admitted to a tertiary hospital in Singapore between 2004 and 2018 was performed. Child-Turcotte-Pugh (CTP) score, Model for End-Stage Liver Disease (MELD)-Na, Chronic Liver Failure Consortium (CLIF)-SOFA, CLIF-C ACLF and AARC prognostic scores (MELD-lactate, AARC-ACLF) were calculated on days 1, 4, 7 of hospital admission and days 1, 4 of ICU admission. Outcomes assessed were survival to discharge without transplant, 30-day survival and 90-day survival. The scores were evaluated by measuring area under receiver operating characteristic (AUROC) curve at each time point and compared.

RESULTS:

28 patients (29.2%) survived to discharge without transplant, 21 patients (21.9%) underwent urgent transplant and 47 patients (49%) died before discharge. 30-day transplant-free survival was 21.9% and 90-day survival was 19.8%. CTP, MELD-Na, MELD-lactate, CLIF-C ACLF and AARC-ACLF scores had high accuracy in predicting hospital mortality on day 4 admission (CTP D1 AUROC 0.642, D4 0.715; MELD-Na D1 0.607, D4 0.721; MELD-lactate D1 0.664, D4 0.861; CLIF-C ACLF D1 0.559, D4 0.697; AARC-ACLF D1 0.571, D4 0.747). CTP, MELD-Na and MELD-lactate scores also had good predictive utility on day 7 admission (CTP D7 0.684; MELD-Na 0.67; MELD-lactate 0.848). This held true regardless of whether APASL or EASL criteria was applied. In addition, the sequential change in CLIF-SOFA and CLIF-C ACLF scores from day 1 to day 4 was significantly associated with need for urgent transplant or death before discharge.

CONCLUSION:

CTP, MELD-Na and MELD-lactate scores are superior at prognosticating outcomes on day 4 and 7 of admission in our multi-ethnic Asian population. The trend of CLIF-SOFA and CLIF-C ACLF scores from day 1 to day 4 of admission may also contribute valuable information to our assessment of ACLF patients.
1120 Assessment of Risk Factors for Mortality With TIPS Placement: Age or Frailty
Authors: Mahmoud Khalid , Abdel Aal Ahmed Kamel , Osman Sarah , Massoud Moustafa , Bae Sejong , Shoreibah Mohamed
Published: October 2019

INTRODUCTION:

The Model for End-stage Liver Disease (MELD) score is used for prediction of mortality in cirrhotics undergoing :following transjugular intrahepatic portosystemic shunt (TIPS) placement. Our recent work showed that frailty (measured by psoas muscle density) is associated with increased risk of mortality. Purpose: We performed a post hoc analysis to examine the association of age on mortality in cirrhotics undergoing TIPS placement as there is a tendency to avoid TIPS in older patients with limited data to guide the decision making.

METHODS:

This a retrospective study encompassing 241 patients with cirrhosis who underwent TIPS placement. The patients had two main indications for TIPS placement, variceal bleeding (VB; n = 113) and volume overload (VO; n = 128). The study included 149 men (62%), and mean patient age was 56 years ± 9.6 (range 24–83). Mean MELD score before TIPS creation was 11.8 ± 5.7. Frailty was assessed by measuring psoas muscle density (PD). A threshold sensitivity of pre-TIPS PD for the assessment of mortality was calculated and then correlated with survival after TIPS creation.

RESULTS:

Mean follow up duration was 29.9 month ± 34.1 (range 1–3700 days). The increase in MELD score after TIPS creation was significant in both groups (VB, P = .0013; VO, P < .0001). The threshold of pre-TIPS PD for discrimination of survival was 29.4 HU (P < .0001), and PD measurements greater than this threshold were associated with a lower risk of mortality (HR: 0.27; 95% confidence interval, 0.13–0.57; P = 0.0006). Conversely, age was not associated with mortality (P = 0.2461).

CONCLUSION:

High MELD score and frailty (determined by PD), not age, are associated with mortality in cirrhotic patients undergoing TIPS placement. Further studies are needed to confirm our findings.
1122 Geriatric Bariatrics: Do Post-Operative Patients Remain at Risk for Micronutrient Deficiencies?
Authors: Nath Anand , Shope Timothy R. , Koch Timothy
Published: October 2019

INTRODUCTION:

We have previously described high prevalence of thiamine deficiency and gastrointestinal symptoms (Nath et al, Nutrition Res, 2017) and of hypovitaminosis D and IBS-like symptoms (Nath et al, Nutrition Res, 2019) in individuals with medically-complicated obesity. As individuals who have undergone bariatric surgery age, it becomes increasingly difficult to obtain blood tests to look for micronutrient deficiencies. Our hypothesis is that older bariatric patients seen for evaluation in gastrointestinal clinic remain at risk for micronutrient deficiencies.

METHODS:

From April 2018 to April 2019, 33 postoperative patients (Gastric Bypass: n = 27; Sleeve Gastrectomy: n = 6) were seen in gastrointestinal clinic in an urban, community teaching hospital. This study included 3 males and 30 females with a mean age of 70 years (SD: 3.4; range 66 to 79), mean body mass index of 35 kg/m 2 (SD: 6.3; range 25.9 to 55.1), and a mean of 11 years since bariatric surgery (SD: 6.7; range 1 to 30). Six patients (22%) had anemia; 5 patients (17%) had weekly or more frequent alcohol use; 12 patients (36%) had a history of diabetes mellitus; 11 patients (33%) were using a diuretic; and 5 patients (15%) were not taking a daily multivitamin. Nine micronutrients were evaluated using commercially available blood testing, but 2 patients did not complete the suggested blood tests.

RESULTS:

Serum folic acid level was elevated in 17 of 22 patients (77%), which supports the presence of small bowel bacterial overgrowth. Hypovitaminosis D was identified in 32 of 33 patients (97%). Low vitamin B12 was identified in 10 of 31 patients (32%). Low vitamin B12 was identified in 10 of 31 patients (32%). Low vitamin A was identified in 3 of 18 patients (16%). Low vitamin E was identified in 4 of 13 patients (31%). Low zinc was identified in 2 of 9 patients (22%) and low iron was identified in 9 of 26 patients (35%), while 10 patients had normal serum copper level. Clinical Vitamin B1 deficiency was identified in 27 of 33 patients (82%).

CONCLUSION:

This study supports our hypothesis that geriatric patients who have undergone bariatric surgery are at risk for multiple micronutrient deficiencies. These results support the notion that ordering of specific micronutrients should focus on thiamine, 25 hydroxy-vitamin D, and serum folic acid in patients evaluated in gastrointestinal clinic. These micronutrients may provide explanations for complaints of gastrointestinal symptoms in this patient population.